**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change for one (Resident #1) of four residents reviewed for notification of changes. The facility failed to notify the NP when Resident #1's diabetic pump malfunctioned in July of 2025. Resident #1's blood sugar readings were sporadically out of range which led her to experience increased dizziness, nausea, and sweatiness. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/25 PM and a template was provided. While the IJ was removed on 08/01/25 at 2:13 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of DKA, dizziness, nausea, and a decreased quality of life. Findings included:Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type I diabetes, gastroparesis (a condition in which the muscles in the stomach do not move well), chronic kidney disease, and muscle weakness. Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Section N (Medications) reflected she received insulin injections since admission. Review of Resident #1's admission care plan, dated 06/30/25, reflected there was not a focus regarding her being a diabetic or having an insulin pump. Review of Resident #1's physician order, dated 07/03/25, reflected the following: Dexcom G7 Receiver Device (Continuous Glucose System Receiver) - Apply to bar of upper arm topically one time a day every 10 day(s) for DM management. Review of Resident #1's TAR, July of 2025, reflected the receiver was changed on 07/03/25 and 07/13/25. Review of Resident #1's physician order, dated 07/01/25, reflected the following: Omnipod 5 Libre2 Plus G6 Kit (Insulin Infusion Disposable Pump) - Inject 200 ml subcutaneously one time a day every 3 day(s) for DM management. Review of Resident #1's MAR, July of 2025, reflected insulin was placed in the pump on 07/01/25, 07/04/25, 07/10/25, and 07/14/25. It reflected she refused on 07/07/25. Review of Resident #1's physician order, dated 07/01/25, reflected Glucagon Emergency Kit 1 MG - Inject 1 mg intramuscularly as need for hypoglycemia per protocol if patient is unconscious or unable to swallow. Review of Resident #1's MAR, July of 2025, reflected she was administered the Glucagon three times: 07/08/25 at 4:36 AM - BS: 7407/09/25 at 4:48 PM - BS: 5307/11/25 at 3:49 AM - BS: 65 Review of Resident #1's blood sugar readings in her EMR, from 07/01/25 - 07/15/25, reflected the following days/times her blood sugar was abnormally out of normal the range (normal range is 70 mg/dL -100 mg/dL): 07/01/25 10:43 PM - 42.0 mg/dL07/05/25 6:21 PM - 300.0 mg/dL07/06/25 6:33 AM - 326.0 mg/dL07/09/25 4:49 PM - 52.9 mg/dL07/13/25 8:55 PM - 350.0 mg/dL07/14/25 7:09 AM - 400.0 mg/dL07/14/25 12:09 PM - 399.0 mg/dL Review of Resident #1's physician order, dated 07/15/25, reflected to d/c insulin pump. Review of Resident #1's physician order, dated 07/15/25, reflected HumaLOG KwikPen Subcutaneous Solution Pen-inject 100 UNIT/ML - Inject subcutaneously before meals for DM. Review of Resident #1's physician order, dated 07/15/25, reflected Lantus Subcutaneous Solution 100 UNIT/ML - Inject 10 unit subcutaneously in the morning for DM - hold if BG is less than 110. During a telephone interview on 07/15/25 at 12:23 PM, Resident #1's NP stated she had been working with the facility for about a week but was familiar with Resident #1. She stated she had a conversation with her that morning (on 07/15/25) and there were concerns that the pump was not functioning the way it should be, so she put in orders to discontinue the pump. She stated she should not have it on her if it was not working. She stated she ordered a sliding scale to better manage her blood sugars. She stated the staff had been informing her of general concerns regarding Resident #1 such as refusing showers and not eating much of her meals, but they had not mentioned irregular blood sugar readings. She stated if she had been, she would have discontinued the pump sooner. She stated if the pump was not working, a negative outcome could be potentially all the negative things with diabetes. She stated there was not a way to check those pumps in these environments. During a telephone interview on 07/15/25 at 12:38 PM, RN A stated she was very familiar with Resident #1. She stated since she had a pump, she would tell the nurses what her blood sugar was, and they would document it. She stated her biggest concern was that the nurses did not know what the pump was set at, so they did not know how much insulin she was getting. She stated Resident #1 had also not been eating much and that was a problem as well. She stated she did relay to the NP that she was not eating but not about the irregular blood sugar readings. She stated a few days prior in the morning (could not remember date), her blood sugar was 400 and she realized the pump was off. She stated there had been a time when her blood sugar was in the 60's and she realized it was not working and changed it out. She stated the day prior, 07/14/25, she had never seen Resident #1 with so much anger. She stated she was mad her pump was off and was not getting the insulin she needed. She stated she notified the NP who said she was going to put her on a sliding scale. She stated insulin pumps were rare in nursing facilities because they are hard to regulate. She stated Resident #1 had a history of being nauseous and did not notice an increase when her blood sugars were extremely high or extremely low. During an interview on 07/15/25 at 12:58 PM, Resident #1 stated the NP saw her that morning and discontinued her insulin pump. She stated that was what she requested because she was having a hard time keeping her blood sugar level up. She stated when it would get really high or really low, she would get extremely nauseated, more than normal. She stated she would get sweaty, dizzy, and was miserable. She stated she had difficulty sleeping and the nurses were aware.During an interview on 07/15/25 at 2:00 PM, the DON stated she had been working at the facility for about a month. She stated if Resident #1's blood sugar was in the 300-400 range that would be abnormal for her. She stated if it were her, she would have rechecked her blood sugar in an hour with one of their glucometers because the insulin pumps were not always accurate. She stated she would expect the nurses to follow-up on the blood sugar and notify the NP. She stated if she had known her blood sugar had not been stable, she would have spoken to the NP sooner about getting the pump discontinued and getting her on a sliding scale. She stated with really high or low blood sugar, a negative outcome could be DKA or feeling really hot or dizzy. During an interview on 07/30/25 at 12:52 PM, RN A stated there was a time (could not remember the date) when Resident #1's diabetic pump had been turned off or was not working properly. She stated she was not trained on the pump and had read the instructions inside the monitor's box on how to apply a new one. She stated the monitoring was being done on Resident #1's phone and she would go into her room every morning to the blood sugar readings off her phone so that she could document the numbers. She stated prior to the removal of her pump, there were no parameters of when to notify the NP in the (electronic monitoring system). She stated after it was removed, she was put on a sliding scaled and nursing staff were in-serviced to notify the NP if her blood sugar was above 400. During an interview on 07/30/25 at 1:13 PM, RN B stated she started working at the facility about two weeks prior and did not work with Resident #1 when she had the insulin pump. She stated when she was hired, she was in-serviced on rechecking the blood sugar when a reading was too high or too low to ensure the reading was accurate. She stated she the in-service also included when to notify the NP (blood sugar above 400). She stated she could not recall if the in-serviced including applying a sensor or pump. During an interview on 07/30/25 at 1:24 PM, RN C stated she had not worked with Resident #1. She stated a few weeks ago (could not remember the date), the DON present an in-service on insulin pumps and continuous glucose monitoring. She stated if there was a high reading (above 400), they would need to do a finger stick to have a comparison reading and then notify the NP. She stated if a resident was being administered insulin, there needed to be parameters in their chart of when to notify the NP if a reading was out of range. She stated if there were no parameters listed, the nurses needed to reach out the NP to get those parameters. She stated if a resident's blood sugar was too high or too low, they could experience increased confusion, drowsiness, and dizziness. During an interview on 07/30/25 at 1:33 PM, the DON stated the glucose monitoring devices/pumps were pretty self-explanatory and had directions in the box. She stated the staff had to read the device instructions to be able to apply it. She stated she was not at the facility at the time that it had to be applied to Resident #1 after it was found nonfunctional, so she did not check or verify that the new one was functioning. She stated she conducted an in-service to nurses on 07/15/25 on what to do if blood sugars were out of range on a Dexcom or Libre and they were required to re-check with a finger stick. She stated there was no in-service conducted on the application of the device itself (when Resident #1 was admitted ). She stated it was her expectation that there be parameters in residents' charts for glucose readings especially if there were fluctuating high and low numbers like she (Resident #1) did. She stated that was her expectation and felt like my nurses all knew that. She stated residents could experience out of parameter symptoms such as being hot or cold, clammy, thirsty, dizziness, and as nurses, we knew to look for those symptoms as they were very educated and taught that in nursing school. She stated there were no diabetic pumps currently in the facility and those devices were not seen much in nursing facilities. She stated if another resident was admitted with one, she would ensure parameters were in place and ensure glucose levels were checked manually AC and HS and that the NP was involved. She stated she would conduct in-services regularly on parameters, monitoring, and what to do if out of range. Review of the facility's undated Change in a Resident's Condition or Status Policy, reflected the following: Our facility shall promptly notify the reside, his or her Attending Physician, and representative of any changes in the resident's medical/mental condition and/or status.The ADM and DON were notified on 07/30/25 at 2:14 PM that an IJ had been identified and an IJ template was provided.The following POR was approved on 07/31/25 at 3:50 PM: IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEPOARDY:On July 30,2025 at approximately 3:00 pm the following actions were initiated upon facility identification of concern. Action: Resident # 1 was assessed to ensure that the resident was not suffering from ongoing negative effects. Prior Glucose Dexcom Receiver Devise (Continuous Glucose System Receiver) was discontinued, and new orders were put in place for monitoring on 7.15.25. There are no other pumps in the facility at this time.