**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and once developed, failed to ensure necessary treatment and services to promote healing for two (Resident #249 and Resident #40) of five residents reviewed for pressure ulcers. A) The facility failed to ensure Resident #249 who was at risk for skin breakdown received weekly skin assessments to identify skin breakdown. Resident #249 did not have a skin assessment from 04/09/2024 through 04/20/2025. Resident #249 developed a necrotic unstageable pressure ulcer to her sacrum that resulted in Resident #249 developing sepsis and requiring surgical debridement. B) The facility failed to ensure RN A notified Resident #249's physician on 04/20/25 at 4:20 PM when she observed a brown spot on Resident #249's sacral area. These failures resulted in an Immediate Jeopardy (IJ) situation on 04/24/2025. The IJ template was provided to the facility on [DATE] at 2:28 PM. While the IJ was removed on 04/25/2025, the facility remained out of compliance at a severity level of no actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. This failure placed the residents at risk for developing worsening pressure ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe pain or death. Non immediate jeopardy B) The facility failed to ensure the Treatment nurse used a cleaning technique on Resident #40's Stage 3 sacral pressure ulcer that did not cross contaminate the pressure ulcer. This failure could place residents at risk for worsening of pressure ulcers leading to discomfort, pain, and potential infections. Finding Include: A) Review of Resident #249's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses fracture of unspecified part of left femur neck (hip fracture), cognitive communication deficit, and muscle wasting and atrophy. Review of Resident #249's 5-Day MDS dated [DATE] reflected a BIMS of 13 indicating she was cognitively intake. Resident #249 was assessed to require supervision or touching assistance with toileting and partial to moderate assistance with transfers. Resident #249 was assessed to be occasionally incontinent of urine and continent of bowel. Review of Resident #249's comprehensive care plan reflected a problem dated 04/08/2025 which reflected The resident has potential impairment to skin integrity related to incontinence. Interventions included Monitor/document location, size, and treatment of skin injury. Report abnormalities . Review of Resident #249's admission nursing assessment dated [DATE] reflected she had no skin issues. Review of Resident #249 PCC skin & wound assessment dated [DATE] reflected no skin concerns noted to peri or coccyx area. Review of Resident #249's weekly skin assessments reflected no skin assessment was conducted from 04/08/2025 until 04/20/2025. Review of Resident #249's PCC skin & wound assessment dated [DATE] conducted by RN A reflected Resident #249 had no new wounds. In an interview on 04/24/2025 at 9:10 am RN A stated Resident #249 had a fall around 4:20 pm on 04/20/2025 in her bathroom. RN A stated Resident #249 went to the bathroom on her own and fell. RN A stated she conducted an assessment after the fall and did not see any injuries. She stated at that time she did not look at her sacral area closely and stated she did not smell anything like necrosis. RN A stated that around 9:45 pm a CNA came to her and reported the resident had a brown spot on her sacral area. She stated she left a note for the next shift to assess the area. Review of Resident #249's nursing progress notes reflected an entry dated 04/20/2025 at 9:50 pm CNA notified this nurse about resident having a new wound. Went to assess, noted small wound to resident's bottom with eschar area to wound bed. Skilled wound care nurse to be notified. Progress note signed by RN A. In an interview on 04/24/2025 at 3:05 pm CNA O stated she worked the evening of 04/20/2025 (2pm-10pm shift) and took care of Resident #249. She stated she helped Resident #249 into the bathroom and noticed red color spot on her bottom but denied seeing a wound or skin tear. She stated that she notified the nurse right away and the nurse whose name she does not remember came right away. In an interview on 04/24/2025 at 9:19 am the Treatment nurse stated she saw Resident #249 for wound care on 04/18/2025. She stated she did not do a full skin assessment on that day that she just looked at Resident #249's left hip incision and did not see anything else. She stated Resident #249 was on the commode when she performed the assessment and that she looked at her buttocks but did not look in depth at her sacral area. She stated she did not do treatments on residents with only surgical wounds that the floor nurses did those wound assessments. The Treatment nurse stated on 04/21/2025 that she did not assess Resident #249's skin. The Treatment nurse stated she had no idea how Resident #249's unstageable sacral pressure injury developed. In an interview on 04/24/2025 at 9:45 am the ADON stated she was working the floor on 04/21/2025. She stated on 04/21/2025 around 3:00 pm the CNAs went to lay Resident #249 down in bed and she was complaining of left hip pain. She stated they then turned Resident #249 over on her side they found a large dark area on her sacral area that had odor and covered her entire sacral area. The ADON stated she informed Resident #249's PA. Review of Resident #249's nursing progress note dated 04/21/2025 at 3:24 pm reflected Sent to (hospital) for