**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation, and resident, staff, and transportation driver interviews, the facility failed to provide safe transportation for Resident #1 when she was being transported by a contracted van transport company from dialysis back to the facility on 5/25/24. Resident #1's wheelchair was not secured to the floor securement system per the manufacturer's instructions. When Driver #1 accelerated the vehicle, Resident #1's wheelchair tipped backward, and the resident hit the right back side of her head. Driver #1 pulled the transportation van over to the shoulder of the road and called 911. Emergency Medical Services (EMS) arrived, assessed the resident, and determined she needed to go to the hospital for evaluation for her complaints of head pain. The accident occurred post hemodialysis and Resident #1 was prescribed and received Plavix (anticoagulant medication). There was a high likelihood of a serious adverse outcome for Resident #1 due to the resident's wheelchair not being secured to the floor of the van per the manufacturer's instructions. Resident #1 was evaluated in the emergency department and the physician noted a right parietooccipital hematoma (blood collection in the back of the head. The CT (Computed Tomography) scan of the neck and head was negative for a head injury. This was for 1 of 3 residents reviewed for accidents (Resident #1). The findings included: The manufacturer's instructions for the 4-point Wheelchair Securement Systems manual, dated 2012, were reviewed. The illustrated manual provided directions for wheelchairs to be secured with four separate floor-mounted restraints at all times when the vehicle was moving. The restraints were to be secured to the corners of the chair, on the frame structure of the wheelchair at approximately a 45-degree angle, not on the wheels or other parts of the chair. In addition to wheelchair securement, seat belts were to be used for securing passengers at all times. The lap belt must be securely fastened around each passenger any time the vehicle was moving, and a shoulder belt be used as well. The 2023 agreement between the Transportation Company #1 and the nursing home was reviewed. The agreement indicated to immediately notify the nursing home of any accidents or incidents, involving any vehicle or clients, whether or not damage or personal injury results. Resident #1 was re-admitted to the facility on [DATE]. Her diagnoses included diabetes mellitus, end stage renal disease (ESRD) with hemodialysis, and bilateral below-knee amputations The quarterly Minimum Data Set (MDS) assessment, dated 5/8/24, indicated that Resident #1 was cognitively intact. She required extensive assistance with activities of daily living (ADL), used the wheelchair for mobility, and was non-ambulatory. The resident received hemodialysis three times a week. Review of Resident 1's plan of care, dated 5/22/24, revealed her diagnoses of ESRD and hemodialysis three times a week, with goals and interventions. Review of the physician's orders for May 2024 for Resident #1 revealed hemodialysis on Tuesday, Thursday, and Saturday outside the facility. Record review of the nurses' notes revealed that on 5/25/24, the staff received a phone call from the Owner of Transportation Company #1 stating on the way from the dialysis center to the facility, Driver #1 did not secure the wheelchair with Resident #1 according to manufacturer recommendations to the van, causing the wheelchair to flip backward. The resident hit her head on the van's door. Driver #1 called EMS, and the resident was transported by EMS to the Emergency Department (ED) for hospital evaluation. Review of the EMS report, dated 5/25/24, revealed at 3:04 PM the EMS dispatch received a call from Driver #1, stating that a (redacted) female fell in the van during the transportation from dialysis center to nursing home. The EMS team arrived on the scene to Resident #1 at 3:10 PM. Upon assessment, the patient had a hematoma, 1.5 by 2 inches, over the posterior (rear) head with moderate pain in her head and no bleeding or other injuries. Driver #1 explained that he had some issues with latching mechanism and thought he had it secured well. Per Resident #1, she flipped over backwards, striking the ramp. Resident #1 was transferred to the stretcher and brought to the ED of the hospital with no changes in condition at 3:39 PM. Review of the hospital records, dated 5/25/24, revealed Resident #1 arrived at ED at 3:49 PM via EMS for her head injury. Upon arrival, the resident was not in acute distress with stable vital signs. She had notable right parietooccipital hematoma. Per resident, she was riding in her wheelchair on the wheelchair accessible van after her dialysis appointment. The wheelchair was not locked down to the van, and when the driver accelerated the vehicle forward, the resident fell backwards, hitting the back of her head on the chair lift. She was not sure if she lost consciousness. Resident #1 endorsed pain in the back of her head and reported that she took daily Plavix (anticoagulant). The resident denied all other pain. The CT (Computed Tomography) (diagnostic test) scan of the head and neck was negative for acute traumatic pathology (sudden onset injury). She received pain management, and during multiple reevaluations, reported a gradual improvement of her headache. Resident #1 was discharged to the nursing home at 10:13 PM in stable condition. On 8/20/24 at 8:05 AM, during an interview, Resident #1 indicated she remembered on one Saturday in May 2024 (could not recall the exact day), she was in her wheelchair in the van for transportation from the dialysis center to the facility. Driver #1 was new to her and secured the wheelchair to the van with straps before leaving the dialysis center parking lot. The resident did not realize the driver secured only the back part of the wheelchair and the front part of the wheelchair frame was unsecured. Driver #1 locked the wheels of the wheelchair and applied the lap and shoulder seat belts to secure the Resident #1 in the wheelchair. On the way to the facility Driver #1 accelerated the vehicle forward, the resident's wheelchair tipped backward, and the resident fell backward together with her wheelchair and hit the right back side of her head against the van's door. The driver immediately pulled the transportation van over to the shoulder of the road and called 911. When EMS arrived, they assessed the resident, who reported moderate pain in her head and took her to the hospital for evaluation. Resident #1 could not recall if there was any blood coming from her head. Resident #1 continued she received a head CT scan (diagnostic procedure), which found no issues, and pain medications. In the ED, her pain was gradually reduced, and she returned to the facility in a few hours with almost no pain in her head. Resident #1 had not used Transportation Company #1 for dialysis appointments since the incident. Instead, the facility provided their van with a driver from the facility and there had been no issues. Attempts to interview Van Driver #1 were unsuccessful. On 8/20/24 at 9:50 AM, during the phone interview, the Owner of Transportation Company #1 indicated on 5/25/24, (did not recall the exact time), he received a phone call from Driver #1, who was assigned to transfer Resident #1 from the dialysis center to the facility. Driver #1 stated he did not fully secure the wheelchair to the van, and on the way to facility, Resident #1 fell backwards and hit her head. The Owner of Transportation Company #1 directed Driver #1 to call 911and then notified the facility. The administration of Transportation Company #1 conducted an internal investigation, which revealed Driver #1 disregarded the protocol and did not secure the wheelchair to the van per manufacturer's instruction, causing the incident with Resident #1. The Owner of Transportation Company #1 confirmed that Driver #1 was terminated, and the facility halted the contract with Transportation Company #1. The Owner of Transportation Company #1 continued that Driver #1 was hired in January 2024 and completed the training related to operating the van, patients' transportation in the van, including the 4-point Wheelchair Securement Systems manual, with return demonstration. Driver #1 did not have any issues prior to 5/25/24. On 8/20/24 at 11:10 AM, during an interview, the Director of Nursing (DON) indicated on 5/25/24, the staff received a phone call from Transportation Company #1, stating Resident #1 fell in the van on the way from the dialysis center to the facility and was