**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the National Pressure Ulcer Advisory Panel (NPUAP) information, and policy review, the facility failed to assess and identify pressure ulcers and failed to implement interventions and treatments to prevent the development and promote healing of pressure ulcers. The facility failed to identify multiple unstageable (blackened in color with necrotic tissue) deep tissue injuries (DTI), failed to contact the physician to implement treatments, resulting in worsening tissue damage and failed to follow infection control protocols during pressure ulcer dressing changes. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries when one resident (#286) was hospitalized with septic shock as she had a large Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed) sacral decubitus ulcer, as well as bilateral heel decubitus ulcers and a urinary tract infection. Additionally, Resident #20 developed an avoidable pressure ulcer to the left ankle that resulted in actual harm that was not immediate jeopardy as the pressure ulcer deteriorated to a Stage III (full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon or muscle are not exposed; slough may be present but does not obscure the depth of tissue loss). Furthermore, Resident #05 developed avoidable pressure ulcers that were not treated timely that placed the resident at risk for more than potential harm that was not immediate jeopardy. This affected three (Residents #286, #20 and #05) of five residents reviewed for pressure ulcers. The facility identified a total of six residents with pressure ulcers, three in-house acquired and three out of house acquired. The facility census was 89. On 11/09/22 at 1:04 P.M., Regional Director of Clinical Services (RDCS) #400, Director of Nursing (DON) #213 and Administrator #278 were notified Immediate Jeopardy began on 08/02/22 when Resident #286 was hospitalized with septic shock as she had a large sacral decubitus ulcer, as well as bilateral heel decubitus ulcers and a urinary tract infection. A Stage IV chronic sacral ulcer and a Stage III left heel ulcer was documented to be present on admission to the hospital. Prior to the hospitalization, the facility documented Resident #286 had only a sacral wound measuring 1.6 cm by 0.2 cm. and the skin around the wound was pink with fragile scar tissue. Resident #286's wounds continued to deteriorate, and she was hospitalized a second time for sepsis on 09/27/22 and received surgical debridement of a Stage IV ulcer to the coccyx. Additionally, Resident #20 developed an avoidable pressure ulcer to the left ankle that deteriorated to a Stage III and Resident #05 developed avoidable pressure ulcers that were not treated timely. The Immediate Jeopardy was removed on 11/11/22, when the facility implemented the following corrective actions: • On 11/10/22, Staff Development Nurse (SDN) #312, Minimum Data Set (MDS) Registered Nurse (RN) #232 and Case Manager Licensed Practical Nurse (CMLPN) #502 completed skin assessments on Residents #20, #05 and #286. • On 11/10/22, SDN #312, MDS Nurse #232, and CMLPN #502 notified the physicians of the updated assessments for Residents #05 and #20. • On 11/10/22, SDN #312, MDS Nurse #232, and CMLPN #502 completed audits of medical records for all residents with wounds to ensure appropriate physician orders were in place. • On 11/10/22, SDN #312, MDS Nurse #232, and CMLPN #502 completed an in-house audit of all residents with wounds to ensure that treatments were completed per physician order. No issues were identified. • On 11/10/22, SDN #312, MDS Nurse #232, and CMLPN #502 completed audits off all residents to ensure that pressure-relieving and offloading interventions were in place as per the plan of care. • On 11/10/22, SDN #312, MDS Nurse #232, and CMLPN #502 completed skin assessments of all remaining residents in the facility. • All nursing staff will be in-serviced by the Director of Nursing (DON)/Designee on or before 11/11/22 on identifying skin concerns/ulcers and reporting any skin concerns/skin ulcers to the nurse or physician, as appropriate, and off-loading and/or ensuring pressure-relieving interventions are implemented in accordance with the plan of care. Any staff members not in serviced by 11/11/22 will be removed from the schedule and not be permitted to work until in-service is completed. • All licensed nurses will be in-serviced by the DON/Designee on or before 11/11/22 on the policy and procedure for assessing/reassessing residents skin conditions, documentation of assessments, implementing treatments in accordance with the physician order, reviewing and revising care plans, accordingly, monitoring of skin and wound conditions and physician notification for the same, and the need to ensure correct physician orders are in the medical record. Any staff members not in serviced by 11/11/22 will be removed from the schedule and not be permitted to work until in-service is completed. • Beginning 11/12/22, the DON/Designee will audit all active residents with skin conditions, concerns, or skin ulcers to ensure pressure relieving interventions are in place, treatments are in place in accordance with the physician orders, assessments are current, and the physician has been notified of the current status of the wound. Audits will be completed 5 times a week for 4 weeks. All adverse findings will be referred to the Quality Assurance and Performance Improvement (QAPI) committee for review and recommendation. • During the survey on 11/14/22 through 11/16/22, the survey team verified interventions to prevent pressure ulcers and/or promote healing of pressure ulcers were in place for identified residents. Although the immediate Jeopardy was removed on 11/11/22, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of medical record for Resident #286 revealed an admission date of 10/25/19. Diagnoses included peripheral vascular disease, atherosclerosis of native arteries of extremities right and left, depression and dementia. Review of the care plan dated 11/04/20 revealed a Stage IV pressure ulcer to right heel with interventions to administer treatments as ordered and monitor for effectiveness, dressing as ordered, pressure relieving device to bed/chair, and monitor dressing to ensure intact and adhering. Review of a wound note dated 01/13/22 documented a Stage IV pressure ulcer present on admission from 05/04/21 to her right heel and an arterial ulcer to her left foot acquired in house on 08/17/21. No other wounds were documented. Resident #286 was hospitalized on [DATE] for concerns of dehydration since a Covid-19 infection and she returned to the facility on [DATE] after a hospitalization. The skin assessment on this date documented open, pink and red areas to her coccyx, with intact area in the middle of open areas, entire area measuring three inches by four inches. There was an area to her left heel measuring 3.0 centimeters (cm) by 0.5 cm by 0.75 cm and an area to her right heel measuring 8.0 cm by 5.0 cm by 0.5 cm. No further description of the wounds was documented. A care plan was created on 01/27/22 for a Stage IV sacral pressure ulcer with interventions to observe area, pressure reducing/relieving mattress and provide skin assessments. There was a physician order dated 01/25/22 for a pressure reducing cushion to chair when out of bed. Review of the wound consultation note dated 01/27/22 revealed documentation of an unstageable sacral wound measuring 7.0 cm by 6.0 cm with a wound base of 90 percent eschar and 10 percent granulation tissue. The resident had a Stage IV pressure ulcer to the right heel measuring 2.5 cm by 2.5 cm by 0.2 cm. The resident had an arterial ulcer to her left foot measuring 0.8 cm by 0.2 cm by 1.0 cm. The resident was seen weekly and on 07/28/22, the wound consultation note documented the sacral wound as improved, measuring 1.6 cm by 0.2 cm and the skin around the wound was pink with fragile scar tissue. There was no mention of any wounds to the feet. Review of a progress note dated 08/02/22 documented the nurse was alerted that Resident #286 was lethargic with a heart rate of 117 beats per minute and oxygen saturation was 90 to 92 percent on room air. Certified Nurse Practitioner (CNP) #403 was notified with the change in condition and orders were received to send the resident to the hospital for further evaluation. Review of the hospital discharge summary documented the resident was hospitalized from [DATE] through 08/07/22 with septic shock, sepsis infection multifactorial as she had a large sacral decubitus ulcer, as well as bilateral heel decubitus ulcers and a urinary tract infection. A Stage IV chronic sacral ulcer and a Stage III left heel ulcer was documented to be present on admission to the hospital. Magnetic Resonance Imaging (MRI) of both feet did not reveal osteomyelitis and the sacral ulcer was evaluated by surgery who did not feel further debridement was needed. Review of the admission skin assessment dated [DATE] revealed documentation of a Stage III pressure ulcer on the resident's right heel, left heel and coccyx. No other skin concerns were documented. The care plan for skin integrity, dated 08/07/22, documented interventions including education of the resident and family of causative factors for prevention, encourage good nutrition, keep skin clean and dry, monitor/document location, size and treatment of skin injury and report any abnormalities. Pressure ulcer interventions included pressure reducing device on bed and chair, barrier cream, positioning with pillows and reposition frequently. Review of the progress note dated 08/09/22 revealed CNP #403 assessed Resident #286 and documented an area on the resident's right hip as a deep tissue injury measuring 6.0 cm by 6.0 cm with the surrounding tissue warm to the touch. Concern was documented the area could easily evolve into something more significant. Wound consult and offloading were ordered. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/11/22, revealed Resident #286 was moderately cognitively impaired. She required extensive two-person assistance for transfers, dressing, toileting, one person assistance for bed mobility and for personal hygiene and supervision for eating. The skin section of the MDS documented one unstageable area and three unstageable Stage IV (muscle and or bone visible) pressure areas which were not present on admission. Review of the wound note dated 08/11/22 revealed Wound Nurse Practitioner (WNP) #404 documented an unstageable wound to the left ischium measuring 3.6 cm by 2.9 cm by 0.3 cm and a deep tissue injury to the right hip measuring 7.0 cm by 8.0 cm. Also documented was a Stage IV sacral wound measuring 0.6 cm by 4.0 cm by 1.0 cm. Review of the physician orders revealed an order dated 08/11/22 to cleanse left ischium with Dakin's solution, pat dry, apply Prisma, a cellulose, collage and silver nitrate dressing, and cover with Optifoam, an occlusive dressing daily. There was no documentation this was completed on 08/13/22, 08/14/22, 08/22/22, 08/23/22, 08/25/22, 08/31/22, 09/02/22, 09/06/22, 09/07/22 and 09/08/22. The order was discontinued on 09/15/22. Review of the physician orders revealed an order dated 08/11/22 for Optifoam every other day to the right hip. There was no documentation this was completed on 08/14/22 or 08/22/22. The order was discontinued on 09/01/22. Review of the Braden scale for predicting pressure score risk, dated 08/14/22, revealed Resident #286 scored a 12, high risk for developing pressure ulcers. Review of the wound progress note dated 09/01/22 revealed a Stage IV pressure ulcer to the sacrum measuring 2.6 cm by 1.2 cm by 1 cm, serosanguinous drainage noted, no odor present. Continue to cleanse with Dakin's solution, pat dry, apply Prisma and cover with Optifoam. Right heel Stage IV pressure area has resolved. Unstageable pressure ulcer to right hip measuring 7.2 cm by 5.0 cm, eschar present, area noted with serosanguinous drainage and foul odor. Cleanse area with normal saline, pat dry, apply calcium alginate, cover with Optifoam change every other day and as needed (PRN). Unstageable pressure ulcer to left ischium measuring 2.0 cm by 2.0 cm by 2.3 cm, serosanguinous drainage noted, foul odor noted. Continue to cleanse area with Dakin's solution, pat dry, apply Alginate, cover with Optifoam and change daily and PRN. Resident #286 did have complaints of pain to feet during assessment. Record review of the wound progress note dated 09/08/22 revealed a Stage IV pressure ulcer to the sacrum measuring 4.0 cm by 2.0 cm by 1.0 cm, serosanguinous drainage noted, no odor present. Continue cleanse with Dakin's solution, pat dry, apply Prisma and cover with Optifoam. Right heel Stage IV pressure area reopened, measuring 3.5 cm by 3.1 cm by 0.1 cm serosanguinous drainage present. New order to cleanse area with Dakin' s, apply Prisma, cover with Optifoam and change daily and PRN. Unstageable pressure ulcer to right hip measuring 7.0 cm by 5.0 cm, eschar present, area noted with serosanguinous drainage and foul odor. Cleanse area with normal saline, pat dry, apply calcium alginate, cover with Optifoam change daily and PRN. Unstageable pressure ulcer to left ischium measuring 2.0 cm by 2.0 cm by 2.0 cm, serosanguinous drainage noted, foul odor noted. Orders were to continue to cleanse area with Dakin's solution, pat dry, apply Alginate, cover with Optifoam and change daily and PRN. Resident #286 did have complaints of pain to feet during assessment. Review of practitioner note by CNP #403, dated 09/13/22, revealed a concern for increased purulent wound drainage with increased odor. A Complete Blood Count (CBC), Complete Metabolic Panel (CMP), Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) laboratory tests were ordered as well as an antibiotic, Keflex, 500 milligrams (mg) for seven days. Resident #286's Power of Attorney (POA) was contacted and updated on the significant worsening condition of the wounds, concerns for osteomyelitis, sepsis and gangrene secondary to her severe peripheral artery disease. Recommendations of code status change (currently full) and hospice referral was made, discussion of quality versus quantity of life for this resident. Review of wound progress note dated 09/15/22 revealed a Stage IV pressure ulcer to the sacrum measuring 3.0 cm by 1.8 cm by 1.0 cm, serosanguinous drainage noted, no odor present. Continue to cleanse with Dakin's solution, pat dry, apply Prisma and cover with Optifoam. Right heel Stage IV pressure area reopened, measuring 3.0 cm by 3.0 cm by 0.1 cm, serosanguinous drainage present. Continue to cleanse area with Dakin's, apply Prisma, cover with Optifoam change daily and PRN. Unstageable pressure ulcer to right hip measuring 8.0 cm by 6.0 cm by 3.0 cm, area debrided this visit, area noted with purulent drainage and foul odor. Order to cleanse area with normal saline, pat dry, apply silver alginate, cover with Optifoam change daily and PRN. Unstageable pressure ulcer to left ischium measuring 2.0 cm by 2.0 cm by 2.6 cm, area was debrided this visit, purulent drainage noted, foul odor noted. New order to cleanse area with Dakin's solution, pat dry, pack loosely with Dakin's-soaked gauze, cover with Optifoam, change daily and PRN. Resident #286 complained of severe generalized pain, Physician #406 was in the facility and updated. Review of the provider note by CNP #403, dated 09/16/22, revealed an acute visit was made on this date. Pain medication was adjusted from Oxycodone to long-acting OxyContin ten milligrams twice daily and every four hours as needed. Discussion was had with Resident #286 regarding advanced care planning, poor nutritional intake to aid in wound healing, ongoing weight loss and severe vascular impairment to no avail. The note revealed communication with the POA, who did speak to Resident #286 regarding code status and no decision was made. He was informed of the concern for sepsis/bacteremia and the need for a potential hospital transfer to rule out osteomyelitis and further treatment if Resident #286 remained a full code. Review of the wound progress note dated 09/23/22 revealed a Stage IV pressure ulcer to the sacrum measuring 7.0 cm by 5.0 cm by 2.8 cm, purulent drainage noted, slight odor present. Continue to cleanse with Dakin's solution, pat dry, apply Prisma and cover with Optifoam. Right heel Stage IV pressure area reopened, measuring 3.0 cm by 3.0 cm by 0.1 cm, serosanguinous drainage present. Continue to cleanse area with Dakin's solution, apply Prisma, cover with Optifoam, change daily and PRN. Unstageable pressure ulcer to right hip measuring 8.0 cm by 6.0 cm by 2.5 cm, area noted with purulent drainage and foul odor. Cleanse area with normal saline pat dry, pack lightly with Dakin's-soaked gauze, cover with Optifoam change daily and PRN. Unstageable pressure ulcer to left ischium measuring 2.0 cm by 2.5 cm by 2.6 cm, purulent drainage noted, foul odor noted. Continue to cleanse area with Dakin's solution, pat dry, pack loosely with Dakin's-soaked gauze, cover with Optifoam, change daily and PRN. Resident #286 complained of severe generalized pain. WNP #404 was in the facility and was updated. New order was written to culture wounds of the right hip and left ischium. Review of progress note dated 09/27/22 revealed resident was found incoherent and difficult to arouse, pulse was 102 beats per minute and oxygen saturation was 77 percent. The nurse practitioner was notified and orders to send to the hospital were received. Review of the hospital documentation revealed Resident #286 was hospitalized from [DATE] to 10/06/22 for sepsis, end organ encephalopathy, urinary tract infection, pneumonia and infection of decubitus ulcers. The history of present illness documented Resident #286's family member voiced concern the care at the nursing facility has worsened since a management change and the resident had not received assistance with her activities of daily living, as turning and repositioning and has had an overall decline over the last three weeks. The skin assessment documented decubitus ulcers to heel, hips and buttocks which were draining green purulent, foul-smelling discharge. A surgical debridement of the sacral ulcer with involvement of underlying bone was performed on 09/29/22. Review of the hospital documentation revealed Resident #286 was admitted to long term acute care facility (LTAC) from 10/06/22 until 10/26/22 for osteomyelitis and continued wound support. She returned to the nursing facility on 10/26/22. Review of the care plan for