**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of hospital records, review of physician's notes and wound assessments, appointment reminder notice review, interviews with residents, family, outside entities, and staff, and policy review, the facility failed to provide adequate, timely and necessary care and services, including timely re-scheduling of vascular surgeon appointments for Resident #100, who had vascular wounds to meet the resident's total care needs. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm beginning on 07/16/24 when a vascular surgery follow-up appointment (with plans to discuss blood flow to the resident's lower extremities) was canceled with no evidence of attempts by facility staff to re-schedule or schedule a new vascular surgery consult until 08/14/24, when an appointment was made for the following week with a new vascular surgeon. However, prior to the appointment, on 08/18/24, Resident #100 suffered a significant change in condition with increasing lower extremity pain unrelieved by as-needed opioid narcotic analgesics and bleeding from his lower extremity wounds resulting in the resident being transferred to a local hospital. Resident #100 was admitted to the intensive care stepdown unit and required a 25-day inpatient hospitalization for sepsis (systemic infection) and infected vascular wounds. The hospital vascular surgeon noted the resident's potential for lower extremity re-vascularization procedures as limited if not non-existent. Resident #100 required lengthy courses of multiple intravenous antibiotics, extensive wound care, and his hospital course was complicated by an acute kidney injury requiring temporary hemodialysis treatments. Resident #100's wounds and overall health continued to decline, and on 09/06/24, Resident #100's legs were documented to be not salvageable with discussion of possible emergent amputations. Resident #100 and his family considered the options and ultimately decided against amputations and opted for end-of-life care with hospice at another skilled nursing facility. Additionally, the facility failed to transcribe and schedule appointments for Residents #27 and #34, whose hospital after visit summaries listed the need for follow up appointments with outside specialists, which placed Residents #27 and #34 at risk for the potential for more than minimal harm that was not Immediate Jeopardy. This affected three residents (#100, #27, and #34) of eight residents reviewed for missed appointments and changes in condition. The facility census was 72. On 09/19/24 at 10:29 A.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services (RCDS) #490 were notified Immediate Jeopardy began on 07/16/24 when Resident #100 arrived at a scheduled follow-up appointment and was notified the appointment had been canceled. Resident #100, who was accompanied by a facility staff member, returned to the facility. There was no evidence of attempts by facility staff to re-schedule or schedule a new vascular surgery consult until 08/14/24, when an appointment was made for the following week with a new vascular surgeon. On 08/18/24, Resident #100 suffered a change in condition with increasing lower extremity pain unrelieved by his as-needed opioid narcotic analgesics and bleeding from lower extremity wounds, for which he was transferred to a local hospital. Resident #100 was admitted to the intensive care stepdown unit and required a 25-day inpatient hospitalization for sepsis (systemic infection) and worsening vascular wounds. The hospital vascular surgeon noted the resident's potential for re-vascularization procedure as limited if not non-existent. Resident #100 required lengthy courses of intravenous antibiotics, extensive wound care, and his hospital course was complicated by an acute kidney injury and progressive gangrene to his left lower extremity. Resident #100's wounds and overall health continued to decline, and on 09/06/24 Resident #100's legs were recorded as not salvageable and discussed possible emergent amputations. Resident #100 and his family considered the options and ultimately decided against amputations and opted for end-of-life care with hospice at another skilled nursing facility. The Immediate Jeopardy was removed on 09/23/24 when the facility implemented the following corrective actions: • On 08/18/24, Resident #100 was transferred to the hospital and admitted for treatment. The resident did not return to the facility. • On 09/19/24 at approximately 11:00 A.M., the Administrator, RDCS #490 and Regional Director of Operations (RDO) #485 educated DON, Licensed Practical Nurse (LPN)/ Assistant Director of Nursing (ADON) #238 and Scheduler #376 on proper documentation, uploading of new orders, and setting up transportation for new appointments. • On 09/19/24 at approximately 1:25 P.M., all staff education was completed on the facility abuse policy. This was completed by the Administrator. • On 09/19/24 at approximately 2:45 P.M., an initial audit of all outside resident appointments for all current residents was completed by the DON and Scheduler #376. Any discrepancies were