**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure there were physician orders for a resident's immediate care at the time the resident was admitted for 1 of 5 (Resident #49) reviewed for admission orders.The facility failed to obtain physician orders for Resident #49's immediate care when he admitted to the facility on [DATE] with a Stage 2 pressure ulcer on his coccyx, which resulted in the resident not receiving physician-ordered wound treatment from 06/02/25-06/24/25 and the Stage 2 pressure ulcer worsening to a Stage 4. An IJ was identified on 07/02/25. The IJ template was provided to the facility on [DATE] at 4:10 PM. While the IJ was removed on 07/03/25, the facility remained out of compliance at a scope of isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems.The failure placed residents at risk for medical complications, wound deterioration, infection, and death. Record review of Resident #49's admission MDS assessment, dated 06/09/25 and signed off as completed by the DON on 06/15/25, reflected the resident was a [AGE] year-old male, who admitted to the facility from the hospital on [DATE]. The resident's active diagnoses included malnutrition, pneumonia, respiratory failure, anxiety disorder, essential hypertension (high blood pressure), and generalized muscle weakness. Resident #49 had moderate cognitive impairment with a BIMS score of 11. The resident required supervision or touching assistance with eating, and he had an admission weight of 128 pounds. The resident required substantial/maximal assistance with toileting hygiene, and he was frequently incontinent of bowel and bladder. The MDS further reflected the resident admitted to the facility with one Stage 2 pressure ulcer, and he was supposed to have pressure ulcer/injury care and a pressure reducing device for bed.Record review of Resident #49's Clinical Admission Initial Assessment, dated 06/02/25, completed by RN L reflected the following questions were answered: .24. Skin Issue - Pressure ulcer/Injury27. Pressure ulcer staging - Stage 2 Pressure Ulcer/Injury: Partial thickness skin loss with exposed dermis[BR5] [LO6] (the skin)35. Acquired - Present on admission36. Onset - Unknown46. Presence of wound pain - No53. Staged by: In-house nursing59. Length (cm) - 360. Width (cm) - 561. Depth (cm) - 0 Record review of Resident #49's Progress notes on 06/02/25 21:50 by LVN K reflected the following Skin: Skin warm & dry, skin color WNL and turgor (skin's elasticity) is normal. Skin Issue: #001: New skin Issue. Location: Coccyx (the final segment of the vertebral column). Laterality / Orientation: Medial (closer to the midline of the body). Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Painful: No. Staged by: In-house nursing. Length (cm): 3 Width (cm): 5 Depth (cm): 0#002: New skin Issue. Location: Left antecubital space (the triangular area on the inner side of the left elbow). Additional location information: Bruises Issue type: Bruising (contusion). Wound was present on admission. It is unknown how long the wound has been present.#003: New skin Issue. Location: Right anterior (nearer the front) elbow. Laterality / Orientation: Right. Additional location information: Bruises Issue type: Bruising. Wound was present on admission. It is unknown how long the wound has been present. Record review of Resident #49's Progress notes from 06/02/25 through 06/24/25 by LVN K, RN L, LVN M, RN Z, and LVN AA reflected the following notes: Skin: Skin Issue: #001: Skin issue has not been evaluated. Location: Coccyx. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Staged by: In-house nursing. #002: Skin issue has not been evaluated. Location: Left antecubital space. Additional location information: Bruises Issue type: Bruising. Wound was present on admission. It is unknown how long the wound has been present. #003: Skin issue has not been evaluated. Location: Right anterior elbow. Laterality / Orientation: Right. Additional location information: Bruises Issue type: Bruising. Wound was present on admission. It is unknown how long the wound has been present. There was no documentation of Wound Care Physician, Nurse Practitioners were made aware of Resident #49's pressure wound. No documentation of any wound care provided to Resident #49.Record review of Resident #49's Nurse Practitioner Visit Notes dated 06/10/25 reflected: Chief complaint - Skilled care visit - Nurse reports abnormal lab results and request to review lab.Review of systems: Skin - neg for rash Objective: Physical Examination: Skin: Warm and Dry. There was no documentation in the Nurse Practitioner's notes reflecting the resident's pressure ulcer was observed. Record review of Resident #49's Initial Wound Evaluation & Management Summary dated 06/25/25 reflected the following exam completed: Stage 4 Pressure Wound Sacrum full thickness - Etiology (quality) Pressure, Stage 4, Wound Size (L x W x D): 4.0 c 4.0 x 0.8 cm. Surface Area: 16.00cm2. Infection Assessment: No sign(s) of infection. Record review of Resident #49's Physician's orders dated 06/25/25 reflected the following orders: Zinc Oral Tablet 50 MG (Zinc) Give 1 tablet by mouth in the evening for wound care for 2 Weeks until wound heals - Start date 06/25/25Wound treatment plan to the sacrum: clean with NS or wound cleanser, pat dry, apply sodium hypochlorite gel (anasept), collagen powder, cover with gauze island w/bdr once daily, every day shift for wound care. - Start Date 06/26/2025Beneprotein Oral Powder (Protein) Give 7 gram by mouth two times a day for WOUND CARE for 90 Days - Start date 06/26/2025. Resident #49 had no medication or treatment orders for his wound from 06/02/25 - 06/25/25. Record review of Resident #49's June 2025 MAR/TAR reflected wound care medication started on 06/25/25 and wound care treatment started on 06/26/25. There was no documentation of wound care treatment provided to Resident #49 from 06/02/25 - 06/25/25.Record review of Resident #49's care plan, revised on 06/27/25, reflected Focus: Resident has current Skin Concerns: Pressure Ulcer on sacral area. Goal: Areas will heal without complications over the next 90 days. Interventions: Assess skin weekly and record findings in clinical record. Perform treatments per order, if no improvement x 2 weeks-report to MD. Provide pressure relieving and positioning devices as needed. Care Plan revised on 07/01/25, reflected: Focus: Resident has a Pressure Area: Stage: 4 (characterized by full-thickness tissue loss, exposing muscle, tendon, or bone) Location: SACRUM (large, triangular bone at the base of the spine that forms the back wall of the pelvis.) TX: Sodium hypochlorite gel (anasept) apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days; Collagen powder apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Goal: Resident will have improved skin integrity as evidenced by a decrease in size and depth of pressure area during the next 90 days. Interventions: Keep family/responsible party and MD informed of resident's progress. Monitor labs and report abnormals to MD. Record review of Resident #49's Wound Evaluation & Management Summary dated 07/02/25 reflected the following exam completed: Stage 4 Pressure Wound Sacrum full thickness - Etiology (quality) Pressure, Stage 4, Wound Size (L x W x D): 4.0 c 4.0 x 0.8 cm. Surface Area: 16.00cm2. Infection Assessment: No sign(s) of infection. Observation and interview on 07/02/25 at 8:51 AM revealed Resident #49 in bed and awake. Observed Resident #49 to be on a pressure relieving mattress. Resident #49 stated he had been at facility for about 2-3 weeks. Resident #49 stated he had a pressure sore on his bottom. He stated he was not sure if he admitted with the wound or if it developed at the facility. Resident #49 stated he had been seen by the wound care doctor twice since being admitted . Resident #49 stated he was seen by the wound care doctor