skin integrity revealed interventions dated 10/28/22 of pressure relieving cushion to chair when out of bed, pressure reduction mattress to the bed and moon boots to both feet while in bed. During an interview on 11/02/22 at 10:51 A.M., Resident #286 stated she had complaints of pain in her feet. Upon questioning, State Tested Nurse Assistant (STNA) #202 stated she had turned Resident #286 around 7:00 A.M. at the start of the shift. She further shared she had been the only STNA until recently and it has been a crazy day, a new resident was admitted , and she had to give report and was unable to turn and or reposition Resident #286. Observation on 11/07/22 at 1:58 P.M. of the dressing change for Resident #286 by Licensed Practical Nurse (LPN) #600 revealed she removed the left heel dressing. Without changing her gloves, she applied Dakin's solution to the nickel sized ulcer and patted it dry. She removed her gloves and donned clean gloves without sanitizing her hands. She applied Calcium Alginate to the wound and wrapped the foot in Kerlix. The same dressing change was done to the right heel, but with proper hand hygiene and glove changing. LPN #600 removed the dirty dressings from the right hip, left hip and ischium. She did not change her gloves or sanitize her hands in between wound sites. LPN #600 stated there was no physician order to treat the wound on the ischium. She applied the same treatment to the left ischium as she did to the left hip of cleansing with Dakin's solution, calcium alginate and ABD pad to both the left hip wound and the ischium. During interview after the completion of the dressing change, LPN #600 stated she did not use proper hand hygiene or change her gloves intermittently during the dressing change. During an interview on 11/07/22 at 4:40 P.M., DON #312 and RDCS #400 stated nursing staff are doing weekly skin assessments to address any new skin concerns but are not documenting on known skin issues. RDCS #400 stated it is the expectation of the facility nurses document wound and drainage assessment with each dressing change and verified this had not been completed. During an interview on 11/08/22 at 9:54 A.M., Registered Nurse (RN) #312 stated she does rounds with WNP #404 and puts the orders into the electronic charts for residents. She stated she is new to the position, hired within the last two months. She verified for Resident #286 there was on order for bilateral hips to cleanse with normal saline, apply calcium alginate and cover with Optifoam. There were also separate orders for each hip. For the left hip, cleanse with normal saline, apply calcium alginate and cover with Optifoam. For the right hip, cleanse with Vashe wound cleanser, pat dry and cover with an ABD pad. There was an order for the sacrum and the coccyx in the electronic chart for Resident #286 and verified although the treatment was the same, due to the number of pressure wounds this may cause confusion. RN #312 verified there were no wound orders in the electronic charting system for the left ischium wound. She further acknowledged wounds assessments/description and drainage assessments/description should be documented with each dressing change to determine a decline. This is a known concern, and the use of agency makes continuity more difficult. During interview on 11/08/22 at 2:07 P.M., WNP #404 stated she did not have a concern for Resident #286's sacral wound when she saw her on 07/28/22. WNP #404 stated the facility became aware of a Stage III ulcer to Resident #286's left heel prior to her next scheduled wound visit on 08/04/22. She was unclear if the facility found it after her 07/28/22 visit, or the hospital reported it; however, it caused the facility to perform a skin sweep of all residents resulting in six new wound referrals. Upon review, there was no documentation of a Stage III ulcer to the left heel for Resident #286 in her electronic chart prior to her hospitalization on 08/02/22. 2. Review of medical record for Resident #20 revealed an admission date of 03/13/17. The resident was admitted with diagnoses including stroke, anxiety, unspecified dementia, hemiplegia and hemiparesis of left non-dominant side. Review of the weekly skin assessment dated [DATE] revealed a new area was discovered to the left outer ankle. It was described as a small opening measuring 0.3 cm by 0.3 cm by 0.1 cm. There was no further documentation of the wound. The medical record contained no physician notification or treatment orders for this pressure ulcer on 08/02/22. Resident #20 was admitted to hospice on 08/03/22. Review of the wound note dated 08/04/22 revealed the left lateral ankle was documented as unstageable measuring 2.0 cm by 2.0 cm and described as non-blanching, deep purple discoloration. A care plan for deep tissue injury dated 08/04/22 revealed individualized interventions which included monitoring and documentation of wound size and description of wound and drainage, treat wound as per facility protocol and position resident off the affected area. A Braden scale for pressure ulcer risk was completed on 08/05/22. The resident scored an 11, which was high risk. The significant change MDS assessment dated [DATE] revealed the resident was severely cognitively impaired. She required extensive two-person assistance for bed mobility, one person assistance for eating and total dependence for toileting. The MDS indicated one deep tissue injury which was not present upon admission. A Braden scale for pressure ulcer risk was completed again on 08/21/22. The resident scored 14, which was high risk. Review of the progress note dated 10/10/22 revealed CNP #403 assessed Resident #20's left ankle and found no signs or symptoms of cellulitis with orders to continue previously ordered Keflex (antibiotic), as it appeared to be effective. The resident's pressure reducing boot (moon boot) was completely saturated with skin debris, evidence of dried blood and scabs covering the entire bottom of the moon boot with the boot itself having a significant odor. Instructed nursing staff to throw these away and to order new moon boots as these would only increase risk of infection with evidence of poor skin care/maintenance. Review of the wound note dated 10/13/22 revealed documentation the wound was a Stage III pressure ulcer and measured 2.5 cm by 1.3 cm by 0.2 cm with a moderate amount of serosanguinous exudate. On 10/27/22, the wound measured 1.0 cm by 1.0 cm by 1.0 cm with a moderate amount of serosanguinous drainage present and was documented as improved. During interview on 11/07/22 at 4:40 P.M., RDCS #400 and DON #213 verified there was no documentation on 08/02/22 the physician was notified, or a treatment was put into place after an assessment of a new skin issue, to prevent further avoidable skin damage. 3. Record review revealed Resident #05 was admitted on [DATE]. Medical diagnoses included acute and chronic respiratory failure, neurogenic bladder, Parkinson's disease, and malnutrition. Review of the Braden Scale for pressure ulcer risk, dated 07/13/22, revealed Resident #05 scored a 13, indicating moderate risk for developing a pressure ulcer. Review of the care plan, dated 07/14/22, revealed there was an unstageable pressure ulcer to the sacrum. Interventions were to avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident and family of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration to promote healthier skin. Follow facility protocols for treatment of injury, keep skin clean and dry. Use lotion on dry skin. Monitor and document location, size, and treatment of skin injury. Report any abnormalities, failure to heal, signs and symptoms of infection or maceration to the physician. Provide pressure relieving/reducing mattress, pillows, sheepskin padding to protect skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. Review of the admission MDS assessment, dated 07/18/22, revealed Resident #05 was cognitively intact. She was totally dependent on two persons for all activities of daily living. She had an indwelling urinary catheter and was frequently incontinent for bowel. She had one Stage II pressure ulcer. She was on oxygen, required suctioning, tracheostomy, and a mechanical ventilator. Review of the skin assessment dated [DATE] revealed an unstageable wound to the sacrum that measured 2.0 cm by 2.0 cm by 0.1 cm with light serosanguinous drainage that was present upon admission. There wasn't another documented skin assessment until 11/01/22. Review of the medical record for Resident #05 from 09/26/22 through 10/16/22 revealed there wasn't any documentation for turning and repositioning. Review of progress note dated 10/02/22 written by RN #242 revealed there was a new open wound observed on the mid-right back and redness to the mid left back for Resident #05. There was no further description of the wound. The open wound was cleaned with normal saline and left open to air. Review of the physician orders and the treatment administration record (TAR) from 10/02/22 through 10/07/22 revealed no order or treatment to the area on the back. Review of progress notes dated 10/07/22 revealed WNP #404 documented an open wound to the mid right back that measured 3.0 cm by 3.0 cm with no depth. The wound was non blanching deep purple tissue with no