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing Action: Director of Nursing was educated on Notification of Changes and Change of Condition protocols.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Clinical Services Action: All Nurses were educated on Notification of Changes. Nursing should also complete Change of Condition in system as well as notify physician and Director of Nursing. Certified Medication Aides and Certified Nursing Aides were also educated on Notifying Charge Nurse of any Change in Condition.Start Date: 7/30/2025Completion Date: This was initiated and completed on 7/30/2025. The Director of Nursing/designee will utilize staff roster to track those who have received education and to determine those who still require it. Anyone not able to be reached by phone or in person, agency and new nurses will be educated prior to the start of their next shift. Responsible: Director of Nursing IDENTIFICATION OF OTHER AFFECTED: All residents with diabetes have the potential to be affected by the alleged deficient practice. Action: Review of 22 residents who have diabetes diagnoses for proper orders and hypo/hyper glycemic protocols in place and care planned. Three were sent to MD to review and see if any orders wanted to be changed. One change to a sliding scale, one added accucheck schedule. The third one we are requesting labs. Nurse will inform physician when admissions occur and go over any devices to ensure proper monitoring and orders are in place.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing SYSTEMIC CHANGES AND/OR MEASURES: Action: ADHOC QAPI was performed for blood glucose monitoring and how to proceed with equipment failure. To perform in service and training to nurses. All residents with accuchecks will be audited to ensure appropriate orders are in place.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing Action: All residents that with diabetes were audited to ensure checks were occurring and that hypo/hyper glycemic protocols were in placed and care planned. Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing TRACKING AND MONITORING: Action: Change of Condition will be monitored by running 24 hour report and order listing report. This will be completed daily for a week, then biweekly for 2 weeks, then monthly for 2 months. This will be kept on a log.Start Date: 7/30/2025Completion Date: 7/30/2025. Responsible Party: Director of Nursing/DesigneeAction: Any new admissions will be reviewed by Director of Nursing/Designee to ensure physician is aware of any devices and that proper orders are in place. This review will take place daily for 2 weeks, then biweekly for 2 weeks, then monthly for 2 months. Any noncompliance will be communicated to nurse responsible and counseled accordingly. This will be tracked on a log.Start Date: 7/30/2025Completion Date: 7/31/2025. Responsible Party: Director of Nursing/DesigneeAction: Implemented interventions immediately if notifications have not been made to the provider of any suspected change in condition. Documentation of notifications made to resident/representative and physician will be noted in the resident's electronic medical record to include alert charting for change in condition if warranted. Staff responsible for the deficient practice will be contacted and counseled accordingly.Start Date: 7/30/2025Completion Date: 7/30/2025. Responsible Party: Director of Nursing/DesigneePlease accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued 7/31/2025. The Surveyor monitored the POR from 07/31/25 - 08/01/25 as followed: During interviews on 08/01/25 from 11:54 AM - 1:05 PM with staff from all shifts - RN A, RN B, RN D, MA E, MA F, CNA G, and CNA H all stated they had been in-serviced before their shifts by the DON. The CNAs and MAs stated they closely monitored the residents for any changes in condition or changes from their baselines. The CNAs and MAs stated they would notify their nurse immediately of any changes and would document in their documenting system. The RNs stated they were in-serviced on changes in condition and notifying the NP/MD immediately. The RNs stated if a residents BS readings were not within parameters it was important for the NP/MD to be informed and for a change of condition form to be completed in their charts. During an interview on 08/01/25 at 1:30 PM, the DON stated Resident #1 remained on long-acting insulin. She stated Resident #1 had type I diabetes and her pancreas did not work, so in her case her blood sugar would remain and, go up and down, and will always have to be closely monitored. She stated she and the ADM were in-serviced by their corporate nurse before providing education to the staff on notification on changes in condition. She stated any time a resident's blood sugar was outside of the parameters, the physician needed to be notified. During an interview on 08/01/25 at 1:38 PM, the ADM stated she and the DON were in-serviced by their DCS on notification of changes in condition before the staff were in-serviced. She stated 94% of the nursing staff had been in-serviced, and none could work the floor until they were.Review of Resident #1's physician order, dated 07/22/25, reflected record blood sugar AC/HS (before meals and at bedtime for monitoring). Review of Resident #1's physician order, dated 07/35/25, reflected HumaLOG Injection Solution - 100 UNIT/ML - Inject subcutaneously before meals for DM. Review of Resident #1's physician order, dated 08/01/25 reflected Insulin Glargine Subcutaneous Solution - 100 UNIT/ML - Infect 14 units subcutaneously in the morning for DM1. Hold if less than 110. Review of the facility's ADHOC meeting agenda, dated 07/30/25, reflected the ADM, DON, MDSC, DOR, and MD were in attendance. Review of an in-service, dated 07/30/25 and conducted by the DCS, reflected the ADM and DON were in-serviced on NP notification of changes with a key point: A malfunctioning diabetic pump and/or elevated blood glucose levels require immediate attention and notification to MD and nurse management. Provider and representative notification must be timely and clearly documented. Documentation should include date/time of change identification, communication, provider response, and new orders. Review of their monitoring audit tool for review the 24-hour report for any changes in condition, on 08/01/25, reflected three different residents had been sampled on 07/30/25 and 08/01/25. It reflected if there was a change in condition in 24 hours, order listing report reviewed, notifications completed, and corrective actions taken if change in condition was identified. Four residents were idented with a change of condition and corrective actions were taken and verified. Review of an in-service dated 07/30/25 - 08/01/25 and conducted by the DON, reflected all nursing staff were notified on of their Notification of Changes/Change in Condition Policy. The CNAs and MAs were expected to notify the nurses of any change and nurses were expected to complete a change of condition form and to notify the NP and DON.The ADM and DON were notified on 08/01/25 at 2:13 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. The facility failed to: - Notify Resident #1's NP when her diabetic insulin pump malfunctioned in July of 2025. - Ensure nursing staff were trained on Resident #1's insulin pump.- Ensure nursing staff were aware of how much insulin Resident #1 was receiving and not relying on her for blood sugar readings.- Ensure there were parameters in place on when to notify Resident #1's NP when her readings were abnormal.These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/25 at 2:14 PM and a template was provided. While the IJ was removed on 08/01/25 at 2:13 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of DKA, dizziness, nausea, and a decreased quality of life, and death. Findings included:Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type I diabetes, gastroparesis (a condition in which the muscles in the stomach do not move well), chronic kidney disease, and muscle weakness. Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Section N (Medications) reflected she received insulin injections since admission. Review of Resident #1's admission care plan, dated 06/30/25, reflected there was not a focus regarding her being a diabetic or having an insulin pump. Review of Resident #1's physician order, dated 07/03/25, reflected the following: Dexcom G7 Receiver Device (Continuous Glucose System Receiver) - Apply to bar of upper arm topically one time a day every 10 day(s) for DM management. Review of Resident #1's TAR, July of 2025, reflected the receiver was changed on 07/03/25 and 07/13/25. Review of Resident #1's physician order, dated 07/01/25, reflected the following: Omnipod 5 Libre2 Plus G6 Kit (Insulin Infusion Disposable Pump) - Inject 200 ml subcutaneously one time a day every 3 day(s) for DM management. Review of Resident #1's MAR, July of 2025, reflected insulin was placed in the pump on 07/01/25, 07/04/25, 07/10/25, and 07/14/25. It reflected she refused on 07/07/25. Review of Resident #1's physician order, dated 07/01/25, reflected Glucagon Emergency Kit 1 MG - Inject 1 mg intramuscularly as need for hypoglycemia per protocol if patient is unconscious or unable to swallow. Review of Resident #1's MAR, July of 2025, reflected she was administered the Glucagon three times: *07/08/25 at 4:36 AM - BS: 74*07/09/25 at 4:48 PM - BS: 53*07/11/25 at 3:49 AM - BS: 65 Review of Resident #1's blood sugar readings in her EMR, from 07/01/25 - 07/15/25, reflected the following days/times her blood sugar was abnormally out of normal the range (normal range is 70 mg/dL -100 mg/dL): *07/01/25 10:43 PM - 42.0 mg/dL*07/05/25 6:21 PM - 300.0 mg/dL*07/06/25 6:33 AM - 326.0 mg/dL*07/09/25 4:49 PM - 52.9 mg/dL*07/13/25 8:55 PM - 350.0 mg/dL*07/14/25 7:09 AM - 400.0 mg/dL*07/14/25 12:09 PM - 399.0 mg/dL Review of Resident #1's physician order, dated 07/15/25, reflected to d/c insulin pump. Review of Resident #1's physician order, dated 07/15/25, reflected HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML - Inject subcutaneously before meals for DM. Review of Resident #1's physician