**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 5 of 16 residents (Resident #9, Resident #21, Resident #36, Resident #40 and Resident #48) reviewed for accidents and supervision. The facility failed to provide adequate supervision to Resident #36 after Resident #36 was suspected to be under the influence of illicit substances. Resident #9, Resident #21, Resident #36, and Resident #40 all tested positive for amphetamines. The facility did not lock and adequately supervise the back door. Further observation revealed Resident #9 and Resident #48 were smoking outside unattended. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:10 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because the facility needed to monitor the implementation of the plan of removal. The failure placed all residents at risk for serious injury, harm, and/or death. The findings included: 1. Record review of Resident #9's admission record revealed a [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses of chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe. It's caused by damage to the lungs that reduces airflow.), vascular dementia (a type of dementia that occurs when blood vessels in the brain are damaged, reducing the flow of oxygen and nutrients to the brain), mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, extrapyramidal and movement disorder (are a group of movement disorders that can occur as a side effect of certain drugs, particularly antipsychotics), nicotine dependence (a chronic disease that occurs when the body becomes addicted to nicotine, a stimulant found in tobacco products), schizophrenia (a chronic mental disorder that affects how people think, perceive reality, and interact with others), and insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep). Record review of Resident #9's quarterly MDS, dated [DATE], revealed the resident had fully intact cognition for daily decision making. Record review of Resident #9's care plan contained a care area, last edited on [DATE], that stated the resident had a history of alcohol or drug abuse as evidenced by recently tested positive with interventions to MD/RP will be notified of any changes in residents behavior / mental state. Also, a care area for Resident #9 smokes cigarettes and he set a fire at the last placement due to hearing what he thought was a gun being loaded. He will have strictly supervised smoking breaks; no lighter will be in his possession with interventions to All smoking materials are kept at the nurse's station between smoke breaks, [Resident #9] will be given two cigarettes a break and offered a light-he will be supervised at all times during the break. Record review of a nursing note written by LVN B, dated [DATE], stated It had been noted by staff that res had been acting abnormally. This nurse was given an order to test urine for drugs. Urine came up positive for amphetamines . Record review of Resident #9's Psychotherapy progress notes, dated [DATE], stated Focus of Session: individual psychotherapy session with patient in his room and [nursing facility]. Patient was reportedly involved in an incident over the weekend but did not bring it up during the therapy session. The issue was not pressed. Patient reports that he is doing OK and that he is getting ready to go on his smoke break once this session is over. Patient reports good sleep, good appetite and patient reports that he is no longer depressed. He reports that he is still tired and lethargic most of the time. Encourage patient to be patient with adjustment. Period for new medications 2. Record review of Resident #21's admission record revealed a [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses of hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease (the high blood pressure has damaged both the heart and kidneys, leading to significant impairment in kidney function and the heart's ability to pump blood effectively), cognitive communication deficit, insomnia (a sleep disorder that makes it difficult to fall asleep, stay asleep, or get enough quality sleep), depression, presence of coronary angioplasty implant and graft, secondary hyperaldosteronism (a patient has had a coronary angioplasty (procedure that uses a balloon to widen a blocked or narrowed coronary artery) procedure and a stent placed in their coronary artery), alcohol dependence, in remission, bipolar disorder, anxiety disorder, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a type of coronary artery disease (CAD) that occurs when plaque builds up in the walls of the heart's arteries. This buildup, also known as atherosclerosis, narrows the arteries and makes them less flexible. The narrowing can reduce blood flow to the heart, which can lead to angina pectoris, or chest pain.), and heart failure. Record review of Resident #21's quarterly MDS, dated [DATE], revealed the resident had mildly impaired cognition for daily decision making. Record review of Resident #21's care plan contained a care area, last edited on [DATE], that stated the resident had a history of alcohol or drug abuse as evidenced by recently tested positive with interventions to MD/RP will be notified of any changes in residents behavior / mental state. Record review of Resident #21's nursing note written by RN A, dated [DATE], stated res was very anxious and agitated. Pacing repeatedly. NP was notified and /her order a urine test for drugs was done He tested positive on our test her for amphetamines. A sample of his urine was also sent to the lab where it again came back positive for amphetamines. NP was notified by DON. Pending NP recommendations at this time Record review of Resident #21's Psychotherapy Progress note, dated [DATE], stated Focus of Session: individual therapy session with [Resident #21] in his room and [Nursing Facility]. Patient was referred for a follow up session today due to an incident that happened over the weekend. Patient was given opportunities to bring up anything that might've happened during the weekend, but he denied any significant event. Patient did discuss his chemo and the fact that it does make him nauseated at times. Patient reports he is not sleeping well and is only getting about five hours of sleep per night. Patient's appetite is good. Patient reports that he is doing OK, however, he presented with flat affect in this current session . Resident #21 Interview on [DATE] at 10:30 am - Resident was observed laying in his bed in his room, he refused to answer or talk about the drug use incident. 3. Record review of Resident #36's admission record revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE] with diagnoses of schizoaffective disorder (a chronic mental illness that involves symptoms of both schizophrenia and a mood disorder, such as bipolar disorder or depression), bipolar type, unspecified atrial fibrillation (a heart condition that causes the upper chambers of the heart to beat irregularly), unspecified convulsions (nerve cell activity in the brain is disrupted, causing muscles to involuntarily contract and spasm), extrapyramidal and movement disorders (a group of movement disorders that can occur as a side effect of antipsychotic and other drugs), bipolar disorder (a serious mental illness that causes extreme mood swings, along with changes in energy, thinking, behavior, and sleep), unspecified, recurrent depressive disorders, and major depressive disorder (a serious mood disorder that can affect how someone feels, thinks, and acts). Record review of Resident #36's quarterly MDS, dated [DATE], revealed the resident had mild cognitive impairment for daily decision making. Record review of Resident #36's care plan contained a care area, last edited on [DATE], that stated the resident had a history of alcohol or drug abuse with interventions