**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident received adequate supervision to prevent accidents for 1 of 1 Residents (Resident #1) reviewed for Accidents and Hazards. On 04/05/2025, the facility failed to secure the van lift strap to Resident #1's wheelchair while in use which resulted in Resident #1 rolling off backwards when the lift was suspended in the air and caused Resident #1 to be hospitalized in the Intensive Care Unit with multiple fractures on his spine. The noncompliance was identified as PNC. The IJ began on 04/05/2025 and ended on 04/07/2025. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents at-risk of harm, serious injury, or death. Findings included: Review of the facility's self-reported incident indicated on 04/05/2025 at approximately 1:00PM Resident #1 was leaving the dialysis center after treatment. He was in his wheelchair and ready to be transported back to the facility in the facility's van by CNA A. The incident report simply stated, Resident #1 was on the van lift and was being transferred back to the facility. He fell backwards off the lift, hitting the ground. Resident #1 was transferred by EMS to [local hospital] ER for further evaluation and treatment. There was also a complaint which was made against the facility in this matter. A by-stander who witnessed the incident felt the actions that took place were grave enough to warrant a complaint on behalf of Resident #1, due to the way CNA A attempted to load Resident #1 into the van. A phone interview with the complainant on 04/22/2025 at 5:38PM reflected the following: The complainant stated she was taking her husband to dialysis on Saturday 04/05/2025 when Resident #1 was being loaded into the facility's van after his dialysis treatment. The complainant stated she saw the van driver use the lift on the side of the van to raise Resident #1's wheelchair but thought CNA A had not secured the wheelchair properly before starting the lift. The complainant stated CNA A started the lift and rode to the top, with Resident #1. The complainant stated CNA A stepped inside the open door of the van, leaving Resident #1 unattended on the lift while in the raised position. Resident #1 immediately rolled off the back of the lift and landed on his back, while still in his wheelchair. The complainant stated the day was cold, wet, and snowy. Resident #1 was not dressed for the weather and had landed in a puddle of water when he fell. The complainant immediately called 911 and her granddaughter got a jacket from their truck to warm Resident #1 until EMS arrived. Record review of Resident #1's clinical records revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses of Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral ( a combination of diabetic complications affecting both eyes, leading to vision loss) Cognitive communication deficit, Unspecified lack of coordination, Muscle wasting and atrophy, not elsewhere classified, unspecified site, Muscle weakness (generalized), Other reduced mobility, Encounter for observation for suspected exposure to other biological agents ruled out, Type 2 diabetes mellitus with diabetic nephropathy, Type 2 diabetes mellitus with diabetic chronic kidney disease, Type 2 diabetes mellitus with hypoglycemia without coma, Venous insufficiency (chronic) (peripheral) (a condition where the veins in the legs have difficulty returning blood to the heart. This results in blood pooling in the lower extremities, leading to symptoms like swelling, pain, and skin changes), Benign prostatic hyperplasia with lower urinary tract symptoms (frequent or urgent urination, waking up multiple times at night to urinate (nocturia), difficulty starting urination, a weak urine stream, dribbling at the end of urination, and the feeling of not fully emptying the bladder), Dependence on renal dialysis (refers to a condition when an individual's kidneys are no longer functioning properly and require regular dialysis treatments to filter blood and maintain bodily function). Review of Resident #1's Quarterly MDS dated [DATE] indicated he had a BIMS score of 15, indicating he was cognitively intact. Resident #1 required a 1- to 2-person assist for all ADLs. His means of mobility were a wheelchair and Hoyer lift. His care plan dated 03/18/2025 revealed he was a fall risk related to impaired sight, Diabetes Mellitus, muscle weakness and occasional low blood pressure. Resident #1 was dependent on a wheelchair for ambulation. An interview with the Administrator on 04/24/2025 at 8:12AM revealed she received a call from the DON at approximately 1:30PM on 04/05/2024 which informed her Resident #1 had fallen in his wheelchair from the van and was at the hospital. The DON told the Administrator they did not know what happened, but he had fallen. The Administrator stated it took approximately 1-hour for her to arrive at the facility from her home. The Administrator stated she interviewed CNA A as soon as she arrived at the facility. In that interview, CNA A told the Administrator she locked Resident #1's wheelchair wheels when she pushed him onto the lift. CNA A stated the lift plate at the back of the lift was up, so she did not know how he could have rolled off. CNA A stated Resident #1 was unable to tell her how he rolled off, as well. The Administrator suspended CNA A from her duties at the facility, in lieu of an investigation and she was no longer allowed to drive the facility's van. A phone interview with Resident #1's RR on 04/24/2025 at 9:46AM reflected stated Resident #1 was not doing well since the fall. The RR stated Resident #1 was still in ICU and was very fragile. He had been in the ICU for almost 2-weeks. Resident #1 broke T4 and T5 in his back and surgery could not be completed due to his fragility. The orthopedic surgeon stated he would not survive the surgery. The RR lived approximately 45 miles out of town, so she called a local friend, who went to the hospital and checked on Resident #1 until she could arrive. The RR stated when the Administrator called her she stated that Resident #1 was not secured when he was lifted with the van lift. The RR was told by the Administrator that EMS had taken Resident #1 to [local hospital] and he had been admitted . The RR was told the van driver had to go back to the facility to meet with HR about the incident, so the facility had sent the maintenance man's son, who was also an employee, to sit with Resident #1 until the RR could arrive. When the RR arrived, no one was with Resident #1. When the RR was able to speak with Resident #1, he told her he was up in the air when he felt himself falling backward. The RR stated Resident #1 was blind, and should have been secured very well, since he had to rely on the help of others for his safety. The RR stated she felt it was incredibly negligent on the part of the facility to let the incident happen. The RR stated she was not sure if Resident #1 lost consciousness and Resident #1 was unable to tell her if he had lost consciousness after the fall. The RR stated the ER took x-rays of Resident #1's head and back and found no injury to his head, but his spine had swelling, and it appeared there were fractures at T4 and T5 in his back. The RR stated Resident #1's quality of life was taken from him, and he would never be the same again. The surgeons had stated he would have chronic back pain and problems with his back, for the rest of his life. The RR stated the Administrator told her the dialysis center had video of the incident. The RR called the dialysis center and made an appointment to view the video, but when she arrived the RR was told the corporate