**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents were free from neglect 1 of 3 (Resident #1) residents reviewed for neglect. The facility failed to have an effective system in place for referrals resulting in Resident #1 not receiving a referral to the vascular specialist as ordered by his primary care physician and having an above the knee amputation to his right leg. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/04/23 at 3:00 p.m. While the IJ was removed on 4/06/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could result in residents not being seen by physicians when needed and lead to further decline in health status, harm, or death. Findings Include: 1. Record review of the face sheet dated 4/05/2023 indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including COPD (a group of lungs diseases that block airflow and make it difficult to breathe), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and difficulty walking. Record review of the physician orders dated 4/05/2023 indicated Resident #1 had an order for wound care to the right toes to cleanse with normal saline, pat dry, apply betadine moistened gauze, apply calcium alginate (a dressing used on moderate to heavy draining wounds during the transition from debridement to repair phase of wound healing) daily and as needed for wound care and infection prevention starting on 3/22/2023. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 11 and was moderately cognitively impaired. The MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required extensive assistance with bed mobility, transferring, toileting, personal hygiene, and dressing. Record review of an undated care plan indicated Resident #1 had impaired cognitive function or impaired thought process related to impaired decision-making abilities. Record review of the nursing progress note dated 2/28/2023 written by LVN F indicated nursing staff was having difficulty locating Resident #1's pedal pulse (foot pulse) to the right lower extremity. The nursing progress note indicated Resident #1's capillary refill was less than 3 seconds to right foot, excluding the second toe. The nursing progress note indicated a new order was received for Resident #1 to have a venous and arterial doppler to the right lower extremity. Record review of the right lower extremity arterial doppler (an ultrasound exam of the arteries on the legs that can help evaluate whether there are blockages caused by plaque in the arteries) report dated 3/01/2023 indicated Resident #1 had moderated atherosclerotic cardiovascular disease. Record review of the right lower extremity venous doppler (an ultrasound exam that evaluates blood as it flows through a blood vessel including the body's major arteries and veins) report dated 3/01/2023 indicated Resident #1 had superficial thrombophlebitis (an inflammatory disorder of superficial veins with coexistent venous thrombosis (blood clot)) of the greater saphenous vein and no deep vein thrombosis. Record review of the nursing progress note dated 3/02/2023 written by the Wound Care Nurse indicated Resident #1's doppler results were sent to the primary care physician. The nursing progress note indicated the primary care physician said Resident #1 needed a referral to a vascular specialist. The nursing progress note indicated the nurse on the floor was aware of the referral and would complete the task. Record review of the nursing progress note dated 3/03/2023 written by the Wound Care Nurse indicated the vascular specialist office was called to make an appointment for Resident #1. The nursing progress note indicated a voicemail was left at the vascular specialist's office and the facility was awaiting a phone call back. Record review of the nursing progress note dated 3/13/2023 written by the Wound Care Nurse indicated the facility had spoken with the vascular specialist's office on 3/09/23 regarding the previous voicemail left concerning Resident #1 getting an appointment. The nursing progress note indicated the vascular specialist's office would let the facility know by the end of the day or by the next day if a referral was received. The nursing progress note indicated the vascular specialist's office did not call back. The nursing progress note indicated the referral was discussed with the nurse practitioner on 3/10/2023. The nursing progress note indicated the nurse practitioner said the primary care physician's office did not do the referrals, but that it should be the facility's social worker who sends the referral. The nursing progress note indicated the social worker was not aware of what was needed for the referral. The nursing progress note indicated the nurse practitioner and the DCO were notified due to Resident #1's right lower extremity. The nursing progress note indicated the facility talked with the vascular specialist's office and the vascular specialist's office said they had not received a referral for Resident #1. The nursing progress note indicated the DCO was notified and will take care of it. Record review of the nursing progress note dated 3/28/2023 written by LVN F indicated Resident #1's right foot and toes were looking significantly worse. The nursing progress note indicated orders were received to transport Resident #1 to the emergency room for further evaluation and treatment. Record review of the hospital records dated 3/28/23 indicated the chief complaint for Resident #1's emergency room visit was wound check. The hospital records indicated the toenail on the 4th right toe came off and the facility staff noted a hole in the toe. The hospital records indicated Resident #1 had dressed wounds to Lt foot. The hospital records indicated Resident #1 had erythema (reddening) and significant discoloration of all toes on right foot with foul smell. The hospital records indicated Resident #1 had ulcers on the 3rd and 4th toes on right foot. The hospital records indicated Resident #1 had decreased sensation to right foot. Record review of the hospital records dated 3/30/23 indicated Resident #1 was admitted from the facility with necrotic right foot and toes. The hospital records indicated Resident #1 was scheduled for an above the knee amputation on 3/31/2023. During an interview on 3/31/23 at 2:25 pm the receptionist at the venous specialist's office said they had never seen Resident #1. The receptionist at the vascular specialist's office said they did not have Resident #1 in their computer system and had no record of a referral. During an interview on 3/31/23 at 2:29 pm, the nurse practitioner said the referral for Resident #1 to see a vascular specialist was regarding vascular issues and arterial blockages. The nurse practitioner said she was unsure how advanced Resident #1's arterial/venous damage was at that time. The nurse practitioner said she would not be comfortable saying whether seeing the vascular specialist would have prevented Resident #1 from such an advanced amputation to right leg. During an interview on 3/31/2023 at 2:55 p.m. the SW said she had called the vascular specialist's office approximately 2 weeks ago. The SW said the vascular specialist's office said they were booked and short-handed. During an interview on 3/31/2023 at 2:56 p.m. the ADCO said the facility had asked the primary care physician's office to send a referral to the vascular specialist. The ADCO said the vascular specialist's office had said the referral had to come from the primary care physician's office. The ADCO said she had called the vascular specialist's office to find out what information they needed for a referral and had not received a call back. The ADCO said Resident #1's right lower extremity had worsened over the past 2 weeks. The ADCO said Resident #1 was sent to the emergency room so they would be taken seriously. During an interview on 3/31/23 at 3:32 pm, the Wound Care Nurse said she did not know if a referral was sent to the vascular specialist's office for Resident #1. The Wound Care Nurse said the DCO was supposed to talk to the SW regarding the referral for Resident #1 to the vascular specialist. The Wound care nurse said the nurse practitioner said the physician's office did not send referrals and that the facility's SW needed to send the referral to the vascular specialist for Resident #1. The Wound Care Nurse said Resident #1's right leg had significantly worsened over the past month. The Wound Care Nurse said Resident #1 was placed on antibiotics for the wounds to his right toes versus being sent out to the hospital. The Wound Care Nurse said Resident #1 was seen by the wound care nurse practitioner every Thursday at the facility. The Wound Care Nurse said Resident #1 did not have any discoloration to his legs but had pitting edema to both legs. The Wound Care Nurse said Resident #1's toes had worsened over the past month. During an interview on 4/03/2023 at 3:47 p.m. the primary care physician said he was informed of the referral for Resident #1 not being sent to the vascular specialist on 3/28/2023. The primary care physician said there was no way to know if Resident #1 had gotten into the vascular specialist if it would have prevented such an advanced right leg amputation. The primary care physician said he was aware of the wounds on Resident #1's toes. The primary care physician said he felt Resident #1 needed a referral to the vascular specialist due to the wounds on his right toes. During an interview on 4/04/2023 at 1:45 p.m. the SW said she handled referrals to mobile optometry, podiatry, hearing, and dental services. The SW said she had never done a referral to a physician or specialist. The SW said she was told by the nursing staff referrals to a physician or specialist was supposed to come from the primary care physician. The SW said she sometimes made appointments/referred residents for optometry, podiatry, hearing, and dental services in the community. The SW said she had never been trained on sending a referral to a physician or specialist. During an interview on 4/04/23 at 1:52 p.m. the ADCO said the facility did not have a process for sending referral to physicians or specialists. The ADCO said the DCO had told her it was the primary care physician's responsibility to send referrals. During an interview on 04/04/23 at 1:54 p.m. the DCO said the physician/Medical Director told the facility they did not send referrals. The DCO said the facility cannot make referrals. The DCO said there was not a process in place for making/sending referrals. During an interview on 04/04/23 at 2:00 p.m. the EDO said for referrals, the charge nurse or SW would make the appointments. The EDO said the facility did not have a policy regarding referrals to outside physicians or specialists. The EDO said if the physician/Medical Director wrote an order for a resident to see an outside physician/specialist, the facility would call to start the process of getting the appointment made. The EDO was notified on 4/04/2023 at 3:20 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The EDO was provided the Immediate Jeopardy template on 4/04/2023 at 3:22 p.m. The facility's Plan of Removal was accepted on 4/06/2023 at 8:28 a.m. and included: In Response to the facility failure to have a referral system or policy in place, the Administrator immediately created and implemented a referral policy on 4-4-23 to ensure that no additional residents are affected by poor quality of care. To ensure no other residents were affected by the facility failure of not having a referral system in place, the Director of Clinical Operations or Assistant Director of Clinical Operations has completed a review all orders on 4-4-23, for any orders requiring physician and or specialist referrals to ensure referrals are handled in a timely manner. No additional missed referrals were found. In Response to the facility failure to follow up with physician, the Medical Director, Licensed Nurses, Social Worker and wound care specialist will be provided in-service education related to the referral process policy. Inservice: Physician referral process for sending residents to a specialist or outside physician services by obtaining the Medical Director's referral order beginning on 4-4-23 to be completed by 04-4-23, by the Administrator or Assistant Director of Nurse's which includes: Referral Policy: 1. Upon receiving directions or recommendations from a provider or nurse practitioner, whether a physician or nurse practitioner, the charge nurse is to contact the Medical Director immediately and enter an order in PCC. 2. The charge Nurse to notify the Director of Nurses and/or the Assistant Director of Nurses and the Social Worker of the referral. 3. Social Worker to call in referral order, confirm insurance, obtain doctor signature on forms if needed and make appointment with Specialist and arrange for appropriate transportation. 4. Administrator to be notified if referrals are refused or denied by physician or Medical Director immediately with the reason for the denial to determine if the resident needs to be sent out to hospital for further evaluation. If it has been found the resident does not need immediate referral, the Director of Nurses will continue to monitor during daily clinical meetings with charge nurses and treatment nurses for change of condition. If a change of condition is found the physician is to be immediately notified. 5. Newly hired nurses will receive in-service from the Assist Director of Nurses regarding physician referral during orientation process, and to be included in the nurse's information book or Brain Book at nurse's station. In response to the facility failure to send a referral to the vascular specialist, the Director of Nurses, Assistant Director of Nurses and Social Worker will be provided in service to obtain the necessary information from the specialist's office, including vascular specialist, for the referral requirements needed from the physician and obtain the required signature's or orders to accommodate the requirements for the specialist to ensure there are no delays in resident's delay in care. In-service provided to Director of Nurses, Assistant Director of Nurses, and Social Worker 04/04/23 by Administrator to be completed by 04/04/23. Validation/Monitoring Tools Director of Clinical Operations or Designee will validate staff knowledge base through random questioning. Director of Clinical Operations or designee will review any referral orders documented by reviewing orders in daily stand up meeting and clinical meetings to ensure appointments are being made, beginning 4-4-21. Director of Clinical Operations or designee has called to follow up with Resident affected by the Failure of Quality of Care 4-4-23. Information obtained was that the resident received an above knee amputation and is being discharged to another skilled nursing facility for rehab. On 4/06/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the chart audits for residents who had been referred to outside providers in March 2023 was performed with no other issues noted. Record review of the facility's undated Referral Policy was performed. The Referral Policy indicated the facility's newly implemented steps in ensuring referrals were made to outside providers in a timely manner. Record review of the facility's Brain Book located at the nurse's station indicated the referral policy had been added into the book and was available to the nursing staff at all times for reference. Record review and signature verification was performed on in-services dated 3/30/23 through 4/13/23 regarding the facility's Referral Policy Interviews of staff on 4/04/2023 between 11:03 a.m. and 11:48 a.m. (LVN A, RN B, LV C, RN D, RN E, ADCO, LVN F, SW, MDS nurse, Wound Care Nurse, and DON) were performed. During the interviews staff were able to correctly identify the process for referrals per the facility's Referral Policy. Interview with the Medical Director and nurse practitioner on 4/04/23 between 11:38 a.m. and 11:41 a.m. regarding the facility's referral policy indicated they had received and agreed with facility's Referral Policy. Both the Medical Director and nurse practitioner said this policy would help ensure residents received appointments and were seen by outside providers and specialists. On 4/06/2023 at 11:51 a.m., the EDO was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care. 1. The Facility Failed to follow-up with the physician regarding referral ordered 3/02/23 to the vascular specialist in a timely manner resulting in Resident #1 not being seen by the vascular specialist and having an above the knee amputation of the right leg on 3/31/23. 