**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #46) of three residents reviewed for pressure ulcers. The facility failed to ensure Resident #46 who was admitted to the facility on [DATE] without a pressure ulcer to his right lateral calf did not develop a pressure ulcer. The facility failed to ensure interventions were in place to perform skin checks under his right leg brace and Resident #46 developed an unstageable DTI (deep tissue injury, a pressure-related injury to subcutaneous tissues under intact skin.) to his right lateral calf on 09/27/2024 . The facility further failed to ensure once a pressure ulcer developed it was assessed routinely and failed to perform a wound assessment from 12/18/2024 until 01/08/2025. These failures resulted in an Immediate Jeopardy (IJ) situation on 01/08/2025. The IJ template was provided to the facility on [DATE] at 5:00 PM. While the IJ was removed on 01/10/2025, the facility remained out of compliance at a severity level of no actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing worsening pressure ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe pain or death. Finding Include: Review of Resident #46's face sheet dated 01/08/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses, fracture lower end of right femur (a break in the thigh bone near the knee joint.), diabetes mellitus type II (A condition results from insufficient production of insulin, causing high blood sugar.), and atherosclerotic heart disease (A condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall). Review of Resident #46's quarterly MDS dated [DATE] reflected Resident #46 was assessed to have a BIMS score of 13 indicating he was cognitively intact. Resident #46 was assessed to require moderate assist with ADLs. Resident #46 was further assessed be at risk for pressure ulcers and was assessed to have one stage four unhealed pressure ulcer. Review of Resident #46's comprehensive care plan not dated reflected a focus area not dated Resident has potential for alteration in skin due to decline in mobility related to fracture of right femur and wearing a splint to right leg. Open area to the right calf. Interventions included Apply treatment as ordered per MD or Wound MD; Apply Wound VAC as ordered, notifying MD & RP of any changes; Encourage good nutrition and hydration in order to promote healthier skin; Identify potential causative factors and eliminate when possible; Keep skin clean and dry, use lotion on dry scaly skin. The care plan did not address a current pressure ulcer or detailed interventions for splint management. Review of Resident #46's hospital discharge instructions dated 09/13/2024 reflected Distal femur fracture treated with immobilization .if you have a removable splint: wear the splint as told by your health are provider. Remove it only as told by your health care provider. Check the skin around the splint every day. Tell your health care provider about any concerns. Loosen the splint if your toes [NAME], become numb . Further review of Resident #46's hospital discharge packet reflected medication orders, post op wound care and therapy orders. Review of Resident #46's admission assessment under the skin integrity section dated 09/14/2024 reflected no open areas to his right lateral calf. Further review of Resident #46's admission assessment reflected the DON signed the skin integrity section as completed by her. Review of Resident #46's nursing progress note dated 09/27/2024 reflected Resident has an open blister on right calf under leg stabilizer. New order to apply Calcium Alginate, gauze and cover with Border Island dressing every day. Signed by RN A. Review of Resident #46's consolidated physician orders dated September 2024 reflected an order dated 09/28/2024 to cleanse right calf open area with wound cleanser or normal saline, pat dry, apply Calcium alginate and cover with gauze dressing every day. Further review reflected an order dated 09/27/2024 Remove splint every shift every and examine skin every shift to monitor skin under the knee immobilizer. Further review of Resident #46 consolidated physician orders dated September 2024 reflected no order to remove the splint and examine Resident #46 skin under the splint prior to 09/27/2024. Review of Resident #46's TAR dated September 2024 reflected an entry dated 09/28/2024 Cleans right calf open area with wound or normal saline, pat dry , apply calcium alginate and cover with gauze and border island dressing every day. With signatures beginning on 09/28/2024. Further review reflected an entry dated 09/27/2024 Remove splint every shift and examine skin every shift to monitor skin under the knee immobilizer. With signatures beginning on 09/27/2024. Review of Resident #46's post-op follow up visit to the orthopedic physician dated 09/30/2024 reflected Resident #46's knee immobilizer was removed .Patient was advised to follow-up with wound care and utilize dressing changes outside the leg for the next 2 weeks .Notified patient we will place him on a hinge knee-brace next visit but allow for this wound to heal at this time . Review of Resident #46's wound care physician notes dated 10/02/2024 reflected etiology-pressure, classified as an unstageable DTI within and around wound measuring 4 cm x 4 cm x 0.1 cm deep. Review of Resident #46's EMR reflected his last wound care MD visit was 12/18/2024 which reflected a Stage 4 pressure ulcer extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments.) of the right, lateral calf full thickness 2.6 cm x 1.2cm x 0.5 cm depth with 30% slough (slough in a wound indicates a healing process that is stalled in the inflammatory phase.) Review of Resident #46's EMR reflected his 12/18/2024 wound assessment was the last wound assessment conducted until 01/08/2025. Observation on 01/08/2025 at 1:45 pm revealed the Treatment Nurse in Resident #46's room to do wound care. She removed the dressing