**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for 1 (Resident #1) of 5 residents reviewed for physician notification. The facility failed to notify the primary physician that Resident #1's wound to her right elbow underneath the splint which led to an infection resulting in hospitalization. An Immediate Jeopardy (IJ) situation was identified on 04/20/2023 at 3:00 PM. While the IJ was removed on 04/21/2023 at 6:35 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. This failure placed residents at risk for improper wound management, deterioration, infection, pain, loss of limb, or death. Findings include: Review of Resident #1's electronic face sheet, dated 04/16/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: displaced comminuted supracondylar fracture without intercondylar fracture right humerus (also called a broken elbow) and unspecified fracture of right pubis (also called a broken pelvis). Review of Resident #1's Comprehensive MDS assessment, dated 02/28/2023, revealed a BIMS score of 10 which indicated moderate impaired cognition. Section G Functional Status revealed Resident #1 required extensive assistance from two persons for bed mobility and transfers, extensive assistance from one staff for locomotion on and off the unit, and extensive assistance from two persons for dressing, personal hygiene, and bathing. Section M Skin Conditions revealed Resident #1 was at risk for pressure ulcers/injuries but did not have any. Review of Resident #1's care plan, initiated 02/22/2023, revealed: Focus Goal Interventions/Tasks Position Freq/Resolved. Resident #1 is at risk for pressure injury. Resident #1will have intact skin, free of redness, blisters, or discoloration by/through review date. Target Date: 03/07/2023. Ensure heels are floated with the use of pillows. The resident needs assistance to turn/reposition at least every 2 hours. The resident requires a cushion to their wheel or Geri chair. Use lifting device, draw sheet, etc. to reduce friction. Further review of care plan revealed no evidence of fractured elbow, no evidence of splint, and no evidence of wounds. Review of Resident #1's skin assessment, dated 04/07/2023, signed 04/14/2023, by the TX Nurse, revealed: 1cm x 0.7cm abrasion to right elbow. Area cleaned with NS, anasept (antimicrobial cleanser) and collagen applied and covered with border foam dressing, daughters aware and present. Discussed with daughters that splint was no longer form fitting and needed to be discontinued or replaced, both verbalized understanding and agreed. Further review of skin assessment revealed no evidence of notification to physician. Review of Resident #1's electronic nurse progress notes, from 02/21/23 to 04/16/23, revealed no evidence of discovering abrasion to right elbow, treating the wound, or notifying the physician. Review of Resident #1's electronic physicians' orders, from 02/21/23 to 04/16/23, active and discontinued, revealed no evidence of treatment orders for abrasion to right elbow. Review of hospital history and physical, dated 04/11/23, signed by Hospitalist, revealed: Assessment: Resident #1's splint was removed from right arm and there was a malodorous lesion above the fracture and the skin was red and warm. Admitting Diagnosis: Septic shock-secondary to right upper extremity wound and cellulitis Sepsis, Acute kidney injury- secondary to sepsis, wound of right upper extremity, cellulitis of right upper extremity, Elevated troponin trend- secondary to sepsis from right elbow wound with cellulitis. Treatment Plan: Admit to ICU. Continue Zosyn and vancomycin (antibiotics), Consult orthopedics. Consult wound care for concerns wound may go down to the fracture and may require debridement. Review of Resident #1's the hospitals wound care notes, dated 04/12/23, revealed: Right lateral elbow abrasion full thickness sero-sanguineous (yellowish-bloody) exudate measuring 2.3x2.3x0.2 (LxWxD in cm), Right posterior heel deep tissue pressure injury persistent non-blanchable deep red, maroon, or purple discoloration measuring 1.1x1 (LxW in cm), Left heel deep tissue pressure injury persistent non-blanchable(unable to make go away by pressing on) deep red, maroon, or purple discoloration measuring 1.2x1.9, Right posterior forearm deep tissue pressure injury persistent non-blanchable deep red, maroon, or purple discoloration measuring 0.6x6, and sacral deep tissue pressure injury persistent non-blanchable deep red, maroon, or purple discoloration measuring 4x4. Review of Resident #1's hospital records, dated 04/11/23 to 04/18/23, revealed Resident #1 was in the intensive care unit from 04/11/23 until 04/17/23 then transferred to the cardiac unit. Further review of hospital records revealed resident received 16 doses of IV (intravenous) Ancef (antibiotic), 6 doses of IV Zosyn (antibiotic), and 4 doses of IV Vancomycin (antibiotic) during her hospital stay. Review of Resident #1's hospital discharge progress note and discharge orders, dated 04/18/23, revealed Resident #1 to continue IV Ancef for 4 weeks ending 05/12/23 and to receive outpatient wound care. During an interview on 04/15/2023 at 1:30 PM, TX Nurse LVN stated she was not aware of any other skin issues until the abrasion on Resident #1's right elbow was discovered on 04/07/23. She stated she advised Resident #1's family members the splint needed to be reformed to the arm because Resident #1 had lost a lot of muscle mass and the splint did not fit perfectly as it was oversized and had gaps. She stated she thought the wound on Resident #1's right elbow was from rubbing of the splint that didn't fit anymore. TX Nurse LVN stated she first discovered the abrasion on Resident #1's right elbow on 04/07/23 while she was working as a charge nurse. She stated she did not receive an order from the doctor for treatment, nor did she call the doctor to notify of the abrasion. She did not follow up on the abrasion or the poor fit of the splint. She stated she was not used to working as a charge nurse and she did not document for this day or when she assessed the skin underneath the splint every other day. TX Nurse LVN, she stated per protocol when a new wound was discovered she notified DON, then notified the physician to receive orders. She stated when she discovered the abrasion to Resident #1' right elbow on 04/07/23 she was busy and notifying the physician to receive an order slipped her mind. She stated it was just an abrasion and she was treating the wound appropriately even though she did not have an order. During an interview on 04/15/2023 at 5:00 PM, DON stated she was unaware what Resident #1's skin looked like under the splint when sent to the hospital. The DON stated she was ultimately responsible for monitoring and overseeing the skin assessments, making sure physicians are notified of changes. DON stated if a wound was identified it needs to be documented on skin assessment. She stated the physician should be contacted immediately to give treatment orders. She stated all wounds should have a treatment order entered in the computer. She stated without an order there was no way to document and ensure treatments are being done. She stated the physician needs to be notified of skin issues that require treatment. She stated the failure of not identifying and treating wounds occurred due to lack of communication between charge nurses, Treatment Nurse, and DON. She stated the failure occurred due to the Treatment Nurse had been working as a charge nurse a lot which takes from her duties as a treatment nurse. She stated all nurses should be responsible skin assessments, notifying physicians, and entering treatment orders. She stated not discovering a wound, treating a wound, or notifying the physician could