**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care within 48 hours of a resident's admission including the minimum healthcare information necessary to properly care for one (Resident #1) of five residents reviewed for baseline care plans. The facility failed to develop and implement a baseline care plan with interventions within 48 hours of admission for Resident #1 that addressed her high fall risk status. The facility failed to complete an admission assessment and baseline care planning, and ensure staff had adequate knowledge and access to care plans. The facility failed to ensure effective use of the [NAME] system as a reference tool by failing to ensure adequate staff knowledge in the updating and referencing of the [NAME]. Resident #1 fell from her wheelchair on 03/29/25 and hit her head and was admitted to the acute care hospital. There was a likelihood of a serious adverse outcome for the resident due to multiple systemic failures. An IJ was identified on 04/03/25. The IJ template was provided to the facility on [DATE] at 3:11 PM. While the IJ was removed on 04/04/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm because all staff had not been trained on the plan of removal. These failures placed residents at risk of not having their needs identified, serious physical harm, injury, and/or death. Findings included: Review of Resident #1's face sheet, printed on 04/02/25, reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged on 03/29/25. Her diagnoses included weakness, cerebral edema (brain swelling), nontraumatic intracerebral hemorrhage (brain bleed), acute respiratory failure with hypoxia (not enough oxygen in the body), and unspecified abnormalities of gait and mobility. Review of Resident #1's MDS assessment list reflected her admission-, five day-, and discharge assessments were all in progress. Review of Resident #1's baseline care plan, initiated on 03/29/25 and created on 04/02/25, reflected in part - Focus: I am at risk for falls r/t Balance problems noted, chronic health problem and comorbid medical problems, debility and weakness, cognitive impairment noted, difficulty moving / propelling self in w/c. 03/29/25 - actual fall, sent to ER. Goal: I will be free from falls and / or will not experience significant injuries associated with falls through next review date. Interventions/Tasks: Provide resident with no touch call bell. Do not leave resident alone in her room when she is up in her wheelchair. Anticipate and meet needs and keep call bell within reach as indicated. Bed at appropriate height when unattended . Review of Resident #1's acute care discharge orders dated 03/24/25, reflected and order, Place patient on fall precautions. Review of Resident #1's Nursing admission assessment completed 03/25/25, Section B (Clinical/Health Conditions) reflected the resident had comorbidities that included CVA (stroke) and Hemiplegia/Hemiparesis (weakness or paralysis on one side of the body). Section C (Physical Assessment) reflected the resident required a mechanical lift and two team members for transfers. Section E (Communication) reflected the resident was incoherent, unaware of her own needs and wants. Section K (Fall Risk Review) reflected recent falls were unknown, the resident was taking two of the medications listed, the resident appeared severely affected by one or more of the psychological factors listed, and her cognitive status was impaired. The Automatic High Risk Status: Box #1 was checked, Recent change in functional status and/or medications with the potential to affect safe mobility. Box #6 was checked, Check if the resident/patient is a high risk for falls. Section O (Initial and 48 Hour Plan of Care) reflected #10 Fall risk, had no boxes checked - no focus, no goals, and no interventions. Review of Resident #1's progress note dated 03/27/25 at 10:00 AM, written by the NP, reflected in part, Patient demonstrates impulsivity and has made attempts to transfer self. She has been moved to room (number) for increased visibility by staff. Will continue to monitor cognitive status and implement safety measures. Review of Resident #1's progress note written by LVN D, reflected a late-entry note dated 03/29/25 at 11:30 AM, This nurse observed resident on floor in resident's room. Resident observed on floor face down and resident's wheelchair position on resident's upper back. Resident stated, I hit my head and face. Head to toe assessment completed and nystagmus observed and resident alert and oriented x2 and some confusion noted of situation. Check for head injuries, nystagmus noted, EMS was called no redness or bruises to resident's face or head .Resident feels pain on left side of face and head .transported to (hospital) for evaluation and treatment. Review of Resident #1's [NAME] printed on 04/04/25, reflected in part - Special Instructions: Resident must be up in dining room for meals. Do not leave alone with any food or drinks. Asperation [sic] precautions. Safety - I must be up for all meals. The [NAME] did not reflect any fall precautions. Review of Resident #1's Order Summary Report printed 04/02/25, reflected no order for fall precautions. During an interview on 04/02/25 at 1:28 PM, the MDS Nurse stated the admitting nurse was responsible for initiating the baseline care plan. She stated she then had seven or eight days to review the baseline care plan. The MDS Nurse stated she expected to see transfer status, how they ambulate, any skin issues, fall risk, nutrition, or g-tube, and whatever was pertinent to taking care of the resident on the baseline care plan. She stated in the care plan meeting they reviewed care plans and made sure everything relevant was documented. She stated the administrative nurses had a meeting every morning where they reviewed new admissions. During an interview on 04/02/25 at 1:49 PM, RN B stated she had completed the admission assessment on Resident #1. She stated she was the treatment nurse at the facility and did not routinely conduct admission assessments. She stated she believed she had marked the box indicating the resident was a high fall risk. She stated she believed that checking that box would trigger the fall risk to go to the baseline care plan and [NAME]. She stated she did not know how to open the care plan to even see what was on the care plan. She stated the fall risk would be passed on in report and the CNAs would have the information on the [NAME]. She stated she did not have all the information needed to complete the assessment and believed the management team would have reviewed and completed the admission assessment including the baseline care plan the next day. During an observation and interview on 04/02/24 at 2:15 PM, CNA A was observed as she signed into the computer and opened a [NAME] for a resident. She stated she did not see Fall Risk on the [NAME]. She opened six more records of residents who she knew had fallen and did not see where the residents were identified as a fall risk. She stated they usually got fall risk information in report every morning from the nurse. She stated, They tell us to look at the [NAME], but I don't see it. During an interview on 04/02/25 at 3:22 PM, the DON stated the admitting nurse was responsible for the admission assessment and the baseline care plan. She stated she and the other administrative nurses met daily and reviewed the admission and baseline care plans the day after admission to ensure they were completed. She stated she did not remember if they had reviewed Resident #1's baseline care plans the day after admission. She stated it was her expectation that the admission assessment, including the baseline care plan, were completed timely. The DON stated every resident who came into their building was a fall risk and every resident had a fall risk care plan with interventions in place. She stated she had in-serviced staff multiple times, and the CNAs all knew that everyone was a fall risk. The DON stated she had educated on the need to get the residents out of their rooms and engaged as most falls happened when residents were left alone. The DON stated she updated Resident #1's fall care plan earlier in the day, 04/02/25, to document the actual fall on 03/29/25. The DON stated there was no fall risk care plan in place prior to her documentation. The DON did not identify any potential adverse outcomes from not having a care plan for fall risk. She stated the CNAs attended a huddle meeting and got report and information about falls from the nurses during the meeting. She stated the CNAs got Resident #1 up in her wheelchair for lunch 0n 03/29/25. They left her alone in her room and that was when she fell. During an interview on 04/03/25 at 10:00 AM with the DON, she stated they had found that companywide, the [NAME] did not reflect the words Fall Risk but there were fall interventions listed in the safety box. She stated they had found a way to update the [NAME] to reflect Fall Risk and they were in process of updating. A policy specific to baseline care plans was requested. A specific policy was not provided but the general care plan policy