Based on interview and record review, the facility failed to immediately inform the resident's primary care provider when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 7 residents (Resident #1) reviewed for notification of changes in that: The facility failed to notify the wound care physician and primary care provider (physician) when Resident #1's left foot great toe had a worsening of the wound and turned black. An IJ was identified on 08/18/2023 at 11:15 a.m. after review of the evidence. The IJ template was provided to the facility on 8/18/2023 at 11:15 a.m. While the IJ was removed on 8/19/2023 at 6:46 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm with a potential for more than minimal harm due to facility's need to evaluate the effectiveness of their plan of removal. This deficient practice could place residents at risk of not having their primary care provider informed when there is a change in condition resulting in a delay in medical intervention and decline in health. The findings included: Record review of Resident #1 face sheet dated 7/25/23 revealed an admission date of 3/21/2022 with readmission date of 9/18/2022 with diagnoses which included: type 2 diabetes mellitus with hyperglycemia, protein-calorie malnutrition (undernutrition), and hypertension (high blood pressure). Record review of Resident #1's Care Plan dated 9/21/2022 revealed the resident had a diagnosis of diabetes with interventions to include: inspect feet during bathing and as needed for open areas, sores, pressure areas, blisters, edema and redness and report to the nurse. Record review of Resident #1's Care Plan dated 7/20/2023 revealed the resident had a potential for the development of a pressure ulcer with no evidence of an actual pressure ulcer or wound. The care plan did not address any actual wounds for Resident #1. Record review of the 24-Hour Report Sheet (nurse to nurse communication between shifts) for Resident #1 revealed: 7/01/2023: Left toe dressing done 7/02/2023: big left toe needs wound nurse orders 7/03/2023: get treatment (nurse) to do wound care to left big toe 7/05/2023: get treatment (nurse) to do wound care to left big toe 7/06/2023: get treatment (nurse) to do wound car to left big toe 7/11/2023: dressing to big left toe 7/12/2023: dressing to big left toe 7/13/2023: dressing to big left toe 7/14/2023: dressing to big left toe 7/15/2023: dressing to big left toe 7/16/2023: dressing to big left toe .hospice now, hospice will be in to write orders on Monday 7/17/2023: dressing to big left toe .hospice not, hospice to write orders Monday 7/18/2023: new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders, culture collected/pending . 7/19/2023: hospice orders pending, new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders . Record review of Resident #1's physician order summary for July 2023 revealed an order for admit to hospice services with a start date of 7/19/2023 (after the change of condition occurred). Record review of Resident 1's progress notes revealed no documentation of the wound/wounds to the residents left foot great toe prior to 7/17/2023. Record review of Resident #1's assessments in the medical record revealed no documentation of the results of a wound or skin assessment. During an interview on 7/25/2023 at 2:17 p.m., the Wound Care Nurse stated she worked a M-F schedule. She stated on 7/03/2023 and 7/10/2023 she documented on a weekly skin assessment sheet that she kept in a binder in her office and was not part of the medical record that Resident #1 had redness to the left foot great toe. She stated on 7/10/2023 Resident #1 also had redness to his bottom (sacrum) that was blanchable. The Wound Care Nurse stated she did not notify the physician about the redness to the bottom (sacrum) because she had zinc oxide as standing orders to take care of it. She stated she did not notify the physician about the redness to Resident #1's left great toe because it was positional. She stated she knew it was positional redness because the resident was bedbound and refuses. She stated in her nursing judgement there was no concern to notify. During an interview on 7/29/2023 at 6:51 p.m. RN D stated she found a wound on Resident #1's left big toe after he was on morphine with hospice (7/19/2023). When asked why it was documented on the 24-hour notes at the beginning of July 2023, RN D stated she went into Resident #1's room one night during night shift, lifted the sheet up and saw that half of his big toe was black. She stated it looked like it was also going to the next toe. She stated she gave Resident #1 a [wound] treatment and wrote it on the 24-hour note to let the Wound Nurse know it needed treatment. RN D stated she put something on it and wrapped it. She stated the facility does not have standing orders for wound care. She stated she did not notify the physician because she thought Resident #1 was on hospice, she stated he needed to be. When asked if she notified a hospice nurse, she stated she could not remember. She stated she knows she should have notified the physician but when a resident was on hospice, they just notify hospice. RN D stated Resident #1 had diarrhea, he did not want to eat, he was on comfort care, and he was on his way to heaven. She stated the reason she documented on the 24-hour notes was because that was what the nurses read. After reviewing the 24-hour notes from July 2023, RN D stated confirmation that the notes were from her. She stated she regretted not notifying someone. During an interview on 8/02/2023 at 12:09 p.m., the ADON stated nurses should notify the physician, family, ADON/DON of any resident change of condition. The ADON stated notification of the physician was important because it was the only way a change of condition could be addressed. He stated some changes of conditions were emergencies and required collaboration with the physician to ensure patient care was done. The ADON stated night shift nurses should follow the same procedures. The ADON stated it was important to notify the physician when a toe turns black because the toe is debilitated, and the condition is eminent. During an interview on 8/03/2023 at 1:34 p.m., Resident's #1's physician/Medical director (MD) stated he first became aware of a wound in mid-July. He stated within a day or so of getting initial orders (7/17/2023) the events unfolded. The MD stated at that time he was told there was a wound with drainage, he stated staff did not give a description of necrosis or ischemic findings (diminished blood supply), just drainage. The MD stated he would have wanted to have been notified immediately of any color changes to a toe. He stated that would be the standard of care. During an interview on 8/03/2023 at 2:49 p.m., the RN Nurse Educator stated the medical doctor/physician should be notified first for a resident change of condition. She stated it was important to notify the physician because even a minor change of condition for foretell a more serious complication. Record review of a facility policy, titled Notification of Changes last revised on 1/10/2020 revealed: To provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately .consult with the resident's physician .: 3. A significant change I the physical, mental or psychosocial status of the resident. The Administrator was notified of an IJ on 8/18/2023 at 11:15 a.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on 8/19/2023 at 6:35 p.m. and included the following: The facility's Plan of Removal was accepted on 8/19/2023 at 6:36 p.m. and included: 1. Immediate Action Taken B. On 7/28/2023 and on 7/30/2023 RN D received education from Regional Nurse consultant of Skin management policy regarding . physician notification . C. On 7/28/2023 and on 7/30/2023 LVN B received education from Regional Nurse consultant on Skin management policy regarding . physician notification . D. On 7/28/2023 and on 7/30/2023 LVN II received education from Regional Nurse consultant on Skin management policy regarding . physician notification . 2. Identification of Residents Affected or Likely to be Affected: A. On 7/27/2023 the DON/Designees completed 100% skin audit throughout the facility and identified other residents with new pressure ulcers. This was completed at 5:30 pm on 7/27/2023. No other resident has been affected by this since 7/27/2023. B. On 7/27/2023 an audit was completed by DON/Designee to validate residents with no pressure ulcers receive a weekly skin assessment by Charge nurse and initialed completion on the skin observation worksheet. This was completed at 8:00 pm on 7/27/2023 and no other resident has been affected by this since 7/27/2023. 3.Actions to Prevent Occurrence/Recurrence: A. On 7/27/2023 the DON/Designee began education with all licensed nurses on Skin Management policy which details . physician notification . This was completed at 6:00 pm on 7/27/2023 and no licensed nurse was allowed to work until they completed this education. C. On 7/27/2023 the DON/Designee began education with licensed nurses and nurse assistants on completion of skin observation worksheets at time of shower/bath to document any identified skin issues and allow charge nurse to complete an assessment and notify the DON/Designee on any identified issue. This was completed at 6:00 pm on 7/27/2023 and no licensed nurse or nurse assistant was allowed to work until they had completed this education. D. On 7/27/2023 the DON/Designee began education with licensed nurses and nurse assistants on Pressure Injury Prevention/Management Policy which details definitions of avoidable and unavoidable, compliance guidance, interventions for prevention, promote healing, treatments, and monitoring. This was completed at 6:00 pm on 7/27/2023, and no licensed nurse or nurse assistant was allowed to work until they had completed this education. On 8/18/2023 the facility administrator notified the Medical Director of Immediate Jeopardy the facility received regarding Abuse and Neglect related to skin management. POR verification: During a phone interview on 8/18/2023 at 4:02 p.m. RN D stated she had received education on Skin Management policy regarding . physician notification . from the Regional Nurse Consultant on 7/28/2023 and on 7/30/2023. Record review of form titled In-service Program Attendance Records dated 7/28/2023 and 7/30/2023 with RN D's signature of attendance. During an interview on 8/18/2023 at 3:59 p.m. LVN B stated she had received education on Skin Management policy regarding . physician notification . from the Regional Nurse Consultant on 7/28/2023 and on 7/30/2023. Record review of form titled In-service Program Attendance Records dated 7/28/2023 and 7/30/2023 with LVN B's signature of attendance. During a telephone interview on 8/18/2023 at 3:58 p.m. LVN II stated she had received education on Skin Management policy regarding . physician notification . from the Regional Nurse Consultant on 7/28/2023 and on 7/30/2023. Record review of form titled In-service Program Attendance Records dated 7/28/2023 and 7/30/2023 with LVN II's signature of attendance. Record review of Skin assessment/shower sheets revealed 100 residents checked for skin issues. Record review of Resident #15's EMR revealed a progress note with 7/27/2023 06:40 Skin/Wound Note skin sweep done this shift, no new skin impairments. Record review of Resident #15's EMR revealed a progress note with 7/27/2023 19:01 Skin/Wound Note skin sweep completed this shift, new change to skin dry scab .5x.5 area to right ankle, tolerated skin assessment well. 7/27/2023 06:49 Skin/Wound Note skin sweep completed this shift, new change to skin noted, skin wrinkly, and lightened in color noted to buttocks, New order for moisture barrier applied q shift and prn after each incontinent care. tolerated skin assessment well. Record review of Resident #16's EMR revealed a progress note with 7/27/2023 07:28 Skin/Wound Note skin sweep completed this shift, new change to skin noted, dry scab with mild redness noted. recent visit with podiatrist due to ingrown toenail being removed and callus resolved. tolerated skin assessment well. Record review of Resident #7's EMR revealed a progress note with 7/27/2023 08:50 Skin/Wound Note skin sweep completed this shift, no new change to skin noted. require podiatrist visit due to elongated toenails. tolerated skin assessment well. Record review of Resident #3's EMR revealed a progress note with 7/28/2023 10:18 Skin/Wound Note Skin sweep completed on 7/26/2023, resident presents with Stage 4 to sacrum - 2.5x2.5x.4 - show signs of improving. 1+ BLE edema noted. dry scab area to right forearm. Resident #3 is on hospice services. Weight has been stable. appetite is good. No s/s of dehydration noted. No s/s of infection noted. continue with wound care order. Record review of Resident #14's EMR revealed a progress note with 7/28/2023-skin sweep. Record review of Resident 17's EMR revealed a progress note with 7/28/23-skin sweep. Interviews with LVNs/RNs on 6am-6pm and 6pm-6am shifts to include weekends revealed 8 6pm-6am LVNs/RNs, 6 6am-6pm LVNs/RNs inservices done on Skin Management policy which included . physician notification . Record review of Inservice signature sheets for Skin Management policy which details . physician notification . 