**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility document review, the facility staff failed to prevent, assess, and treat pressure ulcers appropriately for nine out of 10 residents (R) (R291, R293, R65, R3, R63, R50, R21, R292, and R142) with pressure ulcers. These failures present a likelihood of serious harm, serious injury/impairment, or death related to wound infection and wound deterioration and contributed to hospitalization and subsequent cardiac arrest for R291. On 11/29/223 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 12/4/2023 at 7:35 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/27/2023. At the time of exit on 12/5/2023, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings included: 1. Review of Resident (R) 291's undated admission Record, located under the Profile tab of the electronic medical record (EMR), revealed this resident was admitted to the facility on [DATE] with diagnosis of but not limited to sepsis and an unstageable pressure ulcer to the sacral region. R291's five-day admission Minimum Data Set (MDS) was not completed; however, on the EMPC (Empire Center) Nursing Comprehensive Assessment, dated 11/22/23, it was recorded that R291 was alert and oriented to self, time of day, year, and place. There was also documentation which showed there was a stage IV pressure ulcer to the sacrum and an abdominal fold wound present. Review of R291's record revealed no additional assessments or measurements of the sacral pressure ulcer and abdominal fold wound. Review of R291's physician's orders, located under the Orders tab of the EMR, revealed to the abdominal wound to clean the abdominal wound with wound cleanser, pat dry, and cover with dry dressing daily and to clean the sacral pressure ulcer with Dakin's Solution, pat dry and pack with Dakin's solution daily. These orders had a start date of 11/23/23. Review of 291's Treatment Administration Record (TAR) for November 2023 revealed no dressing changes were provided on 11/25/23 (Saturday) and 11/26/23 (Sunday) for either the sacral or abdominal wound. There was no documentation of the physician being notified these dressing changes were not provided. In an interview with the Nurse Practitioner (NP) on 12/02/23 at 12:15 PM, the NP stated that she had been on vacation the week prior to seeing R291 on 11/27/23. The NP also stated she saw R291's wound and it was beefy red with copious amount of bloody drainage and did have pocketing from debriding in the hospital. The NP confirmed there was no documentation on 11/27/23 in the NP progress notes to reflect this. The NP stated, The wound nurse would chart the specifics of the wound and chart it in PCC (Point Click Care, the facility's electronic charting system). In our notes, we will chart see wound note. In an interview with Licensed Practical Nurse (LPN) 1 on 12/02/23 at 3:19 PM, LPN1 reported she had taken report on R291 and did the resident's skin assessment. LPN1 noted an incision/opening on R291's stomach, an unstageable on the sacral area, and a pressure ulcer on R291's right buttock with small openings. LPN1 stated, The wound was already deteriorating; wasn't beefy red and was big enough to fit fingers in and swirl around inside the wound on admission. Report from the hospital only told me of the big one in the middle. [R291]'s whole dressing and bed was saturated with drainage that had no odor. Review of R291's Progress Notes revealed no documentation the physician was notified of the wound already deteriorating; wasn't beefy red and was big enough to fit fingers in and swirl around inside the wound on admission . [R291]'s whole dressing and bed was saturated with drainage that had no odor as described by LPN1. There was no nursing documentation in the progress notes that reflected the continuation of the copious amounts of drainage from the sacral wound. Review of R291's admission note in the progress note for 11/22/23, revealed documentation of . Pressure sore to sacrum and buttocks . Review of R291's EMPC Skin Check, dated for 11/22/23, revealed documentation that reflected a stage IV sacral wound, an unstageable wound to the right buttocks with several open areas around the wound, and an abdominal fold opening with yellow drainage and dark color surrounding. Review of R291's physician orders for November 2023 revealed no treatment or dressing change orders to be provided to the pressure ulcer of the right buttocks. In an interview with the Director of Nursing (DON) on 12/02/23 at 4:57 PM, the DON stated she had worked on Sunday (referring to 11/26/23) but she had never seen R291 nor her wounds. The DON also stated she had noticed the TARs were not being signed off on and this had been discussed with the management team and the nurses were to be educated on wounds in monthly meetings The DON stated she had not looked at specific nurses across the board and some nurses would say they completed wound care while others would say no. She also stated the risks of no wound care are worsening of the wounds and infection. The DON stated the LPNs cannot do wound measurement and the wound care nurse is an LPN; only the Physician Assistant does these measurements. The DON stated when the nurse discovers a new wound, they should document a change in condition and notify the doctor or nurse practitioner to get orders for treatment. In an interview with the Wound Care Consultant (WCC) on 12/05/23 at 2:25 PM, the WCC stated, I could not come earlier in the week (week of 11/19/23) but I was available to come Thanksgiving morning. The facility told me the Director of Nursing was on vacation and there was no other staff that was able to make rounds with me so there were no visits made by me that week. Review of the facility provided t admission records from the hospital indicated R291 was discharged to the hospital on [DATE], where she was diagnosed with shock due to sepsis, suspected soft tissue infection, acute blood loss anemia, cardiac arrest, acute respiratory failure, and stage IV decubitus ulcer with concern for necrotizing fasciitis. R291 suffered cardiac arrest in the hospital, required resuscitation, and remained in intensive care on a ventilator. Though R291 had shown signs of a change in condition several days prior to her hospitalization on 11/27/23, including copious bleeding, the facility failed to document the change of condition, follow up with assessment of the change of condition, or assess and treat her wounds appropriately. 2. Review of R293's undated admission Record, located under the Profile tab of the EMR revealed this resident was admitted to the facility on [DATE] with the diagnosis of but not limited to pressure ulcer of sacral region unstageable, pressure induced deep tissue damage of the left heel, osteomyelitis of sacral and sacrococcygeal region, sepsis, and methicillin resistant staphylococcus aureus infection (MRSA). Review of R293's admission MDS, with an Assessment Reference Date (ARD) of 10/21/23 revealed R293 was coded as having a Brief Interview for Mental Status (BIMS) score of three out of 15. This indicated R293 was severely cognitively impaired. Review of R293's 10/17/23 EMPC Nursing Comprehensive Assessment, under the section Document location and description, revealed documentation that recorded, Item 53 (site of wound) sacrum and under description recorded wound. There was no documentation of the deep tissue pressure injury to the left heel. Review of R293's orders and admission Note, dated 10/17/23 and conducted by the Nurse Practitioner, revealed . Vancomycin 750mg (milligram)/150 ml (milliliter) Use 1 application intravenously every 12 hours for MRSA [Methicillin-resistant Staphylococcus Aureus] in wound until 10/29/23 . The Medication Administration Record (MAR) was reviewed for R293. On the October 2023 MAR, there was no documentation of R293 receiving the above documented order of Vancomycin on 10/24/23. On 10/31/23, the wound care consultant ordered for R293 to have the sacral wound cleaned with Dakin's ¼ strength solution, apply Collagen with Hydrofera blue to cover, and change daily and as needed. The primary care physician at the facility wrote an order on 11/01/23 to cleanse the wound with wound cleanser or normal saline, apply collagen with blue foam cover with dry protective dressing (DPD), and change daily and as needed. The progress notes for 11/01/23 were reviewed and there were no physician progress notes reflecting the change in order. Review of R293's Physician Orders for November 2023 revealed an order for the right heel DTI (deep tissue injury) but there was no mention of the DTI to the left heel for which R293 had an admitting diagnosis for. Review of R293's TAR for October 2023 revealed wound care was provided three times a week to the deep tissue injury of the left heel with a start date of 10/19/23 and an end date of 11/01/23. Review of R293's TAR for November 2023 revealed orders for Santyl External Ointment 250 Unit/GM [unit per gram] apply to sacrum topically every day shift for wound healing for 14 days. Cleanse with NSS [normal saline solution], pat dry, apply Santyl and cover with DPD [dry protective dressing]. The start date for this order was 11/08/23. The continued review revealed there was no documentation of treatments to the sacrum for 11/09/23 (Thursday), 11/14/23 (Tuesday), 11/18/23 (Saturday), and 11/19/23 (Sunday). For 11/15/23 and 11/16/23, the treatment was noted to have 9 coded for these days and this represented Other/Progress Note. Review of the progress notes for 11/15/23 revealed no documentation related to the treatment to the sacrum and 11/16/23 at 9:29 AM stated, .different order. Review of R293's Physician Orders revealed orders for the sacral wound care were changed on 11/15/23 to Wound 1: Sacral-Cleanse with Dakins, pat dry, apply collagen, blue foam, DPD daily / (and) PRN (as needed) every day shift. Review of R293's November TAR, reflecting the new wound care, revealed there was no treatment provided on 11/18/23 (Saturday), 11/19/23 (Sunday), and 11/26/23 (Sunday). Review of R293's physician orders, dated 11/16/23, revealed an order for Wound 3: Right Metatarsal Head First - Cleanse with wound cleanser, pat dry, apply honey gel, DPD 3x (times) weekly/PRN every day shift every Tue (Tuesday), Thu (Thursday), Sat (Saturday). Review of R293's TAR revealed there was no treatment provided to the right metatarsal head on 11/18/23 (Saturday). Review of R293's orders for the sacral area changed to Cleanse with wound cleaner, pat dry. Dakins 1/4 strength, collagen, blue foam, DPD daily /PRN every shift. This start date of this order was 11/08/23 with a discontinuation date of 11/15/23. Review of R293's November TAR reflecting the new wound care revealed there was no treatment provided on 11/08/23 night shift, 11/09/23 day, evening, and night shift, 11/10/23 through 11/13/23 evening and night shift, and 11/14/23 day, evening, and night shift. Review of R293's Progress Notes for the month of November 2023 revealed no documentation that the physician was not notified of the dressing changes were not provided on the above documented dates and shifts. Review of R293's Wound Weekly Observation Tool, dated 11/08/23, there was a new wound to the resident's right heel that was acquired in the facility with a documented date of 11/01/23. Review of the WCC Note, dated 11/07/23, documented the right heel wound was unstageable with no granulation tissue present and 100% eschar noted in the wound bed. The recommendation of the WCC was to cleanse wound with normal saline, apply betadine, and cover with a DPD .This treatment was recommended for three times a week and PRN. Review of the physician's orders revealed this order had a start date of 11/02/23 and an end date of 11/08/23 and then had a start date of 11/09/23 and an end date of 11/15/23. There were no further orders noted for the right heel. Review of R293's Wound Weekly Observation Tool revealed this tool was last documented for 11/08/23. There was no further documentation on this tool until 12/01/23 and the documentation was for the sacral wound and the right heel wound. The wound to the right metatarsal head of the right great toe was not documented at the time of this review on 12/03/23. On 12/05/23 at 12:15 PM, wound care observations were made, and wound care was provided to sacral, right heel and right metatarsal head of the right great toe areas. The right heel wound was noted to be healed by the wound care consultant. Review of R293's EMPC Skin Checks were documented starting 10/18/23 and were completed weekly through 11/05/23. No further skin checks were documented at the time of this review on 12/03/23. Review of R293's WCC Notes were reviewed and noted there were no visits from the WCC for the week of 11/19/23. These visits are to be conducted on a weekly basis. 