**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers, promote healing, and to prevent new ulcers from developing for 1 (Resident #3) of 18 residents reviewed for pressure ulcers. - The facility failed to perform adequate skin assessments to identify pressure injuries for Resident #3, who was non-ambulatory and wheelchair bound. - The facility failed to identify and treat Resident #3's stage 2 (wound goes through skin and looks like a blister or ulcer but does not go through deep tissues ) and stage 3 (wound goes through deep tissue and fat but does not expose bone) pressure injuries. An Immediate Jeopardy (IJ) was identified on 9/4/2023. The IJ template was provided to the facility on 9/4/2023 at 1:00pm. While the IJ was removed on 9/7/2023 at 2:10pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of developing pressure ulcers/wounds, worsening pressure ulcers/wounds, and could cause pain, infection, hospitalization, or death. Findings include: Record review of Resident #3's undated face sheet revealed he was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of dementia with other behavioral disturbance (dementia with agitation, depression, or psychosis), COPD (group of diseases that cause airflow blockage and breathing problems), seizures, major depression, schizoaffective bipolar (mental illness that can affect thoughts, mood, and behavior), cataracts (cloudy area in eye making it hard to see), right and left-hand contractures (fixed tightening of muscle, tendons, ligaments, or skin), obstructive and reflux uropathy (obstructed urinary flow), borderline intellectual functioning (below average cognition), C6 Cervical spinal cord injury (spinal cord injury near the base of the neck), and acquired absence of right and left leg (amputation of the right and left leg). Record review of Resident #3's Quarterly MDS dated [DATE] revealed, a BIMS score of 15 which indicated normal cognition. According to the MDS, Resident #3 required extensive assistance with personal hygiene, toilet use, eating, dressing, transferring, and bed mobility. He also required 1-2+ people physical assistance with the ADL's. The resident was wheelchair bound and had limitation in ROM for both his upper and lower extremities. He also was totally dependent for shower/baths and required 2+ people physical assistance. The MDS revealed the resident had an indwelling catheter and was always incontinent of bowel. According to the MDS, the resident was at risk for pressure ulcers/injuries but had none. He was using a pressure reducing device for his bed and application of ointment/medication other than to his feet. Record review of Resident #3's care plan dated 7/14/23, had a Focus: Resident #3 experienced bowel incontinence r/t severe impaired physical mobility. Interventions: Check me every two hours and assist with toileting as needed . Focus: Resident #3 had bilateral [both sides] AKAs. Interventions: Change position frequently. Alternate periods of rest with activity out of bed in order to [prevent] respiratory complications, prevent dependent edema [swelling], [prevent] flexion deformity [inability to fully straighten or extend] and skin pressure areas . Focus: Resident #3 had a (moderate) risk for skin breakdown per the Braden scale. Interventions: .Implement weekly skin checks .Turn schedule every 1-2 hours while in bed. Focus: Resident #3 had an ADL self-care performance deficit r/t amputation .Interventions: BATHING/SHOWERING: The resident requires 1-2 staff with showers/bathing. BED MOBILITY: The resident requires 2 staff to turn and reposition in bed .TOILET USE: The resident is totally dependent on (1-2) staff for toilet use .CONTRACTURES: The resident has contractures of the (admitted with bilateral hands contractures). Provide skin care (q shift) to keep clean and prevent skin breakdown .TRANSFER: The resident is totally dependent on (X2) staff for transferring. The resident requires Mechanical Lift with (X2) staff assistance for transfers . Focus: Resident #3 had a behavior problem (refused ADLs assistance .wound care . Interventions: .Document refusals of ADLs assistance, e.g., repositioning assistance, toileting assistance .wound care . Focus: Resident #3 refused to take protein supplements r/t does not like the taste of any of it. Interventions: .Weekly skin care assessment. Wound care as ordered. The 2-posterior (back) thigh/buttock wounds were not care planned. Record review of Resident #3's physician's orders revealed an order for Weekly Skin checks (Monday/AM), one time a day, every Mon. Ordered on 5/27/21 by MD A. The physician's orders did not reveal any wound treatment orders. Record review of Resident #3's Weekly Skin Review/Assessment by LPN MM dated 4/18/23 revealed Woundcare D/C'ed to R Ischium (curved bone at base of pelvis). No new skin issues noted at this time. Record review of Resident #3's Wound Treatment Note by MD B on 4/21/23, revealed the resident was being treated for a Stage III (wound goes through deep tissue and fat but does not expose bone) pressure wound to his right ischium that initially started 6/6/19, and then started again on 2/17/22. According to MD B, on 4/21/23 the right ischium pressure ulcer had resolved; however, MD B documented the resident was at increased risk of wound incidence due to his many comorbidities. Record review of Resident #3's Weekly Skin Review/Assessments, performed by different nurses, from 4/24/23 through 8/28/23 revealed No new skin issues noted. Record review of Resident #3's August 2023 TAR revealed weekly skin checks were not documented as completed on 8/14/23 and 8/21/23. Record review of Resident #3's medical record on 8/28/23 revealed no documentation indicating he refused to be turned every 2hrs, or refeused weekly skin checks. In an observation and interview with Resident #3 on 8/30/23 at 10:02am, it was revealed he was lying on his back in bed, he had both legs amputated, and there was a wheelchair next to his bed. He stated the staff put him into his wheelchair in the morning at about 8:00am or 9:00am via a Hoyer lift and then left him in it all day long, until about 8:00pm. He stated he was only supposed to be in his chair for 3-4hrs, but he was unable to find anyone to put him back into bed with the Hoyer lift in the evening. He said by the time staff put him back into bed, he would be in a lot of pain. He also said staff were not performing skin assessments on him and he had a wound they did not check on (he did not say where the wound was). In an interview with RN AA on 8/31/23 at 2:48pm, she stated she had already identified skin assessments as an issue at the facility and had already done a