**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure treatment and services was provided, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 1 of 4 residents reviewed for quality of care. (Resident #38) 1. The facility failed to appropriately assess Resident #38's skin and wounds after readmission from 06/20/24 through 06/23/24. A new wound to the right lateral glute was identified by the facility on 06/24/24 when it was a Stage III pressure injury (a full thickness loss of skin extending to the subcutaneous tissue). 2. The facility failed to follow previous wound care recommendations from the wound care physician for wounds to the sacrum and left foot for Resident #38 from 06/20/24 through 06/23/24. 3. The facility failed to provide appropriate skin and wound care after readmission on [DATE] through 06/23/24. 4. The facility failed to notify the Dietician of Resident #38's wounds. 5. The facility failed to order supplements to promote wound healing. 6. The facility failed to provide appropriate wound care when LVN A placed a urine-soaked brief over a newly placed dressing during wound care to the unstageable wound to the sacrum. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 06/25/24 at 5:30 p.m. While the IJ was removed on 06/26/24 at 11:05 a.m., 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 jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries. Findings included: Record review of Resident #38's face sheet dated 06/25/24 indicated Resident #38 was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dementia, Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and heart disease. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #38 was usually understood and usually understood others. The MDS indicated a BIMS score of 99 which indicated Resident #38 was unable to complete the interview. The MDS indicated Resident #38 was dependent on staff for all ADLs. The MDS indicated Resident #38 was at risk of developing pressure ulcers/injuries. The MDS did not indicate any unhealed pressure ulcers/injuries. Record review of the care plan last revised on 06/03/24 indicated Resident #38 had potential for impairment to skin integrity and pressure ulcers related to incontinence of bowel and bladder, decreased mobility, use of anticoagulant medications, scratches buttocks causing abrasion or broken skin. There was an intervention to follow facility protocols for treatment of injury. The care plan indicated Resident #38 had an unstageable deep tissue injury to the left medial foot. There were interventions to administer and encourage compliance with supplements to promote wound healing and to administer medication and treatment (skin prep every day) as ordered. The care plan indicated Resident #38 had actual impairment related to an open wound area of the sacrum (area located at the base of the lumbar spine where it connects to the pelvis). There was an intervention to encourage good nutrition and hydration in order to promote healthier skin. Record review of Resident #38's consolidated physician orders dated 06/25/24 indicated an order to cleanse sacrum with wound cleanse and pat dry, apply collagen sheet and cover with island border, daily and as needed for wound treatment. There was an order to cleanse a Stage 3 pressure wound to the right lateral glute (right upper buttock) with wound cleanse, pat dry, apply collagen, cover with dry dressing every day, and as needed, with a start date of 06/24/24. The consolidated physician orders did not indicate orders for wound care for a deep tissue injury to the left foot, Vitamin C, Zinc, a protein supplement, or a dietary consultation. Record review of a facility Weekly Skin Assessments and Treatments In-Service Training Report for nursing staff dated 05/28/24 indicated, .when wound care nurse is not here you are responsible for weekly skin assessments and corresponding wound progress assessments. For every wound the resident has you must complete a weekly skin observation .Treatments are to be completed as ordered . Record review of Resident #38's electronic medical record accessed on 06/24/24 and 06/25/24 did not indicate dietary notes or a skin assessment for 06/20/24. Record review of a Weekly Skin assessment dated [DATE] at 2:45 p.m. indicated Resident #38 had a pressure (an injury to the skin from prolonged pressure), venous (a wound on the leg or ankle caused by abnormal or damaged veins), arterial (an ulcer caused from arterial insufficiency), or diabetic (an ulcer caused by complications with diabetes) ulcer. The assessment did not indicate the type, location, or size of the ulcer. Record review of a Weekly Skin assessment dated [DATE] at 6:27 a.m. indicated Resident #38 had a deep tissue injury to right buttocks and left medial foot with current treatments in place for both. The assessment did not indicate the size of the injuries. Record review of a Weekly Skin Assessment for Resident #38 dated 06/24/24 at 1:07 a.m. indicated, .Noted bleeding to sacrum (area that is located at the base of the lumbar spine, where it connects to the pelvis) area, and to bil (bilateral buttocks) . The size was documented as 5 centimeters x 5.5 centimeters. The assessment did not indicate a pressure, venous, arterial, or diabetic ulcer. Record review of a Weekly Skin assessment dated [DATE] at 19:27 a.m. indicated Resident #38 had a pressure, venous, arterial, or diabetic ulcer. The assessment did not indicate the type, location, or size of the ulcer. Record review of a Wound Evaluation and Management Summary report by the Wound Care Physician dated 06/05/24 indicated an Unstageable DTI (deep tissue injury) of the left, distal (sites located away from a specific area), medial (middle) foot undetermined thickness. The deep tissue injury to the left foot measured 2 centimeters in length x 1.8 centimeters in width. The depth of the wound was no measurable. The Dressing Treatment Plan indicated, Primary Dressing: Betadine apply once daily for 23 days. The report indicated an Unstageable DTI of the right, medial buttock (sacrum). The wound size was 2.8 centimeters in length x 0.8 centimeters in width x 0.1 centimeters in depth. The Dressing Treatment Plan indicated, Primary Dressing: Collagen sheet apply once daily for 30 days. Secondary Dressing: Gauze Island with border apply once daily for 30 days. The report was signed by the Wound Care Physician. The report did not indicate a pressure injury to the right later glute. Record review of a Wound Care Evaluation and Management Summary report by the Wound Care Physician dated 06/12/24 indicated Resident #38 was not seen due to a non-wound-related hospitalization since last visit. Record review of Consult to Wound Care for High Risk Braden Score hospital record dated 06/13/24 at 11:21 a.m. indicated, Resident #38 was admitted to the hospital on [DATE]. The record indicated a Braden Score of 13 which indicated Resident #38 was at moderate risk for pressure injury. The record indicated a pressure injury to the left foot that measured 3 centimeter in length x 3.2 centimeter in width x 0.0 centimeter in depth. The pressure injury to the left foot was staged as a deep tissue pressure injury. The wound was black in color and was intact. The record indicated a wound to buttocks (sacrum wound) that measure 3 centimeters in length x 1 centimeter in width x 0.1 centimeter in depth. The wound was described as red in color with defined edges. The pressure injury was staged as a deep tissue pressure injury. The record indicated a pressure injury to right trochanter (right glute). The record indicated the wound measured 1 centimeter in length x 1 centimeter in width x 0.0 centimeter in depth. The wound was described as pink, red, and non-blanchable. The pressure injury was staged as a Stage 2 pressure injury. The note was signed by a registered nurse and a physician. Record review of Progress Note, Hospital Day 6, dated 06/18/24 at 11:36 a.m. indicated Resident #38 had an unstageable pressure injury to ball of left foot and a sacral pressure injury. There was no documentation of measurements or wound description. The progress note was signed by a Nurse Practitioner. Record review of a readmission Nurses' Note dated 06/20/24 at 6:30 p.m., indicated Resident #38 was readmitted from the hospital. The notes did not include an assessment of the skin or wound care. The note was signed by LVN R. Record review of Hospice Skilled Nursing Visit Note dated 06/20/24 between 6:37 p.m. and 8:40 p.m. indicated an unstageable pressure ulcer to the left medial proximal foot great toe. The wound measurements were 2 centimeters in length x 1.5 centimeters in width. The notes indicated the wound to the sacrum had a dry and intact dress. The note indicated the wound was not visualized due to the fact Resident #38 was hollering with position change for visualization. The note indicated an area to the right posterior lateral outer lower torso hip (right glute). The note indicated this was a Stage 1 pressure ulcer. An additional note describing the wound indicated, Scatter areas of 'white' tissue that are intact. There were no measurements of the area. The Hospice Skilled Nursing Visit Note indicated a Pressure Ulcer Risk Assessment total score of 9 which indicated Resident #38 was a very high risk for pressure ulcers. The Hospice Skilled Nursing Visit Note was signed by Hospice Nurse T. Record review of a Hospice Skilled Nursing Visit Note dated 06/21/24 at 10:00 a.m. indicated, .Wounds not observed at this time as the nurse stated they just turned him and got him settled. Facility staff does wound care . The note was signed by Hospice Nurse S. Record review of a Nursing Progress Note for Resident #38 dated 06/24/24 at 7:08 p.m. indicated, New stage 3 pressure wound of right lateral glute noted 2 cm x 0.9 cm x 0.1 cm light serous drainage noted no foul odor or s/s (signs or symptoms) infection. 25% slough (dead tissue separating from living tissue) noted to wound bed surrounding skin intact normal color. Edges are intact and flush to skin. Hospice notified. NEW ORDER per (Wound Care Physician): Cleanse with wound cleanser, pat dry, apply collagen cover with border gauze QD (daily). Continues with Unstageable DTI (deep tissue injury) of he left distal medial foot 2.7 cm x 2.5 cm x UTD (unable to determine) area is not open dark purple in color. Continues with unstageable to right medial buttock that has extended to left buttock/sacral area. 7.5 cm x 1.2 cm x 0.1 cm. [NAME] eschar to wound bed <25% . Record review of a Weekly Ulcer assessment dated [DATE] at 7:29 p.m. indicated Resident #38 had an ulcer to the left distal medial foot. The type of ulcer was pressure. The Pressure Ulcer Stage was deep tissue injury. The documented wound measurement was 2.5 centimeters in length x 3 centimeters in width. The depth could not be measured. The assessment indicated the current wound treatment was to cleanse with wound cleanser, pat dry, apply betadine every day. There was a note to continue orders from the Wound Care Physician. Record review of a Weekly Ulcer assessment dated [DATE] at 7:36 p.m. indicated Resident #38 had an ulcer to the sacrum. The type of ulcer was pressure. The Pressure Ulcer Stage was deep tissue injury. The documented wound measurement was 5 centimeters in length x 8.7 centimeters in width. The depth could not be measured. The assessment indicated the current wound treatment was to cleanse with wound cleanser, pat dry, apply collagen, and cover with a border gauze daily. There was a note that indicated, wound labeled per (Wound Care Physician) as unstageable of the right medial buttock has extended over to the sacral area. Record review of a Weekly Ulcer assessment dated [DATE] at 7:48 p.m. indicated Resident #38 had an ulcer to the right lateral glute. The type of ulcer was pressure. The Pressure Ulcer Stage was Stage III. The documented wound measurement was 2.7 centimeters in length x 1 centimeters in width. The depth could not be measured. The assessment indicated the current wound treatment was to cleanse with wound cleanser, pat dry, apply betadine every day. Record review of a Wound Administration Record for June 2024 for Resident #38 indicated an order to cleanse right medial buttocks with wound cleanse and pat dry, apply collagen sheet and cover with island border gauze daily with a discontinued date of 06/24/24. The documentation of wound care to the right medial buttock indicated Resident #38 did not receive wound care of this wound on 06/20/24, 06/21/24, 06/22/24, 06/23/24, and 06/24/24. There was an order to cleanse sacrum with wound cleanse and pat dry. Apply collagen sheet and cover with island border gauze daily and as needed one time a day for wound treatment. The documentation of wound care to the right medial buttock indicated Resident #38 did not receive wound care of this wound on 06/20/24, 06/21/24, 06/22/24, 06/23/24, and 06/24/24.There was an order to cleanse an unstageable deep tissue injury of the left distal medial foot with wound cleanser, pat dry, they apply betadine everyday times 30 days. The order was discontinued on 06/13/24. The documentation of wound care to the unstageable deep tissue injury of the left distal medial foot indicated Resident #38 did not receive wound care of this wound on 06/02/24, 06/06/24, 06/20/24, 06/21/24, 06/22/24, 06/23/24, and 06/24/24. There was an order for a stage 3 pressure wound of the right lateral glute to cleanse with wound cleanser, pat dry, apply collagen, and cover with a dry dressing every day and as needed. The documentation of wound care to the right lateral glute indicated Resident #38 did not receive wound care of this wound on 06/20/24, 06/21/24, 06/22/24, and 06/23/24. During an observation and interview on 06/24/24 at 11:08 a.m., LVN F provided wound care to Resident #38. She said Resident #38 had been out to the hospital and was not on the Wound Care Physician's list on 06/19/24. There was wound to the sacrum that was measured by LVN F. The wound measured 7.5 centimeters in length x 7.2 centimeters in with. She said this wound was unstageable because of the slough to the wound bed. There was a wound to right glute 2 centimeters in length x 0.9 centimeters in width. She said this wound was a stage III. Each wound was cleansed with wound cleaner and a collagen dressing was applied. The deep tissue injury to the left foot was not observed and wound care to the wound was not provided by LVN F. During an interview on 06/25/24 on 2:49 p.m., the Wound Care Physician said typically if she was present in the facility, staff would let her know when a resident had returned to the facility. She said if she was not present in the facility staff wound not have to notify her unless there was a new skin issue. She said anytime wound care was not done there was a problem with that. She said Resident #38 had a pressure injury on the left foot and unstageable pressure injury to the right buttock when he left to the hospital. She said she was notified 6/24/24 of the new pressure injury to the right glute. She said staff were allowed to call her for new orders. She said she would expect to be notified anytime a new wound was found. During an observation and interview on 06/25/24 at 3:40 p.m., LVN A provided wound care to Resident #38. LVN A said it was the first time he was seeing Resident #38's wounds. LVN A measured the deep tissue injury to the left foot. The measurements were 2.5 centimeters x 3.0 centimeters. The wound appeared black and was not open. LVN A measured the wound to the right glute. The wound measured 2.7 centimeters x 1 centimeter. The wound was Stage III. The wound open with a small amount of slough. LVN A measured the wound to the sacrum. The wound measured 5 centimeters x 8.7 centimeters. The wound bed was red with slough. During the wound care LVN A did not remove a urine-soaked brief that was under Resident #38. After cleansing the wound to the sacrum, LVN A pulled the urine-soaked brief over the clean dressing in order to turn the resident in bed. During an interview on 06/26/24 at 11:12 a.m., LVN R said when she came on duty on 6/20/24, Resident #38 was already at the facility. She said she did complete his readmission assessment. She said she did not complete a skin assessment because the hospice nurse was in the room admitting him to hospice. She said she was in the room during part of the skin assessment by the nurse. She said she was 100% sure it was done. She said she did not obtain any wound care orders. She said she did not provide any wound care. She said she contacted the ADON off and on during the night of 06/20/24 concerning Resident #38's orders, what needed to be done, and what the resident needed. She said she called the ADON and gave her a verbal report on the morning of 6/21/24 and the ADON told her she would handle it. During an interview on 06/26/24 at 1:34 p.m., a family member of Resident #38 said they were notified of Resident #38's wounds on 6/25/24. They said they were made aware of the new wound at that time. They said Resident #38 only had two wounds present that they were aware of while he was in the hospital. During an interview on 06/26/24 at 1:48 p.m., Hospice Nurse S said Hospice Nurse T was the on-call Hospice nurse when Resident #38 was readmitted to the facility. She said Hospice Nurse T was the nurse that assessed Resident #38. She said Hospice Nurse T did not complete a skin assessment because Resident #38 was agitated and tried to bite her. She said no wound care orders were placed at that time. She said she would have expected for the facility to have followed up on obtaining a skin assessment and obtaining wound care orders. Especially, since he had been to the hospital and had previous wound care orders from the Wound Care Physician. During an interview on 06/26/24 at 1:56 p.m., Hospice Nurse T said she did a skin assessment on Resident #38. She said she was able to observe all wounds except for the sacrum. She said he became agitated and was hitting and biting staff. She said a facility CNA was in the room helping her. She said she documented the wounds in her notes. She said the wound to the right glute was not open when she did the assessment on 06/20/24. She said it was a white area. She said it was only at risk. She said she called the Hospice MD and notified him that she was unable to assess the sacral wound. She said she also told Hospice Nurse S. She said hospice worked in coordination with the facility. She said hospice had 5 days to complete a skin assessment. During an interview on 06/26/24 at 2:40 p.m., LVN A said he had provided care to Resident #38 beginning the morning of 06/21/24. He said Resident #38 had returned on the night of 06/20/24. He said he did not complete a skin assessment. He said he did not know Resident #38 had any wounds and did not lay eyes on his wounds until 6/25/24. He said on the 06/21/24 he was not aware of any skin issues Resident #38 had. He said there were no orders on 06/21/24 for wound care for Resident #38. He said if there had been it would have been his responsibility to have provided wound care. He said at times they do have treatment nurses that volunteer to do wound care for the day. He said there was not a treatment nurse on 6/21/24. He said the admitting nurse should done a skin assessment within 4 hours. Any skin issues should have been assessed and the doctor should have been called to receive orders for the wound. He said during wound care on 06/25/24, he did cover up the new dressing to the sacrum with the urine-soaked brief. He said he was just so focused wound care and did not think about the urine-soaked brief. He said he had been in-serviced on proper incontinent care during wound care. During an interview on 06/26/24 at 3:03 p.m., the ADON said LVN R did not do a skin assessment when Resident #38 was readmitted to the facility. She said even though the hospice nurse did a skin assessment, she would have expected for LVN R to have done a skin assessment immediately. She said the previous orders from the Wound Care Physician should have been immediately restarted to the two wounds that were present on 6/12/24. She said LVN R should have communicated with the hospice nurse concerning wound care. She said she would have expected LVN R to have seen the new skin issue and obtained doctor's orders. She said she had talked to LVN R on the night of 06/20/24 about what all needed to be done. She they discussed assessments, oxygen needs, dietary needs, and care in general. She said she thought between LVN R and the hospice nurse, everything was taken care. She said she did not go in to assess the resident's wounds on 06/21/24. She said that would have been LVN A's responsibility. She said the admitting nurse was responsible for obtaining orders including supplements and a dietary consult. She