Every finding on record at Grenada Living Center

Based on staff interviews, record review, and facility policy review, the facility failed to ensure accurate monitoring and documentation of fluid intake for a resident on fluid restriction for one (1) of (4) four residents reviewed for fluid restrictions (Resident #20). Findings include: Review of the facility policy titled, Fluid Restriction, last reviewed February 2022, revealed the policy statement: Fluids will be restricted for residents as directed by the physician orders . Procedure: 3. Nursing service will document intake . Record review of the Order Summary Report for Resident #20 revealed an order dated 8/26/24 for a 1000 milliliter (ml) fluid restriction. The order directed that fluid intake must be documented and specified the following shift limits: day shift not to exceed 450 ml, evening shift not to exceed 450 ml, and night shift not to exceed 100 ml. Record review of the Intake and Output (I&O) forms for Resident #20 from 3/30/25 through 4/7/25 revealed incomplete documentation. Daily 24-hour totals ranged from 240 ml to 400 ml. The (I&O) records lacked documentation necessary to determine if the resident's prescribed fluid restriction was being maintained. During an interview with Certified Nurse Assistant (CNA) #2 on 4/8/25 at 3:11 PM, she stated she was aware that Resident #20 was on a fluid restriction. CNA #2 further stated that CNAs are expected to report the amount of fluids the resident consumes during meals to the nurse. She confirmed that she had not been reporting the resident's fluid intake to the nurse. During an interview with Licensed Practical Nurse (LPN) #3 on 4/8/25 at 3:15 PM, she revealed she was assigned to Resident #20 on the day shift. LPN #3 stated she was aware the resident was receiving dialysis but was not aware the resident was on a fluid restriction. She also confirmed that the CNAs do not notify her of how much fluid the resident consumes during meals. During an interview with LPN #4 on 4/8/25 at 3:20 PM, she stated she provided care for Resident #20 during the evening shift. LPN #4 confirmed she was aware the resident was on a fluid restriction but was unsure of the prescribed fluid restriction amount. She also confirmed that the CNAs do not report the resident's fluid intake to her during the shift. She stated she only documented the fluids she directly gave to the resident. During an interview with the Director of Nursing (DON) on 4/8/25 at 3:25 PM, she confirmed that upon review of the I&O forms from 3/30/25 to 4/7/25, staff were not accurately documenting the total amounts of fluid consumed by Resident #20. She stated that CNAs are responsible for informing nurses of the amount of fluids the resident drinks during meals, and nurses are expected to ensure the intake is documented correctly and that the resident's prescribed fluid restriction is followed. She acknowledged that the current documentation was inaccurate and incomplete, and therefore staff had no way to accurately assess how much fluid the resident was consuming. The DON expressed that concerns from this deficient practice could result in the residents consuming too much or too little fluid, potentially leading to fluid overload or dehydration. Record review of the Admission Record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart and Kidney Disease with Heart Failure and Stage 5 Chronic KidneyDisease and End-Stage Renal Disease. Record review of Resident #20's Quarterly Minimum Data Set (MDS) dated [DATE], Section O, revealed the resident was receiving dialysis while in the facility.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure a call light was accessible for one (1) of 17 residents reviewed for call lights. Resident #45. Findings Include: Review of the facility policy titled Call Light/Bell with a revision date of 1/24 revealed under, Purpose: To provide the resident with a means of communication with staff members .To provide staff members with a means of summoning assistance when they are with the resident . An observation and interview with Resident #45 on 4/07/25 at 10:50 AM revealed he was sitting in his wheelchair inside his room watching television. The right side of the bed was turned against the wall with the call light cord wrapped around the bed rail multiple times, and the end of the call light was hanging down behind the bed, unreachable. The resident verbalized that he used the call light to request help but could not do that with it tied to the bed rail where he could not access it. He revealed that if he needed help, he would roll his wheelchair to the door and shout for help in the hallway. An observation of Resident #45 on 4/07/25 at 1:42 PM revealed him sitting in his wheelchair in his room. The call light continued to be wrapped around the right bed rail, which was up against the wall. An observation and interview with Certified Nurse Aide (CNA) #4 on 4/07/25 at 1:50 PM confirmed Resident #45's call light was inaccessible to him. She revealed the resident used the call light and explained that without it being accessible, he would not be able to call for help. An interview with Licensed Practical Nurse (LPN) #3 on 4/07/25 at 1:55 PM revealed the call light should always be in reach for Resident #45, so he could call staff if he needed something. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 10, which indicated Resident # 45 was moderately cognitively impaired. Record review of the Admission Record revealed the facility admitted Resident #45 on 2/29/24 with a medical diagnosis of Epilepsy.

Based on observation, staff and resident interview, record review, and facility policy review the facility failed to honor a resident's choice related to food preferences for one (1) of two (2) residents reviewed for choices. Resident #61. Findings Include: Record review of the facility policy Dignity and Respect with revision date of 07/22 revealed A facility must .care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. The facility shall protect and promote the rights of the residents .3. All residents should have autonomy of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care .4 .Resident's individual preferences regarding such things as menus .will be elicited and respected by the facility, and efforts will be made to accommodate these wishes . An observation and interview on 4/07/25 at 12:10 PM with Resident #61 revealed she was sitting in her room eating her lunch meal. She stated that she did not like rice or greens, and they had those foods on her meal tray today. An observation of the resident's lunch tray confirmed she had rice and mustard greens along with red beans, cornbread, pork chop, yogurt and banana pudding. She admitted that she had told them months ago that she didn't eat rice and greens, but they continued to put them on her plate. She also revealed that greens and rice were listed on her meal ticket under dislikes. An observation of the resident's meal ticket confirmed that rice and greens were listed under dislikes. An interview on 4/08/25 at 11:45 AM with Registered Nurse (RN) #1 confirmed that there was a place on the meal ticket's that listed the resident's likes and dislikes, and the residents should not receive those foods. She revealed that staff assisted the residents to fill out their preferences and choices and that the Dietary Manager kept up with them. An interview on 4/08/25 at 1:04 PM with the Dietary Manager (DM) confirmed that Resident #61's Lunch Meal Ticket dated 4/07/25 had dislikes documented that included mustard greens and rice and that she should not have received those two food items. He confirmed that the lunch menu on 4/07/25 consisted of a pork chop, red beans and rice, greens, banana pudding, and cornbread. The Dietary Manager revealed that the kitchen staff were supposed to follow the meal tickets as the plates were being passed down the line and that the greens and rice must have been put on Resident #61's plate by mistake. He revealed that he evaluated residents when admitted , went over their likes, dislikes, and preferences and the dietary staff were supposed to prepare their meal trays accordingly. He confirmed that Resident #61's dislikes were not honored, and she should not have received the greens and rice. An interview on 4/09/25 at 12:50 PM with the Administrator confirmed that resident food likes, dislikes and preferences were assessed when admitted to the facility and that Resident #61 should not have been served foods that were on her dislike list, stating, That's on us. The Administrator also revealed that the dietary staff should be reading and following those meal tickets when serving meals and admitted that residents had the right to make food choices. Record review of Resident #61's Dietary Admission Interview Form with admitted [DATE] revealed that Rice, Mustard and Turnip Greens under Food Preferences were answered No. Record review of Resident #61's Dislike and Allergy Report revealed that she disliked Rice, Turnip Greens, and Mustard Greens. Record review of Resident #61's Lunch Meal Ticket dated 4/07/25 revealed that her dislikes included Mustard Greens and Rice. Record review of Resident #61's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Type 2 Diabetes Mellitus, Unspecified Anemia, and Unspecified Anxiety Disorder. Record review of Resident #61's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to accurately submit a resident's information for Preadmission Screening and Resident Review (PASRR) for a Level II evaluation for one (1) of three (3) residents reviewed for PASRR. (Resident #43) Findings include: Review of the facility policy titled, Pre-Admission Screening PAS/PASRR (MS Only) last reviewed 8/24, revealed, To enter a Long-Term Care program an eligible beneficiary must have a Pre-Admission Screening (PAS) application completed to determine clinical eligibility for individuals seeking admission to a Division of Medicaid certified nursing facility on all residents regardless of payor source . Process . Review the medical records and other relevant medical documentation to verify major medical conditions and services . Record review of the Admission Record revealed Resident #43 was admitted on [DATE], with diagnoses of Unspecified Psychosis, Major Depressive Disorder, and Psychotic Disorder with Delusions. Record review of Resident # 43's Active Orders as of 12/09/24 revealed, Citalopram hydrobromide 20 mg (milligram) one tablet by mouth one time a day related to Major Depressive disorder, Haloperidol 1 (one) mg tablet by mouth every 8 (eight) hours related to Unspecified Psychosis, and Trazodone 50 mg 1 (one) tablet orally at bedtime related to Psychotic disorder with delusions. Record review of Resident #43's intake information for PASRR dated 12/09/24 revealed, Section I: Medications: coded no medications specified .Section J: Disease Diagnoses: coded only the admitting diagnosis of Cerebral Infarction . Section L: Referral Questions: 31. Does Resident # 43 have any history of mental illness? answered No .32. Does Resident #43 take, or have a history of taking psychotropic medications? answered No. During an interview with the Accounts Manager on 4/8/25 at 10:30 AM, she revealed she completed the Pre-Admission Screening on admission for Resident #43. She confirmed that she did not list any diagnoses other than the admitting diagnosis of Cerebral Infarction. She stated she never adds any other diagnosis than the primary diagnosis. She also revealed that she was not familiar with all the psychiatric diagnoses or the psychotropic medications that may need to be included. She confirmed, after reviewing the active orders as of 12/09/24 (the day the PAS was completed), that the resident was admitted on psychotropic medications and had psychiatric diagnoses that should have been submitted to determine the need for a Level II PASRR referral. She acknowledged it was an oversight on her part. She then revealed a concern that incorrectly completing the PAS could result in a resident with psychiatric diagnoses not receiving the additional services they may need. An interview with the Director of Nursing on 4/9/25 at 10:40 AM revealed that she reviewed Resident #43's 12/9/24 PAS and confirmed that it was coded incorrectly. She confirmed that the resident was admitted with mental health diagnoses and on psychotropic medications. She stated that the purpose of the PAS is to identify the resident's needs to ensure the resident is appropriate for placement in the facility and to determine if the resident needs a referral for a Level II PASRR for any extra mental health services. An interview with the Social Worker on 4/8/25 at 11:00 AM confirmed, after review of the PAS completed on admission for Resident #43, that it was not completed correctly. She stated the resident was admitted with psychiatric diagnoses and on psychotropic medications and should have been referred for a Level II PASRR. She revealed that the accuracy of the PASRR is important to ensure the resident is appropriate for the facility and that the facility can meet the resident's mental health needs and provide any additional services required. She then stated that incorrectly completing the PAS could result in a resident not receiving needed care and services. A record review of Resident #43's Admission Minimum Data Set (MDS) dated [DATE], revealed Section N: Medications coded as taking antipsychotic and antidepressant medications.

Based on staff interviews, record review, and facility policy review, the facility failed to implement a care plan related to fluid restriction for one (1) of 17 resident care plans reviewed. (Resident #20). Findings include: Review of a facility policy titled, Care Plan Process, last revised 12/24, revealed, The comprehensive care plan is an interdisciplinary communication tool .The care plan must include measurable objectives and timeframes and must describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of a care plan for Resident # 20 revealed, Focus The resident is at risk for nutritional problems r/t (related to) ESRD (End Stage Renal Disease) with fluid restriction on Hemodialysis . last revised 9/05/24 Interventions: 1000 ml (milliliters) fluid restriction. Document fluid intake. Day shift not to exceed 450 ml. Evening shift not to exceed 450 ml. Night shift not to exceed 100 ml . Record review of the Intake and Output (I&O) forms for Resident #20 from 3/30/25 through 4/7/25 revealed incomplete documentation. Daily 24-hour totals ranged from 240 ml to 400 ml. The (I&O) records lacked documentation necessary to determine if the resident's prescribed fluid restriction was being maintained. An interview on 4/08/25 at 3:25 PM, the Director of Nursing (DON) confirmed that staff were not consistently following the resident's care plan as it related to fluid restriction and intake documentation. During an interview conducted on 4/09/25 at 9:10 AM, the Minimum Data Set (MDS) Nurse reviewed Resident #20's care plan and stated that if staff were not documenting the total daily fluid intake, then the care plan was not being implemented. She stated the care plan serves to direct resident-specific care and failure to implement it could result in the residents receiving more fluids than ordered. Record review of the Admission Record revealed that Resident #20 was admitted to the facility on [DATE] with diagnoses that included Hypertensive Heart and Kidney Disease with Heart Failure and Stage 5 Chronic Kidney Disease (End-Stage Renal Disease).

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to follow a physician 's order for a referral to a pain management clinic for Resident #23, this was for one (1) of three (3) residents reviewed for pain. Findings Include: Review of the facility policy titled Pain Screen and Management with a revision date of 12/23 revealed, All residents who experience routine pain receive a comprehensive pain screening and a treatment plan until an acceptable level of relief of pain is achieved. All residents have the right to treatment for pain. On 4/07/25 at 11:15 AM, an observation and interview with Resident #23 revealed he was lying in bed and verbalized he was hurting in his lower abdomen (kidney area) and his lower ribs (lung area). The resident revealed he was unsure if he had taken something for the pain. An observation and interview of Resident #23 on 4/08/25 at 9:40 AM revealed he was lying in bed and the resident stated that he was hurting all over. The resident revealed that he had had a log truck accident in the past with injuries, including a skull fracture, a broken collarbone, and a broken hip, which required a hip replacement. He reported shoulder and hip pain radiating up his spine, described his pain as throbbing, and rated it 8 out of 10 on a pain scale. He added that he had just taken a bunch of pills and thought the nurse had given him something. During an interview with Licensed Practical Nurse (LPN) #3 on 4/08/25 at 9:50 AM, she confirmed that she gave the resident a PRN (as needed) a Methocarbamol (muscle relaxant) at 8:40 AM after he told her he was hurting in his shoulders and sides. She added the resident took Gabapentin scheduled three times a day for nerve pain and chronic pain and took Robaxin every 6 hours as needed for muscle spasm. According to LPN #3, the resident reported that Neurontin and the muscle relaxer provided relief. She stated that she knew the doctor had made a referral to the pain clinic several months ago, but she was unsure what happened, but he did not go. Record review of Resident #23's Order Details revealed a physician order dated 1/07/25, Refer resident to pain management due to left shoulder and left hip pain. Record review of Resident #23's Medication Administration Record (MAR) revealed, an order dated 7/01/24 Gabapentin (nerve pain/chronic pain) Oral Capsule 300 MG (milligrams) give 1 capsule by mouth three times a day related to pain. Also revealed and order dated 1/27/25, Methocarbamol (muscle relaxant) Oral Tablet 500 MG (milligram) give 1 tablet by mouth every 6 hours as needed for pain related to other muscle spasm. The MAR revealed the resident received Methocarbamol on the following dates and times: 4/01/24 at 6:00 AM 4/02/24 at 12:15 AM 4/03/25 at 12:23 AM and 9:22 AM 4/04/25 at 12:02 AM and 9:34 AM 4/05/25 at 12:18 AM, 9:16 AM, and 11:30 PM 4/07/25 at 6:04 AM and 11:31 PM 4/08/25 at 8:45 AM An interview with the Nurse Practitioner (NP) on 4/08/25 at 11:39 AM revealed Resident #23 has a history of mental illness and drug abuse. She explained that he has multiple allergies to pain medications and commented, Basically there's nothing we can give him. She revealed therapy and lidocaine patches had been tried previously, and x-rays and tests had not revealed any specific injury. The NP revealed the resident says the muscle relaxant was effective. She confirmed the resident's physician made a referral to pain management but was unsure why he never went. An interview with the Director of Nursing (DON) on 4/08/25 at 3:02 PM confirmed that Resident #23's pain management referral was never made and acknowledged that this could result in a delay in the residents receiving appropriate care and pain relief. An interview with the Medical Record's (MR) Nurse on 4/08/25 at 3:15 PM revealed Social Services would have been responsible for making Resident #23's pain appointment. However, the appointment was never scheduled, and the order was discontinued after 90 days. An interview with Social Services (SS) on 4/08/25 at 3:20 PM revealed that she never received a copy of Resident #23's physician's order and was therefore unaware of the pain management referral. During a telephone interview on 4/09/25 at 9:21 AM, with Resident #23's Medical Doctor (MD), he revealed the resident's pain had evolved over time. He described a complex history, including multiple geriatric psychiatry admissions and medication management regimen. He revealed the resident required high doses of medication to manage paranoia, which also lowered his blood pressure and had contributed to nighttime falls. The MD explained that the resident had end-stage chronic obstructive pulmonary disease (COPD) and a history of traumatic injuries. He stated that he believed the resident's pain was neuropathic and that Methocarbamol and Gabapentin may provide some relief with pain brought on by those type of injuries. He confirmed that he made a referral to pain management for the resident's shoulder and hip pain and felt the resident would still benefit from seeing a pain specialist. The MD also noted that during a recent visit on 4/07/25, the resident complained of abdominal pain caused by constipation related to immobility and was started on Simethicone for gas relief. He emphasized that the resident's pain should be addressed and acknowledged that his case was complex due to underlying mental illness and COPD. Record review of Resident #23's Progress Note dated 1/07/25 revealed under, Assessment and Plan: . Chronic pain syndrome-Continue Gabapentin (nerve pain) 300 mg (milligrams) TID (three times daily)-refer to pain management. Record review of the MDS with an Assessment Reference Date (ARD) of 3/14/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #23 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #23 on 8/22/24 with a medical diagnosis that included Chronic Obstructive Pulmonary Disease and Pain, Unspecified.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide privacy during one (1) of seven (7) treatment observations during the survey. Resident #6 Findings include: A review of the facility policy titled, Residents Rights, with a revision date of 11/17 revealed, All residents in a long-term care facility have rights guaranteed to them under Federal and State law. Residents residing at this facility will be guaranteed a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. These rights include: # 5 Privacy and confidentiality . #26 The resident has a right to personal privacy and confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment, written and telephone communications. personal care, visits, and meeting of family and resident groups, but this does not require the facility to provide a private room for each resident . An observation on 10/03/23 at 2:42 PM, of Resident #6 receiving a treatment to left heel revealed that the Treatment Nurse entered room to perform the treatment and did not provide privacy for Resident #6. The Treatment Nurse did not close the door to resident's room, pull the privacy curtain, and did not close blinds in the resident's room leading to the outside of the facility that faces the parking lot. Resident #6's roommate was in the room during treatment care. An interview on 10/04/23 at 12:34 PM, with the Treatment Nurse confirmed that she did not provide privacy before starting the treatment or during the treatment to the resident's left heel. The Treatment Nurse confirmed Resident #6's roommate was in the room and that privacy should have been provided to keep others from seeing Resident #6 receiving treatment. An interview on 10/04/23 at 12:42 PM, with the Director of Nursing (DON) confirmed that the Treatment Nurse should have closed the door, pulled the privacy curtain, and closed the blinds to Resident #6's room while providing care for the resident. A review of the facility Face Sheet for Resident #6 revealed the resident admitted to the facility on [DATE] with diagnoses of Peripheral Vascular Disease, Hypertension and Gastro-esophageal Reflux Disease. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08-16-23 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #6 was cognitively intact.