last week unknown of exact date and today (07/02/25). He stated prior to being seen by the wound care doctor he was not receiving any treatment for his wound. Resident #49 stated he never refused any treatment. Resident #49 stated he had pain but was getting pain medication. Interview by phone on 07/02/25 at 10:51 AM, LVN K revealed Resident #49 admitted to her hall. She stated when Resident #49 admitted to the facility she completed a skin assessment and noted a wound on his bottom. She stated the facility's process of when a resident admitted to the facility was the admitting nurse was responsible for completing the skin assessment and if the resident admitted with a wound the admitting nurse must notify the ADON and the ADON would notify the Wound Care Physician. LVN K stated the Wound Care Physician visits=ed twice a week, and Resident #49 had been seen by the Wound Care Physician, unknown date. She stated she was not sure if Resident #49's treatment was completed during the morning shift or afternoon shift. She stated she could not recall if she provided any treatments during her shift. She stated she could not recall if treatment orders were obtained for his wound upon admission or if the physician was notified. Interview by phone on 07/02/25 at 10:57 AM, RN L revealed she only worked at the facility during the weekends. RN L stated she could not recall admitting Resident #49 and could not recall any wounds or what wound care Resident #49 required. Interview on 07/02/25 at 11:01 AM ADON A/Wound Care Coordinator revealed the process of when a resident admitted to the facility, the admitting nurse must complete a head-to-toe assessment. If wounds were present upon admission, the admitting nurse must complete a communication form, put it in her box and she was responsible for contacting the Wound Care Physician. ADON A stated the nurses were responsible for completing wound care treatments for residents. She stated she was responsible for contacting the Wound Care Physician and completing rounds when the Wound Care Physician visited every Wednesday. She stated every Wednesday before the Wound Care Physician visited, she completed rounds and would ask all the nurses if they had any admitting residents with wounds. She stated Resident #49 admitted to the facility with a wound on his sacrum. ADON A reviewed Resident #49's clinical records and stated Resident #49 was first seen by the Wound Care Physician on 06/25/25 and received treatment orders the same day. ADON A stated based on documentation it did not seem Resident #49 received any wound care treatment. ADON A stated there was a gap from the time Resident #49 admitted until he was seen on 06/25/25 by the Wound Care Physician. ADON A stated Resident #49 admitted to the facility on [DATE] which was a Monday, and the Wound Care Physician would have visited Wednesday, and the reason Resident #49 was not seen was because Resident #49 did not show up in the Wound Care Physician's computer system, and the nurses were told to continue standing treatment orders. ADON A stated if nurses were not able to obtain attending physician's orders for wound care the facility had in-house standing treatment order dry dressing and should be uploaded in the resident's chart. ADON A reviewed Resident #49's discontinued orders and stated in-house standing treatment orders were not put in the system. ADON A stated she was not sure if Resident #49 received any treatment prior to being seen by the Wound Care Physician. She stated she visited Resident #49, but did not document her visit. She stated she would monitor her nurses when the nurses would ask her for wound care supplies, then she would complete a supply count and the count wound be accurate. ADON A stated when nurses would ask her for wound care supply, she would not question the nurses who the supplies were used for. ADON A stated she never obtained a communication form from the admitting nurse who admitted Resident #49, and she did not follow up because she was not aware of the wound. ADON A stated nurses should not measure the wounds and should not stage the wounds because the measurements could be wrong. ADON A stated she was not aware RN L staged and measured Resident #49's pressure wound. She stated the Wound Care Physician was notified of Resident #49's pressure wound. However, she could not recall the exact date, but it was a day or two before Resident #49 was seen by the Wound Care Physician on 06/25/25.Interview on 07/02/25 at 12:35 PM, LVN M revealed she was on leave when Resident #49 admitted to the facility, and she had returned to work on 06/09/25 morning shift. She stated she could not recall the exact date, but it was the week when Resident #49 was seen by the Wound Care Physician on 06/25/25 when she was notified of the pressure wound. She stated CNA J notified her of the wound on Resident #49's sacrum area. When CNA J was providing Resident #49 incontinent care, Resident #49 dressing came off and CNA J needed her to put a new dressing on. She stated she was not aware of the pressure wound. She stated she cleaned it and put a new dressing on. She stated when she cleaned the wound it did not appeared infected, no drainage was noted and had no odor to it. She stated she immediately went and notified ADON A. She stated there should had been orders in the system but there were no treatment orders in the resident's clinical chart when she reviewed it. She stated the facility had standing treatment orders, but she could not recall if any orders were put in the system. LVN M stated she did not put any orders in the system when she cleaned the wound. She stated if it was not documented it did not happen and it was her mistake for not putting the standing treatment orders in the system. She stated the process of when a new resident admitted to the facility the admitting nurse should complete skin assessment, notify the ADON A, obtain orders and put them in the system. LVN M stated prior to CNA J notifying her of the wound, she was never told or received any report from any staff regarding the wound. She stated she never provided any wound care to Resident #49 during her shift until the day CNA J asked her to put a new dressing on. She stated she completed a skin check on Resident #49 and had not noticed the wound; however, Resident #49 would refuse to be checked. She stated it was her mistake for not documenting the refusal. She stated the potential risk of not providing wound care treatment would be infections. She stated it was not good quality of care. Interview on 07/02/25 at 1:27 PM, CNA J revealed she could not recall the exact date, but she was providing Resident #49 incontinent care when his wound dressing had come off. She stated prior to proving the incontinent care Resident #49 had the dressing on his sacrum. She stated when the dressing came off, she notified LVN M and LVN M cleaned the wound and put a new dressing on him. She stated that was the first time she was assigned to Resident #49. She stated she was not aware of the wound until she provided incontinent care. Interview on 07/02/25 at 1:39 PM, ADON B revealed she was working when Resident #49 admitted to the facility. She stated Resident #49 admitted to the facility with a wound on his sacrum and nursing staff were using the standing orders to clean and cover the wound until he was seen by the Wound Care Physician. ADON B stated the admitting nurse was responsible for putting in standing orders in the system and completing a communication form to request wound care for residents to the ADON A. She stated the admitting nurse failed to communicate to ADON A to put Resident #49 on the list to be seen by the Wound Care Physician. ADON B stated LVN M had just resumed her job duty from being on leave and was completing skin assessments on residents when she noticed Resident #49's wound. She stated LVN