PIP on it. She stated she ran a report on skin assessments in their EMR and it showed skin assessments were not being completed. She also stated there was an issue in the EMR with the skin assessment tasks not popping up and alerting staff to perform them. She said she planned on doing chart audits to ensure skin assessments were being completed and if they were not done, residents could have an ulcer/wound which could lead to infection, sepsis (infection through whole body), or could die. She stated she was not going to start as the full time DON until 9/10/23 or 9/11/23. In an interview with LPN N on 9/1/23 at 10:30am, he stated Resident #3 did not have any skin issues to his buttocks or sacrum (triangular bone above the tailbone). He stated if the resident had any skin issues, it was redness to his groin area from the Foley catheter tubing rubbing him. In an interview with the RN AA on 9/1/23 at 3:55pm she stated there was not a wound care nurse and the wounds were handled in house since there were only 4. She stated she walked with MD B on Thursdays and helped assess and enter orders, and the nursing staff were responsible for wound care when she was not assisting with MD B. In an observation and interview on 9/1/23 at 4:26pm with CNA CC, CNA BB, and Resident #3, the resident was observed to have a Stage III pressure wound (wound goes through deep tissue and fat but does not expose bone) about the size of an egg, to his right posterior thigh/buttock, without a dressing. It was also observed that he had a Stage II pressure wound (wound goes through skin and looks like a blister or ulcer but does not go through deep tissues) about the size of a quarter, to his left posterior thigh/buttock area, without a dressing. Both CNAs stated they had not seen and did not know about the wounds until that day. CNA CC stated she had not worked with Resident #3 in a while. She did say that the resident had had a Stage II (wound goes through skin and looks like a blister or ulcer but does not go through deep tissues) or III (wound goes through deep tissue and fat but does not expose bone) to the same area on the right side several months ago when she last worked with him that had healed, and it looked like it had opened again in the same place. CNA BB stated she had been working with the resident but had not noticed the wounds. She stated she must have not turned him far enough to see it when she changed him. CNA BB stated now that she knew about the wounds, she was going to inform the nurse on duty which was LPN H. Record review of the facility's wound documentation list on 9/2/23, revealed there were 6 residents with wounds that were all facility acquired. Resident #3 was not listed as a resident with a wound. In an interview with LPN H on 9/2/23 at 2:30pm she stated she had only been at the facility for 10days. She said she knew skin assessments were done weekly but she did not know what day because she only did them when the task popped up in the EMR. She said she had never checked off the skin assessment task, without actually performing a skin assessment. She said if a skin assessment was missed, a wound could be missed. In an interview with LPN H on 9/3/23 at 10:38am, she stated there were concerns with the skin care system. She said sometimes the skin assessments would not pop up to tell you to perform the assessment, but she knew from being a former manager where to go in the EMR to see the task. She said something was broken with the system, but she could not put her finger on it, and she had not told anyone about it. Record review of Resident #3's Skin/Wound Note by LPN H on 9/3/23 at 10:34am revealed, Area to right hip has reopened [MD A] notified and orders given to consult with [MD B], area cleansed with NS patted dry and covered with dry dressing, until new orders are received. In an interview with the Administrator, the Regional Nurse Consultant, and RN AA on 9/3/23 at 11:23am, it was revealed RN A had been the acting DON and worked on the floor as an RN on the night shift. It was revealed RN A oversaw the nursing department but was not following through, which was why RN AA was going to be taking over as the DON. RN AA stated a skin assessment was performed on 8/28/23 and there were no wounds on Resident #3. Per the Regional Nurse Consultant, it was possible his old wound to his right buttock/ischium (curved bone at base of pelvis) opened back up in 4 days. The Regional Nurse Consultant stated Resident #3 had an old wound in the same area that used to be a Stage 3 (wound goes through deep tissue and fat but does not expose bone) or 4 (wound that goes through deep tissue and fat and exposes bone/muscle) and it could have been developing from the inside before it opened back up and it was not found on the last skin assessment. The Regional Nurse Consultant stated Resident #3 never told anyone he was having any pain or had any wounds. The Regional Nurse Consultant agreed Resident #3 was a paraplegic (no movement/feeling from waist down) and was unable to feel a lot, and it was not up to him to tell staff he had a wound. The Administrator, the Regional Nurse Consultant, and RN AA agreed staff should have been doing skin assessments and noticed the wounds during showers, brief changes, or pericare. Per the Administrator, RN A oversaw the skin assessments and accuracy of staff documentation, even though she was working as a floor nurse at night. The Administrator said the nurses had competencies that were continual and ongoing. Per RN AA, on hire the nurses had a competency sheet they had to fill out with their preceptor. Per the Regional Nurse Consultant, if issues were identified with new employees, they were re-educated, and if it seemed to be a system wide issue, they provided an in-service for the whole facility. Per the Administrator, the Regional Nurse Consultant, and RN AA, they had an issue with their EMR not popping up the skin assessment task. They said if the nurse did not do her skin assessment task, it would turn red and then the assessment would not pop up for any other later shifts. They were trying to address the problem. RN AA stated MD B would call her and ask her if there were any new residents with wounds. He would see those residents with her on Thursdays. RN AA stated she left face sheets in MD B's box at the nurse's station, for him to round on when he came. On 9/3/23 at 12:15pm, a message was left for RN A, the acting DON to call back. On 9/3/23 at 12:49pm, a message was left for MD B to call back. In an interview with the Administrator on 9/3/23 at 1:45pm, she stated RN A oversaw the nurses. The Administrator said RN A was not providing