20 of 20 LVNs/RNs signed for attendance. Interviews with LVNs/RNs, CNAs, CMAs on 6am-6pm and 6pm-6am shifts to include weekends revealed 12 of 20 nurses were inserviced. On 8/18/2023 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Abuse and Neglect and reviewed plan to sustain compliance. On 8/19/23 at 6:46 p.m., the Administrator and Interim DON were notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and severity of harm with a potential for more than minimal harm due to the facility's need to monitor the implementation and effectiveness of its POR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (Resident #1) reviewed for neglect, in that: The facility failed to develop and implement systems to properly treat Resident #1's arterial wound to his left foot great toe from [DATE] until [DATE] which resulted in hospitalization, sepsis, gangrene, necrosis and amputation. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:31 p.m. While the IJ was removed on [DATE] at 11:54 a.m., the facility remained out of compliance at a scope of pattern and severity of harm with a potential for more than minimal harm due to facility's need to evaluate the effectiveness of their plan of removal. This deficient practice placed residents at risk of psychosocial harm, infection, a decline in health, amputation and death. The findings were: Record review of a facility self-report dated [DATE] revealed the facility reported Resident #1 wound care orders placed in chart on [DATE] were not followed up. Resident #1 became septic and resulted in amputation of big toe. The facility listed RN D and LVN B as the alleged perpetrators. Record review of Form 3613-A dated [DATE] and signed by the facility Administrator on [DATE] revealed an allegation of abuse and neglect was made by family of abuse and neglect on an unknown date and time regarding Resident #1. The report stated Resident #1 required total assistance with care and was not interviewable was transferred to a local hospital for a worsening wound on [DATE] with the Wound Care Nurse listed as the perpetrator. The report stated that the Wound Care Nurse was not providing wound care and was not being supervised by the DON. Lack of services, training and supervision led to worsening of the wound. In a verbal conversation with the hospital, the left foot was amputated. The investigative findings were confirmed Record review of Resident #1 face sheet dated [DATE] revealed an admission date of [DATE] with readmission date of [DATE] with diagnoses which included: type 2 diabetes mellitus with hyperglycemia, protein-calorie malnutrition (undernutrition), and hypertension (high blood pressure). Record review of Resident #1's annual MDS assessment dated [DATE] revealed a BIMS's score of 8 which indicated a moderate cognitive impairment. The assessment was coded for no ulcers, wounds, or skin problems. Record review of Resident #1's Care Plan dated [DATE] revealed the resident had a diagnosis of diabetes with interventions to include: inspect feet during bathing and as needed for open areas, sores, pressure areas, blisters, edema and redness and report to the nurse. Record review of Resident #1's Care Plan dated [DATE] revealed the resident had a potential for the development of a pressure ulcer with no evidence of an actual pressure ulcer or wound. The care plan did not address any actual wounds for Resident #1. Record review of a Doctor's Progress Note dated [DATE] revealed: Left foot with arterial wound to great toe, 2nd toe, 3rd toe. Clean left foot arterial wound to great toe, 2nd toe, 3rd toe, apply betadine daily. Wound Consult [illegible word], signed by the NP. Record review of a physician order dated [DATE] for wound care revealed LVN B put orders into the computer on [DATE] at 8:18 p.m. which were signed by the MD on [DATE]. The orders did not have a schedule for administration attached and indicated the orders were for the TX (wound) Nurse as non-medication orders. The orders were: wound care orders for atrial (sic) [arterial] wounds to the left foot, clean with normal saline, pat dry and apply betadine daily until wound consult to follow. Record Review of Resident #1's [DATE] TAR revealed no orders for wound care to the left great toe or left foot. The physician orders for treatment of the wounds to the left foot had not carried over to the TAR and there was no indication wound care was performed. Record review of the facility's wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's [DATE] TAR revealed orders for weekly skin assessments scheduled for Fridays with staff initials to indicate the assessment was completed. Friday [DATE] was not marked as completed. The skin assessments for [DATE], [DATE], and [DATE], were initialed completed by LVN B. Record review of Resident #1's [DATE] TAR revealed no orders for wound care and there was no indication wound care was performed. Record review of the facility wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's [DATE] TAR revealed an order for weekly skin assessments scheduled for Fridays with staff initials to indicate the assessment was completed. Friday [DATE] and Friday [DATE].2023 were not marked as completed. Friday [DATE], had an x marked through the assessment date. The skin assessments were completed 2 out of 5 opportunities. Record review of Resident #1's [DATE] TAR revealed no orders for wound care and there was no indication wound care was performed. Record review of the facilities wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's July TAR revealed orders for weekly skin assessments scheduled for Mondays with staff initials to indicate the assessment was completed. Monday [DATE], and Monday [DATE]th, 2023, were not marked as completed. This indicated skin assessments were completed 1 out of 3 opportunities for [DATE]. Record review of Resident #1's [DATE] TAR revealed no orders for wound care and there was no indication wound care was performed until [DATE]. Record review of the facilities wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's shower sheet dated [DATE] revealed a shower was not given for refusal of care written on the form. No skin issues were documented. The nurse signature was not legible. A second shower sheet dated [DATE] was documented that a shower was given, and no new skin issues were assessed by the nurse. The nurse signature was not legible. No other shower sheets could be located for Resident #1. Record review of Resident #1's progress notes revealed no documentation of skin or wound assessments from [DATE] to date of investigation ([DATE]) in the medical record. Record review of Resident #1's weekly skin integrity review dated [DATE] and signed by the Wound Care Nurse located in a binder in the Wound Care Nurses office revealed Resident #1 had intact dry skin with redness. The areas marked on the picture of the human diagram with an X were the left big toe and the front of both shins. Record review of Resident #1's weekly skin integrity review dated [DATE] and signed by the Wound Care Nurse located in a binder in the Wound Care Nurses office revealed Resident #1 had intact dry skin with redness. The areas marked on the picture of the human diagram with an X were the left big toe and the front of both shins and the buttocks. There was no other skin assessments for Resident #1 prior to [DATE] or after [DATE] in the notebook. Record review of the 24-Hour Report Sheet (nurse to nurse communication between shifts) for Resident #1 revealed the following entries which were note signed or initialed by staff: [DATE]: Left toe dressing done [DATE]: big left toe needs wound nurse orders [DATE]: get treatment (nurse) to do wound care to left big toe [DATE]: get treatment (nurse) to do wound care to left big toe [DATE]: get treatment (nurse) to do wound car to left big toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe .hospice now, hospice will be in to write orders on Monday [DATE]: dressing to big left toe .hospice not, hospice to write orders Monday [DATE]: new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders, culture collected/pending . [DATE]: hospice orders pending, new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders . Record review of Resident #1's progress notes dates [DATE] revealed MD notified of condition of wound to LLE great toe. New orders received to get wound culture, CBC, renal panel, x-ray to LLE great toe to rule to osteomyelitis (infection of the bone), initial dose of Augmentin 500 mg (antibiotic) and Cipro 500 mg given and is to be continued for the next 10 days. Also received wound treatment orders . Record review of Resident #1's progress notes dated [DATE] documented by LVN B revealed: results in from x-ray of left toes .osteomyelitis not excluded .results faxed to MD, new orders pending. Record review of Resident #1's x-ray dated [DATE] of the left toe revealed minimal patchy osteolytic lesion involving first-proximal phalanx (great toe) ; mild diaphysis: osteomyelitis not excluded. (infection of the bone) Record review of Resident #1's physician order summary for [DATE] revealed an order for admit to hospice services with a start date of [DATE]. Record review of Resident #1's progress notes dated [DATE] documented by the ADON revealed: Resident sent out to [a local hospital] for worsening wound issues .that the family is concerned about. Per the family's request after a care plan meeting was completed, facility initiated a call for EMS to com(e) and transfer resident to the hospital. Notified MD of the hospital transfer . Record review of Resident #1's Care Plan Conference notes dated [DATE] and signed by the former DON on [DATE] revealed the form was blank and no information had been entered. Record review of Resident #1's hospital admission record dated [DATE] revealed the resident presented to the ER by EMS for necrotic toe present for over 1 week and a sore on the sacrum that was healing. Necrotic toe on the left gangrene (tissue death), x-rays of extremity foot reveal osteomyelitis with gangrene and necrosis (infection of the bone with tissue death) .concerned about osteomyelitis with severe soft tissue infection. Patient does require admission. Impression: sepsis, toe necrosis, soft tissue infection, elevated lactic acid (indicated infection and is clinically significant as it shows correlation with sepsis and can indicate likelihood of critical illness), osteomyelitis of toe (infection that is in the bone), tachycardia (elevated heart rate which can indicate sepsis). Record review of Resident #1's hospital record of x-ray to foot dated [DATE] revealed .soft tissue swelling is noted about the great toe with osseous erosive change (changes in the bone) involving the proximal phalanx (toe) .concerning for osteomyelitis with possible superimposed fracture (fracture can occur from severe osteomyelitis which weakens the bone). Record review of Resident #1's hospital record of physician assessment dated [DATE] revealed: Musculoskeletal/Skin: .left great toe notes severely necrotic changes to the soft tissue consistent with a mix of dry and wet gangrene, putrid odor coming from the foot. There is a palpable DP (dorsal pedal-pulse on the top of the foot indicating there is blood flow to the foot) pulse. There is surrounding erythema (redness) and purulent drainage (pus). Patient has a sacral decubitus (bed sore) ulcer with granulation tissue overlying it with no evidence of infection. Orthopedic consulted .Patient will need admission for further management and IV antibiotics and possible surgical intervention for his gangrenous infection of the left great toe. Record review of a hospital record for Resident #1 dated [DATE] revealed: Assessment/Plan: severe sepsis with shock initially requiring low dose of vasopressor (medication used to raise blood pressure in ICU setting which a sign of shock), WBC trending up (indicated infection), remains afebrile (without fever). Left first toe gangrene (tissue death with osteomyelitis (infection of the bone): continue vancomycin, cefepime, Flagyl (antibiotics), per ortho needs amputation. Record review of an undated photo of Resident #1's left foot revealed the left great toe from top of the foot view was dark black in color from the tip of the toe to the first joint with the appearance of a missing toenail. The area below the first joint was red and purple in color. There was a partially removed gauze from the toe revealed heavily soiled gauze with discharge that was beige, yellow, brown, pink, and red in color. There was a large amount of swelling to the right side of the great left toe starting at the tip of the toe, with the largest amount of swelling near the first joint that was discolored black, grey, brown, yellow, and pink and extending to the base of the first toe. The skin was peeling off the first toe. There was a large amount of drainage and moisture on the toe, and gauze. The other toes were obscured from view by the gauze. During an interview on [DATE] at 12:01 p.m. the Hospice admission Nurse stated she admitted Resident #1 to hospice on [DATE]. She stated at the time of admission Resident #1 had a wound that was gooey, purulent with foul odor that smelt gangrenous and was poorly bandaged. She stated Resident 1 was very weak and had slow slurred speech that could not be understood. The Hospice admission Nurse stated she asked the facility if Resident #1 was on antibiotics and they confirmed that he was on Augmentin, Cipro (antibiotics) and Dakin's (wound cleaner). She stated that she only admitted Resident #1 to hospice services and had no other interaction prior to his discharge. During