**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to wear proper personal protective equipment (PPE) prior to entering the room of a Resident with a known condition that was highly transmissible. This deficient practice was not related to the Immediate Jeopardy. On 2/28/23 at approximately 9:00 AM, Resident #105 was observed to have a sign on her room door that read, Contact Precautions, Prior to Entering Room: Clean hands using alcohol-based hand rub, gown, gloves. There was a station set-up in the hallway, outside of the room that contained isolation gowns, gloves, etc. On 2/28/23 at approximately 9:03 AM, an interview was conducted with CNA B. CNA B confirmed with the nurse on duty and then responded to the Surveyor that Resident #105 was on isolation for MRSA (Methicillin-resistant Staphylococcus aureus is a cause of staph infection that is difficult to treat because of resistance to some antibiotics). On 2/28/23 at 9:20 AM, Surveyor C observed Employee D enter the room of Resident #105 without putting on an isolation gown or gloves. Upon Employee D's exit from the room she was asked about the signage on the door, which indicated isolation. Employee D said, it was with the roommate she had, I overlooked the sign. On 2/28/23 at 10:12 AM, Employee E, who was a housekeeper was observed in Resident #105's room cleaning without wearing an isolation gown or gloves. When asked about the signage and PPE bin outside of the room, she said it will say hot room if it is COVID, but we haven't had COVID in a while. If it's something that can be transmitted, I wear it, otherwise I don't. When asked how she wound know if it is something that can or cannot be transmitted and she said she didn't know. On 2/28/23 at 10:20 AM, an interview was conducted with LPN D, the unit manager. LPN D said, Everyone should be wearing PPE, including housekeeping. Review of the facility policy titled; Contact Precautions was conducted. This policy read, .3. Use of personal protective equipment (PPE) and hand hygiene: a. Perform hand hygiene by using an alcohol-based hand rub prior to donning PPE and room entry. Wash hands with soap and water or use alcohol-based hand rub, in accordance with hand hygiene practices. b. [NAME] gown and gloves upon room entry, doff and discard PPE in appropriate container, perform hand hygiene prior to room exit. During providing care for residents, gloves and gown will be changed after having contact with infective material that may contain high concentrations of microorganisms or if becomes visibly soiled (fecal material or wound drainage) . On 3/3/23, during an end of day meeting, the facility Administrator and Corporate Clinical Consultant were made aware of the above findings. No additional information was provided, prior to the conclusion of the survey. Based on observations, staff interviews, record review, and facility policy review, the facility failed 1) to ensure a multi-use glucometer was disinfected per manufacturer's instructions between use on each resident to prevent potential spread of bloodborne pathogens during finger-stick blood glucose checks for three of three residents (R104, R100, and R105) observed for blood sugar monitoring. R105 was diagnosed with bloodborne pathogens potentially transmissible to other residents using the glucometer. This failure had the potential to transmit infection to all 15 residents who received finger-stick blood glucose monitoring. On 03/03/23 at 2:55 PM, Immediate Jeopardy was called. The Immediate Jeopardy began on 03/03/23 at 10:29 AM, and was removed on 03/06/23 4:30 PM. Deficiencies remain at a level 2 isolated including 2) The facility staff failed to wear proper personal protective equipment (PPE) prior to entering the room of Resident # 101 in a survey sample of 71 residents. Findings include: 1. Review of R104's undated Profile, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with multiple diagnoses including type II diabetes mellitus. Review of R104's 03/03/23 physician's Orders, located in the Orders tab of the EMR, revealed an 11/09/22 order for Humalog insulin per sliding scale (amount given based on the current blood sugar reading) to be given at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. There was no specific order for finger-stick blood glucose monitoring. 2. Review of R100's undated Profile, found in the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] with multiple diagnoses including type II diabetes mellitus. Review of R100's 03/03/23 physician's Orders, located in the Orders tab of the EMR, revealed a 06/16/22 order for Humalog insulin per sliding scale to be given at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. There was no specific order for finger-stick blood glucose monitoring. 