fixed immediately. • On 09/19/24 at 3:25 P.M., all current residents received a head-to-toe assessment completed with no change in conditions or negative outcomes noted. This was completed by LPN #392, Agency Registered Nurse (RN) #645 and Agency RN #678. • On 09/19/24 at 3:37 P.M., the DON notified facility Medical Director (MD) #900 of the concerns involving Resident #100 identified by the State agency. • On 9/19/2024 at approximately 3:50 P.M., an ad hoc Quality Assurance Performance Improvement (QAPI) committee met to review the facility appointment scheduling process. The Administrator, DON, RDCS #490 and RDO #485 attended. • On 09/19/24, a new tracking log was implemented to track additional details of residents outside appointments. The log included the resident's name, the appointment date and time, transportation arrangements, the need for staff assistance, whether the appointment was completed, whether the appointment needed re-scheduled, and if there was any follow up needed. Scheduler #376 is responsible for maintaining and updating the log five days per week with oversight from the Administrator. Pertinent information regarding appointments will be shared with the interdisciplinary team five days a week, weekly on an ongoing basis. • Beginning on 09/19/24, the DON or designee will monitor 24-hour report and all new orders 5 days a week on an ongoing basis. • Beginning on 09/19/24, an ongoing audit of post-admission chart reviews will be completed to ensure the admitting nurse accurately transcribed physician's orders. This will be completed by LPN/ADON #238 on the first business day following resident admission or re-admission, with the DON as a back-up reviewer. • Beginning on 09/20/24, an ongoing audit of appointments and transportation will be conducted to ensure appointments are accurately transcribed into the resident's record and are added to the appointment tracking log for verification of appointment attendance. This will be completed by the DON or designee, five times weekly, on an ongoing basis and communicated to the interdisciplinary team during morning meetings. • Beginning on 09/20/24, an ongoing audit of outside resident appointments and transportations as listed on the appointment tracking log and will be conducted three times weekly, on random days of the week, by the Administrator. This will be completed 3 times/week on an ongoing basis. • Beginning on 09/20/24, a staffing huddle was implemented with direct care staff to communicate upcoming scheduled appointments, needs for the appointment, and transportation arrangements. This huddle will occur five times weekly, Monday through Friday, at approximately 10:00 A.M., following the conclusion of morning meeting. Any potential weekend appointments will be communicated on Fridays. The staffing huddle will be coordinated by the Administrator and/or DON or designee. • Beginning on 09/23/24, the Administrator will send the appointment tracking log to RDO #485 and RDCS #490, three times weekly on Monday, Wednesday and Fridays, for four weeks. • Beginning the week of 09/23/24, a random audit of outside resident appointments and transportations will be conducted weekly, by RDO #485 or RDCS #490, for additional oversight for a duration of 4 weeks. • On 09/23/24 at approximately 4:00 P.M., staff nurses were educated on scheduling appointments, transcribing appointment orders, and monitoring appointment attendance. This was completed by the Administrator. • On 09/23/24 at approximately 4:30 P.M., two communication binders were implemented and contained pertinent policies, including written appointment scheduling expectations for communication for both agency and staff nurses. Pertinent policies and updates will be placed in the communication book on an ongoing basis by the DON or designee. • Results of ongoing audits will be reported and reviewed through the facility QAPI committee for 6 months and randomly thereafter. The next regularly scheduled QAPI meeting is planned for 09/27/24 at 12:30 P.M. • During interviews conducted on 09/23/24 between 3:53 P.M. and 1:10 P.M., and on 09/24/24 between 7:21 A.M. and 3:10 P.M., Licensed Practical Nurse (LPN) #392, Registered Nurse (RN) #294, LPN #300, LPN #222, RN #398, RN #334, LPN #305, LPN/ADON #238, and Scheduler #376 verified receiving education on the facility appointment scheduling process. Although the Immediate Jeopardy was removed on 09/23/24, the deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the closed medical record for Resident #100 revealed an original admission date of 04/25/24. Medical diagnoses included peripheral vascular disease (PVD), cellulitis, and an unspecified disorder of arteries and arterioles. Resident #100 was noted to have chronic vascular wounds to his bilateral lower extremities, for which he had been previously hospitalized and treated from 06/02/24 to 06/07/24. Resident #100 was transferred to a local hospital on [DATE] and did not return to the facility. A plan of care initiated on 04/25/24 (and revised on 07/03/24), noted Resident #100 had actual areas of skin impairment related to chronic