was provided prior to survey exit. During an interview on 04/03/25 at 10:15 AM, the NP stated it was important to have fall interventions in place. Without the interventions, a resident could have fallen and been injured. During an interview on 04/03/25 at 10:41 AM, LVN D stated she was aware that Resident #1 was a fall risk because of the report she received from the previous shift. She stated the resident was moved to her hall, so the resident had a room closer to the nurse's station. She stated section O of the admission was completed on admit because that was the baseline care plan. She stated the [NAME] was what the CNAs reviewed to see what care the residents required and that information came from the admission assessment. Review of the Care Plans policy, revised January 2023, reflected in part - The care plan should be initiated upon admission, continued to be developed during the initial 48-72 hours, . Review of the Standards of Nursing Practice Observations and Data Collection policy, revised January 2023, reflected in part - .The delivery of nursing care in the community is based on an assessment of the resident to identify his or her care needs. Once resident needs are identified, a comprehensive care plan shall be developed to attain individualized resident goals. The care plan shall be implemented by the interdisciplinary team and is continually evaluated for effectiveness .It is the role of the nursing staff to implement physician prescribed interventions and monitor the resident for their response or any complications .A care plan shall be developed with actions designed to address nursing and collaborative problems or risk areas identified for the resident . Review of the Falls Prevention Guideline, updated 03/28/22, reflected in part, Purpose - To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls. Process - On admission - - Newly admitted or re-admitted residents are assessed for fall risk. - When a risk factor for falls is identified a corresponding intervention addressing that risk factor is developed. - When the risk is identified and intervention determined, it is documented on the care plan and on the [NAME]. - The intervention is initiated. An Immediate Jeopardy (IJ) was identified on 04/03/25. The ADM, DON, and RDCO were notified of the Immediate Jeopardy on 04/03/25 at 3:11 PM and a IJ template was provided to the ADM on 04/03/25 at 3:11 PM. A Plan of Removal was accepted on 04/04/25 3:26 PM and read as follows: Plan of Removal F655 Baseline Care Plan 4/3/2025 F655 - The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission. Immediate Response: o The identified resident transferred to the hospital on: o All admissions/readmissions from__3/3/25__ to 4/3/2025 charts were reviewed for completion of the admission/readmission assessment to include completion of the baseline care plans and all baseline care plans were complete with no other findings. Results: Complete Date completed: 4/3/25 o Director of Nursing Services/Assistant Director of Nursing conducted an audit for all resident's who currently reside in the community care plans to validate accuracy of each residents ADL care needs and no other discrepancies noted. Date completed: 4/3/25 o The Regional Director of Clinical Operations immediately educated the Director of Nursing Services/Assistant Director of Nursing/Reimbursement Nurses on the process for validating the completion of all admission/readmissions timely. In addition, education was extended to include the completion of the baseline care plan to ensure it includes effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours the resident's admission. The in-service education and an acknowledgment statement of the baseline care plan was signed as an acknowledgement of comprehension, and a summary of the training material. Date of completion: 4/3/25 o The Regional Director of Clinical Operations immediately educated the Director of Nursing Services/Assistant Director of Nursing/Reimbursement Nurses on Abuse/Neglect and Residents Rights. The in-service education was signed as an acknowledgement of comprehension, and a summary of the training material. Date completed: 4/3/25 o Director of Nursing Services/Assistant Director of Nursing Services provided immediate education to all licensed nurses on the process of completion of admissions/readmissions in its entirety. In addition, education was extended to include the completion of the baseline care plan to ensure it includes effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours the resident's admission. Date commenced: 4/3/25 Date completed: 4/4/25 Community will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care. Risk Response: All new admissions/readmissions have the potential to be affected by this deficient practice. Systemic Response: o Director of Nursing Services/Assistant Director of Nursing conducted an audit for all resident's care plans who currently reside in the community to validate accuracy of each residents ADL care needs. Date completed: 4/4/25 o Director of Nursing Services/Assistant Director of Nursing Services provided immediate education to all licensed nurses on the process of completion of admissions/readmissions in its entirety. In addition, education was extended to include the completion of the baseline care plan to ensure it includes effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours the resident's admission. Date commenced: 4/3/25 Date completed: 4/4/25 Monitoring Response: o The Director of nurses/Assistant Director of Nurses will conduct weekly skills validations of accuracy and completion of admissions/readmission/baseline care plans of 2-3 nurses, 1-7 days a week for 2 months. o Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate accuracy and completion of admission/readmission/baseline care plans 1-7 days a week for 2 months. o This plan and all education and auditing tools will be placed in binder and kept with the Administrator or Director of Nursing Services. o This plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. o Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months. The Surveyor monitored the POR from 04/04/25 through 04/18/25 as followed: Review of the admission/readmission list for admissions from 03/03/25 to 04/03/25, reflected 26 charts were reviewed, on 04/03/25, for completion of the admission/readmission assessment and baseline care plan, with no additional findings. Review of the in-services dated 04/03/25 reflected the Regional Director of Clinical Operations educated the DON, ADON, and MDS nurse on validating completion of admission assessments, base line care plans with person-centered care being completed withing 48 hours of the resident's admission, and Abuse/Neglect and Resident Rights. Review of the in-service initiated on 04/03/25 and continuing 04/04/25, reflected the DON and ADON provided education to licensed nurses on the process of completing the admission/readmission assessment in its entirety and completion of the baseline care plan within 48 hours. Nurses from all shifts were in-serviced. During interviews on 04/04/25 from 4:17 PM to 6:22 PM, 4 LVNs and 3 RNs from both shifts stated they had been in-serviced on the [NAME], baseline care plans, and resident-centered interventions. The nurses were able to state the baseline care plans were developed within 48 hours after admission. The nurses stated the care plans included information, including fall interventions, needed to care for the residents. The nurses stated fall interventions included reminding the resident to use the call light to call for assistance, not leaving the resident alone in the room while up in a wheelchair, anticipating needs, and keeping items within reach. The nurses stated the [NAME] was like a guidebook or snapshot of care the residents needed. During an interview on 04/04/25 at 5:13 PM, the DON stated she had been in-serviced by the RDCO on baseline care plans. She stated the baseline care plans were completed within 48 hours and interventions, including fall interventions, were implemented. She stated she had been in-serviced on the process of validating the completion of admission/readmission assessments and ongoing monitoring. The information was discussed in the morning meeting to confirm the interventions were in place to meet the resident needs. The DON stated she had been in-serviced on ANE. She was able to speak to the policy. The DON stated after she was in-serviced, she and other administrative nurses in-serviced other nursing staff on the same topics. The ADM was notified on 04/04/25 at 7:15 PM that the IJ had been removed. While the IJ was removed, the facility remained at a scope of isolated an a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for accidents and supervision. The facility failed to ensure staff implemented Resident #1's hospital discharge order upon admission to be placed on fall precautions. The facility failed to develop and implement a baseline care plan with interventions within 48 hours of admission for Resident #1 that addressed her high fall risk status. The facility failed