**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 treatment and services to promote the healing of wounds for one (1) of five (5) wound care observations. Resident #103 The facility's failure to implement and follow physician orders for wound care and treatments put Resident #103 and all other residents who are at risk for skin breakdown at risk for serious harm, injury, impairment, or death. The State Agency (SA) determined the situation to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 12/27/23 when Resident #103 developed a bruised area to the left great toe that deteriorated and became a bruised/blood blister covered in eschar (dead tissue) by 1/24/24. The facility failed to act upon verbal orders resulting in delay in treatment, failed to transcribe these orders into the medical record, and provide treatment for Resident #103's wounds according to the Wound Nurse Practitioner's orders. The facility Administrator was notified of the IJ and SQC and was presented with an IJ template on 1/31/24 at 4:50 PM. The facility provided an acceptable Removal Plan, in which they alleged all corrective action to remove the IJ was completed on 2/01/24 and the IJ was removed as of 02/02/24. The SA validated the Removal Plan on 2/06/24 and determined the IJ and SQC was removed on 2/02/24. Therefore, the scope and severity for 42 CFR 483.25 Quality of Care 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. CROSS REFERENCE F600, F658, F726 Findings Include: Record review of the facility policy titled Skin and Wound with a revision date of 1/24/22 revealed, Policy: To provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure injuries .Skin Impairment Identification: 1. Document presence of skin impairment(s) / new skin impairments(s) when observed and weekly until resolved. 2. Nurse to report changes in skin integrity to the physician/physician extender, resident /resident representative and document in the medical record 3. Develop resident centered interventions and document on the plan of care and the Nurse Aide Kardex .5. Monitor residents' response to treatment, modify as indicated . Resident #103 An observation of wound care for Resident #103, with the Wound Nurse on 1/30/24 at 3:55 PM, revealed removal of the soiled dressing from the wounds on the left foot. A moderate amount of red serosanguinous drainage was observed around the toe portion of the dressing. The left great toe was covered in 100% adherent brown eschar with redness to the peri-wound with a slight odor observed. The wound nurse cleaned the wound to the left great toe and in between the areas of the toes with normal saline, patted dry, and applied xeroform gauze to all the areas and wrapped with a gauze wrap, secured with tape. Record review of the January 2024 Treatment Administration Record (TAR) for Resident #103 revealed there was not a Physician's order for wound care for the left great toe or the breakdown between the inner toes. Record review of the Order Summary Report with active orders as of 1/31/24 for Resident #103 revealed there was not a Physician Order for wound care to the left great toe or in between the toes on the left foot. Record review of the Physician Order Details in the Wound Nurse Practitioner notes for Resident #103 dated 1/24/24 revealed the following orders were not transcribed to the TAR and were not followed during the wound care observation on 1/30/24 with the Wound Nurse, Wound #3 Left Toe . Care of Wound: Enzymatic debriding agent nickel thickness Santyl to the wound bed only. Cover dressing with dry gauze and wrap with Kling/kerlix. Do not put tape directly on the skin. Other: D/C (discontinue) xeroform to left great toe . Thread toes with xeroform on left foot Secure dressing with tape . Change dressing every day and as needed. Also revealed under, Progress Note Details . The bruised/blood blister area to the left great toe is now covered in eschar with bogginess palpated. There are also scattered wounds to the 4th and 5th toes of recent onset Recent amputation to right great toe. Scattered wounds noted to 4th and 5th toes as well on left foot of recent onset with worsening of left great toe. Refer to Proper Name (General Surgeon) for further evaluation 1/25/24: Order for Clindamycin 300 mg (milligrams) 1 (one) po (by mouth) bid (twice daily) x 10 days. An observation of wound care for Resident #103, with the Wound Nurse on 1/30/24 at 3:55 PM, revealed removal of the soiled dressing from the wounds on the left foot. A moderate amount of red serosanguinous drainage was observed around the toe portion of the dressing. The left great toe was covered in 100% adherent brown eschar with redness to the peri-wound with a slight odor observed. The wound nurse cleaned the wound to the left great toe and in between the areas of the toes with normal saline, patted dry, and applied xeroform gauze to all the areas and wrapped with a gauze wrap, secured with tape. Record review of the Weekly Skin Integrity Review forms for Resident #103 dated 1/23/24 and 1/30/24 revealed the wounds in between the toes on the left foot were present and the treatment nurse was aware. The report did not address the left great toe. On 1/30/24 at 3:50 PM, an interview with the Wound Nurse revealed Resident #103 has developed other areas on the left great toe and some areas of breakdown between the toes on the left foot. She revealed the left toe started out as a blood blister and had worsened over the past couple of weeks and now are eschar covered. She stated the left great toe had been debrided by the Wound Nurse Practitioner (NP), but necrotic tissue returned. She revealed an appointment had been made with a general surgeon due to the wounds not healing and the resident's history of previous amputation of the right great toe due to a necrotic wound. Record review of the Wound Nurse Practitioner Progress Note Details dated 12/27/23 for Resident #103 revealed, There is also a 0.8 × 1.5 × 0.0 bruised area on the left great toe that was noted at his most recent visit . Also revealed under, General Notes: Will continue to monitor left great toe. Record review of the Progress Note Details dated 1/03/24 for Resident #103 revealed under, Wound Assessment(s) . Wound #3 Left Toe blister and has received a status of Not Healed. Initial wound encounter measurements are 1 cm (centimeter) length x 1.2 cm (centimeter) width with no measurable depth, with an area of 1.2 sq (square) cm (centimeters). Also revealed under, General Notes: Will continue to monitor left great toe. Staff to notify of any changes . Record review of the Physician Order Details from the Wound NP notes for Resident #103 dated 1/10/24 revealed, Wound #3 Left Toe . Care of Wound: Apply Xeroform cover with Foam Bordered Dressing . Change dressing Every day and as needed . Also revealed under, Progress Note Details . Wound #3 is a Partial Thickness Blister and has received a status of Not healed. Subsequent wound encounter measurements are 0.8 cm (centimeter) length x 1.5 cm (centimeter) width x 0.1 cm (centimeter) depth, with an area of 1.2 cubic cm (centimeter) There is a scant amount of sero-sanguineous drainage noted which has no odor . This order was not transcribed to the TAR. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated, 12/28/23 for the right foot great toe amputation site revealed the TAR was initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of Resident #103's TAR for January 2024 for sheering abrasion to the left buttocks revealed an order dated 12/15/23 was only initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. On 1/31/24 at 9:45 AM, an interview and record review with the Wound Care Nurse revealed all the wound documentation was behind, and she had to catch things up when she transferred to the position. She stated all the wounds were seen in the facility by the Wound Nurse Practitioner (NP) once weekly on Wednesdays and the Wound NP did not give any orders the day she visited but tells her what she wants to be changed up or makes recommendations for the treatments, and she will send the facility the progress notes the following Friday or Monday. She revealed that she worked Monday-Friday and had been doing all the wound care in the facility on those days. She stated that she did do the treatments but did not sit down to initial them until the evenings and occasionally the other nurses had already signed off on the orders already. She revealed that the Medication Cart Nurses did help her with holding certain residents, so they could have gone in and signed the TAR before she got to it. She explained that Resident #103's left great toe wound developed as a dry piece of skin that has continued to worsen, with new areas that developed in between the toes. She revealed the Wound NP visited him last week to assess the wound and made the recommendation to apply xeroform gauze and start Clindamycin for infection, but she did not enter the orders into the system. She confirmed that she would be the person responsible for implementing the orders and that she goes ahead and starts any new treatment recommendations but does not put the order into the system because once she received the NP progress note, she may have changed something up with the wound care. She explained that she was instructed by the Wound NP that the Clindamycin needed to be approved by nephrology, since the resident was on dialysis, so the resident was not started on the Clindamycin when it was originally ordered on 1/24/24. The Wound Nurse confirmed that she never called the dialysis unit to get the antibiotic order approved. Record review of the January 2024 Medication Administration Record (MAR) revealed the Clindamycin order was not implemented. She revealed the wound was not cultured but did show clinical signs of infection and that all medications that the Wound NP recommends must be approved by the Primary Care Practitioner (PCP). She confirmed that she did the treatment on Resident #103's left toes without an active order in the computer and stated, I don't get her notes until a week later, so I can't put in an order, if I don't have one. She confirmed that a verbal order from the NP should be immediately acted upon and that she was given a verbal order from the NP. She revealed not implementing physician orders immediately was a delay in treatment of the wound and treating the infection. She revealed that delay of treatment could result in possible infection, sepsis, or amputation for Resident #103. She confirmed that other nurses had initialed Resident #103's January Treatment Administration Record (TAR) and she revealed she was the person responsible for signing off on the TAR if she completed the treatments. On 1/31/24 at 10:05 AM, an interview with the Assistant Director of Nursing (ADON) confirmed that she was not aware that the Wound Nurse was not utilizing the TAR to complete the wound care each day. She stated the Wound Nurse would have caught that there wasn't a physician's order for care for Resident #103 if she had looked at the TAR and signed off after the treatment was provided. She revealed she was not sure how the nurses on the weekends were providing wound care or if they even were since there was nothing on the TAR for the resident. On 1/31/24 at 3:40 PM, a telephone interview with the Wound Nurse Practitioner revealed she rounds on all the facility wounds every Wednesday and during her visits she makes recommendations for wound care, but the facility does not receive the progress note until Friday evening when it's faxed over. She stated when she makes rounds with the Wound Nurse she gives verbal orders. She revealed some of her recommendations may be delayed because certain orders must go through the resident's primary care provider (PCP) or dialysis, such as antibiotics or pain medication if the resident is on dialysis. She confirmed she was aware of the delay in antibiotics that were ordered on 01/24/24 for Resident #103 because it had to be approved with the PCP due to high risk of drug nephrotoxicity but she assumed that the antibiotic order had been implemented by now. She confirmed that she had not been made aware that the resident still did not have an order for an antibiotic. She revealed that Resident #103 developed a dried blood blister to his left great toe that has deteriorated with a new breakdown in between the toes. She stated the resident had negative Doppler studies and Ankle Brachial Index (ABI) testing that showed moderate Peripheral Vascular Disease. She revealed that Resident #103 was a Diabetic, on dialysis and had a previous history of toe amputation, so she recommended a referral to a General Surgeon due to his high risk of the same outcome (amputation). She revealed she had not been made aware by the facility that Resident #103's left toe wound orders had not been acted upon by the Wound Nurse and the treatment ordered added in the charting system. She revealed that the current Wound Nurse just started, and she was aware that the wound care documentation was behind. She revealed that she had not been made aware of any concerns regarding the Wound Nurse not performing her duties or following physician orders. She confirmed that if the treatments weren't done as ordered, the wounds would deteriorate. On 2/01/24 at 11:25 AM, an interview with the ADON revealed she had not been made aware of any concerns from the Medication Nurses related to wound care. She explained, to her knowledge, the Medication Nurses had never been asked to perform treatments, so the Wound Nurse could catch up on orders or documentation. She confirmed that the nurses should not sign off on treatments that the Wound Nurse performed, and they had never been told to do so. She explained that she had never pulled the TAR to check and see who signed off on the treatments or if all the physicians orders for wounds were on the TAR. She explained that she felt the Wound Nurse got caught up in the day-to-day processes and just didn't make sure things were done. She revealed that she was not aware of a list that was left on the weekends to know which residents needed wound care. She stated the wound care should be administered from the TAR and signed off when completed. On 2/1/24 at 4:35 PM, an interview with the Director of Nursing (DON) she confirmed that the Wound Care Nurse could have implemented the physician order when the NP visited because she was giving the verbal order, which could have been added as a verbal physician's order. She stated, If you are given an order, you should implement that order. She revealed the Wound Nurse should have signed the treatments after they were administered. She explained that she was not aware of the Wound Nurse telling the Medication Nurses that they were required to do treatments because she was behind with orders/documentation. She stated, She could have because I'm not out there on the floor. Record review of the Skills Competency Assessment: Clean Dressing Change dated 7/11/23 revealed under, . 26. Document in the medical Record (TAR) (Treatment Administration Record) after completion of dressing change document findings in the nurse's notes and/or contact the physician when indicated . The Wound Nurse completed this training on 7/1/23. Record review of the facility's Performance Evaluation revealed the Wound Care Nurse read and signed acknowledgment of the job description and duties assigned dated 9/7/23 which revealed, . 8. Complete required documentation in an accurate and timely manner was a requirement. Record review of the admission Record for Resident #103 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Encounter for Orthopedic Aftercare Following Surgical Amputation, acquired absence of Right Great Toe, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Pressure Ulcer of Left Heel, Stage 3, and Pain. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/23 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicates Resident #103 is cognitively intact. The facility submitted the following acceptable Removal Plan on 2/5/24: Brief Summary of Events: On 1/31/2024 at 4:50 pm State Agency (SA) notified the Executive Director (ED) of 5 Immediate Jeopardy's (IJ's) related to F 600 Free from Abuse and Neglect, F 686 Treatment /Services to Prevent /Heal Pressure Ulcers, F 684 Quality of Care, F 726 Competent Nursing Staff and F 658 services Provided Meet Professional Standards. An Immediate jeopardy template was provided to the Executive Director (ED) on 1/31/2024 at 4:50 pm by the State Agency (SA). The facility failed to follow the physician's orders for wound care, failed to provide training and competency skills to the Treatment Nurse to ensure she had adequate knowledge to provide care and services to residents with skin concerns and pressure ulcers and failed to provide the treatment and services to promote healing of pressure ulcer wounds and diabetic ulcers which resulted in delay of healing of pressure ulcers and diabetic ulcers for Resident #52, Resident #103, and Resident #269. Immediate Action Plan: Treatment Nurse was suspended by the Executive Director on 2/1/2024 at 1:00 pm and terminated on 2/1/2024 at 6:43 pm. Treatment Nurse was reported to the Mississippi Board of Nursing on 2/1/2024 at 6:32 pm related to not following professional standards of practice. On 1/31/2024 Assistant Director of Nurses initiated education with 5 Housekeeping employees, 6 Therapist, 4 Dietary employees, 8 Certified Nursing Assistants, 6 office staff, 5 Licensed Practical Nurses and 5 Registered Nurses on Abuse and Neglect with emphasis on following physician orders and timely implementation and documentation of medical treatments of wounds and diabetic ulcers. Employees will be educated prior to accepting an assignment. New hires will be in-serviced on Abuse and Neglect during orientation. Employees will be educated prior to accepting an assignment. On 1/31/2024 the Regional Director of Clinical Services (RDCS) conducted a verbal review of clean dressing change competency with return verbalization from Treatment Nurse RN, RN #1, RN #2, RN #3, RN #4, and Assistant Director of Nurses. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 5 Registered Nurses and 6 Licensed Practical Nurses on Medication Administration and Documentation. Employees will be educated prior to accepting assignments. On 1/31/2024 at 5:40 pm the Regional Director of Clinical Services (RDCS) conducted education with the Treatment Nurse on Skin and Wound Guidelines, Medication Administration and Documentation, Abuse and Neglect, and Following Physician Orders and Clean Dressing Change checklist was reviewed verbally with return verbalization. Education included following the physician order when administering treatments, administering treatment timely, nurse that administers treatment is to sign the electronic administration record that treatment was administered, ensure all skin impairments and pressure ulcers have a physician order for treatment. Employees will be educated prior to accepting assignments. On 1/31/2024 at 1:08 pm Resident #52 received new physician orders to clean the stage 3 pressure ulcer of the coccyx with Dakin's, pat dry, apply Santyl to the wound bed at nickel thickness, cover with foam bordered dressing every day. PRN order for soilage\dislodgement. Resident #103 received new physician orders on 1/31/2024 at 2:02 pm to clean diabetic ulceration between 3rd through 5th toes on left foot with normal saline, pat dry, thread xeroform between toes, cover with dry dressing, wrap with kerlix, and secure with tape every day. PRN order for soilage/dislodgement. Order for clean left great toe blister site with normal saline, pat dry, apply Santyl to wound bed at nickel thickness, cover with dry gauze or ABD pads, wrap with kerlix, and secure with tape every day. PRN order for soilage/dislodgement. No new orders for Resident #269. On 1/31/2024 at 5:05 pm body audits were initiated by Registered Nurse (RN) #1, RN #2, RN #3, RN #4, and Assistant Director of Nurses to identify skin impairment or pressure ulcers. There were 108 body audits completed and 7 refused. No new pressure ulcers or diabetic ulcers identified on the body audits conducted. Audit conducted on the 7 residents refusing body audit to determine any previous skin concerns. No areas of concern were identified. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 6 Licensed Practical Nurses, 5 Registered Nurses, and 23 Certified Nurses Assistants on Skin and Wound Guidelines. Employees will be educated prior to accepting assignments. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 7 Registered Nurses and 10 Licensed Practical Nurses on Following Physician Orders. Employees will be educated prior to accepting assignments. On 1/31/2024 at 8:30 pm Assistant Director of Nurses reviewed physician orders and wound Nurse Practitioner progress notes consisting of diabetic ulcers, pressure ulcers, and skin concerns in the electronic health record (EHR) to ensure physician orders were implemented for 12 of 12 residents. No discrepancies were identified. On 1/31/2024 at 5:40 pm the Regional Director of Clinical Services (RDCS) conducted education with the Treatment Nurse on Skin and Wound Guidelines, Medication Administration and Documentation, Abuse and Neglect, and Following Physician Orders and Clean Dressing Change checklist was used with demonstration and return demonstration. DON and ADON are completing treatments as ordered Monday through Friday until treatment nurse position is filled, and treatment nurse is trained on the skills and expectations of the facility. All dayshift nurses who have completed the skills competency for wound care will provide dressing changes on the weekends. Director of Nurses and Assistant Director of Nurses are checking orders daily to ensure orders have been updated in electronic health records for nurses to complete on weekends. On 2/1/2024 at 2:00 pm Regional [NAME] President of Operation conducted education with Administrator on Abuse and Neglect with emphasis on thorough investigations and reporting guidelines. On 2/1/2024 at 2:30 pm the facility initiated a monitoring tool to check skin concerns, diabetic foot ulcers, pressure ulcers for appropriate orders to treat issues identified. The facility will ensure compliance with all wound care orders for accuracy daily by the Director of Nursing and Assistant Director of Nursing. QAPI: On 1/31/2024 at 7:00 PM a Quality Assurance Performance Improvement (QAPI) Committee meeting was held to review the Immediate Jeopardy template for F 600 Free from Abuse and Neglect, F 686 Treatment /Services to Prevent /Heal Pressure Ulcers, F 726 Competent Nursing Staff and F 658 services Provided Meet Professional Standards and to determine Root Cause Analysis. It was determined through Root Cause Analysis the facility failed to provide approved wound care treatment for Resident #52 and Resident #103 related to failure of the treatment nurse to obtain orders to treat from the provider. The facility failed to provide training and competency skills to the Treatment Nurse to ensure she had adequate knowledge to provide care and services to residents with skin concerns and pressure ulcers and failed to provide the treatment and services to promote healing of pressure ulcer wounds and diabetic ulcers which resulted in delay of healing of pressure ulcers and diabetic ulcers due to change in position and employment status. Attendees were the Executive Director (ED), Minimum Data Service (MDS) Nurse, Medical Record Clerk (MRC), Regional Director of Clinical Services (RDCS), Assistant Director of Nurses (ADON)/Infection Preventionist, Director of Nurses (DON), Nurse Practitioner (NP), and the Medical Director (MD). Director of Nurses (DON), Nurse Practitioner (NP), and Medical Director (MD) attended by phone. It was determined through Root Cause Analysis that the facility failed to provide professional standards of practice for documenting and providing medical treatments for wounds for Resident #52, Resident #103, and Resident #269. As a result, the facility's failure to provide treatment and services for wound care, failure to follow the standards of practice, failure to follow physicians' orders, and failure to provide training and competencies skills, the resident's wound healing was delayed, antibiotic orders were delayed, which resulted in worsening wounds and a need for surgical consult to evaluate the need for amputation. The facility initiated a monitoring tool on 2/1/2024 to check skin concerns, diabetic foot ulcers, pressure ulcers for appropriate orders to treat issues identified. The facility will ensure compliance with all wound care orders for accuracy daily by the Director of Nursing and Assistant Director of Nursing. Weekly wound meeting will be held with Inter Disciplinary Team (IDT) to discuss outcomes and findings. Any adverse findings will immediately be reported to the Executive Director and physician by the Director of Nurses. This process will be on-going and reported to Quality Assurance Committee quarterly. A review of policy and procedures for Abuse and Neglect, Skin and Wound Guidelines, Medication Administration and Documentation, and Following Physician Order was reviewed, and no changes made to policies. All Corrective actions were completed by 2/1/2024 and the facility alleges removal of the Immediate Jeopardy as of 2/2/2024. The State Agency (SA) validated the facility's Removal Plan on 2/06/24: On 2/06/24, the SA validated through staff interviews and record reviews that the Treatment Nurse was terminated and reported to the Mississippi Board of Nursing on 2/1/24. On 2/06/24, the SA validated through staff interviews and record review of the in-service sheet, that education was provided on Abuse and Neglect with emphasis on following physician orders and timely implementation and documentation of medical treatments of wounds and diabetic ulcers. The SA validated through interviews and record reviews that employees will be educated prior to accepting assignments and new hires will be educated during orientation. On 2/06/24, the SA validated through staff interviews and record review that a verbal review of a clean dressing change was conducted for the Treatment Nurse RN, RN #1, RN #2, RN #3, RN #4, and Assistant Director of Nursing. On 2/06/24, the SA validated through in-services sign in sheets and staff interviews that education was conducted on Medication Administration and Documentation. The SA validated through staff interviews and record reviews that all employees will be educated prior to accepting assignment. On 2/06/24, the SA validated through record reviews that education was conducted for the Treatment Nurse on Skin and Wound Guidelines, Medication Administration and Documentation, Abuse and Neglect, Following Physician Orders, and Clean Dressing Change. The SA validated through staff interviews and record review that all employees will be educated prior to accepting assignments. On 2/06/24, the SA validated through record reviews that Resident #52 received a new physician order for pressure wound to the coccyx. Resident #103 received a new physician order for treatment of left great toe blister site and diabetic ulcerations between the 3rd through 5th toes on the left foot. On 2/06/24, the SA validated through staff interview and record review of body audits, that 108 resident skin audits were conducted by Registered Nurse (RN) #1, RN #2, RN #3, RN #4, and the Assistant Director of Nursing, with no new skin impairments identified. The SA validated seven (7) residents refused with an audit conducted to determine if the seven (7) residents had any previous skin concerns on prior skin sweeps and no concerns were identified. On 2/06/24, the SA validated through staff interviews and record review through in-service sign in sheets, that education was provided to nurses and aides for Skin and Wound Guidelines. The SA validated all employees will be educated prior to accepting assignment. On 2/06/24, the SA validated the nurses were educated on Following Physician Orders. The SA validated all employees will be educated prior to accepting assignment. On 2/06/24, the SA validated through interviews and record review that Assistant Director of Nursing reviewed physician orders and wound Nurse Practitioner's progress notes for residents with skin concerns in the Electronic Health Record (EHR) to ensure physician orders were implemented for 12 of 12 residents with no discrepancies found. On 2/06/24, the SA validated through staff interviews and record review that the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were completing treatments Monday through Friday until treatment nurse position was filled. The day shift nurses that have completed the skills competency will cover the weekends. The SA validated through interviews that the DON and ADON were checking the orders daily to ensure orders have been updated in the Electronic Health Record (EHR). On 2/06/24, the SA validated through interviews that the Administrator received education on Abuse and Neglect with emphasis on thorough investigation and reporting that was conducted by the Regional [NAME] President. On 2/06/24, the SA validated through staff interviews and record review that the facility implemented a monitoring tool for skin concerns and to ensure orders are implemented to treat issues identified. The SA validated compliance with wound care orders will be monitored daily by the Director of Nursing and Assistant Director of Nursing. On 2/06/24, the SA validated on 1/31/24, a Quality Assurance and Performance Improvement (QAPI) meeting was held to review he cited deficient practice and determine the root cause analysis lacking appropriate interventions. In attendance were the Executive Di[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to protect a resident's right to be free from neglect as evidenced by failure to implement physician orders for the treatment of wounds for three (3) of five (5) wound observations. Resident #52, Resident #103, and Resident #269. The facility's failure to implement and follow physician orders for wound care and treatments put Resident #52, Resident #103 and Resident #269 and all other residents who are at risk for skin breakdown at risk for serious harm, serious injury, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/20/23 when Resident #269, who had an existing wound to the coccyx was seen by the Wound Nurse Practitioner (NP) and an X-ray was ordered of the coccyx to rule out Osteomyelitis. The X-Ray was not performed until 12/27/23. The resident's coccyx wound worsened. The facility Administrator was notified of the IJ and SQC and was presented with an IJ template on 1/31/24 at 4:50 PM. The facility provided an acceptable Removal Plan on 2/5/24, in which they alleged all corrective action to remove the IJ was completed on 2/01/24 and the IJ was removed as of 02/02/24. The Survey Agency (SA) validated the Removal Plan on 2/06/24 and determined the IJ and SQC was removed on 2/02/24. Therefore, the scope and severity for 42 CFR 483.12 (a) Freedom from Abuse, Neglect, and Exploitation (F600) was lowered from a K to an E, 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. Cross Reference: F658, F684, F686, F726 Findings Include: Record review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation with a revision date of 11/16/22 revealed, Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident Neglect is the failure of the center, its employees .to provide goods and services necessary to avoid physical harm . Resident #269 CROSS REFERENCE F658, F686 An observation and interview with the Wound Nurse Practitioner (NP) and the Wound Nurse on 01/31/24 at 12:00 PM of wound care for Resident #269 confirmed that the resident has a Stage 4 Pressure Ulcer to her Sacrum/Coccyx area. The NP removed the residents brief revealing that the resident was currently having a large bowel movement. After cleaning the resident, the wound care nurse removed a Duoderm from the resident's coccyx area. There was a large amount of fresh brown stool inside the residents wound. The Wound Nurse cleaned the wound with 1/4 strength Dakins solution, packed the wound with ¼ strength Dakins moistened gauze and covered with Duoderm. The Wound NP confirmed that the pressure ulcer is in an area that is very hard to keep a dressing on and to keep clean when the resident has a bowel movement. The dressing was not completely sealed across the bottom due to being in between the folds of the buttocks. She stated, They check on her often to make sure that she has not had a bowel movement. The wound was measured by Wound Nurse Practitioner revealing measurements 5 centimeters (cm) x 5.4 cm x 2.2 cm. There is undermining of the wound at 10 to 2 (spreading from 10:00 to 2:00 on a clock face) with a maximum depth of 2.4 cm. Wound Nurse Practitioner was asked when the resident was first noted to have Osteomyelitis to the Sacrum/Coccyx pressure ulcer and she replied, I don't really remember when it began, and replied, I don't believe it will ever close completely, the goal is to keep infection out of the wound. Record review of the Order Summary Report revealed that the current treatment order dated 1/16/24 was to cleanse stage 4 sacrum with ¼ strength Dakin's, pack with ¼ strength Dakin's moistened gauze and cover with foam bordered dressing every day shift and as needed. Record review of documentation from the Wound Nurse Practitioner on 09/20/23 revealed that staff reported that the sacral wound began to have a prulent drainage and foul odor and the patient began to experience drowsiness, nausea and vomiting. The resident was less talkative and appeared to not feel well. The sacral wound is noted with moderate drainage as well as bone exposure and an x-ray was ordered with the visit to rule out Osteomyelitis. Record review of the Wound Nurse Practitioner visit note on 09/27/23 revealed, Nurse Practitioner to follow up with x-ray and final culture report. Wound Nurse Practitioner visit note on 10/04/23 revealed an x-ray was ordered with a previous visit and is pending. Wound Nurse Practitioner visited again on 10/11/23, 10/18/23, 10/25/23, 11/01/23, 11/08/23, 11/15/23,11/30/23, 12/06/23, 12/13/23, and 12/27/23 and continued to document that the Xray was pending. Wound Nurse Practitioner visit note on 01/03/24 revealed a recent x-ray indicated Osteomyelitis and a midline was placed and the patient is currently receiving Meropenem with recommendations for IV course of antibiotics for a minimum of six weeks, and for patient to be started on probiotic for duration of antibiotic use. An interview, on 01/31/24 at 4:00 PM with Wound Nurse Practitioner confirmed that she was aware that the x-ray that she ordered on 09/20/23 to rule out Osteomyelitis was not acted upon and done until 12/27/23. Wound Nurse Practitioner was asked if she reported to the Director of Nursing or the Assistant Director of Nursing (ADON) that the x-ray had not been performed at any point between the order date of 09/20/23 and the x-ray date of 12/27/23 and the Wound Nurse Practitioner stated No, I did not report it to them, I probably should have , but I didn't. I have to be careful what I say, we are a contracted business in this facility. I probably should have reported it to them, but I didn't. The NP was asked if the treatment for the Osteomyelitis was delayed because the x-ray was not obtained when it was ordered on 09/20/23, and she stated, I would have started the IV whenever the x-ray was gotten if it had showed Osteomyelitis. The NP confirmed that the failure of the facility to treat an infection timely could have brought about sepsis or even death for this resident. An interview on 02/01/24 at 8:45 AM, with the Administrator confirmed that it is the expectation that the Wound Nurse Practitioner notify the Director of Nursing (DON) or Assistant Director of Nursing (ADON) if there is a problem with wounds and if she sees her orders are not being implemented. An interview on 02/01/24 at 9:50 AM, with ADON confirmed that the Wound Nurse Practitioner did not make her aware that the x-ray she ordered on 09/20/23 had not been completed. The ADON stated that around that time in December that she was helping with the wound care because they had terminated the nurse prior for not doing her job and that she found the x-ray order on 12/27/23 had not been done on an audit that she had completed. The ADON confirmed that she immediately called the doctor and got the x-ray ordered and made both the Wound Nurse Practitioner and the Facility Nurse Practitioner aware that the x-ray order had not been completed. She confirmed that the Wound Nurse Practitioner should have reported that the x-ray was not followed through to her or the Director of Nursing immediately, but that she failed to do that. An interview on 02/01/24 at 10:06 AM, with Licensed Practical Nurse (LPN) #5 confirmed that she is the primary nurse for Resident #269 and was unaware that the Wound Nurse Practitioner had ordered an x-ray on 09/20/23. LPN #5 stated, She doesn't tell us anything about the wounds when she sees them. An interview on 02/01/24 at 10:15 AM, with RN #3, Unit Manager confirmed that she was not aware that there was an order for an x-ray on Resident #269 on 09/20/23. RN #3 confirmed that new orders are reviewed each morning in their stand-up meeting and that she never saw an order come through for Resident #269 for an x-ray. Review of the admission Record for Resident #269 revealed that the resident was admitted to the facility on [DATE] with a diagnosis of Heart Failure, Local Infection of the skin and subcutaneous tissue, Pressure Ulcer of Sacral Region Stage 4, Rhabdomyolysis, and chronic kidney disease. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 07 which indicated Resident #269 was cognitively impaired. Resident # 52 CROSS REFERENCE F686, F726 An observation and interview on 01/29/24 at 12:04 PM, with Resident #52 revealed him sitting in a wheelchair in his room. The resident stated he had a wound on his bottom and his left heel. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order dated 12/29/23, Wound Care: Cleanse stage 4 pressure ulcer to coccyx with normal saline, pat dry with gauze, apply Santyl to wound bed and cover with foam bordered dressing daily with a D/C (discontinue) date of 1/12/24, which revealed there was not an active wound care physician's order for the pressure wound to the coccyx after 1/11/24. Record review of Resident #52's Order Summary Report revealed an order dated 1/18/24, Wound Care: Clean unstageable pressure ulcer of left heel with Dakins, pat dry, apply nickel thickness Santyl, apply hydrogel, cover with foam bordered dressing, wrap with kerlix, and secure with tape daily and as needed for soilage/dislodgement . On 1/30/24 at 3:38 PM, an observation of Resident #52's wound care with the Wound Nurse revealed, there was not a wound dressing to the resident's coccyx upon initiating the wound care. The Wound Care nurse provided wound care to the coccyx using a discontinued order dated 1/12/24. An observation of the left heel pressure wound revealed the Wound Nurse failed to provide the correct wound care to the left heel per the current physician orders effective 1/19/24. An interview with the Wound Nurse on 1/30/24 at 3:45 PM, confirmed that the resident did not have a dressing to the coccyx area. She revealed that she did not apply the prescribed hydrogel to the left heel wound as ordered. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order for Santyl to the coccyx with a start date of 12/29/23 was initialed every day however, the order for wound care utilizing Santyl to the coccyx was discontinued on 1/12/24. The TAR was initialed as performed by the Wound Nurse for two (2) of the thirty-one days in January on 1/30/24 and 1/31/24. All the other days were initialed as performed by other facility nurses. Record review of Resident #52's January 2024 TAR revealed, an order dated 12/29/23, Santyl External Ointment . Apply to left heel topically everyday shift for DTI (deep tissue injury). This was initialed as performed by the Wound Nurse two (2) of the thirty-one days in January 1/30 and 1/31. All the other days were initialed as performed by other facility nurses. Record review of Resident #52's Order Summary Report revealed an order dated 1/15/24, Obtain Xray of left heel r/t (related to) increased pain and clinical symptoms of osteoporosis. Record review of the Radiology Report dated 1/20/24 for Resident #52 revealed under, Conclusion: Subtle cortical bone loss at the dorsal lateral aspect of the calcaneus which may represent early osteomyelitis There was a four (4) day delay in obtaining the ordered x-ray for Resident #52's left heel. Record review of Resident #52's Physician Order Details dated 1/24/24 revealed orders for Wound #1 Left Heel and Wound #2 Coccyx . These orders were not transcribed to the TAR to reflect the current orders for Resident #52. Record review of the admission Record revealed Resident #52 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Peripheral Vascular Disease, Pain and Pressure Ulcer of Left Heel, Stage 2. Record review of Resident #52's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 11, which indicates the resident is moderately cognitively impaired. Resident #103 CROSS REFERENCE F684, F686, F726 During an observation and interview on 01/30/24 at 8:19 AM, Resident #103 revealed him lying in bed, awake and alert. He stated he had a wound on his bottom and on his foot that caused him pain. During an interview with the Wound Nurse on 1/30/24 at 3:50 PM, revealed Resident #103 was admitted to the facility with a pressure wound on the left heel that has not shown any progress with healing and the resident has also developed other areas on the left great toe and some areas of breakdown between the toes on the left foot. She revealed the left toe started out as a blood blister and had worsened over the past couple of weeks and now are eschar covered. She stated the left great toe had been debrided by the Wound Nurse Practitioner (NP), but necrotic tissue returned. She revealed an appointment had been made with a general surgeon due to the wounds not healing and the resident's history of previous amputation of the right great toe due to a necrotic wound. During an observation of wound care for Resident #103, with the Wound Nurse on 1/30/24 at 3:55 PM, revealed she removed the soiled dressing from the wounds on the left foot. A moderate amount of red serosanguinous drainage was observed around the toe portion of the dressing. The left great toe wound was covered in 100% adherent brown eschar with redness to the peri-wound with a slight odor observed. The wound nurse cleaned the wound to the left great toe and in between the areas of the toes with normal saline, patted dry, and applied xeroform gauze to all the areas and wrapped with a gauze wrap, secured with tape. Record review for the Physician Order Details for Resident #103 dated 1/24/24 revealed the xeroform to the left great toe was discontinued. New orders were given to apply enzymatic debriding agent (Santyl) to the left great toe wound bed only and wrap with kerlix gauze. Thread toes with xeroform on the left foot, secure with tape daily and as needed. Record review of the January 2024 Treatment Administration Record (TAR) for Resident #103 revealed there was not a wound care order for the diabetic ulcer on the left great toe or the breakdown between the inner toes. Record review of the Order Summary Report with active orders as of 1/31/24 for Resident #103 revealed there was not a Physician Order for wound care to the left great toe or in between the toes on the left foot. Record review of the Weekly Skin Integrity Review forms for Resident #103 dated 1/23/24 and 1/30/24 revealed the wounds in between the toes on the left foot were present and the treatment nurse was aware. The report did not address the left great toe. Record review of the Progress Note Details dated 12/27/23 for Resident #103 revealed, There is also a 0.8 × 1.5 × 0.0 bruised area on the left great toe that was noted at his most recent visit .Will continue to monitor left great toe . Record review of the Progress Note Details dated 1/03/24 for Resident #103 revealed under, Wound Assessment(s) . Wound #3 Left Toe blister and has received a status of Not Healed. Initial wound encounter measurements are 1 cm (centimeter) length x 1.2 cm (centimeter) width with no measurable depth, with an area of 1.2 sq (square) cm (centimeters). Also revealed under, General Notes: Will continue to monitor left great toe. Staff to notify of any changes. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 12/28/23, for wound care to the left heel stage 3 pressure ulcer with a D/C (discontinue) date of 1/18/24. The order was not initialed as completed by the Wound Nurse any of the 18 days in January the order was active. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 1/19/24 for wound care to the left heel stage 3 pressure ulcer. The wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated, 12/28/23 for the right foot great toe amputation site revealed the TAR was initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of Resident #103's TAR for January 2024 for sheering abrasion to the left buttocks revealed an order dated 12/15/23 was only initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of the admission Record for Resident #103 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Encounter for Orthopedic Aftercare Following Surgical Amputation, acquired absence of Right Great Toe, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Pressure Ulcer of Left Heel, Stage 3, and Pain. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/23 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicates Resident #103 is cognitively intact. During an interview with the Wound Care Nurse on 1/31/24 at 9:45 AM, revealed she had been back in the Wound Nurse position since January 1, 2024. She revealed all the wound documentation was behind, and she had to catch things up when she transferred to the position. She stated all the wounds were seen in the facility by the Wound Nurse Practitioner (NP) once weekly on Wednesdays and the Wound NP did not give any orders the day she visited but tells her what she wants to be changed up or makes recommendations for the treatments, and she will send the facility the progress notes the following Friday or Monday. She revealed there were times she did not get the Wound NP's Progress Note until a week later. She confirmed that she had access to the site where the Wound NP uploads the documents, and she could pull the progress notes after it was uploaded. She revealed that Resident #52's left heel pressure wound developed in the facility and was initially a Stage 2 blister and was now unstageable. She stated she was unsure what interventions were put in place to prevent skin breakdown since she had only been in the wound position for a month. She revealed that she worked Monday-Friday and had been doing all the wound care in the facility on those days. She explained that on the weekends, she leaves a list of the residents with wounds so that the nurses will know whom to perform wound care on. She confirmed that her initials were not listed on Resident #52's Treatment Administration Record (TAR) for the month of January 2024 except for 1/30/24 and 1/31/24. She stated that she did do the treatments but did not sit down to initial them until the evenings and occasionally the other nurses had signed off on them already. She revealed that the Medication Cart Nurses did help her with holding certain residents, so they could have gone in and signed the TAR before she got to it. She revealed that she was not aware that Resident #52's treatment order for the coccyx pressure wound had been discontinued on 01/12/24. She explained that she had no idea who would have discontinued the treatment order out of the system and acknowledged that she did not follow the TAR for treatment orders, or she would have caught the error. She explained that Resident #103's left great toe wound developed as a dry piece of skin that has continued to worsen, with new ulcers that developed in between the toes. She revealed the Wound NP visited him last week to assess the wound and made the recommendation to apply xeroform gauze and start clindamycin for infection, but she did not enter the orders into the system. She confirmed that she would be the person responsible for implementing the orders and that she goes ahead and starts any new treatment recommendations but does not put the order into the system because once she received the NP progress note, she may have changed something up with the wound care. She explained that she was instructed by the Wound NP that the clindamycin needed to be approved by nephrology, since the resident was on dialysis, so the resident was not started on the clindamycin when it was originally ordered on 1/24/24. The Wound Nurse confirmed that she never called the dialysis unit to get the antibiotic order approved. She revealed the wound was not cultured but did show clinical signs of infection and that all medications that the Wound NP recommends must be approved by the Primary Care Practitioner (PCP). She confirmed that she did the treatment on Resident #103's left toes without an active order in the computer and stated, I don't get her notes until a week later, so I can't put in an order, if I don't have one. She confirmed that a verbal order from the NP should be immediately acted upon and that she was given a verbal order from the NP. She revealed not implementing physician orders immediately was a delay in treatment of the wound and treating the infection. She revealed that delay of treatment could result in possible infection, sepsis, or amputation for both Resident #52 and #103. She confirmed that other nurses had initialed Resident #103's January Treatment Administration Record (TAR) and she revealed she was the person responsible for signing since she completed the treatments. During an interview with the Assistant Director of Nursing (ADON) on 1/31/24 at 10:05 AM, revealed that the facility had not had a consistent Wound Care Nurse for the past six (6) months. She revealed that the previous Wound Nurse worked for about three (3) months and left without notice, although she was going to be terminated due to lack of documentation on the wounds. The ADON stated that she filled in for the Wound Nurse position for about a month until the current Wound Nurse could transfer from the night shift position. The ADON stated that things were behind as far as documentation on the facility wounds, and the Wound Nurse had to get all the information up to date. She revealed that she had not had any concerns regarding the Wound Nurse and felt as if she did a good job. She stated that the Wound Care Nurse did treatments when she was originally hired in 2019 for about a year, so they felt she had enough experience. She revealed she had no reason to suspect anything was wrong and confirmed that the Wound Nurse had not had any wound care training after switching from the night shift supervisor role to the wound care role in January. She confirmed that Resident #52's treatment order for the coccyx had been discontinued on 1/12/24 unintentionally by a staff member. She confirmed that she was not aware that the Wound Nurse was not utilizing the TAR to complete the wound care each day. She would have caught that the order was discontinued if she had looked at the TAR and signed off after the treatment was provided. She revealed she was not sure how the nurses on the weekends were providing wound care. During a telephone interview with the Wound Nurse Practitioner on 1/31/24 at 3:40 PM, revealed she rounds on all the facility wounds every Wednesday and during her visits she makes recommendations for wound care, but the facility does not receive the progress note until Friday evening when it's faxed over, but that when she makes rounds with the Wound Nurse, she gives verbal orders. She revealed some of her recommendations may be delayed because certain orders must go through the resident's primary care provider (PCP) or dialysis, such as antibiotics or pain medication if the resident is on dialysis. She confirmed she was aware of the delay in antibiotics that were ordered on 01/24/24 for Resident #103 because it had to be approved with the PCP due to high risk of drug nephrotoxicity but she assumed that the antibiotic order had been implemented by now, and confirmed that she had not been made aware that the resident still did not have an order for an antibiotic. She revealed that Resident #103 developed a dried blood blister to his left great toe that has deteriorated with a new breakdown in between the toes. She stated the resident had negative Doppler studies and ABI testing that showed moderate Peripheral Vascular Disease. She revealed that Resident #103 was a Diabetic, on dialysis and had a previous history of toe amputation, so she recommended a referral to a General Surgeon due to his high risk of the same outcome (amputation). She revealed she had not been made aware by the facility that Resident #103's left toe wound orders had not been acted upon by the Wound Nurse and the treatment ordered added in the charting system. She revealed that the current Wound Nurse just started, and she was aware that the wound care documentation was behind. She explained that Resident #52's heel wound was unchanged and had not shown any progress. She explained that she also referred the resident to a general surgeon because she was unable to perform the needed debridement in the facility setting due to pain management. She stated that she was not made aware that Resident #52's coccyx treatment order had been discontinued on 1/12/24. She stated that lack of a dressing to the coccyx wound could cause delay in healing and infection. She revealed that she had not been made aware of any concerns regarding the Wound Nurse not performing her duties or following physician orders. She confirmed that if the treatments weren't done as ordered, the wounds would deteriorate. An interview with Licensed Practical Nurse (LPN) #4 on 2/01/24 at 11:05 AM, revealed that she worked the Medication Cart on 7-3 shift. She revealed that she had been doing the treatments for Resident #52 on the weekends and some during the weekdays. She explained that the facility had not had a consistent or set Wound Nurse in months. She explained that the current Monday through Friday Wound Nurse had been out some, and the nurses had been told that she was not starting full time until February. She confirmed that there were days when the treatments had not been signed off on by the Wound Nurse and the Medication nurses felt responsible for signing them off because they couldn't have things not completed on the TAR at the end of their shift. She explained that there had been times in the past month when the medication nurses were told to do all the wound care because the Wound Nurse was behind and had orders and documentation to complete. LPN #4 explained that she was working this past weekend (1/27/24 and 1/28/24), so she went to the Wound Nurse on Thursday 1/25/24 because she saw that Resident #52's coccyx order had been discontinued in the computer. She revealed that she was told by the Wound Nurse that the order had been discontinued and not to worry about it. She explained that the Wound Nurse never checked in the computer system when she asked her or got up from what she was doing at the time, she simply stated it had been