3. Review of R105's undated Profile in the Profile tab of the EMR revealed she had diagnoses including osteomyelitis (bone infection that can spread via the bloodstream), methicillin-resistant staphylococcus aureus (MRSA) infection (a staph infection that is difficult to treat because of resistance to antibiotics, that can be spread via the blood. https://www.cdc.gov/mrsa), klebsiella pneumoniae (a bacterium associated with pneumonia spread by person-to-person contact and can be spread through the blood. https://www.cdc.gov/hai/organisms/klebsiella/klebsiella.html), and type II diabetes mellitus. Review of R105's 03/03/23 physician's Orders, located in the Orders tab of the EMR, revealed a 02/09/23 order for blood sugar monitoring at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. On 03/03/23 at 10:29 AM, Licensed Practical Nurse (LPN) B was observed as she prepared to perform finger-stick blood glucose checks for R104, R100, and R105. LPN B placed three pairs of gloves, three lancets, one glucometer, and three alcohol prep pads on a piece of paper and brought them with her into R104's room. LPN B donned gloves, opened the alcohol prep pad, and wiped R104's finger. LPN B then used a lancet to pierce R104's skin, inserted the test strip in the glucometer, touched the test strip to the finger to obtain the blood sample, and obtained a blood sugar reading of 75. LPN B then discarded her gloves and exited the room without first washing or sanitizing her hands. LPN B then walked to R100's room and entered the room. LPN B donned gloves without first washing or sanitizing her hands. LPN B then inserted the test strip into the glucometer without first cleaning or sanitizing the glucometer. LPN B then used the lancet to perform the finger stick and touched the test strip to R100'S finger to obtain the blood sample with a blood sugar reading of 254. LPN B then doffed her gloves and exited the room. LPN B proceeded toward R105's room when Surveyor I intervened. LPN B stated she only had one glucometer and used the same glucometer for every resident she cared for. LPN B stated she would wipe it off with an alcohol prep pad when she went back to her cart after obtaining all three residents' blood sugar values. LPN B stated she was trained to sanitize the glucometer between each use, but she was just trying to hurry up and get it done. LPN B stated she used an alcohol prep pad [70% isopropyl alcohol] to clean the glucometer after use. Surveyor I then requested LPN B sanitize the glucometer before proceeding with R105's blood sugar check. LPN B was observed to use one alcohol prep pad to wipe the front of the glucometer, and another pad to wipe the back of the glucometer, then placed it on a tissue on top of the cart to dry. In an interview on 03/03/23 at 10:38 AM, LPN D, who served as the Unit Manager, stated glucometers should be cleaned and sanitized between use on each resident, and the staff were to use the grey-top wipes to sanitize the machine. She stated, We try to have two [glucometers] on each so they can rotate and use one while the other dries. LPN D stated failure to sanitize the glucometer between each resident could lead to transmission of infection and contamination to other residents. Observation of the grey-top wipes revealed they were Sani-Cloth Germicidal Disposable Wipes with Environmental Protection Agency (EPA) registration #9480-9. In an interview with the Administrator and Employee F on 03/03/23 at 2:55 PM, Employee F stated the staff should be using the appropriate Super Sani-cloth for glucometer disinfection between use on each resident. Review of the April 2021Assure Prism glucometer User Instruction Manual under the section Cleaning and Disinfection revealed, The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood-borne pathogens . The meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed. We have validated Clorox Healthcare Bleach Germicidal Wipes [0.55% Sodium Hypochlorite, EPA#67619-12], Dispatch Hospital Cleaner Disinfectant Towels with Bleach [0.65% Sodium Hypochlorite, EPA#56392-8], CaviWipes1 [0.76% Didecyldimethylammonium chloride, 7.5% Ethanol, 15% isopropanol; EPA#46781-13], and PDI Super Sani-Cloth Germicidal Disposable Wipe [n-Alkly (68% C12, 32% C14) dimethyl ethylbenzyl ammonium chlorides, 0.25% n-Alkyl (60% C14, 30% C16, 5% C12, 5% C18) dimethyl benzyl ammonium chlorides, 0.25%, 55% isopropyl alcohol; EPA#9480-4] for disinfecting the Assure Prism multi meter. These disinfectants are available commercially in towelette form . Only wipes with EPA registration numbers listed in the previous tables have been validated for use in cleaning and disinfecting the meter. Any disinfectant product containing the EPA registration numbers may be used on this device. Review of the facility's 05/27/22 Blood Glucose Monitoring policy revealed, It is the policy of this Center to perform blood glucose monitoring per physician/physician extender's orders . The nurse will abide by the infection prevention and control practices of cleaning and disinfection of the glucometer per manufacturer's instructions . The nurse is responsible for cleaning and disinfection of the glucometer between patients following the manufacturer's instructions. On 03/03/23 at 2:55 PM, the Administrator and the Regional Clinical Registered Nurse (employee F) were notified the failure to ensure a multi-use glucometer was disinfected between use on each resident to prevent the potential spread of bloodborne pathogens constituted Immediate Jeopardy to the health and safety of the residents who used the multi-use glucometers. The Immediate Jeopardy began on 03/03/23 at 10:29 AM, when observations of the failure to disinfect the glucometer between use on each resident were first made. The facility presented the following removal plan. 1) All residents have the potential for risk if employee fails to disinfect of glucometer. Facility obtained proper [EPA registered] disinfectant wipes to clean the glucometers. Resident #100 was assessed and is being monitored for any adverse signs or symptoms. MD/RP made aware of incident. All Glucometers disinfected on 3/3/23. 