Every finding on record at Life Care CTR of Lawrenceville

Based on observations, staff interviews, and review of the facility's policy titled, Food Safety and Sanitation, the facility failed to ensure food safety protocols and maintain sanitary conditions for the ice machine, the disposal of expired and opened food in the walk-in refrigerator freezer, and failed to properly label or date food in the dry storage and walk in freezer. The deficient practices had the potential to place 84 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include:Review of the facility's policy titled Food Safety and Sanitation reviewed dated 05/01/2025, documented in Procedure . 2. Pre-packaged food is placed in a leak-proof, pest proof, non-absorbent, sanitary (NSF-National Sanitation Foundation certification) container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to new container). Use by Date is noted on the label or product when applicable. Documented in Food Service/Meal Service .12c. Ice machines must be of a type that eliminates contamination during ice manufacture, storage, and dispensing. During the initial tour on 03/27/2026 at 7:35 AM with the Dietary Manager (DM), the kitchen inspection of food in the dry storage area/emergency preparedness revealed two 2lb. (pound) boxes of cookies, 60 packs with an expiration date of 10/20/2025, two honey thickened flavored water, 46 fl oz. (fluid ounces) with an expiration date of 03/03/2026, and three 1lb. alfredo sauce mix with an expiration date 10/18/2025.The walk-in freezer revealed multiple five-gallon bags containing pre-packaged food products that lacked proper labels and dates. All items confirmed with the DM and listed as follows: cut carrots with date 03/22/2026, sliced pepperoni with date 02/27/2026, catfish with date 03/11/2026, vegetable sausage with date 03/02/2026, pork with date 03/24/2026, roast beef with date 03/08/2026, beef with date 03/23/2026, all food items without any expiration date. Moreover, a box of mixed meats with an expiration date of 07/03/2025; included one gallon bag of vegetable meatballs, 3.4 oz veggie patties, and one gallon bag marked as veggie patties were found.The kitchen tour continued, uncovering a brown-black slime-like substance during the ice machine inspection. The DM verified and witnessed lack of cleanliness. The DM revealed that the ice machine was cleaned quarterly. An examination of the cleaning log attached to ice machine revealed two dates: 03/14/2025 and 05/19/2025. An attached TELS (maintenance request system) update email regarding the ice machine showed that the service date was 10/24/2025, and a note at the bottom of the page indicated the next service date as 01/23/2026Interview with the DM on 03/27/2026 at 8:43 AM confirmed that all the food in the walk-in freezer had dates marked for when they were prepared, but the staff did not write down the use-by dates. The DM explained that an outside company cleaned the ice machine and that it was recently serviced, but there was still a brown-black substance present. She mentioned that even though it was cleaned not long ago, it did not seem like it was thoroughly done.An interview with [NAME] HH on 03/27/2026 at 12:24 PM revealed that he had recently placed pepperoni in the freezer in preparation for lunch but was not able to label and date due to the label device malfunctioning and conducting breakfast meal tray pass.An interview with Dietary Aide (DA) II on 03/29/2026 at 10:36 AM regarding kitchen observation revealed that it was last year since he last cleaned the ice maker. DA II, confirmed he was the morning dietary assistant that carefully checked food products for expiration, dating, and labeling when the truck delivered. DA II revealed that he overlooked the food items in the dry storage area that were identified. An interview on 03/29/2026,at 11:10 AM with Dietary Aide (DA) JJ explained that the night shift crew was usually in charge of cleaning the ice machine, and it was the person designated as E who handles it. However, he pointed out that nobody had been assigned as E lately. DA JJ shared that about two weeks ago, he cleaned the outside of the ice machine because the instructions just said to clean the inside and outside, without any other details. He confirmed he did not clean under the ice compartments, saying he was not sure what was under there. DA JJ also added that he was also responsible for putting away stock when the food delivery came in. DA JJ revealed he did not notice any expired food items in the dry storage area, and he made sure to put new items behind the older ones; he really did not focus on the dates as the morning dietary aide did.

Based on observations, record review, staff interviews and review of the facility policy titled, Oxygen Administration (Infection Control, Safety, and Storage), the facility failed to provide respiratory care consistent with professional standards of practice by ensuring humidification was provided and the oxygen concentrator and filter were clean for one of 20 residents (R) (R81) receiving oxygen (O2) or respiratory therapy. The deficient practice increased the risk of infection for R81. Findings include:Review of the facility policy titled Oxygen Administration (Infection Control, Safety, and Storage) revised date 03/03/2026, revealed in section Infection Control 1. Change oxygen supplies (e.g. cannula, tubing, humidifier) weekly and when visibly soiled. Equipment should be labeled with resident name and dated when setup or changed out.4b. External filters should be checked daily and all dust should be removed. Review of the electronic medical record (EMR) for R81 revealed she was admitted to the facility with diagnoses including but not limited acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), hypertensive heart disease with heart failure, dependence on supplemental oxygen, and obstructive sleep apnea.Review of R81 most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was coded as 15, which indicated no cognitive impairment. Section O, Special Treatments, Procedures, and Programs revealed Oxygen therapy/ Non-invasive Mechanical Ventilator.A review of the care plan initiated on 07/11/2024 revealed the resident has COPD. Intervention: Identify and eliminate sources of respiratory irritation such as cigarette smoke, pollen, perfumes, etc.Observation and Interview on 03/27/2026 at 11:16 AM with R81 revealed the water humidification bottle on the O2 concentrator was empty. Additionally, there was no date recorded on the O2 tubing of the O2 concentrator and the concentrator filter revealed heavy gray-like dust build up on filter. When R81 was asked about her comfort level; the resident confirmed, that's why it is hard for me to breathe and insisted that someone come fix it.Observation on 03/27/2026 at 4:05 PM with the Director of Nursing (DON) revealed O2 in use at four liters via concentrator, no date on tubing, and the humidification was dry/empty. The DON immediately exited and informed the nurse. Observation and Interview on 03/27/2026 at 4:09 PM with Licensed Practical Nurse (LPN) KK revealed that the humidification bottle was empty, there was no date on the tubing, and the name and date were missing from the bottle. Additionally, the concentrator filter was noted to have a significant build-up of dust-like particles. LPN KK explained that the tubing was replaced on Sunday nights, along with the humidification bottles. LPN KK also shared nursing was required to date the tubing and water bottles each time they were replaced. Furthermore, LPN KK clarified that every morning, the nurse evaluated each resident, confirmed the flow rate, inspected the dated tubing, and checked the humidification bottles. LPN KK confirmed that she did not inspect the O2 tubing, concentrator nor water humidification for R81 today.An interview on 03/29/2026 at 12:28 PM with the DON revealed that she had informed her staff on the morning of 03/27/2026 to verify that all O2 tubing, flow liters, and water humidification bottles were checked. The DON clarified that these items were to be replaced weekly on Sundays; however, the humidification bottles may be changed more frequently if they were empty. Additionally, the DON explained that nurses were required to date and label all O2 equipment utilized. She further revealed that the Unit Manager was tasked with checking and completing rounds to ensure that all duties were fulfilled. Nevertheless, the Unit Manager for the 100 hall (Veranda) was currently responsible for interim Infection Control Prevention due to the absence of the Infection Preventionist (IP), and the interim Assistant Director of Nursing (ADON) would provide support in this regard. DON confirmed the risk of residents that were on O2 at 3 Liters per minute (LMP) or higher could cause dehydration, nasal dryness, and respiratory issues. The DON also explained the dust-like build up could cause harm as well, specifically with residents that had pre-existing respiratory conditions.An interview on 03/29/2026 at 1:11 PM with the ADON revealed that she was tasked with providing support to the Unit Manager for the 100 hall. She confirmed that she completed rounds that morning; however, she did not visit R81's room. ADON explained she failed to check the oxygen tubing, humidification, or the O2 concentrator in R81's room before the discovery was made with the DON.

Based on staff interviews, record review and review of the facility's policy titled, Certification of Accuracy of the (Minimum Data Set) MDS, the facility failed to ensure the MDS accurately reflected the status of one of one sampled resident (R) (R28) reviewed for hospice.Findings include:Review of the facility's policy titled Certification of Accuracy of the MDS reviewed 08/29/2025 documented under Definitions: Accuracy of Assessment - means that the appropriate, health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (e.g. comprehensive, quarterly, significant change in status).Review of the Electronic Medical Record (EMR) revealed R28 was admitted to the facility on [DATE] with a diagnosis including but not limited to protein calorie malnutrition.Review of the Admissions MDS dated [DATE] revealed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of five, which indicated R28 had severely impaired cognition, Section O (Special Treatments, Procedures and Programs) revealed R28 was not on hospice.Review of the Quarterly MDS dated [DATE] revealed in Section C a BIMS score of five, which indicated R28 had severely impaired cognition, Section O (Special Treatments, Procedures and Programs) revealed R28 was not on hospice.Review of a care plan dated 01/09/2026 revealed R28 had a terminal prognosis: Admit to hospice. Honor advance directives and provide comfort with dignity through next review.Review of Physician's Orders dated 12/09/2025 revealed, included but not limited to Admit to Hospice.Interview on 03/28/2028 at 10:55 AM with MDS Coordinator EE revealed she confirmed R28's hospice care was not coded correctly in the MDS. She confirmed R28 was admitted to the facility on Hospice care since 12/08/2025 and the admission MDS was coded R28 was not on hospice. The MDS Coordinator further stated that the quarterly MDS was done on 3/14/2026 and it was also not coded that R28 was on Hospice. MDS EE stated the MDS should be an accurate clinical picture which reflects what goes on at a period in time. She stated it was a clerical error, and the Centers for Medicare and Medicaid Services (CMS) would not have received the correct coding for R28.Interview on 03/28/2028 at 10:57 AM with MDS Licensed Practical Nurse (LPN) FF who was present in the office with the MDS Coordinator revealed she confirmed R28 was not coded correctly on the MDS in the admission Assessment and the Quarterly Assessment. She confirmed R28's MDS was coded as not being on hospice and confirmed R28 was on hospice.Interview on 03/28/2028 at 10:58 AM with MDS LPN GG, present in the office with the MDS Coordinator revealed she confirmed R28 was not coded correctly on the MDS in the admission Assessment and the Quarterly Assessment. She confirmed R28 was admitted [DATE] on Hospice and the admission Assessment was not coded as R28 being on Hospice. MDS LPN GG further confirmed the Quarterly Assessment which was done on 03/14/2026 did not code R28 as being on Hospice.Interview on 03/29/2026 at 10:30 AM with the Administrator and Director of Nursing (DON) revealed expectations were for accurate MDS to be done, which reflected the residents' services. She stated if a resident was on Hospice, it should be reflected in the MDS. The DON further stated that if Hospice was not coded in the MDS, it would be an inaccurate reflection of the data.

Based on record review, resident and staff interviews, and review of the facility policies titled, Cardiopulmonary Resuscitation (CPR) Policy and Advance Directives and Advance Care Planning, the facility failed to communicate and ensure preference for the change in code status from full code to do not resuscitate (DNR) was updated in the medical record for one of three sampled residents (R) (R1). The deficient practice had the potential to deny the residents and/or representatives the opportunity to direct health care in the event that they were to become unable to make decisions or communicate health care preferences. Findings include: Review of the facility policy titled Cardiopulmonary Resuscitation (CPR) Policy last revision date of [DATE] documented under Definitions: Do Not Resuscitate (DNR) Order – refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest. Existence of an advance directive does not imply that a resident has a DNR order. The medical record should show evidence of documented discussions leading to a DNR order. Review of the policy titled Advance Directives and Advance Care Planning, revised [DATE] and reviewed [DATE], documented under Procedure: . 6. Residents may revise an advance directive either orally or in writing. With an oral reversal, charting is due immediately, the physician is notified immediately, an immediate notation is made on the care plan, and an immediate entry is made in the medical record. With written reversals, the physician is notified, and the plan is permanently adjusted. The physician must give an order for any changes in the advance directives. Review of the electronic medical record (EMR) revealed R1 was admitted pertinent diagnoses including but not limited to metabolic encephalopathy, progressive neurological conditions, non-Alzheimer's dementia, and malnutrition (protein, calorie), risk of malnutrition. Review of R1's admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicates R1 had severe cognitive impairment. Section GG, Functional Status, revealed R1 required extensive assistance for activities of daily living (ADLs) with one or more-person assistance. Review of R1's care plan dated [DATE] indicated a problem of R1 prefers to remain a full code. Goals included but not limited to R1 wish to remain a full code will be honored. Interventions included but not limited to code status will be reviewed on a quarterly basis and PRN (as needed), Resident has decided to remain a Full Code . Review of the Physician's Orders for R1 included but was not limited to: Order dated for [DATE] FULL CODE, Verbal, Active. Interview on [DATE] at 2:27 pm with R1revealed she was admitted on [DATE] and a discussion with Admissions revealed she had to make a decision on whether R1 would be a DNR or not. She revealed she did have the DNR documents that she signed. She stated the staff of the facility lied and stated staff did not know about the DNR because two doctors had to sign off on it to be a DNR. R1 did not understand why the facility coded her as something different than what was talked about during the planning meeting. Interview on [DATE] at 1:27 pm with the Administrative Assistant revealed she could not find the note in the EMR which should talk about advanced directives for R1. She further revealed the process the facility followed for advanced directives was at admission and they [the facility] would need to go over the forms and sign baseline care plans, the physician order for life sustaining treatment (POLST), and ask questions regarding discharge planning depending on the person and if they were here long term or short term. Phone Interview on [DATE] at 1:44 pm with the Admissions Director revealed she explained the advanced directive process to R1 and family, and specifically R1's daughter became upset and needed to speak with several people and left the POLST un-signed. The Admissions Director revealed that if the POLST was un-signed, the resident was a full code. If they do become a DNR, then the resident would be a full code until it was signed off by the doctor. She further revealed that all families were explained this on admission. She further stated that once she had the [signed] POLST, it went to Social Services to make sure the doctor signed it. She was not aware of the timeframe it took for the doctors to sign it. When asked why the POLST was not dated, she revealed initially she was told the POLST was to be dated once the admission was completed, however, if family members discussed it and a choice was not made, the recommendation was for the family to sign, then call/follow up about their decision, then it was dated and given to Social Services. She further revealed that she felt the daughter came in after hours and completed the POLST form which more than likely got misplaced in a box. Interview on [DATE] at 2:05 pm with the Social Services Director revealed when she received a POLST form that was signed, she had a responsibility of getting it signed by the physicians. Once it had the physician signature, she would scan the form into the EMR system and then send it to medical records and from there she would update the care plan. The timeframe was typically 48 to 72 hours. In the meantime, they had the morning clinical meeting and everyone was made aware of the code status change. When she received the POLST, typically they were dated and since the POLST for R1 was not dated, she revealed she would ask the Admissions Director but she could not recall what happened with this one. Even if it was the wish of the family to have their loved one as a DNR, if it was not signed, it was not valid. She revealed she believed it was signed the day before and would only make a note once the POLST was signed by the physician. She revealed the facility did not put advanced directive decisions in the baseline care plan and was not sure if there was a section for advance directives in the care plan. Any resident that was admitted to the facility would be a full code, even on the baseline care plan, until the POLST was signed by either two physicians or a physician and the resident or someone authorized to sign for the resident. Interview on [DATE] at 2:25 pm with the Administrator revealed the resident would still be a full code if the appropriate documentation had not been received upon admission. The Administrator revealed she was un-sure the amount of time the process would take for the doctors to sign the POLST however, the doctors do come in the facility for the initial visit within 72 hours and would collaborate with the Interdisciplinary Team (IDT) but she was not sure if the doctors were actually a part of the baseline meeting. The Administrator further revealed Social Services and Admissions would collaborate and bring everyone together to discuss the plan for his or her stay.

Based on observations, interviews, review of the facility's policies titled Oxygen Administration (Safety, Storage, Maintenance), Cleaning and Disinfection of Non-Critical Patient Care Equipment, and Hand Hygiene, the facility failed to maintain sanitary conditions for storing respiratory supplies for one of 19 residents that received respiratory treatments. In addition, the facility failed to sanitize shared medical equipment between residents' use during two of four medication pass observations and follow proper hand hygiene practices when providing residents' care during one of four medication pass observation. The deficient practices increased the risk to spread infection, equipment contamination, and other health complications. The sample size was 24 residents. Findings include: Review of the facility's policy titled Oxygen Administration (Safety, Storage, Maintenance) revised on 10/11/2024 revealed the Policy section included 4: Store oxygen and respiratory supplies in bag labeled with resident's name when not in use. Review of the facility's policy titled Hand Hygiene revised 6/3/2024, revealed the Policy section included 2. Associates perform hand hygiene (even if gloves are used) in the following situations: a) Before and after contact with the resident; c) After contact with objects and surfaces in the resident's environment) After removing personal protective equipment. 1. Review of R47's Electronic Medical Records (EMR) revealed, R47 was admitted to the facility with diagnoses including, but not limited to chronic pulmonary edema, acute and chronic respiratory failure with hypoxia, post Covid 19, heart failure, and stroke. Review of the Physician Orders for R47 revealed an order dated 1/2/2025 for Ipratropium-Albuterol Solution (nebulizer to treat chronic obstructive pulmonary disease) 0.5-2.5 (3) MG (milligram) /3ML (milliliters) 3 ml inhale orally via nebulizer four times a day for shortness of breath (SOB). During an observation on 1/28/2025 at 12:04 pm in the resident's room, R47's respiratory supplies (nebulizer mask and tubing) were laying on the nightstand tangled and touching the floor. The respiratory supplies were unbagged and not in use. During an observation on 1/29/2025 at 9:00 am, R47's nebulizer mask and tubing were laying on the nightstand tangled, unbagged, and not in use. Observation and Interview on 1/29/2025 at 12:00 pm in R47's room with RN AA revealed, the nebulizer masks and tubing were unbagged while not in use. She opened the nightstand drawer, revealing a labeled bag designated for the respiratory supplies. RN AA placed the nebulizer mask in the bag and confirmed that it should have been stored in the bag when not in use. In an interview on 1/29/2025 at 3:20 pm with the Staff Development Coordinator, Intern Infection Control Preventionist (ICP), RN FF, she stated that she expected oxygen supplies and respiratory masks to be kept in a labeled bag when not in use. Interview on 1/30/2025 at 9:20 am with the facility's corporate nurses, Registered Nurse (RN) EE and RN DD revealed, that they expected staff to keep oxygen supplies and respiratory masks in labeled bags when not in use. 2. Observation and Interview during medication pass on 1/29/2025 at 11:35 am revealed, RN AA was observed performing a blood sugar check on a resident. RN AA approached the medication cart and gathered the necessary supplies; however, she did not wash or sanitize her hands before collecting the supplies or upon entering the room nor did she clean and disinfect the glucose glucometer before use. RN AA revealed, someone had removed the sanitizer from her cart, and she had forgotten to do so when questioned about not sanitizing or washing her hands before preparing for the glucose check or upon entering the room. RN AA confirmed she should have sanitized her hands in both instances and cleaned the glucometer before use. During an interview on 1/29/2025 at 3:00 pm with RN FF Staff Development Coordinator/Interim Infection Control Preventionist (SDC/ICP) revealed that she expects her staff to perform hand hygiene before and after any contact with each resident. RN FF SDC/ICP revealed, staff members should either sanitize with an alcohol-based hand sanitizer or, after three consecutive uses, wash their hands with soap and water. During the interview on 1/30/2025 at 9:20 am with RN EE and RN DD stated, that they expected staff to perform hand hygiene using either soap and water or an alcohol-based hand sanitizer before and after contact with each resident and to clean the glucometer before and after use.

Based on observations, staff interviews, record review and review the facility document titled, [Name of Company] TELS (The Equipment Lifecycle System): Instructions, the facility failed to keep the residents free of accident hazards as evidenced by water temperatures above 110 degrees Fahrenheit (F) in four out of 68 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). The deficient practices had the potential to cause injury to residents residing in these rooms. Findings include: Review of the facility document titled, [Name of Company] TELS: Instructions, under the section titled Steps revealed, 1. For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temperature can still cause burns if exposure reaches five minutes. Many states have even stricter standards that set maximum temperatures lower than 120 degrees Fahrenheit, although 100 degrees Fahrenheit is considered a safe water temperature for bathing. Observations on 1/28/2025 from 1:15 pm to 1:20 pm of water temperature checks on 226 - 232 corridor with the Assistant of Maintenance Director (AMD) using the facility's digital thermometer revealed, water temperature measurements in room [ROOM NUMBER] at 127.8 degrees F, room [ROOM NUMBER] at 127.2 degrees F, room [ROOM NUMBER] at 127 degrees F and room [ROOM NUMBER] at 126.7 degrees F. No other residents' rooms were affected. Interview on 1/28/2025 at 1:25 pm with the AMD revealed, that maintenance department conducted weekly water temperatures in 10 rooms, in rotation. Interview on 1/28/2025 at 1:30 pm with the Administrator and Maintenance Director (MD) to inform them about the hot water test result. The Administrator stated that the MD would adjust the temperature promptly. Follow-up Observation on 1/28/2025 at 5:40 pm of water temperature checks revealed, room [ROOM NUMBER] at 106.3 degrees F, room [ROOM NUMBER] at 105.9 degrees F, room [ROOM NUMBER] at 105.9 degrees F, and room [ROOM NUMBER] at 105.6 degrees F. Review of facility water temperature log revealed that water temperature checks were completed on 1/2/2025, 1/8/2025, 1/16/2025, and 1/23/2025 with temperatures ranges between 106 degrees F and 106.9 degrees F. Review of the facility's records revealed, no residents sustained burns injuries related to hot water temperatures. Interview on 1/28/2025 at 5:50 pm with the Maintenance Director (MD) confirmed, that when he went to adjust the water temperature, the water heater thermostat was showing 130 degrees Fahrenheit. The MD revealed that he had conducted weekly check of the thermostat to ensure the water temperature remained under 110 degrees however he was unsure why the temperature had gone up.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Oxygen Administration (Safety, Storage, Maintenance),the facility failed to ensure that one out of 19 residents (R) R41 receiving oxygen therapy was administered the therapy in accordance with the physician orders. This deficient practice had the potential to put R41 at risk for medical complications, respiratory depression, and potentially life-threatening complications. Findings include: Review of the facility's policy titled Oxygen Administration (Safety, Storage, Maintenance), dated 10/11/2024, under the section Procedure - Oxygen Administration, outlines the following procedures: 1. Oxygen order should be written for specific liter flow required by the resident. Review of the clinical electronic record for R41 revealed, she was admitted with diagnoses that included but not limited to acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Review of the most recent Minimum Data Set (MDS) dated [DATE] for R41, revealed a Brief Interview for Mental Status (BIMS) was coded as 8, indicating the resident had moderate impaired cognition. Review of Physician orders revealed, oxygen therapy-nasal cannula (N/C) at rate of 1(one) liter, date initiated 1/7/2025. Observation on 1/28/2025 at 12:57 pm revealed, R41's wall mounted oxygen flow meter rate set on 1.5 (one and a half) liters via (by way) N/C. Observation on 1/29/2025 at 11:00 am revealed, R41's wall mounted oxygen flow meter rate set on 2 (two) liters via N/C. Observation on 1/30/205 at 1:37 pm revealed, R41's wall mounted oxygen flow meter rate set on 2 (two) liters via N/C. Observation and interview on 1/30/2025 at 3:40 pm with Licensed Practical Nurse (LPN) TT confirmed that resident's oxygen tank setting was on two liters. LPN TT checked resident's physician orders and confirmed that oxygen flow meter rate should be set on one liter. Cross Reference F656

