**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide basic life support, including CPR to a resident requiring such emergency care and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 31 residents reviewed for CPR. Resident #1 was found unresponsive on [DATE] around 4:00 a.m. by CNA B who immediately notified LVN A. LVN A failed to verify Resident #1's code status before calling hospice which led to the resident being pronounced dead and CPR not being initiated for approximately 2.5 hours after the resident was found to be unresponsive. The facility did not immediately provide CPR and call 911 for Resident #1 who was a full code (wanted all possible life saving measures in the event his heart or breathing stopped) when the resident was found unresponsive by CNA B. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of not receiving life saving measures including CPR and could lead to death. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cerebrovascular disease, pneumonia, and anoxic brain damage. (Brain was deprived of oxygen causing brain cells to die) Record review of Resident #1's significant change MDS dated [DATE] indicated he had a BIMS score of 11 out of 15, which indicated his cognition was moderately impaired. Record review of Resident #1's care plan dated [DATE], indicated Resident #1 had code status as Full Code. Interventions included advanced directives will be kept in chart. If resident was found with no pulse and/or respirations, notify physician, EMT's, and begin CPR. Record review of Resident #1's progress notes dated [DATE] at 4:15 a.m., documented by LVN A stated Resident was found with no signs of life, Hospice notified, and stated they would be here as soon as she can. Stated she will call family and funeral home. Message left for ADON. During an interview on [DATE] at 12:15 p.m., CNA B said she had been employed at facility since February 2024. She said she received orientation including Abuse/Neglect. She said she took the CPR class offered at the facility on [DATE]. She said staff knew of the resident's code statuses in the computer next to their name. CNA B said there was also a binder on the crash cart with every resident's code status and paperwork. She said she made rounds on residents about every 1-2 hours. She said on [DATE] while working her shift, she saw Resident #1 around 2:30 a.m., and he was fine. She said on her next rounding at 4:00 a.m., he was unresponsive. She said his lips were white and his nailbeds were blue/purple, and his body was warm to the touch. She said she yelled for the nurse. She said the nurse went and looked at him and went back to the nurse's station. CNA B said she told the nurse she thought the resident was a full code. She said LVN A threw her hands up in the air and told her the resident was a hospice patient and there was not anything she could do for him. CNA B said she told the nurse she should do something, and the nurse told her he was already gone, and it was too late. CNA B said the nurse did not start CPR or use the AED while she was in facility. CNA B said postmortem care was performed. CNA B said when her shift was over at 6:00 a.m., the resident was still in facility and the LVN A had done nothing. During a phone interview on [DATE] at 2:09 p.m., LVN A said on [DATE] at approximately 4:00 a.m., CNA B summoned her to Resident #1's room. LVN A said when she entered his room, Resident #1's face looked like candle wax. She said he had no pulse, heartbeat, or respirations. LVN A said they turned him, and he had rigor mortis (rigor mortis-stiffening of the joints and muscles of a body a few hours after death). Next, she called the hospice agency at 4:15 a.m. and informed the service of his death. She said the hospice on-call nurse returned her call and told her it would take about 1.5 hours for her to arrive. LVN A said after she hung up with the hospice nurse, she then went about her duties and prepared medications that were due before the end of her shift for other residents. She said when the hospice nurse arrived at 6:30 a.m., the hospice nurse told her the resident was a full code. LVN A said the hospice nurse said she could not pronounce the resident as deceased because he was a full code and CPR or EMS had not been activated. LVN A said she clocked out of her shift and was on her way home when LVN D phoned her to return to the facility. LVN A said after returning to facility, she initiated CPR and hooked up the AED to Resident #1. This was approximately 2.5 hours after finding Resident #1 unresponsive. She said EMS arrived and pronounced Resident #1 dead. She stated, I did not know he was a full code and how can they be with hospice? She added It is fully my fault. I did not check his code status. I knew where to look but it never crossed my mind. She stated I was worried about getting my work done. People are getting fired left and right around here. She said she had been a nurse since 1985 and had done CPR in the past but never on a hospice patient. Record Review of a hospice note for Resident #1's incident indicated the hospice RN arrived at the facility on [DATE] at 6:36 a.m. She noted receiving a call from the hospice answering service that LVN A had reported Resident #1 expired. The hospice RN returned the call to the facility and gave her an estimated time of arrival. Upon arrival to facility, learned that EMS had not been called and no CPR initiated. Pt. was a full code. Informed LVN that EMS needed to be called and CPR initiated. Ambulance service responded and took over from LVN who was doing CPR at bedside. They pronounced patient at 7:32 a.m. During a phone interview on [DATE] at 1:00 p.m., the Hospice RN said she received a message through the hospice answering service that Resident #1 had expired. She said when she arrived at the facility around 6:30 a.m., she opened her computer and saw that the resident was a full code. She asked the facility staff about CPR or calling 911. She said LVN A told her there was a note on his chart saying not to send out to the hospital and this was the reason she did not initiate CPR. She said apparently the nurse exited the facility after her shift and the hospice RN told them to get her back to finish up with the resident. She said LVN A returned and initiated CPR and another staff called EMS. She said she could not pronounce because the resident had been a full code and CPR had not been initiated until after she arrived and was made aware. During an interview on [DATE] at 9:30 a.m., the Administrator said she was notified by MA C of the situation with Resident #1 at approximately 6:30 a.m. She said LVN A said she believed she did nothing wrong because the resident was a hospice patient. The Administrator said LVN A told her the resident was cold to the touch when she found him. She said the nurse called hospice and was told by the hospice nurse that she must do something because the resident was a full code. She was told to call EMS by the hospice nurse. The Administrator said the on-call hospice nurse came to the facility and would not pronounce this resident because the facility nurse had not initiated CPR. She said finally LVN A called EMS and began CPR when she returned to facility approximately within 10 minutes of leaving the facility. The spouse was also called and came to facility. The Administrator said LVN A had not been employed at the facility for a long amount of time and had been a nurse for over 25 years. She said LVN A was CPR certified. The Administrator said LVN A was suspended pending investigation, and on the next day, had phoned to see when she could come back to work. She said LVN A seemed to believe she had done nothing wrong and wanted to return to work. She said all nurses currently were CPR certified and a CPR class was held on Friday after the incident (occurred on Wednesday). She said she held mock codes on Friday and one on Saturday for the staff due to the incident. Her expectations were for all staff to be knowledgeable of the code process and to feel comfortable performing CPR on residents should the occasion arise. Any direct care staff not current on CPR were not allowed to work on floor until current. Following a facility investigation, LVN A was terminated from facility on [DATE]. During an interview at on [DATE] at 12:50 p.m., MA C said she started working at the facility in [DATE]. She said she had attended CPR class offered by the facility following this incident. She said there was a binder on top of the crash cart at the nurses' station which contained all information of the residents' code statuses. She added staff could also look in the computer. She said when she arrived at the facility for her shift, LVN A told her Resident #1 had passed away. She said LVN A told her she had left a message for the DON but had not informed the administrator of resident's death. She said she called the administrator to inform her, and that the administrator was unaware of death at that time. During an interview on [DATE] at 1:40 p.m., the DON said she received a text from the Administrator at 7:00 a.m. informing her of Resident #1 passing away and CPR had not been initiated. She said she arrived at the facility at 8:15 a.m. She said when the nurse for the day shift arrived for her shift at 6:00 a.m., the hospice nurse was freaking out because no one had initiated CPR on Resident #1 and that someone should call EMS/911. The DON said LVN A told her the resident was a hospice patient and the DON told her she still had to do CPR. The DON said LVN A had not informed the resident's physician, the DON, or Administrator of the incident prior to their arrival. The DON said the resident's