**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R32 had diagnoses including fracture of left pubis (admission diagnosis), moderate protein calorie malnutrition, and diabetes mellitus type 2. R32's MDS assessment, dated 9/5/24, indicated R32 had no behaviors or rejection of care and had two stage 4 unhealed pressure injuries. R32 had a BIMS score of 14 which indicated R32 was cognitively intact; however, R32 was a poor historian. R32's care plan, initiated 4/11/24, indicated R32 had potential/actual impairment to skin integrity and was at high-risk due to multiple open wounds (revised 10/22/24). Care plan interventions on admission included: The resident will maintain or develop clean and intact skin by the review date; Keep skin clean and dry. Use lotion on dry skin as ordered/desired/needed; Meds/labs/treatments as ordered. An active physician order with a start date of 5/23/24 stated, Reposition every hour, document refusals, three time a day for repositioning. A Braden Scale assessment, dated 9/1/24, had a score of 12.0 which indicated R32 was at high risk for pressure injuries. R32 had wound care to be done every Monday and Friday by the facility and every Wednesday in the wound clinic. On 7/24/24, R32 was noted to have stage 4 pressure injuries on the coccyx/sacrum and left trochanter/hip. A facility Pressure Injury Weekly Tracker showed: Sacrum 2.4 x 1.4 x 4.2 stage 4, necrotic Left hip: No wound measurements on assessment by the facility Wound Clinic (WC) measurements indicated: Coccyx: 2.4 x 1.4 x 4.2, foul odor, exposed bone and muscle, stage 4 Left hip: 4.0 x 3.7 x 5.1, with tunnel, stage 4 (there was no measurement of the tunnel) WC treatment orders indicated: Wash with Dakin's 0.25% solution. Skin prep to peri-wounds. Bridge wound vac to cover both wounds. Wound vac set to -125 mmHg (millimeters of mercury). To be changed Monday and Friday at the nursing home and Wednesdays in the wound clinic. A WC physician note indicated: No wound vac was applied or came with the patient today. We will do a dakin's wet to dry covered with 4x4 Allevyn in clinic but Nursing Home, please get the wound vac applied today. R32's Treatment Administration Record (TAR) indicated: Wet to dry dressing with normal saline and Kerlix. Skin prep around wound to protect healthy skin and cover with foam adherent dressing. To be completed TID (three times daily) and as needed until wound vac supplies arrive. The treatment was not signed out on 7/22 noon, 7/23 PM, or 7/24 PM. R32's medical record did not indicate the WC physician was updated that R32's wound vac was removed. On 7/31/24, a Pressure Injury Weekly Tracker indicated: Sacrum: 2.2 x 1.4 x 2.5 stage 4, granulation Left hip: 3.2 x 3.2 x 6.3 stage 4, granulation (increased depth of left hip) There were no new interventions on R32's care plan. WC treatment orders indicated: Wound vac-wash with Dakin's 0.25% solution. Apply vacuum-assisted closure device at -125 mmHg. With green foam to left hip and coccyx (note change in treatment to green foam). With bridge dressing to cover both wounds. Apply skin prep to peri-wound and transparent semi-permeable cover dressing. One time a day every Monday, Wednesday, Friday for wound care. Wound clinic to change wound vac on Wednesdays. On 8/7/24, WC measurements indicated: Coccyx: 2.2 x 1.9 x 2.8, with foul odor Left hip: 3.3 x 3.4 x 3.5, with tunnel 8.0 cm A nurses note, dated 8/11/24 at 5:40 PM, stated, Resident refused repositioning at 1600 (4:00 PM); agreed to lift up on arms to give buttocks a break from sitting but refused to lay down and get off buttocks. This was the first documented refusal by R32 since admission on [DATE]. There were no facility weekly wound assessments with measurements or wound clinic notes in R32's record for 8/14/24. R32 was supposed to have a wound clinic appointment on 8/14/24. A Nursing Skin/Wound Note, dated 8/15/24, stated, Note Text: wound care completed by wound care nurse. Wound vac dressing to hip and coccyx changed. Measurements taken. Coccyx measures 2.3 cm x 3.5 cm x 2.0 cm. Left hip measures 3.1 cm x 3.1 cm x 8.4 cm. (increased depth) On 8/21/24, a Pressure Injury Weekly Tracker indicated: Sacrum: 2.2 x 1.9 x 2.8 stage 4, granulation Left hip: 3.3 x 6.4 x 3.5 stage 4, granulation, necrotic fat, necrotic muscle, debrided, with tunnel at 11:00, strong odor (increased width) WC measurements indicated: Coccyx: 1.8 x 1.3 x 2.5 with foul odor Left hip: 2.5 x 2.6 x 3.5 with tunnel 6 cm (Inconsistent measurements from wound clinic compared to facility weekly PI tracker) A WC treatment order on 8/21/24 indicated: Wash with Dakin's 0.25% solution. Skin prep peri-wounds. Apply Puracol collagen to the base of the wounds (whole pack to each wound). [NAME] foam to areas that are visible. Black foam on top of white foam (foams must be touching within the wound). Bridge vac to cover both wounds. Wound vac set to -125 mmHg. To be changed Monday and Friday at the nursing home and Wednesdays in the wound clinic. The wound care treatment was changed on 8/21/24 when the wound increased in size. Puracol collagen was added. R32's treatment was not signed out on 8/23/24. A Nursing Skin/Wound Note, dated 8/25/24,stated, Note Text: Wound vac alarming with a leak alert. Wound vac removed and wounds to right hip and coccyx packed with dakins soaked gauze and to be changed BID (twice daily). Wound vac canisters ordered. There was no evidence the wound physician was updated. On 8/28/24, Pressure Injury Weekly Tracker measurements were the same as the wound clinic and indicated: Coccyx: 2.2 x 1.6 x 2.5 foul odor Left hip: 2.7 x 2.7 x 3.5 with tunnel 8.5 cm The wound care treatment order was the same as 8/21/24. R32's TAR indicated: Pack coccyx and right hip wounds with Kerlix damp with quarter strength Dakin's BID until wound vac is able to be put back on. The treatment was not signed out on the 8/30 PM shift and the order identified the wrong hip. A Nursing Skin/Wound Note, dated 8/29/24, stated, Note Text: Wound care completed by wound care nurse. Wound Vac not on, waiting on white foam, wet to dry applied. A Nursing Skin/Wound Note, dated 8/31/24, stated, Note Text: Wound care completed by this writer. Wound Vac applied. On 9/4/24, a Pressure Injury Weekly Tracker indicated: Sacrum 2.4 x 2.1 x 2.5 stage 4, granulation Left hip: 2.3 x 2.4 x 6.0 stage 4, undermined 6 cm (improved) A WC physician note indicated: Left hip with undermining has a 6 cm tunnel going cranially. The ulcer is stage 4 with necrotic muscle, necrotic fat, necrotic connective tissue. The coccygeal ulcer has some necrotic muscle, necrotic fat present but improved and does not probe to bone but only muscle. A Wound Debridement physician note indicated: Wound debridement to remove necrotic fat, necrotic muscle, necrotic connective tissue, tenacious yellowish slough, necrotic fascia, and fibrin from base of coccyx and left ischium wound. Coccyx pre-debridement measurement: 2.4 x 2.1 x 2.5 with foul odor Left hip pre-debridement measurement: 2.3 x 2.4 x 6.0 with tunnel. WC measurements post debridement indicated: Coccyx: 2.1 x 1.9 x 2.5 stage 4 with foul odor Left hip: 2.1 x 2.1 x 9.0 with tunnel