**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 9 residents (Resident #1) reviewed for quality of care. 1. The facility failed to follow up with a cardiologist appointment on 2/25/25 for Resident #1 for 36 days, from 2/25/25 to 4/1/25. 2. The facility failed to ensure Resident #1 received a vascular surgeon referral when the order was given on 02/12/25, which resulted in the development of gas gangrene (rare but highly lethal and potentially life-threatening bacterial infection that destroys muscle tissue, blood cells, and blood vessels producing a gas that causes tissue death and a foul smell) and an above-the-knee amputation (surgical removal) of his right leg on 04/02/25. An immediate jeopardy (IJ) was identified on 05/04/25 at 11:00 AM. The IJ template was provided to the facility on [DATE] at 11:15 AM. While the IJ was removed on 05/05/25 at 5:32 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems on entering physician orders, scheduling appointments or referrals, and ensuring documentation of missed appointments. These failures could place residents at risk of receiving a delay in treatment or services, serious injury, harm, disfigurement, or death. The findings included: Resident review of Resident #1's face sheet printed on 4/11/25 indicated Resident #1 was an [AGE] year-old male who admitted on [DATE] and discharged on 04/01/25 and did not return. Record review of admission MDS assessment dated [DATE] indicated Resident #1 had clear speech, was able to make self-understood and had the ability to understand others. He had BIMS score of 12 out of 15 indicating he was moderately impaired cognitively. The MDS assessment indicated Resident #1 did not exhibit rejection of care. The MDS assessment indicated Resident #1 required substantial to moderate assist with most ADLs. The MDS assessment indicated Resident #1 had no unhealed pressure ulcer/injuries, no venous and arterial ulcers present and no foot problems. Record review of Resident #1's revised care plan dated 01/31/25 revealed that the Resident #1 as being care planned for skin breakdown: At risk/actual. Related to: History of Cardiovascular Disease. Evidence By: Severe score 6-9 for Pressure Ulcer risk, Confined to bed and/or chair most of the time, extensive bed mobility and total transfer assist. Goal: Resident #1 would maintain clean and intact skin for the next 90 days. - Measures would be taken to prevent skin breakdown over the next 90 days and open area will be healed over the next 90 days. Interventions: -Assist Resident #1 to turn and reposition frequently. - Inspect skin daily with care and bathing and report any changes to charge nurse. - Keep skin clean, dry, and free of irritants. - Treatments and dressings as ordered per physician. Record review of after visit summary also known as the admitting orders printed on 1/24/25 indicated Resident #1 was in the hospital from [DATE] to 1/24/25 due to malignant hypertensive urgency (high blood pressure that requires treatment to bring it down). Follow up appointment with Cardiologist on Tuesday February 25, 2025, at 10:40am (arrive by 10:25am). Record review of an undated physician's orders report printed on 4/11/25 indicated Resident #1 had diagnoses including hypertensive urgency (a clinical situation in which blood pressure is very high with minimal or no symptoms, and no signs or symptoms indicating acute organ damage), unspecified skin changes, muscle weakness (generalized), unspecified diastolic (congestive) heart failure, and essential (primary) hypertension. The physician order's report further revealed the following treatment orders: 1. Dated: 02/06/25 to 02/25/25 - Cleanse right heel with normal saline, pat dry, apply xeroform, apply dry protective dressing, and wrap with Kerlex daily on the 6 AM - 2 PM shift. 2. Dated: 02/06/25 to 02/25/25 - Cleanse right great toe with normal saline, pat dry, apply xeroform, apply dry protective dressing, and wrap with Kerlex daily on the 6 AM - 2 PM shift. 3. Dated: 02/06/25 to 04/05/25 - Skin prep wipes twice daily to the right lateral ankle. 