**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident was free from neglect for 1 (Resident #1) of 5 residents reviewed for neglect. The facility failed to ensure Resident #1 was assessed and treated for a disseminated rash (rash on several parts of the body) that was first identified 05/03/23 by RP #2; the facility failed to ensure Resident #1 was taken to his dermatologist appointment on 07/26/23 on time, which caused the appointment to be rescheduled on 08/21/23 at which time Resident #1 was diagnosed with scabies and treatment was initiated. As a result of the facility's failures Resident #1 suffered continuous pain, itching and discomfort for 3 months, and other residents and staff were exposed to scabies. An IJ for neglect was identified on 08/25/23. The IJ template was provided to the facility on [DATE] at 8:20 pm. While the IJ was removed on 08/27/23 at 10:57 am, the facility remained out of compliance at a scope of isolated and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure caused actual harm to 1 resident and placed all residents in the facility at risk for physical harm and severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of the undated facility titled: policy for prohibition of abuse, neglect, and misappropriation of property revealed the resident has the right to be free from neglect .that the facility prohibited neglect . would investigate and report suspected neglect . neglect was defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . staff would be trained to identify and report neglect . and the facility will immediately correct and intervene in situations in which neglect is at risk of occurring. Record review of Resident #1's undated face sheet, printed on 08/25/23, revealed that he was a [AGE] year-old male first admitted to the facility on [DATE] with diagnoses that included unspecified dementia, need for assistance with personal care, type II diabetes, heart failure, and COPD (lung disease that makes it difficult to get oxygen to the body). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS of 11, which indicated moderate cognitive impairment, he was marked as requiring extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. It further revealed that Resident #1 required walker and wheelchair normally. It further revealed that he was always incontinent of bowel and bladder. No skin conditions were marked. Record review of Resident #1's undated care plan revealed a focus of risk of frequent infections with an intervention of monitoring for skin changes, circulatory problems, or breakdown and to report to RP and MD, this was initiated on 06/13/23. It further revealed that Resident #1 was at risk for increased confusion and decreased ADLs due to the diagnosis of dementia and had an intervention of assisting the resident with ADLs as needed and verbal reminders to assist with daily orientation, these were initiated on 06/13/23. It also revealed that Resident #1 had a potential for skin breakdown related to incontinence and the intervention was body/skin audit at least weekly and to document preventative and treatment measures and descriptions of lesions as required by facility policy, and these were initiated on 06/13/23. Record review revealed no documentation of scabies, rash, or itching in the care plan for Resident #1. Record review of the 05/03/23 facility 24-hr report revealed that Resident #1 had a rash and itching. Record review of the 07/25/23 facility 24-hr report revealed that Resident #1 had a dermatology appointment on 07/26/23 at 2:00 pm. There is no note that reflected RP #2 was informed of the dermatology appointment. Record review of the 07/26/23 facility 24-hr report revealed that Resident #1's dermatology appointment was rescheduled. It further revealed that after the rescheduling, RP #2 was contacted on 07/26/23 (same date, after missed appointment) and informed Resident #1 needed underwear and t-shirts. There is no note stating that RP #2 was notified of the missed appointment. Record review of the treatment report revealed benadryl 12.5 mg once daily for 4 days was ordered daily starting 05/04/23 and ending 05/07/23. Prednisone was ordered daily for 5 days for itching starting 05/04/23 and ending 05/08/23. Hydrocortisone cream was ordered daily for 7 days for itching starting 05/04/23 and ending 05/10/23. Medrol (steroid) was ordered for systemic rash and started on 06/19/23 and ended on 06/23/23. Bendadryl was ordered every 8 hours for itching as needed and started 06/12/23 and ended 07/10/23. A separate order for benadryl was ordered and started 07/05/23 - 07/09/23. Prednisone was ordered daily and started 07/05/23 and ended 07/08/23. Triamcinolone Acetonide (Topical)) was ordered daily for 5 days and started 07/07/23 and ended 07/11/23. Record review of Resident #1's progress notes revealed a note by Wound Care nurse dated 06/12/23 at 5:08 pm he had a rash on his arms, legs and abdomen. Further review revealed a progress note that was effective on 04/19/23 at 5:43 pm, but was not created until 05/05/23 at 5:54 pm (after RP #2 informed the facility of Resident #1's rash on 05/03/23); which indicated the Wound Care nurse created a late entry note and skin assessment on 05/05/23 that she dated 04/19/23. This note reflected his weekly skin evaluation due on 04/19/23 was performed by the Wound Care nurse and revealed no current skin issues and was documented on 05/05/23. A note created on 05/05/23 (after RP #2 informed facility of rash on 05/03/23) and effective 04/26/23 reflected Resident #1's weekly skin evaluation was performed by the Wound Care nurse and revealed no current skin issues. Record review of Resident #1's skin assessments revealed the following: Week of 04/30/23-05/06/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs, documented by Wound Care nurse Week of 05/07/23-05/13/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs, documented by Wound Care nurse Week of 05/14/23-05/20/23 no skin assessment was conducted Week of 05/21/23-05/27/23 no skin assessment was conducted (Resident #1 discharged to hospital on [DATE] for pneumonia) Week of 06/11/23-06/17/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs (readmitted [DATE]), documented by Wound Care nurse Week of 06/18/23-06/24/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs, documented by LVN G Week of 06/25/23-07/01/23 skin assessment was late and Resident #1 had resolving rash on arms, abdomen, and legs, documented by Wound Care nurse Week of 07/02/23-07/08/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs Week of 07/09/23-07/15/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs; dermatology appointment soon Week of 07/16/23-07/22/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs, dermatology on 07/26/23 scheduled Week of 07/23/23-07/29/23 no skin assessment was conducted Week of 07/30/23-08/05/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs Week of 08/06/23-08/12/23 rash on arms, legs, and chest Week of 08/13/23-08/19/23 no skin assessment was conducted *assessments and notes that are created in the EHR on one date/time, but are marked as effective on a different date/time have the effective date/time bolded in the progress notes and the note has Late Entry at the beginning of the progress note Record review of MD clinical documentation for encounter on 06/13/23 revealed skin documented as having no