**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for one of five residents (Resident #1) reviewed for notification of changes. -The facility failed to notify the physician when LVN C observed and documented a new wound on Resident #1's left toe, when Resident #1 was a high risk for infection due to comorbidities. -The facility failed to notify Resident #1's RP when LVN C observed and documented a new wound on Resident #1's left toe, when Resident #1 was a high risk for infection due to comorbidities. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not having their physician notified concerning their medical needs which would cause a delay in treatment and a decline in health. Findings include: Record review of Resident #1's face sheet, dated 12/28/23, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: type II diabetes (inability to regulate blood glucose), muscle weakness, acute osteomyelitis of left ankle and foot (inflammation of bone caused by infection), peripheral vascular disease (circulation disorder) and dementia (loss of memory and thinking). Record review of Resident #1's quarterly MDS assessment, dated 11/20/23, reflected his BIMS score was 08, which indicated moderate cognitive impairment. Record review of Resident #1's care plan, revised 9/13/23, reflected he had an ADL self-care deficit related to dementia, deconditioning, debility and left heel ulcer, with interventions which included staff providing physical assistance with daily self-care as needed. Further review reflected Resident #1 had a diabetic ulcer unstageable to the left heel and was at risk for further skin breakdown due to immobility and diabetes. Interventions included administering treatments as ordered and monitoring for effectiveness, assess/record/monitor wound healing, report improvements and declines to MD, encourage to turn and reposition, and follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #1's orders, dated 12/28/23, reflected an order to consult with MD for wound care. There were no active orders for wound care. Record review of Resident #1's weekly skin assessment, dated 12/7/23, reflected he had multiple wounds to right leg, and an old wound to left heel. Record review of Resident #1's weekly skin assessment, dated 12/14/23, reflected he had multiple wounds to right leg, left toe and an old wound to left heel. Record review of Resident #1's progress notes reflected there was no further documentation about notification to the MD regarding the new wound found on Resident #1's left toe according to his weekly skin assessment on 12/14/23. Record review of in-service titled Weekly skin/ulcer assessment, dated 12/14/23, reflected all nurses were educated by the DON on weekly skin/ulcer assessments and notifying the RP and DON on changes. Record review of Resident #1's hospital records, dated12/28/23, reflected the resident was admitted to the hospital due to gangrene of his bilateral toes and lethargy. Resident #1 was diagnosed with osteomyelitis (inflammation of bone caused by infection) of right 3rd and 2nd toes, left great toes infection, chronic left heel ulcer, chronic anemia, severe tibia artery disease (circulatory disorder), and possible chronic kidney disease. Resident #1 had his left leg amputated below the knee on 12/21/2023 and his right leg was amputated below the knee on 12/26/23. Observation on 12/28/23 at 9:45 AM of Resident #1 at a local hospital, revealed he was lying in bed recovering from having a double below-knee amputation. Resident #1 was unable to be interviewed due to language barrier. In an interview on 12/28/23 at 9:46 AM, Resident #1's RP stated Resident #1 used a wheelchair for mobility; however, he was able to transfer independently and could do most ADLs independently. The RP stated Resident #1 was having a hard time adjusting to his limited abilities after having both legs amputated. The RP stated Resident #1 was active, able to communicate, and alert; however, when family visited him at the nursing facility on 12/28/23, he was disoriented, non-communicative, and did not recognize anyone. The RP stated it was then he noticed the toes on both of Resident #1's feet had turned black and once they complained to the nursing staff, Resident #1 was transported to the local hospital. The RP stated the nursing facility had not reported any changes in Resident #1's condition to him. In an interview on 12/28/23 at 10:28 AM at the local hospital, MD A stated he was the attending MD for Resident #1. MD A stated Resident #1 was admitted to the local hospital in 02/2023 due to wound infections with interventions which included debridement and antibiotic treatment. MD A stated Resident #1's recent amputation of both legs was due to infection and gangrene of multiple toes. MD A stated due to Resident #1's history he could not determine Resident #1's current condition was due to neglect by the facility without knowing information about treatment he was receiving at the facility; however, MD A stated Resident #1's age and diagnoses could have caused the infection to worsen rapidly, within less than a week without treatment. In an interview on 12/28/23 at 12:07 PM, LVN D stated she worked at the facility for 2 months. She stated she usually only worked the weekends but started working during the week about two weeks ago, while the facility's full-time wound care nurse was out. She stated she did wound care on Resident #1's left shin, and her last time providing care to him was a month ago because the wound was resolved. She stated she did not do wound care on Resident #1's feet because he did not have wounds on his feet at the time. She stated she knew because it was protocol to assess the feet when doing wound care on his legs. LVN D also stated she would check the orders and treatment assessment records to check for other treatments the resident needed, and he was not receiving any other wound care. In an interview on 12/28/23 at 12:48 PM, the DON stated she worked at the facility for about 3 weeks. She stated LVN C documented on 12/14/23 on Resident #1's weekly skin assessment he had a wound on his left toe that was not there the week prior. The DON stated LVN C informed her she did not notify the MD or report it to anyone because she thought the wound was already being treated. The DON stated her expectation was for the nurses to document any changes to the residents, check the orders for treatment and notify herself, the MD, and RP. The DON stated there were a lot of residents in the facility with wounds, so she had already provided an in-service on skin assessments and notification to all nurses on 12/14/23 as a precaution and prior to being aware that Resident #1 had a new wound. The DON stated LVN C received the training and still failed to notify anyone of Resident #1's new wound. The DON stated LVN C was terminated for failing to follow the facility's policy. In an interview on 12/28/23 at 1:37 PM, CNA E stated he worked at the facility for four months. He stated he worked with Resident #1 and the resident often refused showers and other care. CNA E stated about a week prior to 12/18/23, when Resident #1 was transferred to the hospital, he noticed Resident #1 was not eating and had severe diarrhea. CNA E also stated Resident #1 had a bad odor that smelled like it was coming from a wound. CNA E stated he reported this to the charge nurse, who was LVN C, and she stated she would notify the MD. CNA E stated he did not know if it was reported to the MD. In an interview on 12/28/23 at 2:25 PM, MD B stated she was one of the attending MDs at the nursing facility. She stated she typically saw Resident #1 once a month unless there was an issue. MD B stated Resident #1 admitted to the facility in 02/2023 with an infection in his foot after being treated at a local hospital. MD B stated it was recommended at that time Resident #1 have an amputation due to being high risk for infections, but his family declined, and Resident #1 was treated with IV antibiotics. MD B stated Resident #1 was also seeing a wound care specialist outside of the facility and his wounds had healed. She stated he would have intermittent wounds on his shins/legs from bumping them, but overall, he healed to her knowledge. MD B stated Resident #1 did not have any active orders for wound care, but she would have given one had she been notified that it was needed, especially due to Resident #1's history and comorbidities. MD B stated it was her expectation for the nurses to notify of any changes to her, and they were usually good about doing so. She stated she was not in front of the charts, but she could not recall being made aware of a new wound on Resident #1's left toe prior to him going to the hospital on [DATE]. She stated her first-time hearing of any issues for Resident #1 was on the day he was sent to the hospital. In a further interview on 12/28/23 at 5:45 PM, the DON stated the risk of not notifying the MD of a change in condition such as a wound could be it leading to a severe situation like sepsis and potentially death. In an interview on 01/17/24 at 10:48 PM, the DON stated since the facility's failure, processes were put in place to ensure it did not happen again. The DON stated a skin sweep of all residents in the facility was started on 12/19/23, with no change in condition or major skin issues found. She stated all CNAs were in-serviced on 12/20/23 on conducting skin assessments during ADL care and reporting any skin issues or change of condition to the charge nurses. The DON stated further education with CNAs would include reminding them to also report concerns or change of condition to management, including herself, the ADONs, or the Administrator. The DON stated all CNAs were informed to document any skin issues found during showers on the resident's shower sheets and to also report everything to the nurse no matter when it was found. The DON stated all nurses were in-serviced on 12/20/23 on addressing change of condition immediately and reporting to the MD, DON, and RPs. The DON stated all staff were also in-serviced on 12/20/23 on reporting abuse and neglect. The DON stated she and the ADONs were conducting daily monitoring of skin assessments completed by the nurses to screen for new skin issues/change of condition and to monitor the condition of existing skin issues. The DON stated there would also be continuous education and reminders to all staff on the importance of skin assessments and immediately reporting any change of condition. The DON stated all CNAs and nurses were given skin assessment skills checkoffs to ensure their understanding on how to conduct them. The DON stated all nurses were expected to know how to assess all shades of skin for discoloration and wounds based on nursing skills obtain in nursing school. In an interview on 01/17/24 at 11:12 PM, LVN Q stated she was the full-time wound care nurse at the facility. She stated she worked with Resident #1 and last provided wound care to him on 11/7/23 when the wound on his right shin was resolved. LVN Q stated all of Resident #1's wounds had resolved and there were no new orders for wound care besides a standing order to consult with the MD for wound care of any new wounds. LVN Q stated she the nurses and CNAs had a good rapport with her and would usually inform her of new wounds and skin issues found on the residents. She stated the CNAs knew to inform the charge nurses of new wounds or any change of condition of the residents, but if they saw her in the hallways, they would inform her also. LVN Q stated she had not been informed that Resident #1 had any new wounds or a change of condition since 11/7/23 after all his wounds were resolved. LNV Q stated Resident #1 had dementia and was Spanish speaking only, so he would often refuse ADL care and not interact with staff due to confusion and language barriers. LVN Q stated she was able to communicate with him in Spanish so he would comply with her more; however, she was had not worked with him since 11/7/23. She stated she was also on vacation for two weeks starting on 12/15/23, which was during the time LVN C found the new wounds. LVN Q stated Resident #1 had already discharged from the facility when she returned to work. LVN Q stated she was never made aware of the new wounds to Resident #1's toes. She stated she also was not aware of multiple wounds on his right leg. LVN Q stated the only wound to Resident #1's right leg that she was aware of was the one she was treating on his right shin that was resolved on 11/7/23. LVN Q stated Resident #1 often had superficial scratches and scabs from bumping his leg on the wheelchair, but he did not have any active orders for wound care. In an interview on 01/17/24 at 12:46 PM, LVN R stated she worked PRN weekends at the facility and worked with Resident #1 on 12/17/23, the day before he was transferred to a local hospital. LVN R stated Resident #1 was acting his normal self and did not display any signs of pain or discomfort. LVN R stated the CNA did not report any change of condition of Resident #1 to her. She stated Resident #1 did not have diarrhea or a change in appetite on 12/17/23 or anything that needed to be reported to the MD. LVN R stated she was not aware of any new wounds that Resident #1 had. She stated she remembered an old wound that Resident #1 had on his left ankle or foot that had been resolved, but no new wounds. LVN R stated Resident #1 had an odor from refusing to shower, but he did not have a distinct odor that wound come from an infected wound that she could recall on 12/17/23. LVN R stated Resident #1 would always refuse his showers. LVN R stated Resident #1 was friendly with her but would even refuse for her to shower him. LVN R stated Resident #1 was mostly independent and could dress himself, so the chance for CNAs to observe skin issues was limited, especially with Resident #1 not being able to communicate with them. LVN R stated the chance for wounds or new skin issues to be found would be during the weekly skin assessments done by the nurses. LVN R stated any new skin issues found on a resident would have to be assessed by the nurse and reported to the MD, DON, and RP immediately. In an interview on 01/17/24 at 3:28 PM, the Administrator stated to ensure that staff were conducting proper skin assessments and reporting all skin issues/change of condition, the DON and ADONs would continue monitoring all skin assessments and the monitoring and findings would be discussed with the team every morning during standup meeting for him to ensure that it was being done. The Administrator stated ongoing education would also continue with all staff and disciplinary actions would be taken for any staff not following protocols and processes put in place. The Administrator stated processes put in place regarding the facility's failure was addressed at the QAPI meeting held on 01/17/24. Record review of Resident #1's shower sheets, dated 12/5/23, 12/14/23, and 12/16/23, reflected the resident refused all showers. There was no documentation of skin issues on any of the shower sheets reviewed. No additional shower sheets could be provided. Record review of Resident #1's 24-hour reports, from 12/14/23-12/18/23, reflected there was no documentation of new skin issues or change of condition until 12/18/23 when LVN C reported the resident was sent out to the hospital for left great toe and right second toe being gangrene like. Record review of skin assessments dated 12/19/23-12/23/23, reflected a skin sweep of all residents in the facility with no findings. Record review of LVN C's personnel file reflected she was terminated on 12/19/23 for failure to notify the RP and physician to request an order for treatment when a new wound was documented on an assessment. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance prior to the survey: Interviews were conducted with CNA E (1st shift), Nurse Aide I (1st shift), LVN F (2nd shift), CNA G (2nd shift), and LVN H (2nd shift), LVN J (3rd shift), CNA K (3rd shift), CNA L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), LVN O (2nd shift), LVN P (1st shift), LVN R (3rd shift) . All licensed staff were able to provide competency regarding in-service over policy on change of condition and when to communicate acute changes in residents' status to MD, DON, and responsible party. All licensed staff were able to state that all residents received skin assessments at least weekly, and more frequently for residents with existing skin issues. They were able to state that any new skin issues or worsening of existing skin issues should be assessed and immediately reported to the DON, MD, and RP, and any new orders followed. All CNAs were able to provide competency regarding in-service over change in condition, skin assessments during ADL care, and when to report changes in condition to the nurse. All CNAs were able to state that opportunities to assess residents' skin was during ADL care such as showers or incontinent care and when repositioning a resident. They were able to state that any change in condition or observation of skin issues should be immediately reported to the charge nurse. All CNAs were also able to state that if the issue was not addressed, they would report it to the DON. Interview and record review of Residents #2, #3, #4, #5, #6, and #7, who all received wound care, revealed there were no changes in condition and all residents had interventions in place to help prevent complications from wounds. Interview with Resident #2's RP revealed the residents wounds were healing and her legs were getting stronger. Interview with Resident #3 revealed he was satisfied with the wound care he was receiving, and the resident denied being in pain. Interview with Resident #4 stated he received wound care as ordered and had no concerns. Interview with Resident #5's RP revealed he had no concerns with the wound care the resident was receiving and that he was notified when there was a change in condition. Interview with Resident #6 revealed no concerns with the wound care she was receiving. Interview with Resident #7 revealed the wound care nurse was great and he had no concerns. In an observation and record review on 01/17/24 of Resident #2, the resident was observed to have an open wound to her right lower leg with and a scab on a resolved wound to left shin. Record review of Resident #2's skin assessment, dated 01/17/24, reflected Resident #2 had one wound to her right lower leg. Record review of Resident #2's orders reflected an active order for daily wound care to right lower leg until resolved. Record review of Resident #2's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #3, the resident was observed to have an open wound to his left ankle and dark discoloration to lower left leg from poor circulation. Record review of Resident #3's skin assessment, dated 01/17/24, reflected he had one wound to his left medial (inner) ankle. Record review of Resident #3's orders reflected an active order to wash and dry his left leg twice daily, and an active order to provide wound care to left inner ankle every Wednesday. Record review of Resident #3's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #4, the resident was observed to have an open wound to his left heel. Resident #4 was wearing cushioned heel protectors. Record review of Resident #4's skin assessment, dated 01/17/24, reflected he had one wound to his left heel. Record review of Resident #4's orders reflected an active order for daily wound care to left heel. Record review of Resident #4's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #5, the resident was observed to have an open wound to her left heel and a resolved wound to the back of her neck. Investigator was unable to observe the wound on Resident #5's coccyx. Resident #5 was observed wearing a cushioned heel protector on left heel. Record review of Resident #5's skin assessment, dated 01/17/24, reflected she had a wound to her left heel and coccyx, and a resolved wound on neck. Record review of Resident #5's orders reflected an active order for daily wound care and heel protector to left heel, daily wound care to coccyx, and daily wound care to back of neck until resolved. Record review of Resident #5's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #6, the resident was observed to have open wounds to her left heel and left Achilles. Investigator was unable to observe Resident #5's sacrum. Record review of Resident #6's skin assessment, dated 01/17/24, reflected Resident #6 had a wound to her left heel, left Achilles, and a resolved wound to her sacrum. Record review of Resident #6's orders reflected an active order for daily wound care to left heel and left Achilles. Record review of Resident #6's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #7, the resident was observed to have a surgical wound to his left below-knee amputation. Record review of Resident #7's skin assessment, dated 01/17/24, reflected he had a surgical wound to his left below-knee amputation medial (inner) and left below-knee amputation lateral (side of). Record review of Resident #7's orders reflected an active order for daily wound care to the resident's left below-knee amputation. Record review of Resident #7's TAR reflected wound care was being administered as ordered. Record review of Resident #7's nursing notes, dated 01/09/24, reflected the resident had a change of condition of the wound to his left below-knee amputation that was indicative of an infection. The MD was notified on 01/09/24 and new orders for antibiotics and an appointment for a debridement procedure was scheduled for 01/11/24. Further review of the nursing notes reflected the debridement procedure was completed on 01/11/24. In an interview on 01/17/24 at 1:00 PM, the LVN Q stated Resident #7 was the only resident in the facility who had a change of condition of wounds. She stated he was the MD was notified and Resident #7 was ordered to have a debridement procedure that was done on 01/11/24. Record review of in-service titled Change of condition/Abuse & Neglect, dated 12/20/23, reflected all staff were educated by the DON on monitoring skin/wounds, notifying the nurse of any changes of condition with residents, incontinent care, turning/repositioning, and charge nurses addressing change in condition as soon as possible, which included when to notify MD, RP of new orders, filling out incident reports, obtaining new orders, documentation and notifying the DON . Record review of the facility's policy titled Significant Change in Condition, revised 05/2007, reflected in part the following: Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedures: 1. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): . -Change in mental status -Any sign or symptom of infection . -Change in medical condition . 2. The Nurse will perform and document an assessment of the resident and identify need for additional interventions . 3. The resident will be placed on the 24-hour report and nursing will provide no less than three days of observation, documentation, and response to any interventions 4. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report. 5. There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgement and shall contact the physician based on the urgency of the situation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure appropriate treatment and care was provided in accordance with professional standards, comprehensive person-centered care plan and resident choices for 1 of 5 residents (Resident #1) reviewed for quality of care. -The facility failed to notify the physician and provide interventions to monitor and treat Resident #1 when LVN C observed and documented a new wound on his left toe. Resident #1 was high risk for infection due to comorbidities. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not having their physician notified concerning their medical needs which would cause a delay in treatment and a decline in health. Findings include: Record review of Resident #1's face sheet, dated 12/28/23, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: type II diabetes (inability to regulate blood glucose), muscle weakness, acute osteomyelitis of left ankle and foot (inflammation of bone caused by infection), peripheral vascular disease (circulation disorder) and dementia (loss of memory and thinking). Record review of Resident #1's quarterly MDS assessment, dated 11/20/23, reflected his BIMS score was 08, which indicated moderate cognitive impairment. Record review of Resident #1's care plan, revised 9/13/23, reflected he had an ADL self-care deficit related to dementia, deconditioning, debility and left heel ulcer, with interventions which included staff providing physical assistance with daily self-care as needed. Further review reflected Resident #1 had a diabetic ulcer unstageable to the left heel and was at risk for further skin breakdown due to immobility and diabetes. Interventions included administering treatments as ordered and monitoring for effectiveness, assess/record/monitor wound healing, report improvements and declines to MD, encourage to turn and reposition, and follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #1's orders, dated 12/28/23, reflected an order to consult with MD for wound care. There were no active orders for wound care. Record review of Resident #1's weekly skin assessment, dated 12/7/23, reflected he had multiple wounds to right leg, and an old wound to left heel. Record review of Resident #1's weekly skin assessment, dated 12/14/23, reflected he had multiple wounds to right leg, left toe and an old wound to left heel. Record review of Resident #1's progress notes reflected there was no further documentation about notification to the MD regarding the new wound found on Resident #1's left toe according to his weekly skin assessment on 12/14/23. Record review of in-service titled Weekly skin/ulcer assessment, dated 12/14/23, reflected all nurses were educated by the DON on weekly skin/ulcer assessments and notifying the RP and DON on changes. Record review of Resident #1's hospital records, dated12/28/23, reflected the resident was admitted to the hospital due to gangrene of his bilateral toes and lethargy. Resident #1 was diagnosed with osteomyelitis (inflammation of bone caused by infection) of right 3rd and 2nd toes, left great toes infection, chronic left heel ulcer, chronic anemia, severe tibia artery disease (circulatory disorder), and possible chronic kidney disease. Resident #1 had his left leg amputated below the knee on 12/21/2023 and his right leg was amputated below the knee on 12/26/23. Observation on 12/28/23 at 9:45 AM of Resident #1 at a local hospital, revealed he was lying in bed recovering from having a double below-knee amputation. Resident #1 was unable to be interviewed due to language barrier. In an interview on 12/28/23 at 9:46 AM, Resident #1's RP stated Resident #1 used a wheelchair for mobility; however, he was able to transfer independently and could do most ADLs independently. The RP stated Resident #1 was having a hard time adjusting to his limited abilities after having both legs amputated. The RP stated Resident #1 was active, able to communicate, and alert; however, when family visited him at the nursing facility on 12/28/23, he was disoriented, non-communicative, and did not recognize anyone. The RP stated it was then he noticed the toes on both of Resident #1's feet had turned black and once they complained to the nursing staff, Resident #1 was transported to the local hospital. The RP stated the nursing facility had not reported any changes in Resident #1's condition to him. In an interview on 12/28/23 at 10:28 AM at the local hospital, MD A stated he was the attending MD for Resident #1. MD A stated Resident #1 was admitted to the local hospital in 02/2023 due to wound infections with interventions which included debridement and antibiotic treatment. MD A stated Resident #1's recent amputation of both legs was due to infection and gangrene of multiple toes. MD A stated due to Resident #1's history he could not determine Resident #1's current condition was due to neglect by the facility without knowing information about treatment he was receiving at the facility; however, MD A stated Resident #1's age and diagnoses could have caused the infection to worsen rapidly, within less than a week without treatment. In an interview on 12/28/23 at 12:07 PM, LVN D stated she worked at the facility for 2 months. She stated she usually only worked the weekends but started working during the week about two weeks ago, while the facility's full-time wound care nurse was out. She stated she did wound care on Resident #1's left shin, and her last time providing care to him was a month ago because the wound was resolved. She stated she did not do wound care on Resident #1's feet because he did not have wounds on his feet at the time. She stated she knew because it was protocol to assess the feet when doing wound care on his legs. LVN D also stated she would check the orders and treatment assessment records to check for other treatments the resident needed, and he was not receiving any other wound care. In an interview on 12/28/23 at 12:48 PM, the DON stated she worked at the facility for about 3 weeks. She stated LVN C documented on 12/14/23 on Resident #1's weekly skin assessment he had a wound on his left toe that was not there the week prior. The DON stated LVN C informed her she did not notify the MD or report it to anyone because she thought the wound was already being treated. The DON stated her expectation was for the nurses to document any changes to the residents, check the orders for treatment and notify herself, the MD, and RP. The DON stated there were a lot of residents in the facility with wounds, so she had already provided an in-service on skin assessments and notification to all nurses on 12/14/23 as a precaution and prior to being aware that Resident #1 had a new wound. The DON stated LVN C received the training and still failed to notify anyone of Resident #1's new wound. The DON stated LVN C was terminated for failing to follow the facility's policy. In an interview on 12/28/23 at 1:37 PM, CNA E stated he worked at the facility for four months. He stated he worked with Resident #1 and the resident often refused showers and other care. CNA E stated about a week prior to 12/18/23, when Resident #1 was transferred to the hospital, he noticed Resident #1 was not eating and had severe diarrhea. CNA E also stated Resident #1 had a bad odor that smelled like it was coming from a wound. CNA E stated he reported this to the charge nurse, who was LVN C, and she stated she would notify the MD. CNA E stated he did not know if it was reported to the MD. In an interview on 12/28/23 at 2:25 PM, MD B stated she was one of the attending MDs at the nursing facility. She stated she typically saw Resident #1 once a month unless there was an issue. MD B stated Resident #1 admitted to the facility in 02/2023 with an infection in his foot after being treated at a local hospital. MD B stated it was recommended at that time Resident #1 have an amputation due to being high risk for infections, but his family declined, and Resident #1 was treated with IV antibiotics. MD B stated Resident #1 was also seeing a wound care specialist outside of the facility and his wounds had healed. She stated he would have intermittent wounds on his shins/legs from bumping them, but overall, he healed to her knowledge. MD B stated Resident #1 did not have any active orders for wound care, but she would have given one had she been notified that it was needed, especially due to Resident #1's history and comorbidities. MD B stated it was her expectation for the nurses to notify of any changes to her, and they were usually good about doing so. She stated she was not in front of the charts, but she could not recall being made aware of a new wound on Resident #1's left toe prior to him going to the hospital on [DATE]. She stated her first-time hearing of any issues for Resident #1 was on the day he was sent to the hospital. In a further interview on 12/28/23 at 5:45 PM, the DON stated the risk of not notifying the MD of a change in condition such as a wound could be it leading to a severe situation like sepsis and potentially death. In an interview on 01/17/24 at 10:48 PM, the DON stated since the facility's failure, processes were put in place to ensure it did not happen again. The DON stated a skin sweep of all residents in the facility was started on 12/19/23, with no change in condition or major skin issues found. She stated all CNAs were in-serviced on 12/20/23 on conducting skin assessments during ADL care and reporting any skin issues or change of condition to the charge nurses. The DON stated further education with CNAs would include reminding them to also report concerns or change of condition to management, including herself, the ADONs, or the Administrator. The DON stated all CNAs were informed to document any skin issues found during showers on the resident's shower sheets and to also report everything to the nurse no matter when it was found. The DON stated all nurses were in-serviced on 12/20/23 on addressing change of condition immediately and reporting to the MD, DON, and RPs. The DON stated all staff were also in-serviced on 12/20/23 on reporting abuse and neglect. The DON stated she and the ADONs were conducting daily monitoring of skin assessments completed by the nurses to screen for new skin issues/change of condition and to monitor the condition of existing skin issues. The DON stated there would also be continuous education and reminders to all staff on the importance of skin assessments and immediately reporting any change of condition. The DON stated all CNAs and nurses were given skin assessment skills checkoffs to ensure their understanding on how to conduct them. The DON stated all nurses were expected to know how to assess all shades of skin for discoloration and wounds based on nursing skills obtain in nursing school. In an interview on 01/17/24 at 11:12 PM, LVN Q stated she was the full-time wound care nurse at the facility. She stated she worked with Resident #1 and last provided wound care to him on 11/7/23 when the wound on his right shin was resolved. LVN Q stated all of Resident #1's wounds had resolved and there were no new orders for wound care besides a standing order to consult with the MD for wound care of any new wounds. LVN Q stated she the nurses and CNAs had a good rapport with her and would usually inform her of new wounds and skin issues found on the residents. She stated the CNAs knew to inform the charge nurses of new wounds or any change of condition of the residents, but if they saw her in the hallways, they would inform her also. LVN Q stated she had not been informed that Resident #1 had any new wounds or a change of condition since 11/7/23 after all his wounds were resolved. LNV Q stated Resident #1 had dementia and was Spanish speaking only, so he would often refuse ADL care and not interact with staff due to confusion and language barriers. LVN Q stated she was able to communicate with him in Spanish so he would comply with her more; however, she was had not worked with him since 11/7/23. She stated she was also on vacation for two weeks starting on 12/15/23, which was during the time LVN C found the new wounds. LVN Q stated Resident #1 had already discharged from the facility when she returned to work. LVN Q stated she was never made aware of the new wounds to Resident #1's toes. She stated she also was not aware of multiple wounds on his right leg. LVN Q stated the only wound to Resident #1's right leg that she was aware of was the one she was treating on his right shin that was resolved on 11/7/23. LVN Q stated Resident #1 often had superficial scratches and scabs from bumping his leg on the wheelchair, but he did not have any active orders for wound care. In an interview on 01/17/24 at 12:46 PM, LVN R stated she worked PRN weekends at the facility and worked with Resident #1 on 12/17/23, the day before he was transferred to a local hospital. LVN R stated Resident #1 was acting his normal self and did not display any signs of pain or discomfort. LVN R stated the CNA did not report any change of condition of Resident #1 to her. She stated Resident #1 did not have diarrhea or a change in appetite on 12/17/23 or anything that needed to be reported to the MD. LVN R stated she was not aware of any new wounds that Resident #1 had. She stated she remembered an old wound that Resident #1 had on his left ankle or foot that had been resolved, but no new wounds. LVN R stated Resident #1 had an odor from refusing to shower, but he did not have a distinct odor that wound come from an infected wound that she could recall on 12/17/23. LVN R stated Resident #1 would always refuse his showers. LVN R stated Resident #1 was friendly with her but would even refuse for her to shower him. LVN R stated Resident #1 was mostly independent and could dress himself, so the chance for CNAs to observe skin issues was limited, especially with Resident #1 not being able to communicate with them. LVN R stated the chance for wounds or new skin issues to be found would be during the weekly skin assessments done by the nurses. LVN R stated any new skin issues found on a resident would have to be assessed by the nurse and reported to the MD, DON, and RP immediately. In an interview on 01/17/24 at 3:28 PM, the Administrator stated to ensure that staff were conducting proper skin assessments and reporting all skin issues/change of condition, the DON and ADONs would continue monitoring all skin assessments and the monitoring and findings would be discussed with the team every morning during standup meeting for him to ensure that it was being done. The Administrator stated ongoing education would also continue with all staff and disciplinary actions would be taken for any staff not following protocols and processes put in place. The Administrator stated processes put in place regarding the facility's failure was addressed at the QAPI meeting held on 01/17/24. Record review of Resident #1's shower sheets, dated 12/5/23, 12/14/23, and 12/16/23, reflected the resident refused all showers. There was no documentation of skin issues on any of the shower sheets reviewed. No additional shower sheets could be provided. Record review of Resident #1's 24-hour reports, from 12/14/23-12/18/23, reflected there was no documentation of new skin issues or change of condition until 12/18/23 when LVN C reported the resident was sent out to the hospital for left great toe and right second toe being gangrene like. Record review of skin assessments dated 12/19/23-12/23/23, reflected a skin sweep of all residents in the facility with no findings. Record review of LVN C's personnel file reflected she was terminated on 12/19/23 for failure to notify the RP and physician to request an order for treatment when a new wound was documented on an assessment. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance prior to the survey: Interviews were conducted with CNA E (1st shift), Nurse Aide I (1st shift), LVN F (2nd shift), CNA G (2nd shift), and LVN H (2nd shift), LVN J (3rd shift), CNA K (3rd shift), CNA L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), LVN O (2nd shift), LVN P (1st shift), LVN R (3rd shift) . All licensed staff were able to provide competency regarding in-service over policy on change of condition and when to communicate acute changes in residents' status to MD, DON, and responsible party. All licensed staff were able to state that all residents received skin assessments at least weekly, and more frequently for residents with existing skin issues. They were able to state that any new skin issues or worsening of existing skin issues should be assessed and immediately reported to the DON, MD, and RP, and any new orders followed. All CNAs were able to provide competency regarding in-service over change in condition, skin assessments during ADL care, and when to report changes in condition to the nurse. All CNAs were able to state that opportunities to assess residents' skin was during ADL care such as showers or incontinent care and when repositioning a resident. They were able to state that any change in condition or observation of skin issues should be immediately reported to the charge nurse. All CNAs were also able to state that if the issue was not addressed, they would report it to the DON. Interview and record review of Residents #2, #3, #4, #5, #6, and #7, who all received wound care, revealed there were no changes in condition and all residents had interventions in place to help prevent complications from wounds. Interview with Resident #2's RP revealed the residents wounds were healing and her legs were getting stronger. Interview with Resident #3 revealed he was satisfied with the wound care he was receiving, and the resident denied being in pain. Interview with Resident #4 stated he received wound care as ordered and had no concerns. Interview with Resident #5's RP revealed he had no concerns with the wound care the resident was receiving and that he was notified when there was a change in condition. Interview with Resident #6 revealed no concerns with the wound care she was receiving. Interview with Resident #7 revealed the wound care nurse was great and he had no concerns. In an observation and record review on 01/17/24 of Resident #2, the resident was observed to have an open wound to her right lower leg with and a scab on a resolved wound to left shin. Record review of Resident #2's skin assessment, dated 01/17/24, reflected Resident #2 had one wound to her right lower leg. Record review of Resident #2's orders reflected an active order for daily wound care to right lower leg until resolved. Record review of Resident #2's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #3, the resident was observed to have an open wound to his left ankle and dark discoloration to lower left leg from poor circulation. Record review of Resident #3's skin assessment, dated 01/17/24, reflected he had one wound to his left medial (inner) ankle. Record review of Resident #3's orders reflected an active order to wash and dry his left leg twice daily, and an active order to provide wound care to left inner ankle every Wednesday. Record review of Resident #3's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #4, the resident was observed to have an open wound to his left heel. Resident #4 was wearing cushioned heel protectors. Record review of Resident #4's skin assessment, dated 01/17/24, reflected he had one wound to his left heel. Record review of Resident #4's orders reflected an active order for daily wound care to left heel. Record review of Resident #4's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #5, the resident was observed to have an open wound to her left heel and a resolved wound to the back of her neck. Investigator was unable to observe the wound on Resident #5's coccyx. Resident #5 was observed wearing a cushioned heel protector on left heel. Record review of Resident #5's skin assessment, dated 01/17/24, reflected she had a wound to her left heel and coccyx, and a resolved wound on neck. Record review of Resident #5's orders reflected an active order for daily wound care and heel protector to left heel, daily wound care to coccyx, and daily wound care to back of neck until resolved. Record review of Resident #5's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #6, the resident was observed to have open wounds to her left heel and left Achilles. Investigator was unable to observe Resident #5's sacrum. Record review of Resident #6's skin assessment, dated 01/17/24, reflected Resident #6 had a wound to her left heel, left Achilles, and a resolved wound to her sacrum. Record review of Resident #6's orders reflected an active order for daily wound care to left heel and left Achilles. Record review of Resident #6's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #7, the resident was observed to have a surgical wound to his left below-knee amputation. Record review of Resident #7's skin assessment, dated 01/17/24, reflected he had a surgical wound to his left below-knee amputation medial (inner) and left below-knee amputation lateral (side of). Record review of Resident #7's orders reflected an active order for daily wound care to the resident's left below-knee amputation. Record review of Resident #7's TAR reflected wound care was being administered as ordered. Record review of Resident #7's nursing notes, dated 01/09/24, reflected the resident had a change of condition of the wound to his left below-knee amputation that was indicative of an infection. The MD was notified on 01/09/24 and new orders for antibiotics and an appointment for a debridement procedure was scheduled for 01/11/24. Further review of the nursing notes reflected the debridement procedure was completed on 01/11/24. In an interview on 01/17/24 at 1:00 PM, the LVN Q stated Resident #7 was the only resident in the facility who had a change of condition of wounds. She stated he was the MD was notified and Resident #7 was ordered to have a debridement procedure that was done on 01/11/24. Record review of in-service titled Change of condition/Abuse & Neglect, dated 12/20/23, reflected all staff were educated by the DON on monitoring skin/wounds, notifying the nurse of any changes of condition with residents, incontinent care, turning/repositioning, and charge nurses addressing change in condition as soon as possible, which included when to notify MD, RP of new orders, filling out incident reports, obtaining new orders, documentation and notifying the DON . Record review of the facility's policy titled Significant Change in Condition, revised 05/2007, reflected in part the following: Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedures: 1. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): . -Change in mental status -Any sign or symptom of infection . -Change in medical condition . 2. The Nurse will perform and document an assessment of the resident and identify need for additional interventions . 3. The resident will be placed on the 24-hour report and nursing will provide no less than three days of observation, documentation, and response to any interventions 4. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report. 5. There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgement and shall contact the physician based on the urgency of the situation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse for one (Resident #1) of three residents reviewed for post-surgical aftercare. The facility failed to ensure Resident #1 received the necessary level of assistance and that staff were aware of physician's orders and PT evaluations to prevent injury. Resident #1 required revision surgery to the right shoulder. The noncompliance was identified as PNC. The IJ began on 09/13/23 and ended on 09/15/23. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of not receiving care and/or treatment recommended by physician. Findings included: Record review of the Acute Care Hospital After Visit Summary dated 08/31/23 to 09/04/23 revealed the following lifting restrictions: okay to work on active assisted range of motion with passive stretch, no active internal rotation as of now. Record review of Resident # 1's admission MDS assessment dated [DATE] revealed he was a [AGE] year-old male admitted on [DATE]. He had a diagnosis of aftercare following joint replacement surgery, presence of artificial right shoulder joint, hypertension (high blood pressure), cerebral vascular accident (stroke) and need for assistance with personal care. He had a BIMS of 12 (moderate cognitive impairment). He required extensive assistance with bed mobility and transfers and used a motorized wheelchair. Record review of the Physical Therapy PT Evaluation & Plan of Treatment dated 09/05/2023 revealed the following precautions: fall risk, RUE NWB (right upper extremity non-weightbearing), AAROM (assisted active range of motion) with passive stretch, and no active internal rotation, left sided weakness. Record review of Resident #1's Physician Order Recap report dated 09/04/2023 to 09/22/2023 reflected the following orders with a start date of 09/04/23 and an end date of 10/08/23: may participate in activity plan as not in conflict with treatment plan. Progress mobility as tolerated and Weight bearing as tolerated. There were no orders from admission [DATE] to 09/22/23 that were specific to the Acute care hospital lifting restrictions and or the PT evaluation precautions. Record review of Resident #1's Progress Note dated 09/08/23 at 7:31pm revealed a change of condition for Left [sic. RIGHT] shoulder swelling, he was sent to an Acute Care Hospital Emergency room. Record Review of the Acute Care Hospital emergency room After Visit Summary for Resident #1 dated 09/08/23 reflected he was seen in the ER for right shoulder pain and swelling. An x-ray was taken at 8:15pm and revealed total reverse shoulder arthroplasty dislocation (arm bone is not in shoulder socket). Per ED physician note it stated replaced shoulder appears to be dislocated anteriorly (behind). Also, likely that this has been dislocated for days. Aftercare directions read: Do not lift anything, do not push, or pull things, do not lift arm above shoulder and follow up with orthopedic surgeon on Monday (9/11/23). Record review of the Physician Order Recap Report for Resident #1 from 09/08/23 to 09/22/23 revealed there were no orders with post dislocation restrictions, limitations, or aftercare. Record review of the Orthopedic Follow-up dated 09/22/23 revealed Resident #1 had decreased range of motion since last visit, pain along the right shoulder, and deformity at the shoulder. X-ray completed during follow up revealed an anterior dislocation of his reverse total shoulder prosthesis. Due to this dislocation, it was noted that Resident #1 will require revision surgery of the right shoulder. Record review of Resident #1s Physician Order Recap Report dated 09/22/23 to 10/08/23 revealed the following orders: Monitor sling in place to right shoulder every shift for post-op care with a start date of 09/22/23 and an end date of 10/08/23. non-weight bearing to right shoulder and sling is in place every shift for dislocation with a start date of 09/22/23 and an end date of 10/08/23. Record review of Resident #1s Acute Care Hospital After Visit Summary dated 10/9/23 to 10/9/23 revealed that he was admitted for dislocation of prosthetic joint shoulder and had surgical interventions during this stay. He was discharged with the following restrictions: non-weight bearing to operative extremity, no lifting with operative extremity, no shoulder range of motion ok to gently straighten and bend elbow, keep sling on at all times, progressive mobility as tolerated, and no driving. Record review of Resident #1's Physician Order Summary Report dated 10/25/23 revealed an order that stated Keep sling on at all times except during shower or bathing with a start date of 10/10/23. No lifting with operative extremity, contact PCP for any distress or questions concerns, SOB, chest pain with a start date of 10/10/23. No shoulder range of motion allowed it is ok to gently straighten and bend the elbow with a start date of 10/10/23. Non weight bearing to RUE (right upper extremity) with a start date of 10/09/23. Use mechanical lift for all transfers with a start date of 10/09/23. Interview on 10/25/23 at 11:32am with Resident #1 revealed he needed a lot of help taking care of himself since he was first admitted on [DATE]. He stated he cannot use his left arm because of a past stroke and his right side he could not use because he just had surgery on his shoulder. He stated he needed help to move in bed, to transfers to the wheelchair, and to wash up because both his right and left arms were not functional. He stated some time before he went to the ER on [DATE] he was rolled on his right shoulder during ADL care, and it felt loose after that. He stated he has swelling and pain and that's when he asked to be sent to the hospital. Interview on 10/25/23 at 2:15pm with CNA J revealed he was not aware of any limitations or restrictions Resident #1 had for his right shoulder. He stated he cared for resident between 09/04/23 and 09/22/23. During that time, he provided care to resident by himself (one person assistance) with bed mobility and transfers. He stated he did not receive any information from the facility about Resident #1 not being able to assist with his ADLs. He stated Resident #1 would help with ADLs by pulling himself over, using the side rails and he would feed himself and help transfer to his motorized scooter and once in the scooter he would smoke using his affected arm. He was unaware of where he could find patient care specific information like how to transfer them or if they were incontinent, he stated he would ask the nurse. Interview on 10/25/23 at 3:25pm with CNA K revealed Resident #1 would use his right arm for things like eating or moving around in bed or to assist with ADLs like rolling to the side to remove soiled linens from underneath him. She was unsure of any restrictions or limitations that he had with the right arm. She was unsure if Resident #1 was cleared to bear weight or use the right arm for ADLs. She stated if a new resident were admitted she would ask the nurse how to transfer them and how much help they needed. If resident were to have any restrictions she would ask the nurse, and there was no physical place this information could be found. Interview on 10/26/23 at 2:39pm with CNA L revealed Resident #1's ADLs could be performed with one person when he first got here. He would use the right arm all the time to help roll over by grabbing the side rails. She stated she was not aware of any restrictions or limitations he had for the right arm, and he used to do everything. She stated if she needed to know how to care for a resident, she would ask the nurses to see how they transfer, eat or how many people were needed to care for them. She stated if she had a new admission, she would have to wait for the nurses to check on the resident so they can gather the plan of care information. Interview on 10/26/23 at 1:49pm with LVN M revealed that Resident #1 was a one person assist with ADLs when he was first admitted . She stated he had more use of the right arm, and he could feed himself and use his motorized wheelchair on his own. She stated she could not recall if he had any orders that would restrict him from using the right arm. She also stated the CNAs get instructions on how to care for the residents by word of mouth from the nurses or the therapy department. She stated with new admissions the nurses were responsible to transcribe the medication orders and send them to the facility doctor to verify. From there she stated medical records picked up the after-visit summary to upload it for the department heads to review for accuracy. Interview on 10/26/23 at 2:18pm with RN N revealed Resident #1 was receiving care with one person assist when he was first admitted . He would utilize his right arm to help with bed mobility by pulling himself over, using the side rail, he would stand and pivot transfer using his right arm to pull up and hold on to the nurse or CNA transferring him to the wheelchair. She also stated that he did not have any restriction with the use of his right arm. She stated when a resident was newly admitted , the CNAs would have to ask the nurse for the details on how to care for the resident and there was no place the CNAs would be able to find how to transfer the residents or any patient specific care information. The information was relayed verbally. She also stated the charge nurse was responsible to input all the orders and then turn in the after-visit summary to medical records takes the paper works to upload it, she was unsure who checked it from there. In an interview on 10/25/23 at 4:12pm with the DSD revealed the facility did an in-service training for the CNAs and nurses on proper transfers due to Resident #1 stating he was not transferred properly. She was not aware of any further complications that came from the improper transfer and was only aware of the request to facilitate a hands-on training for the nurses and CNAs given by the therapy department. That in-service was completed on 09/22/23. Interview on 10/26/23 at 9:30am with the DOR revealed there was an in-service training held by his department as requested by the nursing department. He stated the training was provided to all CNAs and nurses and was on how to use the Hoyer lift and proper transfers. He stated the training was provided in mid to end of September 2023 and he was unsure of any concerns leading to this training request. In an interview on 10/26/23 at 9:40am with DON C revealed the facility decided to do in-service training after Resident #1 returned from the orthopedic follow up visit on 09/22/23 where it was revealed the resident's shoulder was dislocated. There was no disciplinary action for the staff due to being unable to determine when or how the shoulder became dislocated. During an interview on 10/26/23 at 9:54am with DON D revealed restrictions and limitations were put into place for Resident #1 after she spoke with the orthopedic surgeon following the follow-up appointment on 09/22/23. She stated there were no disciplinary actions for staff due to there being no limitations in residents' chart until 09/22/23, so they were following the proper orders. After 09/22/23 Resident #1 was non-weight bearing, bed rest, and was Hoyer transfer only. She stated she was not sure if rolling onto the right shoulder or using the right arm to pull bodyweight to once side was considered wight bearing. She stated there were no restrictions in place from 09/04/23 to 09/22/23 because there were no orders to do so. An interview on 10/26/23 at 10:15am with Administrator B revealed after her investigation initiated on 09/22/23, Resident #1's sheets were being changed during incontinent care and he was rolled to the right side and his shoulder felt different, but no pain was associated, so the CNA that rolled him to his side was reassigned, and concerns were noted to be a customer service issue that was resolved by moving the CNA from having Resident #1. She was not aware of any restrictions or limitations Resident #1 had to the right shoulder and if there was any it would be in his orders in the EMR. An interview on 10/26/23 at 12:57pm with DON D revealed Resident #1 was one person assist with ADLs including transfers and bed mobility from 09/04/23 to 09/22/23. She stated the MDS reflected two-person maximal assistance which was the wrong level of care for Resident #1 because it was the highest level of care, he received during the lookback window. She stated the charge nurses were responsible to input all the orders and notify the doctor for review and once that was done then the DON was the one who checks the after-visit summary to make sure the orders were input correctly. She stated the CNAs had access to information on how to care for the resident properly in the EMR but many of them do not utilize this system and get the information from the nurse's word of mouth. An interview on 10/30/23 at 4:10pm with the Orthopedic Surgeon Office Manager revealed Resident #1 had his initial surgery on 07/27/23. The resident was non-weightbearing and was ok to participate in therapy with specific stretches that did not include bearing weight to the right shoulder. She stated the heaviest thing that would be allowed was a coffee cup. She stated the only range of motion that was approved was gentle non-weight bearing, supporting his own weight on the shoulder, pushing, pulling or any resistance applied to the shoulder was not approved during the healing process. An interview and record review on 10/31/23 at 11:58am with DON D revealed Resident #1's shoulder was not known to be dislocated until after his orthopedic appointment on 09/22/23. A record review was completed with DON D of Resident #1's ER After Visit Summary. The discharge diagnosis of shoulder dislocation and the x-ray results which showed his right shoulder was dislocated were reviewed. She stated she was not the DON at the time this occurred, and DON C would have more information. Interview on 10/31/23 at 12:27pm with DON C revealed, after reviewing Resident #1's ER After Visit Summary dated 09/08/23, it was revealed that his right shoulder was dislocated. She stated it was not reported to the facility physician or the orthopedic surgeon because the ER doctor already told the orthopedic doctor while Resident #1 was in the ER. She also stated she felt it was a complication from the previous surgery. She stated a shoulder dislocation should be considered a change of condition and she was not sure if the care plans or orders were updated. Record review of the After Visit Summary dated 09/04/23 conducted with DON C revealed that Resident #1 had lifting restrictions orders that were not put in to the EMR. She stated that the DONs and ADONs were responsible to make sure the information was accurate after admission. She was not sure why Resident #1s restrictions were missed on admission. She stated the potential harm to the residents could be them not getting the right care if orders were missed. Record review of the policy titled Admission, Transfer and Discharge Rights, admission Practice revealed the facility shall provide uniform guidelines in the admission of residents and admit residents who can be adequately cared for by the facility. Record review of the policy titled Safe Transfers revealed the following guidelines to ensure safe transfers included knowing the residents' abilities and limitations. The transfers status can be found in the [NAME] in PCC and POC which it is labeled care instructions. Review of the Resident Rights Policy Subject: Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment with revision date of 11/28/2017 reflected: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 24 (Residents #95) residents reviewed for abuse. The facility failed to ensure to ensure CNA A was adequately trained to deescalate Resident #95's aggressive behaviors when CNA A and Resident #95 had a verbal altercation in which CNA A aggressively responded to Resident #95's verbal abuse by calling him a derogatory name and threatened she would spit in his face. An Immediate Jeopardy was identified on 09/13/23 at 5:18 PM. The IJ Template was provided to the facility on [DATE] at 5:20 PM. While the Immediate Jeopardy was removed on 09/15/23 at 12:39 PM, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of isolated due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure placed residents at risk for abuse, and physical or psychological harm. Findings included: Review of Resident #95's face sheet dated 09/14/23 reflected the resident was admitted to the facility 07/24/20 with diagnoses of muscle weakness, hemiplegia and hemiparesis (loss of strength on one side of the body) following cerebral infraction (stroke) effecting unspecified side (partial paralysis on one side), mental and behavior disorder. Review of Resident #95's MDS Assessment, dated 08/14/23, Resident #95's BIMs score was 14, indicating intact cognition. The mood interview assessment revealed Resident #95 was moderately depressed with a score of 11. Review of Resident #95's care plan dated 8/1/23, reflected it did not specify the resident had to be in bed by 9:30PM as an intervention. It did specify Resident #95 was wheelchair dependent and had potential to demonstrate verbal/physical behaviors (yelling, cursing, threatening, kicking, and hitting). Interventions included: When becomes agitated guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. An interview with Resident #95 on 9/13/2023 at 10:53 AM revealed staff did not want to put him in bed, and it took staff awhile to answer his call light. He stated on a recent Sunday night