drainage, induration, crepitus, or edema noted. The wound was cleaned with normal saline and an Optifoam dressing was placed. An intervention was implemented to turn Resident #05 from side to side. Review of the physician orders revealed no order for a treatment to the open wound to the right mid back. Review of progress note dated 10/12/22 at 1:57 A.M. documented to make sure WNP #404 was notified to see Resident #05's right ear for suspected pressure ulcer. At 1:53 P.M., CNP #405 ordered the right ear cleansed with normal saline, pat dry, apply calcium alginate and cover with Optifoam. Place rolled towel in between right ear and shoulder and to be seen by WNP #404. Review of progress notes dated 10/13/22 revealed WNP #404 did not assess the wound on the Resident #05's ear. She discovered the wound on Resident #05's coccyx which was DTI measuring 2 cm by 1.8 cm by 0.1 cm. This wound was non blanching deep/red purple discoloration no induration, no crepitus, or edema. Cleanse with normal saline, pat dry, apply calcium alginate and cover with Optifoam. Review of the physician orders revealed the treatment recommended by the wound nurse practitioner was not implemented. Review of the treatment administration record (TAR) for October 2022 revealed no documentation any treatments were provided to the back, ear or coccyx wounds. Resident #05 went out to the hospital on [DATE] and returned on 10/31/22. Review of the skin assessment dated [DATE] revealed Resident #05 had a chronic sacral wound measuring 5.0 cm by 4.0 cm by 0.1 cm, unstageable; a coccyx wound measuring 5.5 cm by 2.5 cm by 0.1 cm; a right upper/mid back wound measuring 9.5 cm by 7.0 cm by 0.1 cm; a right outer ankle wound measuring 3.0 cm by 3.0 cm by 0.1 cm; a right foot wound measuring 1.0 cm by 1.0 cm with no depth; and a right ear wound measuring 1.5 cm by 2.5 cm by 0.1 cm. During observation of Resident #05 on 11/01/22 at 2:06 P.M., she did not have any pressure relieving padded boots on her feet. She was on a pressure relieving mattress. During observation on 11/02/22 at 9:11 A.M, Resident #05 was in bed on her left side. At 11:23 A.M., dressing changes were completed by RN #232 and LPN #405 on all wounds. There was a new wound on the left lateral foot that was not blanching, and it was oval size and reddened. The nurse did not measure the area at this time. Resident #05 was placed back on her left side. There was no pressure relieving device applied to her feet. During observation at 2:57 P.M., Resident #05 was still on her left side. RN #232 was questioned about the turning schedule for Resident #05. At this questioning, RN #232 turned the resident to her right side. She still did not have any pressure relieving devices applied to her feet. Interview with LPN #405 on 11/02/22 at 2:57 P.M. confirmed the resident had not been turned every two hours from side to side. She had been positioned on her left side for six hours. During observation on 11[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Observation on 11/07/22 from 1:09 P.M. through 1:29 P.M. in the Cypress, [NAME] View, Pine Glen and Juniper unit kitchenettes, revealed steam table wells at wheelchair height directly open to a walk-through corridor. There were no sneeze guards or barriers from the steam table edge of eight inches, to the corridor counter edge, where residents were passing by the steam table. Foods were being served from the steam table. Observation on 11/07/22 at 1:40 P.M. of Cypress, [NAME] View, Pine Glen and Juniper unit kitchenettes, after meal service was completed, revealed no barrier between the kitchenettes and adjacent resident dining area. Three steam table controls were exposed and two carafes of hot coffee were unattended. During interview on 11/07/22 at 1:55 P.M., Maintenance Director #220 stated the steam table controls should be covered with a counter cover made with a lock. Maintenance Director #220 demonstrated the steam table cover counter cover with lock. He verified the kitchenette staff should use the steam table counter cover after each meal to prevent residents from entering the kitchenette and turning on the steam table. He verified the coffee carafes were accessible to ambulating and wheel chair residents and could be a hazard with hot coffee. During interview on 11/08/22 at 3:35 PM, Diet Manger #233 verified the kitchenette is not secured with any barrier or gate. She further verified the steam table control covers for knobs not covered or locked by the steam table cover. She stated it was too difficult to put on and take off the steam table covering between meal service and verified residents could turn on the steam table. DM #23 also verified the steam table was accessible at wheelchair height from a resident in the corridor and could reach into the steam table during meal service. She verified the steam table was accessible to respiratory droplets from anyone passing through the corridor. DM #223 verified a resident could reach up and remove the coffee urn off of the coffee maker. During observation on 11/09/22 at 7:41 AM, the Pine Glen kitchenette steam table covers were not in place, exposing the steam table knobs and two carafes full of hot coffee. No staff were in the kitchenette. During interview on 11/09/22 at 7:45 AM, Diet Server #269, who was in the Juniper Unit kitchenette, stated there was no steam table covering when she arrived in the kitchenette on this date. She verified the steam table covers do not lock well and are not put onto the steam table after meal service. During interview on 11/09/22 at 8:16 AM, Diet Server #296, who was in the Pine Glen kitchenette, verified the steam table covers were not on when she arrived in the kitchenette on this date and had not been in place since the previous dinner meal. During observation on 11/15/22 at 12:07 PM, Resident #59 was near the Cypress unit kitchenette asking the surveyor for coffee. There were no staff in the kitchenette. The resident stated he was legally blind and knew there was coffee in the kitchenette. During observation on 11/16/22 at 10:12 AM, the [NAME] View kitchenette steam table covers were not on to cover the exposed steam table controls and there were two carafes of hot coffee accessible to residents. No staff were in the kitchenette. Based on medical record review, review of fall investigations, observations, staff interviews, and review of facility policy on falls, the facility failed to adequately assess the root cause of falls, identify trends and patterns of falls, implement appropriate fall prevention interventions, assess the effectiveness of interventions, ensure previously implemented interventions were in place, and failed to update care plans timely for fall interventions for Residents #11, #29, #38, and #61. This resulted in Immediate Jeopardy when Resident #29 sustained a fall on 01/29/22 that caused a head laceration, which was repaired with skin glue. On 07/03/22, Resident #11 fell and fractured her clavicle. On 08/21/22, Resident #38 fractured her hip during a fall. On 09/18/22, Resident #61 sustained a fall that resulted in a nasal fracture. This affected four (Residents #11, #29, #38, and #61) out of seven residents reviewed for falls. The facility also failed to ensure steam table covers were applied to prevent residents turning on the steam table when the kitchenette was not in use. This affected the Cypress, [NAME] View, Pine Glen and Juniper unit kitchenettes. The census was 89. On 11/09/22 at 1:04 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services (RDCS) #400 were notified Immediate Jeopardy began on 01/29/22 when the facility failed to thoroughly investigate and conduct a root cause analysis to prevent the same actions, situations, and/or practices from occurring in the future to prevent further falls for after Resident #29 sustained a laceration to the head from a fall that required skin glue for repair. On 07/03/22, Resident #11 fractured her clavicle during a fall. On 08/21/22, Resident #38 sustained a hip fracture during a fall that required surgical intervention. On 09/18/22, Resident #61 fell and sustained a nasal fracture. The Immediate Jeopardy was removed on 11/14/22 when the facility implemented the following corrective actions: • On 11/10/22, the floor nurses, Staff Development Nurse (SDN) #312, Minimum Data Set (MDS) Registered Nurse (RN) #232, and Case Manager (CM) Licensed Practical Nurse (CMLPN) #502 completed fall risk assessments on Residents #11, #29, and #38. • On 11/10/22, the Director of Nursing (DON), RDCS #400, and Director of Quality (DOQ) #401 reviewed and revised the care plans for Residents #11, #29, and #38 to ensure fall prevention interventions are in place and consistent with the resident's fall assessment and prior fall reviews. • On 11/10/22, the DON, RDCS #400, and DOQ #401 reviewed all resident falls that occurred in the last 30 days to ensure that the falls were thoroughly investigated, and they were reviewed for trends or patterns and root cause analysis was completed. The DON, RDCS #400, and DOQ #401 also reviewed to ensure care plan interventions put in place after the fall were appropriate and consistent with the fall review and root cause. • On 11/10/22, the Administrator reviewed and revised the Facility Assessment to ensure