**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately consult the physician when there was a significant change in the resident's physical and mental status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 13 residents (Resident #4) whose records were reviewed for change in condition. 1. The facility failed to notify Resident #4's physician when Resident #4 had an increase in bruising while taking an anticoagulant medication (blood thinner that works by preventing red blood cells from forming clots), which indicated a change of condition and resulted in a delay of treatment. An Immediate Jeopardy (IJ) situation was identified on 07/13/23 at 9:30 AM. While the IJ was removed on 07/14/23 at 11:56 AM, the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of a delay in medical intervention and puts residents at an increased risk for adverse reaction while taking an anticoagulant medication (blood thinners), such as severe bruising, external or internal bleeding, or death. The findings included: Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), history of cerebral infarction (stroke), history of a heart attack, hypertension (high blood pressure), mitral (valve) stenosis (narrowing of the mitral valve of the heart that causes tiredness and shortness of breath), and congestive heart failure (progressive heart disease that affects pumping action of the heart muscles). Record review of the MDS assessment, dated 05/30/23, revealed Resident #4 had clear speech and was usually understood by staff. The MDS revealed Resident #4 was usually able to understand others. The MDS revealed Resident #4 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #4 had no behaviors or refusal of care. The MDS revealed Resident #4 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene with a one or two staff assistance. Record review of the comprehensive care plan, revised on 01/28/23, revealed Resident #4 was on anticoagulant therapy. The interventions included Monitor/document/report to the doctor as needed for signs and symptoms of anticoagulant complications: .bruising . Record review of the order summary report, dated 07/12/23, revealed Resident #4 had an order, which started on 12/14/21, for Anticoagulant Monitoring - Place letter of symptoms of excess bleeding .every shift .F. bruising. The orders also revealed an order, which started on 12/13/21, for Aggrenox (blood thinner) Capsule 25-200 mg by mouth two times a day for blood thinner. Record review of the Nurse Administration Record, dated July 2023, revealed bruising was present on the following dates: 07/01/23, 07/03/23, 07/04/23, 07/05/23, 07/06/23, and 07/11/2023. The Nurse Administration Record did not specify the location of the bruising. Record review of the Weekly Skin Check, dated 07/04/23, revealed Resident #4 had no bruising. Record review of the CNA Shower Report, dated 07/10/23, revealed Resident #4 had no skin problems. Record review of the Weekly Skin Check, snipped on 07/11/2023 at 5:27 PM, revealed Resident #4 had no bruising. During an interview on 07/11/23 at 5:55 PM, a copy of Resident #4's Weekly Skin Check dated 07/11/23 was requested from the DON. Record review of the Weekly Skin Check provided by the facility, dated 07/11/23, revealed Resident #4 had the following newly documented skin problem areas: reddish, burgundy discoloration to back of left hand, front of right shoulder, left lower leg (below the knee), front of the left leg (above the knee), front of the right leg (above the knee), and the upper inner arm; bright reddish tint to right and left heel; small scabbing to second right toe and small scabbing to first, second, and fifth toes; red linear scratch to left shoulder in the front; and purplish discoloration to right lateral foot below the fifth toe. During an observation and attempted interview on 07/10/23 at 9:09 AM, Resident #4 was laying in her bed with her bed sheets pulled up. She was moving her legs up and down and holding the bed sheets in her hands close to her face. Resident #4's arms and legs were visible from the door and several large, reddish-purple bruises were observed to Resident #4's upper legs and arms. Resident #4 was unable to remember how the bruising occurred and stared at the surveyor when questions were asked. During an interview on 07/12/23 at 12:02 PM, LVN L stated she was the treatment nurse at the facility and had worked at the facility since March of 2022. LVN L stated Resident #4 had discoloration to several areas on her skin. LVN L stated Resident #4 had the discoloration and skin problems prior to 07/11/23, when they were documented. However, the skin issues did not require a treatment, so they were not documented on the weekly skin assessment. LVN L stated Resident #4 has always had terrible skin and the discoloration came and went frequently. LVN L stated she was unsure if Resident #4 was taking a blood thinning medication. LVN L stated she had not notified anyone of Resident #4's new skin areas of discoloration. LVN L stated the facility staff were aware of Resident #4's skin status because it had been discussed several times, especially regarding transfers. LVN L stated she was unsure how the areas of discoloration occurred on Resident #4's skin. LVN L stated the discoloration had been present since she started working at the facility but had come and went in the same area. LVN L was unable to say if the discoloration was the same or was in the same area. LVN L stated new skin problems or discoloration should have been reported to physician as soon as it was noticed. During an interview on 07/12/23 at 12:20 PM, the ADON stated she used to be the treatment nurse