**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and resident's choice for 1 of 7 (Resident #1) reviewed for Quality of Care. 1.The facility failed to call emergency services and have Resident #1 immediately transferred to the hospital, on 08/09/25 when she experienced a change in condition at 11:30 a.m., including a blood pressure reading of 203/98 and a change in mental status. The facility failed to monitor Resident #1 after the change in condition was noted and used a non-emergency ambulance service, which resulted in a delay in her receiving emergency care until after 1:13 p.m., approximately one hour and 51 minutes after her initial change in condition. Resident #1 was noted to have a blood glucose level of 44 upon arrival to the hospital and was treated for Hypoglycemia (a condition in which the body's blood sugar level goes below the standard range). An Immediate Jeopardy (IJ) was identified on 08/14/25 at 5:35 p.m. The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on 08/16/25, the facility remained out of compliance at a scope of isolated with a severity level of the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents who had a change in condition at risk of prolonged pain, worsening of condition, prolonged recovery, and possible death. Findings included: Record review of Resident #1's face sheet dated 08/12/25 revealed a Resident #1 was a [AGE] year-old female admitted to the NF on 06/03/25 and readmitted on [DATE]. Resident #1's diagnoses included Cerebrovascular Disease (A group of conditions that affect the blood vessels in the brain), Type 2 Diabetes, Hypertension (High blood pressure), Psychotic disorder, Dementia Chronic Kidney Disease, Conversion Disorder with seizures (involves the experience of real, physical seizures that mimic epileptic seizures but have no underlying medical or neurological cause). Record review of Resident #1's Initial MDS assessment dated [DATE] revealed a BIMS score of 07, which indicated severe cognitive impairment. Section GG of the MDS revealed the resident used a wheelchair and walker for mobility devices. The resident required supervision or touching assistance (helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activity, Assistance may be provided throughout the activity or intermittently) for eating, oral and personal hygiene. The resident requires partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for upper body dressing, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer and toilet transfer. The resident requires substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. Record review of Resident #1's care plan dated 06/03/25 revealed, * Focus: The resident has hypertension. Goal: The resident will remain free from signs and symptoms of hypertension. Interventions: Give anti-hypertensive and medications as ordered. Monitor for side effects such as orthostatic hypotension (A form of low blood pressure that happens when standing up from sitting or lying down) and increased heart rate (Tachycardia) and effectiveness. * Focus: The resident uses insulin. Goal: The resident will be free from any signs or symptoms of hyperglycemia (high blood glucose (blood sugar) or hypoglycemia (A condition where the blood sugar (glucose) levels drop below normal) through the review date. Interventions: Administer insulin ordered by physician. Monitor/document for side effect and effectiveness. Blood glucose monitoring per physician orders. Monitor/document/report PRN any signs or symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing ( A deep rapid, and labored breathing pattern often associated with metabolic acidosis, a condition where the body has too much acid), acetone breath (smells fruity), stupor coma(distinct states of impaired consciousness). Monitor/document/report PRN any signs or symptoms of hypoglycemia: Sweating, Tremor, increased heart rate (Tachycardia), Pallor (An abnormal or unusual paleness of the skin or mucous membranes, indicating a lack of color that is different from a person's normal complexion), Nervousness, Confusion, slurred speech, lack of coordination, staggering gait. Rotate site of insulin injections and document site of administration. Monitor for alteration in skin integrity. Record Review of physician orders based on Resident #1's MAR revealed Resident #1 had orders for: MetFORMIN HCl Tablet 1000 MG-(Give 1 tablet by mouth two times a day for diabetes with a start date of 06/02/25). Metoprolol Tartrate Oral Tablet 50 MG-Give 1 tablet by mouth two times a day for hypertension hold for SBP less than 110 and HR less than 55 with a start date of 06/03/25). AmLODIPine Besylate Tablet 10 MG-Give 1 tablet by mouth one time a day for hypertension hold for less than 110 or HR less than 55 with a start date of 06/04/25). HydrALAZINE HCl Tablet 25 MG-Give one tablet by mouth three times a day for hypertension hold for SBP less than 110 or HR less than 55 with a start date of 06/03/25). Record review of Resident #1's MAR for August 2025 revealed: On 08/09/25 Resident #1 received MetFORMIN HCl 1000 MG AT 9:00 a.m. On 08/09/25 Resident #1 received Metoprolol Tartrate Oral Tablet 50 MG at 9:00 a.m. On 08/09/25 Resident #1 received AmLODIPine Besylate Tablet 10 MG at 9:00 a.m. The residents blood pressure was documented as 144/78 and pulse was 76. On 08/09/25 Resident #1 received HydrALAZINE HCl Tablet 25 MG at 9:00 a.m. Record review of Resident #1's progress notes for August 2025 revealed: * On 08/09/25 at 11:30 AM, RN-A documented, Resident found lying in bed, family at bedside. Resident breathing without difficulty, no difficulty in swallowing, moving right arm, pupils respond to light, no verbal response, responds to pain, vital signs 203/98-78-20 (blood pressure) blood sugar 178, family insists we send to ER, MD notified and received order to send to hospital for evaluation. Record review of Resident #1's electronic health record revealed: On 08/09/25 at 11:30 a.m., Resident #1's blood sugar at 176, the residents blood sugar was not taken again. On 08/09/25 at 11:30 a.m., Resident #1's blood pressure was 203/98. The residents blood pressure was 144/78 at 12:47 p.m. and 144/78 at 12:54 p.m. Record review of the hospital's history of present illness for Resident #1 dated 08/09/25, the resident's blood glucose was 44 upon arrival to thehospital. The resident was admitted to the hospital for hypoglycemia. In an interview with Resident #1 on 08/14/25 at 10:57 a.m., she stated everything was going well. She stated the staff checked on her regularly. She stated she went to the hospital recently. She stated she did not know what happened. She stated she did not know what happened but reported that her daughter was with her. She stated she was feeling fine and stated the staff had been checking on her regularly. She stated she liked living at the facility and stated the staff are nice to her. In an interview with RN-A on 08/14/25 at 11:14 a.m., she stated she checked on the resident at 5:30 a.m. on 08/09/25 and Resident #1 was doing fine. She stated at approximately 11:30 a.m. on 08/09/25, a family member of the resident informed her that she was concerned about the resident. She stated she took the resident's blood pressure, and it was 203/98 and the resident's blood sugar was 178. She stated she contacted the on-call physician, and she was informed to send the resident to the hospital. She stated about 45 minutes later she checked the resident's blood pressure again and it was 180/78. She stated the resident was sent out via ambulance transportation. She stated she did not call 911 because the resident was breathing. She stated the resident was responding to touch, swallowing and moving her arms, but was not talking. She stated the resident left to go to the hospital before 1:00 p.m. In an interview with CNA B on 08/14/25 at 11:53 a.m., she stated Resident #1ad a change in condition on 08/09/25. She stated she did not know the exact time of the change in condition, but she remember that it occurred after breakfast. She stated the resident was not really talking and her normal baseline was usually alert and oriented. She stated the resident was sent out to the hospital, but she could not remember what time she was sent out. Interview with the DON on 08/14/25 at 12:24 p.m., he stated Resident #1 was sent out the hospital due to an elevated blood pressure. He stated he was not working the day the resident was sent out. He stated usually if a resident was alert and moving, the resident was sent out via transportation but if something else was going on with the resident they would be sent out via 911. In an interview with on-call Physician on 08/14/25 at 1:06 p.m., he stated RN-A informed him that Resident #1 had a change in condition, reporting a blood pressure of 203/98. He stated he told RN-A to send the resident to the hospital. He stated it was the facility's decision on which form of hospital transportation was used, but he would assume they would use the fastest method. He stated he assumed that 911 was called and was not aware that the ambulance transportation was called. He stated the risk of a resident not going out the hospital during a change in condition would depend on the resident and the situation In an interview with the Administrator on 08/14/25 at 1:51 p.m., he stated he was not employed at the facility when the resident was sent out but reported he was able to obtain information regarding the call outs and pick up from the transportation center. He stated RN-A contacted the ambulance transportation company at 11:22 a.m. and they arrived to pick the resident up at 1:13 p.m. A policy on change in condition was requested, and he stated there was no policy related to change to change only notification of changes. In an interview with Family Member #1 on 08/14/25 at 3:04 p.m., she stated she was with Resident #1 the day that she was sent out to the hospital. She stated she entered the resident's room at approximately 11:00 a.m. She stated the resident appeared to be in a deep sleep. She stated the resident was lying in bed with her eyes closed and it sounded as if she was snoring. She stated she called the resident's name several times, but she did not respond. She stated she began to shake the resident to get her to arise and she did not move. She stated she notified the nurse. She stated RN-A came into the room and attempted to wake the resident. She stated the resident did not move. She stated the resident's blood sugar was taken, and it was 86. She stated RN-A gave the resident a glucose stick and rubbed her throat to help her swallow but she would not swallow. She stated RN-A stated that she would contact the physician and asked if she wanted 911 to be called and she responded yes. She stated RN-A then stated that it would take an hour for the ambulance to arrive. She stated RN-A never returned to check on the resident. She stated 911 never arrived but reported an ambulance transportation company came instead. She stated the ambulance transportation company arrived around 1:30 p.m. Record review of the facility's Notification of Changes revised 12/08/24 revealed: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status: This may include: a. Life threatening conditions, or b. Clinical complications This was determined to be an Immediate Jeopardy (IJ) on 08/14/2025 at 5:35 p.m. The Administrator, DON, Director of Risk and Regulatory, and the Senior Administrator were notified. The Administrator, DON, Director of Risk and Regulatory, and the Senior Administrator were provided with the IJ template on 08/14/2025 at 5:35 p.m. A Plan of Removal was requested at that time. The following Plan of Removal submitted by the facility was accepted on 08/15/25 at 1:54 p.m.: The facility failed to transfer [Resident #1], who had a change in condition at 11:30am in a timely manner. The facility failed to call 911 emergency services to immediately transport [Resident #1] to a higher-level of care for evaluation and treatment 1. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion/ Date: 8/14/25) [Resident #1] returned to facility on 8/12/25 with no ill effects related to alleged deficiency. DON/Regional /Nurse Consultant reviewed 24-hour report for the last 7 days to ensure all changes of conditions including transfers to acute care were addressed in a timely manner. An audit was conducted on all transfers from the last 7 days to acute care to ensure there was no delay in services. Attending Physician and Medical Director were notified of IJ on 8/14/2025 at 08:40pm. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 8/14/25) Facility policy and procedures related to change of condition were reviewed by Director of Nursing, Administrator, Regional Nurse Consultant and Senior Administrator on 8/14/2025, no revisions deemed necessary at this time. DON/Corporate Nurse/Consultant Nurse provided education to nurse involved in alleged incident with 1:1 education related to notifications of change of condition and monitoring of resident while resident remains in facility until transfer occurs or change of condition resolves. Education included definitions of what a change of condition is, circumstances where the clinical teams must be notified, and when the nurse must notify medical providers and when to notify responsible parties. When to call 911 versus non-emergency transportation as appropriate for the identified change of condition. Frequent assessment of resident to address change of condition including specific assessments to be completed when resident has a diagnosis of Diabetes and appropriate interventions (for example, checking blood sugars frequently to assess for hypoglycemia or hyperglycemia). DON/Corporate Nurse/Consultant Nurse provided education to all staff in person, via phone, via facility messaging platform, or prior to next shift on facility policies and procedures related to changes of condition and to report to licensed nurse the findings for immediate assessment. Education included definitions of what a change of condition is, circumstances where the licensed nurse or Director of Nursing must be notified, and when to notify responsible parties if appropriate. DON/Corporate Nurse/Consultant Nurse provided education to all licensed nurses in person, via phone, via facility messaging platform, or prior to next shift on facility policies and procedures related to changes of condition and seeking immediate medical care as to not delay services. Education included definitions of what a change of condition is, circumstances where the clinical teams must be notified, and when the nurse must notify medical providers and when to notify responsible parties. When to call 911 versus non-emergency transportation as appropriate for the identified change of condition. Frequent assessment of resident to address change of condition including specific assessments to be completed when resident has a diagnosis of Diabetes and appropriate interventions (for example, checking blood sugars frequently to assess for hypoglycemia or hyperglycemia). The Director of Nursing or designee will continue to monitor/audit Changes of Condition and Hospital Transfers by reviewing the 24-hour report during morning clinical meetings three times weekly for four weeks, then weekly for eight weeks. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. * Monitoring of the plan of removal included the following: Record review of an Audit/Monitoring dated 08/11/25-08/14/25 revealed residents were reviewed for change in condition, actions taken to address change in condition. The document reflected if the resident were sent out via 911 or non-emergent transportation, was there any delays, comments/corrective action. There were no identified concerns in the audit. Record review of the Summary Report of Education dated 08/14/25 revealed all facility staff were educated on Notifications of Change in Condition by the DON and Senior Administrator. The document revealed in part, The purpose of this policy is to ensure the facility promptly informs the residents, consults the resident's physician; and notifies consistent with his or her authority, resident's representative when there is a change requiring notification (life threatening conditions, Clinical complications, need to alter treatment significantly, right to privacy, circumstances requiring notification and additional considerations). Record review of the Summary Report of Education dated 08/14/25 revealed all licensed staff were educated on Changes of condition and seeking immediate medical care as to not delay services by calling 911 if needed for transportation as appropriate for the identified change in condition by the DON. The document revealed in part, The purpose of this policy is to ensure the facility promptly informs the residents, consults the resident's physician; and notifies consistent with his or her authority, resident's representative when there is a change requiring notification (life threatening conditions, Clinical complications, need to alter treatment significantly, right to privacy, circumstances requiring notification and additional considerations). Record review of Summary Report of Education dated 08/15/25 revealed licensed staff were educated on Monitoring and assessment to be done when a resident who is diabetic has a change in condition by the DON. The document revealed in part, Hypoglycemia Management-It is the policy of this facility to ensure effective management of a resident who experiences a hypoglycemic episode (Definition, Policy explanation, Compliance guidelines, asymptomatic and responsive residents, symptomatic (lethargic, drowsy) but responsive (conscious) residents). Record review of In-service Summary/Report of Education of 1:1 with the DON and RN A dated 08/14/25 revealed RN A was educated on change of condition-monitor resident vital signs, document-all-clinical changes, monitor resident until 911 arrives, document time start and finish, call NP/MD, DON, and RP. Interviews were conducted with staff on 08/14/25 between 5:35 a.m. until 12:00 p.m. including RN A, CNA B, LVN C, CNA D, LVN E, RN F, CNA G, CNA H, CNA I, Medication Aide J, CNA K, LVN L, LVN M, LVN N, Medication Aide O, LVN P, and CNA Q to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. RN A, CNA B, LVN C, CNA D, LVN E, RN F, CNA G, CNA H, CNA I, Medication Aide J, CNA K, LVN L, LVN M, LVN N, Medication Aide O, LVN P, and CNA Q were able to explain the importance of monitoring the residents that had a change in condition, calling 911 when the residents have a change in condition (high/low blood sugar and high/low blood pressures), taking residents vitals until 911 arrived, staying with the resident until 911 arrived, and documenting all changes. The Administrator was informed the Immediate Jeopardy was removed on 08/16/2025 at 12:02 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal 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 that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #21) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure Resident #21 who the facility staff knew he was at risk for fall and update fall precaution interventions after several falls resulting in injuries to the head. An IJ was identified on 02/09/24. The IJ template was provided to the facility on [DATE] at 7:15 p.m. While the IJ was removed on 02/11/24 at 12:50 p.m., with the Administrator, DVP and DVP Clinical. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated due to the facility staff had not been trained on identifying residents at risk for fall, preventions, and interventions, and modification and care plan falls. This failure could affect residents who were fall risk and place them at risk for physical harm, pain, mental anguish, or emotional distress. Findings included : Review of Resident #21's face sheet revealed Resident #21was a [AGE] year-old male who was admitted to the facility on [DATE], re-admission on [DATE] with a diagnosis of Atrial fibrillation, (irregular and often very rapid heartbeat) , cerebral palsy (weakness or problem with using the muscles), history of falls, and epilepsy(unprovoked seizures). Record review of Resident #21's quarterly MDS assessment, dated 02/07/2024, revealed a BIMS score of 04 out of 15, which indicated the resident's cognition was severely impaired. Further review of Resident #21's MDS revealed the resident required supervision assistance with one staff for transfer and dependent on one staff assistance with putting and taking off footwear. Further review of Resident #21 MDS revealed the resident had one fall snice admission. Record review of Resident # 21 order summary report revealed the following: PT to evaluate and treat under PASRR active date 08/25/23, OT to evaluate and treat under PASRR active date 08/25/23, ST to evaluate and treat under PASRR active date 08/25/23, Fall mat placed next to bed every shift active date 12/18/23. Record review of the facility incident report on falls for Resident #21 revealed the following: 7/22/23 - Unwitnessed fall - in resident room, Mental Status: disoriented, Hematoma was on forehead and transported to 911. 10/22/23 - Unwitnessed fall-in resident room, Mental Status: oriented to time, place and person, abrasion to his forehead, I was sitting on my bed putting my shoes on and fell. 12/18/23 - Unwitnessed fall- in resident room, Mental Status: disoriented, large hematoma above left eye trying to get out of bed to wheelchair. 2/1/24 - Unwitnessed fall - in resident room, and hematoma was on forehead. Record review of Resident #21's care plan revealed the care plan was not updated following falls 07/22/23, 10/22/23, 12/18/23.Intervention:be sure call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Further review of Resident #21's care plan revealed resident was at risk for fall related to confusion, deconditioning, gait/balance problem, and history of fall. Intervention: fall mat placed next to bed during all shift was not care planed. During an observation on 02/06/24 at 9:57 a.m., Resident #21 was sitting in a wheelchair in his room, and the call light was on the nightstand and was not within reach. Resident #21 had dark red-purple bruises from the middle of his forehead to the left of his nose, left eyes, and cheeks. He also had a black line about 1 inch thick across his forehead. Resident #21 also had a hematoma about the size of a tennis ball. During an observation on 02/08/24 at 2:39 p.m., Resident #21 was sitting in his room in his wheelchair, and the call light was not within reach. During an interview on 02/09/24 at 12:21 p.m., the DON said Resident #21 had several falls, in which he had some head injuries, and they have done all they could to prevent Resident #21 from falling except for a helmet for the protection of his head. The DON said Resident #21 bed should be at the lowest position whenever he was in bed, and she did not know if his bed was on the lowest position when fell because all his fall were unwitnessed. The DON said all the interventions were care planned. During an observation and interview on 02/09/24 at 1:30 p.m., Resident #21 was in his room sitting in his wheelchair, and the call light was not within reach; it was on the nightstand. Resident # 21 said he fell from the bed but could not remember what day it was or if the bed was low. During an observation and interview on 02/09/24 at 1:34 p.m., LVN R said Resident #21 falls frequently. LVN R said Resident #21's call light was on the nightstand far from Resident #21, and he could not reach it if he wanted to use it. LVN R said the DON and ADON are responsible for implementing any changes in the care plan. During an observation and interview on 02/09/24 at 1:41 p.m., the DON and ADON went into Resident #21's room and the DON said they saw the call light on the nightstand, and Resident #21 could not reach the call light if he wanted to use it. The DON said the call should be within reach whenever the resident was in the room. During an interview on 02/09/24 at 1:43 p.m., CNA F said she just picked up the tray from Resident #21's room and did not notice Resident #21's call light was not within reach. CNA F said Resident #21 could