**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff neglected to provide goods and services to prevent and promote the healing of pressure ulcers for one resident (Resident #5) in a survey sample of 46 Residents, resulting in harm for Resident #5. Immediate Jeopardy was identified on 8/6/19 at 6:17pm and the facility was notified. After verification, Immediate Jeopardy was abated on 8/7/19 at 6:55pm and the scope and severity was lowered to level three, isolated. The findings included; 1. For Resident #5, the facility staff neglected to provide treatments, including a working air mattress for pressure a pressure ulcer. The pressure ulcer worsened from a stage 2 ulcer to a stage 4 ulcer which was identified by surveyors while onsite, resulting in harm. Resident #5 was admitted to the facility on [DATE]. Diagnoses included; vertigo, chronic kidney disease, dementia, benign prostatic hypertrophy, stroke, hypertension, congestive heart failure. and chronic Foley catheter. Resident #5's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 4-26-19. The Resident was coded with mild cognitive impairment, and no aberrant behaviors. Resident #5 required extensive assistance to total dependence on one to two staff members, for activities of daily living care. The Resident was coded as not having any pressure ulcers at the assessment time, nor on admission. The Resident had a long standing Foley catheter (urine drainage) due to an obstruction, and was incontinent of bowel. The Resident was coded as at risk for pressure sores. On 7-14-19, at 3:30 p.m., the first observation and interview of Resident #5 was conducted during initial tour of the facility. The Resident was found laying on a specialty mattress (Genesis II, a low air loss mattress), and the air motor was bogging down and humming, and not infusing air into the mattress. The mattress was flat, hard, and solid, with no air in it. The Resident was laying partially on his left side, and a Foley catheter was noted to be draining dark yellow urine with white sediment in it. The Resident was able to speak and make his needs known, and was found to be oriented to person, time, place and situation. The Resident stated he was thirsty and wanted water. There were 6 water Sippie non-spillable cups on the over-bed table which were all empty. The bedside table was 3 feet from the bed and the Resident could not reach it. Staff were notified. A second observation of Resident #5 was conducted on 7-15-19 at 4:30 p.m., and the Resident was sleeping in bed on his back. The over-bed table was found to be exactly as the last observation, and the bed was deflated with the motor still humming, but not infusing air. The air mattress was replaced on 7-16-19. A third observation occurred on 7-16-19 at 11:30 a.m., with Licensed practical nurse C (LPN C), and Certified nursing assistant N (CNA N). The nurse removed the bandage from the Resident's coccyx. The 4 inch by 4 inch single bandage had a solid center in it which was a tan telfa like non-adherent 2 inch by 2 inch square. The outer circumference of the square bandage was surrounded by a boarder of adherent malleable stretchy tape, reminiscent of Band-Aid fabric. There was no packing or medicated cream in the hollow wound. Immediately after removing the dressing a green purulent discharge was seen. The wound was circular, and deep with full muscle tissue loss and bone protrusion clearly visualized and palpated by the nurse. The wound had undermined and tunneled circumferentially around, only under the circular rolled wound edges. There was also noted yellow tan slough and black necrotic tissue inside the wound, and silvery white fascia could be seen covering the coccygeal bone protrusion. The LPN measured the wound with a long cotton swab and a wound measuring disposable paper tape. She measured the cotton swab after it was laid on the wound, and placed in the wound for an accurate measurement. The wound measured 2 centimeters (cm) long, 1.5 cm wide, and 1.5 cm deep. The exterior wound edges were rolled (epibole). The Resident was pre-medicated with pain medication and stated he felt no pain as the wound was measured. Review of the weekly skin assessment sheets since admission PCC Skin & Wound - Total Body Skin Assessment documents revealed all (including the initial) were completed by LPN's. The findings showed from 1-29-19 until 6-24-19 staff document that the resident had no new wounds however, on 4-29-19, another type of assessment document was initiated and performed by all LPN staff, Skin and Wound Evaluation V 5.0. These documents were started for a new Pressure wound stage 2 on the Resident's sacrum and was described as being treated with povidone iodine after cleaning with normal saline, and no dressing. The wound measured 3 cm long x 1.3 cm wide, no depth, and healable. None of these documents were completed after this initial one until 1 month later, on 5-27-19. On 5-27-19 the next Skin and Wound Evaluation V 5.0 document occurred one month after the first one on 4-29-19. The document describes the sacrum wound as stage 2 unchanged, healable, and documents the measurements of the wound as 1.1 cm long x 0.5 cm wide, and no depth. The treatment remains the same. No eschar, no debridement, no dressing. On 6-24-19 staff pin pointed and documented the Coccyx portion of the sacrum, instead of just stating sacrum, stage 2 pressure ulcer 1.3 cm long x 0.9 cm wide, no depth, Normal saline, and now, cover with foam dressing. Healable. No eschar, No debridement. A Left buttock and a right buttock were found as New areas on 6-24-19, however, had nothing to do with the continuing Sacrum/Coccyx wound according to nursing staff. No assessments by staff described a stage 4 pressure ulcer, and no assessments were completed from 7-14-19. through 7-16-19, until the surveyor found the stage 4 pressure ulcer on 7-16-19. All of the assessments, including the initial assessment, were completed by LPN's. Physician's orders and Medication and Treatment Administration Records (MAR's/TAR's) were reviewed and revealed no physicians order for prevention of pressure sores from bowel incontinent episodes such as an incontinence barrier cream. Only the following 4 orders appeared after the pressure sore developed for the sacral coccyx acquired pressure ulcer treatment; 1. Ordered 4-29-19 start 4-29-19 discontinued 7-8-19 Clean open area to sacrum with normal saline and apply betadine twice per day at morning and bedtime. No dressing. No change to this order occurred after 2.5 months without healing. 2. Ordered 6-3-19 start 6-4-19 discontinued 7-9-19 Clean wound with normal saline & apply Vasolex ointment to coccyx wound topically once per day & as needed with allevyn dressing. 3. Ordered 7-10-19 start 7-10-19 discontinued 7-16-19 Cleanse sacrum/coccyx with normal saline apply intrasite gel (hydrogel water gel to keep wound bed moist) and cover with coversite once every day. 4. Ordered 7-16-19 start 7-17-19 Cleanse sacral wound with saline, apply iodoform (iodine impregnated gauze for packing into a hole) and cover area with coversite one time per day, after the examination by surveyors and an LPN, and was not ordered to be administered until the following day (7-17-19) further delaying care. Review of the MAR/TAR's revealed that the pressure sore treatments that were ordered as above, were not administered on 5/18, 5/24, 6/4, 6/10, 6/20, 6/26, 7/8, and 7/9/19. No nursing notes reveal the reason for the omissions. It is of note to mention that the Vasolex ointment ordered on 6-3-19 was a debridement agent. Debridement is the removal of dead and damaged tissue from a wound. This can be completed by surgical/cutting out removal, or chemical enzyme/liquefying of dead tissue to remove it. Resident #5's skin wound evaluation documents on that date show no necrotic/dead tissue in need of debridement. An interview was conducted via telephone with the Resident's physician and all surveyors present on 7-16-19 at 6:45 p.m. The doctor stated he had seen the Resident on 7-15-19 between the hours of 7:00 a.m., to 8:00 a.m. He stated that he was aware the Resident had a wound, and had reviewed the recent nursing notes which stated the Resident had a stage 2 pressure sore, and so in his progress note dated 7-15-19, he wrote a stage 2 sacral decubitus. The nursing notes were reviewed from the doctor's previous visit of 6-22-19, none stated the Resident had a stage 2 decubitus ulcer. The doctor was informed that an RN surveyor had assessed the wound this morning (7-16-19), and he was asked if he had been made aware of the findings. He stated No. The doctor was asked if he evaluated the wound, and he stated it looked like a stage 2 when I saw him, but I was interested in the shingles, my focus was not the wound. The surveyors asked if he could describe the wound, and he stated it was on his coccyx area. The doctor was asked if a debridement agent would be used for a stage 2 decubitus ulcer which had no eschar, and he stated No., The doctor went on to say, but he has been in failing health for several months with heart disease which is an obvious factor for skin integrity, and we don't need to aggressively treat as the prognosis is poor. The doctor stated that the Resident was also losing weight and nutrition was an issue, with mineral loss. The doctor was asked why minerals and supplements had not been ordered as a replacement to mitigate this, and if that would be of value. The doctor stated yes it would be of value, but due to his age and failing health the Resident was supportive care at this stage and his overall prognosis was poor. The physician was asked why a Resident, regardless of age, who was ambulatory and recovering from a hospitalization and receiving aggressive occupational and physical therapy within the past few months would not be treated for a pressure wound. The doctor repeated I didn't go into the detail of the wound, and chose to look at the nursing notes. The doctor was asked why none of his progress notes discuss evaluation of the wound until this last note yesterday, and he responded that the Resident's prognosis was poor, and I thought he had shingles, but probably just heat rash, I was not there to see the decubitus. The DON was requested to supply surveyors with all policies for skin assessments and pressure ulcers. The DON, and Corporate RN supplied 2 facility policies on skin assessments and pressure ulcers. They are as follows; 1. Pressure ulcers Manual - Skin Assessment Skin assessments will be completed for all patients. A licensed nurse will ensure that the skin risk assessment is done upon admission, and quarterly thereafter. A skin assessment will also be completed upon re-entry to the center (i.e., after ER visit, dialysis, etc.) The weekly skin assessment will be completed thereafter. Care plan specific interventions will be developed based on skin risk assessment outcomes and individual patient needs. 2. Pressure ulcers Manual - Pressure Ulcer monitoring & A licensed nurse will assess patients for the presence of pressure ulcers: if a pressure ulcer is present, the nurse will evaluate for complications. Provide pain management prior to pressure ulcer treatment as indicated. The wound record will be completed weekly by a licensed nurse for any patient with pressure ulcers. There will be a wound record for each site. Guidance is provided for the staging of pressure ulcers by the National Pressure Ulcer Advisory Panel (NPUAP), and is as follows; NPUAP announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury FOR IMMEDIATE RELEASE April 13, 2016. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 4 Pressure Injury: If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness stage 4 pressure injury. Do not use (deep tissue pressure injury) DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. In summary, for Resident #5, the physician ordered treatments were not administered, assessments of skin, and the wound were not completed for 1 month, and the wound was identified by surveyors as a stage 4 pressure ulcer, when staff were still documenting a stage 2 wound. Orders were received for debridement of the wound on 6-3-19, when documents say there was nothing to debride. No supplements were ordered for wound healing. The physician did not evaluate the wound. The air mattress that was being used was not in working order for 3 days. The wound was initially identified as a stage 2 wound which progressed to a stage 4 wound, without staff identifying it. The Administrator, DON, and the Registered Nurse (RN) Regional Consultant were made aware of the harm level deficiency at the end of day debrief on 7-16-19. No further information was supplied by the facility. The facility presented the following plan to remove the Immediate Jeopardy: F600 Identification of those residents in which the center staff was negligent in providing care and treatment to a wound resulting in deterioration, and harm to resident. 1) Resident #5 is currently out of center. Dr. [name redacted] notified on 8.6.19 of negligence related to assessment, improper treatment, delay in initiating and implementing orders, and deterioration of wound resulting in hospitalization. 2) All patients admitted to center will have Skin and Wound Assessment completed by Registered Nurse How corrective action will be accomplished for those resident having potential to be affected by the same deficient practice: A. Education provided to registered nursing staff concerning wound identification on admission, assessment of wounds related to staging, appropriate treatment and/or intervention needed to prevent further deterioration. All Registered nurses will have education prior to next scheduled shift. This is validated through return demonstration utilizing the Skills Validation for Skin and Pressure ulcer prevention and management. B. Weekly wound rounds will be completed by DON, UM , MD and/ or MD extender will document in clinical record in physician notes and nursing wound evaluation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #72, the facility staff failed to administer insulin as scheduled. Resident #72, an [AGE] year old female, was admitted to the facility on [DATE]. Her diagnoses included but are not limited to diabetes, high blood pressure, and generalized weakness. On 7/15/19 at approximately 10:20, Resident #72 expressed concerns stating, the nurses can be slow giving me my scheduled medicines, I take insulin for my diabetes. On 7/15/19, clinical record review was conducted for Resident #72 and an excerpt from the care plan read, The resident has Diabetes Mellitus, the resident will have no complications related to diabetes .diabetes medication as ordered by doctor. The signed physician orders dated 6/24/19 read, Basaglar Kwikpen Solution Pen-injector 100 unit/ml (Insulin Glargine), inject 8 units subcutaneously one time a day for diabetes. Her dose was scheduled to be given at 9:00 AM each morning. A Medication Administration Audit Report for the previous week was requested and provided by facility staff. Resident #72 received Insulin Glargine as follows: 7/9/19, time scheduled 9:00 AM, time administered 10:49 AM 7/11/19, time scheduled 9:00 AM, time administered 10:42 AM 7/12/19, time scheduled 9:00 AM, time administered 11:46 AM 7/13/19, time scheduled 9:00 AM, time administered 11:44 AM 7/14/19, time scheduled 9:00 AM, time administered 10:56 AM 7/15/19, time scheduled 9:00 AM, time administered 10:14 AM On 7/16/19 at approximately 9:50 AM, the Director of Nursing (DON, Employee B) was interviewed and stated, the facility expectations for med pass include [medication to be given] one hour before and one hour after [the] scheduled time. When asked about the possible outcomes if insulin is not given as ordered at the scheduled time, she stated, if the resident does not receive the ordered insulin as scheduled at the correct times, it could cause an elevation in the blood sugar levels and that could cause ketoacidosis [a diabetic emergency]. Review of the facility's policy entitled, 6.0 General Dose Preparation and Medication Administration (revision date 01/01/13), under subheading Procedure, item 5.4 read, Administer medications within timeframes specified by facility policy. COMPLAINT DEFICIENCY 7. For Resident #74 the facility staff failed to follow professional standards with following physician orders for wound care. Resident #74 was admitted to the facility on [DATE]. His diagnoses included but were not limited to: sepsis, encounter for surgical aftercare following surgery of the circulatory system. Resident #74 had a prior history of an infected AV graft on his left arm. On 07/15/19 at 03:23 PM Resident #74 was observed with a border bandage on his left arm. On the bandage the following was written: 7/13/19 JS 3-11 On 7/16/19 at 11:25am Resident #74 was observed with a border dressing on his left arm. Written on the bandage was, 7/13/19 JS 3-11 Review of Resident #74's clinical record revealed a nursing note on 6/22/19 at 13:53 that read, admission skin check, dialysis AV graft to the right upper arm with tape and gauze noted and left elbow wound from an old AV graft that got infected. Review of Resident #74's treatment administration record (TAR) revealed an order, with an order date of 6/23/19 and a d/c [discontinue] date of 7/14/19, that read, wound care to the left old AV graft site: cleanse with 1/4 strength dakins solution, pack wound beds with saline soaked gauze loosely, cover with dry gauze and wrap with kling, secure with tape or stretch netting. to be done daily and prn soilage [sic] or dressing dislodgement. every evening shift for old left AV graft wound site. The border dressing observed on Resident #74's left arm which was dated 7/13/19 was not the ordered treatment for the site on 7/13/19. Review of the TAR for July 2019 revealed that the above stated order had not been carried out on 6 occasions/days from July 1-13, as ordered by the physician. Review of the physician orders for Resident #74 revealed an order with a date of 7/4/19 that read, wound care to the left old AV graft site: cleanse with NS [normal saline] cover with foam boarder [sic] dressing daily every evening shift for old left AV graft wound site. Review of the TAR for July revealed that this ordered treatment had not been completed on 7/14/19 as ordered. It had been signed off on 7/15/19 as being completed despite observation of the border dressing on 7/16/19 with the bandage dated 7/13/19. On 7/16/19 at 4:45pm LPN B was asked to read the orders for Resident #74's left arm, LPN B stated, cleanse with NS [normal saline] daily and cover with foam border dressing daily. LPN B then accompanied the surveyor to the dining room, she observed Resident #74's bandage on his left arm. Upon exit of the dining room LPN B was asked what she saw and LPN B stated, it looks like it was last changed 7/13. You are asking if I see anything wrong with it not being changed in 3 days, yes I do. On 7/16/19 the Director of Nursing (DON) was asked her expectation regarding caring out physician orders, the DON stated, I expect them to be carried out as ordered. The DON stated their nursing standards of practice is, [NAME]. According to Lippincott Manual of Nursing Practice 10th edition, 2014. Under the header Standards of Practice, it was documented on Table 2.1 entitled, Common legal claims for departure from standards of care included Failure to implement a physician's, advanced practice nurse's, or physician's assistant's order properly or in a timely fashion. COMPLAINT DEFICIENCY. 3. For Resident # 63, the facility staff failed to document the administration of medications as ordered by the physician. Resident #63, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included but were not limited to Hyperlipidemia, occlusion and stenosis of the right middle cerebral artery, Aphasia following cerebral infarction and Dysphagia. The most current Minimum Data Set (MDS) assessment was a 30 day admission assessment with an assessment reference date (ARD) of 6/23/2019. Resident # 63 was coded with a Brief Interview of Mental Status score of 7 out of 15 indicating severe cognitive impairment. She required extensive to total assistance of one to two staff persons with activities of daily living. Review of the July 2019 Medication Administration Record revealed missing documentation of medications including: Amlodipine 10 milligrams give one tablet via PEG (Percutaneous Endoscopic Gastrostomy) tube one time per day 7/13/19 at 9 a.m. Aspirin 325 milligrams give one tablet via PEG (Percutaneous Endoscopic Gastrostomy) tube one time per day 7/13/19 at 9 a.m. Baclofen 5 milligrams give one tablet via PEG (Percutaneous Endoscopic Gastrostomy) tube one time per day 7/13/19 at 9 a.m. Hydralazine 100 milligrams give one tablet via PEG (Percutaneous Endoscopic Gastrostomy) tube three times per day 7/13/19 at 8 a.m. and 7/13/19 at 2 p.m. Losartan 100 milligrams give one tablet via PEG (Percutaneous Endoscopic Gastrostomy) tube one time per day 7/13/19 at 9 a.m. Enteral Feed Order every shift Check and record residuals every shift 7/6/19-day shift, 7/9/19-day shift, 7/13/19- day shift Enteral Feed Order every shift flush tube with 20-30 milliliters of water before and after administration of medication pass 7/6/19-day shift, 7/9/19-day shift, 7/13/19- day shift Review of the July 2019 Treatment Administration Record revealed missing documentation of administration including: Enteral Feed Order every evening shift Check and record residuals every shift 7/5/19-evening shift, 7/10/19 evening shift Anchor Feeding tube every shift 7/5/19-evening shift, 7/9/19-day shift, 7/10/19- evening shift The facility policy General Dose Preparation and Medication Administration stated: 4.1.1 Verify each a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in Appendix 17: Facility Medication Administration Times Schedule. 4.1.2 Confirm that the MAR reflects the most recent medication order 5.4 Administer medications within timeframe specified by Facility policy 6.1 Document necessary medication administration/treatment information (e.g. (example) when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms. The Director of Nursing (DON) cited [NAME] as its Nursing professional guidance used by the facility. The DON stated the expectation was that medications should be administered within one hour before or after the scheduled time. Fundamentals of Nursing, by [NAME]cited as the facility nursing practice reference stated The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Guidance is given from [NAME] Solutions, Safe Medication Administration Practices, General 10/02/2015. Document all medications administered in the patient's MAR or EMAR (Electronic Medication Administration Record). If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. Additional Guidance from [NAME]'s Nursing Center.com (www.nursingcenter.com) Rights of Medication Administration . 