**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, Medical Director and Consulting Pharmacist interviews, the facility failed to prevent a significant medication error when Nurse #1 administered 30 units of insulin glargine (a long acting insulin that lasts for 24 hours and does not have a peak of onset) intended for Resident #31 to Resident #16. Resident #16 did not have a diagnosis of diabetes or a physician's order for insulin. Resident #16 was assessed by the Nurse Practitioner (NP) and immediately started on intravenous (IV) dextrose (a solution that contains sugar) fluids for 24 hours. The NP also ordered finger stick blood sugars every hour for 24 hours with instructions to notify the provider if Resident #16's blood sugar was below 90 (Normal range is between 70-99). Resident #16's blood sugar dropped to 61 during the night, Nurse #2 notified the on-call provider and gave Resident #16 eight ounces of orange juice and a snack while she waited for a response from the provider. The on-call provider responded and ordered glucagon (a medication used to increase a resident's blood sugar level) 1milligram (mg) and for Resident #16's blood sugar to be rechecked after 15 minutes. Nurse #2 administered glucagon 1mg subcutaneously (SQ) and the blood sugar recheck was 152. Hypoglycemia (defined as a blood sugar level below 70) can be serious and life threatening if gone untreated; symptoms include tremors, palpitations, anxiety, sweating, dizziness, weakness, drowsiness, confusion, altered mental status, loss of consciousness, or seizures. There was a high likelihood for serious harm. This was for 1 of 3 residents reviewed for unnecessary medications (Resident #16). The findings included: Resident #16 was admitted to the facility on [DATE]. Resident #16 did not have a diagnosis of diabetes mellitus. Resident #16's annual Minimum Data Set (MDS) assessment dated [DATE] indicated she was severely cognitively impaired; Resident #16 was coded that she had not received insulin. Review of Resident #16's physician's orders dated April 2025 revealed no active orders or insulin. Review of Resident #16's April 2025 Medication Administration Record (MAR) revealed no active orders for insulin glargine. Review of Resident #31's physician's orders dated April 2025 revealed an active order for insulin glargine inject 30 units SQ every morning for type 2 diabetes mellitus. Review of Resident #16's medical record revealed a Nurse Practitioner progress note dated 4/14/2025 read in part: Resident #16 was seen today after she was given 30 units of long-acting insulin. No hypoglycemia. She is alert and seated in her wheelchair, conversant. Seated in wheelchair in no acute distress. Plan: Administer D5W (dextrose 5% in water- an infusion used to provide the body with extra water and calories from sugar) at 75 milliliters (ml) an hour for 24 hours. Close monitoring of blood sugar and vital signs, see orders. Review of Resident #16's physician's orders from the NP for 4/14/2025 revealed the following: -Monitor blood sugar for 24 hours- check blood sugar every hour- notify NP if blood sugar is less than 90. -Monitor for signs and symptoms of hypoglycemia- paleness, shakiness, sweating, headache, hunger/nausea, rapid/irregular heartbeat, fatigue, dizziness/lightheadedness, changes in level of consciousness every hour -Monitor vital signs every hour x 8 hours then every 4 hours x 4 -Condition change charting for 72 hours related to medication error -D5W at 75 milliliters (ml) /hour for 24 hours -D5 1/2NS (dextrose 5% in normal saline- an infusion used to provide the body with extra fluids and calories from sugar) at 75ml/hour for 24 hours The Nurse Practitioner was not available for interview during the survey. A nursing progress note written by Nurse #1 on 4/14/2025 at 10:08 am revealed she had made a medication error for Resident #16. The note revealed orders received for intravenous (IV) fluids, blood sugar and vitals were to be checked every hour for 24 hours, resident representative had been notified, and blood sugars were 138 and 129. A telephone interview was conducted with Nurse #1 on 04/23/25 at 9:41 AM. Nurse #1 stated on 4/14/2025 two residents were sitting at the table in the dining room, and she (Nurse #1) administered insulin to Resident #16, insulin that was ordered for Resident #31. Nurse #1 stated she immediately realized her mistake and reported the error to the NP and received orders to check blood sugars and vitals every hour. Nurse #1 was unsure of the exact amount of insulin she had administered to Resident #16 but stated it was the dose intended for Resident #31. Nurse #1 stated she reported the medication error to the assistant Director of Nursing (ADON) and Director of Nursing (DON) and Resident 16's family member. On 4/14/2025 Nurse #1 was scheduled to work 7am-7pm on a hall she was not normally assigned. Nurse #1 stated she failed to administer the right medication to the right resident when she failed to verify the resident's identity prior to insulin being administered and by administering medication in the dining room and not in the resident's room. Nurse #1 stated as soon as the insulin was administered to Resident #16, Nurse #1 realized Resident #31, who was seated next to Resident #16, was intended to receive the insulin. Nurse #1 stated the medication error was a total mishap, a human error and she was normally more focused. Nurse #1 stated Resident #31 received her insulin as ordered after the medication error with Resident #16. A nursing progress note written by Nurse #4 on 04/14/2025 at 10:25 am revealed a subcutaneous (SQ) IV was placed in the left lower quadrant of Resident #16's abdomen. D5W was infused at 75 ml per hour for 24 hours. During a telephone interview on 04/23/25 at 10:49 AM Nurse #4 stated on 4/14/2025 she (Nurse #4) was assigned to Resident #16's hall from 7am to 11pm. Nurse #4 was informed that Nurse #1 had administered insulin to Resident #16 who was not a diabetic and did not require insulin. Nurse #4 assessed and monitored Resident #16 through the rest of her shifts on 4/14/2025 and 7am to 3pm on 4/15/2025. Nurse #4 entered the orders received from the NP and checked Resident #16's blood sugar and vital signs every hour as ordered. Nurse #4 stated she did not observe any hypoglycemic episodes while she monitored Resident #16. Nurse #4 stated Resident #16 was alert to self and place, and some of Resident #16's family had visited Resident #16 on 4/14/2025. Nurse #4 stated the NP orders indicated to notify the NP if Resident # 16's blood sugar went below 90. Nurse #4 stated Resident #16's blood sugars had not been below 90 during her shifts. Nurse #4 stated she instructed the nursing assistants to monitor if Resident #16 did not eat well at meals and extra snacks would be given if needed. Nurse #4 stated Resident #16's vital signs remained stable. During a follow up interview on 4/24/2025 at 9:48am Nurse #4 stated Resident # 16 was not able to communicate with a nurse that she was not supposed to receive insulin. Review of Resident #16's medical record revealed her blood sugar was 61 documented at 12:35 am on 4/15/2025, and 77 documented at 1:13 am on 4/15/2025 by Nurse #2. Review of a progress written by Nurse #2 on 04/15/25 revealed that she notified the on-call provider and received orders on 4/15/2025 for Glucagon reconstituted solution 1mg injection- give 1milligram (mg) SQ and recheck blood sugar (BS) in 15 minutes related to low blood sugar. And to check blood sugar at hour of sleep if BS is greater than 90 NO rechecks are required. During a telephone interview on 4/23/2025 at 10:58 am Nurse #2 stated on 4/14/2025 she was scheduled to work 7pm to 7am and received report that Resident #16 had received the insulin by mistake, Resident #16 was not diabetic. Nurse #2 took over care for Resident #16 at 11pm on 4/14/2025. Nurse #2 stated the facility was out of D5W IV fluids, and new orders were received to start D5 1/2NS at 75ml per hour for remainder of the order. Nurse #2 stated Resident #16's blood sugar dropped to 61 around midnight and Resident #16 was given orange juice and a snack while Nurse #2 waited for a response from the on-call NP. Nurse #2 stated she received the order for glucagon 1mg, and it was administered to Resident #16 as ordered. Nurse #2 stated she stayed with Resident #16 for about 2 hours while the blood sugars were low, and Resident #16 remained alert and able to eat the snacks and drink fluids with no signs of hypoglycemia. During an interview on 4/23/2025 at 1:40 pm the Medical Director stated if a non-diabetic resident received 30 units of long-acting insulin it could cause hypoglycemic events. During a telephone interview on 4/24/2025 at 12:44 pm the Consulting Pharmacist stated if a non-diabetic resident received 30 units of long-acting insulin it could have caused blood sugars to drop, pain or hypoglycemic issues. During an interview on 4/24/2025 at 1:10 pm the Director of Nursing (DON) stated she expected nurses not to administer medications in the