**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to protect the resident's rights to be free from neglect when the resident eloped from the facility unsupervised and unmonitored and made her way to the middle of a busy intersection for (1) of 24 residents sampled. Resident #211 The facility's failure to ensure that Resident #211 was unable to exit the facility unsupervised resulted in her running into the middle of a busy intersection located at an intersection near the facility, placing the resident in a situation that was likely to cause serious injury serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 6/4/25, when Resident #211 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 6/5/25 at 11:40 AM. The State Agency (SA) validated the Removal Plan on 6/6/2025 and determined that the IJ was removed on 6/5/25, prior to exit. Therefore, the scope and severity for CFR §483.12 Freedom from Abuse, Neglect, and Exploitation - F600 - Scope/Severity Jwas lowered to 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: A review of the facility's policy, Freedom of Abuse, Neglect and Exploitation, November 2019, revealed, .This facility shall not condone any acts of resident .neglect .Neglect means failure of the facility, its employees, .to provide .services to a resident that are necessary to avoid physical harm . On 6/4/2025 at 3:15 PM, the State Agency (SA) observed several staff running across the parking lot. It was later determined that Resident #211 had eloped from the front door of the facility. The SA observed the resident had reached the intersection of two adjoining streets near the facility. The distance from the front door of the facility to the intersection is estimated to be 600 feet. Resident #211 was sitting on the back of a trailer that was attached to a pick-up truck that was stopped at the traffic light. Approximately seven (7) cars were observed to be in the street at the time Resident #211 sat in the intersection. Several staff were engaged in removing the resident from the truck's trailer and getting her back to the facility. The resident was initially carried by the staff, but a wheelchair was brought from the facility for the remainder of the trip back. The weather was 86 degrees and sunny. On 6/4/2025 at 3:27 PM an interview with Licensed Practical Nurse (LPN) #2 revealed she was starting her shift and was located at the nursing station, receiving information from the day shift nurse about another resident. LPN #2 stated at approximately 3:15 PM, she heard a Certified Nursing Assistant (CNA) yell, The new lady is out. LPN #2 reported she proceeded to run after the resident with the other nurses. LPN #2 noted the resident was back in the facility at approximately 3:20 PM. LPN #2 denied seeing Resident #211 exit the building. On 6/4/2025 at 3:30 PM an interview with LPN #3 revealed she was at the nursing station providing information on another resident to the evening shift nurse. LPN #3 stated that at approximately 3:10 PM she heard yelling and some saying, She's gone. LPN #3 reported seeing staff running out of the building and she ran behind them. LPN #3 noted she did not see Resident #211 leave the building. On 6/4/2025 at 3:37 PM an interview with the Director of Nursing (DON) revealed at approximately 3:00 PM she was in the Administrators office when she heard someone yell The lady. The DON noted she ran outside with the other staff and went to the intersection to retrieve the resident and bring her back to the facility. The DON noted the resident refused to come with the staff and yelled and kicked them. The DON noted the staff had to physically pick up the resident and carry her while yelling for someone to bring a wheelchair for her. The DON reported that her assessment of the resident revealed no injuries. During the interview the Emergency Medical Transport (EMT) arrived. The DON noted the resident will be sent to a geri-psych unit. On 6/4/2025 at 3:49 PM, an interview with Assistant Director of Nursing (ADON) revealed she was in the Administrator's office when at approximately 3:15 PM she heard an inaudible yelling coming from the hallway. The ADON stated she walked out of the office and saw people running toward the door. The ADON noted she ran after them and noticed the resident at the intersection near the facility. The ADON reported the Resident #211 was combative and held on tightly to the trailer on which she was sitting. The ADON noted the resident yelled that she did not live at the facility and that she wanted to go home. The ADON noted the resident was returned to the facility at approximately 3:25 PM. On 6/4/2025 at 4:10 PM, an interview with the Administrator revealed she was in her office when at approximately 3:15 PM she was alerted by someone screaming, The Lady from the hallway. The Administrator stated she ran to the front door and then to the location of the resident. The Administrator stated the resident was found at the intersection near the facility, sitting the back of a trailer that was attached to a pickup truck in the middle of the street. The Administrator stated Resident #211 was combative and resistant to coming back to the facility with the staff. The Administrator stated the resident was yelling, I want to go home, Don't touch me. The Administrator confirmed the resident was initially carried by the staff but was later placed in a wheelchair to get her back to the facility. The Administrator affirmed the resident was back in the facility at approximately 3:21 PM. The Administrator stated Resident #211 will be going to a geri psych unit. On 6/4/2025 at 4:17 PM an interview with CNA #1 revealed that at approximately 3:15 PM she was at the back door, near the laundry room, clocking out when she saw the resident walking and heard another staff member yell She got out. CNA #1 stated she ran back to the front of the building yelling for help. CNA #1 reported she ran out of the front door and proceeded to go along with the other staff toward the resident. CNA #1 confirmed the resident was located at the intersection near the facility, in the middle of the street, sitting on the back of a truck trailer. CNA #1 noted Resident #211 hysterical and combative. CNA #1 affirmed the resident was back in the building by approximately 3:20 PM. On 6/5/2025 at 8:32 AM an additional interview with the Administrator revealed she had reviewed the surveillance video and confirmed that the resident was able to exit the facility through the front door because the receptionist pushed the button that unlocks the door, allowing Resident #211 to walk out. The Administrator acknowledged that no other staff or visitors were surrounding the resident at the time she exited the facility. On 6/5/2025 at 8:40 AM, an interview with the Receptionist acknowledged that on 6/4/25 she was located at the receptionist desk when Resident #211 approached the door. The Receptionist stated she then pushed the button that unlocked the door and Resident #211 was able to walk out. The Receptionist affirmed that she did not recognize the resident because she was admitted to the facility the previous day after she left work. On 6/06/25 at 10:30 AM, an interview with the Family Nurse Practitioner (FNP) revealed she was made aware of the incident and ordered the resident sent to the hospital for physical and mental evaluation. The FNP noted she does not take part in the preadmission process. On 06/05/25 at 09:56 AM an interview with the Admissions Coordinator (AC) revealed when she receives pre-admission information for a resident, she forwards the information to the DON, ADON, the Administrator, the Business office and the Director of Respiratory to review the information. The AC affirmed that no information in Resident #211's preadmission documents stood out to her as worthy of concern for the resident. The AC confirmed that the resident's daughter mentioned that the resident had become more difficult to have at home. On 06/06/25 at 9:21 AM, during a phone interview with the Resident Representative (RR) revealed she was contacted by the facility staff regarding her mother's elopement from the facility on 6/4/25. The RR affirmed that the facility explained that the receptionist let her out, not knowing she was a resident. The RR stated it had only been 24 hours since her mother was admitted to the facility, and she wants her mother to be safe. The RR stated she has no other plan for her mother's care. On 06/06/25 at 9:46 AM, an additional interview with The Receptionist revealed she recalled buzzing the resident out the front door at time between 3:00 PM and 4:00 PM. The Receptionist recalled it was during the shift change and the second shift had already arrived. On 6/06/25 at 9:51 AM, an additional interview with the Administrator revealed when a resident is admitted to the facility it is the responsibility of the nurse assigned to that resident as well as the DON, ADON and the Nurse Supervisor to keep the resident safe until a care plan has been done. The Administrator confirmed that from the front door of the facility to the intersection where the resident was found was 250 steps approximately 600 feet. On 6/06/25 10:53 AM, an interview with the DON revealed the facility's Wandering Risk Screen and Elopement Evaluation for resident #211 was completed by Registered Nurse (RN) #1. The DON noted all staff are responsible for monitoring newly admitted residents for safety until they have a care plan. On 6/06/25 at 11:20 AM a phone interview RN #1 acknowledged that she is responsible for completing the Elopement Evaluation and the Wandering Risk Screen for Resident #211. RN #1 noted at the time of admission her impression of the resident came from the diagnoses of Altered Mental Status and Urinary Tract Infection (UTI). RN #1 stated she noticed the resident behaving in a confused state and even addressing her as if she were her daughter. RN #1 reported she believed Resident #211's confusion was due to the UTI. RN #1 affirmed that she did not have knowledge of the RR's statement regarding Resident #211 leaving home and wandering in the streets. On 06/06/25 at 12:18 PM, during an interview the Social Services Director (SSD) #1 acknowledged that she is responsible for updating the book that contains residents who are prone to wander. SSD #1 confirmed that the book was not updated to include Resident #211 at the time of her elopement from the facility on 6/4/2025. SSD #1 stated that she adds residents who are prone to wander to the book based on the assessment from the nursing staff at the time of admission. SSD noted that at the time the resident was admitted on [DATE] she was off work and had planned to do the assessment the next day. SSD #1 reported she is not shown preadmission paperwork to assess prior to admission. On 06/06/25 at 1:10 PM, an additional Interview with SSD #1 revealed she updated the wandering binder and included color photographs on 6/4/25. A record review of the Admissions Record revealed the facility admitted Resident #211 on 6/3/25 with diagnoses including Unspecified Dementia and Altered mental status. Removal Plan: Corrective Actions Implemented Immediately Resident Assessment: Upon re-entry, a comprehensive full-body assessment was completed. No injuries were noted. There were no signs of bruising, bumps, skin tears, or lacerations. When asked about any discomfort, Resident #211 reported that her feet felt a little sore. The Director of Nursing (DON) removed the residents' socks and observed no redness or open areas. Acetaminophen (Tylenol) was administered in accordance with the physician's order. Vital signs were obtained and found to be within normal limits. Resident #211 became tearful and expressed a strong desire to return home, stating that her daughter was not adequately caring for her grandchildren and that she needed to be there for them. The Nurse Practitioner was promptly notified and provided an order for the Resident #211 to be transferred to the emergency room for further evaluation at a higher level of care. Resident #211's Responsible Party (RP) was contacted and informed of the situation and the new medical order. An emergency response was called, and the resident was transported by ambulance and taken to the local emergency department. Resident #211 departed the facility on a stretcher at approximately 4:15 PM. At 5:40 PM, a follow-up call was placed to the emergency department, where it was confirmed that the Resident #211 had been admitted to the Geri psych unit for continued evaluation and treatment. Implementation Date: 6/4/2025 o Official report called to the State Agency on June 4, 2025 o Emergency Quality Assurance and Performance Improvement (QAPI) meeting held on June 4, 2025, with leadership to review failures and prevention strategies. Staff in attendance were Administrator, DON, ADON, Infection Preventionist/RN Educator, Maintenance Director, Medical Director via telephone, Social Services #1, Social Services #2, MDS Coordinator, Wound Care, Wound Care Nurse, Rehab Manager, Environmental Services, Activities Director, RNA, Central Supply, Medical Records, Human Resources, Business Office, Staffing, Treatment Nurse Nurse Educator will conduct in-service training for all staff on wandering and elopement (new admits at risk) protocols on June 4, 2025. o Social Services will complete a 100% audit of the wandering binders to ensure all qualifying residents are included and that color photographs are added on June 4, 2025. o Central Supply Clerk, will order neon green armbands to identify residents at risk of wandering or elopement on June 4, 2025 o Maintenance Department will change the front entrance/exit door codes to prevent unauthorized exits on June 4, 2025. o DON and ADON will conduct elopement drills on every shift once a week for four weeks, then monthly thereafter, beginning on June 4, 2025. o DON and ADON will complete a 100% audit of care plans for residents identified as elopement risks to ensure their accuracy and completeness on June 4, 2025. o DON and ADON will complete a 100% audit of all resident assessments to identify those who meet criteria for wandering risk on June 4, 2025. o ADON will complete a 100% audit of the total number of residents in the facility on June 4, 2025. *No employees will be permitted to work until the assigned in-services have been completed. Validation: The SA validated on 06/06/25 through interview and record review that all actions to remove the immediacy were completed on 06/05/25. The Immediate Jeopardy was removed on 06/05/25 prior to the SA exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision, monitoring, and preadmission risk assessment to prevent a resident from exiting the facility unsupervised and without staff awareness or intervention for one (1) of twenty-four (24) sampled residents. (Resident #211). This failure resulted in Resident #211 eloping from the building on 6/4/25, for an estimated 600 feet, and being found seated on the back of a trailer in a public intersection surrounded by traffic, thereby placing the resident in Immediate Jeopardy (IJ) for serious injury, harm, impairment, or death. This situation was determined to be IJ and Substandard Quality of Care (SQC), which began on 06/04/25 when Resident #211 eloped from the facility. The State Agency (SA) notified the Administrator of the Immediate Jeopardy on 06/05/25 at 11:40 AM and provided an IJ template. The facility provided an acceptable Removal Plan on 06/05/25, in which they alleged all corrective actions to remove the IJ were completed on 06/05/2025 and the IJ removed on 06/05/2025. The SA validated Removal Plan on 06/06/25, and determined that the IJ was removed on 06/05/25, prior to SA exit. Therefore, the scope and severity for CFR 483.25(d)(1)(2) Accidents/Hazards - F689 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: A review of the facility's policy titled Wandering/Elopement Risk (Revised November 2017) revealed It is the standard of this facility to identify those residents at risk for wandering/elopement and to take the appropriate steps to minimize the risk of elopement. All residents are assessed for the potential to wander prior to or upon admission. A record review of the admission Record for Resident #211 revealed an admission date of 06/03/25 with diagnoses including Unspecified Dementia and Altered Mental Status. During an observation on 06/04/25 at approximately 3:15 PM, the SA observed several staff running through the facility parking lot. It was later confirmed that Resident #211 exited the facility through the front door after the receptionist pushed the door release button. The resident was found seated on the back of a trailer at the intersection near the facility, an estimated 600 feet from the front entrance of the facility. The resident was combative, yelling, I want to go home, and had to be carried by staff until a wheelchair arrived. Record review of weather records from [NAME], MS on 06/04/25 at 3:15 PM documented a temperature of 86°F and clear skies. During an interview on 06/04/25 at 3:27 PM, Licensed Practical Nurse (LPN) #2 stated she was at the nurses' station receiving report when she heard a Certified Nursing Assistant (CNA) yell, The new lady is out. She ran outside with other staff and saw the resident being retrieved, but did not witness the elopement. On 06/04/25 at 3:30 PM, LPN #3 stated she heard shouting and followed staff outside, confirming the resident was found at the intersection but she did not witness her leaving the building. On 06/04/25 at 3:37 PM, the Director of Nursing (DON) stated she was in the Administrator's office when she heard yelling. She ran outside and saw the resident sitting on the trailer in traffic. The DON confirmed the resident was combative, refused to return, and had to be physically carried while another staff retrieved a wheelchair. During an interview on 06/04/25 at 4:10 PM, the Administrator stated she heard someone yelling The lady and ran to the front door. She saw the resident sitting in the middle of the street on a trailer attached to a pickup truck. The resident was yelling, I want to go home, and Don't touch me. The Administrator confirmed the resident was carried until a wheelchair was brought. She stated the resident would be transferred to a geriatric psychiatric unit. During an interview on 06/04/25 at 4:17 PM, Certified Nursing Assistant (CNA) # 1 stated she was clocking out by the laundry area when she heard yelling. She ran to the front and joined other staff in retrieving the resident from the intersection. She described the resident as hysterical and combative. During an inteview on 06/05/25 at 8:32 AM, the Administrator confirmed that video surveillance showed the receptionist unlocking the door, allowing the resident to exit without being accompanied by staff. During an interview on 06/05/25 at 8:40 AM, the Receptionist stated she pushed the release button for the front door when Resident #211 approached, and she did not recognize the resident because she