**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure surgical wound treatment orders were obtained and treatments were provided for one (#69) of three residents who were reviewed with wounds. The DON identified one resident with a surgical wound. Findings: A Physician's Orders policy, dated December 2018, read in parts, .At the time each resident/patient is admitted , the facility will have Physician's orders for their immediate care . An Emergency Physician Care policy, dated December 2018, read in part, .Contact the facility's Medical Director or their alternate in the event Physician services are required and the attending and/or on-call Physician cannot be reached . Resident #69 was admitted on [DATE] with diagnoses which included partial traumatic amputation of two or more left toes. The Hospital Discharge Summary, dated 01/25/23, read in part, .Admit Diagnoses .Right foot osteomylitis s/p transmetatarsal amputation w/ subsequent partial wound dehicence [sic] . Review of the discharge paperwork from the hospital, faxed to the facility on [DATE] revealed the resident had previously been on a wound vac and no discharge wound treatment orders had been documented. The hospital discharge paperwork documented on 01/23/23 the surgical wound measured 4.5cm in length, 15.1cm in width, and 2.9cm in depth. A Baseline Careplan, dated 01/25/23, documented the resident had skin integrity issues of the left toes. An admission Summary note, dated 01/25/23 at 2:48 p.m., documented the resident had a wound on their right foot. A Skin/Wound note, dated 01/25/23 at 4:03 p.m., read in part, Resident admitted to facility from hospital with surgical wound to right foot s/p amputation all toes. Area has c/d/i dressing in place at this time. Will f/u with surgeon for tx orders. Charge nurse and DON aware . An Administrative Progress Note, dated 01/26/23 at 4:00 p.m., read in part, .Nurse from discharging facility called 01/26 at 1600 [4:00 p.m.] stating we did not have [the resident's] wound vac orders then stated 'Wait let me call you back' . A Health Status Note, dated 01/27/23 at 3:13 a.m., read in part, .Resident has a dressing to .right foot r/t amputation of .toes. Dressing currently CDI. Resident mentioned via a visitor .is supposed to have a wound vac in place . A Skin/Wound Note, dated 01/27/23 at 11:08 a.m., read in part, .[Wound physician name withheld] .reports that resident must f/u with surgeon 60-90 days post surgery. If [surgeon] would like a consult visit .[they] must write a referral to do so. Social services reaching out to surgeon to explain the above info. [Wound care physician] will not see resident at this time. DON aware . An Administrative Progress Note, dated 01/27/23 at 2:02 p.m., read in part, .[Wound physician's name withheld] to look at wound in house today. Facility will follow-up with surgeon. Attempted to reach d/c facility nurse to follow-up on wound vac orders/explanation that they had not sent . The Order Summary Report, dated January 2023, read in part, .Surgical wound right foot: Cleanse with normal saline, pat dry, apply medihoney to wound bed, pack with calcium alginate and cover with dry dressing q day and prn soilage, one time a day for wound healing .Order date 01/27/23 .Start date 01/28/23 .Monitor Surgical wound right foot: for s/s of infection q day .Order date 01/27/23 .Start date 01/28/23 . Review of the order summary report did not reveal a treatment order prior to 01/27/23. Review of the January 2023 MAR/TAR revealed the wound care treatment order was first completed on 01/28/23. The Weekly Skin/Wound Assessment, dated 01/28/23 at 3:23 p.m. and signed and locked on 01/29/23 at 5:15 p.m., documented the resident had a surgical incision to the right toes. The assessment read in part, .Surgical incision wound to right amputation site measuring 17cm in length from lateral foot to posterior, lateral wound width is 5.5cm, mid width at top of foot is 5cm, with exposed bone in 3 areas, depth at right posterior tunneling area is 2.5cm, mid tunneling area is 1.5cm. Dark discoloration to top of foot down to lateral is measuring 8cm with small scabbed area, wound bed is approximately 90% slough and 10% necrotic tissue, thick purulent exudate noted . The wound measurements documented in this assessment, which was signed by LPN #4, revealed a decline in the wound when compared to the measurements obtained at the hospital on [DATE] as indicated above. This wound assessment was the first documented assessment in the clinical record which included wound characteristics/description since admission on [DATE]. A Physician Evaluation v2, signed by APRN #1 on 01/29/23, read in parts, .Effective date 01/25/2023 13:05 [1:05 p.m.] .HPI .amputation of the 4th-5th toes on .right foot and was receiving IV cefepime though [sic] 01/14/23. During [the resident's] followup [sic] visit with [Surgeon's name withheld] - amputation, wound vac placement .on 1/6 [01/06/23] for 1 day. wound adhissed [sic] .Subjective/Objective Additional Information right foot osteomylitis klebsiella pneumoniae cirtobacter coag negative staph post partial right foot amputation .right foot cellulitis/wound . A Physician's Telephone