wound care consult/patient with new sacral wound plus odorous and needs debridement . note signed by the ADON. In an interview on 04/24/2025 at 10:00 am Resident #249's PA stated she received a call from the facility on 04/21/2025 that Resident #249 had a new area to her sacrum. She stated she assessed the area and found an unstageable pressure ulcer to her sacrum that was malodorous. She stated at first, she thought that it might be an abscess, but she had not gotten the hospital paperwork yet to verify that. When asked if Resident #249 could have developed the pressure ulcer in one day since the skin assessment on 04/20/2025 reflected she did not have any skin conditions Resident #249's PA stated a pressure ulcer can develop in that time frame but not necrosis that generally takes about a week. She stated Resident #249 was [AGE] years old but can get up in a wheelchair and move around. Resident #249's PA stated she saw Resident #249 on 04/17/2025 and she complained of hip pain but no other pain. She stated she did not assess her skin at that time. When asked if not performing skin checks could be a factor in the development of the pressure ulcer, she stated it could be a factor yes. She stated, I asked the nurses how we not saw this. Resident #249's PA stated Resident #249's pressure ulcer could not have developed over night, that it was very questionable given the necrosis. Review of Resident #249's PA note dated 04/21/2025 reflected new malodorous decubitus wound .due to concern for infection, I recommend pt (patient) to go to hospital to have wound consult asap (as soon as possible) . Review of Resident #249's hospital records dated 04/21/2025 reflected This is a [AGE] year-old woman with a past medical history of hypertension (high blood pressure), hyperlipemia (high levels of fat in the blood) and hypothyroidism (decreased production of thyroid hormones) who presents from an inpatient rehab facility after having left hip surgery several weeks ago now developing sacral pain over the last week with a large sacral decubitus ulcer. The patient appears to have a central area of necrotic issue with surrounding cellulitis approximately 8 cm in diameter. She will require debridement routinely and antibiotic coverage with PT wound care for healing .8 cm in diameter necrotic decubitus ulcer with surrounding erythema .patient with possible sepsis Further review of Resident #249's hospital record reflected on 04/22/2025 she was diagnosed with sacral wound sepsis. Review of the operative report reflected preoperative diagnosis sacral pressure ulcer (unstageable) postoperative diagnosis sacral pressure ulcer (Stage IV) debridement down to and including sacral bone. Post debridement measurements 20cm x 15cm x 4cm wound vac application. With findings necrotic muscle extending to bone with copious purulence and malodorous smelling wound . Interview on 04/24/2025 at 10:55 am the DON stated when the facility was made aware of Resident #249's new pressure ulcer they sent her out to the hospital right away. She stated the facility started in-servicing staff and did a skin audit. She stated there were a lot of opportunities to see Resident #249's pressure ulcer that were missed. She stated if Resident #249's skin assessment had been done weekly it defiantly could have made a difference in the outcome if it had been caught earlier. In a follow-up interview on 04/24/2025 at 3:00 pm the DON stated that the facility regularly pulls up a list of residents' due weekly skin assessments, she stated every other day of so. She stated when they started looking into Resident #249, she found that her weekly skin assessment did not populate to alert the staff to do a skin assessment. The DON stated she did not know why the assessment did not populate. She stated the facility started training on how to complete a full and thorough skin assessment. She stated residents not being monitored and skin assessments being performed could contribute to residents having pressure ulcers not known by the facility. She stated she expected CNAs to tell nurses if a resident was not bathing and expected the staff nurses and aides to take every care opportunity to view the residents' skin for changes. In an interview on 04/24/2025 at 3:20 pm the Administrator stated he expected skin assessments to be done weekly and a thorough skin assessment be conducted. He stated if a thorough skin assessment had been conducted for Resident #249 the pressure sore would have been caught earlier. He stated if staff were charting on a skin assessment form, then a full and thorough skin assessment should be conducted. Review of the facility's undated policy Skin integrity management system reflected A head-to-toe body evaluation will be completed on every resident upon admission or readmission on the Initial Nursing Evaluation. Weekly thereafter the evaluations will be documented on the Weekly Skin Evaluation UDA. If skin is intact, no further action is required. If skin is compromised, proceed to the Weekly Wound Progress UDA. Identified skin areas will be documented on the Weekly Pressure or Non-Pressure UDA. Wound progress is to be documented each week with measurements and wound descriptions .Routine weekly checks will be completed on each resident; if skin is intact, it will be noted as such. If a new pressure injury is noted, a Weekly Pressure or Non-Pressure UDA will be started. Notification of Physician and Responsible