**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interviews, and policy review, the facility failed to timely notify the physician of signs and symptoms of dry gangrene toes and ankle which in turn resulted in delayed treatment. This resulted in actual harm when Resident #98's toes on the left foot began to show signs and symptoms of dry gangrene and the facility staff had not notified the physician in a timely manner. Resident #98 required a left above knee amputation (AKA) the same night he was sent to the hospital for acute limb ischemia and dry gangrene. This affected one (Resident #98) of three residents reviewed for wound care. Additionally, the facility also failed to ensure the accuracy of skin assessments. This affected two (#98 and #99) of three reviewed for skin assessments. The facility census was 95.1.Review of the medical record revealed Resident #98 was admitted to the facility on [DATE] and discharged [DATE] with the following diagnoses: non-stemi elevation myocardial infarction (a type of heart attack where a coronary artery is partially or completely blocked, reducing blood flow to the heart and causing damage to the heart muscle), sepsis due to Escherichia coli and Type II diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #98 had intact cognition. This resident was assessed to be moderate assistance with toileting and dressing with maximal assistance with bathing. Review of the skin assessment dated [DATE] revealed there was a small area on left lower shin and left toes. Review of the care plan initiated 12/05/24 for Resident #98 revealed skin checks to be completed weekly due to anticoagulants. Review of the skin assessment dated [DATE] revealed there were no skin issues. There were no other skin assessments completed in the medical record. Review of the Physician’s note dated 12/30/24 revealed Resident #98 had ongoing chronic pain syndrome especially with neuropathy pain, and because of issues with lethargy and sleepiness, he will be a poor candidate for Neurontin or Lyrica, and with underlying diabetes, cannot be on NSAIDs. Physician noted: Skin-Warm and dry, no rashes, lesions, or unusual pigmentation, skin turgor normal. Review of shower sheets dated 01/10/25 noted no skin issues and 01/14/25 noted left foot and back of left ankle to be turning black and painful. Review of the Nurse Practitioner’s (NP) #600 note dated 01/14/25 at 3:34 P.M. revealed the NP addressed abnormal laboratory results. Resident #98 complained of increased urinary frequency and requested a sleep aid. NP #600 ordered a urinalysis test to be completed. NP noted: Skin-Warm and dry, no rashes, lesions, or unusual pigmentation, skin turgor normal. Review of the nurse’s notes dated 01/14/25 at 11:13 P.M. revealed Resident #98 had toes on left foot that looked gangrenous and were painful. Nurse placed a note in the doctor’s book and stated she would pass it on to morning shift to notify the physician. Review of the Physician’s notes dated 01/16/25 revealed Resident #98 was having issues with worsening left toe wounds with necrosis and concerns for limb ischemia and concerns for gangrene of the toes with issues of pain control. Resident #98 was sent to the hospital for further workup and possible revascularization. Review of the hospital records dated 01/16/25 to 01/22/25 revealed Resident #98 received a left leg above the knee amputation due to dry gangrene of the left lower extremity on 01/16/25 through 01/17/25. Resident #98 was found to have an occlusion of left superficial femoral artery with blood flow to the left profunda. Contracture to the left lower extremity. The aspect of the foot was dusky purple red. The foot and ankle demonstrated two ulcerated lesions, 1.7 centimeters (cm) and 4.6 cm each in greatest dimension. Toes number one through four demonstrated red-purple dusky areas of skin discoloration that demonstrate sloughing of the skin. Within these dusky areas, there are areas of mummification. Sections through these areas revealed hemorrhagic and necrotic soft tissue. Resident #98 was discharged on 01/22/25 to a different rehabilitation facility. Interview with Administrator on 08/11/25 at 11:10 A.M. revealed gangrenous area was found on 01/14/25 and the physician was notified and saw Resident #98 on 01/16/25. The Administrator educated Registered Nurse (RN) #201 on 01/20/25 regarding notifying physician with high level change of condition. Interview with Nurse Practitioner (NP) #360 on 08/11/25 at 3:51 P.M. revealed NP #360 does not complete a head-to-toe assessment every time a resident is seen. NP #360 stated he does not always look in the doctor’s book because the nurse manager tells him who he needs to see and why. NP #360 recalls Resident #98 and visiting him on 01/14/25 to review the resident’s laboratory results. Resident #98 only complained of frequent urination and a urinalysis was ordered. NP #360 verbalized not being notified the night of 01/14/25 or on 01/15/25 of Resident #98’s condition. NP #360 stated on 01/15/25, he was in the building because Wednesdays are his day to be in the facility. NP #360 was not sure but thought maybe the wound doctor was seeing Resident #98. Interview