Based on record review, staff interview and facility policy review the facility failed to identify triggers to avoid potential re-traumatization and failed to develop the care plan to include individualized trauma- informed approaches for one (1) of four (4) residents reviewed for trauma- informed care. Resident #15. Findings include: A record review of the facility policy, titled Documentation-Social History, with a revision date of 10/23, revealed, Purpose, to record observations, outcomes, and responses in relation to social services as well as interventions, including trauma informed care, as identified in the comprehensive care plan, and the delivery of direct social services . A record review of Resident #15's Face Sheet revealed she was admitted to the facility on [DATE] with a diagnosis of Post-traumatic Stress Disorder (PTSD). A record review of Resident #15's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/11/23 revealed a diagnosis of PTSD. The Brief Interview for Mental Status (BIMS) score was 15, indicating her cognition was intact. A record review of Resident #15's care plan revealed resident was not care planned for individualized approaches related to her history of trauma. A record review of a Social Assessment, dated 8/11/23, for Resident #15 revealed that the resident had not experienced a traumatic event, had no trauma related symptoms, and no impact to the daily routine. During an observation and interview conducted with Resident #15 on 10/2/2023 at 10:30 AM, the resident was sitting in her wheelchair with no behavioral symptoms noted. Resident #15 stated she was doing fine, and she did not have concerns related to staff caring for her. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 10/3/2023 at 11:30 AM, she indicated that she was unaware that Resident #15 had a diagnosis of PTSD and there were no specific interventions or approaches to care. During an interview with the Minimum Data Set (MDS) nurse on 10/3/2023 at 1:15 PM, she verified that Resident #15 had a diagnosis of PTSD but did not have a care plan in place regarding PTSD. She stated that the facility should have a care plan with individualized interventions in place related to Resident #15's history of trauma. During an interview with the Social Worker (SW) #1 on 10/3/2023 at 1:20 PM, she stated that she completed the Social Assessment for Resident #15 and was not aware that the resident had a diagnosis of PTSD. She verified that Resident #15's care plan included no individualized approaches to care for Resident #15 in relation to her diagnosis of PTSD. SW #1 acknowledged that a care plan should be completed for the residents at the facility who have been identified as having PTSD. An interview was conducted with the Director of Nursing (DON) on 10/3/2023 at 2:00 PM, she confirmed her expectation was for a care plan to be developed that included individualized approaches to care for residents who had a diagnosis of PTSD.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by not performing hand hygiene during wound care and medication administration (Residents #6, #36, and #39), failure to use a clean barrier during medication pass (Resident #78) and failure to properly sanitize a glucometer after use (Resident #36) for two (2) of four (4) days of survey. Findings Include: Review of the facility policy titled, General Infection Prevention and Control Nursing Policies with an origination date of 06/14 and a review date of 08/21 revealed It is the policy of this facility that all nursing activities will be performed in a manner to minimize the potential for infection in residents, staff, and visitors. Some of the specific guidelines include: All items used for resident care will be cleaned and disinfected between uses or will be designated for that resident's use only .other common-use items will be cleansed and disinfected according to the manufacturer's recommendations. Review of the facility policy titled, Hand Hygiene with a revision date of 10/17 revealed under Purpose: To cleanse hands to prevent transmissions of infection or other conditions and to provide clean health environment for residents, staff and visitors. This review revealed under Procedure .#4. Before and after applying gloves; #9. Wearing gloves does not replace the need to perform hand hygiene. Review of the facility policy titled, Glove Usage with a revision date of 5/11 revealed under, When to use gloves: #2. After touching a resident's excretions, secretions, blood, body fluids or contaminated items, gloves must be changed if care of that resident has not been completed. Review of the facility policy titled Blood Glucose Quality Control with a revision date of 9/23 revealed, under, Maintenance of Blood Glucose Monitoring Systems: Always clean the meter after each use. Gently wipe and clean surface of the meter with a disinfectant wipe per facility policy . Resident #6 An observation on 10/03/23 at 2:42 PM, of Resident #6 receiving a treatment to the left heel revealed that the Licensed Practical Nurse (LPN)/Treatment Nurse entered the room, used hand sanitizer, put on gloves, cleaned the left heel, changed her gloves, and failed to use hand sanitizer or wash her hands before donning the clean gloves and completing the treatment. An interview on 10/04/23 at 12:34 PM, with the LPN/Treatment Nurse confirmed that she did not sanitize or wash her hands between changing gloves during the treatment. She confirmed she should have sanitized between changing gloves to prevent the spread of infection. An interview on 10/04/23 at 12:42 PM, with the Director of Nursing (DON), confirmed that the policy on wound care states to sanitize in between changing gloves and that it is done to prevent the spread of infection. A review of Resident #6's Physician Orders revealed an order dated 9/05/23, Stage 2 to left heel cleanse with NS (normal saline), pat dry, paint with betadine and leave open to air daily until healed. A review of the Face Sheet for Resident #6 revealed the resident was admitted to the facility on [DATE] with a diagnosis of Peripheral Vascular Disease, Hypertension and Gastro-esophageal Reflux Disease. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/16/23 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #6 was cognitively intact. 44804 Resident #39 An observation and interview on 10/3/23 at 9:48 AM, with LPN/Treatment Nurse and Nurse Practitioner (NP) revealed that LPN/Treatment Nurse put gloves on when she entered Resident #39's room, assisted the NP in turning the resident, suctioned the resident, removed the old dressing from the wound on the left buttock, performed the wound care and applied the new dressing without removing the dirty gloves or performing hand hygiene. An interview with LPN/Treatment Nurse after leaving the resident's room revealed that she should have removed her dirty gloves after removing the dressing, performed hand hygiene, and put on clean gloves before performing the wound care. She stated that not removing the old gloves and performing hand hygiene was an infection control issue and could have caused an infection. An interview on 10/4/23 at 12:15 PM, with LPN/Infection Control Nurse confirmed that gloves should be changed, and hand hygiene performed between a dirty site to a clean site to prevent the spread of infections. She stated that the LPN/Treatment Nurse had received in-services regarding this. An interview on 10/4/23 at 12:45 PM, with the Director of Nurses (DON) confirmed that the LPN/Treatment Nurse should have removed her gloves and performed hand hygiene after removing the old wound dressing and before cleaning the wound. She confirmed that this needed to be done in order to prevent the spread of infection. Record review revealed that LPN/Treatment Nurse attended in-services regarding infection control and hand hygiene on 6/13/23, 8/18/23 and 8/21/23. Record review of Resident #39's Wound Assessment Report dated 10/2/23 revealed the resident had a Stage 2 pressure ulcer to her left buttock that was identified on 10/2/23 with treatment indicated as; Cleanse with normal saline (NS), pat dry, apply hydrogel, and cover with foam dressing daily until healed. Record review of Resident #39's Face Sheet revealed the resident was admitted to the facility on [DATE] with admitting diagnoses that included Acute embolism and thrombus unspecified deep veins of lower extremities. Record review of Resident #39's MDS with an ARD of 7/18/23 revealed in Section C a BIMS score of 04, which indicates the resident is severely cognitively impaired. 47874 Resident # 36 An observation of blood glucose finger stick for Resident #36 on 10/03/23 at 11:00 AM, revealed Licensed Practical Nurse (LPN) #3 performed the glucose check, removed her gloves, and did not perform hand hygiene. She walked to the medication room to get insulin, returned to the medication cart, prepared the ordered insulin, and applied a new pair of gloves, neglecting to perform hand hygiene. She entered the resident's room and administered five (5) units of NovoLog per sliding scale to the residents' left upper arm. LPN #3 removed her gloves, exited the room, and performed the required documentation in the computer, but did not perform hand hygiene. LPN #3 applied new gloves and cleaned the glucometer with a Sani-Cloth, wiping the exterior of the machine for approximately 15 seconds. She removed her gloves and did not perform hand hygiene. During an interview at this time she revealed she normally wrapped the machine in a Sani-Cloth and allowed it to sit for two (2) or three (3) minutes, but confirmed she did not do that this time. The SA (State Agency) and LPN #3 verified the wet (contact) time on the back of the Sani-Cloth wipes was 2 minutes. LPN #3 confirmed that she did not allow the disinfecting wipe to stay in contact with the machine for 2 minutes and that this could lead to cross contamination and infection. She also confirmed that she did not perform hand hygiene after changing gloves during glucose check and insulin administration. She stated, I've got hand sanitizer right here but forgot to use it. She revealed handwashing was important to prevent cross contamination between rooms and the spread of infection. An interview with the Director of Nursing (DON) on 10/03/23 at 1:25 PM, confirmed that the glucometer should be cleaned and remain wet according to the wet (contact) time on the disinfecting wipes to prevent the spread of infection. She revealed that hand hygiene should be done anytime gloves are removed to prevent the spread of infection. An interview on 10/04/23 at 9:26 AM with the LPN/Infection Control Nurse revealed that staff should look at the disinfecting wipe bottle to determine the wet (contact) time and wrap the glucometer with the wipe for the time specified on the bottle. She revealed the purpose of performing hand hygiene and wiping the glucometer for the wet (contact) time was to prevent the spread of infection. Record review of the Inservice Training revealed an in-service was conducted for Infection Control on 2/1/23 that included, Hand hygiene. In-Service revealed, Wash hands with soap and water for at least 20 seconds or use alcohol-based hand rub. Record review of the Inservice Training revealed an in-service was conducted for Glucometer Cleaning on 6/15/23 that included, Always clean between uses. Sani-cloth wet time 2 mins (minutes). Glucometer must be wrapped in wet cloth for 2 mins. Clorox wet time -3 mins. Glucometer must be wrapped in wet cloth for 3 mins. Use tissue as barrier when sitting down in residents' room. Record review of the Inservice Training revealed an in-service was conducted for Infection Control: glucose meter on 8/14/23 that included, Glucose meter must be disinfected between every use. Sani cloth -wet time 2 min (minutes)-air dry: Clorox wipes wet times 3 min-air dry time on bottle . Record review of Resident #36's Electronic Medication Administration Record (EMAR) revealed an order dated 6/02/21, Blood Glucose Finger Sticks Before Meals & (and) Bedtime . Record review of Face Sheet revealed Resident # 36 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus, Heart Failure, Unspecified Dementia, Malignant Neoplasm of Corpus Uteri and Parkinson's Disease. Record review of the MDS with an ARD of 7/12/23 revealed under section C, a BIMS score of 14, which indicates Resident # 36 is cognitively intact. Resident # 78 The facility provided documentation on letter head dated 10/04/23 that read, The facility medication administration policy covers adhering to infection control procedures however it does not specifically state that a barrier is to be used. An observation and interview during medication pass on 10/04/23 at 8:40 AM, with LPN #2 revealed Resident #78 was to receive an Albuterol and a Trelegy inhaler. LPN #2 removed the inhalers from the medication cart and laid them both on the surface of the medication cart, while preparing the other oral medications. LPN #2 entered the resident's room, she laid both inhalers on the resident's bedside table. She administered Resident #78's medications and after completion laid both inhalers back down on the bedside table while preparing a nebulizer treatment. LPN #2 exited the room, laid both inhalers on the surface of the medication cart, picked them up and placed them back inside the medication cart. LPN #2 confirmed that she should have used a barrier when laying the inhalers down to prevent cross contamination. An interview with the LPN/Infection Control Nurse on 10/04/23 at 9:35 AM, confirmed that a barrier must be used when carrying things into the resident's rooms. She revealed that this was an infection control issue and the staff have had in-services regarding use of a barrier during medication pass. An interview with the Director of Nursing (DON) on 10/04/23 at 9:40 AM, revealed that staff know they should be using a barrier when taking anything inside a resident's room. She revealed that this should be done to prevent the spread of infection. Record review of Resident #78's Electronic Medication Administration Record (EMAR) revealed, an order dated 9/06/23, Trelegy Ellipta 100 MCG (microgram)-62.5 MCG -25 MCG Powder For Inhalation-: 1 Puff By Mouth Daily. Record review of Resident #78's EMAR revealed an order dated, 9/06/23, Albuterol Sulfate HFA (Hydrofluoroalkane) 90 MCG/Actuation Aerosol Inhaler: 2 Puffs Via Inhalation by Mouth Daily. Record review of the Face Sheet for Resident #78 revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease and Nicotine Dependence. Record review of the MDS with an ARD of 9/13/23 revealed under section C, a BIMS score of 15, indicating Resident # 78 is cognitively intact.

Based on record review, staff interviews and facility policy review the facility failed develop a comprehensive care plan for one (1) of nine (9) residents reviewed. On 10/7/22, Licensed Practical Nurse (LPN) #2 identified an excoriation area to Resident # 1's buttocks. The area was assessed by the Nurse Practitioner (NP) on 10/7/22 and identified as a stage 2 pressure ulcer. On 10/16/22, the wound status was identified as deteriorating. On 10/20/22, Resident #1 was admitted to Hospital #1 for diagnosis of wound sepsis. The State Agency (SA) identified an Immediate Jeopardy (IJ) that began on 10/16/22 when Resident #1's wound began to deteriorate. The facility failed to develop an updated plan of care when Resident #1 developed actual skin breakdown. This placed Resident #1 in a situation that has caused serious harm, injury and impairment and is likely to cause serious harm, injury, impairment or death for others at risk. On 12/6/22, at 3:00 PM, the SA notified the Quality Improvement Nurse ([NAME]) and Director of Nurses (DON) of the IJ and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 12/7/22, in which they alleged all corrective actions to remove the IJ were completed on 12/6/22 and IJ removed on 12/7/22. The SA validated the Removal Plan on 12/9/22, and determined the IJ was removed on 12/7/22, prior to exit. Therefore, the scope and severity for CFR 483.21 (b)(1)(3) Develop/implement Comprehensive Care Plans (F656)-Scope and Severity J. and were lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy and procedure for the Care Plan Process last revised on 08/17 revealed The facility shall develop and implement a Baseline Care Plan and Summary for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care .The overall care plan should be oriented towards: .5. Evaluating treatment of measurable objectives, timetables and outcomes of care .8. Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities . Record review of Resident #1's Care Plan with a problem onset date 03/30/2017 revealed Resident is at risk for skin breakdown .Goal and target date: Resident will have no skin breakdown through next review 1/28/23 . Approaches .Open area RT (right) and LT (left) buttocks-clean areas with NS (normal saline)/gauze, pat dry, apply Santyl, cover with calcium alginate and foam dressing QD (every day) until healed .Notify MD (Medical Doctor) of any complications or changes to wounds . Record review of Resident #1's October 2022 electronic Treatment Administration Record (ETAR) described this wound as an excoriation from 10/8/22 through 10/12/22 and then an open area from 10/13/22 through 10/20/22. Record review of a nurses note by Licensed Practical Nurse (LPN) #3 dated 10/8/22 at 8:04 AM documented this area as an excoriation. Record review of the Nurse Practitioner (NP) Progress note dated 10/7/22 describes this sacral area as a Stage 2 pressure ulcer measuring 2.5 centimeter (cm) X (by) 8 cm X 0.1 cm. Record review of Physician Orders List page 2 of 2 dated 10/8/22 revealed Clean with normal saline, pat dry, apply zinc and cover with foam dressing daily until healed. Continue the air mattress. Record review of the NP Progress Note dated 10/12/22, revealed an evaluation due to treatment nurse reporting area to sacrum worsening. The NP then stages this wound in her progress note as an unstageable pressure ulcer. The NP discontinued the order from 10/7/22 and ordered the treatment nurse to clean the wound with normal saline, pat dry, apply santyl, calcium alginate, cover with foam dressing daily. The measurements were 7.0 cm X 7.0 cm X 0.1cm. Record review of a physician order written by the NP, dated 10/12/22, identified the area as open area to the right and left buttocks. Record review of a Physician Order written by the NP, dated 10/17/22, revealed an order for Cleocin HCL 300 milligram (MG) (1) three times a day (TID) X 10 days, Cipro 500 MG (1) twice a day (BID) X 10 days to start on 10/18/22, obtain a Complete Blood Count (CBC) the week of 10/16/22. On 12/5/22 at 3:25 PM, interview with MD #2 revealed he was the primary Medical Doctor (MD) for Resident #1. MD #2 stated he was unaware of Resident #1's wound decline until he got to the hospital on 10/20/22. If there was an odor to that wound, he should have been sent out earlier than 10/20/22. Not staging a wound in orders or notes is a problem. When there's an odor, the treatment has to be more aggressive, such as IV antibiotics, debrided and put in the hospital. Someone should have called me to let me know there was a problem, called me to admit him to the hospital for evaluation. I have a problem that nurses knew it was, what was needed and afraid to tell. There are communication problems there. It's been that way for a while. I didn't know there was a problem until he got to the hospital. On 12/7/22 at 12:30 PM, during an interview with the Director of Nurses (DON) revealed when asked by the State Agency (SA) if the DON or treatment nurse contacted Resident #1's MD when the NP was sick at home and she stated I didn't, the treatment RN didn't, not to my knowledge. Interview on 12/5/22 at 10:30 AM with Registered Nurse (RN) #2 revealed that care plans are updated when there are new orders given stating That's when new interventions are added. An accepted Removal Plan was provided to the SA on 12/7/22 at 1:15 PM. Removal Plan: On December 6, 2022, at 3:00 pm State Agency notified the Director of Nursing that the facility was in Immediate Jeopardy (IJ) and templates were provided to the Director of Nursing. Corrective Actions: 1. Seventy residents were assessed with eleven residents identified by Director of Nurses as having excoriation/irritation or staged wounds on December 5, 2022. Seventy residents were assessed with twelve residents identified by Director of Nurses as having an air mattress device. On December 6, 2022, Director of Nurses reviewed all eleven of seventy active resident records for a decline in wound status and for appropriate staging. Of the eleven residents identified with excoriation/irritation or staged wound, three were newly identified with excoriation/irritation and three were newly identified as a staged wounds and three were existing with excoriation/irritation and two were existing with staged wounds. Physicians, Resident Representatives notified of new wounds and new orders obtained for the new wounds. No significant findings were identified on all eleven of seventy active residents assessed. On December 6, 2022, Director of Nurses reviewed all twelve of seventy active residents to identify functioning of air mattress device. No significant findings identified on all twelve of seventy active residents which required have an air mattress device On December 6, 2022, Director of Nurses reviewed all twelve of seventy active records to ensure intervention of air mattress and function checks were present on care plan. No significant findings were identified on all twelve of seventy active residents care plans which were identified to have an air mattress device. Three records were newly identified with excoriation/irritation for implemented care plans and three records were newly identified as staged wounds for implemented care plans. 2. Quality Improvement Nurse ([NAME]) immediately initiated in-services with Registered Nurses and Director of Nursing on December 6, 2022, on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. In-services will be on-going, and no employee will be allowed to work until participation of the in-services are completed. 3. The facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress, no policy changes were made, however, facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders. Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. The following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON. The facility alleges that all corrective actions to remove the IJ were completed on December 6, 2022, and the IJ was removed on December 7, 2022. The SA validated the Removal Plan on 12/9/22. Validation: 1. Based on record reviews, observations and interviews on 12/9/22, the facility did a 100% skin assessment on all residents present in the facility on 12/5/22. Interviews with the [NAME] and DON on 12/9/22 revealed that 11 residents were identified by the DON having either excoriations/ irritation or staged wounds. Interviews, record reviews and observations revealed that 12 residents were identified by the DON as having air mattress devices. Based on record reviews and interviews, there were three (3) residents newly identified with excoriations or irritations and 3 were newly identified as having staged wounds. Record reviews revealed the Medical Doctors (MD) and Responsible Party (RP) of residents were notified of the new skin areas noted with new orders. Record review and interview revealed the DON reviewed the 12 residents on air mattress devices. The DON did not observe significant findings on the 12 residents with air mattress devices. Record review and interview confirmed that on 12/6/22, the DON reviewed the care plans of the 12 residents on air mattress devices to ensure the interventions included the air mattress and function checks were present. No significant findings were identified. The DON confirmed on 12/9/22 that she reviewed the 3 records of newly identified residents with excoriations/irritations and the 3 residents that were newly identified as having staged wounds. 2. Based on record reviews and interviews on 12/9/22, it was confirmed that the [NAME] had initiated an in-service with the Registered Nurses (RN) and Director of Nurses (DON) on 12/6/22. These in-services included information on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. Record review and interviews confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. Interviews and record review confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. Interview and record review confirmed that these in-services will be on-going, and no employee would be allowed to work until participation of the in-services were completed. 3. Record reviews and interviews on 12/9/22 confirmed that the facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Interviews and record review confirmed that the topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress and there were no policy changes made. Record review and interviews did confirm that the facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Record review and interview confirmed that the Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders and that the Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. Record review and interviews with the DON and [NAME] on 12/9/22 confirmed that the DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. Interviews and record reviews with the [NAME] and DON on 12/9/22 confirmed that the following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON.

