**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility's policies and procedures review and staff interviews, the facility failed to ensure staff followed established policies and procedures to honor the advance directives for full code status for 1 (Resident #1) of 3 residents reviewed. On [DATE] at 5:19 a.m., Resident #1 was found unresponsive, without a pulse or respiration. Clinical staff failed to ensure timely confirmation of code status and immediately initiate cardiopulmonary resuscitation (CPR) for Resident #1 who had a full code status. Three Licensed Nurses on duty did not call Emergency Medical Services (EMS) or initiate CPR for 51 minutes while they attempted to locate a non-existent Do Not Resuscitate Order. Resident #1 was pronounced dead by EMS. The failure to honor the residents' right to receive life saving measures, to include CPR, intubation, and defibrillation placed other residents with full code status at a likelihood of serious injury or death and resulted in the determination of Immediate Jeopardy (IJ). On [DATE], after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of [DATE]. The scope and severity were reduced to E, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference to F678, F726, and F835. The facility's policy and procedure titled, Resident's [NAME] of Rights and Dignity Policy with a revision date of [DATE] noted, The resident's bill of rights reflects current federal and state standards governing patient's rights. These rights identify specific prerogatives according to the individual while he/she is a resident at this health care facility. The facility must enforce and ensure resident rights are enforced, including the resident has the right to . self-determination . and access to persons and services inside and outside the facility . The facility must promote and protect the rights of the resident . The facility's policy and procedure titled, Advance Directive. CPR-Cardiopulmonary Resuscitation Policy. Determining Code Status with a date revised of 2/2022 noted, It is the policy of this facility to honor resident advance directives and provide basic life support, including CPR-Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order and resident choice indicated in the resident's advance directives . Nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) or other approved association unless: A valid Do Not Resuscitate order in place . Every competent adult has the fundamental right of self-determination regarding decisions pertaining to his or her own health, including the right to choose or refuse medical treatment . All competent residents have the right to choose or refuse medical treatment during their stay in the facility . Review of the clinical record for Resident #1 revealed an admission date of [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease with acute exacerbation. The baseline care plan initiated on [DATE] did not include Advance Directives. The Social Service admission data collection in the electronic clinical record with an effective date of [DATE] (three days after admission) and did not include advance directives. On [DATE] a physician's progress note noted, Advanced Directives: Full code. On [DATE] at 8:37 a.m., Registered Nurse (RN) Staff A documented in a progress note, This nurse went in to check blood sugar and noted that resident was not responding, at this time I checked for a pulse and respirations. Resident was noted to be with out [sic] pulse and respirations. Then I went to get direction from B wing nurse, then began to look for DNR form when I did not find one I called the PCP (Primary Care Physician) to inform that resident had passed. Next I called the Daughter, then the on call nurse who directed me to call the DON (Director of Nursing). When I spoke with the DON she directed me to start CPR and call 911 when I stated the resident was a full code. At this time, I began CPR and had Cove nurse call 911. On [DATE] at 12:33 p.m., in an interview the Registered Nurse Staff Educator said on [DATE] during morning meeting she found out there was an incident with the process for CPR for Resident #1. From information gathered, CPR was initiated late. She said the nurse on duty did not quite respond and couldn't figure out what to do when she did not find the yellow DNR (Do Not Resuscitate) paper. She was looking for the DNR or Full code or something like that. There was a communication process breakdown. The nurse went to the chart. She found there was no DNR. At this point she did not know what to do so she called the on-call Nurse Manager and also called the DON. She said when a resident is found unresponsive, staff dials (four digit code) from the telephone at the nurse's station to announce a code blue. It is not an overhead page. It will announce on the telephone at each nurse's station. The nurses and CNAs (Certified Nursing Assistants) respond right away. They check the code status by looking in the front of the resident's clinical record for a yellow DNR form. In the absence of a yellow DNR the resident is a full code and they initiate CPR. On [DATE] at 3:01 p.m., the Administrator stated she started an investigation and so far she found out Resident #1 was found unresponsive on [DATE] at 5:19 a.m., and CPR not initiated until [DATE] at 6:10 a.m. The Administrator provided an investigation into Resident #1's delay in receiving lifesaving measures, including CPR which included staff statements, and a timeline of the event which she said she obtained from watching the facility's surveillance video. The investigation noted, At 5:19 a.m. (Staff A) RN (Registered Nurse) went into (Resident #1's room) to check the resident's blood sugar via fingerstick method. She found (Resident #1) unresponsive. She checked for a pulse, no pulse present, sent (Staff D) C.N.A (Certified Nursing Assistant) to get the B (Staff B) and D (Staff C) wing nurses to assist. They checked her code status in EMR (Electronic Medical Record), hard chart and DNR binder, did not see a yellow DNR in the medical record, EMR or DNR binder. (Staff B) went to get the crash cart and CPR was initiated at approximately 06:10am. EMS was called and arrived at 06:24 a.m. and pronounced resident deceased . Delay in the initiation of CPR . Licensed nurses involved suspended pending investigation . A review of Registered Nurse Staff A's statement dated [DATE] noted, I went to check the blood sugar for resident in (Resident #1's room). When I entered the room, I noted the resident was not responding to her name, then rubbed her arm to which did not respond. I then checked for respirations and a pulse which there was none. Resident was noted without pulse and respirations. Then I went to get direction from B wing nurse, then began to look for DNR form. When I did not find one I called the PCP to inform that resident had passed. Next I call the daughter, then the on call nurse who directed me to call the DON. When I spoke with the DON she directed me to start CPR and call 911 when I stated the resident was a full code. At this time, I began CPR and had Cove nurse call 911. A review of Licensed Practical Nurse (LPN) Staff B undated statement noted, At 0530 (5:30 a.m.) or 0540 (5:40 a.m.), A wing nurse came to me for help regarding (Resident #1's room). Walked back to A wing then we checked there was no pulse. We checked code status looked in the chart, there was no code form. Looked in computer, I went to get crash cart. CPR was started when I came to the room. A review of RN Staff C's statement dated [DATE] noted, A wing nurse (RN Staff A) asked me for help around 0520 ish (approximately 5:20 a.m.) stating the patient in (Resident #1's room) was not breathing and had no pulse. I went to Unit and looked for DNR in chart and computer told her to start CPR because she's a full code. I then told her to ask (LPN Staff B) to double check with B wing nurse because he had recently had a death, and he might be able to tell her better. She then went to B wing to ask B wing nurse for help. B wing nurse came to Unit started looking for DNR told him there was no DNR. I then went and checked the patient myself and noted there was no BP (Blood pressure) or pulse. At this point A wing nurse called the DON. DON said to initiate CPR and call 911 and therefore she did. On [DATE] at 2:18 p.m., RN Staff A said in a telephone interview she started employment at the facility on [DATE]. She said on [DATE] at approximately 5:30 a.m., she went in Resident #1's room to do a blood sugar. When she found Resident #1 unresponsive, she went to D wing to get help from RN Staff C. They both started to look for a DNR. They looked in the computer and chart to see if she was a DNR or not. They were not able to find anything. They then went to B wing since that nurse had more experience. LPN Staff B told her not to worry about it, go into the computer or the chart to find out if the resident was hospice. She looked again and couldn't find a DNR. She then drew her own conclusion. She called the resident's daughter, the Unit Manager who was on call and told her to call the DON. She then called the DON who asked if Resident #1 had a DNR. The DON told her if they do not have a yellow DNR form, the resident is a full code. She then told Staff B and Staff C they needed to do CPR. RN Staff A said there was approximately a 15 minutes delay in initiating CPR. Review of the Emergency Medical Services Patient Care Record dated [DATE] noted the call to EMS was received on [DATE] at 6:14 a.m. The EMS Patient Care record documented, Primary impression: Cardiac arrest; Secondary impression: Respiratory arrest. The narrative read, Patient is in cardiac arrest. Nursing home facility staff state that patient was last seen normal around 4:15 this morning. Facility staff stated that when they went to check on her at 5:45 she was found in cardiac arrest. According to facility staff, CPR was delayed until shortly before contacting 911 . Oral tracheal intubation was elected and attempted. While attempting to intubate patient, it was noted patient had rigor mortis (post-mortem stiffening of muscles) to her jaw. Attempt was abandoned and time of death called shortly after. deceased patient was left with NH (Nursing Home) facility RN that was on scene. No further treatment was provided. On [DATE] at 2:04 p.m., in a telephone interview LPN Staff B said on [DATE] he was taking care of a resident on his unit when RN Staff A came to the door and asked him to come and help her. RN Staff A said it was the first time she had someone die. He went in the room and was not able to find a pulse. He went to get the crash cart. He called RN Staff C from another unit. They started CPR and called 911. He said he checked for the code status on the computer and the file. He could not find a DNR. Resident #1 was a full code. He ran to the cart to start CPR. The nurse on duty RN Staff A did not know what to do but he knew what to do. RN Staff C and him did CPR until 911 came. Staff B did not know how long the initiation of CPR was delayed. On [DATE] at 2:48 p.m., in a telephone interview the DON said upon hire, staff receive training on advance directives. She said she has not looked at the training and could not speak to the content. She said the Social Service department was responsible to provide the information to new staff. On [DATE] at 4:58 p.m., in a telephone interview RN Staff C said on [DATE] he was busy taking care of one of his residents when RN Staff A came to ask for help. He said the resident he was taking care of was not in distress. He kept going back and forth between the two residents (his resident and Resident #1). He helped with CPR. He has been employed at the facility for five months, received training related to advance directives and was comfortable with the process. Review of the computer based training for Advance Directives noted a DNRO (Do Not Resuscitate Order) protocol and process that read, Upon admission, the resident and/or resident representative will receive information in regards to advance directives . All valid DNRO Forms . will be kept in front of the resident's chart. If no form in front of the chart resident is a Full code. Review of the personnel file for RN Staff A, LPN Staff B, and RN Staff C revealed they completed one hour on-line training for Do Not Resuscitate Orders-Florida respectively on [DATE], [DATE], and [DATE]. On [DATE] at 10:22 a.m., in an interview the Staff Social Worker said the Social Service Department was responsible to obtain advance directives upon admission. She said Resident #1 was admitted on a Friday. Since there's no one on the premises from the Social Service department on weekends, she did not meet with Resident #1 until Monday [DATE], three days after her admission. The SSD provided a paper document of section C of the Minimum Data Set which she said was in her office. The words Full and No AD were handwritten on the form. Full was circled. The SSD explained full meant full code and no Ad meant no advance directives. She verified the baseline care plan did not include Resident #1's advance directives and expressed wishes to receive CPR in the event of cardiac or respiratory arrest. She verified the resident's wishes were not documented in the baseline care plan and not available to staff to quickly make the determination to start CPR. The SSD said she did not enter care plans for advance directives until the care plan meeting. On [DATE] at 9:30 a.m., the Administrator verified the clinical staff on duty on [DATE] failed to honor Resident #1's advance directives by failing to immediately initiate lifesaving measures, including CPR in the absence of a DNR per the facility's established policy and procedure. The immediate actions implemented by the facility and verified by the surveyors included: The facility reviewed policies and procedures: [DATE] related to resident rights, Advanced Directives, CPR, DNRO form. On [DATE] and [DATE] the surveyor verified through review of items discussed during QAPI on [DATE] to include a review of the policies and procedures related to Advanced Directives, DNRO and CPR, Code policy procedure. A facility wide assessment was completed on all residents advanced directives. [DATE]. On [DATE] the surveyor verified through review of the facility wide assessment. The facility provided a resident census list with the residents with DNR status highlighted. Three random residents were reviewed for accuracy of code status. The code status was accurate on the audit list for Resident #2, Resident #3, and Resident #4. The facility immediately initiated education on the advanced directives/DNRO process to all staff [DATE]. There are 10 employees that will receive education prior to their next shift. On [DATE] the surveyor verified through review of the in-service education provided to staff. On [DATE] at 4:25 p.m., the Staff educator said the scheduler is to notify them when the staff returns to work. The Unit Manager on that shift will be responsible to ensure the education is done. Ad hoc QAPI conducted on [DATE] at 10:30 a.m. on advanced directives, DNRO, CPR. Attended: Administrator, DON, Medical Director, Infection Preventionist, Staff Education, Rehab Director, Social Services Director, Social Services Coordinator, Nurse managers (3) Life enrichment Coordinator. Systemic revision made to include Code Drills quarterly with debrief, feedback and plan, introduced a CPR checklist in clinical orientation. Staff notification to supervisor, off hours administration staff is located on the PCC dashboard and the unit information binder. On [DATE] the surveyor verified through observation of the binder located at the nurse's station of the Cove. On [DATE] the surveyor verified through review of the Ad hoc QAPI meeting and review of code drills with debrief form conducted on [DATE], [DATE] and [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility's policies and procedure reviews and staff interviews the facility staff failed to immediately initiate cardiopulmonary resuscitation (CPR) in the absence of a Do Not Resuscitate (DNR) Order for 1 (Resident #1) of 4 residents reviewed who was found without a pulse or respirations. On [DATE] at 5:19 a.m., Resident #1 was found unresponsive, had no pulse, and no respirations. Clinical staff delayed calling Emergency Medical Services (EMS) and did not initiate CPR for 51 minutes while attempting to locate a non-existent DNR order. CPR is a crucial life-saving technique that aims to sustain blood circulation and oxygenation in individuals experiencing cardiac arrest. Resident #1 was pronounced dead by EMS. The facility's failure to implement their policies and procedures and immediately administer CPR to residents who requires such emergency care placed other residents with full code status at a likelihood of serious injury or death and resulted in the determination of Immediate Jeopardy (IJ). On [DATE] at 11:28 a.m., the facility Administrator was informed of the determination of Immediate Jeopardy and provided the IJ templates. On [DATE], after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of [DATE]. The scope and severity were reduced to E, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference F578, F726 and F835. The facility's policy and procedure titled, CPR-Cardiopulmonary Resuscitation Policy with a reviewed date of 2/2022 noted, . Prompt initiation of CPR (cardiopulmonary resuscitation) is essential as brain death begins four to six minutes following cardiac arrest if CPR is not initiated within that time . Purpose. The facility shall provide basic life support, including CPR to a resident who requires such emergency care prior to the arrival of emergency medical services, consistent with the resident's advance directives and physician orders . Procedure . Identify code status/advance directive preferences by checking for a signed DNRO (Do Not Resuscitate Order) form in front of the chart . If no DNR order/advance directive exists or if advance directive does not indicate Do Not Resuscitate, begin resuscitation efforts . Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease with acute exacerbation, and generalized muscle weakness. The physician's orders dated [DATE] did not include a code status. The care plan initiated on [DATE] did not include a code status. On [DATE] the physician documented in a progress note, Advanced Directives: Full code. Full code means if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR. On [DATE] at 8:37 a.m., Registered Nurse (RN) Staff A documented in a progress note, This nurse went in to check blood sugar and noted that resident was not responding, at this time I checked for a pulse and respirations. Resident was noted to be with out [sic] pulse and respirations. Then I went to get direction from B wing nurse, then began to look for DNR form when I did not find one I called the PCP (Primary Care Physician) to inform that resident had passed. Next I called the Daughter, then the on call nurse who directed me to call the DON (Director of Nursing). When I spoke with the DON she directed me to start CPR and call 911 when I stated the resident was a full code. At this time, I began CPR and had Cove nurse call 911. Review of the facility's incidents investigations revealed on [DATE] the facility initiated an investigation for a delay of initiating CPR for Resident #1. The investigation noted on [DATE] at 5:19 a.m., RN Staff A went into Resident #1's room to check the resident's blood sugar via fingerstick method. She found Resident #1 unresponsive. She checked for a pulse, no pulse present. She sent Certified Nursing Assistant (CNA) Staff D to get Licensed Practical Nurse (LPN) Staff B and RN Staff C to assist. They checked Resident #1's code status in the Electronic Medical Record (EMR), hard chart and DNR binder, did not see a yellow DNR in the medical record, EMR, or DNR binder. LPN Staff B went to get the crash cart and CPR was initiated at approximately 6:10 a.m. Emergency Medical Services (EMS) was called and arrived at 6:24 a.m. and pronounced Resident #1 deceased . Registered Nurse Staff A documented in a statement dated [DATE], I went to check the blood sugar for resident in (Resident #1's room). When I entered the room, I noted the resident was not responding to her name, then rubbed her arm to which did not respond. I then checked for respirations and a pulse which there was none. Resident was noted without pulse and respirations. Then I went to get direction from B wing nurse, then began to look for DNR form. When I did not find one I called the PCP (Primary Care Physician) to inform that resident had passed. Next I call the daughter, then the on call nurse who directed me to call the DON. When I spoke with the DON she directed me to start CPR and call 911 when I stated the resident was a full code. At this time, I began CPR and had Cove nurse call 911. On [DATE] at 12:33 p.m., in an interview the Registered Nurse Staff Educator said on [DATE] during morning meeting she found out there was an incident with the process for CPR. From information gathered, CPR was initiated late. She said the nurse on duty did not quite respond and couldn't figure out what to do when she did not find a yellow DNR paper. She said, she (RN Staff A) was looking for the DNR or Full code or something like that. There was a communication process breakdown. The nurse went to the chart. She found there was no DNR. At this point she did not know what to do so she called the on-call Nurse Manager and also called the DON. She said when a resident is found unresponsive, staff dials (four digit code) from the telephone at the nurse's station to announce a code blue. It is not an overhead page. It will announce on the telephone at each nurse's station. The nurses and CNAs respond right away. They check the code status by looking in front of the resident's clinical record for a yellow DNR form. In the absence of a yellow DNR the resident is a full code and they initiate CPR. The Nurse Educator said the code status can be checked by anyone, CNAs, nurses, managers from any department, including housekeeping, and maintenance. She said the first thing you see is the yellow DNR form in front of the chart. If there is no yellow DNR, the resident is full code and staff initiates CPR. On [DATE] at 2:18 p.m., in a telephone interview RN Staff A said on [DATE] at approximately 5:30 a.m., she went in Resident #1's room to do a blood sugar. When she found Resident #1 unresponsive, she went to D wing to get help from RN Staff C. They both started to look for a DNR. They looked in the computer and chart to see if she was a DNR or not. They were not able to find anything. They then went to B wing since that nurse had more experience. LPN Staff B told her not to worry about it, go into the computer or the chart to find out if the resident was hospice. She looked again and couldn't find a DNR. She then drew her own conclusion. She called the resident's daughter, the Unit Manager who was on call and told her to call the DON. She then called the DON who asked if Resident #1 had a DNR. The DON told her if they do not have a yellow DNR form, the resident is a full code. She then told Staff B and Staff C they needed to do CPR. RN Staff A said there was approximately a 15 minutes delay in initiating CPR. LPN Staff B documented in an undated statement, At 0530 (5:30 a.m.) or 0540 (5:40 a.m.), A wing nurse (RN Staff A) came to me for help regarding (Resident #1's room). Walked back to A wing then we checked there was no pulse. We checked code status looked in the chart, there was no code form. Looked in computer, I went to get crash cart. CPR was started when I came to the room. On [DATE] at 2:04 p.m., in a telephone interview LPN Staff B said on [DATE] he was taking care of a resident on his unit when RN Staff A came to the door and asked him to come and help her. RN Staff A said it was the first time she had someone die. He went in the room and was not able to find a pulse. He went to get the crash cart. He called RN Staff C from another unit. They started CPR and called 911. He said he checked for the code status on the computer and the file. He could not find a DNR. Resident #1 was a full code. He ran to the cart to start CPR. The nurse on duty RN Staff A did not know what to do but he (LPN Staff B) knew what to do. RN Staff C and him did CPR until 911 came. Staff B did not know how long it took to initiate CPR. On [DATE] at 3:01 p.m., in an interview the Administrator stated based on her investigative findings, Resident #1 was found unresponsive on [DATE] at 5:19 a.m., and CPR was not initiated until [DATE] at 6:10 a.m. She said the findings were based on staff statements and watching the facility's surveillance video. RN Staff C documented in a statement dated [DATE], A wing nurse (RN Staff A) asked me for help around 0520 ish (approximately 5:20 a.m.) stating the patient in (Resident #1's room) was not breathing and had no pulse. I went to Unit and looked for DNR in chart and computer told her to start CPR because she's a full code. I then told her to ask (LPN Staff B) to double check with B wing nurse (LPN Staff B) because he had recently had a death, and he might be able to tell her better. She then went to B wing to ask B wing nurse for help. B wing nurse came to Unit started looking for DNR told him there was no DNR. I then went and checked the patient myself and noted there was no BP (Blood pressure) or pulse. At this point A wing nurse called the DON. DON said to initiate CPR and call 911 and therefore she did. On [DATE] at 3:09 p.m., in an interview CNA Staff E said he has been employed at the facility for less than three months and received orientation. He said the process when a resident is found unresponsive, without a pulse or respiration is to call the nurse. If he couldn't find the nurse, he would go and get the nurse from a different unit. If he couldn't find a nurse he would start CPR by himself. He said he would start CPR no matter what. He said he did not receive training at the facility but knew what to do from previous employment. On [DATE] at 3:15 p.m., CNA Staff F said if she found a resident without a pulse or respiration she would call the nurse. If she cannot find a nurse, she would call 911 first and then tell the nurse manager and they would call the resident's family. She said she would get the nurse manager's number from a book at the nurse's station of the unit. Staff F said they also have a book on the unit with all the yellow DNR forms. On [DATE] at 3:30 p.m., RN Staff G said if a resident is found unresponsive she would call for help, check the code status, and start CPR. When asked about the process to call for help to get assistance, she pulled her personal cellular phone and said she would use it to call someone. There's always someone around on the unit. She said she did not know about the facility's process to dial an established code from the phone to get assistance. She said, To be honest, I don't know. On [DATE] at 3:43 p.m., a mock code drill was observed. The Staff Educator dialed (four digit code) and announced Code Blue three times to room [ROOM NUMBER] B. Staff responded immediately to the room. The Staff Educator was observed coming from B wing nurse's station in the hallway with a green binder to room [ROOM NUMBER] B. From the hallway she yelled, Full code and went back down the hall with the binder. The nurse in the room kept saying, what is the code status? Someone please check the code status after the Staff Educator went back to nursing station, RN Staff G yelled Full code from outside room [ROOM NUMBER]. When asked how she determined the code status, she did not answer. On [DATE] at 4:15 p.m., the Staff Educator provided an evaluation of the code drill which noted, Stop once heard EMS (Emergency Medical Services) arrived. She said during the mock drill staff stopped CPR when they heard EMS had arrived. She explained to them CPR must continue until EMS takes over. On [DATE] at 4:58 p.m., in a telephone interview RN Staff C said on [DATE] he was busy taking care of one of his residents when RN Staff A came to ask for help. RN Staff C said his assigned resident was not in distress but he kept going back and forth between the two residents (his resident and Resident #1). He helped with CPR. RN Staff C said he has been employed at the facility for five months, he received training related to advance directives, including CPR, he knew what to do and was comfortable with the process. On [DATE] at 1:30 p.m., a review of the surveillance video provided by the Maintenance Director showed: On [DATE] at 5:19 a.m., RN Staff A entered Resident #1's room. On [DATE] at 5:20 a.m., RN Staff A came out of Resident #1's room. RN Staff A was seen putting gloves on and walk down the hallway. She walked back toward her medication cart, stopped and was seen looking in another room. On [DATE] at 5:22 a.m., RN Staff A stood at the medication cart for a few seconds then walked toward the nurse's station at the end of the hallway. On [DATE] at 5:23 a.m., RN Staff A and CNA Staff D entered Resident #1's room, followed by an unidentified staff member. On [DATE] at 5:24 a.m., RN Staff A came out of Resident #1's room and walked towards the nurse's station. On [DATE] at 5:25 a.m., RN Staff A walked down the hallway and went back in Resident #1's room. On [DATE] at 5:26 a.m., RN Staff A came out of Resident #1's room and walked down the hallway toward the nurse's station. On [DATE] at 5:27 a.m., RN Staff A and RN Staff C were at the nurse's station. They walked down the hall. RN Staff C entered Resident #1's room, while RN Staff A stood at the medication cart in the hallway across from Resident #1's room. On [DATE] at 5:28 a.m., RN Staff C walked out of Resident #1's room and stood at the medication cart with RN Staff A. RN Staff A was looking through a green binder. CNA Staff D was observed leaving Resident #1's room and walked down the hallway. On [DATE] at 5:28 a.m., CNA Staff D walked back in Resident #1's room. On [DATE] at 5:31 a.m., CNA Staff D walked out of Resident #1's room carrying linen and went down the hall. On [DATE] at 5:32 a.m., RN Staff A walked down the hallway toward the nurse's station. RN Staff C remained standing at the medication cart. On [DATE] at 5:33 a.m., RN Staff C walked in Resident #1's room. On [DATE] at 5:34 a.m., RN Staff A and LPN Staff B walked down the hallway to the medication cart. RN Staff A opened and was turning the pages of a binder with LPN Staff B standing next to her. On [DATE] at 5:35 a.m., RN Staff C walked out of Resident #1's room and stood at the medication cart with RN Staff A and LPN Staff B. LPN Staff B was turning the pages of a green binder. On [DATE] at 5:37 a.m., LPN Staff B walked into Resident #1's room. RN Staff A followed LPN Staff B into the room. RN Staff C remained at the medication cart. On [DATE] at 5:38 a.m., LPN Staff B, and RN Staff A walked out of Resident #1's room, and stood at the medication cart with RN Staff C. On [DATE] at 5:39 a.m., RN Staff A walked down the hallway to the nurse's station, then walked back to the medication cart. LPN Staff B was opening and turning the pages of a green binder. On [DATE] at 5:40 a.m., RN Staff C, and LPN Staff B walked down the hallway to the nurse's station. On [DATE] at 5:42 a.m., RN Staff A walked down the hallway to the nurse's station. On [DATE] at 5:43 a.m., RN Staff A walked back to the medication cart, retrieved a green binder, and walked back to the nurse's station. RN Staff A, LPN Staff B, and RN Staff C stood at the nurse's station. On [DATE] at 5:46 a.m., RN Staff A walked back to the medication cart. On [DATE] at 5:47 a.m., LPN Staff B walked to the medication cart. On [DATE] at 5:48 a.m., RN Staff C, LPN Staff B, and RN Staff A walked down the hallway to the nurse's station. On [DATE] at 5:50 a.m., RN Staff A walked down the hallway to the medication cart. On [DATE] at 5:52 a.m., RN Staff A walked back to the nurse's station. On [DATE] at 6:07 a.m., RN Staff A walked back to the medication cart. On [DATE] at 6:08 a.m., RN Staff A pushed the medication cart down the hallway toward the nurse's station. On [DATE] at 6:09 a.m., LPN Staff B pushed a red cart down the hallway towards Resident #1's room, RN Staff A followed LPN Staff B down the hall. On [DATE] at 6:10 a.m., LPN Staff B walked back to the nurse's station and RN Staff A entered Resident #1's room, followed by CNA Staff D. On [DATE] at 6:11 a.m., RN Staff C entered Resident #1's room. On [DATE] at 6:12 a.m., LPN Staff B entered Resident #1's room. Review of the Emergency Medical Services Patient Care Record dated [DATE] noted the call to EMS was received on [DATE] at 6:14 a.m. The EMS Patient Care record documented, Primary impression: Cardiac arrest; Secondary impression: Respiratory arrest. The narrative read, Patient is in cardiac arrest. Nursing home facility staff state that patient was last seen normal around 4:15 this morning. Facility staff stated that when they went to check on her at 5:45 she was found in cardiac arrest. According to facility staff, CPR was delayed until shortly before contacting 911 . Oral tracheal intubation was elected and attempted. While attempting to intubate patient, it was noted patient had rigor mortis (post-mortem stiffening of muscles) to her jaw. Attempt was abandoned and time of death called shortly after. deceased patient was left with NH (Nursing Home) facility RN that was on scene. No further treatment was provided. On [DATE] at 11:35 a.m., in an interview the Administrator said the nurse is supposed to discuss the code status with the resident upon admission but they do not document it anywhere in the record or on the Electronic Medical Record (EMR). She said the facility's management company does not allow it. She said it was clear in the video footage. The nurses can be seen checking the EMR, and the hard chart and they still did not administer CPR for 51 minutes. She said the standard of practice is, If there is no DNR they have to start CPR. The immediate actions implemented by the facility and verified by the survey team included: The facility reviewed policies and procedures: [DATE] for Advanced directives, DNRO policy and procedure, CPR, Code policy procedure. On [DATE] and [DATE] the surveyor verified through review of items discussed during QAPI on [DATE] to include a review of the policies and procedures related to Advanced Directives, DNRO and CPR, Code policy procedure. The facility immediately reviewed, audited all residents who are considered a full code [DATE]. On [DATE] the surveyor verified through review of the audit completed and comparison of the audit results with random residents chart reviewed. The facility immediately audited and reviewed for completion required onboarding and annual education for Advanced Directives, DNRO policy and procedure and CPR, Code policy and procedure for all staff. [DATE]. On [DATE] the surveyor verified through review of the audit completed, and annual education for Advanced Directives, DNRO policy and procedure and CPR, Code policy and procedure for all staff. Corrective actions for nurses involved includes immediate suspension pending investigation. On [DATE] the surveyor verified through telephone interview of all three nurses involved in the incident on [DATE]. Completed mock code drills on [DATE] at 3:00 p.m., with nine employees responding, [DATE] at 3:43 p.m., with 18 employees responding, [DATE] at 5:40 a.m., with eight employees responding, [DATE] at 11:12 a.m., with 16 employees responding, and 10:08 p.m., with eight employees responding. On [DATE], [DATE], [DATE] and [DATE] the surveyor verified through review of the mock drills completed with critique form. Completed competencies to staff on Code procedure [DATE], [DATE], [DATE]. On [DATE], [DATE] and [DATE] the surveyor verified through review of individual checklist of steps when a resident is found unresponsive and interview of six Licensed Nurses and six Certified Nursing Assistants. Reviewed the orientation and continuing education plan in place for all staff on Advanced Directives, DNRO policy and procedure, CPR, Code policy and procedure [DATE]. On [DATE] the surveyor verified through review of the orientation and education plan provided Ad Hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) completed on [DATE] at 10:30 a.m. Attended: Administrator, DON, Medical Director, Infection Preventionist/Staff Educator, Rehabilitation Director, Social Services Director, Social Services Coordinator, Nurse Managers (3), Life Enrichment Director. On [DATE] the surveyor verified through review of the sign-in sheet and items discussed in QAPI and formulation of a Performance Improvement Plan, and interview with the Administrator and the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility's policies and procedures review, and staff interview, the facility failed to ensure nursing staff had the appropriate competencies to immediately initiate lifesaving measures, including cardiopulmonary resuscitation (CPR) when residents with full code status experience cardiac or respiratory arrest. On [DATE] at 5:19 a.m., clinical staff found Resident #1 in cardiac and respiratory arrest. Three nursing staff on duty (two Registered Nurses and one Licensed Practical Nurse) delayed the initiation of CPR and the calling for Emergency Medical Services (EMS) for 51 minutes while they attempted to locate a non-existent Do Not Resuscitate Order. Resident #1 was pronounced deceased by EMS. The facility failure to ensure nursing staff were trained and competent in facility's policies related to advance directives, including CPR created a likelihood for residents identified as a full code being denied lifesaving emergency treatment to include CPR, intubation and defibrillation which can result in serious medical injury or death. This failure resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of pattern (K). On [DATE] at 11:28 a.m., the facility Administrator was notified of the determination of Immediate Jeopardy and provided the IJ templates. On [DATE], after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of [DATE]. The scope and severity were reduced to E no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference F578, F678, and F835. The Gulf Coast Village Facility Assessment revised on [DATE] and reviewed by the Quality Assessment and Quality Assurance and Performance Improvement committed on [DATE] noted, Staff training/education and competencies. On hire mandatory (online training) is completed prior to staff stating on the floor training. They also complete an on-site nursing orientation that includes competencies and scenarios. Clinical checklist are completed upon hire for direct care nursing staff during orientation . Annual skills fairs maintain staff competencies. Drills including . code blue . are facilitated on a schedule throughout the year . The facility's policy and procedure titled, CPR-Cardiopulmonary Resuscitation Policy with a reviewed date of 2/2022 noted, . Prompt initiation of CPR (cardiopulmonary resuscitation) is essential as brain death begins four to six minutes following cardiac arrest if CPR is not initiated within that time . Purpose. The facility shall provide basic life support, including CPR to a resident who requires such emergency care prior to the arrival of emergency medical services, consistent with the resident's advance directives and physician orders . Procedure . Identify code status/advance directive preferences by checking for a signed DNRO (Do Not Resuscitate Order) form in front of the chart . If no DNR order/advance directive exists or if advance directive does not indicate Do Not Resuscitate, begin resuscitation efforts . Review of the facility's incidents investigations revealed on [DATE] the facility initiated an investigation for a delay of initiating CPR for Resident #1. The investigation noted on [DATE] at 5:19 a.m., RN Staff A went into Resident #1's room to check the resident's blood sugar via fingerstick method. She found Resident #1 unresponsive. She checked for a pulse, no pulse present. She sent Certified Nursing Assistant (CNA) Staff D to get Licensed Practical Nurse (LPN) Staff B and RN Staff C to assist. They checked Resident #1's code status in the Electronic Medical Record (EMR), hard chart and DNR binder, did not see a yellow DNR in the medical record, EMR, or DNR binder. LPN Staff B went to get the crash cart and CPR was initiated at approximately 6:10 a.m. Emergency Medical Services (EMS) was called and arrived at 6:24 a.m. and pronounced Resident #1 deceased . On [DATE] at 12:33 p.m., in an interview the Registered Nurse (RN) Staff Educator said on [DATE] during morning meeting she found out about an incident with the process for CPR. From information gathered CPR was initiated late when Resident #1 was found without a pulse or respirations. She said the nurse on duty did not quite respond and couldn't figure out what to do when she did not find a yellow DNR (Do Not Resuscitate) paper. She said, she (RN Staff A) was looking for the DNR or Full Code or something like that. There was a communication process breakdown. The nurse went to the chart. She found there was no DNR. At this point she did not know what to do so she called the on-call Nurse Manager and she also called the DON. The Nurse Educator said the process when a resident is found unresponsive is for staff to dial (four digit code) from the telephone at the nurse's station to announce a code blue. It is not an overhead page. It will