adequate supervision of the nurses and there was a complete system breakdown in the nursing department. The Administrator stated RN A was the RN 8hr coverage at night and the acting DON at night. The Administrator stated she did not have a full time DON who supervised the nursing staff during the day. In an interview with the Medical Director on 9/4/23 at 12:23pm, she stated there were some failures with oversight with the nursing staff since they did not have a DON during the day. She stated the last time they had a full time DON was for 2 weeks in July 2023. She said primarily the previous ADON took care of everything, but she quit 8/4/23. Record review of the facility's policy and procedure for Charting and Documentation (revised July 2017) read in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2. The following information is to be documented in the resident medical record: a. Objective observations .c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward of changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting. Record review of the facility's policy and procedure on Prevention of Pressure Injuries (revised April 2020) read in part: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable .Skin Assessment: 2. During the skin assessment, inspect: a. Presence of erythema [redness]; b. Temperature of skin and soft tissues; and c. Edema [swelling]. 3. Inspect the skin on a daily basis when performing or assisting with personal care of ADLs. A. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema [redness that does not turn white when pushed]). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum [triangular-shaped bone above the tailbone], heels, buttocks, coccyx [tailbone], elbows, ischium, trochanter [hip bone], etc.) .e. Reposition resident as indicated on the care plan .Mobility/Repositioning: 1. Repositioning all residents with or at risk of pressure injuries on an individualized schedule, as determined by the [IDT] care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines .Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. Record review of the facility's policy and procedure on Pressure Ulcers/Skin Breakdown-Clinical Protocol (Revised April 2018) read in part: Assessment and Recognition: .2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates [secretion] or necrotic [black/dead] tissue .d. Current treatments .4. The physician will assist the staff to identify the type .of an ulcer. 5. The physician will help identify and define any complications related to pressure ulcers. Cause Identification: 1. The physician will help identify factors contributing or predisposing residents to skin breakdown .2. The physician will clarify the status of relevant medical issues .and the impact of comorbid conditions on healing an existing wound. Treatment/Management: 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement [removing skin] approaches, dressings .and application of topical agents. 2. The physician will help identify medical interventions related to wound management .Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . An Immediate Jeopardy (IJ) was identified on 9/4/2023. The IJ template was provided to the facility on 9/4/2023 at 1:00pm. The Plan of removal was accepted on 9/6/2023 at 12:38pm. The plan of removal reflected the following: Immediate: Resident 3 had a skin check performed by the Medical Director on 9/4/2023. The physician identified a wound present in sacral/coccyx area and instructed to continue with current treatment order in place for identified skin breakdown. The resident's Care Plan/[NAME] was updated on 9/4/2023 with individualized interventions to address/prevent skin breakdown, including turning/repositioning him at least every two hours. A facility audit of all residents to be completed by the Director of Nursing/Designee by 9/4/2023 of all residents to validate a skin check has been completed in the past 7 days. Any resident who has not had a documented skin check will have a skin check completed by 9/5/2023. Facilities Plan to ensure compliance quickly: An Ad-Hoc QAPI was conducted on 9/3/2023 when the missing skin check issue was brought up to the facility. Facility interventions were implemented: The facility skin assessment schedule was reviewed on 9/3/2023 and adjustments were made. An audit was completed on 9/3/2023 of every resident's skin check schedule in [EMR] and updates were made as needed to validate the skin check would show up in the EMAR on the date/shift that was scheduled. Education was initiated for the facility nursing staff on 9/3/2023 regarding the new skin assessment schedule. Education was initiated for Nursing Assistants on 9/4/2023 on ensuring residents at high risk for skin breakdown are turned and repositioned at least every two hours and who to notify if skin breakdown is identified. Education to be initiated by DON/Designee on 9/4/2023 with all Licensed Nurses regarding the importance of completing a thorough weekly skin assessment and reporting immediately when a resident has incurred a skin impairment. Training to also include proper technique to perform the skin check and how to document the skin check in the EMAR. This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. Education to be completed with all nursing staff working 9/5/2023. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. From 9/6/23-9/7/23 a monitoring visit was conducted to ensure the facility was following its POR. The visits revealed: On 9/6/23 at 1:00pm in an interview with the Interim DON (Regional Nurse Consultant), she said she had started in-services/trainings on 9/5/23 regarding skin assessments, and skin assessment schedule (with a quiz). She stated most of the staff had been trained. On 9/6/23 at 2:00pm in an interview with CNA CC she stated the facility had training on skin assessments on 9/4/23. She was able to re-iterate what she had learned from the skin assessment in-service. She stated it was important to monitor for skin breakdown, turn every 2 hrs, and to notify the nurse if any redness or skin breakdown was noticed. Record review of Resident #3's Wound Treatment documentation by MD B on 9/7/23, revealed the resident had a R Ischium wound that was 4.5 x 3.6 x .1 cm and a L Ischium wound that was .2 x 1.2 x .1 cm, that had reopened. He wrote orders on the paper to limit sitting to < 2hrs/time and to reposition/offload. On 9/7/23 at 11:20am in an interview with RN AA, she said she initiated a whole new skin assessment calendar by room, instead of by resident. She said, if a resident moved, the skin assessment would still be due by room and not by resident. She stated