be very detrimental and could lead to loss of life. She stated it was important to notify the physician of a new wound or a wound change because the physician needs to be aware and can assess and treat the wound appropriately. She stated she was ultimately responsible for ensuring all was done correctly. During an interview on 04/18/23 at 2:30 PM, Resident #1's Primary Physician stated she was not notified of Resident #1's right elbow wound. She stated her expectation was to be notified of all changes including wounds. She stated a wound not properly treated could lead to sepsis. She stated she believed the wound was not discovered by the facility because the facility usually notified her of all changes. During an interview on 04/20/23 at 12:00 PM, ADMIN stated there was obviously a failure in the facilities skin assessment system. She stated the facility should have notified the physician when the wound was discovered. She stated it was ultimately her responsibility to ensure failures not happen. She states the facility staff work as a team and are all responsible. She stated herself and the DON are both new and don't have a lot of experience. Review of the facility's policy titled, Notifying the Physician of Change in Status, revised March 11, 2013, revealed: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deemed it necessary for immediate medical attention . 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 3. The nurse may collect several non-emergent items and place one telephone call during the shift in order to avoid multiple calls to the physician with non-emergent questions. The nurse is responsible, however, for responding to a changing condition in a timely and effective manner. The nurse will document the [NAME] a call to physician in the clinical record. 5. The resident's family member or legal guardian should be notified of significant change in resident status unless he went has specified otherwise. This was determined to be an Immediate Jeopardy on 04/20/2023 at 3:00 PM. The Administrator was notified. The Administrator was provided with the IJ template on 04/20/2023 at 3:00 PM. The following Plan of Removal was submitted by the facility was accepted on 04/21/2023 at 6:20 PM: Problem: Notification of physician of decline in wound Medical Director was notified on 4/20/2023 at 3:05 pm Interventions: Resident #1 was discharged to hospital on 4/11/2023, Charge Nurses were in- serviced by the DON on 4/20/2023 to Notify Physician of any and all issues that might require a change in care immediately. The DON, ADON, and Treatment Nurse were provided a one on one in-service by the RCN, regarding reporting negative changes in skin condition to the physician - i.e. new wound or decline of a current wound. Complete skin rounds, including assessing the skin of all 59 residents from head to toe, were completed on 4/15/23 by the DON, ADON, Treatment Nurse, and MDS Coordinator, with RCN oversight. Four residents were identified with non- intact skin issues on 4/15/23. One resident was identified to have eight stage 2 pressure wounds to buttocks and lumbar spine. One resident was identified to have one stage 2 pressure wound to coccyx. One resident was identified to have stage 1 pressure wounds to left foot 2nd and 5th digits. One resident was identified to have a stage two the coccyx. All skin issues were communicated to the residents' Physicians via phone call on 4/15/23 and 4/16/2023. All skin concerns have treatment orders in place. Care plans have been updated. The following in-services were initiated by the DON and ADON on 4/20/23. Any Licensed Nurses, CNAs, Nurse Aides, and CMA not present or in service on 4/20/23 will not be allowed to assume their duties until in-service. o Licensed Nurses Reporting negative changes in condition assessed by the nurse or reported by the nurse aides to the physician - i.e. any wound discovered or has a decline from previous assessment, physician will be notified timely, before shift ends, and physician orders will be followed. Nurse Aides, CNAs, CMA Pressure ulcer prevention and treatment. Reporting skin issues The Medical Director was notified of the immediate jeopardy situation on 4/20/23 at 3:05 p.m. Monitoring The DON/designee is assessing/monitoring all wound assessment weekly x 4 weeks and as needed by comparing documentation to current wounds for any changes in conditions to ensure the documentation is accurate. The Physician will be notified timely before end of shift via phone of any changes. The QA committee will meet monthly and as needed to review findings and make changes as needed. AD HOC QAPI meeting was conducted on 4/21/2023 at 8:30 a.m. to review IJ findings, interventions, and monitoring for compliance. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observation, interviews, and record reviews as follows: Review of Resident #1's discharge summary revealed Resident #1 was sent to the hospital on 4/11/23. Review of progress notes for 59 residents revealed head-to-toe skin assessment completed on 4/15/23. Four residents identified with new skin issues discovered, physicians notified, and treatment orders received, and care plans were updated. During random observation and interview on 04/21/23 at 4:00 PM revealed 1 nurse aide being educated by the ADON on pressure ulcer prevention and treatment and reporting skin issues. Staff stated understanding of preventing pressure ulcers and the importance of reporting any skin issues. During random interviews on 04/21/2022 at 4:30 PM revealed 8 CNA/NAs and 4 Licensed Nurses who worked the day shift had been educated on pressure ulcer prevention and treatment and reporting skin issues; what to do when a resident was admitted with an immobilizer without orders to remove, when to remove immobilizer to assess skin and check pules, when to report skin issues to the DON, and notifying physician of change in condition. All staff acknowledged understanding of the education. During random observation on 04/21/23 at 6:00 PM revealed 2 nurses who work the night shift being educated by the ADON on Pressure ulcer prevention and treatment, what to do when a resident is admitted with an immobilizer without orders to remove, when to remove and assess skin and check pulses, when to report skin issues to DON, and notifying physician of change in condition. All staff acknowledged understanding of the education. During random observation on 04/21/23 at 6:20 PM revealed 2 CNA's who work the night shift being educated by the ADON on pressure ulcer prevention and treatment and reporting skin issues. All staff acknowledged understanding of the education. Record review in-services initiated 04/14/23 revealed 24 of 24 CNA/NA's had been educated on pressure ulcer prevention and treatment and reporting skin issues. Record review in-services initiated 04/14/23 revealed 16 of 16 nurses had been educated on Pressure ulcer prevention and treatment, what to do when a resident is admitted with an immobilizer without orders to remove, when to remove and assess skin and check pulses, when to report skin issues to DON, and notifying physician of change in condition. All staff acknowledged understanding of the education. Review of QAPI meeting signature page, with medical director signature, with attached meeting minutes with IJ template attached. The Administrator was informed that the Immediate Jeopardy was removed on 04/21/2023 at 6:35 PM. The facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure a resident with a wound received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new wounds from developing for 1 of 4 residents (Resident #1) reviewed for wounds related to splints, braces, and immobilizers. The facility failed to remove