**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, interview and record review, the facility failed to ensure tracheostomy supplies were available for tracheostomy care and emergency treatment, failed to obtain physician orders for tracheostomy care, failed to have a tracheostomy policy and procedure, failed to ensure staff were qualified and/or competent to perform tracheostomy care and order appropriate tracheostomy supplies for 3 of 3 residents (R3, R6, R7) admitted with tracheostomies int the sample of 22. These failures resulted in an Immediate Jeopardy: The Immediate Jeopardy started on [DATE]. The administrator was notified of the Immediate Jeopardy on [DATE]. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of their plan of correction and Quality Assessment oversite. Findings include: R3 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident (stroke), had an inability to speak, was cognitively impaired, had acute respiratory failure that required an insertion of a tracheostomy (an opening in the neck into the windpipe to help air and oxygen reach the lungs). On [DATE] a Physician's Order noted to Provide tracheostomy cleaning daily and PRN/as needed every night shift for Trach (Tracheostomy) care. Suction tracheostomy as needed for increased sputum production and Sodium Chloride Inhalation Nebulization Solution 3% 4 ml (milliliter) inhale orally via nebulizer two times a day for SOB/shortness of breath and wheezing Start Date:[DATE] D/C/discontinue Date: [DATE]. The Medication Administration Record noted R3's lung sounds were clear before and after nebulizer treatments [DATE] through [DATE]. On [DATE] at 3:45 AM, the Progress Note noted the trach was nasopharyngeal (suction catheter inserted into the nose down to the back of the throat to remove upper airway secretions) suctioned for a small amount of thin green secretions. On [DATE] at 5:27 AM, the Progress Note noted V3 (Licensed Practical Nurse/LPN) Attempted to suction resident at beginning of shift due to increased secretions, inner cannula not in place. On [DATE] at 8:35 PM, the Progress Note noted V23 (LPN/Agency) Suctioned trach as needed with return of thin clear secretions. On [DATE] at 2:37 PM, the Progress Note documented V21 (Attending Physician/Medical Director) made aware of residents situation due to trach not having inner canula. Verbal phone order to send resident to ER (emergency room). On [DATE] the ED/Emergency Department Provider's Note stated R3 presented to the ED by ambulance for a tracheostomy tube problem; the ED physician consulted with RT/Respiratory Therapist regarding tracheostomy tube replacement which was ultimately replaced successfully; then, R3 was discharged back to facility. On [DATE] at 7:30 PM, the Progress Note noted R3 returned to facility per AMT/Advanced Medical Transport, no new orders received. Resident remains alert and w/o/without s/s/signs and symptoms of distress. Tracheostomy tube size 4 DCT (disposable cuffed tracheostomy) in place with inner cannula noted. On [DATE] at 8:26 PM, the Progress Note noted the Advanced Practical Nurse was contacted for tracheostomy orders, new orders were received, and an extra trach tube (provided by the hospital) was affixed to the wall above head of bed for emergency interventions. On [DATE] the Order Summary Report noted orders to Change tracheostomy tube (size 4 DCT) every month and prn/as needed; Change tracheostomy inner cannula daily and prn; Tracheal suctioning every shift and prn; Tracheostomy care every shift et (and) prn. On [DATE] at 2:42 PM, V3 (LPN) stated R3 did have an inner cannula upon admission and identified the inner cannula was missing on [DATE]. V3 stated the lack of inner cannula was known by the former Director of Nursing/DON (V4) on [DATE]. V3 stated V4 was observed to suction R3 without the inner cannula in place and that's when we (V3 and V23/LPN) knew R3 had to go to the hospital and get this remedied (new trach tube insertion). Oxygen levels never dropped and R3 was never in distress. On [DATE] at 3:31 PM, V3 stated No, you can definitely not suction a resident without an inner cannula in place or you could damage their airway. On [DATE] at 3:00 PM, V1 (Administrator) stated I know V4 DON took the inner cannula (from R3's room). We didn't have any (tracheostomy tubes) that size. I sent V4 to (a medical supply store) but they didn't have that size. We called the hospital, but they said they didn't have any either. I don't know that the admissions office would call to ensure we had the right size of trach prior to admission and I'm sure it's not in any policy. V1 stated that V4 had been suctioning R3 without the inner canula in place. V1 stated there was a module for tracheostomy care and maintenance on the facilities e-learning software although the module had not been assigned or completed by any employee as of [DATE]. On [DATE] at 1:00 PM, V21 (Medical Director/R3's Attending Physician) stated I asked them (facility) to get a Respiratory Therapist to come down and assess or evaluate R3. I told them they needed to have the RT review the trach protocol with them (facility staff). I specifically told them to consult RT during rounds with V4. I was surprised they had a trach patient here. Staff never stated they felt uncomfortable, but I don't think they get any training on it (trach care). I actually sent them a faxed protocol from (local hospital) for trach care. Yes, they should have emergency equipment available and tach tubes, inner cannulas and ambu bags should be at the patient's bedside. At this point I haven't heard that anything has been put into place to keep this from happening again. We need a Respiratory Therapist, and one should be on call. I didn't even know the facility would accept a trach patient. Really surprised me. As of [DATE] at 1:30 PM, the facility lacked a policy and procedure for tracheostomy care based on nationally recognized guidelines. On [DATE] at 1:59 PM, V1 (Administrator) was notified of the Immediate Jeopardy. On [DATE] at 10:00 AM, V1 (Administrator) stated V21 (Medical Director) had not reviewed policies, the survey plan of care or staff training material. V1 stated the Quality meeting will be next week and the material will be presented to V21 at that time. V1 stated the Tracheostomy Care policy updated [DATE] and the Tracheostomy Care Education presented to the staff on [DATE] and [DATE] lacked a reference it was based on a Nationally Recognized Guidelines. V1 verbally agreed the policy and the staff education presented lacked procedural instruction for tracheostomy suctioning and required emergency equipment. On [DATE] the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. A Service Agreement with a medical staffing agency signed on [DATE] by V38 (Facilities Chief Executive Officer) and the staffing service's National Business Development Manager. The contract noted staffing service will provide CPR certifications (if applicable). This Service Agreement is intended for use of Respiratory Therapy staff. 2. On [DATE], the 2nd (R13, tracheostomy resident) and 3rd floor (R3, tracheostomy resident) nurses' station was observed to have a stock of required tracheostomy equipment and R3 and R13's rooms were observed to have suction, oxygen, and tracheostomy supplies. On [DATE], ambu bags were observed in R3 and R13's rooms. 3. On [DATE] and [DATE], a contracted Respiratory Therapist began in-servicing all nursing staff on tracheostomy care, supplies and treatment. The in-services will continue to be offered until all staff have been trained. 4. On [DATE], the Tracheostomy policy was updated although lacked instruction on suctioning, emergency equipment required and which nationally recognized guidelines the policy was based on. 5. On [DATE], Tracheostomy care audit tools were developed and began implementation of the audit tool on [DATE]. This audit will be ongoing. 6. Quality Assurance/QAA process going forward will be overseen by V1 (Administrator) and V21 (Medical Director).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement wound interventions, failed to notify resident representative of a new wound, failed to follow physician orders, failed to develop a plan of care to address all wounds, failed to assess a posterior knee wound dressing resulting in an avoidable traumatic wound to right contracted posterior knee for one resident (R1) reviewed for wounds in the sample of four. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/27/23, the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of their wound management program. and Quality Assessment oversite. Findings include: Facility Policy/Pressure Ulcers/Skin Integrity/Wound Management (undated) documents: Definitions: Pressure Ulcer: A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction and shear are not primarily causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. Avoidable means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: Define and Implement interventions that are consistent with the resident needs, resident goals, and recognized standards of practice; Monitor and evaluate the impact of the intervention's; and/or revise the interventions as appropriate. Wound Assessment: All interventions should be evaluated for efficacy and modified/changed as needed. Documentation: Assessment information should identify specific factors that might increase the risk of pressure ulcer development or healing of a pressure ulcer such as: decreased mobility, cognitive impairment, significant weight loss in a resident who has mobility/positioning concerns, impaired nutrition or history of impaired nutrition, non-compliance or history of non-compliance, altered sensory perception, incontinence, significant abnormal lab