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Comprehensive Care Plans and Revisions, the facility failed to develop a person-centered, comprehensive care plan related to providing oxygen therapy as ordered for one of 19 Residents (R) (R41) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life. Findings include: Review of the facility policy titled Comprehensive Care Plans and Revisions, dated 9/11/2024 under the section Policy revealed, The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs . Review of the clinical electronic record for R41 revealed, diagnoses that included but not limited to acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Review of R41's physician orders dated 1/7/2025 revealed, oxygen therapy-nasal cannula (N/C) at rate of 1(one) liter. Review of the care plan with date initiated on 1/7/2025 and target date 4/7/2025 revealed, there was no care plan developed related to providing oxygen therapy as ordered. Interview on 1/30/2025 pm at 3:54 pm with the Regional Coordinator of Clinical Services (RCCS) EE office confirmed that the resident did not have a care plan for oxygen therapy. Observation and interview on 1/30/2025 pm at 3:59 pm with the Unit Care coordinator LPN UU confirmed during admission a care plan should have been developed for oxygen but was not. Cross Reference F695

Based on staff interviews, record review, and review of the facility's policy titled, Pre-admission Screening and Resident Review (PASARR), the facility failed to ensure that one of one resident (R) (R13) reviewed for PASARR was evaluated by the state designated authority for a PASARR Level II. This deficient practice had the potential to affect the appropriate level of care and services provided for R13. Findings include: Review of the facility's policy titled Pre-admission Screening and Resident Review (PASARR), with dated 9/26/2024 under Policy revealed, The facility will ensure that potential admissions are to be screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASARR Level I and is completed prior to admission to a nursing facility. A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A positive Level I screen necessitates an in-depth evaluation of the individual by the state designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility Review of the Electronic Medical Record (EMR) revealed R13 was admitted to the facility on [DATE] with diagnoses that included but not limited to, bipolar disorder, depression, and anxiety. Review of R13's most recent entry tracking Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/20/2024 revealed, Section A (Identification Information) documented the resident had not been evaluated by Level II PASARR and determined to have a serious mental illness and/or mental retardation or related condition; Section I (Active Diagnoses) revealed, no neurological diagnoses, Section N (Medications) revealed, antipsychotic, antidepressant, and antianxiety medication use. Review of R13's physician orders revealed, buspirone HCL 15 mg (milligram) oral tablet with start date of 1/5/2025 (anti-anxiety medication), escitalopram oxalate 5 mg oral tablet with start date of 1/21/2025 (anti-depressant medication), olanzapine 20 mg oral tablet with start date of 5/18/2024 (anti-psychotic medication). Review of R13's PASRR Level I assessment dated [DATE] revealed, R13 did not have a Primary diagnosis of a Serious Mental illness that included bipolar disorder, depressive disorder, and anxiety disorder which were all marked No. Further review of R13's EMR revealed no submissions for a PASARR Level II to include diagnoses of bipolar disorder, depression, and anxiety. Interview on 1/29/2025 at 3:50 pm with the Social Services Assistant (SSA) KK, confirmed R13 did not have a PASARR Level II. She stated that she had not been trained on who should have a PASARR Level II. She stated that the facility does not have any resident that has a primary diagnosis for a PASARR Level II. She stated that the old Social Services Director (SSD) told her that if it is not the first diagnosis (primary) then the resident did not need a PASARR Level II. She acknowledged that R13 had diagnosis of bipolar disorder, depression, and anxiety; however, they were not the primary diagnosis. Interview on 1/29/2025 at 4:03 pm with the Admissions Director (AD) revealed, that the SSD was a new hire, and she did not complete the PASARR Level II's. She stated that PASSR Level II's and DMA 6's are typically completed at the local hospital if the resident's stay was not going to be beyond 30 days of admission. She revealed, if the residents stay was beyond 30 days that Business Office Manager (BOM) MM and medical records personnel at the facility were responsible for completing the PASARR Level II's. Interview on 1/29/2025 at 4:10 pm with Business Office Manager (BOM) MM confirmed that the diagnoses of bipolar disorder, depressive disorder, and anxiety disorder would warrant a PASARR Level II however, she did not have a clinical background to complete a PASARR II on a resident. During an interview on 1/30/2025 at 10:57 with the (Health Information Management Director) HIMD Director and the HIMD Assistant, the HIMD Director revealed that the PASARRs were requested by the Director of Nursing (DON). He stated that he inputs the coding, and the clinical management goes through the DON (who was responsible for the PASSRs). He stated that he doesn't know the requirements for the PASARRs. The HMID Assistant stated that the HIMD department is learning something new, because she didn't know it was the responsibility of their department to have PASARR II completed on the residents. HIMD Director stated that he extracts information from the resident's records that come from the local hospital, and he uploads them. He stated that the resident's diagnosis comes from the hospital when they are discharged . He stated that R13's PASARR I was completed by the hospital. Interview on 1/30/2025 at 11:33 am with the SSD and SSA NN revealed they were not too familiar with PASARRs because their office did not deal with PASARRs. SSD checked R13's chart and confirmed that R13's has a diagnosis of bipolar, which is a major mental health issue. Interview on 1/30/2024 at 12:02 pm with the Administrator revealed her expectation for PASARR was for the Business Office Manager to ensure that the PASARR II and correct coding were completed on the PASARR form. She further stated she expect residents with a new diagnosis of mental illness to have a new PASARR Level II completed at the time of the diagnosis.

Based on record review, staff interviews, review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, and review of the facility policies, the facility failed to implement initial and ongoing testing of residents and staff as recommended by Center for Disease Control and Prevention (CDC) and the Georgia Department of Public Health (GDPH) to lessen the exposure of Covid-19 during an outbreak and failed to obtain Physician's Orders for Covid-19 testing for 21 of 28 residents (R#'s 59, 2, 114, 80, 322, 113, 46, 112, 74, 13, 27, 324, 222, 51, 469, 323, 119, 10, 58, 120, and 21) reviewed that were positive for Covid-19. In addition, the facility failed to maintain documentation of negative test results of residents and staff. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Executive Director, Regional Director of Clinical Services, Regional [NAME] President, and the Division Director of Clinical Services were notified on [DATE] at 2:30 p.m. of the Immediate Jeopardy. The IJ situation was ongoing at the time of exit on [DATE]. Findings include: Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated [DATE], revealed when performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any Healthcare Provider (HCP) or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected units) if using a broad-based approach, regardless of vaccination status. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every three to seven days until there are no new cases for 14 days. Review of the facility policy titled Covid-19 Outbreak Investigation revised [DATE] revealed the policy statement is the facility will perform COVID-19 outbreak investigations in accordance with local, state, and federal regulations to mitigate the spread of COVID-19 within the facility. Procedure number 1. An outbreak investigation is initiated when a single new case of Covid-19 occurs among residents or staff to determine if others have been exposed. Number 2. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission. Number 3. Upon identification of a single new case of Covid-19 infection in any associate or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). Number 4. The facility has the option to perform outbreak testing through two approaches, contact tracing or broad-based (facility wide) testing. Number 5. If the facility can identify close contacts of the individual with Covid-19, they could choose to conduct focused testing (contact tracing) based on known close contacts. Number 6. If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide level broad-based) or group level (unit, floor, or other specific area(s) of the facility). Number 7. The use of broad-based testing might also be required if the facility is directed to do so by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt the transmission. Number 8. Perform testing for all residents and associates identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Number 9. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of broad-based approach, testing should continue on affected unit(s) or facility-wide every three to seven days until there are no new cases for 14 days. Review of the facility policy titled Covid-19 (SARS-CoV-2) Resident Testing revised [DATE] revealed the facility should plan to test in accordance with accepted national standards such as the CDC, unless ordered more stringently by the local and state officials. Procedure: Conducting Testing number 1. Obtain an order from a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with the State law, including scope of practice laws to provide or obtain laboratory services for a resident, which includes Covid-19 testing. 2. Rapid Point of Care (POC) testing devices are prescription use tests under the Emergency Use Authorization and must be ordered by a healthcare professional licensed under the applicable state law or a pharmacist under U.S. Department of Health and Human Services (HHS) guidance. Accordingly, the facility must have an order from a healthcare professional or pharmacist, as previously described, to perform a rapid POC Covid-19 test on an individual. Facilities must document compliance with the testing requirements. To do so, facilities should do the following: 1. For symptomatic residents, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results. 2. Upon identification of a new Covid-19 case in the facility (i.e., outbreak), document the date the case was identified, the date that all other residents are tested , the dates that residents who tested negative are retested , and the results of all tests. 5. For residents, the facility must document testing results in the medical record. The following 21 residents were positive for COVID-19 and reviewed related to the ongoing outbreak in the facility: 1. Review of the Admission Minimum Data Set (MDS) Assessment for R#59 dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. A Nurse's Note dated [DATE] documented resident had symptoms of runny nose and nausea. A Covid test was performed, and the result was positive. A Nurse's Note dated [DATE] revealed the resident began complaining of severe abdominal pain and was transferred to the hospital. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There was no physician order for Covid-19 testing. 2. Review of the Quarterly MDS Assessment for R#2 dated [DATE] revealed a BIMS of 15 indicating intact cognition. A Nurse's Note dated [DATE] documented symptoms of malaise and cough. A Covid test was performed, and result was positive. Contact and droplet isolation initiated. Review of the [DATE] Physician Orders revealed there was not an order for Covid-19 testing or isolation. 3. Review of the Admission MDS Assessment for R#114 dated [DATE] revealed a BIMS of 15 indicating intact cognition. A Nurse's Note dated [DATE] documented that resident complained of a sore throat and cough. A Covid test was administered, and the result was positive. Review of the [DATE] Physician Orders revealed Covid-19 testing ordered on [DATE], [DATE] and [DATE]. Droplet and Contact Precautions ordered on [DATE]. 4. Review of the Admission MDS Assessment for R#80 dated [DATE] revealed a BIMS score of six, indicating severely impaired cognition. A Nurse's Note dated [DATE] documented resident tested positive for Covid on [DATE]. Resident was placed on isolation per facility protocol. Review of the [DATE] Physician Orders revealed there was not an order for Covid-19 testing. 5. Review of the Admission MDS Assessment for R#322 dated [DATE] revealed a BIMS score of 13, indicating intact cognition. A Nurse's Note dated [DATE] documented resident with symptoms of upper respiratory infection (cough, congestion, and scratchy throat). A Covid test was performed, and the result was positive. Review of the [DATE] Physician Orders revealed an order on [DATE] for isolation. There were no orders for Covid-19 testing. 6. Review of the Admission MDS Assessment for R#113 dated [DATE] revealed a BIMS score of 12, indicating moderately impaired cognition. A Nurse's Note dated [DATE] documented staff spoke with resident's son regarding residents Covid positive diagnosis and the initiation of contact and droplet isolation. Review of the [DATE] Physician Orders revealed an order for isolation dated [DATE]. There was an order for a Covid test dated [DATE] (11 days after the resident was diagnosed with Covid-19). 7. Review of the Quarterly MDS Assessment for R#46 dated [DATE] revealed a BIMS score of 13, indicating intact cognition. A Nurse's Note dated [DATE] documented resident was tested for Covid, and test result was positive. Resident was placed on isolation per facility policy. Review of the [DATE] Physician Orders revealed an order for Covid-19 testing per state and federal guidelines dated [DATE], and an order for isolation on [DATE]. 8. Review of the Admission MDS Assessment for R#112 dated [DATE] revealed a BIMS score of nine, indicating moderate cognitive impairment. A Nurse's Note dated [DATE] documented resident had symptoms of cough. Resident was tested for COVID-19 and confirmed positive. Resident placed on isolation. Review of the [DATE] Physician Orders did not reveal an order for Covid-19 testing. 9. Review of the Quarterly MDS Assessment for R#74 dated [DATE] revealed a BIMS score of 13, indicating intact cognition. A Nurse's Note dated [DATE] documented resident tested positive for Covid-19 and isolation precautions were in place. Review of the [DATE] Physician Orders revealed there was not an order for Covid-19 testing. 10. Review of the Quarterly MDS Assessment for R#13 dated [DATE] revealed a BIMs of 15, indicating intact cognition. A Nurse's Note dated [DATE] documented the nurse spoke with resident regarding her Covid positive diagnosis and the initiation of contact and droplet isolation. Review of the Nurse's Note dated [DATE] documented resident observed with no vital signs. Respiration ceased and skin was still warm and cooling fast. The DON, Medical Doctor (MD)/Nurse Practitioner (NP), and family were notified. On [DATE] R#13 tested positive for Covid-19 but there was no documented evidence indicating why she was tested , no mention of signs or symptoms or if she had a roommate that was positive that indicated the need for her to be tested . An [DATE] Nurse's Note documented she had no acute changes and there were no other notes related to her health status until she was found deceased on [DATE]. Review of the [DATE] Physician Orders revealed there was not a physician order for Covid-19 testing. 11. Review of the Quarterly MDS Assessment for R#27 dated [DATE] revealed a BIMS of 14 indicating intact cognition. A Nurse's Note dated [DATE] documented resident complained of feeling sick in the stomach and nauseous, resident tested for Covid and was placed on isolation per protocol. Review of the [DATE] Physician Orders revealed an order for Covid-19 test as needed per State and Federal Guidelines on [DATE] with no end date, but it was not listed on the current Medication Administration Record (MAR). 12. Review of the Admission MDS Assessment for R#324 dated [DATE] revealed a BIMS score of 10, indicating moderately impaired cognition. A Nurse's Note dated [DATE] documented due to resident roommate with symptoms, resident and roommate were both tested for Covid. Resident result was positive. MD (medical doctor) made aware. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE] and there was not an order for Covid-19 testing. 13. Review of the Entry MDS Assessment for R#222 dated [DATE] revealed it was in progress and no information was documented. A Nurse's Note dated [DATE] documented resident with symptoms of Covid, was tested and result came back positive for Covid. NP (Nurse Practitioner) made aware. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There was a physician order for Covid testing on [DATE] (five days after testing positive). 14. Review of the Quarterly MDS Assessment for R#51 dated [DATE] revealed a BIMS score of 13 indicating intact cognition. A Nurse's Note dated [DATE] documented resident complained of feeling cold and general malaise. Resident swab for Covid test and was positive. MD notified. Isolation precautions in place. Review of [DATE] Physician Orders revealed an order for Covid-19 testing per state and federal regulations dated [DATE] and an order for isolation dated [DATE]. 15. Review of the Admission MDS Assessment for R#469 dated [DATE] revealed a BIMS score of three, indicating severe cognitive impairment. A Nurse's Note dated [DATE] documented resident tested positive for Covid via rapid test. Patient had one episode of vomiting before lunch. Patient stated that he just didn't feel well and had a runny nose. NP has been notified. Orders to monitor and treat symptoms if they occur. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There was no order for Covid-19 testing. 16. Review of the Admission MDS Assessment for R#323 dated [DATE] revealed a BIMS score of 12, indicating intact cognition. A Nurse's Note dated [DATE] documented resident with complaint of weakness, chills, and body aches. Covid test noted positive. Isolation precaution started. The physician was made aware. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There was no evidence of an order for Covid-19 testing. 17. Review of the Admission MDS Assessment for R#119 dated [DATE] revealed a BIMS score of 15 indicating intact cognition. A Nurse's Note dated [DATE] documented all patient care done in room per contact and droplet precautions due to Covid-19. There was no documentation in the nurse's notes of a Covid-19 test result. Review of the [DATE] Physician Orders revealed there was not an order for Covid-19 testing. 18. Review of the MDS Admission Assessment for R#10 dated [DATE] revealed a BIMS score of 12, indicating intact cognition. A Nurse's Note dated [DATE] revealed resident tested positive for Covid. NP notified. Orders received to encourage fluids. Isolation Precautions initiated. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. Review of the Nurse's Note dated [DATE] documented the resident was found unresponsive by nurse around 8:00 a.m., with respiratory distress and shortness of breath. Resident regained consciousness, 911 was called and resident was then transferred to the hospital for further evaluation and treatment. NP was made aware. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There were no orders for Covid-19 testing. 19. Review of the MDS Admission Assessment for R#58 dated [DATE] revealed a BIMS score of seven, indicating severely impaired cognition. A Nurse's Note dated [DATE] documented received orders from the physician for a one-time COVID test. Resident tested positive with symptoms of increased coughing. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There was no documented physician order for Covid-19 testing. 20. Review of the MDS Admission Assessment for R#120 dated [DATE] revealed a BIMS score of 13, indicating resident was cognitively intact. A Nurse's Note dated [DATE] documented the nurse spoke with the physician and received a one-time order for a COVID test due to resident having an increased runny nose. Resident tested positive for Covid and was put on isolation. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There was no documented physician order for Covid-19 testing. 21. Review of the MDS Admission Assessment for R#21 dated [DATE] revealed a BIMS score of 13, indicating resident was cognitively intact. A Nurse's Note dated [DATE] documented resident had tested positive for Covid, and the physician was notified. Review of the [DATE] Physician Orders revealed an order for isolation on [DATE]. There were no orders for Covid-19 testing. Even with the Covid increasing in the facility as described above, the facility was unable to demonstrate contact tracing or broad-based testing of staff for Covid-19. Review of facility documents and infection control surveillance documentation revealed from [DATE] through [DATE], there was no documented evidence of staff testing for close contacts or facility wide. Staff members QQ, RR, SS, TT, UU, VV, WW, YY were tested due to having symptoms. No other staff were tested . In addition, there was no documented evidence of resident or staff testing negative for Covid-19. Interview on [DATE] at 10:35 a.m. with Registered Nurse (RN) Infection Preventionist (IP) FF stated she was the back-up RN IP. She stated that RN GG was the full time IP. She stated on [DATE] there were 14 residents and two staff members that were positive for Covid-19. She stated the outbreak began on [DATE] when two residents (R) (R#59 and R#2) and one staff member (QQ) tested positive for Covid-19. She stated the Covid positive residents were currently in Transmission Based Precaution (TBP) rooms without roommates. She stated when a resident tested positive for Covid, the roommate was moved to an empty room on the same unit, monitored for symptoms of Covid and tested on days 1, 3, and 5. She stated if the roommate tested positive, the residents remained in the same room on TBP. Interview on [DATE] at 11:55 a.m. with the Administrator and RN IP FF confirmed the Covid-19 outbreak began on [DATE] with R#59 testing positive after exhibiting symptoms of cough, body aches and nausea. It was reported a staff member tested positive on [DATE] after exhibiting symptoms of headache, body aches, and cough, but the staff member was not at work on the day of the positive test. The Administrator stated staff identified as a close contact of a Covid positive resident or staff with symptoms of Covid were tested . The Administrator stated the facility had been in communication with the local Georgia Department of Public Health (GDPH) to report Covid positive residents and staff. Review of the e-mail documentation provided by the Administrator revealed guidance was provided on [DATE] from GDPH that included the document Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated [DATE]. Interview on [DATE] at 3:40 p.m. with the Assistant Director of Therapy stated she could not recall the last time she had had a Covid test performed. She stated she was aware that staff should report signs or symptoms of Covid to the RN IP and have a Covid test if symptomatic. Interview on [DATE] at 3:49 p.m. with Physical Therapy (PT) Assistant HH stated she had provided PT services to R#59 on [DATE] and [DATE] in the resident's room for a total of 40 minutes each day. She stated she wore full Personal Protective Equipment (PPE) consisting of gloves, gown, and face shield after learning resident tested positive Covid test on [DATE]. She stated she would provide therapy services to the residents on TBP as her last residents of each day. Interview on [DATE] at 5:55 p.m. with RN IP FF stated she did not know where to find the documentation of staff testing. She stated she was the back-up RN IP, and the full time RN IP would be in the facility on [DATE]. RN IP FF stated both positive and negative results for residents were documented on the MAR in the electronic medical record (EMR). Interview on [DATE] at 9:55 a.m. with Certified Nursing Assistant (CNA) II stated she had a Covid-19 test on [DATE] due to the facility outbreak. She confirmed she provided resident care to residents on TBP who tested positive for Covid. Interview on [DATE] at 10:07 a.m. with Housekeeping Staff JJ stated she had worked at the facility for two to three weeks. She stated her last Covid test was about one year ago, and she had not had a Covid test while employed at this facility. She stated during orientation she was educated to have a Covid test if she had symptoms of covid. She stated she did clean rooms of residents on TBP due to a positive Covid test. Interview on [DATE] at 10:11 a.m. with RN KK stated he had received recent education to have a Covid test if he had symptoms. He stated if a resident exhibited symptoms, he would notify the physician and obtain a physician's order for testing prior to testing and document the physician's order in the EMR. He further stated he would document the physician's order and document the test results in the progress notes. Interview on [DATE] at 10:21 a.m. with Licensed Practical Nurse (LPN) LL stated she had not received Covid testing education since [DATE] and the only guidance provided by the facility was to test if she was symptomatic. She stated she was aware to monitor residents for symptoms of Covid and if symptoms were present, she would notify the physician and obtain a verbal order to perform a Covid test. She stated the physicians order would be documented in the physician order section of the EMR and the Covid test results should be documented in the nurses' progress notes. Interview on [DATE] at 12:35 p.m. with LPN MM stated she was tested for Covid on [DATE] due to an exposure at the facility. She stated the facility began testing staff every three days on [DATE] due to the outbreak and she was unaware if all staff were tested . She stated prior to [DATE], the facility recommended testing only if staff had symptoms of Covid. She stated if a resident had symptoms of Covid, she would notify the physician to obtain a verbal order for a Covid test, document the order in the physicians' order tab of the EMR, and document the test results in the nurses' progress notes. Interview on [DATE] at 12:56 p.m. with CNA NN stated prior to [DATE], the facility only required Covid testing if staff was symptomatic. Interview on [DATE] at 1:00 p.m. with CNA OO stated the facility required Covid testing for symptomatic staff. Interview on [DATE] at 1:25 p.m. with RN IP GG and RN IP FF revealed the covid outbreak began on [DATE] with two residents and one staff testing positive. They stated the residents were placed on contact and droplet isolation, the physician and family were notified. They were unable to provide names of staff identified as close contacts or documentation of the testing results for staff tested . They stated if staff were in close proximity to a resident with a positive Covid test, the staff member would be tested the following day and results would be documented on a log; if the results were negative, the staff member would be tested again on days three and five and results documented on a log, but they were unable to provide any documentation of staff testing. During further interview it was revealed if a resident exhibited symptoms of covid, the nurse would notify the physician and obtain an order for a covid test and document the results in the nurse's notes, notify the IP and resident representative. They stated the nurses should monitor for symptoms of covid each shift and should document the monitoring each shift. During continued interview, it was reported there were confirmed 17 residents and six staff members to test positive for covid from [DATE] to [DATE], one resident death (R#13) and two resident hospitalization s (R#10 and R#59). They were unable to provide the number of residents or staff with a negative Covid test, and stated the staff Covid test log that contained both positive and negative test results was in the Administrator's office. Interview on [DATE] at 2:10 p.m. with the Administrator stated the only logs she could provide were resident and staff logs of Covid positive results. She verified she could not provide a Covid testing log for staff or residents with negative test results and further verified she was unsure how many staff or residents had been tested or had a negative test. Telephone interview on [DATE] at 12:15 p.m. with the Epidemiology Assistant with the local Health Department revealed on [DATE] she provided guidance to the facility that once there was one Covid positive resident, and the spread of Covid continued with contact tracing, she recommended broad-based testing. During further interview, she stated the facility had an outbreak in [DATE], and she recommended then to conduct broad-based testing when it was identified that contact trace testing did not contain the spread of Covid. Interview on [DATE] at 4:23 p.m. with the Administrator revealed her expectations were for the RN IPs to follow the facility Covid-19 Policies, CDC Guidelines, and GDPH Guidelines. She stated the RN IP attended the morning meetings to report any newly identified infectious disease. She stated her expectations was for the RN IP to keep her informed of any concerns of Covid-19. Review of the line listing dated [DATE], that included dates of [DATE], through [DATE], documented there were 28 residents and eight staff members with Covid-19 positive test results.