fall if he tried to reach for his call light, and he could not call for assistance if he wanted to call because the call light was not within reach. During an interview on 02/09/24 at 3:03 p.m., the ADON said she saw that Resident #21's call light was not within reach of the resident. The ADON said Resident #21 was at risk of falling and could fall if he tried to reach for the call light. The ADON said all of Resident #21's falls should have been care planned and intervention modified. The ADON said she did not know why the falls were not care planed, she said the intervention should be modified with each fall, and she was not responsible for care planning the falls and it was the responsibility of MDS coordinator and social worker. During an interview on 02/09/24 at 3:23 p.m., The DON said any nurse could update the care plan, and all of Resident # 21's falls should have been care planed and intervention modified as needed. The DON said she would investigate and update the surveyor later. During an interview on 02/09/24 at 3:28 p.m., the Corporate Nurse said that all of Resident #21's falls should be care planned and that she would investigate and find out the root cause of his falls so that an intervention could be put in place. During an interview on 02/09/24 at 3:36 p.m., the SW said she had not had any care plan meeting with Resident #21's family about his falls. SW said she was aware of the falls because she would see Resident #21 had a knot on his head and bruises. During an interview on 02/09/24 at 3:41 p.m., the MDS Coordinator said the DON and ADON updated the care plan, and she only coded the MDS. The MDS coordinator stated that the GG section of MDS did not require any coding for staff assistance for Resident #21's bed mobility. The MDS coordinator said the DON and the ADON were responsible for putting and modifying interventions in the care plan. During an interview on 02/09/24 at 3:44 p.m., the Director of Rehabilitation said Resident #21 has been in therapy since March last year, and they are working on his endurance, balance, and memory. The Director of Rehabilitation said he does not work with Resident #21 and would talk to his staff if any recommendation was made for Resident #21. The Director of Rehabilitation said if his department made any recommendations, the nursing department would be responsible for care planning, intervention, and monitoring of Resident #21. Record review of facility policy on fall clinical protocol dated 2001 MED PASS, Inc. (Revised March 2018) read in part .cause identification . #3 The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified .treatment/management .#1 Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .monitoring and follow-Up .#1 . the staff, with the physician 's guidance, will follow up on any fall with associated injury . #2 .the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of fall .#4 if the individual continue to fall, the staff and the physician will re- evaluate the situation and reconsider possible reasons for the resident's falling(instead of, or in addition to those that have already been identified) and also reconsider the current interventions . This was determined to be an Immediate jeopardy (IJ) on 02/09/24 at 7:15 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 02/09/24 at 7:15p.m. The following Plan of Removal submitted by the facility was accepted on 02/10/24 at 9:34 a.m. PLAN OF REMOVAL Name of facility: Fallbrook Rehabilitation and Care Center Date: 02/09/2024 F 689 - The facility failed to ensure that Resident #21 received adequate supervision and assistive devices to prevent accidents. The facility failed to update fall precaution interventions after several falls resulting in injuries to a resident. Immediate action: The Medical Director was notified of the Immediate Jeopardy status on 02/09/2024 at 7:50 pm. Resident #21 promptly had a new fall risk assessment done by ADON 02/09/2024. Resident #21 is currently receiving Physical, Occupational and Speech therapy 5 days a week. Resident's care plan updated to include fall mat, bed to be kept in low position, and verification that call light was in reach 2/9/2024. The Director of Nurses, Assistant Director of Nurses will review all fall risk assessment and update care plans to ensure appropriate interventions are in place and this will be completed by 2/10/2024. Regional nurses will review all current resident fall history and verify falls and fall interventions are captured on care plan by 2/10/2024. Therapy will review all residents who have fallen in the last 90 days to ensure residents have been screened and therapy will implement additional interventions as indicated (to be completed by 2/10/2024). Therapy will provide any needed training to nursing staff for interventions. Rehab director attends fall management meeting during stand-up meeting and will provide any screen and therapy plan information related to resident's falls to nursing staff. Nursing management. To include DON, ADON, MDS, will update care plan and CNA guidance in Point click care. Charge nurses will ensure recommended interventions related to resident's falls are followed and DON, ADON will provide oversight by making rounds daily, All nursing staff, which includes all nurses and nurse aides, will be in-service to ensure call bells are within resident's reach by Nursing manager by 2/10/2024; Nurse staff All nursing staff, which includes all nurses and nurse aides, will not be allowed to start shift until completing in-service training. Facility Plan to ensure compliance quickly Director of Nurses, Assistant Director of Nurses, and Nurse Supervisor will provide education to nursing staff by 2/10/2024 to notify physician and RP and to promptly implement an intervention after fall by updating resident's care plan. The Director of Nurses, Assistant Director of Nurses, and MDS Nurse will review falls in morning meeting and ensure that the nursing staff has updated the care plan, and the physician was notified. IDT team will review the fall intervention implemented by nurses in morning meeting. Education will be completed by the Director of Nurses, Assistant Director of Nurses, and Nurse Supervisor by 02/10/2024 for all nurses and certified nurse aids on importance of ensuring call lights are in resident's reach. CNAs will be educated on ensuring call lights are in resident's reach when doing Q 2-hour rounds. Charge nurses will verify that CNAs have place call bell in reach when their doing rounds. IDT team will do rounds 5 days a week to verify call bells are within resident's reach and document on IDT round sheet. Staff will not be allowed to start shift until completing in-service training. Nursing staff (licensed and certified) will be re-educated on call bell system to include call bell placement by 2/10/2024. Administrator, DON, ADON, and Nurse Supervisor will Inservice Nursing staff/aides on falling star program, which includes stars on name room plate and bands on devices. Interventions will be listed in nurse/CNA care plan in Point click care. Inservice to be completed 2/11/2024Staff will not be allowed to start shift until completing in-service training. QAPI meeting was held 2/9/2024 by the facility IDT team, which included Administrator, DON, ADON, CNO, Housekeeping supervisor, social worker, Human resources to review policy/procedure Fall management program. Surveyor monitored the plan of removal for effectiveness as follows: A record review of the facility removal plan revealed the medical director was notified of the IJ on 2/09/24 at 7:50 p.m. A record review of the risk assessment revealed all residents were reviewed on 02/10/23 by the corporate nurse for fall risk assessment. Record review of the facility in service revealed the DON and ADON in-service the nurses and CNAs on fall prevention, care plans/[NAME] (electronic health record) for personalized interventions, identifying residents at risk for falls, falling star/yellow bands, fall prevention and updating the care plan on 02/10/24. A record review of the progress note revealed Residents with falls for the past 90 days were reviewed by the therapy on 02/10/24 and they are currently in therapy. A record review of fall risk assessment revealed Resident #21 had a new fall risk assessment done by ADON on 02/09/2024. A record review of Resident #21's care plan revision dated 02/09/24 revealed the following up date: with a fall mat, bed in a low position, all the falls were care-planned and currently on PT, OT, ST, under PASRR 5 times a week indefinitely since March 2023. During observations on 02/11/24 from 10:00a.m. to 2:00 p.m., revealed residents(Resident #21, Resident #18, and Resident #25) on the fall list had their call lights attached to the bed, and one Resident #24 was in bed, and she could reach her call light. During interviews on 02/10/24 between 11:21 a.m. and 8:48 P.m., two CNAs and three nurses from the night shift were interviewed on the facility in service and training on fall precautions, interventions, identification of residents at risk of falls, care plan modification of intervention and who was responsible for updating care plans. All staff interviewed were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. During an interview on 02/11/24 between 9:00 a.m. and 9:30 a.m., one CNA, one nurse from the day shift, and The MDS coordinator were interviewed on the facility in service and training on fall precautions, interventions, identification of residents at risk of falls, care plan modification of intervention and who was responsible for updating care plans. All staff interviewed were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. During an interview on 02/11/24 at 9:57 a.m., the DON said she was checking to ensure that all the in-services were done because she did some training, and the Social Worker and the Administrator did some of the in-services. The DON said she provided training for the aides not to move any resident observed on the floor but to call the nurse so the nurse could assess the resident. The DON said she also trained the aides to look at the [NAME] for residents at risk for falls, and the [NAME] also showed the aides the different types of interventions for each resident. The DON said [NAME] told the aides that the resident should have a nonskid stocking, a yellow falling star on the door, and the resident should wear a yellow band. The DON said the nurses were given the same training as the aides, and they were also trained on how to update the care plan if any resident had a fall. The DON said the nurses were in serviced on assessing a resident during a fall, notifying the physician, carrying out the physician's order, and also notifying the responsible party and nurse management. During an interview on 02/11/24 between 10:00 a.m. and 11:00 a.m., two CNAs and three nurses from the day shift were interviewed on the facility in service and training on fall precautions, interventions, identification of residents at risk of falls, care plan modification of intervention and who was responsible for updating care plans. All staff interviewed were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. During an observation on 02/11/24 at 11:17 a.m., it revealed Resident #21 was sitting in his wheelchair in his room close to the foot of the bed close to the door, and the call light was clipped on the linen close to the resident, and he could reach the call light. During an interview on 02/11/24 at 12:11 p.m., the Administrator said he was aware of Resident #21 falls, and they discussed them during IDT meets. The Administrator said they had changed Resident #21's fall precautions, and his care plan has been updated. The Administrator said he assisted with the in-service training for the aides and nurses on falls; they have amended the fall program and implemented the falling star and general intervention for falls but did not go into details about the care plan. The Administrator said the DON and the ADON conducted in-service the staff on updating the care plan, and he told the staff to follow