with Certified Nursing Assistant (CNA) #293 on 08/11/25 at 4:17 P.M. revealed CNA #293 does not remember Resident #98. CNA #293 was the employee who signed the shower sheets for 01/10/25 and 01/14/25. Interview with NP #360 on 08/12/25 at 8:24 A.M revealed dry gangrene usually takes weeks to turn into gangrene and shows signs and symptoms of becoming dry, shrinking, and turning black, related to poor vascular. NP #360 verbalized he was never notified of Resident #98’s change of condition. NP #360 reviewed the chart, and the last skin assessment was completed 12/12/24 stating no skin issues. NP #360 stated he felt skin assessments should have been completed weekly on Resident #98 due to his condition and possibly facility policy. NP #360 verified the facility staff should have noticed Resident #98’s gangrene toes. Interview with Wound Physician #601 on 08/12/25 at 8:39 A.M. revealed Resident #98 was never seen by Wound Physician #601 and facility never sent a consultation. Wound Physician #601 stated a gangrene foot is more of a vascular doctor consult than for wound. Review of facility policy, “Prevention of Pressure Injuries,” dated April 2020, revealed a skin assessment should be conducted on admission, with each risk assessment, as indicated to the resident’s risk factors and prior to discharge. The policy did not address if skin assessment should be completed weekly. Review of facility policy, “Change in Resident’s Condition or Status,” dated February 2021, revealed the nurse will notify the resident’s attending physician or physician on call when there has been a significant change in resident’s physical/emotional/mental condition. 2. Review of the medical record for Resident #99 revealed an admission date of 01/01/25 and discharge date of 01/14/25. Diagnoses included chronic non-pressure ulcer of the left foot with muscle involvement, Lobar pneumonia, atherosclerosis of arteries of extremities with intermittent claudication of the left leg, chronic obstructive pulmonary disease, diabetes, peripheral vascular disease, malnutrition, surgical aftercare following surgery of the skin and tissue, pressure ulcer of the sacral region stage four, rhabdomyolysis, heart failure, and recent COVID-19. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. Resident #99 was dependent on staff for toileting and transfers and required partial and moderate assistance for walking 10 feet. The MDS stated Resident #99 admitted with a stage four pressure wound, a vascular wound, and a surgical incision. Review of hospital discharge information dated 01/01/25 revealed wound treatment recommendations for sacrum wound included cleanse with wound cleanser, pat dry and apply silverdene then silver alginate, cover with bordered foam dressing and change daily and as needed. A treatment order for a right elbow wound included cleanse with wound cleanser, pat dry and apply small piece of Xeroform, cover with bordered foam dressing and change daily and as needed. Review of the admission assessment dated [DATE] revealed the resident was admitted for post acute care with a left vascular foot wound and staples to left pelvic area. Assessment of the skin found the resident had a left heel documented as soft, a left foot dorsal open area measuring five inches by three inches by one centimeter was documented as a suspected deep tissue injury, a groin wound documented as upper left with 36 staples, and a sacrum pressure wound measuring six by five by one to two centimeters and labeled a stage four. It was also mentioned the resident was incontinent of bladder. The assessment included no mention of a right elbow wound. Review of the physician note dated 01/02/25 revealed the resident was seen in the hospital for left foot non-healing wound with excisional debridement and was placed on antibiotics. The physician note did not include any mention of a stage four pressure wound, surgical incision wound, or elbow wound. Review of the comprehensive skin evaluation dated 01/02/25 revealed Resident #99 had a vascular right dorsal foot wound measuring eight by nine by 0.1 and a sacrum pressure wound measuring six by five by two and was documented as a stage four pressure wound. The wound had small serosanguinous drainage with 70% slough and 30% eschar. The assessment was completed by the Director of Nursing (DON). The assessment did not include any information of a surgical wound of the groin with staples, a soft heel, or an elbow wound. Review of the wound Nurse Practitioner (NP) note dated 01/02/25 revealed a vascular right foot wound was assessed and dressing change completed. No other skin impairments were reviewed or assessed by the NP The assessment included inaccurate location as wound was on the left foot. Review of the comprehensive skin evaluation dated 01/08/25 revealed the resident had a vascular right dorsal foot wound measuring nine by seven by 0.1 and a sacrum pressure wound measuring nine by five by 0.1 and was listed as a stage four. The assessment was completed by the DON. Review of the wound NP note dated 01/08/25 revealed a pelvis coccyx wound was assessed with measurements of nine by five by 0.1. The assessment stated the wound was