**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from neglect for 8 of 20 residents (Residents #5, #120, #121, #44, #119, #32, #38 and #220) reviewed for neglect. 1. The facility failed to effectively monitor Residents #'s #32, #38, #119, and #220 weights, to prevent weight loss, and nutritional deficits. Failed to input weekly weight orders. 2. The facility failed to provide daily wound care to prevent the decline in wound conditions for Residents #'s #120 and #121. Resident #'s 120 and 121 both had Stage 4 sacral wounds decline resulting in hospitalizations for wound infections. Resident #121 died on [DATE] during his hospitalization. 3. The facility failed to implement dietary recommendations timely for Resident #121. 4. The facility failed to provide and maintain offloading devices for Residents #'s #120 and #121. 5. The facility failed to educate the nurses providing wound care. 6.Failed to input wound care orders in the computer system to be completed by the treatment nurses, nurses, or weekend nurses. 7. The facility failed to prevent Resident #5 from obtaining 2 new pressure injuries (DTIs) to both feet. 8. The facility failed to monitor and obtain Resident #44's anticoagulant laboratory results since 07/13/2022. 9. The facility failed to implement admission orders ensuring residents received the necessary care and services for: 22 of 80 residents with orders in the queue for implementation. 10. The facility failed to implement dietician recommendations timely for Resident #220. 11. The facility failed to implement heel protectors for Resident #5 while in bed according to the physician's orders. 12. The facility did not identify or document the onset or follow treatment orders for the left thumb of Resident #49 after a stage 2 pressure injury was identified by an outside agency. 13. The facility failed to draw routine hemoglobin A1C (HBA1C) (a blood test that shows what your average blood sugar (glucose) level was over the past two to three months) for Resident #35. 14. The facility failed to obtain Resident #34's Vancomycin (is used to treat infections caused by bacteria. It works by killing bacteria or preventing their growth) trough level (is drawn immediately before the next dose of the drug is administered because it is the lowest concentration in the patient's bloodstream) as ordered prior to administration of first dose of Vancomycin. An Immediate Jeopardy (IJ) situation was identified on 01/13/2023 at 1:20 p.m. While the IJ was removed on 01/18/2022, the facility remained out of compliance at a scope of a pattern with the severity of actual harm that was not immediate jeopardy, with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for negative outcomes and including death. Findings included: Record review of the CMS 672, dated 01/09/2023, indicated in Section G, other. F140 1 resident with unplanned significant weight loss/gain. 1.) Record review of Resident #32's face sheet, dated 1/13/2023, indicated Resident #32 was a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnosis diagnoses which included of stroke, pain, seizures, dysphagia (difficulty swallowing) and malnutrition (lack of nutrition). Record review of Resident #32's consolidated physician's orders, dated 01/13/2023, indicated Resident #32 had a diet order of mechanical soft and nectar thickened fluids, dated 02/05/2022, and a magic cup with lunch and dinner, dated 09/06/2021. Record review of Resident #32's computerized weights indicated her weight was 153.8 pounds on 12/09/2022 and 141.1 pounds on 01/06/2023. Record review of a comprehensive care plan dated 04/08/2023 and revised on 05/03/2021 indicated Resident #32 required assistance with her ADLs including assistance with eating, with staff to feed Resident #32 if she was unable to complete the task. The care plan indicated Resident #32 was at risk for weight loss with the goal of maintaining her current level of weight through 02/16/2023. The interventions included monitor for signs of malnutrition, a weight every month, and report a loss or gain of more than 5%. The comprehensive care plan also indicated Resident #32 was receiving a therapeutic diet and was at risk for nutritional deficit. The goal was Resident #32 would consume adequate fluid and would consume 75% or more of the meals served with no associated weight loss through next review dated 04/08/2021. The interventions included administer snacks, and supplements as ordered, and provide a magic cup with lunch and dinner dated 07/07/2021. Record review of an Annual MDS dated [DATE] indicated Resident #32 was sometimes understood and sometimes understands, and Resident #32's BIMs score was 00 indicating severe cognitive impairment. The MDS indicated Resident #2 required total assistance of one staff with meals. The MDS in Section K indicated Resident #32 did not have a swallow disorder or signs of a swallowing disorder. Section K also indicated Resident #32's height was 70 inches, and her weight was 147 lbs. with no weight loss or weight gain documented. Record review of a weight record, dated 01/1 3/2023, indicated Resident #32's weight 180 days prior was 151.8 pounds, 90 days prior the weight was 152.8 pounds, and on 01/06/2023 Resident #32's weight was 141.1 pounds. During observations on 01/10/2013 - through 01/11/2023 for Resident #32 revealed the following: -On *01/10/23 at 12:55 p.m., there was no supplement with the Resident #32's lunch meal. -On *01/10/2023 at 5:55 p.m., there was no magic cup with her Resident #32's evening tray. - On *01/11/2023 at 12:25 p.m., there was no magic cup with her Resident #32's lunch tray. -On *01/11/2023 at 6:00 p.m., there was no supplement with her Resident #32's evening tray. Record review of the dietician reports revealed the following: -On *10/22/2022, there was: no mention of recommendations for weekly weights for Resident #32. -On *11/11/2022, there was: no mention of recommendations for weekly weights for Resident #32. -On *11/30/2022, there was: no mention of recommendations for weekly weights for Resident #32. -On *12/10/2022, there was: no mention of recommendations for weekly weights for Resident #32. - On *12/18/2022, there was: no mention of recommendation for weekly weights for Resident #32. On *01/08/2023 and 01/09/2023, there was: no mention of recommendations for weekly weights for, Resident #32. 2.) Record review of Resident #38's face sheet, dated 1/13/2023, indicated Resident #38 was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis diagnoses which included of stroke, diabetes (too much sugar in the blood), chronic kidney disease (longstanding disease of the kidney), and muscle weakness. Record review of the consolidated physician orders, dated 1/13/23, indicated Resident #38 did not have a diet ordered. Resident #38 had orders in a que including which included the diet order waiting for processing. Record review of Resident #38's comprehensive care plan, dated 11/29/2022, revealed there was no care plan addressing the risk of weight loss or actual weight loss. Record review of the clinical records for Resident #38 indicated the Initial MDS was not completed. Record review of Resident #38's computerized weights indicated on 11/18/2022 his weight was 225.0 pounds, and his weight was 190.8 pounds on 01/06/2023. Record review of a dietician's consultant, dated 11/30/2022, indicated Resident #38 had no recommendations even though the weights indicated he had already lost 25 pounds. Record review of a dietician's consultant report dated 12/10/2022 indicated Resident #38 was not evaluated. Record review of a dietician's consultant report dated 12/18/2022 indicated Resident #38 was not evaluated. Record review of a dietician's consultant report dated 01/08/2023 indicated Resident #38 was not evaluated. Record review of a dietary profile dated 01/11/2023 indicated Resident #38 was receiving a regular diet with no dietary supplements. 3.) Record review of Resident #119's face sheet, dated 01/11/2023, indicated Resident #119 was an [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of which included joint replacement surgery, muscle weakness, and high blood pressure. Record review of the admission MDS, dated [DATE], indicated Resident #119 understood others and she was understood. The MDS indicated Resident #119 had problems with recall and her BIMs score was an 11, indicating which indicated she had moderate impairment with cognition. The MDS indicated Resident #119 required extensive assistance of one staff member with eating. The Section GG of the MDS indicated Resident #119 was independent eating with no assistance. The MDS indicated Resident #119's weight was 130 pounds in the section K0200. The MDS indicated Resident #119 had no weight loss or weight gain in the section of K0300. Record review of a hospital medication consolidation record dated 12/19/2022, indicated on 12/14/2022 Resident #119's weight was 160 pounds, and her height was 62 inches. Record review of a Dietary Profile dated 12/28/2022 indicated Resident #119 was receiving a regular diet and did not require any nutritional supplements. Record review of Resident #119's weights indicated only one weight was obtained since admission on [DATE] of 130 pounds. Record review of the Dietician Recommendation indicated on 01/08/2023 Resident #119 had no recommendations. Record review of a Dietician Progress Note dated 01/08/2023 indicated Resident #119 was eating 50-75 % of meals, her weight was 130 pounds and stable. The note also indicated Resident #119 had no skin issues. The notes comments indicated the diet was regular diet with thin liquids, to maintain weight without significant change over the next three months and to continue current diet. The dietician note does not indicate there was a significant weight loss from the hospital weight of 160 pounds and the facility weight of 130 pounds. Record review of the dietician reports revealed the following: - On *01/08/2023 and 01/09/2023, there was: no mention of recommendations for weekly weights for Resident #'s #119. Record review of the comprehensive care plan dated 01/10/2023 indicated Resident #119 was receiving a regular diet with the goal of her weight remaining stable through the next review. The interventions included allow choices in food items, and provide snacks or supplements as ordered. During an observation on 01/10/2022 Resident #119 had consumed 50 % of her meal while in her bed. Record review of the consolidated physician's orders dated 01/11/2022 indicated Resident #119's diet was a regular diet with thin liquids started 12/19/22. During an interview with the DON on 01/11/2023 at 3:26 p.m., the DON said she inputs the resident's weights in the computer after their weight was obtained. The DON said the person obtaining the weights just logged the weight obtained. The DON said when she reviews reviewed the weights and, she stars starred them for a reweight to verify the changes. The DON said the hospital weights were often not correct therefore it was important to have a weight. The DON indicated all the systems were a process. During an interview on 01/12/2023 at 2:24 p.m., the ADON A indicated there were no weekly standards of care meetings to review each resident with wounds, weight loss, labs, or accidents. ADON A said she had mentioned this to the management team but was not considered. ADON A said the standards of care meetings was a review of the resident to ensure all the care areas were met. During an interview on 01/17/2023 at 1:36 p.m., LVN L indicated residents should be weighed on admission and monthly. LVN L indicated with not knowing the admission weight there could be a weight loss leading to skin problems, and even the loss of mobility. During an interview on 01/17/2023 at 2:39 p.m., the Regional Nurse Consultant indicated she was unaware of weight loss issues. The Regional Nurse Consultant new admissions should have a weight once a week for 4 weeks or until stable. The corporate nurse indicated the admitting nurse was responsible for obtaining the admission weight. The Regional Nurse indicated there was not a reason for the admission or weekly weights not being obtained. The Regional Nurse Consultant said the DON was responsible for the weight management program. During an interview on 01/17/2023 at 4:55 p.m., the Interim Administrator indicated the physician should be notified when the resident's weight falls fell in the parameter areas of 5% in one month, 7.5% in 3 months and 10% in 6 months either a loss or a gain. The Interim Administrator indicated health issues could arise when weights were not monitored. The Interim Administrator indicated the charge nurses, and DON were responsible for the monitoring of weights. Record review of a Nutritional Management policy, dated 07/01/2022, indicated the facility provides care and services to each resident to ensure the residents maintains acceptable parameters of nutritional status in the context of his or her overall condition. 