dining room and for the correct medication to be administered to the correct resident. The DON stated she expected nurses to follow the 6 medication rights which included the right medication, right dose, right route, right rate and the right time for the right resident. The DON stated that the medication error occurred when Nurse #1 administered insulin in the dining room and failed to verify the identity of the resident prior to medication being administered. During an interview on 4/24/2025 at 2:18pm the Administrator stated she expected the nurses to follow the 6 medication rights when they administer medication. The Administrator was notified of immediate jeopardy on 4/23/2025 at 4:15 pm. The facility provided the following corrective action plan with the completion date of 4/17/2025: How will corrective action be accomplished for those residents found to have been affected by the deficient practice? On 4/14/2025 at 8:34 am Nurse #1 administered Lantus 30 units to Resident #16 who did not have an order for Lantus and immediately reported this to the Director of Nursing and the Provider. The Provider immediately assessed Resident #16 and gave orders to check finger stick blood sugar every hour until 9:00am on 4/15/2025, notify Provider if finger stick blood sugar is below 90 milligrams (mg) per deciliter, Dextrose IV solution for 24 hours and monitor for signs and symptoms of hypoglycemia until 4/15/2025. On 4/14/2025 Provider gave order to monitor Resident #16's vital signs every hour for 8 hours and then vital signs every 4 hours for 16 hours. Resident #16's vital signs remained stable throughout monitoring. On 4/15/2025 at 12:30 am Resident #16 finger stick blood glucose was 61 milligrams per deciliter, on call was notified and while awaiting return call Nurse #2 gave 8oz of orange juice and a snack, Resident #16 was alert and oriented with no signs and symptoms of distress. Nurse #2 rechecked Resident #16's finger stick blood glucose at 1:00 am and was 77 milligrams per deciliter, on call Provider returned call at 1:10 am and gave order to administer Glucagon 1mg now times one dose and recheck finger stick blood sugar in 15 minutes. Nurse #2 administered Glucagon 1mg to Resident #16 at 1:15 am and Nurse #2 rechecked Resident #16's finger stick blood glucose at 1:32 am and Resident #16 finger stick blood glucose was 152 milligrams per deciliter. The remaining hourly blood sugar checks were 90 or above. The Resident #1's Responsible Party was notified of medication error on 4/14/2025 at 10:08am. Nurse #1 was suspended pending investigation on 4/14/2025. The Director of Nursing contacted the Board of Nursing regarding the medication error on 4/15/2025. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 4/14/2025 the Director of Nursing and or Designee reviewed the finger stick blood glucose levels of all residents who require glucose monitoring from 4/13/2025 to 4/14/2025, which captured 24 hours prior to incident to ensure residents had no levels that would indicate signs and symptoms of hypoglycemia. The Director of Nursing and or Designee audited residents who had active orders for blood glucose monitoring and insulin on 4/14/2025 to ensure the insulin was administered per orders. No concerns were identified. On 4/15/2025 the Director of Nursing interviewed cognitively intact residents with Brief Interview Mental Status score of 12 or above to ensure they had no concerns with receiving incorrect medications and cognitively impaired residents with Brief Interview Mental Status score below 12 were assessed by the Director of Nursing and or Designee to ensure no signs and symptoms of hypoglycemia were noted. No concerns were identified. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur? To prevent this from happening again the Director of Nursing and or Designee started education on 4/14/2025 for all Licensed Nurses and Medication Aides including Agency Licensed Nurses and Medication Aides currently working in facility on not administering medications in the dining room and to follow the 6 rights of medication administration, to include the medication is administered to the right resident by verifying using the picture of each resident in the electronic health record. Licensed Nurses and Medication Aides not currently working in facility were educated via phone or in person by the Director of Nursing and or Designee by 4/15/2025 and will not be allowed to work until they have received this education. Any Nurse on leave or paid time off will be provided the education prior to working their next shift by the Director of Nursing and or Designee. The Director of Nursing has list of any Licensed Nurses and/or Medication Aides that are on leave or paid time off that need this education prior to working. The Director of Nursing was educated on 4/15/2025 by the Regional Director of Clinical Services on ensuring any Licensed Nurse or Medication Aide who is on leave or on paid time off received this education prior to their first shift of working. This education will be provided in new hire orientation for all Licensed Nurses and Medication Aides. Agency Licensed Nurses and/or agency Medication Aides will receive this education prior to working. The Director of Nursing called and spoke with each agencies credentialing and/or education specialist regarding education needed for the medication error plan of correction and sent the facility specific plan of correction education packet to the 2 agencies that provide contract staff to this facility 4/14/2025. The agency ensures the Licensed Nurses and or Medication Aides received this education prior to being scheduled at this facility. The Agencies provided confirmation to the Director of Nursing via individual staff education email that all agency Licensed Nurses and/or Medication Aides had received this education prior to working in facility. The Director of Nursing educated the Scheduler on ensuring continuity of staff to attempt to keep them on the same assignment as much as possible to prevent medication errors. This education was completed on 4/15/2025. How will the facility monitor its corrective actions to ensure the deficient practice will not recur? To monitor and maintain compliance starting 4/17/2025 the Director of Nursing and or Designee will observe 3 medication passes for Licensed Nurses and/or Medication Aides weekly to include all three shifts for 8 weeks and then monthly for 1 month to ensure medications are administered as ordered. Starting 4/17/2025 the Director of Nursing and or Designee will observe 5 residents in Dining Room weekly for 8 weeks and then monthly for 1 month to ensure no medications are being passed in the dining room. The Administrator and Director of Nursing discussed Resident #16's medication error on 4/14/2025 and determined to have ADHOC Quality Assurance Process Improvement (QAPI) meeting. ADHOC QAPI was held on 4/15/2025 with the Interdisciplinary team to discuss the incident with Resident #16 and educate the team on the interventions that were put into place to prevent further incidents. The Medical Director was notified by the Director of Nursing via phone on 4/15/2025 regarding the medication error and the interventions that were put in place for Resident #16 and the plan of correction to prevent the medication errors. The Director of Nursing implemented the plan of correction to prevent medication errors on 4/14/2025. The Interdisciplinary team will review and provide recommendations on the audit results provided by the Director of Nursing and or Designee during the QAPI meeting for the next 3 months to ensure sustained compliance. If noncompliance is identified during these three months, immediate correction, re-education of staff members and an ADHOC QAPI meeting will be held to address the noncompliance and make recommendations for adjustments to the plan. The Administrator and Director of Nursing will ensure the corrective action plan is implemented. On 4/24/25, the facility's corrective action plan effective 4/17/25 was validated by the following: During medication pass observations of licensed nursing staff reviewing residents with an active order for insulin on their electronic medical chart, checking the resident's picture and room number to assure they had the correct resident, and administering the correct dosage of insulin to the correct resident inside their room with no issues or concerns noted. Licensed Nurses and Medication Aide interviews revealed they had received education on 6 rights of medication administration to include checking resident electronic medical chart to ensure resident order for insulin and name, room number, and picture of resident to receive insulin. They were also educated on administering insulin inside resident rooms and not in the dining room during meals and reporting a medication error immediately to their supervisor. The facility scheduler received education on trying to schedule nursing staff as much as possible to their same assigned halls consistently to help with continuity