Resident #1's arm splint to identify, treat, and monitor a wound underneath Resident #1's arm splint to Resident #1's right elbow which led to an infection resulting in hospitalization. An Immediate Jeopardy (IJ) situation was identified on 04/20/2023 at 3:00 PM. While the IJ was removed on 04/21/2023 at 6:35 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. This failure placed residents at risk for improper wound management, the development of new pressure ulcers, deterioration, infection, pain, loss of limb, or death. Findings include: Review of Resident #1's electronic face sheet, dated 04/16/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: displaced comminuted supracondylar fracture without intercondylar fracture right humerus (also called a broken elbow) and unspecified fracture of right pubis (also called a broken pelvis). Review of Resident #1's Comprehensive MDS assessment, dated 02/28/2023, revealed a BIMS score of 10 which indicated moderate impaired cognition. Section G Functional Status revealed Resident #1 required extensive assistance from two persons for bed mobility and transfers, extensive assistance from one staff for locomotion on and off the unit, and extensive assistance from two persons for dressing, personal hygiene, and bathing. Section M Skin Conditions revealed Resident #1 was at risk for pressure ulcers/injuries but did not have any. Review of Resident #1's care plan, initiated 02/22/2023, revealed: Focus Goal Interventions/Tasks Position Freq/Resolved. [Resident #1] is at risk for pressure injury. [Resident #] 1will have intact skin, free of redness, blisters, or discoloration by/through review date. Target Date: 03/07/2023. Ensure heels are floated with the use of pillows. The resident needs assistance to turn/reposition at least every 2 hours. The resident requires a cushion to their wheel or Geri chair. Use lifting device, draw sheet, etc. to reduce friction. Further review of care plan revealed no evidence of her fractured elbow, no evidence of the use of a splint, and no evidence of wounds. Review of Resident #1's hospital clinical record titled Physicians Orders, date 02/21/2023, revealed: Follow up with Orthopedic in 1 week. PT/OT eval and treat. Weight bearing as tolerated to hip, non-weight bearing to right arm, no range of motion to right arm, PT/OT to assist with getting up and out of bed. Review of Resident #1's admission nurse's note, dated 02/21/2023, completed by the MDS nurse, revealed no evidence of skin issues and no evidence of splint to her right arm. Review of Resident #1's skin assessment, dated 02/22/2023, completed by TX Nurse LVN, revealed right arm fracture, sling in place blanchable redness to bilateral heels and buttocks. Further review of the initial skin assessment revealed no evidence of documentation of an abrasion to her right arm and no evidence Resident #1 had a splint. Review of Resident #1's order summary report, dated 02/23/23, signed 03/01/23, by the Primary Physician, revealed no evidence of treatment orders for the abrasion to her right elbow and no evidence of orders regarding a splint. Review of Resident #1's Physician's Progress Note, completed by the Orthopedic Physician, from visit on 03/01/2023 revealed: Assessment/Plan: Closed supracondylar fracture of humerus- X rays taken today show mild displacement of her fracture. I discussed this with her and her family. They would like to avoid surgery if at all possible. We will leave her in a splint for now. She was counseled to wear the sling at all times. I will see her back in about two weeks for another check with X-rays. They were counseled that non operative care does increase the chance that she may have limited elbow function both the patient and her family are accepting to this. Further review revealed an order received for no range of motion to right elbow, splint at all times. Review of Resident #1's Physician's Progress Note, completed by the Orthopedic Physician, from visit on 03/20/23 revealed: Assessment/Plan: Closed supracondylar fracture of humerus- X-rays of right elbow show well aligned fracture supracondylar humerus. We will continue to treat this non operatively. There does appear to be some callous formation but not enough for me to remove immobilization. I would like her to continue her splint. I will see her back in two to three weeks for another check with X-rays and see if she is having enough healing, we will discontinue the splint. Further review revealed an order received to continue humorous split. Review of Resident #1's electronic physician's orders, from 02/21/23 to 04/16/23, active and discontinued, revealed Assess skin above and below cast for any redness, s/s of infection and pulses and document any abnormalities twice daily entered on 03/21/2023. Further review revealed no evidence of an order to continue the splint. Review of Resident #1's skin assessments dated, 03/03/23, 03/10/23, 03/18/23, 03/24/23, and 03/31/23 revealed no evidence of an abrasion to her right elbow and no evidence Resident #1 had a splint. Review of Resident #1's skin assessment, dated 04/07/2023, and signed 04/14/2023 by the TX Nurse LVN, revealed: 1cm x 0.7cm abrasion to right elbow. Area cleaned with NS, anasept (antimicrobial cleanser) and collagen applied and covered with border foam dressing, [family members] aware and present. Discussed with [family members] that splint was no longer form fitting and needed to be discontinued or replaced, both verbalized understanding and agreed. Review of Resident #1's electronic physician's orders, from 02/21/23 to 04/16/23, active and discontinued, revealed no evidence of treatment orders for the abrasion to the right elbow. Review of Resident #1's electronic nurse's progress notes, from 02/21/23 to 04/16/23, revealed no evidence of discovering an abrasion to Resident #1's right elbow, treating the wound, or notifying the physician. During an interview on 04/15/2023 at 1:30 PM, TX Nurse LVN stated Resident #1's arm was not assessed underneath the splint at time of admission. She stated she was responsible for the dressing changes for Resident #1. TX Nurse LVN stated a skin tear was found a few days after admission when the bandage was saturated with blood, then the splint and wrap were removed but she did not document nor notify anyone. TX Nurse LVN stated she often forgot to document things in the progress notes. She stated she was not aware of any other skin issues until the abrasion on Resident #1's right elbow was discovered on 04/07/23. She stated she thought the wound on Resident #1's right elbow was from rubbing of the splint. She stated she did contact the doctor for orders to treat the wound nor notification of abrasion. She stated she did not follow up on the abrasion or the poor fit of the splint. She stated the facility protocol for newly admitted residents was the braces, splints, or immobilizer was to remove and assess unless there was a doctor's order to leave in place. She stated Resident #1 was transferred to the hospital on [DATE]. TX Nurse LVN stated she adjusted the dressing around Resident #1's splint on 04/11/23 prior to Resident #1 being transferred to the hospital. During an interview on 04/15/2023 at 5:00 PM, the DON stated she was unaware what Resident #1's skin looked like under the splint when she was sent to the hospital on [DATE]. She stated she had never removed the splint or assessed Resident #1's arm. The DON stated she was ultimately responsible for monitoring and overseeing the skin assessments, making sure they were being done. The DON stated her, and the TX Nurse collaborated to identify wounds when skin assessments were done. She stated they then notified the physician if needed. The DON stated she was not