Based on interviews with staff and Resident Representative interviews, record review and facility policy review, the facility failed to identify a pressure ulcer and prevent its deterioration for one (1) of nine (9) residents reviewed for pressure ulcers, Resident #1. On 10/7/22, Licensed Practical Nurse (LPN) #2 identified an excoriation area to Resident # 1's buttocks. Nurse Practitioner (NP) #1 visited the facility on 10/7/22 and assessed Resident #1's area to the buttocks. NP #1 ordered wound care treatment for Resident #1. Resident # 1 received daily wound care treatments with air mattress function checks every shift. On 10/12/22 Resident #1's wound was assessed again by NP #1 who documented the area as an unstageable pressure ulcer and changed the treatment order for Resident #1. On 10/16/22, the wound status was identified as deteriorating. New orders for antibiotics and laboratory tests for Resident #1 were ordered by NP #1 on 10/17/22. On 10/20/22, Resident #1 was admitted to Hospital #1 for diagnosis of wound sepsis. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 10/16/22 when the facility failed to ensure pressure ulcers did not worsen and failed to provide treatment and services that were required to prevent the worsening of pressure ulcers. This placed Resident #1 in a situation that has caused serious harm, injury and impairment and is likely to cause serious harm, injury, impairment or death for others at risk. On 12/6/22, at 3:00 PM, the SA notified the Quality Improvement Nurse ([NAME]) and Director of Nurses (DON) of the IJ and SQC and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 12/7/22, in which they alleged all corrective actions to remove the IJ were completed on 12/6/22 and IJ removed on 12/7/22. The SA validated the Removal Plan on 12/9/22, and determined the IJ was removed on 12/7/22, prior to exit. Therefore, the scope and severity of CFR 483.25 (b)(1)(i)(ii) Treatment/services To Prevent/heal Pressure Ulcers (F686) was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's Staging of Pressure Ulcer policy and procedure, last review date of 08/21, revealed an unstageable pressure ulcer as Unstageable due to slough and/or eschar: full thickness tissue loss in which to base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. The Definition of a pressure ulcer: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A Registered Nurse shall stage pressure ulcers. Interview with the Resident Representative (RR) and complainant on 11/30/22 at 4:31 PM, revealed he does have copies of the hospital records. There are photos of the sacrum wound. He stated the resident was sent to the hospital 10/20/22. He is now in another facility. He had never been told by the facility that his father had a wound on his butt. The medical doctor (MD) at the hospital had to clean the wound down to the bone. The family is now looking for a new nursing home. He stated he does not want his father to back to this facility. Record review of the Facesheet for Resident #1 revealed he was admitted to the facility on [DATE], with a diagnosis of Diabetes Mellitus, Dementia, Hypertension and Benign Prostatic Hypertrophy, and Osteoarthritis. Record review of Resident #1's October 2022 electronic Treatment Administration Record (ETAR) described this wound as an excoriation from 10/8/22 through 10/12/22 and then an open area from 10/13/22 through 10/20/22. Record review of the Nurse Practitioner (NP) Progress note dated 10/7/22 describes this sacral area as a Stage 2 pressure ulcer measuring 2.5 centimeter (cm) X (by) 8 cm X 0.1 cm. Record review of a nurses note by Licensed Practical Nurse (LPN) #3 dated 10/8/22 at 8:04 AM documented this area as an excoriation. Record review of Physician Orders List page 2 of 2 dated 10/8/22 revealed Clean with normal saline, pat dry, apply zinc and cover with foam dressing daily until healed. Continue the air mattress. Resident #1 received a new order for an air mattress on 3/7/22 per Physician #1. Record review of the NP Progress Note dated 10/12/22, revealed an evaluation due to treatment nurse reporting area to sacrum worsening. The NP then stages this wound in her progress note as an unstageable pressure ulcer. The NP discontinued the order from 10/7/22 and ordered the treatment nurse to clean the wound with normal saline, pat dry, apply santyl, calcium alginate, cover with foam dressing daily. The measurements were 7.0 cm X 7.0 cm X 0.1cm. Record review of Physician Orders List revealed an order dated 10/12/22 identifying the area as open area to the right and left buttocks. Record review of a Physician Orders List revealed an order dated 10/17/22 revealed an order for Cleocin HCL 300 milligram (MG) (1) three times a day (TID) X 10 days, Cipro 500 MG (1) twice a day (BID) X 10 days to start on 10/18/22, obtain a Complete Blood Count (CBC) the week of 10/16/22. Record review of the Departmental Notes for Resident #1 beginning 10/8/22 revealed resident has an excoriated area to resident's buttocks and a treatment was initiated. Departmental Note dated 10/12/22 at 3:26 PM reveal that the wound Medical Doctor (MD) and Certified Nurse Practitioner have new orders for the wounds to resident #1's buttocks. On 10/19/22, at 1:50 PM it is noted that resident continues his antibiotics. It is noted that he has a lower blood pressure (BP), increased heart rate and twitching more than usual. 10/20/22 at 9:59 AM, LPN #2 documented that he has weaker strength, difficulty swallowing medications and pocketing medications. RN #1 assessed resident and documented excessive spasm, jerking motion to all extremities and that Resident #1. RN #1 contacted the NP and gave report along with the results of the CBC. NP ordered Resident #1 be sent to the emergency room (ER) for evaluation. Responsible Party (RP) notified. Record review of the Discharge Summary provided by the local hospital for Resident #1 revealed .Page 2 Sepsis from Stage IV decubitus ulcer with infection and patient has sacral decubitus ulcer, foul smelling odor. Patient with eschar over sacral ulcer . Page 3 revealed assessment by wound care consultant, foul smelling, boggy eschar noted to sacral area. Page 4 revealed debridement 10/26/22, debridement of skin, subcutaneous tissue, muscle and fascia 90 square(sq) cm, application of wound VAC. Page 5 revealed large sacral pressure ulcer with the base of the wound measuring 6 cm X 15 cm. The skin, subcutaneous tissue, muscle and fascia is necrotic all the way to the sacral bone and undermining the skin superiorly another 3 cm and extending inferiorly to the top edge of the anus. Interview with the DON on 11/30/22 at 3:20 PM, revealed I never looked at the area. We have pictures of it. His skin is so dark that there were black areas, but it was excoriation. Interview with the DON on 11/30/22 at 3:40 PM, revealed Since it was an excoriation, we do not have photos. We do not take photos of excoriations. Interview with the DON on 12/1/22 at 1:40 PM, revealed the facility does not have a specific policy/procedure for excoriations. I did see (Resident #1) a week before he went to the hospital. I saw slough and that is when the order changed to Santyl. Yes, the diagnosis should have changed from excoriation. She stated the Nurse Practitioner (NP) ordered the Santyl and Calcium Alginate. When I saw it, it was on both butt cheeks. There was scattered areas of slough and redness and black areas on top layer of African American skin peeling. The drainage was yellow. I would not call the black areas necrosis. Interview with the Director of Nurses (DON) on 12/5/22 at 11:00 AM, revealed she was aware of Resident #1 having air mattress issues. It was replaced twice that I know of. It would deflate and not reinflate on those 2 times I recall it was changed. Interview with the Nurse Practitioner (NP), on 12/5/22 at 1:00 PM, revealed she recalled she saw Resident #1's sacral area on 10/7/22. It was a small open area. I would describe a Stage 2. I will tell the nurses when I'm rounding what the pressure ulcers are staged but I always thought the Registered Nurses (RN's) will stage pressure ulcers as well. She stated there was no slough or drainage at that point and was a small open area. I saw it the next week because the staff reported a decline. It was 100% slough and had worsened. That's when I ordered the Santyl and Calcium Alginate. We started Cleocin, Cipro and ordered a CBC (Complete Blood Count). I believe they sent him out when they got the CBC results. It was unstageable when I started the Santyl and ordered the Cleocin. She revealed she had been out of the facility during the week Resident #1 was sent to the hospital due to a personal illness. I do expect the facility to stage wounds appropriately. She stated that since Resident #1 went into the hospital on 10/20/22, the facility has completed a 100% body audit on all residents. There have been times we haven't seen eye to eye with wound staging. They might not agree with the stage I give when staging pressure ulcers. Interview with the Director of Nurses (DON) on 12/5/22 at 1:05 PM, when asked by the State Agency (SA) about the malfunctioning of Resident #1's air mattress she responded that she, the Administrator, and maintenance looked at the air mattress but unable to recall the date. She stated that maintenance had changed the air mattress out a couple of times but did not recall the specific dates. Interview with the maintenance employee on 12/5/22 at 1:55 PM revealed when he began employment in august 2022 he recalled there were issues with Resident #1's mattress. He stated he changed out the outlet in the room a couple of times and recalled that the air mattress was changed out 1 time. Interview with Staff Member #1, on 12/5/22 at 3:10 PM, revealed that she was making rounds on 10/20/22. She noted there was a Certified Nurse Aide (CNA) feeding Resident #1 breakfast. She stated His eyes were locked on the ceiling. He was pocketing his food. His body was jerking every couple minutes. There was a meeting at 9:00 AM. I told them then someone needed to look at him. Staff member #2 said to the group 'y'all gonna wait around until he dies. Staff member #2 picked up his lab and gave it to Registered Nurse (RN) #1 and he went to the hospital that day. That odor was there for a week. She said the staff in the admission meeting was Staff Member #2, RN #1, DON, and the Administrator. She stated When I said he needed to be checked when in that meeting, it was just crickets. No one said a thing. Interview on 12/5/22 at 3:25 PM, with the primary Medical Doctor (MD) revealed he was the primary physician for Resident #1. MD #2 stated he was unaware of Resident #1's wound decline until he got to the hospital on 10/20/22. If there was an odor to that wound, he should have been sent out earlier than 10/20/22. Not staging a wound in orders or notes is a problem. When there's an odor, the treatment has to be more aggressive, such as intravenous (IV) antibiotics, debrided and put in the hospital. Someone should have called me to let me know there was a problem, called me to admit him to the hospital for evaluation. I have a problem that nurses knew it was, what was needed and afraid to tell. There are communication problems there. It's been that way for a while. I didn't know there was a problem until he got to the hospital. Interview with Staff Member #2 on 12/6/22 at 2:05 PM, by phone revealed that she went into Resident #1's room on 10/20/22. She didn't see him because there was a CNA providing care but could smell him. She stated, He smelled like rotting, dead flesh. She stated she went into the morning stand up meeting and told the participants that if they didn't get him sent to the hospital soon that he was going to die in that room. I remember Staff Member #3 saying something to me about the wound smell. I also asked CNA #2 about him too. I went to the copy room and saw some lab work on him and took it straight to the charge nurse. His white blood count (WBC)'s was elevated and that let me know something was going on with him. Interview with Staff Member #3, on 12/6/22 at 2:15 PM, revealed that when she returned to work and worked her schedule from 10/13/22 through 10/20/22, she said that Resident #1 smelled like rotting flesh. She stated she reported it to the agency nurses during that time. Interview with CNA #2 on 12/7/22 at 10:25 AM revealed there were times when I was assigned to him, I would find the air mattress was deflated a couple of times but maintenance would replace it or fix it. Interview with CNA #3 on 12/7/22 at 12:05 PM revealed that when she was assigned to Resident #1 I found his air mattress deflated 2-3 times. We talked about him laying on the rails. CNA #3 confirmed to the State Agency (SA) that when she said Resident #1 was lying on the rails lyin if she meant g on the bed frame. She stated she made rounds every two (2) hours and that it could have been possible Resident #1 would be lying on the deflated mattress and on the bed frame for the time frame in between her rounds. She stated she had tried plugging and unplugging it to make it work but it would not. She did confirm that she told the administrator and her regional supervisor that was in the administrator's office at that time. She stated that the Regional Supervisor said he had told maintenance to check the electrical outlets. Removal Plan: On December 6, 2022, at 3:00 pm State Agency notified the Director of Nursing that the facility was in Immediate Jeopardy (IJ) and templates were provided to the Director of Nursing. The facility failed to ensure Resident # 1 was free of neglect by failure to provide services to prevent an acquired pressure wound. The facility failed to implement preventative measures to prevent a facility acquired wound for Resident #1. The facility failed to follow and implement a care plan with interventions for preventative measures to prevent a facility acquired wound for Resident #1. The facility failed to provide routine and consistent wound care, wound assessments, wound documentation, and trained staff for Resident #1. The facility failed to sustain and address systems in care and management through the Quality Assurance and Performance Improvement committee related to wound and skin care and ensure care and services delivered met standards of quality. The facility failed to ensure licensed nurses had knowledge, competencies and skill sets to provide routine and consistent wound care, wound assessments, wound documentation, appropriate staging of Pressure Ulcers, and trained staff for Resident #1. Corrective Actions: 1. Seventy residents were assessed with eleven residents identified by Director of Nurses as having excoriation/irritation or staged wounds on December 5, 2022. Seventy residents were assessed with twelve residents identified by Director of Nurses as having an air mattress device. On December 6, 2022, Director of Nurses reviewed all eleven of seventy active resident records for a decline in wound status and for appropriate staging. Of the eleven residents identified with excoriation/irritation or staged wound, three were newly identified with excoriation/irritation and three were newly identified as a staged wounds and three were existing with excoriation/irritation and two were existing with staged wounds. Physicians, Resident Representatives notified of new wounds and new orders obtained for the new wounds. No significant findings were identified on all eleven of seventy active residents assessed. On December 6, 2022, Director of Nurses reviewed all twelve of seventy active residents to identify functioning of air mattress device. No significant findings identified on all twelve of seventy active residents which required have an air mattress device On December 6, 2022, Director of Nurses reviewed all twelve of seventy active records to ensure intervention of air mattress and function checks were present on care plan. No significant findings were identified on all twelve of seventy active residents care plans which were identified to have an air mattress device. Three records were newly identified with excoriation/irritation for implemented care plans and three records were newly identified as staged wounds for implemented care plans. 2. Quality Improvement Nurse ([NAME]) immediately initiated in-services with Registered Nurses and Director of Nursing on December 6, 2022, on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. In-services will be on-going, and no employee will be allowed to work until participation of the in-services are completed. 3. The facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress, no policy changes were made, however, facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders. Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. The following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON. The facility alleges that all corrective actions to remove the IJ were completed on December 6, 2022, and the IJ was removed on December 7, 2022. The SA validated the Removal Plan on 12/9/22. Validation: 1. Based on record reviews, observations and interviews on 12/9/22, the facility did a 100% skin assessment on all residents present in the facility on 12/5/22. Interviews with the [NAME] and DON on 12/9/22 revealed that 11 residents were identified by the DON having either excoriations/ irritation or staged wounds. Interviews, record reviews and observations revealed that 12 residents were identified by the DON as having air mattress devices. Based on record reviews and interviews, there were three (3) residents newly identified with excoriations or irritations and 3 were newly identified as having staged wounds. Record reviews revealed the Medical Doctors (MD) and Responsible Party (RP) of residents were notified of the new skin areas noted with new orders. Record review and interview revealed the DON reviewed the 12 residents on air mattress devices. The DON did not observe significant findings on the 12 residents with air mattress devices. Record review and interview confirmed that on 12/6/22, the DON reviewed the care plans of the 12 residents on air mattress devices to ensure the interventions included the air mattress and function checks were present. No significant findings were identified. The DON confirmed on 12/9/22 that she reviewed the 3 records of newly identified residents with excoriations/irritations and the 3 residents that were newly identified as having staged wounds. 2. Based on record reviews and interviews on 12/9/22, it was confirmed that the [NAME] had initiated an in-service with the Registered Nurses (RN) and Director of Nurses (DON) on 12/6/22. These in-services included information on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. Record review and interviews confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. Interviews and record review confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. Interview and record review confirmed that these in-services will be on-going, and no employee would be allowed to work until participation of the in-services were completed. 3. Record reviews and interviews on 12/9/22 confirmed that the facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Interviews and record review confirmed that the topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress and there were no policy changes made. Record review and interviews did confirm that the facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Record review and interview confirmed that the Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders and that the Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. Record review and interviews with the DON and [NAME] on 12/9/22 confirmed that the DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. Interviews and record reviews with the [NAME] and DON on 12/9/22 confirmed that the following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON.