rash present. Record review of Resident #1's EHR, on the assessments tab there was an alert that Resident #1's weekly skin assessment was 9 days overdue and should have been done on 08/16/23. Further review done at 7:15 pm on 08/25/23 revealed the skin assessment dated [DATE] was in progress by Wound Care nurse. During an interview on 08/25/23 at 11:48 am with RP #1 she stated that Resident #1 had a rash that she was told was bed bugs that was identified on 05/03/23 by RP #2 during a visit. She stated that she and RP #2 found out 08/21/23 that Resident #1 had scabies and was being treated. RP #1 further stated that the facility was not trying to get Resident #1 to take his showers and that the staff would ask if he wanted to take a shower and if he said no they would document he refused and not make further efforts. She also stated that if the staff would ask Resident #1 what time would he like his shower, for example at 3:00 pm or 4:00 pm that he would select a time and comply. She stated that when she visited Resident #1 he was often unkempt and that she would do her best to trim his hair and shave his face to make sure he was comfortable. During an interview on 08/25/23 at 1:10 pm MD phone number was called and answering service stated that MD would be paged with surveyor's number. During an interview on 08/25/23 at 1:15 pm ADM stated that MD was out of the country and would not respond to page. During an interview on 08/25/23 at 1:26 pm with Wound Care nurse she stated that Resident #1 was sent to the hospital for respiratory problems and then went to another facility before transferring back to this facility. She stated the resident came back with scabies or some kind of rash that he got at the other facility. Only when reminded that the resident had a rash before going to the hospital and a different facility (05/24/23-06/12/23) did the Wound Care nurse state the rash was not bad before he went to the hospital. Resident #1's rash was only concerning after Resident #1 returned from his hospitalization. She stated the wound care doctor came to see Resident #1 on 06/20/23 and put in an order for the resident to see a dermatologist; his appointment was scheduled 07/26/23 at 2:00 pm and transport was informed. She stated the doctor could not rule out scabies and nor could shingles be ruled out. The resident was started on Valtrex (an antiviral medication used for treatment of herpes virus, shingles most commonly in nursing facilities), was not isolated, and Valtrex was discontinued due to allergy (diarrhea). During an interview on 08/25/23 at 2:00 pm with ADM and DON (on phone) DON stated that Resident #1 was more than 15 minutes late to his 07/26/23 2:00 pm dermatology appointment and he would not be seen, so it was rescheduled for 08/21/23. ADM stated that Resident #1 was not ready in time for transport to drive him to the appointment on time. DON stated that Resident #1 was not isolated for the disseminated rash because they were not certain the cause of the rash. ADM stated he thought the roommate (Resident #2) of Resident #1 had brought something in with him, and that is what RP #2 was told, but ADM stated he was mistaken, the roommate never had rash symptoms. During an interview on 08/25/23 at 3:35 pm with NP she stated that she was currently working remotely and that when she was notified of the rash the nurses would describe the rash as best they could. She stated that some nurses were not comfortable taking a photograph and sending it to her; she said she and MD would get different reports and initiate different treatments and so they asked the wound care doctor to see the resident and then ordered a dermatology consult so there would be one physician seeing the resident in person to perform the assessment and order treatment. She said the facility would not communicate with her after a course of treatment that she had ordered for Resident #1's skin eruption and so she assumed that meant the treatment was effective. She stated that she was not informed that Resident #1 was not ready in time for his dermatology appointment and that was unacceptable. She stated she orders airborne precautions if shingles was suspected as a standard. During an interview on 08/25/23 at 4:08 pm with Wound Care nurse and DON (on phone) Wound Care nurse stated Resident #1 did not have shingles, they just could not rule it out so Valtrex was started. She further stated that Resident #1 was not ready on time on 07/26/23 at 2:00 pm and that the surveyor could not blame the facility for that. DON stated scabies treatment was started for Resident #1 after his dermatology appointment on 08/21/23 and prophylactic (preventative) treatment was ordered for Resident #2 (roommate) as well. DON stated Resident #1 was isolated for 3 days after the dermatologist diagnosed scabies and initiated treatment. Further interviews with Wound Care nurse were attempted and she became resistant to contact and no further information could be obtained. Attempts to interview Wound Care nurse about the late and missing skin assessments were not productive. During an observation and interview with Resident #1 on 08/25/23 at 4:50 pm, Resident #1 said the itching was terrible and causing him pain. He said the facility gave a cream yesterday, but it wasn't helping. Resident #1 was observed to have bright red bumps on his arms, trunk and legs; these red marks were all over his body with fresh scratch marks and bleeding from the scratching. Resident #1 was scratching as surveyor entered. He looked uncomfortable as he continued to scratch and squirm while lying in his bed. The red marks were various stages of healing with some appearing freshly excoriated (scratching that damages the skin and leaves marks) and inflamed with small amounts of blood. While Resident #1 has a BIMS of 11, indicating moderate cognitive impairment, he was unable to answer questions related to how long he had the rash or what had occurred recently. He was able to discuss the current day. During an interview on 08/25/23 at 6:30 pm with RP #2 he stated that he was visiting Resident #1 on 05/03/23 at 1:00 pm and noticed red lesions spread across Resident #1's chest and both arms; Resident #1 was scratching his arms and chest and there was dry blood on his clothing and sheets. RP #2 informed one nurse (unknown name) and discussed with ADON A. He stated that the unknown nurse thought it was scabies or bed bugs and called the doctor and the doctor ordered Benadryl for 4 days, prednisone for 5 days, and 1% hydrocortisone cream for 7 days. On 06/18/23 RP #2 visited again and noted Resident #1 was scratching his arms and chest again and he informed LVN B who went and got and applied a cortisone cream. RP #2 stated he also informed Wound Care nurse that he was concerned about Resident #1's scratching. RP #2 stated he was notified via phone call on 06/19/23 that Resident #1 was started on Medrol, a steroid pack. RP #2 stated he was not informed of dermatologist appointment scheduled 07/26/23 nor that it was missed, but the facility told him Resident #1 needed clothing and RP #2 ordered items that were delivered to meet that need. RP #2 was informed on 08/21/23 that the dermatologist had diagnosed Resident #1 with scabies and treatment was started, but only after the appointment. He was not informed that Resident #1 was allergic to Valtrex nor that the allergy was