4. Dated 02/06/25 to 04/05/25 - Skin prep wipes twice daily to the right second toe. 5. Dated 02/06/25 to 04/05/25 - Skin prep wipes twice daily to the right lateral foot. 6. Dated 02/25/25 to 04/05/25 - Skin prep wipes twice daily to the right first toe. 7. Dated 02/25/25 to 04/05/25 - Skin prep wipes twice daily to the right heel. Record review of the wound care note, dated 02/06/25, reflected Resident #1 presented with wounds on his right heel, right distal lateral foot, right first toe, right second toe, and right proximal lateral foot. The exam portion reflected the wound care physician was unable to palpate the right pedal (foot) pulses. The recommendations included a right lower extremity arterial doppler. Record review of Resident #1's radiology report from a doppler scan, completed on 02/10/25, reflected The blood flow velocity (movement) is decreased in the arteries of the right lower extremity with a monophasic flow (decreased blood flow), likely moderate inflow disease (type of peripheral artery disease that refers to blockage in the arteries), outflow disease (refers to blockage in the lower extremity affecting the femoral artery and pedal (foot) vessels), and severe arterial disease (a vascular disorder that causes abnormal narrowing of arteries other than those that supply the heart or brain). Record review of the physician progress note, dated 02/12/25, reflected Resident #1 was seen in the facility. The progress note reflected Resident #1 had possible peripheral vascular disease (a vascular disorder that causes abnormal narrowing of arteries other than those that supply the heart or brain) and lower extremity wounds. The plan included Vascular Surgery referral. Record review of the wound care note, dated and signed by the Wound Care Doctor on 02/17/25, reflected Resident #1 had a total of 5 wounds to his right foot. A deterioration of the arterial wound to his right first toe was documented. A Vascular Surgeon referral was recommended. The wounds and measurements as follows: 1. right heel measured 2 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 4 cm x 2 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right second toe measured 1 cm x 0.4 cm x not measurable due to the presence of nonviable tissue and necrosis. 4. right distal, lateral foot measured 1.7 cm x 1.5 cm x not measurable due to the presence of nonviable tissues and necrosis. 5. right proximal, lateral foot measured 0.5 cm x 0.5 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of the wound care note, dated and signed by the Wound Care Doctor on 02/24/25, reflected Resident #1 had a total of 5 wounds to his right foot and was awaiting vascular referral for pad with dry gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection). The wounds and measurements as follows: 1. right heel measured 2 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 4 cm x 2 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right second toe measured 1 cm x 0.4 cm x not measurable due to the presence of nonviable tissue and necrosis. 4. right distal, lateral foot measured 1.5 cm x 1.5 cm x not measurable due to the presence of nonviable tissues and necrosis. 5. right proximal, lateral foot measured 0.5 cm x 0.5 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of the wound care note, dated and signed by the Wound Care Doctor on 03/03/25, reflected Resident #1 had a total of 5 wounds to his right foot. The not reflected Resident #1's wound to his right distal lateral foot was not at goal. The note reflected Resident #1 was awaiting a vascular referral. The wounds and measurements as follows: 1. right heel measured 2 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 4 cm x 2 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right second toe measured 0.8 cm x 0.4 cm x not measurable due to the presence of nonviable tissue and necrosis. 4. right distal, lateral foot measured 2 cm x 1.5 cm x not measurable due to the presence of nonviable tissues and necrosis. 5. right proximal, lateral foot measured 0.5 cm x 0.5 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of Resident #1's physician's telephone order dated 3/6/25 indicated an order for vascular consult referral for previous vascular issues. Diagnosis: Unspecified skin changes. Record review of the wound care note, dated and signed by the Wound Care Doctor on 03/10/25, reflected Resident #1 had a total of 4 wounds to his right foot. The note reflected Resident #1's wound to his right heel was not at goal. The note reflected Resident #1's wound to the right lateral distal foot was worsening. The note reflected Resident #1 was awaiting a vascular referral. The wounds and measurements as follows: 1. right heel measured 3 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 4 cm x 2 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right second toe was resolved. 4. right distal, lateral foot measured 4 cm x 1.5 cm x not measurable due to the presence of nonviable tissues and necrosis. 