**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical records, facility policies, review of professional standard of practice, observations, and interview with staff, it was determined the facility failed to provide treatment as ordered by the physician, to prevent pressure ulcers. This failure resulted in Immediate Jeopardy situation for Resident R2, Resident R3 and Resident R8 who developed pressure ulcers. The facility failed to provide treatment and services consistent with professional standards of practice to promote healing and prevent infection of existing pressure ulcers. This failure resulted in actual harm to R1, R2, R3, R4, R5, R6, R7, and R8 whose pressure ulcers worsened and/or deteriorated for eight of nine residents reviewed. (Residents R1, R2, R3, R4, R5, R6, R7, and R8) Findings Include: Review of US Department of Health and Human Services, Agency for Healthcare Research & Quality, revealed the pressure ulcer best practice incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. Review of the American College of Physicians (ACP) national organization of internists who specialize in the diagnosis, treatment, and care of adults revealed Clinical Practice Guidelines indicating the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. Review of an undated facility policy Prevention of Pressure Ulcers, revealed the following: GENERAL GUIDELINES 1 The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. 2. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. 3. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e. perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. 4. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. 5. Assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. 6. Once identified, the wound NP (Nurse Practitioner)/Physician is notified about the consult by DON (Director of Nursing)/designee. 6. Skin checks weekly are suggested. If done, document. INTERVENTIONS AND PREVENTIVE MEASURES: GENERAL General Preventive Measures 1. Identify risk factors for pressure ulcer development (see procedure entitled Pressure Ulcer Risk Assessment). 2. For a person in bed. a. Change position at least every two hours or more frequently if needed b. Determine if resident needs a special mattress c. If a special mattress is needed, use one that contains foam, air, gel, or water, as indicated d. Raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and medical necessity. 3. For a person in a chair: a. Change position at least every hour b. Use foam, gel, or air cushion as indicated to relieve pressure. 4. When repositioning, reduce friction and shear by lifting (using appropriate lifting technique and equipment) rather than dragging. 5. Do not use donut-shaped cushions. 6. Refer resident to a rehabilitation program, or a restorative nursing program, as indicated. 7. Encourage the resident to participate in active and passive range of motion exercises to improve circulation. 8. Ensure that the resident drinks plenty of fluids and eats a well-balanced diet. 9. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. 10. Immediately report any signs of a developing pressure ulcer to the supervisor. 11. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. Risk Factor - Bed-fast: a. Change position at least every two hours and more frequently as needed. b. Use a special mattress that contains foam, air, gel, or water, as indicated. c. Raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and medical necessity. d. Consider off-loading pressure hourly if the head of the bed is greater than 30 degrees ( e.g., for residents with tube feeding or respiratory issues). e. Unless resident has both sacral and ischial pressure ulcers, avoid placing directly on the greater trochanter for more than momentary placement. Review of an undated facility policy revealed the following: Pressure Ulcer Treatment 1. The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the pressure ulcer(s). b. Managing tissue loads. c. Pressure ulcer care. d. Managing bacterial colonization and infection. e. Operative repair of the pressure ulcers(s). f. Education and quality improvement. Pressure ulcer treatment requires a comprehensive approach, including: 1. Debridement (removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue). 2. Managing infections. 3. Managing systemic issues (edema (swelling), venous insufficiency, etc). 4. Maximizing the potential for healing. 5. Pain control. 6. All wounds are to be seen weekly by wound Nurse Practitioner/Wound Nurse 7. All strategies for treatment are individualized. Stage II (ulcer involving loss of the top layers on the skin) Pressure Ulcer Interventions/Care Strategies Clean, shallow, minimal drainage: 1. Protect 2. Manage drainage 3. Promote moist wound healing 4. Treatment: a. Cleanse with normal saline or other skin cleanser in accordance with physician orders and facility protocol b. Apply barrier cream, or tx (treatment) c. Cover with non-adhesive light gauze or transparent dressing d. Change per physician order and manufacturer's directions. 