**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and facility policy review the facility failed develop a comprehensive care plan for one (1) of nine (9) residents reviewed. On 10/7/22, Licensed Practical Nurse (LPN) #2 identified an excoriation area to Resident # 1's buttocks. The area was assessed by the Nurse Practitioner (NP) on 10/7/22 and identified as a stage 2 pressure ulcer. On 10/16/22, the wound status was identified as deteriorating. On 10/20/22, Resident #1 was admitted to Hospital #1 for diagnosis of wound sepsis. The State Agency (SA) identified an Immediate Jeopardy (IJ) that began on 10/16/22 when Resident #1's wound began to deteriorate. The facility failed to develop an updated plan of care when Resident #1 developed actual skin breakdown. This placed Resident #1 in a situation that has caused serious harm, injury and impairment and is likely to cause serious harm, injury, impairment or death for others at risk. On 12/6/22, at 3:00 PM, the SA notified the Quality Improvement Nurse ([NAME]) and Director of Nurses (DON) of the IJ and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 12/7/22, in which they alleged all corrective actions to remove the IJ were completed on 12/6/22 and IJ removed on 12/7/22. The SA validated the Removal Plan on 12/9/22, and determined the IJ was removed on 12/7/22, prior to exit. Therefore, the scope and severity for CFR 483.21 (b)(1)(3) Develop/implement Comprehensive Care Plans (F656)-Scope and Severity J. and were lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy and procedure for the Care Plan Process last revised on 08/17 revealed The facility shall develop and implement a Baseline Care Plan and Summary for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care .The overall care plan should be oriented towards: .5. Evaluating treatment of measurable objectives, timetables and outcomes of care .8. Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities . Record review of Resident #1's Care Plan with a problem onset date 03/30/2017 revealed Resident is at risk for skin breakdown .Goal and target date: Resident will have no skin breakdown through next review 1/28/23 . Approaches .Open area RT (right) and LT (left) buttocks-clean areas with NS (normal saline)/gauze, pat dry, apply Santyl, cover with calcium alginate and foam dressing QD (every day) until healed .Notify MD (Medical Doctor) of any complications or changes to wounds . Record review of Resident #1's October 2022 electronic Treatment Administration Record (ETAR) described this wound as an excoriation from 10/8/22 through 10/12/22 and then an open area from 10/13/22 through 10/20/22. Record review of a nurses note by Licensed Practical Nurse (LPN) #3 dated 10/8/22 at 8:04 AM documented this area as an excoriation. Record review of the Nurse Practitioner (NP) Progress note dated 10/7/22 describes this sacral area as a Stage 2 pressure ulcer measuring 2.5 centimeter (cm) X (by) 8 cm X 0.1 cm. Record review of Physician Orders List page 2 of 2 dated 10/8/22 revealed Clean with normal saline, pat dry, apply zinc and cover with foam dressing daily until healed. Continue the air mattress. Record review of the NP Progress Note dated 10/12/22, revealed an evaluation due to treatment nurse reporting area to sacrum worsening. The NP then stages this wound in her progress note as an unstageable pressure ulcer. The NP discontinued the order from 10/7/22 and ordered the treatment nurse to clean the wound with normal saline, pat dry, apply santyl, calcium alginate, cover with foam dressing daily. The measurements were 7.0 cm X 7.0 cm X 0.1cm. Record review of a physician order written by the NP, dated 10/12/22, identified the area as open area to the right and left buttocks. Record review of a Physician Order written by the NP, dated 10/17/22, revealed an order for Cleocin HCL 300 milligram (MG) (1) three times a day (TID) X 10 days, Cipro 500 MG (1) twice a day (BID) X 10 days to start on 10/18/22, obtain a Complete Blood Count (CBC) the week of 10/16/22. On 12/5/22 at 3:25 PM, interview with MD #2 revealed he was the primary Medical Doctor (MD) for Resident #1. MD #2 stated he was unaware of Resident #1's wound decline until he got to the hospital on [DATE]. If there was an odor to that wound, he should have been sent out earlier than 10/20/22. Not staging a wound in orders or notes is a problem. When there's an odor, the treatment has to be more aggressive, such as IV antibiotics, debrided and put in the hospital. Someone should have called me to let me know there was a problem, called me to admit him to the hospital for evaluation. I have a problem that nurses knew it was, what was needed and afraid to tell. There are communication problems there. It's been that way for a while. I didn't know there was a problem until he got to the hospital. On 12/7/22 at 12:30 PM, during an interview with the Director of Nurses (DON) revealed when asked by the State Agency (SA) if the DON or treatment nurse contacted Resident #1's MD when the NP was sick at home and she stated I didn't, the treatment RN didn't, not to my knowledge. Interview on 12/5/22 at 10:30 AM with Registered Nurse (RN) #2 revealed that care plans are updated when there are new orders given stating That's when new interventions are added. An accepted Removal Plan was provided to the SA on 12/7/22 at 1:15 PM. Removal Plan: On December 6, 2022, at 3:00 pm State Agency notified the Director of Nursing that the facility was in Immediate Jeopardy (IJ) and templates were provided to the Director of Nursing. Corrective Actions: 1. Seventy residents were assessed with eleven residents identified by Director of Nurses as having excoriation/irritation or staged wounds on December 5, 2022. Seventy residents were assessed with twelve residents identified by Director of Nurses as having an air mattress device. On December 6, 2022, Director of Nurses reviewed all eleven of seventy active resident records for a decline in wound status and for appropriate staging. Of the eleven residents identified with excoriation/irritation or staged wound, three were newly identified with excoriation/irritation and three were newly identified as a staged wounds and three were existing with excoriation/irritation and two were existing with staged wounds. Physicians, Resident Representatives notified of new wounds and new orders obtained for the new wounds. No significant findings were identified on all eleven of seventy active residents assessed. On December 6, 2022, Director of Nurses reviewed all twelve of seventy active residents to identify functioning of air mattress device. No significant findings identified on all twelve of seventy active residents which required have an air mattress device On December 6, 2022, Director of Nurses reviewed all twelve of seventy active records to ensure intervention of air mattress and function checks were present on care plan. No significant findings were identified on all twelve of seventy active residents care plans which were identified to have an air mattress device. Three records were newly identified with excoriation/irritation for implemented care plans and three records were newly identified as staged wounds for implemented care plans. 2. Quality Improvement Nurse ([NAME]) immediately initiated in-services with Registered Nurses and Director of Nursing on December 6, 2022, on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. In-services will be on-going, and no employee will be allowed to work until participation of the in-services are completed. 3. The facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress, no policy changes were made, however, facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders. Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. The following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON. The facility alleges that all corrective actions to remove the IJ were completed on December 6, 2022, and the IJ was removed on December 7, 2022. The SA validated the Removal Plan on 12/9/22. Validation: 1. Based on record reviews, observations and interviews on 12/9/22, the facility did a 100% skin assessment on all residents present in the facility on 12/5/22. Interviews with the [NAME] and DON on 12/9/22 revealed that 11 residents were identified by the DON having either excoriations/ irritation or staged wounds. Interviews, record reviews and observations revealed that 12 residents were identified by the DON as having air mattress devices. Based on record reviews and interviews, there were three (3) residents newly identified with excoriations or irritations and 3 were newly identified as having staged wounds. Record reviews revealed the Medical Doctors (MD) and Responsible Party (RP) of residents were notified of the new skin areas noted with new orders. Record review and interview revealed the DON reviewed the 12 residents on air mattress devices. The DON did not observe significant findings on the 12 residents with air mattress devices. Record review and interview confirmed that on 12/6/22, the DON reviewed the care plans of the 12 residents on air mattress devices to ensure the interventions included the air mattress and function checks were present. No significant findings were identified. The DON confirmed on 12/9/22 that she reviewed the 3 records of newly identified residents with excoriations/irritations and the 3 residents that were newly identified as having staged wounds. 2. Based on record reviews and interviews on 12/9/22, it was confirmed that the [NAME] had initiated an in-service with the Registered Nurses (RN) and Director of Nurses (DON) on 12/6/22. These in-services included information on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. Record review and interviews confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. Interviews and record review confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. Interview and record review confirmed that these in-services will be on-going, and no employee would be allowed to work until participation of the in-services were completed. 3. Record reviews and interviews on 12/9/22 confirmed that the facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Interviews and record review confirmed that the topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress and there were no policy changes made. Record review and interviews did confirm that the facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Record review and interview confirmed that the Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders and that the Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. Record review and interviews with the DON and [NAME] on 12/9/22 confirmed that the DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. Interviews and record reviews with the [NAME] and DON on 12/9/22 confirmed that the following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with staff and Resident Representative interviews, record review and facility policy review, the facility failed to identify a pressure ulcer and prevent its deterioration for one (1) of nine (9) residents reviewed for pressure ulcers, Resident #1. On 10/7/22, Licensed Practical Nurse (LPN) #2 identified an excoriation area to Resident # 1's buttocks. Nurse Practitioner (NP) #1 visited the facility on 10/7/22 and assessed Resident #1's area to the buttocks. NP #1 ordered wound care treatment for Resident #1. Resident # 1 received daily wound care treatments with air mattress function checks every shift. On 10/12/22 Resident #1's wound was assessed again by NP #1 who documented the area as an unstageable pressure ulcer and changed the treatment order for Resident #1. On 10/16/22, the wound status was identified as deteriorating. New orders for antibiotics and laboratory tests for Resident #1 were ordered by NP #1 on 10/17/22. On 10/20/22, Resident #1 was admitted to Hospital #1 for diagnosis of wound sepsis. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 10/16/22 when the facility failed to ensure pressure ulcers did not worsen and failed to provide treatment and services that were required to prevent the worsening of pressure ulcers. This placed Resident #1 in a situation that has caused serious harm, injury and impairment and is likely to cause serious harm, injury, impairment or death for others at risk. On 12/6/22, at 3:00 PM, the SA notified the Quality Improvement Nurse ([NAME]) and Director of Nurses (DON) of the IJ and SQC and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 12/7/22, in which they alleged all corrective actions to remove the IJ were completed on 12/6/22 and IJ removed on 12/7/22. The SA validated the Removal Plan on 12/9/22, and determined the IJ was removed on 12/7/22, prior to exit. Therefore, the scope and severity of CFR 483.25 (b)(1)(i)(ii) Treatment/services To Prevent/heal Pressure Ulcers (F686) was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's Staging of Pressure Ulcer policy and procedure, last review date of 08/21, revealed an unstageable pressure ulcer as Unstageable due to slough and/or eschar: full thickness tissue loss in which to base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. The Definition of a pressure ulcer: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A Registered Nurse shall stage pressure ulcers. Interview with the Resident Representative (RR) and complainant on 11/30/22 at 4:31 PM, revealed he does have copies of the hospital records. There are photos of the sacrum wound. He stated the resident was sent to the hospital 10/20/22. He is now in another facility. He had never been told by the facility that his father had a wound on his butt. The medical doctor (MD) at the hospital had to clean the wound down to the bone. The family is now looking for a new nursing home. He stated he does not want his father to back to this facility. Record review of the Facesheet for Resident #1 revealed he was admitted to the facility on [DATE], with a diagnosis of Diabetes Mellitus, Dementia, Hypertension and Benign Prostatic Hypertrophy, and Osteoarthritis. Record review of Resident #1's October 2022 electronic Treatment Administration Record (ETAR) described this wound as an excoriation from 10/8/22 through 10/12/22 and then an open area from 10/13/22 through 10/20/22. Record review of the Nurse Practitioner (NP) Progress note dated 10/7/22 describes this sacral area as a Stage 2 pressure ulcer measuring 2.5 centimeter (cm) X (by) 8 cm X 0.1 cm. Record review of a nurses note by Licensed Practical Nurse (LPN) #3 dated 10/8/22 at 8:04 AM documented this area as an excoriation. Record review of Physician Orders List page 2 of 2 dated 10/8/22 revealed Clean with normal saline, pat dry, apply zinc and cover with foam dressing daily until healed. Continue the air mattress. Resident #1 received a new order for an air mattress on 3/7/22 per Physician #1. Record review of the NP Progress Note dated 10/12/22, revealed an evaluation due to treatment nurse reporting area to sacrum worsening. The NP then stages this wound in her progress note as an unstageable pressure ulcer. The NP discontinued the order from 10/7/22 and ordered the treatment nurse to clean the wound with normal saline, pat dry, apply santyl, calcium alginate, cover with foam dressing daily. The measurements were 7.0 cm X 7.0 cm X 0.1cm. Record review of Physician Orders List revealed an order dated 10/12/22 identifying the area as open area to the right and left buttocks. Record review of a Physician Orders List revealed an order dated 10/17/22 revealed an order for Cleocin HCL 300 milligram (MG) (1) three times a day (TID) X 10 days, Cipro 500 MG (1) twice a day (BID) X 10 days to start on 10/18/22, obtain a Complete Blood Count (CBC) the week of 10/16/22. Record review of the Departmental Notes for Resident #1 beginning 10/8/22 revealed resident has an excoriated area to resident's buttocks and a treatment was initiated. Departmental Note dated 10/12/22 at 3:26 PM reveal that the wound Medical Doctor (MD) and Certified Nurse Practitioner have new orders for the wounds to resident #1's buttocks. On 10/19/22, at 1:50 PM it is noted that resident continues his antibiotics. It is noted that he has a lower blood pressure (BP), increased heart rate and twitching more than usual. 