medical record indicated what specific hospital Resident #1's spouse did not want the resident sent to, but there were other hospital facilities available. She said LVN A knew the resident was a full code. She added how could you be a nurse for 40 years, or 4 days, and not know you have to do CPR? To ensure all staff received the trainings, she said a CPR audit was conducted on all direct care staff. Any direct care staff not current on CPR were not allowed to work on floor until current. Mock codes utilized a CPR dummy and there was return demonstration. DON/designee will perform monthly audit of direct care staff to ensure all were current on CPR. Current CPR certification will be verified on all new hires of direct care staff. Will perform random mock codes. During a phone interview on [DATE] at 2:00 p.m., LVN D said she worked the day shift. She said during report on [DATE] at 6:00 a.m., she was informed Resident #1 had expired. She said the hospice RN arrived around 6:30 a.m. and started asking questions about the resident such as, had CPR been initiated and had first responders been notified. LVN D said she told the hospice nurse that all she had been told was that the resident had passed. She said the hospice nurse wanted LVN A to come back to facility, so she called her to return. She said after LVN A and the hospice RN spoke, LVN A called EMS and went to the room to initiate CPR. LVN D said she had been a nurse for 21 years and had been at the facility for about one month. She was able to explain code status and response with the state surveyor. During interview on [DATE] at 11:00 a.m., the ADON said LVN A called her about 4:30 a.m. on [DATE] but she did not hear her phone. She said later that morning, when she listened to the voicemail, the message was to inform her of Resident #1 passing. She was not aware of the situation until she arrived at the facility around 7:30 a.m . Reviewed crash cart and AED documents on [DATE] at 11:15 a.m. The crash cart had a binder with a list of every resident's code status with copies of advance directives and out-of-hospital DNRs. Residents with full codes had green sheets with their name and room number in big, bold letters. On [DATE] at 4:00 p.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began. The facility implemented the following interventions: -Immediate suspension of LVN A -CPR audit conducted on all direct care staff -Abuse/Neglect in-service -in-service on emergency procedures for codes (CPR) -Performed 3 mock codes with more planned -held CPR training recertification class These interventions were verified by state surveyor. Review of Provider Investigation Report dated [DATE] indicated the following: *Provider Response - Nurse was immediately suspended pending investigation. Family, physician, NP and local law enforcement notified. Facility wide re-educationinitiated. *Investigation Summary - Nurse did not initiate CPR or call 911 to a full code hospice resident when she found him with no signs of life at 4:15 a.m. *Investigation Findings - confirmed *Provider Action Taken Post - Investigation - Nurse suspended pending investigation. In-service on code status, neglect and proper reporting procedures initiated. Facility verified that all direct care staff has current CPR certification. Mock codes initiated for all shifts. CPR class provided. Record review of training held on [DATE] indicated facility held an in-service on General Abuse and Neglect for all Nursing staff. There were 35 staff members who attended. Record review of training held on [DATE] indicated facility held an in-service on Emergency Procedure for Codes and Documentation. There were 21 in attendance. Record review of training held on [DATE] indicated facility held training on CPR and First Aid and AED. There were 10 direct care staff who updated their CPR cards by recertification. Record review of training for Mock Code - with education on code status emergency response provided held on [DATE] with 4 nursing staff participating. Record review of training for Mock Code - with education on code status emergency response provided held on [DATE] with 4 nursing staff, a housekeeper and a therapy person participating. Record review of training for Mock Code - with education on code status emergency response provided held on [DATE] with 6 nursing staff participating. During interviews on [DATE] from 11:00 a.m. through 4:30 p.m., 3 CNAs (CNA B, CNA G, and CNA H) were able to identify abuse/neglect, were knowledgeable of resident code status, and knew where to locate information of new resident's code status. They were aware of expectations to begin CPR immediately if resident was found unresponsive and was a full code. Each had engaged in the mock code drills performed following this incident. During interviews on [DATE] from 11:00 a.m. through 4:30 p.m., 1 LVN (LVN D) and 3 MAs (MA C, MA E, and MA F) were able to identify abuse/neglect, were knowledgeable of resident code status, and knew where to locate information of new resident's code status. They were aware of expectations to begin CPR immediately if resident was found unresponsive and was a full code. Each had engaged in the mock code drills performed following this incident. During interviews on [DATE] from 11:00 a.m. through 4:30 p.m., the DON, the ADON, the RN supervisor, and Maintenance supervisor were able to identify abuse/neglect, were knowledgeable of resident code status, and knew where to locate information of new resident's code status. They were aware of expectations to begin CPR immediately if resident was found unresponsive and was a full code. Each had engaged in the mock code drills performed following this incident. Record review of an Emergency Procedure - Cardiopulmonary Resuscitation policy dated February 2018 indicated: . Personnel have completed training on the initiation of Cardiopulmonary Resuscitation (CPR) and basic life support, including defibrillation, for victims of sudden cardiac arrest. General Guidelines 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless: a) it is known that a Do Not Resuscitate order that specifically prohibits CPR and/or external defibrillation exists for that individual or b) there are obvious signs of irreversible death. 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review , the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 10 residents reviewed for quality of care. The facility failed to coordinate care with the orthopedic surgeon and attending NP/MD of Resident #1's change in skin condition to RLE surgical area, addressing a scab, dark or discolored skin on top of resident's right foot identified in 02/14/2024. No documentation of an assessment or treatment performed to Resident #1's pressure injury/wound to top of right foot and/or no coordination or communication with orthopedic surgeon or attending physician/NP regarding pressure injury/wound identified on 02/14/2024 by orthopedic surgeon. The facility failed to coordinate with orthopedic surgeon or attending NP/MD documented of right dorsal foot pressure injury when it deteriorated to an unstageable wound with eschar and resident had to be hospitalized and area required surgical debridement and graft application. An Immediate Jeopardy (IJ) was identified on 03/21/2024. The IJ template was provided to the facility on [DATE] at 5:09 p.m. While the IJ was removed on 03/23/2024 at 1:00 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put in place. This failure could place residents at risk for diminished quality of care, untreated medical issues, and death. Findings included: Record review of Resident #1's electronic face sheet dated 03/13/2024 indicated she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: displaced trimalleolar fracture of right lower leg (fracture of lower leg bone, connected to foot/ankle area), Other acute osteomyelitis (infection of the bone), left ankle and foot, Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue-Right ankle ORIF (surgical procedure to replace bones with hardware or attach hardware to fix broken bone), Need for assistance with personal care, Muscle weakness (generalized), End stage renal disease ( a medical condition in which a person's kidneys cease functioning on a permanent basis leading to need for a regular course of long-term dialysis or a kidney transplant to maintain life), Cognitive communication deficit, metabolic encephalopathy ( another health condition, such as diabetes, liver disease, kidney failure, or heart failure, makes it hard for the brain to work), hypertension condition in which the force of the blood against the artery walls was too high, Diabetes mellitus (chronic condition that affects the way the body processes blood sugar). Record review of Resident #1's MDS dated [DATE] indicated she had no pressure injuries. She scored a 15/15 on her BIMS which signified she was cognitively intact. She was incontinent of bowel and bladder and went to dialysis 3 x week for hemodialysis for her end stage renal disease. She required substantial/maximal assistance with her ADL's. Record review of Resident #1's comprehensive care plan date initiated 12/15/2023 and revised on 03/01/2024 indicated Problem .has surgical wound to right ankle with pins in place .Approach . Assess condition of surrounding skin. Report emergence of skin excoriation. Observe and report signs of localized infection (localized pain, redness, swelling, tenderness, loss of function, heat at the infected area.) Further review indicated Problem . potential for impaired skin integrity related to impaired mobility. Approach . Assess feet Q shower day & PRN, noting color, peripheral pulses, sensory