**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment significantly (a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for two (Resident #1 and #2) of three residents reviewed for Notification of Changes. The facility failed to notify the physician of Resident #1's wound care consultant's recommendation of a doppler study six (6 ) times on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] and a recommendation to refer to a vascular doctor/ podiatrist/ or orthopedic doctor five (5) times on [DATE], [DATE], [DATE], [DATE], and [DATE], resulting in a right below knee amputation on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:55 p.m. While the IJ was removed on [DATE] at 12:25 p.m. the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. While not included in the immediate Jeopardy but still out of compliance at a scope of no actual harm: The facility failed to notify the physician of Resident #2's wound care consultant's recommendation of a vascular consult. This deficient practice placed residents at high risk of, or the likelihood of, serious injury, dismemberment, impairment, or death by not receiving treatment, developing complications, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Review of Resident #1's admission Record dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including malnutrition, uropathy (difficulty urinating due to a blocked urinary tract), cirrhosis of liver, and emphysema (damaged lungs). (The pressure ulcer to the heal was not listed) Review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed: He scored a 5 of 15 on his mental status exam. (Indicating severe cognitive impairment) Resident #1 had one stage III pressure ulcer that was present upon admission/entry and an other open lesion(s) on the foot. Review of Resident #1's Care Plan, initiated [DATE], revealed: Problem: The resident has an unstageable pressure injury to right heal related to disease process, history of ulcers and immobility. Updated on [DATE] revealed: wound now Stage III. The Goal was: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Identified approaches included: weekly treatment documentation to include measurement of each area of skin breakdown's width, length, type of tissue, and exudate initiated [DATE]. Review of Resident #1's admission note dated [DATE] revealed he was admitted to facility with an unstageable pressure ulcer to the right heel that was staged at the hospital. Resident #1's first documented assessment by the Wound Care Provider was [DATE] where the heel was staged as an unstageable approximately 3 cm length x 4.2 cm width x 0.1 cm depth with 100% necrotic tissue. Review of Resident #1's Wound Care Consultant's wound assessment, dated [DATE] , at 4:55 p.m., revealed the Wound Care Consultant #1 recommended Resident #1 see a vascular doctor. Review of Resident #1's Skin/Wound Note by the Treatment Nurse, dated [DATE] , at 4:55 p.m. documented: Resident #1 had no new orders at this time. (Nothing about the referral to a vascular doctor or notifying doctor of recommendation and a response) Review of Resident #1's Wound Care Consultant's wound assessment notes, dated [DATE] , at 5:19 p.m., revealed a recommendation for a Doppler Study and wound care orders. Review of Resident #1's Nurse Note by the Treatment Nurse dated [DATE] at 5:19 p.m., documented new order for Mupirocin 2% to be applied to right 4th toe. (Nothing about the referral to a vascular doctor or notifying doctor of recommendation and a response) Review of Resident #1's Wound Care Consultant assessment note dated [DATE] , at 9:25 a.m., documented recommendations to have a vascular consultant and a Doppler Study. Review of Resident #1's Skin/Wound Note by the treatment nurse dated [DATE] , at 9:25 a.m., revealed note received no new orders at this time. (Nothing about the referral to a vascular doctor or notifying doctor of recommendation and a response) Review of Resident #1's Wound Care Consultant note dated [DATE], at 5:33 p.m., revealed a recommendation for a Doppler Study. Review of Resident #1's Skin/Wound Note completed by the Treatment Nurse on [DATE] at 5:33 p.m., documented new orders to clean stage 3 to right heel with normal saline, pat dry with 4x4 gauze, apply anasept and collagen to wound bed and cover with supper absorptive dressing daily and as needed until healed. (Nothing about the recommendation for outside services). Review of Resident #1's Wound Consultant assessment note dated [DATE] revealed orders for: x-ray to right foot to rule out osteomyeliti s (bone infection), labs CBC, CMP, ESR, and CRP., a bone culture for pathology, refer a vascular surgeon to assess PAD/flow status, and once seen by vascular refer to podiatry or orthopedic for right 2nd toe. Review of Resident #1's Skin/Wound note completed by the Treatment Nurse, dated [DATE] at 5:10 p.m., revealed new wound care orders, to draw labs CBC, CMP, ESR and CPR complete a Bone pathology on bone, and an X-ray to right foot to rule out osteomyelitis. Review of Resident #1's Skin/wound note completed by the Treatment Nurse, dated [DATE], at 1:10 p.m. revealed a three-view x-ray to rule out osteomyelitis was completed. Review of Resident #1's Nurse note dated [DATE] at 1:48 p.m. revealed the facility received the lab results and they were forwarded to Resident #1's primary physician. Review of Resident #1's Wound Care Consultant Assessment Note dated [DATE] at 4:15 p.m. revealed recommendations for x-ray right foot, bone pathology, labs CBC, CMP, ESR, and CRP, refer vascular, podiatry/ orthopedic. Notes included: patient removed dressing ' heel wound dry, edges slight peeling no signs or symptoms of infection. Also wound cultures positive. Review of Resident #1's Skin/Wound note completed by the Treatment Nurse, dated [DATE], at 4:58 p.m., documented received no new orders at this time. Review of Resident #1's Wound Care Consultant Note dated [DATE], at 4:59 p.m., documented: MRI scheduled, seeing Vascular in July. There were no other notes. Review of Resident #1's Skin/Wound Notes completed by Treatment nurse, dated [DATE], at 4:59 p.m., revealed new wound care orders. Review of Resident #1's Skin/Wound Notes completed by the treatment nurse dated [DATE] at 5:19 a.m. revealed: no new orders. Review of Resident #1's skin/wound note dated [DATE], at 2:19 p.m. completed by the treatment nurse documented received no new orders Review of Resident #1's Nurse Notes dated [DATE], at 1:55 p.m., revealed: Resident complains of pain to right heel, states the pain is getting worse than it has been, medicated with as needed dose of tramadol, received orders for x-ray to right foot 3 views. Review of Resident #1's Consultant Wound Care Assessment Notes, dated [DATE], at 2:44 p.m. revealed: referrals: refer to podiatrist, following PAD assessment, please refer to vascular surgeon to evaluate PAD severity and revascularization. (This was a telehealth appointment). Review of Resident #1's Skin/Wound Note on [DATE] at 2:52 p.m., by the Treatment Nurse revealed, Received no new orders. Review of Resident #1's Consultant Wound Care Notes dated [DATE] at 8:00 a.m. by Wound Care Specialist B documented the appointment was telehealth. Review of Resident #1's Skin/Wound note dated [DATE] at 8:06 a.m. by the treatment nurse documented no new orders. Review of Resident #1's Wound Consultation Form Completed by Wound Care Specialist B dated [DATE] at 10:00 - 10:12 a.m. revealed it was a telehealth appointment and she recommended arterial studies. Review of Resident #1's Nurse notes dated [DATE] at 11:18 a.m. documented Resident #1 requested to go to emergency room for pain and drainage to right foot, reports he is not feeling well and has not been eating for days due to pain. Notified doctor of resident request to go to emergency room and received orders to send to emergency room for evaluation. Review of Resident #1's Nurse Notes dated [DATE] at 6:06 p.m. revealed: Called hospital for update on Resident #1, spoke with his hospital nurse. Resident admitted to hospital with diagnosis of right foot infection, they attempted an MRI but resident did not stay still so it was unsuccessful., Review of Resident #1's Hospital History and Physical dated [DATE] revealed Patient (Resident #1) reports he was in his usual state of health until approximately 4 months prior to admission when he had a foot ulcer at base of heel. Wound care had been done at nursing home once a week. Nursing home nurse reports patient had POOR compliance and he was nonadherent to advise and recommendations provided from nurses and wound care. Patient was on oral antibiotics at nursing home from 6/19 - 6/26 due to concern for MRSA on wound. Symptoms did not improve. Was going to be taken to city wound care, but today he complained of generalized foot pain, which he states had been present daily for months so he was unsure why he was brought to the local hospital. Subjective: Has necrotic heal and toe gangrene due to vascular insufficiency due to smoking. Review of Resident #1's Nurse's Notes dated [DATE] revealed: Arrived to facility, Wound to right below the knee stump intact/ wrapped. Wound with 17 staples. Interview on [DATE] at 4:15 p.m., the ADON stated Resident #1 was sent to the hospital. The ADON stated on [DATE] Resident #1 went to her and complained of a lot of pain to his right leg so they sent him to the emergency room. The ADON stated at the time of the interview Resident #1 was still in the hospital, but she was told he had a below the knee amputation. The ADON said she was unsure of the reason. The ADON stated Resident #1 had an infection that was being treated at the nursing facility with antibiotics. The ADON said Resident #1 would hang his foot off the edge of the bed instead of elevating it on a cushion. The ADON stated Resident #1 would refuse wound care; take the dressing off because he wanted the wound to air dry; and was a heavy smoker. The ADON said the facility tried to have a wound care consultation in the nearby city's wound care clinic prior to the amputation. Interview