**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record reviews, and interviews, the facility failed to ensure Resident (R)78 was free from neglect. Specifically, the facility failed to properly assess and provide care and services to prevent the loss of a limb for 1 of 1 residents. On 02/14/24 at 5:49 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 02/14/24 at 5:49 PM, the Administrator and the Director of Nursing (DON) were notified that failure to provide care and services for a resident to prevent the loss of a limb constituted Immediate Jeopardy (IJ) at F600. On 02/14/24 at 5:49 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 11/10/23. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 02/15/24 at 1:13 PM, the facility presented an acceptable IJ Removal Plan. On 02/15/24 at 5:00 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Recertification Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, states under Policy Statement, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Review of the facility policy titled, Abuse and Neglect -Clinical Protocol, states, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Also abuse includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well- being. 2. Neglect as defined means, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of R78's Face Sheet revealed R78 was admitted to the facility on [DATE] with diagnoses including, but not limited to: right below knee amputation, severe protein calorie malnutrition, muscle wasting and atrophy, type 2 diabetes mellitus and lack of coordination. Review of R78's medical record revealed R78 was hospitalized from [DATE] through 02/13/24, due to the neglect of the facility to provide care and services to prevent skin breakdown, deterioration of the muscle, bone exposure and loss of his left lower extremity. R78 received a left, below the knee amputation on 02/06/24. It is documented that R78 was walking with a prosthesis when admitted to the facility on [DATE]. Further review revealed, R78 was able to get to the restroom on his own, and bath himself. R78 would also change his bed linens, and bag the soiled linen. It was also documented that R78 liked to wear a sock on his left leg. The Hospital Report dated 02/04/24 at 3:52 PM documented, the facility reportedly noticed the wound today after removing his socks which he had on for a week, signed by the emergency room physician. Review of R78's Skin Worksheets revealed the following: a Skin Worksheet dated 11/10/23 which indicated the left lower extremity is discolored. No open areas. On 11/25/23 the Skin Worksheet revealed discoloration to the left lower extremity. The Skin Worksheet dated 12/09/23, 12/16/23 and 01/06/24 indicates no discoloration or open areas to R78's left lower extremity. Review of the Skin Worksheet dated 01/27/24 which is titled, Body Audit, indicated dry skin to R78's lower left extremity, still no open areas documented. Review of the Skin Worksheet dated 02/03/24 indicated a wound to R78's left lower extremity, and documents that the Nurse Practitioner (NP) needs to look at it. At this time it is open. R78 sent out to hospital on [DATE] and his left leg is amputated below the knee on 02/06/24. Review of R78's Comprehensive Plan of Care dated 09/26/23, revealed a focus area, Activities of Daily Living (ADL) self care deficit related to physical limitations. The goal states, Will receive assistance necessary to meet ADL needs, dated 09/26/23. Interventions include: Acknowledge the patients right to refuse care/services but continue to offer assistance as needed, dated 10/25/23. Assist to bathe/shower as needed. dated 09/26/23. Assist with daily hygiene, grooming, dressing, oral care and eating as needed, dated 09/26/23. Resident is sometimes non-compliant with assistance. Provide education about the risks associated with the denial of services, dated 02/04/24. Resident's preference is to remain independent for ADLs not allowing anyone to see his skin, dated 02/04/24. Further review of the Plan of Care revealed another focus area: At risk for alteration in skin integrity related to impaired mobility, bowel incontinence, and indwelling catheter, dated 09/22/23. Resident does not have use of Foley catheter. The goal states, Skin will remain intact, free from erythema, breakdown, excoriation, or bruising. The interventions include. Encourage to reposition as needed; use assistive devices as needed, dated 10/05/23. Observe skin condition with ADL care daily; report abnormalities, dated 10/05/23. Resident's preference is to remain independent for ADLs not allowing anyone to see his skin. Provide education about the risks associated with the denial of services, dated 02/04/24. Review of R78's Nurses note dated 02/04/24 at 12:01 PM states, Resident has an open wound on his left foot showing bone or tendon, will send him out to the hospital. Review of R78's Nurses Note dated 02/04/24 at 12:45 PM states, Late entry from yesterday, 02/03/2024. Resident asked the janitor to take his sock off which he had on for one week. Janitor tried but the sock was stuck to the resident's left lower extremity. The janitor told me that the resident wanted me to cut his sock off. I looked at it and it was stuck. I removed the sock