Every finding on record at Starkville Manor Health Care and Rehabilitation Ce

Based on observation, resident, staff, and dialysis staff interview, record review, and facility policy review, the facility failed to provide an individualized therapeutic renal diet by failing to assess and incorporate the resident's food preferences into a therapeutic diet for one (1) of four (4) residents reviewed for the dining task. Resident #4.Findings Include: Review of the facility policy titled Dining and Food Preferences revised 9/25 revealed Policy Statement: Individual dining, food, and beverage preferences are identified for all residents/patients. Additionally revealed under, Procedures: .2. The Dining Services Director or designee will interview the resident or resident representative to complete a Food Preference Interview within 72 hours of admission. 4. Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software. 5. The Registered Dietician/Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to ensure adequate fluid volume and appropriate nutritional content for residents/patients that do not consume certain foods or food groups. 7. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies & intolerances, and preferences .Record review of Resident #4's Order Details revealed an order dated 4/28/26, Hemodialysis at (proper name of dialysis company) M (Monday), W (Wednesday), F (Friday) at 12. Record review of the Order Summary Report revealed an order dated 4/28/26, Renal diet Regular texture, Regular/Thin liquids consistency.An interview with Resident #4 on 7/14/26 at 8:10 AM revealed he was receiving dialysis and had food related concerns. He revealed he received the same breakfast every morning which included scrambled eggs, oatmeal, and a piece of bread right out of the loaf, not toasted or buttered. Resident #4 revealed he never gets any meat and stated he could not remember the last time he received meat for breakfast. The resident stated that he orders food from outside restaurants and has a lot of his meals delivered because he was not satisfied with the meal and gets hungry. During a dining observation on 7/14/26 at 11:38 AM, Resident #4 received his lunch meal in his room and was served cheese lasagna, buttered toast, small side salad and sliced apples. Resident voiced he disliked the meal and requested the chicken tenders off the alternate menu.An observation and interview with Licensed Practical Nurse (LPN) #1 on 7/14/26 at 11:44 AM, she was notified of the resident's dislike for cheese lasagna and request for chicken strips. She stated the kitchen probably did not have any, but she would ask. She revealed they only cook so much of the alternate menu and the resident must make his choice by early morning. LPN# 1 stated the resident liked to sleep in, so most of the time he could not get the alternate.An observation of the breakfast meal on 7/15/26 at 7:30 AM revealed the resident ate in his room. The meal provided was 1/4 (one-fourth) cup of scrambled eggs, a piece of plain bread untoasted with no butter, 6-ounce bowl of cream of rice cereal, and 1/2 (one-half) cup of grapes, with no butter or jelly added on the tray. The resident stated he was not going to eat the piece of bread or the rice cereal and would only eat the eggs. The resident reiterated this was the same meal that he received every morning.Record review of the breakfast Meal Ticket provided with the meal revealed Renal Diet with no indication of the residents like and dislikes or meal preferences.An observation and interview with the Dietary Accounts Manager on 7/15/26 at 7:42 AM revealed she oversaw the dietary department and was responsible for getting the meal preferences of the residents. She explained that she had been working in the kitchen for three (3) years but took over this position on Sunday. She stated she had not started interviewing the residents about their meal preferences yet but had it on her list of things to do, confirming no preferences were listed on Resident #4's meal ticket. She confirmed the resident received a plain piece of bread and stated, It must have got mixed up because I toasted his piece. She explained the facility had a preplanned renal diet plan that the kitchen followed, and the resident was only allowed certain foods, confirming the diet restricted breakfast meats. She confirmed that he should have gotten more than a 1/4 cup eggs though and she wasn't sure that this would meet his daily protein goals. She confirmed the residents' preferences were not met, further revealing the resident would have to speak with the Director of Nursing (DON) to sign a waiver to get the foods he preferred.A telephone interview with the Proper name of dialysis Registered Dietician (RD) on 7/15/26 at 8:52 AM she stated she was not opposed to the resident having meat with breakfast, but she indicated there had been some issues with the facility in the past regarding breakfast meats, so she did not interfere. She stated We need to be as less restrictive as we can revealing she was not aware the resident was having meals delivered to the facility. She confirmed the facility RD had not contacted her about anything concerning the resident's diet.A telephone interview with Registered Dietician (RD) on 7/15/26 at 10:25 AM revealed the last time she evaluated the resident was in April, although she reviewed his information and documented on him monthly. The RD stated she did not discuss any preferences with the resident because she would have emailed it to the kitchen, so the meal ticket could be updated. She stated the resident could always let the kitchen know and they could update his preferences. Record review of the RD Medical Nutrition Therapy (MNT) Notes dated 5/21/26, 6/4/26, and 7/6/26 reflected routine monitoring of weight, laboratory values, and diet orders; however, the RD had not evaluated the resident since April despite completing routine monitoring notes. There was no evidence an assessment was completed for preferences.Record review of the Nutrition Evaluation Initial, Annual and Significant Change dated 4/30/26 revealed there was not documentation the RD discussed preferences with the resident.Record review of the admission Record revealed the facility re-admitted Resident #4 on 4/28/26 with medical diagnoses that included Type 2 Diabetes Mellitus Without Complications, Familial Hypophosphatemia, Hypo-Osmolality and Hyponatremia, End Stage Renal Disease, and Dependence on Renal Dialysis.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/5/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #4 was cognitively intact.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure resident grievances related to food preferences and concerns were promptly addressed and resolved for 14 of the 29 sampled residents. (Residents #12, #13, #42, #46, #52, #53, #57, #63, #70, #72, #74, #94, #104, and #106)Findings Include: Review of the facility policy titled, Resident and Family Grievances. with a revision date of 11/14/2025 revealed It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance.12. The facility will make prompt efforts to resolve grievances. On 03/04/26 at 2:00PM the State Agency (SA) held a resident council meeting with Resident #12, Resident #13, Resident #46, Resident #53, Resident #57, Resident #63, Resident #74, Resident #104 and Resident #106 were in attendance. They stated they felt like their grievances related to the food concerns are falling on deaf ears, and Resident #63 stated, They aren't going to do anything about it. They voiced that the menus changed back last year, and they only get meat for breakfast maybe twice a week. They stated that they are served yogurt or cold cereal, and they have voiced their concerns to the Dietary Manager that they don't want that, that they want meat, but the concern has not been resolved yet. All in attendance agreed that food is their biggest concern and that they have told dietary, but it hasn't changed yet. Resident #53 stated, We are depending on you to help make a change in this situation. Interview with the Activity Director on 03/04/26 at 3:10 PM confirmed that she was aware that the residents had grievances regarding the menus and the food choices being served but stated that she had not written the concerns down on the monthly resident council meeting notes because the residents were telling the Dietary Manager weekly, if not daily and were stopping her during their meal times to voice their grievance that they didn't like that they were not getting served meat for breakfast. Interview with the Dietary Manager on 03/04/26 at 3:30PM confirmed that the residents stop her weekly and tell her about their concerns with the food. She confirmed that the residents have been upset about the menus and stated that back in May the company chose a different tier level menu and those menus only allow meat to be served for breakfast a couple times a week and the protein intake comes from yogurt, peanut butter and the eggs that are served each morning. She stated that the residents have stopped her in the dining room since around November and voiced their concerns, but it is the menus the company chose and We can't offer meat because we don't cook it every day, the menus don't call for it. Interview with the Administrator on 03/04/26 at 5:00 PM stated that she was aware that the grievances with the lack of meat for breakfast were a concern for the residents. She stated that they had discussed it and she had told the Dietary Manager to update the food preferences with the residents who wanted meat for breakfast but she was not aware that the residents were still not getting their preferences honored because the breakfast meats were not being cooked every day so there was no way for the residents preferences to be met. She confirmed that the residents' grievances were therefore not being resolved. Record review of Resident #12's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included Heart Failure and Blindness. Record review of Resident #12's Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 01/30/26, revealed a Brief Interview for Mental Status (BIMS) of 12, which indicated the resident was moderately intact. Record review of Resident #13's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder and Type 1 Diabetes. Record review of Resident #13's MDS Section C with ARD of 02/20/26, revealed a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #46's admission Record revealed she was admitted to the facility on [DATE] with diagnoses of Absence of right leg above knee. Record review of Resident #46's MDS Section C with ARD of 12/09/25, revealed a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #53's admission Record revealed he was admitted to the facility on [DATE] with diagnoses of Hemiplegia right side. Record review of Resident #53's MDS Section C with ARD of 02/16/26, revealed a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #57's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included Muscle Weakness and Type 2 Diabetes. Record review of Resident #57's MDS Section C with ARD of 10/14/25, revealed a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #63's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Respiratory Failure and Morbid Obesity. Record review of Resident #63's MDS Section C with ARD of 12/10/25, revealed a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #74's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and Hemiplegia left side. Record review of Resident #74's MDS Section C with ARD of 12/16/25, revealed a BIMS of 12, which indicated the resident was moderately intact. Record review of Resident #104's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Paraplegia. Record review of Resident #104's MDS Section C with ARD of 12/15/25, revealed a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #106's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Absence of left leg below knee and Lack of coordination. Record review of Resident #106's MDS Section C with ARD of 01/28/26, revealed a BIMS of 15, which indicated the resident was cognitively intact. Resident #42 On 03/03/2026 at 10:35 AM, an interview with Resident #42 revealed the resident stated the food was not good and he did not feel like he had enough to eat. On 03/04/2026 at 2:00 PM, during an interview with the resident regarding meals, he stated he does not receive meat every day for breakfast and would like to have sausage or bacon with his breakfast. The resident stated he receives eggs every day but does not want eggs every day. He stated he receives a biscuit daily but would like meat with breakfast as well. The resident stated he asks for milk at meals to obtain protein. The resident stated the residents were only allowed meat approximately three times per week. The resident stated dietary staff were aware of his likes and dislikes and stated, I don't have a problem here except with the food. Resident stated that he has told the lady in dietary many times, but nothing has been done about it, and it is still an on-going grievance. During an interview on 03/04/2026 at 3:40 PM with the Director of Nursing (DON) and Administrator, they revealed they were unaware the resident was unhappy with the food choices but stated several residents had expressed concerns about food. On 03/04/2026 at 4:00 PM, an interview with the Registered Dietitian (RD) revealed she was unaware the resident did not like the food but confirmed that many of the residents have had concerns about the lack of meat for breakfast. Record review of Resident #42's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder. Record review of the MDS Section C with an ARD of 12/24/2025 revealed a BIMS score of 9, indicating the resident was moderately impaired. Resident #52 During an interview on 3/03/26 at 10:57 AM, Resident #52 expressed concerns regarding food portions and the reduction of breakfast meat at the facility. Resident #52 stated, They ration our food. We used to get meat with our breakfast each morning. They told us they were cutting it back to three times a week, but sometimes we don't even get that. Resident #52 revealed that breakfast this morning consisted of a small portion of scrambled eggs, a biscuit, orange juice, and a little carton of milk. Resident #52 stated, I've voiced my concerns regarding the food portions and lack of meat for breakfast, but the kitchen staff told me that it was due to the new corporation purchasing the facility. The record review of Resident #52's breakfast meal ticket dated 3/4/26 revealed that no meat was served. Meal consisted of scrambled eggs-1/2 cup, grits cereal 6 ounces, Biscuit, orange juice and milk. Record review of Resident #52's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus without complications. Record review of Resident #52's MDS Section C with ARD of 12/9/25, revealed a BIMS of 15 which indicated the resident was cognitively intact. Resident #70 During an interview on 3/03/26 at 11:20 AM, Resident #70 revealed we do not get meat every morning for breakfast like we used to, we talk about this in Resident Council, but nothing ever gets changed. Resident #70 stated, We used to have good food, but it has changed, and I believe the portion sizes are smaller as well. The record review of Resident #70's breakfast meal ticket dated 3/4/26 revealed that the meal consisted of a Biscuit, 3 ounces (oz) of sausage gravy, corn flakes- 4 oz, hashbrown patty and 4 oz orange juice. Record review of Resident #70's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Demyelinating Disease of Central Nervous System, and Multiple Sclerosis. Record review of Resident #70's MDS Section C with ARD of 12/22/25, revealed a BIMS of 15, which indicated the resident was cognitively intact. Resident #72 During an interview on 3/3/26 at 10:10 AM, the Dietary Manager revealed multiple residents had voiced concerns and complaints about not receiving a breakfast meat each day. She stated the new menu only provided breakfast meats for two or three breakfast meals each week and the kitchen was unable to provide meats on the other days, even though many residents requested this. On 3/3/26 at 10:55 AM, an interview with Resident #72 revealed he preferred meat with each breakfast meal, and he did not receive this. During an interview on 3/4/26 at 11:45 AM, the resident revealed he received a biscuit and gravy and no meat for today's breakfast. He acknowledged he had asked the staff about this but was told the meat was not available for breakfast each day. An interview with the Administrator on 3/4/26 at 4:05 PM revealed the facility did not provide a meat with each breakfast meal and multiple residents had voiced their grievance concerning this. She acknowledged that each resident had the right for their food preferences to be honored and the facility failed to honor their preference and resolve the grievance in a timely manner. Record review of facility's four weeks rotation menus titled, Week at a Glance revealed for each of the four weeks, breakfast meats were only served on two days. Record review of Resident #72's breakfast meal ticket dated 3/4/26 revealed no meat was served. Record review of Resident #72's admission Record revealed he was admitted by the facility on 3/11/22 with diagnoses included Type 2 Diabetes Mellitus and major depressive disorder. Record review of Resident #72's MDS Section C with ARD of 1/5/26, revealed a BIMS of 13 which indicated the resident was cognitively intact. Resident #94 During an interview on 3/03/26 at 3:05 PM, Resident #94 revealed, I'm tired of this food around here. My breakfast has always consisted of bacon and toast; that's the same breakfast I've always eaten. Resident #94 stated, This was my food choice, and it wasn't a problem until recently. The new corporation has said that we can't have meat every day for breakfast, so now I will only have toast. As much money as we pay to live in this home, it's sad we can't even have bacon for breakfast. We talk about the food all the time in our resident council meetings, and everyone knows my feelings on it, but it doesn't do any good at all. We used to have a choice of food, and it was good, but not anymore and nobody is doing anything to fix it. During an interview on 3/05/26 at 11:25 AM, the Administrator revealed she was not aware of concerns regarding the portion sizes being served to residents. The Administrator stated she was aware that the wording related to portion sizes had changed, but believed the residents were still receiving the same quantities as previously provided. The record review of Resident #94's breakfast meal ticket dated 3/4/26 revealed that no meat was served, and the meal consisted of a Biscuit, toast, jelly, margarine, and a 4-oz orange juice. Record review of Resident #94's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia and Chronic Obstructive Pulmonary Disease. Record review of Resident #94's MDS Section C with ARD of 2/18/26, revealed a BIMS of 15, which indicated the resident was cognitively intact.

Based on record review and staff interview, the facility failed to ensure a copy of the written notice of transfer or discharge was sent to the representative of the Office of the State Long-Term Care Ombudsman for one (1) of twenty-nine (29) sampled residents. (Resident #11) Findings include:Review of facility policy titled, Transfer and Discharge (including AMA) with review date 10/14/2025, revealed, .5. The facility will maintain evidence that the notice was sent to the Ombudsman .Record review of facility document titled, Transfer/Discharge Report undated, revealed Resident #11 discharged home from facility on 2/27/2026 at 9:50 AM.Review of facility document titled, Emergency Transfer Log for the Office of the State Long-Term Care Ombudsman for the month of February 2026, revealed Resident #11 was not listed on the Transfer Log. During an interview on 3/4/2026 at 2:39 PM, the Administrator confirmed the ombudsman was not notified of the discharge as this was not their practice. She stated that they only notify the ombudsman of hospital discharges. She stated that she was not aware of the changes in regulations. Record review of the admission Record indicated Resident #11 was admitted to the facility on [DATE] with medical diagnoses that included Fusion of Spine, Cervical Region.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure adequate supervision and assistance were provided to prevent an avoidable accident for one (1) of five (5) residents reviewed for falls. Resident #28.Findings Include:Review of the facility policy titled Incidents and Accidents revised 11/7/25 revealed under, Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur on facility property and may involve or allegedly involve a resident .An observation of Resident #28 on 3/4/26 at 8:37 AM revealed the resident lying in bed. The resident was talkative but nonsensical. She had a low air loss mattress on her bed with no side rails. A white blood-tinged bandage was intact to the right side of her forehead.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/26 revealed under Section GG that Resident #28 had functional limitation with range of motion impairment on both the upper and lower extremities. The review also revealed the resident was dependent on staff assistance for rolling left and right and toileting hygiene.Record review of Resident #28's Incident Report dated 3/3/26 revealed at approximately 8:52 PM Certified Nurse Aide (CNA) #2 reported to the nurse that Resident #28 rolled out of the bed while CNA #2 was turning the resident to change her diaper. The resident was noted on the floor lying on her right side, undressed, with blood noted from her right eyebrow. The nurse assessed the resident and noted a laceration to the right eyebrow, which was cleaned with normal saline and a pressure dressing applied.Record review of Resident #28's Progress Notes dated 3/3/26 revealed the resident was transferred to the emergency room (ER) for evaluation.Record review of Resident #28's Emergency Department (ED) Note dated 3/3/26 revealed under, Physical Exam: Laceration noted to right eyebrow. Further review revealed under, Laceration Repair Procedure: Laceration length 2 CM (centimeters). After profuse irrigation and exploration, the laceration was repaired with sterile skin adhesive.An interview with CNA #1 on 3/4/26 at 2:19 PM revealed she usually performed the resident's care by herself but stated, I have to be careful because that mattress she has will sway and cause her to roll off. CNA #1 indicated the resident's body was stiff, but she thought the problem was the resident's mattress and stated, It will cause her to continue to roll while turning. She confirmed she was not aware of what Resident #28's Kardex (resident care guide) indicated for the number of staff required to provide care to the resident. An observation of Resident #28's Kardex with CNA #1 revealed the resident was dependent for bed mobility and required two (2) staff members. She confirmed she should be following the Kardex for resident safety.Record review of Resident #28's Kardex revealed under, Bed Mobility: I am dependent x (times) 2 (two) staff with roll left and right.Record review of Resident #28's Care Plan revealed on 7/31/25 the care plan was revised under, Bed Mobility: I require total assistance X (times) 2 (two) staff members for bed mobility. I require total assistance with roll left and right. Further review revealed on 10/28/25 the care plan was revised again, Bed Mobility: I am dependent with roll left and right and did not indicate how many staff members were required for bed mobility.An interview with the Minimum Data Set (MDS) Nurse on 3/4/26 at 2:48 PM revealed before Resident #28's fall the Kardex did not reflect how many staff were required to care for her. She explained that the Kardex only indicated the resident was dependent on staff to roll left and right; therefore, the aides would have no way of knowing how many staff were required if it was not communicated through the Kardex.An interview with CNA #2 on 3/4/26 at 3:02 PM revealed she worked the 3-11 shift and was assigned to Resident #28 during her fall. She stated normally she was able to turn and change the resident by herself. CNA #2 explained she rolled the resident over to change her brief and the resident continued to roll and fell onto the floor on the air conditioner side of the room. CNA #2 stated, She is known for rolling forward or backward when she is turned over and this time she rolled forward. CNA #2 revealed she was not aware of what the resident's Kardex indicated for the number of staff assistance. She also revealed the resident's side rails were removed over a month ago and she thought the side rails helped support the resident. An interview with the Director of Nursing (DON) on 3/4/26 at 3:28 PM revealed Resident #28's side rails were removed in January 2026 after the resident had a bruise and abrasion to her forehead and they suspected the injuries came from the side rails. She explained the resident could not use her arms to grasp or hold onto the side rails. The DON confirmed prior to the fall that the resident's Kardex did not indicate the number of staff required to provide care. She acknowledged the air mattress shifts during turning and two (2) staff should have been indicated for safety concerns, however this intervention was not clearly communicated to staff through the Kardex prior to the incident. Record review of Resident #28's Bed Rail Assessment dated 1/6/26 revealed side rails were not indicated with interventions of: Lower the bed to the floor and provide frequent staff monitoring at night. There was no indication of adding another staff member for bed mobility.Record review of the admission Record revealed the facility admitted Resident #28 on 7/15/21 with medical diagnoses that included Parkinson's Disease without Dyskinesia, Contracture of Right and Left Knee, and Unspecified Dementia. Record review of the MDS with an Assessment Reference Date (ARD) of 1/23/26 revealed under Section C a Brief Interview for Mental Status (BIMS) summary score of 4, indicating Resident #28 was severely cognitively impaired.

Based on observation, interviews, record review, and facility policy review, the facility failed to adhere to infection control measures for one (1) of 29 sampled residents when a dinner tray containing perishable food was left in the resident's room overnight. (Resident #32)Findings Include:Review of the facility policy titled Standard Precautions Infection Control, with a revision date of 11/14/2025 revealed, . all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors .On 03/05/2026 at approximately 8:53 AM, an observation was made in Resident #32's room of a meal tray from the previous evening that had not been removed by staff. The tray contained a full plate of food including food-fortified mashed potatoes, turkey picadillo, shredded lettuce, cornbread, margarine, a peanut butter cookie, whole milk, and chocolate milk. The food appeared untouched and remained in the resident's room overnight.During an interview on 03/05/2026 at approximately 8:54 AM, a day shift certified nursing assistant (CNA) #3, stated that meal trays are expected to be removed after the resident finishes eating and confirmed the tray should have been picked up by staff.On 3/05/26 at 9:00 AM, the Administrator stated the tray should have been picked up the night it was served and should not have remained in the resident's room overnight.During an interview on 03/05/2026 at 9:30 AM, Registered Nurse #1 stated she did not know why the tray had not been removed and confirmed it should have been picked up the night the meal was served.A record review of Resident #32's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease.A record review of Resident #32''s Minimum Data Set with an Assessment Reference Date (ARD) of 12/03/2025 Section C revealed a Brief Interview for Mental Status (BIMS) summary score was 7, indicating severe cognitive impairment.

Based on resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident's right to be treated with dignity and respect was honored for one (1) of five (5) residents sampled. Resident #1Findings include:Record review of facility policy titled, Resident Rights dated 6/1/25, revealed, The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident has a right to be treated with respect and dignity.During an interview on 1/5/26 at 11:15 AM, Resident #1 revealed there was an incident when Certified Nursing Assistant (CNA) #1 failed to treat her with dignity and respect. She stated that CNA #1 was irritated with her because she asked the other CNA to leave the room and due to this, CNA #1 would not speak to her or answer her questions, and she felt the care was done quickly and in a hateful manner. She stated she reported this incident, and administration removed this staff member from her care. A phone interview on 1/5/26 at 2:40 PM with Certified Nursing Assistant (CNA) #1 revealed there was an incident when she was aggravated, and she would not speak to or answer Resident #1. She stated she did the care in a hurried and rude manner. She stated she was in-serviced on resident rights and treating each resident with the dignity and respect they are entitled to. She stated she failed to treat this resident with dignity and respect which was a resident's right. An interview with the Administrator on 1/5/26 at 3:00 PM revealed Resident #1 reported CNA #1 for not being treated with dignity and respect which each resident was to receive. The Administrator revealed an Employee Corrective Action Form was initiated on 11/17/25 for unprofessional conduct. She confirmed the facility failed to ensure a resident's right to be treated with dignity and respect was honored.The record review of the Employee Corrective Action From dated 11/17/25 for CNA #1 revealed the description of the violation was listed as unprofessional conduct. The supervisor's corrective plan of action revealed CNA #1 will be professional at all times while speaking or engaging with staff and residents.Record review of the Description of Violation form dated 11/17/25 revealed, Unprofessional conduct . that creates an unprofessional, intimidating, and/or hostile environment. Record review of CNA #1's in-service for Essentials of Resident Rights was completed on 1/9/25 and 6/3/25. Record review of Resident #1's admission Record revealed she was admitted to the facility on [DATE]. Diagnoses included Polyosteoarthritis, Rhabdomyolysis, and Morbid Obesity.Record review of Resident #1's Minimum Data Set dated 10/13/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on record review, staff interview, and facility policy review, the facility failed to ensure complete and accurate staffing data was submitted to the Centers for Medicare & Medicaid Services (CMS) through Payroll-Based Journal (PBJ) reporting during Quarter 3 of Fiscal Year (FY) 2025 (April 1 - June 30). Findings include: Review of the facility policy titled, Payroll Based Journal, implemented 6/1/25, revealed:Policy: It is the policy of the facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS . Review of the facility's PBJ Staffing Data Report revealed the facility triggered for low weekend staffing for FY Quarter 3 2025 (April 1 – June 30). Review of the PBJ hours submitted for 6/8/25, 6/15/25, 6/22/25, and 6/28/25 revealed fewer direct care staff hours submitted than documented on the facility staffing grid. 6/8/25: PBJ submitted 301.98 hours; staffing grid documented 317 actual hours. 6/15/25: PBJ submitted 312 hours; staffing grid documented 327.75 actual hours. 6/22/25: PBJ submitted 315.80 hours; staffing grid documented 322.68 actual hours. 6/28/25: PBJ submitted 317.45 hours; staffing grid documented 325.42 actual hours. During an interview with the Administrator on 9/10/25 at 7:49 AM, she confirmed that on those four dates, on-call salaried administrative nursing staff worked but their hours were not included in the PBJ data submitted to CMS and confirmed their hours should have been included. She stated the purpose of accurate PBJ reporting is to provide an accurate depiction of the number of staff available to provide quality care to the residents.

Based on observation, interview, record review and facility policy review, the facility failed to provide assistance with meals (Resident #4) and failed to provide personal hygiene and grooming for a dependent resident (Resident #29) for two (2) of 106 residents residing in the facility. Resident #4 and Resident #29. F677 was cited on the last annual survey, therefore the scope and severity was increased to E. Findings Include: Review of the facility policy Activities of Daily Living (ADLs) dated 06/01/25 revealed, .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care 4. Eating to include meals and snacks Resident #4 An observation on 9/8/25 at 11:52AM in the dining room revealed Resident #4 sitting in his wheelchair at the table, with no use of his right upper extremity. He was provided a meal of chicken stir-fried rice, a roll, watermelon in a small bowl, and a glass of tea. The resident was observed attempting to feed himself with a fork using his left hand. He repeatedly dropped his fork, had difficulty scooping food from the plate to his mouth, and began using his left fingers to eat. Food was observed spilling onto his clothing and the floor and when he picked up his tea glass, his hand was shaking which caused the tea to spill on his t-shirt and pants. He also had difficulty setting the tea glass back on the table and instead rested it on his leg. There was no observed assistance from the five staff members present in the dining room at the time. After attempting to eat with his left hand, he ate only a few bites and left the table by self-propelling himself down the hall with his left hand. An observation and interview with Resident #4 on 9/08/25 at 12:05 PM revealed he was sitting in his wheelchair and propelling himself toward his room. When asked whether he got enough to eat, the resident shook his head No. An interview on 9/08/25 at 12:10 PM with the Certified Nurse Aide (CNA) #1 confirmed that staff were responsible for supervising residents during mealtimes and acknowledged that if a resident had trouble feeding themselves, staff should help. She stated that Resident #4 could feed himself. An interview on 9/09/25 at 1:34 PM with the Rehab Director confirmed that Resident #4 had returned from the hospital recently with a physical decline and admitted that he was on the occupational therapy caseload. She explained that he had positioning concerns due to his stroke. The Rehab Director stated the resident should be allowed to feed himself, but if he had trouble, staff should step in and assist. She confirmed the resident could lose weight if he missed meals and stated the dining room staff should have intervened. An interview with the Administrator on 9/09/25 at 2:42 PM acknowledged Resident #4 could lose weight if staff failed to assist if he was having trouble. She revealed that it was her expectation for staff to provide supervision and assistance at mealtimes for residents who required it. A record review of the admission Record revealed the facility admitted Resident #4 on 9/21/20 with medical diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Right Dominant Side, and Need for Assistance with Personal Care. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/05/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 6, indicating Resident #4 had severely impaired cognition. Section GG revealed the resident had upper extremity impairment in range of motion on one side. Resident #29 On 09/09/25 at 8:05 AM during an observation and interview with Resident #29'and her Resident Representative (RR), the resident was sitting in her wheelchair, and the RP was using a comb with a pan of soapy water to comb through the resident's hair. The RR stated that it had been a while since the staff had brushed or washed her (Resident #29) hair. She revealed that Resident #29's hair was dirty and matted up and stated, they need to do better. An observation of Resident #29's hair confirmed there was a large amount of a thick light brown crusty substance to the resident's scalp, over her entire head and throughout her hair with matted knots of hair. The RR revealed she was trying to comb out the knots and remove the brown substance from her hair and stated, She has beautiful hair and I'm thinking about cutting it because of this. The RR then revealed that this was not the first time this had happened and admitted that she had given them the opportunity to wash her hair, but they did not. She revealed that when she reports this to the staff, they take care of it for a moment and then it gets back like it was. An observation and interview on 09/09/25 at 8:20 AM with CNA #2 she stated, Her daughter will let me know when she wants it done. She admitted that it had been two weeks since she had washed Resident #29's hair. She then confirmed that Resident #29's hair was matted up and had a large amount of brown crusty substance on her scalp and throughout her hair and admitted that it should be washed and brushed more often. An observation of Resident #29 and interview with the Assistant Director of Nursing (ADON) on 9/9/25 at 9:00 AM confirmed the resident had a thick brown crusty substance on her scalp and throughout her hair and that her hair was matted. She stated, This is not okay. She admitted that the crusty buildup on Resident #29's head could cause itching and the skin to break down. She also revealed that hair washing should be completed during bath or shower time as part of her grooming needs. Record review of Resident #29's admission Record revealed an admission date of 07/15/21 and that she had diagnoses that included Unspecified Dementia, Parkinson's Disease, and Need for Assistance with Personal Care. Record review of Resident #29's MDS with an ARD of 07/30/25 under Section C, revealed a BIMS score of 03 which indicated that she had severe cognitive deficits and under Section GG revealed that she was dependent on staff to provide personal hygiene.