had been admitted the previous evening after the receptionist's shift. On 06/06/25 at 9:21 AM, the Resident Representative stated she was notified of the elopement and told the receptionist to let the resident out, not realizing she was a new admission. She stated it had only been 24 hours since her mother's admission and she wanted to ensure her mother's safety. During an interview on 06/06/25 at 9:46 AM, the Receptionist recalled unlocking the door for the resident between 3:00 PM and 4:00 PM during shift change. During an interview on 06/06/25 at 9:51 AM, the Administrator stated that when a new resident is admitted , the assigned nurse, DON, Assistant Director of Nurses (ADON), and Nurse Supervisor are responsible for safety monitoring until a care plan is developed. During an interview on 06/06/25 at 10:30 AM, the Family Nurse Practitioner (FNP) stated she was notified of the elopement and ordered the resident to be transferred to a local hospital for evaluation. She confirmed she does not participate in preadmission screening. On 06/05/25 at 9:56 AM, the admissions Coordinator stated she forwarded the resident's preadmission information to the DON, ADON, Administrator, Business Office, and Respiratory Director. She did not identify any concerning information at the time, although she recalled that the daughter mentioned the resident had become difficult to manage at home. During an interview on 06/06/25 at 10:53 AM, the DON stated that the facility's Wandering Risk Screen and Elopement Evaluation were completed by RN #1. She stated that all staff are responsible for monitoring newly admitted residents until a care plan is in place. During an interview on 06/06/25 at 11:20 AM, RN #1 stated she assessed the resident as confused but attributed it to a Urinary Tract Infection (UTI). She acknowledged the resident addressed her as if she were her daughter but denied knowing about the history of wandering reported by the family. During an interview on 06/06/25 at 12:18 PM, the Social Services Director (SSD) #1 stated that she is responsible for updating the facility's wandering book based on nursing assessments. She confirmed that Resident #211 had not yet been added because she was off work at the time of admission. During an interview on 06/06/25 at 1:10 PM, the SSD #1 confirmed that she added Resident #211 to the wandering binder on 06/04/25 with a photograph. Removal Plan: Corrective Actions Implemented Immediately Resident Assessment: Upon re-entry, a comprehensive full-body assessment was completed. No injuries were noted. There were no signs of bruising, bumps, skin tears, or lacerations. When asked about any discomfort, Resident #211 reported that her feet felt a little sore. The Director of Nursing (DON) removed the residents' socks and observed no redness or open areas. Acetaminophen (Tylenol) was administered in accordance with the physician's order. Vital signs were obtained and found to be within normal limits. Resident #211 became tearful and expressed a strong desire to return home, stating that her daughter was not adequately caring for her grandchildren and that she needed to be there for them. The Nurse Practitioner was promptly notified and provided an order for the Resident #211 to be transferred to the emergency room for further evaluation at a higher level of care. Resident #211's Responsible Party (RP) was contacted and informed of the situation and the new medical order. An emergency response was called, and the resident was transported by ambulance and taken to the local emergency department. Resident #211 departed the facility on a stretcher at approximately 4:15 PM. At 5:40 PM, a follow-up call was placed to the emergency department, where it was confirmed that the Resident #211 had been admitted to the Geri psych unit for continued evaluation and treatment. Implementation Date: 6/4/2025 o Official report called to the State Agency on June 4, 2025 o Emergency Quality Assurance and Performance Improvement (QAPI) meeting held on June 4, 2025, with leadership to review failures and prevention strategies. Staff in attendance were Administrator, DON, ADON, Infection Preventionist/RN Educator, Maintenance Director, Medical Director via telephone, Social Services #1, Social Services #2, MDS Coordinator, Wound Care, Wound Care Nurse, Rehab Manager, Environmental Services, Activities Director, RNA, Central Supply, Medical Records, Human Resources, Business Office, Staffing, Treatment Nurse Nurse Educator will conduct in-service training for all staff on wandering and elopement (new admits at risk) protocols on June 4, 2025. o Social Services will complete a 100% audit of the wandering binders to ensure all qualifying residents are included and that color photographs are added on June 4, 2025. o Central Supply Clerk, will order neon green armbands to identify residents at risk of wandering or elopement on June 4, 2025 o Maintenance Department will change the front entrance/exit door codes to prevent unauthorized exits on June 4, 2025. o DON and ADON will conduct elopement drills on every shift once a week for four weeks, then monthly thereafter, beginning on June 4, 2025. o DON and ADON will complete a 100% audit of care plans for residents identified as elopement risks to ensure their accuracy and completeness on June 4, 2025. o DON and ADON will complete a 100% audit of all resident assessments to identify those who meet criteria for wandering risk on June 4, 2025. o ADON will complete a 100% audit of the total number of residents in the facility on June 4, 2025. *No employees will be permitted to work until the assigned in-services have been completed. Validation: The SA validated on 06/06/25 through interview and record review that all actions to remove the immediacy were completed on 06/05/25. The Immediate Jeopardy was removed on 06/05/25 prior to the SA exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to protect the residents' right to be free from neglect for five (5) of 22 residents reviewed as evidenced by facility staff: 1. Did not provide Pressure Ulcer (PU) assessments and care and treatment to prevent complications and worsening of PUs (Resident #53 and Resident #89) 2. Turn and reposition a resident (Resident #87) 3. Ensure incontinent residents were clean and dry (Resident #1 and Resident #31). The facility's neglect to provide wound assessments, documentation, and wound care treatment resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility, and was not assessed by a qualified nurse or practitioner until 9/18/23, causing the wound to worsen. The facility Administrator was notified of the IJ and SQC and was presented with an IJ Template on 12/1/23 at 2:55 PM. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23. The SA validated the Removal Plan on 12/5/23 and determined the IJ was removed on 12/5/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation F600 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: A review of the facility's policy Freedom of Abuse, Neglect, and Exploitation Standard, revised 11/2019, revealed . The purpose of this written Freedom of Abuse, Neglect, and Exploitation Standard is to outline the preventive and action steps taken to reduce the potential for abuse, mistreatment and neglect of residents . Neglect means failure of the facility, its employees .to provide .services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Resident #53 During an observation and interview, on 11/28/23 at 10:30 AM, Resident #53 was sitting up in his wheelchair and he stated that he had a large wound on his bottom. He commented that he thought he would have additional wounds after this past weekend, because he had to lay in bed in his bowel movements and urine for long periods of time on the night shift. At 2:00 PM on 11/28/23, during the resident council meeting, the residents complained that it took a long period of time on the night shift for staff to answer call lights and change them. Resident #53 attended the resident council meeting and stated that he could validate those complaints because it happened to him all the time. He explained that the bandage to his wound would come off and the nurses did not redo the wound care or replace the bandage. During an interview with Licensed Practical Nurse (LPN) #1/Wound Care Nurse, on 11/28/23 at 3:15 PM, he explained that when a resident was admitted to the facility, the initial body assessment was completed by Registered Nurse (RN) #3 (RN)/admission Nurse, and she staged, measured, and documented Pressure Ulcers (PUs). LPN #1 reported that he provided a resident list to the Wound Care Physician of residents that he needed to see. The Wound Care Physician assessed and measured PUs weekly on Mondays and LPN #1 added the physician's measurements to the Wound/Skin Log. He stated that he began documenting on the Wound/Skin logs when RN #4, who was the previous wound care nurse, left the faciity on [DATE]. LPN #1 explained that a Random Skin Sweep was a skin assessment that could be used at any time to document any newly identified skin issues. He further explained that a Weekly Skin Sweep had to be completed by an RN whenever a nurse documented on the Medication Administration Record (MAR) that the resident had a skin issue. LPN #1 confirmed that Resident #53 had only one (1) PU on his bottom that he had upon admission to the facility. He reported that the resident was currently seen by the Wound Care Physician. A record review of the admission Record revealed the facility admitted Resident #53 on 08/29/23 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. Record review of the facility's Brief Interview for Mental Status (BIMS) Evaluation, dated 12/2/23, revealed a score of 13, which indicated Resident #53 was cognitively intact. A record review of the Random Skin Sweep dated 08/29/23, which was the date of admission, revealed Resident #28 had a Pressure area to the Left buttock that measured 8 centimeters (cm) length, 5 cm width, and 4 cm depth and a Skin Tear to the Right lateral foot that measured 3 cm length, 6 cm width, and the depth was listed as UTD (Unable To Determine). Skin Impairment Findings revealed Skin injuries as listed above. Left buttock cleaned with NS (Normal Saline), calcium alginate rope, and bordered gauze applied. Right lateral foot cleaned with NS and bordered gauze applied. (Proper Name of Wound Care Physician) to F/U (Follow Up) with resident. The document was signed by RN #4, who was the previous Wound Care Nurse for the facility and was no longer employed by the facility. A record review of Braden Scale for Predicting Pressure Sore Risk, dated 08/29/23, revealed Resident #53 had a score of 13, which indicated he had a moderate risk of developing PUs. A review of the medical record revealed there was no other Random or Weekly Skin Sweeps documented. During an interview at 4:00 PM on 11/28/23, with the Director of Nursing (DON), she explained that PU wound documentation and skin assessments were to be completed weekly on the Wound/Skin Log by LPN #1. A record review of the facility's Wound/Skin Log, dated 9/04/23, revealed Resident #53 had a Stage IV PU to his Left Buttock that measured 7 cm X 2 cm X 10.75 cm. These measurements were documented six (6) days after Resident #53's admission to the facility and indicated the PU had increased in depth. The log also indicated the resident had a Stage IV PU to his Right Lateral Foot that measured 2 cm X 1.5 cm X and the D (cm) was UTD. This wound had been classified upon admission as a Skin Tear and this was the first documentation that the area was a Pressure type and Stage IV. The Wound/Skin Log documentation did not indicate who had completed the logs and did not include a description of the PU characteristics, the progress toward healing and identification of potential complications, if infections was present, the presence of pain, or a description of dressings and treatment. A record review of the facility's Wound/Skin Log, dated 9/11/23, revealed Resident #53 had a Stage IV PU to his left buttock that measured 6.2 cm x 1.6 cm x 10.6 cm and had a Type or Stage of PVD (Peripheral Vascular Disease) to his right foot that measured 1.7 cm x 1.5 cm x UTD. The documentation of PVD was inconsistent with the Wound/Skin Log dated 9/4/23, which indicated the wound to the right foot was a PU. A record review of the Order Recap Report, with Order Date: 08/29/2023 - 11/30/2023), revealed Resident #53 had a Physician's Order, dated 9/18/23, for Wound consult with skilled wound care surgical group . A record review of a Surgical Note, dated 09/18/23, revealed Resident #53 was seen by the Wound Care Physician 20 days after he was admitted to the facility. The Physician visited the resident because he was asked for his opinion on how to manage the wound located at the left buttock and sacrum. The Wound Location was listed as Left Buttock and Sacrum, and the Etiology was listed as Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury. The note also revealed that the wound area measured 6.2 cm x 1.6 cm x 10.5 cm, which was deeper than the initial measurement upon admission. The wound required the Physician to perform a muscle tissue debridement, which was the removal of dead tissue from the wound. The wound description indicated that the wound had undermining (separation of the wound edges from the surrounding healthy tissue) of 13 cm, had no odor, and had a copious amount of serosanguineous (thin fluid with a light pink tinge) exudate. The tissue of the wound was 20% slough (nonviable skin tissue), 80% granulation (development of new skin tissue), and there was no necrotic or dead tissue present in the wound. This was the first wound assessment that included a complete wound description of the PU characteristics for Resident # 53 since the resident was admitted to the facility on [DATE]. The wound progress was listed as Undetermined: first visit. The wound to the Right Lateral Foot was listed as PVD. The Assessment and Plan revealed, The patient has a wound found on the left buttock and sacrum .there was a sign of tissue decline which will entail continuing supervision and will likely require future debridement .continue offloading .turn per facility protocol. A low air loss mattress is recommended . A record review of the Order Recap Report, with Order Date: 08/29/2023 - 11/30/2023), revealed Resident #53 had a Physician's Order, dated 8/29/23 and discontinued on 9/19/23, for Sacrum pressure injury - clean with NS, Pat dry, apply Calcium Alginate and cover with bordered gauze daily and prn (as needed) for soiled or dislodgement . During an observation and interview with Certified Nurse Aide (CNA) #14 and Resident #53 at 5:05 AM on 11/29/23, she explained that she was going to change Resident #53. Resident #53 commented that was the second time he had seen staff all night and he had not been changed since about 11 PM. The observation revealed that Resident #53's brief was saturated and there was no protective bandage noted covering the PU, nor was there a bandage in his brief indicating the bandage had become dislodged during the night. CNA #14 provided incontinence care and applied a clean brief, but the PU to the sacrum/buttocks did not have a bandage on it, which left the packed wound exposed. CNA #14 confirmed that the resident's brief had been saturated and there was no bandage on the PU wound. She stated she was unsure of the last time she had changed his brief or when the bandage had come off the resident. She said would notify the nurse that the resident did not have a bandage on his PU. CNA #14 explained that they did not document when residents are turned on the tasks, but Resident #53 was good about turning himself. She confirmed that Resident #53 was incontinent of bowel and bladder. During an interview with Registered Nurse (RN) #5, at 5:25 AM on 11/29/23, she explained the CNAs should round every two (2) hours to ensure residents were clean and dry, but she did not check behind them to confirm the rounds are completed. She confirmed CNA #14 had let her know that Resident #53's bandage was off his PU site, and she advised that she would replace the dressing after she completed her medication pass. During an interview with RN #3/admission Nurse, at 8:25 AM on 11/29/23, she explained she was not a wound care nurse. She stated that she had been helping with the assessment of new wounds, admissions, and hospital returns or any other residents the wound care nurse needed help with. She confirmed that she only measured the wounds and she attempted to assess them, but she did not feel comfortable about staging PUs. She said that the Wound Care Physician assessed all wounds until they were healed, and that LPN #1 printed the physician's assessment and that would become part of the resident's medical record. She confirmed that she had never staged PUs and that when a resident was admitted to the facility with an existing PU, the facility used the hospital's discharge wound orders and staging documentation. During an interview with the Director of Nursing, on 11/29/23 at 3:00 PM, she explained she did not know who completed the Wound/Skin Logs before LPN #1 took over after RN #4 had left. She said that different nurses had helped and had completed the logs but there was no signature or identifying information to indicate who completed the measurements. She explained that as far as she knows, those logs were completed with the measurements from the Wound Care Physician's weekly assessments which are completed when he rounds. She confirmed the logs indicated PU measurements but did not include any other assessment information regarding the wounds. She said that she received a copy of the PU logs weekly, but she did not review the logs to determine if the PUs were healing or deteriorating, and she did not keep the logs on file. The DON stated that LPN #1 provided the Wound Care Physician with a list of residents that needed to be seen during his weekly visits, but she was unsure how or who determined which residents should be seen by the physician. During an interview with LPN #1, on 11/30/23 at 10:35 AM, he explained that if a resident was admitted to the facility with an existing PU and had wound treatment orders from the hospital, he would not always refer that resident to the Wound Care Physician. He reported the facility did not have a protocol on when a resident should be seen by the Wound Care Physician. He stated that if a wound was not responding to the treatment orders, he would notify the Wound Care Physician and schedule a consultation for the next Monday. LPN #1 stated that RN #3 documented measurements on the Wound/Skin Log for the residents that the Wound Care Physician did not see. He explained that when a new wound was identified, he got an RN to assess the area and he relied on the RN to complete the Random Skin Sweep documentation. He explained when Resident #53 was admitted to the facility, he was not referred to the Wound Care Physician immediately because the resident had