announce on the telephone at each nurse's station. The nurses and the Certified Nursing Assistants (CNAs) respond right away. They check the code status by looking in front of the resident's clinical record for a yellow DNR form. In the absence of a yellow DNR the resident is a full code and they initiate CPR. She said the code status can be checked by anyone, CNAs, nurses, managers from any department, including housekeeping and maintenance. If there is no yellow DNR from in front of the chart, the resident is a full code and staff initiates CPR. She said RN Staff A did not follow the process. The Staff Educator said since the incident, she started educating the staff about the process and conducted a code blue drill since the incident. She provided a sign-in sheet for a topic of, Code Blue Drill dated [DATE] at 3:00 p.m. The form was signed by three therapists, one receptionist, two Certified Nursing Assistants, one Registered Nurse and two Licensed Practical Nurses. The form did not describe the content of the drill, or an evaluation of the response to the drill. The Nurse Educator said she did not document the staff response to the drill but there were some areas for improvement, not everyone responded or signed the form. On [DATE] at 2:48 p.m., in a telephone interview the Director of Nursing said she has been employed at the facility for one year. The initial training for Advance Directives and Code status is done in general orientation. She said the licensed nurses all went to school and also have the CPR certification verifying they are competent. The facility tells them where to get the DNR information. The process for DNR is done by the Social Worker during orientation. She said she has not looked at the content of the training. Everything is kept by the facility's management company. She said the Regional Nurse Consultant conducts code blue drills periodically but she did not know how often they were done. When asked how she verified the competency of the nursing staff to respond appropriately when a resident is found unresponsive, the DON said she's had conversations with all the nurses to make sure they know what to do if a resident is found unresponsive but since it's not documented anywhere, so it didn't happen. Review of the employee file for Registered Nurse Staff A revealed a date of hire of [DATE]. Review of the training transcript showed on [DATE] Staff A completed one hour of online training on Do Not Resuscitate Orders and 30 minutes training on Essential of Resident Rights. A Basic Life Support certificate with an issue date of [DATE] and a renew by date of 3/2025 noted Staff A had successfully completed basic life support program. The employee file did not include a competency checklist for Registered Nurses. It included a competency checklist for Certified Nursing Assistant dated [DATE]. The competency/skills verification included the location of the crash cart and AED (Automated External Defibrillator). The checklist did not include a competency evaluation of Staff A's response in the event a resident is found unresponsive. On [DATE] at 2:18 p.m., in a telephone interview RN Staff A said the training she received during orientation included CPR and DNR but in her opinion, it wasn't extensive and was not very good. She said on [DATE] at approximately 5:30 a.m., she found Resident #1 unresponsive. She knew the first step was to find out is Resident #1 was a DNR. She went to D wing to get help from RN Staff C. They both looked in the chart and the computer but could not locate a DNR. They then went to B wing nurse to get help from LPN Staff B since he had more experience. They could not find a DNR. RN Staff A said she drew her own conclusion, called the resident's daughter, the Unit Manager on call and told them Resident #1 had expired. RN Staff A said she just got her nursing license. She said, they left three brand new nurses alone at night. She said she felt it was not safe, and the information provided was not clear enough. She needed to figure out for herself what to do. Review of the Florida Department of Health license verification website revealed RN Staff A's original license issue date was [DATE]. Review of the personnel file for LPN Staff B revealed a date of hire of [DATE]. Review of the training transcript showed on [DATE] Staff B completed one hour of online training on Do Not Resuscitate Orders and on [DATE] completed 30 minutes training on Essential of Resident Rights. A certificate of completion dated [DATE], noted Staff B successfully completed, and was certified in standard CPR/AED. The personnel file contained a Certified Nursing Assistant competency checklist dated [DATE]. The competency/skills verification included the location of the crash cart and AED (Automated External Defibrillator). The checklist did not include an evaluation of Staff B's response in the event a resident is found unresponsive. On [DATE] at 2:04 p.m., in a telephone interview LPN Staff B said on [DATE] he was taking care of one of his residents when RN Staff A came to the door and asked him to come out to help her. He said he went in Resident #1's room. She did not have a pulse. RN Staff A said she did not know what to do. He called RN Staff C from another unit. He checked for the code status in the computer and in the file. He did not find a DNR. She was a full code. That's why he ran to the cart to start CPR. LPN Staff B said he works at night. He had three or four days of training. He said he did not know what happens during the day but at night there has been no training or code blue drill. He knew where the crash cart was because he's seen it. Review of the personnel file for RN Staff C revealed a hire date of [DATE]. Review of the training transcript showed on [DATE] Staff C completed one hour of online training on Do Not Resuscitate Orders and 30 minutes training on Essential of Resident Rights. The RN competency checklist signed by the Registered Nurse Consultant on [DATE] was not signed by RN Staff C. A certificate of completion dated [DATE], noted Staff C successfully completed, and was certified in Basic Life Support. On [DATE] at 3:01 p.m., the Administrator said, The nurses are nurses, had CPR certification and passed board. She said they were all CPR certified and it was not the facility's responsibility to teach them CPR. The Administrator looked at the competency checklist for RN Staff A and said she thought it included what to do when a resident is found unresponsive. On [DATE] at 3:09 p.m., in an interview CNA Staff E said he has been employed at the facility for less than three months and received orientation. He said the process when a resident is found unresponsive, without a pulse or respiration is to call the nurse. If he couldn't find the nurse, he would go and get the nurse from a different unit. If he couldn't find a nurse he would start CPR by himself. He said he would start CPR no matter what. He said he did not receive training at the facility but knew what to do from previous employment. On [DATE] at 3:15 p.m., CNA Staff F said if she found a resident without a pulse or respiration she would call the nurse. If she cannot find a nurse, she would call 911 first and then tell the nurse manager and they would call the resident's family. She said she would get the nurse manager's number from a book at the nurse's station of the unit. Staff F said they also have a book on the unit with all the yellow DNR forms. On [DATE] at 3:30 p.m., RN Staff G said if a resident is found unresponsive she would call for help, check the code status, and start CPR. When asked about the process to call for help to get assistance, she pulled her personal cellular phone and said she would use it to call someone. There's always someone around on the unit. She said she did not know about the facility's process to dial an established code from the phone to get assistance. She said, To be honest, I don't know. On [DATE] at 3:43 p.m., a Code Blue drill was observed in room [ROOM NUMBER] B. The Staff Educator dialed (four digits code) and announced Code Blue three times to room [ROOM NUMBER] B. Staff responded immediately to the room. The Staff Educator was observed coming from B wing nurse's station in the hallway with a green binder to room [ROOM NUMBER] B. From the hallway she yelled, Full code and went back down the hall with the binder. The nurse in the room kept saying what is the code status, someone please check the code status after the staff educator went back to nursing station. RN Staff G yelled Full code from the hallway. When asked how she determined the code status, she did not answer. On [DATE] at 4:15 p.m., the Staff Educator provided an evaluation of the drill which noted, Stop once heard EMS arrived. The Staff Educator said during the mock drill staff stopped CPR when they heard EMS had arrived. She explained to them CPR must continue until EMS takes over. On [DATE] at 4:58 p.m., in a telephone interview RN Staff C said on [DATE] he was on duty when RN Staff A came to ask for help. He said he received training on CPR/DNR which included what to do when a resident is found unresponsive. He said he did not remember participating in any code blue drills. He said he was busy taking care of one of his resident and kept going back and forth between his resident and Resident #1. He said his assigned resident was not in distress but he kept going back and forth between the two residents. He helped with CPR. On [DATE] at approximately 7:30 a.m., in an interview Licensed Practical Nurse (LPN) Staff H said a long time ago they used to receive in-services related to CPR, DNR. She said, Now they just put a paper in front of you and tell you to sign it. They don't explain anything. She said there are a lot of new graduates working the night shift. They do not know what to do and are left without supervision. She said they eliminated the night shift supervisor. She told the DON they were endangering the residents' lives. On [DATE] at 10:22 a.m., in an interview the Manager on Duty verified she was on call on [DATE] when Resident #1 passed away. She said RN Staff A called her at 6:00 a.m. and told her Resident #1 had died. Staff A was upset, she was crying. She said it was the first time she experienced a death. She had to tell her to calm down and breathe. Staff A told her Resident #1 was a Full Code. She asked specifically if she initiated CPR and called EMS, Staff A said, Yes. She then directed her to call the DON. When she came to work later that day the DON informed her Staff A never started CPR. On [DATE] at 10:59 a.m., in a telephone interview the Regional Nurse Consultant said the last mock code was done in [DATE] but she did not have the documentation. The immediate actions implemented by the facility and verified by the survey team included: The facility reviewed policies and procedures: [DATE] for Advanced directives/DNRO policy and procedure, CPR/Code policy and procedure. On [DATE] the surveyor verified through review of documentation the policies and procedures were reviewed. The facility immediately reviewed/audited all resident who are a full code [DATE]. On [DATE] the surveyor verified through review of audits and compared with five random residents records for accuracy, residents #2, #3, #4, #5, #6. The facility immediately audited and reviewed for completion of the required onboarding and annual education for Advanced Directives/DNRO policy and procedure and CPR/Code policy and procedure for all staff. On [DATE] the surveyor verified through review of plan for onboarding and annual education. The facility immediately reviewed CPR certifications for all appropriate staff. [DATE]. On [DATE] the surveyor verified through review of a sample of five nurses and five CNAs for CPR certification. The facility immediately provided education: Advanced Directives/DNRO policy and procedure, CPR/ code policy and procedure. [DATE]. On [DATE] the surveyor verified by review of the education provided and interview of four nurses and four CNAs. Administrator educated Social Services Director on determining code status on admission within 48 hours. Admissions RN will assist with this process. On [DATE] the surveyor verified through review of education provided and verification of code status for five new residents admitted within 48 hours, and documentation in baseline care plan. Corrective actions for nurses involved included immediate suspension pending investigation. [DATE]. On [DATE] the surveyor verified through review of schedule and telephone interview with the three nurses involved. Completed mock code drills on [DATE] at 3:00 p.m. with nine employees responding, [DATE] at 3:43 p.m. with 18 employees responding, [DATE] at 5:40 a.m., with eight employees responding, [DATE] at 11:12 a.m. with 16 employees responding and 10:08 p.m. with eight employees responding. On [DATE] the surveyor verified through review of the documentation of the mock drills and documented response to the mock drills. Completed competencies to staff on Code procedure [DATE], [DATE], [DATE]. On [DATE] the surveyor verified through review of the signed individual step by step procedure when a resident is found unresponsive. On [DATE] five licensed nurses and five CNAs interviewed were able to describe the process to follow when a resident is found unresponsive. Reviewed the orientation and continuing education plan in place for all staff on Advanced Directives/DNRO policy and procedure, CPR/Code policy and procedure [DATE]. On [DATE] the surveyor verified through review of the education plan and policies and procedures. Systemic revision made to include Code Drills quarterly with debrief, feedback and plan, introduced a CPR checklist in clinical orientation. On [DATE] the surveyor verified through review of the mock code drills with debrief and review of the CPR checklist in clinical orientation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility's Administration failed to utilize its resources effectively by failing to ensure staff was adequately trained and knowledgeable in policies and procedures to honor residents' rights to advance directives, including the right to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. On [DATE] at 5:19 a.m., Resident #1 was found without pulse or respiration. The clinical staff on duty did not initiate CPR until 6:10 a.m., 51 minutes after Resident #1 was found unresponsive. Resident #1's wishes to be a full code and receive CPR was not documented in the baseline care plan, despite the Social Services Department being aware of the resident's full code status on [DATE]. Resident #1 was pronounced dead by Emergency Medical Services. The facility's failure to manage resources to ensure staff are aware of and honor a resident's expressed advance directives created a likelihood for residents to be identified as a full code being denied lifesaving emergency treatment to include CPR, intubation and defibrillation which can result in serious medical injury or death. This failure resulted in the determination of Immediate Jeopardy (IJ) as a scope and severity of pattern, (K). On [DATE] at 11:28 a.m., the Administrator was notified of the determination of Immediate Jeopardy and provided the IJ templates. On [DATE], after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of [DATE]. The scope and severity were reduced to E, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference F578, F678, and F726. The Administrator's job description signed by the Administrator on [DATE] noted the Administrator provides the management expertise for achieving the goals and objectives of the program in accordance with the mission of the organization. The Administrator should develop an organizational plan that clearly assigns responsibilities for the program's services to functional departments and to individuals. The Administrator should develop, recommend, and implement a plan for continuity that ensures ongoing stability of the program. Such a plan should include performance standards that are stated in terms of continuous improvement targets, opportunities for internal and external development, and a system for evaluating the performance levels of all employees, consultants, and other service providers. The Director of Nursing job description signed by the Director of Nursing on [DATE] noted the Director of Nursing is responsible for ensuring that an adequate level of services is provided to each resident, documented appropriately and regularly evaluated. Instruct staff on various federal, state and facility's regulations, policies and procedures; monitors compliance. Delivery of Nursing Services: Analyzes and evaluates nursing care and related ancillary and therapeutic services rendered to improve quality of patient care and to plan the best utilization of staff time and activities. Develops, monitors, and maintains required and appropriate documentation on the residents' medical records to include a multi-disciplinary plan of care. Review of the facility's incidents investigations revealed on [DATE] the facility Administrator initiated an investigation for a delay of initiating CPR for Resident #1. The investigation noted on [DATE] at 5:19 a.m., RN Staff A went into Resident #1's room to check the resident's blood sugar via fingerstick method. She found Resident #1 unresponsive. She checked for a pulse, no pulse present. She sent Certified Nursing Assistant (CNA) Staff D to get Licensed Practical Nurse (LPN) Staff B and RN Staff C to assist. They checked Resident #1's code status in the Electronic Medical Record (EMR), hard chart and DNR binder, did not see a yellow DNR in the medical record, EMR, or DNR binder. LPN Staff B went to get the crash cart and CPR was initiated at approximately 6:10 a.m. Emergency Medical Services (EMS) was called and arrived at 6:24 a.m. and pronounced Resident #1 deceased . On [DATE] at 3:48 p.m., the Administrator documented in the incident investigation, Determined that the licensed staff involved failed to honor resident's advanced directives as a full code in a timely manner . Conclusions: It is verified that the licensed staff involved delayed the provision of CPR. On [DATE] at 12:33 p.m., in an interview the Registered Nurse Staff Educator said on [DATE] during morning meeting she found out there was an incident with the process for CPR. From information gathered, CPR was initiated late. She said the nurse on duty did not quite respond and couldn't figure out what to do when she did not find a yellow DNR paper. She said, she (RN Staff A) was looking for the DNR or Full code or something like that. There was a communication process breakdown. The nurse went to the chart. She found there was no DNR. At this point she did not know what to do so she called the on-call Nurse Manager and also called the DON. She said when a resident is found unresponsive, staff dials (four digit code) from the telephone at the nurse's station to announce a code blue. It is not an overhead page. It will announce on the telephone at each nurse's station. The nurses and CNAs respond right away. They check the code status by looking in the front of the resident's clinical record for a yellow DNR form. In the absence of a yellow DNR the resident is a full code and they initiate CPR. The RN Staff Educator said the code status can be checked by anyone, CNAs, nurses, managers from any department, including housekeeping, and maintenance. She said the first thing you see is the yellow DNR form in front of the chart. If there is no yellow DNR, the resident is full code and staff initiates CPR. The Staff Educator said since the incident, she started educating the staff about the process and conducted a code blue drill since the incident. At this time, she provided a sign-in sheet for a topic of, Code Blue Drill dated [DATE] at 3:00 p.m. The form was signed by three therapists, one receptionist, two Certified Nursing Assistants, one Registered Nurse and two Licensed Practical Nurses. The form did not describe the content of the drill, or an evaluation of the response to the drill. The RN Staff Educator said she did not document the staff response to the drill but there were some areas for improvement, not everyone responded or signed the form. On [DATE] at 2:48 p.m., in a telephone interview the Director of Nursing said she has been employed at the facility for one year. The initial training for Advance Directives and Code status is done in general orientation. She said the licensed nurses all went to school and also have the CPR certification verifying they are competent. The facility tells them where to get the DNR information. The process for DNR is done by the Social Worker during orientation. She said she has not looked at the content of the training. Everything is kept by VOA (Volunteers