2) Before being permitted to work all licensed nurses (LPNs and RNs) will be educated on and preform [sic] a return demonstration on the process of disinfecting a glucometer after each use. 3) Date of completion 3/3/23 at 6:15pm. The survey team verified the facility's removal plan by doing the following: Resident #100's clinical chart was reviewed, and it was confirmed that a nursing progress note was entered into the record that the nurse practitioner was made aware of the incident and gave no new orders. The Resident's Responsible party was also made aware of the incident. Surveyor C made observations on both nursing stations to verify that the correct purple top Super Sani cloths (EPA registered) were present and available for staff use. Surveyor C conducted staff interviews with all of the nurses (LPN/RN) currently working (10 LPNs and 1 RN) and all were able to verbalize the correct way to disinfect a glucometer, able to verbalize that they would do this prior to use and after each use (between each Resident). They would wipe all surfaces of the glucometer with a purple-top sani wipe and then take a clean super sani-wipe and wrap the glucometer and let it sit for 2 minutes, then remove the super sani-wipe and let the glucometer sit on a clean towel to air dry before using. 2 Nurses performed return demonstration. Facility staff were observed correctly sanitizing glucometers in-between residents. Immediate Jeopardy was removed on 3/6/23 at 4:30 PM

3. For Resident #16, the resident developed an avoidable stage 3 pressure ulcer and the facility staff failed carry out wound physician orders. On the afternoon of 2/28/23, Resident #16 was visited in the day room, where he was sitting in a Geri-chair. Resident #16 did not respond when spoken to. Observations revealed Resident #16 had a contracture of his left arm at the elbow. Review of the clinical record of Resident #16 revealed the following: Resident #16 had diagnoses of, but not limited to: Dementia and Hemiplegia and hemiparesis following cerebrovascular disease affecting right non-dominant side. Resident #16's care plan indicated the Resident was incontinent of bowel and bladder. The care plan also identified that Resident #16 was at risk for skin breakdown. Resident #16 was also noted as being totally dependent upon facility staff for all care needs. Resident #16 had a body audit completed 12/12/22, that noted, left antecubital [of or relating to the inner or front surface of the forearm] skin tear. On 12/14/22, a nurse entered a progress note that read, CNA reported that resident has open area to his left arm. Resident has open area noted to his left AC [antecubital]. Wound bed is red with scant amount of serosanguinous drainage noted. Area is approximately 2 cm by 2 cm. Area cleaned with normal saline and Medi honey applied with dry dressing. RP [responsible party] and NP [nurse practitioner] aware. NP in to assess and new order to clean with normal saline (at dry and apply Medi honey to area daily until healed [sic]. On 12/14/22, the nurse practitioner note indicated that Resident #16 was seen for .Generalized weakness with constipation and dysphagia . There was no mention of the Resident's skin being impaired. On 12/16/22, a Skin & Wound Evaluation was completed by the facility staff that identified the wound on Resident #16's Left antecubital space as a Stage III pressure wound, which measured 1.0 cm x 1.2 cm x 0.3 cm. On 12/18/22, Resident #16 was seen by the wound care physician/specialist that indicated, .a thorough wound care assessment and evaluation was performed today. He has a stage 3 pressure wound of the left arm . there is moderate serous exudate . A surgical excisional debridement procedure was performed to remove necrotic tissue and establish the margins of viable tissue . 15 blade was used to surgically excise devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.4 cm . The wound care physician then ordered, Dressing and treatment plan: Leptospermum honey apply once daily for 30 days; Alginate calcium apply once daily for 30 days. Secondary dressing: Gauze Island with border apply once daily for 30 days. Review of the December 2022 and January 2023, treatment administration record (TAR) revealed the order by the wound care physician was entered as Cleanse left antecubital space skin tear with NS/WC [normal saline/wound cleanser], apply Medi honey, alginate and cover with a dry dressing. every day shift every other day for Skin Tear . This treatment was performed every other day from 12/14/22-12/30/22, and on 1/1/23, for a total of 10 occurrences versus the daily treatment. On 1/2/23, the wound care physician saw Resident #16 and noted the following orders, .Dressing treatment plan: Primary Dressing(s) Alginate calcium w/[with] silver apply once daily for 30 days Secondary Dressing(s) Gauze Island w/ bdr [with border] apply once daily for 15 days . Review of the Treatment Administration Record (TAR) for January revealed the above order from 1/2/23, was transcribed to the TAR as, Cleanse left antecubital space skin tear with NS/WC. apply silver alginate and cover with a dry dressing every day