Based on observation, family and staff interviews, record review, and facility policy review, the facility failed to implement a care plan for the application of a splinting device (Resident #4) and failed to implement a resident's ADL (activities of daily living) care plan related to personal hygiene and grooming (Resident #29) for two (2) of 21 resident care plans reviewed. Resident #4 and #29. F656 was cited on the last annual survey, therefore the scope and severity is increased to E. Findings Include: Review of the facility policy titled, Plans of Care dated 06/01/25 revealed, Develop and implement an Individualized Person-Centered comprehensive plan of care by the Interdisciplinary Team as determined by the resident's needs or as requested by the resident Resident #4 Record review of Resident #4's Care Plan Report revealed under, Focus: I have right dominant side hemiplegia/hemiparesis R/T (related to) CVA (cerebrovascular accident) Also revealed under, Interventions: Resting right hand splint 4 (four) hours daily. CNA (certified nurse aide) to apply and remove, nurse to check. Monitor right hand daily for s/s (signs and symptoms) of skin breakdown before and after splint removal every day shift. On 9/08/25 at 11:52 AM and again on 9/09/25 at 10:32 AM, an observation of Resident #4 revealed he was sitting in his wheelchair without a hand splint. During an interview with Licensed Practical Nurse (LPN) #1 on 9/09/25 at 2:00 PM, he confirmed he did not apply Resident #4's hand splint on 9/8/25 or 9/9/25 and did not follow the plan of care. An interview with the Minimum Data Set (MDS) Nurse on 9/10/25 at 8:40 AM revealed the purpose of the care plan was to ensure the staff performed the care the resident needed. She revealed if Resident #4's splint was not applied his care plan was not followed. Record review of the admission Record revealed the facility admitted Resident #4 on 9/21/20 with medical diagnoses including Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the right dominant side, and Need for Assistance with Personal Care. Record review of the MDS with an Assessment Reference Date (ARD) of 9/05/25 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 6, indicating Resident #4 had severely impaired cognition. Resident #29 Record review of Resident #29's Care Plan Report revealed that she was dependent on staff for meeting emotional, intellectual, physical, and social needs and that she had an ADL (Activities of Daily Living) self-care performance deficit and required total assistance with personal hygiene. During an observation and interview on 09/09/25 at 8:05 AM with Resident #29's Resident Representative (RR), she revealed that it had been a while since the staff had washed her (Resident #29) hair. RR revealed that Resident #29's hair was dirty and matted up and stated, they need to do better. An observation revealed a large amount of thick light brown crusty substance on her scalp, over her entire head and throughout her hair. An observation and interview on 09/09/25 at 8:20 AM with Certified Nursing Assistant (CNA) #2, revealed that she hadn't washed Resident #29's hair in about two weeks. CNA #2 confirmed that Resident #29's hair was matted up and that her hair should be washed and brushed more often. During an observation and interview on 09/09/25 at 9:00 AM with Assistant Director of Nursing (ADON) in Resident #29's room, she confirmed that Resident #29 had a thick brown crusty substance in her hair and confirmed that her hair was matted. The ADON confirmed that personal hygiene included hair washing and grooming and should be completed on bath or shower days unless otherwise indicated, and since Resident #29's hair had not been washed or brushed recently, her care plan was not followed. An interview with MDS Nurse, on 09/10/25 at 8:45 AM, revealed that it was their expectation for residents to get their hair washed on their scheduled shower days three times a week unless otherwise specified. She confirmed that since Resident #29's hair had not been washed on a regular basis, her care plan was not followed. Record review of Resident #29's admission Record revealed an admission date of 07/15/21 and that she had diagnoses that included Unspecified Dementia, Parkinson's Disease, and Need for Assistance with Personal Care. Record review of Resident #29's MDS with an ARD of 07/30/25 under Section C, revealed a BIMS score of 03 which indicated that she had severe cognitive deficits.

Based on observation, staff interview, and record review, the facility failed to ensure the dignity of a resident that needed supervision and/or assistance with meals for one (1) of five (5) residents reviewed during dining. Resident #4.Findings IncludeDuring an observation of the lunch tray pass in the dining room on 9/8/25 at 11:52AM, Resident #4 received his lunch tray from staff as he was sitting in his wheelchair at the table. This observation revealed the resident had no use of his right upper extremity. The meal that was provided included chicken stir-fried rice, a roll, watermelon in a small bowl, and a glass of tea. The resident was observed attempting to feed himself with a fork using his left hand. He repeatedly dropped his fork, had difficulty scooping food from the plate to his mouth, and began using his left fingers to eat. Food was observed spilling onto his clothing and the floor and when he picked up his tea glass, his hand was shaking which caused the tea to spill on his t-shirt and pants. He also had difficulty setting the tea glass back on the table and instead rested it on his leg. There was no observed assistance from the five staff members present in the dining room at the time. After attempting to eat with his left hand, he ate only a few bites and left the table by self-propelling himself down the hall with his left hand.An interview on 9/08/25 at 12:10 PM with the Certified Nurse Aide (CNA) #1 confirmed that staff were responsible for supervising residents during mealtimes and acknowledged that if a resident had trouble feeding themselves, staff should help.An interview on 9/09/25 at 1:34 PM with the Rehab Director confirmed that if Resident #4 had trouble feeding himself then staff should have stepped in and assisted.An interview with the Certified Occupational Therapy Assistant (COTA) on 9/9/25 at 1:50 PM revealed that with Resident #4 having to eat with his hands, it was a dignity concern.An interview with the Administrator on 9/09/25 at 2:42 PM revealed that it was her expectation for staff to provide supervision and assistance at mealtimes for residents who required it.A record review of the admission Record revealed the facility admitted Resident #4 on 9/21/20 with medical diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Right Dominant Side, and Need for Assistance with Personal Care.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/05/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 6, indicating Resident #4 had severely impaired cognition. Section GG revealed the resident had upper extremity impairment in range of motion on one side.

Based on observation, record review, and staff interview, the facility failed to ensure a resident with a contracture received the necessary treatment and services to prevent a decline in range of motion (ROM), as evidenced by the failure to apply a physician-ordered hand splint for one (1) of four (4) residents reviewed for ROM. Resident #4Findings Include: The facility provided a statement on letterhead dated 9/10/25 and signed by the Administrator, We do not have a specific policy related to splints. Record review of Resident #4's September 2025 Treatment Administration Record (TAR) revealed an order dated 4/15/25: Resting right hand splint 4 (four) hours daily. CNA (Certified Nurse Aide) to apply and remove, nurse to check. Monitor right hand daily for s/s (signs and symptoms) of skin breakdown before and after splint removal every day shift and was documented that the splint was applied at 9:00 AM on 9/8/25 and 9/9/25. An observation of Resident #4 on 9/08/25 at 11:52 AM and again on 9/09/25 at 10:32 AM revealed he was sitting in his wheelchair without a hand splint. An interview with CNA #3 on 9/09/25 at 1:31 PM revealed she was assigned to Resident #4 today. She stated the resident had not been wearing a hand splint and she was not aware she was supposed to apply one. An interview with the Rehab Director on 9/09/25 at 1:38 PM revealed Resident #4's hand splint was ordered during a previous therapy session to prevent his right-hand contracture from worsening. She explained that the occupational therapist (OT) had trained and educated staff on how to apply the splint before the resident's therapy discharge. She confirmed that if the resident was not wearing the splint, his contracture could worsen. Record review of Resident #4's Therapy Follow-Up Recommendation dated 4/10/25 confirmed under Overall Goals: Prevent contractures in right hand and place hand in optimal functional position. Documentation revealed that the occupational therapist conducted a staff in-service training on applying the hand splint, with staff signatures recorded. An interview with Licensed Practical Nurse (LPN) #1 on 9/09/25 at 2:00 PM confirmed he did not apply Resident #4's hand splint on 9/8 or 9/9. He acknowledged signing the treatment administration record (TAR) and explained there was miscommunication regarding who was responsible for applying the splint. He confirmed that not applying the splint as ordered could cause worsening contractures. An interview with the Administrator on 9/09/25 at 2:42 PM revealed her expectation was for splinting devices to be applied according to physician orders. Record review of the admission Record revealed the facility admitted Resident #4 on 9/21/20 with medical diagnoses including Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the right dominant side, and Need for Assistance with Personal Care. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/05/25 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 6, indicating Resident #4 had severely impaired cognition. Section GG also revealed upper extremity impairment in range of motion on one side.

Based on resident and staff interviews and facility policy review, the facility failed to ensure a resident's personal funds were available for use on the same day as requested for two (2) of five (5) residents reviewed for personal funds. Resident #2 and Resident #3 Findings include: Record review of facility policy titled, Resident Trust Fund - Cash Disbursements, with revision date of 2/6/24, revealed, Cash disbursements from the Resident Trust Fund petty cash box will be disbursed in accordance with state and federal regulations. The policy also revealed, Procedure: Upon request of a Medicare/HMO/Other Payer/Private resident: Must provide up to $100 on the same day requested; Over $100, must be provided within 3 business days; The resident must sign the withdrawal receipt at the time of disbursement, not the request. Upon request of a Medicaid resident: Must provide up to $70 on the same day requested; Over $70, must be provided within 3 banking days; The resident must sign the withdrawal sheet at the time of disbursement, not the request. Note: If the Business Office Manager is not in the Center, the Executive Director should be made aware of the request and ensure that the request is processed timely. During an interview on 7/1/24 at 2:15 PM, Resident #3 revealed there had been several times he was unable to get his money from the front office due to the facility not having enough money available. He revealed his check would be available on 7/3/24 and he had plans for 7/4/24 and he was already concerned that his funds would not be available when he asks for them on 7/3/24. During an interview on 7/1/24 at 2:18 PM, Resident #2 revealed he had asked for his money on several occasions, and it was not given to him on that day. He stated he had been told that the facility ran out of money and he would have to wait until the next day. Resident #2 stated he tells the Business Office Manager when he needs money and it is usually about $25 every 2-3 weeks and the Receptonist will deliver the money, but sometimes it is not till the next few days. An interview with the Business Office Manager on 7/1/24 at 3:40 PM, revealed the facility kept $750 in a locked box for the residents to have access to their money. She stated if the amount requested by the resident was less than $50, the money would be given at that time, but if over $50 was requested, the facility would need to know in advance so they could obtain the funds. She revealed there were times, especially at the first part of the month when the residents' checks came in and many residents requested their money, that there were times when the facility did not have enough money available for all the residents requesting their money and those residents had to wait until the next day to obtain their funds. During an interview on 7/1/24 at 3:45 PM, the Receptionist stated the residents requested their money from her. She revealed the facility had $750 each day to provide the residents who requested money. She acknowledged she had been in this position since 5/20/24 and there had been several times that the $750 was given out and other residents still wanted their money, but they had to wait until the next day to get theirs. An interview with the Social Worker on 7/2/24 at 8:20 AM, revealed she was one of the staff members who served as a witness and verified the amount of money obtained by each resident. She stated there had been multiple times that money was not available for each resident that was requesting it and those residents had to wait until the next day to receive their money. During an interview on 7/2/24 at 10:00 AM, the Administrator acknowledged there were times when the facility did not have enough money available for each resident who requested their money and they had to wait until the next day to receive their money. She confirmed amounts below $50 should be available the day of request, but larger amounts would take three (3) days to receive. She confirmed the facility failed to keep an adequate amount of money for the residents' use available and it was their right to have their money available. She confirmed this was the residents' money and needed to be available on request as the regulations require. Record review of Resident #2's Admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Record review of Resident #3's Admission Record revealed resident was admitted to the facility on [DATE]. Record review of Resident #3's MDS with ARD of 5/7/24, revealed a BIMS score of 15 which indicated the resident was cognitively intact.

Based on observations, interviews, record review, and facility policy review, the facility failed to protect a resident's right to be free from neglect as evidenced by failure to implement physician orders for the treatment of wounds for three (3) of five (5) wound observations. Resident #52, Resident #103, and Resident #269. The facility's failure to implement and follow physician orders for wound care and treatments put Resident #52, Resident #103 and Resident #269 and all other residents who are at risk for skin breakdown at risk for serious harm, serious injury, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/20/23 when Resident #269, who had an existing wound to the coccyx was seen by the Wound Nurse Practitioner (NP) and an X-ray was ordered of the coccyx to rule out Osteomyelitis. The X-Ray was not performed until 12/27/23. The resident's coccyx wound worsened. The facility Administrator was notified of the IJ and SQC and was presented with an IJ template on 1/31/24 at 4:50 PM. The facility provided an acceptable Removal Plan on 2/5/24, in which they alleged all corrective action to remove the IJ was completed on 2/01/24 and the IJ was removed as of 02/02/24. The Survey Agency (SA) validated the Removal Plan on 2/06/24 and determined the IJ and SQC was removed on 2/02/24. Therefore, the scope and severity for 42 CFR 483.12 (a) Freedom from Abuse, Neglect, and Exploitation (F600) was lowered from a K to an E, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Cross Reference: F658, F684, F686, F726 Findings Include: Record review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation with a revision date of 11/16/22 revealed, Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident Neglect is the failure of the center, its employees .to provide goods and services necessary to avoid physical harm . Resident #269 CROSS REFERENCE F658, F686 An observation and interview with the Wound Nurse Practitioner (NP) and the Wound Nurse on 01/31/24 at 12:00 PM of wound care for Resident #269 confirmed that the resident has a Stage 4 Pressure Ulcer to her Sacrum/Coccyx area. The NP removed the residents brief revealing that the resident was currently having a large bowel movement. After cleaning the resident, the wound care nurse removed a Duoderm from the resident's coccyx area. There was a large amount of fresh brown stool inside the residents wound. The Wound Nurse cleaned the wound with 1/4 strength Dakins solution, packed the wound with 1/4 strength Dakins moistened gauze and covered with Duoderm. The Wound NP confirmed that the pressure ulcer is in an area that is very hard to keep a dressing on and to keep clean when the resident has a bowel movement. The dressing was not completely sealed across the bottom due to being in between the folds of the buttocks. She stated, They check on her often to make sure that she has not had a bowel movement. The wound was measured by Wound Nurse Practitioner revealing measurements 5 centimeters (cm) x 5.4 cm x 2.2 cm. There is undermining of the wound at 10 to 2 (spreading from 10:00 to 2:00 on a clock face) with a maximum depth of 2.4 cm. Wound Nurse Practitioner was asked when the resident was first noted to have Osteomyelitis to the Sacrum/Coccyx pressure ulcer and she replied, I don't really remember when it began, and replied, I don't believe it will ever close completely, the goal is to keep infection out of the wound. Record review of the Order Summary Report revealed that the current treatment order dated 1/16/24 was to cleanse stage 4 sacrum with 1/4 strength Dakin's, pack with 1/4 strength Dakin's moistened gauze and cover with foam bordered dressing every day shift and as needed. Record review of documentation from the Wound Nurse Practitioner on 09/20/23 revealed that staff reported that the sacral wound began to have a prulent drainage and foul odor and the patient began to experience drowsiness, nausea and vomiting. The resident was less talkative and appeared to not feel well. The sacral wound is noted with moderate drainage as well as bone exposure and an x-ray was ordered with the visit to rule out Osteomyelitis. Record review of the Wound Nurse Practitioner visit note on 09/27/23 revealed, Nurse Practitioner to follow up with x-ray and final culture report. Wound Nurse Practitioner visit note on 10/04/23 revealed an x-ray was ordered with a previous visit and is pending. Wound Nurse Practitioner visited again on 10/11/23, 10/18/23, 10/25/23, 11/01/23, 11/08/23, 11/15/23,11/30/23, 12/06/23, 12/13/23, and 12/27/23 and continued to document that the Xray was pending. Wound Nurse Practitioner visit note on 01/03/24 revealed a recent x-ray indicated Osteomyelitis and a midline was placed and the patient is currently receiving Meropenem with recommendations for IV course of antibiotics for a minimum of six weeks, and for patient to be started on probiotic for duration of antibiotic use. An interview, on 01/31/24 at 4:00 PM with Wound Nurse Practitioner confirmed that she was aware that the x-ray that she ordered on 09/20/23 to rule out Osteomyelitis was not acted upon and done until 12/27/23. Wound Nurse Practitioner was asked if she reported to the Director of Nursing or the Assistant Director of Nursing (ADON) that the x-ray had not been performed at any point between the order date of 09/20/23 and the x-ray date of 12/27/23 and the Wound Nurse Practitioner stated No, I did not report it to them, I probably should have , but I didn't. I have to be careful what I say, we are a contracted business in this facility. I probably should have reported it to them, but I didn't. The NP was asked if the treatment for the Osteomyelitis was delayed because the x-ray was not obtained when it was ordered on 09/20/23, and she stated, I would have started the IV whenever the x-ray was gotten if it had showed Osteomyelitis. The NP confirmed that the failure of the facility to treat an infection timely could have brought about sepsis or even death for this resident. An interview on 02/01/24 at 8:45 AM, with the Administrator confirmed that it is the expectation that the Wound Nurse Practitioner notify the Director of Nursing (DON) or Assistant Director of Nursing (ADON) if there is a problem with wounds and if she sees her orders are not being implemented. An interview on 02/01/24 at 9:50 AM, with ADON confirmed that the Wound Nurse Practitioner did not make her aware that the x-ray she ordered on 09/20/23 had not been completed. The ADON stated that around that time in December that she was helping with the wound care because they had terminated the nurse prior for not doing her job and that she found the x-ray order on 12/27/23 had not been done on an audit that she had completed. The ADON confirmed that she immediately called the doctor and got the x-ray ordered and made both the Wound Nurse Practitioner and the Facility Nurse Practitioner aware that the x-ray order had not been completed. She confirmed that the Wound Nurse Practitioner should have reported that the x-ray was not followed through to her or the Director of Nursing immediately, but that she failed to do that. An interview on 02/01/24 at 10:06 AM, with Licensed Practical Nurse (LPN) #5 confirmed that she is the primary nurse for Resident #269 and was unaware that the Wound Nurse Practitioner had ordered an x-ray on 09/20/23. LPN #5 stated, She doesn't tell us anything about the wounds when she sees them. An interview on 02/01/24 at 10:15 AM, with RN #3, Unit Manager confirmed that she was not aware that there was an order for an x-ray on Resident #269 on 09/20/23. RN #3 confirmed that new orders are reviewed each morning in their stand-up meeting and that she never saw an order come through for Resident #269 for an x-ray. Review of the Admission Record for Resident #269 revealed that the resident was admitted to the facility on [DATE] with a diagnosis of Heart Failure, Local Infection of the skin and subcutaneous tissue, Pressure Ulcer of Sacral Region Stage 4, Rhabdomyolysis, and chronic kidney disease. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 07 which indicated Resident #269 was cognitively impaired. Resident # 52 CROSS REFERENCE F686, F726 An observation and interview on 01/29/24 at 12:04 PM, with Resident #52 revealed him sitting in a wheelchair in his room. The resident stated he had a wound on his bottom and his left heel. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order dated 12/29/23, Wound Care: Cleanse stage 4 pressure ulcer to coccyx with normal saline, pat dry with gauze, apply Santyl to wound bed and cover with foam bordered dressing daily with a D/C (discontinue) date of 1/12/24, which revealed there was not an active wound care physician's order for the pressure wound to the coccyx after 1/11/24. Record review of Resident #52's Order Summary Report revealed an order dated 1/18/24, Wound Care: Clean unstageable pressure ulcer of left heel with Dakins, pat dry, apply nickel thickness Santyl, apply hydrogel, cover with foam bordered dressing, wrap with kerlix, and secure with tape daily and as needed for soilage/dislodgement . On 1/30/24 at 3:38 PM, an observation of Resident #52's wound care with the Wound Nurse revealed, there was not a wound dressing to the resident's coccyx upon initiating the wound care. The Wound Care nurse provided wound care to the coccyx using a discontinued order dated 1/12/24. An observation of the left heel pressure wound revealed the Wound Nurse failed to provide the correct wound care to the left heel per the current physician orders effective 1/19/24. An interview with the Wound Nurse on 1/30/24 at 3:45 PM, confirmed that the resident did not have a dressing to the coccyx area. She revealed that she did not apply the prescribed hydrogel to the left heel wound as ordered. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order for Santyl to the coccyx with a start date of 12/29/23 was initialed every day however, the order for wound care utilizing Santyl to the coccyx was discontinued on 1/12/24. The TAR was initialed as performed by the Wound Nurse for two (2) of the thirty-one days in January on 1/30/24 and 1/31/24. All the other days were initialed as performed by other facility nurses. Record review of Resident #52's January 2024 TAR revealed, an order dated 12/29/23, Santyl External Ointment . Apply to left heel topically everyday shift for DTI (deep tissue injury). This was initialed as performed by the Wound Nurse two (2) of the thirty-one days in January 1/30 and 1/31. All the other days were initialed as performed by other facility nurses. Record review of Resident #52's Order Summary Report revealed an order dated 1/15/24, Obtain Xray of left heel r/t (related to) increased pain and clinical symptoms of osteoporosis. Record review of the Radiology Report dated 1/20/24 for Resident #52 revealed under, Conclusion: Subtle cortical bone loss at the dorsal lateral aspect of the calcaneus which may represent early osteomyelitis There was a four (4) day delay in obtaining the ordered x-ray for Resident #52's left heel. Record review of Resident #52's Physician Order Details dated 1/24/24 revealed orders for Wound #1 Left Heel and Wound #2 Coccyx . These orders were not transcribed to the TAR to reflect the current orders for Resident #52. Record review of the Admission Record revealed Resident #52 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Peripheral Vascular Disease, Pain and Pressure Ulcer of Left Heel, Stage 2. Record review of Resident #52's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 11, which indicates the resident is moderately cognitively impaired. Resident #103 CROSS REFERENCE F684, F686, F726 During an observation and interview on 01/30/24 at 8:19 AM, Resident #103 revealed him lying in bed, awake and alert. He stated he had a wound on his bottom and on his foot that caused him pain. During an interview with the Wound Nurse on 1/30/24 at 3:50 PM, revealed Resident #103 was admitted to the facility with a pressure wound on the left heel that has not shown any progress with healing and the resident has also developed other areas on the left great toe and some areas of breakdown between the toes on the left foot. She revealed the left toe started out as a blood blister and had worsened over the past couple of weeks and now are eschar covered. She stated the left great toe had been debrided by the Wound Nurse Practitioner (NP), but necrotic tissue returned. She revealed an appointment had been made with a general surgeon due to the wounds not healing and the resident's history of previous amputation of the right great toe due to a necrotic wound. During an observation of wound care for Resident #103, with the Wound Nurse on 1/30/24 at 3:55 PM, revealed she removed the soiled dressing from the wounds on the left foot. A moderate amount of red serosanguinous drainage was observed around the toe portion of the dressing. The left great toe wound was covered in 100% adherent brown eschar with redness to the peri-wound with a slight odor observed. The wound nurse cleaned the wound to the left great toe and in between the areas of the toes with normal saline, patted dry, and applied xeroform gauze to all the areas and wrapped with a gauze wrap, secured with tape. Record review for the Physician Order Details for Resident #103 dated 1/24/24 revealed the xeroform to the left great toe was discontinued. New orders were given to apply enzymatic debriding agent (Santyl) to the left great toe wound bed only and wrap with kerlix gauze. Thread toes with xeroform on the left foot, secure with tape daily and as needed. Record review of the January 2024 Treatment Administration Record (TAR) for Resident #103 revealed there was not a wound care order for the diabetic ulcer on the left great toe or the breakdown between the inner toes. Record review of the Order Summary Report with active orders as of 1/31/24 for Resident #103 revealed there was not a Physician Order for wound care to the left great toe or in between the toes on the left foot. Record review of the Weekly Skin Integrity Review forms for Resident #103 dated 1/23/24 and 1/30/24 revealed the wounds in between the toes on the left foot were present and the treatment nurse was aware. The report did not address the left great toe. Record review of the Progress Note Details dated 12/27/23 for Resident #103 revealed, There is also a 0.8 x 1.5 x 0.0 bruised area on the left great toe that was noted at his most recent visit .Will continue to monitor left great toe . Record review of the Progress Note Details dated 1/03/24 for Resident #103 revealed under, Wound Assessment(s) . Wound #3 Left Toe blister and has received a status of Not Healed. Initial wound encounter measurements are 1 cm (centimeter) length x 1.2 cm (centimeter) width with no measurable depth, with an area of 1.2 sq (square) cm (centimeters). Also revealed under, General Notes: Will continue to monitor left great toe. Staff to notify of any changes. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 12/28/23, for wound care to the left heel stage 3 pressure ulcer with a D/C (discontinue) date of 1/18/24. The order was not initialed as completed by the Wound Nurse any of the 18 days in January the order was active. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 1/19/24 for wound care to the left heel stage 3 pressure ulcer. The wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated, 12/28/23 for the right foot great toe amputation site revealed the TAR was initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of Resident #103's TAR for January 2024 for sheering abrasion to the left buttocks revealed an order dated 12/15/23 was only initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of the Admission Record for Resident #103 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Encounter for Orthopedic Aftercare Following Surgical Amputation, acquired absence of Right Great Toe, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Pressure Ulcer of Left Heel, Stage 3, and Pain. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/23 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicates Resident #103 is cognitively intact. During an interview with the Wound Care Nurse on 1/31/24 at 9:45 AM, revealed she had been back in the Wound Nurse position since January 1, 2024. She revealed all the wound documentation was behind, and she had to catch things up when she transferred to the position. She stated all the wounds were seen in the facility by the Wound Nurse Practitioner (NP) once weekly on Wednesdays and the Wound NP did not give any orders the day she visited but tells her what she wants to be changed up or makes recommendations for the treatments, and she will send the facility the progress notes the following Friday or Monday. She revealed there were times she did not get the Wound NP's Progress Note until a week later. She confirmed that she had access to the site where the Wound NP uploads the documents, and she could pull the progress notes after it was uploaded. She revealed that Resident #52's left heel pressure wound developed in the facility and was initially a Stage 2 blister and was now unstageable. She stated she was unsure what interventions were put in place to prevent skin breakdown since she had only been in the wound position for a month. She revealed that she worked Monday-Friday and had been doing all the wound care in the facility on those days. She explained that on the weekends, she leaves a list of the residents with wounds so that the nurses will know whom to perform wound care on. She confirmed that her initials were not listed on Resident #52's Treatment Administration Record (TAR) for the month of January 2024 except for 1/30/24 and 1/31/24. She stated that she did do the treatments but did not sit down to initial them until the evenings and occasionally the other nurses had signed off on them already. She revealed that the Medication Cart Nurses did help her with holding certain residents, so they could have gone in and signed the TAR before she got to it. She revealed that she was not aware that Resident #52's treatment order for the coccyx pressure wound had been discontinued on 01/12/24. She explained that she had no idea who would have discontinued the treatment order out of the system and acknowledged that she did not follow the TAR for treatment orders, or she would have caught the error. She explained that Resident #103's left great toe wound developed as a dry piece of skin that has continued to worsen, with new ulcers that developed in between the toes. She revealed the Wound NP visited him last week to assess the wound and made the recommendation to apply xeroform gauze and start clindamycin for infection, but she did not enter the orders into the system. She confirmed that she would be the person responsible for implementing the orders and that she goes ahead and starts any new treatment recommendations but does not put the order into the system because once she received the NP progress note, she may have changed something up with the wound care. She explained that she was instructed by the Wound NP that the clindamycin needed to be approved by nephrology, since the resident was on dialysis, so the resident was not started on the clindamycin when it was originally ordered on 1/24/24. The Wound Nurse confirmed that she never called the dialysis unit to get the antibiotic order approved. She revealed the wound was not cultured but did show clinical signs of infection and that all medications that the Wound NP recommends must be approved by the Primary Care Practitioner (PCP). She confirmed that she did the treatment on Resident #103's left toes without an active order in the computer and stated, I don't get her notes until a week later, so I can't put in an order, if I don't have one. She confirmed that a verbal order from the NP should be immediately acted upon and that she was given a verbal order from the NP. She revealed not implementing physician orders immediately was a delay in treatment of the wound and treating the infection. She revealed that delay of treatment could result in possible infection, sepsis, or amputation for both Resident #52 and #103. She confirmed that other nurses had initialed Resident #103's January Treatment Administration Record (TAR) and she revealed she was the person responsible for signing since she completed the treatments. During an interview with the Assistant Director of Nursing (ADON) on 1/31/24 at 10:05 AM, revealed that the facility had not had a consistent Wound Care Nurse for the past six (6) months. She revealed that the previous Wound Nurse worked for about three (3) months and left without notice, although she was going to be terminated due to lack of documentation on the wounds. The ADON stated that she filled in for the Wound Nurse position for about a month until the current Wound Nurse could transfer from the night shift position. The ADON stated that things were behind as far as documentation on the facility wounds, and the Wound Nurse had to get all the information up to date. She revealed that she had not had any concerns regarding the Wound Nurse and felt as if she did a good job. She stated that the Wound Care Nurse did treatments when she was originally hired in 2019 for about a year, so they felt she had enough experience. She revealed she had no reason to suspect anything was wrong and confirmed that the Wound Nurse had not had any wound care training after switching from the night shift supervisor role to the wound care role in January. She confirmed that Resident #52's treatment order for the coccyx had been discontinued on 1/12/24 unintentionally by a staff member. She confirmed that she was not aware that the Wound Nurse was not utilizing the TAR to complete the wound care each day. She would have caught that the order was discontinued if she had looked at the TAR and signed off after the treatment was provided. She revealed she was not sure how the nurses on the weekends were providing wound care. During a telephone interview with the Wound Nurse Practitioner on 1/31/24 at 3:40 PM, revealed she rounds on all the facility wounds every Wednesday and during her visits she makes recommendations for wound care, but the facility does not receive the progress note until Friday evening when it's faxed over, but that when she makes rounds with the Wound Nurse, she gives verbal orders. She revealed some of her recommendations may be delayed because certain orders must go through the resident's primary care provider (PCP) or dialysis, such as antibiotics or pain medication if the resident is on dialysis. She confirmed she was aware of the delay in antibiotics that were ordered on 01/24/24 for Resident #103 because it had to be approved with the PCP due to high risk of drug nephrotoxicity but she assumed that the antibiotic order had been implemented by now, and confirmed that she had not been made aware that the resident still did not have an order for an antibiotic. She revealed that Resident #103 developed a dried blood blister to his left great toe that has deteriorated with a new breakdown in between the toes. She stated the resident had negative Doppler studies and ABI testing that showed moderate Peripheral Vascular Disease. She revealed that Resident #103 was a Diabetic, on dialysis and had a previous history of toe amputation, so she recommended a referral to a General Surgeon due to his high risk of the same outcome (amputation). She revealed she had not been made aware by the facility that Resident #103's left toe wound orders had not been acted upon by the Wound Nurse and the treatment ordered added in the charting system. She revealed that the current Wound Nurse just started, and she was aware that the wound care documentation was behind. She explained that Resident #52's heel wound was unchanged and had not shown any progress. She explained that she also referred the resident to a general surgeon because she was unable to perform the needed debridement in the facility setting due to pain management. She stated that she was not made aware that Resident #52's coccyx treatment order had been discontinued on 1/12/24. She stated that lack of a dressing to the coccyx wound could cause delay in healing and infection. She revealed that she had not been made aware of any concerns regarding the Wound Nurse not performing her duties or following physician orders. She confirmed that if the treatments weren't done as ordered, the wounds would deteriorate. An interview with Licensed Practical Nurse (LPN) #4 on 2/01/24 at 11:05 AM, revealed that she worked the Medication Cart on 7-3 shift. She revealed that she had been doing the treatments for Resident #52 on the weekends and some during the weekdays. She explained that the facility had not had a consistent or set Wound Nurse in months. She explained that the current Monday through Friday Wound Nurse had been out some, and the nurses had been told that she was not starting full time until February. She confirmed that there were days when the treatments had not been signed off on by the Wound Nurse and the Medication nurses felt responsible for signing them off because they couldn't have things not completed on the TAR at the end of their shift. She explained that there had been times in the past month when the medication nurses were told to do all the wound care because the Wound Nurse was behind and had orders and documentation to complete. LPN #4 explained that she was working this past weekend (1/27/24 and 1/28/24), so she went to the Wound Nurse on Thursday 1/25/24 because she saw that Resident #52's coccyx order had been discontinued in the computer. She revealed that she was told by the Wound Nurse that the order had been discontinued and not to worry about it. She explained that the Wound Nurse never checked in the computer system when she asked her or got up from what she was doing at the time, she simply stated it had been discontinued. She revealed that the order to apply Santyl to the coccyx continued to come up on the TAR, so she applied Santyl to the wound on the coccyx, but did not apply a cover dressing because it was not ordered. She revealed that she was confused because she knew the resident did have a treatment order and all of a sudden, it stopped. She revealed that even when she followed behind the Wound Nurse the last couple of weeks, Resident #52 never had a dressing on his coccyx. LPN #4 stated when she said something again to the Wound Nurse about the wound not having a dressing, she stated, It's been discontinued and acted like it wasn't a big deal. LPN #4 explained that she knew the wound should be covered to keep out urine and feces, because the resident was incontinent, which could cause infection and slow the healing of the wound. She stated that she had never been given a list or left a list of the residents with wounds and treatments for the weekend. She explained that this past Sunday, 1/28/24 they didn't find out that they didn't have a Wound Care Nurse until 1 PM and her shift was over at 3 PM and she wasn't sure who did the wound care that day. During an interview with the Assistant Director of Nursing (ADON) on 2/01/24 at 11:25 AM, revealed she had not been made aware of any concerns from the Medication Nurses related to wound care. She explained, to her knowledge, the Medication Nurses had never been asked to perform treatments so the Wound Nurse could catch up on orders or documentation. She confirmed that the nurses should not sign off on treatments that the Wound Nurse performed, and they had never been told to do so. She explained that she had never pulled the TAR to check and see who signed off on the treatments. She explained that she felt the Wound Nurse got caught up in the day-to-day processes and just didn't make sure things were done. She revealed that she was not aware of a list that was left on the weekends to know which residents needed wound care. She stated the wound care should be administered from the TAR and signed off when completed. She explained that the facility did have a call in Sunday 1/28/24 with the person who was supposed to do the wound care and stated the Director of Nursing (DON) would have been responsible for letting the Unit Managers know. During an interview with the Director of Nursing (DON) on 2/1/24 at 4:35 PM, revealed that she and the Administrator (ADM) had spoken with the Wound Nurse about taking the Wound Care position when the job opened. She stated that the Wound Nurse had performed the treatments before in the facility when she was first hired, and she was knowledgeable, and she felt the Wound Nurse did a good job. She stated the Wound Nurse was full-time and worked Monday through Friday, so she wasn't sure why she told the medication cart nurses that she was just part time. She revealed that the only thing that had changed since the Wound Nurse did previous treatments was, they hired a new Wound Nurse Practitioner (NP). She confirmed that the Wound Care Nurse could have implemented the physician order when the NP visited because she was giving the verbal order, which could have been added as a verbal physician's order. She stated, If you are given an order, you should implement that order. She revealed the Wound Nurse should have signed the treatments after they were administered, just like with giving medication. She said was not aware of the Wound Nurse telling the Medication Nurses that they were required to do treatments because she was behind with orders and documentation. She stated, She could have because I'm not out there on the floor. The DON revealed that the Wound Nurse had not been given any wound training or expectations since she accepted the Wound Care Nurse position in January and stated, We just trusted her that [TRUNCATED]