Based on record review and interviews, the facility failed to provide a competent treatment nurse for one (1) of nine (9) residents to prevent a pressure ulcer from worsening as evidenced by Resident #1 was found on 10/7/22 with an excoriation on the sacral area and was admitted to the hospital on 10/20/22 with an unstageable sacral pressure ulcer with eschar, foul drainage, and sepsis. During the week of treatments beginning 10/8/22 through 10/12/22, there were four (4) different nurses providing treatments and observations of Resident #1's sacral excoriation. This situation was determined to be an Immediate Jeopardy (IJ) which began on 10/16/22, when the facility failed to provide competent and consistent nursing staff and failure to prevent the worsening of a pressure ulcer therefore placing this resident and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment, or death. On 12/6/22, at 3:00 PM, the SA notified the Quality Improvement Nurse ([NAME]) and Director of Nurses (DON) of the IJ and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 12/7/22, in which they alleged all corrective actions to remove the IJ were completed on 12/6/22 and IJ removed on 12/7/22. The SA validated the Removal Plan on 12/9/22, and determined the IJ was removed on 12/7/22, prior to exit. Therefore, the scope and severity for CFR 483.35 (a)(3)(4)(c) Competent Nursing Staff (F726) was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the Treatment Nurse job description revealed Qualifications 1. Demonstrates leadership and managerial ability balanced by strong clinical knowledge and skills . 6. Is capable of implementing changes as mandated by Federal, State and management recommendations . 12. Must demonstrate ability to follow recommendations as designated by the Director of Nursing. Record review of Resident #1 revealed that on the Wound and Skin Status Report for week 10/14/22 he is listed with an Irritation/excoriation and that treatment began 10/8/22 and measured 7.0(length) cm (centimeters)X 7.0W (width) cm X 0.10D (depth) cm on the sacrum with no drainage. Review of the wound report for week 10/21/22 has that Resident #1's wound is on the sacrum, it measures 8.0L cm X 7.0W cm X 0.10D cm. It is described as Irritation/Excoriation with no drainage. The Wound Status is described with a D for Deterioration. It is described with No Drainage. MD/RP (Medical Doctor/Responsible Party) Notification has Yes/Yes. Both wound reports are signed by the Director of Nurses (DON) and initialed by the Administrator. Resident #1 was admitted to the hospital on 10/20/22 with sepsis. Record review of the facility's Treatment Nurse (TN) job description on 12/6/22 revealed The Treatment Nurse (TN) assists in planning, implementing, and evaluating residents skin care needs to promote resident health. The TN communicates with other Licensed Staff of the facility in evaluating resident needs to decrease risk of skin breakdown, contractures, weight loss, skin tears and so forth while in the facility. The TN assists the facility to provide education and intervention to assure prevention programs are implemented. The TN assists the Nursing Department to develop, implement and revise resident's plan of care. The TN documents on records as per policy and procedures and participates in staff meeting as required. Record review of the Discharge Summary dated 11/1/22 provided by the local hospital of Resident #1 revealed on page 2 Sepsis from Stage IV decubitus ulcer with infection and patient has sacral decubitus ulcer, foul smelling odor. Patient with eschar over sacral ulcer. Page 3 revealed assessment by wound care consultant, foul smelling, boggy eschar noted to sacral area. Page 4 revealed Debridement 10/26/22, debridement of skin, subcutaneous tissue, muscle and fascia 90 sq cm, application of wound VAC. Page 5 revealed large sacral pressure ulcer with the base of the wound measuring 6 X 15 cm. The skin, subcutaneous tissue, muscle, and fascia is necrotic all the way to the sacral bone and undermining the skin superiorly another 3 cm and extending inferiorly to the top edge of the anus. Interview with the DON on 11/30/22 at 3:20 PM revealed I never looked at the area. We have pictures of it. His skin is so dark that there were black areas but it was excoriation. Interview with the DON on 11/30/22 at 3:40 PM and she revealed Since it was an excoriation, we do not have photos. We do not take photos of excoriations. Interview with the DON on 12/5/22 at 11:00 AM revealed I'm not wound certified on classifying wounds. I don't feel comfortable staging a pressure ulcer. I know a nurse can't down stage a pressure ulcer but I didn't know if a RN can stage up a pressure ulcer. Interview with the Nurse Practitioner (NP), on 12/5/22 at 1:00 PM revealed she started her NP position at the facility in March 2022. She comes to the facility three (3) times a week. She recalled she saw Resident #1's sacral area on 10/7/22. It was a small open area. I would describe a stage 2. I will tell the nurses when I'm rounding what the pressure ulcers are staged but I always thought the RN's will stage pressure ulcers as well. She stated there was no slough or drainage at that point and was a small open area. I saw it the next week because the staff reported a decline. It was 100% slough and had worsened. That's when I ordered the Santyl and Calcium Alginate. We started Cleocin, Cipro and ordered a CBC. I believe they sent him out when they got the CBC results. It was unstageable when I started the Santyl and ordered the Cleocin. She revealed she had been out of the facility during the week Resident #1 was sent to the hospital due to a personal illness. I do expect the facility to stage wounds appropriately. She stated that since Resident #1 went into the hospital on 10/20/22, the facility has completed a 100% body audit on all residents. There have been times we haven't seen eye to eye with wound staging. They might not agree with the stage I give when staging pressure ulcers. Interview with Licensed Practical Nurse (LPN) #1 on 12/2/22 at 2:55 PM revealed she had performed wound care on Resident #1. I did the treatment on 10/10/22. I noticed drainage and odor. I did the ordered treatment that day. I did a treatment on 10/18/22. I just recall drainage, yellow, slimy and a foul odor. He didn't appear in pain, no grimacing. He was on an air mattress. I felt it looked different than excoriation. When I reported it on the 10th (10/10/22), the order was changed. On 12/2/22 at 10:30 AM, in an interview with Registered Nurse (RN) #2 revealed that she had just taken the full time position for treatment RN on 11/1/22 and that nurses would rotate days they performed wound care until 11/1/22. Interview with Medical Doctor #2 on 12/5/22 at 3:25 PM revealed he was the primary Medical Doctor (MD) for Resident #1. MD #2 stated he was unaware of Resident #1's wound decline until he got to the hospital on 10/20/22. If there was an odor to that wound, he should have been sent out earlier than 10/20/22. Not staging a wound in orders or notes is a problem. When there's an odor, the treatment has to be more aggressive, such as IV antibiotics, debrided and put in the hospital. Someone should have called me to let me know there was a problem, called me to admit him to the hospital for evaluation. Interview with the DON on 12/7/22 at 12:30 PM revealed that when asked by the SA regarding contacting Resident #1's primary medical doctor when the Nurse Practitioner was out with a personal illness, I didn't and the treatment Registered Nurse didn't, not to my knowledge. In a post exit phone interview with the Administrator on 12/12/22 at 11:45 AM, revealed that the previous Registered Nurse (RN) terminated her position as wound care nurse and her last date worked was 1/3/22. The Administrator confirmed that the wound care/treatment nurse position was not filled until 11/1/22 and that staff would rotate doing treatments until the new treatment position was filled by RN #2 on 11/1/22. Record review of Inservice Training for Braden Scale dated 10/24/22 with the DON's signature as the Trainer/Instructor revealed 1. Braden Scale Assessments must be completed on admission, with each MDS (Minimum Data Set), significant change, development of pressure ulcer, and four weeks after new admit. 2. An assessment will fire on admission and then weekly to be completes by MDS. There were three nurses that were present at that in-service. Record review of Inservice Training for Skin Audits dated 2/4/22 with the DON's signature as the Training/Instructor revealed 1. All residents should receive daily bath (or shower days) with proper skin moisturizing. 2. Any new skin issue must be reported immediately to the nurse. 3. Nurses must complete order, TX (treatment) and WAM of any skin issue. The attendees were Certified Nurse Aides (CNA), Licensed Practical Nurses (LPN) and Registered Nurses (RN). Record review of Inservice Training for Skin Assessment and Documentation both dated 2/4/22 with the DON's signature as the Training/Instructor revealed 1. Skin should be assessed on admission, weekly, and after any incident. 2. Document in detail and place in WAM with treatment 3. Pictures should be taken on admit and complete skin sections and RN assessment and admit/readmit screen in detail. The attendees were Certified Nurse Aides (CNA), Licensed Practical Nurses (LPN) and Registered Nurses (RN). Record review of Inservice Training dated 5/4/22 for Prevention Devices: Ordered prevention devices must be in place at all times. Includes: heel boots, foam wedges, splint, turn schedule, air mattress. If the resident refuses, it must be documented The Trainer/Instructor was LPN #4. An accepted Removal Plan was provided to the SA on 12/7/22 at 1:15 PM. Removal Plan: On December 6, 2022, at 3:00 pm State Agency notified the Director of Nursing that the facility was in Immediate Jeopardy (IJ) and templates were provided to the Director of Nursing. The facility failed to ensure Resident # 1 was free of neglect by failure to provide services to prevent an acquired pressure wound. The facility failed to implement preventative measures to prevent a facility acquired wound for Resident #1. The facility failed to follow and implement a care plan with interventions for preventative measures to prevent a facility acquired wound for Resident #1. The facility failed to provide routine and consistent wound care, wound assessments, wound documentation and trained staff for Resident #1. The facility failed to sustain and address systems in care and management through the Quality Assurance and Performance Improvement committee related to wound and skin care and ensure care and services delivered met standards of quality. The facility failed to ensure licensed nurses had knowledge, competencies and skill sets to provide routine and consistent wound care, wound assessments, wound documentation, appropriate staging of Pressure Ulcers, and trained staff for Resident #1. Brief Summary: Resident #1 was admitted to the facility on [DATE], with a diagnosis of Diabetes Mellitus, Dementia, Hypertension and Benign Prostatic Hypertrophy, and Osteoarthritis. Resident #1 received a new order for an air mattress on March 7, 2022 per Physician #1. A routine body audit was completed on October 04, 2022, on Resident #1 by Licensed Practical Nurse (LPN) #1. On October 7, 2022, LPN #2 identified an excoriation area to Resident # 1's buttocks. Nurse Practitioner #1 visited the facility on October 7, 2022, and assessed Resident #1's area to the buttocks. Nurse Practitioner #1 ordered wound care treatment for Resident #1. Resident # 1 received daily wound care treatments with air mattress function checks every shift. On October 12, 2022. Resident #1's wound was assessed again by Nurse Practitioner #1. Nurse Practitioner #1 changed treatment order for Resident #1. On October 16, 2022, wound status identified as deteriorating. New orders for antibiotics and laboratory tests for Resident #1 were ordered by Nurse Practitioner #1 on October 17, 2022. October 20, 2022, Resident #1 was admitted to Hospital #1 for diagnosis of wound sepsis. Corrective Actions: 1. Seventy residents were assessed with eleven residents identified by Director of Nurses as having excoriation/irritation or staged wounds on December 5, 2022. Seventy residents were assessed with twelve residents identified by Director of Nurses as having an air mattress device. On December 6, 2022, Director of Nurses reviewed all eleven of seventy active resident records for a decline in wound status and for appropriate staging. Of the eleven residents identified with excoriation/irritation or staged wound, three were newly identified with excoriation/irritation and three were newly identified as a staged wounds and three were existing with excoriation/irritation and two were existing with staged wounds. Physicians, Resident Representatives notified of new wounds and new orders obtained for the new wounds. No significant findings were identified on all eleven of seventy active residents assessed. On December 6, 2022, Director of Nurses reviewed all twelve of seventy active residents to identify functioning of air mattress device. No significant findings identified on all twelve of seventy active residents which required have an air mattress device On December 6, 2022, Director of Nurses reviewed all twelve of seventy active records to ensure intervention of air mattress and function checks were present on care plan. No significant findings were identified on all twelve of seventy active residents care plans which were identified to have an air mattress device. Three records were newly identified with excoriation/irritation for implemented care plans and three records were newly identified as staged wounds for implemented care plans. 2. Quality Improvement Nurse ([NAME]) immediately initiated in-services with Registered Nurses and Director of Nursing on December 6, 2022, on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. In-services will be on-going, and no employee will be allowed to work until participation of the in-services are completed. 3. The facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress, no policy changes were made, however, facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders. Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. The following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON. The facility alleges that all corrective actions to remove the IJ were completed on December 6, 2022, and the IJ was removed on December 7, 2022. The SA validated the Removal Plan on 12/9/22. Validation: 1. Based on record reviews, observations and interviews on 12/9/22, the facility did a 100% skin assessment on all residents present in the facility on 12/5/22. Interviews with the [NAME] and DON on 12/9/22 revealed that 11 residents were identified by the DON having either excoriations/ irritation or staged wounds. Interviews, record reviews and observations revealed that 12 residents were identified by the DON as having air mattress devices. Based on record reviews and interviews, there were three (3) residents newly identified with excoriations or irritations and 3 were newly identified as having staged wounds. Record reviews revealed the Medical Doctors (MD) and Responsible Party (RP) of residents were notified of the new skin areas noted with new orders. Record review and interview revealed the DON reviewed the 12 residents on air mattress devices. The DON did not observe significant findings on the 12 residents with air mattress devices. Record review and interview confirmed that on 12/6/22, the DON reviewed the care plans of the 12 residents on air mattress devices to ensure the interventions included the air mattress and function checks were present. No significant findings were identified. The DON confirmed on 12/9/22 that she reviewed the 3 records of newly identified residents with excoriations/irritations and the 3 residents that were newly identified as having staged wounds. 2. Based on record reviews and interviews on 12/9/22, it was confirmed that the [NAME] had initiated an in-service with the Registered Nurses (RN) and Director of Nurses (DON) on 12/6/22. These in-services included information on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. Record review and interviews confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. Interviews and record review confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. Interview and record review confirmed that these in-services will be on-going, and no employee would be allowed to work until participation of the in-services were completed. Interviews with staff confirming these in-services on 12/9/22 included: 1 administrative assistant, 1 social services employee, 1 [NAME] nurse, 1 DON, 1 maintenance employee, 3 Certified nurse aides, 2 licensed practical nurses, 1 medical director, 2 registered nurses. 3. Record reviews and interviews on 12/9/22 confirmed that the facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Interviews and record review confirmed that the topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress and there were no policy changes made. Record review and interviews did confirm that the facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Record review and interview confirmed that the Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders and that the Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. Record review and interviews with the DON and [NAME] on 12/9/22 confirmed that the DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. Interviews and record reviews with the [NAME] and DON on 12/9/22 confirmed that the following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON.

Based on facility policy/procedure review, provider's plan of correction review, record review and interviews, the facility failed to contact the Primary Medical Doctor (MD) and failed to update the interventions for Resident #1 in the High-Risk Management Committee Meeting on 10/19/22 for one (1) of nine (9) residents sampled regarding a worsening unstageable sacral ulcer. Resident #1. A routine body audit was completed for Resident #1 on October 04, 2022, by Licensed Practical Nurse (LPN) #1. On 10/7/22, LPN #2 identified an excoriation area to Resident #1's buttocks. On 10/16/22, the wound status was identified as deteriorating. On 10/20/22, Resident #1 was admitted to Hospital #1 for diagnosis of wound sepsis. The primary physician was not aware of the decline in Resident #1 until he was admitted to the hospital on 10/20/22 with sepsis. The State Agency (SA) identified an Immediate Jeopardy (IJ) that began on 10/16/22 when the facility failed to follow the Quality Assurance Performance Improvement (QAPI) plan that was previously initiated related to skin issues on 10/18/21. The facility failed to ensure the physician was notified of a worsening pressure ulcer when the Nurse Practitioner was out with a personal illness and failed to update interventions in the High-Risk Committee meeting. This placed Resident #1 in a situation that has caused or is likely to cause serious harm, injury, impairment, or death. On 12/6/22, at 3:00 PM, the SA notified the Quality Improvement Nurse ([NAME]) and Director of Nurses (DON) of the IJ and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 12/7/22, in which they alleged all corrective actions to remove the IJ were completed on 12/6/22 and IJ removed on 12/7/22. The SA validated the Removal Plan on 12/9/22, and determined the IJ was removed on 12/7/22, prior to exit. Therefore, the scope and severity for CFR 483.75 (a)(1)-(4)(b)(1)-(4)(f)(1)-(6)(h)(i) Quality assurance and performance improvement (QAPI) (F865) and were lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy/procedure for their Five Elements of QAPI (Quality Assurance Performance Improvement) last revised 11/22 revealed that Element 2: The Leadership ensures staff accountability, while creating an atmosphere where staff is comfortable identifying and reporting quality problems as well as opportunities for improvement. Record review of the facility's CMS(Centers for Medicare and Medicaid Services)-2567 Plan of Correction (POC) resulting from a complaint survey with an exit date of 10/18/21 revealed that the POC indicated All surgical wounds/skin issues will be monitored weekly in the High-Risk Committee meeting and all negative findings will be reported to the physician by the Director of Nursing or the Treatment RN (Registered Nurse). Record review of the facility's High Risk Management Committee Meeting dated 10/19/22 revealed Resident #1's name was listed but interventions were not updated on the Intervention section POC revised or Continue POC. Record review of the Discharge Summary from Hospital #1 for Resident #1 admitted on [DATE] revealed on page 2 Sepsis from Stage IV decubitus ulcer with infection and patient has sacral decubitus ulcer, foul smelling odor. Patient with eschar over sacral ulcer. Page 3 revealed assessment by wound care consultant, foul smelling, boggy eschar noted to sacral area. Page 4 revealed Debridement 10/26/22, debridement of skin, subcutaneous tissue, muscle and fascia 90 sq (square) cm (centimeters), application of wound VAC. Page 5 revealed large sacral pressure ulcer with the base of the wound measuring 6 cm X (by) 15 cm. The skin, subcutaneous tissue, muscle, and fascia is necrotic all the way to the sacral bone and undermining the skin superiorly another 3 cm and extending inferiorly to the top edge of the anus. Interview with RN #2 on 12/2/22 at 10:30 AM, revealed that she had just taken the full-time position for Treatment RN on 11/1/22 and that nurses would rotate days they performed wound care until 11/1/22. Interview with Medical Doctor #2 on 12/5/22 at 3:25 PM, revealed he was the primary Medical Doctor (MD) for Resident #1. MD #2 stated he was unaware of Resident #1's wound decline until Resident #1 got to the hospital on 10/20/22. Someone should have called me to let me know there was a problem, called me to admit him to the hospital for evaluation. I didn't know there was a problem until he got to the hospital. Interview with the DON on 12/7/22 at 12:30 PM, revealed that when asked by the SA regarding contacting Resident #1's primary medical doctor when the Nurse Practitioner was out with a personal illness responded, I didn't and the treatment Registered Nurse didn't, not to my knowledge. In a post survey telephone interview with the Administrator on 12/12/22 at 11:45 AM, revealed that the previous RN terminated her position as wound care nurse and her last date worked was 1/3/22. The Administrator confirmed that the wound care/treatment nurse position was not filled until 11/1/22 and that staff would rotate doing treatments until the new treatment position was filled by RN #2 on 11/1/22. An accepted Removal Plan was provided to the SA on 12/7/22 at 1:15 PM. Removal Plan: On December 6, 2022, at 3:00 pm State Agency notified the Director of Nursing that the facility was in Immediate Jeopardy (IJ) and templates were provided to the Director of Nursing. The facility failed to ensure Resident # 1 was free of neglect by failure to provide services to prevent an acquired pressure wound. The facility failed to implement preventative measures to prevent a facility acquired wound for Resident #1. The facility failed to follow and implement a care plan with interventions for preventative measures to prevent a facility acquired wound for Resident #1. The facility failed to provide routine and consistent wound care, wound assessments, wound documentation and trained staff for Resident #1. The facility failed to sustain and address systems in care and management through the Quality Assurance and Performance Improvement committee related to wound and skin care and ensure care and services delivered met standards of quality. The facility failed to ensure licensed nurses had knowledge, competencies and skill sets to provide routine and consistent wound care, wound assessments, wound documentation, appropriate staging of Pressure Ulcers, and trained staff for Resident #1. Brief Summary: Resident #1 was admitted to the facility on [DATE], with a diagnosis of Diabetes Mellitus, Dementia, Hypertension and Benign Prostatic Hypertrophy, and Osteoarthritis. Resident #1 received a new order for an air mattress on March 7, 2022 per Physician #1. A routine body audit was completed on October 04, 2022, on Resident #1 by Licensed Practical Nurse (LPN) #1. On October 7, 2022, LPN #2 identified an excoriation area to Resident # 1's buttocks. Nurse Practitioner #1 visited the facility on October 7, 2022, and assessed Resident #1's area to the buttocks. Nurse Practitioner #1 ordered wound care treatment for Resident #1. Resident # 1 received daily wound care treatments with air mattress function checks every shift. On October 12, 2022. Resident #1's wound was assessed again by Nurse Practitioner #1. Nurse Practitioner #1 changed treatment order for Resident #1. On October 16, 2022, wound status identified as deteriorating. New orders for antibiotics and laboratory tests for Resident #1 were ordered by Nurse Practitioner #1 on October 17, 2022. October 20, 2022, Resident #1 was admitted to Hospital #1 for diagnosis of wound sepsis. Corrective Actions: 1. Seventy residents were assessed with eleven residents identified by Director of Nurses as having excoriation/irritation or staged wounds on December 5, 2022. Seventy residents were assessed with twelve residents identified by Director of Nurses as having an air mattress device. On December 6, 2022, Director of Nurses reviewed all eleven of seventy active resident records for a decline in wound status and for appropriate staging. Of the eleven residents identified with excoriation/irritation or staged wound, three were newly identified with excoriation/irritation and three were newly identified as a staged wounds and three were existing with excoriation/irritation and two were existing with staged wounds. Physicians, Resident Representatives notified of new wounds and new orders obtained for the new wounds. No significant findings were identified on all eleven of seventy active residents assessed. On December 6, 2022, Director of Nurses reviewed all twelve of seventy active residents to identify functioning of air mattress device. No significant findings identified on all twelve of seventy active residents which required have an air mattress device On December 6, 2022, Director of Nurses reviewed all twelve of seventy active records to ensure intervention of air mattress and function checks were present on care plan. No significant findings were identified on all twelve of seventy active residents care plans which were identified to have an air mattress device. Three records were newly identified with excoriation/irritation for implemented care plans and three records were newly identified as staged wounds for implemented care plans. 2. Quality Improvement Nurse ([NAME]) immediately initiated in-services with Registered Nurses and Director of Nursing on December 6, 2022, on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. In-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. In-services will be on-going, and no employee will be allowed to work until participation of the in-services are completed. 3. The facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress, no policy changes were made, however, facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders. Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. The following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON. The facility alleges that all corrective actions to remove the IJ were completed on December 6, 2022, and the IJ was removed on December 7, 2022. The SA validated the Removal Plan on 12/9/22. Validation: 1. Based on record reviews, observations and interviews on 12/9/22, the facility did a 100% skin assessment on all residents present in the facility on 12/5/22. Interviews with the [NAME] and DON on 12/9/22 revealed that 11 residents were identified by the DON having either excoriations/ irritation or staged wounds. Interviews, record reviews and observations revealed that 12 residents were identified by the DON as having air mattress devices. Based on record reviews and interviews, there were three (3) residents newly identified with excoriations or irritations and 3 were newly identified as having staged wounds. Record reviews revealed the Medical Doctors (MD) and Responsible Party (RP) of residents were notified of the new skin areas noted with new orders. Record review and interview revealed the DON reviewed the 12 residents on air mattress devices. The DON did not observe significant findings on the 12 residents with air mattress devices. Record review and interview confirmed that on 12/6/22, the DON reviewed the care plans of the 12 residents on air mattress devices to ensure the interventions included the air mattress and function checks were present. No significant findings were identified. The DON confirmed on 12/9/22 that she reviewed the 3 records of newly identified residents with excoriations/irritations and the 3 residents that were newly identified as having staged wounds. 2. Based on record reviews and interviews on 12/9/22, it was confirmed that the [NAME] had initiated an in-service with the Registered Nurses (RN) and Director of Nurses (DON) on 12/6/22. These in-services included information on Pressure Ulcer and Prevention Treatment Interventions Guidelines, Staging of Pressure Ulcers, Weekly Body Audits and wound assessments. Record review and interviews confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, Resident Rights and Low Air Loss Mattress. Interviews and record review confirmed that in-services were initiated on December 6, 2022, by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, and Temporary Nurse Aides on Care Plan Process. Interview and record review confirmed that these in-services will be on-going, and no employee would be allowed to work until participation of the in-services were completed. Interviews with staff confirming these in-services on 12/9/22 included: 1 administrative assistant, 1 social services employee, 1 [NAME] nurse, 1 DON, 1 maintenance employee, 3 Certified nurse aides, 2 licensed practical nurses, 1 medical director, 2 registered nurses. 3. Record reviews and interviews on 12/9/22 confirmed that the facility Quality Assurance Committee Meeting was held on December 6, 2022, with the committee consisting of facility Director of Nurses, Medical Director via phone, Infection Preventionist, Administrator via phone, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Speech Therapist, Medical Records and Charge Nurse. Interviews and record review confirmed that the topics discussed included Federal Tags F600, F656, F686, F865, F726, and Seven Components of abuse and neglect, Resident Rights, Quality of Care, Change in Resident Medical Status, Care Plan Process, Pressure Ulcer Prevention and Treatment Intervention, Weekly Body Audits, Staging of Pressure Ulcers, Low Air Loss Mattress and there were no policy changes made. Record review and interviews did confirm that the facility made procedural changes on December 6, 2022, to include that anyone that identifies a concern with an air mattress will notify maintenance and complete the maintenance work order. Record review and interview confirmed that the Director of Nurses (DON) will assess excoriation and staged wounds weekly for appropriate staging and notification to physician of deteriorating wounds for further orders and that the Facility Administrator will check air mattress devices weekly to ensure proper function in addition to licensed staff checks each shift. 4. Record review and interviews with the DON and [NAME] on 12/9/22 confirmed that the DON received additional training via learning management software on December 6, 2022, titled Wound Care Guidelines Pathway 2022. 5. Interviews and record reviews with the [NAME] and DON on 12/9/22 confirmed that the following agencies were notified on December 6, 2022: The Mississippi State Department of Health Abuse Hotline was called at 3:55pm by Regional #1. The Office of the Attorney General was notified online at 6:31pm by Regional #1. The local Police Department was called at 3:38pm by DON.