which would have been 9/10/23 (this date conflicts with dates from facility staff members), he and CNA A argued because she did not want to put him in bed when he wanted, and CNA A was telling him off, which upset him. Resident #95 stated he didn't tell anyone because he was waiting until the Administrator came back. The resident stated no CNAs wanted to work with him. He stated when it came to his care, he stated he should be able to tell them how to do it. Resident #95 stated they listened, but they had attitudes. An interview with Resident #95 on 9/13/2023 at 11:15 AM revealed CNA A called Resident #95 a hoe and said she would spit in his face. Resident #95 stated that happened in the hallway. He stated he called CNA A a hoe in response to her name-calling. An interview on 09/13/2023 at 1:50 PM with CNA C revealed she was not at the facility when the altercation between Resident #95 and CNA A happened, but she heard about it on 09/11/23, when she returned to work. She said she heard that Resident #95 and CNA A got into it. She said she did not know what happened, just that they had words. CNA C stated she knew she was supposed to tell the Administrator, but she didn't because she did not see it and only knew a little piece of it. She said if she had known more, she would have told the Administrator. CNA C said she did not know the whole story, so she just kept going on. She said she understood that if she heard a resident and staff member had words it could have possibly been abuse, and she was supposed to report it. She said it was supposed to be reported, so it would not happen again. An interview on 09/13/23 at 1:58 PM with LVN B revealed CNA A came to the nurse's station and Resident #95 said he wanted to go to bed (09/07/23). She said CNA A told him no, said it was past time, and walked away from him. LVN B explained it was care planned for the resident to go to bed at 9:30 PM because it took a lot of time to get him in bed and he wanted to go to bed before the shift changed, which would have been before the 10 PM to 6 AM shift. LVN B said she later saw another staff member put the resident in bed. She denied hearing anyone call anyone names and the only altercation she heard was when the aide refused to put him in bed and they were bickering at the nurse's station. She said she could not find the charge nurse at the time and did not know if someone else had informed her of the incident. She said that another staff member intervened, and the resident was put in bed. LVN B stated refusing to put a resident in bed could be neglect, and if she saw anything that could be abuse or neglect, she was supposed to inform the DON. An interview on 9/13/23 at 2:44PM with CNA D revealed at 9:30 PM one day last weekend (09/09/23-09/10/23) on night shift Resident #95 got mad at CNA A when the CNAs were checking and changing residents. He said when CNA A got to Resident #95's room, the resident was not in his room. He said in the resident's care plan it stated he had to be in his room, in bed, by 9:30 PM. CNA D said that CNA A went back to the nursing station when Resident #95 rolled his wheelchair up to CNA A, blew up on her (got upset, raised his voice, calling CNA A names), and followed her down the hall calling her insulting names. CNA D said that CNA A told Resident #95 she was going to spit in his face. CNA D said he grabbed CNA A to prevent her from further altercation. CNA D stated Resident #95 called CNA A an old hoe, and Resident #95 acted like he was going to hit CNA A. CNA D said that was when CNA A told Resident #95 that if he touched her, she would spit on him. He said RN E was informed and she sent a text message the Administrator about the situation and the Veteran Affairs would come talk to Resident #95. CNA D stated Resident #95 was always antagonizing staff and he had called CNA D a fag before so he did not take care of him anymore either, and he felt Resident #95 had exhausted a lot of his options. An interview and observation on 09/13/23 at 2:58 PM with RN E revealed the incident between CNA A and Resident #95 occured on 09/07/23, after 9:30 PM. RN E verified the timing of the incident by a text message RN E sent to the Operations Manager. RN E stated Resident #95 was extremely particular and it took about 30 minutes to get him in bed due to the number of requests he made. RN E explained he had a rigid routine and wanted it to be followed precisely by staff. She stated because of that, it had been care planned when he was new in the facility, he agreed to be put to bed at 9:30 PM so the staff could leave when their shift ended at 10PM. She stated Resident #95 frequently pushed the limits and would intentionally not show up until after 9:30 PM even though he agreed to the arrangement. She said he did not want to be told when to go to bed. RN E stated she was not present when the incident started on 09/07/23, but CNA A later explained to her what happened. RN E stated she saw Resident #95 aggressively move his wheelchair towards CNA A, screaming at her, berating her, and calling her names. RN E stated she pulled CNA A out of the situation and into the breakroom and the resident continued to harass CNA A until they walked into the breakroom. She stated that CNA A told her that she had been there to put him in bed at 9:30 PM and he was not there. Resident #95 approached CNA A later and demanded she put him in bed. She stated that CNA A told her she told Resident #95 she could not do it and he would have to get someone from the next shift to do it, at which point Resident #95 started being aggressive, pushing his wheelchair at her, swinging at her, and saying you have to put me to bed! It's your job! RN E said that the resident was not really trying to hit CNA A as much as just take swats at her, but CNA A told RN E she felt physically threatened, was very upset, and told Resident #95 I swear, if you hit me, it will be the last day I work here, and I will spit in your face. RN E stated she sent a text message to the Operations Manager and DON, but she did not hear back from them. She stated it was late on a Friday night and the end of the shift, so they were going home anyways. Because Resident #95 had those behaviors so consistently, it did not occur to her that she needed to be more assertive about contacting the Operations Manager and DON. She stated she knew it was not an excuse, but Resident #95 was a fully alert and oriented man, and he had ostracized so many staff members and refused to allow so many into his room that it was hard to provide care for him sometimes. She stated she had failed to make a note about it in the EMR and she knew she should have done so. RN E stated she did not witness CNA A calling Resident #95 and old hoe but only saw him chasing her down the hall and her walking away and not responding. Nobody ever told her that CNA A had called the resident a name, and she only knew about what she saw, and what CNA told her. She showed the surveyors the text message she sent to the DON and Operations Manager on 09/07/23. Review of the text message screen shots provided by RN E reflected a message sent to the DON and Operations Manager at 9:53 PM, but did not reflect the date it was sent, however the text mentioned Friday, which would have been 09/07/23. The message was a description of Resident #95 being verbally abusive to CNA A, and CNA A being upset and saying if he hit her, it would be the last day she worked there and she would spit in his face. The message ended anyway, this is just information, it's Friday night I'll see you guys Monday. Interview on 09/14/23 at 1:16 PM with CNA A revealed CNA A was taking care of Resident #95 last week (date unknown) and before 9:30 PM came, he left his room. CNA A stated she took a picture of his room to prove he wasn't there and went back to the nursing station. Resident #95 came down to the nursing station and was asking if CNA A was going to put him in bed. CNA A told him no because he wasn't in his room by 9:30 PM and it was close to shift change (10 PM to 6 AM shift). CNA A did not indicate she was retaliating against the resident as it was an agreed upon protocol by the resident and staff that Resident #95 would need to be put in bed at 9:30 PM. Staff would not be able to put Resident #95 in bed if he was not in his room to be put in bed. Resident #95 was on the phone with someone but was calling CNA A all kinds of cuss words (profanities and name-calling). CNA A stated she had the proof of Resident #95 not being in his room, which she felt justified why she did not put Resident #95 to bed. Resident #95 then rolled his wheelchair up close to CNA A telling her to show him the proof. CNA A walked outside to get away from Resident #95 with CNA D to throw the trash away. When CNA A came back, Resident #95 started following behind her. CNA D asked CNA A if she was going to put Resident #95 to bed. CNA A stated no because he wasn't in his room by 9:30 PM. Resident #95 started cussing CNA A out telling her he can get into bed whenever he wanted to according to the care plan. Resident #95 started cussing at CNA A and when she walked off Resident #95 raised out of his wheelchair like he was about to hit CNA A. CNA A then stated this would be her last day working here if he touched her. CNA A had shower sheets in her hand and Resident #95 started swinging like he just wanted to put his hands on her. He told CNA A she better keep walking unless he was going to run her over with his wheelchair and that was when CNA A stated she would spit in Resident #95's face. CNA A did confirm she called him an old hoe because he called her a hoe and was cussing at her. CNA A stated she did not receive training on how to deescalate situations like the one with Resident #95. CNA A revealed RN E started walking down the hallway at the end so she heard Resident #95 call me out her name. CNA A stated RN E sent an auto message about what happened to management and CNA A was right there when she sent it. CNA A states RN E knew she was very upset and that she would get put on the list to not take care of Resident #95 when Monday came. CNA A also revealed her last work night was Monday 9/11/23 2-10 PM and the person that was there from the beginning till the end of the incident was CNA D. Review of notes from the Social Worker, dated 09/13/23, revealed SW came up to facility tonight at 9pm. spoke with patient for about 15 minutes. He was in good spirits sitting outside in electrical [wheelchair]. He denied depression and feeling down to SW. He stated he was having no adverse psychosocial effects related to incident with CNA. SW gave patient her work cell and encouraged him to always come to her anytime he has issues with staff etc. at [facility name]. He voiced understanding. SW to follow up with patient in [morning]. SW also asked patient if he would be aggregable to seeing psychiatrist at facility, [psychiatrist's name]. He did agree. SW notified [MD AA] who will see him next visit. He is on antidepressant currently. SW to follow up . Notes did not indicate resident was on psych services prior. Review of facility self-reports for the month of September 2023 revealed no self-reports related to the altercation with CNA A and Resident #95. Review of facility incident reports for the month of September 2023 revealed no incidents relating to the altercation between CNA A and Resident #95. Review of the facility's staffing schedule from 09/10/23 to 09/15/23 revealed CNA A worked on the 2:00 PM to 10:00 PM shifts on 09/10/23 and 09/11/23 on the hall where Resident #95 resided after the incident on 09/07/23. Review of time stamps for CNA A revealed she worked the 2:00 PM to 10:00 PM shifts on 09/08/23, 09/09/23, 09/10/23, and 09/11/23, after the incident on 09/07/23. Review of CNA A's training records reflected her date of hire was 03/31/23. CNA A received Abuse and Neglect training as part of her orientation, and in an in-service on 05/24/2023. There was no evidence on recent training regarding Resident #95's behaviors. Review of the facility policy Abuse: Prevention of and Prohibition Against, revised 10/22, reflected Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. ( .) The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. This policy applies to all Facility staff ( .) Purpose: Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. ( .) Definitions: To assist the Facility's staff members in recognizing incidents of possible abuse, neglect, misappropriation of resident property, or exploitation, the following definitions are provided: o Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse ( .) Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Abuse: Prevention and Prohibition Against: ( .) Verbal Abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. ( .) 2. The Facility will provide oversight and supervision of staff in connection with the above, to confirm that its policies prohibiting abuse, neglect, misappropriation of resident property, and exploitation are being implemented. ( .) An IJ was called at 5:20 PM on 09/13/2023 with the Operations Manager, DON, and Clinical Resource Nurse. The IJ template was reviewed with them during this interview and provided via email 09/13/23 immediately following it . An interview on 09/13/23 at 5:20 PM with the Operations Manager revealed they just learned about the allegation when the surveyor informed them on this date (09/13/23), and had already suspended CNA A, and staff who had not reported the allegation, and started in-servicing staff on what to report, stressing that things they heard about and did not witness were to be reported. She stated the text the RN sent her did not arrive properly as a text and went into a sent note folder so they had not been aware she sent them a text. She stated they had re-educated her and the rest of the staff on calling, not texting, and it was their policy to call to report a concern or allegation. If they had known earlier, they would have done this right away, and they were making sure staff knew to report things directly to the Operations Manager immediately. The Plan of Removal (POR) was accepted and the Operations Manager was notified on 09/15/23 at 12:39 PM. The POR reflected: [Facility Name] F600 Plan of Removal 09/13/23 Per the information provided in the IJ Template given on 09/13/23 at 5:20 PM, the facility failed to prevent actual abuse of a resident and risk of continued abuse to the resident emotionally/psychologically/physically. 1. The Medical Director was notified of IJ on 09/13/23 1813. 2. Alleged abuse perpetrator(s) and witnesses(s) who failed to report the abuse were placed on suspension on 09/13/23 pending investigation and self-report was submitted to HHSC (intake #450876). -Head to toe assessment completed by LVN charge nurse on 9/13/23 -PHQ9 assessment completed 9/13/23. -Resident interviewed by facility DON. Resident was pleased with facility actions and stated he felt safe. 3. Education initiated with all staff on abuse/neglect/exploitation including definitions of abuse/neglect/exploitation, prevention of abuse/neglect/exploitation and employee requirements for reporting abuse/neglect/exploitation to be completed by DON/Clinical Resource/ADON and Operations manager started on 09/13/23 at 1600. Notice for the requirement for all staff to receive education prior to working their next shift was delivered to all staff on 9/13/23 at 1905 [7:05 PM]. All regular staff will receive the education by 9/14/23 at 1400 [2:00 PM] or prior to their next shift at the facility, whichever comes first. PRN staff received the mandatory training notice and will receive education prior to their next shift. 4. Safe surveys were initiated with all residents by the facility LBSW on 09/13/23 at 1600 [4:00 PM]. Safe surveys will be completed on 09/14/23. 5. The ADON, DON, and Clinical resource will complete all staff competency on abuse initiated on 09/13/23 at 1815 [6:15 PM] and will be completed by 09/14/23 6. This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. 7. An ad hoc QA meeting regarding items in the IJ template will be completed on 09/13/23. Attendees will include the Medical Director, Clinical Resource, Administrator, DON, ADON, Operations Manager, and will include the plan of removal items and interventions. 8. The DON, ADON or Clinical Resource will verify staff competency with 5 staff weekly using the abuse check competency checklists for 90 days starting 09/18/23. 9. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring included: An observation on at 12:47 PM on 09/14/23 revealed the Social Worker going from room to room doing safe surveys with residents. An interview on 09/14/23 at 2:24 PM with LVN B revealed she had been in-serviced on abuse and neglect, and that they needed to contact the Abuse Coordinator, the Operations Manager, right away and if she was not reachable to call the DON. She said that if it happened again, she would do it differently and report the incident in person or call the Abuse Coordinator. LVN B stated the Abuse Coordinator would decide if it was abuse or neglect, not her. She stated when there were difficult residents, she was to not engage in abusive behavior but to walk away and get help. An interview on 09/14/23 at 2:48 PM with RN E revealed the facility spent a lot of time in-servicing her on abuse on 09/13/23, and they did a competency checklist on abuse, neglect and reporting. She stated they asked about situations and what she would do. RN E stated if she suspected or saw anything that could be abuse or neglect, she would call the Abuse Coordinator on the phone, not text them, or tell them in person. She stated she sent the message and assumed they would come to her to ask questions. When RN E came to work on 09/11/23 CNA A and Resident #95 were getting along fine, neither of them said anything and she thought everything had worked out OK. She said it was possible that the staff got desensitized after Resident #95's behaviors happened so frequently and she felt bad that she had not realized how serious it was at the time. She stated if the Operations Manager or DON had gotten the message, it would have had a different outcome. She stated from now on she would be contacting them on the phone and making sure they knew. She said the training they did was good, and some of the newer people had questions answered during it. Interview on 9/14/23 at 12:51 PM with Resident #95 revealed Resident #95 had a head-to-toe assessment completed and the resident stated he did not feel unsafe at the facility. He stated he hadn't seen CNA A since and heard she got fired so he didn't have to worry about her anymore. He stated if abuse happened again, he could call the ombudsman or the Administrator. Interviews with staff from 09/14/23 at 9:00 AM to 09/15/23 at 4:00 PM reflected on 09/13/23 or 09/14/23 staff covering all shifts had been re-trained on abuse and neglect protocols, including who to report to, and what types of events were to be reported. Staff interviewed were CNA A, LVN B, CNA C, CNA D, RN E, DON, Operations Manager, LVN F, CNA G, CNA H, LVN I, LVN J, LVN K, LVN L, LVN M, MA N, CNA O, CNA P, CNA Q, CNA R, HK S, PT T, PT U, PT V, PT W, and OT X. Interviews with residents on 09/14/23 from 9:00AM to 4:00PM revealed residents had been asked if they were safe and who to report abuse to if it were to happen. Residents felt safe in the facility, and said they felt they could report problems to any staff, and were not afraid to tell the DON or the Operations Manager if they had a problem with a staff member. Residents interviewed were Resident #95, Resident #131 Resident #66, Resident #103, Resident #143, Resident #121, Resident #141, Resident #13, Resident #78, Resident #207, Resident #205, Resident #206, Resident #51, Resident #67, Resident #57, Resident #43, Resident #118, Resident #303, Resident # 86, Resident #109, Resident # 101, Resident #255, Resident #256, Resident #257, Resident #258, Resident # 137, and Resident #101. Review of in-service documentation, dated 09/13/23 and 09/14/23 reflected all regular staff were in-serviced on abuse an neglect, what needed to be reported, and the exact procedures for reporting, with the exception of some PRN staff, terminated staff who were still on the staff roster, and some regular staff who were on leave, or had not arrived for an on-coming shift yet. Review of safe surveys done on 09/13/23-09/15/23 reflected interviewable residents in all halls were interviewed about whether they felt safe in the facility, had ever had a problem with a staff member or with their care, and if they had any complaints. An interview on 09/15/23 at 11:53 AM with CNA D revealed the Operations Manager had in-serviced him on 09/13/23 and called him on 09/14/23 to suspend him. He said she went over if anything happened, and he saw it, or heard it, or heard about it, he should not hesitate to call her directly. He said it could be anything, if someone was not doing their job right, or if they treated a resident badly in any way. CNA D said if anything like the incident with Resident #95 and CNA A ever happened again, he would call the Operations Manager right away. An interview on 09/15/23 at 12:27 PM with the DON revealed they had an IJ because the staff was aware of abuse and did not report it. She expected them to report anything they have concerns about, and the