up with the DON any time they had any falls. On 02/11/24 at 12:50 p.m., the Administrator, the DON, the VP of operation, and DVP Clinical were notified the Immediate Jeopardy was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum 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 observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 12 residents (Resident #1) reviewed for pharmaceutical services in that: - The facility failed to administer IV antibiotic as ordered by the physician when Resident #1's insurance did not cover the cost for resident to receive the ordered IV antibiotic therapy (Amphotericin B and Avycaz) to treat unresolved infections for 5 days. -The facility failed to review Resident #1's Physician orders and MAR to ensure that all medications were being administered according to physician's orders. An IJ was identified on 8/4/23. The IJ template was provided to the facility on 8/4/23 at 5:03 p.m. While the IJ was removed on 8/8/23, the facility remained out of compliance at a scope of isolated and a severity level of potential for harm that is not immediate due to the facilities need to evaluate the effectiveness of corrective systems These failure places the residents at risk of worsened infection. Findings: Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the Nursing facility on 02/06/2023 with diagnoses that included the following: cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness), respiratory failure (difficult to breathe on your own), with hypoxia (absence of oxygen in the body), type 2 diabetes mellitus, heart disease, heart failure, hypertension (high blood pressure), Gastroesophageal reflux disease (digestive disease), and gastrostomy (opening into the stomach wall, made surgically for the introduction of nutrition). Record review of Resident #1's MDS assessment dated [DATE] revealed that resident had BIMS score of 3 indicating that resident cognition was severely impaired. Further review revealed that resident was totally dependent upon staff for activities of daily living. Record review of Resident #1's Care plan (dated 07/26/2023) revealed that resident was being care planned for isolation precautions secondary to infection of C-Auris (fungus that can cause a serious health threat) and she is resistant to antifungal medications with interventions that included to administer medications as ordered. Record review of Resident #1's Nursing Progress Notes dated 07/12/2023 documented by LVN A revealed in part: .Change in condition blood pressure 110/64, pulse 110 irregular, respirations 22, temperature 98.7 .The physician was notified .orders received to get CXR, UA, CBC, and CMP .07/13/2023 EMS called for transport to the hospital for blood transfusion .Hgb 5.5 Record review of Resident #1's CBC with differential (test that measures the total number of white cells in the blood) dated 07/13/2023 revealed the following -WBC: 19.4 norm (4.0-10.0) -RBC: 2.32 norm (3.93-5.22) -Hgb: 5.5 norm (11.2-15.7) -Hct: 18.6 norm (34.1-44.9) Record review of Resident #1's STAT CMP dated 07/12/2023 revealed the following: -BUN: 75 norm (3-23) -Creatine: 1.30 norm (0.60-1.20) Record review of Resident #1's admitting diagnosis to the hospital on [DATE] was septic shock (widespread infection in the body that is life threatening), candida auris (a species of fungus that grows as yeast in the body), candidemia (yeast in the body blood stream), bacteremia (bacteria in the blood), cavity pneumonia (lung infection), acute or chronic respiratory failure, anemia (low blood) requiring transfusions. Record review of Resident #1's hospital discharge instructions dated 07/25/2023 to continue IV Avycaz for two more weeks and reassess for further duration. Continue IV Amphotericin until 08/03/23 . Call physician for temperature greater than 100.5. Record review of Resident #1's Nursing Progress notes revealed that resident was admitted back to the NF on 07/26/23. Record review of Resident #1's Physician orders included the following: -Ceftazidime-Avibactam (Avycaz) IV 2.5 gm every 8 hours related to pneumonia for 14 days until finished date of order 07/26/2023 -Amphotericin B Lipid IV 450mg one time a day related to Candidiasis for 7 days until finish order date 07/26/2023 -Zoysn 3.375 gm IV every 8 hours for 10 days for pneumonia dated 07/31/2023. Record review of Resident #1's Physician orders revealed an order dated 07/27/2023 created by LVN A revealed in part: -ceftazidime-Avibactam intravenous solution reconstituted 2.5 gm every 8 hours intravenously every 8 hours related to pneumonia and Amphotericin B Lipid intravenous suspension 5mg/ml use 450mg intravenously one time a day related to candidiasis for 7 days until finish 450mg in 250ml were placed on hold. Further review revealed that the attending physician for Resident #1 signed the order on 08/02/2023. Record review of Resident #1's MAR for the month of July 2023 revealed that the medications Amphotericin B and Ceftazidime-Avibactam were never administered to Resident #1. Further review revealed that the IV antibiotic Zoysn 3.375mg was first administered on 07/31/2023. Interview with LVN A on 08/03/2023 at 12:53pm said she was the nurse that readmitted Resident #1 back to the NF on 07/26/2023. LVN A said she called the physician to do a medication reconciliation. LVN A said the physician said to continue with all orders. LVN A said when she returned on 07/27/2023 for the night shift no IV antibiotics were available and therefore she reached out to the pharmacy that informed her that resident insurance did not cover the cost of the medications Amphotericin B 450mg and Avycaz 12.5 mg IV. LVN A said on 07/31/2023 the physician was making rounds and she asked the physician what she wanted to do about Resident #1's antibiotic therapy. LVN A said the physician said she would have to reviewed Resident #1's medical records first. LVN A said the attending physician ordered the IV medication Zoysn 3.375g IV to be administered every 8 hours and said she needed to speak with the ADON. Record review of Resident #1's Nursing Progress Notes dated 07/31/2023 documented by the ADON revealed in part: .Spoke with responsible party of Resident #1 regarding resident current condition. We reviewed resident medication as well as the changes from the MD today to start Zoysn IV ABT therapy current condition. Interview on 08/03/2023 at 1:08pm via phone the pharmacy tech said the pharmacy filled an order for Zoysn 3.375mg on 07/31/2023. The pharmacy tech said the NF sent an order to be filled on she believed 07/26/2023 or 07/27/23 for Amphotericin B IV every 24 hours and Avycaz 2.5mg IV every 8 hours. The pharmacy tech said Resident #1's insurance was Medicaid which did not cover the cost for the medications (Amphotericin B and Avycaz IV). The pharmacy tech said the NF was notified about Resident #1's insurance not covering the IV antibiotics and to ask the physician what other IV antibiotic they would like to prescribe for Resident #1. Interview on 08/03/2023 at 1:53pm via phone the attending physician said she made rounds at the NF on 07/31/2023 and saw that the IV antibiotics Amphotericin B and Avycaz were pending. The attending physician said the facility did not tell her that the insurance would not pay the cost of Resident #1's IV antibiotics amphotericin B and Avycaz. The physician did not place the antibiotic ion hold prior to 8/2/23 and was unaware Resident #1 had not received the antibiotic. The attending physician said she reviewed Resident #1's hospital records and saw that the hospital at one time was administering the IV antibiotic Zosyn 3.375gm and therefore, placed Resident #1 on this IV antibiotic every eight hours for 2 weeks. The attending physician said because there was a delay of resident not receiving her IV antibiotics for 5 days, it placed resident at risk for her pneumonia becoming worse. The attending physician said she had assessed Resident #1 and did not see any clinical changes in her medical condition. The attending physician said she would continue to monitor Resident #1 and order diagnostic testing deemed necessary. Interview on 08/03/2023 at 2:13p.m. the ADON said she called Resident #1's RP regarding the changes made with resident IV antibiotic therapy. The ADON said when a resident is admitted to the NF, the admitting nurse must verify all orders with the physician and the orders were put in the system to be filled by the pharmacy. The ADON said it was the night nurse manger on duty that followed up to ensure all orders had been placed in the system. The ADON said new admissions were discussed in the morning meetings, but the nursing staff never informed her that the insurance did not cover the cost of Resident #1's IV medications Amphotericin B and Avycaz. The ADON said it was herself and the DON that reviewed the resident MARS for missed medications daily. The ADON said because Resident #1's IV medications Amphotericin B and Avycaz were placed on hold, it would not have generated in the system as missed medication. Observation on 08/03/2023 at 3:24pm Resident #1 was in bed with no roommate on isolation precautions. Resident was not interview able. Resident #1 was resting in bed quietly on an air mattress with head of bed elevated, no distress observed. Further observation was made of resident receiving gastrostomy feedings. Resident had a trach connected to a vent with no concerns identified. Resident had an isolation signage on the doorway entrance regarding infection control precautions. There was PPE readily available at the doorway entrance. Interview on 08/03/2023 at 4:00pm RN C said he was the Nurse Manager working the night shift on 07/26/2023 when Resident #1 was readmitted back to the NF. RN C said if a resident is a readmission or a new admission, the physician is notified, and a medication reconciliation is done with the physician. RN C said the orders are put in the system so that the pharmacy can fill prescribed medications and then deliver the medications as soon as possible to the NF. RN C said he was never aware that there was an issue with Resident #1's insurance not covering the cost of Resident ordered IV antibiotics amphoteric b and Avycaz. RN C said no medications should be placed on hold without a doctor's order. RN C said if there was an issue with resident insurance not paying for a specific medication, the logical thing to do is to call the physician to see what alternative medication could be prescribed for the resident. Further interview on 08/03/2023 at 5:34pm LVN A said that on 07/27/2023 she informed the attending physician NP of the pharmacy reporting that Resident #1's ordered IV antibiotic Amphoteric B and Avycaz was not covered by resident insurance. LVN A said it was the attending physician NP that gave the order to hold the ordered IV antibiotics. LVN A said the next few days, she was off work and when she returned, she asked the attending physician what she wanted to do about the IV antibiotics on hold. Interview on 08/04/2023 at 7:00pm Administrator said she called the attending physician of Resident #1 before resident was readmitted to the NF informing resident physician that resident insurance did not cover the ordered antibiotics. The Administrator said resident attending physician was aware and said that Resident #1 needed to have the ordered IV antibiotics and that she would order further cultures as resident had completed her IV antibiotics. The Administrator said she got approval from the Corporate Office to pay the cost of Resident #1's ordered IV antibiotics. Interview on 08/05/2023 at 1:40pm the attending physician NP said that on 07/26/2023 she had received a group text from LVN A around 5:44pm. The NP said LVN A informed that Resident #1 was returning from the hospital and that the IV antibiotics Amphotericin B and Avycaz were not going to be covered by the resident insurance. The NP said the attending physician was also on the group text as well. The NP said the physician said she would have to review Resident #1's medical records to see if the medications could be changed. The