values, history of pressure ulcers and any decline in clinical status or co-morbid diagnoses affecting mobility/positioning or tissue tolerance. Care Planning: For the resident who is at risk for developing a pressure ulcer or who has a pressure ulcer, an individualized care plan will be developed per the Resident Assessment Manual/care plan timelines. The care plan should address prevention of any skin breakdown, including shearing or friction, repositioning or off-loading, pressure relief equipment and the care and treatment to be provided to the resident for a pressure ulcer or non-pressure wound behaviors and preferences. All care plan interventions should be revised if there is recurring pressure ulcers, a lack of progress toward healing, or if the resident acquires a new ulcer. Routine/Ongoing Documentation: Daily and/or routine ongoing documentation should be conducted by the licensed nurse related to the resident's skin condition and the resident's response to the care and treatment of the skin. Measurements of all pressure ulcers and non-pressure wounds will be done at least weekly and with any noticeable changes. Facility Policy/Wound Care Policy, Comprehensive Wound Program (undated) documents: If a residents Braden score equals out to high risk, they will continue to have appropriate interventions in place deemed necessary by wound care nurse/DON (Director of Nursing). Any high-risk resident or a resident with a wound will receive the appropriate pressure relieving devices deemed appropriate by wound care nurse/DON. The designated wound nurse will weekly measure all wounds, completing weekly wound care report. The care committee will review and discuss. The facility wound care program takes into account the patient as a whole including nutrition, Braden scale, dietary supplements needed to heal the wound, weight loss and weekly wound changes. Facility Policy/Wound Care Documentation and Management dated 8/25/19 documents: It is the policy of this facility to provide wound care as needed and to record care given. Wound assessment documentation will be completed at least weekly and as changes in the wound are apparent. Weekly wound documentation will include a description of the area, including color, size, depth, location, extent of any drainage; condition of the wound area, as well as surrounding area; assess for pain. Weekly documentation of skin care will include measures used to prevent development of pressure ulcers (special mattress, protective dressings or lotions, pressure-relief devices, etc.) Also included will be any signs and symptoms of infection, cultures obtained. Documentation of all skin injuries will include a description of condition, size, and treatment required, how the accident happened, reports completed, and notification of family and physician. Treatment of all wounds will be administered per physician/Wound NP (Nurse Practitioner) order. Current Physician Order Summary Report indicates R1 was admitted to the facility on [DATE] with diagnoses that include End Stage Renal Disease/Dialysis Dependent, Seizure Disorder, Hemiplegia/Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Unspecified Protein Calorie Malnutrition, Dementia, Gastrostomy. Order Summary indicates R1 has orders as follows: --Liquid nutritional feeding every 24 hours as needed may give 2 cans of (liquid nutrition) if dialysis meal is not available before leaving for dialysis and/or returning from Dialysis; flush with 170cc water before and after bolus, date ordered 11/13/23. --Enteral Feed three times per day bolus 1 can (liquid nutrition) with water flush 170cc before and after bolus, date ordered 11/30/23. --Instill 500ml (milliliters) water into R1 stomach through feeding tube three times per day, give R1 at least one 8-ounce container of thickened water orally every 8 hours, date ordered 11/8/23. --Cleanse R1 middle finger to left hand with normal saline, pat dry, apply triple antibiotic ointment and cover with bandage every 8 hours everyday shift and as needed. --Doxycycline Hyclate (antibiotic) 100mg (milligrams) two times a day for wound to left middle finger, date ordered 11/27/23. --Left distal thigh treatment: Cleanse with normal saline, apply antibiotic ointment to wound bed, cover with (petrolatum infused gauze) 4 x 4 dressing, abdominal dressing, wrap daily and as needed related to Necrotizing Fasciitis, date ordered 11/27/23. Braden Scale for Predicting Pressure Ulcer Risk dated 8/2/23 indicates R1 is at High Risk for pressure ulcer development. Practitioner Wound Care Note dated 12/11/23 indicates R1 has multiple wounds including a left hip to knee wound with history of Necrotizing Fasciitis and debridement, left hip surgical wound, left posterior knee traumatic wound, and wound to left middle finger knuckle. Note indicates left posterior knee wound Traumatic, onset 11/20/23 suspect related to