Based on record review, staff interviews, and review of the Registered Nurse (RN) Infection Preventionist (IP) job description, the facility failed to ensure that the person in the role of (IP) adequately assessed, developed, implemented, monitored, and managed the Infection Control and Prevention (IPCP) program, to prevent and control the spread of infections. Specifically, a Covid-19 outbreak began on August 2, 2023, and the facility's failure to implement the Centers for Disease Control (CDC) and the Georgia Department of Public Health's (GDPH) recommended practices for contact tracing or broad-based testing, resulted in 28 residents and eight staff members testing positive, three Covid-19 related hospitalization s, and one Covid related death during this outbreak of Covid-19. The census was 99. On August 15, 2023, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Executive Director, Regional Director of Clinical Services, Regional [NAME] President, and the Division Director of Clinical Services were notified on August 15, 2023, at 2:30 p.m. of the Immediate Jeopardy. The IJ situation was ongoing at the time of exit on August 17, 2023. Findings include: 1. Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated May 8, 2023, revealed when performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected units) if using a broad-based approach, regardless of vaccination status. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue for affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. 2. Review of the document titled RN Infection Preventionist (IP), revised September 2, 2022, revealed the position summary for the Registered Nurse (RN) IP is to evaluates the quality of resident care and outcomes as they relate to Healthcare Acquired Infections (HAI) and Community Acquired Infections (CAI) in accordance with all applicable laws, regulations, and {provider}standards. Collects, prepares, and analyzes HAI data. Presents infection data and makes recommendations for actions. Monitors associate compliance with infection control standards through the use of barriers and infection prevention measures. Prepares and presents education for the staff, residents, and families. Serves as a resource to all departments and personnel. Reports to the Director of Nursing. Specific Requirements: include: Serves as designated associate responsible for monitoring Public Health Advisories from local, state, and federal agencies including the CDC. Serves as the on-site IPC for Covid-19 prevention and response activities, in accordance with current CDC recommendations. Maintains a current knowledge of infection control trends, methodologies, and employee health practices. Must be knowledgeable of Infection Prevention and Control practices and procedures as well as the laws, regulations and guidelines governing nursing functions in the post-acute care facility. Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the Infection Prevention and Control Program. Essential Functions include: Must be able to plan, develop, organize, implement, and evaluate facility-wide systems for the prevention, identification, investigation, and control of infections of residents, staff, and visitors. Must be able to plan develop, organize, implement, and evaluate a high-quality infection prevention and control program (ICPC) to prevent, recognize, and control the onset and spread of infection to the extent possible. Must be able to regularly review CDC and State Health websites for Infection Control Guidance for Healthcare Professionals for current information and ensure associates and residents are updated when guidance changes. Must be able to complete on-going monitoring of HAIs and CAIs including antibiotic use, micro report, line listings, and trending of infections. Must be able to conduct outbreak tracking, symptom monitoring, investigation, and reporting in accordance with local health and state agency as required by law. Must be able to initiate follow-up on associate/resident exposure to communicable diseases. Interview on 8/12/2023 at 10:35 a.m. with RN IC FF stated she was the back-up ICP. She confirmed the Covid outbreak began when two residents tested positive for Covid on 8/2/2023. She stated contact tracing was performed and the two residents' roommates were either placed on Transmissions Based Precautions (TBP) in the same room if tested positive or moved to a single resident room on TBP if tested negative. She stated if the roommate tested negative, they would remain on TBP and be retested on days three and five. Interview on 8/14/2023 at 5:55 p.m. with RN IC FF stated she was unsure if staff or other residents were tested on [DATE] when the two residents tested positive for Covid. She stated she did not know where to find documentation of staff testing, but stated if residents were tested , it would be documented in the electronic medical record (EMR). She revealed the full-time RN IC would be in the facility on 8/15/2023. Interview on 8/15/2023 at 1:25 p.m. with RN IC GG confirmed she worked full-time as the RN IC and RN IC FF was the back-up RN IC. They confirmed the Covid outbreak began on 8/2/2023 with two residents and two staff tested positive. She stated the two residents were placed on contact and droplet isolation, and contact tracing was performed. She explained the contact tracing was done by identifying staff who worked on the units where the two residents resided and tested anyone identified as a close contact. The staff identified to have been near the two Covid residents would be tested the following day and results would be documented on a log; if the results were negative, then the staff member would be tested again on days three and five. RN IC GG was unable to provide documentation of staff names identified as close contacts or provide documentation of the testing and/or test results. Interview on 8/15/2023 at 2:10 p.m. with the Administrator stated the only documentation she could provide were resident and staff logs that contained covid positive results. She verified she could not provide a covid testing log of staff or residents that contained documentation of negative test results. Telephone interview on 8/16/2023 at 12:15 p.m. with the Epidemiology Assistant with local Health Department revealed she had been in communication with the facility to provide guidance for Covid-19 testing. She stated she was aware the facility was in Covid outbreak status because the facility made her aware of all new positive Covid cases daily. During further interview, she revealed she informed the facility that once a facility was in Covid outbreak, she recommended broad-based testing. She further stated the facility was in Covid-19 outbreak in May 2023 and she had provided guidance to the facility at that time to implement broad-based testing if contact tracing did not prevent the spread of Covid-19. Interview on 8/16/2023 at 4:23 p.m. the Administrator stated the RN IC attended the morning meetings to report any newly identified infectious disease cases. She stated her expectation was for the RN IC to follow all Covid-19 Infection Control Policies, CDC Guidelines, and the GDPH Guidelines for broad-based testing. She revealed her expectations were for the RN IC to keep her informed of all concerns related to the Infection Control program. The Director of Nursing (DON) was unavailable for interview. Cross reference F880

Based on record review, staff interviews, review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, and review of the job description for the Executive Director (ED), facility Administration failed to ensure the health and safety of the residents by not maintaining an effective Infection Prevention Control Program (IPCP) that would identify and investigate an infection outbreak to prevent or reduce the spread of Covid-19 by not following current guidelines for resident and staff testing (contact tracing or broad based testing). This failure resulted in a total of 28 residents and eight staff members tested positive for COVID-19, three COVID related hospitalization s, and one COVID related death. The census was 99. On August 15, 2023, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Executive Director, Regional Director of Clinical Services, Regional [NAME] President, and the Division Director of Clinical Services were notified on August 15, 2023, at 2:30 p.m. of the Immediate Jeopardy. The IJ situation was ongoing at the time of exit on August 17, 2023. Findings include: Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated May 8, 2023, revealed when performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected units, if using a broad-based approach, regardless of vaccination status. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue for the affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. Review of the document title Executive Director Job Description - Corporate Primary revised January 8, 2021, revealed the position summary is the Executive Director provides leadership and direction for overall facility operations to provide quality patient care in accordance with all laws, regulations, and Life Care standards. Provides oversight of key areas including clinical operations. Implements policies pertaining to patient care, caregiving, and support staff. Reports to Regional [NAME] President. Specific Requirements include knowledge of administration practices and procedures as well as the laws, regulations, and guidelines governing administrative functions in the post-acute care facility, must have the ability to implement and interpret program goals, objectives, policies, and procedures of the administration department, and must perform proficiently in all competency areas including but not limited to: daily leadership responsibilities, supervisory responsibilities, financial responsibilities, regulatory compliance, patient rights, and safety sanitation. The job description was signed by the current Administrator and dated April 25, 2022. Interview on 8/16/2023 at 12: 40 p.m. with the Admissions Department Head, stated it is concerning that the COVID positive numbers are rising. She revealed the facility has a morning meeting with the Administrator with the Infection Control Preventionist (ICP) present and concerns with each department are discussed in the meeting. She revealed the ICP discusses newly identified Covid-19 positive residents, but stated testing is not necessarily covered as it relates to contact tracing or broad-based testing. Interview on 8/16/2023 at 12:45 p.m. with the Physical Therapy Director, revealed the Administrator and ICP are present during all morning meetings. She revealed the rising number of COVID positive residents is increasing in the building, but stated there has been no discussion regarding contact tracing or broad-based testing. During continued interview, she stated facility was only testing residents and staff if they had signs and symptoms. She stated all the therapists are going in and out of resident rooms; and residents are coming to the Therapy Department if they are not COVID positive. She revealed the number of positives is continuing to rise and indicated is a concern. Interview on 8/16/2023 at 1:00 p.m. with the Minimum Data Set (MDS) Director revealed the facility has a morning meeting and confirmed that the Administrator and the ICP are part of the morning meeting. She stated they discuss isolation and the number of COVID cases, but added she cannot recall if they have discussed the testing process in the morning meetings. She stated despite the MDS staff going in and out of resident rooms to perform assessments, while maintaining six feet apart, the number of positive residents is rising. Interview on 8/16/2023 at 2:16 p.m. with the backup IC RN FF, revealed that they have conversations and meetings with the Administrator related to the current outbreak and the increase in COVID cases. They revealed there has not been discussions related to when to do contact trace testing and/or broad-based testing. The ICP revealed they speak with the local Health Department keeping them informed of the cases of COVID in the building and receive guidance that they pass along to the staff. Interview on 8/16/2023 at 2:43 p.m. with the Regional [NAME] President of Operations revealed the Administrator made him aware of number of positive Covid-19 cases in the facility, but it was never discussed what type of testing was being done, if it was contact tracing testing or broad-based testing. He revealed the Administrator is responsible for keeping up to date with both State and Federal Regulatory Guidance and that she is responsible for every department in the facility. Interview on 8/16/2023 at 2:51 p.m. with the Administrator revealed she meets daily with the Department Head staff. She revealed during the morning meeting, she and the ICP discuss residents who have tested positive, their room numbers, and what/if anything was done. The Administrator revealed the facility is following the guidance from the local Health Department related to testing, and monitoring for signs and symptoms. She stated she had discussions with the ICP regarding the COVID positive resident and staff numbers increasing, and revealed local Health Department had not recommended they do broad-based testing during the current outbreak until August 15th. During further interview, the Administrator confirmed she is responsible for all that goes on within the facility. Telephone interview on 8/15/2023 at 12:15 p.m. with the Epidemiology Assistant with the local Health Department confirmed the correspondence with the facility regarding the current outbreak that began on 8/2/2023. She revealed the facility has been doing contact tracing, but when there is more than one positive case in a facility, she recommends doing the broad-based testing. The Epidemiology Assistant revealed during the facility's previous outbreak several months ago, she informed them with more than one positive case, they need to do broad-based testing. She stated she does not know why they did not do the broad-based testing with this current outbreak. During further interview, she revealed she has spoken with the ICP a couple of times, but most of her communications have been with a Licensed Practical Nurse (LPN) who works in Human Resources. She confirmed at this time that she has not spoken with the Administrator related to the current outbreak in the facility. Cross Refer F880, F882

Based on observation, interviews, and record review, the facility failed to ensure an accurate comprehensive assessment for dental status for one of 62 sampled residents (R) (R#26). Findings included: Review of the electronic medical record (EMR) revealed that R#26 was admitted to the facility on [DATE] with diagnose including but not limited to hypertensive heart disease with heart failure, paroxysmal atrial fibrillation, dementia, bipolar disorder, diabetes, Bell's Palsy, hyperlipidemia, hypothyroidism, oral phase dysphagia, need for assistance with personal care, and anxiety disorder. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and a review of the Quarterly MDS assessment of 5/8/2023 revealed a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. Section L revealed no dental concerns (obvious or likely cavity or broken natural teeth was not checked). Continued review of the EMR revealed that there were no dental assessments from a dental provider and no dental care plan found. Observation on 8/11/2023 at 10:57 a.m. R#26 was observed in bed. She was alert with confusion and determined to be family interview candidate. Her natural teeth were observed to be decayed and broken. Phone interview on 8/12/2023 at 10:45 a.m. with family/responsible party of R#26 revealed the resident had not seen the dentist since she has been at the facility, and it had been a while before that because the resident was not mobile. She stated that the resident was admitted to the facility with broken and decaying natural teeth and stated that dental care was never discussed in the care plan meetings. She confirmed that the last care plan meeting was this week, and she was present via phone. Interview on 8/12/2023 at 11:27 a.m. with MDS Coordinator EE, stated that she has worked at the facility for six years and that she is a Registered Nurse (RN). She stated she goes to look at the residents to determine their dental status. She confirmed that she was the MDS Coordinator who evaluated R#26 for the admission MDS dated [DATE]. During an observation of the resident at this time with MDS Coordinator EE, she was observed asking R#26 if she had any pain in her mouth and if she could open her mouth so that she could see her teeth. The resident stated, I can hardly eat. They broken off at the root on the top. She opened her mouth and showed that her teeth were decayed and broken. MDS Coordinator EE confirmed that the resident had broken and decayed teeth and stated that the assessment should have reflected that so that a care plan could be created.

Based on observations, record review, and staff interviews, and review of the policy titled Wound Care Management Program, the facility failed to ensure care was provided in accordance with professional standards of practice related to maintaining skin integrity under geri-sleeves and clean geri-sleeves and boot heel protector for one resident (R) (R#23). The sample size was 63 Residents. Findings include: Review of the facility policy Wound Care Management Program reviewed 3/3/2023 revealed the skin care program is interdisciplinary and implemented using a team approach. Members of the team include the following: Nursing (nursing and Certified Nursing Assistants (CNA), Rehab, the resident, the resident's physician, and or the Medical Director, Registered Dietician, Others as deemed appropriate. Communication is vital and should occur daily at the stand-up meeting, and in Grand Grounds, then weekly at the Resident at Risk (RAR) meeting, and monthly at the Quality Assurance and Performance Improvement (QAPI) Committee meeting. Review of the clinical record for R#23 revealed she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, venous insufficiency, cellulitis of left lower extremity, dementia, anxiety, diverticulitis, urinary tract infection, hypotension, and gastro-esophageal reflux disease (GERD). Review of the 6/12/23 Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. Section G revealed resident required extensive assistance with Activities of Daily Living (ADLs). Section M revealed resident has one stage four pressure ulcer and no skin tears. Care Area Assessment (CAAs) revealed a care plan in place for pressure ulcers. Review of the care plan initiated 5/30/2023 revealed she has a break in skin integrity. Interventions to care include right hand palm protector up to eight hours per day, follow policy/procedures for treatment/prevention of skin breakdown, weekly treatment documentation to include measurement of each area of skin breakdown, and weekly skin checks. Interview on 8/12/2023 at 10:20 a.m. with the Wound Care Nurse (WCN) revealed the geri-sleeves to bilateral lower arms were to protect the resident's fragile skin. She confirmed both geri-sleeves were soiled. The WCN pulled the geri-sleeve on the left arm down toward the wrist and revealed a soiled bandage without a date or staff initials. The WCN left the room and stated she was going to get the Unit Manager (UM). Interview on 8/12/2023 at 10:30 a.m. with Unit Manager (AA), confirmed that R#23 geri-sleeves on both arms were soiled. She revealed she was not aware the resident had a bandage on the left arm. She confirmed on the inside of the left geri-sleeve there were areas of dried, brown substance that appeared to have been there a while. UM AA revealed it is her expectation when a resident has soiled Geri sleeves, they should be changed with clean Geri sleeves. She applied a clean pair of Geri sleeves at this time. She stated the staff should notify the nurse, wound care nurse, and the Unit Manager for changes in skin condition. Interview and observation on 8/12/2023 at 11:45 a.m. the WCN removed the left boot heel protector from R#23 and confirmed there was a dried brown substance on the calf side on the inside of the boot. She confirmed the resident's left calf had a healing skin tear with a dried brown substance noted on the calf area. During this time UM AA revealed when skin assessments are done and there are soiled items discovered, she expects staff to replace those items with clean items immediately and clean any soiled areas on the skin. Review of the medical record for R#23 revealed there was no documentation of a skin tear to the left arm, there were no assessments completed related to the skin tear, and no documentation that indicated anyone was made aware of the skin tear.

Based on observations, record review, interviews, and review of the facility policy titled Oxygen Administration/Safety/Storage/Maintenance, the facility failed to follow Physician Orders for one resident (R) (R#35) to change Oxygen tubing, nebulizer circuit, and to clean concentrator filter weekly for one of eight residents (R) (R#35) receiving respiratory care. Findings include: Review of the policy titled Oxygen Administration/Safety/Storage/Maintenance revised 8/2/2021, revealed the policy was that oxygen will be administered in accordance with physician orders and current standards of practice. Infection Control number 1. Change oxygen supplies weekly and when visibly soiled. Equipment should be dated when setup or changed out. 3. Store oxygen and respiratory supplies in bag labeled with residents' name when not in use. 4. Clean exterior of concentrator weekly with an Environmental Protection Agency (EPA) registered hospital disinfectant. b. External filter should be checked daily, and all dust should be removed. Filters should be washed with soap and water once each week and as needed (PRN). Dry with a towel and reinsert. Discard and replace when damaged. Review of the clinical record for R#35 revealed resident was admitted to the facility on [DATE] with diagnoses including but not limited to fractured sacrum, gastroesophageal reflux disease (GERD), congested heart failure (CHF), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), hyperlipidemia, and atrial fibrillation (A-fib). Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated no cognitive impairment. Section G revealed resident required extensive assistance of one person with care. Section O revealed resident received oxygen therapy. Review of care plan revised 6/12/2023 revealed resident has COPD and requires oxygen therapy as ordered. Interventions to care include observe and report increased difficulty breathing, increased wheezing, and oxygen via nasal cannula per physician orders. Review of August Physician Orders (PO) revealed orders dated 7/27/2023 for oxygen via nasal cannula (N/C) at three liters continuously. Further review revealed to change oxygen tubing and nebulizer circuit and clean oxygen concentrator filter with soap and water weekly on Sundays. Observation on 8/11/2023 at 2:29 p.m. oxygen concentrator flow rate was set on 3.5 liters. The filter on the concentrator was dirty with grey material. The storage bag was hanging on the concentrator and was dated 7/30/2023. Resident's nebulizer mask was lying on the bedside table, unbagged. Observation on 8/12/2023 at 9:03 a.m. revealed resident in bed with oxygen in use via N/C at 3 liters. The oxygen tubing had a date of 7/30/2023. The nebulizer mask was laying on bedside table, in protective storage bag. The date on the bag exterior of the bag was 7/30/2023; however, there was no date on the mask or tubing. The filter on the back of the concentrator was noted to have a large amount of gray fuzzy material on it. Interview on 8/12/2023 at 9:03 a.m. with R#35, revealed she wears the oxygen every day and gets a breathing treatment every night at bedtime. Interview on 8/12/2023 at 9:36 a.m. with Registered Nurse (RN) DD stated the tubing and protective bags for respiratory masks are to be changed according to the schedule on the physician's orders. She stated the oxygen filter was cleaned when the tubing was changed. She confirmed the order was for the oxygen tubing, nebulizer tubing and mask to be changed every Sunday night, and those tasks are documented on the Treatment Administration Record (TARS). RN DD observed the N/C tubing, protective storage bag, nebulizer mask and tubing, and oxygen concentrator filter and verified the respiratory equipment was dated 7/30/2023, and the filter on the concentrator had a large amount of grey fuzzy material on it. Review of the August 2023 TAR with RN DD, confirmed the 8/6/2023 section was incomplete and did not show documentation that the tubing or mask had been changed. She stated if there was no documentation, the respiratory supplies had not been changed. Interview on 8/12/2023 at 12:06 p.m. with the Regional Nurse revealed her expectations were for physician's orders to be followed and documented when tasks are completed. She stated if there was no documentation for the task being completed, it was considered to not have been done. The Regional Nurse verified the physician orders were to change oxygen tubing and nebulizer circuit and to clean the concentrator filter weekly on Sundays. She reviewed the TARS with the surveyor and verified there was no documentation of the tubing and nebulizer circuit being changed or documentation of the concentrator filter being cleaned on 8/6/2023 as scheduled. During continued interview, the Regional Nurse stated R#35 was hospitalized on [DATE] and returned to the facility on [DATE]. She stated upon the residents return to the facility, the staff should have changed the oxygen tubing, nebulizer circuit, and the concentrator filter should have been checked and cleaned.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure that a resident who entered the facility with a pressure ulcer received care and services to promote healing and that wound care staff performed complete evaluations to ensure wound treatment was appropriate for one (Resident (R) 36) of four residents reviewed for pressure ulcers. This deficient practice had the potential to compromise the healing of R36's pressure ulcers. Findings include: Review of the facility's policy titled Documentation & Assessment of Wounds revised 08/23/21 documented that Certain risk factors have been identified that increase a patient's susceptibility to develop or impair healing of pressure ulcers. Examples include - but are not limited to .under nutrition, malnutrition, and hydration deficits and directs A wound assessment/documentation is required to occur at a minimum 'weekly' .A staging tool such as the classification system developed by the National Pressure Injury Advisory panel (NPIAP), found at https://npiap.com/page/PressurelnjuryStages https://npiap.com/page/PressurelnjuryStages, should be used to describe pressure injuries .Pressure injury management calls for a multidisciplinary team approach. A nurse specially trained in wound care typically leads the team. A certified nursing assistant implements measures to prevent pressure injury formation and reports signs of skin breakdown to the nurse. A dietitian provides a dietary plan that promotes wound healing. A wound care practitioner may be needed to debride wounds. The director of nursing oversees the pressure injury program and provides staff members with performance improvement measures so that they can gauge the quality of their care and improve as needed .Complications of pressure injuries include infection, pain, [CONDITION(S)], and social isolation .Document the size, location, depth, and stage of the pressure injury. Also, note the presence or absence of necrosis, slough, tunneling, and exudate. [19] Document the condition of the wound bed (including such evidence of healing as granulation), presence of eschar, and status of the periwound area. Record the presence of signs of infection and pain. Document wound care provided and the resident's response to those interventions. Document teaching provided to (the resident and family (if applicable), their understanding of that teaching, and any need for follow-up teaching. Review of R36's Profile located in the Profile tab in the electronic medical record (EMR) revealed R36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/21 revealed the resident had a Brief Interview for Mental Status Score (BIMS) of 15 out of 15, which indicates the resident is cognitively intact and entered the facility with a Stage three unhealed pressure ulcer, unstageable ulcer(s) and one venous/arterial ulcer. Review of R 36's Care Plan located in the Care Plan tab in the EMR revealed on 12/28/21 documentation of a problem resident has pressure ulcer to coccyx and right buttock r/t [related to] Immobility with planned interventions to Assess wound healing weekly Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD [Medical Doctor]. On 12/30/21 the Care Plan was revised and included an identified problem is at risk for pressure ulcer development due to impaired bed mobility and frequent bowel incontinence with planned interventions to Clean and dry skin after each incontinent episode .Encourage good nutrition and hydration in order to promote healthier skin .Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 12/22/21 Buttock NRSG [Nursing]: Wound Observation Tool located in the Assessments tab in the EMR documented that R36 had an unstageable pressure injury of the right buttock that measured 4.0 centimeters (cm.) length (L) x 7.5 cm width (W) with no drainage, no pain and no signs of infection; however, no depth was documented and no comments were entered to describe the periwound and margins of the wound. Review of additional Buttock NRSG: Wound Observation Tool evaluations dated 12/29/21, and 01/27/22 reviewed they also did not evaluate the depth of the resident's wound. During an interview on 02/03/22 at 1:30 PM Registered Nurse (RN)10 acknowledged some of the nursing documentation did not contain depth measurements and stated they should be there even if the value is none rather than blank. Review of the 12/22/21 Coccyx NRSG: Wound Observation Tool located in the Assessments tab in the EMR documented that R 36 had a Stage 3 Pressure Ulcer of the coccyx that measured 2.0 cm. L x 3.0 cm W with epithelial tissue, no drainage, no pain, and no signs of infection; however, no depth was measured, and no comments were entered to describe the periwound and margins of the wound. Review of additional Coccyx NRSG: Wound Observation Tool evaluations dated 12/29/21, and 01/27/22 reviewed they also did not evaluate the depth or the periwound for R36's wound. During an interview on 02/03/22 at 1:38 PM, the Director of Nursing (DON) acknowledged the resident's wounds had depth based on the Wound Medical Doctor's (Wound MD) documentation and nursing staff should be documenting it along with all wound characteristics. Review of the 01/02/22 initial NUTRITION: Assessment Nutritional Data Collection by the Registered Dietician (RD) located in the Assessments tab of the EMR revealed R36 weighed 276 pounds (lb.) (obese) and the resident requested small portions of a regular diet. Resident stating, he has painful swallowing. The RD documented the 12/22/21 labs TP (Total Protein) 5.6 (normal 6.2-8.2) g/dl Alb ([MEDICATION(S)]) 2.7 (normal 3.5-5.7) g/dl; however, no prealbumin value (indicator of malnutrition) was noted. Resident is consuming less than 25% of all his meals, which does not meet his needs. Review of the Wound MD Notes provided by the Medical Record Director (MRD) revealed the following: On 01/06/22 R36's coccyx deteriorated, unstageable and measured 3.3 cm. L x 1.4 cm. W x 0.2 cm. Depth (D) with 100% necrotic tissue. Surgical debridement with [MEDICATION(S)] anesthesia was performed on the coccyx to remove necrotic tissue and establish viable margins. The Right buttock measured 7.0 cm. L x 5.0 cm. W x 0.1 cm. D with 20% necrosis, 80 % granulation. The wound MD documented My goal for this wound is healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 58 days. This estimate is made with an 80% degree of certainty. The Wound Physician recommended a dietary consultation for an abnormal BMI and to obtain a prealbumin level. Review of the EMR and hard copy chart revealed the prealbumin level was never ordered and obtained. On 01/22/22 R36's coccyx wound deteriorated and was unstageable due to necrosis and measured 3 cm. L x 1.5 cm. W x 0.2 cm. D with light serous exudate and an Unstageable right buttock that measured 9.8 cm. L x 4.5 cm. W x 0.1 cm. depth with 20 % necrotic, 80% granulation. Surgical debridement with [MEDICATION(S)] anesthesia was performed on the coccyx to remove necrotic tissue and establish viable margins. New treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] ¼ strength Dakins (antiseptic solution for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Factors complicating healing diabetes mellitus, however there was no documentation of R36's poor nutritional intake. Review of the 01/26/22 Nutrition Note located in Progress Note tab in the EMR revealed R36's plan of care was discussed at the resident at risk (RAR) meeting on 01/18/22 that revealed R36 continued to consume 25% of a mechanical soft diet and had a significant weight loss of 9.8% (27 lb.) in one month. The RD documented Resident with fluid issues and noted that the resident had no added sugar shake (supplement) BID (twice a day) and 30 ml. ProSource plus (protein supplement) TID (three times a day) which provides additional 700 calories and 63 grams of protein; there was no evaluation of his actual supplement intake. Resident continues to have painful swallowing but does not want puree texture meals tolerates his supplements. MD and resident aware of weight loss. Review of R36's Eating-ADL meal consumption from 01/05/22 to 01/26/22 located in the Tasks tab in the EMR revealed on 15 days R36 ate 0-25% for all meals, on five days R36 ate 0-50% for all meals and only ate 100% for one meal. Review of the January Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During concurrent review of wound documentation and interview on 02/03/22 at 9:46 AM, the Wound MD acknowledged that he initially evaluated the residents wound on 01/06/21 because he was on vacation and that was the earliest time he could get into the facility. The Wound MD stated that the facility staff were competent to perform wound evaluations and routinely contact him for pressure sores. Upon initial evaluation he assesses the buttock and coccyx wounds, provided treatment orders, conferred with staff, and performed debridement when required. The Wound MD stated the coccyx wound remained unchanged and the right buttock wound deteriorated since his first evaluation on 01/06/22. The Wound MD acknowledged that he did not evaluate the wound since 01/22/22 because he was on vacation last week; however, the facility wound nurse evaluated the wounds. The wound MD stated all wounds should be measured to provide a full assessment of length, width, depth, exudate, odor, periwound, and the presence/absence of pain. The Wound MD stated that the nutritional aspects of R36's wound healing should be managed by the dietician and acknowledged that R36's nutritional needs required monitoring for proper wound healing. During a concurrent record review and interview on 02/03/22 at 2:08 PM, the Registered Dietician (RD) acknowledged that upon her initial evaluation she determined the resident was not eating and his intake was suboptimal to meet his nutritional needs including wound healing and she recommended a pureed diet because the resident had painful swallowing. She added supplements and Vitamin C. The RD acknowledged the resident was monitored with weekly weights, continued to lose weight, consume 25% or less and said he had [CONDITION(S)], so it was okay. The RD stated that during that time the facility did not have formal resident at risk (RAR) meetings, described as interdisciplinary team meetings to discuss nutrition problems and other resident issues that require interdisciplinary review, because of a COVID outbreak so the interdisciplinary communication was informal. When R36 was admitted he was on a full liquid diet, the next day he was changed to regular meals, on 01/03/22 he was changed to pureed, then on 01/14/22 he did not want pureed and requested mechanical soft and Occupational Therapy (OT) changed him from an assist with meals and added a curved spoon so he could feed himself. I think I need to recommend meds [medications] to stimulate his appetite. The RD acknowledged that although his meal intake was poor, she did not obtain a prealbumin and was unaware of the recommendations made by the Wound MD. R36 informed her that in the past, he had taken ensure supplements; however, it's not a supplement the facility has, and the family stated they would bring some in. The RD confirmed she did not confer with the physician; she was trusting other professional to reach out to the physician and assumed the nurses talked to the physician(s). During an interview on 02/03/22 at 4:05 PM, R36's attending Medical Doctor (MD) 1 acknowledged that R36's wound were unavoidable due to his functional quadriparesis, and he did not want to move. In addition, MD1 acknowledged that R36 had poor meal intake with protein calorie malnutrition and despite continual nutritional counseling, the resident's nutritional status had not improved, and his wounds have not improved. MD1 acknowledged that the resident's nutritional status is important for wound healing and stated that some of the resident's weight loss was desirable due to [CONDITION(S)], then acknowledged that the small diuretic dose of [MEDICATION(S)] 20 mg administered three times a week would not totally account for the resident's significant weight loss.