unstageable with 100% slough. A treatment for santyl for enzymatic debriding with bordered gauze daily and as needed was recommended. Interview on 08/07/25 at 1:10 P.M. with Wound Nurse #345 revealed she began employment around 01/20/25. She revealed upon admission, a resident should have a full skin assessment completed by two staff with findings documented in the medical record. She revealed the wound NP would come to facility once weekly and could be reached for questions on days she was not onsite at the facility. Wound Nurse #345 verified all skin impairments shall be documented so they can be followed until healed including scratches, bruising, skin tear, pressure wounds, and surgical incisions. Interview on 08/07/25 at 2:15 P.M. with the DON and the Administrator confirmed the admission assessment for Resident #99 had four skin items marked, left foot dorsal wound, heel soft, surgical incision with 36 staples, and a pressure stage four to coccyx/sacrum. The DON confirmed she completed the second assessment the same day (01/02/25) that included two skin notations including the dorsal foot open wound and the stage four pressure sore to the sacrum. The DON reported the heel being soft would not need to go on a skin assessment as it had no treatment. The DON also reported she typically would not put surgical incisions as well as incisions with staples on a comprehensive skin assessment stating, “we don’t always have dressings for surgical incisions.” The DON verified staff would monitor incision sites each shift for signs of infection and also verified the facility had no evidence of orders or documentation to monitor areas and incision sites and confirmed no record of staff documentation of monitoring. Interview on 08/11/25 at 11:00 A.M. with the Administrator revealed the facility had identified non-compliance for skin and wounds and were back in compliance. The Administrator verified compliance meant wound assessments were completed according to nursing standards and per interview with the DON and Administrator on 08/07/25, the expectations for staff did not meet standards of practice. The Administrator confirmed staff should document any and all skin impairments including scratches, bruising, soft heels, and surgical wounds. Interview on 08/11/25 at 3:48 P.M. with Licensed Practical Nurse (LPN) #312 verified all skin impairments should be documented on the admission and weekly assessment no matter the size. He revealed he did not remember caring for Resident #99, but if a wound treatment was mentioned on hospital discharge paperwork, the facility should make a note if they did not see the skin impairment on facility admission skin exam and get clarification from medical provider. LPN #312 also stated the importance of documenting a soft heel due to higher risk of developing a pressure sore and stated it would need increased monitoring or interventions. Review of facility policy titled, Prevention of Pressure Injuries, dated 04/2020, revealed facility shall identify risk factors as well as interventions. Facility shall conduct a comprehensive skin assessment upon admission and as indicated. This deficiency represents non-compliance investigated under Complaint Number 1306087 and 1306090.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, review of hospital records, and policy review, the facility failed to ensure timely treatments and interventions were completed for a resident's pressure ulcer. This resulted in Actual Harm on 01/14/25 when Resident #99 was hospitalized with a pressure ulcer to the sacrum which deteriorated in condition and developed purulent drainage and necrotic tissue from a delay in treatment. This affected one (Resident #99) of three residents reviewed for wounds. The facility identified six residents (#8, #11, #51, #76, #83 and #92) with pressure ulcers. The facility census was 95. Findings include:Review of the medical record for Resident #99 revealed an admission date of 01/01/25 and a discharge date of 01/14/25. Diagnoses included chronic non-pressure ulcer of the left foot with muscle involvement, lobar pneumonia, atherosclerosis of the arteries of the extremities with intermittent claudication of the left leg, chronic obstructive pulmonary disease, diabetes, peripheral vascular disease, malnutrition, surgical aftercare following surgery of the skin and tissue, pressure ulcer of the sacral region stage four (full thickness skin and tissue loss, exposing or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone), rhabdomyolysis, heart failure and recent coronavirus (COVID-19). Review of the hospital referral information dated 12/09/24 to 12/30/24 revealed Resident #99 had a left chronic foot wound with vascular surgery consulted. On 12/19/24 a pre-procedure note stated a plan for debridement of the left foot and possible trans-metatarsal amputation. Hospital orders included Augmentin 875-125 milligrams (mg) tablet twice daily for cellulitis and a coccyx wound treatment order dated 12/18/24 for silver sulfadiazine (Silvadene) topical cream with instructions to cleanse with wound cleanser, pat dry and apply Silvadene then silver alginate, cover with bordered foam dressing and