by putting saline on it. I notified the Nurse Practitioner, she advised to put it in the Provider's Book, which I did. Resident wanted to get another sock on it. I advised him not to. I advised that I will wrap it up. I cleansed the wound with wound cleanser, patted it dry with gauze. Soaked gauze with betadine and covered the wound with it and wrapped the wound with kerlex gauze bandage wrap. Review of R78's Progress Notes revealed progress notes revealed the following: 09/26/24, Under skin assessment it states, Inspection and palpation, no rash, right stump excoriation, hyperpigmented lower extremities dark in color. Left medial scar from the groin to the lower leg. Hypopigmented vitiligo noted to the chest, back and neck. On 10/02/23 at 10:30 AM seen by NP2, and the skin assessment states, Inspection and palpation, no rash, lesions or jaundice, nails normal. On 10/08/23 at 9:45 AM seen by NP2, skin assessment states, Inspection and palpation, no rash, lesions, or jaundice. Nails, normal. On 10/10/23 at 3:45 PM seen by NP3, skin assessment states, Inspection and palpation, no jaundice. Nails normal. On 10/14/23 at 3:30 PM seen by NP3, skin assessment states, Inspection and palpation, good turgor and no jaundice. Nails normal. On 10/16/23 at 8:45 AM seen by NP2, skin assessment states, Inspection and palpation, no rashes or jaundice. Nails normal. On 10/28/23 at 4:16 PM seen by NP2, skin assessment states, Inspection and palpation, no jaundice. Nails normal. On 11/01/23 at 11:15 AM seen by NP2, skin assessment states, Inspection and palpation, no rash, lesions, or jaundice. Nails normal. On 11/15/23 at 9:15 AM seen by the Physician. skin assessment states, Inspection and palpation, no rash, hyperpigmented lower extremities dark in color. Left medial scar from the groin to the lower leg. Hypopigmented vitiligo noted to the chest back and neck. On 01/13/24 at 12:00 PM seen by NP2, skin assessment states, Inspection and palpation, no lesions, jaundice, or rash. Nails normal. On 01/25/24 at 12:30 PM seen by NP2, skin assessment states, Inspection and palpation, no lesions, jaundice, or rash. Nails normal. On 01/27/24 at 10:45 AM seen by NP2, skin assessment states, Inspection and palpation, no lesions, jaundice, or rash. Nails normal. On 01/28/24 at 11:15 AM seen by NP2, skin assessment states, Inspection and palpation, no lesions, jaundice, or rash. Nails normal. On 01/28/24 at 3:15 PM seen by NP1, skin assessment states, Inspection and palpation, no lesions, jaundice or rash. Nails normal. On 02/04/24 at 2:45 PM seen by NP1, no skin assessment documented on progress note. Resident sent out to the hospital for evaluation of left lower extremity. No documentation could be found to ensure any of the nurse practitioners had looked at R78's left lower extremity. During an interview on 02/14/24 at 8:00 AM, R78, when asked about the care he is receiving, stated, No, they are not doing anything for me. During the interview R78 continued to reiterate that the facility staff were not taking care of him. During an interview on 02/14/24 at 10:55 AM, the Wound Care Nurse stated, He [R78] was admitted in September, and he did not have any sores or wounds on his leg. The Wound Care Nurse further stated, His [R78] leg was discolored on admission, he [R78] was not getting any treatments to his left leg at all. During an interview on 02/14/24 at 11:45 AM, Registered Nurse Unit Manager (RN1) stated that R78 was ok on admission and R78 had no skin issues. RN1 further stated the facility was in the process of changing from paper to the computer system at that time. RN1 concluded that the resident would refuse care at times. RN1 stated, He [R78] would not let us look at his body nor his foot. During an interview on 02/14/24 at 12:58 PM, Licensed Practical Nurse (LPN)2 stated she did a body audit on 01/20/24. LPN1 revealed that R78 refused to let her check his left lower extremity. LPN1 stated she documented it under the skin and comprehensive assessments. LPN1 further stated that R78 would let her look at his bottom and privates but not his feet. LPN1 concluded that she did not tell anyone about his refusals. During an interview on 02/14/24 at 1:03 PM, Certified Nursing Assistant (CNA)1 revealed that she has worked at this facility for 14 years and has been a CNA for three years. CNA1 stated they would just set up his bath water and sometimes he would agree to go to the shower. CNA1 further stated there were no wound or sores on his left leg or foot. CNA1 stated his leg was skinny and she noticed no odor. CNA1 concluded, If I tried to wash him he would say that he could do it himself. During an interview on 02/14/24 at 1:09 PM, CNA2 revealed that she has worked at this facility for 22 years. CNA2 stated that R78 had no complaints of pain, he would get himself up every day with no assistance and get into a wheel chair. CNA2 stated she did notice that his leg was skinny, but had no odor. She stated that he would not let you see his body, he wanted to do everything for himself. During an interview at an unspecified date and time, the Nurse Practitioner (NP)1 stated that no one had told her that there was a new wound, once they reported it I saw him the next day. NP1 denies any odor and that most of the time