**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident interview, staff interview, Physician interview, Nurse Practitioner (NP) interview, and facility policy review, the facility failed to complete thorough assessments and interventions when 3 of 3 residents (Residents #1, #4 and #5) sustained skin breakdown. In addition, the facility failed to properly assess one (1) resident following a fall (Resident #2). Resident #1 had a previous history of an amputation on his left foot. Following his surgery, the facility failed to follow physician orders, complete thorough skin assessments, and failed to follow treatments. Per the Podiatrist, Resident #1 had an additional amputation due to the lack of care and treatment he received. This resulted in an immediate jeopardy situation.On 8/14/25 at 5:20 p.m. the Iowa Department of Inspections and Appeals staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The facility staff removed the immediacy on 8/14/25 and decreased the scope to G, after the facility staff completed the following:The Director of Nursing (DON) and the nursing staff identified all residents with wounds.The DON met with Wound Nurse and updated her on the residents with wounds.Assessed all residents with wounds which included measurements, documentation, and notified the primary care physicians. All staff re-educated on proper assessments and utilization of the wound vac. The facility identified a census of 64 residents.Findings include:The Complex Wound Management policy and procedure reviewed July 2022 instructed the facility to provide documentation that enabled the medical staff to evaluate the status of wounds. A complex wound be identified as an arterial ulcer, diabetic neuropathic ulcer, pressure ulcer and/or venous insufficiency ulcers. The Procedure directed the following: a. Complete a weekly skin assessment on all residents and document it in the resident's medical record. b. Measure each wound in centimeters (cm) weekly. Measurements, size and depth, drainage, odor, color and a short statement on the progress (or lack of) on the Skin Pressure Weekly or Skin Ulcer Non-Pressure Weekly forms. c. Use the treatments ordered by the medical provider. If the wound didn't have improvement, the facility must call the medical provider for an evaluation. d. Consider a significant change based on the information in regards to the presence of pressure ulcer(s). The staff must complete a Minimum Data Set (MDS) and Care Plan as soon as identified.According to an email dated 8/28/25 at 10:39 AM the Corporate Clinical Market Leader confirmed the facility's wound policy directed the staff to measure all wounds, even jagged edged wounds as they aren't exempt to the policy.Resident #1's MDS assessment form dated 5/5/25 identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognitive skills. The MDS reflected Resident #1 didn't exhibit rejection of care. He required substantial/maximum assistance with most activities of daily living (ADL's). He didn't walk. The MDS included diagnoses of atherosclerotic native arteries of the left leg with ulceration of the calf, coronary artery disease (CAD), peripheral vascular disease (PVD), diabetes mellitus (DM) with diabetic neuropathy and malnutrition. The assessment indicated Resident #1 had a risk for pressure ulcers but didn't have pressure ulcers at the time of the assessment. However, he had surgical wounds and moisture associated skin damage (MASD). The assessment indicated Resident #1 didn't have a turning and repositioning program.The Care Plan included the following Focuses and Interventions as dated: a. 4/11/25: Potential for pressure injury or impairment to skin integrity related to (r/t) diabetes mellitus (DM). The Interventions instructed the following: i. 5/13/25: Float heels when rested as he allowed. ii. 4/11/25: Left foot heel protector boot when he rested and as he allowed iii. 4/11/25: Provide preventative maintenance to his coccyx as directed and as needed (PRN). iv. Weekly and PRN skin assessments.b. 5/13/25: Actual impairment to the skin integrity r/t a surgical wound to the left foot mid amputation. The Interventions directed the following: i. 5/13/25: Administration of treatment to the left stump as ordered. ii. 5/13/25: Monitor/document