of care and prevention of medication errors. Administrative staff interviews revealed they provided staff education and completed weekly monitoring audits of ensuring medications including insulin are not being administered in the dining rooms during mealtimes, medication passes for all three shifts to ensure medications including insulin are administered as ordered to the correct resident. Education and Auditing tools were reviewed, with no new issues noted. Documents were reviewed from the Facility Quality Assurance and Performance Improvement (QAPI) committee meeting minutes of the audit results. Medication pass was observed on 4/22/2025 and 4/23/2025 with 0% error rate. The facility's corrective action plan with an IJ removal date of 04/17/25 was validated. IJ removal date is 04/17/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews with staff, family member, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to notify the physician or Nurse Practitioner when a sacral pressure ulcer was identified on Resident #36 on 3/3/22 and when the pressure ulcer deteriorated on 3/10/22. The facility failed to notify the Wound PA of two wound culture swabs being discarded by the laboratory. Resident #36 was later diagnosed on [DATE] with sacral osteomyelitis. In addition, the facility failed to notify Resident #36's family member when her pressure ulcer deteriorated on 3/10/22. This failure was for 1 of 3 residents reviewed for notification of changes (Resident #36). Immediate Jeopardy began on 3/3/22 when the facility failed to notify the physician or Nurse Practitioner and obtain treatment orders for new pressure ulcer identified on Resident #36. The immediate jeopardy was removed on 7/3/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: Resident #36 was initially admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, muscle weakness, spinal stenosis, atherosclerotic heart disease, hypertension and history of transient ischemic attack and cerebral infarction. She was recently re-admitted on [DATE] from the hospital due to acute encephalopathy and advanced Parkinson's disease. An admission Skin Evaluation completed by Nurse #1 on 3/3/22 indicated Resident #36 had an open area to sacrum and left lower buttock with treatment in place. An interview with Nurse #1 on 6/28/22 at 3:10 PM revealed she observed an open area on Resident #36's sacrum on 3/3/22 which was much smaller in size than her current pressure ulcer and a raw area on the left lower buttock. Nurse #1 characterized the open area as a stage 1 pressure ulcer because it was slightly opened and required a treatment, so she applied zinc oxide and covered it with a foam dressing to both sacrum and left lower buttock. Nurse #1 stated she thought the pressure ulcer required a different treatment, but she could not remember if she had notified the physician or the Nurse Practitioner about the pressure ulcer and she did not obtain an order. Resident #36's Treatment Administration Record for March 2022 indicated no treatment orders for Resident #36's sacral pressure ulcer until 3/10/22 when Unit Manager #1 initiated the following treatment order: Cleanse area to coccyx with wound cleanser. Apply (brand name) occlusive dressing and cover with foam every 3 days. An interview with Unit Manager (UM) #1 on 6/30/22 at 3:20 PM revealed she couldn't remember if she had been made aware of an open area on Resident #36's sacrum upon her re-admission to the facility on 3/3/22 and she was not sure if she had checked her re-admission orders. UM #1 stated she remembered Resident #36's family member telling her to make sure they kept an eye on her sacrum because an area on her sacrum had opened when she came back from the hospital. UM #1 stated she didn't get around to assessing Resident #36's sacrum until 3/10/22 when Nurse Aide (NA) #1 reported to her that Nurse #3 had been asking her to apply a foam dressing to Resident #36's sacrum and buttocks without the nurse checking the area first. UM #1 stated she observed necrotic tissue covering the ulcer, but she couldn't tell how big it measured. The ulcer did have some drainage but did not have foul odor. UM #1 stated she thought the nurses could initiate wound care orders without consulting with the physician first and she decided on the occlusive dressing based on her previous experience with wound care. UM #1 further stated she did not notify the physician, the Nurse Practitioner, or the Wound Physician Assistant (PA) and just included Resident #36 in the list of residents to be seen by the Wound PA on his next visit at the facility. An interview with Nurse #3 on 6/30/22 at 1:59 PM revealed she couldn't remember doing a skin evaluation on Resident #36, but she had seen her sacral wound progress from being a quarter-sized stage 1 pressure ulcer to being covered with a black necrotic tissue. Nurse #3 stated she didn't think she was the first nurse who had discovered the black necrotic tissue, so she didn't think about reporting this to anybody. A phone interview with Resident #36's family member on 6/27/22 at 4:33 PM revealed she didn't find out about Resident #36's worsened pressure ulcer until 3/14/22 when a nurse aide asked her if she had seen Resident #36's bottom recently. Resident #36's family member stated, it looked terrible, it had an odor and looked deep. She said she informed UM #1 that she wanted the wound clinic to look at Resident #36, but she was told that they were going to get the in-house wound care provider to look at her. A phone interview with the Wound Physician Assistant (PA) on 6/30/22 at 4:56 PM revealed he did not get consulted when an open area was first noted on Resident #36's sacrum on 3/3/22 nor when they started treatment on Resident #36's sacral pressure ulcer on 3/10/22 when it got worse. On 3/31/22, he noted an increase in drainage, so he did a wound culture and sensitivity after he debrided the wound. He was informed at the facility when he came back on 4/7/22 that the laboratory had discarded the swab from the week before because they used the wrong tube, so he obtained another one due to the wound's continued decline and it had started undermining. (Undermining is a closed passageway under the surface of the skin that is open only at the skin surface. It involves a significant portion of the wound edge). When he came back on 4/14/22, he found out that Resident #36 had been to the Wound Center, so he discharged her from her care. He didn't hear back about the last wound culture and sensitivity done on 4/7/22 and assumed it was discarded again by the laboratory. He said if he obtained the result from the first wound culture sooner, it could have made a difference in treating Resident #36's pressure ulcer if the infection was superficial. An interview with Unit Manager (UM) #1 on 6/30/22 at 3:20 PM revealed the first time the Wound PA obtained the wound culture; she was notified by the laboratory that they had to discard it because they couldn't run it due to it being too dry. UM #1 did not notify the Wound PA until the next week when he came back and performed a second wound culture. UM #1 was again informed by the laboratory that they had to discard it because they used the wrong swab. UM #1 did not think to notify the Wound PA about the wound culture not being done a second time, but she called the laboratory twice to request for the appropriate culture swabs. An interview with the Nurse Practitioner (NP) on 6/29/22 at 3:10 PM revealed she became aware of Resident #36's sacral pressure ulcer on 4/11/22 when her family member texted her and asked her if Resident #36 could be seen by the Wound Center. The NP checked the electronic results for the laboratory and found wound cultures on 4/1/22 and 4/8/22 that were originally ordered but had been marked out. The NP stated the facility had been having problems with laboratory tests getting missed and not getting followed through. The NP also stated she was aware that Resident #36's pressure ulcer progressed quickly but she was not aware that Resident #36 did not have a treatment order for the wound prior to the Wound PA seeing her. The NP stated the facility physician usually ordered a treatment for a newly identified wound until the resident was seen by the Wound PA, but she was not sure why she didn't get notified of Resident #36's pressure ulcer that was noted on 3/3/22. The NP stated the nurses should have notified her on 3/3/22 when they noted a pressure ulcer on Resident #36's sacrum so a treatment could have been started while they were waiting for her to be seen by the Wound PA. The Report of Consultation from the Wound Center dated 4/13/22 for Resident #36 indicated a stage 4 pressure ulcer to the sacrum which measured 2.2 cm in length, 2 cm in width and 2.1 cm in depth. Treatment was changed to skin prep to peri wound, antimicrobial gel wet to dry using 2 inch rolled gauze to pack wound, cover with 4x4 gauze, abdominal pad, and tape. Change daily and as needed for soiled or loose dressing. Referral to an Infectious Disease specialist. Bone