dressing and patient contractures. Wound description includes 10% yellow slough, moderate exudate, wound bed pink. Note indicates left middle finger knuckle traumatic wound length 0.9cm (centimeters), width 0.8cm, depth 0.1-0.2cm with slight decline in depth; wound bed pink, moderate exudate; 70% slough with observed shiny striation/suspect possible tendon. Wound Plan Note indicates: Discussed with PT (Physical Therapy) - need for strengthening and endurance exercises. Discussed with Dietician - treatment plan including need for protein supplements with meals. Discussed with OT (Occupational Therapy) need for evaluation for ADL's (Activities of Daily Living). Discussed with patient frequent repositioning for pressure relief/nutritional support/hygiene and incontinent cares. Discussed with RN (Registered Nurse)/ADON (Assistant Director of Nursing) treatment plan, frequent wound care treatment orders and risk for significant wound decline. Patient and staff re-instructed to wear pants/sweats at all times to promote wound healing. Instructed staff to attempt to place small pillow to posterior calf/post thigh for his contracture. On 12/12/23 at 1:30pm R1 was in bed with a mitt restraint on right hand and left hand partially tucked underneath left side of R1's body. R1's left hand was in a closed position with all knuckles of left hand pressing against the mattress surface. R1's left hand was removed from under his body by V4, Wound Nurse and a small bandage was removed from around left middle finger knuckle. At that time V4 stated that I personally believe the wound to (R1's) knuckle is from pressure/friction from the way R1's arm/hand get positioned under his body against the sheets. V4 stated R1's left side of his body is the stroke-affected side. V4 stated she discussed with V5, Wound NP (Nurse Practitioner) about putting a restraint mitt on R1's left hand as well to try to keep the pressure off his knuckles. V4 then removed the bandage from R1's left knuckle which exposed an irregular ulcer of R1's entire knuckle and stated (R1) is receiving antibiotics for wound infection. V4 cleansed the left knuckle wound, re-bandaged and placed R1's arm/hand back onto the bed with no off-loading of affected areas. R1's left leg was noted to be in a contracted position without any pillows or appliances in place to lessen the severity of the contracted leg. V4 removed the wrapped gauze from R1's left upper thigh that extended down past R1's knee which exposed a large scar that extended from mid-left anterior thigh past R1's left kneecap. The area closest to R1's knee was open requiring cleansing and treatment. V4 then assessed behind R1's left knee which also had an open area. At that time V4 stated the wound behind R1's knee was caused from having the gauze wrap dressings too tight - so a combination of constricted pressure and R1's contracted knee joint. The wound behind R1's knee was reddened with a white cord -like striation extending across the open wound. V4 stated The wound didn't look like that the other day. I've never seen it this bad. I think that's an exposed tendon. The other day it was just red with some drainage. V4 stated that when the wound under the knee started out it was from trauma. I believe it was from bandage being too tight. There should have been some padding to prevent a wound from forming. Now as of yesterday we are adding an ABD (abdominal pad) under the gauze wrap. V4 also stated Today is the most extended I've seen (R1's) leg. It's usually more contracted and difficult to assess. No pillow or other positioning device was placed under R1's knee after wound care was completed. V13, R1's POA (Power of Attorney) was also present during R1's wound care. V13 stated that she has talked to staff about keeping a carrot or rolled washcloth in R1's left hand to help with the contraction and would also help keep his knuckles from pressing into or rubbing on the sheets. V13 then asked V4 when R1 had developed the wound under his knee because she was not notified. V13 stated This is the first I'm finding out about this wound. On 12/13/23 at 10am R1 was sitting in a recliner chair in the hallway. R1's left hand was positioned partially under the left side of his body with all fingers/knuckles of left hand in contact with the chair cushion. On 12/14/23 at 9:10am V5, Wound Nurse Practitioner (NP) stated half of the time he encounters R1 at the facility his dressings are off. V5 stated he had to initiate the elastic stocking over R1's left leg to keep the dressings in place for the anterior wounds on R1's left leg. V5 stated the combination of the gauze wrap on R1's leg and leg contractures caused the wound behind R1's left knee. V5 stated If the tendon is exposed behind (R1's) knee it would require a surgeon to assess because that type of wound would be beyond my ability to heal. (R1) is probably not a