location, size and treatment of the skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration and etc. to the Physician. iii. 5/13/25: Weekly skin assessments.c. 7/14/25: Infection of the left surgical site. The Intervention instructed to complete daily dressings by applying betadine-soaked gauze with a non-compressed gauze roll to the left foot surgical site until they could apply the wound vac. Resident #1 had an order that directed no weight bearing and protective boots on at all times.d. 5/15/25: ADL self-care performance deficit r/t limited mobility and impaired balance. The Intervention listed Resident #1 as dependent on staff with toileting hygiene, dressing, and rolling from left to right in the bed.e. 7/10/25: Unstageable pressure ulcer to his left outer ankle. The Interventions reflected the following: i. 7/10/25: Administer treatments as ordered and monitor for effectiveness. ii. 7/10/25: Assess, record, and monitor wound healing. Measure the length, width, and depth where possible. Assess and document the status of the wound perimeter, wound bed, and healing progress. Report improvements and decline to the Physician.The LN-Initial admission Record signed 4/4/25 effective 3/28/25 listed Resident #1 had the following skin issues:a. Left foot fifth toe had a dry intact blood blisterb. Left bottom of the foot center is dark and soft.c. Left heel is non-blanchable and appeared as a deep tissue injury.The Emergency Department (ED) to Hospital - admission dated 5/2/25 indicated on 4/29/25 Resident #1 had a partial amputation to his left foot.The Post - Acute Discharge Report dated 5/13/25 identified Resident #1 discharged from the hospital to the nursing home.Following Resident #1's return, his clinical records lacked measurements of his surgical incision 4 times in May 2025 and 3 times in June 2025. The Wound Center Wound Assessment Details dated 6/25/25, noted eschar (dead tissue) in the surgical wound of his left foot. The LN - Skin Ulcer Non-Pressure Weekly dated 7/2/25, reflected Resident #1's surgical wound had moderate odor, drainage, and the incision reopened. The open area of the wound measured 7x4 cm. The LN - Skin Ulcer Non-Pressure Weekly assessment dated [DATE] indicated on 7/2/25 Resident #1 had a new wound to his left outer ankle.A Braden Scale for Predicting Pressure Sore Risk forms dated 4/28/25, 5/27/25, 6/18/25, and 7/10/25 placed the resident at high risk for pressure ulcers.The facility's undated time line of events related to Resident #1's left foot included the following:a. 3/28/25 - admitted to the facility with a dried intact blood blister on his left foot 5th toe, a dark and non-blanchable area on the bottom of his left foot, a hard, round area to his upper coccyx, a dark soft area on the center on the bottom of his left foot, the left heel appeared to have been a deep tissue injury (DTI) dark red in color and all his right toes amputated. The facility failed to complete thorough assessments of the above documented skin issues. b. 4/4/25 - The facility failed to provide a complete assessment of Resident #1's following areas: left 5th toe, the bottom of his left foot, left planter foot, and his coccyx area. c. 4/10/25 - Left 5th toe and left planter foot - healed.d. The facility failed to provide a complete assessment of the bottom of Resident #1's left foot, coccyx, and his scrotum on the assessments done on 4/11/25, 4/19/25, 4/24/25 and 4/27/25. h. hospitalized [DATE] through 5/13/25.i. 5/13/25 - Resident #1 returned to the facility with the following wounds: i. Coccyx ulcer that measured 0.5 cm x 0.3 cm surrounded by calloused skin ii. The left foot surgical incision following an amputation identified but assessed.j. 5/16/25 - The facility failed to provide a complete and thorough assessment of Resident #1's left foot's stump and coccyx area. k. The facility failed to do complete assessments of the resident's left foot stump on 5/22/25, 5/28/25, and 6/3/25.l. 6/11/25 - Removed sutures to left foot incision.m. 6/12/25 - Identified Resident #1's left foot stump didn't have sutures, but had 11 steri strips in place. The note lacked a complete assessment. The coccyx - healed with scar tissue.n. 6/17/25 - The facility failed to provide a complete and thorough assessment of Resident #1's left foot stump. o. 6/25/25 -The wound on Resident #1's left foot stump declined and revealed a grade 1 wound with etiologies (starting cause) of diabetic/wound ulcer and a dehisced (opened) wound that measured 1.7 x 2.8 x 1.4 cm. Resident #1's wound had subcutaneous (fat) tissue exposed with no tunneling or undermining, red granulation tissue (a new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size.) within the wound bed along with eschar (dead tissue). The peri wound skin appeared dry, scaly, and with maceration (break down of skin from moisture). In addition, the wound had a moderate amount of serosanguinous drainage with the wound bed described as black/brown and edges macerated with surrounding scar tissue.p. 7/2/25 - The lateral (side) aspect of the left foot stump's surgical site had an area that measured 3.0 x 1.5 x 0.8 cm with a moderate amount of serosanguinous drainage, moderate odor, granulation tissue in the wound bed and undefined wound edges. Resident #1 had a new unstageable area on his left-outer ankle that measured 1.0 cm x 1.5 cm. The Timeline described the wound as a dry, thick, scabbed area with surrounding tissue didn't' have discoloration, drainage, undermining, or tunneling. The note reflected the wound bed had black/brown eschar and defined wound edges.q. 7/9/25 - The left foot stump measured 3.0 x 4.6 x 1.6 with a moderate amount of seropurulent drainage (a watery pinkish color, usually a sign of a localized infection) with a foul odor. The wound bed presented with granulation tissue, macerated wound edges, and surrounding scar tissue. The left outer ankle remained unstageable and measured 1.1 x 0.9 x 0.2. The wound description listed a moderate amount of serosanguinous drainage, wound bed black/brown, defined wound edges and normal surrounding tissue. The right coccyx area reopened as a stage II area that measured at 2.0 x 1.0 x 0.1, no drainage, wound bed beefy red, wound edges fibrotic calloused and surround scar tissue.r. The facility failed to complete assessments to Resident #1's left foot and coccyx areas on 7/21/25, 7/28/25 and 8/4/25. According to an email dated 8/29/25 at 10:27 AM the DON confirmed the facility failed to assess Resident #1's open areas on 7/21/25, 7/28/25 and 8/4/25.The Podiatry Physician Progress Notes form dated 7/10/25 identified Resident #1 presented to the office for a post-operative visit from his left midfoot amputation with delayed primary closure performed on 5/6/25. The Podiatrist performed a procedure to debride with sharp dissection (cutting) a lesion on Resident #1's lateral wound. The Podiatrist removed a lesion from the epidermal (a type of skin tissue) layer with a 15 blade. The Podiatrist described the wound with no underlying infection noted and had healthy granular tissue noted on the underlying lesion. The lateral wound measured 4.0 x 2.0 x 1.0 and the medial wound measured 3.0 x 2.0 x 1.0 with exposed bone. The Assessment identified Resident #1 had diagnoses of atherosclerosis (a condition of a buildup of fats, cholesterol, and substances in and on the artery walls causing a narrowing of arteries and reduced blood flow) of the lower extremity, diabetic nephropathy (kidney disease) associated with type 2 DM, uncontrolled type 2 DM with hyperglycemia (increased blood sugar), amputation of the left midfoot and a post-operative examination. The Orders directed to apply a wound vacuum (vac).A Podiatrist Progress Record form dated 7/10/25 included an order for a wound vac at 125 mmHg (millimeters of mercury which measured the pressure of the device) to start when available. The order directed to run the wound vac continuously and change it every Monday, Wednesday and Friday.The Wound Culture with Grain Stain collected 7/4/25 reflected Resident #1's left foot had a heavy growth of pseudomonas aeruginosa (bacterial infection). The NP documented they spoke with podiatry who reported the Wound Center saw Resident #1 that day. They said he likely had a colonization (build of bacteria that becomes part of the body's normal flora) of bacteria but did have heavy growth, so they wanted him started on Augmentin 500 - 125 milligrams (mg) twice a day for 7 days. According to an Order Details form dated 7/15/25 at 5:52 PM the staff scheduled