3. Review of R65's undated admission Record, located under the Profile tab located in the EMR, revealed this resident was admitted to the facility initially on 07/19/23 and readmitted to the facility on [DATE] with the diagnoses of stage IV pressure ulcer to the sacrum, stage IV pressure ulcer to the right heel, stage IV right knee pressure ulcer, stage IV left lower leg/heel pressure ulcer, and stage IV right elbow pressure ulcer. He developed a stage III pressure ulcer to the upper left back on 08/29/23. Review of R65's TAR, for October and November 2023 and located under the Orders tab of the EMR, revealed the following: 1. Sacral wound treatment was not provided on 10/07/23 (Saturday), 10/14/23 (Saturday), 11/04/23 (Saturday), 11/09/23 (Thursday), and 11/16/23 (Thursday). 2. Right heel wound treatment was not provided on 10/07/23 (Saturday), 10/14/23 (Saturday), 11/04/23 (Saturday), 11/09/23 (Thursday), and 11/16/23 (Thursday). 3. Right knee wound treatment was not provided on 10/07/23 (Saturday), 10/14/23 (Saturday), 11/04/23 (Saturday), 11/09/23 (Thursday), and 11/16/23 (Thursday). 4. Left lower leg/heel wound treatment was not provided on 10/07/23 (Saturday), 11/18/23 (Saturday), and 11/30/23 (Thursday). 5. Right elbow wound treatment was not provided on provided on 10/07/23 (Saturday), 10/14/23 (Saturday), 11/04/23 (Saturday), 11/09/23 (Thursday), 11/18/23 (Saturday), and 11/30/23 (Thursday). 6. Upper left back wound treatment was not provided on 10/07/23 (Saturday), 10/14/23 (Saturday), 10/21/23 (Saturday), 11/04/23 (Saturday), 11/09/23 (Thursday), 11/18/23 (Saturday), and 11/30/23 (Thursday). Review of R65's Progress Notes, for October and November 2023 and located under the Progress Notes tab of the EMR, revealed no documentation that the physician was notified of the dressing changes that were not provided on the above documented dates and shifts. Review R65's NP Note, dated 10/20/23 at 9:45 AM and located under the Progress Notes tab of the EMR, revealed, Wound culture results reviewed. Patient has E. Faecalis and Pseudomonas Aeruginosa which was both MDRO (multi-drug resistant organism). Patient started on Levaquin for 21 days . Review of R65's October 2023 MAR, located under the Orders tab of the EMR, revealed on 10/21/23 R65 was ordered Levaquin 500 mg by mouth one time a day for wound infection for 21 days. Review of R65's EMR revealed no documentation of weekly skin checks for this resident since the readmission date on 09/13/23. Review of R65's Wound Care Consultant Progress Notes showed a gap in visits from the last visit of 11/14/23 to the next visit occurring on 11/28/23. 4. Review of R3's undated admission Record, located under the Profile tab in the EMR, revealed this resident was initially admitted to the facility on [DATE] but was readmitted on [DATE] with the diagnoses of heart failure, diabetes mellitus type 2, pressure ulcer to left hip stageIV, atrial fibrillation, and obstructive sleep apnea. Review of the quarterly MDS, located under the MDS tab of the EMR and with an ARD of 11/08/23, revealed R3 was coded as having a BIMS of 15 out of 15. This indicated R3 was cognitively intact. R3 had been followed by the wound care consultant since 03/16/23 for the wound to the left lateral hip. Review of the wound care consultant note, dated 10/03/23, it was recorded that the left, lateral hip wound was an . acute full thickness trauma wound . with measurements of 2 cm length x 3 cm width x 2 cm depth. Review of wound care consultant note, dated 10/10/23, it was recorded, . Pt. (patient) seen for wound care follow up. Discussed the importance of getting surgery consult due to large calcium deposit in soft tissue and protruding to wound bed and continue to worsen pressure injury to left hip. PCP (primary care physician) requested to change tx (treatment) to iodosorb cream and pack. PCP and staff stated that the surgeon will only see her if she can transfer from transport's stretcher to clinic's exam table, and pt is not able to due to body habitus. PCP/NP will contact surgery and outpatient wound clinic where may have equipment and bariatric bed to arrange surgery consult . General Notes: The wound is stagnating . Continued review of the wound care consultant progress notes showed a gap in visits from the last visit of 10/10/23 to the next visit being on 10/24/23. Review of the 10/24/23 Progress Note, completed by the wound care consultant, indicated wound #1 is listed and the location of this wound is the left posterior hip at a stage IV with no mention of the left, lateral wound. It was noted on 10/31/23, the wound care consultant progress note stated, . There is heavy amount of serosanguineous drainage noted with no odor . There is no change noted in the wound progression . The wound care orders remained the same as when the PCP had requested a change in the orders on 10/10/23. Review of R3's October 2023 TAR revealed the dressing change to the left lateral hip was not performed on 10/01/23 (Sunday), 10/02/23 (Monday), 10/14/23 (Saturday), 10/15/23 (Sunday), 10/22 (Sunday) and 10/29/23 (Sunday). Review of R3's Wound Weekly Observation Tool was performed on 10/07/23 with the next documentation noted for this tool was 10/25/23. Review of the Wound Consultant's Progress Note, dated 11/07/23, revealed, . Pt. reports having appt (appointment) with general surgery on 11/20 and will possibly see an outpatient wound clinic. Wound has no significant changes due to calcium deposit. Will recommend continue treatment with iodoform packing . Continued review of the wound care consultant progress notes showed a gap in visits from the last visit of 11/14/23 to the next visit occurring on 11/28/23. Review of R3's November TAR revealed no dressing change to the left lateral hip on 11/01/23 (Wednesday), 11/02/23 (Thursday), and 11/05/23 (Sunday). The left lateral hip wound did not have dressing changes performed per physician orders on 11/18/23 (Saturday), 11/19/23 (Sunday), 11/26/23 (Sunday) 11/29/23 (Wednesday) and 11/30/23 (Thursday). Interview with the DON on 12/01/23 at 4:30 PM revealed, We cannot get [R3] to the surgeon's office because she is not able to transfer herself from the stretcher to the clinic examine table because she is so heavy. The appointment was postponed until sometime in January and R3's [family member] is trying to get transportation. Review of the 11/08/23 Weekly Skin Observation Tools for the two newly identified wounds documented: a wound to the right ischium at a stage II, which was first acquired on 11/04/23 covered by ABD [abdominal] pads and secure w/Medi pore, and a wound to the sacrum at a stage III, which was first acquired on 11/04/23. Review of R3's Progress Notes for October and November 2023 revealed no documentation that the physician was notified that the dressing changes were not provided and of the addition of two newly identified wounds on 11/04/23. In an interview with the DON on 12/02/23 at 4:57 PM, the DON stated she had noticed the TARs were not being signed off on and this had been discussed with the management team and the nurses were to be educated on wounds in monthly meetings. The DON stated she had not looked at specific nurses across the board and some nurses would say they completed wound care while others would say no. She also stated the risks of no wound care are worsening of the wounds and infection. The DON stated the LPNs (licensed practical nurses) cannot do wound measurement and the wound care nurse is an LPN; only the Physician Assistant does these measurements. The DON stated when the nurse discovers a new wound, they should complete a change in condition and notify the doctor or nurse practitioner to get orders for treatment. In an interview with the WCC on 12/05/23 at 2:25 PM, the WCC stated, I could not come earlier in the week (week of 11/19/23) but I was available to come Thanksgiving morning. The facility told me the DON was on vacation and there was no other staff that was able to make rounds with me so there were no visits made by me that week. 5. Review of R63's admission Record, located in the Profile tab of the EMR, revealed R63 was admitted to the facility on [DATE] with diagnoses including paraplegia, neuromuscular dysfunction of bladder, muscular weakness, type two diabetes with foot ulcer, and need for assistance with personal care. Review of R63's annual MDS assessment under the MDS tab of the EMR, with an ARD of 11/21/23, revealed he scored 15 out of 15 on the BIMS, indicating intact cognition. He was able to make himself understood and understand others. R63 required supervision or touching assistance with transferring into/out of bed but was independent with bed mobility. He used an indwelling catheter. R63 was at risk for pressure ulcers and currently had one stage II pressure ulcer and one arterial wound. R63 received a pressure-reducing device for his bed, pressure ulcer care, and dressings to his feet. Review of R63's Care Plan under the Care Plan tab of the EMR, initiated on 03/18/22 and updated on 11/07/23, revealed, I was admitted with actual pressure ulcers and I'm at risk for additional pressure ulcers. New area noted on toe of right foot. 11/07/23: Reopened pressure areas to resident's sacrum. The resident's goal was, I do not want to develop any additional pressure sores. The interventions included: 11/07/23: Recommendation given to get out of wheelchair more often to relieve pressure off sacrum . 11/07/23: [WCC] to follow until resolved . Administer treatments to feet as ordered. Wound team to follow . Assess my skin at least weekly and PRN. Document findings . Assist me with toileting and incontinence care PRN . [and] Assist me with turning and repositioning PRN. In an interview with R63 on 11/27/23 at 2:28 PM, he stated he had developed a pressure wound on his bottom in the facility, but it took facility staff three weeks to start taking care of it. He stated the Certified Nurse Aide (CNA) knew about the pressure ulcer, but he did not know why the CNA did not it report to the nurse or the nurse did not assess and treat it. R3 stated wound care was not provided on the weekends. He stated his wound treatments were ordered for Tuesdays, Thursdays, and Saturdays; however, on Saturdays, there was no wound care period. R63 stated he was paralyzed from the waist down and could not really turn from side to side in bed, so he usually laid on his back. He stated the staff did not reposition him while in bed. R63 stated he typically stayed in his wheelchair in the morning and early afternoon but got into bed around 3:00 PM to relieve some pressure on his bottom. Observations on 11/28/23 revealed R63 was up in his wheelchair throughout the morning and lunch time. At 3:43 PM and 4:50 PM, R63 was observed lying in bed on his back. Observations on 11/29/23 revealed R63 was up in his wheelchair throughout the morning and lunch time. At 4:05 PM, 6:21 PM, and 7:15 PM, R63 was observed lying in bed on his back. Observations on 11/30/23 revealed R63 was up in his wheelchair throughout the morning and lunch time. At 3:08 PM and 5:24 PM, he was observed lying in bed on his back. Review of the 11/07/23 Wound Care Consult note, found in the Miscellaneous tab of the EMR, revealed two newly acquired pressure ulcers: 1. Sacrum, stage III, 6 centimeter (cm) long, 6 cm wide, and 0.1 cm deep. The treatment order was: collagen, foam, and DPD three times per week. 2. Right ischium, stage II, 7 cm long, 2 cm wide, and 0.1 cm deep. The treatment order was: collagen, foam, and DPD three times per week. Review of the 11/08/23 Weekly Skin Observation Tools for the two newly identified wounds, located in the Assessments tab of the EMR, revealed: a wound to the sacrum at a stage III, which was first acquired in the facility on 11/04/23, and a wound to the right ischium at a stage II, which was first acquired in the facility on 11/04/23. Review of R63's record revealed though the wounds were documented as first acquired on 11/04/23, there was no documentation of the wounds, orders for treatment, or new interventions put in place until they were assessed by the WCC on 11/07/23. The wounds were first documented by facility