said all wound care was documented in resident's electronic medical record on the Wound Care Administration Form. She said it was her job and the DON's job to monitor to make sure those things were being done. She said they had a meeting each morning and they went over the new admissions to make sure the assessments had been done. She said if a resident had an incontinent episode, the resident should be cleaned, and a dry brief should have been placed under the resident prior to wound care. She said a resident not receiving timely wound care could cause worsening skin issues, could cause gangrene, or the resident could expire. She said by a wet brief being placed over a freshly cleaned and dressed wound could cause germs to get in the wound and make it worse. During an interview on 06/26/24 at 3:29 p.m., LVN F said she was a charge at the facility. She said she was acting as the treatment nurse on 6/24/24. She 6/24/24 was the first time she provided wound care for Resident #38. She said the nurses were responsible for wound care to their residents. She said 6/24/24 was the first time she had ever assessed his wounds. She said the admitting nurse had 4 hours to do a skin assessment. She said the admitting nurse should then restart any previous orders and obtain new orders for any new skin issues. During an interview on 06/26/24 at 3:59 p.m., the DON said the facility had not had a full-time treatment nurse since first of June 2024. She said the charge nurse was responsible for providing wound care since they did not have a treatment nurse. She said she would have expected for LVN R to have completed a skin assessment on Resident #38 on 6/20/24 regardless of whatever assessments the hospice nurse had completed. She said the nurse should have then called the doctor and/or hospice to get a treatment order. She said the skin assessment should have been completed with 4 hours by the admitting nurse. She said the resident did go from the 06/20/24 to the 06/24/24 without wound care. She said by a resident not having skin assessments could cause the resident to miss treatments and cause a wound to worsen. She said the treatment nurse typically makes the dietician notification. She said now the charge nurse should report to her any skin issues and was responsible for notifying the dietician. She said when Resident #39 readmitted to the facility, supplements should have been ordered. She said she was not notified of any new wounds on 6/20/24 or 6/21/24. She did not find out about the new wound until 6/24/24. She said she had notified the dietician. She said she would have expected for supplements to have been started on 6/21/24. She said not having supplements could delay wound healing. She said LVN A should have completed the incontinent care before starting wound care. She said urine-soaked brief could cause infection to a wound. She said a resident not receiving wound care could cause a delay in healing and cause a wound to worsen. She said all wound care treatments were charted on the Wound Care Administration Form in the electronic medical record. She said herself and the ADON monitor by doing audits Monday - Friday to make sure resident receive the appropriate wound care. She said she was not working on 6/21/24 but she would have expected for the ADON to have followed up. During an interview on 06/26/24 at 4:41 p.m., the Administrator said she expected skin assessments to be completed within 4 hours of admission by the treatment nurse, designee, or the charge nurse. She said she would have expected for Resident #38 to have been assessed within 4 hours of being readmitted to the facility. She said she would have expected for the physician to have been notified and the dietician to have been notified of any skin issues so new wound care orders could be obtained. She said Resident #38 needed wound orders so his wounds would not heal. She said she would have expected wound orders for wounds present prior to the hospital stay to have been restarted as long as the wounds were of the same caliber. She said if they had changed, she would have expected the wound care doctor to be notified for order clarification. She said she would have expected for the wound care doctor to have been notified of the new wound. Record review of a Skin Assessment facility policy dated 08/15/16 indicated, .It is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to ensure appropriate intervention are initiated in a timely manner .All new admits and resident returning from a hospital stall will have a head-to-toe skin assessment completed by the Treatment Nurse/designee within four (4) hours of the resident's arrival at the facility .If the Treatment Nurse/designee is not available, then the charge nurse should complete the skin assessment with four (4) hours of the resident's arrival at the facility .The DON (Director of Nursing) or designee, along with the Treatment Nurse/designee and other team members will review for the follow-up assessment and recommendations .Any alterations in skin integrity will be treated according to physician orders. Notify DON and responsible family member. Documentation will then be entered into the resident's chart . Record review of a Pressure Injury: Prevention, Assessment and Treatment facility policy dated 08/12/16 indicated, .Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, and circulation to prevent breakdown, injury, and infection .Early prevention and/or treatment is essential upon initial assessment of the condition of the skin on admission and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sore(s) is indicated and notify the Treatment Nurse/designee of any potential problems .Notify the physician of pressure sore and obtain and follow any orders as directed by the physician .Notify family and dietary department. Document notification .Maintain adequate nutrition .Assess for early signs of skin breakdown and report any abnormal findings .Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage .Notify physician; obtain an order and monitor site daily .Assessment of the pressure injury should also include the site, size, and WxLxD of the injury. Surrounding tissue, color, exudate, wound edges, sinus tracts, odor, tunneling and undermining should also be documented at least weekly and upon decline . Record review of a Skin Integrity Management facility policy dated 10/05/16 indicated, .If wound is noted, perform an assessment and initiate a treatment plan as soon as possible .Correction of the resident's underlying medical, surgical, and/or nutritional problems must be accomplished if proper healing of pressure sores etc. is to occur .Wound care should be performed as ordered by the physician . The Administrator was notified of an IJ on 06/25/24 at 5:32 p.m., was given a copy of the IJ template, and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 06/26/24 at 8:08 a.m. and included the following: On 6/25/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services had determined that the condition at the facility constituted an Immediate jeopardy to resident health and safety. Problem: F 686 Treatment/Services to Prevent/Heal Pressure Ulcer Interventions: o A head-to-toe assessment was completed on resident # 38 on 6/25/24 by the DON. Weekly ulcer assessments for resident #38 were completed on 6/25/24 to include measurements by DON and Regional Compliance Nurse. o The MD was notified on 6/25/24 of resident #38 new pressure wounds by the DON. Orders were received for treatment and implemented on 6/25/24. o The Dietician was notified on 6/25/24 of resident #38 new pressure wounds by the DON. Recommendations were received and implemented on 6/25/24. o Wound care treatments for residents #38 were completed by the DON as ordered on 6/25/24. o 100% skin rounds were initiated on 6/25/24 by DON, ADON and Compliance Nurse. No additional pressure wounds were identified. o All wound care orders were reviewed on 6/25/24 by DON, ADON, and Compliance Nurse to ensure wound care recommendations are being followed appropriately for all residents. o All residents with wounds have appropriate supplements in place to promote wound healing. Reviewed and completed by the DON and Compliance Nurse on 6/25/24. o Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on 6/25/24 on the following topics. Completed 6/25/24. o Pressure Injury Prevention, Assessment, and Treatment Policy o Skin Integrity management Policy and Skin assessment policy to include appropriate skin care on admission and readmission which includes skin assessments on admission and readmission. o Notification of a Change in Condition Policy- will notify MD with any new or worsening pressure wounds. o Abuse and Neglect - failure to provide a physician ordered treatment to a pressure wound. o Incontinent care to include- placing a clean brief when wound care is being provided. In-services: o The following in-services were initiated by Regional Compliance Nurse, DON on 6/25/24 for all charge nurses. Any charge nurses not present or in-serviced on 6/25/24 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All agency staff or staff on leave will in serviced prior to assuming their next assignment. o Pressure Injury Prevention, Assessment, and Treatment Policy to include providing appropriate wound care. o Skin Integrity management Policy and Skin assessment policy to include appropriate skin assessments on admission [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately consult with the resident's physician when there was significant change in the resident's physical, mental, or psychosocial status for 2 of 7 residents reviewed for notification of changes. (Resident #1 and #3) The facility failed to notify the resident's physician when resident #1 stopped eating or taking medications for about 10 days. The facility failed to notify the resident's physician when Resident #1 and #2 developed pressure sores. An Immediate Jeopardy (IJ) situation was identified on 02/10/23 at 4:14 p.m. While the IJ was removed on 02/11/23 at 7:22 p.m., the facility remained out of compliance at actual harm with a scope of a isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems This failure could place residents at risk of their physicians not being aware of the resident conditions and delay treatments for the resident conditions. Findings included: Record review of Resident #1's admission record with a print date of 02/07/23 indicated she was an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses were myocardial infarction (heart attack), muscle weakness, lack of coordination, hypertension, end stage renal disease and hyperlipidemia. Record review of Resident #1's admission MDS dated [DATE] indicated her cognitive status was severely impaired (BIMS score 7). She required extensive assist with bed mobility, dressing, and toilet use of one-person, limited assistant to transfer with one person. Limited assistance with locomotion off the unit of one person. She was able to eat and drink with supervision and setup help only. There was no significant change MDS. Record review of Resident #1's computerized Physician orders indicated on 1/19/23 a puree diet, pureed texture, nectar consistency. An order dated 12/07/22 for Novasourse Renal two times daily. Record review of Dysphagia(difficulty swallowing) Consultation dated 01/19/23 indicated meal recommendations for Resident #1. Pleasure comfort feedings of pureed as accepted or tolerated, encourage more upright head posture, employ good oral care, cued cough to help clear upper airways, liquids nectar thick and pills are a choking risk crush medication. Feed slowly and carefully, hand over hand assistance, no straws, resident to be fed small bits and sips. SLP or trained staff only and monitor for adequate nutrition and hydration. Record Review of Resident #1's MAR for January 2023 indicated Resident #1 received medications on a regular basis until 01/23/23. Review of the MAR indicated the medications were not given due to the resident refused, or they were on hold. Aspirin 81 mg one time a day - for myocardial infarction- was not given from 01/23/23 through 01/31/23 Atorvastatin Calcium 40 mg one by mouth at bedtime for Hyperlipidemia- was given 01/26/23 and 01/31/23 only Folic Acid 400 mg one daily for supplement was not given from 01/23/23 through 01/31/23 Isosorbide Mononitrate ER 30 mg one time daily for hypertension she was not given from 01/23/23 through 01/31/23 Sensipar Tablet 30 MG one time daily for renal disease given on 01/26/23 and 01/31/23 only Metoprolol tartrate 25 mg for hypertension was not given from 01/23/23 through 01/31/23 Novasource Renal two times daily was given on 01/26/23 and 01/31/23 on the evening shift only Ticagrelor tablet 90 MG two times daily for blood thinner was not given from 01/23/23 through 01/31/23 Tums tablet chewable 500 MG three times daily for Calcium supplement was given on 01/26/23 and 01/31/23 on the evening shift only. She also received it on 01/30/23 at the 2p.m. Megestrol Acetate 40mg by mouth four times a day for appetite was given on 01/26/23 at 2 p.m. and 9 p.m. and on 01/32/23 at 9:00 p.m. Record review of Resident #1's ADL Nutrition sheet (amount eaten) for January 2023 indicated from 01/23/23 through 01/31/23 Resident #1 refused or did not eat except on 01/26/23 and 01/27/23 in the morning she ate 26 to 50 percent. On the evening of 01/25/23 she ate 51 to 75 percent. Record Review of Resident #1's MAR for February 2023 indicated from 02/01/23 through 02/06/23 indicated she was not given any medications. Her medications were not given because she refused, or they were on hold. Record review of Resident #1's ADL Nutrition sheet (amount eaten) for February 2023 indicated from 02/01/23 through 02/06/23 the resident refused or did not eat except on the evening of 02/01/23 the resident ate 26-50 percent and on the morning of 02/04/23 resident #1 ate 51 to 75 percent. Record review of Resident #1's hospital records dated 2/6/23 indicated the resident assessment plan was failure to thrive, the patient had not been eating or drinking for the past week. The plan was to start on gentle fluids resuscitation the diagnosis likely dehydration and possible starvation. The EMS reported Resident #1 had a constant decline for the past couple of weeks. She last dialysis was two times ago. She was too weak to have the procedure. She had not been taking her medications. The physical exam indicated diagnosis of end stage renal disease related to high blood pressure in 2016. Encephalopathy progressing since 12/20/22 severe dehydration and malnutrition. The emaciated chronically ill female lost 10 kg=22.05 pounds in the past 3 to 4 months in no acute distress. Record review on 02/07/23 revealed Resident #1 did not have a comprehensive care plan. Record Review of Resident #1's clinical record indicated no physician notification of her status for not for eating, or taking meds. During an interview on 02/07/23 at 11:47 a.m. LVN E said she worked at the facility for 3 years. LVN E said on 02/06/23 dialysis called and said they were unable to complete dialysis because Resident #1 too unstable. LVN E said Dialysis said she was too lethargic and sent her back to the facility. LVN E said Resident #1 came back to the facility and was sent to the hospital on [DATE]. LVN E said the treatment nurse RN F was the nurse that assessed Resident #1 and sent her to the hospital. LVN E said she did hear Resident #1 was not eating. She said on today, 02/07/23 Resident #1 had an appointment to have a feeding tube placed. LVN E said the nurse at the hospital told her on the phone Resident #1 was not a candidate for a feeding tube because she was too weak. LVN E said they could not get Resident #1 to eat or drink for at least a week or two. LVN E said Resident #1 was not a DNR and she was not on hospice. She said the family would not change Resident #1's code status. LVN E said she had not personally contacted the physician regarding Resident #1 not eating or drinking. LVN E said the administrative staff were aware Resident #1's condition had declined to the resident not eating anything. During a telephone interview on 02/07/23 at 2:23 p.m. Resident #1's Physician said in the old days a resident could send them straight to the ER to receive a feeding tube. He said now the hospital did not do that any longer. He said they had to schedule an appointment through a GI doctor to get a feeding tube placed. He said they got the first available appointment with GI doctor on 02/07/23. He said it would not have done any good to prescribe an appetite stimulant if Resident #1 was not eating at all. He said he did not know until yesterday, 02/06/23 that Resident #1 was not taking any of her meds and was not able to swallow at all for at least a week. He said if he had known he would have sent her to the hospital, and they would have likely gotten some IV fluids started on Resident #1. The Physician said Resident #1 was having swallowing difficulties before she came to the facility. The facility staff did not tell him Resident #1 was not eating, drinking, or taking her medications. He said what he was told was Resident #1 was not eating well until she was sent to the hospital on [DATE]. During a telephone interview on 02/07/23 at 3: 50 p.m. LVN G said Resident #1 could not eat or swallow anything due to her choking. He said it had been at least a week since she was able to swallow anything. He said they had placed Resident #1 on puree diet the later part if January, and even with diet change she only ate about 25 percent. LVN G said about a week ago an aide told him Resident #1could not eat, she was choking on her food. He said he had gone down to the room to try and feed Resident #1 himself. He said he tried to get her to eat but she was choking. LVN G said he was able to get her to take a half cup of thickened liquids, but she had a hard time. He said on the following day Resident #1 was just holding food in her mouth and not drinking anything. The LVN said he asked the DON and she said they set up an appointment for tube feeding. He said the SW at Dialysis had talked to the dialysis doctor and the facility doctor and received a go ahead for a feeding tube. LVN G said at the first of January they sent Resident #1 to the hospital and the hospital sent her right back. He said on one occasion he called the NP because Resident #1's BP was really low, and the NP said to just monitor her. The LVN said he reported in the morning meeting for at least the last week that Resident was not eating or drinking. However, he never called the doctor. During an interview on 02/07/23 at 6:04 p.m. LVN M said she worked at the facility for two years. She said Resident #1 was lethargic and weak. She would take Resident #1s vitals, and they were normal. The LVN said most of time Resident #1's normal BP was low. The LVN said Resident #1 had declined with her eating and was very withdrawn. LVN M said there was nothing alarming that indicated she needed to send Resident #1 to the hospital. LVN M said Resident #1 would take a small amount of liquid. She said that she never called the doctor. LVN M said that during shift change the DON said to monitor her. During an interview on 02/08/23 at 8:49 a.m. LVN N said she worked at the facility for 14 years. She said Resident #1 had an overall decline. She said Resident #1 could still say her name and say she did not want anything to eat, or if she was in pain. LVN N said Resident #1 began pocketing food at one time and not wanting to swallow. She said she had some aides come up and told her Resident #1 was not eating. She said over a week ago she had worked the evening shift and tried to get Resident #1 to drink. She said Resident #1 took a sip and turned her head. LVN N said the MA told her Resident #1 would not swallow meds even when crushed. She said they could not get her to swallow. LVN N said she never called the Physician. She said she worked with Resident #1 a few times and she only worked the floor when they were short. The LVN said she had talked to Resident #1's family member one evening about 3 weeks ago. She said they talked about Resident #1 declining. LVN N said they talked about Resident #1's not eating in morning meeting, and getting with the family about her code status, and her decline changes. The hospital records also indicated Resident #1 had multiple wounds. Record review of Resident #1's Weekly Skin Observation dated 02/7/23 indicated a it was a full assessment for 02/03/23 indicated Resident #1 had MASD (moistures associated skin damage) on the sacrum that measured 2 by 2 by 0.1 And MASD to the right gluteal fold that measured 2 by 2 by 0.1. Hydrocolloid dressing in place, the skin is fragile noted to upper and lower buttocks referred to wound care. Record review of Resident #1's computerized