shift every other day for Skin Tear. This treatment was administered every other day from 1/3/23-1/31/23, for a total of 15 treatments. In February 2023, the treatment continued every other day for a total of 15 Administrations/treatments. This wound continued to deteriorate as evidenced by the wound care physician noting in a progress note dated 2/27/23, that the Resident had . a stage 4 pressure wound of the left arm for at least 66 days duration. There is moderate serous exudate . On 3/6/23, during the afternoon, an interview was conducted with the wound care physician. During the interview, when asked about his expectation regarding treatments he orders for wound care, the physician stated he expects them to be carried out as ordered with regards to frequency. When Resident #16 was discussed, the physician stated he was not aware that the facility staff had not been providing the treatments daily as ordered. The wound care specialist physician also stated that he would expect facility staff to identify skin impairments and wounds prior to being at a stage III or greater. The facility policy titled; Pressure Injury Prevention Guidelines was reviewed. The policy read, Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this Center to implement evidence-based interventions for all patients who are assessed at risk or who have a pressure injury, and in accordance with physician/physician extender orders. During an end of day meeting held, the facility Administration was made aware of the above findings. No further information was provided. 4. For Resident #15 the facility staff failed to provide care and services for the prevention of pressure ulcers and the worsening of pressure ulcers once they have developed. On the morning of 2/28/22 a review of the facility Matrix submitted to the team revealed Resident #15 had a facility acquired state IV pressure ulcer. On 3/1/23 at approximately 10 AM, an observation was made of Resident #15 lying in bed family at bedside. Resident #15 is non communicative, mumbles at times but no meaningful conversation. Resident #15 had eyes open staring at the ceiling, she was dressed in a hospital gown and had a blanket over her. On the afternoon of 3/2/23 an observation was made while CNA D was in the room providing care, CNA D was asked to remove the blanket from Resident # 15's feet. Both feet were flat on the bed and the Surveyor noted redness to right heel. A review of the clinical record revealed that an MDS (Minimum Data Set) with an ARD of 10/19/22 was completed after admission excerpts are as follows: M-0150 At risk of developing pressure ulcers / injury? 1. Yes M-0210 - Unhealed pressure ulcers? 0 - No A review of the clinical record revealed that on 11/18/22 a body audit was conducted and described redness to coccyx. However, on 11/25/22 another body audit was done, and it stated that there was a treatment in place to the sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) not the coccyx (a triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum). A review of the clinical record revealed that on 11/28/22 Resident # 15 was seen by the wound physician for her initial wound visit for the sacral wound . The wound specialist measured the wound at 2.9 cm. x 1.9 cm x 0.4 cm and performed surgical debridement at that time as the wound was described as Full thickness 100 % necrotic. The wound physician documentation describes additional measurements and surgical debridement on the following dates: Sacral wound 12/5/22 measuring 2.9 x 1.9 x 0.4 cm with surgical debridement performed. Sacral wound 12/12/22 measuring 3.2 x 1.1 x 0.4 cm with surgical debridement performed. Sacral wound 1/30/23 measuring 3.4 x 2.8 x 1.4 cm with surgical debridement performed. Sacral wound 2/20/23 measuring 5.5 x 4.3 x 1 cm with surgical debridement performed. On 3/2/23 at 4:30 PM an interview was conducted with the LPN E (Wound Nurse) who stated that the process for identifying wounds and skin issues starts with CNA's. She stated that CNA's document any skin issues noted such as redness or open areas or rashes, in the POC (Point of Care) electronic health record. She stated this flags on the nurse's dashboard and they are to go and assess the Resident and do a body audit notify the MD get treatment orders and interventions in place. Then notify the RP (Responsible Party) The nurses will then notify the wound nurse so that she can evaluate it further. When asked about any training or certification she had in wound care LPN E stated that she had corporate training for 3 months. She did not have any documentation or proof of training to submit to team. When asked about initial assessments and staging of wounds she stated that she has an wound App that is on the phone and it measures wounds she takes a picture of a wound and the app does the measurements, however it does not measure depth of wounds. She stated that she uploads the information into the skin assessment and then confirms the accuracy with the wound doctor. She stated the wound doctor has access to PCC and can see what is uploaded into the system. On 3/6/23 at 2:45 PM an interview was conducted with the wound physician who stated that he probably does have access to PCC (the electronic health record) however he has not ever used it. When asked if he has accessed the photos attached to PCC, he stated