5. Manage pain. Medium drainage: 1. Follow above procedure; consider the need for alginate or foam. Follow-up If wound does not improve in 2-3 weeks, notify physician. Consider a skin consult with a wound specialist. STAGE III (ulcer involving full thickness of skin loss, exposing tissue) PROTOCOL Stage III Pressure Ulcer Interventions/Care Strategies 1. Protect 2. Fill dead space including tunnels and undermining 3. Manage drainage 4. Promote moist wound healing 5. Manage pain No drainage: 1. Treatment a. Irrigate wound with normal saline (NS) or other designated wound cleanser or use circular motion for cleaning from inside of wound to outer edges with NS soaked gauze. b. Apply tx to wound cavity c. Change per order and manufacturer's directions. d. Manage pain Medium to heavy drainage: 1. Follow above procedure. Consider substituting alginate or foam. STAGE IV (ulcer involving loss of skin layers, exposing muscle and bone) PROTOCOL Stage IV Pressure Ulcer Interventions/Care Strategies 1. Protect: a. Fill dead space including tunnels and undermining b. Manage drainage c. Promote moist wound healing. 2. Debride slough/eschar (hardened, dry, black or brown dead tissue, forms a scab-like covering over deep wounds. It acts as a protective barrier but can impede healing) a. Select the method of debridement most appropriate to the resident's condition and goals (note: this is a physician task/NP task) b. Sharp, mechanical, enzymatic, and/or autolytic (breaking down of cells or tissues by their own enzymes) debridement techniques may be used when there is no urgent clinical need for drainage or removal of devitalized tissue c. If there is urgent need for debridement, as with advancing cellulitis or sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), sharp debridement should be used. 3. Treatment: a. Irrigate wound with normal saline or other designated wound cleanser or use circular motion for cleaning from inside of wound to outer edges with NS soaked gauze. b. Apply treatment c. Cover with DSD (Dakin's solution) Review of clinical record for Resident R1 revealed Resident R1 was admitted to the facility on [DATE], with diagnoses including Anoxic Brain Damage (the brain is completely deprived of oxygen, leading to potential brain cell death) and Tracheostomy (surgical procedure where an opening is made in the neck to access the trachea) status. Review of Resident R1's physician orders dated March 18, 2025, revealed an order to turn and reposition every 2 hours - Nurse Aide to document the completion every shift in Nurse Aide charting. Further review of Resident R1's physician orders revealed the resident had a wound care order for sacral wound with calcium alginate and Medi honey and cover with border dressing. Review of Resident R1's Braden Scale (tool used to assess a patient's risk of developing pressure ulcers) assessment for Resident R1 dated March 19, 2025, revealed Resident R1 was at very high risk for developing pressure injuries. Review of skin assessment for Resident R1 dated March 19, 2025, revealed the resident had a skin tear to the sacrum which measured 4 x 0.5 with no depth. (No unit of measurement was included) Review of an admission MDS for Resident R1 (Minimum Data Set- periodic assessment of resident care needs) dated March 23, 2025, revealed that the resident did not have a pressure injury. Review of re-admission nursing note for Resident R1 dated March 27, 2025, revealed the resident had a wound on the sacrum, however, further review of nursing note failed to specify type, measurement, or any other wound characteristics. Review of Braden Scale assessment for Resident R1 dated March 27, 2025, following readmission revealed the resident was at very high risk for developing pressure injuries. Review of skin assessment for Resident R1 dated March 27, 2025, failed to identify if the resident had any wounds including the measurements. Review of an admission MDS (Minimum Data Set-Assessment of resident care needs) for Resident R1 dated April 3, 2025, revealed the resident was not able to complete BIMS (Brief Interview of Mental Status) assessment which indicated that the cognitive status for the resident was severely impaired. Further review of the MDS assessment revealed the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or, the assistance of two or more helpers is required for the resident to complete the activity) on staff for all ADLs (activities of Daily Living) including bed mobility. Additional review of Resident R1's MDS assessment revealed the resident was always incontinent of bowel and bladder. Continued review of MDS assessment revealed the resident had an unstageable pressure injury and was at risk for developing pressure ulcers. It was also revealed the resident was receiving tracheostomy/ventilator treatment. Review of wound care practitioner progress note for Resident R1 dated April 1, 2025, revealed Significant contributors for increased risk of wound incidence and/or impede healing include but not limited to vascular complicating factors, generalized muscle weakness, impaired mobility, and inevitable effects of aging. Education provided regarding pressure relief, general offloading, and frequent repositioning. Wound measurement was 6 cm (centimeters) length x 5cm width x 1 cm depth with an area of volume of 30 cubic cm. Additional review of the wound care practitioner's note dated April 1, 2025 for Resident R1 revealed a recommendation for wound care with Dakin's wound care solution. There were additional orders for off-loading, facility Pressure Injury Prevention