Based on interview and record review, the facility failed to ensure dressing changes were done as ordered (R1), and failed to ensure weekly wound assessments and documentation of the assessments were completed, for 2 of 5 residents (R1, R4) reviewed for non-pressure wound care in the sample of 6.This failure resulted in R1's wound getting a maggot infestation, and the wound dehiscing and getting infected. R1 was sent out to a local emergency room, diagnosed with osteomyelitis, requiring two intravenous (IV) antibiotics to prevent sepsis, surgical intervention, and critical care hospital admission. This failure resulted in an Immediate Jeopardy.The Immediate jeopardy began on 7/3/2025 when the facility failed to do the dressing change as ordered and failed to assess R1's surgical site and document an assessment. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 7/16/2025 at 12:16 PM. The surveyor confirmed by observation, record review, and interview, that the Immediate Jeopardy was removed on 7/17/2025, but noncompliance remains at Level Two, because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include: 1. R1's admission Record, provided by the facility on 7/10/2025, showed she had diagnoses including, but not limited to, transient cerebral ischemic attack (stroke), atherosclerotic heart disease, aneurysm of the ascending aorta without rupture, myocardial infarction (heart attack), cellulitis of unspecified part of limb, and hypertension.R1's Discharge Instructions from a local hospital, dated 6/26/25, showed Wound Care: Dressing to be left in place until seen in the office next week. Do not get wet. R1's 7/1/2025 notes from the follow up appointment showed Wound cleansing and dressings. Dry protective dressing. Do not get wet. The document showed V4 (LPN) clarified the order to be done every other day.R1's Order Summary Report, provided by the facility on 7/10/2025, showed an order, dated 7/1/2025, for Wound #3 right toes area of great toe, 2nd toe, 3rd toe. Wound cleansing and dry protective dressing to be changed every other day. R1's July 2025 Treatment Administration Record (TAR) showed no treatment was documented as being completed from 7/2/2025-7/6/2025.The facility's weekly Skin Condition Report, dated 7/4/2025, showed R1 had arterial ulcers to her right posterior leg, right medial great toe, right second toe and her right third toe. V3 said the measurements on the form were taken from notes from the wound clinic R1 goes to.R1's Progress notes from 7/1/2025-7/5/2025 do not document any dressing change to the surgical site on R1's right foot/toes area. The progress notes only show RLE ((right lower extremity) wound documentation, which was a different wound on R1's right posterior lower leg. There was no documentation of a dressing change or assessment to R1's right foot surgical site until 7/6/2025 at 8:20 PM where it showed, Resident noted with an excessive amount of exudate drainage and possible presence of larvae in wound during wound care. MD (doctor) made aware and gave orders to send resident out for further eval (evaluation).R1's progress note, dated 7/6/2025 at 9:20 PM, showed R1 was noted with an excessive amount of exudate drainage and possible presence of larvae in wound during wound care, Doctor made aware and gave orders to send resident out for further evaluation. when an excessive amount of drainage and larvae were found on R1's right foot surgical wound and she was sent to a local hospital. R1's progress notes from 7/1/2025-7/6/2025 do not show any documentationR1's 7/6/2025 Emergency Department Physician Report from a local hospital showed, Right foot with multiple toe amputations, extensive wound at distal tip with sutures, wound dehiscence, necrotic tissue, copious maggots cleaned from wound, mild surrounding erythema with warmth. the notes showed, admission is required due to the severity of the right foot wound infection with suspected osteomyelitis, need for IV antibiotics, and risk of clinical deterioration. The notes showed Critical Care Statement: Given the patient's presentation with a right foot wound infection and osteomyelitis, which carried a high-risk for rapid clinical deterioration due to potential progression to severe sepsis or septic shock. The emergency room doctor provided 40 minutes of critical care time exclusive of other billable procedures. this time was spent in direct patient care involving high-complexity medical decision making and required constant attendance to prevent sudden, significant deterioration in the patient's condition. The Podiatry Consultation Physician's Report, dated 7/7/2025, showed R1 had surgery approximately two weeks ago due to amputation of the first, second, and third digits of the right foot. This was due to gangrenous changes due to severe peripheral arterial disease. Patient was seen in the office for follow-up and incision site looked good with the wound edges well coaptated and sutures in place. Patient presented to the emergency room last night with dehiscence of the wound and maggots in the wound. The physician debrided the wound and the maggots out. The notes showed R1 was started on IV antibiotics and admitted for further workup. V6's operative notes on 7/8/2025 showed R1, was placed under general