**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that professional standards of practice were implemented relative to skin and wound care for one Resident (#19) of four applicable residents reviewed for wound care, out of a total sample of 26 residents. Specifically, for Resident #19, the facility failed to: -appropriately assess and implement skin care and diabetic foot care for the Resident with a history of Diabetes, Peripheral Vascular Disease and a right below knee amputation (BKA), resulting in left toe wounds not being identified and treated timely. -submit a referral to the Wound Care Provider timely for on-going wound care when diabetic wounds were identified on the toes of the Resident's left foot. -implement treatment orders for the Resident's left toe wounds timely, resulting in delayed treatment interventions when the Resident had suspected osteomyelitis, bone exposure of the left great toe, was subsequently hospitalized and administered intravenous (IV) antibiotics for confirmed osteomyelitis, and resulted in left great toe and left second toe amputations. -obtain accurate treatment orders relative to the left foot surgical sites on the Resident's re-admission from the hospital post left great and second toe amputations. -obtain treatment orders timely for open skin areas to the Resident's left shin. Findings include: The facility failed to assess and document the status of Resident #19's left foot diabetic wounds after the wounds were identified by the Podiatrist on 8/4/25. The Podiatrist recommended wound cultures, an x-ray of the ulcers to the Resident's left foot, daily dressings, antibiotic therapy and Wound Care team follow-up. From 8/5/25 until 8/20/25, there was no documented evidence of the status/condition of the Resident's left toe wounds. Resident #19 was observed with exposed bone of the left great toe by the Wound Care Provider on 8/21/25. The Wound Care Provider recommendations on 8/21/25 for treatments to the left great toe and left second toe, x-ray to evaluate bone involvement for suspicion of osteomyelitis, laboratory draws, wound cultures, surgical and/or vascular consult were not implemented as required. X-ray of the Resident's left foot completed on 8/26/25 (5 days after the Wound Care Provider recommendations) indicated suspected osteomyelitis. Resident #19 was subsequently transferred to the hospital for evaluation on 8/27/25 and treated with intravenous (IV) antibiotics for confirmed osteomyelitis (by MRI) and underwent left great toe and second toe amputations. The facility failed to implement the Podiatrist recommendation on 8/4/25 to have the Resident followed by the Wound Care Team and assess the status of the wound as required for a period of 17 days once the wound was identified on 8/4/25 resulting in the osteomyelitis and bone exposure not being identified timely due to the facility's lack of assessment and implementation of care. The facility further failed to obtain post-surgery Physician orders for NPWT (non-pressure wound therapy) as recommended in the hospital discharge summary and treatment orders for open areas on the Resident's left shin. Resident #19 was admitted to the facility in May 2023 with diagnoses including Type 2 Diabetes, acquired absence of the right leg below the knee amputation (BKA), and Peripheral Vascular Disease (PVD). Review of the Consultant Podiatrist Note, dated 8/4/25, indicated Resident #19 was examined and included the following: -presence of reddened, warm, discolored, and atrophy in the Resident's left foot. -No nails were on the left first, second and third toes, and there were signs of infection present. -Diabetic ulcers: >great left toe measuring 2.0 centimeter (cm) length by(x) 4.0 cm width x 0.2 cm depth which had presence of erythema, redness, edema, drainage and odor >left second toe measuring 2.5 cm length x 1.0 cm width x 0.2 cm depth which had presence of erythema, redness, edema, drainage and odor >third left toe measuring 1.0 cm length x 1.0 cm width x 0.1 cm depth which had presence of erythema, redness, edema -Betadine and dressings were applied to the ulcers. -findings were discussed with Resident #19 and Nurse #2. -recommended wound cultures, an x-ray of the ulcers to the Resident's left foot, daily dressings, antibiotic therapy and wound care team follow-up. Review of the Minimum Date Set (MDS) Assessment, dated 6/17/25, indicated Resident #19: -was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15 possible points -had behaviors including rejection of care 1-3 days of the 7-day reference period. -had lower range of motion impairment on one side -utilized a wheelchair and had a limb prosthesis -required partial to moderate assistance of staff with personal hygiene and dressing -had no venous or arterial ulcers or open lesions Review of the Resident's Comprehensive Care Plans included: -Potential for Skin Alteration Care Plan, initiated 5/28/23 and revised 2/9/24, that indicated the Resident had a history of