venous stasis ulcers to multiple locations on the bilateral lower extremities. Listed interventions included to provide the ordered treatment, ask resident regarding pain levels prior to dressing changes and medicate as needed, enhanced barrier precautions in place, elevate legs as tolerate, and encourage movement of legs and walking. A plan of care dated 05/10/24, noted Resident #100 had inadequate blood circulation or ineffective tissue perfusion related to peripheral vascular disease (PVD). Listed interventions included to administer medications as ordered, observed for side effects and effectiveness, complete laboratory/diagnostic work as ordered, and to follow up as indicated. An additional focus care plan dated 07/10/24, listed the resident as noncompliant with care and treatment as ordered by the physician, with specifics listing the resident was non-compliant with a post-operative shoe, COVID isolation precautions, and rolling his own tobacco. There were no recorded specifics about the resident refusing ordered wound care or ADL care. Listed interventions included to stop care when resident upset and try again later, approach calmly, without rushing and speak in a calm voice, explain procedures and observe and document mood and behavior changes in the nurse's notes or monthly tracking forms if indicated. Review of Resident #100's physician's orders revealed an original order dated 04/26/24, for a vascular surgery appointment on 07/16/24. The order was revised on 06/27/24 and 07/11/24 to provide transportation details and to add start and end dates. Review of Resident #100's prior hospitalization discharge summary from Hospital #02, dated 06/07/24, noted Resident #100 was transferred from Hospital #01 on 06/02/24 for an evaluation of his lower extremity wounds. Resident #100 was noted to have sepsis secondary to his lower extremity vascular wounds at this time. Resident #100 was noted to have diffuse peripheral arterial disease (PAD)/PVD and recommended a revascularization evaluation. The summary indicated Resident #100 was not able to have any vascular intervention during the hospitalization as the resident lacked decision-making capacity to consent to a surgery with complex risks due to altered mental status. The discharge summary noted no health care power of attorney (HCPOA) was in place and no alternate decision makers were able to be located or contacted. Resident #100's mental status improved during the hospitalization, but the concern was still present regarding capacity to understand the risks and benefits completely for a serious procedure. Resident #100 had shared he was established with Vascular Surgeon #500, who was affiliated with Hospital #01, and wanted to get a second surgical opinion from him post-hospital discharge. The summary indicated the plan was to discharge Resident #100 back to the facility, and for the resident to follow up with Vascular Surgeon #500 as an outpatient at the provider's office. The discharge summary noted there was a poor prognosis for Resident #100's legs without vascular intervention, with salvage unlikely even if revascularization was possible. The discharge summary listed Resident #100 as having a follow up appointment with Vascular Surgeon #500 on 06/18/24 to discuss blood flow to the legs, and to call the office to confirm the appointment. Review of Resident #100's hospital after visit summary, dated 06/07/24, revealed Resident #100 had follow up appointments scheduled prior to hospital discharge. On 06/18/24 at 2:00 P.M., Resident #100 was scheduled for a cardiovascular ultrasound of the carotid (neck) arteries, with the address and phone number listed. A second appointment following the ultrasound was listed for 06/18/24 at 3:00 P.M., with Vascular Surgeon #500. A third appointment was listed for 07/16/24 at 10:00 A.M., also with Vascular Surgeon #500, with the provider's office address and phone number listed. Review of Resident #100's interdisciplinary progress notes revealed a note dated 06/18/24 at 1:30 P.M., which stated the resident was transported to his appointment. He was alert and oriented times three (indicating orientation to person, place and time) with no signs of distress as he was escorted to his appointment. A subsequent note also dated 06/18/24 and timed 2:30 P.M., revealed Resident #100 returned to the facility from appointment in stable condition with no signs of distress. The resident's appointment had been rescheduled to 07/16/24 at 10:00 A.M. Review of an appointment reminder notice, dated 06/18/24, revealed Resident #100 was noted to have an upcoming vascular surgery appointment on 07/16/24 at 10:00 A.M. Listed instructions included to bring photo identification, a current list of medications, and any insurance information and a copayment if required. The office address, phone and fax number were listed on the notice and the notice listed to call the office at a provided number to cancel or reschedule the appointment. Resident #100 had an order dated 07/03/24, for bilateral lower extremity wound dressings. The order instructed to cleanse wounds with normal saline