2. Identification/Assessment: a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy. C. A comprehensive nutritional assessment will be completed by a dietician within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed. Record review of the facility's Weight Monitoring policy, dated 07/01/2022, indicated based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. 5. A weight monitoring schedule will be developed upon admission for all residents: A. Weights should be recorded at the time obtained. B. newly admitted residents-monitor weight weekly for 4 weeks, Residents with weight loss -monitor weight weekly. 6. Weight analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in one month, b. 7.5% change in 3 months, c. 10% change in 6 months. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. 4) Record review of Resident #121's face sheet, with the printed date of 1/13/2023, indicated Resident #121 was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of which included sepsis (severe complication of an infection) due to pneumonia, muscle weakness, acute kidney failure, high blood pressure, and malnutrition (lack of caloric needs). Record review of Resident #121's The admission MDS revealed it was not completed. Record review of a Resident #121's Baseline Care Plan, dated 12/14/2021, indicated Resident #121 required extensive assistance with his ADLs, he had a skin concern of a pressure ulcer to the sacrum, with the goals of the wound to show signs of healing with area decreasing in overall size. The interventions included to provide the wound care/preventative skin care, weekly skin checks, turn and reposition, and notify the physician of any changes in the wound or emerging wounds. The physician orders listed in Section M of the Baseline Care plan did not reveal a wound care order with the medication orders. Record review of Resident #121's Admission-readmission Assessment, dated 12/14/2022, indicated Resident #121 was admitted to the facility on [DATE] from a hospital. The assessment indicated Resident #121 had a pressure injury to his vertebrae (upper-mid back) measuring 0.2 cm x 0.2 cm x undetermined depth, a coccyx pressure ulcer measuring 0.5 cm x 0.4 cm x undetermined, and a pressure ulcer to the left buttock measuring 0.5 cm x 0.5 cm x undetermined depth. Record review of a Skin and Wound -total Body Skin Assessment, dated 12/14/2022 on admission, indicated Resident #121's skin turgor (skin elasticity) had poor elasticity, the skin color was normal, temperature was cool, the moisture was normal, the condition dry, and had 3 new wounds. The wounds were not specified in the assessment. Record review of a Braden Scale for Prediction Pressure Sore Risk, dated 12/14/2022, indicated Resident #121 had no sensory perception impairment, he was occasionally moist, and he was chair fast with the ability to walk severely limited. The assessment indicated Resident #121 was slightly limited making frequent though slight changes in body or extremity positions independently, his nutrition was probably inadequate, and he required moderate to maximum assistance with moving. Resident #121's score was 15, indicating which indicated the resident was at risk for developing pressure sores. Record review of a Daily Skilled Note, dated 12/18/2022, indicated Resident #121's indicated his skin was dry, he consumed 75% of meals, consumes consumed a regular diet with thin liquids. The note did not indicate there were no other skin problems. The skin condition section (6f) of the note failed to indicate pressure ulcers were present. Record review of a Dietician Recommendation, dated 12/18/2022, indicated Resident #121 was recommended to have Pro stat 30 milliliters twice a day due to his albumin level (protein in the blood) was 2.8 with the normal range of 3.4 to 5.4. Record review of a Daily Skilled Note, dated 12/19/2022, indicated Resident #121 had fair, dry and fragile skin. The note indicated Resident #121 fed himself and his intake was 75% or more each meal. The skin condition section of the note failed to indicate 6f. pressure ulcers were present. Record review of a Skin assessment dated [DATE], indicted Resident #121's sacral wound measured 4.0 cm x 3.0 cm x 0.1 cm and was a stage 4 pressure ulcer. The skin assessment report indicated the wound was 100% slough (dead tissue) with a light serous drainage. Record review of an Initial Wound Evaluation and Management Summary, dated 12/22/2022, indicated Resident #121 had a Stage 4 full thickness pressure wound to the sacrum measuring 4.0 cm x 3.0 cm x 0.1 cm. The wound was 100% slough (dead tissue) with a light serous drainage. The wound physician recommended leptospermum honey apply once daily for 30 days, cover with a gauze island with border dressing once daily. The Wound Evaluation indicated Resident #121 had a surgical excisional debridement procedure to remove necrotic tissue and establish margins of viable tissue. The additional note of the wound evaluation indicated post-debridement assess of the previously unstageable necrotic wound had been obscured by necrosis prior to this point. The wound now reveals itself to be a Stage 4 pressure injury. The Wound Evaluation's Treatment Plan indicated leptospermum honey would be applied once daily covered with a secondary dressing with a border. The recommendations included off-load the wound, limit sitting to 60 minutes, reposition according to facility protocol turn side to side and front to back in bed every 1-2 hours if able, a group 2 mattress, multivitamin daily, vitamin C 500 milligrams twice daily by mouth and zinc sulfate 220 mg once daily by mouth for 14 days. Record review of the medication administration record, dated December 2022, failed to indicate the initial administration and ongoing administration of Vitamin C 500 mg twice daily by mouth or the zinc sulfate 220 mg once daily by mouth for 14 days. The medication administration record indicated the recommendations were started on 12/26/2022, 8 days after the recommendation was given by the dietician. Record review of Resident #121's consolidated physician's orders dated 12/22/2022-01/31/2023, failed to indicate a low air loss mattress was ordered with appropriate setting to reflect his actual weight. Record review of the Resident #121's December 2022 Treatment Administration Record indicated Resident #121 had no treatment to his sacral wound until after the wound care physician made his first visit on 12/29/2022. Resident #121's treatment record indicated there were no previous treatments to his sacral ulcer for 15 days. Record review of a Skin Assessment, dated 12/29/2022, indicated Resident #121's sacral wound measured 3.5 cm x 3.0 cm x 0.1 cm and was considered a stage 4 pressure ulcer. The skin assessment indicated the wound had a light serous drainage and was 100% slough (dead tissue). Record review of a January 2023 of a treatment administration record, indicated Resident #121's treatment to his sacral pressure ulcer was missed on 01/01/2023 and 01/07/2023. During an interview on 01/11/2023 at 3:00 p.m., ADON A said she had sent Resident #121 to the emergency room related to increase pain to his sacral ulcer. Record review of the Resident #121's progress note, dated 1/11/2023 at 3:34 p.m., indicated Resident #121 was sent to the local hospital for increased confusion, and increased pain. Record review of Resident #121's comprehensive care plan did not reflect a potential impairment of the skin until 1/10/2023. The care plan indicated Resident #121 had the potential for impaired skin integrity related to decreased mobility, and low protein intake. The goal was to show no evidence of skin breakdown through the next review with the interventions of applying a barrier cream as needed, Braden risk assessment per facility protocol, encourage adequate nutrition and hydration, and keep Resident #121 clean, dry, and sheets wrinkle free, all dated 1/21/2022. The comprehensive care plan, dated 1/12/2023, indicated Resident #121 had a stage 4 pressure ulcer or the potential for pressure ulcer development related to impaired mobility. The goal was Resident #121's pressure ulcer would show signs of healing and remain free from infection. The interventions were to administer the treatment per the physician orders, do not massage over boney prominences, and use mild cleaners for peri-care. The other intervention, dated 01/12/2023, indicated Resident #121 required turning and repositioning every 2 hours, or more often as needed or requested. Record review of the January 2023 medication administration record indicated Resident #121 had an order for that stated cleanse stage 4 to sacrum and apply leptospermum honey cover with a border gauze once daily. The treatment administration record indicated Resident #121 missed a treatment on January 1, 2023, and January 7, 2023. Record review of a Weekly Wound Tracking Worksheet dated 01/02/2023 -01/06/2023, indicated Resident #121 had a Stage 4 pressure wound to his sacrum, with light serous drainage, measuring 4.0 cm x 3.0 cm x 0.1 cm, with the treatment was Medi-honey with a bordered dressing. The form indicated Resident #121 was on the corona virus unit during this assessment period. Record review of the progress note, dated 1/11/2023 at 3:34 p.m., indicated Resident #121 was sent to the local hospital for increased confusion, and increased pain. During an observation and interview on 01/09/2023 at 10:59 a.m., Resident #121 was sitting up in his wheelchair. Resident #121 said his wound on his bottom was hurting and he was administered a pain medication. Resident #121 said his wound care had not been completed. Resident #121's bed sheets had blood-tinged drainage on the sheets approximately where his bottom would have been. During an interview on 1/10/2023 at 8:45 a.m., ADON A was asked to see the wound care for Residents #'s #120 and #121. ADON A said all treatments had been done for the day. Record review of a Hospitalist admission Note, dated 01/11/2022, indicated Resident #121's diagnoses included Sepsis secondary to an unstageable sacral decubitus wound and acute on chronic kidney disease lll likely from the sepsis and congestive heart failure. The note indicated the Cat Scan (CT) of the abdomen/pelvis was positive for subcutaneous gas (gas gangrene a potentially deadly form of tissue death). The note indicated Resident #121 was placed on three broad spectrum antibiotics Vancomycin, cefepime, and clindamycin. The note indicated Resident #121 was referred to the general surgeon for wound debridement. The chief complaint was generalized body aches/pain and a worsening decubitus ulcer. The note indicated in the emergency room the sacral ulcer was foul-smelling. The note indicated he was in no acute distress at rest but does did have exquisite pain on any passive movement due to extensive sacra decubitus wound. The laboratory results listed on the admission note indicated Resident #121's white blood cell count was 16.9 (High) with normal range of 4,000 - 11,000/microliters indication of infection, (Albumin level) 1.8 (low) with normal range of 3.4 to 5.4 g/dl, and BUN (Blood urea nitrogen) was 52 (High) normal range 6 to 24 mg/dl indicating which included his kidneys were not functioning well. Record review of a CT (cat scan) of the pelvis, dated 01/11/2023, indicated subcutaneous defect at the sacrum, with scattered subcutaneous gas about the sacrum at midline, as well as subcutaneous gas within the gluteal musculature bilaterally, left greater than right, with surrounding cellulitis. Findings were concerning for gas-forming infection as can could be seen in the setting of necrotizing fasciitis (flesh eating disease). During a record review of the ER record dated 01/11/2023, a picture taken on arrival to the ER displayed a large sacral wound with base of wound covered with 80% in slough and eschar and the base of the spinal column was exposed. During an observation and interview on 01/12/2023 at 11:30 a.m., Resident #121 was noted to be on the ER gurney at the local ER. Resident #121 stated he had been on the gurney for a day and was waiting a hospital bed because he was being admitted to the hospital for a wound infection. Resident #121 stated he had a large wound on his sacrum that was to the bone. Resident #121 stated it was painful and would not allow visualization of the wound. Resident #121 stated the pressure ulcer had gotten worse since he developed it because he was not being turned and he had gone multiple days with no treatment. During an interview on 01/12/2023 at 12:30 p.m., the hospital SW stated the hospital was running test for sepsis and the resident was being admitted for a wound infection. Record review of a Hospital History and Physical dated 01/22/2023 at 6:17 p.m., indicated Resident #121 was admitted to the hospital for severe sepsis (severe life-threatening complication of an infection