anesthesia, the sutures were still in place, however they were not holding any skin or flaps at this time. The sutures were all removed. the wound base and wound edges were debrided back to healthy tissue .several dead bodies of maggots were noted .bony exposure is noted in the wound site. A wound was also noted on the medial aspect of the first metatarsal phalangeal joint area that was likewise debrided .Surgery site was dressed and covered .The area was anesthetized, and patient was extubated .Patient will continue antibiotics.On 7/9/2025 at 3:46 PM, V7 (R1's Power of Attorney/POA) said, (R1) had surgery on 6/25/2025 to amputate her toes. After a brief hospital stay, she returned to the facility. She had a follow up with the surgeon on 7/1/25. The doctor said it was healing nicely on her 7/1/2025 follow up appointment, and everything was okay at that point. V7 said he had not heard any updates from the facility until Sunday night (7/6/2025) after R1 was sent out to the hospital. V7 said the facility staff were supposed to look at her wound every two days. V7 said, Someone from the emergency room (ER) called me on 7/6/2025 and told me (R1) was at the hospital and there were maggots in her surgical wound. (V4, Licensed Practical Nurse-LPN) from the facility called me 10 minutes later. By the time I arrived at the hospital, the emergency room staff had already gotten the maggots out of her wound. There were three maggots in a specimen cup and at least 10 more in a baggie. The reason for (R1's) toes being amputated was due to poor circulation to her feet. Some days (R1) is coherent, but lately she is not as coherent. V7 said he did not think R1 understands why she is in the hospital and did not feel that R1 would be able to say if the facility was doing the dressing changes as ordered. V7 said he spoke with V1 (Administrator) and V2 (Director of Nursing), and they said the facility was doing the dressing changes as ordered. V7 said R1 had to have her surgical site debrided (surgical removal of non-viable tissue). V7 said, It is just too much. This should not have happened. On 7/10/2025 at 10:48 AM, V2 (DON) was shown R1's July 2025 Treatment Administration Record (TAR). V2 said the dressing change for R1's right surgical site/wound in her toes area is not marked off as being completed 7/2/2025-7/6/2025. On 7/11/2025 at 11:50 AM, V3 (Wound Nurse) said the wound clinic provided notes regarding wounds for R1. V3 said the facility got an order to clean the wound and do a dry dressing every other day on 7/1/2025. V7 said he did not do any dressing change or assessment of R1's amputation site. V3 said he did not see any documentation of an assessment being done by any other nurse for R1's surgical site on her right foot in her electronic medical record. V7 said surgical sites should be monitored, assessed, and the assessment should be documented. At 12:51 PM, V3 said, It is important to monitor surgical sites for signs and symptoms of infection, wound dehiscence, a decline, or any changes, and to notify the surgeon of any changes. At 2:11 PM, V3 said the last assessment of R1's right toes, with measurements, was on 6/20/2025. V3 said, When (R1) came back from surgery on 6/26/2025, there was an order to leave covered until her follow up appointment. (R1's) follow-up was on 7/1/2025. The doctor gave an order to cleanse the site and cover with dressing every other day. There was no dressing change completed, no facility assessment, or measurements that I can tell from 7/1/2025-7/6/2025 for (R1's) right foot. V3 said he will do the assessment and dressing change for the residents that are followed by the wound doctor that comes to the facility. He said he does not do the assessments and dressing changes for the residents that go out to wound clinic. V3 provided R1's Skin Impairment/Wound forms for 6/26/2025 and 7/1/2025. V3 said he got the information for the forms from the wound clinic, and did not do the assessments himself. On 7/10/2025 at 3:20 PM, V4 (Licensed Practical Nurse-LPN) said V5 (Certified Nursing Assistant-CNA) told her it looked like the bandage on R1's right foot had some blood on it. V5 said she went in to check it and thought to herself that is not blood. It had a slight odor, and brown drainage was on the sock. V4 said as she was unwrapping the bandage, she saw maggots on the bandage. She notified R1's doctor and he said to send her out to the emergency room (ER) for evaluation. V4 said she worked on 7/1/2025. She called the doctor to verify the treatment orders. V4 said the order was to do the dressing change every other day. V4 said she had not done any assessment or dressing change for R1, because she did not work again until 7/6/2025. V4 said she started her shift at 2:00 PM on 7/6/2025. V4 said she did not recall seeing a date on the dressing, but she was also concerned with what was going on. The color and smell of the drainage is what was concerning me. (R1) was having pain that day. Normally we don't have to give her anything for pain until about 8:00 PM. That day she was having more pain than normal. V4 said as she was unwrapping the bandage to R1's foot, R1 voiced it hurt and pulled back her foot. I had to stop because it was hurting her too much. She was saying 