and pat dry. Apply normal saline moist-to-dry dressing, cover with abdominal pads, wrap with kerlix (rolled gauze) and wrap with ACE (compression) wraps, change daily and as needed. Review of Resident #100's Treatment Administration Record (TAR) for July 2024 revealed Resident #100's daily bilateral wound dressings were completed as ordered, except on four days, 07/05/24, 07/07/24, 07/11/24, and 07/19/24, on which the resident was recorded to have refused. The TAR was blank for 07/30/24, indicating Resident #100 did not receive his ordered treatment on this date. Review of a nurse's note for July 2024 revealed there was no notation of education being provided on wound care or rationale for why the resident refused ADL and/or wound care on the days listed. Subsequent review of the progress notes revealed no corresponding documentation on the reason Resident #100 refused his wound care, that education was provided, or that staff had re-approached or re-offered wound care on the dates he refused. Subsequent review of Resident #100's interdisciplinary progress notes between 06/18/24 and 08/14/24, revealed no notes on or around 07/16/24, reflecting attendance to an outside vascular surgery appointment on this date. There were no notes during the time frame regarding any missed appointments, any attempts to reschedule an appointment, or any attempts finding the resident a new vascular surgeon. Resident #100 was recorded as seeing MD #900 on 06/20/24 and 07/10/24, who noted the resident was previously seen by a vascular surgeon while in the hospital who recommended an outpatient visit to discuss a revascularization procedure versus amputation of the lower extremities, and to follow up with Vascular Surgeon #500. Resident #100 was recorded as seeing Certified Nurse Practitioner (CNP) #875 on 06/21/24 and 07/19/24, who noted the resident had a vascular surgery follow up appointment scheduled on 07/16/24. Resident #100 was additionally seen by CNP #825 on 07/01/24, 07/08/24, 07/18/24, 07/22/24, 08/01/24, 08/05/24, and 08/12/24. Each of CNP #825's visits noted the resident needed to follow up with a vascular surgeon. The note dated 08/01/24, indicated specifically to schedule a follow up appointment to discuss bilateral below the knee amputations. CNP #825's note dated 08/05/24, noted a vascular surgery consult was pending, and the note dated 08/12/24, noted Resident #100's prior vascular surgeon no longer accepted his insurance and to refer the resident to a different health system to see a vascular surgeon. A note dated 08/14/24 at 9:00 A.M., authored by LPN/ADON #238 noted an appointment was made with an unnamed vascular surgeon for 08/21/24. Review of Resident #100's Minimum Data Set (MDS) quarterly assessment, dated 08/02/24, revealed the resident had intact cognition. Resident #100 was not recorded to have hallucinations, delusions, verbal or physical behaviors, or rejection of care. Resident #100 was noted to functional limitations in range of motion to both of his lower extremities and required partial/moderate assistance with bathing and applying and removing footwear. Resident #100 required only supervision/set-up assistance with other activities of daily living (ADLs). Resident #100 was non-ambulatory but required only setup or supervision assistance with mobility tasks. Resident #100 was noted to have four venous and/or arterial ulcers at the time of the assessment, for which he received non-surgical dressings. Review of Resident #100's TAR for August 2024 revealed Resident #100's daily bilateral lower extremity wound dressings were documented as administered as ordered on all but two days, 08/10/24 and 08/17/24, on which the resident was recorded as refusing dressing changes. Review of a nurse's note dated 08/18/24 at 5:32 A.M. and 6:55 A.M., noted the resident refused his wound care. A subsequent note dated 08/18/24 at 6:56 P.M., noted the resident refused wound care and ADLs four times. There was no notation education was provided on wound care or rationale for why the resident refused ADL and/or wound care on that day. Subsequent review of the progress notes revealed no corresponding documentation on the reason Resident #100 refused his wound care, that education was provided, or that staff had re-approached or re-offered wound care on the dates he refused. Review of Resident #100's eINTERACT Change in Condition Evaluation, dated 08/18/24, revealed Resident #100 had a noted change to his skin wound or ulcer on 08/18/24. There was no description of what types of wound changes were seen to Resident #100's wounds. Review of Resident #100's eINTERACT Transfer Evaluation, dated 08/18/24, revealed Resident #100 was sent to the hospital on the evening of 08/18/24, due to bleeding from the legs. The form listed the resident as having no pain. The form listed the resident as having pressure ulcers to the lower extremities and provided no description for the number of wounds, appearance of the wound bed or any wound characteristics, nor did the form list what ordered treatments were. Review of Resident #100's emergency department (ED) records, dated 