The WC treatment order was the same as 8/21/24. R32's treatment was not signed out on 9/2, 9/6, 9/11, or 9/16. A nurses note, dated 9/7/24 at 5:08 AM, stated, Resident refused to be toileted or repositioned on last rounds. This was the second documented refusal and last documented refusal R32's medical record. On 9/11/24, there were no weekly in-house wound assessments or at the wound clinic. On 9/18/24, a Pressure Injury Weekly Tracker indicated: Sacrum 2.1 x 1.9 x 2.5 stage 4 Left hip: 2.1 x 2.1 x 9.0 stage 4, granulation with foul odor, tunnel 9 cm deep R32's treatment was not signed out on 9/20, 9/23, or 9/25. On 9/25/24, a Pressure Injury Weekly Tracker showed same measurements as the wound clinic: Coccyx: 2.1 x 1.9 x 2.0 with foul odor (improved) Left hip: 1.9 x 2.0 x 9.0 with tunnel (improved) On 9/30/24, a Pressure Injury Weekly Tracker indicated: Sacrum 1.0 x 0.9 x 3.0 stage 4, granulation 34-66%, necrotic 34-66% Left hip: 1.2 x 1.5 x 9.0 stage 4, granulation tissue 34-66%, necrotic tissue 34-66% WC measurements indicated: Coccyx: 1.0 x 0.9 x 3.0 with foul odor (improved length x width) Left hip: 1.2 x 1.5 x 9.0 with tunnel (improved length x width) A WC treatment order indicated: Left hip wound vac is on hold for left hip 9/25/24. Wash with Dakin's 0.25% solution. Pack with gauze soaked in Dakin's 0.25% solution (wring out so it's damp but not dripping). Apply 6 x 6 Allevyn or similar dressing over the wound. Clean and change dressing daily. On 10/2/24, WC measurements indicated: Coccyx: 1.1 x 1.2 x 2.5 with foul odor Left hip: 3.6 x 3.1 x 4.0 with 7.5 cm tunnel R32's treatment was not signed out on 10/3, 10/5, 10/9, or 10/10. On 10/9/24, there was no in-house weekly wound assessment or wound clinic note in R32's medical record. R32 was supposed to have a wound clinic appointment on 10/9/24. On 10/16/24, WC measurements indicated: Coccyx: 0.9 x 0.6 x 1.5 foul odor (improved) Left hip: 2.2 x 2.1 x 3.2 with tunnel 6.0 cm (improved) A WC physician note indicated: Continue wound vac for both wounds but the hip ulcer may have to be opened up further. On 10/22/24, DON B was made aware that Surveyor wanted to observe R32's dressing change on 10/23/24. DON B stated the dressing change would not done in-house on 10/23/24 because R32 had a wound clinic appointment. On 10/23/24, WC measurements indicated: Coccyx: 0.7 x 0.8 x 2.0 foul odor Left hip: 3.1 x 1.9 x 3.5 with tunnel 6.5 cm A WC Surgical Debridement note indicated: Sacrum: Necrotic muscle, necrotic fat, necrotic connective tissue, tenacious yellowish slough, necrotic fascia, and fibrin from the base of the wound removed. Left Hip: Necrotic muscle, necrotic fat, necrotic connective tissue, yellowish slough, and fibrin from the base of the wound removed. Has tunneling at 7.5 cm deep. Left hip measurement pre-debridement: 3.1 x 1.9 x 3.5 Coccyx measurement pre-debridement: 0.7 x 0.8 x 2.0 A WC treatment order indicated staff should continue the same left hip/coccyx treatment. On 10/22/24 at 7:03 AM, Surveyor observed R32 in bed asleep. R32 was positioned on the right side facing the doorway. At 7:37 AM, Surveyor observed Certified Nursing Assistant (CNA) L exit R32's room with R32 in a wheelchair and take R32 to the dining area for breakfast. At 7:42 AM, Surveyor observed R32 in the dining room eating breakfast independently. At 8:05 AM, Surveyor observed staff take R32 to therapy. At 9:10 AM, R32 returned from therapy. At 9:16 AM, Surveyor observed CNA L enter R32's room and ask if she needed anything. R32 stated she needed to go to the bathroom. CNA L retrieved gloves from a bin in the hallway. At 9:18 AM, Surveyor observed CNA L exit R32's room and don personal protective equipment (PPE) in the hallway. R32 was not repositioned during those 2 minutes. At 9:21 AM, Surveyor observed CNA L state to R32, I will come back for you and exit R32's room. At 9:44 AM, Surveyor observed staff take R32 to a resident council meeting. At 11:00 AM, Surveyor observed R32 in a wheelchair watching TV in her room. At 11:15 AM, Surveyor observed a CNA take R32 to the dining room. At 12:19 PM, Surveyor observed a CNA take R32 back to her room. Surveyor observed R32 in her wheelchair watching TV from 12:20 PM to 2:45 PM and noted R32 was sitting in her chair from 7:37 AM until she was last observed at 2:45 PM which was approximately 7 hours. An observation of R32's wheelchair cushion on 10/24/24 at 6:49 AM indicated R32 did not have a pressure reducing cushion. The cushion was labeled Comfort Curve. Key specs of Comfort Curve cushion use state, Your Risk of Skin Breakdown: Low. The cushion was not a pressure relieving cushion for the prevention of or promotion of healing pressure injuries. On 10/24/24 at 7:55 AM, Surveyor interviewed R32 regarding wound care and repositioning. R32 stated, The wound is on my butt, and they are changing the bandages on my butt. R32 also stated, They change the bandage on Wednesday, and they use a ruler to take measurements. When asked if staff educated R32 on the risks and benefits of repositioning, R32 stated, Yes. R32 had a poor memory and could not distinguish between facility and wound clinic staff regarding measurements and dressing changes. R32 also could not recall how staff repositioned her in bed or how often. On 10/24/24 at 8:05 AM, Surveyor interviewed CNA L and CNA K regarding R32's wound care and repositioning. CNA L stated, We wash her up. We lotion her and reposition her every 2 hours. CNA K stated, We wash her and lotion her skin, do skin inspections on her bottom to make sure she doesn't have pressure sores. We reposition her from her left side to her right side and keep her dry. On 10/28/24 at 3:35 PM, Surveyor interviewed DON B and Assistant Director of Nursing (ADON) J regarding R32's wound care and assessments. Surveyor shared concerns that the facility's PI measurements were identical to the wound clinic's measurements each week. ADON J stated the facility used the wound clinic physician's wound assessments and measurements for their weekly wound assessments and indicated they had not been doing their own weekly PI assessments on Mondays or Fridays with dressing changes. On 10/29/24 at 12:00 PM, Surveyor interviewed Registered Nurse (RN) Q who was R32's wound clinic case manager. RN Q confirmed R32 saw the wound clinic physician every Wednesday for wound care and debridement. RN Q stated there were three wound physicians and they rotated for R32's wound care. RN Q stated R32 missed wound care appointments on 8/14, 9/11, and 10/8. RN Q stated she felt R32's wounds had gotten better recently but had concerns about wounds in the past. RN Q stated the wound clinic was not updated by the facility that R32's wound vac was removed or that there were concerns with R32's wound care. RN Q stated she could not give an opinion on why the wounds had worsened from 7/24 to 9/18. RN Q stated she put suggestions for better off-loading on R32's wound clinic follow-up instructions. Based on observation, interview and record review, the facility did not ensure 2 of 4 residents (R) reviewed for pressure injuries (PI) (R151 and R32) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R151 was admitted to the facility with a sacral PI and was assessed to be at risk for PI development. R151 developed one unstageable PI on 10/16/24 and three unstageable PIs on 10/18/24. R151's care plan for PI interventions was not developed until 10/18/24 and not updated until 10/23/24 with interventions to off-load pressure areas to R151's bilateral lower extremities and sacral wound. The facility's failure to develop a care plan and implement interventions to off-load pressure to a resident's bilateral lower extremities and sacral wound created a finding of immediate jeopardy that began on 10/18/24. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on 10/28/24 at 3:30 PM. The immediate jeopardy was removed on 10/28/24; however, the deficient practice continues at a scope/severity level G (actual harm/isolated) as evidenced by the following example for R32. R32 had an existing stage IV pressure injury that developed 8.5 centimeters (cm) tunneling on the left hip and a stage IV pressure injury on the coccyx. R32 had wound vac therapy and multiple surgical debridements. The facility did not complete weekly pressure injury assessments, did not complete multiple treatments, and did not offload R32 as the care plan instructed. In addition, R32 missed wound clinic appointments on 8/14/24, 9/11/24, and 10/8/24. This is evidenced by: Guidelines from the National Pressure Injury Advisory Panel (NPIAP) Quick Reference Guide 2019 indicate in part: 2.1 Conduct a comprehensive skin and tissue assessment for all individuals at risk of pressure injuries: As soon as possible after admission/transfer to the health care service .5.1 Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated .5.5 Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved .6.3 For individuals with a Category/Stage III or greater heel pressure injury, elevate the heels using a specifically designed heel suspension device offloading the heel completely in a way as to distribute the weight of the leg along the calf .NPIAP Classification Unstageable Pressure injury: Obscured full thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . Example 1 R151 was admitted to the facility on [DATE] with diagnoses including multiple fractures of ribs, left side, chronic obstructive pulmonary disease (COPD), emphysema, anemia, hypo-osmolality and hyponatremia, atrial fibrillation, chronic kidney disease stage 3, anticoagulants, personal history of transient ischemic attack, atherosclerotic heart disease, peripheral vascular disease, congestive heart failure, prediabetes, and cardiac pacemaker. Hospital patient demographics, dated 10/10/24, documented an active wound on the posterior sacrum first assessed on 10/03/24 with the primary wound being a skin tear. An admission evaluation completed on 10/10/24 documented no skin impairments were present. The comments section documented, Bandage on lower back clean and dry. Bruising on (right) arm. Large Bruising noted to (left) hip area. Coban on (right) FA. R151's admission Minimum Data Set (MDS) assessment, dated 10/16/24, documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated R151 had moderately impaired cognition. The MDS documented R151 had impairment to both lower legs and required partial/moderate assistance of staff for toileting, and upper and lower body cares. The MDS documented R151 was at risk for pressure injuries and had 2 unstageable pressure injuries with slough and or eschar. The MDS indicated R151 did not have a turning or repositioning schedule and did not refuse cares. R151 was discharged home on [DATE]. The facility completed a Braden scale pressure risk skin assessment on 10/11/24 with a score of 18 which indicated R151 was at risk. (The Braden scoring scale is: 15-18 at risk, 13-14 moderate risk, 10-12 high risk, 9 or below very high risk.) The facility completed a Braden assessment on 10/23/24 with a score of 20 which indicated R151 was not at risk. The facility did not develop a care plan addressing this risk until 10/18/24. A pressure injury weekly tracker, dated 10/13/24, documented an unstageable pressure injury on the left buttock that measured 3.5 cm x 4.5 cm with slough and light serosanguinous drainage. A physician order, dated 10/13/24, documented, Reposition every 2 hours and prn (as needed). The order did not mention offloading the buttock PI when repositioning R151. A wound clinic note, dated 10/16/24 at 9:56 AM, documented, Pressure sacrum unstageable due to necrosis, measuring 3.0 cm X 3.5 cm x 0.1 cm with moderate serous drainage. Pressure left lateral foot unstageable DTI (deep tissue injury) with intact skin undetermined thickness. Noted to be present on admission per staff. The PI measured 1.3 cm x 1.5 cm and the depth not measurable. Skin is intact with purple/maroon discoloration. Apply skin prep twice daily for 30 days. This is the first documentation of the wound. A Pressure Injury Weekly Tracker, dated 10/16/24 at 2:07 PM, indicated: Sacrum PI measured 3 cm x 3.5 cm x 0.1 cm, unstageable with necrotic tissue, 20% granulation tissue, 80% slough, 100% necrotic tissue, and had moderate serous drainage. On 10/16/24 at 2:30 PM, date acquired 10/16/24 in-house, R151's left lateral foot PI measured 1.3 cm x 1.5 cm unstageable with 100% necrotic tissue with no drainage, dark red or purple and/or non-blanchable. R151 had the following physician orders: 10/16/24: Heel protectors to be on while in bed. 10/16/24: Air mattress needed for resident. 10/16/24: Wound type: Pressure wound. Location: left buttock/sacrum. Wound cleansing agent: normal saline or wound cleanser. Primary dressing type: Calcium alginate with silver, zinc to peri-wound. Cover dressing: Foam dressing. Frequency of dressing changes: Three times per week Monday-Wednesday-Friday and PRN. Expected duration of need: TBD (to be determined) one time a day every Mon, Wed, Fri for Wound Care and PRN AND as needed for if dressing is soiled or no longer intact. The facility ordered an alternating low air loss mattress on 10/16/24 which was placed on R151's bed on 10/17/24. On 10/16/24, the facility ordered liquid protein 30 milliliters (mls) two times per day. A Pressure Injury Weekly Tracker, dated 10/18/24, indicated: Left lateral foot (acquired on admission), unstageable PI measured 4.3 cm x 2.2 cm with 50% necrotic tissue with no drainage. The first PI weekly tracker assessment of the left lateral foot on 10/16/24 documented the PI was acquired in the facility. On 10/18/24, left plantar foot (acquired on admission), unstageable PI measured 2.2 cm x 1.7 cm, with necrotic tissue and no drainage. This is the first documentation of this PI. On 10/18/24, left heel (acquired admission), unstageable PI measured 1.6 cm x 0.7 cm with necrotic tissue and no drainage. This is the first documentation of this PI. On 10/18/24, right plantar foot (acquired on admission), unstageable PI measured 3.5 cm x 6.5 cm with necrotic tissue and no drainage. This is the first documentation of this PI. R151's care plan was first developed on 10/18/24 with the focus area: The resident has unstageable to heel and unstageable to sacrum pressure ulcer or potential for pressure ulcer development (related to) immobility. Interventions implemented on 10/18/24 included: Administer medications as ordered; Administer treatments as ordered; and Monitor for effectiveness. Interventions implemented on 10/23/24 included: Elevate bilateral lower extremities up on pillow to off load pressure area; Reposition to right side with pillow to off load sacral wound; Please chart refusals from resident; Follow facility policies/protocols for the prevention/treatment of skin breakdown. (The repositioning and heel interventions were added 13 days after R151's admission.) A physician order, dated 10/19/24, stated to apply skin prep to right plantar foot, left plantar foot, left heel, and left lateral foot for wound care two times a day. A nursing note, dated 10/19/24 at 10:00 PM, stated, Behavior Note: Note Text: Resident refused to be turned and repositioned on the evening shift. Went in at least every 2 hours but was in there more than that to ask him to be repositioned and he was refusing. Talked to him about the importance of being repositioned and he said that he already has a sore bottom so what is going to make the difference now. Explained to him that if he just stays in one position then the sore is going to get worse. He said for right now he does not want to be turned or repositioned. R151's medical record did not contain a risk versus benefits statement for refusals of repositioning. R151's behavior monitoring charting indicated no refusals of cares and no documented behaviors. R151's nursing documentation did not indicate R151 refused care or treatments. On 10/21/24 at 11:22 AM, Surveyor interviewed R151's family member about his care. The family member stated R151 came into the facility with one PI on the butt and developed one PI on his foot. The facility changed R151's mattress, but the pillows are on the chair and staff don't elevate his heels. The wound doctor comes in to do the dressing. On 10/22/24 at 5:20 AM, Surveyor observed R151 in bed with his feet directly on the mattress and the pillows on his dresser. On 10/22/24 at 5:39 AM, Surveyor interviewed Registered Nurse (RN) P about R151's positioning and heel protectors. When Surveyor asked RN P to verify if heel protectors were on R151, RN P verified R151 did not have heel protectors on and there were none in the room. RN P checked R151's feet which were pressing on the foot board of the bed and directly on the mattress. When RN P asked R151 if he remembered if he had been wearing the heel boots, R151 said no. When RN P asked if R151 wanted a pillow under his legs, R151 willfully lifted his legs. RN P placed a pillow under R151's legs and stated she would get Certified Nursing Assistant (CNA) Q to assist with a boost. At 5:44 a.m., RN P and CNA Q boosted R151 so his feet were not touching the foot board. On 10/22/24 at 9:22 AM, Surveyor observed RN H provide wound care to R151's feet which were pressing on the foot board. RN H removed R151's socks and applied skin prep to the right foot plantar area, left foot plantar, lateral, and heel. Surveyor noted an area on the right foot that was small and dark with a callused area, the left lateral foot just below 5th digit was black and dry, the left plantar was small, dark, and callused, and the left heel had a small dark area. On 10/22/24 at 10:10 AM, Surveyor interviewed R151 about his feet pressing on the foot board and asked if staff elevated his heels with pillows or if he wore boots. R151 indicated staff have not put the pillows under his legs and the pillows are always sitting on the shelf. R151 indicated someone told him that he shouldn't wear the boots and his feet would heal better without them. R151 could not remember who told him. R151 stated his feet didn't hurt but they press on the foot board when the head of the bed is up and he slides down in bed. Staff boost R151 up when asked. On 10/23/24 at 1:15 PM, Surveyor observed RN M remove Mepilex from R151's buttock. The area had 100% slough and a red peri-wound. RN M stated the area was unstageable with 100% slough. The area measured 2.9 cm x 3.2 cm. RN M assessed R151's left lateral foot below the 5th digit on the pad of the foot and measured 1.8 cm x 1.3 cm. The area appeared dark in color and dry with no raised area or appearance of being open. RN M measured the left foot plantar area to be 2 cm x 1.8 cm. Surveyor observed a small red DTI area with hard skin. RN M measured the left heel to be 0.6 cm x 1.3 cm. Surveyor observed a small red DTI area with hard skin. RN M measured the right foot plantar area to be 3.0 cm x 3.0 cm. Surveyor observed a small red DTI area with hard skin. RN M indicated all the areas were unstageable. RN M looked for boots for R151. When RN M asked if he had been wearing the boots, R151 stated no. Surveyor told RN M that Surveyor observed boots in R151's closet on the top shelf. When RN M got the boots, R151 refused. When RN M asked why R151 didn't want the boots and if they were hot, R151 stated he could not remember who told him that he would be better off not wearing the boots. RN M educated R151 that wearing the boots would help his feet from hitting the foot board and causing more issues. R151 agreed to wear the boots. RN M applied the boots and placed a pillow under R151's calves. On 10/23/24 at 1:40 PM, Surveyor interviewed RN M about R151's documentation of PIs and asked if the PIs were facility-acquired. RN M indicated that she was not sure if the PIs were facility-acquired and thought the PIs were initially assessed upon admission. Surveyor stated the left lateral foot was initially noted to be facility-acquired but the assessments after that documented the PIs were present upon admission. RN M indicated she wasn't sure when she did the assessment so she marked the wounds as present upon admission. RN M indicated she would change the assessments to indicate the PIs were facility-acquired. On 10/24/24 at 8:24 AM, Surveyor interviewed Director of Nursing (DON) B and asked if R151's PIs were avoidable or unavoidable. DON B indicated all PIs are avoidable. On 10/28/24 at 11:57 AM, Surveyor interviewed RN O (the facility's MDS Coordinator) about R151's 10/16/24 admission MDS assessment that coded 2 PIs on admission. RN O indicated the coding was based on information in the chart from admission and the wound clinic note. Surveyor and RN O reviewed the facility's admission evaluation documentation that indicated R151 did not have any skin impairments. There was a PI weekly tracker completed on 10/13/24 of the left buttock and a non-pressure injury to the right buttock. On 10/16/24, the PI weekly tracker assessments stated a sacrum PI and left lateral foot PI were acquired on 10/16/24 in house. A hospital demographics note on 10/10/24 documented the sacrum but did not document the left lateral foot. RN O indicated the wound clinic note documented the left lateral foot was present upon admission. Surveyor stated the wound note documented noted to be present on admission per staff but there was no documentation that staff assessed a left lateral foot PI until 10/16/24 after the wound clinic evaluation. RN O indicated she understood and stated the MDS should have been