'Oh, Oh, Oh.' V4 said when she saw the maggots, she stopped, called the doctor, and about 15 minutes later, R1 was going out the door. V4 said based on the odor and drainage, she felt it could have been noticed earlier. There was a strong smell and the bandage was saturated. V4 said, It is important to make sure to assess wounds to make sure the wound does not get infected, to notice right away and catch it before it gets bad, and update the doctor, to see if he wants to give any new orders. The earlier you catch something the better.On 7/11/2025 at 2:53 PM, V5 (Certified Nursing Assistant/CNA) said he worked the shift that R1 was sent out to the hospital. He said, I was assisting an agency CNA with (R1) and noticed something on the dressing at the top of her foot, where she had the surgery. It was dark in color, something unusual that you would not see on a sock. It did not really look like blood. It was discolored. I went to (V4) and asked her to check (R1's) foot and then went to assist other residents. V5 said he saw R1 leaving on a stretcher. He went into her room after hearing what happened and checked the linen on her bed. V5 said he saw 8-10 maggots on R1's linen, so he threw her linen away in the garbage. On 7/11/2025 at 3:05 PM, V1 (Administrator) and V2 (Director of Nursing-DON) agreed it is important for the nurses to do an assessment on residents with wounds, at least weekly, even if the resident goes out to the wound clinic. V1 and V2 said unless there is an order not to touch the dressing, it is important the facility nurses assess the resident's wound to monitor and determine if the wound is improving or getting worse, so the doctor can be updated, and new orders can be received if needed.On 7/15/2025 at 10:31 AM, V6 (Wound Clinic Doctor) said R1 had her great toe, second and third digits on her right foot amputated on 6/25/2025. She stayed in the hospital overnight and was sent back to the facility on 6/26/2025. I gave an order to not touch the dressing until her follow-up appointment. When I saw her on 7/1/2025 for the follow-up, the wound was a closed surgical site, no opening, drainage or swelling. It looked very good. V6 said, I gave orders on 7/1/2025 to change the dressing every other day. Keflex was ordered prophylactically to prevent infection. The next time I saw (R1) was the day after she was sent to the hospital (7/7/2025). The stitches were no longer holding the tissue together. It was an open wound. (R1) had the wound cleaned out in the ER due to there being maggots in the wound. On 7/8/2025, I had to take out all the stitches, which were still there, but not holding the tissue in place, debride the wound and flushed it out. Bone was exposed. When bone is exposed to the air, you assume it is infected. Osteomyelitis can occur. V6 said R1 was tested for, and he believes she was diagnosed with, osteomyelitis. The wound was infected and had an infestation of maggots. Two antibiotics were given intravenously (IV) for broad-spectrum antibiotic therapy. It was very serious. Infestation and infection. Infection could get in the blood and the patient could become septic. It is important for the facility nurses to do the dressing changes as ordered. If not done as ordered, it will slow the wound healing and increase the risk of infection. I would expect the nurses to assess the wound during the wound changes, so if there is a problem, they could contact me for guidance on how to proceed. V6 said he has a 24-hour answering service. V6 said, If the facility would have done the dressing changes and monitored the surgical site, it may have prevented the wound from getting infected and infested with maggots, and I would not have had to perform the surgical debridement procedure.On 7/16/2025 at 8:24 AM, V1 (Administrator) said, When (R1) came back from her follow up appointment on 7/1/25, there was some ambiguity about the orders. (V4, LPN) called the doctor and clarified the order. (V4) entered the order into the system wrong. She entered it into other orders (no documentation required), not into the Treatment Administration Record (TAR). When an order is entered into the system like this, the nurses cannot see the order. V1 said he investigated what happened, however, he did not document his investigation. V1 said the order was discontinued on 7/6/2025 and entered in the system correctly. V1 said V3 (Wound Nurse) could have followed up to see what the new orders were after her follow up visit and made sure the treatment was being done as ordered, just like any management team member is expected to do with their department. V1 said he let V2 (DON) know the nurses need training on entering medication orders because that is not acceptable. V1 was asked if the nurses that worked on all three shifts from 7/2/2025-7/6/2025 should have verified the orders for R1 after her follow-up appointment to make sure there was no treatment ordered. V1 nodded yes. On 7/16/2025 at 1:56 PM, V12 (facility's Medical Director) said, Some residents go out for wound care, then come back to the facility. They are here for us to provide medical care. It is important to follow the doctor's orders for wound care. If a resident goes out for wound care and comes back with an order to do dressing changes, the facility