they were also starting chart audits where they would go into a resident's chart and pick a random day in the last week, to ensure the nurses were documenting the skin assessments. Also, she said every morning she would go into the EMR and see if the assessment was in red, because when it was not done it would be triggered in red. RN AA stated the facility performed a skin sweep of the facility, so every resident had a new skin assessment as of 9/6/23 and then she was going to start checking the assessments today (9/7/23). She also said she checked the shower sheets, and the staff would bring them to her if they identified something on a resident. RN AA stated she would compare the shower sheets to what she had identified on the residents in the computer. RN AA also said they were hiring a treatment nurse, so once they got a treatment nurse all the identified areas would be funneled through them, and they would only have one person looking at it. On 9/7/23 at 11:52am in an interview with the Interim DON (The Regional Nurse Consultant), she said the plan was to follow up and monitor now. She stated all the training had been completed on skin assessments, showers, shower sheets, ADLs, checking and turning the resident every 2hrs, and ANE. She stated with the skin assessments, she trained on when to do them, where to find them, what to look for, what to do if something is found, and the Stop and Watch notification. She said she also took them to the kiosk and showed them how to perform the Stop and Watch notification, and then had them perform a return demonstration. The Interim DON (The Regional Nurse Consultant) also stated staff were not allowed to work unless they had been trained, and she had gone through next week's schedule and staff that were scheduled to work had already been in-serviced. She said the PRN staff would not be allowed to work until they were in-serviced also. On 9/7/23 at 11:55am in an interview with CNA W, he said they had in-services on showers and were informed to make sure and tell the nurse if any skin concerns were found during the shower, and to document them on the shower sheet and in the EMR. CNA W said staff were in-serviced on skin assessments as well and staff needed to make sure and document anything they saw, and to fill out a Stop and Watch which would also trigger a notification. He said after filling out the Stop and Watch the staff also needed to tell the nurse verbally about any skin issues. On 9/7/23 at 12:10pm in an interview with CNA X, she said they received training on the EMR and where to go to document things, and the Stop and Watch for skin findings. She said if she were to find any skin irregularity on a resident, she was supposed to document it, enter a Stop and Watch that triggered the nurse, and verbally report it to the nurse. She stated, even if the skin irregularity was old, it was important to document it because the other staff may have not seen it before. The CNA said they were supposed to have the nurse come in and assess the resident when they were showering also, to ensure nothing was missed on the resident. She said once the shower sheets were filled out, the ADON checked them to ensure everything was filled out and there were no questions. On 9/7/23 at 2:36pm in an interview with Resident #3, he said that MD B came and saw him today. He said the doctor ordered new treatments for his wounds and staff were going to start treating his wounds. He stated that his pain was ok. He also stated that staff were not leaving him in his wheelchair for as long and putting him back in bed. Record reviews performed by the Surveyor on 9/7/23: - Record of training provided by the Interim DON (Regional Nurse Consultant) to the Nursing staff regarding new skin assessment schedule, performing a head-to-toe skin assessment with return demonstration. - Record of training provided by the Interim DON (Regional Nurse Consultant) to the CNA's regarding skin breakdown prevention, turning and repositioning for residents with high risk for skin breakdown, reporting to nurse if resident refuses to turn/reposition, and reporting to nurse any alteration in skin integrity. - Record of training provided by the ADON to the Nursing staff and CNA's regarding filling out a Stop and Watch in the EMR, for nurses to check their dashboard multiple times a shift for updates from CNA's and updating the DON/ADON about any alerts triggered in the EMR. - Record of re-education provided by the ADON on the resident's [NAME], following it, and where to find it. - Record of the staff's Skin Assessment Post Test. - Record of Resident #3's assessment and orders from MD B. - Record of training provided by the Regional Nurse Consultant regarding nursing oversite and skin program monitoring, including: - Reviewing 24hr report - Reviewing for incidents of abuse/neglect - Monitoring/performing chart audits - Following up on areas of concern - Holding nurses accountable - Maintaining clear, concise, open communication with regional support staff - Monitoring UDA schedules, ensuring assessments are being completed, and intervening when they are not completed - Monitoring for trends - Utilizing root cause analysis and QA process - Continual/ongoing in-services and training of staff An Immediate Jeopardy (IJ) was identified on 9/4/2023. The IJ template was provided to the facility on 9/4/2023 at 1:00pm. While the IJ was removed on 9/7/2023 at 2:10pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with 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 observation and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable, physical, mental, and psychosocial well-being of each resident for 1 (Resident #3) of 18 residents reviewed for Administration. - The Administrator failed to ensure nursing staff were performing weekly skin assessments on Resident #3 and other residents at the facility, causing Resident #3 to get facility acquired Stage 2 (wounds extends through skin and looks like a blister or ulcer but does not extend through deeper tissue) and Stage 3 (wound extends through deep tissue and fat but does not expose bone) pressure wounds. - The Administrator failed to ensure staff were performing showers and daily hygiene care on Resident #3 and other residents at the facility, causing Resident #3 to go a week without a shower which can cause skin breakdown. - The Administrator failed to ensure wounds were being identified and communicated to the physician for Resident #3, which lead to late treatment of his pressure wounds. - The Administrator failed to ensure full-time DON coverage which caused lack of nursing supervision and oversight. - The