office had told the dialysis center, not to release the video. The RR stated she received a call from the DON a few days after the incident, but the RR was too mad to speak with her because Resident #1 could still die. The RR stated that was the last communication she received from anyone at the facility. She stated up to the time of the incident, Resident #1's care at the facility had been good. He got his medications on time, had no issues with his insulin and seemed to be contented living there. Record review of [local hospital] ER visit notes dated 04/05/2025 reflected Resident #1 presented to the ER at 1:19PM with complaints of back pain after a fall prior to arrival. Resident #1 reported he was leaving his dialysis treatment when the accident occurred. He was being loaded into a van while in his wheelchair on the van lift when he fell back off the lift while still in the wheelchair and hit his head and back. He notes that he was elevated off the ground. Resident #1 denied loss of consciousness. Resident #1 denied the use of supplemental 02 at home. ER triage notes read as followed: Patient arrived from dialysis center due to a fall. Patient had just finished dialysis and was being loaded into van by a wheelchair lift when he was not secured properly and fell backwards. Pt hit head and is on Eliquis (blood thinner). Pt did not have loss of consciousness. Resident #1 was discharged from the ER and admitted to the Surgical Critical Care Unit of the same hospital at 4:48PM with the following diagnostic considerations and differential diagnoses: lntra-cranial hemorrhage, skull fracture, subdural hematoma, subarachnoid hemorrhage, epidural hemorrhage, rib fractures, a thoracic/lumbar/ cervical spine fractures, hip fracture, pelvic injury. The plan was as followed: Check general labs electrolytes since the patient did just recently have dialysis. We will also check imaging of the patient's head neck thoracic spine and lumbar spine. The patient does not really appear to have any true cervical spine discomfort with given the mechanism wheel look. The patient was found to have a T4-T5 vertebral fracture with some facet widening along with hemorrhage in that area concerning for significant spinal cord injury. That is said the patient does not have any deficits he is able to move all his extremities without any significant difficulty he has good sensation throughout. The patient's case was discussed with the nurse practitioner for [ Neurosurgeon]. She will have him look at the imaging and once they have reviewed the imaging we will adjust any necessary treatment and then proceed. IMAGING CT Head Without Contrast (Results Pending) CT Thoracic Spine Without Contrast (Results Pending) CT Lumbar Spine Without Contrast (Results Pending) The patient's case was discussed with [Neurosurgeon] through Nurse Practitioner; they recommend that we admit the patient from the trauma service to the SICU; the patient has an unstable fracture at T4 and T5 and will require close monitoring. On 04/05/2025 at 6:02PM The CICU Physician charted the following in Resident #1's [local hospital] medical record: CT Thoracic Spine Without Contrast PROCEDURE: CT THORACIC SPINE WITHOUT CONTRAST COMPARISON: None. INDICATIONS: Fall with thoracic spine pain concern for injury, TECHNIQUE: Multi-planar CT images were obtained and created without intravenous contrast. FINDINGS: VERTEBRAE: There was bridging anterior vertebral body osteophytes throughout the thoracic spine compatible with DISH. There is a fracture through the anterior inferior corner of the T4 vertebral body with extension to the disc space and into the superior T5 end plate. There is associated mild widening of the T4-T5 facet joints with mild retrolisthesis of T4 and TS measuring 4 mm, traumatic in etiology. This results in severe bilateral neural foraminal stenosis and mild spinal canal stenosis. There is mild haziness in the spinal canal ventral to the spinal cord which may represent a small amount of epidural hemorrhage without definite mass effect on the thecal sac. PARASPINAL AREA: Large prevertebral edema or hemorrhage at the level of T4-T5. DISC LEVELS: Fracture through the T4-T5 disc space. ALIGNMENT: Traumatic retrolisthesis of T4 and TS measuring 4 mm. OTHER: Multilevel degenerative changes throughout the thoracic spine with mild multilevel spinal canal and foraminal stenosis. There is a consolidation in the right lower lung which could represent pneumonia or atelectasis. Mild left lower lobe atelectasis. Cardiac pacer leads are present. Moderate atherosclerosis of the coronary arteries and aorta. CONCLUSION: 1. Acute fractures through the anterior inferior corner of the T4 vertebral body with the fracture extending into the disc space in the superior endplate of T5 in the setting of DISH. There is widening of the bilateral T4-TS facet joints which likely indicates facet capsular injuries and associated traumatic retrolisthesis of T4 and TS measuring 4 mm. This results in severe bilateral neural foraminal stenosis and at least mild spinal canal stenosis. Minimal hyperdense stranding in the anterior epidural space at this level may represent blood products, however there is no definite hematoma or substantial mass effect on the thecal sac identified on this exam. An MRI could be performed to assess for mass effect on the spinal cord if clinically indicated. 2. Moderate hemorrhage or edema anterior to the T4-TS fractures. CT Lumbar Spine Without Contrast PROCEDURE: CT LUMBAR SPINE WO CONTRAST COMPARISON: None. INDICATIONS: Fall with a lower back pain concern for injury, TECHNIQUE: Multi-planar CT images of the lumbar spine were obtained without IV contrast. FINDINGS: BONES: No fractures. Bilateral pars defects at L5. Osteophytes all lumbar levels. Schmorl's nodes superior endplates L1 and L2. A mild bi concave deformities L3, L4 and L5. Hypertrophy of the spinous processes with faceted appearance consistent with Braestrup's disease series 8, image 36. ALIGNMENT: Grade 1 anterolisthesis L5 on S1. PARASPINAL AREA: Arterial calcifications. Atrophy left kidney. Right kidney not well seen. LUMBAR DISC LEVELS: T12-L1: No significant disc/facet abnormality, spinal stenosis, or foraminal stenosis. L1-L2: Calcification within the disc. Mild bilateral facet arthrosis. L2-L3: Facet arthrosis and ligamentum flavum thickening contribute to central canal and foraminal stenosis. L3-L4: Bilateral facet arthrosis and ligamentum flavum thickening contribute to central canal and foraminal stenosis. L4-L5: Bilateral facet arthrosis and ligamentum flavum thickening contribute to central canal and foraminal narrowing. L5-S1: Disc space narrowing anterolisthesis leads to narrowing of the foramina bilaterally. CONCLUSION: 1. No acute fractures. 2. Bilateral pars defects of at L5 with grade 1 anterolisthesis of L5 on S1. 3. Degenerative changes all lumbar levels. 4. Baastrup's disease. 5. Atherosclerosis. CT Head Without Contrast PROCEDURE: CT HEAD WO CONTRAST COMPARISON: None. INDICATIONS: Fall with head trauma on Eliquis concern for injury. TECHNIQUE: CT images were created without intravenous contrast. FINDINGS: VENTRICLES: The ventricles, sulci and cisterns are mildly enlarged. CEREBRUM: No intracranial hemorrhage. Symmetrically diminished attenuation in the deep white matter consistent with mild leukoaraiosis. , CEREBELLUM: Small high attenuation extra-axial lesion abutting the [NAME] surface measuring 1.3 x 0.7 cm series 7, image 37 and also demonstrated on axial series 5 images 9-10 consistent with a meningioma. BRAINSTEM: Negative. SKULL: No fractures. Small right frontal scalp laceration. SINUSES: Normal. OTHER: Arterial calcifications. CONCLUSION: 1. No intracranial hemorrhage. 