10/20/22 at 9:59 AM, LPN #2 documented that he has weaker strength, difficulty swallowing medications and pocketing medications. RN #1 assessed resident and documented excessive spasm, jerking motion to all extremities and that Resident #1. RN #1 contacted the NP and gave report along with the results of the CBC. NP ordered Resident #1 be sent to the emergency room (ER) for evaluation. Responsible Party (RP) notified. Record review of the Discharge Summary provided by the local hospital for Resident #1 revealed .Page 2 Sepsis from Stage IV decubitus ulcer with infection and patient has sacral decubitus ulcer, foul smelling odor. Patient with eschar over sacral ulcer . Page 3 revealed assessment by wound care consultant, foul smelling, boggy eschar noted to sacral area. Page 4 revealed debridement 10/26/22, debridement of skin, subcutaneous tissue, muscle and fascia 90 square(sq) cm, application of wound VAC. Page 5 revealed large sacral pressure ulcer with the base of the wound measuring 6 cm X 15 cm. The skin, subcutaneous tissue, muscle and fascia is necrotic all the way to the sacral bone and undermining the skin superiorly another 3 cm and extending inferiorly to the top edge of the anus. Interview with the DON on 11/30/22 at 3:20 PM, revealed I never looked at the area. We have pictures of it. His skin is so dark that there were black areas, but it was excoriation. Interview with the DON on 11/30/22 at 3:40 PM, revealed Since it was an excoriation, we do not have photos. We do not take photos of excoriations. Interview with the DON on 12/1/22 at 1:40 PM, revealed the facility does not have a specific policy/procedure for excoriations. I did see (Resident #1) a week before he went to the hospital. I saw slough and that is when the order changed to Santyl. Yes, the diagnosis should have changed from excoriation. She stated the Nurse Practitioner (NP) ordered the Santyl and Calcium Alginate. When I saw it, it was on both butt cheeks. There was scattered areas of slough and redness and black areas on top layer of African American skin peeling. The drainage was yellow. I would not call the black areas necrosis. Interview with the Director of Nurses (DON) on 12/5/22 at 11:00 AM, revealed she was aware of Resident #1 having air mattress issues. It was replaced twice that I know of. It would deflate and not reinflate on those 2 times I recall it was changed. Interview with the Nurse Practitioner (NP), on 12/5/22 at 1:00 PM, revealed she recalled she saw Resident #1's sacral area on 10/7/22. It was a small open area. I would describe a Stage 2. I will tell the nurses when I'm rounding what the pressure ulcers are staged but I always thought the Registered Nurses (RN's) will stage pressure ulcers as well. She stated there was no slough or drainage at that point and was a small open area. I saw it the next week because the staff reported a decline. It was 100% slough and had worsened. That's when I ordered the Santyl and Calcium Alginate. We started Cleocin, Cipro and ordered a CBC (Complete Blood Count). I believe they sent him out when they got the CBC results. It was unstageable when I started the Santyl and ordered the Cleocin. She revealed she had been out of the facility during the week Resident #1 was sent to the hospital due to a personal illness. I do expect the facility to stage wounds appropriately. She stated that since Resident #1 went into the hospital on [DATE], the facility has completed a 100% body audit on all residents. There have been times we haven't seen eye to eye with wound staging. They might not agree with the stage I give when staging pressure ulcers. Interview with the Director of Nurses (DON) on 12/5/22 at 1:05 PM, when asked by the State Agency (SA) about the malfunctioning of Resident #1's air mattress she responded that she, the Administrator, and maintenance looked at the air mattress but unable to recall the date. She stated that maintenance had changed the air mattress out a couple of times but did not recall the specific dates. Interview with the maintenance employee on 12/5/22 at 1:55 PM revealed when he began employment in august 2022 he recalled there were issues with Resident #1's mattress. He stated he changed out the outlet in the room a couple of times and recalled that the air mattress was changed out 1 time. Interview with Staff Member #1, on 12/5/22 at 3:10 PM, revealed that she was making rounds on 10/20/22. She noted there was a Certified Nurse Aide (CNA) feeding Resident #1 breakfast. She stated His eyes were locked on the ceiling. He was pocketing his food. His body was jerking every couple minutes. There was a meeting at 9:00 AM. I told them then someone needed to look at him. Staff member #2 said to the group 'y'all gonna wait around until he dies. Staff member #2 picked up his lab and gave it to Registered Nurse (RN) #1 and he went to the hospital that day. That odor was there for a week. She said the staff in the admission meeting was Staff Member #2, RN #1, DON, and the Administrator. She stated When I said he needed to be checked when in that meeting, it was just crickets. No one said a thing. Interview on 12/5/22 at 3:25 PM, with the primary Medical Doctor (MD) revealed he was the primary physician for Resident #1. MD #2 stated he was unaware of Resident #1's wound decline until he got to the hospital on [DATE]. If there was an odor to that wound, he should have been sent out earlier than 10/20/22. Not staging a wound in orders or notes is a problem. When there's an odor, the treatment has to be more aggressive, such as intravenous (IV) antibiotics, debrided and put in the hospital. Someone should have called me to let me know there was a problem, called me to admit him to the hospital for evaluation. I have a problem that nurses knew it was, what was needed and afraid to tell. There are communication problems there. It's been that way for a while. I didn't know there was a problem until he got to the hospital. Interview with Staff Member #2 on 12/6/22 at 2:05 PM, by phone revealed that she went into Resident #1's room on 10/20/22. She didn't see him because there was a CNA providing care but could smell him. She stated, He smelled like rotting, dead flesh. She stated she went into the morning stand up meeting and told the participants that if they didn't get him sent to the hospital soon that he was going to die in that room. I remember Staff Member #3 saying something to me about the wound smell. I also asked CNA #2 about him too. I went to the copy room and saw some lab work on him and took it straight to the charge nurse. His white blood count (WBC)'s was elevated and that let me know something was going on with him. Interview with Staff Member #3, on 12/6/22 at 2:15 PM, revealed that when she returned to work and worked her schedule from 10/13/22 through 10/20/22, she said that Resident #1 smelled