Administrator failed to ensure the EMR system notified staff to perform skin assessments on Resident #3 and other residents, causing missed skin assessments and pressure wounds to Resident #3. An Immediate Jeopardy (IJ) was identified on 9/5/2023. The IJ template was provided to the facility on 9/5/2023 at 12:40pm. While the IJ was removed on 9/7/2023 at 2:10pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy. with a scope of isolated. due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for receiving substandard care, missed care, skin break down, wounds developing, and infections. Findings include: Record review of Resident #3's undated face sheet revealed he was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of dementia with other behavioral disturbance (dementia with agitation, depression, or psychosis), COPD (group of diseases that cause airflow blockage and breathing problems), seizures, major depression, schizoaffective bipolar (mental illness that can affect thoughts, mood, and behavior), cataracts (cloudy area in eye making it hard to see), right and left-hand contractures, obstructive and reflux uropathy (obstructed urinary flow), borderline intellectual functioning (below average cognition), C6 Cervical spinal cord injury (spinal cord injury near the base of the neck), acquired absence of right and left leg (amputation of the right and left leg). Record review of Resident #3's Quarterly MDS dated [DATE] revealed, a BIMS score of 15 which indicated normal cognition. According to the MDS, Resident #3 required extensive assistance with personal hygiene, toilet use, eating, dressing, transferring, and bed mobility. He also required 1-2+ people physical assistance with the activities. The resident was wheelchair bound and had limitation in ROM for both his upper and lower extremities. He also was totally dependent for shower/baths and required 2+ people physical assistance. The MDS revealed the resident had an indwelling catheter and was always incontinent of bowel. According to the MDS, the resident was at risk for pressure ulcers/injuries but had none. He was using a pressure reducing device for his bed and application of ointment/medication other than to his feet. Record review of Resident #3's care plan dated 7/14/23, had a Focus: Resident #3 experienced bowel incontinence r/t severe impaired physical mobility. Interventions: Check me every two hours and assist with toileting as needed . Focus: Resident #3 had bilateral AKAs. Interventions: Change position frequently. Alternate periods of rest with activity out of bed in order to [prevent] respiratory complications, prevent dependent edema [swelling], [prevent] flexion deformity and skin pressure areas . Focus: Resident #3 had a (Moderate) risk for skin breakdown per Braden scale. Interventions: .Implement weekly skin checks .Turn schedule every 1-2 hours while in bed. Focus: Resident #3 had an ADL self-care performance deficit r/t amputation .Interventions: BATHING/SHOWERING: The resident requires 1-2 staff with showers/bathing. BED MOBILITY: The resident requires 2 staff to turn and reposition in bed .TOILET USE: The resident is totally dependent on (1-2) staff for toilet use .CONTRACTURES: The resident has contractures of the (admitted with bilateral hands contractures). Provide skin care (q shift) to keep clean and prevent skin breakdown .TRANSFER: The resident is totally dependent on (X2) staff for transferring. The resident requires Mechanical Lift with (X2) staff assistance for transfers . Focus: Resident #3 had a behavior problem (refused ADLs assistance .wound care . Interventions: .Document refusals of ADLs assistance, e.g., repositioning assistance, toileting assistance .wound care . Focus: Resident #3 refused to take protein supplements r/t does not like the taste of any of it. Interventions: .Weekly skin care assessment. Wound care as ordered. The 2-posterior thigh/buttock wounds were not care planned. Record review of Resident #3's physician orders revealed an order for Weekly Skin checks (Monday/AM), one time a day, every Mon. Ordered on 5/27/21 by MD A. The physician orders did not reveal any wound treatment orders. Record review of Resident #3's Weekly Skin Review/Assessments, performed by different nurses, from 4/24/23 through 8/28/23 revealed No new skin issues noted. Record review of Resident #3's August 2023 TAR revealed weekly skin checks were not documented on 8/14/23 and 8/21/23. Record review of Resident #3's August 2023 and September 2023 shower sheets revealed documentation of showers/baths only on 8/8/23, 8/19/23, and 9/2/23. In an observation and interview with Resident #3 on 8/30/23 at 10:02am, he was laying on his back in bed with both legs amputated and a wheelchair next to his bed. He stated the staff put him into his wheelchair in the morning about 8:00am or 9:00am via a Hoyer lift and then left him in it all day long, until about 8:00pm. He stated he was only supposed to be in his chair for 3-4hrs, but he was unable to find anyone to put him back into bed with the Hoyer lift in the evening. He said by the time staff put him back into bed, he would be in a lot of pain. He also said staff did not perform skin assessments on him and he had a wound that they did not check on. He also said he had not been receiving showers 3 x week like he was supposed to, and he had not had a shower in over a week. In the Resident Council meeting on 8/31/23 at 10:30am, it was revealed by the 6 residents that showers were not being given, especially on the 2-10pm shift. They stated that the odd number rooms got showers on Tue/Thu/Sat and the even number rooms got showers on Mon/Wed/Fri. They also stated that the A beds got showers in the morning and the B beds got showers at night. In an interview with RN AA on 8/31/23 at 2:48pm, she stated she was the part-time DON, then she said Interim DON. She said she did not start full time until 9/10/23 or 9/11/23. Her badge stated DON and she stated the employees called her the DON. She said she had already identified skin assessments as an issue at the facility. She had already done a PIP on it. She stated she ran a report on skin assessments in their EMR and it showed skin assessments were not being completed. She also stated there was an issue in the EMR with the skin assessment tasks not popping up and alerting staff to perform them. She said she planned on doing chart audits to ensure skin assessments were being completed and if they were not done, residents could have an ulcer/wound which could lead to infection, sepsis, and could die. She stated she was not going to start as the full time DON until 9/10/23 or 9/11/23. She