**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the medical provider (Physicians and Nurse Practitioners) of a change in condition in which a resident with a history of myocardial infarction (MI; heart attack) reported chest pain for 1 (R #112) of 1 (R #112) residents reviewed for provider notification. If the facility fails to notify the provider of intermittent (not continuous) chest pain for a resident with prior history of MI (a major risk factor for having another MI), then it could likely delay the resident receiving necessary testing to determine if the resident requires life-saving medical intervention. This deficient practice likely contributed to the passing of R #1. The findings are: A. Record review of R #112's facesheet revealed R #112 admitted to the facility on [DATE] with the following list of diagnoses (not all-inclusive): - Diabetes mellitus (a chronic disease that occurs when the body is unable to control blood sugar levels). - Sepsis (a life-threatening extreme immune system response to infection or injury which can cause inflammation, blood clots, and damaged blood vessels reducing the blood flow and oxygen delivered to the body's organs). - Acute respiratory failure (inability to maintain adequate oxygenation in the body). - Atrial fibrillation (a type of irregular heartbeat that occurs when the electrical signals in the heart's upper chambers fire quickly and out of rhythm). - Myocardial infarction type 2 (a type of heart attack that occurs when the supply of oxygen to the heart does not meet the heart's demand). - Hypertension (high blood pressure). - Congestive heart failure (a serious long term condition that occurs when the heart cannot pump enough blood to the meet the body's needs). B. Record review of R #112's admission Minimum Data Set assessment (MDS; a federally mandated comprehensive assessment of each resident's functional capabilities that helps nursing home staff identify health problems), dated [DATE], revealed staff documented the following for the look back period (The time period over which staff observe a resident to capture the resident's condition or status for the MDS assessment. Unless otherwise stated, the look back period is seven days, and only those occurrences during the look back period will be captured on the MDS.): - Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 14, cognitively intact. - Active diagnoses of atrial fibrillation, heart failure, and hypertension. - R 112's pain was rare or non-existent. - R 112's ability to express ideas and wants was usually understood. Resident had difficulty communicating some words or finishing thoughts but was able if prompted or given time. - R 112's was able to understand others. Resident missed some part/intent of the message but comprehended most conversation. - No behaviors. - R 112's prognosis (life expectancy) was greater than 6 months. C. On [DATE] at 4:20 PM during an interview, CNA #2 stated that on [DATE] she checked on R #112 around 4 PM when he reported to her that his chest was hurting. CNA #2 immediately notified the nurse (LPN #1) who assessed the resident and took vital sign measurements. D. Record review R #112's nursing progress note, dated [DATE] at 4:01 PM and authored by Licensed Practical Nurse (LPN) #1, revealed the Certified Nursing Assistant (CNA) reported the resident complained of chest pain. Staff obtained the resident's vital signs as follows: 141/54 (blood pressure should be 120/80 or lower); 88 (normal pulse for adults is between 60 and 100); 22 (normal respiratory rate for a resting adult is between 12 and 20); 98.6 (the usual body temperature is generally considered to be between 97 and 99 degrees fahrenheit); on 2.5 liters (L) of oxygen. Staff assessed the resident, and he did not have any complaints at the time. R #112's color was pale, skin was cool, no diaphoresis (sweating). The resident answered questions appropriately. E. On [DATE] at 2:04 PM and 4:02 PM during an interview, LPN #1 stated the medical provider was not notified about R #112's initial report of chest pain, because he was at his baseline when she assessed him. LPN #1 stated she did not ask R #112 about his chest pain (type, duration, frequency), because he was not actively experiencing it. She stated she could not recall whether she considered his cardiovascular history when she decided not to notify the medical provider. F. On [DATE] at 1:40 PM during an interview, CNP (Certified Nurse Practitioner) #1 stated he expected to be notified if a resident complained of chest pain, even if the pain was not constant. CNP #1 stated staff should always take chest pains seriously, because residents may need diagnostics, such as an electrocardiogram (EKG; a test that checks for problems with the electrical activity of the heart) or blood tests to rule out a heart attack. He stated a resident with significant cardiovascular history such as R #112 was especially at risk and should be sent to the emergency room (ER) if they experienced chest pain in order to be evaluated by a provider. G. On [DATE] at 1:53 PM during an interview, LPN #2 stated residents who experienced any chest pain or other signs of a heart attack or stroke should be sent to out to the ER, and staff should notify the provider of the change in condition. H. Record review of R 112's nursing progress note, dated [DATE] at 5:00 PM and authored by LPN #1, revealed nursing staff found R #112 in bed without signs of life. Staff initiated cardiopulmonary resuscitation (CPR; an emergency procedure that combines chest compression with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken. EMS (Emergency Medical Service) arrived and continued life-saving measures which were ultimately unsuccessful and discontinued CPR at 5:34 PM. The family, facility administrator, nursing unit manager, and on-call provider were notified. Based on interview and record review, Immediate Jeopardy (IJ) was identified on [DATE] at 11:17 AM to the Administrator and the Director of Nursing, in person. The facility took corrective action by providing an acceptable Plan of Removal (POR) on [DATE] at 4:05 PM. Implementation of the POR was verified onsite on [DATE] with ongoing trainings for