surgical candidate due to his present physical state and dialysis. V5 stated I can put in all the best orders but if they're not followed, they won't work. V5 stated that the nutrition and protein supplements are Essential for healing R1's wounds These are key factors in wound healing. V5 stated R1 can't feed himself so he is reliant on staff to follow orders and be sure he is getting the nutrition and hydration he needs. Wound NP wound assessment notes dated 12/11/23 indicates left posterior knee wound measures 1.6cm (centimeter) x 1.4cm x 0.1cm. NP wound assessment notes dated 12/18/23 indicates left posterior knee wound measures 3.1cm x 1.2cm x 0.2cm. Note indicates wound with moderate serosanguinous drainage, 30% yellow with striation - suspect tendon and 70%pink. Note indicates Referral to surgeon related to possible tendon. Progress Note dated 12/18/23 at 3:24pm indicates New order for surgeon in regard to possible tendon (exposure) of left posterior knee. R1's current care plan - date initiated 5/17/23/revised 10/17/23 - indicates R1 has a pressure ulcer or potential for pressure ulcer development related to disease process, history of ulcers. Care plan indicates R1 has necrotizing Fasciitis to left hip, thigh, knee. Care plan does not identify left finger knuckle wound or left (popliteal) posterior knee wound. Interventions include: R1 Requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing, date initiated 5/17/23. Inform caregivers/family of any new area of skin breakdown, date initiated 5/17/23. Weekly treatment documentation to include measurements of each area of skin breakdown - width, length, depth, type of tissue and exudate, date initiated 5/17/23. Dietician to review nutritional needs for wound healing, date initiated 11/23/23. No interventions to off-load, reposition or any preventative interventions are included in R1's current care plan to prevent further damage or deterioration of wounds. Dietary Recommendation dated 11/13/23 indicates R1 had a non-significant undesirable weight change of (negative) 2.5% 1 month, 3 months and 6 months. An order added: On Dialysis days (M/W/F) if dialysis meal is not available before or upon returning from dialysis, give 2 cans (therapeutic liquid nutrition) in place of meal with water flush 170cc (cubic centimeters) before and after bolus. Dietary Recommendation dated 11/30/23 indicates increase R1's nutrient needs related to Hemodialysis. Added liquid nutrition (therapeutic liquid nutrition) bolus three times per day with water flush 170cc (cubic centimeters) before and after bolus. Medication Administration Record (MAR) dated 11/23 to 11/30/23 indicates the following: Progress Notes dated 11/3, 11/6, 11/8, 11/10, 11/13, 11/22, 11/27 and 11/29, 2023 indicates liquid nutrition was not given prior to dialysis due to R1 Ate 100% of breakfast meal. No (liquid nutrition) needed. CNA (Certified Nurse Assistant) documentation Amount Eaten (per meal) indicates R1 did not eat 100% on these dates. Amount eaten was zero on 11/3, 11/8, 11/13, 11/22; 51-75% on 11/27 and 26-50% on 11/29. MAR dated 12/1/23 to 12/31/23 indicates the following: Progress Notes dated 12/6, 12/8, 12/11 and 12/13 indicate liquid nutrition was not given due to R1 Ate 100% of breakfast. No (liquid Supplement) needed. CNA documentation Amount Eaten indicates R1 ate zero on 12/6, 51-75% on 12/8, 12/13 and 25-50% on 12/11, 2023. None of the current physician orders or dietary recommendations are based on a percent of meal eaten by R1. TAR (Treatment Administration Record) dated 12/1/23 to 12/31/23 indicates Record feeding intake at the end of every shift for R1. No intake is documented for day shift on 12/1, 12/3 through 12/10, 100ml is documented on 12/11, 12/12, 12/13, 12/15, 12/16 and 12/18; 500ml is documented on 12/2 and 875ml is documented on 12/18/23. TAR indicates no intake is documented for evening shift on 12/2, 12/3, 12/8, 12/9, 12/10. No intake documentation for night shift except 12/5 and 12/14, 2023. TAR dated 12/1/23 to 12/31/23 indicates Record water intake at end of each shift for gastric tube. No water intake is documented for 12/1, 12/3, 12/4 and 12/6 through 12/10. On 12/13/23 at 2:40pm V7, LPN (Licensed Practical Nurse) stated We haven't had cans of (liquid nutrition) for a long time. We use these and showed a large bottle (1000ml/milliliters) of liquid nutrition. V7 stated she gives R1 320ml three time/day. At that time, V8, LPN stated Well, isn't that interesting? I give 240ml. V7 then stated If you ask other nurses, they will probably also give a different amount. V7 also stated (R1) ate 100% of his meal this morning. He didn't need extra. Both V7 and V8 did not know how much was in one can of liquid supplement or how much the physician's order indicated to give. Both V7 and V8 acknowledged the amount (volume) of liquid nutrition to be given should have been clarified