of America). She said the Regional Nurse Consultant conducts code blue drills periodically but she did not know how often they were done. When asked how she verified the competency of the nursing staff to respond appropriately when a resident is found unresponsive, the DON said she's had conversations with all the nurses to make sure they know what to do if a resident is found unresponsive but since it's not documented anywhere, so it didn't happen. On [DATE] at 3:01 p.m., the Administrator said, The nurses are nurses, had CPR certification and passed board. She said they were all CPR certified and it was not the facility's responsibility to teach them CPR. On [DATE] at 3:43 p.m., a code blue drill was observed in room [ROOM NUMBER] B. The Staff Educator dialed (four digits code) and announced Code Blue three times to room [ROOM NUMBER] B. Staff responded immediately to the room. The Staff Educator was observed coming from B wing nurse's station in the hallway with a green binder to room [ROOM NUMBER] B. From the hallway she yelled, Full code and went back down the hall with the binder. The nurse in the room kept saying what is the code status, someone please check the code status after the staff educator went back to nursing station. RN Staff G yelled Full code from the hallway. When asked how she determined the code status, she did not answer. The Staff Educator provided an evaluation of the drill which noted, Stop once heard EMS (Emergency Medical Services) arrived. On [DATE] at 4:15 p.m., the Staff Educator said during the mock drill staff stopped CPR when they heard EMS had arrived. She explained to them CPR must continue until EMS takes over. The Gulf Coast Village Facility Assessment revised on [DATE] and reviewed by the Quality Assessment and Quality Assurance and Performance Improvement committed on [DATE] noted, Staff training/education and competencies. On hire mandatory (online training) is completed prior to staff stating on the floor training. They also complete an on-site nursing orientation that includes competencies and scenarios. Clinical checklist are completed upon hire for direct care nursing staff during orientation . Annual skills fairs maintain staff competencies. Drills including . code blue . are facilitated on a schedule throughout the year . On [DATE] at 10:59 a.m., in a telephone interview the Regional Nurse Consultant said the last mock code drill was done in [DATE] but she did not have the documentation. The Registered Nurse Consultant said they do not use the term Code Blue when a resident is found unresponsive, staff has to call for help. She said last March she remember conducting some mock code drills when the facility had an interim Director of Nursing. They covered all shifts on all units. She said they went through two other staff educators and did not know where the documentation of the mock drills went. On [DATE], review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease with acute exacerbation, and generalized muscle weakness. The physician's orders as of [DATE] did not include a code status. The care plan initiated on [DATE] did not include a code status. On [DATE] the physician documented in a progress note, Advanced Directives: Full code. Full code means if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR. On [DATE] at 10:22 a.m., in an interview the Staff Social Worker verified Resident #1's advance directives and code status were not documented in the baseline care plan. She said Resident #1 was admitted on a Friday. No one from the Social Service department work on weekends therefore she did not meet with Resident #1 until [DATE], three days after admission. Upon request for documentation of Resident #1's advance directives discussion, the Social Worker said the documentation was on a paper form kept in her office. She brought back a paper copy of section C of the Minimum Data Set Assessment with the word Full circled which she said meant full code and No AD which she said meant no advance directives. She verified the information of Resident #1's code status was not documented in the baseline care plan and not available to staff on [DATE] when Resident #1 was found unresponsive. On [DATE] at 11:35 a.m., in an interview the Administrator said the nurse is supposed to discuss the code status on admission with the resident but they do not document it anywhere in the clinical record or the electronic record. She said in the surveillance video, you can see the nurses checking the electronic record, the hard chart and they still did not administer CPR to Resident #1 for 51 minutes. The immediate actions implemented by the facility and verified by the survey team included: The facility reviewed policies and procedures for Advanced directives/DNRO policy and procedure, CPR/Code policy and procedure. On [DATE] the surveyor verified through review of documentation of facility's policies and procedures review. Administrator and DON educated by Clinical consultant on Advanced Directive/DNRO policy and procedure, CPR/Code policy and procedure [DATE]. On [DATE] the surveyor verified through review of education provided and interview with the Administrator and the DON during a review of Quality Assurance and Performance Improvement process. The facility immediately reviewed/audited all residents who are considered a full code. [DATE]. On [DATE] the surveyor verified through review of the audits completed. The facility immediately audited and reviewed for completion required onboarding and annual education for Advanced Directives/DNRO policy and procedure and CPR/Code policy and procedure for all staff. [DATE]. On [DATE] the surveyor verified through review of the facility's audits of completion of onboarding and annual education for advance directives, DNRO policy and procedure and CPR/Code policy and procedure for all staff. The facility immediately reviewed CPR certifications for all appropriate staff [DATE]. On [DATE] the surveyor verified through review of CPR certification provided for licensed nurses and CNAs. The facility immediately provided education: Advanced Directives/DNRO policy and procedure, CPR/Code Policy and procedure. [DATE]. On [DATE] the surveyor verified through review of education provided for five licensed nurses and five CNAs. Corrective actions for nurses involved included immediate suspension pending investigation [DATE]. On [DATE] the surveyor verified through review of the staffing schedule, and on [DATE] by telephone interview with the three nurses involved. Completed mock code drills on [DATE] at 3:00 p.m. with nine employees responding, [DATE] at 3:43 p.m. with 18 employees responding, [DATE] at 5:40 a.m., with eight employees responding, [DATE] at 11:12 a.m. with 16 employees responding and 10:08 p.m. with eight employees responding. On [DATE] the surveyor verified through review of the documentation of the mock drills and documented response to the mock drills. Completed competencies to staff on Code procedure [DATE], [DATE], [DATE]. On [DATE] the surveyor verified through review of the signed individual step by step procedure when a resident is found unresponsive. On [DATE] five licensed nurses and five CNAs interviewed were able to describe the process to follow when a resident is found unresponsive. Reviewed the orientation and continuing education plan in place for all staff on Advanced Directives/DNRO policy and procedure, CPR/Cod policy and procedure [DATE]. On [DATE] the surveyor verified through review of the education plan and policies and procedures. Ad Hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) completed on [DATE]. On [DATE] the surveyor verified through review of the Ad Hoc QAPI meeting and attendance sign in sheet. On [DATE] the surveyor verified through interview with the Administrator, DON and telephone interview with the Medical Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide the necessary care and services to prevent the development and promote healing of advanced stage pressure ulcers for 3 of 11 sampled residents (Resident #55, #27, and #74) identified at risk for pressure ulcer development. Resident #55 was admitted on [DATE] with a stage 3 (full thickness tissue loss) pressure ulcer to the coccyx and was dependent on staff for all activities of daily living. The facility neglected to complete a thorough skin assessment upon admission. The pressure ulcer was not identified until 11/4/22 and the physician's orders dated 11/4/22 were not implemented until 11/7/22. The facility also failed to assess, obtain orders, and treat an additional in-house acquired pressure ulcer to the right inner knee identified on 11/8/22 and not treated until 11/15/22 for Resident #55. Resident #27 was readmitted to the facility on [DATE] after a surgical repair of a right hip fracture and was dependent on staff for repositioning. The facility neglected to consistently implement preventive measures to prevent the development of an avoidable advanced stage pressure ulcer. On 11/4/22, the facility identified an infected pressure ulcer of the right heel. On 11/9/22, the wound care physician diagnosed an unstageable (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) right heel pressure ulcer with 100% thick necrotic (dead) tissue. The facility neglected to consistently implement the daily wound care and offload the area to promote healing. On 11/16/22, the wound care physician documented the wound had deteriorated. Resident #74 admitted on [DATE] and was at moderate risk for development of pressure ulcers and was dependent on staff for turning and repositioning. The facility failed to consistently offload the resident's heels, turn, and reposition the dependent resident. On 9/14/22 Resident #74 developed an avoidable unstageable pressure ulcer of the right heel requiring surgical debridement. The facility failed to consistently apply the physician's ordered treatment and protective dressing to promote the healing of the in-house acquired advanced stage pressure ulcer. Resident #55, #27 and #74 suffered serious harm from the development and/or worsening of pressure ulcers. The facility's failure to provide the necessary care and services to prevent the development and worsening of pressure ulcers resulted in a determination of Immediate Jeopardy at a scope and severity of isolated (J). The Administrator was notified of the determination of Immediate Jeopardy on 11/17/22 at 1:17 p.m. The findings included: Cross reference to F686, F835 and F867. The facility's policy and procedure titled, Abuse, Neglect, Mistreatment And Misappropriation Of Resident Property with a date revised of 9/2019 noted, An .employee . of a nursing home shall not .mistreat or neglect a resident . Mistreatment means inappropriate treatment or exploitation of a resident . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility's Policy and Procedure for the Prevention and Treatment of Skin Breakdown reviewed 10/2021 specified, It is the policy . to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care . Nursing: Monitoring of skin integrity. Upon admission, all new residents will have the following orders in place: [brand name] No Sting Barrier Film liquid to bilateral heels every 3 days for 14 days. Offload bilateral heels while in bed. Air mattress for any resident with a Braden Scale of 14 or less . Nutrition. The Dietitian will be notified: If a resident is considered nutritionally at risk, upon the discovery of a wound, when a wound declined unexpectedly. 1. Review of the clinical record revealed Resident #27 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including a displaced right hip fracture and dementia. On 9/25/22 Resident #27 sustained a fall at the facility and was transferred to an acute care hospital for increased right hip pain. Resident #27 returned to the facility on [DATE] with a diagnosis of displaced fracture of the right femur. The Nursing Data Collection-Admission/Readmission form with an effective date of 10/3/22 noted the resident was at risk for skin breakdown. She was not able to reposition herself while lying in bed, or when sitting in a chair or wheelchair. Staff was to assist as needed with the repositioning. The Braden Scale (gold standard tool used for identifying pressure ulcer risk) completed on 10/3/22 by a Licensed Practical Nurse (LPN) noted a score of 14 indicative of moderate risk for pressure ulcer. The Significant Change in Status MDS (Minimum Data Set) assessment with a target date of 10/6/22 noted Resident #27 has severe cognitive impairment. The resident required extensive physical assistance of staff for bed mobility and transfer. The Care Area Assessment noted the resident triggered for pressure ulcer and it was addressed in the care plan. The MDS did not include a turning and repositioning program as part of preventive measures. The physician's orders dated 10/3/22 included an air mattress to the bed for pressure ulcer prevention. Review of the Medication Administration Record (MAR) for October 2022 showed documentation the air mattress was applied on 10/3/22 and discontinued on 10/11/22. The clinical record did not include a rationale for discontinuing the air mattress. The MARs for October 2022 and November 2022 did not contain documentation the No Sting Barrier Film Liquid was applied to the resident's bilateral heels every three days for 14 days as per facility policy. On 11/9/22 at 7:09 p.m., the Director of Nursing (DON) said she did not know why the mattress was discontinued and it shouldn't have been. The DON also verified the facility failed to implement their policy and procedure and did not obtain an order for the No Sting Barrier Film liquid to be applied to the resident's bilateral heels every three days for 14 days. The Certified Nursing Assistant (CNA) tasks list for October 2022 and November 2022 had instructions for a turning and repositioning program and encourage the resident to float heels while in bed each shift. On 10/7/22, 10/10/22, 10/22/22, 10/24/22, 10/28/22, 10/30/22 and 11/4/22 the turning and repositioning and encouraging the resident to float heels while in bed were noted as completed only once in a 24-hour period. On 11/4/22 Licensed Practical Nurse (LPN) Staff R documented on a nursing weekly skin check Resident #27 had a right heel pressure area, Open blistered area. has odor. On 11/4/22 the physician issued an order for Doxycycline Hyclate 100 milligrams (antibiotic) two times a day for infection of the right heel ulcer. He also ordered to use podus boots (helps in prevention and healing of heel ulcers) to offload heels while in bed. On 11/9/22 from 12:00 p.m. to 2:09 p.m., during multiple random observations, Resident #27 was observed in her room in a wheelchair wearing nonskid socks. Her heels were not offloaded and were pressing into the hard plastic footrests of the wheelchair. Resident #27 was not able to move her right leg upon command. On 11/9/22 at 2:12 p.m., LPN Staff FF said there was no measure to offload Resident #27's heels when she was out of bed. She verified the resident's heels were not offloaded and pressing into the hard plastic footrests of the wheelchair. She said, I questioned it this morning. Her heels are pressing on the footrests. She said not offloading the resident's heels in the wheelchair was a problem. On 11/9/22 at 2:36 p.m., the nurse obtained a physician's order to apply podus (offloading) boots to Resident #27's heels while in bed and out of bed. On 11/9/22 at 3:05 p.m., observation of Resident #27's right heel with the wound care physician revealed an advanced stage black, necrotic ulcer with moderate amount of drainage. The wound care physician said a resident with a broken hip, and immobile is at risk for developing a pressure ulcer. He said they should offload the heels in bed and out of bed. He said they cannot move, and they are in pain. They cannot rotate the leg. They may develop a pressure ulcer on the heel, ankle, lateral heel. They should have an orthotic device (device designed to protect an existing limb) in place in the wheelchair. The wound care physician said sometimes they develop a pressure ulcer despite all interventions, but you don't know until you try all interventions. On 11/9/22 the wound care physician documented in a progress note Resident #27 had an unstageable (due to necrosis) pressure ulcer of the right heel, full thickness of duration greater than 10 days with moderate serous exudate and thick adherent devitalized necrotic tissue covering 100% of the wound. The physician performed a surgical excisional debridement (removal of dead tissue to promote wound healing) of the right heel. The recommendations included to offload wound. Reposition per facility protocol. Turn side to side and front to back in bed every 1-2 hours if able. On 11/9/22 at 7:09 p.m., the DON said she completed an investigation when Resident #27 developed the pressure ulcer. She said after looking at all the documentation, she concluded the pressure ulcer was avoidable. She said she did not consider it neglect since at the beginning, Resident #27 had all the interventions in place. She said the facility was using a lot of agency nurses and she had not educated them. She said she didn't know if all nurses were educated on pressure ulcer preventive measures. The DON said she did not look into why the air mattress was discontinued or why preventive measures, including applying the No Sting Barrier Film liquid were not implemented. On 11/14/22 at 9:30 a.m., Resident #27 was observed on her back in bed. She was not wearing the offloading boots and her heels were pressing onto a folded sheet placed on the air mattress. On 11/14/22 at 9:35 a.m., CNA HH said she was from a staffing agency and was assigned to care for Resident #27. She said she came on duty at 7:00 a.m. but has not had time to make rounds and see her assigned residents. She said she has not received any orientation before starting to work at the facility. She did not know where to get the information to safely care for the residents. She did not know what preventive measures needed to be in place for Resident #27. On 11/14/22 at 9:40 a.m., Registered Nurse (RN) Staff CC said she was assigned to care for Resident #27. She verified the resident has a pressure ulcer to the right heel. She said she normally gives report to the CNAs when they come in, but she has not given report to CNA BB assigned to Resident #27 and offered no explanation. She said the resident should have a pillow between her legs, so they don't touch the mattress, be careful so we won't bump her legs to anything, turn every 2 hours in bed. After looking at the Medication Administration Record (MAR) RN Staff CC said Resident #27 was supposed to wear offloading boots in and out of the bed. On 11/14/22 at 9:45 a.m., RN Staff CC verified Resident #27 was not wearing the offloading boots as ordered and said she didn't know why. On 11/14/22 at 12:00 p.m., Resident #27 remained on her back in bed. Observation of the dressing change with RN Staff CC revealed a dressing to the resident's right heel with a date of 11/11/22. The dressing bore RN Staff CC's initials. She said the dressing was the one she applied to the resident's right heel on 11/11/22. The soiled dressing was saturated with a large amount of malodorous bloody drainage. Review of the MAR for November 2022 showed RN Staff DD signed on 11/12/22 and 11/13/22 he performed the wound care as ordered to the resident's right heel. On 11/14/22 at 2:40 p.m., the Director of Nursing (DON) said, It's a huge issue if you are signing for things you didn't do, it's neglect. On 11/14/22 at 3:15 p.m., RN Staff DD said in a telephone interview he may have made a mistake signing he completed the treatment on 11/12/22 and 11/13/22. He said he was only human and had a lot of work to do. On 11/16/22 at 4:20 p.m., the wound care physician said Resident #27's pressure ulcer was probably avoidable. On 11/16/22 the wound care physician wrote deteriorated on the wound progress section for the unstageable full thickness right heel pressure ulcer. Review of the Nursing Homes Federal Reporting website revealed on 11/15/22 the facility submitted an Immediate Report to the State Survey Agency for an allegation of neglect. The report read, It was noted by the floor nurse (name) RN during her rounds on 11/14/22 that the resident [Resident #27] had a dressing on her wound that was dated 11/11/22. This resident had treatment orders for daily dressing changes. Therefore, it was determined that the treatment was not completed for 2 days. However, the treatment was signed off as completed on the treatment record by nurse [RN Staff DD] on 11/12/22 and 11/13/22, although it was not completed. Review of the physician's orders for October 2022 revealed to administer a house shake to Resident #27 three times a day for nutritional supplement as of 10/27/2022 and a [brand name for frozen nutritional supplement] two times a day for impaired appetite. On 11/9/22 at 2:50 p.m., the Registered Dietitian said the nursing staff was supposed to document the percent of the supplement consumed. She said she looks in the clinical record to check if the resident is taking the supplement or not. She also asks the nurse if the resident is taking the supplements. She said the facility only notified her today (11/9/22) of Resident #27's pressure ulcer. Review of the MAR from 11/1/22 through 11/8/22 revealed the licensed nurses placed a check mark on the MAR next to the house shake three times a day and the frozen nutritional supplement two times a day. On 11/11/22, RN Staff CC documented Resident #27 consumed 100% of the house shake at 9:00 a.m. and 5:00 p.m., and 50% of the house shake at 1:00 p.m. On 11/14/22 RN Staff CC documented Resident #27 consumed 100% of the house shake at 9:00 a.m. On 11/14/22 at 9:35 a.m., Resident #27's breakfast tray was observed and did not contain a house shake. On 11/14/22 at 12:15 p.m., Resident #27's lunch tray was observed and did not include a frozen nutritional supplement. On 11/14/22 at 12:20 p.m., RN Staff CC verified she documented the amount of supplement Resident #27 consumed on 11/11/22 and 11/14/22 at 9:00 a.m. She said the supplements come on the resident's meal trays. She said she documented the percentage consumed based on what the CNA reported but did not personally see the resident taking the supplements. On 11/14/22 at 12:50 p.m., the Certified Dietary Manager (CDM) provided a list of residents who received supplements on their meal trays. Resident #27 was not included in the list. She said the dietary department did not provide any supplement to Resident #27. On 11/14/22 at 1:05 p.m., Agency CNA EE said the resident did not receive any supplement with her breakfast or lunch meal. RN Staff CC present during the interview said it was a problem and she'll let the DON know about it. On 11/15/22 at 10:15 a.m., the Registered Dietitian (RD) said she needed an accurate report of the resident's meals and supplement intake for her assessments. She said it's been a struggle to obtain the wound report to implement adequate nutritional interventions for residents with pressure ulcers. She said she emailed her concerns to the administrative staff on 10/11/22. The RD provided a copy of an email dated 10/11/22 at 3:15 p.m., addressed to the Administrator, the DON and the CDM that read, Just wanted to let you know I have not received a wound report for several weeks. I am concerned that there may be pressure injuries that have not been addressed. She said the very next day she got a wound report but the next one she received was on 11/9/22. 