**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Wound Nurse, Director of Nursing (DON) #2, Medical Director (MD) #2, and Nurse Practitioner (NP) #2 interviews, the facility failed to notify the MD #2 or NP #2 that Resident #16's developed an abrasion to her left lateral calf under her immobilizer on 9/6/22 resulting in no assessment or treatment until 9/13/22 when the area was discovered as an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). The Wound Physician noted on 9/13/22 the pressure ulcer as measuring 10 centimeters (cm) by 5 cm with 5% of thick adherent black necrotic tissue (eschar) 80% thick adherent devitalized necrotic tissue (slough) and 15% granulation tissue. This was for 1 of 4 residents reviewed for pressure ulcers (Resident #16). Immediate jeopardy began on 09/06/22 when an abrasion to Resident #16's left lateral calf was identified underneath the leg immobilizer and did not notify or consult MD #2 for wound treatment orders. Immediate jeopardy was removed on 2/8/23 when the facility provided and implemented an acceptable credible table allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure the facility completes all staff training and ensure monitoring systems put into place are effective. The findings included: Resident #16 was admitted on [DATE] with cumulative diagnoses of Dementia, Congestive Heart failure, Chronic Kidney Disease, Coronary Artery Disease and osteoporosis. Review of a nursing note dated 8/17/22 at 5:20 PM read she returned from the emergency room on 8/17/22 wearing a left leg immobilizer due to a left distal femur fracture with orders to wear the mobilizer until she was evaluated on 9/6/22 by the orthopedic physician and to check her skin daily to her left lower extremity due to the presence of the leg immobilizer. Review of an orthopedic Physician Assistant (PA) note dated 9/6/22 read there was an observed abrasion to her left lower lateral leg. The note included orders to pad the area under her immobilizer and consult wound management for wound care orders. A telephone interview was completed on 2/6/23 at 9:00 AM with the Orthopedic Physician Assistant (PA). He stated on 9/6/22, he observed an abrasion to Resident #16's left lower leg and wrote on his consult note orders to pad the area for protection and to consult the wound provider for wound care orders. Review of the electronic medical record (EMR) did not include any documented evidence that MD #2 was notified of the abrasion discovered at the orthopedic visit on 9/6/22. A telephone interview was completed on 2/2/23 at 2:50 PM with the Wound Nurse. She stated she thought she recalled a blister on Resident #16's left lower leg under her immobilizer that popped on 9/6/22 and she just covered it with a dry dressing and assumed the orthopedic PA would write wound care orders. She stated she did not notify MD #2 on 9/6/22 when the abrasion was first identified by the orthopedic PA. The Wound Nurse stated she did not read the orthopedic consult note on 9/6/22 because the receiving nurse (Nurse #14) should have reviewed it and implemented any new orders. Review of a Wound Physician note dated indicated she was asked to assess Resident #16 for an unstageable pressure to her left lateral calf on 9/13/22. A telephone interview was completed on 2/2/23 at 4:41 PM with MD #2. He stated he was not notified about Resident #16's pressure ulcer to her left lateral calf until 9/13/22 when the Wound Physician called him because she was concerned about the appearance of the wound and suspected an infection. He stated nobody from the facility notified him of a pressure ulcer until then. He stated he would have expected to be notified due to the risk associated with a pressure ulcer getting infected and he would have given wound care orders on 9/6/22 if the orthopedic PA had not. He stated Resident #16's pressure ulcer that developed underneath an immobilizer was avoidable and any pressure ulcer that was not treated would deteriorate and could lead to infection, sepsis (blood infection) and possible osteomyelitis. A telephone interview was completed on 2/1/23 at 4:28 PM with DON #2. She stated apparently nobody knew about the area identified by the orthopedic office on 9/6/22 until a staff member told the Wound Nurse that there was drainage coming from Resident #16's immobilizer on 9/13/22. She stated she did not read the orthopedic consult note until 9/13/22 when it was discovered Resident #16 had an unstageable pressure ulcer. DON #2 stated after her investigation it was determined that Nurse #14 did not implement the wound care orders from the 9/6/22 orthopedic consult. She stated an untreated open area underneath an immobilizer was avoidable and could lead to complications such as a wound infection sepsis (blood infection) and possible osteomyelitis. Administrator #1 was notified of the immediate jeopardy on 2/6/23 at 5:33 PM. Administrator #1 provided the following credible allegation for the immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 09/06/22 Resident #16 returned from an orthopedic appointment and the transporter gave the nurse the post visit order sheet. The orthopedic MD noted: that a new abrasion was noted to the left lateral aspect of the left lower leg. New orders were received for treatment to the area underneath the immobilizer. The orders included that the dressing and padding must be changed daily, and a wound management consult was advised. The nurse placed the after-visit note/order sheet in the medical records box as she had been instructed to do in the past. It was scanned into PCC on 09/12/22, but no orders were noted or transcribed from that post visit note as no one was aware that there were new orders. On 09/13/22 the Certified Nurse Aide was lifting the resident's immobilized leg and felt a wet area on the immobilizer. On 9/13/22 the resident went to an orthopedic appointment and new orders were received. On 9/13/2022 the wound nurse reviewed the orders and upon assessment of resident #16, noted a dressing placed by the orthopedic doctor to the left lateral calf. On 09/13/22 the wound doctor was notified and evaluated the left lower leg and noted areas to the left lateral calf and left anterior knee. Treatments were initiated to the left lateral unstageable calf wound to cleanse the wound, apply Santyl for 30 days and Gentamycin for 14 days with calcium alginate once daily for 30 days. Per physician's post visit note the treatment to the deep tissue injury to the left anterior knee was to cleanse the wound, apply skin prep to area and cover with protective dressing once daily for 30 days. On 2/7/2023 the Interim Director of Nurses audited notification for residents that were potentially impacted by this practice by reviewing 100% of post appointment documents and any resulting orders received from the appointment, for the last 30 days. The audit was done for completion of notification of the attending physician and the responsible party. Root Cause Analysis was completed on 2/07/2023 with the following staff in attendance: Administrator, Interim Director of Nurses, Regional Operations Manager, the Quality Assurance Nurse Consultant and the Medical Director. Root cause analysis was conducted related to staff failure to notify the attending physician, upon return from an appointment, of newly received orders. Upon interview of the nursing staff/agency it was determined that the root cause was that the nurse failed to put the order in the electronic health record so that the treatment was initiated, and the referral could have been followed up on in the daily clinical meeting. This resulted in the physician not being notified of the new abrasion and ordered treatment. The facility administration's failed to provide effective oversight and leadership to ensure effective systems were in place related to follow up of orders and notification to the physician of new orders or recommendations received from an appointment. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 02/7/2023, the Interim Director of Nurses/Quality Assurance Nurse Consultants began in-service of 100% of all licensed nurses, full time, part time and as needed nurses, including agency. The education included: The Change in Condition/Notification/Documentation Process of the attending physician/responsible party/resident, to include notification of changes in skin/wounds, newly received orders, following return from an appointment and the importance of following the post appointment process. When a resident returns from an appointment, the nurse is to obtain the post visit note and review it for new orders or recommendations. The nurse is to notify the physician and responsible party/resident. The nurse is to transcribe any new orders. The post visit note is sent to medical records and will be uploaded into the electronic health record within 72 hours post visit. The interdisciplinary team will review the post visit note and any applicable orders as part of the Daily Clinical Process. The interdisciplinary team will review the hard copy information from the post visit note to confirm that needed orders are contained in the electronic medical record. If the resident returns without a post visit note or orders, it is the responsibility of the nurse to follow up and call the physician's office to obtain any new orders and then transcribe those orders. The nurse will as well notify the responsible party/resident and document the notification. On 2/7/2023 the Interim Director of Nurses/Administrator and interdisciplinary team were educated on the expectation that the post appointment process, to include newly received orders/progress notes or other physician/NP/PA information received from an appointment involving a change in condition such as a wound, will be followed as part of the Daily Clinical Review Process. The process is to include review of notification of the attending physician and responsible party and that the notification is documented in the electronic health record. This education was completed by the Quality Assurance Nurse Consultant. As of 2/8/2023, no Licensed Nurses will work without the education completed. This is to include agency and new staff. The Interim Director of Nurses and Administrator are responsible to ensure all staff are educated as well as to maintain monitoring and tracking of sustained compliance for staff that still require education to include newly hired licensed nurses and agency nurses as well as any newly hired interdisciplinary team members. After 2/08/23 the Interim Director of Nursing will be responsible to ensure Licensed Nurses are educated on the applicable policies and procedures related to nursing follow up post appointment to assure the notification process is completed and that new orders are initiated to prevent serious complications that might occur for failing to follow these processes Alleged date of immediate jeopardy removal 02/08/23. On 02/09/23, the facility's credible allegation for Immediate Jeopardy removal effective 02/08/23 was validated by staff interviews and record review. Staff were interviewed to validate in- service completion. Review of the appointment and order follow up process education was completed. Review of the appointment/order follow up sheet was completed, and the Quality Assurance (QA) Committee met to discuss the appointment/order follow up findings. Immediate jeopardy was removed on 2/8/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #12 was admitted to the facility on [DATE]. His diagnoses included severe protein-calorie malnutrition, diabetes type 2 and a stroke with paralysis to the left side. A review of Resident #12's active care plan, last reviewed 11/22/22, included the following focus areas: - Risk for pressure ulcer development due to decreased sensation related to left sided hemiparesis (paralysis). The interventions included a pressure reducing mattress to the bed. - Currently with a pressure ulcer to the right heel and at risk for development of additional pressure ulcers due to decreased ability to re-position and incontinence- resident refusing repositioning. The interventions included air mattress to the bed. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 had moderately impaired cognition, required extensive assistance and had been bed bound for the 7-day assessment period. He was coded with two stage 2 and one unstageable pressure ulcer, as well as having a pressure reducing device to the bed. A review of Resident #12's medical record from 9/20/22 to 1/17/23 revealed wound care was provided to a sacral and left hip pressure ulcer. On 1/23/23 at 3:00 PM, an observation was made of Resident #12 while he was lying in the bed. An alternating air mattress machine was hooked to the foot of the bed, however the connection to the mattress was lying on the floor as well as the power plug. Resident #12 was lying on a deflated air mattress. Another observation was made of Resident #12 on 1/24/23 at 9:00 AM while he was lying in bed. The alternating air mattress machine was not connected to the mattress and the power plug remained on the floor. Resident #12 was lying on a deflated alternating air mattress. During an observation of Resident #12 the alternating air mattress machine was no longer present at the end of the bed. The deflated air mattress overlay remained under Resident #12 in the bed. On 1/24/23 at 2:30 PM, an observation of Resident #12 occurred with the Wound Nurse and Nurse Aide (NA) #1. The Wound Nurse verified the alternating air mattress machine was no longer in place at the end of the bed and Resident #12 was lying on the deflated air mattress overlay in the bed. NA #1 and the Wound Nurse both recalled the machine being present at the foot of Resident #12's earlier that morning and was not sure what happened to it. At 3:34 PM on 1/24/23, the Wound Nurse reported the alternating air