5. right proximal, lateral foot measured 0.5 cm x 0.5 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of the wound care note, dated and signed by the Wound Care Doctor on 03/17/25, reflected Resident #1 had a total of 4 wounds to his right foot. The note reflected Resident #1's wound to the right lateral distal foot and the right proximal lateral foot were worsening. The note reflected Per patient, saw vascular last week. Will check on note. The wounds and measurement as follows: 1. right heel measured 3 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 4 cm x 2 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right distal, lateral foot measured 6 cm x 4 cm x not measurable due to the presence of nonviable tissues and necrosis. 4. right proximal, lateral foot measured 1 cm x 1 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of the wound care note, dated and signed by the Wound Care Doctor on 03/24/25, reflected Resident #1 had a total of 4 wounds. The note reflected Resident #1's wound to the right first toe was worsening. The note reflected Resident #1 was to see vascular next week. The wounds and measurements as follows: 1. right heel measured 3 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 6 cm x 4 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right distal, lateral foot measured 6 cm x 4 cm x not measurable due to the presence of nonviable tissues and necrosis. 4. right proximal, lateral foot measured 1 cm x 1 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of the wound care note, dated and signed by the Wound Care Doctor on 03/31/25, reflected Resident #1 had a total of 4 wounds. The note reflected Resident #1 was awaiting a vascular referral. The wounds and measurements as follows: 1. right heel measured 3 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 6 cm x 4 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right distal, lateral foot measured 6 cm x 4 cm x not measurable due to the presence of nonviable tissues and necrosis. 4. right proximal, lateral foot measured 1 cm x 1 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of Resident #1's weekly wound report from 1/24/2025 to 4/11/2025 indicated he was treated by the treatment nurse on the following dates: 2/6/25, 2/10/25, 2/17/25, 2/14/25, and on 3/3/25. Record review of Resident #1's treatment administration records dated March 2025 and April 2025 indicated wound care to Resident #1's right first toe, right second toe, right heel, right lateral ankle, right lateral foot was last completed on 03/31/25. Record review of Resident #1 transfer form dated 4/1/25 indicated he was transferred to a local hospital for signs and symptoms of infections/fever and wound deterioration/treatment. Record review of Resident #1 hospitalist admission note dated 4/1/25 indicated Resident #1 was sent from local nursing home for gangrene foot. Also, indicated Resident #1 was very unkempt and very odorous smelling in general and had a very gangrenous mummified right foot. Record review of Resident #1 hospital vascular surgery note dated 4/2/25 indicated the following: Reason for Consultation: Right foot gangrene; History of present illness: [Resident #1] was an [AGE] year-old male with history of atrial fibrillation, hyperlipidemia, and hypertension who presented to the emergency department yesterday via ambulance from nursing home for right lower extremity wounds. It appeared that the wounds had been there for some time with extensive gangrene to right foot and lower leg . Vascular surgery was consulted for major amputation as right foot was not salvageable. [Resident #1] did not take any blood thinning medications. Record review of after visit summary printed on 4/8/25 indicated Resident #1 was in the hospital from [DATE] to 4/8/25 for above the knee amputation due to gangrene of the right foot. During an interview on 4/11/25 at 3:27pm, LVN L said that she was the admitting nurse for Resident #1 and responsible for entering his orders. She said that she had finished the new admission paperwork and entered the orders and appointments as outlined in the after-visit summary from the admitting hospitals. LVN L said that she was not very proficient with the new admission process and could not remember the admission paperwork for Resident #1. However, she said that if a cardiologist appointment was listed in the after-visit summary for Resident #1, it should have been recorded in the scheduler for the transportation driver. She indicated that the ADONs were responsible for reviewing the new admission orders and paperwork after the admission to ensure their accuracy. LVN L also said that the ADON on the second floor at that time was no longer employed there. During an interview on 4/14/25 at 3:34pm and at 5:54pm, DON O said she was unaware that Resident #1 had missed his cardiology appointment on 02/25/25, as well as the vascular appointment on 03/26/25, until the information was brought to her attention on 04/11/25. DON O stated the charge nurse assigned to the admitting resident's hall was responsible for entering the