fractures, Diabetes, decreased mobility, PVD and included the following interventions: >follow Physician orders for skin care and treatments (utilize best practice), revised 6/21/25 >inspect feet daily with care and moisturize, dated 2/9/24 -Diabetes Care Plan, initiated 6/11/23, included the following interventions: >Check all of body for breaks in skin and treat promptly as ordered by the doctor, initiated 6/11/23 >refer to the podiatrist/foot care nurse to monitor and document foot care needs ., initiated 6/11/23 >wash feet daily with mild soap and water. Dry thoroughly. May use a light dusting of power or lotion. Do not apply lotion or powder between the toes, initiated 6/11/23 >Monitor/document/report, as needed, any signs/symptoms of infection to any open areas: redness, pain, heat, swelling or pus formation, initiated 6/11/23 Review of the Weekly Skin Evaluations from July 2025 through 9/5/25, indicated: -no evidence of weekly skin checks from 7/6/25 through 7/12/25 -no evidence of weekly skin checks from 7/20/25 through 7/26/25 -Weekly Skin Evaluation, dated 7/28/25, indicated the Resident's skin was intact. -Weekly Skin Evaluation, signed on 8/8/25 by Director of Nursing (DON) #2, indicated: -the Resident's skin was not intact. -the left great toe and left second toe had cellulitis. -an X-ray was completed to rule out osteomyelitis and was negative for fracture/dislocation and osteomyelitis. -Under the section indicating to document the measurements of all new areas, DON #2 who completed the assessment indicated toe nails. -The Weekly Skin Evaluation completed by DON #2 failed to indicate measurements or descriptions of the areas noted on the assessment. Review of thePhysician's orders from July 2025 through 9/5/25, included the following: -Wound Consult as indicated, initiated 5/27/23 -Consults: Podiatry ., initiated 6/5/23 -Diabetic foot care: wash foot with gentle soap and water, dry well. Monitor for any abnormalities, daily in the evening, initiated 6/8/23 -Behavior monitoring every shift . which included type of behavior, intervention and outcome, initiated 3/11/25 Review of the Wound Care Specialist Note, dated 8/21/25 (17 days after the initial identification of the wounds and recommendation made by the Podiatrist on 8/4/25 for wound care follow-up), indicated: -left great toe and second toe first evaluation. -Resident's lower extremity sensation was reduced. -Left great toe: >diabetic, measuring 1.0 cm by (x) 1.5 cm x 0.1 cm [wound]. >wound base had hypergranulation (excessive growth of granulation tissue, a symptom of a dysfunctional wound environment). >bone was exposed, peri-wound was callous, and there was small amount of serous drainage. -Left second toe: >diabetic, measuring 1.0 cm x 1.0 cm x 0.1 cm [wound]. >hypergranulation was present. >peri-wound was normal, there was small amount of serous drainage. -the Wound Specialist recommended the following: >cleanse left great toe and left second toe with 0.125% (1/4 strength) Dakin's solution, apply Calcium Alginate to the base of the wound, secure with ABD pad, rolled gauze and change daily and as needed, to treat the hypergranular tissue. >X-ray to evaluate bone involvement. Osteo [sic] is suspected. >update lab work: Complete Blood Count (CBC), Complete Blood Profile (CBP), Erythrocyte Sedimentation Rate (ERP: measures inflammation levels in the body and helps diagnose various inflammatory conditions) and C-Reactive Protein (CRP: measures inflammation in the body and helping to diagnose various conditions). >collect wound cultures and tailor to the results >surgical and/or vascular consult. Patient will likely warrant toe amputations. >no shoe to the left foot. Review of Resident #19's Clinical Record indicated the following: -8/5/25 at 4:27 P.M.: Nurse Progress Note by Nurse #2, indicated Doxycycline (antibiotic) 100 milligrams (mg) twice daily was ordered for ten days for the Resident's infected foot and an x-ray was ordered for a question of osteomyelitis. New dressing orders were obtained. -8/6/25: X-ray of the Resident's left foot was completed and failed to indicate fracture or bony changes to indicate osteomyelitis. -August 2025 MAR indicated Doxycycline 100 mg twice daily, was initiated on 8/5/25 and completed 8/15/25. -August 2025 TAR indicated: >no documented refusals of care or other behaviors by the Resident from 8/5/25 through 8/31/25. -no documented evidence that the Wound Care Specialist recommendations from 8/21/25 for wound treatment to the Resident's left great toe and left second toe were implemented. -Non-Pressure Ulcer Evaluations, dated 8/22/25 which indicated: >Diabetic area to the Resident's left great toe that was: facility acquired, had an onset date of 8/5/25, and required weekly evaluation. The left great toe area measured 1.0 cm in length x 1.0 cm in width x 0.1 cm in depth. >Diabetic ulcer to the Resident's left second toe that was: facility acquired, had an onset date of 8/5/25 and required weekly evaluation. The left second