nursing staff on 11/08/23. Review of R63's 11/08/23 Nurses [sic] Note, located under the Notes tab of the EMR, revealed, Resident noted to have a new acquired pressure area to buttocks. [WCC] to follow until resolved. Skin to buttocks noted to be compromised due to previous pressure areas and resident chooses to sit in wheelchair 12+ hours a day. Resident given education regarding the importance of pressure relieving. At this time, there was no indication the facility considered adding pressure-reducing devices to R63's wheelchair or implementing a turning/repositioning schedule. Review of R63's November 2023 TAR, located in the Orders tab of the EMR, revealed an order was entered on 11/09/23 for: Sacral Wound/Right Ischial: Cleanse wound with wound cleanser, pat dry, apply collagen and DPD every day shift every Tue, Thu, Sat for Stage II Acquired Pressure Injury. Though two wounds, one at stage III and one at stage II, were identified by the WCC on 11/07/23, the order was entered as one wound at a stage II. The treatment was not done on 11/09/23 as the resident was sent to the hospital for an unrelated health issue. R63 returned to the facility on [DATE]. Review of the 11/15/23 re-admission Nursing Comprehensive Assessment completed by LPN5 and located in the Assessments tab of the EMR revealed no documentation of any wounds or skin problems. Review of the EMR revealed there was no documentation of the resident's current wounds in the admission progress notes, there was no separate skin assessment on admission, and there was no further documentation or assessment of wounds. Review of R63's November 2023 TAR revealed the continued order for the Sacral Wound/Right Ischial treatment ordered 11/09/23; however, the treatment was not signed as provided on 11/16/23 (Thursday), 11/18/23 (Saturday), or 11/25/23 (Saturday). Review of R63's EMR revealed no documentation or assessment of the wounds from his re-admission on [DATE] until the next WCC visit on 11/28/23. Review of the 11/28/23 Wound Care Consult note, located in the Miscellaneous tab of the EMR, revealed a stage III pressure ulcer to the sacrum measuring 5 cm long, 6 cm wide, and 0.1 cm deep. The ordered treatment was cleanse with normal saline, apply medical honey and a DPD three times per week and as needed. There was no further documentation in the record regarding the separate stage II ischium wound. Continued review of R63's November 2023 TAR revealed the continued order from 11/09/23 for collagen, foam dressing, and DPD and did not reflect a change to the order from the WCC on 11/28/23 from collagen to medical honey. The treatment was not signed as completed on 11/30/23. Review of R63's December 2023 TAR revealed the 11/09/23 order for collagen, foam, and DPD was provided on 12/02/23. In an interview with the Medical Director, who was also the resident's primary physician, on 12/01/23 at 4:41 PM, he stated he was aware of both the ischium and sacral pressure ulcers and stated they were both still present. He stated he was not involved in wound assessment or treatment, as the wound care consultant handled wound-related matters. The Medical Director stated he was unaware of the wound care consultant's new order on 11/28/23 for medical honey rather than collagen and did not know of a reason why the new order would not be implemented. The Medical Director stated he deferred to the wound care consultant's orders for pressure ulcer care and the new order should have been implemented. Interview with the NP on 12/02/23 at 1:18 PM revealed she was aware of a pressure ulcer on the sacrum but not a second wound on the ischium. She stated she had not visualized R63's wounds and had not seen R63 since his return to the facility on [DATE]. The NP stated she deferred to the wound care consultant for assessment and treatment of pressure ulcers. In an interview with LPN5 on 12/02/23 at 2:40 PM, she denied completing the nursing admission assessment for R63, though it was signed by her. She stated she had not assessed R63's skin or visualized any wounds. In an interview on 12/02/23 2:51 PM, the DON confirmed LPN5 was clocked in at the time the admission assessment was completed and there was no chance the assessment could have been completed by someone else. The DON stated she did not know why the assessment did not reflect R63's current pressure ulcer. In an interview on 12/05/23 at 2:29 PM, the WCC stated R63's ischium wound was healed, but she was unable to find any documentation of the wound healing or documentation of the wound after its original assessment on 11/07/23. The WCC stated R63 still had a stage III pressure ulcer to his sacrum. 6. Review of R50's admission Record under the Profile tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses including: type two diabetes, morbid obesity, stage IV pressure ulcer of sacrum, muscle weakness, and gout. Review of R50's quarterly MDS assessment under the MDS tab of the EMR, with an ARD of 09/29/23, revealed he scored 15 out of 15 on the BIMS, indicating intact cognition. He required substantial/maximum assistance with bed mobility and transfers. He [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and facility policy/job description review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to avoid a system failure with the wound care program and lack of Director of Nursing (DON) supervision over the wound care program. The facility failed to prevent, assess, and treat pressure ulcers appropriately and failed to ensure needed physician services were provided by the primary physician (who also served as the facility's Medical Director) rather than the Nurse Practitioner (NP); the primary physician assessed, measured, and treated pressure ulcers; and the primary physician ensured appropriate treatment and services were provided by the wound care consultant for pressure ulcer prevention, assessment, and treatment. These failures affected nine of 10 residents (R) (R291, R293, R50, R65, R142, R292, R21, R3, and R63) reviewed for pressure ulcers. These failures presented a likelihood of serious harm, serious injury/impairment, or death related to a lack of adequate wound management, which contributed to hospitalization and subsequent cardiac arrest for R291. In addition, the facility failed to conduct an ongoing Quality Assurance and Performance Improvement (QAPI) program that implemented and evaluated corrective actions or performance improvement activities to address systemic failures to prevent, assess, and treat pressure ulcers appropriately and failed to ensure needed physician services were provided by the primary physician, who also served as the facility's Medical Director. On 11/29/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator and DON were informed of the Immediate Jeopardy (IJ) on 12/5/2023 at 8:22 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/27/2023. At the time of exit on 12/5/2023, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings included: During an interview on 12/2/2023 at 4:57 pm, the DON stated the facility implemented a Performance Improvement Plan (PIP) through their QAPI program regarding wounds in July 2023. The facility identified problems with residents not being turned and repositioned every two hours and that wound care was not being completed on weekends in their July 2023 PIP. The interventions included a weekly wound meeting, hiring of a new wound nurse, and staff education. Interview with the DON revealed the weekly wound meetings had not taken place and the new wound nurse had not started working yet. Continued failures with provision of wound care were noted at IJ level during the current survey: -Cross-reference F686: Pressure Ulcers - The facility failed to prevent, assess, and treat pressure ulcers appropriately, resulting in new, facility-acquired pressure ulcers and deterioration of current wounds for R291, R293, R50, R65, R142, R292, R21, R3, and R63. These findings constituted IJ of sever injury, impairment, or death. -Cross-reference F841: Medical Director - the facility failed to provide needed physician services to ensure admission assessments were provided by the primary physician (who also served as the facility's Medical Director) rather than the NP; the primary physician assessed, measured, and treated pressure ulcers; and the primary physician ensured appropriate treatment and services were provided by the wound care consultant for pressure ulcer prevention, assessment, and treatment. -Cross-reference F865: QAPI- the facility failed to conduct an ongoing QAPI program that implemented and evaluated corrective actions or performance improvement activities to address systemic failures to prevent, assess, and treat pressure ulcers appropriately and failed to ensure needed physician services were provided by the primary physician, who also served as the facility's Medical Director. The findings under F686 and F841 revealed: 1. A review of the clinical record revealed that R291 was admitted to the facility on [DATE] post-hospitalization with diagnoses of sepsis and an unstageable pressure ulcer to the sacrum and skin tear to anterior abdomen. Upon admission, the Nursing Comprehensive Assessment documented a stage IV pressure ulcer to the sacrum and unstageable wound with multiple open areas to the right buttock. A review of R291's record revealed no additional assessments or measurements of the documented wounds to the sacrum and right buttock. R291 was discharged to the hospital on [DATE], where she was diagnosed with shock due to sepsis, suspected soft tissue infection, acute blood loss anemia, cardiac arrest, acute respiratory failure, and stage IV decubitus ulcer with concern for necrotizing fasciitis. R291 suffered cardiac arrest in the hospital, required resuscitation, and remained in intensive care on a ventilator. Though R291 had shown signs of a change in condition several days prior to her hospitalization on 11/27/2023, including copious bleeding from the wound, lethargy, and inability to swallow food or medications. The facility failed to document the change of condition, follow up with assessment of the change of condition, or assess and treat her wounds appropriately. R291 had a treatment order for the sacral wound; however, this treatment was not provided on 11/25/2023 or 11/26/2023. There were no orders for care of the buttock wounds. R291 was seen by the NP on 11/27/2023 for her first physician assessment after admission, and the NP did not assess, measure, or document the resident's sacral and buttocks wounds. Neither facility staff, the resident's primary physician (who was also the Medical Director), nor the WCC had assessed, measured, or documented the resident's wounds during her stay, and there was no documentation of the copious bleeding from the wound. An interview with the NP on 12/2/2023 at 12:38 pm revealed she saw R291 on 11/27/2023 at about 9:15 am for the first time, as she was on vacation the week prior. The NP stated the resident's primary physician had not yet seen the resident. She stated she visualized the sacral wound but did not state she visualized the unstageable right buttock wounds. The NP stated she documented her assessment of the wound; however, was unable to locate documentation of the wound in her notes. The NP stated the nursing staff also reported a new cough and difficulty swallowing and taking medications that had been going on for several days; however, there was no documentation regarding this change of condition. In addition, the primary physician had not been notified of the change of condition and had not assessed the resident. During an interview on 12/2/2023 at 4:57 pm, the DON confirmed R291's wound had not been assessed by the WCC, NP, or the primary physician. 2. A review of the clinical record revealed that R293 was admitted to the facility on [DATE] post hospitalization with diagnoses of septic shock secondary to MRSA/MDRO in a stage IV sacral pressure ulcer, a right heel pressure ulcer, and a right inner thigh/calf pressure ulcer. A review of R293's Treatment Administration Record and Orders revealed no treatment orders from 10/17/2023 until 10/19/2023. The resident's primary physician, who was also the Medical Director, made several changes to the wound care orders without evidence of an assessment of the wounds or the appropriateness of the treatments. R293 acquired two new unstageable wounds in the facility, first documented on 11/7/2023, to the right heel and right metatarsal. The resident's wounds were not assessed from 11/720/23 to 11/28/2023, and wound care treatments were not consistently provided as ordered. There was no evidence the primary physician or NP evaluated the wounds during this time. On 11/8/2023, the primary physician changed the sacral wound treatment order from daily to every shift; however, there was no record of an assessment of the wound by the physician. 