2. Small meningioma in the right posterior fossa. 3. Mild atrophy and leukoaraiosis. 4. Small right frontal scalp laceration. ASSESSMENT AND PLAN: Patient Active Problem List Diagnosis o Acute kidney injury superimposed on chronic kidney disease o Type 2 diabetes mellitus with hypoglycemia, with long-term current use of insulin (HCC) o Mixed hyperlipidemia o Morbid obesity with BMI of 50.0-59.9, adult (HCC) o Benign prostatic hyperplasia with lower urinary tract symptoms o Paroxysmal atrial fibrillation (HCC) o Microcytic anemia o Coronary artery disease involving native coronary artery of native heart without angina pectoris o Hypervolemia, unspecified hypervolemia type o Chronic kidney disease requiring chronic dialysis (HCC) o ESRD (end stage renal disease) on dialysis (HCC) o Coagulopathy o Fall o Closed unstable burst fracture of fourth thoracic vertebra, initial encounter (HCC) Fall Assessment & Plan Patient is status post fall complaining of back pain and suffered an unstable thoracic spine fracture. Patient will be admitted to surgical ICU with strict spine precautions. Tertiary evaluation to be performed in the morning. Coagulopathy Assessment & Plan Patient has history of coronary artery disease along with paroxysmal AFib currently on Eliquis. Last dose was this morning. Patient requires full reversal for Eliquis. Paroxysmal atrial fibrillation (HCC) Assessment & Plan Patient has history of coronary artery disease along with paroxysmal AFib currently on Eliquis. Last dose was this morning. Patient requires full reversal for Eliquis. * Closed unstable burst fracture of fourth thoracic vertebra, initial encounter (HCC) Assessment & Plan Patient is status post fall complaining of back pain and suffered an unstable thoracic spine fracture. Patient will be admitted to surgical ICU with strict spine precautions. [Neurosurgeon] has been consulted who will evaluate the patient. He initially recommended MRI, however, could not be done secondary to presence of pacemaker. Also recommended keeping mean arterial pressure greater than 70, IV Decadron. Appreciate his recommendations. Chronic kidney disease requiring chronic dialysis (HCC) Assessment & Plan Patient has history of chronic kidney disease on hemodialysis through a left upper extremity fistula. Will consult [Nephrologist]. Coronary artery disease involving native coronary artery of native heart without angina pectoris. Assessment & Plan Patient has history of coronary artery disease along with paroxysmal AFib currently on Eliquis. Last dose was this morning. Patient requires full reversal for Eliquis. Morbid obesity with BMI of 50.0-59.9, adult (HCC) Assessment & Plan BMI of 48.6 likely related to excess calories. Supportive care at this point. Mixed hyperlipidemia Assessment & Plan Chronic diagnosis. Patient takes atorvastatin. Will resume when able. Type 2 diabetes mellitus with hypoglycemia, with long-term current use of insulin (HCC) Assessment & Plan Chronic diagnosis. We will obtain HbA1c in the morning. Start more moderate category sliding scale. Antibiotics: Ancef on-call Nutrition: Keep NPO Analgesia: Tylenol, Robaxin with as-needed fentanyl Sedation: Not indicated Thromboprophylaxis: SCDs only, no chemoprophylaxis Ulcer prophylaxis: Start Protonix Glucose: Will obtain HbA1c in the morning, start sliding scale insulin Plan for today: o Admit to surgical ICU o Start Levophed to keep mean arterial pressure greater than 70 o Reverse Eliquis o Pain control o Strict spine precautions o Add duo nebs o Will obtain CT chest abdomen pelvis without contrast o I have consulted [Hospitalist] to help assist with medical management The patient is extremely critical. I had an extensive discussion with the patient and his RR over the phone. I updated them about his condition, including the potential risks and complications associated with his fall, given his advanced age, multiple comorbidities (OM, pacemaker, OA, HTN), and current anticoagulation therapy with Eliquis. I also discussed the need for continuous monitoring and potential consultations with orthopedic and neurology specialists. All their questions were answered thoroughly, ensuring they understood the gravity of the situation and the steps being taken. The patient is a full code. ICU RN notes from 04/05/2025 at 6:22PM read as follows: Admitting DX: Burst fracture of 4th thoracic vertebra Current level of care: ICU Current CLS (care level score): 150 Current treatment plan: admitted following a fall for an unstable burst fracture of T4. Nephrology consult for chronic dialysis. Intubated and placed on pressers within 24 hours. Neurosurgery consulted - pt not a good surgical candidate due to multiple factors, recommended palliative care consult. Barriers to discharge: Remains in critical care, not stable to transfer to lower level of care. Resident #1 remained in ICU at [local hospital] until 04/17/2025 at or around 5:00 PM when he was transferred to [local LTAC] for continued care. Resident #1's hospital discharge plan dated 04/17/2025 at 2:36PM read as follows: Spoke with NP regarding discharge plan and patient is able to transfer from ICU to LTAC due to higher level of medical need. Spoke with patient's RR and she has toured [local LTAC] and is agreeable. Patient Care Levels complete. Called and sent referral. Case manager will remain available. Pt has been approved for [local LTAC] and can transfer today at 5:00PM via ambulance. Pt and family informed. Pt scheduled for dialysis today at 2:00PM but will complete dialysis tonight at the LTAC. Nurse given number to call report. No other needs at this time. Primary RN notified this RN patient will be transferring to LTAC at 5:00PM via ambulance. Per Case Manager note, dialysis is to be done tonight at LTAC. Nephrologist notified, no treatment at [local hospital] today. Fax order sheet to dialysis center for LTAC dialysis. Occupational Therapy orders sent to [local LTAC] at 3:43PM read as follows: ROM: patient consulted and evaluated in SICU on 4/9/2025. During evaluation patient demonstrated primary impairments in bed mobility, functional transfers, activity tolerance, sustained grasp, dynamic sitting/standing balance, insufficient spinal precautions, cognition including anxiety and problem solving, visual scanning, and gross weakness/deconditioning impacting safety, participation, and independence with all ADLs. Pt scored 6 out of 24 on the AM-PAC Daily Activity assessment indicating over 100% impairment completing all basic ADLs successfully/independently, meaning patient will require assistance at time of discharge. Therefore, without skilled OT service, patient is at a higher risk for loss of independence with basic necessary ADLs, loss of dignity, and inability to return to the community reducing their quality of life. OTR initiated a Plan of Care to approximate prior level of independence and improve impairments to baseline. Pertinent Surgical History: No plans for surgical intervention per neuro at this time. Assessment: Pt initially evaluated by occupational therapy on 4/9/2025 by OTR. During patient's plan of care, this patient seen by therapy 3 times and received: -Dynamic therapeutic activities utilized to improve functional performance, activity tolerance, and balance with therapist supervision and grading to ensure maximum patient benefit. -AOL training and functional transfer training with OT practitioners providing graded assistance and cueing to ensure maximum safety and independence. Patient made fair progress towards goals however due to pain and short length of