Based on record review, resident and staff interviews, review of the facility's admission packet, and facility policy review, the facility failed to ensure resident wishes were correctly entered into orders to reflect the residents preferred code status, failed to ensure a copy of the resident's advance directives were obtained and filed in the medical record, and/or were provided advance directive education material as well as a written description of the facility's advance directive policy for four of six (Residents (R)19, R23, R29, R38) sampled residents reviewed for advance directives. Findings include: 1. Review of R29's Profile in the electronic medical record (EMR) under the Profile tab revealed R29 was admitted to the facility on [DATE] for rehabilitation on the skilled nursing unit. R29 signed a document on [DATE] that acknowledged R29 had an advance directive prior to admission. This document included prior to admission, I have executed an Advance Directive and will provide the facility with a copy. Review of R29's admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of R29's Social Services notes located in the EMR from [DATE] to [DATE] under the Progress Notes tab revealed no documentation of any discussion about R29's advance directives or code status. During an interview on [DATE] at 10:24 AM, the Social Services Director (SSD) stated during the admission process the admission director will obtain a copy of code status and/or advance directives or ask if they want one. The SSD stated she only gave advance directive information, which included a booklet explaining what advance directives were and the applicable state laws, at admission if the resident or family asked for it. Otherwise, it was not provided. On [DATE] at 5:03 PM during an interview, R29 stated she was a full code, but didn't want heroic measures should her health change. She stated she had an advance director and her brother, who lived locally, kept a copy for her. She went on to say no one had asked her for a copy of her advance directives or about her code status. She stated no one had provided her educational materials about advance directives when she was admitted or during her stay at the facility. During a subsequent interview on [DATE] at 8:45 AM, R29 stated she called her brother to ask if the facility had provided advance directive information or had asked him for a copy of her advance directive and he told her No. Interview on [DATE] at about 5:20 PM, the Admission Director confirmed R29 was marked as having an advance directive in her admission paperwork but stated R29 did not provide a copy of her advance directives at the time of admission. In a subsequent interview on [DATE] at 9:00 AM, the Admission Director stated during the admission process if the resident had an advance directive, she would request for a copy, but she did not document such requests. She stated if the resident or responsible party did not give her a copy, she did not follow-up on it and she wasn't sure what happened from there. She went on to say copies that are provided are scanned into the EMR and a written copy is placed on the hard chart. 2. Review of R38's Profile in the EMR under the Profile tab revealed the resident was readmitted to the facility on [DATE] for rehabilitation on the skilled nursing unit. R38's original admitted was [DATE]. Review of R38's admission MDS located in the EMR under the MDS tab with an ARD of [DATE] revealed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Review of R38's [DATE] Care Plan under the Care Plan tab located in the EMR revealed a focus area for a full code status that included an intervention of Code Status will be reviewed on a quarterly basis and PRN (as needed). During an interview on [DATE] at 9:23 AM, R38 revealed she wanted to be a Do not Resuscitate (DNR) because chest compressions would crush her bones. However, she and her daughter hadn't completed the paperwork for the code and no one at the facility had revisited the topic since she came back from her last hospitalization . She went on to say she had an advance directive. Review of R38's admission paperwork revealed R38's daughter signed a document on [DATE] that acknowledge R38 had an advance directive prior to admission. This document revealed, prior to admission, I have executed an Advance Directive and will provide the facility with a copy. Review of R38's Social Services notes dated [DATE] through [DATE] in the EMR under the Progress Notes tab revealed no documentation of any discussion about R38's advance directives, only that R38 prefers to be a Full Code. During an interview on [DATE] at 10:24 AM, the SSD stated R38 was a Full Code. She stated R38 may have an advance directive, but she was told upon admission R38 wanted to be a Full Code. The SSD admitted she hadn't revisited the topic since R38 had come back from the hospital. 3. Review of R23's Admission Record located under the Profile tab of the EMR revealed R23 was admitted to the facility on [DATE]. Review of R23's admission MDS located in the EMR under the MDS tab with an ARD of [DATE] revealed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Since this time, R23 has had a significant change and according to her quarterly MDS with an ARD of [DATE] revealed a BIMS of seven out of 15, indicating the resident was severely cognitively impaired. Upon admission, R23 provided the facility with her living will dated, [DATE], in which the resident chose a Do Not Resuscitate (DNR) status. Additionally, R23 had a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R23's EMR and hard chart had the resident listed as Full Code status. During an interview on [DATE] at 10:31 AM with the SSD, she revealed that she speaks with the family upon admission to find out the code status. The SSD further stated that she is very familiar with R23 and knows that she is a Full Code. When presented with the R23's living will and POLST, the SSD was unable to explain the discrepancy. During an interview on [DATE] at 10:36 AM with the Director of Nursing (DON), revealed if a resident is found unresponsive, she would look in the EMR for the code status. Specifically, for R23, the DON stated that according to R23's chart, the resident is a Full Code and the DON stated Cardiopulmonary resuscitation (CPR) would be started for this resident. During an interview on [DATE] at 10:42 AM with Licensed Practical Nurse (LPN) 1, she stated if R23 was found unresponsive, she would begin CPR due to R23 being listed as a full code. During an interview on [DATE] at 11:00 AM, R23's son/healthcare surrogate stated that R23 wishes to be a DNR, and he respects her wishes. He also stated he expects the facility to follow R23's preference to be a DNR. During a second interview on [DATE] at 11:13 AM with the DON, she stated R23's code status should have been updated to reflect R23's wishes and that it was the nursing department responsibility to update the record accordingly. 4. Review of R19's Admission Record located in the Profile tab in the EMR revealed R19 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Admission MDS with an ARD of [DATE] and [DATE] revealed R19 had a BIMS score of 13 that indicated the resident had intact cognitive status. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing Progress Notes in the Progress Notes tab in the EMR revealed R19 was discharged to the community on [DATE] and readmitted on [DATE] with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE], R19 stated he has been a DNR for a long time and he did not want any life sustaining treatment and that he formulated advance directives a long time ago. During an interview on [DATE] at 11:46 AM, the Admission Coordinator (AC) obtained files from the business office that documented on [DATE], per the Admission Agreement the resident had advance directives and the resident's living will was in the file, not in the resident's medical record. The Admission Coordinator acknowledged that she does not provide any education or written material regarding advance directives, the Social Services Department does that. Review of Attachment H of R19's Admission Agreement provided by the Admission Coordinator and obtained from the business office dated [DATE] documented Advance Directives Prior to admission, I have executed an Advance Directive and will provide the facility with a copy. Review of R19's Living Will dated [DATE] and obtained from the Admission Coordinator from the [DATE] admission file maintained in the business office directs that my life shall not be prolonged under the circumstances set forth below: 1. If at any time I should .have a terminal condition .become in a coma with no reasonable expectation of regaining consciousness, or .become in a persistent and vegetative state with no reasonable expectation of regaining significant cognitive function . I direct that the application of life-sustaining procedures to my body .including nourishment and hydration .be withheld and I be permitted to die; In the absence of my ability to give directions regarding the use of such life sustaining procedures, it is my intention that this living will be honored by my family and physician(s) as the final expression of my legal right to refuse medical and surgical treatment I understand I may revoke this living will at any time. There was no copy of this Living Will in the resident's EMR of hard chart. Review of Attachment H of R19's Admission Agreement provided by the Admission Coordinator and obtained from the business office dated [DATE] documented Advance Directives Prior to admission, I have executed an Advance Directive and will provide the facility with a copy. During an interview on [DATE] at 1:30 PM the SSD acknowledged that the resident was a DNR during the [DATE] admission and was a Full Code upon readmission on [DATE] based on an interview with the resident when he indicated he wanted to be a Full Code including CPR. The SSD acknowledged that if a resident or family requests information on Advance Directives she will provide them with a pamphlet titled Georgia Advance Directives; however, she does not routinely do that. During an interview on [DATE] at 2:00 PM the DON acknowledged that residents should receive written information on Advance Directives upon Admission and that Advance Directives are a part of the resident's permanent medical record. Review of the facility's policy titled Advance Directives dated [DATE] defines a Living Will - A document that specifies the kind of medical care the resident wants (or doesn't want) regarding measures to prolonged life if he or she became unable to make his/her own decisions in a terminal condition or persistent vegetative state and directs that All residents or their responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care, including the right to accept or refuse medical care, the right to accept or refuse medical or surgical treatment, organ donation requests, and the formation of advance directives upon admission. A written description of the facility's policies regarding advance directives and applicable State law is provided to the resident or resident representative. Information is provided in a manner easily understood by the resident or resident representative . If the resident has an advance directive, the social worker will request a copy of the directive so that it may become part of the medical record. Documentation of such directives are placed in the Social Services progress notes. The resident's attending physician is made aware of such, and the appropriate orders are incorporated into the resident's care plan Note: The advance directive copy should always remain in the resident's record, protected in a plastic cover, even if the chart is thinned . Each time the resident is admitted to the facility, quarterly, and when a change in condition is noted in the resident condition, the facility should review the advance directive and advance care planning information . This review should focus on if the existing advance directives and ACP [advance care plan] match the current goals of care for the resident. The social services director or designee should document this conversion in the medical record and assist as needed with updating the documents that need revision in accordance with state and federal requirements. Review of facility's policy titled, Cardiopulmonary Resuscitation (CPR) Guidelines, revised [DATE] indicated, Facilities must address how resident preferences and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Resident Admission Agreement packet revealed no advance directive education literature or a description of the facility's advance directive policy. The only reference to advance directives revealed on page 10 You or your Representative have been given written material about your right to accept or refuse medical treatments as provided by state law and has been informed of the Resident's right to formulate Advance Directives.

Based on observation, interviews, record review and policy review, the facility failed to ensure that staff followed transmission-based precautions for COVID-19 for two (Resident (R) 122 and R123) of three newly admitted residents on quarantine. In addition, the facility failed to ensure that multiuse glucometers were cleaned and disinfected according to manufacture's instructions and the facility's policy on two (Gateway 1 and Gateway 2) of four medication carts observed for glucometer cleaning and disinfection. Findings include: 1. Review of the facility's policy titled Coronavirus (COVID 19) ([CONDITION(S)]-CoV-2) revised 01/22/22 directs Ensure everyone is aware of recommended Infection Control Preventionist (IPC) practices in the facility . Post signs, or posters at the entrance and in strategic places (e.g., waiting areas, elevators) with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene) .In general, all nonvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. All recommended COVID-19 PPE [Personal Protective Equipment] should be worn during care of residents under quarantine, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Review of the Centers for Medicare and Medicaid Services (CMS) COVID-19 Nursing Home Data dated 01/16/22 located at https://data.cms.gov/covid-19/covid-19-nursing-home-data revealed that Gwinnet County, Georgia had a county positivity rate of 27.88% with a high positivity rate. During an interview on 01/31/22 at 9:26 AM, the Administrator stated that the facility had four to five COVID positive residents residing on a designated COVID Unit and several residents on quarantine who were unvaccinated new admissions, and the staff were wearing N95 masks and eye protection throughout the building. A. Review of R 122's Admission Record located in the profile tab in the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE]. During an observation on 1/31/22 at 12:50 PM Occupational Therapist (OT)8 was instructing R122 to perform arm exercises using a dowel bar in the resident's room. Outside R122's door there was Centers for Disease control and Prevention (CDC) laminated 8-12 x 11 signs that posted Contact Precautions that posted that staff must put on gloves, gown prior to entry into the room and an 8-12 x 11 laminated CDC Droplet Precautions sign that instructed staff to fully cover their eyes, nose, and mouth. OT8 was wearing a N95 mask, a face shield and gloves; however, she was not wearing a gown and was seated in a stationary chair that was three feet away from the resident who was seated in a wheelchair and not wearing a mask. Continued observation of the therapy session revealed at 12:56 PM OT8 adjusted the blanket on R122's lap. At 12:59 PM OT8 instructed the resident to stand up with a walker and contact guard assistance was provided by OT8. R122 ambulated back and forth in her room three times. At 1:03 PM R122 sat back in her wheelchair and the OTR assisted the resident to cleanse her hands with ABHR [alcohol based hand rub]. At 1:07 PM OT8 exited the room after doffing her gloves and using ABHR. During an interview on 01/31/22 at 1:08 PM, OT8 stated that R122 was on observation for 14 days and she did not have to don a gown while she was in the room because R122 did not have any signs and symptoms of COVID. OT8 stated she was last trained on PPE usage in June 2021. The surveyor asked OT8 to read the signs posted outside the R122's room and OT8 acknowledged that she should have worn a gown during the resident's therapy session after reading the signs. B. Review of R 123's Admission Record located in the profile tab in the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE]. During an observation on 01/31/22 at 12:56 PM Certified Occupational Therapy Aide (COTA) 5 went into R123's with no gloves and gown to deliver a glass to the resident. Outside R123's door there was CDC laminated 8-12 x 11 signs that posted Contact Precautions that posted that staff must put on gloves, gown prior to entry into the room and an 8-12 x 11 laminated CDC Droplet Precautions sign that instructed staff to fully cover their eyes, nose, and mouth. R123 was in bed sitting in high fowlers, was wearing oxygen and no mask and coughed several times. COTA5 left the room and used ABHR, During an interview on 01/31/22 at 12:58 PM COTA5 acknowledged that he was not wearing a gown in R123's room because there was no isolation set up outside the door and he was just bringing the resident a cup of ice. When asked if he saw the signage posted outside the resident's room, he acknowledged that the signage stated everyone that enters the room must don a gown prior to entry and doff a gown upon leaving and there were gowns available in the hall near the resident's room. 2. Review of the facility's policy titled Blood glucose Monitoring dated 08/03/21 directs Associates who obtain capillary blood glucose specimens will do so in accordance with their scope of practice and in accordance with all applicable local, state, and federal guidelines. Specimens will be collected in a manner that adheres to current standards of practice and infection control standards . This facility will utilize the Lippincott procedure. Review of the undated Lippincott Procedure provided by the Director of Nursing (DON) from the electronic link contained in the Blood Glucose Monitoring policy dated 08/03/21 directs The CDC recommends refraining from sharing blood glucose monitors among residents whenever possible. If one device must be used to monitor several residents, it must be cleaned and disinfected after every use following the manufacturer's instructions to prevent carryover of blood and infectious agents. Single-use, auto-disabling fingerstick devices should also be used to prevent the spread of bloodborne pathogens. Review of the User Instruction Manual for the Assure Prism Multi Blood Glucose Monitoring System, revised 02/2020, revealed the device manufacturer, . Validated Clorox Healthcare Bleach Germicidal Wipes .and Super Sani-cloth Germicidal Disposable Wipe [sic] for disinfecting the Assure Prism multi meter. Review of the Special Instructions for Cleaning and Decontamination Against [CONDITION(S)]-1, [CONDITION(S)] B Virus (HBV) and [CONDITION(S)] C Virus (HCV) of Surfaces/Objects Soiled with Blood/Body Fluids information on an undated back label of a canister of a PDI Super Sani-Cloth Germicidal Disposable Wipes, revealed that one wipe must first be used to thoroughly clean the surface of all blood and other body fluids. The instructions then directed, Use [a] second germicidal wipe to thoroughly wet [the] surface. Allow to remain wet two (2) minutes, let air dry. During an observation on 02/01/22 at 4:46 PM Licensed Practical Nurse (LPN) 7, who was working on the Gateway 2 Medication Cart, obtained an Assure Prism Glucometer, entered R 56's room, and obtained a blood glucose reading on R56 using the glucometer. Continued observation and interview on 02/01/22 at 5:05 PM LPN7 returned to the medication cart with the meter, acknowledged that this was the last resident of six blood glucose checks that evening, and proceeded to wipe the glucometer with one PDI Saniwipe for five seconds and placed it on the medication cart without a barrier. LPN7 acknowledged that the glucometer was dry within one minute and stated she was taught to clean the meter for one minute by the Infection Control Preventionist (ICP). She acknowledged she only used one wipe on the glucometer. B. During an observation on 02/02/22 at 11:12 AM LPN3 who was working on the Gateway1 Medication Cart, obtained an Assure Prism glucometer that still had the plastic shield on the face, entered R33's room, and obtained a blood glucose reading using the glucometer. Continued observation revealed when LPN3 was done at 02/02/22 11:21 AM, she placed the glucometer on a barrier on the cart after wiping it for 15 seconds with one PDI wipe. LPN3 acknowledged that the glucose meter was dry within one minute and she only used one wipe. Continued concurrent observation and interview on 02/02/22 at 11:23 AM revealed LPN3 used the same glucometer, entered room [ROOM NUMBER]'s room, and performed blood glucose reading using the glucometer. When LPN 3 was finished at 11:27 AM she used one PDI Saniwipe for eight seconds wiping all surfaces, placed the glucometer on a barrier and stated the glucometer needs to dry within two minutes. Continued observation revealed the glucometer was dried at 11:28 AM. LPN3 acknowledged, while looking at the glucometer that it was dry within one minute and noted that the plastic shield was still on the face of the meter. LPN3 removed the shield and wiped the meter for eight seconds with one wipe, acknowledged that this was the only glucometer on the cart for the two residents, and acknowledged that the meter again dried within one minute. LPN 3 stated it was ready for use and stored it in the medication cart. During an interview on 02/03/22 at 03:50 PM, the ICP acknowledged that the facility used the Assure Prism glucometers for multiple residents since none of the diabetic residents have any bloodborne pathogens. When questioned how staff are required to clean and disinfect the glucometers between resident use, the ICP stated for cleaning the glucose meter the facility uses purple top PDI Sani wipes and the glucometers dry within two minutes, then it's ready for use. Upon questioning the cleansing method while reading the directions for use on the product label, the ICP stated that the dry time is two minutes and acknowledged that that is the training she provided to facility staff. During an interview on 02/03/22 at 4:02 PM, the DON acknowledged that staff are supposed to follow facility policy and the manufacturer's instructions and let the glucometer remain wet for two minutes and let it air dry.