Based on facility policy review, observations staff interviews, and record review, the facility failed to discard expired bread as evidenced by the observation of 28 packs of buns and rolls, with expired use by dates, in the dietary department, for one (1) of three (3) dietary tours. Review of facility policy titled, RECEIVING AND INSPECTION OF FOOD, with a review date 0f ,d+[DATE], revealed, Policy: The facility shall ensure that food is delivered to the facility in a safe condition . c. Reject if packaging has the following problems: vii. Expired code or use by date. Findings include: The initial kitchen tour observation, on [DATE] at 10:15 AM, revealed 20 packs of hamburger buns, six (6 )packs of hoagie buns, and two (2) packs of dinner rolls, in the dry goods storage room with an expiration date of [DATE]. The observation also revealed a sign, that was posted, on the fourth brown bread tray, that contained six (6) packs of expired hamburger buns, that read, Use First. The observation revealed that the expired hamburger buns, hoagie buns, and dinner rolls, with the expiration date of [DATE], were stacked together, in brown bread trays, on a red cart, with the trays of hamburger buns, hoagie buns, and dinner rolls with an expiration date of [DATE]. An observation and interview, on [DATE] at 10:20 AM, with the Dietary Staff Member #1, (Dietary Manager), revealed she placed the signage, Use First, on the stack of brown bread trays, to show the dietary staff what trays of bread to start using first, and to go upward, to the other trays, to use older bread, before it expired. She revealed that the bread deliveries are scheduled for every Tuesday, at 05:30 AM, that the last bread delivery took place on, Tuesday, [DATE] at 05:30 AM. She stated that she was not at work at that time of day to check the dates on the bread. She confirmed that she did not check the dates when she arrived at work on [DATE] and confirmed that she was not aware that the bread was expired. The Dietary Staff Member #1 revealed she did not normally check the expiration dates, on any of the bread, and did not assign dietary staff to check the dates on the bread, because the bread delivery service had always made sure that all bread delivered to the facility was not expired. The Dietary Staff Member #1 revealed the bread delivery service brought the entire stack of bread on Tuesday, [DATE], and it was left inside kitchen back door for a dietary staff member to move the bread to the dry storage room. The Dietary Staff Member #1 observed and confirmed the expired bread consisted of 20 packs of hamburger buns, 6 packs of hoagie buns, and 2 packs of dinner rolls, and that all of the bread counted, had an expiration date of [DATE]. The Dietary Staff Member #1 revealed the bread must have already expired before it was delivered on [DATE], because there was also bread stacked in the brown bread trays, with an expiration date of [DATE]. The Dietary Staff Member #1 confirmed she should have checked the bread delivery, to ensure it was in safe condition to be served to the residents. The Dietary Staff Member #1 confirmed there was a possibility for food-borne illness, for the residents who could have possibly eaten the expired bread. An observation and interview ,on [DATE] at 10:25 AM, with the Dietary Staff Member #2, revealed she did not check the expiration dates on the bread. The Dietary Staff Member #2 revealed the process of separating old bread from the new bread, was to place all the expired bread on a red cart to be picked up by the bread delivery service, when a new bread delivery was made. The Dietary Staff Member #2 confirmed that the observation revealed the expired bread, dated [DATE], and the bread with an expiration date of [DATE], was stacked together, in the brown bread trays, on top of a red cart, and that no other red carts were observed in the dry storage room. An interview, on [DATE] at 11:30 AM, with the Administrator, confirmed the dietary staff should not have accepted the expired bread from the bread delivery service, and the dietary staff should have checked the dates on the bread, at the time of delivery, to ensure it was safe. An interview, on [DATE] at 04:35 PM, with the Administrator, confirmed there was a likelihood of food born illness, for the residents that would have possibly eaten the expired bread. Record review of the Menu Calendar Report . Regional Services & Legacy Care Spring/Summer 2022 Week At A Glance .Week 1 (dietary menu indicated for the first week of the month of May), revealed, Thursday . DIN Cheeseburger on Bun . Saturday . LUN . Sloppy [NAME] on Bun.

Based on staff interview, record review, and facility policy review the facility failed to accurately code a Minimum Data Set (MDS) for one (1) of 19 MDS's reviewed. Resident #32 Findings include: Review of the facility policy titled, Resident Assessment, with the latest revision date of 09/19, revealed an assessment will be completed on each resident utilizing the MDS. The completed assessment guides the staff in identifying key information about the resident and serves as a basis for identifying specific issues and objectives in order to develop a care plan. This process assists the resident in reaching the highest practicable physical, mental and psychosocial well-being. The assessment will describe the resident's physical and mental deficits, strenghths, and the requirements of assistance to meet their needs. The assessment will also identify risk factors associated with the possible functional decline and describe the resident's objectives for maintaining or improving their functional abilities. Record review of the physician order, dated 2/25/22, revealed hemodialysis 3x weekly on Tues, Thurs, and Sat with chair time at 12:00 P. Record review of the Admission 5 day MDS, with an Assessment Reference Date (ARD) of 3/4/22, section O, Special treatments, Procedures, and Programs revealed section J. Treatment: [CONDITION(S)] - while resident, was unchecked. An interview, with the MDS nurse confirmed that [CONDITION(S)] in section O of the MDS should be marked for Resident #32. She stated that it is important that it is marked correctly because the resident goes to [CONDITION(S)] and she thinks they get paid for it. She confirmed that the MDS had been sent and she would do a modification. An interview, on 5/5/22 at 9:35 AM with the Administrator confirmed that [CONDITION(S)] should be checked on the MDS because it could affect the resident's care and it is a financial issue. Review of the face sheet revealed that Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS Assessment with an Assessment Reference Date (ARD) of 3/4/22 revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated that the resident was cognitively intact.

Based on record review, policy/procedure review and interviews the facility failed to implement the comprehensive care plan as evidenced by failure to notify the physician of a change in status of a surgical wound for one (1) of nine (9) care plans reviewed. Resident #1. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/14/21, when the facility failed to contact the Primary Physician of one (1) of nine (9) residents sampled to update him on the progress of an acute surgical incision so that treatment orders could be changed. The facility failed to get Medical Doctor (MD) orders to remove the 9 staples present on the incision on his admission to the facility on [DATE]. When the facility neglected to provide the services required, this resulted in the acute surgical incision worsening, dehiscing, becoming necrotic with eschar covering the acute surgical incision and Resident #1 was admitted to the hospital on 10/8/21 with [CONDITION(S)]. The facility's failure to contact the primary MD and get acute surgical wound treatment changes placed this resident and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment, or death. On 10/15/21, at 4:03 PM, the SA notified the Administrator of the IJ and SQC and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 10/16/21, in which they alleged all corrective actions to remove the IJ were completed on 10/15/21 and IJ removed on 10/16/21. The SA validated the Removal Plan on 10/18/21, and determined the IJ was removed on 10/16/21, prior to exit. Therefore, the scope and severity for CFR 483.21(b)(1) Comprehensive Care Plans (F565) were lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. The census at the time of survey was 72, and the facility held a license for 110 beds. Findings include: Record review of the facility's policy/procedure for the Care Plan Process, last revised 08/17, revealed Page 4 of 6 .The facility staff shall follow the care plan. Record review the Face Sheet revealed that Resident #1 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's September 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's October 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Theorders were changed to Unstageable pressure ulcer to sacrum, cleanse with NS and gauze, pat dry, apply Santyl to wound bed, cover with foam dressing daily until healed. The treatment to the surgical incision to the upper mid back wound care did not change. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was in effect from 9/14/21 until transfer to the hospital on 10/8/21. Record review of Resident #1's care plan dated 9/30/21 revealed, Problem: Resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's wound note written by Registered Nurse (RN) #2 dated 9/14/2021 revealed that a Mid upper back surgical incision with Nine (9) staples, well defined, 95% epithelial tissue, surrounding skin pink with slight [CONDITION(S)]. The last note written by RN #2, dated 10/5/2021, states treatment successful, no deterioration noted, 95% epithelial tissue, normal-well defined wound edges, surrounding skin pink with slight [CONDITION(S)], scant serosanguinous drainage, continue current treatment. Record review of the Nurse Practitioner (NP) #1 on 9/21/21 revealed that the surgical incision to the Mid upper back has serous drainage, no odor, edges attached, peri wound pink with slight [CONDITION(S)]. NP #1 documented she visualized the surgical wound to the mid upper back. NP#1's last note written 10/5/21 describes the surgical incision to the Mid upper back with drainage Serosanguineous, edges attached, peri-wound pink with slight [CONDITION(S)] and the progress is improving. She documented she visualized this surgical incision. Record review on 10/8/21 revealed that Resident #1 was transferred to the local hospital (Hospital #1) with coffee-ground emesis for evaluation with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At 3:04 PM, Resident #1 was transferred to Hospital #2. Record review of the 10/8/21 6:34 PM, Hospital #2 records revealed that Resident #1 has 9 staples noted to upper back with eschar to incision. Record review of the Treatment Nurse Job Description, signed by RN #2 on 8/27/19, revealed that the Treatment Nurse will complete the weekly skin records accurately describing onset date, size, location, color, healing, odors, cultures, etc. (pressure sore and non-decub skin condition records) and assists the nursing department to assure the care plans are followed. Interview with the Treatment Nurse, RN #2, on 10/12/21 at 12:15 PM, revealed Resident #1 was admitted with 9 staples. There were no orders to remove the staples. He was supposed to have a follow up visit with the neurosurgeon in 2 months. RN #2 stated, Sometimes we remove the staples, sometimes the doctors remove the staples at the follow-up visit. The order for the surgical incision was to paint with [MEDICATION(S)] and cover with dry dressing daily. Sometimes the initial MD orders will have when to remove the staples. Then there are times I will call to see when the doctor wants the staples removed. I did not contact the neurosurgeon or the primary MD here on when to remove the staples.There was no order to remove the staples. I didn't call the neurosurgeon about the incision. We do not have a wound doctor coming in to assess wounds. I never contacted the primary physician to get the orders changed on the surgical incision from paint with [MEDICATION(S)] daily and cover with a dry dressing. Interview with the Care Plan Nurse revealed she completes the comprehensive care plan for residents. She stated that when approaches change for a resident, the nurses on the floor will update the comprehensive care plan on the chart then she will update the comprehensive care plan in the computer so that when it is time for the quarterly care plan meeting, she will already have the new approaches on the new care plan. Interview with NP #1 on 10/12/21 at 1:05 PM revealed I did change the orders on that incision. On my second visit, I told (RN#2) to hold off on removing the staples. I remember it dehiscing. At 2:50 PM on 10/12/21, State Agency (SA) showed NP #1 the facility's photos of the incision and asked if that was improving, NP #1 stated no, I reread my notes and saw that I was writing improving. I was more focused on his sacral pressure ulcer and not the incision. I didn't see where I wrote a new order for the incision either. Interview on 10/13/21 at 2:09 PM with Physician #1 revealed that he usually has the staples on a back incision removed 10-14 days after surgery. I was not notified that it got worse. Someone should have contacted me about that incision, and no one did. No, this is not typical of NP #1. Interview 10/14/21 at 9:50 AM with Physician #1 revealed There should have been wound treatment changes and if the wound was getting worse they should have contacted me. On 10/14/21 at 11:30 AM an interview with RN #2, the Treatment Nurse revealed she has been the Treatment Nurse at the facility for two (2) years. RN #2 revealed she did not admit Resident #1 but performed his treatment the next day. When RN #2 was asked to compare the condition of the resident's incision site on admission, 9/14/21, and when discharged to the hospital on 10/8/2021 RN #2 revealed his treatment was [MEDICATION(S)] and dressing to the incision site daily. RN#2's first observation and treatment, on 9/15/21 revealed the incision site to be bruised, pink with slight [CONDITION(S)], nine (9) staples intact, and a scant drainage with no open areas. Measurements were 8.0 centimeters (cm) by (X) 0.3 cm X 0.1 cm on 9/14/21. RN #2 described the incision site the day he was sent to the emergency roiagnom on [DATE] and revealed the site was bruised, staples intact, more open areas along the incision site, the tissue was hard and eschar over the incision site, the right side was redder, and the measurements were 7.4 cm X 0.6 cm X .1.0 cm. RN #2 revealed she did not call the MD or get a change in treatment order and does not know why. RN revealed she did not realize a decline. Interview with the facility's Medical Director on 10/15/21 at 7:50 PM revealed I supervise the Nurse Practitioner. She usually sees (name of Physician #1) patients. I do review the charts of the residents she sees for (name of Physician #1). I am really surprised she didn't do more for Resident #1's surgical incision. I've seen the photos of his back incision and it was dehiscing when he left to go to the hospital. It was a healing incision when he was admitted to the nursing home. Neurosurgeons are usually very specific with their treatments. [MEDICATION(S)] does NOT help healing. I'm really shocked they used [MEDICATION(S)] on it. My big concern is if you are admitting somebody and they have an acute surgical wound with staples in it and the admitting orders do not include when the staples are to come out, the admitting nurse should call and ask about the removal of the staples and wound treatment. A nurse should have called him and gotten orders for this surgical wound. Regardless our facility should have called (name of Physician #1) and asked about it. Removal Plan On October 15, 2021, at 4:03 PM the State Agency notified the Administrator that the facility was in Immediate Jeopardy (IJ) related to neglect, notification of Medical Doctor (MD), quality of care and failure to follow care plans and templates were provided to the Administrator. The facility failed to inform Resident #1's physician and Resident Representative of a significant change and a need to alter treatment in Resident #1's surgical wound. The facility neglected to provide wound care services to Resident #1 by failure to obtain wound care orders for a deteriorating surgical wound. The facility failed to follow and implement Resident #1's comprehensive care plan approach of notifying the physician of any significant change. The facility failed to ensure Resident #1 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan as evidenced by failure to notify the physician of a deteriorating surgical wound and obtain treatment orders to address the decline in the wound. Corrective Action: 1. The facility Quality Assurance Committee (QA) Meeting was held on Thursday October 14, 2021 at 9:30 AM with the committee consisting of the facility Director of Nurse (DON), Administrator (ADM), Medical Director by phone, Infection Preventionist, Registered Nurse (RN) #3, Licensed Practical Nurse #1 (LPN), LPN #2, (RN) #4, LPN #3, Occupational Therapist (OT), Physical Therapist Assistant (PTA) , LPN #4, and RN #2. Topics discussed included treatments, reporting and follow up with changes in condition to physician and Resident Representative, abuse and neglect, adherence to orders as prescribed, ensuring that residents representative information is accurately entered into the computer system and infection control. 2 An additional QA meeting was held on Friday October 15, 2021 at 7:45 PM with the committee consisting of the facility DON, ADM, Medical Director, Infection Preventionist, RN #2 and RN #1 on Policy and Procedures of the Care Plan Process, Change in Resident Medical Status, Weekly Treatment Evaluation, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . No policy changes were made, however, the facility made procedural changes on October 15, 2021, to include obtaining surgical wound care orders from the surgeon and/or attending physician for all new surgical wounds and deteriorating surgical wounds. The DON will assess acute surgical wounds weekly for any changes and notify the physician and/or surgeon of deteriorating surgical wounds for further orders. 3. The DON and ADM immediately initiated in-services with RNs and LPNs on October 11, 2021, at 1:00 PM on notification of physician, and Resident Representative regarding changes in condition of wounds. In-services were initiated on October 13, 2021, at 6:30 AM by the DON and ADM with RN's, LPN's, Certified Nurse Aides (CNA), Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Change in Medical Status, Prevention of Abuse and Neglect, and Infection Control. In-services were initiated on October 13, 2021, at 6:30 AM with RN's and LPN's on the Weekly Treatment Evaluations, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 15, 2021 at 6:30 PM In-services were initiated by the DON and ADM with LPN's and RN's on the Care plan Process, what is a Care Plan, and following the Care plan. In-services will be on-going and no employee will be allowed to work until participation of the in-services are completed. 4. A 100% skin audit of all residents in the facility was performed by the RN's paired with LPN's beginning October 13, 2021 and concluding October 15, 2021 with no negative findings. 5. On October 15, 2021, the DON did a record review of the two residents with acute surgical incisions to ensure intervention of physician notification of deteriorating surgical wound was present on the care plan. Of the two residents with acute surgical wounds, it was identified as one resident not having a Care Plan for his acute surgical wound. A Care Plan was initiated by the DON on October 15, 2021, for that surgical wound. 6. On October 13-15, 2021, RN #2, DON, LPN #1, LPN #2, LPN #3, RN #4, RN #5, and RN #1 performed body audits on seventy-four residents that included non-pressure areas. Five of seventy-four active residents were identified with new areas that included a rash, abrasion, irritation, dry skin with callus, and bunion with discoloration. The Physicians were notified, and new orders obtained on the five residents with new areas identified. The Physician #1 visited the facility on October 15, 2021, and assessed two of five active residents identified with new skin conditions and Resident Representatives were notified of new orders and condition on October 15, 2021. New treatment orders were initiated on October 14, 2021, for the other three residents by their physician and the Resident Representative was notified. 7. RN #2 received additional employee education by RN #6 on October 15, 2021, at 8:30 PM on notifying the surgeon and/or attending physician when a surgical wound has a change for the worse or is not responding to current treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Nurse Practitioner received additional employee education by Registered Nurse #6 on October 15, 2021, at 9:00 PM on notifying the surgeon and/or attending physician anytime a surgical wound is not responding to current treatment or deteriorating for further orders and when a resident has a new surgical wound, the surgeon and/or attending physician should be contacted for orders to include staple and/or suture removal. The facility alleges removal of the immediacy as of October 16, 2021, 8:00 AM. VALIDATION OF REMOVAL PLAN On 10/18/21, the SA validated the facility's Removal Plan and verified the facility had implemented the following measures to remove the IJ: 1. Record review and interviews confirmed the facility Quality Assurance Committee (QA) Meeting was held on October 14, 2021 at 9:30 AM with the committee consisting of the facility Director of Nurse (DON), Administrator (ADM), Medical Director by phone, Infection Preventionist, Registered Nurse (RN) #3, Licensed Practical Nurse #1 (LPN), LPN #2, (RN) #4, LPN #3, Occupational Therapist (OT), Physical Therapist Assistant (PTA), LPN #4, and RN #2. Topics discussed included treatments, reporting and follow up with changes in condition to physician and Resident Representative, abuse and neglect, adherence to orders as prescribed, ensuring that resident's representative information is accurately entered into the computer system and infection control. Interviews with the facility Medical Director, Administrator, Director of Nurses/Infection Preventionist, four (4) RN's and one (1) LPN confirmed participation in the QA meeting held on October 14, 2021. 2. Record review and interviews confirmed a QA meeting held on October 15, 2021, at 7:45 PM committee consisting of the facility DON, ADM, Medical Director, Infection Preventionist, RN #2 and RN #1 on Policy and Procedures of the Care Plan Process, Change in Resident Medical Status, Weekly Treatment Evaluation, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no policy changes, however, the facility made procedural changes on October 15, 2021, to include obtaining surgical wound care orders from the surgeon and/or attending physician for all new surgical wounds and deteriorating surgical wounds. Interviews confirmed the DON will assess acute surgical wounds weekly for any changes and notify the physician and/or surgeon of deteriorating surgical wounds for further orders. Interviews with the facility Medical Director, Administrator, Director of Nurses/Infection Preventionist, four (4) RN's and one (1) LPN confirmed participation in the QA meeting held on October 15, 2021. 3. Record review and interviews confirmed in-services with RNs and LPNs on October 11, 2021, at 1:00 PM on notification of physician, and Resident Representative regarding changes in condition of wounds. Interviews confirmed in-services were also initiated on October 13, 2021, at 6:30 AM by the DON and ADM with RN's, LPN's, Certified Nurse Aides (CNA), Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Change in Medical Status, Prevention of Abuse and Neglect, and Infection Control. Interviews confirmed in-services were initiated on October 13, 2021, at 6:30 AM with RN's and LPN's on the Weekly Treatment Evaluations, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 15, 2021, at 6:30 PM In-services were initiated by the DON and ADM with LPN's and RN's on the Care plan Process, what is a Care Plan, and following the Care plan. In-services will be on-going, and no employee will be allowed to work until participation of the in-services are completed. Staff interviews included six (6) RN's, 6 LPN's, ten (10) CNA's, 1 administrative assistant, three (3) housekeeping/laundry staff, 1 social worker. 4. Record review and interviews confirmed the facility performed a 100% skin audit of all residents beginning October 13, 2021, and concluding October 15, 2021 with no negative findings. Interviews were with 6 RN's and 6 LPN's. 5. Record review and interview with the DON confirmed that on October 15, 2021, she did a record review of the two residents with acute surgical incisions to ensure intervention of physician notification of deteriorating surgical wound was present on the care plan. Of the two residents with acute surgical wounds, she identified one resident did not a Care Plan for his acute surgical wound. A Care Plan was initiated by the DON on October 15, 2021, for that surgical wound. 6. Record review and interviews confirmed that on October 13-15, 2021, facility nurses performed body audits on seventy-four residents that included non-pressure areas. Five of seventy-four active residents were identified with new areas that included a rash, abrasion, irritation, dry skin with callus, and bunion with discoloration. Record review confirmed the Physicians were notified, and new orders obtained on the five residents with new areas identified. Record review confirmed that Physician #1 visited the facility on October 15, 2021, and assessed two of five active residents identified with new skin conditions and Resident Representatives were notified of new orders and condition on October 15, 2021. Record review confirmed that treatment orders were initiated on October 14, 2021, for the other three residents by their physician and the Resident Representative was notified. Staff interviews with 2 RN's, 1 LPN and the DON confirmed these body audits. Interview with Physician #1 confirmed his visit to the facility on 0ctober 15, 2021 to assess two of his patients with new skin conditions. 7. Record review and interview with RN #2 confirmed she received additional employee education by RN #6 on October 15, 2021, at 8:30 PM on notifying the surgeon and/or attending physician when a surgical wound has a change for the worse or is not responding to current treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN #6 confirmed she conducted the employee education with RN #2. 8. Record review confirmed that the Nurse Practitioner received additional employee education by Registered Nurse #6 on October 15, 2021, at 9:00 PM on notifying the surgeon and/or attending physician anytime a surgical wound is not responding to current treatment or deteriorating for further orders and when a resident has a new surgical wound, the surgeon and/or attending physician should be contacted for orders to include staple and/or suture removal. Interview with RN #6 confirmed that the Nurse Practitioner received the addition education.