mattress machine was located in a drawer in Resident #12's room. An observation occurred revealing the alternating air mattress machine was connected to the mattress overlay underneath Resident #12 as well as plugged into power. A phone interview occurred with the Wound Physician on 1/25/23 at 2:15 PM and stated she would expect the alternating air mattress to be connected and functioning properly as Resident #12 was at high risk for skin breakdown and had a history of pressure ulcers to his sacrum and left hip. Based on record review, observation and interviews with Orthopedic Physician Assistant (PA), Wound Nurse, Wound Physician, Medical Director (MD) #2, Director of Nursing (DON) #2, Administrator #2, Nurse Practitioner (NP) #2 and family, the facility failed to prevent the development of a pressure ulcer, protect Resident #16's skin under an immobilizer used following a fractured distal femur (the area of the leg just above the knee joint), perform skin checks under the immobilizer and assess skin. At the first orthopedic follow up appointment, an abrasion was identified. Orders were given to pad an abrasion and consult with a wound physician. The orders were not implemented. Skin checks continued not to be done following the identification of the pressure ulcer. The area deteriorated to an unstageable pressure ulcer. An unstageable pressure ulcer means a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by eschar (dry, dark scab of dead skin), slough (yellow tissue that is stingy and thick) and granulation tissue (part of the healing process in which lumpy, pink tissue containing new connective tissue and capillaries form around the edges of a wound). Treatments were not performed. The facility failed to assess the wound after 1/17/23 and it re-opened as a stage 4 (deep wound reaching the muscle, ligaments of bone) pressure ulcer on 1/24/23. The facility also failed to provide treatments as ordered for Resident #45 and ensure the alternating air mattress was functioning and set according to manufacturer's instructions for Resident #12 and Resident #46. This deficient practice affected 4 of 4 sampled residents reviewed for pressure ulcers (#16, #12, #45 and #46). Immediate jeopardy began on 9/6/22 when a pressure ulcer on Resident #16's left lateral calf developed underneath a leg immobilizer and the facility failed to implement interventions to prevent worsening of the ulcer. Immediate jeopardy was removed on 2/6/23 when the facility provided and implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure the facility completes all staff training and ensure monitoring systems put into place are effective. Examples #2, #3 and #4 were cited at scope and severity of E. The findings included: 1. Resident #16 was admitted on [DATE] with cumulative diagnoses of dementia, congestive heart failure, chronic kidney disease, coronary artery disease and osteoporosis. Resident #16 was care planned on 9/17/19 for a risk of pressure ulcers. This care plan was the active care plan during the survey. Interventions were to assist with frequent position changes and turn for pressure reduction and comfort, float her heels in bed, pressure reducing mattress on the bed, provide incontinence care as needed and report to the nurse immediately of any redness, open areas or irritation to her skin. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #16 had severe cognitive impairment, required extensive assistance with bed mobility, transfers and personal hygiene. She was assessed as having no weight loss or weight gain and no pressure ulcers. A nursing note dated 8/17/22 at 5:20 PM read Resident #16 returned from the emergency room on 8/17/22 wearing a left leg immobilizer due to a left distal femur fracture with orders to wear the immobilizer until she was evaluated on 9/6/22 by the orthopedic physician and to check her skin daily to her left lower extremity due to the presence of the leg immobilizer. The electronic medical record (EMR) from 8/17/22 to 8/22/22 did not include any evidence that Resident #16's left lower leg had any skin concerns. An orthopedic PA note dated 8/22/22 read Resident #16 was to have daily checks for skin breakdown due to the leg immobilizer. Resident #16's August 2022 Physician orders included an order dated 8/23/22 that read for staff to check her skin for breakdown daily due to immobilizer use on every shift. Resident #16's August 2022 and September 2022 treatment administration records (TAR) revealed staff initials indicating Resident #16's left lower leg under her immobilizer was intact from 9/6/22 through 9/12/22. A telephone interview was completed on 2/2/23 at 2:50 PM with the Wound Nurse. She stated she thought she recalled a blister that popped on 9/6/22 and she just covered it with a sheet of calcium alginate and a dry dressing and assumed the orthopedic Physician would write wound care orders. An orthopedic PA note dated 9/6/22 read there was an observed abrasion to her left lower lateral leg. The orthopedic consult note included orders to pad the area under her immobilizer and consult wound management for wound care orders. A telephone interview was completed on 2/6/23 at 9:00 AM with the Orthopedic PA. He stated on 9/6/22, he observed an area to Resident #16's left lower leg and wrote on his consult note orders to pad the area for protection and to consult the wound provider for wound care orders. A telephone interview was completed on 2/2/23 at 2:50 PM with the Wound Nurse. She stated she did not follow up after Resident #16's 9/6/22 appointment for wound care orders. A form titled Review to Ensure Quality Pressure Injury related to Leg Immobilizer dated 9/16/22 read wound care orders given at the orthopedic office visit on 9/6/22 were not implemented. The form was initiated by DON #2. The form read Nurse #14 received Resident #16 back from her orthopedic appointment on 9/6/22 and she placed the consult note with wound care orders in the medical records box to be scanned into the electronic medical record (EMR). She stated she read the note but did not recognize that the note included orders to be entered into the EMR and implemented. The facility was unable to provide any contact information for Nurse #14 who was no longer an agency nurse for the facility. A telephone interview was completed on 2/1/23 at 4:50 PM with DON #2. She stated nobody knew about the area discovered at the 9/6/22 orthopedic appointment until on 9/13/22 when a staff member told the Wound Nurse that there was drainage coming from Resident #16's leg immobilizer who consulted with the Wound Physician in the facility at the time. She stated after her investigation it was determined that Nurse #14 did not implement the wound care orders from the 9/6/22 orthopedic consult. The September TAR revealed staff initials indicating Resident #16's left lower leg under her immobilizer was intact from 9/7/22 through 9/12/22. There were no nursing notes in the