Based on record review, review of hospital records, interviews, and facility policy review, the facility failed to develop an interdisciplinary and resident-centered plan of care to manage chronic pain for one of two (R36) reviewed for pain. Findings include: Review of the facility's policy titled Pain Assessment and Management dated 07/17/21 directs All resident will be assessed for pain indicators upon admission/re-admission, quarterly, and with any change of condition .An individualized pain management care plan will be developed an initiated when pain indicators are identified .The facility will utilize the Lippincott Procedure: Pain assessment, long-term care. Review of the Lippincott Procedure dated 05/21/21 provided by the Director of Nursing revealed directs Utilize a numerical pain scale (0-10) for residents who are able to self-report their level of pain .Assess pain every shift and record on MAR [medication administration record] .When performing a pain assessment, assess the following specifics: Location .Intensity .Quality . Onset and duration .Previous treatments .Associated symptoms .Effects on mobility and function .Expectations about pain and pain relief .Objective report about resident's mood and behavior .Effect of pain on functioning and quality of life .The entire health care team is responsible for communicating a resident's report or signs of pain. Review of R36's Profile located in the Profile tab in the electronic medical record (EMR) revealed R36 was admitted to the facility on [DATE]. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/21 located in the MDS tab of the EMR revealed R36 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 that indicated the resident was cognitively intact. Review of the Physical Therapy Summary from the hospital located in the hard chart dated 12/20/21 documented R36 was diagnosed with cervical [CONDITION(S)] [compression of the spinal cord in the neck] with incomplete [CONDITION(S)] [weakness and/or loss of movement of all four limbs]. In addition, R36's goals revealed patient delayed in progression towards goals due to (decreased cognition, unresolved medical issues, and pain). Clinical Impression Pt's [patient's]progression is limited by his pain and decreased cognition. Max [maximum] A[assist] x 2 [staff] with PT [Physical Therapy] to roll in bed to either side. Very poor limb control. PT recs [recommendations] LTAC [Long Term Acute Care] consideration as the patient has many current co-morbidities that need managing including BLE [bilateral lower extremity] wounds, systemic, swelling and is being followed by HMS [health monitoring system]. He is also too low level to tolerate Acute Rehab and to low level to tolerate sub-acute rehab. He needs more medical management with rehab care in an LTAC environment. Review of the Physician Encounter SOAP[Subjective Objective Assessment Plan] note provided by the Medical Records Director (MRD) dated 12/22/21 documented Pain management: May use [MEDICATION(S)] and [MEDICATION(S)] (narcotic pain medication) and that The patient's medication was adjusted and scheduled for optimizing pain management. Review of R36's Care Plan in the Care Plan tab in the EMR documented R36 expresses pain r/t [related to] recent C3 [Cervical 3], C4 anterior cervical discectomy [neck surgery to remove damaged disc] on 12/21/21 with a goal for The resident will express pain relief with planned interventions to Evaluate the effectiveness of pain medication once given. Additional interventions added on 12/30/21 included Anticipate the resident's need for pain relief and respond immediately to any complaint of pain .Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM [Range of Motion], withdrawal or resistance to care .Observe and report to Nurse any s/sx [signs and symptoms] of non-verbal pain .Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o [complaints of] pain or discomfort .Report to nurse loss of appetite, refusal to eat and weight loss. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Orders dated 12/21/21 Assess for pain on a scale of 0-10 every shift, 0 to 3 equals mild pain, 4 to 6 equals moderate pain, and 7 to 10 equals severe pain, and [MEDICATION(S)] capsule 300 mg give one capsule by mouth three times a day for [CONDITION(S)] scheduled at 9:00 AM, 1:00 PM, and 5:00 PM. On 12/22/21 an order was received for [MEDICATION(S)] HCl tablet five mg, give one tablet by mouth every six hours as needed for severe pain. On 12/24/21 an order was received for [MEDICATION(S)] HCl table five mg, give one tablet by mouth every eight hours as needed for Muscle Spasm. On 12/27/21 an order was received for [MEDICATION(S)] HCl table five mg give one tablet by mouth every six hours for Moderate to Severe Pain. On 12/28/21 an order was received for [MEDICATION(S)] HCl table 50 mg, give one tablet by mouth four times a day for Moderate Pain (Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On 01/19/22 an order was received for [MEDICATION(S)] HCl tablet five mg, give one tablet by mouth as needed for moderate to severe pain, three times a day. On 02/02/22 an order was received for [MEDICATION(S)] HCl tablet five mg, give one tablet by mouth one time a day for pain. Review of the Physician Encounter SOAP note provided by the MRD revealed the following documentation related to pain and therapy: On 12/27/21 Muscle spasms: Initiate [MEDICATION(S)] (muscle relaxant) and schedule pain medication. Monitor for sedation or confusion. On 12/29/21 He is tolerating rehab. Although exercise is minimal. He states pain is now well controlled. Denies spasms. Pain management: Well controlled. On 12/31/21 We will review medication and give [MEDICATION(S)] without the Tylenol for pain management. The patient counseled on pain management use and risk of liver failure with current regimen and insistence of use. The patient also counseled on addictive and abuse of opioids. On 01/19/22 The patient is tolerating rehab and is more active. Describes pain as reduced. On 01/20/22 pain management: Reducing dose of [MEDICATION(S)] to three times a day. Previously, he was receiving [MEDICATION(S)] along with [MEDICATION(S)] alternating every three hours. We will monitor for pain. On 01/24/22 pain management is adequate. Review of January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nursing Progress Notes located in the Progress Notes tab in the EMR revealed that the documentation from 12/22/21 to current documented occasionally that pain meds were administered per orders and was effective; however there were no specifics documented that describe location, intensity, quality, onset and duration, previous treatments, associated symptoms, effects on mobility and function, expectations about pain and pain relief, objective report about resident's mood and behavior, and/or effect of pain on functioning and quality of life in accordance with facility policy. During a concurrent interview on 01/31/22 at 10:47 AM, R36 stated he has chronic pain due to surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Orders-Administration Note located in the Progress Notes tab in the EMR by LPN7 dated 01/31/22 12:52 noted that the muscle spasm medication as effective; however, there was no progress note stating the location, duration, exacerbating /alleviating factor and severity of the pain the resident experienced. During a concurrent record review and interview on 02/03/22 at 3:35 PM, LPN 7 stated R36 asked for a muscle relaxer not pain medication on the morning of 01/31/22 and she didn't ask him his pain level because he told me what was going on with him and when she checked the MAR, she determined his pain pill was due around 1:00 PM. LPN7 acknowledged she did not document R36's pain level, nor the source of his discomfort in the progress notes nor the exacerbating or alleviating factors because she knew what was going on with him. LPN7 stated on 01/31/22 she did go back to determine if the medication administration was effective, and it was which she documented at 12:52 PM. LPN 7 stated the source of R36's pain is his legs and his bottom and added that he is always uncomfortable with care. During an interview on 02/03/22 at 4:52 PM, the Assistant Director of Rehabilitation Services (ADOR) stated R36 is scheduled for Physical Therapy (PT) and Occupational Therapy (OT) five days per week. The ADOR stated that typically therapy staff will ask nursing staff to medicate the resident prior to therapy. The ADOR revealed the last time the resident got out of bed was 01/24/22 because his bottom was too sore to get in the wheelchair. When R36 refuses to get out of bed therapy staff work on passive range of motion exercises; however, he has refused left lower extremity exercises due to pain and positioning, so staff have provided some soft tissue massage recently. During an interview on 02/03/22 at 5:07 PM Physical Therapy Assistant (PTA)12 stated staff usually gave R36 [MEDICATION(S)] prior to therapy and his therapy was around noon, generally R36 does not want to move. PTA12 acknowledged that the resident has not participated in therapy since 01/25/22 because he is in too much pain from his bottom and legs. During an interview on 02/03/22 at 4:05 PM, R36's attending Medical Doctor (MD) 1 acknowledged that R36's pain management related to his functional [CONDITION(S)] is problematic and stated, he wants more and more narcotic pain medication and stated he abuses opiates. MD1 stated R36 remains in bed all day and nursing staff are doing the best they can. During an interview on 02/03/22 at 5:40 PM, the DON acknowledged that nursing staff are required to evaluate the resident's pain using the numeric scale and facility policy and reevaluate the effectiveness of the interventions.

Based on observation, record review, physician and staff interview, and review of the facility's Plan of Correction (POC), the facility failed to monitor and ensure that their Quality Assurance (QA) program was effective to correct the citations F 329, F 431, F 441, and F 514 that were cited during the Standard and Abbreviated survey conducted 10/31/16 through 11/4/16. The facility's Plan of Correction documents an alleged compliance date of 12/18/16. In addition, the facility failed to ensure that their QA program was effective in addressing the ongoing concerns related to pressure ulcers. The facility census was 92 residents (R). The sample size was 32 residents. On 2/10/17 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 2/10/17 at 8:00 p.m. the facility's Divisional Vice President, Executive Director, Divisional Director of Clinical, the Director of Nursing, and the Regional Vice-President were informed of the jeopardy related to: F157:J, F281:J, F282:J, F314:J. On 2/13/17 at 3:43 p.m., the Executive Director was informed that Immediate Jeopardy had been identified at F223:J and F520:K in addition to F157:J, F281:J, F282:J, F314:J that were identified on 2/10/17. The noncompliance related to the immediate jeopardy was identified to have existed on 11/14/16. The immediate jeopardy continued through 2/15/17 and was removed on 2/16/17. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on 2/14/17. The Immediate Jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [MEDICAL CONDITION]/[MEDICAL CONDITION] after having a [MEDICAL CONDITIONS]. The resident was dependent on staff for Activities of Daily Living (ADL's) and was incontinent of bowel and bladder. The weekly Skin Integrity Data Collection document indicates that the resident had an open area to the sacrum on 11/14/16, and again on 11/22/16. However, the physician was not notified of the open area and the resident did not receive any treatments or assessments from the wound care nurse, for this open area to the sacrum, until 11/24/16. In addition to this, the resident's care plan was not updated to address any skin care problems. R#1 was transferred, from the facility, to an acute care hospital, on 11/30/16. The hospital Discharge summary, for R#1, revealed that the resident was admitted to the hospital with [REDACTED]. The ulcer required debridement. The resident developed myositis with [DIAGNOSES REDACTED]. The resident suffered complications during her hospitalization , related to aspirating tube feeding, and subsequently died on [DATE]. The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 157: J - 42 C.F.R. 483.10(b)(11) Notify of changes (injury/decline/room, etc), F 223:J - 42 C.F.R. 483.13(b), 483.13(c)(1)(i) Free from abuse/involuntary seclusion, F 281:J - 42 C.F.R. 483.20(k)(3)(i) Services provided meet professional standards, F 282:J - 42 C.F.R. 483.20(k)(3)(ii) Services by qualified persons/per care plan, F 314: J - 42 C.F.R. 483.25(c) Treatment / Svcs to prevent/heal pressure sores, F 520:K - 42 C.F.R. 483.75(o)(1) QAA Committee - Members/meet quarterly/plans. Additionally, Substandard Quality of Care was identified with the requirements at F 223:J - 42 C.F.R. 483.13(b), 483.13(c)(1)(i) Free from abuse/involuntary seclusion and F 314: J - 42 C.F.R. 483.25(c) Treatment / Svcs to prevent/heal pressure sores. A Credible Allegation of Compliance (AoC) was received on 2/14/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 2/16/17. The facility remained out of compliance at a lower scope and severity as follows: and in addition to F157:D, F223:D, F281:D, F282:D, F314:D, F520:E while the facility continued management level staff oversight of notification of physician and pressure ulcer treatment to ensure the continuity of resident care. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing physician notification, initiating and implementing wound care, implementing the interventions of the residents care plans and the necessary steps to ensure continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including physician notification and care plans were current and accurate. After Supervisory review by the State Survey Agency F223:J and F281:J were placed under the appropriate tag and the scope and severity for F520:K was lowered to F520:J. The revised tags, as related to the Immediate Jeopardy are as follows: F157: J, F282: J, F314: J, F520: J. Findings include: 1. Review of the Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of the QA/Audit Forms completed by the facility staff to monitor documentation for residents receiving PRN muscle relaxants revealed that the audit form included the following: Title of the audit listed as: Audit of all residents receiving PRN muscle relaxant to ensure documentation is in place. Columns for items checked on the audit included: 1. Is the resident being given a PRN muscle relaxant? 2. Is documentation in place on the MAR indicated [REDACTED]? 3. Is the need and effect of the PRN being documented? 4. If no, was the documentation corrected within 48 hours? 5. Date. Review of these audits for the dates of 2/3/17, 2/6/17, and 2/8/17 revealed that R #558 was receiving a PRN muscle relaxant, and that the documentation and the need and effect of the medication was documented as yes. Interview on 2/10/17 at 11:13 a.m., with the Assistant Director of Nursing (ADON) HH revealed that they had had some continued problems with the documentation for the effectiveness of PRN meds, especially if the PRN was administered at the end of the shift and the next shift was responsible for documenting the effectiveness. During further interview, the ADON HH revealed that they had given additional in-services in January related to documenting the effectiveness of PRN meds as a reminder for the staff and that the documentation had gotten better, and that she felt their Plan of Correction (POC) was effective and didn't need to be revised. Interview on 2/13/17 at 12:02 p.m., with the Director of Nursing (DON) revealed that she was the one that completed the audits for the required documentation for muscle relaxants for the citations F329 and F514 that were cited during the previous Standard and Abbreviated survey. She further revealed that if she completed an audit on 2/6/17, she would have looked at the muscle relaxant documentation on the Medication Administration Record [REDACTED]. Further interview, with the DON revealed that she had missed that the effectiveness of the [MEDICATION NAME] administered to R #558 on 2/3/17 at 2:04 p.m., 2/4/17 at 8:20 a.m., and 2/4/17 at 3:00 p.m. had not been documented. During additional investigations, there were medical record documentation, accuracy, or availability concerns related to skin and wound records for five residents (R #3, #412, #435, #529, #558), on the Medication Record for two residents (#558 and #559), and on physician's orders [REDACTED].#2). Cross-refer to F 329 and F 514. 2. Observation of the medication storage room and the medication carts revealed that the facility failed to ensure expired medications were removed from three of seven medication carts. Cross-refer to F 431. 3. Observation of wound care for R #435 conducted by Licensed Practical Nurse (LPN) Wound Care Nurse DD on 2/7/17 at 9:26 a.m.; for R #412 on 2/12/17 at 9:55 a.m.; and for R #529 on 2/11/17 at 5:49 p.m., revealed several concerns were identified with her infection control practices, including not washing or sanitizing her hands or changing gloves when touching potentially contaminated surfaces; placing a resident's uncovered wound directly on the unsanitized floor; not cleaning reusable equipment (scissors) in a manner to ensure that they were sanitized; not removing contaminated wound supplies from the resident's room and disposing of them in the designated area; and by not cleaning wounds in a manner to prevent cross-contamination. Interview on 2/10/17 at 11:51 a.m., with the Registered Nurse (RN) Staff Development Coordinator (SDC) revealed that the in-services conducted for F 441 cited during the last survey focused on proper handwashing techniques only. During further interview, the SDC verified that the audits completed did not include observations of the staff performing wound care, despite being previously cited. She further revealed that she, the unit manager and the DON developed the audit tool to monitor for compliance with F441, and she felt the facility's POC for F441 was effective, as it increased the staffs' awareness of handwashing. Cross-refer to F 441. Review of Performance Improvement (PI) Meeting Sign In sheets conducted since the last survey revealed, conducted 10/31/16 through 11/4/16. that PI meetings were held on 12/14/16, 12/20/16, and 1/17/17. Interview on 2/9/17 at 12:52 p.m., with the facility's Medical Director revealed that the Department Directors developed a plan of action to address the concerns cited during the last survey, and this was discussed at the QA meeting so that everyone had input into the plan. He further revealed that as far as he knew, things had been OK related to the effectiveness of their action plans. Interview on 2/13/17 at 2:10 p.m., with the Executive Director and the QA Coordinator revealed that they felt their plan for addressing F 441 was going OK, but thought it would have been prudent for observations to have been made during wound care. She further revealed the focus of F 441 was focused on handwashing. She further revealed that they had not identified any issues with audits for F 329, F 431, and F 514, and did not feel their POC needed to be revised. 4. During pressure ulcer investigations, concerns were found for a total of four of the ten sampled residents, including not performing wound care as ordered for one resident (R #558); not performing accurate skin assessments for one resident (R #435); and not implementing measures to prevent the development of a pressure ulcer for two residents (R #7, R #435). In addition, review of R #1's clinical record revealed that open areas to her sacrum had been identified during weekly skin assessments on 11/14/16 and 11/22/16, but there was no evidence that the physician had been notified to begin treatment. Review of a Pressure Ulcer Status Record dated 11/24/16 revealed that R #1 had an unstageable wound to the sacrum measuring 4.9 by 2.5 centimeters, with 80 percent necrotic tissue. Review of nursing Progress Notes dated 11/29/16 revealed that the resident was discovered to be unresponsive by a family member, and the resident was sent to the hospital, where admission [DIAGNOSES REDACTED]. Cross-refer to F 314. Interview on 2/13/17 at 2:10 p.m., with the Executive Director (ED) revealed that the facility had been aware of issues with pressure ulcers for about seven months, and that they had QA'd the whole process of wounds from the beginning to the end. She further revealed that they would develop a plan to address an identified issue, but would then have to tweak what they were looking at, as one part of the wound program may get better, but another part may get worse. The Executive Director revealed during further interview that what they may have considered as the root cause of the problem with pressure ulcers would change, so they had to look at another part of it. She further revealed that they had not had a corporate nurse consultant since September, and part of what she did when she visited the facility was to evaluate pressure sores. She revealed that they had continued to educate staff on topics such as what they should do if they identified a skin or wound issue; treatments being completed timely; wounds being reported; and prevention of wounds. During additional interview, at this time, The ED revealed that at first the QA program was looking at bits and pieces of the problem, and the system as a whole wasn't looked at until about three months ago. She revealed that at this time they went over each area of the wound care process, what the concern was, what they needed to do to address it, how to educate staff, and how to audit for compliance. During further interview, the Executive Director revealed that the Director of Nursing (DON) and treatment nurse were auditing and presenting the information back at the next PI (Performance Improvement) meeting, and they felt that things were getting better in certain parts of the system over the last three months, and if something was not getting better, they looked at different ways to do the process and reeducated the staff. She further revealed that she was not aware of the problem regarding identification and timeliness of treatment of [REDACTED].#1, but she was only aware that a family member had filed a grievance that she had not been notified of the wound. She further revealed that based on the investigation completed by the DON and the treatment nurse of the grievance placed by the family members of R#1, the investigation that was completed did not include looking at the resident's care prior to the identification of the wound, and therefore the investigation did not identify the delay in the treatment for [REDACTED]. During continued interview with the Executive Director, at this time, she revealed that they had not identified an issue of staff not reporting new areas of skin breakdown. She further revealed that the QA program did not identify a complete process failure with wounds, just a piece of it here and there that would get better after they addressed the issue, such as with care planning. Interview on 2/14/17 at 9:57 a.m., with the facility's Medical Director revealed that pressure ulcers were discussed at every QA meeting, and that they discussed all acquired wounds and what should be done to address the individual resident. He further revealed that they discussed how they could prevent future wounds, but did not recall if the number of acquired wounds had been trended to reveal if there had been improvement. The facility implemented the following actions to remove the Immediate Jeopardy Patients Impacted: The Regional Vice President and Executive Director will educate the Performance Improvement (Pl) Committee on the facility Performance Improvement Program Policy, which includes the committee's responsibility to monitor, evaluate and ensure appropriate follow-up action. The Pl Committee consists of Executive Director, Director of Nursing, Medical Director, Social Service Director, Director of Maintenance, Business Office Manager, Environmental Services Director, Director of Activities, Director of Admissions, Director of Food and Nutrition Services, Health Information Management Director, Staff Development Coordinator, Registered Dietician, Business Development Director, RN Case Manager, and Director of Rehab Service. Will be completed by February 14, 2017. Systemic Changes: The facility will be increasing the frequency of the Performance Improvement Committee meeting from monthly to bi-monthly for 3 months, and then monthly for one year. Monitoring: The Director of Nursing will bring and present the monitoring findings from the regulatory deficiencies cited to the Pl Committee. The Committee will utilize the findings to evaluate the effectiveness of the Pl plans. Upon identification of non-compliance, the Director of Nursing, Staff Development Coordinator, Unit Managers and/or corporate nurse will follow-up with the licensed nurse and/or Certified Nursing Assistant and provide additional education. The Executive Director will be responsible for validating appropriate plan revisions are made based upon the monitoring findings and the committee's recommendations. The Regional Vice President will review the Pl Committee meetings minutes, plan evaluations and updates for appropriateness bi-monthly for 3 months. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: Patients Impacted: Interview on 2/16/17 at 10:51 a.m., with the Executive Director she revealed that they pulled their corporate policy for PI, and all committee members were educated on PI, including the Medical Director, on 2/13/17 and 2/14/17. Interview on 2/16/17 at 12:22 p.m., with the Regional Vice President he revealed that he trained the Executive Director and the PI committee members (mentioned in the AOC) on the PI process on 2/13/17. He further revealed that all of them were told that they had the authority to ask for any of the PI plans to address any concerns they may have, and were told to not bottleneck information so that it did not reach the PI committee. He further revealed that they were going to bring audits to the PI meetings to ensure they were being done, and make changes to their plan as needed. During further interview, he revealed that he would be reviewing the PI meeting notes if he was not physically able to be at the meeting, and would have input into any corrections that may need to be made. Review of In-service Sign-in Sheets revealed the presenters were the Regional Vice President and the Executive Director, and the topic was Performance Improvement Program Policy. Further review of these in service sheets revealed that 19 staff including the DON and Executive Director attended on 2/13/17, and two staff and the Medical Director attended on 2/14/17. Review of the PI Committee members listed on the AOC revealed that all of them attended one of the two in-services. Systemic Changes: Review of In-service Sign-in Sheets and/or Performance Improvement Meeting Sign In sheets revealed that some or all of the PI Committee met on 2/12/17, 2/13/17, and 2/14/17. Interview on 2/14/17 at 9:57 a.m., with the Medical Director he revealed that he attended a QA meeting on 2/12/17, where pressure ulcers were discussed, and he was asked for his input in developing the plan of correction to address the concerns. Interview on 2/16/17 at 10:51 a.m., with the Executive Director she revealed that they had PI meetings on 2/12/17 and 2/14/17, and that the goal for increasing the frequency of the PI meetings was to ensure everyone was informed and had input to any changes that needed to be made. She further revealed that the meetings would be comprised of the same committee members that attend the monthly meetings, and that they would have ad hoc meetings as needed. Interview on 2/16/17 at 12:01 p.m., with the DON she revealed that they have had a couple of PI meetings since the IJ was called, and everyone had input into developing the AOC. Monitoring: Interview on 2/16/17 at 12:01 p.m., with the DON she revealed that the monitoring findings mentioned in the AOC were from audits and observations made from deficiencies cited during the last survey, as well as those cited from the IJ. She further revealed that the unit managers would bring the audit information to her and they would review them, and then present the information in PI. She further revealed that they developed an AOC book that contained everything they had done, such as Braden's, skin assessments, et cetera, and presented that at PI. The DON revealed that they implemented a new process for the weekly skin audits to make them more accessible to the staff, and would be reporting back to PI about if this new process had been successful. Interview on 2/16/17 at 12:01 p.m., with the DON she revealed that they had not yet identified any non-compliance after implementation of components of the AOC, and that the unit managers would be responsible for following up on things like compliance with skin assessments, and that she would be following up to ensure the unit managers re-educated staff as needed. She further revealed that if non-compliance was found, any committee member listed on the AOC could do the follow-up education, but that she wanted to be a part of the process to verify that it was done. The DON provided documentation that she and the Executive Director had reviewed the results of the Daily Grand Round Meetings, where resident condition and review of things like completion of skin assessments were discussed, and that this new process seemed to be working well. Interview on 2/16/17 at 10:51 a.m., with the Executive Director she revealed that she would be responsible for ensuring that everything that they said they would do in the AOC was being implemented, and revise the plan as needed. She further revealed that the audit results were brought to her weekly, so that she could ensure everything was in place, and have an ad hoc PI meeting if necessary to correct something. Interview on 2/16/17 at 12:22 p.m., with the Regional Vice President he revealed that he would be reviewing the PI meeting notes if he was not physically able to be at the meeting, and would have input into any corrections that may need to be made. Cross refer F157, F282, F314