order, dated 07/15/25, reflected Lantus Subcutaneous Solution 100 UNIT/ML - Inject 10 unit subcutaneously in the morning for DM - hold if BG is less than 110. During a telephone interview on 07/15/25 at 12:23 PM, Resident #1's NP stated she had been working with the facility for about a week but was familiar with Resident #1. She stated she had a conversation with her that morning (on 07/15/25) and there were concerns the pump was not functioning the way it should be, so she put in orders to discontinue the pump. She stated she should not have it on her if it was not working. She stated she ordered a sliding scale to better manage her blood sugars. She stated the staff had been informing her of general concerns regarding Resident #1 such as refusing showers and not eating much of her meals, but they had not mentioned irregular blood sugar readings. She stated if she had been, she would have discontinued the pump sooner. She stated if the pump was not working, a negative outcome could be potentially all the negative things with diabetes. She stated there was not a way to check those pumps in these environments. During a telephone interview on 07/15/25 at 12:38 PM, RN A stated she was very familiar with Resident #1. She stated since she had a pump, she would tell the nurses what her blood sugar was, and they would document it. She stated her biggest concern was that the nurses did not know what the pump was set at, so they did not know how much insulin she was getting. She stated Resident #1 had also not been eating much and that was a problem as well. She stated she did relay to the NP that she was not eating but not about the irregular blood sugar readings. She stated a few days prior in the morning (could not remember date), her blood sugar was 400 and she realized the pump was off. She stated there had been a time when her blood sugar was in the 60's and she realized it was not working and changed it out. She stated the day prior, 07/14/25, she had never seen Resident #1 with so much anger. She stated she was mad her pump was off and was not getting the insulin she needed. She stated she notified the NP who said she was going to put her on a sliding scale. She stated insulin pumps were rare in nursing facilities because they are hard to regulate. She stated Resident #1 had a history of being nauseous and did not notice an increase when her blood sugars were extremely high or extremely low. During an interview on 07/15/25 at 12:58 PM, Resident #1 stated the NP saw her that morning and discontinued her insulin pump. She stated that was what she requested because she was having a hard time keeping her blood sugar level up. She stated when it would get really high or really low, she would get extremely nauseated, more than normal. She stated she would get sweaty, dizzy, and was miserable. She stated she had difficulty sleeping and the nurses were aware. During an interview on 07/15/25 at 2:00 PM, the DON stated she had been working at the facility for about a month. She stated if Resident #1's blood sugar was in the 300-400 range that would be abnormal for her. She stated if it were her, she would have rechecked her blood sugar in an hour with one of their glucometers because the insulin pumps were not always accurate. She stated she would expect the nurses to follow-up on the blood sugar and notify the NP. She stated if she had known her blood sugar had not been stable, she would have spoken to the NP sooner about getting the pump discontinued and getting her on a sliding scale. She stated with really high or low blood sugar, a negative outcome could be DKA or feeling really hot or dizzy. During an interview on 07/30/25 at 12:52 PM, RN A stated there was a time (could not remember the date) when Resident #1's diabetic pump had been turned off or was not working properly. She stated she was not trained on the pump and had read the instructions inside the monitor's box on how to apply a new one. She stated the monitoring was being done on Resident #1's phone and she would go into her room every morning to the blood sugar readings off her phone so that she could document the numbers. She stated prior to the removal of her pump, there were no parameters of when to notify the NP in the (electronic monitoring system). She stated after it was removed, she was put on a sliding scaled and nursing staff were in-serviced to notify the NP if her blood sugar was above 400. During an interview on 07/30/25 at 1:13 PM, RN B stated she started working at the facility about two weeks prior and did not work with Resident #1 when she had the insulin pump. She stated when she was hired, she was in-serviced on rechecking the blood sugar when a reading was too high or too low to ensure the reading was accurate. She stated she the in-service also included when to notify the NP (blood sugar above 400). She stated she could not recall if the in-serviced including applying a sensor or pump. During an interview on 07/30/25 at 1:24 PM, RN C stated she had not worked with Resident #1. She stated a few weeks ago (could not remember the date), the DON present an in-service on insulin pumps and continuous glucose monitoring. She stated if there was a high reading (above 400), they would need to do a finger stick to have a comparison reading and then notify the NP. She stated if a resident was being administered insulin, there needed to be parameters in their chart of when to notify the NP if a reading was out of range. She stated if there were no parameters listed, the nurses needed to reach out the NP to get those parameters. She stated if a resident's blood sugar was too high or too low, they could experience increased confusion, drowsiness, and dizziness. During an interview on 07/30/25 at 1:33 PM, the DON stated the glucose monitoring devices/pumps were pretty self-explanatory and had directions in the box. She stated the staff had to read the device instructions to be able to apply it. She stated she was not at the facility at the time that it had to be applied to Resident #1 after it was found nonfunctional, so she did not check or verify that the new one was functioning. She stated she conducted an in-service to nurses on 07/15/25 on what to do if blood sugars were out of range on a Dexcom or Libre and they were required to re-check with a finger stick. She stated there was no in-service conducted on the application of the device itself (when Resident #1 was admitted ). She stated it was her expectation that there be parameters in residents' charts for glucose readings especially if there were fluctuating high and low numbers like she (Resident #1) did. She stated that was her expectation and felt like my nurses all knew that. She stated residents could experience out of parameter symptoms such as being hot or cold, clammy, thirsty, dizziness, and as nurses, we knew to look for those symptoms as they were very educated and taught that in nursing school. She stated there were no diabetic pumps currently in the facility and those devices were not seen much in nursing facilities. She stated if another resident was admitted with one, she would ensure parameters were in place and ensure glucose levels were checked manually AC and HS and that the NP was involved. She stated she would conduct in-services regularly on parameters, monitoring, and what to do if out of range. Review of the facility's undated Change in a Resident's Condition or Status Policy, reflected the following: Our facility shall promptly notify the reside, his or her Attending Physician, and representative of any changes in the resident's medical/mental condition and/or status. Review of the facility's Blood Glucose Monitoring Policy, revised 05/13/25, reflected the following: For residents who have continuous glucose monitoring systems, blood glucose via glucometer for verification of results will be done as per physician order. Review of the facility's Insulin Pump Use Policy, dated 05/16/25, reflected the following: It is the policy of this facility to allow access to administration of insulin via insulin pump in order to meet the needs of residents requiring the use of insulin and to prevent adverse effects on a resident's condition.1. Insulin pump settings will be in accordance with physician's orders. Depending on the pump, settings may include: insulin correction factor, carbohydrate to insulin ratio, basal and bolus settings, maximum bolus limits, glucose goals, correction above what glucose value, target ranges, duration of insulin action, temporary basal and activity settings and pump software updates.2. A hypoglycemia management plan will be documented and followed per physician's orders.The ADM and DON were notified on 07/30/25 at 2:14 PM that an IJ had been identified and an IJ template was provided.The following POR was approved on 07/31/25 at 3:50 PM: IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEPOARDY:On July 30,2025 at approximately 3:00 pm the following actions were initiated upon facility identification of concern. Action: Resident # 1 was assessed to ensure that the resident was not suffering from ongoing negative effects. Prior Glucose Dexcom Receiver Devise (Continuous Glucose System Receiver) was discontinued, and new orders were put in place for monitoring on 7.15.25. There are no other pumps in the facility at this time.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing Action: Director of Nursing was educated on Insulin Pumps, Continuous Glucose Monitors and expectations when monitoring glucose and to check manually with glucometer if readings on a device are out of normal range.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Clinical Services Action: All Nurses were educated on Insulin Pumps, Continuous Glucose Monitors and expectations when monitoring glucose and to check manually with glucometer if readings on a device are out of normal range.Start Date: 7/30/2025Completion Date: This was initiated and completed on 7/30/2025. The Director of Nursing/designee will utilize staff roster to track those who have received education and to determine those who still require it. Anyone not able to be reached by phone or in person, agency and new hires will be educated prior to the start of their next shift. Responsible: Director of Nursing IDENTIFICATION OF OTHER AFFECTED: All residents with diabetes have the potential to be affected by this alleged deficient practice.Action: Review of 22 residents who have diabetes diagnoses for proper orders and hypo/hyper glycemic protocols in place and care planned. Three were sent to MD to review and see if any orders wanted to be changed. One changed to a sliding scale, one added accucheck schedule. The third one we are requesting labs today. Nurse will inform physician when admissions occur and go over any devices to ensure proper monitoring and orders are in place.Start Date: 7/30/2025Completion Date: 7/31/2025Responsible: Director of Nursing SYSTEMIC CHANGES AND/OR MEASURES: Action: ADHOC QAPI was performed for blood glucose monitoring and how to proceed with equipment failure. To perform in service and training to nurses. All residents with accuchecks will be audited to ensure appropriate orders are in place.