reflexes, temperature, presence of edema or verbalizations of pain. Assess skin weekly & PRN & document changes. Record review of Resident #1's Braden Skin Assessment dated 12/15/2023 indicated she scored a 19 which signified she was at a low risk for skin breakdown. The was no o current Braden Skin Assessment noted in medical records. Record review of Resident #1's Orders As of: 12/14/2023 to 02/27/2024 indicated: Treatments .to provide weekly skin assessment once a day on Monday 6:00 a.m. - 6:00 p.m. Dated 11/09/2023. Further review indicated Treatments . check skin surrounding splint to right leg. Check for capillaries refill to lower extremity every shift and as needed . Notify MD of any abnormalities or changes in skin condition. Every Shift: day shift 06:00 a.m. - 06:00 p.m., night shift 06:00 p.m. - 06:00 a.m. Dated 11/23/2023 Ended 02/26/2024. Wound Treatments: cleanse pin site to right ankle surgical site with peroxide once a day every other day 06:00 a.m. - 06:00 p.m. Dated 12/15/2023. Ended 02/27/2024. Record review of Resident #1's Skin - Dignity Weekly Skin Assessment dated 02/12/2024 authored by RN C indicated Resident #1 did not have a pressure, diabetic, venous, arterial ulcer, or incision. Other: Surgical incision with pins to the inner and outer right ankle, wound care in place. Record review of Resident #1's Orthopedic progress note dated 02/14/2024 authored by orthopedic MD indicated that Resident #1 was being seen status post right ankle fusion with hardware removal with external fixator and pins placement on 12/11/2023. The external fixator frame was in place to RLE, swelling was mild, incision healed. Mild redness on the proximal medial and lateral pins. Abrasion with some black scabbing proximally 2 centimeters x 2 centimeters on the top of right foot. Record review of Resident #1's facility medical record dated 01/24/2024 to 02/25/2024 does not indicate facility was coordinating with orthopedic surgeon after follow-up visits provided. No orthopedic office visit notes identified in the medical records at the time of orthopedic office visits and no communication regarding continued treatment or orders noted from orthopedic office. Two orthopedic notes identified in the medical records were requested and received by facility on 02/29/2024 after the deterioration of RLE external pin site and black/dark area to top of right foot. Record review of Resident #1's Skin - Dignity Weekly Skin Assessment dated 02/19/2024 authored by LVN A indicated Resident #1 did not have a pressure, diabetic, venous, arterial ulcer, or incision. Other: Surgical incision with pins to the inner and outer right ankle, wound care in place. Record review of Resident #1's Skin - Dignity Weekly Skin Assessment due 02/26/2024 not found in medical records. Record review of Resident #1's progress notes from 02/14/2024 to 02/27/2024 revealed no documentation of an assessment or treatment performed to Resident #1's pressure injury/wound to top of right foot and/or no coordination or communication with orthopedic surgeon or attending physician/NP regarding pressure injury/wound identified on 02/14/2024 by orthopedic surgeon. Record review of resident #1's TAR dated February 2024 did not have an assessment or treatment for pressure injury/wound on top of right foot. Record review of Resident #1's Progress Note dated 02/23/2024 authored by LVN A, indicated that CN was made aware by CNA that resident's right foot dressing had blood leaking. CN noted resident's right foot with dried blood on skin and pins, with white spots with clear drainage on side of foot too. CN cleaned wound per wound care order, DON, ADON, Administration, and MD notified of findings, no new orders given. Record review of Resident #1's Progress Note dated 02/25/2024 authored by LVN A, indicated that CN nurse cleaned residents' Right foot per wound care order, right foot had purulent drainage, with dried blood, RP notified, MD was already made aware upon first finding on 02/23/24. DON notified, ADON notified. Will monitor. Vital signs were within normal limits . Resident denies any pain or discomfort at this time. Record review of Resident #1's Progress Note dated 02/26/2024 authored by DON G indicates that the facility NP was notified regarding skin integrity and pictures were sent to NP. New orders for stat labs to be obtained and schedule an ortho visit as soon as possible . Record review of Resident #1's image of RLE dated 02/25/2024 and 02/26/2024 indicated that resident has a dark area to top of right foot with redness noted around wound. Record review of Resident #1's Progress Note dated 02/27/2024 authored by NP indicated that Resident #1 was seen today after having hemodialysis (a machine filters waste, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) session this morning. She continued to have drainage from RLE hardware x 5 days, the entry points in the heel, middle, and upper portions of the hardware have purulent drainage. She is complaining of significant pain. She has an appointment with Ortho scheduled for tomorrow, but labs from 02/26/2024 show leukocytosis of 17.9 which is concerning. Spoke with orthopedic MD on the phone and he advised transferring Resident #1 to affiliated hospital for evaluation. Record review of Resident #1's hospital record dated 02/27/2024, indicated Diagnosis: Chronic osteomyelitis (infection in the bone) of the right ankle, has external fixator, infection at sites of external fixator pins and right dorsal foot wound (pressure injury). Resident #1 underwent manipulation of external fixature, pin exchange and irrigation and debridement with application of integra graft to right dorsal foot (pressure injury site) on 02/29/2024. Skin head to toe assessment completed in hospital ER dated 02/27/2024 indicated Resident #1 was found to have pressure injury to right lateral buttock, measuring 2 cm x 2cm - images indicate site missing top layer of skin, pink in color, and a pressure injury to right dorsal foot measuring 2 cm x 4 cm - images indicate black/eschar tissue with redness around wound site. Plan: The patient has had some issues with the pin sites, we recommend surgery to evaluate exchange of pins. The resident was admitted for IV antibiotics, pain management and surgical intervention. Recommend compression of the ankle fusion through the frame as well as debridement of the dorsal midfoot wound that is worsening. Resident #1 underwent surgical intervention of right ankle manipulation of external fixator pin exchanged and wound irrigation, debridement, and graft application to right dorsal foot pressure injury/wound on 02/29/2024. Resident #1 was discharged on 03/03/2024 to another nursing facility with orders to continue IV antibiotics for 8 weeks and to provide care to pressure injury/wound to right dorsal foot and pin sites daily and to follow up with infectious disease and orthopedic physicians. Interview on 03/13/2024 at 2:30 p.m. with LVN A, indicated that she cared for Resident #1, she was a CN nurse on 06:00 a.m. - 06:00 p.m. shift and she provided pin site care, cleansed each site with hydrogen peroxide, and wrapped RLE/external fixator with ace wrap during her shift. LVN A said that Resident #1 had an external fixator/halo device to RLE status post hardware removal following ankle fracture and CN was responsible to provide pin site care every other day. LVN A said her pin sites started looking red, macerated, and purulent drainage on 02/23/2024 and reported the findings to DON, ADON, Administration, and MD notified of findings, no new orders given. LVN A does not recall assessing or providing treatment to an area on top of Resident #1's right foot. LVN A indicates that she took a photo of the resident's right lower extremity/foot and sent it to the DON due to her concerns with the external fixator pin sites. LVN A said the care provided and concerns was focused on the external fixators pin sites, does not recall scab, dark area, or discoloration to top of right foot. LVN A said it is the CN's responsibility to collect new orders or office visit notes/progress notes when resident goes to outside appointments. LVN A said she tries to call to get notes or new orders when residents go to outside appointments but may not have time to follow up if not obtained. LVN A said that DON and/or ADON will follow up with outside appointments if aware. Interview on 03/13/2024 at 4:40 p.m. with LVN B, indicated that she cared for Resident #1, she was a CN on 06:00 a.m. - 06:00 p.m. shift and she provided pin site care and wrap RLE/external fixator with ace wrap during her shift. LVN said that resident had an external fixator/halo device to RLE and CN was responsible to provide pin site care every other day. LVN said that she did recall seeing a dark or discolored skin on top of resident's right foot but was not providing care or treatment to the area to her knowledge, no orders. LVN B said she has only been employed with the facility for about 1 month and follows her MAR/TAR to provide required treatments and medications. LVN B said that if residents go out to outside appointments that she thinks DON or ADON does follow up regarding new orders or treatments. LVN B said Resident #1 was cognitive and she could tell you what the doctor said. Interview on 03/13/2023 at 6:18 p.m. with Resident #1's family member indicated she went to the hospital emergency room to meet the Resident #1 on 02/27/2024. She stated she saw Resident #1 right lower extremity and told the ER staff that she had concerns regarding the care the resident was receiving at the current nursing facility. The FM stated she had redness and purulent drainage from her external fixator pin sites on right