**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, hospital record review, Total Parenteral Nutrition (TPN) Team documentation and interview, the facility failed to develop and implement an effective discharge plan for Resident #30 to ensure total parental nutrition (TPN), a specialized formula given through the vein which provides most of the nutrients the body needs was ordered/provided and a home health infusion nurse was arranged for home care following the resident's discharge home from the facility on 01/19/23. Actual Harm occurred on 01/22/23 when Resident #30 presented to the emergency room with signs of hypovolemic shock (volume depletion) after the facility failed to arrange for home going TPN including the coordination of pharmacy services and a home health infusion nurse at the time of discharge from the facility. Upon discharge, the facility provided enough TPN to administer through 01/21/23 in the A.M. Resident #30 was hospitalized from [DATE] through 02/01/23. This affected one (Resident #30) of three residents reviewed for discharge/transfer. The facility census was 29. Findings include: Review of the closed medical record for Resident #30 revealed an admission date of 12/23/22 post hospitalization for malnutrition. Diagnoses included severe protein malnutrition, disorder of protein plasma metabolism, nutritional anemia, Crohn's disease (chronic inflammatory bowel disease), gastroesophageal reflux disease without esophagitis, generalized anxiety, major depressive disorder, ileostomy (small intestine is diverted through an opening in the abdomen) and fistula of the intestines. The resident was admitted with TPN orders and treatment. The current TPN order details dated 12/24/22 revealed TPN was to be on (infuse) for 12 hours and be off 12 hours. On Monday, Wednesday and Friday Resident #30 received lipid TPN (provides essential fatty acids) at the same rate. Review of the admission Minimum Data Set (MDS) 3.0 assessment for Resident #30, dated 12/30/22, revealed intact cognition. Resident #30 required extensive assist of two for bed mobility, transfer, and extensive assist of one for walking in room. Resident #30 weighed 117 pounds with an unknown weight loss or gain. Resident #30 received parental intravenous (IV) therapy with 51 percent or more of daily calories being received through IV. Review of a service note dated 01/12/23 timed 4:26 P.M. revealed Resident #30 plans regarding home health care were to include transportation and home delivery of TPN and other supplies necessary for returning home safely. Date proposed by Resident #30 was 01/18/23. The note indicated the discharge plan of care evaluation was initiated. Review of a nurse note dated 01/17/23 and timed 1:58 P.M. revealed TPN and ostomy self-care at home was reviewed. Resident #30 verbalized step by step the process of each without any errors in steps. Resident #30 verbalized that she would be returning home with home health services. The note indicated pharmacy was called for written TPN orders and extra TPN. Pharmacy representative stated there would be extra TPN in the tote delivered that night. The note indicated no other concerns at that time. Review of notes provided by the nutritional support team of Cleveland Clinic revealed on 01/17/23 at 3:03 PM., Dietitian #43 was notified by Registered Nurse (RN) #44 the patient (Resident #30) completed teaching and signed a patient agreement. Patient wanted to discharge 01/18/23 from the skilled facility. The noted indicated no information received regarding plans for home infusion pharmacy and home care and no records received from facility. Call made to the facility where patient resided and spoke with case manager (Social Services [SS] #42). The notes further indicated SS #42 had never completed a TPN discharge and was unsure of process. Patient had not been set up with a home infusion pharmacy, but SS #42 was working on setting up home care. Discussed patient first needed to be accepted by a home infusion pharmacy, benefits run, and out-of-pocket cost determined. Examples of home infusion pharmacies in town with contact information were provided. The notes indicated once the patient had been accepted by home infusion pharmacy they should be updated. A request for clinical notes, most recent TPN formula and most recent labs be sent to the clinic to review. Once those were reviewed and patient accepted by a home health care agency and home infusion pharmacy, the nutritional support team would send an order to start home parental nutrition at discharge. Recommendation indicated awaiting documentation from skilled facility including clinic notes labs and TPN formula. Awaiting confirmation, patient accepted by home infusion pharmacy and home care nursing. Review of a 01/17/23 fax sent at 5:53 P.M. to Doctor #41, at the All TPN Team, reflected a 12/22/22 Parenteral Nutrition Progress Note from the Nutritional Support Team included Resident #30 planned to discharge 12/23/22 to a skilled facility. After discharge from skilled facility Doctor #41 would take over TPN management at the home. Review of a note from the Digestive clinic authored by Dietitian #40 dated 