culture and pathology done. Prescription for (brand name) antibiotics sent to the facility. Facility to order pressure relief cushion and specialty air mattress. An Infectious Disease Visit Note dated 4/25/22 in Resident #36's medical record indicated Resident #36 was seen for sacral osteomyelitis. Bone biopsy was positive for Morganella. (Morganella is a species of gram-negative bacteria known to be a causative organism of opportunistic infections in wound infections.) Intravenous antibiotics were ordered. Resident #36 was currently using a wound vac (vacuum-assisted closure of a wound), had gotten an air mattress, and was waiting on a pressure relief cushion for her wheelchair. The Administrator was notified of Immediate Jeopardy on 7/1/22 at 1:03 PM. The facility provided the following IJ Removal Plan with the correction date of 7/3/22. *Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Facility failed to notify the physician or Nurse Practitioner when a sacral pressure ulcer was identified on Resident #36. The nurse who completed the admission assessment on Resident #36 and did not notify the physician or Nurse Practitioner of the pressure ulcer or obtain treatment orders. Resident #36's wound deteriorated over seven days to a stage 4 and there was no notification to the physician or Nurse Practitioner. Facility completed a total body skin assessment and record review on all current residents on 7/1/22 by the unit managers to find no missed notifications or deterioration of residents' wounds, pressure sores or changes in skin integrity. An assessment of Resident #36 revealed on 7/2/22, that there was no further deterioration on the wound, treatment orders in place per physician order, resident being followed by the local wound care clinic. *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. Regional Director of Clinical Services (RDCS) completed education to Director of Nursing (DON) and unit managers (UM) on 7/1/22. The facility process is as follows: a. Licensed nurse completes admission skin assessment, and weekly skin assessment in electronic medical record; b. If any deterioration of skin area or new area observed, the licensed nurse notifies and documents physician or Nurse Practitioner immediately and obtains treatment orders, c. Licensed nurse is to complete notification and documentation of responsible party, d. Notification of DON and/or unit managers by calling or tiger texting (which is a secure web-based communication). All licensed nurses including agency nurses were in-serviced by 7/2/22 from DON or unit manager on completing and documenting admission skin assessments and weekly skin assessments. Licensed nurses are responsible for immediate notification of physician or Nurse Practitioner when they observe any deteriorating wound/pressure ulcer, new wounds/pressure ulcers, or significant change in condition and obtaining physician orders for treatments. Facility requires that all licensed nurses or agency licensed nurses notify and document significant changes in residents' condition, new wounds, or changes in pressure ulcer condition. Licensed nurses are responsible for notification and documentation of responsible party. Licensed nurses are responsible for notification to DON/UM via call or tiger texting. Nurse aides including agency nurse aides have been in-serviced by 7/2/22 by DON/designee on reporting any change in resident condition, such as skin conditions, poor intake, no urine output, observation of new areas to skin, mental status changes, physical abilities, and breathing changes to the licensed nurse immediately. DON is responsible for tracking nurses and nurse aides including agency that have received education. The DON/UM are responsible for providing education to current nurses and nurse aides who were not in-serviced by 7/2/22. Nurses and nurse aides will not be allowed to work until they receive education. New nurses and nurse aides hired after 7/2/22 will receive education during orientation. Beginning the week of 7/4/22, the DON or designee will review five random resident's medical record per week for any change in resident condition, such as skin conditions, poor intake, no urine output, observation of new areas to skin, mental status changes, physical abilities, and breathing changes to ensure any negative changes have been communicated to the physician/Nurse Practitioner. The alleged date of IJ removal is 7/3/22. The credible allegation for the immediate jeopardy removal was validated on 7/7/22 with a removal date of 7/3/22. A review of in-service education records from 7/1/22 to 7/2/22 revealed education was provided to nurses and nurse aides on topics that included reporting any changes in the residents' baseline condition such change in vital signs, change in activity, and change in daily habits to the nurse. Any new orders, changes in residents' conditions, reports, skin integrity issues and laboratory results that have not been addressed need to be communicated timely to the physician/Nurse Practitioner, family, and the Director of Nursing. Interviews with the nursing staff revealed they had been educated on when to report a resident's change in condition as well as who to report the change in condition to. They also verbalized the different signs of changes and what observations to look for while working with the residents at the facility. The nurses stated they had been educated on notifying the physician of changes such as a new pressure wound or open area, any signs of wound infection and any wound deterioration. The laboratory book was observed at the nurses' station, and it included an audit tool that included information on the resident's name, laboratory test order date, laboratory test ordered, date the results were obtained, any critical laboratory test results and the date and time the medical provider was notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews with resident, family member, staff, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to assess, obtain treatment orders from the physician, and identify deterioration of the pressure ulcer which resulted in a serious adverse outcome. Resident #36's open area on her sacrum deteriorated from an open area to an unstageable pressure injury with necrotic tissue in a week (from [DATE] to [DATE]). The facility also failed to have two wound cultures processed on Resident #36's sacral pressure ulcer resulting in delayed treatment for osteomyelitis. In addition, the facility failed to provide pressure ulcer care as ordered by the Wound PA for Resident #11. These failures were for 2 of 3 residents reviewed for pressure ulcers (Resident #36 and Resident #11). Immediate Jeopardy began on [DATE] when the facility failed to provide the necessary care and services for a pressure ulcer that deteriorated in condition. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Example #2 was cited at a scope and severity level of D. The findings included: 1. Resident #36 was initially admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, muscle weakness, spinal stenosis, atherosclerotic heart disease, hypertension and history of transient ischemic attack and cerebral infarction. She was recently re-admitted on [DATE] from the hospital due to acute encephalopathy and advanced Parkinson's disease. An admission Skin Evaluation completed by Nurse #1 on [DATE] indicated Resident #36 had an open area to sacrum and left lower buttock with treatment in place. A Weekly Skin Evaluation completed by Nurse #2 on [DATE] indicated Resident #36 had a wound to sacrum and left lower buttock with treatment in place. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was cognitively intact, had no rejection of care behaviors and required extensive physical assistance with bed mobility, locomotion, and toilet use. Resident #36 had impairment on one side of her upper extremities and used a wheelchair. The MDS further indicated Resident #36 was frequently incontinent of urine, but she was always continent of bowel. Resident #36 was at risk of developing pressure ulcers/injuries, had moisture-associated skin damage but no pressure ulcers. An interview with Resident #36 on [DATE] at 10:04 AM revealed when staff came to change her and got her up out of bed this morning, she was wet and had to be changed. Resident #36 stated staff did check in on her during the night to see if she was wet, but she did not recall the name of the nurse aide or the time they came in. She stated she looked up at the clock on the wall and said she had waited for about 30 minutes this morning for them to come change her. Resident #36 stated she typically went to the bathroom before going to bed in the evening which could be anywhere from 6:30 PM to 9:00 PM depending on how long staff took to help her in bed. She was assisted with incontinence care and to bed around 7:30 PM the night before. Resident #36 further stated staff would get her up in the morning before breakfast, she would stay up through lunch, staff would lie her down after lunch, get