47874 Based on observation, interview, record review and facility policy review, the facility failed to ensure residents received the necessary care and treatment for pressure ulcers to prevent complications and worsening of wounds for three (3) of five (5) residents reviewed for pressure ulcers. Resident #52, Resident #103 and #269 The facility's failure to provide necessary care and treatments for pressure ulcers caused worsening of pressure ulcers for Resident #52, Resident #103, and Resident #269 and placed all other residents at risk for skin breakdown in a situation with the likelihood of serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/20/23 when Resident #269, who had an existing wound to coccyx was seen by the Wound Nurse Practitioner (NP) and an X-ray was ordered of the coccyx to rule out Osteomyelitis. The order for the X-Ray was not performed until 12/27/23, (almost 3 months later) which caused the residents coccyx wound to worsen. The facility Administrator was notified of the IJ and SQC and was presented with an IJ template on 1/31/24 at 4:50 PM. The facility provided an acceptable Removal Plan, in which they alleged all corrective action to remove the IJ was completed on 2/01/24 and the IJ was removed as of 02/02/24. The SA validated the Removal Plan on 2/06/24 and determined the IJ and SQC was removed on 2/02/24. Therefore, the scope and severity for 42 CFR 483.25(b)(1)(i)(ii) Pressure Ulcers was lowered from a K to a E, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: CROSS REFERENCE F600, F658, F726 Record review of the facility policy titled Skin and Wound with a revision date of 1/24/22 revealed under, Policy: To provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure injuries .Pressure Injury Prevention: . 3. Nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record . Skin Impairment Identification: 1. Document presence of skin impairment(s) / new skin impairments(s) when observed and weekly until resolved 2. Nurse to report changes in skin integrity to the physician/physician extender, resident /resident representative and document in the medical record 3. Develop resident centered interventions and document on the plan of care and the Nurse Aide Kardex .5. Monitor residents' response to treatment, modify as indicated . Resident # 52 Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order dated 12/29/23, Wound Care: Cleanse stage 4 pressure ulcer to coccyx with normal saline, pat dry with gauze, apply Santyl to wound bed and cover with foam bordered dressing daily with a D/C (discontinue) date of 1/12/24, which revealed there was not an active wound care physician's order for the pressure wound to the coccyx after 1/11/24. An observation of Resident #52's wound care with the Wound Nurse on 1/30/24 at 3:38 PM revealed, there was not a wound dressing to the resident's coccyx upon initiating the wound care. The coccyx wound bed was 90% yellow, adherent slough, 10% granulation tissue with redness and maceration to the wound edges. The Wound Nurse cleansed the wound with Dakin's solution, patted dry, applied a layer of Santyl and covered with a foam dressing. Record review of Resident #52's Order Summary Report revealed an order dated 1/18/24, Wound Care: Clean unstageable pressure ulcer of left heel with Dakins, pat dry, apply nickel thickness Santyl, apply hydrogel, cover with foam bordered dressing, wrap with kerlix, and secure with tape daily and as needed for soilage/dislodgement . Continued observation on 1/30/24 at 3:38 PM of the left heel pressure wound revealed, 100% adhering brown eschar to the wound bed. Slight redness observed to the peri-wound. The Wound Nurse stated the treatment orders for the left heel were to cleanse the wound with Dakin's solution, pat dry, apply a layer of Santyl, cover with foam and wrap with gauze wrap. An interview with the Wound Nurse on 1/30/24 at 3:45 PM confirmed that the resident did not have a dressing to the coccyx area and that urine and stool could get inside the wound and cause infection and delay the healing of the wound. She revealed the purpose of having the dressing over the wound was to keep bacteria out and provide a moist environment for healing. She revealed that she did not apply the prescribed hydrogel to the left heel wound as ordered. She revealed the hydrogel was ordered along with Santyl to debride the adherent eschar and that the resident recently completed antibiotics due to the left heel wound being infected. She stated they have a Wound Nurse Practitioner (NP) that visits the resident every Wednesday and measures the wounds and prescribes the treatment orders. She stated the NP wanted the resident to see a general surgeon due to the left heel not showing any progress of healing or improvement, and a recent X-ray of the heel could not rule out osteomyelitis. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order dated 12/29/23, Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to coccyx topically everyday shift for Stage 4 Pressure Ulcer initialed as performed by the Wound Nurse two (2) of the thirty-one days in January 1/30 and 1/31. All the other days were initiated as performed by other facility nurses. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed, an order dated 12/29/23, Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to left heel topically everyday shift for DTI (deep tissue injury) initialed as performed by the Wound Nurse two (2) of the thirty-one days in January 1/30 and 1/31. All the other days were initialed as performed by other facility nurses. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order dated 12/28/23, Santyl External Ointment 250 UNIT/GM (grams) (collagenase) Apply to Coccyx topically as needed for Soling or Dislodgement not documented as administered for the month of January. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order dated 12/28/23, Santyl External Ointment 250 UNIT/GM (grams) (collagenase) Apply to Left Heel topically as needed for Soling or Dislodgement not documented as administered for the month of January. Record review of the Wound Diagnostic Report for Resident #52 dated 1/12/24, revealed a culture and sensitivity was performed of the left heel and under Summary Report Organisms identified, were Staphylococcus aureus and Enterococcus faecalis with Moderate growth. Record review of Resident #52's Order Summary Report revealed an order dated 1/15/24, Obtain Xray of left heel r/t (related to) increased pain and clinical symptoms of osteoporosis. Record review of the Radiology Report dated 1/20/24 for Resident #52 revealed under, Conclusion: Subtle cortical bone loss at the dorsal lateral aspect of the calcaneus which may represent early osteomyelitis Record review of the Weekly Wound Report: Pressure Injury for the Week of 11/08/23 for Resident #52 revealed, Facility Acquired Date and Stage . 11/10/23 Stage 2 Measurements 2.5 cm (centimeters) x 3.5 cm (centimeters) . Record review of the Weekly Wound Report: Pressure Injury for the Week of 1/24/24 for Resident #52 revealed, Facility Acquired Date and Stage . 11/10/23 Stage 2 . Visualized Stage UNS (unstageable) .Measurements 3.5 cm (centimeters) x 6.2 cm (centimeters) .Lt (left) heel . Record review of Resident #52's Pressure Ulcer Wound Rounds dated 12/28/23 revealed, Site Left heel . Type Pressure . Length 2.5 Width 5 Depth 0 . Stage Suspected Deep Tissue Injury Also revealed, Site Coccyx . Type Pressure . Length 6 Width 4 Depth 0 . Stage IV . Record review of Resident #52's Physician Order Details dated 1/24/24 revealed, Wound #1 Left Heel . Clean wound with 1/4 (one-fourth) Strength Dakins . Enzymatic Debriding Agent Apply nickel thickness Santyl to the wound bed only. Apply Hydrogel . Other - Foam pad, kerlix .Change dressing Every day and as needed Wound #2 Coccyx . Clean wound with 1/4(one-fourth) strength Dakins. Enzymatic Debriding Agent Apply nickel thickness Santyl to the wound bed only. Apply duoderm or hydrocolloid - or FBD (foam bordered dressing) . Change dressing every day and as needed . Record review of the Wound Nurse Practitioner (NP) visit notes for Resident #52 dated 1/24/24, The wound to the left heel remains unstageable due to eschar Will continue orders for Santyl and add hydrogel in an attempt to loosen the slough The patient has been referred to Proper Name for further evaluation due to HX (history) of amputation, unable to manage pain for deep debridement A recent Xray indicated subtle cortical bone loss at the dorsal lateral aspect of the calcaneus which may represent early Osteomyelitis. Record review of the Wound Nurse Practitioner (NP) visit notes for Resident #52 dated 1/24/24, Wound #1 Left Heel is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3.5 cm (centimeters) length x 6.2 cm (centimeters) width with no measurable depth, with an area of 21.7 Sq (square) cm (centimeters) Wound #2 Coccyx is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 5.2 cm (centimeters) length x 3.6 cm (centimeters) width x 0.2 cm (centimeters) depth, with an area of 18.72 sq (square) cm (centimeters) and volume of 3.744 cubic cm (centimeters). Record review of the Wound Nurse Practitioner (NP) visit notes for Resident #52 dated 1/3/24 revealed, Wound #1 Left Heel is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2 cm (centimeters) length x 4.5 cm (centimeters) width x 0.1 cm (centimeter) depth, with an area of 9 sq (square) cm (centimeter) and volume of 0.9 cubic cm (centimeters) There is a scant amount of yellow drainage noted which has odor Wound bed has no, granulation, 51-75% slough, 1-25%eschar, no epithelialization present. The wound is deteriorating Wound #2 Coccyx is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements 8.2 cm (centimeters) length x 2.3 cm (centimeters) depth, with an area of 18.86 sq (square) cm (centimeters) and a volume of 3.772 cubic cm (centimeters) There is a small amount of sero-sanguineous drainage noted which has no odor The wound margin is well defined Wound bed has no, granulation, 76-100% slough; no eschar and no epithelialization present. Record review of the Weekly Skin Integrity Review for Resident #52 dated 1/12/24 revealed, Coccyx pressure ulcer . Left heel unstageable and under, Notes: Tx (treatment) in process. Record review of the Weekly Skin Integrity Review for Resident #52 dated 1/19/24 revealed, Coccyx Pressure Ulcer . Left heel Unstageable and revealed under, Notes: Continue Current Tx (treatment). Record review of the Weekly Skin Integrity Review for Resident #52 dated 1/26/24 revealed, Coccyx pressure . Left heel pressure and revealed under, Notes: Tx (treatment) in progress) Record review of the Braden Scale for Predicting Pressure Sore Risk for Resident #52 dated 12/27/23 revealed a Braden Score of 14, indicating the resident is at Moderate Risk for pressure wound development. Record review of the Admission Record revealed the facility admitted Resident #52 on 3/8/22 with medical diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Acute on Chronic Systolic (congestive) Heart Failure, Peripheral Vascular Disease, pain and Pressure Ulcer of Left Heel, Stage 2. Record review of Resident #52's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 11, which indicates the resident is moderately cognitively impaired. Also revealed under section M, the current number of Unhealed Pressure Ulcers/Injuries at Each Stage, one (1) Stage 2 pressure ulcer was marked. Resident #103 An observation and interview on 01/30/24 at 8:19 AM, with Resident #103 revealed him lying in bed, awake and alert. He stated he had a wound on his bottom and on his foot that caused him pain. An interview with the Wound Nurse on 1/30/24 at 3:50 PM revealed Resident #103 was admitted to the facility with a pressure wound on the left heel that has not showed improvement. She revealed an appointment had been made with a general surgeon due to the wounds not healing and the resident's history of previous amputation of the right great toe due to a necrotic wound. An observation of wound care for Resident #103, with the Wound Nurse on 1/30/24 at 3:55 PM, revealed she removed the soiled dressing from the wounds on the left foot. Record review of the Treatment Administration Record (TAR) for Resident #103 revealed there was not a wound care order for the ulcer on the left great toe or the breakdown between the inner toes. Record review of the Order Summary Report for Resident #103 revealed there was not a Physician Order for wound care to the left great toe or in between the toes on the left foot. Record review of Resident #103's Order Summary Report revealed an order dated 7/8/23, Weekly skin sweeps on Tuesday 3-11 every evening shift every Tue (Tuesday) . Record review of the Weekly Skin Integrity Review for Resident #103 dated 1/23/24 revealed under, Notes: wounds to right great toe, left heel, preexisting wound orders noted. wounds in-between left 3rd,4th and 4th, 5th toes. treatment nurse aware Record review of the Weekly Skin Integrity Review for Resident #103 dated 1/30/24 revealed under, Notes: wounds to right great toe, left heel, preexisting wound orders noted. Wounds in-between left 3rd,4th and 4th,5th toes. Record review of the Order Summary Report for Resident #103 revealed an order dated 1/25/24, Appointment with Proper Name (General Surgeon) 2/13/24 @ (at) 0800. One time only for NON-HEALING WOUNDS for 2 days . Record review of Resident #103's Doppler Report dated 12/19/23 revealed under, Conclusion: Moderate peripheral vascular disease in the left lower extremity. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 12/28/23, Wound Care: Clean Left heel stage 3 pressure ulcer with normal saline, pat dry with gauze, apply Medi honey to wound bed, cover with foam dressing, wrap with kerlix and secure with tape daily with a D/C (discontinue) date of 1/18/24. The order was not initiated as completed by the Wound Nurse any of the 18 days in January the order was active. The wound care was not documented as administered on 1/22 and 1/28, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated, 12/28/23, Wound Care: Cleanse right foot great toe amputation site with soap and water and apply A&D ointment daily initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22 and 1/28, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 12/15/23, Wound Care: Cleanse shearing abrasion to left buttock with NS (normal saline), apply triad daily initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22 and 1/28, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 1/19/24, Wound Care: Clean left heel stage 3 pressure ulcer with normal saline, pat dry with gauze, apply Santyl to wound bed at nickel thickness, cover with foam dressing, wrap with kerlix and secure with tape daily initialed as completed by the Wound Nurse two (2) of the 13 days that the order was active. The other dates were initialed as completed by other facility nurses. The dates of 1/22 and 1/28 have no initials to support wound care was performed, which was a total of 2 missed treatments. Record review of the Progress Note Details dated 12/27/23 for Resident #103 revealed under, There is also a 0.8 x 1.5 x 0.0 bruised area on the left great toe that was noted at his most recent visit . Also revealed under, General Notes: Will continue to monitor left great toe. Record review of the Progress Note Details dated 1/03/24 for Resident #103 revealed under, Wound Assessment(s) . Wound #3 Left Toe blister and has received a status of Not Healed. Initial wound encounter measurements are 1 cm (centimeter) length x 1.2 cm (centimeter) width with no measurable depth, with an area of 1.2 sq (square) cm (centimeters). Also revealed under, General Notes: Will continue to monitor left great toe. Staff to notify of any changes. Record review of the Physician Order Details for Resident #103 dated 1/10/24 revealed under, Wound #3 Left Toe . Care of Wound: Apply Xeroform cover with Foam Bordered Dressing . Change dressing Every day and as needed . Also revealed under, Progress Note Details . Wound #3 is a Partial Thickness Blister and has received a status of Not healed. Subsequent wound encounter measurements are 0.8 cm (centimeter) length x 1.5 cm (centimeter) width x 0.1 cm (centimeter) depth, with an area of 1.2 cubic cm (centimeter) There is a scant amount of sero-sanguineous drainage noted which has no odor. Record review of the Physician Order Details for Resident #103 dated 1/24/24 revealed, Wound #3 Left Toe . Care of Wound: Enzymatic debriding agent nickel thickness Santyl to the wound bed only. Cover dressing with dry gauze and wrap with Kling/kerlix. Do not put tape directly on the skin. Other: D/C (discontinue) xeroform to left great toe . Thread toes with xeroform on left foot Secure dressing with tape . Change dressing every day and as needed. Also revealed under, Progress Note Details . The bruised/blood blister area to the left great toe is now covered in eschar with bogginess palpated. There are also scattered wounds to the 4th and 5th toes of recent onset Recent amputation to right great toe. Scattered wounds noted to 4th and 5th toes as well on left foot of recent onset with worsening of left great toe. Refer to Proper Name (General Surgeon) for further evaluation 1/25/24: Order for Clindamycin 300 mg (milligrams) 1 (one) po (by mouth) bid (twice daily) x 10 days. Record review of the Admission Record for Resident #103 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Encounter for Orthopedic Aftercare Following Surgical Amputation, acquired absence of Right Great Toe, Nontraumatic Subarachnoid Hemorrhage Left Middle Cerebral Artery, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Pressure Ulcer of Left Heel, Stage 3, and Pain. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/23 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicates Resident #103 is cognitively intact. Also revealed under section M, diabetic foot ulcer(s) were not checked for the MDS look back period. An interview with the Wound Care Nurse on 1/31/24 at 9:45 AM revealed she had worked at the facility for 3 years. She stated she had been back in the Wound Nurse position since January 1, 2024. She revealed prior to her taking the position, they had another wound nurse who worked for about 3 months and resigned, leaving the facility in a bind due to her lack of inconsistent wound charting. She revealed all the wound documentation was behind, and she had to catch things up when she transferred to the position. She revealed that the facility was sending the residents with wounds out to the Proper Name hospital but changed over to Proper Name Wound clinic on Sept. 1, 2023. She stated all the wounds were seen in the facility by the Wound Nurse Practitioner (NP) once weekly on Wednesdays and the Wound NP did not give any orders the day she visited but tells her what she wants to be changed up or makes recommendations for the treatments, and she will send the facility the progress notes the following Friday or Monday. An interview with the Wound Care Nurse on 1/31/24 at 9:45 AM also revealed that Resident #52's left heel pressure wound developed in the facility and was initially a Stage 2 blister and was now unstageable. She stated she was unsure what interventions were put in place to prevent skin breakdown since she had only been in the wound position for a month. She revealed that she worked Monday-Friday and had been doing all the wound care in the facility on those days. She explained that on the weekends, she leaves a list of the residents with wounds so that the nurses will know whom to perform wound care on. She confirmed that her initials were not listed on Resident #52's Treatment Administration Record (TAR) for the month of January 2024 except for 1/30 and 1/31. She stated that she did do the treatments but did not sit down to initial them until the evenings and occasionally the other nurses had signed off on them already. She revealed that the Medication Cart Nurses did help her with holding certain residents, so they could have gone in and signed the TAR before she got to it. She revealed that she was not aware that Resident #52's treatment order for the coccyx pressure wound had been discontinued on 01/12/24. She explained that she had no idea who would have discontinued the treatment order out of the system and acknowledged that she did not follow the TAR for treatment orders, or she would have caught the error. An interview with the Wound Care Nurse on 1/31/24 at 9:45 AM also revealed that Resident #103's left great toe wound developed as a dry piece of skin that has continued to worsen, with new ulcers that developed in between the toes. She revealed the Wound NP visited him last week to assess the wound and made the recommendation to apply xeroform gauze and start clindamycin for infection, but she did not enter the orders into the system. She confirmed that she would be the person responsible for implementing the orders and that she goes ahead and starts any new treatment recommendations but does not put the order into the system because once she received the NP progress note, she may have changed something up with the wound care. She explained that she was instructed by the Wound NP that the clindamycin needed to be approved by nephrology, since the resident was on dialysis, so the resident was not started on the clindamycin when it was originally ordered on 1/24/24. The Wound Nurse confirmed that she never called the dialysis unit to get the antibiotic order approved. She revealed the wound was not cultured but did show clinical signs of infection and that all medications that the Wound NP recommends must be approved by the Primary Care Practitioner (PCP). She confirmed that she did the treatment on Resident #103's left toes without an active order in the computer and stated, I don't get her notes until a week later, so I can't put in an order, if I don't have one. She confirmed that a verbal order from the NP should be immediately acted upon and that she was given a verbal order from the NP. She revealed not implementing physician orders immediately was a delay in treatment of the wound and treating the infection. She revealed that delay of treatment could result in possible infection, sepsis, or amputation for both Resident #52 and #103. She confirmed that other nurses had initialed Resident #103's January Treatment Administration Record (TAR) and she revealed she was the person responsible for signing since she completed the treatments. An interview with Licensed Practical Nurse (LPN) #4 on 2/01/24 at 11:05 AM revealed that she had been doing the treatments for Resident #52 on the weekends and some during the weekdays. She explained that the facility had not had a consistent or set Wound Nurse in months. She revealed that the facility just hired a new Wound Nurse for the weekends, but she had not started yet. She explained that the current Monday through Friday Wound Nurse had been out some, and the nurses had been told that she was not starting full time until February. She confirmed that there were days when the treatments had not been signed off on by the Wound Nurse and the Medication nurses felt responsible for signing them off because they couldn't have things not completed on the TAR at the end of their shift. She explained that there had been times in the past month when the medication nurses were told to do all the wound care because the Wound Nurse was behind and had orders and documentation to complete. LPN #4 explained that she was working this past weekend (1/27 and 1/28), so she went to the Wound Nurse on Thursday 1/25/24 because she saw that Resident #52's coccyx order had been discontinued in the computer. She revealed that she was told by the Wound Nurse that the order had been discontinued and not to worry about it. She explained that the Wound Nurse never checked in the computer system when she asked her or got up from what she was doing at the time, she simply stated it had been discontinued. She revealed that the order to apply Santyl to the coccyx continued to come up on the TAR, so she applied Santyl to the wound on the coccyx, but did not apply a cover dressing because it was not ordered. She revealed that she was confused because she knew the resident did have a treatment order and all of a sudden, it stopped. She revealed that even when she followed behind the Wound Nurse the last couple of weeks, Resident #52 never had a dressing on his coccyx. LPN #4 stated when she said something again to the Wound Nurse about the wound not having a dressing, she stated, It's been discontinued and acted like it wasn't a big deal. LPN #4 explained that she knew the wound should be covered to keep out urine and feces, because the resident was incontinent, which could cause infection and slow the healing of the wound. She stated that she had never been given a list or left a list of the residents with wounds and treatments for the weekend. She explained that this past Sunday, 1/28/24 they didn't find out that they didn't have a Wound Care Nurse until 1PM and her shift was over at 3PM and she wasn't sure who did the wound care that day. An interview with the Assistant Director of Nursing (ADON) on 1/31/24 at 10:05 AM revealed that the facility had not had a consistent Wound Care Nurse for the past 6 months. The ADON stated that she filled in for the Wound Nurse position for about a month until the current Wound Nurse could transfer from the night shift position. The ADON stated that things were behind as far as documentation on the facility wounds, and the Wound Nurse had to get all the information up to date. She revealed that she had not had any concerns regarding the Wound Nurse and felt as if she did a good job. She confirmed that the Wound Nurse had not had any wound care training after switching from the night shift supervisor role to the wound care role in January. She revealed that the Wound Nurse brought a list of the wounds to the last Quality Assurance and Performance Improvement (QAPI) meeting held this month, where the wounds were discussed. She revealed that the facility just QAPI'd the wounds back in December 2023 after the other Wound Nurse left and all the orders were compared to the NP orders versus the Treatment Administration Record (TAR) and verified accuracy by 12/27/23. She confirmed that Resident #52's treatment order for the coccyx had been discontinued on 1/12/24 unintentionally by a staff member. She confirmed that she was not aware that the Wound Nurse was not utilizing the TAR to complete the wound care each day that she would have caught that the order was discontinued if she had looked at the TAR and signed off after the treatment was provided. She revealed she was not sure how the nurses on the weekends were providing wound care. A telephone interview with the Wound Nurse Practitioner on 1/31/24 at 3:40 PM revealed she rounds on all the facility wounds every Wednesday and during her visits she makes recommendations for wound care, but the facility does not receive the progress note until Friday evening when it's faxed over, but that when she makes rounds with the Wound Nurse she gives verbal orders. She revealed some of her recommendations may be delayed because certain orders must go through the resident's primary care provider (PCP) or dialysis, such as antibiotics or pain medication if the resident is on dialysis. She confirmed she was aware of the delay in antibiotics that were ordered on 01/24/24 for Resident #103 because it had to be approved with the PCP due to high risk of drug nephrotoxicity but she assumed that the antibiotic order had been implemented by now, and confirmed that she had not been made aware that the resident still did not have an order for an antibiotic. She stated that she was not made aware that Resident #52's coccyx treatment order had been discontinued on 1/12/24. She stated that lack of a dressing to the coccyx wound could cause delay in healing and infection. She revealed that she had not been made aware of any concerns regarding the Wound Nurse not performing her duties or following physician orders. She confirmed that if the treatments were not done as ordered, the wounds would deteriorate. An interview with the Assistant Director of Nursing (ADON) on 2/01/24 at 11:25 AM revealed she had not been made aware of any concerns from the Medication Nurses related to wound care. She explained, to her knowledge, the Medication Nurses had never been asked to perform treatments, so the Wound Nurse could catch up on orders or documentation. She confirmed that the nurses should not sign off on treatments that the Wound Nurse performed, and they had never been told to do so. She explained that she had never pulled the TAR to check and see who signed off on the treatments. She explained that she felt the Wound Nurse got caught up in the day-to-day processes and just didn't make sure things were done. She revealed that she was not aware of a list that was left on the weekends to know which residents needed wound care. She stated the wound care should be administered from the TAR and signed off when completed. She explained that the facility did have a call in Sunday 1/28/24 with the person who was suppose to do the wound care and stated the Director of Nursing (DON) would have been responsible for letting the Unit Managers know. An interview with the Director of Nursing (DON) on 2/1/24 at 4:35 PM revealed that she and the Administrator (ADM) had spoken with the Wound Nurse about taking the Wound Care position when the job opened. She stated that the Wound Nurse had performed the treatments before in the facility when she was first hired, [TRUNCATED]