nurses should be doing their own wound assessment with every dressing change, document their findings, and notify the physician if there are any changes. The facility's 10/2023 policy and procedure, titled Wound Treatment Management, showed to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician's orders.1. Wound treatments will be provided in accordance with physician's orders, including the cleansing method, type of dressing, and frequency of dressing change.8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. The facility presented an abatement plan to remove the immediacy on 7/16/2025 at 3:34 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 7/17/2025 at 11:29 AM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on 7/17/2025 at 2:37 PM, and the survey team accepted the abatement plan on 7/17/2025.The Immediate Jeopardy that began on 7/3/2025 was removed on 7/17/2025, when the facility took the following actions to remove the immediacy:1. Corrective Actions which will be accomplished for those residents found to be affected by the deficient practice. i. Facility Medical Director was notified of the incident on 7/16/2025 at 2:50 PM. ii. The DON completed a chart audit on every resident with wounds and skin conditions and compared the wound physician's orders and evaluations for accuracy. iii. The DON completed a chart audit on every resident with wounds and skin conditions to ensure all have a completed weekly skin evaluation assessment. iv. The wound nurse assessed all residents with wound and skin conditions to ensure wound treatments were rendered as ordered per MD/NP.2. How the facility will identify other residents having the potential to be affected by the same deficient practice by: The DON and/or designee completed a chart audit on every resident with wounds and skin conditions and compared the wound physician's orders and evaluations for accuracy.The DON and/or designee completed a chart audit on every resident with wounds and skin conditions to ensure all have a completed weekly skin evaluation assessment.The MDS(Minimum Data Set) coordinator and/or designee conducted an audit on every resident with wounds and skin conditions to ensure the care plan reflects their current plan of care. All residents were screened for pressure risk on 7/16/2025, and will be assessed upon admission/re-admission initially, then x 4 weeks, then quarterly. Assessments will be conducted after a change of condition or after any newly identified pressure injury. All residents with wounds and skin conditions treatment orders clarified with medical practitioner and have been changed to AM shift for wound nurse to provide treatments as ordered per MD starting on 7/17/2025. Floor nurses to render wound treatment on weekends and in the absence of wound nurse. Nurse on the floor will render treatment, conduct assessments, and document.A full body, or head-to-toe assessment will be conducted by a licensed or registered nurse and by the wound nurse upon admission/re-admission, quarterly and annually. The assessment will be performed after a change of skin condition, or after any newly identified skin condition a/or pressure injury initially and weekly until resolved. The QAPI (Quality Assurance Performance Improvement) committee reviewed the Skin Assessment and Wound Treatment Management, Quality of Care policies to determine if any revisions needed to be made and determined the policies did not need changes.3. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur:The facility initiated in-service training for staff on 7/15/2025 on Skin Assessment and Wound Treatment Management policy. This training will be conducted by the DON and/or designee, is ongoing and will continue with all the new staff upon hiring, and orientation and agency nurses prior to the start of their next shift. The training includes, but is not limited to: A full body, or head-to-toe assessment will be conducted by a licensed or registered nurse and by the wound nurse upon admission/re-admission, quarterly and annually. The assessment will be performed after a change of skin condition, or after any newly identified skin condition a/or pressure injury initially and weekly until resolved.Wound treatments will be provided in accordance with physician orders, including the cleaning method, type of dressing, and the frequency of dressing change.In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Treatments will be documented on the Treatment Administration record or in the electronic health record. The effectiveness of treatments will be monitored through ongoing assessment of the wound until healed. Considerations for needed modifications include:a. Lack of progression towards healing. b. Changes in the characteristics of the wound.c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.d. Documentation and Completion of Skin Assessment:Include date and time of the assessment, your name, and position title.Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.)Document type of wound.Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). Document if resident refused assessment and why.Document other information as indicated or appropriate. 