Based on record review, staff interview, and policy and procedure review the facility failed ensure Resident #1, received the treatment and care in accordance with professional standards of practice as evidenced by Resident #1was admitted to the facility with an acute surgical incision. The facility failed to contact Resident #1's primary Physician to obtain treatment change for his acute surgical incision resulting in the incision dehiscing and developing eschar for one (1) of nine (9) sampled resident's with wounds. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/14/21 when the facility neglected to contact the Primary Physician of one (1) of nine (9) residents sampled to update him on the progress of an acute surgical incision so that treatment orders could be changed. The facility failed to get Medical Doctor (MD) orders to remove the 9 staples present on the incision on his admission to the facility on [DATE]. When the facility neglected to provide the services required, this resulted in the acute surgical incision worsening, dehiscing, becoming necrotic with eschar covering the acute surgical incision and Resident #1 was admitted to the hospital on 10/8/21 with [CONDITION(S)]. The facility's failure to contact the primary MD and get acute surgical wound treatment changes placed this resident and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment, or death. On 10/15/21, at 4:03 PM, the SA notified the Administrator of the IJ and SQC and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 10/16/21, in which they alleged all corrective actions to remove the IJ were completed on 10/15/21 and IJ removed on 10/16/21. The SA validated the Removal Plan on 10/18/21, and determined the IJ was removed on 10/16/21, prior to exit. Therefore, the scope and severity for CFR 483.25 Quality of Care (F684), and was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy/procedure for Change in Resident Medical Status, last revised 09/17, revealed A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is - .3. A need to alter treatment significantly; (that is a need to discontinue or change an existing treatment due to adverse consequences, or to commence a new form of treatment.) . Record review of the facility's policy/procedure for Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Face Sheet revealed Resident #1 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's September 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment to the surgical incision to upper mid back wound care did not change. Record review of Resident #1's Care Plan dated 9/30/21 revealed, Problem: Resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's HIGH RISK MANAGEMENT WORKSHEET written by Registered Nurse (RN) #2 dated 9/14/2021 revealed a Mid upper back surgical incision with Nine (9) staples, well defined, 95% epithelial tissue, surrounding skin pink with slight [CONDITION(S)]. Record review of Resident #1's HIGH RISK MANAGEMENT WORKSHEET written by RN #2, dated 10/5/2021, revealed mid upper back surgical incision treatment successful, no deterioration noted, 95% epithelial tissue, normal-well defined wound edges, surrounding skin pink with slight [CONDITION(S)], scant serosanguinous drainage, continue current treatment. Record review of the Nurse Practitioner (NP) #1's Progress Note dated 9/21/21 revealed that the surgical incision to the Mid upper back has serous drainage, no odor, edges attached, peri wound pink with slight [CONDITION(S)]. NP #1 documented she visualized the surgical wound to the mid upper back. NP#1's last Progress Note written 10/5/21 describes the surgical incision to the Mid upper back with drainage Serosanguineous, edges attached, peri-wound pink with slight [CONDITION(S)] and the progress is improving. She documented she visualized this surgical incision. At 3:04 PM, Resident #1 was transferred to the hospital. Record review of the 10/8/21 at 4:14 PM hospital Hospitalist History and Physical revealed the admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #1 has 9 staples noted to top of T-spine with yellow slough noted to edges with redness, swelling and tenderness. Record review of the signed Treatment Nurse Job Description, signed 8/27/19, by RN#2, revealed the treatment nurse will complete the weekly skin records accurately describing onset date, size, location, color, healing, odors, cultures, etc. (pressure sore and non-decub skin condition records) and assists the nursing department to assure the care plans are followed. Interview with the Treatment Nurse (RN#2) on 10/12/21 at 12:15 PM, revealed Resident #1 was admitted with 9 staples. There were no orders to remove the staples. He was supposed to have a follow up visit with the neurosurgeon in 2 months. Sometimes we remove the staples, sometimes the doctor's remove the staples at the follow-up visit. The order for the surgical incision was to paint with [MEDICATION(S)] and cover with dry dressing daily. Sometimes the initial Medical Doctor (MD) orders will have when to remove the staples. There are times I will call to see when the doctor wants the staples removed. I did not contact the neurosurgeon or the primary MD here on when to remove the staples.There was no order to remove the staples. No, I didn't call the neurosurgeon about the incision. No, we do not have a wound doctor coming in to assess wounds I never contacted the primary physician to get the orders changed on the surgical incision from paint with [MEDICATION(S)] daily and cover with a dry dressing. On 10/14/21 at 11:30 AM, an interview with RN #2, treatment nurse revealed she has been the treatment nurse at the facility for two (2) years. RN #2 revealed she did not admit Resident #1 but performed his treatment the next day. When RN #2 was asked to compare the condition of the resident's incision site on admission, 9/14/21, and when discharged to the hospital on 10/8/2021 RN #2 revealed his treatment was [MEDICATION(S)] and dressing to the incision site daily. RN#2's first observation and treatment, on 9/15/21 revealed the incision site to be bruised, pink with slight [CONDITION(S)], nine (9) staples intact, and a scant drainage with no open areas. Measurements were 8.0 cm (centimeters) X 0.3 cm X 0.1cm on 9/14/21. RN #2 described the incision site the day he was sent to the emergency roiagnom on [DATE] and revealed the site was bruised, staples intact, more open areas along the incision site, the tissue was hard and eschar over the incision site, the right side was redder, and the measurements were 7.4 cm X .6 cm X .1.0 cm. RN #2 revealed she did not call the MD or get a change in treatment order and does not know why. RN#2 revealed she did not realize a decline in Resident #1's wound. Interview with NP #1 on 10/12/21 at 1:05 PM, revealed I did change the orders on that incision. On my second visit, I told (RN#2) to hold off on removing the staples. I remember it dehiscing. At 2:50 PM on 10/12/21, the SA asked the NP #1 to view the facility's photos of the incision and asked if that was improving. NP #1 stated no, I re-read my notes and saw that I was writing improving. I was more focused on his sacral pressure ulcer and not the incision. I didn't see where I wrote a new order for the incision either. Interview on 10/13/21 at 2:09 PM, with Physician #1 revealed that he usually has the staples on a back incision removed 10-14 days after surgery. I was not notified that it got worse. Someone should have contacted me about that incision, and no one did. No, this is not typical of NP #1. Interview 10/14/21 at 9:50 AM, with Physician #1 revealed There should have been wound treatment changes and if the wound was getting worse they should have contacted me. Interview with the facility's Medical Director on 10/15/21 at 7:50 PM, revealed I supervise the nurse practitioner. She usually sees (name of Physician #1) patients. I do review the charts of the residents she sees for (name of Physician #1). I am really surprised she didn't do more for Resident #1's surgical incision. I've seen the photos of his back incision and it was dehiscing when he left to go to the hospital. It was a healing incision when he was admitted to the nursing home. Neurosurgeons are usually very specific with their treatments. [MEDICATION(S)] does not help healing. I'm really shocked they used [MEDICATION(S)] on it. My big concern is, if you are admitting somebody and they have an acute surgical wound with staples in it and the admitting orders do not include when the staples are to come out, the admitting nurse should call and ask about the removal of the staples and wound treatment. A nurse should have called him and gotten orders for this surgical wound. Regardless our facility should have called (name of Physician #1) and asked about it. Removal Plan On October 15, 2021, at 4:03 PM the State Agency notified the Administrator that the facility was in Immediate Jeopardy (IJ) related to neglect, notification of Medical Doctor (MD), quality of care and failure to follow care plans and templates were provided to the Administrator. The facility failed to inform Resident #1's physician and Resident Representative of a significant change and a need to alter treatment in Resident #1's surgical wound. The facility neglected to provide wound care services to Resident #1 by failure to obtain wound care orders for a deteriorating surgical wound. The facility failed to follow and implement Resident #1's comprehensive care plan approach of notifying the physician of any significant change. The facility failed to ensure Resident #1 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan as evidenced by failure to notify the physician of a deteriorating surgical wound and obtain treatment orders to address the decline in the wound. Corrective Action: 1. The facility Quality Assurance Committee (QA) Meeting was held on Thursday October 14, 2021 at 9:30 AM with the committee consisting of the facility Director of Nurse (DON), Administrator (ADM), Medical Director by phone, Infection Preventionist, Registered Nurse (RN) #3, Licensed Practical Nurse #1 (LPN), LPN #2, (RN) #4, LPN #3, Occupational Therapist (OT), Physical Therapist Assistant (PTA) , LPN #4, and RN #2. Topics discussed included treatments, reporting and follow up with changes in condition to physician and Resident Representative, abuse and neglect, adherence to orders as prescribed, ensuring that residents representative information is accurately entered into the computer system and infection control. 2 An additional QA meeting was held on Friday October 15, 2021 at 7:45 PM with the committee consisting of the facility DON, ADM, Medical Director, Infection Preventionist, RN #2 and RN #1 on Policy and Procedures of the Care Plan Process, Change in Resident Medical Status, Weekly Treatment Evaluation, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . No policy changes were made, however, the facility made procedural changes on October 15, 2021, to include obtaining surgical wound care orders from the surgeon and/or attending physician for all new surgical wounds and deteriorating surgical wounds. The DON will assess acute surgical wounds weekly for any changes and notify the physician and/or surgeon of deteriorating surgical wounds for further orders. 3. The DON and ADM immediately initiated in-services with RNs and LPNs on October 11, 2021, at 1:00 PM on notification of physician, and Resident Representative regarding changes in condition of wounds. In-services were initiated on October 13, 2021, at 6:30 AM by the DON and ADM with RN's, LPN's, Certified Nurse Aides (CNA), Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Change in Medical Status, Prevention of Abuse and Neglect, and Infection Control. In-services were initiated on October 13, 2021, at 6:30 AM with RN's and LPN's on the Weekly Treatment Evaluations, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 15, 2021 at 6:30 PM In-services were initiated by the DON and ADM with LPN's and RN's on the Care plan Process, what is a Care Plan, and following the Care plan. In-services will be on-going and no employee will be allowed to work until participation of the in-services are completed. 4. A 100% skin audit of all residents in the facility was performed by the RN's paired with LPN's beginning October 13, 2021 and concluding October 15, 2021 with no negative findings. 5. On October 15, 2021, the DON did a record review of the two residents with acute surgical incisions to ensure intervention of physician notification of deteriorating surgical wound was present on the care plan. Of the two residents with acute surgical wounds, it was identified as one resident not having a Care Plan for his acute surgical wound. A Care Plan was initiated by the DON on October 15, 2021, for that surgical wound. 6. On October 13-15, 2021, RN #2, DON, LPN #1, LPN #2, LPN #3, RN #4, RN #5, and RN #1 performed body audits on seventy-four residents that included non-pressure areas. Five of seventy-four active residents were identified with new areas that included a rash, abrasion, irritation, dry skin with callus, and bunion with discoloration. The Physicians were notified, and new orders obtained on the five residents with new areas identified. The Physician #1 visited the facility on October 15, 2021, and assessed two of five active residents identified with new skin conditions and Resident Representatives were notified of new orders and condition on October 15, 2021. New treatment orders were initiated on October 14, 2021, for the other three residents by their physician and the Resident Representative was notified. 7. RN #2 received additional employee education by RN #6 on October 15, 2021, at 8:30 PM on notifying the surgeon and/or attending physician when a surgical wound has a change for the worse or is not responding to current treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Nurse Practitioner received additional employee education by Registered Nurse #6 on October 15, 2021, at 9:00 PM on notifying the surgeon and/or attending physician anytime a surgical wound is not responding to current treatment or deteriorating for further orders and when a resident has a new surgical wound, the surgeon and/or attending physician should be contacted for orders to include staple and/or suture removal. The facility alleges removal of the immediacy as of October 16, 2021, 8:00 AM. VALIDATION OF REMOVAL PLAN On 10/18/21, the SA validated the facility's Removal Plan and verified the facility had implemented the following measures to remove the IJ: 1. Record review and interviews confirmed the facility Quality Assurance Committee (QA) Meeting was held on October 14, 2021 at 9:30 AM with the committee consisting of the facility Director of Nurse (DON), Administrator (ADM), Medical Director by phone, Infection Preventionist, Registered Nurse (RN) #3, Licensed Practical Nurse #1 (LPN), LPN #2, (RN) #4, LPN #3, Occupational Therapist (OT), Physical Therapist Assistant (PTA), LPN #4, and RN #2. Topics discussed included treatments, reporting and follow up with changes in condition to physician and Resident Representative, abuse and neglect, adherence to orders as prescribed, ensuring that resident's representative information is accurately entered into the computer system and infection control. Interviews with the facility Medical Director, Administrator, Director of Nurses/Infection Preventionist, four (4) RN's and one (1) LPN confirmed participation in the QA meeting held on October 14, 2021. 2. Record review and interviews confirmed a QA meeting held on October 15, 2021, at 7:45 PM committee consisting of the facility DON, ADM, Medical Director, Infection Preventionist, RN #2 and RN #1 on Policy and Procedures of the Care Plan Process, Change in Resident Medical Status, Weekly Treatment Evaluation, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no policy changes, however, the facility made procedural changes on October 15, 2021, to include obtaining surgical wound care orders from the surgeon and/or attending physician for all new surgical wounds and deteriorating surgical wounds. Interviews confirmed the DON will assess acute surgical wounds weekly for any changes and notify the physician and/or surgeon of deteriorating surgical wounds for further orders. Interviews with the facility Medical Director, Administrator, Director of Nurses/Infection Preventionist, four (4) RN's and one (1) LPN confirmed participation in the QA meeting held on October 15, 2021. 3. Record review and interviews confirmed in-services with RNs and LPNs on October 11, 2021, at 1:00 PM on notification of physician, and Resident Representative regarding changes in condition of wounds. Interviews confirmed in-services were also initiated on October 13, 2021, at 6:30 AM by the DON and ADM with RN's, LPN's, Certified Nurse Aides (CNA), Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Change in Medical Status, Prevention of Abuse and Neglect, and Infection Control. Interviews confirmed in-services were initiated on October 13, 2021, at 6:30 AM with RN's and LPN's on the Weekly Treatment Evaluations, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 15, 2021, at 6:30 PM In-services were initiated by the DON and ADM with LPN's and RN's on the Care plan Process, what is a Care Plan, and following the Care plan. In-services will be on-going, and no employee will be allowed to work until participation of the in-services are completed. Staff interviews included six (6) RN's, 6 LPN's, ten (10) CNA's, 1 administrative assistant, three (3) housekeeping/laundry staff, 1 social worker. 4. Record review and interviews confirmed the facility performed a 100% skin audit of all residents beginning October 13, 2021, and concluding October 15, 2021 with no negative findings. Interviews were with 6 RN's and 6 LPN's. 5. Record review and interview with the DON confirmed that on October 15, 2021, she did a record review of the two residents with acute surgical incisions to ensure intervention of physician notification of deteriorating surgical wound was present on the care plan. Of the two residents with acute surgical wounds, she identified one resident did not a Care Plan for his acute surgical wound. A Care Plan was initiated by the DON on October 15, 2021, for that surgical wound. 6. Record review and interviews confirmed that on October 13-15, 2021, facility nurses performed body audits on seventy-four residents that included non-pressure areas. Five of seventy-four active residents were identified with new areas that included a rash, abrasion, irritation, dry skin with callus, and bunion with discoloration. Record review confirmed the Physicians were notified, and new orders obtained on the five residents with new areas identified. Record review confirmed that Physician #1 visited the facility on October 15, 2021, and assessed two of five active residents identified with new skin conditions and Resident Representatives were notified of new orders and condition on October 15, 2021. Record review confirmed that treatment orders were initiated on October 14, 2021, for the other three residents by their physician and the Resident Representative was notified. Staff interviews with 2 RN's, 1 LPN and the DON confirmed these body audits. Interview with Physician #1 confirmed his visit to the facility on 0ctober 15, 2021 to assess two of his patients with new skin conditions. 7. Record review and interview with RN #2 confirmed she received additional employee education by RN #6 on October 15, 2021, at 8:30 PM on notifying the surgeon and/or attending physician when a surgical wound has a change for the worse or is not responding to current treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN #6 confirmed she conducted the employee education with RN #2. 8. Record review confirmed that the Nurse Practitioner received additional employee education by Registered Nurse #6 on October 15, 2021, at 9:00 PM on notifying the surgeon and/or attending physician anytime a surgical wound is not responding to current treatment or deteriorating for further orders and when a resident has a new surgical wound, the surgeon and/or attending physician should be contacted for orders to include staple and/or suture removal. Interview with RN #6 confirmed that the Nurse Practitioner received the addition education