Y was the nurse assigned to Resident #49 before LVN M returned to work. She stated LVN Y was providing wound care treatment to Resident #49, but it was unknown if it was documented. She stated if the ADON A was not notified of Resident #49's pressure wound then the Wound Care Physician was not notified. She stated the potential risk of not providing any wound care treatment would be infection. Interview on 07/02/25 at 2:00 PM, the DON revealed her expectation for when a resident admitted to the facility was the admitting nurse should complete a skin assessment. If a resident admitted with a wound, the admitting nurse should obtain treatment orders either form the doctor, hospital records or the in-house standing orders and should be put in the system. She stated the nurses should also complete a communication form and provide it to ADON A, and ADON A would place the resident's name on the list to be seen by the Wound Care Physician. The DON stated when Resident #49 was being provided with incontinent care, the resident had a dressing on the sacrum, and it fell off. She stated the nurse put a new dressing on and reported the wound to ADON A. The DON stated the admitting nurse for Resident #49 had not communicated Resident #49 had a wound. She stated she was not aware Resident #49's wound was staged and measured upon admission. She stated wound care treatment was provided to Resident #49; the nurses were using the standing orders, but the standing orders were not put in the system. She stated she was not aware there was no documentation in Resident #49's clinical chart. The DON stated she expected her nurses to put physician orders in the resident clinical chart/system. The DON stated Resident #49's wound was getting better and had no signs of infection. She stated her staff failed to put treatment orders in the system and failed to communicate to ADON A. She stated the Wound Care Physician was not notified until the ADON A was notified of the wound. She stated the potential risk would be infection. Interview on 07/02/25 at 2:06 PM with CNA N revealed she was the CNA assigned to Resident #49 when he was on the 100 Hall. She stated every time she would provide incontinent care to Resident #49, he had a dressing on his bottom. She stated Resident #49 admitted to the facility with a wound. CNA N stated during the morning shift, LVN M would change the wound dressing on Resident #49. She stated Resident #49 always had a dressing on his wound. She stated the nursing staff were aware of Resident #49's sacrum wound. An attempt was made on 07//02/25 at 2:33 PM to interview LVN Y by phone but was unsuccessful. Interview by phone on 07/02/25 at 3:00 PM, the Wound Care Physician stated if a resident admitted with a wound, he expected the Attending Physician or Nurse Practitioner to see the resident and write initial wound care orders, and to add him as an attending. If the resident had hospital orders that included wound orders, staff could follow those orders. ADON A would text him with a new resident's information prior to his next visit. He did not give any standing orders for wound care due to the liability, but he would allow ADON A to start treatment because he had worked with her for many years. He stated he was not aware of Resident #49's wound until he saw him on 6/25/25. He stated all wounds were considered colonized with a bacterium of some form, but that did not mean it was infected. If the wound was not healing, then it would be considered infected. Resident #49's wound was healing so he did not consider it to be infected. Interview on 07/02/25 at 3:13 PM, the Nurse Practitioner revealed she was not made aware of Resident #49's pressure wound when she visited the resident on 06/10/25. She stated she visited Resident #49 and completed an assessment, but she did not inspect the resident's back because she was not aware of the wound. She stated since she was not made aware of the wound no treatment orders were provided. She stated she could not recall the exact date, but she was notified by the DON that Resident #49's wound had worsened and that the Wound Care Physician had been notified and provided treatment orders. She stated when a resident admits to the facility with a wound her expectations were to be notified and for nurses to obtain orders. She stated if a resident had not been seen by the Wound Care Physician or the nurses were not able to get ahold of the Wound Care Physician, the ADON normally would notify her, and she would provide treatment orders. Interview on 07/02/25 at 3:51 PM, the Administrator revealed wound care questions were more of a clinical nursing aspect, but his expectations were for the nurses to assess the wound and notify the Wound Care Physician. The Administrator expected nursing staff to follow treatment orders and to document any care that the resident was being provided with. Record review of facility policy Significant Change in Resident's Status undated reflected the following: It is the policy of this organization that this facility immediate inform the resident, consult with the resident physician, and if knows notifies the resident's legal representative or an interested family when there is: .C. Need to alter treatment significantly (this is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment.4. Deterioration in a resident's health status, where this change: places the resident's life in danger. is associated with a serious clinical complication, e.g., initial development of stage III or stage IV pressure ulcer.When any of the above occurs the attending physician, the resident and/or responsible party and/or legal representative and/or interested family member is notified. Document is made in the Nurses Notes and the Resident Assessment Instrument, and the Comprehensive Care Plan is updated to reflect the changes This was determined to be an Immediate Threat (IT) on 07/02/25 at 4:02 PM. The Administrator and DON were notified. The Administrator was provided with the IT template on 07/02/25 at 4:10 PM. The Facility's Plan of Removal for Immediate Threat was accepted on 07/02/25 at 6:32 PM and reflected the following: Date of IJ Determination: 07/02/2025 Immediate Corrective Actions Taken Physician Notification for Identified ResidentAs of 07/02/2025, the resident identified in the IJ was immediately assessed by the Director of Nursing. The resident's attending physician and the Wound care Physician were immediately consulted, and updated treatment orders were obtained to address the resident's wound and overall plan of care. Chart Review for Timely Physician NotificationA comprehensive audit of all admissions and current residents with significant changes in physical status was completed on 07/02/2025 to ensure physician notification occurred as required. Any instances lacking documented physician notification were immediately corrected by contacting the respective physician and updating the medical records.Immediate Staff EducationOn 07/02/2025, all licensed nurses received in-service training on:- Recognizing and defining significant changes in resident condition.- The requirements for immediate physician consultation upon identification of significant changes.- Accurate and timely documentation of physician notifications and resulting orders.Staff sign-in sheets and education materials are maintained for verification. Process ChangesA Physician Notification Protocol has been implemented requiring nurses to notify the physician within 1 hour of identifying a significant change in a resident's condition, including the development or worsening of pressure ulcers.A physician notification from was created to document:-The date and time change identification.-The date and time of physician notification.