**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(s) when there was a an accident involving the resident which resulted in an injury and had the potential for requiring physician intervention, and or a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 residents (Resident #1) reviewed for notification to the physician. LVN A failed to report to the physician and Resident #1's representative a change of condition when Resident #1 was discovered injured and confused on the floor by her bedside on 04/20/2025 and was hospitalized and diagnosed with acute congested heart failure fluid overload, in addition to right rib fractures to the 3rd, 7th and 9th ribs, 3 hours later. The noncompliance was identified as PNC. The IJ began on 4/20/2025 and ended on 4/25/2025. Facility had implemented intervention on 04/25/2025 prior to surveyor entrance on 04/25/2025. This failure could place residents at risk for harm. The findings include: A record review of Resident #1's admission record, dated 4/25/2025, revealed an admission date of 3/21/2025. Resident #1 had diagnoses which included end stage renal disease (kidney failure) and hypertension (high blood pressure). A record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 was a [AGE] year-old female who was admitted to the facility for long term care after a hospitalization related to a fall. Resident #1 was assessed with a BIMS score of 13 out of a possible 15, which indicated intact cognition. Resident #1 was assessed with minimal difficulty hearing, with clear speech, could usually make herself understood and could usually understand others. Resident #1 was assessed with adequate vision and did not wear glasses. The resident was assessed without a mood disturbance, hallucinations, and or a change in mental status. Resident #1 was assessed with the Important preference of having family or a close friend involved in discussions about your care. Resident #1 was assessed as being independent with Activities of Daily Life, used a manual wheelchair, and had weakness in both arms. Resident #1 was assessed with occasional urinary incontinence and frequent bowel incontinence. Resident #1 was assessed as medically complex. A record review of Resident #1's care plan, dated 3/25/2024, revealed, The resident has bowel incontinence . Check resident every two hours and assist with toileting as needed A record review of Resident #1's hospital record, dated 3/19/2025 , revealed Resident #1 was diagnosed with pancreatic cancer which has spread to other parts of her body and had a fall on 3/10/2025 at her home and was hospitalized . The hospital documented Resident #1's family reported general weakness and Resident #1 had lost the ability to self-transfer from her bed to her wheelchair. A record review of Resident #1's nursing progress notes, on 4/19/2025 prior to 4/20/2025, revealed Resident #1 had increased episodes of altered mental status to which the physician and family were notified, Nursing Progress Note . 4/19/2025 07:00:00 (7:00 AM) . Nursing . Registered Nurse (B) . Note Text: Pt had increased confusion, asked multiple times ' Are you going to kill me?' stating after that 'I cannot hear' .Nursing Progress Note . 4/19/2025 18:38:00 (6:38 PM) . Registered Nurse B . Dr . (physician's name) was notified of the pt's increase confusion. A record review of Resident #1's nurse progress note, dated 4/20/2025 at 4:22 AM, revealed LVN A documented, . Location of event: Resident Room Level of pain from 0-10 . pain:0 . Injury: Yes . Describe any injuries: Abrasion to bilat knees, 0 bleeding noted. CNAs reported that during rounds they found resident kneeling on her knees next to bedside on fall mat. CNA also reported resident was assisted back into bed by CNAs. This nurse entered resident's room and observed resident in bed. Resident noted to have abrasions to bilateral knees: without bleeding. Areas cleansed with wound cleanser and (name brand small bandage) applied to each knee. Initial Treatment/New Orders: Areas cleansed with wound cleanser and (name brand small bandage) applied knee. Resident Statement: When asked why resident was kneeling on floor resident stated, 'I don't know.' Name of MD/NP notified: (NP) N.P. Date/time of notification: 04/21/2025 at 2:02 AM. Name of RP notified: (Resident #1's Representative) Date/time of notification: 04/20/2025 4:22 AM. Interventions: bed in low position, fall mat in place. Call light in reach . A record review of Resident #1's nurse progress note, dated 4/20/2025 at 7:23 AM, revealed RN B documented Resident #1 was assessed with a change in status and sent to the hospital by EMS 911, (Resident #1) was transferred to a hospital on [DATE] at 7:30 AM related to Pt sic(patient) had decreased LOC sic(level of conscience), disoriented, moving in bed constantly erratically. Pt had bruises on left knee, left wrist and palm. A record review of Resident #1's hospital admission records, dated 4/20/2025, revealed she was admitted after a fall at the nursing home and was diagnosed with liver cancer, confusion, and rib fractures, history of present illness chief complaint: patient is a [AGE] year-old female with past medical history significant for end stage renal disease on hemodialysis Mondays, Wednesdays, and Fridays, hypertension, recently diagnosed metastatic gastrointestinal cancer (cancer of the digestive system which has spread to other parts of the body). Presents to our emergency department from nursing home after she had fallen. Per (Resident representative) patient had fallen from bed height at nursing home and became altered. Apparently her usual state until her fall today sic(4/20/2025). The patient had significant change in her mental status. In the emergency department she was found to have bilateral pleural effusion [sic ](fluid in the lungs), moderate pericardial effusion sic (fluid around the heart), right rib fracture 3-7, 9 and CT sic(computed tomography scan) findings of metastasis sic(spread of cancer) to liver. patient currently altered and unable to cooperate with exam. She has a 3cm by 3-centimeter contusion sic(bruise) over the medial aspect of the knee. During an observation and interview on 4/26/2025 at 10:32 AM revealed Resident #1 presented at the hospital asleep in her bed. Resident #1's representative was at the bedside and stated she was not given a report about Resident #1's fall at 4:00 AM on 4/20/2025 until she arrived at the nursing home to visit Resident #1 around 7:00 AM. Resident #1's representative stated she arrived and discovered Resident #1 was confused and had injuries to her knees, Resident #1's representative stated, I reported the injuries to the CNA and the nurse. Resident #1's representative stated after Resident #1's Representative alerted RN B then RN B assessed Resident #1 and called 911 , EMS arrived and took Resident #1 to the hospital where she was discovered with broken ribs and bruises. Resident #1's representative stated she was upset and concerned she was not alerted to the fall and confusion and felt Resident #1 was delayed in receiving care and stated, I don't know if the doctor was called. During an interview on 4/26/2025 at 12:30 PM, RN B stated Resident #1 begun to be confused and hallucinating