to complete an admission assessment and baseline care planning, and ensure staff had adequate knowledge and access to care plans. The facility failed to ensure effective use of the [NAME] system as a reference tool by failing to ensure adequate staff knowledge in the updating and referencing of the [NAME]. On 03/29/2025 Resident #1 was left unsupervised in her room which resulted in a fall from her wheelchair where she hit her head resulting in pain and nystagmus and was admitted to the acute care hospital. There was a likelihood of a serious adverse outcome for the resident due to multiple systemic failures. An IJ was identified on 04/03/25. The IJ template was provided to the facility on [DATE] at 3:11 PM. While the IJ was removed on 04/04/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeoopardy because all staff had not been trained on the plan of removal. This failure could place residents at risk for serious injury or harm due to lack of appropriate supervision. Findings included: Review of Resident #1's face sheet, printed on 04/02/25, reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged on 03/29/25. Her diagnoses included weakness, cerebral edema (brain swelling), nontraumatic intracerebral hemorrhage (brain bleed), acute respiratory failure with hypoxia (not enough oxygen in the body), and unspecified abnormalities of gait and mobility. Review of Resident #1's MDS assessment list reflected her admission, five day, and discharge assessments were all in progress. Review of Resident #1's baseline care plan, initiated on 03/29/25 and created on 04/02/25, reflected in part - Focus: I am at risk for falls r/t Balance problems noted, chronic health problem and comorbid medical problems, debility and weakness, cognitive impairment noted, difficulty moving / propelling self in w/c. 03/29/25 - actual fall, sent to ER. Goal: I will be free from falls and / or will not experience significant injuries associated with falls through next review date. Interventions/Tasks: Provide resident with no touch call bell. Do not leave resident alone in her room when she is up in her wheelchair. Anticipate and meet needs and keep call bell within reach as indicated. Bed at appropriate height when unattended . Review of Resident #1's acute care discharge orders dated 03/24/25, reflected and order, Place patient on fall precautions. Review of Resident #1's Order Summary Report printed 04/02/25, reflected no order for fall precautions. Review of Resident #1's Nursing admission assessment completed by RN B, 03/25/25, Section B (Clinical/Health Conditions) reflected the resident had comorbidities that included CVA (stroke) and Hemiplegia/Hemiparesis (weakness or paralysis on one side of the body). Section C (Physical Assessment) reflected the resident required a mechanical lift and two team members for transfers. Section E (Communication) reflected the resident was incoherent, unaware of her own needs and wants. Section K (Fall Risk Review) reflected recent falls were unknown, the resident was taking two of the medications listed, the resident appeared severely affected by one or more of the psychological factors listed, and her cognitive status was impaired. The Automatic High Risk Status: Box #1 was checked, Recent change in functional status and/or medications with the potential to affect safe mobility. Box #6 was checked, Check if the resident/patient is a high risk for falls. Section O (Initial and 48 Hour Plan of Care) reflected #10 Fall risk had no boxes checked - no focus, no goals, and no interventions. Review of Resident #1's progress note dated 03/27/25 at 10:00 AM, written by the NP, reflected in part, Patient demonstrates impulsivity and has made attempts to transfer self. She has been moved to room (number) for increased visibility by staff. Will continue to monitor cognitive status and implement safety measures. Review of Resident #1's progress note written by LVN D, reflected a late-entry note dated 03/29/25 at 11:30 AM, This nurse observed resident on floor in resident's room. Resident observed on floor face down and resident's wheelchair position on resident's upper back. Resident stated, I hit my head and face. Head to toe assessment completed and nystagmus (rapid eye movements) observed and resident alert and oriented x2 and some confusion noted of situation. Check for head injuries, nystagmus noted, EMS was called no redness or bruises to resident's face or head .Resident feels pain on left side of face and head .transported to (hospital) for evaluation and treatment. Review of a physician progress note from the acute hospital, dated 04/01/25, reflected Resident #1 presented from another hospital ED on 03/29/25 due to persistent left side weakness, left facial deficits, and bleed ing noted. She was admitted for evaluation of new bleed vs residual findings. Case and imaging reviewed with stroke neurology and findings determined to be expected findings of the recent CVA. Review of Resident #1's [NAME] (the information used by the aides that provides key information such as safety, eating, mobility, and ADL assistance) printed on 04/04/25, reflected in part - Special Instructions: Resident must be up in dining room for meals. Do not leave alone with any food or drinks. Asperation [sic] precautions. Safety - I must be up for all meals. The [NAME] did not reflect any fall precautions. During an interview on 04/02/25 at 1:28 PM, the MDS Nurse stated the admitting nurse was responsible for initiating the baseline care plan. She stated the baseline care plan should include the fall risk and interventions. She stated the residents could fall and get injured if the information was not documented in the care plan or [NAME]. After review of Resident #1's [NAME] she stated there were no interventions listed to prevent falls. During an interview on 04/02/25 at 1:49 PM, RN B stated she had completed the admission assessment on Resident #1. She stated she was the treatment nurse at the facility and did not routinely conduct admission assessments. She stated she believed she had marked the box indicating the resident was a high fall risk. She stated she believed that checking that box would trigger the fall risk to go to the baseline care plan and [NAME]. She stated she did not know how to open the care plan to even see what was on the care plan. She stated the fall risk would be passed on in report and the CNAs would have the information on the [NAME]. She stated she did not have all the information needed to complete the assessment and believed the management team would have reviewed and completed the admission assessment including the baseline care plan the next day. During an observation and interview on 04/02/24 at 2:15 PM, CNA A was observed as she signed into the computer and opened a [NAME] for a current resident. She stated she did not see Fall Risk on the [NAME]. She opened six more records of residents who she knew had fallen and did not see where the residents were identified as a fall risk. She stated they usually got fall risk information in report every morning from the nurse. She stated she had assisted another CNA with Resident #1 before she was transferred to the new room. She stated the resident required two staff and a mechanical lift for transfers. During a telephone interview on 04/02/25 at 3:05 PM, the hospitalist (doctor) caring for Resident #1 at the acute hospital stated it was his first day working with her and he had briefly reviewed the neurology notes before calling. He stated he was not sure what caused the fall, but she had a known bleed. He stated with her diagnosis of amyloid angiopathy (a buildup of proteins in the walls of the blood vessels in the brain), she would continue to have bleeds in the future. During an interview on 04/02/25 at 3:22 PM, the DON stated, Everyone who comes in this building was a fall risk, especially for the first three days and for three days after a room change. She stated Resident #1 admitted on [DATE] and they moved her to a different room on 03/26/25. She stated the resident was moved to a room closer to the nurses' stations so she could be monitored more closely. She stated it was her expectation that fall interventions were in place for all residents. She stated the nurses would see the interventions on the care plan and the CNAs would see the interventions on the [NAME]. She stated Resident #1 did not have fall interventions on the care plan or [NAME], but they had moved her room and given her a touch call light and those were some of the interventions . She stated she had in-serviced staff multiple times, and the CNAs all knew that everyone was a fall risk. The DON stated she had educated on the need to get the residents out of their rooms and engaged as residents were at risk for falls left alone. She stated when the resident fell, the nurse noted nystagmus which was a change, so she was sent out to the hospital. During an interview on 04/03/25 at 10:15 AM, the NP stated it was important to have fall interventions in place. Without the interventions, a resident could fall and get injured. The NP stated while the resident