foot, a large black round wound to the top of her right foot, and a pressure sore to her right buttock. She stated she was in shock, the right foot looked horrible since she had last seen it at the orthopedic office on 02/14/2024. She stated the hospital diagnoses was infection at site of external fixator pin, cellulitis, and right foot wound. She stated the area on top of her right foot had dead tissue that had to be surgically removed and a graft placed. She said that the facility staff improper placement of ace wrap caused the wound on top of foot. FM said she was unaware of the pressure injury on right buttocks until she saw it at the hospital ER. FM said resident will not be returning to this facility due to the neglect and inadequate care provided to Resident #1. Interview on 03/14/2024 at 5:22 p.m. with RN C indicated that she works as the RN supervisor usually on weekends but does pick up days during the week if needed. RN C recalls Resident #1's right foot with external fixator device and CN had to provide pin site care using hydrogen peroxide and Q-tip every other day and then wrap RLE/external fixator with ace wrap for protection. RN C does not recall the last time she cared for Resident #1 and has no recollection of resident having any wounds or discolored area to top of right foot area that she assessed or provided care for. RN C said each resident was scheduled a day and shift for weekly skin assessments to be performed by CN. Skin assessment should identify any new wounds, skin tears, abrasions, lacerations, rash, skin impairment/damage, discoloration, bruises, pressure, diabetic, venous, arterial ulcer, or incisions. Interview on 03/18/2024 at 11:27 a.m. with LVN A acknowledges that she took the photographs of Resident #1's RLE and provided a copy to DON. LVN A reviewed the photo previously taken on 02/25/2024 and does identify a dark/discolored area to top of right foot. LVN A said that the dark/discolored area on top of right foot should have been identified on the weekly skin assessments and the orthopedic MD or attending physician should have been made aware so assessment and treatment could have been ordered. LVN A does not recall when the dark/discolored area on top of right foot occurred or was first identified. Interview on 03/18/2024 at 1:41 p.m. with DON G, said she was familiar with Resident #1, she said she had to do a write up/medication error on an LVN because she used Dakin's solution (mixture of bleach or chlorine bleach, boric acid diluted in water) for pin site care instead of hydrogen peroxide on 02/22/2024. DON G communicated with LVN A on 02/23/2024 regarding Resident #1's external fixator pin sites with redness and purulent drainage and told her to contact orthopedic surgeon with report. DON G said she received a text message and image/photo of Resident #1's RLE on 02/25/2024 with concerns that pin sites continue to have drainage and redness noted during wound care. DON G said on 02/26/2024 she contacted orthopedic surgeon's office for an earlier appointment and notified attending NP/MD. DON G said she forwarded the attending NP the photos she had received from LVN A and NP gave new orders for stat labs to be obtained. DON G said that she had not physically observed Resident #1's RLE only the images sent to her. DON G said she reached out to orthopedic surgeon several times trying to get the resident an earlier appointment. DON G said that labs came back on 2/27/2024 indicating elevated white blood count and attending NP notified. She said attending NP consulted with orthopedic surgeon and resident was sent to affiliated hospital for evaluation and treatment. DON G does not recall facility staff mentioning Resident #1 having a dark/discolored area to top of foot but once she reviews the image/photo she acknowledges that image from 2/25/2024 does show a dark/discolored area to top of right foot. DON G said skin assessment should be performed weekly and as needed, DON G said areas like this should be documented and monitored. DON G said that she was no longer employed as the DON with this facility and was terminated at the end of February 2024. Interview on 03/20/2024 at 3:27 p.m. with LVN B, she acknowledges that the ace wrap being too tight could have caused the area to Resident #1's right dorsal foot, she said that she placed a non-adherent pad to area for protection at times. LVN B said that the dark/discolored area on top of right foot should have been identified on the weekly skin assessments and the orthopedic MD or attending physician should have been made aware so assessment and treatment could have been ordered. LVN B does not recall when the dark/discolored area on top of right foot occurred or was first identified. Interview on 03/14/2024 at 3:45 p.m. with DR E., who supervised NP D, he stated that he has seen Resident #1 with the external fixator and pin sites when he was visiting the roommate, approx. 1 week prior to hospitalization, while care was being provided to site, he does not recall seeing a dark/discolored area to top of right foot but says he was focus more on the pin sites which had a little redness but looked ok. DR E said that Resident #1 was seen by orthopedic surgeon routinely and he provided care/orders to RLE. DR E observed a photo of the RLE taken at the hospital ER on [DATE] and said no RLE did not look like that when he saw it, he said that NP D had been notified of the pin sites having drainage and redness on 02/26/2024 and she ordered labs and later consulted with orthopedic surgeon for hospital transfer and evaluation. DR E denied being notified or aware of dark/discolored area on top of right foot. Interview on 03/19/2024 at 8:00 a.m. with NP D indicated that she was notified by facility staff on 02/26/2024 that Resident #1 was having purulent drainage and redness at fixator pin sites, she ordered labs to be collected and for orthopedic appointment to be scheduled ASAP. NP D acknowledges that she received a picture of the Resident #1's RLE on 02/26/2024. NP D said that the focus at the time was the change in the pin site insertion sites, redness and purulent drainage, NP D reviews the photo provided to her on 02/26/2024 and does acknowledge the resident had a dark/discolored area to top of right foot but unable to assess due to poor quality of picture. NP said that Resident #1 was routinely being seen by orthopedic doctor for care, interventions, and treatment to RLE. NP said Resident #1 was sent to affiliated hospital on [DATE] due to abnormal lab values (elevated WBC count) and redness, and purulent drainage from fixator pin sites. Interview on 03/20/2024 at 12:05 p.m. with the ADON indicated initially Resident #1 admitted to facility with cast/splint due to fractured ankle, but due to hardware failure, resident had to have hardware removed and eternal fixator placed back in December 2023. ADON states that Resident #1 was seen by therapy services at first and has remained non-weight bearing. Resident #1 was being seen by orthopedic surgeon weekly, then biweekly then every three weeks. Resident #1 was non- weight bearing to RLE and facility staff was to provide pin site care to external fixator pins every other day using hydrogen peroxide and wrap RLE/external fixature with ace wraps. Resident was transported to orthopedic surgeon appointments and dialysis 3 x week by facility transport. ADON said that resident was cognitive and that she would report to facility what happened during her orthopedic appointments because family members would meet them at appointment and take office visit paperwork. ADON said that the charge nurse was responsible for following up when resident had outside appointment and getting the paperwork or new orders, ADON said that she or the DON was available to assist with getting office visit paperwork if needed assistance. ADON said that she contacted orthopedic surgeon for office visit notes for investigation related to medication error (staff applied wrong treatment to RLE pin sites) and had received and reviewed the documents on 02/29/2024. ADON said she had observed Resident #1's RLE with redness and purulent drainage to pin sites, recalls a dark/dried scab area to top of foot day prior to resident being transferred to hospital for evaluation. ADON said she also spoke with resident on 02/26/2024 regarding pin sites redness and drainage and resident said that orthopedic surgeon was aware of the pin sites redness and drainage during last orthopedic appointment and that they were scheduling surgery for pin sites to be exchanged. ADON denied that she contacted orthopedic surgeon to verify resident statement. ADON said that said that the dark/discolored area on top of right foot should have been identified on the weekly skin assessments and the orthopedic MD or attending physician should have been made aware so assessment and treatment could have been ordered if needed. Attempted to contact the Orthopedic Surgeon 03/20/2024 and 03/21/2024, office staff reports that he was in surgery on Thursday mornings and he would return the call. No return call, called office multiple times and left message, no return call received from the Orthopedic Surgeon. Interview on 03/21/2024 at 2:05 p.m. with the Administrator, she said Resident #1 had a scab on the top of her foot, but the main focus was on her fixator pin sites. Administrator observed images from hospital ER assessment on 02/27/2024 and said that the wound on top of the right foot did not look like that at time of transfer to hospital ER. Administrator acknowledges that she did not observe the RLE prior to transfer to hospital ER but pictures or images she received days prior did not look like the hospital ER images. Administrator was aware that facility staff were not receiving or contacting outside appointment staff for office visit records or new orders and have put a new process in place that CN was to contact and obtain office visit notes and orders from outside appointments. The administrator said she has a perform improvement plan in place for skin assessments not being completed weekly. Resident # 1's skin assessment was completed weekly over the last month except for 02/26/2024 but the skin assessment did not indicate or acknowledge that resident had a dark/discolored area to top of right foot as identified in images/photos taken by facility and hospital staff. Administrator reluctantly agrees that a skin impairment (dark/discolored area, scab, redness) should be assessed and identified on weekly skin assessment and the orthopedic MD or attending physician should have been made aware for treatment plan or intervention. Record review of the facility policy and procedure titled Prevention of pressure injuries revised April 2020, indicated Skin Assessment 1. Conduct a comprehensive scan assessment upon (or soon after) admission, with each risk assessment as indicated according to the resident's risk factors and prior to discharge. 