change daily and as needed.Review of the hospital discharge information dated 01/01/25 revealed wound treatment recommendations for the sacrum wound included orders to cleanse with wound cleanser, pat dry and apply Silvadene then silver alginate, cover with bordered foam dressing and change daily and as needed. Review of the baseline care plan dated 01/02/25 revealed Resident #99 had a history of an ulcer and rhabdomyolysis. An arterial ulcer was documented under the skin integrity section, while pressure ulcers and an option for other were left unmarked. The interventions and goals included a select all that applied question asking reasons for nursing services, other was marked off with a comment stating, physical deconditioning. Wound care and skin breakdown prevention were left blank. No skin related interventions were documented on the baseline care plan.Review of the admission assessment dated [DATE] revealed Resident #99 was admitted to the facility for post-acute care with a left vascular foot wound and staples to the left pelvic area. An assessment of the skin found the resident had a left heel documented as soft, a dorsal left foot open area measured 5 inches by 3 inches by 1 centimeter (cm) was documented as a suspected deep tissue injury, an upper left groin wound with 36 staples, and a sacrum pressure wound measuring 6 by 5 by 1 to 2 centimeters (cm) and labeled as a stage four. It was also mentioned that the resident was incontinent of bladder.Review of the physician note dated 01/02/25 revealed the note did not include any mention of a stage four pressure wound or surgical incision wound.Review of the Braden scale (pressure ulcer risk) assessment dated [DATE] revealed Resident #99 was at risk for the development of pressure sores. Review of the comprehensive skin evaluation dated 01/02/25 revealed Resident #99 had a vascular right dorsal foot wound (though the admission assessment on 01/02/25 stated it was a left foot wound) measuring 8 by 9 by 0.1 deep with no measurement descriptors. The evaluation also noted a sacrum pressure wound measuring 6 by 5 by 2 deep, with no measurement descriptors, and was documented as a stage four pressure wound. It revealed a wound had small serosanguinous drainage with 70% slough and 30% eschar, but it was not specific to which of the two wounds the documentation was referring to. The assessment was completed by the Director of Nursing (DON).Review of the wound Nurse Practitioner (NP) #362 note dated 01/02/25 revealed a vascular right foot wound was assessed and the dressing change was completed. No other skin impairments were reviewed or assessed by the NP.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. Resident #99 was dependent on staff for toileting and transfers and required partial and moderate assistance for walking 10 feet. Further activity was not assessed due to safety concerns. The MDS indicated Resident #99 admitted with a stage four pressure wound, a vascular wound, and a surgical incision.Review of the comprehensive skin evaluation dated 01/08/25 revealed Resident #99 had a vascular right dorsal foot wound measuring 9 by 7 by 0.1, with no measurement descriptors, and a sacrum pressure wound measuring 9 by 5 by 0.1, with no measurement descriptors, and it was listed as a stage four. The assessment was completed by the DON. Review of the wound NP #362 note dated 01/08/25 revealed a pelvis coccyx wound was assessed with measurements of 9 cm by 5 cm by 0.1 cm. The assessment noted the wound was unstageable with 100% slough. A treatment for Santyl for enzymatic debriding with bordered gauze daily and as needed was recommended.Review of the Treatment Administration Record (TAR) from January 2025 revealed barrier cream was ordered from 01/01/25 to 01/14/25 with instructions to administer after each incontinence episode as needed. The barrier cream treatment was not documented as completed. The TAR included a coccyx wound order dated from 01/08/25 to 01/14/25 with instructions to cleanse the area with wound cleanser, apply Santyl and cover with foam dressing once daily. The Santyl treatment was documented as completed daily.Review of the physician note dated 01/14/25 revealed Resident #99 was seen for coughing with shortness of breath. Resident #99 also reported pain on his buttocks where he had a wound. After the initial assessment, Resident #99 began to deteriorate with a pulse in the 30's (normal pulse rate is between 60 beats per minute (bpm) and 100 bpm) and oxygen saturations in the 50's [percent (%)] (normal ranges from between 90 % to 100 %). Resident #99 was placed on five liters of oxygen and the oxygen saturations only increased to the 60's [%]. After a few minutes on oxygen his saturations did not improve over the 80's [%] and the resident was transferred to the hospital for an evaluation.Review of the history and physical dated 01/14/25 revealed Resident #99 reported he was bedbound the past month and developed a bedsore on his backside. Resident #99 stated his backside was very tender with a general surgery consultation for suspected necrosis. Upon physical examination, a large sacral ulcer was noted with a surrounding deep tissue injury