toe area measured 1.0 cm in length x 1.5 cm in width x 0.1 cm in depth. -8/25/25: Nurse Practitioner (NP) Note (dated four days after the Wound Care Specialist Evaluation Note), indicated the Resident was evaluated for new left toe ulcers. Left great toe had bone exposure. Wound care ordered labs, wound cultures and X-ray, but this was not transcribed (not completed). Case was discussed with nursing and re-ordered CBC, Complete Metabolic Panel (CMP), CRP and ESR, X-ray of the left foot and wound cultures. Will refer to the vascular surgeon for evaluation. -8/26/25: X-ray of the Resident's left foot, completed and reported, indicated findings suggest osteomyelitis, recommend MRI. -no documented evidence that lab work and cultures were obtained on 8/21/25 (Wound Care Specialist) and 8/25/25 (NP) as ordered. -The Clinical Record failed to indicate documented evidence of the status/condition of the Resident's left toe wounds from 8/5/25 until 8/20/25. -8/27/25: Discharge/Transfer Evaluation indicated Resident #19 was sent to the emergency room for question of osteomyelitis to the left foot wound. -8/29/25: Social Worker (SW) Progress Note indicated the SW received a call from Resident #19's Representative who reported the hospital informed him/her that the Resident was having his/her first and second toes removed and was currently receiving IV antibiotics. -9/1/25: Nursing Evaluation which indicated under Skin Integrity: left first and second toes removed. Skin tear to left lower leg . -September 2025 Physician's Orders included the following: >Left first and second toe: cleanse with Normal Saline, blot dry, apply Baza AF to periwound, apply 1/4 Dakins soaked gauze to wound bed. Cover with double layer Xeroform, cover with ABD with rolled gauze and tape. Change BID and as needed (PRN), every day and evening shift for wound care, ordered 9/1/25. >Calcium Alginate to the toes on the left foot. Place in-between toes and on tope place ABD on wrap with kling. Clean the wound with saline daily and as needed, ordered 8/6/25. -The September 2025 Physician's orders failed to indicate post-surgery orders for the NPWT and treatment orders for the open areas on the Resident's left shin. Review of the Hospital Discharge summary, dated [DATE], indicated the following relative to Resident #19: -admitted to the hospital for worsening left foot infection involving the first and second toes ongoing for two weeks. -Lab work improved with IV fluids. -Physical exam revealed two 1 x 2 cm wounds on the Resident's left shin and a 1 cm wound on the first and second toes (of left foot) with surrounding erythema and edema. -Doralis pedis pulse was intact. -X-ray showed destructive changes to the distal phalanx of the left hallux (bony bump at the base of the great toe). -MRI confirmed acute osteomyelitis of the first distal/proximal phalanges and second distal/middle phalanges with marrow edema and osseous destruction. -Resident was started on IV Zosyn and Vancomycin (antibiotics). -Underwent surgical amputation of left first and second toes without complication. -Resident was safe for discharge, will continue with antibiotics regimen for a total of 14 days upon discharge, and follow-up with wound care clinic in two weeks. -Wound Care Instructions upon discharge: >left first and second toe amputation site: cleanse with normal saline, pat dry. Apply Adaptec over exposed bone. Apply granufoam to area, cover with drape. Apply ACE wrap for circulatory support. Non-Pressure Wound Therapy (NPWT also referred to as a wound vac) set at 125 mmHg (millimeters of Mercury: pressure measurement), continuous, to be changed Monday/Wednesday/Fridays. If dressing becomes dislodged or NPWT fails for more than two hours, remove the dressing and perform the following: Apply saline soaked gauze to wound bed, cover with Xeroform, gauze, ABD, secure with Kling. Change every eight (8) hours until NPWT can be resumed. >Please do the following dressing twice daily to the left first and second toe amputation sites until the NPWT system arrives: Cleanse with normal saline, blot dry. Baza AF to the periwound. Apply a gauze that is moistened with quarter -strength (1/4) Dakin's solution to the wound. Cover with double layer Xeroform or Vaseline gauze cut to fit. Cover with ABD and secure with rolled gauze and tape. Please avoid tight wraps. On 9/3/25 at 10:16 A.M., the surveyor observed: -Resident #19 was dressed in shorts and seated in a wheelchair in the hallway and wearing a right leg prosthetic. -the Resident's left leg had a large irregularly shaped reddened area on the front left shin and a square, undated bandage in the middle of the Resident's left shin. A yellow scab was observed below the bandage. -the Resident's left foot was wrapped in Kling wrap, that was undated, and he/she was wearing a surgical shoe. During an interview at the time, Resident #19 said he/she had just returned from the hospital where the toes on his/her left foot were amputated. On 9/4/25 at 8:38 