08/18/24, revealed Resident #100 arrived at the ED of Hospital #01 for bilateral lower leg pain. The ED note indicated Resident #100 voiced he had infections in his legs since January 2024 and was scheduled to see a surgeon somewhere in Ohio later that week to discuss possible amputations. Resident #100 told the ED provider the pain in his bilateral legs was what brought him to the ED, and the note indicated Resident #100 was alert and oriented upon arrival. Resident #100 described his pain as usually controlled with as-needed oxycodone (a narcotic opioid analgesic), but on 08/18/24 the pain was out of control. The ED physician's physical examination described Resident #100 as disheveled with poor personal hygiene upon arrival. Resident #100 was tachycardic (heart rate greater than 100 beats per minute). The physician recorded Resident #100's lower extremity dressings as dirty and saturated upon arrival. Multiple open wounds were observed to Resident #100's bilateral lower extremities, with skin sloughed (dead tissue) from the left foot with surrounding erythema (redness) and edema (swelling). The wounds to the bilateral extremities had a foul odor and purulent drainage (indicative of possible infection). The ED physician was unable to palpate pulses in Resident #100's bilateral lower extremities (a sign of impaired blood flow). Resident #100 was noted to have an elevated white blood cell count (WBC) of 21.00 (normal range 4.5-11.0 K/mcL, indicative of infection). A second ED physician saw Resident #100 and noted the lower extremity wounds to the resident's bilateral lower extremities appeared grossly necrotic with foul smelling drainage, and in conjunction with laboratory evaluation and imaging, there was a concern for significant bilateral lower extremity infection. Imaging of Resident #100's leg showed significant vascular compromise, chronic in nature, and noted the patient would benefit from bilateral lower extremity partial amputation once more stabilized. Resident #100 met criteria for admission to the intensive care stepdown unit for sepsis and severe cellulitis of the bilateral lower extremities. Review of Resident #100's vascular surgery consult note dated 08/19/24 while inpatient at the hospital, noted the resident to have chronic limb-threatening ischemia to his bilateral lower extremities and bilateral lower extremity venous ulcers. The note indicated Resident #100 was known to have chronic bilateral lower extremity wounds that had worsened since the last recorded documentation within the hospital system from June 2024. The note indicated Resident #100's options for revascularization may be limited if not non-existent. Additional review of Resident #100's hospital medical records noted the resident required the coordination and care of various specialties throughout a 25-day hospitalization. Resident #100 was seen by an infectious disease physician on 09/19/24. The provider noted leukocytosis (elevated white blood count (WBC) count, indicative of infection), sepsis, and bacteremia (bacteria in the bloodstream) with two multiple infectious organisms identified. The assessment and plan section of the note noted the resident was being treated for bacteremia, bilateral lower extremity wound infections, leukocytosis and PAD. The resident required three intravenous antibiotics to treat the infection and indicated to continue local wound care and supportive care. The note listed Resident #100's prognosis as guarded. Resident #100 was seen by a podiatrist on 08/20/24. The note indicated no podiatric surgery was recommended at that time and agreed with vascular that bilateral below the knee amputations may be the patient's best option. A subsequent note dated 08/22/24, by a second podiatrist noted Resident #100's legs would be salvageable with vascular intervention. The note indicated aggressive surgical intervention could put the resident's legs back together, but without vascular intervention and the levels of disease, an above the knee amputation would be the appropriate course of action. The note stated if Resident #100 did not undergo some procedure, either vascular intervention or above the knee amputation, Resident #100's severe and deep wounds involving the tendons would become severely infected, and Resident #100 would not be able to fight the infection off. Resident #100 saw a nephrologist on 08/23/24, for an acute kidney injury (AKI), severe PAD, hypertension and an elevated vancomycin (antibiotic) level. The note indicated the resident had an AKI related to comorbidity of PAD, receiving intravenous contrast for radiology tests, and multiple intravenous antibiotics with an elevated vancomycin level. The plan indicated the vancomycin was on hold, and nephrology would monitor the patient's laboratory results and symptoms. A subsequent note dated 08/28/24, from an interventional radiologist noted Resident #100 would require the placement of a temporary tunneled internal jugular intravenous line through which the hospital would be able to perform hemodialysis (filtering of the blood when the kidneys are not adequately