at the facility. The ADON stated weekly skin assessments should have been a complete head to toe assessment, to include discoloration or bruising. The ADON stated new bruising or discoloration should have been monitored for 72 hours, initially, then weekly on the skin assessments. The ADON stated new bruising or discoloration should have been reported to the physician. During an interview on 07/12/23 at 1:44 PM, the DON stated she was unaware of Resident #4's increased bruising until this week. The DON stated she expected staff to monitor for bruising and other signs of bleeding every shift for residents taking a blood thinning medication. The DON stated an increase in bruising for resident's taking a blood thinning medication should have been reported to the physician, as soon as it was noticed, because it would have been considered a change of condition. The DON stated the increased bruising for Resident #4 was reported to the physician on 07/12/23 and a new order for a STAT CBC and PT/INR was obtained. The DON stated it had not been reported to physician prior to 07/12/23. The DON stated documenting bruising on the weekly skin assessment, anticoagulant monitoring every shift, and reporting increased bruising to the physician were important to monitor and follow up on side effects of blood thinning medications such as bruising, metabolic functions, and fragile skin. During an interview on 07/12/23 at 2:32 PM, Physician M stated he had been caring for Resident #4 for the last 15 to 20 years. Physician M stated Resident #4 had a history of minor skin areas such as small areas of bruising and skin tears, because of the tremors and fidgeting caused by Parkinson's disease. Physician M stated Resident #4 was taking a blood thinner called Aggrenox which had aspirin in it. Physician M stated Resident #4 was at an increased risk for GI bleeding, bruising, and bleeding because she was taking a blood thinning medication. Physician M stated he was notified on 07/12/23 for the increased bruising on Resident #4. Physician M stated he looked at it while he was making rounds and stated he believed it was bruising and it was on her left shoulder and elbow and right and left thighs. Physician M stated the bruising was not concerning or suspicious of abuse because there were no shapes or fingerprints. Physician M stated he wanted to be notified of increased bruising for residents who were taking a blood thinning medication as soon as it was noticed so he could have ordered some lab work to rule out acute or worsening medical problems. Physician M stated he ordered some STAT labs, which included a CBC to check for platelets and red blood cells, a CMP to check for protein, and a PT/INR to check for clotting factors. Record review of the lab results, dated 07/12/23 at 5:01 PM, revealed on the CBC, Resident #4 had a low red blood cell count 3.2 (normal 3.8 - 5.1), hemoglobin (iron-containing oxygen carrying protein found in red blood cells) 8.8 (normal 11.6 - 15.4), and hematocrit (volume percentage of red blood cells) 28.0 (normal 34-45). The CMP revealed Resident #4 had a low total protein 5.5 (normal 5.7 - 8.0). The PT/INR revealed Resident #4 had a high PT 12.4 (normal is 9.0 to 12.0). During an interview on 07/12/23 at 5:59 PM, Physician M stated Resident #4 had some anemia by looking at the CBC. Physician M said the protein (on the CMP) was a little off but still good. Physician M stated the INR was normal and the PT was only elevated by 0.4 which was not concerning. Physician M stated he wanted the facility to keep monitoring the bruising and to repeat the CBC in one week because Resident #4 might need a blood transfusion, which could indicate bleeding. Physician M stated he wanted to be notified of any changes. During an interview on 07/12/23 at 6:03 PM, CNA N stated he worked 2-10 shift on 07/10/23 and 7/11/23. CNA N stated he helped the treatment nurse with Resident #4's skin assessment on 07/11/23 after the supper meal. CNA N stated during the skin assessment on 07/11/23 was the first time he had noticed bruising on Resident #4, but she did have a history of bruising on and off. CNA N stated he was unsure how Resident #4 received the bruising to her arms and legs. CNA N stated he worked on a different hall on 07/10/23. CNA N stated he would have reported the bruising to the charge nurse if he would have noticed it. CNA N stated the treatment nurse was aware of the bruising, so he did not have to report it. During an interview on 07/12/23 at 6:16 PM, LVN E stated she normally worked with Resident #4. LVN E stated the bruising to Resident #4 had been there but was unable to say for how long. LVN E stated the bruising was present on 07/10/23 (Monday) but she believed the bruising had been documented on a skin assessment. LVN E stated it was normal for Resident #4 to bruise easily because she was on a blood thinner. LVN E stated she was unsure how Resident #4 received the bruising on her arms and legs. LVN E stated the physician should have been notified any time a new bruise or skin problem was identified. LVN E stated it was important to notify the physician for signs of bleeding so lab work could have been ordered to check for internal bleeding and medication could have been adjusted as it was needed. During an interview on 07/13/23 at 1:39 PM, CNA C stated she worked Resident #4's hall on 07/10/23 and she had discoloration to her upper and lower limbs. CNA C she did not report the discoloration to the charge nurse because it had been reported previously and the charge nurse was aware. CNA C was unsure who reported the discoloration previously. CNA C stated she was unsure how the discoloration