01/18/23 and timed 10:22 A.M. revealed receipt of skilled facility information including labs, notes from inpatient stay, and partial formula. Return call to skilled facility to obtain the remaining vital information prior to resuming parenteral nutrition orders. A detailed message was left with SS #42 requesting full TPN formula that included volume and hours to be infused as well as which pharmacy and health home care would be servicing, to be faxed as soon as possible. Awaiting remaining information prior to sending orders. Review of a nurse note dated 01/18/23 timed 12:46 P.M. revealed the author spoke with the provider regarding upcoming discharge orders. Provider approved the release of all pain medications to Resident #30 from the facility at the time of discharge. The prescription for pain medications would need to be acquired from the provider of the resident's choice upon discharge. Education was provided to the resident. Resident verbalized understanding. Review of a fax dated 01/18/23 timed 6:23 P.M. to the All TPN Team revealed the fax included the current TPN formula and titration rate. Review of a note from the Home Nutritional Support Service dated 01/19/23 timed 10:05 A.M. revealed the TPN formula received via email continuing same volume as inpatient. Updated to database for reference. The noted indicated still no update from skilled facility on accepting home health care and infusion pharmacy despite home nutritional support request times three. Call to social worker at skilled facility sent to voicemail. Again, left detailed voice message, requesting a call back to confirm pharmacy, home health care and date of discharge. Recommendation indicated awaiting information to send parental nutrition and standing orders. Review of nurse note dated 01/19/23 timed 12:23 P.M. revealed Resident #30 was scheduled for discharge today. TPN would remain running for the scheduled time until completion and/or discharge time; which ever came first. The note indicated would be discharging with TPN and TPN supplies. Resident was tolerating TPN well. Review of a nurse note dated 01/19/23 timed 3:40 P.M. revealed Resident #30 was discharged at 2:00 P.M. Resident #30 took TPN, pump, and medications including narcotics. Medication education was provided and resident confirmed she understood what medications were for and how to properly administer them. Resident #30 left with her sister and no assistive device was used. Review of the Post Discharge Plan of Care/Recapitulation of Stay Plan and Summary initiated 01/17/23 revealed no home health at this time. Doctor aware and agreed for safe discharge to home as resident was with TPN, wound and ostomy care prior to this stay and felt she was safe without home health. Resident #30 supplied with information for ordering future TPN and ostomy/wound supplies from ostomy specialist appointment. The note included Resident #30 reported she would independently order her supplies. All on hand supplies for ostomy, wounds and TPN would be sent home with Resident #30. Other services post discharge to be determined with primary care provider. Pharmacy preference Cleveland Clinic. Resident would complete TPN infusions as ordered following correct steps. Resident would maintain at an acceptable level of pain. Resident #30 would maintain ostomy/fistula care without adverse effects. Nutritional needs included regular diet, regular texture and thin consistency and needed parenteral/IV feeding. TPN orders printed and given to Resident #30 at discharge. TPN formulary orders faxed to the Cleveland Clinic pharmacy. Review of a note authored by Dietitian #40 dated 01/20/23 timed 1:05 P.M. revealed no return call from skilled facility. Called again to confirm date of discharge, pharmacy, and home health care. Social worker not in today. Administrator stated Resident #30 already discharged . Transferred call to Director of Nursing. No answer. Left detailed message requesting update and plan of care from discharge as soon as possible as their team had not yet sent orders. Review of a note authored by Dietician #41 dated 01/20/23 timed 4:32 P.M. revealed patient return call. Resident #30 said she left the skilled nursing facility yesterday, 01/19/22. Skilled facility sent her with two TPN bags for the weekend as well as flushes. Resident #30 said she did not have a pharmacy or home health care set up and would need TPN after the weekend. Recommendation indicated would need to follow up Monday if skilled facility returned call with information, otherwise would likely need to send patient to emergency room to have TPN arrangements set up. Review of a nurse note dated 01/21/23 at 4:38 P.M. revealed the nurse called the facility pharmacy regarding Resident #30's TPN. The nurse was informed the pharmacy filled Resident #30's order on the 17th and next refill would have been the 20th but Resident #30 was already discharged by that date. Review of a nurse note dated 01/22/23 at 8:33 A.M. revealed on 01/17/23 the pharmacy sent a total of three bags of TPN: one bag of non-lipid TPN that was to be infused Thursday (01/19/23) and two bags of Lipid containing TPN for Wednesday (01/18/23) and