physicians order for 01/15/23 through 02/15/23 indicated an order dated 01/26/23 at 6 p.m. indicated Zinc ointment to sacrum every shift and as needed. On an order dated 02/07/23 at 6:00 p.m. to cleanse left sacral wound #3 with wound cleanser, pat dry apply alginate and foam dressing daily. Cleanse right sacral wound #2 with wound cleanser, pat dry apply alginate and foam dressing daily. Cleanse superior scar wound #1 with wound cleanser, pat dry, apply alginate and foam dressing daily. Record review of hospital records dated 2/7/23 at 3:10 p. m. indicated Resident #1 had a wound care consult due to multiple wounds. She had a deep tissue injury to the sacrum that measured 9 cm by 12 cm by 0.1 cm. she had a right thigh posterior deep tissue injury that was 2 cm by 10 cm by 0.1. cm. During a telephone interview on 02/09/23 at 11:59 a.m. Resident #1's Physician said that no one notified him of Resident #1's pressure sore. He said there is a standard order for wound care. However, they usually notify the Wound doctor and she handled things like that. He was not aware Resident #1 had a wound. During an interview on 02/09/23 at 12:10 p.m. the Wound Care Doctor said first she heard about Resident #1's wounds was 2/5/23 about 8pm. She said the DON called or texted her and told her Resident #1's wounds were getting worse. The Wound Care Doctor said on Monday, 02/06/23 RN F called and told her Resident #1 had wounds and she told her to put alginate on the wounds. The Wound Care Doctor said she never saw the wounds. During a telephone interview on 2/9/23 at 12:16 p.m. RN F/treatment nurse said Resident #1's pressure sores were first brought to her attention Thursday, 02/02/23 by an aide. She said she sent a message to the resident 's physician and put a treatment in place. She said on 02/03/23 when Resident #1 came back from dialysis she reinforced the bandage. She wrote the late entry 02/07/23 because she had put something in place. She said when she saw the areas on 02/03/23 they were not really pressure sores. RN F said when she got to work Monday, 02/06/23 the administrator told her the sores were big enough to put her fist in the wound. She said the administrator told her she had seen a picture of the wounds. According to RN F Resident #1 had 3 stage 2 wounds that measured 2.2 cm by 2/2 cm. RN F said she knew she was not eating because she was on the floor. Wound Care Doctor and she said they would do good with alginate. She said she was on the floor on 02/06/23 and received a call from dialysis saying they were sending Resident #1 back to the facility because she was too weak to attend the treatments. She assessed her and sent her out to the hospital. RN F said they all knew Resident #1 was not eating LVN G talked about it most every morning in the morning meeting. Resident #3 Record review of Resident #3's admission record with a print date of 02/07/23 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis was congestive heart failure, respiratory failure, diabetes, hypertension, kidney disease, and reduced mobility and coordination. The record indicated Resident #3 was discharged on 09/16/22 with 17 days stay to an acute hospitalization. Record review of Resident #3's admission assessment dated [DATE] indicated the resident was admitted to the facility from an ALF due to edema( swelling) to the bilateral LE with high blood pressure. He was oriented to time, place and situation. Resident #3 had poor balance and unsteady gait. He was continent of bowel and bladder. His skin assessment revealed right inner arm bruising, lower left leg rear vascular, lower right leg vascular, left gluteal fold redness, and right gluteal fold. His bed mobility, transfers were assisted by staff, and he used a wheelchair. Record review of Resident #3's Baseline Care Plan dated 08/30/22 indicated he was setup help only with eating. Resident #3 required one person assist with personal hygiene, toilet use, dressing, bathing, bed mobility, and transfers. He required the use of a wheelchair. Resident #3's current skin integrity issues were bruises and vascular to bilateral LE. Record review indicated Resident #3 did not have a Comprehensive Care Plan. Record review of Resident #3's clinical record revealed he saw the Wound Care Doctor on two occasions. However, there was no facility physician doctor's order, facility assessment, or facility treatment documentation of the wound. Record review of Resident #3's Wound Evaluation and Management Summary dated 09/14/22 indicated Wound care assessment and evaluation was performed today. Resident #3 had an unstageable DTI of the left posterior, lateral heel and for at least 1 day's duration. There is no exudated. Site 1- Unstageable DTI of the right heel, partial thickness, etiology pressure, size 6 cm by 7 cm the surface area measured 42 cm the duration is greater than 13 days. Wound progression deteriorated. Dressing hydrogel wafer apply three times per week. The plan was off load, reposition per facility protocol. Sponge boot, prevelone boot. Site 4 Unstageable DTI to left posterior, lateral heel, etiology pressure unstageable DTI . size 1.0 x 1.9 dept not measurable treatment plan the same as site 1. Record Review of Resident #3's hospital records dated 09/16/22 indicated hospital problems were the Primary Right Foot Infection with acute kidney disease. His diagnosis acute renal failure, unspecified, pressure injury of skin of right foot, unspecified injury stage. This [AGE] year-old presented to the emergency department due to generalized weakness and right foot wound. The patient stated generalized weakness for about 3 months and progressively worsening. The patient stated chronic right heel wound. The patient was without redness, and no drainage to the right foot wound the wound was covered and had a compressive boot. Resident #3 arrived form nursing home with inflatable heel boot to relieve pressure. Labs revealed acute kidney injury with creatinine elevated from base line. All labs were review on 09/16/22 at 2:13 p.m. acute coronary syndrome, pneumonia, urinary tract infection, deconditioning, anemia, electrolyte disturbance, pulmonary embolism, COPD , asthma, foot wound, foot ulcer, osteomyelitis, sepsis and congestive heart failure. Patient with bilateral foot wound right with dusky black appearance noted at the right heel. The patient with DP Pt pulse in bilateral legs. Patient able to move legs will. No sensory deficit. Motor strength 5 out of 5 for bilateral lower extremities. Record review of Resident #3's hospital Discharge Course dated 09/26/22 indicated a past history of coronary artery disease, chronic systolic heart failure, stage 3 chronic kidney disease, essential hypertension, prostate cancer, hyperlipidemia who currently resided at the nursing facility came to the hospital with right diabetic food wound. Resident #3 received IV antibiotics during the hospital stay along with two debridement's. His medical status gradually worsened during the hospital sta. Resident #3 had a poor prognosis given his advanced age, and diagnoses. Resident #3 was discharged with hospice services. During record review and interview on 02/13/23 at 3:00 p.m. the DON could not find a physician order or treatments for pressure sores on the TAR for Resident #3's pressure sore. During record review and interview on 02/13/23 at 3:15 p.m. the Director of Clinical Informatics reviewed Resident #3's computer and paper file. She said she did not find a physician order or treatments on the TAR for Resident #3's pressure sore. Record review of Resident #3's clinical record did not reveal any physician notification or physician orders for wound care. During a telephone interview on 02/09/23 at 11:59 a.m. Resident #3's Physician said there is a standard order for wound care. He said staff do not normally notify him of wound or pressure sore issues. He said he did not get wound care calls much with the Wound Care Doctor in place. They usually notify the Wound doctor, and she handled the wounds. During an interview on 02/13/23 at 3:49 p.m. the Wound Care Doctor said when she did her rounds at the facility, she always had a nurse with her. She said she was reviewing her notes on Resident #3 for 09/14/22 The Wound Care Doctor said she did recommendations. She did not write actual orders. Her recommendation for Resident #3's unstageable was hydrogel wafer three times a week. She said with treatment and offloading and it should have healed. The Wound Care Doctor said the Venous ulcers would have resolved if they had been offloaded with or without treatment. She said when she saw Resident #3 on 09/14/22 one of the venous ulcers had resolved. She said her treatment recommendations for both heels, were hydrogel wafer Unstageable. 3 times a week. She also recommended pressure relieving boot and the number one goal is to keep the foot off loaded. The Wound Care Doctor said she did not remember the resident not having a dressing on his wounds when she saw hm. She said there was no reason for her to think his treatments were not completed as recommended. This was determined to be an Immediate Jeopardy (IJ) on 02/10/23 at 4:15 p.m. The facility Administrator, DON, VP of Clinical Operations, and Director of Clinical Informatics were notified. The Administrator was provided with the IJ template on 02/10/23 at 4:15 p.m. The plan of removal was accepted on 02/11/23 at 1:46 p.m. Please accept the following plan of removal for F580-Notify of Changes: 1. Notify V.P. of Clinical Operations of immediate Jeopardy status - o Completed - 02/10/23 @ 4:00pm 2. Notify Regional Director of operations of Immediate Jeopardy status - o Completed - 02/10/23 @ 4:15pm per V.P. of Clinical Operations 3. Notify facility Medical Directors of Immediate Jeopardy status- o Completed - Both notified on 02/10/23 @ 4:35 PM/ 4:50 PM by DON. 4. Resident #1 was transferred to an appropriate medical setting on 02/06/23 for evaluation and treatment. Resident #1 remains hospitalized at the time of this report. 5. Residents' weights will be reviewed for completion and any significant variances identified. o Initiated: 02/10/23@ 5:00 AM by DON. o Completed: 2/10/23 @ 10:15am by Registered Dietician. 6. Residents with significant weight variances (1 month - 5% or greater, 3 months- 7.5% or greater, 6 months-10% or greater) will be identified by DON/designee. MD/PCP and responsible party will be notified. If the resident's MD/PCP does not respond the charge nurse will notify the medical director. o Initiated: 2/10/23 @ 7:45 AM by DON/RD o Completed: 2/10/23 7. The facility DON was provided education by the V.P. of Clinical Operations on the following topics: a) Change in a residents' status - Discussion included review of Change in a Resident's condition or Status Policy & Procedure. Examples of changes in condition and notification expectations to MD/PCP and responsible party. Specific content of the change in a resident's condition status policy were reviewed during the discussion. Three sections of this policy referenced significant changes in the resident physical/emotional/mental condition and defined significant change of condition as a major decline or improvement in the resident's status that: i. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); 11 . Impacts more than one area of the resident's health status; iii . Requires interdisciplinary review and/or revision to the care plan; and iv. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. The policy provided interpretation and implementation guidance for the nurse to record in the residents' EMR information relative to changes in the residents medical/mental condition or status. Refer to attached Policy and Procedure. Other relevant information contained in the policy referenced notification to residents attending physician or physician on call when there had been a need to alter the resident's medical treatment significantly. b) Charting and Documentation - Discussed expectations for completion of nursing documentation in Resident EMR and use of facility 24-Hour report to identify residents with changes in condition /status to facilitate communication and continued monitoring. Refer to Policy and Procedure. c) Implementation of Physician Orders/Appointments - Discussed importance of communication with MD/PCP on order content and any concerns with appointment dates. Appointment process changed for nurses to make and coordinate appointments. d) If the resident's MD/PCP does not respond the charge nurse will notify the medical director. o Initiated: 02/10/23 @ 11:00 pm by V.P. Clinical Operations o Completed: 02/10/23 @ 11:45 PM by V.P Clinical Operations 8. Licensed Nursing Staff will be provided education by the DON/Designee on the following topics: Change in a resident's Condition or Status - The Nurse will promptly notify the Resident's MD/PCP and responsible party of changes in the Resident's medical/mental condition and/or status. i. Examples of change in condition: Incident, weight loss, pressure injuries {new or worsened), refusal of medications or treatments, difficulty 'swallowing, decreased food and fluid intake, skin concerns, pain not relieved by medications or other interventions, critical lab values, vital signs not in baseline range for the Resident, abnormal diagnostic results, change in diet or liquid and significant change consistency change in resident's physical, mental or psycho-social status and /or adverse reactions to medications and /or significant treatments. ii. The facility will utilize the following weight loss parameters to identify significant weight loss variances (1 month - 5% or greater, 3 months- 7.5% or greater, 6 months-10% or greater) that will be monitored by nursing management for notification to residents MD/PCP and responsible party. iii. If the resident's MD/PCP does not respond the charge nurse will notify the medical director. iv. Refer to Policy & Procedure . o Initiated: 02/10/23@ 6:45 AM By V.P. Clinical Operations o Completed: 2/10/23 @ 3:00pm Charting and Documentation-The Nurse is to complete documentation in the Resident's EMR to indicate Nursing evaluation/assessment findings, notification to PCP and responsible party, interventions and orders and response to treatments/interventions. New orders, incidents, appointments, and changes in Resident's condition will be placed on the 24-Hour Report to facilitate communication and continued monitoring. Residents with diet modifications will be monitored by licensed nurses for responses to diet modifications and recorded in the residents' EMR. Any concerns related to the new diet modifications will be communicated to PCP by licensed nursing staff. The nurse will continue to monitor and document on the residents indicated on the 24-Hour report until Nursing Management indicates resident no longer needs follow up monitoring. Refer to Policy and Procedure. o Initiated: 02/10/23@ 6:45 AM By V.P. Clinical Operations o Completed: 2/10/23@ 3:00pm by V.P. Clinical Operations 9. Staff who were not on duty will be notified to come to the facility for education by the DON/designee. No staff will be allowed to work on the floor until education have been completed. o Administrator, DON, and MDS Coordinator will monitor for employee completion of required education topics o Administrator, DON, MDS Coordinator and HR Director will conduct audits of current facility employees and indicate completion dates for required education. Staff are being notified to report to facility for education completion via phone and texts. o Notifications started on 02/09/23 @ 8:00AM and are continuing 02/10/23. o Administrator and DON will continue to audit, notify and provide education items until all employees have completed the requirement. o Initiated: 02/10/23@ 6:45 AM By V.P. Clinical Operations o Completed: 2/10/23@ 3:00pm by V.P. Clinical Operations 10. Facility Administrator and the DON were provided education on compliance and monitoring procedures by the V.P of Clinical Operations.] On 02/11/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews on 2/11/23 between 5:25 p.m. and 6:41 p.m. facility staff: LVN E 6a to 6p LVN R 6p to 6a CNA S 6a to 2p LVN T 6a to 6p CNAU 10 p to 6 a LVN M 6pto 6a CNA V 2p to 10 p CNA P 2p to 10 p and 10p to 2 a CNA W 2p to 10 p LVN X 6a to 6p Record review of in services and staff interviews indicated they were knowledgeable regarding identifying residents with a change in condition and when to notify the physician. They were able to provide information and refer to policies they were educated on during the in-services they received. The administrative staff to include the DON and ADON were knowledgeable as well. The Administrator, DON and ADON, were informed the Immediate Jeopardy was removed on 02/11/23 at 7:22 p.m. The facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from neglect for 2 of 7 residents reviewed for neglect ( Resident #1 and Resident #3). The facility had system failures in that they failed to: 1. Ensure Resident #1 had nutritional interventions in place such as a way to provide nutrition. 2. Ensure Resident #1 had pressure sore interventions in place such as physician notification and treatment of the wounds. 3. Ensure Resident #3 had interventions in place to prevent the development and worsening of pressure sores. 4. Ensure care plans were developed, in place and implemented for Resident #1 and Resident #3's needs. 5. Ensure the dietician was consulted and dietary interventions were in place for Resident #1 that required nutritional interventions of weight loss, and pressure sores for Resident #1 and #3. 6. Ensure physicians were contacted with a change of condition in Resident #1 and a pressure sore for Resident #3. 7. Ensure wound orders and treatments were in place for resident #3. 8. Ensure their policies and procedures regarding nutrition and pressure sores were followed. 