3. A review of the clinical record revealed that R3 had been followed by the wound care consultant since 3/16/2023 for a wound to the left lateral hip. Though a surgery consult was ordered and set up, R3 was unable to attend the appointment due to a lack of bariatric accommodations for transportation. The resident's physician, who was also the Medical Director, was unaware of the missed appointment. Though the physician had requested to change the wound treatment order, there was no evidence of an assessment of the wound by the physician. Though the wound was noted with copious amounts of bloody drainage, this was not addressed in the resident's record. Wound treatments were not provided as ordered, and R3's wounds were not assessed from 11/7/2023 to 11/28/2023. A review of the wound care consultant progress notes shows a gap in visits from the last visit of 10/10/2023 to the next visit being on 10/24/2023. There was no evidence the primary physician or NP evaluated the wounds during this time. Continued review of the wound care consultant progress notes showed a gap in visits from the last visit of 11/14/2023 to the next visit occurring on 11/28/2023. There was no evidence the primary physician or NP evaluated the wounds during this time. During an interview on 12/1/2023 at 4:30 pm, the DON stated, We cannot get R3 to the surgeon's office because she is not able to transfer herself from the stretcher to the clinic examine table because she is so heavy. The appointment was postponed until sometime in January and R3's brother is trying to get transportation. There was no evidence the primary physician was involved in ensuring the resident received the needed surgery. 4. A review of the clinical record revealed that R63's acquired a new stage III pressure ulcer to his sacrum and a new stage II pressure ulcer to his right ischium on 11/4/2023; however, they were not measured or assessed until 11/7/2023. A review of R63's record revealed though the wounds were documented as first acquired on 11/4/2023, there was no documentation of the wounds, order for treatment, or new interventions put in place until 11/7/2023. There was no evidence the primary physician, who also served as medical director, was notified of the wounds until 11/7/2023 or conducted an assessment of the wounds. R63 was hospitalized [DATE] to 11/15/2023, and upon re-admission, the facility failed to identify any current wounds in their assessment. The resident's wounds were not documented, measured, or assessed until 11/28/2023. Treatments were not consistently provided as ordered. There was no evidence the primary physician or NP assessed the resident's wounds upon re-admission on [DATE] to ensure appropriate treatment. An interview with the Medical Director on 12/1/2023 at 4:41 pm revealed he was aware of both the ischium and sacral pressure ulcers and stated they were both still present. The Medical Director stated he was unaware of the wound care consultant's new order on 11/28/2023 for medical honey rather than collagen and did not know the reason why the new order would not be implemented. The Medical Director stated he deferred to the wound care consultant's orders for pressure ulcer care. An interview with the NP on 12/2/2023 at 1:18 pm revealed she was aware of a pressure ulcer on the sacrum but not a second wound on the ischium. She stated she had not visualized R63's wounds and had not seen R63 since his return to the facility on [DATE]. 5. A review of the clinical record revealed that R65 was admitted with a stage IV pressure ulcer to the sacrum, stage IV pressure ulcer to the right heel, stage IV right knee pressure ulcer, stage IV left lower leg/heel pressure ulcer, and stage IV right elbow pressure ulcer. He developed a stage III pressure ulcer to the upper left back on 8/29/2023 in the facility. Wound treatments were not consistently provided as ordered. A review of the wound care consultant visits shows a gap of visits from the last visit of 11/14/2023 to the next visit being on 11/28/2023. There was no evidence the primary physician or NP evaluated the wounds during this time. A review of R65's TAR revealed wound care was consistently not provided as ordered on the weekend and occasionally during the week in October 2023 and November 2023. There was no indication the primary physician had been alerted to the missed treatments. There was no evidence the primary physician or NP evaluated the wounds and/or provided education or assistance to staff regarding performing wound care as ordered. 6. A review of the clinical record revealed that R50 developed a stage I pressure ulcer on 10/13/2023 while in the facility, which progressed into a stage III wound. There were no notifications, assessments, or treatment orders for the noted stage I and it was first assessed and measured on 10/17/2023 as a stage II. There was a lack of wound assessments until 11/7/2023, when the wound had deteriorated to stage III. There was no evidence the wound was observed, assessed, or treated by the primary physician, who was also the Medical Director, during this time. A newly developed, facility-acquired stage II pressure ulcer was noted on 11/21/2023. It was not assessed or measured until 12/5/2023. Wound treatments were not implemented as ordered. The physician failed to assess the wound during that time. A review of the wound care consultant visits shows a gap of visits from the last visit of 11/14/2023 to the next visit being on 11/28/2023. There was no evidence the primary physician or NP evaluated the wounds during this time. 7. A review of the clinical record revealed that R21 had a chronic stage III right heel pressure ulcer. Wound treatments were not consistently provided per the physician's order. A recommended treatment change by the wound care consultant was not implemented. A review of the clinical record revealed that R21 developed a new, facility-acquired sacral pressure ulcer on 11/7/2023; however, the wound was not measured or assessed until 11/14/2023. The resident developed another facility-acquired pressure ulcer to the right lateral foot noted 11/28/2023. The treatment order was for betadine three times week. The order was not documented; thus, the wound did not receive any treatment. Review of the resident's record revealed no additional documentation of a right lateral foot wound. There was no indication the resident's primary physician, who was also the Medical Director, had conducted any assessment of the resident's wounds. 8. A review of R292's admission comprehensive assessment on 11/21/2023 revealed the resident was documented with a stage III sacral pressure ulcer on admission; however, the wound was first assessed on 11/24/2023. At this time, there was also documentation of multiple stage II pressure areas to bilateral buttocks. There were no specifications or measurements of the wounds. A review of R292's admission physician orders documented an order on 11/21/2023 for Dressing to wounds on sacrococcygeal area and left buttock, clean with normal saline, apply Triad hydrophilic wound dressing paste three times a day and PRN. This order came from the primary physician, who was also the medical director, but there was no documentation indicating the physician had yet seen the resident and evaluated the wound. A review of R292's record revealed the first and only encounter with the NP or physician was on 11/27/2023, with the NP, six days after admission. The nurse practitioner did not document visualization of the stage III sacral or stage II bilateral buttocks wounds. Review of R292's record revealed a lack of follow through with wound consultation, continuing monitoring of the resident's wounds, or assessment of the status of the wounds, including measurements and treatments. 9. A review of R142's admission comprehensive assessment on 10/20/2023 revealed the resident was documented with dressings to coccyx, left, and right heel. The resident was not assessed or reviewed for skin concerns until the sixth day of admission. Treatment recommendations for the left heel and right heel were not implemented. The coccyx wound treatments were not provided as ordered. A review of R142's record revealed the first encounter was with the NP on 10/23/2023, the following Monday after admission. The resident was seen at bedside, but the NP failed to visualize or document the wound. There was no evidence the physician, who was also the medical director, had evaluated the wound. The resident was not assessed or reviewed for skin concerns until the sixth day of admission. A review of the wound care consultant visits showed a gap in visits from the last visit of 11/14/2023 to the next visit being on 11/28/2023. There was no evidence the primary physician or NP evaluated the wounds during this time. During a concurrent interview with the Administrator and DON on 12/5/2023 at 7:10 pm, the Administrator stated that she had to stop the staff from reporting to her any issues or problems with clinical care, because the staff were coming to her for everything, and she could not solve all the problems. The Administrator stated she stopped the staff when they were reporting a clinical concern and had them talk to the DON, because clinical care was DON's role. The Administrator stated if there was a clinical problem, the DON would solve it and fix it. The Administrator stated she was not sure of the communication system between the NP and Medical Director, but she expected them to communicate between each other. She also stated there was no direct communication between the WCC, the Medical Director or NP. The DON stated she would communicate information from the WCC to the Medical Director, and NP as needed. The Administrator stated she did not know the Medical Director was not aware of missed treatments and missed wound assessments/measurements. The findings under F865 revealed: A review of the July 2023 Performance Improvement Plan (PIP), provided on paper by the facility, revealed the facility identified problems with residents not being turned and repositioned every two hours and that wound care was not being completed on weekends. Review of the June 2023 PIP revealed a goal to decrease facility-acquired wounds by 7/3/2023. The interventions included a weekly wound meeting, wound nurse replaced due to critical errors, weekend wound nurse hired, staff education, daily review of skin assessment completion. On 12/4/2023, the PIP form documented the plan was in progress and the last update was made 10/13/2023. The DON revealed the weekly wound meetings had not taken place and the new wound nurse had not yet started working at the facility. During a concurrent interview with the Administrator and DON on 12/5/2023 at 7:10 pm, the Administrator stated she was the head of the QAPI program and held meetings monthly. The Administrator stated she solicited information from front-line staff to incorporate in the QAPI program. The Administrator stated the DON had identified that the number of wounds in the facility had significantly increased and the committee looked at trends and numbers from month to month. The Administrator stated the information presented on wounds was basically on the numbers of wounds; there was no in-depth root cause analysis to determine why the numbers increased. The DON added she presented the numbers of wounds each month, and when they increased, a PIP was implemented. The DON stated she would present on only numbers of wounds to identify any trends, and if the number of facility-acquired wounds increased, she would know the PIP was not effective. The DON stated there was no additional root cause analysis into the cause of increased wounds. The DON stated to monitor the effectiveness of the PIP, she would monitor wound numbers and receive verbal information regarding wound numbers from the Unit Mangers that was not documented. The DON stated she did periodic audits of wound care; however, the last one documented was in July 2023 because she now reviewed the UDAs [user-defined assessments] in the EMR software. She stated a skin sweep was done