on 4/19/2025 and reported the change to the physician and the physician had not given any new orders. RN B stated at 10:00 PM, she ended her shift and gave a report to LVN A. RN B stated she returned to work the following morning, 4/20/2025 at 7:20 AM, and received a report from LVN A that Resident #1 had fallen around 4 AM. RN B stated she assessed Resident #1 with Resident #1's representative at the bedside and discovered Resident #1 was confused with bruises and bandages to her knees and called EMS 911 . During an interview on 4/26/25 at 4:15 PM, LVN A stated she was alerted by CNAs Resident #1 was discovered on the floor by her bedside and the CNAs picked her up and placed her back in bed . LVN A stated she assessed Resident #1 in her bed, discovered her knees were red and abraded without bleeding, performed first aid, and applied a small self-adhesive bandages to her knees. LVN A stated Resident #1 could not say how she came to be on her knees next to the bed and no one witnessed the way she became to be on her knees. LVN A stated she had not considered Resident #1's incident a fall and Resident #1 had not complained of pain and was calm and sleepy at 4:00 AM. LVN A stated she documented she reported the incident to Resident #1's physician and her representative but had not reported the incident to the physician nor Resident #1's representative. LVN A stated she documented she reported to the NP and the representative because she had intended to call the NP during business hours. LVN A stated, I called Resident #1's representative and no one answered so I left a message . During an interview on 4/26/2025 at 5:40 PM the Medical Director stated his expectation for unwitnessed falls with injuries was for nursing staff to call and report the finding to a physician and or their Nurse Practitioner within a reasonable time for example an hour after the assessment. The MD stated the risk to residents could have been delayed care. During a joint interview on 4/26/2025 at 5:50 PM, the Administrator and the DON stated they had not recognized LVN A had not followed facility protocols, such as reporting the incident to the physician and to Resident #1's Representative, for Resident #1's unwitnessed fall on 4/20/2025 until early 4/25/2025 and began an investigation and self-reported the incident to the state survey agency. The Administrator and the DON stated they suspended LVN A pending the investigation, assessed all the residents for injuries, developed and implemented in-services for all staff which included fall protocols and reporting to the physician and residents' families. The DON and the Administrator stated their expectations for LVN A was for her to have followed the risk management fall protocol which included a report to the physician and a report to the family. Interviews from 4/26/2025 to 4/27/2025 with 44 of the 69 nursing staff which included all shifts revealed all interviewed were able to confirm they received the in-service which covered unwitnessed falls, assessing residents post falls, documenting the assessments, notifying the physician, and family. A record review of the facility's Risk Management Reporting; Completion Of policy, dated 4/25/2025, revealed The facility will complete an Event report in Risk Management for variances that occur within the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures . All break in planes are considered a fall. All Events resulting in a change in status of a resident must be reported immediately to the attending physician and family member/legal representative of the resident. Documentation of the notification and subsequent interventions and comments must be recorded in the resident's clinical record and/or on the Event Note. Any physician order should be followed. All unwitnessed falls or head injuries require neuros per facility policy. A record review of the facility's Notifying the Physician of Change in Status policy, dated 3/11/2013, revealed The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention . 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record . 5. The resident's family member or legal guardian should be notified of significant change in resident's status . 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions PNC verification The facility identified the deficient practice, took actions to identify residents at risk for the deficiency, and developed and implemented, saftey survey assesments (Quality of Life Rounds) for 88 of 88 residents, in-services for fall protocols and the ANE prevention protocols to the entire staff which included nursing staff. Record review of the facility's nursing roster revealed 113 employees which included 69 nurses and CNAs. A record review of the facility ' s department of social services Quality Life Rounds dated 4/25/2025 revealed 88 of the facility ' s census of 88 residents were assessed for safety with no one evidenced for injuries. Record review of the facility's in-services titled fall protocol and ANE prevention, dated 4/25/2025, revealed 113 staff received the in-service, and the training which included, Falls: all falls require risk management assessments to include reporting to the physician, resident family representative, and immediate supervisor, and SBAR (Situation, Background, Assessment and Recommendation). All unwitnessed falls require neuro checks During an interview on 4/26/2025 at 9:00 PM LVN C stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. LVN C stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:04 PM RN B stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shifts on the weekends. RN B stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:10 PM LVN D stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shifts on the weekends. LVN D stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:14 PM LVN E stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shifts on the weekends. LVN E stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:18 PM RN F stated she as needed and the 2:00 PM to 10:00 PM shifts on the weekends. RN F stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:20 PM LVN G stated she as needed and the 2:00 PM to 10:00 PM shifts on the weekends. LVN G stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:22 PM LVN H stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. LVN H stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:24 PM LVN I stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. LVN I stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:29 PM CNA J stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA J stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 9:59 PM CNA K stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA K stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:01 PM CNA L stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA L stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:03 PM CNA M stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA M stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 1:48 PM CNA N stated he worked the 6:00 AM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA N stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 2:38 PM CNA O stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA O stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 9:59 PM RN P stated she worked the 6:00 AM to 10:00 PM shifts on the weekends and on 4/25/2025 she received in-services which included ANE prevention and Fall Protocols, such as assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 2:38 PM CNA Q stated he worked the 6:00 AM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA Q stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:11 PM CNA R stated she worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA R stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:14 PM RN S stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. RN S stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. The noncompliance was identified as PNC. The IJ began on 4/20/2025 and ended on 4/25/2025. The facility had corrected the noncompliance before the survey began.