Based on observation, interviews, and record review the facility failed to provide training and competency skills to the treatment nurse to ensure she had adequate knowledge to provide care and services to residents with skin concerns and pressure ulcers for two (2) of five (5) residents reviewed with wounds. Resident #52 and Resident #103 The facility's failure to ensure licensed staff had appropriate training and competency skills to provide wound treatments put Resident #52 and Resident #103 and all other residents who are at risk for skin breakdown at risk for serious harm, serious injury, serious impairment, or death. The State Agency (SA) determined the situation to be an Immediate Jeopardy (IJ) that began on 12/27/23 when Resident #103 developed a bruised area to the left great toe that deteriorated and became a bruised/blood blister covered in eschar (dead tissue) by 1/24/24. The facility failed to act upon verbal orders resulting in delay in treatment, failed to transcribe these orders into the medical record, and provide treatment for Resident #103's wounds according to the Wound Nurse Practitioner's orders. The facility Administrator was notified of the Immediate Jeopardy (IJ) and was presented with an IJ template on 1/31/24 at 4:50 PM. The facility provided an acceptable Removal Plan, in which they alleged all corrective action to remove the IJ was completed on 2/01/24 and the IJ was removed as of 02/02/24. The Survey Agency (SA) validated the Removal Plan on 2/06/24 and determined the Immediate Jeopardy (IJ) was removed on 2/02/24. Therefore, the scope and severity for 42 CFR 483.35(a)(3)(4) Nursing Services, was lowered from a K to an E, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility provided documentation on letter head, undated, revealed Skills Competency Assessment is utilized for evaluation of staff competency and training. Resident # 52 On 01/29/24 at 12:04 PM, an observation and interview with Resident #52 revealed him sitting in a wheelchair in his room. The resident stated he had a wound on his bottom and his left heel. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order dated 12/29/23, Wound Care: Cleanse stage 4 pressure ulcer to coccyx with normal saline, pat dry with gauze, apply Santyl to wound bed and cover with foam bordered dressing daily with a D/C (discontinue) date of 1/12/24, which revealed there was not an active wound care physician's order for the pressure wound to the coccyx after 1/11/24. On 1/30/24 at 3:38 PM, an observation of Resident #52's wound care with the Wound Nurse revealed, there was not a wound dressing to the resident's coccyx upon initiating the wound care. The Wound Care nurse provided wound care to the coccyx using a discontinued order dated 1/12/24. An observation of the left heel pressure wound revealed the Wound Nurse failed to provide the correct wound care to the left heel per the current physician orders effective 1/19/24. An interview with the Wound Nurse on 1/30/24 at 3:45 PM, confirmed that the resident did not have a dressing to the coccyx area She revealed that she did not apply the prescribed hydrogel to the left heel wound as ordered. Record review of Resident #52's January 2024 Treatment Administration Record (TAR) revealed an order for Santyl to the coccyx with a start date of 12/29/23 was initialed every day however,the order for wound care utilizing Santyl to the coccyx was discontinued on 1/12/24. The TAR was initialed as performed by the Wound Nurse for two (2) of the thirty-one days in January on 1/30/24 and 1/31/24. All the other days were initialed as performed by other facility nurses. Record review of Resident #52's January 2024 TAR revealed, an order dated 12/29/23, Santyl External Ointment . Apply to left heel topically everyday shift for DTI (deep tissue injury). This was initialed as performed by the Wound Nurse two (2) of the thirty-one days in January 1/30 and 1/31. All the other days were initialed as performed by other facility nurses. Record review of Resident #52's Order Summary Report revealed an order dated 1/15/24, Obtain Xray of left heel r/t (related to) increased pain and clinical symptoms of osteoporosis. Record review of the Radiology Report dated 1/20/24 for Resident #52 revealed under, Conclusion: Subtle cortical bone loss at the dorsal lateral aspect of the calcaneus which may represent early osteomyelitis There was a four (4) day delay in obtaining the ordered x-ray for Resident #52's left heel. Record review of Resident #52's Physician Order Details dated 1/24/24 revealed orders for Wound #1 Left Heel and Wound #2 Coccyx . These orders were not transcribed to the TAR. Record review of the Admission Record revealed Resident #52 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Peripheral Vascular Disease, Pain and Pressure Ulcer of Left Heel, Stage 2. Resident #103 An observation and interview on 01/30/24 at 8:19 AM, with Resident #103 revealed him lying in bed, awake and alert. He stated he had a wound on his bottom and on his foot that caused him pain. An interview with the Wound Nurse on 1/30/24 at 3:50 PM, revealed Resident #103 was admitted to the facility with a pressure wound on the left heel that has not shown any progress with healing and the resident has also developed other areas on the left great toe and some areas of breakdown between the toes on the left foot. She revealed the left toe started out as a blood blister and had worsened over the past couple of weeks and now are eschar covered. She stated the left great toe had been debrided by the Wound Nurse Practitioner (NP), but necrotic tissue returned. She revealed an appointment had been made with a general surgeon due to the wounds not healing and the resident's history of previous amputation of the right great toe due to a necrotic wound. An observation of wound care for Resident #103, with the Wound Nurse on 1/30/24 at 3:55 PM, revealed she removed the soiled dressing from the wounds on the left foot. The wound nurse cleaned the wound to the left great toe and in between the areas of the toes with normal saline, patted dry, and applied xeroform gauze to all the areas and wrapped with a gauze wrap, secured with tape. Record review of the Progress Note Details dated 12/27/23 for Resident #103 revealed, There is also a 0.8 x 1.5 x 0.0 bruised area on the left great toe that was noted at his most recent visit .Will continue to monitor left great toe . Record review of the Progress Note Details dated 1/03/24 for Resident #103 revealed under, Wound Assessment(s) . Wound #3 Left Toe blister and has received a status of Not Healed. Initial wound encounter measurements are 1 cm (centimeter) length x 1.2 cm (centimeter) width with no measurable depth, with an area of 1.2 sq (square) cm (centimeters). Also revealed under, General Notes: Will continue to monitor left great toe. Staff to notify of any changes . Record review of the Treatment Administration Record (TAR) for Resident #103 revealed there was not a wound care order for the wound on the left great toe or the breakdown between the inner toes. Record review of the Order Summary Report with active orders as of 1/31/24 for Resident #103 revealed there was not a Physician Order for wound care to the left great toe or in between the toes on the left foot. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 12/28/23, for wound care to the left heel stage 3 pressure ulcer with a D/C (discontinue) date of 1/18/24. The order was not initialed as completed by the Wound Nurse any of the 18 days in January the order was active. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated, 1/19/24 for wound care to the left heel stage 3 pressure ulcer. The wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated, 12/28/23 for the right foot great toe amputation site revealed the TAR was initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of Resident #103's TAR for January 2024 for sheering abrasion to the left buttocks revealed an order dated 12/15/23 was only initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of the Admission Record for Resident #103 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Encounter for Orthopedic Aftercare Following Surgical Amputation, acquired absence of Right Great Toe, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Pressure Ulcer of Left Heel, Stage 3, and Pain. An interview with the Wound Care Nurse on 1/31/24 at 9:45 AM, revealed she had worked at the facility for 3 years, first starting out as the Wound Nurse, then transferred over to the night shift supervisor and filling in on the medication cart. She stated she had been back in the Wound Nurse position since January 1, 2024. She revealed prior to her taking the position, they had another wound nurse who worked for about 3 months and resigned, leaving the facility in a bind due to her lack of inconsistent wound charting. She revealed all the wound documentation was behind, and she had to catch things up when she transferred to the position. She revealed that the facility was sending the residents with wounds out to the Proper Name hospital but changed over to Proper Name Wound clinic on Sept. 1, 2023. She stated all the wounds were seen in the facility by the Wound Nurse Practitioner (NP) once weekly on Wednesdays and the Wound NP did not give any orders the day she visited but tells her what she wants to be changed up or makes recommendations for the treatments, and she will send the facility the progress notes the following Friday or Monday. She revealed there were times she did not get the Wound NP's Progress Note until a week later. She confirmed that she had access to the site where the Wound NP uploads the documents, and she could pull the progress notes after it was uploaded. She revealed that Resident #52's left heel pressure wound developed in the facility and was initially a Stage 2 blister and was now unstageable. She stated she was unsure what interventions were put in place to prevent skin breakdown since she had only been in the wound position for a month. She revealed that she worked Monday-Friday and had been doing all the wound care in the facility on those days. She explained that on the weekends, she leaves a list of the residents with wounds so that the nurses will know who to perform wound care on. She confirmed that her initials were not listed on Resident #52's Treatment Administration Record (TAR) for the month of January 2024 except for 1/30/24 and 1/31/24. She stated that she did do the treatments but did not sit down to initial them until the evenings and occasionally the other nurses had signed off on them already. She revealed that the Medication Cart Nurses did help her with holding certain residents, so they could have gone in and signed the TAR before she got to it. She revealed that she was not aware that Resident #52's treatment order for the coccyx pressure wound had been discontinued on 01/12/24. She explained that she had no idea who would have discontinued the treatment order out of the system and acknowledged that she did not follow the TAR for treatment orders, or she would have caught the error. She explained that Resident #103's left great toe wound developed as a dry piece of skin that has continued to worsen, with new ulcers that developed in between the toes. She revealed the Wound NP visited him last week to assess the wound and made the recommendation to apply xeroform gauze and start clindamycin for infection, but she did not enter the orders into the system. She confirmed that she would be the person responsible for implementing the orders and that she goes ahead and starts any new treatment recommendations but does not put the order into the system because once she received the NP progress note, she may have changed something up with the wound care. She explained that she was instructed by the Wound NP that the clindamycin needed to be approved by nephrology, since the resident was on dialysis, so the resident was not started on the clindamycin when it was originally ordered on 1/24/24. The Wound Nurse confirmed that she never called the dialysis unit to get the antibiotic order approved. She revealed the wound was not cultured but did show clinical signs of infection and that all medications that the Wound NP recommends must be approved by the Primary Care Practitioner (PCP). She confirmed that she did the treatment on Resident #103's left toes without an active order in the computer and stated, I don't get her notes until a week later, so I can't put in an order, if I don't have one. She confirmed that a verbal order from the NP should be immediately acted upon and that she was given a verbal order from the NP. She revealed not implementing physician orders immediately was a delay in treatment of the wound and treating the infection. She revealed that delay of treatment could result in possible infection, sepsis, or amputation for both Resident #52 and #103. She confirmed that other nurses had initialed Resident #103's January Treatment Administration Record (TAR) and she revealed she was the person responsible for signing since she completed the treatments. An interview with the Assistant Director of Nursing (ADON) on 1/31/24 at 10:05 AM, revealed that the facility had not had a consistent Wound Nurse for the past six (6) months. She revealed that the previous Wound Nurse worked for about 3 months and left without notice, although she was going to be terminated due to lack of documentation on the wounds. The ADON stated that she filled in for the Wound Nurse position for about a month until the current Wound Nurse could transfer from the night shift position. The ADON stated that things were behind as far as documentation on the facility wounds, and the Wound Nurse had to get all the information up to date. She revealed that she had not had any concerns regarding the Wound Nurse and felt as if she did a good job. She stated that the Wound Nurse did treatments when she was originally hired in 2019 for about a year, so they felt she had enough experience. She revealed she had no reason to suspect anything was wrong and confirmed that the Wound Nurse had not had any wound care training after switching from the night shift supervisor role to the wound care role in January. She revealed that the Wound Nurse brought a list of the wounds to the last Quality Assurance and Performance Improvement (QAPI) meeting held this month, where the wounds were discussed. She revealed that the facility just reviewed the wounds back in December 2023 after the other Wound Nurse left and all the orders were compared to the NP orders versus the TAR and verified accuracy by 12/27/23. She confirmed that Resident #52's treatment order for the coccyx had been discontinued on 1/12/24 unintentionally by a staff member. She confirmed that she was not aware that the Wound Nurse was not utilizing the TAR to complete the wound care each day.The ADON stated the Wound Nurse would have caught that the order was discontinued if she had looked at the TAR and signed off after the treatment was provided. She revealed she was not sure how the nurses on the weekends were providing wound care. A telephone interview with the Wound Nurse Practitioner on 1/31/24 at 3:40 PM, revealed she rounds on all the facility wounds every Wednesday and during her visits she makes recommendations for wound care, but the facility does not receive the progress note until Friday evening when it's faxed over, but that when she makes rounds with the Wound Nurse she gives verbal orders. She revealed some of her recommendations may be delayed because certain orders must go through the resident's primary care provider (PCP) or dialysis, such as antibiotics or pain medication if the resident is on dialysis. She confirmed she was aware of the delay in antibiotics that were ordered on 01/24/24 for Resident #103 because it had to be approved with the PCP due to high risk of drug nephrotoxicity but she assumed that the antibiotic order had been implemented by now, and confirmed that she had not been made aware that the resident still did not have an order for an antibiotic. She revealed that Resident #103 developed a dried blood blister to his left great toe that has deteriorated with a new breakdown in between the toes. She revealed that Resident #103 was a Diabetic, on dialysis and had a previous history of toe amputation, so she recommended a referral to a General Surgeon due to his high risk of the same outcome (amputation). She revealed she had not been made aware by the facility that Resident #103's left toe wound orders had not been acted upon by the Wound Nurse and the treatment ordered was not added in the charting system. She revealed that the current Wound Nurse just started, and she was aware that the wound care documentation was behind. She explained that Resident #52's heel wound was unchanged and had not shown any progress. She stated that she was not made aware that Resident #52's coccyx treatment order had been discontinued on 1/12/24. She stated that lack of a dressing to the coccyx wound could cause delay in healing and infection. She revealed that she had not been made aware of any concerns regarding the Wound Nurse not performing her duties or following physician orders. She confirmed that if the treatments weren't done as ordered, the wounds would deteriorate. An interview with Licensed Practical Nurse (LPN) #4 on 2/01/24 at 11:05 AM, revealed that she worked the Medication Cart on 7-3 shift. She revealed that she had been doing the treatments for Resident #52 on the weekends and some during the weekdays. She explained that the facility had not had a consistent or set Wound Nurse in months. She explained that the current Monday through Friday Wound Nurse had been out some. She confirmed that there were days when the treatments had not been signed off on by the Wound Nurse and the Medication nurses felt responsible for signing them off because they couldn't have things not completed on the TAR at the end of their shift. LPN #4 explained that she was working this past weekend (1/27/24 and 1/28/24), so she went to the Wound Nurse on Thursday 1/25/24 because she saw that Resident #52's coccyx order had been discontinued in the computer. She revealed that she was told by the Wound Nurse that the order had been discontinued and not to worry about it. She explained that the Wound Nurse never checked in the computer system when she asked her or got up from what she was doing at the time, she simply stated it had been discontinued. She revealed that the order to apply Santyl to the coccyx continued to come up on the TAR, so she applied Santyl to the wound on the coccyx, but did not apply a cover dressing because it was not ordered. She revealed that she was confused because she knew the resident did have a treatment order and all of a sudden, it stopped. She revealed that even when she followed behind the Wound Nurse the last couple of weeks, Resident #52 never had a dressing on his coccyx. LPN #4 stated when she said something again to the Wound Nurse about the wound not having a dressing, she stated, It's been discontinued and acted like it wasn't a big deal. LPN #4 explained that she knew the wound should be covered to keep out urine and feces, because the resident was incontinent, which could cause infection and slow the healing of the wound. She stated that she had never been given a list or left a list of the residents with wounds and treatments for the weekend. She explained that this past Sunday, 1/28/24 they didn't find out that they didn't have a Wound Care Nurse until 1 PM and her shift was over at 3 PM and she wasn't sure who did the wound care that day. An interview with the Assistant Director of Nursing (ADON) on 2/01/24 at 11:25 AM revealed she had not been made aware of any concerns from the Medication Nurses related to wound care. She explained, to her knowledge, the Medication Nurses had never been asked to perform treatments, so the Wound Nurse could catch up on orders or documentation. She confirmed that the nurses should not sign off on treatments that the Wound Nurse performed, and they had never been told to do so. She explained that she had never pulled the TAR to check and see who signed off on the treatments. She explained that she felt the Wound Nurse got caught up in the day-to-day processes and just didn't make sure things were done. She revealed that she was not aware of a list that was left on the weekends to know which residents needed wound care. She stated the wound care should be administered from the TAR and signed off when completed. She explained that the facility did have a call in Sunday 1/28/24 with the person who was suppose to do the wound care and stated the Director of Nursing (DON) would have been responsible for letting the Unit Managers know. An interview with the Director of Nursing (DON) on 2/1/24 at 4:35 PM, revealed that she and the Administrator (ADM) had spoken with the Wound Nurse about taking the Wound Care position when the job opened. She stated that the Wound Nurse had performed the treatments before in the facility when she was first hired, and she was knowledgeable, and she felt the Wound Nurse did a good job. She stated the Wound Nurse was full-time and worked Monday through Friday, so she wasn't sure why she told the medication cart nurses that she was just part time. She revealed that the only thing that had changed since the Wound Nurse did previous treatments was, they hired a new Wound Nurse Practitioner (NP). She revealed that the NP caused the delay because she sent the orders/progress notes over to the facility later in the week after she visited the residents. She confirmed that the Wound Care Nurse could have implemented the physician order when the NP visited because she was giving the verbal order, which could have been added as a verbal physician's order. She stated, If you are given an order, you should implement that order. She revealed the Wound Nurse should have signed the treatments after they were administered, just like with giving medication. She explained that she was not aware of the Wound Nurse telling the Medication Nurses that they were required to do treatments because she was behind with orders/documentation. She stated, She could have because I'm not out there on the floor. The DON revealed that the Wound Nurse had not been given any wound training or expectations since she accepted the Wound Care Nurse position in January and stated, We just trusted her that she knew what she was doing. She revealed all the nurses were checked off on clean dressing changes, but that was the extent of the wound care training that the facility did. Record review of Skills Competency Assessment: Clean Dressing Change revealed the wound nurse completed the training on hire (9/8/21). Record review of the Skills Competency Assessment: Clean Dressing Change dated 7/11/23 revealed under, . 26. Document in the Medical Record (TAR) (Treatment Administration Record) after completion of dressing change document findings in the nurse's notes and / or contact the physician when indicated . The Wound Nurse completed this training on 7/1/23. Record review of the Education In-service Attendance Record dated 5/1/23-5/5/23 revealed an in-service was conducted on wounds and skin sweeps and the Wound Care Nurse was in attendance. Record review of the facility's Performance Evaluation revealed the Wound Care Nurse read and signed acknowledgment of the job description and duties assigned dated 11/04/19, 9/07/21 and 9/7/23 which revealed, . 8. Complete required documentation in an accurate and timely manner was a requirement. The facility submitted the following acceptable Removal Plan on 2/5/24: Brief Summary of Events: On 1/31/2024 at 4:50pm State Agency (SA) notified the Executive Director (ED) of 5 Immediate Jeopardy's (IJ's) related to F 600 Free from Abuse and Neglect, F 686 Treatment /Services to Prevent /Heal Pressure Ulcers, F 684 Quality of Care, F 726 Competent Nursing Staff and F 658 services Provided Meet Professional Standards. An Immediate jeopardy template was provided to the Executive Director (ED) on 1/31/2024 at 4:50pm by the State Agency (SA). The facility failed to follow the physician's orders for wound care, failed to provide training and competency skills to the Treatment Nurse to ensure she had adequate knowledge to provide care and services to residents with skin concerns and pressure ulcers and failed to provide the treatment and services to promote healing of pressure ulcer wounds and other wounds which resulted in delay of healing of pressure ulcers and wounds for Resident #52, Resident #103, and Resident #269. Immediate Action Plan: Treatment Nurse was suspended by the Executive Director on 2/1/2024 at 1:00 pm and terminated on 2/1/2024 at 6:43 pm. Treatment Nurse was reported to the Mississippi Board of Nursing on 2/1/2024 at 6:32 pm related to not following professional standards of practice. On 1/31/2024 Assistant Director of Nurses initiated education with 5 Housekeeping employees, 6 Therapist, 4 Dietary employees, 8 Certified Nursing Assistants, 6 office staff, 5 Licensed Practical Nurses and 5 Registered Nurses on Abuse and Neglect with emphasis on following physician orders and timely implementation and documentation of medical treatments of wounds and diabetic ulcers. Employees will be educated prior to accepting an assignment. New hires will be in-serviced on Abuse and Neglect during orientation. Employees will be educated prior to accepting an assignment. On 1/31/2024 the Regional Director of Clinical Services (RDCS) conducted a verbal review of clean dressing change competency with return verbalization from Treatment Nurse RN, RN #1, RN #2, RN #3, RN #4, and Assistant Director of Nurses. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 5 Registered Nurses and 6 Licensed Practical Nurses on Medication Administration and Documentation. Employees will be educated prior to accepting assignments. On 1/31/2024 at 5:40pm the Regional Director of Clinical Services (RDCS) conducted education with the Treatment Nurse on Skin and Wound Guidelines, Medication Administration and Documentation, Abuse and Neglect, and Following Physician Orders and Clean Dressing Change checklist was reviewed verbally with return verbalization. Education included following the physician order when administering treatments, administering treatment timely, nurse that administers treatment is to sign the electronic administration record that treatment was administered, ensure all skin impairments and pressure ulcers have a physician order for treatment. Employees will be educated prior to accepting assignments. On 1/31/2024 at 1:08 pm Resident #52 received new physician orders to clean the stage 3 pressure ulcer of the coccyx with Dakin's, pat dry, apply Santyl to the wound bed at nickel thickness, cover with foam bordered dressing every day. PRN order for soilage\dislodgement. Resident #103 received new physician orders on 1/31/2024 at 2:02 pm to clean diabetic ulceration between 3rd through 5th toes on left foot with normal saline, pat dry, thread xeroform between toes, cover with dry dressing, wrap with kerlix, and secure with tape every day. PRN order for soilage/dislodgement. Order for clean left great toe blister site with normal saline, pat dry, apply Santyl to wound bed at nickel thickness, cover with dry gauze or ABD pads, wrap with kerlix, and secure with tape every day. PRN order for soilage/dislodgement. No new orders for Resident #269. On 1/31/2024 at 5:05 pm body audits were initiated by Registered Nurse (RN) #1, RN #2, RN #3, RN #4, and Assistant Director of Nurses to identify skin impairment or pressure ulcers. There were 108 body audits completed and 7 refused. No new pressure ulcers or diabetic ulcers identified on the body audits conducted. Audit conducted on the 7 residents refusing body audit to determine any previous skin concerns. No areas of concern were identified. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 6 Licensed Practical Nurses, 5 Registered Nurses, and 23 Certified Nurses Assistants on Skin and Wound Guidelines. Employees will be educated prior to accepting assignments. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 7 Registered Nurses and 10 Licensed Practical Nurses on Following Physician Orders. Employees will be educated prior to accepting assignments. On 1/31/2024 at 8:30 pm Assistant Director of Nurses reviewed physician orders and wound Nurse Practitioner progress notes consisting of diabetic ulcers, pressure ulcers, and skin concerns in the electronic health record (EHR) to ensure physician orders were implemented for 12 of 12 residents. No discrepancies were identified. On 1/31/2024 at 5:40 pm the Regional Director of Clinical Services (RDCS) conducted education with the Treatment Nurse on Skin and Wound Guidelines, Medication Administration and Documentation, Abuse and Neglect, and Following Physician Orders and Clean Dressing Change checklist was used with demonstration and return demonstration. DON and ADON are completing treatments as ordered Monday through Friday until treatment nurse position is filled, and treatment nurse is trained on the skills and expectations of the facility. All dayshift nurses who have completed the skills competency for wound care will provide dressing changes on the weekends. Director of Nurses and Assistant Director of Nurses are checking orders daily to ensure orders have been updated in electronic health records for nurses to complete on weekends. On 2/1/2024 at 2:00 pm Regional [NAME] President of Operation conducted education with Administrator on Abuse and Neglect with emphasis on thorough investigations and reporting guidelines. On 2/1/2024 at 2:30 pm the facility initiated a monitoring tool to check skin concerns, diabetic foot ulcers, pressure ulcers for appropriate orders to treat issues identified. The facility will ensure compliance with all wound care orders for accuracy daily by the Director of Nursing and Assistant Director of Nursing. QAPI: On 1/31/2024 at 7:00 PM a Quality Assurance Performance Improvement (QAPI) Committee meeting was held to review the Immediate Jeopardy template for F 600 Free from Abuse and Neglect, F 686 Treatment /Services to Prevent /Heal Pressure Ulcers, F 726 Competent Nursing Staff and F 658 services Provided Meet Professional Standards and to determine Root Cause Analysis. It was determined through Root Cause Analysis the facility failed to provide approved wound care treatment for Resident #52 and Resident #103 related to failure of the treatment nurse to obtain orders to treat from the provider. The facility failed to provide training and competency skills to the Treatment Nurse to ensure she had adequate knowledge to provide care and se [TRUNCATED]