staff regarding change in condition and assessment of chest pains, and the facility completed a full sweep of all residents to identify any other resident who may be experiencing a change in condition and required provider notification. After verification of POR on [DATE] at 2:11 PM, the scope and severity was reduced to D. Plan of Removal: Identification/Correction: All residents have the potential to be affected by this alleged deficient practice, if the facility fails to monitor and notify the provider of residents for a change in condition related to chest pain. The following identification/corrections will be completed by [DATE]: Licensed nurses will complete head to toe assessments on current residents residing in the center to determine presence of a medical change in condition. Concentration on residents with the potential for cardiac complications (history of MI, CHF, etc) will be assessed for recent history of chest pain or other signs and symptoms of cardiovascular complications. Identified issues will be reported to the provider for further direction and medical orders. Systematic Measures: The Director of Nursing/designee will educate current staff regarding policy for resident change in condition. The education includes: - Change in condition is a sudden, clinically important deviation from a resident's baseline including physical, mental, or psychosocial status. Nursing assessment should have included description of chest pain, severity and how long pain had lasted. In addition, nurse should have considered the resident's heart history when assessing for chest pain. - All nurses must notify the provider, family and a nurse manager/nurse manager on-call immediately when they identify any change in condition, when the change occurs. If unsure that the residents are having a change, the nurse will consult with the nurse manager or the provider immediately once they have fully assessed the situation and have the information they need. - Nurses will be educated on nurse to nurse shift report that includes any pertinent diagnosis that could put the resident at risk for complications (i.e.: history of MI). The Director of Nursing/designee will begin education [DATE]. As of [DATE], 100% of currently scheduled staff have been educated on this policy. Any staff member that is not on the current schedule as of [DATE], is on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift. New hires/agency staff will be educated on the above during orientation. Current agency staff are being educated on the above information, and will continue to be educated by the facility human resources and mentor as part of the orientation process, prior to their first shift. The Director of Nursing/designee will review resident progress notes, orders and nursing dashboard during the morning clinical meeting to determine if residents noted change in condition identified, process followed, and monitoring occurred. Quality Assurance and Monitoring the Director of Nursing/designee will audit progress notes 5 days per week in morning clinical meeting to monitor for timely notification of change in conditions. Administrator and/or designee will bring results of audits to QAPI committee for further recommendations based on tracking and trending presented monthly for the next 3 months or until ongoing compliance is achieved. The QAPI committee is overseen by the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide quality care to 1 (R #112) of 1 (R #112) residents when they failed to properly assess a resident with history of myocardial infarction (MI; heart attack) ) after the resident reported chest pains. If the facility fails to properly assess a resident who reports chest pains, then the resident may experience unidentified life-threatening conditions such as a heart attack. This deficient practice likely contributed to the passing of R #1 within the hour of reporting chest pain. The findings are: A. Record review of R #112's facesheet revealed that R #112 admitted to the facility on [DATE] with the following list of diagnoses (not all-inclusive): -Diabetes mellitus (a chronic disease in that occurs when the body is unable to control blood sugar levels). -Sepsis (a life-threatening extreme immune system response to infection or injury which can cause inflammation, blood clots, and damaged blood vessels reducing the blood flow and oxygen delivered to the body's organs). -Acute respiratory failure (inability to maintain adequate oxygenation in the body). -Atrial fibrillation (AFIB; a type of irregular heartbeat that occurs when the electrical signals in the heart's upper chambers fire quickly and out of rhythm). -Myocardial infarction type 2 (a type of heart attack that occurs when the supply of oxygen to the heart does not meet the heart's demand). -Hypertension (high blood pressure). -Congestive heart failure (a serious long term condition that occurs when the heart cannot pump enough blood to the meet the body's needs). -Full Code (a medical directive that tells a person's health care team to perform all possible life-saving measures if their heart or lungs stop working). B. Record review of R #112's admission Minimum Data Set assessment (MDS; a federally mandated comprehensive assessment of each resident's functional capabilities that helps nursing home staff identify health problems) dated [DATE] revealed staff documented the following for the look back period (The time period over which staff observe a resident to capture the resident's condition or status for the MDS assessment. Unless otherwise stated, the look back period is seven days, and only those occurrences during the look back period will be captured on the MDS.): - Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 14, cognitively intact. -Active diagnoses of atrial fibrillation, heart failure, and hypertension. -R #112 rated his pain as rare or non-existent -R #112's ability to express ideas and wants was usually understood. Resident had difficulty communicating some words or finishing thoughts but is able if prompted or given time. -R #112 was able to understand others. Resident missed some part/intent of the message but comprehends most conversation. -No behaviors are