sent to the hospital for evaluation via EMS. During further communication with the Owner of Transportation Company #1 via phone and email, the DON learned that Driver #1 did not follow the protocol to secure the resident's wheelchair according to the manufacturer's instruction. The resident fell backward and hit her head. Driver #1 was terminated from the transportation company, and the facility stopped the agreement with Transportation Company #1. Since the incident on 5/25/24, the facility had utilized their van and their own driver for dialysis appointments. On 8/20/24 at 11:30 AM, during an interview, the Maintenance Director explained Driver #1 did not return to the facility and the Maintenance Director did not have a chance to inspect the condition of the securement system in the van as part of the facility's investigation. The Maintenance Director indicated that for newly hired Driver #2, he provided education and training for safe resident transportation in the van, including applying a 4-point securement system, seat belts, and straps with hooks according to the manufacturer's instruction. Driver #2 utilized the facility's van for dialysis appointments, and since the incident on 5/25/24, the Maintenance Director had been checking the van daily to monitor the securement system application. On 8/21/24 at 10:10 AM, during an interview, the Medical Director indicated she was notified of the incident with Resident #1 in the van right after it happened. After the incident, the resident spent a few hours in ED and received the diagnosis of a small right parietooccipital hematoma with no acute abnormalities on imaging tests. The Medical Director understood it was a driver from the transportation company, but the facility should be responsible for providing care within the professional standard at any time. The Medical Director mentioned Resident #1 could have sustained a serious injury during a fall on the van due to her anticoagulant medications, primary diagnosis, and comorbidities. On 8/21/24 at 11:25 AM, during an interview, the Administrator indicated he became aware of the incident on 5/25/24. The Director of Nursing (DON) notified him the staff received a phone call from Transportation Company #1, stating Resident #1 fell in the van during her transfer between the dialysis center and the facility. Her fall resulted in head trauma, EMS was called to the scene, and EMS took her to the hospital for evaluation. The DON and Maintenance Director discussed the issue with the Owner of Transportation Company #1, who clarified Driver #1 did not fully secure the resident in the van per protocol, which led to the fall with injury. Driver #1 was suspended and terminated according to the owner of the transportation company. The facility halted the agreement with Transportation Company #1. The Administrator reported after the incident, the facility conducted a Quality Assurance Performance Improvement (QAPI) meeting to discuss the incident and develop a Corrective Action Plan. The Administrator explained the facility utilized its van for resident's transportation after the accident on 5/25/24. The Maintenance Director was responsible for checking the safety equipment in the van and providing education and training for drivers. The newly hired Driver #2 received education and training for safe resident transportation in the van, including applying the 4-point securement system according to the manufacturer's instructions. The Administrator was notified of immediate jeopardy on 8/21/24 at 10:00 AM. The facility implemented the following Corrective Action Plan with a completion date of 5/27/24. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Residents requiring facility assisted transportation could be affected by the deficient practice. [NAME] Administrator halted the use of the contracted transportation service on May 26th, 2024, and all drivers within their transportation company had to complete education before any further usage. The affected residents are now transported by facility van to appointments. We have contracted with a second transportation service as a backup. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice Any resident needing transportation has the potential to be affected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. [NAME] Administrator halted the use of the contracted transportation service on May 26th, 2024, and all drivers within their transportation company had to complete education before any further usage. Facility Director of Nursing and Maintenance Director completed education on properly securing residents prior to transport. The facility has contracted with a second transportation service who has provided credible evidence of safe transportation and securing residents to meet the potential appointment needs. Residents are currently being transported to their appointments by our transportation aide. Upon hire, the transportation aide received education that including, but not limited to, properly securing residents safely in the vehicle, loading and unloading and vehicle condition. On May 26th, 2024, the Executive Director reeducated the Director of Nursing and Maintenance Director as it relates to vehicle safety while transporting residents to ensure resident are properly secured during transportation. The facility maintenance director provided training on June 7th, 2024, to the transportation aide. No new transportation vendors have been added since May 25th, 2024. We are utilizing our facility van with our transportation aide as the driver. The facility made the decision to monitor/audit and bring this to QA on May 26th, 2024. 4. Include dates when corrective action will be completed. Ongoing audits began on 5/26/2024. 5. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained Quality monitoring will be performed on 2 different residents weekly to ensure they are safely secured prior to transporting to appointments for 12 weeks and then monthly for 3 months by DON and transportation aide to ensure resident is properly secured in van prior to transport. The immediate jeopardy was removed on 5/27/24. The deficiency was corrected on 5/27/24. The Immediate Jeopardy was removed on 5/27/24. The Corrective Action plan was validated on 8/22/24. The facility provided documentation to support their Corrective Action Plan, including education for the Maintenance Director and Driver #2. The pre-trip inspections were completed before any van transportation by Driver #2. The Maintenance Director audited these inspections three times per week from 5/27/24 to 7/22/24. During the observation, Driver #2 and the Maintenance Director demonstrated the correct method to restrain a wheelchair with a resident in the transportation van, using the 4-point securement system. QAPI meetings were discussed with the administrator, and meeting notes were reviewed. The facility's completion date of 5/27/24 for the Corrective Action Plan was validated on 8/22/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Nurse Practitioner #1, Physician and staff interviews, the facility failed to notify the Physician or Nurse Practitioner of a change in wound condition to Resident #32's right heel on 3/20/22. This was for 1 of 8 residents reviewed for pressure ulcers. Immediate Jeopardy began on 3/20/22 when staff had failed to notify the physician or Nurse Practitioner (NP) of a change in wound status for Resident #32's right heel which progressed to an unstageable pressure ulcer. Immediate Jeopardy was removed on 4/9/22 when the facility provided and implemented an acceptable credible allegation of the Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put into place and to complete staff training. The findings included: Resident #32 was admitted to the facility on [DATE] with diagnoses that included a recent right hip fracture with surgical repair, and protein calorie malnutrition. A review of the hospital Discharge summary dated [DATE] did not reveal any skin breakdown to Resident #32's buttocks or heels. A nursing progress note dated 2/24/22 indicated Resident #32 was admitted to the facility. Her skin was warm and dry with redness to the sacrum. No other mention of skin concerns in the progress note. Review of a Change in Condition assessment for Resident #32, dated 3/5/22, timed 4:52 PM and completed by Nurse #5, read a pressure area was identified to the right heel. The assessment was marked unknown for treatment for last episode or if this symptom had occurred before. The Appearance section of the Assessment was summarized as resident with pressure area to right heel. There was