2. Clinical record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including difficulty walking, muscle weakness and Parkinson's disease (disorder of the central nervous system affecting movement). The MAR for 10/1/22 through 10/13/22 noted Resident #55 had a stage 2 (partial thickness loss of tissue) pressure ulcer to the buttocks. Resident #55 was discharged to an acute care hospital on [DATE] and returned to the facility on [DATE]. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Agency for Health Care Administration form 3008) signed and dated 10/24/22 by a physician, revealed a skin assessment noting Resident #55 had a stage 3 (full thickness tissue loss) pressure injury to the buttock and a stage 1 (pressure related alteration of intact skin) pressure injury to the right buttock. The facility's Nursing Data Collection-Admission/readmission Day dated 10/25/22 did not identify the presence of the existing pressure ulcer to the buttocks or the coccyx (tailbone). The form noted Resident #55 was Alert. Confused/Dementia/Alzheimer's. The resident was not able to reposition self while lying in bed or sitting. On 11/2/22, the Nursing Weekly Skin Check completed by a Registered Nurse (RN) noted Resident #55 had a pressure ulcer to the coccyx. The nurse answered No to the question Is this a new skin injury?. The clinical record lacked documentation of treatment to the existing pressure ulcer. On 11/4/22, RN Staff DD completed a skin check and documented a stage 2 (shallow open ulcer with a red, pink wound bed without dead tissue) pressure ulcer to the left, and right gluteal (buttock) fold. On 11/4/22, the wound care physician assessed and documented in a progress note Resident #55 had an unstageable (due to necrosis) pressure ulcer to the coccyx measuring 4.5 centimeters (cm) length by 3.7 cm width with moderate amount of serous exudate. The physician documented performing a surgical excisional debridement (removal of dead tissue) to establish the margins of viable tissue. The physician issued an order to cleanse the coccyx wound, pat dry, apply Santyl (ointment to remove dead tissue), apply Alginate Calcium sheet (used on wounds with moderate to heavy drainage) and cover with boarded gauze dressing daily. There was no documentation the Santyl was applied to the wound as ordered until 11/7/22. The ordered dressing with Alginate Calcium sheet and boarded gauze dressing was not documented as implemented until 11/8/22. Review of the Nursing Homes Federal Reporting website revealed on 11/10/22 the facility submitted a report to the State Survey Agency substantiating the allegation of neglect. The report read, Resident has an unstageable wound that went untreated for multiple days and therefore was at risk for potential decline. The report indicated the resident had a stage 3 pressure ulcer on his coccyx that was identified on the hospital documents upon readmission (on 10/25/22) but not documented by facility staff until 11/2/22. Resident was seen by the wound physician on 11/2/22 but treatment orders were not entered or initiated until 11/7/22. On 11/14/22 at 10:45 a.m., Resident #55 was observed in bed, on his back on an air mattress. A soiled dressing dated 11/11/22 was observed to the resident's right inner knee. On 11/14/22 at 10:55 a.m., observation of the resident's right inner knee with RN Staff CC revealed a stage 2 pressure ulcer with copious amount of greenish/brownish malodorous exudate. RN Staff CC said Resident #55 acquired the pressure ulcer to the right inner knee due to the resident's knees pressing against each other. She said there was no treatment order in place for the pressure ulcer to the right inner knee. On 11/14/22 at 5:15 p.m., the Director of Nursing (DON) presented the survey team with a single sheet of paper titled Skin check audit dated 11/8/22 handwritten by an LPN which noted Resident #55 had an abrasion to the right knee. She said she could not find documentation the physician was notified of the new pressure ulcer to obtain treatment orders. There was no documentation of an RN assessment to the new impaired skin integrity noted by the LPN on 11/8/22. On 11/16/22 at 4:20 p.m., the wound care physician said he had just assessed the resident's pressure ulcer to the coccyx. He said no one told him Resident #55 had an open area to the right inner knee. The wound care nurse, LPN Staff R, present during the interview said, I knew about it, but I didn't tell him (the wound care physician) because it's just an abrasion. On 11/16/22 at 4:30 p.m., the wound care physician assessed and diagnosed Resident #55 with a stage 2 pressure ulcer to the right inner knee with redness to the surrounding area. On 11/16/22 the wound care physician wrote on a progress note Resident #55 had a stage 2 partial thickness pressure wound of the right medial knee. The objective was healing. 3. Review of the clinical record revealed Resident #74 was admitted on [DATE] with diagnoses including chronic kidney disease, dementia with behaviors, anxiety, and hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #74 required extensive assistance of one person for bed mobility, transfers, and toileting. The MDS documented Resident #74 was at risk for pressure ulcer and had no pressure ulcers at the time the assessment was completed. Resident #74 had a Brief Interview for Mental Status score of 4 indicating severe cognitive impairment. The Braden Scale for predicting pressure sore dated 9/17/22 documented the risk score was 14, indicating Resident #74 was at moderate risk for developing a pressure wound. A review of Resident #74's clinical record revealed a care plan initiated on 9/7/22 identifying Resident #74 had skin concerns on both heels. The care plan interventions included to offload heels to decrease pressure. On 9/14/22, the Nurses Weekly Wound Documentation completed by the DON identified Resident #74 had a new onset, in-house acquired, stage 2 pressure wound to the right heel measuring 2.0 centimeters (cm) length by 2.0 cm width with 0.2 cm depth, with small amount of serosanguineous exudate. On 10/5/22 the wound care physician assessed and documented in a progress note Resident #74 had an unstageable (due to necrosis) pressure ulcer to the right heel measuring 2.3 centimeters (cm) length by 1.5 cm width with moderate amount of serous exudate. The physician documented performing a surgical excisional debridement (removal of dead tissue) to establish the margins of viable tissue. The wound care physician specified to offload pressure to the heels. The record showed a physician order dated 11/3/22 to cleanse right heel with Dakin's solution (antiseptic) ¼ strength wet to moist packing, apply border gauze dressing once daily for 16 days. On 11/14/22 at 8:30 a.m., Resident #74 was observed in a wheelchair with grip socks. Her feet and heels were planted firmly on the floor and not offloaded to reduce pressure. There was no dressing noted on the right foot. Licensed Practical Nurse (LPN) Staff AA said she had not completed the scheduled wound care but would do it later in the day. On 11/14/22 at 12:30 p.m., the wound on Resident #74's heel was observed with LPN Staff AA. There was no dressing observed on the right heel to cover the resident's wound, exposing the wound to lint from the sock. LPN Staff AA said she had not removed any dressings from the resident's right foot. LPN Staff AA said she had not completed wound care yet. She said it was just Dakin's solution to the right heel, no dressing was required, the order was to just apply the solution to the wound. A heel protector was noted on the left foot, and there was none on the right foot. On 11/14/22 at 2:45 p.m., the Director of Nursing (DON) said she was ultimately responsible to make sure the wound care was carried out as ordered by the physician. On 11/15/22 at 8:30 a.m., Resident #74 was observed seated in a wheelchair in the activity room. Her feet were firmly planted on the floor, she had grip socks on, and her heels were not offloaded to decrease pressure. LPN Staff Q confirmed the resident's heels were not offloaded and there was no dressing covering Resident #74's right heel wound. Review of the Medication Administration Record for November 2022 revealed the wound care with the Dakin's Solution was not provided as ordered on 11/4/22, 11/7/22, 11/12/22, and 11/13/22. The reason provided was Dakin's Solution on order. On 11/15/22 at 9:00 a.m., LPN Staff Q said the Dakin's Solution was in the medication cart and retrieved it form the cart. LPN Staff Q said the pharmacy filled the Dakin's Solution on 11/7/22, the date written on the label. On 11/15/22 at 9:45 a.m., the DON said the process for wound care when an ordered treatment was not available, was the nurse was responsible to contact the physician and obtain an order for a different dressing or wound care. The DON said she was aware the Dakin's Solution was delivered by the pharmacy on 11/7/22 and was available but did not know why the nurse had documented the solution was unavailable. The DON confirmed Resident #74 did not receive the physician ordered wound care on 11/4/22, 11/7/22, 11/12/22, and 11/13/22 and said there was no documentation the physician was notified the wound care was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the facility Policy and Procedure for the Prevention and Treatment of Skin Breakdown, reviewed 10/2021 noted, It is the policy of Volunteers of America to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures and to provide appropriate treatment modalities for wounds according to industry standards of care. Review of the Significant Change Minimum Data Set (MDS) for Resident #72 with an assessment reference date of 8/21/22 revealed Resident #72 was at risk for developing pressure ulcers but did not have any unhealed pressure ulcers. Review of the Nursing Weekly Skin Checks dated 8/17/22, 8/24/22 and 8/31/22 indicated Resident #72 did not have any pressure ulcers to the coccyx area. Review of the Nursing Weekly Skin Checks dated 10/7/22 and 10/14/22 revealed Resident #72 had blanchable redness to the coccyx indicating no skin damage. Review of the Nursing Weekly Skin Check dated 10/21/22 revealed Resident #72 had a new (single) blister to the left gluteal fold described as a Purple/maroon area/blood blister. Review of the October 2022 Medication Administration Record (MAR) indicated a new treatment for barrier film to Resident #72's right and left gluteal fold daily, twice a day for blanchable redness starting on 10/21/22. Review of the Nursing Weekly Skin Check dated 10/28/22 revealed Resident #72 had two blisters, one to the right gluteal fold, and one to the left gluteal fold, Review of the Nursing Weekly Skin Check dated 11/4/22 revealed Resident #72 had blisters to bilateral buttocks. Review of the Initial Wound Evaluation and Management Summary dated 11/4/22 revealed Resident #72 was assessed by the wound care physician and had a (single) stage 2 pressure wound to the coccyx for at least 14 days. The new treatment plan for Resident #72 included collagen sheet (supports wound healing) apply once daily for 30 days; Alginate Calcium - apply once daily for 30 days; foam silicone border - apply once daily for 30 days. The Initial Wound Evaluation and Management Summary did not indicate Resident #72's pressure ulcer was unavoidable. Review of Resident #72's MARs from 11/4/22 through 11/9/22 did not include the new treatment of collagen sheets, Alginate Calcium, and foam silicone border prescribed by the wound care physician on 11/4/22. On 11/7/22 at 11:15 a.m., during an observation, Resident #72 was in her room, lying in bed on her back, yelling out, My butt hurts and I don't know what to do about it. On 11/7/22 at 11:18 a.m., Resident #72 yelled out, My butt is on fire. These complaints by Resident #72 were loud and could be heard in the hall. On 11/7/22 at 11:20 a.m., Licensed Practical Nurse (LPN) Staff Q entered Resident #72's room. On 11/7/22 at 11:23 a.m., Staff Q exited Resident #72's room and said she gave Resident #72 a pain medication and positioned her on her right side. On 11/7/22 at 11:25 a.m., Resident #72 was observed in bed, lying on her back. On 11/7/22 at 11:39 a.m., Resident #72 yelled, Help I want to move, but I can't move. On 11/7/22 at 11:41 a.m., Staff Q offered Resident #72 a drink of water. On 11/7/22 at 11:43 a.m., Resident #72 yelled, My butt is on fire. On 11/7/22 at 8:51 p.m., during a telephone interview, Resident #72's son said he was visiting his mother at the facility on Sunday, and she complained to him about her butt hurting. He said his brother told him she said it feels like her butt is on fire. On 11/8/22 at 8:11 a.m., observed Resident #72 in her room, in bed lying flat on her back. There were no pressure relieving pillows or devices on Resident #72's bed to relieve pressure on the coccyx. On 11/8/22 at 9:22 a.m., an observation of Resident #72's coccyx revealed a palm-size, purple-pink area of intact skin above the gluteal (buttocks) folds. Within this purple- pink area, there were two dime-size, open ulcers with red-pink wound beds. Staff Q applied barrier film swabs to the open ulcers. Resident #72 moaned during the application of the barrier film, and said the area was painful. On 11/8/22 at 9:42 a.m., Certified Nursing Assistant (CNA) BB said Resident #72 complains her butt is on fire when she cleans her. On 11/9/22 at 10:30 a.m., the Director of Nursing (DON) said the barrier film was part of the facility's wound care protocol for stage 2 pressure ulcers. She acknowledged the wound care physician saw Resident #72 on 11/4/22 for an initial wound care evaluation and ordered a new treatment plan for the stage 2 pressure ulcer. She acknowledged the new treatment order from the wound care physician of collagen sheets, Alginate Calcium, and foam silicone border had not been added to Resident #72's MAR and the resident would not be benefiting from the new treatment. On 11/9/22 at 12:31 p.m., the wound care physician confirmed he saw Resident #72 on 11/4/22 for an initial wound evaluation for a stage 2 pressure ulcer to the coccyx. The wound care physician said the facility uses a wound protocol including a barrier film he does not always agree with. He said the barrier film can sting even if it is the no-sting version and it has no healing properties. He said he would not use the barrier film if the wound was open. He said the new treatment he prescribed on 11/4/22 would promote healing to the Resident #72's stage 2 pressure ulcer of the coccyx. He said he was not aware the facility was not using the new treatment plan. The wound care doctor said he could not conclude Resident #72's pressure ulcer was unavoidable. Based on observation, record review, review of policies and procedures, and staff interview, the facility failed to provide the necessary care and services to prevent the development and worsening, and to promote healing of advanced stage pressure ulcers for 4 of 11 sampled residents (Resident #55, #27, #72 and #74) identified at risk for skin breakdown. Resident #27 was dependent on staff for turning and repositioning following a fall and fracture of the right femur. The facility failed to consistently offload the heels of the resident. On 11/4/22, the facility identified an avoidable, infected, advanced stage pressure ulcer of the right heel. On 11/9/22, the wound care physician diagnosed an unstageable (wound bed covered with dead tissue) pressure ulcer of the right heel with 100% necrotic (dead) tissue requiring surgical removal of the devitalized tissue. The facility failed to consistently implement the physician's orders to prevent the worsening of the pressure ulcer. On 11/16/22, the wound care physician documented the pressure ulcer had deteriorated. Resident #55 admitted on [DATE] and was dependent on staff for all activities of daily living including turning and repositioning. The facility failed to identify, assess, and obtain treatment for a stage 3 (full thickness tissue loss) pressure ulcer present on admission. On 11/4/22, the wound care physician diagnosed an unstageable 100% necrotic pressure ulcer to the coccyx (tail bone) requiring surgical debridement. On 11/8/22 the Licensed Practical Nurse (LPN) documented an abrasion to Resident #55's right knee. The area was not assessed or treated until 11/15/22. On 11/16/22, the wound care physician diagnosed a stage 2 (partial thickness loss of tissue) pressure ulcer to the right inner knee. Resident #74 admitted on [DATE] was at moderate risk for development of pressure ulcer and was dependent on staff for turning and repositioning. The facility failed to consistently offload the resident's heels, turn, and reposition the dependent resident. On 9/14/22, Resident #74 developed an avoidable unstageable pressure ulcer of the right heel requiring surgical debridement. The facility failed to consistently apply the physician ordered treatment and protective dressing to promote the healing of the in-house acquired advanced stage pressure ulcer. Resident #27, #55, and #74 suffered serious harm from the development and/or worsening of the pressure ulcers. The facility's failure to consistently ensure accurate assessment, implement preventive measures, treatments, and physician's orders timely resulted in a determination of Immediate Jeopardy at a scope and severity of isolated (J) beginning on 11/4/22. The Facility Administrator was notified of the determination of ongoing Immediate Jeopardy on 11/17/22 at 1:17 p.m. The findings included: Cross reference to F600, F835 and F867. The facility's Body Audit Policy and Procedures with a revision date of 7/2022 indicated, To be completed on admission and weekly for all residents to identify any alterations in skin integrity. On admission the licensed nurse will complete the body audit/integumentary system section on the admission Day/Data Collection form in the electronic health record. The licensed nurse will need to complete the Nursing Weekly Skin Check weekly thereafter . The Licensed Nurse completes a head to toe inspection of the skin with notation of any new alterations in skin condition on the electronic medical record . Communicate to Interdisciplinary Team, Physician . any changes in skin integrity . 