5. Right time Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug Reference: Nursing 2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania. www.nursingcenter.com Accessed online 7/16/2019. The Administrator and DON were notified of the issue at the end of day meeting on 7/15/19. The Director of Nursing (DON) stated the expectation was that nurses would administer medications as ordered by the physician. The DON (director of nursing) stated that she was newly employed since 7/1/2019 and had identified the failure of the staff to ensure medications were documented as being administered. The DON stated her expectation was for staff to administer medications and treatments per physician's orders and to document them as having been administered, immediately following administration. No further information was provided. 4. For Resident # 503, the facility staff failed to administer medications timely as ordered by the physician. Resident # 503 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses of but not limited to Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Heart Failure and Chronic Kidney Disease Stage 3. Resident # 503's most recent (Minimum Data Set) MDS was an admission Assessment with an (Assessment Reference Date) ARD of 7/12/2019. The MDS coded her has having a (Brief Interview of Mental Status ) BIMS Score of 15 out of 15, indicating no cognitive impairment. During the initial tour of the facility on 7/14/2019 at 3:40 p.m., Resident # 503 complained that her breathing treatments and medications often were given late. Also, Resident # 503 stated medications scheduled for 7/13/2019 at 9 a.m. were not administered until 11 a.m. Review of the July 2019 MAR (Medication Administration Record) revealed documentation that all of the medications were administered on time. Review of the nurses notes revealed no documentation that any medications were administered late. On 7/15/2019 at 2:15 p.m., an interview was conducted with the Director of Nursing and the Corporate Consultant (Employee I) who both stated copy of the Medication Administration Audit Report was requested from the Corporate Consultant (Employee I) who stated he would try to obtain the report. Review of the Medication Admin Audit Report confirmed the 9:00 a.m. medications scheduled for 7/13/2019 at 9:00 a.m. were administered at 11:08 a.m. as Resident # 503 stated. Those medications were: Lisinopril 5 milligrams give 5 milligrams by mouth one time a day Spiriva HandiHaler Capsule 18 micrograms one capsule inhale orally one time a day Potassium Chloride ER (Extended Release) Tablet 20 milliequivalents give one tablet by mouth one time a day Omeprazole Delayed Release 20 milligrams give one capsule by mouth one time a day Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams/3 milliliters one vial inhale orally two times a day Further review of the Medication Admin Audit report revealed other medications administered late: Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams/3 milliliters one vial inhale orally two times a day Scheduled 7/8/2019 at 9:00 p.m., Administered 7/8/19 at 10:26 p.m. Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams/3 milliliters one vial inhale orally two times a day Scheduled 7/11/2019 at 9 p.m., Administered 7/11/19 at 10:43 p.m. The facility policy General Dose Preparation and Medication Administration stated: 4.1.1 Verify each a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in Appendix 17: Facility Medication Administration Times Schedule. 4.1.2 Confirm that the MAR reflects the most recent medication order 5.4 Administer medications within timeframe specified by Facility policy 6.1 Document necessary medication administration/treatment information (e.g. (example) when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms. The Director of Nursing (DON) cited [NAME] as its Nursing professional guidance used by the facility. The DON stated the expectation was that medications should be administered within one hour before or after the scheduled time. Fundamentals of Nursing, by [NAME]cited as the facility nursing practice reference stated The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Guidance is given from [NAME] Solutions, Safe Medication Administration Practices, General 10/02/2015. Document all medications administered in the patient's MAR or EMAR (Electronic Medication Administration Record). If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. Additional Guidance from [NAME]'s Nursing Center.com (www.nursingcenter.com) Rights of Medication Administration . 5. Right time Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug Reference: Nursing 2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania. www.nursingcenter.com Accessed online 7/16/2019. The Administrator and DON were notified of the issue at the end of day meeting on 7/15/19. The Director of Nursing (DON) stated the expectation was that nurses would administer medications as ordered by the physician. The DON (director of nursing) stated that she was newly employed since 7/1/2019 and had identified the failure of the staff to ensure medications were documented as being administered. The DON stated her expectation was for staff to administer medications and treatments per physician's orders and to document them as having been administered, immediately following administration. No further information was provided. 5. For Resident # 87, the facility staff failed to ensure the administration of medications timely as ordered by the physician. Resident # 87's original date of admission was 6/3/2019 and readmitted on [DATE] with diagnoses of but not limited to: Right hip replacement, acute embolism and thrombosis, and Hypertension. Resident #87's most recent MDS (Minimum Data Set) Assessment was a 30 day Assessment with an ARD (Assessment Reference Date) of 7/1/2019 from the original admission. The MDS coded Resident # 87 with a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating no cognitive impairment. During the initial tour of the facility on 7/14/2019 at 3:40 p.m., Resident # 87 complained that her medications often were given late. Also, Resident # 87 stated medications scheduled for 7/13/2019 at 9 a.m. were not administered until after 10 a.m. Review of the July 2019 MAR (Medication Administration Record) revealed documentation that all of the medications were administered on time. Review of the nurses notes revealed no documentation that any medications were administered late. On 7/15/2019 at 2:15 p.m., an interview was conducted with the Director of Nursing and the Corporate Consultant (Employee I) who both stated copy of the Medication Administration Audit Report was requested from the Corporate Consultant (Employee I) who stated he would try to obtain the report. Review of the Medication Admin Audit Report confirmed the 9:00 a.m. medications scheduled for 7/13/2019 at 9:00 a.m. were administered between 10:11 and 10:21 a.m. as Resident # 87 stated. Further review revealed other medications administered late: Acetaminophen 500 milligrams give two tablets by mouth for pain-Scheduled 7/13/19 at 8 a.m., administered at 10:18 a.m. Acetaminophen 500 milligrams give two tablets by mouth for pain-Scheduled 7/14/19 at 8 a.m., administered at 9:39 a.m. Docusate Sodium 100 milligrams give one capsule by mouth -scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. Fish Oil 500 milligrams one capsule by mouth-scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. Metoprolol Extended Release 200 milligrams give one tablet by mouth-scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. Olmesartan 40 milligrams give one tablet by mouth-scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. Tramadol 50 milligrams give two tablets by mouth -scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. Apixaban 5 milligrams give one tablet by mouth -scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. Cetirizine 10 milligrams give one tablet by mouth-scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. Allopurinol 100 milligrams give one tablet by mouth-scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. Furosemide 20 milligrams give one tablet by mouth-scheduled 7/15/19 at 9:00 am, administered at 11:25 a.m. Tramadol 50 milligrams give 2 tablets by mouth -scheduled 7/9/19 at 9 p.m., administered 7/10/19 at 11:53 p.m. Apixaban 5 milligrams give one tablet by mouth -scheduled 7/10/19 at 5:00 p.m., administered 7/10/19 at 9:52 p.m. Acetaminophen 500 milligrams give two tablets by mouth-scheduled 7/11/19 at 4:00 p.m., administered at 5:59 p.m. Tramadol 50 milligrams give 2 tablets by mouth -scheduled 7/11/19 at 9:00 p.m., administered at 10:40 p.m. Acetaminophen 500 milligrams give two tablets by mouth-scheduled 7/13/19 at 4:00 p.m., administered at 5:38 p.m. Acetaminophen 500 milligrams give two tablets by mouth-scheduled 7/14/19 at 4:00 p.m., administered at 5:24 p.m. The facility policy General Dose Preparation and Medication Administration stated: 4.1.1 Verify each a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in Appendix 17: Facility Medication Administration Times Schedule. 4.1.2 Confirm that the MAR reflects the most recent medication order 5.4 Administer medications within timeframe specified by Facility policy 6.1 Document necessary medication administration/treatment information (e.g. (example) when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms. The Director of Nursing (DON) cited [NAME] as its Nursing professional guidance used by the facility. The DON stated the expectation was that medications should be administered within one hour before or after the scheduled time. Fundamentals of Nursing, by [NAME]cited as the facility nursing practice reference stated The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Guidance is given from [NAME] Solutions, Safe Medication Administration Practices, General 10/02/2015. Document all medications administered in the patient's MAR or EMAR (Electronic Medication Administration Record). If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. Additional Guidance from [NAME]'s Nursing Center.com (www.nursingcenter.com) Rights of Medication Administration . 5. Right time Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug Reference: Nursing 2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania. www.nursingcenter.com Accessed online 7/16/2019. The Administrator and DON were notified of the issue at the end of day meeting on 7/15/19. The Director of Nursing (DON) stated the expectation was that nurses would administer medications as ordered by the physician. The DON (director of nursing) stated that she was newly employed since 7/1/2019 and had identified the failure of the staff to ensure medications were documented as being administered. The DON stated her expectation was for staff to administer medications and treatments per physician's orders and to document them as having been administered, immediately following administration. No further information was provided. 