to MD/RP will be notified of any changes in residents' behavior / mental state. Also, a care area for potential for safety hazards, injury related to smoking with an intervention to encourage resident to keep all smoking material at nurse's station after smoke break. Record review of Resident #36's nursing note written by LVN G, dated [DATE] stated As this nurse was administering morning medications, residents' vitals measured @ (BP)158/90 and (P)134. Resident was observed as being overly skittish, could not stop moving while in the bed and acting paranoid that someone was trying to break into her closet and rest room, however there are no locks on her door handles. This nurse performed neuro check on resident and noted left pupil measuring at 6 mm and right pupil measuring at 4 mm. Resident admitted to this nurse that she had been drinking wine, smoking cigars and vaping throughout the night, resident was reminded that she should not be smoking outside of designated smoke times and she should not be holding cigarettes, lighters or vapes on her person. NP [D] notified of residents' condition; order given to have resident sent out to ER. 911 called, EMS arrived, and resident refused to go to hospital. EMS personnel stated that since she is alert enough to answer their questions and is refusing to be transported to hospital, they cannot take her. NP [D] notified of residents' refusal, NP gave orders for STAT labs CBC, BMP and blood drug panel, also monitor vitals every 30 mins for 3 hours. Record review of Resident #36's progress note, dated [DATE], written by NP D stated Seen today per request from Charge Nurse reporting that resident was up all night long on back outdoor patio unsupervised with other residents and has since had erractic behavior, AMS, jerking of arms and legs, twitching of neck, exhibiting paranoid behavior that someone was breaking into her closet. Nurse reported that pupils dilated to 6 mm at 05:37am. Resident admitted to drinking alcohol after she was told 2 weeks prior that this would have adverse effect to her mental status and serious health consequences due to all psychoactive medications, antidepressants, and anxiolytics. Patient made comment to nurse at 05:37 am that she was not doing drugs. Requested patient to be transferred to hospital for evaluation due to severe AMS but when EMS arrived, patient refused to go. Patient seen this afternoon and she is complaining rapid heart rate, SOB, chest tightness. She is still having constant movement of arms and legs, worming around in bed. She made the comment again that I have not done any drugs when patient questioned about chest pain. Record review of Resident #36's nursing note written by LVN G, dated [DATE], stated At beginning of this shift, during report, resident observed in wheelchair at nurses' station having erratic behavior and movement. Resident requested to have staff assist her to her room, once in room resident was heard yelling I'm too high, oh God help me. This nurse and day shift nurse assessed resident; resident admitted she had taken a pill that a man had given to her. 911 called. EMS arrived and resident taken to [hospital]. Resident did ask for staff to notify her sister before leaving facility. NP/DON/Administrator/[family member]. Record review of Resident #36 nursing note written by LVN B, dated [DATE], stated Res had been sent to hospital for erratic behavior on the 15th. This nurse came to work on the 16th and PA had given orders for urine drug screening. Urine collected and res tested positive for amphetamines . Record review of CNA C's statement dated [DATE] on stated I was in the bathroom and heard some people talking and heard a man (Resident #40) asking the lady (Resident #36) in the bathroom which one do you want and I guess she took whatever he gave her. Record review of Resident #36's Psychiatric progress note, dated [DATE], stated Patient is being seen today as a follow up on psychiatric services due to her psychotropic medication management, and psychiatric diagnosis of bipolar disorder, insomnia, major depressive disorder She has a pertinent history of bipolar disorder, multiple mental health hospitalizations, and suicide attempts .Trauma History: reported positive, was a prostitute, was incarcerated, can become physically violent. Substance Use: remote history, was in recover program. illicit drug use: remote history, was in recover program. Tobacco use: quit .Diagnosis #4 substance use disorder -patient had a sponsor in Houston, went to a 12-step program. It's not currently using Record review of Resident #36's hospital documents, dated [DATE], stated [AGE] year-old female brought n by EMS from [NAME] winds skilled nursing facility due to altered mental status. She has a history of schizophrenia. There was concern the patient had taken an unknown medication but EMS reports it was her Xanax. Patient had been complaining of feeling like she had bugs in her hair and on her body. When I went to evaluate her she was sleeping soundly but upon awakening she states that she still feels like she has bugs in her hair, Patient was easily redirectable XXX[AGE] year-old female with history of schizophrenia presenting having an episode of difficult control at the skilled nursing facility. She had taken her Xanax prior to departure and upon, arriving here was calm and directable. She was sleeping comfortably. Vital signs were normal. No indication for further diagnostic evaluation or therapeutic intervention. Patient appears to be at her baseline. Do not suspect sepsis, intracranial hemorrhage, or other acute organic condition. Will discharge patient back to her skilled nursing facility for ongoing care of her underlying condition, currently stable and safe for discharge Record review of Resident #36's Psychotherapy Progress note, dated [DATE], stated .Focus of Session: individual psychotherapy session with [Resident #36] in her room and [Nursing Facility]. Patient was reportedly involved in a situation over the weekend that was potentially compromising. Met with the patient to observe and assess for emotional unrest. Patient did not indicate any out of the ordinary occurrence over the weekend. The issue was not pressed. Patient reports that she needs her eyeglasses fixed and she feels sick to her stomach. Patient reports that she sleeps. OK, maybe too much. Patient denies having a good appetite and report she is not doing as much in the facility as she used to . During an interview on [DATE] at 2:44 p.m. Resident #36 stated Resident #40 and her snorted white powder off her phone last Friday the 15th of November. Resident #36 stated Residents #9, #21 #40, and #48 would smoke drugs from a pipe on the back patio when staff were not around. 