indicated on the MDS assessment. -R #112's prognosis (life expectancy) was greater than 6 months. C. On [DATE] at 4:20 PM during an interview, CNA #2 stated that on [DATE] she checked on R #112 around 4 PM when he reported to her that his chest was hurting. CNA #2 immediately notified the nurse (LPN #1) who assessed the resident and took vital sign measurements. CNA #2 stated she went to check on R #112 again approximately 45 to 60 minutes later and he was gone (deceased ). D. Record review of the National Institutes of Health article titled, Chest Pain, dated [DATE], revealed an assessment for chest pain should include the following components to help rule out serious, life-threatening causes: -Onset: In addition to when the pain started, ask what the patient was doing when the pain started. Was the pain brought on by exertion, or were they at rest? -Location: Can the patient localize the pain with one finger, or is it diffuse? -Duration: How long did the pain last? -Character: Let the patient describe the pain in his or her own words. -Aggravation/alleviating factors: It is very important to find out what makes the pain worse. Is there an exertion component, is it associated with eating or breathing? Is there a positional component? Don't forget to ask about new workout routines, sports, and lifting. Ask what medications they have tried. -Radiation: This may clue you into visceral pain. -Timing: How many times do they experience this pain? For how long does it let up? -Risk factors including: prior myocardial infarction (MI), family history of cardiac disease, smoking, hypertension (HTN), hyperlipidemia (HLD; high cholesterol), and diabetes. E. Record review of R #112's nursing progress note, dated [DATE] at 4:01 PM and authored by Licensed Practical Nurse (LPN) #1, revealed the Certified Nursing Assistant (CNA) reported the resident complained of chest pain. Staff obtained the resident's vital signs as follows: 141/54 (blood pressure should be 120/80 or lower); 88 (normal pulse for adults is between 60 and 100); 22 (normal respiratory rate for a resting adult is between 12 and 20); 98.6 (the usual body temperature is generally considered to be between 97 and 99 degrees fahrenheit); on 2.5 liters (L) of oxygen. Staff assessed the resident, and he did not have any complaints at the time. R #112's color was pale, skin was cool, no diaphoresis (sweating). The resident answered questions appropriately. - The record did not contain any other information regarding the resident assessment conducted by LPN #1 or what questions the resident answered appropriately. F. On [DATE] at 2:04 PM and 4:02 PM during an interview, LPN #1 stated the resident was at his baseline when she assessed him. LPN #1 stated she did not ask R #112 about his chest pain (type, duration, frequency), because he was not actively experiencing it. LPN #1 confirmed she did not notify the doctor of R #112's chest pain. She stated she could not recall whether she considered the resident's cardiovascular history when she assessed R #112 on [DATE]. G. On [DATE] at 1:40 PM during an interview, Certified Nurse Practitioner (CNP) #1 stated staff should always take chest pains seriously, because residents may need diagnostics, such as an electrocardiogram (EKG; a test that checks for problems with the electrical activity of the heart) or blood tests to rule out a heart attack. He stated a resident with significant cardiovascular history, such as R #112, was especially at risk and should be sent to the emergency room (ER) if they experienced chest pain in order to be evaluated by a provider. The CNP stated it was expected for staff to notify him if a resident had chest pain, but staff did not notify him of R #112's chest pain. H. On [DATE] at 1:53 PM during an interview, LPN #2 stated residents who experienced any chest pain or other signs of a heart attack or stroke should be sent to out to the ER to determine if a life-threatening condition exists. I. Record review of R #112's nursing progress note, dated [DATE] at 5:00 PM and authored by LPN #1, nursing staff found R #112 in bed without signs of life. Staff initiated cardiopulmonary resuscitation (CPR; an emergency procedure that combines chest compression with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken). EMS (Emergency Medical Service) arrived and took over life-saving efforts which were ultimately unsuccessful. EMS discontinued CPR at 5:34 PM. The family, facility administrator, nursing unit manager, and on-call provider were notified. J. Record review of R #112's nursing progress note, dated [DATE] at 8:02 PM and authored by Registered Nurse (RN) #1, revealed R #112 was pronounced deceased at 7:23 PM on [DATE]. Based on interview and record review, Immediate Jeopardy (IJ) was identified on [DATE] at 11:17 AM to the Administrator and the Director of Nursing, in person. The facility took corrective action by providing an acceptable Plan of Removal (POR) on [DATE] at 4:05 PM. Implementation of the POR was verified onsite on [DATE] with ongoing trainings for staff regarding change in condition and assessment of chest pains, and the facility completed a full sweep of all residents was completed to identify any other resident who may be experiencing a change in condition and required provider notification. After verification of POR on [DATE] at 2:11 PM, the scope and severity was reduced to D. Plan of Removal: Identification/Correction: All residents have the potential to be affected by this alleged deficient practice, if the facility fails to monitor and notify the provider of residents for a change in condition related to chest pain. The following identification/corrections will be completed by [DATE]: Licensed nurses will complete head to toe assessments on current residents residing in the center to determine presence of a medical change in condition. Concentration on residents with the potential for cardiac complications (history of MI, CHF, etc) will be assessed for recent history of chest pain or other signs and symptoms of cardiovascular complications. Identified issues will be reported to the provider for further direction and medical orders. Systematic Measures: The Director of Nursing/designee