2. The facility failed to send a referral to the vascular specialist resulting in Resident #1 not being seen by the vascular specialist and having an above the knee amputation of the right leg on 3/31/23. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/04/23 at 3:00 p.m. While the IJ was removed on 4/06/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm or death related to not receiving proper care or death by not being seen by a specialist or another physician as ordered by their primary physician. Findings Include: 1. Record review of the face sheet dated 4/05/2023 indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including COPD (a group of lungs diseases that block airflow and make it difficult to breathe), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and difficulty walking. Record review of the physician orders dated 4/05/2023 indicated Resident #1 had an order for wound care to the right toes to cleanse with normal saline, pat dry, apply betadine moistened gauze, apply calcium alginate (a dressing used on moderate to heavy draining wounds during the transition from debridement to repair phase of wound healing) daily and as needed for wound care and infection prevention starting on 3/22/2023. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 11 and was moderately cognitively impaired. The MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required extensive assistance with bed mobility, transferring, toileting, personal hygiene, and dressing. Record review of an undated care plan indicated Resident #1 had impaired cognitive function or impaired thought process related to impaired decision-making abilities. Record review of the nursing progress note dated 2/28/2023 written by LVN F indicated nursing staff was having difficulty locating Resident #1's pedal pulse (foot pulse) to the right lower extremity. The nursing progress note indicated Resident #1's capillary refill was less than 3 seconds to right foot, excluding the second toe. The nursing progress note indicated a new order was received for Resident #1 to have a venous and arterial doppler to the right lower extremity. Record review of the right lower extremity arterial doppler (an ultrasound exam of the arteries on the legs that can help evaluate whether there are blockages caused by plaque in the arteries) report dated 3/01/2023 indicated Resident #1 had moderated atherosclerotic cardiovascular disease. Record review of the right lower extremity venous doppler (an ultrasound exam that evaluates blood as it flows through a blood vessel including the body's major arteries and veins) report dated 3/01/2023 indicated Resident #1 had superficial thrombophlebitis (an inflammatory disorder of superficial veins with coexistent venous thrombosis (blood clot)) of the greater saphenous vein and no deep vein thrombosis Record review of the nursing progress note dated 3/02/2023 written by the Wound Care Nurse indicated Resident #1's doppler results were sent to the primary care physician. The nursing progress note indicated the primary care physician said Resident #1 needed a referral to a vascular specialist. The nursing progress note indicated the nurse on the floor was aware of the referral and would complete the task. Record review of the nursing progress note dated 3/03/2023 written by the Wound Care Nurse indicated the vascular specialist office was called to make an appointment for Resident #1, The nursing progress note indicated a voicemail was left at the vascular specialist's office and the facility was awaiting a phone call back. Record review of the nursing progress note dated 3/07/2023 written by RN B indicated Resident #'1 family reported the dressing to Resident #1's right foot was dirty and leaking pus. The nursing progress note indicated upon inspection Resident #1's dressing to his right foot was clean, dry, and intact. The nursing progress note indicated Resident #1's dressing to his right foot was freshly changed by the treatment nurse. The nursing progress noted indicated Resident #1 did not have any pus noted. Record review of the nursing progress note dated 3/10/2023 written by LVN A indicated a new order was received for the nurse practitioner for Resident #1 to start antibiotic therapy related to Resident #1's right foot being red and warm to the touch. Record review of the nursing progress note dated 3/13/2023 written by the Wound Care Nurse indicated the facility had spoken with the vascular specialist's office on 3/09/23 regarding the previous voicemail left concerning Resident #1 getting an appointment. The nursing progress note indicated the vascular specialist's office would let the facility know by the end of the day or by the next day if a referral was received. The nursing progress noted indicated the vascular specialist's office did not call back. The nursing progress note indicated the referral was discussed with the nurse practitioner on 3/10/2023. The nursing progress note indicated the nurse practitioner said the primary care physician's office did not do the referrals, but that it should be the facility's social worker who sends the referral. The nursing progress note indicated the social worker was not aware of what was needed for the referral. The nursing progress note indicated the nurse practitioner and the DCO were notified due to Resident #1's right lower extremity. The nursing progress note indicated the facility talked with the vascular specialist's office and the vascular specialist's office said they had not received a referral for Resident #1. The nursing progress note indicated the DCO was notified and will take care of it. Record review of the nursing progress note dated 3/18/2023 written by LVN G indicated Resident #1 was lying in bed, hanging his right leg off the bed. The nursing progress note indicated Resident #1 said he did not want his leg up. The nursing progress note indicated Resident #1 said his leg felt better hanging off the bed. The nursing progress note indicated Resident #1 was encouraged to elevate his right leg due to edema. The nursing progress note indicated Resident #1 chose not to elevate his leg. Record review of the nursing progress note dated 3/28/2023 written by LVN F indicated Resident #1's right foot and toes were looking significantly worse. The nursing progress note indicated orders were received to transport Resident #1 to the emergency room for further evaluation and treatment. Record review of the hospital records dated 3/28/23 indicated the chief complaint for Resident #1's emergency room visit was wound check. The hospital records indicated the toenail on the 4th right toe came off and the facility staff noted a hole in the toe. The hospital records indicated Resident #1 had dressed wounds to Lt foot. The hospital records indicated Resident #1 had erythema (reddening) and significant discoloration of all toes on right foot with foul smell. The hospital records indicated Resident #1 had ulcers on the 3rd and 4th toes on right foot. The hospital records indicated Resident #1 had decreased sensation to right foot. Record review of the hospital records dated 3/30/23 indicated Resident #1 was admitted from the facility with necrotic right foot and toes. The hospital records indicated Resident #1 was scheduled for an above the knee amputation on 3/31/2023. Record review of the hospital records last reviewed on 3/31/2023 indicated Resident #1's problem list included cellulitis and abscess of the toe on the right foot noted on 3/282023, peripheral vascular disease noted on 3/28/2023, skin ulcer of the bilateral feet noted on 3/28/2023, venous stasis (a condition in which veins have problems moving blood back to the heart) noted on 3/28/2023, and peripheral arterial disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) noted on 3/30/2023. During an interview on 3/31/23 at 2:25 pm the receptionist at the venous specialist's office said they had never seen Resident #1. The receptionist at the vascular specialist's office said they did not have Resident #1 in their computer system and had no record of a referral. During an interview on 3/31/23 at 2:29 pm the nurse practitioner said the referral for Resident #1 to see a vascular specialist was regarding vascular issues and arterial blockages. The nurse practitioner said she was unsure how advanced Resident #1's arterial/venous damage was at that time. The nurse practitioner said she would not be comfortable saying whether seeing the vascular specialist would have prevented Resident #1 from such an advanced amputation to right leg. During an interview on 3/31/2023 at 2:50 p.m. LVN F said she did not see Resident #1's feet often due to them being wrapped in wound dressing. LVN F said Resident #1 had edema to his bilateral feet. LVN F said the right foot was bluish in color at the beginning of March 2023. LVN F said Resident #1's family had asked his feet approximately 2 weeks prior. LVN F said she performed a dressing change on Resident #1's feet when the family had asked about his feet. LVN F said Resident #1's feet were a reddish/blue color and more swollen when she did the dressing changes approximately 2 weeks ago. During an interview on 3/31/2023 at 2:55 p.m. the SW said she had called the vascular specialist's office approximately 2 weeks ago. The SW said the vascular specialist's office said the were booked and short-handed. During an interview on 3/31/2023 at 2:56 p.m. the ADCO said the facility had asked the primary care physician's office to send a referral for Resident #1 to the vascular specialist. The ADCO said the vascular specialist's office had said the referral had to come from the primary care physician's office. The ADCO said she had called the vascular specialist's office to find out what information they needed for a referral and had not received a call back. The ADCO said Resident #1's right lower extremity had worsened over the past 2 weeks. The ADCO said Resident #1 was sent to the emergency room so they would be taken seriously. During an interview on 3/31/23 at 3:32 pm the Wound Care Nurse said she did not know if a referral was sent to the vascular specialist's office for Resident #1. The Wound Care Nurse said the DCO was supposed to talk to the SW regarding the referral for Resident #1 to the vascular specialist. The Wound care nurse said the nurse practitioner said the physician's office did not send referrals and that the facility's SW needed to send the referral to the vascular specialist for Resident #1. The Wound Care Nurse said Resident #1's right leg had significantly worsened over the past month. The Wound Care Nurse said Resident #1 was placed on antibiotics for the wounds to his right toes versus being sent out to the hospital. The Wound Care Nurse said Resident #1 was seen by the wound care nurse practitioner every Thursday at the facility. The Wound Care Nurse said Resident #1 did not have any discoloration to his legs but had pitting edema to both legs. The Wound Care Nurse said Resident #1's toes had worsened over the past month. During an interview on 4/03/2023 at 3:47 p.m. the primary care physician said he was informed of the referral for Resident #1 not being sent to the vascular specialist on 3/28/2023. The primary care physician said there was no way to know if Resident #1 had gotten into the vascular specialist if it would have prevented such an advanced right leg amputation. The primary care physician said he was aware of the wounds on Resident #1's toes. The primary care physician said he felt Resident #1 needed a referral to the vascular specialist due to the wounds on his right toes. During an interview on 4/03/2023 time unknown the wound care nurse practitioner said she had seen Resident #1 a week and half ago. The wound care nurse practitioner said she was not aware of any of the issues with Resident #1's right foot/toes at the time or the infections. The wound care nurse practitioner said she did not remember any redness or signs of infections to Resident #1's right toes. The wound care nurse practitioner said Resident #1's right foot did not have a pulse. The wound care nurse practitioner said she did not think Resident #1 needed to go to the hospital, but Resident #1 did need a vascular consult During an interview on 4/04/2023 at 1:45 p.m. the SW said she handled referrals to mobile optometry, podiatry, hearing, and dental services. The SW said she had never done a referral to a physician or specialist. The SW said she was told by the nursing staff referrals to a physician or specialist was supposed to come from the primary care physician. The SW said she sometimes made appointments/referred residents for optometry, podiatry, hearing, and dental services in the community. The SW said she had never been trained on sending a referral to a physician or specialist. During an interview on 4/04/23 at 1:52 p.m. the ADCO said the facility did not have a process for sending referral to physicians or specialists. The ADCO said the DCO had told her it was the primary care physician's responsibility to send referrals. During an interview on 04/04/23 at 1:54 p.m. the DCO said the physician/Medical Director told the facility they did not send referrals. The DCO said the facility cannot make referrals. The DCO said there was not a process in place for making/sending referrals. During an interview on 04/04/23 at 2:00 p.m. the EDO said for referrals the charge nurse or SW would make the appointments. The EDO said the facility did not have a policy regarding referrals to outside physicians or specialists. The EDO said if the physician/Medical Director wrote an order for a resident to see an outside physician/specialist the facility would call to start the process of getting the appointment made. Record review of the facility's Change in Condition or Status policy last revised May 2017 indicated, .