no description of the color or size of the area identified. The assessment noted the physician was notified and provided new orders. A late entry, nursing progress note, written by Nurse #4 and dated 3/22/22 indicated Resident #32 had eschar (black, brown, or tan dead tissue that adheres to the wound bed or edges and may be firmer or softer than the surrounding skin) to the left heel when the treatment was completed on 3/20/22. A review of Resident #32's medical record revealed there was no documentation to show the physician or NP were notified of the eschar found to Resident #32's right heel from 3/20/22 to 3/28/22. A phone interview was conducted with Nurse #4 on 3/30/22 at 6:38 PM. She stated Resident #32 had eschar to the right heel when the treatment was completed on 3/20/22. Nurse #4 stated skin prep was already being utilized for the area and she left communication for the Assistant Director of Nursing (ADON) regarding her findings since the ADON had been helping with treatments due to the wound nurse was no longer at the facility. She could not recall notifying the physician or NP of the eschar present to Resident #32's right heel. The ADON was interviewed on 3/30/22 at 10:05 AM and was unable to recall being told about the eschar to Resident #32's heel by Nurse #4. She added, if an Nurse Aide (NA) identified an area of concern during personal care they should report it to herself, the nurses, or Director of Nursing (DON). If a nurse identified an area of concern for a resident, they could report it to herself, the DON or directly to the physician/NP. On 3/30/22 at 3:04 PM, an interview occurred with Nurse #2 who stated if skin concerns were observed on any resident they would either report it to the ADON, since she had been assisting with treatments, to the DON or directly to the physician or NP. She was unable to recall if this had occurred for Resident #32. NP #1 was interviewed on 3/31/22 at 11:20 AM and reported since the treatment nurse was no longer at the facility there had been errors in wound care, which she had addressed with the ADON and DON. The NP stated she had assessed Resident #32 after her admission to the facility and had not identified any pressure ulcers to her heels, only a surgical wound to her right hip. She stated she would have expected to be notified when the area was first identified so proper treatment and oversight could have occurred. An interview was conducted with the DON on 3/31/22 at 2:00 PM and indicated she had been employed at the facility for close to 2 months. She reported there had been turn-overs in staff and there wasn't a full-time treatment nurse currently. The DON added she expected the nurse who identified the open area to document what the area looks like as well as report to the either the physician or NP. A phone interview was completed with the physician on 4/9/22 at 1:11 PM. When asked about being notified of Resident #32's pressure area to the right heel on 3/5/22, he stated he received multiple calls during the day and could not readily recall, however he would have instructed the nurse to use the facility standing orders and have the resident seen by the NP and wound physician. The physician stated he could not recall observing an area of eschar to Resident #32's right heel. The Administrator was notified of the Immediate Jeopardy on 4/8/22 at 10:05 AM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. A late entry nursing progress note dated 3/22/22 indicated Resident #32 was observed with eschar to her heel when a treatment was completed on 3/20/22. On 3/20/22 the facility failed to notify physician of change in wound. On 3/30/2022 new order noted for betadine to right heel pressure area. On 04/08/2022, all residents have been assessed for change in condition to include vital signs and complete head to toe skin assessment. 47 total residents reviewed was completed by licensed nurses to identify residents with a change in condition related to pressure. On 04/08/2022 Physician/NP notification via change in condition (SBAR) was completed with any new pressure areas. On 04/08/2022, all resident's progress notes for the last 30 days have been review for change in condition to include newly identified pressure areas. Change of conditions (SBARS) were reviewed along with progress note and skin sweep completed to identify any change noted and assessment complete. Information below was reviewed and verified by licensed nurse if change was identified. 47 total residents reviewed. - Family/Responsible Party Notification - Physician Notification - Physician order for treatment (if indicated) - Appropriate documentation - Interventions to prevent further changes and /or worsening of condition - Appropriate Care Plan Intervention put in place On 04/08/2022 Physician/NP notification via change in condition (SBAR) was completed with any new pressure areas. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 4/08/22, the Regional Director of Clinical Services and Executive Director initiated education to the Licensed Nurses, Medication Aides and Certified Nursing Aides. After 4/08/2022, Licensed Nurses, Medication Aides and Certified Nursing Aides not educated will receive this education prior to working their next scheduled shift), regarding physician notification of a change of condition related to residents with newly identified pressure areas, recognition, and response to include the following: - Evidence of a Licensed Nurse assessment - Physician's order (if indicated) - Treatments have been performed per Physician's order and documented - Physician and responsible party notification of changes - Appropriate care plan is in place - Accurate documentation - Continued monitoring for change of condition related to On 4/08/22, the Director of Clinical Services and/or Designee initiated education with Certified Nursing Assistants/Medication Aides regarding licensed nurse notification of a change of condition observation to include the following: - Interact - Stop and Watch Tool After 4/08/2022 Certified Nursing Assistants/Medication Aides not previously educated on change of condition observation and Interact- Stop and Watch Tool will be educated prior to working their next scheduled shift. Newly Hired Certified Nursing Assistants/Medication Aides will be educated during the Orientation process going forward. The Director of Nursing has been notified of this responsibility. Newly Hired Licensed Nurses, Medication Aides and Certified Nursing Aids, will be educated during the Orientation process by the Director of Nursing, going forward. The Director of Nursing has been notified of this responsibility. Education is being provided in person and via phone. The Executive Director is tracking who has received education. Validation of understanding has been documented via post-test questionnaire. Post-test will be completed via phone by reading of multiple choice by nurse manager or Executive Director. The Director of Nursing will review electronic record who had a change in condition to the morning meeting to ensure physician notification, to include new orders for wound care and assessments complete for change of condition. Completed change of conditions are noted in point click care and discussed during morning meeting to ensure documentation and notification are complete. The facility alleges the removal of Immediate Jeopardy on 4-9-22. On 4/12/22 the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: The 4/8/22 facility audit was reviewed and revealed 3 current residents were identified with skin integrity concerns during a skin sweep. Change in condition assessments were completed and the Nurse Practitioner and responsible party were notified on 4/8/22. Education to licensed nursing staff regarding provider notification of a change in condition related to newly identified pressure areas was reviewed and sign in sheets were provided. Education for Nurse Aides and Medication Aides, regarding notification to a licensed nurse when a skin impairment was observed were reviewed and sign in sheets were provided. Nurse #2 was interviewed on 4/12/22 at 11:30 AM and stated she had received recent education on notification to the physician or NP when a skin impairment was identified. In addition, a change in condition assessment would be completed and the responsible party and Nurse Manager would be made aware. On 4/12/22 from 11:45 AM until 12:10 PM interviews of 4 Nurse Aides was conducted which revealed they had recently received education on reporting any observed skin concerns immediately to the charge nurse or Nurse Manager. An interview occurred with the Administrator and interim Director of Nursing (DON) on 4/12/22 at 12:15 PM. The interim DON explained when changes in skin conditions or newly identified skin impairments were noted licensed nursing staff were to complete a change in condition assessment and notify the responsible party, physician/NP, dietician and if needed the wound physician. The Administrator stated the physician had asked for the facility staff to contact him during off hours rather than the on-call physician services as they were not familiar with the residents. The facility's Immediate Jeopardy removal date of 4/9/22 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. Resident #9 was admitted to the facility 3/5/2022 with diagnoses that included a stage 4 pressure injury to the left lateral shin. The resident's admission Minimum Data Set (MDS) indicated the resident had moderate cognitive impairment, total dependent upon staff for all activities of daily living, personal hygiene, toileting, and eating. The MDS indicated Resident #9 had a stage 4 pressure injury, had positioning device for his bed and received wound care during the assessment period. Resident #9's medical record revealed the resident was seen by the wound care physician on 3/28/2022 for a stage 4 pressure injury to the left lateral shin that measured 2.5cm x 1.8cm with light serous exudate. Recommendations for wound care were as follows: Primary dressing of hydrogel with silver, secondary dressing of abdominal pad, and skin prep daily for 16 days. The resident's medical revealed a physician's order for wound care that read: Clean open area to left lower lateral leg with wound cleanser, apply skin prep and cover with a dry dressing daily. The order was dated 3/28/2022. On 3/30/22 at 3:15 PM an interview was conducted with the Assistant Director of Nursing (ADON)/treatment nurse regarding wound order not matching resident's active orders. She stated she does not get the orders from the wound physician; they go to the Director of Nursing (DON) and she puts the orders in the electronic medical record. An interview was conducted with the DON on 3/31/2022 at 1:59 PM. She stated she does get the wound care physician's wound evaluation and management summary with all his recommendations. She further stated she did review the recommendations for Resident #9 dated 3/28/2022 and entered the orders in the electronic medical record. When asked to review the recommendations and the orders in the electronic medical record, she stated she was new at entering wound care orders and she did not realize the hydrogel with silver was part of the order. 2b. On 03/29/2022 at 2:45 PM during a wound care observation, the wound was observed to be open approximately 2 centimeters (cm) by 2 cm with dark exudate but free of any odor. The treatment nurse removed a visibly soiled dressing from the left lateral shin of Resident #9 and did not change gloves or perform hand hygiene prior to handing the clean wound care supplies to include the clean dressing. An interview was conducted with the treatment nurse on 3/30/2022 at 10:50 AM. She stated she does not change gloves during wound care unless the wound has a lot of exudate and Resident #9's wound only had a little exudate. On 3/31/2022 the DON was interviewed and stated she expected the treatment nurse to perform wound care per physician's order and in a manner that limits cross contamination. 2c. [NAME] an interview on 3/28/2022 at 11:06 AM the resident stated his mattress was the most uncomfortable mattress he had ever tried to sleep on. Resident #9 had a physician's order for a pressure reducing mattress. On 3/29/2022 at 12:00 observed Resident #9 lying on a pressure reducing mattress. The mattress settings indicated the mattress was set at 250 pounds (lbs.) The medical record revealed the resident's last documented weight was on 3/11/2022 at 166.4 lbs. On 3/29/2022 at 12:02 PM an interview was conducted with Nurse #2 who was assigned to resident. She stated she was not familiar with the resident's mattress. When asked about settings, she stated she was not aware of the settings or what they should be. She observed the mattress was set at 250lbs and she was not sure of the resident's weight. She stated the mattress was set up by maintenance and he may have information on how the mattress was set up. On 3/29/2022 at 12:31 PM an interview was conducted with facilities maintenance. He stated he set the mattress up and made sure it was functioning properly, but the nurses were responsible for setting the weight and monitoring the mattress proper functioning. An interview was conducted with the DON on 3/31/2022 at 1:59 PM. She stated she expected the pressure reducing mattress to be set correctly. 3. Resident #11 was admitted to the facility on [DATE] with diagnoses that included Failure to thrive with protein-calorie malnutrition and pressure injuries. The residents quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was moderately cognitively impaired, was total dependent upon staff for bed mobility and all activities of daily living, toileting, and personal hygiene. The resident had not pressure injuries during the assessment period. Resident #11's comprehensive care plan was last revised on 1/20/2022 and had a focus for skin impairment with a history of pressure injuries to bilateral heels, the sacrum, and the right hip. An interview was conducted with Resident #11 on 3/30/2022 at 9:15 AM. She stated she had wounds, but they were all healed. She further stated she was told she had a special mattress to prevent any future pressure wounds. At the time of the interview the resident was observed on a pressure reducing mattress. The mattress settings were at the firmest level, 400 pounds, (lbs.). Resident #11's medical record revealed her last documented weight was 3/11/2022at 141.4 lbs. On 3/29/2022 at 11:58 AM an interview with Nurse #2, nurse assigned to resident. She observed the pressure reducing mattress to be set at 400 lbs. When asked if that would be accurate for this resident, she stated it would not be accurate. She further stated the mattress was set up by facility's maintenance, but she was not sure who initially set the mattress to 400 lbs or who is responsible for checking the settings. On 3/29/2022 at 12:31 PM an interview was conducted with facilities maintenance. He stated he set the mattress up and made sure it was functioning properly, but the nurses were responsible for setting the weight and monitoring the mattress proper functioning. An interview was conducted with the DON on 3/31/2022 at 1:59 PM. She stated she expected the pressure reducing mattress to be set correctly. Based on observations, record reviews, and interviews with resident's, staff, Nurse Practitioner #1, Physician, and wound Physician, the facility failed to complete scheduled weekly skin sweeps (a head-to-toe skin assessment), provide daily wound care treatments as ordered, and failed to thoroughly complete a comprehensive assessment on 3/5/22 for a change in wound status. All of these actions contributed to the facility failing to identify when Resident #32 developed an unstageable pressure area. In addition, the facility failed to follow wound physician recommendations (Residents #9 and #40), failed to provide wound care as ordered (Resident #9), failed to change gloves and sanitize hands when going from soiled to clean surfaces during wound care (Resident #9) and failed to set a pressure reducing mattress according to resident's weight (Residents #9 and #11). This was for 4 of 8 residents reviewed for wound care. Immediate Jeopardy began on 3/5/22 when a Change in Condition assessment did not thoroughly assess or document the change in wound status to Resident #32's right heel. In addition, staff failed to complete scheduled weekly skin sweeps and failed to provide daily wound care treatments as ordered for a resident that developed an unstageable pressure ulcer (Resident #32). Immediate Jeopardy was removed on 4/9/22 when the facility provided and implemented an acceptable credible allegation of the Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (a deficiency that constitutes a pattern with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put into place and to complete employee in-service training. The facility was also cited at a scope and severity of E for example #1b (Resident #32), example #2 (Resident #9), example #3 (Resident #11), and example #4 (Resident #40). The findings included: 1) Resident #32 was admitted to the facility on [DATE] with diagnoses that included a recent right hip fracture with surgical repair, and protein calorie malnutrition. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 was cognitively intact and had no pressure ulcers only a surgical wound. A pressure reducing device was on the bed. Review of the Care Area Assessment (CAA) summary worksheet dated 3/9/22 indicated Resident #32 would be care planned for the risk for skin integrity issues related to limited mobility, surgical site present and incontinence of urine. The worksheet stated skin sweeps would be completed per protocol and the surgical site would be observed for complications. Resident #32's active care plan included a focus area that was initiated on 3/9/22 for potential/actual impairment to skin integrity related to right hip fracture repair, urinary incontinence, limited mobility and chronic kidney disease. The interventions included to encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, identify/document potential causative factors and eliminate/resolve where possible, keep skin clean and dry and use lotion on dry skin. 1a). A review of the hospital Discharge summary dated [DATE] did not reveal any skin breakdown to Resident #32's heels. An admission assessment completed by Nurse #4 on 2/24/22 was reviewed. The section for skin indicated a skin sweep was completed and skin was clear except for foot problems. Surgical site present to right thigh/hip area. Skin was noted to be warm and dry. The area for description of feet concerns read Right toe(s)- toe nails long, dry and yellow. Left toe(s)- long, dry and yellow. There were no concerns marked for other foot problems, heel problems or drainage to the feet. The active physician orders included an order dated 2/27/22 for weekly skin sweeps. A review of Resident #32's medical record from 2/27/22 to 3/30/22, revealed no weekly skin sweeps were completed as ordered. A physician progress note dated 2/28/22 for Resident #32, read under Review of Systems there were no rashes or skin breakdown. The Physical Exam section of the progress note read Skin: Inspection: No rashes or ulcers. A Nurse Practitioner (NP) progress note dated 3/1/22, indicated Resident #32's skin was inspected, with no skin breakdown noted other than the surgical site to her right hip. Review of a Change in Condition assessment for Resident #32, dated 3/5/22, timed 4:52 PM and completed by Nurse #5, read a pressure area was identified to the right heel. The assessment was marked unknown for treatment for last episode or if this symptom had occurred before. The Appearance section of the Assessment was summarized as resident with pressure area to right heel. There was no description of the color or size of the area identified. The assessment noted the physician was notified and provided new orders. Multiple attempts were made to contact Nurse #5 on 3/31/22 without success. Nurse #5 was scheduled to care for Resident #32 on 3/12/22, 3/13/22, 3/26/22 and 3/27/22. Resident #32's physician orders were reviewed and revealed the following: - An order dated 3/6/22 to apply skin prep to the right heel, pad and protect every day. This order was discontinued on 3/10/22. - An order dated 3/10/22 to apply skin prep to both heels, pad and protect every day. There was no documentation in Resident #32's medical record, from 3/5/22 to 3/22/22, explaining the impairment of her skin integrity to the right heel. The March 2022 Treatment Administration Record (TAR) was reviewed for Resident #32 and revealed the following treatments were not documented as completed: - Bilateral heel treatments were not documented as complete on 3/12/22, 3/13/22, 3/17/22, 3/21/22, 3/26/22 and 3/27/22. A late entry, nursing progress note, written by Nurse #4 and dated 3/22/22 indicated Resident #32 had eschar to the left heel when the treatment was completed on 3/20/22. A phone interview was conducted with Nurse #4 on 3/30/22 at 6:38 PM. She stated Resident #32 had eschar to the right heel when the treatment was completed on 3/20/22. Nurse #4 stated skin prep was already being utilized for the area and she left communication for the Assistant Director of Nursing (ADON) regarding her findings. Review of a wound physician progress note for 3/28/22, revealed Resident #32 was initially assessed for an area to her right heel. The progress note read an unstageable (due to necrosis- black, brown, or tan dead tissue that adheres to the wound bed or edges and may be firmer or softer than the surrounding skin) pressure area to the right heel of at least 23 days duration. There was no drainage or indication of pain. The area measured 3 centimeters (cm) in length and 4.2 cm in width. There was 100% of thick adherent black necrotic tissue. The dressing treatment plan was for Betadine every day to the area for 30 days, float her heels when in bed and use a sponge boot. The form indicated the pertinent history was obtained with nursing staff and Resident #32. A follow-up was scheduled for 7 days with the wound physician On 4/12/22 at 3:46 PM, a phone interview occurred with the wound physician. He explained he assessed Resident #32 on the evening of 3/28/22 for a possible pressure ulcer to her right heel. When asked about the documented duration of greater than 23 days, he stated he gathered this information based on what was told to him by the resident and her daughter who was at the bedside. He was told when Resident #32 was at the hospital they were not protecting her heels and she began to develop a sore to her right heel. The wound physician stated he based the duration of the wound on her hospital discharge date of 2/24/22 as the area clearly didn't evolve in a week or less. The wound physician added based on the look of the area it was highly plausible the right heel pressure area was present on admission to the facility. He described the area as dry heel eschar- noninfected skin. An order was provided to use Betadine daily and offload her heels. The wound physician further stated if the facility had completed the weekly skin sweeps as ordered he would have been able to clearly identify if Resident #32 was admitted with the pressure area to her right heel or when it first developed. The active physician orders for Resident #32 included an order dated 3/29/22 for Betadine to the right heel every day for an unstageable pressure ulcer. Resident #32 was observed on 3/28/22 at 9:50 AM, while she was sitting up in bed. A white dressing wrap was present to her right foot, a cloth protective boot was observed, turned around with the protection on top of her foot instead of on her heel. She stated she had a sore on her heel. When asked about how long the sore was present on her heel, she stated it started either when she was at the hospital or first got the facility all my days have run together On 3/30/22 at 9:45 AM, the ADON was observed providing skin care to Resident #32. She explained Resident #32 was seen by the wound physician last evening and the area to her right heel was identified as an unstageable pressure ulcer due to eschar (tan, brown or black dead tissue that may be crusty) being present. She stated she couldn't state whether the area was present there or not before yesterday. The right heel was observed to have a dark black area to the entire heel, however there was no drainage or odor. When the ADON was asked to measure the wound, she stated only the wound physician measured wounds. The ADON cleansed the area with skin prep and then applied a Betadine swab. Non-skid socks were replaced to her foot and a cloth protective boot was applied. The left heel was observed to be very dry in appearance with no red or dark colored areas present. Skin prep was applied to the left heel as ordered, by the ADON The ADON was interviewed on 3/30/22 at 10:05 AM and explained the treatment order to Resident #32's right heel was recently changed to Betadine solution to the right heel every day related to an unstageable pressure ulcer per the wound physician. The ADON was unable to recall being told about the eschar to Resident #32's heel by Nurse #4. When asked about weekly skin sweeps, the ADON stated they were to be completed every week and that either she or the Director of Nursing (DON) completed them. She added, if an Nurse Aide (NA) identified an area of concern during personal care they should report it to herself, the nurses or DON. If a nurse identified an area of concern for a resident, they could report it to herself, the DON or directly to the physician or NP. The ADON was unable to state why there were no weekly skin sweeps completed for Resident #32 since her admission to the facility. She further stated she felt if they had been completed the unstageable pressure ulcer to the right heel could have been identified sooner. An interview was completed with NA #2 on 3/30/22 at 11:45 AM who was familiar with Resident #32. She stated Resident #32 had her heels wrapped in a dressing when she provided personal care and had not observed her heel area. On 3/30/22 at 3:04 PM, an interview occurred with Nurse #2 who stated weekly skin sweeps were completed by the ADON or DON since there wasn't a treatment nurse. Nurse #2 explained if the ADON was working on a medication cart, then the nurses were responsible for their own treatments. Resident #32's March 2022 TAR was reviewed with Nurse #2 and revealed she had completed wound care to Resident #32's heels last on 3/24/22. She was unable to recall any necrotic areas to Resident #32's heels when treatments were completed. NP #1 was interviewed on 3/31/22 at 11:20 AM and reported since the treatment nurse was no longer at the facility there had been errors in wound care, which she had addressed with the ADON and DON. The NP stated she had assessed Resident #32 after her admission to the facility and had not identified any pressure ulcers to her heels, only a surgical wound to her right hip. She stated she would have expected to be notified when the area was first identified so proper treatment and oversight could have occurred. The NP stated the necrosis found to Resident #32's right heel could have been prevented if weekly skin sweeps as well as the wound treatments had been completed as ordered. An interview was conducted with the Director of Nursing (DON) on 3/31/22 at 2:00 PM and indicated she had been employed at the facility for close to 2 months. She stated she was unaware there were no weekly skin sweeps completed for Resident #32 or her treatments to her heels were not completed consistently as ordered. The DON stated she was unaware Resident #32 had an unstageable pressure area to her right heel until after she was seen by the wound physician on 3/28/22. She reported there had been turn-overs in staff and there wasn't a full-time treatment nurse currently. The DON added she was aware weekly skin sweeps were not occurring before she arrived at the facility and thought if she didn't complete them the ADON had. The DON stated it was her expectation for weekly skin sweeps to occur, so skin impairments were identified and treated in a timely manner. A phone interview was completed with the physician on 4/9/22 at 1:11 PM. When asked about being notified of Resident #32's pressure area to the right heel on 3/5/22, he stated he received multiple calls during the day and could not readily recall, however he would have instructed the nurse to use the facility standing orders and have the resident seen by the NP and wound physician. The physician stated he could not recall observing an area of eschar to Resident #32's right heel. The Administrator was notified of the Immediate Jeopardy on 4/8/22 at 10:05 AM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to complete scheduled skin assessments for a resident who developed an unstageable pressure injury and failed to provide wound care treatments as ordered (Resident #32). Resident #32 has been assessed by a Licensed Nurse on 4-8-22. Licensed Nurse completed chart review and skin sweep of Resident #32 on 4-8-22. Licensed Nurse notified Wound Specialist of current wound orders and protective measures. Recommendations to discontinue skin prep and pad and protection to bilateral heels. Clarification orders obtained for betadine solution daily to right heel and leave open to air after betadine is applied and float heels in bed and apply protective booties as tolerated. Medical Director assessed resident on 4-8-22 and noted the resident clinically stable. Care Plan was reviewed and updated to reflect protective booties as tolerated to promote healing. Resident #32 had interventions put into place by a Licensed Nurse and plan of care were reviewed and updated on 4-8-22. Resident #32 Kardex has been updated by the Nurse Manager and identified from the plan of care and communicated by the nurse that interventions on the Kardex for the nurse aides to review on 4-8-22. Current Facility Residents have the potential to be affected. Current Residents (47) had Braden Risk Assessments completed by a Licensed Nurse on 4-8-22 using a Braden Scale to determine those at risk for skin breakdown. a. Current residents determined to be at risk had a call placed to the Responsible Party as well as to their Physician for notification and further orders. b. These Residents had interventions put into place by a Licensed Nurse and their Plans of care were reviewed and updated on 4-8-22. c. Kardex's have been updated by the Nurse Manager for each resident identified for the plan of care for nurse aides on 4-8-22. Current Residents (47) had Skin Sweeps performed by a Licensed Nurse on 4-8-22 to ensure that skin areas that are impaired have been addressed and appropriate interventions are in place. Current residents determined to have a new skin area of impairment had a call placed to their Responsible Party as well as to their Physician for notification and further orders. a. These affected Residents had interventions put into place by a Licensed Nurse and their Plans of care were updated, accordingly on 4-8-22. b. Kardex's have been updated by the Nurse Manager on 4-8-22, accordingly. c. The Facility has a Certified Wound Physician who makes rounds weekly for consultation, assessment, and treatment orders. The Certified Wound Physician's contract is currently in place. The Certified Wound Physician is available by phone and via telehealth for consultation, assessment and treatment orders. Newly admitted or acquired wounds identified through assessment are referred to Certified wound physician) by licensed nurses. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 4-8-22, the Regional Director of Clinical and or Executive Director conducted re-education with Licensed Nursing Staff to ensure the following: a. Licensed Nursing Staff and Nurse Aides - skin is assessed daily with care and weekly skin assessment is performed by a Licensed Nurse and documented in the medical record. b. Nurse Aides- inform charge nurse of any noted new skin breakdown with care. c. Licensed Nursing Staff- notify the Resident's Physician within the course of their shift or within 24 hours of any new skin breakdown for further interventions and document skin assessment, notification, and new orders in the medical record. d. Licensed Nursing Staff-Treatment orders are to be administered as per physician orders for residents with documentation in the medical record, accordingly. e. The Nurse Manager educated Nursing Staff was on 4-8-22, to include contract nursing staff. Nursing Staff not re-educated on 4-8-22, will not be allowed to work their next scheduled shift prior to being re-educated. The Executive Director will monitor daily according to schedule to ensure all staff are educated prior to the scheduled shift. f. Executive Director informed Nurse Manager on 4-8-22 of newly hired staff will be educated during orientation period. Newly hired nursing staff will be educated by the Nurse Manager during the orientation period going forward. The Nurse Manager has been re-educated by the Regional Director of Clinical Services on 4-8-22 regarding conducting a weekly Wound Meeting with the Interdisciplinary Team to discuss residents who are identified to be at risk identified through skin sweeps and nurse assessment. New and or worsening skin issues will be discussed during morning meeting to ensure appropriate treatment and notification are in place. Verbal presentation of assessments and documentation presented to nurse manager on 4-8-22. The Executive Director will be responsible for implementing and following through with the plan of correction to ensure compliance. The facility alleges the removal of Immediate Jeopardy on 4-9-22. On 4/12/22 the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: The 4/8/22 facility audit was reviewed and revealed 3 current residents were identified with skin integrity concerns. The Nurse Practitioner and responsible party were notified, orders obtained and initiated as well as care plans and Kardex's updated. Progress notes were documented in each resident's medical record. Review of wound care was completed as ordered since 4/8/22. Education regarding completing weekly skin sweeps and documenting in the medical record and completing treatments as ordered for licensed nursing staff was reviewed and sign in sheets were provided. Education for Nurse Aides and Medication Aides regarding assessing residents' skin daily during personal care and reporting to the charge nurse when issues were noted was reviewed and sign in sheets were provided. Review of Resident #32's medical record indicated the following had been completed on 4/8/22: - A full skin sweep was completed on 4/8/22 with the notation of an area to the right heel that was dark red and black in color. No other skin concerns were observed. - Clarification orders were received from the wound physician to discontinue skin prep, pad, and protection to bilateral heels and. Orders provided to use Betadine topically to the right heel every day, leave open to air after Betadine applied to dry then apply protective booties as tolerated and float the heels in bed as tolerated. - An assessment was completed by the physician and noted the resident was clinically stable. - The care plan was updated to include assess/record/monitor wound healing and update physician with any declines; pressure relief mattress; float heels in bed as tolerated; provide protective booties as tolerated; and recurring visits by the wound specialist. - The Kardex was updated to include skin protection methods put into place. A wound care observation of Resident #32 occurred with the interim Director of Nursing on 4/12/22 at 10:45 AM. Resident #32 was observed to be lying in bed watching TV. She had a pillow placed under knees and blue cloth protective booties to both feet. The right foot was observed with a black area on the heel. The area was dry in appearance with no drainage or odor noted. Wound care was provided as ordered with no concerns. Nurse #2 was interviewed on 4/12/22 at 11:30 AM and stated she had received recent education on completing weekly skin sweeps as scheduled as well as completing wound care as ordered until a treatment nurse was hired. On 4/12/22 from 11:45 AM until 12:10 PM interviews of 4 Nurse Aides was conducted which revealed they had recently received education on reporting any observed skin concerns immediately to the charge nurse or Nurse Manager. An interview occurred with the Administrator and interim Director of Nursing (DON) on 4/12/22 at 12:15 PM. The interim DON explained scheduled weekly skin sweeps were embedding into the Medication and Treatment Administration Records of the electronic medical record (EMR) system and would alert the nurse when one was due. In addition, the interim DON stated she reviewed the Dashboard feature of the EMR system multiple times during the day to ensure the scheduled skin sweep and skin treatments were completed as ordered. The interim DON stated she was covering as the wound nurse during the week and the Registered Nurse covered as the wound nurse on the weekends to ensure treatments were completed as ordered. The Administrator reported there were 2 meetings during the day (one in the morning and one in the afternoon) where wound care and concerns would be discussed. The Administrator added a wound care nurse had been hired and was due to start at the facility next week. The facility's Immediate Jeopardy removal date of 4/9/22 was validated. 1b) A nursing progress note dated 2/24/22 indicated Resident #32 was admitted to the facility. Her skin was warm and dry with redness to the sacrum. No other mention of skin concerns in the progress note. Resident #32's active physician orders were reviewed and revealed the following: - An order dated 3/9/22 to apply a thick layer of barrier cream to sacrum/buttocks twice a day for skin breakdown (at 9:00 AM and 5:00 PM). The March 2022 Treatment Administration Record (TAR) was reviewed for Resident #32 and revealed the following treatments were not documented as completed: - Sacrum/buttocks treatment at 9:00 AM on 3/12/22, 3/13/22, 3/17/22, 3/21/22, 3/26/22 and 3/27/22. - Sacrum/buttocks treatment at 5:00 PM on 3/12/22, 3/13/22, 3/15/22, 3/16/22, 3/17/22, 3/20/22, 3/21/22, 3/22/22, 3/23/22, 3/24/22, 3/25/22, 3/27/22, 3/28/22 and 3/29/22. On 3/30/22 at 9:45 AM, the Assistant Director of Nursing (ADON) was observed providing skin care to Resident #32. An observation occurred of Resident #32's buttocks which revealed no redness or skin breakdown. The ADON stated the order should have read to apply barrier cream to buttocks for protection and explained this occurred during incontinence care with the Nurse Aide's(NAs). The ADON was interviewed on 3/30/22 at 10:05 AM and explained she was assigned to do treatments when she wasn't assigned to work on a medication cart. She reported that if the treatment was not signed off on the TAR, the treatment was not provided since she nor the nurses had the chance to do them. The ADON added she used skin prep to cleanse wounds unless the order stated to use wound cleanser. On 3/30/22 at 3:04 PM, an interview occurred with Nurse #2, who worked the day shift (7:00 AM to 3:00 PM). Nurse #2 was assigned to care for Resident #32 on 3/17/22 and 3/21/22. She explained the ADON had been assisting with treatments since the facility didn't have a treatment nurse. When the ADON was assigned to work on a medication cart, the nurses were responsible for treatments. She reported if the TAR was not signed off, the treatment was not provided. Nurse #3 was interviewed on 3/30/22 at 3:07 PM and indicated she normally worked the evening shift (3:00 PM to 11:00 PM). Nurse #3 was assigned to care for Resident #32 on 3/15/22, 3/16/22, 3/17/22, 3/20/22, 3/21/22, 3/22/22, 3/23/22, 3/24/22, 3/25/22, 3/28/22 and 3/29/22. She explained evening shift nurses were responsible for completing treatments, if scheduled, and if the TAR was not signed off as completed it meant there wasn't enough time to get them completed. She was unable to state if the missed t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, Nurse Practitioner #1, Physician, Orthopedic Surgeon, Orthopedic Nurse, Wound Physician, resident and staff interviews, the facility administration failed to provide effective oversight to ensure practitioners were notified when a change in a pressure area was identified, weekly skin sweeps were completed as ordered, and daily wound care was completed as ordered to a resident that developed an unstageable pressure area (Resident #32). In addition, the facility administration also failed to provide effective oversight to ensure wound care for pressure and non-pressure related wounds were completed as ordered (Residents #9, #40, #48, #95, #3 and #195), and residents were transported to scheduled appointments or had appointments rescheduled (Residents # 3, #17, #31 and #195). In addition, the facility administration also failed to provide effective oversight to ensure wound care for pressure and non-pressure related wounds were completed as ordered (Residents #9, #40, #48, #95, #3 and #195), residents had transportation arrangements for scheduled appointments or had appointments rescheduled (Residents #3, #17, #31 and #195), residents had podiatry care arranged (Resident #32), residents medications were administered as ordered (Residents #15, #17, #32, #195 and #196) and the facility was homelike (room [ROOM NUMBER]). Immediate Jeopardy began on 3/5/22 when the facility administration failed to implement effective systems and/or processes to ensure residents received the necessary care and services to assess for pressure ulcers, provide daily wound care as ordered and ensure physician or Nurse Practitioner notification occurred when there was a change in wound status for Resident #32. Immediate Jeopardy was removed on 4/9/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (a deficiency that constitutes a pattern with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: 1a) This citation was cross referred to F 686 K: Based on observations, record reviews, and interviews with resident's, staff, Nurse Practitioner #1, Physician, and wound Physician, the facility failed to complete scheduled weekly skin sweeps (a head-to-toe skin assessment), provide daily wound care treatments as ordered, and failed to thoroughly complete a comprehensive assessment on 3/5/22 for a change in wound status. All of these actions contributed to the facility failing to identify when Resident #32 developed an unstageable pressure area. 2) This citation was cross referred to F 580 J: Based on record review, Nurse Practitioner #1, Physician and staff interviews, the facility failed to notify the Physician or Nurse Practitioner of a change in wound condition to Resident #32's right heel on 3/20/22. This was for 1 of 8 residents reviewed for pressure ulcers. The Administrator was notified of the Immediate Jeopardy on 4/8/22 at 7:56 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The Director of Nursing/Nurse Manger failed to monitor systems to ensure weekly skin sweeps and wound treatments complete. Weekly skin sweeps and progress note/change of condition will be monitored daily in clinical meeting by reviewing of assessments in electronic chart. Completion of ordered treatments will be reviewed daily in the electronic chart by Director of Nursing/Nurse Manager. Weekly wound meetings will be held by DON/Unit Manager along with IDT team and monitored by Executive Director to ensure complete. The Executive Director will monitor daily clinical meeting and weekly wound meeting to ensure done. The facility failed to complete scheduled skin assessments for a resident who developed an unstageable pressure injury and failed to provide wound care treatments as ordered (Resident #32). Resident #32 has been assessed by a Licensed Nurse on 4-8-22. Licensed Nurse completed chart review and skin sweep of Resident #32 on 4-8-22. Licensed Nurse notified Wound Specialist of current wound orders and protective measures. Recommendations to discontinue skin prep and pad and protection to bilateral heels. Clarification orders obtained for betadine solution daily to right heel and leave open to air after betadine is applied and float heels in bed and apply protective booties as tolerated. Medical Director assessed resident on 4-8-22 and noted the resident clinically stable. Care Plan was reviewed and updated to reflect protective booties as tolerated to promote healing. Resident #32 had interventions put into place by a Licensed Nurse and plan of care were reviewed and updated on 4-8-22. Resident #32 [NAME] has been updated by the Nurse Manager and identified from the plan of care and communicated by the nurse that interventions on the [NAME] for the nurse aides to review on 4-8-22. On 03/05/2022 resident #32 had a change in condition completed for pressure wound to R heel. MD was notified and new orders noted for skin prep to R heel. On 3/11/2022 order noted for skin prep to bilateral heels. A late entry nursing progress note dated 3/22/22 indicated Resident #32 was observed with eschar to her heel when a treatment was completed on 3/20/22. On 3/20/22 the facility failed to notify physician of change in wound. On 3/30/2022 new order noted for betadine to right heel pressure area. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The Regional [NAME] President of Operations (RVPO) educated the ED on 4/8/2021 in regard to implementing effective systems or processes to ensure residents received the necessary care and services to assess for pressure ulcers and provide wound care treatments as ordered. During the facility's stand up and stand down meeting on residents with pressure areas will be discussed and reviewed and chart review conducted by nursing manager and Executive Director. The Director of Nursing/Nurse Manager will report to the Executive Director daily during stand up/stand down meetings that wound dressings and skin assessments have been completed. The Executive Director educated on processes to monitor compliance of clinical meeting to include daily clinical and meeting and weekly wound meetings. The Executive Director will be responsible for implementing and following through with the plan of correction to ensure compliance. The facility alleges the removal of Immediate Jeopardy on 4-9-22. On 4/12/22 the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: Education regarding implementation of effective systems or processes to ensure residents will receive the necessary care and services to assess for pressure ulcers and provide wound care as ordered to the Administrator was reviewed and a signature sheet was provided. An interview occurred with the Administrator and interim Director of Nursing (DON) on 4/12/22 at 12:15 PM. The Administrator reported there were 2 meetings during the day (one in the morning and one in the afternoon) where the DON/Nurse Manager would report whether wound care and skin sweeps were completed. The Administrator added compliance would also be monitored in the weekly wound meetings as well. The facility's Immediate Jeopardy removal date of 4/9/22 was validated. This citation was cross referred to F 686 E for examples #1b, #2, #3 and #4: In addition, the facility failed to follow wound physician recommendations (Residents #9 and #40), failed to provide wound care as ordered (Residents #9 and #32), failed to change gloves and sanitize hands when going from soiled to clean surfaces during wound care (Resident #9) and failed to set a pressure reducing mattress according to resident's weight (Residents #9 and #11). This was for 4 of 8 residents reviewed for wound care. 3) This citation was cross referred to F584 D: Based on observations and interviews with resident and staff, the facility failed to address a peeling ceiling for 1 of 1 reviewed for environment (room [ROOM NUMBER]). 4) This citation was cross referred to F658 D: Based on record reviews, observations, and interviews with residents, staff, Nurse Practitioner #1, and Nurse Practitioner #2, the facility failed to administer medications as ordered (Residents #17 and #15) for 2 of 7 residents whose medications were reviewed. 5) This citation was cross referred to F684 G: Based on record reviews, observations, Orthopedic Surgeon, Orthopedic Nurse, Nurse Practitioner #1 (NP) and staff interviews, the facility failed to provide care to a surgical wound by not monitoring for signs and symptoms of infection and by not removing the staples as ordered (Resident #48). In addition, the facility failed to provide non-pressure related wound care as ordered (Residents #95 #3 & # 195). This was for 3 of 4 sampled residents reviewed for non-pressure wounds. Resident #48 was sent to the emergency room (ER) due to change in level of consciousness/unresponsiveness and was diagnosed with a wound infection. 6) This citation was cross referred to F687 D: Based on observation, record review, resident, staff and Nurse Practitioner #1 interviews, the facility failed to provide or arrange foot care for a resident with thick and long toenails (Resident #32) for 1 of 2 residents who were reviewed for foot care. 7) This citation was cross referred to F690 E: Based on record reviews and interviews with residents, staff, and Nurse Practitioner #1, the facility failed to follow up on urology consultations (Residents #31& #17) and failed to administer an antibiotic as ordered (Resident #196) for 3 of 17 resident records reviewed. 8) This citation was cross referred to 745 D: Based on record reviews, observations, and interviews with residents, staff, Nurse Practitioner #1, and Nurse Practitioner #2, the facility failed to ensure Resident #195 had transportation arrangements for a neurology appointment that was indicated on her hospital discharge instructions and failed to ensure Resident #3 had transportation arrangements for a scheduled prosthetic appointment, resulting in both residents missing the appointments. This was for 2 of 2 residents reviewed for medically related social services. 9) This citation was cross referred to F758 D: Based on record review, observation and interviews with staff and Nurse Practitioner #1, the facility failed to transcribe the correct frequency per the physician order for an antidepressant medication resulting in an excessive dose being provided (Resident #195). This was for 1 of 7 residents whose medications were reviewed. 10) This citation was cross referred to F760 E: Based on record reviews, pharmacy technician, Nurse Practitioner #1, and staff interviews, the facility failed to administer an anticoagulant (a medication that prevents blood clots, Residents #32 and #17) and an antipsychotic medication (Residents #15 and #17) in accordance with the physician's orders for 3 of 5 residents reviewed for unnecessary medications. An interview was conducted with the Director of Nursing (DON) on 3/31/22 at 2:00 PM and indicated she had been employed at the facility for close to 2 months and had just started the process of looking at where deficiencies may be in the nursing department. She reported there had been turn-overs in staff. The Administrator was interviewed on 3/31/22 at 3:00 PM. She stated she was aware this had been a problem about 2 years ago with the Resident Transporter and Scheduler not following through with resident scheduled appointments and a plan had been put into place for this to not occur again. She stated he had done better for a while, but it must have fallen by the wayside when the COVID-19 pandemic hit.