secondary because of an infection to an unstageable pressure ulcer. The note indicated Resident #121 was started on two antibiotics for the pressure ulcer infection. The history and physical also indicated Resident #121 was in an acute on chronic kidney failure condition related to the sepsis. The history and physical note indicated in the emergency room, Resident #121's sacral pressure ulcer was foul smelling, extensive, and positive for gases (gas produced by dying tissue). Record review of a Death Summary note, dated 01/22/2023, indicated Resident #121 was treated with pain medication and anxiety medication and died peacefully in the night. The note indicated Resident #121 had intractable pain and the family agreed to make him a do not resuscitate and placed him on palliative care with the intent of discharging to a nursing facility with hospice care. 5) Record review of a Resident #120's face sheet, dated 01/12/2023, indicated Resident #120 was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis diagnoses which included of bacterial peritonitis (infection of the peritoneal cavity), severe sepsis with septic shock (a life-threatening complication of infection), and an unstageable pressure ulcer of the sacral region (low back). Record review of Resident #120's admission assessment dated [DATE], indicated he had a sacral wound with no measurements included. Record review of a Braden Scale for Predicting Pressure Sore Risk, dated 01/03/2023, indicated he was at risk for pressure injuries. Record review of a Resident #120's Baseline Care Plan, dated 01/04/2023, indicated Resident #120 required extensive assistance of one staff for walking, toileting, locomotion, grooming, bathing, and set up help with eating. The care plan for bed mobility was left blank. The care plan indicated Resident #120 had a surgical wound, pressure ulcer, specify locations of treatment ordered (sacrum, upper back, and abdomen). The goal was the wounds would show signs of healing with area decreasing in overall size. The interventions included skin checks weekly, turn, and reposition frequently to decrease pressure, and wound vac. Record review of the Resident #120's admission-readmission assessment, dated 01/03/2022, indicated Resident #120 had alterations in skin integrity. The assessment indicated he had a sacral pressure wound and an abdominal surgical incision. The assessment had no measurements of Resident #120's wounds. Record review of the January 2023 EMR wound care entry for Resident #120's sacral wound indicated the wound care was not performed on 1/03/2023, 1/04/2023, 1/05/2023, 1/06/2023, and 1/08/2023. Record review of Resident #120's skin assessment dated [DATE], indicated he had a stage 4 sacral pressure ulcer measuring 10cm x 10cm x 4cm. Record review of a Resident #120's Dietician Progress Note and Recommendations, dated 01/08/2023, indicated Resident #120 was recommended to receive Juven (dietary supplement to enhance wound healing) twice daily. Record review of Resident #120's EMR indicated the dietician recommendation of Juven 1 package twice daily was not implemented but another Arginaid (dietary supplement to enhance wound healing) one packet twice a day was ordered and implemented on 1/11/2023. Record review of an Initial Wound Evaluation and Management Summary, dated 01/05/2022, indicated Resident #120 had a stage 4 pressure wound to the sacrum measuring 10 cm x 10 cm x 4 cm with 30% of the wound bed slough, 40% granulation tissue, and 30% muscle, facia, and/or bone. The wound care physician recommended off-loading of the wound, and to turn side to side every 1-2 hours, if able. The wound care note indicated the dressing treatment plan was Dakin's solution apply once daily, cover with abdominal pad. The wound care note indicated the wound care physician performed surgical removal of the devitalized tissue including slough, biofilm, and no-viable periosteum and bone were removed at a depth of 4 cm. During an observation on 01/09/2023 at 11:09 a.m., Resident #120 was lying flat on his back on his bed, the wound vacuum was sitting in his wheelchair. Resident #120 said he had been at the facility for 5 days. During an observation and interview on 1/09/2023 at 4:45 p.m., ADON A said Resident #120's wound vacuum will would not seal well due to the proximity to Resident #120's colostomy bag. ADON A indicated she would have to notify the physician for orders. Resident #120 was lying flat on his back. Resident #120's body reaches reached from side to side of the mattress. During an observation on 1/10/2023 at 8:20 a.m., Resident #120 way lying in his bed on a standard hospital bed mattress. Resident #120 did not have a low air loss mattress. Resident #120's body reached the entire width of the bed. R[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #5's electronic face sheet, dated 01/13/23, revealed a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), anxiety (what we feel when we are worried, tense or afraid), high blood pressure, and Alzheimer's ( a type of dementia that affects memory, thinking and behavior). Record review of Resident #5's quarterly MDS assessment, with an ARD of 10/26/22, revealed under Section B, Hearing, Speech, and Vision, was coded as a 0 indicating she understands and was understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 14 which indicated the resident was cognitively intact. Section G, Function Status, under section B indicated she needed extensive assistance with bed mobility, personal hygiene, total assist with transfers, dressing, bathing, and supervision with eating. Section M, Skin Condition, under section M1200 she received pressure ulcer/injury care and application of nonsurgical dressing during the look back period. Record review of Resident #5's comprehensive person-centered care plan, dated initiated 12/27/17, and revised on 01/13/23. revealed the Focus indicted: Resident #5 was at risk for further skin breakdown, also had a wound to right, distal, lateral calf lower leg and pressure area to right ischium related to immobility, incontinence, and disease process. Intervention indicated: Keep physician and RP informed of my progress. During observation and interview on 1/10/23 at 9:02 a.m., Resident #5 was in her bed with her heels not floated and lying flat on top of one pillow. There was no wedge present to float the heels and no pressure relieving boots present. Resident #5 said she did not know what heel protectors were, but she had not had the boots on in a while. She said normally her feet were elevated. Record review of Resident #5's skin assessment completed on 01/05/23, did not reveal the 4 new pressure areas to right and left foot. It did indicate: Left Ischium stage 4 measuring 1.0X0.5X0.5cm, Right Ischium stage 4 measuring 3.0X0.4X0.2cm, Sacrum stage 3 measuring 3.0X2.7X0.3 and right ankle stage 4 measuring 3.0X0.5X0.1cm. In the comment box it indicated; New unstageable areas to feet, we will be using skin prep daily. Record review of Resident #5's wound care notes, dated 12/29/22 indicated: Site1, Left Ischium stage 4 measuring 1.0X0.5X0.5cm, Site2, Right Ischium stage 4 measuring 3.0X1.0X0.2cm, Site3, right calf stage 4 measuring 3.0X0.5X0.1cm and Site 6, Sacrum stage 3 measuring 3.0X2.7X0.3cm. Record review of Resident #5's [NAME] notes, dated 01/05/23, indicated the above wounds and 2 new areas: Site 7, Unstageable DTI of the right foot measuring 3.0X1.0cm. Site 8, Unstageable DTI of the left foot measuring 3.0X2.0cm. It did not reveal 4 new areas on 01/05/23 only 2 new areas. Record review of Resident #5's physician orders., Apply heel protectors to feet while in bed. 1) Apply skin prep once daily to unstageable DTI (deep tissue injury) on outer aspect of right foot, 2) Apply skin prep once daily to unstageable blister to inner left foot arch, 3) Apply skin prep once daily to unstageable DTI on inner aspects of left foot,4) Apply skin prep once daily to unstageable blister to inner aspect of right foot. Record review of Resident #5's wound care note, dated 01/12/23, indicated the following: Site 1,Left Ischium stage 4 measuring 0.8X0.5X0.5cm, Site 2,Right Ischium stage 4 measuring 2.0X0.4X0.2cm, Site 3,right ankle stage 4 measuring 0.2X0.1X0.1cm,Site 6, Sacrum stage 3 measuring 3.0X2.7X0.cm, Site 7, Unstageable DTI of the right foot measuring 2.0X1.0cm Site 8, Unstageable DTI of the left foot measuring 3.0X2.0cm, Site 9, stage 2 pressure wound of left medial foot measuring 6.0X1.0X0.1cm, Site 10, unstageable ulcer on right foot with no measurements. Record review of Resident #5's treatment record, dated 01/12/23, indicated: the following treatment orders started 01/11/23:. Apply skin prep once daily to unstageable blister to inner aspect of right foot. Apply skin prep once daily to unstageable DTI to outer aspect of right foot. Apply skin prep once daily to unstageable blister to inner left foot arch. Apply skin prep once daily to unstageable DTI on inner aspects of left foot. Record review of Resident #5's physicians orders dated 01/13/23 indicated an order for heel protectors to feet when in bed started on 05/04/22. During an observation on 1/11/23 at 10:31 a.m., Resident #5 was observed in her bed watching television. Her heels were not floated and were lying flat on top of one pillow. There was no wedge present to float the heels and no pressure relieving boots present. During an observation and interview on 01/11/23 at 11:10 a.m., ADON G performed wound care on Resident #5, 4 dark purple areas which were not noted on the treatment sheet to left and right foot were observed. They presented as a deep tissue injury (DTI). The ADON G said those were identified last week on 01/05/23 on rounds with the Wound Care Doctor. ADON G said she forgot to add them last week on the treatment record because her computer was messed up. ADON G said without orders being on the treatment administration record (TAR), treatments could go untreated. During an observation on 01/11/23 at 12;25 p.m., ADON G measured Resident #5 other 2 new areas, presenting as DTI that were not on the 01/05/23 wound care notes, right side of foot at 2.0X2.0 cm and left inner top of foot at 3.0x2.0cm. During a phone interview on 01/12/23 at 9:24 a.m., Wound Care Doctor said Resident # 5 had 2 new identified areas to the right and left feet on today's rounds. He said they identified 2 other new areas to right and left feet last week on rounds but was not aware the treatment orders had not be implemented. The Wound Care Doctor said ADON G called him yesterday on 01/11/23 about the 2 new areas and orders were given. During an observation on 1/12/23 at 5:23 p.m., Resident #5 was in her bed with heels floated with a wedge underneath her lower legs but no pressure relieving boots were present. During an observation and interview on 01/13/23 at 2:57 p.m., Resident #5 was in her bed with heel protectors on, but they hung off her feet. Resident #5 feet and toes were touching the footboard and her feet were not off the bed. LVN H said she was aware Resident #5 had 2 new pressure injuries. LVN H said she knew Resident #5 was supposed to have on the heel protectors but felt they could cause her more harm than good. LVN H said she mentioned her concerns to the weekend treatment nurse only. During an interview on 01/13/23 at 3:04 p.m., CNA T went into Resident #5's room and said she was not aware she was supposed to be putting heel protectors on the resident. CNA T said she had just been offloading her heels with 2 pillows. CNA T saw Resident #5 feet touching footboard and feet were not really offloaded of bed with the 2 pillows, LVN H and CNA T repositioned Resident #5. CNA T said now she realized improper offloading or not wearing heel protectors could cause more skin issues. During an interview on 01/13/23 at 3:57 p.m., CNA V said she was aware Resident #5 had wounds and her feet were supposed to be offloaded with pillows. CNA V was not aware of heel protectors. During an interview on 1/17/23 at 2:06p.m., the RNC said the primary nurse should follow up on skin issues and did treatments as ordered. The RNC said the nursing administration were to follow up on all treatments. The RNC said it was a lot of changes at the facility and she had not had time to get all forms in place. The RNC said failure to do treatment could cause numerous things to go wrong with the wounds as well as the resident. During an interview on 01/17/23 at 2:25 p.m., ADON D said she expected if any nurse identified a new skin area to measure, call the doctor and get treatment orders. ADON D said her and ADON G were doing treatments until they hired someone but when they were not at the facility the nurses should take charge of any new wounds identified. ADON D said failure to do treatments could cause wounds to deteriorate or get an infection. During an interview on 1/16/2023 at 10:25 a.m., the Weekend RN said she was not checked off on wound care, but she had experience in nursing with hospice, home health, and hospital patient care. The Weekend RN said she would stay until the treatments were completed on the weekends she worked. The Weekend RN said if she had to delegate the floor nurses to complete the treatments, she would give a report to the nurse indicating who remained on the treatment schedule. 