to change the wound vac every 30 minutes on Monday, Wednesday and Friday starting 7/16/25.Resident #1's Medication Admin Audit Report form printed 8/26/25 at 1:58 PM identified a schedule to change his wound vac on 7/16/25 as 6:00 AM, 6:30 AM, and 7:00 AM. The record indicated the nurse changed the wound dressing at 5:09 AM, 10:59 AM, and 11:00 AM.The eMAR - Medication Administration Note dated 7/16/25 at 4:52 AM indicated Resident #1 got his wound vac changed twice the day before. He required and received an overlay of a clear, adherent dressing to have maintained the unit's function. During an interview on 8/8/25 at 12:57 PM the DON confirmed Staff E, Registered Nurse (RN), entered the Physician Order incorrectly.A handwritten Podiatrist Progress Note form dated 7/25/25 the Podiatrist documented the wound vac cannot be left off.A handwritten Podiatrist Progress Note form dated 8/1/25 the Podiatrist documented Resident #1 arrived at his Podiatrist appointment for a second week in a row without a wound vac or a dead vac. He reinforced it was unacceptable. The note included to send supplies and charge vac.The Nursing Noted related to 8/5/25 at 11:06 PM reflected when his family took him outside to smoke cigarettes, his foot had gnats on it so they brought him back inside. The nurse washed all pressure relief items and changed the dressing to his foot. His dressing had serous drainage with odor. The day shift updated the wound physician on 8/5/25 about the staff not changing his wound vac. The physician gave an order to apply a dressing and restart his wound vac on 8/6/25.The Nursing Note dated 8/6/25 at 7:20 AM indicated the nurse spoke with Resident #1 and he agreed to get evaluated in the ED per his daughter's request because of him vomiting. When the NP visited the facility, they gave an okay for him to be evaluated in the ED. According to an interview on 8/12/25 at 1:00 PM Resident #1's Podiatrist confirmed he expected the facility staff to follow his orders. The Podiatrist indicated the first couple weeks Resident #1 laid down granulation tissue. He explained that without the wound vac running continuously, it directly caused a thick, soupy drainage that affected the granulation tissue and caused further deterioration of his foot. He described measurements as an essential factor in wound management and he expected the staff to measure the jagged incision as well. He explained the deterioration of the wounds resulted due to the lack of appropriate care and treatment of the wounds. Resident #1 had co-morbidities (multiple diagnoses) such as DM which placed him at a higher risk but ultimately those co-morbidities didn't cause his amputations, rather the main contributor of lack of care and treatment. The entire situation caused the Podiatrist frustration because the first time he arrived for an appointment, he didn't have his wound vac attached. When he called the facility, no one answered the telephone. The second time Resident #1 arrived for his appointment with his wound vac not functioning. The Podiatrist called the facility repeatedly until someone finally answered the telephone. The Podiatrist described the entire situation as not acceptable at all.During an interview on 8/19/25 at 5:45 PM Staff B, Registered Nurse (RN), indicated she knew of Resident #1's wound vac device. She reported she worked once with Staff C, RN, who planned to change the device but left the shift without changing the wound vac. Staff B reported the DON went out of town when Resident #1 received his wound vac order. Staff B explained she didn't receive education on wound vacs and/or the proper placement. When the wound vac device arrived, the DON directed her to do the treatment. She told the DON she didn't feel comfortable without training and the DON became upset with her. Staff B reported he didn't get his wound vac changed on 8/4/25 as the physician ordered. She added she knew the facility sent him to the hospital on the 5th or 6th. During an interview on 8/20/25 at 12:54 PM Staff C confirmed she couldn't change Resident #1's wound vac on 8/4/25 because she trained another nurse, had 3 admissions and no management staff support in the facility.During an interview on 8/8/25 at 12:09 PM Staff F, CNA, confirmed when Resident #1 