**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, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed quality of care. On 4/20/2025, early morning, LVN A failed to provide quality care for Resident #1, by not following facility protocol for an unwitnessed fall with injuries to begin neurological assessments, reporting to the physician and the residents representative, when Resident #1 was discovered on the floor by her bedside and hospitalized for chronic heart failure with fluid overload in addition to fractures to right ribs 3rd, 7th and 9th ribs, 3 hours later. On 4/20/2025, CNAs Y and Z discovered Resident #1 on the floor and repositioned her back into bed without having the nurse assess prior to the repositioning. The noncompliance was identified as PNC. The IJ began on 4/20/2025 and ended on 4/25/2025. Facility had implemented interventions on 04/25/2025 prior to surveyor entrance on 04/25/2025. This failure could place residents at risk for harm . The findings include: A record review of Resident #1's admission record, dated 4/25/2025, revealed an admission date of 3/21/2025 with diagnoses which included end stage renal disease (kidney failure) and hypertension (high blood pressure). A record review of Resident #1's admission MDS dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted for long term care after a hospitalization related to a fall. Further review revealed Resident #1 was assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. Resident #1 was assessed with minimal difficulty hearing, with clear speech, could usually make herself understood and could usually understand others. Resident #1 was assessed with adequate vision and did not glasses. Resident was assessed without a mood disturbance, hallucinations, and or a change in mental status. Resident #1 was assessed with the Important preference of having family or a close friend involved in discussions about your care. Resident #1 was assessed as being independent with Activities of Daily Life, used a manual wheelchair, and had weakness in both arms. Resident #1 was assessed with occasional urinary incontinence and frequent bowel incontinence. Resident #1 was assessed as medically complex. A record review of Resident #1's care plan dated 3/25/2024 revealed, The resident has bowel incontinence . Check resident every two hours and assist with toileting as needed A record review of Resident #1's hospital record dated 3/19/2025 revealed, Resident #1 was diagnosed with pancreatic cancer which has spread to other parts of her body and had a fall on 3/10/2025 at her home and was hospitalized . The hospital documented Resident #1's family reported general weakness and Resident #1 has lost the ability to self-transfer from her bed to her wheelchair. A record review of Resident #1's nursing progress notes, on 4/19/2025 prior to 4/20/2025, revealed Resident #1 had increased episodes of altered mental status to which the physician and family were notified, Nursing Progress Note . 4/19/2025 07:00:00 (7:00 AM) . Nursing . Registered Nurse (B) . Note Text:; Pt had increased confusion, asked multiple times ' Are you going to kill me?' stating after that 'I cannot hear' .Nursing Progress Note . 4/19/2025 18:38:00 (6:38 PM) . Registered Nurse B . Dr . (physician's name) was notified of the pt's increase confusion. A record review of Resident #1's nurse progress note dated 4/20/2025 at 4:22 AM revealed LVN A documented, . Location of event: Resident Room Level of pain from 0-10 . pain:0 . Injury: Yes . Describe any injuries: Abrasion to bilat knees, 0 bleeding noted. CNAs reported that during rounds they found resident kneeling on her knees next to bedside on fall mat. CNA also reported resident was assisted back into bed by CNAs. This nurse entered resident's room and observed resident in bed. Resident noted to have abrasions to bilateral knees: without bleeding. Areas cleansed with wound cleanser and (name brand small bandage) applied to each knee. Initial Treatment/New Orders: Areas cleansed with wound cleanser and (name brand small bandage) applied knee. Resident Statement: When asked why resident was kneeling on floor resident stated, I don't know. Name of MD/NP notified: (NP) N.P. Date/time of notification: 04/21/2025 2:02 AM. Name of RP notified: (Resident #1's Representative) Date/time of notification: 04/20/2025 4:22 AM. Interventions: Bed in low position, fall mat in place. Call light in reach. A record review of Resident #1's nurse progress note dated 4/20/2025 at 7:23 AM revealed RN B documented Resident #1 was assessed with a change in status and sent to the hospital by EMS 911, (Resident #1) was transferred to a hospital on [DATE] 7:30 AM related to Pt sic(patient) had decreased LOC sic(level of conscience), disoriented, moving in bed constantly erratically. Pt had bruises on left knee, left wrist and palm. A record review of Resident #1's hospital admission records dated 4/20/2025 revealed she was admitted after a fall at the nursing home and was diagnosed with liver cancer, confusion, and rib fractures, history of present illness chief complaint: patient is a [AGE] year-old female with past medical history significant for end stage renal disease on hemodialysis Mondays, Wednesdays, and Fridays, hypertension, recently diagnosed metastatic gastrointestinal cancer (cancer of the digestive system which has spread to other parts of the body). Presents to our emergency department from nursing home after she had fallen. Per (Resident representative) patient had fallen from bed height at nursing home and became altered. Apparently her usual state until her fall today sic(4/20/2025). The patient had significant change in her mental status. In the emergency department she was found to have bilateral pleural effusion sic(fluid in the lungs), moderate pericardial effusion sic(fluid around the heart), right rib fracture 3-7, 9 and CT sic(computed tomography scan) findings of metastasis sic(spread of cancer) to liver. patient currently altered and unable to cooperate with exam. She has a 3cm by 3-centimeter contusion sic(bruise) over the medial aspect of the knee. During an observation and interview on 4/26/2025 at 10:32 AM revealed Resident #1 presented at the hospital asleep in her bed. Resident #1's representative was at the bedside and