Based on state Nurse Practice Standards, observation, staff interview, record review, and facility policy review, the facility failed to follow the professional standards of practice for documenting and providing medical treatments for wounds for three (3) of five (5) wound observations. Resident #52, Resident #103 and Resident #269. The facility's failure to follow standards of practice by failing to implement and follow physician orders for wound care and treatments caused serious harm to Resident #52, Resident #103 and Resident #269 and placed all other residents who are at risk for skin breakdown at risk for serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/20/23 when Resident #269, who had an existing wound to coccyx was seen by the Wound Nurse Practitioner (NP) and an X-ray was ordered of the coccyx to rule out Osteomyelitis. The order for the X-Ray was not performed until 12/27/23, (almost 3 months later) which caused the residents coccyx wound to worsen. The facility Administrator was notified of the IJ and SQC and was presented with an IJ template on 1/31/24 at 4:50 PM. The facility provided an acceptable Removal Plan in which they alleged all corrective action to remove the IJ was completed on 2/01/24 and the IJ was removed as of 02/02/24. The Survey Agency (SA) validated the Removal Plan on 2/06/24 and determined the Immediate Jeopardy (IJ) was removed on 2/02/24. Therefore, the scope and severity for CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, CFR 483.21(b)(3)(i) Meet professional standards of quality, CFR 483.25 Quality of care, CFR 483.25(b)(1) Pressure ulcers, and CFR 483.35 Nursing Services, will be lowered to a E, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: CROSS REFERENCE F684 Review of the facility policy titled 'LTC Facility's Pharmacy Services and Procedures Manual with a revision date of 1/01/22 revealed under,8.3 Facility staff should immediately record the new orders in the resident's medical record and medication administration record. Also revealed under, 13.5 Facility should ensure that the person receiving a verbal order immediately records it in the resident's chart or electronic order system . Mississippi Board of Nursing; Source: Miss. Code [NAME]. S 73-15-17 (1972, as amended) read: Rule 2.2 Responsibility. The LPN shall be responsible and accountable for: A. Knowledge of and compliance with the laws and regulations governing the practice of nursing in the State of Mississippi. B. Practicing within the scope of practice as established by the Board and according to generally accepted standards of practice. C. Accepting responsibility for individual nursing actions, competence, decisions and behavior in the course of nursing practice. Source: Miss. Code [NAME]. S 73-15-17 (1972, as amended). Resident # 52 An observation and interview on 01/29/24 at 12:04 PM with Resident #52 revealed him sitting in a wheelchair in his room. The resident stated he had a wound on his bottom and his left heel. Record review of an order dated 12/29/23 on Resident #52's January 2024 Treatment Administration Record (TAR) that read, Wound Care: Cleanse stage 4 pressure ulcer to coccyx with normal saline, pat dry with gauze, apply Santyl to wound bed and cover with foam bordered dressing daily with a D/C (discontinue) date of 1/12/24, which revealed there was not an active wound care physician's order for the pressure wound to the coccyx after 1/11/24. An order dated 1/18/24 on Resident #52's Order Summary Report revealed , Wound Care: Clean unstageable pressure ulcer of left heel with Dakins, pat dry, apply nickel thickness Santyl, apply hydrogel, cover with foam bordered dressing, wrap with kerlix, and secure with tape daily and as needed for soilage/dislodgement . An observation of Resident #52's wound care with the Wound Nurse on 1/30/24 at 3:38 PM revealed, there was not a wound dressing to the resident's coccyx upon initiating the wound care. The coccyx wound bed was 90% yellow, adherent slough, 10% granulation tissue with redness and maceration to the wound edges. The Wound Nurse cleansed the wound with Dakin's solution, patted dry, applied a layer of Santyl and covered with a foam dressing which was not the current order. An observation of the left heel pressure wound revealed, 100% adhering brown eschar to the wound bed. Slight redness observed to the peri-wound. The Wound Nurse stated the treatment orders for the left heel were to cleanse the wound with Dakin's solution, pat dry, apply a layer of Santyl, cover with foam and wrap with gauze wrap. An interview with the Wound Nurse on 1/30/24 at 3:45 PM confirmed that the resident did not have a dressing to the coccyx area and that urine and stool could get inside the wound and cause infection and delay the healing of the wound. She revealed that she did not follow the latest wound care orders by failing to apply the prescribed hydrogel to the left heel wound. She revealed the hydrogel was ordered along with Santyl to debride the adherent eschar and that the resident recently completed antibiotics due to the left heel wound being infected. Record review of the Admission Record revealed Resident #52 was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Acute on Chronic Systolic (congestive) Heart Failure, Peripheral Vascular Disease, pain and Pressure Ulcer of Left Heel, Stage 2. Record review of Resident #52's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 11, which indicates the resident is moderately cognitively impaired. Also revealed under section M, the current number of Unhealed Pressure Ulcers/Injuries at Each Stage, one (1) Stage 2 pressure ulcer was marked. Resident #103 An observation and interview on 01/30/24 at 8:19 AM, with Resident #103 revealed him lying in bed, awake and alert. He stated he had a wound on his bottom and on his foot that caused him pain. An observation of wound care for Resident #103, with the Wound Nurse on 1/30/24 at 3:55 PM, revealed she removed the soiled dressing from the wounds on the left foot. A moderate amount of red serosanguinous drainage was observed around the toe portion of the dressing. The left great toe diabetic wound was covered in 100% adherent brown eschar with redness to the peri-wound with a slight odor observed. The wound nurse cleaned the wound to the left great toe and in between the areas of the toes with normal saline, patted dry, and applied xeroform gauze to all the areas and wrapped with a gauze wrap, secured with tape. Record review of the Treatment Administration Record (TAR) for Resident #103 revealed there was not a wound care order for the ulcer on the left great toe or the breakdown between the inner toes. Record review of the Order Summary Report for Resident #103 revealed there was not a Physician Order for wound care to the left great toe or in between the toes on the left foot. Record review of Resident #103's Order Summary Report revealed an order dated 7/8/23, Weekly skin sweeps on Tuesday 3-11 every evening shift every Tue (Tuesday) . Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 12/28/23, Wound Care: Clean Left heel stage 3 pressure ulcer with normal saline, pat dry with gauze, apply Medi honey to wound bed, cover with foam dressing, wrap with kerlix and secure with tape daily with a D/C (discontinue) date of 1/18/24. The order was not initiated as completed by the Wound Nurse any of the 18 days in January the order was active. The wound care was not documented as administered on 1/22 and 1/28, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated, 12/28/23, Wound Care: Cleanse right foot great toe amputation site with soap and water and apply A&D ointment daily initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22 and 1/28, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 12/15/23, Wound Care: Cleanse shearing abrasion to left buttock with NS (normal saline), apply triad daily initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22 and 1/28, which was a total of 2 missed wound treatments. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated 1/19/24, Wound Care: Clean left heel stage 3 pressure ulcer with normal saline, pat dry with gauze, apply Santyl to wound bed at nickel thickness, cover with foam dressing, wrap with kerlix and secure with tape daily initialed as completed by the Wound Nurse two (2) of the 13 days that the order was active. The other dates were initialed as completed by other facility nurses. The dates of 1/22 and 1/28 have no initials to support wound care was performed, which was a total of 2 missed treatments. Record review of the Admission Record for Resident #103 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Encounter for Orthopedic Aftercare Following Surgical Amputation, acquired absence of Right Great Toe, Nontraumatic Subarachnoid Hemorrhage Left Middle Cerebral Artery, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Pressure Ulcer of Left Heel, Stage 3, and Pain. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/23 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicates Resident #103 is cognitively intact. Also revealed under section M, diabetic foot ulcer(s) were not checked for the MDS look back period. Resident #52 An interview with the Wound Care Nurse on 1/31/24 at 9:45 AM revealed she had worked at the facility for 3 years, first starting out as the Wound Nurse, then transferred over to the night shift supervisor and filling in on the medication cart. She stated she had been back in the Wound Nurse position since January 1, 2024. She revealed prior to her taking the position, they had another wound nurse who worked for about 3 months and resigned, leaving the facility in a bind due to her lack of inconsistent wound charting. She revealed all the wound documentation was behind, and she had to catch things up when she transferred to the position. She stated all the wounds were seen in the facility by the Wound Nurse Practitioner (NP) once weekly on Wednesdays and the Wound NP did not give any orders the day she visited but tells her what she wants to be changed up or makes recommendations for the treatments, and she will send the facility the progress notes the following Friday or Monday. She revealed there were times she did not get the Wound NP's Progress Note until a week later. She confirmed that she had access to the site where the Wound NP uploads the documents, and she could pull the progress notes after it was uploaded. She revealed that Resident #52's left heel pressure wound developed in the facility and was initially a Stage 2 blister and was now unstageable. She stated she was unsure what interventions were put in place to prevent skin breakdown since she had only been in the wound position for a month. She confirmed that her initials were not listed on Resident #52's Treatment Administration Record (TAR) for the month of January 2024 except for 1/30 and 1/31. She stated that she did do the treatments but did not sit down to initial them until the evenings and occasionally the other nurses had signed off on them already. She revealed that she was not aware that Resident #52's treatment order for the coccyx pressure wound had been discontinued on 01/12/24. She explained that she had no idea who would have discontinued the treatment order out of the system and acknowledged that she did not follow the TAR for treatment orders, or she would have caught the error. The interview with the Wound Care Nurse on 1/31/24 at 9:45 AM also revealed that Resident #103's left great toe wound continued to worsen, with new ulcers that developed in between the toes. She explained that she was instructed by the Wound NP that the clindamycin needed to be approved by nephrology, since the resident was on dialysis, so the resident was not started on the clindamycin when it was originally ordered on 1/24/24. The Wound Nurse confirmed that she never called the dialysis unit to get the antibiotic order approved. She revealed the wound was not cultured but did show clinical signs of infection. She confirmed that she did the treatment on Resident #103's left toes without an active order in the computer and stated, I don't get her notes until a week later, so I can't put in an order, if I don't have one. During the interview with the Wound Care Nurse on 1/31/24 at 9:45 AM, she confirmed that a verbal order from the NP should be immediately acted upon and that she was given a verbal order from the NP. She revealed not implementing physician orders immediately was a delay in treatment of the wound and treating the infection. She revealed that delay of treatment could result in possible infection, sepsis, or amputation for both Resident #52 and #103. She confirmed that other nurses had initialed Resident #103's January Treatment Administration Record (TAR) and she revealed she was the person responsible for signing since she completed the treatments. An interview with the Assistant Director of Nursing (ADON) on 1/31/24 at 10:05 AM revealed that the ADON stated that things were behind as far as documentation on the facility wounds, and the Wound Nurse had to get all the information up to date. She revealed that she had not had any concerns regarding the Wound Nurse and felt as if she did a good job. She stated that the Wound Care Nurse did treatments when she was originally hired in 2019 for about a year, so they felt she had enough experience. She confirmed that Resident #52's treatment order for the coccyx had been discontinued on 1/12/24 unintentionally by a staff member. She confirmed that she was not aware that the Wound Nurse was not utilizing the TAR to complete the wound care each day that she would have caught that the order was discontinued if she had looked at the TAR and signed off after the treatment was provided. She revealed she was not sure how the nurses on the weekends were providing wound care. A telephone interview with the Wound Nurse Practitioner on 1/31/24 at 3:40 PM revealed she rounds on all the facility wounds every Wednesday and during her visits she makes recommendations for wound care, but the facility does not receive the progress note until Friday evening when it's faxed over, but that when she makes rounds with the Wound Nurse she gives verbal orders. She revealed some of her recommendations may be delayed because certain orders must go through the resident's primary care provider (PCP) or dialysis, such as antibiotics or pain medication if the resident is on dialysis. She confirmed she was aware of the delay in antibiotics that were ordered on 01/24/24 for Resident #103 because it had to be approved with the PCP due to high risk of drug nephrotoxicity but she assumed that the antibiotic order had been implemented by now, and confirmed that she had not been made aware that the resident still did not have an order for an antibiotic. She revealed she had not been made aware by the facility that Resident #103's left toe wound orders had not been acted upon by the Wound Nurse and the treatment ordered added in the charting system. She explained that Resident #52's heel wound was unchanged and had not shown any progress. She explained that she also referred the resident to a general surgeon because she was unable to perform the needed debridement in the facility setting due to pain management. She stated that she was not made aware that Resident #52's coccyx treatment order had been discontinued on 1/12/24. She stated that lack of a dressing to the coccyx wound could cause delay in healing and infection. She revealed that she had not been made aware of any concerns regarding the Wound Nurse not performing her duties or following physician orders. She confirmed that if the treatments weren't done as ordered, the wounds would deteriorate. An interview with Licensed Practical Nurse (LPN) #4 on 2/01/24 at 11:05 AM revealed that she worked the Medication Cart on 7-3 shift. She confirmed that there were days when the treatments had not been signed off on by the Wound Nurse and the Medication nurses felt responsible for signing them off because they couldn't have things not completed on the TAR at the end of their shift. She explained that there had been times in the past month when the medication nurses were told to do all the wound care because the Wound Nurse was behind and had orders and documentation to complete. LPN #4 explained that she went to the Wound Nurse on Thursday 1/25/24 because she saw that Resident #52's coccyx order had been discontinued in the computer. She revealed that she was told by the Wound Nurse that the order had been discontinued and not to worry about it. She explained that the Wound Nurse never checked in the computer system when she asked her or got up from what she was doing at the time, she simply stated it had been discontinued. She revealed that the order to apply Santyl to the coccyx continued to come up on the TAR, so she applied Santyl to the wound on the coccyx, but did not apply a cover dressing because it was not ordered. She revealed that she was confused because she knew the resident did have a treatment order and all of a sudden, it stopped. She revealed that even when she followed behind the Wound Nurse the last couple of weeks, Resident #52 never had a dressing on his coccyx. LPN #4 stated when she said something again to the Wound Nurse about the wound not having a dressing, she stated, It's been discontinued and acted like it wasn't a big deal. LPN #4 explained that she knew the wound should be covered to keep out urine and feces, because the resident was incontinent. She stated that she had never been given a list or left a list of the residents with wounds and treatments for the weekend. She explained that this past Sunday, 1/28/24 they didn't find out that they didn't have a Wound Care Nurse until 1 PM and her shift was over at 3 PM and she wasn't sure who did the wound care that day. An interview with the Assistant Director of Nursing (ADON) on 2/01/24 at 11:25 AM revealed she had not been made aware of any concerns from the Medication Nurses related to wound care. She explained, to her knowledge, the Medication Nurses had never been asked to perform treatments, so the Wound Nurse could catch up on orders or documentation. She confirmed that the nurses should not sign off on treatments that the Wound Nurse performed, and they had never been told to do so. She explained that she had never pulled the TAR to check and see who signed off on the treatments. She explained that she felt the Wound Nurse got caught up in the day-to-day processes and just didn't make sure things were done. She revealed that she was not aware of a list that was left on the weekends to know which residents needed wound care. She stated the wound care should be administered from the TAR and signed off when completed. She explained that the facility did have a call in Sunday 1/28/24 with the person who was suppose to do the wound care and stated the Director of Nursing (DON) would have been responsible for letting the Unit Managers know. An interview with the Director of Nursing (DON) on 2/1/24 at 4:35 PM revealed that she and the Administrator (ADM) had spoken with the Wound Nurse about taking the Wound Care position when the job opened. She stated that the Wound Nurse had performed the treatments before in the facility when she was first hired, and she was knowledgeable, and she felt the Wound Nurse did a good job. She stated the Wound Nurse was full-time and worked Monday through Friday, so she wasn't sure why she told the medication cart nurses that she was just part time. She revealed that the only thing that had changed since the Wound Nurse did previous treatments was, they hired a new Wound Nurse Practitioner (NP). She revealed that the NP caused the delay because she sent the orders/progress notes over to the facility later in the week after she visited the residents. She confirmed that the Wound Care Nurse could have implemented the physician order when the NP visited because she was giving the verbal order, which could have been added as a verbal physician's order. She stated, If you are given an order, you should implement that order. She revealed the Wound Nurse should have signed the treatments after they were administered, just like with giving medication. She explained that she was not aware of the Wound Nurse telling the Medication Nurses that they were required to do treatments because she was behind with orders/documentation. She stated, She could have because I'm not out there on the floor. The DON revealed that the Wound Nurse had not been giving any wound training or expectations since she accepted the Wound Care Nurse position in January and stated, We just trusted her that she knew what she was doing. She revealed all the nurses were checked off on clean dressing changes, but that was the extent of the wound care training that the facility did. Record review of Quality Assurance and Performance Improvement (QAPI) meeting minutes dated 1/12/24 revealed, Wound Care . 100% audit. Wound Care nurse resigned. New Wound care nurse starts 1/1/2024 completed 12/27/23 with a status of Ongoing. Record review of Skills Competency Assessment: Clean Dressing Change revealed the wound nurse completed the training on hire (9/8/21). Record review of the Skills Competency Assessment: Clean Dressing Change dated 7/11/23 revealed under, . 26. Document in the medical Record (TAR) (Treatment Administration Record) after completion of dressing change document findings in the nurse's notes and / or contact the physician when indicated . The Wound Nurse completed this training on 7/1/23. Record review of the Education In-service Attendance Record dated 5/1/23-5/5/23 revealed an in-service was conducted on wounds and skin sweeps and the Wound Care Nurse was in attendance. Record review of the Freedom from Abuse Notice to Employees revealed, . Neglect includes, but is not limited to lack of care and supervision and unmet physical, social, emotional, spiritual, or medical needs. The Wound Care Nurse signed the notice on 7/11/23. Record review of the facility's Performance Evaluation revealed the Wound Care Nurse read and signed acknowledgment of the job description and duties assigned dated 11/04/19, 9/07/21 and 9/7/23 which revealed, . 8. Complete required documentation in an accurate and timely manner was a requirement. Resident #269 Wound Nurse Practitioner visit note on 09/27/23 revealed, Nurse Practitioner to follow up with x-ray and final culture report. Wound Nurse Practitioner visit note on 10/04/23 revealed an x-ray was ordered with a previous visit and is pending. Wound Nurse Practitioner visited again on 10/11/23, 10/18/23, 10/25/23, 11/01/23, 11/08/23, 11/15/23,11/30/23, 12/06/23, 12/13/23, and 12/27/23 and continued to document that the Xray was pending. Wound Nurse Practitioner visit note on 01/03/24 revealed a recent x-ray indicated Osteomyelitis and a midline was placed and the patient is currently receiving Meropenem with recommendations for IV course of antibiotics for a minimum of six weeks, and for patient to be started on probiotic for duration of antibiotic use. An interview, on 01/31/24 at 4:00 PM with Wound Nurse Practitioner confirmed that she was aware that the x-ray that she ordered on 09/20/23 to rule out Osteomyelitis was not acted upon and done until 12/27/23. Wound Nurse Practitioner was asked if she reported to the Director of Nursing or the Assistant Director of Nursing (ADON) that the x-ray had not been performed at any point between the order date of 09/20/23 and the x-ray date of 12/27/23 and the Wound Nurse Practitioner stated No, I did not report it to them, I probably should have , but I didn't. I have to be careful what I say, we are a contracted business in this facility. I probably should have reported it to them, but I didn't. NP was asked if the treatment for the Osteomyelitis was delayed because the x-ray was not obtained when it was ordered on 09/20/23, and she stated, I would have started the IV whenever the x-ray was gotten if it had showed Osteomyelitis. The NP confirmed that the failure of the facility to treat an infection timely could have brought about sepsis or even death for this resident. An interview on 02/01/24 at 8:45 AM with the Administrator confirmed that it is the expectation that the Wound Nurse Practitioner notify the Director of Nursing or Assistant Director of Nursing ADON if there is a problem with wounds and if she sees her orders are not being implemented. An interview on 02/01/24 at 9:50 AM with Assistant Director of Nursing confirmed that the Wound Nurse Practitioner did not make her aware that the x-ray she ordered on 09/20/23 had not been completed. The ADON stated that around that time in December that she was helping with the wound care because they had terminated the nurse prior for not doing her job and that she found the x-ray order on 12/27/23 had not been done on an audit that she had completed. The ADON confirmed that she immediately called the doctor and got the x-ray ordered and made both the Wound Nurse Practitioner and the Facility Nurse Practitioner aware that the x-ray order had not been completed. She confirmed that the Wound Nurse Practitioner should have reported that the x-ray was not followed through to her or the Director of Nursing immediately, but that she failed to do that. An interview on 02/01/24 at 10:15 AM with RN #3, Unit Manager confirmed that she was not aware that there was an order for an x-ray on Resident #269 on 09/20/23. RN #3 confirmed that new orders are reviewed each morning in their stand-up meeting and that she never saw an order come through for Resident #269 for an x-ray. Review of the face sheet for Resident #269 revealed that the resident was admitted to the facility on [DATE] with a diagnosis of Heart Failure, Local Infection of the skin and subcutaneous tissue, Pressure Ulcer of Sacral Region Stage 4, Rhabdomyolysis, and chronic kidney disease. A review of the Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 07 which indicated Resident #269 was cognitively impaired. The facility submitted the following acceptable Removal Plan on 2/5/24: Brief Summary of Events: On 1/31/2024 at 4:50 pm State Agency (SA) notified the Executive Director (ED) of 5 Immediate Jeopardy's (IJ's) related to F 600 Free from Abuse and Neglect, F 686 Treatment /Services to Prevent /Heal Pressure Ulcers, F 684 Quality of Care, F 726 Competent Nursing Staff and F 658 services Provided Meet Professional Standards. An Immediate jeopardy template was provided to the Executive Director (ED) on 1/31/2024 at 4:50 pm by the State Agency (SA). The facility failed to follow the physician's orders for wound care, failed to provide training and competency skills to the Treatment Nurse to ensure she had adequate knowledge to provide care and services to residents with skin concerns and pressure ulcers and failed to provide the treatment and services to promote healing of pressure ulcer wounds and diabetic ulcers which resulted in delay of healing of pressure ulcers and diabetic ulcers for Resident #52, Resident #103, and Resident #269. Immediate Action Plan: Treatment Nurse was suspended by the Executive Director on 2/1/2024 at 1:00 pm and terminated on 2/1/2024 at 6:43 pm. Treatment Nurse was reported to the Mississippi Board of Nursing on 2/1/2024 at 6:32 pm related to not following professional standards of practice. On 1/31/2024 Assistant Director of Nurses initiated education with 5 Housekeeping employees, 6 Therapist, 4 Dietary employees, 8 Certified Nursing Assistants, 6 office staff, 5 Licensed Practical Nurses and 5 Registered Nurses on Abuse and Neglect with emphasis on following physician orders and timely implementation and documentation of medical treatments of wounds and diabetic ulcers. Employees will be educated prior to accepting an assignment. New hires will be in-serviced on Abuse and Neglect during orientation. Employees will be educated prior to accepting an assignment. On 1/31/2024 the Regional Director of Clinical Services (RDCS) conducted a verbal review of clean dressing change competency with return verbalization from Treatment Nurse RN, RN #1, RN #2, RN #3, RN #4, and Assistant Director of Nurses. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 5 Registered Nurses and 6 Licensed Practical Nurses on Medication Administration and Documentation. Employees will be educated prior to accepting assignments. On 1/31/2024 at 5:40 pm the Regional Director of Clinical Services (RDCS) conducted education with the Treatment Nurse on Skin and Wound Guidelines, Medication Administration and Documentation, Abuse and Neglect, and Following Physician Orders and Clean Dressing Change checklist was reviewed verbally with return verbalization. Education included following the physician order when administering treatments, administering treatment timely, nurse that administers treatment is to sign the electronic administration record that treatment was administered, ensure all skin impairments and pressure ulcers have a physician order for treatment. Employees will be educated prior to accepting assignments. On 1/31/2024 at 1:08 pm Resident #52 received new physician orders to clean the stage 3 pressure ulcer of the coccyx with Dakin's, pat dry, apply Santyl to the wound bed at nickel thickness, cover with foam bordered dressing every day. PRN order for soilage\dislodgement. Resident #103 received new physician orders on 1/31/2024 at 2:02 pm to clean diabetic ulceration between 3rd through 5th toes on left foot with normal saline, pat dry, thread xeroform between toes, cover with dry dressing, wrap with kerlix, and secure with tape every day. PRN order for soilage/dislodgement. Order for clean left great toe blister site with normal saline, pat dry, apply Santyl to wound bed at nickel thickness, cover with dry gauze or ABD pads, wrap with kerlix, and secure with tape every day. PRN order for soilage/dislodgement. No new orders for Resident #269. On 1/31/2024 at 5:05 pm body audits were initiated by Registered Nurse (RN) #1, RN #2, RN #3, RN #4, and Assistant Director of Nurses to identify skin impairment or pressure ulcers. There were 108 body audits completed and 7 refused. No new pressure ulcers or diabetic ulcers identified on the body audits conducted. Audit conducted on the 7 residents refusing body audit to determine any previous skin concerns. No areas of concern were identified. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 6 Licensed Practical Nurses, 5 Registered Nurse [TRUNCATED]

Based on observation, interviews, record review, and facility policy review, the facility failed to provide treatment and services to promote the healing of wounds for one (1) of five (5) wound care observations. Resident #103 The facility's failure to implement and follow physician orders for wound care and treatments put Resident #103 and all other residents who are at risk for skin breakdown at risk for serious harm, injury, impairment, or death. The State Agency (SA) determined the situation to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 12/27/23 when Resident #103 developed a bruised area to the left great toe that deteriorated and became a bruised/blood blister covered in eschar (dead tissue) by 1/24/24. The facility failed to act upon verbal orders resulting in delay in treatment, failed to transcribe these orders into the medical record, and provide treatment for Resident #103's wounds according to the Wound Nurse Practitioner's orders. The facility Administrator was notified of the IJ and SQC and was presented with an IJ template on 1/31/24 at 4:50 PM. The facility provided an acceptable Removal Plan, in which they alleged all corrective action to remove the IJ was completed on 2/01/24 and the IJ was removed as of 02/02/24. The SA validated the Removal Plan on 2/06/24 and determined the IJ and SQC was removed on 2/02/24. Therefore, the scope and severity for 42 CFR 483.25 Quality of Care was lowered from a J to a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. CROSS REFERENCE F600, F658, F726 Findings Include: Record review of the facility policy titled Skin and Wound with a revision date of 1/24/22 revealed, Policy: To provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure injuries .Skin Impairment Identification: 1. Document presence of skin impairment(s) / new skin impairments(s) when observed and weekly until resolved. 2. Nurse to report changes in skin integrity to the physician/physician extender, resident /resident representative and document in the medical record 3. Develop resident centered interventions and document on the plan of care and the Nurse Aide Kardex .5. Monitor residents' response to treatment, modify as indicated . Resident #103 An observation of wound care for Resident #103, with the Wound Nurse on 1/30/24 at 3:55 PM, revealed removal of the soiled dressing from the wounds on the left foot. A moderate amount of red serosanguinous drainage was observed around the toe portion of the dressing. The left great toe was covered in 100% adherent brown eschar with redness to the peri-wound with a slight odor observed. The wound nurse cleaned the wound to the left great toe and in between the areas of the toes with normal saline, patted dry, and applied xeroform gauze to all the areas and wrapped with a gauze wrap, secured with tape. Record review of the January 2024 Treatment Administration Record (TAR) for Resident #103 revealed there was not a Physician's order for wound care for the left great toe or the breakdown between the inner toes. Record review of the Order Summary Report with active orders as of 1/31/24 for Resident #103 revealed there was not a Physician Order for wound care to the left great toe or in between the toes on the left foot. Record review of the Physician Order Details in the Wound Nurse Practitioner notes for Resident #103 dated 1/24/24 revealed the following orders were not transcribed to the TAR and were not followed during the wound care observation on 1/30/24 with the Wound Nurse, Wound #3 Left Toe . Care of Wound: Enzymatic debriding agent nickel thickness Santyl to the wound bed only. Cover dressing with dry gauze and wrap with Kling/kerlix. Do not put tape directly on the skin. Other: D/C (discontinue) xeroform to left great toe . Thread toes with xeroform on left foot Secure dressing with tape . Change dressing every day and as needed. Also revealed under, Progress Note Details . The bruised/blood blister area to the left great toe is now covered in eschar with bogginess palpated. There are also scattered wounds to the 4th and 5th toes of recent onset Recent amputation to right great toe. Scattered wounds noted to 4th and 5th toes as well on left foot of recent onset with worsening of left great toe. Refer to Proper Name (General Surgeon) for further evaluation 1/25/24: Order for Clindamycin 300 mg (milligrams) 1 (one) po (by mouth) bid (twice daily) x 10 days. An observation of wound care for Resident #103, with the Wound Nurse on 1/30/24 at 3:55 PM, revealed removal of the soiled dressing from the wounds on the left foot. A moderate amount of red serosanguinous drainage was observed around the toe portion of the dressing. The left great toe was covered in 100% adherent brown eschar with redness to the peri-wound with a slight odor observed. The wound nurse cleaned the wound to the left great toe and in between the areas of the toes with normal saline, patted dry, and applied xeroform gauze to all the areas and wrapped with a gauze wrap, secured with tape. Record review of the Weekly Skin Integrity Review forms for Resident #103 dated 1/23/24 and 1/30/24 revealed the wounds in between the toes on the left foot were present and the treatment nurse was aware. The report did not address the left great toe. On 1/30/24 at 3:50 PM, an interview with the Wound Nurse revealed Resident #103 has developed other areas on the left great toe and some areas of breakdown between the toes on the left foot. She revealed the left toe started out as a blood blister and had worsened over the past couple of weeks and now are eschar covered. She stated the left great toe had been debrided by the Wound Nurse Practitioner (NP), but necrotic tissue returned. She revealed an appointment had been made with a general surgeon due to the wounds not healing and the resident's history of previous amputation of the right great toe due to a necrotic wound. Record review of the Wound Nurse Practitioner Progress Note Details dated 12/27/23 for Resident #103 revealed, There is also a 0.8 x 1.5 x 0.0 bruised area on the left great toe that was noted at his most recent visit . Also revealed under, General Notes: Will continue to monitor left great toe. Record review of the Progress Note Details dated 1/03/24 for Resident #103 revealed under, Wound Assessment(s) . Wound #3 Left Toe blister and has received a status of Not Healed. Initial wound encounter measurements are 1 cm (centimeter) length x 1.2 cm (centimeter) width with no measurable depth, with an area of 1.2 sq (square) cm (centimeters). Also revealed under, General Notes: Will continue to monitor left great toe. Staff to notify of any changes . Record review of the Physician Order Details from the Wound NP notes for Resident #103 dated 1/10/24 revealed, Wound #3 Left Toe . Care of Wound: Apply Xeroform cover with Foam Bordered Dressing . Change dressing Every day and as needed . Also revealed under, Progress Note Details . Wound #3 is a Partial Thickness Blister and has received a status of Not healed. Subsequent wound encounter measurements are 0.8 cm (centimeter) length x 1.5 cm (centimeter) width x 0.1 cm (centimeter) depth, with an area of 1.2 cubic cm (centimeter) There is a scant amount of sero-sanguineous drainage noted which has no odor . This order was not transcribed to the TAR. Record review of Resident #103's Treatment Administration Record (TAR) for January 2024 revealed an order dated, 12/28/23 for the right foot great toe amputation site revealed the TAR was initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. Record review of Resident #103's TAR for January 2024 for sheering abrasion to the left buttocks revealed an order dated 12/15/23 was only initialed as completed by the Wound Care Nurse two (2) of the 31 days in January. The other dates were initialed as completed by other facility nurses. Also, the wound care was not documented as administered on 1/22/24 and 1/28/24, which was a total of 2 missed wound treatments. On 1/31/24 at 9:45 AM, an interview and record review with the Wound Care Nurse revealed all the wound documentation was behind, and she had to catch things up when she transferred to the position. She stated all the wounds were seen in the facility by the Wound Nurse Practitioner (NP) once weekly on Wednesdays and the Wound NP did not give any orders the day she visited but tells her what she wants to be changed up or makes recommendations for the treatments, and she will send the facility the progress notes the following Friday or Monday. She revealed that she worked Monday-Friday and had been doing all the wound care in the facility on those days. She stated that she did do the treatments but did not sit down to initial them until the evenings and occasionally the other nurses had already signed off on the orders already. She revealed that the Medication Cart Nurses did help her with holding certain residents, so they could have gone in and signed the TAR before she got to it. She explained that Resident #103's left great toe wound developed as a dry piece of skin that has continued to worsen, with new areas that developed in between the toes. She revealed the Wound NP visited him last week to assess the wound and made the recommendation to apply xeroform gauze and start Clindamycin for infection, but she did not enter the orders into the system. She confirmed that she would be the person responsible for implementing the orders and that she goes ahead and starts any new treatment recommendations but does not put the order into the system because once she received the NP progress note, she may have changed something up with the wound care. She explained that she was instructed by the Wound NP that the Clindamycin needed to be approved by nephrology, since the resident was on dialysis, so the resident was not started on the Clindamycin when it was originally ordered on 1/24/24. The Wound Nurse confirmed that she never called the dialysis unit to get the antibiotic order approved. Record review of the January 2024 Medication Administration Record (MAR) revealed the Clindamycin order was not implemented. She revealed the wound was not cultured but did show clinical signs of infection and that all medications that the Wound NP recommends must be approved by the Primary Care Practitioner (PCP). She confirmed that she did the treatment on Resident #103's left toes without an active order in the computer and stated, I don't get her notes until a week later, so I can't put in an order, if I don't have one. She confirmed that a verbal order from the NP should be immediately acted upon and that she was given a verbal order from the NP. She revealed not implementing physician orders immediately was a delay in treatment of the wound and treating the infection. She revealed that delay of treatment could result in possible infection, sepsis, or amputation for Resident #103. She confirmed that other nurses had initialed Resident #103's January Treatment Administration Record (TAR) and she revealed she was the person responsible for signing off on the TAR if she completed the treatments. On 1/31/24 at 10:05 AM, an interview with the Assistant Director of Nursing (ADON) confirmed that she was not aware that the Wound Nurse was not utilizing the TAR to complete the wound care each day. She stated the Wound Nurse would have caught that there wasn't a physician's order for care for Resident #103 if she had looked at the TAR and signed off after the treatment was provided. She revealed she was not sure how the nurses on the weekends were providing wound care or if they even were since there was nothing on the TAR for the resident. On 1/31/24 at 3:40 PM, a telephone interview with the Wound Nurse Practitioner revealed she rounds on all the facility wounds every Wednesday and during her visits she makes recommendations for wound care, but the facility does not receive the progress note until Friday evening when it's faxed over. She stated when she makes rounds with the Wound Nurse she gives verbal orders. She revealed some of her recommendations may be delayed because certain orders must go through the resident's primary care provider (PCP) or dialysis, such as antibiotics or pain medication if the resident is on dialysis. She confirmed she was aware of the delay in antibiotics that were ordered on 01/24/24 for Resident #103 because it had to be approved with the PCP due to high risk of drug nephrotoxicity but she assumed that the antibiotic order had been implemented by now. She confirmed that she had not been made aware that the resident still did not have an order for an antibiotic. She revealed that Resident #103 developed a dried blood blister to his left great toe that has deteriorated with a new breakdown in between the toes. She stated the resident had negative Doppler studies and Ankle Brachial Index (ABI) testing that showed moderate Peripheral Vascular Disease. She revealed that Resident #103 was a Diabetic, on dialysis and had a previous history of toe amputation, so she recommended a referral to a General Surgeon due to his high risk of the same outcome (amputation). She revealed she had not been made aware by the facility that Resident #103's left toe wound orders had not been acted upon by the Wound Nurse and the treatment ordered added in the charting system. She revealed that the current Wound Nurse just started, and she was aware that the wound care documentation was behind. She revealed that she had not been made aware of any concerns regarding the Wound Nurse not performing her duties or following physician orders. She confirmed that if the treatments weren't done as ordered, the wounds would deteriorate. On 2/01/24 at 11:25 AM, an interview with the ADON revealed she had not been made aware of any concerns from the Medication Nurses related to wound care. She explained, to her knowledge, the Medication Nurses had never been asked to perform treatments, so the Wound Nurse could catch up on orders or documentation. She confirmed that the nurses should not sign off on treatments that the Wound Nurse performed, and they had never been told to do so. She explained that she had never pulled the TAR to check and see who signed off on the treatments or if all the physicians orders for wounds were on the TAR. She explained that she felt the Wound Nurse got caught up in the day-to-day processes and just didn't make sure things were done. She revealed that she was not aware of a list that was left on the weekends to know which residents needed wound care. She stated the wound care should be administered from the TAR and signed off when completed. On 2/1/24 at 4:35 PM, an interview with the Director of Nursing (DON) she confirmed that the Wound Care Nurse could have implemented the physician order when the NP visited because she was giving the verbal order, which could have been added as a verbal physician's order. She stated, If you are given an order, you should implement that order. She revealed the Wound Nurse should have signed the treatments after they were administered. She explained that she was not aware of the Wound Nurse telling the Medication Nurses that they were required to do treatments because she was behind with orders/documentation. She stated, She could have because I'm not out there on the floor. Record review of the Skills Competency Assessment: Clean Dressing Change dated 7/11/23 revealed under, . 26. Document in the medical Record (TAR) (Treatment Administration Record) after completion of dressing change document findings in the nurse's notes and/or contact the physician when indicated . The Wound Nurse completed this training on 7/1/23. Record review of the facility's Performance Evaluation revealed the Wound Care Nurse read and signed acknowledgment of the job description and duties assigned dated 9/7/23 which revealed, . 8. Complete required documentation in an accurate and timely manner was a requirement. Record review of the Admission Record for Resident #103 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Encounter for Orthopedic Aftercare Following Surgical Amputation, acquired absence of Right Great Toe, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Pressure Ulcer of Left Heel, Stage 3, and Pain. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/23 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicates Resident #103 is cognitively intact. The facility submitted the following acceptable Removal Plan on 2/5/24: Brief Summary of Events: On 1/31/2024 at 4:50 pm State Agency (SA) notified the Executive Director (ED) of 5 Immediate Jeopardy's (IJ's) related to F 600 Free from Abuse and Neglect, F 686 Treatment /Services to Prevent /Heal Pressure Ulcers, F 684 Quality of Care, F 726 Competent Nursing Staff and F 658 services Provided Meet Professional Standards. An Immediate jeopardy template was provided to the Executive Director (ED) on 1/31/2024 at 4:50 pm by the State Agency (SA). The facility failed to follow the physician's orders for wound care, failed to provide training and competency skills to the Treatment Nurse to ensure she had adequate knowledge to provide care and services to residents with skin concerns and pressure ulcers and failed to provide the treatment and services to promote healing of pressure ulcer wounds and diabetic ulcers which resulted in delay of healing of pressure ulcers and diabetic ulcers for Resident #52, Resident #103, and Resident #269. Immediate Action Plan: Treatment Nurse was suspended by the Executive Director on 2/1/2024 at 1:00 pm and terminated on 2/1/2024 at 6:43 pm. Treatment Nurse was reported to the Mississippi Board of Nursing on 2/1/2024 at 6:32 pm related to not following professional standards of practice. On 1/31/2024 Assistant Director of Nurses initiated education with 5 Housekeeping employees, 6 Therapist, 4 Dietary employees, 8 Certified Nursing Assistants, 6 office staff, 5 Licensed Practical Nurses and 5 Registered Nurses on Abuse and Neglect with emphasis on following physician orders and timely implementation and documentation of medical treatments of wounds and diabetic ulcers. Employees will be educated prior to accepting an assignment. New hires will be in-serviced on Abuse and Neglect during orientation. Employees will be educated prior to accepting an assignment. On 1/31/2024 the Regional Director of Clinical Services (RDCS) conducted a verbal review of clean dressing change competency with return verbalization from Treatment Nurse RN, RN #1, RN #2, RN #3, RN #4, and Assistant Director of Nurses. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 5 Registered Nurses and 6 Licensed Practical Nurses on Medication Administration and Documentation. Employees will be educated prior to accepting assignments. On 1/31/2024 at 5:40 pm the Regional Director of Clinical Services (RDCS) conducted education with the Treatment Nurse on Skin and Wound Guidelines, Medication Administration and Documentation, Abuse and Neglect, and Following Physician Orders and Clean Dressing Change checklist was reviewed verbally with return verbalization. Education included following the physician order when administering treatments, administering treatment timely, nurse that administers treatment is to sign the electronic administration record that treatment was administered, ensure all skin impairments and pressure ulcers have a physician order for treatment. Employees will be educated prior to accepting assignments. On 1/31/2024 at 1:08 pm Resident #52 received new physician orders to clean the stage 3 pressure ulcer of the coccyx with Dakin's, pat dry, apply Santyl to the wound bed at nickel thickness, cover with foam bordered dressing every day. PRN order for soilage\dislodgement. Resident #103 received new physician orders on 1/31/2024 at 2:02 pm to clean diabetic ulceration between 3rd through 5th toes on left foot with normal saline, pat dry, thread xeroform between toes, cover with dry dressing, wrap with kerlix, and secure with tape every day. PRN order for soilage/dislodgement. Order for clean left great toe blister site with normal saline, pat dry, apply Santyl to wound bed at nickel thickness, cover with dry gauze or ABD pads, wrap with kerlix, and secure with tape every day. PRN order for soilage/dislodgement. No new orders for Resident #269. On 1/31/2024 at 5:05 pm body audits were initiated by Registered Nurse (RN) #1, RN #2, RN #3, RN #4, and Assistant Director of Nurses to identify skin impairment or pressure ulcers. There were 108 body audits completed and 7 refused. No new pressure ulcers or diabetic ulcers identified on the body audits conducted. Audit conducted on the 7 residents refusing body audit to determine any previous skin concerns. No areas of concern were identified. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 6 Licensed Practical Nurses, 5 Registered Nurses, and 23 Certified Nurses Assistants on Skin and Wound Guidelines. Employees will be educated prior to accepting assignments. On 1/31/2024 at 9:00 pm Assisted Director of Nurses initiated education with 7 Registered Nurses and 10 Licensed Practical Nurses on Following Physician Orders. Employees will be educated prior to accepting assignments. On 1/31/2024 at 8:30 pm Assistant Director of Nurses reviewed physician orders and wound Nurse Practitioner progress notes consisting of diabetic ulcers, pressure ulcers, and skin concerns in the electronic health record (EHR) to ensure physician orders were implemented for 12 of 12 residents. No discrepancies were identified. On 1/31/2024 at 5:40 pm the Regional Director of Clinical Services (RDCS) conducted education with the Treatment Nurse on Skin and Wound Guidelines, Medication Administration and Documentation, Abuse and Neglect, and Following Physician Orders and Clean Dressing Change checklist was used with demonstration and return demonstration. DON and ADON are completing treatments as ordered Monday through Friday until treatment nurse position is filled, and treatment nurse is trained on the skills and expectations of the facility. All dayshift nurses who have completed the skills competency for wound care will provide dressing changes on the weekends. Director of Nurses and Assistant Director of Nurses are checking orders daily to ensure orders have been updated in electronic health records for nurses to complete on weekends. On 2/1/2024 at 2:00 pm Regional [NAME] President of Operation conducted education with Administrator on Abuse and Neglect with emphasis on thorough investigations and reporting guidelines. On 2/1/2024 at 2:30 pm the facility initiated a monitoring tool to check skin concerns, diabetic foot ulcers, pressure ulcers for appropriate orders to treat issues identified. The facility will ensure compliance with all wound care orders for accuracy daily by the Director of Nursing and Assistant Director of Nursing. QAPI: On 1/31/2024 at 7:00 PM a Quality Assurance Performance Improvement (QAPI) Committee meeting was held to review the Immediate Jeopardy template for F 600 Free from Abuse and Neglect, F 686 Treatment /Services to Prevent /Heal Pressure Ulcers, F 726 Competent Nursing Staff and F 658 services Provided Meet Professional Standards and to determine Root Cause Analysis. It was determined through Root Cause Analysis the facility failed to provide approved wound care treatment for Resident #52 and Resident #103 related to failure of the treatment nurse to obtain orders to treat from the provider. The facility failed to provide training and competency skills to the Treatment Nurse to ensure she had adequate knowledge to provide care and services to residents with skin concerns and pressure ulcers and failed to provide the treatment and services to promote healing of pressure ulcer wounds and diabetic ulcers which resulted in delay of healing of pressure ulcers and diabetic ulcers due to change in position and employment status. Attendees were the Executive Director (ED), Minimum Data Service (MDS) Nurse, Medical Record Clerk (MRC), Regional Director of Clinical Services (RDCS), Assistant Director of Nurses (ADON)/Infection Preventionist, Director of Nurses (DON), Nurse Practitioner (NP), and the Medical Director (MD). Director of Nurses (DON), Nurse Practitioner (NP), and Medical Director (MD) attended by phone. It was determined through Root Cause Analysis that the facility failed to provide professional standards of practice for documenting and providing medical treatments for wounds for Resident #52, Resident #103, and Resident #269. As a result, the facility's failure to provide treatment and services for wound care, failure to follow the standards of practice, failure to follow physicians' orders, and failure to provide training and competencies skills, the resident's wound healing was delayed, antibiotic orders were delayed, which resulted in worsening wounds and a need for surgical consult to evaluate the need for amputation. The facility initiated a monitoring tool on 2/1/2024 to check skin concerns, diabetic foot ulcers, pressure ulcers for appropriate orders to treat issues identified. The facility will ensure compliance with all wound care orders for accuracy daily by the Director of Nursing and Assistant Director of Nursing. Weekly wound meeting will be held with Inter Disciplinary Team (IDT) to discuss outcomes and findings. Any adverse findings will immediately be reported to the Executive Director and physician by the Director of Nurses. This process will be on-going and reported to Quality Assurance Committee quarterly. A review of policy and procedures for Abuse and Neglect, Skin and Wound Guidelines, Medication Administration and Documentation, and Following Physician Order was reviewed, and no changes made to policies. All Corrective actions were completed by 2/1/2024 and the facility alleges removal of the Immediate Jeopardy as of 2/2/2024. The State Agency (SA) validated the facility's Removal Plan on 2/06/24: On 2/06/24, the SA validated through staff interviews and record reviews that the Treatment Nurse was terminated and reported to the Mississippi Board of Nursing on 2/1/24. On 2/06/24, the SA validated through staff interviews and record review of the in-service sheet, that education was provided on Abuse and Neglect with emphasis on following physician orders and timely implementation and documentation of medical treatments of wounds and diabetic ulcers. The SA validated through interviews and record reviews that employees will be educated prior to accepting assignments and new hires will be educated during orientation. On 2/06/24, the SA validated through staff interviews and record review that a verbal review of a clean dressing change was conducted for the Treatment Nurse RN, RN #1, RN #2, RN #3, RN #4, and Assistant Director of Nursing. On 2/06/24, the SA validated through in-services sign in sheets and staff interviews that education was conducted on Medication Administration and Documentation. The SA validated through staff interviews and record reviews that all employees will be educated prior to accepting assignment. On 2/06/24, the SA validated through record reviews that education was conducted for the Treatment Nurse on Skin and Wound Guidelines, Medication Administration and Documentation, Abuse and Neglect, Following Physician Orders, and Clean Dressing Change. The SA validated through staff interviews and record review that all employees will be educated prior to accepting assignments. On 2/06/24, the SA validated through record reviews that Resident #52 received a new physician order for pressure wound to the coccyx. Resident #103 received a new physician order for treatment of left great toe blister site and diabetic ulcerations between the 3rd through 5th toes on the left foot. On 2/06/24, the SA validated through staff interview and record review of body audits, that 108 resident skin audits were conducted by Registered Nurse (RN) #1, RN #2, RN #3, RN #4, and the Assistant Director of Nursing, with no new skin impairments identified. The SA validated seven (7) residents refused with an audit conducted to determine if the seven (7) residents had any previous skin concerns on prior skin sweeps and no concerns were identified. On 2/06/24, the SA validated through staff interviews and record review through in-service sign in sheets, that education was provided to nurses and aides for Skin and Wound Guidelines. The SA validated all employees will be educated prior to accepting assignment. On 2/06/24, the SA validated the nurses were educated on Following Physician Orders. The SA validated all employees will be educated prior to accepting assignment. On 2/06/24, the SA validated through interviews and record review that Assistant Director of Nursing reviewed physician orders and wound Nurse Practitioner's progress notes for residents with skin concerns in the Electronic Health Record (EHR) to ensure physician orders were implemented for 12 of 12 residents with no discrepancies found. On 2/06/24, the SA validated through staff interviews and record review that the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were completing treatments Monday through Friday until treatment nurse position was filled. The day shift nurses that have completed the skills competency will cover the weekends. The SA validated through interviews that the DON and ADON were checking the orders daily to ensure orders have been updated in the Electronic Health Record (EHR). On 2/06/24, the SA validated through interviews that the Administrator received education on Abuse and Neglect with emphasis on thorough investigation and reporting that was conducted by the Regional [NAME] President. On 2/06/24, the SA validated through staff interviews and record review that the facility implemented a monitoring tool for skin concerns and to ensure orders are implemented to treat issues identified. The SA validated compliance with wound care orders will be monitored daily by the Director of Nursing and Assistant Director of Nursing. On 2/06/24, the SA validated on 1/31/24, a Quality Assurance and Performance Improvement (QAPI) meeting was held to review he cited deficient practice and determine the root cause analysis lacking appropriate interventions. In attendance were the Executive Director, Minimum Data Set (MDS), Medical Record Clerk, Regional Director of Clinical Services, Assistant Director of Nursing/Infection Preventionist, Director of Nursing, Nurse Practitioner, and the Medical Director. DON, NP, and MD attended by phone. On 2/06/24, the SA validated by staff interviews that a weekly wound meeting will be held with the Interdisciplinary Team (IDT) to discuss outcomes and findings of the new monitoring tool implemented for skin concerns and ensuring any new skin concerns has physician orders to treat issues identified. This process will be on-going and reported to Quality Assurance Committee quarterly.