sat in his chair, he had the wound vac always unplugged and nonfunctional.During an interview on 8/8/25 at 12:20 PM Staff G, CNA, confirmed when Resident #1 got up for meals, he had his wound vac unplugged and nonfunctional.During an interview on 8/8/25 at 2:34 PM Staff I, CNA, confirmed she found the wound vac shut off or unplugged. She knew that because it beeped when it didn't function.2. Resident #4's MDS assessment dated [DATE], indicated he had a short- and long-term memory deficit and severely impaired cognition. The MDS listed Resident #4 as dependent on staff with activities of daily living (ADL's). The MDS reflected Resident #4 didn't walk. The MDS included diagnoses of type II diabetes mellitus, Alzheimer's disease, non-Alzheimer's dementia and malnutrition. The MDS indicated Resident #4 didn't have a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. The MDS identified he had a risk for pressure ulcers/injuries. The MDS reflected he had diabetic foot ulcer(s). He had pressure reducing devices in the bed and chair, but didn't have a turning/repositioning program.Resident #4's MDS assessment dated [DATE], lacked documentation of his skin issues. The form indicated Resident #4 didn't have a risk for pressure ulcers. He had pressure reducing devices in the bed and chair, but didn't have a turning/repositioning program.The Care Plan Focuses indicated the following for Resident #4: a. 5/25/18: Potential for pressure injury or impairment to skin integrity r/t limited mobility, incontinent of bowel and bladder and DM. The Interventions directed the following: i. 5/6/25: Mat placed on wall by window due to resident rubbed his feet and fingers which caused an abrasion. ii. 5/25/18: Weekly skin checks and PRN.b. Potential/actual impairment to skin integrity r/t fragile skin which caused MASD. The Interventions instructed the following: i. 6/12/25: Administration of treatments as ordered.c. 5/25/18: ADL self-care performance deficit r/t limited mobility and slow response. i. 5/12/25: Non-ambulatory. ii. 5/25/18: Required assistance from 1 staff repositioned in bed. Review of the facility's undated timeline of skin breakdown areas the facility lacked an adequate assessment on the following injuries and dates:a. 5/28/25, 6/3/25, 6/10/25, 6/12/25, 6/17/25, 6/19/25, 6/24/25, 6/25/25 - Left great toe diabetic ulcer, left foot 3rd digit diabetic ulcer, outer aspect of the left foot diabetic ulcer and the left pinky toe diabetic ulcer. b. 6/19/25, 6/25/25, 7/2/25 - Right upper buttock with a 3.2 cm intact blister, coccyx 2.0 x 1.0 unopened dry area with no further assessments completed.c. Resident #4's record lacked further completed assessments until 7/17/25. At the time Resident #4's right buttock area contained an assessment. The assessment indicated Resident #4's outer aspect of the left foot wound healed. d. 7/24/25 - The right buttock and outer aspect of the left foot - healed. e. 8/6/25 - Coccyx area healed, onset of a left knee area measured 1.5 x 1.8 x 0.2 unstageable with slough and eschar, no tunneling or undermining, moderate amount of serosanguinous drainage with no odor, wound edges defined with erythema on the surrounding tissue with no further assessments of any other areas completed. f. 8/12/25, 8/13, 8/15 - The facility failed to complete a thorough assessment of Resident #4's left abdominal blister, left knee, and the top of his right buttock.g 8/15/25 - Resident #4 presented with a right shin abrasion that measured 4.0 x 1.0 as a scabbed area with no further assessments completed. o. 8/16/25 - Stage II right buttock measured 3.0 x 2.0 x 0.1 with a scant amount of serous drainage noted on the dressing removed. Also noted a flat pink area located above the stage II area that measured 0.5 x 0.5 and not open at that time, a bandage had been noted on the resident's right shin, when removed noted an area that measured 4.0 x 1.0 with no drainage and no erythema noted on the surrounding tissue. No further assessments completed. p. 8/20/25 - The facility failed to complete a thorough assessment of Resident #4's left knee area and right buttock. During an interview on 8/27/25 at 11:55 AM the Corporate Clinical Market Leader indicated the facility failed to provide any assessments of Resident #4's left