treatment orders for wound care that came with him from the hospital. However, when he noticed that the wound was not responding to the treatment, he referred the resident to the Wound Care Physician. He confirmed Resident #53's wound was deep with tunneling and undermining present. He was not aware that the RNs had not documented anything on the Wound/Skin logs. During an interview with the Assistant Director of Nursing (ADON), at 11:10 AM on 11/30/23, she explained she was not involved in Resident #53's wound care and had never observed his PU. The facility had a Wound Care Physician that came every Monday, and the Nurse Practitioner was in the facility Monday through Friday. She explained that a PU assessment and documentation should include the PU stage, measurement, description of the appearance of the PU, drainage, odor, and healing or deterioration of the PU. All PU wounds and notifications must be documented, and if it was not documented, then it was not completed. The ADON said that she was unsure of the protocol regarding notifying or consulting with the Wound Care Physician when a resident acquired a new PU, but she knew he was provided with a list of residents that he needed to visit. She explained that the facility conducts a Stand Up meeting every morning during the week and discussed all concerns in the facility, including PU concerns. The ADON stated she was unaware that RN #3 was not comfortable in staging PUs, but there were other RNs in the facility that could assist, and RN #3 should have asked them for help. The ADON said that if a PU was not staged or assessed appropriately, the wounds may not be treated appropriately and may worsen. During an interview with the DON, at 12:00 PM on 11/30/23, she explained she expected the nurse to call the Physician or Wound Care Physician if a wound worsened in any way. She also expected all PU assessments and findings to be documented in the medical record, and that if there was no documentation, then it was not done and that she was aware that documentation was a problem. The DON explained that any changes in a resident or a resident's PU should be documented. She confirmed that the facility did not have a system in place to determine when a resident required a consultation with the Wound Care Physician. LPN #1 was responsible for communicating with the Wound Care Physician, who was available as needed. LPN #1 completed the wound/skin logs weekly, but the DON was unaware that PUs were not completely assessed if they are not being seen by the Wound Care Physician. She thought every resident with a wound was seen by the Wound Care Physician but was not aware of the system. She was not aware that RN #3 was not comfortable with staging wounds, because she has been completing admission wound assessments for a long time. The DON said she would have put someone else in the position that was more comfortable if she had known. She confirmed that RN #3 has just recently been filling in with wound assessments other an admission assessments since RN #4 had been employed at the facility. There were other RNs in the facility that could assess and measure if RN #3 had asked for help. The DON was not aware Resident #53 was not seen by the Wound Care Physician and that his wound had gotten deeper from the time he was admitted on [DATE] until he was seen by the Wound Care Physician on 9/18/23. She reported since there was no longer a RN in wound care, other RNs assisted in completing Wound/Skin logs as necessary. Resident #89 During a phone interview with the Complainant, on 11/28/23 at 12:20 PM, she explained she became involved when the resident was admitted to an acute care hospital from the facility with a diagnosis of Sepsis (serious condition in which the body responds improperly to infection) related to a PU to the sacrum. She explained the hospital physicians were concerned that the facility's staff were not turning and repositioning the resident as often as needed and not keeping him dry and clean. She reported the resident's brother and sister had voiced concerns to her and the physicians that staff were not turning Resident #89 frequently and the resident remained wet for long periods of time. The Complainant advised that Resident #89 required wound surgery during his hospital stay and he currently remained in the acute care hospital at the time of the interview. During a phone interview with the Resident Representative (RR), on 11/28/23 at 01:00 PM, , he explained Resident #89, who was his brother, had been in the facility for six (6) weeks and had gotten a bad wound that became septic and required surgery. He explained he stayed at the facility for long periods of time to be with brother and the staff did not turn or change him enough. The staff would not touch the resident for hours, and when they finally came to change him, Resident #89 would be soaked with urine. He said that his brother did not have any wounds when he was admitted to the facility and that he did not have a catheter. He explained the facility discussed inserting a catheter on the day the resident was so sick and was transported to the hospital. The RR felt like if the facility had kept his brother dry and had turned him often, he would not have gotten the PU. A record review of the admission Record revealed the facility admitted Resident #89 on 09/28/23 with diagnoses that included Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration. A record review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/5/23, revealed Resident #89 required a Staff Assessment for Mental Status and his cognition was severely impaired. A review of Section GG revealed that Resident #89 was dependent on staff for all functional abilities. A review of Section M revealed Resident #89 was at risk for developing pressure ulcers/injuries, but he did not have any unhealed pressure ulcers/injuries. A record review of the Braden Scale for Predicting Pressure Sore Risk, dated 9/28/23, revealed Resident #89 had a score of 12 which indicated he had a high risk of developing PUs. A record review of the Nursing Random Skin Sweep, dated 09/28/23, which was the date of admission to the facility for Resident #89, revealed he had skin tears to his left ear, left upper chest, and right upper chest. The document was signed by RN #4, the previous Wound Care Nurse. There was no documentation regarding any skin or PUs to the resident's sacrum or buttocks. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 9/28/23 for Weekly skin assessments . Review of the report revealed there were no Physician Orders that addressed any skin issues or PU treatments to the sacrum upon Resident #89's admission date of 9/28/23. A record review of the Wound/Skin Log, dated 10/8/23 (Sunday), which was 10 days after the Resident #89 was admitted to the facility, revealed he had a PU to the sacrum that measured 6.5 cm x 4.0 cm x UTD. The onset date was recorded as 9/28/23 which was the date of admission and conflicted with the Nursing Random Skin Sweep that was completed on 9/28/23 and the Physician's Orders. This was the first documentation that referred to the PU. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 10/10/23 and ended on 11/8/23, for Sacrum Pressure Injury - Clean with NS, Pat dry apply Zinc Oxide and cover with bordered gauze daily and prn . This order was received two (2) days after the wound/skin log, dated 10/8/23, indicated Resident #89 had a PU that measured 6.5 cm x 4.0 cm x UTD. A record review of the Weekly Skin Sweep, dated 10/12/23, revealed Resident #89 had a PU to the sacrum that measured 2.0 cm length, 1.0 cm width, and UTD for the depth. The measurements conflicted with the measurements documented on the Wound/Skin Log that had been completed four (4) days prior. The documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. The document was signed by RN #3, the admission Nurse. A record review of the Wound/Skin Log, dated 10/16/23, revealed Resident #89 had a PU to the sacrum that measured 6 cm x 4 cm x UTD, which indicated an increase in the size of the wound from the Weekly Skin Sweep completed on 10/12/23, which was four (4) days prior. The onset date was recorded as 9/28/23. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Wound/Skin Log, dated 10/23/23, revealed Resident #89 had a PU to the sacrum that measured 6.25 cm x 4 cm x UTD. The onset date was recorded as 9/28/23. The measurements indicated the wound had increased in size since the log dated 10/16/23. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Wound/Skin Log, dated 11/6/23, revealed Resident #89 had a PU to the sacrum that measured 6.5 cm x 4.2 cm x UTD. The measurements indicated the wound had increased in size from the documentation on the log dated 10/23/23. The onset date was recorded as 9/28. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. There was an additional Wound/Skin Log', dated 11/6/23, which indicated Resident #89 had a PU to the sacrum that measured 6.5 cm x 4.5 cm x UTD and the onset date was 9/28/23. A record review of the Weekly Skin Sweep, dated 11/8/23, revealed Resident #89 had a PU to the sacrum that measured 3.0 cm length, 2.0 cm width, and UTD for the depth. These measurements were inconsistent with the measurements provided two (2) days prior on the wound/skin log dated 11/6/23. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 11/8/23, for Sacrum Pressure Injury - clean with NS, pat dry apply Santyl/Calcium Alginate and cover with bordered gauze daily and prn ., and a Physician's Order, dated 11/9/23, for Low air loss mattress for sacral wound. There was a Physician Order, dated 11/13/23, to consult skilled wound care for evaluation of sacrum wound . A record review of a Surgical Note, dated 11/13/23, revealed Resident #89 was seen by the Wound Care Physician. The Physician visited the resident for management of wounds located on the sacrum. The Wound Location was listed as Sacrum, and the Etiology was listed as Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury. The note also revealed that the wound measured 6.0 cm x 4.0 cm x UTD prior to his debridement, and 6.0 cm x 4.0 cm x 0.5 cm after the debridement procedure. The wound required the Physician to perform a muscle tissue debridement with the Preoperative Indications listed as Biofilm, Devitalized tissue, and Slough. There were no signs of infection. The wound description indicated that the wound had no odor and had a moderate amount of serosanguineous exudate. The Peri wound area was unhealthy and unstable. The tissue of the wound was 80% slough and 20% granulation. This was the first wound assessment that included a complete wound description of the PU characteristics, for Resident # 89, which was 36 days after the PU was first documented on the Wound/Skin Log dated 10/8/23. During an interview with RN #3/admission Nurse, at 8:25 AM on 11/29/23, she confirmed that she had completed the Weekly Skin Sweep for Resident #89 on 10/12/23 and that she did not stage the PU or provide descriptive characteristics of the PU. She explained that she had assumed the wound care team would follow Resident #89, but she did not follow up to ensure he was seen by the team. She explained that the wound care team at that time consisted of LPN #1 and the Wound Care Physician. She was unable to recall what the PU looked like when she had measured it. She confirmed that she only measured the PU and did not complete or document a full assessment of the wound. She said she was unaware that the Wound Care Physician was not seeing the resident when she completed the documentation on 10/12/23. During an interview with the DON, on 11/29/23 at 3:00 PM, she explained she was not aware that RN #3 had not assessed or staged the PU to the sacrum for Resident #89 and that the Wound Care Physician had not assessed or staged the PU for more than four (4) weeks after the PU was first identified by facility staff on 10/8/23. During an interview with the Administrator and the DON, at 3:10 PM on 11/29/23, the Administrator explained that he could not determine who had completed the Wound/Skin logs that were provided. He explained that RN #4 was the previous wound care nurse and her last day at the facility was 10/04/23. The DON and the Administrator were unable to explain the PU measurement inconsistencies of the Wound/Skin logs and the Weekly Skin Sweeps for Resident #89. During an interview with LPN #1, on 11/30/23 at 10:35 AM, he explained when Resident #89 was admitted to the facility, he did not have any PUs. He was unable to recall how he found out that Resident #89 had a PU, but he did recall asking RN #3 to measure the wound. LPN #1 described the PU when he first saw it as measuring approximately 2 cm x 3 cm, the area was discolored, but the skin was intact. He thought the wound was classified as Moisture Associated Skin Damage (MASD), because whenever he provided the treatments to the sacrum, Resident #89 was soiled with urine. He stated that he had instructed CNAs that the resident needed to be kept dry, changed in a timely manner, and turned more frequently, however he did not conduct and document a formal in-service. LPN #1 said that Resident #89's family would be with the resident daily and he would talk to them regarding resident's PU, but he never completed any documentation regarding the PU. LPN #1 said that when the wound was first found, the physician was notified, and new orders were received for zinc oxide, because the skin was intact. He stated that he continued to treat the PU with zinc oxide and did not notify the Wound Care Physician that the wound size was increasing. He confirmed he had no documentation of the wounds, including the progression or deterioration of the wound. When he noticed the PU to the sacrum had slough, he notified the Wound Care Physician and received orders to discontinue the zinc oxide and start a new treatment. He said that he felt like the PU measurements obtained on the Random and Weekly Skin Sweeps were accurate because he assisted RN #3/Admissions Nurse when she measured the wounds. He confirmed Resident #89's wound had deteriorated and increased in size from the time it was first identified on 9/28/23 until the time he was seen by the Wound Care Physician on 11/13/23. He confirmed that on 11/13/23, the PU to the sacrum was classified as a Stage IV. LPN #1 stated that he would not have done anything differently with the resident's wound. He confirmed that Resident #89 did not have a low air loss mattress to help with pressure reduction until 11/9/23. During an interview with the Assistant Director of Nursing (ADON), at 11:10 AM on 11/30/23, she explained she was unaware that Resident #89 had a PU because she was not involved in his care. She stated that it appeared someone dropped the ball, but she didn't know who. She explained that for a resident to develop a Stage 4 PU in less than two (2) months of admission, the resident did not receive adequate care and should have been referred to the Wound Care Physician before a month had passed, especially since the resident had comorbidities, restricted mobility, and was at a high risk for skin breakdown. During an interview with the DON, at 12:00 PM on 11/30/23, she stated she was not aware that Resident #89's PU had increased in size before the Wound Care Physician had gotten involved with his care. During a phone interview with the Nurse Practitioner (NP), at 12:45 PM on 11/30/23, she explained that she had not observed Resident #89's PU, but she would have if she were asked to do so.The NP stated that she reviewed the Wound/Skin Logs, but not in detail. During a phone interview with the Wound Care Physician, at 1:25 PM on 11/30/23, he confirmed that he saw Resident #89 on 11/1[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions as evidenced by: (1) the failure to develop comprehensive care plan interventions for residents with pressure ulcers (PUs) (Resident #53 and Resident #89), (2) the failure to ensure a resident was turned and repositioned (Resident # 87), (3) the failure to ensure residents were clean and dry (Resident #1 and #31), and (4) the failure to ensure nail care was provided to dependent residents (Resident #23 and Resident #41), for six (6) of 22 care plans reviewed. The facility's failure to develop comprehensive care plan interventions related to the prevention of skin breakdown and PU care resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. The facility's failure to put Resident #53, Resident #89, and all other residents who are at risk for skin breakdown at risk for serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility, and was not assessed by a qualified nurse or practitioner until 9/18/23, causing the wound to worsen. The facility Administrator was notified of the IJ and was presented with an IJ Template on 12/1/23 at 2:55 PM. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23. The State Agency (SA) validated the Removal Plan on 12/5/23 and determined that the IJ was removed on 12/5/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.21(b) Comprehensive Care Plans F656 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: A record review of the facility's policy Comprehensive Care Plan revised 03/2019, revealed, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment . Resident #53 A record review of Resident #53's Comprehensive Care Plan undated, revealed a Focus: The resident has Stage 4 pressure ulcer to Left Buttocks .Desired Outcome: The resident's will Pressure ulcer will show signs of healing and remain free from infection by/through review date .Interventions/Tasks: Administer treatments as ordered and monitor for effectiveness, Monitor/document/report to MD (Medical Doctor) PRN (As Needed) changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms), wound size (length X width X depth), stage, Sacrum and left buttock pressure injury State 4-clean with NS (Normal Saline), pat dry, pack with Dakin's solution ¼ strength soaked kerlix and cover with bordered gauze daily and prn for soiled or dislodgement . There were no other interventions developed to stabilize, reduce, or remove underlying risk factors for PUs or to prevent the development of additional PUs. At 9:00 AM on 11/29/23, during an interview with Licensed Practical Nurse (LPN) #1/Wound Care Nurse, he stated that Resident #53 was admitted to the facility with a PU. A record review of the admission Record revealed the facility admitted Resident #53 on 08/29/23 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. A record review of the Comprehensive Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/05/23 revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated he had severe cognitive impairment. Further review revealed that he required extensive assistance with bed mobility and toilet use, was always incontinent of urine and bowel, he was at risk of developing PUs, and had one (1) unstageable PU that was present upon admission to the facility. Record review of Resident #53's Brief Interview for Mental Status (BIMS) Evaluation with an effective date of 12/02/23 revealed a BIMS Summary score of 13, which indicated Resident #53 was cognitively intact. A record review of Braden Scale for Predicting Pressure Sore Risk, dated 08/29/23, revealed Resident #53 had a score of 13, which indicated he was at moderate risk for developing a PU. Resident #89 A record review of the Comprehensive Care Plan undated, revealed a Focus : Resident is at risk for impairment to skin due to Immobility, Incontinence . Desired Outcome: Residents will remain free of complications if skin is impaired through next review date. Interventions . Preventative skin care measures . Record review of the care plan undated, revealed Focus : The resident has potential/actual impairment to skin integrity r/t (related to) Stage 4 to sacrum. Desired Outcome: The resident's pressure injury of the (sacrum) will be healed by review date. Interventions/Tasks: Identify/document potential causative factors and eliminate/resolve where possible, Keep skin clean and dry, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, macerations etc. to MD, Wound care as ordered by MD (santyl, Calcium Alginate, bordered Foam . There were no other interventions developed to stabilize, reduce, or remove underlying risk factors for PUs or to prevent the development of additional PUs. A record review of the admission Record revealed the facility admitted Resident #89 on 09/28/23 with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration. A record review of the Comprehensive Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/05/23 revealed Resident #89 required a staff assessment of mental status, which indicated his cognitive skills were severely impaired. Further review revealed that he was dependent upon staff for functional abilities, was always incontinent of urine and bowel, he was at risk of developing PUs, and had no PUs upon admission to the facility. A record review of Resident #89's Braden Scale for Predicting Pressure Sore Risk, dated 09/28/23, revealed he had a score of 12, which indicated he was at high risk for developing a PU. A record review of the Random Skin Sweep, dated 9/28/23, the date Resident #89 was admitted to the facility, revealed he did not have any PUs. A record review of the Wound/Skin Log, dated 10/8/23, revealed Resident #89 had a PU to the sacrum. On 11/30/23 at 10:35 AM, during an interview with LPN #1, he explained that he reviewed Physician's Orders to complete treatments for the residents and he did not use or review the resident's care plans. He stated that care plan interventions are completed by the Registered Nurses (RNs) and the purpose of the interventions was to instruct the staff on how to provide care to the resident. At 11:35 AM on 11/30/23, during an interview with LPN #4/Care Plan Nurse, she explained the purpose of the care plan is to provide care for the residents, and all care plans should be resident-centered and individualized for the residents. She stated that she and Registered Nurse (RN) # 2/MDS Coordinator, build resident care plans, including interventions, by using the electronic health record care plan library. LPN #4 said they also review the Braden's Scale to help with care planning for residents at risk for PU development and for residents who currently had PUs. She explained that every staff member should use the care plan to assure adequate care was provided for the resident. LPN #4 reviewed Resident #53's PU care plan and confirmed there were no interventions that addressed prevention for further skin breakdown or the development of additional PUs. LPN #4 reviewed Resident #89's PU care plan and confirmed that although there were some preventive measures in place, the interventions did not include everything including supplements, weights, and was not resident centered. She confirmed the intervention of Preventative skin care measures was too vague and should be more specific for the staff to know how to care for the resident. At 12:00 PM on 11/30/23, during an interview with the Assistant Director of Nursing (ADON), she explained the facility had two (2) Care Plan Nurses that complete care plans for the residents. She stated that the Braden Scale was completed by staff on each resident upon admission and care plans are developed based on the results of the assessment. She reported that any resident who was at risk for a PU, or had a current PU, should have a care plan for prevention of skin breakdown or for additional PU development. She confirmed that all care plans should be resident-centered and contain interventions to provide the needs of the resident. She stated that she expected resident care plans to have appropriate interventions in place to provide adequate care to the residents. On 12/01/23 at 11:00 AM, during an interview with RN #2/MDS Coordinator/Care Plan Nurse, she explained the purpose of the care plan was to know what care the resident needed and she expected all staff to follow the care plan. She stated that she used Physician Orders and other assessments to develop care plan interventions to meet the resident's needs. RN #2 reviewed Resident #53's care plan and confirmed the PU care plan interventions did not contain measures to prevent further skin breakdown and the development of additional PUs. RN #2 reviewed Resident #89's care plan and confirmed the interventions for preventative skin care measures should be more resident centered and reported preventative skin care measures should be used for all residents. Resident # 87 A record review of Resident #87's Comprehensive Care Plan revealed a Focus of Resident is at risk for impairment to skin due to immobility and had Interventions/Tasks including Incontinent care q (every) 2 hours and as needed and Turn and reposition q 2 hours and as needed. A record review of the admission Record revealed the facility admitted Resident #87 on 08/07/23 with diagnoses including Nontraumatic Intracerebral Hemorrhage, Chronic Respiratory Failure with Hypoxia, and Hemiplegia and Hemiparesis. On 11/27/23 at 10:27 AM, during an observation, Resident #87 was lying in bed positioned on his back with the head of the bed elevated to approximately a 45 degree angle. On 11/28/23 at 9:00 AM, during an interview with the resident's sister, she complained that the facility was not providing good care to her brother. She reported that she came to the facility to visit him daily and the staff failed to turn and reposition him. She stated that Resident #87 had been on his back for two (2) hours, since 7:00 AM. On 11/28/23 at 1:00 PM and 3:00 PM, during an observation, Resident #87 was positioned on his back with the head of the bed elevated. On 11/29/23 at 8:00 AM and 10:30 AM, during observations, Resident #87 was positioned on his back with the head of the bed elevated. On 11/29/23 at 11:00 AM, in an interview with the DON, she confirmed the facility did not have a schedule for residents to be turned. Resident #1 Record review of the care plan for Resident #1 revealed a Focus of (Proper Name of Resident #1) has bladder incontinence and is at risk for complications and Interventions/Tasks included .Check (Proper Name) every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes . Record review of the admission Record revealed the facility admitted Resident #1 on 8/11/23 with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non dominant side and Morbid Severe Obesity. During an observation and interview on 11/29/23 at 5:15 AM, with CNA #13, revealed Resident #1's brief was saturated with urine and had a strong urine odor. CNA #13 stated that she was not assigned to the resident but confirmed that the resident's brief was saturated with urine and had a strong urine odor. In an interview with LPN #2/Unit Manager, on 11/29/23 at 8:49 AM, she stated that Resident #1 was incontinent of bowel and bladder, and she expected all staff to make rounds every two (2) hours to turn residents and keep them clean and dry. Resident #31 Record review of the care plan revealed Resident #31 had a Focus of The resident has bladder and bowel incontinence r/t Impaired Mobility, with Interventions/Tasks including .Change (every2 hours) and prn, and Check resident and as required for incontinence . Record review of the admission Record revealed the facility admitted Resident #31 on 6/23/23 with a diagnosis of Traumatic Brain Injury. Record review of the Quarterly MDS with an ARD of 9/26/23 revealed Resident #31 had a BIMS score of 15, which indicated she was cognitively intact. A review of Section G revealed she was dependent upon staff for toileting hygiene. An observation and interview with Resident #31, on 11/27/23 at 2:40 PM, revealed there was a urine odor noted. Resident #31 stated that she stayed wet for long periods of time. An observation and interview with CNA #13 on 11/29/23 at 5:22 AM, Resident #31 stated that she was changed once last night before she went to sleep, and she got changed once on the 11 PM to 7 AM shift. The resident's brief was heavily soiled, and there was a strong urine odor. CNA #13 stated she was not the CNA for the resident, but she confirmed that Resident #31's brief was heavily soiled with urine and had a strong urine odor. In an interview with the DON on 11/29/23 at 10:42 AM, she stated that she expected the CNAs to complete rounds every two hours or every hour, if a resident required it more often. At 9:40 AM on 12/01/23, in an interview with CNA #1/Lead CNA, she stated that she worked on all halls and all shifts at the facility. She explained that she expected the CNAs to make rounds every two (2) hours and change the resident if needed. She stated that if a resident was found to have a heavily saturated brief and had a strong urine odor, she would think that the resident had not been changed all night. Resident #23 A record review of the care plan for Resident #23 revealed a Focus of The resident has an ADL (Activities of Daily Living) self care performance deficit r/t activity intolerance, impaired balance, Limited Mobility, with Interventions/Tasks of .Check nail length and trim and clean on bath day and as necessary, and The resident requires extensive assistance .with personal hygiene . A record review of Resident #23's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included Muscle wasting and atrophy, Rheumatoid Arthritis, Osteoarthritis, and Muscle Weakness. A record review of the Quarterly MDS with an ARD of 9/15/22 revealed that Resident #23 had a BIMS core of 15, which indicated that the resident is cognitively intact. SECTION G revealed she is not ambulatory and requires extensive assistance for bed mobility, dressing, and personal hygiene. During an observation and interview on 11/27/23 at 10:56 AM, Resident #23's fingernails were jagged and approximately ¼ of an inch past the tips of her fingers. Her hair was matted at the ends, appearing nappy. Resident #23 stated that she did not like her long fingernails and wished staff would comb her hair and trim her nails regularly. She indicates the staff has not cut her nails or done her hair in several weeks. During an observation on 11/28/23 at 3:42 PM, Resident #23's hair was uncombed, and her nails were long and jagged. During an observation on 11/29/23 at 8:23 AM, Resident #23's hair was not combed, and her nails were not cut. Resident #41 Record review of the care plan for Resident #41 revealed Focus (Proper Name of Resident #41) has an ADL Self Care Performance Deficit r/t Activity Intolerance, Hemiplegia, Impaired balance, Stroke .Interventions .Check nail length and trim and clean on bath day and as necessary . Record review of the care plan revealed Focus (Resident # 41's Proper Name) requires assistance with ADL's related to cognitive impairment, decreased mobility, HX (History) of Cerebral Infarction .Interventions .Staff to assist with ADL's . In an observation and interview on 11/27/23 at 12:17 PM, Resident #41 was lying in bed. His hair was not combed, fingernails were long and jagged, and his face was unshaven. Resident #41 stated that he wanted his nails clipped and to be groomed on a consistent schedule. He stated that staff have not done it as frequently as he would have liked. Record review of Resident #41's admission Record revealed he was admitted to the facility on [DATE] with diagnoses including Lack of Coordination, Contracture of Right Hand and Stiffness in Right Hand. A record review of the Quarterly MDS with an ARD of 09/25/23 revealed that Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, which indicates that the resident is cognitively intact. In an interview with Resident #41 on 11/28/23 at 4:36 PM, he stated that staff had not cut his nails or combed his hair. During an interview on 11/29/23 at 10:02 AM, with Resident #41 and the RN #1/Unit Manager, Resident #41 reiterated that he wished to have his nails clipped, beard shaved, and hair combed every week. RN #1 said he would get this done for the resident immediately. On 11/30/23 at 11:35 AM, during an interview with Licensed Practical Nurse #4 (LPN)/Care Plan Nurse, she stated every staff member should use the care plan to assure adequate care is provided for the residents. On 11/30/23 at 12:00 PM, during an interview with the DON, she explained that she expected staff to follow the residents' care plans to provide the best care for all residents. On 12/01/23 at 11:00 AM, during an interview with RN #2/MDS Coordinator/Care Plan Nurse, she stated that she expected all staff to follow the care plans to be able to provide adequate care for the residents. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23 which included: On December 1st, 2023, at approximately 3:30pm Pine Forest Health and Rehabilitation received 5 Immediate Jeopardies during an Annual and Complaint Survey from the Mississippi Department of Health Licensure and Certification and provided the facility with the Immediate Jeopardy Templates. Brief Summary of Events: Pine Forest Health and Rehabilitation failed to put into place appropriate interventions to ensure proper assessment, staging, treatment and clinical care plans to treat and prevent the development and worsening of new and existing pressure ulcers. Corrective Actions: 1. An Emergency QAPI Meeting was held at approximately 12/1/2023 at 5 PM to review the cited deficient practices and to determine a root cause analysis for the lack of appropriate interventions. This meeting included the Administrator, Director of Nursing/lnfection Preventionist, Medical Director, Respiratory Director, & Business Office Manager. The following items were reviewed, coordinated, and corrected to allege compliance and remove the Immediate Jeopardy. The root cause analysis determined the cause of these occurrences was the facility's failure to be properly train staff on the policies for assessing, staging, preventing, and communicating wound and skin care issues for residents who could be at risk for skin breakdown or are already noted with skin/wound breakdown. 2. The facility did a complete policy review on Care Planning Standard, Skin Management Standard, and Employee Competency Standard. The facility conducted 100% in-services and education using outsourced, Qualified Trainers and Online Software as it pertains to each department and the correlated policies pertaining to the immediate jeopardies. The facility also did a 100% inservice on all staff on the Identification and Reporting of Resident Abuse and Neglect. No individual was allowed to work beginning at approximately 7PM on 12/1/2023 until they were able to successfully complete all prescribed In-services. 3. The facility outsourced a Qualified RN Trainer to properly train with return demonstration all individuals who are responsible for the assessment, staging, and provision of wound care for the Facility. Upon completion and approximately 7:30PM on 12/1/2023, the Facility began to conduct body audits on 100% of in-house residents to determine proper assessment, staging, and treatment of wounds and finished on 12/4/2023. All noted pressure areas were assessed, staged, and determined to have a proper assessment. The wound care physician was notified of all findings and coordinated a Telehealth Visit on all residents with pre-existing wounds to confirm appropriate assessment, staging, and treatment of all existing pressure ulcers. There were no changes noted after having concluded all consult Telehealth visits. The attending physician and facility Medical Director was then notified of all Wound Care Physician's Assessments and concurred with prescribed consultation on all noted patients. Resident #53 was determined to have a pressure ulcer in an optimal condition of healing. Resident #89 remains in the hospital. 4. Both MDS Nurses were immediately trained following the QAPI Meeting regarding the ability to properly develop and/or revise resident care plans interventions for residents with pressure ulcers, ensuring those who were admitted to the facility without pressure ulcers did not acquire pressure ulcers and that existing pressure ulcers did not get worse, or residents did not develop complications from pressure wounds. After completing each Telehealth visit from Wound Care Physician and receiving noted confirmation for Medical Director/Attending Physician on all residents with Pressure ulcers, the facility began assessing and updating all care plans on 12/1/2023 and completed 12/4/2023 on coordination with development and prevention of pressure ulcers according to the prescribed orders. Resident #53 was noted to have a proper care plan regarding his healing pressure ulcer. Resident #89 remains in the hospital. 5. The facility determined to move forward by having the trained Unit RN Managers conduct weekly body audits on all residents as it pertains to their individual Units A & B and report the assessment of those daily audits to the Wound Care Team, consisting of the Wound Care Physician, Treatment Nurse, MDS Nurse, and Director of Nursing. All new admits/readmitting residents will their initial assessment conducted by the Unit Manager, who will be responsible for communicating the results of the audit to the Wound Care Team, Consisting of the Wound Care Physician, Treatment Nurse, MDS Nurse and Director of Nursing. The Director of Nursing has been delegated to report the reconciliation of this weekly review in High Risk and monitored monthly for no less than 1 year by the QAPI Committee. 