2. During the skin assessment, inspect a. presence of erythema; b. Temperature of skin and soft tissue; and c. edema. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) . Prevention Skin Care 4. Use a barrier product to prevent skin from moisture. 6. Do not rub or otherwise cause friction on skin that is at risk of pressure injuries. Device-Related Pressure Injuries 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size shape and its application and ability to secure the device. 2. monitor regularly for comfort and signs of pressure related injury. The Administrator was notified of an Immediate Jeopardy on 03/21/2024 at 5:09 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The POR was accepted on 3/22/24 at 4:48 pm. Plan of Removal Problem: F684- Quality of Care Interventions: 1.DON/Designees will review all residents on resident roster to identify all residents receiving care from outside providers by 3/22/2024. 2.DON/Designees will provide updated clinical information to outside providers (MDs) on residents which pertain to their specific type of care; Ortho, cardiac, GI, urology, dental, podiatrist, etc. by 03/22/2024. DON/designee will pull information from residents' chart, including progress notes, all orders, medications, vital signs. This documentation will accompany the resident to their outside provider appointments. 3. The following in-services were initiated and conducted by Administrator and DON on 3/21/2024. All available staff will begin being in-serviced on 3/21/2024, to be completed on or before 3/22/2024. Any clinical staff member not present or in-serviced by this time will not be allowed to assume their duties until they have been in-serviced. Administrator/designee will ensure that all in-service training has been done for all clinical staff by checking off the clinical staff roster, check off being completed by HR coordinator. All clinical staff Care Coordination with all physicians involved in residents care and change of condition policy reviewed. CNA/CMA- Reporting changes in residents skin conditions when noticed immediately to charge nurse. Nurses-Assess and document changes in skin condition and notify MD. Outside providers shall also be notified if these changes pertain to the reason the resident in also in their care. When a resident returns from an appointment, the nurse will be responsible for ensuring she has received office visit notes and orders. The facility MD will be faxed/emailed this information to ensure he is also aware of the results of any outside office visits and changes/new orders. Should any outside providers see a resident on site at the facility, the nurse will review any notes and orders. These will be forwarded via fax/email to facility provider as well for his review. MOS- Care planning changes in resident's condition. DON/ADON- review 24- hour report for accuracy and care coordination follow-up. The POR was verified by interviews, and record reviews on 3/23/24 at 1:00 p.m. as follows: 4 LVNs and 2 MA and 6 CNAs interviews indicated the staff had been retrained on coordination of care on 3/22/24 and 3/23/24. During interviews with the Administer, DON, ADON indicated the resident's clinical charts were updated with all outside physicians and provided updated clinical information to all outside providers. The Administrator, DON, ADON indicated they were to monitor the 24-hour report for accuracy and care coordination follow-up. Interviews with 4 LVNs indicated they were retrained on the policy change of condition and coordination of care. The nurses were able to voice their role in assessing and document changes in skin condition and other changes in condition with the residents. Then they were to notify all physician involved with each resident's plan of care when a change of condition occurred. The 4 LVN were able to voice their role in coordination of care obtaining office visit notes and orders. The facility MD will be faxed/emailed this information to ensure he is also aware of the results of any outside office visits and changes/new orders. Should any outside providers see a resident on site at the facility, the nurse will obtain and review any notes and orders. These will be forwarded via fax/email to facility provider as well for his review. They said all change of conditions will also be documented on the 24 hour report, resident's clinical record and reported to DON and Administrator. Interviews with 2 MA indicated they were retrained on the policy of change of condition and were able to voice their role in notifying charge nurse, DON and Administrator of all changes of conditions with the residents. Interviews with 6 CNAs indicated they had been retrained and were able to voice what a change of condition was and how they were to report to charge nurse, DON and Administrator immediately. The CNAs said they were to document on stop and watch form and give the form to the charge nurse. Record reviews of the in-service records indicated training of staff was completed for the current staff on 3/23/24 and would be ongoing for any new staff (new staff or agency who had not been retrained) would be given prior to their first shift . The DON was monitoring and assuring the training record was updated after the staff was retrained and indicated the staff's responsibilities in coordination of care and notification to the physicians, nurses, and administration of the facility. Records review of 6 current residents indicated the clinical face sheet had been reviewed and updated as needed. No changes were noted for the 6 reviewed. All residents were assessed for any change of condition and a complete skin assessment was completed by RNs and 1 of the 6 residents had unstageable on her heel. The RN immediately reported to the physician and treatments were provided as ordered. The documentation indicated a coordination of care per notification of physician, nurse, and the facility administration. The care plan was updated, and the physician came to the facility and assessed the resident and ordered a referral and treatment. The primary physician was documenting on the wound and the referral orders. The referral for the wound care physician was being obtained and the charge nurses faxed needed items to the wound care physician. During an interview on 3/23/24 at 2:00 p.m., the DON said her expectations was for the nurses to notify her, ADON, Physician and the Administrator any new skin impairments/wounds and obtain treatment orders. She said all weekly skin assessments will be performed per the list at the nurse's station and followed up on as needed. On 03/23/24 at 1:00 p.m., the Administrator was informed the Immediate Jeopardy was lifted; however, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete i[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received care, consistent with professional standards of practice to prevent pressure injury and does not develop pressure injury unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure injury receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing for 2 (Resident #1 and Resident #2) of 10 residents reviewed for pressure injuries in that: 1.The facility failed to provide assessments, treatment for pressure injuries and notify physican to Resident #1's right dorsal foot pressure injury when it deteriorated to an unstageable wound with eschar from 02/14/2024 to 2/27/2024 where it declined to requiring wound irrigation, debridement, and graft application during her hospitalization on 2/27/2024. 