an interview on [DATE] at 1:22 p.m., Resident #1's RP stated she had noticed the wrap to the resident's toe had not been changed (date unknown). She stated she got hospice involved (unknown date) because she did not feel like Resident #1 was getting the attention, he needed from the facility staff. She stated she had a meeting with the facility (names of staff unknown) on 721/2023. She stated they told her she could not put him in the hospital even though he was declining, but she did it anyway on the same date. She stated she did not want her family member to die. She stated she only got hospice because they told her he would get extra help. The RP stated Resident #1 was now going to have to have an amputation. The RP stated Resident #1 had dementia and was not interviewable. During an interview on [DATE] at 2:17 p.m., the Wound Care Nurse stated she had been in the wound care position officially in [DATE] although she had been in the position and performing wound care before that time (dates unknown). She stated she was notified of resident wounds by the charge nurses or when she completes the head-to-toe skin assessments. She stated the facility had house orders (standing orders/wound protocol) for wound care for wound care orders that she used on new wounds. The Wound Care Nurse stated the facility used to have a WC NP (Wound Care Nurse Practitioner) until two weeks ago. She stated the facility no longer had one as she was not meeting the Corporation's needs. The Wound Care Nurse stated the WC NP would see all residents with wounds except for patients on hospice and those with certain types of insurance. She stated she did not know what types of insurance were excluded. The Wound Care Nurse stated weekly head to toe skin assessments were documented in PCC (electronic medical chart) as a check on the resident TAR to show completion. She stated she did not document the results of the skin assessments in the resident medical record. She stated she kept the results on a paper document in a binder which she kept in her office. The Wound Care Nurse stated she was told to document in the binder. She stated she asked why she was documenting in a binder, and they told her to just keep it in the binder. She stated she does not remember who told her. The Wound care nurse stated she only keeps the current ones in the binder, and she only had [DATE]. When asked how continuity of care was provided where other nurses, physicians, etc. could review the skin assessments a was provided for residents if she was keeping skin assessments in a binder in her office, the Wound Care Nurse stated if there was an issue there would be an order for wound care that would pop up (in the computer). The Wound Care Nurse stated she worked a M-F schedule but was out last week ([DATE]-[DATE]) so no skin assessments were completed, and she did not know if the charge nurse did assessments. She stated she did not know if the nurses had access to the skin assessment binder because she kept it in her office. The Wound Care Nurse stated when she was not in the facility the nurses or the ADON would have to provide wound care. She stated either the ADON or DON would have to inform the nurses she was not at work. The Wound Care Nurse stated the facility did not have a process to document redness on the skin assessment other than just redness. When asked if she assessed if redness was blanchable and how she documented, she stated redness was not anything that was severe. She stated if a wound was not blanchable she would notify the physician because it indicated poor circulation. She stated it was a nursing judgment. She stated redness was usually located on the bum or as dryness to the legs and was nothing to notify the physician about. She stated she had standing orders for zinc oxide to take care of it. The Wound Care Nurse stated the facility relied on wound measurement and wound description documentation as documented by the WC NP who came to the facility 1 time a week. She stated without a WC NP she would document on the skin assessment or progress note if there was a concern, but she did not have to do measurements because the WC NP was already doing them, and she was never told to document it. The Wound Care Nurse stated the facility did not have process to document condition of the wound because the WC NP documents it. When asked about the process for residents in which the WC NP did not see or in absence of a WC NP, the Wound Care Nurse stated the facility had not had any hospice residents with wounds and she hoped to have a new WC NP soon. The Wound Care Nurse stated she received no training when she took the position as Wound Care Nurse. She stated the facilities supplier of wound care supplies, and the physician were available to her for questions or concerns. She stated the wound care supplier was also a LVN that would come and train her when she requested. During an interview on [DATE] at 6:30 p.m., the Wound Care Nurse stated on [DATE] Resident #1 had redness to his sacrum and she applied zinc oxide per standing orders. She stated the next day he was okay and had no more redness. She stated she did not write the zinc oxide as an order in PCC. She stated she thought there was already an order for it in PCC. The Wound Care Nurse denied knowledge that Resident #1 had a wound to his left foot great toe. She stated the redness never progressed to anything beyond redness. The Wound Care Nurse stated sometime last week (date unknown) she heard that LVN B notified the MD and got an x-ray and lab for Resident #1. She stated she also heard that Resident #1 was supposed to be seen by the NP for his toe. The Wound Care Nurse stated she provided wound care and assessed Resident 1's toe but did not document that assessment, only the treatment. She stated she did not know what the toe or wound looked like. She stated she was trained in nursing school to document assessments but had not been trained by the wound care supplier. She stated the wound care supplier gave her the run down on wound care and was supposed to return this week to give her further detail. The Wound Care Nurse stated she was notified by LVN B that Resident #1's toe was an open wound, but she could not remember the date. She stated it was sometime last week. The Wound Care Nurse stated she could not recall if Resident #1's toe or wound was discussed or if it was brought up during morning meetings. The Wound Care Nurse stated she was not in for parts of last week or she came in late, so she was not aware. Record review of the Wound Care Nurses Timecard for [DATE] revealed: Monday, [DATE]-clocked in for 5.25 hours from 8:54 a.m.-2:51 p.m. Tuesday, [DATE]-clocked in for 9.75 hours from 8:18 a.m.-6:30 p.m. Wednesday, [DATE]-clocked in for 3 hours from 4:05 p.m.-6:59 p.m. Thursday, [DATE]-clocked in for 5.75 hours from 6:49 am-8:34 am and 12:32 p.m.-4:56 p.m. Friday, [DATE]-clocked in for 7.75 hours from 8:44 a.m.-5:02 p.m. Monday, [DATE]-clocked in for 8.0 hours from 9:00 a.m.-5:25 p.m. Tuesday, [DATE]-clocked in for 9.0 hours from 9:00 a.m.-6:34 p.m. Wednesday, [DATE]-clocked in for 9.0 hours from 7:25 a.m.-5:07 p.m. Thursday, [DATE]-clocked in for 10.25 hours from 7:39 a.m.-6:28 p.m. Friday, [DATE]-clocked in for 4 hours from 2:25 p.m.-6:34 p.m. Monday, [DATE]- did not clock in or out, no hours reported Tuesday, [DATE]-clocked in for 6.0 hours from 1:10 p.m.-7:47 p.m. Wednesday, [DATE]-clocked in for 12 hours from 9:21 a.m.-9:49 p.m. Thursday, [DATE]- clocked in for 11.25 hours from 8:44 a.m.-8:29 p.m. Friday, [DATE]-clocked in for 8.25 hours from 10:58 a.m.-7:43 p.m. During an interview on [DATE] at 9:59 a.m., CNA A stated she used to be the shower aide on Resident #1's hallway approximately 1 month ago. She stated there was a lot of staff inconsistency because it was a heavy workload hall, and nobody wanted to work it. CNA A stated she had not provided Resident 1 showers in the last month. She stated previously he had a wound on his bottom (unknown date) She stated she notified the nurse. She stated she did not remember who the nurse was at the time. She stated she was trained that anytime she saw something new she would go immediately to the nurse. CNA A stated when she saw the wound on Resident #1's bottom it was an open wound without skin on top, about the size of a dime. She stated she thought it might have been LVN B that she notified but could not be certain. She stated later she saw white medicine on Resident #1's bottom. CNA A stated her responsibility was to report and it was the nurse's responsibility to take the next steps. She stated her communicated with the nurses verbally. CNA A stated she saw Resident #1 with a bandage on his foot, and she smelled something rotten. She stated she started looking in Resident #1's room for the location of the smell and finally realized it was coming from his foot. CNA A stated it was the same day Resident #1 got the x-ray of his foot. She stated after assisting with the x-ray she told the nurse that his foot smelled really bad, and the toe was brown. She stated the following day when she came in the bandage had been changed and the smell was better. CNA A stated when she first noticed the wound on Resident #1's bottom, he already had a bandage on his foot. She stated the whole foot was bandaged (unsure if it was right or left foot) and there was blood on the bandage near his big toe. She stated she never saw the wound and even during rounds when coming on shift it was never reported that Resident #1 had a wound during rounds. During an interview on [DATE] at 11:01 a.m., LVN B stated she was assigned as the nurse to Resident #1's hallway and worked 6 a.m. to 6 p.m. LVN B stated Resident #1 had an old atrial [arterial] wound to his left foot since [DATE]. LVN B stated in [DATE], CNA A came to her and told her about a wound to Resident 1's foot. She stated she called the MD and received wound care orders in [DATE] and the receptionist at the MD's office told her to inform the in house Wound Care Nurse. LVN B stated she notified the Wound Care Nurse via text. She stated she had since deleted the text. She stated there were orders to treat the wound that she put in PCC. LVN B stated she did not provide wound care to the wound because the facility had a Wound Care Nurse to provide treatments. LVN B stated she did not know what happened to the order for wound care in [DATE]. She stated she got the orders the very first time she saw it but may have passed the orders on to the next shift to complete. She stated she could not remember. She stated she did not know the outcome of the wound because she left the charge nurse position to do facility staffing, although she came back to the charge nurse position in [DATE]. LVN B stated she looked at the wound on the weekends and it looked good. LVN B stated Resident #1 was a diabetic and was not moving around and he could no longer sit himself up in bed. She stated he had become bedbound. LVN B stated the resident was not eating and the facility had recommended hospice. LVN B stated the family initially refused hospice. LVN B stated, in [DATE], a family member and herself saw blood on the floor, a few specks. LVN B stated she discovered the blood was coming from Resident #1's toe, but nothing big. LVN B stated she first noticed the wound on his foot approximately [DATE] and that was the last time she assessed it. LVN B stated Resident #1 was put on hospice care ([DATE]) right before he went to the hospital ([DATE]). She stated the (left foot great) toe looked discolored, but not necrotic. She said the toe was purplish kind of like a bruise and had the same opening on it from April. LVN B stated it looked the same. LVN B stated the ADON went to see the wound. LVN B stated she was not aware of a wound to Resident #1's bottom (sacrum). She stated she also completed a skin assessment but did not document the findings. LVN B stated she only documents negative findings in progress notes and does not document otherwise. LVN B stated Resident #1's wound was documented in the 24-hour notes (not part of medical record). LVN B stated she did not document because a family member was in the room and the facility had a WC NP who would do wound care rounds. She stated she addressed the wounds with the WC NP. LVN B stated in [DATE] Resident #1 declined. She stated Resident #1's family member said he looked sick, and he was not eating. LVN B stated Resident #1 looked kind of grayish, like he was going to pass on. She stated that was expected. LVN B stated Resident #1 did not go to the hospital because of his wound, he went because the family requested. She stated the family kept telling EMS that Resident #1 was not on hospice and that the facility did not care about him. During an interview on [DATE] at 11:19 a.m., CNA C stated when he provided care to Resident #1 (unknown date), he had noticed scratches to his arms which had resolved and a wound to the left foot ankle area (unknown time frame). CNA C stated he never saw a wound on Resident #1's bottom (sacrum). CNA C stated he had an uncle that was similar to Resident #1, so he did not look at Resident #'1 feet because it grossed him out. CNA C stated he knew Resident #1 had a wound to his big toe, although he was not sure which foot. CNA C stated he first noticed the wound when he removed a blanket from Resident #1 and his toe stuck to the sheet, pulling off a piece of skin when he removed the sheet. He stated