NP said she told the physician about the organisms that the IV antibiotics were treating, and that the physician said the antibiotics could not be changed. The NP said she did not know what happened after that. The NP said she was new to the facility and had been working at the NF for about a month. The NP said when she was coming to the facility, Resident #1 had not been added to her list as one of the residents to see initially. The NP said she was at the facility on 07/27/2023 and the nursing staff had informed her that Resident #1 had been readmitted to the NF. The NP said although Resident #1 was not on her list of residents to see on 07/27/203, she went in Resident #1's room to do a quick assessment and resident was stable (lung sounds were clear, trach intact, vital signs stable with no identified concerns). The NP said because of the group text that was had on 07/26/2023 and speaking with the physician later, she thought Resident #1's IV antibiotics Amphotericin B and Avycaz had been resolved. The NP did not place the antibiotic on hold and was unaware the medication was not administered to Resident #1. The NP said the next time she saw Resident #1 again was on 08/02/2023. The NP said the delay in administering Resident #1's IV antibiotics as ordered placed resident at higher risk for increased infections and becoming septic making it more difficult to treat the organisms. The NP said the antibiotics Amphotericin B and Avycaz were very strong antibiotics and that the hospital placed resident on the antibiotics for a reason. The NP said the antibiotic Zoysn was compatible to treat the bacteria pneumonia but not the antifungal. Further interview on 08/05/2023 at 2:40pm via phone the attending physician said the IV medication Zoysn could help Resident #1 and that she would be coming to the facility on [DATE] to reassess resident and do something different regarding Resident #1's care. The attending physician said she told the NF that they had to continue resident on the ordered antibiotics. The attending physician said she did not know that Resident #1 was not receiving the IV antibiotics Amphotericin B and Avycaz. The attending physician said she signed off on a lot of orders and did not recall signing orders to hold Resident #1's ordered IV antibiotics. Interview on 08/06/2023 at 12:17pm the CNO said she was now the NF interim DON since 08/05/2023. The CNO said it was the CEO that gave the Administrator the approval to have the ordered IV antibiotics Amphotericin B and Avycaz be administered to Resident #1. The CNO said she was not aware of Resident #1's insurance not covering the cost for the ordered IV antibiotics until an IJ was called on 08/04/2023. The CNO said the previous interim DON resigned on 07/28/2023 without notice. The CNO said the previous DON worked at the NF on 07/24/23-07/26/2023 and was off on 07/28/2023. The CNO said on 07/28/2023 she received an e-mail from the DON that she would not be returning to the facility. The CNO said the NF has hired a new DON that would be starting to work on 09/05/2023. The CNO said the reason she believed that the NF was in an IJ was because of the following: The facility failed to make sure that Resident #1 was receiving the ordered antibiotics after being readmitted back to the NF from the hospital. The CNO said when the IV antibiotic was placed on hold the NF should have followed up with the physician right away to see what was an alternative medication that could have been administered. The CNO said it was ultimately the NF's responsibility to ensure that the resident (s) needs were being met. Interview on 08/06/2023 at 12:35pm the CEO said the Administrator of the NF had contacted her prior to Resident #1 being readmitted back to the NF informing her that Resident #1 would be returning to the NF on expensive medications that the resident insurance would not be covering. The CEO said she gave the Administrator the approval to order the IV medications for Resident #1 and that the NF would be covering the cost. The CEO said that was normal protocol and did not know if the NF had a policy on covering the cost of treatment when a resident insurance did not pay. Attempted interview on 08/06/2023 via phone at 1:02pm and at 1:50pm on 08/08/2023 with the previous DON, no answer, left voicemail with a call back number. Interview on 08/08/2023 at 9:12am via phone the Infectious Disease Doctor said after reviewing Resident #1's medical records the IV medications Amphotericin B and Avycaz were not to be substituted and that resident should have received the medications as ordered. The Infectious Disease Doctor said although he could not predict what would happen to Resident #1 with the delay in not receiving the prescribed ordered IV antibiotics for 5 days, it did place resident at risk of her disease process worsening. Record review of the NF Medication Administration Policy (no date or revision date) revealed in part: .Medications are administered in accordance with prescriber orders . Record review of the NF Medication Therapy Policy revised April 2007 revealed in part: The Physician will identify situations where medications should be tapered, discontinued, or changed to another medication, for example .when a medication is not approved by the payer source, and when a medication is being prescribed to treat, or in anticipation of, an adverse consequence of another prescribed drug . An IJ was identified on 8/4/23. The IJ template was provided to the facility on 8/4/23 at 5:03 p.m. While the IJ was removed on 8/8/23, the facility remained out of compliance at a scope of isolated and a severity level of potential for harm that is not immediate due to the facilities need to evaluate the effectiveness of corrective systems PLAN OF REMOVAL F 755 Date: 08/04/2023 Immediate Action: Immediate Jeopardy called for F755- Pharmacy Svcs./ Procedures/ Pharmacist/ Records. The facility will conduct an audit of all patients with anti-infective orders to ensure that ordered meds are on site and being administered. The facility will audit all on hold orders and review those noted with the appropriate primary care physician to determine any actions needed that may include the DC, re-start and/or change of said medication., RN, BSN, will complete the audit before midnight tonight, 08/04/23. The Medical Director, primary care physician, and patient responsible parties will be notified regarding any patients with missed, new, changed and/or discontinued medications. , RN, BSN, will complete the notifications with the assistance of charge nurses on duty. This audit and notifications will be completed before midnight tonight, 08/04/23. Facility Plan to Ensure Compliance Quickly (and Ongoing): Nursing staff (licensed) will be re-educated on medication management including ordering, and a focus on how to deal with medications not covered by the patient's insurance and on-hold orders. In-servicing will also include the importance of notifying the physician to obtain any additional orders that may be needed for medications not administered for any given reason. When a patient's insurance denies any medication, nurse management and the administrator need to be notified so they can resolve the issue with the assistance of the physician. The facility will either pay for the medication in question or if appropriate a new medication will be ordered. Nurse education that on-hold orders need to be resolved within 72 hours of hold with the assistance of the physician and/or extender is in progress. The resolution is to discontinue the medication or re-start the medication. Nurse Managers were educated to check on-hold orders daily via EHR system to ensure that any medication or treatment on hold is resolved timely. Education will begin on 08/05/23 and include all charge nurses with the completion target date of Sunday, 08/06/23. Any nursing employee not available for education by 08/06/23 will complete the in-service at the start of their next shift. Nurses will need to demonstrate understanding of the process on what to do when meds are denied by the insurance company verbally and through testing/ questionnaire., RN, BSN and , LVN, ADON will conduct the education and tracking of completion. On- going competency of Medication Management will be monitored by asking oral/verbal questions, daily auditing of documentation, related to anti-infective, and on-hold orders. This in service will occur upon hire, and quarterly moving forward. This will be tracked by LNFA, and , LVN, ADON monthly to ensure education is completed and said standards are met. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview with RN D said she worked full time at the NF 7am-7pm and had been in-serviced on the following: when the NF receives a new admission or readmit, call the physician to do a medication reconciliation and to place the orders in the system for pharmacy to fill the medications. If the resident medication is not covered under the resident insurance, call the Administrator right away as well as the doctor and responsible party documenting in the Nursing Progress Notes, and the 24-hour report sheet as well as providing a verbal report at shift change. RN D said she was also in-serviced that a medication could not be on hold for more than 72-hours and to follow up with the physician. RN D said she had to take a test on medication administration. Interview on 08/06/2023 at 1:55pm RN E said she had been in-serviced on medication administration and medication errors. RN E said she was in-serviced on not to hold medications without a physician order. RN E said if the resident insurance did not cover a prescribed medication, she had been in-serviced to notify the administrator, doctor, and the RP. RN E said she would ask the doctor if he or she wanted to order another medication that was compatible. RN E said she was in-serviced to document all actions taken in the Nursing Progress Notes, 24-hour report sheet, and give the oncoming nurse a verbal report of the actions taken. RN E said if a medication is placed on hold by the physician, she would have to follow-up with the doctor no later than 72-hours to see what alternative medication the physician wanted to order for the resident. RN E said she would also inform the Nurse Manager so that this could be shared in the NF morning meetings. RN E said she had to take a medication test. Interview on 08/06/2023 at 2:42 pm LVN F said he worked at the NF 7am7pm as a supervisor. LVN F said he had been in-serviced on medication administration that if a doctor had placed a medication on hold, the nurse needed to follow-up with the doctor no later than 72-hours to get the matter resolved. LVN F said if a resident insurance did not cover a particular medication, a nurse needed to let the administrator and doctor be made aware so that the doctor could possibly order a different medication to treat the resident and if not, the facility would have to pay the cost. LVN F said the nurse needed to document everything in the Nursing Progress Notes and on the 24-hour report sheet and give a verbal report to the oncoming nurse. LVN F said the resident RP needed to be made aware of what all had taken place. Interview on 08/07/2023 at 5:15a.m. LVN G via phone said she worked at the NF full time on the 7p-7a shift and had received in-service on medications that entailed orders and making sure that medication was available. LVN G said if a medication was not available or the resident insurance did not cover a medication, the administrator and the doctor needed to be notified right away to see if the doctor wanted to order a different medication. LVN G said if the doctor gave an order to hold a particular medication, the nurse needed to follow-up with the doctor on that medication that was on hold no more than 72-hours to see what changes the physician wanted to make and document all actions taken in the Nursing Progress Notes, 24-hour report sheet, and give a verbal report to the nurse coming on duty. LVN G said she had to take a medication administration test as well. LVN G said the