admission orders and scheduling the appointments in their system. During the morning meetings, department heads reviewed all new admissions from the previous day, and she did not know how the ball got dropped with Resident #1. DON O said she had access to the cardiologist's company system and was able to verify that Resident #1 indeed missed the appointment on 02/25/25, which was not rescheduled due to the failure to enter it at the time of admission, and the oversight was not identified until it was too late. DON O indicated Resident #1 maintained stable vital signs with no acute cardiac events of record and was followed by [their] in-house physician, NP and wound care doctor. She expressed her expectation was the Transportation Driver would have taken Resident #1 to the appointment on 03/26/25, as he was not a nursing staff member and was not qualified to make that decision. Additionally, she expected the nurse to document any missed appointments, reschedule them, and notify her, which had not occurred. DON O said she expected for the Treatment nurse to follow up on all orders given by the wound doctor because she was the only staff who had access to the wound doctor's notes. She said the Treatment nurse should be documenting on Resident #1's chart and followed up with Resident #1's vascular consult. During an interview on 4/11/25 at 1:28pm, LVN L said that she was the charge nurse for [NAME] Hall and the left side of North Hall during the 6am-2pm shift. She indicated that Resident #1 was located on her hall and had a scheduled vascular surgeon appointment on an unspecified date in March 2025, which was missed because Transportation Driver P was impatient and refused to wait for CNA M to wash and clean Resident #1's face. LVN L said Resident #1 was positioned in a wheelchair near the nurse station, and when Transportation Driver P arrived to pick up Resident #1, CNA M was in the process of preparing to clean his face. At that moment, Transportation Driver P informed both her and CNA M that he did not have time to wait for the cleaning and subsequently decided it was too late to take Resident #1 to the appointment. LVN L attempted to explain to Transportation Driver P that most appointments typically allow a 15-minute grace period and expressed her belief that Resident #1 could have arrived on time since the appointment location was not far from the facility. However, Transportation Driver P dismissed her comments and left without taking Resident #1. LVN L mentioned she called to reschedule the appointment but was unable to provide a new date nor confirm the rescheduling had occurred, and she stated she did not document this information in Resident #1's chart. LVN L stated she did not remember informing anyone about Resident #1 missing the scheduled appointment and she should have documented it but failed to do so. During an interview on 4/11/25 at 1:35pm, CNA M said she worked as the NA for [NAME] Hall during the 6 am to 2 pm shift. She said Resident #1 resided on her hall and had a scheduled appointment on an unspecified date in March 2025. Resident #1 was unable to attend because Transportation Driver P refused to wait for her to clean Resident #1's face prior to the appointment. CNA M asserted the cleaning would not take long and communicated this to Transportation Driver P but, he determined it was too late to transport Resident #1 to the appointment. LVN L informed the driver Resident #1 still had sufficient time to arrive, but Transportation Driver P chose to walk away and instructed them to reschedule the appointment. CNA M stated she was unaware if Resident #1's appointment had been rescheduled. During an interview on 4/14/25 at 2:49pm, Transportation Driver P said he worked Monday-Friday from 7am to 3pm and rotated weekends since November 2024.He stated he received minimal on-the-job training when he first began his role. The limited training he did receive was from the previous driver he replaced, who provided instruction for approximately four days, after which he learned independently. Transportation Driver P recalled the incident involving Resident #1, LVN L, and CNA M. He stated on that morning, he had several back-to-back appointments. Due to the type of van, he operated, he could only transport one resident at a time if they were in a wheelchair, as that was the maximum capacity. He informed an unidentified nurse to ensure that Resident #1 was prepared for his appointment, given his busy schedule. Transportation Driver P could not recall the exact time, he attempted to pick up Resident #1 twice, but on both occasions, the resident was not ready. During the first attempt, Resident #1 was still in bed in his room, prompting him to notify