Based on observation, medical record review, resident and staff interviews, the facility's policy titled Pressure Ulcer Prevention (revised [DATE]), policy titled treatment of [REDACTED]., Screenings, and Assessments policy and procedure the facility failed to implement measures to prevent development of a pressure ulcer and failed to provide timely treatment for [REDACTED].#1. In addition to this, the facility failed to perform wound care as ordered for one resident (R) (#558); failed to perform accurate skin assessments for one resident (R #435); and failed to implement measures to prevent the development of a pressure ulcer for two residents (R #7, R #435). Ten residents were reviewed for pressure ulcers, and the sample size was 32 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 8:00 p.m. the facility's Divisional Vice President, Executive Director, Divisional Director of Clinical, the Director of Nursing, and the Regional Vice-President were informed of the jeopardy related to: F157:J, F281:J, F282:J, F314:J. On [DATE] at 3:43 p.m., the Executive Director was informed that Immediate Jeopardy had been identified at F223:J and F520:K in addition to F157:J, F281:J, F282:J, F314:J that were identified on [DATE]. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The Immediate Jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [MEDICAL CONDITION]/[MEDICAL CONDITION] after having a [MEDICAL CONDITIONS]. The resident was dependent on staff for Activities of Daily Living (ADL's) and was incontinent of bowel and bladder. The weekly Skin Integrity Data Collection document indicates that the resident had an open area to the sacrum on [DATE], and again on [DATE]. However, the physician was not notified of the open area and the resident did not receive any treatments or assessments from the wound care nurse, for this open area to the sacrum, until [DATE]. In addition to this, the resident's care plan was not updated to address any skin care problems. R#1 was transferred, from the facility, to an acute care hospital, on [DATE]. The hospital Discharge summary, for R#1, revealed that the resident was admitted to the hospital with [REDACTED]. The ulcer required debridement. The resident developed myositis with [DIAGNOSES REDACTED]. The resident suffered complications during her hospitalization , related to aspirating tube feeding, and subsequently died on [DATE]. The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 157: J - 42 C.F.R. 483.10(b)(11) Notify of changes (injury/decline/room, etc), F 223:J - 42 C.F.R. 483.13(b), 483.13(c)(1)(i) Free from abuse/involuntary seclusion, F 281:J - 42 C.F.R. 483.20(k)(3)(i) Services provided meet professional standards, F 282:J - 42 C.F.R. 483.20(k)(3)(ii) Services by qualified persons/per care plan, F 314: J - 42 C.F.R. 483.25(c) Treatment / Svcs to prevent/heal pressure sores, F 520:K - 42 C.F.R. 483.75(o)(1) QAA Committee - Members/meet quarterly/plans. Additionally, Substandard Quality of Care was identified with the requirements at F 223:J - 42 C.F.R. 483.13(b), 483.13(c)(1)(i) Free from abuse/involuntary seclusion and F 314: J - 42 C.F.R. 483.25(c) Treatment / Svcs to prevent/heal pressure sores. A Credible Allegation of Compliance (AoC) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity as follows: and in addition to F157:D, F223:D, F281:D, F282:D, F314:D, F520:E while the facility continued management level staff oversight of notification of physician and pressure ulcer treatment to ensure the continuity of resident care. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing physician notification, initiating and implementing wound care, implementing the interventions of the residents care plans and the necessary steps to ensure continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including physician notification and care plans were current and accurate. After Supervisory review by the State Survey Agency F223:J and F281:J were placed under the appropriate tag and the scope and severity for F520:K was lowered to F520:J. The revised tags, as related to the Immediate Jeopardy are as follows: F157: J, F282: J, F314: J, F520: J. Findings include: Review of the facility's policy titled Pressure Ulcer Prevention (revised [DATE]), in pertinent part, documents the following measures should be taken to protect the patient against the adverse effects of external mechanical forces such as pressure, friction and shear are implemented in the plan of care. Measures included: a) Reposition at least every ,[DATE] hours as consistent with overall patient goal and medical condition. b) Utilize positioning devices to keep bony prominences from direct contact. c) Ensure proper body alignment when side-lying h) When positioned in a wheelchair, the patient is to be placed on a pressure reduction device and repositioned. (Donut-type devices are not used.) Heel protection/suspension should be implemented while the patient is in bed. The Pressure Ulcer Prevention policy also documents When skin breakdown occurs, it requires attention and a change in the plan of care to appropriately treat the patient. Review of the facility's policy titled, Evaluations, Screenings, and Assessments and procedure in pertinent included: Appropriate disciplines are notified if the patient either has skin breakdown or is at risk for the development of skin breakdown. The Nursing department coordinates the response to patient need (in the area of skin integrity) by the following means: With implementing appropriate preventive measures when the patient has been identified as being at risk. Review of the facility's policy titled, Heel Protectors policy and procedure revealed the purpose was: To provide comfort and protection of skin. To prevent skin irritation and pressure. To prevent break in skin integrity. Review of the facility policy titled treatment of [REDACTED]. It is the intent of this center to provide a comprehensive treatment plan designated to meet the individual patient's goal utilizing a multidisciplinary approach. It is the intent of this center that a patient having a wound receives necessary medical treatment to prevent infection, deterioration or development of wounds in keeping with the patient's medical condition. 1. Medical record review revealed that R # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Sheet ((MDS) dated [DATE] documented that R#1 had a Brief Interview for Mental Status score of 13, indicating that the resident was cognitively intact. This MDS also documented that the resident was at risk for developing pressure ulcers but had no unhealed pressure ulcers. Review of Section M of the resident Admission MDS dated [DATE] M1040 - H - documents that the resident was documented to have Moisture Associated Skin Damage (MASD). A review of the comprehensive care plan, for R#1, titled Risk for Pressure Ulcers with an onset date of [DATE] indicated that the resident was at risk for developing a pressure ulcer related to decreased mobility and incontinence with a documented goal that the resident will have intact skin through the next review date. Interventions listed on the care plan, in pertinent part, included: Report changes in skin status to physician. (Licensed nurse) Review of the comprehensive care plan implemented on [DATE] and titled Impaired Skin Integrity, for R#1, documented that the Resident is at risk for skin impairment, incontinence, weakness,(status [REDACTED]. The goal documented the resident's disruption of skin surface (no documentation of what the disruption of skin surface was) will remain free from infection and show evidence of healing by the next review date. Interventions were documented as follows: Complete Braden Scale Risk Assessment quarterly and as needed. (Licensed nurse) Complete weekly skin assessment. (Licensed Nurse) Report changes in skin condition to physician. (Licensed nurse. There were no additional interventions noted. Medical record review revealed a document titled Weekly Skin Integrity Data Collection form dated [DATE], Licensed Practical Nurse (LPN) NN documented, R#1's skin was dry and there was an open area on the resident's sacrum. Review of a Weekly Skin Integrity data Collection form, for R#1, dated [DATE], Licensed Practical Nurse (LPN) CC documents an open area on the resident's sacrum. Review of the medical record for R#1 revealed there was not any evidence of any documentation that the physician was notified of the opened area and there was not any evidence that treatment orders were obtained and there was not any evidence of any documentation that R#1 received any treatment for [REDACTED]. Further medical record review of the Pressure Ulcer Status Record dated [DATE], documented by LPN AA revealed that on [DATE], R# 1 had an unstageable wound to the sacrum measuring 4.9 centimeters (cm) x 2.5 cm with eighty percent necrotic tissue. Interview on [DATE] at 9:45 a.m., with LPN MM (Unit Manager) revealed that the weekly skin assessments are completed by nursing, and if a nurse documents a possible wound or area of pressure, then that nurse is responsible for notifying the physician and implementing treatment. LPN MM Unit Manager further revealed that the nurse is also responsible for notifying the resident's responsible party as well. Interview on [DATE] at 9:50 a.m. with LPN NN, and review of the Weekly Skin Integrity Data Collection sheet, revealed that if the wound was new, she would have documented it as new. She revealed that if she was aware a resident had a new wound, she would have contacted the physician and notified the family Interview and record review on [DATE] at 10:30 a.m., with Registered Nurse (RN) HH, Assistant Director of Nursing (ADON) revealed that there was not any evidence that the physician was notified, and there was not any evidence of any documentation that the open area to the residents sacrum that was first observed on [DATE] was assessed or treatment orders obtained prior to [DATE]. Interview on [DATE] at 2:35 p.m., with LPN CC review of the Weekly Skin Integrity Data Collection Sheet with LPN CC revealed that she completed the assessment, for R#1, on [DATE] but that she could not explain why wound care was not ordered for R#1 until [DATE]. Interview on [DATE] at 3:55 p.m., with the Director of Nursing (DON) revealed that the care plans for R#1 did not have the interventions implemented as indicated in the facility's policy titled, Pressure Ulcer Prevention and the facility's policy titled, treatment of [REDACTED]. Interview on [DATE] at 8:55 a.m., with the resident's physician UU revealed that she expected to be notified promptly if a resident developed a wound. Dr. UU could not recall when she was notified regarding this resident's wound. 2. Review of the clinical record, for R#558, revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), for R#558, dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 (a score between 13 and 15 indicated no cognitive deficits), this same MDS documents that R#558 required total dependence for bed mobility and transfers, and had three Stage II pressure ulcers. Review of a care plan dated [DATE] revealed that R#558 had a pressure ulcer to the right heel, and the care plan was updated to include a Stage II wound to the left upper and lower buttock, and a Stage II to the right buttock. Review of the Braden Scale, for R#558, dated [DATE] revealed a score of 14 (a score of ,[DATE] indicated moderate risk for skin breakdown). Review of Physician Orders dated [DATE] included: Tx (treatment) to right heel: Clean with normal saline, apply mupirocin ointment (an antibiotic) 2%, and cover with dry dressing every other day and PRN (as needed). Skin prep left heel callous (sic) X 14 days daily. Observation on [DATE] at 2:37 p.m., of wound care, for R#558, by Licensed Practical Nurse (LPN) Treatment Nurse DD revealed that a dressing was observed to the resident's right foot and heel that was observed to be dated [DATE]. This date was verified during interview with LPN DD at this same time, and verified again after the residents wound care was completed. Review of the February 2017 Treatment Administration Record (TAR) for R#558 revealed that there was not any evidence of any documentation that the resident received the seventh and eighth treatments for the skin prep to the left heel on [DATE] or [DATE]. Further review of the February 2017 TAR revealed that the treatment to the right heel was documented as being provided on [DATE], despite the nurse and surveyor observation on [DATE], that the dressing in place to the resident's right foot was dated [DATE]. (Which was verified with LPN DD during the wound care observation on [DATE]). This revealed that the dressing to the resident's right heel had not been changed for four days, instead of every other day as the physician ordered. Interview on [DATE] at 2:05 p.m., with LPN DD revealed that she had been the treatment nurse since December, and up until last week there had been another treatment nurse. LPN DD further revealed that she had been able to keep up with her workload since then as extra staff had been brought in to help her. During further interview, LPN DD revealed that she received training from the Assistant Director of Nursing (ADON) on how to provide treatments by observing the ADON for a few days, but that she had never received any formal training. Interview on [DATE] at 12:05 p.m., with the Director of Nursing (DON) revealed that there was not any documentation on the February 2017 TAR, for R#558, that he had received treatment as ordered to the residents left heel on [DATE] and [DATE]. During further interview, the DON verified that treatment to the right heel had been documented as being provided on [DATE] on the February 2017 TAR. Interview on [DATE] at 2:10 p.m., with the Executive Director (ED) revealed that as of [DATE] they had two treatment nurses, but one of them was suspended last week, and LPN DD resigned last night. The ED further revealed that the nurse that was suspended had extensive wound care experience prior to coming to work at the facility, but that LPN DD was new as a treatment nurse and was being trained by the other (suspended) nurse, but the Executive Director didn't know the details of what training LPN DD had received other than observing the other (suspended) treatment nurse. Review of the employee file, for LPN DD revealed that there was not any evidence of any documentation of any training or certification on skin or wound care. This was verified during interview with the Executive Director on [DATE] at 10:51 a.m., who revealed that they had future plans to send LPN DD for training. 3. Review of the clinical record for R#435 revealed that she was readmitted to the facility on [DATE] after surgical repair of the right femur. Further review of the clinical record revealed that she had [DIAGNOSES REDACTED]. Review of the Quarterly MDS, for R#435, dated [DATE] revealed that she had a BIMS score of 13, however, the resident was not able to answer the screening questions that was asked. Further review of this MDS revealed that R#435 required extensive assist for bed mobility and transfers, walking in the room happened only once or twice, and walking in the hall did not occur during the assessment period. R #435 was assessed on this MDS as being at risk for pressure ulcers, but she had no unhealed pressure ulcers. Review of the Interim Care Plan, for R#435, dated [DATE] revealed that she had a break in skin integrity related to a surgical wound, and interventions included to reposition q (every) 2 hours in bed and chair, weekly skin checks, and a therapy consult. Review of the Braden Scale, for R#435, dated [DATE] (on readmission to the facility) revealed a score of 13 (a score of ,[DATE] indicated moderate risk for skin breakdown). Review of the Initial Data Collection Tool/Nursing Service admission assessment, for R#435, dated [DATE] documented there was no indication of a skin concern to the right heel. Review of the Weekly Skin Integrity Data Collection forms, for R#435, revealed that there was not any skin breakdown identified on [DATE] or on [DATE]. Review of the CNA's (Certified Nursing Assistant) Skin Care Alert forms (forms completed to alert the nurse of any skin concerns when a shower or bath was given) revealed that no skin irregularities were observed on [DATE], on [DATE], or [DATE]. However, review of a nursing Progress Notes dated [DATE] documented that upon assessment R #435 was observed to have a light purple DTI to the right heel. Review of the Physician's Orders, for R#435, dated [DATE] revealed an order for [REDACTED]. Wound care observation on [DATE] at 9:26 a.m., with LPN DD R #435 was observed to have an area of black and dark pink skin to her right heel Interview on [DATE] at 3:55 p.m., with the DON revealed that the Weekly Skin Integrity Data Collection form, for R#435, dated [DATE] did not document a wound to the resident's right heel, despite documentation of treatment in progress for a DTI to the right heel per the Pressure Ulcer Status Record on [DATE], [DATE], and [DATE], and she did not know why the nurse did not identify the wound. Further interview, at this time, with the DON revealed that she thought that heel protectors had been implemented, that this could be in the care plan, and that the CNAs should know to do this. During observation in R #435's room with the DON, at this time, the DON was unable to find any heel protectors in the resident's room. During further observation in the resident's closet, a Care Directive form, for R#435, was posted which the DON revealed was to let the CNAs know what a resident's care needs were. Review of R #435's Care Directive form, for R#435, dated [DATE] revealed there was not any documentation related to pressure reduction measures documented on the form. Interview on [DATE] at 11:50 a.m., with the RN Director of Clinical Services QQ revealed that the staff nurses were not doing a good, thorough job in completing the skin assessments, and the unit managers were not following up on the skin assessments. She further revealed that there were no systems and processes in place to ensure that things like skin assessments and wounds were being overseen. Interview on [DATE] at 4:55 p.m., with LPN Wound Care Nurse OO revealed that approaches to offload R #435's heels could have been added as an intervention on the interim care plan. Interview on [DATE] at 11:54 a.m., with the DON revealed that the facility found that the problem they were having with pressure ulcers was related to the charge nurses not completing the weekly skin assessments accurately. Interview on [DATE] at 2:03 p.m., with the DON revealed that when they did the 100% skin sweep (a head to toe skin assessment of all the residents in the facility), they identified three residents with previously unidentified wounds. Review of a facility-provided list of residents discovered with these new wounds included R #7, who was observed to have a blister to her right heel. 4. Review of the clinical record, for R#7, revealed that she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS, for R#7, dated [DATE] revealed that she had a BIMS score of 13, needed extensive assist for bed mobility and transfers, walking in the room and corridor did not occur, she was at risk for developing pressure ulcers but had no unhealed pressure ulcers. Review of a care plan dated [DATE] for pressure ulcer to right heel/ankle relating to immobility included approaches to float heels when in bed as resident allows, and to minimize pressure over boney (sic) prominences. Review of the Initial Data Collection Tool/Nursing Service, admission assessment, for R#7, dated [DATE] documented that the resident's skin was intact. Review of nursing Progress Notes, for R#7, dated [DATE] documented skin otherwise intact. Review of a Braden Scale, for R#7, completed on [DATE] revealed a score of 18 (indicating the resident was at risk for pressure ulcer development). Review of a Weekly Skin Integrity Data Collection form, for R#7, dated [DATE] documented skin intact, redness, but there was not any documentation on this form that specified where the redness was located. Further review of these skin assessments dated [DATE], for R#7, revealed redness, but again the skin assessments failed to document the location of the redness. Review of the skin assessment completed on [DATE], for R#7, documented the residents skin was intact. Review of the Weekly Skin Integrity Data Collection, for R#7, dated [DATE] (when the skin sweep was completed) revealed that the resident [MEDICAL CONDITION] of her feet; left toenail into next toe; old scar to the right lower abdomen; bandage to right abdomen; third left toe was discolored; and right ankle surrounding skin discolored with bruise and blister. Review of a Physician's Order, for R#7, dated [DATE] documented the following: to clean right outer ankle/heel blister with N/S (normal saline) pat dry and apply dry dressing every 3 days and PRN (as needed) until resolved. Review of the Pressure Ulcer Status Record, for R#7, dated [DATE] documented that the resident had an unstageable wound to the right ankle with the appearance of a blood-filled blister, measured as 0.8 centimeters (cm) by 0.4 cm. Interview on [DATE] at 8:50 a.m., with R #7 revealed that she recently had a stroke, and was paralyzed on her right side. She further revealed that during the weekend, two staff came in and completed a skin assessment on her, and when they pressed on her right ankle the area was very tender to the touch, and the two staff members applied a dressing to it. The resident further revealed that she asked the staff to put a pillow under her feet to keep her heels elevated off the bed, as both of her feet were sore. Observation at this time, with the resident's permission, revealed a pillow was observed under the resident's mid-calf to her knees, but her feet were observed to be directly on the mattress. Further observation, at this time, revealed that the resident's right leg was turned outward so that her right lateral right ankle was resting directly on the mattress. Further interview at this time, the resident revealed that because of her stroke, she really did not have any control over her right leg. Interview on [DATE] at 12:45 p.m., with the DON revealed that they considered a resident to be at risk for skin breakdown if their Braden score was between 10 and 12. She further revealed that they would consider use of heel protectors and/or float a resident's heels if a resident was bedbound or couldn't move their legs, and that any nurse could implement heel protectors. Interview on [DATE] at 1:20 p.m., with LPN Wound Care Nurse OO revealed that they encouraged the CNAs to offload residents' feet at night when they're in bed. Observation on [DATE] at 9:30 a.m., revealed R #7 was observed in bed with a pillow under her knee and upper part of her lower legs, but her feet were observed on the mattress. Further observation, at this time, revealed that the resident's right foot was turned outward so that the right lateral ankle was resting directly on the mattress. Interview on [DATE] at 9:21 a.m., with R #7 revealed that her right ankle was very tender last night, and that she had to request pain medicine for it. Observation, at this time, revealed that the resident's right foot was rotated outward and that her foot and lower leg were positioned on a flat pillow, but her foot was not extended over the end of the pillow and her right lateral ankle was positioned directly on the surface of the pillow. This was verified during interview with LPN OO at this same time, who revealed that the pillow should have been folded in half to raise the resident's foot off the end of the pillow so that it would not be touching the pillow or the mattress. Wound care observation on [DATE] at 6:45 p.m. with Registered Nurse (RN) HH, for R#7, revealed a dark-red area on the resident's right lateral ankle with redness surrounding the area. Interview with LPN OO at this time, revealed that the area was fluctuant when she palpated (touched it), and that's how she knew it was a blister. LPN OO further revealed that the blister was directly over a pressure point, and that the area should be offloaded. LPN OO further revealed that the staff may need to be educated on the proper way to float heels, if the pillow had been observed so far up under the resident's legs that the resident's feet were not off the mattress. The facility implemented the following actions to remove the Immediate Jeopardy Patients Impacted: The facility has changed treatment nurses as of February 13, 2017. The Assistant Director of Nursing has assumed the role of facility treatment nurse until a permanent one has been hired and trained. The Assistant Director of Nursing will be provided training and given assistance by a WTA certified wound nurse x 4 weeks. All patients have had skin assessments and Braden scales completed by licensed nursing leadership team which includes the Director of Nursing, Assistant Director of Nursing, Unit Managers, Treatment Nurse, MDS Coordinator, ,[DATE] Supervisor, Restorative Nurse, LPN Business Development Director and LPN Medical Records Director. This will be completed February 14, 2017. All patients identified with pressure ulcers will have physician notification and any new orders obtained will be implemented by a licensed nurse as ordered by the physician. This will be completed February 14, 2017. All patients identified with pressure ulcers will have their patient representative notified of pressure ulcer condition change and plan of care by a facility licensed nurse. This will be completed February 14, 2017. All patients identified with pressure ulcers will have their care plans updated by February 14, 2017. Systemic Changes: All licensed nurses will receive in-service training on the following by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Managers and/or corporate nurse. This will be completed by February 14, 2017. Performing and documenting patient skin assessments Physician and patient representative notification of skin condition changes Implementing and documenting treatment orders/TARS Pressure ulcer care planning All certified nursing assistants have received in-service training on the following by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Managers and/or corporate nurses. This will be completed by February 14, 2017. Pressure ulcer prevention Reporting changes in skin condition to nursing supervisor 90% of licensed nurses have received the above training. 83.6% of Certified Nursing Assistants have received the above training. Any licensed nurse or Certified Nursing Assistant that do not have the in¿ service training by February 14, 2017 February 14, 2017, will receive this in-service training upon their return to work. These associates will not be able to provide direct patient care until completion of the in-service. Monitoring: During daily clinical meeting/rounds, nursing leadership will review daily scheduled skin assessments for completion, new areas identified, physician and patient representative notification and pressure ulcers care plans are completed. Upon identification of non-compliance, the Director of Nursing, Staff Development Coordinator, Unit Managers and/or corporate nurse will follow-up with the licensed nurse and provide additional education. The Director of Nursing will review the above findings with the Executive Director weekly for any additional follow-up. This will occur weekly for 3 weeks, and monthly for one year. The Director of Nursing will bring and present the monitoring findings from the regulatory deficiencies cited to the Pl Committee. The Committee will utilize the findings to evaluate the effectiveness of the Pl plans. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: Patients Impacted: Interview on [DATE] at 11:50 a.m., with the Registered Nurse (RN) Division Director of Clinical Services QQ she revealed that Licensed Practical Nurse (LPN) Treatment Nurse DD had resigned, and that LPN Treatment Nurse OO was brought in from another facility over the weekend (of [DATE]) to assist and train the Assistant Director of Nursing (ADON), who was going to temporarily do treatments. RN QQ further revealed that the facility was actively seeking a replacement for the treatment nurse position, and that LPN OO would be in the facility for at least four weeks. Review of the Allegation Of Compliance (AOC) notebook revealed that it Included a copy of LPN OO's Certified Wound Care Associate card with an expiration date of [DATE], as well as Certificate of Completions on [DATE] for an Ostomy Workshop (7 contact hours), and on [DATE] for Current Concepts in Skin Care and Wound Management (24.5 contact hours). Further review of the AOC notebook revealed that there was a Separation Notice for LPN DD effective [DATE]. Further review revealed a signed statement that as of [DATE] the facility had changed treatment nurses, and that the ADON would assume this responsibility until a permanent nurse was hired. Interview on [DATE] at 4:12 p.m., with LPN CWCA (Certified Wound Care Associate) OO she revealed that she had been asked to train the ADON and make sure she understood th