-Physician response and orders.admission protocols were updated to require physician notification within 24 hours for all residents admitted with pressure ulcers or other significant health conditions. Ongoing MonitoringThe Director of Nursing or designee will conduct daily audits of residents with significant changes in condition to confirm timely physician notification and documentation.Weekly audits of 10% of resident charts will be performed for 3 months to ensure compliance with the physician notification protocol. Quality Assurance and OversightPhysician notification compliance will be a standing agenda item at the facility monthly Quality Assurance Performance Improvement (QAPI) meeting for at least 3 months. Audit results and corrective actions will be reviewed by the Administrator and Medical Director. How the Plan Removes the Immediate JeopardyImmediate assessment and physician consultation for the identified resident ensures appropriate and timely medical oversight, mitigating current risk. Staff education and protocol changes ensure future prompt physician notification for any significant changes, reducing the risk of delayed treatment. Ongoing audits and oversight confirm sustained complaint, preventing recurrence of the issue and ensuring resident rights are protected. Date IJ was Corrected:We believed the Immediate Jeopardy was removed on 07/02/2025, the date corrective actions were implemented. Ensuring Staff Not Present Received TrainingAll nursing staff who are not present on 07/02/2025 for the in-services training will receive a make-up in-service by the Staff Development Nurse within 5 calendar days of returning to work, and before providing direct resident care. Completing will be tracked on a staff education log. Implementation Date for Physician Notification Protocol:The updated Physician Notification Protocol was implemented on 07/02/2025, the same day as the initial corrective actions. Title of Staff Conducting Audit and In-Service:The Director of Nursing (DON) conducted the comprehensive char audit for physician notifications.The Staff Development Nurse (SDN) provided the in-service training on physician notification requirements. Electronic In-Service Distribution and Acknowledgement:Nursing staff who are not present for in-person in-services will receive the training materials electronically through the facility's secure communication platform within 5 calendar days of returning to work. Staff will be required to review the material and electronically signs and acknowledgements from confirming their understanding. Record of completion and acknowledgements will be maintained by the Staff Development Nurse and made available for surveyor review. In-Service: Recognizing Significant Changes & Physician NotificationObjective: Train nursing staff to recognize significant changes in resident condition, promptly notify the physician, and properly document the process to ensure timely treatment and protect resident rights. Agenda: Defining Significant Change - Examples: new/worsening wounds, sudden mental status changes, falls with injury, acute infections, uncontrolled pain. Timeframes for Physician Notification - Immediate vs. urgent vs. routine notification standards - Facility policy on notifying the physician within 1 hour of significant changes. Documentation of Notification - How to complete the physician notification form. - Documenting date/time of change, date/time of call, physician response. Communication Best Practices - SBAR (Situation, Background, Assessment, Recommendation) approach when calling providers. - Tips for effective and concise communication Policy & Procedure Review- Physician notification protocol - Review of facility admission protocols requiring physician notification. Q&A Session Materials: Physician notification form Updated physician notification policyCompetency Validation: Staff sign-in sheet Charting exercise: completing a sample physician notification form Electronic In-Service Distribution and Acknowledgement:Nursing staff who are not present for in-person in-services will receive the training materials electronically through the facility's secure communication platform within 5 calendar days of returning to work. Staff will be required to review the material and electronically signs and acknowledgements from confirming their understanding. Record of completion and acknowledgements will be maintained by the Staff Development Nurse and made available for surveyor review. Monitoring of the facility's Plan of Removal included the following: Record review of a facility in-service training report for facility nurses across all shifts dated 07/02/25 reflected the following: Skin Issues on Admission. Protocol: Do a thorough assessment. 1) Document. Initially nurses are not to measure unless you're a wound care certified nurse. 2) Make sure there is a treatment ordered. (Hospital order, standing order or MD/NP order) Fill up a communication form and submit it to the Wound Care Nurse (ADON) for Dr. (Name) (Wound MD) to look at on his next visit. Document everything! Do Skin assessments every week! Notification of MD for worsening wounds if it's not documented it's not done!! Record review of a facility in-service training report for facility nurses across all shifts dated 07/02/25 reflected the following: Accurate and timely wound assessment and documentation. The requirement for immediate physician notification for wounds at admission or with signs of worsening. Proper initiation for treatment orders for wounds. Staff sign-in sheets and education materials are maintained for verification. Record review of the facility QAPI meeting revealed the facility medical director was notified by the director of nurses of the immediate jeopardy via phone while in attendance with the facility administrator on 07/02/25. Record review of the facility admission Wound Assessment Checklist form reflected on 07/02/2025 the form included the name of the resident, date of admission, wound treatment, MD Notified, notes. Record review of the facility Weekly Audit tool blank form revealed it included the date, resident, treatment, and documentation in PCC. Record review of the facility Communication Form revealed it must include information pertaining the resident, new admission/readmission, indicate which department it applied to and to include message/comments. Record review of the facility Physician notification Form undated, reflected staff should provide the date and time change identification, the date and time of physician notification and Physician response and orders. Record review of the Facility SBAR (Situation, Background, Assessment, Recommendation) reflected staff should document when a change of condition occurred and when the provider was notified. Record review of Resident #49's progress noted dated 07/02/25 by the DON reflected Pressure wound on sacrum assess with wound MD. Stage 4 full thickness. Wound size (LxWxD) 4.0x3.5x0.8 cm Surface area = 14, exudate - Moderate serous (clear fluid drainage from a wound). Wound has improved since last visit as evidence by decrease surface area. No signs of infection noted. Treatment review with physician. No changes made at this time. Resident remains on air mattress. No c/o pain but instructed to call the nurse if he has pain. PRN pain medication ordered. Dietician made aware of the nutritional consult for the resident. Staff instructed to turn and reposition resident Q 2 hours. Call light within reach. Record review of Skin Assessments revealed they were completed on 07/02/25 for all 73 residents. The assessments indicated any skin concerns and the location of the skin concerns. Record review of a facility in-service training report for facility nurses across all shifts dated 07/03/25 reflected the following: On wound assessment on admission, the Admitting Nurse is required to document the following: 1. Wound measurements. 2) Notification of the physician w/in 24 Hrs. of identification. 