A.M., the surveyor observed the following: -Resident #19 was up, dressed in shorts and seated in a wheelchair in the hallway. -An undated wrap was observed on the Resident's left foot, and he/she was wearing a surgical shoe. -The left shin was deep red in color, there were no bandages on the left leg, and a round dime sized open area was observed on the middle front of the left shin. A clear colored fluid was observed from the red colored wound bed. During an interview at the time, Resident #19 said he/she never had pain in his/her left leg and was not aware of any treatment to the shin area. Resident #19 said that the Nurse was supposed to change his/her dressing to the left foot twice daily, but it was only changed once since he/she had been re-admitted to the facility.The surveyor observed Resident #19 touching the fluid located in the exposed open area on the left shin with his/her fingers during the interview. Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) from July 2025 through 8/4/25 indicated: -7/13/25: one episode of screaming/cursing -7/17/25: one episode of refusal of care -No other documented behaviors. -Diabetic foot care was administered daily from 7/1/25 through 7/31/25. -No behaviors or refusals of care were documented for 8/1/25 through 8/4/25. -Diabetic foot care was administered daily from 8/1/25 through 8/5/25. Review of the September 2025 TAR indicated both treatments to the Resident's left toes (dated 8/6/25 and 9/1/25) were documented (indicated with a check mark) as administered to Resident #19 from 9/2/25 through 9/4/25. Further review of the September 2025 TAR indicated: -the treatment started on 9/1/25, was ordered twice daily -9/2/25: checked off as administered twice -9/3/25 and 9/4/25: checked off as administered once On 9/5/25 at 7:26 A.M., the surveyor observed the following: -Resident #19 was lying in bed on his/her right side. -black surgical shoe was on the bed (not on the Resident's foot). -the Resident's left foot was bare, and Kling wrap was observed around his/her left ankle. -the Resident's left foot was laying on the bed, the first and second toes on the Resident's left foot were absent and the first and second toe amputated areas on the top of the foot were open, red and exposed. -the left lower front leg was red in color and had a dime sized circular area that was not covered. During an interview at the time, Resident #19 said he/she very upset because the Nurse who worked the previous night had completed the dressing to his/her left foot late and the wound dressing was incorrectly done. On 9/5/25 at 9:00 A.M., the surveyor reviewed the Resident's Clinical Record with the Assistant Director of Nurses (ADON), Administrator, and Director of Nursing (DON). During an interview at the time, the ADON said the following: -there were two treatment orders for the Resident's left foot dated 8/6/25 and 9/1/25 that were both supposed to be in place. The ADON said the treatment order dated 8/6/25 was the treatment prior to the Resident's hospitalization, and the treatment dated 9/1/25 was the ordered treatment after the Resident's surgical amputation. -the documentation in the September 2025 TAR indicated both treatments were being administered by the Nurses. -the Hospital Discharge Summary indicated a NPWT was ordered and there had been no NPWT utilized for Resident #19's wound since he/she was re-admitted to the facility. -the orders for the Resident's wound care outlined in the Hospital Discharge Summary should be reviewed with the Provider upon re-admission. The Administrator said the facility had utilized NPWT previously and had the equipment available previously in the facility. During an interview on 9/5/25 at 10:09 A.M., the NP said the following: -Resident #19 had a history of left lower leg cellulitis which required treatment with multiple antibiotics. -The NP could not recall being notified of any concerns about Resident #19's toes prior to being contacted by the Wound Care Provider, who at the time of notification had requested an x-ray of the Resident's left foot, lab work and cultures to be completed which were ordered. -The NP returned to the facility the following week and the x-ray of the Resident's left foot, lab work and cultures of the wound had not been completed, so she reordered them to be completed. It was her expectation that when the Wound Care Provider made recommendations, those recommendations would be ordered/completed on the same day. -The results from the x-ray of the Resident's left foot completed on 8/26/25, suggested possible osteomyelitis and recommended an MRI, so the Resident was transferred out to the hospital for evaluation. -If there were any concerns about the Resident's skin or if an area on the Resident's skin was worsening, the NP would expect the facility to notify her. -The NP was not made aware of any areas on the Resident's left lower extremities since he/she was re-admitted back to the facility. During an interview on 9/5/25 at 10:38 