6. For Resident # 203, the facility staff failed to ensure the Antibiotic eyedrops, Ciprofloxacin 0.3 % eye drops and Cipro 500 milligrams tablets were administered as ordered by the physician. Resident #203, was a [AGE] year old male admitted to the facility on [DATE]. Diagnoses included but were not limited to: acute sacral fractures, progressive osteoporosis, and history of falls. Resident #203's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12-15-17 was coded as a full admission assessment. Resident #203 was coded as having a BIMS (brief interview of mental status) score of 12 out of a possible 15, or moderate cognitive impairment. Resident # 203 was also coded as requiring limited to extensive assistance of one staff member to perform activities of daily living, such as bed mobility, transferring, locomotion, and toileting. Resident # 203 was assessed as frequently incontinent of bowel and bladder. Review of the clinical record was conducted on 7/15/19. The Nurses Notes revealed documentation of green drainage from left eye on 6/25/18 at 15:34 (3:34 PM). A new order was written for Ciprofloxacin 0.3 % eye drops, 2 drops in both eyes every 8 hours for 5 days. Review of the June 2018 Medication Administration Record revealed an order written: 6/25/18 at 3:24 PM-Ciprofloxacin Solution 0.3 % instill 2 drops in both eyes every 8 hours for infection X 5 days related to conjunctivitis until 6/30/18. Scheduled Midnight, 8 AM, and 4 PM daily. Documentation revealed the eye drops were not available for administration on 6/26/18. The first dose was administered on 6/27/18 at midnight. Review of the Pharmacy Proof of Delivery invoices revealed the Ciprofloxacin Solution 0.3 % eye drops were not delivered to the facility until 6/26/18 at 9:26 PM. It was over 30 hours after the order was written before the medication was delivered to the facility. The medication was discontinued on 6/30/18. Therefore, Resident # 203 did not receive the antibiotic eye drops for 5 days. He received them for 4 days 6/27-6/30/18. There was no documentation the physician was notified. Further review of the July 2018 Medication Administration Record (MAR) revealed orders: 6/28/18 at 4:55 PM-Cipro 500 milligrams give one tablet by mouth two times a day for 7 days, scheduled at 9 AM and 6 PM-Discontinue date of 7/5/18. The first dose was given on 6/28/18 at 6 PM. There was one dose that was not administered on 6/30/18 at 6 PM because the medication was unavailable according to the nurses notes. On 7/16/19,an interview was conducted with the Assistant Director of Nursing regarding the documentation about the antibiotics. The ADON reviewed the Medication Administration Records and nurses notes. The ADON stated that the nurses should have given all of the doses of the antibiotics. The ADON also stated the physician should have been notified if any doses were missed. The ADON stated nurses should ensure the full course of all medications are administered. On 7/16/19 at 11 AM, an interview was conducted with the Corporate Consultant (Employee I) who stated nurses are expected to administer medications as ordered by the physician. Employee I stated the antibiotic, Cipro, was available in the Stat box. A copy of the Stat Box contents and the Pharmacy Proof of Delivery report were requested. Review of the facility's Stat Box contents revealed there was Cipro 250 milligrams-quantity 6 tablets available in the box. Review of the Pharmacy Proof of Delivery invoices revealed the Ciprofloxacin 500 milligrams tablets quantity 14 were delivered to the facility on 6/28/18 at 9:38 PM. Fundamentals of Nursing, by [NAME]cited as the facility nursing practice reference stated The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. The Administrator and DON were notified of the issue at the end of day meeting on 7/16/19. The Director of Nursing (DON) stated the expectation was that the Pharmacy would ensure medications would be available for nurses to administer as ordered by the physician. The DON stated the nurses were The Director of Nursing (DON) stated the expectation was that nurses would administer medications as ordered by the physician. The DON stated her expectation was for staff to administer medications and treatments per physician's orders and to document them as having been administered, immediately following administration. No further information was provided. COMPLAINT DEFICIENCY Based on observation, staff interview, facility documentation review, clinical record review, and during the course of a complaint investigation the facility staff failed to ensure professional standards of quality were met for eight Residents (Resident #5, #72, #63, #503, #87, #203, #74, #54) in a survey sample of 46 residents. This resulted in harm for Resident #5. The findings included: Immediate Jeopardy was identified on 8/6/19 at 6:17pm and the facility was notified. After verification, Immediate Jeopardy was abated on 8/7/19 at 6:55pm and the scope and severity was lowered to level three, isolated. The findings included; 1. For Resident #5, the facility staff failed to identify wounds, accurately assess wounds, obtain and implement appropriate treatment orders. Resident #5 was admitted to the facility on [DATE]. Diagnoses included; vertigo, chronic kidney disease, dementia, benign prostatic hypertrophy, stroke, hypertension, congestive heart failure. and chronic Foley catheter. Resident #5's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 4-26-19. The Resident was coded with mild cognitive impairment, and no aberrant behaviors. Resident #5 required extensive assistance to total dependence on one to two staff members, for activities of daily living care. The Resident was coded as not having any pressure ulcers at the assessment time, nor on admission. The Resident had a long standing Foley catheter (urine drainage) due to an obstruction, and was incontinent of bowel. The Resident was coded as at risk for pressure sores. At area M-0100 through M-1200 under the MDS skin conditions section of the assessment, the Resident was coded to be at risk for pressure ulcers, had no pressure ulcers, and had no other skin problems such as rashes, and or moisture associated skin damage. On 7-16-19 at 11:30 a.m., an observation of wound treatment for Resident #5 was conducted with Licensed practical nurse C (LPN C), and Certified nursing assistant N (CNA N). The nurse removed the bandage from the Resident's coccyx. The 4 inch by 4 inch single bandage had a solid center in it which was a tan telfa like non-adherent 2 inch by 2 inch square. The outer circumference of the square bandage was surrounded by a boarder of adherent malleable stretchy tape, reminiscent of Band-Aid fabric. There was no packing or medicated cream in the hollow wound. Immediately after removing the dressing a green purulent discharge was seen. The wound was circular, and deep with full muscle tissue loss and bone protrusion clearly visualized and palpated by the nurse. The wound had undermined and tunneled circumferentially around, only under the circular rolled wound edges. There was also noted yellow tan slough and black necrotic tissue inside the wound, and silvery white fascia could be seen covering the coccygeal bone protrusion. The LPN measured the wound with a long cotton swab and a wound measuring disposable paper tape. She measured the cotton swab after it was laid on the wound,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. For Resident # 62 the facility staff failed to follow their Pressure Ulcer Treatment Guide and applied barrier cream to a pressure ulcer instead of a Hydrocolloid dressing. Resident #62 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Cerebral infarction (stroke) affecting left side, Hemiplegia and Hemiparesis following stroke, Diabetes and heart failure. Resident #62's most recent MDS (minimum Data Set) with an ARD (Assessment Reference Date) of 6/24/19 coded Resident as being extensive assistance with physical assistance of 1 person for bathing, and dressing and for bed mobility, transfer and toileting she is coded as total dependence staff assistance of 2. Resident was coded as having a (Brief Interview of Mental Status) BIMS of 15. On 8/5/19 during clinical record review it was discovered that Resident # 62 had a pressure ulcer to her sacrum. On 8/5/19, observed Resident #62's sacral wound long with RN A (the unit manager). The Resident was in bed dressed in hospital gown, incontinence brief was removed and wound was found to be an open area to sacrum, uncovered by a dressing. When asked what she would consider this wound she stated it looked like Sheering kind of wound opening up the top layer of skin. When asked if the Care Plan had been updated to reflect this she indicated that it had been. According to the TAR (Treatment Administration Record) and the Physicians order the resident had been given an order on 8/1/19 at 12:43 AM for Calmoseptine (wound barrier cream) to sacrum Apply to sacrum every shift for open area on sacrum until healed The Resident care plan read: Focus: The resident has a sacral pressure ulcer. Created on 9/12/17 with a revision on date of 8/2/19. Goal: Resident's will Pressure Ulcer [sic] will show signs of healing and remain free from infection by/ through review date: Created on 9/12/17. Revision on 8/2/19. Target date 10/29/19. Interventions: Administer treatments as ordered and monitor for effectiveness. Created on 9/12/17. Revision on 8/2/19 Monitor nutritional status. Provide supplements as ordered. Monitor intake and record Created on 9/12/17 Revision on 8/2/19 Position Resident as needed created 9/12/17 Revision on 8/2/19 RESOLVED- Report dressing not intact during care to nurse- Created on 9/12/17 Revision on 12 /11/17 RESOLVED- 12/11/17 RESOLVED - Treat pain prior to treatment as needed to ensure resident's comfort Created on 9/12/17 RESOLVED 12/11/17 On 8/5/19 at approximately 4:00 PM in an interview was conducted with RN A. When asked if the care plan had been updated to include the current pressure area she stated that it should be updated and correct. On 8/5/19 at approximately 4:35 PM an interview was conducted with the DON, when asked about the treatments for wounds she stated that all the Treatment Carts have a Pressure Ulcer Treatment Guide which shows pictures of the types of wounds and the appropriate treatments for each one. When asked if all nurses and physicians had access and were aware of this, she indicated that they had all seen it and were aware. According to the facility Treatment Guide copy provided to the surveyors, with the type of wound Resident # 62 had, the nursing staff should use Hydrocolloid dressing, foam dressing, and petroleum based non-adherent dressing, transparent film or alginate cover with secondary dressing. On 8/6/19 at approximately 4:15 an interview with the Corporate RN employee I was conducted and he also stated that open areas should be covered with a dressing. On 8/7/19 at approximately 8:45 AM an interview was conducted with Employee O (Acting Medical Director), and when shown the Pressure Ulcer Treatment Guide and asked was he familiar with the document he stated that he was not and had not seen it before. When asked if a stage II wound would be an open area he said Yes you are correct. When asked if the Pressure Ulcer Treatment guide was correct when it states a Hydrocolloid dressing or another kind of protective dressing should be applied he stated Yes that is right an open wound needs a dressing. When asked if a Barrier Cream would be appropriate for an open wound he stated that it would not. He stated it is impossible for me to check everyone's skin I rely on the Nurses for that. They will tell me if I need to look at someone. He also stated that Dr. (Medical Director Employee L name redacted) usually handles the wounds as he is wound certified. On 8/7/19 during the end of day meeting the Administrator was made aware and no information was provided. 