1. Review of the clinical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including difficulty walking, muscle weakness and Parkinson's disease (disorder of the central nervous system affecting movement). Resident #55 was discharged to an acute care hospital on [DATE] and returned to the facility on [DATE]. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Agency for Health Care Administration form 3008) signed and dated 10/24/22 by a physician revealed a skin assessment noting Resident #55 had a stage 3 (full thickness tissue loss) pressure injury to the buttock and a stage 1 (pressure related alteration of intact skin) pressure injury to the right buttock. The facility's Nursing Data Collection-Admission/readmission Day dated 10/25/22 noted Resident #55 was Alert. Confused/Dementia/Alzheimer's. The resident was not able to reposition self while lying in bed or sitting. The licensed nurse completing the form did not document the presence of the existing pressure ulcer to the buttocks or the coccyx. On 11/2/22, the Nursing Weekly Skin Check completed by Agency Registered Nurse (RN) K noted Resident #55 had a pressure ulcer to the coccyx. The nurse answered No to the question Is this a new skin injury?. The clinical record lacked documentation of treatment to the existing pressure ulcer. On 11/4/22, the wound care physician assessed and documented in a progress note Resident #55 had an unstageable (due to necrosis) pressure ulcer to the coccyx measuring 4.5 centimeters (cm) length by 3.7 cm width with moderate amount of serous exudate. The physician documented performing a surgical excisional debridement (removal of dead tissue) to establish the margins of viable tissue. The physician issued an order to cleanse the coccyx wound, pat dry, apply Santyl (ointment to remove dead tissue), apply Alginate Calcium sheet and cover with boarded gauze dressing daily. There was no documentation the Santyl was applied to the wound as ordered until 11/7/22. The ordered dressing with Alginate Calcium sheet (used on wounds with moderate to heavy drainage) and boarded gauze dressing was not documented as implemented until 11/8/22. On 11/14/22 at 10:45 a.m., Resident #55 was observed in bed, on his back on an air mattress. His heels were not offloaded and were firmly pressing into the mattress. A soiled dressing dated 11/11/22 was observed to the resident's right inner knee. On 11/14/22 at 10:55 a.m., RN Staff CC verified the dressing to the resident's right inner knee was dated 11/11/22. Observation of the right inner knee wound with RN Staff CC revealed an open ulcer (stage 2) with copious amount of greenish/brownish malodorous exudate. RN Staff CC said Resident #55 acquired the pressure ulcer to the right inner knee due to the resident's knees pressing against each other. RN Staff CC said she would classify the pressure ulcer as a stage 1 (intact skin with non-blanchable redness) even though the wound was open and draining. Upon review of the clinical record, RN Staff CC said she could not find a physician's wound care order for the pressure ulcer to the right inner knee. On 11/14/22 at 5:15 p.m., the Director of Nursing (DON) presented the survey team with a single sheet of paper titled Skin check audit dated 11/8/22 in which a Licensed Practical Nurse (LPN) noted Resident #55 had an abrasion to the right knee. The DON said she just assessed the area to the resident's right inner knee as a stage 2 pressure ulcer. She said she could not find documentation the physician was notified of the new pressure ulcer to obtain treatment orders. On 11/15/22 at 7:40 a.m., Resident #55 was observed in bed, on his back with legs rotated to the right. The resident's heels were not offloaded and pressing firmly into a folded sheet placed on the air mattress. On 11/15/22 at 7:45 a.m., the Agency Nurse assigned to the resident said he could not help or answer any questions regarding Resident #55 as this was his first day working at the facility. On 11/15/22 at 7:45 a.m., Agency Certified Nursing Assistant (CNA) GG said she was assigned to Resident #55, and verified his heels were not offloaded. She said no one gave her report and she did not know how to care for the resident. On 11/15/22 at 8:00 a.m., the DON said approximately a year ago she implemented printing the [NAME] (document that provides a summary and overview of the resident's care) and placing them inside the residents' closets. This way any staff member could answer call lights and it would be easier for agency staff to care for the residents. She said she did not know if the two agency CNAs on the unit today were aware of it. On 11/15/22 at 8:15 a.m., the DON verified the resident's heels were not offloaded and said they should have been. The DON verified the [NAME] was in the closet and specified to elevate heels off the bed to maintain pressure relief. The [NAME] also had instructions for the CNAs to re-educate/encourage on positioning in bed. On 11/15/22 at 8:20 a.m., Agency CNA GG said she did not know where to locate the [NAME] and said, Maybe in the chart?. The DON was present during the interview. Review of the CNA documentation from 10/25/22 through 11/17/22, revealed instructions for the CNAs to encourage to turn and reposition in bed every two hours and as needed. There was no documentation the resident was encouraged or assisted to turn and reposition every two hours and as needed from 11/1/22 through 11/13/22. On 11/16/22 at 4:20 p.m., the wound care physician said he had just assessed the resident's pressure ulcer to the coccyx. The wound care physician said no one told him about an open area to the right inner knee. The wound care nurse Licensed Practical Nurse Staff R was present during the interview. She said she knew about the resident's wound to the right inner knee. She said, I knew about it, but I didn't tell him (the wound care physician) because it's just an abrasion. On 11/16/22 at 4:30 p.m., the wound care physician assessed Resident #55's right inner knee and said it was a stage 2 pressure ulcer with redness to the surrounding area. On 11/16/22 the wound care physician wrote on a progress note Resident #55 had a stage 2 partial thickness pressure wound of the right medial knee. The objective was healing. The facility's policy and procedure for the prevention and treatment of skin breakdown reviewed on 10/2021 read, It is the policy . to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care . Nursing: Monitoring of skin integrity. Upon admission, all new residents will have the following orders in place: [brand name] No Sting Barrier Film liquid to bilateral heels every 3 days for 14 days. Offload bilateral heels while in bed. Air mattress for any resident with a Braden Scale of 14 or less. The manufacturer's insert for the No Sting Barrier Film Liquid noted it was intended for use as a film-forming product that upon application to intact or damaged skin forms a long-lasting waterproof barrier, which acts as a protective interface between the skin. and friction and shear. 2. Review of the clinical record revealed Resident #27 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including a displaced right hip fracture and dementia. On 9/25/22, Resident #27 sustained a fall at the facility and was transferred to an acute care hospital for increased right hip pain. Resident #27 returned to the facility on [DATE] with a diagnosis of displaced fracture of the right femur. The Braden scale (gold standard tool used for identifying pressure ulcer risk) completed on 10/3/22 by an LPN noted a score of 14 indicative of moderate risk for pressure ulcer. The Nursing Data Collection-Admission/Readmission form with an effective date of 10/3/22 noted the resident was at risk for skin breakdown. She was not able to reposition herself while lying in bed, or when sitting in a chair or wheelchair. Staff was to assist as needed with the repositioning. The Significant Change in Status MDS (Minimum Data Set) assessment with a target date of 10/6/22 noted Resident #27 has severe cognitive impairment. The resident required extensive physical assistance of staff for bed mobility and transfer. The Care Area Assessment noted the resident triggered for pressure ulcer and it was addressed in the care plan. The MDS did not include a turning and repositioning program as part of preventive measures. The physician's orders dated 10/3/22 included an air mattress to the bed for pressure ulcer prevention. Review of the Medication Administration Record (MAR) for October 2022 showed documentation the air mattress was applied on 10/3/22 and discontinued on 10/11/22. The clinical record did not include a rationale for discontinuing the air mattress. The MARs for October 2022 and November 2022 did not contain documentation the No Sting Barrier Film Liquid was applied to the resident's bilateral heels every three days for 14 days as per facility policy. On 11/9/22 at 7:09 p.m., the DON said she did not know why the mattress was discontinued and it shouldn't have been. The DON also verified the facility failed to implement their policy and procedure and did not obtain an order for the No Sting Barrier Film liquid to be applied to the resident's bilateral heels every three days for 14 days. The Certified Nursing Assistant (CNA) tasks list for October 2022 and November 2022 had instructions for a turning and repositioning program and encourage the resident to float (offload) heels while in bed each shift. On 10/7/22, 10/10/22, 10/22/22, 10/24/22, 10/28/22, 10/30/22 and 11/4/22 the turning and repositioning and encouraging the resident to float heels while in bed were noted as completed only once in a 24-hour period. On 11/4/22 LPN Staff X documented on a nursing weekly skin check Resident #27 had a right heel pressure area, Open blistered area. has odor. On 11/4/22 LPN Staff X documented on an Incident-Post incident review form Resident #27 developed a pressure injury to the right heel. The form noted the resident was resting in bed and the nurse observed drainage to the bed linen. The clinical record lacked documentation of a Registered Nurse assessment of the right heel ulcer. On 11/4/22 the physician issued an order for Doxycycline Hyclate 100 milligrams (antibiotic) two times a day for infection of the right heel ulcer. He also ordered to use podus boots (helps in prevention and healing of heel ulcers) to offload heels while in bed. On 11/9/22 at 5:54 p.m., the Area Clinical Manager verified the lack of an RN assessment of the right heel pressure ulcer. She said it should have been communicated to the Nurse Manager who would have completed an assessment of the wound. On 11/9/22 from 12:00 p.m. to 2:09 p.m., during random observations, Resident #27 was observed in her room in a wheelchair wearing nonskid socks. Her heels were not offloaded and were pressing into the hard plastic footrests of the wheelchair. Resident #27 was not able to move her right leg upon command. On 11/9/22 at 2:12 p.m., LPN Staff FF said there was no measure to offload Resident #27's heels when she was out of bed. She verified the resident's heels were not offloaded and pressing into the hard plastic footrests of the wheelchair. She said, I questioned it this morning. Her heels are pressing on the footrests. She said not offloading the resident's heels in the wheelchair was a problem. On 11/7/22, three days after the advanced stage pressure ulcer to the right heel was identified, the physician issued an order for an air mattress to the bed due to the right heel wound. On 11/9/22 at 1:35 p.m., the wound care physician said if a resident has a broken hip and is not able to move, preventive measures would include prevalon boots (help reduce the risk of bed sores by keeping the heel floated, relieving pressure), offload on pillows, cover bony prominences, cushions, even a low air loss mattress. On 11/9/22 at 2:36 p.m., the nurse obtained a physician's order to apply podus boots to offload Resident #27's heels while in bed and out of bed. On 11/9/22 at 3:05 p.m., observation of Resident #27's right heel with the wound care physician revealed an advanced stage black, necrotic ulcer with moderate amount of drainage. The wound care physician said a resident with a broken hip and immobile is at risk for developing a pressure ulcer. He said they should offload the heels in bed and out of bed. He said they cannot move, and they are in pain. They cannot rotate the leg. They may develop a pressure ulcer on the heel, ankle, lateral heel. They should have an orthotic device in place in the wheelchair. The wound care physician said sometimes they develop a pressure ulcer despite all interventions, but you don't know until you try all interventions. On 11/9/22 the wound care physician documented in a progress note Resident #27 had an unstageable (due to necrosis) pressure ulcer of the right heel, full thickness of duration greater than 10 days with moderate serous exudate and thick adherent devitalized necrotic tissue covering 100% of the wound. The physician performed a surgical excisional debridement of the right heel. The recommendations included to offload wound. Reposition per facility protocol. Turn side to side and front to back in bed every 1-2 hours if able. On 11/9/22 at 7:09 p.m., the DON said she completed an investigation when Resident #27 developed the pressure ulcer. She said after looking at all the documentation, she concluded the pressure ulcer was avoidable. She said the facility was using a lot of agency nurses and she has not educated them. She said she didn't know if all nurses were educated on pressure ulcer preventive measures. On 11/14/22 at 9:30 a.m., Resident #27 was observed on her back in bed. She was not wearing the offloading boots and her heels were pressing onto a folded sheet placed on the air mattress. On 11/14/22 at 9:35 a.m., CNA HH said she was from a staffing agency and was assigned to care for Resident #27. She said she came on duty at 7:00 a.m. but has not had time to make rounds and see her assigned residents. She said she has not received any orientation before starting to work at the facility. She did not know where to get the information to safely care for the residents. She did not know what preventive measures needed to be in place for Resident #27. On 11/14/22 at 9:40 a.m., RN Staff CC said she was assigned to care for Resident #27. She verified the resident has a pressure ulcer to the right heel. She said the resident should have a pillow between her legs, so they don't touch the mattress, be careful so we won't bump her legs to anything, turn every 2 hours in bed. She said she normally gives report to the CNA when they come in, but she has not given report to CNA HH assigned to Resident #27 and offered no explanation. After looking at the Medication Administration Record (MAR) RN Staff CC said Resident #27 was supposed to wear offloading boots in and out of the bed. On 11/14/22 at 9:45 a.m., RN Staff CC verified Resident #27 was not wearing the offloading boots and said she didn't know why. On 11/14/22 at 12:00 p.m., Resident #27 remained on her back in bed. Observation of the dressing change with RN Staff CC revealed a dressing to the resident's right heel with a date of 11/11/22 and RN Staff CC's initials. She said the dressing was the one she applied to the resident's right heel on 11/11/22. The soiled dressing was saturated with a large amount of malodorous bloody drainage. Review of the MAR for November 2022 showed RN Staff DD signed on 11/12/22 and 11/13/22 he performed the wound care as ordered. On 11/14/22 at 3:15 p.m., RN Staff DD said in a telephone interview he may have made a mistake signing he completed the treatment on 11/12/22, and 11/13/22. He said he was only human and had a lot of work to do. On 11/15/22 at 8:10 a.m., a joint observation with the DON of Resident #27's closet failed to reveal a [NAME] available for staff to safely care for the resident. On 11/16/22 at 4:20 p.m., the wound care physician said Resident #27's pressure ulcer was probably avoidable. On 11/16/22 the wound care physician wrote deteriorated on the wound progress section for the in house acquired unstageable full thickness right heel pressure ulcer. Resident #74's clinical record showed a physician order dated 11/3/22 to cleanse the right heel pressure ulcer with Dakin's solution (strong topical antiseptic) ¼ strength wet to moist packing, apply border gauze dressing once daily for 16 days. Review of the MAR for November 2022 revealed the wound care was not provided 11/4/22, 11/7/22, 11/12/22, and 11/13/22. The reason provided was Dakin's Solution on order. On 11/15/22 at 9:00 a.m., LPN Staff Q retrieved the Dakin's solution dated 11/7/22 from the medication cart. LPN Staff Q confirmed the Dakin's solution was filled by the pharmacy on 11/7/22. On 11/15/22 at 9:45 a.m., the DON said the process for wound care when an ordered treatment was not available, was the nurse was responsible to contact the physician and obtain an order for a different dressing or wound care. The DON said she was aware the Dakin's solution was delivered by the pharmacy on 11/7/22 and was available but did not know why the nurse had documented the solution was unavailable. The DON confirmed Resident #74 did not receive the physician ordered wound care on 11/4/22, 11/7/22, 11/12/22, and 11/13/22 and said there was no documentation the physician was notified the wound care was not provided. Further review of Resident #74's clinical record revealed a care plan initiated on 9/7/22 to offload the resident's heels to decrease pressure due to skin concerns on both heels which identified Resident #74 had a skin concern on both heels. On 11/14/22 at 8:30 a.m., Resident #74 was observed in a wheelchair with grip socks on. Her feet and heels were planted firmly on the floor. There was no dressing noted on the right foot. Licensed Practical Nurse (LPN) Staff BB said she had not completed the scheduled wound care but would do it later in the day. On 11/14/22 at 12:30 p.m., Resident #74's right heel in-house acquired advanced stage pressure ulcer was observed with LPN Staff BB. The right heel ulcer was not covered with the border gauze dressing as per the physician's order, exposing the wound to the lint from the sock. LPN Staff BB verified the pressure ulcer was not covered with the physician's ordered dressing. She said she had not removed any dressing from the resident's right foot. LPN Staff BB said the wound care order was to just apply the Dakin's solution to the right heel and no dressing was required. On 11/14/22 at 2:45 p.m., the Director of Nursing (DON) said she was ultimately responsible to make sure the wound care was carried out as ordered by the physician. On 11/15/22 at 8:30 a.m., Resident #74 was observed seated in a wheelchair in the activity/day room. There was no dressing covering the resident's right heel pressure ulcer, and her heels were not offloaded. The resident was wearing grip socks and both her feet and heels were firmly planted on the floor. LPN Staff Q confirmed there was no dressing covering the right heel wound. 