A.M., the Wound Care Provider said the following: -She conducted wound rounds for residents in the facility weekly on Thursdays with the ADON. -The facility staff would provide a list of residents with wounds for her to evaluate. -She was not made aware of Resident #19's left foot wounds until 8/21/25. -When she evaluated the Resident on 8/21/25, she had concerns for osteomyelitis due to the bone exposure and hypergranulation that was observed. At that time, she ordered an x-ray, lab work and wound cultures to be completed. During interviews on 9/5/25 at 9:00 A.M., 11:30 A.M., and 12:59 P.M., the DON said the following: -all residents should have weekly skin checks completed and if they were not completed, there should be documentation in the clinical record as to why the skin assessment was not done. -Resident #19 was at increased risk of skin issues because of his/her diagnoses of Diabetes, PVD and history of non-compliance, so it was important to complete the weekly skin evaluations. -The DON was unable to find evidence that lab work and wound cultures were completed for Resident #19. -The DON reviewed the Resident's clinical record, saw the two treatment orders which were in place and still active for the Resident's left foot wounds and said that the treatment ordered for 8/6/25 was not an appropriate order and should have been discontinued. -there were no current policies relative to non-pressure areas for the facility and that the Nurses would refer to professional standards for wound care. -If a resident was identified with a skin issue/area, the Wound Care Provider would be notified so they would be monitored during weekly wound rounds with the ADON. During those wound rounds, measurement of the wounds would be obtained. -In addition to the weekly wound rounds, the Nurses should be completing the treatments as ordered by the Provider and be notifying the Provider if there were any changes. The Nurses should also be completing a weekly Non-Pressure Ulcer Evaluation for Resident #19 since the wounds were identified on 8/4/25. The DON reviewed the Resident's clinical record, and found this evaluation was not completed until 8/22/25. During a follow-up interview on 9/5/25 at 1:47 P.M., the DON said it appears that the Podiatrist identified the Resident's left toe wounds on 8/4/25. The DON said when a resident was admitted , a skin check would be completed and if a skin area/wound was identified, it would be documented, Physicians orders for treatment of the area would be obtained and then the wound would be monitored/assessed weekly by the facility Nurses and weekly by the Wound Care Specialist and ADON. The DON said admission orders would be reviewed with the Provider, and if the Provider did not agree to the orders as indicated on a Hospital Discharge Summary, the Nurse would document this in a progress note. The DON said relative to Resident #19, there was no documentation indicating that the Provider did not want to follow the Wound Care Instructions for the NPWT, and that the treatment order on re-admission (dated 9/1/25) should have indicated the order for NPWT when the equipment was available in the facility. During an interview on 9/05/25 at 3:26 P.M., Nurse #2 said Resident #19 had been requesting to be seen by the Podiatrist, so she made sure he/she was put on the list to be seen. Nurse #2 said when the Podiatrist assessed the Resident on 8/4/25, the Podiatrist notified Nurse #2 of the status of the Resident's left great first and second toes and asked her to assess the toes with him. Nurse #2 said the Resident's nails on the left great toe was off, the area was open, red and draining fluid and that the left second toe also had the nail coming off, was open, red and draining fluid.Nurse #2 said she was not aware of any issues with the Resident's feet prior to when the Podiatrist alerted her. Nurse #2 said the Resident did refuse care at times and would not allow anyone to touch his/her feet. Nurse #2 said the Resident has orders for diabetic foot care to be performed every night which includes washing and assessing his/her feet if receptive. Nurse #2 said if the Resident was not receptive to diabetic foot care, it would be documented that the Resident refused. Nurse #2 said she notified the NP about the Podiatrist's concerns of the Resident's left toes and showed the NP the photo that was taken of the Resident's wound areas, and the NP ordered an antibiotic and wound treatments. Nurse #2 said the Resident was receptive to the wound care treatments that were ordered and had not refused them.Nurse #2 said she thought the Resident's left foot wounds were improving and did not observe any bone exposure when completing the dressing changes (to the left toes) prior to the Resident's transfer to the hospital. Nurse #2 further said she observed necrotic areas on the Resident's toes prior to his/her hospitalization but thought the Wound Care Provider would have taken care of those necrotic areas. Please refer to F726.