6. For Resident # 79 the facility staff failed to provide appropriate care and treatment to treat a pressure ulcer. Resident #79 had an order for her pressure ulcer dressing to be changed every three days but also had an order for Desitin paste to be applied to the pressure ulcer twice each day. In addition the pressure ulcer worsened. Resident #79 a [AGE] year old woman originally admitted to the facility on [DATE] with diagnoses of but not limited to Chronic Obstructive Pulmonary Disease, Dementia with behaviors, Urinary Tract Infection, Chronic Kidney Disease, HTN, and muscle weakness. On 8/5/19, during clinical record review, it was discovered that Resident #79 had a Stage 2 sacral pressure discovered on readmission from hospital stay. The Skin and Wound Evaluation dated 5/31/19 read: A. Describe: 1. Type: 15 Pressure 15 a -Stage: 2. Stage 2: Partial thickness skin loss with exposed dermis 22. Location: Sacrum 23. Acquired: 2. - Present on Admission B. Measurements -Area: 0.1 cm2 Length-0.5 cm Width - 0.4 cm The rest of skin assessment was left blank and notifications boxes were not checked for Practitioner or Responsible Party. Skin and wound assessment dated [DATE] shows progression of wound (wound increased in size). 1. Type - 15 Pressure 15 a -Stage: 2. Stage 2: Partial thickness skin loss with exposed dermis Location - Sacrum 23. Acquired: 2. Present on Admission B. Measurements -Area: 0.8 cm2 Length-1.6 cm Width - 0.7 cm F. Wound Pain 1. Cognitively Impaired H. Treatment: 1. Dressing appearance 6. None 2. Cleansing Solution 5. Normal Saline 4. Primary Dressing 17 Other The Physicians Orders were as follows: Desitin Max Strength Paste 40% (zinc oxide) Apply to sacral topically every day and evening shift for sacral ulcer. Order Date 6/24/19 at 3:04 PM - D/C [Discontinue] Date: 7/28/19 at 1:03 PM. A printout of Location of Administration Report shows Resident had Desitin Paste applied twice a daily to the sacrum from 7/1/19 until 7/28/19. Exuderm LP 4 X 4 Pad (Hydroactive Dressing) - Apply to back and sacrum topically every day shift every 3 days for wound. Order 7/11/19 at 3:21 PM (no end date). A printout of Location of Administration shows Nurses signed that they applied this 4 X 4 Pad (dressing) on 7/12/19, 7/15/19, 7/18/19, 7/21/19, 7/24/19, 7/27/19, 7/30/19, 8/2/19 and 8/5/19 (every 3 days as ordered) Venelex Ointment (Balsam Peru Castor Oil) Apply to sacral topically every day and evening shift for sacral ulcer. Order Date 6/24/19 at 4:09 PM (No end date). A printout of Location of Administration shows Nurses signed that they applied Venelex Ointment to sacrum twice a day from 6/24/19 to 8/5/19. On 8/6/19 at approximately 6:00 PM in an interview with the DON and Employee I (Corporate Nurse Consultant) when asked how these treatments were to be administered if one of them was a dressing to be changed every three days and the other two were creams to be applied twice a day. They must have forgotten to discontinue the creams after the dressing was ordered. The Physician Progress Notes dated 4/20/19, 4/22/19, 4/24/19, 4/26/19, 5/25/19, 6/3/19, 6/7/19, 6/28/19, 7/9/19 and 7/17/19 (all signed by Medical Director) do not address wound or assessment by the physician. Physician Progress Notes (by the acting Medical Director) read: 8/6/19 at 10:22 PM -Skin / Wound note- Resident skin to sacrum and buttocks re-assessed, resident remains on comfort care wounds to right and left buttock healed. Sacrum noted to be stage 3 full thickness wound noted about the size of a dime. No wound measurements at this time due to comfort care. Resident is at risk for further skin breakdown due to COPD, Kidney Failure, and DM. Treatment order changed to cover sacrum with Allevyn [wound dressing] Q day. New order for skin prep to bilateral heels for prevention. New order for air mattress and heels up - [Acting Medical Director Name redacted] present with nurse at bedside during assessment. RP [name redacted] Author: [DON name redacted] 8/7/19 at 8:41 AM - Assessment of right and left buttock and sacrum no wound observed to right or left buttock, stage 3 full thickness wound to sacrum, patient is on comfort measure conservative treatment at this time, current treatment order review and appropriate. Patient is at risk for unavoidable skin breakdown due to end stage copd, heart failure, and diabetes. On 8/7/19 during the end of day meeting the Administrator was made aware and no information was provided. The facility presented the following plan to remove the Immediate Jeopardy: F 686 Center staff failed to provide care and services to prevent the development of and / worsening of pressure ulcers A. Resident #5 is currently out of center. Dr. [name redacted] notified on 8.6.19 of negligence related to assessment, improper treatment, delay in initiating and implementing orders, and deterioration of wound resulting in hospitalization. B. Resident #19's AtmosAir with SAT mattress implemented on Care Plan 2.25.2016. Upon review of chart MD order was entered for AtmosAir with SAT mattress on 3.30.2016. Order was discontinued at 4.1.2016. Resident #19 is currently on an AtmosAir with SAT mattress. Dr. [name redacted] notified of negligence on 8.6.2019 related to promptly identifying and implementing treatment orders for a deterioration in the wound. Dr. [name redacted] assessed resident #19 on 8.6.2019 and clarified location of wound (sacrum), and reviewed/updated treatment order: Cleanse Sacrum with Normal Saline, apply Santyl to wound bed, apply moist 4x4 gauze, and cover with Alleyvn [sic] dressing. C. Resident #155's Bariatric Genesis III mattress implemented 8.6.2019. Dr. [name redacted] notified of negligence on 8.6.2019 related to assessment, improper treatment, delay in initiating and implementing orders, and deterioration of wound. According to Hospital Discharge Summary (Pg. 14 of 17) under wound care instructions it states General Wound Care. Furthermore in the Hospital Discharge Summary (Pg. 27 of 29) under wound care assessment it states, Open to Air. Resident admitted to center on 7.29.2019, Skin and Wound Evaluation completed by [name redacted], noted Stage 3 to Coccyx measuring 3 x 0.5 with 30% slough in wound bed. On 7.29.2019 Calmoseptine ointment was initiated. On 8.2.2019, resident seen by Charge Nurse and Corporate Nursing Consultant to re-evaluate wound due to suspected changes, new treatment from Dr. [name redacted] initiated: Cleanse Sacral ulcer with Normal Saline, Apply scant amount of Santyl with lite dressing, every shift. On 8.4.2019, [name redacted], DON adjusted treatment order per Dr. [name redacted] to: Cleanse Coccyx ulcer with Normal Saline, apply Santyl to wound bed, and cover with Alleyvn [sic] On 8.7.2019, Wound specialty Nurse RN, DON, and Dr. [name redacted] re-evaluated Stage 3 to Coccyx. Treatment updated: Cleanse Sacrum with Normal Saline, apply Santyl to wound bed, apply moist 4x4 gauze, and cover with Alleyvn [sic] dressing. D. Dr. [name redacted] notified on 8.6.19 of negligence on related to assessment, improper treatment, delay in initiating and implementing orders, and deterioration of wound on 8.6.2019 of Resident #156. On 7.31.2019 treatment order obtained from Dr. [name redacted]: Cleanse Sacrum with Normal Saline, Apply Santyl to wound bed, and cover with Allevyn Review of documentation on 7.29.2019 entered by [name redacted], ADON showed DTI to Sacrum. On 7.31.2019, DON and ADON reviewed wound, which was noted as Unstageable. Dr. [name redacted] assessed resident #156 on 8.6.2019 and clarified location of wound (sacrum), and reviewed/updated treatment order: Cleanse Sacrum with Normal Saline, apply Santyl to wound bed, apply moist 4x4 gauze, and cover with Alleyvn [sic] dressing. On 7.31.2019, AtmosAir with SAT Mattress added, on 8.4.2019 the care plan was updated and revised to reflect Device. On 8.6.2019 AtmosAir with SAT mattress was added to physician order set. How corrective action will be accomplished for those resident having potential to be affected by the same deficient practice: A) Registered Nursing staff educated in correct identification, wound staging, and appropriate treatments for initial assessment before there next scheduled shift. All licensed staff will be educated on re-evaluation of wounds, appropriate treatments, and notification to registered nurse and physician or extender if wound deterioration is suspected prior to next scheduled shift. B) Weekly wound rounds will be completed by DON, UM [unit manager] , MD and/ or MD extender and documented in physician progress notes and skin wound evaluation. 2. For Resident #19, facility staff failed to carry over wound treatment orders from the hospital, resulting in a delay in treatment. In addition, the wound worsened. Resident #19 was admitted to the facility from the hospital on [DATE]. Resident #19's diagnoses included, but were not limited to: seizures, sepsis(1), right-sided hemiplegia(2), and congestive heart failure(3). Resident #19's most recent Minimum Data Set (MDS) Assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 05/14/2019. The Brief Interview for Mental Status (BIMS) scored Resident #19 at a 9, indicating moderate impairment. Resident #19 was coded as requiring total assistance of 1 person for toileting, and requiring extensive assistance of 1 person for other Activities of Daily Life (ADLs). A review of Resident #19's medial record was conducted beginning on 08/05/2019. Resident #19 was admitted to the facility from the hospital on [DATE]. A review of Resident #19's Hospital Discharge Summary revealed the following: .Stage 3 Sacral (on the sacrum) ulcer POA (Present on admission) c/w (continue with) wound care. A review of the Hospital discharge document entitled DISCHARGE MEDICATIONS revealed the following: .iodine-sodium (IODINE) 2% external solution: Apply to affected area three (3) times daily. To left buttocks and sacral area. The Assessment entitled admission Assessment/Screening V.1.2 dated 05/08/2019 at 1:49p.m. entered by Licensed Practical Nurse (LPN) B does not contain a section reviewing the skin. No documentation of a skin issue is noted in the section entitled Other Concerns. The Assessment entitled PCC Skin and Wound - Total Body Skin Assessment dated 05/08/2019 reveals no documentation of a wound. A review of Resident #19's Physician Orders revealed the following orders: Apply betadine to left buttock every day shift - start date 07/05/2019 Apply EPC (cream) to buttocks every shift and with incontinent episodes every shift for skin protection - start date 07/23/2019 Clean left and right buttocks with NS (normal saline) apply betadine every shift for left and right buttocks open area - start date 07/29/2019 A discontinued order for Santyl(4) was noted as being initiated on 06/12/2019 and continuing until 07/01/2019. A progress note entitled Health Status Note dated 06/10/2019 at 3:40p.m. by LPN G reads: Resident was found to have an open area one[sic] the left buttock. In the same area that he usually does. Picture taken of area and RP (Responsible Party) [NAME] notified. N.O. (new orders) for prostat(5) and betadine. [RP NAME] is aware of the new orders as well. Betadine applied. Wedge cushion in placed[sic] and resident repositioned at q2h (every 2 hours). Temp 97.1, Resident remains on abt (antibiotic) therapy, 600cc (cubic centimeter) output noted yellow urine. A