was at the facility, her orientation waxed and waned. She stated the resident was impulsive and not always cognizant of her surroundings. She stated the resident was a fall risk because she made attempts to get up unassisted and did not follow commands. She stated she had read the notes from Resident #1's fall on 03/29/25. She stated she was not on call that day and did not assess the resident after the fall. She stated it was reported that the resident had nystagmus after the fall, and she did not have nystagmus prior to the fall. She stated the resident had a seizure in acute care, and a seizure could have caused the nystagmus. She stated a fall with a head injury could also cause nystagmus. During an interview on 04/03/25 at 10:41 AM, LVN D stated she was aware that Resident #1 was a fall risk because of the report she received from the previous shift. She stated the resident required assistance with transfers and used a mechanical lift which put her at risk for falls. She stated the resident was moved to her hall, so the resident had a room closer to the nurse's station and was more visible. She stated the resident needed frequent visual checks and supervision with meals due to aspiration precautions. She stated on 03/29/25, she heard Resident #1 call out for help and went to the room where the resident was found on the floor, face down. She stated the wheelchair was nearby and the mechanical lift sling was still in the wheelchair. She stated the resident could not say what had happened but complained that her head/face hurt and pointed to the left cheekbone . She stated CNA E and NA C worked the day of the fall. LVN D stated if a resident hit their head during a fall, it could have caused a head injury. A telephone interview was attempted on 04/03/25 at 11:52 AM. A voice message was left for CNA E, but the call was not returned prior to the survey exit. During a telephone interview on 04/03/25 at 11:56 AM, NA C stated she had worked at the facility about a month. She stated worked with Resident #1 on the day she fell. She stated she helped a CNA and a nurse get the resident up with the lift. She stated the resident was up in her wheelchair and her family member was visiting in the room. She stated she did not know when the family member left the room or how long the resident was alone in the room. She stated the nurse or other CNA told her who was a fall risk when she worked. She stated Resident #1 wore grippy sock the day of the fall but did not remember other fall interventions in place. During an interview on 04/03/25 at 1:03 PM, the DON stated she or the other administrative nurses entered the orders into their computer system for new admissions. She stated she did not remember ever seeing an order for a resident to be on fall precautions but if she had seen that order, she would have placed the resident on fall precautions. The DON stated Resident #1 fell because she had a seizure and that was why she had nystagmus . She stated there was no other head injury. She stated she had not witnessed the fall or a seizure because it happened on the weekend. During a telephone interview on 04/04/25 at 12:19 PM, the NP stated she could not answer if a fall where the resident hits their head could exacerbate or worsen the bleed the Resident #1 already had. She stated she did not see or examine Resident #1 after the fall, so she was not aware of any injuries or bruising from the fall. She stated the neurologist would have been more able to answer that question. During a telephone conversation on 04/04/25 at 12:29 PM, the receptionist at the neurology department of the acute care hospital transferred the call to the patient relations department. A voice message was left requesting a return call. During a telephone conversation on 04/04/25 at 2:31 PM, a staff member from the patient relations department at the acute care hospital returned the call. He stated he would send the request to speak with Resident #1's neurologist to the head of the neurology department. A return call from a neurologist was not received prior to the survey exit. Review of the Falls Prevention Guideline, updated 03/28/22, reflected in part, Purpose - To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls. Process - On admission - - Newly admitted or re-admitted residents are assessed for fall risk. - When a risk factor for falls is identified a corresponding intervention addressing that risk factor is developed. - When the risk is identified and intervention determined, it is documented on the care plan and on the [NAME]. - The intervention is initiated. An Immediate Jeopardy (IJ) was identified on 04/03/25. The ADM, DON, and RDCO were notified of the Immediate Jeopardy on 04/03/25 at 3:11 PM and a IJ template was provided to the ADM on 04/03/25 at 3:11 PM. Review of a physician progress note from the acute hospital, dated 04/03/25, and received after the IJ was called, reflected in part, Patient was trying to get up out of her wheelchair felt dizzy and fell hitting the right side of her head . Resolving known R temporal IPH, no new hemorrhage . A Plan of Removal was accepted on 04/04/25 at 3:26 PM and read as follows: Plan of Removal 4/3/2025 Immediate Jeopardy 4/3/2025 F689 Accidents and Supervision The facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents. Immediate Response: o Resident #1 no longer resides in the community. o Physician notification by licensed nurse of the fall Date completed: 3/29/2025 o Responsible party notified by licensed nurse of the fall Date completed: 3/29/2025 o Resident sent to the hospital. Date completed: 3/29/2025. o Director of Nursing Services/Assistant Director of Nursing Services/Registered Nurse Assessment Coordinator conducted a 100% Audit of all residents who reside in the community to review Fall Risk Assessments. All residents identified as a fall risk care plans were reviewed to ensure person centered interventions were in place falls and no other residents/patients identified. Date completed: 4/3/2025 o Director of Nursing Services, and administrative nurses provided immediate education by way of in-service. The in-service education was signed as an acknowledgement of comprehension, and a summary of the training material for the nurse involved in completing the resident's admission and all other nurses on Abuse Neglect, Residents Rights, initiating interventions to prevent a fall and Fall Prevention Guidelines. All admissions will be reviewed during daily clinical connect meeting to ensure interventions are initiated to prevent a fall for those residents identified as a fall risk by Director of Nursing Services/Designee. Date completed: 4/3/2025 and ongoing. o The Director of Nursing Services/Administrative Nursing is responsible for ensuring compliance and oversight of monitoring and education to ensure compliance. o The Director of Nursing Services/Administrative Nurses initiated education by way of in-service. The in-service education was signed as an acknowledgement of comprehension, and a summary of the training material to all nurses on initiating interventions to prevent a fall, Fall Prevention Guidelines, Resident Rights, Abuse and Neglect. o Direct care team to include licensed nurses, certified nurse assistants, certified medication aides, and nurse aides in training educated on review of the [NAME] before providing care to all residents assigned to them to ensure proper assistance and interventions are utilized according to the resident's need and adherence to the resident's plan of care. Reporting any concerns or inaccuracies to the charge nurse/licensed nurse for additional direction prior to care provided. The expectation is for all direct care staff to include licensed nurses, certified nurse assistants/certified medication aides/nurse aides in training to review the [NAME] prior to providing care. o Licensed nurses will initiate interventions to prevent falls for those identified as a fall risk upon admission and/or as indicated. o All nursing staff will receive the in-service prior to working next shift. o All newly hired nursing staff will receive in-service training prior to assuming shift responsibility during orientation process. o All agency nursing staff will receive in-service training prior to assuming shift responsibility. o Director of Nursing Services/Administrative nurses conducted 100% skills validation all nurse aides in training and certified nurse assistants of accessing the [NAME] by Date completed: 4/3/2025 and ongoing Community will ensure all staff on leave/agency staff /PRN/new hires staff are in serviced prior to working their shift. No licensed nurse, nurse aides in training and certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the [NAME]. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. To include licensed nurses, nurse aide in trainings and certified nurse aides. Risk Response: All residents who currently reside in community potentially can be affected by the deficient practice. Systemic Response: o Director of Nursing Services/administrative nurses provided immediate education to direct care team to include licensed nurses, certified nurse assistants, certified medication aides, nurse aide in training on: Fall Prevention Guidelines/Abuse Neglect/Residents Rights, [NAME] Use prior to providing care to the residents. Date completed: 4/3/2025 o Director of Nursing Services/Administrative Nurses is responsible for ensuring compliance and oversight of monitoring and education to ensure compliance of education. All Nursing Team Members including PRN/Agency/New Hires were educated on providing care to residents and were re-educated/re-trained by the Director of Nursing/administrative nurses on the following: o Review of the [NAME] before providing care to all residents assigned to them to ensure proper assistance and interventions are utilized according to the resident's need and adherence to the resident's plan of care. Reporting any concerns or inaccuracies to the charge nurse/licensed nurse for additional direction prior to care provided. o Licensed nurse will initiate interventions to prevent falls upon admission and as indicated for those that are at risk for falls. o Director of Nursing Services/Administrative nurses conducted 100% skills validation to direct care staff to include certified nurse assistants, certified medication aides, and nurse aides in training on accessing the [NAME] Date completed: 4/3/2025 and ongoing. Community will ensure all staff on leave/agency/PRN staff /new hires are in serviced prior to working their shift. No licensed nurse, certified medication aide or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the [NAME]. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires Monitoring Response: o Director of Nursing Services/Administrative nurses will review Admission/readmission Assessments 5-7 days a week in the Daily Clinical Connect meeting to ensure residents/patients that are at risk for falls have interventions in place to prevent falls and documented using a monitoring tool. o The Administrator/Director of Nursing Services will conduct random audits of 3 care plans review a week for 4 weeks and 1 care plan review weekly for 8 weeks to validate fall intervention care plans are in place for residents/patients at risk for falls. o The Director of Nursing Services/Administrative Nurses/Designee will conduct random skills validations regarding [NAME] use 3-7 days a week for 2 months to ensure direct staff is compliant with the use of the [NAME]. o Policies are followed to ensure the safety and wellbeing of our residents. Additional education will take place based on needs observed during this process. All findings will be reported to the QAPI committee during monthly meeting until there is 100% compliance observed during observations. The Surveyor monitored the POR on 04/04/25 through 04/18/25 as followed: During interviews on 04/04/25 from 4:17 PM - 7:05 PM, three RNs, four LVNs, and 9 CNAs from all shifts stated they were in-serviced before their shifts on fall precautions, falls, using the [NAME], and abuse/neglect. They all stated the [NAME] was to be reviewed prior to providing care to know what type of care the resident required and any precautions identified. They stated they could also utilize the residents' care plans for that information. Staff reported fall interventions including reminding the resident to call for assistance, call light within reach, bed in low position, and non-slip socks. Staff stated performing frequent rounds, anticipating needs, and getting residents up and in common areas. The staff were able to speak to the abuse and neglect policy and name the ADM as the abuse coordinator. During an interview on 04/04/25 at 5:13 PM, the DON stated she was in-serviced by the RDCO on baseline care plans. She stated the baseline care plans were completed within 48 hours and interventions, including fall interventions, were implemented. She stated she had been in-serviced on the process of validating the completion of admission/readmission assessments and ongoing monitoring. The information was discussed in the morning meeting to confirm the interventions were in place to meet the resident needs. The DON stated she had been in-serviced on ANE. She was able to speak to the policy. The DON stated after she was in-serviced, she and other administrative nurses in-serviced other nursing staff on the same topics. The DON stated she would be reviewing all admission/readmission assessments going forward to ensure all interventions for falls were place. She stated she would also be conducting audits frequently on care plans to validate the fall interventions. During an interview on 04/04/25 at 5:47 PM, the ADON stated she was in-serviced by the RDCO on the process that validated the completion of admission/readmission assessments including head to toe assessment and baseline care plan to ensure interventions were in place. She stated she was in-serviced on abuse and neglect and was able to speak to the policy. Review of the Fall Risk Assessment audit dated 04/03/25, conducted by the administrative nursing staff, reflected the residents identified as a fall risk had interventions in place. Review of in-service education conducted by the administrative nursing staff, dated 04/03/25, reflected licensed nurses, CNAs, MAs, and nurse aides in training, were in-serviced on Fall Prevention Guidelines, Abuse and Neglect, Resident Rights, and [NAME] use. Review of the skills validation, conducted by the administrative nursing staff, dated 04/03/25, reflected nurse aides in training and CNA were able to demonstrate access to the [NAME]. Review of the undated Monitoring Tool reflected the form used for monitoring fall risk interventions in place for admissions/readmissions. During observations of residents, including newly admitted residents on 04/18/25 between 12:35PM and 1:12 PM , revealed beds in low positions, call lights within reach, anti-slip strips on the floor, and clear, uncluttered pathways in the rooms. Review of the care plans and [NAME] of residents observed on 04/18/25, reflected fall interventions in place on the documents matched the interventions observed. The ADM was notified on 04/04/25 at 7:15 PM that the IJ had been removed. While the IJ was removed, the facility remained at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for treatment of pressure ulcers. The facility failed to recognize and provide treatment, and prevention measure for an open skin area on Resident #1. The area was first noted on 6/25/24 with admission, the first documentation of care being provided to the area was on 7/7/24. On 7/10/24 Resident #1 was diagnosed with a stage III pressure injury (a full thickness loss of skin extending to the subcutaneous tissue). The noncompliance was identified as PNC. The IJ began on 06/25/24 and ended on 07/26/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at increased risk of a wound infection and delay the healing process. Findings included: Review of Resident #1's Face sheet, undated, revealed he was admitted to the facility on [DATE] from a local rehabilitation hospital, with diagnoses including infarction with hemiplegia (paralysis on one side) and hemiparesis (partial paralysis or weakness on one side), depression and PTSD. Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 11 indicating his cognition was moderately impaired. Section M of the MDS indicated Resident #1 has one unhealed pressure ulcer/injury. Review of Resident #1's Care Plan revealed an area of focus initiated 6/25/24 (date of admission) at risk for skin impairment with actual sites on feet and coccyx. Review of Resident #1's PCC Skin &Wound Total Body Skin Assessments, dated 6/25/24, question #6 Enter the # of New Wounds, the number entered was 0. Review of Resident #1's admission assessment, dated 6/25/24 notes an open wound to his coccyx, circular and approximately 3x3x0.3 cm with an irregular border. Review of Resident #1's Progress Notes from 6/25/24 through 7/26/24 revealed an admission note on the following dates: 6/26 NP A notes included a new admission note. The Review of Systems section includes Skin/Breast: No reported skin issues. 6/28 NP A notes an acute/follow-up visit the assessment note has the Review of System section includes Skin/Breast: No reported skin issues. The Physical Exam section includes Skin: Inspection: no rashes or ulcers. 7/2 The Facility MD noted he had conducted an initial H&P. The Review of Systems section includes Skin/Breast: No reported skin issues. 7/3 A medication administration note for pain medication notes Resident c/o pain during wound care treatment, unable to describe or rate. PRN given. 7/7 A medication administration note for WC TO COCCYX-CLEAN WITH NS OR WOUND CLEANSER-APPLY COLLAGEN, ALGINATE AND COVER WITH PROTECTIVE DRESSING. CHANGE DAILY. 7/9 NP A notes an acute/follow-up visit the assessment note has the Review of System section includes Skin/Breast: No reported skin issues. The Physical Exam section includes Skin: Inspection: no rashes or ulcers. 7/10 Nurse noted Resident was seen by the [wound care] NP for wound care consult today. 