3) Initiation of wound treatment per protocol or physician order. 4) A standing protocol has been established requiring automatic wound consult for any Stage 2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one of five residents (Resident #49) reviewed for pressure ulcers.The facility staff failed to notify the Wound Care Physician of Resident #49's Stage 2 pressure ulcer on his coccyx upon admission. Resident #49 was not provided with wound care treatment from 06/02/25 - 06/25/25 which resulted in resident's pressure ulcer worsening from a Stage 2 to a Stage 4. An IJ was identified on 07/02/25. The IJ template was provided to the facility on [DATE] at 4:10 PM. While the IJ was removed on 07/03/25, the facility remained out of compliance at a scope of isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems.These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, decreased quality of life, and hospitalization.Findings included: Record review of Resident #49's admission MDS assessment, dated 06/09/25 and signed off as completed by the DON on 06/15/25, reflected the resident was a [AGE] year-old male, who admitted to the facility from the hospital on [DATE]. The resident's active diagnoses included malnutrition, pneumonia, respiratory failure, anxiety disorder, essential hypertension (high blood pressure), and generalized muscle weakness. Resident #49 had moderate cognitive impairment with a BIMS score of 11. The resident required supervision or touching assistance with eating, and he had an admission weight of 128 pounds. The resident required substantial/maximal assistance with toileting hygiene, and he was frequently incontinent of bowel and bladder. The MDS further reflected the resident admitted to the facility with one Stage 2 pressure ulcer, and he was supposed to have pressure ulcer/injury care and a pressure reducing device for bed. Record review of Resident #49's Clinical Admission Initial Assessment, dated 06/02/25, completed by RN L reflected Resident #49 admitted to the facility with a Stage 2 pressure ulcer that measured 3.0 cm x 5.0 cm x 0.0 cm. Record review of Resident #49's Progress Notes written by LVN K, dated 06/02/25 at 9:50 PM, reflected the following: Skin: Skin warm & dry, skin color WNL and turgor (skin's elasticity) is normal. Skin Issue: #001: New skin Issue. Location: Coccyx (the final segment of the vertebral column). Laterality / Orientation: Medial (closer to the midline of the body). Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Painful: No. Staged by: In-house nursing. Length (cm): 3 Width (cm): 5 Depth (cm): 0. Record review of Resident #49's Progress notes from 06/02/25 through 06/24/25 by LVN K, RN L, LVN M, RN Z, and LVN AA reflected they all used the same note in all their entries regarding Resident #49's pressure ulcer: Skin: Skin Issue: #001: Skin issue has not been evaluated. Location: Coccyx. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound was present on admission. It is unknown how long the wound has been present. Staged by: In-house nursing.There was no documentation in Resident #49's Progress Notes reflecting the Physician, Nurse Practitioner, or the Wound Care Physician had been made aware of Resident #49's pressure ulcer. There was also no documentation in the Progress Notes reflecting Resident #49 was receiving wound care nor was there documentation reflecting the resident was on a low air loss mattress. Record review of Resident #49's Nurse Practitioner Visit Notes dated 06/05/25 reflected the resident had a diagnosis of protein calorie malnutrition prior to his admission the facility in the hospital on [DATE]. Regarding the resident's skin, the Nurse Practitioner documented: .Physical Examination.Skin: No visible skin lesions or rashes noted in exposed BUE or BLE. There was no documentation in the Nurse Practitioner's notes reflecting the resident's pressure ulcer was observed nor was there an order for care/treatment of the pressure ulcer.Record review of Resident #49's Care Plan, initiated on 06/09/25, reflected Resident #49 was at risk for weight loss as evidenced by being a new admission and consuming less than 25% of meals with a poor appetite. Care Plans, initiated on 06/21/25, reflected: Resident #49 was at risk for skin breakdown; the resident had ADL deficits to include bed mobility, transfers, eating, toilet use, dressing, personal hygiene, and bathing; and the resident was incontinent of bowel and bladder. Record review of Resident #49's Initial Wound Evaluation & Management Summary dated 06/25/25 reflected the following exam completed: Stage 4 Pressure Wound Sacrum full thickness - Etiology (quality) Pressure, Stage 4, Wound Size (L x W x D): 4.0 c 4.0 x 0.8 cm. Surface Area: 16.00cm2. Infection Assessment: No sign(s) of infection. Record review of Resident #49's Physician's Orders dated 06/25/25 reflected the following orders were initiated to treat Resident #49's pressure ulcer as follows: Zinc Oral Tablet 50 MG (Zinc) Give 1 tablet by mouth in the evening for wound care for 2 Weeks until wound heals - Start date 06/25/25 Wound treatment plan to the sacrum: clean with NS or wound cleanser, pat dry, apply sodium hypochlorite gel (anasept), collagen powder, cover with gauze island w/bdr once daily, every day shift for wound care. - Start Date 06/26/2025 Beneprotein Oral Powder (Protein) Give 7 gram by mouth two times a day for wound care for 90 Days - Start date 06/26/2025. Resident #49 had no medication or treatment orders for his wound from 06/02/25 - 06/25/25. Record review of Resident #49's June 2025 MAR/TAR reflected wound care medication started on 06/25/25 and wound care treatment started on 06/26/25. There was no documentation of wound care treatment provided to Resident #49 from 06/02/25 - 06/25/25. The June 2025 TAR also reflected the resident was placed on a low air loss mattress starting on 06/27/25 to address wound healing for the pressure ulcer. Record review of Resident #49's care plan, revised on 06/27/25, reflected: Focus: Resident has current Skin Concerns: Pressure Ulcer on sacral area. Goal: Areas will heal without complications over the next 90 days. Interventions: Assess skin weekly and record findings in clinical record. Perform treatments per order, if no improvement x 2 weeks-report to MD. Provide pressure relieving and positioning devices as needed. Care Plan revised on 07/01/25, reflected: Focus: Resident has a Pressure Area: Stage: 4 (characterized by full-thickness tissue loss, exposing muscle, tendon, or bone) Location: SACRUM (large, triangular bone at the base of the spine that forms the back wall of the pelvis.) TX: Sodium hypochlorite gel (anasept) apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days; Collagen powder apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Goal: Resident will have improved skin integrity as evidenced by a decrease in size and depth of pressure area during the next 90 days. Interventions: Keep family/responsible party and MD informed of resident's progress. Monitor labs and report abnormals to MD. Record review of Resident #49's Wound Evaluation & Management Summary dated 07/02/25 reflected the following exam completed: Stage 4 Pressure Wound Sacrum full thickness - Etiology (quality) Pressure, Stage 4, Wound Size (L x W x D): 4.0 c 4.0 x 0.8 cm. Surface Area: 16.00cm2. Infection Assessment: No sign(s) of infection. Observation and interview on 07/02/25 at 8:51 AM revealed Resident #49 in bed and awake. Observed Resident #49 to be on a pressure relieving mattress. Resident #49 stated he had been at facility for about 2-3 weeks. Resident #49 stated he had a pressure sore on his bottom. He stated he was not sure if he admitted with the wound or if it developed at the facility. Resident #49 stated he had been seen by the wound care doctor twice since being admitted . Resident #49 stated he was seen by the wound care