**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 8 residents reviewed for pain. Facility failed to ensure Resident #1's pain was recognized, properly assessed and received pain management in accordance with professional standards of practice. Facility nurse aides and occupational therapy assistant moved Resident #1 from the floor to the wheelchair to the bed, after a fall without a nurse assessing the resident for any pain or injuries on 4/8/25 at approximately 6PM. Facility nurse aides failed to relay Resident #1's pain to nurse immediately after a fall on 4/8/25 at approximately 6PM. Facility nurse failed to complete a proper pain assessment on Resident #1 when later notified of a resident leg pain on 04/08/25 at approximately 7:00PM. Resident #1 was transported to the local community hospital and was diagnosed with a femoral fracture. An Immediate Jeopardy (IJ) situation was identified on 6.23.25. The IJ template was provided to the facility on 6.23.25 at 4:20 pm. While the IJ was lowered on 6.25.25 at 4:27 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of isolated, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could put residents at pain not being managed by the facility. The findings included: Record review of Resident #1's face sheet dated 6.5.25 revealed Resident #1 was admitted on 4.8.25 and was [AGE] years old. Resident #1 had diagnoses of metabolic encephalopathy (a condition where a systemic health issue or imbalance impairs brain function, causing a range of symptoms from confusion and memory loss to coma), type 2 diabetes, cirrhosis of liver (a condition where healthy liver tissue is replaced by scar tissue, preventing the liver from functioning properly), and sepsis due to Escherichia coli (occurs when an E. coli infection spreads to the bloodstream and triggers a dangerous overreaction of the body's immune system, potentially leading to organ damage and even death). Record review of Resident #1's comprehensive care plan reflected: No Care plan available. Resident #1 was only in building for 6 hours total. Record review of Resident #1's medical record dated 4.9.25 indicated: Department of Radiology and Nuclear Medicine. Exam: {lain films of the left knee (xray). Findings: On the AP view there is a cortical irregularity in the lateral distal femoral metaphysis consistent with fracture. Record review of Resident #1's progress notes written by LVN W dated 4.8.25 indicated: Late Entry: Note Text: Pt. family member approached this nurse and reported that Pt. is c/o pain to the leg, according to family member the pain was R/T fall. This nurse explained to the family member that no fall, was reported during shift change. This nurse f/u to find out from Pt. when the fall occurred. It was reported that prior to shift change the resident was lowered to floor during toileting due to her legs getting too weak to stand. Pt. stated, I was being cleaned up in the restroom while standing and my legs gave up on me and sat in the floor. Head to toe assessment was completed, Pt. was A&O x2. Pt. was able to move the upper limb but refuse to move the lower limb and complained pain of 12 to the whole of left. Comparing L-leg to right leg, no shortness was noted however, Slight swelling was noted to left knee, but this nurse couldn't confirm if that was R/T fall because it was the 1st time seeing this Pt. Family explained that was not normal for Pt. Acetaminophen 325 mg po x 2 tabs was administered per order. Vital signs: T-97.3, BP-141/94. Day nurse, LVN A was contacted due to Pt. complain of fall, and LVN A said CNA B reported that Pt. had assisted fall. This explained to family that X-ray will be done to find out what was causing the pain but for stat X-ray pt. might has to transfer to the ER for and family said yes. EMT was contacted and at 9:03 pm Pt. together with family members left the facility to the ER. DON notified. During an interview on 6.3.25 at 12:05 pm LVN A stated he does remember Resident #1. He stated that he did do her initial documentation when Resident #1 admitted to the facility. He stated that the hospital never mentioned that Resident #1 needed lift assistance or anything like that. He stated that the resident was seen to transfer with no assistance, but he would say he would recommend Resident #1 at least had two persons to assist her. He stated he must have missed filling out the mobility/safety section in Resident #1 initial assessment. He stated that he should have filled this part of the document out because it indicates to other staff the type of assistance Resident #1 needed. He stated this information could help Resident #1 not sustain any falls. Record review of CNA B witness statement dated 4.8.25 indicated: CNA C then carefully raised Resident #1's leg so CNA D could put a pillow under Resident #1 knee and then CNA C carefully and slowly laid Resident #1 leg down on the pillow. The lady (Resident #1) didn't complain that it hurt until after CNA C had laid Resident #1 knee back down on the pillow. I gave Resident #1 the bed control as CNA D gave her the call light, I walked out of the room. Record review of CNA C witness statement dated 4.8.25 indicated: Me and CNA B held her up as PT E and CNA D tried to put the wheelchair underneath her. When she finally had the bottom in the wheelchair enough to pull her out of the bathroom, PT E told the lady to bend her knees so she can scoot back in the chair. At that time of bending the knee is when she yelled that it hurt. Record review of PT E witness statement dated 4.8.25 indicated: Transitioned resident from EOB to supine with 4 people. Resident complained of pain upon being positioned in supine and notified night shift nurse as day shift nurse was on the phone receiving report for new admission. During interview on 6.22.25 at 10:20 am PT E stated that when she went to report to LVN W that Resident #1 had a fall, she stated that all she told LVN W was that Resident #1 complained of left knee pain. She stated she did not tell the nurse that Resident #1 had a fall because she assumed LVN W already knew because CNA C let LVN A know about the fall. During an interview on 6.20.25 at 6:45 pm LVN W stated that a fall is any change in position from one height to another. She stated this was a fall and the resident should have been assessed. She stated during shift change LVN A was usually good about letting her know about every situation, but he forgot to on the day of the incident. She stated she could not remember at what time, but PT E came to her and said Resident #1 was complaining of left leg pain. She stated she should have asked more questions but did not. She stated she was in the middle of giving out medications, so she took 2 Tylenol to Resident #1. She stated she did not do an assessment of Resident #1 at this time, only that she gave Resident #1 pain medication. She stated later when she was working at the nurse's station and the daughter of Resident #1 came to her and stated that Resident #1 had a fall. She stated to the daughter, when, thinking it just happened. She stated the daughter said no earlier. She stated she went to assess the resident. She stated on doing an assessment you must do a head-to-toe assessment of the resident looking for any abnormalities. She stated, that can include, bruising, swelling, redness, etc. She stated that Resident #1's left knee/leg was a little bit swollen, and the resident did state it was painful. She stated this was the first time she had ever seen the resident since she was a new admit today, so she was not sure if this was the resident's baseline. She stated she went and called LVN A to ask if he knew anything and found out about the incident over the phone. She stated at that point she let the daughter know that there was no portable stat xray available at this time, so the only other option was to send the resident out to the hospital via EMS to go get the residents xray complete. She stated that was what the family wanted and that was why the resident was sent out. She stated she has no idea why anyone would have moved the resident from the floor to the wheelchair without letting a nurse assess the resident first and she has no idea why all this information was not provided to her during shift change. She stated when it comes to a fall and the resident was on the ground they are to stay there until the resident was assessed by a nurse. She stated in this case, if a fall occurs and the resident was assessed and noted to have pain to hip or knee area, she would make the resident comfortable on the floor and call ems because she would not want to move the resident if there was a break to the knee or hip. She stated but this did not happen. During an interview on 6.20.25 at 7:15 pm CNA D he stated that this was literally his first or second day on the job. He stated that when he came into work, he noticed that the residents call light was on so he was going to answer it. He stated that CNA B joined him because she had assisted the resident to the restroom and the resident had already started to pee and got some on herself. He stated so CNA B wanted to come and help him, so he was not cleaning and doing everything by himself. He stated they went into the resident room they assisted the resident to stand from toilet using gait belt. He stated they were both cleaning the resident up when the resident stated she couldn't do it and began to go down. He stated CNA B was behind the resident at this time in which the resident was lowered down onto CNA B. He stated it was very slow. He stated around the same time CNA C had entered the room. He stated he was not sure but believe CNA C went to let the nurse know about the assessment. He stated CNA C came back to the room and he was not sure how long but maybe 10 mins and PT E came by and asked if they needed assistance. He stated he can't remember if CNA B said anything about no assessment had been done by a nurse or not, but they all assisted the resident back into the wheelchair. He stated the only thing he could remember was that the resident was stating that her knee hurt while they were waiting on the nurse to assess the resident. He stated he was not sure why they didn't wait on the assessment to be completed but they should have waited. He stated this was all new to him. During an interview on 6.5.25 at 11:15 am admin stated that before a resident was accepted into the building the assessment of the resident should be complete. He stated the administration side he may not know everything, but he knows that the information that was needed before accepting the resident was if the resident needs any devices, (walker, wheelchair, etc.), if the resident was ambulatory, needs assistance, what kind of assistance, if the resident needs oxygen or any extra equipment. He stated this should all be known before the resident was accepted into the building. He stated this information is necessary to know that the facility can provide the proper care for the resident and that the resident will have all their needs met. He stated if any of this information was not acquired then it could result in an injury to the resident. During an interview on 6.5.25 at 1:25 pm the DON she stated that the readmit screener documentation should have been filled out completely which was not done. She stated LVN A should have completed that documentation so the staff/facility would have known the assistance required by the resident. She stated overall there were a few misses here in this situation, but she started in-services on the situation to cover documentation. She stated the pain assessment and head-to-toe should have been done while Resident #1 was still on the floor. She stated this did not occur. She stated there were a lot of misses that occurred during this incident. Record review of facility policy dated December 2016 titled: Comprehensive Assessments and the Care Delivery Process indicated: Assessment and information collection includes (WHAT, WHERE and WHEN). The objective of the information collection (assessment) phase is to obtain, organize, and subsequently analyze information about a patient. This was determined to be an Immediate Jeopardy (IJ) on 6.23.25 at 4:20 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 6.23.25 at 4:20 pm. Record review of Plan of Removal accepted on 6.24.25 at 12:10 PM reflected the following: Impact Statement: On 6/23/2025 an abbreviated survey was initiated on 6/23/25 the facility was provided with notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure for 1 of 87 residents pain being recognized, properly assessed, and receiving pain management. What corrective actions have been implemented for the identified residents? a. The resident involved in the incident on 4/8/25 received immediate pain management and evaluation once identified. The resident was sent to the emergency room on 4/8/25 and diagnosed with a femoral fracture. Resident's pain was managed per physician orders and follow-up care was provided. b. Ambassador rounds were completed by the interdisciplinary team on 4/8/25 and incident reports of falls that occurred in the last 24 hours were reviewed to ensure any resident pain was properly assessed, reported, and addressed by direct care staff and no other discrepancies were identified. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? a. On 6/23/25 the Director of Nursing and/or nurse managers in-serviced direct care staff on recognizing, properly assessing, and receiving pain management. Staff educated on reporting recognized resident pain to the charge nurse, the charge nurse is to immediately assess the resident's pain, and administer pain medication in accordance to the results of the pain assessment completed. All Direct care staff employees will be in-serviced by the Director of Nursing and/or nurse managers on recognizing, properly assessing, and receiving pain management prior to their next scheduled shift. Staff members will recite understanding of the education to the educator and 5 staff interviews will be completed daily for seven days. b. The facility DON or nurse manager will in-service new hires during orientation, on recognizing, properly assessing, and receiving pain management prior to their next scheduled shift. Staff educated on reporting recognized resident pain to the charge nurse, the charge nurse is to immediately assess the resident's pain, and administer pain medication in accordance to the results of the pain assessment completed. Effectiveness of staff educated on recognizing, properly assessing, and receiving pain management will be evaluated with staff reciting information and 5 staff interviews per day for seven days to ensure information is retained. How will the system be monitored to ensure compliance? a. Starting 6/23/25 the DON or nurse manager will complete resident interviews and/or assessments daily for seven days to ensure are pain was recognized, properly assessed and received pain medication in a timely manner. Post the daily monitoring on 6/30/25 the DON/nurse manager will round on residents to ensure pain was recognized, properly assessed and received pain medication in a timely manner effectively 2x week X 6 weeks or until it is determined the metric is met. Any discrepancies identified will be addressed immediately by the nurse manager and further education provided by the DON or designee when necessary. b. Starting 6/23/25 the DON and/or nurse manager will review the 24 hour report in electronic medical record that identifies all nurse documentation, PRN pain administration, resident assessments completed, and progress note documentation daily for 7 days and then 5x week for 3 weeks to ensure any documented pain was recognized, properly assessed and received pain medication in a timely manner. c. Administrator and/or designee will review the 24 hour report and round on residents daily for seven days and then on a weekly basis for six weeks to ensure nurse managers are following the plan of removal or until it is determined the metric is met starting 6/23/25. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/23/25 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring of facilities Plan of Removal through observations, interviews, and record reviews from 06/24/2025 to 06/25/2025: During an interview on 6.24.25 at 1:10 pm CNA F stated she got in-serviced yesterday 6.23.25 at roughly late afternoon. She stated that there were so many that they molded together, but she knows she did at least 3. She stated one in-service covered falls. She stated that it covered what constitutes as a fall, what to do in case of a fall and who to call. She stated if a fall occurred assisted or not she was not allowed to touch the resident. She stated if there was another CNA with you that CNA can go and let the nurse know but if you were by yourself you need to call out for help because you do not leave the resident. She stated that nothing was to be done to the resident until the nursing assessment had been completed by the nurse. She stated the nursing assessment was to be completed by the nurse, and there was no reason for the resident to ever be moved until it was completed. She stated but if a resident did complain of pain, no associated to a fall or anything witnessed, then the CNA would ask the resident basic questions such as, how bad is the pain, how did you hurt yourself etc. She stated once that information was received she would go directly to the charge nurse to let them know the resident had pain. During an interview on 6.24.25 at 1:25 pm CNA G stated she has been doing this for many years and this was all a refresher for her. She stated that the topics discussed in the in-services were falls, nursing assessments and pain. She stated a fall is any time a resident ends up on the ground without intending to. She stated it did not matter if it was assisted or witnessed, with injury or no injury, a fall was to be reported to the charge nurse immediately. She stated she should not move the resident, sit the resident up, assist the resident in anyway. She stated the focus at that time was to make sure the resident did not move and stayed on the floor and then go and inform the charge nurse. She stated nothing at all was to be done even while waiting on the nurse to come and do the assessment. She stated ever fall in the building must have a nursing assessment completed. She stated lastly pain was discussed. She stated anytime a resident has any sort of pain, major or minor, she would repot to the charge nurse and let them know the resident was complaining of pain. During an interview on 6.24.25 at 1:35 pm CNA H stated she was in-serviced 3 different times over the past day or so. She stated pain was a big one she can remember. She stated she is not a nuse so assessing the resident for pain was not something required. She stated but inquiring about pain level and maybe how the resident hurt themselves was okay. She stated right when the resident let her know of any pain she would report it to the charge nurse. She stated the next two topics kind of went hand in hand. She stated that if a resident has a fall, assisted or not, it must be reported to the nurse and nothing should be done to the resident until the nuse has completed her assessment of the resident. She stated, essentially, if a resident falls, let charge nurse know, don't move the resident and wait for the nurse to do their assessment of the resident before any moving of the resident was allowed. During an interview on 6.24.25 at 1:45 pm CNA I stated any fall any was any change in residents plane. She stated even if it's a 3 inch movement, different plane means a fall. She stated it also doesn't matter if it was assisted, witnessed or unwitnessed it was still a fall and had to be reported to the nurse. She stated even while waiting on the nurse to get to the residents room, the resident was not to be moved or assisted in any way. She stated once the nurses assessment was complete she would be allowed to, with the help of the nurse, get the resident up. She stated the other in-service covered pain. She stated this could be any pain, in general or associated to a fall. She stated all pain should be immediately reported to the nurse and the nurse would come and do the assessment of the resident. During an interview on 6.24.25 at 2:00 pm RN J stated she has been nurse since 23. She stated she was in-serviced this morning before she was allowed to work. She stated that she went through a few in-services. She stated the first one covered falls. She stated, it covered what constitutes as a fall, with injury or no injury. She stated that the in-service covered what a CNA must do related to a fall and what a nurse must do related to a fall. She stated that a CNA was not to assist or move the resident, but only too report the fall to the nurse and wait for the nurse to come do the nursing assessment. She stated second the nursing assessment covered a head to toe assessment that checked for swelling, bruising, bleeding, how the resident was acting, etc. she stated if there were concerns the resident hit their head the resident would not be moved at all and EMS would be called to come and get the resident. She stated after assessment was completed on resident then the resident could be moved and then monitored. She stated lastly, if any resident complains of any sort of pain, to CNA, the CNA should come report to the nurse immediately, but if the pain was notated directly from resident to nurse, the nurse must do a head to toe assessment and pull meds pending level of pain or reach out to physician if pain was high. During an interview on 6.24.25 at 2:15 pm LVN K stated that this was a refresher, but it was everything that she did consistently. She stated the main topic was about falls and pain associated to falls. She stated the CNA's got a little bit different of an in-service then the nurses did. She stated for the nurses, the requirement was no matter how big of a fall, a nurse must go and assess the resident before they were allowed to be moved by anyone. She stated pain was covered and the overview was that any resident who complains of any sort of pain, associated to a fall or not should be assessed from head to toe and meds could be given associated to the level of pain and what medications were available to the resident. She stated primary focus, no moving of any resident associated to any fall could be done until the nursing assessment was completed. During an interview on 6.24.25 at 2:25 pm RN L stated that she was in-serviced and it covered 3 parts. She stated two parts went together, any fall occurs in the building a nurse must respond to the resident and do a full body head to toe assessment of the resident before the resident was allowed to be moved by anyone. She stated that CNA's were to either call for help while still being able to see the resident or have another CNA who was with them to go and let the nurse know that they had a fall and a nursing assessment must be done. She stated that all pain in the same process should be notated to the nurse at this time as well. She stated beyond a fall, any pain a resident notates to any CNA, the CNA must immediately come to the nurse and let the nurse know of the pain and the nurse must go and perform a pain assessment on the resident and provide the resident with any medication the resident may have for pain or reach out to the physician. During an interview on 6.24.25 at 2:45 pm ADON stated that he was aware of the situation going on. He stated that he has been helping/part of every in-service provided by the DON to all nursing staff. He stated that the main topic was falls and pain, which went for both CNA's and nurses. He stated that any fall in the facility must be responded to and a nurse must do a nursing assessment before the resident was allowed to be moved at all. He stated that it was imperative that any CNA does not move the resident at all until the resident was assessed by the nurse. He stated it was also imperative that a nurse do a head to toe nursing assessment on all residents who had a fall, checking for swelling, bruising, blood, etc. he stated second topic for both CNA and nurse was to communicate fully to each other when any resident complains of pain anywhere on their body. He stated the CNA just needs to inform the nurse that resident complained of pain and where on the body. He stated it was then the nurses responsibility to go and assess the resident for any pain. During an interview on 6.24.25 at 3:00 pm CNA M stated she was in serviced last night before she came on shift. Phone interview. She stated that she got in-serviced the night before. She stated it was roughly around 5:30pm. She stated there were 3 topics covered, falls, pain, and nursing assessments. She stated the main thing for the CNA's that was covered was falls. She stated the definition of a call, which was anytime a residents body went to the floor. She stated it does not matter if it was assisted or not, it was still considered a