will educate current staff regarding policy for resident change in condition. The education includes: -Change in condition is a sudden, clinically important deviation from a resident's baseline including physical, mental, or psychosocial status. Nursing assessment should have included description of chest pain, severity and how long pain had lasted. In addition, nurse should have considered the resident's heart history when assessing for chest pain. -All nurses must notify the provider, family and a nurse manager/nurse manager on-call immediately when they identify any change in condition, when the change occurs. If unsure that the residents are having a change, the nurse will consult with the nurse manager or the provider immediately once they have fully assessed the situation and have the information they need. A full head-to-toe assessment needs to be completed by the nurse. The eInteract change in condition documentation needs to be completed specific to the change (ie: chest pain, fall, etc), with the notification noted. The assessment for the eInteract will trigger a specific assessment for chest pain that asks for a description, severity, length of time and if shortness of breath is occurring. This assessment will pull over a resident diagnosis list into the eInteract, change in condition form. It also needs to include all abnormal findings in each system within the form, vital signs, neurological status, chest pain with a history, blood glucose etc. The nurse needs to include a narrative note about what happened before, during and after the event, and the provider orders and interventions that were put into place. Monitoring needs to occur per the change in condition UDA (user defined assessment), and in progress notes as needed, to ensure that if further change occurs, the process is repeated and documented. If the change in condition is an immediate emergency, a nurse should stay with the resident to monitor until EMS arrives. The eInteract UDA, after the initial eInteract change in condition has been completed, triggers continued monitoring of the identified concern. If it is the same concern, continue with the UDA documentation. If it is a different concern, begin another eInteract change in condition assessment. When communicating with the doctor, the nurse must include all information pertinent (including diagnosis pertaining to the change in condition ie: cardiac related diagnosis for chest pain) to the change in condition, and should have it available when calling the doctor. -Nurses will be educated on nurse to nurse shift report that includes resident assessment and any pertinent diagnosis that could put the resident at risk for complications (ie: history of MI). The Director of Nursing/designee will begin education [DATE]. As of [DATE], 100% of currently scheduled staff have been educated on this policy. Any staff member that is not on the current schedule as of [DATE], is on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift. New hires/agency staff will be educated on the above during orientation. Current agency staff are being educated on the above information, and will continue to be educated by the facility human resources and mentor as part of the orientation process, prior to their first shift. The Director of Nursing/designee will review resident progress notes, orders and nursing dashboard during the morning clinical meeting to determine if residents noted change in condition identified, process followed, and monitoring occurred. Quality Assurance and Monitoring The Director of Nursing/designee will audit progress notes 5 days per week in morning clinical meeting to monitor for timely notification of change in conditions. Administrator and/or designee will bring results of audits to QAPI committee for further recommendations based on tracking and trending presented monthly for the next 3 months or until ongoing compliance is achieved. The QAPI committee is overseen by the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 1 (R #11) of 3 (R # 11, 12, 13) resident reviewed for medications. This deficient practice resulted in R#11's pulmonary embolism [blood clots in the lungs (PE)] getting worse since the last CT scan (medical imaging technique used to obtain detailed internal images of the body) on 09/08/23 putting resident at increased risk for stroke and blockage of blood flow to the heart which could result in death. The findings are: A. Record review of R #11's face sheet revealed she was admitted to the facility on [DATE] with a diagnosis of a dislocated (disturb the normal arrangement or position) right knee, broken right ankle, and pulmonary embolism [blood clots in the lungs (PE)] resulting from a fall at home on [DATE]. B. Record review of R #11's transfer orders from the hospital, dated 09/15/23, revealed Eliquis (blood thinner), 5 mg (milligrams), 1 tablet twice daily was ordered to treat and prevent the blood clots in her lungs from getting worse. C. Record review of R #11's Program of All-Inclusive Care for the Elderly (PACE) orders sent to the facility, dated 09/15/23, did not include an order for Eliquis or include a diagnosis of pulmonary embolism. D. Record review of R #11's hospital transfer orders and the PACE orders revealed both were uploaded to R #11's Electronic Medical Record (EMR) on 09/14/23. E. Record review of R #11's PACE progress note, dated 09/22/23, revealed R #11 was sent by emergency medical ambulance to the hospital from the facility because the PACE provider found out R #11 had not been receiving Eliquis since her admission on [DATE]. F. Record review of R #11's hospital CT scan (medical imaging technique used to obtain detailed internal images of the body) of her lungs, dated 09/23/23, revealed R #11's PE had gotten worse by increasing the burden (causing the lungs to work harder to oxygenate the blood) in the left lower lobe since CT chest 9/8/2023. G. On 10/30/23 at 9:47 am during an interview with the Director of Nursing (DON), he stated all orders, medications, and diagnosis for residents upon admission must be reconciled for accuracy. The DON further stated he did not identify R #11's order for Eliquis upon R #11's admission and confirmed that he should have. H. On 10/31/23 at 1:30 pm during an interview with the daughter (D) of R #11, she stated on 09/22/23 she visited R #11 and found her lying in bed, unable to be woken up. She made the facility aware of R #11's condition and called the PACE provider. R#11 was put on 5 liters per minute of oxygen via nasal canula (tube providing oxygen into the nose) and became more alert. She stated when the PACE provider got to the facility, she became aware R #11 was never started on Eliquis and immediately had R #11 transported to the hospital. The PACE provider told R #11's daughter that because R #11 had not been on Eliquis for almost 7 days, she was in danger of forming more blood clots, which could cause a stroke, myocardial infarction (blockage of blood flow to heart), and or death. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J which was announced on 10/30/23 at approximately 12:40 pm to the Administrator, in-person. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 10/31/23 at 9:30 am. Implementation of the POR was verified onsite 10/31/23 by conducting record reviews and staff interviews. Scope and severity was lowered to level 2, D. Plan of Removal: On 10/30/23 the nursing team (Director of Nursing responsible) initiated a 30-day audit on all admissions to ensure all orders, diagnosis, and medications were reconciled and entered into the MAR as ordered. Any discrepancies will include a provider notification and review to ensure accurate medication orders are in place. On 10/30/23 the nursing team (Director of Nursing responsible) initiated an audit of all residents currently receiving anticoagulant medications to ensure medications are being given as ordered. Any identified concerns will include a change in condition documentation and notification to the provider and family. Any new orders will be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings for R #65 EE. Record review of R #65's admissions facesheet revealed R #65 was admitted to the facility on [DATE] with a diagnoses of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region (area located below the lumbar spine and above the tailbone), unstageable (when the stage of the ulcer is not clear because the base of the wound is covered by a layer of dead tissue that may be yellow, grey, green, brown, or black and the doctor cannot see the base of the wound to determine the stage). FF. On 08/28/23 at 11:22 am, during an interview, R #65 stated the wound on his butt (buttock) was hurting due to the dressing sticking. He stated the dressing was supposed to be changed daily, but it was not getting changed daily. GG. Record review of R #65's weekly wound evaluation revealed R #65 diagnosed with the following skin injuries: - 08/03/23 Pressure - Unstageable (Slough and/or eschar) Body location: coccyx (commonly known as the tailbone). New - 1 month old. Acquired: In-House (a pressure injury acquired while residing at the facility) - 08/03/23 Pressure - Deep Tissue Injury Body Location: Right heel. New - 7 days old. Acquired: Present on admission. HH. Record review of the physician orders for R #65 revealed the following orders: - Order, dated 08/4/23: Wound care, right buttock: clean with wound with wound cleaner. Apply generous layer of medhoney (a brand name wound and burn gel made from 100% Leptospermum (Manuka) honey) to slough and cover with foam dressing. Fold dressing flat into buttock cleft to secure. Change each day and as needed if soiled or off. - Order dated 08/04/23: Wound care, bilateral heels: paint heels with betadine (a topical antiseptic that provides infection protection against a variety of germs to help prevent infection and promote healing in skin wounds, pressure sores, or surgical incisions) each day every shift. II. Record review of R # 65's Treatment Administration Record (TAR), dated August, 2023, revealed the following for wound treatment: - Order with start date of 08/04/23, Wound care, right buttock: clean with wound with wound cleaner. Apply generous layer of medhoney to slough and cover with foam dressing. Fold dressing flat into buttock cleft to secure. Change each day and as needed if soiled or off. - Staff did not document wound care treatment for the dates of 08/05/23, 08/07/23, 08/09/23, 08/14/23, 08/17/23, 08/19/23, 08/21/23, and 08/24/23. - Order with start date of 08/04/23, Wound care, bilateral heels: pain heels with betadine each day every shift. - Staff did not document wound care treatment for the dates of 08/05/23, 08/07/23, 08/09/23, 08/14/23, 08/17/23, 08/19/23, 08/21/23, and 08/24/23. HH. Record review of R #65's wound evaluations revealed the following: - Coccyx wound evaluations: - Weekly wound evaluations were completed for R #65 on the dates of: 08/03/23 , 08/15/23, and 08/31/23. - 16 days passed between the assessment of 08/15/23 and 08/31/23. - Photos indicate the wound is on the left buttock and not the right buttock as identified in the physician's orders and the TAR for wound care. - Right heel: - Weekly wound evaluations were completed for R #65 on the dates of: 08/03/23 , 08/15/23, and 08/31/23. - 16 days passed between the assessment of 08/15/23 and 08/31/23. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of K which was announced on 08/30/23 at approximately 6:28 pm to the administrator, in-person. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 08/31/23 at 12:11 pm. Implementation of the POR was verified onsite 08/31/23 by conducting record reviews and staff interviews. Plan of Removal: On 08/30/23 -08/31/23 the nursing team initiated a whole house resident skin sweep to identify all current wounds in the facility, and assess for correct identification and treatment. Any identified concerns, including refusals of wound care/assessment and worsening wounds will include change in condition documentation and notification to the provider and family. Any new orders will be followed. Resident #29 R. Record review of Face Sheet dated 11/15/22 for R #29 revealed this as an initial admission date and included the following diagnoses: Morbid Obesity, Venous Insufficiency (condition in which blood pools in veins, straining the walls of the vein), Stage 2 Pressure Ulcer of Right Buttock, Chronic Pain syndrome, Peripheral Vascular Disease (narrowing of blood vessels which reduces blood flow to the arms or legs), and Muscle Weakness. S. Record review of Physicians Orders for R #29 revealed the following: - Wound care, left buttock . change QD (every day) and PRN (as needed) if soiled (dirty) or off, every day shift. Start date: 06/07/23. D/C date: 06/08/23. - Wound care, bilat (bilateral - both sides) buttocks/posterior (back side) thighs . Q (every) change and PRN every day and night shift. Start date: 12/29/22. D/C date: 06/01/23. - Clean wounds to BLE (bilateral lower extremities - both legs) . change Tuesday (Tuesday), Fri (Friday), and PRN if soiled or off. Every day shift Tue, Fri. Start date: 02/14/23. D/C date: 06/09/23. - Wound care BLE . change QD and PRN if soiled or off, every day shift . Start date: 09/02/23. [no D/C date] - Weekly skin check . every day shift every Sun (Sunday) . Start date 02/06/23. [no D/C date] - Wound care, right scapula (shoulder) . change q day and PRN if soiled or off, every day shift. Start date: 03/09/23. D/C date: 03/31/23. - Wound care, LLE (left lower extremity - leg) . change QD and PRN if soiled or off, every day shift every Tue, Fri. Start date: 06/13/23. D/C date: 08/31/23. - Wound care, right posterior thigh change q day and PRN if soiled or off, every day shift. Start date: 07/12/23. [No D/C date] T. Record review of Treatment Administration Records (TAR), dated June 2023, for R #29, revealed the following: - Cleanse wounds to BLE . change Tue Fri Day Shift and PRN if soiled or off. Start date: 02/14/23. D/C date: 06/09/23. - 06/09/23 (Friday) - No documentation - Weekly skin check . every Monday night. Start date: 02/06/23. 06/26/23 (Monday) - No documentation - Wound care, bilat buttocks . q change and PRN every day shift. Start date: 06/07/23 D/C date: 06/08/23. 06/07/23 and 06/08/23 - No documentation - Wound care, LLE . change Tue, Fri Day Shift and PRN if soiled or off. Start date: 06/13/23. D/C date: 08/31/23. 06/16/23 - Documented as NN (See Nursing Notes) 06/20/23 (Tuesday) - No documentation 06/30/23 (Friday) - No documentation -Wound care, right posterior thigh . change q day and PRN if soiled or off. Start date: 06/28/23. D/C date: 07/11/23. 06/28/23 and 06/30/23 - No documentation - Wound care, right posterior thigh . change q day and PRN if soiled or off. Start date: 06/02/23. D/C date: 06/27/23. 06/06/23, 06/08/23, 06/09/23, 06/12/23, 06/13/23, 06/19/23, and 06/21/23 - Documented as R (refusal) 06/05, 06/07, 06/10 - 06/11, 06/14 - 06/15, 06/17 - 06/18, 06/20, 06/25 and 06/27 - No documentation U. Record review of TAR, dated July 2023, for R #29, revealed the following: - Wound care, LLE. Change Tuesday and Friday. Day Shift and PRN if soiled or off. Start date: 06/13/23. D/C date: 08/31/23. - 07/04/23 (Tuesday) - No documentation - 07/14/23 (Friday) - Documented as NN - 07/21/23 (Friday) - No documentation - 07/25/23 (Tuesday) - Documented as NN - Wound care, right posterior thigh. Change q day and PRN if soiled or off. Start date: 07/12/23. 07/15/23 - No documentation 07/20/23 - 07/22/23 - No documentation 07/24/23 - No documentation 07/29/23 - No documentation 07/30/23 - Documented as NN 07/31/23 - No documentation - Wound care, right posterior thigh. Change q day and PRN if soiled or off. Start date 06/28/23. D/C date: 07/11/23. 07/02/23 - No documentation 07/04/23 -07/05/23 - No documentation 07/10/23 - Documented as R (Refused) 07/11/23 - No documentation V. Record review of R #29's TAR, dated August 2023, for R #29, revealed the following: - Weekly skin check . every Monday Night. Start date: 02/06/23. [No D/C date] 08/14/23 (Monday) - Documented as R - Wound care, LLE . change Tue, Fri Day Shift and PRN if soiled or off. Start date: 06/13/23. D/C date: 08/31/23. 08/01/23 (Tuesday) - Documented as NN 08/04/23 (Friday) and 08/08/23 (Tuesday) - Documented as R 08/15/23 (Tuesday) - Documented as NN 08/18/23 (Friday) - Documented as R - Wound care, right posterior thigh . change q day and PRN if soiled or off. Start date: 07/12/23. Documented as NN on 08/01. 08/02/23 - Documented as R 08/04/23 - Documented as R 08/05/23 - No documentation 08/07/23 - Documented as NN 08/09/23 - Documented as R 08/10/23 - No documentation 08/14/23 - No documentation 08/15/23 - Documented as NN 08/16/23 - 08/18/23 - Documented as R 08/20/23 - Documented as NN 08/27/23 - No documentation W. Record review of TAR, dated September 1 - 6, 2023, for R #29, revealed the following: - Wound care, BLE . change QD and PRN if soiled or off. Start date: 09/02/23. 09/03/23 - Documented as NN 09/04/23 - No documentation - Wound care, LLE . change QD and PRN if soiled or off. Start date: 09/01/23. D/C date: 09/01/23. 09/01/23 - No documentation - Wound care, right posterior thigh . change q day and PRN if soiled or off. Start date: 07/12/23. 09/03/23 - Documented as NN 09/04/23 - No documentation X. Record review of nursing progress notes (referenced above as see nurse notes for wound care) revealed no nursing notes identifying that wound care was provided for 07/14/23, 07/25/23, 07/30/23, 08/01/23, 08/07/23, 08/15/23, 08/20/23 or 09/03/23. Y. Record review of nursing progress notes dated 06/06/23 at 10:01 am for R #29 revealed, IDT (interdisciplinary team) review for new pressure wound on 6/5/23. Resident has new wound to L (left) buttock . Z. Record review of nursing progress notes dated 06/07/23 at 12:33 pm for R #29 revealed, Wound documents as a new PI (pressure ulcer) is the same one that has been present since admission. Tx (treatment) orders remain in place for it and others . AA. Record review of nursing progress notes dated 06/16/23 at 16:59 (4:59 pm) for R #29 revealed, . Rsd (resident) denies refusing care . Rsd stated during care plan meeting that he did not receive wound care for 3 (three) weeks at one point . BB. Record review of nursing progress notes dated 07/08/23 at 12:13 pm for R #29 revealed, . Left post calf deteriorated sharply (to become worse quickly), r/t (related to) rsd refusals of care. New open areas where thick plaques (when dead skin and white blood cells can't shed fast enough, they build up and create thick, scaly surfaces of the skin.) have