**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician of G- tube dysfunction or malfunction for 1 of 4 residents reviewed for physician notification (Resident #1). The facility failed to immediately consult with the resident's physician when facility staff did not implement physician order due to the inadequate supply of adnominal binder to protect G-tube and G-tube site for 1 of 4 residents reviewed for physician notification (Resident #1). The facility failed to notify the resident's physician of complications related to Resident# 1 G-tube site pain and administering medications to Resident #1 via the G-Tube. The failure resulted in LVN V administering medications by plunger pushing the medications with force into Resident #1 gastrostomy tube instead of administering to gravity, placing the resident at immediate risk for potential harms associated G-Tube blockage and Aspiration (occurs when liquid or food enters the lungs). The facility failed to notify the physician that physician's order for an abdominal binder indicated to prevent complications of gastrostomy tube was not implemented. The facility failure resulted in Resident #1 requiring discharge to the hospital for G-Tube replacement. An Immediate Jeopardy (IJ) was identified on 03/27/2024. The Administrator and DON were informed on 03/27/2024 at 5:40pm. The IJ was lowered on 03/29/23 at 1:33pm, the facility remained out of compliance at a scope of pattern and a severity level of no harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The failures have the potential to cause significant complications, including infections, aspiration, hospitalizations, or death, in residents with gastrostomy tubes. Findings included: Record review of Resident #1's face sheet dated 03/25/2024 revealed resident was admitted to the facility on [DATE], age [AGE] years old female. Resident #1 had a diagnosis of Gastrostomy Status (the creation of an artificial external opening into the stomach for nutritional support or gastric decompression via a G- Tube) and Gastro-Esophageal Reflux Disease (GERD - occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus) dated 08/26/2023. Record review of clinical record, Resident #1's Care Plan revealed that Resident #1 require to have an abdominal feeding tube. Care Plan Goal: Resident was to remain free of side effect of complication Resident insertion site will be free of sign and symptoms of infection. Interventions Task: Check tube placement and gastric contents/residual volume per facility protocol and record (policy). Monitor/document/ report tube dysfunction or malfunction, abdominal pain, and infection at the tube site provide local care to G-Tube site as ordered administer medication as ordered. Record review of clinical record, Resident #1's MDS revealed that Resident #1 required abdominal feeding tube. Record review of Resident #1's physician's order summary report revealed the following order: every shift for flush feeding tube with 30ml(cc) of water before and after administration of medication pass. clean and change dressing one time a day. Apply abdominal binder, order dated as of 12/07/2023. Record review of clinical record, Resident #1's MAR/TAR revealed no documentation that the physician order for abdominal binder had been followed and implemented from 12/07/2023 thru 03/25/2024. Observation made on 03/25/2024 at 10:30am revealed Resident #1 was not wearing abdominal binder. The surveyor was unsuccessful in attempt to interview Resident #1 due to symptoms related to Dementia (intermittent confusion). Observation and interview with CNA T, on 03/25/2024, at 3:45pm, revealed CNA T positioned Resident #1 to aid in the surveyor's observation of Resident #1's abdominal gastrostomy tube site. Observation revealed Resident #1 was lying flat on her designated bed and was not wearing abdominal binder. Resident #1's abdominal gastrostomy tube site was not clean. There was a visibly soiled dressing, with dark red hanging below the gastrostomy tube site. Abdominal gastrostomy tube site was cover with dark red substance. Resident #1's gastrostomy tube contained dark red substance. Resident #1 was tensed and expressed that there was pain at the gastrostomy tube site. CNA T stated that the Resident often complained that there was pain at the gastrostomy tube site; and Resident #1 was often seen pulling the gastrostomy tube. CNA T stated that he had no knowledge of abdominal binder that was ordered for Resident #1. During observation the surveyor observed that there was signage post on the wall and the head of the resident bed reading resident is to remain in a 45-degree position. CNA T stated that he was aware of the sign but was not sure why the sign was posted. CNA T stated that the resident head of bed was always flat when he worked. Interview on 03/25/2024, at 4:00pm with the DON and Administrator, the Administrator stated that they were aware of the physician's order to implement the abdominal binder. According to the Administrator, Resident #1 was not wearing the abdominal binder due to the facility not having the proper sized abdominal binder. The DON and Administrator did not disclose the date they were made aware of the improper fit; how they were able to determine the appropriate/best size for the resident; why the facility did not have the proper size; and why the proper sized abdominal binder had not been implemented. The Administrator stated that the physician should have been notified that the order was not implemented and did not disclose why the physician was not notified. Interview on 03/25/2024 at 4:45pm with LVN V, LVN V stated that she had worked at the facility for three months. LVN V stated that she provided care for Resident #1 often since employed with the facility. LVN V stated that she was not aware that Resident #1 had an order to wear an abdominal binder. The surveyor asked LVN V how she was made aware of all orders for any given resident she worked with. She stated that the information was usually communicated during shift ending handoff report. LVN V confirmed that she had access to the clinical record including all active order for resident she was assigned to provide care to. LVN V stated that she did not routinely check the resident order each shift. LVN V stated that Resident #1 often complained of pain at the gastrostomy tube site and the resident was often seen pull on the G-tube. LVN V stated that she had noticed complications with the G-Tube and G-tube site. LVN V that she had not notified the physician of complications related to the G-Tube and site. The surveyor asked LVN V if she had knowledge related to why a resident would be ordered an abdominal binder. LVN V stated that the abdominal binder would usually prevent possible complication with the G-tube. LVN V stated that she noticed that the dressing had not been changed. She stated that the dressing containing the dark red substance appeared to be the dressing from when she cleaned the gastrostomy tube site three days ago, on Friday, 03/22/2024 as the dressing was dated for Friday, 03/22/2024 and not new dress had been applied. LVN V stated that Resident #1's gastrostomy tube site was to be cleaned daily and a clean dressing should be applied. LVN V stated that when orders were missed it could place residents at risk for medical neglect. LVN V stated that by missing the order for the abdominal binder it placed Resident #1 at risk for complications with the G-tube. Interview on 03/26/2024 at 9:45am with RN J, who state that she had worked with Resident # 1 since January/2024. RN J stated that Resident #1 often complained of pain at the gastrostomy tube site and the resident was often redirected from pulling on the G-tube. RN J stated that she had often experienced complications with the G-Tube when administrating medication via the G-Tube. RN J stated that she had not notified the physician of the complications with the G-Tube. RN J stated that she was not aware that Resident #1 had an order to for an abdominal binder prior to the start of her shift on 03/26/2024. RN J was not able to explain how the order was missed. RN J stated that she usually reviewed and confirmed orders in the electronic clinical record for all resident she was assigned to work with each shift. RN J stated that she was made aware at the start of her shift during handoff report that the resident was sent out to the hospital related to complications of the G- tube and G-tube site. The surveyor asked RN J if she had knowledge related to why a resident would be ordered an abdominal binder. RN J stated that an abdominal binder is to protect the G-tube and G- Tube site. RN J stated that she was informed that the resident was provided an abdominal binder that was placed on the resident at the hospital during the hospital visit on 03/15/2024. RN J stated that she had not previously seen the resident wearing an abdominal binder. The surveyor asked what could happen to a resident by not implementing physician orders. RN J stated that Resident #1 could possibly have complications or dislodge her G- Tube. Record review on 03/26/2024 of Resident #1 clinical record, nurse progress note revealed that Resident #1 was sent out to the hospital for G-Tube replacement on 03/25/2024 at 6:20pm. Progress note 03/25/2024 at 11:19 revealed that Resident # 1 was discharged from the hospital with discharge instructions to follow up with gastroenterology specialty service for replacement of G tube. The surveyor was unable to interview the assigned nurse working the night shift (11pm - 6am) who received the Resident # 1 upon return from the hospital. Observation and interview of Resident #1's medication administration pass performed by LVN V on 3/26/2024 at 5:45pm revealed LVN V explained to Resident #1 that she was going to administer medication with the standby assistance of CNA T. LVN V prepared Resident #1's medications by crushing them and mixing them in water to dissolve them. LVN V went to the bedside without a stethoscope and there was no stethoscope at the resident's bedside. LVN V removed an enteral feeding and irrigation syringe from an opened package, not dated, at the bedside. LVN V removed the plunger from the syringe, preceded and did not aspirate gastric content from the g-tube. LVN V did not check Resident #1's g-tube for placement by auscultating (listening with a stethoscope) for bowel sounds, visualizing the site to ensure the tube had not become dislodged and or was not infected or compromised in any way. LVN V proceeded by plunger pushing a full 60 ml syringe of water into Resident #1's g-tube. Resident observed guarding her abdomen and yelled it hurt, stop. Resident #1's bed was flat, and the head of the bed was not elevated. The surveyor stopped LVN V and asked her if that was the technique, she normally used to check to assess a resident's g-tube placement. LVN V stated, Yes, if it flushes then it is good to use. When asked if that was the way she had been trained to check for g-tube placement, she said she had only worked at the facility for three months. LVN V stated that she had been trained. LVN V tried to resume the medication administration and was stopped again by the surveyor when LVN V aspirated the medication out of the cup she had used to crush and mix Resident #1's medication with water and began to plunger push the medication with force into Resident #1's g-tube as if giving an injection. When asked to stop and asked if that was how she was trained to administer g-tube medications, LVN V confirmed that was the way she was trained. LVN V stated that she always pushed Resident #1's medications when administering via g-tube. LVN V stated that she knew how to administer g-tube medications to gravity. She then stated that in the past when she attempted to administer Resident #1 medications to gravity, she often experienced complications. LVN V stated that she never reported complications related to the g-tube. LVN V did not disclosed why she did not notify the physician of complications. The surveyor stopped the medication administration observation and requested the DON. LVN V plunger push the medication with force instead of administering medications to gravity. LVN V did not follow physician orders to flush feeding tube with 30ml(cc) of water before and after administration of medication pass. Interview on 03/26/2024, at 6:00pm with DON, Administrator, and Corporate Regional Nurse, the DON confirmed that nursing staff had been trained on medication administration via g-tube and managing the care of Resident's with G-Tubes. Interview on 03/26/2024, at 8:00pm with the facility Physician, the Physician stated that the abdominal binder that was ordered and indicated because Resident #1 continued to attempt to pull out g-tube. The Physician stated that he was not notified that the facility had not implemented the abdominal binder prior to 03/26/2024. The Physician confirmed that the order was a current and active order to prevent complications of the g-tube and comprise to the g-tube site. The Physician confirmed that he should have been notified with related to failure to implement the abdominal binder and any complication related to the G-tube and G-Tube site. Interview on 03/27/2024, at 9:30am with the DON, the surveyor asked what the expectation for nursing staff was related to implementing physician orders. The DON stated that all nursing staff were expected to implement orders. The DON stated that when staff failed to implement orders the failure could have a negative impact and decline related to the resident's overall wellbeing. The facility policy related to implementing doctor's orders and management of G-Tubes was requested. The policy related to implementing doctor's orders, medication administration, and management of G-Tubes was requested at 9:30am on 03/37/2024. Proof of in-services and staff training for medication administration. The facility failed to provide requested information as of 03/27/2024 at 5:00pm. Interview on 03/29/24 at 11:30am Central Supply Staff A stated that she started working at the facility in January of 2024. Central Supply Staff A stated that she was made aware on 01/11/2024 that Resident #1 had an order for an abdominal binder. Central Supply Staff A stated that she did not have access to place a supply order for an abdominal binder. She stated that the previous DON was responsible for placing the supply order. She stated she was aware that the order had been placed and that the binder had arrived because there was a big deal about the wrong size being delivered so she re-ordered it at that time in the correct size. She provided invoices for original delivery date of 12/26/23 and reorder on 2/20/24. She said she did not know the resident had been without the abdominal binder. An Immediate Jeopardy (IJ) was identified on 03/27/2024. The Administrator and DON were notified on 03/27/2024 at 5:40pm. Plan of Removal - F580 Notice of Changes (submitted by facility/accepted at 03/28/2024 at 12:00pm) The facility failed to notify the resident's physician when the facility was unable to implement the physician order for abdominal binder. Immediate Action Resident #1 immediately assessed with no signs of distress noted. Abdominal binder obtained and placed on resident 3/25/24. LVN V immediately in serviced by DON and RNC related to g-tube care, checking placement, pushing and medication administration. Resident #1's orders were reviewed on 3/28/2024 and updated as needed to facilitate proper documentation. A gastroenterology follow-up appointment was set up by the facility for the next available day. The first available date was June 6, 2024. However, in consultation with the family and hospice, the g-tube will be removed as the resident is taking adequate PO intake/nutrition and the presence of the g-tube causes her undue distress. The facility reviewed the system for tube feeding and a review of the tube feeding policy was conducted by RNC to address any ambiguities that may have contributed to the incident. The facility revised a system including administrative nurses are reviewing residents that receive nutrition and/or medications via g-tube to assure that orders are followed, and new orders have been implemented as ordered during clinical meeting Monday - Friday. Ad HOC QAPI meeting will be completed with IDT consisting of Administrator, Regional Nurse Consultant, Administrative nurses and Medical Director 3/28/24 at 10 am. Facility interventions were implemented to remove immediate jeopardy: 1. Audit was completed by DON/RNC on 3/26/24 to identify any other residents with g- tubes in place to assure there were no complications related to g-tube care with no issues noted. 2. An audit was conducted by DON/RNC on 3/28/24 to identify other residents with changes of condition in the past 14 days to ensure MD was notified. 3. Education provided 3/26/24 to LVN V DON and RNC related to g-tube care, resident positioning, checking g-tube placement, pushing and medication administration. 4. Education initiated for licensed nursing staff by DON/Designee related to g-tube care, resident positioning, checking placement, pushing and medication administration and steps to take when g-tube is not functioning properly. On 3/28/2024, an in-service with all licensed nursing staff was initiated by RNC to reinforce the importance of maintaining proper positioning with residents receiving feeding by tube feeding and proper placement of abdominal binders. 5. Education was initiated on 3/28/2024 on notification of MD when resident refuses treatment, when a prescribed treatment is not available, or when a full amount of a medication is unable to be administered. This includes g-tube medication administration and site care. 6. Facility will be in compliance 3/28/24 by 1 PM *Education to be completed with all licensed nursing staff working 3/28/2024. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. State Surveyor Monitored the plan of removal as follows: Interview on 03/28/2024 at 12:13 with RN K (Day shift), RN K stated that General G-Tube Care training and in-service was provided by the facility on 03/27/2024. RN K was able to verbalize knowledge and understanding congruent with facility G- Tube policy. Interview on 03/28/2024 at 12:42 with RN J (Day shift), RN J stated that General G-Tube Care training and in-service was provided by the facility on 03/27/2024. RN J was able to verbalize knowledge related to G-Tube policy. Interview on 03/28/2024 at 6:00pm with, LVN V (2-10 shift), LVN V stated that General G-Tube Care training and in-service was provided by the facility on 03/27/2024. LVN V was able to verbalize knowledge of positioning and administering medications via G-Tube. LVN V was also able to verbalize knowledge related checking placement of a G-Tube, pushing and medication administration, the importance to of an abdominal binder, and the process for notifying the physician and follow up related to change in resident status and inability to implement a physician's orders. Interview on 03/28/2024 at 6:15 with CNA T (2-10pm shift), CNA T stated that training was provided on 03/27/2024 and 03/28/2024 on how to position a resident with and G-Tube. Interview on 03/28/2024 at 6:35pm with MA M (2-10pm shift), MA M stated that training was provided on 03/27/2024 on how to position a resident with and G-Tube. MA was able to verbalize her knowledge related positioning Resident's with G-Tubes. Interview on 03/29/24 at10:00am CNA J stated she had been trained that if they needed any supplies or supplies were missing, she would let her charge nurse and central supply know. She stated that the facility had been trained on how to make sure the residents with g-tubes were not left flat and that the head of the bed was up to at least 30-45 degrees. She said she had been trained to report any behaviors or changes in resident to charge nurse. She said they did not have access to supplies like abdominal binders so she would have to check with the charge nurse or central supply but if something got soiled or needed to be cleaned or replaced, she would report it to charge nurse. Interview on 03/29/24 at10:16 AM RN J, RN J stated she was recently in-serviced on G-tubes including medication administration processes including flushing, checking placement and medications administered to gravity never pushing. She said she would report any changes in the resident's condition including G-tube function and site to the medical doctor as well as the nurse practitioner. She stated that if a resident refused care, she would always document but leave and try again and if unsuccessful during follow up attempts and would notify the medical doctor and nurse practitioner. She stated that night shift changed g-tube site dressings daily and that she checked her sites underneath the dressings on day shift when she came on-shift. Interview on 03/29/24 at 10:19am RN K stated that she was retrained on G-tube med pass and had been trained upon hire. She stated that if a resident refused care to go away, let them calm down and come back and try again later, if still unsuccessful, or time sensitive, she would notify the medical doctor and nurse practitioner right away. She stated that a g-tube resident should never be left lying flat and that she did sometimes work 300 halls but was not aware Resident #1 had an abdominal binder ordered. She stated that if something was unavailable, she would let medical doctor know so order could be validated, changed, or held. Interview on 03/29/24 at 10:25am RN L stated she had recently been trained on G-tubes, abdominal binder. She said that G- tubes in-service was regarding medication administration and positioning of the resident head elevated at least 30 degrees. She stated that medications were to be administered to gravity and no medications should be push via the G- Tube, as well as, checking placement and site and notifying physician of all changes including if an ordered intervention or medication is not available. She stated that refusals of medications or ordered interventions, therapies were also to be reported to physician and practitioner. She stated she would document accordingly in the resident's clinical record. Interview on 03/29/24 at 10:34am MA M stated she had recently been trained to ensure any residents with G-tubes were not left flat after ADL care and that the head of the bed was elevated to at least 30 degrees. She stated that if anything was different, changed, or abnormal for the resident she would report to her charge nurse. Interview on 03/29/24 at 10:35am MA D stated he had worked at the facility since 2021. He stated he had been trained upon hire but then recently trained on g-tubes and making sure residents with g-tubes are not left flat and have their heads raised to at least 30 degrees to prevent the resident from aspirating. He said that if anything was beeping or leaking or looked abnormal for any resident, he would immediately report it to the charge nurse. MA D stated that it is not in in scope to administer any medications via g-tubes. He stated that if he was working as an aide and he took anything off the resident like a binder during a shower or bath and took it to laundry, he would ensure it was placed back with or on the resident once cleaned, and if not report it to charge nurse so they know it's off. Interview on 03/29/24 at 10:54am wound care LVN T stated she had recently been trained on G-tubes including medication administration, and only administering via gravity and not pushing medications via G- Tube. She stated that in-service included how to check placement, flushing G- Tube, resident positioning, and if there are any issues with G-Tube how to notify the medical doctor, she stated staff was trained to call medical doctor or nurse practitioner for any changes/refusals of treatment, and document action in the resident clinical record. Interview on 03/29/24 at 11:30am Central Supply Staff A stated that she started working at the facility in January of 2024. She stated she had a recent in-service on G-tube feedings. She stated that residents with g- tubes should be left at a 30-45-degree angle. The surveyor team was able verify that facility implemented the following to remove the immediacy: The facility provided an audit list of residents with G-Tube placement. The physician's order was verified for identified the residents. No additional change condition identified for residents listed. In-service/training records for licensed nurses by regarding the proper care and management of tube feeding residents, including proper procedure for checking g-tube placement, administration techniques, and required actions/documentation when interventions are refused was verified by the surveyor team. Education/training record for LVN V related to g-tube care, resident positioning, checking g-tube placement, and medication administration was verified by the surveyor team. In-service/training records for implementing measures of monitoring, documenting, and reporting G-tube complications, provided care and management to G-Tube was verified by the surveyor team. In-service/training records for importance of maintaining proper positioning with residents receiving feeding by tube feeding and proper placement of abdominal binders provided was verified by the surveyor team. Record of those in attendance for QAPI meeting on 3/28/24 at 10:00am was provided and verified by the surveyor teams. An Immediate Jeopardy (IJ) was identified on 03/27/2024. The Administrator and DON were informed on 03/27/2024 at 5:40pm. The IJ was lowered on 03/29/23 at 1:33pm, the facility remained out of compliance at a scope of pattern and a severity level of no harm, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of four residents (Resident #1) who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, in that: The facility failed to implement the physician's order for an abdominal binder indicated to prevent complications of gastrostomy tube. The facility failure resulted in Resident #1 requiring discharge to the hospital for G-Tube replacement. LVN V failed to use the facility's identified proper technique and safety precautions for Resident # 1 for administering medications via G- Tube. LVN V's failure resulted in LVN V administering medications by plunger pushing the medications into Resident #1 gastrostomy tube instead of administering to gravity, placing the resident at immediate risk for potential harms associated G-Tube blockage and Aspiration (occurs when liquid or food enters the lungs). The facility failed to implement physician's order to provide gastrostomy tube site care to Resident #1 G-Tube site. The facility failure placed Resident #1 at immediate risk the development of infection. An Immediate Jeopardy (IJ) was identified on 03/27/2024. The Administrator and DON were informed on 03/27/2024 at 5:40pm. The IJ was lowered on 03/29/23 at 1:33pm, the facility remained out of compliance at a scope of isolated and a severity level of no harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The identified failures have the potential to cause significant complications, including infections, aspiration, hospitalizations, or death, in residents with gastrostomy tubes. Findings included: Record review of Resident #1's face sheet dated 03/25/2024 revealed resident was admitted to the facility on [DATE], age [AGE] years old female. Resident #1 had a diagnosis of Gastrostomy Status (the creation of an artificial external opening into the stomach for nutritional support or gastric decompression via a G- Tube) and Gastro-Esophageal Reflux Disease (GERD - occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus) dated 08/26/2023. Record review of clinical record, Resident #1's Care Plan revealed that Resident #1 require to have an abdominal feeding tube. Care Plan Goal: Resident was to remain free of side effect of complication Resident insertion site will be free of sign and symptoms of infection. Interventions Task: Check tube placement and gastric contents/residual volume per facility protocol and record (policy). Monitor/document/ report tube dysfunction or malfunction, abdominal pain, and infection at the tube site provide local care to G-Tube site as ordered administer medication as ordered. Record review of clinical record, Resident #1's MDS revealed that Resident #1 required abdominal feeding tube. Record review of Resident #1's physician's order summary report revealed the following order: every shift for flush feeding tube with 30ml(cc) of water before and after administration of medication pass. clean and change dressing one time a day. Apply abdominal binder, order dated as of 12/07/2023. Record review of clinical record, Resident #1's MAR/TAR revealed no documentation that the physician order for abdominal binder had been followed and implemented from 12/07/2023 thru 03/25/2024. Record review of clinical record, Resident #1 progress notes revealed no documentation of G-tube complication such as dysfunction or malfunction and ongoing reported abdominal pain as of 03/25/2024. Observation made on 03/25/2024 at 10:30am revealed Resident #1 was not wearing abdominal binder. The surveyor was unsuccessful in attempt to interview Resident #1 due to symptoms related to Dementia (intermittent confusion). Observation and interview with CNA T, on 03/25/2024, at 3:45pm, revealed CNA T positioned Resident #1 to aid in the surveyor's observation of Resident #1's abdominal gastrostomy tube site. Observation revealed Resident #1 was lying flat on her designated bed and was not wearing abdominal binder. Resident #1's abdominal gastrostomy tube site was not clean. There was a visibly soiled dressing, with dark red hanging below the gastrostomy tube site. Abdominal gastrostomy tube site was cover with dark red substance. Resident #1's gastrostomy tube contained dark red substance. Resident #1 was tensed and expressed that there was pain at the gastrostomy tube site. CNA T stated that the Resident often complained that there was pain at the gastrostomy tube site; and Resident #1 was often seen pulling the gastrostomy tube. CNA T stated that he had no knowledge of abdominal binder that was ordered for Resident #1. During observation the surveyor observed that there was signage post on the wall and the head of the resident bed reading resident is to remain in a 45-degree position. CNA T stated that he was aware of the sign but was not sure why the sign was posted. CNA T stated that the resident head of bed was always flat when he worked. Interview on 03/25/2024, at 4:00pm with the DON and Administrator, the Administrator stated that they were aware of the physician's order to implement the abdominal binder. According to the Administrator, Resident #1 was not wearing the abdominal binder due to the facility not having the proper sized abdominal binder. The DON and Administrator did not disclose the date they were made aware of the improper fit; how they were able to determine the appropriate/best size for the resident; why the facility did not have the proper size; and why the proper sized abdominal binder had not been implemented. The Administrator stated that the physician should have been notified that the order was not implemented and did not disclose why the physician was not notified. Interview on 03/25/2024 at 4:45pm with LVN V, LVN V stated that she had worked at the facility for three months. LVN V stated that she provided care for Resident #1 often since employed with the facility. LVN V stated that she was not aware that Resident #1 had an order to wear an abdominal binder. The surveyor asked LVN V how she was made aware of all orders for any given resident she worked with. She stated that the information was usually communicated during shift ending handoff report. LVN V confirmed that she had access to the clinical record including all active order for resident she was assigned to provide care to. LVN V stated that she did not routinely check the resident order each shift. LVN V stated that Resident #1 often complained of pain at the gastrostomy tube site and the resident was often seen pull on the G-tube. LVN V stated that she had noticed complications with the G-Tube and G-tube site. LVN V that she had not notified the physician of complications related to the G-Tube and site. The surveyor asked LVN V if she had knowledge related to why a resident would be ordered an abdominal binder. LVN V stated that the abdominal binder would usually prevent possible complication with the G-tube. LVN V stated that she noticed that the dressing had not been changed. She stated that the dressing containing the dark red substance appeared to be the dressing from when she cleaned the gastrostomy tube site three days ago, on Friday, 03/22/2024 as the dressing was dated for Friday, 03/22/2024 and not new dress had been applied. LVN V stated that Resident #1's gastrostomy tube site was to be cleaned daily and a clean dressing should be applied. LVN V stated that when orders were missed it could place residents at risk for medical neglect. LVN V stated that by missing the order for the abdominal binder it placed Resident #1 at risk for complications with the G-tube. Interview on 03/26/2024 at 9:45am with RN J, who state that she had worked with Resident # 1 since January/2024. RN J stated that Resident #1 often complained of pain at the gastrostomy tube site and the resident was often redirected from pulling on the G-tube. RN J stated that she had often experienced complications with the G-Tube when administrating medication via the G-Tube. RN J stated that she had not notified the physician of the complications with the G-Tube. RN J stated that she was not aware that Resident #1 had an order to for an abdominal binder prior to the start of her shift on 03/26/2024. RN J was not able to explain how the order was missed. RN J stated that she usually reviewed and confirmed orders in the electronic clinical record for all resident she was assigned to work with each shift. RN J stated that she was made aware at the start of her shift during handoff report that the resident was sent out to the hospital related to complications of the G- tube and G-tube site. The surveyor asked RN J if she had knowledge related to why a resident would be ordered an abdominal binder. RN J stated that an abdominal binder is to protect the G-tube and G- Tube site. RN J stated that she was informed that the resident was provided an abdominal binder that was placed on the resident at the hospital during the hospital visit on 03/15/2024. RN J stated that she had not previously seen the resident wearing an abdominal binder. The surveyor asked what could happen to a resident by not implementing physician orders. RN J stated that Resident #1 could possibly have complications or dislodge her G- Tube. Record review on 03/26/2024 of Resident #1 clinical record, nurse progress note revealed that Resident #1 was sent out to the hospital for G-Tube replacement on 03/25/2024 at 6:20pm. Progress note 03/25/2024 at 11:19 revealed that Resident # 1 was discharged from the hospital with discharge instructions to follow up with gastroenterology specialty service for replacement of G tube. The surveyor was unable to interview the assigned nurse working the night shift (11pm - 6am) who received the Resident # 1 upon return from the hospital. Observation and interview of Resident #1's medication administration pass performed by LVN V on 3/26/2024 at 5:45pm revealed LVN V explained to Resident #1 that she was going to administer medication with the standby assistance of CNA T. LVN V prepared Resident #1's medications by crushing them and mixing them in water to dissolve them. LVN V went to the bedside without a stethoscope and there was no stethoscope at the resident's bedside. LVN V removed an enteral feeding and irrigation syringe from an opened package, not dated, at the bedside. LVN V removed the plunger from the syringe, preceded and did not aspirate gastric content from the g-tube. LVN V did not check Resident #1's g-tube for placement by auscultating (listening with a stethoscope) for bowel sounds, visualizing the site to ensure the tube had not become dislodged and or was not infected or compromised in any way. LVN V proceeded by plunger pushing a full 60 ml syringe of water into Resident #1's g-tube. Resident observed guarding her abdomen and yelled it hurt, stop. Resident #1's bed was flat, and the head of the bed was not elevated. The surveyor stopped LVN V and asked her if that was the technique, she normally used to check to assess a resident's g-tube placement. LVN V stated, Yes, if it flushes then it is good to use. When asked if that was the way she had been trained to check for g-tube placement, she said she had only worked at the facility for three months. LVN V stated that she had been trained. LVN V tried to resume the medication administration and was stopped again by the surveyor when LVN V aspirated the medication out of the cup she had used to crush and mix Resident #1's medication with water and began to plunger push the medication with force into Resident #1's g-tube as if giving an injection. When asked to stop and asked if that was how she was trained to administer g-tube medications, LVN V confirmed that was the way she was trained. LVN V stated that she always pushed Resident #1's medications when administering via g-tube. LVN V stated that she knew how to administer g-tube medications to gravity. She then stated that in the past when she attempted to administer Resident #1 medications to gravity, she often experienced complications. LVN V stated that she never reported complications related to the g-tube. LVN V did not disclosed why she did not notify the physician of complications. The surveyor stopped the medication administration observation and requested the DON. LVN V plunger push the medication with force instead of administering medications to gravity. LVN V did not follow physician orders to flush feeding tube with 30ml(cc) of water before and after administration of medication pass. Interview on 03/26/2024, at 6:00pm with DON, Administrator, and Corporate Regional Nurse, the DON confirmed that nursing staff had been trained on medication administration via g-tube and managing the care of Resident's with G-Tubes. Interview on 03/26/2024, at 8:00pm with the facility Physician, the Physician stated that the abdominal binder that was ordered and indicated because Resident #1 continued to attempt to pull out g-tube. The Physician stated that he was not notified that the facility had not implemented the abdominal binder prior to 03/26/2024. The Physician confirmed that the order was a current and active order to prevent complications of the g-tube and comprise to the g-tube site. The Physician confirmed that he should have been notified with related to failure to implement the abdominal binder and any complication related to the G-tube and G-Tube site. Interview on 03/27/2024, at 9:30am with the DON, the surveyor asked what the expectation for nursing staff was related to implementing physician orders. The DON stated that all nursing staff were expected to implement orders. The DON stated that when staff failed to implement orders the failure could have a negative impact and decline related to the resident's overall wellbeing. The facility policy related to implementing doctor's orders and management of G-Tubes was requested. The policy related to implementing doctor's orders, medication administration, and management of G-Tubes was requested at 9:30am on 03/37/2024. Proof of in-services and staff training for medication administration. The facility failed to provide requested information as of 03/27/2024 at 5:00pm. Interview on 03/29/24 at 11:30am Central Supply Staff A stated that she started working at the facility in January of 2024. Central Supply Staff A stated that she was made aware on 01/11/2024 that Resident #1 had an order for an abdominal binder. Central Supply Staff A stated that she did not have access to place a supply order for an abdominal binder. She stated that the previous DON was responsible for placing the supply order. She stated she was aware that the order had been placed and that the binder had arrived because there was a big deal about the wrong size being delivered so she re-ordered it at that time in the correct size. She provided invoices for original delivery date of 12/26/23 and reorder on 2/20/24. She said she did not know the resident had been without the abdominal binder. An Immediate Jeopardy (IJ) was identified on 03/27/2024. The Administrator and DON were notified on 03/27/2024 at 5:40pm. Plan of Removal - F693 Tube Feeding Management (submitted by facility/accepted at 03/28/2024 at 12:00pm) PLAN OF REMOVAL: F693 Tube Feeding Management The facility failed to implement the physician's order for abdominal binder, and medication administration through the gastrostomy was not performed in accordance with facility policy and procedure. Immediate Action Resident #1: An abdominal binder was placed on 3/25/2024 per physician's orders. LVN V immediately in serviced by DON and RNC related to g-tube care, checking placement, pushing and medication administration. The resident was immediately assessed by DON for adverse effects from gastrostomy feeding on 3/26/24. The resident was offered site care, and the refusal of care was documented. An incident report was completed related to the incorrect feeding procedure, missed dose of lactulose, and missed documentation of gastrostomy tube site care refusal. Resident #1's orders were reviewed on 3/28/2024 and updated as needed to facilitate proper documentation. A gastroenterology follow-up appointment was set up for June 6, 2024. However, in consultation with the family and hospice, the g-tube will be removed as the resident is taking adequate PO intake/nutrition and the presence of the g-tube causes her undue distress. The facility reviewed the system for tube feeding and a review of the tube feeding policy was conducted by RNC to address any ambiguities that may have contributed to the incident. The facility revised a system including administrative nurses are reviewing residents that receive nutrition and/or medications via g-tube to assure that proper procedures are followed during clinical meeting Monday - Friday. Ad HOC QAPI meeting will be completed with IDT consisting of Administrator, Regional Nurse Consultant, Administrative nurses and Medical Director 3/28/24 at 10 am. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: 1. An audit was completed by RNC on 3/27/2024 of all residents receiving tube feedings to validate that physician's orders were implemented and that the g-tube and g-tube site were clean and functioning. No further issues were identified. 2. On 3/26/2024, an in-service was initiated with all licensed nurses by DON regarding the proper care and management of tube feeding residents, including proper procedure for checking g-tube placement, administration techniques, and required actions/documentation when interventions are refused. 3. 3/28/2024, a review of the Point Click Care enteral feeding batch orders was conducted by RNC, and orders were reviewed to validate they prompt the nurse to document each shift that they were implemented or refused. 4. On 3/28/2024, an in-service with licensed nurses was initiated by RNC to reinforce the importance of maintaining proper positioning with residents receiving feeding by tube feeding and proper placement of abdominal binders. 5. On 3/28/2024, a review of the facility in-service schedule was conducted by RNC and updated to implement quarterly in-services regarding the care of residents receiving enteral feeding. 6. Facility will be in compliance by 3/28/2024 at 1pm. *Education to be completed with all nurses working 3/28/2024. Staff who did not receive this training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. State Surveyor Monitored the plan of removal as follows: Interview on 03/28/2024 at 12:13 with RN K (Day shift), RN K stated that General G-Tube Care training and in-service was provided by the facility on 03/27/2024. RN K was able to verbalize knowledge and understanding congruent with facility G- Tube policy. Interview on 03/28/2024 at 12:42 with RN J (Day shift), RN J stated that General G-Tube Care training and in-service was provided by the facility on 03/27/2024. RN J was able to verbalize knowledge related to G-Tube policy. Interview on 03/28/2024 at 6:00pm with, LVN V (2-10 shift), LVN V stated that General G-Tube Care training and in-service was provided by the facility on 03/27/2024. LVN V was able to verbalize knowledge of positioning and administering medications via G-Tube. LVN V was also able to verbalize knowledge related checking placement of a G-Tube, and medication administration, the importance to of an abdominal binder, and the process for notifying the physician and follow up related to change in resident status and inability to implement a physician's orders. Interview on 03/28/2024 at 6:15 with CNA T (2-10pm shift), CNA T stated that training was provided on 03/27/2024 and 03/28/2024 on how to position a resident with and G-Tube. Interview on 03/28/2024 at 6:35pm with MA M (2-10pm shift), MA M stated that training was provided on 03/27/2024 on how to position a resident with and G-Tube. MA was able to verbalize her knowledge related positioning Resident's with G-Tubes. Interview on 03/29/24 at10:00am CNA J stated she had been stated that she had been trained if they needed any supplies or supplies were missing, she would let her charge nurse and central supply know. She stated that the facility had been trained on how to make sure the residents with g-tubes were not left flat and that the head of the bed was up to at least 30-45 degrees. She said she had been trained to report any behaviors or changes in resident to charge nurse. She said they did not have access to supplies like abdominal binders so she would have to check with the charge nurse or central supply but if something got soiled or needed to be cleaned or replaced, she would report it to charge nurse. Interview on 03/29/24 at10:16 AM RN J , RN J stated she was recently in-serviced on G-tubes including medication administration processes including flushing, checking placement and medications administered to gravity never pushing. She said she would report any changes in the resident's condition including G-tube function and site to the medical doctor as well as the nurse practitioner. She stated that if a resident refused care, she would always document but leave and try again and if unsuccessful during follow up attempts and would notify the medical doctor and nurse practitioner. She stated that night shift changed g-tube site dressings daily and that she checked her sites underneath the dressings on day shift when she came on-shift. Interview on 03/29/24 at 10:19am RN K stated that she was retrained on G-tube med pass and had been trained upon hire. She stated that if a resident refused care to go away, let them calm down and come back and try again later, if still unsuccessful, or time sensitive, she would notify the medical doctor and nurse practitioner right away. She stated that a g-tube resident should never be left lying flat and that she did sometimes work 300 halls but was not aware Resident #1 had an abdominal binder ordered. She stated that if something was unavailable, she would let medical doctor know so order could be validated, changed, or held. Interview on 03/29/24 at 10:25am RN L stated she had recently been trained on G-tubes, abdominal binder. She said that G- tubes in-service was regarding medication administration and positioning of the resident head elevated at least 30 degrees. She stated that medications were to be administered to gravity and no medications should be push via the G- Tube, as well as, checking placement and site and notifying physician of all changes including if an ordered intervention or medication is not available. She stated that refusals of medications or ordered interventions, therapies were also to be reported to physician and practitioner. She stated she would document accordingly in the resident's clinical record. Interview on 03/29/24 at 10:34am MA M stated she had recently been trained to ensure any residents with G-tubes were not left flat after ADL care and that the head of the bed was elevated to at least 30 degrees. She stated that if anything was different, changed, or abnormal for the resident she would report to her charge nurse. Interview on 03/29/24 at 10:35am MA D stated he had worked at the facility since 2021. He stated he had been trained upon hire but then recently trained on g-tubes and making sure residents with g-tubes are not left flat and have their heads raised to at least 30 degrees to prevent the resident from aspirating. He said that if anything was beeping or leaking or looked abnormal for any resident, he would immediately report it to the charge nurse. MA D stated that it is not in in scope to administer any medications via g-tubes. He stated that if he was working as an aide and he took anything off the resident like a binder during a shower or bath and took it to laundry, he would ensure it was placed back with or on the resident once cleaned, and if not report it to charge nurse so they know it's off. Interview on 03/29/24 at 10:54am wound care LVN T stated she had recently been trained on G-tubes including medication administration, and only administering via gravity and not pushing medications via G- Tube. She stated that in-service included how to check placement, flushing G- Tube, resident positioning, and if there are any issues with G-Tube how to notify the medical doctor, she stated staff was trained to call medical doctor or nurse practitioner for any changes/refusals of treatment, and document action in the resident clinical record. Interview on 03/29/24 at 11:30am Central Supply Staff A stated that she started working at the facility in January of 2024. She stated she had a recent in-service on G-tube feedings. She stated that residents with g- tubes should be left at a 30-45-degree angle. The surveyor team was able verify that facility implemented the following to remove the immediacy: The facility provided an audit list of residents with G-Tube placement. The physician's order was verified for identified the residents. In-service/training records for licensed nurses by regarding the proper care and management of tube feeding residents, including proper procedure for checking g-tube placement, administration techniques, and required actions/documentation when interventions are refused was verified Record review of MAR/TAR and nursing progress note revealed that nursing staff have implemented measures of monitoring, documenting, and reporting G-tube complications, provided care and management to G-Tube. In-service/training records for importance of maintaining proper positioning with residents receiving feeding by tube feeding and proper placement of abdominal binders provided was verified by the surveyor team. Record of those in attendance for QAPI meeting on 3/28/24 at 10:00am was provided and verified by the surveyor teams. An Immediate Jeopardy (IJ) was identified on 03/27/2024. The Administrator and DON were informed on 03/27/2024 at 5:40pm. The IJ was lowered on 03/29/23 at 1:33pm, the facility remained out of compliance at a scope of isolated and a severity level of no harm, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 (Resident # 1) of 7 residents reviewed for respiratory care. The facility failed to ensure Resident #1 was provided oxygen during transport to doctors appointment in which Resident #1 arrived to appointment with O2 level at 73%, had difficulty breathing adn required O2. An IJ was identified on 3/7/2024. The IJ template was provided to the facility on 3/7/2024 at 4:20 pm. While the IJ was removed on 3/8/2024, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents who received oxygen therapy at risk of respiratory complications and/or death. The findings included: Record review of Resident # 1's admission Records, dated 2/12/2022, revealed a [AGE] year-old male who was admitted on [DATE]. Resident's diagnoses included Chronic Obstructive Pulmonary Disease (obstructed airflow from the lungs), Atrial Fibrillation (an irregular rapid heart rate that causes poor blood flow), Atherosclerotic Heart Disease of Native Coronary Artery without Angina(Coronary artery disease starts when fats, cholesterols and other substances collect on the inner walls of the heart arteries), Diabetes Mellitus (A group of diseases that result in too much sugar in the blood), and Hypertensive Heart Disease with Heart Failure (Hypertensive heart disease can lead to either diastolic heart failure, systolic failure, or a combination of the two). Record review of Resident #1's care plan, dated 2/119/2024, revealed Resident # 1 had COPD, Hypoxic (an absence of enough oxygen), Hypercapnic(high levels of carbon dioxide in the blood) , Respiratory Failure(blood does not have oxygen or has to much carbon dioxide), Pulmonary Hypertension(high blood pressure that affects arteries), and Pulmonary Edema ( excess fluid in the lungs). Goal: The resident would be free of s/sx of complications of cardiac problems through the review date. The resident will display optimal breathing patterns daily through the review date. Interventions: aerosol or bronchodilators as ordered, give cardiac medication as ordered by physician, monitoring for difficulty breathing (Dyspnea) on exertion, and monitoring for s/sx for acute respiratory insufficiency. Record review of Resident # 1's physician orders, dated 1/9/2024, reflected in part oxygen at 5L/min via nasal cannula continuous. Directions: every shift for Dyspnea, start date 1/9/2024 . Record review of Resident # 1's O2 sat summary, dated 2/21/2024- 2/23/2024, reflected in part: Date/Time Value Method 2/23/2024 at 8:19 am 97% Room Air 2/22/2024 at 10:58 pm 97% Oxygen via Nasal Canula 2/22/2024 at 8:29 pm 95% Oxygen via Nasal Canula 2/22/2024 at 9:50 am 93% Oxygen via Nasal Canula 2/21/2024 at 11:16 pm 94% Oxygen via Nasal Canula 2/21/2024 at 10:44 am 95% Oxygen via Nasal Canula 2/21/2024 at 6:30 am 94% Room Air 2/21/2024 at 00:15 am 95% Oxygen via Nasal Canula In a telephone interview with the Clinic Nurse on 2/23/2024 at 11:00 am she reported that Resident #1 had an office visit on 2/22/2024. She reported that Resident # 1 arrived without a portable oxygen tank. She reported that Resident #1 oxygen level was at 73% and Resident # 1 stated he had shortness of breath but was not under respiratory distress. She reported that Resident # 1 was administered 4L O2 supply and Resident # 1 breathing improved. She stated that Resident # 1's oxygen saturation increased to 91-93%. She stated that Resident # 1 should have a portable oxygen tank. She stated that she contacted the Nursing Facility and she spoke with the ADON who confirmed that Resident # 1 was oxygen dependent. In an interview with Resident # 1 on 2/23/2024 at 12:10 pm he stated he was administered oxygen throughout the day 3 times a day. He stated that he was transported to a Pulmonary visit a on 2/22/2024. He stated was given oxygen earlier that day and when he left the facility he felt fine. He stated he walked from the waiting area to the examining room and was short of breath. He stated that he always had shortness of breath due to his COPD. He stated that the clinic nurse checked his oxygen, and it was low. He stated that the nurse at the clinic administered oxygen and he felt better. He stated that in the past when he left the facility, he was transported with a portable oxygen tank. In an interview with the ADON on 2/23/2024 at 2:40 pm she stated that Resident # 1 was transported to the clinic without a portable oxygen tank. She stated that Resident # 1 is on continuous oxygen and the portable oxygen tank should have been transported with Resident # 1. She stated that she was informed by the clinic nurse that when Resident # 1 arrived at the clinic his oxygen level was at 75%. The ADON stated that was Resident # 1's attending nurse LVN A) responsibility to make certain that he was transported with a portable oxygen tank. She stated if a residents oxygen level was 74%, he could have gone into respiratory failure. She stated it could have been fatal. In an interview with LVN A on 2/23/2024 at 2:59 pm she stated she was Resident # 1's nurse and she was not aware that Resident # 1 had left the facility. She stated she was aware the Resident # 1 had an appointment. She stated that the transporter asked her to print out paperwork for Resident # 1. She stated that she informed the transporter that she would print the paperwork for Resident # 1 once she finished assisting another resident. She stated that when she returned to the desk to retrieve the paperwork Resident # 1 was gone. She stated that she did not assess Resident # 1 prior to him being transported to his appointment. She stated that Resident # 1 is oxygen dependent, and he should have been transported with a portable oxygen tank. She stated that Resident # 1 was on continuous oxygen. She stated that the nurse is responsible for making certain the resident is transported with a portable oxygen tank. She stated that if a resident's oxygen level is low the resident could have gone into respiratory distress. In an interview with the Transporter, on 2/23/2024 at 3:32 pm he stated that LVN A was aware that Resident # 1 was being transported to a clinic visit. The Transporter stated that LVN A printed the admission paperwork for Resident # 1 and gave it to him. He stated that he met Resident # 1 in the hallway, and he assumed Resident # 1 was ready for transport. He stated that Resident # 1 was transported to the clinic visit without the portable oxygen tank. The Transporter stated that the nurse is responsible for making certain that residents have all needed items prior to being transported. He stated that he does not review the Resident's paperwork. He stated that LVN A gave him Resident # 1 paperwork and he transported Resident # 1 to his appointment. He stated that he is aware that Resident # 1 is on oxygen, however, he normally saw Resident # 1 off oxygen as Resident # 1 is a smoker. He stated that Resident # 1 did not have portable oxygen tank during transport. In an interview with the Administrator, on 2/23/2024 at 4:00 pm he stated that he was aware that Resident # 1 was on oxygen, however, he did not know if the oxygen was prn or continuous. He stated he was not aware that Resident # 1 left the facility without the portable oxygen tank. The Administrator stated that when a resident is transported from the facility the transporter meets with the nurse regarding the resident needs. The Regional Nurse and Administrator were notified on 3/7/2024 at 4:20 pm that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was presented to the facility at this time and a plan of removal was requested The facility's Plan of Removal was accepted on 3/8/2024 at 1:41 pm and included: PLAN OF REMOVAL: F695 Name of facility: Cascades at Galveston Date: March 7, 2024 The facility failed to ensure Resident #1 was provided respiratory care consistent with professional standards of practice. Resident #1 was transported to an offsite physician's office and was not provided continuous oxygen as ordered by his physician. Immediate action: Resident #1 was immediately assessed ADON upon return to the facility from appointment on 2/22/24 and found to have an O2 sat of 97%. Since time of incident, resident's oxygen order was changed and only to be administered PRN based on his oxygen level. On 3/7/24 the facility IDT reviewed/revised the system for assuring that any resident that is to be on continuous oxygen has the oxygen in place prior to leaving the facility for any appointments where transportation is provided by the facility and created a plan of improvement to address changes including placing an additional transportation binder that identifies each resident that is on continuous oxygen. In addition, a blue alert sheet will be placed in front of the individual sign out sheet for resident that is on continuous oxygen that will alert anyone wishing to sign the resident out of the facility to Please see nurse prior to signing resident out on pass. Ad Hoc QAPI meeting completed with IDT, Regional Nurse Consultant, Administrator, Administrative Nurses, and Medical Director on 3/7/24 at 7 p.m. Policy for transportation reviewed and updated by IDT on 3/7/24 to address residents on continuous oxygen. Approved by medical director on 3/7/24. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: 1. A facility audit was conducted by Regional Nurse Consultant (RNC), on 3/7/24 to identify any resident currently ordered to be on continuous oxygen to determine if they had any appointments within the last 30 days that they went to without oxygen in place. None were identified. 2. RNC completed education to transportation tech on 3/7/24 related to determining if a resident requires continuous oxygen by utilizing the transportation binder at the nurse's station that lists all residents with orders for continuous oxygen, assuring that the resident has the oxygen in place prior to leaving facility and steps to take if issues arise. In addition, a blue alert sheet will be placed in front of the individual sign out sheet for resident that is on continuous oxygen that will alert anyone wishing to sign the resident out of the facility to Please see nurse prior to signing resident out on pass. 3. Education initiated by RNC/ADON to nursing staff related to determining if a resident requires continuous oxygen, assuring that the resident has the oxygen in place prior to leaving for any facility transported appointment. If a resident is being transferred by an outside transportation company or family member, a copy of the blue alert sheet will be attached to the resident face sheet indicating that they require continuous oxygen. *Education to be completed with all nursing staff working 3/8/2024. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. 4. Administrative nurse in-serviced 3/7/24 by RNC regarding assuring that any resident that is placed on continuous oxygen is placed in the binder and to check appointments daily in clinical meeting, updating the transport binder at the nurses station if needed, assuring that any resident that receives a new order for continuous oxygen is placed in the binder and an alert sheet is placed in the sign out book. Nursing staff and the transportation tech will have access to the transportation binder at the nurse's station. 5. Facility will be in compliance 3/8/24 by 1 PM Following the acceptance of the facility's Plan of Removal ( POR), the facility was monitored on 3/8/2024. Monitoring of the POR included: Record review of in-service that discussed all residents that are to be on continuous oxygen must have a portable tank sent with them any time they leave the facility for an appointment. If a resident refuses to wear oxygen that is ordered to be continuous, the MD and RP must be notified. Any resident that is to be on continuous oxygen will be additionally identified by the presence of a blue alert sheet in the transportation binder at the nurse's station, dated 3/7/2024, revealed 29 signatures and 4 phone in-services. The targeted audience: Nurses. Record review of in-service that discussed all residents that are to be on continuous oxygen must have a portable tank sent with them any time they leave the facility for an appointment. If a resident refuses to wear oxygen that is ordered to be continuous, the MD and RP must be notified. Any resident that is to be on continuous oxygen will be additionally identified by the presence of a blue alert sheet in the transportation binder at the nurse's station. Van driver is to verify if the resident being transported has a blue sheet indicating that they are to be on continuous oxygen. If a blue sheet is present the van driver should not leave the facility without the resident having a portable oxygen bottle. Any issues are to be reported to the DON/ADON prior to leaving the facility with the resident, dated 3/7/2024, revealed 1 signature. The targeted audience: Van Driver. Record review of in-service that discussed it is the responsibility of the nurse management team to review any appointment scheduled for the day to determine if any resident that currently has an order for continuous oxygen has a scheduled appointment for that day. If an appointment is scheduled, you must assure that the staff responsible for the resident's care and transportation are aware that the resident must have oxygen in place via portable O2 tank for the appointment, dated 3/2024, revealed 1 signature. The targeted audience: ADON. Record review of in-service that discussed if a resident is being transferred by an outside transportation company or family member, a copy of the blue alert sheet will be attached to the resident face sheet indicating that they require oxygen. In order to ensure that family members or other parties that are taking residents out on a pass are aware that they need to have oxygen, a blue sheet will be placed in front of the resident's individual sign out sheet indicating to Please see nurse prior to signing resident out on pass, dated 3/8/2024, revealed 17 signatures. Record review of Resident # 1's orders revealed 02 per nc@2-4 L/min PRN. Goal to maintain Sats at or above 90%. Check O2sat qshift. Use lowest level of oxygen required to achieve desired O2 saturation, start date 3/7/2024. During interviews on 3/8/2024, the following nurses were able to verbalize an understanding that all residents that are to be on continuous oxygen must have a portable oxygen tank sent with them any time they leave the facility: Nurse A, B, C, AND D; LVN B, C, D, AND E; and the Transporter. An Immediate Jeopardy (IJ) was identified on 3/7/2024 at 4:20 pm. While the IJ was removed on 3/8/2024 at 4:41 pm the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (CR #1) of 5 residents reviewed for resident rights. -The facility failed to notify CR #1's physician when CR #1 became weak, confused, and short of breath which resulted in CR #1 falling and passing away at the facility on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:35 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of not receiving appropriate care, interventions, and/or death. The findings included: Record review of CR #1's admission Record, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnoses included chronic obstructive pulmonary disease (obstructive airflow from the lungs) with acute exacerbation (sudden worsening of COPD symptoms), anxiety disorder, acute and chronic respiratory failure with hypoxia (condition where the lungs and the blood cannot exchange enough oxygen, causing low oxygen levels in the blood and tissues), and malignant neoplasm of unspecified kidney, except renal pelvis (cancer that affects the kidney, excluding the part that connects to the ureter). Record review of CR #1's MDS assessment, dated [DATE], revealed Section C, C0100, BIMS was not completed. Further review revealed resident required one-person assist with mobility, transferring, and setup help with toileting. Record review of CR #1's physician orders, undated, reflected in part .haloperidol tablet 5 mg, give 1 tablet by mouth every 4 hours as needed for mental disorder related to anxiety disorder, start date [DATE] .morphine sulfate (concentrate) oral solution 20 mg/ml, give 1 ml by mouth every 1 hours as needed for pain, start date [DATE] ., albuterol sulfate HFA inhalation aerosol solution 108, 2 puff inhale orally one time a day for COPD, start date [DATE] .methadone HCL tablet 10 mg, give 1 tablet by mouth three times a day for pain, start date [DATE] .ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/ml, 1 application inhale orally every 6 hours as needed for SOB/wheezing .O2 per nc at 4-5L/min continuous. Check O2 sat qshift. Goal to maintain O2 sats >90%, start date [DATE] .house MD to assume care, start date [DATE] . Record review of CR #1's Care Plan, undated, included the following: -CR #1 had COPD r/t smoking. Interventions included: aerosol or bronchodilators as ordered, monitoring for s/sx for acute respiratory insufficiency and infection and oxygen as ordered. -CR #1 had a terminal prognosis r/t liver and kidney cancer and was under hospice services. Interventions included: working cooperatively with hospice team to ensure the resident's emotional, intellectual, and physical needs were met. -CR #1 had an ADL self-care deficit r/t progression of cancer. Interventions included: resident required 1 staff assist with bed mobility, transferring, and toileting and monitoring/documenting/reporting PRN declines in function. -CR #1 had limited physical mobility r/t disease progression. Intervention noted resident was weight bearing. -CR #1 had fluid overload or potential fluid overload r/t kidney failure and liver cancer. Interventions included: monitoring and recording vital signs, notifying MD of significant abnormalities, monitoring/documenting/reporting PRN and s/sx mood/behavior changes, confusion, shortness of breath, difficulty breathing, increased respirations, and difficulty breathing when lying flat. -CR #1 was a high risk for falls related to liking to keep bed in high position, weakness with expected continue to decline. Interventions included: continually educate the resident regarding safety issues and monitoring for any changes in mental, emotional, or physical condition, and monitoring medications for side effects that could contribute to a fall. -CR #1 had an actual fall on [DATE] due to terminal restlessness at 0400 a.m. and another one on [DATE] (time not specified). Interventions included: encouraging resident to not sit on side of the bed or getting up without assistance and monitoring/documenting/reporting PRN x 72h to MD for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, all with a date initiated of [DATE]. -CR #1 used an anti-anxiety medication r/t anxiety disorder. Interventions included: administer medications as ordered, monitor for side effects and effectiveness Q-Shift. Monitor the resident safety. The resident is taking anti-anxiety medications associated with an increased risk of confusion, loss of balance, increased risk of falls, and monitor/document/report PRN any adverse actions to anti-anxiety therapy: drowsiness, lack of energy, slurred speech, and confusion. Record review of CR #1's incident assessment, completed by Nurse C, dated [DATE] 12:20, read in part .found on floor in prone position at the foot of her bed .unable to give description .assisted to bed x2 personnel and cleaned .continuous O2 placed via nasal canula at 3L/min .unresponsive at the time however breathing is at 6 to 8 bpm. Notified hospice of fall and current status. Laceration face . Administrator notified at 12:40 p.m. and Hospice Care notified at 12:30 p.m. on [DATE]. Record review of CR #1's progress note, dated [DATE] 10:51, read in part .Resident very weak, confused and SOB. Resident O2 @90% on 3L/min .Resident given prn dose morphine and Haldol. Resident visibly anxious. Resident continues to sit at the edge of her bed and then laying backwards, causing resident to lay in a perpendicular manner while at the same time being flat on her back. Throughout shift nursing staff and NOD continue to make sure residents head is raised and is not laying perpendicular in bed. Vitals O2 @90% on 3L/MIN, BP-155/97, Pulse-96, resp labored at 22. Resident continuously reminded to not sit on side of bed and to keep head elevated. Will continue to monitor . Record review of CR #1's progress note, dated [DATE] 2:20 p.m., read in part .NOD was in hall .heard a faint male voice yelling coming from resident's room .nurse immediately walked into resident's room .and immediately saw [CR #1] laying prone at the foot of her bed with a small pool of blood collecting on the floor surrounding resident's facial area. Nurse then immediately notified NOD via cellphone to call NOD .NOD noted resident prone on floor with bleeding coming from resident's facial area. Resident was breathing with a pace of 6 to 8 breaths per minute. Resident noted to have a laceration on the bridge of her nose. Resident slowly helped back to her bed where she was immediately cleaned up and oxygen placed to aide in oxygen saturation. NOD asked Resident's roommate on how resident ended up on the floor in the prone position. Resident's roommate stated, she got up onto her wheelchair and then faceplanted right away after getting onto her wheelchair. Resident breath rate low at 6 bpm. Resident would then slowly stop breathing 20 minutes later, resident's pulse not able to be palpated 20 minutes after fall. Time of death 1240. Notified hospice, family, and admin . In a telephone interview on [DATE] at 1:17 p.m., Nurse C said CR #1 was found lying face down on the floor of her room on [DATE] by Nurse A. He said he was on a different hall performing blood sugar checks at the time of the incident. He said Nurse B called him and told him CR #1 was found on the floor. He said when he entered CR #1's room, he saw her lying face down near the foot of her bed. He said she was unconscious, breathing, and there was a small pool of blood near her head. He said it appeared CR #1 had fallen onto the floor. He said Nurse A and him placed CR #1 in the recovery position [on her side]. He said he called CNA A and told her they needed her help. He said CNA A, Nurse A, and himself transferred CR #1 to her bed. He said once the resident was transferred back onto her bed, her O2 was placed back on her with continuous oxygen at 3L/min and the HOB was elevated. He said the resident was cleaned up and noted to have a laceration on the bridge of her nose. He said when the O2 was placed back on CR #1, she was breathing at a low pace of 6 to 8 breaths per minute. He said he asked CR #1's roommate what happened, and he told him she got up onto her wheelchair and then faceplanted right away after getting onto her wheelchair. He said he called and notified the hospice nurse and Administrator of the incident. He said the day before, Saturday, [DATE], the resident was lethargic, not able to open her eyes very much the entire day and would continuously sit on the side of her bed with her feet hanging over the side. He said CR #1 was educated on the importance of not sitting on the side of her bed, but CR #1 was unable to retain the information. He said nursing staff made 5-minute rounds around the clock to ensure the resident was not lying flat on her back, or sideways in her bed, and/or her room floor. He said the resident showed signs of anxiousness, restlessness, was fidgety, and could not get comfortable for long periods of times. He said CR #1 kept taking off her O2 and he thought that was what was causing her behavior. He said before the incident, he contacted the hospice company and notified them of the resident's condition. He said he asked hospice if they had critical care nurses that could sit with the resident, and he said he was told they did not provide those type of services. He said he was just going to monitor the resident and did not contact the physician. In a telephone interview on [DATE] at 1:59 p.m., Nurse A said she was performing blood sugar checks at approximately 12:05 p.m. on [DATE] when she heard a crash like noise. She said she heard a man yelling and went down the hallway. She said the calls for help were coming from CR #1's roommate. She said when she entered the room, CR #1 was lying face down with her head in a pool of blood. She said CR #1's head was pointed towards the door and her feet were near the foot of her bed. She said she checked for respirations and a pulse and then called for Nurse C. She said Nurse C and she placed the resident in the recovery position, and she started cleaning the blood off her face. She said Nurse C called CNA A to help them transfer the resident back to her bed. She said all three of them, placed the resident back onto her bed, elevated the head of her bed to 45 degrees, and placed her O2 nasal cannula back on at 3L. She said CR #1 had deep, gasping respirations of 6 to 8 breaths per minute and a laceration to the bridge of her nose. She said CR 1's roommate told Nurse C that she attempted to get into her wheelchair and faceplanted on the ground. She said shortly after CR #1 was transferred back to her bed, she took approximately two more breaths and then slowly stopped breathing. She said the time of death was 12:40 p.m. In a telephone interview on [DATE] at 2:24 p.m., Hospice Nurse said she saw CR #1 the day before she passed away on Saturday, [DATE], sometime between 12p.m. and 4 p.m. She said the resident was doing okay. She said the resident was not displaying any signs of agitation, was not lethargic, was able to open her eyes, and answered questions appropriately. She said she was the on-call nurse that weekend and the day, [DATE], CR #1 fell. She said the facility basically called her to inform her that the resident passed away after she fell and not to report that she had fallen. She said when the nurse (could not recall his name) called her, he told her the resident passed away 20 minutes ago. She said the resident should have been sent to the hospital. She said she felt 911 should have been called and then hospice when the resident fell because she could have sustained a head injury. She said she was not asked about critical care services. She said she went to the facility the day CR #1 passed away. She said the police were in CR #1's room with her family member who was her roommate. She said he was inconsolable and expressed to police that she blead profusely. She said she saw the resident after she passed away and her nose was fractured. She said she believed the resident's death was a result from the fall. In an interview on [DATE] at 3:07 p.m., the ADON, said she had been working at the facility for approximately 3 weeks. She said she was not notified of CR #1's fall. She said the Regional Nurse Consultant was filling in for the DON. She said the DON and/or ADON, the Administrator, Hospice company if the resident was on Hospice, the family/responsible party, and physician should be notified. She said the Regional Nurse Consultant could also be notified. She said the nurse on duty that was assigned to the resident should complete the head-to-toe assessment (check vitals and check for injuries). She said she became aware of the fall on Monday morning, [DATE], when she read the progress notes and risk management report. In an interview on [DATE] at 3:37 p.m., the Regional Nurse Consultant said she was providing oversite for the building until they got an interim DON. She said she was notified about the fall by the Administrator after the resident expired at approximately 1:00 p.m. on Sunday, [DATE]. She said staff did not usually call her about a fall unless they had questions. She said they would typically notify the Administrator, ADON and/or DON. She said the nurse on duty should notify the DON and/or ADON, hospice if receiving services, physician, and family. She also said it varied case by case. She said there could be other notifications that needed to be made, but those were the standard notifications for a routine fall. In an interview on [DATE] at 3:54 p.m., the Administrator said she had been working at the facility since February 27, 2023. She said Nurse C notified her at 1:07 p.m. on Sunday, [DATE], via text message that CR #1 passed away. She said the text message mentioned CR #1 had fallen out of her wheelchair. She said she asked Nurse C to call her. She said she did not recall if the physician and/or hospice was notified. She said Nurse C told her hospice was notified but did not say when they were notified. She said Nurse C did not say whether or not he notified the physician. She said she did not notify the facility's physician because that was what the nurses typically did. She said the facility's accident/incident policy said the physician, family, Administrator, ADON, and Hospice, if they were on services, should be notified. In a telephone interview on [DATE] at 4:52 p.m., the