2. The facility initiated in-service training for staff on 7/16/2025 on Provision of Quality of Care. The training is ongoing and the DON and/or designee will continue with all the new staff upon hiring and orientation and agency nurses prior to the start of next shift.The training includes but is not limited to each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 3. The facility initiated in-service training for nursing assistants on 7/17/2025 on Skin Audits by Nursing Assistants policy. The training is ongoing, and the DON and/or designee will continue with all the new nursing assistant staff upon hiring and orientation and agency nursing assistants prior to the start of next shift. The training includes, but is not limited to: Nursing assistants shall inspect all skin surfaces during bath/shower and report any concerns to the resident's nurse immediately after the task. Nursing assistants shall also report changes in skin condition that are noted during any care procedure. Skin Conditions that shall be reported include, but are not limited to:Redness, bruising, swelling rashes, hives, blisters (clear or blood filled), skin tears, open areas, ulcers, lesions. Notification shall be made to the nurse verbally or in writing.Notification shall be made to nurse verbally or in writing on any noted soiled or non-intact dressings. The Director of Clinical Excellence scheduled Mandatory All Nursing Staff, DON and Wound Nurse wound care training with (the contracted wound care company that comes to the facility and oversees residents' wounds). DON and/or designee conducted a wound care competency with wound nurse on 7/14/2025 and will conduct one weekly with the wound nurse and nursing staff on all shifts until every staff has participated at least once. This will be ongoing and will continue to be held weekly for two months. Findings will be reviewed at the monthly QAPI committee meeting. 4. Quality Assurance plans to monitor facility performance to make sure that corrective actions are achieved and are permanent. 1. Facility created quality assurance tool Wound Treatment Orders and Assessments will be implemented on 7/16/2025 used by the DON and/or designee to assess all residents and new admissions/re-admissions with wounds and/or skin conditions daily for month and then weekly for 3 months, then quarterly for a year to monitor that the facility is following the policy, and treatments are being completed as ordered, and assessments are being done and completed. Findings will be reported at the monthly QAPI Committee meeting.2. Facility-created quality assurance tool Quality of Care will be implemented on 7/16/2025 and used by the DON and/or designee daily to randomly assess 2 residents daily for a month, then monthly for 3 months, then quarterly for one year to monitor that the facility is following the policy and residents are provided with Quality of Care and Services. The results will be reviewed during the facility's QAPI meetings. Any issues identified will be immediately addressed. On 7/17/2025, a review of the facility's in-service documentation showed all the facility's nurses received the in-service training from the contracted wound care company on 7/17/2025. The Agency nurses, and any new staff will be educated prior to the start of their next shift. The Certified Nursing Assistants working received in-service training on reporting any changes to nurses. The remainder of staff, and any new staff will receive education prior to the start of their next shift. Interviews with staff working on 7/17/2025 showed staff have received the education and were able to verbalize the education they had received that aligned with the facility's abatement plan. 2. R4's admission Record, provided by the facility on 7/16/2025, showed diagnoses including, but not limited to type II diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur with diabetes. Symptoms include pain, numbness, and slow healing of leg or foot sores), hypertension, congestive heart failure, acquired absence of left leg below the knee, iron deficiency anemia, ischemic cardiomyopathy, acute hematogenous osteomyelitis, chronic obstructive pulmonary disease, and acquired absence of right foot. R4's Order Summary Report, printed by the facility on 7/11/2025, showed an order, dated 7/11/2025, to clean wound on right foot with normal saline. Apply xeroform to wound. Cover with abdominal pad and (rolled gauze) once daily and as needed. The report showed an order, dated 7/11/2025, for a nuclear stress test on 7/21/2025 (a cardiac imaging procedure that assesses blood flow to the heart muscle at rest and during stress. It helps doctors diagnose coronary artery disease and determine the extent of any blockages or damage).R4's care plan, dated 5/20/2025, showed, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, and any other notable changes or observations.R4's July 2025 TAR showed the dressing changes were being done as ordered. On 7/10/2025 at 9:59 AM, R4 was sitting in his wheelchair in his room. R4's left leg was amputated below the knee. R4's right foot and lower leg was wrapped with rolled gauze. No drainage or odor was observed on R4's dressing. R4 said when he was first admitted to the facility, they missed a couple dressing changes. R4 said the nurses change his dressing every morning now. R4 said the dressing