on [DATE] at 4:42 p.m., the DON stated Resident #1 was admitted to the hospital on [DATE] due to complaint of leg pain on the right side. The DON said Resident #1 was admitted to the facility with the wound and was seen by a wound care consultant company. The DON stated Resident #1 had labs and an x-ray done as well as wound cultures which showed MRSA . The DON said Resident #1's physician referred Resident #1 to a wound care center in a nearby city because they might have more things to treat Resident #1 with. The DON stated Resident #1 was sent to the hospital prior to that appointment. The DON stated she thought Resident #1 needed to go to the hospital because his foot was discolored, and Resident #1 would not keep his foot elevated. The DON denied Resident #1 being in constant pain. The DON said Resident #1 received daily wound care and the wound care orders came directly from the wound care specialist. Interview on [DATE] at 12:18 p.m., Resident #1's Responsible Party stated the facility kept him informed of the treatments they were doing. The Responsible Party said he did not know if the treatments worked but he was kept informed. The Responsible Party stated he wondered if Resident #1's amputation could have been prevented. The Responsible Party said the facility was in process of getting an appointment scheduled to see a wound care doctor but then Resident #1 went to the hospital on [DATE] due to leg pain and got it amputated while there thus the appointment was cancelled. Interview on [DATE] at 1:25 p.m., Resident #1's Doctor stated he was aware of the amputation. The physician stated Resident #1 had PAD and that could quickly turn into gangrene. The physician felt the wound care specialists whom was seeing the resident at the facility had a good plan going for the resident and he was happy with the plan. Interview on [DATE] at 2:28 p.m., the Treatment Nurse stated Resident #1 was admitted to the facility with an unstageable pressure ulcer. The Treatment Nurse stated she told the physician of the wound care consultant's recommendations. The Treatment Nurse stated the wound was stable and Resident #1 had wound care daily. The Treatment Nurse stated she did the wound care on [DATE] prior to Resident #1 going to the hospital and did not notice anything different with the wound. The Treatment Nurse stated Resident #1 complained of pain which was usual, but he had taken his pain medication at that time on [DATE]. The Treatment Nurse said the wound did not look like gangrene to her. The Treatment Nurse stated the wound care consultant would do appointments through tele med which was like Facetime with a cellphone. The Treatment Nurse explained she would take her cell phone into Resident #1's room and show the wound care consultant the wound and the consultant would say what it looked like. The Treatment Nurse was shown the Consultant's Noted dated [DATE] that documented a referral to a podiatrist or vascular doctor. The Treatment Nurse said she did recall the consultant asking for the referral but she just forgot to do it (contact the physician and set up the vascular consult). The Treatment Nurse said she remembered about the vascular consult appointment when the Ombudsman came and asked if it was done on [DATE] (19 days later) and that was when she started to set up the appointment but then the resident had his leg amputated. The Treatment Nurse stated she was aware the Wound Care Specialists recommended Resident #1 be seen by a vascular doctor and have a doppler study to the right foot on [DATE], [DATE], [DATE], and [DATE] but she forgot to get it done. Interview on [DATE] at 4:22 p.m., the Administrator and DON stated their expectation was for the wound care specialists' recommendations to be brought up to the physician by the Treatment Nurse. They stated the physician would usually approve recommendations or change the order as he wanted to. The DON stated she did not know there were orders for Resident #1 to be seen by a vascular doctor since [DATE]. The DON said she should have probably checked on the Treatment Nurse to make sure she was following the recommendations suggested by the wound care specialists. A phone interview on [DATE] at 12:58 p.m., the Wound Care Specialist A stated she recommended Resident #1 be seen by a vascular doctor numerous times and for the facility to get a doppler study done. The Wound Care Specialist stated she was told by facility staff that the physician refused the recommendations and the doppler study and had recommended Resident #1's foot just be monitored. The Wound Care Specialist stated she did not know if Resident #1 being seen by a vascular doctor would have prevented Resident #1's amputation but earlier intervention was better than no intervention at all. Phone interview on [DATE] at 1:14 p.m., Resident #1's physician stated he did not say no to the recommendations made by the wound care specialists. The physician said he would not just ask for the resident's leg to just be monitored. The physician stated he would have welcomed recommendations since the wound care specialist saw the wound in person and had a better idea of what to do next. Interview on [DATE] at 2:02 p.m., the DON confirmed there was the same order for a vascular doctor and doppler study for three months. The DON said the Treatment Nurse never turned in the wound care assessments. The DON stated when she asked the Treatment Nurse why it was not done the Treatment Nurse said she did not know how. Phone interview on [DATE] at 4:42 p.m., the Treatment Nurse stated Resident #1 received wound care daily and saw the wound care consultant weekly. The Treatment Nurse said in the beginning there were no recommendations. The Treatment Nurse stated at the end the wound care specialists were recommending a vascular, labs, x-rays, cultures - all of it. The Treatment Nurse said she did it all except for the vascular doctor. She said she did not know why did not do it. The Treatment Nurse did not answer when asked why it was not done for three months. The Treatment Nurse stated one time she told the ADON and the ADON told the treatment Nurse that doppler studies were not done in their city. At the end of the interview, the Treatment Nurse stated I don't know, I guess I thought I could take care of it myself and now it's too late. Non-IJ Review of Resident #2's admission Record dated [DATE] reviewed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare following surgical amputation, acquired absence of other right toe(s), reduced mobility, abnormal weight loss. Review of Resident #2's Quarterly MDS Assessment, dated [DATE], revealed: She scored a 0 of 15 on her mental status exam (indicating severe cognitive impairment). She had a stage III pressure ulcer. Review of Resident #2's Care Plan, initiated [DATE], revealed: Focus: Resident has a stage III to right lower lateral extremity. Goal: The resident's Pressure ulcer will signs of healing and remain free from infection through review date. The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions: Assess/record/monitor wound healing daily. Measure length, width, and depth where possible weekly. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Follow facility policies/ protocols for the prevention/treatment of skin breakdown. Review of Resident #2's Order Summary Report, dated [DATE], revealed orders: Wound Care Consultant Company dated [DATE] Review of Resident #2's Wound Care Consultant report, dated [DATE], revealed refer to vascular surgery, evaluate Peripheral Artery Disease and potential treatment options. Review of Resident #2's Skin/Wound note dated [DATE] by the Treatment Nurse revealed: Wound care specialist evaluated via telemed at this time. Right lower lateral extremities measures approximately 3cm x 1.5cm x 0.4 cm. Wound tissue is 100% granulation. No new orders at this time. Interview on [DATE] at 1:03 p.m. the DON confirmed Resident #2's Wound Care Consultant Report and skin/wound notes did not match and there had been a referral made. Interview on [DATE] at 1:38 p.m. the DON agreed Resident #2's notes was another referral that was not reflected in the skin/wound notes. The DON stated she did not understand why everything in-house was completed but outside appointments were not made The DON re-iterated that out-of-town appointments were made Tuesday/ Thursday but the facility would go where they needed to go. The DON said she could not think of a reason why the referrals were not made. Review of the facility's policy and procedure on Change in Condition, dated [DATE], revealed: Policy - Corporation communities will use the interact definition for Change in Condition. It will be the policy that once the nurse has notified the physician for a change in condition, the resident/patient will be monitored for 1 hour until the physician has responded. The monitoring will included vital signs, pulse ox, and finger stick blood sugar if a diabetic (one time only). A physical assessment should be completed relative to the symptoms present a pain assessment. If you are unable to reach physician within 2 hours, repeat call. If you are still unable to reach the physician you may call the Medical Director. If the resident/patient condition appears emergent, transfer to local emergency room may occur with physician order. The Administrator and DON were informed an Immediate Jeopardy on [DATE] at 2:55 p.m., due to the above failures and provided the IJ template. A plan of removal was requested at that time. The Plan of Removal was accepted on [DATE] at 12:25 p.m.,. and included the following: All orders with wound care consultant company will be reviewed with DON within 24 hours of visit. The Administrator and DON will review all physician, pharmacy and support services recommendations to be reviewed within 20 hours of the recommendation and all orders sent, written and reviewed. DON or ADON will review all orders requiring physician and/or specialist referrals to ensure referrals are handled in a timely manner beginning [DATE]. The Medical Director, Licensed Nurses and wound care specialist will be provided in-service education related to the referral process. Physician referral process for sending residents to a specialist or outside physician services by obtaining the Medical Director's referral order beginning on [DATE] by DON or Designee which includes: 1. Notify DON to confirm need for resident referral. 