with an exposed dermis and a large area of necrotic tissue at the center of the wound. Review of the pelvic computed tomography (CT) scan dated 01/14/25 revealed no definite osseous erosion of the sacrum could be confirmed. There was suggestion of some osseous erosion of the distal two coccygeal segments suspicious for osteomyelitis. It noted to suspect coccygeal osteomyelitis.Review of hospital record acute care surgery consult dated 01/14/25 revealed Resident #99 presented from the nursing facility due to shortness of breath and was found to have a malodorous sacral decubitus ulcer stage three to four. A CT of the pelvis on 01/14/25 showed a decubitus ulcer with suspected coccygeal osteomyelitis. It noted that Resident #99 would benefit from a sharp debridement of the sacral wound this admission. Interview on 08/07/25 at 1:10 P.M. with Wound Nurse #345 revealed she began employment around 01/20/25. She revealed upon admission; a resident should have a full skin assessment completed by two staff with findings documented in the medical record. She revealed the wound NP #362 would come to the facility once weekly and could be reached for questions on days she was not onsite at the facility.Interview on 08/07/25 at 2:15 P.M. with the Director of Nursing (DON) and the Administrator confirmed the admission assessment for Resident #99 had four skin items marked including a left foot dorsal wound, a soft left heel, a surgical incision with 36 staples and a stage four pressure wound to the coccyx/sacrum. The DON confirmed she completed a second assessment the same day (01/02/25) that included two skin notations including the dorsal foot open wound and the stage four pressure sore to the sacrum. The DON confirmed the baseline care plan was not thoroughly completed including no mentions of wound care or skin protection and treatments. The DON confirmed she signed off on the baseline care plan and revealed it was a new form the facility was not familiar with and confirmed there was no documented evidence of wound or pressure relieving interventions on the care plan. The DON confirmed the wound NP #362 saw Resident #99 for the foot wound on 01/02/25 and did not see Resident #99 for the pressure wound until 01/08/25. The DON had no explanation for the delay in the NP seeing the wound as she had assessed his foot wound the week prior, and no explanation for the delay in treatment/interventions until he was seen by the wound NP on 01/08/25. Interview on 08/07/25 at 3:51 P.M. with Wound Nurse Practitioner (WNP) #362 revealed she was onsite once weekly at the facility. She confirmed she rounded with the wound nurse and worked from the list of residents from the prior week while adding residents based on the nursing report of new admissions or new wounds that needed evaluation. She reported the facility would place a consult for a resident with wounds and she could follow the resident for any and all wounds as needed. WNP #362 revealed Resident #99 was admitted while the facility was between wound nurses. WNP #362 revealed she would round with the DON or bedside nurses during that time. She confirmed she was not informed of the stage four pressure wound for Resident #99 and stated she would definitely want to see a resident with a stage four pressure wound during her rounds. The WNP confirmed she only saw the foot wound on the first visit with Resident #99 on 01/02/25 and confirmed the pressure wound had no treatment orders in place until her first assessment of it on 01/08/25.Interview on 08/11/25 at 11:00 A.M. with the Administrator revealed she thought the wound had improved but acknowledged the measurements increased and that Resident #99's wound, going from stage four to unstable, was a decline. Interview on 08/11/25 at 12:50 P.M. with the Administrator, the DON, Regional Nurse #365, and Wound Nurse #345 confirmed the facility identified errors and non-compliance regarding Resident #99's care but stated they had made changes such as terminating the previous wound nurse on 12/30/24 and hiring Wound Nurse #345. They revealed the facility was going through a change in ownership and the facility had put new practices in place. They acknowledged Resident #99 was admitted during the time the wound nurse had been terminated. Review of the facility policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, dated 04/2018, revealed nursing staff and practitioners (NP) shall assess and document risk factors for pressure ulcers. The nurse shall also document a full assessment of pressure sores. The NP shall examine skin for evidence of pressure ulcers. The Physician shall order pertinent wound treatments including wound dressings and treatments. Review of the facility policy titled, Care Plan - Baseline, dated 03/2022, revealed the facility shall include instructions needed to provide effective person-centered care. The baseline care plan was used until staff could complete the comprehensive care plan. The baseline care plan shall include any services and treatments to be administered by facility and personnel acting on behalf of the facility.This deficiency represents non-compliance investigated under Complaint Number OH001306087.