stated she was not given a report about Resident #1's fall at 4:00 AM on 4/20/2025 until she arrived at the nursing home to visit Resident #1 around 7:00 AM. Resident #1's representative stated she arrived and discovered Resident #1 was confused and had injuries to her knees, Resident #1's representative stated, I reported the injuries to the CNA and the nurse. Resident #1's representative stated after Resident #1's Representative alerted RN B then RN B assessed Resident #1 and called 911 , EMS arrived and took Resident #1 to the hospital where she was discovered with broken ribs and bruises. Resident #1's representative stated she was upset and concerned she was not alerted to the fall and confusion and felt Resident #1 was delayed in receiving care and stated, I don't know if the doctor was called. During an interview on 4/26/2025 at 12:30 PM, RN B stated Resident #1 begun to be confused and hallucinating on 4/19/2025 and reported the change to the physician and the physician had not given any new orders. RN B stated at 10:00 PM, she ended her shift and gave a report to LVN A. RN B stated she returned to work the following morning, 4/20/2025 at 7:20 AM, and received a report from LVN A that Resident #1 had fallen around 4 AM. RN B stated she assessed Resident #1 with Resident #1's representative at the bedside and discovered Resident #1 was confused with bruises and bandages to her knees and called EMS 911 . During an interview on 4/26/25 at 4:15 PM, LVN A stated she was alerted by CNAs Resident #1 was discovered on the floor by her bedside and the CNAs picked her up and placed her back in bed . LVN A stated she assessed Resident #1 in her bed, discovered her knees were red and abraded without bleeding, performed first aid, and applied a small self-adhesive bandages to her knees. LVN A stated Resident #1 could not say how she came to be on her knees next to the bed and no one witnessed the way she became to be on her knees. LVN A stated she had not considered Resident #1's incident a fall and Resident #1 had not complained of pain and was calm and sleepy at 4:00 AM. LVN A stated she documented she reported the incident to Resident #1's physician and her representative but had not reported the incident to the physician nor Resident #1's representative. LVN A stated she documented she reported to the NP and the representative because she had intended to call the NP during business hours. LVN A stated, I called Resident #1's representative and no one answered so I left a message . During an interview on 4/26/2025 at 5:40 PM the Medical Director stated his expectation for unwitnessed falls with injuries was for nursing staff to call and report the finding to a physician and or their Nurse Practitioner within a reasonable time for example an hour after the assessment. The MD stated the risk to residents could have been delayed care. During a joint interview on 4/26/2025 at 5:50 PM, the Administrator and the DON stated they had not recognized LVN A had not followed facility protocols, such as reporting the incident to the physician and to Resident #1's Representative, for Resident #1's unwitnessed fall on 4/20/2025 until early 4/25/2025 and began an investigation and self-reported the incident to the state survey agency. The Administrator and the DON stated they suspended LVN A pending the investigation, assessed all the residents for injuries, developed and implemented in-services for all staff which included fall protocols and reporting to the physician and residents' families. The DON and the Administrator stated their expectations for LVN A was for her to have followed the risk management fall protocol which included a report to the physician and a report to the family. Interviews from 4/26/2025 to 4/27/2025 with 44 of the 69 nursing staff which included all shifts revealed all interviewed were able to confirm they received the in-service which covered unwitnessed falls, assessing residents post falls, documenting the assessments, notifying the physician, and family. A record review of the facility's Risk Management Reporting; Completion Of policy, dated 4/25/2025, revealed The facility will complete an Event report in Risk Management for variances that occur within the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures . All break in planes are considered a fall. All Events resulting in a change in status of a resident must be reported immediately to the attending physician and family member/legal representative of the resident. Documentation of the notification and subsequent interventions and comments must be recorded in the resident's clinical record and/or on the Event Note. Any physician order should be followed. All unwitnessed falls or head injuries require neuros per facility policy. A record review of the facility's Notifying the Physician of Change in Status policy, dated 3/11/2013, revealed The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention . 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record . 5. The resident's family member or legal guardian should be notified of significant change in resident's status . 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions PNC verification The facility identified the deficient practice, took actions to identify residents at risk for the deficiency, and developed and implemented, saftey survey assesments (Quality of Life Rounds) for 88 of 88 residents, in-services for fall protocols and the ANE prevention protocols to the entire staff which included nursing staff. Record review of the facility's nursing roster revealed 113 employees which included 69 nurses and CNAs. A record review of the facility ' s department of social services Quality Life Rounds dated 4/25/2025 revealed 88 of the facility ' s census of 88 residents were assessed for safety with no one evidenced for injuries. Record review of the facility's in-services titled fall protocol and ANE prevention, dated 4/25/2025, revealed 113 staff received the in-service, and the training which included, Falls: all falls require risk management assessments to include reporting to the physician, resident family representative, and immediate supervisor, and SBAR (Situation, Background, Assessment and Recommendation). All unwitnessed falls require neuro checks During an interview on 4/26/2025 at 9:00 PM LVN C stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. LVN C stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:04 PM RN B stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shifts on the weekends. RN B stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:10 PM LVN D stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shifts on the weekends. LVN D stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:14 PM LVN E stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shifts on the weekends. LVN E stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:18 PM RN F stated she as needed and the 2:00 PM to 10:00 PM shifts on the weekends. RN F stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:20 PM LVN G stated she as needed and the 2:00 PM to 10:00 PM shifts on the weekends. LVN G stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:22 PM LVN H stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. LVN H stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:24 PM LVN I stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. LVN I stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 9:29 PM CNA J stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA J stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 9:59 PM CNA K stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA K stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:01 PM CNA L stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA L stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:03 PM CNA M stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA M stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 1:48 PM CNA N stated he worked the 6:00 AM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA N stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 2:38 PM CNA O stated he worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA O stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 9:59 PM RN P stated she worked the 6:00 AM to 10:00 PM shifts on the weekends and on 4/25/2025 she received in-services which included ANE prevention and Fall Protocols, such as assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. During an interview on 4/26/2025 at 2:38 PM CNA Q stated he worked the 6:00 AM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA Q stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:11 PM CNA R stated she worked the 2:00 PM to 10:00 PM shift and on 4/25/2025 he received in-services which included ANE prevention and Fall Protocols, such as alerting the nurse whenever anyone falls and reporting any suspected ANE. CNA R stated he would not reposition anyone and would stay with the Resident until the nurse assessed the Resident for injuries. During an interview on 4/26/2025 at 10:14 PM RN S stated she worked the Monday through Friday 6:00 AM to 2:00 PM shift. RN S stated she received the in-services regarding ANE prevention and risk management protocols for falls which included assessing the Resident for injuries, documenting the fall by starting the incident report, SBARing (reporting to the doctor) the physician, reporting the incident to the Resident's representative, alerting the nursing supervisor, and fully documenting the details in the residents nursing notes. The noncompliance was identified as PNC. The IJ began on 4/20/2025 and ended on 4/25/2025. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on o interviews and record reviews, the facility failed to ensure residents received care, consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for pressure ulcers in that: The facility failed to acquire and administer treatment to Resident #1's sacral wound when it deteriorated to a Stage 3 (involves the full thickness of the skin and may extend into the subcutaneous tissue layer) on 09/25/2023 until 10/01/2023 where it declined to a Stage 4 pressure ulcer (deepest extending into the muscle, tendon, ligament, cartilage or even bone) prior to her discharge to the hospital on [DATE]. An IJ was identified on 12/21/2023. The IJ template was provided to the facility on [DATE] at 5:31 p.m. While the IJ was removed on 12/22/2023 at 7:41 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy. This facility failure could place residents at risk of untreated wounds, infection, a decline in health, further surgeries with associated complications leading to death. Findings included: Record review of Resident #1's electronic face sheet dated 12/21/2023 reflected she was originally admitted to the facility on [DATE], readmitted on [DATE] and recently admitted on [DATE]. Her diagnoses included: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), displaced comminuted fracture of shaft of left femur (the bone of the thigh has broken into three or more pieces), hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (mild loss of strength in leg, arm, or face) following cerebral infarction (necrotic tissue in the brain caused by disrupted blood supply) affecting right dominant side, type 2 diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels) and neuromuscular dysfunction of bladder (lack of bladder control due to a brain, spinal cord or nerve problem). Record review of Resident #1's quarterly MDS assessment with an ARD of 09/20/2023 reflected she had no pressure sores and had MASD which she was being treated with barrier cream. She scored a 6/15 on her BIMS which signified she was moderately cognitively impaired; she could usually understand and be understood. She had an indwelling urinary catheter and she was always incontinent of bowel. She required extensive assistance with her ADL's. Record review of Resident #1's comprehensive care plan date initiated 06/28/2021 and revised on 11/08/2022 reflected Focus .has MASD to buttocks and sacrum (forms the posterior pelvic wall and strengthens and stabilizes the pelvis. Joined at the very end of the scrum are fused vertebrae known as the coccyx or tailbone) .Interventions .Avoid scratching and keep hands and body parts from excessive moisture .monitor skin rashes for increased spread or signs of infection. Further review reflected Focus .resident has a stage 3 pressure injury to sacrum revised on 10/01/2023 .Interventions .Administer medications as ordered .assess/record/monitor wound healing at least weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report declines to the MD. Record review of Resident #1's Braden Skin Assessment dated 01/30/23 reflected she scored a 13 which signified she was a medium risk for skin breakdown. Record review of Resident #1's Active Orders As of: 09/01/2023 to 09/30/2023 reflected: Wound care .to evaluate and treat .active. Dated 11/03/2023. Further review reflected Wound Care: MASD to bilateral buttocks and sacrum: apply Zinc oxide (used to treat and prevent minor skin irritations, forming a barrier on the skin to protect it from irritants and moisture) mixed with Nystatin cream (antifungal cream to prevent yeast infection) after perineal care daily. OFFLOAD!!!!!!! Every 24 hours as needed for MASD .Active .dated 09/01/2023. No orders were found for a Stage Record review of Resident #1's Weekly Skin Assessment dated 09/18/2023 reflected Resident #1 did not have a pressure sore and had MASD to the sacrum/buttocks. Record review of Resident #1's Pressure Ulcer Sheet dated 09/25/2023 reflected that Resident #1 had a Stage 3 pressure injury to the coccyx (a small triangular bone at the base of the spinal column) (2.0 cm x 2.0s x 0.3 cm). Record review of Resident #1's Pressure Ulcer Sheet dated 10/01/2023 reflected that Resident #1 had a Stage 3 pressure injury to the coccyx (3.5 cm x 3.5 cm x 0.6 cm). Record review of Resident #1's Active Orders as of: 10/01/2023 reflected Wound Care: Stage 3 pi to the sacrum: clean with wound cleanser, pat dry with 4x4 gauze, apply Santyl (used to remove damaged tissue from chronic skin ulcers) to the wound bed, cover with a foam dressing. One time a day for Wound Care .Verbal Active Order Date 10/01/2023 Start Date: 10/02/2023. Record review of Resident #1's Pressure Ulcer Sheet dated 10/06/2023 reflected Resident #1 had a Stage 4 pressure injury