Friday (01/20/23). According to the nurse's note related to the pharmacy call, Resident #30 had enough TPN to last through Friday (01/20/23). If she infused the TPN at night she would have finished what she took home with her Saturday morning (01/21/23) which would be consistent with Resident #30 calling the facility Saturday asking if there were more bags of TPN there for her. Review of note authored by Dietician #45 dated 01/23/23 timed 9:23 A.M. revealed Resident #30 was admitted to the hospital from the emergency room yesterday (01/22/23). Recommendation indicated awaiting hospital discharge and home health care agencies to be arranged for a safe discharge. Review of the hospital Discharge summary dated [DATE] revealed Resident #30 presented to the emergency room with signs of hypovolemic shock. Resident #30 presented with dizziness hypertension, tachycardia, acute kidney injury. History was most consistent with hypokalemia (low potassium) from not getting TPN and fluids following discharge from skilled facility. Resident #30 also had shortness of breath for several months which could be the result of weakness and deconditioning tear. Also has a history of Crohn's disease and TPN dependent, having multiple abdominal surgeries, multiple fistulas, and chronic abdominal pain. Elevated, alkaline phosphates, and liver function test, acute kidney injury pre-renal poor intake and hypotension, hyponatremia, hypovolemia due to poor oral intake and absence of TPN the last few days. The resident was also assessed to have a deep vein thrombosis (DVT) in upper extremity. Interview 02/17/23 at 10:24 A.M. with All TPN Team Dietician #40 from the Cleveland Digestive Clinic revealed Resident #30 was discharged from the skilled facility without a plan and was re-hospitalized three days after she was discharged with lightheadedness, generalized weakness, hypovolemic shock, and tachycardia. Dietician #40 included the clinic repeatedly reached out to the facility, left voicemails and verbal directions of the clinic needing current TPN orders, laboratory test and what home health agency and pharmacy Resident #30 was going to use. Dietician #40 revealed she called SS #42 leaving a voicemail without a return call. The initial fax she received from the skilled facility had partial information. The second fax contained the TPN order. However, the clinic was not informed of what pharmacy to send the TPN to and what home health agency Resident #30 would be using for an infusion nurse. Dietician #41 included Resident #30 had been on TPN for two years but was new to the Digestive Clinic as of December of 2022 due to moving to Ohio. Interview 02/17/23 at 1:49 P.M. with SS #42 revealed this was her first social services position and she was new to the job. SS #42 had never set up home health and stated she called every facility in the rolodex. It did not occur to SS #42 to call the Digestive clinic to inquire about providers with an infusion nurse. Follow up interview 02/17/23 at 2:38 P.M. with SS #42 revealed Resident #30 had a goal to go home before her birthday. The facility staff did not feel she was ready to go home. SS #42 attempted to find home health for Resident #30 but was unable to find a home health nurse for TPN and she told Resident #30 this. The Cleveland Clinic SS #42 and she had several discussions. On 01/18/23 SS #42 spoke to Dietician #40 from the TPN team at the Cleveland Clinic about setting up the pharmacy for the resident's TPN. They decided on a provider. Dietician #40 asked for TPN formulary, recent labs, and clinical notes. SS #42 faxed the TPN formula, labs, and progress notes. SS #42 did not hear back from them that night and was off sick the next two days. SS #42 sent a fax earlier and Dietician #40 called indicating it was not complete and SS #42 sent a second fax on 01/18/23 at 6:18 P.M. When SS #42 returned to work on Monday (01/23/23) she had a message from someone else from the TPN team indicating they thought Resident #30 was discharged and they needed to know what pharmacy she chose. SS #42 called them Monday (01/23/23) and left multiple messages. Someone called back and said Resident #30 had gone back to the Cleveland Clinic (hospital). SS #42 explained to them she thought they were connected to the pharmacy and that they would call and make the needed arrangements with the pharmacy. SS #42 said she was not told she needed to find a home infusion nurse; Resident #30 told SS #42 she had a home infusion nurse. When SS #42 told Resident #30 she could not find a home infusion nurse she was very upset and wanted to go home. SS #42 did not speak to a doctor regarding the TPN and discharge. SS #42 did not call the TPN team to tell them she could not find a home health infusionist or a pharmacy to provide the TPN. Interview 02/17/23 at 5:20 P.M. with the administrator revealed he did not know if he received a call regarding Resident #30. Interview 02/17/23 at 5:26 P.M. with the Director of Nursing (DON) revealed she did not have a message on her phone from the Digestive Clinic. The DON said the day Resident #30 went home her TPN was started at the facility at 9:00 A.M. and ran until she left at 2:00 P.M. The DON indicated Resident #30 infused the TPN 12 hours at night when home. Resident #30 called the facility on 01/21/23 asking if there were any more bags of TPN at the facility for her. The DON referred to the 01/22/23 nurse note timed 8:33 A.M. indicating on 01/17/23 the pharmacy sent a total of three bags of TPN. One bag of non-lipid TPN that was to be infused that Thursday (01/19/23) and two bags of Lipid containing TPN for that Wednesday (01/18/23) and Friday (01/20/23). The DON verified Resident #30 was readmitted to the hospital when she did not have any TPN to infuse at home. This deficiency represents non-compliance investigated under Complaint Number OH00139912.