electronic medical record from 9/8/22 through 9/12/22 and a nursing note dated 9/13/22 at 12:21 PM read Resident #16's skin was being monitored for irritation to her leg. The daily skin checks under her immobilizer from 9/6/22 through 9/12/22 indicated no concerns. A telephone interview was completed on 2/2/23 at 1:27 PM with Nurse #13. She stated she initialed off on 9/7/22 and 9/12/22 that she completed the skin check under Resident #16's left leg immobilizer when she did not do it. A telephone interview was completed on 2/2/23 at 1:40 PM with Nurse #8. She stated she initialed off that she assessed the skin under Resident #16's leg immobilizer on 9/8/22, 9/10/22 and 9/11/22 but she did not see any open areas. If she had seen any open areas, she would have notified the Charge Nurse or MD #2. A weekly skin assessment completed by Nurse #3 dated 9/9/22 indicated there were no skin abnormalities. A telephone interview was completed on 2/2/23 at 2:37 PM with Nurse #3. She was unable to recall completing Resident #16's weekly skin assessment on 9/9/22 but stated she must not have seen an open area to Resident #16's left lower leg. A telephone interview was completed on 2/2/23 at 2:50 PM with the Wound Nurse. She did not assess the area until 9/13/22 when it was reported that there was drainage noted on her leg immobilizer. A Wound Physician note dated 9/13/22 indicated she was asked to assess Resident #16 for an unstageable pressure to her left lateral calf on 9/13/22. The assessment revealed Resident #16 had an unstageable pressure ulcer to her left lateral calf with moderate serosanguinous (consisting of both blood and serous fluid) drainage at least 7 days in duration. The note described the wound as measuring 10 centimeters (cm) by 5 cm with 5% of thick adherent black necrotic tissue (eschar) 80% thick adherent devitalized necrotic tissue (slough) and 15% granulation tissue. There was no pain associated with the pressure ulcer. The note read the Wound Physician performed an in-house mechanical debridement (removal of dead, damaged, or infected tissue) of the area with orders to cleanse the left lateral calf with wound cleaner, apply Gentamicin (antibiotic) ointment with Santyl (debriding agent) and to cover it with a calcium alginate (a dressing made from salts of alginic acid obtained from seaweed) dressing and wrap with gauze every day. Resident #16's cumulative Physician orders indicated the Wound Physician's new wound care orders were written on 9/13/22. A telephone interview was completed on 2/3/23 at 8:15 AM with the Wound Physician. She recalled there was redness or the beginning of cellulitis so that's why she started the Gentamycin ointment. She stated the area identified on 9/13/22 to Resident #16's left lateral calf was avoidable and an untreated pressure ulcer could lead to infections and possible osteomyelitis (bone infection). A telephone interview was completed on 2/2/23 at 4:41 PM with MD #2. He stated he thought he recalled getting a phone care from the Wound Physician on 9/13/22 to discuss Resident #16's pressure ulcer. He stated Resident #16's pressure ulcer that developed underneath an immobilizer was avoidable and any pressure ulcer that was not treated would deteriorate and could lead to infection, sepsis (blood infection) and possible osteomyelitis. A grievance dated 9/23/22 indicated Resident #16's family member found a dressing to her left lower calf dated 9/20/22. The grievance read the Wound Nurse and floor staff were interviewed and verified the treatment was ordered for daily. The facility began auditing of residents with pressure ulcers for documentation of treatments along with re-education to the nurses to follow the treatment orders frequency as ordered. A form titled Review to Ensure Quality completed by DON #2 dated 9/23/22 read Nurse #13 and Nurse #14 documented Resident #16's wound care treatments completed on 9/21/22 and 9/22/22 but the wound care treatment was not provided. The facility was unable to provide any contact information for Nurse #14 why documented she completed Resident #16's stating she was an agency nurse. Resident #16's TARs for September 2022 through October 2022 indicated documented evidence of daily skin checks under her left leg immobilizer until the immobilizer was discontinued on 10/27/22. A Wound Physician note dated 12/6/22 read Resident #16's left lateral calf pressure ulcer had improved measuring 5.3 cm by 1.3 cm x 0.1 cm with moderate serous drainage with 50% granulation and 50% skin. A Wound Physician note dated 12/13/22 read Resident #16's left lateral calf pressure ulcer had deteriorated from her last visit on 12/6/22. The area measured 5.5 cm by 2.0 cm by 0.1 cm with moderate serosanguinous drainage with 70% granulation tissue and 30% skin. Resident #16's new treatment orders dated 12/14/22 were to cleanse her left lateral calf with wound cleaner, apply a Collagen sheet (sheet, pad or gel derived from bovine or porcine collagen), cover with an ABD (a highly absorbent, multilayer, soft, non-woven moisture barrier) pad and secure with gauze wrap every day. Resident #16's December 2022 treatment administration records (TAR) indicated no documented evidence that her wound care to her left lateral calf was completed on 12/28/22, 12/29/22 and 12/31/22. An interview on 1/24/23 at 3:00 PM was completed with the Wound Nurse about the lack of wound care documentation on 12/28/22. She confirmed she was assigned Resident #16 on 12/28/22 but stated she did not do the treatment on 12/28/22. She stated she was on a medication cart and the MDS Nurse took over around noon that day and she assumed the MDS Nurse would do the dressing change. An interview was completed on 1/26/23 at 10:40 AM with the MDS Nurse. She recalled only completing the noon medication pass on 12/28/22 and she did not complete Resident #16's dressing change. She stated she was relieved by a Medication Aide (MA), and she could not provide treatments to pressure ulcers. An interview was completed on 1/26/23 at 10:10 AM with Nurse #4. She confirmed she worked with Resident #16 on 12/29/22 and 12/31/22. She reported she did not complete her wound treatments. She stated Nurse #3 relieved her on those days and she did not ask Nurse #3 to complete Resident #16's wound care. A telephone interview was completed on 1/26/23 at 10:25 AM with Nurse #3. She stated she worked the evening of 12/29/22 and 12/31/22. She stated she was not instructed in report that Resident #16's pressure ulcer care needed to be completed to her left lower calf on 12/29/22 and 12/31/22. A Wound Physician note dated 1/10/23 read as follows. Resident #16 had a stage 4 pressure ulcer 114 days in duration. The note read the area to her left lateral calf was resolved with the area scabbed. There were new orders to apply a Vaseline or equivalent and cover with a dry dressing daily for one week. Review of Resident #16's January 2023 orders included this order and read to