9. Ensure residents were assessed timely regarding pressure sores and ensure documentation was accurate regarding the care and services they required for Resident #1 and Resident #3. An Immediate Jeopardy (IJ) situation was identified on 02/13/23 at 6:05 p.m. While the IJ was removed on 02/15/23 at 6:32 p.m., the facility remained out of compliance at actual harm with a potential for more than minimal harm at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for negative outcomes including death. Findings included: Record review of Resident #1's admission record with a print date of 02/07/23 indicated she was an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses were myocardial infarction, muscle weakness, lack of coordination, hypertension, end stage renal disease and hyperlipidemia. Record review of Resident #1's admission MDS dated [DATE] indicated her cognitive status was severely impaired (BIMS score 7). She required extensive assist with bed mobility, dressing, and toilet use of one-person, limited assistant to transfer with one person. Limited assistance with locomotion off the unit of one person. She was able to eat and drink with supervision and setup help only. Record review of Resident #1's baseline care plan dated 8/30/22 indicated she was a setup help only with eating. She required one person assist with personal hygiene, bed mobility, transfer, and toilet use. She used a wheelchair for a mobility device. The care plan indicated she was alert and cognitively intact. She was occasional incontinent of bowel and bladder. Record review on 02/07/23 revealed Resident #1 did not have a comprehensive care plan. Record review of Resident #1's Nutrition Risk, Mini Nutrition assessment dated [DATE] indicated she weighed 150 pounds. She was on dialysis with no nutritional issues noted. Record review of Dysphagia(swallowing difficulty) Consultation dated 01/19/23 indicated meal recommendations for Resident #1. Pleasure comfort feedings of pureed as accepted or tolerated, encourage more upright head posture, employ good oral care, cued cough to help clear upper airways, liquids nectar thick and pills are a choking risk crush medication. Feed slowly and carefully, hand over hand assistance, no straws, resident to be fed small bits and sips. SLP or trained staff only and monitor for adequate nutrition and hydration. On 01/19/23 at 4:31 p.m. Resident #1 received a new order to discontinue regular texture diet and thin liquids start. Texture and nectar thick liquids. recommended pleasure feeding crushed medications small bites sips and foods recommendations were upright body and head positioning. Signed by LVN G. Record Review of Resident #1's MAR for January 2023 indicated Resident #1 received medications on a regular basis until 01/23/23. Review of the MAR indicated the medications were not given because the resident refused, or they were on hold: Aspirin 81 mg one time a day - for myocardial infraction- was not given from 01/23/23 through 01/31/23 Atorvastatin Calcium 40 mg one by mouth at bedtime for Hyperlipidemia- was given 01/26/23 and 01/31/23 only Folic Acid 400 mg one daily for supplement was not given from 01/23/23 through 01/31/23 Isosorbide Mononitrate ER 30 mg one time daily for hypertension she was not given from 01/23/23 through 01/31/23 Sensipar Tablet 30 MG one time daily for renal disease given on 01/26/23 and 01/31/23 only Metoprolol tartrate 25 mg for hypertension was not given from 01/23 through 01/31/23 Novasourse Renal two times daily was given on 01/26/23 and 01/31/23 on the evening shift only Ticagrelor tablet 90 MG two times daily for blood thinner was not given from 01/23 through 01/31/23 Tums tablet chewable 500 MG three times daily for Calcium supplement was given on 01/26/23 and 01/31/23 on the evening shift only. She also received it on 01/30/23 at the 2p.m. Megestrol Acetate 40mg by mouth four times a day for appetite was given on 0//26/23 at 2 p.m. and 9 p.m. and on 01/27/23 at 9:00 p.m. Record Review of Resident #1's MAR for February 2023 indicated she was not given any medications from 02/01/23 through 02/06/23. Her medications were not given because she refused, or they were on hold. Record review of Resident #1's ADL Nutrition sheet (amount eaten) for January 2023 indicated from 01/23/23 through 01/31/23, Resident #1 refused or did not eat except on 01/26/23 and 01/27/23 in the morning she ate 26 to 50 percent. On the evening of 01/25/23 she ate 51 to 75 percent. Record review of Resident #1's ADL Nutrition sheet (amount eaten) for February indicated from 02/01/23 through 02/06/23 the resident refused or did not eat except. On the evening of 02/01/23 the resident ate 26-50 percent on the morning of 02/04/23 resident #1 ate 51 to 75 percent. Record review of the Resident #1's facility's weights indicated: 12/30/22- 146.3 01/04/23- 146.3 1/12/23 - 147.6 1/20/23- 143.2 1/28/23 -137.1 In 3 months, 9.6 percent. In one month, 5.3 percent both significant weight loss. Record review of the last dialysis sheet dated 01/23/23 the facility presented indicated Resident #1's weight was 61.9 kilometers. (136.47 pounds). Record review of an email provided by the DON dated 02/01/23 indicated the email was to the Dietician. The email stated please look at the following residents Resident #1 had a referral for a tube placement. Record Review of nursing notes for February 2023 nursing notes revealed: On 02/01/23 at 8:49 a.m. Resident #1 refused her medications signed by MA H On 02/01/23 at 4:19 p.m. Resident #1 received new order for G-tube placement per the facility physician and the dialysis physician. Pending appointment. On 02/2/23 at 8:02 a.m. Resident #1 refused medications On 2/2/23 at 4:02 p.m. Resident #1 noted with areas to the right buttock and coccyx that appeared to be moisture associated. There was a small amount of serous exudate cleansed from wound, patted dry and applied Hydrocolloid dressing. Referral to Wound care signed by RN F On 02/03/23 at 9:34 a.m. Resident #1 was unable to swallow. Signed by MA H On 02/04/24 at 454 a.m. Resident #1 laying in bed sleeping currently. She is withdrawn. The resident was refusing to eat, refusing to take medication and had an open area noted to her buttocks. Signed by LVN M On 02/04/23 at 10:11 a.m. medications not administered. Resident #1 was unable to swallow. MA H On 02/05/23 at 10:00 a.m. medications not administered. Resident #1 was unable to swallow. MA H On 02/05/23 at 7:43 p.m. medications not administered. Resident #1 was unable to swallow. LVN Q On 02/06/23 at 12:33 a.m. Resident awake in bed. Hydrocolloid dressing intact to coccyx, sacrum area. Pillows in place. Peg tube placement pending. The resident appetite and fluid intake remained poor. The family visited on 02/05/23 and are aware of Resident #1's global decline. The resident continued dialysis three times a week. On 02/06/23 at 11:24 a.m. a call from the dialysis center stating Resident #1 was unstable to receive her treatment, and they were sending her back to nursing home. Signed by LVN E. On 02/06/23 at 11:39 a.m. Resident #1 refused medications. Signed by MA H. Record revie of nursing notes dated 02/06/23 at 11:45 a.m. Resident #1 Returned from dialysis center with flat affect. She did not respond to verbal stimuli but grimaces her face when turned and repositioned. Wounds to buttocks assessed and reported findings to Wound Care Doctor. Verbal orders were received to discontinue hydrocolloid to coccyx nd begin to cleanse coccyx with wound cleaner, pat dry, apply alginate, cover with foam dressing daily. Signed by RN F On 02/06/23 at 11:45 a.m. Resident #1 Returned from the dialysis center with flat affect. She did not respond to verbal stimuli but grimaces her face when turned and repositioned. Wounds to buttocks assessed and reported findings to Wound Care Doctor. Verbal orders were received to discontinue hydrocolloid to coccyx and begin to cleanse coccyx with wound cleaner, pat dry, apply alginate, cover with foam dressing daily. Signed by RN F On 02/06/23 at 12:05 p.m. during visual rounds, Resident #1 appeared lethargic with difficulty arousing. She did not respond to tactile or verbal stimuli. Three failed attempts to collect her blood pressure on the left wrist. Her heart rate was 78, temperature 96.8 and her respirations were 16. The physician was contacted regarding Resident #1's status and verbal orders were received to send her to the ER for evaluation and treatment. Record review of Resident #1 hospital records dated 2/6/23 indicated the resident assessment plan was failure to thrive. The patient had not been eating or drinking for the past week. Would start on gentle fluids resuscitation; the diagnosis likely dehydration and possible starvation. The EMS reported Resident #1 had a constant decline for the past couple of weeks. She last dialysis was two times in the last week. She was too weak to complete the treatment. She had not been taking her medications. The physical exam indicated diagnosis of end stage renal disease related to high blood pressure in 2016. Encephalopathy progressing since 12/20/22 severe dehydration and malnutrition. The emaciated chronically ill female lost 10 kg=22.05 pounds in the past 3 to 4 months in no acute distress. During an interview on 02/07/23 at 11:47 a.m., LVN E said she worked at the facility for 3 years. She said on 02/06/23 dialysis called and said they were unable to complete dialysis on Resident #1 because she was too unstable. LVN E said dialysis said she was too lethargic and sent her back to the facility. She said Resident #1 came back to the facility and was sent to the hospital on [DATE]. LVN E said the treatment nurse, RN F, was the nurse that assessed Resident #1 and sent her to the hospital. LVN E said she did hear Resident #1 was not eating. She said on 02/07/23, Resident #1 had an appointment to have a feeding tube placed. LVN E said the nurse at the hospital told her on the phone Resident #1 was not a candidate for a feeding tube because she was too weak. She said the staff could not get Resident #1 to eat or drink for a least a week or two. LVN E said Resident #1 was not a DNR and she was not on hospice. She said the family would not change Resident #1's code status. LVN E said she had not personally contacted the physician regarding Resident #1 not eating or drinking. LVN E said the administrative staff were aware Resident #1's condition had declined to not eating anything. During an interview on 02/07/23 at 12:24 p.m. the Administrator said she thought the dialysis clinic sent Resident #1 back to the facility on [DATE] because she refused to allow them to complete dialysis. The Administrator said she knew they had talked to the family about hospice, and the family did not want her to put her on hospice. The Administrator said she thought Resident #1 was supposed to have gotten the feeding tube, 02/07/23. She said Resident #1 was in the hospital, and someone mentioned the hospital said Resident #1 was not a candidate for the feeding tube. The Administrator said she was aware as she could be that Resident #1 was not eating well. She was not familiar with the medical aspect of resident care. During a telephone interview on 02/07/23 at 1:15 p.m., the DON stated she was on leave, at that time, and her last day at work was 02/01/23. The DON the SW from dialysis called and wanted to know if Resident #1 was a DNR. She said the dialysis SW said they were having trouble with Resident #1 tolerating dialysis or receiving full treatment due to her weakness. The Nephrologist recommended putting her on hospice. The DON said the dialysis SW said the family would not consent to Hospice. She said on 02/01/23, the dialysis SW said she received consent from the family, the Nephrologist, and the facility physician for Resident #1 to have feeding tube placed. She said at that time, an appointment was scheduled for a gastrologist to do the feeding tube procedure on 02/07/23. The DON said, as far as she knew, Resident #1 was eating but not a whole lot. She said when Resident #1 ate less than 50 percent, the facility staff would give her a health shake or a sandwich. The DON said there were occasion when Resident #1 was at dialysis and her blood pressure would be too low to perform the procedure, and dialysis had to send Resident #1 back to the facility. During a telephone interview on 02/07/23 at 2:23 p.m., Resident #1's Physician said in the old days a resident could send them straight to the ER to receive a feeding tube. He said now the hospital did not do that any longer. He said they had to schedule an appointment through a GI doctor to get a feeding tube placed. He said they got the first available appointment with GI doctor on 02/07/23. The Physician said potentially, they could have done a nasal gastric tube, but the patient reached and pulled the tube out regularly. He said it would not have done any good to prescribe an appetite stimulate if Resident #1 was not eating at all. He said he did not know until 02/06/23, that Resident #1 was not taking any of her meds and was not able to swallow at all for at least a week. He said if he had known he would have sent her to the hospital, and they would have likely gotten some IV fluids started on Resident #1. The Physician said Resident #1 was having swallowing difficulties before she came to the facility. The facility staff did not tell him Resident #1 was not eating, drinking, or taking her medications. He said what he was told was Resident #1 was not eating well. During an interview on 02/07/23 at 3:20 p.m., LVN J -MDS nurse said Resident #1 did not have a current care plan. She said they were working on getting care plans into the system. LVN J said they had gotten tags in the past regarding residents not having care plans. She said she could not work any faster to get them caught up. She said they hired one staff and she quit so they have not really had any staff since August 2022, and they are doing the best they can. She said some of the older residents had paper care plans in their chart. They are currently updating all the care plans to the system. She said if a resident did not have a care plan in the system and they did not have a paper chart, they did not have a care plan in place. During a telephone interview on 02/07/23 at 3:50 p.m., LVN G said Resident #1 could not eat or swallow anything due to her choking. He said it had been at least a week since she was able to swallow anything. He said they had placed Resident #1 on puree diet the later part if January, and even with diet change she only ate about 25 percent. LVN G said about a week ago an aide told him Resident #1 could not eat, she was choking on her food. He said he had gone down to the room to try and feed Resident #1 himself. He said he tried to get her to eat but she was choking. LVN G said he was able to get her to take half cup thickened liquids, but she had a hard time. He said on the flowing day Resident #1 was just holding food in mouth and not drinking anything. The LVN said he asked the DON and she said they set up an appointment for tube feeding. He said the SW at Dialysis had talked to the dialysis doctor and the facility doctor and receive a go ahead for a feeding tube. LVN G said at the first of January they sent Resident #1 to the hospital and the hospital sent her right back. He said on one occasion he called the NP because Resident #1' BP was really low, and the NP said to just monitor her. The LVN said he reported in the morning meeting, Resident was not eating or drinking. However, he never called the doctor. During an interview on 02/07/23 at 6:04 p.m. LVN M said she worked at the facility for two years. She said Resident #1 was lethargic and weak. She would take Resident #1's vitals, and they were normal. The LVN said most of time, Resident #1's normal BP was low. The LVN said Resident #1 had decline with her eating and was very withdrawn. LVN M said there was nothing alarming that indicated she needed to send Resident #1 to the hospital. LVN M said Resident #1 would take a small amount of liquid. She said that she never called doctor. LVN M said that during shift change DON said to monitor her. During an interview on 02/08/23 at 8:49 a.m., LVN N said she worked at the facility for 14 years. She said Resident #1 had an overall decline. She said Resident #1 could still say her name and say she did not want anything to eat, or if she was in pain. LVN N said Resident #1 began pocketing food at one time and not wanting to swallow. She said she had some aides come up and told her Resident #1 was not eating. She said over a week ago she had worked the evening shift and tried to get Resident #1 to drink. She said Resident #1 took a sip and turned her head. LVN N said the MA told her Resident #1 would not swallow meds even when crushed. She said they could not get her to swallow. LVN N said she never called the Physician. She said she worked with Resident #1 a few times she only worked the floor when they were short. The LVN said she had talked to Resident #1's daughter one evening about 3 weeks ago. She said they talked about Resident #1 declining. LVN N said they talked Resident #1's not eating in morning meeting, and getting with the family about her code status, and her decline changes. The hospital records also indicated Resident #1 had multiple wounds. During a telephone interview on 02/08/23 at 11:07 a.m., the NP said she got a message on 2/6/23 that Resident #1 was sent to the hospital. She said she was aware Resident #1 had a decline, and the facility staff were trying to catch up with the family to see if they wanted to put her on hospice. The NP said she did not know that Resident #1 was not taking any of her mediations. The NP said she was aware the resident refused medications on occasion. She said Resident #1 was [AGE] years old and on dialysis, and dialysis was hard on the body. The NP said dialysis was designed to extend the life but not indefinitely; it was only a short term fix. She said Resident #1 had additional heart concerns. The family did not want to stop dialysis or make her a DNR. She said if she had known Resident #1 was not eating or drinking anything, she would have sent her to the hospital. She said she remembered someone contacting her about Resident #1's low blood pressure but her blood pressure ran low. She said if she had known, she would have sent her out sooner. During an interview on 02/09/23 at 11:59 a.m. the Physician said that no one notified him of Resident #1's pressure sore. He said there is a standard order for wound care. However, they usually notify the Wound doctor and she handled things like that. He was not aware Resident #1 had a wound. During an interview on 02/09/23 at 12:10 p.m. Wound Care Doctor said first she heard about Resident #1's wounds was 2/5/23 about 8pm. She said the DON called or texted her and told her Resident #1's wounds were getting worse. The Wound Care Doctor said on Monday, 02/06/23 RN F called and told her Resident #1 had wounds and she told her to put alginate on the wounds. The Wound Care Doctor said she never saw the wounds. During a telephone interview on 02/08/23 at 1:15 p.m. the Dietician recommendation were made in December. She said Resident #1 did not trigger for weight loss. The Dietician said the last weight I have is 143 on 01/20/23 and that was only a two-pound weight loss. The last time I was at the facility was 1/27/23. The Dietician said the DON sent an email that said the Resident #1 was going to be getting a feeding tube not she had weight loss. She said she had access to the system. If the weight was not in the system, she had no way of knowing there was a problem unless someone physically contacted her. She said with a pressure sore she was notified there was a change in condition, and she needed to see the resident for nutritional interventions. During a telephone interview on 2/9/23 at 12:16 p.m. RN F/treatment nurse said Resident #1's pressure sores were first brought to her attention Thursday, 02/02/23 by an aide. She said she sent a message to the resident's physician and put a treatment in place. She said on 02/03/23 when Resident #1 came back from dialysis she reinforced the bandage. She wrote the late entry 02/07/23 because-she had put something in place and wanted it known that she had done her job, even if she had quit. She said when she saw the areas on 02/03/23 they were not really pressure sores. RN F said when she got to work Monday, 02/06/23 the administrator told her the sores were big enough to put her fist in the wound. She said the administrator told her she had seen a picture of the wounds. According to RN F, Resident #1 had 3 stage 2 wounds that measured 2.0 cm by 2.0 cm. RN F said she knew she was not eating because she had to work on the floor as a charge nurse. The Wound Care Doctor and she said they would do good with alginate. She said she was on the floor on 02/06/23 and received a call from dialysis saying they were sending Resident #1 back to the facility because she was too weak to attend the treatments. She assessed her and sent her out to the hospital. RN F said they all knew Resident #1 was not eating for at least a week. LVN G talked about it most every morning in the morning meeting. Resident #3 Record review of Resident #3's admission record with a print date of 02/07/23 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis was congestive heart failure, respiratory failure, diabetes, high blood pressure kidney disease, and reduced mobility and coordination. The record indicated Resident #3 was discharged on 09/16/22. Record review of Resident #3's admission MDS dated 09/06//22 indicated his cognitive status was moderately impaired. His bed mobility was extensive assist with two people. His ability to transfer was limited assistance with one person. He was able to walk in the room with the supervisor of one person. Resident #3's functional abilities indicated he required supervision or touching assistance to put on or take off socks and shoes. He required the set-up help of one staff. Record review of Resident #3's admission assessment dated [DATE] indicated the resident was admitted to the facility from and ALF due to edema to the bilateral LE with high blood pressure. He was alert times 4. Resident #3 had poor balance and unsteady gait. He was continent of bowel and bladder. His skin assessment revealed right inner arm bruising, lower left leg rear vascular, lower right leg vascular, left gluteal fold redness, and right gluteal fold. His bed mobility, transfers were assisted by staff, and he used a wheelchair. Record review of Resident #3's Baseline Care Plan dated 08/30/22 indicated he was setup help only with eating. Resident #3 required one person assist with personal hygiene, toilet use, dressing, bathing, bed mobility, and transfers. He required the use of a wheelchair. Resident #3 current skin integrity issues were bruises and vascular to bilateral LE. Record review indicated Resident #3 did not have a Comprehensive Care Plan. Record review of Resident #3's skin assessment dated [DATE] indicated no skin issues noted. There was no other skin assessments. Record review of Resident #3's MAR and TAR dated September 2022 showed no documentation of pressure sores or any indication of treatments completed. The MAR indicated Resident #3 received Zinc 50 mg, Vitamin C 500 mg, and B complex starting on 09/27/22. the was no indication the Prostat( protein supplement) was given or on the MAR. There were no orders for treatment of Resident #3's wounds. Record review of a Wound Evaluation and Management Summary (Wound Doctor Note) dated 09/07/22 revealed the chief complaint was multiple wounds. Resident #3 had an unstageable DTI of the right heel for at least 7 days duration. The exam for