had already been changed at 6:30 AM. R4 said he goes to (a local wound clinic) once a week on Mondays. The doctor said I am making steady progress in healing, especially with my circulatory issues. R4 said since he was admitted to the facility, he has not had any infection or decline in his wound. R4 said he is not sure if the nurses do an assessment of the wound or not. No nurse at the facility has measured it that he is aware of. Sometimes his wound does have drainage, that is why it is wrapped, and he has a boot on his foot. R4 said his wound doctor at the wound clinic said he is pleased with the progress so far considering all R4's circulation issues. R4 said the wound doctor thinks something else may be going on and has ordered a nuclear test be done. R4 said he also has anemia, diabetes, and other issues. R4 said he had the amputations prior to admission. I came to the facility because I could not take care of the wounds. They were very bad.On 7/11/2025, R4's wound assessments from 6/1/2025 through the present were requested from V3. V3 (Wound Nurse) said he did not do weekly assessments on R4 due to R4 going out to the wound clinic for wound care. V3 said the facility nurses change R4's dressing daily as ordered; however, weekly wound assessments are done at the wound clinic. V3 said he gets the information from the wound clinic notes, and uses the information from the wound clinic to fill out the Skin Impairment/Wound Forms on R4. On 7/11/2025 at 1:54 PM, V3 said, I will do measurements and wound assessments for the residents that use (contracted wound company that comes to the facility) when I do rounds with the wound doctor. If a resident is not seen by (the contracted wound company), and goes out for wound care, then we go by the measurements and assessments done by the outside wound clinics. There are 3 residents in the facility with wounds that go out for wound care. (R1), (R4) and (R5) are the residents that go out to wound clinics. At 2:48 PM, V3 said there was not a wound nurse when he first took the job, so he did not really receive any training on how to do the job. V3 said he is still learning things.On 7/15/2025 at 10:00 AM, V3 said, Initially, (R1) was being seen by (contracted wound company) that comes to the facility. (R1) was referred to (a local wound clinic) around the end of April/beginning of May. She had a doppler scan and other tests and was referred to the wound clinic. V3 said, The only trainingI received for the wound nurse position was about 4 hours of training when I took the job. Mostly on paper and laptop. A regional consultant provided some guidance. V3 was asked if he had any specific wound training or certification prior to taking the Wound Nurse position. V3 said he had been a nurse for 20 yrs. Other than that, he said he has not had any specific wound training or certification.V3 provided Skin Impairment/Wound Forms for R4, dated 6/23/2025, 7/1/2025, and 7/8/2025. V3 said he filled out the forms with the information provided by the local wound clinic. V3 also provided wound clinic notes for R4, dated 6/30/2025, 7/7/2025, and 7/14/2025, as well as R4's initial admission assessment form for the local wound clinic. The only other assessment V3 provided was dated 6/12/2025; V3 did assess R4's wound and documented a partial assessment (No measurements. Just the wound bed characteristics). The facility's September 2024 policy and procedure titled Skin Assessment showed. 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. The policy showed documentation and Completion of Skin Assessment: A. Include date and time of the assessment, your name and position title. B. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). C. Document type of wound. D. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). E. Document if resident refused assessment and why. F. Document other information as indicated or appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to perform CPR (Cardio-Pulmonary Resuscitation) correctly as per standards of practice, failed to call a code blue within the facility, and failed to call EMS system (911) for an unresponsive resident identified as a full code on the physician's orders in accordance with the Facility policy. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE], at 5:25 AM, when R55, who had full code orders, expired in the facility after being found unresponsive and staff did not perform CPR as per the Standards of Practice and did not follow their policy for Medical Emergencies. V1 (Administrator) and V24 (Regional Director of Operations) were informed of the Immediate Jeopardy on [DATE], at 4:17 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but the facility remains out of compliance at a severity level two because additional time is needed to evaluate the implementation and effectiveness of the training. This applies to 31 of 53 residents (R1, R5, R10, R11, R13, R15, R17, R18, R19, R20, R23, R25, R29, R33, R36, R37, R38, R39, R40, R42, R44, R45, R47, R48, R49, R52, R53, R55, R158, R257 and R307) reviewed for code status and request CPR to be performed. The Findings include: The admission record showed R55 was admitted to the facility on [DATE], with diagnoses of fracture of the right femur subsequent encounter