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure residents received adequate, necessary and timely care and treatment to meet their total care needs. The facility failed to ensure antibiotics and x-rays were completed as ordered for Resident #16, failed to ensure monthly weights were completed for Resident #1, and failed to ensure physician orders were in place for blood glucose monitoring of Resident #84. Actual Harm occurred on 12/08/22 when Resident #16, who was cognitively impaired and required staff assistance for activities of daily living was admitted to the hospital with a diagnosis of sepsis (blood infection) related to a wound to the left heel. Physician's orders for the antibiotic, Doxycycline and imaging to rule out osteomyelitis were not completed as ordered contributing to the hospitalization. This affected one resident (#16) of one resident reviewed for wounds and two residents (#1 and #84) of 14 sampled residents. The facility identified one resident as having wounds, Resident #16. The facility census was 34. Findings include: 1. Review of Resident #16's medical records revealed an admission date of 09/16/22 with diagnoses including non pressure chronic ulcer of right foot, peripheral vascular disease (PVD) and diabetes. Record review revealed Resident #16 was admitted with two unstageable pressure ulcers (areas were not identified). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/25/22 revealed Resident #16 had impaired cognition, required extensive assistance with bed mobility, transfers, toileting and personal hygiene, and was incontinent of bowel and bladder. Review of the care plan dated 10/25/22 revealed Resident #16 was at risk for skin impairment related to decreased mobility and muscle weakness. Interventions included weekly head to toe skin assessments and observe wound dressing frequently to ensure intact. Review of physician's orders from 09/19/22 through 10/17/22 revealed Resident #16 was ordered the antibiotic, Doxycycline 100 milligrams (mg) twice a day for 28 days for wound infection. Review of Resident #16's physician orders for November 2022 revealed an order to cleanse left heel with normal saline, pack with Dakins (antiseptic) soaked gauze, cover with absorbent dressing and wrap with Kerlix daily and as needed, and paint right heel with Betadine (antiseptic) and apply absorbent dressing every Monday, Wednesday and Friday. Review of a skin and wound assessment for Resident #16 dated 11/18/22 revealed the wound nurse practitioner suspected osteomyelitis (bone infection) and a new order to consult with the house physician to obtain imaging was given. Review of the wound care progress note/wound evaluation for Resident #16 dated 11/18/22 revealed an order for calcium alginate with silver (antimicrobial wound dressing to prevent infection) to the right heel, cover with an absorbent dressing and gauze daily and as needed. The left heel wound was ordered to be packed with Dakins soaked gauze, cover with an absorbent dressing and wrap with gauze daily and as needed. Review of Resident #16's progress note dated 11/18/22 authored by the Assistant Director of Nursing (ADON) revealed the wound nurse practitioner suspected osteomyelitis and to consult with house physician to obtain imaging. Review of the wound care progress note/wound evaluation authored by the wound nurse practitioner, for Resident #16, dated 11/23/22 revealed to continue with calcium alginate to right heel, cover with absorbent dressing and gauze daily and as needed. Left heel wound was to be packed with Dakins soaked gauze twice daily. The evaluation indicated the wound had an odor and thick drainage. Doxycycline (an antibiotic) 100 mg was recommended. The note indicated to notify the house physician of recommendations for antibiotic therapy. Review of the physician's orders revealed no order for Doxycycline on 11/23/22. Review of the wound care progress note/wound evaluation for Resident #16, dated 11/30/22 revealed to discontinue the calcium alginate to right heel and begin packing the wound with Dakins soaked gauze twice daily. Wound was noted to be odorous. Left heel wound continued to be packed with Dakins soaked gauze twice daily. The note stated to extend the Doxycycline 100 mg for an additional 10 days, and might require diagnostic imaging at the discretion of the house physician due to the high risk of osteomyelitis. The note indicated nursing to notify the house physician. Review of physician's