her up about 30 minutes before supper, and then put her to bed between 6:30 PM to 9:00 PM. Resident #36 stated she never refused to lie down in bed and stated it felt good to get off her bottom for a while. She also did not refuse assistance with positioning on her side in bed and stated staff did come in and offer to turn her. Resident #36 stated she has had a pressure ulcer to her sacrum for a long time and it hurt. She said it felt like something was sticking her all the time. An interview with Nurse #1 on [DATE] at 3:10 PM revealed she observed an open area on Resident #36's sacrum on [DATE] which was much smaller in size than her current pressure ulcer and a raw area on the left lower buttock. Nurse #1 characterized the open area as a stage 1 pressure ulcer because it was slightly opened and required a treatment, so she applied zinc oxide and covered it with a foam dressing to both sacrum and left lower buttock. Nurse #1 stated she thought the pressure ulcer required a different treatment, but she could not remember if she had notified the physician or the Nurse Practitioner about the pressure ulcer and she didn't get an order. Nurse #1 also stated she didn't think she had to complete a wound assessment because wound assessments were usually completed by the Unit Managers whenever they rounded with the Wound Physician Assistant. Nurse #1 further stated Resident #36 always had an issue with her sacral area and they had struggled to keep it intact because Resident #36 liked to sit up in her wheelchair during the day, but she was adamant about having her naps and usually lied down in bed after lunch. Resident #36 also had sensitive skin. Prior to her hospitalization, Resident #36 often rang her call light, was continent of both urine and bowel and walked to the bathroom with staff assistance. After coming back from the hospital on [DATE], Resident #36 got a little weaker, but she was still ambulatory. Nurse #1 also stated Resident #36 did not refuse to be turned to her side but often preferred to lie flat on her back. An interview with Nurse #2 on [DATE] at 3:36 PM revealed she completed a skin check on Resident #36 on [DATE] and observed a foam dressing on her sacrum. Nurse #2 stated she knew Resident #36 had a pressure ulcer on her sacrum, but she did not remove the dressing to assess the wound underneath. Nurse #2 stated she did not have a reason as to why she did not complete a wound assessment on Resident #36's sacral pressure ulcer. Nurse #2 further stated back in February 2022 prior to Resident #36's hospitalization, staff used to roll Resident #36's wheelchair to the bathroom and assisted her to use the commode but when she came back from the hospital, Resident #36 had a decline and they often had to provide incontinence care to her, but she never refused to be turned on her side while in bed. The Braden Scale Pressure Ulcer Risk assessment dated [DATE] for Resident #36 indicated she was at moderate risk for developing pressure ulcers due to slightly limited sensory perception, very moist skin, very limited mobility, chairfast, adequate nutrition and problem with friction and shear. Complete lifting without sliding against sheets was impossible. Resident #36's Treatment Administration Record for [DATE] indicated no treatment orders for Resident #36's sacral pressure ulcer until [DATE] when Unit Manager #1 initiated the following treatment order: Cleanse area to coccyx with wound cleanser. Apply (brand name) occlusive dressing and cover with foam every 3 days. An interview with Unit Manager (UM) #1 on [DATE] at 3:20 PM revealed she couldn't remember if she had been made aware of an open area on Resident #36's sacrum upon her re-admission to the facility on [DATE] and she was not sure if she had checked her re-admission orders. UM #1 stated all her treatment orders probably got discontinued because there were no orders from the hospital for any treatment to her sacral wound. UM #1 stated Nurse #1 should have initiated a treatment when she observed an open area to Resident #36's sacrum on [DATE] and she should have completed a wound assessment. UM #1 stated she remembered Resident #36's family member telling her to make sure they kept an eye on her sacrum because an area on her sacrum had opened when she came back from the hospital. UM #1 stated she didn't get around to assessing Resident #36's sacrum until [DATE] when Nurse Aide (NA) #1 reported to her that Nurse #3 had been asking her to apply a foam dressing to Resident #36's sacrum and buttocks without the nurse checking the area first. UM #1 stated she observed necrotic tissue covering the ulcer, but she couldn't tell how big it measured. The ulcer did have some drainage but did not have foul odor. UM #1 stated she thought the nurses could initiate wound care orders without consulting with the physician first and she decided on the occlusive dressing based on her previous experience with wound care. UM #1 further stated she did not notify the physician, the Nurse Practitioner, or the Wound Physician Assistant (PA) and just included Resident #36 in the list of residents to be seen by the Wound PA on his next visit at the facility. UM #1 stated she did not think about documenting an assessment or complete measurements of Resident #36's pressure ulcer on [DATE] because she was going to be seen by the Wound PA the next week. An interview with Nurse #3 on [DATE] at 1:59 PM revealed she couldn't remember doing a skin evaluation on Resident #36, but she had seen her sacral wound progress from being a quarter-sized stage 1 pressure ulcer to being covered with a black necrotic tissue. Nurse #3 denied ever handing a foam dressing to the nurse aides and asking them to place it on Resident #36's sacrum. She recalled placing a dressing according to the treatment record whenever the nurse aides told her Resident #36's dressing was off. She also stated she didn't think she was the first nurse who had discovered the black necrotic tissue, so she didn't think about reporting this to anybody. A phone interview with Nurse Aide (NA) #1 on [DATE] at 10:19 AM revealed she took care of Resident #36 on the day shift, but she always came in early to help the night shift aides get the residents up in the mornings. NA #1 stated there were multiple times when she would come in early that she would see Resident #36's call light on and her bed would be soaked from urine. At those times, Resident #36 was still continent of urine and whenever she asked Resident #36 if the staff had come to check on her, she told her that they came in and turned her light off, thinking that she was asleep and didn't come back. NA #1 stated there were multiple times when she would come in and observed Resident #36 without a dressing to her sacrum and her clothes would be soaked from drainage from her wound. Whenever she asked the night shift nurse aides, they couldn't tell her anything as to why Resident #36 did not have a dressing on to her sacrum. NA #1 stated Resident #36 always had a soft, boggy, purplish red spot on her sacrum that would close and re-open, but she had no clue as to how she got the hole on her sacrum which had a lot of drainage and smelled really bad. NA #1 reported there had been some nurses who had handed her a dressing to put on Resident #36's sacrum and she did it in order to help out, but she got written up for it when she reported this to UM #1. She also stated that Resident #36 never refused to lie down after lunch and never refused to be turned and repositioned in bed. A phone interview with Nurse #4 on [DATE] at 7:44 PM revealed she worked with Resident #36 on the night shift, but she didn't remember having to replace her sacral pressure ulcer dressing. Nurse #4 stated she relied on the nurse aides to report to her if her dressing had come off whenever they did their incontinence rounds. Resident #36 usually got up after Nurse #4 had already left, and Resident #36 never refused to be turned and repositioned to her sides when in bed. Nurse #4 stated she had concerns about the nurses not completing skin assessments and wound assessments which were usually scheduled for the day and evening shifts. She stated she would often see alerts on the electronic medical record that they were past due and some of them would even be over 15 days late. Nurse #4 further stated she reported this to UM #1 and the DON, but she wasn't sure if anything had been done about it. The Wound Evaluation and Management Reports in Resident #36's medical record indicated she was seen by the Wound Physician Assistant (PA) on the following dates: [DATE] - Unstageable pressure ulcer to the sacrum measured 2.5 cm (centimeters) in length, 1.5 cm in width and 0.3 cm in depth. The pressure ulcer was covered with excessive necrotic tissue and had mild serous drainage. Will treat with sodium hypochlorite solution moistened gauze and foam daily. No signs of acute infection. [DATE] - Unstageable pressure ulcer to the sacrum measured 2.5 cm in length, 1.5 cm in width and 1.5 cm in depth. The pressure ulcer was