for closed fracture with routine healing, hypopituitarism, type 2 diabetes, chronic diastolic congestive heart failure, obstructive sleep apnea and cerebral infarction due to embolism of the cerebral artery. R55's progress note dated [DATE], at 3:00 PM showed R55 was admitted for further rehabilitation, was a full code status and transferred from another SNF (Skilled Nursing Facility), R55's hospital referral notes to prior facility dated [DATE], showed R55 had a fall on [DATE], and had surgery for femur fracture on [DATE]. R55 was hospitalized from [DATE], until [DATE]. R55 transferred to this facility on [DATE]. The transfer orders showed under advanced directives that R55 was a full code. R55's vital signs at the time of admission showed blood pressure 144/80, Pulse 62 beats per minute, Temperature 98.0 F, Respirations 18 breaths per minute and oxygen saturation was 97% on room air. The next documentation after R55's initial admission note was [DATE], at 08:04 AM written by V11 (RN) that showed R55 was found unresponsive, no pulse and cool to touch at 5:25 AM and pronounced dead by 2 nurses. During interview of V11 (RN), on [DATE], at 2:10 PM, V11 stated she had seen R55 sleeping on his side with regular respirations during her first round at around 11:00 PM. V11 stated the next time she did rounds was between 2:30 AM and 3:00 AM, she observed R55 and appeared to be sleeping, but was making coughing type noises while breathing. V11 stated she did not assess R55 at that time. V11 stated the next time she saw R55 when she went to his room to administer medications at around 5:20 AM and attempted to wake R55 up but R55 did not respond. V11 stated she then turned on the light, did not find a pulse, found R55 was lying in brown, yellow stained sheets, did a sternal rub and left the room to call for help. V11 stated it appeared R55 had defecated, and stool was on the bed and on the floor. V11 stated she used the nurses desk phone to call the other nurses' station to get the other nurse, (V10) to help and told V13 (CNA) to go to R55's room. V11 stated she did not overhead page a code blue because she had never been taught how to overhead page. V11 then stated she called V14 (former DON) from her cell phone and went back to R55's room. V11 stated while on the cell phone with V14, V11 stated she started to do chest compressions for less than a minute, when V14, who was not in the facility, instructed her to stop compressions and not to call 911. V11 stated she did not bring the crash (emergency) cart to R55's room. V11 stated she was unsure what to do in the situation and was looking for guidance. V11 stated in hindsight she would have called 911 and started CPR as soon as she found R55 unresponsive. V11 stated she was unaware of R55's code status until she was contacting the funeral home. V11 stated as of now she does not know how to use the facility's intercom system to announce a Code Blue. V14 was no longer employed by the facility and not available for interview. On [DATE], at 3:47 PM, V10 (LPN) stated she worked the overnight shift with V11 on [DATE]. V10 stated she was in a resident's room when she heard the desk phone ring at the nurses' station, she was unsure of the time but said it was at the end of the shift. She stated she made the resident safe and went to answer the desk phone. V10 stated V11 was calling her to come to R55's room. V10 stated by the time she got to R55's room, V11 was talking on the cell phone to V14, so she left and did not provide any assistance and did not assess R55. V10 stated when she saw V11 talking on the cell phone she left the room and went back to her assignment. V10 stated she did not call a code blue; she did not bring the crash cart and she did not call 911. When asked about who could pronounce a resident dead in the facility, V10 stated she was not sure if the facility had a policy, but only an RN can pronounce a resident dead in the facility. On [DATE], at 3:15 PM, V13 (CNA) was working on the unit with V10. V13 stated near the end of the shift, V11 asked him to help clean R55 because the family was coming. V13 stated when he walked into R55's room he did a sternal rub, but R55 did not respond. V13 stated he thought R55 might be dead, but he also thought only a doctor could pronounce someone dead. V13 stated there was no crash cart at the room, he was not aware of a code blue and the paramedics were not in the facility. On [DATE], at 5:40 PM, V12 (Medical Director) stated if a resident is found unresponsive, without a pulse and is a full code, the paramedics should be called. V12 stated CPR should be initiated unless rigor mortis is present. V12 stated the presence of feces on or around the resident is not an indication that CPR should not be performed. R55's progress notes on [DATE], did not indicate an assessment for signs of clinical death or the presence of rigor mortis was done and was not documented. On [DATE], at 3:05 PM, V1 (Administrator) stated there was no investigation regarding the death of R55. V1 stated he was not the Administrator at that time, both the Administrator and Director of Nursing at the time of R55's death were no longer employed by the facility. On [DATE], at 10:30 AM, V24 (Regional Director of Operations) stated the