this might have occurred during the first week of [DATE], but he was not certain. CNA C stated Resident #1's toenail was intact but some of the skin was missing near the side of the nail approximately 1 cm long. He stated there was goo but no blood. He described the goo as what a wound looks like when a scab is removed. CNA C stated there was no redness or swelling. He stated he notified RN D, who stated she would look at it, he said RN D never mentioned it again and his assignment changed during the shift, so he did not see what happened. During an interview on [DATE] at 12:19 p.m., the ADON stated the facility did not have a DON. He stated the other ADON, (ADON DD) died suddenly a few days ago. The ADON stated he was new the facility as ADON as of [DATE]. The ADON stated the facility did not have an internal process to assess wounds and track wounds. He stated the WC NP did their own assessment and submitted a weekly wound report for the wounds the NP treated. The ADON stated confirmation that Resident #1 had a wound to the toe (left great toe) in which LVN B put created an order for wound care on [DATE] but did not activate the order and it did not populate to the MAR (TAR) as an order. The ADON stated a CNA pointed out to LVN B that the wound had not been changed and LVN B let the Wound Care Nurse know. The ADON stated the CNA saw the wound had not been changed a told the Wound Care Nurse know and she changed the wound (dressing) right then. The ADON stated the wound was not changed from then (date unknown) until he saw the wound on [DATE]. The ADON stated he went to look at the wound when the RP demanded the facility address some issues in which the RP thought the dressing looked old. The ADON stated the dressing was a kerlix gauze that was stretched out and discolored with red, black, and yellow drainage. He stated the dressing was not dated and it did look old. The ADON stated the wound had an odor that smelled rancid, like a rotting smell. He stated once he removed the old dressing the odor hit him in the face. He described the smell as overwhelming. The ADON stated when he removed the dressing multiple layers of skin were also removed with the dressing. He stated there was yellow, green, and necrotic tissue that was moist, black and liquidly. The ADON stated the entire toenail from the base forward came off with the dressing. He stated the area under the nail was completely black. After looking at a photo of the toe, the ADON stated the toe was worse than the picture. He stated in the picture parts of the wound looked dry, but when he saw it was completely moist. The ADON stated there were bubbles of stuff resembling pus coming out of the toe when he tried to clean the wound. He described the pus as yellow/black in color with a mixture of greyish brown. He stated no one had told him of the condition of the wound before he saw it. He stated it was very alarming to him. The ADON stated he was not even aware there was a wound at all. He stated no one had notated the wound. He stated the Wound Care Nurse was responsible for weekly skin assessments. The ADON stated if the Wound Care Nurse was not at the facility or unable to complete a wound or skin assessment, she was supposed to personally notify a floor nurse to do it or should catch up on the day she returned. The ADON stated he had not seen her books until after this occurred. He stated after reviewing the Wound Care Nurses documentation he does not believe skin assessments were being doing consistently. He stated he did not even know about the Wound Care Nurses skin assessment book until this situation occurred. He stated there were shower sheets the CNAs were supposed to document wound issues. The ADON stated once a week the WC NP completed weekly rounds and submitted a weekly wound report that they used to track wound progress. The ADON stated he noticed the skin assessments were not catching all wounds. He stated he told the DON and the WC NP told the DON. He stated the DON, and the Wound Care Nurse blamed the WC NP which ended the WC NP contract. The ADON stated the WC NP contract was severed last Thursday ([DATE]). The ADON stated he his job duties did not include monitoring of medical records or audits. He stated the former ADON (ADON DD) was responsible for ensuring completion of orders. The ADON stated his expectations of the CNA staff were for them to immediately notify a charge nurse or the Wound Care N[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 8 residents (Resident #1) reviewed for quality of care in that: The facility failed to assess and treat resident #1's left foot great toe when the resident developed a wound to his LLE from [DATE] until [DATE] which resulted in a decline in health, a worsening of the wound including the toe turning black, infection, necrosis, gangrene, sepsis, hospitalization, and amputation. The facility also failed to identify and treat a wound to Resident #1's sacrum. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:31 p.m. While the IJ was removed on [DATE] at 11:54 a.m., the facility remained out of compliance at a scope of pattern and severity of actual harm with a potential for more than minimal harm due to facility's need to evaluate the effectiveness of their plan of removal. This deficient practice placed residents at risk of unidentified and untreated wounds, infection, a decline in health, amputation, and death. The findings included: Record review of a facility self-report dated [DATE] the facility reported Resident #1 wound care orders placed in chart on [DATE] were not followed up. Resident #1 became septic and resulted in amputation of big toe. The facility listed RN D and LVN B as the alleged perpetrators. Record review of Form 3613-A dated [DATE] and signed by the facility Administrator on [DATE] revealed an allegation of abuse and neglect was made by family of abuse and neglect on an unknown date and time regarding Resident #1. The report stated Resident #1 required total assistance with care and was not interviewable was transferred to a local hospital for a worsening wound on [DATE] with the Wound Care Nurse listed as the perpetrator. The report stated that the Wound Care Nurse was not providing wound care and was not being supervised by the DON. Lack of services, training and supervision led to worsening of the wound. In a verbal conversation with the hospital, the left foot was amputated. The investigative findings were confirmed Record review of Resident #1 face sheet dated [DATE] revealed an admission date of [DATE] with readmission date of [DATE] with diagnoses which included: type 2 diabetes mellitus with hyperglycemia, protein-calorie malnutrition (undernutrition), and hypertension (high blood pressure). Record review of Resident #1's Care Plan dated [DATE] revealed the resident had a diagnosis of diabetes with interventions to include: inspect feet during bathing and as needed for open areas, sores, pressure areas, blisters, edema and redness and report to the nurse. Record review of Resident #1's Care Plan dated [DATE] revealed the resident had a potential for the development of a pressure ulcer with no evidence of an actual pressure ulcer or wound. The care plan did not address any actual wounds for Resident #1. Record review of a Doctor's Progress Note dated [DATE] revealed: Left foot with arterial wound to great toe, 2nd toe, 3rd toe. Clean left foot arterial wound to great toe, 2nd toe, 3rd toe, apply betadine daily. Wound Consult [illegible word], signed by the NP. Record review of a physician order dated [DATE] for wound care revealed LVN B put orders into the computer on [DATE] at 8:18 p.m. which were signed by the MD on [DATE]. The orders did not have a schedule for administration attached and indicated the orders were for the TX (wound) Nurse as non-medication orders. The orders were: wound care orders for atrial (sic) [arterial] wounds to the left foot, clean with normal saline, pat dry and apply betadine daily until wound consult to follow. Record Review of Resident #1's [DATE] TAR revealed no orders for wound care to the left great toe or left foot. The physician orders for treatment of the wounds to the left foot had not carried over to the TAR and there was no indication wound care was performed. Record review of the facility wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's [DATE] TAR revealed orders for weekly skin assessments scheduled for Fridays with staff initials to indicate the assessment was completed. Friday [DATE] was not marked as completed. The skin assessments for [DATE], [DATE], and [DATE], were initialed completed by LVN B. Record review of Resident #1's [DATE] TAR revealed no orders for wound care and there was no indication wound care was performed. Record review of the facility wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's [DATE] TAR revealed an order for weekly skin assessments scheduled for Fridays with staff initials to indicate the assessment was completed. Friday [DATE] and Friday [DATE].2023 were not marked as completed. Friday [DATE], had an x marked through the assessment date. The skin assessments were completed 2 out of 5 opportunities. Record review of Resident #1's [DATE] TAR revealed no orders for wound care and there was no indication wound care was performed. Record review of the facilities wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's annual MDS assessment dated [DATE] revealed a BIM's score of 8 which indicated a moderate cognitive impairment. The assessment was coded for no ulcers, wounds, or skin problems. Record review of Resident #1's July TAR revealed orders for weekly skin assessments scheduled for Mondays with staff initials to indicate the assessment was completed. Monday [DATE], and Monday [DATE]th, 2023, were not marked as completed. This indicated skin assessments were completed 1 out of 3 opportunities for [DATE]. Record review of Resident #1's [DATE] TAR revealed no orders for wound care and there was no indication wound care was performed until [DATE]. Record review of the facilities wound log for [DATE] revealed Resident #1 was not listed on the log. Record review of Resident #1's shower sheet dated [DATE] revealed a shower was not given for refusal of care written on the form. No skin issues were documented. The nurse signature was not legible. A second shower sheet dated [DATE] was documented that a shower was given, and no new skin issues were assessed by the nurse. The nurse signature was not legible. No other shower sheets could be located for Resident #1. Record review of Resident #1's progress notes revealed no documentation of skin assessment or wound assessments from [DATE]-current in the medical record. Record review of Resident #1's weekly skin integrity review dated [DATE] and signed by the Wound Care Nurse located in a binder in the Wound Care Nurses office revealed Resident #1 had intact dry skin with redness. The areas marked on the picture of the human diagram with an X were the left big toe and the front of both shins. Record review of Resident #1's weekly skin integrity review dated [DATE] and signed by the Wound Care Nurse located in a binder in the Wound Care Nurses office revealed Resident #1 had intact dry skin with redness. The areas marked on the picture of the human diagram with an X were the left big toe and the front of both shins and the buttocks. There was no other skin assessment prior to [DATE] or after [DATE] in the notebook. Record review of the 24-Hour Report Sheet (nurse to nurse communication between shifts) for Resident #1 revealed: [DATE]: Left toe dressing done [DATE]: big left toe needs wound nurse orders [DATE]: get treatment (nurse) to do wound care to left big toe [DATE]: get treatment (nurse) to do wound care to left big toe [DATE]: get treatment (nurse) to do wound car to left big toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe [DATE]: dressing to big left toe .hospice now, hospice will be in to write orders on Monday [DATE]: dressing to big left toe .hospice not, hospice to write orders Monday [DATE]: new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders, culture collected/pending . [DATE]: hospice orders pending, new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders . Record review of Resident #1's progress notes dates [DATE] revealed MD notified of condition of wound to LLE great toe. New orders received to get wound culture, CBC, renal panel, x-ray to LLE great toe to rule to osteomyelitis (infection of the bone), initial dose of Augmentin 500 mg (antibiotic) and Cipro 500 mg given and is to be continued for the next 10 days. Also received wound treatment orders . Record review of Resident #1's progress notes dated [DATE] documented by LVN B revealed: results in from x-ray of left toes .osteomyelitis not excluded .results faxed to MD, new orders pending. Record review of Resident #1's x-ray dated [DATE] of the left toe revealed minimal patchy osteolytic lesion involving first-proximal phalanx (great toe) ; mild diaphysis: osteomyelitis not excluded. Record review of Resident #1's physician order summary for [DATE] revealed an order for admit to hospice services with a start date of [DATE]. Record review of Resident #1's progress notes dated [DATE] documented by the ADON revealed: Resident sent out to [a local hospital] for worsening wound issues .that the family is concerned about. Per the family's request after a care plan meeting was completed, facility