6. The Facility alleges compliance on 12/5/2023. The facility alleges that all corrective actions to remove the Immediate Jeopardy were completed on 12/4/2023 and the Immediate Jeopardy was removed on 12/5/2023. The SA validated the facility's Corrective Actions on 12/5/23: The SA validated through interviews and record review on 12/5/2023 that an Emergency QAPI meeting was held on 12/01/2023 with all members in attendance. The SA validated through interviews and record reviews all policies on Care Planning Standards, Skin Management Standards, and Employee Competency Standards were reviewed with no corrections made. The facility conducted 100% in-services and education including Identification and Reporting of Resident Abuse and Neglect. The SA validated through interviews and record reviews the facility outsourced a Qualified RN Trainer to properly train and return demonstration all individuals who are responsible for the assessment, staging, and provision of wound care for the Facility. The facility completed 100% body audits of in-house residents to determine proper assessment, staging, and treatment of wounds and finished on 12/04/23. The Wound Care Physician was notified of all findings and coordinated a Telehealth Visit on all residents with pre-exiting wounds to confirm appropriate assessment, staging, and treatment of all exiting pressure ulcers. The Medical Director was notified of all findings. Resident #53 was determined to have a pressure ulcer in an optimal condition of healing. Resident #89 remains in the hospital. The SA validated through interviews and record reviews both MDS Nurses were immediately trained following the QAPI meeting regarding the proper development and/or revise resident care plans interventions for residents with pressure ulcers, ensuring those who were admitted to the facility without pressure ulcers did not acquire pressure ulcers and that existing pressure ulcers did not get worse, or residents did not develop complications from pressure wounds. The facility assessed and updated all care plans and completed them on 12/04/23. The SA validated through interviews and record reviews the facility trained Unit RN Managers conduct weekly body audits on all resident as it pertains to their individual Units A and B and report the assessment of those daily audits to the Wound Care Team, consisting of the Wound Care Physician, Treatment Nurse, MDS Nurse, and DON. The DON has been delegated to report the reconciliation of this weekly review in High Risk and monitored monthly for no less than one (1) year by the QAPI Committee. The SA validated through interviews and record reviews and no associate can return to work until they have received this in-service training. The SA validated that all corrective actions were completed on 12/04/2023 and the IJ was removed as of 12/05/2023.

Based on interviews, record review, and facility policy review, the facility failed to revise resident-centered comprehensive care plan interventions for residents with Pressure Ulcers (PUs) to prevent worsening or complications from PUs for two (2) of 22 care plans reviewed. (Resident #53 and Resident #89). The facility's failure to revise comprehensive care plan interventions related to PU care put Resident #53, Resident #89, and all other residents with skin breakdown in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility, and was not assessed by a qualified nurse or practitioner until 9/18/23, causing a PU to worsen. The facility Administrator was notified of the IJ and was presented with an IJ Template on 12/1/23 at 2:55 PM. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23. The State Agency (SA) validated the Removal Plan on 12/5/23 and determined that the IJ was removed on 12/5/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.21(b) Comprehensive Care Plans F657 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: A record review of the facility's policy Comprehensive Care Plan revised 03/2019, revealed, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .Policy Explanation and Compliance Guidelines .8. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment . A record review of the facility's policy Skin Management Standards, revised 04/2021, . Wound Documentation and Tracking .Procedure .4. Care plans are reviewed and revised as needed consistent with overall plan of care. Aggressive wound management with plan of healing . Resident #53 A record review of Resident #53's Comprehensive Care Plan undated revealed a Focus of The resident has Stage 4 pressure ulcer to Left Buttocks ., with Interventions/Tasks that included, Sacrum and Left Buttock Pressure Injury Stage 4-Clean with NS (Normal Saline), Pat Dry, Pack with Dakin's Solutions ¼ strength soaked kerlix and cover with bordered gauze daily and prn (as needed) for soiled or dislodgement. The care plan did not reflect the current physician's order dated 11/1/23. A record review of the Order Recap Report, with Order Date: 08/29/2023 - 11/30/2023, revealed Resident #53 had a discontinued Physician's Order, with an order date of 10/16/23 and an end date of 11/1/23, for Sacrum and Left Buttock pressure injury Stage 4 - clean with NS, Pat dry, pack with Dakins solution ¼ strength soaked kerlix and cover with bordered gauze daily and prn for soiled or dislodgement . The current care plan did not reflect that the order for Dakins was discontinued on 11/1/23. A record review of the Order Recap Report, with an Order Date: 08/29/2023 - 11/30/2023, revealed Resident #53 had a current Physician's Order, dated 11/1/23 for Sacrum and Left Buttock pressure injury Stage 4 - clean with NS, Pat dry, apply Calcium Alginate and cover with bordered gauze daily and prn (as needed) for soiled or dislodgement . The current care plan was not revised to include the current order dated 11/1/23 for Calcium Alginate. At 9:00 AM on 11/29/23, during an interview with Licensed Practical Nurse (LPN) #1/Wound Care Nurse, confirmed Resident #53 had a Pressure Ulcer to his sacrum that he had when he was admitted to the facility. A record review of the admission Record revealed the facility admitted Resident #53 on 08/29/23 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. In an interview on 11/30/23 at 10:35 AM, with LPN #1, he explained that he reviewed Physician's Orders to complete treatments for the residents and he did not use or review the resident's care plans. He stated that care plan interventions are completed by the Registered Nurses (RNs) and the purpose of the interventions was to instruct the staff on how to provide care to the resident. He reviewed Resident #53's wound care plan and confirmed the wound care plan had not been revised to include the most recent wound care orders. Resident #89 A record review of the Comprehensive Care Plan for Resident #89 revealed a Focus of Resident is at risk for impairment to skin due to Immobility, Incontinence, with Interventions/Tasks that included, 10/11/23 treatment to sacrum wound (clean with ns, pat dry, apply zinc oxide and cover with bordered gauze daily. The care plan focus intervention was not revised to reflect the current Physician's Order for wound care dated 11/8/23. The Comprehensive Care Plan also included a Focus of The resident has potential/actual impairment to skin integrity r/t (related to) Stage 4 to sacrum, which included Interventions/Tasks of Wound care as ordered by MD (Medical Doctor) (santyl, Calcium Alginate, bordered Foam, but neither care plan was revised to include the intervention of a low air loss mattress as ordered on 11/9/23. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 10/10/23 and ended on 11/8/23, for Sacrum Pressure Injury - Clean with NS, Pat dry apply Zinc Oxide and cover with bordered gauze daily and prn . A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 11/8/23, for Sacrum Pressure Injury - clean with NS, pat dry apply Santyl/Calcium Alginate and cover with bordered gauze daily and prn ., and a Physician's Order, dated 11/9/23, for Low air loss mattress for sacral wound. A record review of Resident #89's admission Record revealed the facility admitted resident on 09/28/23 with the diagnoses of Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration. In an interview with the Assistant Director of Nursing (ADON) at 11:10 AM on 11/30/23, she explained the facility had two (2) Care Plan Nurses that completed care plans. She stated that when a wound care order was changed, she expected the care plan to be revised to ensure proper wound care was completed because if the interventions are not updated, the wrong care could be provided. At 11:35 AM on 11/30/23, during an interview with LPN #4/Care Plan Nurse, she explained the care plans were mostly updated when the Minimum Data Set (MDS) were due, but they try to revise and update care plans as needed to provide the care for the residents. She stated that every staff member should use the care plan to assure adequate care was provided for the resident, but if the care plan was not revised or updated, inadequate care could be provided. The Care Plan Nurse reviewed the Comprehensive Care Plans and confirmed the care plan had not been revised to include the most current wound care orders. She also confirmed that Resident #89's care plan had not been revised to include the intervention of a low air loss mattress. At 12:00 PM on 11/30/23, during an interview with the Director of Nursing (DON), she explained she expected all residents' care plans to be revised and updated to provide the best care for all residents. She expected staff to revise and update the care plan any time wound care changes to assure adequate care was provided. On 12/01/23 at 11:00 AM, during an interview with RN#2 /MDS Coordinator/Care Plan Nurse, she explained she usually completed the care plans for the Skilled residents. She stated that she tried to update the care plans as needed. She explained that the purpose of the care plan was to know what care the resident needed. She confirmed that if the care plan were not revised or updated, it would be hard to follow and provide adequate care for the resident. She explained that when she developed resident care plans, she used the physician's orders and revised the care plan as new orders were entered. She stated that sometimes she may not get back to the care plan to revise it until the next MDS Assessment. RN #2 reviewed Resident #53's and Resident #89's care plans and confirmed the wound care plans did not include the most recent wound care orders and Resident #89's care plan was not revised to include the intervention of a low air loss mattress. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23. Removal Plan On December 1st, 2023, at approximately 3:30pm Pine Forest Health and Rehabilitation received 5 Immediate Jeopardies during an Annual and Complaint Survey from the Mississippi Department of Health Licensure and Certification and provided the facility with the Immediate Jeopardy Templates. Brief Summary of Events: Pine Forest Health and Rehabilitation failed to put into place appropriate interventions to ensure proper assessment, staging, treatment and clinical care plans to treat and prevent the development and worsening of new and existing pressure ulcers. Corrective Actions: 1. An Emergency QAPI Meeting was held at approximately 12/1/2023 at 5 PM to review the cited deficient practices and to determine a root cause analysis for the lack of appropriate interventions. This meeting included the Administrator, Director of Nursing/lnfection Preventionist, Medical Director, Respiratory Director, & Business Office Manager. The following items were reviewed, coordinated, and corrected to allege compliance and remove the Immediate Jeopardy. The root cause analysis determined the cause of these occurrences was the facility's failure to be properly train staff on the policies for assessing, staging, preventing, and communicating wound and skin care issues for residents who could be at risk for skin breakdown or are already noted with skin/wound breakdown. 2. The facility did a complete policy review on Care Planning Standard, Skin Management Standard, and Employee Competency Standard. The facility conducted 100% in-services and education using outsourced, Qualified Trainers and Online Software as it pertains to each department and the correlated policies pertaining to the immediate jeopardies. The facility also did a 100% inservice on all staff on the Identification and Reporting of Resident Abuse and Neglect. No individual was allowed to work beginning at approximately 7PM on 12/1/2023 until they were able to successfully complete all prescribed In-services. 3. The facility outsourced a Qualified RN Trainer to properly train with return demonstration all individuals who are responsible for the assessment, staging, and provision of wound care for the Facility. Upon completion and approximately 7:30PM on 12/1/2023, the Facility began to conduct body audits on 100% of in-house residents to determine proper assessment, staging, and treatment of wounds and finished on 12/4/2023. All noted pressure areas were assessed, staged, and determined to have a proper assessment. The wound care physician was notified of all findings and coordinated a Telehealth Visit on all residents with pre-existing wounds to confirm appropriate assessment, staging, and treatment of all existing pressure ulcers. There were no changes noted after having concluded all consult Telehealth visits. The attending physician and facility Medical Director was then notified of all Wound Care Physician's Assessments and concurred with prescribed consultation on all noted patients. Resident #53 was determined to have a pressure ulcer in an optimal condition of healing. Resident #89 remains in the hospital. 4. Both MDS Nurses were immediately trained following the QAPI Meeting regarding the ability to properly develop and/or revise resident care plans interventions for residents with pressure ulcers, ensuring those who were admitted to the facility without pressure ulcers did not acquire pressure ulcers and that existing pressure ulcers did not get worse, or residents did not develop complications from pressure wounds. After completing each Telehealth visit from Wound Care Physician and receiving noted confirmation for Medical Director/Attending Physician on all residents with Pressure ulcers, the facility began assessing and updating all care plans on 12/1/2023 and completed 12/4/2023 on coordination with development and prevention of pressure ulcers according to the prescribed orders. Resident #53 was noted to have a proper care plan regarding his healing pressure ulcer. Resident #89 remains in the hospital. 5. The facility determined to move forward by having the trained Unit RN Managers conduct weekly body audits on all residents as it pertains to their individual Units A & B and report the assessment of those daily audits to the Wound Care Team, consisting of the Wound Care Physician, Treatment Nurse, MDS Nurse, and Director of Nursing. All new admits/readmitting residents will their initial assessment conducted by the Unit Manager, who will be responsible for communicating the results of the audit to the Wound Care Team, Consisting of the Wound Care Physician, Treatment Nurse, MDS Nurse and Director of Nursing. The Director of Nursing has been delegated to report the reconciliation of this weekly review in High Risk and monitored monthly for no less than 1 year by the QAPI Committee. 6. The Facility alleges compliance on 12/5/2023. The facility alleges that all corrective actions to remove the Immediate Jeopardy were completed on 12/4/2023 and the Immediate Jeopardy was removed on 12/5/2023. The SA validated the facility's Corrective Actions on 12/5/23: The SA validated through interviews and record review that an Emergency QAPI meeting was held on 12/01/2023 with all members in attendance. The SA validated through interviews and record reviews all policies on Care Planning Standards, Skin Management Standards, and Employee Competency Standards were reviewed with no corrections made. The facility conducted 100% in-services and education including Identification and Reporting of Resident Abuse and Neglect. The SA validated through interviews and record reviews the facility outsourced a Qualified RN Trainer to properly train and return demonstration all individuals who are responsible for the assessment, staging, and provision of wound care for the Facility. The facility completed 100% body audits of in-house residents to determine proper assessment, staging, and treatment of wounds and finished on 12/04/23. The Wound Care Physician was notified of all findings and coordinated a Telehealth Visit on all residents with pre-exiting wounds to confirm appropriate assessment, staging, and treatment of all exiting pressure ulcers. The Medical Director was notified of all findings. Resident #53 was determined to have a pressure ulcer in an optimal condition of healing. Resident #89 remains in the hospital. The SA validated through interviews and record reviews both MDS Nurses were immediately trained following the QAPI meeting regarding the proper development and/or revise resident care plans interventions for residents with pressure ulcers, ensuring those who were admitted to the facility without pressure ulcers did not acquire pressure ulcers and that existing pressure ulcers did not get worse, or residents did not develop complications from pressure wounds. The facility assessed and updated all care plans and completed them on 12/04/23. The SA validated through interviews and record reviews the facility trained Unit RN Managers conduct weekly body audits on all resident as it pertains to their individual Units A and B and report the assessment of those daily audits to the Wound Care Team, consisting of the Wound Care Physician, Treatment Nurse, MDS Nurse, and DON. The DON has been delegated to report the reconciliation of this weekly review in High Risk and monitored monthly for no less than one (1) year by the QAPI Committee. The SA validated through interviews and record reviews and no associate can return to work until they have received this in-service training. The SA validated that all corrective actions were completed on 12/04/2023 and the IJ was removed as of 12/05/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were assessed and received care and treatment for Pressure Ulcers (PUs) to prevent complications and worsening of PUs for two (2) of four (4) residents reviewed for PUs. Resident #53 and Resident #89. The facility's failure to provide wound assessments, documentation, and wound care treatment resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility and was not assessed by a qualified nurse or practitioner until 9/18/23, causing the wound to worsen. The facility Administrator was notified of the IJ and SQC and was presented with an IJ Template on 12/1/23 at 2:55 PM. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ removed on 12/5/23. The SA validated the Removal Plan on 12/5/23 and determined the IJ was removed on 12/5/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.25 (b) (1) (i) (ii) Pressure Ulcers 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: Resident #53 On 11/28/23 at 10:30 AM, during an observation and interview, Resident #53 was sitting up in his wheelchair and he stated that he had one (1) large wound to his bottom. He commented that he thought he would have additional wounds after this past weekend, because he had to lay in bed in his bowel movements and urine for long periods of time on the night shift. On 11/28/23 at 3:15 PM, during an interview with Licensed Practical Nurse (LPN) #1/Wound Care Nurse, he explained that when a resident was admitted to the facility, the initial body assessment was completed by Registered Nurse (RN) #3 (RN)/admission Nurse, and she staged, measured, and documented Pressure Ulcers (PUs). LPN #1 reported that he provided a resident list to the Wound Care Physician of residents that he needed to see. The Wound Care Physician assessed and measured PUs weekly on Mondays and LPN #1 added the physician's measurements to the Wound/Skin Log. He stated that he began documenting on the Wound/Skin logs when RN #4, who was the previous wound care nurse, left the faciity on [DATE]. LPN #1 explained that a Random Skin Sweep was a skin assessment that could be used at any time to document any newly identified skin issues. He further explained that a Weekly Skin Sweep had to be completed by an RN whenever a nurse documented on the Medication Administration Record (MAR) that the resident had a skin issue. LPN #1 confirmed that Resident #53 had only one (1) PU on his bottom that he had upon admission to the facility. He reported that the resident was currently seen by the Wound Care Physician. A record review of the admission Record revealed the facility admitted Resident #53 on 08/29/23 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. Record review of the facility's Brief Interview for Mental Status (BIMS) Evaluation, dated 12/2/23, revealed a score of 13, which indicated Resident #53 was cognitively intact. A record review of the Random Skin Sweep dated 08/29/23, which was the date of admission, revealed Resident #28 had a Pressure area to the Left buttock that measured 8 centimeters (cm) length, 5 cm width, and 4 cm depth and a Skin Tear to the Right lateral foot that measured 3 cm length, 6 cm width, and the depth was listed as UTD (Unable To Determine). Skin Impairment Findings revealed Skin injuries as listed above. Left buttock cleaned with NS (Normal Saline), calcium alginate rope, and bordered gauze applied. Right lateral foot cleaned with NS and bordered gauze applied. (Proper Name of Wound Care Physician) to F/U (Follow Up) with resident. The document was signed by RN #4, who was the previous Wound Care Nurse for the facility and was no longer employed by the facility. A record review of Braden Scale for Predicting Pressure Sore Risk, dated 08/29/23, revealed Resident #53 had a score of 13, which indicated he had a moderate risk of developing PUs. A review of the medical record revealed there was no other Random or Weekly Skin Sweeps documented. At 4:00 PM on 11/28/23, during an interview with the Director of Nursing (DON), she explained that PU wound documentation and skin assessments were to be completed weekly on the Wound/Skin Log by LPN #1. A record review of the facility's Wound/Skin Log, dated 09/04/23, revealed Resident #53 had a Stage IV PU to his Left Buttock that measured 7 cm X 2 cm X 10.75 cm. These measurements were documented six (6) days after Resident #53's admission to the facility and indicated the PU had increased in depth. The log also indicated the resident had a Stage IV PU to his Right Lateral Foot that measured 2 cm X 1.5 cm X and the D (depth) (cm) was UTD. This wound had been classified upon admission as a Skin Tear and this was the first documentation that the area was a Pressure type and Stage IV. The Wound/Skin Log documentation did not indicate who had completed the logs and did not include a description of the PU characteristics, the progress toward healing and identification of potential complications, if infections were present, the presence of pain, or a description of dressings and treatment. A record review of the facility's Wound/Skin Log, dated 9/11/23, revealed Resident #53 had a Stage IV PU to his left buttock that measured 6.2 cm x 1.6 cm x 10.6 cm and had a Type or Stage of PVD (Peripheral Vascular Disease) to his right foot that measured 1.7 cm x 1.5 cm x UTD. The documentation of PVD was inconsistent with the Wound/Skin Log dated 9/4/23, which indicated the wound to the right foot was a PU. A record review of the Order Recap Report, with Order Date: 08/29/2023 - 11/30/2023), revealed Resident #53 had a Physician's Order, dated 9/18/2023, for Wound consult with skilled wound care surgical group . A record review of a Surgical Note, dated 09/18/23, revealed Resident #53 was seen by the Wound Care Physician 20 days after he was admitted to the facility. The Physician visited the resident because he was asked for his opinion on how to manage the wound located at the left buttock and sacrum. The Wound Location was listed as Left Buttock and Sacrum, and the Etiology was listed as Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury. The note also revealed that the wound area measured 6.2 cm x 1.6 cm x 10.5 cm, which was deeper than the initial measurement upon admission. The wound required the Physician to perform a muscle tissue debridement, which was the removal of dead tissue from the wound. The wound description indicated that the wound had undermining (separation of the wound edges from the surrounding healthy tissue) of 13 cm, had no odor, and had a copious amount of serosanguineous (thin fluid with a light pink tinge) exudate. The tissue of the wound was 20% slough (nonviable skin tissue), 80% granulation (development of new skin tissue), and there was no necrotic or dead tissue present in the wound. This was the first wound assessment that included a complete wound description of the PU characteristics for Resident # 53 since the resident was admitted to the facility on [DATE]. The wound progress was listed as Undetermined: first visit. The wound to the Right Lateral Foot was listed as PVD. The Assessment and Plan revealed, The patient has a wound found on the left buttock and sacrum .there was a sign of tissue decline which will entail continuing supervision and will likely require future debridement .continue offloading .turn per facility protocol. A low air loss mattress is recommended . A record review of the Order Recap Report, with Order Date: 08/29/2023 - 11/30/2023), revealed Resident #53 had a Physician's Order, dated 8/29/23 and discontinued on 9/19/23, for Sacrum pressure injury - clean with NS, Pat dry, apply Calcium Alginate and cover with bordered gauze daily and prn (as needed) for soiled or dislodgement . At 5:05 AM on 11/29/23, during an observation and interview with Certified Nurse Assistant (CNA) #14 and Resident #53, the CNA explained that she was going to change him. Resident #53 commented that was the second time he had seen staff all night and he had not been changed since about 11 PM. The observation revealed that Resident #53's brief was saturated and there was no protective bandage noted covering the PU, nor was there a bandage in his brief indicating the bandage had become dislodged during the night. CNA #14 provided incontinence care and applied a clean brief, but the PU to the sacrum/buttocks did not have a bandage on it, which left the packed wound exposed. CNA #14 confirmed that the resident's brief had been saturated and there was no bandage on the PU wound. She stated she was unsure of the last time she had changed his brief or when the bandage had come off the resident. She said would notify the nurse that the resident did not have a bandage on his PU. At 5:25 AM on 11/29/23, during an interview with RN #5, she explained the CNAs should round every two (2) hours to ensure residents were clean and dry, but she did not check behind them to confirm the rounds are completed. She confirmed CNA #14 had let her know that Resident #53's bandage was off his PU site, and she advised that she would replace the dressing after she completed her medication pass. At 8:25 AM on 11/29/23, during an interview with RN #3/admission Nurse, she explained she was not a wound care nurse. She stated that she had been helping with the assessment of new wounds, admissions, and hospital returns or any other residents the wound care nurse needed help with. She confirmed that she only measured the wounds and she attempted to assess them, but she did not feel comfortable about staging PUs. She said that the Wound Care Physician assessed all wounds until they were healed, and that LPN #1 printed the physician's assessment and that would become part of the resident's medical record. She confirmed that she had never staged PUs and that when a resident was admitted to the facility with an existing PU, the facility used the hospital's discharge wound orders and staging documentation. On 11/29/23 at 3:00 PM, during an interview with the DON, she explained she did not know who completed the Wound/Skin Logs before LPN #1 took over after RN #4 had left. She said that different nurses had helped and had completed the logs but there was no signature or identifying information to indicate who completed the measurements. She explained that as far as she knows, those logs were completed with the measurements from the Wound Care Physician's weekly assessments which are completed when he rounds. She confirmed the logs indicated PU measurements but did not include any other assessment information regarding the wounds. She said that she received a copy of the PU logs weekly, but she did not review the logs to determine if the PUs were healing or deteriorating, and she did not keep the logs on file. The DON stated that LPN #1 provided the Wound Care Physician with a list of residents that needed to be seen during his weekly visits, but she was unsure how or who determined which residents should be seen by the physician. On 11/30/23 at 10:35 AM, during an interview with LPN #1, he explained that if a resident was admitted to the facility with an existing PU and had wound treatment orders from the hospital, he would not always refer that resident to the Wound Care Physician. He reported the facility did not have a protocol on when a resident should be seen by the Wound Care Physician. He stated that if a wound was not responding to the treatment orders, he would notify the Wound Care Physician and schedule a consultation for the next Monday. LPN #1 stated that RN #3 documented measurements on the Wound/Skin Log for the residents that the Wound Care Physician did not see. He explained that when a new wound was identified, he got an RN to assess the area and he relied on the RN to complete the Random Skin Sweep documentation. He explained when Resident #53 was admitted to the facility, he was not referred to the Wound Care Physician immediately because the resident had treatment orders for wound care that came with him from the hospital. However, when he noticed that the wound was not responding to the treatment, he referred the resident to the Wound Care Physician. He confirmed Resident #53's wound was deep with tunneling and undermining present. He was not aware that the RNs had not documented anything on the Wound/Skin logs. At 11:10 AM on 11/30/23, during an interview with the Assistant Director of Nursing (ADON), she explained she was not involved in Resident #53's wound care and had never observed his PU. The facility had a Wound Care Physician that came every Monday, and the Nurse Practitioner was in the facility Monday through Friday. She explained that a PU assessment and documentation should include the PU stage, measurement, description of the appearance of the PU, drainage, odor, and healing or deterioration of the PU. All PU wounds and notifications must be documented, and if it was not documented, then it was not completed. The ADON said that she was unsure of the protocol regarding notifying or consulting with the Wound Care Physician when a resident acquired a new PU, but she knew he was provided with a list of residents that he needed to visit. She explained that the facility conducts a Stand Up meeting every morning during the week and discussed all concerns in the facility, including PU concerns. The ADON stated she was unaware that RN #3 was not comfortable in staging PUs, but there were other RNs in the facility that could assist and RN #3 should have asked them for help. The ADON said that if a PU was not staged or assessed appropriately, the wounds may not be treated appropriately and may worsen. At 1:10 PM on 11/30/23, during an interview with RN #3, she reported she did not tell the DON that she was not comfortable staging wounds. She confirmed she did not know the protocol or system for a resident being admitted with an existing PU or for a resident who acquired a PU while in the facility to be referred to the Wound Care Physician. She stated she was only filling in since there was no RN currently in the wound care role. She stated that she had not been asked to assess any wounds, but only to measure wounds. She confirmed that the facility had daily stand-up meetings, but wounds were not discussed in detail until the monthly Quality Assurance (QA) meetings. At 12:00 PM on 11/30/23, during an interview with the DON, she explained she expected the nurse to call the Physician or Wound Care Physician if a wound worsened in any way. She also expected all PU assessments and findings to be documented in the medical record, and that if there was no documentation, then it was not done and that she was aware that documentation was a problem. The DON explained that any changes in a resident or a resident's PU should be documented. She confirmed that the facility did not have a system in place to determine when a resident required a consultation with the Wound Care Physician. LPN #1 was responsible for communicating with the Wound Care Physician, who was available as needed. LPN #1 completed the wound/skin logs weekly, but the DON was unaware that PUs were not completely assessed if they are not being seen by the Wound Care Physician. She thought every resident with a wound was seen by the Wound Care Physician but was not aware of the system. She was not aware that RN #3 was not comfortable with staging wounds, because she has been completing admission wound assessments for a long time. The DON said she would have put someone else in the position that was more comfortable if she had known. She confirmed that RN #3 has just recently been filling in with wound assessments other than admission assessments since RN #4 left employment at the facility. There were other RNs in the facility that could assess and measure if RN #3 had asked for help. The DON was not aware Resident #53 was not seen by the Wound Care Physician and that his wound had gotten deeper from the time he was admitted on [DATE] until he was seen by the Wound Care Physician on 9/18/23. She reported since there was no longer a RN in wound care, other RNs assisted in completing Wound/Skin logs as necessary. At 1:25 PM on 11/30/23, during a phone interview with the Wound Care Physician, he confirmed that he was a consultant for the facility and was not involved in resident care plan or facility meetings. He stated LPN #1 faxed a list to his office of residents that he needed to see when he comes to the facility. He did not know the facility's policy regarding wound care or the system the facility used to determine which residents he should see, but he felt the wound care nurse (LPN #1) knew to consult him if a wound worsened and he could be consulted at any time via Tele-Med (Telephone Medical) services. Resident #89 On 11/28/23 at 12:20 PM, during a phone interview with the Complainant, she explained she became involved when the resident was admitted to an acute care hospital from the facility with a diagnosis of Sepsis (serious condition in which the body responds improperly to infection) related to a PU to the sacrum. She explained the hospital physicians were concerned that the facility's staff were not turning and repositioning the resident as often as needed and not keeping him dry and clean. She reported the resident's brother and sister had voiced concerns to her and the physicians that staff were not turning Resident #89 frequently and the resident remained wet for long periods of time. The Complainant advised that Resident #89 required wound surgery during his hospital stay and he currently remained in the acute care hospital at the time of the interview. On 11/28/23 at 1:00 PM, during a phone interview with the Resident Representative (RR), he explained Resident #89, who was his brother, had been in the facility for six (6) weeks and had gotten a bad wound that became septic and required surgery. He explained he stayed at the facility for long periods of time to be with brother and the staff did not turn or change him enough. The staff would not touch the resident for hours, and when they finally came to change him, Resident #89 would be soaked with urine. He said that his brother did not have any wounds when he was admitted to the facility and that he did not have a catheter. He explained the facility discussed inserting a catheter on the day the resident was so sick and was transported to the hospital. The RR felt like if the facility had kept his brother dry and had turned him often, he would not have gotten the PU. A record review of the admission Record revealed the facility admitted Resident #89 on 09/28/23 with diagnoses that included Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration. A record review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/5/23, revealed Resident #89 required a Staff Assessment for Mental Status and his cognition was severely impaired. A review of Section GG revealed that Resident #89 was dependent on staff for all functional abilities. A review of Section M revealed Resident #89 was at risk for developing pressure ulcers/injuries, but he did not have any unhealed pressure ulcers/injuries. A record review of the Braden Scale for Predicting Pressure Sore Risk, dated 9/28/23, revealed Resident #89 had a score of 12 which indicated he had a high risk of developing PUs. A record review of the Nursing Random Skin Sweep, dated 09/28/23, which was the date of admission to the facility for Resident #89, revealed he had skin tears to his left ear, left upper chest, and right upper chest. The document was signed by RN #4, the previous Wound Care Nurse. There was no documentation regarding any skin or PUs to the resident's sacrum or buttocks. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 9/28/23 for Weekly skin assessments . Review of the report revealed there were no Physician Orders that addressed any skin issues or PU treatments to the sacrum upon Resident #89's admission date of 9/28/23. A record review of the Wound/Skin Log, dated 10/8/23 (Sunday), which was 10 days after the Resident #89 was admitted to the facility, revealed he had a PU to the sacrum that measured 6.5 cm x 4.0 cm x UTD. The onset date was recorded as 9/28/23 which was the date of admission and conflicted with the Nursing Random Skin Sweep that was completed on 9/28/23 and the Physician's Orders. This was the first documentation that referred to the PU. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 10/10/23 and ended on 11/8/23, for Sacrum Pressure Injury - Clean with NS, Pat dry apply Zinc Oxide and cover with bordered gauze daily and prn . This order was received two (2) days after the wound/skin log, dated 10/8/23, indicated Resident #89 had a PU that measured 6.5 cm x 4.0 cm x UTD. A record review of the Weekly Skin Sweep, dated 10/12/23, revealed Resident #89 had a PU to the sacrum that measured 2.0 cm length, 1.0 cm width, and UTD for the depth. The measurements conflicted with the measurements documented on the Wound/Skin Log that had been completed four (4) days prior. The documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. The document was signed by RN #3, the admission Nurse. A record review of the Wound/Skin Log, dated 10/16/23, revealed Resident #89 had a PU to the sacrum that measured 6cm x 4 cm x UTD, which indicated an increase in the size of the wound from the Weekly Skin Sweep completed on 10/12/23, which was four (4) days prior. The onset date was recorded as 9/28/23. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Wound/Skin Log, dated 10/23/23, revealed Resident #89 had a PU to the sacrum that measured 6.25 cm x 4 cm x UTD. The onset date was recorded as 9/28/23. The measurements indicated the wound had increased in size since the log dated 10/16/23. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Wound/Skin Log, dated 11/6/23, revealed Resident #89 had a PU to the sacrum that measured 6.5 cm x 4.2 cm x UTD. The measurements indicated the wound had increased in size from the documentation on the log dated 10/23/23. The onset date was recorded as 9/28. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. There was an additional Wound/Skin Log', dated 11/6/23, which indicated Resident #89 had a PU to the sacrum that measured 6.5 cm x 4.5 cm x UTD and the onset date was 9/28/23. A record review of the Weekly Skin Sweep, dated 11/8/23, revealed Resident #89 had a PU to the sacrum that measured 3.0 cm length, 2.0 cm width, and UTD for the depth. These measurements were inconsistent with the measurements provided two (2) days prior on the wound/skin log dated 11/6/23. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 11/8/23, for Sacrum Pressure Injury - clean with NS, pat dry apply Santyl/Calcium Alginate and cover with bordered gauze daily and prn ., and a Physician's Order, dated 11/9/23, for Low air loss mattress for sacral wound. There was a Physician Order, dated 11/13/23, to consult skilled wound care for evaluation of sacrum wound . A record review of a Surgical Note, dated 11/13/23, revealed Resident #89 was seen by the Wound Care Physician. The Physician visited the resident for management of wounds located on the sacrum. The Wound Location was listed as Sacrum, and the Etiology was listed as Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury. The note also revealed that the wound measured 6.0 cm x 4.0 cm x UTD prior to his debridement, and 6.0 cm x 4.0 cm x 0.5 cm after the debridement procedure. The wound required the Physician to perform a muscle tissue debridement with the Preoperative Indications listed as Biofilm, Devitalized tissue, and Slough. There were no signs of infection. The wound description indicated that the wound had no odor and had a moderate amount of serosanguineous exudate. The Peri wound area was unhealthy and unstable. The tissue of the wound was 80% slough and 20% granulation. This was the first wound assessment that included a complete wound description of the PU characteristics, for Resident # 89, which was 36 days after the PU was first documented on the Wound/Skin Log dated 10/8/23. A low air loss mattress is recommended . At 3:00 PM on 11/28/23, during an interview with the DON, she explained Resident #89 was sent to the hospital on [DATE] because he was in respiratory distress. A record review of the Internal Medicine H & P (History and Physical), dated 11/16/23, revealed Resident #9's History or Present Illness (HPI) as . presents from his nursing facility with fever and tachycardia (increased heart rate) . appears to have increased work of breathing . heart rates were noted to be in the 120's to 130's . Date review of the recent labs revealed Resident #89 had an abnormal white blood cell count. The Physical Exam revealed, .Skin: Sacral ulcer covered with bandage . A review of the Assessment/Plan revealed . Sepsis, suspected secondary to sacral decubitus ulcer .Bone culture with moderate growth . Review of the Indication for Surgery was necrosis (death of body tissue) and the Procedure: sharp excisional debridement sacral wound including bone 5 x 6.5 x 3 . At 8:25 AM on 11/29/23, during an interview with RN #3/admission Nurse she confirmed that she had completed the Weekly Skin Sweep for Resident #89 on 10/12/23 and that she did not stage the PU or provide descriptive characteristics of the PU. She explained that she had assumed the wound care team would follow Resident #89, but she did not follow up to ensure he was seen by the team. She explained that the wound care team at that time consisted of LPN #1 and the Wound Care Physician. She was unable to recall what the PU looked like when she had measured it. She confirmed that she only measured the PU and did not complete or document a full assessment of the wound. She said she was unaware that the Wound Care Physician was not seeing the resident when she completed the documentation on 10/12/23. On 11/29/23 at 3:00 PM, during an interview with the DON, she explained she was not aware that RN #3 had not assessed or staged the PU to the sacrum for Resident #89 and that the Wound Care Physician had not assessed or staged the PU for more than four (4) weeks after the PU was first identified by facility staff on 10/8/23. At 3:10 PM on 11/29/23, during an interview with the Administrator and the DON, the Administrator explained that he could not determine who had completed the Wound/Skin logs that were provided. He explained that RN #4 was the previous wound care nurse and her last day at the facility was 10/04/23. The DON and the Administrator were unable to explain the PU measurement inconsistencies of the Wound/Skin logs and the Weekly Skin Sweeps for Resident #89. On 11/30/23 at 10:35 AM, during an interview with LPN #1, he explained when Resident #89 was admitted to the facility, he did not have any PUs. He was unable to recall how he found out that Resident #89 had a PU, but he did recall asking RN #3 to measure the wound. LPN #1 described the PU when he first saw it as measuring approximately 2 cm x 3 cm, the area was discolored, but the skin was intact. He thought the wound was classified as Moisture Associated Skin Damage (MASD), because whenever he provided the treatments to the sacrum, Resident #89 was soiled with urine. He stated that he had instructed CNAs that the resident needed to be kept dry, changed in a timely manner, and turned more frequently, however he did not conduct and document a formal in-service. LPN #1 said that Resident #89's family would be with the resident daily and he would talk to them regarding resident's PU, but he never completed any documentation regarding the PU. LPN #1 said that when the wound was first found, the physician was notified, and new orders were received for zinc oxide, because the skin was intact. He stated that he continued to treat the PU with zinc oxide and did not notify the Wound Care Physician that the wound size was increasing. He confirmed he had no documentation of the wounds, including the progression or deterioration of the wound. When he noticed the PU to the sacrum had slough, he notified the Wound Care Physician and received orders to discontinue the zinc oxide and start a new treatment. He said that he felt like the PU measurements obtained on the Random and Weekly Skin Sweeps were accurate because he assisted RN #3/Admissions Nurse when she measured the wounds. He confirmed Resident #89's wound had deteriorated and increased in size from the time it was first identified on 9/28/23 until the time he was seen by the Wound Care Physician on 11/13/23. He confirmed that on 11/13/23, the PU to the sacrum was classified as a Stage IV. LPN #1 stated that he would not have done anything differently with the resident's wound. He confirmed that Resident #89 did not have a low air loss mattress to help with pressure reduction until 11/9/23. At 11:10 AM on 11/30/23, during an interview with the Assistant Director of Nursing (ADON), she explained she was unaware that Resident #89 had a PU because she was not involved in his care. She stated that it appeared someone dropped the ball, but she didn't know who. She [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure the clinical staff were educated and trained on staging Pressure Ulcers (PUs), providing complete and accurate wound assessments, and implementing appropriate treatments for identified wounds for two (2) of four (4) residents reviewed for PU care. Resident # 53 and Resident #89. The facility's failure to ensure staff were competent with PU assessments, documentation, and treatments resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility, and was not assessed by a qualified nurse or practitioner until 9/18/23, causing the wound to worsen. The facility Administrator was notified of the IJ and was presented with an IJ Template on 12/1/23 at 2:55 PM. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23. The SA validated the Removal Plan on 12/5/23 and determined the IJ was removed on 12/5/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.35 (a) (3) Nursing Services 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: A record review of the facility's policy, Employee Competency Standard, revised 1/2020, revealed . In-service training classes are conducted to provide associates with ongoing knowledge concerning their job responsibilities, methods, and procedures to follow when implementing assigned duties . current information regarding the provision of quality of care . Orientation includes topics and information which contribute to positive resident care . Resident #53 During an interview on 11/28/23 at 3:15 PM, with Licensed Practical Nurse (LPN) #1/Wound Care Nurse, he explained that when a resident was admitted to the facility, the initial body assessment was completed by Registered Nurse (RN) #3 (RN)/admission Nurse, and she staged, measured, and documented Pressure Ulcers (PUs). LPN #1 reported that the Wound Care Physician assessed and measured PUs weekly on Mondays and LPN #1 added the physician's measurements to the Wound/Skin Log. He stated that he began documenting on the Wound/Skin logs when RN #4, who was the previous wound care nurse, left the faciity on [DATE]. LPN #1 confirmed that Resident #53 had only one (1) PU on his bottom that he had upon admission to the facility. LPN #1 explained that a Random Skin Sweep was a skin assessment that could be used at any time to document any newly identified skin issues. He further explained that a Weekly Skin Sweep had to be completed by an RN whenever a nurse documented on the Medication Administration Record (MAR) that the resident had a skin issue. A record review of the admission Record revealed the facility admitted Resident #53 on 08/29/23 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. A record review of the Random Skin Sweep dated 08/29/23, which was the date of admission, revealed Resident #28 had a Pressure area to the Left buttock that measured 8 centimeters (cm) length, 5 cm width, and 4 cm depth and a Skin Tear to the Right lateral foot that measured 3 cm length, 6 cm width, and the depth was listed as UTD (Unable To Determine). Skin Impairment Findings revealed Skin injuries as listed above. (Proper Name of Wound Care Physician) to F/U (Follow Up) with resident. The document was signed by RN #4, who was the previous Wound Care Nurse for the facility and was no longer employed by the facility. On 11/28/23 at 4:00 PM, during an interview with the Director of Nursing (DON), she explained that PU wound documentation and skin assessments were to be completed weekly on the Wound/Skin Log by LPN #1. A record review of the facility's Wound/Skin Log, dated 09/04/23, revealed Resident #53 had a Stage IV PU to his Left Buttock that measured 7 cm X 2 cm X 10.75 cm. These measurements were documented six (6) days after Resident #53's admission to the facility and indicated the PU had increased in depth. The log also indicated the resident had a Stage IV PU to his Right Lateral Foot that measured 2 cm X 1.5 cm X and the D (cm) was UTD. This wound had been classified upon admission as a Skin Tear and this was the first documentation that the area was a Pressure type and Stage IV. The Wound/Skin Log documentation did not indicate who had completed the logs and did not include a description of the PU characteristics, the progress toward healing and identification of potential complications, if infections were present, the presence of pain, or a description of dressings and treatment. A record review of the facility's Wound/Skin Log, dated 9/11/23, revealed Resident #53 had a Stage IV PU to his left buttock that measured 6.2 cm x 1.6 cm x 10.6 cm and had a Type or Stage of PVD (Peripheral Vascular Disease) to his right foot that measured 1.7 cm x 1.5 cm x UTD. The documentation of PVD was inconsistent with the Wound/Skin Log dated 9/4/23, which indicated the wound to the right foot was a PU. A record review of the Order Recap Report, with Order Date: 08/29/2023 - 11/30/2023), revealed Resident #53 had a Physician's Order, dated 9/18/23, for .Wound consult with skilled wound care surgical group . A record review of a Surgical Note, dated 09/18/23, revealed Resident #53 was seen by the Wound Care Physician 20 days after he was admitted to the facility. The Physician visited the resident because he was asked for his opinion on how to manage the wound located at the left buttock and sacrum. The Wound Location was listed as Left Buttock and Sacrum, and the Etiology was listed as Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury. The note also revealed that the wound area measured 6.2 cm x 1.6 cm x 10.5 cm, which was deeper than the initial measurement upon admission. The wound required the Physician to perform a muscle tissue debridement, which was the removal of dead tissue from the wound. The wound description indicated that the wound had undermining (separation of the wound edges from the surrounding healthy tissue) of 13 cm, had no odor, and had a copious amount of serosanguineous (thin fluid with a light pink tinge) exudate. The tissue of the wound was 20% slough (nonviable skin tissue), 80% granulation (development of new skin tissue), and there was no necrotic or dead tissue present in the wound. This was the first wound assessment that included a complete wound description of the PU characteristics for Resident # 53 since the resident was admitted to the facility on [DATE]. On 11/29/23 at 5:05 AM, during an observation and interview with Certified Nurse Assistant (CNA) #14 and Resident #53, the CNA explained that she was going to change him. Resident #53 commented that was the second time he had seen staff all night and he had not been changed since about 11 PM. The observation revealed that Resident #53's brief was saturated and there was no protective bandage noted covering the PU, nor was there a bandage in his brief indicating the bandage had become dislodged during the night. CNA #14 provided incontinence care and applied a clean brief, but the PU to the sacrum/buttocks did not have a bandage on it, which left the packed wound exposed. CNA #14 confirmed that the resident's brief had been saturated and there was no bandage on the PU wound. She stated she was unsure of the last time she had changed his brief or when the bandage had come off the resident. She said would notify the nurse that the resident did not have a bandage on his PU. On 11/29/23 at 5:25 AM, during an interview with RN #5, she explained the CNAs should round every two (2) hours to ensure residents were clean and dry, but she did not check behind them to confirm the rounds are completed. She confirmed CNA #14 had let her know that Resident #53's bandage was off his PU site, and she advised that she would replace the dressing after she completed her medication pass. On 11/29/23 at 8:25 AM, during an interview with RN #3/admission Nurse, she explained she was not a wound care nurse. She stated that she had been helping with the assessment of new wounds, admissions, and hospital returns or any other residents the wound care nurse needed help with. She confirmed that she only measured the wounds and she attempted to assess them, but she did not feel comfortable about staging PUs. She confirmed that she had never staged PUs and that when a resident was admitted to the facility with an existing PU, the facility used the hospital's discharge wound orders and staging documentation. At 3:00 PM on 11/29/23, during an interview with the DON, she explained she did not know who completed the Wound/Skin Logs before LPN #1 took over after RN #4 had left. She said that different nurses had helped and had completed the logs but there was no signature or identifying information to indicate who completed the measurements. She explained that as far as she knows, those logs were completed with the measurements from the Wound Care Physician's weekly assessments which are completed when he rounds. She confirmed the logs indicated PU measurements but did not include any other assessment information regarding the wounds. She said that she received a copy of the PU logs weekly, but she did not review the logs to determine if the PUs were healing or deteriorating, and she did not keep the logs on file. The DON stated that LPN #1 provided the Wound Care Physician with a list of residents that needed to be seen during his weekly visits, but she was unsure how or who determined which residents should be seen by the physician. At 10:35 AM on 11/30/23, during an interview with LPN #1, he explained that if a resident was admitted to the facility with an existing PU and had wound treatment orders from the hospital, he would not always refer that resident to the Wound Care Physician. He reported the facility did not have a protocol on when a resident should be seen by the Wound Care Physician. LPN #1 stated that RN #3 documented measurements on the Wound/Skin Log for the residents that the Wound Care Physician did not see. He explained when Resident #53 was admitted to the facility, he was not referred to the Wound Care Physician immediately because the resident had treatment orders for wound care that came with him from the hospital. However, when he noticed that the wound was not responding to the treatment, he referred the resident to the Wound Care Physician. He confirmed Resident #53's wound was deep with tunneling and undermining present. He was not aware that the RNs had not documented anything on the Wound/Skin logs. On 11/30/23 at 11:10 AM, during an interview with the Assistant Director