4.Record review of Resident #49's electronic face sheet, dated 01/13/23, revealed a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses which included Respiratory failure (a serious condition that makes it difficult to breathe on your own), gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), anxiety (what we feel when we are worried, tense or afraid), high blood pressure(elevated blood pressure), and stroke(occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). Record review of Resident #49's quarterly MDS assessment, dated 01/04/23, revealed under Section B, Hearing, Speech, and Vision, she was coded as a 3 indicated Resident #49 rarely understands and was rarely understood by others. Section C, Cognitive Patterns, under section C0700 indicated she has short term memory loss, C0800 indicated long term memory problems, and C0100 coded as a 3 indicating Resident #49 had severely impaired decision making. Section G, Function Status under section G0110 indicated she required total assist with bed mobility, personal hygiene, dressing, bathing, and eating. Record review of Resident #49's care plan did not reveal anything related to a left thumb injury noted on 01/02/23. Record review of Resident #49's nurses note did not reveal any documentation about left thumb injury identified on 01/02/23 until 01/11/23. Record review of Resident #49's physicians orders, dated 01/13/23, revealed an order, dated 01/11/23, to clean area to left thumb with wound cleanser apply collagen and dry dressing. Change every day and as needed. During an observation on 01/10/23 at 12:32p.m., with the DON, a band aide was observed to Resident #49's left thumb. Resident #49 left hand was contracted.The DON removed the band aid and revealed a small open area to the left thumb. The DON said she was unaware of any area to Resident #49's thumb prior to removing the band aid. ADON G came to measure the left thumb revealing measurements of 2.0x1.0 cm (centimeters). The ADON G indicated she was going to classify this area a stage 2 to left thumb. During an interview on 01/10/23 at 1:01 p.m., ADON G said she was not aware of any issue with this Resident #49's hand but she was not assigned to her hall. ADON G said she and ADON D were responsible for all skin assessments and treatments until they hired a wound care nurse. During an interview on 01/11/23 at 4:48 p.m., ADON D said she was unaware Resident #49's had an open area to left thumb until yesterday. ADON D said after stage 2 was identified yesterday on Resident #49's thumb she notified the physician, obtained orders, and notified daughter. Record review of Resident # 49's skin assessment dated [DATE] did not indicate any areas to left thumb. Record review of Resident # 49's skin assessment dated [DATE] did indicate a stage 2 to left thumb measuring 2.0X1.0 cm. During a phone interview on 01/12/23 at 10:45 a.m., the hospice nurse said she went to the facility to assess Resident #49's thumb on 01/02/23 because the family member called. The hospice nurse said she gave verbal orders to a male nurse. The hospice nurse said the order was to cleanse the left thumb daily, pat dry, apply Neosporin and leave open to air, notify if any changes. The hospice nurse said she did not measure the area but did leave a note from her visit for the DON. The hospice nurse said she never heard from the DON. Record review of Resident #49's hospice note dated 01/02/23 indicated, Left hand is contracted with left hand guard not in place at this time. Abrasion on left thumb is noted without drainage from possible handguard. Wound care orders given to Nurse U to cleanse area with warm water and soap, pat dry apply Neosporin and leave open to air, if drainage occurred apply bandage. During an interview on 01/13/23 at 11:08 a.m., LVN N said he did not remember the exact date, but he felt it was around 01/04/23 when the night nurse LVN U gave report about Resident #49's thumb with an abrasion. LVN N said he told LVN U he would take care of it. LVN N said the nurse practitioner from hospice went and looked at the left thumb and gave an order to apply a dressing daily. LVN N said he did not remember what happened, but he did not write the order, nor measure the area or fill out an incident report as he should. LVN N said the family member was there and was aware of area to the left thumb. LVN N said failure to follow through with orders could lead to infection or worsen wound. During an interview and observation on 1/15/23 at 6:00 p.m., observed the left thumb with dressing in place dated 1/15/23. LVN T said she was one of Resident #49's main nurses and she was not aware of the stage 2 to left thumb prior to today. During an interview on 01/17/23 at 6:30 p.m., LVN U said she was not aware of any open area on Resident #49's hand. LVN U said she remembered an indention only on Resident #49's hand. LVN U said she reported it to ADON D and LVN N so they could monitor for any changes, not because of anything opening on her thumb. During an interview on 1/17/2022 at 4:39 p.m., the Interim Administrator said he would expect the nurses to input the wound care orders on admission, expected the wounds to be measured, expected the treatments to be implemented. The Interim Administrator said not receiving wound care could cause a serious health issue. During an interview on 1/17/2023 at 5:31 p.m., the CEO said a new treatment nurse was hired and started on 1/16/2023. The CEO said he believed the DON and the Administrator were not working together as a team therefore they missed important information overall about the facility. The CEO said the DON had never held a director of nurse's position and he went on to say he believed she did not know the priorities. The CEO said the facility used agency staff and possibly things have been missed or go unnoticed for periods of time which played a vital role in the overall care of the residents. Record review of a Wound Treatment Management policy, dated 07/01/2022, indicated: Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse This was determined to be an Immediate Jeopardy (IJ) situation on 01/12/2023 at 4:55 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 01/12/2023 at 4:59 p.m. The following Plan of Removal submitted by the facility was accepted on 1/13/2023 at 5:06 p.m. and included the following: 1. Facility has hired a wound treatment nurse to begin 01/16/2023. The ADON's will receive wound care training as well as the new wound care nurse with the wound care physicians. The new wound treatment nurse will receive training on wound identification, treatment as well as order completion. The DON and chief nursing officer to monitor performance. 2. ADON will check people with wounds, check current wound orders and current treatments to ensure correct treatments are ordered and correct treatments are done. DON and Administrator counseled. Completed 01/13/2023 3. All direct care staff in-serviced to check each resident each shift for appropriate date of dressings to wounds. If missing, DON notified immediately. Complete 01/12/2023 a. Offloading resident feet Completed 01/13/2023 b. Use of heel protectors Completed 01/13/2023 4. ADON counseled on Follow through with implementation of dietary orders timely. Completed on 01/12/2023 5. Treatment nurses implement recommendations by wound care physician as written. Completed 01/12/2023 6. ADON review dietary recommendations and implement recommendations immediately. Complete 01/13/2023 (as dietician arrives and completes recommendations) 7. Treatment nurses follow company recommendations regarding appropriate equipment for wound management. Example: low air loss mattresses, repositioning equipment. Complete on 01/13/2023 8. All direct care staff in-serviced for turn and repositioning. Complete 01/12/2023 9. Facility skin sweep completed 01/13/2023 10. Nursing staff in-serviced on skin assessment upon admission to include wound measurements if any wounds are identified. Completed on 01/13/2023. Record review of in-service training report for turning and reposition dated 1/12/23 indicated: Residents who are unable to turn themselves need to be turned and repositioned every two hours. Positioning devices should be used such as pillows, wedges, etc to help off load and to bad bone areas. If resident refuse, notify charge nurse and charge nurse to document. Record review of in-service training report dated 1/12/23 indicated direct care staff were in-serviced on skin assessments and reporting skin change, dressing change. The in-service included: 1. RNs, LVNs, and CNAs were to inspect skin of residents daily. CNAs report any change in skin to nurse. If dressing is not dated for that day during care, notify your nurse. 2. RNs and LVNs skin assessment should be done when caring for residents and treatments as ordered. Check dates on wounds and if not completed or changed as ordered, change dressing. 3. If notice change in wound, call physician and update change. Record review of in-service training report dated 1/12/23 indicated to implement all orders in a timely manner. 1. Dietary, wound care treatments, and any other orders must be implemented in a timely manner. 2. Orders must coincide with treatment and carried out as ordered. Record review of in-service training report dated 1/12/23 indicated nurses were in-serviced on skin assessments. The in-service included: skin assessments to be completed on admission by the admitting nurse. A full head to toe with measurements of any wounds, old or new. If no orders come with the resident, obtain orders from attending physician and treat as well as document before leaving at the end of shift. Report to oncoming nurse and oncoming nurse to follow up. Skin should be checked daily each shift by nurse and CNA. Record review of in-service training report for low air loss mattress dated 1/13/23 indicated nurses were in-serviced on the following: 1)What is a low air loss mattress? A low air loss mattress is a mattress designed to prevent and treat pressure wounds. The mattress is composed of multiple inflatable air tubes that alternately inflate and deflate, mimicking the movement of a patient shifting in bed or being rotated by a caregiver, never leaving the patient in one position for any extended length of time. This action relieves pressure under the body - particularly in parts with less padding, like hips, shoulders, elbows, and heels - and helps ensure proper air circulation, helping to prevent, manage, and treat the occurrence of pressure wounds. 2)Who can benefit from a low air loss mattress? Low air loss mattresses can be used for both the prevention and treatment of pressure wounds, and are well suited to any patients susceptible to these events such as those who are immobilized or lack adequate sensory perception (e.g. those with spinal cord injuries or neurological conditions), or patients with medical conditions affecting blood flow; essentially any patient that is unable to shift and reposition themselves while lying in bed. 3)Medical documentation for low air loss mattresses must include: o Frequent Changes in Body Position All medical records and charts must demonstrate that the patient requires frequent changes in body position or have an immediate need for changes in body position. o Need for Elevation Make sure to document that the patient needs to have their head elevated more than 30 degrees and list the reason(s) why. This is one of the key elements in whether the patient qualifies for coverage. o Medical Condition Requiring Frequent Changes in Body Position In order to qualify for coverage, the patient must have a condition that requires their body to be positioned in ways not possible in an ordinary bed. Make sure to outline the condition and explain why a regular bed won't suffice. o Changes in Body Position to Alleviate Pain If the patient experiences pain in certain positions, make sure to document it. List how repositioning the patient will alleviate these pains and why they cannot be alleviated in an ordinary bed. o The Need for Traction Equipment If the patient requires traction equipment, detail because traction equipment is necessary. 4)The in-service also included that a physician had to give the order for a low air loss mattress, the setting was set according to the resident's weight; and nurses were to check every shift for accurate weight and proper functioning. An in-service dated 01/13/2023 with the topic of heels and offloading included what causes heel breakdown, who is at risk for heel breakdown, prevention of heel pressure ulcers, heel specific constant low pressure constant low-pressure devices, pillows and wedges, and an order must be written for heel protectors, and use pillows for offloading. 