resident RP was to be notified of what was going on. Interview on 08/07/2023 at 5:30am LVN H via phone said he worked the 7p-7a shift and had been in-serviced on medication administration to notify the doctor and administrator if a medication was not available or not covered by the resident insurance. LVN H said if a medication was placed on hold, the nurse needed to follow-up with the doctor no later than 72 hours and to document all actions taken. LVN H said this had to be documented in the Nursing Progress Notes, 24-hour report sheet, and a verbal report had to be given to the nurse coming on duty. Interview on 08/07/2023 at 5:38am LVN I via phone said she worked the night shift 7p-7a full time at the NF. LVN I said she had been in-serviced on the management of medication administration that if a doctor gave an order to hold a medication, the nurse needed to follow-up with the physician within 72 hours to see if he wanted to discontinue the medication or order another medication. LVN I said if a resident insurance did not cover a medication or the medication was not available, the administrator and the doctor needed to be informed right away in order to get the matter resolved. LVN I said the nurse needed to call the RP to let them know what all was going on. LVN I said she was also in-serviced on the importance of documenting in the Nursing Progress Notes, 24-hour report sheet all actions taken as well as providing a verbal report to the oncoming nurse. Interview on 08/07/2023 at 7:30am LVN J via phone said he worked at the NF full time 7p-7a and had been in-serviced on medication administration that if the doctor placed a medication on hold, the nurse needed to follow-up with the doctor no later than 72 hours to see what changes the doctor wanted to make. LVN J said if a resident medication was not available or there were some issues with the resident insurance not covering the medication, the nurse needed to notify the administrator and the doctor to see what changes needed to be made to resolve the issue and to document in the Nursing Notes what all had taken place. Interview on 08/07/2023 at 9:20am LVN K via phone said she worked 7p-7a shift and had received in-service on medication administration if a medication was not available to contact the administrator and doctor to try and get it resolved. LVN K said she had also been in-serviced on following up with the doctor within 72-hours on all medication orders that had been placed on hold and document in the Nursing Progress notes. LVN K said she had to provide the oncoming nurse a verbal report regarding the matter. Interview on 08/07/2023 at 11:38am via phone LVN L said she worked at the NF on the 7p-7a shift and had received in-service on medication administration that if a medication was not available or insurance was not covering the cost of medication, the administrator and the doctor needed to be called right away to see if there was alternative medication that could be prescribed for the resident. LVN L said medications on hold had to be followed-up with the doctor within 72 hours and documented in the Nursing Progress Notes as well as on the 24-hour report sheet. LVN L said she had to include this in her shift verbal report to the oncoming nurse and notify the RP. Interview on 08/07/2023 at 1:45pm LVN A said she had been in-serviced on when she receives an order to hold a medication, a follow-up needed to be done with the physician within 72 hours to see if the physician wanted to discontinue the medication or order another medication. LVN A said if a resident insurance did not cover a particular medication to notify the administrator and the physician to see if the doctor wanted to order an alternative medication that the resident insurance would cover. LVN A said she would contact the pharmacist before calling the doctor to see what an alternative medication was covered by the resident insurance so that when she called the physician, she could provide this information as well. LVN A said she was also in-serviced to document all happenings in the Nursing Progress Notes, 24-hour report sheet and report to oncoming nurse verbally in shift report. LVN A said the resident RP also had to be notified of what was going on regarding the resident's care. Interview on 08/07/2023 at 2:15p.m. LVN M said she worked the morning shift 7am-7pm. LVN M said she had been in-serviced on medication administration, new admissions, and readmissions. LVN M said if a resident medication was placed on hold by the doctor, the nurse would need to follow-up with the doctor within 72-hours to see about getting the medication discontinued or a new medication that was compatible. LVN M said the administrator as well as the doctor had to be informed if a medication was not covered by the resident insurance or not available. LVN M said the nurse had to document all happenings in the Nursing Progress notes, 24-hour sheet and give a verbal report to the oncoming nurse. Interview on 08/07/2023 at 2:20p.m. RN N said he worked at the NF full time 7am-7pm and had been in-serviced on medication administration. RN N said if a resident insurance did not cover a certain medication or the medication was not available, the nurse must call the administrator and the doctor to see if there was alternative in resolving the matter such as the doctor ordering a medication that was compatible and covered by the resident insurance. RN N said if there was an order to hold a medication, he would have to call the doctor within 72-hours to get an order to discontinue the medication or an order for alternative medication. RN N said the resident RP also had to be notified and to document everything in the Nursing Notes and the 24-hour report sheet and informing the oncoming nurse verbally in shift report. On 08/08/2023 at 4:00pm the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a scope of isolated and a severity level of potential for harm that is not immediate due to the facilities need to evaluate the effectiveness of corrective systems

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three (CR#9, CR#10, and CR#11) of four residents reviewed for treatment/services of pressure ulcers. 1. Facility failed to fully assess CR #9's wound to establish baseline for treatment and obtain treatment orders. 2. Facility failed to ensure CR#9 received wound care for six (6) days during his admission to the facility on 04/12/2023 through 04/17/2023. 3. Facility failed to provide daily wound care to CR#9, CR#10, and CR#11 having multiple days of missed wound care, resulting in CR#11's wound deterioration. An Immediate Jeopardy (IJ) was identified on 06/09/2023. The IJ template was provided to the facility on 6/9/23 at 12:58 p.m. While the IJ was removed on 06/13/2023, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to failure occurred to multiple residents over multiple days and the facility's need to evaluate the effectiveness of the corrective systems. These deficiencies could expose residents to wound deterioration, worsening of condition, infection, sepsis, and hospitalization. Findings include: Review of face sheet revealed CR#9 was a [AGE] year-old male who was admitted to the facility on [DATE]. CR #9's diagnoses included metabolic encephalopathy, anemia, heart failure, type 2 diabetes mellitus, respiratory failure, tracheostomy, osteomyelitis, and muscle wasting. Record review of the progress note dated 04/12/2023 during admission revealed CR #9 had wounds identified as unstageable wound to sacrum and DTI (deep tissue injury) to right stump. Record review of CR #9's Physician Orders revealed there was no wound care orders for CR #9 the day of his admission on [DATE] through 04/17/2023. Record review of CR#9's Progress Note dated 4/12/2023 during admission revealed Sacrum wound stage 4 noted to scrum. Coccyx wound noted, DTI to right hell, right toes are amputated, multiple bruises to upper and lower extremities, old healed wounds and scars to lower and upper extremities. Review of facility admission assessment dated [DATE] did not reveal detail about CR #9's wound. The admission Assessment only revealed the following: - Turgor: good - Skin color: normal for ethnic group - Temperature: warm - Moisture: normal - Condition: normal - New wounds: 5 Record review of Wound Care Doctor's assessment dated [DATE] revealed the following detail regarding CR #9's wound: - wound size as length = 7cm, width = 7cm, and depth = 1.3cm. - Surface Area: 49.00 cm2 - Exudate Moderate Sero - sanguinous - Thick adherent black necrotic tissue (eschar) 20 % - Thick adherent devitalized necrotic tissue 30 % - Slough 20 % - Granulation tissue 10 % Record review of the careplan dated 04/18/2023 revealed CR#9 had impairment to skin integrity with stage 4 pressure wound (severely damaged skin) to the sacrum. Record review of MDS (Minimum Data Safety) dated 04/17/2023 section M0100 through section M0300 revealed CR#9 has pressure injury. Review of TAR (Treatment Administration Record) for the month of April 2023 revealed there was no wound care treatment performed for CR#9 during his admission on [DATE] through 04/17/2023 Record review of progress note dated 04/18/2023 revealed resident (CR#9) was sent to hospital on [DATE] for change in condition. Record review of hospital emergency room note dated 04/20/2023 revealed CR #9 was brought to ER (Emergency Room) on 4/18/2023 due to Cardiac arrest. Review of face sheet showed CR #10 was a [AGE] year-old female who was initially admitted to the facility on [DATE]. CR #10's current re-admission to the facility was on 04/26/2023, her diagnoses included type 2 diabetes mellitus, diabetic neuropathy, Peripheral Vascular disease, cerebral infarction, and metabolic encephalopathy. Record review of CR #10's Progress Note dated 10/04/2022 during initial admission to the facility revealed CR #10 have a stage 3 wound on her sacrum and left leg Record review of a careplan dated 03/21/2023 revealed CR#10 has a pressure ulcer to the sacrum and left thigh with potential for further skin breakdown related to disease process and immobility. Record review of the MDS (Minimum Data Safety) dated 03/13/2023 section M0100 revealed CR#10 has pressure injury. Review of the TAR (Treatment Administration Record) for the months of January 2023 through April 2023 revealed there was no wound care provided for CR #10 on the following dates: - 4/13/23. - 3/18/23, 3/26/23. - 2/7/23, 2/8/23, 2/10/23, 2/12/23, 2/24/23, 2/25/23. - 1/9/23, 1/14/23, 1/30/23. Record review of physician order dated 04/08/2023 revealed CR #10's order for sacrum wound as Cleanse stage 4 pressure wound to the sacrum with ns/wc. pat dry. apply collagen powder and alginate calcium w/silvercover w/bdr foam dressing daily and prn and order for left lateral thigh as Cleanse stage 4 pressurewound to the left lateral thigh with ns/wc. pat dry apply collagen powder cover w/bdr foam dressing daily and prn. Record review of physician order revealed, on 1/7/23 - 1/13/23 patient received Ceftaroline Fosamil Intravenous Solution Reconstituted (Ceftaroline Fosamil) Use 200 mg intravenously every 12 hours for Wound Infection for 5 Weeks. On 4/26/23 CR #10 received APTOmycin Intravenous Solution Reconstituted 500 MG (Daptomycin) intravenously every 48 hours for Wound Infection for 5 Weeks. Record review of CR#10 hospital records revealed CR#10 was hospitalized on [DATE] to 1/13/23- patient received prophylaxis Cefdinir Oral Capsule 300 MG (Cefdinir). Review of CR#11 face sheet revealed CR#11 was admitted to the facility on [DATE]. CR#11's diagnoses included anxiety disorder, osteomyelitis, hypertension, respiratory failure, stage 3 pressure ulcer of the left heel, pressure ulcer of left ankle, pressure ulcer of sacral region, and tracheostomy status. Record review of a careplan revision dated 02/10/2023 revealed CR#11 has a stage 4 sacral pressure ulcer and was at risk for wound becoming infected, worsening with poor response to treatment, and other complications to include at risk for additional pressure ulcers and skin breakdown related to contractures and