Based on observation, medical record review, resident and staff interview, the facility failed to follow the care plan intervention to notify the physician of changes in skin condition in a timely manner for one Resident (R) #1. In addition, the facility failed to follow the care plan related to floating heels and minimizing pressure over bony prominences for one resident (R) (#7). Ten residents were reviewed for pressure ulcers, and the sample size was 32 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 8:00 p.m. the facility's Divisional Vice President, Executive Director, Divisional Director of Clinical, the Director of Nursing, and the Regional Vice-President were informed of the jeopardy related to: F157:J, F281:J, F282:J, F314:J. On [DATE] at 3:43 p.m., the Executive Director was informed that Immediate Jeopardy had been identified at F223:J and F520:K in addition to F157:J, F281:J, F282:J, F314:J that were identified on [DATE]. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The Immediate Jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [MEDICAL CONDITION]/[MEDICAL CONDITION] after having a [MEDICAL CONDITIONS]. The resident was dependent on staff for Activities of Daily Living (ADL's) and was incontinent of bowel and bladder. The weekly Skin Integrity Data Collection document indicates that the resident had an open area to the sacrum on [DATE], and again on [DATE]. However, the physician was not notified of the open area and the resident did not receive any treatments or assessments from the wound care nurse, for this open area to the sacrum, until [DATE]. In addition to this, the resident's care plan was not updated to address any skin care problems. R#1 was transferred, from the facility, to an acute care hospital, on [DATE]. The hospital Discharge summary, for R#1, revealed that the resident was admitted to the hospital with [REDACTED]. The ulcer required debridement. The resident developed myositis with [DIAGNOSES REDACTED]. The resident suffered complications during her hospitalization , related to aspirating tube feeding, and subsequently died on [DATE]. The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 157: J - 42 C.F.R. 483.10(b)(11) Notify of changes (injury/decline/room, etc), F 223:J - 42 C.F.R. 483.13(b), 483.13(c)(1)(i) Free from abuse/involuntary seclusion, F 281:J - 42 C.F.R. 483.20(k)(3)(i) Services provided meet professional standards, F 282:J - 42 C.F.R. 483.20(k)(3)(ii) Services by qualified persons/per care plan, F 314: J - 42 C.F.R. 483.25(c) Treatment / Svcs to prevent/heal pressure sores, F 520:K - 42 C.F.R. 483.75(o)(1) QAA Committee - Members/meet quarterly/plans. Additionally, Substandard Quality of Care was identified with the requirements at F 223:J - 42 C.F.R. 483.13(b), 483.13(c)(1)(i) Free from abuse/involuntary seclusion and F 314: J - 42 C.F.R. 483.25(c) Treatment / Svcs to prevent/heal pressure sores. A Credible Allegation of Compliance (AoC) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity as follows: and in addition to F157:D, F223:D, F281:D, F282:D, F314:D, F520:E while the facility continued management level staff oversight of notification of physician and pressure ulcer treatment to ensure the continuity of resident care. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing physician notification, initiating and implementing wound care, implementing the interventions of the residents care plans and the necessary steps to ensure continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including physician notification and care plans were current and accurate. After Supervisory review by the State Survey Agency F223:J and F281:J were placed under the appropriate tag and the scope and severity for F520:K was lowered to F520:J. The revised tags, as related to the Immediate Jeopardy are as follows: F157: J, F282: J, F314: J, F520: J. Findings include: 1. Review of medical records revealed that R# 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the comprehensive care plan, for R#1, titled Risk for Pressure Ulcers with an onset date of [DATE] indicates that the resident is at risk for developing a pressure ulcer related to decreased mobility and incontinence with a documented goal that the resident will have intact skin through the next review date. Interventions listed, in pertinent part, include: Report changes in skin status to physician. (Licensed nurse) Review of the comprehensive care plan implemented on [DATE] and titled Impaired Skin Integrity noted the Resident is at risk for skin impairment, incontinence, weakness, s/p [MEDICAL CONDITION], physical limitations. The goal revealed the resident's disruption of skin surface will remain free from infection and show evidence of healing by next review date. Interventions listed, in pertinent part, include: Report changes in skin condition to physician. (Licensed nurse.) Review of the document titled Weekly Skin Integrity Data Collection dated [DATE], Licensed Practical Nurse (LPN )NN documented R # 1's skin was dry and there was an open area at the sacrum. Review of the medical records for R#1 revealed that there was not any evidence of any documentation that R#1's physician was notified of the open area or that a treatment order was obtained. Review of the documented titled, Weekly Skin Integrity data Collection dated [DATE], LPN CC documented an open area at R#1's sacrum. Review of the medical records for R#1 revealed that there was not any evidence of any documentation that R#1's physician was notified of the open area or that a treatment order was obtained In a Pressure Ulcer Status Record dated [DATE], LPN AA documents R#1 has an unstageable wound to the sacrum measuring 4.9 centimeters (cm) x 2.5 cm with eighty percent necrotic tissue. Interview on [DATE] at 9:45 a.m., with LPN MM (Unit Manager) revealed that weekly skin assessments are completed by nursing, and if a nurse notes a possible wound or area of pressure, she is responsible for notifying the physician and implementing treatment. She states the nurse is also responsible for notifying the responsible party. Interview and record review on [DATE] at 10:30 a.m., with Registered Nurse (RN) HH, Assistant Director of Nursing (ADON) revealed that there was not any evidence of any documentation of a physician order [REDACTED]. 2. Review of the clinical record, for resident (R) #7 (R#7), revealed that she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), for R#7, dated [DATE], revealed that the resident had a Brief Interview for Mental Status score of 13 (a score of 13 to 15 indicates that a resident is cognitively intact), this same MDS documented that the resident needed extensive assist for bed mobility and transfers, walking in the room and corridor did not occur, was a pressure ulcer risk but had no unhealed pressure ulcers. Review of a care plan for pressure ulcer to the right heel/ankle related to immobility, for R#7, revealed that the care plan included approaches that included: float heels when in bed as resident allows, and minimize pressure over boney (sic) prominences. Review of the Pressure Ulcer Status Record, for R#7, dated [DATE] documented that the resident had an unstageable wound to the right ankle first identified on [DATE] with the appearance of a blood-filled blister Interview on [DATE] at 8:50 a.m., with R #7 revealed that she recently had a stroke, and was paralyzed on her right side. The resident further revealed that she asked the staff to put a pillow under her feet to keep her heels elevated off of the bed, as both of her feet were sore. During an observation, at this time, a pillow was observed under the resident's mid-calf to her knees, but her feet were observed to rest directly on the mattress. During further observation, at this time, the resident's right leg was observed to be turned outward so that her lateral right ankle was resting directly on the mattress. Observation on [DATE] at 9:30 a.m., revealed that R #7 was in bed with a pillow under her knee and upper part of her lower legs, but her feet were observed to be on the mattress. During further observation, at this time, the resident's right foot was observed turned outward so that her right lateral ankle was observed resting directly on the mattress. Interview on [DATE] at 9:21 a.m., with R #7 revealed that her right ankle was very tender last night, and that she had to request pain medicine for it. During observation at this time, her right foot was rotated outward and her foot and lower leg were positioned on a flat pillow, but her foot was not extended over the end of the pillow and her right lateral ankle was positioned directly on the surface of the pillow. This was verified during an interview with Licensed Practical Nurse (LPN) Treatment Nurse OO at this time, who revealed that the pillow should have been folded in half to raise the resident's foot so that it was not touching the pillow or the mattress. Observation on [DATE] at 6:45 p.m., of wound care for R #7 with LPN OO, LPN OO revealed that the blister on the resident's right ankle was directly over a pressure point, and that the area should be offloaded. Cross-refer to F 314. The facility implemented the following actions to remove the Immediate Jeopardy Patients Impacted: The facility has changed treatment nurses as of February 13, 2017. The Assistant Director of Nursing has assumed the role of facility treatment nurse until a permanent one has been hired and trained. The Assistant Director of Nursing will be provided training and given assistance by a WTA certified wound nurse x 4 weeks. All patients have had skin assessments and Braden scales completed by licensed nursing leadership team which includes the Director of Nursing, Assistant Director of Nursing, Unit Managers, Treatment Nurse, MDS Coordinator, ,[DATE] Supervisor, Restorative Nurse, LPN Business Development Director and LPN Medical Records Director. This will be completed February 14, 2017. Systemic Changes: All licensed nurses will receive in-service training on the following by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Managers and/or corporate nurse. This will be completed February 14, 2017. Performing and documenting patient skin assessments Physician and patient representative notification of skin condition changes Implementing and documenting treatment orders/TARS Pressure ulcer care planning All certified nursing assistants have received in-service training on the following by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Managers and/or corporate nurses. This will be completed February 14, 2017. Pressure ulcer prevention Reporting changes in skin condition to nursing supervisor 90% of licensed nurses have received the above training. Any licensed nurse that does not have the in¿ service training by February 14, 2017, will receive this in-service training upon their return to work. These associates will not be able to provide direct patient care until completion of the in-service. Monitoring: During daily clinical meeting/rounds, nursing leadership will review daily scheduled skin assessments for completion, new areas identified, physician and patient representative notification and pressure ulcers care plans are completed. Upon identification of non-compliance, the Director of Nursing, Staff Development Coordinator, Unit Managers and/or corporate nurse will follow-up with the licensed nurse and provide additional education. The Director of Nursing will review the above findings with the Executive Director weekly for any additional follow-up. This will occur weekly for 3 months, and monthly for one year. The Director of Nursing will bring and present the monitoring findings from the regulatory deficiencies cited to the Pl Committee. The Committee will utilize the findings to evaluate the effectiveness of the Pl plans. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: Patients Impacted: Interview on [DATE] at 11:50 a.m., with the Registered Nurse (RN) Division Director of Clinical Services QQ she revealed that Licensed Practical Nurse (LPN) Treatment Nurse DD had resigned, and that LPN Treatment Nurse OO was brought in from another facility over the weekend (of [DATE]) to assist and train the Assistant Director of Nursing (ADON), who was going to temporarily do treatments. RN QQ further revealed that the facility was actively seeking a replacement for the treatment nurse position, and that LPN OO would be in the facility for at least four weeks. Review of the Allegation Of Compliance (AOC) notebook revealed that it Included a copy of LPN OO's Certified Wound Care Associate card with an expiration date of [DATE], as well as Certificate of Completions on [DATE] for an Ostomy Workshop (7 contact hours), and on [DATE] for Current Concepts in Skin Care and Wound Management (24.5 contact hours). Further review of the AOC notebook revealed that there was a Separation Notice for LPN DD effective [DATE]. Further review revealed a signed statement that as of [DATE] the facility had changed treatment nurses, and that the ADON would assume this responsibility until a permanent nurse was hired. Interview on [DATE] at 4:12 p.m., with LPN CWCA (Certified Wound Care Associate) OO she revealed that she had been asked to train the ADON and make sure she understood the pressure ulcer prevention, treatment and notification policy, and to help her with the basics of wound care such as measuring, treating and assessing. She further revealed that the ADON's training would include filling out pressure ulcer and non-pressure ulcer wound sheets correctly; notifying the physician; addressing pain; proper infection control technique including prevention of cross-contamination. She further revealed that education on staging and recognizing the difference between Stage 1 and DTI (deep tissue injury) wounds would be covered. LPN OO further revealed that she was not yet sure if she was going to be coming back to the facility on an ongoing basis for follow-up of the wound care program, but that she had been asked to be at the facility for a minimum of four weeks. She revealed that she came in the facility on Saturday [DATE] and was following up on skin assessments that had been done, and if an assessment noted a concern she helped with the assessment and staging. She further revealed that on [DATE] she started doing all the measurements on the residents found to have pressure ulcers after the skin sweep (a head to toe skin assessment of all residents in the facility). LPN OO revealed that she also reviewed and/or updated care plans for all the residents found to have pressure ulcers or non-pressure wounds. She further revealed that treatments were done for all wounds, as well as physician and family notification of the presence of a new wound and/or present status of the existing wound(s). Interview on [DATE] at 10:14 a.m., with ADON HH she revealed that she had been told to ensure that the weekly skin assessments were being done and accurate, and any follow-up implemented. She revealed that the skin assessments were now being kept in a binder on each unit instead of the treatment books, which made them more accessible, and that she was told to check in the mornings to see if there were any new skin issues. She further revealed that she was told to ensure that Braden scale scores were completed per policy, to make sure initial skin assessments were done on admission, and that she would do an actual skin assessment on the new admissions to ensure nothing was missed. She further revealed that part of her new responsibilities would be to make rounds with the wound physician, and to check the TARs (Treatment Administration Records) to ensure that the correct treatments were on them and they were being documented as done. The ADON revealed during further interview that LPN Treatment Nurse OO would be with her at least four weeks for training, and that she had actually done wound care in the facility in the past, from August to November of 2014, The ADON revealed that she was not certified in wound care, but had attended a one-day workshop on wound care in the past. The ADON further revealed that the DON said that the facility was going to hire another wound care nurse, and they would both be sent out for training to a wound care class. Review of the AOC notebook revealed that a skin sweep and Braden Scale scores were completed for 100% of the residents by [DATE]. Further review revealed that an audit form had been developed that included the resident's name and room number; if the skin assessment and Braden Scale were completed; if any new pressure ulcers were identified; if the resident was at risk for pressure ulcer development; if the physician and/or Nurse Practitioner were notified; if the treatment order was initiated; if the care plan was updated; and an area for any comments. Interview on [DATE] at 2:03 p.m., with the DON she revealed that when the 100% skin sweep was done, they identified three residents with previously unidentified wounds. She further revealed that she ensured the staff followed through with notification of the physician and responsible party. During further interview, she revealed that the treatment nurse would be providing a copy of the pressure ulcer report weekly on Tuesdays, but that any new areas of skin breakdown would be addressed as they were identified on a daily basis. She added that this weekly pressure ulcer report was just another check to ensure that the care plan was completed. Review of the sampled residents' clinical records revealed that they had skin assessments and Braden Scale scores completed on the following dates as follows: R #4: [DATE] R #5: Braden on [DATE], skin assessment on [DATE] R #7: [DATE] R #8: Braden on [DATE], skin assessment on [DATE] R #412: [DATE] R #424: [DATE] R #435: [DATE] R #529: [DATE] R #558: [DATE] Review of the facility's AOC audits revealed 105 residents had updated Braden scores. There were 103 weekly skin integrity data collection tools noted. An interview with the Regional Clinical Director on [DATE] at 12:30 p.m. revealed that skin assessments were not completed on 1 resident that was transferred to the hospital and another resident that expired. There were 14 residents noted to have skin breakdown. Pressure ulcer status records were completed on all 14 residents. Nursing notes for all 14 residents indicated the physicians and responsible parties were notified. In addition, 3 additional residents were identified as having pressure ulcers during the facility's skin assessments. All three residents had physician wound treatment orders documented and care plans for pressure ulcers initiated. Nursing progress notes revealed Responsible parties were notified on these residents. Interview on [DATE] at 3:35 p.m. with Corporate MD nurse XX. She states that 100 % of at risk residents care plans were reviewed and updated if indicated. If the care plans were current with interventions, they were not updated. Interview on [DATE] at 3:55 p.m. with RN QQ revealed that residents who were deemed at risk and above on the Braden scale were reviewed. The residents had skin assessments completed and care plans reviewed for accuracy. 14 residents were initially identified as having pressure ulcers. All 14 had documentation in the progress notes that the physician and responsible party were notified of the presence or progress of the pressure ulcer. One resident (R 424)) had orders changed, and these were noted on an order sheet. Review of a Braden score, for R#8, dated ,[DATE] documents a score of 11, indicating the resident is at high risk for pressure ulcers. A weekly skin integrity data collection dated [DATE] revealed resident has an open area to her sacrum in addition to dry skin at the left shoulder and a dressing to the left elbow. Pressure ulcer status record, for R#8, dated [DATE] documented a 2.0x1.5 unstageable wound to the sacrum; in house acquired. The wound nurse RN OO documented a superficial opening on non-blanching discolored tissue consistent with DTI. An Addendum progress note, for R#8, dated [DATE] at 10:53 p.m. by RN Staff Development Coordinator (SDC), noted the physician were updated regarding the wound. An Addendum progress note, for R#8, dated [DATE], at 10:53 p.m. by RN Staff Development Coordinator (SDC), revealed the physician was notified regarding the wound and family member was updated. Review of a care plan, for R#8, initiated [DATE], documented care review on [DATE] and notes Sacrum PU unstageable DTI. Updated interventions dated [DATE] include skin treatments as ordered, report any changes in skin condition to physician and responsible party, and pressure reduction surface area provided. Observation on [DATE] at 10:20 a.m. R#8 observed in activities sitting in wheelchair. Wheelchair pad observed to be in place. Observation on [DATE] at 3:55 p.m. R#8 observed in bed lying on side. Gel cushion noted in wheelchair with small cushion on top. Observation on [DATE] at 9:50 a.m. R#8 observed in bed lying on side. Duoderm in place to sacral wound, dated [DATE] Review of a Braden score, for R#5, dated ,[DATE]//17 documents a score of 16, indicating the resident is at risk for pressure ulcers. A skin assessment completed [DATE] documents the resident was admitted with a wound to her right heel. The wound measures 3.0x3.8 and is unstageable. A Progress note, for R#5, dated [DATE] at 10:49 p.m. by Registered Nurse (RN) HH documents MD aware of wound, and to continue with current treatment. Nursing notes, for R#5, dated [DATE] at 10:49 p.m. by RN HH documents resident updating on care plan for wound to right foot and verbalized understanding. Granddaughter called. MD made aware and will continue with current treatment. Review of a care plan initiated, for R#5, dated [DATE] notes the following problem: Resident has pressure ulcer to right heel r/t immobility. Interventions include: Avoid skin to skin contact Complete Braden Scale Risk Assessment quarterly and prn Consult/make referral for screen prn Wound nurse Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. Notify resident or RP of any new areas of breakdown Wound care as ordered by physician. (See current Wound Treatment and Progress Record) Documentation indicates care plan reviewed on [DATE]. Updates dated [DATE] include off-loading heels while in bed, pressure reduction surface, and cushion in chair. Observation on [DATE] at 3:40 p.m. R#5 observed to be out of bed in wheelchair. Dressing in place to foot dated [DATE]. No concerns noted. Observation on [DATE] at 10:12 p.m. revealed R#5 out of bed in day room. Wound dressing to right foot intact and dated [DATE]. No concerns noted. Review of Braden scale, for Resident R dated [DATE] documents a score of 14, indicating the resident is at moderate risk for skin breakdown. Review of skin assessment dated [DATE] documented skin excoriation to buttocks, dressing to right heel with dressing in place. Addendum to Progress note, for Resident R dated [DATE] at 10:54 PM by LPN MM revealed MD aware of heel wound and treatment orders changed to Santyl and foam dressing and prn. Progress note, for Resident R, dated [DATE] at 10:54 PM by LPN MM documented MD and daughter informed of new wound and new treatment orders to left heel. Review of care plan, for Resident R, revealed care plan initiated [DATE]. Review documented on [DATE] with documentation of unstageable pressure ulcer to left heel and resident at risk for additional pressure wounds. Updated interventions include off load heels, consult wound MD, report change in skin status to physician and responsible party, wound care as ordered, pressure reduced surface Observations on [DATE] at 10:00 a.m. revealed Resident R sitting in wheelchair during activities. Dressing to left heel dated [DATE]. Resident left heel observed to be floated. Review of a Braden Scale, for R#424, completed on [DATE]. Score is 17 indicating resident is at risk for breakdown. Weekly Skin Integrity Data Collection, for R#424, indicates skin assessment completed on [DATE]. Body diagram indicates DTI to left heel, blanching redness to right heel, and open area to sacrum. A physician's orders [REDACTED]. Nursing note dated [DATE] by ADON HH documents that the resident was updated on care plan and progress of wounds. Responsible Party notified as well. MD notified and will continue with treatment orders. A care plan for R#424 documents the following: Problem: [DATE]: Resident has pressure ulcer on left lower buttock, left buttock, right buttock, and left heel r/t immobility. Interventions include assist prn to reposition/shift weight to relieve pressure. Complete weekly skin check Consult/make referral for screen prn for PT, Wound Care Encourage use of side rails and/or trapeze to assist turning in bed Float heels when in bed as resident allows Minimize pressure over boney prominence. Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. Provide incontinence care after incontinence episodes. Provide pressure relieving or reduction device. Update ,[DATE] indicated mattress to be added. Report changes in skin status, non-healing new area to MD and responsible party [DATE]; Pressure reduction surface area [DATE]: cushion in chair. Observation on [DATE] at 10:10 a.m. revealed the dressing to R#424's buttocks dated as ordered as follows: [DATE] and a dressing to the heel dated [DATE]. The resident was on her side with a pressure relieving mattress underneath her. A pressure relieving cushion was noted in her wheelchair. The following interviews were conducted on [DATE] at 10:30 a.m., with RN K who works the 7:00 a.m. to 3:00 p.m. shift; at 9:50 a. m , with CNA XX , at 10:00 a.m. with RN FF., at 10:05 a.m., with CNA YY at 9:30 a.m., at 9:45 a.m. with LPN NN , at 10:10 a.m. with LPN PP, at 12:30 p.m. with RN GG, Interviews for the ,[DATE] shift were conducted on [DATE] at 3:15 p.m. with LPN AAA, at 3:45 p.m. with RN EE works all shifts, with LPN unit manager EE at 3:45 p.m., at 4:00 p.m. with unit manager LPN MM , at 4:15 p.m. with CNA CCC, at 4:20 p.m. with LPN DDD, at 4:45 LPN MMM, at 5:00 p.m. with RN VV. Interviews on [DATE] ,[DATE] shift interviews were conducted at 6:25 a.m. with CNA FFF, at 6:30 a.m. with RN KKK, at 6:38 a.m., with CNA JJJ, at 7:00 a.m. with CNA III, at 7:05 a.m. with CNA HHH, at 7:10 am with CNA III, at 7:10 a.m. RN GGG, , at 7:50 a.m. with LPN ZZ. Interviews with the licensed nurses and CNA's revealed that all licensed nursing had received in-service education training related to Physician and patient representative notification of pressure ulcers and implementation of treatment, performing and documenting patient skin assessments, Physician and patient representative notification of skin changes, Implementing and documenting orders/TARS, pressure ulcer care planning and abuse and Neglect which include ident cation and reporting. All Certified Nursing Assistants verified that they had received in-service training on the following pressure ulcer prevention, reporting skin condition to nursing supervisor and abuse and neglect policies which include identification and reporting Monitoring: Interview on [DATE] at 10:51 a.m., with the Executive Director she revealed that in the daily clinical grand rounds meeting, they will review everything going on each unit, including to ensure the initial skin assessment and Braden score was done for new residents, treatment in place for any wounds, and that this was care planned. She further revealed that if there was a change in a wound, they would ensure that the family and physician has been notified and everything was in place to treat the wound. She revealed that they would be reviewing the previous day's skin assessments to ensure they were done, and that the Unit Managers and DON would also be responsible for checking skin assessments, new treatment orders, notification, implementation, and that the care plan was updated at the end of each day. The Executive Director further revealed that she would be responsible for ensuring that everything that they said they would do was being implemented, and revise the plan as needed. She further revealed that audit results would be brought to her weekly so she could ensure everything was in place, and have an ad hoc PI meeting if necessary to correct any problem areas. She further revealed that the DON would be responsible for bringing audit results back to the PI Committee. Interview on [DATE] at 12:01 p.m., with the DON she revealed that the monitoring findings mentioned in the AOC came from audits and observations made from deficiencies cited during the last survey as well as from the Immediate Jeopardy (IJ) deficiencies. She revealed that the unit managers will bring audit information to her and they review them, and the findings are presented in the PI (Performance Improvement) meeting. The DON revealed during further interview that they have had a couple of PI meetings since the IJ was identified, and everyone in the committee had input in developing the AOC. She revealed that they put together an AOC book that contained everything they had done related to the AOC, such as Braden scores and skin assessments, and presented that at PI. She further revealed that there were a lot of things they would be monitoring, such as admission skin assessments, which would also be presented to PI. The DON revealed that they implemented a new process for the weekly skin audits to make it more accessible to the staff, and would be reporting back to PI about if this has been successful for monitoring. The DON further revealed that they had not yet identified any non-compliance for implementation of components of the AOC as it had only been a few days, but if they did find non-compliance, anyone listed on