start the new treatment on 1/11/23 for 7 days. Review of Resident #16's January 2023 treatment orders read a new order dated 1/10/23 for 7 days the staff were to apply a Vaseline dressing and cover with a dry dressing daily through 1/17/23. There were no additional orders for the area after 1/17/23. Resident #16's January 2023 TAR indicated documented evidence that her wound care was completed 1/11/23 through 1/16/23 but there was no documented evidence that Resident #16's wound care was completed on 1/17/23. A telephone interview was completed with Nurse #5 on 2/2/23 11:54 AM. She remembered completing Resident #16's wound care on 1/14/23 and 1/15/23 and recalled the wound as in healing stage. She stated there was no observed drainage, but she did not recall seeing a scab. A telephone interview was completed on 1/26/23 at 11:40 AM with the Nurse #8. She stated she completed Resident #16's wound care on 1/16/23 but she did not recall exactly how the area looked but stated it must have looked healed since she did not document anything unusual that day. A telephone call was attempted on 2/2/23 at 12:00 PM to Nurse #12 to inquire why she did not do Resident #16's wound care on 1/17/23 but the voice message mailbox was full. An observation and family interview were conducted on 1/23/23 at 11:18 AM. Resident #16 was sitting up in her wheelchair and her family member stated she just returned from an appointment with her orthopedic physician. Observed to Resident #16's left lateral calf was a dressing dated 1/16/23. It appeared to have not been changed since 1/16/23 for a total of 7 days. There was old bloody drainage and new bloody drainage observed on and around the old dressing. The family member stated this was not the first time she had found Resident #16's pressure ulcer dressing days old and she had brought it to the attention of the facility in the past. Resident #16's skin assessment completed by Nurse #3 on 1/21/23 noted an existing skin concern. A telephone interview was completed on 1/26/23 at 10:05 AM with Nurse #3. She confirmed she completed Resident #16's skin assessment dated [DATE]. She recalled seeing a dressing to her left lower calf, but she did not notice the date written on the dressing nor did she remove it. When Nurse #3 was informed that at the time of her assessment on 1/21/23, the dressing to Resident #16's left lower calf was 5 days old. She stated the Wound Nurse or Wound Physician would be the ones to assess an open wound. An interview on 1/23/23 at 3:00 PM was completed with the Wound Nurse. She stated she completed wound rounds with the Wound Physician on Tuesdays. She stated after the order for the Vaseline dressing was completed after 7 days, there were no additional orders since the area was resolved by the Wound Physician on 1/10/23. Arrangements were made for a surveyor observation of the healed area to her left lateral calf on 1/24/23. The Wound Nurse agreed to get surveyor prior to the Wound Physician's assessment was completed on 1/24/23. An observation was conducted on 1/24/23 at 8:35 AM of Resident #16's left lateral calf. The old dressing previously described dated 1/16/23 was still in place. An interview was completed on 1/24/23 at 2:50 PM with DON #1. She stated she received a call from the orthopedic office on 1/23/23 who reported the dressing on Resident #16's left lower leg dated 1/16/23 appeared to be bleeding and that she told the Wound Nurse to assess it at that time. She stated she would ensure the Wound Nurse followed up with the surveyor regarding the scheduled wound assessment on 1/24/23. She stated it was her expectation that resident wound treatments were administered as ordered and observation be done of a newly healed pressure ulcer due to the increased likelihood it could reopened. An interview on 1/24/23 at 3:00 PM was completed with the Wound Nurse. She stated after the order for the Vaseline dressing was completed after 7 days, there were no additional orders since the area was resolved by the Wound Physician on 1/10/23. She stated she did not assess Resident #16's left lateral leg after her Vaseline treatment orders were completed. She stated she assumed that the floor nurses would notify her if the area had not resolved or declined when they completed their skin assessments. The Wound Nurse stated she forgot to assess the area reported by the orthopedic office on 1/23/23 but asked the Wound Physician to assess it earlier today. She stated the previously healed pressure ulcer had reopened and was now a stage 4 pressure ulcer again. The Wound Nurse stated she forgot to get the surveyor earlier to observe Resident #16's left lateral calf and that her next wound treatment was not until Thursday 1/26/23. The Wound Physician note dated 1/24/23 read as follows: Resident #16 was assessed and evaluated for a stage 4 pressure ulcer to her left lateral calf that was at least 1 day in duration. It measured 6.0-centimeter (cm) by 1.5 cm x 0.1 cm with area of necrotic (dead) tissue and granulated (healing) tissue. The wound was debrided, new treatment orders were given, and the Wound Physician estimated the wound would heal with continued physician evaluation and interventions in 63 days. A telephone interview was completed on 1/25/23 at 2:15 PM with the Wound Physician. She stated the original onset of the left lateral calf pressure ulcer was from her left leg immobilizer she wore after the left femur fracture in August 2022. The Wound Physician stated there was only a scabbed area near the bottom of her left lateral leg on 1/10/23 and she assumed the facility would have contacted her if on 1/17/23 the area did not appear intact. She stated she was asked by the facility to assess Resident #16's left lateral calf on 1/24/23 and noted the healed pressure ulcer had re-opened and presented with 10% of necrotic tissue and 90% granulation. The Wound Physician stated it was her opinion that resident skin surveillance was a problem at the facility. She stated Resident #16's re-opened area should have been discovered and treated immediately when the facility noted a concern as of 1/23/23. She further stated she expected all of Resident #16's pressure ulcer treatments be administrated as ordered. A telephone interview was completed on 1/25/23 at 1:43 PM with NP #1 who stated she recently started at the facility the end of December 2022. She stated she was told that Resident #16's pressure ulcer to her left lower calf was resolved but could not recall who told her. She stated the Wound Nurse, and the Wound Physician assessed all pressure ulcers every Tuesday and the Wound Physician wrote her own treatment orders. NP #1 stated she did not routinely observe a pressure ulcer unless specifically requested by a nurse. She stated it was her expectation that Resident #16 receive her treatments as ordered and would have expected the area to her left lateral leg be assessed after 1/17/23 when the Vaseline dressing for 7 day