to his right lateral calf to reveal a Stage IV pressure ulcer 0.4 x .03 approximately .5 deep with moderate drainage no odor 100% granulation tissue no slough. In an interview on 01/08/2025 at 1:55 PM Resident #46 stated he was not admitted with the pressure ulcer to his right leg. He stated he got the pressure ulcer at the facility when his brace was digging into his leg. Resident #46 stated he told the facility the brace was rubbing his leg, but they did not look at it right away. He stated it was only when he continued to complain about the brace rubbing and pushing into his leg that they took it off. He stated they told him he had a sore on the outside of his calf from the brace. Resident #46 stated he did not remember them taking the brace off his right leg to look at his skin before he went to his post op appointment about two weeks after he was admitted to the facility. In an interview on 01/08/2025 at 2:10 PM the DON stated the pervious wound care nurse was in charge of wound assessments and she was supposed to assess Resident #46 on admission and develop a plan of care. She stated she realized she had not done that and that orders for removing the splint were missed only after Resident #46 developed his pressure ulcer. In an interview on 01/08/2025 at 3:58 PM the Wound Care MD stated the first time he saw Resident #46 was 10/02/2024. He stated at that time he had an unstageable DTI to his right lateral calf. The Wound Care MD stated the last time he saw Resident #46 was 12/18/2024. He stated he was out of town after that. The Wound Care MD stated the pressure ulcer on Resident #46 right lateral calf was definitely avoidable if the splint had been removed regular. In an interview on 01/08/2025 at 4:09 PM the DON stated after reviewing Resident #46's EMR that there had not been a wound assessment done for Resident #46 since 12/18/2024. The DON stated she did not know a wound assessment had to be done weekly. She stated the wound care nurse just started on 01/06/2025 to replace the last wound care nurse whose last day was 11/15/2024. She stated she had not conducted recent wound assessment for Resident #46 and did not see one in his medical record. The DON stated the wound care MD was at the facility and a wound assessment would be performed. In an interview on 01/09/2025 at 10:34 AM RN A stated her last day at the facility was 11/15/2024. She stated she did not know it was her responsibility for the wound care plans. She stated the facility had the wound care MD seeing Resident #46 for wound care and she thought he was doing the splint care. RN A stated the splint was in place for Resident #46 when he was admitted but they never had instructions to remove it. RN A stated the DON or MDS coordinator were in charge of doing care plans. RN A stated she did the assessments of the current wounds not the new wounds. She stated Resident #46's surgeon put the brace on Resident #46, and she did not remove it because she did not have orders to remove it. RN A stated she was not aware of any discharge instructions for splint care. She stated she did not do care plans. RN A stated she was not the only one taking care of Resident #46 and she only did his wounds periodically. RN A stated there were other nurses, the charge nurses doing his wounds as well. She stated she was in charge of following up on skin assessments the charge nurse did. She stated she would follow up after an assessment if they found any new skin areas and she would do the weekly skin reports. She did not remember the DON asking her about Resident #46's splint and stated she believed the DON did that. RN A stated the charge nurses would tell her if they found something, and she would check it out. RN A stated it would have been the charge nurses who did the weekly skin checks and who should have checked the splint for Resident #46 but since they did not have instructions to remove the splint and perform skin checks they would not have. In an interview on 01/09/2025 at 10:40 AM the DON stated she was ultimately responsible for ensuring that once a residents was admitted that the baseline care plan was done, a full skin assessment was complete and the plan for wound care or splints was completed. She stated RN A was her wound care nurse and she asked her to look at all of Resident #46 wounds and to make sure orders were in place for care and pressure ulcer prevention interventions. She stated she asked RN A to check Resident #46's splint for pressure points. The DON stated she did not follow up with RN A. The DON stated she was not aware of the issue with Resident #46 until the pressure ulcer had already developed. She stated a full assessment and order review just did not get done and she should have followed up. She stated, I relied on her (RN A) to take care of it. In an interview on 01/09/2025 at 12:40 PM the Administrator stated the facility had a wound care nurse that monitored the wounds but she left in November, she stated she expected the DON to follow up on new wound orders and new admits to make sure the residents had everything they needed for care and to prevent pressure ulcers. In an interview on 01/10/2025 at 11:13 AM the Nurse Consultant stated it was facility policy that an RN complete weekly wound assessment. The Nurse Consultant stated it was also the facility policy that residents who admitted with splints were to have orders to remove and monitor the skin under any splints or removable casts. Review of the facility's policy Skin assessment dated (no month) 2024 reflected It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury .Begin head to toe, thoroughly examining the resident's skin for conditions. Pay close attention to pressure points, bony prominences, and underneath medical devices. Review of the facility's policy Stabilization and Securement devise dated 02/2022 reflected .The device is removed regularly, and the resident assessed for the following: a. Circulation; b. Skin integrity ;c. Catheter functionality; and d. Range of motion . Review of the facility's policy Prevention of pressure ulcers/injuries dated 07/2017 reflected The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors .Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity - any evidence of existing or developing pressure ulcers or injuries. b. Tissue tolerance - the ability of the skin (and supporting structures) to endure the effects of pressure; and c. Areas of impaired circulation due to pressure from positioning or medical devices . The Administrator was notified on 01/08/2025 at 5:47 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 01/09/2025 at 4:55 PM. On 01/08/2025 an abbreviated survey was initiated at[name of facility]. On 01/08/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: _____1/8/2025_________) All residents with a pressure ulcer were assessed and measured by the wound care MD on 1/8/25. Resident #46 was assessed by the wound MD on 1/8/25. No other individuals were found to be affected by this practice. The wound care doctor assessed all other residents with wounds. The medical director was notified of the IJ on 1/8/25. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 1/9/25 and ongoing for PRN staff before returning to the floor). All facility policies and procedures related to skin care, wound care, and pressure injury prevention were reviewed 1/8/25. Corporate Nurse/Consultant Nurse provided education to the Administrator, DON and facility nurses on facility policies and procedures related to skin/wound care, as well as appropriate wound treatment measures, including weekly assessment and measuring by a RN. A self-test will be completed by all nurses. The treatment nurse will be responsible for daily wound care. A self-test will be monitored by DON or designee. A direct in-service was done with the facility DON/RN that wound measurements must be done by a RN weekly in the weekly wound assessment UDA (User Defined Assessment,. following physician orders, splints/brace care and plans of care for any resident. We will do a self with Physician orders, braces, and splints. DON/Corporate Nurse/Consultant Nurse Monitoring will continue to monitor/audit the following: Weekly skin assessments/wound assessments. Corporate nurse will complete system validation checklist weekly for compliance. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. The Survey Team monitored the POR on 01/09/2025 through 01/10/2025 as followed: In an interview on 1/10/2025 at 11:10 AM the Nurse consultant stated she reviewed all the facility policies with the DON on 1/8/25 that included: skin and wound care and pressure injury prevention. In an interview on 01/10/2025 at 11:13 AM the Nurse Consultant stated I did in-service with DON that a RN has to complete a weekly wound assessment for all wounds and pressure weekly, also trained administrator, DON, and all nursing staff on site to make sure any resident admitted with a splint that the splint is removed and a skin assessment is completed and to make sure they get with the residents MD so they have an order to remove and monitor the skin under any splints or removable casts. She stated she made an audit sheet for her monitoring, she stated she will go into PCC and check that all wound assessments and measurements were done. She stated the facility was to send her a weekly wound report. She stated the wound report was updated on 1/8/2025 and she reviewed the report and checked the wound assessments. She stated the facility was supposed to notify her of any residents admitted with splints or removable cast. She stated after the training with the Administrator , DON, and nurses on duty she turned the training over to the Administrator to complete for nurses that were not on duty or coming in later. In an interview on 01/10/2025 at 12:46 PM the administrator stated the NC in-serviced her on the proper precautions that need to be in place for residents with splints and devices and that she instructed the nurses to notify the administrator so she can assist in tracking and monitoring to ensure orders are in place for monitoring skin She stated they will review the skin reports and audits in the morning meetings and in QA she stated the NC will notify her of all audit results she stated they had a QA meeting on 12/19/24 and did discuss the wound care system because we had an aid out for a wound care nurse she stated they also reviewed the current pressures ulcers. In an interview on 01/10/2025 at 12:55 the DON stated the nurse consultant performed her training on 01/09/2025 regarding the need for a RN to perform weekly wound assessment, the wound care system and splint management. She stated she will be sending the weekly wound tracker to her and will be making rounds with the wound care doctor on Wednesday and hospice nurses for the hospice residents with wounds. She stated the QA team did discuss the pressure ulcers at the last QA meeting, she stated they went over the wounds, stages, and measurements. She stated during the meeting they did discuss the fact that they did not have a wound care nurse and one was hired but did not start till this week. She stated she was out for about 10 days at the end of November and did not come back till the beginning of December and at that time the wound care nurse was gone. She stated she took full responsibility for the current situation, I just had so much going on I did not look at his wounds or catch the issue. In an interview on 01/10/2025 at 12:06 PM the MDS Coordinator stated she was in-serviced on skin assessments on weekly basis and as needed. She stated the DON was going to assess the skin once a week. If anyone comes in with splint, brace or wrap it needs to be removed and checked on a daily basis. They were to check the physician order and follow the physician orders. If they remove the splint