Peripheral Vascular( narrowed blood vessels that reduce blood flow the limbs), examination of left lower extremities with moderate edema and foot warm, examination of the right lower extremities indicated moderate edema(swollen) foot warm, wound present. Pedal pulses( pulse of blood between the big toe and second toe) to left and right dorsalis pedis( pulse on the lateral extensor tendon of the great toe) detected by portable doppler ( ultrasound used to estimate the blood flow through the vessels. Focused Wound Exam (site 1) Unstageable DTI of right heal partial thickness, Etiology pressure Unstageable DTI within and around the wound with a duration of 7 days, the size of the wound 5cm by 5 cm the surface area is 25cm, exudate was light serous( a thing watery fluid that is produced in response to local inflammation.). The dressing plan was hydrogel wafer apply three times per week for 30 days. Plan of care reviewed and addressed. The recommendations were to off load wound, reposition per facility protocol, sponge boot, Prevalon boot (cushioned bottom that floats the heel off the surface of the matters. A Sage boot.), Zinc sulphate 220 mg by mouth for 14 days, Vitamin C 500 mg twice daily and multivitamin once daily. Site two was a venous wound ( wound with abnormal vein function) of the right superior shin partial thickness and site 3 venous wound of the right, inferior shin partial thickness. Record review of Resident #3's Wound Evaluation and Management Summary dated 09/14/22 indicated Wound care assessment and evaluation was performed. Resident #3 had an unstageable DTI of the left posterior, lateral heel and for at least 1 day's duration. There was no exudated. Site 1- Unstageable DTI of the right heel, partial thickness, etiology pressure, size 6 cm by 7 cm the surface area measured 42 cm the duration is greater than 13 days. Wound progression deteriorated. Dressing hydrogel wafer apply three times per week. The plan was off load, reposition per facility protocol. Sponge boot, prevelon boot. Site 4 Unstageable DTI to left posterior, lateral heel, etiology pressure unstageable DTI . size 1.0 x 1.9 dept not measurable treatment plan the same as site 1. Record review of a nursing note dated 9/11/22 at 1:03 p.m. indicated Resident #3 continued with skilled services for strengthening and conditioning. He continued with wound treatment to the right heel. The resident required assistance with transfers to the bathroom, all needs met at that time. signed by LVN G. (the only nursing note that mentioned wound care.) Record review of Physical Therapy note dated 09/15/22 indicated nursing advised PT Resident #3 should not ambulate any more due to the opening of wound on right heel. Bed mobility was performed. Resident #3 regressed overall due to the wound on the right heel, continued with PT as advised by nursing and Wound Care Doctor. Record review of Physical Therapy notes dated indicated 09/16/22 Resident #3 stated that he felt weak and tired but would try to do his best. Bed mobility performed. Resident #3 was regressing with all mobility tasks since the worsening of wound on right heal. Record review of Occupational Therapy notes indicated on 09/16/22 Resident #3 verbalized pain that limited his functional activities. The resident required increased assistance with ADL performance. Resident #3 said the pain exacerbates with standing. The resident described that pain with movement as 5/10, constant in the heel. With increased aching. Nursing notified and discussed sending the patient to the hospital due to change in condition. Record Review of Resident #3's hospital records dated 09/16/22 indicated hospital problems were the Primary Right Foot Infection with acute kidney disease. His diagnosis acute renal failure, unspecified, pressure injury of skin of right foot, unspecified injury stage. This [AGE] year-old presented to the emergency department due to generalized weakness and right foot wound. The patient stated generalized weakness for about 3 months and progressively worsening. The patient stated chronic right heel wound. The patient was without redness, and no drainage to the right foot wound the wound was covered and had a compressive boot. Resident #3 arrived form nursing home with inflatable heel boot to relieve pressure. Labs revealed acute kidney injury with creatinine elevated from base line. All labs were review on 09/16/22 at 2:13 p.m. acute coronary syndrome, pneumonia, urinary tract infection, deconditioning, anemia, electrolyte disturbance, pulmonary embolism, COPD , asthma, foot wound, foot ulcer, osteomyelitis, sepsis and congestive heart failure. Patient with bilateral foot wound right with dusky black appearance noted at the right heel. The patient with DP Pt pulse in bilateral legs. Patient able to move legs at will. No sensory deficit. Motor strength 5 out of 5 for bilateral lower extremities. Record review of Resident #3's hospital Discharge Course dated 09/26/22 indicated Resident #3 resided at the nursing facility came to the hospital with right diabetic foot wound. Resident #3 received IV antibiotics during the hospital stay along with two debridement's. His medical status gradually worsened during the hospital stay. Resident #3 had a poor prognosis given his advanced age, and diagnoses. Resident #3 was discharged with hospice services. During record review and interview on 02/13/23 at 3:00 p.m., the DON could not find a physician order or treatments for pressure sores on the TAR for Resident #3's pressure sore. During record review and interview on 02/13/23 at 3:15 p.m. the Director of Clinical Informatics reviewed Resident #3's computer and paper file. She said she did not find a physician order or treatments on the TAR for Resident #3's pressure sore. During an interview on 02/09/23 at 11:59 a.m., the Physician said there was a standard order for wound care. He said staff do not normally notify him of wound or pressure sore issues. He said he did not get wound care calls much with the Wound Care Doctor in place. They usually notified the Wound doctor and she handled the wounds. During an interview on 02/13/23 at 3:49 p.m., the Wound Care Doctor said when she did her rounds at the facility, she always had a nurse with her. She said she was reviewing her notes on Resident #3 for 09/14/22. The Wound Care Doctor said she did recommendations. She did not write actual orders. Her recommendation for Resident #3's unstageable be treated with hydrogel waver three times a week. She said with treatment and offloading it should have healed. She said the Venous ulcers would have resolved if they had been offloaded with or without treatment. She said when she saw Resident #3 on 09/14/22 one of the venous ulcers had resolved. She said her treatment recommendations for both heels, were hydrogel waver Unstageable. 3 times a week. She also

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 4 residents reviewed for care plans (Resident #1, Resident #3) Resident #1 had overall ADL decline due to poor nutrition, weight loss and pressure sores with no care plan interventions in place, and she was hospitalized . Resident #3 had a pressure sore that was not treated and caused an overall decline and hospitalization with no care plan interventions in place. The facility was cited for failure to develop and implement a comprehensive person-centered care plan on 08/17/22 during their annual survey. They were also cited on 12/07/22. The facility had an extended period and did not provide care plans as needed for continuity of resident care needs. An Immediate Jeopardy (IJ) situation was identified on 02/10/23 at 4:14 p.m. While the IJ was removed on 02/11/23 at 7:22 p.m., the facility remained out of compliance at actual harm with a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not having individual needs met, and decreased the quality of life. Findings included: Resident #1 Record review of Resident #1's admission record with a print date of 02/07/23 indicated she was an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses were myocardial infarction (heart attack, muscle weakness, lack of coordination, high blood pressure, end stage renal disease and hyperlipidemia. Record review of Resident #1's admission MDS dated [DATE] indicated her cognitive status was severely impaired (BIMS score 7). She required extensive assist with bed mobility, dressing, and toilet use of one-person, limited assistance to transfer with one person. Limited assistance with locomotion off the unit of one person. She was able to eat and drink with supervision and set help only. Record review of Resident #1's admission assessment dated [DATE] indicated she received dialysis 3 times a week. She weighed 150 pounds. She was incontinent of bowels and bladder and had no skin issues identified. She was totally dependent for bed mobility, transfers, personal hygiene, bathing, and dressing. Resident #1 required assistance of staff for eating. She used a wheelchair. She did not receive therapy. Record review of Dysphagia ( difficulty swallowing) Consultation dated 01/19/23 indicated meal recommendations for Resident #1. Pleasure comfort feedings of pureed as accepted or tolerated, encourage more upright head posture, employ good oral care, cued to cough to help clear upper airways, liquids nectar thick and pills are a choking risk crush medication. Feed slowly and carefully, hand over hand assistance, no straws, resident to be fed small bits and sips. SLP or trained staff only and monitor for adequate nutrition and hydration. Record review of Resident #1 hospital records dated 2/6/23 indicated the resident assessment plan was failure to thrive. The patient had not been eating or drinking for the past week. Would start on gentle fluids resuscitation; the diagnosis likely dehydration and possible starvation. The EMS reported Resident #1 had a constant decline for the past couple of weeks. She last dialysis was two times in the last week. She was too weak to complete the treatment. She had not been taking her medications. The physical exam indicated diagnosis of end stage renal disease related to high blood pressure in 2016. Encephalopathy progressing since 12/20/22 severe dehydration and malnutrition. The emaciated chronically ill female lost 10 kg=22.05 pounds in the past 3 to 4 months in no acute distress. Record review on 02/07/23 revealed Resident #1 did not have a comprehensive care plan. Record review of Resident #3's admission record with a print date of 02/07/23 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis was congestive heart failure, respiratory failure, diabetes, hypertension, kidney disease, and reduced mobility and coordination. The record indicated Resident #3 was discharged on 09/16/22 with 17 days stay to an acute hospitalization. Record review of Resident #3's admission assessment dated [DATE] indicated the resident was admitted to the facility from an ALF due to edema to the bilateral LE with high blood pressure. He was alert times 4. Resident #3 had poor balance and unsteady gait. He was continent of bowel and bladder. His skin assessment revealed right inner arm bruising, lower left leg rear vascular, lower right leg vascular ( areas caused by decreased blood flow), left gluteal fold redness, and right gluteal fold. His bed mobility, transfers were assisted by staff, and he used a wheelchair. Record review of Resident #3's Baseline Care Plan dated 08/30/22 indicated he was setup help only with eating. Resident #3 required one person assist with personal hygiene, toilet use, dressing, bathing, bed mobility, and transfers. He required the use of a wheelchair. Resident #3 current skin integrity issues were bruises and vascular to bilateral LE. Record review revealed Resident #3 did not have a Comprehensive Care Plan. Record review of a Wound Evaluation and Management Summary( Wound Doctor Note) dated 09/07/22 reflected The chief complaint was multiple wounds. He had an unstageable DTI( deep tissue injury) of the right heel for at least 7 days duration. There is light serous drainage. Focused Wound Exam (site 1) Unstageable DTI of right heal partial thickness, Etiology pressure Unstageable DTI within and around the wound with a duration of 7 days, the size of the wound 5cm by 5 cm the surface area is 25cm, exudate was light serous. The dressing plan was hydrogel wafer apply three times per week for 30 days. Plan of care reviewed and addressed with facility staff. The recommendations were to off load wound, reposition per facility protocol, sponge boot, Prevalon boot(cushioned bottom that floats the heel off the surface of the matters. A Sage boot.), Zinc sulphate 220 mg by mouth for 14 days, Vitamin C 500 mg twice daily and multivitamin once daily. Discussed the etiology of wound, offloading, repositioning, prevalon boot, nutrition, vitamin supplementation with treatment nurse Record review of Resident #3 clinical record reveled he did not have a facility physician orders to treat his wounds, and no treatment administration record that indicated his wounds were being treated. He did not have an order for a pressure reducing boot. During an interview on 02/07/23 at 3:20 p.m. the Corporate MDS Nurse said LVN J said they had gotten tags in the past regarding residents not having care plans. The Corporate MDS Nurse said they cannot work any faster to get them caught up. She said they hired one staff and she quit so they have not really had any staff since August 2022, and they are doing the best they can. LVN J said some of the older residents had paper care plans in their paper chart. They are currently updating all the care plans to the system. She said if a resident did not have a care plan in the system and they did not have a paper chart, they did not have a care plan in place. She said Resident #1 and Resident # 3 did not have care plans at the current time. Resident #3 was discharged but they would work on getting Resident #1's care plan completed today. During an interview on 02/07/23 at 4:00 p.m. the ADON and Administrator said they did not have a care plan for Resident #3. The Administrator said they have some paper charts at the nurse's station, and they are working to get all care plans uploaded into their computer system. The ADON said Resident #3 was discharged and he was not on the list for his care plan to be updated. The Administrator said she was aware the facility had care plans that were not current. The administrator said they had some staffing issues with the MDS nurses but hopefully they had staff. During an interview on 02/08/23 9:45 a.m. the ADON said Care plans on Resident #1 was completed last night by the Corporate MDS nurse. She said Residents #3 did not have valid a care plan. Review of the facility policy on Care Plans, Comprehensive Person Center dated December 2016 indicated . A comprehensive, person centered care plan that included measurable objectives and time tables to meet the residents' physical, psychosocial and functional needs is developed and implemented for each resident . The care plan interventions are derived from a through analysis of the information gathered as part of the comprehensive assessment. The facility was notified of the IJ in Comprehensive Care plans on 03/06/23 at 12:00 p.m. via email. The facility provided a plan of removal on 2/11/23 that addressed the development of Baseline Care Plans and Comprehensive Care Plans. [POR for F656 and 692 1. Residents with significant weight variances will be reviewed for RD evaluation, care plan implementation and notification to MD/PCP and responsible party. Corrective actions taken for identified significant weight loss variances (1 month - 5% or greater, 3 months - 7.5% or greater, 6 months - 10% or greater) will include notification to residents PCP/designee and responsible party by nurse management/ designee, care plans will be reviewed by nurse management/designee for weight loss and specific interventions implemented. Resident care plans will be reviewed/revised to include specific interventions for weight loss concerns by MDS Coordinator and/or nursing management. o Initiated: 2/10/23 @ 7:45 AM by DON/RD o Completed: 2/10/23 @ 8:30pm 2. Residents EMR will be reviewed for baseline care plan completion. No residents were identified to need a baseline care plan as a result of the audit. o Initiated: 2/10/23 @ 7:45 AM by DON/ RD. o Completed: 2/10/23 @ 10:45am by MDS Coordinator. 3. The facility DON was provided education by the V.P. of Clinical Operations on the following topics: a) Change in a residents' status - Discussion included review of Change in a Resident's condition or Status Policy & Procedure. Examples of changes in condition and notification expectations to MD/PCP and responsible party. Specific content of the change in a residents condition status policy were reviewed during the discussion. Three sections of this policy referenced significant changes in the resident physical/emotional/mental condition and defined significant change of condition as a major decline or improvement in the residents status that : i. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); ii. Impacts more than one area of the resident's health status; iii. Requires interdisciplinary review and/or revision to the care plan; and iv. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. The policy provided interpretation and implementation guidance for the nurse to record in the residents' EMR information relative to changes in the residents medical/mental condition or status. Refer to attached Policy and Procedure. Other relevant information contained in the policy referenced notification to residents attending physician or physician on call when there had been a need to alter the resident's medical treatment significantly. b) Baseline Care Plan - Discussion of timeframe and procedure for completion. The Baseline care plan policy indicated that a baseline plan of care to meet the resident's immediate needs should be developed for each resident within 48 hrs of admission. The baseline care plan is to assure that the resident's immediate care needs are met and maintained. The policy indicated areas to review to develop the baseline care plan to meet the residents immediate care needs including dietary and physician orders. The baseline care plan will be used until the comprehensive assessment and interdisciplinary person-centered care plan is developed. The policy indicates the process for communicating the baseline care plan summary content to the resident and their representative. The summary content can include resident's medications, dietary instructions, and initial goals of the residents. Refer attached Policy and Procedure. o Initiated: 02/10/23 @ 11:00 pm by V.P. Clinical Operations. o Completed: 02/10/23 @ 11:45 PM by V.P Clinical Operations o Initiated: 02/10/23@ 6:45 AM By V.P. Clinical Operations o Completed: 2/10/23@ 3:00pm a) Baseline Care Plan - The Baseline care plan auto flags in EMR on the Resident's admission assessment. The charge nurse must initiate and complete within 48 hours after admission. Print the Resident's baseline care plan, Order Summary and review with the Resident and/or responsible party. After review the nurse will obtain signature(s) of the resident /responsible party and the nurse is to sign the care plan after completed. Nurse will then place in organizer file for medical records to scan. Refer to Policy and Procedure. o Initiated: 02/10/23 @ 6:45 AM By V.P. Clinical Operations o Completed: 2/10/23 @ 3:00pm by V.P. Clinical Operations The Interdisciplinary care plan team will be provided education by the V.P. of Clinical] On 02/11/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews on 2/11/23 between 5:25 p.m. and 6:41 p.m. facility staff: LVN E 6a to 6p LVN R 6p to 6a CNA S 6a to 2p LVN T 6a to 6p CNAU 10 p to 6 a LVN M 6pto 6a CNA V 2p to 10 p CNA P 2p to 10 p and 10p to 2 a CNA W 2p to 10 p LVN X 6a to 6p Indicated they were knowledgeable regarding the importance of developing and implementing care plans for the administrative staff. They were able to provide information an refer to policies they were educated on during the in-services they received. The administrative staff to include the DON and ADON were knowledgeable as well. The facility also provided an audit of care plans that indicated all care plans were up to date as of 2/10/23. Review of two additional residents care plans indicated care plans were updated. The facility completed and updated care plan of Resident #1 after her return to the facility. The Administrator, DON and ADON, were informed of the Immediate Jeopardy on 3/6/23 at 12:00p.m. The facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review based on the comprehensive assessment the facility failed to ensure residents received care consistent with professional standards of