stay, all goals remain active at time of discharge from hospital to SNF. Continued occupational therapy services are recommended. Plan of care, discharge recommendations, AE equipment, and safety education with spinal precaution with TLSO education reviewed with patient and/or family prior to discharge from hospital. Will discontinue acute care OT orders at this time. An interview with the Administrator on 04/24/2025 10:33AM revealed CNA A had returned to work after her internal investigation, because they could not prove she had done anything wrong during the transport of Resident #1. She stated she had called the dialysis center to inquire about video footage but was told the cameras would not have picked up the area where Resident #1 fell. She stated the doctors at the hospital told the RR, Resident #1 was not secured on the lift, not herself or anyone else at the facility. The Administrator stated Resident #1 was very particular about the brakes on his wheelchair due to his blindness and any time there were issues with his wheelchair he called the MD immediately. An interview with the CM of the dialysis center on 04/24/2025 at 1:00PM revealed there was video of the incident involving Resident #1 falling off the lift of the facility's van. Review of the video with the CM clearly showed CNA A push Resident #1 onto the lift and up to the front of the lift platform. It was difficult to see if CNA A or Resident #1 locked the wheelchair wheels, but CNA A activated the lift and rode with Resident #1 to the top, where they were both even with the open entrance to the van. CNA A then stepped inside the van, out of the video frame and Resident #1 was seen rolling backward off the lift and onto the parking lot pavement below. It was approximated from the video footage that the fall height was about 3-3 ½ feet. Resident #1 was still in his wheelchair at the time of the fall and bystanders came to his aid. At that point, the video stopped. An interview with CNA A on 04/24/2025 at 2:12PM revealed she pushed Resident #1 out of the dialysis center to the place in the parking lot where the van was waiting. CNA A operated the lift into the down position and then pushed Resident #1 onto the lift platform. CNA A stated she made sure Resident #1's wheels were locked and then took two steps inside the van to try to pull him forward into the back of the van. CNA A stated when she looked back, Resident #1 was not there, and she heard him scream. CNA A stated she ran to him, and he was on his back, on the parking lot pavement, in the wheelchair. CNA A stated she pushed Resident #1 out of the dialysis center, but tried to pull him into the van, because he was too heavy to push over the lip of the van entrance. This investigator told CNA A the security footage from the day of the event was viewed at the dialysis center and she was seen pushing Resident #1 out of the dialysis center in the snow. CNA A had trouble getting Resident #1 off the sidewalk but kept pushing until she got him over a small patch of snow and onto the parking lot and the van's lift. CNA A changed her story and could not remember if she pushed or pulled him onto the ramp of the van. This investigator told her the video footage revealed she pushed him onto the ramp, rode the ramp to the top with Resident #1 and then stepped inside the van, where Resident #1 was left unattended. Resident #1 was then seen rolling off the back of the elevated lift and onto the pavement below. CNA A had no comment. An interview on 04/24/2025 at 2:34PM with Resident #2 revealed she also was a dialysis patient but had never been driven to dialysis by CNA A. Resident #2's RR was in the room at the time of the interview and stated Resident #2 had not had any issues with transportation provided by the facility. Resident #2 stated she felt safe during her travels. An interview on 04/24/2025 at 2:43PM with Resident #3 revealed she also was a dialysis patient but had never been driven to dialysis by CNA A. Resident #3 stated she had not had any issues with the transportation provided by the facility and felt safe during her travels. An interview on 04/24/2025 at 3:07PM with the MD the van had not been used by the facility and had been in the repair shop since the incident. The MD stated the lift on the van held 800 lbs. which was more than ample to lift Resident #1 and his wheelchair. The MD stated the plate at the back of the platform was designed to keep wheelchairs from rolling off the lift should have been in an upright position if the lift was engaged and moving up. He stated there should not have been a way for Resident #1 to roll off the platform. The MD stated he had checked all circuits after the incident, and all were working properly. The MD provided the maintenance work order dated 04/05/2025 which reflected the following: Drove van to facility. Upon arrival I inspected the lift operation. Pushed the unfold button. Lift unfolded ¼ of way down and stopped. Manually operated lift into van and discontinued van operation. The requested priority was High meaning the lift needed to be evaluated by an outside source within 24-hours. Record review on 4/24/25 of the MD provided policy for Transporting Wheelchair-bound Residents which was used as part of his re-training for van drivers on 04/06/2025 revealed: Safety for Using a Wheelchair Lift: 1. Move the wheelchair, outward facing, all the way onto the lift. If you need a handhold, use one indicated by the lift manufacturer. Set both wheelchair breaks and fasten the lift safety restraint, if applicable. 2. Do no ride on the lift with the passenger but go int the van and meet the lift. 3. Move the patient/resident so they are facing forward in the van. 4. Lock the wheelchair and secure the wheelchair to the van and buckle the patient/resident in. 5. Keep the patient/resident away for any heat source or other hazard that would lead to an injury or irritate the skin. If the passenger has a cane make sure it is secured. If the patient/resident is visually impaired, secure the cane within the passenger's reach. The MD stated CNA A was not trained to load residents onto the platform of the lift, facing the inside of the van; they were to be loaded outward facing. The MD stated CNA A was trained to double-check the breaks on all resident's wheelchairs to ensure safety. The MD stated the van did not have safety restraints on the lift platform. The restraints were used once the resident was loaded inside the van. The MD stated CNA A was not trained to ride on the lift with Resident #1 but had been trained to go up the stairs and meet the resident inside the van. The MD stated CNA A had passed the competency test as a van driver on 02/05/2024 and had attended all in-services given by him, since that time. The MD stated there was not a check list to validate safe van lift use. The MD stated the manufacturer's recommendations were used instead. The MD did not provide a copy of the recommendations. The MD provided the invoice from [Fleet management] after the incident which indicated the van had been inspected by the owner and a technician on 04/08/2025 and reported the following: Inspected the van on-site. Took videos and pictures. Upon inspection it was determined by both parties that the outer barrier (roll stop) had no faults and worked as designed. [Fleet Management] will hold off on the repairs until the State agency looks over the lift. Record review on 4/24/25 of re-training on Transport Accidents on 04/07/2025 to all van drivers regarding any falls or accidents which occurred while on transportation revealed the following: A. Do not move the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide the necessary care, treatment, and services, consistent with professional standards of practice, to prevent development of pressure injuries for three (Resident #1, Resident#2, Resident# 3) of twelve residents reviewed for pressure ulcer. 