2. Notify Physician of Referral Order Needed with details of the diagnosis and reason for referral. 3. Charge Nurse, Social Worker and/or designee to call in referral order, confirm insurance, and make appointment with Specialist and arrange for appropriate transportation. 4. Administrator to be notified if referrals are refused or denied by physician or Medical Director and reason for the denial. All current and newly hired nurses will receive in-service regarding physician referral to begin [DATE]. Validation/Monitoring Tools: DON or designee will validate staff knowledge base through random questioning [DATE]. DON and/or designee will review any referral orders documented by reviewing orders daily in the daily in clinical meeting to ensure appointments are being made. Referrals and appointment will be placed on the 24-hour report. Beginning [DATE]. DON and/or designee will review all wound care patient's progress and status for the need for referrals during Standards of Care Meeting weekly Beginning [DATE]. The Administrator, DON, and/or designee will review the action plan developed related to the Referral Process in QA meeting monthly during the next six months. Beginning [DATE]. DON/ADON/Regional RN auditing/reviewing all skin treatment orders, all wound care specialist's notes and recommendations, assessing appropriateness of orders for all skin issues. [DATE] (No further referrals or recommendations found). One wound care specialist recommendation sent to Medical Director. Immediate Action: The Administrator/DON provided one on one in-servicing to all on-duty staff on [DATE] and [DATE]. Immediate Action -Observation on [DATE] at 10:54 a.m. surveyor observed Administrator calling the Medical Doctor and handing the phone to the DON for the wound care specialist's recommendation on Resident #2. Facility provided signed one on one in-services by facility staff on [DATE]. Review of the 24-hour report for [DATE] and [DATE] revealed appointments needed to be made were written in red by the resident's name. If a follow up appoint was made it was written under it in a black pen. Review of the calendar on the ADON's wall on [DATE] at 12:00 revealed appointments were scheduled. Immediate Action - a 100% skin sweep was completed by the DON, the Corporate Compliance RN, the ADON and LVN C. No new pressure ulcers were identified. The administrator was notified the IJ was removed on [DATE] at 12:43 p.m., however the facility remained out of compliance, at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from neglect for 1 of 3 residents reviewed for neglect (Resident #1). The facility failed to ensure that the Treatment Nurse made the referral for a doppler study six times on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], or an orthopedic/ podiatrist/ and/or a vascular doctor five times on [DATE], [DATE], [DATE], [DATE], and [DATE]). This resulted in Resident #1 having a below the knee amputation on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:55 p.m. While the IJ was removed on [DATE] at 12:43 p.m., the facility remained out of compliance at actual harm with a potential for more than minimal harm at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for negative outcomes including decline in wounds, dismemberment, severe infection, and death. Findings included: Review of Resident #1's admission Record dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including malnutrition, uropath y (difficulty urinating due to a blocked urinary tract), cirrhosis of liver, and emphysem a (damage of the lung tissue). (The pressure ulcer to the heal was not listed) Review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed: He scored a 5 of 15 on his mental status exam. (Indicating severe cognitive impairment) Resident #1 had one stage III pressure ulcer that was present upon admission/entry and an other open lesion(s) on the foot. Review of Resident #1's Care Plan, initiated [DATE], revealed: Problem: The resident has an unstageable pressure injury to right heal related to disease process, history of ulcers and immobility. Updated on [DATE] revealed: wound now Stage III. The Goal was: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Identified approaches included: weekly treatment documentation to include measurement of each area of skin breakdown's width, length, type of tissue, and exudate initiated [DATE]. Review of Resident #1's admission note dated [DATE] revealed he was admitted to facility with an unstageable pressure ulcer to the right heel that was staged at the hospital. Resident #1's first documented assessment by the Wound Care Provider was [DATE] where the heel was staged as an unstageable approximately 3 cm length x 4.2 cm width x 0.1 cm depth with 100% necrotic tissue. Review of Resident #1's Wound Care Consultant's wound assessment, dated [DATE], at 4:55 p.m. revealed the Wound Care Consultant #1 recommended Resident #1 see a vascular doctor. Review of Resident #1's Skin/Wound Note by the Treatment Nurse, dated [DATE], at 4:55 p.m. documented: no new orders at this time . Review of Resident #1's Wound Care Consultant's wound assessment notes, dated [DATE], at 5:19 p.m. revealed a recommendation for a Doppler Study . Review of Resident #1's Skin/Wound Note by the Treatment Nurse dated [DATE] at 5:19 p.m. p.m. documented new order for Mupirocin 2% (antibiotic ointment) to be applied to right 4th toe (there was nothing about the Doppler Study). Review of Resident #1's Wound Care Consultant assessment note dated [DATE] at 9:25 a.m., documented recommendations to have a vascular consultant and a Doppler Study for Resident #1. Review of the Skin/Wound Note for Resident #1, written by the treatment nurse dated [DATE] at 9:25 a.m. revealed note received no new orders at this time. Review of Resident #1's Wound Care Consultant assessment note dated [DATE] at 5:33 p.m. revealed a recommendation for a Doppler study. There was no corresponding nurse's or skin/wound note for Resident #1 on [DATE]. Review of Resident #1's Wound Care Consultant note dated [DATE] at 5:33 p.m., revealed a recommendation for a Doppler Study. Review of Resident #1's Skin/Wound Note completed by the Treatment Nurse on [DATE] at 5:33 p.m. documented new orders to clean stage 3 to right heel with normal saline, pat dry with 4x4 gauze, apply anasept and collagen to wound bed and cover with supper absorptive dressing daily and as needed until healed. (Nothing about the recommendation for outside services) Review of Resident #1's Wound Consultant assessment note dated [DATE] at 5:10 p.m. revealed orders for: x-ray to right foot to rule out osteomyelitis (bone infection), Labs CBC, CMP, ESR, and CRP., a bone culture for pathology, refer a vascular surgeon to assess PAD/flow status, and once seen by vascular refer to podiatry or orthopedic for right 2nd toe. Review of Resident #1's Skin/Wound note completed by the Treatment Nurse, dated [DATE] at 5:10 p.m., revealed new wound care orders, to draw labs CBC, CMP, ESR and CPR complete a Bone pathology on bone, and an X-ray to right foot to rule out osteomyelitis. Review of Resident #1's Skin/wound note completed by the Treatment Nurse, dated [DATE] at 5:10 p.m., revealed a three-view x-ray to rule out osteomyelitis was completed. Review of Resident #1's Nurse note dated [DATE] at 1:48 p.m. revealed the facility received the lab results and they were forwarded to Resident #1's primary physician. Review of Resident #1's Wound Care Consultant Assessment Note dated [DATE] at 4:15 p.m. revealed recommendations for x-ray right foot, bone pathology, labs CBC, CMP, ESR, and CRP, refer vascular, podiatry/ orthopedic. Notes included: patient removed dressing ' heel wound dry, edges slight peeling no signs or symptoms of infection. Also wound cultures positive. Review of Resident #1's skin/wound note completed by the Treatment Nurse, dated [DATE] at 4:58 p.m., documented received no new orders at this time. Review of Resident #1's Wound Care Consultant Note dated [DATE] at 4:59 p.m. documented: MRI scheduled, seeing Vascular in July. There were no other notes. Review of Resident #1's Skin/Wound Notes completed by Treatment nurse, dated [DATE] at 4:59 p.m., revealed new wound care orders. Review of Resident #1's Skin/Wound Notes completed by the treatment nurse dated [DATE] at 5:19 a.m. revealed: no new orders. Review of Resident #1's skin/wound note dated [DATE] at 2:19 p.m. completed by the treatment nurse documented received no new orders Review of Resident #1's Nurse's Notes dated [DATE] at 1:55 p.m. revealed: Resident complains of pain to right heel, states the pain is getting worse than it has been, medicated with as needed dose of tramadol, received orders for x-ray to right foot 3 views. Review of Resident #1's Consultant Wound Care Assessment Notes, dated [DATE] at 2:33 p.m., revealed: referrals: refer to podiatrist, following PAD assessment, please refer to vascular surgeon to evaluate PAD severity and revascularization. (This was a telehealth appointment). Review of Resident #1's Skin/Wound Note dated [DATE] at 2:52 p.m. revealed received no new orders. Review of Resident #1's Consultant Wound Care Notes dated [DATE] a 8:00 a.m. by Wound Care Specialist B documented the appointment was telehealth. Review of Resident #1's skin/wound note dated [DATE] at 8:06 a.m. by the treatment nurse documented no new orders. Review of Resident #1's Wound Consultation Form Completed by Wound Care Specialist B dated [DATE] at 10:00 a.m. - 10:12 a.m. revealed it was a telehealth appointment and she recommended arterial studies. Review of Resident #1's Nurse notes dated [DATE] at 11:18 a.m. documented Resident requesting to go to emergency room for pain