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): .significant change in the resident's physical/emotional/mental condition .need to transfer the resident to a hospital or treatment center . The EDO was notified on 4/04/2023 at 3:20 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The EDO was provided the Immediate Jeopardy template on 4/04/2023 at 3:22 p.m. The facility's Plan of Removal was accepted on 4/06/2023 at 8:28 a.m. and included: In Response to the facility failure to have a referral system or policy in place, the Administrator immediately created and implemented a referral policy on 4-4-23 to ensure that no additional residents are affected by poor quality of care. To ensure no other residents were affected by the facility failure of not having a referral system in place, the Director of Clinical Operations or Assistant Director of Clinical Operations has completed a review all orders on 4-4-23, for any orders requiring physician and or specialist referrals to ensure referrals are handled in a timely manner. No additional missed referrals were found. In Response to the facility failure to follow up with physician, the Medical Director, Licensed Nurses, Social Worker and wound care specialist will be provided in-service education related to the referral process policy. Inservice: Physician referral process for sending residents to a specialist or outside physician services by obtaining the Medical Director's referral order beginning on 4-4-23 to be completed by 04-4-23, by the Administrator or Assistant Director of Nurse's which includes: Referral Policy: 1. Upon receiving directions or recommendations from a provider or nurse practitioner, whether a physician or nurse practitioner, the charge nurse is to contact the Medical Director immediately and enter an order in PCC. 2. The charge Nurse to notify the Director of Nurses and/or the Assistant Director of Nurses and the Social Worker of the referral. 3. Social Worker to call in referral order, confirm insurance, obtain doctor signature on forms if needed and make appointment with Specialist and arrange for appropriate transportation. 4. Administrator to be notified if referrals are refused or denied by physician or Medical Director immediately with the reason for the denial to determine if the resident needs to be sent out to hospital for further evaluation. If it has been found the resident does not need immediate referral, the Director of Nurses will continue to monitor during daily clinical meetings with charge nurses and treatment nurses for change of condition. If a change of condition is found the physician is to be immediately notified. 5. Newly hired nurses will receive in-service from the Assist Director of Nurses regarding physician referral during orientation process, and to be included in the nurse's information book or Brain Book at nurse's station. In response to the facility failure to send a referral to the vascular specialist, the Director of Nurses, Assistant Director of Nurses and Social Worker will be provided in service to obtain the necessary information from the specialist's office, including vascular specialist, for the referral requirements needed from the physician and obtain the required signature's or orders to accommodate the requirements for the specialist to ensure there are no delays in resident's delay in care. In-service provided to Director of Nurses, Assistant Director of Nurses, and Social Worker 04/04/23 by Administrator to be completed by 04/04/23. Validation/Monitoring Tools Director of Clinical Operations or Designee will validate staff knowledge base through random questioning. Director of Clinical Operations or designee will review any referral orders documented by reviewing orders in daily stand up meeting and clinical meetings to ensure appointments are being made, beginning 4-4-21. Director of Clinical Operations or designee has called to follow up with Resident affected by the Failure of Quality of Care 4-4-23. Information obtained was that the resident received an above knee amputation and is being discharged to another skilled nursing facility for rehab. On 4/06/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the chart audits for residents who had been referred to outside providers in March 2023 was performed with no other issues noted. Record review of the facility's undated Referral Policy was performed. The Referral Policy indicated the facility's newly implemented steps in ensuring referrals were made to outside providers in a timely manner. Record review of the facility's Brain Book located at the nurse's station indicated the referral policy had been added into the book and was available to the nursing staff at all times for reference. Record review and signature verification was performed on in-services dated 3/30/23 through 4/13/23 regarding the facility's Referral Policy Interviews of staff on 4/04/2023 between 11:03 a.m. and 11:48 a.m. (LVN A, RN B, LVN C, RN D, RN E, ADCO, LVN F, SW, MDS nurse, Wound Care Nurse, and DON) were performed. During the interviews staff were able to correctly identify the process for referrals per the facility's Referral Policy. Interview with the Medical Director and nurse practitioner on 4/04/23 between 11:38 a.m. and 11:41 a.m. regarding the facility's referral policy indicated they had received and agreed with facility's Referral Policy. Both the Medical Director and nurse practitioner said this policy would help ensure residents received appointments and were seen by outside providers and specialists On 4/06/2023 at 11:51 a.m., the EDO was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately inform the physician when there was a significant change in the resident's physical and mental status for 1 of 6 residents whose records were reviewed for change in condition. (Resident #1) 1. The facility failed to notify the physician Resident #1 was not receiving her indefinitely prescribed antibiotic related to vertebral osteomyelitis. 2. The facility failed to notify the physician Resident #1 did not receive her vertebral x-ray that was ordered related to her complaints of severe back pain. 3. The facility failed to notify the physician Resident #1 had pressure wounds to her feet and a surgical wound over her lumbar spine, upon her admission to the facility. An Immediate Jeopardy (IJ) situation was identified on 11/04/22 at 12:50 p.m. While the IJ was removed on 11/06/22 at 2:50 p.m., the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures resulted in the resident not receiving urgent medical care and resulted in death. Findings included: Record review of Resident #1's face sheet, with a print date of 11/07/22, indicated she was [AGE] years old, admitted on [DATE], readmitted on [DATE] and discharged on 10/28/22. She had diagnoses including osteomyelitis of the lumbar (lower back) vertebra, diabetes, bipolar (a condition causing extreme mood swings from emotional highs to emotional lows), anxiety, high blood pressure, and acute (short term) kidney failure. Record review of Resident #1's hospital history and physical, with an admission date of 08/30/22, indicated she had lumbar surgery in May 2022, but did not give the exact date. Her wound became infected, and she was readmitted to the hospital in July 2022 for removal of hardware in her spine. Blood cultures were positive for MRSA (a bacteria that is resistant to most antibiotics and causes hard to treat infections) and she was placed on antibiotics. After a few more re-hospitalizations, she was diagnosed with osteomyelitis and underwent another surgery to stabilize her spine. An active drug list sent to the facility from the hospital on [DATE], indicated she was on doxycycline monohydrate 100mg and was to receive it long term. The orders did not indicate she was to follow up with any physician and did not address wound care or monitoring of wounds. Record review of Resident #1's baseline care plan, completed on 09/27/22 by the interim-DON indicated she had no wounds or skin alterations. Record review of Resident #1's admission MDS, dated [DATE], indicated she had adequate hearing and vision, could understand and was understood by others, and had intact cognition. She exhibited behavioral symptoms not directed at others from 1 to 3 days of the look back period and she disrupted the living environment of others. She was totally dependent on two staff members with bed mobility, transfers, walking, dressing and toileting. She utilized a wheelchair for mobility. She was documented as not having surgery 100 days prior to admission, being at risk for pressure sores, but not having any pressure sores or surgical wounds. The MDS also did not indicate she had received antibiotics within the first 7 days of her stay. Record review of Resident #1's care plan, with an admission date of 10/21/22, indicated she had a history of falls due to her cognition, had impaired cognitive function, and had current skin conditions. The skin conditions were marked as surgical incision, surgical wound and open lesions other than stasis/venous areas. Interventions included treating per physician orders, monitor areas for increased breakdown or infection, monitor for and treat pain per physician orders, and assess skin weekly and record findings in the clinical record. Record review of Resident #1's order summary report, indicated active orders as of 11/07/22 included orders for three areas to her lumbar spine to be cleansed with normal saline, dried, treated with collagen and honey, and dressed once a day. Orders for the areas were entered on 10/27/22. An order for doxycycline 100mg capsule by mouth twice a day (an antibiotic) was entered on 10/21/22 and had a start date of 10/26/22. Record review of Resident #1's order summary report, indicated discontinued orders as of 10/01/22 through 10/28/22 included the following orders: *doxycycline monohydrate 100mg capsules twice a day and give long term, ordered on 9/27/22 and an end date of 10/03/22. *doxycycline hyclate 100mg tablet twice a day was ordered on 10/21/22 and ended on 10/21/22. *doxycycline monohydrate 100mg capsules twice a day was ordered on 10/21/22 with a start date of 10/26/22. *an x-ray to her lumbar spine for severe pain was ordered on 10/08/22 and ended on 10/11/22. Record review of Resident #1's September MAR, indicated she did not receive doxycycline monohydrate through 09/01/22 to 09/30/22. Record review of Resident #1's October MAR, indicated she began receiving doxycycline monohydrate 100mg capsules on 10/26/22 at 9 p.m. Record review on 11/03/22 at 3:00 p.m. of the facility drug destruction log revealed no record of Resident #1's doxycycline being destroyed within the past month. Record review of Resident #1's admission assessment, dated 09/27/22 and completed by LVN A, indicated she had a surgical incision to her upper-mid vertebrae, a pressure wound to the outer side of her left foot and the inner side of her left foot. The assessment did not indicate the size or condition of the wounds. Record review of Resident #1's weekly skin assessment, dated 09/27/22 and completed by LVN A, indicated she had a post-surgical site to her mid lumbar with 2 sutures noted, and a small area to the mid-site. The wound was covered with a dressing and tape. The two wounds to her left foot were covered with a foam dressing. The assessment did not indicate the size or condition of the wounds. Record review of Resident #1's electronic chart throughout the duration of the investigation between 11/01/22 to 11/9/22 revealed no other weekly skin assessments during her stay in the facility. Record review of a nurse's note, written by LVN A and dated 09/27/22 at 12:45 p.m. indicated Resident #1 was just admitted to the facility from the hospital. LVN A completed a head-to-toe assessment on the resident and wrote see assessments. The resident was described as alert and oriented, in no pain, and her medications were on order. The note did not indicate the resident having a surgical incision to her back or pressure wounds to her left foot. Record review of the 24-hour report dated 09/27/22 indicated Resident #1 admitted to the facility with a diagnosis of osteomyelitis, diabetes, high blood pressure, low thyroid, a foley catheter, and weakness. The report did not indicate her surgical incision or the wounds to her feet. Record review of the 24-hour report dated 09/29/22 indicated Resident #1 yelled out all shift on the day shift. The night shift indicated she had osteomyelitis of the vertebra. Record review of a nurse's note, written by LVN A and dated 09/30/22 at 3:27 p.m., indicated Resident #1 had nausea and vomiting caused by coughing. A COVID test was conducted, and she was found to be positive. Isolation and contact precautions were to be initiated. Record review of the 24-hour report dated 09/30/22 revealed no report found. Record review of the 24-hour report dated 10/01/22, during Resident #1's COVID isolation, indicated she changed rooms to 314. Record review of Resident #1's weekly skin assessment, dated 10/04/22 and completed by agency LVN B, indicated she had no surgical wounds, pressure wounds, or skin alterations. Record review of a nurse's note, written by agency LVN C and dated 10/08/22 at 1:10 p.m., indicated Resident #1 was yelling out, had increased agitation/anxiety, was throwing things, and reporting pain to her lower back. The physician gave an order to x-ray her lumbar spine related to severe pain. Record review of the 24-hour report dated 10/08/22, during Resident #1's COVID isolation, indicated she was to receive an x-ray to the lumbar spine on the day shift. She continued to yell out constantly on the night shift. Record review of the 24-hour report dated 10/09/22, during Resident #1's COVID isolation, indicated they were still awaiting the x-ray to her spine. Record review of the 24-hour report book on 11/03/22 at 4:00 p.m., revealed no other COVID wing 24-hour reports except for 10/01/22, 10/08/22 and 10/09/22. Record review of a nurse's note, written by agency LVN D and dated 10/10/22 at 3:26 a.m., indicated Resident #1 was continuing to yell out, banging on the walls, and yelling for staff to help her. LVN D indicated the resident was still awaiting the x-ray to her lumbar spine related to frequent pain. Record review of Resident #1's physician consult note, with an admission date of 10/19/22, indicated she admitted for hospice and was to continue doxycycline hyclate 100mg twice a day upon discharge and was to be on hospice services. The ID Physician who had previously treated Resident #1 indicated in her progress notes on 10/20/22, that the resident had discharged from the hospital on antibiotics with instructions to continue them indefinitely due to recurrent back infections. The physician also indicated the resident had gone off the antibiotics while residing in the facility. The paperwork did not indicate the condition of the resident's wounds, only wound care orders, and the resident's family wanted her to begin hospice care. Record review of a nurse's note, written by LVN A and dated 10/21/22 at 12:00 p.m., indicated Resident #1 was readmitted to the facility on hospice services. She was described as having discoloration to her heels, the dehisced wound over her lumbar vertebrae, and two open areas to her buttocks. Record review of Resident #1's readmission assessment, dated 10/21/22 and completed by LVN A, indicated she had a surgical incision to her upper-mid vertebrae, a pressure wound to her sacrum (the base of the spine, helping to form the pelvis), and vascular wounds to her left and right heels. The assessment did not indicate the size or condition of the wounds. Record review of Resident #1's discharge MDS, dated [DATE], indicated she had short-term memory problems, moderately impaired decision-making skills, and continued to exhibit behaviors not directed at others. She was totally dependent on staff for all ADLs, except for eating, which required only supervision. She was again documented as not having skin concerns or wounds, and as not receiving an antibiotic in the past 7 days. During an interview