initiated a call for EMS to com(e) and transfer resident to the hospital. Notified MD of the hospital transfer . Record review of Resident #1's Care Plan Conference notes dated [DATE] and signed by the former DON on [DATE] revealed the form was blank and no information had been entered. Record review of Resident #1's hospital admission record dated [DATE] revealed the resident presented to the ER by EMS for necrotic toe present for over 1 week and a sore on the sacrum that is healing. Necrotic toe on the left gangrene (tissue death) , x-rays of extremity foot reveal osteomyelitis with gangrene and necrosis (infection of the bone with tissue death) .concerned about osteomyelitis with severe soft tissue infection. Patient does require admission. Impression: sepsis, toe necrosis, soft tissue infection, elevated lactic acid (indicated infection and is clinically significant as it shows correlation with sepsis and can indicate likelihood of critical illness), osteomyelitis of toe (infection that is in the bone), tachycardia (elevated heart rate which can indicate sepsis) . Record review of Resident #1's hospital record of x-ray to foot dated [DATE] revealed .soft tissue swelling is noted about the great toe with osseous erosive change involving the proximal phalanx (toe) .concerning for osteomyelitis with possible superimposed fracture (fracture can occur from severe osteomyelitis which weakens the bone). Record review of Resident #1's hospital record of physician assessment dated [DATE] revealed: Musculoskeletal/Skin: .left great toe notes severely necrotic changes to the soft tissue consistent with a mix of dry and wet gangrene, putrid odor coming from the foot. There is a palpable DP (dorsal pedal-pulse on the top of the foot indicating there is blood flow to the foot) pulse. There is surrounding erythema (redness) and purulent drainage (pus). Patient has a sacral decubitus (bed sore) ulcer with granulation tissue overlying it with no evidence of infection. Orthopedic consulted .Patient will need admission for further management and IV antibiotics and possible surgical intervention for his gangrenous infection of the left great toe. Record review of Resident #1's hospital record of wound culture to left great toe revealed the toe was infected with a moderate growth of proteus mirabilis (bacteria), very light growth of klebsiella pneumoniae a multi-drug resistant organism (bacteria that is resistant to many antibiotics), moderate growth of staphylococcus (bacteria). Record review of a hospital record for Resident #1 dated [DATE] revealed: Assessment/Plan: severe sepsis with shock initially requiring low dose of vasopressor (medication used to raise blood pressure in ICU setting which a sign of shock), WBC trending up (indicated infection), remains afebrile (without fever). Left first toe gangrene (tissue death with osteomyelitis (infection of the bone): continue vancomycin, cefepime, Flagyl (antibiotics), per ortho needs amputation. Record review of an undated photo of Resident #1's left foot revealed the left great toe from top of the foot view was dark black in color from the tip of the toe to the first joint with the appearance of a missing toenail. The area below the first joint was red and purple in color. There was a partially removed gauze from the toe revealed heavily soiled gauze with discharge that was beige, yellow, brown, pink, and red in color. There was a large amount of swelling to the right side of the great left toe starting at the tip of the toe, with the largest amount of swelling near the first joint that was discolored black, grey, brown, yellow, and pink and extending to the base of the first toe. The skin was peeling off the first toe. There was a large amount of drainage and moisture on the toe, and gauze. The other toes were obscured from view by the gauze. During an interview on [DATE] at 12:01 p.m. the Hospice admission Nurse stated she admitted Resident #1 to hospice on [DATE]. She stated at the time of admission Resident #1 had a wound that was gooey, purulent with foul odor that smelt gangrenous and was poorly bandaged. She stated Resident 1 was very weak and had slow slurred speech that could not be understood. The Hospice admission Nurse stated she asked the facility if Resident #1 was on antibiotics and they confirmed that he was on Augmentin, Cipro (antibiotics) and Dakin's (wound cleaner). She stated that she only admitted Resident #1 to hospice services and had no other interaction prior to his discharge. During an interview on [DATE] at 1:22 p.m., Resident #1's RP stated she had noticed the wrap to the resident's toe had not been changed (date unknown). She stated she got hospice involved (unknown date) because she did not feel like Resident #1 was getting the attention, he needed from the facility staff. She stated she had a meeting with the facility (names of staff unknown) on 721/2023. She stated they told her she could not put him in the hospital even though he was declining, but she did it anyway on the same date. She stated she did not want her family member to die. She stated she only got hospice because they told her he would get extra help. The RP stated Resident #1 was now going to have to have an amputation. The RP stated Resident #1 had dementia and was not interviewable. During an interview on [DATE] at 1:49 p.m. CNA E stated she was assigned to provide showers. She stated she had not given Resident #1 a shower because she thought he was on hospice and hospice usually provided showers. She stated she had a paper that told her which residents were on hospice but was unable to produce the paper. She stated she did not see any wounds to Resident #1 because she did not give him a shower. She stated she was trained to document open wounds on a shower sheet and verbally tell the nurse. During an interview on [DATE] at 1:55 p.m., CNA EE stated she never gave Resident #1 a shower because she was told (unknown person) he was on hospice and hospice was showering him. She stated she did not know of any wounds. She stated she reviewed a list of residents on hospice provided by former ADON DD. During an interview on [DATE] at 2:05 p.m. CNA FF stated she was assigned to Resident #1's hallway. She stated she did not remember ever filling out a shower sheet for Resident #1. She stated she thought he was hospice. She stated sometimes she would get him in the shower, but he did not like to take a shower and he would say stuff and yell. She stated she was mostly providing Resident #1 with bed baths. She stated she could not remember any wounds on his sacrum or wounds on his feet and did not remember if she saw any dressings. CNA FF stated Resident #1 had declined but she did not know why he left the facility. CNA FF stated she was trained to notify the nurse and wound care of any skin issues or wounds. She stated she was trained to fill out a shower sheet for showers and bed baths and document any wounds, redness, or anything unfamiliar or new. She stated she was trained to turn the shower sheet into the nurse and also tell the nurse verbally. During an interview on [DATE] at 2:17 p.m., the Wound Care Nurse stated she worked a M-F schedule. She stated on [DATE] and [DATE] she documented on a weekly skin assessment sheet that she kept in a binder in her office and was not part of the medical record that Resident #1 had redness to the left foot great toe. She stated on [DATE] Resident #1 also had redness to his bottom (sacrum) that was blanchable. The Wound Care Nurse stated she did not notify the physician about the redness to the bottom (sacrum) because she had zinc oxide as standing orders to take care of it. She stated she did not notify the physician about the redness to Resident #1's left great toe because it was positional. She stated she knew it was positional redness because the resident was bedbound and refuses. She stated in her nursing judgement there was no concern to notify. The Wound Care Nurse stated weekly head to toe skin assessments were documented in PCC (electronic medical chart) as a check on the resident TAR to show completion. She stated she did not document the results of the skin assessments in the resident medical record. She stated she kept the results on a paper document in a binder which she kept in her office. The Wound Care Nurse stated she only had weekly skin assessments documented for [DATE]. She stated she did not have any other documentation for July other than [DATE] and [DATE]. She stated she did not do weekly skin assessments last week ([DATE]-[DATE]) because she was out. She stated she did not know if weekly skin assessments had been completed in her absence and did not know if the nurses had access to the binder in her office. She stated the nurses or the ADON would have to do wound care in her absence. She stated she was told to keep the weekly skin assessment in a binder in her office. She stated she asked (unknown person) why she was not documenting in the medical record and was told by someone she could not remember to just keep them the skin assessments in her office. When asked how continuity of care was provided, where other nurses, physicians, etc. could review the skin assessments for residents if she was keeping skin assessments in a binder in her office, the Wound Care Nurse stated if there was an issue there would be an order for wound care that would pop up (in the computer). She stated she is notified of resident wounds by the charge nurses or when she completes the head-to-toe skin assessments. She stated the facility had house orders (standing orders/wound protocol) for wound care for wound care orders that she used on new wounds. The Wound Care Nurse stated the facility used to have a WC NP (Wound Care Nurse Practitioner) until two weeks ago. She stated the facility no longer had one as she was not meeting the Corporation's needs. The Wound Care Nurse stated the WC NP would see all residents with wounds except for patients on hospice and those with certain types of insurance. She stated she did not know what types of insurance were excluded. The Wound Care Nurse stated the facility did not have process to document condition of the wound because the WC NP documents it. When asked about the process for residents in which the WC NP did not see or in absence of a WC NP, the Wound Care Nurse stated the facility had not had any hospice residents with wounds and she hoped to have a new WC NP soon. The Wound Care Nurse stated she had received no training when she took the position as Wound Care Nurse, she stated the facility supplier of wound care supplies, and the physician were available to her for questions or concerns. She stated the wound care supplier was also a LVN that would come and train her when she requested. During an interview on [DATE] at 6:30 p.m., the Wound Care Nurse denied knowledge that Resident #1 had a wound to his left foot great toe. The Wound Care Nurse stated on [DATE] Resident #1 had redness to his sacrum and she applied zinc oxide per standing orders. She stated the next day he was okay and had so more redness. She stated she did not write the zinc oxide as an order in PCC. She stated she thought there was already an order for it in PCC. She stated the redness never progressed to anything beyond redness. The Wound Care Nurse stated sometime last week (date unknown) she heard that LVN notified the MD and got an x-ray and lab for Resident #1. She stated she also heard that Resident #1 was supposed to be seen by the NP for his toe. The Wound Care Nurse stated she provided wound care and assessed Resident 1's toe but did not document that assessment, only the treatment. She stated she did not know what the toe or wound looked like. She stated she was trained in nursing school to document assessments but had not been trained by the wound care supplier. She stated the wound care supplier gave her the run down on wound care and was supposed to return this week to give her further detail. The Wound Care Nurse stated she was notified by LVN B that Resident #1's toe was an open wound, but she could not remember the date. She stated it was sometime last week. The Wound Care Nurse stated she could not recall if Resident #1's toe or wound was discussed or if it was brought up during morning meetings. The Wound Care Nurse stated she was not in for parts of last week or she came in late, so she was not aware. Record review of the Wound Care Nurses Timecard for [DATE] revealed: Monday, [DATE]-clocked in for 5.25 hours from 8:54 a.m.-2:51 p.m. Tuesday, [DATE]-clocked in for 9.75 hours from 8:18 a.m.-6:30 p.m. Wednesday, [DATE]-clocked in for 3 hours from 4:05 p.m.-6:59 p.m. Thursday, [DATE]-clocked in for 5.75 hours from 6:49 am-8:34 am and 12:32 p.m.-4:56 p.m. Friday, [DATE]-clocked in for 7.75 hours from 8:44 a.m.-5:02 p.m. Monday, [DATE]-clocked in for 8.0 hours from 9:00 a.m.-5:25 p.m. Tuesday, [DATE]-clocked in for 9.0 hours from 9:00 a.m.-6:34 p.m. Wednesday, [DATE]-clocked in for 9.0 hours from 7:25 a.m.-5:07 p.m. Thursday, [DATE]-clocked in for 10.25 hours from 7:39 a.m.-6:28 p.m. Friday, [DATE]-clocked in for 4 hours from 2:25 p.m.-6:34 p.m. Monday, [DATE]- did not clock in or out, no hours reported Tuesday, [DATE]-clocked in for 6.0 hours from 1:10 p.m.-7:47 p.m. Wednesday, [DATE]-clocked in for 12 hours from 9:21 a.m.-9:49 p.m. Thursday, [DATE]- clocked in for 11.25 hours from 8:44 a.m.-8:29 p.m. Friday, [DATE]-clocked in for 8.25 hours from 10:58 a.m.