fall. She stated second the topic that was associated to the fall was that a CNA's was not to move or get the resident up after the fall unless a nurse had completed the nursing assessment of the resident. She stated lastly was pain, she stated pain does not have to be only associated to a fall but anytime a resident complains of any pain on their body they are to report it to the nurse so the nurse could come and do a pain assessment of the resident. During a phone interview on 6.24.25 at 3:10 pm CNA N stated that there were 3 topics covered. She stated pain, falls, and nursing assessment. She stated that pain can be any complaint made by the resident no matter how big or small of a complaint, the complaint should be reported to the nurse immediately. She stated she was not a nurse so she would not assess the resident for pain but may ask how it happened or level of pain. She stated the other topic that was covered, was falls and reporting falls to the nurse. She stated not only do you have to report the fall to the nurse but stay with the resident, do not move them until the nurse has physically come and done a nursing assessment. She stated that it was drilled into the CNA's that they are not to move the resident for no reason until that nursing assessment was completed. During a phone interview on 6.24.25 at 3:15 pm CNA O stated she works nights and can work both sides. she stated she got in-serviced yesterday 6.23.25 at roughly late afternoon. She stated that there were so many that they molded together, but she knows she did at least 3. She stated one in-service covered falls. She stated that it covered what constitutes as a fall, what to do in case of a fall and who to call. She stated if a fall occurred assisted or not she was not allowed to touch the resident. She stated if there was another CNA with you that CNA can go and let the nurse know but if you were by yourself you need to call out for help because you do not leave the resident. She stated that nothing was to be done to the resident until the nursing assessment had been completed by the nurse. She stated the nursing assessment was to be completed by the nurse, and there was no reason for the resident to ever be moved until it was completed. She stated but if a resident did complain of pain, no associated to a fall or anything witnessed, then the CNA would ask the resident basic questions such as, how bad is the pain, how did you hurt yourself etc. She stated once that information was received she would go directly to the charge nurse to let them know the resident had pain. Record Review of in-service presented by DON titled communication of complaints of pain-CNA's from residents, dated 6.23.25, signature page provided. Inservice covered CAN/CMA's: When a resident reports having pain, specifically after a fall, ask the resident where the pain is coming from on their body. Then tell the resident's charge nurse immediately. DO NOT MOVE RESIDENT AFTER A FALL WITHOUT A NURSE COMPLETING AN ASSESSMENT OF PAIN AND/OR INJURY. All employees interviewed were verified with signatures. During a phone interview on 6.24.25 at 3:20 pm LVN P stated she worked the north side. She stated that she got in-serviced last night. She stated that the main topic covered for the nurses was that an assessment had to be done from head to toe for each resident now matter how minor of a fall occurred. She stated there was no excuse that a resident after a fall was not assessed before the resident was moved off of the ground. She stated the second topic covered was pain in general. She stated pain associated to a fall or not, must be brought to the attention of the nurse even if it was minor. She stated once being reported that a resident complained of pain, the nurse must go to the resident and assess the resident for pain level, location, injury, etc. she stated once the pain was identified, medications could be administered if resident has prn meds or pain meds in general. Record review of in-service presented by DON titled Resident Assessment of Pain-Nurses. Do not move resident after a fall without completing an assessment of pain and/or injury. Assess: onset- Mechanism of injury or etiology of pain, if identifiable. Location/distribution. Duration. Course or temporal pattern. Character and quality of the pain. Aggravating/provoking factors. Alleviating factors. And Associated symptoms. Administer pain medication as ordered by physician. If no pain medication is previously ordered by physician, notify physician immediately of residents pain/pain assessment. Acquire orders as given by physician for pain control and/or additional orders as received. All employees interviewed were verified with signatures. Record Review of Qapi Signature Page. Quapi meeting covering PoR and topic of IJ. Attendees included administrator, Dr A, DON, ADON, RUP, and DRO. During a phone interview on 6.24.25 at 3:40 pm RN Q stated that she got in-serviced last night. She stated that the main topic covered for the nurses was that an assessment had to be done from head to toe for each resident now matter how minor of a fall occurred. She stated there was no excuse that a resident after a fall was not assessed before the resident was moved off of the ground. She stated the second topic covered was pain in general. She stated pain associated to a fall or not, must be brought to the attention of the nurse even if it was minor. She stated once being reported that a resident complained of pain, the nurse must go to the resident and assess the resident for pain level, location, injury, etc. she stated once the pain was identified, medications could be administered if resident has prn meds or pain meds in general. During a phone interview on 6.24.25 at 3:50 pm CNA R stated topics covered pain, then falls, wait for assessment before anyone is moved. She stated there were a few in-services. She stated that the topics discussed in the in-services were falls, nursing assessments and pain. She stated a fall is any time a resident ends up on the ground without intending to. She stated it did not matter if it was assisted or witnessed, with injury or no injury, a fall was to be reported to the charge nurse immediately. She stated she should not move the resident, sit the resident up, assist the resident in anyway. She stated the focus at that time was to make sure the resident did not move and stayed on the floor [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety anfor 1 of 8 (Resident #1) resident reviewed for staffing, in that: Facility failed to ensure licensed nurses and nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents need. Facility nurse aides failed to relay resident complaint of pain to appropriate nurse after a fall so that resident could be promptly assessed. Facility nurse failed to provide the on-coming nurse with information about the residents assisted fall from earlier in the day in order for resident to be monitored. Facility nurse aides and staff (PT) moved a resident after a fall without a nurse completing an assessment of resident for pain or injury. Facility nurses did not fully assess resident pain before administering pain medication. An Immediate Jeopardy (IJ) situation was identified on 6.23.25. The IJ template was provided to the facility on 6.23.25 at 4:20 pm. While the IJ was removed on 6.25.25 at 4:27 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of isolated, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could put residents at risk of not being provided care by nursing staff with sufficient skills/training. Findings included: Record review of Resident #1's face sheet dated 6.5.25 revealed Resident #1 was admitted on 4.8.25 and was [AGE] years old. Resident #1 had diagnoses of metabolic encephalopathy (a condition where a systemic health issue or imbalance impairs brain function, causing a range of symptoms from confusion and memory loss to coma), type 2 diabetes, cirrhosis of liver (a condition where healthy liver tissue is replaced by scar tissue, preventing the liver from functioning properly), and sepsis due to Escherichia coli (occurs when an E. coli infection spreads to the bloodstream and triggers a dangerous overreaction of the body's immune system, potentially leading to organ damage and even death). Record review of Resident #1's comprehensive care plan reflected: No Care plan available. Resident #1 was only in building for 6 hours total. Record review of Resident #1's medical record dated 4.9.25 indicated: Department of Radiology and Nuclear Medicine. Exam: {lain films of the left knee (xray). Findings: On the AP view there is a cortical irregularity in the lateral distal femoral metaphysis consistent with fracture (fracture of femur). Record review of Resident #1's admit/readmit form indicated all sections to be completed by LVN A except for section mobility/safety. Record review of Resident #1's progress notes dated 4.8.25 indicated: Late Entry: Note Text: Pt. family member approached this nurse and reported that Pt. is c/o pain to the leg, according to family member the pain was R/T fall. This nurse explained to the family member that no fall, was reported during shift change. This nurse f/u to find out from Pt. when the fall occurred. It was reported that prior to shift change the resident was lowered to floor during toileting due to her legs getting too weak to stand. Pt. stated, I was being cleaned up in the restroom while standing and my legs gave up on me and sat in the floor. Head to toe assessment was completed, Pt. was A&O x2. Pt. was able to move the upper limb but refuse to move the lower limb and complained pain of 12 to the whole of left. Comparing L-leg to right leg, no shortness was noted however, Slight swelling was noted to left knee, but this nurse couldn't confirm if that was R/T fall because it was the 1st time seeing this Pt. Family explained that was not normal for Pt. Acetaminophen 325 mg po x 2 tabs was administered per order. Vital signs: T-97.3, BP-141/94. Day nurse, LVN A was contacted due to Pt. complain of fall, and LVN A said CNA B reported that Pt. had assisted fall. This explained to family that X-ray will be done to find out what was causing the pain but for stat X-ray pt. might has to transfer to the ER for and family said yes. EMT was contacted and at 9:03 pm Pt. together with family members left the facility to the ER. DON notified. During an interview on 6.3.25 at 11:45 am CNA B stated the resident was brand new that day. She stated that when she went to answer the call light the resident was already in her wheelchair. She stated before she went to the restroom, she asked the resident how stable she was and if she needed much help because she was not sure how much assistance the resident needed. She stated that the resident told her that at the hospital she really didn't even need much assistance to transfer from wheelchair to toilet. She stated that she took the resident to the restroom and told the resident to use her call light after she was done, and she would come help her. She stated the resident used to the call light indicating resident was complete. She stated that CNA D and herself went to the resident's room and went to assist the resident off the toilet. She stated the resident stood up and she was standing behind the resident while CNA D was on the front/side of the resident. She stated the resident stood fully up, then stated I can't do this, and went to sit back down. She stated the resident started to sit down and slowly slid down to the ground, basically using her legs as a slide down to the floor landing on her foot. She stated that CNA C let LVN A know of the assisted fall and then was called into Resident #1's room, the entire time the resident was on her foot, the resident was assisted back to the wheelchair and then put back into bed. She stated that roughly 15min later the resident complained of her left knee hurting. She stated this all happened around shift change, the resident was sent out and she is not sure what has happened since then. During an interview on 6.3.25 at 1:55 pm LVN A stated he did not go in and do an assessment of the resident because the way he was told it was like the resident just was assisted and sat on the floor. He stated he should have went and assessed Resident #1 before she was moved from the floor. He stated any resident that sustained a fall, must be assessed by a nurse before the resident was allowed to be moved. During an interview on 6.5.25 at 11:55 am CNA C stated that the nurse should have come and assessed the resident, but it did not happen. She stated she let him know and he said OK but never came down to assess the resident. She stated the protocol for any fall, assisted or not needs to be assessed by a nurse before moved. She stated blood pressure and vitals everything before the resident was moved, but this did not happen. During interview on 6.22.25 at 10:20 am PT E stated that when she went to report to LVN W that Resident #1 had a fall, she stated that all she told LVN W was that Resident #1 complained of left knee pain. She stated she did not tell the nurse that Resident #1 had a fall because she assumed LVN W already knew because CNA C let LVN A know about the fall. Record review of CNA B witness statement dated 4.8.25 indicated: CNA C then carefully raised Resident #1's leg so CNA D could put a pillow under Resident #1 knee and then CNA C carefully and slowly laid Resident #1 leg down on the pillow. The lady (Resident #1) didn't complain that it hurt until after CNA C had laid Resident #1 knee back down on the pillow. I gave Resident #1 the bed control as CNA D gave her the call light, I walked out of the room. Record review of CNA C witness statement dated 4.8.25 indicated: Me and CNA B held her up as PT E and CNA D tried to put the wheelchair underneath her. When she finally had the bottom in the wheelchair enough to pull her out of the bathroom, PT E told the lady to bend her knees so she can scoot back in the chair. At that time of bending the knee is when she yelled that it hurt. Record review of PT E witness statement dated 4.8.25 indicated: Transitioned resident from EOB to supine with 4 people. Resident complained of pain upon being positioned in supine and notified night shift nurse as day shift nurse was on the phone receiving report for new admission. During an interview on 6.20.25 at 6:45 pm LVN W stated that a fall is any change in position from one height to another. She stated this was a fall and the resident should have been assessed. She stated that PT E did let her know about Resident #1's knee pain so she went and gave Resident #1 two Tylenol. She stated she did not assess Resident #1 at this time, but only gave her Tylenol. She stated during shift change LVN A was usually good about letting her know about every situation, but he forgot to on the day of the incident. She stated that she was working at the nurse's station and the of the resident came to her and stated that the resident had a fall. She stated to the, when, thinking it just happened. She stated the said no earlier. She stated she went to assess the resident. She stated on doing an assessment you must do a head-to-toe assessment of the resident looking for any abnormalities. She stated, that can include, bruising, swelling, redness, etc. She stated that the resident's left leg/knee was a little bit swollen, and the resident did state it was painful. She stated this was the first time she had ever seen the resident since she was a new admit today, so she was not sure if this was the resident's baseline. She stated she went and called [NAME] to ask if he knew anything and found out about the incident over the phone. She stated at that point she let the daughter know that there was no portable stat xray available at this time, so the only other option was to send the resident out to the hospital via EMS to go get the residents xray complete. She stated that was what the family wanted and that was why the resident was sent out. She stated she has no idea why anyone would have moved the resident from the floor to the wheelchair without letting a nurse assess the resident first and she has no idea why all this information was not provided to her during shift change. She stated when it comes to a fall and the resident was on the ground they are to stay there until the resident was assessed by a nurse. She stated in this case, if a fall occurs and the resident was assessed and noted to have pain to hip or knee area, she would make the resident comfortable on the floor and call EMS because she would not want to move the resident if there was a break to the knee or hip. She stated but this did not happen. During an interview on 6.5.25 at 11:15 am Admin stated that from what he knows, any fall that occurs in the building a nurse must go and assess the resident before the resident is allowed to be moved from the ground. He stated this was protocol and from what he found out; this did not occur. During an interview on 6.5.25 at 1:25 pm DON stated this was absolutely a fall. She stated the first time she heard of the incident was when the night nurse LVN E reached out to her asking her if she was aware of any fall by that resident. She stated she didn't know, she stated she started to reach out to her aids via text and realized this was a fall. She stated that LVN A the nurse on shift during the incident should have gone and assessed the resident. She stated that the way it was described to LVN A it was not a fall, so he didn't assess. She stated it should have been treated as a fall. She stated overall there were a few misses here in this situation, but she started in-services on the situation to cover documentation and what was considered a fall. She stated a change in plane was considered a fall. Record review of facility policy dated September 2012 titled: Falls-Clinical Protocol indicated: 2. In addition, the nurse shall assess and document/report the following: a. vital signs, b. recent injury, especially fracture or head injury, c. musculoskeletal function, observing for changing in normal range of motion, weight bearing etc., d. change in cognition or level of consciousness, e. neurological status, f. pain, g. frequency and number of falls since last physician visit. H. precipitating factors, details on how fall occurred, i. all current medications, especially those associated with dizziness or lethargy, and j. all active diagnosis. This was determined to be an Immediate Jeopardy (IJ) on 6.23.25 at 4:20 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 6.23.25 at 4:20 pm. And a Pla of Removal was requested. The facility Plan of Removal was accepted on 6.24.25 at 12:10 PM and reflected the following: Impact Statement: On 6/23/2025 an abbreviated survey was initiated on 6/23/25 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to protect 1 of 87 residents in ensuring licensed nurses and nurse aides were able to demonstrate competency in skills and techniques necessary to care for resident's needs. What corrective actions have been implemented for the identified residents? a. The resident involved in the incident on 4/8/25 received immediate pain management and evaluation once identified. The resident was sent to the emergency room on 4/8/25 and diagnosed with a femoral fracture. Resident's pain was managed per physician orders and follow-up care was provided. Resident was closely monitored for any complications related to the injury or delayed treatment on 4/8/25. b. On 6/23/25 all current residents who have had an incident in the last two weeks were reviewed to ensure the resident was not moved prior to a nurse assessing the patient and pain was assessed by licensed nurse prior to administering medication. No other discrepancies identified with licensed nurses and nurse aides being able to demonstrate competency in skills and techniques necessary to care for the residents needs. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? a. On 6/23/25 the Director of Nursing and/or nurse managers initiated an in-service direct care staff reporting recognized resident pain to the charge nurse, the charge nurse is to immediately assess the resident's pain, and administer pain medication in accordance to the results of the pain assessment completed. The in-service will be completed by 6/24/25. All Direct care staff employees will be in-serviced by the Director of Nursing and/or nurse managers on recognizing, properly assessing, and receiving pain management and any PRN or weekend staff will be in-serviced by 6/24/2025. If PRN or weekend staff are unable to be reached, they will be removed from the schedule until in-service is completed. Effectiveness of staff educated on reporting recognized resident pain to the charge nurse, the charge nurse is to immediately assess the resident's pain, and administer pain medication in accordance to the results of the pain assessment completed will be evaluated with staff reciting information and 5 staff interviews per day for seven days to ensure information is retained. b. On 6/23/25 an in-service was initiated by the Director of Nursing and nurse managers with nurse aides on relaying resident's complaint of pain to charge nurse when a resident expresses signs of pain and not moving a resident after a fall without a nurse completing an assessment of resident for pain or injury. All nursing assistants will be in-serviced by 6/24/2025 by the Director of Nursing and/or nurse managers on relaying resident's complaint of pain to charge nurse when a resident expresses signs of pain and not moving a resident after a fall without a nurse completing an assessment of resident for pain or injury including PRN and Weekend staff. If staff are unable to be reached to provide in-service by 6/24/25 they will removed from the schedule until in-service is completed. Effectiveness of staff educated on relaying resident's complaint of pain to charge nurse when a resident expresses signs of pain and not moving a resident after a fall without a nurse completing an assessment of resident for pain or injury will be evaluated with staff reciting information and 5 staff interviews per day for seven days to ensure information is retained. c. On 6/23/25 the Director of Nursing and nurse managers initiated an in-service with licensed nurses on completing a full assessment of a residents pain prior to administering pain medication. The in-service will be completed 6/24/25. All licensed nurses will be in-serviced by the Director of Nursing and/or nurse managers initiated an in-service with licensed nurses on completing a full assessment of a residents pain prior to administering pain medication including PRN and weekend staff by 6/24/25 or they will be removed from the schedule until in-service is completed. Effectiveness of staff educated on completing a full assessment of a residents pain prior to administering pain medication will be evaluated with staff reciting information and 5 staff interviews per day for seven days to ensure information is retained. d. The facility DON or nurse manager will in-service new hire nursing assistants and licensed nurses during orientation, relaying resident's complaint of pain to nurse so the resident can be properly assessed, not to move a resident post resident fall without a nurse completing an assessment of resident for pain or injury, and the need to fully assess a resident's pain before administering pain medication. Staff members will recite understanding of the education to the educator. How will the system be monitored to ensure compliance? a. Starting 6/23/25 the DON or nurse manager will complete interviews and/or assessments with residents daily for seven days to ensure pain was recognized, properly assessed and received pain medication in a timely manner. Post the daily monitoring on 6/30/25 the DON/nurse manager will round on residents to ensure pain was recognized, properly assessed and received pain medication in a timely manner effectively 2x week X 6 weeks or until it is determined the metric is met. Any discrepancies identified will be addressed immediately by the nurse manager and further education provided by the DON or designee when necessary. b. Starting 6/23/25 the DON and/or nurse manager will review the 24 hour report in electronic medical record that identifies all nurse documentation, PRN pain administration, resident assessments completed, and progress note documentation daily for 7 days and then 5x week for 3 weeks to ensure any documented pain was recognized, properly assessed, the resident was fully assessed prior to pain medication administration, and received pain medication in a timely manner c. Starting on 6/23/25 the DON and/or nurse manager will review fall incident reports daily in the electronic medical record for seven days and then 3x week for six weeks to ensure resident was assessed for pain and/or injury by a licensed nurse prior to moving the resident post fall and that the resident was fully assessed for pain prior to providing pain medication by the licensed nurse. If it is identified that a resident was not assessed prior to being moved, the resident will immediately be assessed and the employee will receive further education. d. Administrator and/or designee will review the 24 hour report in the electronic medical record and round on residents daily for seven days and then on a weekly for six weeks basis to ensure nurse managers are following the plan of removal of ensuring staff are competent in skills and techniques necessary to care for resident needs or until it is determined the metric is met starting 6/23/25. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/23/25 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring of facilities Plan of Removal through observations, interviews, and record reviews from 06/24/2025 to 06/25/2025 revealed: During an interview on 6.24.25 at 1:10 pm CNA F stated she got in-serviced yesterday 6.23.25 at roughly late afternoon. She stated that there were so many that they molded together, but she knows she did at least 3. She stated one in-service covered falls. She stated that it covered what constitutes as a fall, what to do in case of a fall and who to call. She stated if a fall occurred assisted or not she was not allowed to touch the resident. She stated if there was another CNA with you that CNA can go and let the nurse know but if you were by yourself you need to call out for help because you do not leave the resident. She stated that nothing was to be done to the resident until the nursing assessment had been completed by the nurse. She stated the nursing assessment was to be completed by the nurse, and there was no reason for the resident to ever be moved until it was completed. She stated but if a resident did complain of pain, no associated to a fall or anything witnessed, then the CNA would ask the resident basic questions such as, how bad is the pain, how did you hurt yourself etc. She stated once that information was received she would go directly to the charge nurse to let them know the resident had pain. During an interview on 6.24.25 at 1:25 pm CNA G stated she has been doing this for many years and this was all a refresher for her. She stated that the topics discussed in the in-services were falls, nursing assessments and pain. She stated a fall is any time a resident ends up on the ground without intending to. She stated it did not matter if it was assisted or witnessed, with injury or no injury, a fall was to be reported to the charge nurse immediately. She stated she should not move the resident, sit the resident up, assist the resident in anyway. She stated the focus at that time was to make sure the resident did not move and stayed on the floor and then go and inform the charge nurse. She stated nothing at all was to be done even while waiting on the nurse to come and do the assessment. She stated ever fall in the building must have a nursing assessment completed. She stated lastly pain was discussed. She stated anytime a resident has any sort of pain, major or minor, she would repot to the charge nurse and let them know the resident was complaining of pain. During an interview on 6.24.25 at 1:35 pm CNA H stated she was in-serviced 3 different times over the past day or so. She stated pain was a big one she can remember. She stated she is not a nuse so assessing the resident for pain was not something required. She stated but inquiring about pain level and maybe how the resident hurt themselves was okay. She stated right when the resident let her know of any pain she would report it to the charge nurse. She stated the next two topics kind of went hand in hand. She stated that if a resident has a fall, assisted or not, it must be reported to the nurse and nothing should be done to the resident until the nuse has completed her assessment of the resident. She stated, essentially, if a resident falls, let charge nurse know, don't move the resident and wait for the nurse to do their assessment of the resident before any moving of the resident was allowed. During an interview on 6.24.25 at 1:45 pm CNA I stated any fall any was any change in residents plane. She stated even if it's a 3 inch movement, different plane means a fall. She stated it also doesn't matter if it was assisted, witnessed or unwitnessed it was still a fall and had to be reported to the nurse. She stated even while waiting on the nurse to get to the residents room, the resident was not to be moved or assisted in any way. She stated once the nurses assessment was complete she would be allowed to, with the help of the nurse, get the resident up. She stated the other in-service covered pain. She stated this could be any pain, in general or associated to a fall. She stated all pain should be immediately reported to the nurse and the nurse would come and do the assessment of the resident. During an interview on 6.24.25 at 2:00 pm RN J stated she has been nurse since 2023. She stated she was in-serviced this morning before she was allowed to work. She stated that she went through a few in-services. She stated the first one covered falls. She stated, it covered what constitutes as a fall, with injury or no injury. She stated that the in-service covered what a CNA must do related to a fall and what a nurse must do related to a fall. She stated that a CNA was not to assist or move the resident, but only too report the fall to the nurse and wait for the nurse to come do the nursing assessment. She stated second the nursing assessment covered a head to toe assessment that checked for swelling, bruising, bleeding, how the resident was acting, etc. she stated if there were concerns the resident hit their head the resident would not be moved at all and EMS would be called to come and get the resident. She stated after assessment was completed on resident then the resident could be moved and then monitored. She stated lastly, if any resident complains of any sort of pain, to CNA, the CNA should come report to the nurse immediately, but if the pain was notated directly from resident to nurse, the nurse must do a head to toe assessment and pull meds pending level of pain or reach out to physician if pain was high. During an interview on 6.24.25 at 2:15 pm LVN K stated that this was a refresher, but it was everything that she did consistently. She stated the main topic was about falls and pain associated to falls. She stated the CNA's got a little bit different of an in-service then the nurses did. She stated for the nurses, the requirement was no matter how big of a fall, a nurse must go and assess the resident before they were allowed to be moved by anyone. She stated pain was covered and the overview was that any resident who complains of any sort of pain, associated to a fall or not should be assessed from head to toe and meds could be given associated to the level of pain and what medications were available to the resident. She stated primary focus, no moving of any resident associated to any fall could be done until the nursing assessment was completed. During an interview on 6.24.25 at 2:25 pm RN L stated that she was in-serviced and it covered 3 parts. She stated two parts went together, any fall occurs in the building a nurse must respond to the resident and do a full body head to toe assessment of the resident before the resident was allowed to be moved by anyone. She stated that CNA's were to either call for help while still being able to see the resident or have another CNA who was with them to go and let the nurse know that they had a fall and a nursing assessment must be done. She stated that all pain in the same process should be notated to the nurse at this time as well. She stated beyond a fall, any pain a resident notates to any CNA, the CNA must immediately come to the nurse and let the nurse know of the pain and the nurse must go and perform a pain assessment on the resident and provide the resident with any medication the resident may have for pain or reach out to the physician. During an interview on 6.24.25 at 2:45 pm ADON stated that he was aware of the situation going on. He stated that he has been helping/part of every in-service provided by the DON to all nursing staff. He stated that the main topic was falls and pain, which went for both CNA's and nurses. He stated that any fall in the facility must be responded to and a nurse must do a nursing assessment before the resident was allowed to be moved at all. He stated that it was imperative that any CNA does not move the resident at all until the resident was assessed by the nurse. He stated it was also imperative that a nurse do a head to toe nursing assessment on all residents who had a fall, checking for swelling, bruising, blood, etc. he stated second topic for both CNA and nurse was to communicate fully to each other when any resident complains of pain anywhere on their body. He stated the CNA just needs to inform the nurse that resident complained of pain and where on the body. He stated it was then the nurses responsibility to go and assess the resident for any pain. During an interview on 6.24.25 at 3:00 pm CNA M stated she was in serviced last night before she came on shift. Phone interview. She stated that she got in-serviced the night before. She stated it was roughly around 5:30pm. She stated there were 3 topics covered, falls, pain, and nursing assessments. She stated the main thing for the CNA's that was covered was falls. She stated the definition of a call, which was anytime a residents body went to the floor. She stated it does not matter if it was assisted or not, it was still considered a fall. She stated second the topic that was associated to the fall was that a CNA's was not to move or get the resident up after the fall unless a nurse had completed the nursing assessment of the resident. She stated lastly was pain, she stated pain does not have to be only associated to a fall but anytime a resident complains of any pain on their body they are to report it to the nurse so the nurse could come and do a pain assessment of the resident. During a phone interview on 6.24.25 at 3:10 pm CNA N stated that there were 3 topics covered. She stated pain, falls, and nursing assessment. She stated that pain can be any complaint made by the resident no matter how big or small of a complaint, the complaint should be reported to the nurse immediately. She stated she was not a nurse so she would not assess the resident for pain but may ask how it happened or level of pain. She stated the other topic that was covered, was falls and reporting falls to the nurse. She stated not only do you have to report the fall to the nurse but stay with the resident, do not move them until the nurse has physically come and done a nursing assessment. She stated that it was drilled into the CNA's that they are not to move the resident for no reason until that nursing assessment was completed. During a phone interview on 6.24.25 at 3:15 pm CNA O stated she works nights and can work both sides. she stated she got in-serviced yesterday 6.23.25 at roughly late afternoon. She stated that there were so many that they molded together, but she knows she did at least 3. She stated one in-service covered falls. She stated that it covered what constitutes as a fall, what to do in case of a fall and who to call. She stated if a fall occurred assisted or not, she was not allowed to touch the resident. She stated if there was another CNA with you that CNA can go and let the nurse know but if you were by yourself you need to call out for help because you do not leave the resident. She stated that nothing was to be done to the resident until the nursing assessment had been completed by the nurse. She stated the nursing assessment was to be completed by the nurse, and there was no reason for the resident to ever be moved until it was completed. She stated but if a resident did complain of pain, no associated to a fall or anything witnessed, then the CNA would ask the resident basic questions such as, how bad is the pain, how did you hurt yourself etc. She stated once that information was received she would go directly to the charge nurse to let them know the resident had pain. Record Review of in-service presented by DON titled communication of complaints of pain-CNA's from residents, dated 6.23.25, signature page provided. Inservice covered CAN/CMA's: When a resident reports having pain, specifically after a fall, ask the resident where the pain is coming from on their body. Then tell the resident's charge nurse immediately. DO NOT MOVE RESIDENT AFTER A FALL WITHOUT A NURSE COMPLETING AN ASSESSMENT OF PAIN AND/OR INJURY. All employees interviewed were verified with signatures. During a phone interview on 6.24.25 at 3:20 pm LVN P stated she worked the north side. She stated that she got in-serviced last nig[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment in accordance with professional standards of practice for 1 of 4 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure Resident #1 was making appointments with the Podiatrist/Orthopedic Surgeon (OS) post amputation of 5th digit of left foot. 2. The facility failed to obtain orders from Resident #1's Podiatrist/Orthopedic Surgeon (OS) Podiatrist when appointments were missed status post amputation of 5th digit of left foot. 3. The facility failed to follow Podiatrist/Orthopedic Surgeon (OS)'s orders for daily dressing changes. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm with a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of infections, worsening of wounds, injuries, emotional distress, and even death due to missed appointments, lack of follow-up, dressing changes, and lack of monitoring of amputations Findings include: Resident # 1 Review of Resident # 1's closed record face sheet dated [DATE] revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmission date of [DATE] and discharge date of [DATE] with the following diagnosis metabolic encephalopathy (primary), encounter for orthopedic aftercare following surgical amputation, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, need assistance with personal care, dependence on renal dialysis and end stage renal disease Review of Resident #1's hospital records dated [DATE] revealed Resident #1 was admitted to local hospital on [DATE] with stroke like symptoms, diabetes, and end stage renal disease requiring dialysis. Further review of hospital records revealed metatarsal resection (amputation of toe) on [DATE]. Further review of hospital record revealed resident Resident #1 was discharged from local hospital on [DATE] at 4:30pm with diagnosis of ulcer of left foot due to necrosis (death of tissues) of bone because of chronic osteomyelitis (inflammation of bone due to infection) of left foot with orders to follow up with Podiatrist/Orthopedic Surgeon in two weeks ([DATE]). Review of Resident # 1's closed record admission MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 10 (moderate cognitive impairment); Section G- Functional Status revealed Resident #1 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bladder and Bowel revealed Resident # 1 always incontinent for bowel and bladder; Section M-Skin Conditions revealed Resident #1 was at risk of developing pressure ulcers/injuries. Review of Resident #1's closed record care plan dated on [DATE] revised on [DATE] revealed: Focus The resident has infection of the left foot r/t candidiasis. Date Initiated: [DATE] Revision on: [DATE]. Interventions: Administer medication as ordered. Date Initiated [DATE]. Follow facility policy and procedures for line listing, summarizing infections. Date Initiated: [DATE]. Maintain universal precautions when providing resident care. Date Initiated: [DATE]. Perform and document weekly assessment of skin for changes or observations. Record review of Resident #1's closed record progress note on [DATE] written by NP revealed Patient was admitted for sepsis of multi sourced infection sites. Patient was started on empiric antibiotics and blood cultures were negative. Patient underwent a left fifth metatarsal head resection on [DATE]. Patient was medically stabilized and subsequently discharged to facility on [DATE] . Patient to have follow-up with OS on [DATE] at10:30 a.m. Dressing is to remain on the left foot until he is seen by the orthopedic surgeon. Further review of Resident #1's closed record revealed no evidence of documentation of missing Resident #1's appointment with OS on [DATE]. Record review of Resident #1's closed record nurses progress note dated [DATE] revealed Resident return from OS per physician progress notes: 1) Please do NOT change the patients dressing 2)RTC on [DATE] @ 1130AM. Transportation notified of f/u appt. and Info updated on 24 hour report. Record review of Resident #1's closed record nurses progress note dated [DATE] revealed Resident return from OS office per physician progress notes Please change Resident #1's foot wound dressing daily. No further need for ACE wrap. Please see that patient gets his augmentin as ordered. Call placed to OS office for clarification on orders what does provider want for dressing orders and orders for augmentin. Per nurse at OS office to cleanse wound then swab with betadine cover with 4x4 and secure. Augmentin 875mg q12 hours x10days. Orders updated in chart and placed on24 hr{hour} report. Record review of Resident #1's closed record nurses progress note dated [DATE] revealed Resident return from OS appointment per physician's progress notes: Continue daily dressing changes with betadine to wound base . Return in 1 week appt of [DATE] @ 1045am Transportation notified. Record review of Resident # 1 physician orders revealed start date [DATE] Location of wound: left foot with order to be performed every day shift Treatment order: Cleanse with NS or Wound Cleanser and pat dry. Swab with betadine swab. Cover with 4x4 and secure with tape. and no end date. Record Review of Resident #1's TAR dated [DATE] - [DATE], revealed no evidence of treatment for order being completed on: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of Resident #1's hospital records dated [DATE] revealed Resident #1 was re-admitted to local community hospital on [DATE] due to complications related to End Stage Renal Disease requiring dialysis. Further review of Resident #1's hospital records revealed resident was discharged [DATE] to in house hospital hospice. During an interview on [DATE] at 12: 59 PM, Resident # 1's family member stated he/she had concerns about Resident 1's care while at the facility. Resident #1's family member stated he/she felt Resident #1 was neglected by the facility which led to his death. Resident #1's dressing on his wounds were never changed timely. During an interview on [DATE] at 5:35 PM, the DON stated documentation for wound care should have been on the TAR. The DON stated if there were no initials of nursing staff then it meant that the wound treatment was not provided. The DON stated her expectation was that wound care orders be followed and need to be completed, and if resident refused the refusal should have been documented that resident refused wound care. The DON stated she was not aware of missed treatments, she stated she thought treatments were done because she saw TX G's pushing treatment cart up and down the hall. The DON stated that was why she went in and initiated some of the treatment dates. The DON stated that missed treatments could have caused resident decline in wounds. The DON stated if nurse did not document there was no way to prove treatments were done. The DON stated the negative affect on residents, if wound care treatments were not completed, could have caused skin breakdown, and could have caused the wounds to worsen in various ways. The DON stated that RNWS J and LVN F should have provided wound care on the blank entry dates for missed wound care for Resident #1. During an interview on [DATE] at 6:13 PM, RNSW J stated he had never heard of Resident #1. RNWS J stated if wound care was not done it could have caused infection, or resident to become septic. RNWS J stated he had never not documented work, if you do not document it did not happen. During an interview on [DATE] at 6:32 PM, LVN F stated she had never done wound care on Resident #1. LVN F state skin assessments were completed by treatment nurse, and for new admissions the nurse on unit would complete skin assessments. During an interview on [DATE] at 12:05 CSD stated thru her audits she discovered issues with TX G documentation and reeducated TX G. CSD stated she continued to see missed documentation and TX G was removed from treatment nurse about the [DATE]th. TX G stated if someone were to document late then there should be a progress note that explained the late documentation. CSD stated NA was not appropriate entry into TAR, that documentation needed to reflect what was assessed and observed during treatment. CSD stated skin assessments needed to be completed weekly. CSD stated she could run a report that would identify who documented and the date and time they completed the documentation. During an interview on [DATE] at 4:00 PM CSD stated she had ran a report, Medication Admin Audit Report. CSD stated the report showed that DON and ADON E had completed documentation after surveyors had entered the building. During an interview on [DATE] at 4:30 PM, RN OS stated OS had concerns with facility not showing up for appointments or calling to reschedule. RN OS stated Resident #1 was scheduled for one week follow up o [DATE] after surgery and missed appointment. RN OS stated the facility never called to clarify treatment orders, or to called to reschedule appointment. RN OS stated when she called to reschedule, facility stated visits were missed because another resident had an appointment. RN OS stated Resident #1 did not make it to the office for 3 weeks. The bandage had not been changed in 3 weeks and had to be soaked to remove dressing and Resident #1 received bandage burns to his skin. During an interview on [DATE] at 11:50 AM, the OS stated he had concerns Resident #1 was a no call/no show for his first scheduled post-operation visit on [DATE]. The OS stated the facility never called to reschedule visit or to clarify orders. The OS stated Resident #1 went over 3 weeks without bandage being changed, which led to the bandage had to be soaked to be removed and Resident #1 had bandage burns. The OS stated he was never notified of missed wound treatments. The OS stated Resident #1 missing wound care treatments postponed his foot healing. During an interview on [DATE] at 4:46 PM, MR stated she is responsible for making transportation arrangements. She stated she doesn't make the doctor's appointments and when residents are discharged from hospital with a card, the nurse is responsible to make the appointments. MR stated she did not have documentation to why Resident #1 missed appointment on [DATE]. MR stated there were days when the transportation van was not working in order to take residents to appointments; however, it was functioning and working properly on [DATE]. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:15pm. The Administration was informed of the IJ. The Administrator was provided with the IJ template on [DATE] at 5:15pm. Record review of Plan of Removal accepted on [DATE] at 2:35 PM reflected the following: What corrective actions have been implemented for the identified residents? A. Resident # 1 was unable to be assessed (expired 7/23). B. Transportation Log, Hospital Discharge Paperwork and Nurses notes will be reviewed during clinical morning meeting - appointments will be placed in log for Medical Records and Appointments will be reviewed with Administrator/Designee to ensure transportation for residents is provided. C. Transportation barriers will be communicated to Administrator/Designee to ensure appointments are followed. In event of transportation barrier facility will utilize outside resources (ie local transportation company, rental companies) to provide transportation for residents. D. Clinical Staff will notify Medical Records (via appointment sheets) of resident's MD appointments of cancelations or requests for rescheduling of appointment by family members. Medical Records will coordinate with MD office for appointment changes, cancelations or rescheduling of appointments. Clinical Staff will confirm with MD if current orders will remain in place or change any orders until next appointment. Clinical Staff will document changes in appointments in EHR. E. Medical Records / Designee with call family members and resident MD office to verify appointments, place on transportation log, upon return from MD appointment new appointment sheet will be made to reflect next appointment if necessary. How were other residents at risk to be affected by this deficient practice identified? All residents residing in the facility have the potential to be affected by this proposed deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. On [DATE] Administrator in-serviced the DON, Medical Records and ADONs on reviewing hospital discharge records and nursing documentation in clinical records for any MD appointments, place appointments on appointment sheet for medical records to coordinate transportation. DON and ADONs verbalized teach back of education provided to them. B. An in-service was initiated on [DATE] by Medical Records with clinical staff on appointment sheets for hospital discharge appointments, and MD appointment follow ups. Licensed staff verbalized teach back of education provided to them. C. Newly hired nurses and contract staff will be in-serviced by the Director of Nursing or ADON on appointment sheets for hospital discharge appointments, and MD appointment follow ups. Licensed staff will verbalized teach back of education provided to them. How will the system be monitored to ensure compliance? A. Medical Records / Designee will review during morning clinical meeting any clinical notes, hospital discharge records for MD appointments, will place on Transportation log, verify appointments. B. Medical Records / Designee will communicate with family prior to appointments, if family is unable to attend Medical Records will communicate with MD office on reschedule, will notify Charge Nurse and document in nurses note reason for change of MD appointment. C. Medical Records and Administrator will communicate regarding any appointment conflicts or families who are unable to attend appointments to ensure staff able to attend if needed. Quality Assurance Administrator / Designee will conduct 3 random transportation calendar audits a week for 2 months. Findings of audits and system management will be reported to the QAPI committee during the monthly meetings for the next 2 months, identifying system compliance or need for further education and clinical oversight. Administrator / Medical Records / IDT will conduct on [DATE] Ad Hoc QAPI meeting to review issue and response plan as indicated. An impromptu Quality Assurance and Performance Improvement review of the plan of removal will be completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from [DATE] at 8:00 am to [DATE] at 2:35pm as follows: During an interview on [DATE] at 11:08AM with TX D, she said neglect was not performing a doctor order, not documenting a doctor order, and not changing a resident's wound care dressings. She said the nurse aides were to notify the nurse about any new skin issue and at that time the nurse was supposed to go and do a skin assessment on the resident and notify the resident's physician and family. TX D said that would be the time to get an order from the physician and document the work in the resident's record. She said orders needed to be instant and should never take longer than an hour much less days from the physician and they needed to be implemented immediately as well. She said the treatment nurse was responsible for completed weekly skin assessments and they should reflect the actual picture of resident and their skin. TX D said progress notes and the TAR were supposed to be completed daily with an assessment of the wounds on the TAR and that NA was not an appropriate answer for the assessment of the wound, as it was not an accurate finding. During an interview on [DATE] at 11:25AM with CNA N, she said neglect from an aide would be to not report a skin issue to a nurse and not turning or repositioning a resident so not to put pressure on their wounds or causing pressure sores. CNA N said that the aides did not have an area to document issues, only that they were supposed to report abnormal things to their nurses. is report Nurse first, Skin issue get nurse to look at the skin issue, does not have a place to document. During an interview on [DATE] at 11:33AM with CNA P, she said that neglect from the aides would be not turning and repositioning a resident at least every 2 hours or not telling the nurse about a new skin problem when it was first seen. She said that the residents ran the risk of developing sores or their sores getting worse if the aides didn't frequently reposition the residents. During an observation and interview on [DATE] at 3:30PM with CNA R and Resident #8. Residnet #8 had a pillow behind her right shoulder, and she was inclined approx 45 degrees in the bed wearing oxygen. Resident #8 said the pillow was uncomfortable. While talking with Resident #8, CNA R came into her room, and told her that she wanted to be repositioned. CNA R said she would get help. While waiting for help to arrive, CNA R said the nurse aides were supposed to notify the charge nurses for any change in residents. For residents that had incontinence, the facility had barrier cream they could use for each change, but if they noticed reddened or open sores they were to call the charge nurse immediately. The residents were supposed to be repositioned at least every 2 hours. Resident #8 had an additional mattress overlay on her bed. CNA R said Resident #8 was on hospice, and they must have brought that overlay that morning. Resident #8 said the overlay was fine and she liked it, just didn't like the pillow at her shoulder. CNA R reminded Resident #8 that she had a sore on her lower back and bottom that they needed to try and take some pressure off to help it heal. During an interview on [DATE] at 12:06PM with ADON M, she said she had not been the RN that has been monitoring the skin of the residents of the facility. She said she became the ADON as of [DATE] and started at facility at the very end of May as an RN. she said CSD went over information regarding treatments, skin assessments, documenting in a timely manner, notifying the Dr of changes or if a resident had a refusal of treatment, and scheduling appointments. She said, if you did treatment and didn't sign the MAR, make a late entry to show that it was completed and forgot the documentation but do not go back and fill in the hole after the shift. She said the nurses were supposed to place any and all information on the 24-hour report sheets to help with continuity of care. ADON M said the treatment nurse was supposed to do the treatments and skin assessments, but if not, then the nurse for each resident should do them. She said at least 1 nurse key set has the treatment cart key to access supplies. ADON M said when she did treatments she would date and initial the bandage on the resident so anyone else could see when it was done last. She said, Personally, as a nurse if I see that it wasn't done, or the dates are old I would do a treatment myself. She said with the EHR you can go and change the date in the computer and lookback at the MAR and TAR to see the holes and back date for an assessment. She said, she would not see that as a competent nurse that it would be as a standard of nurse practice to, sign for another person or write something that you had not done yourself. She said she wouldn't want someone to fill in her own work. ADON M said she didn't think that could be a 28-day gap of knowing what I had done at work. I work 2 jobs, so it would definitely be hard to think back more than a couple of days what I had done. She said she would talk to the person that worked previously and ask them then to make a late entry if she seen that documentation had been missed. ADON M said she felt like the window of time that the information was not in the resident's records did not make them an accurate record for the resident. During an interview on [DATE] at 12:49PM with ADON E, he said he had been an LVN for 20 years and he had been working at the facility since May of 2023. ADON E said he started training as a floor nurse first with the expectation as he was going to be the ADON. He said as he was an LVN, he was not managing or monitoring wounds in the facility. He said TX G was managing wounds then TX D was and starting [DATE] it would be ADON C, all of those which were LVN's, so there were no RNs overall who were managing the wounds. ADON E said it had been himself and ADON C that had performed the skin sweep on [DATE] using a resident roster and the full body sheets to mark any skin issue a resident had. He said they did not do an assessment on the residents named in the allegations, as that was the responsibility of DON. He said after they completed the skin sweep, they took their paperwork to DON, but did not do new individual skin assessments in any of the resident's EHR's. ADON E said, So, I learned my lesson, will leave it red and put in a progress note, regarding filling in holes in the MAR and TAR. He said he would do treatment, or an assessment and just didn't get the documentation done, stating, days have just run together. He said, No it is not a standard of practice to go back in and back date or fill in holes in the MAR, TAR or assessments. It's the wrong thing to do. He said you do not chart the next date or later that something was done in a timely manner and never chart for someone else's work or lack of work. I wouldn't know how to defend that in court. He said he would not feel comfortable if someone else did his charting because you never know if you have an enemy. ADON E said he did inservice staff on wounds, charting, just make a note if it was wrong or late, aide to notify the nurse and the nurse needed to notify the doctor that there was a new skin issue. He said they had the 24-hour clip board for the writing of issues. ADON E said Have your shift to document your work. He said the nurses should make a note that the something was not done. He said for any changes, or refusals, the nurses should notify the dr sometime in the shift. During an interview on [DATE] at 1:28PM with MR, she said now they had 2 binders for appointments so each nurses station had 1. She said she was to look at the binders each day and transfer them to the appointment logs. MR said she was in-serviced on the doctor's notes to follow up about an appointment. She said ADM was her manager and if an appointment needed to be rescheduled, then she was to tell ADM and give an explanation. MR said she would be part of the clinical meetings each morning so she could also find out about resident issues and possible appointments, then further check on the binders. She said the facility had their own van and could use local van services or a taxi if needed to get residents to the doctor. MR said, if a family wanted to be with the resident, they did their best to accommodate. She said she a new change would be that they had to follow-up within the day with the family and the doctor's office to confirm appointments and rescheduling of appointments. She said the nurse looked through the admission paperwork for needed appts, and she would as well. During an interview on [DATE] at 1:45PM with ADON C she said, she had been an LVN for 16 yrs and had been working at the facility for 2 yrs. and 2 months. She said yesterday ([DATE]) she became the treatment nurse and before that she was an ADON. The weekend supervisor was the treatment nurse for the weekends. She said new admissions had to have a skin assessment and if they had any types of wounds they needed to have something as far as treatment orders in place within 24 hrs even on weekends. ADON C said every resident had a weekly skin assessment and they were able to run a report for the list of residents with skin assessments to see if they were done. She said, If you didn't document, it wasn't done. Regarding skin assessments and holes in MAR and TAR. She said she wouldn't feel comfortable to have another nurse document for her or doing so for another nurse. She said, That would be false documentation. ADON C said, There is no way I can even remember what I ate for supper last night. There is no way I would remember what I did last week or even further than that, regarding documentation that was days and weeks later. She said CSD was monitoring and managing the skin assessment reports and TAR's to make sure the nurses were getting their work done. She said herself and ADON E did the skin sweep on [DATE] and took skin sweep sheets to DON that had her notes on them. She said they used a skin sheet with the body, if there was nothing on the residents skin, they just put an x or line over body, if there was an area then they circled it with quick description, like redness or sore. ADON C said they didn't do any measurements, just noted any issue. She said CSD in-serviced them to document as you go and at latest the end of the shift, if its after the shift then have to write a progress note indicating it's a late entry and the reason documentation might have been missed or if it wasn't completed. Do not back date or fill in holes. Do not strike out an inaccurate assessment, just do a progress not to indicate the inaccuracy. ADON C said not doing a treatment or a skin assessment was a neglectful action. She said that was how skin issues were identified past a redness or stage 1 and why some wounds got worse. The intact then open sore or intact then DTI within days proved to be inaccurate representation of the resident's skin. She said the admission nurse had to look at new resident's paperwork to see if a resident either had an appointment or needed a follow up appointment and it was the admission nurse's responsibility to call and make the appointment and to put the information in the appointment book at the nurses station. ADON C said she worked with other orthopedic doctors in the past that at times would have orders not to touch the surgical dressing until follow-up appointments and it would sometimes be 2 weeks before a resident could be seen. She said that after the incident with Resident #1, they would now have to make follow-up calls for clarification of the treatment orders with those situations as well as follow up calls to the dr if the dressings were becoming dirty or heavy drainage through the dressing. ADON C said the biggest fix that she could do herself was to step down as an ADON and go back to being the treatment nurse herself. It had been several months since it was her responsibility so she would have to take some time to familiarize herself with wounds again. During an interview on [DATE] at 3:00PM with LVN B, she said she had been an LVN since 2005 and had been working at the facility since December of 2022. She said she had been in serviced regarding wound care in that the nurses needed to complete documentation on wounds either through the skin assessment sheets or the TAR when they were due and to make sure to notify doctor if something was new or a treatment was not completed due to a refusal. She said the nurse that admitted the resident had a skin assessment as a part of the admission paperwork. LVN B said the assessment would include what the skin looked like and if there were any wounds then should describe what the wound looked like, the approximate the size and the location of the wound. She said if there were wounds already present on the resident, they were to review the resident's paperwork for treatment orders and if there were not any orders then the nurses were supposed to notify the doctor to get treatment orders. In the case of resident doctors appointments, most especially if a resident had wounds, LVN B said the nurses reviewed the resident's paperwork for an already scheduled follow-up appointment or if an appointment needed to be scheduled for a resident. She said the nurses were responsible for calling the doctors office to confirm or set up an appointment and to clarify if a treatment was supposed to stay in place, or due to the extended period that it would be before the resident would be seen by the doctor, if the doctor would like to make an order for wound care treatments until the resident could be seen by the doctor. LVN B said each nurses station had an appointment book that the nurses were supposed to either place the appointment card in or write down the resident's name, date of appointment, which doctor and their address in the book. During an interview on [DATE] at 3:20PM with DON, she said she had been a nurse since 2008. She said she had been the DON since [DATE]th of 23. DON said there had been a big learning curve on the change of EHR system from what she had been used to in other facilities in the past. She said she is just very overwhelmed. DON said her orientation was really just a welcoming to the company not a EHR orientation. She said she did not really know how to pull reports to see what the nurses were completing or not. The CSD had been at the facility 3 times since DON came to facility. DON said the CSD has been available by phone has only recently showed her how to run reports. She said the CSD brought it to her attention that skin assessments had not been completed several times for several residents. DON said nursing management started with audits and was having daily all-day meetings checking on the nurses work, and TX G (former tx nurse) didn't want to participate, was not doing her work, would not communicate with DON that she could not get her work done. DON said the CSD said that there was a lot of issues with no documentation regarding treatments and said there was an issue back in March and April of 23 with TX G not getting her work done or her documentation done. She did not know the full description of which nurses did skin assessments for which residents but thought that the floor nurses split odd rooms day shift and even rooms night shift maybe. She said the treatment nurse should be the person that did residents skin assessments that had wounds. DON said she just got hyper focused on catching up the skin assessments and was just so overwhelmed that I was on auto pilot trying to get the documentation caught up. DON said, knows that you should not fill in holes in the MAR and TAR. Said she had never just maliciously done something like that before. She said, I know I have made mistakes, if someone will just tell me it is a mistake, I can fix it, but if you don't tell me whats wrong, I can't fix it. She said the last few days CSD had been going through the system showing her how to run different reports. She said she did a skin sweep when she first came to the facility with the other ADON's s and TX, and over the last week the ADON's s and TX had been doing them almost daily. She said Thursday ([DATE]) she went to the residents that had wounds and had the wound care doctor's notes from that morning and just made sure that there were no [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the physician when there was a significant change of condition for 4 (Resident #4, Resident #1, Resident #2, Resident #6) of 8 residents reviewed for notification of changes. 1. The facility failed to notify physician of Resident #4's missed treatments to wounds. 2. The facility failed to notify physician of Resident #1's missed treatments to wounds. 3. The facility failed to notify physician of Resident #2's newly acquired pressure ulcer. Resident #2 went 12 days without treatment to wound. 4. The facility failed to notify physician of Resident #6's left heel Deep Tissue Injury. Resident #6 went 5 days without treatment to wound. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk for not receiving care and services to meet their needs. Findings include: 1.Resident #4 Review of Resident # 4's face sheet dated [DATE] revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmission date of [DATE], with the following diagnosis Sepsis (primary) and need for assistance with personal care. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed Resident #4 had physical help limited to transfer only (mostly setup help or one person physical assist); Section H- Bowel and Bladder revealed always continent for bowel and bladder; Section M-Skin Conditions revealed Resident #4 was at risk of developing pressure ulcers/injuries and that Resident #4 had stage 4 pressure ulcer. Review of Resident #4's care plan dated [DATE] revealed: Focus: The resident has the potential for pressure ulcer development r/t impaired mobility, incontinence, obesity. Date Initiated: [DATE]. Revision on: [DATE]. Interventions: Notify nurse immediately of any signs of skin breakdown: redness, blisters, bruises and discoloration noted during bath or daily care. Date Initiated: [DATE]. Provide assist with turning and repositioning during rounds. Date Initiated: [DATE]; Focus: The resident has (DTI) pressure injury to Rt medial heel r/t Reduced Mobility. Date Initiated: [DATE]. Revision on: [DATE]. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: [DATE]. Administer treatments as ordered and monitor for effectiveness. Date Initiated: [DATE]. Assess/record/and monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: [DATE]. Revision on: [DATE]. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. Date Initiated: [DATE]. Record review of Resident #4's physician order revealed the following orders start date [DATE] Location of wound: Plantar right heel with order to be performed topically one time a day for Apply betadine to plantar right heel unstageable ulcer daily apply betadine until healed. Offloading @ all times. F/U with wound care and end date [DATE]. Record Review of Resident #4's TAR dated [DATE] - [DATE] revealed no evidence of treatment being completed on: [DATE] and [DATE]. Record review of Resident #4's physician order revealed the following order start date [DATE] Location of wound: Right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Leptospermum honey in to wound bed cover with border dressing. and end date [DATE]. Record Review of Resident #4's TAR dated on [DATE] - [DATE] revealed no evidence of treatment for order with being completed on: [DATE], [DATE] and [DATE]. Record review of Resident #4 physician order revealed the following order start date [DATE] Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Collagen powder and Calcium alginate with silver cover with border dressing. and end date [DATE]. Record Review of Resident #4's TAR dated on [DATE] - [DATE] revealed no evidence of treatment for order with being completed on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Record review of Resident #4's physician order revealed the following order start date [DATE] Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Collagen powder and Calcium alginate with silver cover with border dressing. and end date [DATE]. Record Review of Resident #4's TAR dated on [DATE] - [DATE] revealed no evidence of treatment for order with being completed on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Record review of Resident #4's physician order revealed the following order start date [DATE] Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen powder and sodium hypochlorite get (anapest) cover with border dressing. And end date [DATE]. Record Review of Resident #4's TAR dated on [DATE] - [DATE] revealed no evidence of treatment for order with being completed on: [DATE]. Record review of Resident #4 physician order revealed the following order start date on [DATE] Location of wound: Stage 4 right posterior medial heel to be performed every day shift every Tue, Thu, Sat Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date [DATE]. Record Review of Resident #4's TAR dated on [DATE] - [DATE] revealed no evidence of treatment for order with being completed on: [DATE]. Record review of Resident #4 physician order revealed the following order start date on [DATE] Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date [DATE]. Record Review of Resident #4's TAR dated on [DATE] - [DATE] revealed no evidence of treatment for order with being completed on: [DATE], and [DATE]. During interview on [DATE] at 10: 50 AM, the WCS stated he was not made aware of missed treatments or treatment refusals. WCS stated missing treatments and/or delay in treatment would have interfered with improvement of wound. 2. Resident # 1 Review of Resident # 1's closed record face sheet dated [DATE] revealed, [AGE] year-old male originally admitted on [DATE] with most recent hospital readmission date of [DATE], with the following diagnosis metabolic encephalopathy (primary), encounter for orthopedic aftercare following surgical amputation, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, need assistance with personal care, dependence on renal dialysis and end stage renal disease. Review of Resident # 1's closed record admission MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 10 (moderate cognitive impairment); Section G- Functional Status revealed Resident #1 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bladder and Bowel revealed Resident # 1 always incontinent for bowel and bladder; Section M-Skin Conditions revealed Resident #1 was at risk of developing pressure ulcers/injuries. Review of Resident #1's closed record care plan dated [DATE] (revised on [DATE]) revealed: Focus: The resident is at risk for pressure injury r/t History of Pressure Injuries, Poor nutrition, Reduced Mobility, Sheering/friction problems. Date Initiated: [DATE] Revision on: [DATE]; Perform and document weekly assessment form of skin for changes or observations. Date Initiated: [DATE] Protect elbows and heels from friction. Date Initiated: [DATE] Protect heels-offload when in bed. Administer medication as ordered. Date Initiated [DATE]. Follow facility policy and procedures for line listing, summarizing infections. Focus The resident has a stage 1 pressure injury to his R buttocks r/t Reduced Mobility, Incontinence, Sheering/Friction. Date Initiated: [DATE] Revision on: [DATE]. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: [DATE]. Administer treatments as ordered and monitor for effectiveness. Date Initiated [DATE] Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: [DATE]. Revision on: [DATE]. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: [DATE]. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated [DATE]. Provide low air loss mattress to bed. Date Initiated: [DATE]. Provide pressure relieving cushion to wheelchair. Monitor for placement and condition. Notify supervisor if cushion needs to be replaced. Date Initiated: [DATE]. Record review of Resident #1's closed record physician orders revealed start date [DATE] stating Location of wound: left foot with order to be performed every day shift Treatment order: Cleanse with NS or Wound Cleanser and pat dry. Swab with betadine swab. Cover with 4x4 and secure with tape. and no end date written. Record Review of Resident #1's closed record TAR dated [DATE] - [DATE], revealed no evidence of treatment for order being completed on: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Record review of Resident #1's closed record physician orders revealed start date [DATE] Location of wound: Unstageable Rt Ischium (hip) with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated [DATE] - [DATE], revealed no evidence of treatment for order being completed on: [DATE], [DATE], [DATE], [DATE] and [DATE]. Record review of Resident #1's closed record physician orders revealed start date [DATE] stating Location of wound: right Ischium with order to be performed every day shift Treatment order: Cleanse with NS/wound cleanser. Pat dry Apply Triad cream and cover with silicone dressing with end date [DATE]. Record Review of Resident #1's TAR dated [DATE] - [DATE], revealed no evidence of treatment for order being completed on: [DATE], [DATE], [DATE]. Record review of Resident #1's closed record physician orders revealed order with start date [DATE] stating Location of wound: Unstageable right Ischium with order to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Anasept and TAO to wound bed cover bordered gauze dressing with end date [DATE] written. Record Review of Resident #1's closed record TAR dated [DATE] - [DATE], revealed no evidence of treatment for completed on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Record review of Resident #1's closed record physician orders dated [DATE] revealed start date [DATE] stating Location of wound: Unstageable right Ischium with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated [DATE] - [DATE], revealed no evidence of being completed on: [DATE] and [DATE]. During an interview on [DATE] at 4:30 PM, RN OS stated OS had concerns with facility not showing up for appointments or calling to reschedule. RN OS stated Resident #1 was scheduled for one week follow up on [DATE] after surgery and missed appointment. RN OS stated the facility never called to clarify treatment orders, or to called to reschedule appointment. RN OS stated when she called to reschedule, facility stated visits were missed because another resident had an appointment. RN OS stated Resident #1 did not make it to the office for 3 weeks. The bandage had not been changed in 3 weeks and had to be soaked to remove dressing and Resident #1 received bandage burns to his skin. During an interview on [DATE] at 11:50 AM, the OS stated he had concerns Resident #1 was a no call/no show for his first scheduled post-operation visit on [DATE]. The OS stated the facility never called to reschedule visit or to clarify orders. The OS stated Resident #1 went over 3 weeks without bandage being changed, which led to the bandage had to be soaked to be removed and Resident #1 had bandage burns. The OS stated he was never notified of missed wound treatments. The OS stated Resident #1 missing wound care treatments postponed his foot healing. During an interview on [DATE] at 4:46 PM, MR stated she is responsible for making transportation arrangements. She stated she doesn't make the doctor's appointments and when residents are discharged from hospital with a card, the nurse is responsible to make the appointments. MR stated she did not have documentation to why Resident #1 missed appointment on [DATE]. MR stated there were days when the transportation van was not working in order to take residents to appointments; however, it was functioning and working properly on [DATE]. 3. Resident #2 Review of Resident # 2's face sheet dated [DATE] revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmission date of [DATE], with the following diagnosis unspecified dementia (primary), need for assistance with personal care, flaccid hemiplegia (inability to move without assistance) affecting right dominant side. Review of Resident # 2's annual MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 8 (moderate); Section G- Functional Status revealed Resident #2 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bowel and Bladder revealed always incontinent for bowel; Section M-Skin Conditions revealed Resident #2 was at risk of developing pressure ulcers/injuries. Review of Resident #2's care plan dated [DATE] revealed: Focus: The resident is at risk for pressure ulcer development r/t disease process and immobility. Date Initiated: [DATE] Revision on: [DATE]; Interventions: administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated [DATE]. Administer treatments as ordered and monitor for effectiveness. Date initiated [DATE]. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiate initiated: [DATE]. Inform the resident/family/caregivers of any new area of skin breakdown. Date initiated: [DATE]. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, S/SX of infection, wound size (length X width X depth), stage. Date Initiated: [DATE]. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Weekly skin assessments. Date initiated: [DATE]. Revision on: [DATE]; Focus: patient has a stage 4 pressure injury to right posterior calf with potential for further skin breakdown R/T: disease process, immobility, impaired mobility, lack of sensation, non-compliance with therapeutic regimen. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: [DATE]. Assist resident with turning/repositioning during rounds. Date Initiated: [DATE]. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: [DATE]. Review of Resident # 2's nurses notes dated [DATE] at 11:00 PM written by LVN T revealed: Aide has brought to my attention that [Resident #2] has open area on back of right ankle area. When this nurse assessed, I found wound that is denuded, partial thickness and has black eschar in wound bed. I cleansed wound with wound cleanser, applied hydrophilic ointment and covered with bordered gauze. Entire leg and foot have severe outward rotation. It is stroke effected side. Heel is elevated off bed and wound area is hanging free with no pressure. Review of Resident # 2's nurses note dated [DATE] at 1:37 PM written by LVN A revealed: Resident noted to have a DTI per night nurse to his right lower calf area cleaned Review of Resident #2's physician orders revealed no evidence of pressure ulcer treatment between [DATE] and [DATE]. Review of Resident #2's physician orders revealed: Order date [DATE] at 2:15 PM Cleanse right lower posterior calf with dermal wound cleaner apply Triad Debriding Cream to wound bed and cover with boarder dressing. Every day shift every Mon, Wed, Fri for promote Wound healing and every 1 hour as needed for skin irritation. During an interview on [DATE] at 5:35 PM, the DON stated she had completed skin assessment on [DATE] for Resident #2. The DON stated the system was new to her, and she must have gotten confused between patients. The DON stated she had not completed a thorough assessment and that her assessment did not give an accurate assessment of Resident # 2. The DON stated the negative affect on residents, if wound care treatments were not completed, could have caused skin breakdown, and could have caused the wounds to worsen in various ways. During interview on [DATE] at 10: 50 AM, the WCS stated he was not made aware of missed treatments or treatment refusals. WCS stated missing treatments and/or delay in treatment would have interfered with improvement of wound. 4. Resident # 6 Review of Resident # 6's face sheet dated [DATE] revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmission date of [DATE], with the following diagnosis Type 2 diabetes (primary), age-related physical debility, cognitive communication deficit, and unspecified dementia. Review of Resident # 6's significant change in status MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 99 (Unable to complete interview); Section G- Functional Status revealed patient had extensive dependence with most activities (1 physical assist); Section F- Bowel and Bladder revealed always incontinent to bowel and bladder. Section M-Skin Conditions revealed Resident #6 had a risk of developing pressure ulcers/injuries. Review of Resident #6's care plan dated [DATE] revealed no intervention related to Deep Tissue Injury prevention or care. Review of Resident #6's Weekly Skin Integrity Review dated [DATE] completed TX D revealed; Suspected Deep Tissue Injury to left heel measuring 4cm in length by 3cm in width. Review of Resident #6's physician orders revealed no evidence of wound treatment order for Deep Tissue Injury between [DATE] and [DATE]. Review of Resident #6's physician orders dated [DATE] revealed Skin prep to left heel every day and prn every day shift for wound care related to weakness. During an interview on [DATE] at 5:35 PM, the DON stated orders for new skin issues should be obtained within the shift but not later than 24 hours after identified. During interview on [DATE] at 10: 50 AM, the WCS stated he was not made aware of missed treatments or treatment refusals. WCS stated missing treatments and/or delay in treatment would have interfered with improvement of wound. During an interview on [DATE] at 8:19 AM TX G stated she had been the treatment nurse until mid-July. TX G stated she documented when she performed wound care. TX G stated if there were blanks in the TAR treatments were not done. TX G stated she had to work the floor on day or night shifts on several occasions and was not able to complete her duties as treatment nurse. TX G stated when she worked the floor, if she was am not the treatment nurse that day or not working, the charge nurses were responsible for wound care of their patients. During an interview on [DATE] at 9:38 AM, the ADM stated her expectation was that treatments were followed per physician's order. The ADM stated if treatment orders were missed it should have been documented why the treatment was missed and notify the physician that treatments were missed. The ADM stated missed treatments could have caused wounds to worsen. The DON was to monitor that treatments were completed. The ADM stated missing treatment could have put the residents at risk of neglect. The ADMN stated what led to the failure of physician not being contacted for orders and/or updating the physician was that staff got busy with other tasks or assumed that another shift had contacted physician. During an interview on [DATE] at 11:08 AM TX D stated neglect was not contacting a doctor when new issues were identified, not following doctor and/or performing a doctor's order. TX D stated the doctor should be contacted immediately when resident had a change of condition. TX D stated there was not any reason that a resident should have to wait for over 24 hours for orders. TX D stated missed wound treatments could have resulted in poor wound healing or worsening of wound. Record Review of Facility policy titled, Pressure Ulcer/Injury Risk Assessment dated [DATE] revealed: If the resident refuses the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification. Notify attending MD {Medical Director} if new skin alteration noted. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:15pm. The Administration was informed of the IJ. The Administrator was provided with the IJ template on [DATE] at 5:15pm. Record review of the Plan of Removal accepted on [DATE] at 2:35 PM reflected the following: What corrective actions have been implemented for the identified residents? A. Resident # 1 was unable to be assessed (expired 7/23). B. Resident # 2 was assessed by Director of Nursing on [DATE] at the time the concern was identified. No new concerns were identified. Wound Care physician also assessed patient on 8/3. No new concerns were identified C. Resident # 4 was assessed by Director of Nursing on [DATE] at the time the concern was identified. No new concerns were identified. Wound Care physician also assess patient on 8/3. No new concerns were identified. D. Resident # 6 was assessed by Director of Nursing on [DATE] at the time the concern was identified. No new concerns were identified. E. Facility nurse management (Assistant Directors of Nursing) completed a skin audit on residents residing in the facility on [DATE], [DATE] and [DATE]. Skins audits were reviewed by DON and Nurse management team. Two residents were identified that had open areas. Physician was notified and orders received by facility for treatment. F. Residents physician will be notified upon the identification of a new wound, any wounds that have progressively worsened and any missed treatment or treatments that were refused by the resident. This notification will be documented in the resident's chart. G.DON and/or designee will review and ensure that orders, treatments and notification to the physician are completed through the facilities daily clinical meeting. Any concerns identified will be addressed immediately. How were other residents at risk to be affected by this deficient practice identified? A. All residents residing in the facility have the potential to be affected by this proposed deficient practice. B. Facility nurse management (Assistant Directors of Nursing) completed a skin audit on residents residing in the facility on [DATE], [DATE] and [DATE]. Skins audits were reviewed by DON and Nurse management team. Two residents were identified that had open areas. Physician was notified and orders received by facility for treatment. The facility has 15 total residents with skin issues. The physician has been notified of all issues. The two additional residents were identified on the 8/2 skin round. Resident A had two areas (irritant dermatitis from body fluid) on this scrotum/anterior thigh. Resident B had one area on each buttock. Hospice and physician were notified on both patients. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. During the facilities morning clinical meeting the DON and/or designee will review any new wounds, any new treatments, wounds that have progressively worsened and any treatments that were missed or refused and ensure physician notification was completed and documented appropriately in the residents chart. B. On [DATE] Corporate Clinical Services Director in-serviced the DON and nurse managers on properly and accurately assessing resident's skin, monitoring for change of condition, wound care documentation, clinical records documentations, and any omissions of treatments in the treatment record. This in-service included MD notification. DON, ADONs and Treatment Nurse will verbalize teach back of education provided to them. Any staff not available will be required to receive in-service prior to their next schedule shift. C. Facility direct care staff was in-serviced by the Clinical Management team on [DATE] regarding pressure ulcer prevention. This in-service included MD notification. Any staff not available will be required to receive in-service prior to their next schedule shift. D. An in-service was initiated on [DATE] by Director of Nursing and ADONs with the licensed nursing staff on properly assessing resident's skin, monitoring for change of condition, wound care documentation, clinical records documentation, and omissions of treatments in the treatment record. Licensed staff will verbalize teach back of education provided to them. This in-service included MD notification. Any staff not available will be required to receive in-service prior to their next schedule shift. E. Newly hired nurses and contract staff will be in-serviced by the Director of Nursing or ADON on properly assessing resident's skin, monitoring for change of condition, wound care documentation, clinical records documentation, and omissions of treatments in the treatment record. This in-service included MD notification. Licensed staff will verbalize teach back of education provided to them. F. Facility has implemented/re-implemented the following procedure to ensure How will the system be monitored to ensure compliance? Facility Director of Nursing and/or designee will review skin assessments, treatment administration records, documentation and physician notification through facilities clinical morning meeting. Any identified concerns will be address immediately. Facility Administrator and/or designee will attend the clinical morning meeting and ensure system is being followed. Any concerns identified will be addressed immediately. This process began immediately on [DATE] and will continue weekly DON will Monitor and the Administrator will oversee Clinical documentation review upon admission/readmission noting pressure injury/skin and that physician was notified, orders were received, and area treated. Any identified concerns will be addressed immediately with staff and physician. Monitoring will continue 5x weekly for the next 8 weeks. DON will monitor and the Administrator will oversee that upon admission/readmission that the charge nurse on duty has completed the full body skin assessment - intentionally assessing the resident head to toe for evidence of any pressure injury or skin concerns. DON and facility treatment nurse will review to ensure accuracy and to ensure the physician was notified of any identified concerns. Monitoring will continue 5x weekly for the next 8 weeks. DON will monitor and Administrator will oversee conducting weekly skin assessments shall be completed upon admission/readmit at least every 7 days thereafter. This will be monitored through the facility's clinical morning meeting. Monitoring will continue 5x weekly for the next 8 weeks. DON will monitor and Administrator will oversee the signing out for weekly skin assessments on the MAR and signing out the treatments as ordered and administered by licensed nurse a minimum of 5x weekly for three months during the morning clinical meeting. If there is an omission in the TAR or an assessment showing not completed the assigned nurse will be called immediately to verify if there was a reason for the omission. If truly missed the resident will be assessed immediately and the physician notified of the missed treatment/assessment. DON will monitor and Administrator will oversee that the Charge Nurse / Wound Care Nurse conducts a head - to - toe skin assessment upon admission / readmission and that physician is notified and orders received and that this is documented in the resident chart. Charge nurses will perform a complete skin assessment for each admission/re-admission including notifying the physician, receiving orders and documenting such. DON, ADONs or Treatment Nurse will conduct post admission skin assessments within 24 -72 hours after the initial admission/readmission skin assessment to validate accuracy of documentation of skin condition. Any remedial education or reprimand will occur at this time. DON will monitor and the Administrator will oversee weekly for the next 8 weeks that the IDT will review the plan of care to ensure appropriate interventions are in place to address the prevention of or minimizing the risks associated with skin injury in relation to the identified residen[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for 6 of 8 residents (Resident #4, Resident #1, Resident #2, Resident #6, Resident #7, Resident #8) reviewed for neglect. 1. The facility failed to follow physician's orders to prevent Resident #4's Deep Tissue Injury to right medial heel to deteriorate to a stage 4 pressure ulcer. 2. The facility failed to follow physician's orders to prevent Resident #1's Right Ischium(hip) pressure ulcer to deteriorate from a stage 2 to a stage 3. 3. The facility failed to obtain orders from Resident #1's Podiatrist when appointments were missed status post amputation of 5th digit of left foot. 4. The facility failed to obtain physician orders for treatment of Resident #2's pressure ulcer on right posterior calf. Resident #2 went 12 days without treatment to wound. Resident #2 was assessed on 08/03/2023 with Stage IV. 5. The facility failed to obtain physician orders for treatment of Resident #6's left heel Deep Tissue Injury. Resident #6 went 5 days without treatment to wound. 6. The facility failed to complete skin assessments of Resident #7 which led to the development of a stage 2 pressure ulcer to the right upper buttocks and stage 2 to the right lower buttocks. 7. The facility failed to complete weekly skin assessments which led to Resident #8 developing stage 2 pressure ulcer to left buttock and stage 2 pressure ulcer to right buttock. 8. The facility failed to ensure Resident # 2 and Resident #4 ' s skin assessments were completed, assessed accurately and accurately documented by the DON. 9. The facility failed to ensure Resident #1, Resident #4 and Resident #5 ' s wound treatments were completed and accurately documented by DON and ADON E. 10. The facility failed to maintain accurate list of residents with pressure ulcers. The facility did a skin sweep and found Resident #7's and Resident #8's wounds after surveyor intervention requesting accurate lists of residents with pressure ulcers. An Immediate Jeopardy (IJ) was identified on 08/03/23. While the IJ was lowered on 08/07/23, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of infections, worsening of wounds, injuries, emotional distress, and even death. Findings included: 1.Resident #4 Record review of Resident # 4's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmission date of 01/11/2023, with the following diagnosis Sepsis (primary) and need for assistance with personal care. Record Review of Resident #4's quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed Resident #4 had physical help limited to transfer only (mostly setup help or one person physical assist); Section H- Bowel and Bladder revealed always continent for bowel and bladder; Section M-Skin Conditions revealed Resident #4 was at risk of developing pressure ulcers/injuries and that Resident #4 had stage 4 pressure ulcer. Record review of Resident #4's care plan dated 05/15/2023 revealed: Focus: The resident has the potential for pressure ulcer development r/t impaired mobility, incontinence, obesity. Date Initiated: 08/23/2022. Revision on: 08/23/2022. Interventions: Notify nurse immediately of any signs of skin breakdown: redness, blisters, bruises and discoloration noted during bath or daily care. Date Initiated: 08/23/2022. Provide assist with turning and repositioning during rounds. Date Initiated: 08/23/2022; Focus: The resident has (DTI) pressure injury to Rt medial heel r/t Reduced Mobility. Date Initiated: 03/29/2023. Revision on: 03/29/2023. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 03/29/2023. Administer treatments as ordered and monitor for effectiveness. Date Initiated: 03/29/2023. Assess/record/and monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 03/29/2023. Revision on: 06/05/2023. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. Date Initiated: 03/29/2023. Record review of Resident #4's physician order revealed start date 03/14/2023 Location of wound: Plantar right heel with order to be performed topically one time a day for Apply betadine to plantar right heel unstageable ulcer daily apply betadine until healed. Offloading @ all times. F/U with wound care and end date 04/13/2023. Record Review of Resident #4's TAR dated 04/01/2023 - 04/30/2023 revealed no evidence of treatment being completed on: 04/08/2023 and 04/09/2023. Record review of Resident #4's physician order revealed the order start date 04/13/2023 Location of wound: Right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Leptospermum honey in to wound bed cover with border dressing. and end date 05/04/2023. Record Review of Resident #4's TAR dated on 04/01/2023 - 04/30/2023 revealed no evidence of treatment for order with being completed on: 04/14/2023, 04/15/2023 and 04/23/2023. Record review of Resident #4's physician order revealed the following order start date 05/04/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Collagen powder and Calcium alginate with silver cover with border dressing. and end date 06/27/2023. Record Review of Resident #4's TAR dated on 05/01/2023 - 05/31/2023 revealed no evidence of treatment for order with being completed on: 05/08/2023, 05/15/2023, 05/16/2023, 05/22/2023, 05/29/2023, 05/30/2023 and 05/31/2023. Record Review of Resident #4's TAR dated on 06/01/2023 - 06/30/2023 revealed no evidence of treatment for order with being completed on: 06/02/2023, 06/03/2023, 06/04/2023, 06/12/2023, 06/19/2023, 06/20/2023, 06/21/2023 and 06/24/2023. Record review of Resident #4's physician order revealed the following order start date 06/27/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen powder and sodium hypochlorite get (anapest) cover with border dressing. And end date 06/29/2023. Record Review of Resident #4's TAR dated on 06/01/2023 - 06/30/2023 revealed no evidence of treatment for order with being completed on: 06/28/2023. Record review of Resident #4's physician order revealed the following order start date on 06/29/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift every Tue, Thu, Sat Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date 07/10/2023. Record Review of Resident #4's TAR dated on 07/01/2023 - 07/31/2023 revealed no evidence of treatment for order with being completed on: 07/01/2023. Record review of Resident #4's physician order dated 07/29/2023 revealed the following order start date on 07/10/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date 07/20/2023. Record Review of Resident #4's TAR dated on 07/01/2023 - 07/31/2023 revealed no evidence of treatment for order with being completed on: 07/14/2023, 07/15/2023, and 07/23/2023. Record review of Resident #4's Medication Administration Audit Report generated by CSD revealed: -Scheduled for 07/14/2023 at 06:00AM and charted as completed on 07/29/2023 8:58PM by DON. -Scheduled for 07/15/2023 at 06:00AM was charted as completed on 07/29/2023 9:06PM by DON. -Scheduled for 07/23/23 at 6:00AM was charted as completed on 7/29/23 at 9:53PM by DON. Record review of Resident #4's nurse's skin assessment dated [DATE] revealed DTI (deep tissue injury) to right medial heel. Record review of Resident #4's nurse's skin assessment dated [DATE] completed by DON revealed Skin Intact. Record review of Resident #4's WCS physician note dated 05/18/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.8cm in length by 2.4cm in width by 0.3cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. Record review of Resident #4's WCS physician note dated 05/25/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.8cm in length by 2.4cm in width by 0.3cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. Treatment options - risks - benefits and the possible need for subsequent additional procedures on this wound were explained on 04/13/2023 to the patient. Record review of Resident #4's WCS physician note titled dated 07/27/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.4cm in length by 2.2cm in width by 0.2cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. During an observation and interview on 08/01/2023 at 4:30PM Resident #4 was sitting up in wheelchair with offloading boot to right foot and elevated with extended wheelchair footrest. Resident #4 stated she gave permission to observe foot and take a photograph of wound. Resident #4's right foot pressure ulcer had thick green tinged skin surrounding a circular wound with beefy red granulation tissue observed to wound bed. Observation of small amount of drainage observed to bandage and no odor. Resident #4 stated she had no concerns with her wound. 2. Resident # 1 Record review of Resident # 1's closed record face sheet dated 07/29/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent hospital readmission date of 06/03/2023, with the following diagnosis metabolic encephalopathy (primary), encounter for orthopedic aftercare following surgical amputation, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, need assistance with personal care, dependence on renal dialysis and end stage renal disease. Record review of Resident # 1's closed record admission MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 10 (moderate cognitive impairment); Section G- Functional Status revealed Resident #1 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bladder and Bowel revealed Resident # 1 always incontinent for bowel and bladder; Section M-Skin Conditions revealed Resident #1 was at risk of developing pressure ulcers/injuries. Record review of Resident #1's closed record care plan dated 05/15/2022 (revised on 06/04/2023) revealed: Focus: The resident is at risk for pressure injury r/t History of Pressure Injuries, Poor nutrition, Reduced Mobility, Sheering/friction problems. Date Initiated: 08/20/2020 Revision on: 02/21/2022; Perform and document weekly assessment form of skin for changes or observations. Date Initiated: 08/20/2020 Protect elbows and heels from friction. Date Initiated: 08/20/2020 Protect heels-offload when in bed. Administer medication as ordered. Date Initiated 11/29/2022. Follow facility policy and procedures for line listing, summarizing infections. Focus The resident has a stage 1 pressure injury to his R buttocks r/t Reduced Mobility, Incontinence, Sheering/Friction. Date Initiated: 08/18/2022 Revision on: 10/24/2022. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/18/2022. Administer treatments as ordered and monitor for effectiveness. Date Initiated 08/18/2022 Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 08/18/2022. Revision on: 08/23/2022. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: 08/18/2022. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated 08/18/2022. Provide low air loss mattress to bed. Date Initiated: 08/18/2022. Provide pressure relieving cushion to wheelchair. Monitor for placement and condition. Notify supervisor if cushion needs to be replaced. Date Initiated: 08/18/2022. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed no new areas, continue tx{treatment} to diabetic ulcer to lt{left} foot. Record review of Resident #1's closed record admission Summary Progress Note dated 06/03/2023 revealed stage 2 pressure wound on coccyx. Record review of Resident #1's closed record progress note titled Skin/Wound Note dated 06/15/2023 revealed WCS here this am to see resident. Stage 3 on rt ischium measures3x4.5x0.3. Light serous drainage with45% slough 5% granulation, 50% skin. Deterioration noted. [NAME] tinge to drainage concerning for Pseudomonas. No signs of infection. WCS preformed surgical excisional debridement to remove necrotic tissue and establish the margins of viable tissue. Record review of Resident #1's closed record nurses progress note dated 06/21/2023 revealed Resident return from OS per physician progress notes: 1) Please do NOT change the patients dressing 2)RTC on June 25 @ 1130AM. Transportation notified of f/u appt. and Info updated on 24 hour report. Record review of Resident #1's closed record nurses progress note dated 06/30/2023 revealed Resident return from OS office per physician progress notes Please change Resident #1's foot wound dressing daily. No further need for ACE wrap. Please see that patient gets his augmentin as ordered. Call placed to OS office for clarification on orders what does provider want for dressing orders and orders for augmentin. Per [NAME] nurse at OS office to cleanse wound then swab with betadine cover with 4x4 and secure. Augmentin 875mg q12 hours x10days. Orders updated in chart and placed on24 hr{hour} report. Record review of Resident #1's closed record nurses progress note dated 07/07/2023 revealed Resident return from OS appointment per physician's progress notes: Continue daily dressing changes with betadine to wound base . Return in 1 week appt of 7/14/23 @ 1045am Transportation notified. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 4 pressure ulcer to R Ischium with wound care and left leg dressing intact. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 3 pressure ulcer to R Ischium measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth and left leg dressing intact. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 3 pressure ulcer to R Ischium measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 05/18/2023 revealed diabetic wound of the left, distal, plantar, lateral foot full thickness. Surgical excisional debridement procedure indicated for removal of necrotic tissue and establish the margins of viable tissue. No mention of R Ischium wound. Record review of Resident #1's closed record WCS physician notes dated 06/08/2023 revealed R Ischium wound measuring 2.3cm in length by 4.5cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/15/2023 revealed R Ischium wound measuring 3.0cm in length by 4.5cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/22/2023 revealed R Ischium wound measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/29/2023 revealed R Ischium wound measuring 3.5cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 07/06/2023 revealed R Ischium wound measuring 4.0cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record hospital records dated 05/16/2023 revealed Stage 2 coccygeal & gluteal PI-POA. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed start date 06/27/2023 Location of wound: Unstageable Rt Ischium with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated July 1, 2023 - July 31, 2023, revealed no evidence of treatment for order being completed on: 07/01/202, 07/03/2023, 07/05/2023, 07/07/2023 and 07/12/2023. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed start date 06/05/2023 stating Location of wound: right Ischium with order to be performed every day shift Treatment order: Cleanse with NS/wound cleanser. Pat dry Apply Triad cream and cover with silicone dressing with end date 06/09/2023. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of treatment for order being completed on: 06/07/2023, 06/08/2023, 06/09/2023. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed order with start date 06/09/2023 stating Location of wound: Unstageable right Ischium with order to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Anasept and TAO to wound bed cover bordered gauze dressing with end date 06/27/2023 written. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of treatment for completed on: 06/09/2023, 06/14/2023, 06/19/2023, 06/20/2023, 06/21/2023, 06/24/2023, 06/25/2023 and 06/26/2023. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed start date 06/27/2023 stating Location of wound: Unstageable right Ischium with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of being completed on: 06/27/2023 and 06/30/2023. Record review of Resident #1's physician orders dated 7/29/23 revealed no evidence of treatment orders for Resident #1 left foot from 06/01/2023 to 06/30/2023. Record review of Resident # 1 physician orders revealed start date 06/30/2023 Location of wound: left foot with order to be performed every day shift Treatment order: Cleanse with NS or Wound Cleanser and pat dry. Swab with betadine swab. Cover with 4x4 and secure with tape. and no end date. Record Review of Resident #1's TAR dated July 1, 2023 - July 31, 2023, revealed no evidence of treatment for order being completed on: 07/01/2023, 07/03/2023, 07/05/2023, 07/07/2023, 07/09/2023 and 07/12/2023. Record review of Resident #2's Progress note dated 08/03/23 revealed: DON performed skin assessment of this resident who has stage 4 pressure wound to right posterior, lower extremity, measures 3.2 x 1.8 x 1.0cm with minimal serous drainage noted, peri wound of normal skin color for resident. 70% granulation tissue noted, no slough, and tendon and bone noted. Suprapubic cath site to mid-lower abdomen area, no drainage or leakage to area noted. No sis of infection or further abnormalities noted. Signed DON 8/3/23 at 7:40PM Record review of Resident #2's Wound Care Physician Assessment Note dated 08/03/23 revealed: Focused Wound Exam (Site 1) STAGE 4 PRESSURE WOUND OF THE RIGHT, LATERAL CALF FULL THICKNESS. Etiology (quality), Pressure. Stage. 4. Duration > 1 days During an interview on 07/29/2023 at 12: 59 PM Resident # 1's family member stated he/she had concerns about Resident 1's care while at the facility. Resident #1's family member stated he/she felt Resident #1 was neglected by the facility which led to his death. Resident #1's family member stated his room always smelled like urine and that Resident #1's dressing on his wounds were never changed timely. During an interview on 08/03/2023 at 11:50 AM the OS stated he had concerns Resident #1 was a no call/no show for his first scheduled post-operation visit. The OS stated the facility never called to reschedule visit or to clarify orders. The OS stated Resident #1 went over 3 weeks without bandage being changed, which led to the bandage had to be soaked to be removed and Resident #1 had bandage burns. The OS stated he was never notified of missed treatments. The OS stated Resident #1 missing wound care treatments postponed his foot healing. 3. Resident #2 Review of Resident #2's face sheet dated 08/03/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmission date of 10/05/2022, with the following diagnosis unspecified dementia (primary), need for assistance with personal care, flaccid hemiplegia affecting right dominant side. Review of Resident #2's annual MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 8 (moderate); Section G- Functional Status revealed Resident #2 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bowel and Bladder revealed always incontinent for bowel; Section M-Skin Conditions revealed Resident #2 was at risk of developing pressure ulcers/injuries. Review of Resident #2's care plan dated 07/04/2022 revealed: Focus: The resident is at risk for pressure ulcer development r/t disease process and immobility. Date Initiated: 06/26/2018 Revision on: 04/15/2021; Interventions: administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 06/26/2018. Administer treatments as ordered and monitor for effectiveness. Date initiated 06/26/2018. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiate initiated: 06/26/2018. Inform the resident/family/caregivers of any new area of skin breakdown. Date initiated: 06/26/2018. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, S/SX of infection, wound size (length X width X depth), stage. Date Initiated: 06/26/2018. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Weekly skin assessments. Date initiated: 06/26/2018. Revision on: 03/03/2023; Focus: patient has a stage 4 pressure injury to right posterior calf with potential for further skin breakdown R/T: disease process, immobility, impaired mobility, lack of sensation, non-compliance with therapeutic regimen. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: 07/29/2023. Assist resident with turning/repositioning during rounds. Date Initiated: 07/29/2023. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: 07/29/1013. Review of Resident #2's nurses notes dated 07/15/2023 at 11:00 PM written by LVN T revealed: Aide has brought to my attention that [Resident #2] has open area on back of right ankle area. When this nurse assessed, I found wound that is denuded, partial thickness and has black eschar in wound bed. I cleansed wound with wound cleanser, applied hydrophilic ointment and covered with bordered gauze. Entire leg and foot have severe outward rotation. It is stroke effected side. Heel is elevated off bed and wound area is hanging free with no pressure. Review of Resident #2's nurses note dated 07/17/2023 at 1:37 PM written by LVN A revealed: Resident noted to have a DTI per night nurse to his right lower calf area cleaned Review of Resident #2's physician orders revealed no evidence of pressure ulcer treatment between 07/15/2023 and 07/27/2023. Review of Resident #2's physician orders revealed: Order date 07/27/2023 at 2:15 PM Cleanse right lower posterior calf with dermal wound cleaner apply Triad Debriding Cream to wound bed and cover with boarder dressing. Every day shift every Mon, Wed, Fri for promote Wound healing and every 1 hour as needed for skin irritation. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by DON revealed Skin Intact. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by TX D revealed Right lower leg stage 3 pressure ulcer measuring 2.5cm in length by 2.7cm in width by 0.5cm in depth. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by TX D revealed right lower leg unstageable pressure ulcer measuring 2.5cm in length by 2.0cm in width by 0.5cm in depth. During an observation on 07/29/2023 at 4:10PM of Resident #2 revealed Resident #2 lying in bed with right leg on pillow. Resident #2's right lower leg was covered by gauze and secured with tape. The dressing did not have a date on the outside. During an observation on 7/30/2023 at 3:30 PM of Resident #2 revealed Resident #2's lower right leg had a wound that had red tissue present, surrounding skin within normal limits for race, no tendon or bone observed, no necrosis observed, measurements were not taken appeared to be a Stage 3. During an interview on 07/30/2023 at 5:35 PM, the DON stated she had completed skin assessment on 7/20/2023 for Resident #2. The DON stated that she should have looked at the nurses notes to verify that Resident #2 did have a pressure ulcer. The DON stated the system was new to her, and she must have gotten confused between patients. The DON stated she had not completed a thorough assessment and that her assessment did not give an accurate assessment of Resident # 2, because if nurses note on 07/13 and 7/15 stated he had a pressure ulcer then her assessment on 7/20 should have reflected that. The DON stated the negative affect on residents, if wound care treatments were not completed, could have caused skin breakdown, and could have caused the wounds to worsen in various ways. 4. Resident # 6 Review of Resident #6's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmission date of 08/31/2018, with the following diagnosis Type 2 diabetes (primary), age-related physical debility, cognitive communication deficit, and unspecified dementia. Review of Resident #6's significant change in status MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 99 (Unable to complete interview); Section G- Functional Status revealed patient had extensive dependence with most activities (1 physical assist); Section F- Bowel and Bladder revealed always incontinent to bowel and bladder. Section M-Skin Conditions revealed Resident #6 had a risk of developing pressure ulcers/injuries. Review of Resident #6's care plan dated 5/15/2023 revealed no intervention related to Deep Tissue Injury prevention or care. Review of Resident #6's Weekly Skin Integrity Review dated 07/25/2023 completed TX D revealed; Suspected Deep Tissue Injury to left heel measuring 4cm in length by 3cm in width. Review of Resident #6's physician orders dated 07/29/2023 revealed no evidence of wound treatment order for Deep Tissue Injury between 07/25/2023 and 07/29/2023. Review of Resident #6's physician orders dated 07/30/2023 revealed Skin prep to left heel every day and prn everyday shift for wound care related to weakness. During an observation and interview on 08/01/2023 at 4:25 PM revealed Resident #6 laying on her back not wearing her offloading boot, the boot was to the left side of her foot. Resident #6's wound was located on left heel, the wound was circular and purple in color, there was no drainage and skin appeared. During an interview on 08/01/2023 at 4:25 PM ADON C stated Resident #6 should have been wearing the offloading boot while in laying bed. ADON C stated that Resident #6's wound was not healed and needed further treatment. 5. Resident #7 Review of Resident #7's face sheet dated 08/02/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmission date of 07/27/2023, with the following diagnosis cerebral infarction (primary), muscle weakness, need for assistance with personal care, and Type 2 diabetes. Review of Resident #7's quarterly MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed limited to extensive assist needing 1 - 2+ persons for assistance; Section- H Bowel and Bladder revealed occasionally incontinent to bladder and frequently incontinent to bowel. Section M- Skin Conditions revealed resident is at risk for developing pressure ulcers/injuries. Review of Resident #7's care plan dated 05/31/2023 revealed: Focus: The resident has pressure injury to Rt buttock stage 3 with potential for further skin breakdown r/t: chronic progressive disease, impaired mobility, obesity. Date Initiated: 03/02/2023. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: 03/02/2023. Assist resident with turning/repositioning during rounds. Date Initiated: 03/02/2023. Check for incontinence during rounds and provide care as needed. Keep resident clean and dry. Date Initiated: 03/02/2023. Document wound appearance, color, wound healing, s/sx of infection, wound size (length X width X depth) and stage, and report to MD PRN any changes in skin status. Date Initiated: 03/02/2023. Notify Nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: 03/02/2023. Provide pressure relieving device in bed. Date Initiated: 03/02/2023. Refer to dietician and follow recommendation. Date Initiated: 03/02/2023. Serve diet as ordered. Date Initiated: 03/02/2023. Review of Resident #7's Weekly Skin Integrity Review dated 07/28/2023 completed by TX D revealed redness to right buttock. Review of Resident #7's Skin Note dated 07/31/2023 completed by TX D revealed Wounds to bilateral gluteal ischium tuberosities are healed, discontinue wound care to these areas, will continue to monitor. Review of [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibited and prevented abuse and neglect for 6 of 8 residents (Resident #4, Resident #1, Resident #2, Resident #6, Resident #7, Resident #8) reviewed for neglect. 1. The facility failed to follow physician's orders to prevent Resident #4's Deep Tissue Injury to right medial heel to deteriorate to a stage 4 pressure ulcer. 2. The facility failed to follow physician's orders to prevent Resident #1's Right Ischium(hip) pressure ulcer to deteriorate from a stage 2 to a stage 3. 3. The facility failed to obtain orders from Resident #1's Podiatrist when appointments were missed status post amputation of 5th digit of left foot. 4. The facility failed to obtain physician orders for treatment of Resident #2's pressure ulcer on right posterior calf. Resident #2 went 12 days without treatment to wound. Resident #2 was assessed on 08/03/2023 with Stage IV. 5. The facility failed to obtain physician orders for treatment of Resident #6's left heel Deep Tissue Injury. Resident #6 went 5 days without treatment to wound. 6. The facility failed to complete skin assessments of Resident #7 which led to the development of a stage 2 pressure ulcer to the right upper buttocks and stage 2 to the right lower buttocks. 7. The facility failed to complete weekly skin assessments which led to Resident #8 developing stage 2 pressure ulcer to left buttock and stage 2 pressure ulcer to right buttock. 8. The facility failed to ensure Resident # 2 and Resident #4 ' s skin assessments were completed, assessed accurately and accurately documented by the DON. 9. The facility failed to ensure Resident #1, Resident #4 and Resident #5 ' s wound treatments were completed and accurately documented by DON and ADON E. 10. The facility failed to maintain accurate list of residents with pressure ulcers. The facility did a skin sweep and found Resident #7's and Resident #8's wounds after surveyor intervention requesting accurate lists of residents with pressure ulcers. An Immediate Jeopardy (IJ) was identified on 08/03/23. While the IJ was lowered on 08/07/23, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of infections, worsening of wounds, injuries, emotional distress, and even death. Findings included: 1.Resident #4 Record review of Resident # 4's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmission date of 01/11/2023, with the following diagnosis Sepsis (primary) and need for assistance with personal care. Record Review of Resident #4's quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed Resident #4 had physical help limited to transfer only (mostly setup help or one person physical assist); Section H- Bowel and Bladder revealed always continent for bowel and bladder; Section M-Skin Conditions revealed Resident #4 was at risk of developing pressure ulcers/injuries and that Resident #4 had stage 4 pressure ulcer. Record review of Resident #4's care plan dated 05/15/2023 revealed: Focus: The resident has the potential for pressure ulcer development r/t impaired mobility, incontinence, obesity. Date Initiated: 08/23/2022. Revision on: 08/23/2022. Interventions: Notify nurse immediately of any signs of skin breakdown: redness, blisters, bruises and discoloration noted during bath or daily care. Date Initiated: 08/23/2022. Provide assist with turning and repositioning during rounds. Date Initiated: 08/23/2022; Focus: The resident has (DTI) pressure injury to Rt medial heel r/t Reduced Mobility. Date Initiated: 03/29/2023. Revision on: 03/29/2023. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 03/29/2023. Administer treatments as ordered and monitor for effectiveness. Date Initiated: 03/29/2023. Assess/record/and monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 03/29/2023. Revision on: 06/05/2023. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. Date Initiated: 03/29/2023. Record review of Resident #4's physician order revealed start date 03/14/2023 Location of wound: Plantar right heel with order to be performed topically one time a day for Apply betadine to plantar right heel unstageable ulcer daily apply betadine until healed. Offloading @ all times. F/U with wound care and end date 04/13/2023. Record Review of Resident #4's TAR dated 04/01/2023 - 04/30/2023 revealed no evidence of treatment being completed on: 04/08/2023 and 04/09/2023. Record review of Resident #4's physician order revealed the order start date 04/13/2023 Location of wound: Right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Leptospermum honey in to wound bed cover with border dressing. and end date 05/04/2023. Record Review of Resident #4's TAR dated on 04/01/2023 - 04/30/2023 revealed no evidence of treatment for order with being completed on: 04/14/2023, 04/15/2023 and 04/23/2023. Record review of Resident #4's physician order revealed the following order start date 05/04/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Collagen powder and Calcium alginate with silver cover with border dressing. and end date 06/27/2023. Record Review of Resident #4's TAR dated on 05/01/2023 - 05/31/2023 revealed no evidence of treatment for order with being completed on: 05/08/2023, 05/15/2023, 05/16/2023, 05/22/2023, 05/29/2023, 05/30/2023 and 05/31/2023. Record Review of Resident #4's TAR dated on 06/01/2023 - 06/30/2023 revealed no evidence of treatment for order with being completed on: 06/02/2023, 06/03/2023, 06/04/2023, 06/12/2023, 06/19/2023, 06/20/2023, 06/21/2023 and 06/24/2023. Record review of Resident #4's physician order revealed the following order start date 06/27/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen powder and sodium hypochlorite get (anapest) cover with border dressing. And end date 06/29/2023. Record Review of Resident #4's TAR dated on 06/01/2023 - 06/30/2023 revealed no evidence of treatment for order with being completed on: 06/28/2023. Record review of Resident #4's physician order revealed the following order start date on 06/29/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift every Tue, Thu, Sat Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date 07/10/2023. Record Review of Resident #4's TAR dated on 07/01/2023 - 07/31/2023 revealed no evidence of treatment for order with being completed on: 07/01/2023. Record review of Resident #4's physician order dated 07/29/2023 revealed the following order start date on 07/10/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date 07/20/2023. Record Review of Resident #4's TAR dated on 07/01/2023 - 07/31/2023 revealed no evidence of treatment for order with being completed on: 07/14/2023, 07/15/2023, and 07/23/2023. Record review of Resident #4's Medication Administration Audit Report generated by CSD revealed: -Scheduled for 07/14/2023 at 06:00AM and charted as completed on 07/29/2023 8:58PM by DON. -Scheduled for 07/15/2023 at 06:00AM was charted as completed on 07/29/2023 9:06PM by DON. -Scheduled for 07/23/23 at 6:00AM was charted as completed on 7/29/23 at 9:53PM by DON. Record review of Resident #4's nurse's skin assessment dated [DATE] revealed DTI (deep tissue injury) to right medial heel. Record review of Resident #4's nurse's skin assessment dated [DATE] completed by DON revealed Skin Intact. Record review of Resident #4's WCS physician note dated 05/18/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.8cm in length by 2.4cm in width by 0.3cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. Record review of Resident #4's WCS physician note dated 05/25/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.8cm in length by 2.4cm in width by 0.3cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. Treatment options - risks - benefits and the possible need for subsequent additional procedures on this wound were explained on 04/13/2023 to the patient. Record review of Resident #4's WCS physician note titled dated 07/27/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.4cm in length by 2.2cm in width by 0.2cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. During an observation and interview on 08/01/2023 at 4:30PM Resident #4 was sitting up in wheelchair with offloading boot to right foot and elevated with extended wheelchair footrest. Resident #4 stated she gave permission to observe foot and take a photograph of wound. Resident #4's right foot pressure ulcer had thick green tinged skin surrounding a circular wound with beefy red granulation tissue observed to wound bed. Observation of small amount of drainage observed to bandage and no odor. Resident #4 stated she had no concerns with her wound. 2. Resident # 1 Record review of Resident # 1's closed record face sheet dated 07/29/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent hospital readmission date of 06/03/2023, with the following diagnosis metabolic encephalopathy (primary), encounter for orthopedic aftercare following surgical amputation, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, need assistance with personal care, dependence on renal dialysis and end stage renal disease. Record review of Resident # 1's closed record admission MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 10 (moderate cognitive impairment); Section G- Functional Status revealed Resident #1 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bladder and Bowel revealed Resident # 1 always incontinent for bowel and bladder; Section M-Skin Conditions revealed Resident #1 was at risk of developing pressure ulcers/injuries. Record review of Resident #1's closed record care plan dated 05/15/2022 (revised on 06/04/2023) revealed: Focus: The resident is at risk for pressure injury r/t History of Pressure Injuries, Poor nutrition, Reduced Mobility, Sheering/friction problems. Date Initiated: 08/20/2020 Revision on: 02/21/2022; Perform and document weekly assessment form of skin for changes or observations. Date Initiated: 08/20/2020 Protect elbows and heels from friction. Date Initiated: 08/20/2020 Protect heels-offload when in bed. Administer medication as ordered. Date Initiated 11/29/2022. Follow facility policy and procedures for line listing, summarizing infections. Focus The resident has a stage 1 pressure injury to his R buttocks r/t Reduced Mobility, Incontinence, Sheering/Friction. Date Initiated: 08/18/2022 Revision on: 10/24/2022. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/18/2022. Administer treatments as ordered and monitor for effectiveness. Date Initiated 08/18/2022 Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 08/18/2022. Revision on: 08/23/2022. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: 08/18/2022. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated 08/18/2022. Provide low air loss mattress to bed. Date Initiated: 08/18/2022. Provide pressure relieving cushion to wheelchair. Monitor for placement and condition. Notify supervisor if cushion needs to be replaced. Date Initiated: 08/18/2022. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed no new areas, continue tx{treatment} to diabetic ulcer to lt{left} foot. Record review of Resident #1's closed record admission Summary Progress Note dated 06/03/2023 revealed stage 2 pressure wound on coccyx. Record review of Resident #1's closed record progress note titled Skin/Wound Note dated 06/15/2023 revealed WCS here this am to see resident. Stage 3 on rt ischium measures3x4.5x0.3. Light serous drainage with45% slough 5% granulation, 50% skin. Deterioration noted. [NAME] tinge to drainage concerning for Pseudomonas. No signs of infection. WCS preformed surgical excisional debridement to remove necrotic tissue and establish the margins of viable tissue. Record review of Resident #1's closed record nurses progress note dated 06/21/2023 revealed Resident return from OS per physician progress notes: 1) Please do NOT change the patients dressing 2)RTC on June 25 @ 1130AM. Transportation notified of f/u appt. and Info updated on 24 hour report. Record review of Resident #1's closed record nurses progress note dated 06/30/2023 revealed Resident return from OS office per physician progress notes Please change Resident #1's foot wound dressing daily. No further need for ACE wrap. Please see that patient gets his augmentin as ordered. Call placed to OS office for clarification on orders what does provider want for dressing orders and orders for augmentin. Per [NAME] nurse at OS office to cleanse wound then swab with betadine cover with 4x4 and secure. Augmentin 875mg q12 hours x10days. Orders updated in chart and placed on24 hr{hour} report. Record review of Resident #1's closed record nurses progress note dated 07/07/2023 revealed Resident return from OS appointment per physician's progress notes: Continue daily dressing changes with betadine to wound base . Return in 1 week appt of 7/14/23 @ 1045am Transportation notified. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 4 pressure ulcer to R Ischium with wound care and left leg dressing intact. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 3 pressure ulcer to R Ischium measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth and left leg dressing intact. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 3 pressure ulcer to R Ischium measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 05/18/2023 revealed diabetic wound of the left, distal, plantar, lateral foot full thickness. Surgical excisional debridement procedure indicated for removal of necrotic tissue and establish the margins of viable tissue. No mention of R Ischium wound. Record review of Resident #1's closed record WCS physician notes dated 06/08/2023 revealed R Ischium wound measuring 2.3cm in length by 4.5cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/15/2023 revealed R Ischium wound measuring 3.0cm in length by 4.5cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/22/2023 revealed R Ischium wound measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/29/2023 revealed R Ischium wound measuring 3.5cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 07/06/2023 revealed R Ischium wound measuring 4.0cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record hospital records dated 05/16/2023 revealed Stage 2 coccygeal & gluteal PI-POA. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed start date 06/27/2023 Location of wound: Unstageable Rt Ischium with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated July 1, 2023 - July 31, 2023, revealed no evidence of treatment for order being completed on: 07/01/202, 07/03/2023, 07/05/2023, 07/07/2023 and 07/12/2023. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed start date 06/05/2023 stating Location of wound: right Ischium with order to be performed every day shift Treatment order: Cleanse with NS/wound cleanser. Pat dry Apply Triad cream and cover with silicone dressing with end date 06/09/2023. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of treatment for order being completed on: 06/07/2023, 06/08/2023, 06/09/2023. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed order with start date 06/09/2023 stating Location of wound: Unstageable right Ischium with order to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Anasept and TAO to wound bed cover bordered gauze dressing with end date 06/27/2023 written. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of treatment for completed on: 06/09/2023, 06/14/2023, 06/19/2023, 06/20/2023, 06/21/2023, 06/24/2023, 06/25/2023 and 06/26/2023. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed start date 06/27/2023 stating Location of wound: Unstageable right Ischium with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of being completed on: 06/27/2023 and 06/30/2023. Record review of Resident #1's physician orders dated 7/29/23 revealed no evidence of treatment orders for Resident #1 left foot from 06/01/2023 to 06/30/2023. Record review of Resident # 1 physician orders revealed start date 06/30/2023 Location of wound: left foot with order to be performed every day shift Treatment order: Cleanse with NS or Wound Cleanser and pat dry. Swab with betadine swab. Cover with 4x4 and secure with tape. and no end date. Record Review of Resident #1's TAR dated July 1, 2023 - July 31, 2023, revealed no evidence of treatment for order being completed on: 07/01/2023, 07/03/2023, 07/05/2023, 07/07/2023, 07/09/2023 and 07/12/2023. Record review of Resident #2's Progress note dated 08/03/23 revealed: DON performed skin assessment of this resident who has stage 4 pressure wound to right posterior, lower extremity, measures 3.2 x 1.8 x 1.0cm with minimal serous drainage noted, peri wound of normal skin color for resident. 70% granulation tissue noted, no slough, and tendon and bone noted. Suprapubic cath site to mid-lower abdomen area, no drainage or leakage to area noted. No sis of infection or further abnormalities noted. Signed DON 8/3/23 at 7:40PM Record review of Resident #2's Wound Care Physician Assessment Note dated 08/03/23 revealed: Focused Wound Exam (Site 1) STAGE 4 PRESSURE WOUND OF THE RIGHT, LATERAL CALF FULL THICKNESS. Etiology (quality), Pressure. Stage. 4. Duration > 1 days During an interview on 07/29/2023 at 12: 59 PM Resident # 1's family member stated he/she had concerns about Resident 1's care while at the facility. Resident #1's family member stated he/she felt Resident #1 was neglected by the facility which led to his death. Resident #1's family member stated his room always smelled like urine and that Resident #1's dressing on his wounds were never changed timely. During an interview on 08/03/2023 at 11:50 AM the OS stated he had concerns Resident #1 was a no call/no show for his first scheduled post-operation visit. The OS stated the facility never called to reschedule visit or to clarify orders. The OS stated Resident #1 went over 3 weeks without bandage being changed, which led to the bandage had to be soaked to be removed and Resident #1 had bandage burns. The OS stated he was never notified of missed treatments. The OS stated Resident #1 missing wound care treatments postponed his foot healing. 3. Resident #2 Review of Resident #2's face sheet dated 08/03/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmission date of 10/05/2022, with the following diagnosis unspecified dementia (primary), need for assistance with personal care, flaccid hemiplegia affecting right dominant side. Review of Resident #2's annual MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 8 (moderate); Section G- Functional Status revealed Resident #2 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bowel and Bladder revealed always incontinent for bowel; Section M-Skin Conditions revealed Resident #2 was at risk of developing pressure ulcers/injuries. Review of Resident #2's care plan dated 07/04/2022 revealed: Focus: The resident is at risk for pressure ulcer development r/t disease process and immobility. Date Initiated: 06/26/2018 Revision on: 04/15/2021; Interventions: administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 06/26/2018. Administer treatments as ordered and monitor for effectiveness. Date initiated 06/26/2018. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiate initiated: 06/26/2018. Inform the resident/family/caregivers of any new area of skin breakdown. Date initiated: 06/26/2018. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, S/SX of infection, wound size (length X width X depth), stage. Date Initiated: 06/26/2018. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Weekly skin assessments. Date initiated: 06/26/2018. Revision on: 03/03/2023; Focus: patient has a stage 4 pressure injury to right posterior calf with potential for further skin breakdown R/T: disease process, immobility, impaired mobility, lack of sensation, non-compliance with therapeutic regimen. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: 07/29/2023. Assist resident with turning/repositioning during rounds. Date Initiated: 07/29/2023. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: 07/29/1013. Review of Resident #2's nurses notes dated 07/15/2023 at 11:00 PM written by LVN T revealed: Aide has brought to my attention that [Resident #2] has open area on back of right ankle area. When this nurse assessed, I found wound that is denuded, partial thickness and has black eschar in wound bed. I cleansed wound with wound cleanser, applied hydrophilic ointment and covered with bordered gauze. Entire leg and foot have severe outward rotation. It is stroke effected side. Heel is elevated off bed and wound area is hanging free with no pressure. Review of Resident #2's nurses note dated 07/17/2023 at 1:37 PM written by LVN A revealed: Resident noted to have a DTI per night nurse to his right lower calf area cleaned Review of Resident #2's physician orders revealed no evidence of pressure ulcer treatment between 07/15/2023 and 07/27/2023. Review of Resident #2's physician orders revealed: Order date 07/27/2023 at 2:15 PM Cleanse right lower posterior calf with dermal wound cleaner apply Triad Debriding Cream to wound bed and cover with boarder dressing. Every day shift every Mon, Wed, Fri for promote Wound healing and every 1 hour as needed for skin irritation. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by DON revealed Skin Intact. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by TX D revealed Right lower leg stage 3 pressure ulcer measuring 2.5cm in length by 2.7cm in width by 0.5cm in depth. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by TX D revealed right lower leg unstageable pressure ulcer measuring 2.5cm in length by 2.0cm in width by 0.5cm in depth. During an observation on 07/29/2023 at 4:10PM of Resident #2 revealed Resident #2 lying in bed with right leg on pillow. Resident #2's right lower leg was covered by gauze and secured with tape. The dressing did not have a date on the outside. During an observation on 7/30/2023 at 3:30 PM of Resident #2 revealed Resident #2's lower right leg had a wound that had red tissue present, surrounding skin within normal limits for race, no tendon or bone observed, no necrosis observed, measurements were not taken appeared to be a Stage 3. During an interview on 07/30/2023 at 5:35 PM, the DON stated she had completed skin assessment on 7/20/2023 for Resident #2. The DON stated that she should have looked at the nurses notes to verify that Resident #2 did have a pressure ulcer. The DON stated the system was new to her, and she must have gotten confused between patients. The DON stated she had not completed a thorough assessment and that her assessment did not give an accurate assessment of Resident # 2, because if nurses note on 07/13 and 7/15 stated he had a pressure ulcer then her assessment on 7/20 should have reflected that. The DON stated the negative affect on residents, if wound care treatments were not completed, could have caused skin breakdown, and could have caused the wounds to worsen in various ways. 4. Resident # 6 Review of Resident #6's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmission date of 08/31/2018, with the following diagnosis Type 2 diabetes (primary), age-related physical debility, cognitive communication deficit, and unspecified dementia. Review of Resident #6's significant change in status MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 99 (Unable to complete interview); Section G- Functional Status revealed patient had extensive dependence with most activities (1 physical assist); Section F- Bowel and Bladder revealed always incontinent to bowel and bladder. Section M-Skin Conditions revealed Resident #6 had a risk of developing pressure ulcers/injuries. Review of Resident #6's care plan dated 5/15/2023 revealed no intervention related to Deep Tissue Injury prevention or care. Review of Resident #6's Weekly Skin Integrity Review dated 07/25/2023 completed TX D revealed; Suspected Deep Tissue Injury to left heel measuring 4cm in length by 3cm in width. Review of Resident #6's physician orders dated 07/29/2023 revealed no evidence of wound treatment order for Deep Tissue Injury between 07/25/2023 and 07/29/2023. Review of Resident #6's physician orders dated 07/30/2023 revealed Skin prep to left heel every day and prn everyday shift for wound care related to weakness. During an observation and interview on 08/01/2023 at 4:25 PM revealed Resident #6 laying on her back not wearing her offloading boot, the boot was to the left side of her foot. Resident #6's wound was located on left heel, the wound was circular and purple in color, there was no drainage and skin appeared. During an interview on 08/01/2023 at 4:25 PM ADON C stated Resident #6 should have been wearing the offloading boot while in laying bed. ADON C stated that Resident #6's wound was not healed and needed further treatment. 5. Resident #7 Review of Resident #7's face sheet dated 08/02/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmission date of 07/27/2023, with the following diagnosis cerebral infarction (primary), muscle weakness, need for assistance with personal care, and Type 2 diabetes. Review of Resident #7's quarterly MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed limited to extensive assist needing 1 - 2+ persons for assistance; Section- H Bowel and Bladder revealed occasionally incontinent to bladder and frequently incontinent to bowel. Section M- Skin Conditions revealed resident is at risk for developing pressure ulcers/injuries. Review of Resident #7's care plan dated 05/31/2023 revealed: Focus: The resident has pressure injury to Rt buttock stage 3 with potential for further skin breakdown r/t: chronic progressive disease, impaired mobility, obesity. Date Initiated: 03/02/2023. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: 03/02/2023. Assist resident with turning/repositioning during rounds. Date Initiated: 03/02/2023. Check for incontinence during rounds and provide care as needed. Keep resident clean and dry. Date Initiated: 03/02/2023. Document wound appearance, color, wound healing, s/sx of infection, wound size (length X width X depth) and stage, and report to MD PRN any changes in skin status. Date Initiated: 03/02/2023. Notify Nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: 03/02/2023. Provide pressure relieving device in bed. Date Initiated: 03/02/2023. Refer to dietician and follow recommendation. Date Initiated: 03/02/2023. Serve diet as ordered. Date Initiated: 03/02/2023. Review of Resident #7's Weekly Skin Integrity Review dated 07/28/2023 completed by TX D revealed redness to right buttock. Review of Resident #7's Skin Note dated 07/31/2023 completed by TX D revealed Wounds to bilateral gluteal ischium tuberosities are healed, discontinue wound care to these areas, will continue[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers that were avoidable and failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 6 of 8 residents (Resident #4, Resident #1, Resident #2, Resident #6, Resident #7, Resident #8) reviewed for skin integrity. 1. The facility failed to follow physician's orders to prevent Resident #4's Deep Tissue Injury to right medial heel to deteriorate to a stage 4 pressure ulcer. 2. The facility failed to follow physician's orders to prevent Resident #1's Right Ischium(hip) pressure ulcer to deteriorate from a stage 2 to a stage 3. 3. The facility failed to obtain physician orders for treatment of Resident #2's stage 4 pressure ulcer on right posterior calf. Resident #2 went 12 days without treatment to wound. 4. The facility failed to obtain physician orders for treatment of Resident #6's left heel Deep Tissue Injury. Resident #6 went 5 days without treatment to wound. 5. The facility failed to complete skin assessments of Resident #7 which led to the development of a stage 2 pressure ulcer to the right upper buttocks and stage 2 to the right lower buttocks. 6. The facility failed to complete weekly skin assessments which led to Resident #8 developing stage 2 pressure ulcer to left buttock and stage 2 pressure ulcer to right buttock. 