1.Who is at risk for heel breakdowns? o immobility, age, mental status, nutrition, chronic illness, and orthopedic surgical procedures, especially hip pinning, and hip replacement surgeries. 2. What can you do to prevent pressure ulcer? o Skin assessment is key to pressure injury prevention, classification/diagnosis, and treatment. All residents should have a skin assessment to determine its' general condition and identify factors that increase the risk for PI development. o Malnourished are at increased risk of pressure injury development due to their compromised ability to maintain healthy skin and mucosa. Hydration and nutritional support should be aimed at preventing and correcting these deficits. o Increased moisture on the skin or excessive dryness can exacerbate pressure injury development due to the risk of skin breakdown and altered skin integrity. Keep residents clean and dry and apply barrier cream after each incontinent episode. When given a shower, dry thoroughly and inspect skin for any new areas and report to nurse or physician. 3. What can you do for mobility and positioning? o For residents who need assist or unable to assist with moving themselves, it is recommended that they be repositioned every two hours. o Always check the positioning of the bony prominences (e.g. shoulders, elbows, ankles, ears) and heels when repositioning the patient into any position. Heels should be suspended off the bed using pillows or heel pads for residents spending prolonged periods in bed. o For residents who are unable to assist in moving themselves, use appropriate transfer assistance devices (e.g. sheets) to reduce friction and shear forces. Always lower the bed head before repositioning patients. o To reduce shear forces on the sacrum, the head of the bed should be raised in conjunction with the knee bend and/or pillows under the knee. Monitoring included: Interview on 01/17/2022 from 4:43 p.m. until 6:00 p.m. the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with 3 (6am-6pm) nurses LVN B, LVN D and LVN R, 2 (6pm-6am) nurses LVN U and LVN HH who indicated they had received a written in-service regarding the use of low air loss mattress and monitoring, providing wound care, notifying the physician, and implementing physician orders. LVNs said they were in-serviced on confirming the orders in the queue, how to check orders for completion, how to complete skin assessments with measurements and documentation, when to notify the physician with any new or wound changes, why and how to properly set an air mattress and to monitor throughout the shift for placement and function and why and how to properly offload heels and to monitor for placement throughout shift. Interviews with 4 CNAs (6am-6pm) CNA FF, CNA GG, CNA D, and 4 CNAs (6pm-6am) CNA MM, CNA OO, CNA PP and CNA LL indicated they were in-serviced on obtaining weights on admission, reporting any new skin issues to the nurse, notifying the nurse if any dressing is soiled, dislodged or without a date and document on the skin sheets any new skin issues. The Interim Administrator, Regional Nurse Consultant, and CEO were informed the Immediate Jeopardy was removed on 01/17/2023 at 6:06 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 4 of 20 residents (Residents #5, #49, #120, and #121) reviewed for pressure injury. *The facility failed to provide wound care to Resident #121s sacral pressure injury until 12/29/22, which was 15 days after his admission with pressure injuries. *The facility failed to consistently provide wound care for Resident #121 after beginning wound care, missing treatments on 1/1/23 and 1/7/23. *The facility failed to implement a dietician recommendations of Pro-stat (given to provide body with additional protein to promote healing) for Resident #121 on 12/18/22 until 12/26/22 , 8 days after the recommendation was made. *The facility failed to administer the initial and on-going minerals and vitamins to Resident #121 as ordered by the wound care physician on 1/22/22. *Resident #121's sacral wound deteriorated and increased in size from 0.5 cm x 0.4 cm x undetermined depth on 12/14/2022 to 4.0 cm x 3.0 cm x 0.1 cm on 12/22/2022. Resident developed an infection in his wound and was admitted to the hospital 1/11/23 with a diagnosis of sepsis secondary to an unstageable sacral decubitus wound. Resident # 121 died 1/22/23. *The facility failed to measure Resident #120's sacral wound upon admission. *The facility failed to implement the wound care physician's orders to offload Resident #120's pressure ulcer. *The facility failed to provide Resident #120 a low air loss mattress to prevent wound decline. *The facility failed to provide daily wound care to Resident # 120's sacral wound as ordered on 01/4/2023, 01/05/2023, 01/06/2023, and 01/08/2023. *The facility failed to prevent Resident #120's wound from becoming infected requiring which required hospitalization. *The facility failed to prevent Resident #5 from developing two new DTIs (deep tissue injuries), one on her left inner bottom of her foot, and one on the right outer foot. (DTIs caused from bilateral feet pressure against each other) The facility failed to document newly identified DTIs and implement treatment orders for Resident #5 when the wound care physician identified the new wounds on 1/5/23. *The facility failed to identify the onset or followup orders for the left thumb of Resident #49 which resulted in a stage 2 pressure injury. An immediate Jeopardy (IJ) situation was identified on 01/12/2023 at 4:35 p.m. While the IJ was removed on 01/17/2022, the facility remained out of compliance at a scope of a pattern with actual harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the effectiveness of the corrective systems. These failures placed residents at risk of pain, worsening of wounds, wound infection, emotional distress, harm or even death. Findings included: 1. Record review of Resident #121's face sheet, with the printed date of 1/13/2023, indicated a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Sepsis (severe complication of an infection) due to pneumonia, muscle weakness, acute kidney failure, high blood pressure, and malnutrition (lack of caloric intake). Record review of Resident #121's The admission MDS revealed it was not completed. Record review of a Resident #121's Baseline Care Plan, dated 12/14/2021, indicated Resident #121 required extensive assistance with his ADLs, he had a skin concern of a pressure ulcer to the sacrum, with the goals of the wound to show signs of healing with area decreasing in overall size. The interventions included to provide the wound care/preventative skin care, weekly skin checks, turn and reposition, and notify the physician of any changes in the wound or emerging wounds. The physician orders listed in Section M of the Baseline Care plan did not reveal a wound care order with the medication orders. Record review of an Admission-readmission Assessment, dated 12/14/2022, indicated Resident #121 was admitted to the facility on [DATE] from a hospital. The assessment indicated Resident #121 had a pressure injury to his vertebrae (upper-mid back) measuring 0.2 cm x 0.2 cm x undetermined depth, a coccyx pressure ulcer measuring 0.5 cm x 0.4 cm x undetermined, and a pressure ulcer to the left buttock measuring 0.5 cm x 0.5 cm x undetermined depth. Record review of a Skin and Wound -total Body Skin Assessment, dated 12/14/2022, indicated Resident #121's skin turgor (skin elasticity) had poor elasticity, the skin color was normal, temperature was cool, the moisture was normal, the condition dry, and had 3 [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #220's face sheet, dated 1/13/23, revealed the resident was [AGE] year old male who admitted to the facility on [DATE] with diagnoses which included: chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), sepsis (the body's extreme response to an infection), Type 2 diabetes mellitus without complications (an impairment in the way the body regulates and uses sugar (glucose) as a fuel), peroration of intestine (a loss of continuity of the bowel wall), paroxysmal atrial fibrillation (terminates spontaneously or with intervention within seven days of onset), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and acute cystitis without hematuria (a sudden inflammation of the urinary bladder). Record review of Resident #220's Quarterly MDS assessment was not completed and was not due according to admit date . Record review was attempted of Resident #220's baseline care plan but one was not completed. No comprehensive care plan was due according to admit date . Record review of Dietary consult visit dated, 1/8/23, for updated nutritional assessments. It was recommended that Resident #220 his tube feeding, Glucerna, be increased 650 ML per hour from 500 ML per hour, as prescribed on discharge summary, and water increased to 35 ML per hour from 20ML per hour, as prescribed on discharge summary. Dietician requested accurate height and weight be completed as none was available. Record review of hospital discharge documents dated 12/29/22 indicated Resident #220 weighted 90.5 Kg (199.52 pounds) on 12/29/22, date of discharged . Record review of weight check on 1/11/23 indicated Resident #220 weighed 164.8 for a total weight loss of 34.3 (17.40 percent). This showed significant weight loss in less than a 30-day period . During observation on 1/9/23 at 5:45 p.m., Resident #220 was asleep in his bed. The head of the bed was elevated, and he was receiving his tube feeding via pump . The pump read 500 ML per hour of Glucerna and 20ML per hour of water. During observation of weight check for Resident #220 on 1/11/23, CNA S conducted an in-bed weight and the scale indicated, 164.8. During observation and interview on 1/11/23 at 09:49 AM with Resident #220, he said he was new the facility and was just placed back on the regular floor. He said he contracted COVID-19. He said he had not been weighed when he arrived. He said he was weighed, maybe a day ago. He said he was unsure if he has lost any weight. He said he received his food through tube feeding placed while in the hospital prior to his admission. He said he has not seen anyone that said they was a dietician or nutritionist. During observation of weight check for Resident #220 on 1/13/23, CNA S conducted an in-bed weight and the scale indicated, 162.4. During interview on 1/13/23 at 3:57 PM with CNA S, she said the DON usually had her to complete the weights weekly or monthly for residents. She said she knew she had to weigh new admits four times weekly and then it depended on if they have had any issues if she had to continue. She said she must weigh all residents at the beginning of the month. She said the weights must be done before the dietitian visits for the month. She said when she completed all the weights, she gave them to the DON, and usually within the next few days she would ask her to re-weigh a resident if needed. She said the DON entered all the weights into the electronic medical records, to her knowledge, after they have been reviewed and corrected. During an interview on 01/12/2023 at 2:24 p.m., the ADON A indicated there were no weekly standards of care meetings to review each resident with wounds, weight loss, or accidents. During an interview on 01/17/2023 at 1:36 p.m., LVN L indicated residents should be weighed on admission. LVN L indicated with not knowing the admission weight there could be a weight loss leading to skin problems, and even the loss of mobility. During an interview on 01/17/2023 at 2:39 p.m., the Regional Nurse Consultant indicated she was unaware of weight loss issues. The corporate nurse indicated new admissions should have a weight once a week for 4 weeks or until stable. The corporate nurse indicated the admitting nurse was responsible for obtaining the admission weight. The corporate nurse indicated there was not a reason for the admission or weekly weights not being obtained. During an interview on 01/17/2023 at 4:55 p.m., the Interim Administrator indicated the physician should be notified when the resident's weight falls in the parameter areas either a loss or a gain. The Interim Administrator indicated health issues could arise when weights were not monitored. The Interim Administrator indicated the charge nurses, and DON were responsible for the monitoring of weights. Record review of a Nutritional Management policy dated 07/01/2022 indicated the facility provides care and services to each resident to ensure the residents maintains acceptable parameters of nutritional status in the context of his or her overall condition. 