4. Record review of Resident #40's admission record revealed a [AGE] year-old male admitted [DATE] with diagnoses of chronic obstructive pulmonary disease, disruption of external operation (surgical) wound, acquired absence of right leg below knee, acquired absence of left leg above knee, and depression. Record review of Resident #40's care plan contained a care area, last edited on [DATE], that stated the resident had a history of illicit drug use/abuse with interventions to MD/RP will be notified of any changes in resident's behavior/mental state. Also, a care area for potential for safety hazard, injury related to smoking. Resident assessed to be a supervised smoker. Resident smokes traditional cigarettes. Interventions included Encourage resident to keep all smoking material at nurse's station after smoke break. Record review of Resident #40's progress notes, revealed a note dated [DATE] for [DATE], written by NP F, stated Questionable activities reported that pt may be bringing unknown substance and giving it to other residents, his drug screen is pending . Record review of Resident #40's Psychotherapy Progress note, dated [DATE], stated .History of Present Illness: Patient came to the facility following an amputation of leg. Patient has a dx of .depression unspecified in his history. Patient was referred for assessment an reduction of inappropriate behaviors. Staff description of Patient Behavior: noncompliant uncooperative. Substance Misuse: client denies substance abuse Risk factors and summary of findings. Narrative: individual psychotherapy session with patient in his room. Patient was alert and presented as dysphoric and with flat or sad effect. Patient is in the facility due to amputation of legs. Patient reports that he is depressed most every day and anxiety is present some days. Patient has some issues with appetite and sleep. Patient denies any suicidal ideation or psychiatric inpatient care. Patient is a current smoker and denies alcohol or drug abuse. Patient is Patient PHQ9 score (is a depressive symptom scale and diagnostic tool) at present time is a nine. Patient is divorced. Has three girls, obtain an associate's degree on electronics, and was a delivery driver most of his life Record review lab results collected on [DATE] and ran on [DATE] showed urine drug screen results for Resident #9, Resdient #21, Resident #36, and Resident #40, were all positive for amphetamine. [DATE] at 10:40 am - Resident #40 interview - resident refused to answer or talk about the drug abuse incident. He just shook his head no. 5. Record review of Resident #48 face sheet dated [DATE] for Resident #48 showed an admission date of [DATE] with diagnosis of Cerebral Infarction (mini stroke), Epilepsy (chronic brain disease that causes seizures), and Diabetes (chronic disease where the body doesn ' t produce enough insulin). Record review of Resident #48 ' s MDS dated [DATE] showed a BIMS score of 14 indicating the resident has normal cognitive functioning. Record review of Resident #48 ' s Care Plan dated [DATE] revealed, Potential for safety hazard, injury related to smoking. Record review of Resident #48 ' s Smoking assessment dated [DATE] revealed a score of 13 which indicated resident is Potentially unsafe smoker. During an observation on [DATE] at 11:07 am - Resident #48 and Resident #9 were observed smoking unsupervised for about 15 minutes. No staff were present at the time. During an interview on [DATE] at 11:09 am, Resident #48 - when asked where he got his cigar and how he lit it, he stated that he had it previously and that sometimes he doesn ' t smoke it all and saves it. He stated that he already had the old cigar and that a guy walking by lit it for me. During an interview on [DATE] at 11:00 am with the DON, she stated that smoke breaks are timed. Residents go about 6 times a day. Staff should be present when residents smoke. Staff keep the residents ' cigarettes and lighters. Policy stated they will be discharged if they are unsupervised. Told by corporate not to lock the doors anymore which allows residents to go outside whenever they want. Potential for harm could be an injury. During an interview on [DATE] at 11:43 am with the Administrator, he stated that residents who go outside alone to smoke, we are addressing it with the ombudsman. They are re-educating residents regarding smoking rules. He had a meeting with all the resident who smoke, and they signed the smoking policy about a month ago. Smoking residents should always be supervised regardless of whether they are deemed safe or not. Regarding residents who go out to smoke by themselves, it is frustrating because it does happen due to the doors not being locked. During an observation on [DATE] at 11:07 a.m. Resident #48 and Resident #9 were observed smoking unsupervised for about 15 minutes. No staff were present at the time. Observation on [DATE] at 4:34 p.m. revealed an unlocked door lead to the smoking area on the back side of the facility. There was no fence around the perimeter of the facility. The smoking area had open access to a sidewalk, neighborhood street, and houses across the street. The back door was unlocked for entry at any time. During an interview on [DATE] at 9:50 a.m. RN A revealed she would observe Residents #9, #21, #36, and #40 on the smoking patio huddled down and outside of designated smoking times. RN A stated Resident #40 had a visitor who would enter through an unlocked door in the back of the facility at any time - usually late in the evenings. Shortly after this visitor came, the above residents would begin to act differently with exaggerated movements and posturing, odd behaviors, and more aggression. RN A stated she was concerned about the unlocked doors at the facility because strangers would sometimes just sit inside the facility. RN A stated she had reported these concerns to management, but they never addressed them. During an interview on [DATE] at 10:11 a.m. LVN B stated she began to notice Resident #36 was having behaviors that were not normal for her. LVN B stated she noticed it was always after she was hanging out with a group of residents that included Resident #9, #21, and #40. LVN B stated they would go out on the smoking patio outside of smoking hours unsupervised and smoke. LVN B stated on [DATE] Resident #36 began acting strange and she notified NP D who ordered a blood panel to test for drugs. LVN B said there was a long delay in obtaining the blood panel drug test results and they still did not have those. LVN B stated while she had no proof that Resident #40 was suppling drugs to other resident's she suspected it was him because other residents would always visit him in his room, and he sometimes had a late-night visitor who would enter through the back unlocked door. LVN B stated Resident #36 had a history of Angina and recently had an abnormal EKG and had been a resident there for a long time and never behaved like this before. LVN B stated on [DATE] she observed Resident #36 run into the hallway and yell that she was too high. LVN B stated Resident #36 was tested along with Resident #9, #21, and #40 on [DATE] and they all tested positive for amphetamines. LVN B stated Resident #36 initially tested positive for MDMA, meth, and amphetamines. During an interview on [DATE] at 3:32 p.m. NP D stated she was informed on [DATE] that Residents #9, #21, #36, and #40 were out on the patio all night on [DATE] unsupervised. NP D stated they became suspicious that drug use was going on because resident #36's behaviors and mannerisms were different, and she stated she was not using drugs during her assessment of the resident. NP D stated she told facility staff she did not want patients under her care outside unsupervised all night because they have access to the community. NP D stated it was unhealthy for them to be up all night because many of them are on medications to help them sleep, are on psychiatric medications, and will miss out on ADLs, activities, and meals during the day. NP D stated these Residents were in a nursing home for a reason and should not be left unsupervised in the middle of the night. NP D stated she knew Resident #36 had a history of drug use and inquired why resident #36 used drugs again after a long period of sobriety and Resident #36 stated because of who she was hanging out with and because she had access to the drugs at the facility. NP D stated Resident #36 had a history of angina but in the past few months had an increase in chest pain complaints. NP D stated she had since educated the resident that amphetamines are bad for her heart and could lead to a heart attack or death. NP D stated Resident #36 had an abnormal EKG on [DATE] when she was sent to the ER after suspected drug use and seen for chest pain. During an interview on [DATE] at 10:40 a.m. the DON stated on [DATE] Resident #36 began acting erratic but denied any drug use. The DON stated they did collect a blood sample for drug testing but had issues with getting results from the lab. The follow week Resident #36 was again acting erratic and they sent her to the hospital for chest pain. The DON stated CNA C told staff she overheard Resident #40 was this what you want and Resident #36 said yes. The DON stated after that Resident #36 was heard yelling in the hallway that she was too high. The DON said later the NP ordered urine drug screening on all residents who were hanging out in the group together (Resident #9, #21, #36, and #40). The DON stated they did in house ones that showed multiple drugs in their systems and also sent the urine to the lab that showed just amphetamines in their systems. The DON stated she notified the Administrator. The DON stated they did call the police to come search for drugs and none were found on any of the residents involved. The DON stated she did not think the Administrator reported the drug use to the stated because the ombudsman told them they did not need to report it. During an interview on [DATE] at 11:35 a.m. the Administrator stated corporate and the ombudsman came on Monday [DATE] to discuss what to do about all the residents who tested positive for amphetamines. He was planning to reach out to the PM because they were unsure what this would be reported under if necessary to report to the state. The Administrator stated they used the SUD policy for guidance on how to handle the residents who were using amphetamines. The Administrator stated they could not find anywhere that stated they needed to report this to the state because the residents took the drugs because they wanted to and it was not coercion. The Administrator stated the company used to lock the doors but they since had changed the policy and that was why they do not accept wanderers at the facility. The Administrator stated they prefer to keep the doors unlocked to keep a home like environment and so they can have visitors. The Administrator stated he felt it was safe to have the doors unlocked because they are always watching them. The Administrator stated he has heard of times that residents are on the back patio smoking unsupervised and him and the ombudsman have reviewed the smoking policy with the residents and had them sign on [DATE]. The Administrator stated all residents should be supervised while smoking per policy and if they are unsupervised it was because they are sneaking out. The Administrator stated it was a constant issue that residents smoke unsupervised and he has asked the ombudsman if he can do a 30 day discharge or immediate if they are violating the smoking policy. The Administrator stated he did not think locking the doors would make a difference on residents having access to areas unsupervised because if they want to do something they are going to find a way to do it. The Administrator stated after the 4 residents tested positive for amphetamines on [DATE] they called law enforcement to investigate the drug use on [DATE] and no drugs or paraphernalia were found. Record review of the facility's policy titled Safety for Residents with Substance Use Disorder, dated 10/22, stated It is the policy of this facility to create an environment as free of accident hazards as possible for residents with a history of substance use disorder. Definitions: Substance Use Disorder (SUD) is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Policy Explanation and Compliance Guidelines: 1. Residents with a history of SUD will be assessed for risks including the potential to leave the facility without notification and use of illegal/prescription drugs. Care plan interventions will be implemented to include increased monitoring and supervision of the resident and their visitors. 2. When substance use is suspected, (in the facility or upon return from an absence from the facility) which could lead to overdose, facility staff should implement the care plan interventions, which includes notification of the resident's physician or non-physician practitioner. 3. Care planning interventions will address risks by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the resident's health and/or safety . 6. Residents with SUD may try to continue using substances during their stay in the nursing home. Facility staff will assess the resident for the risk for substance use in the facility and have knowledge of signs and symptoms of possible substance that include, but are not limited to: a. Frequent leaves of absence with or without facility knowledge b. Odors c. New needle marks d. Changes in resident behaviors, especially after interaction with visitors of absences from facility . 7. The facility will make an effort to prevent substance use which may include providing substance use treatment services, such as behavioral health services, medication-assisted treatment (MAT), alcoholic/narcotics anonymous meetings, working with the resident and the family, if appropriate, to address goals related to their stay in the nursing home, and increased monitoring and supervision. 8. Staff will be prepared to address emergencies related to substance use by maintaining and having knowledge of administering opioid reversal agents like naloxone, initiating CPR as appropriate, and contacting emergency medical services as soon as possible. Record review of a facility policy titled Smoking policy, dated 10/2022, showed Residents may not have or keep any smoking articles ., The facility may impose smoking restrictions on a resident at anytime if it is determined that the resident cannot smoke safely or use smokeless tobacco with the available levels of support and supervision. An Immediate Jeopardy was identified on [DATE]. The Administrator and the DON were notified of the Immediate Jeopardy on [DATE] at 1:10 p.m. and were given a copy of the IJ template and a Plan of Removal (POR) was requested. The facility's Plan of Removal for the Immediate Jeopardy was accepted on [DATE] at 10:45 a.m. and reflected the following: Summary of Details which lead to outcomes. On [DATE], during a standard survey [facility]. A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the facility constitute immediate jeopardy to resident health. Problem: Failed to provide adequate supervision (F689) Plan: 1). [DATE]: Administrator/Designee re-educated residents who smoke individually on the smoking policy. The facility has an updated list of residents who smoke and once re-educated it is documented in the resident's electronic health record. Completion date [DATE] 2). [DATE]: DON/Designee presented re-education individually to each licensed and certified staff on substance use disorder to include signs of substance abuse using the facility policy to include notifying the Charge Nurse/Supervisor resident exhibiting signs of substance abuse. Facility is utilizing an employee roster to track licensed and certified staff in-service. Completion date [DATE] 3). [DATE]: DON/Designee presented In-service to all staff on supervised smoking policy to include smoking times, locations, and what to do when a resident is observed smoking unattended. Any staff not currently working will be contacted via phone. Completion date [DATE]. DON/designee will monitor to ensure staff have received the in-service training. [DATE] at 11:00 am - Observation of residents #9, #48, #21, #31, #41, #40 were [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 9 (Resident #1) reviewed for quality of care, in that: 1. On 04/17/2023, nursing staff found Resident #1's left heel/ankle wound had a strong foul odor and purulent drainage on the wound dressing. Resident #1 was sent to the hospital and admitted on [DATE] for a wound evaluation. At the hospital Resident #1 was intubated, went septic on 04/26/2023 and while at the hospital, an emergency left lower extremity amputation was performed on 04/26/2023 a. Resident #1 had 4 maggots on a heel/ankle wound removed by LVN B on 4/14/2023. An order for treatment solution was not entered correctly and the supply was not sent to the facility resulting in treatment not being provided to the resident. On 4/17/23 the resident was sent out to the hospital. b. Resident #1 was not seen/assessed by the Wound care team for 2 weeks. c. The facility-initiated trainings/in-services on 04/14/2023 nursing staff on proper entries but on 04/28/2023 not all nursing staff had been education and additional in-service training was needed. d. LVN J found 1 maggot on 4/17/2023. This failure to put measures in place could result in residents' physical needs not being met, diminished quality of life and medical complications. This failure resulted in identification of an Immediate Jeopardy (IJ) situation; an IJ was identified on 04/29/2023. The IJ template was provided to the facility on [DATE] at 5:52 p.m. While the IJ was removed on 05/01/2023 at 7:50 p.m.,the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of pattern due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal. The finding was: 1. Record review of Resident #1's admission record revealed dated 4/28/2023 revealed he was admitted on [DATE] and discharged on 4/17/2023 at 11 AM with diagnoses of sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), dependence on renal dialysis, open wound foot, cognitive communication deficit, need for assistance for personal care, muscle weakness, muscle wasting and atrophy, heart disease, peripheral vascular disease ( systemic disorder that involves the narrowing of peripheral blood vessels (vessels situated away from the heart or the brain). This happens as a result of arteriosclerosis, or a buildup of plaque, and can happen with veins or arteries), acquired absence of right leg below the knee, acquired absence of right leg above knee, end stage renal disease, pain, limitations of activity due to disability and anxiety. Record review of Resident #1's telephone order dated 4/14/2023 at 6: 19 PM for Dakin solution (OTC) 0.5% amount 30 cc topical twice a day for diagnoses of unspecified open wound, unspecified food, created by LVN B, transmission status-not requested, Pharmacy directive-substitution permitted. This telephone order was discontinued on 4/17/2023 at 7:20 PM by Regional Nurse. Record review of Resident #1's consolidated orders for April 2023 revealed DTI (deep tissue injury) wound of the left ankle, cleanse with wound cleanser, pat dry, apply skin prep, monitor for signs and symptoms of infection once a day; cleanse left heel wound with normal saline and pat dry, apply betadine, painting wound and per-wound area and apply Santyl and Lepto honey and cover with boarded dressing, offload heel at all times while in bed once a day; Dakin Solution 0.5%, 30 cc topical twice a day for unspecified open wound; dialysis treatment on Tuesdays, Thursdays and Saturdays. No hydrogen peroxide and water order for wound treatment on Resident #1. Record review of Resident #1's admission MDS dated [DATE] revealed Section C-Cognitive Patterns BIMS score was 14/15 (cognitively intact), Section G-Functional Status ADL Bed mobility, transfers, dressing, personal hygiene he required extensive assistance with one person assistance, bathing he required total dependence with two person assistance, Functional limitations in range of motion was impaired on one side lower extremity, he required a wheelchair for mobility devices; Section H -Bladder and Bowel he was always incontinent of bowel/bladder; Section M-Skin Conditions he was at risk for pressure ulcers/injuries, he had unhealed pressure ulcers/injuries, a stage 4, 3 venous and arterial ulcers (Arterial ulcers develop as the result of damage to the arteries due to lack of blood flow to tissue. Venous ulcers develop from damage to the veins caused by an insufficient return of blood back to the heart. Unlike other ulcers, these leg wounds can take months to heal, if they heal at all) and surgical wound, Treatments included pressure ulcer/injury care, application of non-surgical dressing and applications of ointment/medications. Section O-Special Treatments, Procedures, and Programs included J. Dialysis. Record review of Resident #1's wound evaluation and management summary dated 1/25/2023 revealed Resident #1 had an arterial wound of the left heel for at least 1 day duration. Record Review of wound management on left heel full thickness stated diabetes and PVS were relevant conditions that contributed to wound healing and were considered. Wound measurement was 7x10x not measurable, reason for debridement non-infected heel necrosis and dressing and interventions. Record review of Resident #1's wound physicians, specialty physician wounds evaluation and management summary dated 3/29/2023. During review VOHRA revealed on 3/29/2023 at the request of the referring provider Dr K, wound care assessment and evaluation was performed today. Past Medical History: dependence on renal dialysis, coronary artery disease, diabetes II and Peripheral Arterial Disease (PVD). The VOHRA wound management evaluated and assessed Resident #1's multiple wounds to include, site 4 Arterial wound of the left heel full thickness, surgical excisional debridement was performed today on this wound, wound size 11x12x0.8 centimeters, 90% necrotic tissue, 10% slough, wound progress- no change. Will continue to monitor weekly. The VOHRA visit on 3/29/2023 was Resident #1's last visit from the wound management group. Record review of Resident #1 received wound care treatments, cleaning with hydrogen peroxide wound cleanser and covering the wound, from facility staff in the period between 03/29/2023 and 04/14/2023. Facility staff were not measuring or assessing the resident's wound during this period. Record review of Resident #1's MAR dated April 2023 revealed DTI wound of the left ankle cleanse with wound cleanser, pat dry, apply skin prep and cleanse left heel wound with normal saline and pat dry, apply betadine, painting wound and per-wound area and apply Santyl and Lepto honey and cover with boarded dressing off-load heel at all times while in bed once a day; no Dakin's solution on the MAR was administered. Record review of Resident #1's MAR for April 2023 revealed for wound care on left ankle 4/14/2023 was LVN B on 4/15/2023 was DON I , on 4/16/2023 was RN H and on 4/17/2023 was LVN J. Record review of Resident #1's care plan dated 4/14/2023 revealed arterial wound to left heel and interventions were to offload wounds and float heels, administer medications as ordered and monitor side effects, administer treatments as ordered and monitor effectiveness, provide supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing and provide with pressure relieving cushion while up in wheelchair. Record review of Resident #1's progress note dated 4/14/2023 at 6:24 PM revealed while doing wound care to the left ankle this nurse noticed maggots in the wound. Cleansed with hydrogen peroxide and removed 4 maggots. This nurse contacted NP G about the wound, NP G gave a new order to cleanse wounds with Dakin's solution (a dilute sodium hypochlorite (NaClO) solution commonly known as bleach, Dakin's Full-Strength Solution is an antibiotic that fights bacteria. Dakin's Full-Strength Solution was used to treat or prevent infections caused by cuts or abrasions, skin ulcers, pressure ulcers, diabetic foot ulcers, or surgery. New order for vascular consult in one week created by LVN B. Record review of Resident #1's progress note dated 4/17/2023 at 2:09 PM revealed left ankle wound care done around 9 AM. wound had extremely