in October 2023; however, the sweep only served to identify existing wounds and not evaluate prevention measures or whether the wounds were assessed and treated appropriately. A review of the undated and unsigned Administrator Job Description revealed, The Administrator . plans, develops, organizes, implements, evaluates, and directs the overall operation of the facility as well as its programs and activities . identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. Establishes an ongoing system to monitor these key indicators such as the Quality Assurance and Performance Improvement process throughout the facility . evaluates key performance indicator outcomes . to determine the need for action from leadership and/or management . evaluates work performance of department heads and maintains accountability across all departments . ensures delivery of compassionate quality care and services across an interdisciplinary team approach . [and] identifies and collaborates with members of the interdisciplinary team, physicians, consultants, and community agencies to identify opportunities for enhanced services to the residents and/or to resolve issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and facility policy/contract review, the facility failed to provide needed physician services to ensure admission assessments were provided by the primary physician (who also served as the facility's Medical Director) rather than the Nurse Practitioner (NP); the primary physician assessed, measured, and treated pressure ulcers; and the primary physician ensured appropriate treatment and services were provided by the wound care consultant for pressure ulcer prevention, assessment, and treatment for nine of 10 resident (R) (R291, R293, R50, R65, R142, R292, R21, R3, and R63) reviewed for pressure ulcers. These failures presented a likelihood of serious harm, serious injury/impairment, or death related to a lack of adequate wound management, which contributed to hospitalization and subsequent cardiac arrest for R291. On 11/29/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 12/4/2023 at 7:35 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/27/2023. At the time of exit on 12/5/2023, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings included: During a telephone interview on 12/1/2023 at 4:41 pm with the primary physician for the above residents, who also served as the facility's Medical Director, he stated he was not involved in wound assessment or treatment, as the wound care consultant (WCC) handled wound-related matters. He added that he deferred all wound-related issues to the wound care consultant. The Medical Director stated the facility staff did not assess or measure wounds and waited for the weekly visit by the WCC. The Medical Director stated when a new pressure ulcer was found, the facility was expected to keep the wound as clean as possible and provide dressings if deemed necessary until evaluation by the WCC, which could be up to a week, or longer if the WCC was on vacation. During an interview on 12/2/2023 at 1:18 pm, the NP, who worked under the Medical Director, stated she conducted all initial visits of residents after admission, as the primary physician could take up to 30 days to visit the resident. The NP stated when she conducted admission visits, she did not assess any pressure ulcers, as that was the responsibility of the WCC. The NP stated she typically did not review the WCC's assessments and treatment plan in the notes; this information would be relayed to her through the DON. During an interview on 12/2/2023 at 4:57 pm, the DON stated the facility did not have a Registered Nurse (RN) to assess and measure wounds, so the WCC was expected to assess and measure all pressure ulcers. The DON stated the WCC came to the facility once per week on Tuesdays, but had not been in the week of 11/20/2023, as the DON was on vacation and there was no one else available to conduct rounds with the consultant. The DON stated she asked all her nurse managers, but no one was available to fill in on wound rounds, and she could not make them do it. The Medical Director was not present to assist the wound care consultant with wound rounds the week of 11/20/2023, and the NP was on vacation that week. The DON stated that new wounds should be assessed and measured by the consultant on the next weekly visit after a wound was found; however, there was no system in place for the primary physician to ensure wounds were assessed and measured when first discovered and/or if the wound care consultant was not available. Cross-reference F686: Pressure Ulcers - The facility failed to prevent, assess, and treat pressure ulcers appropriately, resulting in new, facility-acquired pressure ulcers and deterioration of current wounds for R291, R293, R50, R65, R142, R292, R21, R3, and R63. These findings constituted Immediate Jeopardy of sever injury, impairment, or death. The findings under F686 revealed: 1. A review of the clinical record revealed that R291 was admitted to the facility on [DATE] post-hospitalization with diagnoses of sepsis and an unstageable pressure ulcer to the sacrum and skin tear to anterior abdomen. Upon admission, the Nursing Comprehensive Assessment documented a stage IV pressure ulcer to the sacrum and unstageable wound with multiple open areas to the right buttock. A review of R291's record revealed no additional assessments or measurements of the documented wounds to the sacrum and right buttock. R291 was discharged to the hospital on [DATE], where she was diagnosed with shock due to sepsis, suspected soft tissue infection, acute blood loss anemia, cardiac arrest, acute respiratory failure, and stage IV decubitus ulcer with concern for necrotizing fasciitis. R291 suffered cardiac arrest in the hospital, required resuscitation, and remained in intensive care on a ventilator. Though R291 had shown signs of a change in condition several days prior to her hospitalization on 11/27/2023, including copious bleeding from the wound, lethargy, and inability to swallow food or medications, the facility failed to document the change of condition, follow up with assessment of the change of condition, or assess and treat her wounds appropriately. R291 had a treatment order for the sacral wound; however, this treatment was not provided on 11/25/2023 or 11/26/2023. There were no orders for care of the buttock wounds. R291 was seen by the NP on 11/27/2023 for her first physician assessment after admission, and the NP did not assess, measure, or document the resident's sacral and buttocks wounds. Neither facility staff, the resident's primary physician (who was also the Medical Director), nor the WCC had assessed, measured, or documented the resident's wounds during her stay, and there was no documentation of the copious bleeding from the wound. An interview with the NP on 12/2/2023 at 12:38 pm revealed she saw R291 on 11/27/2023 at about 9:15 am for the first time, as she was on vacation the week prior. The NP stated the resident's primary physician had not yet seen the resident. She stated she visualized the sacral wound but did not state she visualized the unstageable right buttock wounds. The NP stated she documented her assessment of the wound; however, was unable to locate documentation of the wound in her notes. The NP stated the nursing staff also reported a new cough and difficulty swallowing and taking medications that had been going on for several days; however, there was no documentation regarding this change of condition. In addition, the primary physician had not been notified of the change of condition and had not assessed the resident. During an interview on 12/2/2023 at 4:57 pm, the DON confirmed R291's wound had not been assessed by the WCC, NP, or the primary physician. 2. A review of the clinical record revealed that R293 was admitted to the facility on [DATE] post hospitalization with diagnoses of septic shock secondary to Methicillin-resistant Staphylococcus aureus/Multi-drug Resistant Organism (MRSA/MDRO) in a stage IV sacral pressure ulcer, a right heel pressure ulcer, and a right inner thigh/calf pressure ulcer. A review of R293's Treatment Administration Record (TAR) and Orders revealed no treatment orders from 10/17/2023 until 10/19/2023. The resident's primary physician, who was also the Medical Director, made several changes to the wound care orders without evidence of an assessment of the wounds or the appropriateness of the treatments. R293 acquired two new unstageable wounds in the facility, first documented on 11/7/2023, to the right heel and right metatarsal. The resident's wounds were not assessed from 11/7/2023 to 11/28/2023, and wound care treatments were not consistently provided as ordered. There was no evidence the primary physician or NP evaluated the wounds during this time. On 11/8/2023, the primary physician changed the sacral wound treatment order from daily to every shift; however, there was no record of an assessment of the wound by the physician. 3. A review of the clinical record revealed that R3 had been followed by the wound care consultant since 3/16/2023 for a wound to the left lateral hip. Though a surgery consult was ordered and set up, R3 was unable to attend the appointment due to a lack of bariatric accommodations for transportation. The resident's physician, who was also the Medical Director, was unaware of the missed appointment. Though the physician had requested to change the wound treatment order, there was no evidence of an assessment of the wound by the physician. Though the wound was noted with copious amounts of bloody drainage, this was not addressed in the resident's record. Wound treatments were not provided as ordered, and R3's wounds were not assessed from 11/7/2023 to 11/28/2023. A review of the wound care consultant progress notes shows a gap in visits from the last visit of 10/10/2023 to the next visit being on 10/24/2023. There was no evidence the primary physician or NP evaluated the wounds during this time. Continued review of the wound care consultant progress notes showed a gap in visits from the last visit of 11/14/2023 to the next visit occurring on 11/28/2023. There was no evidence the primary physician or NP evaluated the wounds during this time. During an interview on 12/1/2023 at 4:30 pm, the DON stated, We cannot get R3 to the surgeon's office because she is not able to transfer herself from the stretcher to the clinic examine table because she is so heavy. The appointment was postponed until sometime in January and R3's brother is trying to get transportation. There was no evidence the primary physician was involved in ensuring the resident received the needed surgery. 4. A review of the clinical record revealed that R63's acquired a new stage III pressure ulcer to his sacrum and a new stage II pressure ulcer to his right ischium on 11/4/2023; however, they were not measured or assessed until 11/7/2023. A review of R63's record revealed though the wounds were documented as first acquired on 11/4/2023, there was no documentation of the wounds, order for treatment, or new interventions put in place until 11/7/2023. There was no evidence the primary physician, who also served as medical director, was notified of the wounds until 11/7/2023 or conducted an assessment of the wounds. R63 was hospitalized [DATE] to 11/15/2023, and upon re-admission, the facility failed to identify any current wounds in their assessment. The resident's wounds were not documented, measured, or assessed until 11/28/2023. Treatments were not consistently provided as ordered. There was no evidence the primary physician or NP assessed the resident's wounds upon re-admission on [DATE] to ensure appropriate treatment. An interview with the Medical Director on 12/1/2023 at 4:41 pm revealed he was aware of both the ischium and sacral pressure ulcers and stated they were both still present. The Medical Director stated he was unaware of the wound care consultant's new order on 11/28/2023 for medical honey rather than collagen and did not know the reason why the new order would not be implemented. The Medical Director stated he deferred to the wound care consultant's orders for pressure ulcer care. An interview with the NP on 12/2/2023 at 1:18 pm revealed she was aware of a pressure ulcer on the sacrum but not a second wound on the ischium. She stated she had not visualized R63's wounds and had not seen R63 since his return to the facility on [DATE]. 