on 11/01/22 at 2:10 p.m. with RN F and LVN A, RN F said she had issues earlier in the day, on 11/01/22, while putting in orders for doxycycline hyclate for a different resident. She said the pharmacy automatically kicked out the order and wanted to switch it to doxycycline monohydrate instead. She said she had been looking for the order and realized it was no longer there, then she realized the pharmacy had sent the new order for her to confirm. She said because LVN A was an LVN, she could not confirm orders, only RNs could. She said LVN A would have put in the doxycycline order and then when an order change confirmation came in, the DON would have to approve it since she was an RN. LVN A said Resident #1 admitted and very quickly into her stay was sent to the COVID unit. She said she did not know if anything was done for the resident, such as skin assessments, wound care, and medication administration. The nurses said they did not have a wound care nurse and had do their own treatments on their halls. During an interview on 11/01/22 at 3:52 p.m. CNA E said she had worked with Resident #1 on the COVID hall. She denied observing any wounds on her back because on the COVID hall the resident would scream when touched and she would not turn all the way over. She said the night she found the wound on her back, 10/18/22, the resident had been complaining of pain from not having a bowel movement. The nurse gave the resident a laxative and later, the resident told the aide she had gone to the bathroom and needed to be changed. The aide went to change her, and saw the sheets were soiled and it was a very substantial amount. She said she believed the resident felt the wetness from her wound and thought it was a bowel movement. She said she initially thought it was a bowel movement as well, until she rolled the resident all the way over and saw the wound. The wound was purple and covered by the flaps of skin due to her obesity. She said when she pulled the resident's skin taught, she could physically see into the wound and large amounts of drainage came out with even minor touch. She said the drainage was chunky and gritty and was a yellowish-green tint, like a snot color, and it smelled. She said agency LVN B was unaware of the wound and looked in the chart to see if any wound care had been ordered for the wound but did not find any. She said LVN B sent the resident out because of the state of the wound. She said before the resident went to the hospital, she was cognitive and knew the aide's name and was with it, but after the hospital she did not know anyone and was no longer cognitively intact and would just holler out for help. During an interview on 11/01/22 at 4:18 p.m. CNA G said she did not remember Resident #1 having any wounds to her back or any wounds at all. She said she was never aware the resident had a surgical incision over her spine and had never been told of any wounds. She said she was not very familiar with the resident and only worked with her maybe 4 or 5 times during the resident's stay. During a phone interview on 11/01/22 a 4:30 p.m. agency LVN B said she had been going back and forth between days and nights. She said the 6a-2p was supposed to do most of the wound care. She said Resident #1 was obese and flabby and a skin fold on her back covered the wound. She said she had to pick up the fold and pull her skin taught, all while the resident was screaming and swinging at staff. She said the wound was pretty long because it was a surgical incision, but she did not know how long for sure. She said maybe a quarter of her spine. She said when she pulled the skin back, dark brown drainage poured out of it. She said she went back to look at the resident's chart and saw she had MRSA in her spine before she came to the facility. She said the drainage did not have an odor and the wound did not appear to be red or swollen. She said she did not remember the skin assessment she did for the resident on 10/04/22, but if she documented the resident had no wounds, she must have looked the resident over completely. She said she remembered the last time she took care of the resident, she recalled giving the resident brown and yellow pills, which would be doxycycline. She said that was right before the resident left with her family on 10/28/22. During a phone interview on 11/02/22 at 9:00 a.m. the Pharmacist said the medical director had signed for therapeutic interchanges to be made whenever an order was put in for a wrong medication. For example, if the doctor ordered doxycycline monohydrate and staff entered doxycycline hyclate, the system would kick out the order for hyclate and enter a new order for the monohydrate, which an RN must approve. She said the corporate office was usually the one that requested the therapeutic interchanges and if one facility under the corporation did it then most likely all facilities under that corporation did. She said there were different reasons for the therapeutic interchanges, such as cost to the facility, or ensuring the correct order was followed. She said she saw in the system where the doxycycline was ordered on 09/27/22 and the system changed it to doxycycline monohydrate capsules. She said they sent out 60 pills that day. The next order for them came in on 10/21/22, they did not send any out because the refill was too soon from the last fill date. During a phone interview on 11/02/22 at 10:36 a.m. the ID physician said she was told by the family and Resident #1, at the hospital, that she had not been receiving antibiotics at the facility. She said she had wanted the resident to follow up with her, but that never happened. She was unsure why a follow up never happened, whether it was due to hospital error, facility error, or even family error. She said she could not recall what the wound looked or smelled like at the hospital when she arrived for treatment. She said she did give an order for the resident to have indefinite doxycycline at the facility, but since she did not go to the facility, or write orders there, she was not sure if the resident received the antibiotics or not. During an interview on 11/03/22 at 2:20 p.m. LVN A said she did part of Resident #1's admission assessment and paperwork. She said she was told in report from the discharging hospital that the resident had a surgical incision over her spine. When the resident arrived at the facility, she had a dressing over the incision. The nurse did not take off the bandage because she was told wound care had been done before the resident left the hospital. She did a thorough head to toe skin assessment and noted the resident had the wound to her spine and two wounds to her feet. She said the hospital did not say anything about what kind of wound care orders they had in place at the hospital or anything about the resident following up with a physician. She said when she saw the wounds to the resident's feet and back, she should have put the orders in for wound care, but she gave all the paperwork to the ADON. The ADON said she would put all the orders in, and the oncoming shift could take care of the rest. She said if she had given the initial dose of the resident's doxycycline, she would have followed up on it for 72 hours, so if there were no notes following up on it, then she did not administer it. During an interview on 11/03/22 at 2:55 p.m. agency LVN D said she did not remember seeing any wound care orders for Resident #1 and did not remember seeing any wounds when she would do incontinent changes for her on the COVID wing. She said the resident was bad at turning and could not turn all the way over. She said she did not remember if the resident was on an antibiotic or not. During a phone interview on 11/03/22 at 4:00 p.m. agency LVN H said she did not remember Resident #1 having wounds while she worked the COVID wing. She said she did not remember the resident being on an antibiotic while she worked the COVID wing. During a phone interview on 11/03/22 at 4:05 p.m. agency LVN J said she did not ever remember doing wound care on Resident #1 while she worked the COVID wing. She did not remember if the resident was on an antibiotic or not. During a phone interview on 11/03/22 4:10 p.m. agency LVN K said she could not say for sure if Resident #1 had wounds while she worked the COVID wing. She said she did not remember if the resident took an antibiotic. She said she just remembered the resident yelling out and when they would go in her room, she would say she had not been yelling and did not need anyone to come in there. During an interview on 11/03/22 at 4:25 p.m. with the ADON and interim-DON, the ADON said she was not aware of Resident #1 having any wounds to her feet but did know she had a wound to her spine. She said she helped LVN A put the orders in and since she did not see any orders for wound care or for following up with a physician, she did not put any in. The ADON and the interim-DON said they were both unaware no one followed up on getting her wound care or to follow up with a physician. They also were unaware the pharmacy kept kicking out the doxycycline orders and the LVNs could not see the orders were being kicked out automatically and then resubmitted. They both denied knowing about the resident not receiving her antibiotics until 10/26/22. The interim-DON said she could not find the resident's x-ray of her back and it appeared the x-ray was never obtained. During a phone interview on 11/04/22 at 10:30 a.m. Resident #1's Physician said he was not aware of the resident not receiving wound care to her feet or her back. He was also not aware of her not receiving her doxycycline. He said he had not received the results of the x-ray to her back and had not been aware the x-ray was not obtained. He said had he known all this information, he would have made sure staff were giving her the ordered antibiotics, obtained the spinal x-ray, and gotten her into the ID for follow up. He said he believed she was seen by (ID physician's name) and was not aware the facility had never made a follow up appointment. During a phone interview on 11/05/22 at 10:19 a.m. agency LVN C said she did not remember if Resident #1 had wounds anywhere on her body. She said the resident would not let them turn her all the way over, so she did not know if the resident had any wounds to her back. She said the physician did order an x-ray for the resident's lumbar spine on 10/08/22 since she was complaining of pain to her there. She said the resident said she had pain to her back but then would not let them reposition her or turn her all the way over. She said she worked the 6a to 2p shift on 10/08/22 and then had to come back to work a 10p to 6 a shift. She said when she came back that night, she saw where the x-ray result was not received so she called the x-ray company to see where the results were. She said when she called the x-ray company , the on-call operator said the system had been out and he was not able to see anything on his end but would send a message to the x-ray technician. She said the technician never came on her shift and she notified the 6a to 2p nurse, the morning of 10/09/22 that the x-ray technician had not come and to call and follow up with the x-ray company about getting it done that day. During a phone interview on 11/08/22 at 3:28 p.m. LVN L denied ever being notified about an x-ray for Resident #1's back pain. She said the resident was always yelling out due to her psychological issues. She did not remember the resident having any wounds to her feet or her back. She denied anyone ever notifying her of the resident having a surgical wound to her back. Record review of the facility's Change in a Resident's Condition or Status policy indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care .resident rights, etc.) . Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): . .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; . .g. need to transfer the resident to a hospital/treatment center; . Record review of the facility's General Guidelines for Medication Administration policy indicated, .6. If a dose of regularly scheduled medication is withheld, refused, or given at a time other than the scheduled time (e.g., the resident is not in the facility at a scheduled time or a started dose of an antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If 3 consecutive doses, or in accordance with facility policy, of a vital medication are withheld, refused, or not available, the physician is notified. Nursing documents the notification and physician response. An Immediate Jeopardy (IJ) was identified on 11/04/22 at 12:50 p.m., due to the above failures. The Administrator and DON were notified of the IJ and the IJ template was provided on 11/04/22 at 1:09 p.m. During an interview on 11/04/22 at 1:09 p.m. with the interim-DON, ADON and Administrator, the interim-DON and ADON both indicated they had not been aware of Resident #1's skin assessment on 10/04/22 not reflecting her wounds. The interim-DON said she documented the resident had no skin alterations because she did not know the resident had any skin issues. She said she could only go by what the LVN A had documented, and she didn't see any documentation about wounds. The interim-DON said she accepted the resident's change in doxycycline when she saw it was in the system awaiting approval. She did not realize the resident's doxycycline had been pending approval since 10/21/22 and was not approved by her until 10/26/22. She said she approved orders as they popped up in the system, but she did not realize they were popping up due to therapeutic interchanges. She said the reason it took her until 10/26/22 to approve the doxycycline was because she left the building on 10/21/22 and did not return until 10/26/22. The following Plan of Removal submitted by the facility was accepted on 11/06/22 at 8:52 a.m. and included the following: 11-4-22 Neglect Plan of Action Resident in question (Resident #1) that did not receive her antibiotics as ordered and is no longer in the building. A chart review of her pharmacy orders and therapeutic interchange was completed by the Director of Clinical Operations to review what transpired. At the time a new Director of Nurses in training was to review orders and failed to confirm new antibiotic orders. Audit of all medications compared to current orders for all residents in house was completed on 11/05/22 to ensure that no other residents have missed medications. Director of Clinical Operations, Assistant Director of Clinical Operations, Clinical Reimbursement Coordinator and Treatment Nurse reviewed clinical records for residents with wounds to ensure documented notification of family and physician. Director of Clinical Operations, Assistant Director of Clinical Operations, will review all x-rays ordered with over the last six months to ensure follow thru and notification of findings. The Director of Clinical Operations, Assistant Director of Clinical Operations, Treatment Nurse and All Licensed Nurses will be provided in-service education related to Notification of Change, including any signs and symptoms of worsening infections beginning on 11-4-22 by Director of Clinical Operations or designee which includes: 1. Physician must be notified of any new orders that were not written by the physician within 2 hours of admission or re-admission via phone. 2. Physician must be notified of any missed dosages of medication as prescribed no later than 3 missed doses as per policy. See attached. 