to Resident #4's arms and legs occurred. CNA C stated Resident #4 had other signs of bleeding. CNA C stated it was important to document and report new bruising to the charge nurse because it could have been a change of condition and the charge nurse would want to be aware. Record review of the Change of Condition Notification policy, revised 06/2020, revealed I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent an acute change of condition (ACOC). The policy further revealed I. The Licensed Nurse will notify the resident's Attending Physician when there is an A. Incident/accident involving the resident; B. an accident involving the resident which results injury and has the potential for requiring physician intervention; C. A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions, or clinical complications; D. A need to alter treatment significantly . The Administrator was notified on 07/13/23 at 10:53 AM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 07/13/23 at 10:57 AM and the plan of removal was requested. The facility's Plan of Removal was accepted on 07/13/23 at 8:47 PM and included: 1. Immediate action(s) taken for the resident(s) found to have been affected include: 1. Resident Notification to Family Treatment nurse at 1:59pm attempted left message and 2:02pm family called back and was notified by ADON, Medical Director/Physician 7-12-23 ADON 1:25pm 2. SBAR (change in condition) Completed 7-12-23 ADON 1:25pm 3. Medical Director / Physician Evaluated Resident for changes in condition related to bruises 7-12-23 1:45pm 4. New orders to monitor bruising, Labs - CBC/INR Orders 7-12-23 1:25pm Labs Drawn at 2:21PM on 7-12-23 and results received at 3:21PM and MD notified 3:25pm and order to repeat CBC in one week received. 5. Trauma Assessment completed 7-12-23 Charge Nurse LVN A 1:47 PM 6. Pain Assessment completed 7-12-23 Charge Nurse LVN A 1:45pm 7. Care Plan Updated 7-12-23 MDS Nurse, Added Skin Care BUE/BLE Bruising- updated with Intervention monitoring skin for the bruising until healed and report abnormality to MD. 8. Therapy Screening completed 7-12-23 RN DON 3:57pm and Therapy screened completed DOR COTA on 7-12-23 7:15pm, Resident is on services as of 7-13-23 on OT services. 9. Incident Report ADON LVN 7-12-23 at 6:42pm Self-Report Completed 7-12-23 by the Administrator 3:21PM 10. Skin assessment conducted for all residents that resided in the facility completed 7-12-23 7:30pm completed by Charge Nurse A LVN, Charge Nurse B LVN, all undocumented concerns were reported to MD/Families by LVN ADON, and RN DON completed by 7-13-23 by 4:00pm Include actions that were performed toa address to citation: 7-13-23 11:00am 1. Facility Wide Resident Skin Sweep completed 7-12-23 Charge Nurses A LVN, Charge Nurse LVN B, completed at 7:30pm 2. Safe Survey with residents that are cognitively intact. 7-13-23 at 1:47pm by Social Worker completed at 4:00pm 3. Staff Safe Survey completed 7-13-23 Administrator and Regional Director of Operations started at 12:25pm completed at 3:45pm 4. One on One Inservice with treatment nurse on skin assessment initiated 4:00pm and completed on 7-12-23 conducted by DON RN completed 4:30pm on 7-12-23, Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan and job duties. 5. One on One Inservice with DON conducted by Regional Nurse Consultant on change in condition/skin assessment and notification. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Initiated 3:00pm 7-12-23 and completed on 7-12-23 3:30pm. Regional Nurse Consultant 6. In-services for licensed nursing staff on Skin Assessment/Skin initiated on 7/13/2023 at 11:45am by Regional Nurse Consultant. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Completed 7-13-23 5:00pm. 7. Training for licensed staff was initiated 7-12-23 at 11:45am on Anticoagulant monitoring/documentation timely and accurately 7-13-23 at 5:00pm. Training consisted of how to recognize changed with anticoagulant, monitoring, and orders and care plan in place. 8. Training for licensed staff was initiated 7-12-23 at 11:45am on Following care plan of anticoagulant completed 7-13-23 at 5:00pm. Training consisted of the following care plan. 9. Training for Clinical Licensed staff was initiated 7-12-23 at 11:45am on ADL transfers, this Inservice training consisted of transfer safety and how to conduct proper transfers. This Inservice was conducted at a precaution. Training completed on 7-13-23 at 5:00pm. 10. Training for Clinical Licensed staff was initiated on 7/12/23 at 11:45am, on Notification of Change completed on 7/13/23 at 5:00pm. This training includes what is a change in a condition, proper notification, reported and documentation of change in conditions. 11. Training with facility staff was initiated on 7/12/23 at 11:45am, by DON on Abuse and Neglect. This training includes what is abuse and neglect, procedures of abuse and neglect, reporting of abuse and the abuse coordinator, completed on 7/13/23 at 5:00pm. 12. All new hires will be educated on abuse and neglect protocol/change in condition/skin assessment, and anticoagulant ongoing. 13. The ADON and Director of Nursing will ensure competency through signing of in service, verbalization of understanding. All licensed nurses will notify DON/Administrator/Physician/Family regarding change in conditions. The ADON/DON will audit all skin assessments daily in morning clinical meetings to ensure compliance. 14. Team members will receive required training prior to their shifted. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 7/12/2023 at 4:00pm and conducted an Ad HOC QAPI regarding the change in condition and skin assessment protocol. The Medical Director was notified about the immediate Jeopardy on 7/13/2023 at 1:30pm, the Plan of removal was reviewed with IDT Team and Medical Director. Involvement of QAPI An Ad Hoc QAPI meeting was held with the Medical Director via phone, facility administrator, director of nursing, and social services director to review plan of removal on 7/13/2023 at 2:30pm. The Director of Nursing and Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 7/12/2023. Monitoring and reviewing skin assessment during clinical meeting to ensure compliance with facility policy. On 07/14/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the following documents, dated 07/12/23, were as follows: 1. The SBAR was completed. 2. A physician progress note was completed and addressed Resident #4's bruising. 3. The incident report was completed, and the physician, family, DON, and Administrator were notified. 4. New orders were obtained for labs. 5. The trauma assessment was completed. 6. The pain assessment was completed. 7. The care plan was updated, which included monitoring Resident #4's skin for bruising until healed and report abnormalities to the physician. 8. The therapy screen was completed. 9. The provider investigation report was completed. 10. The skin assessments were reviewed for all residents in the facility. 11. Skin sweeps were reviewed and completed for all residents in the facility. 12. Safe surveys for residents and staff were reviewed with no problems identified. 13. Ad Hoc QAPI plan was reviewed and completed with meeting minutes signed by the medical director, Administrator, DON, ADON, MDS, HR, AD, Maintenance, Social Worker, Dietary Manager, Medical Records, DOR, Housekeeping Supervisor, Business Office Manager, and RDO. Interviews with the Treatment Nurse (LVN L) and DON revealed one-on-one in-services were completed. During the interviews the Treatment Nurse and DON were able to correctly identify how to conduct a thorough skin assessment, how to accurately document a weekly skin assessment, changes in the skin, and care plan. Interviews of licensed nurses (LVN A, LVN E, LVN R, LVN S, LVN T, LVN U, RN B, RN O, RN P, RN Q, MDS Nurse, and the ADON) were performed. During the interviews all licensed nurses were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, and documenting the change of condition. All licensed nurses were able to correctly identify when skin assessments should be completed and how to conduct a thorough skin assessment, what should be documented on a skin assessment, changes in the skin, and updating the care plan. All licensed nurses were able to correctly identify how to recognize changes for resident's taking an anticoagulant medication, proper monitoring, orders, and following the care plan. All licensed nurses were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All licensed nurses were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. Interview of clinical licensed staff (CNA D, CNA K, CNA N, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, CNA CC, CNA DD, CNA EE, CNA FF, MA V, and MA W) were performed. During the interviews all clinical licensed staff were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All clinical licensed staff were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, documenting the change of condition, and who to report a change of condition to. All clinical licensed staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. Interviews of staff (BOM, HR, Receptionist, Maintenance Supervisor, Housekeeping Supervisor, Dietary Manager, Social Worker, AD, Housekeeper GG, Housekeeper HH, Housekeeper KK, LA LL, LA MM, [NAME] NN, [NAME] OO, [NAME] PP, DA QQ, and DA RR) were performed. During the interviews all staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. On 07/14/23 at 11:56 AM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 13 (Resident #4) residents reviewed for quality of care. 1. The facility failed to intervene when Resident #4, who was taking an anticoagulant medication (blood thinner that works by preventing red blood cells from forming clots), had increased bruising, which indicated a change of condition. 2. The facility did not ensure LVN L, who was the treatment nurse, accurately performed weekly skin assessments. An Immediate Jeopardy (IJ) situation was identified on 07/13/23 at 9:30 AM. While the IJ was removed on 07/14/23 at 11:56 AM, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at an increased risk for adverse reactions while taking an anticoagulant medication (blood thinners), such as severe bruising, external or internal bleeding, or death. The findings included: Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), history of cerebral infarction (stroke), history of a heart attack, hypertension (high blood pressure), mitral (valve) stenosis (narrowing of the mitral valve of the heart that causes tiredness and shortness of breath), and congestive heart failure (progressive heart disease that affects pumping action of the heart muscles). Record review of the MDS assessment, dated 05/30/23, revealed Resident #4 had clear speech and was usually understood by staff. The MDS revealed Resident #4 was usually able to understand others. The MDS revealed Resident #4 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #4 had no behaviors or refusal of care. The MDS revealed Resident #4 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene with a one or two staff assistance. Record review of the comprehensive care plan, revised on 01/28/23, revealed Resident #4 was on anticoagulant therapy. The interventions included Monitor/document/report to the doctor as needed for signs and symptoms of anticoagulant