and drainage to right foot, reports he is not feeling well and has not been eating for days due to pain. Notified doctor of resident request to go to emergency room and received orders to send to emergency room for evaluation. Review of the Nurse Notes dated [DATE] at 6:05 p.m. revealed: Called hospital for update on resident, spoke with his hospital nurse. Resident admitted to hospital with diagnosis of right foot infection, they attempted an MRI but resident did not stay still so it was unsuccessful, Review of Resident #1's Hospital History and Physical dated [DATE] revealed Patient reports he was in his usual state of health until approximately 4 months prior to admission when he had a foot ulcer at base of heel. Wound care had been done at nursing home once a week. Nursing home nurse reports patient had POOR compliance and he was nonadherent to advise and recommendations provided from nurses and wound care. Patient was on oral antibiotics at nursing home from 6/19 - 6/26 due to concern for MRSA on wound. Symptoms did not improve. Was going to be taken to city wound care, but today he complained of generalized foot pain, which he states had been present daily for months so he was unsure why he was brought to the local hospital. Subjective: Has necrotic heal and toe gangrene due to vascular insufficiency due to smoking. Review of Resident #1's Nurse Notes dated [DATE] at 3:45 p.m. revealed: Arrived to facility, Wound to right below the knee stump intact/ wrapped. Wound with 17 staples. Interview on [DATE] at 4:15 p.m., the ADON stated Resident #1 was sent to the hospital. The ADON stated on [DATE] Resident #1 went to her and complained of a lot of pain to his right leg so they sent him to the emergency room. The ADON stated at the time of the interview Resident #1 was still in the hospital, but she was told he had a below the knee amputation. The ADON said she was unsure of the reason. The ADON stated Resident #1 had an infection that was being treated at the nursing facility with antibiotics. The ADON said Resident #1 would hang his foot off the edge of the bed instead of elevating it on a cushion. The ADON stated Resident #1 would refuse wound care; take the dressing off because he wanted the wound to air dry; and was a heavy smoker. The ADON said the facility tried to have a wound care consultation in the nearby city's wound care clinic prior to the amputation. Interview on [DATE] at 4:42 p.m., the DON stated Resident #1 was admitted to the hospital on [DATE] due to complaint of leg pain on the right side. The DON said Resident #1 was admitted to the facility with the wound and was seen by a wound care consultant company. The DON stated Resident #1 had labs and an x-ray done as well as wound cultures which showed MRSA . The DON said Resident #1's physician referred Resident #1 to a wound care center in a nearby city because they might have more things to treat Resident #1 . The DON stated Resident #1 was sent to the hospital prior to that appointment. The DON stated she thought Resident #1 needed to go to the hospital because his foot was discolored, and Resident #1 would not keep his foot elevated. The DON denied Resident #1 being in constant pain. The DON said Resident #1 received daily wound care and the wound care orders came directly from the wound care specialist. Interview on [DATE] at 12:18 p.m., Resident #1's Responsible Party stated the facility kept him informed of the treatments they were doing. The Responsible Party said he did not know if the treatments worked but he was kept informed. The Responsible Party stated he wondered if Resident #1's amputation could have been prevented. The Responsible Party said the facility was in process of getting an appointment scheduled to see a wound care doctor but then Resident #1 went to the hospital on [DATE] due to leg pain and got it amputated while there thus the appointment was cancelled. Interview on [DATE] at 1:25 p.m. Resident #1's Doctor stated he was aware of the amputation. The physician stated Resident #1 had PAD and that could quickly turn into gangrene. The physician felt the wound care specialists who was seeing the resident at the facility had a good plan going for the resident and he was happy with the plan. Interview on [DATE] at 2:28 p.m. the Treatment Nurse stated Resident #1 was admitted to the facility with an unstageable pressure ulcer. The Treatment Nurse stated she told the physician of wound care consultant's recommendations. The Treatment Nurse stated the wound was stable and Resident #1 had wound care daily. The Treatment Nurse stated she did the wound care on [DATE] prior to Resident #1 going to the hospital and did not notice anything different with the wound. The Treatment Nurse stated Resident #1 complained of pain which was usual, but he had taken his pain medication at that time on [DATE]. The Treatment Nurse said the wound did not look like gangrene to her. The Treatment Nurse stated the wound care consultant would do appointments through telemed which was like Facetime with a cellphone. The Treatment Nurse explained she would take her cell phone into Resident #1's room and show the wound care consultant the wound and the consultant would say what it looked like. The Treatment Nurse was shown the Consultant's Noted dated [DATE] that documented a referral to a podiatrist or vascular doctor. The Treatment Nurse said she did recall the consultant asking for the referral but she just forgot to do it (contact the physician and set up the vascular consult). The Treatment Nurse said she remembered about the vascular consult appointment when the Ombudsman came and asked if it was done on [DATE] (19 days later) and that was when she started to set up the appointment but then the resident had his leg amputated. The Treatment Nurse stated she was aware the Wound Care Specialists recommended Resident #1 be seen by a vascular doctor and have a doppler study to the right foot on [DATE], [DATE], [DATE], and [DATE] but she forgot to get it done. Interview on [DATE] at 4:22 p.m., the Administrator and DON stated their expectation was for the wound care specialists' recommendations to be brought up to the physician by the Treatment Nurse. They stated the physician would usually approve recommendations or change the order as he wanted to. The DON stated she did not know there were orders for Resident #1 to be seen by a vascular doctor since [DATE]. The DON said she should have probably checked on the Treatment Nurse to make sure she was following the recommendations suggested by the wound care specialists. Phone interview on [DATE] at 12:58 p.m., Wound Care Specialist A stated she recommended Resident #1 be seen by a vascular doctor numerous times and for the facility to get a doppler study done. The Wound Care Specialist stated she was told by facility staff that the physician refused the recommendations and the doppler study and had recommended Resident #1's foot just be monitored. The Wound Care Specialist stated she did not know if Resident #1 being seen by a vascular doctor would have prevented Resident #1's amputation but earlier intervention was better than no intervention at all. Phone interview on [DATE] at 1:14 p.m. Resident #1's physician stated he did not say no to the recommendations made by the wound care specialists. The physician said he would not just ask for the resident's leg to just be monitored. The physician stated he would have welcomed recommendations since the wound care specialist saw the wound in person and had a better idea of what to do next. Interview on [DATE] at 1:04 p.m. the Administrator summarized that Resident #1 was admitted with a wound. The Administrator stated Resident #1 was a smoker and was non-compliant with elevating his foot. The Administrator said the Treatment Nurse was monitoring the wound. The Administrator stated fast forward the wound care specialists texted the Treatment Nurse recommendations of a referral to a vascular doctor and it was not done. The Administrator said it was not done and the Treatment Nurse said she missed it. The Administrator said the DON was not getting the wound care specialist's notes so would not get the recommendation. Interview on [DATE] at 2:02 p.m. the DON confirmed there was the same order for a vascular doctor and doppler study for three months. The DON said the Treatment Nurse never turned in the wound care assessments. The DON stated when she asked the Treatment Nurse why it was not done the Treatment Nurse said she did not know how. Phone interview on [DATE] at 3:58 p.m. Wound Care Specialist B stated the Treatment Nurse told her that vascular recommendation was not followed because it was a transportation issue. Wound Care Specialist B said she recommended the vascular doctor every week and she understood it was difficult. Wound Care Specialist B stated she mainly did telehealth appointments with the facility. The Wound Care Specialist stated to her knowledge the facility did not follow through with the recommendation, then the facility informed Wound Care Specialist B that Resident #1 went to the hospital, and they amputated his leg. Wound Care Specialist B said she made the recommendation weekly and the Treatment Nurse told her it was a transportation issue. Wound Care Specialist B said to her knowledge her recommendations were not done. Wound Care Specialist B said she understood the facility was in a rural area and the closest vascular doctor was an hour and half away in the closest city. Wound Care Specialist B said Resident #1's physician was involved because at some point Resident #1 was placed on an antibiotic she did not prescribe. Wound Care Specialist B said she (Wound Care Specialist B) and Wound Care Specialist A had similar recommendations. Wound Care Specialist B said she and the Treatment Nurse talked weekly, but the Treatment Nurse would not always inform her of every change. Treatment Nurse B was informed there was a referral made to the nearest city's wound care clinic and responded I can't imagine they would get a different result. Wound Care