-7:43 p.m. During an interview on [DATE] at 9:59 a.m., CNA A stated she used to be the shower aide on Resident #1's hallway approximately 1 month ago. She stated there was a lot of staff inconsistency because it was a heavy workload hall, and nobody wanted to work it. CNA A stated she had not provided Resident 1 showers in the last month. She stated previously he had a wound on his bottom (unknown date) She stated she notified the nurse. She stated she did not remember who the nurse was at the time. She stated she was trained that anytime she saw something new she would go immediately to the nurse. CNA A stated when she saw the wound on Resident #1's bottom it was an open wound without skin on top, about the size of a dime. She stated she thinks it might have been LVN B that she notified but could not be certain. She stated later she saw white medicine on Resident #1's bottom. CNA A stated her responsibility was to report and it was the nurse's responsibility to take the next steps. She stated her communicated with the nurses verbally. CNA A stated she saw Resident #1 with a bandage on his foot, and she smelled something rotten. She stated she started looking in Resident #1's room for the location of the smell and finally realized it was coming from his foot. CNA A stated it was the same day Resident #1 got the x-ray of his foot. She stated after assisting with the x-ray she told the nurse that his foot smelled really bad, and the toe was brown. She stated the following day when she came in the bandage had been changed and the smell was better. CNA A stated when she first noticed the wound on Resident #1's bottom, he already had a bandage on his foot. She stated the whole foot was bandaged (unsure if it was right or left foot) and there was blood on the bandage ear his big toe. She stated she never saw the wound and even during rounds when coming on shift it was never reported that Resident #1 had a wound during rounds. During an interview on [DATE] at 11:01 a.m., LVN B stated she was assigned as the nurse to Resident #1's hallway and worked 6 a.m. to 6 p.m. LVN B stated Resident #1 had an old atrial [arterial] wound to his left foot since [DATE]. LVN B stated in [DATE], CNA A came to her and told her about a wound to Resident 1's foot. She stated she called the MD and received wound care orders in [DATE] and the receptionist at the MD's office told her to inform the in house Wound Care Nurse. LVN B stated she notified the Wound Care Nurse via text. She stated she had since deleted the text. She stated there were orders to treat the wound that she put in PCC. LVN B stated she did not provide wound care to the wound because the facility had a Wound Care Nurse to provide treatments. LVN B stated she did not know what happened to the order for wound care in [DATE]. She stated she got the orders the very first time she saw it but may have passed the orders on to the next shift to complete. She stated she could not remember. She stated she did not know the outcome of the wound because she left the charge nurse position to do facility staffing, although she came back to the charge nurse position in [DATE]. LVN B stated she looked at the wound on the weekends and it looked good. LVN B stated resident #1 was a diabetic and was not moving around and he could no longer sit himself up in bed. She stated he had become bedbound. LVN B stated the resident was not eating and the facility had recommended hospice. LVN B stated the family initially refused hospice. LVN B stated, in [DATE], a family member and herself saw blood on the floor, a few specks. LVN B stated she discovered the blood was coming from Resident #1's toe, but nothing big. LVN B stated she first noticed the wound on his foot approximately [DATE] and that was the last time she assessed it. LVN B stated Resident #1 was put on hospice care ([DATE]) right before he went to the hospital ([DATE]). She stated the (left foot great) toe looked discolored, but not necrotic. She said the toe was purplish kind of like a bruise and had the same opening on it from April. LVN B stated it looked the same. LVN B stated the ADON went to see the wound. LVN B stated she was not aware of a wound to Resident #1's bottom (sacrum). She stated she also completed a skin assessment but did not document the findings. LVN B stated she only documents negative findings in progress notes and does not document otherwise. LVN B stated Resident #1's wound was documented in the 24-hour notes (not part of medical record). LVN B stated she did not document because a family member was in the room and the facility had a WC NP who would do wound care rounds. She stated she addressed the wounds with the WC NP. LVN B stated in [DATE] Resident #1 declined. She stated Resident #1's family member said he looked sick, and he was not eating. LVN B stated Resident #1 looked kind of grayish, like he was going to pass on. She stated that was expected. LVN B stated Resident #1 did not go to the hospital because of his wound, he went because the family requested. She stated the family kept telling EMS that Resident #1 was not on hospice and that they facility do not care about him. During an interview on [DATE] at 11:19 a.m., CNA C stated when he provided care to Resident #1 (unknown date), he had noticed scratches to his arms which had resolved and a wound to the left foot ankle area (unknown time frame). CNA C stated he never saw a wound on Resident #1's bottom (sacrum). CNA C stated he had an uncle that was similar to Resident #1, so he did not look at Resident #'1 feet because it grossed him out. CNA C stated he knew Resident #1 had a wound big toe, although he was not sure which foot. CNA C stated he first noticed the wound when he removed a blanket from Resident #1 and his toe stuck to the sheet, pulling off a piece of skin when he removed the sheet. He stated this might have occurred during the first week of [DATE], but he was not certain. CNA C stated Resident #1's toenail was intact but some of the skin was missing near the side of the nail approximately 1 cm long. He stated there was goo but no blood. He described the goo as what a wound looks like when a scab is removed. CNA C stated there was no redness or swelling. He stated he notified RN D, who stated she would look at it. He stated RN D never mentioned it again and his assignment changed during the shift, so he did not see what happened. During an interview on [DATE] at 12:19 p.m., the ADON stated the facility did not have a DON. He stated the other ADON, (ADON DD) died suddenly a few days ago. The ADON stated he was new the facility as ADON as of [DATE]. The ADON stated confirmation that Resident #1 had a wound to wound to toe (left great toe) in which LVN B put created an order for wound care on [DATE] but did not activate the order and it did not populate to the MAR (TAR) as an order. The ADON stated a CNA pointed out to LVN B that the wound had not been changed and LVN B let the Wound Care Nurse know. The ADON stated the CNA saw the wound had not been changed a told the Wound Care Nurse know and she changed the wound right then. The ADON stated the wound was not changed from then (date unknown) until he saw the wound on [DATE]. The ADON stated he went to look at the wound when the RP demanded the facility address some issues in which the RP thought the dressing looked old. The ADON stated the dressing was a kerlix gauze that was stretched out and discolored with red, black and yellow drainage. He stated the dressing was not dated and it did look old. The ADON stated the wound had an odor that smelled rancid, like a rotting smell. He stated once he removed the old dressing the odor hit him in the face. He described the smell as overwhelming. The ADON stated when he removed the dressing multiple layers of skin were also removed with the dressing. He stated there was yellow, green and necrotic tissue that was moist, black and liquidly. The ADON stated the entire toenail from the base forward came off with the dressing. He stated the area under the nail was completely black. After looking at a photo of the toe, the ADON stated the toe was worse than the picture. He stated in the picture parts of the wound looked dry, but when he saw it was completely moist. The ADON stated there bubbles of stuff resembling pus coming out of the toe when he tried to clean the wound. He described the pus as yellow/black in color with a mixture of greyish brown. He stated no one had told him of the condition of the wound before he saw it. He stated it was very alarming to him. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that licensed nurses had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety for 1 of 8 residents (Resident #1) and for 4 of 6 licensed staff (Wound Care Nurse, RN D, LVN B and LVN II) reviewed for competent staff, in that: 1. The facility failed to ensure the Wound Care Nurse had completed training for a license violation and remediation and failed to ensure she was competent to perform skin assessments, wound assessments, obtain and implement physician orders and document her finding in the medical record resulting in Resident #1 becoming septic and the amputation of the resident's big toe. 2. The facility failed to ensue RN D had the competencies to identify a resident change of condition, obtain and implement physician orders for wound care, assess wounds and document her findings in the medical record resulting in Resident #1 becoming septic and the amputation of the resident's big toe. 3. The facility failed to ensure LVN B had the competencies and training to assess and identify wounds, obtain, and implement wound care orders and document her findings in the medical record resulting in Resident #1 becoming septic and the amputation of the resident's big toe. 4. The facility failed to ensure LVN II had the competencies and training to assess and identify wounds, obtain, and implement wound care orders and document her findings in the medical record resulting in Resident #1 becoming septic and the amputation of the resident's big toe. An IJ was identified on 8/18/2023. The IJ template was provided to the facility on 8/18/2023 at 11:15 a.m. While the IJ was removed on 8/19/2023 at 6:46 p.m., the facility remained out of compliance at a scope of pattern and severity of actual harm with a potential for more than minimal harm due to facility's need to evaluate the effectiveness of their plan of removal. These failures could place residents at risk for not receiving nursing services by adequately trained and licensed nurses and could result in untreated wounds, a decline in health, infection, amputation and/or death. The findings included: 1. Record review of a facility self-report dated 8/2/2023 the facility reported Resident #1 wound care orders placed in chart on 4/27/2023 were not followed up. Resident #1 became septic and resulted in amputation of big toe. The facility listed RN D and LVN B as the alleged perpetrators. Record review of Form 3613-A dated 8/02/2023 and signed by the facility Administrator on 8/4/2023 revealed an allegation of abuse and neglect was made by family of abuse and neglect on an unknown date and time regarding Resident #1. The report stated Resident #1 required total assistance with care and was not interviewable was transferred to a local hospital for a worsening wound on 7/21/2023 with the Wound Care Nurse listed as the perpetrator. The report stated that the Wound Care Nurse was not providing wound care and was not being supervised by the DON. Lack of services, training and supervision led to worsening of the wound. In a verbal conversation with the hospital, the left foot was amputated. The investigative findings were confirmed. Record review of Resident #1 face sheet dated 7/25/23 revealed an admission date of 3/21/2022 with readmission date of 9/18/2022 with diagnoses which included: type 2 diabetes mellitus with hyperglycemia, protein-calorie malnutrition (undernutrition), and hypertension (high blood pressure). Record review of Resident #1's Care Plan dated 9/21/2022 revealed the resident had a diagnosis of diabetes with interventions to include: inspect feet during bathing and as needed for open areas, sores, pressure areas, blisters, edema and redness and report to the nurse. Record review of Resident #1's Care Plan dated 7/20/2023 revealed the resident had a potential for the development of a pressure ulcer with interventions to included administer analgesics as needed for discomfort or pain, reposition frequently and check frequently for wetness or soiling. The care plan did not address an actual pressure ulcer or wound for Resident #1 Record review of a Doctor's Progress Note dated 4/27/2023 revealed: Left foot with arterial wound to great toe, 2nd toe, 3rd toe. Clean left foot arterial wound to great toe, 2nd toe, 3rd toe, apply betadine daily. Wound Consult [illegible word], signed by the NP. Record review of a physician order dated 4/27/2023 for wound care revealed LVN B put orders into the computer on 4/27/2023 at 8:18 p.m. which were signed by the MD on 4/30/2023. The orders did not have a schedule for administration attached and indicated the orders were for the TX (wound) Nurse as non-medication orders. The orders were: wound care orders for atrial (sic) [arterial] wounds to the left foot, clean with normal saline, pat dry and apply betadine daily until wound consult to follow. Record Review of Resident #1's April 2023 TAR revealed no orders