complications: .bruising . Record review of the order summary report, dated 07/12/23, revealed Resident #4 had an order, which started on 12/14/21, for Anticoagulant Monitoring - Place letter of symptoms of excess bleeding .every shift .F. bruising. The orders also revealed an order, which started on 12/13/21, for Aggrenox (blood thinner) Capsule 25-200 mg by mouth two times a day for blood thinner. Record review of the Nurse Administration Record, dated July 2023, revealed bruising was present on the following dates: 07/01/23, 07/03/23, 07/04/23, 07/05/23, 07/06/23, and 07/11/2023. The Nurse Administration Record did not specify the location of the bruising. Record review of the Weekly Skin Check, dated 07/04/23, revealed Resident #4 had no bruising. Record review of the CNA Shower Report, dated 07/10/23, revealed Resident #4 had no skin problems. Record review of the Weekly Skin Check, snipped on 07/11/2023 at 5:27 PM, revealed Resident #4 had no bruising. During an interview on 07/11/23 at 5:55 PM, a copy of Resident #4's Weekly Skin Check dated 07/11/23 was requested from the DON. Record review of the Weekly Skin Check provided by the facility, dated 07/11/23, revealed Resident #4 had the following newly documented skin problem areas: reddish, burgundy discoloration to back of left hand, front of right shoulder, left lower leg (below the knee), front of the left leg (above the knee), front of the right leg (above the knee), and the upper inner arm; bright reddish tint to right and left heel; small scabbing to second right toe and small scabbing to first, second, and fifth toes; red linear scratch to left shoulder in the front; and purplish discoloration to right lateral foot below the fifth toe. Record review of the Weekly Wound Progress, dated 07/12/23, revealed scabbing to toes that measured pinpoint; multiple areas or discoloration to left leg below that knee that measured scattered; discoloration to bottom of right foot 5th toe that measured 2.5 cm x 1.5 cm; linear scratch to left front of shoulder that measured 3.5 cm x 0.1 cm; dicoloration to right upper arm that measured 6 cm x 5.5 cm; discoloration to left anterior leg above the knee that measured 16 cm x 18.5 cm; disocloration to right anterior leg above the knee with scabbing that measured 11.5 cm x 9 cm; discoloration to right front shoulder that measured 4 cm x 3 cm; discoloration to back of left hand that measured 2 cm x 3 cm. During an observation and attempted interview on 07/10/23 at 9:09 AM, Resident #4 was laying in her bed with her bed sheets pulled up. She was moving her legs up and down and holding the bed sheets in her hands close to her face. Resident #4's arms and legs were visible from the door and several large, reddish-purple bruises were observed to Resident #4's upper legs and arms. Resident #4 was unable to remember how the bruising occurred and stared at the surveyor when questions were asked. During an interview on 07/12/23 at 12:02 PM, LVN L stated she was the treatment nurse at the facility and had worked at the facility since March of 2022. LVN L stated Resident #4 had discoloration to several areas on her skin. LVN L said she was unable to call the discoloration a bruise because bruising was usually blue, green, or reddish-purple and the discoloration on Resident #4 was reddish burgundy. LVN L stated when she completed the weekly skin assessments, she was only documenting skin impairments on the form. LVN L stated skin impairments were areas on the skin that required a treatment. LVN L stated she did not document areas on the skin that did not require a treatment, such as bruising. LVN L stated she was asked by the DON to reopen her skin assessment and document a complete head to toe assessment because the state agency wanted them to. LVN L stated Resident #4 had the discoloration and skin problems prior to 07/11/23, when they were documented. However, the skin issues did not require a treatment, so they were not documented on the weekly skin assessment. LVN L stated Resident #4 has always had terrible skin and the discoloration came and went frequently. LVN L stated she was unsure if Resident #4 was taking a blood thinning medication. LVN L stated she had not notified anyone of Resident #4's new skin areas of discoloration. LVN L stated the facility staff were aware of Resident #4's skin status because it had been discussed several times, especially regarding transfers. LVN L stated if Resident #4 had a history of discoloration and skin problems that should have been addressed on the care plan. LVN L stated she was unsure how the areas of discoloration occurred on Resident #4's skin. LVN L stated the discoloration had been present since she started working at the facility but had come and went in the same area. LVN L was unable to say if the discoloration was the same or was in the same area. During an interview on 07/12/23 at 12:20 PM, the ADON stated she used to be the treatment nurse at the facility. The ADON stated weekly skin assessments should have been a complete head to toe assessment, to include discoloration or bruising. The ADON stated new bruising or discoloration should have been monitored for 72 hours, initially, then weekly on the skin assessments. The ADON stated new bruising or discoloration should have been reported to the physician. During an interview on 07/12/23 at 1:44 PM, the DON stated the treatment nurse was responsible for ensuring weekly skin assessments were completed. The DON stated she expected all skin integrity issues to be documented, which included bruising or areas or discoloration. The DON stated she did not ask the treatment nurse to reopen her skin