orders revealed no orders for imaging on 11/30/22. However, review of Resident #16's progress note, dated 11/30/22 revealed an order was placed with an x-ray company and a confirmation number and contact person at the x-ray company were listed. Further review of Resident #16's physician orders revealed an order for Doxycycline 100 mg on 12/01/22 through 12/10/22 twice a day for infection. Interview on 12/05/22 at 2:45 P.M. with the Director of Nursing (DON) revealed Resident #16's orders did not contain an order for an imaging. The DON stated she would need to check the resident's chart to see if an x-ray had been performed. Review of Resident #16's physician's orders revealed following the interview with the DON, on 12/06/22 an order was obtained for an x-ray of bilateral feet. Review of Resident #16's progress note, dated 12/06/22 revealed the facility contacted the x-ray company and was informed the company did not have an x-ray tech available and would send one on 12/07/22. Interview on 12/06/22 at 9:33 A.M. with Licensed Practical Nurse (LPN) #446 revealed she was asked by the DON to place orders for an x-ray for Resident #16. LPN #446 stated she worked for an agency and was not aware of the situation regarding Resident #16's wounds/x-rays. Interview on 12/06/22 at 9:38 A.M. with the DON revealed the DON was unable to locate an order for the x-ray and the DON asked LPN #446 to place orders for the x-ray to be completed. The DON further stated there was no physician order in place for the antibiotic until she entered the order on 12/01/22. Interview on 12/06/22 at 12:08 P.M. with the Assistant Director of Nursing (ADON) revealed the ADON received verbal orders for Resident #16 on 11/18/22 to obtain imaging and consult with the house physician. The ADON was unable to state why the orders were not completed or in the computer system. Observation of wound care on 12/07/22 at 10:55 A.M. for Resident #16 with the DON and LPN #433 revealed wounds to the resident's bilateral heels had a strong odor and thick yellowish drainage coming from the wounds. Interview on 12/07/22 at 11:22 A.M. with the DON revealed she received the wound progress notes and evaluations weekly and stated she must have missed the recommended orders for the x-ray and the antibiotics. The DON confirmed the recommended antibiotics were ordered on 12/01/22 and the x-ray would be completed on 12/07/22. Review of the progress note, dated 12/07/22 revealed the x-ray results showed Resident #16 had osteomyelitis of the left heel. The note indicated the nurse practitioner was notified and Resident #16 was to be transported to the hospital. Review of the progress note dated 12/08/22 revealed Resident #16 was admitted to the hospital with sepsis (blood infection). 2. Review of the medical record for Resident #1 revealed an admission date of 03/05/19 with diagnoses including Alzheimer's disease, dementia, acute kidney failure and moderate protein-calorie malnutrition. Review of the MDS quarterly assessment dated [DATE] revealed Resident #1 had severe cognitive impairment and required supervision with set up for eating and limited assistance of one staff for walking in his room and on the unit. Further review of Resident #1's medical record revealed the last recorded weight was on 09/23/22 and no weight refusals were documented in the nursing progress notes or under the monthly weight task listed in the task bar. Review of Resident #1's current physician orders for December 2022 did not reveal an order for monthly weights. Review of the nutrition assessment completed by Registered Dietitian (RD) #444 on 12/05/22 revealed no new weights since 09/23/22 to review and weights were usually stable. Interview on 12/12/22 at 9:30 A.M. with Registered Dietitian (RD) #444 revealed residents should be weighed monthly and if a resident refused to be weighed it should be documented in the medical record. Interview on 12/12/22 at 10:15 A.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed Resident #1 had not been weighed between 09/23/22 and 12/06/22. Review of the 07/14/21 revised facility policy titled, Weight Management revealed weekly weights would be completed by the 10 th of each month and documented in the medical record. The Dietary Manager and/or Registered Dietitian would communicate weight changes to the interdisciplinary team, attending physician and resident responsible party and be documented in the medical record. 3. Record review of Resident #84 revealed he was admitted to the facility 11/19/22 and had diagnoses including cognitive communication deficit, hyperkalemia, and type 2 diabetes. Review of Resident #84's hospital discharge instructions dated 11/18/22 revealed Resident #84 was to receive blood glucose checks with meals and at bedtime. Review of Resident #84's physician orders revealed no current or previous orders for blood sugar monitoring. Review of the resident's vital signs records revealed no documented blood sugar checks for the resident. Review of Resident #84's progress notes and physician assessments revealed no explanation as to why the hospital instructions were not carried out. Interview with the Director of Nursing on 12/07/22 at 4:16 P.M. confirmed the above findings and lack of blood glucose monitoring for Resident #84 who had a diagnoses of type 2 diabetes.