discontinued. She revealed that the order to apply Santyl to the coccyx continued to come up on the TAR, so she applied Santyl to the wound on the coccyx, but did not apply a cover dressing because it was not ordered. She revealed that she was confused because she knew the resident did have a treatment order and all of a sudden, it stopped. She revealed that even when she followed behind the Wound Nurse the last couple of weeks, Resident #52 never had a dressing on his coccyx. LPN #4 stated when she said something again to the Wound Nurse about the wound not having a dressing, she stated, It's been discontinued and acted like it wasn't a big deal. LPN #4 explained that she knew the wound should be covered to keep out urine and feces, because the resident was incontinent, which could cause infection and slow the healing of the wound. She stated that she had never been given a list or left a list of the residents with wounds and treatments for the weekend. She explained that this past Sunday, 1/28/24 they didn't find out that they didn't have a Wound Care Nurse until 1 PM and her shift was over at 3 PM and she wasn't sure who did the wound care that day. During an interview with the Assistant Director of Nursing (ADON) on 2/01/24 at 11:25 AM, revealed she had not been made aware of any concerns from the Medication Nurses related to wound care. She explained, to her knowledge, the Medication Nurses had never been asked to perform treatments so the Wound Nurse could catch up on orders or documentation. She confirmed that the nurses should not sign off on treatments that the Wound Nurse performed, and they had never been told to do so. She explained that she had never pulled the TAR to check and see who signed off on the treatments. She explained that she felt the Wound Nurse got caught up in the day-to-day processes and just didn't make sure things were done. She revealed that she was not aware of a list that was left on the weekends to know which residents needed wound care. She stated the wound care should be administered from the TAR and signed off when completed. She explained that the facility did have a call in Sunday 1/28/24 with the person who was supposed to do the wound care and stated the Director of Nursing (DON) would have been responsible for letting the Unit Managers know. During an interview with the Director of Nursing (DON) on 2/1/24 at 4:35 PM, revealed that she and the Administrator (ADM) had spoken with the Wound Nurse about taking the Wound Care position when the job opened. She stated that the Wound Nurse had performed the treatments before in the facility when she was first hired, and she was knowledgeable, and she felt the Wound Nurse did a good job. She stated the Wound Nurse was full-time and worked Monday through Friday, so she wasn't sure why she told the medication cart nurses that she was just part time. She revealed that the only thing that had changed since the Wound Nurse did previous treatments was, they hired a new Wound Nurse Practitioner (NP). She confirmed that the Wound Care Nurse could have implemented the physician order when the NP visited because she was giving the verbal order, which could have been added as a verbal physician's order. She stated, If you are given an order, you should implement that order. She revealed the Wound Nurse should have signed the treatments after they were administered, just like with giving medication. She said was not aware of the Wound Nurse telling the Medication Nurses that they were required to do treatments because she was behind with orders and[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on state Nurse Practice Standards, observation, staff interview, record review, and facility policy review, the facility failed to follow the professional standards of practice for documenting and providing medical treatments for wounds for three (3) of five (5) wound observations. Resident #52, Resident #103 and Resident #269. The facility's failure to follow standards of practice by failing to implement and follow physician orders for wound care and treatments caused serious harm to Resident #52, Resident #103 and Resident #269 and placed 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) and Substandard Quality of Care (SQC) that began on 9/20/23 when Resident #269, who had an existing wound to coccyx was seen by the Wound Nurse Practitioner (NP) and an X-ray was ordered of the coccyx to rule out Osteomyelitis. The order for the X-Ray was not performed until 12/27/23, (almost 3 months later) which caused the residents coccyx wound to worsen. The facility Administrator was notified of the IJ and SQC and was presented with an IJ template on 1/31/24 at 4:50 PM. The facility provided an acceptable Removal Plan in which they alleged all corrective action to remove the IJ was completed on 2/01/24 and the IJ was removed as of 02/02/24. The Survey Agency (SA) validated the Removal Plan on 2/06/24 and determined the Immediate Jeopardy (IJ) was removed on 2/02/24. Therefore, the scope and severity for CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, CFR 483.21(b)(3)(i) Meet professional standards of quality, CFR 483.25 Quality of care, CFR 483.25(b)(1) Pressure ulcers, and CFR 483.35 Nursing Services, will be lowered to a E, 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: CROSS REFERENCE F684 Review of the facility policy titled 'LTC Facility's Pharmacy Services and Procedures Manual with a revision date of 1/01/22 revealed under,8.3 Facility staff should immediately record the new orders in the resident's medical record and medication administration record. Also revealed under, 13.5 Facility should ensure that the person receiving a verbal order immediately records it in the resident's chart or electronic order system . Mississippi Board of Nursing; Source: Miss. Code [NAME]. § 73-15-17 (1972, as amended) read: Rule 2.2 Responsibility. The LPN shall be responsible and accountable for: A. Knowledge of and compliance with the laws and regulations governing the practice of nursing in the State of Mississippi. B. Practicing within the scope of practice as established by the Board and according to generally accepted standards of practice. C. Accepting responsibility for individual nursing actions, competence, decisions and behavior in the course of nursing practice. Source: Miss. Code [NAME]. § 73-15-17 (1972, as amended). Resident # 52 An observation and interview on 01/29/24 at 12:04 PM with Resident #52 revealed him sitting in a wheelchair in his room. The resident stated he had a wound on his bottom and his left heel. Record review of an order dated 12/29/23 on Resident #52's January 2024 Treatment Administration Record (TAR) that read, Wound Care: Cleanse stage 4 pressure ulcer to coccyx with normal saline, pat dry with gauze, apply Santyl to wound bed and cover with foam bordered dressing daily with a D/C (discontinue) date of 1/12/24, which revealed there was not an active wound care physician's order for the pressure wound to the coccyx after 1/11/24. An order dated 1/18/24 on Resident #52's Order Summary Report revealed , Wound Care: Clean unstageable pressure ulcer of left heel with Dakins, pat dry, apply nickel thickness Santyl, apply hydrogel, cover with foam bordered dressing, wrap with kerlix, and secure with tape daily and as needed for soilage/dislodgement . An observation of Resident #52's wound care with the Wound Nurse on 1/30/24 at 3:38 PM revealed, there was not a wound dressing to the resident's coccyx upon initiating the wound care. The coccyx wound bed was 90% yellow, adherent slough, 10% granulation tissue with redness and maceration to the wound edges. The Wound Nurse cleansed the wound with Dakin's solution, patted dry, applied a layer of Santyl and covered with a foam dressing which was not the current order. An observation of the left heel pressure wound revealed, 100% adhering brown eschar to the wound bed. Slight redness observed to the peri-wound. The Wound Nurse stated the treatment orders for the left heel were to cleanse the wound with Dakin's solution, pat dry, apply a layer of Santyl, cover with foam and wrap with gauze wrap. An interview with the Wound Nurse on 1/30/24 at 3:45 PM confirmed that the resident did not have a dressing to the coccyx area and that urine and stool could get inside the wound and cause infection and delay the healing of the wound. She revealed that she did not follow the latest wound care orders by failing to apply the prescribed hydrogel to the left heel wound. She revealed the hydrogel was ordered along with Santyl to debride the adherent eschar and that the resident recently completed antibiotics due to the left heel wound being infected. Record review of the admission Record revealed Resident #52 was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Acute on Chronic Systolic (congestive) Heart Failure, Peripheral Vascular Disease, pain and Pressure Ulcer of Left Heel, Stage 2. Record review of Resident #52's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 11, which indicates the resident is moderately cognitively impaired. Also revealed under section M, the current number of Unhealed Pressure Ulcers/Injuries at Each Stage, one (1) Stage 2 pressure ulcer was marked. Resident #103 An observation and interview on 01/30/24 at 8:19 AM, with Resident #103 revealed him lying in bed, awake and alert. He stated he had a wound on his bottom and on his foot that caused him pain. An observation of wound care for Resident #103, with the Wound Nurse on 1/30/24 at 3:55 PM, revealed she removed the soiled dressing from the wounds on the left foot. A moderate amount of red serosanguinous drainage was observed around the toe portion of the dressing. The left great toe diabetic wound was covered in 100% adherent brown eschar with redness to the peri-wound with a slight odor observed. The wound nurse cleaned the wound to the left great toe and in between the areas of the toes with normal saline, patted dry, and applied xeroform gauze to all the areas and wrapped with a gauze wrap, secured with tape. Record review of the Treatment Administration Record (TAR) for Resident #103 revealed there was not a wound care order for the ulcer on the left great toe or the breakdown between the inner toes. Record review of the Order Summary Report for Resident #103 revealed there was not a Physician Order for wound care to the left great toe or in between the toes on the left foot. Record review of Resident #103's Order Summary Report revealed an order dated 7/8/23, Weekly skin sweeps on Tuesday 3-11 every evening shift every Tue (Tuesday) . Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 12/28/23, Wound Care: Clean Left heel stage 3 pressure ulcer with normal saline, pat dry with gauze, apply Medi honey to wound bed, cover with foam dressing, wrap with kerlix and secure with tape daily with a D/C (discontinue) date of 1/18/24. The order was not initiated as completed by the Wound Nurse any of the 18 days in January the order was active. The wound care was not documented as administered on 1/22 and 1/28, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated, 12/28/23, Wound Care: Cleanse right foot great toe amputation site with soap and water and apply A&D ointment daily initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22 and 1/28, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 12/15/23, Wound Care: Cleanse shearing abrasion to left buttock with NS (normal saline), apply triad daily initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22 and 1/28, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 1/19/24, Wound Care: Clean left heel stage 3 pressure ulcer with normal saline, pat dry with gauze, apply Santyl to wound bed at nickel thickness, cover with foam dressing, wrap with kerlix and secure with tape daily initialed as completed by the Wound Nurse two (2) of the 13 days that the order was active. The other dates were initialed as completed by other facility nurses. The dates of 1/22 and 1/28 have no initials to support wound care was performed, which was a total of 2 missed treatments. Record review of the admission Record for Resident #103 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Encounter for Orthopedic Aftercare Following Surgical Amputation, acquired absence of Right Great Toe, Nontraumatic Subarachnoid Hemorrhage Left Middle Cerebral Artery, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Pressure Ulcer of Left Heel, Stage 3, and Pain. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/23 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicates Resident #103 is cognitively intact. Also revealed under section M, diabetic foot ulcer(s) were not checked for the MDS look back period. Resident #52 An interview with the Wound Care Nurse on 1/31/24 at 9:45 AM revealed she had worked at the facility for 3 years, first starting out as the Wound Nurse, then transferred over to the night shift supervisor and filling in on the medication cart. She stated she had been back in the Wound Nurse position since January 1, 2024. She revealed prior to her taking the position, they had another wound nurse who worked for about 3 months and resigned, leaving the facility in a bind due to her lack of inconsistent wound charting. She revealed all the wound documentation was behind, and she had to catch things up when she transferred to the position. She stated all the wounds were seen in the facility by the Wound Nurse Practitioner (NP) once weekly on Wednesdays and the Wound NP did not give any orders the day she visited but tells her what she wants to be changed up or makes recommendations for the treatments, and she will send the facility the progress notes the following Friday or Monday. She revealed there were times she did not get the Wound NP's Progress Note until a week later. She confirmed that she had access to the site where the Wound NP uploads the documents, and she could pull the progress notes after it was uploaded. She revealed that Resident #52's left heel pressure wound developed in the facility and was initially a Stage 2 blister and was now unstageable. She stated she was unsure what interventions were put in place to prevent skin breakdown since she had only been in the wound position for a month. She confirmed that her initials were not listed on Resident #52's Treatment Administration Record (TAR) for the month of January 2024 except for 1/30 and 1/31. She stated that she did do the treatments but did not sit down to initial them until the evenings and occasionally the other nurses had signed off on them already. She revealed that she was not aware that Resident #52's treatment order for the coccyx pressure wound had been discontinued on 01/12/24. She explained that she had no idea who would have discontinued the treatment order out of the system and acknowledged that she did not follow the TAR for treatment orders, or she would have caught the error. The interview with the Wound Care Nurse on 1/31/24 at 9:45 AM also revealed that Resident #103's left great toe wound continued to worsen, with new ulcers that developed in between the toes. She explained that she was instructed by the Wound NP that the clindamycin needed to be approved by nephrology, since the resident was on dialysis, so the resident was not started on the clindamycin when it was originally ordered on 1/24/24. The Wound Nurse confirmed that she never called the dialysis unit to get the antibiotic order approved. She revealed the wound was not cultured but did show clinical signs of infection. She confirmed that she did the treatment on Resident #103's left toes without an active order in the computer and stated, I don't get her notes until a week later, so I can't put in an order, if I don't have one. During the interview with the Wound Care Nurse on 1/31/24 at 9:45 AM, she confirmed that a verbal order from the NP should be immediately acted upon and that she was given a verbal order from the NP. She revealed not implementing physician orders immediately was a delay in treatment of the wound and treating the infection. She revealed that delay of treatment could result in possible infection, sepsis, or amputation for both Resident #52 and #103. She confirmed that other nurses had initialed Resident #103's January Treatment Administration Record (TAR) and she revealed she was the person responsible for signing since she completed the treatments. An interview with the Assistant Director of Nursing (ADON) on 1/31/24 at 10:05 AM revealed that the ADON stated that things were behind as far as documentation on the facility wounds, and the Wound Nurse had to get all the information up to date. She revealed that she had not had any concerns regarding the Wound Nurse and felt as if she did a good job. She stated that the Wound Care Nurse did treatments when she was originally hired in 2019 for about a year, so they felt she had enough experience. She confirmed that Resident #52's treatment order for the coccyx had been discontinued on 1/12/24 unintentionally by a staff member. She confirmed that she was not aware that the Wound Nurse was not utilizing the TAR to complete the wound care each day that she would have caught that the order was discontinued if she had looked at the TAR and signed off after the treatment was provided. She revealed she was not sure how the nurses on the weekends were providing wound care. A telephone interview with the Wound Nurse Practitioner on 1/31/24 at 3:40 PM revealed she rounds on all the facility wounds every Wednesday and during her visits she makes recommendations for wound care, but the facility does not receive the progress note until Friday evening when it's faxed over, but that when she makes rounds with the Wound Nurse she gives verbal orders. She revealed some of her recommendations may be delayed because certain orders must go through the resident's primary care provider (PCP) or dialysis, such as antibiotics or pain medication if the resident is on dialysis. She confirmed she was aware of the delay in antibiotics that were ordered on 01/24/24 for Resident #103 because it had to be approved with the PCP due to high risk of drug nephrotoxicity but she assumed that the antibiotic order had been implemented by now, and confirmed that she had not been made aware that the resident still did not have an order for an antibiotic. She revealed she had not been made aware by the facility that Resident #103's left toe wound orders had not been acted upon by the Wound Nurse and the treatment ordered added in the charting system. She explained that Resident #52's heel wound was unchanged and had not shown any progress. She explained that she also referred the resident to a general surgeon because she was unable to perform the needed debridement in the facility setting due to pain management. She stated that she was not made aware that Resident #52's coccyx treatment order had been discontinued on 1/12/24. She stated that lack of a dressing to the coccyx wound could cause delay in healing and infection. She revealed that she had not been made aware of any concerns regarding the Wound Nurse not performing her duties or following physician orders. She confirmed that if the treatments weren't done as ordered, the wounds would deteriorate. An interview with Licensed Practical Nurse (LPN) #4 on 2/01/24 at 11:05 AM revealed that she worked the Medication Cart on 7-3 shift. She confirmed that there were days when the treatments had not been signed off on by the Wound Nurse and the Medication nurses felt responsible for signing them off because they couldn't have things not completed on the TAR at the end of their shift. She explained that there had been times in the past month when the medication nurses were told to do all the wound care because the Wound Nurse was behind and had orders and documentation to complete. LPN #4 explained that she went to the Wound Nurse on Thursday 1/25/24 because she saw that Resident #52's coccyx order had been discontinued in the computer. She revealed that she was told by the Wound Nurse that the order had been discontinued and not to worry about it. She explained that the Wound Nurse never checked in the computer system when she asked her or got up from what she was doing at the time, she simply stated it had been discontinued. She revealed that the order to apply Santyl to the coccyx continued to come up on the TAR, so she applied Santyl to the wound on the coccyx, but did not apply a cover dressing because it was not ordered. She revealed that she was confused because she knew the resident did have a treatment order and all of a sudden, it stopped. She revealed that even when she followed behind the Wound Nurse the last couple of weeks, Resident #52 never had a dressing on his coccyx. LPN #4 stated when she said something again to the Wound Nurse about the wound not having a dressing, she stated, It's been discontinued and acted like it wasn't a big deal. LPN #4 explained that she knew the wound should be covered to keep out urine and feces, because the resident was incontinent. She stated that she had never been given a list or left a list of the residents with wounds and treatments for the weekend. She explained that this past Sunday, 1/28/24 they didn't find out that they didn't have a Wound Care Nurse until 1 PM and her shift was over at 3 PM and she wasn't sure who did the wound care that day. An interview with the Assistant Director of Nursing (ADON) on 2/01/24 at 11:25 AM revealed she had not been made aware of any concerns from the Medication Nurses related to wound care. She explained, to her knowledge, the Medication Nurses had never been asked to perform treatments, so the Wound Nurse could catch up on orders or documentation. She confirmed that the nurses should not sign off on treatments that the Wound Nurse performed, and they had never been told to do so. She explained that she had never pulled the TAR to check and see who signed off on the treatments. She explained that she felt the Wound Nurse got caught up in the day-to-day processes and just didn't make sure things were done. She revealed that she was not aware of a list that was left on the weekends to know which residents needed wound care. She stated the wound care should be administered from the TAR and signed off when completed. She explained that the facility did have a call in Sunday 1/28/24 with the person who was suppose to do the wound care and stated the Director of Nursing (DON) would have been responsible for letting the Unit Managers know. An interview with the Director of Nursing (DON) on 2/1/24 at 4:35 PM revealed that she and the Administrator (ADM) had spoken with the Wound Nurse about taking the Wound Care position when the job opened. She stated that the Wound Nurse had performed the treatments before in the facility when she was first hired, and she was knowledgeable, and she felt the Wound Nurse did a good job. She stated the Wound Nurse was full-time and worked Monday through Friday, so she wasn't sure why she told the medication cart nurses that she was just part time. She revealed that the only thing that had changed since the Wound Nurse did previous treatments was, they hired a new Wound Nurse Practitioner (NP). She revealed that the NP caused the delay because she sent the orders/progress notes over to the facility later in the week after she visited the residents. She confirmed that the Wound Care Nurse could have implemented the physician order when the NP visited because she was giving the verbal order, which could have been added as a verbal physician's order. She stated, If you are given an order, you should implement that order. She revealed the Wound Nurse should have signed the treatments after they were administered, just like with giving medication. She explained that she was not aware of the Wound Nurse telling the Medication Nurses that they were required to do treatments because she was behind with orders/documentation. She stated, She could have because I'm not out there on the floor. The DON revealed that the Wound Nurse had not been giving any wound training or expectations since she accepted the Wound Care Nurse position in January and stated, We just trusted her that she knew what she was doing. She revealed all the nurses were checked off on clean dressing changes, but that was the extent of the wound care training that the facility did. Record review of Quality Assurance and Performance Improvement (QAPI) meeting minutes dated 1/12/24 revealed, Wound Care . 100% audit. Wound Care nurse resigned. New Wound care nurse starts 1/1/2024 completed 12/27/23 with a status of Ongoing. Record review of Skills Competency Assessment: Clean Dressing Change revealed the wound nurse completed the training on hire (9/8/21). Record review of the Skills Competency Assessment: Clean Dressing Change dated 7/11/23 revealed under, . 26. Document in the medical Record (TAR) (Treatment Administration Record) after completion of dressing change document findings in the nurse's notes and / or contact the physician when indicated . The Wound Nurse completed this training on 7/1/23. Record review of the Education In-service Attendance Record dated 5/1/23-5/5/23 revealed an in-service was conducted on wounds and skin sweeps and the Wound Care Nurse was in attendance. Record review of the Freedom from Abuse Notice to Employees revealed, . Neglect includes, but is not limited to lack of care and supervision and unmet physical, social, emotional, spiritual, or medical needs. The Wound Care Nurse signed the notice on 7/11/23. Record review of the facility's Performance Evaluation revealed the Wound Care Nurse read and signed acknowledgment of the job description and duties assigned dated 11/04/19, 9/07/21 and 9/7/23 which revealed, . 8. Complete required documentation in an accurate and timely manner was a requirement. Resident #269 Wound Nurse Practitioner visit note on 09/27/23 revealed, Nurse Practitioner to follow up with x-ray and final culture report. Wound Nurse Practitioner visit note on 10/04/23 revealed an x-ray was ordered with a previous visit and is pending. Wound Nurse Practitioner visited again on 10/11/23, 10/18/23, 10/25/23, 11/01/23, 11/08/23, 11/15/23,11/30/23, 12/06/23, 12/13/23, and 12/27/23 and continued to document that the Xray was pending. Wound Nurse Practitioner visit note on 01/03/24 revealed a recent x-ray indicated Osteomyelitis and a midline was placed and the patient is currently receiving Meropenem with recommendations for IV course of antibiotics for a minimum of six weeks, and for patient to be started on probiotic for duration of antibiotic use. An interview, on 01/31/24 at 4:00 PM with Wound Nurse Practitioner confirmed that she was aware that the x-ray that she ordered on 09/20/23 to rule out Osteomyelitis was not acted upon and done until 12/27/23. Wound Nurse Practitioner was asked if she reported to the Director of Nursing or the Assistant Director of Nursing (ADON) that the x-ray had not been performed at any point between the order date of 09/20/23 and the x-ray date of 12/27/23 and the Wound Nurse Practitioner stated No, I did not report it to them, I probably should have , but I didn't. I have to be careful what I say, we are a contracted business in this facility. I probably should have reported it to them, but I didn't. NP was asked if the treatment for the Osteomyelitis was delayed because the x-ray was not obtained when it was ordered on 09/20/23, and she stated, I would have started the IV whenever the x-ray was gotten if it had showed Osteomyelitis. The NP confirmed that the failure of the facility to treat an infection timely could have brought about sepsis or even death for this resident. An interview on 02/01/24 at 8:45 AM with the Administrator confirmed that it is the expectation that the Wound Nurse Practitioner notify the Director of Nursing or Assistant Director of Nursing ADON if there is a problem with wounds and if she sees her orders are not being implemented. An interview on 02/01/24 at 9:50 AM with Assistant Director of Nursing confirmed that the Wound Nurse Practitioner did not make her aware that the x-ray she ordered on 09/20/23 had not been completed. The ADON stated that around that time in December that she was helping with the wound care because they had terminated the nurse prior for not doing her job and that she found the x-ray order on 12/27/23 had not been done on an audit that she had completed. The ADON confirmed that she immediately called the doctor and got the x-ray ordered and made both the Wound Nurse Practitioner and the Facility Nurse Practitioner aware that the x-ray order had not been completed. She confirmed that the Wound Nurse Practitioner should have reported that the x-ray was not followed through to her or the Director of Nursing immediately, but that she failed to do that. An interview on 02/01/24 at 10:15 AM with RN #3, Unit Manager confirmed that she was not aware that there was an order for an x-ray on Resident #269 on 09/20/23. RN #3 confirmed that new orders are reviewed each morning in their stand-up meeting and that she never saw an order come through for Resident #269 for an x-ray. Review of the face sheet for Resident #269 revealed that the resident was admitted to the facility on [DATE] with a diagnosis of Heart Failure, Local Infection of the skin and subcutaneous tissue, Pressure Ulcer of Sacral Region Stage 4, Rhabdomyolysis, and chronic kidney disease. A review of the Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 07 which indicated Resident #269 was cognitively impaired. The facility submitted the following acceptable Removal Plan on 2/5/24: Brief Summary of Events: On 1/31/2024 at 4:50 pm State Agency (SA) notified the Executive Director (ED) of 5 Immediate Jeopardy's (IJ's) related to F 600 Free from Abuse and Neglect, F 686 Treatment /Services to Prevent /Heal Pressure Ulcers, F 684 Quality of Care, F 726 Competent Nursing Staff and F 658 services Provided Meet Professional Standards. An Immediate jeopardy template was provided to the Executive Director (ED) on 1/31/2024 at 4:50 pm by the State Agency (SA). The facility failed to follow the physician's orders for wound care, failed to provide training and competency skills to the Treatment Nurse to ensure she had adequate knowledge to provide care and services to residents with skin concerns and pressure ulcers and failed to provide the treatment and services to promote healing of pressure ulcer wounds and diabetic ulcers which resulted in delay of healing of pressure ulcers and diabetic ulcers for Resident #52, Resident #103, and Resident #269. Immediate Action Plan: Treatment Nurse was suspended by the Executive Director on 2/1/2024 at 1:00 pm and terminated on 2/1/2024 at 6:43 pm. Treatment Nurse was reported to the Mississippi Board of Nursing on 2/1/2024 at 6:32 pm related to not following professional standards of practice. On 1/31/2024 Assistant Director of Nurses initiated education with 5 Housekeeping employees, 6 Therapist, 4 Dietary employees, 8 Certified Nursing Assistants, 6 office staff, 5 Licensed Practical Nurses and 5 Registered Nurses on Abuse and Neglect with emphasis on following physician orders and timely implementation and documentation of medical treatments of wounds and diabetic ulcers. Employees will be educated prior to accepting an assignment. New hires will be in-serviced on Abuse and Neglect during orientation. Employees will be educated prior to accepting an assignment. On 1/31/2024 the Regional Director of Clinical Services (RDCS) conducted a verbal review of clean dressing change competency with return verbalization from Treatment Nurse RN, RN #1, RN #2, RN #3, RN #4, and Assistant Director of Nurses. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 5 Registered Nurses and 6 Licensed Practical Nurses on Medication Administration and Documentation. Employees will be educated prior to accepting assignments. On 1/31/2024 at 5:40 pm the Regional Director of Clinical Services (RDCS) conducted education with the Treatment Nurse on Skin and Wound Guidelines, Medication Administration and Documentation, Abuse and Neglect, and Following Physician Orders and Clean Dressing Change checklist was reviewed verbally with return verbalization. Education included following the physician order when administering treatments, administering treatment timely, nurse that administers treatment is to sign the electronic administration record that treatment was administered, ensure all skin impairments and pressure ulcers have a physician order for treatment. Employees will be educated prior to accepting assignments. On 1/31/2024 at 1:08 pm Resident #52 received new physician orders to clean the stage 3 pressure ulcer of the coccyx with Dakin's, pat dry, apply Santyl to the wound bed at nickel thickness, cover with foam bordered dressing every day. PRN order for soilage\dislodgement. Resident #103 received new physician orders on 1/31/2024 at 2:02 pm to clean diabetic ulceration between 3rd through 5th toes on left foot with normal saline, pat dry, thread xeroform between toes, cover with dry dressing, wrap with kerlix, and secure with tape every day. PRN order for soilage/dislodgement. Order for clean left great toe blister site with normal saline, pat dry, apply Santyl to wound bed at nickel thickness, cover with dry gauze or ABD pads, wrap with kerlix, and secure

**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 received the necessary care and treatment for pressure ulcers to prevent complications and worsening of wounds for three (3) of five (5) residents reviewed for pressure ulcers. Resident #52, Resident #103 and #269 The facility's failure to provide necessary care and treatments for pressure ulcers caused worsening of pressure ulcers for Resident #52, Resident #103, and Resident #269 and placed all other residents at risk for skin breakdown in a situation with the likelihood of 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 9/20/23 when Resident #269, who had an existing wound to coccyx was seen by the Wound Nurse Practitioner (NP) and an X-ray was ordered of the coccyx to rule out Osteomyelitis. The order for the X-Ray was not performed until 12/27/23, (almost 3 months later) which caused the residents coccyx wound to worsen. The facility Administrator was notified of the IJ and SQC and was presented with an IJ template on 1/31/24 at 4:50 PM. The facility provided an acceptable Removal Plan, in which they alleged all corrective action to remove the IJ was completed on 2/01/24 and the IJ was removed as of 02/02/24. The SA validated the Removal Plan on 2/06/24 and determined the IJ and SQC was removed on 2/02/24. Therefore, the scope and severity for 42 CFR 483.25(b)(1)(i)(ii) Pressure Ulcers was lowered from a K to a E, 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: CROSS REFERENCE F600, F658, F726 Record review of the facility policy titled Skin and Wound with a revision date of 1/24/22 revealed under, Policy: To provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure injuries .Pressure Injury Prevention: . 3. Nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record . Skin Impairment Identification: 1. Document presence of skin impairment(s) / new skin impairments(s) when observed and weekly until resolved 2. Nurse to report changes in skin integrity to the physician/physician extender, resident /resident representative and document in the medical record 3. Develop resident centered interventions and document on the plan of care and the Nurse Aide Kardex .5. Monitor residents' response to treatment, modify as indicated . Resident # 52 Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order dated 12/29/23, Wound Care: Cleanse stage 4 pressure ulcer to coccyx with normal saline, pat dry with gauze, apply Santyl to wound bed and cover with foam bordered dressing daily with a D/C (discontinue) date of 1/12/24, which revealed there was not an active wound care physician's order for the pressure wound to the coccyx after 1/11/24. An observation of Resident #52's wound care with the Wound Nurse on 1/30/24 at 3:38 PM revealed, there was not a wound dressing to the resident's coccyx upon initiating the wound care. The coccyx wound bed was 90% yellow, adherent slough, 10% granulation tissue with redness and maceration to the wound edges. The Wound Nurse cleansed the wound with Dakin's solution, patted dry, applied a layer of Santyl and covered with a foam dressing. Record review of Resident #52's Order Summary Report revealed an order dated 1/18/24, Wound Care: Clean unstageable pressure ulcer of left heel with Dakins, pat dry, apply nickel thickness Santyl, apply hydrogel, cover with foam bordered dressing, wrap with kerlix, and secure with tape daily and as needed for soilage/dislodgement . Continued observation on 1/30/24 at 3:38 PM of the left heel pressure wound revealed, 100% adhering brown eschar to the wound bed. Slight redness observed to the peri-wound. The Wound Nurse stated the treatment orders for the left heel were to cleanse the wound with Dakin's solution, pat dry, apply a layer of Santyl, cover with foam and wrap with gauze wrap. An interview with the Wound Nurse on 1/30/24 at 3:45 PM confirmed that the resident did not have a dressing to the coccyx area and that urine and stool could get inside the wound and cause infection and delay the healing of the wound. She revealed the purpose of having the dressing over the wound was to keep bacteria out and provide a moist environment for healing. She revealed that she did not apply the prescribed hydrogel to the left heel wound as ordered. She revealed the hydrogel was ordered along with Santyl to debride the adherent eschar and that the resident recently completed antibiotics due to the left heel wound being infected. She stated they have a Wound Nurse Practitioner (NP) that visits the resident every Wednesday and measures the wounds and prescribes the treatment orders. She stated the NP wanted the resident to see a general surgeon due to the left heel not showing any progress of healing or improvement, and a recent X-ray of the heel could not rule out osteomyelitis. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order dated 12/29/23, Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to coccyx topically everyday shift for Stage 4 Pressure Ulcer initialed as performed by the Wound Nurse two (2) of the thirty-one days in January 1/30 and 1/31. All the other days were initiated as performed by other facility nurses. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed, an order dated 12/29/23, Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to left heel topically everyday shift for DTI (deep tissue injury) initialed as performed by the Wound Nurse two (2) of the thirty-one days in January 1/30 and 1/31. All the other days were initialed as performed by other facility nurses. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order dated 12/28/23, Santyl External Ointment 250 UNIT/GM (grams) (collagenase) Apply to Coccyx topically as needed for Soling or Dislodgement not documented as administered for the month of January. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order dated 12/28/23, Santyl External Ointment 250 UNIT/GM (grams) (collagenase) Apply to Left Heel topically as needed for Soling or Dislodgement not documented as administered for the month of January. Record review of the Wound Diagnostic Report for Resident #52 dated 1/12/24, revealed a culture and sensitivity was performed of the left heel and under Summary Report Organisms identified, were Staphylococcus aureus and Enterococcus faecalis with Moderate growth. Record review of Resident #52's Order Summary Report revealed an order dated 1/15/24, Obtain Xray of left heel r/t (related to) increased pain and clinical symptoms of osteoporosis. Record review of the Radiology Report dated 1/20/24 for Resident #52 revealed under, Conclusion: Subtle cortical bone loss at the dorsal lateral aspect of the calcaneus which may represent early osteomyelitis Record review of the Weekly Wound Report: Pressure Injury for the Week of 11/08/23 for Resident #52 revealed, Facility Acquired Date and Stage . 11/10/23 Stage 2 Measurements 2.5 cm (centimeters) x 3.5 cm (centimeters) . Record review of the Weekly Wound Report: Pressure Injury for the Week of 1/24/24 for Resident #52 revealed, Facility Acquired Date and Stage . 11/10/23 Stage 2 . Visualized Stage UNS (unstageable) .Measurements 3.5 cm (centimeters) x 6.2 cm (centimeters) .Lt (left) heel . Record review of Resident #52's Pressure Ulcer Wound Rounds dated 12/28/23 revealed, Site Left heel . Type Pressure . Length 2.5 Width 5 Depth 0 . Stage Suspected Deep Tissue Injury Also revealed, Site Coccyx . Type Pressure . Length 6 Width 4 Depth 0 . Stage IV . Record review of Resident #52's Physician Order Details dated 1/24/24 revealed, Wound #1 Left Heel . Clean wound with ¼ (one-fourth) Strength Dakins . Enzymatic Debriding Agent Apply nickel thickness Santyl to the wound bed only. Apply Hydrogel . Other - Foam pad, kerlix .Change dressing Every day and as needed Wound #2 Coccyx . Clean wound with ¼(one-fourth) strength Dakins. Enzymatic Debriding Agent Apply nickel thickness Santyl to the wound bed only. Apply duoderm or hydrocolloid - or FBD (foam bordered dressing) . Change dressing every day and as needed . Record review of the Wound Nurse Practitioner (NP) visit notes for Resident #52 dated 1/24/24, The wound to the left heel remains unstageable due to eschar Will continue orders for Santyl and add hydrogel in an attempt to loosen the slough The patient has been referred to Proper Name for further evaluation due to HX (history) of amputation, unable to manage pain for deep debridement A recent Xray indicated subtle cortical bone loss at the dorsal lateral aspect of the calcaneus which may represent early Osteomyelitis. Record review of the Wound Nurse Practitioner (NP) visit notes for Resident #52 dated 1/24/24, Wound #1 Left Heel is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3.5 cm (centimeters) length x 6.2 cm (centimeters) width with no measurable depth, with an area of 21.7 Sq (square) cm (centimeters) Wound #2 Coccyx is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 5.2 cm (centimeters) length x 3.6 cm (centimeters) width x 0.2 cm (centimeters) depth, with an area of 18.72 sq (square) cm (centimeters) and volume of 3.744 cubic cm (centimeters). Record review of the Wound Nurse Practitioner (NP) visit notes for Resident #52 dated 1/3/24 revealed, Wound #1 Left Heel is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2 cm (centimeters) length x 4.5 cm (centimeters) width x 0.1 cm (centimeter) depth, with an area of 9 sq (square) cm (centimeter) and volume of 0.9 cubic cm (centimeters) There is a scant amount of yellow drainage noted which has odor Wound bed has no, granulation, 51-75% slough, 1-25%eschar, no epithelialization present. The wound is deteriorating Wound #2 Coccyx is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements 8.2 cm (centimeters) length x 2.3 cm (centimeters) depth, with an area of 18.86 sq (square) cm (centimeters) and a volume of 3.772 cubic cm (centimeters) There is a small amount of sero-sanguineous drainage noted which has no odor The wound margin is well defined Wound bed has no, granulation, 76-100% slough; no eschar and no epithelialization present. Record review of the Weekly Skin Integrity Review for Resident #52 dated 1/12/24 revealed, Coccyx pressure ulcer . Left heel unstageable and under, Notes: Tx (treatment) in process. Record review of the Weekly Skin Integrity Review for Resident #52 dated 1/19/24 revealed, Coccyx Pressure Ulcer . Left heel Unstageable and revealed under, Notes: Continue Current Tx (treatment). Record review of the Weekly Skin Integrity Review for Resident #52 dated 1/26/24 revealed, Coccyx pressure . Left heel pressure and revealed under, Notes: Tx (treatment) in progress) Record review of the Braden Scale for Predicting Pressure Sore Risk for Resident #52 dated 12/27/23 revealed a Braden Score of 14, indicating the resident is at Moderate Risk for pressure wound development. Record review of the admission Record revealed the facility admitted Resident #52 on 3/8/22 with medical diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Acute on Chronic Systolic (congestive) Heart Failure, Peripheral Vascular Disease, pain and Pressure Ulcer of Left Heel, Stage 2. Record review of Resident #52's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 11, which indicates the resident is moderately cognitively impaired. Also revealed under section M, the current number of Unhealed Pressure Ulcers/Injuries at Each Stage, one (1) Stage 2 pressure ulcer was marked. Resident #103 An observation and interview on 01/30/24 at 8:19 AM, with Resident #103 revealed him lying in bed, awake and alert. He stated he had a wound on his bottom and on his foot that caused him pain. An interview with the Wound Nurse on 1/30/24 at 3:50 PM revealed Resident #103 was admitted to the facility with a pressure wound on the left heel that has not showed improvement. She revealed an appointment had been made with a general surgeon due to the wounds not healing and the resident's history of previous amputation of the right great toe due to a necrotic wound. An observation of wound care for Resident #103, with the Wound Nurse on 1/30/24 at 3:55 PM, revealed she removed the soiled dressing from the wounds on the left foot. Record review of the Treatment Administration Record (TAR) for Resident #103 revealed there was not a wound care order for the ulcer on the left great toe or the breakdown between the inner toes. Record review of the Order Summary Report for Resident #103 revealed there was not a Physician Order for wound care to the left great toe or in between the toes on the left foot. Record review of Resident #103's Order Summary Report revealed an order dated 7/8/23, Weekly skin sweeps on Tuesday 3-11 every evening shift every Tue (Tuesday) . Record review of the Weekly Skin Integrity Review for Resident #103 dated 1/23/24 revealed under, Notes: wounds to right great toe, left heel, preexisting wound orders noted. wounds in-between left 3rd,4th and 4th, 5th toes. treatment nurse aware Record review of the Weekly Skin Integrity Review for Resident #103 dated 1/30/24 revealed under, Notes: wounds to right great toe, left heel, preexisting wound orders noted. Wounds in-between left 3rd,4th and 4th,5th toes. Record review of the Order Summary Report for Resident #103 revealed an order dated 1/25/24, Appointment with Proper Name (General Surgeon) 2/13/24 @ (at) 0800. One time only for NON-HEALING WOUNDS for 2 days . Record review of Resident #103's Doppler Report dated 12/19/23 revealed under, Conclusion: Moderate peripheral vascular disease in the left lower extremity. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 12/28/23, Wound Care: Clean Left heel stage 3 pressure ulcer with normal saline, pat dry with gauze, apply Medi honey to wound bed, cover with foam dressing, wrap with kerlix and secure with tape daily with a D/C (discontinue) date of 1/18/24. The order was not initiated as completed by the Wound Nurse any of the 18 days in January the order was active. The wound care was not documented as administered on 1/22 and 1/28, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated, 12/28/23, Wound Care: Cleanse right foot great toe amputation site with soap and water and apply A&D ointment daily initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22 and 1/28, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 12/15/23, Wound Care: Cleanse shearing abrasion to left buttock with NS (normal saline), apply triad daily initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22 and 1/28, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 1/19/24, Wound Care: Clean left heel stage 3 pressure ulcer with normal saline, pat dry with gauze, apply Santyl to wound bed at nickel thickness, cover with foam dressing, wrap with kerlix and secure with tape daily initialed as completed by the Wound Nurse two (2) of the 13 days that the order was active. The other dates were initialed as completed by other facility nurses. The dates of 1/22 and 1/28 have no initials to support wound care was performed, which was a total of 2 missed treatments. Record review of the Progress Note Details dated 12/27/23 for Resident #103 revealed under, There is also a 0.8 × 1.5 × 0.0 bruised area on the left great toe that was noted at his most recent visit . Also revealed under, General Notes: Will continue to monitor left great toe. Record review of the Progress Note Details dated 1/03/24 for Resident #103 revealed under, Wound Assessment(s) . Wound #3 Left Toe blister and has received a status of Not Healed. Initial wound encounter measurements are 1 cm (centimeter) length x 1.2 cm (centimeter) width with no measurable depth, with an area of 1.2 sq (square) cm (centimeters). Also revealed under, General Notes: Will continue to monitor left great toe. Staff to notify of any changes. Record review of the Physician Order Details for Resident #103 dated 1/10/24 revealed under, Wound #3 Left Toe . Care of Wound: Apply Xeroform cover with Foam Bordered Dressing . Change dressing Every day and as needed . Also revealed under, Progress Note Details . Wound #3 is a Partial Thickness Blister and has received a status of Not healed. Subsequent wound encounter measurements are 0.8 cm (centimeter) length x 1.5 cm (centimeter) width x 0.1 cm (centimeter) depth, with an area of 1.2 cubic cm (centimeter) There is a scant amount of sero-sanguineous drainage noted which has no odor. Record review of the Physician Order Details for Resident #103 dated 1/24/24 revealed, Wound #3 Left Toe . Care of Wound: Enzymatic debriding agent nickel thickness Santyl to the wound bed only. Cover dressing with dry gauze and wrap with Kling/kerlix. Do not put tape directly on the skin. Other: D/C (discontinue) xeroform to left great toe . Thread toes with xeroform on left foot Secure dressing with tape . Change dressing every day and as needed. Also revealed under, Progress Note Details . The bruised/blood blister area to the left great toe is now covered in eschar with bogginess palpated. There are also scattered wounds to the 4th and 5th toes of recent onset Recent amputation to right great toe. Scattered wounds noted to 4th and 5th toes as well on left foot of recent onset with worsening of left great toe. Refer to Proper Name (General Surgeon) for further evaluation 1/25/24: Order for Clindamycin 300 mg (milligrams) 1 (one) po (by mouth) bid (twice daily) x 10 days. Record review of the admission Record for Resident #103 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Encounter for Orthopedic Aftercare Following Surgical Amputation, acquired absence of Right Great Toe, Nontraumatic Subarachnoid Hemorrhage Left Middle Cerebral Artery, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Pressure Ulcer of Left Heel, Stage 3, and Pain. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/23 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicates Resident #103 is cognitively intact. Also revealed under section M, diabetic foot ulcer(s) were not checked for the MDS look back period. An interview with the Wound Care Nurse on 1/31/24 at 9:45 AM revealed she had worked at the facility for 3 years. She stated she had been back in the Wound Nurse position since January 1, 2024. She revealed prior to her taking the position, they had another wound nurse who worked for about 3 months and resigned, leaving the facility in a bind due to her lack of inconsistent wound charting. She revealed all the wound documentation was behind, and she had to catch things up when she transferred to the position. She revealed that the facility was sending the residents with wounds out to the Proper Name hospital but changed over to Proper Name Wound clinic on Sept. 1, 2023. She stated all the wounds were seen in the facility by the Wound Nurse Practitioner (NP) once weekly on Wednesdays and the Wound NP did not give any orders the day she visited but tells her what she wants to be changed up or makes recommendations for the treatments, and she will send the facility the progress notes the following Friday or Monday. An interview with the Wound Care Nurse on 1/31/24 at 9:45 AM also revealed that Resident #52's left heel pressure wound developed in the facility and was initially a Stage 2 blister and was now unstageable. She stated she was unsure what interventions were put in place to prevent skin breakdown since she had only been in the wound position for a month. She revealed that she worked Monday-Friday and had been doing all the wound care in the facility on those days. She explained that on the weekends, she leaves a list of the residents with wounds so that the nurses will know whom to perform wound care on. She confirmed that her initials were not listed on Resident #52's Treatment Administration Record (TAR) for the month of January 2024 except for 1/30 and 1/31. She stated that she did do the treatments but did not sit down to initial them until the evenings and occasionally the other nurses had signed off on them already. She revealed that the Medication Cart Nurses did help her with holding certain residents, so they could have gone in and signed the TAR before she got to it. She revealed that she was not aware that Resident #52's treatment order for the coccyx pressure wound had been discontinued on 01/12/24. She explained that she had no idea who would have discontinued the treatment order out of the system and acknowledged that she did not follow the TAR for treatment orders, or she would have caught the error. An interview with the Wound Care Nurse on 1/31/24 at 9:45 AM also revealed that Resident #103's left great toe wound developed as a dry piece of skin that has continued to worsen, with new ulcers that developed in between the toes. She revealed the Wound NP visited him last week to assess the wound and made the recommendation to apply xeroform gauze and start clindamycin for infection, but she did not enter the orders into the system. She confirmed that she would be the person responsible for implementing the orders and that she goes ahead and starts any new treatment recommendations but does not put the order into the system because once she received the NP progress note, she may have changed something up with the wound care. She explained that she was instructed by the Wound NP that the clindamycin needed to be approved by nephrology, since the resident was on dialysis, so the resident was not started on the clindamycin when it was originally ordered on 1/24/24. The Wound Nurse confirmed that she never called the dialysis unit to get the antibiotic order approved. She revealed the wound was not cultured but did show clinical signs of infection and that all medications that the Wound NP recommends must be approved by the Primary Care Practitioner (PCP). She confirmed that she did the treatment on Resident #103's left toes without an active order in the computer and stated, I don't get her notes until a week later, so I can't put in an order, if I don't have one. She confirmed that a verbal order from the NP should be immediately acted upon and that she was given a verbal order from the NP. She revealed not implementing physician orders immediately was a delay in treatment of the wound and treating the infection. She revealed that delay of treatment could result in possible infection, sepsis, or amputation for both Resident #52 and #103. She confirmed that other nurses had initialed Resident #103's January Treatment Administration Record (TAR) and she revealed