Based on observation, resident and staff interviews, record review and facility policy review, the facility failed to assess and provide effective pain management for a resident with wounds for one (1) of five (5) residents reviewed for wound care. Resident #103 Findings Include: Record review of the facility policy titled Pain Management Guideline with a revision date of 8/28/17 revealed, Policy: The center strives to improve patient/resident comfort and minimize pain in order to help a resident attain or maintain his or her highest practicable level of well-being .Pain Evaluation: Identify if a resident is experiencing pain using either the resident's self report of pain (utilizing a 0-10 scale) or for those patient/resident's who cannot self-report, use the non-verbal clinical indicators . Resident #103 An interview with Resident #103 on 01/30/24 8:19 AM, revealed he had a wound on his bottom and foot that caused him pain. He explained that he had pain medication but could only have it every eight (8) hours. The resident voiced it did not hold him the entire time and that sometimes he asked for pain medication, and they told him it was too early to take it. He revealed that he spoke with the Wound Nurse last week, and she was going to speak to the Nurse Practitioner (NP) about increasing his medication, but so far, his pain medication had remained the same. An interview with Licensed Practical Nurse (LPN) #2 on 1/30/24 at 12:10 PM, revealed that Resident #103 had Norco 5/325 mg (milligrams) every eight (8) hours as needed for pain. He revealed that the resident had been taking it regularly since he had a toe amputated. He stated on medication follow-up, the resident always voiced that the medication was effective. LPN #2 stated that the resident will ask for the medicine in 8 hours, exactly when it's due, and sometimes early. During an observation of wound care with the Wound Nurse on 1/30/24 at 3:55 PM, Resident # 103 immediately voiced complaints of left foot pain. Resident #103 stated, It's hurting; Can you put that pillow under my foot? Certified Nurse Aide (CNA) #4 placed a pillow under the left foot while waiting on the Wound Nurse to gather the needed supplies. The Wound Nurse entered the room and did not assess the resident's pain. She removed the soiled dressing from the left foot and the resident cried out. During the cleaning of the wounds to the left great toe and the left heel, the resident hollered out Oh god! The resident told the wound nurse That's it and he tried to pull back his left leg. The resident allowed the nurse to complete the treatment. The Wound Nurse did not stop treatment to address the resident's voiced complaints of pain. An interview with Resident #103 with Wound Nurse present on 1/30/24 at 4:10 PM revealed that he took a pain pill today at 1:00 PM and confirmed it was not controlling his pain during wound care. She stated Resident #103 did have increased pain with wound care, and she had discussed this with the Director of Nursing (DON) last week. She revealed that the Wound Nurse Practitioner (NP) did not prescribe pain medication. She explained that they have another Nurse Practitioner (NP) and a Medical Director that could prescribe pain medication, but cannot because the resident is on dialysis and all his medication must be approved through his nephrologist. The Wound Nurse revealed the resident received Norco and confirmed it was not effective at pain management during wound care. She revealed the resident had been experiencing increased pain for about a week. An interview with the Director of Nursing (DON) on 1/30/24 at 4:35 PM, confirmed that she was notified by the Wound Nurse last week that Resident #103 was experiencing increased pain during wound care. She explained that she told the Wound Nurse that day let's monitor him and she would follow up to assess his pain. She revealed that she checked on him on Friday, 1/26/24 while he was in the dining room and the resident told her his pain was ok. She confirmed that the Wound Nurse should have assessed the resident's pain before starting the treatment and stopped when the resident experienced pain and called the physician. She explained that the resident's pain medication was not ordered through dialysis. The DON stated he was taking Percocet after his recent toe amputation, but after the prescription was exhausted, the facility Nurse Practitioner (NP) changed him over to Norco 5/325 mg (milligrams). The DON revealed that the resident should be comfortable during wound care and confirmed she should have notified the NP of the residents' increased pain last week. Record review of the Admission Record revealed Resident #103 was admitted to the facility on [DATE] with medical diagnoses that included Encounter for Orthopedic Aftercare following Surgical Amputation, Acquired Absence of Right Great Toe, Pressure Ulcer Left Heel, Stage 3, Pain Unspecified, End Stage Renal Disease, and Dependence on Renal Dialysis. Record review of Resident #103's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicates the resident is cognitively intact. Also revealed under section J, the resident experienced frequent pain with a numeric rating (pain intensity) of 07 on a scale from 1-10 during the 5-day MDS look back period for pain presence.

Based on staff interview, record review, and facility policy review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. 4th Quarter 2023. Findings Include: Record review of the facility policy titled, Exempt (Salaried) Staff undated, revealed, If a salaried position covers a direct care position, you may move up to 8 hours out of the home department to direct care Registered Nurse (RN) via PBJ Instance on (Proper name of facility). Record review of the facility policy titled, Recap-Your role as Executive Director undated, revealed, under Timely and accurate timekeeping. Daily review. Weekly review prior to payroll close, and review weekend RN coverage. Record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 4 2023 (July 1-September 30), revealed the facility triggered on this report for excessively low weekend staffing. During an interview on 01/31/24 at 2:50 PM, the Administrator (ADM) revealed there have been times that the salaried nurses would have to work the weekend for adequate coverage. She revealed the shifts for the fourth quarter of 2023 were covered, however, the data was entered incorrectly and did not capture the direct care on the PBJ. She revealed the Corporate Office submits the PBJ and the error was found in December 2023 and was corrected by them. During an interview on 02/01/24 at 8:45 AM, the Assistant Director of Nurses (ADON) revealed on the weekends when someone calls in, we just work on getting that position filled and use salaried staff to get it taken care of if need be. She revealed if a nurse works on the weekend, we give them a day off during the week and we will let human resources (HR) know and she will change our days and hours to reflect the correct day. During an interview on 02/01/24 at 11:20 AM, the Human Resources Director revealed that when a salary staff member works the weekend shift, they can take a day off during the week. She revealed I go in and delete the hours for the day they are taking off and put it on the day they work on the weekend. She confirmed during the fourth quarter of 2023 she failed to submit the staffing hours correctly which caused the discrepancy with the PBJ information.

Based on staff interview, record review, and facility policy review, the facility failed to develop a care plan for a resident with wounds (Resident #103), and implement a care plan related to nail care and shaving for five (5) of twenty-four sampled residents. Resident #49, Resident #52, Resident #72, Resident #103, and Resident #105. Findings Include: Review of the facility policy titled, Plans of Care, with a revision date of 9/25/2017, revealed it is the policy that an individualized person-centered care plan will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. The procedure includes to Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions .The individualized person centered care plan may include but is not limited to the following: Resident strengths and needs and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements. Resident #49 Record review of Resident #49's Care Plan Focus .The resident has an Activities of Daily Living self-care performance deficit related to Limited Mobility, Musculoskeletal impairment, Gout . Interventions .Personal Hygiene .The resident requires extensive assistance by 1 staff member to perform oral hygiene and personal hygiene. During an observation and interview on 01/29/24 at 10:29 AM, revealed Resident #49 lying in bed with approximately 1-inch facial hair growth on his chin, above his lip, and on his cheeks. Resident #49 revealed he would like to be shaved. Resident #49 stated It's been a very long time since I was shaved. During an observation and interview on 01/30/24 at 11:45 AM, CNA #2 confirmed Resident #49 was shaved about a month ago and revealed his facial hair was long and he needed to be shaved. An interview on 01/30/24 at 3:55 PM, the Assistant Director of Nurses (ADON) confirmed the plan of care was not being followed regarding grooming the resident. She revealed the personal hygiene in the care plan includes shaving and the resident should be shaved each time he has a shower or a bed bath. An interview on 01/30/24 at 4:05 PM, the Minimum Data Set (MDS) nurse revealed the residents' care plans are to be individualized for each resident so the staff will know what they specifically need to do for each resident. She revealed the CNA's know they are supposed to do personal hygiene for the residents each day which includes shaving. She confirmed Resident #49's care plan was not being followed regarding personal hygiene. A record review of the Admission Record for Resident #49 revealed he was admitted to the facility on [DATE] with diagnoses of Cerebrovascular disease, gout, and Major depressive disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #49 with a Brief Interview for Mental Status (BIMS) score of 09 which indicated the resident has moderate cognitive impairment. Resident #72 Record review of Resident #72s Care Plan Focus .The resident has an Activities of Daily Living self-care performance deficit related to Dementia and Schizoaffective disorder .Interventions .Bathing/Showering: Check nail length and trim/clean on bath day and as necessary.The resident requires substantial/maximal assist by staff member 3 times per week and as needed (PRN). During an observation and interview on 01/30/24 at 10:55 AM, revealed Resident #72 fingernails were long and jagged with a brown substance under his nails. Resident #72 stated he wanted his nails cut. During an observation and interview on 01/30/24 at 11:45 AM, LPN #2 revealed, Resident #72's fingernails were horrible and needed to be taken care of.LPN #2 revealed, the resident could scratch himself and cause a skin tear. An interview on 01/30/24 at 3:30 PM, the MDS nurse revealed on the resident's care plans doesn't list nail care, because they only put the nail care for those that are diabetic. She revealed under Resident #72 ADL care plan it would be personal hygiene. The aides know they are to do nailcare and shaving with personal hygiene. She confirmed that Resident #72's plan of care for grooming was not being followed. An interview on 01/30/24 at 4:02 PM, the ADON revealed under personal grooming and showering/bathing the CNA's should know that includes nail care unless it is specific for the nurses. She confirmed the ADL plan of care was not being followed for Resident #72. She revealed he should have had his nails cleaned and trimmed when he had his shower. A record review of the Admission Record for Resident #72 revealed he was admitted to the facility on [DATE] with diagnoses of Extrapyramidal and movement disorder and Major depressive disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #72 with a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident is cognitively intact. Resident #105 Record review of Resident #105's Care Plan Focus .The resident has an Activities of Daily Living self-care performance deficit . Interventions . Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . Personal/hygiene . The resident requires substantial/maximal assist by staff member 3 x (times) weekly and PRN. During an observation and interview on 01/29/24 at 10:25 AM, revealed Resident #105 had facial hair that was approximately 3/4 inch long on the resident's chin and sides of his face. Bilateral fingernails were approximately 1/2 inch long and had a brown substance under each nail. Resident #105 revealed it's been a while since he was shaved and wasn't sure of the last time his nails were trimmed. During an observation and interview on 01/30/24 5:17 PM LPN #3 confirmed that the resident needed to be shaved, and his nails were long and jagged and needed to be cleaned. Resident #105 revealed It's been over at least two weeks since I've been shaved. An interview with Registered Nurse (RN) #2 on 01/30/24 at 5:30 PM revealed the CNA's are responsible for ensuring Resident #105 is properly groomed. She revealed this includes shaving and his nails cleaned and trimmed. She confirmed that the plan of care for personal hygiene and nail care was not being followed and it should have been. A record review of the Admission Record for Resident #105 revealed he was admitted to the facility on [DATE] with diagnoses of Chronic Diastolic (Congestive) Heart Failure, End-stage renal disease. Record review of the MDS with an ARD of [DATE], revealed Resident #105 with a BIMS score of 07 which indicated the resident has severe cognitive impairment. 47874 Resident #52 Record review of Resident #52's ADL (Activities of Daily Living) Care Plan revealed under, BATHING/SHOWERING: Check nail length and clean on bath day and as necessary. Report any changes to the nurse. An observation on 01/29/24 at 12:04 PM, of Resident #52, revealed long nails on both hands measuring approximately three-eights (3/8) inch in length. An observation and interview with the Director of Nursing (DON) on 1/30/24 at 12:30 PM, confirmed that Resident #52 had long nails that needed cutting. An interview with the Assistant Director of Nursing (ADON) on 2/01/24 at 8:30 AM revealed the Care Plan provides individualized treatment for staff to know the basic needs and the specific needs of each resident. She confirmed the Care Plan was not followed for Resident #52's nail care. An interview with the Minimum Data Set (MDS) Nurse on 2/01/24 at 4:30 PM, revealed the purpose of the care plan was to give the staff a guide of what care should be done for the resident daily. She confirmed the care plan was not followed for Resident #52 and nail care. Record review of the Admission Record revealed Resident #52 was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Type 2 Diabetes Mellitus with Diabetic Neuropathy and Peripheral Vascular Disease. Record review of the MDS an ARD of 11/30/23 revealed under section C, a BIMS summary score of 11, indicating Resident #52 is moderately cognitively impaired. Resident #103 Record review of Resident #103's Care Plans revealed a Care Plan was not developed for wounds to the left great toe and in between the 3rd through 5th toes on the left foot. Record review of the Weekly Skin Integrity Review for Resident #103 dated 1/30/24 revealed under, Notes: wounds to right great toe . preexisting wound orders noted. Wounds in-between left 3rd, 4th and 4th, 5th toes . There was a discrepancy in wound documentation related to the right great toe. Resident #103 had documentation of a previous right great toe amputation. An interview with the Assistant Director of Nursing (ADON) on 1/31/24 at 10:05 AM, confirmed Resident #103 did not have an active care plan for wounds to the left great toe and in-between the left 3rd, 4th and 5th toes. An interview with the Minimum Data Set (MDS) Nurse on 2/01/24 at 4:30 PM, revealed the purpose of the care plan was to give the staff a guide of what care should be done for the resident daily. She revealed that every morning she pulled the active, discontinued and completed orders and updates the care plans. She confirmed that because Resident #103 did not have a physician order for wound care to the left great toe and between the toes she would not have known to care plan the problem. Record review of the Admission Record for Resident #103 revealed he was admitted to the facility on [DATE] with medical diagnoses that included Encounter for Orthopedic Aftercare Following Surgical Amputation, Acquired absence of Right Great Toe, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Pressure Ulcer of Left Heel, Stage 3 and Pain. Record review of the MDS with an ARD of 12/05/23 revealed under section C, a BIMS summary score of 13, which indicates Resident #103 is cognitively intact.