5. A review of the clinical record revealed that R65 was admitted with a stage IV pressure ulcer to the sacrum, stage IV pressure ulcer to the right heel, stage IV right knee pressure ulcer, stage IV left lower leg/heel pressure ulcer, and stage IV right elbow pressure ulcer. He developed a stage III pressure ulcer to the upper left back on 8/29/2023 in the facility. Wound treatments were not consistently provided as ordered. A review of the wound care consultant visits shows a gap of visits from the last visit of 11/14/2023 to the next visit being on 11/28/2023. There was no evidence the primary physician or NP evaluated the wounds during this time. A review of R65's TAR revealed wound care was consistently not provided as ordered on the weekend and occasionally during the week in October and November 2023. There was no indication the primary physician had been alerted to the missed treatments. There was no evidence the primary physician or NP evaluated the wounds and/or provided education or assistance to staff regarding performing wound care as ordered. 6. A review of the clinical record revealed that R50 developed a stage I pressure ulcer on 10/13/2023 while in the facility, which progressed into a stage III wound. There were no notifications, assessments, or treatment orders for the noted stage I and it was first assessed and measured on 10/17/2023 as a stage II. There was a lack of wound assessments until 11/7/2023, when the wound had deteriorated to stage III. There was no evidence the wound was observed, assessed, or treated by the primary physician, who was also the medical director, during this time. A newly developed, facility-acquired stage II pressure ulcer was noted on 11/21/2023; it was not assessed or measured until 12/5/2023. Wound treatments were not implemented as ordered. The physician failed to assess the wound during that time. A review of the wound care consultant visits shows a gap of visits from the last visit of 11/14/2023 to the next visit being on 11/28/2023. There was no evidence the primary physician or NP evaluated the wounds during this time. 7. A review of the clinical record revealed that R21 had a chronic stage III right heel pressure ulcer. Wound treatments were not consistently provided per the physician's order. A recommended treatment change by the wound care consultant was not implemented. A review of the clinical record revealed that R21 developed a new, facility-acquired sacral pressure ulcer on 11/7/2023; however, the wound was not measured or assessed until 11/14/2023. The resident developed another facility-acquired pressure ulcer to the right lateral foot noted 11/28/2023. The treatment order was for betadine three times week. The order was not documented; thus, the wound did not receive any treatment. Review of the resident's record revealed no additional documentation of a right lateral foot wound. There was no indication the resident's primary physician, who was also the Medical Director, had conducted any assessment of the resident's wounds. 8. A review of R292's admission comprehensive assessment on 11/21/2023 revealed the resident was documented with a stage III sacral pressure ulcer on admission; however, the wound was first assessed on 11/24/2023. At this time, there was also documentation of multiple stage II pressure areas to bilateral buttocks. There were no specifications or measurements of the wounds. A review of R292's admission physician orders documented an order on 11/21/2023 for Dressing to wounds on sacrococcygeal area and left buttock, clean with normal saline, apply Triad hydrophilic wound dressing paste three times a day and PRN. This order came from the primary physician, who was also the medical director, but there was no documentation indicating the physician had seen the resident and evaluated the wound. A review of R292's record revealed the first and only encounter with the NP or physician was on 11/27/2023, with the NP, six days after admission. The nurse practitioner did not document visualization of the stage III sacral or stage II bilateral buttocks wounds. Review of R292's record revealed a lack of follow through with wound consultation, continuing monitoring of the resident's wounds, or assessment of the status of the wounds, including measurements and treatments. 9. A review of R142's admission comprehensive assessment on 10/20/2023 revealed the resident was documented with dressings to coccyx, left, and right heel. The resident was not assessed or reviewed for skin concerns until the sixth day of admission. Treatment recommendations for the left heel and right heel were not implemented. The coccyx wound treatments were not provided as ordered. A review of R142's record revealed the first encounter was with the NP on 10/23/2023, the following Monday after admission. The resident was seen at bedside, but the NP failed to visualize or document the wound. There was no evidence the physician, who was also the medical director, had evaluated the wound. The resident was not assessed or reviewed for skin concerns until the sixth day of admission. A review of the wound care consultant visits showed a gap in visits from the last visit of 11/14/2023 to the next visit being on 11/28/2023. There was no evidence the primary physician or NP evaluated the wounds during this time. During a telephone interview with the Medical Director on 12/4/2023 at 5:51 pm, he stated residents at risk for pressure ulcer development should have orders to be turned/repositioned at regular intervals. He stated he was not sure whether the above residents had repositioning orders. The Medical Director stated when a resident was admitted with a wound or developed a new wound, the wound would not be assessed or measured until the WCC visit the following Tuesday, as he deferred all wound care and treatment to the WCC. The Medical Director stated he was aware the facility had issues with wound care and prevention and had developed a performance improvement plan to address the issues, but he was unsure what the plan entailed. He stated the biggest issue was prevention of new wounds with the most important aspect being frequent turning and repositioning. The Medical Director stated he was not aware of any corrective actions implemented to address pressure ulcer care or turning/repositioning. The Medical Director stated if there was concern regarding a deteriorating wound, he would expect notification from the WCC and would send the resident to another wound care clinic or the hospital. The Medical Director stated surgery could be beneficial but was often times not an option for elderly and compromised individuals. A review of the facility's Medical Director Services Agreement, dated 6/1/2022, revealed, Medical Director shall be responsible for the implementation of resident medical care policies . Medical Director shall be responsible for the coordination of physician services and medical care at Facility . Medical Director shall provide for the maintenance and continuous collection of information concerning Facility's experience with negative health care outcomes . Medical Director shall be responsible for taking necessary corrective measures when a physician . fails to provide services which meet generally accepted standards of practice .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, facility document review, and facility policy review, the facility failed to 1. control measures to prevent the spread of COVID-19 among 17 (Resident (R)83, R79, R51, R291, R73, R52, R80, R86, R57, R77, R81, R26, R8, R74, R66, and R28) of 85 current facility residents; 2. follow infection control guidelines during pressure ulcer dressing change observations for four of seven residents (R142, R21, R292, and R63); 3. perform hand hygiene during meal service; and 4. maintain a urinary catheter bag off the floor. At the time of the survey team's entrance in the facility on 11/27/2023, there were five confirmed cases of COVID-19, with an additional six cases on 11/27/23. On 11/28/2023, the facility reported six more new cases of COVID-19 to the survey team totaling 17 cases of COVID-19 present in the facility. All 17 residents had co-morbid diagnoses which placed them at risk of severe illness or death. On 11/29/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 11/29/2023 at 10:25 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/18/2023. At the time of exit on 12/5/2023, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing. Findings included: 1.a. Upon entrance to the facility on [DATE] at 9:00 AM, the Administrator stated several residents currently had COVID-19 and they were on C Hall. A list of residents with COVID-19 which consisted of five residents was provided by the facility and given to the survey team at approximately 11:00 AM. Review of R83's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/23 revealed this resident was admitted to the facility on [DATE] with diagnoses of but not limited to stroke, renal insufficiency, and diabetes mellitus. R83 tested positive for COVID-19 on 11/22/23. Review of R79's admission MDS with an ARD of 09/19/23 revealed this resident was admitted to the facility on [DATE] with diagnoses of but not limited to stroke, hypertension, and respiratory failure. R79 tested positive for COVID-19 on 11/18/23. Review of R51's quarterly MDS with ARD of 08/29/23 revealed this resident was readmitted to the facility on [DATE] with diagnoses of but not limited to coronary artery disease, heart failure, and diabetes mellitus. R51 tested positive for COVID-19 on 11/22/23. Review of R292's undated admission Record under the Profile tab in the electronic medical record (EMR) revealed this resident was admitted to the facility on [DATE] with the diagnoses of but not limited to sepsis and acute renal failure. R292 tested positive for COVID-19 on 11/25/23. Review of R73's admission MDS with ARD of 11/03/23 revealed this resident was readmitted to the facility on [DATE] with diagnoses of but not limited to seizure disorder, psychotic disorder other than schizophrenia, and hypertension. R73 tested positive for COVID-19 on 11/18/23. Review of R52's admission MDS with ARD of 10/17/23 revealed this resident was admitted to the facility on [DATE] with diagnoses of but not limited to peripheral vascular disease, pneumonia, and septicemia. R52 tested positive for COVID-19 on 11/27/23. Review of R80's admission MDS with ARD of 11/07/23 revealed this resident was admitted to the facility on [DATE] with diagnoses of but not limited to atrial fibrillation and diabetes mellitus. R80 tested positive for COVID-19 on 11/27/23. Review of R86's admission MDS with ARD of 11/13/23 revealed this resident was admitted to the facility on [DATE] with diagnoses of but not limited to cancer and atrial fibrillation. R86 tested positive for COVID-19 on 11/27/23. Review of R57's admission MDS with ARD of 10/16/23 revealed this resident was admitted to the facility on [DATE] with diagnoses of but not limited to Huntington's Disease. R57 tested positive for COVID-19 on 11/27/23. Review of R291's undated admission Record under the Profile tab revealed an admission date of 11/22/23 along with diagnoses of but not limited to sepsis, colon cancer, and stroke. R291 tested positive for COVID-19 on 11/27/23. Review of R291's progress notes revealed the family requested the facility send R291 to the emergency room to be evaluated due to being COVID positive. R291 was transferred to the emergency room on [DATE] at 7:11 PM. Review of the emergency room's documentation on 11/29/23 revealed admitting diagnoses of but not limited to mixed septic and hemorrhagic shock, acute blood loss secondary to disseminated intravascular coagulation (DIC) from sepsis, cardiac arrest, acute kidney injury, acute respiratory failure, stage four decubitus ulcer with concern for necrotizing fasciitis, and history of colon cancer. Review of R77's quarterly MDS with ARD of 08/30/23 revealed this resident was readmitted to the facility on [DATE] with diagnoses of but not limited to coronary artery disease, renal insufficiency, multi-drug resistant organism, and diabetes mellitus. R77 tested positive for COVID-19 on 11/27/23. Review of R81's admission MDS with ARD of 10/21/23 revealed this resident was admitted to the facility on [DATE] with diagnoses of but not limited to hypertension, thyroid disorder, and asthma. R191 tested positive for COVID-19 on 11/28/23. Review of R26's quarterly MDS with ARD of 11/11/23 revealed this resident