and see a new wound she will do assessment, document my information, call the doctor, family and get an order for the treatment if the doctors' orders a treatment will document it in physician orders. She stated she would notify the DON, the administrator, and the Treatment nurse. She stated they had a quiz on skin assessments and splints. She stated she was in-serviced on care planning for splint and skin care. She said an order needs to be written about the splint and brace such as what type of care the resident needs for the splint brace and all orders need to be reviewed on admission. In an interview on 01/10/2025 at 12:17 PM the Treatment Nurse stated they had a quiz. She stated she learned the splint/ brace and skin care needed to be care planned and documented on physician order. She further stated she learned that the physician orders needed to be reviewed on new admits check residents' skin under and around splint this is supposed to be checked daily. Check splints, boot, wrapping, Geri- sleeves we are to check the resident's skin daily. The residents wearing any device such as splint check daily - Q Shift. She stated if you see a new wound or red area on residents' skin she would call the doctor and see if the doctor has a referral for wound care. She further stated she would contact the wound care doctor if needed and would report to the DON and report to the family. She stated If the resident received a new order from the doctor for any type of skin treatment she would input the order in the medical record PCC and would follow the order. She further stated she was in-serviced on skin assessments- they were to be completed weekly on every resident in the facility. In an interview on 01/10/2025 at 12:48 PM LVN O stated she was in-serviced on skin assessments, and they were to be completed weekly, but they do not do skin assessments on night shift, and she worked night shift. She stated if she worked during the day if it was time for a resident to have a skin assessment she would make sure it was completed. She stated the staff was to take off any type of medical device on resident skin including splint every shift and check skin for any redness of new wounds or decline in an existing wound. She stated if she observed any new skin concerns she would call the physician and follow his orders, call the DON, call the treatment nurse, and call the family. She stated if there was a new treatment she would enter it in PCC and do a skin assessment and a nurses note. She stated she would document everything she did and who she called. She stated she took a quiz about skin issues and splints. She stated she learned all orders needs to be reviewed and any device a resident has needed to be on the care plan and physician order and that skin needs to be check under the splints. In an interview on 01/10/2025 at 1:21 PM LVN N stated she completed a wound care in-service this morning. She learned that mobilizing and checking the skin was necessary to avoid wounds and if she notices a wound they instructed her on when to report it and to whom. She would report it to the DON and notify the physician. If she had a resident with a splint she would remove it if the orders allowed, check the area, and determine if there were any skin concerns. If she does find a skin concern she will ask for a second set of eyes. She will notify the DON and the physician of any concerns. She will provide wound care according to physician orders received. In an interview on 01/10/2025 12:39 PM LVN M stated she completed two in-services today, one on Splints and the other on Skin Assessments. She said she learned that RNs have to do skin assessments on residents. She said all residents with any skin concerns should be reported immediately to the DON. She said anything new or different observed on a resident was an immediate report and it was important to keep the integrity of the resident's skin. It is important to inspect the area of the splint and ensure can wiggle fingers or toes, review physician orders, and follow any treatment directions. In an interview on 01/10/2025 02:15 PM LVN D stated he completed an online training yesterday and was tested on skin assessments. He said he learned when to assess and to check the pulse and the area. He said if he found any concerns with a skin assessment he would report to his supervisor and wound care staff. He said if he had a resident with a splint he would ensure he check the area thoroughly and report any new or changes to an area. Any concerns identified he would report directly to his supervisor to move forward with notifying the physician. Review of the weekly wound tracking worksheet completed on 01/10/2025 reflected all current pressures ulcers were documented. Review of Resident #46's wound MD assessment reflected it was completed on 01/8/2025. Review of in-service training reflected in-service dated 01/10/2025 attended by all nine nurses including DON reflected the training topic was Wounds must be evaluated by an RN weekly. If a resident has a device the device must be removed frequently to check skin integrity, wounds must be evaluated by a RN to include measurements. Review of Knowledge check for nursing regarding splint care reflected training taken by all nurses and covered the following areas: 1) All orders should be reviewed on new admission 2) Use of a splint should be included in the resident's care plan. 3) The resident's skin under and around the splint should be checked and results documented at least daily. 4) An order should be written for skin assessment under a splint/brace. Review of the weekly wound tracking worksheet completed on 01/10/2025 reflected all current pressures ulcers were documented. The Administrator was informed the IJ was removed on 01/10/2024 at 3:30 PM, the facility remained out of compliance at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of its corrective systems.