that he has not. He stated the facility has access to him through email and phone and text. When asked when he would expect wounds to be discovered he stated that it would depend on condition of the patient but usually it starts out with redness or irritation, and small area that gets bigger over time. When asked if you would expect wounds to be found before they reach Stage III, he stated that he would. A review of Resident #15's current care plan obtained on 3/2/23 revealed that Resident #15 had no treatment or interventions for pressure ulcers in place and her care plan did not mention wounds actual or potential for pressure ulcers. On 3/3/23 during the end of day meeting the acting DON was asked if the care plan should reflect the presence of a wound and associated wound care and interventions. The acting DON stated that it should. When asked why this information was not in Resident #15's care plan she stated that it was. She then presented a care plan that read as follows: Focus Is at risk for skin breakdown pressure injury to sacrum and right heel Date Initiated: 12/19/2022 Created on: 12/19/2022. There were interventions entered for the same date (12/19/22). When the acting DON was questioned about why the copy of the care plan that the survey team obtained did not mention the wound or interventions, she stated that it had been marked as Resolved in Jan. She stated that when she was reviewing the wound she noticed that there was no mention of wounds and she, (the DON) had just Reactivated it in the system. NOTE: the care plan focus and interventions were dated 12/19/22 and the wound was identified on 11/9/22 indicating that the care plan was not updated timely and was discontinued too soon before the wound healed. On 3/8/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. On 03/01/23 at 5:08 PM, the Administrator, the interim Director of Nursing, and the Regional Clinical Registered Nurse (employee F) were notified the failure to conduct timely assessment and identification of pressure wounds constituted Immediate Jeopardy to the health and safety of the residents. The facility presented the following removal plan: 1. All residents have the potential for risk. One hundred percent completion of body audits were performed to determine residents current skin condition between 3/1/2023-3/8/2023. Any newly identified skin impairment will be assessed and have treatment initiated as ordered. Appropriate revisions will be made to the care plans to reflect all current skin impairment with preventive interventions. On 3/1/2023 The Director of Nursing or designee conducted a body audit on Residents #75. Body audits newly identified unable to stage pressure ulcer noted to her left ear, stage 3 to right buttock, sacrum [a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis] deteriorated to an unable to stage, right heel deteriorated to unable to stage, right lateral malleolus [the bony prominence on the lateral side of the ankle joint] deteriorated to unable to stage, newly acquired left medial malleolus [the small prominent bone on the inner side of the ankle] unable to stage pressure ulcer, newly acquired left heel (1) deep tissue injury, newly acquired left heel (2) unable to stage pressure ulcer, newly acquired left heel (3) unable to stage (identified on 3/2/23, reassessed on 3/3/23), newly identified left lateral malleolus deep tissue injury (identified on 3/3/2023), newly identified left foot first digit (hallux) deep tissue injury (identified on 3/3/2023) were assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury prevention interventions. The treatment nurse reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023. As of 3/6/2023, Resident #75 no longer resides in the center. On 3/1/2023 the Director of Nursing or designee conducted a body audit on Residents #16. Body audit identified stage 4 pressure area to the left antecubital space [triangular region on the anterior side of the elbow between the forearm and the anatomical arm], which was assessed, measured, an order was obtained for treatment, and treatment was initiated as ordered. Newly identified left hand lesion, not pressure related. Resident was re-assessed on 3/5/2023, newly identified DTI to right calf on 3/8/23 wound reclassified as a stage 2 pressure ulcer. At this time, the area was assessed, measured, an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury prevention interventions. The treatment nurse reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/1/2023 the Director of Nursing or designee conducted a body audit on Residents #15. Body audit identified stage 4 pressure area to the sacrum, which was assessed, measured, staged, and an order was obtained for treatment, and treatment was initiated as ordered. Newly identified DTI to the right heel. Resident was also noted with ingrown and decolorated right and left great toes. Mottling noted to bilateral feet. The wound was assessed, measure, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury prevention interventions. The treatment nurse reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023. As of 3/4/2023, resident no longer resides in facility. On 3/1/2023 and 3/2/2023 the Director of Nursing or designee conducted a body audit on Resident #39. Body audit identified stage 4 wound to the right ischial tuberosity [where