come free. Area macerated (softening and breaking down) . balls of both feet red but blanching (skin becomes pale or white), rsd does not believe he has irritated areas to balls of feet . CC. Record review of nursing progress notes dated 08/28/23 at 23:18 (11:18 pm) for R #29 revealed, . Skin breakdown on buttocks . DD. On 08/30/23 at 9:48 am, during an observation and interview, prior to Licensed Practical Nurse (LPN) #2 providing wound care for R #29's right leg, she appeared to have difficulty locating the wound care supplies. LPN #2 stated she was just cleaning and wrapping the leg, but that there were no orders for treating the wound. Based on observation, interview, and record review the facility failed to provide quality care for 5 (R #29, 38, 61, 65 and 81) of 5 (R #s 29, 38, 61, 65 and 81) residents reviewed by not monitoring and treatment of wounds. This deficient practices could likely cause a decline in residents' health and well-being if physician orders are not followed, wounds could likely become infected causing sepsis (blood infection), osteomyelitis (bone infection) and/or other medical conditions could likely worsen.The findings are: A. Record review of R #81's facesheet revealed the following diagnoses: Type II diabetes (means that your body doesn't use insulin properly), chronic kidney disease (impaires kidney function), osteomyelitis diagnosed during stay at facility (inflammation of one or more joints), methicillin resistant staphylococcus aureus infection (Infections caused by specific bacteria that are resistant to commonly used antibiotics), peripheral vascular disease (is a slow and progressive circulation disorder), acquired absence of left toes diagnosed during stay at facility (amputation of left toes). This is not a complete listing of R #81's diagnoses. R #81 was initially admitted on [DATE] and was readmitted on [DATE]. B. Record review of hospital admission description indicated that R #81 had a laceration on his toe and was seeing podiatrist. It was noted on 06/20/23 in a podaitrist note that the laceration was healing. On 07/07/23 the podiatrist noted that R #81's left fifth digit was infected and disarticulated (seperation of two bones at their joint). R #81 was admitted to the hopsital on 07/05/23 for left toe gangrene (death of body tissue due to a lack of blood) and osteomyelitis. Left toe amputation was completed on 07/05/23. Resident was re-admitted to the facility on [DATE]. C. Record review of the physician orders indicated an order dated 07/26/23 for wound care to be provided every day and as needed. D. On 08/27/23 at 7:18 pm, during an observation and interview, R #81 had two preventive boots (helps to prevent skin breakdown). One boot was on his right foot, and the other boot was not on his left foot. The dressing on his left foot was dirty and very bloody (both wet and dry blood) and was not a clean dressing. The dressing did not have a date or initials on it indicating when the dressing was last changed and who changed it. R #81 stated he did not know when the dressing was last changed. E. On 08/28/23 at 8:00 am, during an observation, R #81 was asleep in bed, and staff had not changed his dressing. The dressing was observed to be the same dressing as the day prior, with no date or initials. F. Record review of the Treatment Administration Record (TAR) for the month of August 2023 indicated that no wound care was completed on 08/27/23. G. On 08/28/23 at 2:25 pm, during an observation and interview, Family Member #1 (R #81's wife) was in the room while staff provided care to R #81. The dressing on R #81's left foot was the same dressing as previously observed this morning 08/28/23 at 8:00 am and on 08/27/23 at 7:18 pm, and the wife pointed at the wound dressing. She stated it (the dressing) had not been changed, and she had just asked staff to change the dressing. H. Record review of R #81's nursing progress notes, dated 07/05/23 at 8:49 am, indicated R #81 went to a podiatry (foot doctor) appointment and was sent to the hospital due to progression (worsening) of wounds. R #81 had a deteriorating venous wound (can be shallow, irregularly shaped sores and skin surrounding the stasis ulcer may be hard and discolored) on his left foot. I. Record review of R #81's wound care note dated 07/28/23 at 16:47 (4:47 pm), indicated wound care to the left 5th toe amputation (surgical removal of a body part): clean w (with) wound cleaner. Fill hole loosely with maxorb absorbent dressing. Paint heel dti (deep tissue injury) w betadine swab (impregnated with 10% povidone-iodine solution). Cover both w/ abd pads and wrap w entire roll kerlix. May use net stocking to secure, no compression. Change q day and PRN if soiled or off, everyday shift. Necrotic (dead tissue) areas to proximal (closer to the main part of body) aspects of wound are increasing. Distal (further away from the main part of body) wound end is black and soggy. No granulation (new tissue on surface of healing wounds) visible in wound, yellow thin slough (dead tissue) present, suspicious for more extensive depth. Awaiting provider input, rsd (resident) does have podiatry appt (appointment) on Monday [07/31/23] but might need to be seen in ER (emergency room) prior. J. Record review of R #81's nursing progress note, dated 08/01/23 at 11:57 am, indicated Rsd returned from (name of clinic) podiatry appt yesterday (07/31/23) w no paperwork. Writer spoke w Chief of Podiatry (name of) about rsd's foot wound (left toe amputation). Goals of care discusses (discussed) (name of physician) reports they recommended a BKA (below the knee amputation on left leg), but family at that point did not want to go that route. Wound worsening, tendon and bone exposed and tunnels 8 cm (centimeters) up towards the ankle at this time. Slough and eschar (type of necrotic tissue that is secondary to cell death following tissue injury) to the edges. (name of physician) reports that goal is to dessicate (to dry up) the wound and dry it out, to possibly provide a stable dry gangrene (is a condition where body tissues die due to lack of blood supply or infection) bed that could be left alone. Goal is to attempt to prevent sepsis r/t (related to) wound on