practice to promote healing and prevent infection and new pressure sores from developing for 2 of 5 residents reviewed for pressure sores. (Resident #1 and Resident #3) 1. The facility failed to notify the physician of the pressure sores for Resident #1 and Resident #3 2. The facility failed to obtain treatment orders for treatment wounds for Resident #1 and Resident #3 3. The facility failed to ensure the dietician was notified, and the resident receive nutritional interventions Resident #1 and Resident #3 4. They failed to ensure the Wound Care Doctor recommendations were followed for Resident #3 5. They failed to ensure Resident #3 had an order and the correct pressure relieving boot were applied for Resident #3 6. They failed to ensure timely skin assessments for Resident #1 and Resident #3 7. They failed to ensure they had a comprehensive assessment that addressed resident care needs for Resident #1 and Resident #3. An Immediate Jeopardy (IJ) situation was identified on 02/13/23 at 6:05 p.m. While the IJ was removed on 02/15/23 at 6:32 p.m., the facility remained out of compliance at actual harm with a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems These failures placed residents at risk for pain, worsening of wounds, wound infection, emotional distress, harm, and death. Findings Included: Record review of Resident #3's admission record with a print date of 02/07/23 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis was congestive heart failure, respiratory failure, diabetes, hypertension, kidney disease, and reduced mobility and coordination. The record indicated Resident #3 was discharged on 09/16/22 with 17 days stay to an acute hospitalization. Record review of Resident #3's admission MDS dated 09/06//22 indicated his cognitive status was moderately impaired. His bed mobility was extensive assist with two people. His ability to transfer was limited assistance with one person. He was able to walk in the room with the supervisor of one person. Resident #3's functional abilities indicated he required supervision or touching assistance to put on or take off socks and shoes. He required the set-up help of one staff. Record review of Resident #3's admission assessment dated [DATE] indicated the resident was admitted to the facility from and ALF due to edema to the bilateral LE with high blood pressure. He was alert times 4. Resident #3 had poor balance and unsteady gait. He was continent of bowel and bladder. His skin assessment revealed right inner arm bruising, lower left leg rear vascular, lower right leg vascular, left gluteal fold redness, and right gluteal fold. His bed mobility, transfers were assisted by staff, and he used a wheelchair. Record review of Resident #3's Baseline Care Plan dated 08/30/22 indicated he required setup help only with eating. Resident #3 required one person assistance with personal hygiene, toilet use, dressing, bathing, bed mobility, and transfers. He required the use of a wheelchair. Resident #3's skin integrity issues were bruises and vascular( areas caused by decreased blood vessel flow) to bilateral LE. Record review indicated Resident #3 did not have a Comprehensive Care Plan. Record review of Resident #3's skin assessment dated [DATE] indicated no skin issues noted. There was no other skin assessment noted. Record review of Resident #3's Braden Scale dated 08/30/22 indicated he had a score of 18 (15-18 high risk) high risk for pressure sores. His skin was occasionally moist, he was chair fast, his mobility was slightly limited, he received adequate nutrition. Resident #3 was not at risk for shear or friction. Record Review of a Physician's Order Form dated 08/29/22 indicated Resident #3 was released from the hospital yesterday. He was weak and unable to care for himself. Please send order for him to go to rehab. Record review of Resident # 3 History and Physical dated 08/31/22 indicated the [AGE] year-old was admitted to the facility due to recent heart failure. He denied any pain and his skin was warm and dry. His restorative potential was fair. Record review of Resident #3's computerized Physician order for September 2022 indicated an order for pressure reducing cushion to the wheelchair and pressure reducing mattress to the bed with a start date of 08/31/22. There were no treatments noted for pressure sores. There was no order for pressure relieving boots. Record review of Resident #3's handwritten orders indicated on 09/07/22 an order for vitamin C 500 mg a day for 14 days, Zinc 50 mg a day for 14 days, B Complex a day for 14 days and Prostat 30ml two times daily for 14 days all for wound healing of the right heel. Record review of Resident #3's MAR and TAR dated September 2022 showed no documentation pressure sores or any indication of treatments completed. The MAR indicated Resident #3 received Zinc 50 mg, Vitamin C 500 mg, and B complex starting on 09/27/22 the was no indication the Prostat( protein supplement) was given or on the MAR Record review of a Wound Evaluation and Management Summary( Wound Doctor Note) dated 09/07/22 The chief complaint was multiple wounds. At the referring providers request and evaluation was performed on Resident #3. He had and unstageable DTI of the right heel for at least 7 days duration. There is light serous exudate. There is no indication of pain associated with this condition. Diabetic Foot Exam indicated left and right foot response to monofilament testing with limited sensation. The exam for Peripheral Vascular, examination of left lower extremities with moderate edema and foot warm, examination of the right lower extremities indicated moderate edema foot warm, wound present. Pedal pulses to left and right dorsalis pedis detected by portable doppler. Focused Wound Exam (site 1) Unstageable DTI of right heal partial thickness, Etiology pressure Unstageable DTI within and around the wound with a duration of 7 days, the size of the wound 5cm by 5 cm the surface area is 25cm, exudate was light serous. The dressing plan was hydrogel wafer apply three times per week for 30 days. Plan of care reviewed and addressed. The recommendations were to off load wound, reposition per facility protocol, sponge boot, Prevalon boot(cushioned bottom that floats the heel off the surface of the matters. A Sage boot.), Zinc sulphate 220 mg by mouth for 14 days, Vitamin C 500 mg twice daily and multivitamin once daily. Site two was a venous wound of the right superior shin partial thickness and site 3 venous wound of the right, inferior shin partial thickness. The plan was to discuss Resident #3's BMI with the dietician. Resident #3's care was discussed with another health care provider assigned nurse (LVN E) during this visit. Discussed the etiology of wound, offloading, repositioning, prevalon boot, nutrition, vitamin supplementation with treatment nurse (LVN E- who said she did not remember anything about Resident #3.) Record review of Resident #3's Mini Nutrition assessment dated [DATE] indicated an admission assessment. The resident weighed 208 pounds. He had no automatic referrals checked. (Pressure sore was listed as an automatic referral. ) The assessment indicated no issues noted, Resident #3 had no weight loss and fed himself. No signature Record review of Medical Nutritional Therapy assessment dated [DATE] indicated Resident #3 weighed 206 pounds. He had no pressure injuries. Indicated intakes and meals adequate to meet his needs. Signed by Dietician. Record review of Occupational Therapy notes indicated the on 09/05/22 Resident #3 performed UB exercise in all planes. Used a can for 2 sets of 25. Resident #3 required moderate assistance with shoes and sink side ADLs with set up assist. Record review of Physical Therapy notes dated indicated on 09/07/22 Resident #3 said he felt great this morning and is ready to work with PT. He was able to ambulate approximate 100 to 150 feet with rolling walker. Record review of a nursing note dated 9/11/22 at 1:03 p.m. indicated Resident #3 continued with skilled services for strengthening and condition. He continued with wound treatment to the right heel. The resident required assistance with transfers to the bathroom, all needs meet at this time. signed by LVN G. (the only nursing note that mentioned wound care.) Record review of Physical Therapy notes dated indicated on 09/13/22 Resident #3 reported pain and discomfort on the right heel with weight bearing. Nursing is aware and a dressing was placed on the heel for protection. The resident was able to ambulate approximately 100 to 80 feet with rolling walker. Record review of a NP note dated 9/13/22 indicated Resident denied any pain or distress. He had 2 plus edema to his bilateral to the LE. Resident #3 was also noted with superficial venous wounds time two the right leg and a DTI to the right heel. The assessment/plan was to continue LE elevation three times a day, Venous insufficiency with right LE wounds, continue follow-up with Wound Care Doctor and wound care, right heel DTI, see above, continue no shoe to right foot, and heel float off the bed while lying or reclined. Record review of Physical Therapy notes dated indicated on 09/14/22 Resident #3 report pain and discomfort in the right heel with all weight bearing tasks, nursing is aware of patient's status. Record review of Resident #3's Wound Evaluation and Management Summary dated 09/14/22 indicated Wound care assessment and evaluation was performed today. Resident #3 had an unstageable DTI of the left posterior, lateral heel and for at least 1 day's duration. There is no exudated. Site 1- Unstageable DTI of the right heel, partial thickness, etiology pressure, size 6 cm by 7 cm the surface area measured 42 cm the duration is greater than 13 days. Wound progression deteriorated. Dressing hydrogel wafer apply three times per week. The plan was off load, reposition per facility protocol. Sponge boot, prevelon boot. Site 4 Unstageable DTI to left posterior, lateral heel, etiology pressure unstageable DTI . size 1.0 x 1.9 dept not measurable treatment plan the same as site 1. Record review of Physical Therapy notes dated indicated on 09/15/22 nursing advised PT that Resident #3 should not ambulate any more due to opening of wound on right hell. Bed mobility performed. Resident #3 is regressing overall due to the wound on the right heel, continue with PT as advised by nursing and Wound Care Doctor. Record review of Physical Therapy notes dated indicated 09/16/22 Resident #3 stated that he felt weak and tired but would try to do his best. Bed mobility preformed. Resident #3 was regressing with all mobility tasks since the worsening of wound on right heal. Record review of Occupational Therapy notes indicated the on 09/16/22 Resident #3 verbalized pain that limed his functional activities. The resident required increased assistance with ADL performance. Resident #3 said the pain exacerbates with standing. The resident described that pain with movement as 5/10, constant in the heel. With increased aching. Nursing notified and discussed sending the patient to the hospital due to change in condition. Review of nursing note dated 9/16/22 indicated at 9:50 a.m. staff voiced the resident with decline in condition, increased weakness and required maximum assistance with all care and ADLs. Review of nursing note dated 9/16/22 at 10:27 a.m. indicated the family was notified of changes in Resident #3's condition and he was going to the hospital. The resident voiced he is feeling tired and not himself. Noted wound to the right heel, therapy indicated he tolerated poorly today. Record Review of Resident #3's hospital records dated 09/16/22 indicated hospital problems were the Primary Right Foot Infection with acute kidney disease. His diagnosis acute renal failure, unspecified, pressure injury of skin of right foot, unspecified injury stage. This [AGE] year-old presented to the emergency department due to generalized weakness and right foot wound. The patient stated generalized weakness for about 3 months and progressively worsening. The patient stated chronic right heel wound. The patient was without redness, and no drainage to the right foot wound the wound was covered and had a compressive boot. Resident #3 arrived form nursing home with inflatable heel boot to relieve pressure. Labs revealed acute kidney injury with creatinine elevated from base line. All labs were review on 09/16/22 at 2:13 p.m. acute coronary syndrome, pneumonia, urinary tract infection, deconditioning, anemia, electrolyte disturbance, pulmonary embolism, COPD , asthma, foot wound, foot ulcer, osteomyelitis, sepsis and congestive heart failure. Patient with bilateral foot wound right with dusky black appearance noted at the right heel. The patient with DP Pt pulse in bilateral legs. Patient able to move legs will. No sensory deficit. Motor strength 5 out of 5 for bilateral lower extremities. Record review of Resident #3's hospital Discharge Course dated 09/26/22 indicated a past history of coronary artery disease, chronic systolic heart failure, stage 3 chronic kidney disease, essential hypertension, prostate cancer, hyperlipidemia who currently resided at the nursing facility came to the hospital with right diabetic food wound. Resident #3 received IV antibiotics during the hospital stay along with two debridement's. His medical status gradually worsened during the hospital stay. Resident #3 had a poor prognosis given his advanced age, and diagnoses. Resident #3 was discharged with hospice services. During record review and interview on 02/13/23 at 3:00 p.m. the DON could not find a physician order or treatments for pressure sores on the TAR for Resident #3's pressure sore. During record review and interview on 02/13/23 at 3:15 p.m. the Director of Clinical Informatics reviewed Resident #3's computer and paper file. She said she did not find a physician order or treatments on the TAR for Resident #3's pressure sore. During record review and interview on 02/13/23 at 3:37 p.m. the VP of Clinical Operations said she did action plan 10/24/22 and did an action plan on skin. Fixed problem in the POR for skin. During an interview on 02/13/23 at 3:49 p.m. the Wound Care Doctor said when she did her rounds at the facility, she always had a nurse with her. She said she was reviewing her notes on Resident #3 for 9/14/22. The Wound Care Doctor said she did recommendations. She did not write actual orders. Her recommendation for Resident #3's treatment for the unstageable was hydrogel waver three times a week. She said with treatment and offloading it should have healed. She said the Venous ulcers would have resolved if they had been offloaded with or without treatment. She said her treatment recommendations for both heels, were hydrogel waver Unstageable. 3 times a week. She also recommended pressure relieving boot. The number one goal is to keep the foot off loaded. The Care Doctor said she did not remember the resident not having a dressing on his wounds when she saw hm. She said there was no reason for her to think his treatments were not completed as recommended. During an interview on 02/08/23 8:49 a.m. LVN N said she worked at the facility for 14 years. She said she remembered Resident #3 was admitted for therapy was diabetes. LVN N said she recalled sending Resident # 3 out to the hospital on [DATE]. She said during therapy he had a change of condition. She said therapy had informed her Resident #3 could not assist in toileting or dressing himself. LVN N said she checked his vitals and noted an overall change. She said she contacted the NP and sent him out. LVN N said staff noted his change may have begun the night before, LVN N said she did not remember much about Resident #3, she did not work the floor regularly. During an interview on 02/09/23 at 9:50 DON said Resident # 3 was admitted with a pressure sore and was on antibiotics- for the wound on admission. (there was no documentation on this information) During an interview on 02/09/23 at 11:50 a.m. the PTA said she remembered Resident #3 was up and walking around. She said the day before he went to the hospital, he said he did not feel well and did not participate well with therapy that day, 09/15/22. The PTA said next day he was unable to dress himself and had a total ADL decline. The PTA said she talked to ADON, and they sent him out. She said she remembered he did have a pressure sore on his heel, and he wore a boot, but could not remember what kind. During an interview on 02/09/23 at 11:59 a.m. the Physician said there was a standard order for wound care. He said staff did not normally notify him of wound or pressure sore issues. He said he did not get wound care calls much with the Wound Care Doctor in place. They usually notify the Wound Doctor and she handled the wounds. During a telephone interview on 02/10/23 at 10:45 a.m. a family friend. They said prior to admission to the facility the [AGE] year-old man was very with it and was driving. They said when Resident #3 was admitted to the facility he had an area on his heel. The family friend said they had visited with him a few times during his stay at the facility. They came to see him one day and he was sick, he was not himself at all. They said he had on a boot that they removed the boot, and the sore on his heel was large, black, and draining. They said he did not have a bandage on the heel. The family friend said she had pointed out the area to the facility staff. They said that may have been the day he went to the hospital. During an interview on 02/13/23 at 11:40 a.m. LVN E said she did not remember Resident #3. She said he was not on her hall. LVN E said she sometimes did rounds with the Wound Care Doctor. She did not remember if Resident #3 had a wound or not. LVN E said she could not remember who the treatment nurse was during that time Resident #3 was in the facility or if they had a treatment nurse. During record review and interview on 02/13/23 at 4:00 p.m. LVN G said he did complete Resident #3's admission assessment dated [DATE]. He said when Resident #3 was admitted he had some redness on his lower extremities but no pressure sore. LVN G said he had written a note on 9/11/22 regarding Resident #3's pressure sore. He said he did not provide a treatment and did not know if there was an order or not. Resident #3 had some skin that was loose on his heel, and LVN G said he had just cleaned that area. He said he did not follow an order for that. LVN G said. the Wound Care Doctor must have seen him before because he remembered something about that. He said it had been a while and his memory was foggy. During an interview on 02/13/23 at 4:05 p.m. LVN E said she did not remember Resident #3. She said she did not remember if she did anything with him or not. (LVN E was identified by the DON as the person the named in the Wound Care Doctor documentation on 9/7/22 that LVN E was informed of the doctor's plan of care for Resident #3.) During an interview on 02/13/23 at 5:50 p.m. the administrator said she vaguely remember Resident #3. She knew he came from an assisted living. She said if they had a system problem it was due to poor documentation and the facility not following policy and procedures. During an interview on 02/15/230 at 3:43 p.m. the Regional Director of Therapy said she could not find an order for a boot for Resident #3. During an interview on 02/15/230at 3:58 p.m. CPTA said Resident #3 wore dress shoes. she thought he could put them on himself. She said the last few days he had a decline and required more assistance with everything. During an observation and interview on 02/15/230a t 3:58 p.m. the DON said they did not have inflatable pressure reduction boots. She said sometimes residents came for the hospital with their own. The DON said if Resident # 3 had an inflatable boot they were not provided by the facility. The DON said they used Prevalon heel protectors, they were cloth, washable, and went little over half way up the calf. She said they also the used the cloth heal protectors that stop at the ankle. She said if the residents had heel protectors they usually had an order for the boots. During an interview on 02/15/23 at 5:56 p.m., CNA P said she worked at the facility for 10 years. She said she remembered Resident # 3, he was good resident that was basically independent when he was first admitted . She said he did have a boot and she thought he brought a boot with him from home and it was plastic. She said she did not think the facility had that kind of boot. She said he would try to wear shoes all the time and they would have to remind him to keep his shoes off his feet. She said the sore on his heel got worse. CNA P said the last few days he was not able to put shoes on, he declined. She said a few days prior to hospitalization Resident #3 said his foot was hurting Resident #1 Record review of Resident #1's admission record with a print date of 02/07/23 indicated she was an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses were myocardial infraction, muscle weakness, lack of coordination, hypertension, end stage renal disease and hyperlipidemia. Record review of Resident #1's admission MDS dated [DATE] indicated her cognitive status was severely impaired (BIMS score 7). She required extensive assist with bed mobility, dressing, and toilet use of one-person, limited assistant to transfer with one person. Limited assistance with locomotion off the unit of one person. She was able to eat and drink with supervision and set help only. Record review on 02/07/23 revealed Resident #1 did not have a comprehensive care plan. Record review of Resident #1's weekly skin observation dated 12/5/22 indicated no skin issues. Record review of Resident #1's Braden Scale for Predicting Pressure Ulcer Risk indicated she had no sensory impairment, she had skin that was moist most of the time, she was chair fast, and slightly limited mobility, she had adequate nutrition, a potential problem for friction and shear. Her score was 16 ( 15-18 high risk) Record review of Resident #1's Nutrition Risk, Mini Nutrition assessment dated [DATE] indicated she weighed 150 pounds. She was on dialysis with no nutritional issues noted. Record review of Resident #1's Weekly Skin Observation dated 01/20/23 indicated a blister to the sacrum and a rash to the left gluteal fold. (last) Record review of nursing note dated 01/ 25/ 23 at 5:01 p.m. indicated resident number one was laying in bed open area noted to her buttocks will continue to monitor incontinent care. Signed by LVN M Record review of a nursing note dated 01/26/23 at 12:37 p.m. indicated a full assessment was performed on Resident #1. she was lying in bed on right side she appeared the lethargic but aroused to tactile stimuli the resident denied pain when asked but grimaced when repositioned in bed. There was a small area of MSD to the sacrum, zinc ointment applied and to apply every shift and as needed for incontinent episodes resident #3 tolerated without difficulty. this skilled nurse to monitor and meet needs as they arise. Signed by LVN F. Record review of nursing note dated 2/2/23 at 4:02 p.m. Resident #1 noted with areas to the right buttock and coccyx that appeared to be moisture associated. There was a small amount of serous exudate cleansed from wound, patted dry and applied Hydrocolloid dressing. Referral to Wound care signed by RN F. Record review of nursing notes dated 02/06/23 at 12:33 a.m. Resident awake in bed. Hydrocolloid dressing intact to coccyx, sacrum area. Pillows in place. Peg tube placement pending. Record review of nursing notes dated 02/06/23 at 11:45 a.m. Resident #1 Returned form dialysis center with flat affect. She did not respond to verbal stimuli but grimaces her face when turned and repositioned. Wounds to buttocks assessed and reported findings to Wound Care Doctor. Verbal orders were received to discontinue hydrocolloid to coccyx and begin to cleanse coccyx with wound cleaner, pat dry, apply alginate, cover with foam dressing daily. Signed by RN F Record review of Resident #1's computerized physicians order for 01/15/23 through 02/15/23 indicated an order dated 0/26/23 at 6 p.m. indicated Sin ointment to sacrum every shift and as needed. On an order dated 02/07/23 at 6:00 p.m. to cleanse left sacral wound #3 with wound cleanser, pat dry apply alginate and foam dressing daily. Cleanse right sacral wound #2 with wound cleanser, pat dry apply alginate and foam dressing daily. Cleanse superior scar wound #1 with wound cleanser, pat dry, apply alginate and foam dressing daily. Record review of Resident #1's Weekly Skin Observation dated 02/7/23 indicated a it was a full assessment for 02/03/23 indicated Resident #1 had MASD (moistures associated skin damage) on the sacrum that measured 2 by 2 by 0.1 And MASD to the right gluteal fold that measured 2 by 2 by 0.1. Hydrocolloid dressing in place, the skin is fragile noted to upper and lower buttocks referred to wound care. Record review of hospital records dated 2/7/23 at 3:10 p. m. indicated Resident #1 had a wound care consult due to multiple wounds. She had a deep tissue injury to the sacrum that measured 9 cm by 12 cm by 0.1 cm. she had a right thigh posterior deep tissue injury that was 2 cm by 10 cm by 0.1. cm. During an interview on 02/07/23 at 5:56 p.m. CNA L said she did not see a pressure sore on Resident #1 but they said she had one from the other staff, no one in particular. She said she did not work with her often. However the resident did not want turn roll, move, pick up head nothing During an interview on 02/07/23 at 6:00 p.m. CNA K said she saw a sore on Resident #1's right hip about a week before she left. She did not remember there being a bandage on the area and could not remember how big. She put her fingers together like a quarter size area. During an interview on 02/07/23 at 6:04 p.m. LVN M said she found Red open area on Resident #1's bottom. She said she sent a communication form to the treatment nurse/ RN F During an interview on 02/08/23 9:45 a.m. the ADON said LVN F's quit work on the morning of 02/07/23. She said LVN F's computer access was terminated due to her putting a skin assessment in the computer system on the night of 02/07/23. During an interview on 02/08/23 at 10:04 a.m. Administrator said Resident #1 did not have a skin assessment on 02/07/23 in the system. She said she had one that day because the RN F had put a skin assessment in after she asked her why they were not completed. The Administrator said they were looking at the computer last night and saw RN F had put a note in system after 5:00 p.m. During an interview on 02/08/23 at 11:12 the DON said LVN E called on Sunday, 02/05/23 and told her about pressure sores on Resident #1. The DON said she texted the wound care doctor on Sunday to see if she would look at the wounds on her regular visit on 02/07/23. During an interview on 02/08/23 at 1:25 p.m. LVN E said she saw some areas on Resident #1's bottom on Friday 2/3/23. She said there were 3 wounds. LVN E said one was about two centimeters and bleeding it was opened, there was one the right hip area, when she saw them on Friday, they were about quarter size. She said there was scar tissue beside the smaller one. She said she notified the treatment nurse RN F. Then on Sunday, 02/05/23 there was a Hydrocolloid bandage on the wound. She said she did not know if there was an order, she just put the same thing back on. She said Resident #1 had a BM and the bandage was dirty. LVN E said Resident #1's wounds were bigger and worse. she said they were about the size of a 50-cent piece. LVN E said at that time she called the DON and reported her findings. During an interview on 02/09/23 at 11:59 a.m. the Physician said that no one notified him of Resident #1's pressure sore. He said there is a standard order for wound care. However, they usually notify the Wound doctor and she handled things like that. He was not aware Resident #1 had a wound. During an interview on 02/09/23 at 12:10 p.m. Wound Care Doctor said first she heard about Resident #1's wounds was 2/5/23 about 8pm. She said the DON called or texted her and told her Resident #1's wounds were getting worse. The Wound Care Doctor said on Monday, 02/06/23 RN F called and told her Resident #1 had wounds and she told her to put alginate on the wounds. The Wound Care Doctor said she never saw the wounds. During a telephone interview on 2/9/23 at 12:16 p.m. RN F/treatment nurse said Resident #1's pressure sores were first brought to her attention Thursday, 02/02/23 by and aide. She said she sent a message to the resident 's physician and put a treatment in place. She said on 02/03/23 when Resident #1 came back from dialysis she reinforced the bandage. She wrote the late entry 02/07/23 because-she had put something in place. She said when she saw the areas on 02/03/23 they were not really pressure sores. RN F said when she got to work Monday, 02/06/23 the administrator told her the sores were big enough to put her fist in the wound. She said the administrator told her she had seen a picture of the wounds. According to RN F Resident #1 had 3 stage 2 wounds that measured 2.2 cm by 2/2 cm. RNF said she knew she was not eating because she was on the floor. Wound Care Doctor and she said they would do good with alginate. She said she was on the floor on 02/06/23 and received a call from dialysis saying they were sending Resident 1 back to the facility because she was too weak to attend the treatments. She assessed her and sent her out to the hospital. RN F said they all knew Resident #1 was not eating LVN G talked about it most every morning in the morning meeting. During an interview on 02/09/23 at 12:45 p.m. the Administrator said LVN E sent a picture to the DON. She had saw the picture. She may have exaggerated some, but it looked big on the picture. She used her fingers to indicate the wound was about the size of a small orange. During an interview on 02/09/23 at 12: 57 pm. The DON said she received a call and pictures of Resident #1's wounds on 02/05/23 from LVN E. She said just looking at the picture it was more than 2 cm wide and looked like it could have been unstageable. She had erased the picture from her phone. She had texted the Wound care doctor and asked her to see the resident on Wednesday. This was determined to be an Immediate Jeopardy (IJ) on 02/13/23 at 6:05 p.m. The facility Administrator, DON, VP of Clinical Operations, and Director of Clinical Informatics were notified. The Administrator was provided with the IJ template on 02/13/23 at 6:05 p.m. The plan of removal was accepted on 02/15/23 at 3:30 p.m. [Please accept the following plan of removal for F-686 Pressure Sores. 33. Notify V.P. of Clinical Operations of immediate Jeopardy status - o Onsite during notification 02/13/23 @6:05 P.M. 34. Notify Regional Director of operations of Immediate Jeopardy status - o Completed :02/13/23 @ 6:54 PM per V.P. of Clinical Operations 35. Notify facility PCP /Medical Director of Immediate Jeopardy status- o Completed :02/13/23 @ 6:43 PM 36. Resident #1 was readmitted to the facility on [DATE] @ 12:50 PM. Resident #1 was assessed / evaluated by licensed nursing staff. Resident #1 readmitted on Hospice services and is to receive comfort medications only. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 needs for 1 of 4 residents reviewed for weight loss (Resident #1). The facility failed to ensure Resident #1 was provided food, water, for about a 10-day period. The facility failed to ensure the dietician was notified and dietary recommendations were in place. The facility failed to follow their nutritional policy regarding weight loss. They failed to ensure the resident did not have skin breakdown due to poor nutrition. Resident #1 had a significant weight loss of 5.3 percent in one month and 9.6 percent in 3 months Resident #1 was sent to the hospital with diagnoses of malnutrition and dehydration. The facility failed to provide care to Resident #1 for about 10 days over multiple shifts and multiple staff were aware she was not eating and they put no interventions in place to prevent continued decline. An Immediate Jeopardy (IJ) situation was identified on 02/09/23 at 5:15 p.m. While the IJ was removed on 02/11/23 at 7:22 p.m., the facility remained out of compliance at actual harm with a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents as risk for decreased nutritional status, decline in health serious illness, or hospitalization. Findings included: Record review of Resident #1's admission record with a print date of 02/07/23 indicated she was an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses were myocardial infarction( heart attack), muscle weakness, lack of coordination, hypertension, end stage renal disease and hyperlipidemia. Record review of Resident #1's admission MDS dated [DATE] indicated her cognitive status was severely impaired (BIMS score 7). She required extensive assist with bed mobility, dressing, and toilet use of one-person, limited assistance to transfer with one person. Limited assistance with locomotion off the unit of one person. She was able to eat and drink with supervision and setup help only. Record review of Resident #1's admission assessment dated [DATE] indicated she received dialysis 3 times a week. She weighed 150 pounds. She was incontinent of bowels and bladder and had no skin issues identified. She was totally dependent for bed mobility, transfers, personal hygiene, bathing, and dressing. Resident #1 required assistance of staff for eating. She used a wheelchair. She did not receive therapy. Record review of Resident #1's Nutrition Risk, Mini Nutrition assessment dated [DATE] indicated she weighed 150 pounds. She was on dialysis with no nutritional issues noted. Record review of nursing notes indicated: On 01/12/23 at 8:40 p.m. Resident #1 was lethargic unable to answer questions the physician was notified regarding her change in level of consciousness, and she was sent to the ER On 01/14/23 at 12:58 a.m. Resident #1 returned to the facility by ambulance she remained lethargic and unable to answer questions appropriately. On 01/15/23 9;38 a.m. Resident #1 was lethargic and could not swallow. Signed by MA H. On 01/15/23 at 3:07 p.m. Resident #1 was having difficulty swallowing food. A new order for swallow study was received. Signed by LVN G. On 01/17/23 at 12:11 a.m. Resident #1 was lying in bed sleeping no acute distress noted, and a new order to for swallow study related to appetite. Resident #1 ate less than 25% of her dinner, health shake offered and took 100 percent. signed by LVN M. On 01/18/23 at 7:00 p.m. the nurse assisted Resident #1 with supper. Her appetite remined poor. She consumed 25 percent of meal, accepted health shake, and drank about 75 percent. Continued generalized weakness. On 01/19 23 at 1:18 p.m. Resident #1's swallow study test was conducted per professional imaging. Record review of Dysphagia Consultation dated 01/19/23 indicated meal recommendations for Resident #1. Pleasure comfort feedings of pureed as accepted or tolerated, encourage more upright head posture, employ good oral care, cued cough to help clear upper airways, liquids nectar thick and pills are a choking risk crush medication. Feed slowly and carefully, hand over hand assistance, no straws, resident to be fed small bites and sips. SLP or trained staff only and monitor for adequate nutrition and hydration. Record review of Resident # 1's computerized physician orders for 01/15/23 to 02/15/223 indicated an order for puree diet, pureed texture, Nectar consistency due to swallowing difficulty. Record Review of nursing notes January 2023 notes indicated: On 01/19/23 at 4:31 p.m. Resident #1 received a new order to discontinue regular texture diet and thin liquids start. Texture and nectar thick liquids. recommended pleasure feeding small bites sips and foods recommendations were upright body and head positioning. Signed by LVN G. On 01/23/23 at 10:12 a.m. Novasource Renal give one bottle two times daily. Resident #1 was very lethargic. Signed by MA H On 01/24/23 at 8:28 a.m. Novasource renal give one bottle twice a day Resident #1 was lethargic and cannot swallow good signed by MA H. On 01/24/23 at 4:26 p.m. the Resident #1 was noted lying in bed facing up with head turn to the right, the skin was warm to touch but difficult to arouse. Her blood pressure was 97 / 56, pulse 80, and her O2 stats was 97. Respirations noted 14 and shallow. The NP was notified her recommendations to monitor the resident. The DON was notified they will continue to monitor notes signed by LVN G On 01/24/23 at 8:28 a.m. lethargic and cannot swallow good. Signed by MA H On 01/ 25/ 23 at 5:01 a.m. indicated Resident #1 was lying in bed sleeping at this time the resident is withdrawn she is refusing to eat . Signed by LVN M On 01/26/23 at 12:37 p.m. completed a full assessment was performed on resident #1. she was lying in bed on right side. She appeared the lethargic but aroused to tactile stimuli. The resident denied pain when asked but grimaced when repositioned in bed. There was a small area of MSD to the sacrum, zinc ointment applied. Apply the ointment every shift and as needed for incontinent episodes. Resident #1 tolerated without difficulty. The nurse would monitor and meet needs as they arise. Signed by LVN F. On 01/27/23 add 3:00 p.m. Resident #1 was back from dialysis weakness noted with decline. She took only a few sips of nectar water, noted poor balance and weakness. Resident #1 with a steady decline Max assist with all care and ADL. She only speaks a few words denied pain signed by LVN N. On 1/27/23 at 9:00 p.m. Resident # 1 was resting in bed with the head of the bed elevated she was noted with a global decline Signed by LVN Q On 01/28/10:21 a.m. Novasource renal not given Resident #1 unable to swallow. Signed by MA H On 01/30/23 at 1:37 a.m. Resident #1 lying in bed at this time sleeping with eyes closed. There was no acute distress noted. Resident #1 poor appetite noted. Signed by LVN M On 01/30/23 at 5:25 p.m. Resident #1 in bed with eyes closed. She exhibited generalized body weakness. Shallow respirations. At this am the nurse attempted to feed the resident but noticed the resident having difficulty in swallowing. Oral care performed, covid test conducted per dialysis request. Negative results. Signed by LVN G. Record review of Resident #1's ADL Nutrition sheet (amount eaten) for January 2023 indicated from 01/23/23 through 01/31/23 Resident #1 refused or did not eat except on 01/26/23 and 01/27/23 in the morning she ate 26 to 50 percent. On the evening of 01/25/23 she ate 51 to 75 percent. Record review of the facility weights indicated 12/30/22- 146.3 01/04/23- 146.3 1/12/23 - 147.6 1/20/23- 143.2 1/28/23 -137.1 Record review of the last dialysis sheet the facility presented dated 01/23/23 indicated Resident #1's weight was 61.9 kilometers. 61.9 x 2.2 equals 136.47 pounds. Record review of Resident #1's weights indicated for November 2022 her weight was 150.04 pounds, December 146.3 pounds, O1/20/23 143.2 on 02/01/23 her weight was 135.5 pounds. In 3 months, 9.6 percent. In one month, 5.3 percent; both significant weight loss. Record Review of nursing notes for February 2023 nursing notes revealed: On 02/1/23 at 4:19 p.m. Resident #1 received new order for G-tube placement per the facility physician and the dialysis physician. Pending appointment. Record review of an email provided by the DON dated 02/01/23 indicated the email was to the Dietician. The email stated please look at the following residents Resident #1 had a referral for a tube placement. Record Review of nursing notes for February 2023 nursing notes indicated: On 02/03/23 at 9:34 a.m. Resident #1 was unable to swallow. Signed by MA H. On 02/04/24 at 454 a.m. Resident #1 laying in bed sleeping currently. She is withdrawn. The resident was refusing to eat. Signed by LVN M. On 02/06/23 at 12:33 a.m. Resident awake in bed. Pillows in place. Peg tube placement pending. The resident appetite and fluid intake remained poor. The family visited on 02/05/23 and are aware of Resident #1's global decline. The resident continued dialysis three times a week. On 02/06/23 at 11:24 a.m. a call from the dialysis center stating Resident #1 was unstable to receive her treatment, and they were sending her back to nursing home. Signed by LVN E. On 02/06/23 at 11:45 a.m. Resident #1 Returned form dialysis center with flat affect. She did not respond to verbal stimuli but grimaces her face when turned and repositioned. Signed by RN F. On 02/06/23 at 12:05 p.m. during visual rounds, Resident #1 appeared lethargic with difficulty arousing. She did not respond to tactile or verbal stimuli. Three failed attempts to collect her blood pressure on the left wrist. Her heart rate was 78, temperature 96.8 and her respirations were 16. The physician was contacted regarding Resident #1's status and verbal orders were received to send her to the ER for evaluation and treatment. Record review of Resident #1's ADL Nutrition sheet (amount eaten) for February indicated from 02/01/23 through 02/06/23 the resident refused or did not eat except on the evening of 02/01/23 the resident ate 26-50 percent on the morning of 02/04/23 resident #1 ate 51 to 75 percent. Record review of Resident #1 hospital records dated 2/6/23 indicated the resident assessment plan was failure to thrive, the patient had not been eating or drinking for the past week. Would start on gentle fluids resuscitation the diagnosis likely dehydration and possible starvation. The EMS reported Resident #1 had a constant decline for the past couple of weeks. She last dialysis was two times. She was too weak. The physical exam indicated diagnosis of end stage renal disease related to high blood pressure in 2016. Encephalopathy progressing since 12/20/22 severe dehydration and malnutrition. The emaciated chronically ill female lost 10 kg=22.05 pounds in the past 3 to 4 months in no acute distress. Record review of the hospital records dated 02/06/23 indicated Resident #1's weight was 56.7 kilometers. 