strong odor and purulent drainage was noted on old dressing (from day before). Area cleaned and redressed as ordered. Resident #1 denies any pain or discomfort to the area as it was being cleansed and redressed. Notified NP G about progression of wound, and writer was instructed to send to emergency room for evaluation and treatment. Resident #1 left facility on stretcher via ambulance at 10:40 AM by LVN J. Observation on 4/27/2023 at 2:27 PM at the hospital bed of Resident #1 revealed he was lying in bed, was intubated, had tube feeding, had catheter and had both legs amputated. Interview on 4/27/2023 at 2:28 PM with Resident #1's spouse stated Resident #1 had his leg amputated, had not awoken, since the surgery and was intubated this morning. Interview on 4/27/2023 at 2:00 PM with RN Q-hospital nurse caring for Resident #1 stated he was admitted on [DATE] at 11:01 AM to hospital due to wound evaluation and foul odor (infection). RN Q stated on 4/21/2023 at 1 PM Resident #1 had a left leg lower amputation. RN Q stated Resident #1 had surgery for amputation to left lower leg, he was ICU on 4/26/2023 at 1:07 PM, he was septic and was intubated this morning on 4/27/2023. RN Q stated Resident #1 was intubated due to altered mental status and failure to thrive. Interview on 4/28/2023 at 11:23 AM with LVN B stated Resident #1 was admitted with the right leg amputated, she was treating the surgical site and the left foot/ankle it looked discolored, he had vascular issues, he had poor circulation. LVN B stated the last day she treated was on the week Resident #1 went to hospital, she stated LVN J was assisting her that Monday, 4/17/2023. LVN B stated Resident #1 was seen by wound management weekly and the nurses will administer the treated as ordered by the wound management. LVN B stated Resident #1 went to dialysis treatment three times a week. LVN B stated Resident #1 had to be reminded and re-directed often to off load his foot to keep the swelling down. LVN B stated she found maggots and removed them on 4/14/2023 had order and referred Resident #1 to vascular MD in one week, then when she returned to work on 4/17/2023., Monday during treatment for Resident #1, LVN J sent Resident #1 to emergency room per order for wound evaluation. LVN B stated during treatment on 4/17/2023, LVN J found 1 maggot in his wound. Interview on 4/28/2023 at 3:34 PM the Regional Nurse stated she started reviewing Resident #1's chart when he went out to the hospital on 4/17/2023., she stated LVN B had notified the MDS nurse, and she then notified her (Regional Nurse) about finding maggots on Resident #1's wound during treatment. The Regional Nurse stated the order for Dakin's solution was placed in the wrong area, so the incoming nurse did not see the pending order for Dakin's solution, the order should have been under treatments event. The Regional Nurse stated the Dakin's solution was never delivered from pharmacy and Resident #1 was not administered Dakin's solution by the facility as ordered. The Regional Nurse stated staff had called local pharmacies to get Dakin's solution but it was not available. The Regional Nurse stated she did not report that Resident #1 had maggots in his wound because she did not feel that it was harm and instructed by corporate, and there was no change in wound due to maggots (Some flies deposit their eggs on or near a wound or sore, the larvae that hatch burrow into the skin. Certain species' larvae will move deeper in the body and cause severe damage.). Regional Nurse stated. Interview on 4/28/2023 at 4:31 PM the Regional Nurse stated she asked staff where the VOHRA wound management had come in to assess residents wound, the staff stated the previous VOHRA MD D had left and the new VOHRA wound management DR C was supposed to start back up on 4/18/2023. Surveyor asked Regional Nurse why VOHRA wound managements had not visited the facility to care for resident wounds from 3/29/2023 to 4/19/2023. The Regional Nurse stated, she could not answer why the residents did not have their wounds assessed. The Regional Nurse stated it was the responsibility of the DON to ensure that residents wounds was assessed weekly by wound management, VOHR. The Regional Nurse stated if residents were on VOHRA wound management case, then nurses do not do the wound assessments or measurements. Interview on 4/28/2023 at 5:55 PM with the Regional Nurse stated she had started in-servicing staff on 4/14/2023 at 2 PM, on skin orders, this was in a booklet. This in-service included 9 nurses. Interview on 4/28/2023 at 7:34 PM NP G stated Resident #1 was seen by VOHRA wound management once a week. NP G stated staff did call him in regard to Resident #1's during wound treatment when the nurse found maggots and she sent an image to him. NP G stated he was not able to see maggots, and he ordered Dakin's solution. NP G stated the staff had not called him to let him know Resident #1 was not administered the Dakin's solution. NP G stated he did not get to visit with Resident #1 because he had gone to hospital. NP G stated the hydrogen peroxide and water was not enough treatment for Resident #'s maggots. NP G stated his expectation of the facility was to follow the medical orders. NP G stated he did have remoted access to resident records. NP G stated he was not able to see wound managements notes and was not made aware that VOHRA wound managements did not visit facility for 2 weeks. Interview 4/29/2023 at 11:18 AM with previous DON I stated she now works as needed at the facility. DON I stated when conducting wound treatment for Resident #1 she did not see maggots in his wound. DON I stated when she starts her shift on the floor, she looks at the previous reports to the next shift, look at progress notes, the previous nurse did not alert to any maggots in Resident #1's wounds. DON I stated the nurses work 12 hr. shift. DON I stated she did the wound treatment for 4/15/2023. She revealed Resident #1's wound looked pretty bad, but she does not do treatment daily. DON I stated the previous wound care management-VOHR MD D came to visit on Wednesdays to assess resident wounds, there was no documentation of magots in his wound. DON I stated Resident #1 goes out to dialysis and he does go out on pass at times with family. DON I stated when nurse's input orders for residents in the computer software, they were automatically sent to the pharmacy and nurses should document a progress note of the order. DON I stated the pharmacy delivers the resident medications and, depending on the medication, for example if it is the weekend the medications sometimes does not get to facility until Monday, it takes 1-3 days for the medications to be delivered. DON I stated VOHR wound management does the measurements of the wound, nurses do not do measurements and MD's keeps track for wound system. DON I stated the nurse follows the wound care orders from VOHR wound management. DON I stated the VOHR wound management assesses resident wounds with nurse for the day and nurse takes the verbal orders, the nurse's document progress note in regard to VOHR wound management MD orders and any interventions. DON I stated she was trained on the computer system for inputting order in the correct area example if it is a treatment order it goes in the treatment event (flow log) when she first started working and received training on 4/29/2023. She stated she was pretty knowledgeable with the computer system, and she stated she received training since she last worked on 4/15/2023. Interview on 4/29/2023 at 11:31 AM with previous MDS A she now had a regional position now. MDS A stated she did not observe the maggots that day on 4/14/2023. MDS A stated there was no facility DON at the time. MDS A stated she was not at facility at the time when LVN B notified