7/11 NP A notes an acute/follow-up visit, the summary includes Appears to be in moderate distress. When asked patient stated that he was in significant pain. Pain level 9/10. 7/16 NP A notes an acute/follow up visit, the summary includes Reports from nursing about intermittent noncompliance with nursing care specifically dressing changes for his pressure ulcer. This is of greatest concern as he has a worsening stage III pressure ulcer to the sacrum. 7/22 NP A notes an acute/follow up visit, the summary includes Shared with patient that results from wound culture returned positive for bacteria. Wound care NP will follow up regarding treatment. 7/23 Nurse notes Called [medical services provider] at this time for midline placement [catheter placed in vein for intravenous access] order. 7/23 Nurse notes Resident had Midline placed to his left basilic vein this afternoon and will start IV ABT in the morning. 7/25 Social services notes include SW had another careplan meeting with [RP's name]. In attendance: Administrator, DNS, Activities, Therapy, Dietary, MDS nurse, Wound Care and SW All aspects of patients care was discussed and medications reviewed. Nursing tried to explain the current state of Resident #1's wound and the lack of healing being seen. Nursing tried to explain the current state of [Resident #1's] wound and the lack of healing being seen. 7/26 nurse noted Resident #1 was transferred to the ED per PR request. Review of Resident #1's Order Summary Report, from 6/25/24 to 7/27/24 revealed the following regarding wound care: -7/6 WC to coccyx-cleanse with NS or wound cleanser, apply collagen, alginate (alginic acid) and cover with a protective dressing. Change daily, every dayshift. -7/17 Wound panel (detects pathogens found in infected wounds) lab, collected 7/17/24. -7/17 WC to coccyx-cleanse with Dakin's (sodium hypochlorite)or vashe (hydroporic acid) wound cleansers, apply Santyl (collagenase) & honey to slough (yellow tissue on wound bed), apply collagen powder to granulation(new tissues in wound), cover with alginate sheets, cover sacral foam dressing and foam dressing, apply barrier cream to peri wound (skin around wound) every day, night shift and if soiled. -7/23 Imipenem/cilastatin (antibiotic that interferes with bacterial cell walls) intravenous solution reconstituted 500mg. Use one application intravenously four times a day for infection for 10 days. -7/24 Stat x-ray (electromagnetic radiation used to generate an image) of sacrum coccygeal (relating to coccyx) 3 view to rule out osteomyelitis(bone infection). -7/24 WC to coccyx-cleanse with Dakin's or vashe wound cleansers, apply Santyl & honey, pack with alginate sheets, cover with sacral foam dressing, apply barrier cream with collagen powder to peri wound every day, night shift and if soiled. Review of Resident #1's MAR for July 2024 revealed on 7/24/24 an order was added, Imipenem-Cilastatin Intravenous Solution Reconstituted 500MG. Use one application intravenously four times a day for infection for 10 days. Review of Resident #1's TARs for June 2024 contained No order data found for TREATMENT ADMINISTRATION RECORD. There was no monitoring by nursing included for area identified to buttocks. July 2024 had entries for coccyx wound care starting on 7/7 WC TO COCCYX-CLEANSE WITH NS OR WOUND CLEANSER-APPLY COLLAGEN, ALGINATE AND COVER WITH PROTECTIVE DRESSING. On 7/13 and 7/14 there are blank areas with no initials indicating wound care had not occurred. -On 7/17 new orders were implemented: WC TO COCCYX- cleanse with Dakin's/vashe, Apply Santyl & honey to slough, apply collagen powder to granulation, cover with alginate & foam dressing, Apply barrier cream to peri wound. Every day and night shift. -On 7/24 a new order was implemented WC TO COCCYX cleanse with Dakin's/ vashe, apply Santyl & honey, pack with alginate sheets, cover sacral foam dressing. Apply barrier cream w/[with] collagen powder to peri wound. every day and night shift. Continued review revealed the same order written for as needed changes if soiled. Review of the Wound Care visit reports written by the Wound Care NP revealed the following: 7/10/24 initial visit reveals, Patient is being seen today for evaluation of a wound to his coccyx. Per nursing patient has been non-compliant with turns and has been refusing care. As a result, patient has developed a wound. The active problem lists, and the diagnoses section contain, Pressure ulcer of the sacral region. The physical exam section includes Wound #1 is a Stage 3 Pressure Injury Pressure Ulcer and has received the status of Not Healed. Initial wound encounter measurements are 4cm length x 3.5cm width x 0.2cm depth, with an area of 14 sq cm and a volume of 2.8 cubic cm. There is a moderate amount of Sero-sanguineous drainage [blood and serum] noted which has a Mild odor. Wound bed has 1-25%, granulation, 26-50% slough, 1-25% epithelialization[ the process of repairing epithelial tissue]. 7/17/24 follow-up of a wound to coccyx includes, Very strong odor noted to patient's wound this visit with increased dimensions. The NP noted that a wound panel is being collected. Wound Assessment section includes wound measurement of 7cm in length x 7.2 cm width x 0.3cm depth, with an area of 50.4 sq cm and a volume of 15.12 cubic cm. There is a Moderate amount of sero-sanguineous drainage noted which has a strong odor. Wound bed has 1-25 % ,granulation, 26-50 % slough , 1-25% epithelialization. The wound is deteriorating. 7/24/24 follow-up to a wound visit includes, Significant deterioration noted to patients wound this visit. [Resident] was started on IV Imipenem 500 mg q 6hrs x10 days yesterday based on findings from recent wound panel. An x-ray is being ordered this visit of patients sacrococcygeal region to r/o[rule out] OM[osteomyelitis]. Measurements of the wound are 8.2 cm x 7.6cm x 3.4 cm depth with an area of 62.32 sq cm and a volume of 211.888 cubic cm. There is a Moderate amount of purulent [pus/excudate fluid indicating an infection] drainage noted which has a strong odor. Wound bed has 1-25 % ,granulation, 51-75% slough , 1-25% epithelialization. The wound is deteriorating. Review of the local hospital Emergency Medicine note, dated 7/26/24, notes an ED clinical impression of a skin ulcer of sacrum with necrosis [death of body tissue] of muscle. And Patient will be statused as inpatient due to sacral ulcer and osteomyelitis. During an interview on 7/27/24 with the FM at 10:10am revealed at the time of admission the plans were to have Resident #1 in a nursing home till he became strong enough to come home with home health. The FM stated now instead of stronger he was weaker. He has developed an infected wound that goes down to the bone due to the facility not taking care of the area. The FM stated she was at the facility frequently and no one told her about the condition of this wound. When Resident #1 was admitted into the facility the area was the size of a thumbnail now it was the size of a palm. The hospital has already done surgery once and was discussing if a second surgery was needed. During an interview on 7/27/24 at 1:15 pm LVN C she stated she was an agency nurse and has been a while since she has worked at this facility. She was notified by the agency and the facility that she needed to complete in-services prior to working the floor. She already knew but the in-services stated the charge nurse was to do wound care if there was not a wound care nurse. When an assessment was done it has to be accurate and from an eye on description of the resident's skin. For any issues, the size needs to be documented. LVN C stated he nurse was to notify the NP or MD of any new changes or issues They will know, whether there is a change, by reviewing the orders and previous documentation. During an interview on 7/27/24 at 2:08pm the WC Nurse/LVN revealed although she was an agency nurse she has started recently as the wound care nurse, she works weekdays M-F. The WC/LVN stated the facility was now assigning someone to do wound care treatments on the weekend. She stated she was not providing wound care to Resident #1 until sometime at the end of or after the first week in July. She stated prior to that she was not aware that he had a wound. The WC/LVN stated when she became aware, she began treatments, the NP and Physician had been notified and she had orders for the treatment. She assessed the wound and noted the size. The WC NP was notified about the wound soon after she had been notified. The WC Nurse/LVN stated she received in-services on July 26th on what to do if the wound care nurse was not available. She stated inservices included that admissions must have a thorough assessment and they need to report any issues to the NP or MD. If no response from NP or MD they are to notify the DNS. Everything must be documented. The WC/LVN stated she will be assisting the DNS with doing second assessments on new admissions to make sure initial assessment was accurate. During an interview on 7/27/24 at 2:51pm with the WC/NP revealed he became aware of Resident #1's wound on 7/7/24. He stated he does not provide wound care on all skin issues so the wound may not