administrative staff could figure out what needs to go further. They would report either to her or the Operations Manager, who is the Abuse Coordinator. They have put the Operations Manager's photos up all over the facility, so everyone knows who to report to. She said they expected staff to walk up to them and tell them in person or call them if they were not able to do that. She had explained to the staff that they want them to report more, rather than less, and they needed to report anything they think could possibly be an issue. She and the Operations Manager and a Nurse Manager would make sure the new hires were properly oriented about abuse and neglect reporting, and they would continue to monitor and educate them. They would do rounds daily, the department heads during the week, and the weekend supervisor during the weekend, to make sure residents felt safe, and were receiving care. The DON stated the facility would question a sample of staff weekly to make sure they were able to answer questions about what to do and cover all shifts. It would be on-going in their QAPI process. They would do spot checks of the night shift, and administrative nursing staff would continue to work a night shift periodically to oversee care. They would continue their policy of checking skin checks from the previous nights and weekends to make sure there were no indicators of possible abuse. An interview on 09/15/23 at 12: 39 PM with the Operations Manager revealed she believed they had an IJ because the Operations Manager and DON did not know about abuse that occurred in the facility. The policy and her expectations of the staff were that if they witnessed, or heard of, or saw anything that could be considered abuse or neglect, they were to speak with her in person or call her immediately to report it. She stated she would be overseeing all of the monitoring and continued training, and nursing management would be part of that as well. Their monitoring would consist of what was in their POR, and in addition they would be doing spot checks on every shift, beyond the POR. She said she would review those quality checks weekly to make sure every shift was covered. She said the issue of training and monitoring for abuse and reporting would be addressed in their QAPI process, ongoing. She said Resident #95 had very difficult periods, and they had staff who were afraid to come to work because of him, so they were going to meet with the VA to ask their help in finding him alternate placement. An Immediate Jeopardy was identified on 09/13/23 at 5:18 PM. The IJ Template was provided to the facility on [DATE] at 5:20 PM. While the Immediate Jeopardy was removed on 09/15/23, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of isolated due to the facility's need to implement and monitor the effectiveness of its corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (Resident #1) of 6 residents reviewed for pressure ulcers. The facility failed to provide treatment and services to prevent Resident #1 from developing a bilateral (affecting both sides) deep tissue pressure injury to buttocks, before she was seen for unrelated emergency services at a local hospital on [DATE]. An Immediate Jeopardy (IJ) was identified on 07/26/23. The IJ template was provided to the facility on [DATE] at 5:04 PM. While the IJ was removed on 07/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their corrective systems These failures could place residents at an increased and unnecessary risk of complications such as pain, acquiring new wounds, pressure ulcer/pressure injury development, worsening of existing wounds, and infection. Findings included: Record review of Resident #1's face sheet, printed on 07/17/23, revealed a [AGE] year-old female, who admitted to the facility on [DATE] with the following diagnoses: encounter for orthopedic aftercare following surgical amputation, muscle weakness, T2DM (a chronic condition that affects the way the body processes glucose (blood sugar)) with diabetic neuropathy (nerve damage due to prolong high blood sugar levels), PVD (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), Osteomyelitis (infection of the bone), and acquired absence of left great toe. Record review of Resident #1's MDS, dated [DATE], revealed Resident #1 had a BIMS of 11 which indicated Resident #1 had a moderate cognitive impairment. Section G0110 of the MDS indicated Resident #1's functional status required one-person physical assist with ADLs. Section H indicated Resident #1 was occasionally incontinent of bowel and bladder. Section M of the MDS assessment revealed Resident #1 was at risk to develop pressure ulcers/injuries and did not have one or more unhealed pressure ulcers/injuries. Section M1040 revealed Resident #1 had surgical wound(s) that were present at the time of admission. Record review of Resident #1's care plan, dated 6/23/23, created by the DSD, indicated a care focus - Resident #1 had potential for pressure ulcer development r/t immobility, amputation L hallux (big toe), weakness but there was no goal or interventions listed. On 07/13/23, (day of surveyor entrance and after Resident #1 discharged on 07/10/23) the care focus was revised by MDS CC to reflect: GOAL [Initiated: 07/13/23; Created on: 07/13/23; Created by: MDS CC; Target Date: 10/11/23]: - Will have intact skin, free of redness, blisters, or discoloration by/through the review date. INTERVENTIONS [Initiated: 07/13/23; Created on: 07/13/23; Created by: MDS CC; Target Date: 10/11/23]: - Administer treatments as ordered and monitor for effectiveness - Call light within reach - Follow facility policies/protocols for the prevention/treatment of skin breakdown Further review of Resident #1's care plan, dated 6/23/23, revealed a care area initiated 07/13/23 that reflected: FOCUS [Initiated: 07/13/23; Created on: 07/13/23; Created by: MDS CC; Target Date: 10/11/23]: - . has episodes of bowel/bladder incontinence r/t deconditioning and debility GOAL [Initiated: 07/13/23; Created on: 07/13/23; Created by: MDS CC; Target Date: 10/11/23]: - Will remain free from skin breakdown due to incontinence and brief use through the review date INTERVENTIONS [Initiated: 07/13/23; Created on: 07/13/23; Created by: MDS CC; Target Date: 10/11/23]: - INCONTINENT: Check as required for incontinence. Wash, rinse, and dry Perineum [anatomy] (the area between the anus and the scrotum (a pouch of skin containing the testicles) or vulva (the female external genitals)) - Change clothing PRN after incontinence episodes Review of An Internal Medicine Progress Note entered by the NP dated and e-signed 06/26/23 at 11:24 PM indicated [Resident #1] seen and examined. Chart reviewed. Discussed with the nurse of the patient . Hx of PVD: Bilateral SFA occlusions (blockage or closing of a major lower extremity artery) . bilateral lower extremity angiography on 06/19/23 revealed left SFA occlusion and right SFA in-stent stenosis. Record review of Resident #1's weekly non pressure ulcer skin assessment, dated 6/28/23, completed by LVN A, revealed Resident #1 had surgical wound to the left great toe and left lateral heal. Documented interventions were listed as daily wound care provided, weekly wound consultations with [Doctor]. Heel protectors on. Record review of Resident #1's Skin Evaluation - PRN / Weekly, dated 7/3/23, completed by LVN B, revealed Resident #1 had bruising to the front of her left lower leg and surgical incisions to her left toes. Additional Comments were included as Bruising on admission to LLE, PICC RUE. The evaluation did not indicate skin integrity issues Resident #1's bottom. Record review of a Wound Physician progress note indicated a LATE ENTRY, Effective Date: 07/05/2023 at 11 :14 AM, entered by the WNP indicated reason for consultation - follow-up visit for wound assessment and treatment for wound on left foot surgical sites. The WNP reflected in the Wound Physician progress note that A 9-point comprehensive examination [of body areas] performed of the following sites: head and face, scalp, neck, left upper extremities, right upper extremities, right lower extremities, left foot, and right foot to examine for any new or current lesions . Wound Location: left foot; Etiology: surgical; s/sx of infection: None. Assessment and Plan: . Off load pressure point areas and turn per facility protocol while in bed as needed.\ . Minimize friction and shearing Record review of Resident #1's weekly non pressure ulcer skin assessment, dated 7/5/23 and completed by LVN A, revealed Resident #1 had surgical wound to the left great toe and left lateral heal. Documented interventions were listed as daily wound care provided, weekly wound consultations with [Doctor]. Heel protectors on. The assessment did not indicate skin integrity issues Resident #1's bottom. Record review of Resident #1's progress notes tab of her electronic health record revealed a progress note, written by LVN C on 07/10/23 at 11:10 a.m., indicated Received report that resident transferred to [hospital]. [family member] aware. A record review of hospital medical records, for admission date 07/10/23, indicated [Resident #1] presented to the ED on 07/10/23 at 11:35 AM EMS reports that patient was at [Specialty Appointment] for a follow up on foot wound care due to diabetes . Per EMS, aphasia (loss of ability to understand or express speech) and mild right sided facial droop was reported but patient states that her aphasia might be going of for a few weeks. Pts face appears symmetrical to RN upon assessment, but aphasia is noted. GCS = 14 (used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients). Pt comes with Foley catheter and midline in place. Hx of diabetes and cirrhosis (a chronic disease of the liver marked by degeneration of cells, inflammation, and fibrous thickening of tissue). Record review of the hospital Wound Care Consult Note, dated 7/11/23 at 10:13 AM, revealed wounds in addition to the two surgical (left foot) wounds documented at the SNF: A wound first assessed on 07/11/23 at 12:30 AM, present on hospital admission, to the Left Dorsal (the upper surface) Foot, described as purple/red tissue discoloration w/ open areas; wound bed color - maroon, purple, pink; non-blanching (skin redness that does not turn white when pressed - is an important skin change); no drainage An Arterial Ulcer, first assessed on 07/11/23 at 12:30 AM, present on hospital admission, to the Left calf, wound bed - maroon, pink; firm; non-blanching A Pressure Deep Tissue Injury (DTI), first assessed on 07/10/23, present on hospital admission, to Resident #1 bilateral buttocks; wound bed color - maroon, purple, pink; wound bed texture - non-blanching; and blistered Record Review of SOM defined an arterial ulcer as ulceration that occurs as the result of arterial occlusive disease when non-pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis . Arterial ulcers may be present in individuals with moderate to severe peripheral vascular disease . is characteristically painful, usually occurs in the distal portion of the lower extremity and may be over the ankle or bony areas of the foot (e.g., top of the foot or toe, outside edge of the foot). Record review of the hospital Wound Care Consult Note, dated 7/11/23 at 10:13 AM, revealed in the physical exam, multiple left foot necrotic ulcers . Left foot necrosis s/p great toe AMP--sutures noted, full thickness necrosis of the surround tissue of the AMP site . Left heel diabetic ulcers x 2, full thickness ulcer with devitalized (deaden) tissue . adjacent necrotic full thickness ulcer with dry eschar . Left dorsal foot necrotic diabetic ulcers, full thickness ulcers with dry black eschar . Sacral and bilateral buttock pressure DTI, deep purple bruising with extensive non-blanchable redness to both buttocks - POA. During an observation of wound care on Resident #1 at a local hospital on [DATE] at 12:16 p.m., Resident #1 was observed to have an open wound across her buttock area, covering both buttocks. By visual inspection, the length [measured from the resident's head to the toe] of the wound appeared to be about seven inches (the size of an adult hand) and the width [measured from the lateral positions on the resident] by visual inspection appeared about three inches (the size of the palm of an adult hand). The altered skin integrity appeared as shallow open ulcer(s) (break on the skin) with a bright red, pink wound bed. The surrounding area around the open ulcer(s) appeared red and irritated. A darker red, purplish discoloration noted at upper left outer area of surrounding skin. Resident #1 winced when wound was cleansed with gauze saturated with NS. Wound care completed to buttocks. Resident #1 tolerated well. In an interview on 07/13/23 at 1:24 p.m., LVN C stated she worked in the facility for roughly 3 months. LVN C stated on 07/10/23 around 11:30 a.m., she received a call from Resident #1's physician asking if facility staff noticed any drooping to the right side of Resident #1's face, which they did not see. LVN C stated Resident #1 went to the physician for a follow-up visit and was sent to the emergency room for the facial drooping. LVN C stated she assessed Resident #1 prior to her leaving for her appointment and she saw no skin integrity concerns. LVN C stated if a skin integrity issue was observed she would notify the residents family and physician for wound consultation and guidance. In a telephone interview on 07/14/23 at 11:29 a.m., the clinical director from the physician office Resident #1 was seen at on 07/10/23 stated Resident #1 was seen for a follow-up appointment. The clinical director stated Resident #1 appeared to have an altered mental status and a droop to the right side of her face, which was why the physician sent her to the emergency room. The clinical director stated the physician did not assess Resident #1's skin and had no knowledge of any skin integrity issue except her surgical incisions to her left foot. The clinical director stated the resident was diagnosed with a urinary tract infection at the hospital. In a telephone interview on 07/14/23 at 3:08 p.m., Resident #1's family member stated she had given Resident #1 a shower on 07/07/23 and noticed redness and what appeared to be blisters to her bottom. The family member stated she went to the nurse and asked for cream and was given a blue single use packet of cream, which she placed on Resident #1's bottom. The family member stated she reported the redness and blisters to the same nurse who had given her the blue packet of cream but could not recall her name. In an interview on 07/14/23 at 5:05 p.m., ADON D stated skin assessments were conducted weekly by the charge nurses. ADON D stated the responsibility of the treatment nurse to ensure the skin assessments were conducted as scheduled and accurately and to follow up on any new findings. ADON D stated to her knowledge no residents had new skin integrity issue of redness and blisters reported recently, but if redness and blisters were found the expectation was to notify the residents family, physician, and treatment nurse. ADON D stated the facility's single use barrier cream was packaged in a blue packet. In an interview on 07/14/23 at 5:31 p.m., LVN E stated she was the Resident #1's charge nurse on the 2:00 p.m. to 10:00 p.m. shift on 07/07/23. LVN E stated during her shift, no resident, family member or staff member asked her for barrier cream or reported new skin integrity issues to her. LVN E stated if new skin integrity issues are reported, they were trained to assess the resident, notify the residents family and physician and the treatment nurse. In a telephone interview on 07/17/23 at 12:25 p.m., CNA F stated she was the overnight aide for Resident #1 from 07/07/23 through 07/09/23. CNA F stated Resident #1 was able to do for herself, did not call for assistance and often declined peri care and showers because a family member would provide that for Resident #1. CNA F stated Resident #1 normally slept through her shift, so showers and peri care were declined. CNA F stated on her last shifts, Resident #1 did not complain of pain or skin integrity issues to her, and her family did not request barrier cream from her. CNA F stated when any skin integrity issues are identified, she was trained to report the issue to the charge nurse. In a telephone interview on 07/17/23 at 1:08 p.m., LVN A (WCN) stated she worked in the facility as the wound treatment nurse for roughly 13 years. LVN A (WCN) stated she was responsible for all wounds in the facility, except infected surgical incisions and incisions that were healing properly. LVN A (WCN) stated she was responsible for new skin assessments to ensure wound care needs were provided as needed. LVN A (WCN) stated her skin assessments were documented as progress notes and identified skin integrity issues were documented under the skin assessment. LVN A (WCN) stated skin concerns she looked for were discoloration, skin tears or abrasions and redness. LVN A (WCN) stated if new skin integrity issues were identified, she would document the finding, notify the physician, and wound doctor and start recommended wound care. LVN A (WCN) stated skin concerns identified by other facility nurses were reported to her on skin communication forms or verbally. LVN A (WCN) stated when she visited her residents to provide wound care, she only looked at the known areas of concern, unless the resident or staff notify her of new skin integrity issues. LVN A (WCN) stated Resident #1 had surgical incisions to her left toe and heel areas and received weekly wound care. LVN A (WCN) stated the only additional skin integrity issue observed was discoloration of the skin under Resident #1's left toes, which was reported to her physician and was scheduled for a follow-up on 07/10/23. LVN A (WCN) stated she had not received any reports of skin integrity issues to Resident #1's bottom, and Resident #1 had not complained of pain to her bottom. In a telephone interview on 07/17/23 at 1:56 p.m., LVN G stated she was Resident #1's overnight nurse on 07/07/23. LVN G stated Resident #1 had surgical wounds on her left foot and had not complained of any skin issues or pain to her sacral area. LVN G stated no resident or family member had requested barrier cream from her and no one report skin issues of any kind to her. LVN G stated if new skin integrity issues were identified she would assess the resident and notify the physician, family, and the treatment nurse and/or wound doctor. In a telephone interview on 07/17/23 at 4:12 p.m., LVN H stated she was Resident #1's overnight nurse on 07/08/23. LVN H stated conducted a head-to-toe assessment on Resident #1 that shift and found no skin integrity issues to her sacral area. LVN H stated she did not receive report of skin integrity issues and no resident or family member had requested barrier cream. In a telephone interview on 07/17/23 at 5:32 p.m., LVN I stated she was Resident #1's day shift nurse, the charge nurse on 07/08/23. LVN I stated redness and blisters were not reported to her from any staff, residents or family member. LVN I stated if redness was reported to her, she would conduct a skin assessment, notify the appropriate parties and monitor the area for changes. LVN I stated she had not provided barrier cream to any family members during this shift. In an interview on 07/17/23 at 5:38 p.m., the IDON stated Resident #1 was taken to a follow-up appointment on 07/10/23 and was sent to the emergency room from the doctor's office. The IDON stated the only skin integrity issues she was aware Resident #1 had was the surgical incisions to her left foot, which were the only issues documented. The IDON stated to her knowledge there was no issues with peri care or showers, she was aware of. The IDON stated she was not aware that Resident #1 had a deep tissue injury to her sacral area, that was discovered by hospital staff. The IDON stated there were no indications of redness and blisters to Resident #1's sacral area and she believed the redness could have developed as Resident #1 waited to be seen at her doctor's office. The IDON stated the treatment nurse was responsible for wound care and charges nurses were responsible for weekly skin assessments. The IDON stated there were follow behind skin assessments to ensure skin assessments were conducted accurately, as that would be insane due to the amount of skin assessments would be needed. The IDON stated if skin integrity issues are identified, the expectation is for nurses to obtain a treatment order and ensure the area is treated. The IDON stated if skin integrity areas were not identified and treated, the area could get worse. She states she planned to re-educate nursing staff on skin assessments and implement monthly skin sweeps to ensure no skin integrity issues are missed moving forward. In an interview on 07/17/23 at 7:09 p.m., the ADMIN stated the IDON notified him (prior )of the surveyor's concern regarding Resident #1's sacral area. The ADMIN stated the expectation was for staff to use shower sheets and skin assessments to document all skin integrity issues and to ensure the facility policy was followed regarding skin integrity issues and wounds. The ADMIN stated if skin integrity issues were not identified and treated, the area had potential to get worse. The ADMIN stated he planned to re-educate staff on