3. Resident #74 was admitted to the facility on [DATE] with anemia, hypertension, dementia, difficulty walking and muscle weakness, depression, and anxiety. The most recent Minimum Data Set (MDS) dated [DATE] showed Resident #74 had a Brief Mental Health Interview Score (BIMS) of 7 which indicated a severe cognitive deficit. A Nurses Weekly Wound Documentation dated 9/14/22 showed a new onset, stage 2 pressure ulcer to Resident #74's right heel. The wound measured 2 centimeters (cm) in length by 2 cm in width by 0.2 cm in depth. There were no further wound assessments documented until 10/5/22 (more than 3 weeks later). The nurses weekly wound documentation dated 10/5/22 showed the pressure ulcer to the resident's right heel had worsened to an unstageable pressure ulcer measuring 2.5 cm in length by 2 cm in width. On 10/10/22, five days after documentation of the worsening of the pressure ulcer, the physician ordered Santyl ointment (used to remove dead tissue) to be applied to the wound bed. The facility also had a two-week gap in assessing the wound from 10/19/22 to 11/3/22. On 11/9/22 at approximately 2:00 p.m., Resident #74's right outer heel was observed to have a round unstageable pressure ulcer measuring approximately 2.1 cm circumference. On 11/9/22 at approximately 7:00 p.m., the Director of Nursing (DON) said the facility had no additional wound documentation assessments. The DON verified Resident #74's pressure ulcer to the right heel had not been assessed weekly. The DON said the facility had identified the nurses were not completing the weekly wound assessments but provided no documentation of staff education or audits to ensure weekly completion of wound assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, the facility's administration failed to use its resources effectively to protect residents' rights to be free from neglect and ensured staff implemented processes and physician's orders to prevent the development and/or worsening of pressure ulcers for 3 (Resident #55, #27, and #74) of 4 residents sampled for development or worsening of pressure ulcers. Resident #27 was dependent on staff for turning and repositioning following a fall and fracture of the right femur. The facility failed to consistently offload the heels of the resident. On 11/4/22, the facility identified an avoidable, infected, advanced stage pressure ulcer of the right heel. On 11/9/22, the wound care physician diagnosed an unstageable pressure ulcer of the right heel with 100% necrotic (dead) tissue requiring a surgical debridement (removal of dead tissue). The facility failed to consistently implement the physician's orders to prevent the worsening of the pressure ulcer. On 11/16/22, the wound care physician documented the pressure ulcer had deteriorated. Resident #55 admitted on [DATE] and was dependent on staff for all activities of daily living, including turning and repositioning. The facility failed to identify, assess, and obtain treatment for a stage 3 (full thickness) pressure ulcer present on admission. On 11/4/22, the wound care physician diagnosed an unstageable 100% necrotic pressure ulcer to the coccyx requiring surgical debridement. The wound care orders dated 11/4/22 were not implemented until 11/7/22. On 11/8/22, the Licensed Practical Nurse documented an abrasion of the resident's right knee. The area was not assessed or treated until 11/15/22. On 11/16/22, the wound care physician diagnosed a stage 2 (partial thickness) pressure ulcer to the right inner knee. Resident #74 admitted on [DATE] and was at moderate risk for development of pressure ulcer and was dependent on staff for turning and repositioning. The facility failed to consistently offload the resident's heels, turn, and reposition the dependent resident. On 9/14/22, Resident #74 developed an avoidable unstageable pressure ulcer of the right heel requiring surgical debridement. The facility failed to consistently apply the physician ordered treatment and protective dressing to promote the healing of the in-house acquired advanced stage pressure ulcer. The failure of the facility's administration to ensure the ongoing implementation of a process to prevent the development, assess, and treat avoidable pressure ulcers resulted in a determination of isolated (J) Immediate Jeopardy beginning on 11/4/22. The Administrator was notified of the determination of ongoing Immediate Jeopardy on 11/17/22 at 1:17 p.m. The findings included: Cross reference to F600, F686, F867 Review of the Nursing Home Administrator's Position Description revised 4/25/22 revealed the position summary was to Plan and direct all day-to-day functions of the Care Center in accordance with applicable company, Federal, State, and local standards to promote that the highest degree of quality is provided to its residents .Plans, develops, organizes, implements, and evaluates the Care Center's programs and activities with strong collaboration with other organizational leaders . Ensures that adequate number of appropriately trained professionals and auxiliary personnel are on duty at all times to meet the needs of the residents. Review of the Director of Nursing's job description dated November 2017 revealed the primary purpose of the position is to plan, budget, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current Federal, State and local standards, guidelines and regulations that govern the facility to ensure that the highest degree of quality of care is maintained at all times. Responsible for ensuring that an adequate level of services is provided to each resident, documented appropriately and regularly evaluated. The facility's Policy and Procedure for the Prevention and Treatment of Skin Breakdown reviewed 10/2021 specified, It is the policy . to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Nursing: Monitoring of skin integrity. Upon admission, all new residents will have the following orders in place: [brand name] No Sting Barrier Film liquid to bilateral heels every 3 days for 14 days. Offload bilateral heels while in bed. Air mattress for any resident with a Braden Scale of 14 or less. 1. Clinical record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including difficulty walking, muscle weakness and Parkinson's disease (disorder of the central nervous system affecting movement). Resident #55 was discharged to an acute care hospital on [DATE] and returned to the facility on [DATE]. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Agency for Health Care Administration form 3008) signed and dated 10/24/22 by a physician revealed a skin assessment noting Resident #55 had a stage 3 pressure injury to the buttock, and a stage 1 (pressure related alteration of intact skin) pressure injury to the right buttock. The facility's Nursing Data Collection-Admission/readmission Day dated 10/25/22 did not note the presence of the existing pressure ulcer to the buttocks or the coccyx (tailbone). The resident was not able to reposition self while lying in bed or sitting. On 11/2/22 the Nursing Weekly Skin Check completed by a Registered Nurse (RN) noted Resident #55 had a pressure ulcer to the coccyx. The nurse answered No to the question Is this a new skin injury?. The clinical record lacked documentation of treatment to the existing pressure ulcer. On 11/4/22 the wound care physician assessed and documented in a progress note Resident #55 had an unstageable (due to necrosis) pressure ulcer to the coccyx measuring 4.5 centimeters (cm) length by 3.7 cm width with moderate amount of serous exudate. The physician documented performing a surgical excisional debridement to establish the margins of viable tissue. The physician issued an order to cleanse the coccyx wound, pat dry, apply Santyl (ointment to remove dead tissue), apply Alginate Calcium sheet and cover with boarded gauze dressing daily. There was no documentation the Santyl was applied to the wound as ordered until 11/7/22. The ordered dressing with Alginate Calcium sheet and boarded gauze dressing was not documented as implemented until 11/8/22. On 11/14/22 at 10:45 a.m., Resident #55 was observed in bed, on his back on an air mattress. A soiled dressing dated 11/11/22 was observed to the resident's right inner knee. On 11/14/22 at 10:55 a.m., observation of the resident's right inner knee with RN Staff CC revealed a stage 2 pressure ulcer with copious amount of greenish/brownish malodorous exudate. She said there was no treatment orders for the pressure ulcer to the right inner knee. On 11/16/22 at 4:30 p.m., the wound care physician assessed and diagnosed Resident #55 with a stage 2 pressure ulcer to the right inner knee with redness to the surrounding area. On 11/16/22 the wound care physician wrote in a progress note Resident #55 had a stage 2 partial thickness pressure wound of the right medial knee. The objective was healing. 2. Review of the clinical record revealed Resident #27 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including a displaced right hip fracture and dementia. On 9/25/22, Resident #27 sustained a fall at the facility and was transferred to an acute care hospital for increased right hip pain. Resident #27 returned to the facility on [DATE] with a diagnosis of displaced fracture of the right femur. The Nursing Data Collection-Admission/Readmission form with an effective date of 10/3/22 noted the resident was at risk for skin breakdown. She was not able to reposition herself while lying in bed, or when sitting in a chair or wheelchair. Staff was to assist as needed with the repositioning. The Braden scale (gold standard tool used for identifying pressure ulcer risk) completed on 10/3/22 by a Licensed Practical Nurse noted a score of 14 indicative of moderate risk for pressure ulcer. The Significant Change in Status MDS (Minimum Data Set) assessment with a target date of 10/6/22 noted Resident #27 had severe cognitive impairment. The resident required extensive physical assistance of staff for bed mobility and transfer. The Care Area Assessment noted the resident triggered for pressure ulcer and it was addressed in the care plan. The MDS did not include a turning and repositioning program as part of preventive measures. The physician's orders dated 10/3/22 included an air mattress to the bed for pressure ulcer prevention. Review of the Medication Administration Record (MAR) for October 2022 showed documentation the air mattress was applied on 10/3/22 and discontinued on 10/11/22. The clinical record did not include a rationale for discontinuing the air mattress. The MAR for October 2022 and November 2022 did not contain documentation the No Sting Barrier Film Liquid was applied to the resident's bilateral heels every three days for 14 days as per facility policy. On 11/9/22 at 7:09 p.m., the DON said she did not know why the mattress was discontinued and it shouldn't have been. The DON also verified the facility failed to implement their policy and procedure and did not obtain an order for the No Sting Barrier Film liquid to be applied to the resident's bilateral heels every three days for 14 days. The Certified Nursing Assistant (CNA) tasks list for October 2022 and November 2022 had instructions for a turning and repositioning program and encourage the resident to float heels while in bed each shift. On 10/7/22, 10/10/22, 10/22/22, 10/24/22, 10/28/22, 10/30/22, and 11/4/22 the turning and repositioning and encouraging the resident to float heels while in bed were noted as completed only once in a 24-hour period. On 11/4/22 a Licensed Practical Nurse Staff I documented on a nursing weekly skin check Resident #27 had a right heel pressure area, Open blistered area. has odor. On 11/4/22 the physician issued an order for Doxycycline Hyclate 100 milligrams (antibiotic) two times a day for infection of the right heel ulcer. He also ordered to use podus boots (helps in prevention and healing of heel ulcers) to offload heels while in bed. On 11/9/22 from 12:00 p.m. to 2:09 p.m., during multiple random observations, Resident #27 was observed in her room in a wheelchair wearing nonskid socks. Her heels were not offloaded and were pressing into the hard plastic footrests of the wheelchair. Resident #27 was not able to move her right leg upon command. On 11/9/22 at 2:12 p.m., LPN Staff FF said there was no measure to offload Resident #27' heels when she was out of bed. She verified the resident's heels were not offloaded and pressing into the hard plastic footrests of the wheelchair. She said, I questioned it this morning. Her heels are pressing on the footrests. She said not offloading the resident's heels in the wheelchair was a problem. On 11/9/22 at 3:05 p.m., observation of Resident #27's right heel with the wound care physician revealed an advanced stage black, necrotic ulcer with moderate amount of drainage. On 11/9/22 the wound care physician documented in a progress note Resident #27 had an unstageable (due to necrosis) pressure ulcer of the right heel, full thickness of duration greater than 10 days with moderate serous exudate and thick adherent devitalized necrotic tissue covering 100% of the wound. On 11/9/22 at 7:09 p.m., the DON said she completed an investigation when Resident #27 developed the pressure ulcer. She said after looking at all the documentation, she concluded the pressure ulcer was avoidable. She said the facility was using a lot of agency nurses and she has not educated them. She said she didn't know if all nurses were educated on pressure ulcer preventive measures. The DON said she did not look into why the air mattress was discontinued or why preventive measures, including applying the No Sting Barrier Film liquid were not implemented. On 11/14/22 at 9:30 a.m., Resident #27 was observed on her back in bed. She was not wearing the offloading boots and her heels were pressing onto a folded sheet placed on the air mattress. On 11/14/22 at 9:35 a.m., Agency CNA HH said she was from a staffing agency and was assigned to care for Resident #27. She said she came on duty at 7:00 a.m. but has not had time to make rounds and see her assigned residents. She said she has not received any orientation before starting to work at the facility. She did not know where to get the information to safely care for the residents. She did not know what preventive measures needed to be in place for Resident #27. On 11/14/22 at 9:40 a.m., RN Staff CC said she was assigned to care for Resident #27. RN Staff CC said Resident #27 was supposed to wear offloading boots in and out of the bed. On 11/14/22 at 9:45 a.m., RN Staff CC verified the offloading boots were not in place for the resident and said she didn't know why. On 11/14/22 at 12:00 p.m., Resident #27 remained on her back in bed. Observation of the dressing change with RN Staff CC revealed a dressing to the resident's right heel with a date of 11/11/22. The dressing bore RN Staff CC's initials. She said the dressing was the one she applied to the resident's right heel on 11/11/22. The soiled dressing was saturated with a large amount of malodorous bloody drainage. Review of the MAR showed nurse RN Staff DD signed on 11/12/22 and 11/13/22 he performed the wound care as ordered. On 11/14/22 at 3:15 p.m., RN Staff DD said in a telephone interview he may have made a mistake signing he completed the treatment on 11/12/22 and 11/13/22. He said he was only human and had lot of work to do. On 11/16/22 at 4:20 p.m., the wound care physician said Resident #27's pressure ulcer was probably avoidable. On 11/16/22, the wound care physician wrote deteriorated on the wound progress section for the unstageable full thickness right heel pressure ulcer. On 11/9/22 at 2:50 p.m., the Registered Dietitian said the facility only notified her today (11/9/22) of Resident #27's pressure ulcer. On 11/15/22 at 10:15 a.m., the Registered Dietitian (RD) said it's been a struggle to obtain the wound report to implement adequate nutritional interventions for residents with pressure ulcers. She said she emailed her concerns to the administrative staff on 10/11/22. The RD provided a copy of an email dated 10/11/22 at 3:15 p.m., addressed to the Administrator, the DON, and the Certified Dietary Manager (CDM) that read, Just wanted to let you know I have not received a wound report for several weeks. I am concerned that there may be pressure injuries that have not been addressed. She said the very next day she got a wound report but the next one she received was on 11/9/22. Review of the physician's orders for October 2022 revealed to administer a house shake to Resident #27 three times a day for nutritional supplement as of 10/27/22 and a [brand name for frozen nutritional supplement] two times a day for impaired appetite. On 11/9/22 at 2:50 p.m., the Registered Dietitian said the nursing staff was supposed to document the percent of the supplement consumed. She said she looks in the clinical record to check if the resident is taking the supplement or not. She also asks the nurse if the resident is taking the supplements. On 11/11/22 RN Staff CC documented on the MAR Resident #27 consumed 100 % of the house shake at 9:00 a.m. and 5:00 p.m., and 50% of the house shake at 1:00 p.m. On 11/14/22 RN Staff CC documented Resident #27 consumed 100% of the house shake at 9:00 a.m. On 11/14/22 at 9:35 a.m., Resident #27's breakfast tray was observed and did not contain a house shake. On 11/14/22 at 12:15 p.m., Resident #27's lunch tray was observed and did not include a frozen nutritional supplement. On 11/14/22 at 12:20 p.m., RN Staff CC said the supplements come on the resident's meal trays. She said she documented the percentage consumed based on what the CNA reported but did not personally see the resident taking the supplements. On 11/14/22 at 12:50 p.m., the Certified Dietary Manager (CDM) provided a list of residents who received supplements on their meal trays. Resident #27 was not included in the list. She said the dietary department did not provide any supplement to Resident #27. On 11/14/22 at 1:05 p.m., Agency CNA EE said the resident did not receive any supplement with her breakfast or lunch meal. RN Staff CC present during the interview said it was a problem and she'll let the DON know about it. 3. Review of the clinical record revealed Resident #74 was admitted on [DATE]. Diagnoses included chronic kidney disease, dementia with behaviors, anxiety, and hypertension. The Braden Scale for predicting pressure sore dated 9/17/22 documented the risk score was 14, indicating Resident #74 was at moderate risk for developing a pressure wound. A review of Resident #74's clinical record revealed a care plan initiated on 9/7/22 identifying Resident #74 had a skin concern on both heels. The care plan interventions included to offload heels to decrease pressure. On 9/14/22 the Nurses Weekly Wound Documentation, completed by the Director of Nursing (DON), identified Resident #74 had a new onset, in-house acquired, stage 2 (partial thickness) pressure wound to the right heel measuring 2.0 centimeters (cm) length by 2.0 cm width with 0.2 cm depth, with small amount of serosanguineous exudate. On 10/5/22 the wound care physician assessed and documented in a progress note Resident #74 had an unstageable (due to necrosis) pressure ulcer to the right heel measuring 2.3 centimeters (cm) length by 1.5 cm width with moderate amount of serous exudate. The physician documented performing a surgical excisional debridement (removal of dead tissue) to establish the margins of viable tissue. The wound care physician specified to offload pressure to heels. The record showed a physician order dated 11/3/22 to cleanse right heel with Dakin's (strong antiseptic) solution ¼ strength wet to moist packing, apply border gauze dressing once daily for 16 days. On 11/14/22 at 8:30 a.m., Resident #74 was observed in a wheelchair with grip socks on and her feet and heels were planted firmly on the floor and not offloaded to reduce pressure. There was no dressing noted on the right foot. Licensed Practical Nurse (LPN) Staff AA said she had not completed the scheduled wound care but would do it later in the day. On 11/14/22 at 12:30 p.m., observation of the wound on Resident #74's heels with LPN Staff AA revealed there was no dressing observed on the right heel to cover the resident's wound, exposing the wound to lint from the sock. LPN Staff AA said she had not removed any dressings from the resident's right foot. LPN Staff AA said she had not completed wound care yet and said it was just Dakin's solution to the right heel, no dressing was required; the order was to just apply the solution to the wound. A heel protector was noted on the left foot, and there was none on the right foot. On 11/14/22 at 2:45 p.m., the Director of Nursing (DON) said she was ultimately responsible to make sure the wound care was carried out as ordered by the physician. On 11/15/22 at 8:30 a.m., Resident #74 was observed seated in a wheelchair in the activity room. Her feet were firmly planted on the floor, and she had grip socks on, and her heels were not offloaded to decrease pressure. LPN Staff Q confirmed there was no dressing covering Resident #74's the right heel wound. Review of the Medication Administration Record for November 2022 revealed the wound care with the Dakin's solution was not provided as ordered on 11/4/22, 11/7/22, 11/12/22, and 11/13/22. The reason provided was Dakin's Solution on order. On 11/15/22 at 9:00 a.m., LPN Staff Q said the Dakin's solution was in the medication cart and retrieved it form the cart. LPN Staff Q confirmed the date the Dakin's solution was filled by the pharmacy was 11/7/22. On 11/15/22 at 9:45 a.m., the DON said she was aware the Dakin's solution was delivered by the pharmacy on 11/7/22, and was available, but did not know why the nurse had documented the solution was unavailable. The DON confirmed Resident #74 did not receive the physician ordered wound care on 11/4/22, 11/7/22, 11/12/22, and 11/13/22 and said there was no documentation the physician was notified the wound care was not provided. On 11/15/22 at 10:54 a.m., Unit Manager Registered Nurse Staff T said the wound care to the right heel was done five times on 11/14/22 because Resident #74 removes the dressing. The Unit Manager said the right heel