1. The facility failed to identify pressure ulcer for Resident #1 on residents left heel when completing weekly skin assessments from 01/13/2023 admission date until 02/19/2023, when a family member asked staff to look at the black area on Resident #1's left heel. 2. The facility failed to complete an initial skin assessment to identify any skin concerns for Resident #1 upon admission to the facility on [DATE]. 3. The facility failed to complete an accurate comprehensive care plan for Resident #1 to indicate Resident #1 was at risk for pressure ulcers. 4. The facility failed to identify a new pressure ulcer for Resident #2, failed to identify an open area on Resident #3's coccyx. On 02/24/2023 at 5:45 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/27/23 at 2:15 PM, the facility remained out of compliance at a severity level of actual harm at a scope of pattern, due to facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents who are at risk for developing worsening pressure ulcers, Osteomyelitis (infection of the bone), Sepsis (infection of the blood) pain, loss of limb and or death. Finding included: Record review of Resident #1's undated face sheet reflected, Resident #1 was admitted to the facility on [DATE] with the following diagnoses: pyogenic arthritis (pain in join), muscle weakness, cognitive communication deficit (difficulty with thinking), difficulty in walking, muscle wasting and atrophy, (decrease in muscle tissue), sepsis unspecified organism, edema. Record review of the MDS for Resident #1 dated 01/17/2023 reflected a BIMS score of 11. (Moderately impaired). Section M0150 revealed the resident was at risk for pressure ulcers 1, indicating yes. Section M0210 revealed Resident #1 did not have any unhealed pressure ulcers 0 indicating none, Section M1040 revealed other skin problems- surgical wound. Record review of Resident #1's care plan revised 2/23/23 reflected that Resident #1 was at risk for pressure ulcers R/T impaired mobility. Goal -Resident #1's skin will remain intact. Approach - Conduct a systematic skin inspection _ (left blank on care plan no indication of how many times) (weekly, daily, etc). Pay particular attention to the bony prominences. Report any signs of skin breakdown, (sore, tender, red, or broken areas). Resident #1 has a surgical incision and is at increased risk for infection. Approach - Weekly skin assessments by licensed nurse notify physician of any changes to skin. Record review of Braden Scale for Resident #1 dated 01/13/2023 had a score of 16 indicating at risk for pressure ulcers and one dated 02/27/2023 had a score of 16 indicating at risk for pressure ulcers. (Interpretation of score: 19 or higher = not at risk, 15-18 = at risk, 13-14 = moderate risk, and 10-12 = high risk, and 9 or less = very high risk). During an interview on 02/23/2023 at 2:10PM, the family member for Resident #1, stated that the care has gotten worse the longer Resident #1 has been at the facility. The family member stated that after Resident #1 had gotten out of the hospital she noticed a blister on the back of his foot on 01/18/2023. Family Member stated that she has been telling the staff at the facility about the red spot and blister on his heel for several weeks. The family member stated they could not recall which staff members were notified because they are floaters and never the same person working. The family member stated she notified the facility staff about the blister on 01/18/2023 and stated then on 02/19/2023 while visiting she noticed that Resident #1's heel was black. The family member stated the area on Resident #1's heel was huge and looks like his foot is dying. The family member stated she spoke with the nurse working on 02/19/2023 about Residents #1 heel and the nurse told her she would look to see if there was anything about Resident #1's heel documented and then told her no it was not in his books. The family member stated she could not recall the name of the nurse working on 02/19/2023. The family member stated the nurse did look at his heel and put ointment on his heel and told her they would float it, family member stated not sure what they have done since 02/19/2023 for Resident #1's heel. During an interview on 02/23/2023 at 4:20PM, Resident #1 stated everything has been pretty good but he has a bad heel and he pointed to his left foot and stated, 'well I have a bad foot. Resident #1 stated he was not having any pain with his left foot. Resident #1 agreed to an observation of his lower legs and feet to be completed. RN B, assisted with the observation of Resident #1's skin assessment of his lower legs and feet. Observation on 02/23/2023 at 4:25PM of Resident #1's left heel revealed a black circular area on the left heel. During an interview on 02/23/2023 at 4:30PM RN B, stated she provided care for Resident #1 on 02/23/2023. RN B, stated she provided care for Resident #1 before shortly after he was admitted to the facility and then not again until 02/23/2023. She stated that Resident #1 does have some edema in his lower extremities however she was not aware of any open areas or wounds, that nothing was reported to her in report about wounds. RN B, stated she was not aware of the wound on his left heel and did not have anything documented on her notes for the wound and did not receive any information from the previous shift in report about the wound. RN B, stated that she would look at the electronic records and see if there is any documentation about the wound. Record reviewed of progress note for Resident #1 dated 02/19/2023 revealed on assessment res. Had a black sore on his L heel, wound care provided, and float heels while in bed. Record review of physician orders for Resident #1 dated 02/20/2023 revealed an order for daily wound treatment: Cleanse heel with cleanser and apply betadine to heel and allow to dry. Special Instructions: Drainage: S=Saturated, M=Moist, D=Dry General Appearance: R=Red, Y=Yellow, B=Black, W=White, P=Pink, T=Tan, PU=Purple, BR=Brown, GR=Gray Surrounding Skin: M=Macerated, R=Reddened, F=Firm, N=Normal, Once a Day 0600-1400. Cephalexin capsule; 500mg oral three times a day. During an interview on 02/23/2023 at 5:08PM, NP C with Wound Care Specialist stated she had received a call the day before, from WCN D asking if she could look at Resident #1' left heel. NP C evaluated Resident #1's left heel on 02/23/2023. NP C stated that the wound on his heel has had to have been there for some time, the wound doesn't look infected, it is stable eschar, that he has had it for a while. NP C stated she cleaned it really good and then she removed a little of the skin, stated stable black eschar, he had old skin prep and betadine areas. Peeled off a little bit of callus around it. NP C stated the facility staff didn't mention any time frame to her of how long Resident #1 had the wound, just that WCN had cleaned it and was unsure what to do for the resident. NP C stated Resident #1's wound doesn't look infected and it is attached and that he had good pulses. NP C, stated, the question is when did it occur and that takes several weeks to occur and turn that color. She stated that she was not sure how the facility does their skin assessments here at the facility, but she will ask the ADON about the initial skin assessments how they do them upon admission. NP C then called