his left foot and toe amputation. They are going to discuss palliative care w family at next visit. (name of physician) to fax visit notes from 7/31 to facility. K. Record review of R #81's nursing progress note, dated 08/07/23 at 17:34 (5:34 pm), indicated the following, Per VA Hospital per appointment: - Left foot wound vacuum (vacuum assisted closure for wound therapy). - Dressing changes: Change x (times) 2, weekly (Wed, Fri). - VA podiatry will see every Monday. - Black foam with plastic wrap. - Make sure vacc running at 125 mmHg (pressure setting) continuous pressure. - Dress foot with 4 x 4 gauze,abd pad around vacc hose to ensure no pressure wounds, kerlix and or loose dressings around foot. - No weight bearing to left foot. L. Record review of R #81's Treatment Administration Record (TAR), for August 2023 and Nursing progress notes, indicated the following: - The TAR did not contain orders for the wound vac. - The wound order in place on the TAR was wound care, left 5th toe amputation: clean w wound cleaner. Saturate 4 x 4 gauze and wrap w entire roll kerlix. may use net stocking or ace to secure, no compression. Change q date and PRN if soiled or off every day shift start on 08/05/23. - The staff documented the following in the TAR for wound care: - August 5th indicated to see nursing note. Nursing note indicated that family requested wound care to be done later due to family visiting. - August 6th wound care was done. - August 7th and 8th indicated hold see nursing notes. Nursing notes indicated a wound vac was in place. - August 9th nothing was documented. - August 10th and 11th indicated to see nursing notes. Nursing notes indicated a wound vac was in place. - August 12th and 13th wound care was documented as being completed. - August 14th nothing was documented. - August 15th indicated to see nursing notes. Note Text: wound vac not present at time of wound care. No new orders returned from (name of hopsital) after visit. Contacting (name of hospital) for current plan of treatment for foot wound. Wound has worsened, increased eschar and slough areas r/t (due to) circulation issues . - August 16th -20th wound care was documented as being completed. - August 21st nothing was documented. - August 22nd -26th wound care was documented as being completed. - August 27th nothing was documented. - August 28th-31st wound care was documented as being completed. M. Record review of R #81's podiatry follow up note, dated 08/14/23 [Monday], indicated, Follow up on delayed primary closure of the left fourth and fifth ray (toe) amputation [refers to the ablation (removal of body tissue) of digital (fingers and toes) elements] date of service on 07/05/23 and 07/07/23. Patient has been in SNF (Skilled Nursing Home) for wound management. Presents to clinic with wife and daughter who states the vac last changed on Wednesday. Today, wound vac and dressings intact, however vac was not on and low battery. Patient endorses pain to the area. Removed wound vac, confirmed it has not been on since August 9th, 2023, while patient was at (name of) SNF. N. On 08/28/23 at 12:49 pm, during an interview, Family Member #2 stated the wound on her father's left foot had not been healing. She had taken him to a podiatry When her father went to a podiatry appoinment on 08/07 /23 he stated that the wound wasn't healing and ordered a wound vacuum. R #81 came back to the facility on [DATE] with the wound vacuum. She stated that when she (FM #2) got back to the facility from the 08/07/23 appointment, she gave the orders and supplies to Licensed Pracitcal Nurse (LPN) #3. FM #2 told LPN #3 that If they (the facility), were not able to change the wound vac, then they should send him back to the clinic and the clinic would change it. LPN #3 told her that they do it all the time, and it would not be a problem. She took her father (R #81) back to the podiatrist on Monday 08/14/23 and at that time the podiatrist realized that the wound vac was not turned on and the dressing had not been changed. The Podiatrist took the wound vac off at that point. They were discussing the BKA with the family, but the family decided not at this time.She stated that when she took him back on 08/14/23 the Podiatrist stated that the wound wasn't healing O. On 08/29/23 at 4:09 pm, during an interview with LPN #3, she stated that she was familiar with R #81's wound, and she remembers when he came back with a wound vac [08/07/23]. She stated she was the one who put in the progress note for his wound vac. LPN #3 stated that she did not put it in as an order, but she did let the Unit Manager know about the wound vac order. She thought the Wound Care nurse would enter the order into the electronic medical record. She stated that if there were no wound orders then it would not have triggered the nurses to have completed wound care for the wound vac. She stated I did not ever do any wound care while R #81 had the wound vac. She has been R #81's nurse and was at the time he had a wound vac. P. On 08/29/23 at 4:19 pm, during an interview, Director of Nursing (DON) stated she was not aware of the situation with the wound vac. She was aware R #81 had one, but she was unaware staff did not put the orders for the wound vac in R #81's medical record. The DON confirmed there was not an order for the wound vac, only a progress note. The DON stated the wound nurse would have entered in the orders for the wound vacc in this case; however, the wound nurse was off on Mondays, and she was on vacation sometime the beginning of August. The DON stated the Unit Manager would have put the orders in since the wound nurse was not available to do it. She stated if the nurse was familiar with the orders then the nurse could enter the orders into the resident's medical record. Q. On 08/30/23 at 4:55 pm, during an interview, DON stated the wound nurse was out last week, this week, and earlier in the month. The DON stated there was not a particular staff responsible for the oversight of wound care or to provide wound care in the absence of the wound nurse. The nursing staff should do the wound care if the wound care nurse was out. The DON wasn't aware that the wound vac for R #81 was never put in as an order.