the nurse to have the resident prepared for his return. After taking another resident to an appointment, he returned to the facility for Resident #1, only to find that CNA M had still not prepared him. He was informed they needed a few more minutes to clean Resident #1's face, but the process was taking longer than anticipated. When he returned to check on Resident #1 again, he found that the resident was still not ready. He then informed LVN L that Resident #1 would not make it to his appointment on time, as the time required to prepare the resident, transport him down the elevators, and secure him in the van would exceed the 15-minute grace period. Transportation Driver P stated that LVN L was responsible for rescheduling Resident #1's missed appointment, but he did not recall seeing a new appointment scheduled for the resident. He expressed that he did not believe the situation was his fault. During an interview on 4/14/25 at 6:21pm, the Treatment Nurse said that the wound doctor had instructed her to arrange an appointment for Resident #1 with the vascular specialist, which was her duty. She said the Vascular Consult was recorded on 3/6/25, and although she attempted to schedule the vascular appointments for Resident #1, her efforts were unsuccessful, and she failed to document those attempts in Resident #1's medical record. The Treatment Nurse could not clarify the reason for the 14-day delay between 3/6/25 and 3/20/25 in scheduling the vascular appointment. She said her last assessment of the Resident #1's wound occurred on Friday, 03/28/25, at which point there was no odor present, and Resident #1 had wounds located only on the right foot's side and heel, with indications that healing was taking place. Treatment nurse said herself and the wound doctor examined Resident #1's right foot the following Monday, 03/31/25, they detected an odor and noted a deterioration in the condition of the resident's wounds, which had begun to spread to the toes. She stated she only became aware of the situation on 3/31/25 when the Wound Doctor inquired about the outcome of Resident #1's vascular appointment scheduled for 3/26/25. Upon reviewing Resident #1's chart, she learned from an unidentified nurse that Resident #1 had missed the appointment due to transportation issues. The Treatment Nurse stated her responsibility to follow up on the wound doctor's orders, which she failed to do in this case. She did not reschedule the missed appointment because she was unaware of it until after the fact, and by the time she realized the oversight, Resident #1 was sent to the hospital the following day, 4/1/25. During an interview on 4/14/25 at 12:46pm, the Wound Care Doctor said Resident #1 had significantly inadequate blood flow, and the poor blood flow affected the healing, and the outcome of amputation might not have changed even with going to the appointment. During an observation and interview on 4/12/25 at 1:56pm, Resident #1 was at a different facility with an above-the-knee amputation on the right leg, accompanied by approximately 22 to 24 staples. He expressed no complaints or concerns regarding the previous facility. He mentioned feeling somewhat anxious at the hospital when informed about the impending loss of his leg, but he desired relief from pain and instructed the medical team to proceed with necessary actions. Resident #1 reported that he was free from pain. During an interview on 05/03/25 at 10:02 AM, CNA M stated she worked with Resident #1 regularly. CNA M stated Resident #1's wounds developed an odor prior to being sent to the hospital. CNA M stated she never saw the wounds because they were wrapped up most of the time. CNA M stated she had reported Resident #1's wound odor to multiple charge nurses and they handled it. CNA M was unable to remember when the odor started but stated it was approximately 1 week before he was sent to the hospital. During an interview on 05/03/25 at 10:22 AM, LVN L stated she did not recall any discoloration, edema, or wounds to Resident #1's legs when he admitted to the facility. LVN L stated she remembered Resident #1 developing a wound on his heel but was unable to remember the wound. LVN L stated on 04/01/25 CNA M reported that Resident #1 had an odor to his wounds. LVN L stated CNA M had reported she had told other nurses about the odor. LVN L stated Resident #1 was in therapy when CNA M reported the odor, so she requested Resident #1 be laid down after lunch so she could assess the wound. LVN L stated before she was able to assess Resident #1's wounds, LVN J and ADON D had assessed Resident #1 and sent him to the hospital for evaluation. LVN L stated she had not seen Resident #1's foot wounds for a couple of weeks