7. The facility failed to ensure Resident #2 and Resident #4's skin assessments were completed, assessed accurately and accurately documented by the DON. 8. The facility failed to ensure Resident #1, Resident #4 and Resident #5's wound treatments were completed and accurately documented by DON and ADON E. 9. The facility failed to maintain accurate list of residents with pressure ulcers. The facility did a skin sweep and found Resident #7's and Resident #8's wounds after surveyor intervention requesting accurate lists of residents with pressure ulcers. An Immediate Jeopardy (IJ) was identified on 08/03/23. While the IJ was lowered on 08/07/23, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of wound deterioration, wound development, and infection. Findings include: 1.Resident #4 Record review of Resident # 4's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmission date of 01/11/2023, with the following diagnosis Sepsis (primary) and need for assistance with personal care. Record Review of Resident #4's quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed Resident #4 had physical help limited to transfer only (mostly setup help or one person physical assist); Section H- Bowel and Bladder revealed always continent for bowel and bladder; Section M-Skin Conditions revealed Resident #4 was at risk of developing pressure ulcers/injuries and that Resident #4 had stage 4 pressure ulcer. Record review of Resident #4's care plan dated 05/15/2023 revealed: Focus: The resident has the potential for pressure ulcer development r/t impaired mobility, incontinence, obesity. Date Initiated: 08/23/2022. Revision on: 08/23/2022. Interventions: Notify nurse immediately of any signs of skin breakdown: redness, blisters, bruises, and discoloration noted during bath or daily care. Date Initiated: 08/23/2022. Provide assist with turning and repositioning during rounds. Date Initiated: 08/23/2022; Focus: The resident has (DTI) pressure injury to Rt medial heel r/t Reduced Mobility. Date Initiated: 03/29/2023. Revision on: 03/29/2023. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 03/29/2023. Administer treatments as ordered and monitor for effectiveness. Date Initiated: 03/29/2023. Assess/record/and monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 03/29/2023. Revision on: 06/05/2023. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition, and frequent repositioning. Date Initiated: 03/29/2023. Record review of Resident #4's physician order revealed start date 03/14/2023 Location of wound: Plantar right heel with order to be performed topically one time a day for Apply betadine to plantar right heel unstageable ulcer daily apply betadine until healed. Offloading @ all times. F/U with wound care and end date 04/13/2023. Record Review of Resident #4's TAR dated 04/01/2023 - 04/30/2023 revealed no evidence of treatment being completed on: 04/08/2023 and 04/09/2023. Record review of Resident #4's physician order revealed the order start date 04/13/2023 Location of wound: Right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Leptospermum honey in to wound bed cover with border dressing. and end date 05/04/2023. Record Review of Resident #4's TAR dated on 04/01/2023 - 04/30/2023 revealed no evidence of treatment for order with being completed on: 04/14/2023, 04/15/2023 and 04/23/2023. Record review of Resident #4's physician order revealed the following order start date 05/04/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Collagen powder and Calcium alginate with silver cover with border dressing. and end date 06/27/2023. Record Review of Resident #4's TAR dated on 05/01/2023 - 05/31/2023 revealed no evidence of treatment for order with being completed on: 05/08/2023, 05/15/2023, 05/16/2023, 05/22/2023, 05/29/2023, 05/30/2023 and 05/31/2023. Record Review of Resident #4's TAR dated on 06/01/2023 - 06/30/2023 revealed no evidence of treatment for order with being completed on: 06/02/2023, 06/03/2023, 06/04/2023, 06/12/2023, 06/19/2023, 06/20/2023, 06/21/2023 and 06/24/2023. Record review of Resident #4's physician order revealed the following order start date 06/27/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen powder and sodium hypochlorite get (anapest) cover with border dressing. And end date 06/29/2023. Record Review of Resident #4's TAR dated on 06/01/2023 - 06/30/2023 revealed no evidence of treatment for order with being completed on: 06/28/2023. Record review of Resident #4's physician order revealed the following order start date on 06/29/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift every Tue, Thu, Sat Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date 07/10/2023. Record Review of Resident #4's TAR dated on 07/01/2023 - 07/31/2023 revealed no evidence of treatment for order with being completed on: 07/01/2023. Record review of Resident #4's physician order dated 07/29/2023 revealed the following order start date on 07/10/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date 07/20/2023. Record Review of Resident #4's TAR dated on 07/01/2023 - 07/31/2023 revealed no evidence of treatment for order with being completed on: 07/14/2023, 07/15/2023, and 07/23/2023. Record review of Resident #4's Medication Administration Audit Report generated by CSD revealed: -Scheduled for 07/14/2023 at 06:00AM and charted as completed on 07/29/2023 8:58PM by DON. -Scheduled for 07/15/2023 at 06:00AM was charted as completed on 07/29/2023 9:06PM by DON. -Scheduled for 07/23/23 at 6:00AM was charted as completed on 7/29/23 at 9:53PM by DON. Record review of Resident #4's nurse's skin assessment dated [DATE] revealed DTI (deep tissue injury) to right medial heel. Record review of Resident #4's nurse's skin assessment dated [DATE] completed by DON revealed Skin Intact. Record review of Resident #4's WCS physician note dated 05/18/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.8cm in length by 2.4cm in width by 0.3cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. Record review of Resident #4's WCS physician note dated 05/25/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.8cm in length by 2.4cm in width by 0.3cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. Treatment options - risks - benefits and the possible need for subsequent additional procedures on this wound were explained on 04/13/2023 to the patient. Record review of Resident #4's WCS physician note titled dated 07/27/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.4cm in length by 2.2cm in width by 0.2cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. During an observation and interview on 08/01/2023 at 4:30PM Resident #4 was sitting up in wheelchair with offloading boot to right foot and elevated with extended wheelchair footrest. Resident #4 stated she gave permission to observe foot and take a photograph of wound. Resident #4's right foot pressure ulcer had thick green tinged skin surrounding a circular wound with beefy red granulation tissue observed to wound bed. Observation of small amount of drainage observed to bandage and no odor. Resident #4 stated she had no concerns with her wound. 2. Resident # 1 Record review of Resident # 1's closed record face sheet dated 07/29/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent hospital readmission date of 06/03/2023, with the following diagnosis metabolic encephalopathy (primary), encounter for orthopedic aftercare following surgical amputation, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, need assistance with personal care, dependence on renal dialysis and end stage renal disease. Record review of Resident # 1's closed record admission MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 10 (moderate cognitive impairment); Section G- Functional Status revealed Resident #1 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bladder and Bowel revealed Resident # 1 always incontinent for bowel and bladder; Section M-Skin Conditions revealed Resident #1 was at risk of developing pressure ulcers/injuries. Record review of Resident #1's closed record care plan dated 05/15/2022 (revised on 06/04/2023) revealed: Focus: The resident is at risk for pressure injury r/t History of Pressure Injuries, Poor nutrition, Reduced Mobility, Sheering/friction problems. Date Initiated: 08/20/2020 Revision on: 02/21/2022; Perform and document weekly assessment form of skin for changes or observations. Date Initiated: 08/20/2020 Protect elbows and heels from friction. Date Initiated: 08/20/2020 Protect heels-offload when in bed. Administer medication as ordered. Date Initiated 11/29/2022. Follow facility policy and procedures for line listing, summarizing infections. Focus The resident has a stage 1 pressure injury to his R buttocks r/t Reduced Mobility, Incontinence, Sheering/Friction. Date Initiated: 08/18/2022 Revision on: 10/24/2022. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/18/2022. Administer treatments as ordered and monitor for effectiveness. Date Initiated 08/18/2022 Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD. Date Initiated: 08/18/2022. Revision on: 08/23/2022. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. Date Initiated: 08/18/2022. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated 08/18/2022. Provide low air loss mattress to bed. Date Initiated: 08/18/2022. Provide pressure relieving cushion to wheelchair. Monitor for placement and condition. Notify supervisor if cushion needs to be replaced. Date Initiated: 08/18/2022. Record review of Resident #1's closed record admission Summary Progress Note dated 06/03/2023 revealed stage 2 pressure wound on coccyx. Record review of Resident #1's closed record progress note titled Skin/Wound Note dated 06/15/2023 revealed WCS here this am to see resident. Stage 3 on rt ischium measures3x4.5x0.3. Light serous drainage with45% slough 5% granulation, 50% skin. Deterioration noted. [NAME] tinge to drainage concerning for Pseudomonas. No signs of infection. WCS preformed surgical excisional debridement to remove necrotic tissue and establish the margins of viable tissue. Record review of Resident #1's closed record nurses progress note dated 06/21/2023 revealed Resident return from OS per physician progress notes: 1) Please do NOT change the patients dressing 2) RTC on June 25 @ 1130AM. Transportation notified of f/u appt. and Info updated on 24 hour report. Record review of Resident #1's nurses progress note dated 06/30/2023 revealed Resident return from OS office per physician progress notes Please change Resident #1's foot wound dressing daily. No further need for ACE wrap. Please see that patient gets his augmentin as ordered. Call placed to OS office for clarification on orders what does provider want for dressing orders and orders for augmentin. Per [NAME] nurse at OS office to cleanse wound then swab with betadine cover with 4x4 and secure. Augmentin 875mg q12 hours x10days. Orders updated in chart and placed on24 hr{hour} report. Record review of Resident #1's closed record nurses progress note dated 07/07/2023 revealed Resident return from OS appointment per physician's progress notes: Continue daily dressing changes with betadine to wound base . Return in 1 week appt of 7/14/23 @ 1045am Transportation notified. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 4 pressure ulcer to R Ischium with wound care and left leg dressing intact. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 3 pressure ulcer to R Ischium measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth and left leg dressing intact. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 3 pressure ulcer to R Ischium measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 05/18/2023 revealed diabetic wound of the left, distal, plantar, lateral foot full thickness. Surgical excisional debridement procedure indicated for removal of necrotic tissue and establish the margins of viable tissue. No mention of R Ischium wound. Record review of Resident #1's closed record WCS physician notes dated 06/08/2023 revealed R Ischium wound measuring 2.3cm in length by 4.5cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/15/2023 revealed R Ischium wound measuring 3.0cm in length by 4.5cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/22/2023 revealed R Ischium wound measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/29/2023 revealed R Ischium wound measuring 3.5cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 07/06/2023 revealed R Ischium wound measuring 4.0cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record hospital records dated 05/16/2023 revealed Stage 2 coccygeal & gluteal PI-POA. Record review of Resident #1's closed record physician orders revealed start date 06/05/2023 stating Location of wound: right Ischium with order to be performed every day shift Treatment order: Cleanse with NS/wound cleanser. Pat dry Apply Triad cream and cover with silicone dressing with end date 06/09/2023. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of treatment for order being completed on: 06/07/2023, 06/08/2023, 06/09/2023. Record review of Resident #1's closed record physician orders revealed start date 06/09/2023 stating Location of wound: Unstageable right Ischium with order to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Anasept and TAO to wound bed cover bordered gauze dressing with end date 06/27/2023 written. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of treatment for completed on: 06/09/2023, 06/14/2023, 06/19/2023, 06/20/2023, 06/21/2023, 06/24/2023, 06/25/2023 and 06/26/2023. Record review of Resident #1's closed record physician orders revealed start date 06/27/2023 stating Location of wound: Unstageable right Ischium with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of being completed on: Record Review of Resident #1's closed record TAR dated June 1, 2023 - July 31, 2023, reviewed on 07/29/2023 at 1:17 pm, revealed no evidence of treatment for order being completed on: 06/27/2023, 06/30/2023, 07/01/2023, 07/03/2023, 07/05/2023, 07/07/2023 and 07/12/2023. Record review of Resident #1's closed Medication Administration Audit Report for July 2023 revealed Instructions were: Location of wound: Unstageable Rt Ischium every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep to pen wound. Apply Leptospermum honey to wound bed cover border gauze dressing. Record review of Resident #1's closed Medication Administration Audit Report generated by CSD revealed: -Scheduled date of 7/1/23 at 6:00AM charted as N/A for assessment of wound bed and completed on 7/29/23 at 9:11PM by ADON E. -Scheduled date of 7/3/23 at 6:00AM charted as N/A for assessment of wound bed and completed on 7/29/23 at 9:09PM by ADON E. -Scheduled date of 7/12/23 at 6:00AM charted as N/A for assessment of wound bed and completed on 7/29/23 at 9:27PM by ADON E. During an interview on 07/29/2023 at 12: 59 PM Resident # 1's family member stated he/she had concerns about Resident 1's care while at the facility. Resident #1's family member stated he/she felt Resident #1 was neglected by the facility which led to his death. Resident #1's family member stated his room always smelled like urine and that Resident #1's dressing on his wounds were never changed timely. 3. Resident #2 Review of Resident #2's face sheet dated 08/03/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmission date of 10/05/2022, with the following diagnosis unspecified dementia (primary), need for assistance with personal care, flaccid hemiplegia affecting right dominant side. Review of Resident #2's annual MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 8 (moderate); Section G- Functional Status revealed Resident #2 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bowel and Bladder revealed always incontinent for bowel; Section M-Skin Conditions revealed Resident #2 was at risk of developing pressure ulcers/injuries. Review of Resident #2's care plan dated 07/04/2022 revealed: Focus: The resident is at risk for pressure ulcer development r/t disease process and immobility. Date Initiated: 06/26/2018 Revision on: 04/15/2021; Interventions: administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 06/26/2018. Administer treatments as ordered and monitor for effectiveness. Date initiated 06/26/2018. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiate initiated: 06/26/2018. Inform the resident/family/caregivers of any new area of skin breakdown. Date initiated: 06/26/2018. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, S/SX of infection, wound size (length X width X depth), stage. Date Initiated: 06/26/2018. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Weekly skin assessments. Date initiated: 06/26/2018. Revision on: 03/03/2023; Focus: patient has a stage 4 pressure injury to right posterior calf with potential for further skin breakdown R/T: disease process, immobility, impaired mobility, lack of sensation, non-compliance with therapeutic regimen. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: 07/29/2023. Assist resident with turning/repositioning during rounds. Date Initiated: 07/29/2023. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: 07/29/1013. Review of Resident #2's nurses notes dated 07/15/2023 at 11:00 PM written by LVN T revealed: Aide has brought to my attention that [Resident #2] has open area on back of right ankle area. When this nurse assessed, I found wound that is denuded, partial thickness and has black eschar in wound bed. I cleansed wound with wound cleanser, applied hydrophilic ointment and covered with bordered gauze. Entire leg and foot have severe outward rotation. It is stroke effected side. Heel is elevated off bed and wound area is hanging free with no pressure. Review of Resident #2's nurses note dated 07/17/2023 at 1:37 PM written by LVN A revealed: Resident noted to have a DTI per night nurse to his right lower calf area cleaned Review of Resident #2's physician orders revealed no evidence of pressure ulcer treatment between 07/15/2023 and 07/27/2023. Review of Resident #2's physician orders revealed: Order date 07/27/2023 at 2:15 PM Cleanse right lower posterior calf with dermal wound cleaner apply Triad Debriding Cream to wound bed and cover with boarder dressing. Every day shift every Mon, Wed, Fri for promote Wound healing and every 1 hour as needed for skin irritation. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by DON revealed Skin Intact. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by TX D revealed Right lower leg stage 3 pressure ulcer measuring 2.5cm in length by 2.7cm in width by 0.5cm in depth. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by TX D revealed right lower leg unstageable pressure ulcer measuring 2.5cm in length by 2.0cm in width by 0.5cm in depth. During an observation on 07/29/2023 at 4:10PM of Resident #2 revealed Resident #2 lying in bed with right leg on pillow. Resident #2's right lower leg was covered by gauze and secured with tape. The dressing did not have a date on the outside. During an observation on 7/30/2023 at 3:30 PM of Resident #2 revealed Resident #2's lower right leg had a wound that had red tissue present, surrounding skin within normal limits for race, no tendon or bone observed, no necrosis observed, measurements were not taken appeared to be a Stage 3. During an interview on 07/30/2023 at 5:35 PM, the DON stated she had completed skin assessment on 7/20/2023 for Resident #2. The DON stated that she should have looked at the nurses notes to verify that Resident #2 did have a pressure ulcer. The DON stated the system was new to her, and she must have gotten confused between patients. The DON stated she had not completed a thorough assessment and that her assessment did not give an accurate assessment of Resident # 2, because if nurses note on 07/13 and 7/15 stated he had a pressure ulcer then her assessment on 7/20 should have reflected that. The DON stated the negative affect on residents, if wound care treatments were not completed, could have caused skin breakdown, and could have caused the wounds to worsen in various ways. 4. Resident # 6 Review of Resident #6's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmission date of 08/31/2018, with the following diagnosis Type 2 diabetes (primary), age-related physical debility, cognitive communication deficit, and unspecified dementia. Review of Resident #6's significant change in status MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 99 (Unable to complete interview); Section G- Functional Status revealed patient had extensive dependence with most activities (1 physical assist); Section F- Bowel and Bladder revealed always incontinent to bowel and bladder. Section M-Skin Conditions revealed Resident #6 had a risk of developing pressure ulcers/injuries. Review of Resident #6's care plan dated 5/15/2023 revealed no intervention related to Deep Tissue Injury prevention or care. Review of Resident #6's Weekly Skin Integrity Review dated 07/25/2023 completed TX D revealed; Suspected Deep Tissue Injury to left heel measuring 4cm in length by 3cm in width. Review of Resident #6's physician orders dated 07/29/2023 revealed no evidence of wound treatment order for Deep Tissue Injury between 07/25/2023 and 07/29/2023. Review of Resident #6's physician orders dated 07/30/2023 revealed Skin prep to left heel every day and prn every day shift for wound care related to weakness. During an observation and interview on 08/01/2023 at 4:25 PM revealed Resident #6 laying on her back not wearing her offloading boot, the boot was to the left side of her foot. Resident #6's wound was located on left heel, the wound was circular and purple in color, there was no drainage and skin appeared firm. ADON C voiced that facility treatment nurse applying skin prep daily. ADON C placed offloading boot to left foot that was lying to the left of her left leg when surveyor entered room. During an interview on 08/01/2023 at 4:25 PM ADON C stated Resident #6 should have been wearing the offloading boot while in laying bed. ADON C stated that Resident #6's wound was not healed and needed further treatment. 5. Resident #7 Review of Resident #7's face sheet dated 08/02/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmission date of 07/27/2023, with the following diagnosis cerebral infarction (primary), muscle weakness, need for assistance with personal care, and Type 2 diabetes. Review of Resident #7's quarterly MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed limited to extensive assist needing 1 - 2+ persons for assistance; Section- H Bowel and Bladder revealed occasionally incontinent to bladder and frequently incontinent to bowel. Section M- Skin Conditions revealed resident is at risk for developing pressure ulcers/injuries. Review of Resident #7's care plan dated 05/31/2023 revealed: Focus: The resident has pressure injury to Rt buttock stage 3 with potential for further skin breakdown r/t: chronic progressive disease, impaired mobility, obesity. Date Initiated: 03/02/2023. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: 03/02/2023. Assist resident with turning/repositioning during rounds. Date Initiated: 03/02/2023. Check for incontinence during rounds and provide care as needed. Keep resident clean and dry. Date Initiated: 03/02/2023. Document wound appearance, color, wound healing, s/sx of infection, wound size (length X width X depth) and stage, and report to MD PRN any changes in skin status. Date Initiated: 03/02/2023. Notify Nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: 03/02/2023. Provide pressure relieving device in bed. Date Initiated: 03/02/2023. Refer to dietician and follow recommendation. Date Initiated: 03/02/2023. Serve diet as ordered. Date Initiated: 03/02/2023. Review of Resident #7's Weekly Skin Integrity Review dated 07/28/2023 completed by TX D revealed redness to right buttock. Review of Resident #7's Skin Note dated 07/31/2023 completed by TX D revealed Wounds to bilateral gluteal ischium tuberosities are healed, discontinue wound care to these areas, will continue to monitor. Review of Resident #7's Weekly Skin Integrity Review dated 08/02/2023 completed by TX D revealed new stage 2 right upper gluteal fold pressure ulcer measured 2cm in length by 2cm in width and 0.1cm in depth and stage 2 right lower gluteal fold pressure ulcer measured 1cm in length by 0.3cm in width and 0.1cm in depth. During an interview on 08/02/2023 at 9:40 AM, Resident #7 stated he wished the facility was more proactive and would have prescribed antibiotics for his possible wound infection. 6. Resident #8 Review of Resident # 8's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmission date of 07/15/2021, with the following diagnosis Chronic Obstructive Pulmonary Disease (primary), type 2 diabetes mellitus, mild cognitive impairment, muscle weakness, and need for assistance with personal care. Review of Resident # 8's quarterly MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 11 (moderately impaired); Section G- Functional Status revealed patient had extensive dependence with most activities (1-to-2-person assistance with physical assist); Section H- Bowel and Bladder revealed Resident #8 Frequently incontinent to bowel and bladder M-Skin Conditions revealed Resident #8 had a risk of developing pressure ulcers/injuries. Review of Resident #8's care plan on 08/02/2023 revealed: Focus: The resident has the potential for pressure ulcer development r/t disease process, [TRUNCATED]