doctor last week unknown of exact date and today (07/02/25). He stated prior to being seen by the wound care doctor he was not receiving any treatment for his wound. Resident #49 stated he never refused any treatment. Resident #49 stated he had pain but was getting pain medication. Interview by phone on 07/02/25 at 10:51 AM, LVN K revealed Resident #49 admitted to her hall. She stated when Resident #49 admitted to the facility she completed a skin assessment and noted a wound on his bottom. She stated the facility's process of when a resident admitted to the facility was the admitting nurse was responsible for completing the skin assessment and if the resident admitted with a wound the admitting nurse must notify the ADON and the ADON would notify the Wound Care Physician. LVN K stated the Wound Care Physician visits=ed twice a week, and Resident #49 had been seen by the Wound Care Physician, unknown date. She stated she was not sure if Resident #49's treatment was completed during the morning shift or afternoon shift. She stated she could not recall if she provided any treatments during her shift. She stated she could not recall if treatment orders were obtained for his wound upon admission or if the physician was notified. Interview by phone on 07/02/25 at 10:57 AM, RN L revealed she only worked at the facility during the weekends. RN L stated she could not recall admitting Resident #49 and could not recall any wounds or what wound care Resident #49 required. Interview on 07/02/25 at 11:01 AM ADON A/Wound Care Coordinator revealed the process of when a resident admitted to the facility, the admitting nurse must complete a head-to-toe assessment. If wounds were present upon admission, the admitting nurse must complete a communication form, put it in her box and she was responsible for contacting the Wound Care Physician. ADON A stated the nurses were responsible for completing wound care treatments for residents. She stated she was responsible for contacting the Wound Care Physician and completing rounds when the Wound Care Physician visited every Wednesday. She stated every Wednesday before the Wound Care Physician visited, she completed rounds and would ask all the nurses if they had any admitting residents with wounds. She stated Resident #49 admitted to the facility with a wound on his sacrum. ADON A reviewed Resident #49's clinical records and stated Resident #49 was first seen by the Wound Care Physician on 06/25/25 and received treatment orders the same day. ADON A stated based on documentation it did not seem Resident #49 received any wound care treatment. ADON A stated there was a gap from the time Resident #49 admitted until he was seen on 06/25/25 by the Wound Care Physician. ADON A stated Resident #49 admitted to the facility on [DATE] which was a Monday, and the Wound Care Physician would have visited Wednesday, and the reason Resident #49 was not seen was because Resident #49 did not show up in the Wound Care Physician's computer system, and the nurses were told to continue standing treatment orders. ADON A stated if nurses were not able to obtain attending physician's orders for wound care the facility had in-house standing treatment order dry dressing and should be uploaded in the resident's chart. ADON A reviewed Resident #49's discontinued orders and stated in-house standing treatment orders were not put in the system. ADON A stated she was not sure if Resident #49 received any treatment prior to being seen by the Wound Care Physician. She stated she visited Resident #49, but did not document her visit. She stated she would monitor her nurses when the nurses would ask her for wound care supplies, then she would complete a supply count and the count wound be accurate. ADON A stated when nurses would ask her for wound care supply, she would not question the nurses who the supplies were used for. ADON A stated she never obtained a communication form from the admitting nurse who admitted Resident #49, and she did not follow up because she was not aware of the wound. ADON A stated nurses should not measure the wounds and should not stage the wounds because the measurements could be wrong. ADON A stated she was not aware RN L staged and measured Resident #49's pressure wound. She stated the Wound Care Physician was notified of Resident #49's pressure wound. However, she could not recall the exact date, but it was a day or two before Resident #49 was seen by the Wound Care Physician on 06/25/25. Interview on 07/02/25 at 12:35 PM, LVN M revealed she was on leave when Resident #49 admitted to the facility, and she had returned to work on 06/09/25 morning shift. She stated she could not recall the exact date, but it was the week when Resident #49 was seen by the Wound Care Physician on 06/25/25 when she was notified of the pressure wound. She stated CNA J notified her of the wound on Resident #49's sacrum area. When CNA J was providing Resident #49 incontinent care, Resident #49 dressing came off and CNA J needed her to put a new dressing on. She stated she was not aware of the pressure wound. She stated she cleaned it and put a new dressing on. She stated when she cleaned the wound it did not appeared infected, no drainage was noted and had no odor to it. She stated she immediately went and notified ADON A. She stated there should had been orders in the system but there were no treatment orders in the resident's clinical chart when she reviewed it. She stated the facility had standing treatment orders, but she could not recall if any orders were put in the system. LVN M stated she did not put any orders in the system when she cleaned the wound. She stated if it was not documented it did not happen and it was her mistake for not putting the standing treatment orders in the system. She stated the process of when a new resident admitted to the facility the admitting nurse should complete skin assessment, notify the ADON A, obtain orders and put them in the system. LVN M stated prior to CNA J notifying her of the wound, she was never told or received any report from any staff regarding the wound. She stated she never provided any wound care to Resident #49 during her shift until the day CNA J asked her to put a new dressing on. She stated she completed a skin check on Resident #49 and had not noticed the wound; however, Resident #49 would refuse to be checked. She stated it was her mistake for not documenting the refusal. She stated the potential risk of not providing wound care treatment would be infections. She stated it was not good quality of care. Interview on 07/02/25 at 1:27 PM, CNA J revealed she could not recall the exact date, but she was providing Resident #49 incontinent care when his wound dressing had come off. She stated prior to proving the incontinent care Resident #49 had the dressing on his sacrum. She stated when the dressing came off, she notified LVN M and LVN M cleaned the wound and put a new dressing on him. She stated that was the first time she was assigned to Resident #49. She stated she was not aware of the wound until she provided incontinent care. Interview on 07/02/25 at 1:39 PM, ADON B revealed she was working when Resident #49 admitted to the facility. She stated Resident #49 admitted to the facility with a wound on his sacrum and nursing staff were using the standing orders to clean and cover the wound until he was seen by the Wound Care Physician. ADON B stated the admitting nurse was responsible for putting in standing orders in the system and completing a communication form to request wound care for residents to the ADON A. She stated the admitting nurse failed to communicate to ADON A to put Resident #49 on the list to be seen by the Wound Care Physician. ADON B stated LVN M had just resumed her job duty from being on leave and was completing skin assessments on residents when she noticed Resident #49's wound. She stated