Order, dated 01/30/23, read in part, Augmentin 100mg po bid x 30 days. Review of the clinical record did not reveal this medication was provided as ordered by the physician. A Health Status Note, dated 01/30/23 at 1:01 p.m., documented the resident was sent to the emergency room for evaluation and treatment of the open wound to the right foot which had purulent drainage. A Physician Progress Note, dated 01/30/23, read in part, .presented to ER from SNF with worsening R foot infection .the SNF did not do wound care so [the resident's] infection got worse and [the resident] was sent to ER . A Hospital Discharge Summary, dated 02/04/23, read in part, .admitted for evaluation of worsening right foot infection .underwent surgical debriedment, surgical pathology report showed active osteomylitis .' On 03/24/23 at 9:41 a.m., the administrator and ADON was asked about the treatment orders for Resident #69. The administrator stated they had called the referring hospital several times to obtain wound care orders for the resident's surgical wound. The ADON and administrator was asked how the facility's medical director was involved in the resident's care. The administrator stated the medical director had not observed the surgical wound for Resident #69. The ADON and administrator was asked why the resident's physician or the medical director was not contacted for treatment orders for the surgical wound. The ADON stated they should have contacted the facility's physicians when they were unable to contact the surgeon. The administrator and ADON were asked what wound care orders had been obtained from 01/25/23 until 01/27/23. The administrator stated they were able to contact the surgeon on 01/27/23 and completed a dressing change. The administrator was asked where the treatment was documented for the dressing change on 01/27/23. They stated they knew the resident had received a dressing change on 01/27/23 but they dropped the ball on 01/26/23. On 03/24/23 at 12:46 p.m., LPN #4 was asked what the facility's protocol was if a wound was assessed to have purulent drainage. They stated when they had assessed the wound for Resident #69 APRN #1 was at the facility. They stated APRN #1 assessed the surgical wound and was going to contact the resident's physician for antibiotic orders. LPN #4 was asked when the Weekly Skin/Wound Assessment had been completed. They stated they completed the assessment on 01/28/23. On 03/24/23 at 1:16 p.m., APRN #1 was asked about the surgical wound for Resident #69. They stated they had assessed the wound on 01/28/23 or 01/29/23 with LPN #4. APRN #1 stated the wound had dehisced and the hospital had dressed it and sent the resident to the facility. They stated their assessment revealed the wound was open, bone was visible, and necrotic. APRN #1 was asked what interventions had been implemented following their assessment. APRN #1 stated they contacted the physician, obtained antibiotic orders, and was to start the process of to transfer the resident back to the hospital. APRN #1 was asked what antibiotics had been ordered. They stated the order should be in the EMR. They were asked if they had been contacted for treatment orders for Resident #69 prior to the assessment on 01/28/23 or 01/29/23. They stated no. On 03/24/23 at 1:41 p.m., the DON was asked who was responsible to obtain treatment orders for residents with surgical wounds. They stated the charge nurse. The DON was asked who the charge nurse was to obtain the orders from. They stated the referring hospital. They were asked what the protocol was if a resident was sent to the facility without treatment orders. The DON stated the charge nurse was to contact the facility's physicians for orders. The DON was asked what the time frame was to obtain orders for surgical wounds after admission to the facility. They stated they would need to review the protocol. The DON was asked how they ensured treatment orders were obtained and wound treatments were completed. They stated they conducted wound meetings weekly. The DON was asked if an antibiotic had been ordered for Resident #69. They stated they would check the EMR. The DON was asked why wound care orders had not been obtained for the surgical wound before 01/27/23. The DON stated they did not have an answer. On 03/24/23 at 2:12 p.m., the ADON provided a hand-written Physician's Telephone Order, dated 01/30/23, for Augmentin 100 mg bid for 30 days. The ADON was asked why the antibiotic order had not been obtained until 01/30/23, the date Resident #69 had been transferred to the emergency room. They stated they had written the wrong date and it should have been dated for 01/28/23. The ADON was asked why the antibiotic order had not been implemented. They stated the dosage was wrong and they thought LPN #4 was getting a clarification order. They stated they did not know why the antibiotic was not clarified and administered. On 03/27/23 at 5:29 p.m., the DON was asked if they had any further information on why treatment orders for the surgical wound had not been obtained until 01/27/23 and why the first treatment was not completed until 01/28/23. The DON stated, No I do not have any more information.