2. The facility failed to provide assessments, treatment for pressure injuries and notify physican to Resident #2's blister to right heel when it deteriorated to an unstageable wound with eschar from 3/16/24 to 3/22/24. An Immediate Jeopardy (IJ) was identified on 03/21/2024. The IJ template was provided to the facility on [DATE] at 5:09 p.m. While the IJ was removed on 03/23/2024 at 1:00 p.m., the facility remained out of compliance at a scope of a pattern and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put in place. This facility failure could place residents at risk of untreated wounds, infection, a decline in health, further surgeries with associated complications leading to death. Findings included: Record review of Resident #1's electronic face sheet dated 03/13/2024 indicated she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: displaced trimalleolar fracture of right lower leg (fracture of lower leg bone, connected to foot/ankle area), Other acute osteomyelitis (infection of the bone), left ankle and foot, Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue-Right ankle ORIF (surgical procedure to replace bones with hardware or attach hardware to fix broken bone), Need for assistance with personal care, Muscle weakness (generalized), End stage renal disease ( a medical condition in which a person's kidneys cease functioning on a permanent basis leading to need for a regular course of long-term dialysis or a kidney transplant to maintain life), Cognitive communication deficit, metabolic encephalopathy ( another health condition, such as diabetes, liver disease, kidney failure, or heart failure, makes it hard for the brain to work), hypertension condition in which the force of the blood against the artery walls is too high, Diabetes mellitus (chronic condition that affects the way the body processes blood sugar). Record review of Resident #1's MDS dated [DATE] indicated she had no pressure injuries. She scored a 15/15 on her BIMS which signified she was cognitively intact. She was incontinent of bowel and bladder and went to dialysis 3 x week for hemodialysis for her end stage renal disease. She required substantial/maximal assistance with her ADLs. Record review of Resident #1's comprehensive care plan date initiated 12/15/2023 and revised on 03/01/2024 indicated Problem .has surgical wound to right ankle with pins in place .Approach . Assess condition of surrounding skin. Report emergence of skin excoriation. Observe and report signs of localized infection, (localized pain, redness, swelling, tenderness, loss of function, heat at the infected area.) Further review indicated Problem . potential for impaired skin integrity R/T impaired mobility. Approach . Assess feet every shower day & as needed, noting color, peripheral pulses, sensory reflexes, temperature, presence of edema or verbalizations of pain. Assess skin weekly & as needed & document changes. Record review of Resident #1's Braden Skin Assessment dated 12/15/2023 indicated she scored a 19 which signified she was at a low risk for skin breakdown. No current Braden Skin Assessment noted in medical records. Record review of Resident #1's Orders As of: 12/14/2023 to 02/27/2024 indicated: Treatments .to provide weekly skin assessment once a day on Monday 6:00 a.m. - 6:00 p.m. Dated 11/09/2023. Further review indicated Treatments . check skin surrounding splint to right leg. Check for capillaries refill to lower extremity Q shift and PRN. Notify MD of any abnormalities or changes in skin condition. Every Shift: day shift 06:00 a.m. - 06:00 p.m., night shift 06:00 p.m. - 06:00 a.m. Dated 11/23/2023 Ended 02/26/2024. Wound Treatments: cleanse pin site to right ankle surgical site with peroxide once a day every other day 06:00 a.m. - 06:00 p.m. Dated 12/15/2023. Ended 02/27/2024. Record review of Resident #1's Skin - Dignity Weekly Skin Assessment dated 02/12/2024 authored by RN C indicated Resident #1 did not have a pressure, diabetic, venous, arterial ulcer, or incision. Other: Surgical incision with pins to the inner and outer right ankle, wound care in place. Record review of Resident #1's Orthopedic progress note dated 02/14/2024 authored by orthopedic MD indicated that Resident #1 was being seen status post right ankle fusion with hardware removal with external fixator and pins placement on 12/11/2023. The external fixator frame was in place to RLE, swelling was mild, incision healed. Mild redness on the proximal medial and lateral pins. Abrasion with some black scabbing proximally 2cm x 2cm on the top of right foot. Record review of Resident #1's Skin - Dignity Weekly Skin Assessment dated 02/19/2024 authored by LVN A indicated Resident #1 did not have a pressure, diabetic, venous, arterial ulcer, or incision. Other: Surgical incision with pins to the inner and outer right ankle, wound care in place. Record review of Resident #1's Skin - Dignity Weekly Skin Assessment due 02/26/2024 not found in medical records. Record review of Resident #1's progress notes from 02/14/2024 to 02/27/2024 revealed no documentation of an assessment or treatment performed to Resident #1's pressure injury/wound to top of right foot and/or pressure injury to right buttocks. Record review of resident #1's TAR dated February 2024 did not have an assessment or treatment for pressure injury/wound on top of right foot or pressure injury to right buttocks. Record review of Resident #1's Progress Note dated 02/23/2024 authored by LVN A, indicated that CN was made aware by CNA that resident's right foot dressing had blood leaking. CN noted resident's right foot with dried blood on skin and pins, with white spots with clear drainage on side of foot too. CN cleaned wound per wound care order, DON, ADON, Administration, and MD notified of findings, no new orders given. Record review of Resident #1's Progress Note dated 02/25/2024 authored by LVN A, indicated that CN nurse cleaned residents' Right foot per wound care order, right foot had purulent drainage, with dried blood, RP notified, MD was already made aware upon first finding on 02/23/24. DON notified, ADON notified. Will monitor. V/S WNL limits. Resident denies any pain or discomfort at this time. Record review of Resident #1's Progress Note dated 02/26/2024 authored by DON G indicates that the facility NP was notified regarding skin integrity and pictures were sent to NP. New orders for stat labs to be obtained and schedule an ortho visit ASAP. Record review of Resident #1's image of RLE dated 02/25/2024 and 02/26/2024 indicated that resident has a dark area to top of right foot with redness noted around wound. Record review of Resident #1's Progress Note dated 02/27/2024 authored by NP indicated that Resident #1 was seen today after having hemodialysis (a machine filters waste, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) session this morning. She continued to have drainage from RLE hardware x 5 days, the entry points in the heel, middle, and upper portions of the hardware have purulent drainage. She is c/o significant pain. She has an appointment with Ortho scheduled for tomorrow, but labs from 02/26/2024 show leukocytosis of 17.9 which is concerning. Spoke with orthopedic MD on the phone and he advised transferring Resident #1 to affiliated hospital for evaluation. Record review of Resident #1's hospital record dated 02/27/2024, indicated Diagnosis: Chronic osteomyelitis (infection in the bone) of the right ankle, has external fixator, infection at sites of external fixator pins and right dorsal foot wound (pressure injury). Resident #1 underwent manipulation of external fixature, pin exchange and irrigation and debridement with application of integra graft to right dorsal foot (pressure injury site) on 02/29/2024. Skin head to toe assessment completed in hospital ER dated 02/27/2024 indicated Resident #1 was found to have pressure injury to right lateral buttock, measuring 2 cm x 2cm - images indicate site missing top layer of skin, pink in color, and a pressure injury to right dorsal foot measuring 2 cm x 4 cm - images indicate black/eschar tissue with redness around wound site. Plan: The patient has had some issues with the pin sites, we recommend surgery to evaluate exchange of pins. The resident was admitted for IV antibiotics, pain management and surgical intervention. Recommend compression of the ankle fusion through the frame and debridement of the dorsal midfoot wound. Resident #1 underwent surgical intervention of right ankle manipulation of external fixator pin exchanged and wound irrigation, debridement, and graft application to right dorsal foot pressure injury/wound on 02/29/2024. Resident #1 was discharged on 03/03/2024 to another nursing facility with orders to continue IV antibiotics for 8 weeks and to provide care to pressure injury/wound to right dorsal foot and pin sites daily and to follow up with infectious disease and orthopedic physicians. Interview on 03/13/2024 at 2:30 p.m. with LVN A, indicated that she cared for Resident #1, she was a CN on 06:00 a.m. - 06:00 p.m. shift and she provided pin site care, cleansed each site with hydrogen peroxide, and wrapped RLE/external fixator with ace wrap during her shift. LVN said that resident had an external fixator/halo device to RLE status post hardware removal following ankle fracture and CN was responsible to provide pin site care every other day. LVN said her pin sites started looking red, macerated, and purulent drainage on 02/23/2024 and reported the findings to DON, ADON, Administration, and MD notified of findings, no new orders given. LVN A does not recall assessing or providing treatment to an area on top of Resident #1's right foot. LVN A indicates that she took a photo of the resident's right lower extremity/foot and sent it to the DON due to her concerns with the external fixator pin sites. LVN A said the care provided and concerns was focused on the external fixators pin sites, does not recall dark area, scab, or discoloration to top of right foot. LVN A said it is the CN's responsibility to collect new orders or office visit notes/progress notes when resident goes to outside appointments. LVN A said she tries to call to get notes or new orders when residents go to outside appointments but may not have time to follow up if not obtained. LVN A said that DON and/or ADON will follow up with outside appointments if aware. Interview on 03/13/2024 at 4:15 p.m. with orthopedic surgeon indicated that Resident #1 had been seen by orthopedic for several months due to fractured ankle, osteomyelitis, hardware failure/removal, and back in December 2023 