functioning). Resident #100 received hemodialysis on 08/29/24, 08/30/24, and 08/31/24. A follow-up vascular surgery note dated 09/05/24 revealed the vascular surgeon discussed with Resident #100 that his legs are potentially the source of his deteriorating medical status and that vascular surgery, and his other teams recommend bilateral above the knee amputations. The risks of not proceeding, including worsening infection, sepsis, clinical deterioration to the point of altered mental status (AMS), cardiac arrest, multiorgan failure and death were discussed. Given the risks, Resident #100 declined intervention and was adamant he did not want to live without his legs. The note concluded with a note indicating that the patient was able to properly participate in decision making and the vascular surgery team could not with good conscious proceed with surgery with the patient adamantly declining. The palliative care team was consulted, and after multiple discussions regarding Resident #100's complex and comorbid healthcare needs, Resident #100 and his family ultimately opted to decline amputation and decided to elect for end-of-life care with hospice services at another skilled nursing facility. Interview on 09/12/24 at 10:20 A.M., with Advocate #990, who wished to remain anonymous, revealed familiarity with Resident #100's stays at the facility and hospital admission since 08/18/24. Advocate #990 reported Resident #100, was still inpatient at the hospital, was not doing well. Resident #100 was described as having a lot of pain. Advocate #990 stated Resident #100 and his family had discussed care with the various specialists and elected for end-of-life care with hospice services. Advocate #990 stated Resident #100's legs were so infected that specialists did not believe he would survive a surgery. Advocate #990 stated another concerning aspect to Resident #100's care was that a surgeon was consulted in early June 2024 during a prior hospitalization, and were talking potential lower extremity amputations then, and questioned why Resident #100 did not have any vascular surgery follow up appointments since that time. A telephone interview on 09/12/24 at 10:32 A.M., with Anonymous Individual #860 revealed the individual was familiar with Resident #100's care and hospital stay. Anonymous Individual #860 stated when Resident #100 arrived at the hospital he appeared to have been neglected at the facility. When he arrived at the ED, he was disheveled; his wound bandages to his lower extremities had been on for a long period of time, and once removed, his vascular wounds appeared infected with a foul odor and purulent drainage. Resident #100 was known to have extensive vascular disease with chronic vascular wounds to his legs. He had previously been seen by a vascular surgeon and had discussed a prior amputation. Anonymous Individual #860 wondered what the hold up was? following up with a vascular surgeon and described Resident #100's decline in condition as heartbreaking and horrifying and questioned how it got to this point. An interview on 09/12/24 at 2:10 P.M., with Scheduler #376 revealed she was the staffing scheduler and scheduled transportation for outside resident appointments. Scheduler #376 assisted in updating a spreadsheet of upcoming appointments but was unable to provide a copy of the current or past months' appointment schedule as entries get deleted after the appointment date had passed. An interview on 09/12/24 at 3:35 P.M., with the Administrator revealed the facility was unable to provide a monthly appointment calendar for outside resident appointments. The facility utilized a spreadsheet to track upcoming resident appointments, but once the appointment date/time passed, the facility deleted the resident and appointment from the spreadsheet. The Administrator reported there was no way to see prior months' data, nor was there a way to see prior versions of the log. The Administrator stated the facility's process was to type orders into the resident's electronic health record (EHR), and the scheduler with review the orders for upcoming appointments to ensure transportation was scheduled. When asked about the process of ensuring residents attend scheduled appointments, the Administrator stated nurses should enter a progress note to indicate the resident attended an appointment and to note any new orders reflected on the hospital paperwork following the appointment. Appointment paperwork would then be scanned into the resident's EHR record as the facility does not have any physical charts. An interview on 09/17/24 at 8:58 A.M., with the DON revealed she was familiar with Resident #100's care. She described Resident #100 as having terrible leg wounds that she believed had progressed because the resident was non-compliant with wound care. The DON reported Resident #100 had longstanding vascular compromise and not enough blood flow to his bilateral lower extremities. The DON reported the resident did see a vascular surgeon and went back and forth with a decision to amputate his legs but was unsure when the resident's last appointment with vascular surgery