LVN Y was the nurse assigned to Resident #49 before LVN M returned to work. She stated LVN Y was providing wound care treatment to Resident #49, but it was unknown if it was documented. She stated if the ADON A was not notified of Resident #49's pressure wound then the Wound Care Physician was not notified. She stated the potential risk of not providing any wound care treatment would be infection. Interview on 07/02/25 at 2:00 PM, the DON revealed her expectation for when a resident admitted to the facility was the admitting nurse should complete a skin assessment. If a resident admitted with a wound, the admitting nurse should obtain treatment orders either form the doctor, hospital records or the in-house standing orders and should be put in the system. She stated the nurses should also complete a communication form and provide it to ADON A, and ADON A would place the resident's name on the list to be seen by the Wound Care Physician. The DON stated when Resident #49 was being provided with incontinent care, the resident had a dressing on the sacrum, and it fell off. She stated the nurse put a new dressing on and reported the wound to ADON A. The DON stated the admitting nurse for Resident #49 had not communicated Resident #49 had a wound. She stated she was not aware Resident #49's wound was staged and measured upon admission. She stated wound care treatment was provided to Resident #49; the nurses were using the standing orders, but the standing orders were not put in the system. She stated she was not aware there was no documentation in Resident #49's clinical chart. The DON stated she expected her nurses to put physician orders in the resident clinical chart/system. The DON stated Resident #49's wound was getting better and had no signs of infection. She stated her staff failed to put treatment orders in the system and failed to communicate to ADON A. She stated the Wound Care Physician was not notified until the ADON A was notified of the wound. She stated the potential risk would be infection. Interview on 07/02/25 at 2:06 PM with CNA N revealed she was the CNA assigned to Resident #49 when he was on the 100 Hall. She stated every time she would provide incontinent care to Resident #49, he had a dressing on his bottom. She stated Resident #49 admitted to the facility with a wound. CNA N stated during the morning shift, LVN M would change the wound dressing on Resident #49. She stated Resident #49 always had a dressing on his wound. She stated the nursing staff were aware of Resident #49's sacrum wound. An attempt was made on 07//02/25 at 2:33 PM to interview LVN Y by phone but was unsuccessful. Interview by phone on 07/02/25 at 3:00 PM, the Wound Care Physician stated if a resident admitted with a wound, he expected the Attending Physician or Nurse Practitioner to see the resident and write initial wound care orders, and to add him as an attending. If the resident had hospital orders that included wound orders, staff could follow those orders. ADON A would text him with a new resident's information prior to his next visit. He did not give any standing orders for wound care due to the liability, but he would allow ADON A to start treatment because he had worked with her for many years. He stated he was not aware of Resident #49's wound until he saw him on 6/25/25. He stated all wounds were considered colonized with a bacterium of some form, but that did not mean it was infected. If the wound was not healing, then it would be considered infected. Resident #49's wound was healing so he did not consider it to be infected. Interview on 07/02/25 at 3:13 PM, the Nurse Practitioner revealed she was not made aware of Resident #49's pressure wound when she visited the resident on 06/10/25. She stated she visited Resident #49 and completed an assessment, but she did not inspect the resident's back because she was not aware of the wound. She stated since she was not made aware of the wound no treatment orders were provided. She stated she could not recall the exact date, but she was notified by the DON that Resident #49's wound had worsened and that the Wound Care Physician had been notified and provided treatment orders. She stated when a resident admits to the facility with a wound her expectations were to be notified and for nurses to obtain orders. She stated if a resident had not been seen by the Wound Care Physician or the nurses were not able to get ahold of the Wound Care Physician, the ADON normally would notify her, and she would provide treatment orders. Interview on 07/02/25 at 3:51 PM, the Administrator revealed wound care questions were more of a clinical nursing aspect, but his expectations were for the nurses to assess the wound and notify the Wound Care Physician. The Administrator expected nursing staff to follow treatment orders and to document any care that the resident was being provided with. Record review of facility policy Significant Change in Resident's Status undated reflected the following: It is the policy of this organization that this facility immediate inform the resident, consult with the resident physician, and if knows notifies the resident's legal representative or an interested family when there is: . C. Need to alter treatment significantly (this is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. 4. Deterioration in a resident's health status, where this change: places the resident's life in danger. is associated with a serious clinical complication, e.g., initial development of stage III or stage IV pressure ulcer. When any of the above occurs the attending physician, the resident and/or responsible party and/or legal representative and/or interested family member is notified. Document is made in the Nurses Notes and the Resident Assessment Instrument, and the Comprehensive Care Plan is updated to reflect the changes This was determined to be an Immediate Jeopardy (IJ) on 07/02/25 at 4:02 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 07/02/25 at 4:10 PM. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 07/02/25 at 6:32 PM and reflected the following: Date of IJ Determination: 07/02/2025 Immediate Corrective Actions Taken Physician Notification for Identified Resident As of 07/02/2025, the resident identified in the IJ was immediately assessed by the Director of Nursing. The resident's attending physician and the Wound care Physician were immediately consulted, and updated treatment orders were obtained to address the resident's wound and overall plan of care. Chart Review for Timely Physician Notification A comprehensive audit of all admissions and current residents with significant changes in physical status was completed on 07/02/2025 to ensure physician notification occurred as required. Any instances lacking documented physician notification were immediately corrected by contacting the respective physician and updating the medical records. Immediate Staff Education On 07/02/2025, all licensed nurses received in-service training on: - Recognizing and defining significant changes in resident condition. - The requirements for immediate physician consultation upon identification of significant changes. - Accurate and timely documentation of physician notifications and resulting orders. Staff sign-in sheets and education materials are maintained for verification. Process Changes A Physician Notification Protocol has been implemented requiring nurses to notify the physician within 1 hour of identifying a significant change in a resident's condition, including the development or worsening of pressure ulcers. A physician notification from was created to document: -The date and time change identification. -The date and time of physician notification. -Physician response and orders. admission protocols were updated to require physician notification within 24 hours for all residents admitted with pressure ulcers