Medical Director/Attending Physician said he did not personally receive a telephone call about CR #1's fall on Sunday, [DATE] or about her passing away. In a follow-up telephone interview, on [DATE] at 5:16 p.m., the Medical Director/Attending Physician said the Nurse Practitioner on call, did not receive a text message or phone call regarding CR #1's fall on Sunday, [DATE]. He said he was notified today, [DATE], that CR #1 passed away. In an interview on [DATE] at 7:37 a.m., CR #1's roommate said on the day of the incident, [DATE], she was getting out of bed, fell, and that was all. He said he guessed she was trying to get up and go to the bathroom. He said she was trying to get in her wheelchair and fell on her face. He said that she was always on oxygen. He said the nurse heard her. He said the nurses tried to revive her but could not and gave her oxygen. He said he did not think CR #1 hurt herself. He said there was a man nurse that was taking care of her. In a telephone interview on [DATE] at 7:51 a.m., the Nurse Practitioner said he was on-call, on [DATE], but was not notified that CR #1's fell or that she passed away on [DATE]. He said he found out CR #1 passed away yesterday, [DATE]. He said he was at the facility on Monday, [DATE], and no one said anything. In a follow-up telephone interview on [DATE] at 9:23 a.m., Nurse C said he contacted hospice after making sure CR #1 was stable which was at approximately 12:25 p.m. on [DATE]. He said 911 was not called because by the time he finished talking to the hospice nurse, about 2 minutes later, the resident had passed away. He said it was a little too late to call 911. In a follow-up interview on [DATE] at 10:38 a.m., the Nurse Practitioner said based on CR #1's progress note, dated [DATE] at 10:51 a.m., he would have asked staff if they were giving CR #1 breathing treatments, what her lungs sounded like, recommended a chest x-ray, and probably ordered stat labs. He said from what the progress note described, it sounded like she was in mild distress with respiratory and anxiety affecting each other. He said considering her known comorbidities of lung cancer and COPD, a saturation rate of 90% was not unexpected. He said once again, he was not contacted. He said writing in a book on Sunday was not contacting the physician knowing they did not go to the facility on Sundays. He said someone was always on call 24 hrs. a day, 7 days a week, 365 days. He said staff knew that a resident with a change in condition, with an emergent concern, must make personal contact with the provider at that time. He said if they were to have mentioned that they were thinking of administering Haldol, he would have recommended that they held off on administration. He said this was all hypothetical as he was not notified. In a follow-up telephone interview on [DATE] at 10:57 a.m., Nurse C said he worked the 6:00 a.m. to 10:00 p.m. shift on Saturday, [DATE]. He said initially there was a small puddle of blood, but the bleeding would not stop. He said they cleaned the resident up after they transferred her to her bed which took a while. He said she was still breathing. He said on Saturday, [DATE], she slowly started to decline but could help a little bit to get back into bed and said her mental state was confused. He said her normal baseline was she would go to the store, gas station, and could make her needs known. He said resident's physician and hospice was not notified on [DATE] at 10:51 a.m. because I'm not sure why. He said he notified hospice after CR #1 passed away. In a follow-up interview on [DATE] at 11:28 a.m., the Administrator said she did not follow-up with the NP or physician to see if they were notified about CR #1 falling or passing away. She said the nurses had first-hand knowledge of the information and the protocol was for them to notify the physician, on-call, and/or NP. She said during the weekend they called the on-call and during the week they called the MD or NP. She said if the MD or NP were out-of-town, they set someone else up for staff to contact. She said there was also a posted list of what the Administrator should be notified of at the nurse's station. In a follow-up interview on [DATE] at 12:01 p.m., the Hospice Nurse said based on the nursing progress note dated [DATE] at 10:51 a.m., the facility should have notified her about the resident's change in condition but did not. She said they should have notified her because it sounded like CR #1 was restless and needed hospice to lay eyes on her. She said if the interventions in place were effective, then they would not have had to call but if it was a continuous problem, they should have called to say crisis was needed. In an interview on [DATE] at 3:21 p.m., CNA B said she had been working at the facility for approximately 1 year. She said she worked on [DATE] from 6:00 a.m. to 10:00 p.m. and worked hall 200. She said she saw CR #1 at approximately 6:00 a.m. and she was sleeping. She said she then saw her between 7:00 a.m. and 7:15 am. and she was still sleeping and did not wake up to eat her breakfast. She said she next saw her around 9:30 a.m. and she was still asleep. She said at approximately 10:30 a.m., her roommate started yelling and said the resident needed help. She said CR #1 was sitting up on the side of her bed and asked her for some water. She said after she gave her some water, she laid back down and covered her up. She said she did not say anything else and went back to sleep. She said the resident showed no signs of distress, restlessness, or anxiousness. She said to her, the resident always seemed short of breath, but she did have her O2 on. She said there were no changes with her breathing that she could tell. She said when she passed out lunch trays between 12:00 p.m. and 12:15 p.m., the resident was still asleep and that was the last time she saw CR #1. She said at approximately 12:30 p.m., she found out the resident fell. She said she worked hall 200 by herself. She said Nurse C and Nurse A worked hall 200 as well. She said CR #1 was not herself that day because she slept a lot. She said she worked on Saturday, [DATE], from 6:00 a.m. to 6:00 p.m. and worked hall 200. She said CR #1 was a little more active this day. She said she was going to the bathroom on her own and ate 1 meal. She said she slept a lot but would not be still in her bed. She said she was not sure if it was because she was hot or cold. She said the resident was only SOB when she tried to go to the bathroom. She said CR #1 was not confused and answered her with a yes and/or no. In a follow-up telephone interview on [DATE] at 12:18 p.m., Nurse A said CR #1 was unconscious when she found her. She said she checked her pulses, and the resident was still breathing and was gasping for air. She said she did not remember what she grabbed, but it was either a blanket, sheet, or towel and she started wiping the blood off from her face so she could breathe better. She said CR #1's face was covered in what she thought was a lot of blood. She said she called Nurse B who called Nurse C. She said Nurse C came within seconds. She said the resident was still unconscious, not able to answer them, but was breathing. She said she noticed the resident had a laceration to her nose after they wiped the rest of the blood from her face. She said CR #1's respirations were approximately 6 to 8 breaths per minute, she was gasping, and working hard to take breaths. She said CR #1 took a couple more breaths and then slowly passed away. She said she did not call 911 because by the time they put CR #1 in bed, she passed away shortly after. She said from the time the resident was transferred back to her bed and to the time she passed away, it was approximately 10 to 15 minutes. She said Nurse C, CNA A, and she were at the CR #1's bedside when she passed away. She said she checked the resident's pulse and respirations, which were impalpable. She said she called it, checked her phone and it was 12:40 p.m., so she called the time of death at 12:40 p.m. She said after she called the time of death, Nurse C stepped out and she assumed it was to make the proper calls. She said she felt there was nothing they could have done to prevent it from happening. She said the same steps would have been taken for a resident that was not on hospice. She said she did not see the resident that day aside from the incident. She said the resident was assigned to Nurse C. She said the night before, [DATE], she heard Nurse C talking about CR #1 and how much she was declining and how he would be surprised if she made it through the night. She said before she left her shift that night, she went in the resident's room at approximately 10:00 p.m. to look at her and she said what he said was true and she was surprised CR #1 made it through the night. On [DATE] at 12:35 p.m., Nurse A called and said if a resident was a full code, once they would have put them back in bed, put the O2 back on them and opened their airway, she would have called 911. She said one of them would have gotten the crash cart. She said if a resident was full code and they stopped breathing, they would have resuscitated or did their best to resuscitate. She said they may have even gotten the electrical device with the pads to put on the resident. She said if the resident was a DNR and did not pass away quickly, they would have called 911, but CR #1 passed away very quickly and very shortly after putting her on her bed. She said they did not have time to call 911. She said by the time 911 would have gotten there, she would have been gone. Record review of the facility's policy titled Accidents and Incidents - Investigating and Reporting, revised [DATE], read in part .Policy Interpretation and Implementation .2 .g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions . Record review of the facility's policy titled Hospice Program, revised [DATE], read in part .10.it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: .c. Notifying the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status .d. Communicating with the hospice provider (and documenting such communications) to ensure that the needs of the resident are addressed and met 24 hours per day. The Administrator was notified on [DATE] at 3:35 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was presented to the facility at this time. The facility's Plan of Removal was accepted on [DATE] at 4:13 p.m. and included: PLAN OF REMOVAL: F580 Name of facility: [] Date: [DATE] Immediate action: F 580 Resident CR#1 was deceased at the time the IJ was issued. A facility audit to be completed by the Director of Nursing/Designee by [DATE] of all residents having a change in condition within the last 7 days to check for proper physician notification. Physician orders will be reviewed, and care plans will be updated if any issues are identified. Any identified issues related to discrepancies in orders or care plans will be addressed as identified with primary care provider notification by DON/Designee if indicated. In-services initiated by DON/Designee on [DATE] with licensed nursing staff present in facility related to Changes in Resident Conditions including identification of respiratory distress, steps to take if current orders do not alleviate symptoms and consulting with the MD for further instruction. Ad Hoc QAPI meeting completed with IDT and Medical Director on [DATE]. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: -Audit to be completed [DATE] by DON/Designee to identify any residents receiving Oxygen Therapy to assure that the order entered matches the amount of oxygen being received. Any areas of concern will be addressed as identified with primary care provider notification by DON/Designee if indicated. -Education was completed on [DATE] with the administrative nursing team by the Regional Nurse Consultant related to supervision to prevent missed resident changes in condition and physician notification. Education included assuring that resident changes in condition are addressed promptly and appropriately, and monitoring new oxygen orders and changes to existing oxygen orders to assure that resident is receiving correct dose. -In-services initiated by DON/Designee on [DATE] with licensed nursing staff present in facility related Changes in Resident Conditions, steps to take if current orders do not alleviate symptoms and consulting with the MD for further instruction. -The DON and/or designee will follow up in the morning clinical meeting to ensure resident changes in condition are addressed promptly and appropriately and that MD notifications were made if warranted. LVN A and RN A have been given disciplinary action and trained one on one by administrative nursing team. -This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. *Education to be completed with all nursing staff working on [DATE]. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from [DATE] through [DATE]. Monitoring of the POR included: Record review of in-service discussing falls, completion of assessments prior to moving unless in respiratory distress, required notifications, and other required documentation, dated [DATE] and [DATE], revealed 10 signatures. Record review of in-service, dated [DATE], titled Interact: Change in Condition, When to Report to The MD/NP/PA revealed 30 signatures. During interviews on [DATE], the following nurses were able to verbalize an understanding of change in condition and physician notification: Nurse A, B, C, D, E, F, G, H, and I. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:35 p.m. While the IJ was removed on [DATE] at 2:31 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 (CR #1) of 5 residents reviewed for quality of care. -The facility failed to follow physician orders for CR #1 who was weak, confused, and short of breath resulting in a O2 saturation at 90% and who passed away a little under 2 hours later. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:35 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents who received oxygen therapy at risk of respiratory complications and/or death. The findings included: Record review of CR #1's admission Record, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE] and a discharge date of [DATE]. Resident's diagnoses included chronic obstructive pulmonary disease (obstructive airflow from the lungs) with acute exacerbation (sudden worsening of COPD symptoms), anxiety disorder, acute and chronic respiratory failure with hypoxia (condition where the lungs and the blood cannot exchange enough oxygen, causing low oxygen levels in the blood and tissues), and malignant neoplasm of unspecified kidney, except renal pelvis (cancer that affects the kidney, excluding the part that connects to the ureter). Record review of CR #1's care plan, undated, revealed CR #1 had COPD related to smoking. Goal: The resident would be free of s/sx of respiratory infections through the reviewed date. Interventions: aerosol or bronchodilators as ordered, monitoring for s/sx for acute respiratory insufficiency and infection, and oxygen as ordered, wean as able, check RA sats as ordered. Record review of CR #1's MDS assessment, dated [DATE], revealed Section C, C0100, BIMS was not completed. Further review revealed resident required one-person assist with mobility, transferring, and setup help with toileting. It also indicated that the resident was not on oxygen therapy. Record review of CR #1's physician orders, undated, reflected in part .O2 per nc at 4-5L/min continuous. Check O2 sat qshift. Goal to maintain O2 sats >90%, start date [DATE] . Record review of CR #1's progress note, dated [DATE] at 10:51, read in part .Resident very weak, confused and SOB. Resident O2 @90% on 3L/min .Resident given prn dose morphine and Haldol. Resident visibly anxious. Resident continues to sit at the edge of her bed and then laying backwards, causing resident to lay in a perpendicular manner while at the same time being flat on her back. Throughout shift nursing staff and NOD continue to make sure residents head is raised and is not laying perpendicular in bed. Vitals O2 @90% on 3L/MIN, BP-155/97, Pulse-96, resp labored at 22. Resident continuously reminded to not sit on side of bed and to keep head elevated. Will continue to monitor. In a telephone interview on [DATE] at 1:17 p.m., Nurse C said CR #1 was found lying face down on the floor of her room on [DATE] by Nurse A. He said he was on a different hall performing blood sugar checks at the time of the incident. He said Nurse B called him and told him that CR #1 was found on the floor. He said when he entered CR #1's room, he saw her lying face down near the foot of her bed. He said she was unconscious, breathing, and there was a small pool of blood near her head. He said it appeared CR #1 had fallen onto the floor. He said Nurse A and him placed CR #1 in the recovery position [on her side]. He said he called CNA A and told her they needed her help. He said CNA A, Nurse A, and himself transferred CR #1 to her bed. He said once the resident was transferred back onto her bed, her O2 was placed back on her with continuous oxygen at 3L/min and the HOB was elevated. He said the resident was cleaned up and noted to have a laceration on the bridge of her nose. He said when the O2 was placed back on CR #1, she was still breathing at a low pace of 6 to 8 breaths per minute. He said he asked CR #1's roommate what happened, and he told him she got up onto her wheelchair and then faceplanted right away after getting onto her wheelchair. He said he called and notified the hospice nurse and the Administrator. He said the day before, Saturday, [DATE], CR #1 was lethargic, unable to open her eyes very much the entire day and would continuously sit on the side of her bed with her feet hanging over the side. He said CR #1 was educated on the importance of not sitting on the side of her bed, but resident was unable to retain the information. He said nursing staff made 5-minute rounds around the clock to ensure the resident was not lying flat on her back, or sideways in her bed, and/or her room floor. He said the resident showed signs of anxiousness, restlessness, was fidgety, and could not get comfortable for long periods of times. He said she kept taking off her O2 and thought that was what was causing her behavior. He said he was just going to monitor the resident and did not contact the physician. In a telephone interview on [DATE] at 4:52 p.m., the Medical Director/Attending Physician said he did not personally receive a telephone call about the resident on Sunday, [DATE]. In a follow-up telephone interview, on [DATE] at 5:16 p.m., the Medical Director/Attending Physician said the Nurse Practitioner on call, did not receive a text message or phone call regarding CR #1 on Sunday, [DATE]. He said he was notified today, [DATE], that CR #1 passed away. In a telephone interview on [DATE] at 7:51 a.m., the Nurse Practitioner said on [DATE] he was on-call but was not notified about CR #1's passing on [DATE]. He said he found out the resident passed away yesterday, [DATE]. He said he was at the facility on Monday, [DATE], and no one said anything. In a follow-up interview on [DATE] at 12:01 p.m., the Hospice Nurse said based on the nursing progress note dated [DATE] at 10:51 a.m., the facility should have notified her about the resident's change in condition but did not. She said they should have notified her because it sounded like CR #1 was restless and needed hospice to lay eyes on her. She said if the interventions in place were effective, then they would not have had to call but if it was a continuous problem, they should have called to say crisis was needed. In an interview on [DATE] at 2:45 p.m., the ADON said O2 at 4-5L/min continuous was an intervention put into place to help CR#1 breathe. In a follow-up interview on [DATE] at 10:38 a.m., the Nurse Practitioner said based on CR #1's progress note, dated [DATE] at 10:51 a.m., he would have asked staff if they were giving CR #1 breathing treatments, what her lungs sounded like, recommended a chest x-ray, and probably ordered stat labs. He said from what the progress note described, it sounded like she was in mild distress with respiratory and anxiety affecting each other. He said considering her known comorbidities of lung cancer and COPD, a saturation rate of 90% was not unexpected. He said staff knew that a resident with a change in condition, with an emergent concern, must make personal contact with the provider at that time. He said if they were to have mentioned that they were thinking of administering Haldol, he would have recommended that they held off on administration. He said this was all hypothetical as he was not notified. In a follow-up interview, on [DATE] at 4:03 p.m., Nurse C said he checked CR #1's O2 orders but when he increased it to 4 L/min she gave him a look as if it was uncomfortable for her to be at that level. He said in the past she had told him 4 L/min was uncomfortable. He said the physician was not notified at that time because he was going to continue to monitor. The Administrator was notified on [DATE] at 3:35 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was presented to the facility at this time. The facility's Plan of Removal was accepted on [DATE] at 4:13 p.m. and included: PLAN OF REMOVAL: F695 Name of facility: [] Date: [DATE] Immediate action: F 695 Resident CR#1 was deceased at the time the IJ was issued. A facility audit initiated by the Director of Nursing/Designee on [DATE] of all residents receiving oxygen therapy to assure that the order entered matches the amount of oxygen being received. Physician orders and care plans reviewed and updated if indicated. Any identified issues related to discrepancies in orders or care plans will be addressed as identified with primary care provider notification by DON/Designee if indicated. In-services initiated by DON/Designee on [DATE] with licensed nursing staff present in facility related to Changes in Resident Conditions including identification of respiratory distress and steps to take if current orders do not alleviate symptoms, Physician notification, Administration of Oxygen Therapy, Interact System, and Accidents. The regional nurse consultant in-serviced the Nursing Administration team on [DATE] related to monitoring change in condition forms and progress notes to identify any residents that have experienced respiratory distress to assure that appropriate steps were followed until residents' distress was relieved. Ad Hoc QAPI meeting to be completed with IDT and Medical Director on [DATE]. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: -Audit to be completed [DATE] by DON/Designee to identify any residents receiving Oxygen Therapy. -Education was completed with the administrative nursing team by the Regional Nurse Consultant on [DATE] related to supervision in order to assure that resident changes in condition are addressed promptly and appropriately, and monitoring new oxygen orders and changes to existing oxygen orders to assure that resident is receiving correct dose. -In-services initiated by DON/Designee on [DATE] with licensed nursing staff present in facility related Changes in Resident Conditions including residents receiving hospice services, MD notification, Administration of Oxygen Therapy, Interact System, and Accidents. The DON and/or designee will follow up in the morning clinical meeting to ensure compliance with all clinical processes/systems. LVN A and RN A to be given disciplinary action and trained one on one by Regional Nurse Consultant and/or designee by [DATE]. -Nursing Administration team to monitor change in condition forms and progress notes to identify any residents that have experienced respiratory distress to assure that appropriate steps were followed until residents' distress was relieved. -This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. *Education to be completed with all nursing staff working by [DATE]. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored on [DATE]. Monitoring of the POR included: Record review of in-service that discussed completion of assessments prior to moving unless in respiratory distress, required notifications, and other required documentation, dated [DATE] and [DATE], revealed 10 signatures. Record review of in-service, dated [DATE], titled Interact: Change in Condition, When to Report to The MD/NP/PA revealed 30 signatures. During interviews on [DATE], the following nurses were able to verbalize an understanding of change in condition, physician notification, and oxygen orders: Nurse A, B, C, D, E, F, G, H, and I. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:35 p.m. While the IJ was removed on [DATE] at 2:31 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (CR#1) of five residents reviewed for quality of care. The facility failed to ensure CR#1 received necessary care and treatment for a diabetic foot wound on the 4th toe on his right foot resulting in dry gangrene and bone infection. The facility failed to ensure that no new wounds were acquired at the facility. The 1st right toe, left ischium and left buttock wounds were acquired at the facility. CR#1 was admitted to the ER at local hospital on 9/15/2023 after the Wound care Physician B completed an assessment and found that his wounds were worse than documented by Wound Care Physician A. This failure caused CR#1 to be hospitalized and two leg amputations due to the infected wounds and placed the other four residents at risk for wounds worsening, pain and discomfort. An Immediate jeopardy (IJ) situation was identified on 9/25/2023 at 2:03 p.m. While the IJ was removed on 9/27/2023 at 12:52 p.m., the facility remained out of compliance at a scope of pattern with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. Findings Included: Record review of a list of in-house wounds provided by the DON on 9/20/23, revealed that the facility listed four residents with non-presure wounds. Record review of CR#1 face sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] and had diagnoses of osteomyelitis of vertebra (infection of vertebral body of the spine), diabetes mellitus(inadequate control of the blood levels of glucose), chronic kidney disease(kidney are damaged and cannot filter blood), peripheral vascular disease(condition in which narrowed arteries reduce blood flow to the limbs), paraplegia(incomplete), gangrene (not elsewhere classified), pressure ulcer on sacral region(unstageable), deep tissue damage to left heel and right heel, post-surgical wound of the upper back and anemia. Record review of the admission patient care summary dated 2/6/2023 revealed that a local acute hospital reported to the facility that CR#1 had lumbar osteomyelitis (which is the most common form of vertebral infection), surgical wound to the lumbar, sacral wound (unstageable), gangrene 4th right toe, deep tissue injury to left heel, diabetes mellitus (Type 2), and peripheral vascular disease. Plan: Continue local care to right fourth toe and use zinc oxide on left heel and offload while in bed. Record review of CR#1's MDS dated [DATE], revealed that his brief interview of mental status had a score of 15, which meant that he was cognitively intact. His functional ability was coded: Bed mobility, transfers, dressing and toilet use as (3)- extensive assistance and support was coded as (3) for two persons assist. Section H0400 was coded as (2) as CR#1 was frequently incontinent and required assistance of 1 staff. Record review of CR#1's care plan dated 4/10/23 revised revealed it to state in part .CR#1 has pressure injuries on his sacrum that was stage 4 and right heel unstageable. Goal: CR#1 will not have no complications from pressure injuries through the review date. Intervention: Assess for signs and symptoms, elevate with float heels to keep off bed and wheelchair and implement weekly skin checks. ADL's care plan revised on 7/17/2023 read in part .skin inspection weekly to observe for redness, open areas, scratches, cuts, bruises and report any changes to the nurse. Record review of the initial skin assessment upon admission dated 2/20/23 read in part: Right toes had wounds that were considered vascular. It was e-signed by LVN A. There was no reference to the 4th toe. Review of the nursing weekly skin review for CR#1 dated 3/6/2023 listed wounds to the right heel, sacrum, lumbar and the right 4th toe had a wound that was 2.0 in length and 2.0 width. It was e-signed by the former DON. Record review of his medical record revealed this was the first time the #4 toe wound was identified and documented. No treatment was put into place for the 4th right toe. Review of the wound care initial assessment and evaluation for CR#1 competed by Wound care physician A dated 3/20/2023 listed the following wounds: Site #1- Post surgical wound upper back, Site #2- unstageable pressure wound on sacrum, Site #3- unstageable right heel wound, Site # 4 unstageable (due to necrosis) left heel. The right 4th toe was not listed. Record review of the weekly skin evaluations by Wound Care doctor A between 3/13/2023 -9/6/2023 revealed no reference about the wound located on CR#1's right 4th toe. Record review of the nursing weekly skin assessment for CR#1 wounds completed by LVN B dated between 3/27/2023-6/20/2023, listed 1-5 wounds: (sacral, upper back, left heel, right heel and 1st right toe). The right 4th toe wound was not documented. Record review of the nursing weekly skin assessment for CR#1 wounds completed by LVN B dated 6/27/2023-8/14/2023, listed 1-7 wounds:(sacral, upper back, lumbar, left heel, right heel, 1st right toe and left ischium). The right 4th toe wound was not documented. Record review of the Physician order summary for CR#1 for April 1-30/2023, revealed: Left heel wound was added and ordered betadine to wound daily one time day every Monday-Friday for wound healing starting 4/10/2023-5/2/2023. Right 4th toe order changed to -clean wound with cleanser, pat dry, apply betadine cover and secure with island border Monday-Friday 1 time per day. (Start date 4/10/2023) Sacrum order changed to- clean wound with cleanser, pat dry and apply Sodium Hypochlorite solution (Dakin) soaked gauze daily for healing for 30 days. (Start date 4/12/2023) Record review of the treatment administration record for CR#1 dated 4/1/2023-4/30/2023, revealed: Left heel- had no documentation of treatment on 4/11/2023(Tuesday), 4/26/2023(Wednesday) Right 4th toe- no documentation of treatment for the right 4th toe on 4/11/2023(Tuesday) and 4/26/2023 (Wednesday). Sacrum- had no documentation of treatment on 4/15, 4/16, and 4/26/2023. Record review of the physician order summary for CR#1 dated 8/1/2023-8/30/2023 revealed: DTI bilateral toes on left and right foot: apply skin prep three times a week for 16 days (M, W, F)- start date 8/16/2023. Left Buttock pressure wound was added: clean with cleanser, pat dry and apply Medi honey and apply alginate calcium daily for 30 days. Start date: 8/9/2023. Sacrum order changed to clean with cleanser then pack with Vashe wound solution socked gauze for 30 days one time a day for wound healing start date: 8/3/2023. Left Ischium(left hip joint) was added- clean with cleanser, pat dry, apply alginate calcium and cover with bordered gauze dressing daily for 30 days. Record review of Wound administration record for CR#1 dated 9/1-9/30/2023 revealed: Wound care treatment was not documented for the sacrum, left heel, right heel or 4th toe on the right foot on 9/7, 9/10, 9/11, or 9/13/2023. Record review of an initial Wound assessment by Physician B for CR#1 dated 9/15/2023 revealed the following: Site #1 Post surgical wound of the upper back full thickness Site #2 - Stage 4 Pressure wound sacrum - Site #3- Stage 4 Pressure wound on right heel Site #4- Stage 4 Pressure wound of the left heel Site #5 Unstageable DTI of the right 1st toe Site #6 Stage 3 pressure wound of left ischium Site #7 -Wound of the right 4th toe -had purulent drainage The wound care physician wrote: Please transfer to ER due to purulent drainage and worsening wounds. Record review of a grievance dated 8/28/2023, revealed that CR#1 FM had concerns about him not getting daily treatments to his sacrum area, feet, toes and the wounds were getting worse. Record review of communication book located at nursing station revealed that there were no orders or communication concerning CR#1's 4th toe on the right foot or the worsening of his right heel, left heel or sacrum. There were no communications concerning the left ischium, which was newly acquired. Record review of the hospital records for CR#1 revealed he was admitted on [DATE]. His admission diagnosis or concern was multiple diabetic foot wounds that were infected, 4th toe on right foot dry gangrene. Assessment: left and right heel open wound possible calcaneal osteomyelitis, right foot 4th toe osteomyelitis, left and right lower extremity paralysis and type 2 diabetes. Recommendation: Patient advised he has a bone infection to right foot 4th toe. Patient declined right foot 4th toe amputation and calcaneal resection. Biopsy of right toe bone was done on 9/20/2023. Below knee amputations of both left and right legs scheduled for 9/26/2023 due to bacterial bone infection. Observation of CR#1 at a local hospital on 9/20/2023@ 2:40 p.m., revealed that he was receiving wound care at the time. Interview with CR#1 on 9/20/2023 @ 2:55 p.m., revealed he stated that he was not receiving wound treatment as he was supposed to get daily. He stated that the wound to the sacrum and his heels were supposed to be done daily and sometimes he did not receive treatment for days. He stated that the wounds on his right and left heels were badly infected. He said that the right 4th toe was getting better when LVN B was providing care, but when she resigned sometime in August 2023, it got infected again. He said the nurse assigned his hall (Hall 200) was supposed to care for his wounds. He said he felt like they did not want to do his wound treatments. He said that he was sometimes in pain and was given pain medication. He said that his FM filed a grievance because the facility did not provide adequate or daily wound care treatment and said that they had pictures of his wounds before he came to the facility and after. As a result not getting adequate wound treatment, he stated that he was scheduled for two amputations below the knee in two weeks due to bone infection. He said that this had been the worst experience in his life. Interview with LVN C on 9/21/2023 at 1:00 p.m., revealed her to state she did not normally work the Hall (200) where CR#1 resided. She said that the facility wound care nurse had resigned several weeks ago and she learned that the floor nurses were supposed to provide wound care. She said that the usual process was upon arrival of her shift she would review MARS/TARS/WARS in PCC and there was a list of all medications and treatments they had to administer on each shift. She said on 9/13/2023, she logged into Wound Treatment Administration (WAR) to see treatments. She said that she did not see any treatments that were needed for CR#1. She said that she had received disciplinary action or a write up due to the missed treatment for CR#1 on 9/13/2023. She denied observing his wounds. She said that she did not provide treatment for CR#1 and did not usually work his hall. Interview with the new DON on 9/21/2023 at 1:27 p.m., she stated that she had been employed at the facility for about 1 week. She stated that she did rounds with facility physician on or about 9/13/2023 and due to CR#1's wounds having an odor, he ordered antibiotics. She said during these rounds she did notice that one of his toes was black. She said she could not recall which foot or toe. She said she had not reviewed his record prior to the rounds so she was not aware of all the pressure ulcers that he had at the time. She said after reviewing his record, she learned that wound care treatments were missed or not documented by the nurses on 9/7, 9/10, 9/11, and 9/13/2023. She did not see any treatments for the 4th right toe. The missed treatments were for the sacrum and both left and right heels as far as she could tell. She said those nurses had been or will be reprimanded. She said as far as she could tell, RN A, LVN's C and D were the nurses that were scheduled to work and responsible for wound treatment for CR#1 but did not provide the care. She stated that the communication book was used for communication between nurses and physicians. She was informed that no orders or communication was found for CR#1's wound to his 4th toe on the right foot and that the facility used wound administration records to put the treatments necessary for residents. She stated missed wound care treatments can cause increased risk of infection, infections could become worst and residents' health could decline. Interview with the Administrator on 9/21/2023 at 1:40 p.m., she said that Wound Care Physician A was terminated due to inadequate wound care. She stated she learned from her care staff that he was debriding wounds quickly and moving on to the next resident without applying dressing on the wounds. She said that his last day was on or about 9/5/2023. She said the Wound Care Physician B started on 9/15/2023 and after assessing CR#1, he sent him to the hospital. She said that he said that the wounds looked worse than the former wound care physician A had documented and even the sizes were not accurate. She said that the floor nurses were responsible for providing CR#1's wound care between 9/5/2023-9/15/2023 and prior to that LVN B provided the care for several months before resigning. She stated that a PRN wound nurse started on today (9/21/2023) and that she hired a full-time wound nurse that would start in two weeks. She said she had just started to investigate the incident and had a few more days to complete. She stated that the DON would be providing in-services soon. Interview with RN A on 9/21/2023 at 1:54 p.m., she stated that she started working at the facility in July 2023 on 2-10pm shift and recently changed to 6a-2pm shift. She stated that on 9/7/2023 she worked down the Hall where CR#1 resided and once she opened PCC and logged in that it was supposed to tell the nurse which residents needed treatment, area and the physician orders. She stated that she does recall what areas she treated because she does not normally work down Hall 200 and she had not cared for CR#1 before 9/7/2023. She stated that she did not miss any of his treatments, if anything she forgot to click that it was completed. She agreed that if there was no documentation that the treatment was not done. She said that she was not provided any training on providing wound care. She said wound treatment was nursing 101 and that she always provided a head-to-toe assessment when she was not familiar with a resident. However, she could not recall missing his treatments. She stated that any changes or new skin conditions are documented in PCC and this information was reviewed by the DON. She said that she would use the communication book as well to notify the physician and they would also call and text the doctors. Interview with LVN D on 9/21/2023 at 2:06 p.m., revealed that she worked 6am-2pm shift usually down Hall 100. She stated that she was hired to work Hall 100 but was told that she would have to work Halls 200 and 400. She said that she only recalled treating CR#1 maybe once. Halls 200 and 400 had heavy acuity residents. She stated that she recalled that he needed wound treatment of the ischium, heels, and sacrum. She stated that she provided treatment on or before 9/13/2023. She said she could not recall. She stated that any changes to the residents' wounds were documented in PCC and in the communication book. She stated that missed treatments could cause infections, and discomfort. Interview with the Regional Nurse on 9/21/2023 on 2:55 p.m., she stated that she was unable to locate an order for wound treatment of the 4th toe on the right foot after she searched through almost two months of orders. She stated that the process was that any telephone orders