Party will be documented in the Progress Notes. Assignments for skin evaluations will be scheduled. These assignments are to be monitored for completion . B) Review of Resident #40's face sheet dated 04/16/2025 revealed Resident #40 was a [AGE] year old female admitted to the facility on [DATE] with a diagnoses of Cognitive Communication Deficit (problem with communication caused by cognition rather than a language or speech deficit), Dysphagia (difficulty swallowing), Parkinson's Disease with Dyskinesia (a progressive disorder that affects the nervous system), Neurocognitive disorder with Lewy Bodies (a dementia where protein deposits develop in nerve cells in the brain), and unspecified Fracture of Sacrum (a broken bone in the lower back near the tailbone). Record review of Resident #40's MDS assessment, dated 04/16/2025, reflected Resident #40 was readmitted to the facility on [DATE] following a short-term hospital stay. MDS assessment had not been completed at the time of the survey. Record review of Resident #40's care plan reflected a focus area, dated 04/23/2025, reflected The resident has stage 3 pressure ulcer to sacrum date of development 04/21/2025 r/t skin frailty, immobility and incontinence. Goal included, resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Target date: 06/28/2025. Observation on 04/23/2024 at 8:18 am revealed the Treatment Nurse in Resident #40's room to provide wound care. She removed the dressing covering the wound, then provided incontinent care to Resident #40. She wiped feces off the resident's perianal area with a moist perineal wipe and used the soiled wipe to wipe the skin around the open wound. She later used clean moistened gauze to wipe the skin surrounding the wound, before using the soiled gauze to wipe the open wound bed. Interview with Treatment Nurse on 4/24/25 at 09:20 AM stated that the proper technique for performing wound care is to wipe from the inner aspect of a wound and clean outward to prevent cross-contamination of a wound. Stated, that wasn't ideal at all when informed that she wiped around the open wound when cleaning feces off the resident's skin, and then later wiped the surrounding skin before cleaning the wound bed with the same moistened gauze during wound care to Resident #40. She stated that the resident could get an infection if the wound was contaminated with feces. Interview on 4/24/25 at 02:32 pm with DON stated that her expectations for wound care technique is that the wound bed be cleaned from the center of the wound bed outward. Stated that fecal contamination of the wound could lead to a wound infection and decline of the wound. Stated that hand hygiene should be done prior to medication administration per policy. Stated that the staff could cross contaminate the resident if hand hygiene is not performed. Interview on 4/24/25 at 03:31 pm with Administrator stated that his expectation is that incontinent care be performed prior to proceeding with wound care. In a follow-up interview on 04/25/2025 at 09:40 am the Administrator stated that if there was contamination in a wound, there is a possibility that a resident may need further intervention such as antibiotics. Review of facility's policy on Infection Prevention and Control Program dated 05/13/2023, reflected All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Review of the facility's policy on Pressure Ulcer Prevention and Management dated 08/15/2022, reflected The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to .ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. The Administrator was notified on 04/24/2025 at 1:37 pm, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 04/25/2025 at 1:15 pm. Letter of Credible Allegation For Removal of Immediate Jeopardy Attention Sir or Madam On 04/22/25 an annual survey was initiated at the facility. On 04/24/25 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy situation to resident health and safety. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusion set for in the verbal and written notice of immediate jeopardy and/ or any subsequent Statement of Deficiencies. The immediate jeopardy allegations are as follows. F686 Quality of Care Pressure The facility failed to ensure Resident # 249 who was at risk for skin breakdown received weekly skin assessments to identify skin breakdown. Resident #249 did not have a skin assessment from 04/09/2025 through 04/20/2025. Resident # 249 developed a necrotic unstageable pressure ulcer to her sacrum that resulted in Resident #249 developing sepsis and requiring surgical debridement. Resident #249 remains hospitalized . Actions for Resident Involved * On 4/24/2025 the Treatment Nurse was re-educated on completing thorough skin assessments by the Director of Nurses and suspended. Identification of Others * On 4-24-2025, the nursing facility conducted 100% head to toe assessment to ensure that residents with skin alterations were identified and documented. All skin assessments were documented on the PCC total body skin assessment form and saved in the resident's medical record. For any alterations in skin integrity, orders will be reviewed, and documentation reviewed to ensure license staff are following facility skin assessment and pressure ulcer prevention and management policy. * 3 residents were identified with newly developed rashes, MD was notified, orders for treatment were received, RP was notified, and care plan was updated to reflect