her during wound care treatment for Resident #1 that she found maggots, so MDS A called Regional Nurse and they suggested to call NP G. MDS A stated they did not have Dakin's in house, so flushed out hydrogen peroxide and wound cleanser, then LVN B told her there were 4 maggots and she removed them all. MDS A stated the next day she worked was Monday at 9a.m. staff had already sent out Resident #1 to the hospital. MDS A stated she was not sure if the Dakin's order was ever delivered or administered to Resident #1, because she was not there. MDS A stated the Regional Nurse was at the facility and reviewing orders on Monday, 4/17/2023. MDS A stated the Regional Nurse had been at facility due not having a DON at the time. MDS A stated she was trained on inputting in orders and wound care, recently. MDS A stated the process (flow log) for wound orders and orders was automatically sent to pharmacy, then medications are delivered and can vary on when the medications are delivered. MDS A stated when the order was transcribed in the computer system, it automatically shows up on MAR for the nurse to administer order. MDS A stated VOHR wound management had not been at facility for about a couple of weeks. MDS A stated the Regional Nurse called VOHR wound management on the second week, they stated a new MD would visit next week and they should visit once a week to assess residents wounds. Interview on 4/29/2023 at 12:36 PM the Regional Nurse stated she only found out about the flow log (process to input orders in software system) yesterday when I questioned DON I. She said she did not see the order so it prompted to investigate that and I noticed, the order was on the wrong flow log on a flow log that really does not exist for us. My clinical VP was on with matrix right now trying to get rid of that flow log, but it prompted me to educate the nurses and that was an in-service I started right away last night, and we got two signatures today from nurses that did not sign yesterday they were not here and will be training nurses. Interview on 4/29/2023 at 12:37 PM with RN H stated she did not observe any maggots on Resident #1's wounds during wound treatment on 4/16/2023. RN H stated she would see flies in resident rooms at times and resident rooms had to be cleaned and she would make the housekeeper aware. RN H stated when she started her shift at work she would see Resident #1's wounds looked bad and smelled bad, Resident #1 would not wear socks and have his foot on the floor and not wrapped. She would make sure Resident #1 had socks on and elevated his foot. RH H sated she did not see any maggots when she did the wound treatment for Resident #1. RN H sated she did not see any flies in Resident #1's room when doing wound treatment. RN H stated she did follow orders to treat his wounds, Resident #1 was so fragile, she remembers there was multiple areas, she was an agency nurse and did not see wounds on a daily basis. RN H stated she did receive training on how to input skin orders for resident wounds into the computer system. RN H stated she recently received training on orders, supplies (call management), wound assessments and change of condition-notifying MD, MD order-documentation on progress note and put in chart, put TO for management, when put treatment goes under treatment, etc., so each shift can see, pharmacy gets orders electronically and see if still not in, she should call the pharmacy and to notify MD and family of any change of conditions with residents that day. RN H stated she had seen Resident #1 go to dialysis and family would come to facility to visit him. Interview on 4/29/2023 at 1:27 PM with MD D VOHRA wound management stated she worked for VOHRA and left in March 2023. MD D stated her last wound assessment visit was on 3/29/2023 and she stated she discussed last day with the previous Administrator, RN A and MDS A know when her last day was at the facility, she remembers there was a lot of transition of managements staff at the time. MD D stated Resident #1 had multiple wounds that were difficult to heal due to poor blood circulation on leg (arterial doppler) and treated the best way, talked with resident about situation and tried to manage, no sign of infections in the last visit. MD D stated Resident #1's heel was a tough wound to heal, long-term the leg was eventually heading towards amputation. She could not fully heal wound due to vascular issues. MD D stated she never ordered magot therapy and had not seen magots on Resident #1's wounds during assessment and treatments. MD D stated during her visit she rounded with the nurse and verbally told them the orders to follow for wound treatment. MD D stated at end of the visit she would document a summary of resident wounds and treatment for the week and place them on the VOHRA site, that staff at facility had access too. Interview on 4/29/2023 at 1:59 PM with LVN B confirmed she did see and remove 4 magots from Resident #1's ankle/heel wound on 4/14/2023. LVN B confirmed she did notify NP G during Resident #1's wound treatment she removed 4 maggots; she followed orders and for wound and covered it. LVN B stated NP G order Dakin solution and vascular referral. LVN B stated she called local pharmacies to see if they had Dakin's solution, but no local pharmacies did, so she input order into system, so it would be processed through the pharmacy and delivered. LVN B stated she did not administer Dakin's solution to Resident #1's because she could not find at a local pharmacy that day, 4/14/2023. LVN B stated Dakin should come in next drop and reported to the oncoming nurse, Nurse L, about the magots in the wounds and the Dakin order from NP G. LVN B stated she did receive training on inputting orders and notifying MD for change of condition, supplies, treatment orders should go under orders for treatments (flow/events), prn medications, go to right spot and populate for nurse to see on next shift. In an interview on 04/30/2023 at 11:55 a.m., the Regional Nurse stated the facility did not have a policy on how frequently residents with pressure ulcers would be seen by a physician from Wound Care Physician's Group E. An Immediate Jeopardy (IJ) situation was identified on 4/29/2023. While the IJ was removed on 5/1/2023, the facility remained out of compliance at a scope of a pattern and a severity level of actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The Regional Nurse was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 04/29/2023 at 5:52 PM; and a plan of removal was requested. On 4/30/23, the facility provided a POR, and it was accepted on 5/1/2023 at 8 PM. It was documented as follows: Plan to remove immediate jeopardy. The facility failed to put measures in place to meet the needs for Resident #1. Resident #1 was found to have maggots in a left heel/ankle wound on 4/14/2023. F684 Resident #1 is not currently residing at the facility. On 4/29/2023 DON and Nursing team completed skin checks on all residents in the facility and checked wound care orders for proper locations on EHR to make sure they are on treatment flowsheet. Medical Director was notified of the Immediate Jeopardy on 4/29/2023 by RNC (Regional Nurse Consultant). On 4/29/23, the regional nurse consultant (RNC) educated the DON/ADON/MDS on measuring wounds weekly, completing an assessment, and entering the information into the EMR wound system if VOHRA is not available for a weekly visit. ON 4/29/23, DON/Designee initiated education with nurses on measuring wounds weekly, completing an assessment, and entering the information into the EMR wound system if [NAME] wound management is not available for a weekly visit and will be completed on 4/30/2023. Staff will not be allowed to work until they receive training. Ad-Hoc QAPI meeting was held on 4/29/2023, with the Medical Director, NHA (Nursing Home Administrator), Regional Nurse Consultant, DON, RDO (Regional Director of Operations) regarding the action plan for Wound care documentation of orders and completing weekly measurements, if [NAME] physician has not assessed and measured wounds. 