2. Identification/Assessment: a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy. C. A comprehensive nutritional assessment will be completed by a dietician within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed. Record review of a Weight Monitoring policy dated 07/01/2022 indicated based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. 5. A weight monitoring schedule will be developed upon admission for all residents: A. Weights should be recorded at the time obtained. B. newly admitted residents-monitor weight weekly for 4 weeks, Residents with weight loss -monitor weight weekly. 6. Weight analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in one month, b. 7.5% change in 3 months, c. 10% change in 6 months. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. These were determined to be an Immediate Jeopardy (IJ) on 01/13/2023 at 1:20 p.m. The Administrator was notified on 01/13/2023 at 1:20 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The Administrator was provided with the IJ template The IJ template was provided on 01/13/2023 at 1:25 p.m. The following Plan of Removal submitted by the facility. The plan of removal for F692 was accepted on 01/15/2023 at 5:16 p.m. and included the following: Weight: Residents at the care center reweighed to compare to January weights by DON, ADON, and transportation aide completed 01/14/2023: verified by record review of weekly weight logs. Any significant increase or decrease in weight addressed by notifying MD, dietician, and family. DON made notifications completed by 01/14/2023; verified by record review of resident printed orders. Any identified increase or decrease in weight was placed on weekly weights x 4 weeks and or until weight has been stabilized or until MD orders discontinue. Completed on 01/14/2023: verified by record review of the weekly weight log. Any new orders implemented immediately by licensed care staff. Completed 01/14/2023: verified by record review of the printed physician's orders. Admitting nurse or CNA will obtain admission weights with follow up by the ADON within 24 hours. admission will have weekly weights x 4 weeks or until stable weights. Monitoring by DON, ADON, and MDS to prevent further systemic failure. Record review of weekly weight variance record dated 1/14/23 indicated 19 residents had weight variances identified. Record review of the physician orders indicated the physician had implemented supplements, dietician referrals, and weekly weight monitoring. Record review of in-service training report dated 1/12/23 indicated to implement all orders in a timely manner. 1. Dietary, Wound consultant treatments, and any other orders must implemented in a timely manner. 2. Orders must coincide with treatment and carried out as ordered. Interviews on 01/17/23 from 5:00 p.m. until 5:48 p.m. the surveyor confirmed the facility implemented their plan of removal. Interviews with 3 (6am-6pm) nurses LVN B, LVN D and LVN R, 2 (6pm-6am) nurses LVN U and LVN HH ,said they were in-serviced on obtaining weights on admission then every week for 4 weeks or stable, reporting weight changes to the physician. Interviews with 4 CNAs (6am-6pm) CNA FF, CNA GG, CNA D, and 4 CNAs (6pm-6am) CNA MM, CNA OO, CNA PP and CNA LL indicated they were in-serviced on obtaining weights on admission. The CEO and interim Administrator were informed the Immediate Jeopardy was removed on 01/17/23 at 6:16 p.m. The facility remained out of compliance at a severity level of potential for harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Based on observation, interview, and record review, the facility failed to maintain acceptable parameters for nutritional status such as usual body weight or desirable body weight range by failing to provide nutritional and hydration care and services to residents consistent with the resident's comprehensive assessment for 4 of 21 Residents reviewed for weight loss. (Resident #'s 32, 38, 119, 220) 1.The facility did not address Resident #32's weight loss of 12.7-pounds in one month. 2.The facility failed to provide Resident #32 her magic cup (nutritional ice cream) with lunch and dinner meals. The facility failed to have the dietician to address Resident #32 weight loss. 3.The facility did not address Resident #38's weight loss of 35 pounds since admission on [DATE]. 4.The facility did not obtain an admission weight for Resident #119. The facility did not address Resident #119's weight loss of 30 pounds. 5.The facility failed to ensure Resident #220 received an accurate weight upon admission or within the two weeks following. 6. The facility failed to implement dietician recommendations timely for Resident #220. An Immediate Jeopardy (IJ) situation was identified on 01/13/2023 at 1:20 p.m. While the IJ was removed on 01/17/2022, the facility remained out of compliance at a scope of a pattern with the severity of potential for harm that was not immediate jeopardy, with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization. Findings included: Record review of the CMS 672, dated 01/09/2023, indicated in Section G, other. F140 1 resident with unplanned significant weight loss/gain. 1). Record review of Resident #32's face sheet, dated 1/13/2023, indicated Resident #32 was a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnosis diagnoses which included of stroke, pain, seizures, dysphagia (difficulty swallowing) and malnutrition (lack of nutrition). Record review of Resident #32's consolidated physician's orders dated 01/13/2023 indicated Resident #32 had a diet order of mechanical soft and nectar thickened fluids dated 02/05/2022, and a magic cup with lunch and dinner dated 09/06/2021. Record review of Resident #32's computerized weights indicated her weight was 153.8 pounds on 12/09/2022 and 141.1 pounds on 01/06/2023. Record review of a comprehensive care plan dated 04/08/2023 and revised on 05/03/2021 indicated Resident #32 required assistance with her ADLs including assistance with eating, with staff to feed Resident #32 if she was unable to complete the task. The care plan indicated Resident #32 was at risk for weight loss with the goal of maintaining her current level of weight through 02/16/2023. The interventions included monitor for signs of malnutrition, a weight every month, and report a loss or gain of more than 5%. The comprehensive care plan also indicated Resident #32 was receiving a therapeutic diet and was at risk for nutritional deficit. The goal was Resident #32 would consume adequate fluid and would consume 75% or more of the meals served with no associated weight loss through next review dated 04/08/2021. The interventions included administer snacks, and supplements as ordered, and provide a magic cup with lunch and dinner dated 07/07/2021. Record review of an Annual MDS dated [DATE] indicated Resident #32 was sometimes understood and sometimes understands, and Resident #32's BIMs score was 00 indicating severe cognitive impairment. The MDS indicated Resident #2 required total assistance of one staff with meals. The MDS in Section K indicated Resident #32 did not have a swallow disorder or signs of a swallowing disorder. Section K also indicated Resident #32's height was 70 inches, and her weight was 147 lbs. with no weight loss or weight gain documented. Record review of a weight record dated 01/13/2023 indicated Resident #32's 180 days prior was 151.8 pounds., 90 days prior weight was 152.8 pounds., and on 01/06/2023 Resident #32's weight was 141.1 pounds. Record review of the dietician reports revealed the following: -On *10/22/2022, there was: no mention of recommendations for weekly weights for Resident #32. -On *11/11/2022, there was: no mention of recommendations for weekly weights for Resident #32. -On *11/30/2022, there was: no mention of recommendations for weekly weights for Resident #32. -On *12/10/2022, there was: no mention of recommendations for weekly weights for Resident #32. - On *12/18/2022, there was: no mention of recommendation for weekly weights for Resident #32. On *01/08/2023 and 01/09/2023, there was: no mention of recommendations for weekly weights for, Resident #32. During observations on 01/10/2013 - through 01/11/2023 for Resident #32 revealed the following: -On *01/10/23 at 12:55 p.m., there was no supplement with the Resident #32's lunch meal. -On *01/10/2023 at 5:55 p.m., there was no magic cup with her Resident #32's evening tray. - On *01/11/2023 at 12:25 p.m., there was no magic cup with her Resident #32's lunch tray. -On *01/11/2023 at 6:00 p.m., there was no supplement with her Resident #32's evening tray. During an interview with the DON on 01/11/2023 at 3:26 p.m., The DON said she inputs the resident's weights in the computer after their weight was obtained. The DON said the person obtaining the weights just logs the weight obtained. The DON said when she reviews the weights, she stars them for a reweight to verify. The DON said the hospital weights were often not correct therefore it was important to have a weight. Record review of the undated dietary supplement list, there were no residents receiving a magic cup at lunch or dinner. 2) Record review of Resident #38's face sheet, dated 1/13/2023, indicated Resident #38 was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis diagnoses which included of stroke, diabetes (too much sugar in the blood), chronic kidney disease (longstanding disease of the kidney), and muscle weakness. Record review of the consolidated physician orders dated 1/13/23 indicated Resident #38 did not have a diet ordered. Resident #38 had orders in a que including the diet order waiting for processing. Record review of Resident #38's comprehensive care plan dated 11/29/2022 there was no care plan addressing the risk of weight loss or actual weight loss. Record review of the clinical records for Resident #38 indicated the Initial MDS was not completed. Record review of Resident #38's weights indicated his weight on 11/18/2022 was 225 pounds, his weight on 11/29/2022 was 200 pounds, his weight on 12/17/2022 was 242 pounds, and on 01/06/2023 was 190 pounds. Record review of a dietician progress note dated 11/30/2022 indicated Resident #38 weight was 200.0 pounds with a height of 73 inches. The dietician's note indicated Resident #38 had a regular diet with thin liquids, he could feed himself with supervision. The goal of the recommendations was he would maintain weight without a significant change. And the recommendations were to continue the diet. Record review of a dietician's consultant, dated 11/30/2022, indicated Resident #38 had no recommendations even though the weights indicated he had already lost 25 pounds. Record review of a dietician's consultant report dated 12/10/2022 indicated Resident #38 was not evaluated. Record review of a dietician's consultant report dated 12/18/2022 indicated Resident #38 was not evaluated. Record review of a dietician's consultant report dated 01/08/2023 indicated Resident #38 was not evaluated. During an observation on 01/09/2023 at 1:05 p.m., Resident #38 was eating lunch in his room. Resident #38 remains on isolation precautions for C-diff, an infection causing profuse diarrhea. During an observation on 01/10/2023 at 1:15 p.m., Resident #38 was eating lunch while lying in his bed. Record review of a dietary profile dated 01/11/2023 indicated Resident #38 was receiving a regular diet with no dietary supplements. 