Based on record review, policy/procedure review and interviews the facility failed to notify the Primary Physician and Resident Representative of a significant change in the resident's physical status related to an acute surgical incision and the need to alter treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/14/21 when the facility neglected to contact the Primary Physician to update him on the progress of an acute surgical incision so that treatment orders could be changed. The facility failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When the facility neglected to provide the services required, this resulted in the acute surgical incision worsening, dehiscing, becoming necrotic with eschar covering the acute surgical incision and Resident #1 was admitted to the hospital on 10/8/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to contact the primary Medical Doctor (MD) and obtain acute surgical wound treatment orders placed this resident and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment, or death. On 10/15/21, at 4:03 PM, the SA notified the Administrator of the IJ and SQC and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 10/16/21, in which they alleged all corrective actions to remove the IJ were completed on 10/15/21 and IJ removed on 10/16/21. The SA validated the Removal Plan on 10/18/21, and determined the IJ was removed on 10/16/21, prior to exit. Therefore, the scope and severity for CFR 483.10(g)(14)(i)(B)(C) Notification of Changes (F580) was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy/procedure for Change in Resident Medical Status, last revised 09/17, revealed A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is - .3. A need to alter treatment significantly; (that is a need to discontinue or change an existing treatment due to adverse consequences, or to commence a new form of treatment.) . Record review of Face Sheet revealed that Resident #1 was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's September 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's October 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Theorders were changed to Unstageable pressure ulcer to sacrum, cleanse with NS and gauze, pat dry, apply Santyl to wound bed, cover with foam dressing daily until healed. The treatment to the surgical incision to the upper mid back wound care did not change. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was in effect from 9/14/21 until transfer to the hospital on 10/8/21. Record review of Resident #1's care plan dated 9/30/21 revealed, Problem: Resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's HIGH RISK MANAGEMENT WORKSHEET written by Registered Nurse (RN) #2 dated 9/14/2021 revealed a Mid upper back surgical incision with Nine (9) staples, well defined, 95% epithelial tissue, surrounding skin pink with slight [CONDITION(S)]. Record review of Resident #1's HIGH RISK MANAGEMENT WORKSHEET written by RN #2, dated 10/5/2021, revealed mid upper back surgical incision treatment successful, no deterioration noted, 95% epithelial tissue, normal-well defined wound edges, surrounding skin pink with slight [CONDITION(S)], scant serosanguinous drainage, continue current treatment. Record review of the Nurse Practitioner (NP) #1 Progress Note dated 9/21/21 revealed that the surgical incision to the Mid upper back has serous drainage, no odor, edges attached, peri wound pink with slight [CONDITION(S)]. NP #1 documented she visualized the surgical wound to the mid upper back. NP#1's last Progress Note written 10/5/21 describes the surgical incision to the Mid upper back with drainage Serosanguineous, edges attached, peri-wound pink with slight [CONDITION(S)] and the progress is improving. The NP documented she visualized this surgical incision. At 3:04 PM, Resident #1 was transferred to the hospital. Record review of the 10/8/21 at 4:14 PM hospital Hospitalist History and Physical revealed the admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #1 has 9 staples noted to top of T-spine with yellow slough noted to edges with redness, swelling and tenderness. Record review of Resident #1 revealed that on the Face Sheet the Resident Representative section is blank. The second contact is his daughter/complainant. Review of Progress Notes revealed that when there were changes in his medications, the staff would document they informed the resident of the changes. Record review of the signed Treatment Nurse Job Description states that the treatment nurse will complete the weekly skin records accurately describing onset date, size, location, color, healing, odors, cultures, etc. (pressure sore and non-decub skin condition records) and assists the nursing department to assure the care plans are followed. Interview with RN #2, Treatment Nurse, on 10/12/21 at 12:15 PM revealed Resident #1 was admitted with 9 staples. There were no orders to remove the staples. He was supposed to have a follow up visit with the neurosurgeon in 2 months. RN#2 stated, Sometimes we remove the staples, sometimes the doctors remove the staples at the follow-up visit. The order for the surgical incision was to paint with [MEDICATION(S)] and cover with dry dressing daily. She stated, Sometimes the initial MD orders will have when to remove the staples. Then there are times I will call to see when the doctor wants the staples removed. I did not contact the neurosurgeon or the primary MD here on when to remove the staples.There was no order to remove the staples I didn't call the neurosurgeon about the incision.We do not have a wound doctor coming in to assess wounds. I never contacted the primary physician to get the orders changed on the surgical incision from paint with [MEDICATION(S)] daily and cover with a dry dressing. Interview with NP #1 on 10/12/21 at 1:05 PM revealed I did change the orders on that incision. On my second visit, I told (RN#2) to hold off on removing the staples. I remember it dehiscing. At 2:50 PM on 10/12/21, State Agency (SA) showed NP #1 the facility's photos of the incision and asked if that was improving, NP #1 stated no, I reread my notes and saw that I was writing improving. I was more focused on his sacral pressure ulcer and not the incision. I didn't see where I wrote a new order for the incision either. Interview on 10/13/21 at 2:09 PM with Physician #1 revealed that he usually has the staples on a back incision removed 10-14 days after surgery. He stated, I was not notified that it got worse. Someone should have contacted me about that incision, and no one did. This is not typical of NP #1. Interview 10/14/21 at 9:50 AM with Physician #1 revealed There should have been wound treatment changes and if the wound was getting worse they should have contacted me. On 10/14/21 at 11:30 AM an interview with RN #2, Treatment Nurse revealed she has been the Treatment Nurse at the facility for two (2) years. RN #2 revealed she did not admit Resident #1 but performed his treatment the next day. When RN #2 was asked to compare the condition of the resident's incision site on admission, 9/14/21, and when discharged to the hospital on 10/8/2021, RN #2 revealed his treatment was [MEDICATION(S)] and dressing to the incision site daily. RN#2's first observation and treatment, on 9/15/21 revealed the incision site to be bruised, pink with slight [CONDITION(S)], nine (9) staples intact, and a scant drainage with no open areas. Measurements were 8.0 centimeters (cm) X 0.3 cm X 0.1 cm on 9/14/21. RN #2 described the incision site the day he was sent to the emergency roiagnom on [DATE] and revealed the site was bruised, staples intact, more open areas along the incision site, the tissue was hard and eschar over the incision site, the right side was redder, and the measurements were 7.4 cm X .6 cm X .1.0 cm. RN #2 revealed she did not call the MD or get a change in treatment order and does not know why. RN revealed she did not realize a decline. Interview with the facility's Medical Director on 10/15/21 at 7:50 PM, revealed I supervise the nurse practitioner. She usually sees (name of Physician #1) patients. I do review the charts of the residents she sees for (name of Physician #1). I am really surprised she didn't do more for Resident #1's surgical incision. I've seen the photos of his back incision and it was dehiscing when he left to go to the hospital. It was a healing incision when he was admitted to the nursing home. Neurosurgeons are usually very specific with their treatments. [MEDICATION(S)] does not help healing. I'm really shocked they used [MEDICATION(S)] on it. My big concern is if you are admitting somebody and they have an acute surgical wound with staples in it and the admitting orders do not include when the staples are to come out, the admitting nurse should call and ask about the removal of the staples and wound treatment. A nurse should have called him and gotten orders for this surgical wound. Regardless our facility should have called (name of Physician #1) and asked about it. Interview with Resident #1's Resident Representative (RR) on 10/12/21 at 8:30 AM, revealed she had never been contacted when there were medication changes. The RR stated whoever input his admit paperwork put him as his own RR. I signed him into the nursing home. I'm his RR. I made that clear. His back surgery was on 9/8/21. I went to the facility yesterday 10/11/21 and spoke with the DON and social worker. The social worker brought it to the DON's attention that someone entered him as his own RR. My Dad's short-term memory is awful since his stroke. The DON said multiple time we dropped the ball from day one. I sent him to the nursing home because he needed 12 weeks of intravenous (IV) therapy, and he needed physical therapy. I am an RN, work full time and wasn't able to stay with him 24/7. I thought he would get the care he needed. The treatment nurse came in during the meeting and I asked her if she thought it was ok to leave the staples in this long and she never answered. The DON said this was an isolated incident. I asked her if she didn't know this was happening how could she be sure this was an isolated incident. Removal Plan On October 15, 2021, at 4:03 PM the State Agency notified the Administrator that the facility was in Immediate Jeopardy (IJ) related to neglect, notification of Medical Doctor (MD), quality of care and failure to follow care plans and templates were provided to the Administrator. The facility failed to inform Resident #1's physician and Resident Representative of a significant change and a need to alter treatment in Resident #1's surgical wound. The facility neglected to provide wound care services to Resident #1 by failure to obtain wound care orders for a deteriorating surgical wound. The facility failed to follow and implement Resident #1's comprehensive care plan approach of notifying the physician of any significant change. The facility failed to ensure Resident #1 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan as evidenced by failure to notify the physician of a deteriorating surgical wound and obtain treatment orders to address the decline in the wound. Corrective Action: 1. The facility Quality Assurance Committee (QA) Meeting was held on Thursday October 14, 2021 at 9:30 AM with the committee consisting of the facility Director of Nurse (DON), Administrator (ADM), Medical Director by phone, Infection Preventionist, Registered Nurse (RN) #3, Licensed Practical Nurse #1 (LPN), LPN #2, (RN) #4, LPN #3, Occupational Therapist (OT), Physical Therapist Assistant (PTA) , LPN #4, and RN #2. Topics discussed included treatments, reporting and follow up with changes in condition to physician and Resident Representative, abuse and neglect, adherence to orders as prescribed, ensuring that residents representative information is accurately entered into the computer system and infection control. 2 An additional QA meeting was held on Friday October 15, 2021 at 7:45 PM with the committee consisting of the facility DON, ADM, Medical Director, Infection Preventionist, RN #2 and RN #1 on Policy and Procedures of the Care Plan Process, Change in Resident Medical Status, Weekly Treatment Evaluation, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . No policy changes were made, however, the facility made procedural changes on October 15, 2021, to include obtaining surgical wound care orders from the surgeon and/or attending physician for all new surgical wounds and deteriorating surgical wounds. The DON will assess acute surgical wounds weekly for any changes and notify the physician and/or surgeon of deteriorating surgical wounds for further orders. 3. The DON and ADM immediately initiated in-services with RNs and LPNs on October 11, 2021, at 1:00 PM on notification of physician, and Resident Representative regarding changes in condition of wounds. In-services were initiated on October 13, 2021, at 6:30 AM by the DON and ADM with RN's, LPN's, Certified Nurse Aides (CNA), Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Change in Medical Status, Prevention of Abuse and Neglect, and Infection Control. In-services were initiated on October 13, 2021, at 6:30 AM with RN's and LPN's on the Weekly Treatment Evaluations, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 15, 2021 at 6:30 PM In-services were initiated by the DON and ADM with LPN's and RN's on the Care plan Process, what is a Care Plan, and following the Care plan. In-services will be on-going and no employee will be allowed to work until participation of the in-services are completed. 4. A 100% skin audit of all residents in the facility was performed by the RN's paired with LPN's beginning October 13, 2021 and concluding October 15, 2021 with no negative findings. 5. On October 15, 2021, the DON did a record review of the two residents with acute surgical incisions to ensure intervention of physician notification of deteriorating surgical wound was present on the care plan. Of the two residents with acute surgical wounds, it was identified as one resident not having a Care Plan for his acute surgical wound. A Care Plan was initiated by the DON on October 15, 2021, for that surgical wound. 6. On October 13-15, 2021, RN #2, DON, LPN #1, LPN #2, LPN #3, RN #4, RN #5, and RN #1 performed body audits on seventy-four residents that included non-pressure areas. Five of seventy-four active residents were identified with new areas that included a rash, abrasion, irritation, dry skin with callus, and bunion with discoloration. The Physicians were notified, and new orders obtained on the five residents with new areas identified. The Physician #1 visited the facility on October 15, 2021, and assessed two of five active residents identified with new skin conditions and Resident Representatives were notified of new orders and condition on October 15, 2021. New treatment orders were initiated on October 14, 2021, for the other three residents by their physician and the Resident Representative was notified. 7. RN #2 received additional employee education by RN #6 on October 15, 2021, at 8:30 PM on notifying the surgeon and/or attending physician when a surgical wound has a change for the worse or is not responding to current treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Nurse Practitioner received additional employee education by Registered Nurse #6 on October 15, 2021, at 9:00 PM on notifying the surgeon and/or attending physician anytime a surgical wound is not responding to current treatment or deteriorating for further orders and when a resident has a new surgical wound, the surgeon and/or attending physician should be contacted for orders to include staple and/or suture removal. The facility alleges removal of the immediacy as of October 16, 2021, 8:00 AM. VALIDATION OF REMOVAL PLAN On 10/18/21, the SA validated the facility's Removal Plan and verified the facility had implemented the following measures to remove the IJ: 1. Record review and interviews confirmed the facility Quality Assurance Committee (QA) Meeting was held on October 14, 2021 at 9:30 AM with the committee consisting of the facility Director of Nurse (DON), Administrator (ADM), Medical Director by phone, Infection Preventionist, Registered Nurse (RN) #3, Licensed Practical Nurse #1 (LPN), LPN #2, (RN) #4, LPN #3, Occupational Therapist (OT), Physical Therapist Assistant (PTA), LPN #4, and RN #2. Topics discussed included treatments, reporting and follow up with changes in condition to physician and Resident Representative, abuse and neglect, adherence to orders as prescribed, ensuring that resident's representative information is accurately entered into the computer system and infection control. Interviews with the facility Medical Director, Administrator, Director of Nurses/Infection Preventionist, four (4) RN's and one (1) LPN confirmed participation in the QA meeting held on October 14, 2021. 2. Record review and interviews confirmed a QA meeting held on October 15, 2021, at 7:45 PM committee consisting of the facility DON, ADM, Medical Director, Infection Preventionist, RN #2 and RN #1 on Policy and Procedures of the Care Plan Process, Change in Resident Medical Status, Weekly Treatment Evaluation, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no policy changes, however, the facility made procedural changes on October 15, 2021, to include obtaining surgical wound care orders from the surgeon and/or attending physician for all new surgical wounds and deteriorating surgical wounds. Interviews confirmed the DON will assess acute surgical wounds weekly for any changes and notify the physician and/or surgeon of deteriorating surgical wounds for further orders. Interviews with the facility Medical Director, Administrator, Director of Nurses/Infection Preventionist, four (4) RN's and one (1) LPN confirmed participation in the QA meeting held on October 15, 2021. 3. Record review and interviews confirmed in-services with RNs and LPNs on October 11, 2021, at 1:00 PM on notification of physician, and Resident Representative regarding changes in condition of wounds. Interviews confirmed in-services were also initiated on October 13, 2021, at 6:30 AM by the DON and ADM with RN's, LPN's, Certified Nurse Aides (CNA), Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Change in Medical Status, Prevention of Abuse and Neglect, and Infection Control. Interviews confirmed in-services were initiated on October 13, 2021, at 6:30 AM with RN's and LPN's on the Weekly Treatment Evaluations, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 15, 2021, at 6:30 PM In-services were initiated by the DON and ADM with LPN's and RN's on the Care plan Process, what is a Care Plan, and following the Care plan. In-services will be on-going, and no employee will be allowed to work until participation of the in-services are completed. Staff interviews included six (6) RN's, 6 LPN's, ten (10) CNA's, 1 administrative assistant, three (3) housekeeping/laundry staff, 1 social worker. 4. Record review and interviews confirmed the facility performed a 100% skin audit of all residents beginning October 13, 2021, and concluding October 15, 2021 with no negative findings. Interviews were with 6 RN's and 6 LPN's. 5. Record review and interview with the DON confirmed that on October 15, 2021, she did a record review of the two residents with acute surgical incisions to ensure intervention of physician notification of deteriorating surgical wound was present on the care plan. Of the two residents with acute surgical wounds, she identified one resident did not a Care Plan for his acute surgical wound. A Care Plan was initiated by the DON on October 15, 2021, for that surgical wound. 6. Record review and interviews confirmed that on October 13-15, 2021, facility nurses performed body audits on seventy-four residents that included non-pressure areas. Five of seventy-four active residents were identified with new areas that included a rash, abrasion, irritation, dry skin with callus, and bunion with discoloration. Record review confirmed the Physicians were notified, and new orders obtained on the five residents with new areas identified. Record review confirmed that Physician #1 visited the facility on October 15, 2021, and assessed two of five active residents identified with new skin conditions and Resident Representatives were notified of new orders and condition on October 15, 2021. Record review confirmed that treatment orders were initiated on October 14, 2021, for the other three residents by their physician and the Resident Representative was notified. Staff interviews with 2 RN's, 1 LPN and the DON confirmed these body audits. Interview with Physician #1 confirmed his visit to the facility on 0ctober 15, 2021 to assess two of his patients with new skin conditions. 7. Record review and interview with RN #2 confirmed she received additional employee education by RN #6 on October 15, 2021, at 8:30 PM on notifying the surgeon and/or attending physician when a surgical wound has a change for the worse or is not responding to current treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN #6 confirmed she conducted the employee education with RN #2. 8. Record review confirmed that the Nurse Practitioner received additional employee education by Registered Nurse #6 on October 15, 2021, at 9:00 PM on notifying the surgeon and/or attending physician anytime a surgical wound is not responding to current treatment or deteriorating for further orders and when a resident has a new surgical wound, the surgeon and/or attending physician should be contacted for orders to include staple and/or suture removal. Interview with RN #6 confirmed that the Nurse Practitioner received the addition education.