ADON on speaker phone during the interview and asked ADON about the admission skin assessments. The ADON stated the facility does not have a nurse that does admitting skin assessments it would be the nurse on the floor doing the admitting skin assessments. NP C stated that type of wound is from pressure and the wound will heal that the wound is 3.6X4.5 centimeters. That if Resident #1 eats properly and keeps pressure off it then should heal out in about 6-8 weeks. Record Review of wound report dated 02/24/2023 from NP C, for Resident #1 reflected Wound was currently classified as unstageable/unclassified wound with etiology of Pressure Ulcer and is located on the Left Calcaneus. The wound measures 3.5cm length X 4.6cm width; 12.645cm^2 area. There is no tunneling, or undermining noted. There is a none present amount of drainage noted. The wound margin is distinct with the outline attached to the wound base. There is no granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including Eschar. The peri-wound skin appearance had no abnormalities noted for color. Peri-wound temperature was noted as No Abnormality. Record review of wound care order dated 02/24/2023 form NP C, revealed Primary Wound Dressing: Wound #1 Left Calcaneus: Other- Cleanse with wound cleanser. Pat dry. Paint entire heel liberally with betadine q shift. Heel cup or heel pillow while in wheelchair. During an interview on 02/24/2023 at 9:48 AM with DON E regarding Resident #1, stated about 3 weeks ago she removed Resident #1's PICC line. DON E denied anyone coming to her regarding his left heel wound. DON E stated that when NP C from wound care was at the facility on 02/23/2023, that the only thing she talked to her about was where to find different reports in electronic records regarding resident's skin. During an interview on 02/24/2023 at 10:05 AM with ADON regarding admission assessments, she stated that a complete head to toe assessment should be completed by the admitting charge nurse. ADON stated after WCN F quit working at the facility on 01/13/2023, she verbally informed the nursing staff that they would be responsible for doing the skin checks and treatments. Regarding CNA shower sheets, she stated that they had them, but it was not being enforced. ADON stated that WCN D completed an in-service on 02/20/2023 indicated that the CNA's were responsible for filling them out on every resident and turning them in to their charge nurse for review and signature, then the form should go to, WCN D, who will then assess any resident that was identified to have skin issues. The ADON stated without thorough skin assessments being completed, a lot could happen to a resident. The ADON stated NP C voiced she would be back to see him next week. The ADON stated that she only became aware of the wound on Monday 2/20/23 when WCN D notified her on what needed to be done. The ADON stated, WCN D notified NP I, and she ordered po antibiotic Keflex for prophylactic since resident was scheduled to be discharged , and to get a referral for a podiatry consult. The SWK worked on the referral and Resident #1 wasn't going to be able to be seen until June. Resident #1 also developed C-diff, which delayed discharged , and Resident #1 remained at the facility. The ADON stated WCN D reached out to NP I, to come assess. The ADON stated that when WCN D notified her of the wound she did not go look at Resident #1's heel. The ADON stated that WCN D was new, so she was just telling her what steps needed to be followed, what should occur upon identification of a wound, wound observation, physician notification, ADON's/MDS update care plan. During an interview on 02/24/2023 at 11:24 AM, with RN B, she stated she does skin assessments, will get with the CNA's, and try to get the assessment done with their shower, she stated that was the best time. RN B, stated she had taken care of Resident #1 on 02/23/2023, and did not see the wound prior to that. RN B, stated she was not sure how she missed it. RN B, stated she did not receive in report anything regarding Resident #1's wound. During an interview on 02/24/2023 at 11:15 AM, the ADON stated she did not find any documentation of the wound on Resident #1's heel. The ADON stated the facility had a 24 - hour report that they can print and pass on to staff for each shift so staff will know what care was needed for each resident. During an interview on 02/24/2023 at 11:17 AM, the Administrator stated the only documentation they have for Resident #1's heel was the physician order for the antibiotic and wound care dated 02/20/2023. The Administrator stated, If you don't document it didn't happen, we dropped some balls here its been the craziest thing in the world trying to get people and we have had a lot of agency staff. The Administrator stated he received an email from Resident #1's family member earlier in the week maybe, Wednesday (02/22/2023) . The Administrator stated the family member mentioned the wound in the email and he had passed that information on to the ADON. The Administrator was asked to provide a copy of the email he received from the family for Resident #1 and he did not provide a copy. During an interview on 02/24/2023 at 11:45 AM, LVN A stated she provided care for Resident #1 on 02/19/2023. LVN A stated a family member for Resident #1 was in the facility visiting Resident #1 and mentioned the area on the heel to her (LVN A). LVN A stated the family member for Resident #1 was cutting or filing Resident #1's toenails and that was how the family member noticed the area. LVN A stated she went to the room of Resident #1 and looked at his left heel. LVN A stated she observed a circle not open but really, really blackish hard, not opened, like the size of if you put your thumb and pointer finger together and make a circle. LVN A stated she contacted WCN D or the ADON on (02/19/2023) to let them know about it and then made the progress note. LVN A stated the family member for Resident #1 mentioned she saw it a few weeks ago but was like a pinpoint size small dot. LVN A stated she has not had to do a full skin assessment on him because they had a wound nurse, and she does that. LVN A stated she did work in the facility on 2/19/23 and prior to that she worked on 2/17/23 and 2/18/23. She stated no one had mentioned anything to her about his foot and when she has seen him, he had on socks. LVN A stated the 24 - hour report sheets were usually two days old if not older and she doesn't always get one. LVN A stated there had not been a wound nurse that does a complete skin assessment for a while at the facility. LVN A stated the new wound nurse was the one that would do a full skin assessment. LVN A stated the admitting floor nurse was the one that would do the initial skin assessment on admission. During an interview on 02/24/2023 at 12:00 PM, WCN D reported that LVN A was not the one that reported the wound for Resident #1 to her. WCN D stated it was CNA H that came to her on Monday (02/20/2023) to ask her if she could look at Resident #1's heel. WCN D stated she went to assess Resident #1 and there was a dressing on his left heel. WCN D stated she took that off and cleaned it, then notified ADON and contacted NP I for orders. During an interview on 02/24/2023 at 1:00 PM, WCN F denied knowing about Resident #1 being admitted on [DATE] the same day she quit her job at the facility. WCN F stated that his name was not familiar to her, and she verified she did not see that resident. During an interview on 02/24/2023 at 3:30 PM with Resident #1, resident agreed for skin assessment. Resident's left heel was observed with an area of black