skin assessments to ensure all skin concerns were addressed. In an interview and record review on 07/26/23 at 9:27 a.m., revealed MDS DD stated she worked as one of the facilities two MDS nurse for roughly 13 years. MDS DD stated she was responsible for Medicare and managed care MDS assessments and MDS CC was responsible for all other MDS assessments. MDS DD stated that LVN A (WCN), was responsible for updating any residents care plan to include any skin integrity issues. MDS DD reviewed Resident #1's care plan with surveyor and acknowledged the care plan did not list interventions for Resident #1's risk for pressure ulcers. MDS DD stated when the care plan was updated, the person should ensure the care plan was updated entirely. In an interview on 07/26/23 at 11:06 a.m., LVN A stated as the wound care nurse, she was not responsible for updating residents care plans with skin integrity issues or risks. LVN A (WCN) stated the IDON was responsible for updating care plans. LVN A (WCN) stated if she observed redness and blisters on a resident, she would report to the wound care doctor, the resident would receive an air mattress and depending on the doctor's orders, would receive wound care. In an interview on 07/26/23 at 12:35 p.m., the IDON replied to expectations with care plan development stating the MDS nurses have the skills and qualifications to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and able to recognize areas of decline to accurately develop care plans. The IDON stated leadership and department heads meet every morning to discuss resident status updates, changes in condition, and pertinent information to collaboratively with the MDS nurses to develop and update care plans as needed. In an interview on 07/27/23 at 1:04 p.m., MDS CC stated was responsible for Resident #1's care plan. MDS CC stated when the MDS assessment was completed, CAAs are triggered which must be signed by a nurse. MDS CC stated they have seven days to care plan triggers. MDS CC stated one of Resident #1's triggered CAAs was risk of pressure ulcer, which should have been care planned. MDS CC stated while she updates Resident #1's care plan pressure risk standard interventions, she might have been interrupted. MDS CC stated she thought she had completed the care plan update but had not. In an interview on 07/27/23 at 4:45 p.m., the Admin was not able to speak to the process of care plan development/update; FC care; MD Notification; Incontinent Care; IV management./dressing changes. The Admin stated his expectation was that all staff participate in facility in-services & trainings to maintain update skills and follow facility protocols on resident care. The Admin stated nursing department heads and leadership ensure nursing staff have the competency to perform their jobs appropriately and provide quality care. Record review of the facility policy entitled Skin and Wound Monitoring and Management, revised in January of 2022, read in part: POLICY: It is the policy of this facility that: 1. A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and 2. A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection and prevent, new avoidable pressure injuries from developing. PROCEDURE: The purpose of this policy is that the facility provides care and services to: 1. Promote interventions that prevent pressure injury development . The Admin was notified of an Immediate Jeopardy (IJ) on 07/26/23 at 5:04 PM due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 07/27/23 at 12:58 PM and included: 1. The Medical Director was notified of IJ on 07/26/23 at 5:45pm. 2. Skin sweep (on the spur of the moment skin checks) of total census initiated 07/26/23 and will be completed 07/26/23 by CRN, Clinical Leaders, MDS Nurse, ADON and DON. 3. Review of all pressure ulcer treatments orders was initiated and will be completed. 07/26/23 by the DON. All orders were reviewed and were accurate and complete on 7/26/23. 4. Review completed by DON on 07/26/23 of all residents who are at risk for PU/PI and care plans updated for all residents at risk. 5. Education initiated with Nurses and CNAs that included change in condition procedures for wounds, change in behaviors, refusal of care, notification of changes in condition, wound identification, and notification. 6. All licensed nurses will complete competency on skin assessments started on 07/26/23. 7. All CNA's will complete competency on skin check started on 07/26/23. All CNAs will have competencies/education completed prior to their next shift if unable to come in immediately. 8. This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 9. An ad hoc meeting regarding items in the IJ template will completed on 07/26/23. Attendees will include the Medical Director, CRN, Admin, DON, ADON, Clinical Resources and will include the plan of removal items and interventions. 10. The DON, ADON or CRN will verify staff competency with 10 staff weekly using the skin check competency checklists. 11. All residents with pressure ulcers be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to the DON, ADON, Rehab Director and WCN. The DON and Admin will be responsible for ensuring this meeting is held weekly and all residents with pressure ulcers/pressure injury are reviewed. 12. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring conducted on 07/27/23 of the facility's implementation of their POR included: Interview(s) with CRN, ADON D, ADON M, and IDON indicated POR entry #2, Skin sweep (on the spur of the moment skin checks) of total census initiated 07/26/23 was completed 07/26/23 by CRN, Clinical Leaders, MDS Nurse, ADON and DON. Interview(s) with CRN, ADON D, ADON M, and IDON indicated POR entry #3, Review of all pressure ulcer treatments orders were initiated and completed by the IDON. Interview with the IDON indicated she reviewed all pressure ulcer treatment orders on 07/26/23 and the IDON stated all orders were accurate and complete. The IDON stated that she reviewed care plans of residents at risk for PU/PI and the care plans were updated. Interviews conducted with nursing staff scheduled 6a - 2p and 2p - 10p shift on 07/27/23 [ADON D, LVN Q, LVN O, CNA L, CNA K, MDS CC, MDS DD, CNA BB, NA AA, CNA Z, LVN C, CNA Y, CNA X, CNA W, CMA T, LVN S, LVN I, RN R, LVN E, CMA V, CNA U, and ADON M] stated they participated in an in-service training about changes in condition of skin, , assessing and treating wounds, appropriate interventions when skin issues are found, notifying RP/MD, consulting wound doctor on admission, conducting and documenting weekly skin assessments in PCC. The nurses summarized the topic of discussion as identifying, assessing, and monitoring wounds clinical protocol. Each nurse stated in their own words the difference between pressure and vascular/arterial ulcers, appropriate interventions when abnormal skin issues are discovered, procedure to notify physicians immediately of resident change in condition, and actions to take if unable to contact a physician. The CNAs and CMAs summarized the topic of training in their own words purpose of skin sheets, how to complete skin sheets and POC documentation, and reportable s/sx to charge nurse. Record review of in-services conducted by the CRN beginning 07/26/23 titled Skin/Wound Care reflected 10P - 6A nursing staff signatures participated in the in-service - CNA F, LVN EE, NA FF, LVN GG, CNA HH, CNA II, LVN H, CNA JJ, CNA KK, CNA LL, and CNA MM. Staff signatures from 6A - 2P and 2P - 10P shifts included, LVN S, LVN E, CMA V, LVN I, RN R, NA NN, LVN OO, RN PP, CNA AA, CNA HH, CNA QQ, CNA RR, CNA J, and CNA SS An IJ was identified on 07/26/23. The IJ template was provided to the facility on [DATE] at 5:04 PM. While the IJ was removed on 07/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not IJ due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary, and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of eight residents reviewed for Urinary Tract Infection (UTI), in that: 1. The facility failed to monitor Resident #1's urinary catheter for changes in condition, recognize, and address such changes to prevent urinary tract infections. Resident #1 was hospitalized on [DATE] for acute encephalopathy (altered mental state - confused, and not acting normal) and urinary tract infection. 2. The facility failed to obtain physician orders for insertion, ongoing indwelling catheter care, and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures for Resident #1 after placement of an indwelling catheter on 07/06/23. 3. The facility failed to develop an individualized care plan after placement of an indwelling catheter on 07/06/23. 4. The facility failed to implement interventions for Resident #1 in accordance with the resident's needs, goals for care and professional standards of practice, to recognize, report, ongoing monitoring for changes in condition and addressing such changes related to potential CAUTI's after placement of an indwelling catheter on 07/06/23. An Immediate Jeopardy (IJ) was identified on 07/26/23. The IJ template was provided to the facility on [DATE] at 5:04 PM. While the IJ was removed on 07/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their corrective systems This failure to provide appropriate treatment and services to residents with an indwelling catheters place residents at risk of UTIs, potential CAUTI's (a urinary tract infection associated with urinary catheter use), developing complications such as injury to the urinary tract, and the development of sepsis. Findings included: A record review of Resident #1's admission MDS (a standardized assessment tool that measures health status in nursing home residents) assessment dated [DATE] revealed a 53 y.o. female admitted on [DATE]. Resident #1 had diagnoses of HTN (when the pressure in the blood vessels is too high - 140/90 mmHg or higher); PVD (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel); DM (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high); HLD (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides); osteomyelitis, unspecified; acquired absence of left great toe; and encounter for orthopedic aftercare following surgical AMP (the loss or removal of a body part). Resident #1's BIMS score was 11, which suggested moderately impaired cognition. Resident #1 had no behavioral symptoms or exhibited rejection of care behavior during the MDS review period. In Section G - Functional Status revealed in Section G0110 of the MDS indicated Resident #1's functional status required one-person physical assist with ADLs. Section G0400 reflected Resident #1 had an impairment to the lower extremity on one side that interfered with daily functions or placed at risk of injury. Section H indicated Resident #1 was occasionally incontinent of bowel and bladder. A review of Resident #1's care plan, dated 06/23/23, revealed a care area initiated 07/13/23 that reflected: FOCUS [Initiated: 07/13/23; Created on: 07/13/23; Created by: MDS CC; Target Date: 10/11/23]: - . has episodes of bowel/bladder incontinence r/t deconditioning and debility GOAL [Initiated: 07/13/23; Created on: 07/13/23; Revision on 07/13/23]: - Will remain free from skin breakdown due to incontinence and brief use through the review date INTERVENTIONS [Initiated: 07/13/23; Created on: 07/13/23; Target Date: 10/11/23]: - Ensure there is an unobstructed path to the bathroom - INCONTINENT: Check as required for incontinence. Wash, rinse, and dry Perineum [anatomy] (the area between the anus and the scrotum (a pouch of skin containing the testicles) or vulva (the female external genitals)) - Change clothing PRN after incontinence episodes - Monitor/document for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increase temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns Record Review of Resident #1's physician orders revealed: - Prescriber Entered Order. Start date 07/05/23: Bladder scan x 1, If retaining more than 400 mL, Insert a Foley catheter and place Foley catheter orders. One time only for urinary retention for 1 day do bladder scan. - Verbal Order. Start date 07/06/23: Bladder scan x 1, If retaining more than 400 mL, Insert a Foley catheter and place Foley catheter orders. One time only for urinary retention for 1 day. - Prescriber Entered Order. Start date 07/06/23: Place Foley catheter stat. STAT for place Foley catheter. There were no other orders for Foley care, monitor output, or Foley replacement PRN. Record review of Resident #1's July 2023 MAR reflected orders were completed as evidenced by: Bladder scan x 1, If retaining more than 400 mL, Insert a Foley catheter and place Foley catheter orders. One time only for urinary retention for 1 day [Order date 07/06/23], revealed: - 07/06/23 2:53 PM: LVN C's initials. Result: 650 ML Record review of Resident #1's July 2023 TAR reflected orders were completed as evidenced by: Bladder scan x 1, If retaining more than 400 mL, Insert a Foley catheter and place Foley catheter orders. One time only for urinary retention for 1 day do bladder scan. [Order date 07/05/23], revealed: - 07/05/23 5:16 PM: A checkmark and LVN E's initials. Result: 643 ML Place Foley catheter stat. STAT for place Foley catheter. [Order date 07/06/23], revealed: - 07/06/23 5:05 PM: A checkmark and LVN E's initials Record review of progress notes for Resident #1 revealed: - A Daily Skilled Note, dated 07/06/23 at 1:39 PM as a LATE ENTRY, entered by ADON M indicated Vital Signs: BP 132/68 (7/6/2023 at 09:02 AM); T 98.2 (7/6/2023 1:40 PM); Pulse 74 (7/6/2023 at 09:02AM); Resp 17 (7/6/2023 at 1:40 PM); Pain: No Urine is normal urine output No GU changes observed. No GU appliances used. - A progress note entered by Resident #1's attending PCP dated and e-signed 07/06/23 at 2:31 PM indicated 7/6/23: bladder scan shows distended bladder (a condition in which the bladder becomes enlarged) with volume 643 ml. Will place foley catheter. - 07/06/23 at 3:42 PM, LVN C entered: N/O (new order) for foley cath implemented . - 07/07/23 There was not a Daily Skilled or narrative note to indicate any nursing care and treatment provided, detailing all assessments, health issues, personalized care plan, actionable treatments, or evaluation. - 07/08/23 at 7:01 PM, IDON entered: Vital Signs: BP 129/70 (07/07/23 5:29 PM); Temp 97.0 (07/07/23 5:29 PM); Pulse 65 (07/07/23 5:29 PM); Resp. 18.0 (07/07/23 5:29 PM); Pain: No COGNITION, MOOD, BEHAVIOR: Resident is Alert, Oriented X 3 No Active Symptoms or Treatments effecting Level of Consciousness, Cognition, Sleep, Mood, or Behavior. GENITOURINARY and RENAL: Urine is clear and yellow No GU changes observed. GU appliance used is an indwelling catheter. The IDON did not document or indicate that she performed catheter care. Resident #1's last vital signs measured as reflected in the progress note entered by the IDON on 07/08/23 at 7:01 PM, were 07/07/23 at 5:29 PM. - 07/09/23 at 4:44 AM, LVN H entered: Vital Signs: BP 130/77 (07/09/23 4:45 AM); Temp 97.6 (07/09/23 4:45 AM); Pulse 70 (07/09/23 4:46 AM); Resp. 17.0 (07/09/23 4:47 AM); Pain: No COGNITION, MOOD, BEHAVIOR: Resident is Alert, Oriented X 3 No Active Symptoms or Treatments effecting Level of Consciousness, Cognition, Sleep, Mood, or Behavior. GENITOURINARY and RENAL: Urine is Dark Yellow Urine Present in Foley Catheter Bag 250ml no Sediment s/s of Infection Present. Catheter Care Performed No GU changes observed. GU appliance used is an indwelling catheter. Other observations and interventions include Foley Catheter Present - Draining to Gravity on Lowest Immobile Bed Rail - Emptied Drainage Bag - Patient Slept through Catheter Care - Tolerated well. - 07/10/23 4:02 AM, LVN H entered: Vital Signs: BP 132/65 (07/10/23 4:02 AM); Temp 97.8 (07/10/23 4:02 AM); Pulse 82 (07/10/23 4:02 AM); Resp. 18.0 (07/10/23 4:02 AM); Pain: No COGNITION, MOOD, BEHAVIOR: Resident is Alert, Oriented X 3 No Active Symptoms or Treatments effecting Level of Consciousness, Cognition, Sleep, Mood, or Behavior. GENITOURINARY and RENAL: Urine is Dark Yellow Urine Present in Foley Catheter Bag 250ml no Sediment s/s of Infection Present. Catheter Care Performed No GU changes observed. GU appliance used is an indwelling catheter. Other observations and interventions include Foley Catheter Present - Tolerates Catheter Care well - did not Wake A record review of hospital medical records obtained on 07/14/23, for admission date 07/10/23 indicated [Resident #1] presented to the ED on 07/10/23 at 11:35 AM EMS reports that patient was at [Specialty Appointment] for a follow up on foot wound care . Per EMS, aphasia (loss of ability to understand or express speech) and mild right sided facial droop was reported . face appears symmetrical to RN upon assessment, but aphasia is noted. GCS = 14 (used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients). Pt comes with Foley catheter and midline in place. Review of ED Provider Notes dated 07/10/23 at 11:59 AM indicated Resident #1 arrived confused, appears ill, and disoriented . due to continued confusion in the ED, was admitted for further workup and treatment. Review of Resident #1 UA collected in the ED at 07/10/23 at 1:43 PM, resulted (*) abnormal (AB!) lab values at 1:52 PM: URINALYSIS, ROUTINE - Abnormal; Notable for the following components: GLUCOSE, UA - Pos 1+ (AB!) | Range: Negative BLOOD UA - Pos 1+ (AB!) | Range: Negative LEUKOCYTES ESTERASE - 500 | Range: Negative URINE MICROSCOPIC - Abnormal; Notable for the following components: EPITHELIAL CELLS - Frequent (*) | Range: Few WBC, URINE - 65 (*) | Range: 0 - 5 RBC, URINE - 10 (*) | Range: 0 - 3 BACTERIA UA - Light (*) | Range: Absent MUCUS UA - Present (*) | Range: Absent YEAST - Present (*) | Range: Absent URINE MICROSCOPIC EXTENDED - Abnormal; Notable for the following components: WBC CLUMPS - Few (*) | TRANSITIONAL EPITHELIALS - Rare (*) | A review of the ED physician H & P notes dated 07/10/23 at 3:27 PM indicated [Resident #1] presented to ED with confusion . was confused and slow to respond to questions . A, A x O (to person, being [in hospital], not oriented to year and having difficulty recalling the full situation. The Assessment and Plan indicated [Resident #1] given ceftriaxone given concern for UTI . came from SNF with Foley catheter; Foley catheter removed and replaced in the ED . Admit to Inpatient. The ED physician discontinued Urine Culture on 07/10/23 at 3:30 PM due to UA consistent with UTI. [Urine cultures are not usually required with positive findings of UTIs in uncomplicated UTIs] [NAME] MJ, [NAME] SW, Reygaert WC. Urinary Tract Infection. [Updated 2022 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470195/ During a phone interview on 07/14/23 at 11:37 AM, Resident #1's family member stated that [Resident #1] went from fine to not fine in the short time at SNF. The family member said that during visitation [at SNF], [the family member] would ask nurse(s) for update and the nurses would say [Resident #1] was just sleeping and everything fine. The family member stated that concerns about [Resident #1] constant drowsiness/sleeping and confused bx when awake were brought to the nurses' attention . then stated, there is no reason [Resident #1] was escorted by ambulance to the hospital from the [VMD] follow-up appointment for confusion after nurses were told something was wrong with [Resident #1]. During an interview on 07/17/23 at 3:02 PM, LVN E stated she worked 2P - 10P, was familiar with Resident #1, and described [Resident #1] as able to feed self whenever alert enough . family member assisted with ADLs . had a Foley catheter. LVN E stated (he/ she) did not know if [Resident #1] admitted with Foley catheter but recalled a few weeks ago there was an order to perform a bladder scan and if the result was greater than (could not recall amount), to insert a Foley catheter. LVN E stated that a mobile diagnostic company performed the bladder scan but had not received results before end of shift. LVN E said that she followed up on the results on her shift the following day, after found the results on the fax machine, and sent to NP for review around 8:30 PM. LVN E said that the NP called back just as [LVN E] was leaving for home at the end of shift, so LVN E verbally told the on-shift night nurse the orders received from NP for LVN N to follow through. LVN E indicated that it was her user initials that reflected on the TAR on 07/06/23 who inserted the Foley catheter as ordered but did not actually perform the task. LVN E could not explain why she signed the TAR for a task she did not perform. LVN E stated that she had only stood by to assist with an indwelling catheter insertion and never performed on her own. LVN E verbalized the steps of procedure but stated that she would access resources on the procedure before performing because she was not comfortable with the task. LVN E stated whenever she provided catheter care to a resident she checked the entrance area, which was free from pus, discharge, and drainage; also, would check the tubing was not clogged and drained clear yellow urine. LVN E said CNAs were typically responsible for emptying the catheter drainage bag, measured urine, and informed the charge nurse of the color, any odor, and the amount. LVN E said that poor peri-/catheter care placed residents at risk of an UTI. LVN E described a change in condition as a change from the resident's day to day baseline vital signs or behavior - acting