supervision is provided by staff based on resident acuity and needs. • On 11/11/22, the floor nurses, SDN #312, MDSRN #232, and CMLPN #502 completed fall risk assessment on all other residents. • On 11/11/22, the Interdisciplinary Team (IDT) which consisted of Business Office Manager (BOM) #276, Maintenance Director (MD) #220, Housekeeping Director (HD) #229, Dietary Technician (DT) #251, Human Resource Coordinator (HRC) #263, Nutrition Service Supervisor (NSS) #233, Activities Director (AD) #314, Business Development (BD) #246, Social Services Coordinator (SSC) #218, SDN #312, MDSRN #232, CMLPN #502 and the Administrator were in serviced by the RDCS #400, on the need to ensure that the facility thoroughly investigates all falls to determine the root cause, reviewing for trends or patterns, and the need to assess the appropriateness of interventions put in place after the fall in an effort to prevent the same action, situation, and/or practice from occurring in the future. The IDT will establish an appropriate fall intervention based on the root cause analysis of each fall. • On 11/11/22, the IDT was in serviced by the RDCS #400 on the need to ensure care plans are reviewed and revised as needed after every fall to ensure fall prevention interventions are developed and implemented for each fall. • All licensed nursing staff will be in serviced on or before 11/11/22 by the DON/Designee on the need to ensure all falls are thoroughly investigated and that the care plans are reviewed and revised after each fall with appropriate interventions, consistent with the investigation, root cause analysis and any trends or patterns identified in the investigation. Any staff members not in serviced by 11/11/22 will be removed from the schedule and not be permitted to work until the in service is completed. • All nursing staff will be in serviced on or before 11/11/22 by the DON/designee on the need to ensure all fall prevention interventions are implemented in accordance with the plan of care, including adequate supervision based on the resident's acuity and needs. Any staff members not in serviced by 11/11/22 will be removed from the schedule and not be permitted to work until in service is completed. • Beginning 11/12/22, the DON or designee will audit all resident falls to ensure that they are thoroughly investigated, trends or patterns are identified, if applicable, and post fall interventions are appropriate and consistent with the investigation and the root cause analysis and fall prevention interventions, including supervision, is being implemented in accordance with the plan of care. The random audits will be done 5 times a week for 4 weeks. All adverse findings will be referred to the Quality Assurance and Performance Improvement (QAPI) committee for review and recommendation. • On 11/14/22, the DON, RDCS #400, SDN #312, MDSRN #232, and CMLPN #502 reviewed and revised the care plans for all other residents in the facility to ensure fall prevention interventions are in place and consistent with the resident's fall assessment and prior fall reviews. • Observations on 11/16/22 from 12:10 P.M. through 12:30 P.M. revealed fall prevention interventions were in place for Residents #11, #29, #38, and #81. Observations on 11/03/22 from 8:04 A.M. through 4:05 P.M., 11/07/22 at 12:49 P.M., and 11/08/22 at 8:57 A.M. revealed fall interventions were in place for Resident #61. Resident #64 had interventions to call for assistance and proper footwear; however, the resident was not observed out of bed. • Review of the medical records for Residents #11, #29, #38, and #81 were reviewed for updated fall risk assessments and care plan revisions. • Interviews on 11/16/22 from 12:20 P.M. through 12:30 P.M. with Licensed Practical Nurse (LPN) #405, LPN #219, and State Tested Nursing Assistant (STNA) #202 revealed they had all been educated on the fall policy recently and were knowledgeable regarding the fall protocol at the facility. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #29 revealed she was admitted to the facility on [DATE]. Diagnoses included cerebral atherosclerosis, poly-osteoarthritis, spondylosis without myelopathy or radiculopathy, lumbar region, mixed hyperlipidemia, hypothyroidism, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and hypertensive heart disease with heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/15/22, revealed this resident had severely impaired cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, personal hygiene, toileting, and supervision for eating. Review of the plan of care for Resident #29, initiated 07/02/20, revealed the resident was at high risk for falls related to multiple falls. Interventions included anticipate and meet resident needs, review information on past falls and attempt to determine cause of falls, record root causes, alter/remove any potential causes if possible, educate resident/family/caregivers/IDT as to causes, educate resident on use of call light, bed in lowest position at all times except during care, ensure resident has fresh water, resident to reside on memory care unit to give greater supervision, administer meds as ordered, resident places self on the floor, visual reminders in bathroom to remind resident to call for help when toileting/transferring, visual reminders in room to remind resident to call for help with transfers/toileting, non-skid footwear to be worn at all times and floor mats next to bed while resident is in bed. The intervention for floor mats was canceled on 08/05/22. Additionally, staff were to encourage resident to call for help when she needs to reach an item in the closet, Dycem (anti-slip mat/pad) to wheelchair, and physical therapy referral. There was also an intervention for the resident to wear a soft helmet while out of bed, which was created on 09/16/20 and canceled on 04/13/21. The intervention of the soft helmet when out of bed was added to the plan of care again on 11/02/21 and canceled on 11/10/21. Review of the assessment titled Nursing Fall Review, dated 01/11/22, revealed Resident #29 was at moderate risk for falls. Review of the progress notes for 01/25/22 revealed no documentation related to a fall on this date. Review of the fall investigation, dated 01/25/22, revealed maintenance staff reported Resident #29 was on the floor. Resident #29 was observed lying on the floor on her left side near the bathroom door. Resident #29's arms were out in front of her, and she had a small amount of blood on her left hand as well as an egg sized knot on her left temple. The investigation indicated the resident was alert to herself and was lifted to her wheelchair by staff. Vitals were obtained and the nurse practitioner was notified as well as the resident's family. Review of the assessment titled Nursing Fall Review, dated 01/25/22, revealed it was unknown what Resident #29 was doing at the time of the fall. An immediate intervention was not documented. Review of the progress note, dated 01/26/22, revealed the interdisciplinary team met to discuss Resident #29's fall on 01/25/22. It was noted Resident #29 was referred to physical therapy. There was no documentation related to the root cause of the fall. Review of the progress note, dated 01/29/22, revealed Resident #29 was found lying on her left side on the floor of her room. Resident #29 was observed to have a laceration on the back of her head on the left side. The on-call provider was notified of the laceration and gave an order to send Resident #29 out to the hospital. The note indicated Resident #29 was unable to describe what she was doing when the fall occurred. Review of the assessment titled Nursing Fall Review, dated 01/29/22, revealed not applicable was documented for what the resident was doing at the time of the fall. The immediate intervention was non-skid socks and call light. Review of the fall investigation, dated 01/29/22, revealed the nurse was walking by the resident's room and observed the resident lying on the floor and bleeding from her head. Resident #29 was unable to explain what she had been doing at the time of the fall. Review of the progress note, dated 01/29/22, revealed Resident #29 returned to the facility from the hospital, and the laceration on her head had been closed with Dermabond (skin glue), which would fall off in the next ten to 14 days. Review of the progress note, dated 01/31/22, revealed the interdisciplinary team met to discuss Resident #29's fall on 01/29/22. The note indicated interventions continue and remain appropriate. There was no documentation regarding a root cause analysis of the fall. Review of the progress note, dated 02/12/22, revealed Resident #29 was sent to the hospital after she fell out of bed and hit her head on the nightstand by the bed and floor. Review of the assessment titled Nursing Fall Review, dated 02/12/22, revealed Resident #29 was getting out of bed at the time of the fall. Immediate interventions were documented as vitals taken, range of motion assessed, and family and doctor notified. Review of the fall investigation, dated 02/12/22, revealed an aide alerted the nurse that Resident #29 was in her room and on the floor. The investigation indicated the nurse and aide assessed Resident #29, the nurse called the physician and family, and