**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Medical Director, and Orthopedic Surgeon interviews, the facility failed to complete and document assessments of a surgical site. Resident #63 had an unwitnessed fall on 11/28/24 and suffered a fracture in the epicondyle region (bony prominence on the humerus bone in the arm) of the elbow. Resident #63's on 12/13/24 the resident underwent an open reduction internal fixation (ORIF) surgical procedure (involves making an incision to realign the bone and then holding the pieces together with hardware like plates, screws, or rods). At Resident #63's follow-up appointment with the Orthopedic Surgeon on 12/26/24 Occupational Therapy (OT) for range of motion (ROM), pain and edema (swelling caused by a buildup of fluid) control, home exercise program (HEP), and splint wear with removal for hygiene purposes and active ROM exercises was ordered. This order was not processed or communicated to OT. The 1/23/25 follow-up appointment with the Orthopedic Surgeon was cancelled due to Resident #63 being ill. The Transportation Aide rescheduled the appointment for 2/20/25. The facility did not seek guidance for care from the Orthopedic Surgeon in consideration of the delay with the follow-up appointment. There were no documented nursing assessments of Resident #63's surgical site from 12/13/24 through 2/20/25. The Orthopedic Surgeon removed the splint on 2/20/25 and observed a pressure wound over the medial aspect (area closest to the body) of the elbow with limited elbow range of motion and ordered wound care for the pressure wound. The Wound Nurse first observation of the surgical site was on 2/20/25. The Wound Care Provider saw the Resident weekly beginning on 2/25/25 and noted the wound was consistent with a medical device related stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). The pressure wound continued to deteriorate and on 3/26/25 Resident #63 was brought to the hospital for emergent surgery for irrigation and debridement of her right elbow with hardware removal. Resident #63 was admitted postoperatively and given intravenous (IV) antibiotics for MRSA (Methicillin-Resistant Staphylococcus aureus) which were continued after her discharge on [DATE]. This deficient practice affected 1 of 3 residents reviewed for quality of care. Immediate jeopardy began on 12/26/24 when the facility failed to implement and complete routine assessments of Resident #63's surgical site. Immediate jeopardy was removed on 04/11/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: Resident #63 was admitted on [DATE] with diagnoses that included non-traumatic brain dysfunction, hypertension, and Alzheimer's disease. Resident #63's quarterly Minimum Data Set (MDS) dated [DATE] indicated she had severe cognitive impairment and required maximal assistance with upper body dressing and personal hygiene. Resident #63 did not have any pressure wounds and was not receiving any therapy. On 11/28/24 at 4:15 PM Nurse #1 wrote Resident #63 was found lying on her right side, face down on the floor on the left side of the bed. The resident was noted to have right arm in flexed position and was unable to move her arm independently. The right arm was immediately immobilized to prevent further injury, and the resident was instructed not to move arm. Resident #63 was carefully placed onto her bed with multiple staff members. The Medical Director (MD) was notified and new orders received to obtain STAT (without delay) right humerus (long bone of the upper arm), elbow, radius (forearm), and ulna (one of two long bones in the forearm) x-ray due to the fall. Nurse #1 wrote on 11/28/24 at 4:35 PM the X-Ray technician performed an x-ray at bedside and confirmed a fracture in the epicondyle region of elbow. The x-ray technician was unable to perform other exams (radial/ulna/humerus) secondary to the resident's condition. A verbal order was received from the on-call provider to send to the emergency department (ED) for fracture of right elbow after the residents fall and the residents responsible party was aware of new orders. The Director of Nursing (DON) was contacted, and the [local county] emergency medical services (EMS) was in route to the facility. Resident #63's emergency department (ED) summary dated 11/28/24 revealed Resident #63 was brought to the ED after a fall and had a fractured right olecranon (bony prominence that forms the tip of the elbow). The discharge instructions indicated Resident #63 needed to see an orthopedic specialist within 10 days. Nurse #2 progress note written on 11/29/24 at 8:46 AM read Resident #63 returned from the hospital on a stretcher with maximum assistance x 2 transfer from the stretcher to bed. The resident is resting comfortably and responds to verbal and tactile stimulation. The resident's sling is intact to her right arm with good CNS to fingertips noted. Review of a physician order dated 11/29/24 read for non-weight bearing to right arm and sling to be worn at all times and for oxycodone 5 mg (milligrams) every 4 hours as needed for pain management were continued. The Orthopedic Surgeon's progress note dated 12/5/24 noted Resident #63 to clinic today with a transfer aide from her skilled nursing facility for evaluation of a right olecranon fracture. The resident reported that her pain has been 4/10 in severity. Resident #63 has been in a posterior slab splint but the transfer aide from her facility reports that she is taking it off. The Orthopedic Surgeon took Resident #63's splint down to evaluate her skin and found no open wounds or abrasions and there was no threatened skin. There was ecchymosis and swelling along the posterior aspect of her elbow and gentle range of motion of the shoulder did not seem to cause significant pain. All of the resident's fingers were pink and warm and well-perfused with brisk capillary refill. A nurse's note dated 12/6/24 at 11:08 AM written by the Director of Nursing (DON) indicated Resident #63's responsible party had consented with the orthopedic group for the resident to have surgery on her right upper extremity (RUE) to repair her fracture on 12/13/24. Outpatient surgery had been scheduled with the surgery center and pre-operation orders were received. The hospital discharge instructions dated 12/13/24 indicated Resident #63 had surgery for open reduction internal fixation (hardware placed on bone for stabilization). The discharge instructions were to follow up with the Orthopedic Surgeon on 12/26/24, take pain medications as instructed, non-weight bearing for operated limb. Incision care instructions were to wear a plastic bag over the effective extremity when taking a shower and to notify the provider if the splint gets wet to have it replaced. Other incision care instructions were to not use lotions or creams near the affected area and call the provider if the incision has drainage. The hospital discharge instructions dated 12/13/24 included physician orders for doxycycline hyclate (antibiotic) one (1) tab 100 mg twice daily for 14 days to treat or prevent infections. Also included was an order for acetaminophen-hydrocodone 325/5 mg oral tablet one (1) every 6 hours times 4 days for pain and non-weightbearing for operated limb. There were no assessments of the surgical documented by nursing staff from 12/13/24 through 12/26/24. An orthopedic progress note dated 12/26/24 indicated Resident #63 was seen by the Orthopedic Surgeon for a two-week follow-up post open reduction internal fixation of a right olecranon fracture. The resident was fitted with a custom fitted long arm posterior orthosis (an external device like a brace or a splint) for her right upper extremity by the orthopedic office occupational therapist. The progress note instructed to contact the occupational therapy department if needed. The progress note included the goal for Resident #63 was to be independent with wearing the orthosis and with its care and to follow surgical precautions with the orthosis. It was noted that the surgical incision was healing well along the posterior aspect of Resident #63's elbow. In addition, gentle range of motion of the elbow did not cause any significant pain and she had stable alignment of her elbow status post open reduction internal fixation with olecranon plate. The occupational therapist educated Resident #63 and her caregiver (Transportation Aide) on how to wear and provide care for the orthosis (an external medical device such as a brace or splint). The Transportation Aide was unavailable for interview. A signed paper Orthopedic Surgeon referral order dated 12/26/24 for Resident #63 to receive occupational therapy had been scanned into Resident #63's health record on 1/2/25 under the tab medications and treatments when all other orthopedic information was found under the consults tab. The occupational therapy referral order was for the resident to be evaluated and to treat the right olecranon ORIF with ROM (range of motion), pain and edema control, modalities, and HEP (home exercise program). It was noted Resident #63 needed to wear the splint at all times except for hygiene purposes and gentle AROM (active range of motion) exercises 1 to 2 times weekly for 8 weeks. Nurse #7 was identified as the nurse assigned to Resident #63 on 12/26/24. Attempts to contact Nurse #7 for a phone interview were not successful. Resident #63's physician's orders for December 2024 were reviewed and found no order entered on 12/26/24. The DON stated in an interview on 4/7/25 at 3:50 PM that Resident #63 had a follow up appointment scheduled with the Orthopedic MD on 01/23/25 but Resident #63 was sick, and the appointment was rescheduled for 02/20/25 by the Transportation Aide. Nurse #2 wrote on 1/27/25 at 5:41 PM the resident's splint is intact to right arm with good CNS to fingertips. There were no documented nursing assessments of Resident #63's surgical site or Occupational Therapy notes entered in the medical record from 12/26/24 through 2/20/25. An Orthopedic Surgeon progress note dated 02/20/25 indicated Resident #63 was seen today for a follow-up of her right olecranon fracture. The Orthopedic Surgeon wrote that he last saw the resident on 12/26/24, the resident was supposed to come back 4 weeks after that appointment, and it had been almost 2 months since he last saw her. The progress note included the resident had been wearing the splint at night and the nursing aide with her said the resident had been taking it off during the day. Upon removing the splint, the Orthopedic Surgeon indicated he noticed a pressure wound over the medial aspect (area closest to the body) of the elbow with limited elbow range of motion. Resident #63 still had steri-strips on her elbow from the last visit with the Orthopedic Surgeon and he wrote that it concerned him as to the hygiene of this area and whether she had been spending time out of the splint to work with therapy. The Orthopedic Surgeon indicated he was discontinuing her splint device and ordered wound care for the medial elbow wound. Additionally, he wrote the medial elbow wound was far away from her surgical incision and did not appear infected. He indicated there was no concern for exposed hardware in her elbow and wanted to be called by the facility right away if it became infected. The Orthopedic Surgeon wanted to see the resident for an appointment on 3/26/25 at 10:30 AM. Medication Aide #1 was interviewed on 4/9/25 at 1:33 PM. She stated that she had been assigned to Resident #63 regularly in December 2024, January and February 2025. She stated she remembered Resident #63 had a splint on her right arm in December, January and February and she had never removed that splint and had never seen any other nurses or NA's remove the splint. The Medication Aide said the splint was black and went from the back of the resident's upper arm to her forearm and it had Velcro straps that held it in place. She stated she never noticed a smell and did not recall Resident #63 complaining of pain in her right arm. Nurse #4 was interviewed on 4/09/25 at 1:50 PM. Nurse #4 worked was usually assigned to Resident #63 on night shift and had been assigned to the resident in December 2024 through April 2025. She stated she had never taken the splint off the resident and had not noticed the wound on her right arm smell. Nurse #4 stated she did check the capillary refill and circulation for the resident and that the resident never complained of pain. Nurse #4 stated her understanding was the splint was supposed to stay on Resident #63 because she did not see any orders for taking it off. NA #5 was interviewed on 4/9/25 at 1:32 PM and stated she remembered Resident #63 having 2 different types of splints and that the resident was able to take off both. NA #3 stated she was instructed that the splint was to stay on at all times. NA #5 stated she had never noticed a smell from the residents wound and the resident was able to communicate if she was in any pain. NA #5 said Resident #5 would sometimes complain of pain and NA #5 would tell her nurse. The Wound Nurse documented a progress note on 2/20/25 at 5:54 PM. The wound Nurse wrote Resident #63 had arrived back from her orthopedic office appointment. The resident had an elastic bandage wrap and cast padding on her right upper extremity after removing her splint. When splint was removed, the resident was noted to have a small open area to her right elbow measuring approximately 0.8 cm (centimeters) x 0.9 cm x 0.1 cm depth with rusty discoloration located around wound edges. There was mild serous drainage (wound discharge, clear to yellow in color) noted and the resident had complained of mild pain when palpation was performed that resolved once the stimulus was removed. Resident #63 was observed to also have hypergranulation tissue (overgrowth of healing tissue) above the ulcer as well. The Wound Provider was notified, and new orders were received from the Wound Provider. The Wound Nurse stated during an interview on 4/9/25 at 10:11 AM that Resident #63 came back from the orthopedic appointment on 2/20/25 and the resident was not wearing her splint for the first time since it was placed on her. The Wound Nurse stated it was his first observation of the resident's surgical site. He stated he did call the Orthopedic Surgeon to get treatment orders for the wound and he also called the Wound Provider for treatment orders. The Wound Nurse said the Wound Provider ordered the wound to be treated with Dakin's solution (diluted bleach used to kill germs) to pat dry, cover the wound with a pad and cover with tape. The Wound Nurse said it was a daily treatment and as needed. The Wound Provider's order written by the Wound Nurse on 02/20/25 read once daily, clean right elbow wound with quarter strength Dakin's and pat dry. Apply xeroform to wound bed and cover with a non-sticky pad. Wrap with kerlix (gauze bandage rolls) and secure with soft cloth surgical tape. Change daily and as needed. The Wound Nurse progress note dated 2/25/25 at 5:24 PM read that he had reached out to the resident's Orthopedic Surgeon regarding the Wound Providers treatment recommendations and to schedule the residents 6-week follow-up appointment. The appointment was rescheduled for Thursday 02/27/2025 at 8:00 AM. The orthopedic office was updated regarding the Wound Providers current treatment recommendations and the current treatment regimen that was in place. The Wound Nurse wrote he had spoken to the triage nurse for the Orthopedic Surgeon who said a message would be transcribed to the Orthopedic Surgeon. The progress note read the Wound Nurse had attempted to reach out to the orthopedic office to get further clarification and a second message was sent to the Orthopedic Surgeon. Resident #63 was first seen by the Wound Provider on 2/25/25. The Wound Provider noted the right elbow wound had full-thickness tissue loss overlying the olecranon. On examination, the surgical hardware was noted in the wound bed base and the wound site was reported to have developed secondary to a brace status post ORIF right olecranon. The Wound Provider indicated the wound was consistent with a medical device related stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) measuring 0.5 cm x 0.6 cm x 0.3 cm depth. The Wound Provider wrote the right medial elbow wound had full thickness tissue loss overlying the right medial epicondyle (bony prominence at the end of a long bone) with hypergranulation tissue present. The right medial elbow wound was reported to have developed secondary to a brace status post ORIF right olecranon and consistent with medical devise related stage 3 pressure injury measuring 0.8 cm x 0.8 cm x 0.2 cm depth. There were no signs of acute infection for any wounds. The treatment orders for the right medial elbow wound were from the Orthopedic Surgeon to cleanse the wound with normal saline, pat dry and apply xeroform to the wound bed. Then cover it with non-adherent pad and secure with rolled gauze wrap daily. The wound treatment orders for the right elbow wound with exposed surgical hardware were to loosely pack the wound with quarter strength Dakin's moistened gauze to provide topical antimicrobial control per Orthopedic Surgeons approval. The Wound Provider added she requested staff notify Orthopedic Surgeon of the hardware exposed in base of right elbow wound with the treatment recommendation above and requested for further evaluation per the Orthopedic Surgeon. On 2/26/25, the Wound Provider wrote an order that read to cleanse right elbow wound with quarter strength Dakin's solution and pat dry. Loosely pack with a quarter strength Dakin's moistened gauze and cover with a non-adherent pad, wrap with kerlix. Secure with soft cloth surgical tape. Change daily and as need for soiling or dislodgement. A physician order from the Orthopedic Surgeon on 2/26/25 indicated doxycycline hyclate (antibiotic) 100 mg twice daily by mouth for 21 days for medial elbow pressure wound. A review of the treatment administration record (TAR) dated 02/20/25 to 02/28/25 found the wound treatment order for right elbow wound was initialed completed once daily on 2/21/25 through 2/26/25. The right elbow wound treatment order written on 02/26/25 were initialed as completed 02/26/25, 02/27/25 and 02/28/25 on the TAR. A progress note dated 02/27/25 from the Orthopedic Surgeon indicated Resident #63 was seen for follow-up of her fractured right olecranon. Resident #63 was treated with open reduction and internal fixation on 12/13/24. The Orthopedic Surgeon wrote Resident #63 had seen him the previous week and was able to take her splint off and get her moving. The Orthopedic Surgeon noted he did not think Resident #63 had been moving much at the skilled nursing facility and her splint was still in place. Resident #63 returned to the clinic today at the Orthopedic Surgeon's request because he received a call from Resident #63's Wound Nurse who stated the medial elbow wound was healing but the wound over the posterior aspect of the elbow had opened up and you could see the plate at the bottom of the wound. The wound over the medial aspect was healing quite nicely and there was a small wound now present over the olecranon with some serosanguineous drainage (thin, pinkish, red drainage) coming from that wound. He wrote that he did think he saw Resident #63's olecranon plate in the base of the wound. The note included an order for doxycycline (antibiotic) 100 mg twice daily for 21 days prescribed on 02/26/25. The Orthopedic Surgeon wanted her to be seen again in 3 weeks. He wrote that the hardware might need to be removed if the wound did not heal up. The resident next appointment date was scheduled on 3/26/25 at 10:30 AM. The Wound Provider saw Resident #63 on 3/4/25 and wrote in the progress note the right elbow wound had decreased in length and width with an increase in depth noted measuring 0.3 cm x 0.3 cm x 0.4 cm depth. The Wound Provider wrote there was a decrease in overall wound volume and the exposed surgical hardware was present in wound bed base. The right medial elbow wound had measurements of 0.2 cm x 0.2 cm x 0.2 cm depth with a decrease in overall wound volume. The Wound Provider's treatment orders for the right elbow wound were to continue the treatment of normal saline cleanse to pat dry and apply xeroform to the wound bed. Additionally, to cover it with nonadherent pad and secure with rolled gauze wrap daily to provide topical antimicrobial control and to promote moisture balance. The treatment orders for the wound with exposed hardware were to continue treatment with loosely packing the wound with quarter-strength Dakin's moistened gauze. Then to continue with the current secondary treatment to provide topical antimicrobial control. The progress note included there were no signs of acute infection for any wound. A physician's order dated 3/05/25 read clean posterior biceps wound with normal saline and pat dry. Apply xeroform (non-adhering wound dressing) to wound bed and cover with a nonstick pad. Wrap with kerlix and secure with soft cloth surgical tape. Change daily. The Wound Provider progress noted dated 3/11/25 indicated right elbow wound with surgical hardware measured 0.3 cm x 0.4 cm x 0.2 cm depth and was healing. The Wound Provider noted there was a slight decrease in wound width with an increase in granulation tissue in the wound bed and the exposed surgical hardware was present in wound bed base. The wound did not have any signs of acute infection. It was documented that the right medial wound had been resolved. The wound treatment order for the right elbow wound was changed to a quarter-strength Dakin's irrigation, followed by loosely packing the wound with quarter strength Dakin's moistened gauze. Then to secure with silicone bordered super absorbent dressing daily to provide topical antimicrobial control. A Wound Provider order dated 3/11/25 read cleanse right elbow wound with quarter strength Dakin's solution and pat dry and loosely pack with quarter strength Dakin's moistened gauze. Cover with a silicone bordered super absorbent dressing and change daily as needed. The Wound Provider progress noted dated 3/18/25 revealed the right elbow wound with surgical hardware exposed measured 0.3 cm x 0.2 cm x 0.4 cm depth and the wound had not improved. The Wound Provider's note indicated the wound had signs of infection with moderate edema and mild seropurulent drainage present at the right elbow wound site. The Wound Provider additionally wrote there was no induration, no erythema, no odor, and no calor (warmth). Resident #63 did not have a fever on exam. The wound treatment orders were changed to quarter-strength Dakin's irrigation, followed by loosely packing the wound with Iodoform packing strip then secure the area with silicone bordered super absorbent dressing daily to provide topical antimicrobial control. A Wound Provider order dated 3/18/25 read to irrigate the right elbow wound with quarter strength Dankins. Pat dry/ loosely pack wound with moistened quarter strength Dakin's gauze. Cover with a large gauze wound dressing and secure with rolled gauze and tape once daily and as needed. A nurse's note written on 3/23/25 at 10:43 AM by the Wound Nurse read, new wound characteristics were observed with moderate seropurulent drainage (cloudy drainage) noted. The Wound Care Provider and attending Medical Director were notified. New orders were received for change in treatment, Ciprofloxacin (antibiotic) 500 mg twice a day for 10 days prophylaxis, and obtain a Complete Blood Count (CBC) with differential, Sedimentation Rate (Sed Rate), /C-Reactive Protein (CRP) on 03/24/2025. The TAR and MAR were updated, and orders were carried out as indicated. The Wound Nurse attempted to reach RP regarding new orders and current plan of care and was unable to reach or leave message. The Physician's order dated 3/23/25 read irrigate right elbow wound with quarter strength Dakin's, Pat dry/loosely pack wound with moistened quarter strength Dakin's gauze. Cover with a large gauze wound dressing and secure with rolled gauze and tape once daily and as needed. Physician's order dated 3/24/25 read Ciprofloxacin (antibiotic) 500mg twice a day for 10 days prophylaxis (preventative treatment for infection) and obtain CBC with diff/Sed Rate/CRP on 03/24/2025. The Wound Nurse wrote on 3/24/25 at 1:25 PM that the orthopedic office was contacted regarding the change in wound characteristics and increased inflammation present with seropurulent drainage noted. The resident's vital signs were 98.3, 85 pulse, 20 respirations, 124/85 blood pressure, 96% oxygen saturation on room air with no shortness of breath present. Resident #63 had lab work obtained today and continues on by mouth antibiotic for prophylaxis wound infection. A physician's order dated 3/25/25 read to irrigate right elbow wound with quarter strength Dakin's solution, pat dry/ loosely pack wound with moistened quarter strength Dakin's gauze. Cover with a large gauze wound dressing and secure with rolled gauze and tape twice daily and as needed. The Wound Provider saw Resident #63 on 3/25/25 and wrote in the progress note that the right elbow wound with surgical hardware exposed measured 0.9 cm x 0.9 cm x 0.8 cm depth and the wound had not improved. The Wound Provider wrote there was a large amount of edema, induration (thickening and hardening of soft tissue) and moderate erythema (redness) was present in the elbow. The Wound Provider indicated there was a large amount of seropurulent drainage (indicates potential infection) present on exam with no odor noted. The resident was in moderate pain with the palpation of the wound and PRN (as needed) medication was requested and administered by nursing staff. The Wound Provider wrote to premedicate the resident for pain prior to wound care exam. The wound care treatment order was changed to quarter-strength Dakin's irrigation and loosely pack the wound with quarter-strength Dakin's moistened packing strip. The order continued with covering the area with super absorbent dressing and secure with rolled gauze wrap and tape BID (two times daily) to provide topical antimicrobial control. A Physician's order dated 3/25/25 read for right elbow wound to irrigate with quarter strength Dakin's, pat dry. Loosely pack wound with moistened quarter strength Dakin's gauze. Cover with and large gauze wound dressing and secure with rolled gauze and tape two times daily and as needed. The Orthopedic Surgeon's progress note dated 3/26/25 and signed at 11:51 AM wrote Resident #63 returned to the clinic today. The facility had noticed over the past few days increasing redness, swelling and draining from her elbow wound. The Orthopedic Surgeon wrote the resident had developed an infection going down to her plate and in the olecranon bursa (small fluid filled sack at the tip of the elbow). The progress note indicated an x-ray was conducted and the Orthopedic Surgeon reviewed the x-ray and wrote he did not see any indication of osteomyelitis (infection of the bone) from the elbow's bony prominence. The Orthopedic Surgeon noted they should proceed to the operating room today for irrigation, debridement (removing dead damaged or infected tissue) and hardware removal. The Orthopedic Surgeon concluded this would allow the resident to be admitted to the hospital for IV (intravenous) antibiotics and postoperatively and for him to better provide treatment to the resident moving forward. A nurse's note written on 03/26/25 at 1:30 PM by Nurse #3 indicated Resident #63 returned from her appointment at the orthopedic office with scheduled surgery for hardware removal today (03/26/25). The resident's responsible party was notified, and consent was given. Resident #63's hospital Discharge summary dated [DATE] revealed Resident #63 was brought to the hospital on [DATE] for irrigation and debridement of her right elbow with hardware removal. A progress note dated 3/27/25 by the admitting hospitalist wrote Resident #63 was received from the orthopedic office with a swollen and erythematous (red and swollen) right elbow for emergent surgery on 3/26/25. Resident #63 was admitted postoperatively and given IV antibiotics for MRSA (Methicillin-Resistant Staphylococcus aureus). The hospital Discharge summary dated [DATE] read Resident #63 was to receive PT or OT 2 to 4 days week. The resident will receive IV antibiotics via PICC (peripherally inserted central catheter, is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart). The wound dressings were to remain until seen in Orthopedic Surgeons follow up appointment. The discharge summary included orders to assist with IV vancomycin 1 gram every 12 hours for wound and bone infection and end after 5/5/25. Additional orders read to assist with getting labs drawn every Monday for vancomycin trough, CRP, ESR, BMP, and CBC. Furthermore, the resident is to be non-weight bearing to operative arm and to follow-up with the Orthopedic Surgeon on 4/16/25 at 10:45 AM. A nurse's note dated 04/01/25 written by Nurse #2 indicated Resident #63 was re-admitted to the facility on [DATE] at 2:20 pm. Resident #63 was sent to the hospital on [DATE] from the orthopedic office due to a right elbow infection. The resident was taken into emergency surgery for irrigation and debridement of her right elbow with hardware removal. Resident #63 was non-weightbearing to the right arm, splint was to remain in place and dry until follow-up, if splint got wet a call was to be made to the Orthopedic Surgeon immediately. Resident #63 had a midline port (Intravenous catheter inserted into the upper arm) placed in her right upper chest and received vancomycin (antibiotic) 1 gram every 12 hours until 05/8/25. A physician order written on 04/01/25 for Resident #63 indicated vancomycin-diluent combo 1 gram/200 milliliters intravenous for right elbow methicillin-resistant Staphylococcus aureus (MRSA). Infuse over one hour with 200 milliliters per hour PICC to right chest, every 12 hours until 05/08/25. Order written on 04/01/25 for splint to right upper extremity to remain in place until follow-up appointment on 4/16/25. Nurse to assess circulation to right upper extremity every shift. A review of the April 2025 MAR found the order for assessing circulation to right upper extremity every shift was signed completed each shift. Review of the medical record revealed Resident #63 was not seen by OT at the facility after the 12/26/24 order from the Orthopedic Surgeon until 04/02/25. The Therapy Director was interviewed on 04/08/25 at 4:58 PM. She stated she did not receive a referral for Resident #63 to be evaluated or receive treatment until 4/2/25. She stated the splint on Resident #63's arm and elbow was not difficult to remove and was used to keep the elbow and arm stable. The Therapy Director said the splint device might have been able to be changed to another splint to allow for easier hygiene care with agreement from the orthopedic provider. The Therapy Director said had she seen a therapy referral for Resident #63, an occupational therapist would have been sent to evaluate the resident specifically for the need indicated on the referral. Resident #63's plan of care for therapy would then be developed for her treatment, and the resident's hygi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Medical Director, and Orthopedic Surgeon interviews, the facility failed to communicate to the therapy department an Occupational Therapy (OT) referral ordered by Resident #63's Orthopedic Surgeon for evaluation and treatment of the resident's right olecranon (tip of the elbow). On 12/13/24 the resident underwent an open reduction internal fixation (ORIF) surgical procedure (involves making an incision to realign the bone and then holding the pieces together with hardware like plates, screws, or rods). At Resident #63's follow-up appointment with the Orthopedic Surgeon on 12/26/24 he ordered OT for range of motion (ROM), pain and edema (swelling caused by a buildup of fluid) control, home exercise program (HEP), and splint wear with removal for hygiene purposes and active ROM exercises. Resident #63's splint was not removed until her 2/20/25 follow up appointment with the Orthopedic Surgeon and she was not evaluated by OT until 4/2/25. Resident #63 developed 2 pressure ulcers to the right elbow, she required surgery for an infection with removal of the previously inserted surgical hardware, and treatment with intravenous (IV) antibiotics. Resident #63 had a high likelihood of suffering serious harm as a result of this failure. This deficient practice affected 1 of 1 resident reviewed for therapy. Immediate jeopardy began on 12/26/24 when the facility failed to implement the OT referral that included splint removal placing Resident #63 at high risk for development of pressure wounds and infection. Immediate jeopardy was removed on 04/10/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: Resident #63 was admitted on [DATE] with diagnoses that included non-traumatic brain dysfunction, hypertension, anxiety, depression, and Alzheimer's disease. Resident #63's quarterly Minimum Data Set (MDS) dated [DATE] indicated she had severe cognitive impairment and required maximal assistance with upper body dressing and personal hygiene. Resident #63 did not have any pressure wounds and was not receiving any therapy. Resident #63's emergency department (ED) summary dated 11/28/24 revealed Resident #63 was brought to the ED after a fall and had a fractured her right olecranon. The discharge instructions indicated Resident #63 needed to see an orthopedic specialist within 10 days. A nurse's note dated 12/6/24 at 11:08 AM written by the Director of Nursing (DON) indicated Resident #63's responsible party had consented with the orthopedic group for the resident to have surgery on her right upper extremity (RUE) to repair her fracture on 12/13/24. Outpatient surgery had been scheduled with the surgery center and pre-operation orders were received. The hospital discharge instructions dated 12/13/24 indicated Resident #63 had surgery for open reduction internal fixation. The discharge instructions were to follow up with the Orthopedic Surgeon on 12/26/24, take pain medications as instructed, and she was to be non-weight bearing for operated limb (right upper extremity). An orthopedic progress note dated 12/26/24 indicated Resident #63 was seen for follow-up 2 week's status post open reduction internal fixation of a right olecranon fracture. The resident was fitted with a custom fitted long arm posterior orthosis (an external device like a brace or a splint) for her right upper extremity by the orthopedic office occupational therapist. The occupational therapist indicated Resident #63 and her caregiver were educated on how to wear and provide care for the orthosis. The progress note indicated to contact the occupational therapy department if needed. The progress note included the goal for Resident #63 to be independent with wearing the orthosis and with its care and to follow surgical precautions with orthosis. The surgical incision was healing well along the posterior aspect of Resident #63's elbow. Gentle range of motion of the elbow did not cause any significant pain and she had stable alignment of her elbow status post open reduction internal fixation with olecranon plate. A signed Orthopedic Surgeon referral order dated 12/26/24 had been scanned into Resident #63's health record on 1/2/25 under the tab medications and treatments when all other orthopedic information was found under the consults tab. The referral order was for the resident to be evaluated and to treat the right olecranon ORIF with ROM, pain and edema control, modalities, and HEP (home exercise program). Resident #63 needed to wear the splint at all times except for hygiene purposes and gentle AROM (active range of motion) exercises 1 to 2 times weekly for 8 weeks. An Orthopedic Surgeon progress note dated 02/20/25 indicated Resident #63 was seen today for a follow-up of her right olecranon fracture. The Orthopedic Surgeon indicated he last saw the resident on 12/26/24, the resident was supposed to come back 4 weeks after that appointment, and it had been almost 2 months since he last saw her. The progress note indicated the resident had been wearing the splint at night and the nursing aide with her said the resident had been taking it off during the day. Upon removing the splint, the Orthopedic Surgeon indicated he noticed a pressure wound over the medial (area closest to the body) aspect of the elbow with limited elbow range of motion. Resident #63 still had steri-strips on her elbow from the last visit with the Orthopedic Surgeon and he wrote that it concerned him as to the hygiene of this area and whether she had been spending time out of the splint to work with therapy. He wrote that he questioned if she still had surgical prep (anti-microbial agent used in preparation of a surgical site) on her hands and indicated she definitely had scaly skin in the area. The Orthopedic Surgeon indicated he was completely discontinuing her splint device and ordered wound care for the medial elbow wound. Additionally, he indicated the medial elbow wound was far away from her surgical incision and did not appear infected. He noted there was no concern for exposed hardware in her elbow and wanted to be called right away by the facility if it became infected. A nurse's note dated 2/20/25 at 5:54 PM written by Nurse #2 indicated Resident #63 had arrived back from her orthopedic appointment with an elastic bandage wrap and cast padding on RUE secondary to removal of her splint. When the splint was removed, Resident #63 was noted to have a small open area to her right elbow measuring approximately 0.8 cm (centimeters) x 0.9 cm x 0.1 cm depth with rusty discoloration located around wound edges and mild serosanguineous (cloudy fluid) drainage noted. The resident complained of mild pain when palpation (touched with hand) was performed but pain resolved once the stimulus was removed. Resident #63 was observed to have hypergranulation (healing tissue expanding beyond the wound) tissue above the ulcer. The Wound Provider was notified and new orders were received. The treatment administration record (TAR) was updated, and new orders were carried out. A physician order from the Orthopedic Surgeon on 2/26/25 indicated doxycycline hyclate (antibiotic) 100 milligram 2 times daily by mouth for 21 days for medial elbow pressure wound. A progress note dated 02/28/25 from the Orthopedic Surgeon indicated Resident #63 was seen for a follow-up of her fractured right olecranon. Resident #63 was treated with open reduction and internal fixation on 12/13/24. The Orthopedic Surgeon wrote Resident #63 had seen him the previous week and was able to take her splint off and get her moving. The Orthopedic Surgeon noted he did not think Resident #63 had been moving much at the skilled nursing facility and her splint was still in place. Resident #63 returned to the clinic today at the Orthopedic Surgeon's request because he received a call from Resident #63's Wound Nurse who stated the medial elbow wound was healing but the wound over the posterior aspect of the elbow had opened up and you could see the plate at the bottom of the wound. The wound over the medial aspect was healing quite nicely and there was a small wound now present over the olecranon with some serosanguineous explain fluid coming from that wound. He wrote that he did think he saw Resident #63's olecranon plate in the base of the wound. The note included an order for doxycycline antibiotic 100 milligrams twice daily for 21 days prescribed on 02/26/25. The Orthopedic Surgeon wanted her to be seen again in 3 weeks. He wrote that the hardware might need to be removed if the wound did not heal up. The Orthopedic Surgeon's progress note dated 3/26/25 and signed at 11:51 AM indicated Resident #63 returned to the clinic today. The facility had noticed over the past few days increasing redness, swelling and draining from her elbow wound. Resident #63 had developed an infection going down to her plate (surgical hardware) and in the olecranon bursa (a small, fluid-filled sac located at the olecranon). An x-ray was completed and the Orthopedic Surgeon reviewed the x-ray and wrote he did not see any indication of osteomyelitis from the elbow's bony prominence. The Orthopedic Surgeon went on to note they should proceed to the operating room today for irrigation, debridement and hardware removal. This will allow the resident to be admitted to the hospital for IV antibiotics and postoperatively and for him to better provide treatment to the resident moving forward. A nurse's note written on 03/26/25 at 1:30 PM by Nurse #3 indicated Resident #63 returned from her appointment at the orthopedic office with scheduled surgery for hardware removal today (03/26/25). The resident's responsible party was notified and consent was given. Resident #63's hospital Discharge summary dated [DATE] revealed Resident #63 was brought to the hospital on [DATE] for irrigation and debridement of her right elbow with hardware removal. A progress note dated 3/27/25 by the admitting hospitalist wrote Resident #63 was received from the orthopedic office with a swollen and erythematous (red and swollen) right elbow for emergent surgery on 3/26/25. Resident #63 was admitted postoperatively and given IV antibiotics for MRSA (Methicillin-Resistant Staphylococcus aureus). The hospital Discharge summary dated [DATE] read Resident #63 was to receive PT or OT 2 to 4 days week. The resident will receive IV antibiotics via PICC (peripherally inserted central catheter, is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart). The wound dressings were to remain until seen in Orthopedic Surgeons follow up appointment. The discharge summary included orders to assist with IV vancomycin 1 gram every 12 hours for wound and bone infection and end after 5/5/25. Additional orders read to assist with getting labs drawn every Monday for vancomycin trough, CRP, ESR, BMP, and CBC. Furthermore, the resident is to be non-weight bearing to operative arm and to follow-up with the Orthopedic Surgeon on 4/16/25 at 10:45 AM. A nurses note dated 04/01/25 written by Nurse #2 indicated Resident #63 was re-admitted to the facility on [DATE] at 2:20 pm. Resident #63 was sent to the hospital on [DATE] from the orthopedic office due to a right elbow infection. The resident was taken into emergency surgery for irrigation and debridement of her right elbow with hardware removal. Resident #63 was non-weightbearing to the right arm, splint was to remain in place and dry until follow-up, if splint got wet a call was to be made to the Orthopedic Surgeon immediately. Resident #63 had a midline port (Intravenous catheter inserted into the upper arm) placed in her right upper chest and received vancomycin (antibiotic) 1 gram every 12 hours until 05/08/25. A physician order written on 04/01/25 for Resident #63 indicated vancomycin-diluent combo 1 gram/200 milliliters intravenous for right elbow methicillin-resistant Staphylococcus aureus (MRSA). Infuse over one hour with 200 milliliters per hour PICC (thin tube inserted into a vein in the upper arm that extends into a larger vein leading to the heart) to right chest, every 12 hours until 05/08/25. The medical record revealed Resident #63 was not seen by OT at the facility after the 12/26/24 order from the Orthopedic Surgeon until 04/02/25. The DON verified in an interview on 04/07/25 at 3:50 PM that Resident #63 went to a follow-up orthopedic appointment on 02/20/25 and when the splint was removed by the Orthopedic Surgeon, he found a pressure wound under the splint. The DON stated the splint had not been removed from 12/26/24 to 02/20/25 because the Transportation Aide told her on 12/26/24 that the splint was not supposed be removed for any reason. The DON indicated she saw the 12/26/24 orthopedic progress note but had not seen the referral order. She explained these were separate documents and they were scanned into the electronic medical record on different tabs. The DON stated she thought the orthopedic progress note indicating OT was for the orthopedic OT and not the facility's OT. The DON stated in interview on 04/09/25 at 1:57 PM that she was not aware of the orthopedic office referral order dated 12/26/24 for Resident #63 to receive occupational therapy 1-2 times per week for hygiene and active range of motion. The DON stated the order from the Orthopedic Surgeon should have been read and reviewed by the nurse who was working when the resident returned from the appointment (Nurse #7), and the order should have been placed in Resident #63's chart in with other orthopedic information. The DON said normally, a referral from an outside provider was handed directly to her by the Transportation Aide or nurse for review and sometimes appointment information was given to medical records before the DON. Medical records would scan in the appointment progress notes and then give the hard copy to the DON or nurse. The DON indicated she thought the referral order was given to medical records by the Transportation Aide because she was unaware of the order. She explained she thought this because the referral order was scanned in and not delivered to her or the resident's nurse when she returned to the facility because no one was aware of the order. The Transportation Aide was not available for interview. The Orthopedic Surgeon was interviewed via phone of 04/09/25 at 3:30 PM. He stated Resident #63 was his patient and had come to his office with a fractured right olecranon on 12/05/24 and had surgery to stabilize the fracture on 12/13/25. The Orthopedic Surgeon stated he saw Resident #63 on 12/26/24 for a follow-up appointment. He stated in his notes he ordered Resident #63's splint to be removed for hygiene and active range of motion therapy with occupational therapy in the resident's facility. The Orthopedic Surgeon said hygiene included removing the splint to look for skin breakdown and cleanliness. Additionally, he would not order an elbow splint to remain on the resident for 2 months because the elbow could become very stiff. He said Resident #63 had a diagnosis of dementia and needed assistance with the splint and was not able to advocate for herself. Resident #63 could not be relied on by herself to care for her splint which included removing it for hygiene and active range of motion. On 12/26/24 the Orthopedic Surgeon ordered Resident #63 to receive occupational therapy in her facility for active range of motion and hygiene for 1 to 2 times per week and the orders were sent to Resident #63's facility with the Transportation Aide. He said he recalled the resident having a Transportation Aide with Resident #63 at the appointments and he told her about the care Resident #63 needed along with his orders. He stated he reviewed his orders with the Transportation Aide before Resident #63 left her appointment with him. The Orthopedic Surgeon said Resident #63 was in a skilled nursing facility and should have been receiving occupational therapy as he ordered. The Orthopedic Surgeon went on to say the 2 wounds that developed on Resident #63's elbow could not be attributed directly to the splint that was not removed from 12/26/24 until 02/20/25. The elbow was susceptible to developing wounds with the comorbidities Resident #63 had and her advanced age. The Orthopedic Surgeon stated not removing the splint for hygiene and therapy did increase the risk for the resident to develop pressure wounds under the splint and infection. The Therapy Director was interviewed on 04/08/25 at 4:58 PM. She stated she did not receive a referral for Resident #63 to be evaluated or receive treatment until 4/2/25. She stated the splint on Resident #63's arm and elbow was not difficult to remove and was used to keep the elbow and arm stable. The Therapy Director said the splint device might have been able to be changed to another splint to allow for easier hygiene care with agreement from the orthopedic provider. The Therapy Director said had she seen a therapy referral for Resident #63, an occupational therapist would have been sent to evaluate the resident specifically for the need indicated on the referral. Resident #63's plan of care for therapy would then be developed for her treatment, and the resident's hygiene under the splint would have been done per the treatment order. The Therapy Director said hygiene for Resident #63's splint would include removing the splint and checking the skin for integrity or infection. She said soap and a washcloth would be used to clean the skin. Additionally, the Therapy Director said when the splint was removed the resident's range of motion and blood flow would be evaluated. The Therapy Director stated she felt Resident #63's range of motion and blood flow might have helped reduce the risk of a pressure wound from developing. She stated it was a collaboration between therapy and nursing to ensure the resident was receiving the care needed for the resident's therapy progression. The Therapy Director went on to say she received therapy referrals from outside providers in different ways such as progress notes or direct referral orders that would have been given to her by nursing. The Therapy Director stated she did think Resident #63 should have been seen by the therapist in the facility for range of motion and hygiene. A follow-up interview with the Therapy Director occurred on 04/08/25 at 5:30 PM. She stated Resident #63 was last seen by therapy in September 2024 and had not been to therapy until 04/02/25. The Therapy Director stated that HEP as written on the 12/26/24 orthopedic referral meant for the resident to do exercises to help with range of motion. She stated Resident #63 had a diagnosis of dementia and would not have been able to do a HEP without assistance. The Medical Director (MD) was interviewed via phone on 04/08/25 at 4:46 PM. The MD stated normally a copy of notes or orders from an outside provider would have been given to him to review by a nurse, the DON or placed in the doctor's book for him to review. The MD said he did not recall seeing a consult for an occupational therapist referral for Resident #63 from the orthopedic office in December 2024. The MD went on to say the Orthopedic Surgeon's notes should have been reviewed by a nurse or the DON and then scanned into the electronic medical record for the resident. The MD stated he expected orthopedic orders to be followed by the facility. The Administrator was interviewed on 4/9/25 at 2:03 PM and stated the Orthopedic Surgeon referral orders from 12/26/24 should have been reviewed and the orders followed. The order for the resident to receive OT and hygiene should have been captured. The facility's Administrator was notified of Immediate Jeopardy on 04/09/25 at 5:15 PM. The facility provided the following credible allegation of immediate jeopardy removal: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: On 12/26/24 the facility failed to communicate a therapy referral from an orthopedic provider for Resident #63 to have Occupational Therapy (OT) evaluate and treat the right elbow fracture. The referral also had recommendations for Resident #63 to wear the splint at all times except for hygiene purposes and gentle active range of motion exercise. Resident #63 was not evaluated by OT until 04/02/25. On 02/20/25 Resident #63 returned to the orthopedic doctor's office. At the visit the splint was removed and a pressure ulcer over the medial aspect of the elbow with some limited range of motion was noted. On 02/20/25 the Wound Nurse received new wound care orders from the wound provider for Resident #63. On 02/25/25 the Wound Provider evaluated the wound and determined that it was a stage 3 and stage 4 pressure ulcer and the orthopedic hardware was exposed. The Wound Provider instructed the staff to notify the Orthopedic doctor and provided new wound care orders. On 03/26/25 Resident #63 required surgery to remove the exposed hardware and returned to the facility on [DATE] on intravenous (IV) antibiotic for Methicillin resistant staphylococcus aureus (MRSA) of the wound. Because all residents with new orders for referrals to therapy services are at risk when a physician's order is not followed the following plan has been devised: On 04/09/25 the Administrator and the Director of Clinical Services reviewed all resident orders with outside appointments in the past 90 days to ensure they were in place and correct. No new issues were identified. No other referral orders for therapy were missing. On 04/09/25 the Therapy Director completed an audit of all current facility residents with therapy orders to ensure the correct physician ordered treatment was in place. All resident treatments were correct and matched the physician's order. 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. Director of Nursing, Unit Manager's, Minimum Data Set (MDS) Nurse, and Medical Director conducted an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting to review and determine root cause of the deficient practice. By root cause analysis, the QAPI committee determined that the referral form was returned with Resident #63 on 12/26/24 but was not given to the nurse to review. Instead, it was placed in the Medical Record folder to be uploaded to the medical record. The recommendations for an Occupational Therapist referral and to take the splint off for hygiene and active range of motion were not implemented. To address the root cause the facility implemented education on who will be responsible for ensuring the referral form is brought back to the facility when a resident has an outside appointment so new recommendations or orders can be implemented. The Unit Manager will be responsible for ensuring the referral form returns with the resident. If it is the weekend or after the Unit Manager has left, the hall nurse will be responsible. The transporter will notify the Unit Manager the resident is back from the appointment and will give her any paperwork at that time. If there is no referral form, the Unit Manager will call the physician office to obtain a copy of the form. On 04/09/25, the Director of Clinical Services provided education to the Administrator, DON, Transportation driver and ADON that included the following: A) The transportation driver will notify the Unit Manager or hall nurse the resident has returned from the outside appointment, the Unit Manager will be responsible for obtaining a completed referral form or encounter notes from the appointment visit. For appointments/ER visits occurring on weekends the hall nurse will be responsible for obtaining and reviewing the referral. B.) Unit manager, or designee, will be responsible for entering orders and ensuring any therapy referrals are received by therapy. For appointments/ER visits occurring on the weekends the hall nurse will be responsible for entering orders and ensuring any therapy referrals are received by therapy. C.) The DON will have a list of daily resident appointments and will follow up with the Unit Managers daily to ensure all referral forms have been returned and reviewed, with any new orders entered into the medical record. D.) Nurse Aides that accompany a resident to an outside appointment are there to care for the resident. The Transportation Driver will be responsible for ensuring any paperwork, and the referral form, are returned to the Nurse Manger or hall Nurse. E.) On 04/09/25 the Unit Manager was educated that when a family member signs the resident out for an outside appointment, they are to follow up with the family when they sign the resident back into the facility to ensure all paperwork has been given to the nurse for review. F.) Unit Managers, or designee will be responsible for taking any therapy referral orders for new admissions to the therapy department on the day of admission. On 04/09/25 DON and ADON provided education to all facility Licensed Nurses and Nurse Aides that included the following: A) Unit Manager, or designee, will be responsible for obtaining a completed referral form or encounter note from the appointment visit. For appointments/ER visits occurring on weekends, the hall nurse will be responsible for obtaining and reviewing the referral. B.) Unit manager, or designee, will be responsible for entering orders and ensuring any therapy referrals are received by therapy. For appointments/ER visits occurring on the weekends, the hall nurse will be responsible for entering orders and ensuring any therapy referrals are received by therapy. C.) Nurse Aides that accompany a resident to an outside appointment are there to care for the resident. The Transportation Driver will be responsible for ensuring any paperwork and the referral form are returned to the Unit Manager or hall Nurse. D) The DON will have a list of daily resident appointments and will follow up with the Unit Managers every day to ensure all referral forms have been returned and reviewed, with any new orders entered into the medical record. E.) On 04/09/25 the Unit Manager was educated that when a family member signs the resident out for an outside appointment, they are to follow up with the family when they sign the resident back into the facility to ensure all paperwork has been given to the nurse for review. F.) Unit Managers, or designee will be responsible for taking any therapy referral orders for new admissions to the therapy department on the day of admission. The current facility Licensed Nurses and newly hired nurses not received education on 04/09/25 will not be allowed to work until the education has been completed. The DON will utilize an active employee list to track completion of education and validate the post education written test was completed and passed. This responsibility was communicated to the DON by the Administrator on 04/09/25. Education will also be included during orientation for newly hired facility Licensed Nurses, Nurse Aides, and Transportation drivers, to be completed by Director of Nursing or Nurse Manager. Effective 4/09/25, the Administrator and Director of Nursing will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged noncompliance. Alleged Date of Immediate Jeopardy Removal: 4/10/25 Onsite validation of the facility's immediate jeopardy removal plan was completed on 4/14/25. The facility's QAPI meeting to determine a root cause of the deficient practice was verified to be held on 4/9/25 and included the Administrator, Medical Director, DON, Dietary Manager, Social Worker, Therapy Director, MDS nurse, floor nurses, Regional Operations Manager, and Director of Clinical Services. The 4/9/25 audits were both verified as completed to include a review of every resident's appointment dates and locations from the past 90 days and the orders for therapy to ensure the correct physician ordered treatment was in place for all disciplines (PT, OT, ST). Education was conducted on 4/9/25 as indicated in the removal plan by the Director of Clinical Services to the Administrator, DON, Transportation Driver and ADON. Additional education note in the removal plan was conducted on 4/9/25 that included all licensed nurses, nursing aides. Education was verified as complete by reviewing the education signature sheet and staff interviews. The education included a test that each participant completed and passed, and each participant had signed completion and understanding of the education. Furthermore, the education was verified to be added to orientation for new hires. The immediate jeopardy removal date of 4/10/25 was validated.