resident had right ankle fusion with an external fixator device applied. Orthopedic surgeon denies that the use of Dakin's solution rather than hydrogen peroxide could have caused any damage or further skin impairment to Resident #1's external pin sites. The surgeon acknowledges that Resident #1 had upcoming surgery for external fixator pins to be exchanged. Interview on 03/13/2024 at 4:40 p.m. with LVN B, indicated that she cared for Resident #1, she was a CN nurse on 06:00 a.m. - 06:00 p.m. shift and she provided pin site care and wrap RLE/external fixator with ace wrap during her shift. LVN said that resident had an external fixator/halo device to RLE and CN was responsible to provide pin site care every other day. LVN said that she did recall seeing a scab, or dark or discolored skin on top of resident's right foot but was not providing care or treatment to the area to her knowledge, no orders. LVN B said she has only been employed with the facility for about 1 month and follows her MAR/TAR to provide required treatments and medications. LVN B said that if residents go out to outside appointments that she thinks DON or ADON does follow up regarding new orders or treatments. LVN B said Resident #1 was cognitive and she could tell you what the doctor said. Interview on 03/13/2023 at 6:18 p.m. with Resident #1's FM indicated she went to the hospital ER to meet the resident on 02/27/2024. She stated she saw Resident #1 right lower extremity and told the ER staff that she had concerns regarding the care the resident was receiving at the current nursing facility. The FM stated she had redness and purulent drainage from her external fixator pin sites on right foot, a large black round wound to the top of her right foot, and a pressure sore to her right buttock. She stated she was in shock, the right foot looked horrible since she had last seen it at the orthopedic office on 02/14/2024. She stated the hospital diagnoses was infection at site of external fixator pin, cellulitis, and right foot wound. She stated the area on top of her right foot had dead tissue that had to be surgically removed and a graft placed. She said that the facility staff improper placement of ace wrap caused the wound on top of foot. FM said she was unaware of the pressure injury on right buttocks until she saw it at the hospital ER. FM said resident will not be returning to this facility due to the neglect and inadequate care provided to Resident #1. Interview on 03/14/2024 at 5:22 p.m. with RN C indicated that she works as the RN supervisor usually on weekends but does pick up days during the week if needed. RN C recalls Resident #1's right foot with external fixator device and CN had to provide pin site care using hydrogen peroxide and Q-tip every other day and then wrap RLE/external fixator with ace wrap for protection. RN C does not recall the last time she cared for Resident #1 and has no recollection of resident having any wounds or discolored area to of right foot or to right buttocks area that she assessed or provided care for. RN C said each resident was scheduled a day and shift for weekly skin assessments to be performed by CN. Skin assessment should identify any new wounds, skin tears, abrasions, lacerations, rash, skin impairment/damage, discoloration, bruises, pressure, diabetic, venous, arterial ulcer, or incisions. Interview on 03/18/2024 at 11:27 a.m. with LVN A acknowledges that she took the photographs of Resident #1's RLE and provided a copy to DON. LVN A reviewed the photo previously taken on 02/25/2024 and does identify a dark/discolored area to top of right foot. LVN A said that the dark/discolored area on top of right foot should have been identified on the weekly skin assessments and the orthopedic MD or attending physician should have been made aware so assessment and treatment could have been ordered. LVN A does not recall when the dark/discolored area on top of right foot occurred or was first identified. LVN A denies being notified by CNA that resident had a new skin impairment to right buttock. Interview on 03/18/2024 at 1:41 p.m. with DON G, said she was familiar with Resident #1, she said she had to do a write up/medication error on an LVN/CN because she used Dakin's solution for pin site care instead of hydrogen peroxide on 02/22/2024. DON G communicated with LVN A on 02/23/2024 regarding Resident #1's external fixator pin sites with redness and purulent drainage and told her to contact orthopedic surgeon with report. DON G said she received a text message and image/photo of Resident #1's RLE on 02/25/2024 with concerns that pin sites continue to have drainage and redness noted during wound care. DON G said on 02/26/2024 she contacted orthopedic surgeon's office for an earlier appointment and notified attending NP/MD. DON G said she forwarded the attending NP the photos she had received from LVN A and NP gave new orders for stat labs to be obtained. DON G said that she had not physically observed Resident #1's RLE, only the images sent to her. DON G said she reached out to the orthopedic surgeon several times trying to get resident an earlier appointment. DON G said that labs came back on 2/27/2024 indicating elevated white blood count and attending NP notified. She said attending NP consulted with orthopedic surgeon and resident was sent to affiliated hospital for evaluation and treatment. DON G does not recall facility staff mentioning Resident #1 having a dark/discolored area to top of foot but once she reviews the image/photo she acknowledges that image from 2/25/2024 does show a dark/discolored area to top of right foot. DON G said skin assessment should be performed weekly and as needed, DON G said areas like this should be documented and monitored. DON G said that she was no longer employed as the DON with this facility, was terminated at the end of February 2024. Interview on 03/20/2024 at 3:00 p.m. with CNA F, said she works 06:00 a.m. to 06:00 p.m. shift and provides personal care and assistance to residents. CNA F said she recalls Resdient#1 and her halo device to her right foot, she recalls that she reported to the CN once that the ace wrap had blood on it and pin sites appeared to be bleeding, she said CN assessed the right foot after reporting the incident. CNA F said she recalled providing care to Resident #1 days before or day of her being transferred to hospital, can't remember exact day, and when she place her hand on right hip area resident said ouch that hurt, CNA said she saw a fluid filled area to right hip/buttocks area, she completed her care and notified CN of her findings of fluid filled blister to right hip/buttocks area. CNA said I usually work with LVN B, but I cannot remember who I reported it to, but I remember reporting it to the CN. Interview on 03/20/2024 at 3:27 p.m. with LVN B, she acknowledges that the ace wrap being too tight could have caused the area to Resident #1's right dorsal foot, she said that she placed a non-adherent pad to area for protection at times. LVN B denies being notified by CNA that resident had a new skin impairment to right buttock. LVN B said that the dark/discolored area on top of right foot should have been identified on the weekly skin assessments and the orthopedic MD or attending physician should have been made aware so assessment and treatment could have been ordered. LVN B does not recall when the dark/discolored area on top of right foot occurred or was first identified. Interview on 03/14/2024 at 3:45 p.m. with DR E., who supervised NP D, he stated that he has seen Resident #1 with the external fixator and pin sites when he was visiting the roommate, approx. 1 week prior to hospitalization, while care was being provided to site, he does not recall seeing a dark/discolored area to top of right foot but says he was focus more on the pin sites which had a little redness but looked ok. DR E said that Resident #1 was seen by orthopedic surgeon routinely and he provided care/orders to RLE. DR E observed a photo of the RLE taken at the hospital ER on [DATE] and said no RLE did not look like that when he saw it, he said that NP D had been notified of the pin sites having drainage and redness on 02/26/2024 and she ordered labs and later consulted with orthopedic surgeon for hospital transfer and evaluation. DR E denied being notified or aware of dark/discolored area on top of right foot or fluid filled blister to right hip/buttocks area. Interview on 03/19/2024 at 8:00 a.m. with NP D indicated that she was notified by facility staff on 02/26/2024 that Resident #1 was having purulent drainage and redness at fixator pin sites, she ordered labs to be collected and for orthopedic appointment to be scheduled ASAP. NP D acknowledges that she received a picture of the Resident #1's RLE on 02/26/2024. NP D said that the focus at the time was the change in the pin site insertion sites, redness and purulent drainage, NP D reviews the photo provided to her on 02/26/2024 and does acknowledge the resident had a dark/discolored area to top of right foot but unable to access due to poor quality of picture. NP said that Resident #1 was routinely being seen by orthopedic doctor for care, interventions, and treatment to RLE. NP said Resident #1 was sent to affiliated hospital on [DATE] due to abnormal lab values (elevated WBC count) and redness, and purulent drainage from fixator pin sites. Interview on 03/20/2024 at 12:05 p.m. with the ADON indicated initially Resident #1 admitted to facility with cast/splint due to fractured ankle, but due to hardware failure, resident had to have hardware removed and eternal fixator placed back in December 2023. ADON states that Resident #1 was seen by therapy