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing Action: All residents with diabetes were audited to ensure checks were occurring and that hypo/hyper glycemic protocols were in placed and care planned. Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing TRACKING AND MONITORING: Action: Audits will be conducted on blood sugar monitoring daily for a week, biweekly for 2 weeks and then monthly for 2 months. This will be tracked on a log.Start Date: 7/30/2025Completion Date: 7/30/2025. Responsible Party: Director of Nursing/Designee Action: Any new admissions will be reviewed by Director of Nursing/Designee to ensure physician is aware of any devices and that proper orders are in place. This review will take place daily for 2 weeks, then biweekly for 2 weeks, then monthly for 2 months. Any noncompliance will be communicated to nurse responsible and counseled accordingly. This will be tracked on a log. Start Date: 7/30/2025Completion Date: 7/31/2025. Responsible Party: Director of Nursing/DesigneeThe Surveyor monitored the POR from 07/31/25 - 08/01/25 as followed: During interviews on 08/01/25 from 11:54 AM - 1:05 PM with staff from all shifts - RN A, RN B, RN D, MA E, MA F, CNA G, and CNA H all stated they had been in-serviced before their shifts by the DON. The CNAs and MAs stated they closely monitored the residents for any changes in condition or changes from their baselines. The CNAs and MAs stated they would notify their nurse immediately of any changes and would document in their documenting system. The RNs stated they were in-serviced on changes in condition and notifying the NP/MD immediately. The RNs stated if a residents BS readings were not within parameters it was important for the NP/MD to be informed and for a change of condition form to be completed in their charts. The nurses stated if a resident was on an insulin pump and their sugar level was too high or too low (out of parameters), they were to recheck it with glucometer to ensure accuracy. The nurses stated if they believed an insulin pump was malfunctioning, they would notify the DON and NP/MD immediately. The nurses stated any resident that was administered insulin should have parameters in place on when to notify the NP/MD. The nurses stated signs and symptoms of blood sugar being outside of parameters could be nausea, dizziness, lethargy, or being unable to swallow. During an interview on 08/01/25 at 1:30 PM, the DON stated Resident #1 remained on long-acting insulin. She stated Resident #1 had type I diabetes and her pancreas did not work, so in her case her blood sugar would remain and, go up and down, and will always have to be closely monitored. She stated she and the ADM were in-serviced by their corporate nurse before providing education to the staff on notification on changes in condition, glucose monitoring, and insulin pumps. She stated any time a resident's blood sugar was outside of the parameters, the physician needed to be notified. During an interview on 08/01/25 at 1:38 PM, the ADM stated she and the DON were in-serviced by their DCS on notification of changes in condition, glucose monitoring, and insulin pumps before the staff were in-serviced. She stated 94% of the nursing staff had been in-serviced, and none could work the floor until they were. Review of Resident #1's physician order, dated 07/22/25, reflected record blood sugar AC/HS (before meals and at bedtime for monitoring). Review of Resident #1's physician order, dated 07/35/25, reflected HumaLOG Injection Solution - 100 UNIT/ML - Inject subcutaneously before meals for DM. Review of Resident #1's physician order, dated 08/01/25 reflected Insulin Glargine Subcutaneous Solution - 100 UNIT/ML - Inject 14 units subcutaneously in the morning for DM1. Hold if less than 110. Review of five sampled residents' charts that required insulin, on 08/01/25, reflected their care plans had diabetic interventions and there were ordered parameters for their blood sugar levels. Review of the facility's ADHOC meeting agenda, dated 07/30/25, reflected the ADM, DON, MDSC, DOR, and MD were in attendance. Review of an in-service, dated 07/30/25 and conducted by the DCS, reflected the ADM and DON were in-serviced on two key points: A malfunctioning diabetic pump and/or elevated blood glucose levels require immediate attention and notification to MD and nurse management. Provider and representative notification must be timely and clearly documented. Documentation should include date/time of change identification, communication, provider response, and new orders. Timely recognition and management of changes in condition, including care and management of diabetic pumps, and blood glucose readings. Clinical assessments and documentation must reflect staff recognizing when a blood glucose reading is inconsistent or clinically abnormal. Staff to recognize when to utilize a backup manual finger stick for malfunctioning diabetic pumps. Delay in response or lack of intervention may constitute a deficiency. Review of an audit conducted by the DON, dated 07/30/25 - 07/31/25, reflected all 22 residents who had a diagnosis of diabetes were audited for proper orders and hyper/hypo glycemic protocols in place and care planned. Of the 22 audited residents, three residents' clinicals were sent to the MD to review for a determination if any orders wanted to be changed. One resident was put on a sliding scale, one resident was added to the accucheck schedule, and one received an order for lab work. Review of their monitoring audit tool for review the 24-hour report for any changes in condition, on 08/01/25, reflected three different residents had been sampled on 07/30/25 and 08/01/25. It reflected if there was a change in condition in 24 hours, order listing report reviewed, notifications completed, and corrective actions taken if change in condition was identified. Four residents were idented with a change of condition and corrective actions were taken appropriately and verified. Review of an in-service dated 07/30/25 - 08/01/25 and conducted by the DON, reflected all nursing staff were notified on of their Notification of Changes/Change in Condition Policy. The CNAs and MAs were expected to notify the nurses of any change and nurses were expected to complete a change of condition form and to notify the NP and DON. Review of an in-service dated 07/30/25 - 08/01/25 and conducted by the DON, reflected all nurses were in-serviced on their Continuous Glucose Monitors Policy. Review of an in-service dated 07/30/25 - 08/01/25 and conducted by the DON, reflected all nurses were in-serviced on their Insulin Pump Use Policy.The ADM and DON were notified on 08/01/25 at 2:13 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change for one (Resident #1) of four residents reviewed for notification of changes. The facility failed to ensure the NP was notified on 02/10/25 when there was reported swelling and tenderness to Resident #1's incision sites. On 02/11/25 one of the incisions dehisced requiring hospitalization where he was diagnosed with an infection to the surgical site requiring antibiotics. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/02/25 at 4:44 PM. While the IJ was removed on 05/05/25 12:46 PM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary medical care, pain, infection, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including chronic pain, osteoarthritis (inflammation of one or more joints), hemiplegia (paralysis or severe weakness on one side of the body), and hemiparesis (one-sided muscle weakness). Review of Resident #1's quarterly MDS assessment, dated 01/19/25, reflected a BIMS score of 13, indicating he was cognitively intact. Section J (Health conditions) reflected he was almost constantly in pain. Review of Resident #1's quarterly care plan, revised 01/30/25, reflected he had chronic pain and neuropathy with an intervention of having a pain stimulator in place. Revision on 03/20/25 reflected he had the potential for infections related to infection to back pain stimulator with an intervention of notifying the MD as needed. Review of Resident #1's document from the surgical center, dated 01/06/25, reflected he was scheduled for a Spinal Cord Stimulator Implant on 01/07/25. Review of Resident #1's EMR, on 04/05/25, reflected no physician orders to monitor the surgical sites. Review of Resident #1's skin assessment, dated 01/16/25 and completed by RN E, reflected he had a total of 18 staples - 9 in the middle of the back and 9 on the left flank. Review of Resident #1's skin assessment, dated 01/26/25 and completed by LVN D, reflected s/p spinal cord stimulator placement. Incisions OTA closed/healed. (Staples presumably removed at recent ortho appointment - unknown date) Review of Resident #1's progress notes, dated 02/11/25 at 9:34 PM and documented by LVN A, reflected the following: [Resident #1] was sent to (hospital), [Resident #1]'s surgical site from pain stimulator was bleeding, mixture of blood and puss [sic] over left hip, bleeding was persistent . Review of Resident #1's hospital records, dated 02/11/25, reflected he had a left lower back spinal stimulator placed one month ago, site had dehisced, and there was purulent drainage. Review of the facility's Infection Control binder, on 04/16/25, reflected Resident #1 had a skin infection on 02/11/25 with symptoms of pus/bleeding. Review of Resident #1's progress notes, dated 02/12/25 at 3:22 AM and documented by LVN B, reflected the following: [Resident #1] returned to room at 3:15am with personal belongings . rcvd 1G Rocephin and 1L NS at hospital, dressing clean, dry and intact. New orders for clindamycin 150mg . Review of Resident #1's Infection Surveillance Form, dated 02/12/25, reflected pus was present at wound, skin, or soft tissue site and he met McGreers (infection surveillance checklist). Review of Resident #1's physician orders, dated 02/12/25, reflected Clindamycin HCl Oral Capsule 150 MG - Give 3 capsules by mouth three times a day for cellulitis for 10 days and Bactrim DS Oral Tablet 800-160 MG - Give 1 tablet by mouth two times a day. Review of Resident #1's physician orders, dated 02/13/25, reflected wound care with dressing changes twice daily, partially open