Specialist B repeated she recommended vascular studies and to her knowledge they were never followed up. Wound Care Specialist B stated the last time she saw Resident #1 was [DATE] and the wound looked the same and she made the same recommendation of a vascular consult. Wound Care Specialist B said she was trying to be patient for the facility to get it done and the Treatment Nurse just told her (Specialist B) that it was very difficult to get the tests done. Phone interview on [DATE] at 4:42 p.m. the Treatment Nurse stated Resident #1 received wound care daily and saw the wound care consultant weekly. The Treatment Nurse said in the beginning there were no recommendations. The Treatment Nurse stated at the end the wound care specialists were recommending a vascular, labs, x-rays, cultures - all of it. The Treatment Nurse said she did it all except for the vascular doctor. She said she did not know why did not do it. The Treatment Nurse did not answer when asked why it was not done for three months. The Treatment Nurse said she did not know why she told Wound Care Specialist B that it was a transportation issue, then added it was because she (the Treatment Nurse) overlooked it and did not know what to say. The Treatment Nurse stated one time she told the ADON and the ADON told the treatment Nurse that doppler studies were not done in their city. The Treatment Nurse said she did not know why she did not put the vascular appointment/ doppler study/ orthopedic / podiatrist referrals in her notes when all the other recommendations were in the notes. At the end of the interview, the Treatment Nurse stated, I don't know, I guess I thought I could take care of it myself and now it's too late. Interview on [DATE] at 4:59 p.m., the ADON stated she Resident #1 was noncompliant and smoked a lot. The ADON said the day she sent Resident #1 to the Emergency Room; Resident #1 was complaining of a lot of pain to his foot and requested to go. The ADON stated that was the first time she sent Resident #1 to the emergency room for foot pain. The AODN stated there was a nurse's meeting every day and issues that came up were discussed; she said the Treatment Nurse would bring up that wounds were not healing because Resident #1 was noncompliant and would not use a heel cushion and hang his foot off the bed. The ADON stated she was not present if the Treatment Nurse brought up wound care recommendations. The ADON stated she was never told of any referrals. The ADON stated the doppler study statement made by Treatment Nurse was maybe because the facility tried to get a doppler study on another resident about a year ago and the ADON said the hospital at their city did not do them. The ADON stated she should have been made aware of the Wound Care Specialist's recommendations because she was the ADON. The ADON stated under the previous DON, the Treatment Nurse would talk to the ADON about the wounds because the previous DON did not know much about wound care. Interview on [DATE] at 5:14 p.m. the Administrator, stated whoever got the order for a referral was responsible for notifying the physician and putting in the order. The Administrator stated the facility did go as far as the nearest city. The Administrator stated typically the Transportation Aide would take the resident and a CNA. The Administrator stated appointments to other cities were done on Tuesdays and Thursdays because of the dialysis appointments on Monday/ Wednesday/ Friday. The DON said she was not made aware of any referrals to a vascular doctor, so she got the order for Resident #1 to go to the wound care clinic in the nearest city. The DON said Resident #1 was sent to the emergency room before the appointment could occur. Interview and record review on [DATE] at 12:07 p.m., the Transportation Aide stated she did the dialysis appointments on Monday/ Wednesday/ Friday but on Tuesday/ Thursday she took the residents to other appointments. The Transportation aide said the facility would go where the resident needed to go. The Transportation Aide said she did take residents to the nearest city at least weekly. The Transportation Aide said she did not remember taking Resident #1 to any appointments and she was never told to make an appointment for him. The Treatment Nurse handed over the calendar for 2023 and it did show other residents were taken to other cities for outside appointments. Review of the transportation schedule from [DATE] - [DATE] showed Resident #1 had no appointments made. Interview on [DATE] at 4:18 p.m., the DON stated the definition of neglect would be not meeting the resident's needs. She stated neglect did not have to be intentional and it could be subtle. The DON stated not getting the appointments for Resident #1 did meet the definition of neglect because the Treatment Nurse knew about it and did not get it. The DON said the facility could not say if the outcome to Resident #1 would be the same if Resident #1 got the referrals. The DON said the order should have been put into Resident #1's record. The DON said she could not wrap her head around the whole situation but did feel it was neglectful. Interview on [DATE] at 4:57 p.m., the Administrator stated the facility trained all staff that residents were to be from any type of abuse or neglect and if the staff felt the resident was being neglected, they needed to report up the chain of command. The Administrator said the referrals were overlooked but she could not argue that not having the referrals done did not meet the definition of neglect. Review of the facility's policy and procedure on Compliance with Abuse, revised [DATE] revealed: the purpose of this policy is to ensure that each resident has the right to be free from any form of abuse, neglect, intimidation, involuntary seclusion/confinement and or misappropriated of property Review of the facility's policy and procedure on Clinical Protocol on Abuse and Neglect, revised 4/2013 revealed: Assessment and Recognition: 1. The nurse will assess the individual and document related findings. Assessment data will include: Injury assessment (bleeding, bruising, deformity, swelling etc.) 2. The nurse will report findings to they physician. As needed, the physician will assess the resident to verify or clarify such findings, especially if the cause or source of the problem is unclear. 3. As part of the initial assessment, the physician will help identify individuals who have a history of being abused or neglect, or those who might have been abused or neglected; for example, individuals admitted from home or the hospital with multiple pressure ulcers and severe under-nutrition. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility's computer training (done on a rotating basis) on identifying Neglect revealed: Policy Statement: As part of the strategy to prevent abuse, neglect, mistreatment and exploitation of residents, volunteers, employees, and contractors hired by this facility are expected to be able to identify neglect as it may occur against residents. Policy Interpretation and Implementation: Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident are necessary to avoid physical harm, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference to or disregard for resident care, comfort, or safety results (or have resulted in) physical harm, pain, mental anguish, or emotional distress. Neglect may be a pattern of failures or may be the result of one or more failures involving one resident and one staff person. Neglect of goods or services may occur when staff are aware of, or should have been aware, of residents/' care needs based on assessment and care planning but are unable to meet the identified needs due to other circumstances. Goods and services that the resident needs are identified and addressed through the following: Oversight and monitoring of staff performance. Oversight and monitoring of contracted services or services provided under arrangement. Examples of failure to provide care and services to the resident that result in neglect include: Failure to identify, assess, and/or contact a physician and/or prescriber for an acute change in condition, and/or a change in condition that requires the plan of care to be revised to meet the resident's needs in a timely manner. Failure to ensure staff respond correctly to medical emergencies The Administrator and DON were informed an Immediate Jeopardy on [DATE] at 2:55 p.m., due to the above failures and provided the IJ template. A plan of removal was requested at that time. The Plan of Removal was accepted on [DATE] at 12:25 p.m. ,p.m., and indicated the following: DON or ADON and/or designee will review all orders requiring physician and/ or specialist referrals to ensure referrals are handled in a timely manner. Referrals will be documented on 24-hour until referral and/or appointment is completed. Beginning [DATE] The Medical Director, Licensed Nurses and wound care specialist will be provided in-service education related to the referral process. Physician referral process for sending residents to a specialist or outside physician services by obtaining the Medical Director's referral order beginning on [DATE] by DON or designee which includes: 1. Notify DON to confirm need for resident referral 2. Notify Physician of Referral Order Needed with details of the diagnosis and reason for referral. 3. Charge Nurse or Social Worker and/or designee to call in referral order, confirm insurance, and make appointment with Specialist and arrange for appropriate transportation. All referrals will be discussed and acknowledged in morning meetings. 4. All referrals will be kept on 24-hour report until appointment has been confirmed and/or attended. 