she was the person responsible for signing since she completed the treatments. An interview with Licensed Practical Nurse (LPN) #4 on 2/01/24 at 11:05 AM revealed that she had been doing the treatments for Resident #52 on the weekends and some during the weekdays. She explained that the facility had not had a consistent or set Wound Nurse in months. She revealed that the facility just hired a new Wound Nurse for the weekends, but she had not started yet. She explained that the current Monday through Friday Wound Nurse had been out some, and the nurses had been told that she was not starting full time until February. She confirmed that there were days when the treatments had not been signed off on by the Wound Nurse and the Medication nurses felt responsible for signing them off because they couldn't have things not completed on the TAR at the end of their shift. She explained that there had been times in the past month when the medication nurses were told to do all the wound care because the Wound Nurse was behind and had orders and documentation to complete. LPN #4 explained that she was working this past weekend (1/27 and 1/28), so she went to the Wound Nurse on Thursday 1/25/24 because she saw that Resident #52's coccyx order had been discontinued in the computer. She revealed that she was told by the Wound Nurse that the order had been discontinued and not to worry about it. She explained that the Wound Nurse never checked in the computer system when she asked her or got up from what she was doing at the time, she simply stated it had been discontinued. She revealed that the order to apply Santyl to the coccyx continued to come up on the TAR, so she applied Santyl to the wound on the coccyx, but did not apply a cover dressing because it was not ordered. She revealed that she was confused because she knew the resident did have a treatment order and all of a sudden, it stopped. She revealed that even when she followed behind the Wound Nurse the last couple of weeks, Resident #52 never had a dressing on his coccyx. LPN #4 stated when she said something again to the Wound Nurse about the wound not having a dressing, she stated, It's been discontinued and acted like it wasn't a big deal. LPN #4 explained that she knew the wound should be covered to keep out urine and feces, because the resident was incontinent, which could cause infection and slow the healing of the wound. She stated that she had never been given a list or left a list of the residents with wounds and treatments for the weekend. She explained that this past Sunday, 1/28/24 they didn't find out that they didn't have a Wound Care Nurse until 1PM and her shift was over at 3PM and she wasn't sure who did the wound care that day. An interview with the Assistant Director of Nursing (ADON) on 1/31/24 at 10:05 AM revealed that the facility had not had a consistent Wound Care Nurse for the past 6 months. The ADON stated that she filled in for the Wound Nurse position for about a month until the current Wound Nurse could transfer from the night shift position. The ADON stated that things were behind as far as documentation on the facility wounds, and the Wound Nurse had to get all the information up to date. She revealed that she had not had any concerns regarding the Wound Nurse and felt as if she did a good job. She confirmed that the Wound Nurse had not had any wound care training after switching from the night shift supervisor role to the wound care role in January. She revealed that the Wound Nurse brought a list of the wounds to the last Quality Assurance and Performance Improvement (QAPI) meeting held this month, where the wounds were discussed. She revealed that the facility just QAPI'd the wounds back in December 2023 after the other Wound Nurse left and all the orders were compared to the NP orders versus the Treatment Administration Record (TAR) and verified accuracy by 12/27/23. She confirmed that Resident #52's treatment order for the coccyx had been discontinued on 1/12/24 unintentionally by a staff member. She confirmed that she was not aware that the Wound Nurse was not utilizing the TAR to complete the wound care each day that she would have caught that the order was discontinued if she had looked at the TAR and signed off after the treatment was provided. She revealed she was not sure how the nurses on the weekends were providing wound care. A telephone interview with the Wound Nurse Practitioner on 1/31/24 at 3:40 PM revealed she rounds on all the facility wounds every Wednesday and during her visits she makes recommendations for wound care, but the facility does not receive the progress note until Friday evening when it's faxed over, but that when she makes rounds with the Wound Nurse she gives verbal orders. She revealed some of her recommendations may be delayed because certain orders must go through the resident's primary care provider (PCP) or dialysis, such as antibiotics or pain medication if the resident is on dialysis. She confirmed she was aware of the delay in antibiotics that were ordered on 01/24/24 for Resident #103 because it had to be approved with the PCP due to high risk of drug nephrotoxicity but she assumed that the antibiotic order had been implemented by now, and confirmed that she had not been made aware that the resident still did not have an order for an antibiotic. She stated that she was not made aware that Resident #52's coccyx treatment order had been discontinued on 1/12/24. She stated that lack of a dressing to the coccyx wound could cause delay in healing and infection. She revealed that she had not been made aware of any concerns regarding the Wound Nurse not performing her duties or following physician orders. She confirmed that if the treatments were not done as ordered, the wounds would deteriorate. An interview with the Assistant Director of Nursing (ADON) on 2/01/24 at 11:25 AM revealed she had not been made aware of any concerns from the Medication Nurses related to wound care. She explained, to her knowledge, the Medication Nurses had never been asked to perform treatments, so the Wound Nurse could catch up on orders or documentation. She confirmed that the nurses should not sign off on treatments that the Wound Nurse performed, and they had never been told to do so. She explained that she had never pulled the TAR to check and see who signed off on the treatments. She explained that she felt the Wound Nurse got caught up in the day-to-day processes and just didn't make sure things were done. She revealed that she was not aware of a list that was left on the weekends to know which residents needed wound care. She stated the wound care should be administered from the TAR and signed off when completed. She explained that the facility did have a call[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to provide training and competency skills to the treatment nurse to ensure she had adequate knowledge to provide care and services to residents with skin concerns and pressure ulcers for two (2) of five (5) residents reviewed with wounds. Resident #52 and Resident #103 The facility's failure to ensure licensed staff had appropriate training and competency skills to provide wound treatments put Resident #52 and Resident #103 and all other residents who are at risk for skin breakdown at risk for serious harm, serious injury, serious impairment, or death. The State Agency (SA) determined the situation to be an Immediate Jeopardy (IJ) that began on 12/27/23 when Resident #103 developed a bruised area to the left great toe that deteriorated and became a bruised/blood blister covered in eschar (dead tissue) by 1/24/24. The facility failed to act upon verbal orders resulting in delay in treatment, failed to transcribe these orders into the medical record, and provide treatment for Resident #103's wounds according to the Wound Nurse Practitioner's orders. The facility Administrator was notified of the Immediate Jeopardy (IJ) and was presented with an IJ template on 1/31/24 at 4:50 PM. The facility provided an acceptable Removal Plan, in which they alleged all corrective action to remove the IJ was completed on 2/01/24 and the IJ was removed as of 02/02/24. The Survey Agency (SA) validated the Removal Plan on 2/06/24 and determined the Immediate Jeopardy (IJ) was removed on 2/02/24. Therefore, the scope and severity for 42 CFR 483.35(a)(3)(4) Nursing Services, was lowered from a K to an E, 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: The facility provided documentation on letter head, undated, revealed Skills Competency Assessment is utilized for evaluation of staff competency and training. Resident # 52 On 01/29/24 at 12:04 PM, an observation and interview with Resident #52 revealed him sitting in a wheelchair in his room. The resident stated he had a wound on his bottom and his left heel. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order dated 12/29/23, Wound Care: Cleanse stage 4 pressure ulcer to coccyx with normal saline, pat dry with gauze, apply Santyl to wound bed and cover with foam bordered dressing daily with a D/C (discontinue) date of 1/12/24, which revealed there was not an active wound care physician's order for the pressure wound to the coccyx after 1/11/24. On 1/30/24 at 3:38 PM, an observation of Resident #52's wound care with the Wound Nurse revealed, there was not a wound dressing to the resident's coccyx upon initiating the wound care. The Wound Care nurse provided wound care to the coccyx using a discontinued order dated 1/12/24. An observation of the left heel pressure wound revealed the Wound Nurse failed to provide the correct wound care to the left heel per the current physician orders effective 1/19/24. An interview with the Wound Nurse on 1/30/24 at 3:45 PM, confirmed that the resident did not have a dressing to the coccyx area She revealed that she did not apply the prescribed hydrogel to the left heel wound as ordered. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order for Santyl to the coccyx with a start date of 12/29/23 was initialed every day however,the order for wound care utilizing Santyl to the coccyx was discontinued on 1/12/24. The TAR was initialed as performed by the Wound Nurse for two (2) of the thirty-one days in January on 1/30/24 and 1/31/24. All the other days were initialed as performed by other facility nurses. Record review of Resident #52's January 2024 TAR revealed, an order dated 12/29/23, Santyl External Ointment . Apply to left heel topically everyday shift for DTI (deep tissue injury). This was initialed as performed by the Wound Nurse two (2) of the thirty-one days in January 1/30 and 1/31. All the other days were initialed as performed by other facility nurses. Record review of Resident #52's Order Summary Report revealed an order dated 1/15/24, Obtain Xray of left heel r/t (related to) increased pain and clinical symptoms of osteoporosis. Record review of the Radiology Report dated 1/20/24 for Resident #52 revealed under, Conclusion: Subtle cortical bone loss at the dorsal lateral aspect of the calcaneus which may represent early osteomyelitis There was a four (4) day delay in obtaining the ordered x-ray for Resident #52's left heel. Record review of Resident #52's Physician Order Details dated 1/24/24 revealed orders for Wound #1 Left Heel and Wound #2 Coccyx . These orders were not transcribed to the TAR. Record review of the admission Record revealed Resident #52 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Peripheral Vascular Disease, Pain and Pressure Ulcer of Left Heel, Stage 2. Resident #103 An observation and interview on 01/30/24 at 8:19 AM, with Resident #103 revealed him lying in bed, awake and alert. He stated he had a wound on his bottom and on his foot that caused him pain. An interview with the Wound Nurse on 1/30/24 at 3:50 PM, revealed Resident #103 was admitted to the facility with a pressure wound on the left heel that has not shown any progress with healing and the resident has also developed other areas on the left great toe and some areas of breakdown between the toes on the left foot. She revealed the left toe started out as a blood blister and had worsened over the past couple of weeks and now are eschar covered. She stated the left great toe had been debrided by the Wound Nurse Practitioner (NP), but necrotic tissue returned. She revealed an appointment had been made with a general surgeon due to the wounds not healing and the resident's history of previous amputation of the right great toe due to a necrotic wound. An observation of wound care for Resident #103, with the Wound Nurse on 1/30/24 at 3:55 PM, revealed she removed the soiled dressing from the wounds on the left foot. The wound nurse cleaned the wound to the left great toe and in between the areas of the toes with normal saline, patted dry, and applied xeroform gauze to all the areas and wrapped with a gauze wrap, secured with tape. Record review of the Progress Note Details dated 12/27/23 for Resident #103 revealed, There is also a 0.8 × 1.5 × 0.0 bruised area on the left great toe that was noted at his most recent visit .Will continue to monitor left great toe . Record review of the Progress Note Details dated 1/03/24 for Resident #103 revealed under, Wound Assessment(s) . Wound #3 Left Toe blister and has received a status of Not Healed. Initial wound encounter measurements are 1 cm (centimeter) length x 1.2 cm (centimeter) width with no measurable depth, with an area of 1.2 sq (square) cm (centimeters). Also revealed under, General Notes: Will continue to monitor left great toe. Staff to notify of any changes . Record review of the Treatment Administration Record (TAR) for Resident #103 revealed there was not a wound care order for the wound on the left great toe or the breakdown between the inner toes. Record review of the Order Summary Report with active orders as of 1/31/24 for Resident #103 revealed there was not a Physician Order for wound care to the left great toe or in between the toes on the left foot. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 12/28/23, for wound care to the left heel stage 3 pressure ulcer with a D/C (discontinue) date of 1/18/24. The order was not initialed as completed by the Wound Nurse any of the 18 days in January the order was active. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated, 1/19/24 for wound care to the left heel stage 3 pressure ulcer. The wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated, 12/28/23 for the right foot great toe amputation site revealed the TAR was initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of Resident #103's TAR for January 2024 for sheering abrasion to the left buttocks revealed an order dated 12/15/23 was only initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of the admission Record for Resident #103 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Encounter for Orthopedic Aftercare Following Surgical Amputation, acquired absence of Right Great Toe, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Pressure Ulcer of Left Heel, Stage 3, and Pain. An interview with the Wound Care Nurse on 1/31/24 at 9:45 AM, revealed she had worked at the facility for 3 years, first starting out as the Wound Nurse, then transferred over to the night shift supervisor and filling in on the medication cart. She stated she had been back in the Wound Nurse position since January 1, 2024. She revealed prior to her taking the position, they had another wound nurse who worked for about 3 months and resigned, leaving the facility in a bind due to her lack of inconsistent wound charting. She revealed all the wound documentation was behind, and she had to catch things up when she transferred to the position. She revealed that the facility was sending the residents with wounds out to the Proper Name hospital but changed over to Proper Name Wound clinic on Sept. 1, 2023. She stated all the wounds were seen in the facility by the Wound Nurse Practitioner (NP) once weekly on Wednesdays and the Wound NP did not give any orders the day she visited but tells her what she wants to be changed up or makes recommendations for the treatments, and she will send the facility the progress notes the following Friday or Monday. She revealed there were times she did not get the Wound NP's Progress Note until a week later. She confirmed that she had access to the site where the Wound NP uploads the documents, and she could pull the progress notes after it was uploaded. She revealed that Resident #52's left heel pressure wound developed in the facility and was initially a Stage 2 blister and was now unstageable. She stated she was unsure what interventions were put in place to prevent skin breakdown since she had only been in the wound position for a month. She revealed that she worked Monday-Friday and had been doing all the wound care in the facility on those days. She explained that on the weekends, she leaves a list of the residents with wounds so that the nurses will know who to perform wound care on. She confirmed that her initials were not listed on Resident #52's Treatment Administration Record (TAR) for the month of January 2024 except for 1/30/24 and 1/31/24. She stated that she did do the treatments but did not sit down to initial them until the evenings and occasionally the other nurses had signed off on them already. She revealed that the Medication Cart Nurses did help her with holding certain residents, so they could have gone in and signed the TAR before she got to it. She revealed that she was not aware that Resident #52's treatment order for the coccyx pressure wound had been discontinued on 01/12/24. She explained that she had no idea who would have discontinued the treatment order out of the system and acknowledged that she did not follow the TAR for treatment orders, or she would have caught the error. She explained that Resident #103's left great toe wound developed as a dry piece of skin that has continued to worsen, with new ulcers that developed in between the toes. She revealed the Wound NP visited him last week to assess the wound and made the recommendation to apply xeroform gauze and start clindamycin for infection, but she did not enter the orders into the system. She confirmed that she would be the person responsible for implementing the orders and that she goes ahead and starts any new treatment recommendations but does not put the order into the system because once she received the NP progress note, she may have changed something up with the wound care. She explained that she was instructed by the Wound NP that the clindamycin needed