coded with 1 PI to the sacrum on admission and 1 PI to the left lateral foot facility-acquired and indicated the MDS would be updated. On 10/28/24 at 12:46 PM, Surveyor interviewed Nurse Practitioner (NP) N about R151 having PIs on admission. NP N reviewed R151's admission notes and did not see any documentation of R151 having PIs on his feet. NP N indicated she would have reviewed the hospital discharge note and would follow-up with R151 when next seen. NP N reviewed the hospital discharge note and noted there were no PIs on R151's feet and the only skin area noted was the sacrum. NP N indicated she should be notified by the facility if there was a change in condition and expected to be notified of the start of a PI. NP N reviewed her communication with the facility and dictation and stated there was no documentation of R151 having any PIs. NP N indicated she was not aware that R151 had any PIs on his feet. NP N indicated she would have reviewed the wound clinic orders, ensured the facility was following the orders, and would have assessed R151 on her next visit. NP N indicated the only time R151 refused care was related to the use of oxygen upon discharge. NP N indicated R151 told her everything was fine and he had no pain or concerns. The failure to initiate a care plan and implement interventions to prevent pressure injuries resulted in serious harm for R151 and led to a finding of immediate jeopardy. The facility removed the jeopardy on 10/28/24 when it completed the following: 1. Completed wound assessments for residents with pressure injuries and skin assessments for all in-house residents. 2. Updated care plans with pressure prevention interventions. 3. Educated licensed nursing staff on the facility's policy, assessing residents upon admission, implementing pressure injury prevention interventions, implementing treatment orders, documentation, and provider notification. 4. Educated nursing and therapy staff on implementing pressure injury prevention interventions. 5. Implemented audits to ensure compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure code status was determined for 1 Resident (R) (R1) of 2 sampled residents which led to the failure to perform cardiopulmonary resuscitation (CPR) for the resident after the resident was found pulseless and non-breathing (PNB). R1's Power of Attorney for Healthcare (POAHC) document indicated R1 wished to be resuscitated. On [DATE], staff did not initiate resuscitation efforts when R1 was found PNB. R1 passed away at the facility on [DATE]. The facility's failure to ensure code status was determined and perform CPR when R1 was found PNB created a finding of Immediate Jeopardy (IJ) which began on [DATE]. The State Agency (SA) notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on [DATE] at 4:46 PM. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity level D as the facility continues to implement its action plan. Findings include: The facility's Cardiopulmonary Resuscitation (CPR) policy, dated [DATE], indicates: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding CPR .If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order, and c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition). On [DATE], Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancer) of the prostate with metastasis (secondary cancer) to bone, atrial fibrillation (an irregular and often rapid heart rate), obstructive sleep apnea (when throat muscles intermittently relax and block the airway during sleep), and history of transient ischemic attacks (commonly known as a mini-strokes). R1's Minimum Data Set (MDS) assessment, dated [DATE], contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had little cognitive impairment. R1's medical record indicated R1 was responsible for R1's healthcare decisions. R1 passed away at the facility on [DATE]. On [DATE], Surveyor reviewed R1's POAHC document, dated [DATE], which indicated, I want to be resuscitated, with R1's initials in a corresponding box on the document. R1's medical record indicated R1 received Hospice services. R1's progress notes indicated R1 was undecided whether R1 wanted a Do Not Resuscitate order. R1's physician orders did not contain a code status order. R1's care plan did not mention R1's code status or wish to be resuscitated. R1's progress notes contained the following: ~A progress note, dated [DATE] at 9:59 AM and written by Licensed Practical Nurse (LPN)-C, indicated: .The current status is (R1) found by this LPN at 6:45 AM on floor between bed and window lying on abdomen. (R1's) head was turned slightly to the left. Oxygen cannula was shifted out of (R1's) nose. (R1) was cold and motionless. Assisted by (LPN-D) and repositioned (R1) on (R1's) back to assess. No breathing, pulse or blood pressure. Skin was cold and body with obvious rigidity. Face was dusky, skin cold, eyes fixed and no pupil reaction, mouth was relaxed. Seen by (Registered Nurse (RN)-E) for assessment. (LPN-D) called (Director of Nursing (DON)-B) .(Hospice Company) called and spoke with (RN). RN to call (Hospice RN (HRN)-F) and Coroner. (On-call Hospice staff) requested nursing home call family. (DON-B) here and saw (R1). (DON-B) assisted with transfer back onto the bed. (DON-B) called (R1's sibling). (R1's sibling) will not come to nursing home. (HRN-F) here at 9:20 AM and assisted with paperwork for (Funeral Home). Order written to release R1's body. (Funeral Home) here at 9:30 AM . On [DATE] at 9:31 AM, Surveyor interviewed LPN-C who indicated a resident's code status is in their medical record and in a binder at the nurses' station. Surveyor and LPN-C reviewed a binder titled DNR Book. The front section of the binder contained documentation for each resident on the unit who expressed DNR wishes. The back section of the binder contained documentation for each resident on the unit who expressed Full Code (resuscitation) wishes. When asked about R1's code status, LPN-C indicated R1 received Hospice services and stated, I believe (R1) wanted to be resuscitated. (R1) had not come to grips with making that decision. (DON-B) told me (R1) was on the fence. LPN-C verified LPN-C found R1 on the morning of [DATE]. LPN-C indicated when LPN-C entered R1's room sometime between 6:30 AM and 6:45 AM, R1 was not in R1's bed so LPN-C checked the bathroom. LPN-C indicated R1 was not in the bathroom, so LPN-C looked again and saw R1's feet on the floor between the bed and the window. LPN-C indicated R1 was lying on the floor on R1's abdomen, R1's head was turned, and R1's right cheek was on the floor. LPN-C indicated R1 felt cool to the touch. LPN-C stated, No way I could render aid in the position (R1) was in. LPN-C indicated LPN-C instructed staff to get another nurse. LPN-C indicated LPN-D entered the room and assisted LPN-C with repositioning R1 onto R1's back. LPN-C indicated R1's extremities were flaccid (hanging loosely or limply). LPN-C indicated LPN-C listened for R1's heartbeat, felt for a pulse and checked for breathing, but found none. LPN-C indicated staff asked RN-E to come to the unit. LPN-C indicated RN-E also listened to R1's heart and found no heartbeat. LPN-C stated, No mistaking