like rotting flesh. She stated she reported it to the agency nurses during that time. Interview with CNA #2 on 12/7/22 at 10:25 AM revealed there were times when I was assigned to him, I would find the air mattress was deflated a couple of times but maintenance would replace it or fix it. Interview with CNA #3 on 12/7/22 at 12:05 PM revealed that when she was assigned to Resident #1 I found his air mattress deflated 2-3 times. We talked about him laying on the rails. CNA #3 confirmed to the State Agency (SA) that when she said Resident #1 was lying on the rails lyin if she meant g on the bed frame. She stated she made rounds every two (2) hours and that it could have been possible Resident #1 would be lying on the deflated mattress and on the bed frame for the time frame in between her rounds. She stated she had tried plugging and unplugging it to make it work but it would not. She did confirm that she told the administrator and her regional supervisor that was in the administrator's office at that time. She stated that the Regional Supervisor said he had told maintenance to check the electrical outlets. Removal Plan: On December 6, 2022, at 3:00 pm State Agency notified the Director of Nursing that the facility was in Immediate Jeopardy (IJ) and templates were provided to the Director of Nursing. The facility failed to ensure Resident # 1 was free of neglect by failure to provide services to prevent an acquired pressure wound. The facility failed to implement preventative measures to prevent a facility acquired wound for Resident #1. The facility failed to follow and implement a care plan with interventions for preventative measures to prevent a facility acquired wound for Resident #1. The facility failed to provide routine and consistent wound care, wound assessments, wound documentation, and trained staff for Resident #1. The facility failed to sustain and address systems in care and management through the Quality Assurance and Performance Improvement committee related to wound and skin care and ensure care and services delivered met standards of quality. The facility failed to ensure licensed nurses had knowledge, competencies and skill sets to provide routine and consistent wound care, wound assessments, wound documentation, appropriate staging of Pressure Ulcers, and trained staff for Resident #1. Corrective Actions: 1. Seventy residents were assessed with eleven residents identified by Director of Nurses as having excoriation/irritation or staged wounds on December 5, 2022. Seventy residents were assessed with twelve residents identified by Director of Nurses as having an air mattress device. · On December 6, 2022, Director of Nurses reviewed all eleven of seventy active resident records for a decline in wound status and for appropriate staging. Of the eleven residents identified with excoriation/irritation or staged wound, three were newly identified with excoriation/irritation and three were newly identified as a staged wounds and three were existing with excoriation/irritation and two were existing with staged wounds. Physicians, Resident Representatives notified of new wounds and new orders obtained for the new wounds. No significant findings were identified on all eleven of seventy active residents assessed. · On December 6, 2022, Director of Nurses reviewed all twelve of seventy active residents to identify functioning of air mattress device. No significant findings identified on all twelve of seventy active residents which required have an air mattress device · On December 6, 2022, Director of Nurses reviewed all twelve of seventy active records to ensure intervention of air mattress and function checks were present on care plan. No significant findings were identified on all twelve of seventy active residents care plans which were identified to have an air mattress device. Three records were newly identified with excoriation/irritation for implemented care plans and three records were newly identified as staged wounds for implemented care plans. 2. Quality Improvement Nurse ([NAME]) immediately initiated in-services with Registered Nurses and Director of Nursing on December 6, 2022, on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. In-services will be on-going, and no employee will be allowed to work until participation of the in-services are completed. 3. The facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress, no policy changes were made, however, facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders. Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. The following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON. The facility alleges that all corrective actions to remove the IJ were completed on December 6, 2022, and the IJ was removed on December 7, 2022. The SA validated the Removal Plan on 12/9/22. Validation: 1. Based on record reviews, observations and interviews on 12/9/22, the facility did a 100% skin assessment on all residents present in the facility on 12/5/22. Interviews with the [NAME] and DON on 12/9/22 revealed that 11 residents were identified by the DON having either excoriations/ irritation or staged wounds. Interviews, record reviews and observations revealed that 12 residents were identified by the DON as having air mattress devices. Based on record reviews and interviews, there were three (3) residents newly identified with excoriations or irritations and 3 were newly identified as having staged wounds. Record reviews revealed the Medical Doctors (MD) and Responsible Party (RP) of residents were notified of the new skin areas noted with new orders. Record review and interview revealed the DON reviewed the 12 residents on air mattress devices. The DON did not observe significant findings on the 12 residents with air mattress devices. Record review and interview confirmed that on 12/6/22, the DON reviewed the care plans of the 12 residents on air mattress devices to ensure the interventions included the air mattress and function checks were present. No significant findings were identified. The DON confirmed on 12/9/22 that she reviewed the 3 records of newly identified residents with excoriations/irritations and the 3 residents that were newly identified as having staged wounds. 2. Based on record reviews and interviews on 12/9/22, it was confirmed that the [NAME] had initiated an in-service with the Registered Nurses (RN) and Director of Nurses (DON) on 12/6/22. These in-services included information on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. Record review and interviews confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. Interviews and record review confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. Interview and record review confirmed that these in-services will be on-going, and no employee would be allowed to work until participation of the in-services were completed. 