to be approved by nephrology, since the resident was on dialysis, so the resident was not started on the clindamycin when it was originally ordered on 1/24/24. The Wound Nurse confirmed that she never called the dialysis unit to get the antibiotic order approved. She revealed the wound was not cultured but did show clinical signs of infection and that all medications that the Wound NP recommends must be approved by the Primary Care Practitioner (PCP). She confirmed that she did the treatment on Resident #103's left toes without an active order in the computer and stated, I don't get her notes until a week later, so I can't put in an order, if I don't have one. She confirmed that a verbal order from the NP should be immediately acted upon and that she was given a verbal order from the NP. She revealed not implementing physician orders immediately was a delay in treatment of the wound and treating the infection. She revealed that delay of treatment could result in possible infection, sepsis, or amputation for both Resident #52 and #103. She confirmed that other nurses had initialed Resident #103's January Treatment Administration Record (TAR) and she revealed she was the person responsible for signing since she completed the treatments. An interview with the Assistant Director of Nursing (ADON) on 1/31/24 at 10:05 AM, revealed that the facility had not had a consistent Wound Nurse for the past six (6) months. She revealed that the previous Wound Nurse worked for about 3 months and left without notice, although she was going to be terminated due to lack of documentation on the wounds. The ADON stated that she filled in for the Wound Nurse position for about a month until the current Wound Nurse could transfer from the night shift position. The ADON stated that things were behind as far as documentation on the facility wounds, and the Wound Nurse had to get all the information up to date. She revealed that she had not had any concerns regarding the Wound Nurse and felt as if she did a good job. She stated that the Wound Nurse did treatments when she was originally hired in 2019 for about a year, so they felt she had enough experience. She revealed she had no reason to suspect anything was wrong and confirmed that the Wound Nurse had not had any wound care training after switching from the night shift supervisor role to the wound care role in January. She revealed that the Wound Nurse brought a list of the wounds to the last Quality Assurance and Performance Improvement (QAPI) meeting held this month, where the wounds were discussed. She revealed that the facility just reviewed the wounds back in December 2023 after the other Wound Nurse left and all the orders were compared to the NP orders versus the TAR and verified accuracy by 12/27/23. She confirmed that Resident #52's treatment order for the coccyx had been discontinued on 1/12/24 unintentionally by a staff member. She confirmed that she was not aware that the Wound Nurse was not utilizing the TAR to complete the wound care each day.The ADON stated the Wound Nurse would have caught that the order was discontinued if she had looked at the TAR and signed off after the treatment was provided. She revealed she was not sure how the nurses on the weekends were providing wound care. A telephone interview with the Wound Nurse Practitioner on 1/31/24 at 3:40 PM, revealed she rounds on all the facility wounds every Wednesday and during her visits she makes recommendations for wound care, but the facility does not receive the progress note until Friday evening when it's faxed over, but that when she makes rounds with the Wound Nurse she gives verbal orders. She revealed some of her recommendations may be delayed because certain orders must go through the resident's primary care provider (PCP) or dialysis, such as antibiotics or pain medication if the resident is on dialysis. She confirmed she was aware of the delay in antibiotics that were ordered on 01/24/24 for Resident #103 because it had to be approved with the PCP due to high risk of drug nephrotoxicity but she assumed that the antibiotic order had been implemented by now, and confirmed that she had not been made aware that the resident still did not have an order for an antibiotic. She revealed that Resident #103 developed a dried blood blister to his left great toe that has deteriorated with a new breakdown in between the toes. She revealed that Resident #103 was a Diabetic, on dialysis and had a previous history of toe amputation, so she recommended a referral to a General Surgeon due to his high risk of the same outcome (amputation). She revealed she had not been made aware by the facility that Resident #103's left toe wound orders had not been acted upon by the Wound Nurse and the treatment ordered was not added in the charting system. She revealed that the current Wound Nurse just started, and she was aware that the wound care documentation was behind. She explained that Resident #52's heel wound was unchanged and had not shown any progress. She stated that she was not made aware that Resident #52's coccyx treatment order had been discontinued on 1/12/24. She stated that lack of a dressing to the coccyx wound could cause delay in healing and infection. She revealed that she had not been made aware of any concerns regarding the Wound Nurse not performing her duties or following physician orders. She confirmed that if the treatments weren't done as ordered, the wounds would deteriorate. An interview with Licensed Practical Nurse (LPN) #4 on 2/01/24 at 11:05 AM, revealed that she worked the Medication Cart on 7-3 shift. She revealed that she had been doing the treatments for Resident #52 on the weekends and some during the weekdays. She explained that the facility had not had a consistent or set Wound Nurse in months. She explained that the current Monday through Friday Wound Nurse had been out some. She confirmed that there were days when the treatments had not been signed off on by the Wound Nurse and the Medication nurses felt responsible for signing them off because they couldn't have things not completed on the TAR at the end of their shift. LPN #4 explained that she was working this past weekend (1/27/24 and 1/28/24), so she went to the Wound Nurse on Thursday 1/25/24 because she saw that Resident #52's coccyx order had been discontinued in the computer. She revealed that she was told by the Wound Nurse that the order had been discontinued and not to worry about it. She explained that the Wound Nurse never checked in the computer system when she asked her or got up from what she was doing at the time, she simply stated it had been discontinued. She revealed that the order to apply Santyl to the coccyx continued to come up on the TAR, so she applied Santyl to the wound on the coccyx, but did not apply a cover dressing because it was not ordered. She revealed that she was confused because she knew the resident did have a treatment order and all of a sudden, it stopped. She revealed that even when she followed behind the Wound Nurse the last couple of weeks, Resident #52 never had a dressing on his coccyx. LPN #4 stated when she said something again to the Wound Nurse about the wound not having a dressing, she stated, It's been discontinued and acted like it wasn't a big deal. LPN #4 explained that she knew the wound should be covered to keep out urine and feces, because the resident was incontinent, which could cause infection and slow the healing of the wound. She stated that she had never been given a list or left a list of the residents with wounds and treatments for the weekend. She explained that this past Sunday, 1/28/24 they didn't find out that they didn't have a Wound Care Nurse until 1 PM and her shift was over at 3 PM and she wasn't sure who did the wound care that day. An interview with the Assistant Director of Nursing (ADON) on 2/01/24 at 11:25 AM revealed she had not been made aware of any concerns from the Medication Nurses related to wound care. She explained, to her knowledge, the Medication Nurses had never been asked to perform treatments, so the Wound Nurse could catch up on orders or documentation. She confirmed that the nurses should not sign off on treatments that the Wound Nurse performed, and they had never been told to do so. She explained that she had never pulled the TAR to check and see who signed off on the treatments. She explained that she felt the Wound Nurse got caught up in the day-to-day processes and just didn't make sure things were done. She revealed that she was not aware of a list that was left on the weekends to know which residents needed wound care. She stated the wound care should be administered from the TAR and signed off when completed. She explained that the facility did have a call in Sunday 1/28/24 with the person who was suppose to do the wound care and stated the Director of Nursing (DON) would have been responsible for letting the Unit Managers know. An interview with the Director of Nursing (DON) on 2/1/24 at 4:35 PM, revealed that she and the Administrator (ADM) had spoken with the Wound Nurse about taking the Wound Care position when the job opened. She stated that the Wound Nurse had performed the treatments before in the facility when she was first hired, and she was knowledgeable, and she felt the Wound Nurse did a good job. She stated the Wound Nurse was full-time and worked Monday through Friday, so she wasn't sure why she told the medication cart nurses that she was just part time. She revealed that the only thing that had changed since the Wound Nurse did previous treatments was, they hired a new Wound Nurse Practitioner (NP). She revealed that the NP caused the delay because she sent the orders/progress notes over to the facility later in the week after she visited the residents. She confirmed that the Wound Care Nurse could have implemented the physician order when the NP visited because she was giving the verbal order, which could have been added as a verbal physician's order. She stated, If you are given an order, you should implement that order. She revealed the Wound Nurse should have signed the treatments after they were administered, just like with giving medication. She explained that she was not aware of the Wound Nurse telling the Medication Nurses that they were required to do treatments because she was behind with orders/documentation. She stated, She could have because I'm not out there on the floor. The DON revealed that the Wound Nurse had not been given any wound training or expectations since she accepted the Wound Care Nurse position in January and stated, We just trusted her that she knew what she was doing. She revealed all the nurses were checked off on clean dressing changes, but that was the extent of the wound care training that the facility did. Record review of Skills Competency Assessment: Clean Dressing Change revealed the wound nurse completed the training on hire (9/8/21). Record review of the Skills Competency Assessment: Clean Dressing Change dated 7/11/23 revealed under, . 26. Document in the Medical Record (TAR) (Treatment Administration Record) after completion of dressing change document findings in the nurse's notes and / or contact the physician when indicated . The Wound Nurse completed this training on 7/1/23. Record review of the Education In-service Attendance Record dated 5/1/23-5/5/23 revealed an in-service was conducted on wounds and skin sweeps and the Wound Care Nurse was in attendance. Record review of the facility's Performance Evaluation revealed the Wound Care Nurse read and signed acknowledgment of the job description and duties assigned dated 11/04/19, 9/07/21 and 9/7/23 which revealed, . 8. Complete required documentation in an accurate and timely manner was a requirement. The facility submitted the following acceptable Removal Plan on 2/5/24: Brief Summary of Events: On 1/31/2024 at 4:50pm State Agency (SA) notified the Executive Director (ED) of 5 Immediate Jeopardy's (IJ's) related to F 600 Free from Abuse and Neglect, F 686 Treatment /Services to Prevent /Heal Pressure Ulcers, F 684 Quality of Care, F 726 Competent Nursing Staff and F 658 services Provided Meet Professional Standards. An Immediate jeopardy template was provided to the Executive Director (ED) on 1/31/2024 at 4:50pm by the State Agency (SA). The facility failed to follow the physician's orders for wound care, failed to provide training and competency skills to the Treatment Nurse to ensure she had adequate knowledge to provide care and services to residents with skin concerns and pressure ulcers and failed to provide the treatment and services to promote healing of pressure ulcer wounds and other wounds which resulted in delay of healing of pressure ulcers and wounds for Resident #52, Resident #103, and Resident #269. Immediate Action Plan: Treatment Nurse was suspended by the Executive Director on 2/1/2024 at 1:00 pm and terminated on 2/1/2024 at 6:43 pm. Treatment Nurse was reported to the Mississippi Board of Nursing on 2/1/2024 at 6:32 pm related to not following professional standards of practice. On 1/31/2024 Assistant Director of Nurses initiated education with 5 Housekeeping employees, 6 Therapist, 4 Dietary employees, 8 Certified Nursing Assistants, 6 office staff, 5 Licensed Practical Nurses and 5 Registered Nurses on Abuse and Neglect with emphasis on following physician orders and timely implementation and documentation of medical treatments of wounds and diabetic ulcers. Employees will be educated prior to accepting an assignment. New hires will be in-serviced on Abuse and Neglect during orientation. Employees will be educated prior to accepting an assignment. On 1/31/2024 the Regional Director of Clinical Services (RDCS) conducted a verbal review of clean dressing change competency with return verbalization from Treatment Nurse RN, RN #1, RN #2, RN #3, RN #4, and Assistant Director of Nurses. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 5 Registered Nurses and 6 Licensed Practical Nurses on Medication Administration and Documentation. Employees will be educated prior to accepting assignments. On 1/31/2024 at 5:40pm the Regional Director of Clinical Services (RDCS) conducted education with the Treatment Nurse on Skin and Wound Guidelines, Medication Administration and Documentation, Abuse and Neglect, and Following Physician Orders and Clean Dressing Change checklist was reviewed verbally with return verbalization. Education included following the physician order when administering treatments, administering treatment timely, nurse that administers treatment is to sign the electronic administration record that treatment was administered, ensure all skin impairments and pressure ulcers have a physician order for treatment. Employees will be educated prior to accepting assignments. On 1/31/2024 at 1:08 pm Resident #52 received new physician orders to clean the stage 3 pressure ulcer of the coccyx with Dakin's, pat dry, apply Santyl to the wound bed at nickel thickness, cover with foam bordered dressing every day. PRN order for soilage\dislodgement. Resident #103 received new physician orders on 1/31/2024 at 2:02 pm to clean diabetic ulceration between 3rd through 5th toes on left foot with normal saline, pat dry, thread xeroform between toes, cover with dry dressing, wrap with kerlix, and secure with tape every day. PRN order for soilage/dislodgement. Order for clean left great toe blister site with normal saline, pat dry, apply Santyl to wound bed at nickel thickness, cover with dry gauze or ABD pads, wrap with kerlix, and secure with tape every day. PRN order for soilage/dislodgement. No new orders for Resident #269. On 1/31/2024 at 5:05 pm body audits were initiated by Registered Nurse (RN) #1, RN #2, RN #3, RN #4, and Assistant Director of Nurses to identify skin impairment or pressure ulcers. There were 108 body audits completed and 7 refused. No new pressure ulcers or diabetic ulcers identified on the body audits conducted. Audit conducted on the 7 residents refusing body audit to determine any previous skin concerns. No areas of concern were identified. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 6 Licensed Practical Nurses, 5 Registered Nurses, and 23 Certified Nurses Assistants on Skin and Wound Guidelines. Employees will be educated prior to accepting assignments. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 7 Registered Nurses and 10 Licensed Practical Nurses on Following Physician Orders. Employees will be educated prior to accepting assignments. On 1/31/2024 at 8:30 pm Assistant Director of Nurses reviewed physician orders and wound Nurse Practitioner progress notes consisting of diabetic ulcers, pressure ulcers, and skin concerns in the electronic health record (EHR) to ensure physician orders were implemented for 12 of 12 residents. No discrepancies were identified. On 1/31/2024 at 5:40 pm the Regional Director of Clinical Services (RDCS) conducted education with the Treatment Nurse on Skin and Wound Guidelines, Medication Administration and Documentation, Abuse and Neglect, and Following Physician Orders and Clean Dressing Change checklist was used with demonstration and return demonstration. DON and ADON are completing treatments as ordered Monday through Friday until treatment nurse position is filled, and treatment nurse is trained on the skills and expectations of the facility. All dayshift nurses who have completed the skills competency for wound care will provide dressing changes on the weekends. Director of Nurses and Assistant Director of Nurses are checking orders daily to ensure orders have been updated in electronic health records for nurses to complete on weekends. On 2/1/2024 at 2:00 pm Regional [NAME] President of Operation conducted education with Administrator on Abuse and Neglect with emphasis on thorough investigations and reporting guidelines. On 2/1/2024 at 2:30 pm the facility initiated a monitoring tool to check skin concerns, diabetic foot ulcers, pressure ulcers for appropriate orders to treat issues identified. The facility will ensure compliance with all wound care orders for accuracy daily by the Director of Nursing and Assistant Director of Nursing. QAPI: On 1/31/2024 at 7:00 PM a Quality Assurance Performance Improvement (QAPI) Committee meeting was held to review the Immediate Jeopardy template for F 600 Free from Abuse and Neglect, F 686 Treatment /Services to Prevent /Heal Pressure Ulcers, F 726 Competent Nursing Staff and F 658 services Provided Meet Professional Standards and to determine Root Cause Analysis. It was determined t[TRUNCATED]