Based on observations, staff and resident interviews, record review and facility policy review, the facility failed to provide incontinent care timely to heal skin breakdown for reoccurring Stage II pressure ulcers for one (1) of five (5) residents reviewed with skin concerns. Resident #105. Findings include: Review of the facility policy titled, Skin and Wound, with a revision date of 1/24/2022 revealed the policy is to provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention, and healing of pressure injuries. An observation and interview, on 10/17/22 at 2:40 PM with Resident #105 revealed that she had an incontinent episode and had a wet brief and while the State Agency (SA) surveyor was in her room, she pressed her call light for assistance. An observation, at 3:00 PM on 10/17/22, while the SA was still in the resident's room, revealed a facility staff member came into the room and asked Resident #105 what she needed. The resident then responded that she needed to be changed. The staff member turned the call light off and told the resident that You (Resident #105) know it is 3:00 o'clock, I will have to see what they can do. An interview, with Resident #105 at 3:15 PM, revealed that the facility staff don't want to help her and stated that they never come to help when she calls. An observation, on 10/17/22 at 3:25 PM, revealed Resident #105 again turned her call light on at the request of the SA because nobody had come to the room since the facility staff member turned the light off at 3:00 PM. No staff had answered by 3:30 PM, so the SA left the resident's room and walked to the nurse's station where four (4) to five (5) staff were standing. At that time, one of the staff members at the nurse's desk paged overhead that Resident #105's light was on. At 3:35 PM, (2) two Certified Nursing Assistants (CNA) entered the room to provide incontinent care for the resident. An interview on 10/18/22 at 10:30 AM, with Resident #105 revealed that she had another incontinent episode this morning and was currently sitting in urine and bowel movement. She stated that she told CNA #1 and was told she would have to wait, and the resident stated it had been around an hour ago that she called to be changed. An observation and interview, on 10/18/22 at 10:35 AM, revealed CNA #1 entered Resident #105's room, then exited the room and obtained pads and brief and re-entered the room. She placed the pads and briefs in the room and left the room. CNA #1 revealed that she just found out the resident needed changed because her light was on. CNA #1 then walked across the hall to another resident's room. CNA #1 stated that she was going to another room to get someone else up. An observation 15 minutes later, on 10/18/22 at 10:50 AM, revealed incontinent care was provided by CNA #1 and an assistant. The observation revealed the resident had several superficial open areas over both buttocks and areas of pink discoloration on both buttocks and right upper posterior thigh. An observation and interview on 10/18/22 at 11:05 AM, revealed Registered Nurse (RN) #2 performed wound care to Resident #105's buttocks. She stated that the resident has had a problem with skin damage in the past. An interview, on 10/19/22 at 10:00 AM with RN #2, the wound care nurse, stated that the areas on Resident #105's buttocks were worsened by moisture from incontinence and confirmed that not being changed timely when she is incontinent would cause this red, boggy skin around the wound areas and could also cause an infection and that it was not helping to improve the areas of wounds. She stated that the resident has had these types of areas in the past and that the wounds would heal but come right back when incontinent care was not provided timely. RN #2 confirmed that Resident #105 tells staff when she is wet. An observation of wound care with RN #2 on 10/19/22 at 11:50 AM, revealed open areas on left buttock #1 V-shaped measures 2.5 centimeters (cm) x 1.1 cm and round area on the right buttock that measured 0.8 cm x 1.1 cm. An area on the right buttock measures 1.2 cm x 0.5 cm. An interview, on 10/19/22 at 3:05 PM with the Director of Nursing (DON) confirmed that Resident #105 has breakdown on her buttocks. The DON stated that no one should have to wait an hour to get changed, all staff should help to answer the call lights and provide care to the residents. The DON confirmed that the resident can call and tell the nurses when she needs to be changed. An interview with the Administrator (ADM) at the same time revealed that he wanted to look more into this event and that the staff should handle these matters better. Record review of the physician's active orders as of 10/19/22 revealed barrier cream to the buttocks every (q) shift to prevent skin breakdown dated 1/21/21 and clean stage 2 left buttock with normal saline (NS), pat dry, cover w/ alginate foam, cover w/foam bordered 3x/week and prn, as needed, dated 10/14/22. Record review of the Pressure Ulcer Rounds-CHC for Resident #105 revealed the pressure areas failed to heal as evidenced by the wounds would decrease in size then increase in size over the past month. The resident's wound on the left buttock dated 10/17/22 revealed a Stage II pressure ulcer to the left buttock that measured 7.1 cm (centimeters) by 2.7 cm. The wound bed was red, epithelial tissue with firm edges. There was a moderate amount of sero-sanguineous drainage, pink/red in color. The peri wound area was described as intact with redness and a mushy/boggy appearance. Notes revealed multiple separate smaller openings within the measurements. Record review of the record for the week prior dated 10/10/22 revealed measurements revealed 11.8 cm by 3.8 cm with redness and mushy boggy wound area with multiple separate openings. Record review of documentation dated 10/03/22 measurements revealed 2.9 cm by 1.1 cm with redness, mushy boggy skin with multiple pinpoint areas with measurements. Record review of 09/26/22 wound measurements revealed 2.1 cm by 2.7 cm with redness, mushy boggy with previous area of moisture associated skin disease (MASD) scar tissue. Record review of the measurements for 9/26/22 revealed the left buttock Stage II pressure ulcer measured 2.1 cm by 2.7 cm and the peri wound skin had a mushy/boggy appearance. Record review of the Pressure Ulcer Rounds-CHC for Resident #105 dated 10/10/22 for the right buttock Stage II pressure ulcer revealed an increase in the wound with measurement 11.2 cm by 2.8 cm from measurement on 09/26/22 that measured 1.0 cm by 1.2 cm. The wound bed was red epithelial tissue with redness of the wound edges. Drainage was moderate sero-sanguineous pink/red in color. The peri wound area exhibited redness and a mushy/boggy appearance. Notes revealed multiple openings. Review of the Admission Record page revealed Resident #105 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 of 9/21/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #105 was cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to implement a care plan related to Activities of Daily Living (ADL) and incontinent care for two (2) of 27 residents. Resident #34 and #105. Findings include: Review of the facility policy titled, Plans of Care, with a revision date of 9/25/2017, revealed it the policy that an individualized person-centered care plan will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. The procedure includes the individualized person centered care plan may include but is not limited to the following: Resident strengths and needs and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements. Resident #105 Record review of Resident 105's care plan for Mixed Bladder Incontinence related to (r/t) Impaired Mobility, date initiated 11/18/2020 revealed the goal; the resident will remain free from skin breakdown due to incontinence and brief use. The Interventions/Tasks revealed under BRIEF USE: the resident uses disposable briefs. Change Q (every) 2 and prn (as needed). INCONTINENT: check Q 2 hours and as required for incontinence. An interview on 10/17/22 at 2:40 PM, with Resident #105 revealed that she was wet and had a brief on and the call light was turned on by Resident #105 while the State Agency (SA) was in the resident's room. An observation and interview on 10/17/22 at 3:00 PM, revealed a staff member came into the room and asked Resident #105 what she needed. The resident responded that she needed to be changed. The staff member came into the room and turned the call light off and told the resident that you (Resident #105) know it is 3:00 o'clock, she would have to see what they can do. The SA remained in the resident's room and at 3:15 PM Resident #105 stated that they don't want to help her. She stated that they never come to help when she calls. At 3:25 PM, Resident #105 turned her call light on at the request of the surveyor. At 3:30 PM this surveyor left the resident's room and walked to the nurses station where 4-5 staff members were standing and at that time one of the staff member's paged that Resident #105's call light was on. An interview on 10/18/22 at 10:30 AM, with Resident #105 revealed that she was wet and had a bowel movement earlier this morning. She stated that she told Certified Nursing Assistant (CNA) #1 that she needed to be changed and was told she would have to wait. An observation and interview on 10/18/22 at 10:35 AM, revealed CNA #1 entered Resident #105's room, then exited the room and obtained pads and a brief and re-entered the room. She placed the pads and briefs in the room and left the room. An interview with CNA #1 revealed that she just found out the resident needed changing because her light was on. CNA #1 then walked across the hall to another room. An interview with CNA #1 revealed that she was going to another room to get someone up. An interview, on 10/19/22 at 10:00 AM with Registered Nurse (RN) #2 stated that the areas on Resident #105's buttocks was caused by moisture and confirmed that not being changed timely when she is incontinent could cause this and stated that the resident tells them when she is wet and that she is cognitive. An interview, with the Director of Nursing (DON) on 10/19/22 at 3:20 PM confirmed that Resident #105 had skin breakdown and the care plan for bladder incontinence and actual impairment to skin was not being followed. Review of the Admission Record page revealed Resident #105 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 of 9/21/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #105 was cognitively intact. Resident #34 Record review of Resident #34's Care Plan Focus .The resident has an Activities of Daily Living (ADL) self-care performance deficit related to the Disease process, Limited Mobility. Interventions . Bathing/showering. Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse .Provide a sponge bath when a full bath or shower cannot be tolerated . The resident requires extensive assistance from 1 staff with showering 3x (times) weekly and as necessary. Observation and interview on 10/16/22 at 5:00 PM, revealed Resident #34 had approximately 1/2-inch facial hair growth on his chin and on his cheeks. Resident #34 revealed he hasn't had a shower or bed bath since last week. An observation on 10/17/22 at 10:45 AM, revealed Resident #34 was unshaved and was observed with the same shirt on as the day before. Observation and interview, on 10/17/22 at 4:17 PM, revealed Resident #34 was not shaved and in the same clothes as earlier in the day. The resident revealed I haven't been shaved or had a bath today and have not had my clothes changed since last week. An interview and observation on 10/18/22 at 8:10 AM, revealed Resident #34 in the bed with the same clothes on that he was first seen in on 10/16/22 at 5:00 PM and with approximately 1/2-inch facial stubble, and a strong urine odor was noted. Resident #34 revealed I still haven't had a bath, nor had my clothes changed. During observation and interview on 10/18/22 at 9:25 AM, the DON confirmed that Resident #34 needed to be bathed, shaved, and his haircut. The DON assured Resident #34 that he would get a bath today. The DON revealed the aides have a shower/bath schedule they go by and on the days, they don't get a shower each resident is to get a bed bath. An interview on 10/19/22 at 2:48 PM, with RN #3 confirmed according to the ADL- Bathing documentation that Resident #34 did not receive a shower on October 1-18. She confirmed his ADL bath care plan reflects, Resident #34 is to receive a shower 3x weekly and on the other days, he is supposed to receive a bed bath. She confirmed according to the bathing documentation that there are days he didn't get a bed bath either. She confirmed that on Monday 10/17/22 Resident #34 did not receive a bed bath or shower and it was not documented that he refused. An interview on 10/19/22 at 3:30 PM with the Assistant Director of Nurses (ADON) confirmed Resident #34 had no showers listed on the ADL documentation guide for the month of October. She revealed and confirmed according to his ADL care plan he is to have a shower 3x weekly and on the other days he is to have a bed bath and she confirmed that the care plan has not been followed. A record review of the Admission Record for Resident #43 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/3/2022 revealed Resident #34's Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

Based on observation, interview, record review, facility policy review, State Board of Nursing documentation review, and the Nurse Practice Act, the facility failed to provide consistent respiratory care services to a resident with a [MEDICAL CONDITION] (Trach) by qualified personnel, a Registered Nurse (RN) and/or Respiratory Therapist (RT), 24 hours each day to deep suction the Trach, if needed, and/or provide other emergency care related to the Trach, for one (1) of one (1) current residents reviewed with a Trach, Resident #31. Resident #31 was admitted with a [MEDICAL CONDITION] with orders to suction as needed. The order did not indicate the depth of suction. Deep suction can only be provided by a RN/PT. Review of the nursing schedule from 7/23/18 through 11/27/18, revealed approximately 25 days, or 30 shifts that a RN/RT was not available, beginning 8/4/18, to deep suction a resident with a Trach, if needed. One (1) other resident with a Trach, Resident #158, resided in the facility until discharged on (MONTH) 31, (YEAR). The discharge was unrelated to the [MEDICAL CONDITION]. The facility's failure to provide a RN/RT to provide deep suctioning of a resident with a [MEDICAL CONDITION] on a 24 hour basis, from 8/4/18 through 11/27/18, placed Resident #31 and other residents with a Trach, in a situation that was likely to cause serious harm, injury or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), identified on 11/27/18, which began on 8/4/18, when the facility failed to ensure qualified staff (a RN and/or a RT) was in the facility to provide 24 hour a day coverage to deep suction residents with a [MEDICAL CONDITION], if needed. The facility's Administrator was notified of the IJ on 11/27/18. An acceptable Allegation of Compliance (AoC) was received on 11/28/18, in which the facility alleged all corrective actions were completed on 11/27/18, and the IJ removed on 11/28/18. The State Agency (SA) validated the AoC and determined the IJ to be removed on 11/28/18, prior to exit. The scope and severity for the IJ and SQC at CFR(s) 483.25(i), was lowered from a J to a D level, while the facility develops and implements a Plan of Correction (P[NAME]) and monitors the effectiveness of the systemic changes, to ensure the facility sustains compliance with the regulatory compliance. Findings include: Review of the facility policy titled, [MEDICAL CONDITION] Care, dated 11/30/2014, and revised 08/24/2017, revealed: [MEDICAL CONDITION] care is performed for aseptically cleaning the [MEDICAL CONDITION] and stoma site to prevent plugging of the [MEDICAL CONDITION], prevent airway obstruction, prevent infection or superinfection [MEDICAL CONDITION], and to maintain a patent airway for suctioning. Review of the facility policy, titled,Tracheal Suctioning, dated 11/30/2014, and revised 08/24/2017, revealed: Tracheal suctioning is an effective way to maintain a clear airway and to aid in the removal of secretions for residents who are unable to clear their secretions with coughing. The policy did not address deep suctioning of [MEDICAL CONDITION] what staff was responsible to suction the resident. Review of the MS State Board of Nursing (BON) web site, revealed frequently asked questions (FAQ's). The BON's statement, under [MEDICAL CONDITION], Question 91, regarding the LPN's scope of practice with [MEDICAL CONDITION] care revealed: It is not within the scope of practice for Licensed Practical Nurse to perform deep Right Main Stem suctioning. If deep right main suctioning is required for the patient, a Registered Nurse must perform this procedure. Review of the Mississippi State Board of Nursing Laws and Rules Administrative Code Part 2830, Practice of Nursing Title 30: Professions and Occupations Chapter 2, Functions of the Licensed Practical Nurse revealed: Rule 2.1-LPN Supervision ; The LPN gives nursing care which does not require the specialized skill, judgement, and knowledge required of a RN, Advanced Practice Registered Nurse (APRN), Licensed Physician, or Licensed Dentist. Observation of Resident #31 on 11/27/2018 at 11:38 AM, revealed the resident in bed, with [MEDICAL CONDITION] in place. Resident #31 was unable to be interviewed due to his cognitive status. Review of the working schedule for licensed nurses, from 7/23/2018 to 11/27/2018, revealed a total of 30 shifts, nine (9) 3:00 PM-11:00 PM shifts and 21 of the 11:00 PM-7:00 AM shifts; in which there was no documented RN coverage for the facility, over a period of 25 days. The facility did not employ a Respiratory Therapist. There were no qualified staff to deep suction a resident's Trach, during this time period, if needed. This included six (6) shifts for (MONTH) (YEAR), seven (7) shifts for (MONTH) (YEAR), six (6) shifts for (MONTH) (YEAR), and 11 shifts for (MONTH) (YEAR). The facility admitted Resident #31 on 8/17/2016, with [DIAGNOSES REDACTED]. Review of Resident #31's Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 9/21/2018, revealed staff assessed Resident #31 with severely impaired cognition. Review of a Physician Order, dated 8/17/2016, revealed to suction Resident #31 as needed. The order did not address whether to shallow suction or deep suction, nor who was responsible to carry out this order. Review of Resident #31's care plan revealed: Suction as ordered. Review of the medical record revealed a Progress Note, documented by the Nurse Practitioner (NP), dated 11/12/2018, revealed Resident #31 continued with [MEDICAL CONDITION], requiring frequent suctioning, but most often on room air with no recent fevers or signs of respiratory distress. In an interview on 11/27/2018 at 11:45 AM, RN #1 stated the facility usually had RN coverage on all shifts Monday through Friday, but does not always have RN coverage on the 3:00 PM-11:00 PM shift and/or the 11:00 PM-7:00 PM shift on the weekend. In an interview on 11/27/2018 at 12:05 PM, the DON stated she tried to cover all shifts with a RN, but does not always have RN coverage for the weekends. The DON stated that if the resident needed to be suctioned (deep suctioned) when no RN was available, the resident would be sent to the hospital. When the DON was asked what would be done if the resident needed immediate suctioning, she stated I know what you are getting at. The DON acknowledged the risk that a resident with [MEDICAL CONDITION] require deep suctioning, and there were times a RN was not present in the building. The DON confirmed that the facility did not have Respiratory Therapy coverage and didn't always have 24 hour RN coverage from (MONTH) 23, (YEAR) through (MONTH) 27, (YEAR), in order to deep suction a resident's Trach, if needed. In an interview on 11/27/2018 at 1:00 PM, the DON stated that the facility had 24 hour RN coverage until approximately two (2) months ago when the weekend RN quit. The DON stated that she had RN coverage for weekend 7:00 AM-3:00 PM shifts and some 3:00 PM-11:00 PM shifts. The DON stated that Resident #31 was admitted with [MEDICAL CONDITION] 8/17/2016, and has not required transfer to the hospital for any respiratory issues. The DON confirmed that typically the 11:00 PM-7:00 AM RN Unit Manager [MEDICAL CONDITION], and if unavailable, the 7-3 RN Unit Manager [MEDICAL CONDITION]. In an interview on 11/27/2018 at 1:05 PM, RN #1 stated she was responsible for suctioning Resident #31 if needed. RN #1 stated that she had not had to suction Resident #31 since becoming Unit Manager in (MONTH) (YEAR). She stated that Resident #31'[MEDICAL CONDITION] is performed daily, and as needed, and the the Resident normally had thin, white secretions and occasionally needed the drain sponge changed due to secretions. RN #1 stated that she does not recall any hospitalization s of Resident #31, related to respiratory distress. RN #1 confirmed if [MEDICAL CONDITION] needed deep suctioning, a RN would be required to perform the deep suction. Interview with RN #2, per phone on 11/27/2018 at 2:30 PM, revealed that she had worked at the facility two (2) years and has only had to [MEDICAL CONDITION] and suctioning of Resident #31 once, which was approximately two (2) or three (3) months ago. Interview with the Physician on 11/27/2018 at 5:40 PM, revealed that he was not made aware that the facility did not have 24 hour RN coverage available [MEDICAL CONDITION] and deep suctioning, as needed, for residents with a Trach. The Physician stated that he was made aware of 24 hour coverage of qualified staff to perform deep suctioning of [MEDICAL CONDITION] ago, but was not aware of the loss of nurses, resulting in 24 hour daily RN staffing issues. The physician stated that he was not aware of Resident #31 having any issues [MEDICAL CONDITION] respiratory distress since initial admission. The Physician [MEDICAL CONDITION] always had a risk for deep suctioning. Interview with RN #3, per phone on 11/27/2018 at 11:25 PM, revealed that she has never had to perform deep suctioning on Resident #31's Trach, but has performed oral suctioning for saliva. RN #3 confirmed she was aware that deep suctioning of [MEDICAL CONDITION] a RN. Interview on 11/28/2018 at 9:28 AM, with the Nurse Practitioner (NP) revealed that she evaluated Resident #31's overall respiratory status on visits, and that he would require suctioning [MEDICAL CONDITION]. The FNP stated that Resident #31 remained stable and has not required hospitalization due to respiratory conditions. Interview with the Administrator (ADM) on 11/28/2018 at 2:35 PM, revealed that she was aware that the facility did not have 24 hour RN coverage and she was aware that it must be a RN to perform [MEDICAL CONDITION], but she thought Resident #31 did not need [MEDICAL CONDITION]. In an interview, per phone, on 11/28/2018 at 4:06 PM, RN #5 stated that she only worked a shift occasionally, but recalled a need to [MEDICAL CONDITION] Resident #31 once, which was several months ago. Interview with LPN #2 on 11/28/2018 at 4:10 PM, revealed that she takes care of Resident #31. She confirmed if the resident needed to be deep suctioned, she would find a RN to deep suction the Trach. Interview with LPN #3 on 11/28/2018 at 4:13 PM, revealed that Resident #31 had never needed to be suctioned on her shift, but if needed, she would find a RN to deep suction the resident. LPN #3 confirmed she was aware of the requirement for the RN to deep suction a Trach, if needed. Allegation of Compliance for Lack of Registered Nurse (RN) coverage: Brief Summary: On (MONTH) 27, (YEAR) at 3:35 PM, Mississippi State Department of Health Annual Survey Team identified an immediate jeopardy for not having RN coverage 24 hours per day for the care of Resident #31, who had a [MEDICAL CONDITION] which required [MEDICAL CONDITION] care, including suctioning. This is the only [MEDICAL CONDITION] resident presently in the facility. There was an additional resident, Resident #158, identified with a [MEDICAL CONDITION] who was discharged (MONTH) 31, (YEAR), for reasons unrelated to the [MEDICAL CONDITION]. 1. On (MONTH) 23, (YEAR) through (MONTH) 27, (YEAR), there was no RN coverage on the weekends for a total of 25 days. In this time period the facility has had a total number of 30 shifts with no RN coverage on the weekends, nine (9) on the 3-11 PM shift and 21 on 11-7 PM shift. 2. Resident #31 was admitted on [DATE], with the following Diagnoses: [REDACTED]. Resident #31's history upon admission reflects in (MONTH) (YEAR), findings of right-sided lower zone pneumonia. Resident #31 has not been hospitalized or received any medical treatment for [REDACTED]. Corrective Action: 1. On (MONTH) 27, (YEAR) at 5:25 PM, Resident #31 was assessed by the RN Unit Manager with vitals signs stable and no respiratory issues noted related to his [MEDICAL CONDITION]. Resident #31 is the only resident with a [MEDICAL CONDITION]. No other residents are at risk for this deficient practice. Resident #31's care plan was revised by the RN Minimum Data Set (MDS) Nurse on (MONTH) 27, (YEAR) at 5:27 PM, to deep suction as ordered via an RN related to his [MEDICAL CONDITION]. 2. An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held on Tuesday, (MONTH) 27, (YEAR) at 5:30 PM, with the Medical Director, Executive Director (ED), Director of Nurses (DON), Assistant Director of Nurses (ADON), RN Unit Manager, RN MDS Nurse, Licensed Practical Nurse (LPN) MDS Nurse, Human Resources Director, Social Services (SS) Director, Medical Records Nurse, RN Infection Control Nurse, and Business Office Manager, to discuss the opportunity of improvement, assess current situation of the one [MEDICAL CONDITION] resident in facility, root cause analysis, and plan of correction to include in-service education to licensed nurses and agency staff, and RN [MEDICAL CONDITION] care/deep suctioning skills competencies checklists on all facility RNs and agency staff related to the lack of RN coverage 24 hours per day for the care of Resident #31 with [MEDICAL CONDITION] care. The facility assessment tool was updated to reflect 24 hours per day RN coverage for [MEDICAL CONDITION] care, by the ED, and approved through the QAPI Committee meeting that was held at 5:30 PM on (MONTH) 27, (YEAR). 3. On (MONTH) 27, (YEAR) at 6:00 PM, the DON ensured RN coverage 24 hours per day for the [MEDICAL CONDITION] care of Resident #31 by covering the weekend shifts through (MONTH) 31, (YEAR), with current RNs employed and/or agency staff to ensure 24 hour RN coverage including weekend shifts. 4. On (MONTH) 27, (YEAR) at 6:00 PM, the ADON initiated education for licensed nurses related to: (1) following Physician Orders for deep suctioning as needed by an RN (2) following Care Plans for deep suctioning as needed by an RN (3) [MEDICAL CONDITION] Care and Suctioning for RNs to perform [MEDICAL CONDITION] care/deep suctioning (4) Mississippi (MS) Board of Nursing Scope of Practice related to [MEDICAL CONDITION] and only RNs can perform deep suctioning. Current licensed nurses will not be permitted to work until educated. Newly hired licensed nurses and agency RNs will be educated by the ADON during orientation regarding: (1) following Physician Orders (2) following Care Plans (3) [MEDICAL CONDITION] Care and Suctioning for RNs to perform [MEDICAL CONDITION] care/deep suctioning (4) MS Board of Nursing Scope of Practice related to [MEDICAL CONDITION] and only RNs can perform deep suctioning. 5. On (MONTH) 27, (YEAR) at 6:15 PM, the ED/DON/ADON initiated education for seven (7) RNs of 14 total RNs of the following skills competency checklist: [MEDICAL CONDITION] Care/ Deep Suctioning can only be provided by an RN. Current licensed nurses and agency staff will not be permitted to work until educated. Newly hired RNs and contracted agency RNs will be educated during orientation by the ADON regarding the following skills competency checklist: [MEDICAL CONDITION] Care/Deep Suctioning can only be provided by an RN. 6. On (MONTH) 27, (YEAR) at 6:25 PM, a quality improvement data collection form was developed by the ED, to monitor RN coverage for 24 hours per day for the [MEDICAL CONDITION] resident. The ED/DON/RN Unit Manager will be responsible to conduct quality improvement monitoring. 7. On (MONTH) 27, (YEAR) at 6:30 PM, the ED and DON reviewed the RN nursing coverage through (MONTH) 31, (YEAR), to identify if the RN staffing schedule was completed and if there was sufficient staff scheduled to care for the [MEDICAL CONDITION] Resident #31. No issues were identified. 8. The facility alleges all corrective action was completed as of (MONTH) 27, (YEAR), and the Immediate Jeopardy was removed (MONTH) 28, (YEAR). The Survey Team Validated the Facility's A[NAME] through interview, record review, review of sign-in sheets and observation: 1. The SA validated a skilled assessment was performed by the RN Unit Manager by review of the Nurses Notes and interview with RN Unit Manager. Observation and interview revealed Resident #31 as the only resident in the facility with a Trach. Review of Physician orders and the care plan revealed orders and care plans for deep suctioning of [MEDICAL CONDITION] be performed by a Registered Nurse (RN). 2. The SA validated a Quality Assurance Performance Improvement (QAPI) meeting was held on Tuesday, (MONTH) 27,2018, by review of the sign-in sheet and interview with attendees about the agenda and recommendations. Review of the Facility Assessment Tool reflected the update of having 24 hour RN coverage [MEDICAL CONDITION]/suctioning. 3. The SA validated through interview with the Director of Nursing (DON) and record review that the nurse's schedule had been updated to ensure RN coverage 24 hours a day for deep suction of a resident with a [MEDICAL CONDITION]. 4. The SA validated through interview with LPN's and RN's that in-service education was provided by the ADON regarding only RN's can provide deep suction and [MEDICAL CONDITION], following the care plan, and the need for 24 hour RN coverage for residents with a Trach. The SA validated through interview that this education would be provided to any new facility/agency nursing staff during orientation. 5. The SA validated through interview with RN's that skills competency was performed for [MEDICAL CONDITION] care, beginning 11/27/2018. 6. The SA validated a quality improvement data collection tool had been developed to monitor compliance with RN coverage 24 hours a day for residents with a [MEDICAL CONDITION], and monitored by the DON/Administrator/RN Unit Manager. 7. The SA validated through interview with the DON and review of the schedule that RN coverage was available 24 hours a day for deep suction of a resident with a [MEDICAL CONDITION], through (MONTH) 31, (YEAR). 8. The SA validated that all corrective actions listed were accomplished by 11/27/18, and the IJ removed 11/28/18.

Based on record review, interview, and facility policy review, the facility failed to provide qualified, sufficient nursing staff, a Registered Nurse (RN) to provide respiratory services/deep suctioning on a 24 hour basis for a resident with a [MEDICAL CONDITION] (Trach) tube for one (1) of one (1) current residents reviewed with a Trach, Resident #31. Review of the nursing schedule from 7/23/18 through 11/27/18, revealed there were approximately 25 days, 30 shifts, beginning 8/4/18, with no RN coverage. Resident #31 was currently the [MEDICAL CONDITION] in the facility. Resident #158, prior resident with a Trach, was discharged from the facility 10/31/18, unrelated to Trach/respiratory issues. The facility's failure to provide RN coverage every shift to provide deep suctioning of a resident with a Trach, if needed, and/or [MEDICAL CONDITION] on a 24 hour a day basis, placed Resident #31, and other residents with a Trach, in a situation that was likely to cause serious harm, injury or death. The situation was determined to be an Immediate Jeopardy (IJ) on 11/27/18, which began on 8/4/18, when the facility failed to ensure RN coverage 24 hours a day to deep suction residents with a [MEDICAL CONDITION], if needed. The facility's Administrator (ADM) was notified of the IJ on 11/27/18. An acceptable Allegation of Compliance (AoC) was received on 11/28/18, in which the facility alleged all corrective actions were completed on 11/27/18, and the IJ removed 11/28/18. The State Agency (SA) validated the AoC and determined the IJ to be removed on 11/28/18, prior to exit. The scope and severity of the IJ at CFR(s) 483.35 (a) (1) (2) was lowered from a J to a D level, while the facility develops and implements a Plan of Correction (P[NAME]) and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory requirements. Findings include: Review of a statement on facility letterhead, undated and unsigned, revealed: The facility does not have a policy on requiring 24 hours RN coverage per day related to [MEDICAL CONDITION] care/deep suctioning. Review of the Mississippi State Board of Nursing Laws and Rules Administrative Code Part 2830 Practice of Nursing Title 30: Professions and Occupations Chapter 2, Functions of the Licensed Practical Nurse, revealed: Rule 2.1-LPN Supervision; The LPN gives nursing care which does not require the specialized skill, judgement, and knowledge required of a RN, Advanced Practice Registered Nurse (APRN), Licensed Physician, or Licensed Dentist. Review of the MS State Board of Nursing (BON) web site, revealed frequently asked questions (FAQ's). The BON's statement, under [MEDICAL CONDITION], Question 91, regarding the LPN's scope of practice with [MEDICAL CONDITION] care revealed: It is not within the scope of practice for Licensed Practical Nurse to perform deep Right Main Stem suctioning. If deep right main suctioning is required for the patient, a Registered Nurse must perform this procedure. Review of the working schedule for nurses, from 7/23/2018, when the designated 11:00 PM-7:00 AM weekend RN resigned, to 11/27/2018, revealed a total of 30 shifts in which there was no documented RN coverage for the facility, beginning 8/4/18. This include nine (9) 3:00 PM-11:00 PM shifts and 21 of the 11:00 PM-7:00 AM shifts. The facility did not have a RN on staff in the facility during those shifts, if a resident needed to be deep suctioned. The facility did not have RT available for these shifts. This included six (6) shifts in (MONTH) (YEAR), seven (7) shifts in September, (YEAR), six (6) shifts in (MONTH) (YEAR), and 11 shifts in (MONTH) (YEAR). The facility admitted Resident #31 on 8/17/2016, with diagnoses, which included Chronic [MEDICAL CONDITION] Unspecified whether with [MEDICAL CONDITION] or Hypercapnia, with [MEDICAL CONDITION] Status, Muscle Spasm, and Dysphagia. Review of Resident #31's Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/2018, revealed Resident #31 had severely impaired cognition. Review of a Physician Order, dated 8/17/2016, revealed an order to suction Resident #31 as needed. Review of Resident #31's care plan revealed to suction as ordered. Review of the medical record revealed a Progress Note, dated 11/12/2018, documented by the Nurse Practitioner, which noted Resident #31 continued with [MEDICAL CONDITION] requiring frequent suctioning. Interview on 11/27/2018 at 11:45 AM, with RN #1, revealed the facility did not always have 24 hour RN coverage, especially on the evening and night shift on the weekend. In an interview on 11/27/2018 at 12:05 PM, the DON confirmed she tried to have RN coverage on all shifts, but does not always have RN coverage for the weekends. The DON confirmed if the resident needed to be deep suctioned when no RN was available, the resident would have to be sent to the hospital. The DON acknowledged the risk that a resident with [MEDICAL CONDITION] require deep suctioning, and there were times a RN was not present in the building. In an interview 11/27/2018 at 1:00 PM, the DON confirmed the facility had 24 hour RN coverage daily until approximately two (2) months ago when the weekend RN quit (7/23/18). The DON stated that Resident #31 has had [MEDICAL CONDITION] admission on 08/17/2016, and has not required transfer to hospital for any respiratory issues since admission. During an interview with the Administrator (ADM) on 11/28/2018 at 2:35 PM, she confirmed that she was aware the facility did not have 24 hour RN coverage, and she was aware that it must be a RN to perform [MEDICAL CONDITION], but she thought Resident #31 did not need [MEDICAL CONDITION]. Allegation of Compliance for Lack of Registered Nurse (RN) coverage: Brief Summary: On (MONTH) 27, (YEAR) at 3:35 PM, Mississippi State Department of Health Annual Survey Team identified an immediate jeopardy for not having RN coverage 24 hours per day for the care of Resident #31, who had a [MEDICAL CONDITION] which required [MEDICAL CONDITION] care, including suctioning. This is the only [MEDICAL CONDITION] resident presently in the facility. There was an additional resident, Resident #158, identified with a [MEDICAL CONDITION] who was discharged (MONTH) 31, (YEAR), for reasons unrelated to the [MEDICAL CONDITION]. 1. On (MONTH) 23, (YEAR) through (MONTH) 27, (YEAR), there was no RN coverage on the weekends for a total of 25 days. In this time period the facility has had a total number of 30 shifts with no RN coverage on the weekends, nine (9) on the 3-11 PM shift and 21 on 11-7 PM shift. 2. Resident #31 was admitted on [DATE], with the following Diagnoses: [REDACTED]. Resident #31's history upon admission reflects in (MONTH) (YEAR), findings of right-sided lower zone pneumonia. Resident #31 has not been hospitalized or received any medical treatment for [REDACTED]. Corrective Action: 1. On (MONTH) 27, (YEAR) at 5:25 PM, Resident #31 was assessed by the RN Unit Manager with vitals signs stable and no respiratory issues noted related to his [MEDICAL CONDITION]. Resident #31 is the only resident with a [MEDICAL CONDITION]. No other residents are at risk for this deficient practice. Resident #31's care plan was revised by the RN Minimum Data Set (MDS) Nurse on (MONTH) 27, (YEAR) at 5:27 PM, to deep suction as ordered via an RN related to his [MEDICAL CONDITION]. 2. An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held on Tuesday, (MONTH) 27, (YEAR) at 5:30 PM, with the Medical Director, Executive Director (ED), Director of Nurses (DON), Assistant Director of Nurses (ADON), RN Unit Manager, RN MDS Nurse, Licensed Practical Nurse (LPN) MDS Nurse, Human Resources Director, Social Services (SS) Director, Medical Records Nurse, RN Infection Control Nurse, and Business Office Manager, to discuss the opportunity of improvement, assess current situation of the one [MEDICAL CONDITION] resident in facility, root cause analysis, and plan of correction to include in-service education to licensed nurses and agency staff, and RN [MEDICAL CONDITION] care/deep suctioning skills competencies checklists on all facility RNs and agency staff related to the lack of RN coverage 24 hours per day for the care of Resident #31 with [MEDICAL CONDITION] care. The facility assessment tool was updated to reflect 24 hours per day RN coverage for [MEDICAL CONDITION] care, by the ED, and approved through the QAPI Committee meeting that was held at 5:30 PM on (MONTH) 27, (YEAR). 3. On (MONTH) 27, (YEAR) at 6:00 PM, the DON ensured RN coverage 24 hours per day for the [MEDICAL CONDITION] care of Resident #31 by covering the weekend shifts through (MONTH) 31, (YEAR), with current RNs employed and/or agency staff to ensure 24 hour RN coverage including weekend shifts. 4. On (MONTH) 27, (YEAR) at 6:00 PM, the ADON initiated education for licensed nurses related to: (1) following Physician order [REDACTED]. Current licensed nurses will not be permitted to work until educated. Newly hired licensed nurses and agency RNs will be educated by the ADON during orientation regarding: (1) following Physician order [REDACTED]. 5. On (MONTH) 27, (YEAR) at 6:15 PM, the ED/DON/ADON initiated education for seven (7) RNs of 14 total RNs of the following skills competency checklist: [MEDICAL CONDITION] Care/ Deep Suctioning can only be provided by an RN. Current licensed nurses and agency staff will not be permitted to work until educated. Newly hired RNs and contracted agency RNs will be educated during orientation by the ADON regarding the following skills competency checklist: [MEDICAL CONDITION] Care/Deep Suctioning can only be provided by an RN. 6. On (MONTH) 27, (YEAR) at 6:25 PM, a quality improvement data collection form was developed by the ED, to monitor RN coverage for 24 hours per day for the [MEDICAL CONDITION] resident. The ED/DON/RN Unit Manager will be responsible to conduct quality improvement monitoring. 7. On (MONTH) 27, (YEAR) at 6:30 PM, the ED and DON reviewed the RN nursing coverage through (MONTH) 31, (YEAR), to identify if the RN staffing schedule was completed and if there was sufficient staff scheduled to care for the [MEDICAL CONDITION] Resident #31. No issues were identified. 8. The facility alleges all corrective action was completed as of (MONTH) 27, (YEAR), and the Immediate Jeopardy was removed (MONTH) 28, (YEAR). The Survey Team Validated the Facility's A[NAME] through interview, record review, review of sign-in sheets and observation: 1. The SA validated a skilled assessment was performed by the RN Unit Manager by review of the Nurses Notes and interview with RN Unit Manager. Observation and interview revealed Resident #31 as the only resident in the facility with a Trach. Review of Physician orders [REDACTED]. 2. The SA validated a Quality Assurance Performance Improvement (QAPI) meeting was held on Tuesday, (MONTH) 27,2018, by review of the sign-in sheet and interview with attendees about the agenda and recommendations. Review of the Facility Assessment Tool reflected the update of having 24 hour RN coverage [MEDICAL CONDITION]/suctioning. 3. The SA validated through interview with the Director of Nursing (DON) and record review that the nurse's schedule had been updated to ensure RN coverage 24 hours a day for deep suction of a resident with a [MEDICAL CONDITION]. 4. The SA validated through interview with LPN's and RN's that in-service education was provided by the ADON regarding only RN's can provide deep suction and [MEDICAL CONDITION], following the care plan, and the need for 24 hour RN coverage for residents with a Trach. The SA validated through interview that this education would be provided to any new facility/agency nursing staff during orientation. 5. The SA validated through interview with RN's that skills competency was performed for [MEDICAL CONDITION] care, beginning 11/27/2018. 6. The SA validated a quality improvement data collection tool had been developed to monitor compliance with RN coverage 24 hours a day for residents with a [MEDICAL CONDITION], and monitored by the DON/Administrator/RN Unit Manager. 7. The SA validated through interview with the DON and review of the schedule that RN coverage was available 24 hours a day for deep suction of a resident with a [MEDICAL CONDITION], through (MONTH) 31, (YEAR). 8. The SA validated that all corrective actions listed were accomplished by 11/27/18, and the IJ removed 11/28/18.