Protocol, Pressure Redistribution Mattress per Facility Protocol, Wheelchair Pressure Redistribution Cushion per Facility Protocol and Offload heels per Facility Protocol. Review of April 2025's physician orders and April 2025's Treatment Administration Record (TAR) for Resident R1 failed to reveal documented evidence of an air mattress provided as recommended by the physician. Further review of April 2025 TAR revealed the resident received wound care treatment with Dakin's and there was treatment which was signed out as completed for Calcium Alginate and Medi honey and cover with border dressing. It was unclear which treatment the resident received. Interview with the Director of Nursing on May 2, 2025, at 1:00 p.m. confirmed the resident had two different orders for wound care and signed as administered, however the Director of Nursing was not able to specify which treatment the resident received. Review of wound care practitioner's note dated April 8, 2025, revealed that wound measurement was 5 cm length x 6 cm width x 2 cm depth with an area of volume of 60 cubic cm. The wound was staged as Stage 4 (ulcer involving full thickness of skin layers, exposing muscle and bone) pressure injury. There was also moderate amount of serosanguineous (type of wound drainage composed of blood serum and red blood cells) drainage. Further review of the wound care practitioner's note revealed a recommendation for wound care with Dakin's wound care solution, cover with alginate (highly absorbent, conformable, and fast-gelling dressings derived from seaweed, and are used to manage moderate to heavily exuding wounds) and border gauze daily and as needed. Continued review revealed additional orders for off-loading, facility Pressure Injury Prevention Protocol, pressure redistribution mattress per facility protocol, wheelchair pressure redistribution cushion per facility protocol and offload heels per facility protocol. Review of wound care practitioner's note dated April 15, 2025, revealed wound measurement was 5 cm length x 6 cm width x 3 cm depth with an area of volume of 90 cubic cm. The wound was staged as Stage 4 (ulcer involving loss of skin layers, exposing muscle and bone) pressure injury. There was also moderate amount of serosanguineous drainage. Further review of the wound care practitioner progress note revealed a recommendation for wound care with Dakin's wound care solution, cover with Alginate and border gauze daily and as needed. Review of wound care practitioner progress note dated April 22, 2025, revealed the wound measurement was 7 cm length x 6 cm width x 3 cm depth with an area of volume of 126 cubic cm. Undermining (condition where the tissue beneath the edges of a wound separates from the underlying structures, creating a cavity or pocket) has been noted at 12:00 and ends at 12:00 with a maximum distance of 4 cm. The wound was staged as Stage 4 pressure injury. Further review of the wound care practitioner progress note revealed a recommendation for wound care with Dakin's wound care solution, cover with Alginate and border gauze daily and as needed. Review of Resident R1's April 2025 TAR (Treatment Administration record) revealed Resident R1 received wound care treatment with Dakin's however Alginate was not added to the wound care order as instructed by the physican. Review of care plan of March 18, 2025 for Resident R1 failed to reveal a turning and repositioning intervention, air mattress or other off-loading measures. The only interventions noted were dietary consult and monitoring of skin injury. Interview with the Wound Care Practitioner, Employee E3, on May 6, 2025, at 11:34 a.m. revealed wound care with Calcium Alginate was prescribed for Resident R1 who had wound drainage. When Calcium Alginate is prescribed it was important to provide the wound care with Calcium Alginate to minimize the chances of infection and prevent the deterioration of wound. Employee E3 revealed he was not aware of the resident not receiving the ordered prescribed. Review of Resident R1's clinical record revealed the initial wound care order placed on April 1, 2025, was not changed by the facility as recommended by the wound care practitioner. Facility continued the same wound care, which was ordered on March 20, 2025, for the same wound. Review of Resident R1's clinical record and facility documentation failed to reveal evidence of turning and repositioning, pressure reducing devices including air mattress were provided as ordered by the physician. These failures resulted in worsening/deterioration of pressure ulcers for Resident R1 whose wound size increased from 4 x 0.5 with no depth on March 19, 2025, to 6 cm length x 5cm width x 1 cm depth with an area of volume of 30 cubic cm on April 23, 2025. The wound further deteriorated to 7 cm length x 6 cm width x 3 cm depth with an area of volume of 126 cubic cm. Review of clinical record for Resident R3 revealed that resident was admitted to the facility on [DATE], with diagnoses including anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to potential brain cell death) and tracheostomy (a surgical procedure where an opening is made in the neck to access the trachea) status. Review of quaterly MDS (Minimum Data Set-Assessment of resident care needs) for Resident R3 dated February 21, 2025, revealed that the resident