muscle atrophy (decrease in size and wasting of muscle tissue) with impaired mobility and dependent on staff for turning and repositioning and all areas of mobility. Record review of MDS (Minimum Data Safety) dated 03/24/2023 section M0100 through section M0300 revealed CR#11 has a pressure injury. Review of TAR for the months of March 2023 and April 2023 revealed there were no wound care on 03/23/2023, 03/26/2023, and 4/16/2023. Review of Wound Care Doctors note revealed the following: - 0n 3/21/23 the following wounds deteriorated: Wound site #2 Stage 4 pressure wound of left, lateral ankle Wound site #9 stage 4 pressure wound sacrum Wound site #23 stage 4 pressure wound of the left, posterior elbow - On 3/7/23 the Wound site #9 stage 4 pressure wound sacrum deteriorated - On 2/14/23 Wound site #2 Stage 4 pressure wound of left; lateral ankle deteriorated - On 1/10/23 Wound site #9 stage 4 pressure wound sacrum deteriorated On 5/25/23 at 1:59PM during interview with the DON, she stated she started working at the facility since May 1st, 2023. She stated she did not know what happened to all these residents' wound care. She also stated there was a wound care nurse who was let go at the time she started working with the facility. She stated they got a new wound care nurse who just started this Monday (05/22/2023). She stated her expectation was for nurses to assess resident during admission, document everything that they assessed, and notify doctor for all necessary orders including wound care order, and that this deficient practice place resident at risk for infection. When Surveyor asked how this could affect the resident, DON stated oh you know it, don't test my intelligence On 05/24/2023 at 3:55PM, in an interview with RN C on the floor regarding wound care and who would be responsible for wound/skin assessment during admission and when the wound care nurse not in the building. RN C stated he started working at the facility about two months ago. He said he was not so familiar with the three residents (CR#9, CR#10, and CR#11). He stated if they had any admission the nurses on the floor would do skin assessment on all admissions, and if any resident was admitted with a wound, they would also do wound the assessment and contact the doctor for the order. He stated these three resident's wounds was being cared for by the wound care nurse and he was not familiar with their wound. On 05/25/2023 at 4:02PM Surveyor requested the contact number of 4 nurses, including CR#9's admitting nurse, for interview. The DON stated she would provide the contacts information. On 05/24/2023 at 4:14PM on the 200 hall, with LVN F, who was one of the nurses on the floor. She stated the floor nurses would do the skin assessment during admission. She also said they had a wound care nurse who was doing all resident's wound care. She stated nurses only did wound care when the wound care nurse was not in the building. Surveyor observed LVN F was in a hurry, she entered into a resident's room. On 05/25/2023 at 4:32PM during interview with the New Wound Care Nurse, she stated she had been working at the facility for almost 2 years as a floor nurse, but she started as a wound care nurse on Monday 05/22 2023. The Wound Care Nurse stated when she was working as the floor nurse, the expectation for the Floor nurses was to do patient assessment during admission, document, and notify physician for orders. She stated when wound care nurse comes, she would also do wound /skin assessment on all new admission. She stated, now that she became the wound care nurse, she also did the same thing - she stated she would always do skin assessment on all new admission. She said if resident did not get wound care, it could affect them by causing infection and the wound could get progressively worse. On 05/25/2023 at 4:52PM, Surveyor followed-up with the DON regarding the nurses' contact numbers, at this time she stated the HR was pulling the contacts. However, contact numbers were not provided. On 06/08/2023 at between 11:03AM through 11:50AM, Surveyor called the Wound Care Doctor multiple times, but his line was breaking up and did not go through. Surveyor asked the DON if the Wound Care Doctor had another contact number, the DON stated she did not know of any other number, she said the contact given to the Surveyor was the same number the facility used to contact the Wound Care Doctor. The DON stated further that the wound care Doctor would be in the building soon and Surveyor would be able to speak with him. On 06/08/2023 at 11:52AM, attempt made to interview LVN G, who was the admitting nurse of CR #9. LVN G stated she just lost her younger brother yesterday (06/07/2023), she stated she only came to the facility today (06/08/2023) to take time off. She said she was unable to concentrate to answer any question. On 06/08/2023 at 11:54AM, the DON notified the Surveyor that the Wound care Doctor just came in. Surveyor stepped out to talk to the Wound Care Doctor, but he stated he did not have time at the moment, he said, I have not been here in two weeks and that he needed to do rounds right away. He stated he would call surveyor today (06/08/2023) or tomorrow (06/09/2023). Surveyor requested Doctor to kindly try to call today (06/08/2023) and gave a business card to the Wound Care Doctor. On 06/08/2023 at 12:08PM Surveyor called the Former Wound Care Nurse, but there was no response, Surveyor left message on the voicemail. On 06/08/2023 at 12:27PM Surveyor called LVN H, a nurse on 300 hall, CR#10's hall. LVN H answered the phone but after few seconds, the line cut off. Surveyor called back but there was no response. Surveyor left voice message. On 06/08/2023 at 12:42PM Surveyor called LVN J, the nurse who cared for CR#9. Surveyor spoke with a lady who said she was a family member of LVN J and told Surveyor that LVN J would be around in about an hour and a half. On 06/08/2023 at 12:50PM Surveyor called DNP the call went straight to voicemail. Surveyor left a voice message. On 06/08/2023 at 12:53PM Surveyor attempted to called Respiratory Therapist who cared for CR#9 on the day CR #9 was sent to hospital. There was no response. On 6/8/2023 at 3:11PM, in an interview with the DNP, she stated she was not a DNP for state of Texas, she was a DNP for the state of Illinois. She said she only had RN license for Texas and not DNP for Texas. She said she was consulting at the facility as a regional consultant at that time. She stated she was told to sit for the position of DON at the facility because there was no DON at that time. The DNP said she was not aware of any of the residents having their wound care not done. She stated her area of specialization was ventilation., She said she was a consult at the facility to train/ in-service the nurses on ventilation. She stated her expectation as the DON while she was at the facility was that the wound care should be done according to the order. On 06/08/2023 at 3:18PM. Surveyor made another attempt to call the Respiratory Therapist who cared for CR#9 on the day CR #9 was sent to hospital. There was no response. On 06/08/2023 at 6:21PM. Surveyor attempted call to the Wound Care Doctor again, but the call did not get through. On 06/08/2023 at 6:28 PM, another attempt was made to call LVN J back but there was no response. On 06/08/2023 at 6:29PM, another attempt was made to reach out to the Former Wound Care Nurse again, but there was no response. On 07/05/2023 at 10:10AM Surveyor called the Former Wound Care Nurse in an attempt to interview her. There was no response, message was left on voice mail. On 07/05/2023 at 10:53AM in an interview with RN B, she said she had been working at the facility about 2 years and she worked 12 hours day shift. She stated CR#9's names was vague, she said she was not familiar with the resident probably because she did not work on the CR #9's hall - she said she worked 200 hall most of the time. She stated she was not sure if she worked with CR #9 once - she said she might have cared for the CR #9 maybe once in the past, but she can't recall. She stated she did not recall CR #9's wounds as well. RN B said she knew CR #11, and she could remember him on 200 hall where she usually worked. She stated they had a wound care nurse, who usually did wound assessment and wound care on all residents. She said she did not perform wound care for CR #11, and floor nurses did not usually perform wound care - she stated they always had wound care or treatment nurse who was responsible for that. She stated if she ever did wound care on any resident, it was very rare. RN B said when the treatment nurse was not there in the building, nurses would be responsible to do treatment. She stated if any resident was a re-admit, they still looked at wound and made documentation. She said if they admitted a new patient, they looked at the wound as well. She said usually they got orders from the hospital or wherever the resident was coming from and wound bring them over into the resident's record. She stated if they admitted a resident without wound care orders, they would call the doctor., She said they could call the residents PCP and get orders in place before the wound care nurse would take over. She stated she believed the deficient practice happened maybe because some of the new nurses were not really following the process. She stated they facility had done series of training for the nurses, and for the past month, they have been very strict about that. RN B stated they have wound care/ treatment nurses everyday in the facility. She stated if any of the nurses on schedule, or the treatment nurse did not come in, the ADON would step in to do wounds, even on weekends as well. She said Nurse 1, a PRN nurse also would come some weekends to do wounds too. She stated she never saw any wound dressing outdated. However, she said in the past, she heard some people talked about wound being outdated - she did not recall who she heard from, or which specific resident. She said they had a former wound care nurse who no longer worked at the facility. She said the former wound care nurse had an assistant/treatment Aide who used to work with the former wound care nurse, but both of them were no longer working at the facility anymore. RN B said the only time when nurses would have to look at wounds was during admission. She said the nurses did weekly skin assessment on all residents, and the treatment nurse would do weekly skin assessment on all residents with wound of stage II and above. She also stated each hall has each day of the week assigned when the residents would get skin assessments. On 07/05/2023 at 11:07AM, during an interview with LVN H, she stated she always worked day shift on the 300 hall. She said she recalled CR #10 had wounds. LVN H stated one time in the past, they said the resident had sepsis LVN H was not sure what was the cause. Nurse also said CR #10 got an antibiotic sometime in the past when she came back from the hospital, but she could not recall details. LVN H stated she did CR #10's wound one time when there was no wound care nurse in the building. She said CR #10's wound was not bad when she looked at it. LVN H stated if treatment nurse was not in the building and they admitted any resident with wound, the nurse on duty would be responsible to contact doctor for wound care order, and then treatment nurse would take over the wound care from there. She stated they would call the resident's doctor for orders. On 07/05/2023 at 11:13AM, Surveyor called LVN J, there was no response, Surveyor left Voice Message and send text message. On 07/05/2023 at 11:30AM, Surveyor called LVN G, the admitting nurse of CR #9 Phone did not ring. Surveyor called again, someone picked up but did not speak. Surveyor sent text message. On 07/05/2023 at 12:02PM, in an interview with the Wound Care Doctor. He stated he came to the building today (7/5/2023) for rounding because of the July 4th holiday, He stated he normally comes to the building on Tuesdays. He said he remembered the residents, CR#10 and CR#11. He stated he always did