progress note entitled Skin/Wound Note dated 06/10/2019 at 8:30p.m. by LPN A reads: Skin Assessment Complete. Findings: Turgor: Good Elasticity Skin Color: Temperature: Warm (normal) Moisture: Normal Condition: Extremely Dry New Wounds: 1 An Assessment entitled Skin & Wound Evaluation V5.0 dated 07/08/2019 at 8:47p.m. describes the following: The form contains several sections, where the staff member may select an option for each section from multiple choices. In the section entitled Describe, the option 15. Pressure is selected. In the section Stage, the option 2. Stage 2: Partial thickness skin loss with exposed dermis is selected. In the Location, a free text box, contained the words Left Buttock. In the section Measurements, the following measurements are documented: Area: 1.2 cm2, Length: 0.9cm, Width: 2.1cm, Depth: Not Applicable, Undermining: Not applicable, Tunneling: Not applicable. No description of the wound bed is made. On the morning of 08/06/2019, an observation of Resident #19's wound was made by this surveyor and Employee B, the Director of Nursing (DON). The wound stretched horizontally across both buttocks, roughly midway down the buttock. No dressing was in place. On the left buttock, the wound bed was obscured by tan/yellow slough (dead tissue, usually cream or yellow in color). The portion of the wound on the right buttock consisted of red, moist, abraded looking skin. Employee B documented her assessment of the wound in a Skin/Wound note dated 08/06/2019 at 4:59p.m.: skin assessment of wound to right and left buttock. Left buttock noted to be UTS (unable to stage) with 90% thick adherent slough to wound bed 10% on the edges of the wound noted dark brown necrotic tissue. Periwound intact irregular edges noted to wound bed. Right buttock UTS noted to be improving dark red tissue noted with irregular edges, periwound intact. Resident #19's primary Physician was Employee L, the Medical Director. Surveyors request copies of all notes Employee L made of his visits to see Resident #19. None of Employee L's notes refer to a skin condition or pressure wound. Employee L was not available for interview during the 8/5/19 - 8/7/19 portion of the survey. On 8/7/19 at 9:14am, an interview was conducted with Employee O, another facility Physician and the Acting Medical Director in Employee L's absence, in the conference room. When asked about skin assessments; he replied: I do not do a full skin exam, when they shower and look at their skin, they would determine that. I cover 6 different facilities and it's just not physically possible. I go by their assessment unless they say come look at this wound, then I look at it. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 08/07/2019. No further documentation was provided. 3. For Resident #155, facility staff failed to assess the resident and initiate treatment for pressure wounds upon admission, resulting in a delay in treatment. In addition, the wound worsened. Resident #155 was admitted to the facility on [DATE]. His diagnoses included but were not limited to: atrial fibrillation (6), hypertension (elevated blood pressure), and muscle weakness. Resident #155's most recent MDS Assessment was an Entry Assessment with an ARD of 07/29/2019. The Entry MDS did not have the BIMS or ADL Assessment completed. Resident #155 had a Skin/Wound Evaluation V5.0 assessment dated [DATE] at 6:42p.m. by LPN I. This assessment described a Stage 3 pressure ulcer with 30% slough. A Review of Resident #155's Physician Orders dated 08/05/2019 revealed an order for: Santyl Ointment 250 UNIT/GM (Collagenase) Apply to sacrum topically every evening shift for decubitus related to RASH AND OTHER NONSPECIFIC SKIN ERUPTION (R21) clean sacral ulcer with NS, apply scant amount of Santyl ointment with light drsg (dressing) q (every) evening. No order was noted for an alternative/specialty air mattress. Resident #155's Comprehensive Care Plan revealed a Focus of: actual skin impairment pressure ulcer to coccyx (tailbone) This focus had a created on date of 08/02/2019 and a revision date of 08/04/2019. No orders related to wound care with an earlier start date were found. On the morning of 08/06/2019, an observation of Resident #155's wound was conducted by this surveyor and Employee B, the DON. Resident #155's wound was observed with a slough-filled base with red borders. The wound was covered with a clear plastic opsite style dressing over gauze. The dressing was clean but was not dated. Employee B documented her observation in a Skin/Wound note dated 08/06/2019 at 4:57p.m. The note states: assessment of residents [sic] coccyx wound assessed today noted stage 3 to coccyx with 50% slough to wound bed periwound intact. Will continue with current treatment plan. A review of the facility document entitled Pressure Ulcer Treatment Guidance revealed the following under the heading for Pressure Ulcers - Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, black) in the wound bed. Resident #155's primary Physician was Employee L, the Medical Director. Surveyors request copies of all notes Employee L made of his visits to see Resident #155. None of Employee L's notes refer to a skin condition or pressure wound. Employee L was not available for interview during the 8/5/19 - 8/7/19 portion of the survey. On 8/7/19 at 9:14am an interview was conducted with Employee O, another facility Physician and the Acting Medical Director in Employee L's absence, in the conference room. When asked about skin assessments; he replied: I do not do a full skin exam, when they shower and look at their skin, they would determine that. I cover 6 different facilities and it's just not physically possible. I go by their assessment unless they say come look at this wound, then I look at it. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 08/07/2019. No further documentation was provided. 4. For Resident #156, facility staff failed to carry over wound treatment orders from the hospital, resulting in a delay in treatment. In addition, the wound worsened. Resident #156 was admitted to the facility on [DATE]. His diagnoses included but were not limited to: discitis (inflammation of the discs of the spine), muscle weakness, hypertension, and chronic kidney disease (7). Resident #156's most recent MDS Assessment was an Admission/5 Day Assessment with an ARD of 08/02/2019. The BIMS scored Resident #156 at a 14, indicating little to no impairment. Resident #156 was coded as requiring extensive assistance of 1 person for bed mobility, transfers, and dressing; and requiring extensive setup assistance for ambulation, eating, and personal hygiene. A review of Resident #156's medical record was conducted beginning on 08/05/2019. It was noted that Resident #156 was admitted to the facility from the hospital on [DATE]. Resident #156's hospital Discharge Documentation revealed, under Discharge Wound Care Instructions: Therahoney(8) Gel and Silicone foam dressing to sacral area/buttocks - change daily after cleansing with saline. An admission Note dated 07/26/2019 at 4:03p.m. describes numerous small abrasions to Resident #156's arms and legs but does not describe a wound to the sacrum/buttocks. A Skin/Wound note dated 07/29/2019 at 10:21a.m. by Employee K, the Assistant Director of Nursing (ADON) states: New admission Skin Assessment completed, resident with scattered old scabs to bilateral arms and feet, and small abrasion to Left knee, all of which are open to air. Resident has a vascular area to right great toe 1.5cm x .5cm no drainage noted. Resident also has a DTI (deep tissue injury) 6cm x 2.1 treatment in place. Resident is educated to the importance of off loading pressure to his sacrum, verbalizes understanding. A review of Resident #156's Physician Orders dated 08/05/2019 reveals no orders for treatment of the sacral wound. A Review of Resident #156's Comprehensive Care Plan reveals a Focus entitled The Resident has an actual pressure ulcer sacrum and right toe development r/t (related to) immobility. The focus has a Created On of 08/04/2019 and a Revision on of the same date. On the morning of 08/06/2019, this surveyor observed Resident #156's wound with the DON. The wound displayed eschar and slough to the base of the wound, with tunneling at the 12 o'clock to 1 o'clock position. Employee B, the DON, documented her observation in a Skin/Wound Note dated 08/06/2019 at 5:04p.m.: assessed resident wound to sacrum noted 75% black Eschar from 3 o'clock to 6 o'clock of wound bed 25% slough noted around wound edges. Edges of wound irregular tunneling noted at 12 o'clock. Will continue with current treatment plan. Resident #155's primary Physician was Employee L, the Medical Director. Surveyors request copies of all notes Employee L made of his visits to see Resident #155. None of Employee L's notes refer to a skin condition or pressure wound. Employee L was not available for interview during the 8/5/19 - 8/7/19 portion of the survey. On 8/7/19 at 9:14am, an interview was conducted with Employee O, another facility Physician and the Acting Medical Director in Employee L's absence, in the conference room. When asked about skin assessments; he replied: I do not do a full skin exam, when they shower and look at their skin, they would determine that. I cover 6 different facilities and it's just not physically possible. I go by their assessment unless they say come look at this wound, then I look at it. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 08/07/2019. No further documentation was provided. 1. Sepsis is a serious illness. It happens when your body has an overwhelming immune response to a bacterial infection. The chemicals released into the blood to fight the infection trigger widespread inflammation. This leads to blood clots and leaky blood vessels. They cause poor blood flow, which deprives your body's organs of nutrients and oxygen. In severe cases, one or more organs fail. In the worst cases, blood pressure drops and the heart weakens, leading to septic shock. - https://medlineplus.gov/sepsis.html 2. Hemiplegia, paralysis of the muscles of the lower face, arm, and leg on one side of the body. - https://www.britannica.com/science/hemiplegia 3. Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. - https://medlineplus.gov/heartfailure.html 4. This product is used to help the healing of burns and skin ulcers. Collagenase is an enzyme. It works by helping to break up and remove dead skin and tissue. This effect may also help antibiotics to work better and speed up your body's natural healing process. - https://www.medicinenet.com/collagenase_oint-topical/article.htm 5. Prostat is a high protein liquid nutrition supplement. - https://www.medline.com/product/Pro-Stat-Sugar-Free-Liquid-Protein-Nutritional-Supplement/Z05-PF11003 6. An arrhythmia is a problem with the speed or rhythm of the heartbeat. Atrial fibrillation (AF) is the most common type of arrhythmia. The cause is a disorder in the heart's electrical system. - https://medlineplus.gov/atrialfibrillation.html 7. Chronic kidney disease (CKD) means that your kidneys are damaged and can't filter blood as they should. This damage can cause wastes to build up in your body. It can also cause other problems that can harm your health. Diabetes and high blood pressure are the most common causes of CKD. - https://medlineplus.gov/chronickidneydisease.html 8. TheraHoney Gel Honey Dressing has high sugar level that helps promote autolytic debridement of necrotic tissue, a moist wound healing environment and rapidly reduces wound odor. - https://www.healthproductsforyou.com/p-therahoney-wound-gel-honey-dressing.html Based on observation, Resident interview, spouse interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to perform services to prevent and promote the healing of pressure ulcers for six residents (Resident #5, #19, #155, #156, #62, #79) in a survey sample of 46 Residents, resulting in harm for Resident #5. Immediate Jeopardy was identified on 8/6/19 at 6:17pm and the facility was notified. After verification, Immediate Jeopardy was abated on 8/7/19 at 6:55pm and the scope and severity was lowered to level three, isolated. The findings included; 1. For Resident #5, the facility staff failed to provide ordered treatments, monitoring for worsening of the ulcer for an acquired potentially avoidable stage 4 pressure ulcer. The staff then failed to change the treatment of the ulcer as it worsened from a stage 2 ulcer to a stage 4 ulcer which was identified by surveyors while onsite, resulting in harm. Resident #5 was admitted to the facility on [DATE]. Diagnoses included; vertigo, chronic kidney disease, dementia, benign prostatic hypertrophy, stroke, hypertension, congestive heart failure. and chronic Foley catheter. Resident #5's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 4-26-19. The Resident was coded with mild cognitive impairment, and no aberrant behaviors. Resident #5 required extensive assistance to total dependence on one to two staff members, for activities of daily living care. The Resident was coded as not having any pressure ulcers at the assessment time, nor on admission. The Resident had a long standing Foley catheter (urine drainage) due to an obstruction, and was incontinent of bowel. The Resident was coded as at risk for pressure sores. At area M-0100 through M-1200 under the MDS skin conditions section of the assessment, the Resident was coded to be at risk for pressure ulcers, had no pressure ulcers, and had no other skin problems such as rashes, and or moisture associated skin damage. The only preventative measure for skin breakdown ordered by a physician, for the Resident, was a ROHO wheel chair cushion ordered 4-21-19 (3 months after admission) and the day before PT was discontinued. The cushion was signed as administered, and was observed in the Resident room in his wheel chair. On 7-14-19, at 3:30 p.m., the first observation and interview of Resident #5[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility failed to ensure nursing staff have the appropriate skills and competencies to conduct assessment and treatment of pressure injuries which resulted in deterioration of the injuries and/or hospitalization for one resident (Resident #5) in a survey sample of 46 Residents, resulting in harm for Resident #5. Immediate Jeopardy was identified on 8/6/19 at 6:17pm and the facility was notified. After verification, Immediate Jeopardy was abated on 8/7/19 at 6:55pm and the scope and severity was lowered to level three, isolated. The findings included; 1. For Resident #5, staff continually failed to accurately assess a pressure ulcer, resulting in harm. Resident #5 was admitted to the facility on [DATE]. Diagnoses included; vertigo, chronic kidney disease, dementia, benign prostatic hypertrophy, stroke, hypertension, congestive heart failure. and chronic Foley catheter. Resident #5's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 4-26-19. The Resident was coded with mild cognitive impairment, and no aberrant behaviors. Resident #5 required extensive assistance to total dependence on one to two staff members, for activities of daily living care. The Resident was coded as not having any pressure ulcers at the assessment time, nor on admission. The Resident had a long standing Foley catheter (urine drainage) due to an obstruction, and was incontinent of bowel. The Resident was coded as at risk for pressure sores. At area M-0100 through M-1200 under the MDS skin conditions section of the assessment, the Resident was coded to be at risk for pressure ulcers, had no pressure ulcers, and had no other skin problems such as rashes, and or moisture associated skin damage. A wound observation occurred on 7-16-19 at 11:30 a.m., with Licensed practical nurse C (LPN C), and Certified nursing assistant N (CNA N). The nurse removed the bandage from the Resident's coccyx. The 4 inch by 4 inch single bandage had a solid center in it which was a tan telfa like non-adherent 2 inch by 2 inch square. The outer circumference of the square bandage was surrounded by a boarder of adherent malleable stretchy tape, reminiscent of Band-Aid fabric. There was no packing or medicated cream in the hollow wound. Immediately after removing the dressing a green purulent discharge was seen. The wound was circular, and deep with full muscle tissue loss and bone protrusion clearly visualized and palpated by the nurse. The wound had undermined and tunneled circumferentially around, only under the circular rolled wound edges. There was also noted yellow tan slough and black necrotic tissue inside the wound, and silvery white fascia could be seen covering the coccygeal bone protrusion. The LPN measured the wound with a long cotton swab and a wound measuring disposable paper tape. She measured the cotton swab after it was laid on the wound, and placed in the wound for an accurate measurement. The wound measured 2 centimeters (cm) long, 1.5 cm wide, and 1.5 cm deep. The exterior wound edges were rolled (epibole). The Resident was pre-medicated with pain medication and stated he felt no pain as the wound was measured. Nursing progress notes were reviewed from wound identification to the time of survey. No notes describe any pressure ulcer identification, treatments, assessments for pressure ulcers, or changes to the care plan for Resident #5 after the first identification of the wound on 4-29-19. The initial note described the pressure injury as a red bruise with open skin, and the skin evaluation document of 4-29-19 gave further measurements. Review of the weekly skin assessment sheets since admission PCC Skin & Wound - Total Body Skin Assessment documents revealed all (including the initial) were completed by LPN's. The findings were as follows; 1-29-19 - no new wounds 2-5-19 - no new wounds 2-12-19 - no new wounds 2-19-19 - no new wounds 2-26-19 - no new wounds 3-5-19 - no new wounds 3-13-19 - no new wounds 3-25-19 -no new wounds 4-1-19 - no new wounds 4-8-19 -no new wounds 4-15-19 -no new wounds 4-22-19 -no new wounds From 4-22-19 through 5-26-19, no weekly skin checks were completed. 5-27-19 -no new wounds 6-3-19 -no new wounds 6-10-19 -no new wounds 6-17-19 - no new wounds 6-24-19 - 2 new wounds (left and right buttocks) 7-1-19 -no new wounds 7-8-19 -no new wounds 7-15-19 -no new wounds. On 4-29-19, another type of assessment document was initiated and performed by all LPN staff, Skin and Wound Evaluation V 5.0. These documents were started for a new Pressure wound stage 2 on the Resident's sacrum and was described as being treated with povidone iodine after cleaning with normal saline, and no dressing. The wound measured 3 cm long x 1.3 cm wide, no depth, and healable. None of these documents were completed after this initial one until 1 month later, on 5-27-19. The Rest of these particular assessment documents follow below in chronological order: On 5-27-19 the next Skin and Wound Evaluation V 5.0 document occurred one month after the first one on 4-29-19. The document describes the sacrum wound as stage 2 unchanged, healable, and documents the measurements of the wound as 1.1 cm long x 0.5 cm wide, and no depth. The treatment remains the same. No eschar, no debridement, no dressing. On 6-3-19 Sacrum stage 2 pressure ulcer 1.7 cm long x 0.5 cm wide, no depth, same treatment. Healable. No eschar, No debridement, no dressing. On 6-10-19 sacrum stage 2 pressure ulcer 1.9 cm long x 0.5 cm wide, no depth, same treatment. Healable. No eschar, No debridement, no dressing. On 6-17-19 sacrum stage 2 pressure ulcer 1.2 cm long x 0.6 cm wide, no depth, same treatment. Healable. No eschar, No debridement, no dressing. On 6-24-19 staff pin pointed and documented the Coccyx portion of the sacrum, instead of just stating sacrum, stage 2 pressure ulcer 1.3 cm long x 0.9 cm wide, no depth, Normal saline, and now, cover with foam dressing. Healable. No eschar, No debridement. A Left buttock and a right buttock were found as New areas on 6-24-19, however, had nothing to do with the continuing Sacrum/Coccyx wound according to nursing staff. On 7-2-19 coccyx stage 2 pressure ulcer 1.4 cm long x 0.2 cm wide, no depth, same treatment. Healable. No debridement, No eschar. On 7-8-19 coccyx stage 2 pressure ulcer 1.5 cm long x 0.5 cm wide, no depth, same treatment. Healable, Deteriorating. No debridement, No eschar. On 7-9-19 (one day later) the last assessment documented coccyx stage 2 pressure ulcer 1.2 cm long x 0.6 cm wide, no depth, Eschar 20%, deteriorating, healable, treatment; normal saline and enzymatic debridement (ordered 6-3-19). No assessments by staff described a stage 4 pressure ulcer, and no assessments were completed from 7-14-19. through 7-16-19, until the surveyor found the stage 4 pressure ulcer on 7-16-19. All of the assessments, including the initial assessment, were completed by LPN's. The DON was requested to supply surveyors with all policies for skin assessments and pressure ulcers. The DON, and Corporate RN supplied 2 facility policies on skin assessments and pressure ulcers. They are as follows; 1. Pressure ulcers Manual - Skin Assessment Skin assessments will be completed for all patients. A licensed nurse will ensure that the skin risk assessment is done upon admission, and quarterly thereafter. A skin assessment will also be completed upon re-entry to the center (i.e., after ER visit, dialysis, etc.) The weekly skin assessment will be completed thereafter. Care plan specific interventions will be developed based on skin risk assessment outcomes and individual patient needs. 2. Pressure ulcers Manual - Pressure Ulcer monitoring & A licensed nurse will assess patients for the presence of pressure ulcers: if a pressure ulcer is present, the nurse will evaluate for complications. Provide pain management prior to pressure ulcer treatment as indicated. The wound record will be completed weekly by a licensed nurse for any patient with pressure ulcers. There will be a wound record for each site. Guidance is provided for the staging of pressure ulcers by the National Pressure Ulcer Advisory Panel (NPUAP), and is as follows; NPUAP announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury FOR IMMEDIATE RELEASE April 13, 2016. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant (fat) adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. Stage 4 Pressure Injury: If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness stage 4 pressure injury. Do not use (deep tissue pressure injury) DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The Administrator, DON, and the Registered Nurse (RN) Regional Consultant were made aware of the harm level deficiency at the end of day debrief on 7-16-19. No further information was supplied by the facility. The facility presented the following plan to remove the Immediate Jeopardy: F726 Center failed to ensure Nursing staff have appropriate skills and competencies to conduct assessment and treatment of pressure of pressure injuries resulting in deterioration of injuries /hospitalization Registered Nurse Consultant educated Director of Nursing (DON) on wound identification, Staging, and appropriate treatment on 8.6.2019. Competency validated through wound rounds and visualizing DON completing assessments. DON will assume responsibility of coordinating Weekly Wound Rounds. Registered Nursing staff educated in correct identification, wound staging, and appropriate treatments for initial assessment before there next scheduled shift.All licensed staff will be educated on re-evaluation of wounds, appropriate treatments, and notification to registered nurse and physician or extender if wound deterioration is suspected prior to next scheduled shift. This is validated through return demonstration utilizing the Skills Validation for Skin and Pressure ulcer prevention and management. Wound identification charts with appropriate treatments/products, based on staging, are available to staff in the narcotic books on each of the medication carts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility has failed to ensure the Medical Director has coordinated medical care in the facility and implemented resident care policies for one resident (Resident #5) in a survey sample of 46 Residents, resulting in harm for Resident #5. Immediate Jeopardy was identified on 8/6/19 at 6:17pm and the facility was notified. After verification, Immediate Jeopardy was abated on 8/7/19 at 6:55pm and the scope and severity was lowered to level three, isolated. The findings included; 1. For Resident #5, the facility staff failed to ensure the Medical Director has coordinated medical care, resulting in harm. Resident #5 was admitted to the facility on [DATE]. Diagnoses included; vertigo, chronic kidney disease, dementia, benign prostatic hypertrophy, stroke, hypertension, congestive heart failure. and chronic Foley catheter. Resident #5's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 4-26-19. The Resident was coded with mild cognitive impairment, and no aberrant behaviors. Resident #5 required extensive assistance to total dependence on one to two staff members, for activities of daily living care. The Resident was coded as not having any pressure ulcers at the assessment time, nor on admission. The Resident had a long standing Foley catheter (urine drainage) due to an obstruction, and was incontinent of bowel. The Resident was coded as at risk for pressure sores. At area M-0100 through M-1200 under the MDS skin conditions section of the assessment, the Resident was coded to be at risk for pressure ulcers, had no pressure ulcers, and had no other skin problems such as rashes, and or moisture associated skin damage. A wound observation occurred on 7-16-19 at 11:30 a.m., with Licensed practical nurse C (LPN C), and Certified nursing assistant N (CNA N). The nurse removed the bandage from the Resident's coccyx. The 4 inch by 4 inch single bandage had a solid center in it which was a tan telfa like non-adherent 2 inch by 2 inch square. The outer circumference of the square bandage was surrounded by a boarder of adherent malleable stretchy tape, reminiscent of Band-Aid fabric. There was no packing or medicated cream in the hollow wound. Immediately after removing the dressing a green purulent discharge was seen. The wound was circular, and deep with full muscle tissue loss and bone protrusion clearly visualized and palpated by the nurse. The wound had undermined and tunneled circumferentially around, only under the circular rolled wound edges. There was also noted yellow tan slough and black necrotic tissue inside the wound, and silvery white fascia could be seen covering the coccygeal bone protrusion. The LPN measured the wound with a long cotton swab and a wound measuring disposable paper tape. She measured the cotton swab after it was laid on the wound, and placed in the wound for an accurate measurement. The wound measured 2 centimeters (cm) long, 1.5 cm wide, and 1.5 cm deep. The exterior wound edges were rolled (epibole). The Resident was pre-medicated with pain medication and stated he felt no pain as the wound was measured. Nursing progress notes were reviewed from wound identification to the time of survey. No notes describe any pressure ulcer identification, treatments, assessments for pressure ulcers, or changes to the care plan for Resident #5 after the first identification of the wound on 4-29-19. The initial note described the pressure injury as a red bruise with open skin, and the skin evaluation document of 4-29-19 gave further measurements. Physician's orders and Medication and Treatment Administration Records (MAR's/TAR's) were reviewed and revealed no physicians order for prevention of pressure sores from bowel incontinent episodes such as an incontinence barrier cream. Only the following 4 orders appeared after the pressure sore developed for the sacral coccyx acquired pressure ulcer treatment; 1. Ordered 4-29-19 start 4-29-19 discontinued 7-8-19 Clean open area to sacrum with normal saline and apply betadine twice per day at morning and bedtime. No dressing. No change to this order occurred after 2.5 months without healing. 2. Ordered 6-3-19 start 6-4-19 discontinued 7-9-19 Clean wound with normal saline & apply Vasolex ointment to coccyx wound topically once per day & as needed with allevyn dressing. 3. Ordered 7-10-19 start 7-10-19 discontinued 7-16-19 Cleanse sacrum/coccyx with normal saline apply intrasite gel (hydrogel water gel to keep wound bed moist) and cover with coversite once every day. 4. Ordered 7-16-19 start 7-17-19 Cleanse sacral wound with saline, apply iodoform (iodine impregnated gauze for packing into a hole) and cover area with coversite one time per day, after the examination by surveyors and an LPN, and was not ordered to be administered until the following day (7-17-19) further delaying care. Review of the MAR/TAR's revealed that the pressure sore treatments that were ordered as above, were not administered on 5/18, 5/24, 6/4, 6/10, 6/20, 6/26, 7/8, and 7/9/19. No nursing notes reveal the reason for the omissions. It is of note to mention that the Vasolex ointment ordered on 6-3-19 was a debridement agent. Debridement is the removal of dead and damaged tissue from a wound. This can be completed by surgical/cutting out removal, or chemical enzyme/liquefying of dead tissue to remove it. Resident #5's skin wound evaluation documents on that date show no necrotic/dead tissue in need of debridement. An interview was conducted via telephone with the Resident's physician (who was also the facility medical director) and all surveyors present on 7-16-19 at 6:45 p.m. The doctor stated he had seen the Resident on 7-15-19 between the hours of 7:00 a.m., to 8:00 a.m. He stated that he was aware the Resident had a wound, and had reviewed the recent nursing notes which stated the Resident had a stage 2 pressure sore, and so in his progress note dated 7-15-19, he wrote a stage 2 sacral decubitus. The nursing notes were reviewed from the doctor's previous visit of 6-22-19, none stated the Resident had a stage 2 decubitus ulcer. The doctor was informed that an RN surveyor had assessed the wound this morning (7-16-19), and he was asked if he had been made aware of the findings. He stated No. The doctor was asked if he evaluated the wound, and he stated it looked like a stage 2 when I saw him, but I was interested in the shingles, my focus was not the wound. The surveyors asked if he could describe the wound, and he stated it was on his coccyx area. The doctor was asked if a debridement agent would be used for a stage 2 decubitus ulcer which had no eschar, and he stated No., The doctor went on to say, but he has been in failing health for several months with heart disease which is an obvious factor for skin integrity, and we don't need to aggressively treat as the prognosis is poor. The doctor stated that the Resident was also losing weight and nutrition was an issue, with mineral loss. The doctor was asked why minerals and supplements had not been ordered as a replacement to mitigate this, and if that would be of value. The doctor stated yes it would be of value, but due to his age and failing health the Resident was supportive care at this stage and his overall prognosis was poor. The physician was asked why a Resident, regardless of age, who was ambulatory and recovering from a hospitalization and receiving aggressive occupational and physical therapy within the past few months would not be treated for a pressure wound. The doctor repeated I didn't go into the detail of the wound, and chose to look at the nursing notes. The doctor was asked why none of his progress notes discuss evaluation of the wound until this last note yesterday, and he responded that the Resident's prognosis was poor, and I thought he had shingles, but probably just heat rash, I was not there to see the decubitus. The DON was requested to supply surveyors with all policies for skin assessments and pressure ulcers. The DON, and Corporate RN supplied 2 facility policies on skin assessments and pressure ulcers. They are as follows; 1. Pressure ulcers Manual - Skin Assessment Skin assessments will be completed for all patients. A licensed nurse will ensure that the skin risk assessment is done upon admission, and quarterly thereafter. A skin assessment will also be completed upon re-entry to the center (i.e., after ER visit, dialysis, etc.) The weekly skin assessment will be completed thereafter. Care plan specific interventions will be developed based on skin risk assessment outcomes and individual patient needs. 2. Pressure ulcers Manual - Pressure Ulcer monitoring & A licensed nurse will assess patients for the presence of pressure ulcers: if a pressure ulcer is present, the nurse will evaluate for complications. Provide pain management prior to pressure ulcer treatment as indicated. The wound record will be completed weekly by a licensed nurse for any patient with pressure ulcers. There will be a wound record for each site. The Administrator, DON, and the Registered Nurse (RN) Regional Consultant were made aware of the harm level deficiency at the end of day debrief on 7-16-19. No further information was supplied by the facility. The facility presented the following plan to remove the Immediate Jeopardy: F841 Identification of those residents were the Medical Director failed to coordinate medical care in the center and ensure timely and appropriate treatment for wound management Resident #5's Medical Director failed to coordinate medical care in the center and ensure timely and appropriate treatment for wound management. Current Acting Medical Director, Dr. [redacted] , notified on 8/6/19 of negligence from lack of oversight. How corrective action will be accomplished for those residents having potential to be affected by the same deficient practice Acting Medical Director, Dr. [redacted] has been notified on 8/6/19 of Medical Director Responsibilities: those responsibilities are as follows 1. Directing and Coordinating care in the center 2. Coordinating Physical Exams, which also includes skin assessment, documenting all assessments in patient clinical record with current treatment plan. 3. Participates in Policy, Procedures and Guidelines to oversee comprehensive care of patients 4. Participates in Resident Care Management 5. Improves Performance of Medical Services within the center 6. Participates in QAPI process