covered with excessive yellowish necrotic tissue and had mild serous drainage. Wound had remained stable in diameter but increased in depth. No signs of acute infection. Wound was debrided with scalpel. Wound depth increased to 15 mm (millimeters). Will change treatment to collagenase, filling the narrow wound with the collagenase and covering with calcium alginate and foam daily. [DATE] - Unstageable pressure ulcer to the sacrum measured 2.5 cm in length, 1.5 cm in width and 1.8 cm in depth. The pressure ulcer was covered with excessive yellowish necrotic tissue. Wound had remained stable in size, but depth had increased due to debridement. Patient had moderate drainage, so a wound culture and sensitivity was taken. Awaiting results. Wound debrided with scalpel removing necrotic tissue. Will order a low air loss mattress and discuss with therapy to get her set up with a pressure relief cushion. [DATE] - Unstageable pressure ulcer to the sacrum measured 3 cm in length, 1.5 cm in width and 2 cm in depth. Wound now had undermining of 20 mm at 12 o'clock position. Wound culture and sensitivity had an unknown issue last week, so it was redone this week. No exposed bone present at this time. Mild odor and mild drainage present, no erythema or pain. Wound debrided with scalpel. Less necrotic tissue present this week than before. Treated wound with sodium hypochlorite solution moistened gauze, lightly packed in the wound and foam daily. A phone interview with the Wound Physician Assistant (PA) on [DATE] at 4:56 PM revealed he did not get consulted when an open area was first noted on Resident #36's sacrum on [DATE] nor when they started treatment on Resident #36's sacral pressure ulcer on [DATE] when it got worse. The Wound PA stated he would not have recommended to use the occlusive dressing that was started on [DATE] because he didn't typically use it on the sacrum, and it was not appropriate treatment for the unstageable ulcer that was present on [DATE]. He stated if the facility provided consistent treatment to Resident #36's pressure ulcer, it would have made a difference in preventing the pressure ulcer from worsening. The Wound PA stated Resident #36's pressure ulcer could have been avoided if the facility provided the appropriate treatment and took preventive measures such as offloading and regular skin checks. The Wound PA further stated he expected the nurses to perform skin checks by looking at all surfaces of the skin from head to toe and paying particular attention to skin folds and creases which were susceptible to fungal infections. The Wound PA also stated if a dressing was present, the nurses were supposed to remove the dressing so they could visualize and assess the wound underneath especially for residents who were not currently being treated by him. On [DATE], he noted an increase in drainage, so he did a wound culture and sensitivity after he debrided the wound. He was informed at the facility when he came back on [DATE] that the laboratory had discarded the swab from the week before because they used the wrong tube, so he obtained another one due to the wound's continued decline and it had started undermining. (Undermining is a closed passageway under the surface of the skin that is open only at the skin surface. It involves a significant portion of the wound edge). When he came back on [DATE], he found out that Resident #36 had been to the Wound Center, so he discharged her from her care. He didn't hear back about the last wound culture and sensitivity done on [DATE] and assumed it was discarded again by the laboratory. He said if he obtained the result from the first wound culture sooner, it could have made a difference in treating Resident #36's pressure ulcer if the infection was superficial. But he couldn't say it would have made a difference if the infection had already reached the bone. And he didn't see any exposed bone after debridement, so he didn't think to do a bone biopsy. The Wound PA stated Resident #36's pressure ulcer was avoidable. An interview with Unit Manager (UM) #1 on [DATE] at 3:20 PM revealed the first time the Wound PA obtained the wound culture; she was notified by the laboratory that they had to discard it because they couldn't run due to it being too dry. UM #1 did not notify the Wound PA until the next week when he came back and performed a second wound culture. UM #1 was again informed by the laboratory that they had to discard it because they used the wrong swab. UM #1 did not think to notify the Wound PA about the wound culture not being done a second time, but she called the laboratory twice to request for the appropriate culture swabs. No one from the laboratory sent any of the swabs that she had requested. An interview with the Nurse Practitioner (NP) on [DATE] at 3:10 PM revealed she became aware of Resident #36's sacral pressure ulcer on [DATE] when her family member texted her and asked her if Resident #36 could be seen by the Wound Center. The NP checked the electronic results for the laboratory and found wound cultures on [DATE] and [DATE] that were originally ordered but had been marked out. The NP stated the facility had been having problems with laboratory tests getting missed and not getting followed through. The NP also stated she was aware that Resident #36's pressure ulcer progressed quickly but she was not aware that Resident #36 did not have a treatment order for the wound prior to the Wound PA seeing her. The NP stated the facility physician usually ordered a treatment for a newly identified wound until the resident was seen by the Wound PA, but she was not sure why she didn't get notified of Resident #36's pressure ulcer that was noted on [DATE]. The NP stated the nurses should have notified her on [DATE] when they noted a pressure ulcer on Resident #36's sacrum so a treatment could have been started while they were waiting for her to be seen by the Wound PA. The Report of Consultation from the Wound Center dated [DATE] for Resident #36 indicated a stage 4 pressure ulcer to the sacrum which measured 2.2 cm in length, 2 cm in width and 2.1 cm in depth. Treatment was changed to skin prep to peri wound, antimicrobial gel wet to dry using 2 inch rolled gauze to pack wound, cover with 4x4 gauze, abdominal pad, and tape. Change daily and as needed for soiled or loose dressing. Referral to an Infectious Disease specialist. Bone culture and pathology done. Prescription for (brand name) antibiotics sent to the facility. Facility to order pressure relief cushion and specialty air mattress. An Infectious Disease Visit Note dated [DATE] in Resident #36's medical record indicated Resident #36 was seen for sacral osteomyelitis. Bone biopsy was positive for Morganella. (Morganella is a species of gram-negative bacteria known to be a causative organism of opportunistic infections in wound infections.) Intravenous antibiotics were ordered. Resident #36 was currently using a wound vac (vacuum-assisted closure of a wound), had gotten an air mattress, and was waiting on a pressure relief cushion for her wheelchair. An observation of wound care was made on [DATE] at 2:43 PM on Resident #36 and performed by Nurse #3 and assisted by Nurse Aide (NA) #2. Resident #36 was turned towards her left side while NA #2 stood facing Resident #36 and supported her trunk. Nurse #3 sprayed wound cleanser into the sacral pressure ulcer which measured approximately 2 cm (centimeters) in length, 3 cm in width and 2 cm in depth. The wound bed had beefy red granulation tissue with 20% slough (yellow/white material in the wound bed consisting of dead cells). The skin surrounding the wound was red. Nurse #3 applied skin prep barrier to the surrounding skin and well over towards the right buttock. Nurse #3 cut a piece of green foam that fit exactly into the wound bed and applied it to the wound. She cut a plastic drape in half, cut, and measured a hole to fit the foam and applied it to cover Resident #36's buttocks and sacral area. She cut another piece of green foam approximately 6 inches long and 1 inch wide to serve as a bridge to the foam covering the wound. Nurse #3 placed the bridge over the plastic drape and covered it with another piece of plastic drape. She cut a small piece of the drape at the top and placed the track pad with the tubing towards Resident #36's sacrum. She secured the track pad with another piece of tape and then coiled the tubing into a circle and taped it to Resident #36's right hip. Nurse #3 connected the tubing to the canister that was placed inside the wound vac and turned the machine on. The wound vac was set at 125 mmHg (millimeters Mercury). The Administrator was notified of Immediate Jeopardy on [DATE] at 1:03 PM. The facility provided the following IJ Removal Plan with the correction date of [DATE]. *Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #36 readmitted on [DATE] and had an identified wound/pressure ulcer without physician notification or ordered treatment. The facility failed to assess, obtain treatment orders from physician, identify