confused. LVN E stated early s/sx of UTI included confusion; urine with foul odor, sediment, or blood; and stomach pain. LVN E said that she provided direct care to Resident #1 but did not recall a change in condition, behavior, or vital signs that caused concern. LVN E said that there are orders to monitor for signs of UTI, 30 days order from day of admission to replace catheter, and to change the catheter as needed . the 10P - 6A shift change the catheter and the 6A - 2P shift performs catheter care. LVN E stated the purpose of performing catheter care and replacing the catheter at least every thirty days is to decrease risk of infection. A telephone interview was attempted on 07/17/23 at 4:34 p.m. for LVN S, but the call was not answered or returned prior to exit. During an interview on 07/17/23 at 5:38 PM, the IDON stated that she monitored 30-day catheter orders. The IDON said based on the CDC it was not required to change the catheter every 30 days. The IDON stated catheter care is used to prevent UTIs and catheter care is considered cleaning the peri area (the private areas) and performing peri care (involves cleaning the private areas). The IDON said that she ran reports to ensure there were no blanks on the MAR/TAR, then stated that ADON M was responsible for monitoring Peri-care is completed daily by monitoring the TAR. The IDON was unable to present policy, procedure, or guidelines that reflected CDC documentation that indicated changing an indwelling catheter at least every 30 days was not necessary. During an interview on 07/17/23 at 6:34 PM, ADON M stated his responsibilities included reviewing new orders, run Orders Reports to review new orders, update resident chart, follow-up on labs, and communicating with nurses. ADON M recalled Resident #1 admitted with IV abx for an UTI. ADON M stated the attending PCP ordered a bladder scan for Resident #1 . resulted urine retention . the PCP ordered placement of an indwelling catheter . and then, [Resident #1] was started on IV abx for UTI. ADON M said that he ran a report daily to monitor that scheduled tasks were incomplete/completed on the current day shift (6A - 2P). ADON M stated nurses should assess the catheter and urine output when assessed the resident during their shift. ADON M said that scheduled tasks alert nurses to perform care . if a task was not completed on a shift, it would be completed by the nurse on the next shift. ADON M stated that all nurses were trained on the risks of infections and to provide timely care. ADON M stated that he followed up with nurses to ensure catheter care was done. ADON M stated that the orders were scheduled to conduct catheter/peri care daily, to change catheter every 30 days and as needed. When asked if the reports ran revealed there were no orders entered to perform catheter care or monitor Resident #1 urine output, ADON M stated that a nurse who did not work regularly, could miss, or overlook a scheduled task. ADON M never provided an answer or explained the missing [indwelling catheter care] orders. ADON M stated the nurses were responsible for selecting all interventions related to care when entering orders and if needed clarification about incomplete or if needed additional orders, such as the need to provide catheter care/peri care, should contact the attending doctor. ADON M stated that best practice was for the CNA to communicate with the nurse . the nurse should assess concerns that the CNA told them . notify the provider, RP, and IDT to update the care plan. During an interview and record review on 07/26/23 at 9:27 AM, MDS DD stated she worked as an MDS nurse for nearly 13 years, but Resident #1 was not one of the resident's care plans managed [Resident #1 was assigned to MDS CC]. MDS DD reviewed Resident #1's care plan with investigator and stated that by reading the care plan it appeared that [Resident #1] had DM, HLD, PVD, was on IV abx for osteomyelitis, but did not reflect what type of IV access . Resident #1 had HTN, COPD, had the great toe AMP on Left foot . episodes of B & B incontinence, at risk for falls, on psych meds, potential for nutritional issues r/t DM, risk for PU, had a surgical wound to left great toe and left lateral heel . had a diagnosis of depression, anxiety, potential for pain r/t neuropathy and [left great toe] AMP, required assistance with ADLs, and goal was to go back home. When MDS DD was asked about the emphasis that the care plan did not reflect type of IV line, MDS DD replied it was important to identify the type of IV line to implement interventions for appropriate care of the IV access, what solution to flush with, how to monitor, dressing changes, and to include doctor specific orders. When asked if Resident #1 had other lines, tubes, or drains by reviewing the care plan, MDS DD denied. MDS DD indicated the care plan did not reflect an indwelling catheter. MDS DD stated if the indwelling catheter was placed after the ARD, the care plan was closed and the ADONs were responsible for care plan updates . that could be a reason a care plan was not developed for the catheter. MDS DD indicated if a resident discharged from the facility before the ARD, the care plan would not be updated unless the resident returned to the facility. MDS DD stated when the care plan was developed or updated, the person would ensure the care plan was updated entirely. A review of the July 2023 Infection Log revealed 7 residents with facility acquired UTIs [onset dates 07/03/23, 07/04/23, 07/05/23, 07/08/23, 07/13/23, 07/15/23, and 07/17/23] and 1 resident with a CAUTI infection [onset date 07/04/23]. Three residents were admitted to the same hall as Resident #1 with UTIs [2 residents on 07/06/23; 1 resident on 07/08/23]. Record review revealed the IDON completed The CDC Nursing Home Infection Preventionist Training Course (Web-based) on 02/28/23; and ADON D completed the course on 05/23/23. During an interview on 07/26/23 at 12:35 PM, the IDON stated expectations that MDS nurses were skilled and qualified to assess relevant care areas and were knowledgeable about the resident's status, needs, strengths, and recognized areas of decline to accurately develop care plans. The IDON said that Leadership and department heads met every morning to discuss resident status updates, changes in condition, and pertinent information to collaborate with the MDS nurses to develop and update care plans as needed. The IDON provided the Comprehensive Person-Centered Care Planning policy to investigator as requested. The IDON indicated that there was not a specific policy for peri-care or catheter care . we just follow the CDC guideline. The IDON stated that there was a protocol on how to perform peri-/catheter care and provided it to the investigator. During a phone interview on 07/26/23 at 2:06 PM, the attending PCP said that any change from baseline behavior, vital signs . from the resident's normal was considered a change in condition. The attending PCP agreed when asked if a resident presented AMS or more confused was considered a change in condition. The attending PCP said that early s/sx of UTI/CAUTI could be a fever, change in urine characteristics, or lab values. The attending PCP stated that it would be likely recommended to obtain labs or other diagnostic studies to determine if a resident had a UTI/CAUTI. The attending PCP stated instructions given were to notify MD/NP immediately of a resident's change in condition. The attending PCP indicated (he/ she) was familiar with Resident #1 but did not currently have Resident #1's chart available to review notes. When asked if Resident #1 was at risk for UTI, the attending PCP replied anyone incontinent or with an [indwelling] catheter is at risk for UTI. The attending PCP indicated lab work and follow up labs were ordered for Resident #1 and monitored for kidney function. The attending PCP stated that it was common sense to make sure a resident with a catheter had orders to monitor and provide care . the nurses could call if they needed the order to monitor and provide appropriate catheter care to Resident #1 if they had to. The attending PCP stated that Resident #1 was very complicated, and issues could occur r/t the other infections. The attending PCP said (he/she) needed to check notes and could not recall if notified about Resident #1 AMS or decline in ADLs. The attending PCP stated he/she would call the hospital, review notes, and follow up with the investigator. There was no further communication with the attending PCP before exiting the facility. On 07/26/23 at 2:30 PM, an outbound call was placed to LVN N. There was no answer. The IDON was informed that the investigator needed to speak with LVN N. The IDON acknowledged, and stated that LVN N worked nights and the night before. He/She stated LVN N was probably asleep, but would communicate with LVN N to contact the investigator. The call was not answered or returned prior to exit. During an interview on 07/27/23 at 1:04 PM, MDS CC stated she was responsible for Resident #1's care plan. MDS CC stated when the MDS assessment was completed, CAAs were triggered, and the care plan was implemented within seven days after signed by the nurse [RN/DON]. MDS CC stated she thought she had completed the care plan update but had not. In an interview on 07/27/23 at 4:45 p.m., the Admin was not able to speak to the process of care plan development/updates, FC care, MD Notification, Incontinent Care, or IV mgmt./dressing changes. The Admin stated his expectation was that all staff participated in facility in-services and trainings to maintain updated skills and follow facility protocols on resident care. The Admin indicated nursing department heads and leadership ensured nursing staff had the competency to perform their jobs appropriately and provide quality care. Review of a policy and procedure provided by the facility titled Perennial, routine procedures, revised May 2007, indicated that it is the policy of this facility to cleanse perineum, eliminate odor, prevent irritation or infection, enhance resident's self-esteem Review of a policy and procedure provided by the facility titled, Physician Orders, Pharmacy Services, revised May 2007, indicated that it is the policy of this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments. The Admin was notified of an Immediate Jeopardy (IJ) on 07/26/23 at 5:04 PM due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 07/27/23 at 12:58 PM and included: 1. The Medical Director was notified of IJ on 07/26/23 at 5:45pm. 2. Review completed by DON of all residents with catheters in facility to assure appropriate monitoring and treatment orders are in place and active. 3. Review completed by DON on 07/26/23 of all residents with foley catheters and care plans updated for all residents at risk. 4. Resources, DON, ADON, and clinical leadership-initiated education with Nurses and CNAs on monitoring foley catheters, foley catheter care and UTI/CAUTI prevention. 5. CRN provided education to DON on 7/26/23 6. All licensed nurses will complete competency on foley catheter care started on 07/26/23. 7. All CNA's will complete competency on foley catheter care started on 07/26/23 8. This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 9. An ad hoc meeting regarding items in the IJ template will completed on 07/26/23. Attendees will include the Medical Director, CRN, Admin, DON, ADON, Clinical Resources and will include the plan of removal items and interventions. 10. The DON, ADON or CRN will verify staff competency with 10 staff weekly using the skin check competency checklists. 11. All residents with foley catheters will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to the DON, ADON, Rehab Director and WCN The DON and Admin will be responsible for ensuring this meeting is held weekly and all residents with foley catheters are reviewed. 12. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring conducted on 07/27/23 of the facility's implementation of their POR included: Interview with IDON indicated she was educated by the CRN about the steps of procedure related to catheter care and completed POR entry #2 on 07/26/23. The IDON assured that appropriate monitoring and treatment orders were in place and active for all residents with catheters in the facility. Interview with IDON indicated she completed POR entry #3 on 07/26/23. The IDON indicated that she reviewed the care plans of all residents with foley catheters, and the care plans were updated. Interview with the CRN indicated she completed POR entry #5 and provided education to the IDON on 07/26/23. Interviews conducted with nursing staff scheduled 6a - 2p and 2p - 10p shift on 07/27/23 [ADON D, LVN Q, LVN O, CNA L, CNA K, MDS CC, MDS DD, CNA BB, NA AA, CNA Z, LVN C, CNA Y, CNA X, CNA W, CMA T, LVN S, LVN I, RN R, LVN E, CMA V, CNA U, and ADON M] indicated they participated in an in-service training about foley catheters. The nurses indicated they had received an in-service regarding catheter care, which included proper catheter care and continual treatment to ensure prevention of UTIs and ensure all current resident with a catheter had an order on the TAR. The CNAs and CMAs summarized the topic of training in their own words how to perform catheter care/peri-care, appropriate placement of the drainage bag, cover with privacy bag, must hang below the bladder, not rest drainage bag on floor, POC documentation, and reportable s/sx to nurse. Record Review of an in-service conducted by the CRN, dated 07/26/23, reflected the IDON signature. The summary of the in-service in a general way, covered catheter care, obtaining orders, and monitoring. Record review of in-services conducted by the CRN beginning 07/26/23 titled Foley Catheter Care reflected 10P - 6A nursing staff signatures participated in the in-service - CNA F, LVN EE, NA FF, LVN GG, CNA HH, CNA II, LVN H, CNA JJ, CNA KK, CNA LL, and CNA MM. Staff signatures from 6A - 2P and 2P - 10P shifts included, LVN S, LVN E, CMA V, LVN I, RN R, NA NN, LVN OO, RN PP, CNA AA, CNA HH, CNA QQ, CNA RR, CNA J, and CNA SS. An IJ was identified on 07/26/23. The IJ template was provided to the facility on [DATE] at 5:04 PM. While the IJ was removed on 07/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not IJ due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 4 halls reviewed for infection control. 1. The facility failed to test all residents and staff when Resident #61 tested positive for COVID-19 at the facility. The facility did not test all residents until after the 6th resident tested positive. 61 residents out of 121 residents developed COVID-19. 2. The facility failed to ensure facility staff did not reuse the same cloth gowns on more than one resident. 3. The facility failed to ensure devices used by more than one resident were cleaned and sanitized between uses. 4. The facility failed to wear PPE masks properly. An Immediate Jeopardy (IJ) was identified on 07/19/2022 at 2:45 PM. While the IJ was removed on 07/22/2022 at 4:10 PM, the facility remained out of compliance at a scope of widespread and a severity of the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents who had a negative COVID-19 status at risk of exposure to infection and complications of the COVID-19 virus including hospitalization and death. Findings include : 1. Review of Resident #61's Face Sheet, dated 07/21/22, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease. She lived on Hall 1. Review of Resident #61's Nurse Note, dated 06/30/22, reflected: 1:56 PM Reported by physical therapy that patient had not been participating well in therapy, decreased appetite, dry cough noted as well. 4:28 PM Covid rapid test completed and resulted positive, due to patient wandering and impaired memory transferred to another facility. A record review of the facility's list of COVID-19 positive residents, not dated, reflected: Resident #61 was the 1st resident to test positive on 06/30/22 and lived on Hall 1 (wander-guarded unit where all residents had memory issues and were not able to leave the unit). Her Roommate #115 tested COVID-19 positive on 07/12/22. An interview on 07/22/22 at 1:00 PM with the OTA revealed he did therapy with Resident #61 (1st COVID positive resident) on 06/30/22. The OTA said for therapy they bounced a ball and did aerobics, strength, and safety training. He said the resident did not wear a surgical mask. He said the resident was ill with lethargy a few days before she tested positive on 06/30/22. He said he told the nurse she was lethargic. He said there were four other residents he worked with around the time of 06/30/22 and all four of them tested positive for COVID-19. An interview on 07/21/22 at 12:25 PM with CNA M revealed she provided care to Resident #61 (1st COVID positive resident) on Hall 1. CNA M said the resident did not use a wheelchair, was ambulatory, and wore a wander guard. She said her roommate and her were close and did everything together. She said the resident went to the dining room for activities with other residents. CNA M said Resident #61 interacted with everyone on the hall and would pat people on the back. An interview on 07/22/22 at 11:49 AM with CNA L (first staff to test positive for COVID-19) revealed she was assigned to work on Hall 1 and Hall 2. She said she was assigned to work with Resident #61 (1st COVID positive resident) on 06/30/22 and the resident had signs and symptoms of COVID-19. She said the resident had a history of walking in the hallway (Hall 1) and eating in the dining room. 2. Review of Resident #70's Face Sheet, dated 07/22/22, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hemiplegia and cognitive communication deficit. He lived on Hall 1. Review of Resident #70's Nurse Note, dated 07/08/22, reflected: Received phone call from spouse stating she tested positive for COVID on 07/07/22 and last visited with resident on 07/04/22. Resident complained of feeling bad complaints of pain all over, no cough or congestion noted. Covid test resulted positive. A record review of the facility's list of COVID-19 positive residents, not dated, reflected: Resident #70 was the 2nd resident to test positive on 07/08/22 and lived on Hall 1. 