to the coccyx (3.7 cm x 3.0 cm x 2.7 cm, palpable coccyx bone). Record review of Resident #1's Wound Consultation dated 10/06/2023 reflected Consult for wound evaluation and treatment .High Risk for Skin Breakdown .3.7 x 2.7 x 2.7 with moderate serosanguinous drainage (thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells) .debridement .surgical, dermis, subcutaneous, muscle and bone .percent debrided .100%. Record review of Resident #1's Transfer Sheet dated 10/08/2023 reflected Resident #1 was transferred to the hospital 10/08/2023 at 07:45 p.m. related to unresolved wound to sacrum per family request. Record review of Resident #1's hospital record dated 12/01/2023, her second admission to another hospital reflected Diagnosis: Pressure ulcer of sacral region, stage 4 .transferred for further care .Impression/Plan .Osteo/sacral decub .continue wound care here .ID (Identification of bacteria) for abx .Diagnoses codes .Osteomyelitis (infection in the bone) of vertebra, sacral and Sacro coccyx. Interview on 12/19/2023 at 4:06 p.m. with the Treatment Nurse revealed that Resident #1 was at high risk for skin breakdown. He stated he identified the Stage 3 pressure injury on Resident #1, and knew he ordered something, but did not see the written order. Interview on 12/19/2023 at 1:00 p.m. with the RN C revealed the facility did not do quarterly Braden Skin Assessments, and only did them for significant changes in condition. RN C stated Resident #1 did not have a Braden Skin Assessment since the one done on January 30, 2023. Interview on 12/20/2023 at 2:30 p.m. with the Treatment Nurse, he stated there was never a Stage 3 on 09/25/2023 and that his documentation was inaccurate because he was behind in his charting. Notes were locked in (finalized) on 10/06/2023. [NAME] asked by the surveyor why the wound measurements were different from the 10/01/2023 assessment if they were late and were larger, he could not respond. Record review of the facility pressure sore log dated September 2023 reflected Resident #1 was listed to have a Stage 3 and the treatment was Santyl. Record review of Resident #1's progress notes from (09/25/2023) to (10/1/2023) revealed no documentation of a treatment performed to Resident #1's Stage 3 pressure injury with Santyl, prior to the physician orders on 10/01/2023 and to start on 10/02/2023. Record review of Resident #1's clinical record did not have a WAR dated September 2023. Record Review of Resident #1's TAR dated 09/2023 did not have treatment for Santyl. There was only a wound treatment Wound Care: MASD to bilateral buttocks and sacrum: apply Zinc oxide mixed with Nystatin cream after perineal care daily. every 24 hours as needed for MASD which was discontinued on 10/04/2023. Record review of Resident #1's TAR dated September 2023 reflected Wound Care: MASD to bilateral buttocks and sacrum: apply Zinc oxide mixed with Nystatin cream after perineal care daily .D/C date 10/04/2023 initialed off by the Treatment Nurse and nurses who did the treatment when the Treatment Nurse was not on duty. Record review of Resident #1's WAR dated 10/01/2023 to 10/31/2023 reflected Wound Care: Stage 3 pi to the sacrum: clean with wound cleanser; pat dry with 4x4 gauze, apply Santyl to the wound bed, cover with a foam dressing, one time a day for wound care. Further review reflected the wound care to Resident #1's Stage 3 pressure injury to her sacrum was started and performed on 10/02/2023 and continued through 10/08/2023 as initialed off by the nursing staff. Record review of Resident #'s progress note dated 09/30/2023 by Dr. E reflected Late entry pt seen 09/25/2023. Pt here for LTC. Pt seen for monthly. Pt seen by wound care. She has MASD to bilat buttocks and scratched it and has open areas. Interview on 12/20/2023 at 2:30 p.m. with NP C (the provider the Treatment Nurse referred to for care of Resident #1) revealed he saw Resident #1 the last week in September and she still only had a Stage 2. He stated the first week in October, the Treatment Nurse informed him Resident #1's wound was worse. He stated another physician Dr. D. rounded on residents on Mondays and would have seen the resident. When asked why his notes from June 2023 to October 2023 had similar verbiage in them to include a pressure sore on the heel that was unstageable, he stated he copied and pasted his notes and the heel pressure sore was inaccurate documentation. NP C was asked how other providers could refer or rely on his progress notes, he did not respond. Interview on 12/21/2023 at 11:27 p.m. with Dr. E. who supervised NP C, he stated the wound care team, treatment, and facility are responsible to determine wound care. He stated he believed the wound care team needed to be involved with Resident #1's wound earlier. He was not aware that NP C copied and pasted his notes, they were inaccurate, and he stated he would talk to NP C about the issue. Interview on 12/21/2023 at 12:05 p.m. with the DON revealed initially Resident #1 had MASD. He stated Resident #1 was at high risk for skin breakdown and he and the Treatment Nurse looked at Resident #1's wound as being treatable and avoidable. He stated that he was under the assumption that the wound care treatment team was involved, and that was his mistake. He stated the Treatment Nurse informed him of the changes in Resident #1's condition and he was accountable for resident care. He further stated that his expectation of documentation of skin assessments was for them to be accurate and accomplished on the same day they were performed and acquire orders for treatments and provide them. Interview on 12/21/2023 at 1:07 p.m. the Treatment Nurse revealed he was not sure when documentation on skin assessments were to be completed. He stated the wound care team provider came to the facility each week, and he did not feel Resident #1 needed to see the provider prior to October 6th, 2023. He stated he would have to consult for them to see the resident. He stated he already conferred with NP C and Santyl was ordered. Interview on 12/21/2023 at 2:00 p.m. with Dr. D. revealed she did come in and did rounds on patients on 09/26/2023. She stated she did not see Resident #1's wounds and relied on observations and other provider notes and orders to do her documentation. Interview on 12/21/2023 at 3:45 p.m. with Resident #1's RP revealed she went to the facility after the Treatment Nurse called her 3 days in a row. She stated she saw Resident #1, and the resident stated that if she was not moved out of the facility she would die there. The RP stated she insisted Resident #1 go to the hospital, and when she went to the ED of the first hospital, the staff assessed her and she had a UTI, MRSA and C-Diff. The RP saw a gaping hole on Resident #1's sacrum and she could see Resident #1's spine. She stated she cried and was in shock, the wound looked horrible. She stated the diagnoses was MRSA of the wound and myelitis (inflammation of the spinal cord). She stated Resident #1 stayed at that hospital for 3 months, and eventually ended up at the present hospital . She stated Resident #1 had a colostomy and a wound vac, and was due to have more surgery. Record review of the facility policy and procedure titled