added to Resident #1's chart. Record review of photos provided by RP #2 revealed on 05/03/23 between 1:00 pm and 1:30 pm 3 photos were taken that revealed Resident #1 lying in his bed with red lesions disseminated across both arms and his trunk. They further revealed drops of dried blood on Resident #1's clothing. Record review of a video provided by RP #2 dated 06/18/23 at 1:15 pm and showed Resident #1 laying in his bed with red lesions on his arms and scratching his arms and chest. During an interview on 08/25/23 at 8:07 pm with ADM he stated RP was not notified of Resident #1's Valtrex allergy and neither were any listed emergency contacts for Resident #1. On 08/25/23 at 8:20 pm the ADM was informed an immediate jeopardy for neglect was identified, and the IJ template was provided to the ADM. During an interview on 08/26/23 at 10:24 am with DON she stated that all residents have weekly skin assessments conducted by Wound Care nurse and additional assessments are done if other staff identify an issue. She stated Resident #2 did not have similar skin issues. During an interview and observation on 08/26/23 at 12:20 pm with Resident #1 he said his skin felt better and staff spent 30 minutes applying creams and medications; he said he felt better and had no pain. He was sitting in bed with head of bed elevated to approximately 35 degrees, there was food on his tray on his over-bed table, and his skin was less red and inflamed. He looked more relaxed and there was no blood visible. He only scratched one time for a moment on his upper right chest. During an interview on 08/28/23 at 8:50 am with Transport she stated that Resident #1 was not ready in time for his 07/26/23 2:00 pm dermatologist appointment, so they never left the building and called the dermatologist and rescheduled the appointment for 08/21/23. On 08/27/23 at 10:57 am the following plan of removal was accepted: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY Impact Statement On 08/25/23 a complaint investigation survey was initiated at the facility. On 08/25/23 the facility was provided notification that the Survey Agency had determined that the conditions at the facility constitute Immediate Jeopardy to all residents' health and safety due to neglect of resident who suffered from a case of scabies and continued without resolution for some time. The facility also failed to notify the resident's physician and Responsible Party of this change of condition. Summary of Details: F600-The facility failed to ensure residents were free from neglect. IJ Template states as follows: Resident continued with rash, itching, scratching to the point of bleeding through 08/21/23 when dermatology initiated treatment for scabies. Resident missed appointment 07/26/23 because he was more than 15 minutes late for the appointment. 08/01/23 Resident started on Valtrex for shingles, not on isolation. Identify residents who could be affected All residents have the potential to be affected by the deficient practice. Problem 1: Facility failed to ensure residents were free from neglect. Action Taken: *Facility's Abuse/Neglect Prevention Coordinator began in-servicing all staff on abuse/neglect and report such instances to him. This will be all facility staff, including PRN staff. This will be covered during new hire orientation for new staff. Start Date: 08/26/23 End Date: 08/27/23 Who will be responsible: Abuse/Neglect Prevention Coordinator Who will monitor: Administrator *Facility updated it's policy on use Standards of Care meeting to review all skin issues. Any ongoing skin issues that have not resolved or show marked improvement within 7 days will be escalated to the medical director for new treatment or referral to another doctor. Training for members of the Standards of Care Committee for this policy update was accomplished by the Administrator at the Special Standards of Care meeting held today 08/26/23. The escalation is a committee decision as the weekly skin report is being reviewed during Standards of Care each week. Start Date: 08/26/23 (Special Standards of Care meeting held this day)(All skin reviewed.) End Date: Ongoing Who will be responsible: DON, ADONs, Skin Treatment Nurse, Administrator(who is a member of the Standards of Care committee) Who will monitor: Administrator being present at the meeting, ensuring it is held, and that pertinent issues are acted on. *The facility van driver will be notified by charge nurses when they have received a referral for specific doctor's visits. The van driver will make the appointment with specific doctor's office, van driver will then print out doctor appointment notices and make ready times to be placed on corresponding resident's doors. This way direct care staff can be notified when residents must be ready for appointments. This is a make ready information only with no actual doctor's name, etc. that might be a breach of confidentiality. These notices will be posted the Friday before the week that the residents have appointments. If a resident is not ready when the van driver comes to pick them up she will immediately notify the Director of Nurses who will assess the timeliness of the resident's need to get seen by that particular doctor. Director of Nursing will also make arrangements for rescheduling an ASAP appointment or transport the resident to a local hospital to get them seen by the appropriate physician. Administrator will monitor by reviewing appointment list and ensuring postings are accomplished. All nursing staff, including PRN staff are being trained by ADONs on this on 8/26/23-8/27/23. All new nursing staff will be trained on this procedure during new hire orientation by the HR Manager. Start Date: 08/25/23 End Date: Ongoing Who will be responsible: Van driver/DON Who will monitor: Administrator Involvement of Medical Director The Medical Director was notified about the Immediate Jeopardy related to Neglect by ADON on the evening of 8/25/23. He had no new orders at that time. Involvement of QA On 8/26/23 an Ad Hoc QAPI meeting was held with Administrator, Administrative Nurses, Care Plan Nurse, and Skin Treatment Nurse to review plan of removal. Who is responsible for the implementation of the process? The administrator will be responsible to ensure that training on new policies have been accomplished and that appropriate communication meetings are being held and postings have been accomplished. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 8/25/23 POR monitoring . Record review of Resident #1's 08/21/23 4:29 pm progress note revealed that upon return from the appointment with the dermatologist, the resident had a diagnosis of scabies and new orders for permethrin cream applied topically to treat scabies. It further ordered tacrolimus cream twice daily for seven days for atopic dermatitis (chronic inflammation and itching in the skin); the resident was ordered onto contact isolation. Resident #1 was scheduled for a follow up visit with the dermatologist on 09/21/23 at 9:20 am. NP was informed of dermatologist orders and agreed. Record review of Resident #1's [DATE] MAR revealed permethrin cream was applied on 08/23/23. It further revealed a second application was scheduled 08/30/23. The [DATE] MAR further revealed the tacrolimus cream was applied daily except the evening dose on 08/24/23 which showed awaiting pharmacy. The MAR showed the cream was applied on 08/25/23. During an interview on 08/27/23 at 1:36 pm with ADON A, she stated she had been in-serviced over the process for the 24-hour report, documentation, notification. Staff was able to discuss the process for when a resident has a change in condition step by step. 1. Contact the doctor 2. Document assessment on 24-hour report and in progress notes 3. Call RP She stated all information from the previous shift will be placed on the 24-hour report and stated that report would then be given to the oncoming nurse for continued care. She stated she was also in-serviced over abuse /neglect stated all abuse /neglect was reported to the abuse/neglect coordinator who is the administrator, and they ensure that the resident is safe. Stated she has never seen or suspected abuse/neglect at this facility. Stated she was also in-serviced over skin assessments and the process for making the wound care nurse aware if a resident has any skin issues or wounds. During an interview on 08/27/23 at 2:00 pm with MDS nurse, she stated she has been in-serviced on care plans when there is a change in condition, stated she was also in-serviced on abuse/neglect. She was able to discuss the process for when new orders are received and the process of updating the care plans to reflect the new orders and to discontinue any old orders. Stated the process for abuse/neglect was to report immediately to the administrator who is the abuse/neglect coordinator. Stated she has never seen or suspected abuse /neglect at this facility. During an interview on 08/27/23 at 2:07 pm with CNA C, CNA D, and CNA E they stated they had been in-serviced on resident's care and where to find in the EHR system. They stated they were also in-serviced in abuse/neglect and were able to discuss types of abuse and the process of reporting to the ADM. who is the abuse/neglect coordinator. They further stated they have never seen or suspected abuse /neglect at this facility. Staff were able to discuss the process if a resident has change in condition. They stated they use their shower sheets to document any skin issues for the residents. Staff were able to discuss the process for residents when they have appointments. Staff were able to discuss the process of where to find the care needs and special needs for the residents. During an observation and interview on 08/27/23 at 2:28 pm with Resident #3 she stated she was ok. Resident #3 appeared happy as she was smiling and laughing; the resident did not appear to be in any discomfort or pain. The resident was clean and dressed appropriately with no marks or bruises noted. During an interview on 08/27/23 at 2:31 pm with RP #3 (RP for Resident #3) she stated things are ok but could be a little better, and she stated she has a care conference scheduled for next week with the facility in which they will update her care needs and expectations. She stated for the most part things are pretty good and Resident #3 was getting her needs met. During an observation on 08/27/23 at 2:35 pm of Resident #1 he was observed lying in bed, resident appeared to be resting. Resident #1 did not appear to be in any pain or discomfort at the time of observation and he appeared to be clean and dressed appropriately. During an interview and observation on 08/27/23 at 2:40 pm with Resident #4 she stated she had no concerns at this time. Resident #4 appeared to be clean and dressed appropriate no marks or bruises noted during visit. During an interview on 08/27/23 at 2:50 pm with DON she stated all staff will be in-serviced on abuse/neglect stated they still had a few more people to get as they come to work, but they will be in-serviced before working. She stated all care plans and orders have been reviewed and updated. She stated when the resident returned to the facility he was assessed, care plan updated with current care/ treatment for rash and the resident was being monitored for any changes in condition. She stated the resident appeared to be doing well at this time. During an interview on 08/27/23 at 3:00 pm with ADM he stated it was his expectation that staff continued to monitor residents when they had issues and to document improvements or lack there of, and re-evaluate for further treatment/care needs for the residents. He stated it was his expectation that all staff follow the policy and procedures when reporting abuse/neglect, which was to report immediately if they see or suspect abuse/neglect. The ADM stated it was his expectation for each resident to receive the best quality of care at this facility. Records were reviewed of in-service regarding 24-hour report, Abuse/Neglect, Appointments, change in condition, and orders and were dated 8/25/2023- 8/26/2023. Records were reviewed on in-service for abuse/neglect reflected as of 08/27/23, 88 staff completed the in-service. Records reviewed on in-service regarding appointments, change in condition, and orders reflected as of 08/27/23 that 33 staff completed this in-service and it was required of CNAs and nurses. Records reviewed on in-service that addressed 24-hour reports, reflected as of 08/27/23, 5 nursing staff completed this in-service: DON, 2 ADONs, and 2 LVNs. Records reviewed of Clinical standards Committee meeting held on 8/26/2023 addressed the following - orders, documentation, training on policy skin assessments, care plans, and change in condition. Record review of the Centers for Disease Control and Prevention (CDC) website indicated Scabies can spread easily under crowded conditions where close body and skin contact is common. Institutions such as nursing homes, extended-care facilities, and prisons are often sites of scabies outbreaks. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The intense itching of scabies leads to scratching that can lead to skin sores which can become infected. Based on observation, interview, and record review the plan of removal was implemented and the IJ was removed on 08/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to identify a disseminated rash on Resident #1 prior to identification by RP #2 on 05/03/23; the facility further failed to ensure weekly skin checks were completed and documented in a timely manner in that 4 weekly skin checks were not done for Resident #1 since identification of his rash on 05/03/23. The facility failed to ensure that Resident #1's care plan reflected a rash that started on 05/03/23 and was still present on 08/28/23, and the facility failed to ensure Resident #1 was seen by a dermatologist as scheduled on 07/26/23, which delayed his diagnoses and initiation of treatment until 08/21/23. As a result of the facility's failures Resident #1 suffered continuous pain, itching and discomfort for 3 months, and other residents, visitors and staff were exposed to scabies. An IJ was identified on 08/28/23. The IJ template was provided to the facility on [DATE] at 11:25 am. While the IJ was removed on 08/28/23 at 3:25 pm, the facility remained out of compliance at a scope of isolated and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could affect all residents by placing them at risk substandard quality of care if the residents are not receiving treatment and care in accordance with professional standards, comprehensive person-centered care plans, and resident choices. Findings included: Record review of Resident #1's undated face sheet, printed on 08/25/23, revealed that he was a [AGE] year-old male first admitted to the facility on [DATE] with diagnoses that included unspecified dementia, need for assistance with personal care, type II diabetes, heart failure, and COPD (lung disease that makes it difficult to get oxygen to the body). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS of 11, which indicated moderate cognitive impairment, he was marked as requiring extensive assistance with med mobility, transfers, dressing, toilet use, and personal hygiene. It further revealed that Resident #1 required walker and wheelchair normally. It further revealed that he was always incontinent of bowel and bladder. No skin conditions were marked. Record review of Resident #1's undated care plan revealed a focus of risk of frequent infections with an intervention of monitoring for skin changes, circulatory problems, or breakdown and to report to RP and MD, this was initiated on 06/13/23. It further revealed that Resident #1 was at risk for increased confusion and decreased ADLs due to the diagnosis of dementia and had an intervention of assisting the resident with ADLs as needed and verbal reminders to assist with daily orientation, these were initiated on 06/13/23. It also revealed that Resident #1 had a potential for skin breakdown related to incontinence and the intervention was body/skin audit at least weekly and to document preventative and treatment measures and descriptions of lesions as required by facility policy, and these were initiated on 06/13/23. Record review revealed no documentation of scabies, rash, or itching in the care plan for Resident #1. Record review of the 05/03/23 facility 24-hr report revealed that Resident #1 had a rash and itching. Record review of the 07/25/23 facility 24-hr report revealed that Resident #1 had a dermatology appointment on 07/26/23 at 2:00 pm. There is no note that reflected RP #2 was informed of the dermatology appointment. Record review of the 07/26/23 facility 24-hr report revealed that Resident #1's dermatology appointment was rescheduled. It further revealed that after the rescheduling, RP #2 was contacted on 07/26/23 (same date, after missed appointment) and informed Resident #1 needed underwear and t-shirts. There is no note stating that RP #2 was notified of the missed appointment. Record review of the treatment report revealed benadryl 12.5 mg once daily for 4 days was ordered daily starting 05/04/23 and ending 05/07/23. Prednisone was ordered daily for 5 days for itching starting 05/04/23 and ending 05/08/23. Hydrocortisone cream was ordered daily for 7 days for itching starting 05/04/23 and ending 05/10/23. Medrol (steroid) was ordered for systemic rash and started on 06/19/23 and ended on 06/23/23. Bendadryl was ordered every 8 hours for itching as needed and started 06/12/23 and ended 07/10/23. A separate order for benadryl was ordered and started 07/05/23 - 07/09/23. Prednisone was ordered daily and started 07/05/23 and ended 07/08/23. Triamcinolone Acetonide (Topical)) was ordered daily for 5 days and started 07/07/23 and ended 07/11/23. Record review of Resident #1's progress notes revealed a note by Wound Care nurse dated 06/12/23 at 5:08 pm he had a rash on his arms, legs and abdomen. Further review revealed a progress note that was effective on 04/19/23 at 5:43 pm, but was not created until 05/05/23 at 5:54 pm (after RP #2 informed the facility of Resident #1's rash on 05/03/23); which indicated the Wound Care nurse created a late entry note and skin assessment on 05/05/23 that she dated 04/19/23. This note reflected his weekly skin evaluation due on 04/19/23 was performed by the Wound Care nurse and revealed no current skin issues and was documented on 05/05/23. A note created on 05/05/23 (after RP #2 informed facility of rash on 05/03/23) and effective 04/26/23 reflected Resident #1's weekly skin evaluation was performed by the Wound Care nurse and revealed no current skin issues. Record review of MD clinical documentation for encounter on 06/13/23 revealed skin documented as having no rash present. Record review of Resident #1's progress notes revealed a note by Wound Care nurse dated 06/12/23 at 5:08 pm he had a rash on his arms, legs and abdomen. Further review revealed a progress note that was effective on 04/19/23 at 5:43 pm, but was not created until 05/05/23 at 5:54 pm (after RP #2 informed the facility of Resident #1's rash on 05/03/23); which indicated the Wound Care nurse created a late entry note and skin assessment on 05/05/23 that she dated 04/19/23. This note reflected his weekly skin evaluation due on 04/19/23 was performed by the Wound Care nurse and revealed no current skin issues and was documented on 05/05/23. A note created on 05/05/23 (after RP #2 informed facility of rash on 05/03/23) and effective 04/26/23 reflected Resident #1's weekly skin evaluation was performed by the Wound Care nurse and revealed no current skin issues. Record review of Resident #1's skin assessments revealed the following: Week of 04/30/23-05/06/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs, documented by Wound Care nurse Week of 05/07/23-05/13/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs, documented by Wound Care nurse Week of 05/14/23-05/20/23 no skin assessment was conducted Week of 05/21/23-05/27/23 no skin assessment was conducted (Resident #1 discharged to hospital on [DATE] for pneumonia) Week of 06/11/23-06/17/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs (readmitted [DATE]), documented by Wound Care nurse Week of 06/18/23-06/24/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs, documented by LVN G Week of 06/25/23-07/01/23 skin assessment was late and Resident #1 had resolving rash on arms, abdomen, and legs, documented by Wound Care nurse Week of 07/02/23-07/08/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs Week of 07/09/23-07/15/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs; dermatology appointment soon Week of 07/16/23-07/22/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs, dermatology on 07/26/23 scheduled Week of 07/23/23-07/29/23 no skin assessment was conducted Week of 07/30/23-08/05/23 skin assessment was late and Resident #1 had rash on arms, abdomen, and legs Week of 08/06/23-08/12/23 rash on arms, legs, and chest Week of 08/13/23-08/19/23 no skin assessment was conducted *assessments and notes that are created in the EHR on one date/time, but are marked as effective on a different date/time have the effective date/time bolded in the progress notes and the note has Late Entry at the beginning of the progress note Record review of Resident #1's EHR, on the assessments tab there was an alert that Resident #1's weekly skin assessment was 9 days overdue and should have been done on 08/16/23. Further review done at 7:15 pm on 08/25/23 revealed the skin assessment dated [DATE] was in progress by Wound Care nurse. During an interview on 08/25/23 at 11:48 am with RP #1 she stated that Resident #1 had a rash that she was told was bed bugs that was identified on 05/03/23 by RP #2 during a visit. She stated that she and RP #2 found out 08/21/23 that Resident #1 had scabies and was being treated. RP #1 further stated that the facility was not trying to get Resident #1 to take his showers and that the staff would ask if he wanted to take a shower and if he said no they would document he refused and not make further efforts. She