eschar. WCN D stated that upon assessment the area of eschar was hard, Peri-wound is firm without redness or any drainage. Resident #1 denied any pain when WCN D was cleaning and treating area. The residents' right heel was firm with no redness noted. Observations of legs, chest, elbows, shoulders, back, and bottom revealed no issues. During an interview on 02/24/2023 at 1:50PM, CNA H stated she worked with Resident #1 off and on over the three months she has worked at the facility. CNA H and worked with him this week and showered him on Tuesday (02/20/2023). She stated she washed his feet and she saw a black dot maybe the size of a dime. She stated Resident #1 didn't say anything about it. She stated she told the nurse about it, but it was an agency nurse, and she doesn't recall her name. She stated the agency nurse said she would look at it in a little bit. She stated that was the first time it was noticeable to her. She stated she believed the new wound care nurse WNC D, had looked at it by then. She stated the facility has trained her that if she sees something she reports to the nurse and that since the new wound care nurse WCN D started the CNA's had to fill out a shower sheet for each resident when assisting them with showers. CNA H stated prior to that they were not doing the showers sheets. During an interview on 02/24/2023 at 3:55 PM, Surveyor introduced herself and asked NP I if she could come to the conference room for an interview. NP I stated, I'm busy and if I have time I will see. NP I did not comply with interview request. During an interview on 02/24/2023 at 3:57 PM, with LVN G regarding the admission Assessment on Resident #1 and the blank area on the skin section. LVN G verbalized she had been told by WCN F, that she will come back and fill that information in. She was not aware of Resident #1 having any skin issues, not to my knowledge. LVN G stated she has worked with him since admission, and she has not done a skin assessment on him because she was told all skin assessments are done by WCN F. Record review of Resident #2's undated face sheet, reflected that Resident #2 was admitted to the facility on [DATE], with a readmission on [DATE] with the following diagnoses: unspecified intracranial injury with loss of consciousness of unspecified duration (traumatic brain injury), osteomyelitis of vertebrae (infection of the bone), sacral, sacrococcygeal region, pressure ulcer of right buttock, attention and concentration deficit following cerebral infarction (memory difficulty, trouble focusing, stroke), seizures, obesity, moderate protein-calorie malnutrition, history of stage 3 pressure ulcer of left heel, Polyosteoarthritis (pain in swelling in multiple joints), fusion of spine in lumbar region, depression, and history of traumatic brain injury at 14-years old. Record review of the Annual MDS dated [DATE] reflected Resident #2 had a BIMS score of 9 (moderately impaired), and extensive assistance of two staff members for bed mobility and transferring. Section M0150 indicated that Resident #2 was at risk of developing pressure ulcers/injuries. Section M0210 indicated that Resident #2 has one or more unhealed pressure ulcers/injuries. Section M0300 indicated there was one unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar that was present upon admission/entry or reentry. M1040 indicated no other ulcers, wounds, or skin problems. During interview on 02/24/2023 at 2:15 PM with Resident #2, he indicated he was doing ok and the only problem he had was a sore on his hip. Resident #2 voiced that he had been in healthcare facilities since he was 17-years-old. During an observation on 2/24/2023 at 2:18 PM of Resident #2's skin assessment, performed by WCN D, revealed that left heel was soft and red with a dark-brownish discoloration. Wound measurement noted to be 3 cm x 2 cm. During interview on 02/24/2023 at 2:28 PM with WCN D and charge nurse LVN L revealed they were not aware of Resident #2's left heel DTI. Record review of Resident #2's care plan with a date of 02/24/2023 as being last date reviewed/revised does not reflect Resident #2's DTI (deep tissue injury) to left heel or that Resident #2 was at risk for altered skin integrity. Record review on 02/25/2023 of Resident #2's medical record reflected that Resident #2's Braden Scale for Predicting Pressure Score Risk dated 02/04/2023 had a score of 12, which indicates high risk. (Interpretation of score: 19 or higher = not at risk, 15-18 = at risk, 13-14 = moderate risk, and 10-12 = high risk, and 9 or less = very high risk). Record review of progress notes from 02/04/2023-02/24/2023 did not reflect Resident #2's left heel. Record review of Wound Management tab did not address the left heel. Record review of Physician Orders reflected an order for weekly skin assessments every Wednesday with a start date of 05/27/2022. There was no order for treatment to left heel wound until 02/24/2024, indicating daily wound treatment of left heel to clean with wound cleanser, skin prep, and float heels. Record review of Weekly Skin Observation dated 02/15/2023 does not reflect Resident # 2's left heel. Review of Weekly Skin Observation dated 02/22/2023 reflected no alterations in skin. During an interview on 02/26/2023 at 10:40 AM with MDS J reflected that a care plan was a guideline for the staff to provide appropriate care to the resident. If a care plan does not address all areas of concern, then it could prevent the resident from getting the appropriate care. During an interview on 02/26/2023 at 11:52 AM with MDS K revealed if a wound was not identified and addressed, then the wound could get worse. MDS K stated she had recently been in-serviced on wounds, and that the Braden Scale for Predicting Pressure Ulcer will be done on admission and then weekly. Record review of Resident #3's undated face sheet reflected that Resident #3 was admitted to the facility on [DATE], with the following diagnoses: Alzheimer's disease with late onset (affects memory), dementia in other diseases with other behavioral disturbance. Record review of Resident #3's Annual MDS assessment dated [DATE], reflected that Resident #3 had a BIMS score of 01 (sever cognitive impact) extensive assistance of two staff for bed mobility and transferring. Section M0150 reflected Resident #3 was at risk for developing pressure ulcers/injuries. M0210 reflected that Resident #3 has one or more unhealed pressure ulcers/injuries. M0300 reflected one unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar, not present upon admission/entry or reentry. M1040 indicated no other ulcers, wounds, or skin problems. During an observation on 2/24/2023 at 2:35 PM of Resident #'3's skin assessment by WCN D revealed buttocks with blanchable redness and 0.5 cm x 0.8 cm open area on Resident #3's coccyx. During an interview on 02/24/2023 at 2:45 PM with the ADON and WCN D reflected they were unaware of open area to Resident #3's coccyx. The ADON verbalized that there was a standing order for barrier cream. Record review of Resident #3's care plan dated 02/08/2023 as being last date reviewed/revised did not reflect resident was at risk for alterations in skin integrity, or the 0.5 cm x 0.8 open area to Resident #3's coccyx. Record of Resident #3's medical record on 02/25/2023 revealed there was no Braden Scale For Predicting Pressure Ulcer during the dates of 09/01/2022 to 02/25/2023. Record review of Nursing Progress Notes for Resident #3 revealed no documentation regarding coccyx until 02/24/2023 when WCN D put in a note for the charge nurse to contact the physician for ulcer on coccyx. Record review of the Wound