deterioration of the pressure ulcer, and process a wound culture which resulted in a serious adverse outcome. A culture was ordered by physician and completed however not resulted by lab. twice from an expired swab and dry specimen. The facility failed to follow up on lab. results and did not ensure lab. supplies were not expired. Facility completed a full body skin assessment and record review on all current residents on [DATE] by the unit managers. Resident #36 was the only identified resident who has suffered an adverse outcome related to non-compliance. The Regional Director of Clinical Services (RDCS) audited lab. supplies to ensure appropriate supplies on hand. An assessment of Resident #36 revealed on [DATE], no further deterioration of pressure ulcer, treatment orders in place per physician order, resident being followed by local wound care clinic. *Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The Regional Director of Clinical Services (RDCS) educated the Director of Nursing (DON) and nurse unit managers (UM) of the existing/revised process of labs. on [DATE]. Process is as follows for labs.: A. Licensed nurse records lab. order in electronic medical record. B. Notification of Responsible Party (RP) of order. C. Licensed nurse completes lab. requisition in facility lab. book. D. Licensed nurse completes patient log in facility lab. book. E. Phlebotomist from lab. obtains specimen. F. Licensed nurse receives results via lab. fax. G. Licensed nurse checks off in facility lab. book on patient log. H. Licensed nurse notifies physician of abnormal lab. results or places within normal limits labs. in physician box and notifies RP. Location of lab. supplies for blood specimens are located in medication rooms, in addition to lab. supplies for urine samples. Wound culture supplies are located in medication rooms, in addition to lab. supplies for urine samples. Wound culture supplies are located in DON office in cabinet. If a physician or Nurse Practitioner orders a wound culture, the licensed nurse will obtain the culture, place in lab. refrigerator, complete the lab. requisition and complete the patient log in the facility lab. book. Results are received via lab. fax. In addition, the DON/designee are responsible for tracking lab. results beginning [DATE]. If a licensed nurse is contacted by the lab. about a problem, the licensed nurse will be responsible for notifying physician and reentering the order and obtaining sample. Any pressure ulcers or skin conditions that are referred to wound physician are communicated via order and requested resident information are communicated by DON and/or UM. No licensed nurse can initiate treatments without a physician order. On [DATE], the RDCS also completed education with DON and unit managers on the process of notification. Notification process is as follows: A. Licensed nurse complete admission skin assessment, and weekly skin assessment in electronic medical record as it is assigned as triggered by electronic medical records system. B. If any deterioration of skin area or new area observed, the licensed nurse notifies physician or Nurse Practitioner immediately, and obtains treatment orders. C. Completes notification of responsible party (RP). D. Reports to the DON and/or unit managers by calling or tiger texting (which is a secure web-based communication). The DON/unit managers along with Wound Nurse Practitioner are responsible for weekly wound/pressure ulcer measurements and assessments. A comprehensive list of wounds will be maintained by the DON/unit managers. Licensed nurses including agency nurses were in-serviced [DATE] by the DON and unit managers on facility process for labs., facility process for notification, location of lab. supplies, responsibilities and of admission and weekly skin assessments, completing weekly wound assessment. Notification process is as follows: A. Licensed nurse complete admission skin assessment, and weekly skin assessment in electronic medical record as it is assigned as triggered by electronic medical records system. B. If any deterioration of skin rea or new area observed, the licensed nurse notifies physician or Nurse Practitioner immediately, and obtains treatment orders. No licensed nurse can initiate treatments without a physician order. C. Completes notification of responsible party (RP). D. Reports to the DON and/or unit managers by calling or tiger texting (which is a secure web-based communication). If any changes in resident conditions, including skin, deterioration (change in size, appearance, skin color, smell, drainage, redness) of wounds/pressure sores, physical or mental changes the licensed nurse must report findings to physician immediately. Facility process for labs. is as follows: A. Licensed nurse records lab. order in electronic medical record. B. Notification of Responsible Party (RP) of order. C. Licensed nurse completes lab. requisition in facility lab. book. D. Licensed nurse completes patient log in facility lab. book. E. Phlebotomist from lab. obtains specimen. F. Licensed nurse receives results via lab. fax. G. Licensed nurse checks off in facility lab. book on patient log. H. Licensed nurse notifies physician of abnormal lab. results or places within normal limits labs. in physician box and notifies RP. Location of lab. supplies for blood specimens are located in medication rooms, in addition to lab. supplies for urine samples. Wound culture supplies are located in DON office in cabinet. If a physician or Nurse Practitioner orders a wound culture, the licensed nurse will obtain the culture, place in lab. refrigerator, complete the lab. requisition and complete the patient log in the facility lab. book. Results are received via lab. fax. The nurse aides, including agency nurse aides will be in-serviced by [DATE] by DON/designee on reporting any changes in resident's condition including skin, (such as: redness, drainage, open areas, odor, temperature, and complaints of pain) to the licensed nurse immediately. DON is responsible for tracking nurses and nurse aides including agency that have received education. The DON/UM are responsible for providing education to current nurses and nurse aides who were not in-serviced by [DATE]. Nurses and nurse aides will not be allowed to work until they receive education. New nurses and nurse aides hired after [DATE] will receive education during orientation. The DON/unit managers are responsible for tracking labs. and notification of physician during clinical morning meeting beginning the week of [DATE]. The facilities interdisciplinary team (IDT) will continue to conduct a weekly resident review of all residents with pressure sores to discuss and document pressure ulcers. The alleged date of IJ removal is [DATE]. The credible allegation for the immediate jeopardy removal was validated on [DATE] with a removal date of [DATE]. On [DATE], the facility's credible allegation was validated through record reviews and staff interviews. The facility provided education documentation for all staff on identifying and reporting a change in condition especially in skin integrity. In addition, the facility provided signed education sheets on performing and documenting weekly wound assessments, notification of the physician, Nurse Practitioner and wound doctor of new/worsening pressure ulcers, actions to take if new/deteriorating pressure ulcer observed and what changes in skin integrity to report, following up and processing of laboratory orders and reviewing laboratory process to ensure supplies were within date. The nursing aides were interviewed and described the different signs of changes in skin integrity to be reported to the nurse during provision of care. The in-service also included reporting all changes in condition and signs of wound infection/wound deterioration to the nurse. A skin/wound audit was completed on [DATE] for any unreported skin issues and the results were compared with the skin assessment documentation, if the physician was notified, if family was notified and if care plan was updated. This was verified through interviews with the Unit Managers and MDS Coordinator who completed the audits. The RDCS completed an audit of all laboratory supplies on [DATE] wherein she removed and discarded expired laboratory supplies and validated that all current in house supplies were sufficient in quantity and there were no other expired supplies in house. She also completed a laboratory audit on [DATE] and checked all laboratory orders within the last 7 days if they had obtained the results and if the physician was notified of the results. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, hypertension, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 was severely cognitively impaired, had no rejection of care behaviors and required extensive physical assistance with bed mobility and transfer. She had impairment to both sides of upper and lower extremities. The MDS further indicated Resident #11 had one stage 3 pressure ulcer, one stage 4 pressure ulcer, one deep tissue injury and one venous ulcer. Resident #11's care plan revised on [DATE] indicated Resident #36 had impaired skin integrity to left heel, left leg and right leg. Interventions included consult with wound care provider as indicated, elevate heels off mattress per routine, inspect skin during routine care daily, pillows for positioning as needed, turn, and reposition during care rounds and as needed and treatment as indicated to impaired skin. The Weekly Wound assessment dated [DATE] indicated Resident #36 had a stage 4 pressure ulcer to the right lower extremity posterior that measured 13.5 cm (centimeters) in length, 3 cm in width and 0.5 cm in depth. The wound had moderate serous drainage with pink and red wound bed and faint odor. The wound had maceration to peri wound. She was seen and evaluated by the Wound Physician Assistant. A physician order dated [DATE] indicated the following treatment for Resident #11's right lower leg pressure ulcer: Cleanse wound on right lower leg using wound cleanser, pat dry. Apply skin prep barrier to [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews with resident, family member, staff, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to provide effective leadership and implement effective systems to manage pressure ulcers, laboratory tests and physician notification. This failure affected 2 of 3 residents reviewed for administration (Resident #36 and Resident #11). Immediate Jeopardy began on 3/3/22 when the facility failed to provide the necessary care and services for a pressure ulcer that deteriorated in condition that involved Resident #36. The immediate jeopardy was removed on 7/3/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: This tag is cross-referred to: F-580: Based on record reviews, and interviews with staff, family member, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to notify the physician or Nurse Practitioner when a sacral pressure ulcer was identified on Resident #36 on 3/3/22 and when the pressure ulcer deteriorated on 3/10/22. The facility failed to notify the Wound PA of two wound culture swabs being discarded by the laboratory. Resident #36 was later diagnosed on [DATE] with sacral osteomyelitis. In addition, the facility failed to notify Resident #36's family member when her pressure ulcer deteriorated on 3/10/22. This failure was for 1 of 3 residents reviewed for notification of changes (Resident #36). F-686: Based on observations, record reviews and interviews with resident, family member, staff, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to assess, obtain treatment orders from the physician, and identify deterioration of the pressure ulcer which resulted in a serious adverse outcome. Resident #36's open area on her sacrum deteriorated from an open area to an unstageable pressure injury with necrotic tissue in a week (from 3/3/22 to 3/10/22). The facility also failed to have two wound cultures processed on Resident #36's sacral pressure ulcer resulting in delayed treatment for osteomyelitis. In addition, the facility failed to provide pressure ulcer care as ordered by the Wound PA for Resident #11. These failures were for 2 of 3 residents reviewed for pressure ulcers (Resident #36 and Resident #11). An interview with the Regional Director of Clinical Services (RDCS) on 6/30/22 at 6:59 PM revealed one of the factors that contributed to the facility's not having effective leadership was due to the facility's lack of Administrative nurses to help the Director of Nursing. The RDCS stated the facility had experienced a quick turnover of Administrative nurses including an Assistant Director of Nursing who was supposed to oversee the unit managers on the floor. They had recently hired 2 unit managers, but they sometimes got pulled to work on the hall and away from their Administrative duties. The Administrator was notified of Immediate Jeopardy on 7/1/22 at 1:03 PM. The facility provided the following IJ Removal Plan with the correction date of 7/3/22. I. Facility failed to provide effective leadership and implement systems to manage pressure ulcers, laboratory tests and physician notification. II. Regional team to include the Regional [NAME] President of Operations and the Regional Director of Clinical Services identified there were breakdown in the execution of critical clinical services. a. Regional team immediately provided oversight and education to the leadership staff. b. Policies related to pressure ulcers and notification for change in condition were reviewed to assure they would be appropriate for the center, and they were deemed to be appropriate. Issues related to pressure ulcers and notifications were not policy driven but issues were identified with implementation of the policy, so education occurred. The center's process for handling labs. and laboratory supplies was reviewed and found to be inadequate, so process was updated and put into place effective 7/2/22. c. Education to the Administrator and DON was provided by the Regional [NAME] President of Operations and the Regional Director of Clinical Services. d. Education included policies and implementing systems for oversight and execution of critical nursing systems identified in the immediate jeopardy. These were completed on 7/2/22. 1. Education to the pressure ulcer policy was completed and implemented on 7/2/22. 2. Education for updated process for laboratory testing and acquiring laboratory supplies was completed and implemented on 7/2/22. 3. Notification for resident change in condition policy and procedure was educated and implemented on 7/2/22. 4. Leadership education also included the company's QAPI process and morning clinical meeting process. Completed 7/2/22. III. Regional team member will participate in each QAPI meeting with the center for the next 3 months to assure appropriate issues are identified and follow-up is put into place. IV. Regional team member will participate in the center's morning clinical meeting on a weekly basis for the next 30 days to assure meeting is thorough and captures any clinical issues that need to be addressed. V. Regional team member will review all audits and in-services related to this plan for the next three months on a weekly basis and repeat in-servicing as appropriate. VI. The Regional team will randomly audit 3 resident charts per week for the next three months to assure accuracy of pressure ulcer documentation, lab. testing compliance and appropriate physician notification. VII. Regional team has set an expectation that the center will hold QAPI meetings monthly. Clinical morning meetings and daily stand-up meetings will be held daily Monday through Friday according to policy. VIII. Regional team will conduct a weekly leadership meeting that involves the Regional [NAME] President or designee, Regional Director of Clinical Services or designee, the facility Administrator and facility Director of Nursing for the next 3 months. Other regional or corporate staff will be invited as appropriate. This leadership meeting will review progress to the plan of correction for the current survey, review process or policy changes that have been implemented for effectiveness and discuss any current issues needing addressed on a clinical level. Date of removal for alleged IJ is 7/3/22. The credible allegation for the immediate jeopardy removal was validated on 7/7/22 with a removal date of 7/3/22. A root cause analysis was completed by the Regional [NAME] President of Operations which identified the following root causes for the IJ concerns identified at the survey: new leadership, agency staffing and adherence to company systems. The audit tools completed by the facility on skin status and laboratory results were reviewed. The physician/Nurse Practitioner were notified of results from the audits for additional follow-up as needed. On 7/2/22, the Regional [NAME] President of Operations provided education with the new Administrator and Director of Nursing on identifying issues with immediate jeopardy cited and discussed with them the components of the regulations for F-580, F-686, and F-835. The education also included QA (Quality Assurance) roles and responsibilities, morning stand-up, clinical stand-up, pressure ulcer policy, policy on resident change in condition, laboratory process, correction plans and monitoring processes. Interviews with nurses and nurse aides revealed they received education on identifying any changes in resident condition including skin issues, changes in vital signs and daily habits and reporting these changes to the nurses and the medical providers. An ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was conducted on 7/2/22 with the following key personnel in attendance: Administrator, Regional Director of Clinical Services, Regional [NAME] President for Operations, Nurse Practitioner and Director of Nursing. They discussed conducting weekly risk meetings to put practice back in place to ensure IDT discusses key resident conditions, makes recommendations and changes to care plans as needed.