3. Record reviews and interviews on 12/9/22 confirmed that the facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Interviews and record review confirmed that the topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress and there were no policy changes made. Record review and interviews did confirm that the facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Record review and interview confirmed that the Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders and that the Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. Record review and interviews with the DON and [NAME] on 12/9/22 confirmed that the DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. Interviews and record reviews with the [NAME] and DON on 12/9/22 confirmed that the following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide a competent treatment nurse for one (1) of nine (9) residents to prevent a pressure ulcer from worsening as evidenced by Resident #1 was found on 10/7/22 with an excoriation on the sacral area and was admitted to the hospital on [DATE] with an unstageable sacral pressure ulcer with eschar, foul drainage, and sepsis. During the week of treatments beginning 10/8/22 through 10/12/22, there were four (4) different nurses providing treatments and observations of Resident #1's sacral excoriation. This situation was determined to be an Immediate Jeopardy (IJ) which began on 10/16/22, when the facility failed to provide competent and consistent nursing staff and failure to prevent the worsening of a pressure ulcer therefore placing this resident and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment, or death. On 12/6/22, at 3:00 PM, the SA notified the Quality Improvement Nurse ([NAME]) and Director of Nurses (DON) of the IJ and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 12/7/22, in which they alleged all corrective actions to remove the IJ were completed on 12/6/22 and IJ removed on 12/7/22. The SA validated the Removal Plan on 12/9/22, and determined the IJ was removed on 12/7/22, prior to exit. Therefore, the scope and severity for CFR 483.35 (a)(3)(4)(c) Competent Nursing Staff (F726) was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the Treatment Nurse job description revealed Qualifications 1. Demonstrates leadership and managerial ability balanced by strong clinical knowledge and skills . 6. Is capable of implementing changes as mandated by Federal, State and management recommendations . 12. Must demonstrate ability to follow recommendations as designated by the Director of Nursing. Record review of Resident #1 revealed that on the Wound and Skin Status Report for week 10/14/22 he is listed with an Irritation/excoriation and that treatment began 10/8/22 and measured 7.0(length) cm (centimeters)X 7.0W (width) cm X 0.10D (depth) cm on the sacrum with no drainage. Review of the wound report for week 10/21/22 has that Resident #1's wound is on the sacrum, it measures 8.0L cm X 7.0W cm X 0.10D cm. It is described as Irritation/Excoriation with no drainage. The Wound Status is described with a D for Deterioration. It is described with No Drainage. MD/RP (Medical Doctor/Responsible Party) Notification has Yes/Yes. Both wound reports are signed by the Director of Nurses (DON) and initialed by the Administrator. Resident #1 was admitted to the hospital on [DATE] with sepsis. Record review of the facility's Treatment Nurse (TN) job description on 12/6/22 revealed The Treatment Nurse (TN) assists in planning, implementing, and evaluating residents skin care needs to promote resident health. The TN communicates with other Licensed Staff of the facility in evaluating resident needs to decrease risk of skin breakdown, contractures, weight loss, skin tears and so forth while in the facility. The TN assists the facility to provide education and intervention to assure prevention programs are implemented. The TN assists the Nursing Department to develop, implement and revise resident's plan of care. The TN documents on records as per policy and procedures and participates in staff meeting as required. Record review of the Discharge summary dated [DATE] provided by the local hospital of Resident #1 revealed on page 2 Sepsis from Stage IV decubitus ulcer with infection and patient has sacral decubitus ulcer, foul smelling odor. Patient with eschar over sacral ulcer. Page 3 revealed assessment by wound care consultant, foul smelling, boggy eschar noted to sacral area. Page 4 revealed Debridement 10/26/22, debridement of skin, subcutaneous tissue, muscle and fascia 90 sq cm, application of wound VAC. Page 5 revealed large sacral pressure ulcer with the base of the wound measuring 6 X 15 cm. The skin, subcutaneous tissue, muscle, and fascia is necrotic all the way to the sacral bone and undermining the skin superiorly another 3 cm and extending inferiorly to the top edge of the anus. Interview with the DON on 11/30/22 at 3:20 PM revealed I never looked at the area. We have pictures of it. His skin is so dark that there were black areas but it was excoriation. Interview with the DON on 11/30/22 at 3:40 PM and she revealed Since it was an excoriation, we do not have photos. We do not take photos of excoriations. Interview with the DON on 12/5/22 at 11:00 AM revealed I'm not wound certified on classifying wounds. I don't feel comfortable staging a pressure ulcer. I know a nurse can't down stage a pressure ulcer but I didn't know if a RN can stage up a pressure ulcer. Interview with the Nurse Practitioner (NP), on 12/5/22 at 1:00 PM revealed she started her NP position at the facility in March 2022. She comes to the facility three (3) times a week. She recalled she saw Resident #1's sacral area on 10/7/22. It was a small open area. I would describe a stage 2. I will tell the nurses when I'm rounding what the pressure ulcers are staged but I always thought the RN's will stage pressure ulcers as well. She stated there was no slough or drainage at that point and was a small open area. I saw it the next week because the staff reported a decline. It was 100% slough and had worsened. That's when I ordered the Santyl and Calcium Alginate. We started Cleocin, Cipro and ordered a CBC. I believe they sent him out when they got the CBC results. It was unstageable when I started the Santyl and ordered the Cleocin. She revealed she had been out of the facility during the week Resident #1 was sent to the hospital due to a personal illness. I do expect the facility to stage wounds appropriately. She stated that since Resident #1 went into the hospital on [DATE], the facility has completed a 100% body audit on all residents. There have been times we haven't seen eye to eye with wound staging. They might not agree with the stage I give when staging pressure ulcers. Interview with Licensed Practical Nurse (LPN) #1 on 12/2/22 at 2:55 PM revealed she had performed wound care on Resident #1. I did the treatment on 10/10/22. I noticed drainage and odor. I did the ordered treatment that day. I did a treatment on 10/18/22. I just recall drainage, yellow, slimy and a foul odor. He didn't appear in pain, no grimacing. He was on an air mattress. I felt it looked different than excoriation. When I reported it on the 10th (10/10/22), the order was changed. On 12/2/22 at 10:30 AM, in an interview with Registered Nurse (RN) #2 revealed that she had just taken the full time position for treatment RN on 11/1/22 and that nurses would rotate days they performed wound care until 11/1/22. Interview with Medical Doctor #2 on 12/5/22 at 3:25 PM revealed he was the primary Medical Doctor (MD) for Resident #1. MD #2 stated he was unaware of Resident #1's wound decline until he got to the hospital on [DATE]. If there was an odor to that wound, he should have been sent out earlier than 10/20/22. Not staging a wound in orders or notes is a problem. When there's an odor, the treatment has to be more aggressive, such as IV antibiotics, debrided and put in the hospital. Someone should have called me to let me know there was a problem, called me to admit him to the hospital for evaluation. Interview with the DON on 12/7/22 at 12:30 PM revealed that when asked by the SA regarding contacting Resident #1's primary medical doctor when the Nurse Practitioner was out with a personal illness, I didn't and the treatment Registered Nurse didn't, not to my knowledge. In a post exit phone interview with the Administrator on 12/12/22 at 11:45 AM, revealed that the previous Registered Nurse (RN) terminated her position as wound care nurse and her last date worked was 1/3/22. The Administrator confirmed that the wound care/treatment nurse position was not filled until 11/1/22 and that staff would rotate doing treatments until the new treatment position was filled by RN #2 on 11/1/22. Record review of Inservice Training for Braden Scale dated 10/24/22 with the DON's signature as the Trainer/Instructor revealed 1. Braden Scale Assessments must be completed on admission, with each MDS (Minimum Data Set), significant change, development of pressure ulcer, and four weeks after new admit. 