this (person) was very, very, very gone. LPN-C indicated there was no blood on the floor, but there was saliva on floor where R1's mouth was. LPN-C indicated R1's facial color was cyanotic (bluish skin color due to decreased amounts of oxygen) and discolored. LPN-C stated when DON-B arrived, (DON-B) agreed with me that (R1) was very expired. LPN-C indicated DON-B took over as LPN-C needed to administer medications to other residents. On [DATE] at 10:16 AM, Surveyor interviewed Social Service Director (SSD)-G who indicated SSD-G tries to determine a resident's code status upon admission. SSD-G indicated SSD-G speaks with residents about the meaning of Full Code and DNR and asks specific questions to ensure understanding. SSD-G indicated some residents choose to wait and don't want to decide right away. SSD-G stated SSD-G informs residents who are undecided that staff are required to consider them Full Code status. When asked about R1's code status, SSD-G indicated R1 was undecided. SSD-G indicated SSD-G talked with R1 several times and each time R1 indicated R1 wanted to discuss the issue with R1's family before deciding. On [DATE] at 11:06 AM, Surveyor interviewed HRN-F via phone who indicated HRN-F was the primary Hospice nurse assigned to R1. HRN-F indicated R1 was a Full Code status. HRN-F indicated HRN-F arrived at the facility at 8:47 AM on [DATE] and stated, When I got there, the funeral home was already there. (R1) was on their cot ready to leave. HRN-F indicated Hospice medical records indicated the Hospice Triage RN received a call from the facility at 6:45 AM and was told R1 was found expired in room at 6:30 AM. When asked about the expectations for a resident with a Full Code status, HRN-F stated, Generally they (facility staff) would initiate CPR and call EMTs (Emergency Medical Technicians). HRN-F indicated Hospice staff had numerous conversations with R1 regarding code status and stated, (R1) didn't want to talk about it. HRN-F stated, It was strange having the funeral home there. HRN-F indicated usually the facility waits for Hospice staff to arrive before calling the funeral home. HNR-F indicated Hospice medical records indicated the Hospice Triage RN called the Coroner and notified the facility at 7:30 AM that the Coroner would not be taking the case. On [DATE] at 11:28 AM, Surveyor interviewed DON-B who indicated DON-B received a call from staff on DON-B's way to work that R1 passed away. Upon arrival at the facility, DON-B was informed staff called Hospice, but had not yet called R1's family. DON-B stated, We were waiting on funeral home notification and Hospice to return the call. DON-B indicated a short time later, the facility received a call from Hospice who indicated Hospice was sending a staff, the Coroner was going to meet R1 at the funeral home instead of the facility, and it was okay for the facility to call family and move R1 from the floor into bed. DON-B indicated DON-B called R1's family and asked staff to help DON-B move R1 into bed. DON-B indicated DON-B and staff moved R1 into bed at approximately 8:20 AM or 8:30 AM. When asked if R1 was a Full Code status, DON-B stated, As far as I could tell yes. When asked the expectation for a Full Code status resident found PNB, DON-B stated, If no obvious sign of rigidity, then start CPR. When asked why CPR was not started in R1's case, DON-B stated, I am only going by what the nurses told me. (R1) was pulseless, dusky in face, eyes fixed with obvious rigidity. Two LPNs and an RN assessed (R1). When asked what R1's extremities were like when R1 was moved into bed, DON-B indicated DON-B observed mottling (a bluish-red, lace-like pattern under the skin caused by deoxygenated blood pools that can occur prior to death), no bruising, no pooling meaning no dependent lividity, and R1's extremities were rigid. On [DATE] at 1:21 PM, Surveyor interviewed LPN-D via phone. LPN-D indicated LPN-D assisted LPN-C with rolling R1 onto R1's back on the floor. LPN-D indicated R1's face was blue and R1's fingers were blue and ashen. LPN-D indicated LPN-C stated to LPN-D, I think (R1's) gone. LPN-D indicated LPN-D called DON-B while LPN-C called Hospice. LPN-D indicated LPN-D then returned to LPN-D's assigned unit to administer medications to other residents. When asked what R1's body was like when LPN-D assisted LPN-C with rolling R1 over, LPN-D stated, I was only in room for like two minutes. (R1's) arms weren't stiff, but (R1's) torso was stiff. When asked if the facility provided code status education since R1's death, LPN-D stated, (R1) was DNR Hospice. When informed by Surveyor that R1 was a Full Code status, LPN-D stated, I didn't know. On [DATE] at 1:37 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-H via phone who verified CNA-H worked the night shift on R1's unit on [DATE] into [DATE]. CNA-H indicated CNA-H spoke with R1 on midnight rounds when R1 refused to wear R1's CPAP (continuous positive airway pressure) machine (a common treatment for obstructive sleep apnea). CNA-H also checked R1 on 2:00 AM rounds and stated R1 was asleep with the head of the bed elevated. CNA-H indicated the last time CNA-H saw R1 was at 4:45 AM and R1 was asleep with the head of the bed elevated. When asked about R1's code status, CNA-H stated, I know (R1) was on Hospice, so I don't think (R1) was a code (Full Code). On [DATE] at 2:38 PM, Surveyor interviewed DON-B who, when asked to define rigidity stated, Limbs are stiff, like rigor mortis. Surveyor discussed the above interview with DON-B in which LPN-C indicated R1's arms were flaccid, and LPN-D indicated R1's arms weren't stiff. When Surveyor asked DON-B the expectation regarding CPR given the knowledge that R1's arms were not stiff when R1 was found, DON-B stated, They should have looked at (R1's) code status. If wasn't one, (R1) would have been a Full Code. When asked if flaccid arms are considered rigor mortis, DON-B stated, Not by my definition, but I can only go by what they told me. When asked what DON-B would have done if DON-B found a resident PNB with flaccid arms, DON-B indicated DON-B would check the resident's code status and stated, By policy, (R1) would have been a Full Code. On [DATE], Surveyor reviewed the facility's resident list that indicated 25 of 52 residents had a Full Code order, 27 of 52 residents had a DNR order, and 1 resident was undecided. On [DATE] at 8:30 AM, Surveyor interviewed RN-E via phone who indicated at approximately 6:45 AM on [DATE], RN-E responded to R1's unit. RN-E indicated when RN-E entered R1's unit, LPN-C was at the nursing station. LPN-C indicated LPN-C called Hospice and told RN-E that R1 passed away. RN-E entered R1's room and observed R1 on R1's back on the floor between the bed and the window. RN-E indicated R1 was cold to the touch, mottling, and ashen in color. RN-E listened for a heartbeat and heard none. RN-E indicated RN-E did not try to move R1's extremities. RN-E indicated LPN-C picked up R1's right hand and R1's wrist was limp. When asked about R1's code status, RN-E stated, I'm not sure, I didn't look at that. Surveyor informed RN-E that R1 was considered a Full Code. RN-E indicated RN-E did not observe any dependent lividity in R1 and stated, Everything was grey. When asked what RN-E would have done if RN-E found a resident PNB with flaccid arms, RN-E indicated RN-E would start CPR. RN-E indicated RN-E did not ask LPN-C about R1's code status. The failure to ensure code status was determined which led to the failure to perform CPR when a resident was found PNB created a reasonable likelihood for serious harm which created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE] when it completed the following: 1. Audited residents' medical records to ensure they contained a code status form and physician order. 