are placed in a communication binder. She said from there the medical records coordinator input the information into PCC and the DON would check the e-fax and update the care plan. She stated that she was not sure why the nurses were not providing treatments as ordered. She said that the floor nurses were supposed to provide wound care as the physician ordered. She said that wound care treatments missed or not provided can cause wounds to get worst and infections. Interview with FM on 9/22/2023 at 11:56am, FM stated that she visited with CR#1 nearly every day. FM said when he was first admitted to the facility, he only had one surgical wound that was not healed. FM said in the past he did have a sacrum wound that was very small and was not opened. FM stated sometime around June 2023, FM had noticed that staff were not re-positioning him as he was always in the bed when FM visited, and no one came in to turn him while FM was there. FM visited with CR#1 between 3-4 hours daily. FM said that his wound on the sacrum was opened and had an odor on or around July 2023. FM talked to the former DON about his care. FM said the DON assured her that they were working on his wounds to get them better and FM spoke with LVN B, who was the wound care nurse, and she also said his wounds were getting better. FM said that his wounds on his heels were like hard callus and was told at the previous hospital that he resided that they were fine if they were not opened. FM said they were not infected because FM would often rub his feet and heels with lotion to soften the callused skin. FM learned that the wound care doctor had debrided his heels and they were now opened and infected from a CNA (which she could not name) and that his 4th right toe had turned to dark color. FM stated that CR#1 heels were bandaged and that is why the condition of them were not known for a few weeks. FM said CR#1 did not have a wound vac that he was supposed to have and that felt like that was because he started having issues with his insurance around August 2023. FM said that with all the staff turnover she could not recall all the names of the people spoken to on CR#1's behalf (but mostly nurses and aides). FM does not recall speaking with the Administrator. FM stated that around the beginning of August 2023, she was trying to find another facility to have him transferred. FM said that it was difficult to find a facility that would take CR#1 because of all the wounds he had acquired while at the facility. FM said that his feet was wrapped most of time but do not recall boots being on his heels. Interview with LVN B on 9/25/2023 at 6:48 p.m., she stated that she started working at the facility March 2023. She stated that she did wound treatments for CR#1. She stated that she was not certified to complete wound care. She stated that CR#1 had wounds to his heels, sacral, upper back had a surgical wound, and she recalled the 1st right toe. She said that the heels were only getting betadine for awhile until they were debrided. She said that the worse wounds were the sacral area and the heels after the debridement. She stated that the facility administration expected her to provide wound care, pass medications, take vitals and weights, and overall patient care on halls 200 and 400 was hard because the residents on those halls had the highest acuity. She stated that she had a stroke several months ago and it forced her to recognize that she had been under a lot of stress working at the facility, which is why she resigned. She stated that she did not recall the exact treatments for every wound without access to PCC. Interview with the facility Physician on 9/26/2023 at 2:01pm, he stated that his NP provided a referral for Wound care Physician A to start treating CR#1 wounds when he was admitted . He stated that he was currently the facility physician and the MD. He said that he was aware of the wound on the right 4th toe and that at some point it had gotten better. He said that his wounds were cared for by the Wound care doctor. He stated that the Administrator made him aware that she terminated the services of Wound care physician A on or about 9/5/2023. He said that she did not say why she no longer wanted his services, and he did not ask. He said that he assessed CR#1 again to assume care until the administrator found another doctor on or about 9/6/2023. He stated that once he made a referral for wound care that physician would provide all the wound care services. He attempted to pull up CR#1's records on his phone. He said that it was a HIPAA violation to show his record, but that anytime he observed a new wound on CR#1 it was documented, and orders were placed as needed. He stated that he would send an e-fax and it would be directly uploaded into the facility's PCC system. He said that he was not aware of any issues with orders were not in the system. He was then made aware that no orders were found for CR#1's 4th right toe, and wounds on his left and right heels and sacrum were worse than when CR#1 was admitted . He said that he was made aware of the issues after wound care doctor A was terminated. Interview with Wound Care Physician B on 9/28/23 at 3:26pm, revealed him to state that on 9/15/23, he conducted an assessment on CR#1. He stated that from the current documentation from former Wound Care Physician A, the sacral wound was measured larger than the documentation showed and the wound on right foot (4th toe) was having purulent drainage and he did not see any documentation, multiple wounds for a complex patient, high risk with drainage was his reason for sending his to the hospital. He stated that he thought the most appropriate thing for him to do was send him to have advanced imaging and possible surgical evaluation. He said that it was appropriate to escalate care based on those issues. He stated that he consulted with the facility due to a referral by the facility physician on only residents that the facility wants him to consult. He said that he does not see all residents that have wounds in the facility. Post surgical wounds are usually handled by the facility doctor and he does not care for those same residents. Interview with hospital surgeon on 9/28/2023 at 5:07pm, he stated that he was a vascular surgeon. He stated that he performed the below knee amputations(BKA) of both of CR#1's left and right legs. He said that his pressure ulcers on the left and right heels were deep in the tissue and badly infected. He said the bone infection was very serious and amputating the limbs were the only option. He said that he maintained the knees so CR#1 could possibly use prosthetics in the future. He said that the wounds were not adequately cared for by the facility where CR#1 resided. He said that he could tell that there could not have been heel supports used to keep his heels from the bed and the facility staff probably did not reposition him as needed. He said that although the resident had peripheral vascular disease, his blood flow was not an issue. He stated that the SW had a statement in his chart to find alternate placement upon his discharge and he agreed. He said that he will need to go to a facility that will properly care for his wounds. An Immediate jeopardy (IJ) situation was identified on 9/25/2023 at 2:03p.m. While the IJ was removed on 9/27/2023 at 12:52 p.m., the facility remained out of compliance at a scope of pattern with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. The adminsitrator was provided a copy of the template and plan of removal. Immediate action taken: Resident #1 had been discharged to the hospital on 9/16/23 and had not returned to the facility at the time the immediate jeopardy was issued. Once resident #1 was seen by the wound care doctor on 9/16/23, an order to send to the ER for evaluation was given and implemented immediately. A facility audit of all residents to be completed by the Director of Nursing/Designee by 9/25/2023 of all residents to validate a skin check has been completed in the past 7 days and that any areas identified had been communicated to the physician. Any resident who has not had a documented skin check within the past 7 days had a skin check completed by Regional Nurse Consultant and/or DON on 9/25/2023. The facility reviewed/revised the system for receiving orders from the physician and communicating with the physician more efficiently and effectively. The facility created a plan of improvement to address changes including acceptable methods of communication, order transcription and use of order binder. Care plan audit for all residents with wounds to be completed on 9/26/23 by MDS coordinator and Regional MDS support to assure that the CP matches current wounds and interventions. Nursing administration to initiate acute care plans and IDT to monitor and assure that care plans are updated timely. In-services initiated 9/26/23 with administrative nursing team related to completion and updating of acute and chronic wound care plans Ad Hoc QAPI meeting completed with IDT, Regional Nurse Consultant and Medical Director on 9/26/2023. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: Skin checks were completed by DON/designee on 9/25/23 including 100% of residents in the facility with no unknown wounds discovered. A facility wound audit was completed on 9/25/2023 to validate all wounds had current and appropriate treatment. Education was initiated for the facility nursing staff by Administrator/designee on 9/25/23 related to ensuring all resident's health and safety are protected from abuse and neglect*. Education was initiated for Nursing Assistants by DON/designee on 9/25/2023 on ensuring residents at high risk for skin breakdown are turned and repositioned at least every two hours, how to provide proper bathing/personal cares with residents with wounds, who to notify if skin breakdown is identified and using the Stop and Watch tool in POC to alert nurse*. Education was initiated for the DON by the Regional Nurse Consultant related to oversight of the wound care program on 9/25/23. Education to be initiated by DON/Designee on 9/25/2023 with all Licensed Nurses regarding changes in resident condition, the importance of completing a thorough weekly skin assessment, completing, and documenting wound care per physician orders, validating that all wounds have orders for treatment, reporting immediately when a resident has incurred a skin impairment notifying the doctor of new or worsening skin areas, and proper documentation*. This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. *Education to be completed with all nursing staff working 9/25/2023. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. Monitoring included: Record review of an in-service on 9/25/2023 revealed, Regional Nurse conducted oversight of wound care program, required documentation, interventions and follow-up with DON. All wounds must have care plans that indicate the location and etiology of each wound present. Interventions must be updated in a timely manner. Record review of an in-services on 9/25/2023, revealed Regional nurse covered stop and watch documentation of new alterations in skin integrity. Skin breakdown prevention, turning and repositioning residents at high risk of skin breakdown, change in condition, completing wound assessments, validating wound orders, reporting new wounds and documenting. Interviews were conducted between 9/26/2023-9/28/2023 with 3 CNA's, 4 LVN's, 2 RN's on day, evening and night shifts. They reported that they were in-serviced on observing wounds, documenting, stop and watch, reporting changes to physicians, accurate weekly assessments, abuse, neglect and exploitation as well as protocol for pressure wounds. They were able to verbalize their understanding of the in services provided. Subsequent interview with the Administrator on 9/28/2023 at 12:25pm, she stated that after all physician visits to the facility, they will leave a visit summary. The summaries will also be emailed and followed up by the DON. She said that their system will get better and so treatments were adequate and timely for residents. Subsequent interview with the DON on 9/28/2023 at 12:55pm, she stated that she was aware that it was her responsibility to ensure physician orders complete and that there was a care plan for wounds, treatments were conducted timely and without any missed treatments. She said that she was still new but will learn the system and work with staff to make the facility better. An Immediate jeopardy (IJ) situation was identified on 9/25/2023 at 2:03p.m. While the IJ was removed on 9/27/2023 at 12:52 p.m., the facility remained out of compliance at a scope of pattern with actual harm due to the facility's need to evaluate the effectiveness of the corrective system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide care consistent with professional standards of practice promoting healing and prevent new pressure ulcers from developing for 1(CR#1) of 5 residents reviewed for pressure ulcers. The facility failed to ensure that no new pressure wounds were acquired at the facility. The 1st right toe, left ischium and left buttock wounds were acquired at the facility. CR#1 was admitted to the ER at local hospital on 9/15/2023 after the Wound care Physician B completed an assessment and found that his wounds were worse than documented by Wound Care Physician A. This failure caused (CR#1) bone infection and placed other residents at risk for pain, worsening wounds, infection, emotional distress and harm. An Immediate Jeopardy (IJ) situation was identified on 9/25/2023 at 2:03 p.m. While the IJ was removed on 9/27/2023 at 12:52 p.m., the facility remained out of compliance at a scope of pattern with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. Findings Included: Record review of a list of in-house wounds provided by the DON on 9/20/23, revealed that the facility listed four residents with pressure wounds. Record review of CR#1 face sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] and had diagnoses of osteomyelitis of vertebra (infection of vertebral body of the spine), diabetes mellitus(inadequate control of the blood levels of glucose), chronic kidney disease(kidney are damaged and cannot filter blood), peripheral vascular disease(condition in which narrowed arteries reduce blood flow to the limbs), paraplegia(incomplete), gangrene (not elsewhere classified), pressure ulcer on sacral region(unstageable), deep tissue damage to left heel and right heel, post-surgical wound of the upper back and anemia. Record review of the admission patient care summary dated 2/6/2023 revealed that a local acute hospital reported to the facility that CR#1 had lumbar osteomyelitis (which is the most common form of vertebral infection), surgical wound to the lumbar, sacral wound (unstageable), gangrene 4th right toe, deep tissue injury to left heel, diabetes mellitus (Type 2), and peripheral vascular disease. Plan: Continue local care to right fourth toe and use zinc oxide on left heel and offload while in bed. Record review of CR#1's MDS dated [DATE], revealed that his brief interview of mental status had a score of 15, which meant that he was cognitively intact. His functional ability was coded Bed mobility, transfers, dressing and toilet use as (3)- extensive assistance and support was coded as (3) for two persons assist. Section H0400 was coded as (2) as CR#1 was frequently incontinent and required assistance of 1 staff. Record review of CR#1's care plan dated 4/10/23 revised revealed it to state in part .CR#1 has pressure injuries on his sacrum that was stage 4 and right heel unstageable. Goal: CR#1 will not have no complications from pressure injuries through the review date. Intervention: Assess for signs and symptoms, elevate with float heels to keep off bed and wheelchair and implement weekly skin checks. ADL's care plan revised on 7/17/2023 read in part .skin inspection weekly to observe for redness, open areas, scratches, cuts, bruises and report any changes to the nurse. Review of the nursing weekly skin review for CR#1 dated 3/6/2023 listed wounds to the right heel, sacrum, lumbar and the right 4th toe had a wound that was 2.0 in length and 2.0 width. It was e-signed by the former DON. Record review of his medical record revealed this was the first time the #4 toe wound was identified and documented. Review of the wound care initial assessment and evaluation for CR#1 competed by Wound care physician A dated 3/20/2023 listed the following wounds: Site #1- Post surgical wound upper back, Site #2- unstageable pressure wound on sacrum, Site #3- unstageable right heel wound, Site # 4 unstageable (due to necrosis) left heel. Record review of the nursing weekly skin assessment for CR#1 wounds completed by LVN B dated between 3/27/2023-6/20/2023, listed 1-5 wounds: (sacral, upper back, left heel, right heel and 1st right toe). Record review of the nursing weekly skin assessment for CR#1 wounds completed by LVN B dated 6/27/2023-8/14/2023, listed 1-7 wounds:(sacral, upper back, lumbar, left heel, right heel, 1st right toe and left ischium). Record review of the Physician order summary for CR#1 for April 1-30/2023, revealed: Left heel wound was added and ordered betadine to wound daily one time day every Monday-Friday for wound healing starting 4/10/2023-5/2/2023. Right 4th toe order changed to -clean wound with cleanser, pat dry, apply betadine cover and secure with island border Monday-Friday 1 time per day. (Start date 4/10/2023) Sacrum order changed to- clean wound with cleanser, pat dry and apply Sodium Hypochlorite solution (Dakin) soaked gauze daily for healing for 30 days. (Start date 4/12/2023) Record review of the treatment administration record for CR#1 dated 4/1/2023-4/30/2023, revealed: Left heel- had no documentation of treatment on 4/11/2023(Tuesday), 4/26/2023(Wednesday) Sacrum- had no documentation of treatment on 4/15, 4/16, and 4/26/2023. Record review of the physician order summary for CR#1 dated 8/1/2023-8/30/2023 revealed: DTI bilateral toes on left and right foot: apply skin prep three times a week for 16 days (M, W, F)- start date 8/16/2023. Left Buttock pressure wound was added: clean with cleanser, pat dry and apply Medi honey and apply alginate calcium daily for 30 days. Start date: 8/9/2023. Sacrum order changed to clean with cleanser then pack with Vashe wound solution socked gauze for 30 days one time a day for wound healing start date: 8/3/2023. Left Ischium(left hip joint) added- clean with cleanser, pat dry, apply alginate calcium and cover with bordered gauze dressing daily for 30 days. Record review of Wound administration record for CR#1 dated 9/1-9/30/2023 revealed: Wound care treatment was not documented for the sacrum, left heel, right heel or 4th toe on the right foot on 9/7, 9/10, 9/11, or 9/13/2023. Record review of an initial Wound assessment by Physician B for CR#1 dated 9/15/2023 revealed the following: Site #1 Post surgical wound of the upper back full thickness Site #2 - Stage 4 Pressure wound sacrum Site #3- Stage 4 Pressure wound on right heel Site #4- Stage 4 Pressure wound of the left heel Site #5 Unstageable DTI of the right 1st toe Site #6 Stage 3 pressure wound of left ischium Site #7 -Wound of the right 4th toe -had purulent drainage The wound care physician wrote: Please transfer to ER due to purulent drainage and worsening wounds. Record review of a grievance dated 8/28/2023, revealed that CR#1 FM had concerns about him not getting daily treatments to his sacrum area, feet, toes and the wounds were getting worse. Record review of communication book located at nursing station revealed that there were no orders or communication concerning CR#1's 4th toe on the right foot or the worsening of his right heel, left heel or sacrum. There were no communications concerning the left ischium or left buttock or 1st right toe, which were acquired at the facility. Record review of the hospital records for CR#1 revealed he was admitted on [DATE]. His admission diagnosis or concern was multiple diabetic foot wounds that were infected. Assessment: left and right heel open wound possible calcaneal osteomyelitis, right foot 4th toe osteomyelitis, left and right lower extremity paralysis and type 2 diabetes. Recommendation: Patient advised he has a bone infection to right foot 4th toe. Patient declined right foot 4th toe amputation and calcaneal resection. Biopsy of right toe bone was done on 9/20/2023. Below knee amputations of left and right legs were to be performed on 9/26/2023 due to bacterial bone infection. Observation of CR#1 at a local hospital on 9/20/2023@ 2:40 p.m., revealed that he was receiving wound care at the time. Interview with CR#1 on 9/20/2023 @ 2:55 p.m., revealed he stated that he was not receiving wound treatment as he was supposed to get daily. He stated that the wound to the sacrum and his heels were supposed to be done daily and sometimes he did not receive treatment for days. He stated that the wounds on his right and left heels were badly infected. He said that the right 4th toe was getting better when LVN B was providing care, but when she resigned sometime in August 2023, it got infected again. He said the nurse assigned his hall (Hall 200) was supposed to care for his wounds. He said he felt like they did not want to do his wound treatments. He said that he was sometimes in pain and was given pain medication. He said that his FM filed a grievance because the facility did not provide adequate or daily wound care treatment and said that they had pictures of his wounds before he came to the facility and after. As a result not getting adequate wound treatment, he stated that he was scheduled for two amputations below the knee in two weeks due to bone infection. He said that this had been the worst experience in his life. Interview with LVN C on 9/21/2023 at 1:00 p.m., revealed her to state she did not normally work the Hall (200) where CR#1 resided. She said that the facility wound care nurse had resigned several weeks ago and she learned that the floor nurses were supposed to provide wound care. She said that the usual process was upon arrival of her shift she would review MARS/TARS/WARS in PCC and there was a list of all medications and treatments they had to administer on each shift. She said on 9/13/2023, she logged into Wound Treatment Administration (WAR) to see treatments. She said that she did not see any treatments that were needed for CR#1. She said that she had received disciplinary action or a write up due to the missed treatment for CR#1 on 9/13/2023. She denied observing his wounds. She said that she did not provide treatment for CR#1 and did not usually work his hall. Interview with the new DON on 9/21/2023 at 1:27 p.m., she stated that she had been employed at the facility for about 1 week. She stated that she did rounds with facility physician on or about 9/13/2023 and due to CR#1's wounds having an odor, he ordered antibiotics. She said during these rounds she did notice that one of his toes was black. She said she could not recall which foot or toe. She said she had not reviewed his record prior to the rounds so she was not aware of all the pressure ulcers that he had at the time. She said after reviewing his record, she learned that wound care treatments were missed or not documented by the nurses on 9/7, 9/10, 9/11, and 9/13/2023. She did not see any treatments for the 4th right toe. The missed treatments were for the sacrum and both left and right heels as far as she could tell. She said those nurses had been or will be reprimanded. She said as far as she could tell, RN A, LVN's C and D were the nurses that were scheduled to work and responsible for wound treatment for CR#1 but did not provide the care. She stated that the communication book was used for communication between nurses and physicians. She was informed that no orders or communication was found for CR#1's wound to his 4th toe on the right foot and that the facility used wound administration records to put the treatments necessary for residents. She stated missed wound care treatments can cause increased risk of infection, infections could become worst and residents' health could decline. Interview with the Administrator on 9/21/2023 at 1:40 p.m., she said that Wound Care Physician A was terminated due to inadequate wound care. She stated she learned from her care staff that he was debriding wounds quickly and moving on to the next resident without applying dressing on the wounds. She said that his last day was on or about 9/5/2023. She said the Wound Care Physician B started on 9/15/2023 and after assessing CR#1, he sent him to the hospital. She said that he said that the wounds looked worse than the former wound care physician A had documented and even the sizes were not accurate. She said that the floor nurses were responsible for providing CR#1's wound care between 9/5/2023-9/15/2023 and prior to that LVN B provided the care for several months before resigning. She stated that a PRN wound nurse started on today (9/21/2023) and that she hired a full-time wound nurse that would start in two weeks. She said she had just started to investigate the incident and had a few more days to complete. She stated that the DON would be providing in-services soon. Interview with RN A on 9/21/2023 at 1:54 p.m., she stated that she started working at the facility in July 2023 on 2-10pm shift and recently changed to 6a-2pm shift. She stated that on 9/7/2023 she worked down the Hall where CR#1 resided and once she opened PCC and logged in that it was supposed to tell the nurse which residents needed treatment, area and the physician orders. She stated that she does recall what areas she treated because she does not normally work down Hall 200 and she had not cared for CR#1 before 9/7/2023. She stated that she did not miss any of his treatments, if anything she forgot to click that it was completed. She agreed that if there was no documentation that the treatment was not done. She said that she was not provided any training on providing wound care. She said wound treatment was nursing 101 and that she always provided a head-to-toe assessment when she was not familiar with a resident. However, she could not recall missing his treatments. She stated that any changes or new skin conditions are documented in PCC and this information was reviewed by the DON. She said that she would use the communication book as well to notify the physician and they would also call and text the doctors. Interview with LVN D on 9/21/2023 at 2:06 p.m., revealed that she worked 6am-2pm shift usually down Hall 100. She stated that she was hired to work Hall 100 but was told that she would have to work Halls 200 and 400. She said that she only recalled treating CR#1 maybe once. Halls 200 and 400 had heavy acuity residents. She stated that she recalled that he needed wound treatment of the ischium, heels, and sacrum. She stated that she provided treatment on or before 9/13/2023. She said she could not recall. She stated that any changes to the residents' wounds were documented in PCC and in the communication book. She stated that missed treatments could cause infections, and discomfort. Interview with the Regional Nurse on 9/21/2023 on 2:55 p.m., she stated that she was unable to locate an order for wound treatment of the 4th toe on the right foot after she searched through almost two months of orders. She stated that the process was that any telephone orders are placed in a communication binder. She said from there the medical records coordinator input the information into PCC and the DON would check the e-fax and update the care plan. She stated that she was not sure why the nurses were not providing treatments as ordered. She said that the floor nurses were supposed to provide wound care as the physician ordered. She said that wound care treatments missed or not provided can cause wounds to get worst and infections. Interview with FM on 9/22/2023 at 11:56am, FM stated that she visited with CR#1 nearly every day. FM said when he was first admitted to the facility, he only had one surgical wound that was not healed. FM said in the past he did have a sacrum wound that was very small and was not opened. FM stated sometime around June 2023, FM had noticed that staff were not re-positioning him as he was always in the bed when FM visited, and no one came in to turn him while FM was there. FM visited with CR#1 between 3-4 hours daily. FM said that his wound on the sacrum was opened and had an odor on or around July 2023. FM talked to the former DON about his care. FM said the DON assured her that they were working on his wounds to get them better and FM spoke with LVN B, who was the wound care nurse, and she also said his wounds were getting better. FM said that his wounds on his heels were like hard callus and was told at the previous hospital that he resided that they were fine if they were not opened. FM said they were not infected because FM would often rub his feet and heels with lotion to soften the callused skin. FM learned that the wound care doctor had debrided his heels and they were now opened and infected from a CNA (which she could not name) and that his 4th right toe had turned to dark color. FM stated that CR#1 heels were bandaged and that is why the condition of them were not known for a few weeks. FM said CR#1 did not have a wound vac that he was supposed to have and that felt like that was because he started having issues with his insurance around August 2023. FM said that with all the staff turnover she could not recall all the names of the people spoken to on CR#1's behalf (but mostly nurses and aides). FM does not recall speaking with the Administrator. FM stated that around the beginning of August 2023, the family wanted to find another facility to have CR#1 transferred. FM said that it was difficult to find a facility that would take CR#1 because of all the wounds he had acquired while at the facility. FM said that his feet were wrapped most of time and do not recall boots being on his heels. Interview with LVN B on 9/25/2023 at 6:48 p.m., she stated that she started working at the facility March 2023. She stated that she did wound treatments for CR#1. She stated that she was not certified to complete wound care. She stated that CR#1 had wounds to his heels, sacral, upper back had a surgical wound, and she recalled the 1st right toe. She said that the heels were only getting betadine for awhile until they were debrided. She said that the worse wounds were the sacral area and the heels after the debridement. She stated that the facility administration expected her to provide wound care, pass medications, take vitals and weights, and overall patient care on halls 200 and 400 was hard because the residents on those halls had the highest acuity. She stated that she had a stroke several months ago and it forced her to recognize that she had been under a lot of stress working at the facility, which is why she resigned. She stated that she did not recall the exact treatments for every wound without access to PCC. Interview with the facility Physician on 9/26/2023 at 2:01pm, he stated that his NP provided a referral for Wound care Physician A to start treating CR#1 wounds when he was admitted . He stated that he was currently the facility physician and the MD. He said that he was aware of the wound on the right 4th toe and that at some point it had gotten better. He said that his wounds were cared for by the Wound care doctor. He stated that the Administrator made him aware that she terminated the services of Wound care physician A on or about 9/5/2023. He said that she did not say why she no longer wanted his services, and he did not ask. He said that he assessed CR#1 again to assume care until the administrator found another doctor on or about 9/6/2023. He stated that once he made a referral for wound care that physician would provide all the wound care services. He attempted to pull up CR#1's records on his phone. He said that it was a HIPAA violation to show his record, but that anytime he observed a new wound on CR#1 it was documented, and orders were placed as needed. He stated that he would send an e-fax and it would be directly uploaded into the facility's PCC system. He said that he was not aware of any issues with orders were not in the system. He was then made aware that no orders were found for CR#1's 4th right toe, and wounds on his left and right heels and sacrum were worse than when CR#1 was admitted . He said that he was made aware of the issues after wound care doctor A was terminated. Interview with Wound Care Physician B on 9/28/23 at 3:26pm, revealed him to state that on 9/15/23, he conducted an assessment on CR#1. He stated that from the current documentation from former Wound Care Physician A, the sacral wound was measured larger than the documentation showed and the wound on right foot (4th toe) was having purulent drainage and he did not see any documentation, multiple wounds for a complex patient, high risk with drainage was his reason for sending his to the hospital. He stated that he thought the most appropriate thing for him to do was send him to have advanced imaging and possible surgical evaluation. He said that it was appropriate to escalate care based on those issues. He stated that he consulted with the facility due to a referral by the facility physician on only residents that the facility wants him to consult. He said that he does not see all residents that have wounds in the facility. Post surgical wounds are usually handled by the facility doctor and he does not care for those same residents. Interview with hospital surgeon on 9/28/2023 at 5:07pm, he stated that he was a vascular surgeon. He stated that he performed the below knee amputations(BKA) of both of CR#1's left and right legs. He said that his pressure ulcers on the left and right heels were deep in the tissue and badly infected. He said the bone infection was very serious and amputating the limbs were the only option. He said that he maintained the knees so CR#1 could possibly use prosthetics in the future. He said that the wounds were not adequately cared for by the facility where CR#1 resided. He said that he could tell that there could not have been heel supports used to keep his heels from the bed and the facility staff probably did not reposition him as needed. He said that although the resident had peripheral vascular disease, his blood flow was not an issue. He stated that the SW had a statement in his chart to find alternate placement upon his discharge and he agreed. He said that he will need to go to a facility that will properly care for his wounds. An Immediate Jeopardy (IJ) situation was identified on 9/25/2023 at 2:03p.m. While the IJ was removed on 9/27/2023 at 12:52 p.m., the facility remained out of compliance at a scope of pattern with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. Immediate action taken: Resident #1 had been discharged to the hospital on 9/16/23 and had not returned to the facility at the time the immediate jeopardy was issued. Once resident #1 was seen by the wound care doctor on 9/16/23, an order to send to the ER for evaluation was given and implemented immediately. A facility audit of all residents to be completed by the Director of Nursing/Designee by 9/25/2023 of all residents to validate a skin check has been completed in the past 7 days and that any areas identified had been communicated to the physician. Any resident who has not had a documented skin check within the past 7 days had a skin check completed by Regional Nurse Consultant and/or DON on 9/25/2023. The facility reviewed/revised the system for receiving orders from the physician and communicating with the physician more efficiently and effectively. The facility created a plan of improvement to address changes including acceptable methods of communication, order transcription and use of order binder. Care plan audit for all residents with wounds to be completed on 9/26/23 by MDS coordinator and Regional MDS support to assure that the CP matches current wounds and interventions. Nursing administration to initiate acute care plans and IDT to monitor and assure that care plans are updated timely. In-services initiated 9/26/23 with administrative nursing team related to completion and updating of acute and chronic wound care plans Ad Hoc QAPI meeting completed with IDT, Regional Nurse Consultant and Medical Director on 9/26/2023. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: Skin checks were completed by DON/designee on 9/25/23 including 100% of residents in the facility with no unknown wounds discovered. A facility wound audit was completed on 9/25/2023 to validate all wounds had current and appropriate treatment. Education was initiated for the facility nursing staff by Administrator/designee on 9/25/23 related to ensuring all resident's health and safety are protected from abuse and neglect*. Education was initiated for Nursing Assistants by DON/designee on 9/25/2023 on ensuring residents at high risk for skin breakdown are turned and repositioned at least every two hours, how to provide proper bathing/personal cares with residents with wounds, who to notify if skin breakdown is identified and using the Stop and Watch tool in POC to alert nurse*. Education was initiated for the DON by the Regional Nurse Consultant related to oversight of the wound care program on 9/25/23. Education to be initiated by DON/Designee on 9/25/2023 with all Licensed Nurses regarding changes in resident condition, the importance of completing a thorough weekly skin assessment, completing, and documenting wound care per physician orders, validating that all wounds have orders for treatment, reporting immediately when a resident has incurred a skin impairment notifying the doctor of new or worsening skin areas, and proper documentation*. This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. *Education to be completed with all nursing staff working 9/25/2023. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. Monitoring included: Record review of an in-service on 9/25/2023 revealed, Regional Nurse conducted oversight of wound care program, required documentation, interventions and follow-up with DON. All wounds must have care plans that indicate the location and etiology of each wound present. Interventions must be updated in a timely manner. Record review of an in-services on 9/25/2023, revealed Regional nurse covered stop and watch documentation of new alterations in skin integrity. Skin breakdown prevention, turning and repositioning residents at high risk of skin breakdown, change in condition, completing wound assessments, validating wound orders, reporting new wounds and documenting. Interviews were conducted between 9/26/2023-9/28/2023 with 3 CNA's, 4 LVN's, 2 RN's on day, evening and night shifts. They reported that they were in-serviced on observing wounds, documenting, stop and watch, reporting changes to physicians, accurate weekly assessments, abuse, neglect and exploitation as well as protocol for pressure wounds. They were able to verbalize their understanding of the in services provided. Subsequent interview with the Administrator on 9/28/2023 at 12:25pm, she stated that after all physician visits to the facility, they will leave a visit summary. The summaries will also be emailed and followed up by the DON. She said that their system will get better and so treatments were adequate and timely for residents. Subsequent interview with the DON on 9/28/2023 at 12:55pm, she stated that she was aware that it was her responsibility to ensure physician orders complete and that there was a care plan for wounds, treatments were conducted timely and without any missed treatments. She said that she was still new but will learn the system and work with staff to make the facility better. An Immediate Jeopardy (IJ) situation was identified on 9/25/2023 at 2:03 p.m. While the IJ was removed on 9/27/2023 at 12:52 p.m., the facility remained out of compliance at a scope of pattern with actual harm due to the facility's need to evaluate the effectiveness of the corrective system.