aware of the abrasion to Resident #1's right elbow until 04/07/23. The DON stated her expectation was skin assessments were to be completed and documented on day of admission. The DON stated the protocol should have been to remove splint and assess underneath every day and notify the physician if needed. She stated the failure of not identifying and treating wounds and pressure ulcers occurred due to lack of communication between charge nurses, the TX Nurse, and herself. She stated the failure occurred due to the TX Nurse had been working as a charge nurse a lot which took from her duties as a treatment nurse. She stated all nurses should be responsible skin assessments, notifying physicians, and entering treatment orders. She stated not discovering a wound, treating a wound, or notifying the physician could be very detrimental and could lead to loss of life. She stated it was important to notify the physician of a new wound or a wound change because the physician needed to be aware and could assess and treat the wound appropriately. She stated she was ultimately responsible for ensuring all was done correctly. Review of Resident #1's hospital history and physical, dated 04/11/23, signed by the Hospitalist, revealed: Assessment: [Resident #1's] splint was removed from right arm and there was a malodorous lesion above the fracture and the skin was red and warm. Admitting Diagnosis: Septic shock-secondary to right upper extremity wound and cellulitis (skin infection), Sepsis, Acute kidney injury- secondary to sepsis, wound of right upper extremity, cellulitis of right upper extremity, Elevated troponin trend- secondary to sepsis from right elbow wound with cellulitis. Treatment Plan: Admit to ICU. Continue Zosyn and vancomycin (antibiotics), Consult orthopedics. Consult wound care for concerns wound may go down to the fracture and may require debridement. Review of Resident #1's hospital wound care notes, dated 04/12/23, indicated 5 wounds total. The notes reflected a right lateral (outer) elbow abrasion full thickness sero-sanguineous (yellowish-bloody) exudate measuring 2.3 x 2.3 x 0.2 (LxWxD in cm); right posterior (back) heel deep tissue pressure injury persistent non-blanchable deep red, maroon, or purple discoloration measuring 1.1 x 1 (LxW in cm); left heel deep tissue pressure injury persistent non-blanchable(unable to make go away by pressing on) deep red, maroon, or purple discoloration measuring 1.2 x 1.9; right posterior forearm deep tissue pressure injury persistent non-blanchable deep red, maroon, or purple discoloration measuring 0.6 x 6; and sacral deep tissue pressure injury persistent non-blanchable deep red, maroon, or purple discoloration measuring 4x4. Review of Resident #1's hospital records, dated 04/11/23 to 04/18/23, revealed Resident #1 was in the intensive care unit from 04/11/23 until 04/17/23 then transferred to the cardiac unit. Further review of hospital records revealed resident received 16 doses of IV (intravenous) Ancef (antibiotic), 6 doses of IV Zosyn (antibiotic), and 4 doses of IV Vancomycin (antibiotic) during her hospital stay. Further review of Resident #1's hospital discharge progress note and discharge orders, dated 04/18/23, revealed Resident #1 to continue IV Ancef for 4 weeks ending 05/12/23 and to receive outpatient wound care. During an interview on 04/17/23 at 09:45 PM, the Hospitalist stated the sepsis came from Resident #1's right elbow wound infection. He stated the dressing was saturated with blood and malodorous (foul odor). He stated the bloody saturated dressing was removed from around the split and he was unable to see if the dressing was dated due to the saturation. He stated the splint was removed, and a bloody bordered gauze was on the elbow abrasion. The Hospitalist stated, There was no way the facility did not notice the dressing being saturated with blood and the foul odor. He stated the resident was septic and needed intensive care. During an interview on 04/18/23 at 11:30 AM, the ADON stated he was aware that Resident #1 had a splint to the right arm. He stated a couple of days after Resident #1 was admitted her bandage was bleeding. He stated he did not remove the splint to assess where the bleeding was coming from. He stated he rewrapped the splint with a bandage. He stated he was never aware that Resident #1 had a wound or abrasion to the right elbow. He stated he had not seen or noticed any drainage to the arm since then. During an interview on 04/18/23 at 12:20 PM, LVN A stated she was the nurse on duty the day that Resident #1 was sent to the hospital, and she did not notice any drainage to her bandage on her arm. During an interview on 04/18/23 at 2:30 PM, Resident #1's Primary Physician stated she was not notified of Resident #1's right elbow wound. She stated her expectation was to be notified of all changes including wounds. She stated a wound not properly treated could lead to sepsis. She stated she believed the wound was not discovered by the facility because the facility usually notified her of all changes. During an interview on 04/20/23 at 12:00 PM, ADMIN stated there was obviously a failure in the facilities skin assessment system. She stated it was ultimately her responsibility to ensure failures did not happen. She stated the facility staff worked as a team and are all responsible. She stated herself and the DON are both new and don't have a lot of experience. During an interview on 04/21/23 at 4:00 PM, NA C stated she had showered Resident #1 multiple times. She stated she did not remove the split. NA C stated she did not do anything with splints or immobilizers. She stated she had never noticed any drainage to the bandage on Resident #1's arm. She stated she wrapped Resident #1's arm with plastic wrap when she showered her. Review of the facility's policy, dated 2003, titled Immobilization Devices, Splints/Slings/Collars/Straps indicated: Goals 1. The resident will achieve safe and effective application of supportive immobilization devices. 2. The resident will maintain baseline neurovascular and skin integrity status. 3. The resident will be free from injury associated with immobilization devices. Procedure 1. Review physician's order. 4.4. Remove the splint periodically to assess skin and maintain cleanliness and dryness under the splint. 8. All immobilization devices, except clavicle straps, should be removed periodically. All devices will be monitored on every two-hour schedule. Monitoring will be documented in the clinical record or flow sheet. 9. Neurovascular assessment should be performed before, during, and after the application of the immobilization device. Assessments will be documented on the clinical record or flow sheet. 10. Skin integrity should be assessed periodically when the device is removed. Review of the facility's policy, dated 2003, titled Skin Assessments indicated: It is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to allow of appropriate intervention be initiated in a timely manner. Procedure: 1. All new admits and residents returning from a hospital stay will have a head-to-toe skin assessment completed. If the facility treatment nurse is available, he/she should complete the assessment within four hours of resident's arrival at the facility. If the treatment nurse isn't available, then the charge nurse should complete the assessment within four hours of the resident arrival to the facility. The charge nurse will notify the treatment nurse of any skin problems noted. Completely appropriate attachments/assessments. The DON, along with treatment nerves, and other team members will review for the follow up assessment and recommendations. Any pressure ulcer should also be care planned. Any alteration in skin integrity will be treated according to physicians' orders. Notify DON and responsible family member. Documentation will then be entered into the residence chart with the following information. 