5. Administrator to be notified if referrals are refused or denied by physician or Medical Director and reason for the denial. All current and/or newly hired nurses will be in-serviced regarding physician referral and contracted consultants beginning [DATE]. Validation/Monitoring Tools DON and/or designee will validate staff knowledge base through random questioning, education, and in-serving beginning [DATE]. DON or designee will review any referral orders documented by reviewing orders daily in clinical meeting to ensure appointments are being made. Beginning [DATE]. DON or designee will review any referral orders documented by reviewing orders daily in daily clinical meeting to ensure appointments are being made. Beginning [DATE]. DON or designee will review all wound care patient's progress and status and need for referrals during Standards of Care Meeting weekly. Beginning [DATE]. The Administrator, DON, or designee will review the action plan developed related to Referral Process in QA meetings monthly during the next six months. Beginning [DATE]. Audit was completed [DATE] on by clinical for missing referrals, notes and/or documentation by Regional Nurse. Consultant Wound Care Company will forward all clinical notes and referrals to DON and Regional Nurse beginning [DATE]. Observation on [DATE] at 10:54 a.m. surveyor observed Administrator calling the Medical Doctor and handing the phone to the DON for the wound care specialist's recommendation on Resident #2. Facility provided signed one on one in-services by facility staff on [DATE]. Review of the 24-hour report for [DATE] and [DATE] revealed appointments needed to be made were written in red by the resident's name. If a follow up appoint was made it was written under it in a black pen. Review of the calendar on the ADON's wall on [DATE] at 12:00 pm revealed appointments were scheduled. Immediate Action - a 100% skin sweep was completed by the DON, the Corporate Compliance RN, the ADON and LVN C. No new pressure ulcers were identified. Interview on [DATE] at 10:40 a.m. the Administrator stated all the floor nurses knew the referral process prior to the in-service, but all full-time staff had been in-serviced. The Administrator stated the in-service was done verbally and then the staff had to take a test on the facility's in-servicing program . The Administrator stated upcoming appointments were already on the morning meeting report so there was no reason to add it. The facility provided all one-on-one sign-in forms and the in-servicing program completion. The Treatment Nurse was unavailable to verify in-services and understanding of corrective action . The administrator was notified the IJ was removed on [DATE] at 12:43 p.m., however the facility remained out of compliance, at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed for pressure ulcers. The facility failed to ensure the Treatment Nurse accurately transcribed the Wound Care Consultant's recommendation for Resident #1 to have a doppler study six (6) times on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] and/or see a vascular/orthopedic/ podiatrist doctor five (5) times on [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility failed to ensure Resident #1's physician was notified of the Wound Care Consultant's recommendations. The facility failed to ensure the recommended actions were followed through with. This resulted in Resident #1 having a below the knee amputation on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:55 PM. While the IJ was removed on [DATE] at 12:43 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. This failure placed residents at risk for improper wound management, the development of new pressure ulcers, deterioration, infection, pain, loss of limb, or death. Findings include: Review of Resident #1's admission Record dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including malnutrition, uropathy, cirrhosis of liver, and emphysema. (The pressure ulcer to the heal was not listed) Review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed: He scored a 5 of 15 on his mental status exam. (Indicating severe cognitive impairment) Resident #1 had one stage III pressure ulcer that was present upon admission/entry and an other open lesion(s) on the foot. Review of Resident #1's Care Plan, initiated [DATE], revealed: Problem: The resident has an unstageable pressure injury to right heal related to disease process, history of ulcers and immobility. Updated on [DATE] revealed: wound now Stage III. The Goal was: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Identified approaches included: weekly treatment documentation to include measurement of each area of skin breakdown's width, length, type of tissue, and exudate initiated [DATE]. Review of Resident #1's admission note dated [DATE] revealed he was admitted to facility with an unstageable pressure ulcer to the right heel that was staged at the hospital. Resident #1's first documented assessment by the Wound Care Provider was [DATE] where the heel was staged as an unstageable approximately 3 cm length x 4.2 cm width x 0.1 cm depth with 100% necrotic tissue. Review of Resident #1's Wound Care Consultant's wound assessment, dated [DATE] at 4:55 p.m., revealed the Wound Care Consultant #1 recommended Resident #1 see a vascular doctor. Review of Resident #1's Skin/Wound Note by the Treatment Nurse, dated [DATE] at 4:55 p.m., documented: no new orders at this time Review of Resident #1's Wound Care Consultant's wound assessment notes, dated [DATE] at 5:19 p.m , revealed a recommendation for a Doppler Study. Review of Resident #1`s Skin/Wound Note by the Treatment Nurse dated [DATE] at 5:19 p.m. documented new order for Mupirocin 2% (antibiotic ointment) to be applied to right 4th toe (Nothing about the Doppler Study) Review of Resident #1's Wound Care Consultant assessment note dated [DATE] at 9:25 a.m., documented recommendations to have a vascular consultant and a Doppler Study. Review of the Skin/Wound Note by the treatment nurse dated [DATE] at 9:25 a.m. revealed note received no new orders at this time. Review of Resident #1's Wound Care Consultant note dated [DATE] at 5:33 p.m. revealed a recommendation for a Doppler Study. Review of Resident #1's Skin/Wound Note completed by the Treatment Nurse on [DATE] at 5:33 p.m. documented new orders to clean stage 3 to right heel with normal saline, pat dry with 4x4 gauze, apply anasept and collagen to wound bed and cover with supper absorptive dressing daily and as needed until healed. (Nothing about the recommendation for outside services) Review of Resident #1's Wound Consultant assessment note dated [DATE] at 5:10 p.m. revealed orders for: x-ray to right foot to rule out osteomyelitis (bone infection), Labs CBC, CMP, ESR, and CRP., a bone culture for pathology, refer a vascular surgeon to assess PAD/flow status, and once seen by vascular refer to podiatry or orthopedic for right 2nd toe. Review of Resident #1's Skin/Wound note completed by the Treatment Nurse, dated [DATE] at 5:10 p.m., revealed new wound care orders, to draw labs CBC, CMP, ESR and CPR complete a Bone pathology on bone, and an X-ray to right foot to rule out osteomyelitis. Review of Resident #1's Skin/wound note completed by the Treatment Nurse, dated [DATE] at 5:10 p.m., revealed order for a three-view x-ray to rule out osteomyelitis was completed. Review of Resident #1's Nurse's note dated [DATE] revealed the facility received the lab results and they were forwarded to Resident #1's primary physician. Review of Resident #1's Wound Care Consultant Assessment Note dated [DATE] at 4:15 p.m. revealed recommendations for x-ray right foot, bone pathology, labs CBC, CMP, ESR, and CRP, refer vascular, podiatry/ orthopedic. Notes included: patient removed dressing ' heel wound dry, edges slight peeling no signs or symptoms of infection. Also wound cultures positive. Review of Resident #1's Skin/Wound note completed by the Treatment Nurse, dated [DATE] at 4:58 p.m., documented received no new orders at this time. Review of Resident #1's Wound Care Consultant Note dated [DATE] at 4:59 p.m. documented: MRI scheduled, seeing Vascular in July. There were no other notes Review of Resident #1's Skin/Wound Notes completed by Treatment nurse, dated [DATE] at 4:59 p.m., revealed new wound care orders. Review of Resident #1's Skin/Wound Notes completed by the treatment nurse dated [DATE] at 5:19 a.m. revealed: no new orders. Review of Resident #1's skin/wound note dated [DATE] at 2:19 p.m. completed by the treatment nurse documented received no new orders Review of Resident #1's Nurse's Notes dated [DATE] at 1:55 p.m. revealed: Resident complains of pain to right heel, states the pain is getting worse than it has been, medicated with as needed dose of tramadol, received orders for x-ray to right foot 3 views. Review of Resident #1's Consultant Wound Care Assessment Notes, dated [DATE] at 2:44 p.m., revealed: referrals: refer to podiatrist, following PAD assessment, please refer to vascular surgeon to evaluate PAD severity and revascularization. (This was a telehealth appointment). Review of Resident #1's Skin/Wound Note dated [DATE] at 2:52 p.m. revealed received no new orders. Review of Resident #1's Consultant Wound Care Notes dated [DATE] at 8:00 a.m. by Wound Care Specialist B documented the appointment was telehealth. Review of Resident #1's skin/wound note dated [DATE] at 8:06 a.m. by the treatment nurse documented no new orders. Review of Resident #1's Wound Consultation Form Completed by Wound Care Specialist B dated [DATE] at 10:00 a.m. - 10:12 a.m. revealed it was a telehealth appointment and she recommended arterial studies. Review of Resident #1's Skin/Wound Note dated [DATE] at 10:12 a.m. revealed the Treatment Nurse documented Received no new orders. Review of Resident #1's Nurse's notes dated [DATE] at 11:18 a.m. documented Resident requesting to go to emergency room for pain and drainage to right foot, reports he is not feeling well and has not been eating for days due to pain. Notified doctor of resident request to go to emergency room and received orders to send to emergency room for evaluation. Review of Resident #1's Nurse's Notes dated [DATE] at 6:05 p.m. revealed: Called hospital for update on resident, spoke with his hospital nurse. Resident admitted to hospital with diagnosis of right foot infection, they attempted an MRI but resident