3. Physician must be notified of any wounds present on admission or readmission and or wound orders within 2 hours of admission or re-admission via phone. 4. Physician to be notified of any change in medical conditions including worsening infections, falls, or medical changes withing 2 hours of assessment. See Monitoring form for changes in condition attached. The Director of Clinical Operations, Assistant Director of Clinical Operations, Treatment Nurse, and licensed nurses to be provided education on following physician's orders as it pertains to x-ray services on 11-4-22 by Director of Clinical Operations or designee which includes: 1. Nurses must complete orders as written. 2. If an order is not or cannot be complete physician must be notified via phone within 2 hours of receiving notification. 3. Each shift must follow up on x-ray orders until results are obtained. Newly hired nurses will receive in-services on proper physician notification processes. Validation/Monitoring Tools Director of Clinical Operations or designee will validate staff knowledge base through random questioning. Director of Clinical Operations or designee will review records for any newly admitted or readmitted resident daily in clinical meeting to ensure physician notification and appropriate follow up. Beginning 11-7-22. Director of Clinical Operations or designee will review all x-ray order daily in the clinical meeting to ensure x-rays are obtained and physician notification is completed. admission check list form is to be completed by admitting nurse to ensure appropriate notification and completion of assessments to be initiated within 2 hours of admission. See form attached. Change in conditions check list to be utilized to ensure nurse competency with completion of assessments and physician notification. Beginning 11-7-22. On 11/06/22 from 11:40 a.m. to 2:50 p.m. the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews with the RN weekend supervisor, the ADON, LVN L and LVN N between 11:45 a.m. and 2:15 p.m., staff indicated they had received adequate training regarding skin assessments, antibiotics, antibiotic orders and use of 24 hour reports. Record review of A Midnight Census Report dated 11/05/22 at 3:18 PM, by the interim-DON showed 37 Residents had been checked off as being reviewed by the DON for narcotics and all medications. Record review between 12:47 p.m. and 1:15 p.m. of staff who had received training, indicated 12 staff had been educated over the phone and stated their understanding of the education provided. During an interview on 11/02/22 at 12:47 p.m., the interim-DON said she conducted a full sweep of all 37 residents to ensure there were no new skin issues. She said she also reviewed all medications to ensure each resident had orders and medication available. The interim-DON said she also assessed each resident for pain. The interim-DON said all residents were to have a skin assessment on admission or re-admission within 2 hours. She said all nursing staff had been trained on skin assessments. She said nurses had also been trained on monitoring antibiotics for the duration of the schedule and 3 days after for any reactions. She said nurses were to notify the DON any time antibiotics are ordered. She said she is the Infection Control Preventionist for the facility at the time, until the new wound care nurse completes her training, then the new wound care nurse will take over that responsibility. Record review of PCP records between 12:47 p.m. and 1:15 p.m. showed orders were showing on the 24-hour report in the system. Paper 24-hour reports were also reviewed, and the nurses had documented new orders on the report. The Administrator and DON were informed the Immediate Jeopardy was removed on 11/06/22, at 2:50 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated 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 interview and record review, the facility failed to ensure treatment and care was provided based on the comprehensive assessment and in accordance with standards of practice for 1 of 6 residents reviewed for quality of care. (Resident #1) 1. The facility failed to ensure Resident #1's surgical incision to her lower back was monitored or received wound care. The surgical incision was found to be reopened, infected and draining on [DATE]. Two pressure wounds to her left foot, identified upon admission on [DATE], also never were monitored, or received treatment. 2. The resident was sent to the hospital on [DATE] when her surgical wound was found by staff and appeared to be infected. She returned to the facility on [DATE], under the care of hospice, with antibiotic orders which were not started until [DATE]. She left with her family AMA on [DATE] and expired at home on [DATE]. These failures could place residents at risk for not receiving necessary care and services to meet their needs, serious impairment, and death. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 12:50 p.m. While the IJ was removed on [DATE] at 2:50 p.m., the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure resulted in the resident not receiving urgent medical care and resulted in death. Findings included: Record review of Resident #1's face sheet, with a print date of [DATE], indicated she was [AGE] years old, admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. She had diagnoses including osteomyelitis of the lumbar (lower back) vertebra, diabetes, bipolar (a condition causing extreme mood swings from emotional highs to emotional lows), anxiety, high blood pressure, and acute (short term) kidney failure. Record review of Resident #1's hospital history and physical, with an admission date of [DATE], indicated she had lumbar surgery in [DATE], but did not give the exact date. Her wound became infected, and she was readmitted to the hospital in [DATE] for removal of hardware in her spine. Blood cultures were positive for MRSA (a bacteria that is resistant to most antibiotics and causes hard to treat infections) and she was placed on antibiotics. After a few more re-hospitalizations, she was diagnosed with osteomyelitis and underwent another surgery to stabilize her spine. An active drug list sent to the facility from the hospital on [DATE], indicated she was on doxycycline monohydrate 100mg and was to receive it long term. The orders did not indicate she was to follow up with any physician and did not address wound care or monitoring of wounds. Record review of Resident #1's baseline care plan, completed on [DATE] by the interim-DON indicated she had no wounds or skin alterations. Record review of Resident #1's admission MDS, dated [DATE], indicated she had adequate hearing and vision, could understand and was understood by others, and had intact cognition. She exhibited behavioral symptoms not directed at others from 1 to 3 days of the look back period and she disrupted the living environment of others. She was totally dependent on two staff members with bed mobility, transfers, walking, dressing and toileting. She utilized a wheelchair for mobility. She was documented as not having surgery 100 days prior to admission, being at risk for pressure sores, but not having any pressure sores or surgical wounds. Record review of Resident #1's care plan, with an admission date of [DATE], indicated she had a history of falls due to her cognition, had impaired cognitive function, and had current skin conditions. The skin conditions were marked as surgical incision, surgical wound and open lesions other than stasis/venous areas. Interventions included treating per physician orders, monitor areas for increased breakdown or infection, monitor for and treat pain per physician orders, and assess skin weekly and record findings in the clinical record. Record review of Resident #1's order summary report, indicated active orders as of [DATE] included orders for three areas to her lumbar spine to be cleansed with normal saline, dried, treated with collagen and honey, and dressed once a day. Orders for the areas were entered on [DATE] and no wound care orders were noted between her admission on [DATE] and her discharged on [DATE]. The resident was to receive a lumbar x-ray that was ordered on [DATE], with an end date of [DATE]. Record review of Resident #1's admission assessment, dated [DATE] and completed by LVN A, indicated she had a surgical incision to her upper-mid vertebrae, a pressure wound to the outer side of her left foot and the inner side of her left foot. The assessment did not indicate the size or condition of the wounds. Record review of Resident #1's weekly skin assessment, dated [DATE] and completed by LVN A, indicated she had a post-surgical site to her mid lumbar with 2 sutures noted, and a small area to the mid-site. The wound was covered with a dressing and tape. The two wounds to her left foot were covered with a foam dressing. The assessment did not indicate the size or condition of the wounds. Record review of Resident #1's electronic chart throughout the duration of the investigation between [DATE] to [DATE] revealed no other weekly skin assessments during her stay in the facility. Record review of a nurse's note, written by LVN A and dated [DATE] at 12:45 p.m. indicated Resident #1 was just admitted to the facility from the hospital. LVN A completed a head-to-toe assessment on the resident and wrote see assessments. The resident was described as alert and oriented, in no pain, and her medications were on order. The note did not indicate the resident having a surgical incision to her back or pressure wounds to her left foot. Record review of the 24-hour report dated [DATE] indicated Resident #1 admitted to the facility with a diagnosis of osteomyelitis, diabetes, high blood pressure, low thyroid, a foley catheter, and weakness. The report did not indicate her surgical incision or the wounds to her feet. Record review of the 24-hour report dated [DATE] indicated Resident #1 yelled out all shift on the day shift. The night shift indicated she had osteomyelitis of the vertebra. Record review of a nurse's note, written by LVN A and dated [DATE] at 3:27 p.m., indicated Resident #1 had nausea and vomiting caused by coughing. A COVID test was conducted, and she was found to be positive. Isolation and contact precautions were to be initiated. Record review of the 24-hour report dated [DATE] revealed no report found. Record review of the 24-hour report dated [DATE], during Resident #1's COVID isolation, indicated she changed rooms to 314. Record review of Resident #1's weekly skin assessment, dated [DATE] and completed by agency LVN B, indicated she had no surgical wounds, pressure wounds, or skin alterations. Record review of a nurse's note, written by agency LVN C and dated [DATE] at 1:10 p.m., indicated Resident #1 was yelling out, had increased agitation/anxiety, was throwing things, and reporting pain to her lower back. The physician gave an order to x-ray her lumbar spine related to severe pain. Record review of the 24-hour report dated [DATE], during Resident #1's COVID isolation, indicated she was to receive an x-ray to the lumbar spine on the day shift. She continued to yell out constantly on the night shift. The report did not contain any information regarding the resident's wounds to her feet or back. Record review of the 24-hour report dated [DATE], during Resident #1's COVID isolation, indicated they were still awaiting the x-ray to her spine. The report did not contain any information regarding the resident's wounds to her feet or back. Record review of the 24-hour report book on [DATE] at 4:00 p.m., revealed no other COVID wing 24-hour reports except for [DATE], [DATE] and [DATE]. Record review of a nurse's note, written by agency LVN D and dated [DATE] at 3:26 a.m., indicated Resident #1 was continuing to yell out, banging on the walls, and yelling for staff to help her. LVN D indicated the resident was still awaiting the x-ray to her lumbar spine related to frequent pain. Record review of Resident #1's physician consult note, with an admission date of [DATE], indicated she admitted for hospice and was to continue doxycycline hyclate 100mg twice a day upon discharge and was to be on hospice services. The ID Physician who had previously treated Resident #1 indicated in her progress notes on [DATE], that the resident had discharged from the hospital on antibiotics with instructions to continue them indefinitely due to recurrent back infections. The physician also indicated the resident had gone off the antibiotics while residing in the facility. The paperwork did not indicate the condition of the resident's wounds, only wound care orders, and the resident's family wanted her to begin hospice care. Record review of a nurse's note, written by LVN A and dated [DATE] at 12:00 p.m., indicated Resident #1 was readmitted to the facility on hospice services. She was described as having discoloration to her heels, the dehisced wound over her lumbar vertebrae, and two open areas to her buttocks. Record review of Resident #1's readmission assessment, dated [DATE] and completed by LVN A, indicated she had a surgical incision to her upper-mid vertebrae, a pressure wound to her sacrum (the base of the spine, helping to form the pelvis), and vascular wounds to her left and right heels. The assessment did not indicate the size or condition of the wounds. Record review of Resident #1's discharge MDS, dated [DATE], indicated she had short-term memory problems, moderately impaired decision-making skills, and continued to exhibit behaviors not directed at others. She was totally dependent on staff for all ADLs, except for eating, which required only supervision. Further review indicated the resident as not having skin concerns or wounds. During an interview on [DATE] at 2:10 p.m. LVN A said Resident #1 admitted and very quickly into her stay was sent to the COVID unit. She said she did not know if anything was done for the resident, such as skin assessments, wound care, and medication administration. The nurses said they did not have a wound care nurse and had do their own treatments on their halls. During a phone interview on [DATE] at 3:14 p.m. Resident #1's family member said she did not know if the resident was given antibiotics at the facility, but had assumed she was not given them, since her infection never got better. She said she took Resident #1 out of the facility and took her home on hospice care. She said Resident #1 died at home on [DATE]. During an interview on [DATE] at 3:52 p.m. CNA E said she had worked with Resident #1 on the COVID hall. She denied observing any wounds on her back because on the COVID hall the resident would scream when touched and she would not turn all the way over. She said the night she found the wound on her back, [DATE], the resident had been complaining of pain from not having a bowel movement. The nurse gave the resident a laxative and later, the resident told the aide she had gone to the bathroom and needed to be changed. The aide went to change her, and saw the sheets were soiled and it was a very substantial amount. She said she believed the resident felt the wetness from her wound and thought it was a bowel movement. She said she initially thought it was a bowel movement as well, until she rolled the resident all the way over and saw the wound. The wound was purple and covered by the flaps of skin due to her obesity. She said when she pulled the resident's skin taught, she could physically see into the wound and large amounts of drainage came out with even minor touch. She said the drainage