services at first and has remained non-weight bearing. Resident #1 was being seen by orthopedic surgeon weekly, then biweekly then every three weeks. Resident #1 was non- weight bearing to RLE and facility staff was to provide pin site care to external fixator pins every other day using hydrogen peroxide and wrap RLE/external fixature with ace wraps. Resident was transported to orthopedic surgeon appointments and dialysis 3 x week by facility transport. ADON said that resident was cognitive and that she would report to facility what happened during her orthopedic appointments because family members would meet them at appointment and take office visit paperwork. ADON said that the charge nurse was responsible for following up when resident had outside appointment and getting the paperwork or new orders, ADON said that she or the DON was available to assist with getting office visit paperwork if needed assistance. ADON said that she contacted orthopedic surgeon for office visit notes for investigation related to medication error (staff applied wrong treatment to RLE pin sites) and had received and reviewed the documents on 02/29/2024. ADON said she had observed Resident #1's RLE with redness and purulent drainage to pin sites, recalls a dark/dried scab area to top of foot day prior to resident being transferred to hospital for evaluation. ADON said she also spoke with resident on 02/26/2024 regarding pin sites redness and drainage and resident said that orthopedic surgeon was aware of the pin sites redness and drainage during last orthopedic appointment and that they were scheduling surgery for pin sites to be exchanged. ADON denied that she contacted orthopedic surgeon to verify resident statement. ADON said that said that the dark/discolored area on top of right foot should have been identified on the weekly skin assessments and the orthopedic MD or attending physician should have been made aware so assessment and treatment could have been ordered if needed. Attempted to contact the Orthopedic Surgeon 03/20/2024 and 03/21/2024, office staff reports that he was in surgery on Thursday's mornings and would have return the call. No return call, called office multiple times and left message, no return call received from orthopedic surgeon. Interview on 03/21/2024 at 2:05 p.m. with the Administrator, she said Resident #1 had a scab on the top of her foot, but the focus was on her fixator pin sites. Administrator observed images from hospital ER assessment on 02/27/2024 and said that the wound on top of the right foot did not look like that at time of transfer to hospital ER. Administrator acknowledges that she did not observe the RLE prior to transfer to hospital ER but pictures or images she received days prior did not look like the hospital ER images. Administrator was aware that facility staff are not receiving or contacting outside appointment staff for office visit records or new orders and have put a new process in place that CN is to contact and obtain office visit notes and orders from outside appointments. The administrator said she has a PIP in place for skin assessments not being completed weekly. Resident # 1's skin assessment was completed weekly over the last month except for 02/26/2024 but the skin assessment did not indicate or acknowledge that resident had a dark/discolored area to top of right foot as identified in images/photos taken by facility and hospital staff. Administrator reluctantly agrees that a skin impairment (dark/discolored area, scab, redness) should be assessed and identified on weekly skin assessment and the orthopedic MD or attending physician should have been made aware for treatment plan or intervention. Record review of the facility policy and procedure titled Prevention of pressure injuries revised April 2020, indicated Skin Assessment 1. Conduct a comprehensive scan assessment upon (or soon after) admission, with each risk assessment as indicated according to the resident's risk factors and prior to discharge. 2. During the skin assessment, inspect a. presence of erythema; b. Temperature of skin and soft tissue; and c. edema. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). Prevention Skin Care 4. Use a barrier product to prevent skin from moisture. 6. Do not rub or otherwise cause friction on skin that is at risk of pressure injuries. Device-Related Pressure Injuries 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size shape and its application and ability to secure the device. 2. monitor regularly for comfort and signs of pressure related injury. The Administrator was notified of an Immediate Jeopardy (IJ) on 03/21/2024 at 5:09 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. 2. Record review of Resident #2's face sheet dated 01/30/24 indicated she was a [AGE] year-old female, initially admitted on [DATE], and her diagnoses included dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and high blood pressure. Resident #2 was readmitted on [DATE] with diagnosis of fracture of the femur (broken thigh bone). Record review of Physician orders for Resident #2 dated March 2024 indicated an order to elevate, off load right heel and monitor blister, report changes to MD with a start date of 2/2/24. Another order was to apply hydrogel to the right heel and cover with dry dressing daily with a start date of 3/22/24. Record review of Resident #2's admission MDS assessment dated [DATE] indicated she had severely impaired cognition with BIMS of 04. She was dependent on one staff for transfer and showers. Section M (skin): indicated no wounds, no issues with feet and no areas were noted. Record review of Resident #2's care plan dated 1/30/24 to 3/23/24 indicated on 3/23/24 there was an unstageable pressure ulcer on right heel with eschar (dead tissue), there was no mention of the blister on the right heel the resident admitted on [DATE]. Record review of Resident #2's admission assessment dated [DATE] at 6:52 p.m., indicated she was readmitted with a quarter size blister on her right heel that was covered with bandage from the hospital. The orders noted on 02/02/24 to elevate, offload right heel, and monitor blister and notify physician of any changes. Record review of weekly skin assessments for Resident #2 as follows: On 2/2/24, other: intact blister to right heel; offloading; On 2/9/24, other: intact blister to right heel; offloading; On 2/16/24, other: intact blister to right heel; offloading; On 2/23/24, other: N/A; On 3/1/24, other: N/A; On 03/08/24, other: N/A; and On 3/15/24, other: N/A. During an interview and observation on 3/23/24 at 10:40 a.m., MD E observed Resident #2's right heel and MD E said Resident #2 would need an appointment with wound care specialist for treatment. He said the facility notified him of the area yesterday (3/22/24). He said normally the facility would notify his nurse practitioner and receive orders to treat or referral to wound care. He said he was not told about the wound before 3/22/24. He stated, I will ask my Nurse Practitioner if she was aware of the wound. He said if the facility failed to notify him that failure could cause a delay in care. He said he felt responsible too. During an interview on 3/23/24 at 11:30 a.m., the NP D said she was not notified about Resident #2 having a blister on her right heel since readmission on [DATE] or having eschar on her right heel. She said the routine order for a blister would be to elevate, offload the heel, monitor the blister, and notify the physician of any changes. She said then on her next onsite visit, she would have assessed the area and order specific treatment, pain management, referral to wound care and make a progress note. During an interview on 3/23/24 at 12:30 p.m., The ADON said the weekly skin assessments for Resident #2 were not correct for 2/23/24 to 3/15/24 and should have included the blister on the right heel. She said there was no documentation of the physician being notified on the weekly skin assessments. Record review of podiatry note dated 2/21/24 indicated Resident #2 was seen and treated for trimming of the nails and no documentation about the blister. Record review of the nurse's note dated 03/16/24 indicated Resident #2 had a blister on right heel and was an unstageable wound do to wound was covered with eschar (a thick layer attached to the wound bed and often requires medical intervention from wound care specialist for debridement). There was no documentation of the physician being notified of Resident #2's blister on right heel had changed from a blister to eschar tissue on the right heel. The POR on 3/22/24 at 6:22 pm was accepted. Plan of Removal Problem: F686- Pressure Injuries Interventions: 1.DON/Designee will conduct a facility wide skin sweep to verify accuracy of documented wounds to be completed by 3/22/2024. 2.Registered Nurse consultant completed DON check off on staging and wound care 3/22/2024. 3.DON checked off registered nurses on wound staging and wound care on 3/22/2024. 4.DON initiated checked off on assessing and documenting changes in wounds and wound care with LVNs on 3/22/2024. Nurses will not be allowed to work the floor until education and in-service is completed. Education: 1.The following in-services were initiated by DON/designee on 3/21/2024: All available staff will begin being in-serviced on 3/21/2024, to be completed on or before 3/22/2024. Any staff member not present or in-serviced by this time will not be allowed to assume their duties until they have been in-serviced. 2. Administrator/designee to ensure that all in-service training has been done for all staff (nurses, CNAs, Medication Aides, dietary, housekeeping, and maintenance} by che[TRUNCATED]