for wound care to the left great toe or left foot. The physician orders for treatment of the wounds to the left foot had not carried over to the TAR and there was no indication wound care was performed. Record review of the facility wound log for April 2023 revealed Resident #1 was not listed on the log. Record review of Resident #1's May 2023 TAR revealed no orders for wound care and there was no indication wound care was performed. Record review of the facility wound log for May 2023 revealed Resident #1 was not listed on the log. Record review of Resident #1's June 2023 TAR revealed no orders for wound care and there was no indication wound care was performed. Record review of the facilities wound log for June 2023 revealed Resident #1 was not listed on the log. Record review of Resident #1's July 2023 TAR revealed no orders for wound care and there was no indication wound care was performed until July 18, 2023. The TAR revealed on July 18, 2023 the left great toe was treated with ½ strength Dakin's external solution 0.25% and covered with a non-adherent dressing. Record review of the facilities wound log for July 2023 revealed Resident #1 was not listed on the log. Record review of Resident #1's annual MDS assessment dated [DATE] revealed a BIM's score of 8 which indicated a moderate cognitive impairment. The assessment was coded for no ulcers, wounds, or skin problems. Record review of Resident #1's weekly skin integrity review dated 7/02/2023 and signed by the Wound Care Nurse located in a binder in the Wound Care Nurses office revealed Resident #1 had intact dry skin with redness. The areas marked on the picture of the human diagram with an X were the left big toe and the front of both shins. There were no other skin assessments prior to 7/02/2023. Record review of Resident #1's weekly skin integrity review dated 7/10/2023 and signed by the Wound Care Nurse located in a binder in the Wound Care Nurses office revealed Resident #1 had intact dry skin with redness. The areas marked on the picture of the human diagram with an X were the left big toe and the front of both shins and the buttocks. There was no other skin assessment after 7/10/2023 in the notebook. Record review of the 24-Hour Report Sheet (nurse to nurse communication between shifts) for Resident #1 revealed the following entries between July 1- July 19th, 2023. There were no signatures or indication of who wrote the entries: 7/01/2023: Left toe dressing done 7/02/2023: big left toe needs wound nurse orders 7/03/2023: get treatment (nurse) to do wound care to left big toe 7/05/2023: get treatment (nurse) to do wound care to left big toe 7/06/2023: get treatment (nurse) to do wound car to left big toe 7/11/2023: dressing to big left toe 7/12/2023: dressing to big left toe 7/13/2023: dressing to big left toe 7/14/2023: dressing to big left toe 7/15/2023: dressing to big left toe 7/16/2023: dressing to big left toe .hospice now, hospice will be in to write orders on Monday 7/17/2023: dressing to big left toe .hospice not, hospice to write orders Monday 7/18/2023: new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders, culture collected/pending . 7/19/2023: hospice orders pending, new order for antibiotics/infection to LLE great toe. Cipro and Augmentin x 10 days, x-ray negative, new treatment orders . Record review of Resident #1's progress notes dates 7/18/2023 revealed MD notified of condition of wound to LLE great toe. New orders received to get wound culture, CBC, renal panel, x-ray to LLE great toe to rule to osteomyelitis (infection of the bone), initial dose of Augmentin 500 mg (antibiotic) and Cipro 500 mg given and is to be continued for the next 10 days. Also received wound treatment orders . Record review of Resident #1's progress notes dated 7/18/2023 documented by LVN B revealed: results in from x-ray of left toes .osteomyelitis not excluded .results faxed to MD, new orders pending. Record review of Resident #1's x-ray dated 7/18/2023 of the left toe revealed minimal patchy osteolytic lesion involving first-proximal phalanx (great toe) ; mild diaphysis: osteomyelitis not excluded. Record review of Resident #1's physician order summary for July 2023 revealed an order for admit to hospice services with a start date of 7/19/2023. Record review of Resident #1's progress notes dated 7/21/2023 documented by the ADON revealed: Resident sent out to [a local hospital] for worsening wound issues .that the family is concerned about. Per the family's request after a care plan meeting was completed, facility initiated a call for EMS to com(e) and transfer resident to the hospital. Notified MD of the hospital transfer . Record review of Resident #1's Care Plan Conference notes dated 7/21/2023 and signed by the former DON on 7/21/2023 revealed the form was blank and no information had been entered. Record review of Resident #1's hospital admission record dated 7/21/2023 revealed the resident, presented to the ER by EMS for necrotic toe present for over 1 week and a sore on the sacrum that is healing. Necrotic toe on the left gangrene (tissue death) , x-rays of extremity foot reveal osteomyelitis with gangrene and necrosis (infection of the bone with tissue death) .concerned about osteomyelitis with severe soft tissue infection. Patient does require admission. Impression: sepsis, toe necrosis, soft tissue infection, elevated lactic acid (indicated infection and is clinically significant as it shows correlation with sepsis and can indicate likelihood of critical illness), osteomyelitis of toe (infection that is in the bone), tachycardia (elevated heart rate which can indicate sepsis) . Record review of Resident #1's hospital record of x-ray to foot dated 7/21/2023 revealed, .soft tissue swelling is noted about the great toe with osseous erosive change involving the proximal phalanx (toe) .concerning for osteomyelitis with possible superimposed fracture (fracture can occur from severe osteomyelitis which weakens the bone). Record review of Resident #1's hospital record of physician assessment dated [DATE] revealed: Musculoskeletal/Skin: .left great toe notes severely necrotic changes to the soft tissue consistent with a mix of dry and wet gangrene, putrid odor coming from the foot. There is a palpable DP (dorsal pedal-pulse on the top of the foot indicating there is blood flow to the foot) pulse. There is surrounding erythema (redness) and purulent drainage (pus). Patient has a sacral decubitus (bed sore) ulcer with granulation tissue overlying it with no evidence of infection. Orthopedic consulted .Patient will need admission for further management and IV antibiotics and possible surgical intervention for his gangrenous infection of the left great toe. Record review of a hospital record for Resident #1 dated 7/22/2023 revealed: Assessment/Plan: severe sepsis with shock initially requiring low dose of vasopressor (medication used to raise blood pressure in ICU setting which a sign of shock), WBC trending up (indicated infection), remains afebrile (without fever). Left first toe gangrene (tissue death with osteomyelitis (infection of the bone): continue vancomycin, cefepime, Flagyl (antibiotics), per ortho needs amputation. Record review of an undated photo of Resident #1's left foot revealed the left great toe from top of the foot view was dark black in color from the tip of the toe to the first joint with the appearance of a missing toenail. The area below the first joint was red and purple in color. There was a partially removed gauze from the toe revealed heavily soiled gauze with discharge that was beige, yellow, brown, pink, and red in color. There was a large amount of swelling to the right side of the great left toe starting at the tip of the toe, with the largest amount of swelling near the first joint that was discolored black, grey, brown, yellow, and pink and extending to the base of the first toe. The skin was peeling off the first toe. There was a large amount of drainage and moisture on the toe, and gauze. The other toes were obscured from view by the gauze. During an interview on 7/25/2023 at 12:01 p.m. the Hospice admission Nurse stated she admitted Resident #1 to hospice on 7/19/2023. She stated at the time of admission Resident #1 had a wound that was gooey, purulent with foul odor that smelt gangrenous and was poorly bandaged. She stated Resident 1 was very weak and had slow slurred speech that could not be understood. The Hospice admission Nurse stated she asked the facility if Resident #1 was on antibiotics and they confirmed that he was on Augmentin, Cipro (antibiotics) and Dakin's (wound cleaner). She stated that she only admitted Resident #1 to hospice services and had no other interaction prior to his discharge. During an interview on 7/25/2023 at 1:22 p.m., Resident #1's RP stated she had noticed the wrap to the resident's toe had not been changed (date unknown). She stated she got hospice involved (unknown date) because she did not feel like Resident #1 was getting the attention, he needed from the facility staff. She stated she had a meeting with the facility (names of staff unknown) on 721/2023. She stated they told her she could not put him in the hospital even though he was declining, but she did it anyway on the same date. She stated she did not want her family member to die. She stated she only got hospice because they told her he would get extra help. The RP stated Resident #1 was now going to have to have an amputation. The RP stated Resident #1 had dementia and was not interviewable. During an interview on 7/25/2023 at 2:17 p.m., the Wound Care Nurse stated she worked a M-F schedule. She stated on 7/03/2023 and 7/10/2023 she documented on a weekly skin assessment sheet that she kept in a binder in her office and was not part of the medical record that Resident #1 had redness to the left foot great toe. She stated on 7/10/2023 Resident #1 also had redness to his bottom (sacrum) that was blanchable. The Wound Care Nurse stated she did not notify the physician about the redness to the bottom (sacrum) because she had zinc oxide as standing orders to take care of it. She stated she did not notify the physician about the redness to Resident #1's left great toe because it was positional. She stated she knew it was positional redness because the resident was bedbound and refuses to be turned and positioned. She stated in her nursing judgement there was no concern to notify. The Wound Care Nurse stated she only had weekly skin assessments documented for July 2023. The Wound Care Nurse stated she worked a M-F schedule but was out last week (7/17/21-7/21/23) so no skin assessments were completed, and she did not know if the charge nurse did assessments. She stated she did not know if the nurses had access to the skin assessment binder because she kept it in her office. The Wound Care Nurse stated when she was not in the facility the nurses or the ADON wound have to provide wound care. She stated either the ADON or DON would have to inform the nurses she was not at work. The Wound Care Nurse stated she had been in the wound care position officially in June 2023 although she had been in the position and performing wound care before that time (dates unknown). She stated she is notified of resident wounds by the charge nurses or when she completes the head-to-toe skin assessments. She stated the facility had house orders (standing orders/wound protocol) for wound care for wound care orders that she used on new wounds. The Wound Care Nurse stated the facility used to have a WC NP (Wound Care Nurse Practitioner) until two weeks ago. She stated the facility no longer had one as she was not meeting the Corporation's needs. The Wound Care Nurse stated the WC NP would see all residents with wounds except for patients on hospice and those with certain types of insurance. She stated she did not know what types of insurance were excluded. The Wound Care Nurse stated weekly head to toe skin assessments were documented in PCC (electronic medical chart) as a check on the resident TAR to show completion. She stated she did not document the results of the skin assessments in the resident medical record. She stated she kept the results on a paper document in a binder which she kept in her office. The Wound Care Nurse stated she was told to document in the binder. She stated she asked why she was documenting in a binder, and they told her to just keep it in the binder. She stated she does not remember who told her. The Wound care nurse stated she only keeps the current ones in the binder, and she only had July 2023. When asked how continuity of care where other nurses, physicians, etc. could review the skin assessments a was provided for residents if she was keeping skin assessments in a binder in her office, the Wound Care Nurse stated if there was an issue there would be an order for wound care that would pop up (in the computer). The Wound Care Nurse stated the facility did not have a process to document redness on the skin assessment other than just redness. When asked if she assessed if redness was blanchable and how she documented, she stated redness was not anything that was severe. She stated if a wound was not blanchable she wound notify the physician because it indicated poor circulation. She stated it was a nursing judgment. She stated redness was usually located on the bum or as dryness to the legs and was nothing to notify the physician about. She stated she had standing orders