Based on physician and staff interview, record review, review of the facility's policy titled, Changes in Resident's Condition or Status Policy and Procedure, review of the facility's procedure titled, [MEDICAL CONDITIONS], or [MEDICATION NAME] Procedure the facility failed to notify the physician of a newly developed pressure ulcer and failed to obtain treatment orders for 10 days for one resident (R) (#1). In addition, the facility failed to notify the attending physician or surgeon when one resident's [MEDICAL CONDITION] bag was leaking and the skin was becoming red for (R #3), and the facility failed to notify the physician or responsible party (RP) when one resident (#2) refused ordered nutritional shakes. The facility census was 92, the sample size was 32. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 8:00 p.m. the facility's Divisional Vice President, Executive Director, Divisional Director of Clinical, the Director of Nursing, and the Regional Vice-President were informed of the jeopardy related to: F157:J, F281:J, F282:J, F314:J. On [DATE] at 3:43 p.m., the Executive Director was informed that Immediate Jeopardy had been identified at F223: J and F520: K in addition to F157: J, F281: J, F282: J, F314: J that were identified on [DATE]. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The Immediate Jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [MEDICAL CONDITION]/[MEDICAL CONDITION] after having a [MEDICAL CONDITIONS]. The resident was dependent on staff for Activities of Daily Living (ADL's) and was incontinent of bowel and bladder. The weekly Skin Integrity Data Collection document indicates that the resident had an open area to the sacrum on [DATE], and again on [DATE]. However, the physician was not notified of the open area and the resident did not receive any treatments or assessments from the wound care nurse, for this open area to the sacrum, until [DATE]. In addition to this, the resident's care plan was not updated to address any skin care problems. R#1 was transferred, from the facility, to an acute care hospital, on [DATE]. The hospital Discharge summary, for R#1, revealed that the resident was admitted to the hospital with [REDACTED]. The ulcer required debridement. The resident developed myositis with [DIAGNOSES REDACTED]. The resident suffered complications during her hospitalization , related to aspirating tube feeding, and subsequently died on [DATE]. The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 157: J - 42 C.F.R. 483.10(b)(11) Notify of changes (injury/decline/room, etc.), F 223:J - 42 C.F.R. 483.13(b), 483.13(c)(1)(i) Free from abuse/involuntary seclusion, F 281:J - 42 C.F.R. 483.20(k)(3)(i) Services provided meet professional standards, F 282:J - 42 C.F.R. 483.20(k)(3)(ii) Services by qualified persons/per care plan, F 314: J - 42 C.F.R. 483.25(c) Treatment / Svcs to prevent/heal pressure sores, F 520:K - 42 C.F.R. 483.75(o)(1) QAA Committee - Members/meet quarterly/plans. Additionally, Substandard Quality of Care was identified with the requirements at F 223:J - 42 C.F.R. 483.13(b), 483.13(c)(1)(i) Free from abuse/involuntary seclusion and F 314: J - 42 C.F.R. 483.25(c) Treatment / Svcs to prevent/heal pressure sores. A Credible Allegation of Compliance (AoC) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity as follows: and in addition to F157:D, F223:D, F281:D, F282:D, F314:D, F520:E while the facility continued management level staff oversight of notification of physician and pressure ulcer treatment to ensure the continuity of resident care. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing physician notification, initiating and implementing wound care, implementing the interventions of the residents care plans and the necessary steps to ensure continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including physician notification and care plans were current and accurate. After Supervisory review by the State Survey Agency F223: J and F281: J were placed under the appropriate tag and the scope and severity for F520: K was lowered to F520:J. The revised tags, as related to the Immediate Jeopardy are as follows: F157: J, F282: J, F314: J, F520: J. Findings include: Review of the facility's policy titled, Changes in Resident's Condition or Status Policy and Procedure revealed the following: The facility will notify the resident, his/her attending physician, and representative (sponsor) of changes in the resident's condition and/or status. Nursing services will be responsible for notifying the resident's attending physician when: -There is a significant change in the resident's physical, mental or emotional status. -The resident refuses treatment or medications and reason(s) why. All changes in the resident's medical condition must be properly recorded in the resident's medical record in accordance with our documentation policies and procedures 1. Record review revealed that Resident (R) # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Initial Data Collection Tool/Nursing Service dated [DATE] documents that R#1 had an old surgical scar to her right leg. There are no wounds documented on the diagram. Record review of the document titled Weekly Skin Integrity Data Collection, for R#1, dated [DATE], LPN NN documented that R# 1's skin was dry and there was an open area at the residents sacrum. There was no evidence of any documentation that the physician was notified of the open area to the resident's sacrum. Medical record review of the document titled, Weekly Skin Integrity data Collection, for R#1, dated [DATE], Licensed Practical Nurse (LPN) CC documents an open area to the residents sacrum. There is no evidence of any documentation that the physician was notified of the open area on the resident's sacrum. Medical record review revealed a Pressure Ulcer Status Record dated [DATE], LPN AA documents that R#1 has an unstageable wound to the sacrum measuring 4.9 centimeters (cm) x 2.5 cm with eighty percent necrotic tissue. Medical record review revealed a Nurse's note, for R#1, dated [DATE] documents the RN nurse manager was notified by the Wound Nurse that the resident had an unstageable wound. Further medical record review revealed that the resident's physician was notified of the sacrum wound on [DATE]. Treatment orders were documented as being obtained at that time. Interview on [DATE] at 9:45 a.m., with LPN Unit Manager MM revealed that weekly skin assessments are completed by nursing staff, and if a nurse documents a possible wound or area of pressure, then that nurse is responsible for notifying the physician. LPN Unit Manager MM revealed that the nurse is also responsible for notifying the resident's family as well. Interview on [DATE] at 10:30 a.m., and record review with Registered Nurse (RN) HH, Assistant Director of Nursing (ADON) revealed that there was not any evidence of any documentation that the physician was notified of the open area prior to [DATE]. Interview and review on [DATE] at 2:35 p.m. with LPN CC of the Weekly Skin Integrity Data Collection sheet revealed that LPN CC completed the assessment, for R#1, on [DATE]. LPN CC was unable to recall the resident, but states she would have told the wound care nurse if the resident had a new wound. She also revealed that if the resident had developed a wound and the wound nurse was not available, she would have contacted the physician for orders and notified the family that there were new orders. Interview and review of the Weekly Skin Integrity Data Collection sheet on [DATE] at 9:50 a.m. with LPN NN revealed that if she was aware a resident had a new wound, she would have contacted the physician and notified the family. Interview [DATE] at 10:10 a.m. with physician UU, the physician for R#1, revealed that physician UU expected to be notified promptly if a resident developed a wound. Further interview with physician UU revealed that she could not recall when she was notified regarding this resident's wound. 2. Review of the closed clinical record, for R#3, revealed that she was admitted to the facility on [DATE] Review of the facility's procedure titled, [MEDICAL CONDITIONS], or [MEDICATION NAME] Procedure revealed that a physician's order will be obtained for ostomy care to include specific physician preference regarding appliance, skin barrier, and skin care. Review of a History and Physical form dated [DATE] revealed that resident (R) #3 underwent an exploratory laparotomy with a right hemicolectomy and [MEDICAL CONDITION] due to a cecal perforation. Review of all of the Physician's Orders, for R#3, revealed that there were no evidence of any orders related to the type of [MEDICAL CONDITION] appliance to use, or the type care to provide for the skin surrounding the [MEDICAL CONDITION]. Review of nursing Progress Notes revealed that on [DATE] at 3:54 a.m., the [MEDICAL CONDITION] bag was changed due to leakage. Review of nursing Progress Notes dated [DATE] at 7:13 a.m. revealed that the [MEDICAL CONDITION] bag was changed twice, and that the skin around the stoma was red. Review of the nursing Progress Note dated [DATE] at 10:56 p.m. revealed that the ostomy bag was changed twice and paste applied around the stoma, and the resident was sent out to the emergency room , per family request, due to continued leakage. Review of the Resident Transfer Record dated [DATE] documented that the resident was transferred to the emergency room due to the leaking [MEDICAL CONDITION] bag and that the skin condition around the stoma was red and irritated. Review of the clinical record revealed that there was no evidence of any documentation that the physician was notified that the skin around the [MEDICAL CONDITION] was red, nor any evidence that the surgeon that performed the [MEDICAL CONDITION] surgery, was contacted for the proper appliance to use to prevent leakage. Interview on [DATE] at 5:50 p.m., with Licensed Practical Nurse (LPN) CC revealed that the [MEDICAL CONDITION] bag the facility used, for R#3, was different from the [MEDICAL CONDITION] bag that came from the hospital, and that the facility didn't have an [MEDICAL CONDITION] bag that would fit the residents [MEDICAL CONDITION] as well as the one from the hospital, and that the resident's skin was getting red. Interview on [DATE] at 12:45 p.m., with the Director of Nursing (DON) revealed that the ostomy, for R#3, was flat on the surface of the skin, and that the staff had a problem getting a bag to fit and the leakage to stop. The DON further revealed that the hospital didn't tell them what type of bag to use on the transfer orders, from the hospital to the facility, and the DON verified that there was no evidence of any documentation that the doctor or hospital was contacted regarding the resident's [MEDICAL CONDITION] or the type of appliance that should be used. Interview on [DATE] at 1:10 p.m., with physician SS revealed that the facility staff should have followed the hospital discharge orders or contacted the [MEDICATION NAME] at the hospital to find out what the correct [MEDICAL CONDITION] bag to use, and should not have accepted the patient if they didn't have the right type of bag. Physician SS further revealed that she did not specifically recall anything about the resident's [MEDICAL CONDITION] leaking, and that if she did not have anything documented about the [MEDICAL CONDITION] leaking and the skin becoming irritated in her notes, that the staff had not notified her. Interview on [DATE] at 5:05 p.m., with LPN Wound Care Nurse OO revealed that if the resident's skin was irritated and the ostomy bag was leaking, that she would contact the physician and/or the surgeon that did the ostomy surgery. She further revealed that if a resident was having high output from their ostomy and the bag was leaking, that she would have contacted the surgeon as the output from ileostomies is very acidic. Cross-refer to F 309. 3. Review of the closed clinical record for R#2 revealed that she was admitted to the facility on [DATE]. Review of a hospital Consultation report dated [DATE] revealed that the resident's appetite prior to admission, to the facility, was on the low side, and that the resident's [MEDICATION NAME] level was very low at 1.8. Review of an [MEDICATION NAME] level obtained on [DATE] revealed a result of 2.1 (normal range 3XXX,[DATE].0). Review of the Hospital Post-Acute Transfer Orders dated [DATE] revealed an order for [REDACTED]. Review of a Nutrition Data Collection/assessment dated [DATE] revealed that R#2 needed additional protein to meet increased demands, and that the Registered Dietician's (RD) recommendation was for the resident to receive four ounces (oz.) of a nutrition shake twice a day, and further medical record review revealed that this order, for the 4 oz. of nutrition shake twice a day, was written on a Physician's Orders dated [DATE]. Review of the [DATE] Medication Administration Record [REDACTED]. Further review of the [DATE] MAR indicated [REDACTED]. Review of the reverse side of the MAR, documented under the Nurse's Medication Notes, revealed documentation that from [DATE] through [DATE], a Refusal for the Nutritional Shake (resident is) lactose intolerant, and on [DATE] there was documentation that the Nutritional Shake was discontinued. Review of all of the nursing Progress Notes, for R#2, revealed that there was no evidence of any documentation regarding the resident's refusal to accept the nutritional supplement, nor was there any evidence of any documentation that the physician, RD, or the residents Responsible Party had been contacted to notify them that the Nutritional Shake was refused and to see if they wanted to try a different nutritional intervention. Interview on [DATE] at 4:29 p.m. with the Assistant Director of Nursing HH confirmed that the physician, the RD, or the Responsible Party had not been contacted regarding the residents Nutritional shakes. Cross-refer to F 325. The facility implemented the following actions to remove the Immediate Jeopardy Patients Impacted: All patients will have skin assessments and Braden Scales completed by the licensed nursing leadership team which includes the Director of Nursing, Assistant Director of Nursing, Unit Managers, Treatment Nurse, MDS Coordinator, ,[DATE] Supervisor, Restorative Nurse, LPN Business Development Director and LPN Medical Records Director. This will be completed by February 14, 2017. All patients identified with pressure ulcers will have physician notification and any new orders obtained will be implemented by a licensed nurse as ordered by the physician. This will be completed by February 14, 2017. All patients identified with pressure ulcers will have their patient representative notified of pressure ulcer condition change and plan of care by a facility licensed nurse. This will be completed by February 14, 2017. Systemic Changes: All licensed nurses will receive in-service training on the following by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Unit Managers and/or corporate nurse. This will be completed by February 14, 2017. Physician and patient representative notification of pressure ulcers and implementation of treatment 90% of all licensed nurses have received the above training. Any licensed nurse that does not have the in-service training by February 14, 2017, will receive this in-service training upon their return to work. These associates will not be able to provide direct patient care until completion of the in-service. Monitoring: During daily clinical meeting/rounds, nursing leadership will review daily scheduled skin assessments for completion, new areas identified and physician and patient representative notifications. Upon identification of non-compliance, the Director of Nursing, Staff Development Coordinator, Unit Managers and/or corporate nurse will follow-up with the licensed nurse and provide additional education. The Director of Nursing will review the weekly pressure ulcer report with the Executive Director for new pressure ulcers and verify physician and patient representative notifications. This will occur weekly for 3 months, and monthly for one year. The Director of Nursing will bring and present the monitoring findings from the regulatory deficiencies cited to the Pl Committee. The Committee will utilize the findings to evaluate the effectiveness of the Pl plans. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: Review of the AOC notebook revealed that a skin sweep (a head to toe skin assessment of all residents in the facility) and Braden Scale scores were completed for 100% of the residents by [DATE]. Further review revealed that an audit form had been developed that included the resident's name and room number; if the skin assessment and Braden Scale were completed; if any new pressure ulcers were identified; if the resident was at risk for pressure ulcer development; if the physician and/or Nurse Practitioner were notified; if the treatment order was initiated; if the care plan was updated; and an area for any comments. Interview on [DATE] at 2:03 p.m., with the DON revealed that when the 100% skin sweep was done, they identified three residents with previously unidentified wounds. She further revealed that she ensured the staff followed through with notification of the physician and responsible party. During further interview, she revealed that the treatment nurse would be providing a copy of the pressure ulcer report weekly on Tuesdays, but that any new areas of skin breakdown would be addressed as they were identified on a daily basis. She added that this weekly pressure ulcer report was just another check to ensure that the care plan was completed. Review of the sampled residents' clinical records revealed that they had skin assessments and Braden Scale scores completed on the following dates as follows: R #4: [DATE] R #5: Braden on [DATE], skin assessment on [DATE] R #7: [DATE] R #8: Braden on [DATE], skin assessment on [DATE] R #412: [DATE] R #424: [DATE] R #435: [DATE] R #529: [DATE] R #558: [DATE] Review of the Medical Record for R#8 revealed an Addendum noted dated [DATE] by RN Staff Development Coordinator (SDC) documented that the physician was notified regarding the wound. Review of the Medical Record for R#8 revealed an Addendum noted dated [DATE] by RN Staff Development Coordinator (SDC) documented that the residents Responsible Party was notified regarding the wound. No concerns noted. Review of the medical record for Resident R revealed a progress note dated [DATE] at 10:54 p.m. documented by LPN MM revealed documentation that the residents physician and Responsible Party were notified of wound and new treatment orders to the residents left heel. Review of the medical record for R#424 revealed a nurse's note dated [DATE] documented by ADON JJ revealed that the resident's physician and Responsible Party were notified that they will continue treatment orders. During the facility's skin sweep there were 14 residents noted to have skin breakdown. Medical Record review revealed that the resident's physicians were called for all 14 residents. Further medical record review revealed that the responsible parties were notified for all of the 14 residents. The following interviews were conducted on [DATE] at 10:30 a.m., with RN K who works the 7:00 a.m. to 3:00 p.m. shift; at 9:50 a. m , with CNA XX , at 10:00 a.m. with RN FF., at 10:05 a.m., with CNA YY at 9:30 a.m., at 9:45 a.m. with LPN NN , at 10:10 a.m. with LPN PP, at 12:30 p.m. with RN GG, Interviews for the ,[DATE] shift were conducted on [DATE] at 3:15 p.m. with LPN AAA, at 3:45 p.m. with RN EE works all shifts, with LPN unit manager EE at 3:45 p.m., at 4:00 p.m. with unit manager LPN MM , at 4:15 p.m. with CNA CCC, at 4:20 p.m. with LPN DDD, at 4:45 LPN MMM, at 5:00 p.m. with RN VV. Interviews on [DATE] ,[DATE] shift interviews were conducted at 6:25 a.m. with CNA FFF, at 6:30 a.m. with RN KKK, at 6:38 a.m., with CNA JJJ, at 7:00 a.m. with CNA III, at 7:05 a.m. with CNA HHH, at 7:10 am with CNA III, at 7:10 a.m. RN GGG, , at 7:50 a.m. with LPN ZZ. Interviews with the licensed nurses and CNA's revealed that all licensed nursing had received in-service education training related to Physician and patient representative notification of pressure ulcers and implementation of treatment, Physician and patient representative notification of skin changes, All Certified Nursing Assistants verified that they had received in-service training on the following reporting skin condition to nursing supervisor and abuse and neglect policies which includes identification and reporting Interview on [DATE] at 10:51 a.m., with the Executive Director revealed that in the daily clinical grand rounds meeting, they will review everything going on each unit, including to ensure the initial skin assessment and Braden score was done for new residents, treatment in place for any wounds, and that this was care planned. She further revealed that if there was a change in a wound, they would ensure that the family and physician has been notified and everything was in place to treat the wound. She revealed that they would be reviewing the previous day's skin assessments to ensure they were done, and that the Unit Managers and DON would also be responsible for checking skin assessments, new treatment orders, notification, implementation, and that the care plan was updated at the end of each day. The Executive Director further revealed that she would be responsible for ensuring that everything that they said they would do was being implemented, and revise the plan as needed. She further revealed that audit results would be brought to her weekly so she could ensure everything was in place, and have an ad hoc PI meeting if necessary to correct any problem areas. She further revealed that the DON would be responsible for bringing audit results back to the PI Committee. Interview on [DATE] at 12:01 p.m., with the DON revealed that the monitoring findings mentioned in the AOC came from audits and observations made from deficiencies cited during the last survey as well as from the Immediate Jeopardy (IJ) deficiencies. She revealed that the unit managers will bring audit information to her and they review them, and the findings are presented in the PI (Performance Improvement) meeting. The DON revealed during further interview that they have had a couple of PI meetings since the IJ was identified, and everyone in the committee had input in developing the AOC. She revealed that they put together an AOC book that contained everything they had done related to the AOC, such as Braden scores and skin assessments, and presented that at PI. She further revealed that there were a lot of things they would be monitoring, such as admission skin assessments, which would also be presented to PI. The DON revealed that they implemented a new process for the weekly skin audits to make it more accessible to the staff, and would be reporting back to PI about if this has been successful for monitoring. The DON further revealed that they had not yet identified any non-compliance for implementation of components of the AOC as it had only been a few days, but if they did find non-compliance, anyone listed on the AOC could do the follow-up education, but added that she wanted to be a part of the process to verify it was done. During further interview, the DON revealed that the nursing leadership and clinical management staff will participate in daily clinical rounds, to include the Executive Director, the DON, the Unit Managers, Staff Development Coordinator, Minimum Data Set nurses, and the ADON. She revealed that they would be going unit to unit to ensure that the skin assessments scheduled on the previous day were completed, and anything in place to address concerns such as notification and care planning. The DON further revealed that she and the Executive Director have sat down together and discussed findings from the AOC plan. The copies of the documentation that the DON and the Administrator signed when they went over the results of the Daily Grand Round Meetings were provided by the DON and reviewed at this time. The DON added that she had presented monitoring findings from the regulatory deficiencies already to the PI Committee, and everyone was in agreement and accepted that the AOC plan was working.