2. An assessment will fire on admission and then weekly to be completes by MDS. There were three nurses that were present at that in-service. Record review of Inservice Training for Skin Audits dated 2/4/22 with the DON's signature as the Training/Instructor revealed 1. All residents should receive daily bath (or shower days) with proper skin moisturizing. 2. Any new skin issue must be reported immediately to the nurse. 3. Nurses must complete order, TX (treatment) and WAM of any skin issue. The attendees were Certified Nurse Aides (CNA), Licensed Practical Nurses (LPN) and Registered Nurses (RN). Record review of Inservice Training for Skin Assessment and Documentation both dated 2/4/22 with the DON's signature as the Training/Instructor revealed 1. Skin should be assessed on admission, weekly, and after any incident. 2. Document in detail and place in WAM with treatment 3. Pictures should be taken on admit and complete skin sections and RN assessment and admit/readmit screen in detail. The attendees were Certified Nurse Aides (CNA), Licensed Practical Nurses (LPN) and Registered Nurses (RN). Record review of Inservice Training dated 5/4/22 for Prevention Devices: Ordered prevention devices must be in place at all times. Includes: heel boots, foam wedges, splint, turn schedule, air mattress. If the resident refuses, it must be documented The Trainer/Instructor was LPN #4. An accepted Removal Plan was provided to the SA on 12/7/22 at 1:15 PM. Removal Plan: On December 6, 2022, at 3:00 pm State Agency notified the Director of Nursing that the facility was in Immediate Jeopardy (IJ) and templates were provided to the Director of Nursing. The facility failed to ensure Resident # 1 was free of neglect by failure to provide services to prevent an acquired pressure wound. The facility failed to implement preventative measures to prevent a facility acquired wound for Resident #1. The facility failed to follow and implement a care plan with interventions for preventative measures to prevent a facility acquired wound for Resident #1. The facility failed to provide routine and consistent wound care, wound assessments, wound documentation and trained staff for Resident #1. The facility failed to sustain and address systems in care and management through the Quality Assurance and Performance Improvement committee related to wound and skin care and ensure care and services delivered met standards of quality. The facility failed to ensure licensed nurses had knowledge, competencies and skill sets to provide routine and consistent wound care, wound assessments, wound documentation, appropriate staging of Pressure Ulcers, and trained staff for Resident #1. Brief Summary: Resident #1 was admitted to the facility on [DATE], with a diagnosis of Diabetes Mellitus, Dementia, Hypertension and Benign Prostatic Hypertrophy, and Osteoarthritis. Resident #1 received a new order for an air mattress on March 7, 2022 per Physician #1. A routine body audit was completed on October 04, 2022, on Resident #1 by Licensed Practical Nurse (LPN) #1. On October 7, 2022, LPN #2 identified an excoriation area to Resident # 1's buttocks. Nurse Practitioner #1 visited the facility on October 7, 2022, and assessed Resident #1's area to the buttocks. Nurse Practitioner #1 ordered wound care treatment for Resident #1. Resident # 1 received daily wound care treatments with air mattress function checks every shift. On October 12, 2022. Resident #1's wound was assessed again by Nurse Practitioner #1. Nurse Practitioner #1 changed treatment order for Resident #1. On October 16, 2022, wound status identified as deteriorating. New orders for antibiotics and laboratory tests for Resident #1 were ordered by Nurse Practitioner #1 on October 17, 2022. October 20, 2022, Resident #1 was admitted to Hospital #1 for diagnosis of wound sepsis. Corrective Actions: 1. Seventy residents were assessed with eleven residents identified by Director of Nurses as having excoriation/irritation or staged wounds on December 5, 2022. Seventy residents were assessed with twelve residents identified by Director of Nurses as having an air mattress device. On December 6, 2022, Director of Nurses reviewed all eleven of seventy active resident records for a decline in wound status and for appropriate staging. Of the eleven residents identified with excoriation/irritation or staged wound, three were newly identified with excoriation/irritation and three were newly identified as a staged wounds and three were existing with excoriation/irritation and two were existing with staged wounds. Physicians, Resident Representatives notified of new wounds and new orders obtained for the new wounds. No significant findings were identified on all eleven of seventy active residents assessed. On December 6, 2022, Director of Nurses reviewed all twelve of seventy active residents to identify functioning of air mattress device. No significant findings identified on all twelve of seventy active residents which required have an air mattress device On December 6, 2022, Director of Nurses reviewed all twelve of seventy active records to ensure intervention of air mattress and function checks were present on care plan. No significant findings were identified on all twelve of seventy active residents care plans which were identified to have an air mattress device. Three records were newly identified with excoriation/irritation for implemented care plans and three records were newly identified as staged wounds for implemented care plans. 2. Quality Improvement Nurse ([NAME]) immediately initiated in-services with Registered Nurses and Director of Nursing on December 6, 2022, on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. In-services will be on-going, and no employee will be allowed to work until participation of the in-services are completed. 3. The facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress, no policy changes were made, however, facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders. Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. The following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON. The facility alleges that all corrective actions to remove the IJ were completed on December 6, 2022, and the IJ was removed on December 7, 2022. The SA validated the Removal Plan on 12/9/22. Validation: 1. Based on record reviews, observations and interviews on 12/9/22, the facility did a 100% skin assessment on all residents present in the facility on 12/5/22. Interviews with the [NAME] and DON on 12/9/22 revealed that 11 residents were identified by the DON having either excoriations/ irritation or staged wounds. Interviews, record reviews and observations revealed that 12 residents were identified by the DON as having air mattress devices. Based on record reviews and interviews, there were three (3) residents newly identified with excoriations or irritations and 3 were newly identified as having staged wounds. Record reviews revealed the Medical Doctors (MD) and Responsible Party (RP) of residents were notified of the new skin areas noted with new orders. Record review and interview revealed the DON reviewed the 12 residents on air mattress devices. The DON did not observe significant findings on the 12 residents with air mattress devices. Record review and interview confirmed that on 12/6/22, the DON reviewed the care plans of the 12 residents on air mattress devices to ensure the interventions included the air mattress and function checks were present. No significant findings were identified. The DON confirmed on 12/9/22 that she reviewed the 3 records of newly identified residents with excoriations/irritations and the 3 residents that were newly identified as having staged wounds. 