was completed to ensure the wound had not reopened or declined since it apparently still was scabbed as of 1/10/23. A wound care observation of Resident #16's left lateral calf was completed on 1/26/23 at 9:43 AM with the Wound Nurse. There was noted necrotic tissue to the center of the lower, smaller section of the pressure ulcer with pink/red tissue extending higher up on her calf. The Wound Physician stated it was a stage 4 pressure ulcer. Another wound care observation was completed on 2/2/23 at 10:35 AM with Nurse #1. The old dressing had a small amount of serosanguinous drainage. There was no evidence of redness or infection. The area was improved since previous observation completed on 1/26/23. Administrator #1 was notified of the immediate jeopardy on 2/3/23 at 10:00 AM. Administrator #1 provided the following credible allegation for the immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 09/06/23 Resident #16 returned from an orthopedic appointment and the transporter gave the nurse the post visit order sheet. The orthopedic MD noted: that a new abrasion was noted to the left lateral aspect of the left lower leg. New orders were received for treatment to the area underneath the immobilizer. The orders included that the dressing and padding must be changed daily, and a wound management consult was advised. The nurse placed the after-visit note/order sheet in the medical records box as she had been instructed to do in the past. On 09/13/23 the Certified Nurse Aide was lifting the resident's immobilized leg and felt a wet area on the immobilizer with her hand. On 9/13/23 the resident went to an orthopedic appointment and new orders were received. On 9/13/2023 the wound nurse reviewed the orders and upon assessment of the resident #16 noted a dressing placed by the orthopedic doctor. On 09/13/22 the wound doctor evaluated the left lower leg and noted areas to the left lateral calf and left anterior knee. Treatments were initiated to both left lateral calf stage 4 pressure ulcer and to the unstageable deep tissue injury to the left anterior knee based on the wound physician's assessment and orders. On 09/15/22 the Director of Nursing completed the Root Cause Analysis. This is an internal process of review to help determine how the wound occurred and what could be done to correct the occurrence or action. On 1/10/23 the wound doctor assessed the wound and documented that the area was epithelized and had resolved, and that the area presented with a scab. The recommendation was for a Vaseline or equivalent and dry protective dressing for 7 days. The new wound care orders initiated were for a collagen sheet apply once daily x 7days. The dressing dated 1/16/23 was the last day of ordered wound care. The dressing remained in place until noted on 01/23/23. The dressing was removed on 01/23/23 by the wound nurse and a new dressing was applied. On 1/24/23 the wound physician assessed the area and noted that a previous stage 4 injury that closed on 1/10/23 had reopened to the left lateral calf and orders were initiated to the wound. Resident #16 received a total body skin assessment on 02/02/2023 by the Interim Director of Nursing (DON). The total body skin assessment revealed that Resident #16 had a current wound on the left lateral calf and a treatment was in place that was being managed by the treatment nurse or the staff nurse according to the physician's order. On 02/03/2023, the Interim Director of Nurses reviewed Resident #16's orders and care plan to ensure preventative measures were currently in place to prevent new skin issues and worsening of current wounds. On 02/02/2023, the Interim Director of Nurses began identification of residents that were potentially impacted by this practice by completing total body skin assessments on all current residents on 02/03/23. This audit was completed by reviewing 100% of current residents to identify any residents with new pressure wounds or skin integrity alterations. On 02/02/2023- 02/03/23, the Interim Director of Nurses assessed and audited 100% of all current pressure wounds to assure current wound measurements were completed. On 2/3/2023, the nurse consultant audited 100% of all residents with identified pressure wounds to assure a current treatment order was correct and in place on the electronic treatment record. On 2/3/2023 the Interim DON completed a 100% audit of all resident Braden scores for risk for pressure ulcers. On 2/03/2023, 100% of residents with pressure wounds or at risk for pressure ulcers were audited by the Minimum Data Set nurse to ensure preventative measures were currently in place to prevent new skin breakdown and address the current pressure wound. Root Cause Analysis was completed on 2/03/2023 with the following staff in attendance: Administrator, Interim Director of Nurses, Regional Operations Manager, the Quality Assurance Nurse Consultant and the Medical Director. Root cause analysis was done related to staff members lack of daily skin surveillance and thorough skin assessments to identify changes in skin integrity and initiate interventions/treatments for a resident at risk for skin breakdown. Upon interview of the nursing staff/agency it was determined that the root cause was the facility administration failure to provide effective oversight and leadership to ensure effective systems were in place to: Prevention of avoidable pressure sores. Identification of residents at risk. Provide wound care and dressing changes per physician's orders. Conduct thorough skin assessments. Review and provide needed treatment from physician referrals regarding identified wounds. Ensure physician's orders for wound care were followed. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 02/02/2023, the Interim Director of Nurses/Quality Assurance Nurse Consultant/Senior Regional Staff Education Specialist began in-service of 100% of all licensed nurses, full time, part time, as needed nurses, including agency to include: The Skin Assessment/Pressure Ulcer Assessment Process to include how to identify when a skin or wound assessment is due to be completed in the electronic health record. Identification of New Orders and Provision of Ordered Treatments. Wound/Skin/Treatment/Order Documentation Process. The Post Follow Up of Appointment Orders Process and the Order Clarification Process. Documentation and notification of the Administrator/Director of Nurses if a treatment cannot be completed for any reason. On 02/02/23 education was initiated by the Quality Assurance Nurse Consultants for 100% of all licensed nurses, including agency nurses, on the Nurse Practice Act and North Carolina Board of Nursing Position statement on Wound Care. In addition, on 02/02/23, the Quality Assurance Nurse Consultants/ Senior Regional Staff Education Specialist began direct observation, with return demonstration, of how to complete a skin assessment/wound assessment utilizing a competency check list of