2. All residents should have a skin assessment on a weekly basic completed in PCC. 3. If the resident has any type of ulcer (pressure injury, arterial, venous, diabetic) an ulcer assessment should be completed at least weekly. This was determined to be an Immediate Jeopardy on 04/20/2023 at 3:00 PM. The ADMIN was notified. The ADMIN was provided with the IJ template on 04/20/2023 at 3:00 PM. The following Plan of Removal was submitted by the facility was accepted on 04/21/2023 at 6:20 PM: Problem: Failure to prevent pressure injury in splints/braces/immobilizers Interventions: Two residents requiring the use of splints/braces/immobilizers have had a head-to-toe skin assessment completed on 4/15/23. No issues found. Residents requiring the use of splints/braces/immobilizers will be checked daily by the Charge Nurse/Treatment Nurse/DON to ensure skin is intact with no signs of discoloration, pain, discomfort, or edema caused by the splint/brace/immobilizer. Any new issues found will be addressed, treatment orders will be obtained by notifying the Physician by phone immediately, ulcer assessment will be completed, and care plans updated. Families and physicians will be notified of any skin issues found before the end of the shift. Orders for two residents requiring the use of a splint, brace or immobilizer were entered 4/21/23 into PCC to remove splint/brace/immobilizer to assess skin each shift. Residents not requiring the use of splints/braces/immobilizers will have a weekly head to toe skin assessment completed by the Treatment Nurse and documented accordingly in PCC. Skin assessments completed on 100% of residents on 4/15/23 by the DON, ADON, Treatment Nurse, and MDS Coordinator, with RCN oversight to ensure all adverse skin conditions are being addressed. Four residents were identified with non- intact skin issues on 4/15/23. One resident was identified to have eight stage 2 pressure wounds to buttocks and lumbar spine. One resident was identified to have one stage 2 pressure wound to coccyx. One resident was identified to have stage 1 pressure wounds to left foot 2nd and 5th digits. One resident was identified to have a stage 2 to coccyx. All skin issues were communicated to the residents' Physicians via phone call on 4/15/23 and 4/16/2023. All skin concerns have treatment orders in place. Care plans have been updated. Five residents with existing pressure ulcers were also assessed 4/15/23 to ensure ulcer assessments were complete and treatment order in place. One resident with left heel DTI and left lateral foot unstageable; one resident with right heel DTI, posterior right calf unstageable, right lateral malleus stage 3; one resident with left heel stage 3; one resident had midline sacral unstageable, lumbar spine stage 3, left heel stage 3, right heel unstageable; one resident with stage 2 to sacral. Resident #1 was discharged from facility on 4/11/23 to a higher level of care hospital due to a change of condition and Resident #2 still resides in facility, immobilizer has been discontinued, complete head to toe assessment done 4/15/23 and has right heel DTI, posterior right calf unstageable originated and right lateral malleus stage 3 - all present prior to 4/14/23. Residents affected: Residents requiring the use of splints/braces have the potential to be affected by alleged deficient practice. Systemic Changes: The DON, ADON and Treatment Nurse were in serviced one on one by Regional Compliance Nurse on 4/15/23. Any direct care staff not present or in-serviced on 4/15/23, will not be allowed to assume their duties until in-serviced. o Licensed Nurses: Pressure ulcer prevention and treatment. What to do when a resident is admitted with an immobilizer without orders to remove, when to remove and assess skin and check pulses. When to report skin issues to DON o Nurse Aides: Pressure ulcer prevention and treatment. Reporting skin issues The medical director was notified of the immediate jeopardy situation on 4/20/23 at 3:05pm. No new orders were given at this time. Monitoring The DON/designee will monitor all newly admitted residents or any existing residents that obtain new orders for a immobilizers/brace/splint to ensure orders are in place for removal of immobilizer per physician orders, treatments have been ordered, ensure assessments done daily, 5 days a week for the duration of the resident brace/splint/immobilizer to ensure compliance. The DON/designee will view each pressure ulcer weekly for the duration of the use of the brace/splint/immobilizer. DON/designee will audit initial skin assessment charting to ensure documentation matches the resident condition. Newly and readmitted residents. The QA committee will review findings at the monthly QA meeting and make changes as needed. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observation, interviews, and record reviews as follows: Review verified two residents in the facility required the use of splints/braces/immobilizers. Review of progress notes revealed head-to-toe skin assessment completed on 4/15/23 with no issues discovered. Review of physician's orders for the two residents in the facility required the use of splints/braces/immobilizers verified. Both residents had orders remove splint/brace/immobilizer each shift and assess skin underneath two times a day entered on 04/21/23. Review of care plans addressed care for splint/brace/immobilizer. Review of physician's orders for 59 residents revealed orders for weekly skin assessments. Review of progress notes for 59 residents revealed head-to-toe skin assessment completed on 4/15/23. Four residents identified with new skin issues discovered, physicians notified, and treatment orders received, care plans updated. Review of records revealed all five residents with existing pressure ulcers had: weekly ulcer assessments, treatment orders for all pressure ulcers, and all pressure ulcers were addressed on care plans. Review of Resident #1's discharge summary revealed Resident #1 was sent to the hospital on 4/11/23. Review of Resident #2's's physicians orders revealed order to discontinue immobilizer on 03/29/23 and orders to treat pressure ulcers. Weekly ulcer assessments were initiated and completed when each ulcer was discovered. During random observation and interview on 04/21/23 at 4:00 PM revealed 1 nurse aide being educated by the ADON on pressure ulcer prevention and treatment and reporting skin issues. Staff stated understanding of preventing pressure ulcers and the importance of reporting any skin issues. During random interviews on 04/21/2022 at 4:30 PM revealed 8 CNA/NAs and 4 Licensed Nurses who worked the day shift had been educated on pressure ulcer prevention and treatment and reporting skin issues; what to do when a resident was admitted with an immobilizer without orders to remove, when to remove immobilizer to assess skin and check pules, and when to report skin issues to the DON. All staff acknowledged understanding of the education. During random observation on 04/21/23 at 6:00 PM revealed 2 nurses who work the night shift being educated by the ADON on Pressure ulcer prevention and treatment, what to do when a resident is admitted with an immobilizer without orders to remove, when to remove and assess skin and check pulses, and when to report skin issues to DON. During random observation on 04/21/23 at 6:20 PM revealed 2 CNA's who work the night shift being educated by the ADON on pressure ulcer prevention and treatment and reporting skin issues. All staff acknowledged understanding of the education. Record review in-services initiated 04/14/23 revealed 24 of 24 CNA/NA's had been educated on pressure ulcer prevention and treatment and reporting skin issues. Record review in-services initiated 04/14/23 revealed 16 of 16 nurses had been educated on Pressure ulcer prevention and treatment, what to do when a resident is admitted with an immobilizer without orders to remove, when to remove and assess skin and check pulses, and when to report skin issues to DON. Review of QAPI meeting signature page, with medical director signature, with attached meeting minutes with IJ template attached. The ADMIN was informed that the Immediate Jeopardy was removed on 04/21/2023 at 6:35 PM. The facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems that were put into place.