have been significant enough to report to him earlier for care. In meeting Resident #1 and the nurses reports he believes part of the issue was that the resident was noncompliant with care which allowed the wound to progress. When the WC/NP saw it for the first time on 7/10/24 it was a stage III because he saw subcutaneous tissue, since then it has become progressively worse. On 7/17/24 the wound had declined and had a strong odor. He had ordered a wound panel and changed the wound care orders. On 7/24/24 it had again deteriorated, and the wound was unstageable. The WC/NP stated he ordered an x-ray to rule out osteomyelitis and an intravenous antibiotic. The x-ray did not show evidence of osteomyelitis. The WC/NP stated he did not feel Resident #1 needed to go to the hospital as they were providing treatment there at the facility. The wound may have been different if he started treating the area sooner but the first time that he assessed it there was no infection so it probably would have concluded with the same results. During an interview on 7/28/24 at 3:10pm with LVN D stated they have had all kinds of in-services since yesterday. She was an agency nurse. LVN D stated she did work with Resident #1, he was not always willing to cooperate with what they needed to do. She does recall doing dressing changes for Resident #1 stating there were orders on treatment when she worked with him. They all got notification yesterday from the agency to review in-services and that they cannot work until sign all in-services. The in-services were on assessments, doing accurate descriptions size, shape, location, and condition. On Admissions the MD and/or the NP must be notified of any skin issues and orders obtained to monitor at minimum. The RP must be notified of any issues. During an interview on 7/28/24 at 3:19pm with RN B revealed she was not an agency nurse. She stated she was the only nurse working today that was not agency. She believes that maybe part of the problem with communication in the case of Resident #1. RN B stated she believes that the bandages were being changed daily but the problem was there was no documentation indicating that was occurring. The nurse admitting Resident #1 should have notified the NP or MD about the site and documented the notification. Every nurse, including agency nurses was given in-services yesterday and every resident was assessed for skin issues whether the skin assessment was due or not. There were no other skin issues identified. The in-services were over admissions, assessments and accuracy, NP or MD notification. During an interview on 7/28/24 at 3:30pm with LVN E revealed she was an agency nurse. She stated she was notified yesterday that to work here she had to take several in-services. LVN E stated the in-services were very detailed. They included admission details and assessments must be accurate and notify the MD or NP and family of any skin issues. Document description and that the notifications were made. During an interview on 7/28/24 at 3:18 pm with the facility DNS when asked if she could provide any documentation regarding interventions and/or precautions put in place at admission to monitor skin area identified, she stated it was being done but the nurses were not documenting it. It was not included on the TAR at admission. The DNS stated the weekend supervisor notified her on 7/6/24 of the wound she found during her assessment. New orders for wound care were added to TAR on 7/7/24. Wound Care NP saw on 7/10/24. Her expectation and the in-services/training they have provided includes the admission nurse notifying the NP or MD of any skin issues at the time of admission. The initial assessment must include specific descriptions and measurements of the area of skin issues/wounds. The nurse can initiate standing orders that can be used for all residents. Once the area was resolved it can be taken from the TAR. In this case she believes the wound care was occurring but was not being documented regularly and was not on the TAR. On 7/3/24 a nurse documented Resident #1 complained of pain during a dressing change. The DNS pointed out that the wound was not infected when first identified and when first seen by the wound care NP. The weekly skin assessments ask for new wounds the existing wounds should be being monitored for any changes. She and the LNAC will be doing random audits of skin assessments and treatments to verify the assessment is correct. With each new admission an assessment will be conducted by herself, the LNAC or the wound care nurse to ensure the accuracy of the admission nurses' assessment. All new admissions were discussed in the morning meetings. She and the LNAC will review skilled nurses' notes at each of the morning meetings for appropriate documentation. During an interview on 7/28/24 at 11:36 am with the facility LNAC/LVN revealed that they were going to review every new admission in morning meeting which happens 5 days a week if a new admission comes in on the w/e they will call the nurse. We are going to make sure they MD or NP because they must verify orders and if there was any wound. Me and/or the DON will be doing an eye on skin assessment by one of us. Measurements are done if they are pressure ulcers, and they would be on our wound care sheet. Done weekly. admission nurse cannot say pressure ulcer or stage the wound, but the area should be described in detail. They will also be randomly checking 3 people a week for any new skin issues by doing a skin assessment. During an interview on 7/28/24 at 10:18am with the facility NP A revealed she did not recall if she signed off on the admission orders for Resident #1 or if it was the Doctor. She stated she did recall that the admission paperwork was scarce with the minimal amount of information. NP A stated her initial skin assessment was her assessing Resident #1 as he sat in a chair, he was not compliant with a full assessment. Her progress notes were based on her assessment and the nurses' assessment, she would ask him every time she saw him and all other residents do you allow me to do my assessment today. NP A stated she first saw the wound via a picture that the wound care nurse had taken. She does not recall the date, but it was documented in her progress notes. NP A stated she had ordered a full panel lab, but it was not able to be done because Resident #1 refused the lab draw. Nursing assessment do expect that the nurses do an eye on assessment. NP A stated she has been told that hers need to be eye on assessments too, which she was already doing unless the resident refuses. Her expectation was that if a resident has an open area it needs to be reported to her or the doctor as soon as it was noted, they could have implemented interventions sooner as opposed to addressing a declining condition. NP A stated she thinks it was a possibility that they could have prevented the wound from the current state. She was surprised about finding out about the wound initially when it was at a stage III. NP A stated she thinks that part of the problem was nursing staff were constantly agency nurses, it was a hit or miss on whether they report issues.NP A stated she was surprised by this situation but not surprised at the same time. NP A stated they had addressed the wound not being reported way before Friday the 7/26, was at the beginning of the week before or around 7/17. During an interview on 7/28/24 at 9:11am with the facility DCO/Regional Nurse stated that the nursing staff had known Resident #1's pressure ulcer was declining. A chart review occurred because Resident #1 was going to the hospital at the family's request. When they reviewed the EHR they realized that there was not a treatment order in place at the time of admission. The Charge Nurse on duty at the admission should have done a head-to-toe assessment and reported to the NP or MD and the family of the skin issue. An appropriate plan of care could have been implemented, which may have included orders to treat. The DCO stated they did address that the skin concern needs to have an accurate description including size and description, documentation of notification of the physician and weekly skin assessments. The in-service training included correct accurate documentation and the wound being included on the skilled notes. The DNS has let nursing staff know the expectation was that they do an eye on assessment. The DNS will review and then validate the correctness of the assessment by eye with a head-to-toe assessment of her own, validating notification and documentation of notifications. The DCO stated the MD was told what they were in servicing on, he attended the Ad-hop QAPI meeting on 7/26 where the issues identified in the 4-step plan was reviewed. The DNS stated she became aware of the issue on 7/7 that there was no documentation of wound care. The DCO stated she was not sure what all the DNS did after the 7th. From this point on they will be in servicing for at least the next two months each nursing staff before they work. She comes in to validate that the processes were in place and was typically there