assessment. The DON stated it was a miscommunication because she thought it was requested by the state agency. The DON stated a one-on-one in-service on accurately completing and documented skin assessments was given to the treatment nurse on 07/12/23 and prior to that she was provided training by the ADON on how to perform skin assessments when she was hired at the facility. The DON stated Resident #4 had long-term, recurring bruising and discoloration. The DON stated Resident #4 should have had a care plan in place to address recurrent bruising. The DON was unsure why Resident #4 did not have a care plan in place to address recurrent bruising. The DON was unsure if Resident #4 was taking a blood thinning medication. The DON stated she was unaware of Resident #4's increased bruising until this week. The DON stated she expected staff to monitor for increased bruising, especially if a resident was taking a blood thinning medication. The DON stated she expected staff to monitor for bruising and other signs of bleeding every shift for residents taking a blood thinning medication. The DON stated an increase in bruising for resident's taking a blood thinning medication should have been reported to the physician, as soon as it was noticed, because it would have been considered a change of condition. The DON stated the increased bruising for Resident #4 was reported to the physician on 07/12/23 and a new order for a STAT CBC and PT/INR was obtained. The DON stated it had not been reported to physician prior to 07/12/23. The DON stated documenting bruising on the weekly skin assessment, anticoagulant monitoring every shift, and reporting increased bruising to the physician were important to monitor and follow up on side effects of blood thinning medications such as bruising, metabolic functions, and fragile skin. During an interview on 07/12/23 at 2:32 PM, Physician M stated he had been caring for Resident #4 for the last 15 to 20 years. Physician M stated Resident #4 had a history of minor skin areas such as small areas of bruising and skin tears, because of the tremors and fidgeting caused by Parkinson's disease. Physician M stated Resident #4 was taking a blood thinner called Aggrenox which had aspirin in it. Physician M stated Resident #4 was at an increased risk for GI bleeding, bruising, and bleeding because she was taking a blood thinning medication. Physician M stated he was notified on 07/12/23 for the increased bruising on Resident #4. Physician M stated he looked at it while he was making rounds and stated he believed it was bruising and it was on her left shoulder and elbow and right and left thighs. Physician M stated the bruising was not concerning or suspicious of abuse because there were no shapes or fingerprints. Physician M stated he wanted to be notified of increased bruising for residents who were taking a blood thinning medication as soon as it was noticed so he could have ordered some lab work to rule out acute or worsening medical problems. Physician M stated he ordered some STAT labs, which included a CBC to check for platelets and red blood cells, a CMP to check for protein, and a PT/INR to check for clotting factors. Record review of the lab results, dated 07/12/23 at 5:01 PM, revealed on the CBC, Resident #4 had a low red blood cell count 3.2 (normal 3.8 - 5.1), hemoglobin (iron-containing oxygen carrying protein found in red blood cells) 8.8 (normal 11.6 - 15.4), and hematocrit (volume percentage of red blood cells) 28.0 (normal 34-45). The CMP revealed Resident #4 had a low total protein 5.5 (normal 5.7 - 8.0). The PT/INR revealed Resident #4 had a high PT 12.4 (normal is 9.0 to 12.0). During an interview on 07/12/23 at 5:59 PM, Physician M stated Resident #4 had some anemia by looking at the CBC. Physician M said the protein (on the CMP) was a little off but still good. Physician M stated the INR was normal and the PT was only elevated by 0.4 which was not concerning. Physician M stated he wanted the facility to keep monitoring the bruising and to repeat the CBC in one week because Resident #4 might need a blood transfusion, which could indicate bleeding. Physician M stated he wanted to be notified of any changes. During an interview on 07/12/23 at 6:03 PM, CNA N stated he worked 2-10 shift on 07/10/23 and 7/11/23. CNA N stated he helped the treatment nurse with Resident #4's skin assessment on 07/11/23 after the supper meal. CNA N stated during the skin assessment on 07/11/23 was the first time he had noticed bruising on Resident #4, but she did have a history of bruising on and off. CNA N stated he was unsure how Resident #4 received the bruising to her arms and legs. CNA N stated he worked on a different hall on 07/10/23. CNA N stated he would have reported the bruising to the charge nurse if he would have noticed it. CNA N stated the treatment nurse was aware of the bruising, so he did not have to report it. During an interview on 07/12/23 at 6:16 PM, LVN E stated she normally worked with Resident #4. LVN E stated the bruising to Resident #4 had been there but was unable to say for how long. LVN E stated the bruising was present on 07/10/23 (Monday) but she believed the bruising had been documented on a skin assessment. LVN E stated it was normal for Resident #4 to bruise easily because she was on a blood thinner. LVN E stated she was unsure how Resident #4 received the bruising on her arms and legs. LVN E stated she monitored for signs and symptoms of bleeding on the anticoagulant monitoring form that was on the Nurse Administration Record. LVN E stated the bruising was normal for Resident #4 and she did not document on the anticoagulant monitoring