**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 1 of 5 residents (Resident #2) reviewed for skin integrity. 1. The facility failed to prevent avoidable pressure ulcers caused by a knee immobilizer for Resident #2 that led to an infection which resulted in hospitalization. 2. The facility failed to obtain orders for wound care and treatments for Resident #2 that led to an infection which resulted in hospitalization. 3. The facility failed to provide appropriate interventions to prevent pressure ulcers for Resident #2 that led to an infection which resulted in hospitalization. An Immediate Jeopardy (IJ) situation was identified on 04/20/2023 at 3:00 PM. While the IJ was removed on 04/21/2023 at 6:35 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. These failures could place residents at risk of wound deterioration, wound development, and infection. Findings included: Resident #2 Review of Resident #2's electronic face sheet, dated 04/16/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: unspecified fracture of right femur (thigh bone), urinary tract infection, and dementia. Review of Resident #2's Comprehensive MDS assessment, dated 03/22/2023, revealed a BIMS score of 03 which indicated severe impaired cognition. Section G Functional Status revealed Resident #2 required extensive assistance from two persons for bed mobility and transfers, extensive assistance from one staff for locomotion on and off the unit, and extensive assistance from one person for dressing, personal hygiene, and bathing. Section M Skin Conditions revealed Resident #2 was at risk for pressure ulcers/injuries but did not have any. Review of Resident #2's Care Plan, initiated 06/09/2022, revealed: Focus Goal Interventions/Tasks Position Freq/Resolved. [Resident #2] is at risk for pressure injury. [Resident #2] will have intact skin, free of redness, blisters, or discoloration by/through review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Do not massage over bony prominences and use mild cleansers for peri care/washing. 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. Ensure heels are floated with the use of pillows. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Incontinent care after each episode and apply moisture barrier. Inform the resident/family/caregivers of any new area of skin breakdown. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Notify nurse immediately of any new areas of skin breakdown: Open area, redness, Blisters, Bruises, discoloration noted during bath or daily care. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. The resident needs assistance to turn/reposition at least every 2 hours. The resident requires a cushion to their wheel or Geri chair. The resident requires the bed as flat as possible to reduce shear. Use lifting device, draw sheet, etc to reduce friction. Further review of care plan revealed no evidence of Resident #2's fractured femur, no evidence of the use of an immobilizer, and no evidence of pressure ulcers. Review of Resident #2's hospital discharge records prior to admission, dated 02/27/23, revealed: Knee immobilizer on right lower extremity to be on lower extremity at all times. Further review of hospital records revealed no evidence of wounds. Review of Resident #2's Initial skin assessment signed, 02/27/2023, by LVN B, revealed: redness from brace down entire right leg. Further review of initial skin assessment revealed no evidence of documentation regarding Resident #2's right calf. Review of Resident #2's electronic progress notes, from 02/27/23 to 03/03/23, revealed no evidence of documentation regarding Resident #2's right calf, no treatments or interventions put into place to prevent injury, or immobilizer on admission. Review of Resident #2's Weekly Ulcer Assessment signed 03/03/23, by TX Nurse LVN, revealed unstageable pressure ulcer covered by necrotic tissue to right posterior calf measured 6cm x 4cm (LxW). Further review of Resident #2's Weekly Ulcer Assessment revealed physician and family member notified on 02/27/23 at 18:00. Review of Resident #2's Weekly Ulcer Assessment signed 03/08/23, by TX Nurse LVN, revealed deep tissue injury pressure ulcer to the right heel measured 3cm x 3.7cm. Further review of Resident #2's Weekly Ulcer Assessment revealed physician and family member notified on 03/28/23 at 00:00. Review of Resident #2's Weekly Ulcer Assessment signed 03/28/23, by TX Nurse LVN, revealed pressure ulcer right lateral malleolus (outer side of ankle) measured 7cm x 1.5cm. Review of Resident #2's electronic physicians orders, from 02/27/23 to 04/15/23, active and discontinued, revealed: Start date 02/28/23: monitor skin daily and do skin care. Monitor for any open areas under brace every day shift Start date 03/03/23: clean posterior right calf with normal saline and gauze, apply aquacel (antimicrobial dressing) and cover with dressing, Start date 03/06/23: may remove brace to check skin weekly and prn every Monday Start date 03/09/23: paint right heel with betadine daily every day shift for deep tissue injury to right heel., Start date 03/20/23: Immobilizer to be worn only while in bed, Discontinue date 03/29/23: Start date 04/17/23: clean right lateral malleolus with normal saline and gauze, apply aquacel (antimicrobial dressing), ABD and wrap every day shift every Monday and Friday, Review of Resident #2's Treatment Administration Record, from 03/01/23 to 03/31/23, revealed: monitor skin daily and do skin care. Monitor for any open areas under brace every day shift initialed as completed every day. Review of Resident #2's hospital admission records, dated 03/12/23, revealed Resident #2 was admitted with diagnosis of confusion, disorientation, and cellulitis (skin infection) of right leg. Further review of hospital admission records revealed: [Resident #2] admitted due to altered mental status; multiple bed sores on her buttock region; right leg from the knee immobilizer; and right calcaneal heel) region. Review of Resident #2's hospital wound care notes, dated 03/13/23, revealed right calf trauma wound measured 7.1cm x3 cm with slough (necrotic tissue formed because of infection) present. Review of Resident #2's physician Discharge summary dated [DATE], revealed: admission Diagnosis: Confusion and disorientations and Cellulitis of leg.' Further review or physician discharge summary revealed: Resident #2 was admitted for delirium. Delirium was due to abscess to left middle finger and cellulitis to right lower extremity. Resident #2 was kept on IV (intravenous) Cefepime (antibiotic) and IV Vancomycin (antibiotic) during her hospitalization. During an observation on 04/16/23 at 10:00 AM, Resident #2 was resting in bed with both legs flat. Her heels were not elevated. Immobilizer was not in place. Dressing to wounds clean with no date on them. Resident was unable to answer questions. During an interview on 04/15/2023 at 5:00 PM, the DON stated she was ultimately responsible for