the resident was transported to the hospital. Review of the progress note, dated 02/13/22, revealed Resident #29 returned from the hospital with a hematoma on her forehead and sutures to a laceration on the scalp. Resident #29 had a new order to remove sutures on 02/19/22. The note indicated frequent checks were in place and staff would continue to monitor. Review of the progress note, dated 02/17/22, revealed the interdisciplinary team met to discuss Resident #29's fall on 02/12/22. It was noted interventions continue and remain appropriate. There was no documentation related to the root cause of the fall. Review of the progress note, dated 02/28/22, revealed Resident #29 had an unwitnessed fall and was found by aides sitting on the floor in the hall next to a room. A head-to-toe assessment was completed, the nurse practitioner, DON, and family were notified. Resident #29 was transferred to the hospital due to an open laceration on the back of the head. Review of the assessment titled Nursing Fall Review, dated 02/28/22, revealed Resident #29 was attempting to transfer self at the time of the fall on 02/27/22. The immediate intervention was a head-to-toe assessment. Review of the fall investigation, dated 02/28/22, revealed Resident #29 had an unwitnessed fall outside of her room, was confused, and attempted to transfer herself. Review of the progress note, dated 02/28/22, revealed the interdisciplinary team met to discuss Resident #29's fall on 02/27/22. The note indicated the resident was sent to the emergency room for a laceration to the head and returned to the facility with staples. A referral for physical and occupational therapies was submitted. The note also revealed other interventions continue and remain appropriate. There was no documentation related to the root cause of the fall. Review of the progress note, dated 04/09/22, revealed Resident #29 was observed on the floor of the room and was bleeding from a laceration on the back of her head. There is no documentation regarding any medical treatment provided to Resident #29 to address the bleeding. Review of the assessment titled Nursing Fall Review, dated 04/09/22, revealed it was unable to be determined what Resident #29 was doing at the time of the fall. The immediate intervention was head-to-toe assessment, neuro checks, and vitals. Review of the fall investigation, dated 04/09/22, revealed Resident #29 was observed on the floor and was bleeding from the back of her head. The immediate action taken included head-to-toe assessment, vitals, and neuro checks. Review of the progress notes from 04/09/22 through 04/12/22 revealed no documentation of follow-up from the interdisciplinary team regarding the fall on 04/09/22, including a root cause analysis of the fall. Review of the progress note, dated 04/12/22, revealed a call was placed to Resident #29's responsible party regarding a fall. There is no documentation regarding the details of the fall on this date. Review of the assessment titled Nursing Fall Review, dated 04/12/22, revealed Resident #29 was unable to explain what she was doing at the time of the fall. The immediate intervention was assessment of body for wounds. Review of the fall investigation, dated 04/12/22, revealed Resident #29 was found on the floor in the hall. The investigation indicated the nurse practitioner was observed next to the resident. Resident #29 was noted with an injury to the left temple with some bleeding and swelling. Resident #29 was unable to describe what happened at the time of the fall. Review of the plan of care for falls revealed an intervention of a medication review request was added on 04/12/22. Review of the progress note, dated 04/13/22, revealed Resident #29 was found on the floor at the foot of the bed by an aide. Resident #29 was noted to be lying on her left side and was barefoot. The call light was noted to be in reach and not on. Resident #29 was observed to have a skin tear to the left temple with some blood. Review of the assessment titled Nursing Fall Review, dated 04/13/22, revealed Resident #29 was self-ambulating at the time of the fall. The immediate intervention was non-skid socks. Review of the fall investigation, dated 04/13/22, revealed Resident #29 was found on the floor on her left side at the foot of the bed, and was unable to describe what happened. Resident #29's call light was within reach and not on. Resident #29 was barefoot, but no environmental hazards were noted. The immediate action taken included an assessment, neuro checks, and the resident was assisted to wheelchair and moved to the common area. Review of the progress notes from 04/13/22 through 04/23/22 revealed no documentation of follow-up from the interdisciplinary team regarding the falls on 04/12/22 and 04/13/22, including a root cause of the fall or information regarding effectiveness of fall prevention interventions in place. Review of the plan of care for falls revealed interventions of encourage resident to remain in common areas during the day for closer supervision by staff and toilet resident frequently were added on 04/14/22. Review of the progress note, dated 04/23/22, revealed the nurse returned to the memory care unit and heard Resident #29 yelling out for assistance. The nurse and one of the aides entered the room and found Resident #29 lying on the floor and in a puddle of blood as she was bleeding from her head. Review of the assessment titled Nursing Fall Review, dated 04/23/22, revealed Resident #29 was unable to describe what she was doing at the time of the fall. The immediate intervention was a head-to-toe assessment, vitals, and pressure was applied to the wound. Review of the fall investigation, dated 04/23/22, revealed the incident description was a summary of the progress note regarding the fall. The immediate action taken was pressure applied to the laceration until paramedics arrived. Review of the progress notes from 04/23/22 through 05/02/22 revealed no documentation of follow-up from the interdisciplinary team regarding the fall on 04/23/22, including the root cause of the fall or information regarding fall prevention interventions, such as implementation of new interventions or the effectiveness of interventions in place. Review of the discontinued orders revealed an order dated 04/25/22 to remove staples on 04/30/22. Review of the plan of care for falls revealed an intervention of hospice notified to evaluate resident for wheelchair type for safety and medication review completed with changes made on 04/25/22. Review of the progress note, dated 05/02/22, revealed Resident #29 was found crawling on the floor in the hallway from her bed. The note indicated a head-to-toe assessment was completed with no injuries identified. Review of the fall investigation, dated 05/02/22, revealed the aide informed the nurse that Resident #29 was on the floor. The investigation indicated Resident #29 appeared to have crawled out of her bed and into the hallway. A head-to-toe assessment was completed, and vitals were taken with no injuries noted. There were no immediate fall prevention interventions documented. Review of the progress notes from 05/02/22 through 05/08/22 revealed no documentation of follow-up from the interdisciplinary team regarding the fall on 05/02/22, including root cause of the fall or assessment of fall prevention interventions. Review of the plan of care for falls revealed an intervention for a perimeter mattress was added on 05/04/22. Review of the progress note, dated 05/08/22, revealed the nurse was in the room across the hall from Resident #29, and when she exited the room after administering medications, Resident #29 was observed sitting on the floor in the doorway of her room with her legs stretched out, and it was noted that her call light was on. Resident #29 denied pain and reported she was unsure what happened. Resident #29 then attempted to scoot herself across the floor, but staff assisted her back to her wheelchair. The note indicated no injuries were noted upon assessment, and Resident #29 was sitting in the common area with staff to be monitored. Review of the fall investigation, dated 05/08/22, revealed Resident #29 was found sitting on the floor in the doorway of room. The investigation indicated the call light was noted to be in use. Resident #29 denied any pain and was unable to explain what happened. Review of the progress note, dated 05/09/22, revealed Resident #29 was found sitting on the floor of the room and was scooting herself across the floor on her buttock. Review of the assessment titled Nursing Fall Review, dated 05/09/22, revealed it was unknown when Resident #29 was last toileted, and it was noted she was found sitting on floor at the time of the fall. There was no immediate intervention documented. Review of the fall investigation, dated 05/09/22, revealed the nurse observed Resident #29 sitting on the floor of her room and scooting across the floor on her buttock. The immediate action take included a head-to-toe assessment, neuro checks, and vitals with no injuries noted. There was no immediate intervention documented. Review of the progress notes from 05/09/22 through 05/20/22 revealed no documentation of follow-up from the interdisciplinary team regarding the falls on 05/08/22 and 