Based on staff interview, record review, Mississippi Board of Nursing web site review, and Policy and Procedure review, the facility failed to ensure qualified staff were available and designated on the care plan to perform deep suctioning for a [MEDICAL CONDITION] resident, if needed, on a 24 hour basis for one (1) of one (1) current residents with a [MEDICAL CONDITION] (Trach), Resident #31. Resident #31 was observed as the only resident with a [MEDICAL CONDITION]. Review of the nursing schedule from (MONTH) 23, (YEAR) through (MONTH) 27, (YEAR), revealed the facility failed to ensure 24 hour, seven (7) days a week coverage by qualified professionals, a Registered Nurse (RN) and/or Respiratory Therapist (RT), to provide deep suctioning and/or emergency care to a resident with a [MEDICAL CONDITION], for approximately 25 days beginning (MONTH) 4, (YEAR), until (MONTH) 27, (YEAR). This included 30 shifts with no RN coverage, mostly on the weekends, nine (9) on the 3:00 PM-11:00 PM shift and 21 on 11:00 PM-7:00 AM shift. The failure to have qualified personnel designated on the care plan and available to perform deep suctioning for residents with a Trach, if needed, placed Resident #31 and other residents admitted to the facility with a Trach, in a situation that was likely to cause serious injury, harm, impairment, or death. Resident #31 was the only Resident in the facility with [MEDICAL CONDITION] survey, however, Resident #158, a prior resident with a Trach, was discharged on [DATE], unrelated [MEDICAL CONDITION]. The situation was determined to be an Immediate Jeopardy (IJ) on 11/27/18, which began on 8/4/18, when the facility failed to ensure residents with [MEDICAL CONDITION] care planned for the appropriate discipline and have readily available and qualified staff to deep suction the Trach, if needed, 24 hours a day. The facility's Administrator (ADM) was notified of the IJ on 11/27/18. An acceptable Allegation of Compliance (AoC) was received on 11/28/18, in which the facility alleged all corrective actions were completed on 11/27/18, and the IJ removed 11/28/18. The State Agency (SA) validated the AoC and determined the IJ to be removed on 11/28/18, prior to exit. Therefore, the scope and severity for the IJ at CFR(s) 483.21(b) (3) (ii) Comprehensive Care Plan Services Provided by Qualified Persons, (F659), was lowered from a J to a D level, while the facility develops and implements a Plan of Correction (P[NAME]) and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with the regulatory requirements. Findings include: Review of the facility policy titled, Plans of Care, effective date 11/30/2014, and revised 09/25/2017, revealed: An individualized person-centered care plan will be established by the interdisciplinary team and updated in accordance with regulatory requirements. The Care Plan includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being. Review of the MS State Board of Nursing (BON) web site, revealed frequently asked questions (FAQ's). The BON's statement, under [MEDICAL CONDITION], Question 91, regarding the LPN's scope of practice with [MEDICAL CONDITION] care revealed: It is not within the scope of practice for Licensed Practical Nurse to perform deep Right Main Stem suctioning. If deep right main suctioning is required for the patient, a Registered Nurse must perform this procedure. Review of Resident #31's Plan of Care with a target date of 1/10/2019, revealed Resident #31 had a Focus Problem/Category of Respiratory, History of [MEDICAL CONDITION]/Pneumonia, and #8 [MEDICAL CONDITION] with potential for ineffective breathing pattern, with thin white secretions coming from the [MEDICAL CONDITION] at times; Resident is suctioned as needed (prn). The goal and target revealed: the resident will maintain clear and equal breath sounds through next review date, 1/10/2019. The approaches revealed:[MEDICAL CONDITION] as ordered and suction as ordered. This care plan did not specify which discipline was to do the suctioning (Registered Nurse or the License Practical Nurse) or whether deep suction or surface suction was to be performed. The facility admitted Resident #31 on 8/17/2016, with [DIAGNOSES REDACTED]. Review of Resident #31's Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 9/21/2018, revealed staff assessed Resident #31 to have severely impaired cognition. Review of the medical record revealed that Resident #31 had a #[MEDICAL CONDITION] to Chronic [MEDICAL CONDITION] and had not been hospitalized related [MEDICAL CONDITION] or respiratory distress since initial admission, 8/17/2016. Interdisciplinary Progress Notes, dated 10/18/18, revealed Resident #31 has had Pneumonia in the past. On 11/27/2018 at 11:38 AM, Resident #31 was observed lying in bed with a [MEDICAL CONDITION] in place. He was non-interviewable with no respiratory distress noted. In an interview on 11/29/2018 at 9:15 AM, RN #6 stated the facility policy for care plans is to make care plans person-centered. RN #6 confirmed that the care plan for Resident #31 did not specify the type of suctioning and who can perform suctioning of the Trach. RN #6 confirmed that she was in-serviced this week to be specific [MEDICAL CONDITION] on the care plan, including the type of suctioning and who could perform each type of suctioning, and that deep suctioning is performed only by a RN. An interview with the Director of Nursing (DON) on 11/27/2018 at 12:05 PM, confirmed that the care plan for Resident #31 was not specific to the type of suction or the discipline required to suction the resident's Trach. The DON confirmed 24 hour RN/RT coverage was not always available and/or on the premises in order to deep suction the resident's Trach, if needed. The DON confirmed if the resident with [MEDICAL CONDITION] deep suctioning and a RN was not in the building, the resident would have to be sent to the hospital. Allegation of Compliance for Lack of Registered Nurse (RN) coverage: Brief Summary: On (MONTH) 27, (YEAR) at 3:35 PM, Mississippi State Department of Health Annual Survey Team identified an immediate jeopardy for not having RN coverage 24 hours per day for the care of Resident #31, who had a [MEDICAL CONDITION], which required [MEDICAL CONDITION] care, including suctioning. This is the only [MEDICAL CONDITION] resident presently in the facility. There was an additional resident, Resident #158, identified with a [MEDICAL CONDITION] who was discharged (MONTH) 31, (YEAR), for reasons unrelated to the [MEDICAL CONDITION]. 1. On (MONTH) 23, (YEAR) through (MONTH) 27, (YEAR), there was no RN coverage on the weekends for a total of 25 days. In this time period the facility has had a total number of 30 shifts with no RN coverage on the weekends, nine (9) on the 3-11 PM shift and 21 on 11-7 PM shift. 2. Resident #31 was admitted on [DATE], with the following Diagnoses: [REDACTED]. Resident #31's history upon admission reflects in (MONTH) (YEAR), findings of right-sided lower zone pneumonia. Resident #31 has not been hospitalized or received any medical treatment for [REDACTED]. Corrective Action: 1. On (MONTH) 27, (YEAR) at 5:25 PM, Resident #31 was assessed by the RN Unit Manager with vitals signs stable and no respiratory issues noted related to his [MEDICAL CONDITION]. Resident #31 is the only resident with a [MEDICAL CONDITION]. No other residents are at risk for this deficient practice. Resident #31's care plan was revised by the RN Minimum Data Set (MDS) Nurse on (MONTH) 27, (YEAR) at 5:27 PM, to deep suction as ordered via an RN related to his [MEDICAL CONDITION]. 2. An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held on Tuesday, (MONTH) 27, (YEAR) at 5:30 PM, with the Medical Director, Executive Director (ED), Director of Nurses (DON), Assistant Director of Nurses (ADON), RN Unit Manager, RN MDS Nurse, Licensed Practical Nurse (LPN) MDS Nurse, Human Resources Director, Social Services (SS) Director, Medical Records Nurse, RN Infection Control Nurse, and Business Office Manager, to discuss the opportunity of improvement, assess current situation of the one [MEDICAL CONDITION] resident in facility, root cause analysis, and plan of correction to include in-service education to licensed nurses and agency staff, and RN [MEDICAL CONDITION] care/deep suctioning skills competencies checklists on all facility RNs and agency staff related to the lack of RN coverage 24 hours per day for the care of Resident #31 with [MEDICAL CONDITION] care. The facility assessment tool was updated to reflect 24 hours per day RN coverage for [MEDICAL CONDITION] care, by the ED, and approved through the QAPI Committee meeting that was held at 5:30 PM on (MONTH) 27, (YEAR). 3. On (MONTH) 27, (YEAR) at 6:00 PM, the DON ensured RN coverage 24 hours per day for the [MEDICAL CONDITION] care of Resident #31 by covering the weekend shifts through (MONTH) 31, (YEAR), with current RNs employed and/or agency staff to ensure 24 hour RN coverage including weekend shifts. 4. On (MONTH) 27, (YEAR) at 6:00 PM, the ADON initiated education for licensed nurses related to: (1) following Physician Orders for deep suctioning as needed by an RN (2) following Care Plans for deep suctioning as needed by an RN (3) [MEDICAL CONDITION] Care and Suctioning for RNs to perform [MEDICAL CONDITION] care/deep suctioning (4) Mississippi (MS) Board of Nursing Scope of Practice related to [MEDICAL CONDITION] and only RNs can perform deep suctioning. Current licensed nurses will not be permitted to work until educated. Newly hired licensed nurses and agency RNs will be educated by the ADON during orientation regarding: (1) following Physician Orders (2) following Care Plans (3) [MEDICAL CONDITION] Care and Suctioning for RNs to perform [MEDICAL CONDITION] care/deep suctioning (4) MS Board of Nursing Scope of Practice related to [MEDICAL CONDITION] and only RNs can perform deep suctioning. 5. On (MONTH) 27, (YEAR) at 6:15 PM, the ED/DON/ADON initiated education for seven (7) RNs of 14 total RNs of the following skills competency checklist: [MEDICAL CONDITION] Care/ Deep Suctioning can only be provided by an RN. Current licensed nurses and agency staff will not be permitted to work until educated. Newly hired RNs and contracted agency RNs will be educated during orientation by the ADON regarding the following skills competency checklist: [MEDICAL CONDITION] Care/Deep Suctioning can only be provided by an RN. 6. On (MONTH) 27, (YEAR) at 6:25 PM, a quality improvement data collection form was developed by the ED, to monitor RN coverage for 24 hours per day for the [MEDICAL CONDITION] resident. The ED/DON/RN Unit Manager will be responsible to conduct quality improvement monitoring. 7. On (MONTH) 27, (YEAR) at 6:30 PM, the ED and DON reviewed the RN nursing coverage through (MONTH) 31, (YEAR), to identify if the RN staffing schedule was completed and if there was sufficient staff scheduled to care for the [MEDICAL CONDITION] Resident #31. No issues were identified. 8. The facility alleges all corrective action was completed as of (MONTH) 27, (YEAR), and the Immediate Jeopardy was removed (MONTH) 28, (YEAR). The Survey Team Validated the Facility's A[NAME] through interview, record review, review of sign-in sheets and observation: 1. The SA validated a skilled assessment was performed by the RN Unit Manager by review of the Nurses Notes and interview with RN Unit Manager. Observation and interview revealed Resident #31 as the only resident in the facility with a Trach. Review of Physician orders and the care plan revealed orders and care plans for deep suctioning of [MEDICAL CONDITION] be performed by a Registered Nurse (RN). 2. The SA validated a Quality Assurance Performance Improvement (QAPI) meeting was held on Tuesday, (MONTH) 27,2018, by review of the sign-in sheet and interview with attendees about the agenda and recommendations. Review of the Facility Assessment Tool reflected the update of having 24 hour RN coverage [MEDICAL CONDITION]/suctioning. 3. The SA validated through interview with the Director of Nursing (DON) and record review that the nurse's schedule had been updated to ensure RN coverage 24 hours a day for deep suction of a resident with a [MEDICAL CONDITION]. 4. The SA validated through interview with LPN's and RN's that in-service education was provided by the ADON regarding only RN's can provide deep suction and [MEDICAL CONDITION], following the care plan, and the need for 24 hour RN coverage for residents with a Trach. The SA validated through interview that this education would be provided to any new facility/agency nursing staff during orientation. 5. The SA validated through interview with RN's that skills competency was performed for [MEDICAL CONDITION] care, beginning 11/27/2018. 6. The SA validated a quality improvement data collection tool had been developed to monitor compliance with RN coverage 24 hours a day for residents with a [MEDICAL CONDITION], and monitored by the DON/Administrator/RN Unit Manager. 7. The SA validated through interview with the DON and review of the schedule that RN coverage was available 24 hours a day for deep suction of a resident with a [MEDICAL CONDITION], through (MONTH) 31, (YEAR). 8. The SA validated that all corrective actions listed were accomplished by 11/27/18, and the IJ removed 11/28/18.

Based on record review, staff interview and policy review, the facility failed to follow physician's orders for one (1) of 21 residents reviewed as evidenced by failure to schedule/obtain a consult with a wound care specialist and a urologist as ordered by the resident's physician (Resident #2). Findings include: Resident #2 Record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review revealed a progress note of 04/23/13 signed by the nurse practitioner for Resident #2 for a "consult with (name of wound care center) in (name of town) pending." There was no documented evidence in the medical record that this consult had been conducted. Review of the handwritten physician's orders, revealed an order, dated 5/3/13 at 12:05 p.m., for "Consult a wound clinic for wounds." Review of nurse's notes, dated 5/8/13 at 1453 (2:53 p.m.) noted, "Wound care specialists was consulted about wounds due to family request." Cross refer to F314 for the facility's failure to provide services to promote healing of current wounds and prevent new occurrences of pressure ulcers for Resident #2. In addition, review of the May 2013 physician's orders revealed an order, dated 4/2/13, to " ... 2. Consult Urologist R/T (related to) reoccurring UTI's (Urinary Tract Infections)." There was no documented evidence that the consult was scheduled or completed. Review of nurse's notes, dated 5/16/13, noted, "Late Entry for 5/15/13 revealed an appointment with an Urologist for 5/20/13 had been made on 5/15/13 by Licensed Practical Nurse (LPN) #8. Interview on 5/16/13 at 6:15 p.m. with Licensed Practical Nurse #8 revealed she had made Resident #2 an appointment with an Urologist on 5/15/13, after it was brought to her attention that the resident had not had an Urologist consult as ordered by the physician on 4/2/13. Review of the facility's "Physician ' s Orders" policy, revised 1/4/13, noted, "A Clinical Nurse shall transcribe and review all physician orders in order to effect their implementation."

Based on record review, staff interview and facility policy review, the facility failed to develop a comprehensive care plan for one (1) of six (6) residents reviewed for pressure ulcers when the pressure ulcer was initially identified on 02/03/13 (Resident #2); and for one (1) of 13 residents (Resident #5) reviewed for care plans. The facility failed to address psychosocial needs/the absence of family support for Resident #5. Findings include: Resident #2 Record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 8, which indicated Resident #2's cognitive status was moderately impaired. Record review revealed Resident #2 was admitted to the facility with unstageable pressure ulcers to coccyx and left trochanter on 11/20/12. On 2/3/13 Resident #2 had a new area documented as a Stage II PU (pressure ulcer) R (right) posterior thigh. Review of Resident # 2's care plan revealed, there was no documented evidence that the new pressure ulcer to the right posterior thigh had been identified as a problem until 3/5/13, and that measures were developed for the treament of this pressure ulcer. The care plan was not revised as the pressure ulcer increased in size until 5/7/13 when wound care orders were changed. Cross refer to F314 for the facility's failure to provide services to promote healing of current wounds and prevent new occurrences of pressure ulcers for Resident #2. Resident #5 Record revealed Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed Resident #5 was coded as comatose. Resident #5 was not able to be assessed for cognitive status. Review of the Social Service Progress Notes, dated 9/25/12, noted, "Her (Resident #5's) family are not supportive and do not visit. No potential discharge. Review of the Social Service Progress Notes, dated 12/13/12, noted, "Her (Resident #5) family are not supportive. No potential discharge. Review of the Social Service Progress Notes, dated 3/11/13, noted, "Her (Resident #5) family do not visit. Have sent certified letters to get a response for new contact # (number). No response. Resident remains a Full Code, No Advanced Directives." Review of the care plan revealed there was no description or identification of Resident #5's absence of family support, the interventions to be taken by the facility to address this issue, or plans to meet Resident #5's needs in order to obtain highest practical well-being. Interview on 5/15/13 at 4:47 p.m. with Social Services staff #1 confirmed that staff has not been able to contact Resident #5's responsible party or family. Social Services staff #1 stated that no responses have been received from certified letters, and the facility planned to seek guidance from legal services to address Resident #5's lack of a responsible party to make decisions. Social Services staff #1 confirmed there was no documentation regarding the absence of family support, or interventions addressed in Resident #5's care plan. Review of the care plan, dated 5/16/13, noted, "Problem Onset: 5/15/2013 No Family Support, Goal & Target Date (Resident #5's) needs will be met by facility 8/15/13, Approaches: *Administration will consult with legal consultant in regard to ward of the state. *Attempted to notify RP (responsible party) by certified letter." Review of the facility's "Care Plan" policy, revised 9/1/11, noted, "An interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis ...Procedure: ... 22. There may be additional problem areas not triggered by the MDS (Minimum Data Set), which will need to be addressed in the care plan."

Based on record review, staff interview and policy review, the facility failed to ensure that treatment records were accurate and complete for one (1) of 21 records reviewed (Resident #2). The facility staff failed to document that treatment orders were performed as ordered by the physician for multiple wounds/pressure ulcers for Resident #2. Findings include: Resident #2 Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Cross refer to F314 for the facility's failure to provide treatment and services to promote healing of current wounds and prevent new occurrences of pressure sores for Resident #2. Review of Resident #2's March 2013 Treatment Administration Record (TAR) revealed a treatment, dated 2/20/13, for, "Uns To Lt Trochanter-Clean With Cleanser Dry Apply [MEDICATION NAME] And Foam Dressing Daily And PRN Til Slough Removed." There was no documentation of staff initials in the blanks on the Treatment Administration Record to indicate the treatment was performed on 3/24/13 and 3/27/13. There was no further documentation charted as to why the treatment was not completed. Review of the March 2013 TAR revealed a treatment, dated 1/16/13, for "Arterial Wound Rt Heel-Skin Prep Apply Foam And Wrap With Gauze Daily And PRN Until Healed." There were no staff initials indicating the treatment was performed on 3/24/13. There was no additional documentation charted as to why treatment was not completed. Review of the May 2013 TAR revealed a treatment, dated 4/19/13, for "Stage IV To LT Trochanter - Clean With Cleanser Dry Apply Calcium Alginate And Foam Dressing Daily And PRN Until Healed." There were no staff initials documented to indicate the treatment was performed on 5/5/13. There was no further documentation charted as to why the treatment was not completed. Review of the May 2013 TAR revealed a treatment, dated 5/7/13, "Stage IV L trochanter - clean with cleanser, dry pack with Ag Calcium Alginate and cover with foam dressing BID (twice daily) and prn until healed." There were no staff initials documented on 5/9/13 on the 3-11 shift to indicate that the treatment was performed. There was no further documentation charted as to why the treatment was not completed. Review of the May 2013 TAR revealed a treatment, dated 5/7/13, for " Stage IV coccyx- clean with cleanser, dry, pack with Ag calcium alginate and cover with foam dressing BID and prn until healed." There were no staff initials documented to indicate the treatment was performed on 5/9/13 on the 3-11 shift. There was no further documentation charted as to why the treatment was not completed. Review of the May 2013 TAR revealed a treatment, dated 5/7/13, for "Open lesion R post thigh-clean with cleanser, dry, pack with Ag calcium alginate and cover with foam dressing BID and prn until healed." There were no staff initials documented to indicate the treatment was performed on 5/9/13 on 3-11 shift. There was no further documentation charted as to why the treatment was not completed. Review of the May 2013 TAR revealed a treatment, dated 5/7/13, for " Open lesion R lower buttocks-clean with cleanser, dry, pack with Ag calcium alginate and cover with foam dressing BID and prn until healed. " A blank with no initials indicating the treatment was performed was noted on 5/9/13 on 3-11 shift. " There was no further documentation charted as to why treatment was not completed. Interview on 5/16/13 at 5:50 p.m. with the Administrator acknowledged she was aware of some Treatment Administration Records that did not have initials indicating treatments were performed. The Administrator acknowledged she had "written up" some employees already for this. Interview on 5/16/13 at 6:25 p.m. with Registered Nurse (RN) #2/Assistant Director of Nursing confirmed that if a treatment was completed it should be documented on the TAR. RN #2/ADON confirmed that if a treatment was not completed, then the reason it was not completed should be documented. Review of the facility ' s Dressing Change " policy, revised 1/1/09, noted, " ... 15. Document in medical record..."

Based on observation, record review, staff interview, and policy review, the facility failed to properly assess, formulate treatment and provide services to promote healing of current wounds and prevent new occurrences of pressure ulcers for one (1) of six (6) residents (Resident #2). Findings include: Resident #2 Record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 8, which indicated Resident #2's cognitive status was moderately impaired. Observation on 5/15/13 at 9:40 a.m. revealed Licensed Practical Nurse (LPN) #5 performed wound care on Resident #2's wounds. Resident #2 had wounds to the coccyx, the left trochanter, the right lower buttocks, and the right posterior thigh. Resident #2 had moderate amount of stool noted to rectal area, lower buttocks and in diaper. After completing wound care, LPN #5 refastened resident's soiled diaper without cleaning stool off of resident. Registered Nurse #2 assisted LPN #5 with the dressing change. Interview on 5/15/13 at 10:10 a.m., Licensed Practical Nurse (LPN) #5 acknowledged that she had seen stool on resident and did not clean it off the resident. LPN #5 acknowledged she had refastened resident's diaper with stool in it. LPN #5 acknowledged it is her usual practice to clean stool off the resident as soon as possible to avoid contamination of a wound and to prevent further skin breakdown. Interview on 5/5/13 at 10:15 a.m., Registered Nurse (RN) #2 confirmed that it is not usual practice to refasten a resident's diaper with stool noted on resident and stool noted in resident's diaper. Confirmed it would be the nurse's responsibility to assure resident was cleaned, if stool was noted while nurse was performing wound care. RN #2 confirmed that stool should have been cleaned off of resident promptly to avoid possible contamination of wounds and to prevent further skin breakdown. Record review revealed Resident #2 was admitted to the facility with unstageable pressure ulcers to coccyx and left trochanter on 11/20/12. On 2/3/13 Resident #2 had a new area documented as a Stage II PU (pressure ulcer) R (right) posterior thigh. Right Posterior Thigh Record review revealed a physician's orders [REDACTED]. Cleanse with wound cleanser. Pat dry. Apply Calazmine with Zinc. Cover with secondary dressing daily and prn (as needed) dislodgement." Review of the May 2013 physician's orders [REDACTED]." Wound measurements at this time were 1.2 cm x 1.0 cm with no depth. Wound treatment was not changed until 5/7/13 when wound measured 2.3 cm x 2.7 cm x 1.4 cm. Resident #2's wound had an odor documented on this date. Treatment was then changed to "Clean with cleanser, dry, pack with Ag Calcium alginate & cover with foam dressing BID (twice a day) & prn (as needed) until healed." Record review revealed there was no further documentation (such as measurements, wound description, etc.) of the right posterior thigh pressure ulcer was noted in chart from 2/3/13 until the 3/5/13 physicians orders. Review of the "Non-Decubitus Skin Condition Record" form, dated 3/5/13, noted, "Open lesion to R (right) posterior thigh; 1.2 cm x 1.0 cm; red wound bed. Review of the "Weekly Evaluation: 3/13/13: 1.5 X 1.4, drainage- serosang, Color-red/yellow; 3/18/13: 2.3 X 2.3, Drainage- serosang, Color- red & Yellow; 3/25/13: 2.0 X 2.2, Drainage- serosang, Color- red & yellow; 4/15/13: 3.0 X 2.4, Drainage-serosang, Color- yellow, and 5/7/13: 2.3 cm x 2.7 cm x 1.4 cm (depth), Drainage- serosang, Color- red & yellow". Review of Resident #2's record revealed there were 11 days between the measurements of resident's "open lesion to R (right) posterior thigh" documented, from 4/15/13 and 4/26/13. Interview on 5/16/13 at 6:25 p.m. revealed Registered Nurse (RN) #2/Assistant Director of Nurses (ADON) was not able to provide documentation of resident having a lesion prior to documentation on 3/5/13 of "open lesion to R (right) posterior thigh; 1.2 cm x 1.0 cm" Interview on 5/15/13 at 10:10 a.m. with Licensed Practical Nurse (LPN) #5 acknowledged that resident's wounds were measured weekly by a Registered Nurse. Interview on 5/15/13 at 10:15 a.m. with Registered Nurse (RN) #2 confirmed that resident's wound were measured weekly by a Registered Nurse. RN #2 stated that there was no one in the facility was certified for wound care. Interview with Resident #2's attending physician confirmed that he did not look at resident's wounds unless the facility staff asked him to. Review of Resident #2's record revealed a note dated 4/23/13 signed by the nurse practitioner that had seen resident in facility. The note noted, "Consult with (name of wound care center) in (name of town) pending." There was no documentation of this consult noted in the chart. Review of the handwritten physician's orders [REDACTED]." Review of nurse's notes, dated 5/3/13 at 12:05 p.m., noted, "Received N.O. (new order) Consult a wound clinic for wounds. RP (responsible party) notified." Review of nurse's notes, dated 5/8/13 at 1453 (2:53 p.m.) noted, "Wound care specialists was consulted about wounds due to family request." Interview on 5/16/13 at 6:25 p.m. with Registered Nurse #2 confirmed that a weekly skin assessment should be completed on every resident Interview on 5/16/13 at 6:25 p.m. with Registered Nurse #2 confirmed the wound care consultant had came to see the resident on 5/6/13, and the wound care consultant had said that resident needed an Magnetic Resonance Imaging (MRI) to rule out osteo[DIAGNOSES REDACTED] prior to wound care accepting resident. MRI was completed on 5/15/13 with results noted, "Impression (1) recommend follow up radiograph of the left hip to exclude fracture (2) small 28 x18 mm focus of probable osteomylitis invovling the posterior margin of the left sacral ala." mm meaning millimeter Review of the facility's "Skin/Wound Care Decision Tree"policy, revised 1/12, noted, "...Infected Wound ...Evaluate wound daily and document location, stage if visible, length, width , color, odor, drainage and progress at least weekly and if the condition of the would (wound) changes ..." Review of the facility's "Skin Assessment-Weekly" policy, dated 9/1/11, noted, "Policy ...A Licensed Nurse will complete a total body assessment on each resident weekly, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure ulcers, [MEDICAL CONDITION], abrasions, reddened areas and skin turgor problems. The purpose of the Skin Assessment is to evaluate the condition of the resident's skin on a regular basis ...1. A Licensed Nurse will complete a total body assessment on each resident weekly and document the assessment on the Weekly Skin Integrity Checks form..."