monitoring and overseeing the skin assessments to ensure they were being completed. She stated that pressures ulcers are to be documented in the skin assessment of the resident's record to ensure that wound care was monitored consistently. She stated when pressure ulcers were discovered, she was to be notified to assess and stage the pressure ulcer. The DON stated the facility protocol was for nursing staff to remove splints/braces/immobilizers to assess the skin underneath every day. She stated she was responsible for monitoring the treatment, but she lacked training and was new to long term care. She stated the failure was because she did not review skin assessments, physicians' orders, and care plans adequately. During an interview on 04/16/23 at 12:30 PM, TX Nurse LVN stated Resident #2 was admitted from the hospital on [DATE] with an unstageable pressure ulcer to her right posterior calf from the immobilizer. TX Nurse LVN stated she was primarily responsible for performing skin assessments. She stated she often forgot to document things in the progress notes. She stated she conducted a weekly ulcer assessment on Resident #2 on admission but failed to sign the documentation until 03/03/23. TX Nurse LVN stated she did notify the physician but could not recall reason for not entering Resident #2's treatment order in resident's record until 03/03/2023. TX Nurse LVN stated Resident #2's condition declined, and she was sent to the hospital on [DATE] and returned on 03/15/23 with a new pressure ulcer to her right lateral malleolus. She stated she completed the weekly pressure ulcer assessment on 03/15/23 but forgot to sign it until 03/28/23. She stated the protocol for newly admitted residents was the braces, splints, or immobilizer was to be removed and assessed unless there was a doctor's order to leave in place. During an interview on 04/16/23 at 1:00 PM, the RCN stated she was aware the facility had issues with poor documentation. She stated all pressure ulcers are avoidable with the proper interventions. During a follow up interview on 04/20/23 at 10:30 AM, the DON stated Resident #2 had a knee immobilizer since admission on [DATE]. She stated the immobilizer had been discontinued at the end of March. The DON stated all braces/splints/immobilizers that could be removed needed to be removed and the skin underneath assessed upon admission. She stated the facility should call the physician to receive an order that reflects to check the pulses and to check the skin above and below the device. She stated if the device could not be removed there should be an order not to remove. She stated braces/splints/immobilizers and pressure ulcers should be documented on admission in the admission assessment and on the initial skin assessment. She stated if a pressure ulcer was identified on admission, the nursing staff were to document on the initial skin assessment as well as notifying the physician immediately to obtain treatment orders. The DON stated that her expectation was that all pressure ulcers were to have treatment orders entered in the resident electronic record. She stated without an order there was no way to document and ensure treatments were being done. She stated the failure of not identifying and treating pressure ulcers occurred due to lack of communication between charge nurses, the Treatment Nurse, and herself. She stated all nurses should be responsible skin assessments, notifying physicians, and entering treatment orders. She stated not discovering a wound, treating a wound, or notifying the physician could be very detrimental and could lead to loss of life. She stated it was important to notify the physician of a new wound or a wound change because the physician needed to be aware and could assess and treat the wound appropriately. She stated she was ultimately responsible for ensuring all was done correctly. During an interview on 04/20/23 at 12:00 PM, the ADMIN stated there was obviously a failure in the facility's skin assessment system. She stated it was ultimately her responsibility to ensure failures not happen. She stated the facility staff worked as a team and were all responsible. She stated herself and the DON were both new and didn't have a lot of experience. During an interview on 04/21/23 at 4:00 PM, NA C stated she had showered Resident #2 multiple times. She stated she did not remove the split. NA C stated she did not do anything with splints or immobilizers. She stated she had the charge nurse remove resident #2's knee immobilizer prior to the shower. She stated she wrapped Resident #2's leg with plastic wrap when she showered her because she had dressings in place. NA C stated Resident #2 had worn a knee immobilizer since she fell and went to the hospital in February. Review of the facility's policy, revised 8/12/16, titled Pressure Injury: Prevention, Assessment and Treatment indicated: Procedure: 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection. 2. Early prevention and/or treatment is it sensual upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs. the nurse will determine if prevention and/or treatment Add pressure stores is indicated and notify the treatment nurse of any potential problems.3. upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse. The nurse will: 1. notify the position of pressure sore and obtain and follow any orders as directed by the physician. 2. Notify the family and dietary department. Document notification .6. Nursing action/rationale: 1. Prevention: the nurse can assist in the prevention of pressure injuries by performing the following nursing intervention and add any interventions to the care plan. 1. Determining residence skin tolerance to pressure and develop a turning schedule residents should be turned every two hours or more often if necessary and notify the treatment nurse of any potential problems. 2. Pressure sore identification: director of nursing or treatment nurse will classify the pressure injury according to the following descriptions and the different stages. Review of the facility's policy, revised 8/12/16, titled Skin Assessment indicated: It is the policy of this facility to establish a method whereby nursing can assess a residence skin integrity to allow of appropriate interventions be initiated in a timely manner. Procedure: 1. All new admins and residents returning from a hospital stay will have a head-to-toe skin assessment completed. If the facility treatment nurse is available, he/she should complete the assessment within four hours of the resident's arrival at the facility. If the treatment nurse isn't available, then the charge nurse should complete the assessment within four hours of their residence arrival at the facility. The charge nurse will then notify the treatment nurse of any skin problems noted. Complete the appropriate assessments. The Don, along with the treatment nurse and the team members will review for follow up assessment and recommendations. Any pressure ulcer should also be care planned. Any alterations in skin integrity will be treated accordingly to physician orders. Notified [NAME] and responsible family member. Documentation will then be entered into the residence start with the following information. 2. All residents should have a skin assessment on a weekly basis completed. 3. if the resident has any type of ulcer an ulcer assessment should be completed at least weekly. The ADMIN was notified of an Immediate Jeopardy on 04/20/2023 at 3:00 PM. The ADMIN was notified. The Administrator was provided with the IJ template on 04/20/2023 at 3:00 PM. The following Plan of Removal was submitted by the facility and was accepted on 04/21/2023 at 6:20 PM: Problem: QOC related to Failure to prevent pressure injury Interventions: 1. Two residents requiring the use of splints/braces/immobilizers have had a head-to-toe skin assessment completed on 4/15/23. No skin issues or concerns found. 