Skin Integrity Management revised October 5, 2026, reflected If wound is noted, perform an assessment and initiate a treatment plan as soon as possible. The Administrator was notified of an IJ on 12/21/2023 at 5:31 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 12/22/2023 at 7:41 p.m., and included the following: 1. Immediate Action Taken A. ADHOC QA Completed on 12/21/23 with IDT team. Action plan completed. B. Assessment for all residents with Pressure ulcers completed on 12/21/23 by RCN Ulcer assessments verified for correct documentation, Wound orders verified to ensure they are entered correctly. care plan updated; Treatments done. No other discrepancies noted with ulcer assessment documentation. Wound orders have been transcribed correctly. In-services initiated on 12/21/23 by RCN for Direct care staff (Licensed nurses/CNAS) on reporting to DON/designee new skin changes) C. The following in-services were initiated by the RCN on 12/21/23. Direct care nursing staff (licensed nurses and certified nurse's aides) not present or in-serviced on 12/21/2023, will not be allowed to assume their duties until in-serviced. Anticipated completion of in servicing will be completed by 12/22/23. Any newly hired CNA or Licensed nurse hired will be in serviced prior to assuming their duties by the DON and/or ADON. Any agency staff will be reviewed by the DON and/or ADON prior to assuming their duties, if they have not been in-serviced on the topics below, the DON and/or ADON will provide that in servicing. In-service will be completed by DON/Designee for Licensed nurses (To include agency if in use). a. Licensed Nurses: i. Pressure Injury and prevention ii. Skin integrity management iii. Following physician orders iv. Documentation to include accurate assessment of the wound condition and accurate entry of physician orders into the EMR. v. Notification of Physician with change of condition. D. The following in-services were initiated by the RCN 12/21/23. CNA: CNAs to report to DON/Designee if a new skin change is noted. E. The following in-services were initiated by RCN on 12/21/23 by for DON. Validating skin assessments. Skin assessments will be validated by DON/Designee within 24 hours of notification of new skin change. 2. Identification of Residents Affected or Likely to be Affected: A. Assessment for all residents with Pressure ulcers completed on 12/21/23 by RCN Ulcer assessments verified for correct documentation, Wound orders verified to ensure they are entered correctly. care plan updated; Treatments done. No other discrepancies noted with ulcer assessment documentation. Wound orders have been transcribed correctly. In-services initiated on 12/21/23 by RCN for Direct care staff (Licensed nurses/CNAS) on reporting to DON/designee new skin changes) B. Skin assessments will be performed on all residents weekly by the treatment nurse and/or designee to identify any new skin issues. Assessments will take place indefinitely. At least 5 days per week, the DON/Designee will monitor the EMR (PCC) to ensure that the previous day(s) weekly skin assessments were completed timely. This monitoring will occur for 6 weeks and if compliance is maintained, monitoring will be decreased to 1 time weekly to ensure the prior week's skin assessments are completed. 3. Actions to Prevent Occurrence/Recurrence: A. The following in-services were initiated by the RCN on 12/21/23. Direct care nursing staff (licensed nurses and certified nurse's aides) not present or in-serviced on 12/21/2023, will not be allowed to assume their duties until in-serviced. Anticipated completion of in servicing will be completed by 12/22/23. Any newly hired CNA or Licensed nurse hired will be in serviced prior to assuming their duties by the DON and/or ADON. Any agency staff will be reviewed by the DON and/or ADON prior to assuming their duties, if they have not been in-serviced on the topics below, the DON and/or ADON will provide that in servicing. In-service will be completed by DON/Designee for Licensed nurses (To include agency if in use). a. Licensed Nurses: i. Pressure Injury and prevention ii. Skin integrity management iii. Following physician orders iv. Documentation to include accurate assessment of the wound condition and accurate entry of physician orders into the EMR. v. Notification of Physician with change of condition. B. The following in-services were initiated by the RCN 12/21/23. CNA: CNAs to report to DON/Designee if a new skin change is noted. C. The following in-services were initiated by RCN on 12/21/23 by for DON. Validating skin assessments. Skin assessments will be validated by DON/Designee within 24 hours of notification of new skin change. D. Skin assessments will be performed on all residents weekly by the treatment nurse and/or designee to identify any new skin issues. Assessments will take place indefinitely. At least 5 days per week, the DON/Designee will monitor the EMR (PCC) to ensure that the previous day(s) weekly skin assessments were completed timely. This monitoring will occur for 6 weeks and if compliance is maintained, monitoring will be decreased to 1 time weekly to ensure the prior week's skin assessments are completed. E. Monitoring The DON / designee will monitor all new ulcers, ensure treatments have been ordered, and completed 7 days a week X's 6 weeks and periodically thereafter to to ensure compliance using the monitoring tool. The DON / designee will view pressure ulcers weekly X 6 weeks and periodically thereafter to ensure compliance. The DON / designee will audit ulcer assessments weekly to ensure all assessment match the resident's current condition for 6 weeks and periodically thereafter to ensure compliance. DON/designee will monitor ulcer treatments being done for accuracy per orders weekly x 6 weeks and periodically thereafter to ensure compliance. RCN/ADO will review monitoring forms weekly x 6 weeks and periodically thereafter to ensure compliance. The QA committee will review findings at the monthly QA meeting and makes changes as needed. On 12/21/2023 at 5:40 p.m. the facility administrator notified the Medical Director of the immediate jeopardy relating to pressure ulcer assessment, neglect, ulcer treatment, physician orders and documentation. POR Verification: Monitoring: Observation on 12/20/2023 at 10:14 a.m. of the Treatment Nurse as he performed wound care for Resident # 5 Wound care Stage 3 .to sacrum, clean the wound with cleanser, pat dry with 4 x 4 gauze, apply veneex ointment, cover with dry dressing revealed he followed physician orders, faciity policy and procedure and used aseptic technique. Verification Interviews Day Shift: 12/22/2023 at 1:55 p.m. with RN G: I had training on skin integrity, changes in condition, reporting, wound care, and documentation. We were in-serviced on following physician orders. We were trained on prevention. If we have a change in condition we notify the physician, responsible party, DON, and treatment nurse. 12/22/2023 at 1:57 p.m. with MA H revealed an in-service was provided recently on wound care, informing nurses and supervisors of changes in skin. We report changes immediately. If there is a change we document as soon as possible. 