was not able to complete BIMS (Brief Interview of Mental Status) assessment which indicated that the cognitive status for the resident was severely impaired. Further review of the MDS revealed that the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for all ADLs (Activities of Daily Living) including bed mobility. MDS also revealed that the resident was always incontinent of bowel and bladder. Continued review of MDS assessment revealed the resident had an unstageable pressure injury and was at risk for developing pressure ulcers. The assessment further revealed the resident was receiving tracheostomy/ventilator treatment. The assessment documented the resident had one Stage 4 unhealed pressure ulcer at the time of assessment which was documented as present on admission. Review of Braden Scale (tool used to assess a patient's risk of developing pressure ulcers) assessment for Resident R3 dated September 26, 2024, revealed that the resident was at very high risk for developing pressure injuries. Review of skin assessment for Resident R3 dated March 24, 2025, revealed that the resident had no skin impairment. Review of skin assessment for Resident R3 dated March 27, 2025, revealed that the resident had skin impairment to sacrum and left toe. There was no type, measurement or other wound characteristics specified on the skin assessment report. Review of wound care practitioner's note for Resident R3 dated March 25, 2025, revealed that the resident had a total of three (3) wounds one of which was a sacral pressure injury which measured 2cm length x 1.8 cm width x 1 cm depth, with an area volume of 3.6 cubic cm. The wound had no tunneling or undermining. The wound was staged as Stage 4. The two other wounds were non-pressure injury related wounds. Further review of the wound care practitioner's note for Resident R3 revealed a recommendation for wound care with collagen, moistened gauze with normal saline and cover with dry dressing. There were additional orders for off-loading, facility Pressure Injury Prevention Protocol, pressure redistribution mattress per facility protocol, avoid direct pressure to wound site, protocol and offload heels per facility protocol. Review of March 2025 TAR, revealed no documented evidence that the facility provided air-mattress for Resident R3 as ordered by the physician. Review of wound care practitioner's note for Resident R3 dated April 1, 2025, revealed that the resident developed a new unstageable wound to the right ischial tuberosity (protuberance of a bone) which measured 1.0 cm x1. 0 cm x 0.1 cm. with an area of volume of 0.1 cm. The sacral pressure injury which measured 2cm length x 1.7 cm width x 1 cm depth, with an area volume of 3.6 cubic cm. Further review of the wound care practitioner's note for Resident R3 revealed a recommendation for sacral wound care with Alginate and cover with dry dressing. The right ischial tuberosity wound care with honey gel and cover with border gauze. There were additional orders for off-loading, facility Pressure Injury Prevention Protocol, pressure redistribution mattress per facility protocol, avoid direct pressure to wound site, protocol and offload heels per facility protocol. Review of Resident R3's April 2025 TAR failed to reveal documented evidence the facility provided an air-mattress for Resident R3 as ordered by the physician. Review of wound care practitioner's note for Resident R3 dated April 8, 2025, revealed that the resident developed another new stage 2 (partial thickness skin loss) wound to the left buttocks which measured 2.0 cm x 2.0 cm x 0.1 cm. with an area of volume of 0.4 cm. The right ischial tuberosity which measured 3.0 cm x 3.0 cm x 0.1 cm. with an area of volume of 0.9 cm. The sacral pressure injury which measured 2 cm length x 1.7 cm width x 1 cm depth, with an area volume of 3.4 cubic cm. Review of wound care practitioner's note for Resident R3 dated April 15, 2025, revealed that the left buttocks wound measured 5.0 cm x 2.5 cm x 0.1 cm. with an area of volume of 1.25 cm. The right ischial tuberosity which measured 3.0 cm x 5.5 cm x 0.1 cm. with an area of volume of 0.9 cm. The sacral pressure injury which measured 2cm length x 2 cm width x 1 cm depth, with an area volume of 4 cubic cm. Further review of the wound care practitioner's note for Resident R3 dated April 15, 2025, revealed a recommendation for sacral wound care with Alginate and cover with dry dressing. The right ischial tuberosity wound care with honey gel, apply Alginate and cover with border gauze. The left buttock wound care with honey gel, apply Alginate and cover with border gauze. Additional review of wound care practitioner's note dated April 15, 2025 revealed additional orders for off-loading, facility Pressure Injury Prevention Protocol, pressure redistribution mattress per facility protocol, avoid direct pressure to wound site, protocol and offload heels per facility protocol. Review of Resident R3's April 2025 TAR failed to reveal documented evidence wound treatment was provided to left buttock wound for the month of April 2025. The right ischial wound care was not changed as recommended by the wound care practitioner. Review of wound care practitioner's note for Resident R3 dated April 22, 2025, revealed that the left buttocks wound measured 5.0 cm x 2.6 cm x 0.1 