for zinc oxide to take care of it. The Wound Care Nurse stated the facility relied on wound measurement and wound description documentation as documented by the WC NP who came to the facility 1 time a week. She stated if without a WC NP she wound document on the skin assessment or progress note if there was a concern, but she did not have to do measurements because the WC NP was already doing them, and she was never told to document it. The Wound Care Nurse stated the facility did not have process to document condition of the wound because the WC NP documents it. When asked about the process for residents in which the WC NP did not see or in absence of a WC NP, the Wound Care Nurse stated the facility had not had any hospice residents with wounds and she hoped to have a new WC NP soon. The Wound Care Nurse stated she had received no training when she took the position as Wound Care Nurse, she stated the facility supplier of wound care supplies, and the physician were available to her for questions or concerns. She stated the wound care supplier was also a LVN that would come and train her when she requested. During an interview on 7/25/2023 at 6:30 p.m., the Wound Care Nurse denied knowledge that Resident #1 had a wound to his left foot great toe. The Wound Care Nurse stated on 7/10/2023 Resident #1 had redness to his sacrum and she applied zinc oxide per standing orders. She stated the next day he was okay and had so more redness. She stated she did not write the zinc oxide as an order in PCC. The Wound Care Nurse stated she thought there was already an order for it in PCC. She stated the redness never progressed to anything beyond redness. The Wound Care Nurse stated sometime last week (date unknown) she heard that LVN B notified the MD and got an x-ray and lab for Resident #1. She stated she also heard that Resident #1 was supposed to be seen by the NP for his toe. The Wound Care Nurse stated she provided wound care and assessed Resident #1's toe but did not document that assessment, only the treatment (after intervention by LVN B). The Wound Care Nurse stated she did not know what the toe or wound looked like. She stated she was trained in nursing school to document assessments but had not been trained by the wound care supplier. She stated the wound care supplier gave her the run down on wound care and was supposed to return this week to give her further detail. The Wound Care Nurse stated she was notified by LVN B that Resident #1's toe was an open wound, but she could not remember the date. She stated it was sometime last week. The Wound Care Nurse stated she could not recall if Resident #1's toe or wound was discussed or if it was brought up during morning meetings. The Wound Care Nurse stated she was not in for parts of last week or she came in late, so she was not aware. Record review of the Wound Care Nurses Timecard for July 2023 revealed: Monday, 7/03/2023-clocked in for 5.25 hours from 8:54 a.m.-2:51 p.m. Tuesday, 7/04/2023-clocked in for 9.75 hours from 8:18 a.m.-6:30 p.m. Wednesday, 7/05/2023-clocked in for 3 hours from 4:05 p.m.-6:59 p.m. Thursday, 7/06/2023-clocked in for 5.75 hours from 6:49 am-8:34 am and 12:32 p.m.-4:56 p.m. Friday, 7/07/2023-clocked in for 7.75 hours from 8:44 a.m.-5:02 p.m. Monday, 7/10/2023-clocked in for 8.0 hours from 9:00 a.m.-5:25 p.m. Tuesday, 7/11/2023-clocked in for 9.0 hours from 9:00 a.m.-6:34 p.m. Wednesday, 7/12/2023-clocked in for 9.0 hours from 7:25 a.m.-5:07 p.m. Thursday, 7/13/2023-clocked in for 10.25 hours from 7:39 a.m.-6:28 p.m. Friday, 7/14/2023-clocked in for 4 hours from 2:25 p.m.-6:34 p.m. Monday, 7/17/2023- did not clock in or out, no hours reported Tuesday, 7/18/2023-clocked in for 6.0 hours from 1:10 p.m.-7:47 p.m. Wednesday, 7/19/2023-clocked in for 12 hours from 9:21 a.m.-9:49 p.m. Thursday, 7/20/2023- clocked in for 11.25 hours from 8:44 a.m.-8:29 p.m. Friday, 7/21/2023-clocked in for 8.25 hours from 10:58 a.m.-7:43 p.m. During an interview on 7/26/2023 at 9:59 a.m., CNA A stated she used to be the shower aide on Resident #1's hallway approximately 1 month ago. She stated there was a lot of staff inconsistency because it was a heavy workload hall, and nobody wanted to work it. CNA A stated she had not provided Resident 1 showers in the last month. She stated previously he had a wound on his bottom (unknown date) She stated she notified the nurse. She stated she did not remember who the nurse was at the time. She stated she was trained that anytime she saw something new she would go immediately to the nurse. CNA A stated when she saw the wound on Resident #1's bottom it was an open wound without skin on top, about the size of a dime. She stated she thinks it might have been LVN B that she notified but could not be certain. She stated later she saw white medicine on Resident #1's bottom. CNA A stated her responsibility was to report and it was the nurse's responsibility to take the next steps. She stated her communicated with the nurses verbally. CNA A stated she saw Resident #1 with a bandage on his foot, and she smelled something rotten. She stated she started looking in Resident #1's room for the location of the smell and finally realized it was coming from his foot. CNA A stated it was the same day Resident #1 got the x-ray of his foot. She stated after assisting with the x-ray she told the nurse that his foot smelled really bad, and the toe was brown. She stated the following day when she came in the bandage had been changed and the smell was better. CNA A stated when she first noticed the wound on Resident #1's bottom, he already had a bandage on his foot. She stated the whole foot was bandaged (unsure if it was right or left foot) and there was blood on the bandage near his big toe. She stated she never saw the wound and even during rounds when coming on shift it was never reported that Resident #1 had a wound during rounds. During an interview on 7/27/2023 at 1:25 p.m., the Administrator stated the WC NP was let go on 7/21/2023 after giving her a 30-day notice on 6/21/2023. The Administrator stated the wound care product supplier was not providing wound care, only education. During an interview on 7/27/2923 at 1:36 p.m., an LVN from the wound care product supplier stated her company provided part B wound care products. She stated they also assisted with in-service training, skin sweeps and staff training. The LVN stated she was training the Wound Care Nurse and started approximately 1 week ago with desk training. She stated they did not go in depth during the training, and she was supposed to come back. During an interview on 7/27/2023 at 1:52 p.m., the Regional Compliance RN stated she spoke with the former DON about getting more education for the Wound Care Nurse. She stated they scheduled the training, but the Wound Care Nurse did not come in and another time it did not happen (dates unknown). She stated she had provided the educational opportunities, but they had not yet happened. The Regional Compliance RN stated the Wound Care Nurse needed additional training because she was asking questions about treatment. She stated she told the former DON she needed to help the Wound Care Nurse out and support her to be successful. The Regional Compliance RN stated she had been in the building on and off but not every week. She stated she had no set schedule. The Regional Compliance RN stated she spoke with the former DON about getting more education for the Wound Care Nurse. She stated they scheduled the training, but the Wound Care Nurse did not come in and another time it did not happened (dates unknown). She stated she had provided the educational opportunities, but they had not yet happened. The Regional Compliance RN stated the Wound Care Nurse needed additional training because she was asking questions about treatment. She stated she told the former DON she needed to help the Wound Care Nurse out and support her to be successful. The Regional Compliance RN stated she had not recently seen the Wound Care Nurses work. She stated she was with her in the past (dates unknown). She stated the Wound Care Nurse was nervous, but she could not say she did a bad job. She stated the Wound Care Nurse had started as an intern and stepped up to the role and offered to help the facility out and the former DON and former Administrator put her in the job permanently. The Regional Compliance RN stated she did not have any input on that decision. She stated the Wound Care Nurse should do measurements, know drainage, condition wound bed, condition of the surrounding tissues, but as a LVN she could not stage a wound. She stated they had asked the Wound Care Nurse to describe the wounds and then the RN/NP wound then determine etiology and staging. She stated the Wound Care RN was to document the wound description in the wound care product supplier website and as a wound note in PCC. The Regional Compliance RN stated the Wound Care RN should be assessing wounds and documenting at least weekly. She stated the former DON was responsible for oversight of wound care and resident care and systems. The Regional Compliance RN stated the DON may delegate but she had overall responsibility to effectively manage it. During an interview on 7/27/2023 at 2:11 p.m. the WC NP (Wound Care Nurse Practitioner) stated she no worked at the facility as of July 17, 2023. She stated while she was working for the facility the staff would notify her of new wound. She stated she saw all new wounds and all new admits checking their skin. The WC NP stated there were some hospice residents she did not see unless hospice requested it. She stated there was just a few incidents of residents she did not see. She stated Resident #1 discharged from the facility on 7/21/2023. She stated she last saw Resident #1 on 4/10/2023 due to a right traumatic amputation (other foot, not current foot involved). She stated she never saw Resident #1 after that date and was never called again to consult on him and never heard his name again. The WC NP stated she did have concerns about the Wound Care Nurse not changing bandages (unknown residents) but not related to Resident #1. She stated on 7/17/2023 she rounded with the ADON because the Wound Care Nurse was not at the facility. She stated during round there were some patients with the same bandages from 7/12/2023 and the ADON saw it too. She stated she put a list together and gave it to the ADON via email and discussed it with the former DON. She stated she did not have access to the resident names at the time of interview. The WC NP stated she discussed concerns with the former DON of numerous occasions including not having supplies ordered and staff putting on wrong bandages. She stated it was important for the residents to receive the correct bandages. The WC NP stated she was having issues with the supply person. She stated without the proper supplies the wounds were not getting proper treatment. The WC NP stated she was relieved when her contract with the facility ended. She stated she felt like the Wound Care Nurse did not feel like putting in an effort. She stated the nurses were complaining that the Wound Care Nurse was asking them to do wound care when she had been at the facility all day. During an interview on 7/27/2023 at 2:32 p.m., the ADON stated confirmation that he had received complaints about the Wound Care Nurse. He stated she had written new dates on old dressings with sharpy. He stated he told the former Administrator who referred him to the former DON. The ADON stated he told the former DON who stated she would handle it and address it. The ADON stated the DON had told him that they (clinical management team) were all equals, so he did not have authority to correct the Wound Care Nurse. He stated the DON told him he was not allowed to counsel the Wound Care Nurse on wound care. She said she would do it herself. The ADON stated he thought Resident #1's wounds and wound care got missed due to lack of professionalism from the Wound Care Nurse and the DON. He stated no corrective action was ever taken by the DON. He stated he communicated with the former Administrator and former DON depending on the issue they always get notified either by text or in-person. He stated he was not given the authority to monitor staff. He stated the staff would have to tell him when they would go on break, when they clocked in and out, but nothing related to resident care. The ADON stated as an ADON in other facilities he had previously worked at he would do audits. He stated when he started at this facility, he was told he could not do that by the Wound Care Nurse and the former DON backed her up. The ADON stated the DON asked him not to document in PCC and document on paper. He stated he did what she asked him to do and gave her the document like she requested. He stated he did not know what happened to the note. The ADON stated he was familiar with the wound care policy. He stated it was available on the shared drive to all staff including the DON. The ADON stated to protect residents from harm he had to take charge, just like he did when he found out about Resident #1's toe wound. He stated when he found out (7/17/2023) he did not delegate he notified the MD, got antibiotics orders, labs and x-rays ordered. The ADON stated yes, this was neglect. He stated he did not consider it abuse because the actions were not intentional. He stated the lack of wound care to Resident #1 had some factors[TRUNCATED]