3. Review of Resident #72's Face Sheet, dated 07/21/22, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia. He lived on Hall 1. Review of Resident #72's Nurse Note, dated 07/08/22, reflected: 4:46 PM Resident having shortness of breath upon exertion and rattling noises. Resident profusely sweating. Notified wife and Nurse Practitioner. Notified 911. Dispatcher states someone will be out shortly to send resident to hospital. A record review of the facility's list of COVID-19 positive residents, not dated, reflected: Resident #72 was the 3rd resident to test positive on 07/08/22 and lived on Hall 2. The roommate was not on the list of COVID-19 positive residents. Resident #4 and roommate Resident #3 were the 4th and 5th residents to test positive on 07/09/22 and lived on Hall 1. Resident #93 was the 6th resident to test positive on 07/10/22 and lived on Hall 2. His roommate tested positive at a later date. Resident #11 was the 7th resident to test positive on 07/11/22 and lived on Hall 1. He did not have a roommate. Resident #19 was the 8th resident to test positive on 07/12/22 and lived on Hall 2. Her roommate tested positive at a later date. Resident #17 was the 9th resident to test positive on 07/12/22 and lived on Hall 1. His roommate tested positive at a later date. Resident #39 was the 10th resident to test positive on 07/12/22 on and lived on Hall 1. His roommate tested positive at a later date. An observation on 07/19/22 at 10:40 AM -11:00 AM revealed the facility had 4 separate halls. Hall 1 was sectioned off and was identified as the Hot Unit (COVID-19 positive). Hall 2 was closed off with double doors and a pink PPE sign was on the double doors. The sign did not indicate if it was a hot unit, warm unit (COVID-19 status unknown), or a cold unit (COVID-19 negative.) Individual resident rooms on Hall 2 did not have isolation signs posted. On Hall 2 residents had their doors open and there were attached hooks on the walls next to their bathroom. There were two or more yellow, cloth gowns hanging on each hook. There were also resident rooms with hooks that had resident clothes hanging on them next to the yellow, cloth gowns. Staff were wearing N95 masks and goggles/face shields. PPE was not available next to each resident room. Hall 3 was closed off with double doors and a pink PPE sign was on the double doors. The sign did not indicate if it was a hot unit, warm unit, or a cold unit. Individual resident rooms on Hall 3 did not have isolation signs posted. PPE was not available next to each resident room. Laundry Staff O entered a resident room on Hall 3 without wearing eye protection. Hall 4 was a separate unit that was not closed off and no isolation signs were posted on resident doors. The sign did not indicate if it was a hot unit, warm unit or a cold unit. PPE was not available next to each resident room. An interview on 07/19/22 at 9:05 AM with the Clinical Market Director revealed the DON was COVID-19 positive with symptoms and was working on Hall 1, hot unit . An observation on 07/19/22 at 10:44 AM of Hall 3 revealed Speech Therapist K left Hall 3 (warm unit), with her cloth gown on, entered the supply room (cold room) wearing her cloth gown, saw the Surveyor and said, I'm not supposed to wear this (gown) out here, sorry and then walked back into Hall 3. An interview on 07/19/22 at 10:55 AM with CNA D revealed she was assigned to work on Hall 2 (warm unit). She said to work on the warm unit, she had to wear an N95 mask and a yellow, cloth gown. She said she reused the gown during her shift, and it was kept on a hook in the assigned resident's room. An observation on 07/19/22 at 11:05 AM revealed Resident #81 returned to Hall 2 (warm unit) from the dayroom (cold unit). The resident had a runny nose and was cleaning her nose with a tissue. She had her surgical mask pulled down. The Physical Therapist was with the resident, and he was wearing an N95 mask. An interview on 07/19/22 at 11:07 AM with Resident #81 revealed she was alert and confused. She said she was not feeling well, and she had her surgical mask pulled down. She said she had a runny nose, and her voice was crappy. She said she did not know when she was last tested for COVID-19 . An interview on 07/19/22 at 11:10 AM with the Physical Therapist revealed Resident #81 was not supposed to leave the warm unit to go to therapy. He said he did not know why she left Hall 2 (warm unit). An observation of the facility kitchen on 07/19/22 at 12:05 PM revealed 2 kitchen staff were placing meals in foam containers. They were both wearing KN95 masks on their chin instead of covering their nose. The Dietary Manager was also wearing her mask on her chin instead of over her nose. An interview on 07/19/22 at approximately 12:10 PM with the Dietary Manager revealed she spoke to the Surveyor, pulled her mask down, and began wiping her mouth and chin with a paper towel. The Dietary Manager said she could not stand all of the sweating that happened while wearing a mask. Interviews on 07/19/22 at 9:45 AM and 07/20/22 at 3:50 PM with the DON revealed she was working on Hall 1 the hot unit of the facility and was COVID-19 positive with symptoms. The DON said she tested COVID-19 positive on Friday, 07/15/22, and currently had a cough, congestion, and fever while working on Hall 1. The DON said on 07/01/22 (records revealed 06/30/22), Resident #61 was symptomatic with COVID-19 symptoms and tested positive on Hall 1. The DON said they transferred the resident to another facility and her roommate, Resident #115, was moved off Hall 1 and placed on quarantine in Hall 3. The DON said she made the decision at that time to do contact tracing instead of outbreak testing for the facility COVID-19 outbreak because she said both residents stayed together in their room except for dining and therapy. The DON said on 07/08/22, Resident #70 from Hall 1 was symptomatic and tested positive and was transferred to another facility. The DON said Resident #70's roommate, Resident #48, tested negative and was placed in quarantine. The DON said Resident #48 had a history of wandering. (Resident #48 remained negative for COVID-19.) The DON said at that time, all staff were tested for COVID-19, but the residents were not and contact tracing was continued for the residents. She said no staff tested positive for COVID-19. The DON said Resident #72 went to the hospital on [DATE] and tested COVID-19 positive but the facility did not find out until 07/11/22. The DON said on 07/10/22, Resident #94 was symptomatic, and tested positive on 07/10/22. (Per the facility COVID-19 Resident List, dated June/July 2022, Resident #94 was the 6th resident to test positive, not the 4th resident.) The DON said she made the decision to do facility-wide outbreak testing on 07/11/22 - 07/12/22 and found there were 25 COVID-19 positive residents with 6 COVID-19 positive staff. The DON said facility wide testing was completed again on 07/18/22, and an additional 23 residents tested positive. The DON said that most residents and most staff received the vaccine and first booster, but not the 2nd booster. She said for Hall 2 (warm unit) and Hall 3 (warm unit), staff were supposed to be wearing an N95/KN95 mask, eye protection, and a yellow, cloth gown to provide care to residents in quarantine. She said on Hall 1, hot hall, staff were supposed to wear a gown, N95 mask, and eye protection. The DON said she monitored to ensure staff were wearing PPE correctly. She said staff knew which yellow, cloth gown belonged to each staff member because the resident rooms had hooks to separate the gowns. She said she did not know staff were placing more than one yellow, cloth gown on each hook in the resident room. She said staff reused cloth, yellow gowns because that was the way they had always done it and she did not know disposable gowns were required. She said if she had known disposable gowns were required, she would have a stock of them to use. She said the first COVID-19 positive staff was confirmed on 07/11/22. The DON said she thought the outbreak spread so quickly because she found 3 staff were working when they were symptomatic. She said MA G was symptomatic and left work early when she tested positive on 07/12/22. The DON stated CNA H left work feeling ill and tested positive on 07/11/22. The DON stated LVN I was ill and tested positive on 07/14/22. She said for the facility decision on contact tracing instead of facility-wide outbreak testing there were a number of people involved in the decision-making process. She said in hindsight, she should have completed facility-wide outbreak testing. An interview on 07/19/22 at 12:31 PM with the Clinical Market Director revealed when the facility outbreak started, outbreak testing was not performed facility-wide because the facility decided to do contact tracing instead. Interviews on 07/20/22 at 2:07 PM and 07/22/22 02:03 PM with ADON E revealed she was assigned to Hall 1 (hot unit). She said the facility had plenty of PPE and in the hot unit, staff wore their isolation gowns without removing them for their shift. She said in hindsight, the facility could have started facility-wide outbreak testing to prevent the infection from snow-balling. ADON E said Hall 1 was a wander guard unit and the residents ate and did all activities together on Hall 1. She said about half of the residents would hang out together and all of the residents on the wander guard unit had memory issues. An interview on 07/20/22 at 2:31 PM with ADON F revealed she worked on Hall 3 and Hall 4. She said Hall 3 had residents who had developed COVID-19. She said her contact tracing revealed Hall 3 did not have any COVID-19 positive residents until they were moved from Hall 1. She said the residents who were moved to Hall 3 were placed in quarantine. She said staff on Hall 3 used N95 masks, face shields, and reusable, yellow, cloth gowns to provide care. She said staff were supposed to use one gown per resident room. She said she was not involved in the contact tracing for Hall 1 and Hall 2. She said the charge nurses were responsible for making sure staff used the cloth gowns correctly. She said staff were in-serviced about the cloth gowns when the outbreak started. ADON F said she did not complete any monitoring to make sure PPE was worn correctly. She said she did have to direct some staff to wear their masks. An observation and interview on 07/20/22 12:15 PM with CNA A revealed she was assigned to room [ROOM NUMBER] (Hall 2) on the warm unit. room [ROOM NUMBER] had several white hooks hanging on the wall next to the bathroom. The hooks had blue, disposable, isolation gowns hanging on the hooks. CNA A said she had to reuse the blue, disposable gown to provide care to the resident in the room. She said she was supposed to hang it on a CNA hook in the room after each use and dispose of it in a gray barrel in the hall at the end of her shift . Observations on 07/20/22 at 12:36 PM of the kitchen revealed Kitchen Staff B was at the sink in the kitchen with her N95 mask pulled down below her chin with her mouth and nose exposed. Kitchen Staff C was removing bread from a bread bag with her N95 mask pulled under her nose. An interview on 07/20/22 at 12:43 PM with the Dietary Manager revealed she instructed Kitchen Staff B and Kitchen Staff C to keep their N95 masks pulled up over their nose. The Dietary Supervisor said both staff were in-serviced on 07/19/22 to wear their masks appropriately . An observation and interview on 07/21/22 at 9:42 AM - 9:52 AM with MA J revealed she used the blood pressure cuff on the cart to take Resident #55's blood pressure. MA J took the blood pressure cuff back to the cart but did not clean it. MA J performed hand hygiene, donned PPE, put on gloves and took the same blood pressure cuff into a resident room to take their blood pressure. MA J said she did not have to clean the blood pressure cuff between resident uses. An interview on 07/21/22 at 10:00 AM with ADON F revealed staff were supposed to sanitize the blood pressure cuff between uses and she would address the issue with MA J. An interview on 07/21/22 at 12:40 PM with CNA N revealed she provided care to residents on Hall 2. She said staff would have one, yellow, cloth gown to use for both residents in each resident room. She said staff re-used the gown all shift. Interviews on 07/20/22 at 4:36 PM and 07/21/22 at 8:20 AM with the Administrator revealed he did not know when the last facility COVID-19 outbreak was, and the facility had plenty of disposable gowns. He said the facility used contact tracing instead of outbreak testing for the outbreak because Resident #61 who tested positive, pretty much kept to herself. He said the next resident was positive because of a COVID-19 positive family member who visited the resident. He said the facility did screen visitors for COVID-19 symptoms and staff were being tested two times a week. The Administrator said he was not sure why COVID-19 was a big deal because people were not dying, and symptoms were less severe. Review of the facility COVID Timeline/Contact Tracing, not dated, reflected: June 30, 2022 - [Resident #61 ] with decreased activity level and appetite. Tested COVID positive and transferred to another facility. We did contact tracing -consistent with her [family member] who visited three to four days prior to her testing positive who is not vaccinated and non-compliant with masking determined that was the culprit of the positive. June 30th, 2022 [Resident #61's] roommate, [Resident #115] (COVID test was negative on 07/01/22) transferred to Hall 3 for contact/droplet isolation as a precaution. [Resident #61] and [Resident #115] tend to self-isolate in room and watch TV. They eat seated at a table with each other and rarely interact with other residents for more than a casual hello. Which is less than 15 minutes of contact. Staff assigned to Hall 1 tested on [DATE] and repeated on 07/07/22 and 07/14/22 to comply with county transmission rate. July 8, 2022 - [Resident #70] with c/o 'feeling bad' and 'hurting all over.' Resident tested positive for COVID. Resident transferred to another facility. We completed contact tracing and determined resident's [family member] visited on 07/04/22. [Family member] tested positive Tuesday but did not notify the facility until Friday . Staff assigned to Hall 1 already being tested. [Resident #70's] roommate, [Resident #48] tends to wander and requires redirection. [Resident #48] maintained on contact/droplet precautions. [Resident #48] tested during outbreak testing and remains negative as of 07/20/22. July 9, 2022 - [Resident #3] had episode of emesis (vomiting) and tested positive for COVID. [Resident #3's roommate [(Resident #4)] frequently helps him with tasks and also tested positive. [Residents #3 and #4] transferred to another facility. [Resident #48] and [Resident #4] share a bathroom and [Resident #48] frequently wanders into the [(Residents #3 and #4)] room and is redirected. July 11, 2022 - [Resident #11] presented with a temperature of 101.6 degrees Fahrenheit on evening shift resident tested COVID positive. Resident maintained on contact/droplet precautions and transferred to another facility on 07/12/22. The facility initially contact-traced and tested residents usually present in the Hall 1 dining room with whom [Resident #11] has interactions/sat at the table .Upon noting additional positive cases, the decision was made to test all residents of Hall 1 and Hall 2. An interview was attempted on 07/22/2022 at 2:16 PM with the Medical Director. He did not return the call of the Surveyor. Review of the Facility In-service, Personal Protective Equipment Commitment, dated 01/31/21, reflected: .wear appropriate PPE .This means an N95 mask while working, gown, and gloves each time you enter a resident's room . Review of the facility Infection Control Policy/Procedure, dated May 2007, reflected: 1. Goals. The goals of the Infection Control Program are to: A. Decrease the risk of infection to patients and personnel. B. Monitor for occurrence of infection and implement appropriate control measures. C. Identify and correct problems relating to infection control practices. D. Ensure compliance with state and federal regulations relating to infection control. Review of the CDC, COVID-19 Interim Infection Prevention and Control Recommendations to prevent SARS-CoV-2 spread in nursing homes located in the facility COVID-19 binder, dated 02/04/22, reflected: .Testing. Create a plan for testing residents and HCP for SARS-CoV-2 Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible .facilities should prioritize resources to test symptomatic people and all close contacts, as well as be prepared to initiate outbreak response immediately if a nursing home-onset infection is identified among residents of HCP .HCP should not work while acutely ill .Managing Residents with Suspected SARS-CoV-2 Infection. HCP caring for residents with suspected or confirmed SARS-CoV-2 infection or equivalent . should use full PPE (gowns, gloves, eye protection, and a .N95 .New Infection in Healthcare Personnel or Residents .Because of the risk of unrecognized infection among residents, a single new case of SARS-CoV-2 infection in any HCP or .in a resident should be evaluated as a potential outbreak .HCP and residents with symptoms of COVID-19: Symptomatic HCP, regardless of vaccination status, should be restricted from work .Perform contact tracing .A facility-wide .approach, should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission .Broad-based approach: Perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately .and if negative, again 5-7 days later. Review of the Facility Personal Protective Equipment: Conservation during Crisis or Pandemic Policy, dated 03/23/20, Isolation Gowns. Contingency Capacity (Rationing PPE): Shift to cloth isolation gown if available - single use, laundering after each use. Crisis Capacity (PPE in very limited supply) Extended use of isolation gowns (disposable or cloth) if no co-infectious diagnoses requiring contact isolation. Reuse of isolations gowns by wearing an apron over the gown to prevent excessive exposure. This was determined to be an Immediate Jeopardy (IJ) on 07/19/22 at 2:25 PM. The Clinical Market Director was notified of the IJ (the Administrator and DON were not at the facility) and the IJ template was provided on 07/19/2022 at 2:45 PM. The following Plan of Removal was submitted by the facility and was accepted on 07/20/2022 at 4:45pm. It reflected: .Immediate Action Taken: 1. The Medical Director was immediately notified at roughly 3:20pm on 7/19/22. 2. DON/ED/admission Coordinator/Designee will assure that all new admissions, exposures and positive residents are placed in designated area by following the CMS/CDC/HHSC guidelines. 3. Facility failed to perform COVID outbreak testing once a positive resident as identified by HHSC on 7/19/22. a. All residents were tested on i. 07/12/22 - 20 positive resident's [sic] identified ii. 07/18/22 - 25 positive resident's [sic] identified b. All residents will continue on outbreak testing until the current COVID outbreak has cleared: i. ED/DON/Resource/Designee are responsible to assure that this is completed per CDC, CMS, HHSC guidelines. ii. Outbreak testing will occur for staff and resident's 3-7 days until no new case are identified for at least 14 days from most recent positive test. c. Any resident displaying symptoms will immediately be tested by charge nurse and DON notified. d. Cohorting/Placement of residents i. Facility will establish designated cohorts based on resident covid status 1. Hot Unit - Resident's [sic] who are confirmed covid positive 2. Warm Unit- Resident's [sic] who are unknown covid status or exposed to covid 3. Cold Unit - Residents who have no history of covid exposure and are confirmed negative covid status. e. ED/DON/Resource/Designee will be responsible to assure that testing during out break is completed per CMS/HHSC/CDC guidelines. f. Routine testing of staff who are not up to date with COVID-19 will be completed based on county positive rate published weekly per CMS/CDC i. Resource/ED/DON/Designee will assure that staff testing is completed per listed guidelines g. Contact tracing vs Outbreak Testing per CDC guidelines i. ED/DON/Designee will initiate contact tracing if the facility has the ability to identify close contacts of the individual with COVID-19. ii. If the ED/DON/Designee is unable to complete contact tracing the ED/DON/Designee will initiate broad based testing of the facility residents and staff. h. Staff regardless of vaccine status will also be tested based on triggers upon entrance/screening to the facility i. Resource/DON/ED/Staffing coordinator/Designee will be responsible for reviewing the staff screen log daily to assure anyone who has triggered positive on the screening is tested and follow up completed. i. In the event that a newly identified covid-19 case is identified with staff or resident with close contact i. Resource/ED/DON/Designee will assure that all staff are tested regardless of vaccination status that had close contact with COVID-19 positive individual ii. Resource/ED/DON/Designee will test all residents regardless of vaccine status that had close contact with COVID-19 positive individual. j. In the event that a newly identified COVID-19 positive staff or resident in the facility that is unable to identify close contacts i. Resource/ED/DON/Designee will test all staff regardless of vaccination status facility wide or at a group level if staff are assigned to a specific location where the new case occurred (for example unit, floor or specific area of the facility) ii. Resource/ED/DON will test all residents regardless of vaccination status facility wide or at a group level (for example unit, floor or specific area of the facility). 4. The DON was on the COVID unit from 9 a.m.to 11 a.m. 7/19/22 after testing positive with signs and symptoms. a. The DON was sent home at 11 a.m. on 7/19/22 - DON upon arrival to the facility was asymptomatic, however when her symptoms developed, she went home. i. In the event that an employee becomes symptomatic while on duty they will notify the on call/DON/Designee ii. Employee will be removed from the patient care area, sent to test and wait in a secure non- patient care area for test results. b. The DON will be in-serviced on infection control and complete donning/doffing competency prior returning to work at facility, this will be completed by the Clinical Resource. 5. Staff not wearing N95 masks/eye protection a. Staff on Hot/Warm units not wearing N95 masks i. All staff provided N95 masks to wear immediately ii. All staff will have eye protection on in the warm/hot unit patient care areas iii. IDT/Resource/Designee will round to assure that staff have the appropriate mask for assigned unit. iv. HCP who are up to date with all recommended COVID-19 vaccine doses once outbreak has been cleared: 1. Could choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms, kitchen). 2. They should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors) v. Donning/Doffing station has been setup at dock entrance of the COVID unit 1. ED/DON/Staffing Coordinator/Designee will assure that adequate supplies of PPE are stocked daily 2. ED/DON/Staffing Coordinator/Designee will assure that facility has adequate supplies of ppe on hand and monitor three times a week. 3. If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions while not in outbreak per CDC. a. All staff working in facilities located in counties with substantial or high transmission should also use PPE as described below i. KN95, equivalent or higher-level mask should be used for care of residents who have been identified in the cold zone. 4. If SARS-CoV-2 infection is suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow contact/droplet precautions i. N95, equivalent or higher level mask for care of residents in warm zone or hot zone. ii. Face shield or eye protection iii. Isolation gown 6. Staff not wearing masks appropriately (pulling masks down in patient care area) a. IDT/Resource/Designee will round to assure that all staff are wearing masks appropriately 3 x daily for 4 weeks and results of these observations will be reviewed by the QAPI committee for recommendations. b. Resource/ED/DON/Designee will complete in-service on infection control and masking for staff starting on 07/19/22 will be completed by 07/21/22, all staff who are not present will complete training prior to first scheduled sh[TRUNCATED]