stated she had already identified showers as a concern at the facility also. She stated she planned to pull a CNA to be the shower tech once she started as the full time DON. She said she was also going to ensure the documentation in the chart was clear if the resident refused a shower, and make sure staff notified the resident's RP and notified the DON if they refused. RN AA stated the reason why the 2pm-10pm shift was not getting showers was due to lack of accountability, since management was not there. In an interview with LPN N on 9/1/23 at 10:30am he stated Resident #3 had no skin concerns to his buttocks or sacrum (triangular bone above the tailbone). He stated if the resident had anything, it was just some redness to his groin from the Foley catheter tubing. He stated he never noticed any wounds on Resident #3 but had not performed a skin assessment on him before. He stated that Resident #3 had mentioned he was in pain, but the resident always had pain and exaggerated on things. In an interview on 9/1/23 at 11:00am, CNA HH said on MWF, A-Bed residents in even numbered rooms were to be showered by 6-2pm staff; B-Bed residents were showered by 2-10pm staff. On TTS, A-Bed residents in odd numbered rooms were to be showered by 6-2pm staff; B-Bed residents were showered by 2-10pm staff. In an interview with the Administrator on 9/1/23 at 1:35pm, it was revealed showers had already been identified as a concern and they were not being performed. She stated the plan was to hire a shower tech to assist with giving showers. In an interview with the RN AA on 9/1/23 at 3:55pm she stated there was not a wound care nurse and the wounds were handled in house since there were only 4. She stated she walked with MD B on Thursdays and helped assess and enter orders, and the nursing staff were responsible for wound care when she was not assisting with MD B. In an observation and interview on 9/1/23 at 4:26pm with CNA CC, CNA BB, and Resident #3, resident was observed to have a Stage III (wound extends through deep tissue and fat but does not expose bone) pressure wound to his right posterior thigh/buttock area and a Stage II (wound extends through skin and looks like a blister or ulcer but does not go through deeper tissue) pressure wound to his left posterior thigh/buttock area. Both CNAs stated they had not seen and did not know about the wounds until that day. CNA CC stated she had not worked with Resident #3 in a while. She did say that the resident had had a Stage II or III to the same area on the right side several months ago that had healed, and it looked like it had re-opened again in the same place. CNA BB stated she had been working with the resident but had not noticed the wounds. She stated she must have not turned him far enough to see it when she changed him. CNA BB stated now that she knew about the wounds, she was going to inform the nurse on duty which was LPN H. Record review of the facility's wound documentation list on 9/2/23, revealed there were 6 residents with wounds that were all facility acquired. Resident #3 was not listed as a resident with a wound. In an interview with CNA Z on 9/2/23 at 2:27pm, he stated residents received showers on alternating days. He said A beds got them in the morning and B beds got them at night. He said they documented showers in the computer and on shower sheets in a binder at the nurse's station. He also stated he felt like they had enough staff to provide adequate showers. CNA Z said RN AA was the DON and identified herself as the DON to all the staff. There were not any shower sheets in the shower binder for Resident #3 for August 2023 or September 2023. In an interview with LPN H on 9/2/23 at 2:30pm she stated she had only been at the facility for 10days. She knew skin assessments were done weekly but she did not know what day because she only did them when the task popped up in the EMR. She said she had never checked off the skin assessment task, without actually performing a skin assessment. She said if a skin assessment was missed, a wound could be missed. LPN H stated the DON was RN AA and that she identified herself as the DON to all the staff. In an interview with Resident #3 on 9/3/23 at 10:34am he said, he finally had received a shower the night before (9/2/23) and he felt much better. Record review of Resident #3's Skin/Wound Note by LPN H on 9/3/23 at 10:34am revealed, Area to right hip has reopened [MD A] notified and orders given to consult with [MD B], area cleansed with NS patted dry and covered with dry dressing, until new orders are received. In an interview with LPN H on 9/3/23 at 10:38am she stated she did not perform a head-to-toe assessment on all residents, only when the skin assessment task popped up. She stated today (9/3/23) was the first day she saw Resident #3's wound and was informed of it. She stated she had been his nurse before but had not done a skin assessment on him. In an interview with LPN N on 9/3/23 at 10:51am, he stated he had no problems with the skin assessments and had not noticed any not popping up. He also stated there were only a few wounds at the facility and he felt comfortable and had plenty of time to perform skin assessments and wound care. LPN N stated the DON was RN AA and she identified herself as such to the employees. He said he never noticed any wounds on Resident #3, but he had not performed a skin assessment on him in a long time. In an interview with the Administrator, the Regional Nurse Consultant, and RN AA on 9/3/23 at 11:23am, it was revealed RN AA was not the acting DON, even though staff identified her as such, and DON was on her name tag. Per the Administrator, RN A was the acting DON at night, and worked on the floor as an RN on the night shift. It was revealed RN A oversaw the nursing department but was not following through with oversight, which was why RN AA was going to be taking over as the DON. However, RN AA was not taking over until 9/10/23. RN AA stated a skin assessment was performed on 8/28/23 and there were no wounds on Resident #3. Per the Regional Nurse Consultant, it was possible his old wound to his right buttock/ischium (curved bone at base of pelvis) opened back up in 4 days. The Regional Nurse Consultant stated Resident #3 had an old wound in the same area that used to be a Stage 3 (wound extends through deep tissue and fat but does not expose bone) or 4 (wound extends through deep tisse/fat and muscle or bone is shown) and it could have been developing from the inside before it opened back up and it was not found on the last skin assessment. The Regional Nurse Consultant stated Resident #3 never told anyone he was having any