form. LVN E stated the physician should have been notified any time a new bruise or skin problem was identified. LVN E stated it was important to notify the physician for signs of bleeding so lab work could have been ordered to check for internal bleeding and medication could have been adjusted as it was needed. LVN E stated it was important to monitor and follow up with Resident #4 for signs and symptoms of bleeding, which included increased bruising because she could have had internal bleeding. LVN E stated it was important to document bruising so it could have been monitored and followed up on. During an interview on 07/13/23 at 1:39 PM, CNA C stated she worked Resident #4's hall on 07/10/23 and she had discoloration to her upper and lower limbs. CNA C she did not report the discoloration to the charge nurse because it had been reported previously and the charge nurse was aware. CNA C was unsure who reported the discoloration previously. CNA C stated she was unsure how the discoloration to Resident #4's arms and legs occurred. CNA C stated Resident #4 had other signs of bleeding. CNA C stated it was important to document and report new bruising to the charge nurse because it could have been a change of condition and the charge nurse would want to be aware. Record review of the Change of Condition Notification policy, revised 06/2020, revealed I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent an acute change of condition (ACOC). The policy further revealed I. The Licensed Nurse will notify the resident's Attending Physician when there is an A. Incident/accident involving the resident; B. an accident involving the resident which results injury and has the potential for requiring physician intervention; C. A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions, or clinical complications; D. A need to alter treatment significantly . Record review of the Anticoagulant Therapy policy, revised 06/2020, revealed VI. Complete a head-to-toe assessment of the resident. Document any pre-existing bruising. VII. Initiate the care plan following initiation of anticoagulant therapy. The policy further revealed XI. Educate the resident and family regarding the side effects and adverse drug effects of anticoagulant therapy. The policy did not address monitoring for signs and symptoms of bleeding or bruising. The Administrator was notified on 07/13/23 at 10:53 AM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 07/13/23 at 10:57 AM and the plan of removal was requested. The facility's Plan of Removal was accepted on 07/13/23 at 8:47 PM and included: 1. Immediate action(s) taken for the resident(s) found to have been affected include: 1. Resident Notification to Family Treatment nurse at 1:59pm attempted left message and 2:02pm family called back and was notified by ADON, Medical Director/Physician 7-12-23 ADON 1:25pm 2. SBAR (change in condition) Completed 7-12-23 ADON 1:25pm 3. Medical Director / Physician Evaluated Resident for changes in condition related to bruises 7-12-23 1:45pm 4. New orders to monitor bruising, Labs - CBC/INR Orders 7-12-23 1:25pm Labs Drawn at 2:21PM on 7-12-23 and results received at 3:21PM and MD notified 3:25pm and order to repeat CBC in one week received. 5. Trauma Assessment completed 7-12-23 Charge Nurse LVN A 1:47 PM 6. Pain Assessment completed 7-12-23 Charge Nurse LVN A 1:45pm 7. Care Plan Updated 7-12-23 MDS Nurse, Added Skin Care BUE/BLE Bruising- updated with Intervention monitoring skin for the bruising until healed and report abnormality to MD. 8. Therapy Screening completed 7-12-23 RN DON 3:57pm and Therapy screened completed DOR COTA on 7-12-23 7:15pm, Resident is on services as of 7-13-23 on OT services. 9. Incident Report ADON LVN 7-12-23 at 6:42pm Self-Report Completed 7-12-23 by the Administrator 3:21PM 10. Skin assessment conducted for all residents that resided in the facility completed 7-12-23 7:30pm completed by Charge Nurse A LVN, Charge Nurse B LVN, all undocumented concerns were reported to MD/Families by LVN ADON, and RN DON completed by 7-13-23 by 4:00pm Include actions that were performed toa address to citation: 7-13-23 11:00am 1. Facility Wide Resident Skin Sweep completed 7-12-23 Charge Nurses A LVN, Charge Nurse LVN B, completed at 7:30pm 2. Safe Survey with residents that are cognitively intact. 7-13-23 at 1:47pm by Social Worker completed at 4:00pm 3. Staff Safe Survey completed 7-13-23 Administrator and Regional Director of Operations started at 12:25pm completed at 3:45pm 4. One on One Inservice with treatment nurse on skin assessment initiated 4:00pm and completed on 7-12-23 conducted by DON RN completed 4:30pm on 7-12-23, Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan and job duties. 5. One on One Inservice with DON conducted by Regional Nurse Consultant on change in condition/skin assessment and notification. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Initiated 3:00pm 7-12-23 and completed on 7-12-23 3:30pm. Regional Nurse Consultant 6. In-services for licensed nursing staff on Skin Assessment/Skin initiated on 7/13/2023 at 11:45am by Regional Nurse Consultant. Training consisted of how to conduct a thorough skin assessment, documentation, weekly skin assessment, changes in skin and care plan. Completed 7-13-23 5:00pm. 7. Training for licensed staff was initiated 7-12-23 at 11:45am on Anticoagulant monitoring/documentation timely and accurately 7-13-23 at 5:00pm. Training consisted of how to recognize changed with anticoagulant, monitoring, and orders and care plan in place. 