the steps of the skin/wound/order/treatment process and the nurses were instructed to identify on the skin assessment, for residents with immobilizers/braces, the condition of the skin under or surrounding the immobilizer or brace. Including notification of the physician and wound nurse for further assessment and treatment orders for any new or worsening changes to the skin. On 2/2/2023, the Interim Director of Nurses/Quality Assurance Nurse Consultant/Senior Regional Staff Education Specialist began education of all Certified Nursing Assistants, Medication Aides and agency Certified Nursing Assistants on observing the resident's skin when providing care and timely notification of the nurse regarding noted areas of alterations in skin integrity. The Certified Nursing Assistant education included: what skin integrity concerns are to be reported to the nurse. This includes changes such as odor from a wound/swelling/increased redness/pain/drainage from wound site/new areas of redness or new skin breakdown. As of 2/02/23 the Quality Assurance Nurse Consultants began education of all licensed nurses, including agency on the following ex[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and Administrator #1 and Director of Nursing (DON) #1 interviews the facility administration failed to have effective systems in place to prevent, identify, assess, treat, and manage residents with and at risk for pressure sores. This failure resulted in Resident #16 developing an avoidable abrasion under her left leg immobilizer identified on 09/06/22 at an orthopedic consult visit. The abrasion went untreated and area deteriorated into an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) on 9/13/22. The Wound Physician resolved Resident #16's avoidable pressure ulcer on 1/10/23 with an order for 7 days of dressing changes to protect of the healed area. The lack of reassessment after 1/10/23 resulted in the Wound Physician being consulted on 1/24/23 where she observed the area had reopened into a stage 4 pressure ulcer (deep wound reaching the muscle, ligaments of bone) on 1/24/23. This was for 1 of 4 residents reviewed for pressure ulcers (Resident #16). The facility also failed to provide care to a diabetic ulcer as ordered by the Wound Physician for 1 of 3 residents reviewed for care to maintain well-being (Resident #10). Immediate jeopardy began on 9/6/22 when the facility administration failed have effective systems in place to identify and prevent further deterioration of an abrasion on Resident #16's left lateral calf underneath her leg immobilizer. Immediate jeopardy was removed on 2/7/23 when the facility provided and implement an acceptable creditable allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure the facility completes all staff training and ensure monitoring systems put into place are effective. Examples #2, #3 and #4 were cited at scope and severity of E. The findings included: Cross Reference to: F 684: Based on record review, observations, staff and Wound Physician interviews, the facility failed to provide wound care as ordered by the Wound Physician to a diabetic ulcer on the lower extremity (Resident #10) for 1 of 3 residents reviewed for well-being. F 686: Based on record review, observation and interviews with Orthopedic Physician Assistant (PA), Wound Nurse, Wound Physician, Medical Director (MD) #2, Director of Nursing (DON) #2, Administrator #2, Nurse Practitioner (NP) #2 and family, the facility failed to prevent the development of a pressure ulcer, protect Resident #16's skin under an immobilizer used following a fractured distal femur (the area of the leg just above the knee joint), perform skin checks under the immobilizer and assess skin. At the first orthopedic follow up appointment, an abrasion was identified. Orders were given to pad an abrasion and consult with a wound physician. The orders were not implemented. Skin checks continued not to be done following the identification of the pressure ulcer. The area deteriorated to an unstageable pressure ulcer. An unstageable pressure ulcer means a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (dead tissue) or eschar (dead tissue). Treatments were not performed. The facility failed to assess the wound after 1/17/23 and it re-opened as a stage 4(deep wound reaching the muscle, ligaments of bone) pressure ulcer on 1/24/23. The facility also failed to provide treatments as ordered for Resident #45 and ensure the alternating air mattress was functioning and set according to manufacturer's instructions for Resident #12 and Resident #46. This deficient practice affected 4 of 4 sampled residents reviewed for pressure ulcers (#16, #12, #45 and #46). An interview was completed on 2/3/23 at 10:00 AM with Administrator #1. He stated the facility's administration identified a problem with pressure ulcers in the facility the first part of January 2023 but had not had an opportunity to address the concerns. An interview was completed on 2/7/23 at 10:00 AM with Director of Nursing (DON) #1. She stated she started as the DON on 1/13/23 was not aware of the problem with skin surveillance and avoidable pressure ulcers until it was brought to her attention on 1/23/23 by Resident #16's orthopedic Physician follow up visit. Administrator #1 was notified of the immediate jeopardy on 2/3/23 at 10:00 AM. Administrator #1 provided the following credible allegation for the immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to provide leadership and oversight to implement effective systems to identify changes in skin integrity, complete thorough skin assessments, provide treatments as ordered, and manage pressures ulcers. In September of 2022, the facility identified a care concern involving Resident # 16. The resident had an orthopedic appointment 9/6/2023 and the physician had ordered care to be provided to an abrasion that was noted under the immobilizer. There was a delay in care, which allowed the wound to worsen due to a lack of monitoring. The facility conducted a root cause analysis with input from the Medical Director as to the cause of the wound and implemented a plan of correction including wound education, looking under the immobilizer, and documentation of skin checks. The Director of Nursing was responsible for monitoring the plan of correction and reporting progress to the Quality Assurance Team. On 1/10/2023, the wound physician assessed Resident # 16. The wound was resolved, and orders given to apply a protective dressing. On 1/23/2023, noted resident to have a dressing dated 01/16/23 to the left lateral leg with dried blood and new blood. The wound physician reassessed the area on 1/24/2023 and provided a diagnosis of a stage IV [NAME] ulcer. It was determined that the adverse event response initiated in September 2022 with regards to the wound on the backside of Residents #16 left leg, was completed by the administrative team on 9/28/2022. However, monitoring of this event had not continued or been integrated into the quality assurance processes. Monitoring of pressure ulcers, prevention, identification of risk, providing wound care and dressing changes per physician orders, conducting thorough skin assessments, review of needed treatments from physician referrals regarding identified wounds, and ensuring physician all orders for wound care were followed had not consistently been audited or reported on during daily clinical meetings. All residents have the potential to be affected by the deficient practice. 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 completed As a part of the root cause analysis, the Corporate Chief Clinical Officer, Director of Clinical Services, Nurse Consultant, Regional Director of Operations, and Administrator conducted a review on 2/3/2023 of the policies for daily clinical and wound prevention and treatment. Based on this review, it was determined that reeducation on the daily clinical process was needed for the Administrator and Interim Director of Nursing. A review was conducted of the tools and work process for alerts with the Administrator and the Interim Director of Nursing. The Regional Clinical Consultant provided this education on 2/3/2023. This included the need for the Administrator and Interim Director of Nursing to use the tools provided by the corporate team for this process. A review of the work process for alerts in the clinical dashboard was also included. No changes were required to the policies. The facility failed to implement and follow through with the policies. The Regional Operations Director and the Quality Assurance Nurse Consultant will monitor ongoing compliance by attending this daily clinical meeting weekly for a minimum of six months. Regional Director of Operations and Quality Assurance Nurse Consultant determined on 2/2/2023 that the administrative team completed the adverse event response initiated in September 2022 on 9/28/2022. However, monitoring of this event had not continued nor integrated into the quality assurance processes. Monitoring of pressure ulcer prevention, identification of risk, providing wound care and dressing changes per physician orders, conducting thorough skin assessment, review of needed treatments from physician referrals regarding identified wounds, and ensuring physician orders for wound care had not consistently been audited or reported on during daily clinical meetings. On 2/3/2023, the Interim Director of Nursing and Administrator were educated on the need to adhere to the clinical review meeting objectives which including staying focused on adverse events that require ongoing monitoring have been addressed. The Quality Assurance (QA) Nurse Consultant completed this education on 2/3/2023. The clinical review meeting is a meeting held at least three times a week. This meeting is attended by the Administrator, Interim Director of Nursing, Wound Nurse, MDS Nurse, Dietary Manager, Social Services Director and Activities Director. During this meeting, the team reviews monitoring of pressure ulcer prevention, identification of risk, providing wound care and dressing changes per physician orders, conducting thorough skin assessment, review of needed treatments from physician referrals regarding identified wounds, and ensuring physician order for wound care. This information will be annotated on a form created specifically for this meeting and will be given to the Medical Director to review and initial. Then this form will be taken to the monthly Quality Assurance meeting to ensure continual compliance with policy. Additionally, on 2/3/2023 the QA Nurse Consultant reeducated the Interim Director of Nursing and Administrator on the need to review during the daily clinical meeting all orders since the previous daily clinical meeting. The Interim Director of Nursing will print the order listing report from the electronic health record by entering a date range and attach it to the daily clinical meeting form. If a dressing has a stop date identified, then the Interim Director of Nursing, Wound Nurse, or MDS Nurse should enter an additional order for the next day to remove the dressing and initial next to the specific order listing identifying it as corrected. Inter-Disciplinary Team (IDT,) consisting of Interim Director of Nursing, MDS Nurse, Director of Rehabilitation, Dietary Manager, RN Unit Manager, Wound Nurse, and Administrator, in daily clinical meeting should review the alerts dashboard for alerts related to existing pressure ulcers. If an alert for an existing pressure ulcer is identified, then the Interim Director of Nursing, Wound Nurse, or MDS Nurse should review the resident's assessment and chart to ensure that this wound has been previously assessed, is being seen by the Wound Physician, and has a wound care order. The IDT was educated on 2/6/2023 by the QA Nurse Consultant on the new process. This trigger will create an alert on the electronic medical record clinical main alert/overview screen that the IDT reviews as part of the daily clinical meeting whenever a nurse documents a new or existing wound on the skin check user defined assessment. The Interim DON will start the audits on 2/6/23 that focus on direct observation of the nurses accurately performing skin and wound assessments and wound treatments to assure compliance on all shifts to include weekends. On 2/3/2023, the Regional Director of Operations and the QA Nurse Consultant were onsite to provide supervision of the Interim Director of Nursing and Administrator to ensure implementation of this credible allegation and the credible allegation related to F686. This supervision will continue with weekly monitoring to ensure completion of the plans of correction, that the daily clinical process is occurring, timely identification of adverse events, and completed review by the IDT. The Regional Director of Operations and the QA Nurse Consultant will attend the monthly Quality Assurance Committee meetings either in person or remotely to ensure that compliance is being monitored and that adverse events are consistently reviewed during monthly QA. Alleged date of immediate jeopardy removal 02/07/23. On 02/07/23, the facility's credible allegation for Immediate Jeopardy removal effective 02/07/23 was validated by the following: The facility's creditable allegation for immediate jeopardy removal was validated by Administrator #1 and Director of Nursing (DON) #1 interviews and record review. Administrator #1 and DON #1 received re-education and in-serviced on 2/3/23 by the Quality Assurance Nurse Consultant. Policies were reviewed but there were no changes in facility's policies made. The in-servicing sign in sheets were reviewed for administration signatures. Validation of the education of the new process was completed by interviews with the Administrator #1, DON #1 Minimum Data Set (MDS) Nurse and Nurse Practitioner (NP) #1. Immediate jeopardy was removed on 2/7/23.