4/29/2023 RNC will provide physical oversight at facility weekly x 4 weeks and then monthly reviews after. The Regional Nurse Consultant initiated audit of VOHRA orders for completion and correct flow log entry as well as entry into the EMR wound management system starting on 4/29/23, then weekly for one (1) month and monthly for two (2) months. Any concerns will be corrected immediately, and education given. New employees will receive training on the EMR including flow logs upon hire by DON/Designee. The administrator/designee will bring any concerns to the monthly quality assurance performance improvement meeting for tracking, trending, and further interdisciplinary team recommendations. Confirmation of Trainings: Eight out of the twelve nurses scheduled to work were trained on the POR and in-serviced in detail of what that looks like on the computer system. The staff were trained to ask management/MDs if they were unsure of any order. Interviews: Interviews between on 4/30/2023 at 4:45 PM to and 5/1/2023 at 12:05 PM with RN H, RN I, LVN J, RN O, RN A, MDS F, LVN B, Nurse L and LVN M confirmed they were trained on in-services for skin orders, wound/skin assessments and Management staff were trained on assessing wound if VOHRA wound management was not able to visit that week. The staff were all trained on how to input orders in computer system, EMR, weekly skin assessments, ordering supplies, how to create Event (flow log), completing weekly wound management assessment (wound measurements), notifying MD. The DON or designee responsible for reviewing weekly VOHRA wound management assessments, validating EMRs, ensure the wounds are care planned and the regional nurse will be notified of any concerns. Interview on at 5/1/2023 at 11:24 PM- with Regional Nurse stated she called the pharmacy and said it was OTC (over the counter) medication and if medications are OTC move to different profile and they do not send it. Regional Nurse stated the pharmacy should have sent the Dakin's solution. The Regional Nurse stated the pharmacists told her it would have had to be requested and approved to deliver an OTC medication. Regional Nurse stated they fill the weekly staffing schedule with 3 agency company nurses, and they own one of the agency nursing companies. Regional Nurse stated they had 10 in-house nurses and 4 outside agency nurses, which work as needed (prn). Regional Nurse stated the DON they hired resigned on 4/28/2023. Regional Nurse stated RN H, RN I, LVN J, and RN O our in-house agency and work as needed; RN A and MDS F are in-house and work 8-5 pm daily; and LVN B, Nurse L and LVN M are from another agency staffing company and work as needed. Interview on 5/1/2023 at 11:37 AM with LVN J revealed when doing wound care for Resident #1 on Monday, 4/17/2023/ LVN J described Resident #1's wound treatment to heel/ankle smelled a pungent odor on foot/ankle wound, looked necrotic tissue, white strands, maybe tendon, further up 6 inches above the ankle bone, dark spot, white sticking out, sprayed and wiggle, she saw 1 maggot, immediately called NP G, and he gave order to send Resident #1 to hospital to evaluate and treat. LVN J told Resident #1 she was sending him to emergency room due to severe breakdown and concerned it was a tendon LVN J stated Resident #1 started to cry and called family when discussed LVN J's concern of smell and he had a bug in the wound. LVN J stated during wound care for Resident #1 she discovered his ankle/heel wound was upper part was tunneled from heel, but thought it was 2 wounds LVN J stated when smelled Resident #1's wound she knew something was wrong, not sure why others did not smell, usually indicates rot or severe infection, dead tissue. Attempted Interview 5/1/2023 at 1:52 PM with New MD C VOHRA wound management left a voicemail with no return call before exit. Attempted Interview on 5/1/2023 at 2:23 PM with nurse L left a message with no return call before exit. Interview on 5/1/2023 at 2:24 PM with Pharmacist P stated the orders were automatically sent from facility via computer/fax, they can be verbal as well. The delivery times were 1pm and 9pm, within 2-hour delivery and weekends 5 pm delivery. Pharmacist P stated they could do a stat delivery run. Pharmacist P confirmed they did receive a Dakin's solution order for Resident #1 on 4/15/2023 processed, never filled and stuck on billing section and 4/19/2023 it was discontinued. Pharmacist P stated Dakin's was an OTC product and they do not send OTC medications, unless SNF specifies. Pharmacist P stated he did not revied receive a call from the facility about the Dakin's solution to be delivered as a request. Pharmacist P revealed the Dakin's solution was for an unspecified wound, usually means to clean wounds. Pharmacist P stated hydrogen peroxide would not be the same solution, it is a small portion of bleach. Interview on 5/1/2023 at 5:51 PM with interim Administrator stated he started work at facility on 4/10/2023, Monday -Friday. The interim Administrator stated he was notified on 4/14/2023 of Resident #1's wound and the LVN B found magots during wound treatment. The interim Administrator stated he did not feel Resident #1 was neglected and the nurse was treating wounds, and that is how they found it, the nurse flushed the wounds. The interim Administrator stated the Dakin's solution would not have helped he had poor circulation. The interim Administrator stated he was not aware that the VOHRA wound management was not visiting/assessing resident wounds weekly. The interim Administrator stated they had started an action plan binder with staff in-services, QAUPI and spoke to Medical Director K. The interim Administrator stated the action taken to prevent an incident again was that staff were trained on action plan, better plan for wound assessments, orders and VOHRA wound management back assessing residents weekly. Record review of Resident #1's chart was sent to the hospital on [DATE] due the worsening of a left heel/ankle wound. While at the hospital an emergency left lower extremity amputation was performed. Confirmation- Record Review Interview with Medical Director K confirmed he was notified of the IJ and attended the QUAPI on 4/29/2023. Record review of the facility resident list revealed Resident #1 was not present at the facility. Record review of Resident #1's chart revealed MDS and care plan were verified that he had wounds with interventions. Record review of facility's resident list revealed that a 100 % audit was verified by nursing management from 04/29/2023 on skin audits. Record review of in-service training from 4/14/2023-4/29/2023 (ongoing until all nurses received training, to include outside agency nurse) for all nurses and management nurse on skin/wound orders, measuring wounds, completing assessments, entering information on EMR wound system if VOHRA is not available for a weekly visit, including new residents with newly identified wounds including hospice residents, completing an assessment, and entering the information into the EMR wound system if VOHRA is not available for a weekly visit, and verified new employees will receive training on the EMR including flow logs upon hire by DON/Designee. Record review of QAPI sign-in sheet on 04/29/2023 revealed signatures: Interim Administrator, Regional Nurse, Regional Director of Operations, and MD K. While the IJ was removed on 05/01/2023 at 7:50 p.m.,the facility remained out of compliance at a severity level of a[TRUNCATED]