facility does not have a policy regarding nurses determining death and pronouncing time of death of a resident. V24 stated he would have to ask the Regional Clinical Consultant what the policy should be. On [DATE], at 1:00 PM, the facility provided a list of residents in the facility with their code status and there were 30 residents (R1, R5, R10, R11, R13, R15, R17, R18, R19, R20, R23, R25, R29, R33, R36, R37, R38, R39, R40, R42, R44, R45, R47, R48, R49, R52, R53, R158, R257, and R307) identified as full code status in the facility. The Facility's policy titled Medical Emergency Response dated reviewed [DATE], showed Policy Explanation and Compliance Guidelines .1. The employee who first witnesses or is first on the sight of a medical emergency, will initiate immediate action, including CPR as appropriate . 3. A Nurse will .b. Stay with the resident . c. Designate a staff member to announce a Code Blue, notify the physician and call 911 .4. A Code Blue will be announced over the intercom system. 5. All available staff will respond to the emergency accordingly .6. The staff on the unit will take the emergency cart to the code .7. This will continue until emergency personnel arrive and resident is transported to the emergency room via EMS (Emergency Medical Services) .8. If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services, and a. In accordance with the resident's advance directives. The facility submitted an abatement plan to remove the immediacy on [DATE], at 6:08 PM. The Survey Team reviewed the abatement plan and was unable to accept the plan and returned the abatement plan to the facility for revisions. The Facility presented a revised abatement plan on [DATE], at 12:34 PM. The Survey Team reviewed the plan and was unable to accept the abatement plan and it was returned to the facility for revisions. The Facility presented a revised abatement plan on [DATE], at 5:34 PM. The Survey Team reviewed the abatement plan and was unable to accept the third revision. The abatement plan was returned to the facility for fourth revision. The Facility submitted the revised abatement plan on [DATE], at 6:15 PM. The Survey Team accepted the abatement plan on [DATE], at 6:20 PM. The Immediate Jeopardy that began on [DATE], was removed on [DATE], when the facility took the following actions to remove the immediacy: -Administrator/ designee will provide training for all staff, initiated on [DATE], on Medical Emergency Response and CPR policy. This includes the employee who first witnesses or is first on the site of a medical emergency will initiate immediate action. The training also includes if a resident experiences cardiac arrest or unresponsiveness, the facility staff will provide basic life support including CPR, prior to the arrival of emergency medical services in accordance with the resident's advanced directives. The Training will continue until all staff have attended. Agency staff and staff who missed the training will receive training prior to working their next scheduled shift. -Administrator/designee will provide training for all staff, initiated on [DATE], on Resident Rights regarding Treatment and Advance Directives. -Provide Mock Code evaluation drills, initiated on [DATE], in a Mandatory Meeting and continue until all staff have attended a drill. The Mock Code Blue Audit tool will be used during the drill as a guide for staff roles and tasks during a Code Blue. The Administrator/designee will provide the training. The training will continue until all staff have been trained. -The Maintenance Director will provide training on the use of the intercom system, to announce Code Blue on the overhead page, to all staff, as part of the Mock Code evaluation drills initiated on [DATE]. The training will continue until all staff have been trained. -The facility developed a process to determine if a resident has executed an advance directive. The Social Service Director reviewed Advance Directive with the residents, initiated [DATE], and the process is ongoing. - Upon admission, the Nurse will ensure a resident with an advance directive, will communicate the resident's choice to the Health Care Practitioner and obtain the order, and provide a copy of the Advanced Directive to Social Services/designee, initiated [DATE], and ongoing. -The Facility Quality Assurance Committee (Administrator, Regional Director of Operations, Regional Clinical Director and Medical Director) met on [DATE], at 5:00 PM to review the F678 IJ (Immediate Jeopardy). -The Facility created a Quality Assurance audit tool to be implemented on [DATE], used by the DON (Director of Nursing)/Designee, for all Licensed Nurses, for Medical Emergency Response. The Audit will be done with every nurse and then twice weekly with random nurses for three months. The results of the Audits will be reviewed with the QA (Quality Assurance) Committee at their monthly meetings. -The Facility created a QA audit tool to be used by Social Service/designee daily to assess all new admissions and readmissions for Code Status and or POLST orders, care plan and update the list of resident code status. The audit tool will be done daily for one month, then monthly for 3 months and then quarterly for a year. The audit tool to be implemented on [DATE].