comprehensive notes with orders given for every patient. He also stated daily dressing for wounds should be done daily according to the order. He stated wounds are not expected to remain the same, he said wounds changes - drainage changes week to week, same thing with color and size. The Wound Care Doctor said he did not see any concern regarding residents wound in the building. He stated facility had low hospital admission rate for wounds, given the complexity of wounds they have. He stated resident CR#11's wound might have deteriorated at some point, but he would not expect the wound to keep deteriorating week after week for maybe 4 to 5 weeks, he said that would be a concern for him. He stated CR #11 had many wounds and he could recall each time CR #11 went to hospital he would come back with either more wounds or existing wounds deteriorating. The Wound Care Doctor stated CR #11 was frail, had multiple wounds and many co-morbidities, he said his wound care would take them about 30 - 40 minutes to do. The Wound Care Doctor stated he remembered CR#10. He said CR #10's wound was not bad. He said the resident was a dialysis patient and she would go to the hospital mostly for non-wound related issues. He said when these residents go to hospital, there were usually high probability that they would come back with deteriorating wounds. The Wound Care Doctor stated he did not recall CR #9. Surveyor reminded the Wound Care Doctor he had one visit with CR #9 on 04/18/2023 which was initial wound evaluation, and he gave orders for daily wound care for CR#9. Surveyor also inquired if the Wound Care Doctor, in his expertise, believed the resident could have benefited from daily wound care from the time/day of resident's admission, and what could have happened to these residents if their wounds was not cared for, and what his expectation was regarding wound care. The Wound Care Doctor stated he would not answer what could happen if residents missed some wound care days. He stated further that he did not want to go hypotheticals on what could have happened. He stated he would rather focus on what actually happened and the intervention they were giving to the residents. He stated in the case of CR #11 that, deterioration was probably because of resident's co-morbidities, he said but generally, wound deterioration is not expected to be seen week after week. He said wounds could deteriorate this week, remain the same next week and improve the week after. The Wound Care Doctor stated further that the new wound care nurse was a great nurse, he said he could see the passion in the nurse for her job. He said he had been working pretty well with the new wound care nurse. He stated however, that the former wound care nurse was not on the same pedestal with the new wound care nurse. He said he had some issues with the former wound care nurse - He did not say further what the issues were. On 07/05/2023 at 12:18PM Surveyor called Aide 1 who used to work with the former wound care nurse. There was no response, Surveyor left voice message and text. Surveyor called Nurse 1 - the PRN nurse who sometimes did wound care on weekends. There was no response. Surveyor left voice and text messages. On 07/05/2023 at 1:12PM in an interview with the New Wound Care Nurse. She stated she was initially employed as a floor nurse and, she usually worked on the 200 hall. She stated she did not know CR#9, she knew CR#10 but she did not usually work on CR#10's hall. She stated she knew CR#11, she stated when she was the floor nurse, she mostly worked opposite end of CR#11's room. She stated she did not care for CR#11's wounds. The New Wound Care Nurse said she sometimes would fill in for the treatment nurse if the treatment nurse was not in the building. She stated she became the treatment nurse May 22nd, 2023. She stated when she assumed the position, it was hard to say if any wound deteriorated or not because she did not know all of the residents wound condition before that time. She stated she could remember that wound documentation was all over the place. She stated documentation was not being done. She stated now that she became the treatment nurse, corporate looked behind her to make sure documentations were being done. The New Wound Care Nurse stated if she was not in the building, the floor nurse who admitted the resident would be responsible to get orders for wound and perform wound care whenever she was not in the building. She said most of the residents came in with wounds and were sick. She said if wound care was supposed to be done daily and not done, the wounds could deteriorate, get infected, and resident could even get sepsis. On 07/05/2023 at1:32PM in an interview with the ADON. She stated she would sometimes do wound care because she was a Certified wound care nurse. She stated she had done wound care in the past when the former wound care nurse was not in the building, and at that time the wounds she cared for looked good, and she had no concerns - The ADON did not recall the specific resident's wound she cared for at that time. She said they had a weekend wound care nurse (Nurse 2) who usually did wound care for residents in the facility. She stated the Nurse 2 did not work at the facility anymore. The ADON stated further that at the time the residents (CR#9, CR #10, CR #11) were in the building, she was not really looking into wounds at that time, because she had a lot of administrative duties to do. The ADON said CR #9 was in the building briefly and was admitted with wounds as she could see it in the record. She said the admitting nurses were responsible to make sure they get orders for new admission's wound. The ADON said she did not know the full detail/status of CR #9's wound. The ADON said she could vaguely recall CR#10. She said she did not know about resident's wound infection, she stated but she would look in the record. The ADON stated if the treatment nurse not in the building, and nobody else was designated to do wound care, the nurse on the floor would be responsible to do wound care. The Surveyor asked if the ADON thought there would be enough time for nurses to do all wounds on their floor coupled with the responsibility of giving meds and other nursing duties. The ADON stated yes she said because sometimes they only have about 6 to 7 residents on a hall and that would not be too much for the nurses to handle. The ADON stated if residents' daily wound care were not done daily as stated in physician order, the wound could deteriorate and get worse and cause harm to the patient. On 07/05/2023 at 2:07PM Surveyor called Nurse 2, the former weekend wound care nurse. There was no response, voice mail not set up. Surveyor sent text message. On 07/05/2023 at 3:01PM, the ADON said she went through recent notes and did not see anything about CR#10's wound infection, she said she had to dig deeper to find out about that. She stated CR #10 went out to hospital, during the last hospitalization, for other reason not wound related. The ADON said regarding the missed wound care days shown on the TAR, she stated she understood the Number one rule of nursing is, if it is not documented, it is not done. Record review of facility policy titled 'Skin System' no date, revealed in part, .skin assessment will be completed on day of admission and documented by the admitting nurse or treatment nurse upon admission (including re-admission) the admitting nurse will notify the physician and resident representative of any identified areas, implement treatment/ interventions and document An Immediate Jeopardy (IJ) was identified on 06/09/2023. The IJ template was provided to the facility on 6/9/23 at 12:58 p.m. While the IJ was removed on 06/13/2023, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to failure occurred to multiple residents over multiple days and the facility's need to evaluate the effectiveness of the corrective systems. The plan of removal was accepted on 06/10/2023. The plan of removal reflected the following: Immediate Jeopardy PLAN OF REMOVAL Immediate Action: Immediate Jeopardy called for Treatment/ Services to Prevent/ Heal Pressure Ulcers. The facility will conduct a head-to-toe skin assessment on each resident in the facility to ensure all residents with Non-Pressure and/or Pressure Ulcers are identified. The nurses to complete this task include the ADON, and the Treatment Nurse. This audit will be completed by 06/09/23 at midnight. Treatment orders will be audited to ensure that all existing wounds have a wound order in place. This audit will be completed by 06/09/23 at midnight. Nurses, Regional Nurse and Chief Nursing Officer will conduct this audit. The Medical Director, primary care physician, and resident responsible parties will be notified regarding any residents with new non pressure and/or pressure areas identified. Treatment Orders will be obtained and initiated for any newly identified areas. Nurses to complete this task will include the ADON, and the Treatment Nurse. This audit and notifications will be completed by 06/10/23 at 12 noon. The facility will provide the status of previously identified wounds to the PCP and Medical Director, noting any deterioration or healing progress. Nurses to complete this task will include the ADON, and the Treatment nurse. This audit will be completed by 06/10/23 at 12 noon. Facility Plan to Ensure Compliance Quickly (and Ongoing): Nursing staff (licensed and certified) will be re-educated on the Skin Management System starting on 06/10/23 by the Regional Nurse and the Chief Nursing Officer with the target completion date of 06/11/23. Nursing staff members will not be allowed to work their oncoming shift until this education is completed. On- going competency of the Skin Management System will be monitored by asking oral/verbal questions, rounding and auditing of documentation and orders in the electronic medical record. This in servicing will occur upon hire, and quarterly moving forward. This will be tracked by the Administrator and the DON monthly to ensure said standards are met. Nursing staff will be re-educated on the stop and watch tool and the skin identification form. Education will be completed prior to nursing staff commencing their next assigned shift. Nurses to complete this task will include the ADON, and the Treatment Nurse. This education will be completed by 06/11/23. Any nursing employee not present will complete the in-service prior to starting their next shift. The facility will conduct an audit to ensure that all residents have current Braden scores in place to reflect risk for Pressure Ulcer development and to ensure interventions are in place. Nurses completing this task include the Regional Nurse and the Chief Nursing Officer. This audit will be completed by 06/09/23 at midnight. New or readmitted residents with wounds will have a head-to-toe skin assessment completed by the Treatment Nurse. If the Treatment nurse is off, the Admitting Charge Nurse will complete the Head to Toe for Skin. The Nurse Managers, ADON, and Infection Preventionist, will do a follow up skin review no later than 24 hours post admission to confirm initial findings and to ensure the treatment order is in place, and that the physician and responsible party are aware of any identified wounds as well as the plan of care. Education on this process will be provided by the DON, and will be completed by Sunday, 06/11/23 at midnight. Any nursing employee not present will complete the in-service prior to starting their next shift. Surveyor confirmed the POR for the IJ by monitoring from 06/10/2023 through 06/13/2023 as follows: Record review of the in-services dated 06/08/23 to 6/12/23 revealed no concerns and nursing staff were trained on the following: Admission/readmission skin assessments, Braden Scales, Skin Management Program, POC Kardex Compliance, Off-loading Devices, Nutritional Guidelines for Pressure Ulcers, Showers, Weekly Skin Assessments, Notification of Medical Director/Responsible Party/Registered Dietician Change in Condition, Contracture Management, Care Plans, Un[TRUNCATED]