also stated that if the staff would ask Resident #1 what time would he like his shower, for example at 3:00 pm or 4:00 pm that he would select a time and comply. She stated that when she visited Resident #1 he was often unkempt and that she would do her best to trim his hair and shave his face to make sure he was comfortable. RP #1 stated she had never been invited to a care plan meeting, and nor had RP #2, or she would have discussed the shower and grooming concerns with staff and recommended interventions that would be effective for Resident #1's compliance with sanitary and grooming needs. During an interview on 08/25/23 at 1:10 pm MD phone number was called and answering service stated that MD would be paged with surveyor's number. During an interview on 08/25/23 at 1:15 pm ADM stated that MD was out of the country and would not respond to page. ADM provided instruction sheet that showed coverage while MD was out of country, which included contacting NP and in emergency other physicians via after-hours answering service. During an interview on 08/25/23 at 1:26 pm with Wound Care nurse she stated that Resident #1 was sent to the hospital for respiratory problems and then went to another facility before transferring back to this facility. She stated the resident came back with scabies or some kind of rash that he got at the other facility. Only when reminded that the resident had a rash before going to the hospital and a different facility (05/24/23-06/12/23) did the Wound Care nurse state the rash was not bad before he went to the hospital. Resident #1's rash was only concerning after Resident #1 returned from his hospitalization. She stated the wound care doctor came to see Resident #1 on 06/20/23 and put in an order for the resident to see a dermatologist; his appointment was scheduled 07/26/23 at 2:00 pm and transport was informed. She stated the doctor could not rule out scabies and nor could shingles be ruled out. The resident was started on Valtrex (an antiviral medication used for treatment of herpes virus, shingles most commonly in nursing facilities), was not isolated, and Valtrex was discontinued due to allergy (diarrhea). During an interview on 08/25/23 at 2:00 pm with ADM and DON (on phone) DON stated that Resident #1 was more than 15 minutes late to his 07/26/23 2:00 pm dermatology appointment and he would not be seen, so it was rescheduled for 08/21/23. ADM stated that Resident #1 was not ready in time for transport to drive him to the appointment on time. DON stated that Resident #1 was not isolated for the disseminated rash because they were not certain the cause of the rash. ADM stated he thought the roommate (Resident #2) of Resident #1 had brought something in with him, and that is what RP #2 was told, but ADM stated he was mistaken, the roommate never had rash symptoms. During an interview on 08/25/23 at 3:35 pm with NP she stated that she was currently working remotely and that when she was notified of the rash the nurses would describe the rash as best they could. She stated that some nurses were not comfortable taking a photograph and sending it to her; she said she and MD would get different reports and initiate different treatments and so they asked the wound care doctor to see the resident and then ordered a dermatology consult so there would be one physician seeing the resident in person to perform the assessment and order treatment. She said the facility would not communicate with her after a course of treatment that she had ordered for Resident #1's skin eruption and so she assumed that meant the treatment was effective. She stated that she was not informed that Resident #1 was not ready in time for his dermatology appointment and that was unacceptable. She stated she orders airborne precautions if shingles was suspected as a standard. During an interview on 08/25/23 at 4:08 pm with Wound Care nurse and DON (on phone) Wound Care nurse stated Resident #1 did not have shingles, they just could not rule it out so Valtrex was started. She further stated that Resident #1 was not ready on time on 07/26/23 at 2:00 pm and that the surveyor could not blame the facility for that. DON stated scabies treatment was started for Resident #1 after his dermatology appointment on 08/21/23 and prophylactic (preventative) treatment was ordered for Resident #2 (roommate) as well. DON stated Resident #1 was isolated for 3 days after the dermatologist diagnosed scabies and initiated treatment. Further interviews with Wound Care nurse were attempted and she became resistant to contact and no further information could be obtained. Attempts to interview Wound Care nurse about the late and missing skin assessments were not productive. During an observation and interview with Resident #1 on 08/25/23 at 4:50 pm, Resident #1 said the itching was terrible and causing him pain. He said the facility gave a cream yesterday, but it wasn't helping. Resident #1 was observed to have bright red bumps on his arms, trunk and legs; these red marks were all over his body with fresh scratch marks and bleeding from the scratching. Resident #1 was scratching as surveyor entered. He looked uncomfortable as he continued to scratch and squirm while lying in his bed. The red marks were various stages of healing with some appearing freshly excoriated (scratching that damages the skin and leaves marks) and inflamed with small amounts of blood. While Resident #1 has a BIMS of 11, indicating moderate cognitive impairment, he was unable to answer questions related to how long he had the rash or what had occurred recently. He was able to discuss the current day. During an interview on 08/25/23 at 6:30 pm with RP #2 he stated that he was visiting Resident #1 on 05/03/23 at 1:00 pm and noticed red lesions spread across Resident #1's chest and both arms; Resident #1 was scratching his arms and chest and there was dry blood on his clothing and sheets. RP #2 informed one nurse (unknown name) and discussed with ADON A. He stated that the unknown nurse thought it was scabies or bed bugs and called the doctor and the doctor ordered Benadryl for 4 days, prednisone for 5 days, and 1% hydrocortisone cream for 7 days. On 06/18/23 RP #2 visited again and noted Resident #1 was scratching his arms and chest again and he informed LVN B who went and got and applied a cortisone cream. RP #2 stated he also informed Wound Care nurse that he was concerned about Resident #1's scratching. RP #2 stated he was notified via phone call on 06/19/23 that Resident #1 was started on Medrol, a steroid pack. RP #2 stated he was not informed of dermatologist appointment scheduled 07/26/23 nor that it was missed, but the facility told him Resident #1 needed clothing and RP #2 ordered items that were delivered to meet that need. RP #2 was informed on 08/21/23 that the dermatologist had diagnosed Resident #1 with scabies and treatment was started, but only after the appointment. He was not informed that Resident #1 was allergic to Valtrex nor that the allergy was added to Resident #1's chart. RP #2 stated that he was not informed of the care plan meeting on 07/13/23 for Resident #1, and nor was RP #1 or they would have participated; he also stated he had never been informed of any care plan meetings. Record review of photos provided by RP #2 revealed on 05/03/23 between 1:00 pm and 1:30 pm 3 photos were taken that revealed Resident #1 lying in his bed with red lesions disseminated across both arms and his trunk. They further revealed drops of dried blood on Resident #1's clothing. Record review of a video provided by RP #2 dated 06/18/23 at 1:15 pm and showed Resident #1 laying in his bed with red lesions on his arms and scratching his arms and chest. Resident #1 appeared clearly uncomfortable as he scratched various body parts. During an interview on 08/28/23 at 8:50 am with Transport she stated that Resident #1 was not ready in time for his 07/26/23 2:00 pm dermatologist appointment, so they never left the building and called the dermatologist and rescheduled the appointment for 08/21/23. During an interview on 08/26/23 at 10:24 am with DON she stated that all residents have weekly skin assessments conducted by Wound Care nurse and additional assessments are done if other staff identify an issue because skin issue could progress to infections and lead to worsening of condition including hospitalization. She stated Resident #2 did not have similar skin issues. During an interview and observation on 08/26/23 at 12:20 pm with Resident #1 he said his skin felt better and staff spent 30 minutes applying creams and medications; he said he felt better and had no pain. He was sitting in bed with head of bed elevated to approximately 35 degrees, there was food on his tray on his over-bed table, and his skin was less red and inflamed. He looked more relaxed and there was no blood visible. He only scratched one time for a moment on his upper right chest. On 8/28/23 11:25 am the ADM was informed an immediate jeopardy for quality of care was identified, and the IJ template was provided to the ADM. During an observation on 08/28/23 at 11:38 am Resident #1 was observed resting in his bed; his skin was improved, and the redness was decreased with no fresh scratch marks. On lifted 8/28/23 3:25 pm the following plan of removal was accepted: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY Impact Statement: On 08/25/23 a complaint investigation survey was initiated at the facility. On 8/28/23 the facility was provided notification that the Survey Agency had determined that the conditions at the facility constitute Immediate Jeopardy to all residents' health and safety due to resident not receiving treatment of care in accordance with professional standards who suffered from a case of scabies and continued without resolution for some time. Summary of Details: F684 Facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. IJ Template states as follows: Resident continued with rash, itching, scratching to the point of bleeding through 08/21/23 when dermatology initiated treatment for scabies. 08/01/23 Resident started on Valtrex for shingles, not on isolation. Resident missed appointment 07/26/23 because he was more than 15 minutes late for the appointment. Resident's RP states he wasn't notified of the reaction to Valtrex and it was discontinued. Resident's plan of care revealed no care planning for rash, scabies, or itching. Identify residents who could be affected All residents have the potential to be affected by the deficient practice. Problem 1 Facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. *Facility updated it's policy on use Standards of Care meeting to review all skin issues. Any ongoing skin issues that have not resolved or show marked improvement within 7 days will be escalated to the medical director for new treatment or referral to another doctor. Training for members of the Standards of Care Committee for this policy update was accomplished by the Administrator at the additional Special Standards of Care meeting held today 8/28/23. The escalation is a committee decision as the weekly skin report is being reviewed during Standards of Care each week. Start Date: 08/28/23 ( additional Special Standards of Care meeting held this day)(All skin reviewed.) End Date: Ongoing Who will be responsible: DON, ADONs, Skin Treatment Nurse, Administrator(who is a member of the Standards of Care committee) Who will monitor: Administrator being present at the meeting, ensuring it is held, and that pertinent issues are acted on. *The facility van driver will be notified by charge nurses when they have received a referral for specific doctor's visits. The van driver will make the appointment with specific doctor's office, van driver will then print out doctor appointment notices and make ready times to be placed on corresponding resident's doors. This way direct care staff can be notified when residents must be ready for appointments. This is a make ready information only with no actual doctor's name, etc. that might be a breach of confidentiality. These notices will be posted the Friday before the week that the residents have appointments. If a resident is not ready when the van driver comes to pick them up she will immediately notify the Director of Nurses who will assess the timeliness of the resident's need to get seen by that particular doctor. Director of Nursing will also make arrangements for rescheduling an ASAP appointment or transport the resident to a local hospital to get them seen by the appropriate physician. Administrator will monitor by reviewing appointment list and ensuring postings are accomplished. All nursing staff, including PRN staff are being trained by ADONs on this on 8/28/23. All new nursing staff will be trained on this procedure during new hire orientation by the HR Manager. (Orientation held 08/28/23) Start Date: 08/28/23 End Date: Ongoing Who will be responsible: Van driver/DON Who will monitor: Administrator *The resident's care plan was updated to include the rash and itching problems. The facility care plan policy was updated to include the care plan nurse will attend weekly Standards of Care meetings to obtain weekly skin report and be notified of any new changes of condition or physician orders that must be care planned. The Care Plan nurse and MDS Coordinator were in attendance at the additional Special Standards of Care meeting held on 08/28/23 and were trained on the policy update by the Administrator. This will ensure any recent focus can be added to any resident's care plan in between assessment periods. Care plan letters mailed every week will be scanned to a file by the Care Plan nurse as proof of notification to RP of care plan meetings. Care plan nurse will also call RPs to ensure they have received mailed notification. Documentation of phone call will be placed in nurses notes. MDS coordinator will audit CP letter file and nurses notes each month to ensure this is being accomplished. Start Date: 08/28/23 End Date: Ongoing Who is Responsible: Care Plan Nurse Who will Monitor: MDS Coordinator Involvement of Medical Director The Medical Director was notified about the Immediate Jeopardy related to Neglect 08/28/23 Involvement of QA On 08/28/23 an additional Ad Hoc QAPI meeting was held with Administrator, Administrative Nurses, Care Plan Nurse, and Skin Treatment Nurse, Maintenance Director, Social Worker, HR Manager, Dietary Manager, and Marketing Director to review plan of removal. Who is responsible for the implementation of the process? The administrator will be responsible to ensure that training on new policies have been accomplished and that appropriate communication meetings are being held and postings have been accomplished. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 08/28/23 POR monitoring . Record review of Resident #1's 08/21/23 4:29 pm progress note revealed that upon return from the appointment with the dermatologist, the resident had a diagnosis of scabies and new orders for permethrin cream applied topically to treat scabies. It further ordered tacrolimus cream twice daily for seven days for atopic dermatitis (chronic inflammation and itching in the skin); the resident was ordered onto contact isolation. Resident #1 was scheduled for a follow up visit with the dermatologist on 09/21/23 at 9:20 am. NP was informed of dermatologist orders and agreed. Record review of Resident #1's [DATE] MAR revealed permethrin cream was applied on 08/23/23. It further revealed a second application was scheduled 08/30/23. The [DATE] MAR further revealed the tacrolimus cream was applied daily except the evening dose on 08/24/23 which showed awaiting pharmacy. The MAR showed the cream was applied on 08/25/23. During an interview on 08/27/23 at 1:36 pm with ADON A, she stated she had been in-serviced over the process for the 24-hour report, documentation, notification. Staff was able to discuss the process for when a resident has a change in condition step by step. 1. Contact the doctor 2. Document assessment on 24-hour report and in progress notes 3. Call RP She stated all information from the previous shift will be placed on the 24-hour report and stated that report would then be given to the oncoming nurse for continued care. She stated she was also in-serviced over abuse /neglect stated all abuse /neglect was reported to the abuse/neglect coordinator who is the administrator, and they ensure that the resident is safe. Stated she has never seen or suspected abuse/neglect at this facility. Stated she was also in-serviced over skin assessments and the process for making the wound care nurse aware if a resident has any skin issues or wounds. During an interview on 08/27/23 at 2:00 pm with MDS, she stated she has been in-serviced on care plans when there is a change in condition, stated she was also in-serviced on abuse/neglect. She was able to discuss the process for when new orders are received and the process of updating the care plans to reflect the new orders and to discontinue any old orders. Stated the process for abuse/neglect was to report immediately to the administrator who is the abuse/neglect coordinator. Stated she has never seen or suspected abuse /neglect at this facility. During an interview on 08/27/23 at 2:07 with CNA C, CNA D, and CNA E they stated they had been in-serviced on resident's care and where to find in the EHR system. They stated they were also in-serviced in abuse/neglect and were able to discuss types of abuse and the process of reporting to the ADM. who is the abuse/neglect coordinator. They further stated they have never seen or suspected abuse /neglect at this facility. Staff were able to discuss the process if a resident has change in condition. They stated they use their shower sheets to document any skin issues for the residents. Staff were able to discuss the process for residents when they have appointments. Staff were able to discuss the process of where to find the care needs and special needs for the residents. During an observation and interview on 08/27/23 at 2:28 pm with Resident #3 she stated she was ok. Resident #3 appeared happy as she was smiling and laughing; the resident did not appear to be in any discomfort or pain. The resident was clean and dressed appropriately with no marks or bruises noted. During an interview on 08/27/23 at 2:31 pm with RP #3 (RP for Resident #3) she stated things are ok but could be a little better, and she stated she has a care conference scheduled for next week with the facility in which they will update her care needs and expectations. She stated for the most part things are pretty good and Resident #3 was getting her needs met. During an observation on 08/27/23 at 2:35 pm of Resident #1 he was observed lying in bed, resident appeared to be resting. Resident #1 did not appear to be in any pain or discomfort at the time of observation and he appeared to be clean and dressed appropriately. During an interview and observation on 08/27/23 at 2:40 pm with Resident #4 she stated she liked her bedding comforter on her bed, and she stated it was new. Resident #4 stated she had no concerns at this time. Resident #4 appeared to be clean and dressed appropriate no marks or bruises noted during visit. During an interview on 08/27/23 at 2:50 pm with DON she stated all staff will be in-serviced on abuse/neglect stated they still had a few more people to get as they come to work, but they will be in-serviced before working. She stated all care plans and orders have been reviewed and updated. She stated when the resident returned to the facility he was assessed, care plan updated with current care/ treatment for rash and the resident was being monitored for any changes in condition. She stated the resident appeared to be doing well at this time. During an interview on 08/27/23 at 3:00 pm with ADM he stated it was his expectation that staff continued to monitor residents when they had issues and to document improvements or lack there of, and re-evaluate for further treatment/care needs for the residents. He stated it was his expectation that all staff follow the policy and procedures when reporting abuse/neglect, which was to report immediately if they see or suspect abuse/neglect. The ADM stated it was his expectation for each resident to receive the best quality of care at this facility. During an interview on 08/28/23 at 8:50 am with Transport she stated she was educated on process of nurse notifying her of transport needs and she would put sign on door for week prior stating resident had an appointment (no specifics for HIPAA reasons) so all care givers would be aware of the date and time so the resident would be ready. An example sign was pointed out on a resident door. During an interview on 08/28/23 at 11:55 am with LVN F she stated she was in-serviced by the DON today and listed the topics covered. She explained and answered correctly questions related to Quality of Care plan of removal. Record review of Clinical standard committee meeting held on 08/28/23 revealed the following topics were addressed: weights, wound (pressure and non-pressure), infection control, new admissions, change in condition, coumadin, dialysis, and new orders: care plan, documentation, notification of physician/family. Record review of Doctor Appointment Notification policy and training was held on 08/28/23 with Transport and revealed that Transport would prepare a sheet stating an appointment was upcoming (no medical information) and posted on the door of the resident to inform staff of date and time that a resident needed to be ready for transport to an appointment. Record review revealed on 08/28/23 a QAPI meeting was held with the following topics addressed: monitoring plan of removal, review of unresolved skin issues, Transport and missed appointments, notification of change in condition, and ensuring residents receive treatment within professional standards. Record review revealed on 08/28/23 an in-service for all staff was held relating to appointments, change of condition, and orders. The in-service was presented by the DON and 20 staff had attended, and on-coming staff wou[TRUNCATED]