2. Based on record reviews and interviews on 12/9/22, it was confirmed that the [NAME] had initiated an in-service with the Registered Nurses (RN) and Director of Nurses (DON) on 12/6/22. These in-services included information on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. Record review and interviews confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. Interviews and record review confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. Interview and record review confirmed that these in-services will be on-going, and no employee would be allowed to work until participation of the in-services were completed. Interviews with staff confirming these in-services on 12/9/22 included: 1 administrative assistant, 1 social services employee, 1 [NAME] nurse, 1 DON, 1 maintenance employee, 3 Certified nurse aides, 2 licensed practical nurses, 1 medical director, 2 registered nurses. 3. Record reviews and interviews on 12/9/22 confirmed that the facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Interviews and record review confirmed that the topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress and there were no policy changes made. Record review and interviews did confirm that the facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Record review and interview confirmed that the Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders and that the Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. Record review and interviews with the DON and [NAME] on 12/9/22 confirmed that the DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. Interviews and record reviews with the [NAME] and DON on 12/9/22 confirmed that the following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy/procedure review, provider's plan of correction review, record review and interviews, the facility failed to contact the Primary Medical Doctor (MD) and failed to update the interventions for Resident #1 in the High-Risk Management Committee Meeting on 10/19/22 for one (1) of nine (9) residents sampled regarding a worsening unstageable sacral ulcer. Resident #1. A routine body audit was completed for Resident #1 on October 04, 2022, by Licensed Practical Nurse (LPN) #1. On 10/7/22, LPN #2 identified an excoriation area to Resident #1's buttocks. On 10/16/22, the wound status was identified as deteriorating. On 10/20/22, Resident #1 was admitted to Hospital #1 for diagnosis of wound sepsis. The primary physician was not aware of the decline in Resident #1 until he was admitted to the hospital on [DATE] with sepsis. The State Agency (SA) identified an Immediate Jeopardy (IJ) that began on 10/16/22 when the facility failed to follow the Quality Assurance Performance Improvement (QAPI) plan that was previously initiated related to skin issues on 10/18/21. The facility failed to ensure the physician was notified of a worsening pressure ulcer when the Nurse Practitioner was out with a personal illness and failed to update interventions in the High-Risk Committee meeting. This placed Resident #1 in a situation that has caused or is likely to cause serious harm, injury, impairment, or death. On 12/6/22, at 3:00 PM, the SA notified the Quality Improvement Nurse ([NAME]) and Director of Nurses (DON) of the IJ and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 12/7/22, in which they alleged all corrective actions to remove the IJ were completed on 12/6/22 and IJ removed on 12/7/22. The SA validated the Removal Plan on 12/9/22, and determined the IJ was removed on 12/7/22, prior to exit. Therefore, the scope and severity for CFR 483.75 (a)(1)-(4)(b)(1)-(4)(f)(1)-(6)(h)(i) Quality assurance and performance improvement (QAPI) (F865) and were lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy/procedure for their Five Elements of QAPI (Quality Assurance Performance Improvement) last revised 11/22 revealed that Element 2: The Leadership ensures staff accountability, while creating an atmosphere where staff is comfortable identifying and reporting quality problems as well as opportunities for improvement. Record review of the facility's CMS(Centers for Medicare and Medicaid Services)-2567 Plan of Correction (POC) resulting from a complaint survey with an exit date of 10/18/21 revealed that the POC indicated All surgical wounds/skin issues will be monitored weekly in the High-Risk Committee meeting and all negative findings will be reported to the physician by the Director of Nursing or the Treatment RN (Registered Nurse). Record review of the facility's High Risk Management Committee Meeting dated 10/19/22 revealed Resident #1's name was listed but interventions were not updated on the Intervention section POC revised or Continue POC. Record review of the Discharge Summary from Hospital #1 for Resident #1 admitted on [DATE] revealed on page 2 Sepsis from Stage IV decubitus ulcer with infection and patient has sacral decubitus ulcer, foul smelling odor. Patient with eschar over sacral ulcer. Page 3 revealed assessment by wound care consultant, foul smelling, boggy eschar noted to sacral area. Page 4 revealed Debridement 10/26/22, debridement of skin, subcutaneous tissue, muscle and fascia 90 sq (square) cm (centimeters), application of wound VAC. Page 5 revealed large sacral pressure ulcer with the base of the wound measuring 6 cm X (by) 15 cm. The skin, subcutaneous tissue, muscle, and fascia is necrotic all the way to the sacral bone and undermining the skin superiorly another 3 cm and extending inferiorly to the top edge of the anus. Interview with RN #2 on 12/2/22 at 10:30 AM, revealed that she had just taken the full-time position for Treatment RN on 11/1/22 and that nurses would rotate days they performed wound care until 11/1/22. Interview with Medical Doctor #2 on 12/5/22 at 3:25 PM, revealed he was the primary Medical Doctor (MD) for Resident #1. MD #2 stated he was unaware of Resident #1's wound decline until Resident #1 got to the hospital on [DATE]. Someone should have called me to let me know there was a problem, called me to admit him to the hospital for evaluation. I didn't know there was a problem until he got to the hospital. Interview with the DON on 12/7/22 at 12:30 PM, revealed that when asked by the SA regarding contacting Resident #1's primary medical doctor when the Nurse Practitioner was out with a personal illness responded, I didn't and the treatment Registered Nurse didn't, not to my knowledge. In a post survey telephone interview with the Administrator on 12/12/22 at 11:45 AM, revealed that the previous RN terminated her position as wound care nurse and her last date worked was 1/3/22. The Administrator confirmed that the wound care/treatment nurse position was not filled until 11/1/22 and that staff would rotate doing treatments until the new treatment position was filled by RN #2 on 11/1/22. An accepted Removal Plan was provided to the SA on 12/7/22 at 1:15 PM. Removal Plan: On December 6, 2022, at 3:00 pm State Agency notified the Director of Nursing that the facility was in Immediate Jeopardy (IJ) and templates were provided to the Director of Nursing. The facility failed to ensure Resident # 1 was free of neglect by failure to provide services to