Management reflected that Resident #3's right heel ulcer was identified on 05/27/2022. There was no documentation related to the open area on coccyx identified on 02/24/2023. Record review of February 2023 physician orders reflected an order for weekly skin assessment every Friday with a start date of 04/11/2022. There was no treatment order noted for the wound on coccyx. Record review of Weekly Skin Observation for Resident #3 dated 02/03/2023 revealed treatment to right heel, Weekly Skin Observation dated 02/17/2023 revealed no alterations in skin. During an interview on 02/26/2023 at 9:55 AM with LVN N, reflected that she had been recently in-serviced on wounds, skin assessments and reporting any changes. LVN N stated that the ADON and DON E had in-serviced her, but she had not signed any papers. During an interview on 02/26/2023 at 10:15 AM with RN M reflected that she had been recently in-serviced regarding skin assessments and reporting any changes by the ADON and DON E. RN M stated that it was not anything new, verbalizing that she already does that. RN M was not aware of Resident #3's wound to coccyx. During an interview on 02/26/2023 at 11:52 AM with MDS K reflected that she does the skilled assessments and stated that she developed her care plan based on the admission assessment, diagnoses, medications, behaviors, and she also pulls the wound report. MDS K stated that she was not aware of Resident #1's unstageable heel wound until Wednesday 02/22/2023, and then stated she updated the care plan on Friday 02/24/2023. MDS K stated if a wound is not identified and addressed, then the wound could get worse. MDS K stated she had recently been in-serviced by the ADON and DON E on wounds, and that the Braden Scale for Predicting Pressure Ulcer will be done on admission and then weekly. Record review completed of the following policies: Wound Care: Pressure Ulcer (All rights reserved -2017 CMS FR: 9/7/2017 F684 F686 Email revision 3/23/2017, MR revision 1/18/2017. Complete revision 6/1/2015 Subject: Pressure Ulcers Policy: Pressure ulcers will be evaluated and treated in accordance with professional standards of practice to heal and prevent pressure ulcers unless clinically avoidable. Definitions: Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and maybe painful. The injury occurs as a result on intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and conditions of the soft tissue. Procedures 1. Evaluate the pressure ulcer initially for location; stage (see specific policy), size (in cm's), sinus tracts, undermining, tunneling, exudate (type, odors), necrotic tissue, and the presence and or absence of granulation tissue and epithelialization. 2. Determine and record the date of onset for each pressure ulcer identified as Stage II or greater. The date of onset is included in the information for the wound on the weekly wound tracking sheet and carried over week to week until healed. If a wound deteriorates to a higher stage, the original onset date is retained. 5. Identify the most sever tissue type for any pressure ulcer on the appropriate forms as follows: D. Necrotic tissues (Eschar): dead or devitalized tissue that is hard or soft in texture: black, brown, or tan color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. 6. Re-Evaluate pressure ulcers at least weekly. If the patient's/resident's condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame (2 weeks), the treatment plan should be re-evaluated. Record review completed for facility policy: Wound Care Policies and Procedures (All Rights Reserved 2015. Complete Revision: 6/1/2015 Subject: Wound Evaluations Policy: Evaluation of wounds will be preformed on admission, weekly and on discovery. Procedures: Evaluation is the formal process in which wound characteristics, underlying conditions and contributory medical history are identified/quantified. Evaluation should result in treatment approaches including elimination or compensation for causative factors and a prognosis for healing. 3. Evaluation results are communicated to the members of the care team through documentation, care plan meetings, and care planning. This was determined to be an Immediate Jeopardy (IJ) on 02/24/2023 at 5:45PM. The Administrator, ADON, WCN D, DON E, were notified. The Administrator was provided with the IJ Template on 02/24/2023 at 5:45PM. The following Plan of Removal submitted by the facility was accepted on 02/25/2023 at 2:15PM Record review of the facility Plan of Removal reflected the following: (Facility Name) Plan of Removal 2/24/2023 F686 Revision 2 Resident #1 had complete full body assessment on 2/24/3023, Physician was notified, and treatment order was received. Responsible party was notified of current skin condition & treatment Resident #1 care plan reflects: current skin condition, ordered treatment, offloading of left heel while in bed, Wound Care, Nurse practitioner weekly visits and dietary referral to prevent further skin breakdown. Residents who reside in the facility have the potential to be affected by this alleged deficient practice. A facility wide skin sweep, using current census, starting 2/24/2023 will be completed by 2/25/2023 to validate wounds/skin integrity status. Any concern identified will be addressed upon discovery. Braden Scales will be updated on each resident to determine residents at risk for skin breakdown. Pressure Ulcer Risk Evaluation form will be completed on residents with Braden score of 18 or below to further identify conditions which may contribute to skin breakdown Physician and responsible party will be notified if any resident is identified with new skin concerns during facility wide skin sweep. The Nursing team will implement any new physician orders. Any resident identified during facility wide skin sweep will have their care plan appropriately updated to reflect their current skin condition, including additional approaches to prevent further skin breakdown based on the root cause of their current skin issue. The Registered Nurse (Acting Director of Nursing) was re-educated by the Clinical Consultant on 2/24/2023 on the expectations and oversite on the skin program. This included: Full body skin assessments will be completed by admission Nurse on New Admissions/Readmissions Braden Scales will be completed by admission nurse on admission, readmission, weekly for 3 weeks then quarterly and or residents with changes of condition to determine residents at risk for skin breakdown. Pressure Ulcer Risk Evaluation form will be completed by admission nurse on residents with Braden score of 18 or below to further identify conditions which may contribute to skin breakdown Resident Care plans will be updated identifying Resident at risk for skin breakdown or resident with actual skin integrity concerns Certified Nurse's Aides will complete skin inspections using shower sheets following resident scheduled shower days. 24-hour report will be monitored Monday through Friday during Morning Clinical meeting to identify any new Changes of condition or new skin concerns and validate information being shared to nurses shift to shift. Nurse management will review on weekends. Validation of Admission/Weekly skin assessments and Braden scales will be completed daily Monday through Friday by Director of Nursing/Nurse managers during Morning Clinical meeting to validate completion, accuracy and timeliness. Director of Nursing/Designee will Round Weekly to validate skin prevention measures are in place/occurring and on weekends by charge nurse The Registered Nurse (Acting Director of Nursing) was able to verbalize understanding of education given in