on a weekly basis. During an interview on 7/28/24 with the MD at 11:05 am revealed he became aware of the pressure ulcer Resident #1 had when the NP started providing care. The wound was a stage III when he was notified, he was shocked because that was a significant wound. The MD stated he gave orders for the WC NP to treat the wound. The MD stated he was at the facility weekly, his role was more of an Administration role but will see the residents within the first 5 days usually. He was at an Ad-Hoc QAPI meeting on 7/26 regarding this situation and the training that needed to occur. His expectation was that the appropriate care was documented and that the nurses do eye on assessments and notify him or the NP of any skin care issues/open areas. The MD stated they possibly could have prevent Resident #1's wound from worsening had they had known about it earlier. During an interview on 7/28/24 at 11:19 am the Administrator revealed she became aware of the severity of the nursing issues at the point the DNS became aware of the issues. The Administrator stated she does not know of any documentation by the DNS. She oversees the DNS and was her supervisor. The DCO supervises in respect to training and guidance. The Ad-Hoc QAPI meeting they reviewed the 4-point areas of nursing needing to be addressed. The in-services were sent out to all staff and the nursing agencies that they use. All were informed the in-services were to be completed prior to working a shift. Review of the Facility Skin and Wound Prevention and Management policy dated 3/14/19 revealed the Guideline statement includes, Each resident will receive the care and services necessary to retain or regain optimal skin integrity. The Skin Prevention Program will: Identify associated risks for alteration in skin integrity or development of pressure ulcer injuries. Identify early onset skin breakdown so that the IDT may implement appropriate interventions as clinically indicated. Implement interventions designed to stabilize, reduce, or remove underlying risk factors. Ongoing evaluation of the plan of care and modifying or changing interventions as appropriate. Guidelines include, Assessment of a resident's skin condition helps determine prevention strategies. Review of the facility's Ad-Hoc QAPI agenda, dated 7/26/24, reflected the ADM, DNS, MD, and key nursing leadership were in attendance. They discussed notification of change in condition and Skin Management. A 4 Step Plan was initiated on 7/26/24. Review of facility 4-points, 7/26/24 It is the policy of this community to provide safe and quality nursing/medication administration practices to minimize and/or prevent less than quality of care provided to the residents we serve. 1. Resident not currently in the community. 2. 100% skin assessments completed on all residents. Skin assessments updated. Outcome: No negative outcomes identified. Completed 7/26/24 3. Education provided to all licensed nurses related to the process for system management to include: Administrative nurses (DNS and Nurse Leader LNAC received re-education by the DCO (Regional Nurse) ensuring that identified new admissions treatment orders are verified with the accepting MD/NP upon admission/readmission, communicating changes in condition to the medical provider, to include newly identified and/or deteriorating wounds. Thus, ensuring appropriate documentation of the identified wound status and medical provider's wound care orders are noted within the E.H.R accordingly. Date completed 7/26/24. Administrative nurses( DNS and Nurse Leader LNAC received re-education by the DCO (regional nurse) on the importance the administrative nurses will notify the charge nurses on shift of their responsibility to administer wound care and complete assigned skin assessments for that shift in the event the wound care nurse calls off shift. DNS (Director of nursing will monitor this process to validate appropriate communication and to ensure patient care needs are met. DNS (director of nurses) educated the licensed nurses on ensuring that identified new admission treatment orders are verified with the accepting MD/NP upon admission/readmission, communicate changes in condition to the provider to include newly identified and/or deteriorating wounds. Thus, ensuring appropriate documentation of the identified wound status and medical provider's wound care orders are noted within the E.H.R accordingly. Date completed 7/26/24 and ongoing. DNS (director of nurses) educated the licensed nurses on the importance the administrative nurses will notify the charge nurses on shift of their responsibility to administer wound care and complete assigned skin assessments for that shift in the event the wound care nurse calls off shift. DNS (director of nursing will monitor this process to validate appropriate communication and ensure patient care needs are met. Date completed 7/26/24 and ongoing. DNS (director of nurses) educated the licensed nurses on clinical documentation review upon admit/readmit noting pressure injury/skin concerns identified. A full body skin assessment -intentionally assessing the resident head to toe for evidence of any pressure injury or skin concerns identified. Completed 7/26/24 and ongoing. DNS (director of nurses) educated the licensed nurses on the Braden Risk Assessment to be completed by the assigned nurse upon admission, significant change of condition and quarterly reviews in addition to routine re-assessment the Braden Risk Assessment will be completed upon identifying a new onset of pressure related skin injury. Completed 7/26/24 and ongoing. DNS (director of nurses) educated the licensed nurses on conducting weekly skin assessments/evaluations shall be completed upon admission/readmit at least every 7 days thereafter and as clinically indicated thereafter. Head to toe skin assessments -consist of conducting a head -to-toe skin assessment to identify actual skin concerns, such as a pressure injury or other skin concerns. After completing the assessment, the nurse will document accordingly. PCP and RP notification and follow through with any new orders. Plan of care will be updated. Completed 7/26/24 and ongoing. DNS (director of nurses) educated the licensed nurses on conducting weekly skin assessments should be conducted by the designated nurse and/or designated wound care nurse and follow up with new communication to PCP and others accordingly. Sign out for weekly skin assessments on the MAR and signing out the treatments as ordered and administered by licensed nurse. Completed 7/26/24 and ongoing. DNS (director of nurses) educated the licensed nurses on proper documentation of site, staging as indicated, measurement taken and noting wound bed appearance to be completed on the skin UDA within the E.H.R. Nursing obtaining wound care orders for identified wounds and implementing treatment orders as per MD/NP orders and ensuring that the RP is notified. Completed 7/26/24 and ongoing. DNS, Nurse Leader LNAC, or Wound Care nurse will conduct post admission assessment within 24-72 hours post admission/readmit to validate accuracy of documentation of skin condition noting wound type, presentation, appropriate state for pressure injuries, validation of proper treatment orders is in place and any consultations are made as clinically indicated. Completed:7/26/24 Ad hoc QAPI completed with Medical Director to review plan of action. Completed:7/26/24 Findings of audits and system management will be reported to the Administrator and the QAPI committee during the monthly meetings for the next 2 months, identifying system compliance or need for further education and clinical oversight. Completed:7/26/24 Hospital discharge paperwork to be reviewed, PCP/NP will be contacted to verify admission/readmission orders. Completed:7/26/24 If PCP/NP does not call back timely to give orders, contact DNS/Medical Director for orders. Completed: 7/26/24 Proper skilled nurse's notes documentation in electronic medical record. Completed 7/26/24 If treatment nurse is absent for any reason, licensed nurse will contact DNS/ADNS or nurse leader. DNS/ADNS, Nurse Leader LNAC reassign treatments and verify completion. Completed 7/26/24 4. During the daily clinical review meeting held (5-7 days per week) the DNS/Designee will review new admissions and changes in condition (SBARS) r/t skin/wound concerns in order to ensure accuracy and to ensure appropriate follow up interventions are in place. During the daily clinical review meeting held (5-7 days per week) the DNS/LNAC will review skilled nurse's notes 5x week x 8 weeks for proper documentation. DNS/ADNS, Nurse Leader LNAC will conduct weekly random audits 3x week x 8 weeks of resident's skin assessments and treatments to verify assessment is correct, orders are in place, and care plan is up to date. Review of Facility In-service titled Identifying and Reporting Changes in Condition/Notification of Changes/Abnormal Findings, dated 7/27/24 and 7/28/24 regarding 1.) The BON/Nurse Practice Act obligations of a nurse to identify, report and document all changes in condition. 2. Contin[TRUNCATED]