05/09/22, including root cause analysis of the falls and assessment of fall prevention interventions. Review of the plan of care for falls revealed interventions for a medication review and nurse practitioner to review falls for further possible intervention were added on 05/11/22. An intervention of resident known to refuse to wear soft helmet was also added on 05/11/22 and resolved on 08/05/22. Review of the progress note, dated 05/20/22, revealed Resident #29 was observed by staff on the floor of her room. Resident #29 denied hitting her head or having any injuries but was confused at baseline. The note indicated vital signs were obtained and a head-to-toe assessment was completed. Review of the assessment titled Nursing Fall Review, dated 05/20/22, revealed it was unknown when Resident #29 was last toileted, or what she was doing at the time of the fall. There was no immediate intervention documented. Review of the fall investigation, dated 05/20/22, revealed Resident #29 was found on her side next to her wheelchair. Resident #29 denied hitting her head and denied having any pain. The investigation noted Resident #29 was alert but was confused at baseline. The immediate action taken included head-to-toe assessment and vitals with no injuries documented. There was no documentation of immediate interventions. Review of the progress notes from 05/20/22 through 06/02/22 revealed no documentation of follow-up from the interdisciplinary team regarding the fall on 05/20/22, including a root cause of the fall or effectiveness of fall prevention interventions. Review of the progress note, dated 06/02/22, revealed Resident #29 was observed coming out of her room by scooting on her bottom and yelling for help. Staff assisted Resident #29 to her wheelchair, and vital signs, neuro checks, and a head-to-toe assessment were done with no injuries observed. The note indicated Resident #29's call light was in reach and staff would continue to monitor. Review of the assessment titled Nursing Fall Review, dated 06/02/22, revealed it was unknown what Resident #29 was doing at the time the fall occurred, and no immediate intervention was documented. Review of the fall investigation, dated 06/02/22, revealed Resident #29 scooted herself into the hall from her room and was yelling for help. It was noted her wheelchair was in her room and next to her bed. A head-to-toe assessment was completed, vitals were obtained, and neuro checks were started with no injuries observed. Review of the progress note, dated 06/03/22, revealed fall interventions and goals reviewed and remain appropriate. There was no documentation regarding the root cause of the fall. Review of the progress note, dated 06/24/22, revealed Resident #29 was observed on the floor on her buttock next to her bed and was scooting on her buttock and pushing her wheelchair. A skin assessment revealed she had a bruise on her left shin. Resident #29 reported no pain, dizziness, and range of motion was within normal limits. Review of the fall investigation, dated 06/24/22, revealed Resident #29 was observed on the floor on her buttock next to her bed with her feet out in front of her, and was scooting on her buttock and pushing her wheelchair. Resident #29 was unable to describe what happened. A skin assessment revealed a bruise on her shin, but Resident #29 reported she did not have any pain. Vital signs were obtained, neuro checks were done, and range of motion was within normal limits. There was no documentation regarding root cause of the fall or immediate interventions implemented. Review of the progress notes from 06/24/22 through 08/05/22 revealed no documentation of follow-up from the interdisciplinary team regarding the fall on 06/24/22. Review of the plan of care for falls revealed an intervention of a care conference with family to discuss resident plan of care was added on 06/27/22. Review of the progress note, dated 08/05/22, revealed Resident #29 was found on the floor on this date. Review of the assessment titled Nursing Fall Review, dated 08/05/22, revealed it was unknown what Resident #29 was doing at the time of the fall. The immediate intervention was assisted Resident #29 to her wheelchair and then back to bed. Review of the fall investigation, dated 08/05/22, revealed Resident #29 was observed lying on her left side in front of her wheelchair, but was unable to describe what happened. The immediate action taken included an assessment, which revealed no injuries, and staff assisted the resident to her wheelchair. There was no documentation regarding immediate interventions. Review of the progress notes from 08/05/22 through 08/15/22 revealed no documentation of follow-up from the interdisciplinary team regarding the root cause of the fall or assessment of fall prevention interventions. Review of the plan of care for falls revealed an intervention of offer toileting throughout the night was added on 08/05/22. Review of the progress note, dated 08/15/22, revealed Resident #29 was found beside the bed on the floor. The note indicated Resident #29 was confused and unable to explain what happened, which was noted to be not a new onset. Resident #29 was observed bleeding from the top of her head. Staff applied pressure and ice and contacted emergency services. Resident #29 was transferred to the emergency room for evaluation and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the hospital record, staff and family interview, observation, review of the skills checklist for catheter care, and policy review, the facility failed to ensure Resident #10 was timely sent to the hospital when the resident exhibited signs and symptom of sepsis. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries when Resident #10 had symptoms of lethargy, foul-smelling urine, and had no urinary output for 48 hours. Subsequently, Resident #10's condition progressively worsened, was sent to the hospital, and diagnosed with sepsis/bacteremia with proteus [a gram-negative rod-shaped bacterium that is a main pathogen causing complicated urinary tract infection (UTI) especially catheter-associated UTI] growing in her urine and blood, an indwelling urinary catheter obstruction with bilateral hydronephrosis (an enlargement of the parts of the kidney that collects the urine), and an acute kidney injury. This affected one (#10) out of three residents reviewed for indwelling urinary catheter use. The facility identified six residents with an indwelling urinary catheter in the facility. The facility census was 89. On 11/15/22 at 11:54 A.M., the Administrator, the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #40 were notified Immediate Jeopardy began on 08/17/22 at 2:03 P.M., when Resident #10 presented with lethargy, foul smelling urine, and no urine output, and a physician was notified and made no return call. This continued to 08/18/22 at 10:09 A.M. when another physician was contacted and gave orders to send the resident to the hospital at 11:21 A.M. when Resident #10 was unresponsive, diaphoretic, and had a blood pressure reading of 151/118 millimeters of mercury (mm/Hg), heartrate was 140 beats per minute, respirations were 26 breaths per minute, and there was no urine output for two days. Upon admission to the hospital, Resident #10 had an observed catheter obstruction with bilateral hydronephrosis, acute kidney injury, and sepsis/bacteremia (the body's overactive and extreme response to an infection and is a life-threatening medical emergency and without quick treatment, it can lead to tissue damage, organ failure, and death) with proteus growing in the urine and blood. The Immediate Jeopardy was removed on 11/16/22 when the facility implemented the following corrective action: • On 11/15/22, the DON assessed Resident #10 to ensure she was having urinary output and showing no signs and symptoms of urinary sepsis, lethargy, or having foul smelling urine. The care plans were reviewed to ensure appropriate interventions and care was in place and staff were aware of what to monitor and assess for Resident #10. • On 11/15/22, all other residents with a diagnosis or history of urinary retention, cystitis, and catheter use were assessed by the DON and Unit Manager (UM) #312 and #232 to ensure within the past 30 days they were having urinary output and showing no signs of urinary sepsis, lethargy, or having foul smelling urine. The medical records were reviewed to ensure appropriate interventions and care plans were in place and staff were aware of what to monitor and assess for residents (#03, #05, #15, #29, #39 and #63). There were no findings identified for those residents reviewed. • On 11/15/22, Nurse Practitioner (NP) #403 and Medical Director (MD) #406 were consulted to develop a procedure for staff to know what to do in case the physician could not be reached. If the facility was unable to reach the physician, they notify the DON for further instruction which may include sending the resident to the emergency room (ER) for evaluation and treatment. The on-call schedule was revised to ensure accuracy of who the nurses should notify. • All new nursing staff will be trained during orientation on recognizing signs and symptoms, monitoring urinary output and documenting in the resident's plan of care. • All nursing staff will