was chunky and gritty and was a yellowish-green tint, like a snot color, and it smelled. She said agency LVN B was unaware of the wound and looked in the chart to see if any wound care had been ordered for the wound but did not find any. She said LVN B sent the resident out because of the state of the wound. She said before the resident went to the hospital, she was cognitive and knew the aide's name and was with it, but after the hospital she did not know anyone and was no longer cognitively intact and would just holler out for help. During an interview on [DATE] at 4:18 p.m. CNA G said she did not remember Resident #1 having any wounds to her back or any wounds at all. She said she was never aware the resident had a surgical incision over her spine and had never been told of any wounds. She said she was not very familiar with the resident and only worked with her maybe 4 or 5 times during the resident's stay. During a phone interview on [DATE] a 4:30 p.m. agency LVN B said she had been going back and forth between days and nights. She said the 6a-2p was supposed to do most of the wound care. She said Resident #1 was obese and flabby and a skin fold on her back covered the wound. She said she had to pick up the fold and pull her skin taught, all while the resident was screaming and swinging at staff. She said the wound was pretty long because it was a surgical incision, but she did not know how long for sure. She said maybe a quarter of her spine. She said when she pulled the skin back, dark brown drainage poured out of it. She said she went back to look at the resident's chart and saw she had MRSA in her spine before she came to the facility. She said the drainage did not have an odor and the wound did not appear to be red or swollen. She said she did not remember the skin assessment she did for the resident on [DATE], but if she documented the resident had no wounds, she must have looked the resident over completely. She said she remembered the last time she took care of the resident, she recalled giving the resident brown and yellow pills, which would be doxycycline. She said that was right before the resident left with her family on [DATE]. During a phone interview on [DATE] at 10:36 a.m. the ID physician said she had wanted the resident to follow up with her, but that never happened. She was unsure why a follow up never happened, whether it was due to hospital error, facility error, or even family error. She said she could not recall what the wound looked or smelled like at the hospital when she arrived for treatment. During an interview on [DATE] at 2:20 p.m. LVN A said she did part of Resident #1's admission assessment and paperwork. She said she was told in report from the discharging hospital that the resident had a surgical incision over her spine. When the resident arrived at the facility, she had a dressing over the incision. The nurse did not take off the bandage because she was told wound care had been done before the resident left the hospital. She did a thorough head to toe skin assessment and noted the resident had the wound to her spine and two wounds to her feet. She said the hospital did not say anything about what kind of wound care orders they had in place at the hospital or anything about the resident following up with a physician. She said when she saw the wounds to the resident's feet and back, she should have put the orders in for wound care, but she gave all the paperwork to the ADON. The ADON said she would put all the orders in, and the oncoming shift could take care of the rest. During an interview on [DATE] at 2:55 p.m. agency LVN D said she did not remember seeing any wound care orders for Resident #1 and did not remember seeing any wounds when she would do incontinent changes for her on the COVID wing. She said the resident was bad at turning and could not turn all the way over. During a phone interview on [DATE] at 4:00 p.m. agency LVN H said she did not remember Resident #1 having wounds while she worked the COVID wing. During a phone interview on [DATE] at 4:05 p.m. agency LVN J said she did not ever remember doing wound care on Resident #1 while she worked the COVID wing. During a phone interview on [DATE] 4:10 p.m. agency LVN K said she could not say for sure if Resident #1 had wounds while she worked the COVID wing. She said she just remembered the resident yelling out and when they would go in her room, she would say she had not been yelling and did not need anyone to come in there. During an interview on [DATE] at 4:25 p.m. with the ADON and interim-DON, the ADON said she was not aware of Resident #1 having any wounds to her feet but did know she had a wound to her spine. She said she helped LVN A put the orders in and since she did not see any orders for wound care or for following up with a physician, she did not put any in. The ADON and the interim-DON said they were both unaware no one followed up on getting her wound care or to follow up with a physician. The interim-DON said she could not find the resident's x-ray of her back and it appeared the x-ray was never obtained. During a phone interview on [DATE] at 10:30 a.m. Resident #1's Physician said he was not aware of the resident not receiving wound care to her feet or her back. He said he had not received the results of the x-ray to her back and had not been aware the x-ray was not obtained. He said had he known all this information, he would have made sure staff were giving her the ordered antibiotics, obtained the spinal x-ray, and gotten her into the ID for follow up. He said he believed she was seen by (ID physician's name) and was not aware the facility had never made a follow up appointment. During a phone interview on [DATE] at 10:19 a.m. agency LVN C said she did not remember if Resident #1 had wounds anywhere on her body. She said the resident would not let them turn her all the way over, so she did not know if the resident had any wounds to her back. She said the physician did order an x-ray for the resident's lumbar spine on [DATE] since she was complaining of pain to her there. She said the resident said she had pain to her back but then would not let them reposition her or turn her all the way over. She said she worked the 6a to 2p shift on [DATE] and then had to come back to work a 10p to 6 a shift. She said when she came back that night, she saw where the x-ray result was not received so she called the x-ray company to see where the results were. She said when she called the x-ray company , the on-call operator said the system had been out and he was not able to see anything on his end but would send a message to the x-ray technician. She said the technician never came on her shift and she notified the 6a to 2p nurse, the morning of [DATE] that the x-ray technician had not come and to call and follow up with the x-ray company about getting it done that day. During a phone interview on [DATE] at 3:28 p.m. LVN L denied ever being notified about an x-ray for Resident #1's back pain. She said the resident was always yelling out due to her psychological issues. She did not remember the resident having any wounds to her feet or her back. She denied anyone ever notifying her of the resident having a surgical wound to her back. Record review of the facility's Change in a Resident's Condition or Status policy indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care .resident rights, etc.) . Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): . .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; . .g. need to transfer the resident to a hospital/treatment center; . An Immediate Jeopardy (IJ) was identified on [DATE] at 12:50 p.m., due to the above failures. The Administrator and DON were notified of the IJ and the IJ template was provided on [DATE] at 1:09 p.m. During an interview on [DATE] at 1:09 p.m. with the interim-DON, ADON and Administrator, the interim-DON and ADON both indicated they had not been aware of Resident #1's skin assessment on [DATE] not reflecting her wounds. The interim-DON said she documented the resident had no skin alterations because she did not know the resident had any skin issues. She said she could only go by what the LVN A had documented, and she didn't see any documentation about wounds. The interim-DON said she accepted the resident's change in doxycycline when she saw it was in the system awaiting approval. She did not realize the resident's doxycycline had been pending approval since [DATE] and was not approved by her until [DATE]. The following Plan of Removal submitted by the facility was accepted on [DATE] at 8:52 a.m. and included the following: 11-4-22 Neglect Plan of Action Resident in question (Resident #1) that did not receive her antibiotics as ordered and is no longer in the building. A chart review of her pharmacy orders and therapeutic interchange was completed by the Director of Clinical Operations to review what transpired. At the time a new Director of Nurses in training was to review orders and failed to confirm new antibiotic orders. Audit of all medications compared to current orders for all residents in house was completed on [DATE] to ensure that no other residents have missed medications. Director of Clinical Operations, Assistant Director of Clinical Operations, Clinical Reimbursement Coordinator and Treatment Nurse reviewed clinical records for residents with wounds to ensure documented notification of family and physician. Director of Clinical Operations, Assistant Director of Clinical Operations, will review all x-rays ordered with over the last six months to ensure follow thru and notification of findings. The Director of Clinical Operations, Assistant Director of Clinical Operations, Treatment Nurse and All Licensed Nurses will be provided in-service education related to Notification of Change, including any signs and symptoms of worsening infections beginning on 11-4-22 by Director of Clinical Operations or designee which includes: 1. Physician must be notified of any new orders that were not written by the physician within 2 hours of admission or re-admission via phone. 2. Physician must be notified of any missed dosages of medication as prescribed no later than 3 missed doses as per policy. See attached. 3. Physician must be notified of any wounds present on admission or readmission and or wound orders within 2 hours of admission or re-admission via phone. 4. Physician to be notified of any change in medical conditions including worsening infections, falls, or medical changes withing 2 hours of assessment. See Monitoring form for changes in condition attached. The Director of Clinical Operations, Assistant Director of Clinical Operations, Treatment Nurse, and licensed nurses to be provided education on following physician's orders as it pertains to x-ray services on 11-4-22 by Director of Clinical Operations or designee which includes: 1. Nurses must complete orders as written. 2. If an order is not or cannot be complete physician must be notified via phone within 2 hours of receiving notification. 3. Each shift must follow up on x-ray orders until results are obtained. Newly hired nurses will receive in-services on proper physician notification processes. Validation/Monitoring Tools Director of Clinical Operations or designee will validate staff knowledge base through random questioning. Director of Clinical Operations or designee will review records for any newly admitted or readmitted resident daily in clinical meeting to ensure physician notification and appropriate follow up. Beginning 11-7-22. Director of Clinical Operations or designee will review all x-ray order daily in the clinical meeting to ensure x-rays are obtained and physician notification is completed. admission check list form is to be completed by admitting nurse to ensure appropriate notification and completion of assessments to be initiated within 2 hours of admission. See form attached. Change in conditions check list to be utilized to ensure nurse competency with completion of assessments and physician notification. Beginning 11-7-22. On [DATE] from 11:40 a.m. to 2:50 p.m. the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews with the RN weekend supervisor, the ADON, LVN L and LVN N between 11:45 a.m. and 2:15 p.m., staff indicated they had received adequate training regarding skin assessments, antibiotics, antibiotic orders and use of 24 hour reports. Record review of A Midnight Census Report dated [DATE] at 3:18 PM, by the interim-DON showed 37 Residents had been checked off as being reviewed by the DON for narcotics and all medications. Record review between 12:47 p.m. and 1:15 p.m. of staff who had received training, indicated 12 staff had been educated over the phone and stated their understanding of the education provided. During an interview on [DATE] at 12:47 p.m., the interim-DON said she conducted a full sweep of all 37 residents to ensure there were no new skin issues. She said she also reviewed all medications to ensure each resident had orders and medication available. The interim-DON said she also assessed each resident for pain. The interim-DON said all residents were to have a skin assessment on admission or re-admission within 2 hours. She said all nursing staff had been trained on skin assessments. She said nurses had also been trained on monitoring antibiotics for the duration of the schedule and 3 days after for any reactions. She said nurses were to notify the DON any time antibiotics are ordered. She said she is the Infection Control Preventionist for the facility at the time, until the new wound care nurse completes her training, then the new wound care nurse will take over that responsibility. Record review of PCP records between 12:47 p.m. and 1:15 p.m. showed orders were showing on the 24-hour report in the system. Paper 24-hour reports were also reviewed, and the nurses had documented new orders on the report. The Administrator and DON were informed the Immediate Jeopardy was removed on [DATE], at 2:50 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated 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 interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured accurate administering of all drugs to meet the needs of the residents, for 1 of 6 residents reviewed for medication regimen. (Resident #1) The facility failed to ensure Resident #1 was given her indefinitely prescribed doxycycline between 09/27/22 and 10/18/22 and again between 10/21/22 and 10/26/22. This failure placed residents at risk for medical complications, decreased quality of life, or even death. An Immediate Jeopardy (IJ) situation was identified on 11/04/22 at 12:50 p.m. While the IJ was removed on 11/06/22 at 2:50 p.m., the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #1's face sheet, with a print date of 11/07/22, indicated she was [AGE] years old, admitted on [DATE], readmitted on [DATE] and discharged on 10/28/22. She had diagnoses including osteomyelitis of the lumbar (lower back) vertebra. Record review of Resident #1's hospital history and physical, with an admission date of 08/30/22, indicated she had lumbar surgery in May 2022, but did not give the exact date. Her wound became infected, and she was readmitted to the hospital in July 2022 for removal of hardware in her spine. Blood cultures were positive for MRSA (a bacteria that is resistant to most antibiotics and causes hard to treat infections) and she was placed on antibiotics. After a few more re-hospitalizations, she was diagnosed with osteomyelitis and underwent another