did not stay still so it was unsuccessful, Review of Resident #1's Hospital History and Physical dated [DATE] revealed Patient reports he was in his usual state of health until approximately 4 months prior to admission when he had a foot ulcer at base of heel. Wound care had been done at nursing home once a week. Nursing home nurse reports patient had POOR compliance and he was nonadherent to advise and recommendations provided from nurses and wound care. Patient was on oral antibiotics at nursing home from 6/19 - 6/26 due to concern for MRSA on wound. Symptoms did not improve. Was going to be taken to city wound care, but today he complained of generalized foot pain, which he states had been present daily for months so he was unsure why he was brought to the local hospital. Subjective: Has necrotic heal and toe gangrene due to vascular insufficiency due to smoking. Review of Resident #1's Nurse's Notes dated [DATE] revealed: Arrived to facility, Wound to right below the knee stump intact/ wrapped. Wound with 17 staples. Interview on [DATE] at 4:15 p.m. the ADON stated Resident #1 was sent to the hospital. The ADON stated on [DATE] Resident #1 went to her and complained of a lot of pain to his right leg so they sent him to the emergency room. The ADON stated at the time of the interview Resident #1 was still in the hospital, but she was told he had a below the knee amputation. The ADON said she was unsure of the reason. The ADON stated Resident #1 had an infection that was being treated at the nursing facility with antibiotics. The ADON said Resident #1 would hang his foot off the edge of the bed instead of elevating it on a cushion. The ADON stated Resident#1 would refuse wound car; take the dressing off because he wanted the wound to air dry; and was a heavy smoker. The ADON said the facility tried to have a wound care consultation in the nearby city's wound care clinic prior to the amputation. Interview on [DATE] at 4:42 p.m. the DON stated Resident #1 was admitted to the hospital on [DATE] due to complaint of leg pain on the right side. The DON said Resident #1 was admitted to the facility with the wound and was seen by a wound care consultant company. The DON stated Resident #1 had labs and an x-ray done as well as wound cultures which showed MRSA. The DON said Resident #1's physician referred Resident #1 to a wound care center in a nearby city because they might have more things to treat Resident #1 with. The DON stated Resident #1 was sent to the hospital prior to that appointment. The DON stated she thought Resident #1 needed to go to the hospital because his foot was discolored and Resident #1 would not keep his foot elevated. The DON denied Resident #1 being in constant pain. The DON said Resident #1 received daily wound care and the wound care orders came directly from the wound care specialist. Interview on [DATE] at 12:18 p.m. Resident #1's Responsible Party stated the facility kept him informed of the treatments they were doing. The Responsible Party said he did not know if the treatments worked but he was kept informed. The Responsible Party stated he wondered if Resident #1's amputation could have been prevented. The Responsible Party said the facility was in process of getting an appointment scheduled to see a wound care doctor but then Resident #1 went to the hospital on [DATE] due to leg pain and got it amputated while there thus the appointment was cancelled. Interview on [DATE] at 1:25 p.m. Resident #1's Doctor stated he was aware of the amputation. The physician stated Resident #1 had PAD and that could quickly turn into gangrene. The physician felt the wound care specialists who Resident #1 was seeing at the facility had a good plan going for the resident and he was happy with the plan. Interview on [DATE] at 2:28 p.m. the Treatment Nurse stated Resident #1 was admitted to the facility with an unstageable pressure ulcer. The Treatment Nurse stated she told the physician of wound care consultant's recommendations. The Treatment Nurse stated the wound was stable and Resident #1 had wound care daily. The Treatment Nurse stated she did the wound care on [DATE] prior to Resident #1 going to the hospital and did not notice anything different with the wound. The Treatment Nurse stated Resident #1 complained of pain which was usual, but he had taken his pain medication at that time on [DATE]. The Treatment Nurse said the wound did not look like gangrene to her. The Treatment Nurse stated the wound care consultant would do appointments through telemed which was like Facetime with a cellphone. The Treatment Nurse explained she would take her cell phone into Resident #1's room and show the wound care consultant the wound and the consultant would say what it looked like. The Treatment Nurse was shown the Consultant's Noted dated [DATE] that documented a referral to a podiatrist or vascular doctor. The Treatment Nurse said she did recall the consultant asking for the referral but she just forgot to do it (contact the physician and set up the vascular consult). The Treatment Nurse said she remembered about the vascular consult appointment when the Ombudsman came and asked if it was done on [DATE] (19 days later) and that was when she started to set up the appointment but then the resident had his leg amputated. The Treatment Nurse stated she was aware the Wound Care Specialists recommended Resident #1 be seen by a vascular doctor and have a doppler study to the right foot on [DATE], [DATE], [DATE], and [DATE] but she forgot to get it done. Interview on [DATE] at 4:22 p.m. the Administrator and DON stated their expectation was for the wound care specialists' recommendations to be brought up to the physician by the Treatment Nurse. They stated the physician would usually approve recommendations or change the order as he wanted to. The DON stated she did not know there were orders for Resident #1 to be seen by a vascular doctor since [DATE]. The DON said she should have probably checked on the Treatment Nurse to make sure she was following the recommendations suggested by the wound care specialists . Phone interview on [DATE] at 12:58 p.m. Wound Care Specialist A stated she recommended Resident #1 be seen by a vascular doctor numerous times and for the facility to get a doppler study done. The Wound Care Specialist stated she was told by facility staff that the physician refused the recommendations and the doppler study and had recommended Resident #1's foot just be monitored. The Wound Care Specialist stated she did not know if Resident #1 being seen by a vascular doctor would have prevented Resident #1's amputation but earlier intervention was better than no intervention at all. Phone interview on [DATE] at 1:14 p.m. Resident #1's physician stated he did not say no to the recommendations made by the wound care specialists. The physician said he would not just ask for the resident's leg to just be monitored. The physician stated he would have welcomed recommendations since the wound care specialist saw the wound in person and had a better idea of what to do next. Interview on [DATE] at 1:04 p.m. the Administrator summarized that Resident #1 was admitted with a wound. The Administrator stated Resident #1 was a smoker and was non-compliant with elevating his foot. The Administrator said the Treatment Nurse was monitoring the wound. The Administrator stated fast forward the wound care specialists texted the Treatment Nurse recommendations of a referral to a vascular doctor and it was not done. The Administrator said it was not done and the Treatment Nurse said she missed it. The Administrator said the DON was not getting the wound care specialist's notes so would not get the recommendation. Interview on [DATE] at 2:02 p.m. the DON confirmed there was the same order for a vascular doctor and doppler study for three months. The DON said the Treatment Nurse never turned in the wound care assessments. The DON stated when she asked the Treatment Nurse why it was not done the Treatment Nurse said she did not know how. The DON said she never saw the Wound Care Specialist's reports so she dropped the ball in looking at them. The DON stated her expectation was for skin notes to be turned in and uploaded into the computer system. Phone interview on [DATE] at 3:58 p.m. Wound Care Specialist B stated the Treatment Nurse told her that vascular recommendation was not followed because it was a transportation issue. Wound Care Specialist B said she recommended the vascular doctor every week and she understood it was difficult. Wound Care Specialist B stated she mainly did telehealth appointments with the facility. The Wound Care Specialist stated to her knowledge the facility did not follow through with the recommendation, then the facility informed Wound Care Specialist B that Resident #1 went to the hospital, and they amputated his leg. Wound Care Specialist B said she made the recommendation weekly and the Treatment Nurse told her it was a transportation issue. Wound Care Specialist B said to her knowledge her recommendations were not done. Wound Care Specialist B said she understood the facility was in a rural area and the closest vascular doctor was an hour and half away in the closest city. Wound Care Specialist B said Resident #1's physician was involved because at some point Resident #1 was placed on an antibiotic she did not prescribe. Wound Care Specialist B said she (Wound Care Specialist B) and Wound Care Specialist A had similar recommendations. Wound Care Specialist B said she and the Treatment Nurse talked weekly, but the Treatment Nurse would not always inform her of every change. Treatment Nurse B was informed there was a referral made to the nearest city's wound care clinic and responded, I can't imagine they would get a different result. Wound Care Specialist B repeated she recommended vascular studies and to her knowledge they were never followed up. Wound Care Specialist B stated the last time she saw Resident #1 was [DATE] and the wound looked the same and she made the same recommendation of a vascular