be educated by the DON/Designee on or before 11/16/22 to ensure appropriate interventions and care plans are in place and staff are aware of what to do in terms of monitoring, and the assessment of residents who are not having urinary output, showing signs of urinary sepsis, lethargy, or having foul smelling urine. They were also educated on notification and following output amount parameters in place for residents with indwelling urinary catheters. Any nursing staff members not educated by 11/16/22 will be removed from the schedule and not be permitted to work until the education is completed. • Beginning 11/17/22, the DON/Designee will audit all active residents with a diagnosis or history of urinary retention, cystitis, and catheter use to ensure they are having urinary output and showing no signs of urinary sepsis, lethargy, or having foul smelling urine. They will also audit notification and following output amount parameters if in place for residents with indwelling urinary catheters. Each of these residents will be audited to ensure appropriate interventions and care plans are in place and staff are aware of what to monitor and assess of these residents. The audits will be completed by the DON/Designee five times a week for four weeks. All adverse findings will be referred to the Quality Assessment and Performance Improvement (QAPI) committee for review and recommendation. Although the Immediate Jeopardy was removed on 11/16/22, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #10 revealed an admission date of 07/21/22. Diagnoses included stroke, cancer, pneumonia, septicemia, urinary tract infection in the past thirty days, retention of urine, and cystitis. Review of the bladder assessment dated [DATE] revealed Resident #10 was a poor candidate for toileting or bladder retraining. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was severely cognitively impaired. Her functional status was extensive assistance for bed mobility, total dependence for transfers, eating, and toilet use. She was coded for an indwelling urinary catheter. She was frequently incontinent of bowel. Review of the care plans revealed Resident #10 had no plan for catheter use. Review of a progress note by Nurse Practitioner (NP) #407 dated 08/17/22 at 2:03 P.M. revealed there was a low growth urinalysis (UA) and nursing reported increased lethargy and foul urine and Ceftin (antibiotic) was added. Review of a progress note dated 08/17/22 at 3:54 P.M. by Licensed Practical Nurse (LPN) #408 revealed Resident #10 had no urine output on the shift. The catheter was reinserted without output. The nurse called the on-call physician two times without an answer. The UM #224 was made aware of the situation. The resident denied pain and discomfort. Resident #10's lower abdomen was distended, and the nurse was awaiting a call back from the physician. Review of a progress note dated 08/18/22 at 6:40 A.M. revealed Registered Nurse (RN) #221 found a minimal amount of mucoidal and dark red discharges from Resident #10's genital and stains on her bed pad while being changed. The resident would be monitored and follow-up for any significant changes on the discharges. The on-call NP would be notified. Review of NP #403's progress note dated 08/18/22 at 10:09 A.M. revealed a phone call was received from the nursing staff of Resident #10 who was experiencing increased shortness of breath despite oxygen in place via nasal cannula at eight liters. There was hypertension reported with a systolic blood pressure at 160 mm/Hg, heart rate of 120 beats per minute and minimal responsiveness. The nursing staff reported there was zero output for the past twenty-four hours and the bladder scan showed zero. This was despite increased orders for free water of 250 cubic centimeter (cc) every four hours from an examination completed on 08/15/22. Further review of the note revealed there had been no reports of this condition until this report. The NP offered clysis (the introduction of large amounts of fluid into the body by parenteral injection to replace lost fluids, to provide nutrients, or to maintain blood pressure) and laboratory testing, but the family refused and wanted the resident sent out to the hospital. Review of the change in condition note dated 08/18/22 at 11:21 A.M. by UM #224 revealed Resident #10 was not responding after a sternal rub, was diaphoretic, had a blood pressure of 151/118 mm/Hg, the heart rate was 140 beats per minute, respirations were 26 breaths per minute, and no urine output in two days even with bolus flushes via the gastrostomy tube (G-tube) every four hours. Review of the hospital records dated 08/18/22 revealed upon admission to the emergency room Resident #10 had an observed catheter obstruction with bilateral hydronephrosis and a new catheter was placed, and two liters of urine was drained. The computed tomography (CT) scan showed severe sepsis proteus bacteremia. Resident #10 had an acute kidney injury, likely related to obstructive hydronephrosis and sepsis. Observation of catheter care on 11/03/22 at 3:48 P.M. with State Tested Nursing Assistant (STNA) #409 revealed she had a basin full of water and took a washcloth and wiped the catheter tubing away from Resident #10 but had not touched the meatus. STNA #409 took the washcloth and put soap and water on the cloth and washed the perineum area on both sides in a downward motion. She rinsed and dried this area. STNA #409 had not washed the labia at all during the observed care. Interview with agency STNA #409 on 11/03/22 at 4:24 P.M., revealed she was nervous and had been doing catheter care for a few years. She verified she had not wiped the tubing with soap and water on or around the meatus and admitted she had not cleaned the labia area and knew she should have. Interview with NP #403 on 11/07/22 at 1:12 P.M., revealed she had been notified about the condition of Resident #10 on 08/15/22 of dark odorous urine and ordered a 250 cc's G-tube flush. Then on 08/18/22 she was notified of the change in condition of the resident, and she was sent out to the hospital. She denied anyone had contacted her on 08/17/22 or the on-call NP. Interview with NP #407 on 11/07/22 at 1:44 P.M., revealed she ordered the Ceftin for Resident #10 on 08/17/22 but denied she had heard from the facility after that and if she had she would have called back and she would have placed a note into the record. Interview with Medical Director (MD) #406 on 11/14/22 at 9:53 A.M., revealed the staff read the on-call posting incorrectly and called someone who was not on-call, and that person would not call back. If nursing could not get in touch with the on-call person, then the facility should have called her. Interview with agency LPN #408 on 11/14/22 at 2:38 P.M., revealed she provided care for Resident #10 on 08/17/22 for first shift. She said she was aware the resident had not had any urine output in her catheter and even the bladder scanner read zero output on her shift. She tried to see if the catheter was inserted all the way and pulled on it and pushed it back into the resident but didn't get any output and urine wasn't leaking around the catheter either. She said she tried to call the on-call NP twice, with no response. She reported all of this to UM #225 and left the facility and had not taken care of the resident again. She felt she followed proper procedure in telling the UM of the situation. Interview with RDCS #400 on 11/14/22 at 3:12 P.M., revealed if the nursing staff was not getting any urine output, they should have called the physician and if they had not called back the staff should have sent the resident out to the hospital. RDCS #400 had no rationale why the staff had not timely sent the resident to the hospital. She further revealed the nurses who took care of Resident #10 on 08/18/22 at 6:40 A.M. (RN #221 and UM #224) no longer worked at the facility. Interview with the Power of Attorney (POA) for Resident #10 on 11/15/22 at 12:39 P.M., revealed she went out to the hospital on [DATE] because her catheter was clogged, and she wasn't producing any urine output. He said when she arrived at the hospital, she was septic, and the hospital drained 2.1 liters of urine from her bladder. Review of the skills checklist for catheter care (undated) revealed to wet and soap one washcloth and grasp catheter close to the meatus and avoid tugging on it. Cleanse around the meatus and down the catheter at least four inches from the meatus. The staff should change to a clean area of the washcloth and wipe the labia from front to back and using a clean area of the washcloth for each stroke. Review of the policy titled Notification of Changes, dated 11/02/16 revealed the facility will inform the resident, the attending physician and the resident's representative or interested family member of changes which affect the resident. I. The facility must inform the resident immediately, the attending physician and the resident's representative or interested family member when there is: a. An accident involving the resident, which may or may not result in injury. b. A significant change in the resident's physical. mental or psychosocial status. c. A need to alter treatment significantly. d. A decision to transfer or discharge the resident from the Manor.