prevent an acquired pressure wound. The facility failed to implement preventative measures to prevent a facility acquired wound for Resident #1. The facility failed to follow and implement a care plan with interventions for preventative measures to prevent a facility acquired wound for Resident #1. The facility failed to provide routine and consistent wound care, wound assessments, wound documentation and trained staff for Resident #1. The facility failed to sustain and address systems in care and management through the Quality Assurance and Performance Improvement committee related to wound and skin care and ensure care and services delivered met standards of quality. The facility failed to ensure licensed nurses had knowledge, competencies and skill sets to provide routine and consistent wound care, wound assessments, wound documentation, appropriate staging of Pressure Ulcers, and trained staff for Resident #1. Brief Summary: Resident #1 was admitted to the facility on [DATE], with a diagnosis of Diabetes Mellitus, Dementia, Hypertension and Benign Prostatic Hypertrophy, and Osteoarthritis. Resident #1 received a new order for an air mattress on March 7, 2022 per Physician #1. A routine body audit was completed on October 04, 2022, on Resident #1 by Licensed Practical Nurse (LPN) #1. On October 7, 2022, LPN #2 identified an excoriation area to Resident # 1's buttocks. Nurse Practitioner #1 visited the facility on October 7, 2022, and assessed Resident #1's area to the buttocks. Nurse Practitioner #1 ordered wound care treatment for Resident #1. Resident # 1 received daily wound care treatments with air mattress function checks every shift. On October 12, 2022. Resident #1's wound was assessed again by Nurse Practitioner #1. Nurse Practitioner #1 changed treatment order for Resident #1. On October 16, 2022, wound status identified as deteriorating. New orders for antibiotics and laboratory tests for Resident #1 were ordered by Nurse Practitioner #1 on October 17, 2022. October 20, 2022, Resident #1 was admitted to Hospital #1 for diagnosis of wound sepsis. Corrective Actions: 1. Seventy residents were assessed with eleven residents identified by Director of Nurses as having excoriation/irritation or staged wounds on December 5, 2022. Seventy residents were assessed with twelve residents identified by Director of Nurses as having an air mattress device. On December 6, 2022, Director of Nurses reviewed all eleven of seventy active resident records for a decline in wound status and for appropriate staging. Of the eleven residents identified with excoriation/irritation or staged wound, three were newly identified with excoriation/irritation and three were newly identified as a staged wounds and three were existing with excoriation/irritation and two were existing with staged wounds. Physicians, Resident Representatives notified of new wounds and new orders obtained for the new wounds. No significant findings were identified on all eleven of seventy active residents assessed. On December 6, 2022, Director of Nurses reviewed all twelve of seventy active residents to identify functioning of air mattress device. No significant findings identified on all twelve of seventy active residents which required have an air mattress device On December 6, 2022, Director of Nurses reviewed all twelve of seventy active records to ensure intervention of air mattress and function checks were present on care plan. No significant findings were identified on all twelve of seventy active residents care plans which were identified to have an air mattress device. Three records were newly identified with excoriation/irritation for implemented care plans and three records were newly identified as staged wounds for implemented care plans. 2. Quality Improvement Nurse ([NAME]) immediately initiated in-services with Registered Nurses and Director of Nursing on December 6, 2022, on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. In-services will be on-going, and no employee will be allowed to work until participation of the in-services are completed. 3. The facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress, no policy changes were made, however, facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders. Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. The following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON. The facility alleges that all corrective actions to remove the IJ were completed on December 6, 2022, and the IJ was removed on December 7, 2022. The SA validated the Removal Plan on 12/9/22. Validation: 1. Based on record reviews, observations and interviews on 12/9/22, the facility did a 100% skin assessment on all residents present in the facility on 12/5/22. Interviews with the [NAME] and DON on 12/9/22 revealed that 11 residents were identified by the DON having either excoriations/ irritation or staged wounds. Interviews, record reviews and observations revealed that 12 residents were identified by the DON as having air mattress devices. Based on record reviews and interviews, there were three (3) residents newly identified with excoriations or irritations and 3 were newly identified as having staged wounds. Record reviews revealed the Medical Doctors (MD) and Responsible Party (RP) of residents were notified of the new skin areas noted with new orders. Record review and interview revealed the DON reviewed the 12 residents on air mattress devices. The DON did not observe significant findings on the 12 residents with air mattress devices. Record review and interview confirmed that on 12/6/22, the DON reviewed the care plans of the 12 residents on air mattress devices to ensure the interventions included the air mattress and function checks were present. No significant findings were identified. The DON confirmed on 12/9/22 that she reviewed the 3 records of newly identified residents with excoriations/irritations and the 3 residents that were newly identified as having staged wounds. 2. Based on record reviews and interviews on 12/9/22, it was confirmed that the [NAME] had initiated an in-service with the Registered Nurses (RN) and Director of Nurses (DON) on 12/6/22. These in-services included information on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. Record review and interviews confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. Interviews and record review confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. Interview and record review confirmed that these in-services will be on-going, and no employee would be allowed to work until participation of the in-services were completed. Interviews with staff confirming these in-services on 12/9/22 included: 1 administrative assistant, 1 social services employee, 1 [NAME] nurse, 1 DON, 1 maintenance employee, 3 Certified nurse aides, 2 licensed practical nurses, 1 medical director, 2 registered nurses. 3. Record reviews and interviews on 12/9/22 confirmed that the facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Interviews and record review confirmed that the topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress and there were no policy changes made. Record review and interviews did confirm that the facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Record review and interview confirmed that the Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders and that the Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. Record review and interviews with the DON and [NAME] on 12/9/22 confirmed that the DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. Interviews and record reviews with the [NAME] and DON on 12/9/22 confirmed that the following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON.