**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and Medical Director (MD) interviews, the facility failed to notify the physician for a resident who had a significant change in condition. On [DATE] Resident #1 was observed with audible congestion, difficulty swallowing, and was trying to cough up phlegm. The MD or Nurse Practitioner (NP) were not notified. On [DATE] Resident #1 had his mouth open with clear phlegm noted in his mouth and he was coughing. Resident #1's vital signs included a blood pressure (BP) of 90/86 (normal 120/80), pulse of 48 (normal range 60-100), oxygen at 89% (normal range between 95% and 100%) on room air, and respirations of 12 (normal range 12-18). He had audible congestion, and his skin was extremely hot to touch. The MD or Nurse Practitioner (NP) were not notified. At 5:00 AM Resident #1 was found not breathing and was pronounced deceased at 6:15 AM. This was for 1 of 3 residents reviewed for notification of change of condition. The findings included: Resident #1 was readmitted to the facility on [DATE]. His diagnosis included type 2 diabetes mellitus (DM), anxiety, chronic congestive heart failure (CHF), and dysphagia (difficulty swallowing). Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was intact. There was no rejection of care or behaviors coded. A Nurse Practitioner (NP) progress note dated [DATE] revealed Resident #1 was lying in bed with eyes closed, easily arousable and answering questions when asked. He denied shortness of breath and there was no cough observed. The note also revealed that during physical exam of Resident #1's chest/pulmonary and general/constitutional systems that no physical findings pertinent to this encounter. An interview with Med Aide (MA) #1 was conducted on [DATE] at 10:40 AM. She verified she was the direct care MA for Resident #1 on [DATE] and she did not observe any concerns with him on first shift (7A-3P). She further stated he was talkative and did not voice any concerns. An interview with Nurse #3 was conducted on [DATE] at 10:05 AM. Nurse #3 stated she cared for Resident #1 on [DATE] from 3:00 PM to 4:00 PM. Nurse #3 explained she was the wound care nurse however they had a call out and she was covering the assignment until Nurse #1 arrived. Nurse #3 also stated when she received report from first shift, they informed her that Resident #1 refused his medications at noon. Nurse #3 verified she did go and speak with Resident #1 at approximately 3:25 PM, and he was fine. Nurse #3 did not observe Resident #1 with increased cough or congestion. Nurse #3 also stated she was still working assisting with meal trays and Resident #1 refused dinner on [DATE], however that was not a new behavior, as he refused meals and medications at times. A phone interview was conducted with Nursing Assistant (NA) #1 on [DATE] at 3:01 PM. She verified she worked from [DATE] at 11:00 PM through [DATE] at 7:00 AM and she was the direct care NA for Resident #1. NA #1 stated she notified Nurse #1 at 2:00 AM that Resident #1's roommate had requested her to come look at Resident #1 because he did not sound good. NA #1 stated she observed Resident #1 coughing, and she could hear congestion. NA #1 also notified Nurse #1 at 3:30 AM that Resident #1 had his mouth open, and you could see phlegm in his mouth, and he was coughing. She stated Nurse #1 went to his room but did not tell her anything. NA #1 indicated she had not worked with the resident that often and she was not sure of his baseline. NA #1 explained at 5:00 AM she went in to change him and he was not breathing and had no pulse. She immediately notified Nurse #1. A nursing progress note recorded as a late entry on [DATE] for [DATE] by Nurse #1 revealed at 4:28 AM she entered Resident #1's room and heard rales (fine crackles, are abnormal breath sounds that occur when a person inhales and sound like small clicking, bubbling, or rattling) during inspiration. She checked his vital signs which included a blood pressure (BP) of 90/86, pulse of 48, oxygen at 89% room air, and temperature of 96.1 (axillary). Resident #1 had previously refused to have continuous positive airway pressure (CPAP) on for the night. Nursing Assistant (NA) observed that Resident #1 wasn't breathing. This nurse walked down to Resident #1's room and also observed that he wasn't breathing. Code status was validated, and CPR initiated. EMS pronounce death 6:15 AM. A phone interview was conducted with Nurse #1 on [DATE] at 11:30 AM. Nurse #1 verified she was the nurse for Resident #1 on [DATE] from 4:00 PM through [DATE] at 7:00 AM. Nurse #1 indicated she checked on Resident #1 at 4:15 PM and observed Resident #1 resting with his eyes closed, even rise and fall of chest, and no distress noted. Nurse #1 asked Resident #1 if he wanted his afternoon medication and Resident #1 shook his head no. Nurse #1 told Resident #1, she would be back later. Nurse #1 indicated she did not normally crush Resident #1's medications however she did crush his 8:00 PM medications due to him exhibiting congestion, trying to cough up clear phlegm, and difficulty swallowing. Nurse #1 verified these symptoms were not normal for Resident #1. Resident #1 did not voice any concerns at that time and Nurse #1 she did not check Resident #1's vital signs. Nurse #1 indicated she left Resident #1's room to administer other resident's medications. Nurse #1 explained she checked on Resident #1 at 10:50 PM and she could still hear audible congestion, but no difficulty breathing was observed. He was resting with eyes closed. Nurse #1 checked on Resident #1 at 2:00 AM and he was resting with eyes closed and exhibiting audible congestion. Nurse #1 stated she checked on Resident #1 again at 3:30 AM, Resident #1 had his eyes closed and did not appear to be in distress. Resident #1 had his mouth open, clear phlegm was noted in his mouth, and he was coughing which was not normal for Resident #1. She stated she did not notify the physician or Nurse Practitioner (NP) of the coughing, audible congestion, and phlegm. Nurse #1could not give a reason for not notifying the physician or NP. Nurse #1 explained she returned to check on Resident #1 at 4:28 AM and she could still hear the audible congestion, but no difficulty breathing or coughing was observed. Nurse #1 checked his vital signs which included: blood pressure (BP) 90/86, pulse 48, oxygen level 89% on room air, respirations 12, and his skin was clammy and tepid. Nurse #1 removed his blanket and put a sheet on him to help cool him off because his skin was extremely hot to the touch. Resident #1 did not speak to Nurse #1 during this assessment. Nurse #1 stated she did not know why she did not notify the physician or Nurse Practitioner (NP) at that time, she said, I just didn't. She further explained when she returned to the hall at 5:00 AM NA #1 exited Resident #1's room and stated he was not breathing. Emergency medical services (EMS) report revealed the following: the call was received/dispatched at 6:01 AM, on scene at 6:09 AM, and at patient at 6:11 AM. Primary Impression was obvious death, at scene, emergency medical services (EMS) crew directed to Resident #1's room by facility staff. The fire department (FD) and police department (PD) were already at bedside. Per report from FD, staff reported Resident #1 was last known well (LKW) at 5:15 AM this morning. FD and law enforcement (LE) on scene reported that cardiopulmonary resuscitation (CPR) was not in progress by facility staff at their arrival. No facility staff were present at bedside. EMS crew requested a firefighter to obtain patient information and code status from facility staff. Resident #1 found to be full code on facility paperwork. The primary impression was obvious death. Resident #1 found supine in facility bed. Resident #1 found to be apneic (cessation of respiration) and without pulse. A 4-lead electrocardiogram (ECG) (a test that measures the heart's electrical activity) performed and noted asystole (when your heart's electrical system fails, causing your heart to stop pumping) in all pre-cordial leads. Mottling (blotchy patches of discoloration on the skin) noted in extremities and posterior of patient's trunk. Eyes non-reactive to light. Per protocol, due to extended downtime without CPR and asystole upon presentation, CPR efforts not initiated, and time of death noted at 6:15 AM. A phone interview was conducted with the Medical Director (MD) on [DATE] at 3:08 PM. He stated he would have expected the staff to call him or the Nurse Practitioner (NP) when the difficulty swallowing, audible congestion, and cough were first observed. The MD had not received a call about Resident #1 having a change in condition that included swallowing difficulties, cough, congestion, or low vital signs. He also stated that it was standard practice to call the MD when a change occurs. He stated he thought the nurse deviated out of the standard practice when she did not call a NP or MD. He indicated if Resident #1's vital signs were low, and he was having difficulty breathing he would have needed to be sent to the hospital for evaluation. An interview with the Director of Nursing (DON) was conducted on [DATE] at 11:18 AM. She stated Nurse #1 should have applied oxygen due to Resident #1's oxygen levels dropping, and she expected Nurse #1 to notify the physician for a change in condition of a resident as soon as it was observed. The Administrator was notified of immediate jeopardy on [DATE] at 1:15 PM. The facility provided the following corrective action plan with a completion date of [DATE]. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE], Nurse #1 obtained vital signs for Resident #1 at 0428. Vital signs documented: axillary temperature 96.1, pulse 48, respirations 12, blood pressure 90/84, oxygen saturation 89% on room air. Nurse #1 identified congestion, difficulty swallowing, and the presence of phlegm on the 3p-11p shift with no follow up or ongoing monitoring. Nurse #1 failed to notify physician of Resident #1's change in condition during her shift. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE] all current interviewable residents were interviewed by the Director of Social Services to ensure that they felt any change in conditions were acted upon timely by the staff including physician notification and to ensure there were no concerns with delay or withholding of care and treatment. On [DATE] a 30 day look back of progress notes was reviewed by the Assistant Director of Nursing for current non-interviewable residents to ensure that there were no concerns related to change in condition or delay or withholding of care and treatment, including physician notification. On [DATE] all staff were interviewed by the Director of Nursing or designee to determine if there were any concerns related to delay or withholding of care related to a resident change in condition including physician notification. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On [DATE] the Staff Development Coordinator or designee educated all staff on care services related to identification of change in condition, providing timely treatment as ordered not withholding care, reporting any concerns and notification to physician. The same education will be provided by the Staff Development Coordinator or designee to agency staff upon first shift worked and all new hires during orientation effective [DATE] per directive of the Director of Nursing. Change in condition identification, notification of physician, validation of timely treatment and follow up will be reviewed in clinical morning meeting by the Interdisciplinary Team Monday through Friday. Any negative findings will be acted upon immediately. The Interdisciplinary Team includes the Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Wound Nurse, Clinical Coordinator, Director of Social Services, Director of Rehabilitation, Life Enrichment Director, Dietary Manager, MDS Coordinator per the directive of the Director of Nursing on [DATE]. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On [DATE] it was established by the Interdisciplinary Team that beginning the week of [DATE] through [DATE], the following steps will be completed and documented weekly for 8 weeks. Five interviewable residents will be interviewed weekly by the Director of Social Services or designee to ensure that resident concerns are addressed timely, that there are no unresolved concerns, that facility is respecting Resident Rights, that the facility is identifying resident changes in condition, if a resident has had a medical concern the facility has addressed it timely and notified the physician, and have no concerns that have the potential to be considered abuse/neglect. Five non-interviewable residents will have their medical record reviewed weekly by a clinical manager to identify any concerns related to change in condition, any delay or withholding of care or treatment, or any concerns with Resident Rights, code statuses not being honored will also be reviewed. Any concerns will be immediately addressed to include physician notification if indicated. Five staff members will be interviewed weekly the Administrator or designee to determine if there are any concerns related to delay in identification in resident Change in Condition, delay or withholding of treatment or concerns regarding physician notification. Facility Activity Report will be reviewed Monday through Friday in Clinical Morning Meeting to ensure timely identification of Change in Condition, notification of physician, prompt treatment if indicated, appropriate response for a resident that is a full code, timely identification of potential neglect. The Quality Improvement Committee will review the results of the audits for further recommendation weekly for 8 weeks. Should the committee feel that further auditing is necessary, it will be determined at that time. Above responsibilities were discussed during Ad-hoc QAPI completed on [DATE]. Alleged Compliance date: [DATE] Date if immediate jeopardy removal is [DATE] On [DATE] the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: The facility provided documentation to support their corrective action plan. The initial facility audits dated [DATE] were reviewed and revealed no issues were noted. Education to licensed nursing, nurse aides and medication aide staff regarding a change in condition was reviewed and sign in sheets were provided. Staff interviews across all departments were able to verbalize that they had received education on change in condition, examples of change in condition, and who to notify of a change in resident condition. QAPI meetings were discussed with the Administrator and meeting notes were reviewed. The facility's date of [DATE] for the corrective action plan was validated on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and physician, Nurse Practitioner (NP), and staff interviews, the facility failed to protect a resident's right to be free from neglect when staff failed to provide necessary care and services for 1 of 3 residents reviewed for neglect. Resident #1 had a significant change in condition on [DATE] and the nurse did not recognize the seriousness, notify the physician or provide thorough and ongoing assessments. In addition, Resident #1 was found not breathing and without a pulse on [DATE] and Cardiopulmonary Resuscitation (CPR) was not immediately administered. Resident #1 was pronounced deceased by emergency medical services (EMS) on [DATE]. This was for 1 of 3 residents reviewed for neglect (Resident #1). The findings included: This citation is cross referred to: 1. F580 Based on record review, and staff and Medical Director (MD) interviews, the facility failed to notify the physician for a resident who had a significant change in condition. On [DATE] Resident #1 was observed with audible congestion, difficulty swallowing, and was trying to cough up phlegm. The MD or Nurse Practitioner (NP) were not notified. On [DATE] Resident #1 had his mouth open with clear phlegm noted in his mouth and he was coughing. Resident #1 ' s vital signs included a blood pressure (BP) of 90/86 (normal 120/80), pulse of 48 (normal range 60-100), oxygen at 89% (normal range between 95% and 100%) on room air, and respirations of 12 (normal range 12-18). He had audible congestion, and his skin was extremely hot to touch. The MD or Nurse Practitioner (NP) were not notified. At 5:00 AM Resident #1 was found not breathing and was pronounced deceased at 6:15 AM. This was for 1 of 3 residents reviewed for notification of change of condition. 2. F678 Based on observation, record review, and staff, and Nurse Practitioner (NP) interviews the facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered immediately and failed to operationalize an effective system so staff could respond to an emergency situation as needed. On [DATE] Nurse #1 was notified that Resident #1 was unresponsive, not breathing and had no pulse. Nurse #1 verified Resident #1 was not breathing. Nurse #1 did not verify Resident # s code status and resumed her nursing duties on another hall. Nurse #1 was later informed that Resident #1 was a full code, Nurse #1 then started CPR without initiating a code blue protocol. Nurse #1 stopped CPR when she became tired. Resident #1 was pronounced deceased by emergency medical services (EMS) on [DATE]. This was for 1 of 3 residents reviewed for CPR (Resident #1). 3. F684 Based on record review, staff interviews, Nurse Practitioner (NP) and Medical Director (MD) interviews, the facility failed to provide complete, thorough, and ongoing assessments, and failed to intervene when Nurse #1 failed to recognize the seriousness of a resident ' s (Resident #1) change in condition. Resident #1, who was a full code, was experiencing a change in condition on [DATE] with symptoms of difficulty swallowing, audible congestion (able to hear without the use of stethoscope), and trying to cough up phlegm. Nurse #1 did not obtain vital signs or put interventions into place to relieve the congestion. On [DATE] Resident #1 had his mouth open, clear phlegm was noted in his mouth, audible congestion continued, and he was coughing. Resident #1's vital signs, which included a blood pressure (BP) of 90/86 (normal 120/80), pulse of 48 (normal range 60-100), oxygen saturation at 89% (normal range between 95% and 100%) on room air, respirations 12 (normal range 12-18), and temperature 96.7 (axillary/arm pit). Nurse #1 did not obtain another set of vital signs, and at 5:00 AM when Resident #1 was discovered with no pulse. Nurse #1, who did not verify Resident #1's full code status, did not initiate lifesaving resuscitative efforts and returned to administering medications. At 5:55 AM when Nurse #1 became aware of Resident #1's full code status, she initiated Cardiopulmonary Resuscitation (CPR). Emergency medical services (EMS) were called at 6:00 AM, arrived at 6:10 AM, and Resident #1 was pronounced deceased at 6:15 AM. This was for 1 of 3 residents reviewed for change of condition. An interview with the Director of Nursing (DON) was conducted on [DATE] at 11:18 AM. The DON stated she did not feel the failure to monitor, assess, call the physician when a change of condition was observed, not checking Resident #1's code status and not initiating CPR was neglect but a lack of nursing competency of Nurse #1. She indicated Nurse #1 should have notified the physician, should have been obtaining vital signs and monitoring Resident #1 throughout the shift. The DON further also expected Nurse #1 to notify the physician of a change in condition of a resident as soon as it was observed and to verify a resident's code status immediately if found without a pulse. The Administrator was notified of immediate jeopardy on [DATE] at 1:15 PM. The facility provided the following corrective action plan with a completion date of [DATE]. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE] Nurse #1 failed to notify physician of change in condition of Resident #1. Nurse #1 failed to monitor Resident #1 ' s change in condition. Nurse #1 failed to verify Resident #1's code status and failed to initiate CPR for Resident #1 with Advanced Directive of Full Code. Nurse #1 neglected to honor Resident #1's rights. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE] Director of Social Services interviewed all alert and oriented residents to ensure they felt their rights were honored; change in conditions were acted upon timely by the staff and to ensure there were no concerns with delay or withholding of care and treatment. On [DATE] Medical records were reviewed by the Assistant Director of Nursing for current non-verbal residents to identify any concerns related to change in condition or delay or withholding of care. On [DATE] All staff were interviewed by Director of Nursing or designee to determine if there were any concerns related to delay or withholding of care or identification of resident change in condition and treatment, violation of resident rights, or concerns with any code status not being provided as ordered. On [DATE] A record review of the last 30 days of deaths was audited by the Director of Nursing. There were no deaths or change in condition identified that required Cardiopulmonary Resuscitation. On [DATE] crash carts were audited to ensure that all appropriate equipment is on the cart and in working condition. On [DATE] the wound nurse completed a full facility review of all code status orders and care plans to ensure there were no concerns, no discrepancies noted. On [DATE] the Staff Development Coordinator reviewed employee files for licensed staff to ensure they have up to date CPR certification to include licensed staff present at the time of the event. On [DATE] Nurse #1's agency was notified of event to review her employee file for any previous issues or disciplinary action. The Director of Compliance & Client Services of Convergence Medical Staffing validated no previous issues or disciplinary action documented. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On [DATE] the Staff Development Coordinator or designee educated all staff on care services related to identification of change in condition, providing timely treatment as ordered not withholding care, facility CPR policy, honoring resident rights, reporting any concerns immediately, Abuse policy and procedures with a special focus on neglect. The same education will be provided by the Staff Development Coordinator or designee to agency staff upon first shift worked and all new hires during orientation effective [DATE] per directive of the Director of Nursing. On [DATE], mock codes were conducted across all shifts by the Staff Development Coordinator with nursing department staff. Nursing department staff includes Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides. On [DATE] Change in condition identification, notification of physician, validation of timely treatment, follow up, appropriate code response, concerns of resident right violations and any potential abuse will be reviewed in clinical morning meeting Monday through Friday. Any negative findings will be acted upon immediately. On [DATE] Routine resident council will be held by the facility leadership routinely but no less than monthly. Resident Rights will be reviewed. Any concerns will be addressed by the appropriate department manager. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On [DATE] it was established by the Interdisciplinary Team that beginning the week of [DATE] through [DATE], the following steps will be completed and documented weekly for 8 weeks. Director of Life Enrichment or designee will conduct and follow up on a weekly Resident Council meeting to ensure that resident concerns are addressed timely, that there are no unresolved concerns, that facility is respecting Resident Rights, that the facility is identifying resident changes in condition and if a resident has had a medical concern, has the facility addressed it timely. Five interviewable residents will be interviewed weekly by the Director of Social Services or designee to ensure that resident concerns are addressed timely, that there are no unresolved concerns, that facility is respecting Resident Rights, that the facility is identifying resident changes in condition, if a resident has had a medical concern the facility has addressed it timely, and have no concerns that have the potential to be considered abuse/neglect. Five non-interviewable residents will have their medical record reviewed weekly by a clinical manager to identify any concerns related to change in condition, any delay or withholding of care or treatment, or any concerns with Resident Rights, code statuses not being honored will also be reviewed. Five staff members will be interviewed weekly the Administrator or designee to determine if there are any concerns related to delay in identification in resident Change in Condition, delay or withholding of treatment, violation of Resident Rights, or concerns with code status not being provided as ordered. All resident deaths or code activity will be reviewed by the clinical team to ensure the resident ' s code status was carried out by staff without delay. Mock codes will be conducted one random shift per week by the Director of Nursing or designee across all shifts to ensure timely and appropriate response. Any identified concerns will be addressed immediately. Crash carts will be audited daily by the Assistant Director of Nursing or designee to ensure that appropriate equipment is present. Facility Activity Report will be reviewed Monday through Friday in Clinical Morning Meeting to ensure timely identification of Change in Condition, notification of physician, prompt treatment if indicated, appropriate response for a resident that is a full code, timely identification of potential neglect. The Quality Improvement Committee will review the results of the audits for further recommendation weekly for 8 weeks. Should the committee feel that further auditing is necessary, it will be determined at that time. Above responsibilities were discussed during Ad-hoc QAPI completed on [DATE]. Alleged Compliance date: [DATE] Date of immediate jeopardy removal is [DATE] On [DATE] the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: The facility provided documentation to support their corrective action plan. The initial facility audits dated [DATE] were reviewed and revealed no issues were noted. Education to licensed nursing, nurse aides and medication aide staff regarding a change in condition was reviewed and sign in sheets were provided. Staff interviews across all departments were able to verbalize they had received education on change in condition, examples of change in condition, and who to notify in the event of a change in condition of a resident. Quality Assurance and Performance Improvement (QAPI) meetings were discussed with the Administrator and meeting notes were reviewed. The facility's compliance date of [DATE] for the corrective action plan was validated on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff, and Nurse Practitioner (NP) interviews the facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered immediately and failed to operationalize an effective system so staff could respond to an emergency situation as needed. On 9/19/24 Nurse #1 was notified that Resident #1 was unresponsive, not breathing and had no pulse. Nurse #1 verified Resident #1 was not breathing. Nurse #1 did not verify Resident #1's code status and resumed her nursing duties on another hall. Nurse #1 was later informed that Resident #1 was a full code, Nurse #1 then started CPR without initiating a code blue protocol. Nurse #1 stopped CPR when she became tired. Resident #1 was pronounced deceased by emergency medical services (EMS) on 9/19/24. This was for 1 of 3 residents reviewed for CPR (Resident #1). The findings included: Review of the facility's CPR policy revised October 2023 indicated the following: Activate the emergency response team: The resident should not be left alone. If you are alone with the victim, call out for help. If someone is nearby, instruct them to dial 911 immediately. In the event help is not available, call 911 and retrieve emergency cart prior to starting CPR, return as soon as possible. Use an AED as soon as possible if one is available. If no AED is available, continue the cycle of compressions: Breaths for about two minutes then recheck pulse and continue if none noted. Continue CPR efforts until pulse is restored, EMS arrives, an onsite physician or nurse practitioner instructs otherwise, or until the team can no longer continue due to exhaustion. Resident #1 was readmitted to the facility on [DATE]. His diagnosis included type 2 diabetes mellitus (DM), anxiety, chronic congestive heart failure (CHF), and dysphagia (difficulty swallowing). A physician order dated 03/23/24 indicated Resident #1 was a full code. Chart review did not reveal a Medical Orders for Scope of Treatment (MOST) form (a legal document that allows patients to outline their treatment preferences and end-of-life care. No MOST form indicates that a resident wishes the full scope of treatment for saving their life) for Resident #1. Resident #1's care plan, last reviewed/revised on 07/17/24, revealed a focus that read: Category: Advanced Directives/Code Status Resident #1 has chosen full code status A nursing progress note written 09/19/24 at 5:33 AM by Nurse #1 revealed Resident #1expired at 5:00 AM. A nursing progress note recorded as a late entry on 09/23/24 for 09/19/24 by Nurse #1 read: This nurse did resident rounding at 4:28 AM on the 800 hall before starting medication pass on the 200 hall. Walked in Resident #1 ' s room and heard rales (abnormal rattling sound in the lungs) during inspiration. This nurse checked vitals BP:90/84, P:48, R:12, O2: 89% room air, T:96.1 (auxiliary) resident previously refused to have CPAP place on for the night. NA started her resident rounding at the bottom of the 800 hall. NA observed that Resident #1 wasn't breathing. This nurse walked down to Resident #1's room and also observed that patient wasn't breathing. Code status was validated, and CPR initiated. EMS pronounce death 6:15 AM. Postmortem care done. A phone interview was conducted with Nurse #1 on 09/24/24 at 11:30 AM. Nurse #1 verified she was the nurse for Resident #1 on 09/18/24 from 4:00 PM through 09/19/24 at 7:00 AM. She explained at 5:00 AM Nursing Assistant (NA) #1 was exiting Resident #1's room and stated he was not breathing. She stated she told NA #1 she knew it was coming because his vital signs were sitting low at 4:28 AM. Nurse #1 verified she did not check his code status at 5:00 AM. She also stated, I don't know why I didn't check his code status, I thought he was a Do Not Resuscitate (DNR). She explained she was informed at 5:55 AM by NA #2 that Resident #1 was a full code. NA # 2 proceeded to the nurses' station to call 911 and Nurse #1 started CPR, however she stopped CPR a short time later to retrieve the crash cart. When Nurse #1 returned to Resident #1, she put the back board under him and resumed CPR at approximately 6:00 AM. She stated Resident #1's body was warm to the touch. NA #2 returned to Resident #1's room and Nurse #1 told her she did not have anything on the crash cart to do CPR such as an AED, oxygen, tubing, or a suction machine. Nurse #1verified she did not ask for assistance from other staff members, nor did she activate the code blue protocol. She explained she stopped performing CPR at 6:06 AM because she was tired. Law enforcement arrived at 6:08 AM and then emergency medical services (EMS) arrived at 6:10 AM. Resident #1 was pronounced deceased at 6:15 AM by EMS. She further stated when she wrote the nursing note on 09/23/24 for the events that occurred on 09/19/24 she did not add the times that she verified Resident #1 did not have a pulse or what time she started CPR. Nurse #1 indicated she did not know why she thought Resident #1 was a DNR, she just assumed he was. A phone interview was conducted with Nursing Assistant (NA) #1 on 09/24/24 at 3:01 PM. NA #1 explained that at 5:00 AM on 09/19/24 she went in to change Resident #1, he was warm to the touch, however he was unresponsive, not breathing and had no pulse. NA #1 immediately notified Nurse #1. NA #1 stated Nurse #1 said she figured it was coming due to his vital signs being low earlier. NA #1 observed Nurse #1 check for Resident #1's pulse and the rise and fall of his chest which were absent. Nurse #1 verified Resident #1 was not breathing. NA #1 stated that Nurse #1 did not start cardiopulmonary resuscitation (CPR) and she went to another hall to pass medications. NA #1 explained she provided postmortem care to Resident #1. NA #1 further stated at approximately 5:55 AM she informed Nurse #2 that Resident #1 had passed away. A phone interview was conducted with Nurse #2 on 09/24/24 at 2:54 PM. Nurse #2 stated she was coming up the 100 hall when she was approached at 5:55 AM by Nursing Assistant (NA) #1 and was told that Resident #1 had passed away. Nurse #2 explained that after she had spoken to NA #1, she was at the nurses' station on the 100/300 hundred hall and she informed NA #2 that Resident #1 had passed away. Nurse #2 stated NA #2 jumped up and said, oh my god he's a full code, as she went towards the main nursing station to check the code status binder. Between 6:02 AM and 6:06 AM she went to the 800 hall to see if Nurse #1 needed help and Nurse #1 stated no, she did not need help and emergency medical services (EMS) were on the way. Nurse #2 went back to the 100/300 hall to check on her residents then went back to the 800 hall. Nurse #2 explained she went back to the 100/300 hall for two or three minutes then went to Resident #1's room at approximately 6:08 AM, law enforcement and first responders were in the room. At that time EMS was at the side door of the building. Nurse #2 recalled Nurse #1 was talking to law enforcement, and she went to make copies of Resident #1's paperwork. She further stated Nurse #1 did not call the code overhead when she was made aware of his code status. Nurse #2 confirmed she did not observe Nurse #1 perform CPR at any time. An interview was conducted with Nursing Assistant (NA) #2 on 09/24/24 at 11:44 AM. NA #2 verified she worked on 09/18/24 from 11:00 PM through 09/19/24 at 7:00 AM on the 100/300 halls. NA #2 stated she was sitting at the nursing station when Nurse #2 told her Resident #1 had passed away. She explained that she jumped up and said, oh my god, he's a full code, as she went up the hall towards the main nursing station. She looked in the Do Not Resituate (DNR) binder and removed Resident #1's sheet that indicated he was a full code. NA #2 then stated she took that sheet to Nurse #1 which was halfway down the 800 hall to show her Resident #1 was a full code. She explained that Nurse #1 stated several times, you've got to be kidding me. NA #2 told Nurse #1 to grab the crash cart, and she would call 911. NA # 2 proceeded to the nurse station to call 911. After the call was completed, she went to Resident #1's room where Nurse #1 was going through the drawers of the crash cart saying she didn't have anything to do CPR with such as an automated external defibrillator (AED), oxygen, tubing, or a suction machine. NA #2 stated the ambu-bag was located on the side of the crash cart unopened, it appeared that the backboard was under Resident #1's back and she reminded Nurse #1 the oxygen tank was located beside the crash cart. She looked up and saw law enforcement and the first responders coming up the hall. She indicated she then went back to her assignment. She was unaware Nurse #1 initiated CPR prior to grabbing the crash cart. NA #2 explained that she also did medical records at the facility and that was how she was aware of Resident #1's code status. Emergency medical services (EMS) report revealed the following: the call was received/dispatched at 6:01 AM, on scene at 6:09 AM, and at patient at 6:11 AM. Primary Impression was obvious death, at scene, emergency medical services (EMS) crew directed to Resident #1's room by facility staff. The fire department (FD) and police department (PD) were already at bedside. Per report from FD, staff reported Resident #1 was last known well at 5:15 AM this morning. FD and law enforcement on scene reported that cardiopulmonary resuscitation (CPR) was not in progress by facility staff at their arrival. No facility staff were present at bedside. EMS crew requested a firefighter to obtain patient information and code status from facility staff. Resident #1 found to be full code on facility paperwork. The primary impression was obvious death. Resident #1 found supine in facility bed. Resident #1 found to be apneic (cessation of respiration) and without pulse. A 4-lead electrocardiogram (ECG) (a test that measures the heart's electrical activity) performed and noted asystole (when your heart's electrical system fails, causing your heart to stop pumping) in all pre-cordial leads. Mottling (blotchy patches of discoloration on the skin) noted in extremities and posterior of patient's trunk. Eyes non-reactive to light. Per protocol, due to extended downtime without CPR and asystole upon presentation, CPR efforts not initiated, and time of death noted at 6:15 AM. A phone interview was conducted with the Nurse Practitioner (NP) on 09/24/24 at 4:00 PM. He stated he would expect the nurse to verify code status immediately if a resident was observed with no pulse. The NP stated he could not speculate and say that if CPR was immediately initiated that Resident #1's outcome would have been different. An interview with the Director of Nursing (DON) was conducted on 09/25/24 at 11:18 AM. She stated Nurse #1 should have checked Resident #1's code status when she observed increased congestion, change in his oxygen levels, and immediately after verifying, he was without a pulse. She also stated everything was on the crash cart that the facility keeps on it and the oxygen is located right beside the crash cart. The facility does not utilize an AED. The Administrator was notified of immediate jeopardy on 9/25/24 at 1:15 PM. The facility provided the following corrective action plan with a completion date of 09/20/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 9/19/2024 at 0500, NA #1 notified Nurse #1 that Resident #1 was unresponsive. Nurse #1 failed to verify Resident #1's code status and failed to initiate Cardiopulmonary Resuscitation timely. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 9/19/2024, a record review of the last 30 days of deaths was audited by the Director of Nursing. There were no deaths or change in condition identified that required Cardiopulmonary Resuscitation. On 9/19/2024, crash carts were audited by the wound nurse to ensure that all appropriate equipment is on the cart and in working condition. On 9/19/2024, the wound nurse completed a full facility review of all code status orders and care plans to ensure there were no concerns, no discrepancies noted. On 9/19/2024, the Staff Development Coordinator reviewed employee files for licensed staff to ensure they have up to date CPR certification to include licensed staff present at the time of the event. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 9/19/2024 the Staff Development Coordinator or designee educated all staff on the facility Cardiopulmonary Resuscitation Policy. The same education will be provided by the Staff Development Coordinator or designee to agency staff upon first shift worked and all new hires during orientation effective 9/19/2024 per directive of the Director of Nursing. On 9/19/2024, mock codes were conducted across all shifts by the Staff Development Coordinator with nursing department staff. Nursing department staff includes Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides. Routine crash cart audits will be completed daily by a member of the Interdisciplinary Team effective 9/23/2024 per the Administrator. The Interdisciplinary Team includes Medical Records Coordinator, Director of Social Services, Life Enrichment Director, Director of Environmental Services, Food Service Director, Administrator, Business Office Coordinator, and Central Supply Manager. These members of the Interdisciplinary Team have been educated on crash cart equipment compliance per the Administrator and Director of Nursing. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On 9/19/2024 it was established by the Interdisciplinary Team that beginning the week of 9/23/2024 through 11/15/2024, the following steps will be completed and documented weekly for 8 weeks. Mock code audits will be conducted one random shift per week by the Director of Nursing or designee across all shifts to ensure timely and appropriate response. Any identified concerns will be addressed immediately. Crash carts will be audited daily by the Assistant Director of Nursing or designee to ensure that appropriate equipment is present. The Quality Improvement Committee will review the results of the audits for further recommendation weekly for 8 weeks. Should the committee feel that further auditing is necessary, it will be determined at that time. Above responsibilities were discussed during Ad-hoc QAPI completed on 9/19/2024. Alleged Compliance date: 9/20/24 Date of immediate jeopardy removal is 9/20/24 On 09/25/24 the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: The facility provided documentation to support their corrective action plan. The initial facility audits dated 09/19/24 were reviewed and revealed no issues were noted. Education across all staff departments regarding CPR was reviewed and sign in sheets were provided. Staff interviews across all departments were completed and those staff were able to verbalize that they had received education and knew the procedures to take. QAPI meetings were discussed with the Administrator and meeting notes were reviewed. An observation of the crash cart at the main nursing station on 09/25/24 at 12:35 PM revealed the cart to be stocked with an ambu bag and backboard along with numerous others supplies that would be required for an emergency. The facility's date of 09/20/24 for the corrective action plan was validated on 09/26/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Nurse Practitioner (NP) and Medical Director (MD) interviews the facility failed to provide complete, thorough, and ongoing assessments, and failed to intervene when Nurse #1 failed to recognize the seriousness of a resident's (Resident #1) change in condition. Resident #1, who was a full code, was experiencing a change in condition on [DATE] with symptoms of difficulty swallowing, audible congestion (able to hear without the use of stethoscope), and trying to cough up phlegm. Nurse #1 did not obtain vital signs or put interventions into place to relieve the congestion. On [DATE] Resident #1 had his mouth open, clear phlegm was noted in his mouth, audible congestion continued, and he was coughing. Resident #1's vital signs, which included a blood pressure (BP) of 90/86 (normal 120/80), pulse of 48 (normal range 60-100), oxygen saturation at 89% (normal range between 95% and 100%) on room air, respirations 12 (normal range 12-18), and temperature 96.7 (axillary/arm pit). Nurse #1 did not obtain another set of vital signs, and at 5:00 AM when Resident #1 was discovered with no pulse. Nurse #1, who did not verify Resident #1's full code status, did not initiate lifesaving resuscitative efforts and returned to administering medications. At 5:55 AM when Nurse #1 became aware of Resident #1's full code status, she initiated Cardiopulmonary Resuscitation (CPR). Emergency medical services (EMS) were called at 6:00 AM, arrived at 6:10 AM, and Resident #1 was pronounced deceased at 6:15 AM. This was for 1 of 3 residents reviewed for change of condition (Resident #1). The findings included: Resident #1 was readmitted to the facility on [DATE]. His diagnosis included type 2 diabetes mellitus (DM), anxiety, chronic congestive heart failure (CHF), and dysphagia (difficulty swallowing). A physician order dated [DATE] indicated Resident #1 was a full code. A physician order dated [DATE] to apply Bi-pap (Bilateral Positive Airway Pressure-a noninvasive breathing machine that helps people breathe by delivering pressurized air into their airways) every HS (hour of sleep) and remove in the morning. Note if resident does not wear. Chart review did not reveal a Medical Orders for Scope of Treatment (MOST) form for Resident #1. Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was intact without behaviors. There was no rejection of care or behaviors coded. Resident #1's care plan, last reviewed/revised on [DATE], revealed a focus that read he had the potential for altered respiratory status/difficulty breathing related to a history of respiratory failure. The interventions included for staff to assess/document/report abnormal breathing patterns to physician, elevate head of bed to facilitate breathing per resident comfort level, as needed, and provide oxygen as ordered. Another focus read Resident #1 was at risk for complications related to vascular congestion and was on diuretic therapy which placed him at risk for adverse effects due to medication use. The interventions included for staff to administer medication as ordered and monitor for possible side effects such as dizziness, postural hypotension, fatigue, and an increased risk for falls. Notify physician as needed. A focus that read: Category: Advanced Directives/Code Status Resident #1 had chosen full code status. The interventions included for staff to notify physician of any changes, as needed, and if resident /responsible party chooses to change code status, necessary protocol will be completed: new order, update documentation/care plan, face sheet/identifying tool. Note by the Nurse Practitioner (NP) dated [DATE] revealed Resident #1 was lying in bed with eyes closed, easily arousable and answering questions when asked. He denied shortness of breath and there was no cough observed. The note also revealed that during physical exam of Resident #1's chest/pulmonary and general/constitutional systems that no physical findings pertinent to this encounter. An interview with Medication Aide (MA) #1 was conducted on [DATE] at 10:40 AM. MA #1 verified she was the direct care MA for Resident #1 on [DATE] and MA #1 did not observe any concerns with him on first shift (7A-3P). She further stated he was talkative and did not voice any concerns. Review of medication administration record (MAR) for medications received on [DATE] and [DATE]. [DATE]-refused all 5:00 PM medications. All 8:00 PM medications were signed as being administered. No medications were documented as having been administered on [DATE]. Treatment administration record (TAR) for refusing Bi-PAP on [DATE], [DATE], [DATE] and [DATE]. An interview with Nurse #3 was conducted on [DATE] at 10:05 AM. Nurse #3 stated she cared for Resident #1 on [DATE] from 3:00 PM to 4:00 PM. Nurse #3 explained she was the wound care nurse however the facility had a call out and she was covering the assignment until Nurse #1 arrived. Nurse #3 also stated when she received report from first shift. Nurse #3 verified she did go and speak with Resident #1 at approximately 3:25 PM, and he was fine. Nurse #3 did not observe Resident #1 with increased cough or congestion. Nurse #3 also stated she was still working assisting with meals and Resident #1 refused dinner, however that was not a new behavior, he refused meals and medications at times. A nursing progress note recorded as a late entry on [DATE] for [DATE] by Nurse #1 read: This nurse did patient rounding at 4:28 AM on 800 hall before starting medication pass on 200 hall. Walked in Resident #1's room and heard rales (abnormal breath sounds that occur when a person inhales and sound like small clicking, bubbling, or rattling) during inspiration. This nurse checked vitals BP:90/84, P:48, R:12, O2: 89% room air, T:96.1 (axillary) patient previously refused to have CPAP place on for the night. CNA (Certified Nursing Assistant) started her pt. (patient) rounding at the bottom of the eight hundred hall. CNA observed that pt. (Resident #1) wasn't breathing. This nurse walked down to the resident's room and also observed that patient wasn ' t breathing. Code status was validated, and CPR initiated. EMS pronounce death at 6:15 AM. Postmortem care done. A phone interview was conducted with Nurse #1 on [DATE] at 11:30 AM. Nurse #1 verified she was the nurse for Resident #1 on [DATE] from 4:00 PM through [DATE] at 7:00 AM. Nurse #1 indicated she checked on Resident #1 at 4:15 PM and observed Resident #1 resting with his eyes closed, even rise and fall of chest, and no distress noted. Nurse #1 asked Resident #1 if he wanted his afternoon medication and Resident #1 shook his head no. Nurse #1 indicated she normally did not crush Resident #1's medications, however she did crush his 8:00 PM medications due to him exhibiting congestion, trying to cough up clear phlegm, and difficulty swallowing. Nurse #1 stated the symptoms she observed when administering Resident #1 his 8:00 PM medications were abnormal for Resident #1. She said Resident #1 did not voice any concerns at that time and she did not check Resident #1's vital signs. Nurse #1 indicated she left Resident #1's room to administer other residents their medications. Nurse #1 explained she checked on Resident #1 at 10:50 PM and she could still hear audible congestion, but no difficulty breathing was observed such as gasping. He was resting with his eyes closed. Nurse #1 checked on Resident #1 at 2:00 AM and he was resting with his eyes closed and continued to exhibit audible congestion. Nurse #1 stated she checked on Resident #1 again at 3:30 AM, Resident #1 had his eyes closed and did not appear to be in distress. Nurse #1 described Resident #1 as having had his mouth open, clear phlegm was noted in his mouth, and he was coughing which was not normal for Resident #1. She stated she did not notify the physician or Nurse Practitioner (NP) of the coughing, audible congestion, and phlegm. Nurse #1could not give a reason for not notifying the physician or NP. Nurse #1 explained she returned to check on Resident #1 at 4:28 AM and she could still hear the audible congestion, but no difficulty breathing or coughing was observed such as gasping. Nurse #1 checked his vital signs which included: blood pressure (BP) 90/84, pulse 48, oxygen level 89% on room air, respirations 12, and his skin was clammy and tepid. Nurse #1 removed his blanket and put a sheet on him to help cool him off because his skin was extremely hot to the touch. Resident #1 did not speak to Nurse #1 during this assessment, and she believed he was asleep. Nurse #1 stated she did not know why she did not notify the physician or Nurse Practitioner (NP) at that time about Resident #1's coughing, audible congestion, and low vital signs, she said, I just didn't. She further explained when she returned to the 800 hall from passing medications on the 200 hall at 5:00 AM NA #1 exited Resident #1's room and stated he was not breathing. Nurse #1 checked for Resident #1's pulse and the rise and fall of his chest which were absent. Nurse #1 verified Resident #1 was not breathing. A phone interview was conducted with Nursing Assistant (NA) #1 on [DATE] at 3:01 PM. She verified she worked from [DATE] at 11:00 PM through [DATE] at 7:00 AM and she was the direct care NA for Resident #1. NA #1 stated she notified Nurse #1 at 2:00 AM that Resident #1's roommate had requested her to come look at Resident #1 because he did not sound good. NA #1 stated she observed Resident #1 coughing, and she could hear congestion. NA #1 notified Nurse #1 again at 3:30 AM about Resident #1 having had his mouth open, phlegm was visible in his mouth, he was coughing, and she went and told the nurse immediately. She stated Nurse #1 went to his room but did not tell her anything. NA #1 indicated she had not worked with the resident that often and she was not sure of his baseline. NA #1 explained at 5:00 AM she went in to change him and he was not breathing and had no pulse. She immediately notified Nurse #1. Resident #1's roommate was not able to be interviewed. A phone interview was conducted with Nurse #2 on [DATE] at 2:54 PM. Nurse #2 stated she was coming up the 100 hall when she was approached at 5:55 AM by Nursing Assistant (NA) #1 and was told that Resident #1 had passed away. Nurse #2 explained that after she had spoken to NA #1, she was at the nurses' station on 100/300 hall with NA #2, and she informed NA #2 that Resident #1 had passed away. Nurse #2 stated NA #2 jumped up and said, Oh my god he's a full code, as NA #2 went towards the main nursing station. Nurse #2 then stated NA #2 checked the code status binder that was located at the 800 nurses' station and verified Resident #1 was a full code. Between 6:02 AM and 6:06 AM she went to the 800 hall to see if Nurse #1 needed help and Nurse #1 stated no, she did not need help and emergency medical services (EMS) were on the way. Nurse #2 went back to the 100/300 hall to check on her residents then went back to the 800 hall. Nurse #2 then explained the crash cart was on the hall in front of Resident #1's room and law enforcement, first responders, and fire department were in the room assessing Resident #1, Resident #1 was not receiving CPR. At that time EMS was at the side door of the building. Nurse #2 recalled Nurse #1 was talking to law enforcement, and she went to make copies of Resident #1's paperwork. She further stated Nurse #1 did not call the code overhead when she was made aware of Resident #1's code status. An interview was conducted with Nursing Assistant (NA) #2 on [DATE] at 11:44 AM. She verified she worked on [DATE] from 11:00 PM through [DATE] at 7:00 AM on the 100/300 hall, not the hall where Resident #1 resided. NA #2 stated she was sitting at the nursing station when Nurse #2 told NA #2 Resident #1 had passed away. NA #2 explained she jumped up and said, oh my god, he's a full code, as NA #2 went up the hall towards the main nursing station. NA #2 said she looked in the Do Not Resituate (DNR) binder and removed Resident #1's sheet that indicated he was a full code. NA #2 then stated she took that sheet to Nurse #1 who was halfway down the 800 hall to show her Resident #1 was a full code. NA #2 explained that Nurse #1 stated several times, you've got to be kidding me. NA #2 told Nurse #1 to grab the crash cart, and NA #2 went to call 911. NA # 2 proceeded to the nurses' station to call 911. NA #2 explained she is responsible for medical records at the facility, and she was an NA, that was how she was aware of Resident #1's code status. NA # 2 stated she had not been assigned to Resident #1 at all from [DATE] to [DATE]. Emergency medical services (EMS) report revealed the following: the call was received/dispatched at 6:01 AM, on scene at 6:09 AM, and at patient at 6:11 AM. Primary Impression was obvious death, at scene, emergency medical services (EMS) crew directed to Resident #1's room by facility staff. The fire department (FD) and police department (PD) were already at bedside. Per report from FD, staff reported Resident #1 was last known well (LKW) at 5:15 AM this morning. FD and law enforcement (LE) on scene reported that cardiopulmonary resuscitation (CPR) was not in progress by facility staff at their arrival. No facility staff were present at bedside. EMS crew requested a firefighter to obtain patient information and code status from facility staff. Resident #1 found to be full code on facility paperwork. The primary impression was obvious death. Resident #1 found supine in facility bed. Resident #1 found to be apneic (cessation of respiration) and without pulse. A 4-lead electrocardiogram (ECG) (a test that measures the heart's electrical activity) performed and noted asystole (when your heart's electrical system fails, causing your heart to stop pumping) in all pre-cordial leads. Mottling (blotchy patches of discoloration on the skin) noted in extremities and posterior of patient's trunk. Eyes non-reactive to light. Per protocol, due to extended downtime without CPR and asystole upon presentation, CPR efforts not initiated, and time of death noted at 6:15 AM. A phone interview was conducted with the Medical Director (MD) on [DATE] at 3:08 PM. He stated he would have expected the staff to obtain vital signs and to call him or the NP when the difficulty swallowing, audible congestion, and cough were first observed. The MD had not received a call about Resident #1 having a change in condition that included swallowing difficulties, cough, congestion, or low vital signs. He also stated that it was standard practice to call the MD when a change occurs. He stated he thought the nurse deviated out of the standard practice when she did not call a NP or MD. He indicated if his vital signs were low, and he was having difficulty breathing he would have needed to be sent to the hospital for evaluation. A phone interview was conducted with the Nurse Practitioner (NP) on [DATE] at 4:00 PM. He stated he saw Resident #1 on [DATE] and he seemed to be in his normal state, alert and oriented to per, place, and time. He also stated he observed the resident as having no cough or shortness of breath. He indicated staff should have obtained vital signs and monitored Resident #1 and he would have expected the staff to call him or the Medical Director (MD) when the difficulty swallowing, audible congestion, and cough were first observed. An interview with the Director of Nursing (DON) was conducted on [DATE] at 11:18 AM. She stated Nurse #1 should have applied oxygen due to Resident #1's oxygen levels dropping, she should have notified the physician, and she should have been obtaining vital signs throughout the shift. She also expected Nurse #1 to notify the physician for a change in condition of a resident as soon as it was observed. On [DATE] at 1:15 PM the Administrator and DON were made aware of the Immediate Jeopardy. The facility implemented the following corrective action plan with a completion date of [DATE]. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE], Resident #1 was noted with abnormal vital signs at 4:28 AM per Nurse #1. Nurse #1 identified congestion, difficulty swallowing, and the presence of phlegm on the 3-11p shift with no follow up or ongoing monitoring. Nurse #1 failed to further assess Resident #1's change in condition or implement interventions to improve Resident #1's condition. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE] all current interviewable residents were interviewed by the Director of Social Services to ensure that they felt any change in conditions were acted upon timely by the staff including physician notification and to ensure there were no concerns with delay or withholding of care and treatment. On [DATE] a 30 day look back of progress notes was reviewed by the Assistant Director of Nursing for current non-interviewable residents to ensure that there were no concerns related to change in condition or delay or withholding of care and treatment, including physician notification. On [DATE] all staff were interviewed by the Director of Nursing or designee to determine if there were any concerns related to delay or withholding of care related to a resident change in condition including physician notification. On [DATE] a record review of the last 30 days of deaths was audited by the Director of Nursing. There was no change in condition identified that required Cardiopulmonary Resuscitation. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On [DATE] the Staff Development Coordinator or designee educated all staff on care services related to identification of change in condition, providing timely treatment as ordered not withholding care, reporting any concerns and notification to physician. The same education will be provided by the Staff Development Coordinator or designee to agency staff upon first shift worked and all new hires during orientation effective [DATE] per directive of the Director of Nursing. Change in condition identification, notification of physician, validation of timely treatment and follow up will be reviewed in clinical morning meeting Monday through Friday. Any negative findings will be acted upon immediately. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On [DATE] it was established by the Interdisciplinary Team that beginning the week of [DATE] through [DATE], the following steps will be completed and documented weekly for 8 weeks. Five interviewable residents will be interviewed weekly by the Director of Social Services or designee to ensure that resident concerns are addressed timely, that there are no unresolved concerns, that facility is respecting Resident Rights, that the facility is identifying resident changes in condition, if a resident has had a medical concern the facility has addressed it timely and notified the physician, and have no concerns that have the potential to be considered abuse/neglect. Five non-interviewable residents will have their medical record reviewed weekly by a clinical manager to identify any concerns related to change in condition, any delay or withholding of care or treatment, or any concerns with Resident Rights, code statuses not being honored will also be reviewed. Five staff members will be interviewed weekly the Administrator or designee to determine if there are any concerns related to delay in identification in resident Change in Condition, delay or withholding of treatment or concerns regarding physician notification. Facility Activity Report will be reviewed Monday through Friday in Clinical Morning Meeting to ensure timely identification of Change in Condition, notification of physician, prompt treatment if indicated, appropriate response for a resident that is a full code, timely identification of potential neglect. The Quality Improvement Committee will review the results of the audits for further recommendation weekly for 8 weeks. Should the committee feel that further auditing is necessary, it will be determined at that time. Above responsibilities were discussed during Ad-hoc QAPI completed on [DATE]. Alleged Compliance date: [DATE] Date of immediate jeopardy removal is [DATE] On [DATE] the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: The facility provided documentation to support their corrective action plan. The initial facility audits dated [DATE] were reviewed and revealed no issues were noted. Education to licensed nursing, nurse aides and medication aide staff regarding a change in condition was reviewed and sign in sheets were provided. Staff interviews across all departments were able to verbalize they had received education on change in condition, examples of change in condition, and who to notify in the event of a change in condition of a resident. Quality Assurance and Performance Improvement (QAPI) meetings were discussed with the Administrator and meeting notes were reviewed. The facility's compliance date of [DATE] for the corrective action plan was validated on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview of the staff, Physician Assistant (PA), Nurse Practitioner (NP), Wound Nurse Practitioner #1, and Physician, the facility failed to notify the medical staff of the Resident #1's sacral pressure ulcer deterioration to the point the wound was 11.5 centimeters (cm) long by 16 cm wide and failed to notify the medical staff when Resident #1 sustained a full-thickness skin tear injury which extended down into the subcutaneous tissue (tissue below the skin) and measured 7 centimeters (cm) long by 3 cm wide on 12/31/22 for 1 of 2 residents reviewed for pressure ulcer(s) and skin tear(s). Immediate jeopardy began on 12/31/22 for Resident #1 when staff failed to notify medical staff of Resident #1's lower right leg injury at the time of hospitalization on 1/14/23 directly after being discharged from the facility. The wound was bleeding and required pressure to control, was open with an approximate/unknown depth, and was unable to approximate (close skin edges). Immediate jeopardy continued on 1/9/23 when staff failed to notify medical staff of Resident #1's sacral pressure ulcer deterioration when the wound increased in size and was discovered to have a foul odor. Immediate jeopardy was removed on 3/4/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. Findings included: a. On 2/28/23 at 9:50 am an interview was conducted with the Wound Nurse. The Wound Nurse stated she was aware of Resident #1's deterioration in sacral pressure ulcer wound on 1/9/23 and 1/13/23 and had not informed the medical staff (Wound NP, facility NP, PA, or Physician). She further stated she was not informed by Nurse #1 of any wound deterioration over the weekend of 1/7/23 -1/8/23. On 2/28/23 at 10:26 am an interview was conducted with the Director of Nursing (DON). The DON stated she was asked by the Wound Nurse to look at Resident #1's sacral wound on 1/13/22, not medical staff. The DON stated, if there was a concern with a wound you would ask the staff to reach out to the medical staff. The DON stated she had not contacted medical staff regarding the resident's sacral wound decline and initiated a nurse judgement of treatment change. On 2/28/23 at 12:20 pm an interview was conducted with the Discharge Nurse. The Discharge Nurse was aware of the reported deterioration to Resident #1's sacral pressure ulcer on 1/14/23 and she had not reported to medical staff. On 2/28/23 at 2:45 pm an interview was conducted with Nurse # 1. Nurse #1 stated she worked every weekend and provided sacral pressure ulcer wound care to Resident #1 on 1/7/23 and 1/8/23 and noted the sacral wound had changed compared to the prior weekend. The wound was horrible with black tissue and odor and this change was not reported to medical staff. She stated the change was not reported because she thought Wound NP #1 was going to see the resident during the week. If the Wound NP was not following, she would call the medical staff member covering the weekend. On 2/28/23 at 11:03 am an interview was conducted with the facility NP. The NP stated she started her position at the facility on 1/6/23. She stated she first saw Resident #1 on 1/10/23 for a medical visit and had not evaluated the resident's wounds. On 3/1/23 at 10:30 am an interview was conducted with the Physician Assistant (PA). The PA stated she saw Resident #1 on 1/6/23 and assessed the resident but was not informed by nursing or aware that there was a second skin tear to the right leg and the right leg was not evaluated. On 3/1/23 at 11:20 am an interview was conducted with Nurse #2. Nurse #2 stated she assisted the Medication Aide with sacral pressure ulcer wound care and observed that the wound had opened, drainage changed to white purulent, and had foul odor on 1/14/23 and had not reported this to medical staff. The resident was discharged to home as planned. Nurse #2 had not stated why this change was not reported. b. A nursing note written by Nurse #1 dated 12/31/2022 at 7:37 pm documented: This nurse across the hall in another room when the NA (nurse aide) came to this nurse and stated resident got a skin tear when they (were) transferring resident into her wheelchair. This nurse into room and assess a large skin tear noted to the (right lower leg). Skin and subcutaneous tissue noted to be pushed to the right side of the wound and unable to be approximated. On 3/1/23 at 3:02 pm an interview was conducted with Nurse #1. Nurse #1 stated she was assigned to Resident #1 when staff transferred her without the mechanical lift and the resident hit her right lower leg on the wheelchair footrest, on 12/31/22 and sustained an injury. Nurse #1 stated she completed an incident report and called the weekend medical staff on-call voice mail and left a message on the skin tear line (where to leave a message regarding skin tear). Nurse #1 stated she had not informed medical staff nor considered sending the resident to the Emergency Department at the time of accident because the bleeding had stopped after pressure was applied, and she did not think the wound was that bad. Nurse #1 had not entered a physician order or notice in the physician follow-up book for the treatment she initiated to the injury. On 2/28/23 at 11:03 am an interview was conducted with the facility Nurse Practitioner (NP). The NP stated she started her position at the facility on 1/6/23. She stated she first saw Resident #1 on 1/10/23 for a medical visit and had not evaluated the resident's wounds. She stated there was a communication breakdown and missing documentation regarding the wounds. The NP stated when the Wound NP was not available, she wanted to be informed by the Wound Nurse or Wound NP any changes to the resident's wound to follow up. She stated the 1/4/23 wound NP #2 by telehealth note was not in the medical record for her to review. She stated the right lower leg injury should have been evaluated by medicine before discharge on [DATE] since it significant. On 2/28/23 at 2:00 pm an interview was conducted with Wound NP #1. She stated she was not available on 12/31/22 when Resident #1 suffered the injury to her leg. Wound NP #1 stated she reviewed the resident's record and Wound NP #2 who was covering by telehealth visit had not assessed the right lower leg skin tear (no documentation). On 3/1/23 at 10:30 am an interview was conducted with the Physician Assistant (PA). The PA stated she saw Resident #1 on 1/6/23 and assessed the resident but was not informed or aware that there was a skin tear injury to the right leg and the right leg was not evaluated. Nor was she made aware of the severity of the injury. On 3/1/23 at 12:40 pm and interview was conducted with the Physician. The Physician stated she was not informed of Resident #1's right lower leg injury until 1/4/23 when an order was requested. The physician further explained she was not informed of its severity and because of the severity she would have expected to be notified or the resident sent out to the Emergency Department when the injury happened. The Administrator was advised of immediate jeopardy on 3/1/23 at 6:21 pm. The facility provided a credible allegation of immediate jeopardy removal. Credible Allegation of Compliance on 3/4/23. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of noncompliance The facility failed to notify the medical staff Resident #1 sacral wound deterioration and change on 1/9/2023, 1/13/2023 and 1/14/2023 and failed to notify the physician of the severity of the right lower leg injury on 12/31/2022 which resulted in no medical attention being provided. Resident was hospitalized with an infected sacral wound pressure ulcer stage 4 which resulted in sepsis. In addition, Resident #1 sustained a 7 cm by 2cm by 0.1 cm skin tear to the lower right leg. This wound deteriorated to expose bone and subcutaneous tissue and had the high likelihood to become infected. All residents have the potential to be affected. On 3/2/2023 the facility completed a 100% skin sweep for all current residents. No issues were identified. On 3/2/2023 the Director of Nursing/Designee reviewed previously completed wound reports for the last 30 days for any wound declines or changes. There were no wound declines or changes. On 3/2/2023 the Director of Nursing/Designee reviewed the previous 30 days of eInteract (electronic assessment tool in the Electronic Health Record) Change in Condition assessments for any missed physician notifications. There were no missed notifications identified. 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 3/2/2023 the Director of Nursing provided 1:1 education with the facility Designated Wound Nurse on notification to Medical Provider (Medical Doctor (MD)/Nurse Practitioner (NP)/Wound Nurse Practitioner (NP)) for changes in condition including deterioration of wounds, notification of injuries at the time of injury, and wound protocol to ensure that proper protocol is followed and in place. The facility wound protocol includes a description along with a picture of different types of altered skin integrity and acceptable treatment options to implement for each. On 3/2/2023 all Licensed Nursing Staff, including agency staff were educated by the Nursing Administration Team on notification to Medical Provider (MD/NP/Wound NP) for changes in condition including deterioration of wounds, facility wound protocol and location of wound protocol (available on each medication cart and at the main nurses station), immediate notification of injuries that cannot be treated per facility wound protocol, description of the problem and immediate need of the situation, per physician triage line as indicated which is available 24 hours a day, 7 days per week. Education of all Licensed Nursing Staff including current agency Licensed Nurses was completed on 3/3/2023. All newly hired Licensed Nursing Staff, including agency staff will be educated by the Director of Nursing/Designee during the facility orientation process on Notification to Medical Provider (MD/NP) for changes in condition including changes in wounds, notification of injuries and the wound protocol. The Regional Director of Clinical Services notified the Director of Nursing on 3/2/2023 on the implementation for new hires. An Ad Hoc QAPI was completed with the Interdisciplinary Team (IDT) which includes the Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Managers, Director of Rehab, Director of Life Enrichment, Director of Social Services, Environmental Services Director, Admissions Director, Business Office Manager, Minimum Data Set (MDS) Nurse, Wound Nurse, Clinical Coordinator, and the Medical Director on 3/2/2023. The IDT was updated regarding Immediate Jeopardy (IJ) citations the facility received on 3/1/2023 along with regulation, policy, and necessary education that is needed in order to be in compliance. The Director of Nursing/Designee will audit Weekly Wound reports for deterioration and MD/NP notification beginning 3/3/2023. The Director of Nursing/Designee will audit all incident reports to ensure appropriate treatment, MD/NP notification beginning 3/6/2023. Alleged date of IJ removal is 3/4/23. The credible allegation of immediate jeopardy removal was validated on 3/7/23. On 3/7/23 observation and nursing interviews of all shifts were done of nursing education for resident change notification, use of the wound care protocol, and injury notification, for proper assessment/evaluation of wound status and care care, wound changes (including deterioration) and, and medical staff involvement (notification). New nursing hires and contract staff would receive the education before assignment. Current and ongoing wound care planned audits were reviewed. A Quality Assurance meeting was held by the Administrator and Corporate and plans for improvement were outlined. The facility's immediate jeopardy removal date of 03/04/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, family member, home health liaison, and staff interviews, the facility failed to safely discharge 1 of 3 residents to home (Resident #1). The facility failed to submit a signed order for home health services to the home health agency until 3 days after discharge from the facility. Resident #1 had an unstageable pressure wound of the sacrum with purulent malodorous drainage and a large skin tear of the lower right leg that the family described as very deep, and she was able to see white meat that looked like a bone. Additionally, Resident #1 had an unstageable pressure wound of the left heel and a skin tear of the left lower leg. Resident #1 was sent home with incorrect wound care supplies and incorrect wound care orders. Resident #1 was taken to the emergency room by family members immediately after the facility discharged Resident #1. The family members recognized Resident #1 had serious wounds that needed medical treatment and could not be cared for at home. Immediate Jeopardy began on 1/14/2023 when Resident #1 was discharged home with an unstageable pressure wound of the sacrum with purulent malodorous drainage, an unstageable pressure wound of the left heel, a skin tear of the lower left leg, and a large skin tear of the lower right leg and without an order for home health services, with incorrect wound care supplies and instructions for wound care. Immediate Jeopardy was removed on 3/4/2023 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses to include acute on chronic respiratory failure, (an acute illness affecting a patient with chronic respiratory insufficiency), COVID-19 virus infection, anemia (requiring blood transfusions), kidney disease with acute kidney injury, pain in right knee, 2 Stage 2 pressure ulcers (ulcer extends into the deeper layers of the skin and can look like a shallow crater or blister) of the sacrum, deep tissue injuries (a pressure injury that begins in the muscle closest to the bone and appears as dark, non-blanchable skin) of the right and left heel, congestive heart failure and debility. A hospital admission note dated 1/14/2023 documented Resident #1 had an ejection fraction (measurement of the percentage of blood leaving the heart with each heartbeat) of 45% (normal 50-70%). A care plan dated 12/14/2022 addressed Resident #1's plan to discharge to the community after rehabilitation services. The goal for the care plan was to provide Resident #1 with a safe transition back to the community with interventions to involve home health agencies and appropriate community support services (none specified in the care plan). The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 to be moderately cognitively impaired. The MDS documented Resident #1 required extensive assistance with bed mobility, dressing, hygiene, and bathing, and total assistance to transfer and to toilet. The MDS assessment indicated Resident #1 was to be discharged to the community after rehabilitation services. A physician order dated 12/15/2022 was reviewed. The order was to float heels (elevate off the bed). An order dated 12/27/2022 directed for both heels to have betadine (a topical antiseptic) applied daily. A wound assessment dated [DATE] documented an unstageable pressure wound on the left heel that measured 7 centimeters (cm) by 6.5 cm, and the depth of the wound was unable to be determined. The note documented that the wound had no drainage and no odor and was improving. A physician order dated 1/9/2023 directed for left lower leg wound care to be completed daily with normal saline to clean the wound, calcium alginate (an absorbent dressing that promotes wound healing) to the wound bed, cover with an absorbent pad and apply gauze to secure. A wound assessment dated [DATE] documented the skin tear to the left lower leg to measure 7.1 cm by 1.9 cm and 0.1 cm. the wound was described as a trauma that was acquired in-house with a scant (very small) amount of serosanguineous (pink) drainage, a red wound bed, and no odor to the drainage was noted. The wound care documented wound care including applying calcium alginate to the wound, covering the wound with an absorbent pad, and securing the dressing with gauze. A wound assessment dated [DATE] documented the skin tear on the lower right leg that measured 7.2 cm by 3.5 cm by 0.1 cm. The wound was documented to have a moderate amount of serosanguineous drainage with a pink wound bed. Wound care orders dated 1/12/2023 for the right lower leg read to clean with normal saline, apply collagen powder (used to promote wound healing), cover with absorbent dressing, and wrap with gauze to secure once daily. A wound assessment dated [DATE] documented Resident #1 had an unstageable pressure ulcer of the sacrum that measured 11.5 cm by 16 cm. The depth of the wound was unable to be determined due to the presence of slough (dead, moist, stringy tissue). The note documented a moderate amount of serosanguineous drainage with a faint odor and noted the wound was deteriorating. Wound care orders for the sacrum dated 1/12/2023 read to apply an antiseptic solution (sodium hypochlorite and boric acid diluted in water) to clean the wound, then apply an antiseptic soaked gauze to the wound bed, cover with calcium alginate, cover with absorbent dressing, and secure with tape. This dressing change was to be completed daily. An email dated 1/11/2023 from the Social Worker (SW) to a home health agency liaison read, in part: Attached is the face sheet for (Resident #1). She is scheduled to be discharged on Saturday, 1/14/2023. She will need home health for nursing (medication management) .as soon as I have the signed orders, I will send them to you. An interview was conducted with the SW on 2/28/2023 at 1:41 PM. The SW explained that Resident #1 and her family planned on her returning home after rehabilitation services and a home health agency had been chosen by the family members. The SW reported that she had reached out to home health on 1/11/2023 to alert them to the referral. The SW reported the family was concerned about the discharge home because of Resident #1's high care needs (including transfers, toileting, and bed mobility, as well as wound care) but was relieved to know that home health would be out to assist with Resident #1's care. The family told the SW they had a male family member who was able to lift Resident #1 for transfers. The Director of Nursing (DON) was interviewed on 3/1/2023 at 9:45 AM. The DON reported she was asked by the Wound Nurse to assess Resident #1's sacral wound on 1/13/2023 because the wound was deteriorating. The DON reported that she did not measure the sacral wound and did not remember the status of the wound bed. The DON explained that based on her experience with wounds and her judgement, she decided to change the wound care from medihoney to an antiseptic wound care because she noticed an odor. The DON spoke to the nurse practitioner, who did not observe Resident #1's sacral wound but wrote orders for the antiseptic solution to be used. The DON reported she was not certain if the Wound Nurse had notified the Wound Nurse Practitioner that the sacral wound had deteriorated. The DON reported the facility discharged residents with wounds that home health managed, she felt Resident #1's sacral and right lower leg wound could be managed at home. A physician discharge order dated 1/13/2023 was reviewed. The order documented Resident #1 was to be discharged on 1/14/2023 and required a home health evaluation for nursing and therapy services. The facility Discharge summary dated [DATE] listed the equipment ordered for Resident #1, which included a wheelchair, walker, bedside commode, shower chair, and oxygen. A physician order dated 1/13/2023 ordered for Resident #1 to be discharged on 1/14/2023 with home health to evaluate for nursing and therapy services. The follow-up appointment with Resident #1's primary physician was noted, as well as medical equipment for Resident #1's home. No wound care orders or mention of wounds were included in the physician order. A certified medication assistant (CMA) #1 was interviewed on 3/1/2023 at 11:12 AM. CMA #1 reported she had assisted Nurse #2 with Resident #1's discharge from the facility on 1/14/2023. The CMA reported the family members were present during wound care for Resident #1 and observed the pressure ulcer care and asked her for wound care supplies. CMA #1 listed the supplies she had given to Resident #1's family members: absorbent pads, wound cleanser, medihoney and gauze. CMA #1 reported Resident #1's pressure ulcer on the sacrum was large, foul-smelling, and had a pus-like, red-brown drainage. CMA #1 reported she had not sent the wound care supplies for the lower right leg wound care. Nurse #2 was interviewed on 3/1/2023 at 11:20 AM. Nurse #2 reported she was the weekend supervisor and had discharged Resident #1 from the facility on 1/14/2023. Nurse #2 explained she and CMA #1 performed wound care on Resident #1 before she was discharged , and she had explained wound care to the family members. Nurse #2 reported the family members did not indicate they were going to take Resident #1 to the hospital, nor did they seem to be concerned with the pressure ulcer on the sacrum. Nurse #2 reported she did not think the wound appeared to be infected. Nurse #2 concluded by reporting she had received a call later in her shift from the hospital requesting medication administration records for Resident #1. The discharge instructions signed by the family dated 1/14/2023 noted follow-up appointments with Resident #1's primary care physician on 1/20/2023, the name and phone number of the home health agency, scheduled infusion appointments (for treatment of anemia) on 1/17/2023, 1/24/2023, 1/31/2023, and 2/7/2023. The discharge instructions included a note that a list of medications had been provided to the family and written prescriptions were sent to the pharmacy. The discharge instructions did not include a list of wound care supplies or ordered wound care for the sacrum or right lower leg wound. Discharge instructions dated 1/14/2023 without a signature of the family member for Resident #1 were reviewed. These instructions included wound care to the sacrum (medihoney [an antibacterial wound treatment that removes dead tissue and keeps the wound moist], and dry dressing daily) as well as wound care for the wounds on her right calf (betadine, calcium alginate [anti-microbial absorbent dressing], absorbent pad, wrap with gauze). This summary was faxed to the home health agency on 1/17/2023. The family member of Resident #1 was interviewed on 3/12023 at 12:09 PM. The family member reported she was with Resident #1 during the discharge process on 1/14/2023. The family member reported Nurse #2 and the CMA performed wound care and gave them instructions before discharge on [DATE]. The family member reported she and her sister saw Resident #1's pressure ulcer on her bottom and decided they were going to take Resident #1 directly to the hospital for evaluation because the pressure ulcer was very deep, smelled bad, had a lot of drainage, and it needed to be evaluated by a physician. The family member described the wound on the right lower leg to be very deep, and she was able to see white meat that looked like a bone. The family member concluded by stating she and her sister did not take Resident #1 home but drove directly from the facility to the hospital emergency room. The emergency room (ER) notes dated 1/14/2023 documented Resident #1 had been brought to the ER for evaluation, after discharge from the facility. The notes documented the family reported they were concerned that Resident #1 had an infected pressure ulcer of her sacrum. The diagnoses for Resident #1 included infected decubitus (pressure) ulcer, unstageable (full thickness tissue loss but is covered by extensive necrotic (dead) tissue). The admission note documented 3 different antibiotics were started and surgical consult was needed for pressure ulcer debridement (surgical removal of dead tissue). The right lower leg wound was documented as a chronic wound without further description. Blood cultures completed at the hospital on 1/14/2023 tested positive for 3 different bacteria. A wound culture of the sacral wound was obtained on 1/14/2023 and showed positive growth of 2 different bacteria. An email dated 1/17/2023 at 3:24 PM from the home health liaison to the SW was reviewed. The email read, in part: Just checking on the orders for (Resident #1). A reply from the SW to the home health liaison dated 1/17/2023 at 3:30 PM read, in part, I just sent you the order for (Resident #1). The Home Health Administrator was interviewed by phone on 3/1/2023 at 10:23 AM. The Home Health Administrator reported that the home health agency had not received orders for Resident #1 until 1/17/2023 and home health services would not have been initiated until after the home health agency received those orders. A follow-up interview was conducted with the SW on 3/1/2023 at 1:42 PM. The SW was not certain why she had not sent the orders to the home health agency until 1/17/2023. The SW returned at 2:23 PM with a log of discharge residents for January 2023. The log indicated Resident #1's family had been contacted by phone call on 1/16/2023 by the SW. The SW explained the family told her that Resident #1 was hospitalized . The SW reported the orders were signed by the physician on 1/13/2023, but she had left for the day and did not get the signed orders sent to the home health agency. The SW reported she had not worked on 1/14/2023.The SW reported that because Resident #1 was in the hospital, the orders for home health slipped her mind and she did not send the orders until she received the email from the home health liaison on 1/17/2023. The SW reported this was not a safe discharge home for Resident #1 without the home health referral. The facility Administrator was notified of Immediate Jeopardy on 3/1/2023 at 5:51 PM. *Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a results of the noncompliance: The facility failed to prepare for a safe discharge as evidenced by the signed order for home care services was not submitted to the home care agency until 3 days after discharge from the facility. Resident #1 would have been at home without skilled home care nursing services for an unstageable pressure ulcer of the sacrum with purulent odorous drainage from 1/14/2023 until 1/17/2023 when the facility sent the signed physician order to the home care agency. The family member recognized this was a serious wound that needed medical treatment and could not be cared for at home. All residents discharging home have the potential to be affected. On 3/2/2023 the Social Services Director/Designee reviewed all residents that discharged home or to Assisted Living Facilities for the last 30 days to ensure the order for home care services were sent to the agency prior to discharge. Any issues were immediately corrected. *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 3/2/2023 the [NAME] President of Social Services for [NAME] Healthcare Group provided education to the facility Social Service Director on Discharge Planning Policy to include timely notification to outside agencies. Social Services Director will confirm with outside agencies that discharge information has been received and confirm start date of services. Newly hired Social Service employees will receive education as part of the orientation process. An Ad Hoc QAPI was completed with the Interdisciplinary Team (IDT) which includes the Administrator, Director of Nursing (DON), Assistant Director of Nursing, Nurse Managers, Director of Rehab, Director of Life Enrichment, Director of Social Services, Environmental Services Director, Admissions Director, Business Office Manager, Minimum Data Set (MDS) Nurse, Wound Nurse, Clinical Coordinator, and the Medical Director on 3/2/2023. The IDT was updated regarding Immediate Jeopardy (IJ) citations the facility received on 3/1/2023 along with regulation, policy, and necessary education that is needed in order to be in compliance. Beginning on 3/3/2023 a review of all planned discharges will be reviewed during morning clinical meeting, which is attended by the Administrator, DON, ADON and all department heads, to ensure proper notification, communication, and documentation has been/will be made with any and all outside agencies as indicated to ensure a safe discharge. Notification of outside agencies will occur as soon as discharge date is determined. Alleged date of IJ removal 3/4/23. On 3/7/2023, the facility's credible allegation for immediate jeopardy removal was validated by the following: Review of the education provided to the SW related to timely notification of outside agencies, and confirmation of the information with the outside agency. Interview with SW and nursing staff to review education provided and procedure for discharging residents to home with outside agencies. Review of the discharges from 3/4/2023: 2 discharges noted with correct process in place. Review of audits completed by the facility. The facility's date of the immediate jeopardy removal plan of 3/4/2023 was validated on 3/7/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, family member, Physician Assistant (PA), Nurse Practitioner (NP), and Physician interviews, the facility failed to identify the seriousness and complete and document a thorough assessment of an injury to Resident #1's right lower leg sustained during a transfer on 12/31/22. The injury was described as a deep skin tear which measured 7 centimeters (cm) in length, width of 2.5 cm and approximately 0.5 cm deep and required direct pressure with a towel for several minutes to stop the bleeding. The edges of the wound were not able to be approximated (skin was unable to be pulled over the open wound to provide protection to the healing wound). This was reported to the on-call physician via voicemail as a skin tear with no other details provided. There was no treatment order until 1/4/23. The family member described the injury as very deep and was able to see white meat that looked like a bone. This deficient practice occurred for 1 of 2 residents reviewed for quality of care (Resident #1). Immediate jeopardy began on 12/31/22 when the facility failed to identify the seriousness of an injury to Resident #1's right lower leg and the need for medical attention. Immediate jeopardy was removed on 3/4/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. Findings included: Resident #1 was admitted from the hospital to the facility on [DATE] acute on chronic respiratory failure, (an acute illness affecting a patient with chronic respiratory insufficiency), COVID-19 virus infection, anemia (requiring blood transfusions), kidney disease with acute kidney injury, pain in right knee, 2 Stage 2 pressure ulcers (ulcer extends into the deeper layers of the skin and can look like a shallow crater or blister) of the sacrum, deep tissue injuries (a pressure injury that begins in the muscle closest to the bone and appears as dark, non-blanchable skin) of the right and left heel, congestive heart failure and debility. A hospital admission note dated 1/14/2023 documented Resident #1 had an ejection fraction (measurement of the percentage of blood leaving the heart with each heartbeat) of 45% recorded on 11/22 (normal 50-70%). Resident #1's admission Minimum Data Set, dated [DATE] documented moderately impaired cognition. The resident was dependent with all activities of daily living. The resident required two-person assist for transfer. Resident #1's admission care plan had a focus for actual and potential skin breakdown and assistance with activities of daily living. The transfer intervention was for mechanical lift. An interview was conducted on 2/28/2023 at 4:24 PM with NA #1, and she reported she had worked on 12/31/2022. NA #1 explained she was working on the 100 hall, and the 300 hall NA (NA #4) had asked her to come to Resident #1's room. NA #1 reported she was orienting NA #5 and the two of them went to Resident #1's room on the 300 hall. NA #1 described Resident #1 was in bed with her upper body supported on 3 pillows and NA #4 told her the bed control was not working to elevate the head and she wanted to move Resident #1 to a bed that worked. Resident #1's family member was at the bedside during this time. NA #1 left the room to get the lift to transfer Resident #1 to the other bed. NA #1 shared that when she returned to Resident #1's room, and Resident #1's family member had sat Resident #1 up on the side of the bed. According to NA #1's report, Resident #1 was unable to support herself sitting on the side of the bed and was crying out, I can't take it. NA#1 described how NA #5 said, I used to be an EMT (emergency medical technician), I know how to do this (transfer Resident #1), and proceeded to lift Resident #1 from the bed over to the wheelchair, bumping Resident #1's leg on the wheelchair footrest and causing a skin tear. NA #1 reported she got a towel to hold on the open area of the skin tear to top the bleeding and NA #4 went to get the nurse. NA #1 reported that Nurse #1 arrived in just a few seconds. NA #5 was interviewed on 3/7/2023 at 4:18 PM. NA #5 reported her first time working on the floor of the facility was 12/31/2022 and she was assigned to train with NA #1. NA #5 reported she was standing behind the wheelchair and NA #1 and NA #4 lifted Resident #1 from the side of the bed to the wheelchair, and during the transfer, Resident #1's leg scraped against the footrest of the wheelchair. NA #5 reported she had alerted NA #1 and NA #4 that the footrest was [NAME] out and to push it back, but the other NAs did not correct the position of the footrest. NA #5 reported the wound was bleeding and she took a bedsheet and held pressure on the wound until the nurse arrived almost 20 minutes later. NA #4 was interviewed on 3/1/2023 at 4:27 PM and she reported she was working 12/31/2022 and assigned to Resident #1 on that date. NA #4 verbalized she was not in the room, when NA #5 transferred Resident #1 and she did not see Resident #1 moved from the bed to the wheelchair but remembered that Resident #1 had sustained a large skin tear on her lower right leg and NA #1 was holding a towel on the leg to stop the bleeding. A nursing note written by Nurse #1 dated 12/31/2022 at 7:37 PM documented: This nurse across the hall in another room when the NA came to this nurse and stated resident got a skin tear when they (were) transferring resident into her wheelchair. This nurse into room and assess a large skin tear noted to the (right lower leg). Skin and subcutaneous tissue noted to be pushed to the right side of the wound and unable to be approximated. Area cleaned with wound cleanser, (non-stick, antibacterial dressing) applied to wound bed and (absorbent) pad placed on top and wrapped in (gauze). Resident states this area is sore. (Family member) in the facility at this time and was notified of skin tear by this nurse. (On-call physician) was notified via (voicemail) of skin tear. The nurse documented Resident #1 reported pain at a level 5 (1-10 scale, 10 being the most intense pain) of the lower right leg at the skin tear site. Nurse #1 was interviewed on 2/28/2023 at 2:37 PM. Nurse #1 reported she was assigned to Resident #1 on 12/31/2022 and was notified by the nursing assistant (NA) that Resident #1 had sustained a skin tear to her right lower leg during a transfer. Nurse #1 reported she arrived at Resident #1's room and found 3 NAs at the bedside, 2 fulltime employees and 1 orienting staff member. Nurse #1 reported NA #1 was holding a towel on Resident #1's leg to stop the bleeding from a heck of a large skin tear on her lower right leg. Nurse #1 reported she was told by NA #1 that Resident #1 hit her leg on the wheelchair when she was being transferred. Nurse #1 reported she did not think the skin tear was serious and did not require evaluation at the hospital. On 3/1/23 at 3:02 pm an interview was conducted with Nurse #1. Nurse #1 stated she was assigned to Resident #1 on 12/31/22 when staff transferred her without the mechanical lift and the resident hit her right lower leg on the wheelchair footrest. NA #1 informed her the resident had cut her leg. When she arrived NA #1 was holding a towel and providing pressure on the resident's right lower leg injury due to the bleeding. There was blood on the floor and the resident's leg, and it took a couple of minutes of pressure to stop the bleeding. Nurse #1 stated she completed an incident report and documented that subcutaneous tissue could be observed. Nurse #1 indicated the injury was 7 centimeters (cm) long by 2.5 cm wide and depth approximately 0.5 cm. Nurse #1 further stated, I placed a non-stick dressing into the wound and covered with a large, absorbent cotton pad dry dressing and wrapped as nursing judgement. Nurse #1 stated there was not a wound protocol for placement of the dressing and I made the decision to place a non-stick dressing to prevent adherence to the wound. The leg wound was approximately 2.5 centimeters open (wide), and I was unable to approximate the edges (place them together), and I had not considered sending the resident to the Emergency Department because the bleeding had stopped. I called the physician on-call and left a message on the skin tear notification voicemail line (on-call physician phone line). Nurse #1 stated she had not initiated an order for the wound care to the resident's leg and she had not placed the injury in the physician notification book. Nurse #1 stated she completed the resident's right lower leg wound care on 1/1/23 and the following weekend 1/7/23 and 1/8/23. The wound looked the same size (had not measured), was without signs and symptoms of infection, and the drainage was a small amount of serosanguineous. Nurse #1 stated she had not documented the resident's wound observation; she initialed the treatment administration record on 1/7/23 and 1/8/23. On 1/2/23 there was a multi-disciplinary team meeting documented by the Wound Nurse. It was documented Resident #1 was noted with a skin tear to her right lower leg after being transferred from bed to the wheelchair. The area was noted to be treated per standing orders (there was no standing order for use of non-adherent dressing to an injury). Resident #1's Treatment Administration Record (TAR) revealed no orders for wound care to the residents right lower leg until 1/4/23 when an order was entered to cleanse with normal saline, place a non-stick dressing to the wound bed, and cover with dry dressing each day initiated by the Wound Nurse and signed by the Physician electronically (documented in the order). Documentation of a telehealth visit by Wound Nurse Practitioner (NP) #2 completed on 1/4/23 did not include an assessment of Resident #1's right lower leg skin tear. The Wound Nurse note dated 1/4/23 documented Wound NP #2's telehealth visit to evaluate Resident #1's sacral pressure ulcer wound and both heels. There was no evaluation of the resident's skin tear of the right lower leg documented. On 3/1/23 at 2:00 pm an interview was attempted with Wound NP #2, and she was unavailable. On 2/28/23 at 9:30 am an interview was conducted with the Wound Nurse. The Wound Nurse stated she assessed Resident #1's right lower leg skin tear on 1/4/23 and informed the physician the resident had a skin tear injury to her right lower leg but had not documented a measurement or condition. A new order was received from the physician to place hydrogel (wound healing ointment) to the wound bed and cover with a large dry dressing (change from the non-stick dressing initiated by Nurse #1). The Wound Nurse stated she had not informed nor asked Wound NP #2 to evaluate the resident's right lower leg skin tear during the 1/4/23 telehealth visit. The Wound Nurse dressed the resident's right lower leg injury each day and measured and documented the condition of the injury on 1/9/23 and reported findings to the physician. An order dated 1/4/23 was initiated by the Wound Nurse to apply hydrogel in the wound bed on the right lower leg and cover with dry dressing every day as prescribed by the Physician and was signed electronically by the Physician (after the telehealth visit). A review of Resident #1's record revealed the PA saw Resident #1 on 1/6/23 and assessed her sacral wound, both heels, and left leg. The right lower leg was not assessed. On 3/1/23 at 10:30 am an interview was conducted with the PA. The PA stated she saw Resident #1 on 1/6/23 and assessed the resident sacral pressure ulcer, both heels, and left leg skin tear. The PA stated she was not informed by nursing nor aware that there was a second skin tear to the right leg and the right leg was not evaluated. The PA stated 1/6/23 was her last day at the facility. A wound assessment dated [DATE] documented a skin tear of the right lower leg that measured 7.6 centimeters (cm) by 3.5 cm by 0.1 cm and had a pink wound bed and a moderate amount of serosanguinous (pink) drainage. The note documented the wound was cleaned with normal saline, and an antimicrobial non-stick dressing was applied to the open wound, it was covered with an absorbent pad, and wrapped with gauze. The nursing note that correlated with wound assessment dated [DATE] documented Resident #1 was reporting 3 pain to her right lower leg. The Wound Nurse's note dated 1/9/23 documentated the resident's right lower leg skin tear by the Wound Nurse. The entry documented Resident #1's skin tear to the right lower leg measured 7 cm length by 3.5 cm wide by 0.1 cm deep. There was moderate serosanguineous drainage, wound bed was pink, there was pain level 3, and the wound was improving. The physician was notified of the wound status and a new order was obtained electronically. The Wound Nurse was interviewed on 3/1/23 at 9:20 am. The Wound Nurse stated she informed the physician by phone of the resident's right leg skin tear status on 1/9/23 and was provided a new treatment order but did not remember why. She had not asked the physician or any other medical staff member to assess the resident's skin tear. Nursing assessed the wounds during daily dressing changes on the weekends and the Wound Nurse assessed the wound during daily dressing changes Monday through Friday and measured and documented the wound status once a week. Resident #1's new order documented by the Wound Nurse for the right lower leg skin tear dated 1/9/23 was to place calcium alginate in the wound and cover with a dry dressing and wrap with rolled gauze. The order was initiated by the Wound Nurse as prescribed by the Physician and signed electronically. Wound care orders dated 1/12/2023 for the right lower leg read to clean with normal saline, apply collagen powder (used to promote wound healing), cover with absorbent dressing, and wrap with gauze to secure once daily was initiated by the Wound Nurse and signed by the physician. There was no further documentation about Resident #1's right lower leg wound after 1/9/23. On 2/27/23 at 1:40 pm an interview was conducted with the family member. She stated the family visited on Monday (1/2/23) and that the resident had a large wound to the right lower leg. The dressing was soiled and falling off. The nurse was informed, and the Wound Nurse changed the dressing. The family member stated they asked nursing about the dressing to the right leg, and it was changed. The resident complained of pain in the right leg wound. The family member was interviewed on 3/1/2023 at 12:09 PM. The family member recalled she and other family members were in the facility on 12/31/2023 and the nursing staff had asked the family to step out of the room so they could transfer Resident #1 to a different bed and apply the air mattress to the bed. The family member reported that when she and the other family members returned to the room, they were told that Resident #1 had sustained a skin tear from the wheelchair. The family member explained that they asked for the wound dressing on the right lower leg to be removed and when they saw the skin tear, they told the nurse that the wound needed to be evaluated at the hospital. The family member described the wound on the right lower leg to be very deep, and she was able to see white meat that looked like a bone. The family member reported the skin was pushed back away from the wound and the nurse said she had not been unable to pull it back over the open wound and Resident #1 reported pain at the wound site. The family member said that Nurse #1 told them the physician had been notified of the skin tear and didn't feel that the wound needed to be assessed at the hospital. On 2/28/23 at 10:26 an interview was conducted with the Director of Nursing (DON). The DON stated, if there was a concern with a wound you would ask the staff to reach out to the medical staff. I would use nursing judgement for standing orders only. Resident #1's skin tear to the right lower leg was not assigned to Wound NP #1 to follow, nursing was taking care of the skin tear by initiating the wound treatment and obtained an order from the Physician. The DON stated she was not sure if the wound treatment initiated by Nurse #1 for Resident #1's skin tear was part of the standing orders. The DON had no comment about the lack of the Wound Nurses' documentation of the right lower leg skin tear. She stated that all wounds were to be assessed and measured each week by the Wound Nurse and the Wound NP if following. The Wound Nurse completed all resident wound care Monday through Friday and assigned nursing staff were to complete wound care on the weekends. The DON stated that the resident's skin tear was treated each day and the physician provided an order and the Wound Nurse was responsible to report any decline in the wound. The DON stated she had not assessed the resident's right lower leg injury herself and was aware that the Wound Nurse was following and had provided updates to the Physician. On 2/28/23 at 11:03 am an interview was conducted with the NP for the facility. The NP stated she started her position here on 1/6/23 and took the place of the PA. She stated she first saw Resident #1 on 1/10/23 for a medical visit and had not evaluated the resident's wounds on 1/10/23. She was of the understanding the Wound NP was following all the residents' wounds and was to be notified of concerns and changes. She stated that the skin tear to the lower right leg should have been followed by medical staff and wanted to be informed by the Wound Nurse or Wound NP of the changes to the resident's wound. All the resident's wounds should have been evaluated by medicine before discharge on [DATE] since it was significant and there was a change. On 3/1/23 at 12:40 pm an interview was conducted with the Physician. The Physician stated she was not informed of the severity of Resident #1's right lower leg skin tear. The Wound Nurse communicated her assessments she provided the wound care order. The physician stated the resident should have been sent to the Emergency Department on 12/31/22 or at least followed by the medical staff in the facility from when the injury occurred on 12/31/22. The Physician was not aware that the NP or PA had not assessed/observed the right lower leg wound. Resident #1's hospital record dated 1/14/23 documented the right lower leg wound was a chronic wound without further description. The Administrator was notified of IJ on 3/1/23 at 6:21 pm. The facility provided a 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 noncompliance. The facility failed to ensure that Resident #1 accidental injury on 12/31/22 to her right calf which resulted in a 7 cm by 2cm by 0.1 cm skin tear to the lower right leg was evaluated by a medical provider (MD/NP/Wound NP). There was no physician order for treatment for 4 days. Notification of the accidental injury to Resident #1 lower right leg was reported on the physician triage line voicemail per protocol as a skin tear. The resident's hospital record dated 1/14/2023 documented that the resident's injury to her right lower leg was trauma with tissue injury depth to the bone. All residents have the potential to be affected. On 3/2/2023 the Wound Nurse, Assistant Director of Nursing, and Clinical Coordinator completed head to toe skin assessments on all residents in the facility to include assessment of current wounds. Appropriate treatment orders are in place. No issues were identified. On 3/2/2023 the Director of Nursing/Designee reviewed all incident reports for the last 30 days to ensure thorough assessment of injury, Medical Provider (MD/NP/Wound NP) notification, treatment orders were obtained timely as indicated, and care plans were up to date. No issues were identified. On 3/2/2023 eInteract (electronic assessment tool in the Electronic Health Record) Change in Condition assessment for the last 30 days were reviewed by the Director of Nursing to ensure MD/NP notification and orders were obtained timely as indicated. No issues were noted. 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 3/2/2023 the Director of Nursing provided 1:1 education with the facility Designated Wound Nurse on notification to Medical Provider (Medical Director (MD)/Nurse Practitioner (NP)/Wound Nurse Practitioner (NP)) for changes in condition including notification of injuries, obtaining orders timely, wound protocol, ensuring the medical provider (MD/NP/Wound NP) evaluates and an appropriate treatment order is in place as indicated. The Wound Nurse was educated to follow up with Medical Providers to ensure evaluation of wounds has been completed when they are in the facility. The Wound Nurse will continue to complete weekly wound assessments and assigned Licensed Nurses complete treatments and dressing changes per physician orders. The facility wound protocol includes a description along with a picture of different types of altered skin integrity and acceptable treatment options to implement for each. The NP will be educated by the respective physician group manager regarding proper assessment and evaluation of all residents to include assessment of wounds/skin integrity concerns by 3/3/2023 in order to prevent deterioration of wounds and to ensure appropriate orders are in place to prevent worsening of wounds/skin conditions and follow up with facility Wound Nurse/Designee to ensure no evaluation needs have been missed. Education for all Licensed Nurses and agency Licensed Nurses was completed on 3/3/2023 regarding following facility wound protocol, notifying Medical Providers of any abnormal assessment findings during routine dressing changes immediately to ensure timely evaluation is completed and any changes to treatments be implemented immediately as indicated, and notification of Medical Providers if a new skin condition cannot be treated with facility wound protocol. Education will be provided to any newly hired Licensed Nurses and agency Licensed Nurses prior to providing direct care. Education was completed on 3/3/2023 with all Licensed Nursing Staff, including Licensed agency nursing staff of wound protocol and location of wound protocol (in binder on medication carts and at main nurses station), documentation of any skin integrity concerns, notification of medical provider (MD/NP/Wound NP) regardless of day or time, notification of new skin concerns for the Wound Nurse to ensure proper follow up and assessment is completed. An Ad Hoc QAPI was completed with the Interdisciplinary Team (IDT) which includes the Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Managers, Director of Rehab, Director of Life Enrichment, Director of Social Services, Environmental Services Director, Admissions Director, Business Office Manager, Minimum Data Set (MDS) Nurse, Wound Nurse, Clinical Coordinator, and the Medical Director on 3/2/2023. The IDT was updated regarding Immediate Jeopardy (IJ) citations the facility received on 3/1/2023 along with regulation, policy, and necessary education that is needed in order to be in compliance. Alleged date of IJ removal 3/4/23. The credible allegation of immediate jeopardy removal was validated on 3/7/23. On 3/7/23 observation and nursing interviews of all shifts were done of nursing education and the in-service signed roster was reviewed regarding proper assessment/evaluation of wound care, notification of changes, use of the wound care protocol, and medical staff involvement. A documented resident audit was completed of all residents for injuries. New nursing hires and contract staff would receive the education before assignment. A Quality Assurance meeting was held by the Administrator and Corporate and plans for improvement were outlined. The facility's immediate jeopardy removal date of 03/04/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff, Wound Nurse Practitioner (NP) #1, Physician Assistant, Facility Nurse Practitioner, Physician, and Family Member, the facility failed to provide treatment and services, consistent with the facility's wound protocol, to promote healing and identify infection of the pressure areas Resident #1 had on admission. Resident #1's Stage 2 pressure ulcers deteriorated, increased in size and developed odor, drainage, and eschar (dead tissue) during her one month stay. Staff did not consult with medical staff when there was drainage and deterioration of the wound. On the day of discharge, the Family Member took Resident #1 directly to the hospital where she was diagnosed with a stage 4, open and infected decubitus ulcer of the sacrum. The infection was not identified at the facility. This deficient practice affected 1 of 2 residents reviewed for pressure sores (Resident #1). Immediate jeopardy began on 1/9/23 for Resident #1 when staff failed to address the resident's continued sacral pressure ulcer deterioration. Immediate jeopardy was removed on 3/4/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. Findings included: The facility standing order revised 3/2021 documented Wound Care Protocol, 1. Document wound assessments to include measurements and description of the wound. 2. Only wound nurse to stage wounds. 3. Place in problem book for follow up with PEC (on-call physician). The unstageable pressure ulcer wounds that are completely covered with nonviable necrotic (dead) tissue cannot be staged. Ulcers should be carefully evaluated for the presence of undermining, sinus tracts or tunning. A physician or wound care specialist should evaluate wounds that show signs and symptoms of infection. Debridement of ulcers with unstable devitalized tissue is necessary. Notify the medical doctor or wound consultant for debridement options (i.e., enzymatics, referral for sharp debridement). Debridement is the removal of non-viable material, foreign bodies, and poorly healing tissue. Resident #1 was admitted from the hospital to the facility on [DATE] acute on chronic respiratory failure, (an acute illness affecting a patient with chronic respiratory insufficiency), COVID-19 virus infection, anemia (requiring blood transfusions), kidney disease with acute kidney injury, pain in right knee, 2 Stage 2 pressure ulcers (ulcer extends into the deeper layers of the skin and can look like a shallow crater or blister) of the sacrum, deep tissue injuries (a pressure injury that begins in the muscle closest to the bone and appears as dark, non-blanchable skin) of the right and left heel, congestive heart failure and debility. A hospital admission note dated 1/14/2023 documented Resident #1 had an ejection fraction (measurement of the percentage of blood leaving the heart with each heartbeat) of 45% recorded on 11/22 (normal 50-70%). An admission nurses' note dated 12/14/22 documented pressure ulcer assessment as follows: The right buttock had a stage two ulcer 3.0 centimeters (cm) x 3.9 cm x 0.1 cm. The wound bed was red. The left buttock had a stage two ulcer 4.9 cm x 3.5 cm x 0.1 cm. The wound bed was red. The right gluteal fold had a stage two ulcer 0.4 cm x 0.6 cm x 0.1 cm (newly identified on admission). Resident #1's physician order dated 12/14/22 was to cleanse the buttocks with normal saline and cover with foam dressing. Resident #1's admission Minimum Data Set, dated [DATE] documented a moderately impaired cognition. The resident was dependent with all activities of daily living. The resident had 4 stage 2 pressure ulcers. The resident was always incontinent of urine and stool. The resident required 1 staff member assistance for bed mobility. A pressure ulcer risk assessment scale completed on admission documented high risk for pressure ulcer development. Resident #1's admission care plan dated 12/20/22 had a focus for actual and potential skin breakdown. The interventions were to provide treatment as ordered, assess, and document the status, monitor, document and report changes to the physician, turn and reposition as indicated, and use pressure relieving devices. The Wound Nurse note dated 12/20/22 indicated the pressure ulcer assessment to the buttocks was as follows: The right buttock had a stage two ulcer 3.0 x 3.9 x 0.1 cm. The wound bed was red with no odor and drainage was a small amount of sanguineous (watery red). The wound was unchanged and pain level was none. The right inferior buttock had a stage two ulcer 1.0 x 0.8 x 0.1. The wound and dressing order were unchanged and there was no pain. The left buttock had a stage two ulcer 4.9 x 3.5 x 0.1. There was scant sanguineous drainage. Wound bed was pink with no odor. The right gluteal fold had a stage 2 ulcer 0.4 x 0.6 x 0.1. The wound was unchanged. A white blood cell count result was 6.6 on 12/21/23 (range 6 - 10). Resident #1 had a multidisciplinary note written by the Wound Nurse dated 12/22/22 documented the stage 2 pressure ulcers to the buttocks, a protein drink was added to promote healing, and staff were to turn and position. The Wound NP was supposed to follow up on 12/27/22. The Wound Nurse note dated 12/27/22 documented that all the buttock areas were measured together and described as a sacral pressure ulcer stage 2. The wound bed was pink and yellow with no odor. The wound was assessed by the Wound NP #1. The measurement was 4.8 x 5.6 x 0.3 with no drainage. The Wound NP #1 ordered honey-based wound gel and dry dressing daily. On 12/27/22 Wound NP #1 documented her initial assessment of Resident #1's sacral pressure ulcer wound. The chief complaint was necrotic tissue in the wound and services were requested. The wound was present on admission and unstageable. Tissue depth was subcutaneous with mild serous drainage. The measurement was 4.8 x 5.6 x 0.3. The wound was documented as unavoidable. On 2/28/23 at 2:00 pm an interview was conducted with Wound NP #1. She stated she saw Resident #1 for her first visit on 12/27/22 for sacral pressure ulcer. The ulcer was stable and the same size as when admitted . She stated she went on leave after the 12/27/22 visit and was not available for resident care until 1/17/23. Arrangements were made for telehealth wound care on 1/4/23. A multidisciplinary meeting on 12/29/22 documented by the Wound Nurse the resident had an air mattress in place. The Wound Nurse note dated 1/4/23 documented the Wound NP #2 telehealth visit evaluated the resident's sacral pressure ulcer wound. The Wound Nurse measured the sacral wound during the evaluation. Measurements were, 11.5 x 15 and depth was undetermined. It had a small amount of sanguineous drainage. The wound bed had pink and yellow tissue with a necrotic appearance and slough (dead skin tissue) with no odor. The wound had gotten significantly larger, deteriorated with necrotic tissue and was close to the sacral bone. New orders were received to apply hydrogel to the wound, imaging to assess the sacral bone for involvement, and labs. Autolytic debridement (medication added to stimulate the body to naturally eliminate dead tissue) was being utilized and Wound NP #1 will continue to follow. On 2/28/23 at 9:50 am an interview was conducted with the Wound Nurse. The Wound Nurse stated on 1/4/23 there was a noted change in Resident #1's sacral pressure ulcer wound. A wound NP telehealth visit was done with Wound NP #2 by video. The wound had new necrosis (dead tissue in the wound bed). The order was changed to use hydrogel with silver to the wound bed. Wound NP #2 ordered labs and a sacral x-ray. Wound NP #2's note dated 1/4/23 for documented the sacral wound length 11.5 cm by width 15 cm and depth was 0.5 cm down to the subcutaneous (tissue below the skin) layer. The wound bed had 80% yellow/black tissue with mild serous drainage. The wound was unstageable and deteriorating. The deterioration was significant with an increase in wound volume and percentage of necrotic tissue. Labs were ordered to rule out osteomyelitis. A new order to cleanse with normal saline, apply skin prep around the wound, place hydrogel with silver to the wound bed, and dry protective dressing each day was written. On 3/1/22 at 2:00 pm an attempt was made to interview Wound NP #2 and she was not available. A Physician Assistant (PA) note, dated 1/6/23, documented that Resident #1's sacral pressure ulcer wound was assessed and had small drainage with no odor and pink with yellow wound bed. The wound order was changed to honey-based wound gel with dressing each day. No measurement was documented. On 3/1/23 at 10:30 am an interview was conducted with the PA. The PA stated she saw Resident #1 on 1/6/23 and assessed the resident's sacral pressure ulcer. The PA stated the sacral wound had minimal drainage with no odor and the wound was unstageable with pink tissue and yellow slough. She stated the sacral wound order was changed to honey-based wound gel with calcium alginate instead of the hydrogel ordered two days earlier. She was not aware that Wound NP #2 documented the sacral wound was deteriorating and to the bone and had ordered an x-ray to assess for osteomyelitis and a complete blood count to assess for infection. The PA stated she had not read Wound NP #2's note prior to changing the dressing order. The PA stated 1/6/23 was her last day at the facility. On 2/28/23 at 2:45 pm an interview was conducted with Nurse #1. Nurse #1 stated she provided wound care to Resident #1 on the weekends. Nurse #1 stated on the weekend of 1/7/23 and 1/8/23 she noted the sacral wound had deteriorated from the prior weekend. There was black necrosis and red around the black part with drainage and odor. Nurse #1 stated she had to use a larger dressing to cover the wound that had gotten larger. Nurse #1 stated she was aware there was a telehealth visit by Wound NP #2 who was following the resident and thought the Wound NP #2 was following. Nurse #1 had not contacted medical staff about her concerns and had not documented her findings. The Wound Nurse note dated 1/9/23 documented the Wound Nurse assessed and measured Resident #1's sacral pressure ulcer wound as follows: the length 11.5 cm by width 16 cm and depth was 0.5 cm. There was a moderate amount of serosanguineous drainage, and the wound bed appeared yellow with slough and faint odor. The wound was deteriorating, and the resident had a pain level score of 3 (0 to 10 scale with 0 being no pain). The family was notified. No medical staff communication was documented. Lab results were collected on 1/9/23 for a complete blood count. The 1/9/23 result revealed an elevated white blood cell count of 13.2 (range 6 - 10). An elevated white blood cell count can be an indicator of infection. The radiograph taken on 1/6/23 of the sacrum showed a result dated 1/6/23 that reported no osteomyelitis (bone infection). On 2/28/23 at 11:25 am an interview was conducted with the Facility Nurse Practitioner. She stated she started her position on 1/6/23 and took the place of the Physician Assistant. She saw Resident #1 on 1/10/23 for a medical visit and had not evaluated the resident's wounds. She stated the Wound NPs were seeing the resident and she did not evaluate the wounds, unless there was a need. She stated there was a mildly elevated white blood cell count lab, but that there was no concern for wound infection and the x-ray did not show osteomyelitis of the sacrum. She stated staff had not informed her Wound NP #1 was not available to consult from 12/31/22 to 1/17/23. A review of the resident's record did not document a nursing assessment of the sacral pressure ulcer wound condition or measurements for 1/13/23. A new order for antiseptic solution cleanse and wet to dry dressing with the solution each day was written by the Director of Nursing and signed by the Physician without observation of the wound. On 2/28/23 at 9:50 am an interview was conducted with the Wound Nurse. The Wound Nurse stated she was not aware that the resident's white blood cell count was elevated. She said the physician was responsible for labs. She added the Nurse Supervisor would provide lab reports to whoever need the labs. She said if wounds changed and developed odor, then you would change the course of treatment. She stated she asked the DON to look at the sacral wound because the wound had deteriorated further. She stated, usually, an antiseptic solution was initiated when there was a concern for infection. The Director of Nursing (DON) and she decided on 1/13/23 there was an odor to the resident's sacral wound and started using antiseptic solution to clean and pack. There was no physician order. On 2/28/23 at 10:26 an interview was conducted with the Director of Nursing (DON). The DON stated she was asked by the Wound Nurse to look at Resident #1's sacral wound on 1/13/22 for a second opinion for treatment change. On 1/13/22 the Wound Nurse asked me to evaluate Resident #1's sacral wound and the DON said she was not familiar with the status of the wound. She stated that she could not recall if using an antiseptic for a deteriorating pressure ulcer was part of the standing order. The record had no further documentation of the sacral wound's status. On 2/28/23 at 11:25 am, the Facility Nurse Practitioner (NP) stated staff had not informed her that the resident's wound had deteriorated and had odor and increased drainage until 1/13/23. The DON informed her that the nurses changed the wound treatment to antiseptic cleanse and packed it with gauze wet to dry and she wanted to be informed of the wound deterioration. The Facility Nurse Practitioner evaluated the resident for discharge on [DATE] and had not evaluated her wounds. The DON gave report of the wounds' condition but not of the amount of deterioration. She observed a photo of the sacral wound taken on 1/14/23 from the resident's hospital record. She stated there was a breakdown in communication and missing documentation when Wound NP #1 was not available and wanted to be informed by the nurse of the changes to the resident's wound. On 2/28/23 at 12:20 pm an interview was conducted with the Discharge Nurse. She stated the Wound Nurse completed the dressing changes and she was informed that the sacral wound was getting worse. She stated there was an odor coming from the resident's wound during the 1/4/23 dressing change reported by the nurse assigned (was not reported to medical staff). She stated the odor and drainage was a concern by the nursing staff. The family would visit and complain that there was an odor and drainage coming from the sacral wound. She stated when she saw the sacral wound during the week of 1/9/23, it was pink, getting larger with yellow slough. The resident was noted to have declined the last week of her admission. On 3/1/23 at 9:45 am an interview was conducted with the DON. She stated that on 1/13/23 she accompanied the Wound Nurse as requested and observed Resident #1's sacral pressure ulcer wound because of wound changes. The DON stated the Wound Nurse was new to her role and the DON was asked to look at the wound. The DON stated she had not measured the wound or evaluated the depth nor remembered if the pressure ulcer had black eschar. The DON stated she made the decision to change the wound care order from honey-based gel treatment with calcium alginate to antiseptic solution cleanse and wet to dry with the solution. The DON stated she gave her assessment of what she saw to the Facility NP later. The Facility NP had not assessed the resident's wound. The DON stated she was not aware that Wound NP #1 instructed the Wound Nurse to contact the Wound NP consultant's office if there were changes to the wound so that an assessment could be done by telehealth. The DON stated she was not aware that the Wound Nurse had not contacted medical staff that the resident's sacral wound had continued to deteriorate, and the plan was to notify the Wound NP consultant's office if there were changes. The DON stated that the physician signed off on orders electronically from her computer and had not assessed the resident's sacral wound. The DON stated she had not documented her observation on 1/13/23 of the resident's sacral wound. On 3/1/23 at 11:12 am an interview was conducted with the Medication Aide (MA). The MA stated she was assigned to Resident #1 on the day of discharge 1/14/23. She changed the dressing to the resident's sacral pressure ulcer wound and found that it had a bad odor and was open. The wound had a reddish, brown purulent drainage. Nurse #2 was present for the wound care. She had not reported her findings to medical staff. On 3/1/23 at 11:20 am an interview was conducted with Nurse #2. Nurse #2 stated she was present when the MA changed Resident #1's sacral wound dressing and provided assistance. She was not concerned about the wound and provided the supplies for wound care to take home. Nurse #2 stated that the sacral wound had opened, had black tissue, and had white drainage. On 3/1/23 at 12:50 pm an interview was conducted with the Physician. The physician stated she was not aware of Resident #1's sacral pressure ulcer wound deterioration. The physician stated she would have wanted the nursing staff to report changes and continued deterioration of a wound to the medical staff. The medical staff was required to evaluate all wounds at least 5 days before discharge. The physician stated she was not aware Resident #1 had no medical staff assessment within this timeframe. The physician stated she was not sure the pressure ulcer was avoidable, but the lack of medical staff attention was avoidable. She further stated the resident outcome was hard to predict because of the many other diagnoses. On 2/27/23 at 1:40 pm an interview was conducted with Resident #1's family member. She stated the resident had a sacral wound that had a strong odor and pain. I reported my concerns to the nurse several times and the wound was not treated by a physician. On the day of discharge (1/14/23) the resident's smell and pain to the sacrum was so bad we went straight to the hospital. The family member commented that before hospitalization for COVID the resident had never had a pressure ulcer. Resident #1's hospital record documented the resident was brought to the hospital by the family on 1/14/23 instead of being taken home as discharge planned by the facility. The resident was seen for complaint about wound to the buttock. The family felt the wound was not addressed (at the facility). The family reported foul smell coming from the buttock wound. The hospital physician assessment documented the resident had two lower extremity wounds that were prior and a new wound from trauma in wheelchair. The buttock wound was a large, open stage 4 pressure ulcer that was malodorous, had a large amount of purulent (containing pus) drainage, and had pitting edema surrounding. The diagnosis was unstageable infected decubitus ulcer of the sacrum. The Administrator was notified of immediate jeopardy on 3/1/23 at 6:22 PM. The facility provided a 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 noncompliance The facility failed to seek medical attention for Resident #1's sacral pressure ulcer that had deteriorated and had become larger and developed sour odor, increased pain, increased drainage, black eschar tissue, and purulent drainage to determine the appropriate wound changes (1/9/2023, 1/13/2023 and 1/14/2023). Nursing had not followed their wound protocol and discontinued a physician order for sacral wound care and initiated antiseptic solution treatment without medical evaluation/observation (last completed 1/6/2023) of deteriorating wound on 1/13/2023. The resident was hospitalized with an infected sacral wound pressure ulcer stage 4 (as staged by the hospital) which resulted in sepsis. A review of the residents' hospital record admission dated 1/14/2023 documented blood cultures and wound culture to be positive of the same organism for infection and sepsis. All residents have the potential to be affected. On 3/2/2023 the facility completed a 100% skin sweep for all current residents. No issues were identified. On 3/2/2023 the Director of Nursing/Designee reviewed previously completed wound reports for the last 30 days for any wound declines or changes. No issues were identified. On 3/2/2023 all wound physician orders for the last 30 days were reviewed by Director of Nursing/Designee for appropriateness of treatment orders. No issues were identified. On 3/2/2023 Braden Scale Skin Risk assessment were reviewed by the Director of Nursing/Designee and updated if indicated. On 3/2/2023 Care Plans for identified skin risk were reviewed and updated as indicated by the Director of Nursing/Designee. 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 3/2/2023 the Director of Nursing provided 1:1 education with the facility Designated Wound Nurse on notification to Medical Provider (Medical Director (MD)/Nurse Practitioner (NP)/Wound Nurse Practitioner (NP)) for changes in condition including wounds/skin tears/pressure injuries (PIs), obtaining orders timely, following facility wound protocol, ensuring the medical provider (MD/NP/Wound NP) is notified timely of new or deteriorating wounds, evaluates and that an appropriate treatment order is in place as indicated. The facility wound protocol includes a description along with a picture of different types of altered skin integrity and acceptable treatment options to implement for each. On 3/2/2023 all Licensed Nursing Staff, including Licensed Nursing agency staff were educated by the Nursing Administration Team on notification to Medical Provider (MD/NP/Wound NP) for changes in skin condition including deterioration of wounds regardless of day or time, wound protocol location (in binder on medication carts and at main nurses station) and entering orders into the electronic health record (EHR). All education completed on 3/3/2023. All Certified Nurse Aides (C.N.A.s) including agency C.N.A.s were educated to report any identified skin integrity concerns (redness, open areas, saturated dressings, odors from wounds) to Licensed Nursing Staff immediately. All education completed on 3/3/2023. All newly hired Licensed Nursing Staff and Certified Nurse Aides, including Licensed Nursing and Certified Nurse Aide agency staff will be educated by the Director of Nursing/Designee during the facility orientation process on Notification to Medical Provider (MD/NP/Wound NP) for changes in condition including deterioration of wounds and wound protocol. The Regional Director of Clinical Services notified the Director of Nursing on 3/2/2023 on the implementation for new hires. The Director of Nursing/Designee will audit Weekly Wound reports for deterioration beginning on 3/3/2023. The Director of Nursing/Designee will audit all new treatment orders to ensure wound protocol is followed and assessment by medical provider (MD/NP/Wound NP) beginning on 3/3/2023. Residents with current wounds including pressure injuries (PI) will continue to be reviewed by the Interdisciplinary Team during weekly Resident Review Meeting. An Ad Hoc QAPI was completed with the Interdisciplinary Team (IDT) which includes the Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Managers, Director of Rehab, Director of Life Enrichment, Director of Social Services, Environmental Services Director, Admissions Director, Business Office Manager, Minimum Data Set (MDS) Nurse, Wound Nurse, Clinical Coordinator, and the Medical Director on 3/2/2023. The IDT was updated regarding Immediate Jeopardy (IJ) citations the facility received on 3/1/2023 along with regulation, policy, and necessary education that is needed in order to be in compliance. Alleged date of IJ removal 3/4/23. The credible allegation of immediate jeopardy was validated on 3/7/23. On 3/7/23 observation and nursing interviews of all shifts were done of nursing education and the in-service signed roster was reviewed regarding proper assessment/evaluation of wound care and changes, timely entering of orders, use of the wound care standing order, and medical staff involvement notification. New nursing hires and contract staff would receive the education before assignment. Current and ongoing wound care planned audits were reviewed. A Quality Assurance meeting was held by the Administrator and Corporate and plans for improvement were outlined. The facility's immediate jeopardy removal date of 03/04/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, family member, physician, Nurse Practitioner, and staff interviews, the facility failed to ensure 1 of 3 residents were transferred safely (Resident #1). Resident #1 was transferred to the wheelchair by one NA without the use of a mechanical lift which resulted in a 7 centimeter (cm) long by 2 cm wide by 0.1 cm deep skin tear of her right lower leg that the family described as very deep, and the family member was able to see white meat that looked like a bone. This wound required pressure to control the bleeding and the edges of the wound were not able to be approximated (skin was unable to be pulled over the open wound to provide protection to the healing wound). Immediate Jeopardy began on 12/31/2022 when Resident #1 was transferred unsafely by one NA without the use of a mechanical lift, resulting in a 7 cm by 2 cm by 0.1 cm skin tear of the lower right leg that required pressure to stop the bleeding and could not be approximated. Immediate Jeopardy was removed on 3/4/2023 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses to include acute on chronic respiratory failure, (an acute illness affecting a patient with chronic respiratory insufficiency), COVID-19 virus infection, anemia (requiring blood transfusions), kidney disease with acute kidney injury, pain in right knee, 2 Stage 2 pressure ulcers (ulcer extends into the deeper layers of the skin and can look like a shallow crater or blister) of the sacrum, deep tissue injuries (a pressure injury that begins in the muscle closest to the bone and appears as dark, non-blanchable skin) of the right and left heel, congestive heart failure and debility. A hospital admission note dated 1/14/2023 documented Resident #1 had an ejection fraction (measurement of the percentage of blood leaving the heart with each heartbeat) of 45% (normal 50-70%). The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 to be moderately cognitively impaired. The MDS assessed Resident #1 to require total assistance of 2 people to transfer. The MDS documented Resident #1 had limited range of motion of both lower legs and she required a wheelchair for mobility. Resident #1 was unable to perform surface to surface transfers without staff assistance. A care plan dated 12/14/2022 identified Resident #1 was at risk of falling, with an intervention to transfer total lift with 2+ assistance. A review of the physician orders revealed Resident #1 was not prescribed blood thinners. The [NAME] (a brief summary of resident care needs available for review within the electronic documentation system) for Resident #1 was reviewed, and it was noted that transfer instructions included the extensive assistance of 2 people with the use of a mechanical lift. A physical therapy evaluation note written by physical therapist (PT) #1 dated 12/14/2022 assessed Resident #1 to require maximum assistance of 2 people to transfer. The evaluation noted that Resident #1 was unable to assist with transfers. PT #1 was interviewed on 3/6/2023 at 2:21 PM. PT #1 reported she was the primary therapist for Resident #1 during her stay at the facility. PT #1 reported Resident #1 able to stand and bear weight for brief periods of time but required 2-person extensive assistance to transfer safely. PT #1 explained NA staff used the mechanical lift to transfer Resident #1. PT #1 clarified transferring a resident with 2-person extensive assistance without a mechanical lift involved one person standing behind the resident and using the gait belt to lift, with another person in front of the resident to stabilize them and guide the resident to the chair. PT #1 reported Resident #1 had limited range of motion of both of her knees and required one person to move her legs to transfer from the bed to the chair. PT #1 concluded that a transfer with one person would not be a safe transfer. The Director of Rehabilitation was interviewed on 3/6/2023 at 2:09 PM. The Director of Rehabilitation reported she had provided treatment to Resident #1 once prior to 12/31/2022. The Director of Rehabilitation reported Resident #1 was very weak and she declined getting out of bed for therapy treatment. An interview was conducted with the Certified Occupational Therapist Assistant (COTA) on 2/28/2023 at 12:54 PM The COTA reported that Resident #1 was very weak, and she required 2-person assistance to transfer with a mechanical lift. The COTA reported that Resident #1 was able to bear weight on her legs to stand, but she was unable to pivot to transfer from the bed to the wheelchair, and she was unable to lift her legs to take steps to transfer without extensive assistance of 2 people. The COTA reported that one person transferring Resident #1 by lifting her under her arms was very unsafe and could result in serious injury. An incident report dated written by Nurse #1 on 12/31/2022 documented Resident #1 sustained a skin tear to her lower right leg after transfer to the wheelchair. The note documented Resident #1's family members were at the facility and notified of the incident, and the on-call physician services were notified by a voice mail that Resident #1 had a skin tear. A nursing note written by Nurse #1 dated 12/31/2022 at 7:37 PM documented: This nurse across the hall in another room when the NA came to this nurse and stated resident got a skin tear when they (were) transferring resident into her wheelchair. This nurse into room and assess a large skin tear noted to the (right lower leg). Skin and subcutaneous tissue noted to be pushed to the right side of the wound and unable to be approximated. Area cleaned with wound cleanser, (non-stick, antibacterial dressing) applied to wound bed and (absorbent) pad placed on top and wrapped in (gauze). Resident states this area is sore. (Family member) in the facility at this time and was notified of skin tear by this nurse. (On-call physician) was notified via (voicemail) of skin tear. The nurse documented Resident #1 reported pain at a level 5 (1-10 scale, 10 being the most intense pain) of the lower right leg at the skin tear site. Nurse #1 was interviewed on 2/28/2023 at 2:37 PM. Nurse #1 reported she was assigned to Resident #1 on 12/31/2022 and was notified by the nursing assistant (NA) that Resident #1 had sustained a skin tear to her right lower leg during a transfer. Nurse #1 reported she arrived at Resident #1's room and found 3 NAs at the bedside, 2 fulltime employees and 1 orienting staff member. Nurse #1 reported NA #1 was holding a towel on Resident #1's leg to stop the bleeding from a heck of a large skin tear on her lower right leg. Nurse #1 reported she was told by NA #1 that Resident #1 hit her leg on the wheelchair when she was being transferred. Nurse #1 went on to explain that NA#1 and NA #4 were in the room, as well as NA #5 who was orienting. Nurse #1 reported Resident #1 was transferred to the wheelchair by the NA #5 and they had not used a mechanical lift. Nurse #1 reported she did not think the skin tear was serious and did not require evaluation at the hospital. A follow-up interview was conducted with Nurse #1 on 3/1/2023 at 3:02 PM. Nurse #1 reported she had called the Director of Nursing (DON) right after the incident to report it and had been instructed by the DON to talk to NA #1, NA #4, and NA #5 to instruct them on proper transfer techniques. Nurse #1 reported that when she arrived to assess the wound and apply a dressing, the skin that had been torn was dry and curled away from the wound. Nurse #1 reported she was unable to pull the skin back over the wound because it was so dry. Nurse #1 estimated that it took her about 1 minute to get to the resident's room after being notified of the injury. An interview was conducted on 2/28/2023 at 4:24 PM with NA #1, and she reported she had worked on 12/31/2022. NA #1 explained she was working on the 100 hall, and the 300 hall NA (NA #4) had asked her to come to Resident #1's room. NA #1 reported she was orienting NA #5 and the two of them went to Resident #1's room on the 300 hall. NA #1 described Resident #1 was in bed with her upper body supported on 3 pillows and NA #4 told her the bed control was not working to elevate the head and she wanted to move Resident #1 to a bed that worked. Resident #1's family member was at the bedside during this time. NA #1 left the room to get the lift to transfer Resident #1 to the other bed. NA #1 shared that when she returned to Resident #1's room, and Resident #1's family member had sat Resident #1 up on the side of the bed. According to NA #1's report, Resident #1 was unable to support herself sitting on the side of the bed and was crying out, I can't take it. NA#1 described how NA #5 said, I used to be an EMT (emergency medical technician), I know how to do this (transfer Resident #1), and proceeded to lift Resident #1 from the bed over to the wheelchair, bumping Resident #1's leg on the wheelchair footrest and causing a skin tear. NA #1 reported she got a towel to hold on the open area of the skin tear to top the bleeding and NA #4 went to get the nurse. NA #1 reported that Nurse #1 arrived in just a few seconds. NA #4 was interviewed on 3/1/2023 at 4:27 PM and she reported she was working 12/31/2022 and assigned to Resident #1 on that date. NA #4 explained NA #1 was training NA #5. NA #4 said that Resident #1's bed would not work to elevate the head of the bed, and they were planning to transfer her to another bed using the mechanical lift. NA #4 verbalized she was not in the room, when NA #5 transferred Resident #1 and she did not see Resident #1 moved from the bed to the wheelchair but remembered that Resident #1 had sustained a large skin tear on her lower right leg and NA #1 was holding a towel on the leg to stop the bleeding. NA #5 was interviewed on 3/7/2023 at 4:18 PM. NA #5 reported her first time working on the floor of the facility was 12/31/2022 and she was assigned to train with NA #1. NA #5 explained that they were called to Resident #1's room because the bed did not work, and they were going to transfer her to a new bed. NA #5 reported she was standing behind the wheelchair and NA #1 and NA #4 lifted Resident #1 from the side of the bed to the wheelchair, and during the transfer, Resident #1's leg scraped against the footrest of the wheelchair. NA #5 reported she had alerted NA #1 and NA #4 that the footrest was [NAME] out and to push it back, but the other NAs did not correct the position of the footrest. NA #5 reported the wound was bleeding and she took a bedsheet and held pressure on the wound until the nurse arrived almost 20 minutes later. NA #5 reported that after the incident, they were instructed to correctly transfer residents by Nurse #1. NA #5 concluded by stating she didn't return to work at the facility after that night. The family member was interviewed on 3/1/2023 at 12:09 PM. The family member recalled she and other family members were in the facility on 12/31/2023 and the nursing staff had asked the family to step out of the room so they could transfer Resident #1 to a different bed and apply the air mattress to the bed. The family member reported that when she and the other family members returned to the room, they were told that Resident #1 had sustained a skin tear from the wheelchair. The family member explained that they asked for the wound dressing on the right lower leg to be removed and when they saw the skin tear, they told the nurse that the wound needed to be evaluated at the hospital. The family member described the wound on the right lower leg to be very deep, and she was able to see white meat that looked like a bone. The family member reported the skin was pushed back away from the wound and the nurse said she had not been unable to pull it back over the open wound and Resident #1 reported pain at the wound site. The family member said that Nurse #1 told them the physician had been notified of the skin tear and didn't feel that the wound needed to be assessed at the hospital. A wound assessment dated [DATE] documented a skin tear of the right lower leg that measured 7.6 centimeters (cm) by 3.5 cm by 0.1 cm and had a pink wound bed and a moderate amount of serosanguinous (pink) drainage. The note documented the wound was cleaned with normal saline, and an antimicrobial non-stick dressing was applied to the open wound, it was covered with an absorbent pad, and wrapped with gauze. The nursing note that correlated with wound assessment dated [DATE] documented Resident #1 was reporting 3 pain to her right lower leg. Wound care orders dated 1/4/2023 for the right lower leg read to clean with normal saline, apply antimicrobial non-stick dressing, cover with absorbent dressing, and wrap with gauze to secure once daily. The Wound Nurse was interviewed on 3/1/2023 at 11:48 AM. The Wound Nurse reported she was also the staff development coordinator and she had provided orientation to the NA #5 before the NA went out onto the floor for hands-on training. The Wound Nurse reported that during orientation, new staff are shown videos with proper transfer techniques, and they are shown where to find the information related resident care for each resident in the [NAME]. The Wound Nurse explained she was unable to do further training with the NA #5 because she had quit without notice the next day and did not return to the facility. The Wound Nurse reported she had assessed the right lower leg wound on 1/2/2023. The Wound Nurse reported that she had not considered sending Resident #1 out for further treatment of the wound to the right lower leg. The facility nurse practitioner (NP) was interviewed on 2/28/23 at 11:03 AM. The NP stated that the skin tear to the lower right leg should have been followed by medical staff. She stated that the trauma wound was a full-thickness skin tear to the right lower leg. The Physician (MD) was interviewed on 3/1/23 at 12:40 pm. The MD reported she was not informed of Resident #1's right lower leg skin tear with its severity. The MD reported the resident should have been sent to the Emergency Department on 12/31/22 or at least followed by the medical staff in the facility due to the size of the skin tear. The Administrator was notified of Immediate Jeopardy on 3/1/2023 at 5:51 PM. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of noncompliance. The facility failed to ensure Resident #1 was transferred safely from her bed to the wheelchair by the use of the total lift. Resident #1 was transferred to the wheelchair by one NA which resulted in a 7 centimeter (cm) long by 2 cm wide by 0.1 cm deep skin tear of her right lower leg. This wound deteriorated to expose bone and subcutaneous tissue and had the high likelihood to become infected. In addition, there was the high likelihood of a serious adverse outcome when the resident was not transferred using the total lift. All residents not transferred as determined by their assessment or plan of care could be affected. On 3/2/2023 each Electronic Health Record (EHR) was reviewed by the Director of Nursing/Designee to ensure the [NAME] and Care plans reflected the correct transfer status. On 3/2/2023 the Director of Nursing reviewed all incident reports for the last 30 days to ensure resident were transferred as specified in their plan of care. 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 3/2/2023 all Licensed Nursing Staff and Certified Nurse Aides, to include agency Licensed Nursing staff and Certified Nurse Aides were educated with return demonstration by the Nursing Administration Team and/or Rehab staff on transferring according to the resident's individualized plan of care according to the facility Mechanical Lift Policy and accessing transfer status from the [NAME] or Care Plan. The Director of Nursing/Designee will supply a list of all nursing department individuals that have not completed return demonstration of transfers on 3/3/2023 to the Nursing Administration Team (RN Weekend Supervisor notified of this responsibility on 3/3/2023) to ensure no Nursing Staff work before the return demonstration has been validated. All verbal education was completed on 3/3/2023. All newly hired Licensed Nursing Staff and Certified Nurse Aides, including agency nursing staff will be educated with return demonstration during the facility orientation process on total lift transfers according to the facility Mechanical Lift Policy and accessing transfer status from [NAME] or Care Plan. The Regional Director of Clinical Services notified the Director of Nursing on 3/2/2023 on the implementation for new hires. An Ad Hoc QAPI was completed with the Interdisciplinary Team (IDT) which includes the Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Managers, Director of Rehab, Director of Life Enrichment, Director of Social Services, Environmental Services Director, Admissions Director, Business Office Manager, Minimum Data Set (MDS) Nurse, Wound Nurse, Clinical Coordinator, and the Medical Director on 3/2/2023. The IDT was updated regarding Immediate Jeopardy (IJ) citations the facility received on 3/1/2023 along with regulation, policy, and necessary education that is needed in order to be in compliance. Alleged IJ removal date 3/4/23. On 3/7/2023, the facility's credible allegation for immediate jeopardy removal was validated by the following: Review of the education provided to the nursing staff and NA staff related to safe transfer techniques. Interview with nursing staff to review education provided and procedure for transfers, with transfer competencies for each staff member included. Observation of transfer of a resident with mechanical lift. Review of audits completed by the facility. The facility's date of the immediate jeopardy removal plan of 3/4/2023 was validated on 3/7/2023.