Based on record review, facility policy review and interviews, the facility failed to ensure a resident was free from neglect and provided the necessary care and services to avoid physical harm as evidenced by the failure to notify the Physician to obtain orders for an acute surgical incision which resulted in the incision dehiscing and developing eschar for one (1) of nine (9) residents reviewed with wounds. Resident #1. Resident #1 admitted to the facility on [DATE]with an acute surgical incision and the facility did not contact Resident #1's Primary Physician to obtain treatment change for his acute surgical incision resulting in the incision dehiscing and developing eschar. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/14/21 when the facility neglected to contact the Primary Physician of one (1) of nine (9) residents sampled to update him on the progress of an acute surgical incision so that treatment orders could be changed. The facility failed to get Medical Doctor (MD) orders to remove the 9 staples present on the incision on his admission to the facility on [DATE]. When the facility neglected to provide the services required, this resulted in the acute surgical incision worsening, dehiscing, becoming necrotic with eschar covering the acute surgical incision and Resident #1 was admitted to the hospital on 10/8/21 with [CONDITION(S)]. The facility's failure to contact the primary MD and get acute surgical wound treatment changes placed this resident and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment, or death. On 10/15/21, at 4:03 PM, the SA notified the Administrator of the IJ and SQC and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 10/16/21, in which they alleged all corrective actions to remove the IJ were completed on 10/15/21 and IJ removed on 10/16/21. The SA validated the Removal Plan on 10/18/21, and determined the IJ was removed on 10/16/21, prior to exit. Therefore, the scope and severity for CFR 483.12 (F600), was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy/procedure for Seven Components to Reduce, Detect, and Prevent Abuse and Neglect, dated 06/19, revealed Protect-The facility seeks to support and protect individuals receiving services, their families and staff. Additionally, the facility makes an effort to protect individuals from abuse and neglect during investigation of allegations of abuse or neglect. Record review of the facility's policy/procedure for Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Face Sheet revealed that Resident #1 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's September 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's October 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Theorders were changed to Unstageable pressure ulcer to sacrum, cleanse with NS and gauze, pat dry, apply Santyl to wound bed, cover with foam dressing daily until healed. The treatment to the surgical incision to the upper mid back wound care did not change. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was in effect from 9/14/21 until transfer to the hospital on 10/8/21. Record review of Resident #1's care plan dated 9/30/21 revealed, Problem: Resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's HIGH RISK MANAGEMENT WORKSHEET written by Registered Nurse (RN) #2 dated 9/14/2021 revealed a Mid upper back surgical incision with Nine (9) staples, well defined, 95% epithelial tissue, surrounding skin pink with slight [CONDITION(S)]. Record review of Resident #1's HIGH RISK MANAGEMENT WORKSHEET written by RN #2, dated 10/5/2021, revealed mid upper back surgical incision treatment successful, no deterioration noted, 95% epithelial tissue, normal-well defined wound edges, surrounding skin pink with slight [CONDITION(S)], scant serosanguinous drainage, continue current treatment. Record review of the Nurse Practitioner (NP) #1's Progress Note on 9/21/21 revealed that the surgical incision to the Mid upper back has serous drainage, no odor, edges attached, peri wound pink with slight [CONDITION(S)]. NP #1 documented she visualized the surgical wound to the mid upper back. NP#1's last Progress Note written 10/5/21 describes the surgical incision to the Mid upper back with drainage Serosanguineous, edges attached, peri-wound pink with slight [CONDITION(S)] and the progress is improving. She documented she visualized this surgical incision. At 3:04 PM, Resident #1 was transferred to the hospital. Record review of the 10/8/21 at 4:14 PM hospital Hospitalist History and Physical revealed the admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #1 has 9 staples noted to top of T-spine with yellow slough noted to edges with redness, swelling and tenderness. Record review of the signed Treatment Nurse Job Description, signed 8/27/19, by RN#2, revealed the treatment nurse will complete the weekly skin records accurately describing onset date, size, location, color, healing, odors, cultures, etc. (pressure sore and non-decub skin condition records) and assists the nursing department to assure the care plans are followed. Interview with the Treatment Nurse (RN#2) on 10/12/21 at 12:15 PM, revealed Resident #1 was admitted with 9 staples. There were no orders to remove the staples. He was supposed to have a follow up visit with the neurosurgeon in 2 months. Sometimes we remove the staples, sometimes the doctor's remove the staples at the follow-up visit. The order for the surgical incision was to paint with [MEDICATION(S)] and cover with dry dressing daily. Sometimes the initial Medical Doctor (MD) orders will have when to remove the staples. There are times I will call to see when the doctor wants the staples removed. I did not contact the neurosurgeon or the primary MD here on when to remove the staples.There was no order to remove the staples. No, I didn't call the neurosurgeon about the incision. No, we do not have a wound doctor coming in to assess wounds I never contacted the primary physician to get the orders changed on the surgical incision from paint with [MEDICATION(S)] daily and cover with a dry dressing. On 10/14/21 at 11:30 AM, an interview with RN #2, the Treatment Nurse revealed she has been the treatment nurse at the facility for two (2) years. RN #2 revealed she did not admit Resident #1 but performed his treatment the next day. When RN #2 was asked to compare the condition of the resident's incision site on admission, 9/14/21, and when discharged to the hospital on 10/8/2021 RN #2 revealed his treatment was [MEDICATION(S)] and dressing to the incision site daily. RN#2's first observation and treatment, on 9/15/21 revealed the incision site to be bruised, pink with slight [CONDITION(S)], nine (9) staples intact, and a scant drainage with no open areas. Measurements were 8.0 cm (centimeters) X 0.3 cm X 0.1cm on 9/14/21. RN #2 described the incision site the day he was sent to the emergency roiagnom on [DATE] and revealed the site was bruised, staples intact, more open areas along the incision site, the tissue was hard and eschar over the incision site, the right side was redder, and the measurements were 7.4 cm X .6 cm X .1.0 cm. RN #2 revealed she did not call the MD or get a change in treatment order and does not know why. RN#2 revealed she did not realize a decline in Resident #1's wound. Interview with NP #1 on 10/12/21 at 1:05 PM revealed I did change the orders on that incision. On my second visit, I told (RN#2) to hold off on removing the staples. I remember it dehiscing. On 10/12/21 during an interview at 2:50 PM, the SA asked NP #1 to view the facility's photos of the incision and asked if that was improving. NP #1 stated No, I re-read my notes and saw that I was writing improving. I was more focused on his sacral pressure ulcer and not the incision. I didn't see where I wrote a new order for the incision either. Interview on 10/13/21 at 2:09 PM with Physician #1 revealed that he usually has the staples on a back incision removed 10-14 days after surgery. I was not notified that it got worse. Someone should have contacted me about that incision, and no one did. This is not typical of NP #1. Interview 10/14/21 at 9:50 AM with Physician #1 revealed There should have been wound treatment changes and if the wound was getting worse they should have contacted me. Interview with the facility's Medical Director on 10/15/21 at 7:50 PM, revealed I supervise the nurse practitioner. She usually sees (name of Physician #1) patients. I do review the charts of the residents she sees for (name of Physician #1). I am really surprised she didn't do more for Resident #1's surgical incision. I've seen the photos of his back incision and it was dehiscing when he left to go to the hospital. It was a healing incision when he was admitted to the nursing home. Neurosurgeons are usually very specific with their treatments. [MEDICATION(S)] does not help healing. I'm really shocked they used [MEDICATION(S)] on it. My big concern is, if you are admitting somebody and they have an acute surgical wound with staples in it and the admitting orders do not include when the staples are to come out, the admitting nurse should call and ask about the removal of the staples and wound treatment. A nurse should have called him and gotten orders for this surgical wound. Regardless our facility should have called (name of Physician #1) and asked about it. At 4:03 PM on 10/15/21, the SA with the Director of Nurses, Administrator, facility's Quality Improvement Nurse and the facility's Regional Administrator and informed the group of the IJ at facility for Notification of RP, Neglect, Care plans MD with changes in condition and Quality of Care. Interview with RN #2 on 10/18/21 revealed she acknowledged that neglect is when a resident is denied goods or services that will help a resident heal. REMOVAL PLAN October 15, 2021 RE: Removal Plan On October 15, 2021, at 4:03 PM the State Agency notified the Administrator that the facility was in Immediate Jeopardy (IJ) related to neglect, notification of Medical Doctor (MD), quality of care and failure to follow care plans and templates were provided to the Administrator. The facility failed to inform Resident #1's physician and Resident Representative of a significant change and a need to alter treatment in Resident #1's surgical wound. The facility neglected to provide wound care services to Resident #1 by failure to obtain wound care orders for a deteriorating surgical wound. The facility failed to follow and implement Resident #1's comprehensive care plan approach of notifying the physician of any significant change. The facility failed to ensure Resident #1 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan as evidenced by failure to notify the physician of a deteriorating surgical wound and obtain treatment orders to address the decline in the wound. Corrective Action: 1. The facility Quality Assurance Committee (QA) Meeting was held on Thursday October 14, 2021 at 9:30 AM with the committee consisting of the facility Director of Nurse (DON), Administrator (ADM), Medical Director by phone, Infection Preventionist, Registered Nurse (RN) #3, Licensed Practical Nurse #1 (LPN), LPN #2, (RN) #4, LPN #3, Occupational Therapist (OT), Physical Therapist Assistant (PTA) , LPN #4, and RN #2. Topics discussed included treatments, reporting and follow up with changes in condition to physician and Resident Representative, abuse and neglect, adherence to orders as prescribed, ensuring that residents representative information is accurately entered into the computer system and infection control. 2 An additional QA meeting was held on Friday October 15, 2021 at 7:45 PM with the committee consisting of the facility DON, ADM, Medical Director, Infection Preventionist, RN #2 and RN #1 on Policy and Procedures of the Care Plan Process, Change in Resident Medical Status, Weekly Treatment Evaluation, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . No policy changes were made, however, the facility made procedural changes on October 15, 2021, to include obtaining surgical wound care orders from the surgeon and/or attending physician for all new surgical wounds and deteriorating surgical wounds. The DON will assess acute surgical wounds weekly for any changes and notify the physician and/or surgeon of deteriorating surgical wounds for further orders. 3. The DON and ADM immediately initiated in-services with RNs and LPNs on October 11, 2021, at 1:00 PM on notification of physician, and Resident Representative regarding changes in condition of wounds. In-services were initiated on October 13, 2021, at 6:30 AM by the DON and ADM with RN's, LPN's, Certified Nurse Aides (CNA), Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Change in Medical Status, Prevention of Abuse and Neglect, and Infection Control. In-services were initiated on October 13, 2021, at 6:30 AM with RN's and LPN's on the Weekly Treatment Evaluations, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 15, 2021 at 6:30 PM In-services were initiated by the DON and ADM with LPN's and RN's on the Care plan Process, what is a Care Plan, and following the Care plan. In-services will be on-going and no employee will be allowed to work until participation of the in-services are completed. 4. A 100% skin audit of all residents in the facility was performed by the RN's paired with LPN's beginning October 13, 2021 and concluding October 15, 2021 with no negative findings. 5. On October 15, 2021, the DON did a record review of the two residents with acute surgical incisions to ensure intervention of physician notification of deteriorating surgical wound was present on the care plan. Of the two residents with acute surgical wounds, it was identified as one resident not having a Care Plan for his acute surgical wound. A Care Plan was initiated by the DON on October 15, 2021, for that surgical wound. 6. On October 13-15, 2021, RN #2, DON, LPN #1, LPN #2, LPN #3, RN #4, RN #5, and RN #1 performed body audits on seventy-four residents that included non-pressure areas. Five of seventy-four active residents were identified with new areas that included a rash, abrasion, irritation, dry skin with callus, and bunion with discoloration. The Physicians were notified, and new orders obtained on the five residents with new areas identified. The Physician #1 visited the facility on October 15, 2021, and assessed two of five active residents identified with new skin conditions and Resident Representatives were notified of new orders and condition on October 15, 2021. New treatment orders were initiated on October 14, 2021, for the other three residents by their physician and the Resident Representative was notified. 7. RN #2 received additional employee education by RN #6 on October 15, 2021, at 8:30 PM on notifying the surgeon and/or attending physician when a surgical wound has a change for the worse or is not responding to current treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Nurse Practitioner received additional employee education by Registered Nurse #6 on October 15, 2021, at 9:00 PM on notifying the surgeon and/or attending physician anytime a surgical wound is not responding to current treatment or deteriorating for further orders and when a resident has a new surgical wound, the surgeon and/or attending physician should be contacted for orders to include staple and/or suture removal. The facility alleges removal of the immediacy as of October 16, 2021, 8:00 AM. VALIDATION OF REMOVAL PLAN 1. Record review and interviews confirmed the facility Quality Assurance Committee (QA) Meeting was held on October 14, 2021 at 9:30 AM with the committee consisting of the facility Director of Nurse (DON), Administrator (ADM), Medical Director by phone, Infection Preventionist, Registered Nurse (RN) #3, Licensed Practical Nurse #1 (LPN), LPN #2, (RN) #4, LPN #3, Occupational Therapist (OT), Physical Therapist Assistant (PTA), LPN #4, and RN #2. Topics discussed included treatments, reporting and follow up with changes in condition to physician and Resident Representative, abuse and neglect, adherence to orders as prescribed, ensuring that resident's representative information is accurately entered into the computer system and infection control. Interviews with the facility Medical Director, Administrator, Director of Nurses/Infection Preventionist, four (4) RN's and one (1) LPN confirmed participation in the QA meeting held on October 14, 2021. 2. Record review and interviews confirmed a QA meeting held on October 15, 2021, at 7:45 PM committee consisting of the facility DON, ADM, Medical Director, Infection Preventionist, RN #2 and RN #1 on Policy and Procedures of the Care Plan Process, Change in Resident Medical Status, Weekly Treatment Evaluation, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no policy changes, however, the facility made procedural changes on October 15, 2021, to include obtaining surgical wound care orders from the surgeon and/or attending physician for all new surgical wounds and deteriorating surgical wounds. Interviews confirmed the DON will assess acute surgical wounds weekly for any changes and notify the physician and/or surgeon of deteriorating surgical wounds for further orders. Interviews with the facility Medical Director, Administrator, Director of Nurses/Infection Preventionist, four (4) RN's and one (1) LPN confirmed participation in the QA meeting held on October 15, 2021. 3. Record review and interviews confirmed in-services with RNs and LPNs on October 11, 2021, at 1:00 PM on notification of physician, and Resident Representative regarding changes in condition of wounds. Interviews confirmed in-services were also initiated on October 13, 2021, at 6:30 AM by the DON and ADM with RN's, LPN's, Certified Nurse Aides (CNA), Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Change in Medical Status, Prevention of Abuse and Neglect, and Infection Control. Interviews confirmed in-services were initiated on October 13, 2021, at 6:30 AM with RN's and LPN's on the Weekly Treatment Evaluations, Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 15, 2021, at 6:30 PM In-services were initiated by the DON and ADM with LPN's and RN's on the Care plan Process, what is a Care Plan, and following the Care plan. In-services will be on-going, and no employee will be allowed to work until participation of the in-services are completed. Staff interviews included six (6) RN's, 6 LPN's, ten (10) CNA's, 1 administrative assistant, three (3) housekeeping/laundry staff, 1 social worker. 4. Record review and interviews confirmed the facility performed a 100% skin audit of all residents beginning October 13, 2021, and concluding October 15, 2021 with no negative findings. Interviews were with 6 RN's and 6 LPN's. 5. Record review and interview with the DON confirmed that on October 15, 2021, she did a record review of the two residents with acute surgical incisions to ensure intervention of physician notification of deteriorating surgical wound was present on the care plan. Of the two residents with acute surgical wounds, she identified one resident did not a Care Plan for his acute surgical wound. A Care Plan was initiated by the DON on October 15, 2021, for that surgical wound. 6. Record review and interviews confirmed that on October 13-15, 2021, facility nurses performed body audits on seventy-four residents that included non-pressure areas. Five of seventy-four active residents were identified with new areas that included a rash, abrasion, irritation, dry skin with callus, and bunion with discoloration. Record review confirmed the Physicians were notified, and new orders obtained on the five residents with new areas identified. Record review confirmed that Physician #1 visited the facility on October 15, 2021, and assessed two of five active residents identified with new skin conditions and Resident Representatives were notified of new orders and condition on October 15, 2021. Record review confirmed that treatment orders were initiated on October 14, 2021, for the other three residents by their physician and the Resident Representative was notified. Staff interviews with 2 RN's, 1 LPN and the DON confirmed these body audits. Interview with Physician #1 confirmed his visit to the facility on 0ctober 15, 2021 to assess two of his patients with new skin conditions. 7. Record review and interview with RN #2 confirmed she received additional employee education by RN #6 on October 15, 2021, at 8:30 PM on notifying the surgeon and/or attending physician when a surgical wound has a change for the worse or is not responding to current treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN #6 confirmed she conducted the employee education with RN #2. 8. Record review confirmed that the Nurse Practitioner received additional employee education by Registered Nurse #6 on October 15, 2021, at 9:00 PM on notifying the surgeon and/or attending physician anytime a surgical wound is not responding to current treatment or deteriorating for further orders and when a resident has a new surgical wound, the surgeon and/or attending physician should be contacted for orders to include staple and/or suture removal. Interview with RN #6 confirmed that the Nurse Practitioner received the addition education.

Based on observation, staff interviews, facility policy review and in-service record review, the facility failed to maintain an infection control program related to not wearing a face mask properly during serving food on resident's lunch trays for one (1) of five (5) dietary staff and not performing hand hygiene while passing resident's lunch trays for one (1) of three (3) Certified Nursing Assistants observed potentially affecting four (4) residents. Findings include: Observation 1 Record review of the facility policy titled Hand Hygiene with revision date of 10/17, revealed the purpose is to cleanse hands to prevent transmission of infection or other conditions is to provide clean, healthy environment for residents, staff and visitors. Indications for hand washing and/or alcohol-based hand rub revealed to perform between all contact with residents or when entering and exiting a resident's rooms. During an observation on 9/14/20 at 12:10 PM Certified Nursing Assistant (CNA) #1 was passing lunch trays on B-unit residents. CNA #1 was observed removing a tray from the tray cart, entered room B-1 and walked to the middle bed, moved the over bed table near the resident, which contaminated her hands, set up the tray by opening and placing items for the resident, exited the room and did not wash her hands or use a hand sanitizer. CNA #1 removed a tray from the cart, entered room B-1 and walked to the bed near the window, moved the resident's water pitcher from the over bed table to the bed side table which contaminated her hands, opened and set up the items on the tray for the resident, exited the room and did not wash her hands or use the hand sanitizer. CNA #1 moved a wet floor sign in the hall near the tray cart, removed a tray from the cart with contaminated hands entered room B-1, walked to the bed near the door, moved the over bed table near the resident, opened and moved items on the tray for the resident, and exited the room without washing her hands or using hand sanitizer. CNA #1 removed a tray from the cart, entered room B-4, walked to the bed near the window, set up the tray by opening and moving items on the tray, exited room and did not wash hands or use hand sanitizer. Interview with CNA #1 on 9/14/20 at 12:25 PM confirmed she did not wash her hands or use a hand sanitizer between delivering lunch trays to three (3) residents in room B-1 and to one resident in B-4. CNA #1 revealed she had some sanitizer in her pocket but did not use it. She stated she knows she should use the sanitizer or wash her hands, but she forgot. CNA #1 revealed she has attended training's on hand hygiene and realizes by not cleaning her hands between the residents she could spread an infection. Observation 2 Record review of the facility policy titled Donning PPE dated 6/14 revealed instructions for a mask included to secure ties or elastic band at middle of head and neck, fit flexible band to nose bridge, and fit snug to face and below chin. During an observation on 9/14/20 at 12:35 PM, Dietary Cook (DC) #1 was seen standing at the steam table serving food onto the residents' trays with her face mask placed below her chin, not covering her nose or mouth. DC #1 was talking to other staff members while standing over the food on the steam table and serving the lunch trays. Interview with DC #1 during the above observation revealed she believed she was more than six (6) feet away from other staff, and because she has Asthma, it is difficult for her to breath when wearing a mask. DC #1 confirmed she was not wearing the face mask in the manner she was trained. The DC revealed she was trained to wear a face mask that covers her nose and mouth to prevent the spread of infection. An interview with the Dietary Manager (DM) confirmed DC #1 was not wearing the face mask in a manner that covers her nose or mouth and could possibly cause the spread of an infection. An interview with the Infection Control Registered Nurse (ICRN) on 9/14/20 at 12:55 PM revealed the nursing staff should always either wash their hands or use hand sanitizer before and after entering a resident's room. The ICRN revealed the facility has provided training on hand hygiene because by not disinfecting their hands between resident care they could spread [MEDICAL CONDITION]. The ICRN revealed all staff including the dietary staff should always wear their masks covering their nose and mouth. [MEDICAL CONDITION] (COVID-19) is spread through the air and the mask will prevent the spread of [MEDICAL CONDITION]. On 9/14/20 at 1:00 PM an interview with the Director of Nursing (DON) revealed the facility has provided training for all staff on the proper use of wearing masks and they should always be worn over their nose and mouth. DON revealed [MEDICAL CONDITION] travels in the air, and you have to cover your mouth and nose. The DON revealed the nursing staff have attended training related to the importance of performing hand hygiene before and after entering and exiting a resident's room. The DON revealed hand hygiene is very important in preventing the spread of infection to the residents. Record review of an In-Service Training, dated 7/16/20 and presented by the ICRN, revealed the subject included hand hygiene and proper use of face masks. The signatures of DC #1 and CNA #1 were noted on the sign in sheet.