treatment. * 1 resident identified with MASD to the sacrum, MD was notified, orders for treatment were received, RP was notified, and care plan was updated to reflect treatment. * 1 open blister was identified, MD was notified, orders for treatment were received, RP was notified, and care plan was updated to reflect the treatment. Systemic Changes/ Education On the Director of Nursing initiated education with 100% of licensed staff. Education was completed 4-24-2025. Those that are PRN and/ or out on FMLA/ LOA will be taken off schedule and have the education completed prior to accepting assignment for their next scheduled shift. * Skin Assessment Policy * A full body, or head 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. * Pressure Ulcer Prevention and Management Policy * Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury or skin alteration. Findings will be documented in the medical record. * Assessments of pressure injuries or skin alterations will be performed by a Licensed Nurse (Licensed Vocational Nurse and Registered Nurse) and documented in the medical record. Documentation will include the site, type, stage, measurement, presence of exudate and amount, odor, wound bed. surrounding skin color, surrounding tissue edges, tunneling, undermining and response to treatment. * The attending physician will be notified of: * The presence of a new pressure injury or skin alteration upon identification. * The progression towards healing, or lack of healing, of any pressure injuries or skin alteration weekly. * Any complications (such as infection, development of a sinus tract, etc.) as needed. * Skin Integrity Management System * Notification of Changes Policy On 4/24/25 The Regional Clinical Specialist initiated the following education with 100% of licensed staff. Education will be completed 4-25-2025. Those that are PRN and/ or out on FMLA/ LOA will be taken off schedule and have the education completed prior to accepting assignment for their next scheduled shift. * Comprehension of training was verified by having nurses voice understanding of the training and repeat back training contents. * Skin Assessment Policy * 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 DON and/or designee will provide oversight of completion of skin assessments up-on admission/re- admission and weekly thereafter and will document on the findings on the facility clinical [NAME]-up form. * the documentation of each assessment is noted in PCC by the nurse completing assessment. The Director of Nurses/ designee will run the Total Body Skin Assessment from PCC each weekday, audit for missing assessments, and assign completion as appropriate. * Pressure Ulcer Prevention and Management Policy * Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury or skin alteration. Findings will be documented in the medical record. * Assessments of pressure injuries or skin alterations will be performed by a Licensed Nurse (Licensed Vocational Nurse and Registered Nurse) and documented in the medical record. Documentation will include the site, type, stage, measurement, presence of exudate and amount, odor, wound bed. surrounding skin color, surrounding tissue edges, tunneling, undermining and response to treatment. * The attending physician will be notified of: * The presence of a new pressure injury or skin alteration upon identification. * The progression towards healing, or lack of healing, of any pressure injuries or skin alteration weekly. * Any complications (such as infection, development of a sinus tract, etc.) as needed. * The notification of the physician is noted in PCC and will be tracked for completion by the DON and/or designee through the review of the PCC 24 hrs. report. * Skin Integrity Management System. The documentation of this training is recorded on the facility's Inservice Training Report. * Notification of Changes Policy- The documentation of this training is recorded on the facility's Inservice Training Report. On 4-24-2025, the Regional Clinical Specialist re-educated the Director of nursing and ADONS on monitoring the skin integrity system to include completion of weekly skin assessment for each resident. Training recorded on the facility Inservice Training Report * Comprehension of training was verified by having nurses voice understanding of the training and repeat back training content. Monitoring The Director of Nursing or designee will audit PCC total body assessment each weekday to ensure timely completion of skin assessments for each resident. o The PCC total body assessment audit will be documented on the facility's Clinical Stand-up Meeting form. The Director of Nursing and/or designee will ensure competency of the Licensed Nurses (Licensed Vocational Nurses and Registered Nurses) weekly x 4 by return demonstration of head-to-to-toe assessment and visual inspection of the resident's skin. o The verification of licenses nurse's competency will be documented on the facility Skin Assessment competency form. The Director of Nursing or designee will review the pressure ulcer log weekly following wound measurements to ensure that up-on identification of a new wound the physician was notified and that the wound assessments reflect the change in condition. o The review of the pressure ulcer log will be documented on the facility Clinical Stand-up Meeting form. o For any new admissions or resident requiring daily attention on the weekend, the on-call facility nurse manager will monitor for completion of assessment and ordered treatments. The Director of Nursing or designee will monitor compliance each weekday morning. The results of the findings will be discussed in the monthly QAPI meeting for three months and the plan will be continued as needed. o The compliance monitoring will be documented on the facility's monthly QAPI form. Skilled Wound Care Physician group will provide weekly review of residents with wounds. o Skilled Wound Care Physicians will provide weekly assessment and review of the residents with wounds by conducting weekly rounds. Rounds will be documented on the SWC provider Communication Log for Daily Rounds. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing and/ or designee reviews the documentation in PCC during the morning clinical meeting. The facility will evaluate the effectiveness of this plan during the Monthly Quality Assessment and Assurance Committee Meeting attended by at least the Administrator, Director of Nursing, Medical Director and at least three other staff members and the Infection Preventionist. The facility QAPI Committee reviews facility trends including Pressure Ulcer Reports and completion of weekly skin assessments. An Ad Hoc QAPI was conducted on 4-24-2025, by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist concerning pressure ulcers and to develop the above-mentioned plan of care. We respectfully submit this action plan for the removal of Immediate Jeopardy. The Survey Team monitored the POR on 04/24/2025 through 04/25/2025 as followed: In an interview on 04/25/2025 at 1:23 pm LVN P (6-2 shift) stated she was in-serviced on skin and wound care on 4/24/2025 by the DON and the Nurse Consultant. The in-service was on wound and skin assessments and how to do assessments and notification of changes. We do weekly skin assessments on everyone in the building, on new admits, readmits and residents with change of condition. Know how to properly assess the resident. Know what to look for on a head-to-toe assessment. Know the 2 forms total body assessment do this on everyone whether they have wounds or do not have wounds. The 2nd form is what we do in iPad, and we do the wound assessment on it, and we take a picture of the wound we fill out the characteristics progress of the wound and it automatically does the measurements of the wound. Document this on a skin assessment form and it has the width length and depth for the nurse to document. The total body assessment- document skin color, temperature, moisture, condition and enter the number of wounds. I cannot recall everything on the skin assessment without looking at the form. The nurse documents the type of wound she stated LVN's could not stage a wound and would need someone else to stage such as RN or the Physician or Nurse Practitioner. If Resident has a burn put what type of degree of burn and would refer to RN or Physician for assistance if needed. Document if there was any slough if resident has staples how many does the resident have. The measurements of the wound how long the resident had the wound. Was the resident admitted with the wound. In an interview on 04/25/2025 1:48 pm LVN Q (6-2 shift) stated she was in-serviced on skin and wound care on 4/24/2025 by the Nurse Consultant and the DON did the in- service. Every time do a skin assessment do it weekly, any new admits, readmits, or change of condition. Inservice on notification of changes. I had to repeat what I learned during in-service to the DON. We have a list of who gets a skin assessment included people with wounds and without wounds every day. We must do head to toe assessment if there are some findings any bruises any skin tears pressure ulcer, we must make sure the pressure points are not red. She stated head to toe assessment was looking at the scalp, all areas of the ears, underneath both arms - arm pits, both arms, stomach area, if a female look under the breast and if a male would look under [NAME] the scrotum. I would open the buttocks area and look to determine if there was any wounds or area inside the buttocks look outside the buttocks, especially the sacral area. If have any fat rolls anywhere on the body look under the fat rolls. Would look at the thighs, both upper and lower leg extremity, look at ankles, heels, underneath the feet and in between toes. Would follow the skin assessment and document any findings of the skin assessment of the resident on the skin assessment. If find a pressure ulcer I will do skin assessment on IPAD we can take picture of the wound, I would look first photo how it looked and if needed to take another photo would take another photo. After the picture is taken on the IPAD it directs you what to do next. And you would click on options and the IPAD would measure the wound. You would point the iPad to the head of the resident and take picture and it would show you the measurements of where the wound was located. When you take a picture it gives option where it says where is the position where the head of the patient point the camera to the wound it tells where is the location of the wound and click on it and it gives you a diagram of the person it has option to rotate to get the actual site of the wound it will ask all characteristics of the wound such as is it draining, does it have an odor s/s of infection and gives the option it gives to measure but as an LVN cannot stage. I would call the doctor and get orders and tr[TRUNCATED]