pinky toe.3. Resident #5's MDS assessment dated [DATE] included diagnoses of type II DM, malnutrition, a cognitive deficit and lymphedema. The assessment indicated Resident #4 had a risk for pressure ulcers/injuries and had 1 unstageable pressure injury which presented as a deep tissue injury.Review of LN-Skin Pressure Ulcer Weekly forms revealed the following as dated: a. 7/2/25 at 5:55 PM - Right buttock measured 15 cm x 7.5 cm, non-blanchable and dark purple in color, left buttock measured 12 cm x 9 cm with no further assessment and her right gluteal fold measured 2.0 cm x 1.0 cm x 0.2 cm deep. The staff further described the right gluteal fold Description tab as the area not open and remained with a scarred area with no further assessment/documentation. b. 7/10/25 at 10:17 AM - The facility failed to complete an assessment of the resident's right buttock. The resident now presented with an area on the left buttock that measured 6.5 cm x 3.5 cm x 0.0 cm described as a dark purple, non-blanchable areas up higher on the buttock than the area to the right side and the right gluteal fold measured 10 cm x 8.0 cm x 0.0 cm described as purple in color located on the lower aspect of the right buttock, a fatty area that the resident had near the gluteal fold. c. The facility failed to assess the above documented skin areas 7/14/25, 7/21/25, 7/28/25 and 8/6/25.During an interview on 8/26/25 at 4:30 PM the Corporate Clinical Market Leader, DON and the Assistant Director of Nursing (ADON) reported the week of 8/25/25 the ADON started her first week in the role of the skin care nurse on a full-time basis. The prior nurses who performed skin assessments failed to properly assess all areas and also mis-coded if the skin areas presented as pressure, non-pressure, MSAD and/or a diabetic ulcer so the facility couldn't track areas and paint a complete picture of what actually occurred with the residents' skin issues.A Quality Improvement Activity Sheet form dated 8/27/25 at 2:53 PM reflected the facility started a project on 8/4/25 for skin/wound assessments, due to the facility's identification of incomplete wound assessment with incomplete weekly documentation.4. Resident #2's MDS assessment dated [DATE] identified a BIMS score of 6, indicating severely impaired cognition. Resident #2 required substantial to maximal assistance of staff with toileting and transfers. The MDS listed Resident #2 as non-ambulatory (nonwalking). The MDS included diagnoses of non-Alzheimer's dementia, age related physical debility, lumbago with sciatica (back pain with nerve involvement), weakness, and other reduced mobility.During an interview on 8/7/25 at 2:48 PM Staff D, CNA indicated after Resident #2 fell Staff H, RN, stated let's get her up without an assessment.During an interview on 8/8/25 at 12:00 PM Staff F, CNA, indicated after Resident #2 fell Staff H failed to assess them while positioned on the floor. During an interview on 8/8/25 at 12:15 PM Staff G, CNA, indicated Staff H failed to assess Resident #4 while on the floor.During an interview on 8/8/25 at 1:30 PM Staff H confirmed she failed to assessed Resident #2 while on the floor rather she performed an assessment once staff moved/positioned her in the wheelchair. Staff H added she had no excuses and/or reason for her failure to assess Resident #2.During an interview on 8/21/25 at 1:05 PM Resident #2's NP confirmed he expected the facility staff complete a thorough assessment of Resident #2 while on the ground after she fell prior to transferring her to the wheelchair. In addition, the NP confirmed even if her legs appeared the same length with no noticeable internal or external rotation of her lower extremities, the staff should have done a thorough head-to-toe assessment of Resident #2 prior to moving her. A thorough assessment may not reveal any damage, but they expected it done before moving her. The NP indicated he suspected all of her fractures occurred at the time of the fall.The History of Present Illness dated 7/18/25 at 8:27 AM the Physician documented Resident #2 came to the ED. The evaluation listed Resident #2 sustained a closed fracture of the right distal femur (outer part of the upper leg) and a closed fracture of the left proximal tibia (inner side of the leg bone).