surgery to stabilize her spine. An active drug list sent to the facility from the hospital on [DATE], indicated she was on doxycycline monohydrate 100mg and was to receive it long term. The orders did not indicate she was to follow up with any physician and did not address wound care or monitoring of wounds. Record review of Resident #1's admission MDS, dated [DATE], indicated she had adequate hearing and vision, could understand and was understood by others, and had intact cognition. She exhibited behavioral symptoms not directed at others from 1 to 3 days of the look back period and she disrupted the living environment of others. She was totally dependent on two staff members with bed mobility, transfers, walking, dressing and toileting. She utilized a wheelchair for mobility. She was documented as not having surgery 100 days prior to admission, being at risk for pressure sores, but not having any pressure sores or surgical wounds. The MDS also did not indicate she had received antibiotics within the first 7 days of her stay. Record review of Resident #1's care plan, with an admission date of 10/21/22, indicated she had a history of falls due to her cognition, had impaired cognitive function, and had current skin conditions. The skin conditions were marked as surgical incision, surgical wound and open lesions other than stasis/venous areas. Interventions included treating per physician orders, monitor areas for increased breakdown or infection, monitor for and treat pain per physician orders, and assess skin weekly and record findings in the clinical record. Record review of Resident #1's order for doxycycline 100mg capsule by mouth twice a day (an antibiotic) was entered on 10/21/22 and had a start date of 10/26/22. Record review of Resident #1's order summary report, indicated discontinued orders as of 10/01/22 through 10/28/22 included the following orders: *doxycycline monohydrate 100mg capsules twice a day and give long term, ordered on 9/27/22 and an end date of 10/03/22. *doxycycline hyclate 100mg tablet twice a day was ordered on 10/21/22 and ended on 10/21/22. *doxycycline monohydrate 100mg capsules twice a day was ordered on 10/21/22 with a start date of 10/26/22. *an x-ray to her lumbar spine for severe pain was ordered on 10/08/22 and ended on 10/11/22. Record review of Resident #1's September MAR, indicated she did not receive doxycycline monohydrate through 09/01/22 to 09/30/22. Record review of Resident #1's October MAR, indicated she began receiving doxycycline monohydrate 100mg capsules on 10/26/22 at 9 p.m. Record review on 11/03/22 at 3:00 p.m. of the facility drug destruction log revealed no record of Resident #1's doxycycline being destroyed within the past month. Record review of the 24-hour report dated 09/27/22 indicated Resident #1 admitted to the facility with a diagnosis of osteomyelitis, diabetes, high blood pressure, low thyroid, a foley catheter, and weakness. The report did not indicate her surgical incision or the wounds to her feet. Record review of the 24-hour report dated 09/29/22 indicated Resident #1 yelled out all shift on the day shift. The night shift indicated she had osteomyelitis of the vertebra. Record review of the 24-hour report dated 09/30/22 revealed no report found. Record review of a nurse's note, written by agency LVN C and dated 10/08/22 at 1:10 p.m., indicated Resident #1 was yelling out, had increased agitation/anxiety, was throwing things, and reporting pain to her lower back. The physician gave an order to x-ray her lumbar spine related to severe pain. Record review of Resident #1's physician consult note, with an admission date of 10/19/22, indicated she admitted for hospice and was to continue doxycycline hyclate 100mg twice a day upon discharge and was to be on hospice services. The ID Physician who had previously treated Resident #1 indicated in her progress notes on 10/20/22, that the resident had discharged from the hospital on antibiotics with instructions to continue them indefinitely due to recurrent back infections. The physician also indicated the resident had gone off the antibiotics while residing in the facility. The paperwork did not indicate the condition of the resident's wounds, only wound care orders, and the resident's family wanted her to begin hospice care. Record review of Resident #1's discharge MDS, dated [DATE], indicated she had short-term memory problems, moderately impaired decision-making skills, and continued to exhibit behaviors not directed at others. She was totally dependent on staff for all ADLs, except for eating, which required only supervision. She was again documented as not having skin concerns or wounds, and as not receiving an antibiotic in the past 7 days. During an interview on 11/01/22 at 2:10 p.m. with RN F and LVN A, RN F said she had issues earlier in the day, on 11/01/22, while putting in orders for doxycycline hyclate for a different resident. She said the pharmacy automatically kicked out the order and wanted to switch it to doxycycline monohydrate instead. She said she had been looking for the order and realized it was no longer there, then she realized the pharmacy had sent the new order for her to confirm. She said because LVN A was an LVN, she could not confirm orders, only RNs could. She said LVN A would have put in the doxycycline order and then when an order change confirmation came in, the DON would have to approve it since she was an RN. LVN A said Resident #1 admitted and very quickly into her stay was sent to the COVID unit. She said she did not know if anything was done for the resident, such as skin assessments, wound care, and medication administration. The nurses said they did not have a wound care nurse and had do their own treatments on their halls. During an interview on 11/01/22 at 3:52 p.m. CNA E said she had worked with Resident #1 on the COVID hall. She said the night she found the wound on her back, 10/18/22, the resident had been complaining of pain from not having a bowel movement. The aide went to change her, and saw the sheets were soiled and it was a very substantial amount. She said she believed the resident felt the wetness from her wound and thought it was a bowel movement. She said she initially thought it was a bowel movement as well, until she rolled the resident all the way over and saw the wound. The wound was purple and covered by the flaps of skin due to her obesity. She said when she pulled the resident's skin taught, she could physically see into the wound and large amounts of drainage came out with even minor touch. She said the drainage was chunky and gritty and was a yellowish-green tint, like a snot color, and it smelled. She said agency LVN B was unaware of the wound and looked in the chart to see if any wound care had been ordered for the wound but did not find any. During a phone interview on 11/01/22 a 4:30 p.m. agency LVN B said when she pulled Resident #1's skin back, dark brown drainage poured out of the wound over her spine. She said she went back to look at the resident's chart and saw she had MRSA in her spine before she came to the facility. She said the drainage did not have an odor and the wound did not appear to be red or swollen. She said she remembered the last time she took care of the resident, she recalled giving the resident brown and yellow pills, which would be doxycycline. She said that was right before the resident left with her family on 10/28/22. During a phone interview on 11/02/22 at 9:00 a.m. the Pharmacist said the medical director had signed for therapeutic interchanges to be made whenever an order was put in for a wrong medication. For example, if the doctor ordered doxycycline monohydrate and staff entered doxycycline hyclate, the system would kick out the order for hyclate and enter a new order for the monohydrate, which an RN must approve. She said the corporate office was usually the one that requested the therapeutic interchanges and if one facility under the corporation did it then most likely all facilities under that corporation did. She said there were different reasons for the therapeutic interchanges, such as cost to the facility, or ensuring the correct order was followed. She said she saw in the system where the doxycycline was ordered on 09/27/22 and the system changed it to doxycycline monohydrate capsules. She said they sent out 60 pills that day. The next order for them came in on 10/21/22, they did not send any out because the refill was too soon from the last fill date. During a phone interview on 11/02/22 at 10:36 a.m. the ID physician said she was told by the family and Resident #1, at the hospital, that she had not been receiving antibiotics at the facility. She said she did give an order for the resident to have indefinite doxycycline at the facility, but since she did not go to the facility, or write orders there, she was not sure if the resident received the antibiotics or not. During an interview on 11/03/22 at 2:20 p.m. LVN A said she did part of Resident #1's admission assessment and paperwork. She said if she had given the initial dose of the resident's doxycycline, she would have followed up on it for 72 hours, so if there were no notes following up on it, then she did not administer it. During a phone interview on 11/03/22 at 4:00 p.m. agency LVN H said she did not remember the resident being on an antibiotic while she worked the COVID wing. During a phone interview on 11/03/22 at 4:05 p.m. agency LVN J said she did not remember if the resident was on an antibiotic or not. During a phone interview on 11/03/22 4:10 p.m. agency LVN K said she did not remember if the resident took an antibiotic. She said she just remembered the resident yelling out and when they would go in her room, she would say she had not been yelling and did not need anyone to come in there. During an interview on 11/03/22 at 4:25 p.m. with the ADON and interim-DON, the ADON said she was not aware of Resident #1 having any wounds to her feet but did know she had a wound to her spine. She said she helped LVN A put the orders in and since she did not see any orders for wound care or for following up with a physician, she did not put any in. The ADON and the interim-DON said they were unaware the pharmacy kept kicking out the doxycycline orders and the LVNs could not see the orders were being kicked out automatically and then resubmitted. They both denied knowing about the resident not receiving her antibiotics until 10/26/22. The interim-DON said she could not find the resident's x-ray of her back and it appeared the x-ray was never obtained. During a phone interview on 11/04/22 at 10:30 a.m. Resident #1's Physician said he was not aware of her not receiving her doxycycline. He said had he known this information, he would have made sure staff were giving her the ordered antibiotics. During a phone interview on 11/08/22 at 3:28 p.m. LVN L denied ever being notified about an x-ray for Resident #1's back pain. She said the resident was always yelling out due to her psychological issues. She did not remember the resident having any wounds to her feet or her back. She denied anyone ever notifying her of the resident having a surgical wound to her back. Record review of the facility's General Guidelines for Medication Administration policy indicated, .6. If a dose of regularly scheduled medication is withheld, refused, or given at a time other than the scheduled time (e.g., the resident is not in the facility at a scheduled time or a started dose of an antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If 3 consecutive doses, or in accordance with facility policy, of a vital medication are withheld, refused, or not available, the physician is notified. Nursing documents the notification and physician response. An Immediate Jeopardy (IJ) was identified on 11/04/22 at 12:50 p.m., due to the above failures. The Administrator and DON were notified of the IJ and the IJ template was provided on 11/04/22 at 1:09 p.m. During an interview on 11/04/22 at 1:09 p.m. with the interim-DON, ADON and Administrator, the interim-DON said she accepted the resident's change in doxycycline when she saw it was in the system awaiting approval. She did not realize the resident's doxycycline had been pending approval since 10/21/22 and was not approved by her until 10/26/22. She said she approved orders as they popped up in the system, but she did not realize they were popping up due to therapeutic interchanges. She said the reason it took her until 10/26/22 to approve the doxycycline was because she left the building on 10/21/22 and did not return until 10/26/22. The following Plan of Removal submitted by the facility was accepted on 11/06/22 at 8:52 a.m. and included the following: 11-4-22 Neglect Plan of Action Resident in question (Resident #1) that did not receive her antibiotics as ordered and is no longer in the building. A chart review of her pharmacy orders and therapeutic interchange was completed by the Director of Clinical Operations to review what transpired. At the time a new Director of Nurses in training was to review orders and failed to confirm new antibiotic orders. Audit of all medications compared to current orders for all residents in house was completed on 11/05/22 to ensure that no other residents have missed medications. Director of Clinical Operations, Assistant Director of Clinical Operations, Clinical Reimbursement Coordinator and Treatment Nurse reviewed clinical records for residents with wounds to ensure documented notification of family and physician. Director of Clinical Operations, Assistant Director of Clinical Operations, will review all x-rays ordered with over the last six months to ensure follow thru and notification of findings. The Director of Clinical Operations, Assistant Director of Clinical Operations, Treatment Nurse and All Licensed Nurses will be provided in-service education related to Notification of Change, including any signs and symptoms of worsening infections beginning on 11-4-22 by Director of Clinical Operations or designee which includes: 1. Physician must be notified of any new orders that were not written by the physician within 2 hours of admission or re-admission via phone. 2. Physician must be notified of any missed dosages of medication as prescribed no later than 3 missed doses as per policy. See attached. 3. Physician must be notified of any wounds present on admission or readmission and or wound orders within 2 hours of admission or re-admission via phone. 4. Physician to be notified of any change in medical conditions including worsening infections, falls, or medical changes withing 2 hours of assessment. See Monitoring form for changes in condition attached. The Director of Clinical Operations, Assistant Director of Clinical Operations, Treatment Nurse, and licensed nurses to be provided education on following physician's orders as it pertains to x-ray services on 11-4-22 by Director of Clinical Operations or designee which includes: 1. Nurses must complete orders as written. 2. If an order is not or cannot be complete physician must be notified via phone within 2 hours of receiving notification. 