2. Educated staff on following code status and to ensure medical records contain a code status upon admission. 3. Initiated interviews with nurses on various shifts involving case studies and what if scenarios to validate understanding and expectations during a code situation. 4. Initiated code drills. 5. Reviewed their CPR policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure care and treatment in accordance with professional standards of practice was provided for 1 Resident (R) (R1) of 9 sampled residents. R1 experienced a change in condition, including altered mental status, on the [DATE] AM shift. The facility did not complete an appropriate assessment or notify a physician. EMS (Emergency Medical Services) was notified at 8:50 PM when R1 was found unresponsive. R1 was transferred to the hospital and passed away on [DATE]. The facility's failure to complete an appropriate assessment and timely notify a physician for a resident who experienced a change in condition created a finding of immediate jeopardy that began on [DATE]. The State Agency (SA) notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on [DATE] at 5:14 PM. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a severity/scope level D as the facility continues to implement its action plan. Findings include: The facility's Change in Condition of the Resident policy, with a review date of [DATE], indicates: A facility should immediately inform the resident; consult with the resident's physician .when .a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .When a resident presents with a possible change of condition .1. Assess the resident's need for immediate care .2. Assess/evaluate the resident. This assessment/evaluation could include, but is not limited to, the following: a. Vital signs, oxygen saturation, blood glucose level .e. Personality, behavioral and/or cognitive changes. F. Alteration in level of consciousness, ability to respond .k. Gait, posture, or balance change .3. Notify resident's physician .a. Immediate notification: Immediate notification for any symptom, sign or apparent discomfort that is: i. Acute or sudden in onset, and: ii. A marked change (i.e., more severe) in relation to usual symptoms and signs .Do not fax for issues requiring immediate notification . According to https://www.ncbi.nlm.nih.gov/books/NBK430939/, patients progressing to septic shock will experience signs and symptoms of severe sepsis with hypotension. With the progression of septic shock into the uncompensated stage, hypotension ensues, and patients may present with cool extremities, delayed capillary refill (more than three seconds), and thready pulses, also known as cold shock. After that, with continued tissue hypoperfusion, shock may be irreversible, progressive rapidly into multiorgan dysfunction syndrome and death. On [DATE], Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including paraplegia (impairment in motor or sensory function of the lower extremities), chronic kidney disease and chronic pain syndrome. R1's Minimum Data Set (MDS) assessment, dated [DATE], contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had little to no cognitive impairment. R1's medical record indicated R1 was responsible for R1's healthcare decisions. R1's medical record contained a Do Not Resuscitate (DNR) order which complied with the wishes expressed in R1's Power of Attorney for Healthcare (POAHC) document, dated [DATE]. R1 was transferred to an emergency room (ER) on [DATE] and did not return to the facility. R1 passed away at the hospital on [DATE]. R1's medical record contained the following information: A Nurse Practitioner (NP) note, dated [DATE], indicated: .(R1) denies pain, shortness of breath, chest pain, nausea/vomiting, constipation. (R1) reports pain is well managed with current regimen. (R1) reports smoking 1/2 pack of cigarettes per day, has no interest in quitting. Nursing denies any concerns . A care conference summary, dated [DATE], indicated: (R1) did not have any nursing concerns or questions regarding medications or treatments .(R1) had no questions or concerns regarding (R1's) care plan .SSD (Social Services Director) reviewed (R1's) code status with (R1) . A nursing note, dated [DATE] at 1:16 PM, indicated: (R1) was sleepy at lunch time and writer had to wake (R1) up for medication administration. (R1) was mildly difficult to wake. (R1) ate only a bite or two of lunch. After lunch, (R1) was found slouching to the right of (R1's) wheelchair sleeping hard. Staff had to shake (R1) moderately to awake. (R1) was cold and clammy. Blood sugar-138. (R1) insistent (R1) was ok. (R1) admits 'its been a few' days when asked when (R1) last had a bowel movement. (R1) did not want to lie down for a suppository. Writer advised (R1) should lie down for a suppository. (R1) said (R1) wanted to wait until later. Charting shows (R1) has not had a bowel movement since [DATE] AM. DON (Director of Nursing) notified. Surveyor reviewed the facility's Medication Administration Audit Report for medications administered to R1 on [DATE]. The report indicated Licensed Practical Nurse (LPN)-D administered R1's medication at 11:19 AM. A nursing note, dated [DATE] at 1:46 PM, indicated: Writer went to advise (R1) that (R1) hadn't had a bowel movement in 8 days and found (R1) slumped to (R1's) right and hard to wake. (R1) agreed to lay down and have a suppository administered. (R1) continues to be diaphoretic (excessive sweating for no apparent reason, often described as cold and clammy). R1's Medication Administration Record (MAR) indicated LPN-D administered a bisacodyl suppository 10 mg (milligrams) rectally at 1:49 PM on [DATE] with effective results. A nursing note, dated [DATE] at 8:00 PM, indicated: (R1) observed to be unresponsive. Not responsive at this time. Blood pressure-155/88; Pulse-103; Temperature-97.3; Respiratory rate-3 to 4, periods of apnea (not breathing) lasting 20-30 seconds. Oxygen saturation level is between 55 and 75% (normal oxygen saturation is above 90%) on 5 liters of oxygen. (Physician's Assistant) updated and gave order to send to ER for evaluation and treatment. (R1) sent to ER. DON updated. Surveyor reviewed a Run Report from the ambulance service, dated [DATE], that indicated: .The unit was notified at 8:50 PM, responded at 8:52 PM, arrived at the scene at 8:58 PM, left the scene at 9:32 PM, arrived at the hospital at 9:36 PM, and completed the call at 9:58 PM .When we arrived, we were told (R1) was a DNR and earlier in the day (R1) expressed that (R1) did not want CPR (cardiopulmonary resuscitation) if (R1's) heart stops. (R1) also expressed that (R1) was ready to die and wanted to be left alone. The staff noticed how relaxed (R1) seemed after that and said they felt (R1) knew the end was coming. At noon, they laid (R1) down in bed and went to check on (R1) around 5:00 PM and found (R1) sleeping. They checked on (R1) around 9:00 PM and found (R1) unconscious. They informed the doctor .and the doctor ordered (R1) be transported to the hospital. The staff told us that (R1) is still unconscious and is agonal breathing. We found (R1) supine (laying flat on back) on the bed .