was admitted to the facility on [DATE] with diagnoses of but not limited to coronary artery disease, renal insufficiency, diabetes mellitus, and asthma. R26 had a COVID (+) test on 11/28/23. Review of R8's quarterly MDS with ARD of 10/17/23 revealed this resident was readmitted to the facility on [DATE] with the diagnoses of but not limited to coronary artery disease, diabetes mellitus, asthma, and respiratory failure. R8 tested positive for COVID-19 on 11/28/23. Review of R74's quarterly MDS with ARD of 09/10/23 revealed this resident was readmitted to the facility on [DATE] with the diagnoses of but not limited to renal insufficiency, septicemia, diabetes mellitus, and cerebral palsy. R74 tested positive for COVID-19 on 11/28/23. Review of R66's quarterly MDS with ARD of 11/06/23 revealed this resident was readmitted to the facility on [DATE] with the diagnoses of but not limited to stroke, seizure disorder, and malnutrition. R66 tested positive for COVID-19 on 11/28/23. Review of R28's annual MDS with ARD of 11/14/23 revealed this resident was admitted to the facility on [DATE] with the diagnosis of but not limited to renal insufficiency, asthma, and renal failure. R28 tested positive for COVID-19 on 11/28/23. Observations on C Hall began on 11/27/23 at 12:30 PM. At 12:40 PM R62 stated, I have to share a bathroom with the lady next door that has COVID. R73 was confirmed positive for COVID-19 on 11/18/23 and shared a bathroom with R62. Both residents were able to use this bathroom. On 11/27/23 at 12:45 PM, 12:45 PM, R292 and R191 were listed in the same room. During an interview Licensed Practical Nurse (LPN)1 stated, Only R292 is in the room, R191 was moved to B Hall because R191 had requested not to be in the room with someone that has COVID. During an interview on 11/28/23 at 11:48 AM, the Staff Development/Infection Control Preventionist Registered Nurse (SDC ICP). stated there was an in service on 11/01/23 that covered donning and doffing of gowns in case there was an outbreak of COVID again and 52 employees had received this in service. She further stated when residents became positive for COVID the facility wanted them in a more contained area and the roommates would transfer to another room. COVID testing had been only for C Hall residents until today and now all residents would be tested twice weekly. The positive residents would go into isolation and They will come off after the 8th day when they test negative, or they are asymptomatic. I think they are doing that. During an observation on 11/27/23 at 1:54 PM, Laundry Staff Member1 was observed going into a Droplet Precaution Isolation Room of R80 without PPE consisting of a N95 mask, gown, gloves, or face shield when delivering a shirt to R80 who was COVID positive. When Laundry Staff Member1 came out of R80's room and was asked what PPE she should have been wearing when entering a COVID positive room she stated, I didn't see that at all (referring to the isolation signage on the resident's door). The Director of Nursing (DON) was notified and stated, Anyone going into the room has to wear a gown and gloves, N95 mask and face shield if direct care is given to the resident. I will test her and will have her go home today and we will begin in services immediately with all staff. During an observation on 11/28/23 at 1:46 PM, Licensed Practical Nurse (LPN)6 was observed going into R51's room, who was COVID-19 positive, and left the door ajar open to the hallway and when she returned to the hallway. LPN6 did not have on a N95 mask. LPN6 only had on a surgical mask. This employee was noted to have signed the in service conducted this morning which covered infection control precautions and what was needed to be worn as far as personal protective equipment (PPE). During an observation on 11/28/23 at 1:58 PM, Certified Nursing Assistant (CNA)3 was observed walking in the hallway of C Hall, which housed the COVID-19 positive residents, with only a surgical mask on. CNA3 stated, I wasn't here yesterday. This employee was noted to have signed the in service conducted this morning which covered infection control precautions and what was needed to be worn as far as PPE. During an observation on11/28/23 2:25 PM, CNA3 stepped almost completely out of the door of R57's room wearing his gown, face shield, N95 mask, gloves, and booties. CNA3 doffed his gown outside the room with the door ajar and began rolling it up with gloves on and all other PPE. A female staff member came down the hallway and handed CNA3 a new disposable gown. She opened the door more and informed him to step into the room to doff the gown and provided a small red bag. CNA3 took the doffed gown (while 2/3 into the room), placed it into the bag, and handed it to her. She tied it up and took it down the hall. CNA3 donned the new gown on and stepped back into the room and shut the door. This employee was noted to have signed the in service conducted this morning which covered infection control precautions and what was needed to be worn as far as PPE. During an interview on 11/28/23 at 1:05 PM, the DON stated R193 was admitted with COVID-19 on 11/17/23, and the current COVID-19 outbreak began on 11/18/23 when R79 and R73 tested positive. R79's room was right next to R193 's room on the C Hall and R73 resided in the C Hall as well. R51 tested positive on 11/22/23 and R83 tested positive on 11/23/23. Both residents were in C Hall. R83's roommate, R57, was moved to another room on C Hall. R292, who resided on C Hall, tested positive on 11/25/23. Her roommate, R81, was moved to a shared room in B Hall. A staff member tested positive on 11/26/23. On 11/27/23, seven additional residents tested positive for COVID-19 on the C Hall: R77, R80, R194, R57, R52, R86, and R291. On 11/28/23, the facility provided in-service sign in sheets for employees that received an in service on the topics of COVID, PPE, and Handwashing. This in-service was provided to the employees on 11/27/23 with 39 employee signatures noted on the Attendance Form. The facility provided in-service sign in sheets for employees that received an in-service regarding the topic on COVID-19 which included donning/doffing PPE, handwashing, understanding the spread of the virus, understanding how to care for COVID (+) residents, what to do if you present with signs and symptoms of COVID-19, outbreak testing, contact tracing, room changes, exposed resident, and vital signs. This in-service was to be held on 11/29/23 but the facility failed to provide the employee sign in sheets to the survey team prior to exit conference on 12/05/23. The facility provided resident testing that was conducted on 11/27/23 through 12/05/23. There was a total of 18 residents who were tested positive for COVID-19 in these listed timeframes. The facility provided staff testing that was conducted on 11/27/23 through 12/05/23. There was a total of 9 staff members who tested positive for COVID-19 in these listed timeframes. The facility provided employee competencies for COVID-19 testing for residents and staff members. From 11/30/23 to 12/04/23, there were a total of 16 employees that completed their competencies for COVID-19 testing. b Review of R81's admission Record, located in the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] with diagnoses including: traumatic amputation of left lower leg, chronic obstructive pulmonary disease (COPD), and hypertension. Review of R81's admission MDS assessment, with an ARD of 10/21/23, revealed a Brief Interview for Mental Status (BIMS) score 15 out of 15 which indicated intact cognition. She was able to make herself understood and understand others. Review of the facility's Change of Room or Roommate tracker, provided on paper, documented R81 originally resided in a room on the C Hall shared with R292. R292 tested positive for COVID-19 on 11/25/23 and R81 was moved, per request, to a room on the B Hall shared with R28. During observations on 11/27/23 at 12:04 PM R81 was in a shared room without any transmission-based precautions in place. During an interview at the same time, R81 stated she typically resided in the C Hall, but since her roommate on C Hall was tested positive for COVID-19, she was moved to B Hall into a room shared with R28. R81 stated she never had COVID-19 and was hoping she could avoid catching it. Review of R81's EMR revealed there was no documentation of monitoring for signs or symptoms of COVID-19 from 11/25/23, when she came in close contact with a positive resident, to 11/28/23. There were no COVID-19 testing results provided for R81 from 11/25/23 to 11/28/23. Review of R81's COVID-19 (Point-of-Care) Antigen Testing - Patient report, located in the Miscellaneous tab of the EMR, revealed she tested positive for COVID-19 on 11/28/23. Review of R81's Communication - With Resident note, dated 11/28/23, located under the Notes tab of the EMR, revealed she was moved to a room in the C Hall due to a new diagnosis of COVID-19. c. Review of R28's admission Record revealed she was admitted to the facility on [DATE] with diagnoses including COPD, chronic pancreatitis, respiratory failure with hypoxia, and chronic kidney disease. Review of R28's annual MDS assessment, with an ARD of 11/14/23, revealed a BIMS score of 15 out of 15 which indicated intact cognition. R28 was able to make herself understood and was able to understand others. During an interview on 11/27/23 at 12:05 PM, R28 stated R81 had just moved into her room because of COVID-19, and she did not want to stay in a room with R81. Review of R28's EMR revealed there was no documentation of monitoring for signs or symptoms of COVID-19 from 11/25/23, when R81 (who was in close contact with a positive resident) was moved into her room, and 11/28/23. Review of R28's COVID-19 POC Antigen Testing - Patient report, located in the Miscellaneous tab of the EMR, revealed she tested positive for COVID-19 on 11/28/23. During an interview on 11/28/23 at 11:48 AM, the SDC/ICP stated a resident in close contact with a positive resident should not be moved into a shared room to limit the potential spread of the infection. She stated in the event of R81 moving to the B Hall, we've already potentially exposed the other person in the room. The SDC/ICP stated anyone with close contact should be monitored daily for signs or symptoms of COVID-19 and tested twice weekly. During an observation on 11/29/23 at 2:13 PM, CNA7 was observed wearing only a surgical mask while taking blankets out of room [ROOM NUMBER], which housed a COVID-19 positive resident, to a resident's room across the hall, which was a COVID-19 free room with two residents. CNA7 stated the blankets belonged to the resident across the hall who had been removed from the room, and she was told by the DON it was ok to move them to her room without laundering. During an interview on 11/29/23 at 2:25 PM, the DON stated the staff should not have removed blankets from a COVID-19 room to a non COVID-19 room without first laundering the blankets to help prevent spread of the infection. Review of the facility's policy titled, Coronavirus Prevention and Response, dated 12/22, revealed, This facility will respond promptly upon suspicion of illness associated with a SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus . Staff shall be alert to signs of COVID-19 and notify the resident's physician if evident: a. Fever or chills b. Cough c. Shortness of breath or difficulty breathing d. Fatigue e. Muscle or body aches f. Headache g. New loss of taste or smell h. Sore throat i. Congestion or runny nose j. Nausea or vomiting k. Diarrhea HCP [health care professionals] should follow standard precautions if SARS-CoV-2 infection is not suspected in a resident presenting for care or transmission-based precautions if required based on the suspected diagnosis. 