3) Record review of a face sheet dated 01/11/2023 indicated Resident #119 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of joint replacement surgery, muscle weakness, and high blood pressure. Record review of the admission MDS dated [DATE] indicated Resident #119 understood others and she was understood. The MDS indicated Resident #119 had problems with recall and her BIMs score was an 11 indicating she had moderate impairment with cognition. The MDS indicated Resident #119 required extensive assistance of one staff member with eating. The section GG of the MDS indicated Resident #119 was independent eating with no assistance. The MDS indicated Resident #119 weight was 130 pounds in the section K0200. The MDS indicated Resident #119 had no weight loss or weight gain in the section of K0300. Record review of a hospital medication consolidation record dated 12/19/2022 indicated on 12/14/2022 Resident #119's weight was 160 pounds, and her height was 62 inches. Record review of a Dietary Profile dated 12/28/2022 indicated Resident #119 was receiving a regular diet and did not require any nutritional supplements. Record review of Resident #119's weights indicated only one weight was obtained since admission on [DATE] of 130 pounds. Record review of a Dietician Progress Note dated 01/08/2023 indicated Resident #119 was eating 50-75 % of meals, her weight was 130 pounds and stable. The note also indicated Resident #119 had no skin issues. The notes comments indicated the diet was regular diet with thin liquids, to maintain weight without significant change over the next three months and to continue current diet. The dietician note does not indicate there was a significant weight loss from the hospital weight of 160 pounds and the facility weight of 130 pounds. Record review of the Dietician Recommendation indicated on 01/08/2023 Resident #119 had no recommendations. Record review of the comprehensive care plan dated 01/10/2023 indicated Resident #119 was receiving a regular diet with the goal of her weight remaining stable through the next review. The interventions included allow choices in food items, and provide snacks or supplements as ordered. During an observation on 01/10/2022 Resident #119 had consumed 50 % of her meal while in her bed. Record review of the consolidated physician's orders dated 01/11/2022 indicated Resident #119's diet was a regular diet with thin liquids started 12/19/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Record review of the original in-service conducted with all nursing staff addressed the policy for all residents with lab orders. The in-service included lab and diagnostic test result protocol. Monitoring to be completed by DON, and ADONs. In-service completed by the DON on 01/13/2023; verified by interview of in-serviced material. After re-entering the facility on 2/8/23 at 9:05 a.m. additional information was gathered and included the following interviews and record reviews: Record review of the laboratory process effective 01/18/23 indicated: *admission orders were reviewed during next the clinical meeting. *All orders were checked to ensure they were entered correctly. Any unclear orders were clarified. *Any laboratory orders were verified of placement in the EMR to ensure laboratory requisitions were completed in the laboratory requisition book. *Nursing to monitor laboratory results and review to ensure the MD was aware. Any new orders received would be implemented. *Clinical meetings will occur twice a day to ensure communication was followed and any changes were updated. *Initial requisition would indicate if a resident had recurring laboratory orders. *During the daily clinical meeting, the PCC dashboard will be utilized to monitor for lab results, MD review, and followed for any order changes. Interviews on 02/08/23 from 09:51 a.m. until 11:05 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interview with 3- 6am-6pm (LVN B, LVN R and LVN Y) nurses who indicated the laboratory process included: when an order for a laboratory was obtained, the order was placed in the resident's electronic medical record, the laboratory requisition was filled out, placed in the laboratory book, and was written on the 24hr report. Residents with standing laboratory orders were indicated on the lab requisition form. The three LVNs said the ADONs review the lab book daily. Interview with ADON A, ADON G, and RNC indicated they had placed a laboratory monitoring process on 1/18/23. New orders and admission orders were reviewed during the next clinical meeting. The laboratory process was: -Laboratory orders received were ensured they were entered corrected in the EMR. -The laboratory requisition was completed. -The laboratory requisition was placed in the laboratory book. The laboratory book was checked daily by the ADONs. Nursing would monitor for laboratory results, notify medical director, and implement any new orders received. If a laboratory result had not been received by 3:00 p.m., the ADON would then call the laboratory to check on the results. Record review of 6 of 6 new admissions revealed if they had orders for laboratory services the laboratory levels were obtained according to orders. Record review of 2 of 2 resident receiving vancomycin had their vancomycin troughs completed as ordered. Record review of 4 of 4 residents reviewed for monthly laboratory orders were on the monthly laboratory log to be obtained. Record review of Resident #34's vancomycin trough level, collected on 01/18/23, was 12.1. The medical director had reviewed and signed the laboratory results which included orders to discontinue the vancomycin due to the resident's refusal. Record review of Resident #44's PT/INR results indicated his INR was 2.8. Resident #44 was to have his INR rechecked on 02/20/23. Resident #44 was on the scheduled monthly laboratory log. The administrator was notified on 2/8/23 at 7:25 p.m. the immediacy remained in place until 1/18/23. Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of 3 of 20 residents reviewed for laboratory services. (Resident # 44, Resident #35, and Resident #34) The facility failed to draw PT/INR (A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results) level for medication Coumadin (is a blood-thinning medicine that's used to treat and prevent dangerous blood clots) for Resident # 44 as ordered monthly for five months. The facility failed to draw routine hemoglobin A1C (HBA1C) (a blood test that shows what your average blood sugar (glucose) level was over the past two to three months) for Resident #35. The facility failed to obtain Resident #34's Vancomycin (is used to treat infections caused by bacteria. It works by killing bacteria or preventing their growth) trough level (is drawn immediately before the next dose of the drug is administered because it is the lowest concentration in the patient's bloodstream) as ordered prior to administration of first dose of Vancomycin. These failures resulted in an identification of an Immediate Jeopardy (IJ) at 12:05 p.m. on 01/13/23. While the IJ was removed on 01/18/23, the facility remained out of compliance at the severity of no actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not having their medications at a therapeutic level, delays in treatment, and/or deterioration in condition. Findings included: 1. Review of Resident #44's electronic face sheet dated 01/13/23 revealed he was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of high blood pressure, seizures, stroke, and anemia (low blood). Review of Resident #44's quarterly MDS assessment dated [DATE] revealed under Section B, Hearing, Speech, and Vision, he was coded as 2 for sometimes understands and sometimes understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 99 for severely impaired cognition. Section G, Function Status under section B indicated he needed total assist with dressing, personal hygiene, and extensive assist with bed mobility, transfers, eating and toileting. Section N, Medication, under section N0410 indicated Resident #44 received 7 days of Coumadin during the look back period. Review of Resident #44's physicians orders dated 1/13/22 revealed PT/INR to be drawn every 30 days for diagnosis of prostatic heart value (are designed to replicate the function of native valves by maintaining unidirectional blood flow). Review of Resident #44's comprehensive person-centered care plan dated 01/13/21 when it was initiated, and it was revised on 01/14/21. Focus indicated: Resident #44 had the potential for alteration in bleeding tendencies and increased bruising related to anticoagulants therapy of Coumadin. Interventions indicated: Administer medication as ordered, monitor for side effects and report ill findings to physicians. Review of Resident #44's labs did not reveal any PT/INR labs since 07/13/22 which was ordered monthly. During an interview on 01/12/23 at 5:37 p.m., LVN C said Resident #44 was on Coumadin and should be getting monthly Coumadin levels and failure to get labs could result in bleeding. During an interview on 01/12/23 at 5:46 p.m., LVN R said when charge nurses received new lab orders, they filled out a lab requisition and placed it in the lab book. LVN R said charge nurses then placed on the 24-hour report book to follow up on labs. LVN R said Resident #44 took Coumadin and thought he had a recent lab result. LVN R called the lab company to verify the last PT/INR and they confirmed his last results were PT-31.2 indicating high and INR-2.7 indicating high drawn on 07/13/22. LVN R said failure to do labs as ordered with Coumadin could cause Resident #44 to bleed out. During an interview on 01/12/23 at 5:50 p.m., the DON said she was aware Resident #44 did not have his Coumadin level drawn monthly as ordered. The DON said Resident #44's last coumadin level was last drawn on 07/13/22. The DON said it took time to get things in order and she was still working on this process. The DON said she did not have a system in place to monitor labs at this time During an interview on 01/12/23 at 6:10 p.m., the RNC said she was unaware Resident # 44 did not have a current PT/INR level but would make sure he got one done. The RNC said it is important to have the PT/INR drawn as ordered to ensure residents are in therapeutic levels and failure to do labs could cause bleeding. During a phone interview on 01/13/23 at 8:40 a.m., the Primary doctor said he was not aware PT/INR levels had not been drawn since 07/13/22. The Primary doctor said the facility should have drawn the PT/INR level as ordered. The Primary doctor said failure to draw PT/INR levels could lead to Resident #44 bleeding and having another stroke. Record review of Resident #44's progress note dated 01/13/2023 at 5:28 p.m., revealed PT/INR lab results received, PT 17.1, (normal range=9.0-12.2) and INR 1.4 (normal range 0.8-1.1). Physician made aware, new order to discontinue Coumadin 7.5mg and begin Coumadin 10 mg, give 1 tablet by mouth daily. Attempted to notify daughter to make aware of changes, call went unanswered. Resident #44 made aware of new change. Coumadin 10mg administered at this time, and new order to recheck PT/INR in one week. 2. Record review of a face sheet dated 01/17/23 indicated Resident #34 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cellulitis (bacterial skin infection that causes redness, swelling, and pain to the affected area), Chronic obstructive pulmonary disease with acute exacerbation (group of lung diseases that cause airflow blockage and breathing related problems), acute systolic congestive heart failure (left ventricle of heart becomes weak), and weakness. Record review of the quarterly MDS dated [DATE] indicated Resident #34 was usually understood and understood others. The MDS revealed Resident #34 had a BIMS score of 13 indicating intact cognition. The MDS indicated Resident #34 required extensive assistance with bed mobility, toileting, and personal hygiene. Resident #34 was totally dependent on dressing and bating. The MDS under section O, special treatments, procedures, and programs, had IV medications checked indicating Resident #34 had received IV medications within the last 14 days. Record review of Resident #34's comprehensive care plan did not indicate Resident #34 was receiving IV antibiotics. Record review of the order summary report dated 01/17/23 indicated Resident #34 had an order for Vancomycin HCL intravenous solution 750-0.9mg/150mls-% Use 150ml intravenously every 12 hours for cellulitis to right hand for 10 days with an order start date of 01/16/23. Record review of the hospital patient discharge summary report dated 01/15/23 indicated new medications to start included Vancomycin HCL injection 750mg/sodium chloride 0.9% bag 250ml take IV piggyback every 12 hours. 250ml/hr. *Hold dose and DO NOT administer IF Trough is 20 or higher. Get trough level before 1st dose on 01/16/23. Record review of the lab request form dated 01/16/23 indicated Vancomycin trough to be collected on 01/18/23. During an interview on 01/17/23 at 09:45 AM, Resident #34 said he received his first dose of IV medication last night. During an interview on 01/17/23 at 09:50 AM, LVN L said Resident #34 received his first dose of Vancomycin last night and was unsure if the vancomycin trough was obtained prior to Resident #34's first dose of vancomycin. During an interview on 01/17/23 at 12:51 PM, ADON A said she did not see the order to obtain a trough level before the first dose of vancomycin for Resident #34 and it was not obtained. ADON A said by not obtaining the vancomycin trough level, Resident #34 could be at risk for receiving more than the therapeutic dose of vancomycin. During an interview on 01/17/23 at 1:57 PM, the RNC said they should have obtained a vancomycin trough level prior administering the first dose of vancomycin. The RNC said by not obtaining the trough level as ordered the resident was a risk for receiving the wrong dose of vancomycin. The RNC said the nurse who hung the medication was responsible for ensuring Resident #34 had a vancomycin trough level prior to receiving his first dose of vancomycin. During an interview on 01/17/23 at 5:00 PM, the Interim Administrator said he expected the nurses to follow the physician orders. The Interim Administrator said by not following the physicians' orders could cause the resident to have adverse effect. Record review of the facility's policy titled Diagnostic Testing Services dated 07/01/22 indicated . this facility will provide the appropriate diagnostic services (laboratory and radiology) required maintain the overall health of its residents and in accordance with state and federal guidelines . 