cm. with an area of volume of 1.3 cm. This wound was re-staged as Stage 3 (full thickness skin loss) pressure ulcer. The right ischial tuberosity which measured 8.0 cm x 8 cm x 0.2 cm. with an area of volume of 12.8 cm. The sacral pressure injury which measured 2.1 cm length x 2 cm width x 1 cm depth, with an area volume of 4.2 cubic cm. Further review of the wound care practitioner's notes for Resident R3 revealed a recommendation for sacral wound care with Alginate and cover with dry dressing. The right ischial tuberosity (bony prominence in the pelvis that serves as a key weight-bearing structure when sitting) wound care with Santyl, cover with Dakin's moistened gauze cover with border gauze. The practitioner documented the reason for change as Right ischial unstageable increased in size and eschar. Will change treatment to Santyl with 1/4 Dakin's moistened gauze and cover with border gauze daily. The left buttock wound care consisted of honey gel, apply alginate and cover with border gauze. Review of Resident R3's April 2025 TAR failed to reveal documented evidence treatment was provided to left buttock wound. The right ischial wound care was not changed as recommended by the practitioner. The recommended wound care in response to the wound deterioration was not implemented for the right ischial wound. Review of wound care practitioner's note for Resident R3 dated April 22, 2025, revealed that Right ischial unstageable increased in size and odor. Recommend x-ray of right ischium and hip to rule out Osteomyelitis (bone infection). No surrounding erythema (swelling), induration or purulence. Will continue with Santyl and 1/4 Dakin's moistened gauze and cover with border gauze daily and as needed, wound with high risk for worsening and infection due to critical care condition, immobility, impaired cognition, comorbid conditions. Continued review revealed that the left buttocks wound measured 5.0 cm x 3.0 cm x 0.1 cm. with an area of volume of 1.5 cm. The right ischial tuberosity which measured 10.0 cm x 10 cm x 0.5 cm. with an area of volume of 50 cubic cm. There was also light amount of sero-sanguineous drainage with 80% eschar and 20% slough. The sacral pressure injury which measured 2.2 cm length x 2 cm width x 1 cm depth, with an area volume of 4.4 cubic cm. Review of Resident R3's clinical record and facility documentation revealed the facility did not provide wound care recommended by the wound care practitioner on April 15, 2025, April 22, 2025, and April 29, 2025 for right ischium wound. Facility documentation lacked evidence that air mattress were provided as ordered by the physician. These failures resulted in development and worsening/deterioration of the right ischium pressure ulcers for Resident R3 whose wound size increased from 3.0 cm x 5.5 cm x 0.1 cm. with an area of volume of 0.9 cubic cm on April 15, 2025, to 10.0 cm x 10 cm x 0.5 cm. with an area of volume of 50 cubic cm with light amount of sero-sanguineous drainage with 80% eschar and 20% slough. on April 29, 2025. It was also revealed that the facility did not provide wound care recommended by the wound care practitioner on April 8, 2025, April 15, 2025, April 22, 2025, and April 29, 2025, for left buttocks wound. Facility documentation lacked evidence an air mattress was provided as ordered by the physician. These failures resulted in the development and worsening/deterioration of the left buttock pressure ulcer wounds for Resident R3, who developed the wound and the wound size increased from 2.0 cm x 2.0 cm x 0.1 cm. with an area of volume of 0.4 cm. on April 8, 2025, to 5.0 cm x 3.0 cm x 0.1 cm. with an area of volume of 1.5 cm on April 29, 2025. Resident's wound deteriorated from Stage 2 to 3. Review of clinical record for Resident R2 revealed that resident was admitted to the facility on [DATE], with diagnoses including Anoxic Brain damage (occurs when the brain is completely deprived of oxygen, leading to potential brain cell death) and Tracheostomy (surgical procedure where an opening is made in the neck to access the trachea) status. Review of Resident R2's admission MDS January 27, 2025 revealed that the resident was not able to complete BIMS assessment which indicated that the cognitive status for the resident was severely impaired. Further review of the MDS assessment revealed the resident was dependent on staff for all ADL activities including bed mobility. The MDS assessment further revealed the resident was always incontinent of bowel and bladder. Continued review of MDS revealed the resident had an unstageable pressure injury and was at risk for developing pressure ulcers. It was also revealed that the resident was receiving tracheostomy/ventilator treatment. It was documented as the resident had one Stage 4 unhealed pressure ulcer at the time of assessment which was documented as present on admission. Review of Braden Scale assessment for Resident R2 dated March 11, 2025, revealed the resident was at very high risk for developing pressure injuries. Review of the physician order for Resident R2 dated March 12, 2025, revealed an order for Prevalon boot (devise use to help prevent pressure ulcers) when in bed. Review of wound care practitioner note for Resident R2 dated March 18, 2025, revealed that the resident had a sacral pressure injury which measured 6 cm length