the adductor and hamstring muscles of the thigh, as well as the sacrotuberous ligaments, attach], Moisture associated dermatitis to right buttock and scrotum resident also has large amount defuses [sic] scar tissue noted on both right and left buttock which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/5/2023 the Director of Nursing or designee conducted a body audit on Resident #27. Body audit identified scar tissue to sacrum, re-classification of left lateral foot from opened wound to stage 4 pressure ulcer which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/4/2023 the Director of Nursing or designee conducted a body audit on Resident #101. Body audit identified previous diabetic wound to left heel. Newly identified stage 2 right lateral malleolus [the bone on the outside of the ankle joint], pressure ulcer which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/4/2023 the Director of Nursing or designee conducted a body audit on Resident #65. Body audit identified previous moisture associated dermatitis to left buttock. On 3/8/2023, the area was reclassified as a stage 2 pressure ulcer which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/5/2023 the Director of Nursing or designee conducted a body audit on Resident #29. Body audit newly identified unable to stage to right foot fifth digit which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/5/2023 the Director of Nursing or designee conducted a body audit on Resident #365. Body audit newly identified stage 2 left buttock pressure ulcer which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/5/2023 the Director of Nursing or designee conducted a body audit on Resident #371. Body audit newly identified DTI to sacrum noted protruding sacral bone no adipose tissue present which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/4/2023 the Director of Nursing or designee conducted a body audit on Resident #105. Body audit previously identified right ischium tuberosity moisture associated dermatitis, surgical wound to right BKA [below-the-knee amputation], diabetic left heel wound. Newly identified on 3/4/2023, right hip skin tear, fungal rash to abdominal fold. Newly identified on 3/8/2023 sacral split (stage 2) which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/5/2023 the Director of Nursing or designee conducted a body audit on Resident #36. Body audit newly identified stage one right malleolus which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/3/2023 the Director of Nursing or designee conducted a body audit on Resident #14. Body audit newly identified stage one to left and right heel which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/2/2023 the Director of Nursing or designee conducted a body audit on Resident #59. Body audit newly identified stage 3 to sacrum which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/3/2023 the Director of Nursing or designee conducted a body audit on Resident #47. Body audit newly identified stage one pressure ulcer to left great toe, fungal rash to left and right breast, which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/4/2023 the Director of Nursing or designee conducted a body audit on Resident #76. Body audit newly identified unable to stage pressure ulcer to left heel, which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/5/2023 the Director of Nursing or designee conducted a body audit on Resident #100. Body audit newly identified re-opened stage four to left heel that presents as a DTI [deep tissue injury- an injury to underlying tissue below the skin's surface that results from prolonged pressure] which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/1/2023 the Director of Nursing or designee conducted a body audit on Resident #9. Body audit newly identified DTI on right and left heel, which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Body audit on 3/8/2023 identified improvements of DTI on right and left heel to stage one on left heel and stage two on right heel. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/2/2023 the Director of Nursing or designee conducted a body audit on Resident #57. Body audit newly identified stage one right buttock which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. On 3/6/2023, stage one pressure ulcer was resolved. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/5/2023 the Director of Nursing or designee conducted a body audit on Resident #22. Body audit newly identified right heel deep tissue injury, which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/3/2023 the Director of Nursing or designee conducted a body audit on Resident #117. Body audit newly identified stage three left sacrum cluster and stage three right sacrum cluster which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/1/23 the Director of Nursing or designee conducted a body audit on Resident #8. Body audit newly identified stage 3 to the sacrum. On 3/5/2023 re-classified pressure ulcer on sacrum to unable to stage, newly identified unable to stage to right lateral malleolus, stage two to the left dorsal foot. Wound rounds completed on 3/6/2023, pressure ulcer to left dorsal foot re-classified to stage three which was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/8/2023 the Director of Nursing or designee conducted an admission body audit on Resident #369. Body