wound was wrapped together with the right shin wound so the resident would not be able to remove the right heel dressing. The Unit Manager confirmed there was no documentation the wound care was provided five times on 11/14/22 and no physician order to wrap the resident's entire right leg and combine the two separate wound dressings. The Unit Manager said the Dakin's solution was pulled from the medication cart because of concerns last week the ordered solution was not the correct dosage. She said once we determined it was correct, it was placed back in the cart. The Unit Manager said she did not know how many days the Dakin's solution was not in the cart and said the nurse just provided standard wound care. The Unit Manager said the nurse just followed the physician order without applying the Dakin's solution, and that was considered standard wound care. The Unit Manager confirmed there was no physician order for the nurse to provide standard wound care without the Dakin's solution. On 11/14/22 at 2:40 p.m., the Director of Nursing (DON) said the unit managers and supervisors were responsible to conduct audits to ensure timely and accurate completion of skin checks. On a day-to-day basis the nurses on the unit along with the unit managers were responsible to make sure the care was being provided and supervise the Certified Nursing Assistants (CNAs). The DON said she did not have documentation of the audits performed by the unit managers. On 11/15/22 at 9:25 a.m., RN Unit Manager Staff N said she has been a unit manager at the facility for approximately 10 months. She said her responsibilities are a lot. She has a whole book on responsibilities. They do not include making sure the wound care physician's orders are implemented timely. On 11/15/22 at 10:30 a.m., Unit Manager Staff II said she has been a unit manager at the facility for almost three years. She said there was no specific focus on residents with pressure ulcers. She said she was not responsible to make sure the wound care physician's orders were implemented. She said it was the wound care nurse's responsibility to make sure the orders are entered in the system, and the primary nurse's responsibility to make sure the orders are implemented. On 11/15/22 at 10:55 a.m., RN Staff T said she has been the unit manager for Unit B and C for about two months. She said she rounds her unit as soon as she gets in the building. She makes sure the air mattress is on and inflated properly, heels are up, drinks in front of them. She offered no explanation for the observation on 11/14/22 of Resident #27's not wearing the offloading boots. She said Resident #27 was transferred to her unit on Friday and they should have brought the [NAME] to her room. She said she also completes audits for skin checks. She looks over and verifies the accuracy of the skin assessments on the resident. She said she went over all the skin checks from 11/8/22 and 11/11/22. She said the wound care nurse mentioned the area to Resident #55's right inner knee but from the description she wasn't sure what it was. She cleaned it and left it open to air. On 11/15/22 at 3:15 p.m., a review of the Quality Assurance and Performance Improvement (QAPI) program related to pressure ulcers was conducted with the Administrator. She declined for the DON to attend. She said the DON was busy doing other things. She said a skin PIP (Performance Improvement Plan) was introduced in QAPI on 7/13/22. The PIP was developed because they identified skin checks were not done timely and skin issues were not identified timely. They discussed completing a head-to-toe assessment as a baseline. Skin assessments were reviewed to make sure appropriate interventions were in place. She said she did not have information of the findings from the head-to-toe assessments. The Administrator said from what she was told, the skin protocol was reviewed at the time and appropriate interventions were put into place, but she just does not have the documentation to show that. There was no set completion date for the PIP. It was ongoing for three months and then reviewed to determine if an extension was needed. On 8/10/22 the PIP was reviewed. They discussed auditing the new admissions by the wound nurse to make sure appropriate interventions were in place if residents were deemed at risk. She said she could not speak to why this intervention was added. As far as the head-to-toe assessment, she said she did not have documentation it was done, one way or the other. On 9/14/22 the PIP was reviewed again. They reviewed implementation of appropriate interventions. On 9/14/22 they had a total of 10 active wounds. One was facility acquired and it was a vascular issue. The Regional Clinical Manager or designee was going to audit 100% of the skin assessments and skin checks weekly to ensure compliance for the next three months. She said she did not have documentation of how many audits were done and the results of the audits. On 10/19/22 the PIP was reviewed again. It was decided all nursing staff needed to be reeducated on completion of the weekly skin checks. She said she did not have the data or rationale for the decision to reeducate the nurses. As of 10/19/22, the Nurse Managers were also to review the Agency for Health Care Administration form 3008 of all the new admissions to identify any skin issues upon admission for all new admissions. She said she was not certain they reviewed Resident #55's 3008 form when he was admitted on [DATE]. She said she wasn't sure where they document the audits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility's Quality Assurance and Performance Improvement (QAPI) program failed to develop and implement effective corrective actions for identified quality deficiencies related to skin assessment, prevention, identification, and treatment of pressure ulcers. Resident #27 and #74 developed an unstageable (advanced stage) pressure ulcer. The facility failed to consistently implement the physician's orders to promote healing and prevent the worsening of the pressure ulcers. Resident #55 was admitted on [DATE] with a pressure ulcer to the coccyx. The facility failed to identify, assess, and treat the pressure ulcer upon admission until 11/7/22. Resident #55 suffered worsening of the pressure ulcer. The facility failed to implement effective corrective actions and monitor results, creating a likelihood of serious harm and impairment to other residents. The facility failure to have an effective Quality Assurance and Performance Improvement (QAPI) program resulted in a determination of isolated (J) Immediate Jeopardy beginning on 11/4/22. The Administrator was notified of the determination of Immediate Jeopardy on 11/17/22 at 1:17 p.m. The findings included: Cross reference to F600, F686 and F835 The facility's Quality Assurance Performance Improvement (QAPI) Plan with an annual update of 4/19/22 noted the purpose of the QAPI plan is to ensure a systematic approach to performance excellence of the organization that includes all stakeholders and is on-going. The Quality Assurance and Performance Improvement plan ensures the organization is always providing surveillance to ensure systems and processes are in place and effective. When there is a change in the metrics/outcomes, the communities will be tracking and trending to identify issues early and avoid adverse events from reaching the individuals they serve. When key issues are identified and/or data indicating potential system breakdown, communities will consider this a proactive opportunity for improvement. Communities will be identifying and addressing the key issues by engaging the stakeholders in the identification of opportunities for improvement, providing a safe environment for reporting issues, and participation in seeking the right improvement interventions. The plan also noted the organization will conduct Performance Improvement Projects (PIP's) that are designed to take a systematic approach to revise and improve care or services in areas identified as needing attention. The facility will conduct PIP's that will lead to changes and guide corrective actions in the systems, which cross multiple departments, and have impact on the quality of life and quality of care for residents living in the community. They will conduct PIPs that will improve care and service delivery, increase efficiencies, lead to improved staff and resident outcomes, and lead to greater staff, resident, and family satisfaction. An important aspect of the PIP is a plan to determine the effectiveness of the performance improvement activities and whether the improvement is sustained. 1. Review of the facility's compliance history revealed on 10/8/21 the facility failed to implement timely effective measures in accordance with professional standards of practice to prevent the development of pressure ulcers for two residents identified at risk for pressure ulcers. 2. Clinical record review revealed Resident #27 was readmitted to the facility on [DATE] after a surgical repair of a right hip fracture. The resident was dependent on staff for repositioning. The facility failed to consistently implement preventive measures to prevent the development of an avoidable advanced stage pressure ulcer. On 11/4/22 the facility identified an infected, pressure ulcer of the right heel. On 11/9/22 the wound care physician diagnosed an unstageable right heel pressure ulcer with 100% thick necrotic tissue. The facility failed to consistently implement the daily wound care, offload the area to promote healing. On 11/16/22, the wound care physician documented the wound had deteriorated. 3. Clinical record review revealed Resident #55 was admitted on [DATE] with a stage 3 pressure ulcer to the coccyx and was dependent on staff for all activities of daily living. The facility failed to complete a thorough skin assessment. The pressure ulcer was not identified until 11/4/22, and the physician's ordered treatment was not implemented until 11/7/22. The facility also failed to assess, obtain orders, and treat an additional in-house acquired pressure ulcer for Resident #55 identified on 11/8/22 until 11/15/22. 4. Review of the clinical record revealed Resident #74 admitted on [DATE] and was at moderate risk for development of pressure ulcer. Resident #74 was dependent on staff for turning and repositioning. The facility failed to consistently offload the resident's heels, turn, and reposition the dependent resident. On 9/14/22, Resident #74 developed an avoidable unstageable pressure ulcer of the right heel requiring surgical debridement. The facility failed to consistently apply the physician ordered treatment and protective dressing to promote the healing of the in-house acquired advanced stage pressure ulcer. 5. On 11/9/22 review of the facility's wound tracking log revealed the facility had 12 residents with pressure ulcers, 11 of the 12 residents acquired the pressure ulcer at the facility. 6. On 11/14/22 at 2:40 p.m., an interview was conducted with the Director of Nursing (DON) in the presence of the facility Administrator. The DON said since the survey of 10/8/21 that identified noncompliance with development of pressure ulcers, the facility made sure skin assessments were completed to ensure appropriate interventions were in place such as turning and repositioning, air mattress as appropriate. The nurse managers were to review the electronic clinical records daily to ensure all skin issues were addressed appropriately. All nursing staff were educated on pressure ulcer prevention including floating heels, turning, and repositioning. The target date was February 2022, but they were to continue with all interventions and audits. The DON said in July 2022, they developed a PIP because skin concerns were missed on admission. The nurse assigned to round with the wound care physician said, they were doing well. She was accountable to speak with the unit managers if something was not taken care of. The unit managers and supervisors were responsible to conduct audits to ensure timely and accurate completion of skin checks. On a day-to-day basis, the nurses on the unit, along with the unit managers, were responsible to make sure the care was being provided and supervise the Certified Nursing Assistants (CNAs). The DON said the wound care physician does not attend QAPI meetings. Review of the PIP with a date initiated of 7/8/22 and revised 9/30/22 revealed the problem was the facility failure to identify and manage skin issues, weekly skin checks not completed timely. The goal of the PIP was to ensure all skin issues were identified and managed timely and appropriately. The date expected to be completed was Ongoing. The interventions listed included staff education on pressure ulcer prevention, including floating heels, turning, and repositioning, change of condition, stop and watch, and skin checks. The nurse managers were also to review the Agency for Health Care Administration form 3008 of all the new admissions to identify any skin issues upon admission for all new admissions. On 11/14/22 at 2:40 p.m., at the time of the interview, the DON and the Administrator said they did not have documentation of education or audits completed since the development of the PIP in July 2022. On 11/15/22 at 3:15 p.m., a review of the QAPI program related to pressure ulcers was conducted with the Administrator. She declined for the DON to attend. She said the DON was busy doing other things. She said the skin PIP was introduced in QAPI on 7/13/22. The PIP was developed because they identified skin checks were not done timely and skin issues were not identified timely. They discussed completing a head-to-toe assessment as a baseline. Skin assessments were reviewed to make sure appropriate interventions were in place. She said she did not have information of the findings from the head-to-toe assessments. The Administrator said from what she was told the skin protocol was reviewed at the time and appropriate interventions were put into place, but she just does not have the documentation to show that. There was no set completion date for the PIP. It was ongoing for three months and then reviewed to determine if an extension was needed. On 8/10/22 the PIP was reviewed. They discussed auditing the new admissions by the wound nurse to make sure appropriate interventions were in place if residents were deemed at risk. She said she could not speak to why this intervention was added. As far as the head-to-toe assessment, she said she did not have documentation it was done, one way or the other. On 9/14/22 the PIP was reviewed again. They reviewed implementation of appropriate interventions. On 9/14/22 they had a total of 10 active wounds. One was facility acquired and it was a vascular issue. The Regional Clinical Manager or designee was going to audit 100% of the skin assessments and skin checks weekly to ensure compliance for the next three months. She said she did not have documentation of how many audits were done and the results of the audits. On 10/19/22 the PIP was reviewed again. It was decided all nursing staff needed to be reeducated on completion of the weekly skin checks. She said she did not have the data or rationale for the decision to reeducate the nurses. As of 10/19/22 the nurse managers were also to review the Agency for Health Care Administration form 3008 of all the new admissions to identify any skin issues upon admission for all new admissions. She said she was not certain they reviewed Resident #55's 3008 form when he was admitted on [DATE]. She said she wasn't sure where they document the audits. The Administrator said she offers the CNAs to attend QAPI, but they don't have any interest. 8. On 11/16/22 at 1:25 p.m., the Area Clinical Manager said she provides support to the nursing home and the nursing home administrator. When she comes to the facility, she meets with the DON and Administrator and to discuss concerns or issues they'd like her to assist with. She said she recommended a PIP for pressure ulcer in July based on a review of the new skin integrity risk management reports. She found skin issues not identified and treatments not done. She said she did not develop the PIP for the pressure ulcers. She makes her recommendations but they're not final. The Administrator and DON are the ones who ultimately decide what they'll end up doing. She did some education after July and would look on her calendar. She said she also completed some audits which she shared on a weekly basis with the DON, the Administrator, the CEO, and the Area Operation Supervisor. Review of the Support Services Report-Clinical reports completed by the Area Clinical Manager showed the week of 7/11/22 the areas of review included, Skin Concerns/Any New Facility Acquired Pressure Ulcer-Any stage. Ensure prevention measures are in place. PIP initiated and brought to QAPI. The week of 7/25/22 the report noted improvements were made. She noted the wound care nurse was not numbering wounds in the weekly wound documentation and would talk to her the following week. Skin assessment had improved but five were overdue for the week. The week of 8/1/22 the report noted the PIP was being worked by the DON. The unit managers were doing weekly skin assessment audits, to be turning in to the DON. The week of 8/15/22 the report noted she needed to work with the wound care nurse on doing electronic wound logs for all departments to access. The paper copy was not being shared with everyone. The Area Clinical Manager also noted the facility needed to start weekly wound meetings and review all wounds weekly to ensure care plans and protocols are in place. She also wrote Skin PIP-no audits in house for me to review. Please continue. The week of 8/22/22 the report noted, Electronic wound log still not being updated correctly. Uncertain if wounds were discussed in Standards of Care. Skin integrity RM (Risk Management) reports: Need to establish process for ensuring treatment is set up for New Skin integrity concerns. 4 of 5 reviewed the RM report stated a treatment was initiated, but there was no treatment put in place. The week of 9/12/22 the report noted, Wound log is not being saved to the G drive for everyone to access. RM reports reviewed for skin still with trouble following through with orders. Weekly skin assessments continue with some incomplete, missing or late. Recommend a pip or process of ensuring that orders get put in place from Risk Management reports. Reviewing Risk management reports in IDT (Interdisciplinary Team) for new skin issues, the nurse indicated that she put a treatment on, which was an appropriate treatment, but an order was not written. Nurse manager is following up but remains a problem. An undated report noted, There were some pressure ulcers identified that did not have weekly wound documentation. Weekly skin assessments still not 100%. Concerns with wound log not accurate. Reviewed a handful of skin integrity RM reports to see if treatment, care plan and follow up completed as to what the RM report stated. Orders were in place, but I did not see wound tracking for those that were pressure ulcers. One Right buttock wound the weekly wound report said it was Vascular. The report for the week of 10/21/22 noted, [DON] is working on updated wound and skin logs. [DON] is working on long term plan for wound management in the building. Please ensure wounds are discussed weekly in Standards of care. I have not seen audits skin wound PIP status? Continued wound concerns. The report for the week of 10/25/22 noted, At the end of last week, there were 10 Facility acquired Pressure Ulcers at various stages, and a handful to follow up on. I did a whole house review of skin checks: 10 residents were not timely with weekly skin checks, 5 of them had not had a skin check in over a month. The list was sent to [DON] to follow up on last week. I provided all the VOA (Volunteers of America) Wound Skin Protocol and policies to [DON] and [Administrator], which were already on the G drive, but provided again for references. The report for the week of 11/7/22 noted, We reported as a Federal Day 1 for a facility acquired Pressure Ulcer that went without treatment for several days. I am working on a training to do for next week for the Nurses on VOA wound care protocol and process. [DON] is working on having whole house skin audits completed. All the reports noted the responsible person was the DON. 9. On 11/17/22 at 8:23 a.m., the DON said sometimes she would talk to the unit managers about the issues identified in the reports and sometimes she would take care of it herself. The DON had no documentation verifying she addressed the concerns with pressure ulcers noted on the Area Clinical Manager's weekly reports and said, The skin audits were improving.