x 5 cm width x 3 cm depth, with an area volume of 90 cubic cm. Further review of the wound care practitioner notes for Resident R2 revealed a recommendation for sacral wound care with Vashe moistened rolled gauze and cover with border dressing. There were additional orders for off-loading, facility Pressure Injury Prevention Protocol, pressure redistribution mattress per facility protocol, wheel chair pressure redistribution cushion, and offload heels per facility protocol. Review of March 2025 TAR, revealed no documented evidence that the facility provided air-mattress for Resident R2 as ordered by the physician. Observation of the Resident R2 on May 2, 2025, at 12:00 p.m. revealed that the resident was lying flat in the bed, resident was not an air mattress. It was observed that the resident's heel was lying flat on the bed without any offloading measures. This observation was confirmed by the Wound Care Nurse, Employee E4. Review of wound care practitioner note for Resident R2 dated March 25, 2025, revealed that the sacral pressure injury which measured 6 cm length x 5 cm width x 3 cm depth, with an area volume of 90 cubic cm. Further review of wound care documentation revealed that the resident developed a heel pressure ulcer on March 24, 2025, which measured 4 cm length x 4 cm width x 0.1 cm depth, with an area volume of 1.6 cubic cm. Review of wound care practitioner note for Resident R2 dated April 1, 2025, revealed that the sacral pressure injury which measured 6 cm length x 5 cm width x 3 cm depth, with an area volume of 90 cubic cm. The heel pressure ulcer measured 3 cm length x 3 cm width x 0.1 cm depth, with an area volume of 0.9 cubic cm. Further review of the wound care practitioner's note for Resident R2 revealed a recommendation for sacral wound care with Vashe moistened rolled gauze and cover with border dressing. Continued review of the wound care practitioner's note for Resident R2 revealed a recommendation for sacral wound care with Vashe moistened rolled gauze and cover with border dressing and Alginate with border gauze for heel ulcer. Review of April 2025 TAR revealed that the heel ulcer was treated with Alginate with medihoney which was not according to the wound care practitioner's recommendation. Review of Nurse Aide Documentation revealed that from April 5, 2025, to May 5, 2025 only 8 shifts out of 240 shifts documented that the offloading of heel was provided. Review of wound care practitioner's note for Resident R2 dated April 8, 2025, revealed that the sacral pressure injury which measured 7 cm length x 5 cm width x 3 cm depth, with an area volume of 105 cubic cm. The right heel pressure ulcer measured 3 cm length x 3 cm width x 0.1 cm depth, with an area volume of 0.9 cubic cm. but noted with moderate amount of serosanguinous drainage. New right ischial (hip bone) pressure injury measured 3 x 3 x 0.1 with an area volume of 0.9 cubic cm. Continued review of Resident R2's wound care practit[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident received treatment and care in a timely manner related to high glucose levels and emergent transfer to a hospital. This failure resulted in Immediate Jeopardy to a Resident CL1 who had elevated blood sugar levels and was not emergently transferred to a hospital for one of five residents reviewed (Resident CL1). Findings Include: Review of Resident CL1's clinical record reveled that Resident CL1 was admitted to the facility on [DATE], with diagnosis of Diabetes Mellitus (DM-a chronic condition that affects the way the body processes blood sugar (glucose). Review of Resident CL1's [DATE], physician's order revealed an order for Insulin Lispro Injection Solution 100 UNIT/ML; Insulin Regular Human Injection Solution (Insulin Regular (Human) 30 unit subcutaneously one time only for DM (Diabetes Mellitus) for 1 day. If resident shows S/S (signs and symptoms) of fruity smelling breath vomiting, excessive hunger and thirst, rapid heartbeat- Perform BG (blood sugar), If BG (blood sugar) >400, immediately contact physician. Review of Resident CL1's nursing note revealed on [DATE], at 5:38 p.m. A call was placed to on call physician about [Resident's CL1's] elevated blood sugar, nurse check blood sugar for the evening check and it read high. On call physician told nurse to give resident 20 units of regular insulin and recheck in an hour. Review of Resident CL1's [DATE], Medication Administration Record revealed no evidence that 20 units of regular insulin was administered to the resident on [DATE]. Interview with the Director of Nursing, Employee E2 on [DATE], at 10:10 a.m. confirmed that there was not a physician order for 20 unit of regular insulin. Review of Resident CL1's nursing note revealed a nursing entry dated [DATE], at 8:06 p.m. nurse called on call physician again to inform that the Resident CL1's blood sugar remained elevated. The on-call physician stated to stop the Dextrose 5 percent and give her an additional 30 units of regular insulin and to recheck in an hour. Continued review of Resident's CL1's nursing note dated [DATE], at 9:01 p.m. indicated that the resident was in bed with hyperglycemia BG (blood glucose) checked at approx. (approximately) 19:30 (7:30 p.m.) result 507 and on Dextrose 5% percent IV (intravenous) immediately stopped. Regular insulin given per MD's orders to recheck and supervisor aware. Review of Resident CL1's medication administration record for the month of [DATE], revealed that regular insulin 30 units was given one time at 8:50 p.m. on [DATE], by night Supervisor, Licensed practical, Employee E5. Review of Resident CL1's nursing note written by Registered nurse, Employee E3 dated [DATE], at 12:25 a.m., revealed Patient (Resident CL1) presents on report with status change all day hyperglycemic, diaphoretic, tachycardic and in acute resp. Distress with blood glucose reading high. Blood glucose later read 507 after multiple attempts at approximately. 