(R1's) respiratory rate was about 10 breaths per minute and (R1) was cool to the touch .We attempted a sternal rub which was unsuccessful. We took an initial set of vitals .Blood pressure-98/60; Heart rate-94 beats per minute; Respiratory rate-10 breaths per minute; Oxygen saturation level-90%; Blood sugar-113 . An Emergency Medicine note, dated [DATE] at 10:14 PM, indicated: .Presentation consistent with altered mental status and respiratory compromise .Diagnoses .Altered Mental Status .Acute Kidney Injury .Severe Sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever) . On [DATE], Surveyor reviewed a hospital Discharge summary, dated [DATE], that indicated: .(R1's) admission findings were consistent with acute respiratory failure with hypoxia (lower than normal level of oxygen in the blood) and hypercapnia (higher than normal level of carbon dioxide in the blood. (R1) never regained consciousness during (R1's) stay. Blood cultures remained negative. (R1) was adamantly DNR/DNI (Do Not Intubate) so treatment options were limited. We were unable to correct the acidosis (a condition in which acids build up in the body) with basic oxygen support .(R1's) multi-organ failure (renal, hepatic and cardiac) failed to respond to therapies .Throughout the last 24 hours, (R1) was progressively more agonal (relating to, or associated with the act of dying) and slowed with breathing. (R1) did not demonstrate tachypnea (rapid shallow breathing), restlessness or other cues of pain or air hunger .Actual time of death is 7:16 AM .Likely cause of death: sepsis with multi-organ failure due to pneumonia . On [DATE] at 10:16 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who indicated CNA-C remembered R1 well and worked the AM shift on [DATE]. CNA-C indicated R1 required staff assistance with personal cares and was alert, able to express R1's needs, and cooperative with cares. CNA-C indicated when CNA-C delivered a lunch tray to R1 on [DATE], R1 was incoherent. CNA-C stated, It took a bit, but (R1) woke up. CNA-C reported R1's change in mental status to the nurse. On [DATE] at 12:04 PM, Surveyor interviewed LPN-D who verified LPN-D worked the AM shift on [DATE]. LPN-D indicated when LPN-D administered R1's medication prior to lunch, R1 was sleeping in R1's wheelchair and was mildly difficult to wake up which was unusual for (R1). When LPN-D asked nursing staff if R1 ate lunch, staff said (R1) only ate a bite or two. LPN-D checked on R1 after lunch and found R1 sleeping and slumped to the right side in R1's wheelchair which was not normal for R1 who usually had good posture. LPN-D had to wake (R1) again and stated, (R1) was cold and clammy, like a cold sweat. LPN-D checked R1's blood sugar and R1 insisted R1 was okay. LPN-D indicated R1 refused to lay down in bed and LPN-D reported the above information to DON-B. LPN-D did not recall if LPN-D checked R1's vital signs and verified vital signs for that timeframe were not documented in R1's medical record. When asked what type of assessment should be completed when a resident is found with altered mental status, LPN-D indicated staff should obtain a full set of vital signs. LPN-D also indicated LPN-D should have called R1's physician. On [DATE] at 4:09 PM, Surveyor interviewed CNA-G who started work at 2:00 PM on the [DATE] PM shift. CNA-G indicated CNA-G remembered R1 well and stated, The day before, (R1) was fine. CNA-G indicated R1 was in bed when CNA-G entered R1's room at 2:15 PM on [DATE]. When asked if R1 woke up, CNA-G stated, No, (R1) had end of life breathing going on. CNA-G went to the nurses' station and asked, What's going on with (R1)? CNA-G indicated the PM shift nurse checked R1's vital signs, but CNA-G was unable to remember further details and stated, I was crying. On [DATE] at 11:29 AM, Surveyor interviewed CNA-H via phone. CNA-H verified CNA-H worked the [DATE] PM shift and remembered R1. CNA-H indicated staff were unable to wake R1 all shift and stated, When we checked and changed (R1), (R1) turned blue. CNA-H could not recall when R1's apnea started and indicated R1 was gurgling like when the tongue gets caught in the back of the throat and had abnormal breathing most of the shift. CNA-H stated, Apparently (R1) was fine in the morning. Later on in the day before our shift, they laid (R1) down because (R1) was all sweaty and not (R1's) self. Usually, (R1) stayed up all day until we put (R1) to bed. On [DATE] at 1:33 PM, Surveyor interviewed DON-B who indicated DON-B remembered telling staff to notify a physician on [DATE] after DON-B was notified of R1's symptoms. When asked if DON-B told the AM or PM shift nurse to notify a physician, DON-B stated, I don't remember which one. DON-B reviewed R1's nursing notes and verified LPN-D should have taken R1's vital signs and notified a physician regarding R1's altered mental status and change in condition. DON-B indicated staff education was completed following the incident. Surveyor reviewed the facility's Training Log/Sign In Sheet, dated [DATE], which contained the following objectives: Medication/Insulin Administration, Hand Hygiene, Dressing Changes, and MD notification. The document contained nine nurses' signatures with dates from [DATE] through [DATE]. The document did not contain LPN-D's signature. On [DATE] at 1:46 PM, Surveyor interviewed DON-B who verified the Training Log/Sign In Sheet did not contain LPN-D's signature. On [DATE] at 3:21 PM, Surveyor interviewed Medical Director (MD)-E and NP-F together via phone. MD-E indicated MD-E expected an evaluation of R1's condition to include a complete set of vital signs at a minimum. MD-E and NP-F verified LPN-D should have notified R1's provider (NP-F or the provider on-call) of R1's altered mental status and change in condition. When asked what would have been ordered if MD-E or NP-F were notified, MD-E indicated the orders would have been dependent on R1's vital signs and stated, Vitals would have guided my decisions. The failure to complete an appropriate assessment and notify a physician timely for a resident who experienced a change in condition led to serious harm for R1 which created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when it completed the following: 1. Completed an audit to determine if other residents were experiencing a change of condition. 2. Reviewed the Change of Condition policy. 3. Completed education with licensed nurses. 4. Implemented ongoing change of condition audits including completion of assessment/data gathering and appropriate MD notification.