12/22/2023 at 2:00 p.m. with LVN I revealed that she received training on skin issues, protocols, documentation. We are to provide prevention, notification, assessments and get orders. We notify the DON and treatment nurse. 12/22/2023 at 2:05 p.m. with Medication Aide J revealed she was trained on pressure sores, turning and repositioning, and report any changes to the charge nurse. Any changes in condition. 12/22/2023 at 2:07 p.m. with CAN K revealed she received training on wound care and maintain residents dry. If there are any changes, we report to the wound nurse so they can take care of them. If we do showers report any skin changes. 12/22/2023 at 2:10 p.m. with CAN L revealed she just received training on handwashing, skin care. If we find any new issues report it just in case it hasn't been. We report it to the nurse. We were trained to turn and reposition the resident every 2 hours. 12/22/2023 at 2:132 p.m. with CAN M revealed she received training on skin assessment and hand washing. If we see any difference in the skin or breakdown to report it to the nurse, DON, and the Treatment Nurse. I would report it immediately. 12/22/2023 at 2:15 p.m. with CAN N Fees revealed she was trained on skin issues. If we see any open sores to report it to the charge nurse. If we are changing the resident, we are supposed to put the skin barrier on, not the one with Zinc. We are supposed to report it to the wound care nurse and the charge nurse. We turn and reposition. 12/22/2023 at 2:17 p.m. with CAN O revealed that she was provided an in-service on skin integrity and repositioning. If we see any changes in condition, we are to report the changes as soon as possible to the charge nurse and the Treatment Nurse. 12/22/2023 at 2:20 p.m. with LVN P revealed she just received training on infection control. We received in-servicing on documentation, skin integrity, Hipaa, turning and repositioning. Report anything to the supervisor and DON. I do like to check the skin. I will help the CAN's with changing the residents, so I will see the skin. 12/22/2023 at 2:20 p.m. RN Q revealed that Training completed: Physician orders, skin assessments, documentation, report changes from baseline. DON, Treatment nurse and document. 12/22/2023 at 2:30 p.m. with CAN R revealed she was trained on reporting wounds, changes in condition and hand washing and who you report to. I report to the charge nurse if I see any change in condition right away. Evening Shift: 12/22/2023 at 3:00 p.m. Medication [NAME] S revealed she received training on wound care, how and where to report it. Document it on PCC. Tell the nurse immediately. Try to reposition the resident. Document and tell the nurse. 12/22/23 at 3:10 p.m. with LVN T revealed she was just trained on skin issues, wounds, report any changes to the DON. Physician orders. Report changes to the treatment nurse and responsible party. Document any changes. 12/22/23 at 3:15 p.m. with LVN U revealed they were trained on infection control, change in condition, abuse and neglect and skin issues. Report any changes to DON, family, RP, and Treatment nurses. Document everything. 12/22/23 at 4:40 p.m. with LVN V revealed she received training on pressure ulcer prevention treatment, documentation, reporting any new findings to physician. PPE. We report skin changes immediately to the DON, ADON, and notify doctor, and get orders. 12/22/23 at 4:45 p.m. with LVN W revealed he received in-service training on pressure sore management, documentation, and skin issues. Change in condition. I notify the responsible party, DON, and treatment nurse. I notify them as soon as possible. 12/22/23 at 4:45 p.m. with CAN X revealed she just received training on wounds and change in condition. We would report it to the charge nurse as soon as possible. 12/22/23 at 4:50 p.m. with Hospitality Aide Y revealed she was trained on pressure wounds. If I see something I should tell the charge nurse. I would tell them right away of any change in condition. 12/22/23 at 6:20 p.m. with RN Z revealed she was trained on wound care and changes in condition. Tell the nurse about any changes in condition. I tell the charge nurse right away, the DON, ADON and the doctor and I tell them right away. We need to document any changes. Infection control and skin assessments. 12/22/23 at 6:40 p.m. with C NA AA revealed (PRN) works evenings, he stated that he was in-serviced on skin assessment, any breakdown, go to nurse and Treatment nurse and report any changes to the nurse right away. Night Shift: 12/22/2023 at 4:30 p.m. with LVN BB (PRN) via phone revealed she was trained on skin conditions, notify DON. Anything new notify DON immediately. 12/22/2023 at 5:20 p.m. with LVN CC revealed she received training on wound care, orders for the admissions. The CAN's report it to the nurse, we report it to the DON and wound care nurse. We get orders. We need to document. 12/22/2023 at 2:30 p.m. with C NA R revealed she was trained on reporting wounds, changes in condition and hand washing and who you report to. I report to the charge nurse if I see any change in condition right away. (Works evenings and nights). Verification Record Reviews: Record review of an Off Cycle (ADHOC) QA Meeting Document signature page, dated 12/21/2023, revealed an Ad Hoc meeting was held to discuss facilities wound care practices/skin system on 12/22/2023. In attendance was the DON, administrator, treatment nurse, ADON, and other department heads. Record review of Resident's #3 and #5 EMR's reflected they had new assessments accomplished on 12/21/2023 with no changes. Record review of the In-Service Training Attendance Roster for Pressure Injury Preventing Assessments Treatment presented to nursing staff on 12/21/2023 revealed 38 nursing staff members were in-serviced on the facility's Pressure Injury: Prevention, Assessment and Treatment Policy. Record review of the In-Service Training Attendance Roster Skin Integrity Management presented to nursing staff on 12/21/2023 revealed 37 nursing staff members were in-serviced on the facility's Skin Integrity Management Policy. Record review of the In-Service Training Attendance Roster Physician Orders presented to nursing staff on 12/21/2023 revealed 19 nurse staff members were in-serviced on the facility's Physician's Orders Policy. Record review of the In-Service Training Attendance Roster Documentation presented to nursing staff on 12/21/2023 revealed 36 nursing staff members were in-serviced on the facility's Documentation Policy. Record review of the In-Service Training Attendance Roster Notifying Physician of Change presented to nursing staff on 12/21/2023 revealed 20 nurses were in-serviced. Record review of the In-Service Training Attendance Roster Notifying Charge Nurse, DON, Treatment Nurse, of Skin Change presented to nursing staff on 12/21/2023 revealed 27 nursing staff members were in-serviced. On 12/22/2023 at 7:41 p.m. the Administrator was notified the IJ was removed. An IJ was identified on 12/21/2023. The IJ template was provided to the facility on [DATE] at 5:31 p.m. While the IJ was removed on 12/22/2023 at 7:41 p.m., the facility remained out of compliance at a scope of isolation and severity level of actual harm that is not immediate jeopardy.