pain or had any wounds. The Regional Nurse Consultant agreed Resident #3 was a paraplegic (no movement/feeling from waist down) and was unable to feel a lot, and it was not up to him to tell staff he had a wound. The Administrator, the Regional Nurse Consultant, and RN AA agreed staff should have been doing skin assessments and noticed the wounds during showers, brief changes, or pericare. Per the Administrator, RN A oversaw the skin assessments and accuracy of staff documentation, even though she was working as a floor nurse at night. The Administrator said the nurses had competencies that were continual and ongoing. Per RN AA, on hire the nurses had a competency sheet they had to fill out with their preceptor. Per the Regional Nurse Consultant, if issues were identified with new employees, they were re-educated, and if it seemed to be a system wide issue, they provided an in-service for the whole facility. Per the Administrator, the Regional Nurse Consultant, and RN AA, they had an issue with their EMR not popping up the skin assessment task. They said if the nurse did not do her skin assessment task, it would turn red and then the assessment would not pop up for any other later shifts. They were trying to address the problem. RN AA stated MD B would call her and ask her if there were any new residents with wounds. He would see those residents with her on Thursdays. RN AA stated she left face sheets in MD B's box at the nurse's station, for him to round on when he came. On 9/3/23 at 12:15pm, a message was left for the acting DON (RN A) to call back. On 9/3/23 at 12:49pm, a message was left for MD B to call back. In an interview with the Administrator on 9/3/23 at 1:45pm, she stated RN A oversaw the nurses. The Administrator said RN A was not providing adequate supervision of the nurses and there was a complete system breakdown in the nursing department. The Administrator stated RN A was the RN 8hr coverage at night and also the acting DON at night. The Administrator stated she did not have a full time DON who supervised the nursing staff during the day. She stated the last time there was a full time DON was for 2 weeks back in July and the previous ADON had been taking care of everything, but she left on 8/4/23. In an interview with the Medical Director on 9/4/23 at 12:23pm, she stated there were some failures with oversight since they did not have a DON during the day. She stated the last time they had a full time DON was for 2 weeks in July. She said primarily the previous ADON took care of everything, but she quit 8/4/23. In an observation and interview with Resident #64 and RN AA on 9/4/23 at 3:30pm, it was revealed the resident had a fitted sheet soaked with, what appeared to be urine, from his head all the way down to his legs. There was a foul smell in the room that got worse when his brief was opened. RN AA was there with 2 CNAs while performing a skin assessment. RN AA stated the resident had just been changed about 30min ago. She was unsure how the sheet was soaked and stated the CNA who changed him must have placed a new cloth chuck on top of the soiled sheet, without changing it. She stated it was unacceptable for them to not have changed the sheet and would investigate it. In an interview with Resident #3 on 9/6/23 at 1:30pm, he stated he had not had a shower since 9/2/23, and he was supposed to have received one on 9/5/23 but did not get one. He stated he did not receive a shower on 9/4/23, and the documentation was wrong that he had received a shower on 9/4/23. In an interview on 9/6/23 at 1:40pm, CNA W said if a resident declined to have ADLs performed, the CNA was to report it to the charge nurse who would follow up with the resident. In an interview on 9/6/23 at 1:42pm, LPN L said if a resident declined to have ADLs performed, the CNA reported it to the charge nurse. She said the charge nurse would follow up with the resident to see if the nurse could encourage the resident to accept care. She said if the resident continued to decline care, the care would be offered again later, and the nurse would document the refusal and notify the resident's RP. Record review of the facility's policy and procedure for Charting and Documentation (revised July 2017) read in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2. The following information is to be documented in the resident medical record: a. Objective observations .c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward of changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting. Record review of the facility's policy and procedure for Change in a Resident's Condition of Status (Revised February 2021) read in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .b. discovery of injuries of an unknown source .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly .2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting) c. requires [IDT] review and/or revisions to the care plan . Record review of the facility's policy and procedure on CNA Expectations (undated) read in part: .Daily hygiene needed on ALL resident EVERYDAY AM/PM: Brush Hair and Teeth- Shave all facial hair unless resident requests otherwise. Trim/File Nails- clean under nails. Fresh Clothing- Morning: Fresh clothing, Night: Pjs, Skid resistant socks/footwear at all times. Rounds should be Q2H and as needed with assistance provided timely Turning and Repositioning Q2H and as needed for ALL BED BOUND residents: Heels should be offloaded on pillow (hanging off) when in bed. Wheelchair Cushions need to be provided for all resident without one .Get Up List- ALL residents should be OUT OF BED for ALL meals and Activities as tolerated: Night Shift- get up 50% of all abled residents. Day Shift- get up all abled residents .Showers: All residents showers to be completed daily as scheduled day/evening shifts- All skin abnormalities to be reported to nurse on duty. Record review of the facility's policy and procedure on Prevention of Pressure Injuries (revised April 2020) read in part: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable .Skin Assessment: 2. During the skin assessment, inspect: a. Presence of erythema [redness]; b. Temperature of skin and soft tissues; and c. Edema [swelling]. 3. Inspect the skin on a daily basis when performing or assisting with personal care of ADLs. A. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema [skin that does not turn white when pushed]). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum [triangular bone above tailbone], heels, buttocks, coccyx [tailbone], elbows, ischium [curved bone at base of pelvis], trochanter [hip bone], etc.); c. Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan. Prevention: 1. Keep the skin clean and hydrated. 2. Clean promptly after episodes of incontinence .4. Use a barrier product to protect skin from moisture .Mobility/Repositioning: 1. Repositioning all residents with or at risk of pressure injuries on an individualized schedule, as determined by the [IDT] care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines .Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. Record review of the facility's policy and procedure on Pressure Ulcers/Skin Breakdown-Clinical Protocol (Revised April 2018) read in part: Assessment and Recognition: .2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .d. Current treatments .4. The physician will assist the staff to identify the type .of an ulcer. 5. The physician will help identify and define any complications related to pressure ulcers. Cause Identification: 1. The physician will help identify factors contributing or predisposing residents to skin breakdown .2. The physician will clarify the status of relevant medical issues .and the impact of comorbid conditions on healing an existing wound. Treatment/Management: 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement [removing skin] approaches, dressings .and application of topical agents. 2. The physician will help identify medical interventions related to wound management .Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . Record review of the facility's policy and procedure for Department Supervision, Nursing (Revised August 2022) read in part: The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times. 1. A licensed nurse (RN/LPN/LVN) is on duty twenty-four hours per day, seven (7) days per week, to provide resident care services and supervise the nursing services activities provided by unlicensed staff. A licensed nurse is designated as a charge nurse on each shift .b. A charge nurse is a licensed nurse with designated responsibilities that may include staff supervision, emergency coordination, provider or physician support and direct resident care. c. The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents .3. Licensed nurses are required to supervise nurse aides/nursing assistants and are scheduled in such a way that permits adequate time to do so. 4. A registered nurse (RN) is employed as the director of nursing services (DNS). The DNS is on duty a minimum of 40 hours per week. 5. During the absence of the DNS, a nurse supervisor/charge nurse is responsible for the supervision of all nursing department activities including supervision of direct care staff . An Immediate Jeopardy (IJ) was identified on 9/5/2023. The IJ template was provided to the facility on 9/5/2023 at 12:40pm. The Plan of removal was accepted on 9/6/2023 at 12:38pm. The plan of removal reflected the following: Immediate action: A plan has been created to ensure full time Director of Nursing coverage until the part time DON is able to start full time on 9/7/2023. The RN Clinical Nurse Resource will assume DON duties, including reviewing weekly skin check assessments, ADL documentation, wound care, and physician communication. Signage will be posted throughout the facility to assist staff to know who to contact with clinical concerns. The Chief Nursing Officer provided training with the RN Clinical Nurse Resource and the facility Administrator about Director of Nursing responsibilities 09/5/23. Resident 3 had a skin check performed by the Medical Director on 9/4/2023. The physician identified wound present in sacral/coccyx area and instructed to continue with current treatment order in place for identified skin breakdown. The resident's Care Plan/Kardex was updated on 9/4/2023 with individualized interventions to address/prevent skin breakdown, including turning/repositioning him at least every two hours. Resident 3 was assessed for pain/discomfort. The resident's physician reviewed his pain management interventions. The resident's Care Plan/Kardex was updated on 9/4/2023 with individualized interventions to address/prevent pain, including turning/repositioning him at least every two hours. A facility audit of all residents to be completed by the Director of Nursing/Designee by 9/4/2023 of all residents to validate a skin check has been completed in the past 7 days. Any resident who has not had a documented skin check will have a skin check completed by 9/5/2023. Facilities Plan to ensure compliance quickly: An Ad-Hoc QAPI was conducted on 9/3/2023 when the missing skin check issue was brought up to the facility. Facility interventions were implemented: The facility skin assessment schedule was reviewed on 9/3/2023 and adjustments were made. An audit was completed on 9/3/2023 of every resident's skin check schedule in [EMR] and updates were made as needed to validate the skin check would pop up in the EMAR on the date/shift that was s cheduled. Education was initiated for the facility nursing staff on 9/3/2023 regarding the new skin assessment schedule. Education was initiated for Nursing Assistants on 9/4/2023 on ensuring residents at high risk for skin breakdown are turned and repositioned at least every two hours and who to notify if skin breakdown is identified. Education to be initiated by DON/Designee on 9/4/2023 with all Licensed Nurses regarding the importance of completing a thorough weekly skin assessment with return demonstration and reporting immediately when a resident has incurred a skin impairment. Training to also include proper technique to perform the skin check and how to document the skin check. This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. Education to be initiated by Administrator/Designee on 9/4/2023 with all facility staff on the conditions that lead to neglect and who/when to report suspicion of neglect to. Education to be completed with all nursing staff working 9/5/2023. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. Administrator and Clinical Nurse Resource to create a schedule to validate that facility has sufficient oversight of clinical systems to attain the highest, practicable physical, mental, and psychosocial well-being of each resident while the new Director of Nursing is in training. Administrator and facility administrative nursing team educated by Regional Nurse Consultant on 9/5/23 related to their responsibilities in clinical oversight, clinical audits, and skin program. From 9/6/23-9/7/23 a monitoring visit was conducted to ensure the facility was following its POR. The visits revealed: On 9/6/23 at 11:20am in an interview with the Regional Nurse Consultant she said she was the Interim DON for the next 24hrs and had started as the Interim