8. Training for licensed staff was initiated 7-12-23 at 11:45am on Following care plan of anticoagulant completed 7-13-23 at 5:00pm. Training consisted of the following care plan. 9. Training for Clinical Licensed staff was initiated 7-12-23 at 11:45am on ADL transfers, this Inservice training consisted of transfer safety and how to conduct proper transfers. This Inservice was conducted at a precaution. Training completed on 7-13-23 at 5:00pm. 10. Training for Clinical Licensed staff was initiated on 7/12/23 at 11:45am, on Notification of Change completed on 7/13/23 at 5:00pm. This training includes what is a change in a condition, proper notification, reported and documentation of change in conditions. 11. Training with facility staff was initiated on 7/12/23 at 11:45am, by DON on Abuse and Neglect. This training includes what is abuse and neglect, procedures of abuse and neglect, reporting of abuse and the abuse coordinator, completed on 7/13/23 at 5:00pm. 12. All new hires will be educated on abuse and neglect protocol/change in condition/skin assessment, and anticoagulant ongoing. 13. The ADON and Director of Nursing will ensure competency through signing of in service, verbalization of understanding. All licensed nurses will notify DON/Administrator/Physician/Family regarding change in conditions. The ADON/DON will audit all skin assessments daily in morning clinical meetings to ensure compliance. 14. Team members will receive required training prior to their shifted. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 7/12/2023 at 4:00pm and conducted an Ad HOC QAPI regarding the change in condition and skin assessment protocol. The Medical Director was notified about the immediate Jeopardy on 7/13/2023 at 1:30pm, the Plan of removal was reviewed with IDT Team and Medical Director. Involvement of QAPI An Ad Hoc QAPI meeting was held with the Medical Director via phone, facility administrator, director of nursing, and social services director to review plan of removal on 7/13/2023 at 2:30pm. The Director of Nursing and Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 7/12/2023. Monitoring and reviewing skin assessment during clinical meeting to ensure compliance with facility policy. On 07/14/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the following documents, dated 07/12/23, were as follows: 1. The SBAR was completed. 2. A physician progress note was completed and addressed Resident #4's bruising. 3. The incident report was completed, and the physician, family, DON, and Administrator were notified. 4. New orders were obtained for labs. 5. The trauma assessment was completed. 6. The pain assessment was completed. 7. The care plan was updated, which included monitoring Resident #4's skin for bruising until healed and report abnormalities to the physician. 8. The therapy screen was completed. 9. The provider investigation report was completed. 10. The skin assessments were reviewed for all residents in the facility. 11. Skin sweeps were reviewed and completed for all residents in the facility. 12. Safe surveys for residents and staff were reviewed with no problems identified. 13. Ad Hoc QAPI plan was reviewed and completed with meeting minutes signed by the medical director, Administrator, DON, ADON, MDS, HR, AD, Maintenance, Social Worker, Dietary Manager, Medical Records, DOR, Housekeeping Supervisor, Business Office Manager, and RDO. Interviews with the Treatment Nurse (LVN L) and DON revealed one-on-one in-services were completed. During the interviews the Treatment Nurse and DON were able to correctly identify how to conduct a thorough skin assessment, how to accurately document a weekly skin assessment, changes in the skin, and care plan. Interviews of licensed nurses (LVN A, LVN E, LVN R, LVN S, LVN T, LVN U, RN B, RN O, RN P, RN Q, MDS Nurse, and the ADON) were performed. During the interviews all licensed nurses were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, and documenting the change of condition. All licensed nurses were able to correctly identify when skin assessments should be completed and how to conduct a thorough skin assessment, what should be documented on a skin assessment, changes in the skin, and updating the care plan. All licensed nurses were able to correctly identify how to recognize changes for resident's taking an anticoagulant medication, proper monitoring, orders, and following the care plan. All licensed nurses were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All licensed nurses were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. Interview of clinical licensed staff (CNA D, CNA K, CNA N, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, CNA CC, CNA DD, CNA EE, CNA FF, MA V, and MA W) were performed. During the interviews all clinical licensed staff were able to correctly identify how to transfer resident's properly and safely using a gait belt and Hoyer lift. All clinical licensed staff were able to correctly identify when to notify and report to the physician a resident's change in condition, what constitutes a change of condition, including bruising, documenting the change of condition, and who to report a change of condition to. All clinical licensed staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. Interviews of staff (BOM, HR, Receptionist, Maintenance Supervisor, Housekeeping Supervisor, Dietary Manager, Social Worker, AD, Housekeeper GG, Housekeeper HH, Housekeeper KK, LA LL, LA MM, [NAME] NN, [NAME] OO, [NAME] PP, DA QQ, and DA RR) were performed. During the interviews all staff were able to correctly identify the different types of abuse, when to report abuse, the abuse coordinator, and abuse procedures for an injury of unknown origin. On 07/14/23 at 11:56 AM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.