to air to allow drainage two times a day. During a telephone interview on 04/16/25 at 12:28 PM, Resident #1's NP was asked if pus was related to cellulitis and she stated it could be, but it could also be an infected surgical site. She stated it would depend on what she was looking at. She stated if there was pus, redness, blood, or warmth at a surgical site, there would be concern for infection. During a telephone interview on 04/15/25 at 12:42 PM, Resident #1's FR stated he was currently in the hospital. She stated when he had his procedure in January (2025) he had staples closing it shut. She stated she did not think the staff did anything for the incision and believed that was why he got an infection. During a telephone interview on 04/16/25 at 1:16 PM, LVN A stated she was the nurse who sent him to the hospital in February (2025) when there was drainage to the surgical site. She stated he came back from the hospital with orders for dressing changes and antibiotics. During a telephone interview on 04/16/25 at 1:33 PM, LVN C stated she worked with Resident #1. She stated she did not remember seeing staples to his incision site but did remember it being glued shut. During an interview on 04/16/25 at 2:09 PM, the DON was asked how Resident #1's incision could have dehisced in February (2025) if there was no opening, she stated that was not possible. She stated he went back to the clinic for a follow-up on 01/12/25 and again did not return with any new orders nor was she notified he had his staples removed. She stated if Resident #1 had sutures after his procedure, she would have expected him to have orders to monitor the site for signs and symptoms of infection, and she was not aware if there had been an actual opening. During a telephone interview on 04/16/25 at 3:30 PM, LVN B stated she had recently started working at the facility when Resident #1 had his procedure for the pain stimulator. She stated she remembered he had staples closing the incision on his back. She stated she remembered he began having a lot of bloody drainage and they had to start covering it with a dressing. During an observation and interview on 05/02/25 at 10:42 AM revealed Resident #1 watching television in his room. He stated he did not remember if the nurses were checking his surgical sites after the staples were removed. His incision sites were intact with no redness or swelling. He stated he remembered a for a few days before he was sent to the hospital (02/11/25), the sites felt sore, but he thought it was just part of the process. He stated he could not see the incisions so he could not tell if anything else was going on, but he knew they were not completely healed yet. He stated on the day he was sent out to the hospital, CNA F was giving him a bed bath and he saw some blood coming out of one of the incisions. He stated he got the nurse came and pushed on it and told him blood and pus were coming out. He stated he was sent to the hospital and was prescribed antibiotics. During a phone interview on 05/02/25 at 11:08 AM, LVN A stated she worked with Resident #1 on 02/10/25 and 02/11/25. She stated days leading up to the day the site had drainage (on 02/11/25), the sites looked like they were healing, and she had no concerns. She stated the day prior (02/10/25), CNA F informed her that the sites appeared swollen. She stated she assessed them, notified ADON G, who told her she would look at it in the morning with the NP. She stated she did not remember if she documented it. She stated Resident #1 was not complaining of pain just that they felt a little tender. She stated the following day (02/11/25), CNA F was giving him a bed bath and when he rolled him on his side, one of the sites (the one on the left, closer to his buttocks) began leaking. She stated CNA F came and informed her and she went to assess and saw what looked to be a pinhole to the site draining pus and blood. She stated she applied pressure with gauze and sent him to the ER. During an interview on 05/02/25 at 11:17 AM, ADON H stated she was also the WCN at the facility. She stated she primarily covered the 200 hall and ADON G covered the 100 hall, but she provided wound care for the whole facility. She stated if a resident had a procedure that required a surgical incision, she and the NP would assess the surgical sites. She stated neither she nor the NP ever assessed his surgical sites because they had not been communicated to about the procedure. She stated it was her expectations she be notified of any skin integrity issues, including surgical incision sites. She stated the facility did contract with an outside WCD, but she only followed some residents. She stated they decided collectively as a nursing team who should be followed by the WCD. During a telephone interview on 05/02/25 at 11:42 AM, CNA F stated Resident #1 had two incisions after his procedure in January (2025), one on his spine (which was bigger) and one on his left side close to his buttocks. He stated after the procedure he had a lot of staples but was not sure how many. He stated the incision sites looked fine until 02/10/25 when they appeared swollen, and Resident #1 complained of them feeling tender/sore. He stated he informed LVN A and assumed she had passed it on to the doctor. He stated the follow day, he was giving Resident #1 a bed bath and when he turned him on his side, the incision on his left side started dripping, and that was when he went and got LVN A. He stated when LVN A assessed it, the incision opened a little bit and started oozing much more. He stated the opening was bigger than a pinhole. During a telephone interview on 05/02/25 at 12:02 PM, ADON G stated she over-saw the 100 hall (the hall Resident #1 resided on). She stated if a wound was brought to her attention and ADON H was not there, she would do the assessment. She stated she was aware of Resident #1's procedure and thought ADON H knew about it. She stated the admitting nurse after the procedure should have notified ADON H. She stated she never assessed or saw the incisions and did not know what they looked like. She stated if there was a change with the incision sites, her expectation would be for the nurse to notify the WCN and NP. She stated a change could be redness, warmth, drainage, or swelling. She stated she was never informed Resident #1's incision sites had become swollen on 02/10/25. She stated she would have expected to have been notified so she could also follow-up with the WCN and NP. During a telephone interview on 05/02/25 at 12:19 PM, Resident #1's NP stated she did lay eyes on his surgical incisions right after the procedure (on 01/07/25). She stated she pulled off the dressing and noted the staples and that they did not show any signs of infection. She stated she was not notified of swelling to the sites on 02/10/25 but she her expectation was that she was notified with any change for with any resident. She stated if she had been notified, she would have assessed the sites, ordered labs, notified the clinic of where he got the procedure done, and would have started Rocephin (antibiotic) temporarily. She stated if the incision sites had been completely healed, she could not image they could dehisce, but anything was possible. During an interview on 05/02/25 at 1:01 PM, RN E stated she worked the day shift with Resident #1 and was not working when his incision site opened (it happened during the night shift). She stated she was not notified or aware if there was any swelling to the sites (on 02/10/25). She stated if she had been notified, she would have notified the NP immediately. She stated swelling could indicate infection, pus, or leakage. She stated nurses could not determine if a wound or surgical site was healed, it had to be the NP or MD. During an interview on 05/02/25 at 1:23 PM, the DON stated usually a physician was who determined a site was healed. She stated normally the WCN will clear it and then the NP or physician would follow-up. She stated she was not notified the day before Resident #1 was sent to the hospital (on 02/11/25) that his surgical sites were swollen. She stated she did not always expect to be notified. She would expect the nurses to follow up with the NP. She stated swelling to an incision site was natural. She stated if the sites were healed and was swollen a week later, she would think maybe something happened like his body was rejecting the pain stimulator or there could be other factors that would warrant a concern. When asked if a healed wound could dehisce, she stated, His (Resident #1) surgical site? I do not know anything about that. During a telephone interview on 05/02/25 at 4:07 PM, LVN D stated she did not remember if she completed a skin assessment on 01/26/25 for Resident #1, but if her name was on it, she completed it. She stated if she documented the surgical sites were healed, that was what she thought. She could not answer if a nurse was able to determine if a wound/surgical site was healed. Review of the facility's undated Change in a Resident's Condition or Status Policy reflected the following: Our facility shall promptly notify the resident, his or her Attending Physician . of changes in the resident's medical/mental condition and/or status. . Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The ADM and DON were notified on 05/02/25 at 4:44 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/03/25 at 6:23 PM: IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEOPARDY: On May 2,2025 at approximately 5:00 pm the following actions were initiated upon facility identification of concern: Action: Assessed Resident #1 to validate that the resident was not suffering from any ongoing negative effects related to the deficient practice and that there were no new issues with skin integrity that would need to be reported to the physician. Resident #1 was found to be free from adverse effects related to deficiency. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing/Designee Action: Administrator was educated on Change in a Resident's Condition or Status, Surgery-Related (Pre-Postoperative) Management - Clinical Protocol in accordance with professional standards. Nursing should notify physician on call when there is change in status, Director of Nursing/Assistant Director of Nursing and resident family. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Area President Action: Director of Nursing was educated on Change in a Resident's Condition or Status, Surgery-Related (Pre-Postoperative) Management - Clinical Protocol in accordance with professional standards. Nursing should notify physician on call when there is change in status, Director of Nursing/Assistant Director of Nursing and resident family. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Chief Nursing Officer IDENTIFICATION OF OTHER AFFECTED: All residents with surgical sites or skin integrity issues have the potential to be affected by the deficient practice. Action: A skin sweep of current residents to identify residents who have surgical sites or other skin integrity issues and initiated evaluations these residents through chart review and physical exam/interview, to determine if any were suffering a change in condition related to their skin impairment such as increased redness, swelling, drainage, increased or unmanaged pain or any other signs or symptoms of infection such as fever. The above was completed with 0 of 72 residents identified as having a change in condition related to their skin impairment. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing/Designee SYSTEMIC CHANGES AND/OR MEASURES: Action: An ADHOC QAPI was conducted. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Administrator, Director of Nursing, ADON, MDS, Staffing Nurse and Medical Director. Action: Nurses including new and PRN and agency employees, were education regarding the expectation that skin integrity issues (including residents admitted after surgical procedure) be reported to the wound care nurse, DON, provider upon identification or with any noted change in condition that would indicate deterioration or infection and that interventions be implemented timely to ensure residents are being cared for appropriately. Start Date: 5/2/2025 Completion Date: This was initiated and completed on 5/2/2025. Staff not onsite or unable to reached, agency and new employees will be in-serviced upon hire and prior to the start of their first shift. Responsible Party: Director of Nursing/Designee. Action: Assistant Director of Nursing was educated on Change in a Resident's Condition or Status, Surgery-Related (Pre-Postoperative) Management - Clinical Protocol in accordance with professional standards. Nursing should notify physician on call when there is change in status, Director of Nursing/Assistant Director of Nursing and resident family. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing Action: Director of Maintenance, Directory of Rehabilitation, Medical Data Set Nurse, Business Office Manager, Activities, Marketing, Social Worker and Housekeeping/Laundry Manager were educated on Change in a Resident's Condition or Status, Surgery-Related (Pre-Postoperative) Management - Clinical Protocol in accordance with professional standards. Nursing should notify physician on call when there is change in status, Director of Nursing/Assistant Director of Nursing and resident family. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: This was initiated and completed on 5/2/2025. Leaders not able to be present were educated by phone and will complete the checklist before starting work. Responsible Party: Administrator/Designee Action: Certified nurses aides were educated regarding the expectation that concern for skin integrity issues be reported to the licensed nurse on duty and Assistant Director of Nurses upon identification or with any noted change that might indicate deterioration or infection such as increased pain, redness, swelling, fever or increased or foul drainage so that further evaluation may be conducted. Start: 5/2/2025 Completion Date: This was initiated and completed on 5/2/2025. The Director of Nursing/Designee will utilize a signed staff roster to track those who have received education and to determine those who still require it. Anyone not in attendance at education sessions, or unable to be reached by phone, as evidenced by missing signatures on the staff roster sheet, due to vacation, sick leave, or casual work status will be educated upon their return, prior to their first shift worked. Responsible Party: Director of Nursing/Designee. TRACKING AND MONITORING: Action: Audits will be conducted on skin assessments for 7 days then daily Monday-Friday for 3 weeks, then weekly thereafter to ensure that providers are notified of any changes in skin condition timely to ensure that residents with skin integrity issues are cared for appropriately. This will be tracked on a log. Start Date: 5/2/2025 Completion Date: 5/2/2025. Responsible Party: Director of Nursing/Designee. Action: Implemented interventions immediately if notifications have not been made to the provider of any suspected change in condition related to skin integrity. Documentation of notifications made to resident/representative and physician will be noted in the resident's electronic medical record to include alert charting for change in skin condition. Staff responsible for the deficient practice will be contacted and counseled accordingly. Start Date: 5/2/2025 Completion Date: 5/2/2025. Responsible Party: Director of Nursing/Designee. Action: Audit alert charting daily in the morning meeting, M-F, to validate that alert charting for changes in skin condition is present for those who need it. Any trends or concerns will be addressed with the Quality Assurance Performance Committee and monitoring will continue until a lessor frequency is deemed appropriate. Results of audits will be presented by the Administrator or designee at the monthly QAPI meeting with the IDT and Medical Director on or before 5/30/2025 then monthly and as needed thereafter to identify trends and sustainability. If ongoing deficiencies or concerns are noted through these audits, resident interventions and staff education will be implemented immediately. Monitoring will not be discontinued until the facility completes three consecutive rounds of monthly monitoring that demonstrate sustained compliance as approved by the QAPI committee and medical director. Additional interventions, education and monitoring will be implemented, as needed, based on the recommendations of the QAPI committee for any negative trends identified to ensure sustainability. Start Date: 5/2/2025 Completion Date: 5/2/2025. Responsible Party: Director of Nursing/Designee. Please accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued 5/2/2025. The Surveyor monitored the POR from 05/04/25 - 05/05/25 as followed: During observations on 05/05/25 from 10:52 AM - 11:05 AM revealed the WCN conducting a skin assessment on three residents. There was no skin breakdown, redness, or any concerns. During interviews on 05/04/25 from 2:26 PM - 4:02 PM and on 05/05/25 from 11:15 AM - 11:38 AM, staff from both shifts including three RNs, three LVNs, and three CNAs all stated they were interviewed before their shifts on abuse and neglect, changes in condition, skin assessments, and reporting skin issues/concerns. All staff knew their Abuse and Neglect Coordinator was their ADM and were able to give several times of abuse such as emotional, physical, and sexual. The CNAs all stated it was important to check all areas of a resident's skin when providing care so they could notify the nurse, so nothing worsened. The CNAs stated they would report to their nurse rashes, redness, skin tears, swelling, or any open areas. The CNAs all stated they also documented any changes on a resident's skin on their shower sheets. The nurses all stated their expectations were for the CNAs to report any change in a resident's skin to them immediately. They stated they would complete a skin assessment and notify the WCN. The nurses all stated skin assessments should be conducted weekly in order to ensure the residents' skin was intact or nothing was worsening. The nurses all stated any changes such as swelling, redness, or drainage would be relayed to the WCN and NP immediately. The nurses stated only the NP or MD could determine if a wound was healed. Review of the Facility's Ad Hoc QAPI Agenda, dated 05/02/25, reflected the ADM, the DON, ADON G, ADON H, the MDSC, and the MD were in attendance. Review of an in-service titled Regulatory Education - Resident Surgical Wound Case, dated 05/02/25 and conducted by the AP, reflected the ADM and DON were educated on the following: Timely recognition and management of changes in condition, including a wound deterioration, is required. Clinical assessments and documentation must reflect wound progression and corresponding interventions. Review of an audit, dated 05/02/25 and conducted by the DON, reflected seven residents with skin integrity issues that had treatment orders in place and had no signs or symptoms of infection. Review of an in-service, dated 05/01/25 - 05/03/25 and conducted by the DON, reflected all staff were in-serviced on their Abuse and Neglect Policy. Review of In-Service Education Quiz, dated 05/01/25 - 05/03/25, reflected all licensed nurses and agency staff completed a quiz covering skin issues with no concerns. Review of an in-service, dated 05/01/25 - 05/03/25 and conducted by the DON, reflected all staff were in-serviced on their Change of Condition Policy. Review of In-Service Education Quiz, dated 05/01/25 - 05/03/25, reflected all staff completed a quiz covering Notification of Changes with no concerns. Review of eight resident's EMR, on 05/05/25, reflected they had a skin assessment conducted with no concerns on 05/02/25. The ADM and DON were notified on 05/02/25 12:46 that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. The facility failed to ensure Resident #1's surgical sites were determined to be healed by the NP or MD. On 02/10/25 there was reported swelling to the incisions and on 02/11/25 one of the incisions dehisced requiring hospitalization where he was diagnosed with an infection to the surgical site requiring antibiotics. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/02/25 at 4:44 PM. While the IJ was removed on 05/05/25 12:46 PM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary medical care, pain, infection, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including chronic pain, osteoarthritis (inflammation of one or more joints), hemiplegia (paralysis or severe weakness on one side of the body), and hemiparesis (one-sided muscle weakness). Review of Resident #1's quarterly MDS assessment, dated 01/19/25, reflected a BIMS score of 13, indicating he was cognitively intact. Section J (Health conditions) reflected he was almost constantly in pain. Review of Resident #1's quarterly care plan, revised 01/30/25, reflected he had chronic pain and neuropathy with an intervention of having a pain stimulator in place. Revision on 03/20/25 reflected he had the potential for infections related to infection to back pain stimulator with an intervention of notifying the MD as needed. Review of Resident #1's document from the surgical center, dated 01/06/25, reflected he was scheduled for a Spinal Cord Stimulator Implant on 01/07/25. Review of Resident #1's EMR, on 04/05/25, reflected no physician orders to monitor the surgical sites. Review of Resident #1's skin assessment, dated 01/16/25 and completed by RN E, reflected he had a total of 18 staples - 9 in the middle of the back and 9 on the left flank. Review of Resident #1's skin assessment, dated 01/26/25 and completed by LVN D, reflected s/p spinal cord stimulator placement. Incisions OTA closed/healed. (Staples presumably removed at recent ortho appointment - unknown date) Review of Resident #1's progress notes, dated 02/11/25 at 9:34 PM and documented by LVN A, reflected the following: [Resident #1] was sent to (hospital), [Resident #1]'s surgical site from pain stimulator was bleeding, mixture of blood and puss [sic] over left hip, bleeding was persistent . Review of Resident #1's hospital records, dated 02/11/25, reflected he had a left lower back spinal stimulator placed one month ago, site had dehisced, and there was purulent drainage. Review of the facility's Infection Control binder, on 04/16/25, reflected Resident #1 had a skin infection on 02/11/25 with symptoms of pus/bleeding. Review of Resident #1's progress notes, dated 02/12/25 at 3:22 AM and documented by LVN B, reflected the following: [Resident #1] returned to room at 3:15am with personal belongings . rcvd 1G Rocephin and 1L NS at hospital, dressing clean, dry and intact. New orders for clindamycin 150mg . Review of Resident #1's Infection Surveillance Form, dated 02/12/25, reflected pus was present at wound, skin, or soft tissue site and he met McGreers (infection surveillance checklist). Review of Resident #1's physician orders, dated 02/12/25, reflected Clindamycin HCl Oral Capsule 150 MG - Give 3 capsules by mouth three times a day for cellulitis for 10 days and Bactrim DS Oral Tablet 800-160 MG - Give 1 tablet by mouth two times a day. Review of Resident #1's physician orders, dated 02/13/25, reflected wound care with dressing changes twice daily, partially open to air to allow drainage two times a day. During a telephone interview on 04/16/25 at 12:28 PM, Resident #1's NP was asked if pus was related to cellulitis and she stated it could be, but it could also be an infected surgical site. She stated it would depend on what she was looking at. She stated if there was pus, redness, blood, or warmth at a surgical site, there would be concern for infection. During a telephone interview on 04/15/25 at 12:42 PM, Resident #1's FR stated he was currently in the hospital. She stated when he had his procedure in January (2025) he had staples closing it shut. She stated she did not think the staff did anything for the incision and believed that was why he got an infection. During a telephone interview on 04/16/25 at 1:16 PM, LVN A stated she was the nurse who sent him to the hospital in February (2025) when there was drainage to the surgical site. She stated he came back from the hospital with orders for dressing changes and antibiotics. During a telephone interview on 04/16/25 at 1:33 PM, LVN C stated she worked with Resident #1. She stated she did not remember seeing staples to his incision site but did remember it being glued shut. During an interview on 04/16/25 at 2:09 PM, the DON was asked how Resident #1's incision could have dehisced in February (2025) if there was no opening, she stated that was not possible. She stated he went back to the clinic for a follow-up on 01/12/25 and again did not return with any new orders nor was she notified he had his staples removed. She stated if Resident #1 had sutures after his procedure, she would have expected him to have orders to monitor the site for signs and symptoms of infection, and she was not aware if there had been an actual opening. During a telephone interview on 04/16/25 at 3:30 PM, LVN B stated she had recently started working at the facility when Resident #1 had his procedure for the pain stimulator. She stated she remembered he had staples closing the incision on his back. She stated she remembered he began having a lot of bloody drainage and they had to start covering it with a dressing. During an observation and interview on 05/02/25 at 10:42 AM revealed Resident #1 watching television in his room. He stated he did not remember if the nurses were checking his surgical sites after the staples were removed. His incision sites were intact with no redness or swelling. He stated he remembered a for a few days before he was sent to the hospital (02/11/25), the sites felt sore, but he thought it was just part of the process. He stated he could not see the incisions so he could not tell if anything else was going on, but he knew they were not completely healed yet. He stated on the day he was sent out to the hospital, CNA F was giving him a bed bath and he saw some blood coming out of one of the incisions. He stated he got the nurse came and pushed on it and told him blood and pus were coming out. He stated he was sent to the hospital and was prescribed antibiotics. During a phone interview on 05/02/25 at 11:08 AM, LVN A stated she worked with Resident #1 on 02/10/25 and 02/11/25. She stated days leading up to the day the site had drainage (on 02/11/25), the sites looked like they were healing, and she had no concerns. She stated the day prior (02/10/25), CNA F informed her that the sites appeared swollen. She stated she assessed them, notified ADON G, who told her she would look at it in the morning with the NP. She stated she did not remember if she documented it. She stated Resident #1 was not complaining of pain just that they felt a little tender. She stated the following day (02/11/25), CNA F was giving him a bed bath and when he rolled him on his side, one of the sites (the one on the left, closer to his buttocks) began leaking. She stated CNA F came and informed her and she went to assess and saw what looked to be a pinhole to the site draining pus and blood. She stated she applied pressure with gauze and sent him to the ER. During an interview on 05/02/25 at 11:17 AM, ADON H stated she was also the WCN at the facility. She stated she primarily covered the 200 hall and ADON G covered the 100 hall, but she provided wound care for the whole facility. She stated if a resident had a procedure that required a surgical incision, she and the NP would assess the surgical sites. She stated neither she nor the NP ever assessed his surgical sites because they had not been communicated to about the procedure. She stated it was her expectations she be notified of any skin integrity issues, including surgical incision sites. She stated the facility did contract with an outside WCD, but she only followed some residents. She stated they decided collectively as a nursing team who should be followed by the WCD. During a telephone interview on 05/02/25 at 11:42 AM, CNA F stated Resident #1 had two incisions after his procedure in January (2025), one on his spine (which was bigger) and one on his left side close to his buttocks. He stated after the procedure he had a lot of staples but was not sure how many. He stated the incision sites looked fine until 02/10/25 when they appeared swollen, and Resident #1 complained of them feeling tender/sore. He stated he informed LVN A and assumed she had passed it on to the doctor. He stated the follow day, he was giving Resident #1 a bed bath and when he turned him on his side, the incision on his left side started dripping, and that was when he went and got LVN A. He stated when LVN A assessed it, the incision opened a little bit and started oozing much more. He stated the opening was bigger than a pinhole. During a telephone interview on 05/02/25 at 12:02 PM, ADON G stated she over-saw the 100 hall (the hall Resident #1 resided on). She stated if a wound was brought to her attention and ADON H was not there, she would do the assessment. She stated she was aware of Resident #1's procedure and thought ADON H knew about it. She stated the admitting nurse after the procedure should have notified ADON H. She stated she never assessed or saw the incisions and did not know what they looked like. She stated if there was a change with the incision sites, her expectation would be for the nurse to notify the WCN and NP. She stated a change could be redness, warmth, drainage, or swelling. She stated she was never informed Resident #1's incision sites had become swollen on 02/10/25. She stated she would have expected to have been notified so she could also follow-up with the WCN and NP. During a telephone interview on 05/02/25 at 12:19 PM, Resident #1's NP stated she did lay eyes on his surgical incisions right after the procedure (on 01/07/25). She stated she pulled off the dressing and noted the staples and that they did not show any signs of infection. She stated she was not notified of swelling to the sites on 02/10/25 but she her expectation was that she was notified with any change for with any resident. She stated if she had been notified, she would have assessed the sites, ordered labs, notified the clinic of where he got the procedure done, and would have started Rocephin (antibiotic) temporarily. She stated if the incision sites had been completely healed, she could not image they could dehisce, but anything was possible. During an interview on 05/02/25 at 1:01 PM, RN E stated she worked the day shift with Resident #1 and was not working when his incision site opened (it happened during the night shift). She stated she was not notified or aware if there was any swelling to the sites (on 02/10/25). She stated if she had been notified, she would have notified the NP immediately. She stated swelling could indicate infection, pus, or leakage. She stated nurses could not determine if a wound or surgical site was healed, it had to be the NP or MD. During an interview on 05/02/25 at 1:23 PM, the DON stated usually a physician was who determined a site was healed. She stated normally the WCN will clear it and then the NP or physician would follow-up. She stated she was not notified the day before Resident #1 was sent to the hospital (on 02/11/25) that his surgical sites were swollen. She stated she did not always expect to be notified. She would expect the nurses to follow up with the NP. She stated swelling to an incision site was natural. She stated if the sites were healed and was swollen a week later, she would think maybe something happened like his body was rejecting the pain stimulator or there could be other factors that would warrant a concern. When asked if a healed wound could dehisce, she stated, His (Resident #1) surgical site? I do not know anything about that. During a telephone interview on 05/02/25 at 4:07 PM, LVN D stated she did not remember if she completed a skin assessment on 01/26/25 for Resident #1, but if her name was on it, she completed it. She stated if she documented the surgical sites were healed, that was what she thought. She could not answer if a nurse was able to determine if a wound/surgical site was healed. Review of the facility's undated Change in a Resident's Condition or Status Policy reflected the following: Our facility shall promptly notify the resident, his or her Attending Physician . of changes in the resident's medical/mental condition and/or status. . Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. A request was made to the ADM on 04/16/25 at 3:35 PM and 5:09 PM and 05/02/25 at 2:16 PM for a policy on wound care/treatment orders. A policy was not received prior to exit. The ADM and DON were notified on 05/02/25 at 4:44 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/03/25 at 6:23 PM: IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEOPARDY: On May 2,2025 at approximately 5:00 pm the following actions were initiated upon facility identification of concern. Action: Administrator was educated on abuse and neglect, resident's rights, comprehensive person-centered care plans and the treatment and care in accordance with professional standards. Ensure care plans are up to date for the individual resident and constantly monitored. If there is anything identified that needs to be updated, immediate notification to Directory of Nursing. Ensure documentation and all notifications occur timely. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Area President Action: Director of Nursing was educated on abuse and neglect, resident's rights, comprehensive person-centered care plans and the treatment and care in accordance with professional standards. Ensure care plans are up to date for the individual resident and constantly monitored. If there is anything identified that needs to be updated, immediate notification to Directory of Nursing. Ensure documentation and all notifications occur timely. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Chief Nursing Officer Action: Assistant Director of Nursing was educated on abuse and neglect, resident's rights, comprehensive person-centered care plans and the treatment and care in accordance with professional standards. Ensure care plans are up to date for the individual resident and constantly monitored. If there is anything identified that needs to be updated, immediate notification to Directory of Nursing. Ensure documentation and all notifications occur timely. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing Action: Resident #1 was assessed to ensure that the resident was not suffering from any ongoing negative effects related to the deficient practice and that there were no new issues with skin integrity that would need to be reported to the physician. Resident #1 was found to be free from adverse effects related to deficiency. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing or Designee Action: A skin sweep of current residents was completed to identify residents who have surgical sites or other skin integrity issues and initiated evaluations these residents, through chart review and physical exam/interview, to determine if any areas were in need of treatment, that providers, responsible parties, and residents were aware of status of wounds, and if any were suffering ongoing negative consequences related to the deficient practice such as redness, swelling, increased or unmanaged pain or any other signs or symptoms of infection such as fever. 0 residents were found to have a change in condition related to their skin impairment. Skin assessments are in the medical record. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing/Designee Action: Nursing staff including new hires and PRN employees, were educated on abuse and neglect, resident's rights, comprehensive person-centered care plans and the treatment and care in accordance with professional standards. Ensure care plans are up to date for the individual resident and constantly monitored. If there is anything identified that needs to be updated, immediate notification to Directory of Nursing. Ensure documentation and all notifications occur timely. Review questions were answered correctly. A checklist verifying understanding of policies was completed. Staff not onsite or unable to reached, agency and new employees will be in-serviced upon hire and prior to the start of their first shift. Start Date: 5/2/2025 Completion Date: This was initiated and completed on 5/2/2025. Responsible Party: Director of Nursing/Designee. Action: Director of Maintenance, Directory of Rehabilitation, Medical Data Set Nurse, Business Office Manager, Activities, Marketing, Social Worker and Housekeeping/Laundry Manager were educated on abuse and neglect, resident's rights, comprehensive person-centered care plans and treatment and care in accordance with professional standards. Ensure care plans are up to date for the individual resident and constantly monitored. If there is anything identified that needs to be updated, immediate notification to Directory of Nursing. Ensure documentation and all notifications occur timely. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: This was initiated and completed on 5/2/2025. Leaders not able to be present were educated by phone and will complete the checklist before starting work. Responsible Party: Administrator/Designee IDENTIFICATION OF OTHER AFFECTED: All residents with skin conditions have the potential to be affected by the deficient practice. Action: Skin assessment on 72 of 72 residents. No new skin conditions were identified. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing/Designee SYSTEMIC CHANGES AND/OR MEASURES: Action: An ADHOC QAPI was conducted. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Administrator, Director of Nursing, ADON, MDS, Staffing Nurse and Medical Director. Action: Initiated process effective immediately, all new surgical wounds/incisions will be referred to the ADON/designee upon admission or upon return from a procedure. The ADON/designee will complete wound assessments weekly (or more often as needed) until wounds/incisions are determined healed by NP or MD. All referrals will be tracked on a Wound Care Log maintained by the ADON/designee. Start Date: 5/2/2025 Completion Date: 5/3/2025 Responsible Party: Director of Nursing/Designee TRACKING AND MONITORING: Action: Audits will be performed on residents with surgical sites and other wounds to ensure that NP or MD determination of wound/incision healing is documented, and wound changes are promptly reported and addressed. A log will be kept. Start Date: 5/2/2025 Completion Date: 5/3/2025 Responsible Party: Director of Nursing/Designee Action: Wound care log will be submitted weekly to Director of Nursing and Regional Clinical Nurse to ensure compliance with notification and documentation. Start Date: 5/2/2025 Completion Date: 5/3/2025 Responsible Party: Director of Nursing/Designee Action: Audits will be conducted daily x 2 weeks, 3x weekly x 2 weeks, and then weekly x 4 weeks, or until sustained compliance is achieved. A log will be kept. Start Date: 5/2/2025 Completion Date: 5/3/2025 Responsible Party: Director of Nursing/Designee Action: Results will be provided to the Quality Assurance Committee monthly, for three months and as needed thereafter. Start Date: 5/2/2025 Completion Date: 5/3/2025 Responsible Party: Director of Nursing/Designee The Surveyor monitored the POR from 05/04/25 - 05/05/25 as followed: During observations on 05/05/25 from 10:52 AM - 11:05 AM revealed the WCN conducting a skin assessment on three residents. There was no skin breakdown, redness, or any concerns. During interviews on 05/04/25 from 2:26 PM - 4:02 PM and on 05/05/25 from 11:15 AM - 11:38 AM, staff from both shifts including three RNs, three LVNs, and three CNAs all stated they were interviewed before their shifts on abuse and neglect, changes in condition, skin assessments, and reporting skin issues/concerns. All staff knew their Abuse and Neglect Coordinator was their ADM and were able to give several times of abuse such as emotional, physical, and sexual. The CNAs all stated it was important to check all areas of a resident's skin when providing care so they could notify the nurse, so nothing worsened. The CNAs stated they would report to their nurse rashes, redness, skin tears, swelling, or any open areas. The CNAs all stated they also documented any changes on a resident's skin on their shower sheets. The nurses all stated their expectations were for the CNAs to report any change in a resident's skin to them immediately. They stated they would complete a skin assessment and notify the WCN. The nurses all stated skin assessments should be conducted weekly in order to ensure the residents' skin was intact or nothing was worsening. The nurses all stated any changes such as swelling, redness, or drainage would be relayed to the WCN and NP immediately. The nurses stated only the NP or MD could determine if a wound was healed. Review of the Facility's Ad Hoc QAPI Agenda, dated 05/02/25, reflected the ADM, the DON, ADON G, ADON H, the MDSC, and the MD were in attendance. Review of an in-service titled Regulatory Education - Resident Surgical Wound Case, dated 05/02/25 and conducted by the AP, reflected the ADM and DON were educated on the following: Timely recognition and management of changes in condition, including a wound deterioration, is required. Clinical assessments and documentation must reflect wound progression and corresponding interventions. Delay in response or lack of intervention may constitute a deficiency under F684. Review of an audit, dated 05/02/25 and conducted by the DON, reflected seven residents with skin integrity issues that had treatment orders in place and had no signs or symptoms of infection. Review of an in-service, dated 05/01/25 - 05/03/25 and conducted by the DON, reflected all staff were in-serviced on their Abuse and Neglect Policy. Review of In-Service Education Quiz, dated 05/01/25 - 05/03/25, reflected all licensed nurses and agency staff completed a quiz covering skin issues with no concerns. Review of an in-service, dated 05/01/25 - 05/03/25 and conducted by the DON, reflected all staff were in-serviced on their Change of Condition Policy. Review of In-Service Education Quiz, dated 05/01/25 - 05/03/25, reflected all staff completed a quiz covering Notification of Changes with no concerns. Review of eight resident's EMR, on 05/05/25, reflected they had a skin assessment conducted with no concerns on 05/02/25. The ADM and DON were notified on 05/02/25 12:46 that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.