7:50 PM. Doctor [Employee E6] was notified by outgoing nurse and gave an order to stop patient Dextrose 5% at approx. 8 pm give 30 unit of regular insulin. Order was administered. After rechecking two times [Resident CL1] still read high. Supervisor was immediately called to assess patient at approximately 9:45 pm. Presented resident status to the supervisor [Registered nurse, Employee E4] and informed her that [Resident CL1] has to be sent out via 911 (Emergency Medical Services) to the hospital but supervisor [Employee E4] was dismissive refused to assess and evaluate the resident. Supervisor [Register nurse, Employee E4], became extensively aggressive argumentative, belligerent, condescending, rude, and yelling in the hallway in front of co-workers insisting [Resident CL1] does not need to be sent out to the hospital. Call placed to MD [Physician, Employee E6] at approximately 9:50 pm to inform [Resident CL1] status. R/T called in to resident's room for assistance while preparing [Resident's CL1's] paperwork and calling 911. Supervisor [Registered nurse, Employee E4] returned to the nursing station yelling at nurse [Register nurse, Employee E3] stating that by referring to [Resident's CL1]. this is her baseline per her mom she has always been diaphoretic and you are going to send the Resident's CL1 out just because she is diaphoretic?' [Supervisor Employee E4 repeatedly refused to listen to writer that this is a medical emergency for [Resident CL1] to be transported via 911 to the hospital. Doctor [Employee E6] returned phone call at approximately 10:20 PM to send [Resident CL1] out via 911. Supervisor Register nurse, Employee E4, interrupted writer on 911 call to go and give Dextrose 5% with DON on the phone again refusing to listen this is a medical emergency and the doctor has given an order to transport [Resident CL1] out, while the DON is on the phone in the midst of the emergency insisting not to transfer resident's out arguing. Supervisor [Registered nurse, Employee E4] repeatedly disregarding the doctors order and refused to speak to the doctor. The [Register nurse, Employee E3] tried to confirm the DON's directives again with the supervisor. Supervisor [Registered nurse, Employee E4] was dismissive, yelling out in the hallway refusing to listen. Supervisor [Register nurse, Employee E4], insisted the [Register nurse, Employee E3] come to her office and paged the [Register nurse, Employee E3] while calling 911 again at approximately 22:35 (10:35 p.m.) call placed to MD in the presence of the supervisor [Registered nurse, Employee E4], with the night supervisor [Licensed practical nurse, Employee E5], MD insisted to send [Resident CL1] out via medical emergency while supervisor [Registered nurse, Employee E4] still yelling and refused to speak to the doctor or attend to the resident. Night supervisor LPN attempted to get supervisor [Employee E4] to speak to the doctor but supervisor [Employee E4] was still belligerent and aggressively refused to speak to doctor arguing with the night supervisor [Licensed practical nurse, Employee E5], yelling at him. Supervisor [Register nurse, Employee E4] left the facility while [Resident CL1] was still in acute medical distress. 911 was immediately call at 22:50 (10:50 p.m.) [Register nurse, Employee E3] was with [Resident CL1] obtained sat at 99 percent on vent 60 percent setting and heart rate 168. [Resident CL1] coded at approximately 10:58 pm code blue immediately announced on overheard board CPR (cardiopulmonary resuscitation) immediately initiated with all nurses on board at approximately 11:02 with [Resident CL1] pulseless. At approximately 11:10 pm 911 called again and 911 paramedics arrived at facility at 11:25 pm and immediately took over. After multiple rounds of CPR 911 pronounced [Resident CL1] expiration at 11:51 pm. Review of nursing note dated [DATE], at 5:06 a.m. revealed Resident was found unresponsive by the nurse @ appr 2358 (11:58 p.m.) and immediately called code blue. CPR (Cardio Pulmonary Resuscitation) was initiated immediately and 911 called. EMT (Emergency Medical Technician) personnel got here at 2325 (11:25 p.m.). Eleven sets of chest compressions was completed before the EMT personnel got here and took over the process. Both the EMT personnel and RN declared resident at 2351 (11:51 p.m.) Review of the investigation statement from night Supervisor, Licensed practical nurse, Employee E5 on [DATE], revealed that [Resident's CL1's register nurse, Employee E3 told me that [Resident CL1] looked some sort of way, and she thinks the resident needs to be sent out. The residents were also already on fluids. Supervisor [Registered nurse, Employee E4] had told night supervisor [Licensed practical nurse, Employee E5], I don't think she needs to be sent out and director of nursing doesn't either. [Register nurse, Employee E3], came to night supervisor [Licensed practical nurse, Employee E5], and said the doctor wants to talk to the supervisor [Registered nurse, Employee E4], wasn't interested and said that because I'm also a night supervisor, that I could talk to on call doctor [Employee E6], and supervisor [Registered nurse, Employee E4], also state that director of nursing said the resident doesn't need to be sent out. Night supervisor [Licensed practical nurse, Employee E5], said to supervisor [Registered nurse, Employee E4], the doctor wants to send the patient out. Supervisor [Registered nurse, Employee E4], didn't talk to the doctor. Attempts made to conduct interviews with Registered nurse, Employee E3 and the night supervisor, Licensed practical nurse, Employee E5 were unsuccessful. Interview conducted with Supervisor, Registered nurse, Employee E4 on [DATE], at 12:00 p.m. revealed that on [DATE], the employee came for her 3-11 p.m. shift and stated to reviewed labs and reports. Around 8:00 p.m. she went to Registered nurse, Employee E3 to report that there was an order for Resident CL1 for D5 2L that needed to be giving. Registered nurse, Employee E3 didn't ' t want to give the D5 2L iv to the resident because of high blood sugars. [Registered nurse, Employee E3] refused to give D5 iv and wanted to call the MD to inform to change the order. 'I called DON to inform everything with [Registered nurse, Employee E3] not giving the D5 iv to resident but walked away. Wanted to call the doctor together with her but she walked away, and I couldn't ' t deal with her attitude and asked night supervisor to talk and take over [Registered nurse, Employee E3] and [Resident CL1]. I didn't ' t know anything about the blood sugar high for resident and I didn't ' t talk to the doctor. No call blue on my shift, I left my shift didn't ' t know that she went to the ER. But got a late text that resident passed away. Interview conducted with facility's prior Director of Nursing on [DATE],4 at 2:29 p.m. confirmed that she received a call from Supervisor, Registered nurse, Employee E4 to inform her that Registered nurse, Employee E3 was refusing to give the Dextrose 5 iv and that Registered nurse, Employee E3 wanted to cancel the order and contact the MD about the resident's high level of blood sugar levels. Interview with on-call physician, Employee E6, on [DATE], at 2:37 p.m. revealed that he got a call from a nurse about Resident CL1's high blood sugar level (still elevated) and order to stop the Dextrose 5 and give her an additional 30 units of regular insulin and to recheck in an hour. After one hour nurse informed that resident's blood sugar was high, and I order to be sent out to the hospital for more care. In the background I heard register nurse [Employee E3] was talking to supervisor [Registered nurse, Employee E4], why you're not send [Resident CL1] out to hospital. An Immediate Jeopardy situation was identified to the Nursing Home Administrator, Employee E1 and Regional Director of Nursing, Employee E8 on [DATE], at 10:33 a.m. for the facility's failure to ensure that a resident received treatment and care in a timely manner related to high glucose levels and failed to ensure that a resident was emergently transfer to the hospital. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator and Regional, Director of Nursing on [DATE], at 10:33 a.m. The following action plan was received and accepted on [DATE], 1:48 p.m. -Resident no longer resides at the facility. -Audited other residents who receive treatment and care related to high glucose level with no findings. -Current 7 a.m. -7 p.m. licensed nursing staff have been educated on the facility's significant change in condition and hyperglycemia policies. 100% of current in- house staff during this shift have been in serviced. The rest of the licensed nursing staff upcoming shift at 7p.m. -7 a.m. will be educated at the start of their shift. 100 percent of all staff will be in serviced by tomorrow [DATE]. -Facility also educated nurses in ensuring that the physician is notified timely of abnormal blood glucose levels for all residents with a diagnosis of diabetes mellitus. -NHA, DON and/ or Designee will conduct daily audits for a week, and weekly for 4 weeks, then monthly for 3 months to ensure care compliance. -Results of monthly audits will be reported to the QA Steering committee by the NHA/DON and /or Designee for 3 months to the QA Steering committee for action. Following the 3 months, the committee will determine the frequency and need of additional audits moving forward. Review of facility documentation revealed that the corrective action plan was immediately developed and initiated on [DATE]. Review of in-service records revealed that in-service training was provided to licensed nursing staff on the change in condition policy and the hyperglycemia policy. Interviews conducted with licensed nursing staff confirmed knowledge of the resident change in condition and hyperglycemia policies. The Immediate Jeopardy was lifted on [DATE], at 12: 01 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f)(ii)(iii) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services