Based on observation, record review and interview the facility failed to ensure antibiotics were ordered and administered to Resident #16 in a timely manner to treat suspected osteomyelitis (bone infection). Actual Harm occurred on 12/08/22 when Resident #16 was admitted to the hospital with a diagnosis of sepsis (blood infection) related to a wound to the left heel. Physician order for the antibiotic, doxycycline was not obtained as recommended to treat suspected osteomyelitis contributing to the hospitalization. This affected one resident (#16) of one resident reviewed for wounds. The facility identified one resident as having wounds, Resident #16. The facility census was 34. Findings include: 1. Review of Resident #16's medical records revealed an admission date of 09/16/22 with diagnoses including non pressure chronic ulcer of right foot, peripheral vascular disease (PVD) and diabetes. Resident #16 was admitted with two unstageable pressure ulcers (areas were not identified). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/25/22 revealed Resident #16 had impaired cognition, required extensive assistance with bed mobility, transfers, toileting and personal hygiene, and was incontinent of bowel and bladder. Review of physician's orders from 09/19/22 through 10/17/22 revealed Resident #16 was ordered the antibiotic, doxycycline 100 milligrams (mg) twice a day for 28 days for wound infection. Review of Resident #16's physician orders for November 2022 revealed an order to cleanse left heel with normal saline, pack with Dakins (antiseptic) soaked gauze, cover with absorbent dressing and wrap with Kerlix daily and as needed, and paint right heel with Betadine (antiseptic) and apply absorbent dressing every Monday, Wednesday and Friday. Review of a skin and wound assessment for Resident #16 dated 11/18/22 revealed the wound nurse practitioner suspected osteomyelitis and a new order to consult with the house physician to obtain imaging was given. Review of the wound care progress note/wound evaluation for Resident #16 dated 11/18/22 revealed an order for calcium alginate with silver (antimicrobial wound dressing to prevent infection) to the right heel, cover with an absorbent dressing and gauze daily and as needed. The left heel wound was ordered to be packed with Dakins soaked gauze, cover with an absorbent dressing and wrap with gauze daily and as needed. Review of Resident #16's progress note dated 11/18/22 authored by the Assistant Director of Nursing (ADON) revealed the wound nurse practitioner suspected osteomyelitis and to consult with house physician to obtain imaging. Review of the wound care progress note/wound evaluation authored by the wound nurse practitioner, for Resident #16, dated 11/23/22 revealed to continue with calcium alginate to right heel, cover with absorbent dressing and gauze daily and as needed. Left heel wound was to be packed with Dakins soaked gauze twice daily. The evaluation indicated the wound had an odor and thick drainage. Doxycycline 100 mg was recommended. The note indicated to notify the house physician of recommendations for antibiotic therapy. Review of the physician's orders revealed no order for doxycycline on 11/23/22. Review of the wound care progress note/wound evaluation for Resident #16, dated 11/30/22 revealed to discontinue the calcium alginate to right heel and begin packing the wound with Dakins soaked gauze twice daily. Wound was noted to be odorous. Left heel wound continued to be packed with Dakins soaked gauze twice daily. The note stated to extend the doxycycline 100 mg for an additional 10 days, and might require diagnostic imaging at the discretion of the house physician due to the high risk of osteomyelitis. The note indicated nursing to notify the house physician. Further review of Resident #16's physician orders revealed an order for Doxycycline 100 mg on 12/01/22 through 12/10/22 twice a day for infection. Interview on 12/06/22 at 9:38 A.M. with the Director of Nursing (DON) revealed although a recommendation for doxycycline was made on 11/23/22 there was no physician order in place for the antibiotic until she entered the order on 12/01/22. Observation of wound care on 12/07/22 at 10:55 A.M. for Resident #16 with the DON and LPN #433 revealed wounds to the resident's bilateral heels had a strong odor and thick yellowish drainage coming from the wounds. Interview on 12/07/22 at 11:22 A.M. with the DON revealed she received the wound progress notes and evaluations weekly and stated she must have missed the recommended order for antibiotics. The DON confirmed the antibiotics recommended on 11/23/22 were ordered on 12/01/22. Review of the progress note, dated 12/07/22 revealed x-ray results showed Resident #16 had osteomyelitis of the left heel. The note indicated the nurse practitioner was notified and Resident #16 was to be transported to the hospital. Review of the progress note dated 12/08/22 revealed Resident #16 was admitted to the hospital with sepsis (blood infection).