57.7 x 2.2 equals 125 pounds. During an interview on 02/07/23 at 10:32 a.m. CNA A said she worked at the facility since July 2022. She said Resident #1 had a swallowing problem. CNA A said she was told last week not to feed Resident #1 because she would choke. She said Resident #1 was a total care resident, she was incontinent, and on dialysis. CNA A did not want to talk to the Investigator. She said the nurse was the person to answer the questions. She said Resident #1 was supposed to get a feeding tube on today, 02/07/23. During an interview on 2/7/23 at 10:39 am. CNA B said she worked at the facility for 8 years. She said she had been off for two days. CNA B said Resident #1 was not eating the last few times she had worked with her. CNA B said she would try to feed Resident #1 and would start choking. Resident #1 was on thicken liquid and her choking got to the point they only gave her liquids. She said sometimes she would choke on the liquids as well. Then she was told not to give her anything because she would choke. During an interview on 02/07/23 at 11:47 a.m. LVN E said she worked at the facility for 3 years. She said on 02/06/23 dialysis called and said they were unable to complete dialysis on Resident #1 because she was too unstable. LVN E said Dialysis said she was too lethargic and sent her back to the facility. She said Resident #1 came back to the facility and was sent to the hospital on [DATE]. LVN E said the treatment nurse RN F was the nurse that assessed Resident #1 and sent her to the hospital. LVN E said she did hear Resident #1 was not eating. She said on today, 02/07/23 Resident #1 had an appointment to have a feeding tube to be placed. LVN E said the nurse at the hospital told her on the phone Resident #1 was not a candidate for a feeding tube because she was too weak. She said they could not get Resident #1 to eat or drink for a least a week or two. LVN E said Resident #1 was not a DNR and she was not on hospice. She said the family would not change Resident #1's code status. LVN E said she had not personally contacted the physician regarding Resident #1 not eating or drinking. LVN E said the administrative staff were aware Resident #1's condition had declined to not eating anything. During an interview on 02/07/23 at 12:24 p.m. the Administrator said she thought the dialysis clinic sent Resident #1 back to the facility on [DATE] because she refused to allow them to allow them to dialysis her. The Administrator said she knew they had talked to the family about hospice, and the family did not want her to put her on hospice. The Administrator said she thought Resident #1 was supposed to have gotten the feeding tube today, 02/07/23. She said Resident #1 was in the hospital, and someone had mentioned the hospital said Resident #1 was not a candidate for the feeding tube. The Administrator said she was aware as she could be that Resident #1 was not eating well. She was not familiar with the medical aspect of resident care. During an interview on 02/07/23 at 1:00 p.m. the ADON said she worked at the facility for about three years. She said Resident #1's appetite steadily had decreased over the past month. She said Resident #1 was scheduled to have a feeding tube procedure on today, 02/07/23. She said they had tried to get an earlier appointment but were unable to. The ADON said she was aware Resident # 1 was not eating well, per the need for the feeding tube. She said she did believe she was eating a little something. The ADON said she did not think Resident #1 was not eating at all. During a telephone interview on 02/07/23 at 1:15 p.m. the DON she was currently on leave and her last day at work was 02/01/23. The DON the SW from dialysis called and wanted to know if Resident #1 was a DNR. She said the dialysis SW said they were having trouble with Resident #1 tolerating dialysis or receiving full treatment due to her weakness. The Nephrologist recommended putting her on Hospice. The DON said the dialysis SW said the family would not consent to Hospice. She said on 02/01/23 the dialysis SW said she had received consent from the family, the Nephrologist and the facility physician for Resident #1 to have feeding tube placed. She said at that time an appointment was scheduled for a gastrologist to do the feeding tube procedure on 02/07/23. The DON said as far as she knew Resident #1 was eating but not a whole lot. She said when Resident #1 ate less than 50 percent, the facility staff would give her a health shake or a sandwich. The DON said there were occasion when Resident #1 was at dialysis and her blood pressure would be too low to perform the procedure, and dialysis had to send Resident #1 back to the facility. During an interview on 02/07/23 at 1:55 p.m. the facility SW said Resident #1's family was hard to contact and they did not return her phone calls. The SW said the family did not want to stop dialysis and Resident #1 was still a full code. She said on 02/01/23 dialysis did the referral for a feeding tube. The SW said she was not a part of the referral. She said she felt they had done the referral for GI doctor because Resident #1 had gone downhill. The SW said she was in the morning meetings, and it was said Resident #1 was not eating very well. During a telephone interview on 02/07/23 at 2:23 p.m., Resident #1's Physician said in the old days a resident could send them straight to the ER to receive a feeding tube. He said now the hospital did not do that any longer. He said they had to schedule an appointment through a GI doctor to get a feeding tube placed. He said they got the first available appointment with GI doctor on 02/07/23. The Physician said potentially, they could have done a nasal gastric tube, but the patient reached and pulled the tube out regularly. He said it would not have done any good to prescribe an appetite stimulate if Resident #1 was not eating at all. He said he did not know until 02/06/23, that Resident #1 was not taking any of her meds and was not able to swallow at all for at least a week. He said if he had known he would have sent her to the hospital, and they would have likely gotten some IV fluids started on Resident #1. The Physician said Resident #1 was having swallowing difficulties before she came to the facility. The facility staff did not tell him Resident #1 was not eating, drinking, or taking her medications. He said what he was told was Resident #1 was not eating well. During an interview on 02/07/23 at 2:51 p.m. CMA/CNA I said LVN G told her not to give Resident #1 anything because she could not swallow. During an interview on 02/07/23 at 3:40 p.m. CNA K said she worked at the facility about 5 years. She said the last time she worked with Resident #1 was on Saturday, 02/04/23 and she was not eating at all. She said her mouth was open and the food would not stay in her mouth. She said the last time she fed Resident #1 was about a month ago and she was swallowing a little bit at that time. CNA K said she did not work with Resident #1 often. During a telephone interview on 02/07/23 at 3: 50 p.m. LVN G said Resident #1 could not eat or swallow anything due to her choking. He said it had been at least a week since she was able to swallow anything. He said they had placed Resident #1 on puree diet the later part if January, and even with diet change she only ate about 25 percent. LVN G said about a week ago an aide told him Resident #1 could not eat, she was choking on her food. He said he had gone down to the room to try and feed Resident #1 himself. He said he tried to get her to eat but she was choking. LVN G said he was able to get her to take half cup thickened liquids, but she had a hard time. He said on the following day Resident #1 was just holding food in her mouth and not drinking anything. The LVN said he asked the DON and she said they set up an appointment for tube feeding. He said the SW at Dialysis had talked to the dialysis doctor and the facility doctor and received a go ahead for a feeding tube. LVN G said at the first of January they sent Resident #1 sent to hospital and the hospital sent her right back. He said on one occasion he called the NP because Resident #1's BP was really low, and the NP said to just monitor her. The LVN said he reported in the morning meeting Resident was not eating or drinking. During an interview on 02/07/23 at 4:17 p.m. the Administrator and ADON said after reviewing the dietary recommendations for January they did not find anything regarding Resident #1. They said the last time the Dietician was in the building was 01/13/23. During an interview on 02/07/23 at 5:56 p.m. CNA L said Resident #1 would not eat but she had tried to feed her. She said Resident #1 was swallowing a little bit about a week ago. She said the Resident #1 appeared weak and lethargic. During an interview on 02/07/23 at 6:04 p.m. LVN M said she worked at the facility for two years. She said Resident #1 was lethargic and weak. She would take Resident #1's vitals, and they were normal. The LVN said most of time Resident #1's normal BP was low. The LVN said Resident #1 had declined with her eating and was very withdrawn. LVN M said there was nothing alarming that indicated she needed to send Resident #1 to the hospital. LVN M said Resident #1 would take a small amount of liquid. LVN M said that during shift change the DON said to monitor her. During an observation at the hospital on [DATE] at 7:35 a.m. Resident #1 was lying in bed on her left side with her head slanted in the pillow. She opened her eyes when her name was called but did not respond otherwise. She had an IV set up by her bed. During an interview on 02/08/23 at 8:30 a.m. the facility SW said she was told by staff in the morning meeting Resident #1 was not eating for at least a week. They had set an appointment for Resident #1 to receive a feeding tube for 02/07/23 but she went to the hospital on [DATE]. The SW said she had tried to get in touch with the family several times because Resident #1 had a decline. The SW said she did get in touch with the family member one day last week to schedule a care plan meeting. The SW said the family said they did not want a DNR or to stop dialysis which seemed to be really hard on the Resident #1. During an interview on 02/08/23 at 8:49 a.m. LVN N said worked at the facility for 14 years. She said Resident #1 had an overall decline. She said Resident #1 could still say her name and say she did not want anything to eat, or if she was in pain. LVN N said Resident #1 began pocketing food at one time and not wanting to swallow. She said she had some aides come up and told her Resident #1 was not eating. She said over a week ago she had worked the evening shift and tried to get Resident #1 to drink. She said Resident #1 took a sip and turned her head. She said she worked with Resident #1 a few times she only worked the floor when they were short. The LVN said she had talked to Resident #1's family member one evening about 3 weeks ago. She said they talked about Resident #1 declining. LVN N said they talked Resident #1's not eating in morning meeting, and getting with the family about her code status, and her decline changes. During a telephone interview on 02/08/23 at 9:31 a.m. Resident #1's family member said the facility changed Resident #1's diet to puree and changed her medications to crushed. The family member said in the last couple of weeks they suggested doing a feeding tube and they were going to place the feeding tube on 02/07/23. The family member said they did not know she was not eating at all, she said Resident #1 was talking and now she is not. The family said first they said she failed the swallow study. She said Resident #1 did not like the food, but would eat the food the family brought. After the diet was changed to puree, she just stopped eating. The family member said during the last months they had been ill, and not come to visit often. The said in the last month Resident #1 had not been able to feed herself. During an interview on 02/08/23 at 10:43 a.m. the DON said when the dietician came, she looked at all weekly weights. When she was last here on 1/24/23 she did not look and Resident #1. The DON said she did the residents on dialysis and received weekly weights. The DON said on the morning of 2/1/23 an aide told her Resident #1 did not eat. The DON said on 2/1/23 she was provided the weight list and Resident #1 had lost weight. She said she contacted the dietician and asked if she could send a recommendation. She said she had informed the dietician via email Resident #1's weight was down 10 pounds from the previous weight. She said she had emailed the dietician and told her Resident #1 needed a consult. During a telephone interview on 02/08/23 at 11:07 a.m. the NP said she got a message on 2/6/23 that Resident #1 was sent to the hospital. She said she was aware Resident #1 had a decline, and the facility staff were trying to catch up with the family to see if they wanted to put her on hospice. She said Resident #1 was [AGE] years old and on dialysis, and dialysis was hard on the body. The NP said dialysis was designed to extend the life but not indefinitely; it was only a short term fix. She said Resident #1 had additional heart concerns. The family did not want to stop dialysis or make her a DNR. She said if she had known Resident #1 was not eating or drinking anything she would have sent her to the hospital. She said she remembered someone contacting her about Resident #1's low blood pressure but her blood pressure ran low. She said if she had known would have sent her out sooner. During an interview on 0/08/23 at11:12 the DON said she was not aware she did not take for over 10 days not eating for 10 days. During a telephone interview on 02/08/23 at 1:15 p.m. the Dietician said Resident #1 did not trigger for weight loss. The Dietician said the last weight she had was 143 and that was only a two-pound weight loss. The last time she was at the facility was 1/27/23. The Dietician said the DON sent an email that said the Resident #1 was going to be getting a feeding tube not she had weight loss. She said she had access to the system. If the weight was not in the system, she had no way of knowing there was a problem unless someone physically contacted her. She said with a pressure sore she was notified there was a change in condition, and she needed to see the resident for nutritional interventions. During an interview on 02/08/23 at 4:25p.m. the DON said Resident #1's weight for 2/1/23 had not been placed in the system. They just finished doing the weights. Resident #1 had not triggered for weights prior, and she did not know if she would trigger now. The DON said Resident #1's weights were up and down. She said they did not use dialysis weights. The DON said Resident #1's weight was 135 on 02/01/23. During an interview on 02/09/23 at 10:30 a.m. the DON conversation with the SW at dialysis but they were the facility sit up the swallow study. The DON said they had tried to talk to the family about stopping dialysis and changing Resident #1's. She said that was the conversation they had with dialysis. The next thing she knew it was putting in a peg tube. She said dialysis did not complain about Resident #1 losing weight. The DON said the family did not want to stop Resident treatment and wanted her to remain a full code. During an interview on 02/09/23 at 10:52 a.m. CNA C said that she used the dialysis weight and converted the kilograms to pounds. However, she did not appear to have the correct formula. She said on 2/1/23 she used the lift pad to weigh her on that day and she recorded that weight. Record review of the facility Weight Assessment and Intervention policy last revised September 2008 indicated. The nursing staff will measure resident weights on admission, the next day and weekly for two weeks thereafter. If there are no weight concerns weights will be monthly. Weight will be recorded . in individual medical record. Any weight change of 5 percent or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. The Dietician will respond withing 24 hours of receipt of written notification. The dietician will review the weight record by the 15th of each month. The threshold for significant up planned and undesired weight loss will be based on the following criteria. (where percentage of body weight less- usual weight - actual weight/usual weight x 100) one month is significant if 5 percent and if greater than 5 percent, is severe weight loss. For 3 months 7.5 percent is significant and if greater than 7.5, is severe weight loss. This was determined to be an Immediate Jeopardy (IJ) on 02/09/23 at 5:15 p.m. The facility Administrator, DON, ADON were notified. The Administrator was provided with the IJ template on 02/09/23 at 5:15 p.m. The plan of removal was accepted on 02/11/23 at 1:46 p.m. [Please accept the following plan of removal for F692-Nutrition: 1. Notify V.P. of Clinical Operations of immediate Jeopardy status - o Completed - 02/09/23 @5 :17 PM per DON 2. Notify Regional Director of operations of Immediate Jeopardy status - o Completed - 02/09/23@ 5:19 PM per V.P. of Clinical Operations 3. Notify facility Medical Directors of Immediate Jeopardy status- o Completed - Both notified on 02/09/23@ 8:15 PM/ 8:20 PM by ADON. 4. Notify Corporate Account manager for Dietary consultants and request onsite RD support. o Completed - 02/09/23@5:59 PM per V.P. of Clinical Operations. RD scheduled for 02/ 10/ 23. o RD onsite 02/10/23 @ 7:30 AM 5. Resident #1 was transferred to an appropriate medical setting on 02/06/23 for evaluation and treatment. Resident #1 remains hospitalized at the time of this report. 6. Residents skin assessments will be audited for completion and any identified skin areas. o Initiated: 02/10/23 @ 1:00 AM by DON. o Completed: 02/10/23@7:15 AM by DON. 7. Residents with identified skin concerns will be reviewed for treatment orders, care plan implementation and RD evaluation. Corrective actions will be completed for identified concerns. o Initiated: 02/10/23@ 7:45 AM by DON. o Completed: 02/10/23 @ 8:00pm 8. Residents' weights will be reviewed for completion and any significant variances identified. o Initiated: 02/10/23@ 5:00 AM by DON. o Completed: 2/10/23 @ 10:15am by Registered Dietician. 9. Residents with significant weight variances will be reviewed for RD evaluation, care plan implementation and notification to MD/PCP and responsible party. Corrective actions taken for identified significant weight loss variances (1 month - 5% or greater, 3 months - 7.5% or greater, 6 months - 10% or greater) will include notification to residents PCP/designee and responsible party by nurse management/ designee, care plans will be reviewed by nurse management/designee for weight loss and specific interventions implemented. Resident care plans will be reviewed/revised to include specific interventions for weight loss concerns by MDS Coordinator and/or nursing management. RD evaluations and recommendations will be reviewed with MD/PCP notified for consideration for implementation. The DON will be assigned to monitor the weight system for significant variances (1 month -5% or greater, 3 months- 7.5% or greater, 6 months - 10% or greater). The DON will monitor the PCC clinical dashboard, POC meal intake and any alerts less than 50%. The DON will notify the RD, PCP/designee, and RP of weight intake concerns via phone or electronically on a weekly basis. o Initiated: 2/10/23 @ 7:45 AM by DON/RD o Completed: 2/10/23 @ 8:30pm 10. Residents EMR will be reviewed for baseline care plan completion. No residents were identified to need a baseline care plan as a result of the audit. o Initiated: 2/10/23 @ 7:45 AM by DON/ RD. o Completed: 2/10/23 @ 10:45am by MDS Coordinator. 11. The facility DON was provided education by the V.P. of Clinical Operations on the following topics: a) Change in a residents' status - Discussion included review of Change in a Resident's condition or Status Policy & Procedure. Examples of changes in condition and notification expectations to MD/PCP and responsible party. Specific content of the change in a residents condition status policy were reviewed during the discussion. Three sections of this policy referenced significant changes in the resident physical/emotional/mental condition and defined significant change of condition as a major decline or improvement in the residents status that : i. Will not normally re[TRUNCATED]