with the dietician. Nutrition/Dietary Note dated 12/18/23 at 1:44pm indicates RD (Registered Dietician) note for malnutrition diagnosis, dialysis and tube feeding. Note indicates R1 oral intake per intake log is between zero and 75% which most likely does not meet enteral nutrition as evidenced by general appearance and dialysis information. On 12/19/23 at 9:41am V14, RD (Registered Dietician) stated that one can of (liquid supplement) is 237ml or 8 ounces. V14 stated she was not aware the facility did not have cans of liquid supplements or that nurses were giving various amounts. V14 stated her expectation is R1 should be getting meals and supplements as ordered. V14 stated R1 is no longer getting the liquid supplements based on percent of meal eaten That order changed on 11/30/23. V14 stated she spoke to the dialysis dietician on 11/30/23 and was told R1 was coming into dialysis dehydrated so recommendation was made to give additional water by bolus and orally. V14 stated that R1's Albumin level did drop and is now 3.2g/dl (grams per deciliter). V14 stated We are offering an excessive amount of calories to maintain his general nutritional status. The focus with residents with dialysis and wounds is protein - an essential part of healing. On 12/15/23 at 11:30am V4, Wound Nurse stated prior to 12/13/23 there was no wound documentation in R1's chart. V4 stated R1 does not have an air mattress but he should have because he is prone to pressure. On 12/19/23 at 11:40am V4 stated she previously was the ADON) Assistant Director of Nursing) at the facility and in the summer she became the wound nurse. V4 stated she does not have any specific wound training and only started (this month) doing wound care plans. The Immediate Jeopardy was identified on 11/20/23. V1, Administrator was notified of the Immediate Jeopardy on 12/20/23 at 1:23pm. The following Abatement Plan was submitted on 12/20/23: In order to abate this Immediate Jeopardy and to ensure that all associated issues are resolved, the facility has completed and/or will have completed the following by end of day on 12/21/23: 1) All residents who have been assessed as high risk for pressure ulcers shall have their clinical records reviewed assuring that updated skin/pressure ulcer assessments are in place; all dietary recommendations for these residents are either put in place or otherwise declined by the physician and then put in place and care planned accordingly; and that all wound measurements and assessments are entered into the electronic health record as part of the resident's clinical record. 2) All residents who have been identified as high risk for pressure ulcers have their wound care plans updated and current with any preventative measures appropriately care planned, 3) All nursing staff are being re-in serviced/educated on the facility's policies and procedures regarding skin care, repositioning, assessing skin, use of shower sheets, reporting any areas of concern to nurse responsible for communicating those issues to the wound nurse/wound NP/physician and POAs/responsible family members. This education has been conducted with those staff who have been on site since time of IJ citation and training will be ongoing each day until all nursing staff have received this education. 4) Audit tools have been developed for the purpose of auditing: Wound care/skin/pressure ulcer assessments being completed timely and recorded in the resident's medical record. Dietary recommendations and/or nutritional orders for the purpose of wound healing being implemented or otherwise declined by physician and care planned accordingly; Wound care plans for residents with pressure ulcers or at high risk being kept current and accurate. These tools shall be implemented with audits being conducted for 8 residents per week for 3 weeks, then 4 residents per week for 4 weeks and 2 residents per week for 2 additional weeks. All results to be reviewed weekly and addressed at morning leadership meeting so issues can be addressed immediately. Total results to be reviewed at QAPI (Quality Assurance Performance Improvement) meeting with determination if additional PIP (Performance Improvement Plan) needs to be initiated or audits need to be continued. COMPLETION DATE: December 21, 2023 Facility has also hired a new Wound Care Nurse/RN (registered Nurse) to oversee facility's wound care program. She will join the team on January 2, 2024. The removal plan could not be accepted until 12/27/23 due to the amount of wound care documentation needing to be added to resident medical records and the absence of the only wound care nurse in the facility that had access to resident wound assessments and documentation. On 12/27/23 the surveyor confirmed through observation, interview and record review the facility fully implemented all components of its abatement plan and immediacy was removed.