consult. Wound Care Specialist B said she was trying to be patient for the facility to get it done and the Treatment Nurse just told her (Specialist B) that it was very difficult to get the tests done. Phone interview on [DATE] at 4:42 p.m. the Treatment Nurse stated Resident #1 received wound care daily and saw the wound care consultant weekly. The Treatment Nurse said in the beginning there were no recommendations. The Treatment Nurse stated at the end the wound care specialists were recommending a vascular, labs, x-rays, cultures - all of it. The Treatment Nurse said she did it all except for the vascular doctor. She said she did not know why did not do it. The Treatment Nurse did not answer when asked why it was not done for three months. The Treatment Nurse said she did not know why she told Wound Care Specialist B that it was a transportation issue, then added it was because she (the Treatment Nurse) overlooked it and did not know what to say. The Treatment Nurse stated one time she told the ADON and the ADON told the treatment Nurse that doppler studies were not done in their city. The Treatment Nurse said she did not know why she did not put the vascular appointment/ doppler study/ orthopedic / podiatrist referrals in her notes when all the other recommendations were in the notes. At the end of the interview, the Treatment Nurse stated, I don't know, I guess I thought I could take care of it myself and now it's too late. Interview on [DATE] at 4:59 p.m. the ADON stated she Resident #1 was noncompliant and smoked a lot. The ADON said the day she sent Resident #1 to the Emergency Room; Resident #1 was complaining of a lot of pain to his foot and requested to go. The ADON stated that was the first time she sent Resident #1 to the emergency room for foot pain. The AODN stated there was a nurse's meeting every day and issues that came up were discussed; she said the Treatment Nurse would bring up that wounds were not healing because Resident #1 was noncompliant and would not use a heel cushion and hang his foot off the bed. The ADON stated she was not present if the Treatment Nurse brought up wound care recommendations. The ADON stated she was never told of any referrals. The ADON stated the doppler study statement made by Treatment Nurse was maybe because the facility tried to get a doppler study on another resident about a year ago and the ADON said the hospital at their city did not do them. The ADON stated she should have been made aware of the Wound Care Specialist's recommendations because she was the ADON. The ADON stated under the previous DON, the Treatment Nurse would talk to the ADON about the wounds because the previous DON did not know much about wound care. Interview on [DATE] the DON and Administrator stated whoever got the order for a referral was responsible for notifying the physician and putting in the order. The Administrator stated the facility did go as far as the nearest city. The Administrator stated typically the Transportation Aide would take the resident and a CNA. The Administrator stated appointments to other cities were done on Tuesdays and Thursdays because of the dialysis appointments on Monday/ Wednesday/ Friday. The DON said she was not made aware of any referrals to a vascular doctor, so she got the order for Resident #1 to go to the wound care clinic in the nearest city. The DON said Resident #1 was sent to the emergency room before the appointment could occur. Interview and record review on [DATE] at 12:07 p.m. the Transportation Aide stated she did the dialysis appointments on Monday/ Wednesday/ Friday but on Tuesday/ Thursday she took the residents to other appointments. The Transportation aide said the facility would go where the resident needed to go. The Transportation Aide said she did take residents to the nearest city at least weekly. The Transportation Aide said she did not remember taking Resident #1 to any appointments and she was never told to make an appointment for him. The Treatment Nurse handed over the calendar for 2023 and it did show other residents were taken to other cities for outside appointments. Review of the transportation schedule from [DATE] - [DATE] showed Resident #1 had no appointments made. Review of the facility's policy and procedure on Skin Management: Prevention and Treatment of Wounds, effective [DATE] revealed: Policy: The purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds. Procedure: Notification A licensed nurse will notify resident's physician, responsible part, and hospice nurse if on services, with new onset of wounds, deterioration in wound status. Communication of new wounds will be relayed during shift-to-shift report for 24 hours. Treatment: A licensed nurse will obtain order from physician for new skin wounds and transcribe into resident's treatment record for follow up. Review of the facility's online in-service program's for Caring for Pressure Injuries (completed on a rotating basis) revealed: Documentation: Report any deterioration in appearance of the injury to the nurse in charge or the health care provider. Record unexpected outcomes and related nursing interventions. Review of the facility's online in-service program's in-service for Assessing Wounds (completed on a rotating basis) revealed: Procedure Guideline for Assessing Wounds. Verify the health care provider's orders. Follow up: Compare the wound assessment to the previous assessment, and determine progress toward healing. If there is no improvement, or if you notice deterioration, consider a wound care consultation. Lack of wound healing is often related to infection. Notify the health care provider and wound, ostomy, and continence nurse or team. The Administrator and DON were informed an Immediate Jeopardy on [DATE] at 2:55 p.m., due to the above failures and provided the IJ template. A plan of removal was requested at that time. The Plan of Removal was accepted on [DATE] at 12:25 p.m,. and included the following: All orders with Wound Care Company will be reviewed with DON within 24 hours of visit. Wound care company will round with Treatment Nurse, DON, and/or ADON during visit. Wound Care Consultant will e-mail all orders, recommendations etc. to DON and Treatment nurse Administrator reviewed with DON all physician, pharmacy, and support services to be reviewed within 24-hours.; recommendations to be sent, orders written and received. Administrator will review all contracted orders and recommendations with DON and Interdisciplinary Team within 48 hours of exit. Administrator or DON will attempt to exit with all contracted support at end of each visit and/or will review upon receipt. DON/ADON will assist in reviewing all skin issues on a daily/weekly and as needed basis. Treatment nurse/ Charge Nurse will report all new skin issues immediately to DON/ADON immediately. Treatments and recommendations to be reviewed and entered that day. Intervention will be reviewed in morning nurse's meeting as to progress. Reviewed Morning Meeting, Standards of Care, Trends during QA meetings. DON/ADON will do spot checks on skin. Skin assessments by wound/charge nurses are to be completed daily; any skin issues that are discussed in nurse's meeting or on the 24-hour report will be addressed and noted. DON to monitor weekly. Treatment Nurse/Charge Nurse and/or MDS Nurse to ensure all treatments are care planned, orders written, documentation completed. Treatment Nurse/ Charge Nurse to document all new treatments, skin tears, rashes, bruises etc. Care Plan to be updated by nurse/ MDS nurse of treatments' clear documentation in facility's documentation program of notification to DON, Medical Director, and/or primary care physician. DON/ADON to monitor nursing meeting, stand up meeting, Standards of Care. Treatment Nurse, DON, ADON and/or designee may attend Infection Preventionist in-services and training. ADON/Infection Control Preventionist will educate and assist all wounds that have infections - monitoring and updating treatment to prevent spread. Wound log to be completed in a timely manner. Treatment Nurse and/or designee will attend QA/ Quality Improvement Performance Plan meetings. Quality Improvement Performance Plan Component will cover all skin issues, will review wounds and skin system. Theis will address meeting Quality Improvement Plan metrics. The component will be monitored by the entire interdisciplinary team for the next year with Quality Improvement Performance Plan until the facility is at goals set. To be used for preventative care. Observation on [DATE] at 10:54 a.m. surveyor observed Administrator calling the Medical Doctor and handing the phone to the DON for the wound care specialist's recommendation on Resident #2. Facility provided signed one on one in-services by facility staff on [DATE]. Review of the 24-hour report for [DATE] and [DATE] revealed appointments needed to be made were written in red by the resident's name. If a follow up appoint was made it was written under it in a black pen. Review of the calendar on the ADON's wall on [DATE] at 12:00 revealed appointments were scheduled. Immediate Action - a 100% skin sweep was completed by the DON, the Corporate Compliance RN, the ADON and LVN C. No new pressure ulcers were identified. Interview on [DATE] at 10:40 a.m. the Administrator stated all the floor nurses knew the referral process prior to the in-service, but all full-time staff had been in-serviced. The Administrator stated the in-service was done verbally and then the staff had to take a test on the facility's in-servicing program. The Administrator stated upcoming appointments were already on the morning meeting report so there was no reason to add it. The facility provided all one-on-one sign-in forms and the in-servicing program completion. The Treatment Nurse was unavailable to verify in-services and understanding of corrective action. The administrator was notified the IJ was removed on [DATE] at 12:43 p.m. however, the facility remained out of compliance, at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their Plan of Removal.