13. IPC practices when caring for residents with suspected or confirmed SARS-CoV-2 infection: For asymptomatic residents following close contact with someone with SARS-CoV-2 infection: i. Asymptomatic residents do not require empiric use of transmission-based precautions while being evaluated for SARS-CoV-2 following close contact with someone with SARS-CoV-2 infection. The resident should still wear source control and those who have not recovered from SARS-CoV-2 infection in the prior 30 days should be tested as per the testing policy. ii. Empiric transmission-based precautions following close contact to be considered may include: 1. Resident is unable to be tested or wear source control as recommended for l0 days following their exposure 2. Resident is moderately to severely immunocompromised 3. Resident is residing on a unit with others who are moderately to severely immunocompromised 4. Resident is residing on a unit experiencing ongoing SARS-CoV-2 transmission that is not controlled with initial interventions. Resident placement considerations: a. Residents with suspected or confirmed SARS-CoV-2 infection should be placed in a single-person room with the door kept closed, if safe to do so, and a dedicated bathroom if possible. i. If cohorting, only residents with the same respiratory pathogen should be housed in the same room, . c. Limit transport and movement of the resident outside the room to medically essential purposes.15. HCP who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. Review of facility's policy titled, PPE Source Control, dated 12/22, revealed This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Definitions: Personal protective equipment, or PPE, refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with pathogens. It includes gloves, gowns, face protection (facemasks, goggles, and face shields), and respiratory protection (respirators). Policy Explanation and Compliance Guidelines: 1. All staff who have contact with residents and/or that environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. 2. PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status. 3. Multiple factors determine the appropriate selection of PPE for a particular task: a. The type of exposure anticipated (e.g., splash, /spray versus touch) b. The volume of fluid or tissue to which there is a potential exposure. c. The likelihood of exposure d. The probable route of exposure (e.g., direct contact versus inhalation) e. The need for transmission-based precautions . 2. a. Review of R142's MDS with an ARD of 10/24/23 revealed this resident was admitted to the facility on [DATE] with diagnoses of but not limited to cirrhosis and thyroid disorder. R142 was coded for stage two which was located on the sacral and an unstageable wound that was located on the left heel. These pressure ulcers were present on admission to the facility. During a wound care observation on 12/04/23 at 9:27 AM the DON donned a pair of gloves and repositioned the resident. The DON proceeded to pull the adult brief down, perform peri care due to resident having bowel movement on her skin, removed the old dressing off and touched the wound bed on the sacral area with the same gloves on. Then the DON removed her old gloves and reapplied a clean pair of gloves on. The DON did not use hand sanitizer or perform hand washing with soap and water between the glove changes. b. Review of R21's significant change MDS with an ARD of 09/28/23 revealed this resident was admitted to the facility on [DATE] with diagnoses of but not limited to cancer, diabetes mellitus, Alzheimer's disease, dementia, and Parkinson's disease. Pressure Ulcers were located on the right heel stage three, right lateral foot unstageable, and coccyx area stage three. These pressure areas were facility acquired. During a wound care observation on 12/04/23 at 9:56 AM, the DON donned a pair of gloves and repositioned the resident assisted by a CNA. The DON donned a pair of clean gloves and proceeded to remove the old dressings on the right lateral foot and the right heel. She then removed the dirty pair of gloves and donned a new pair of clean gloves. The DON did not use hand sanitizer or perform hand washing with soap and water between the glove changes. The wounds to these areas were cleaned with the same gloves on. The DON removed her gloves and donned a pair of new gloves without using hand sanitizer or performing hand washing with soap and water. The heel and lateral aspect of the right foot was performed by the DON doing the lateral right foot first then dressing the right heel. The same pair of gloves were used to dress both areas. The old gloves were removed, and a pair of new gloves were applied without using hand sanitizer or handwashing with soap and water. The DON proceeded to pull the adult brief down, perform peri care due to resident having bowel movement on the buttocks, and then removed the old dressing to the coccyx area with the same gloves on. The DON removed her old gloves and reapplied a clean pair of gloves on. Again, the DON did not use hand sanitizer or perform hand washing with soap and water between the glove changes. The DON continued to clean the area as per Medical Doctor (MD) orders and then dressed the coccyx area. The DON did not change her gloves between cleaning and dressing the coccyx area. c. Review of R292's undated admission Record located under the Profile tab revealed this resident was admitted to the facility on [DATE] with diagnoses of but not limited to cellulitis to left and right lower legs, sepsis, acute kidney injury, lymphedema, and pressure ulcer to sacral region, stage three. During a wound care observation on 12/04/23 at 10:38 AM, the DON donned a pair of gloves and repositioned the resident with the assistance of the CNA. R292 had diarrhea that had run down her legs and onto the dressing to her left lower leg dressing. The dressing was saturated with green liquid diarrhea. The DON attempted to change the dressing to this area and R292 screamed at the DON stating, Don't touch that leg. It is okay. The DON explained to R292 the dressing on her left lower leg had diarrhea on it and it needed to be changed. R292 refused to have this dressing changed and stated, I have the right to refuse to have that dressing changed, and I am refusing. The DON proceeded to pull the pad on the bed down that R292 was lying on and performed peri care due to resident having diarrhea on the buttocks and the back of R292's legs bilaterally. R292 stated to the DON, Can't you stop talking and change the pads on my backside. You aren't going to do anything else but that today. The DON again attempted to explain to R292 and stated, I need to clean this area before I change the pads. R292 replied, You will only change the pads so hurry up and get this done. The DON removed the old dressing with the same gloves that peri care was performed to clean the diarrhea on R292's buttocks and the back of the resident's legs. Then the DON removed her old gloves and reapplied a clean pair of gloves on. The DON did not use hand sanitizer or perform hand washing with soap and water between the glove changes. d. Review of R63's MDS with an ARD of 10/04/23 revealed this resident was readmitted to the facility on [DATE] with diagnoses of but not limited to anemia, hypertension, and paraplegia. R63 was coded as not having any pressure ulcers. Review of the wound care progress notes dated 11/28/23, there was a sacral wound at a stage three pressure ulcer, and the left great toe that was a diabetic ulcer at a stage two. R63 tested positive for COVID-19 on 12/01/23. During a wound care observation on 12/05/23 at 1:30 PM, the DON donned a pair of gloves and repositioned the resident. The DON proceeded to pull the adult brief down, perform peri care due to resident having bowel movement on the buttocks, and then removed the old dressing from the sacral area. The DON removed her old gloves and reapplied a clean pair of gloves. The DON did not use hand sanitizer or perform hand washing with soap and water between the glove changes. During an interview on 12/05/23 at 2:20 PM the Wound Care Consultant (WCC) revealed, When you are dressing two wounds on different places on the same foot for example, you would completely perform the wound care to one site and dress, then proceed to the next wound and completely perform that wound care. Every wound should be treated as a separate wound, so you are not spreading infection from one wound to another. During an interview regarding performing hand hygiene during glove changes on 12/05/23 at 6:15 PM, the DON stated, I was so nervous I forgot. It was really hot in the room during the wound care, and I rushed to get done. 3. Observation of room meal tray service in B Hall on 11/27/23 beginning at 1:24 PM revealed Restorative Aide (RA) 2 was serving the majority of the trays. RA2 served R38 her lunch in her room. RA2 exited the room without performing hand hygiene, grabbed another meal tray off the cart, and served it to R54. She exited the room without sanitizing her hands, then grabbed another tray and served it to R15. She exited the room without sanitizing her hands and served another tray to R53. She placed the meal tray down in his room but R53 refused his meal and asked RA2 to remove the tray. RA2 brought the tray back to the cart and grabbed another tray to serve without first performing hand hygiene. RA2 then served a tray to R48 in her room, exited the room without performing hand hygiene, and wheeled the cart down the hall. RA2 removed the plastic cover over the cart and balled it up against her arms and torso before throwing it away. She then removed another tray from the cart without performing hand hygiene. RA2 served the meal to R190 in her room, exited the room without performing hand hygiene, and removed another tray from the cart. She served the meal to R26, moving the resident's bedside table and items on it while serving, then exited the room without performing hand hygiene. RA2 touched her hair, then grabbed another tray from the cart without performing hand hygiene. She then served the tray to R28. During a concurrent interview on 11/27/23 at 3:29 PM with RA1 and RA2, RA2 stated she received training on hand hygiene during meal service and did a return demonstration when she was first hired in August 2023. She stated the training included hand sanitation between each meal tray served. RA2 stated there was no reason she did not perform hand hygiene during lunch service, it was just an oversight. She stated hand hygiene was especially important now, as the facility was experiencing an outbreak of COVID-19. RA1 stated hands should have been sanitized after each tray. During an interview on 11/28/23 at 12:09 PM, the SDC/ICP stated staff should have sanitized their hands when they came out of the room after each tray served. She stated the staff had received education on this topic. Review of the facility's undated policy titled, Handwashing/Hand Hygiene, revealed Use an alcohol-based hand rub containing at least 62% alcohol; or, alternative, soap (antimicrobial or non-antimicrobial) and water for the following situations:. Before and after direct contact with residents;. After contact with objects (e.g., medical equipment in the immediate vicinity of the resident . Before and after eating or handling food . Before and after assisting a resident with meals; and . After personal use of the toilet or conducting your personal hygiene. 4. Review of R63's admission Record, located in the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses which included paraplegia, urinary incontinence, and neuromuscular dysfunction of the bladder. Review of R63's annual MDS assessment under the MDS tab of the EMR, with an ARD of 11/21/23 revealed he used an indwelling urinary catheter. The resident required supervision or touching assistance with transferring into/out of bed. Review of R62's Care Plan located in the Care Plan tab of the EMR, dated 10/30/23, revealed The resident has foley Catheter. The approaches included: Position catheter bag and tubing below the level of the bladder and away from entrance room door . Check tubing for kinks each shift and PRN [as needed] . [and] Monitor/record/report to [physician] for s/sx [signs or symptoms of] UTI [urinary tract infection]. During an observation in R63's room on 11/28/23 at 3:43 PM, R63 was lying in bed with his catheter bag in direct contact with the floor. The bag was not covered with a privacy cover; it had a clear side that was facing the bed and an opaque side facing the room door that ensured the urine was not visible. During an observation on 11/29/23 at 4:05 PM R63 was lying in bed with the catheter bag resting on the floor. During an observation on 11/30/23 at 3:08 PM R63 was lying in bed with his catheter bag resting on the floor. At this time, an interview with CNA1 confirmed the catheter bag was lying on the floor but should have been kept off the floor for infection control. CNA1 stated she did not notice the resident's catheter bag in contact with the floor but would fix the situation by hanging the bag on the bed frame with the attached [TRUNCATED]