of Nursing (ADON), she explained she was not involved in Resident #53's wound care and had never observed his PU. She explained that a PU assessment and documentation should include the PU stage, measurement, description of the appearance of the PU, drainage, odor, and healing or deterioration of the PU. All PU wounds and notifications must be documented, and if it was not documented, then it was not completed. The ADON said that she was unsure of the protocol regarding notifying or consulting with the Wound Care Physician when a resident acquired a new PU, but she knew he was provided with a list of residents that he needed to visit. The ADON stated she was unaware that RN #3 was not comfortable in staging PUs, but there were other RNs in the facility that could assist, and RN #3 should have asked them for help. The ADON said that if a PU was not staged or assessed appropriately, the wounds may not be treated appropriately and may worsen. On 11/30/23 at 12:00 PM, during an interview with the DON, she explained she expected the nurse to call the Physician or Wound Care Physician if a wound worsened in any way. She also expected all PU assessments and findings to be documented in the medical record, and that if there was no documentation, then it was not done and that she was aware that documentation was a problem. The DON explained that any changes in a resident or a resident's PU should be documented. She confirmed that the facility did not have a system in place to determine when a resident required a consultation with the Wound Care Physician. LPN #1 was responsible for communicating with the Wound Care Physician, who was available as needed. LPN #1 completed the wound/skin logs weekly, but the DON was unaware that PUs were not completely assessed if they are not being seen by the Wound Care Physician. She thought every resident with a wound was seen by the Wound Care Physician but was not aware of the system. She was not aware that RN #3 was not comfortable with staging wounds, because she has been completing admission wound assessments for a long time. The DON said she would have put someone else in the position that was more comfortable if she had known. She confirmed that RN #3 has just recently been filling in with wound assessments other than admission assessments since RN #4 had left employment at the facility. There were other RNs in the facility that could assess and measure if RN #3 had asked for help. The DON was not aware Resident #53 was not seen by the Wound Care Physician and that his wound had gotten deeper from the time he was admitted on [DATE] until he was seen by the Wound Care Physician on 9/18/23. She reported since there was no longer a RN in wound care, other RNs assisted in completing Wound/Skin logs as necessary. On 11/30/23 at 1:10 PM, during an interview with RN #3/admission Nurse, she reported she did not tell the DON that she was not comfortable staging wounds. She confirmed she did not know the protocol or system for a resident being admitted with an existing PU or for a resident who acquired a PU while in the facility to be referred to the Wound Care Physician. She stated she was only filling in since there was no RN currently in the wound care role. She stated that she had not been asked to assess any wounds, but only to measure wounds. She confirmed that the facility had daily stand-up meetings, but wounds were not discussed in detail. Resident #89 At 1:00 PM, on 11/28/23 during a phone interview with the Resident Representative (RR), he explained Resident #89, who was his brother, had been in the facility for six (6) weeks and had gotten a bad wound that became septic and required surgery. He explained he stayed at the facility for long periods of time to be with his brother and the staff did not turn or change him enough. The staff would not touch the resident for hours, and when they finally came to change him, Resident #89 would be soaked with urine. He said that his brother did not have any wounds when he was admitted to the facility. The RR felt like if the facility had kept his brother dry and had turned him often, he would not have gotten the PU. A record review of the admission Record revealed the facility admitted Resident #89 on 09/28/23 with diagnoses that included Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration. A record review of the admission MDS, with an ARD of 10/5/23, revealed Resident #89 required a Staff Assessment for Mental Status and his cognition was severely impaired. A review of Section GG revealed that Resident #89 was dependent on staff for all functional abilities. A review of Section M revealed Resident #89 was at risk for developing pressure ulcers/injuries, but he did not have any unhealed pressure ulcers/injuries. A record review of the Nursing Random Skin Sweep, dated 09/28/23, which was the date of admission to the facility for Resident #89, revealed he had skin tears to his left ear, left upper chest, and right upper chest. The document was signed by RN #4, the previous Wound Care Nurse. There was no documentation regarding any skin or PUs to the resident's sacrum or buttocks. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 9/28/23 for Weekly skin assessments . Review of the report revealed there were no Physician Orders that addressed any skin issues or PU treatments to the sacrum upon Resident #89's admission date of 9/28/23. A record review of the Wound/Skin Log, dated 10/8/23 (Sunday), which was 10 days after the Resident #89 was admitted to the facility, revealed he had a PU to the sacrum that measured 6.5 cm x 4.0 cm x UTD. The onset date was recorded as 9/28/23 which was the date of admission and conflicted with the Nursing Random Skin Sweep that was completed on 9/28/23 and the Physician's Orders. This was the first documentation that referred to the PU. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 10/10/23 and ended on 11/8/23, for Sacrum Pressure Injury - Clean with NS, Pat dry apply Zinc Oxide and cover with bordered gauze daily and prn . This order was received two (2) days after the wound/skin log, dated 10/8/23, indicated Resident #89 had a PU that measured 6.5 cm x 4.0 cm x UTD. A record review of the Weekly Skin Sweep, dated 10/12/23, revealed Resident #89 had a PU to the sacrum that measured 2.0 cm length, 1.0 cm width, and UTD for the depth. The measurements conflicted with the measurements documented on the Wound/Skin Log that had been completed four (4) days prior. The documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. The document was signed by RN #3, the admission Nurse. A record review of the Wound/Skin Log, dated 10/16/23, revealed Resident #89 had a PU to the sacrum that measured 6 cm x 4 cm x UTD, which indicated an increase in the size of the wound from the Weekly Skin Sweep completed on 10/12/23, which was four (4) days prior. The onset date was recorded as 9/28/23. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Wound/Skin Log, dated 10/23/23, revealed Resident #89 had a PU to the sacrum that measured 6.25 cm x 4 cm x UTD. The onset date was recorded as 9/28/23. The measurements indicated the wound had increased in size since the log dated 10/16/23. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. A record review of the Wound/Skin Log, dated 11/6/23, revealed Resident #89 had a PU to the sacrum that measured 6.5 cm x 4.2 cm x UTD. The measurements indicated the wound had increased in size from the documentation on the log dated 10/23/23. The onset date was recorded as 9/28. The Wound /Skin Log documentation did not include a description of the PU characteristics, the progress toward healing, identification of potential complications, if infections were present, or the presence of pain. There was no indication of who had completed the wound/skin log. There was an additional Wound/Skin Log', dated 11/6/23, which indicated Resident #89 had a PU to the sacrum that measured 6.5 cm x 4.5 cm x UTD and the onset date was 9/28/23. A record review of the Weekly Skin Sweep, dated 11/8/23, revealed Resident #89 had a PU to the sacrum that measured 3.0 length, 2.0 width, and UTD for the depth. These measurements were inconsistent with the measurements provided two (2) days prior on the wound/skin log dated 11/6/23. A record review of the Order Recap Report with Order Date: 09/28/2023 -11/30/2023 revealed Resident #89 had a Physician's Order, dated 11/8/23, for Sacrum Pressure Injury - clean with NS, pat dry apply Santyl/Calcium Alginate and cover with bordered gauze daily and prn ., and a Physician's Order, dated 11/9/23, for Low air loss mattress for sacral wound. There was a Physician Order, dated 11/13/23, to consult skilled wound care for evaluation of sacrum wound . A record review of a Surgical Note, dated 11/13/23, revealed Resident #89 was seen by the Wound Care Physician. The Physician visited the resident for management of wounds located on the sacrum and right elbow. The Wound Location was listed as Sacrum, and the Etiology was listed as Pressure injury/ulcer - Wound Stage: 4 - Pressure Injury. The note also revealed that the wound measured 6.0 cm x 4.0 cm x UTD prior to his debridement, and 6.0 cm x 4.0 cm x 0.5 cm after the debridement procedure. The wound required the Physician to perform a muscle tissue debridement with the Preoperative Indications listed as Biofilm, Devitalized tissue, and Slough. There were no signs of infection. The wound description indicated that the wound had no odor and had a moderate amount of serosanguineous exudate. The Peri wound area was unhealthy and unstable. The tissue of the wound was 80% slough and 20% granulation. This was the first wound assessment that included a complete wound description of the PU characteristics, for Resident # 89, which was 36 days after the PU was first documented on the Wound/Skin Log dated 10/8/23. At 8:25 AM on 11/29/23, during an interview with RN #3/admission Nurse, she confirmed that she had completed the Weekly Skin Sweep for Resident #89 on 10/12/23 and that she did not stage the PU or provide descriptive characteristics of the PU. She explained that she had assumed the wound care team would follow Resident #89, but she did not follow up to ensure he was seen by the team. She explained that the wound care team at that time consisted of LPN #1 and the Wound Care Physician. She was unable to recall what the PU looked like when she had measured it. She confirmed that she only measured the PU and did not complete or document a full assessment of the wound. She said she was unaware that the Wound Care Physician was not seeing the resident when she completed the documentation on 10/12/23. At 3:00 PM on 11/29/23, during an interview with the DON, she explained she was not aware that RN #3 had not assessed or staged the PU to the sacrum for Resident #89 and that the Wound Care Physician had not assessed or staged the PU for more than four (4) weeks after the PU was first identified by facility staff on 10/8/23. On 11/29/23 at 3:10 PM, during an interview with the Administrator and the DON, the Administrator explained that he could not determine who had completed the Wound/Skin logs that were provided. The DON and the Administrator were unable to explain the PU measurement inconsistencies of the Wound/Skin logs and the Weekly Skin Sweeps for Resident #89. At 10:35 AM on 11/30/23, during an interview with LPN #1, he explained when Resident #89 was admitted to the facility, he did not have any PUs. He was unable to recall how he found out that Resident #89 had a PU. LPN #1 described the PU when he first saw it as measuring approximately 2 cm x 3 cm, the area was discolored, but the skin was intact. He thought the wound was classified as Moisture Associated Skin Damage (MASD), because whenever he provided the treatments to the sacrum, Resident #89 was soiled with urine. He stated that he had instructed CNAs that the resident needed to be kept dry, changed in a timely manner, and turned more frequently, however he did not conduct and document a formal in-service. LPN #1 said that Resident #89's family would be with the resident daily and he would talk to them regarding resident's PU, but he never completed any documentation regarding the PU. LPN #1 said that when the wound was first found, the physician was notified, and new orders were received for zinc oxide, because the skin was intact. He stated that he continued to treat the PU with zinc oxide and did not notify the Wound Care Physician that the wound size was increasing. He confirmed he had no documentation of the wounds, including the progression or deterioration of the wound. When he noticed the PU to the sacrum had slough, he notified the Wound Care Physician and received orders to discontinue the zinc oxide and start a new treatment. He said that he felt like the PU measurements obtained on the Random and Weekly Skin Sweeps were accurate because he assisted RN #3/Admissions Nurse when she measured the wounds. He confirmed Resident #89's wound had deteriorated and increased in size from the time it was first identified on 9/28/23 until the time he was seen by the Wound Care Physician on 11/13/23. He confirmed that on 11/13/23, the PU to the sacrum was classified as a Stage IV. LPN #1 stated that he would not have done anything differently with the resident's wound. He confirmed that Resident #89 did not have a low air loss mattress to help with pressure reduction until 11/9/23. On 11/30/23 at 11:10 AM, during an interview with the Assistant Director of Nursing (ADON), she explained she was unaware that Resident #89 had a PU because she was not involved in his care. She stated that it appeared someone dropped the ball, but she didn't know who. She explained that for a resident to develop a Stage 4 PU in less than two (2) months of admission, the resident did not receive adequate care and should have been referred to the Wound Care Physician before a month had passed, especially since the resident had comorbidities, restricted mobility, and was at a high risk for skin breakdown. On 11/30/23 at 1:10 PM, during an interview with RN #3/admission Nurse, she reported she did not tell the DON that she was not comfortable staging wounds. She confirmed she did not know the protocol or system for a resident being admitted with an existing PU or for a resident who acquired a PU while in the facility to be referred to the Wound Care Physician. She stated she was only filling in since there was no RN currently in the wound care role. She stated that she had not been asked to assess any wounds, but only to measure wounds. She confirmed that the facility had daily stand-up meetings, but wounds were not discussed in detail. On 11/30/23, at 12:00 PM during an interview with DON, she stated she was not aware that Resident #89's PU had increased in size before the Wound Care Physician had gotten involved with his care. On 11/30/23 at 01:25 PM, during a phone interview with the Wound Care Physician, he confirmed that he saw Resident #89 on 11/13/23 for the first time. The Wound Care Physician stated that he felt the etiology of the wound was pressure due to his restricted mobility and the resident was completely dependent upon staff for offloading. He stated that all wounds should be assessed by the facility's protocol. At 1:50 PM on 11/30/23, during a phone interview with the Medical Director, he explained that he never observed Resident #89's PU. He stated that wounds should be assessed daily and if there were any changes, the facility should notify the physician and document accordingly. At 10:05 AM on 12/02/23, during an interview with LPN #6 /Weekend Wound Care Nurse, she stated that Resident #89's PU started out with redness and then had slough in the wound. She confirmed that she did not notify the Wound Care Physician or the Attending Physician regarding the change in the wound. She stated that Resident #89 was dependent upon staff for turning and repositioning. The facility provided an acceptable Removal Plan on 12/4/23, in which they alleged all corrective action to remove the IJ was completed on 12/4/23 and the IJ was removed on 12/5/23. Removal Plan On December 1st, 2023, at approximately 3:30pm Pine Forest Health and Rehabilitation received 5 Immediate Jeopardies during an Annual and Complaint Survey from the Mississippi Department of Health Licensure and Certification and provided the facility with the Immediate Jeopardy Templates. Brief Summary of Events: Pine Forest Health and Rehabilitation failed to put into place appropriate interventions to ensure proper assessment, staging, treatment and clinical care plans to treat and prevent the development and worsening of new and existing pressure ulcers. Corrective Actions: 1. An Emergency QAPI Meeting was held at approximately 12/1/2023 at 5 PM to review the cited deficient practices and to determine a root cause analysis for the lack of appropriate interventions. This meeting included the Administrator, Director of Nursing/lnfection Preventionist, Medical Director, Respiratory Director, & Business Office Manager. The following items were reviewed, coordinated, and corrected to allege compliance and remove the Immediate Jeopardy. The root cause analysis determined the cause of these occurrences was the facility's failure to be properly train staff on the policies for assessing, staging, preventing, and communicating wound and skin care issues for residents who could be at risk for skin breakdown or are already noted with skin/wound breakdown. 2. The facility did a complete policy review on Care Planning Standard, Skin Management. Standard, and Employee Competency Standard. The facility conducted 100% in-services and education using outsourced, Qualified Trainers and Online Software as it pertains to each department and the correlated policies pertaining to the immediate jeopardies. The facility also did a 100% inservice on all staff on the Identification and Reporting of Resident Abuse and Neglect. No individual was allowed to work beginning at approximately 7PM on 12/1/2023 until they were able to successfully complete all prescribed In-services. 3. The facility outsourced a Qualified RN Trainer to properly train with return demonstration all individuals who are responsible for the assessment, staging, and provision of wound care for the Facility. Upon completion and approximately 7:30PM on 12/1/2023, the Facility began to conduct body audits on 100% of in-house residents to determine proper assessment, staging, and treatment of wounds and finished on 12/4/2023. All noted pressure areas were assessed, staged, and determined to have a proper assessment. The wound care physician was notified of all findings and coordinated a Telehealth Visit on all residents with pre-existing wounds to confirm appropriate assessment, staging, and treatment of all existing pressure ulcers. There were no changes noted after having concluded all consult Telehealth visits. The attending physician and facility Medical Director was then notified of all Wound Care Physicia[TRUNCATED]