2. Residents requiring the use of splints/braces/immobilizers will be assessed daily by the Charge Nurse/Treatment Nurse/DON to ensure skin is intact with no signs of discoloration, pain, discomfort, or edema caused by the splint/brace/immobilizer. Any new issues found will be addressed, treatment orders will be obtained by notifying the Physician by phone immediately, ulcer assessment will be completed, and care plans updated. Families and physicians will before the end of shift of any skin issues found. 3. Two resident orders were entered in PCC (Point Click Care) by the DON on 4/21/23 to remove splint/brace/immobilizer to assess skin each shift. Residents not requiring the use of splints/braces/immobilizers will have a weekly head to toe skin assessment completed by the Treatment Nurse. 4. Skin assessments completed on 100% of residents on 4/15/23 by DON, ADON, Treatment Nurse and MDS Coordinator, with RCN oversight to ensure all adverse skin conditions are being addressed. Four residents had adverse skin conditions. The physician was notified, via telephone, treatment orders given and were entered in PCC (Point Click Care). 5. Four residents were identified with non- intact skin issues on 4/15/23. One resident was identified to have eight stage 2 pressure wounds to buttocks and lumbar spine. One resident was identified to have one stage 2 pressure wound to coccyx. One resident was identified to have stage 1 pressure wounds to left foot 2nd and 5th digits. One resident was identified to have a stage two the coccyx. All skin issues were communicated to the residents' Physicians via phone call on 4/15/23 and 4/16/2023. All skin concerns have treatment orders in place. Care plans have been updated. 6. Any alteration of intact skin is considered a new skin issue. 7. Six residents with existing pressure ulcers were also assessed by the Treatment Nurse/DON/ADON on 4/15/23 to ensure appropriate treatment orders and interventions were in place. 8. Resident #2 still resides in the facility. The immobilizer has been discontinued, complete head to toe assessment done 4/15/23 and has right heel DTI, posterior right calf unstageable originated and right lateral malleus stage 3 - all present prior to 4/14/23. Resident #1 was discharged from the facility to a higher level of care hospital on 4/11/23 due to a change in condition. Residents affected: 9. Residents requiring the use of splints/braces have the potential to be affected by alleged deficient practice. Systemic Changes: 10. The following in-services were initiated by the RCN 4/15/23: Any direct care staff not present or in-serviced on 4/15/23, will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/TREATMENT NURSE/OR RN Supervisor, until all staff, weekend, prn, and agency staff is completed. The following in-services were initiated by the RCN 4/15/23: o Licensed Nurses: Pressure ulcer prevention and treatment. What to do when a resident is admitted with an immobilizer without orders to remove, when to remove and assess skin and check pulses. When to report skin issues to DON o Nurse Aides: Pressure ulcer prevention and treatment. Reporting skin issues 11. The Medical Director was notified of the immediate jeopardy situation on 4/20/23 at 3:05 p.m. No new orders were given at this time. Monitoring 12. The DON/designee will monitor all residents with immobilizers/braces to ensure orders are in place for removal of immobilizer per physician orders, treatments have been ordered, ensure assessments are done daily, 5 days a week for the duration of the resident brace to ensure compliance. 13. The DON / designee will view each pressure ulcer weekly for the duration of the use of the brace/splint/immobilizer. 14. The DON/designee will audit the initial skin assessment charting to determine that the assessment matches the skin issues new and readmitted residents. 15. The QA committee will review findings at the monthly QA meeting and make changes as needed. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observation, interviews, and record reviews as follows: Review verified two residents in the facility required the use of splints/braces/immobilizers. Review of progress notes revealed head-to-toe skin assessment completed on 4/15/23 with no issues discovered. Review of physician's orders for the two residents in the facility required the use of splints/braces/immobilizers verified. Both residents had orders to remove splint/brace/immobilizer each shift and assess skin underneath two times a day entered on 04/21/23. Review of active care plans addressed care for splint/brace/immobilizer. Review of physician's orders for 59 residents of 59 residents revealed orders for weekly skin assessments. Review of progress notes for 59 residents revealed head-to-toe skin assessment completed on 4/15/23. Four residents identified with new skin issues discovered, physicians notified, and treatment orders received, care plans updated. Review of records revealed all five residents with existing pressure ulcers had: weekly ulcer assessments, treatment orders for all pressure ulcers, and all pressure ulcers were addressed on care plans. Review of Resident #1's discharge summary revealed Resident #1 was sent to the hospital on 4/11/23. Review of Resident #2's's physicians orders revealed an order to discontinue immobilizer on 03/29/23 and orders to treat pressure ulcers. Weekly ulcer assessments were initiated and completed when each ulcer was discovered. During an observation and interview on 04/21/23 at 4:00 PM revealed 1 nurse aide being educated by the ADON on pressure ulcer prevention and treatment and reporting skin issues. Staff stated understanding of preventing pressure ulcers and the importance of reporting any skin issues. During interviews on 04/21/2022 from 4:30 PM - 6:00 PM revealed 8 CNA/NAs and 4 Licensed Nurses who worked the day shift had been educated on pressure ulcer prevention and treatment and reporting skin issues; what to do when a resident was admitted with an immobilizer without orders to remove, when to remove immobilizer to assess skin and check pules, and when to report skin issues to the DON. All staff acknowledged understanding of the education. During an observation on 04/21/23 at 6:00 PM revealed 2 nurses who work the night shift being educated by the ADON on pressure ulcer prevention and treatment, what to do when a resident is admitted with an immobilizer without orders to remove, when to remove and assess skin and check pulses, and when to report skin issues to DON. During an observation on 04/21/23 at 6:20 PM revealed 2 CNAs who worked the night shift being educated by the ADON on pressure ulcer prevention and treatment and reporting skin issues. All staff acknowledged understanding of the education. Record review of in-services initiated 04/14/23 revealed 24 of 24 CNA/NAs had been educated on pressure ulcer prevention and treatment and reporting skin issues. Record review of in-services initiated 04/14/23 revealed 16 of 16 nurses had been educated on pressure ulcer prevention and treatment, what to do when a resident is admitted with an immobilizer without orders to remove, when to remove and assess skin and check pulses, and when to report skin issues to DON. Review of the QAPI meeting signature page, with Medical Director signature, with attached meeting minutes with IJ template attached. The Administrator was informed that the Immediate Jeopardy was removed on 04/21/2023 at 6:35 PM. The facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems that were put into place.