or other significant health conditions. Ongoing Monitoring The Director of Nursing or designee will conduct daily audits of residents with significant changes in condition to confirm timely physician notification and documentation. Weekly audits of 10% of resident charts will be performed for 3 months to ensure compliance with the physician notification protocol. Quality Assurance and Oversight Physician notification compliance will be a standing agenda item at the facility monthly Quality Assurance Performance Improvement (QAPI) meeting for at least 3 months. Audit results and corrective actions will be reviewed by the Administrator and Medical Director. How the Plan Removes the Immediate Jeopardy Immediate assessment and physician consultation for the identified resident ensures appropriate and timely medical oversight, mitigating current risk. Staff education and protocol changes ensure future prompt physician notification for any significant changes, reducing the risk of delayed treatment. Ongoing audits and oversight confirm sustained complaint, preventing recurrence of the issue and ensuring resident rights are protected. Date IJ was Corrected: We believed the Immediate Jeopardy was removed on 07/02/2025, the date corrective actions were implemented. Ensuring Staff Not Present Received Training All nursing staff who are not present on 07/02/2025 for the in-services training will receive a make-up in-service by the Staff Development Nurse within 5 calendar days of returning to work, and before providing direct resident care. Completing will be tracked on a staff education log. Implementation Date for Physician Notification Protocol: The updated Physician Notification Protocol was implemented on 07/02/2025, the same day as the initial corrective actions. Title of Staff Conducting Audit and In-Service: The Director of Nursing (DON) conducted the comprehensive char audit for physician notifications. The Staff Development Nurse (SDN) provided the in-service training on physician notification requirements. Electronic In-Service Distribution and Acknowledgement: Nursing staff who are not present for in-person in-services will receive the training materials electronically through the facility's secure communication platform within 5 calendar days of returning to work. Staff will be required to review the material and electronically signs and acknowledgements from confirming their understanding. Record of completion and acknowledgements will be maintained by the Staff Development Nurse and made available for surveyor review. In-Service: Recognizing Significant Changes & Physician Notification Objective: Train nursing staff to recognize significant changes in resident condition, promptly notify the physician, and properly document the process to ensure timely treatment and protect resident rights. Agenda: Defining Significant Change - Examples: new/worsening wounds, sudden mental status changes, falls with injury, acute infections, uncontrolled pain. Timeframes for Physician Notification - Immediate vs. urgent vs. routine notification standards - Facility policy on notifying the physician within 1 hour of significant changes. Documentation of Notification - How to complete the physician notification form. - Documenting date/time of change, date/time of call, physician response. Communication Best Practices - SBAR (Situation, Background, Assessment, Recommendation) approach when calling providers. - Tips for effective and concise communication Policy & Procedure Review - Physician notification protocol - Review of facility admission protocols requiring physician notification. Q&A Session Materials: Physician notification form Updated physician notification policy Competency Validation: Staff sign-in sheet Charting exercise: completing a sample physician notification form Electronic In-Service Distribution and Acknowledgement: Nursing staff who are not present for in-person in-services will receive the training materials electronically through the facility's secure communication platform within 5 calendar days of returning to work. Staff will be required to review the material and electronically signs and acknowledgements from confirming their understanding. Record of completion and acknowledgements will be maintained by the Staff Development Nurse and made available for surveyor review. Monitoring of the facility's Plan of Removal included the following: Record review of a facility in-service training report for facility nurses across all shifts dated 07/02/25 reflected the following: Skin Issues on Admission. Protocol: Do a thorough assessment. 1) Document. Initially nurses are not to measure unless you're a wound care certified nurse. 2) Make sure there is a treatment ordered. (Hospital order, standing order or MD/NP order) Fill up a communication form and submit it to the Wound Care Nurse (ADON) for Dr. (Name) (Wound MD) to look at on his next visit. Document everything! Do Skin assessments every week! Notification of MD for worsening wounds if it's not documented it's not done!! Record review of a facility in-service training report for facility nurses across all shifts dated 07/02/25 reflected the following: Accurate and timely wound assessment and documentation. The requirement for immediate physician notification for wounds at admission or with signs of worsening. Proper initiation for treatment orders for wounds. Staff sign-in sheets and education materials are maintained for verification. Record review of the facility QAPI meeting revealed the facility medical director was notified by the director of nurses of the immediate jeopardy via phone while in attendance with the facility administrator on 07/02/25. Record review of the facility admission Wound Assessment Checklist form reflected on 07/02/2025 the form included the name of the resident, date of admission, wound treatment, MD Notified, notes. Record review of the facility Weekly Audit tool blank form revealed it included the date, resident, treatment, and documentation in PCC. Record review of the facility Communication Form revealed it must include information pertaining the resident, new admission/readmission, indicate which department it applied to and to include message/comments. Record review of the facility Physician notification Form undated, reflected staff should provide the date and time change identification, the date and time of physician notification and Physician response and orders. Record review of the Facility SBAR (Situation, Background, Assessment, Recommendation) reflected staff should document when a change of condition occurred and when the provider was notified. Record review of Resident #49's progress noted dated 07/02/25 by the DON reflected Pressure wound on sacrum assess with wound MD. Stage 4 full thickness. Wound size (LxWxD) 4.0x3.5x0.8 cm Surface area = 14, exudate - Moderate serous (clear fluid drainage from a wound). Wound has improved since last visit as evidence by decrease surface area. No signs of infection noted. Treatment review with physician. No changes made at this time. Resident remains on air mattress. No c/o pain but instructed to call the nurse if he has pain. PRN pain medication ordered. Dietician made aware of the nutritional consult for the resident. Staff instructed to turn and reposition resident Q 2 hours. Call light within reach. Record review of Skin Assessments revealed they were completed on 07/02/25 for all 73 residents. The assessments indicated any skin concerns and the location of the skin concerns. Record review of a facility in-service training report for facility nurses across all shifts dated 07/03/25 reflected the following: On wound assessment on admission, the Admitting Nurse is required to document the following: 1. Wound measurements. 2) Notification of the physician w/in 24 Hrs. of identification. 3) Initiation of wound treatment per