3. Each shift must follow up on x-ray orders until results are obtained. Newly hired nurses will receive in-services on proper physician notification processes. Validation/Monitoring Tools Director of Clinical Operations or designee will validate staff knowledge base through random questioning. Director of Clinical Operations or designee will review records for any newly admitted or readmitted resident daily in clinical meeting to ensure physician notification and appropriate follow up. Beginning 11-7-22. Director of Clinical Operations or designee will review all x-ray order daily in the clinical meeting to ensure x-rays are obtained and physician notification is completed. admission check list form is to be completed by admitting nurse to ensure appropriate notification and completion of assessments to be initiated within 2 hours of admission. See form attached. Change in conditions check list to be utilized to ensure nurse competency with completion of assessments and physician notification. Beginning 11-7-22. On 11/06/22 from 11:40 a.m. to 2:50 p.m. the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews with the RN weekend supervisor, the ADON, LVN L and LVN N between 11:45 a.m. and 2:15 p.m., staff indicated they had received adequate training regarding skin assessments, antibiotics, antibiotic orders and use of 24 hour reports. Record review of A Midnight Census Report dated 11/05/22 at 3:18 PM, by the interim-DON showed 37 Residents had been checked off as being reviewed by the DON for narcotics and all medications. Record review between 12:47 p.m. and 1:15 p.m. of staff who had received training, indicated 12 staff had been educated over the phone and stated their understanding of the education provided. During an interview on 11/02/22 at 12:47 p.m., the interim-DON said she conducted a full sweep of all 37 residents to ensure there were no new skin issues. She said she also reviewed all medications to ensure each resident had orders and medication available. The interim-DON said she also assessed each resident for pain. The interim-DON said all residents were to have a skin assessment on admission or re-admission within 2 hours. She said all nursing staff had been trained on skin assessments. She said nurses had also been trained on monitoring antibiotics for the duration of the schedule and 3 days after for any reactions. She said nurses were to notify the DON any time antibiotics are ordered. She said she is the Infection Control Preventionist for the facility at the time, until the new wound care nurse completes her training, then the new wound care nurse will take over that responsibility. Record review of PCP records between 12:47 p.m. and 1:15 p.m. showed orders were showing on the 24-hour report in the system. Paper 24-hour reports were also reviewed, and the nurses had documented new orders on the report. The Administrator and DON were informed the Immediate Jeopardy was removed on 11/06/22, at 2:50 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated 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 observations, interviews and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 15 residents (Resident #11) reviewed for accidents The facility failed to ensure Resident #11 was properly secured in his wheelchair during transport resulting in the Resident #11 coming out of his wheelchair and having bilateral femur fractures and a clavicle fracture. This was determined to be past a non-compliance Immediate Jeopardy (IJ) with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The Administrator was notified of the past non-compliance Immediate Jeopardy (IJ) on 9/13/22 at 4:22 p.m. This failure could place residents at risk for injury/death from a vehicle accident and decreased quality of life. Findings Include: 1. Record review of the face sheet dated 9/15/22 indicated Resident #11 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including fracture of the left femur, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), fracture of the left clavicle, fracture of the right femur, Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), and muscle weakness. Record review of the comprehensive MDS dated [DATE] indicated Resident #11 was usually understood by others and usually understood others. The MDS indicated Resident #11 had a BIMS assessment had not been completed. The MDS indicated Resident #11 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS indicated Resident #11 required limited assistance with eating. Record review of the care plan last revised on 5/31/22 indicated Resident #11 was at risk for falls related to diagnoses of cerebral palsy, Parkinson's disease, paraplegia, and unspecified convulsions. The care plan indicated Resident #11 had limited physical mobility related to cerebral palsy, Parkinson's disease, and paraplegia with interventions including resident had a manual wheelchair and a motorized wheelchair special made for his body/contractures. The care plan indicated Resident #11 had alteration in mobility related to sustained multiple fractures (bilateral femurs (upper leg bone) and left clavicle (collar bone)). Record review of the provider investigation report dated 5/31/22 indicated Resident #11 and Resident #15 were being transported by the facility van and accompanied by facility staff when Resident #11 fell out of his wheelchair when the vehicle stopped. The provider investigation report indicted Resident #11 was transferred from the scene of the incident to the emergency department by ambulance for assessment. The provider investigation report indicated the facility was notified by the hospital on 5/31/22 Resident #11 had a fracture to both lower extremities that would require surgery and may have had additional injuries as some results were still pending. The provider investigation report indicated CNA R and the former SW were found negligent in their actions when failing to properly secure Resident #11 and his wheelchair after performing a demonstration of how the Resident #11 and his wheelchair were secured prior to the accident. The provider investigation report indicated CNA R and the former SW were both terminated following the investigation by the facility. Record review of an in-service dated 5/31/22 indicated staff had been in-serviced on driver and vehicle safety, driver and vehicle safety policy, and hands on demonstration. Record review of Resident #15's witness statement dated 6/01/22 indicated Resident #15 said she and Resident #11 were not buckled in securely during the transport on 5/31/22. Resident #15 said in her witness statement the driver was reckless and hit the brakes hard. Resident #15 said in her witness statement she had to brace herself when the van came to a stop and Resident #11 came out of his wheelchair. Resident #15 said on the trip from the facility to her appointment her wheelchair had not been strapped down and that only the wheelchair break had been applied. Record review of an action plan agenda dated 6/1/22 indicated the facility recognized an issue/concern of securing and transporting residents. The action plan agenda had a measurable goal of no resident would be injured during transport related to loading or securing mechanisms. The action plan agenda included the following interventions: All staff that would be allowed to operate the facility van had performed a return demonstration on loading residents who use wheelchairs and securing residents in wheelchairs. All new employees who would operate the facility van, on the skill check off, including loading riders who use wheelchairs, power chairs vs wheelchair, and procedures for securing wheelchairs. Director of Maintenance and/or any trained administrative designee will in-service and train all staff that would provide transportation. Record review of CNA R employee file indicated she was terminated from the facility on 6/8/22. Record review of the former SW's employee file indicated she was terminated from the facility on 6/8/22. Record review of CNA C's employee file it indicated had a New Driver Form including DL number signed by the administrator on 8/04/22, had signed acknowledgement and consent agreement company or rental vehicle policy on 8/04/22, had Vehicle Safety Acknowledgement signed 8/04/22, and a Securing Resident in Van Competency signed by the Administrator. Record review of the Maintenance Supervisor's employee file indicated New Driver Form including DL number signed by the administrator on 8/04/22, had signed acknowledgement and consent agreement company or rental vehicle policy on 8/04/22, had Vehicle Safety Acknowledgement signed 8/04/22, and a Securing Resident in Van Competency signed by the Administrator. During an interview on 9/12/22 at 10:49 a.m. Resident #11 said on 5/31/22 he had gone to the surgical center and was transported by the facility van. Resident #11 said he went to the surgical center for pain management. Resident #11 said he was picked up by the facility van. Resident #11 said the driver of the facility van was a transportation aide in training. Resident #11 said there was stuff on the floor of facility van. Resident #11 said the transportation aides had to move things around to put him on the facility van. Resident #11 said the transportation aides only secured his wheelchair with two straps on the left-hand side. Resident #11 said he did not have a strap across his body (shoulder harness or lap belt). Resident #11 said the transportation aide came to abrupt stop and resident flipped out of his WC. Resident #11 said he was lying in the floor of the bus. Resident #11 said he insisted the facility staff call the for transport to the emergency department. Resident #11 said he was transferred to the emergency department and test results revealed he had bilateral femur fractures and a clavicle fracture. During an interview on 9/12/22 at 12:19 pm the BOM said the former SW had transported residents in the facility van prior to the accident involving Resident #11. She said the former SW was training new transportation drivers at the time of the accident involving Resident #11. During an interview on 9/12/22 at 3:08 p.m. Resident #15 said she remembered the incident on 5/31/22 involving Resident #11 getting injured on the facility van. Resident #15 said they were being transported in the facility van and the transportation aide stopped too fast. Resident #15 said Resident #11's wheelchair was not locked down properly and he came out of the wheelchair. Resident #15 said she was pulled forward by the sudden stop, but her wheelchair did not move and she did not come out of her wheelchair. During an interview and observation on 9/13/22 at 9:00 a.m. CNA, C demonstrated securing a wheelchair in the facility van. CNA C secured the wheelchair with 5 straps attached to the floor and a shoulder strap and lap belt over where the resident would be sitting in the wheelchair. CNA C said she had been working at the facility for about 1 month. CNA C said she was trained on facility transport by the Maintenance Supervisor. The van was observed to have accommodations for one wheelchair to be secured in the facility van. CNA C said she had been trained to only transport one resident in a wheelchair at a time. During an interview on 9/13/22 at 9:46 am the Administrator said she expected only one resident in a wheelchair to be transported at a time. The Administrator said only one resident in a wheelchair should be transported due to the van only being equipped to safely secure one wheelchair. During an interview on 9/13/22 at 9:49 a.m. the former SW said she was not training the transport person. The former SW said she was in the van with the transport person when she picked up the Resident #11. The former SW said she had assisted in transporting residents. The former SW said she had not been trained on transporting residents. The former SW said she had transported residents on her own and with CNA's. The former SW said there were 2 residents in the van both were in wheelchairs at the time of the accident. The former SW said she did not know how many wheelchairs the van could safely secure. The former SW said that was the first time 2 residents in wheelchairs had been transported at the same time. During an interview on 9/13/22 at 10:50 a.m. the Maintenance Supervisor said he trained the new certified transportation aide. The Maintenance Supervisor said he was trained by the Administrator. The Maintenance Supervisor said he watched videos and performed demonstrations to become trained. The Maintenance Supervisor said when he trains a new transportation aide they watched the required videos and then performed safety demonstrations on securing residents who were in wheelchairs and who ambulate, using the lift, securing loose items, and driving the facility van. During an interview on 9/13/22 at 10:52 a.m. the former DON said it was her first week working in the facility when the accident occurred on 5/31/22. The former DON said she was notified of the accident by the former Administrator. The former DON said Resident #11 was sent to the ER after the accident. The former DON said Resident #11 suffered a clavicle fracture and bilateral femur fractures. The former DON said there had been 2 residents on the van in wheelchairs when the accident occurred. The former DON said she thought the van was equipped to transport 2 residents in a wheelchair at the same time. The former DON said the former SW and CNA R were not trained on transporting residents. The former DON said after the incident the former Administrator, the former SW, CNA R, and she were trained regarding transporting residents by the corporate nurses. During an interview on 9/13/22 at 11:30 a.m. the former Administrator said the former SW was training CNA R on transporting. The former Administrator said he had been led to believe the former SW had been trained on transports. The former Administrator said on 5/30/22 CNA R shadowed the former SW during resident transports. The former Administrator said on 5/31/22 CNA R return demonstrated back to the former SW the proper way to transport residents. The former Administrator said 2 residents in wheelchairs had been transported together at the time of the accident. The former Administrator said the van was equipped to secure 2 residents in wheelchairs at the same time. The former Administrator said there was adequate equipment to secure both residents when the accident occurred. The former Administrator said Resident #11 sustained injuries including 2 broken femurs and a broken clavicle. The former Administrator said the Maintenance Supervisor was trained along with other staff members a day or two after the incident. The former Administrator said the training was performed by corporate nurses. During an observation on 9/13/22 at 3:15 p.m. the surveyor watched the following training videos provided by the facility: SURE-LOK Wheelchair Restraints by NW Bus Sales Commercial Wheelchair Operators Video Wheelchair Lift Overview Video All videos observed by the survey gave instruction for properly loading and unloading residents via the lift on the facility van and properly securing a resident in a wheelchair for transport. Record review of the facility's undated Driver and Vehicle Safety Manual indicated, .The objective of this policy is to implement safe driving policies and practices so that the following goals are met .No employee or resident injuries in or around a vehicle .Residents are properly secured at all times .Employees droving the company vehicle shall also: Know how to safely load and unload residents/passengers and properly secure wheelchairs and other equipment if responsible for transporting residents .Team members who drive the company vehicle for residents must watch the following videos: SURE-LOK Wheelchair Restraints by NW Bus Sales, Commercial Wheelchair Operators Video, and Wheelchair Lift Overview Video .