he was up in the wheel chair with a blanket over his head. He had no fever at all. NP1 stated that they do an annual head to toe assessments. NP1 mentioned a communication book at the desk and there was no documentation of a new wound documented in the book for this resident. NP1 further stated the resident will decline help from staff and ask them to get out of his room. He can be nasty. He did not get looked at completely due to his behaviors. He has not been seen by psych and she stated she does not know his background. During an interview on 02/15/24 at 11:50 PM, NP2 stated she had not physically seen the resident's foot at all. She stated it was a vascular issue, no odor at all. NP2 went on to say that monthly and annually the doctor or the nurse practitioner will look at their skin and do a head-to-toe assessment. NP2 concluded the staff and techs will bring any acute skin issues to their attention by writing it in a communication book at the desk and then the physician will address any issues. During an interview on 02/15/24 at 2:20 PM, the attending Physician who is also the Medical Director (MD), stated that when he saw the resident's left leg it was only discolored, no open wounds or odor. The MD stated he first saw his left lower extremity on 09/26/24 when the resident was first admitted . He also mentioned the communication book at the nurse's desk, and stated that if the nurse sees any skin issues they will write it in the communication book. He went on to say that the nurse practitioner sees the residents more than he does. On 02/15/24 at 1:13 PM, the facility provided an acceptable Allegation of Compliance which documented the following: Immediate actions taken: NP was notified of the wound once staff were aware and she evaluated and resident was sent to the ER for further evaluation. Investigation was initiated immediately into the development of the wound and lack of documentation. QAPI initiated to address lack of documentation regarding, his skin assessments, his preferences, and refusals to allow staff to assess his skin and lack of care planning of his preferences and refusals. 100% audit of all residents in the facility complete on 02/05/2024 to ensure there were not other wounds in the facility that staff were unaware of. Educations initiated on 02/24/2024 for all licensed nurses and CNAs regarding skin assessments, baths, and assessing skin during baths, ensure baths are given as scheduled, ensuring resident refusals and preferences are all care planned appropriately. ADHOC QA Meeting held on 02/15/2024. Members present: Administrator, Director of Nursing, Regional Director of Clinical Services, the Social Services Director, the MDS, Care Plan Coordinator, and the Medical Director. Root cause of issue related to wound development and staff unaware: lack of documentation in medical record to support resident refusals to allow staff to assist with bathing or dressing or to assess his skin and lack of documentation on his care plan related to his refusals or his preferences. Audits of 100% of residents in facility completed on 02/05/2024 to ensure no other wounds in facility that staff were unaware of. There were no new wounds identified. Education was initiated with all licensed nurses and CNAs to include completion of body audits, documentation of refusals and resident preferences to include care planning. MDS education, completion of shower sheets to be completed by the CNA with each bath/shower. Education to ensure nurses and CNAs document any and all refusals of care as well as preferences. Any nurses left at this point will receive the education prior to next shift worked. Education initiated with 100% of staff on 02/14/2024 to review abuse and neglect policy and reporting. Any staff who were unable to be reached will have education complete prior to next shift worked. Audits will be complete M-Fri by the administrative nursing team to maintain a master list of residents and their bath schedules to ensure baths given as scheduled and that shower sheets were complete by CNA and any f/u was obtained. Review of all body audits that were due the previous day will be reviewed daily Monday through Friday during the daily clinical meeting by the Administrative to ensure that they were complete and any f/u needed was complete. Review of the eTAR will be reviewed daily during clinical meeting by Administrative nursing team for discrepancies and or missing documentation. Any refusals or variances in skin integrity noted on body audits and or shower sheets will be f/u to ensure any notifications and or communication needed with provider or nursing management and any further education needed for staff. QAPI committee will meet weekly to ensure all data from the previous week will be reviewed to determine effectiveness of the initial education and of the ongoing action plan. Documentation of this meeting should include the names of all parties present, topics that were discussed, minutes and any action items that were created as a result of a particular meeting. Administrator along with QAPI committee will determine need for continued monitoring and any adjustments needed to the plan. The above components have been implemented and complete as of 02/15/2024 by 10:00 AM.