audit previously identified left heel unable to stage unable to stage to the sacrum was assessed, measured, staged and an order was obtained for treatment, and treatment was initiated as ordered. On 3/8/2023, newly identified stage 2 to left ischium which was assessed, measured, staged, and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. On 3/4/2023 the Director of Nursing or designee conducted an admission body audit on Resident #66. Body audit previously identified stage four to sacrum. On 3/8/2023, newly identified stage two to the right malleolus, which was assessed, measured, staged, and an order was obtained for treatment, and treatment was initiated as ordered. Appropriate revisions were made to the care plans to reflect all current pressure injury preventive interventions. Reviewed the revised care plans with all staff involved in the care of the resident on 3/3/2023-3/8/2023. 2. A. All nurses re-educated on body audit policy, center process for skin observation on admission. Proper identification of new skin impairment. Implementation of treatment and process communication to wound care nurse completed by 3/8/2023. The remaining staff education is ongoing and will be completed prior to the start of their next assigned shift until all staff re-education requirement is met. B. All certified nursing assistants will be re-educated on center process of reporting skin impairment to nurse immediately, and residents point of care documentation. This will be completed by 3/8/2023. The remaining staff education is ongoing and will be completed prior to the start of their next assigned shift until all staff re-education requirement is met. 3. To prevent reoccurrence direct care nurse will complete body audit at time of identification of skin impairment, will describe the wound in body audit, and immediately implement treatment and preventative measures. Within 24-48 hours of identification, wound nurse or designee will reassess skin impairment to identify staging, appropriate treatment, and preventative measures. 4. Completion date on 3/8/2023 at 3:00pm. The survey team did the following to verify the facility's removal plan. The survey team verified that all Residents in the IJ removal plan were assessed and had treatments in place. The survey team verified all residents in the facility had current body audits in the clinical record, and that those Residents identified with pressure wounds had wound assessments in their clinical record and treatments in place. The survey team reviewed the education provided to facility staff and verified the education was provided to the CNAs and the nurses by interviewing the CNAs and nurses. The CNAs were asked what they were expected to do if a wound or skin change is noticed. The CNAs were able to verbalize the expectation of entering it into the ADL computerized documentation and notifying the nurse. The nurses were able to verbalize that they should assess the area, notify the Resident's representative, the MD, and implement any treatments ordered, and put in place any interventions to prevent worsening or further wound development, and to notify the wound nurse of the new area. The survey team selected 10 percent of the Resident population (this included Residents who had pressure wounds and Residents who the facility identified as not having pressure wounds but were at high risk of developing pressure wounds) plus an additional six random Residents and, along with facility staff, compared the assessments and body audits with the actual wounds found on the Resident to verify the accuracy of wound description, measurements, staging, appropriateness of treatments and interventions orders. Immediate Jeopardy was removed on 3/9/23 at 12:02 PM. 5. For Resident #16 the facility staff failed to provide care and position changes for an extended period (9 hours) which resulted in the development of a Deep Tissue Injury. Review of the clinical record of Resident #16 revealed the following: Resident #16 had diagnoses of, but not limited to: Dementia and Hemiplegia and hemiparesis following cerebrovascular disease affecting right non-dominant side. Resident #16's care plan indicated the Resident was incontinent of bowel and bladder. The care plan also identified that Resident #16 was at risk for skin breakdown. Review of the interventions to prevent skin breakdown included but were not limited to: Encourage frequent position changes for pressure relief, observe for moisture and incontinence issues that affect skin. Report for further assessment if noted and Provide pressure reduction surfaces as ordered/indicated. On 2/28/23 at approximately 9:00 AM, Resident #16 was observed to reside in room [redacted] and was on droplet precautions as identified by signage on the door. Staff interviews confirmed that Resident #16 was under quarantine for COVID-19. On 2/28/23 at 10:12 AM, Resident #16 was noted to no longer be in room [redacted] and the signage had been removed from the door alerting to droplet precautions. An interview was conducted with the unit manager/LPN D. The unit manager stated that Resident #16 was being moved back to the room he was in previously, due to his quarantine period had ended at mid-night. On 2/28/23 at approximately 1:00 PM, Resident #16 was observed in a Geri chair in the day room. The assigned room th[TRUNCATED]