3. Record review of Resident #35's electronic face sheet, dated 01/13/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Metabolic encephalopathy (is a problem in the brain. It is caused by a chemical imbalance in the blood), diabetes, high blood pressure, Chronic obstructive pulmonary disease (COPD) (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of Resident #35's quarterly MDS assessment, with an ARD of 10/07/22, revealed under Section B, Hearing, Speech, and Vision, she was coded as 1 for usually understand and usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 10, which indicated moderately impaired cognition. Section G, Function Status, under section G0110 indicated she needed supervision with bed mobility, transfers dressing, eating, personal hygiene and toileting. Review of Resident #35's physicians orders revealed, HGBA1C every 6 months in March and September. Review of Resident #35's comprehensive person-centered care plan dated 03/30/18 when it was initiated, and it was revised on 11/08/22. Focus indicated: Resident #35 has the potential for complications related to diagnosis of Diabetes Melilites. Intervention: HBGA1c every 6 months, administer medication as ordered by physician and monitor for side effects. During an interview on 01/12/23 at 5:46 p.m., LVN R said when charge nurses receive new lab orders, they fill out a lab requisition and place in lab book. LVN R said charge nurses then place on 24-hour report book to follow up on labs. LVN R verified order for Resident #35's HGBA1C to be drawn in March and September. LVN R said failure to do this lab as ordered could lead to Resident #35 not receiving correct dose of medication. During an interview on 1/17/23 at 2:06 p.m., the RNC said all labs should be drawn as ordered. RNC said the charge nurses are responsible to ensure orders are received and lab requisitions are filled out completely. The RNC said administrative nurses was to follow up on all labs. The RNC said without labs been drawn as ordered, doctors would not know if the residents were within a therapeutic range. During an interview on 01/17/23 at 2:25 p.m., ADON D said she expected the charge nurses to fill out the lab requisition and to make sure it was done. ADON D said she expected the charge nurses once lab received back to notify the physician because writing faxed on paper does not tell us anything. ADON D said the ADON's should be following up on labs. ADON D said Resident #44 could bleed out without propre dose of medication. ADON D said Resident #35's oral, or insulin medication could need readjustment but without proper lab they could not detect therapeutic levels and could lead to organ failure. During an interview on 01/17/23 at 6:00 p.m., ADON D said Resident # 35 did not get her HGBAIC in September as ordered. ADON D said she was unaware why Resident #35 HGBA1C was not done. ADON D said with the new lab system, hopefully no more labs will be missed. The Administrator was notified 01/13/22 at 1:20 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was provided on 01/13/22 at 1:25 p.m. and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 01/15/23 at 5:00 p.m. and included the following: 1. Resident has received lab draw on 01/12/23. 2. All resident on anticoagulant identified, only one identified. Identified by report and database confirming any resident on anticoagulant. Every monthly order in DCOL lab binder. Completed 01/13/23. 3. MD notified of any residents without current PT/INR. Zero identify. Completed 1/13/23 4. Order for new PT/INR to be immediately and lab notified. Completed 01/13/23 5. Families made aware. Completed 01/13/23 6. Orders for routine lab draws for anticoagulants current and corrected. DON insured lab and orders corrected. Completed 01/13/23. 7. In-serviced all nursing staff of all residents on anticoagulants and routine lab orders. In-service completed by DON. In-service included anticoagulants and monitoring. In-service included how to run anticoagulant report from PCC. Completed 01/13/23 Monitoring: Interviews on 01/17/23 from 5:00 p.m. until 5:48 p.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with 3-6am-6pm (LVN KK, LVN R and ADON G and 2-6pm-6am (LVN OO and LVN M) nurses who indicated they had received a written in-service regarding monitoring of labs. What blood thinners are such as medicines that prevent blood clots from forming. Residents who may needs blood thinners, with a certain heart or blood vessel diseases or an abnormal heart rhythm called atrial fibrillation. The different types of blood thinners which are anticoagulants, such as heparin or Coumadin, because they slow down your body's process of making clots and antiplatelets, such as aspirin and clopidogrel, which prevent blood cells called platelets from clumping together to form a clot. How to take blood thinners safely by getting labs to ensure you're taking enough medicine to prevent clots, but not so much that it causes bleeding; and the side effects of blood thinners was bleeding. All the nurses above stated they knew how to run a report to check to ensure any resident on Coumadin had an order for PT/INR. Record review of an in-service training report dated 1/13/23 indicated anticoagulants and monitoring were the topic of the in-service. The training session included: What are blood thinners? Blood thinners are medicines that prevent blood clots from forming. They do not break up clots that you already have. But they can stop those clots from getting bigger. It's important to treat blood clots, because clots in your blood vessels and heart can cause heart attacks, strokes, and blockages. Who needs blood thinners? You may need a blood thinner if you have: Certain heart or blood vessel diseases An abnormal heart rhythm called atrial fibrillation A heart valve replacement A risk of blood clots after surgery Congenital heart defects What are the different types of blood thinners? There are different types of blood thinners: Anticoagulants, such as heparin or warfarin (also called Coumadin), slow down your body's process of making clots. Antiplatelets, such as aspirin and clopidogrel, prevent blood cells called platelets from clumping together to form a clot. Antiplatelets are mainly taken by people who have had a heart attack or stroke. How can I take blood thinners safely? When you take a blood thinner, follow the directions carefully. Blood thinners may interact with certain foods, medicines, vitamins, and alcohol. Make sure that your health care provider knows all of the medicines and supplements you are using. You may need regular blood tests to check how well your blood is clotting. It is important to make sure that you're taking enough medicine to prevent clots, but not so much that it causes bleeding. What are the side effects of blood thinners? Bleeding is the most common side effect of blood thinners. They can also cause an upset stomach, nausea, and diarrhea. Other possible side effects can depend on which type of blood thinner that you are taking. Call your provider if you have any sign of serious bleeding, such as: Menstrual bleeding that is much heavier than normal Red or brown urine Bowel movements that are red or black Bleeding from the gums or nose that does not stop quickly Vomit that is brown or bright red Coughing up something red Severe pain, such as a headache or stomachache Unusual bruising A cut that does not stop bleeding A serious fall or bump on the head Dizziness or weakness ANTICOAGULANT MONITORING Keywords: Oral anticoagulant therapy TYPES OF ANTICOAGULANT APPROPRIATE TESTS See also Thrombolytic therapy (Thrombolysis). The type of tests and frequency of testing depends on the anticoagulant therapy and indication, as well as clinical history. Heparin (standard, unfractionated) Prior to commencing Full blood count (including platelet count), Coagulation profile (including APTT, INR, Prothrombin time). Platelet count is recommended on day 5 post commencement of therapy. The method for monitoring continuous IV heparin infusion is usually APTT, however Activated clotting time (ACT) and Anti factor Xa are also used. The level of anticoagulation may be monitored with the APTT and/or Anti factor Xa level, however monitoring(including the test and frequency) should be according to local guidelines. Prophylactic (low dose) heparin does not usually require monitoring. In the event of bleeding on heparin, urgent APTT and Full blood count should be performed. If progression of thrombosis, or thrombosis in other site(s) while patient on heparin, causes include: Inadequate anticoagulation Heparin-induced thrombocytopenia (HIT type II) Antithrombin deficiency APTT, Anti factor Xa See also Heparin-induced thrombocytopenia investigation Antithrombin - ideally should be deferred until heparin has been ceased (if not performed for some reason prior to heparin therapy), since heparin will reduce the measured level. Consultation with a haematologist is recommended to guide further testing and management. See also Thrombosis - venous. Low molecular weight heparin (LMWH) and heparinoids Prior to commencing, Full blood count (including platelet count), Coagulation profile (including APTT, INR, Prothrombin time) and renal function should be performed. Platelet count is recommended on day 5 post commencement of therapy. Monitoring of (full dose) low molecular weight heparin (LMWH) therapy is not generally required, except in renal failure, extremes of body weight, pregnancy or other situations where there is an increased risk of bleeding. LMWH should be used with care and monitoring in patients with any abnormality of renal function, particularly the elderly. Monitoring is with an Anti factor Xa level, but should be done in consultation with a haematologist and according to local guidelines. Monitoring of routine LMWH prophylaxis is not cost effective, is not required to achieve clinical efficacy and is not indicated to predict risk of bleeding, which is minimal with prophylactic doses in patients with normal renal function. Oral anticoagulants Warfarin (Marevan/Coumadin) Prothrombin time, INR Increased frequency of testing may be required following change in dose, change in diet/oral intake, intercurrent illness and change in concomitant medications (including antibiotics). For information on reversal of warfarin, see guidelines below. New oral anticoagulants (NOACS) NOAC do not require monitoring when used for thromboprophylaxis or therapeutic anticoagulation. However, the anticoagulant effect should be measured if: 1. Clinically significant bleeding occurs 2. There is a change in clinical circumstances (eg, urgent surgery is required) Routine coagulation studies may (but sometimes do not) provide information about the presence of anticoagulant effect (see below). Specific assays for quantitation of drug levels may or may not be available depending on the drug and laboratory. Due to the short half-life of these drugs, information on the time of the last dose is important in interpreting the results. Refer to coagulation laboratory. Dabigatran The Thrombin time (TT) is the most sensitive routine coagulation assay to detect the presence of dabigatran. A normal TT excludes the presence of dabigatran, however low drug levels may significantly prolong the TT, therefore the assay cannot be used to estimate plasma levels. Some laboratories may perform a drug level assay (dilute thrombin clotting time assay). Rivaroxaban The Prothrombin time, INR (using a thromboplastin that is sensitive to rivaroxaban) is the most sensitive routine coagulation assay, however a normal PT does not exclude its presence. The APTT and PT cannot estimate the intensity of anticoagulant effect Some laboratories may provide a drug specific anti-Xa for quantitative assessement of drug plasma levels. The clinical relevance of drug plasma levels is not known, and therefore should not be used to inform drug doses. Apixaban A normal PT and APTT does not exclude significant anticoagulant effect. Drug specific anti-Xa assay may be used to estimate drug plasma levels, but this is not yet widely available. Please consult with laboratory. References: [NAME] DA et al; American College of Chest Physicians. Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis. 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (2 Suppl): e24S-43S. [NAME] H et al. An update of consensus guidelines for warfarin reversal. MJA 2013; 198: 198-199. [NAME] H et al. New oral anticoagulants: a practical guide on prescription, laboratory testing and peri-procedural/bleeding management. IMJ 2014; 44: 525-536. Record review of a written in-service dated 01/15/23 indicated licensed staff had been educated on labs. The CEO and interim Administrator were informed the Immediate Jeopardy was removed on 01/18/23; however, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.