because the Treatment Nurse was completing the treatments. During an interview on 05/03/25 at 11:01 AM, LVN J stated she was the treatment nurse at the facility. LVN J stated she completed treatments Monday through Friday unless she was working the floor. LVN J stated on the weekends and when she worked the floor the charge nurses were responsible for completing the treatments. LVN J stated on 02/06/25 she was alerted by therapy via a communication app that Resident #1 had some blisters to his right foot. LVN J stated the wound care doctor was in the facility, so she had him assess the wounds. LVN J stated the wound care doctor looked at the wounds, ordered treatments and an arterial doppler study. LVN J stated the wounds started off as fluid filled blisters than with treatment initiated, they started to dry out. LVN J stated the wounds appeared arterial or vascular from the beginning, which was why a doppler study was ordered. LVN J stated Resident #1 had no discoloration to his foot in the beginning. LVN J stated she was unaware Resident #1 had no palpable pedal pulses to his right foot, until she read the wound care doctors notes. LVN J stated she communicated the results of the doppler to the wound care doctor and he ordered a vascular surgeon referral. LVN J stated the DON had asked ADON Q to make the appointment, but he did not. LVN J stated after a few weeks had passed it was discovered that ADON Q had not made the appointment. LVN J stated she had made a few calls to attempt to schedule the appointment, but they had not gotten back to her, and she did not follow up. LVN J stated Resident #1's wounds started off as fluid-filled blisters, then dried and became black. LVN J stated Resident #1's feet were normal color and had no problems when he first admitted . LVN J stated LVN R reported Resident #1 had a deterioration of his wounds the day before he was sent to the hospital, but she was off and told her she would handle it tomorrow. LVN J stated pedal pulses were assessed each time the wound care doctor was at the facility. LVN J stated no pedal pulses to his right foot were able to be felt. LVN J stated the wound care doctor followed up with her every week regarding the vascular referral appointment and she would follow up with nursing management. LVN J stated Resident #1's right foot have no palpable pedal pulses, indicated there was no blood flow to that foot. LVN J stated when there was no blood flow, there was no blood circulation. LVN J stated complications of no blood flow to the foot or tissues included: hardening of the foot, increased risk of infection, and loss of limb. LVN J stated the vascular appointment and cardiologist appointment could have prevented the loss of his leg. LVN J stated she was responsible for following up with the wound care doctors' orders. LVN J stated she pulled an order report every day to review order changes for wounds. During an interview on 05/03/25 at 12:21 PM, the Wound Care Doctor stated Resident #1 presented with fluid-filled blisters to his right foot and there was no pulses present to the right foot. The Wound Care Doctor stated he believed it could have been arterial, so he ordered a doppler study. When the doppler study results were received he then ordered a vascular referral. The Wound Care Doctor stated he followed up with the referral status each time he was at the facility. The Wound Care Doctor stated the facility reported multiple issues which caused a delay in the appointment. The Wound Care Doctor stated Resident #1 had poor circulation from the first day he was treated, which was why the priority for his treatment was getting the Vascular Surgeon referral. The Wound Care Doctor stated his main goals for his wound care was to prevent infection and keep it dry and scabbed over. The Wound Care Doctor stated complication of residents with vascular disease and wounds included: the wounds would not heal, the wounds were more prone to infection, and the wounds would have progressively worsened, which could lead to gangrene. During an interview on 05/03/25 at 1:01 PM, ADON Q stated he worked at the facility until March 2025. ADON Q stated he was the ADON at the facility. ADON Q stated he was unable to remember Resident #1 or anything to do with his care. ADON Q stated if a new admission arrived at the facility with a referral or an appointment the charge nurse would have looked at the paperwork and then placed it in the DON's box for review. ADON Q stated the Treatment Nurse was responsible for making the appointments or referrals requested from the Wound Care Doctor. ADON Q stated he was not involved in the wound care processes. ADON Q stated if a referral or specialist appointment was wound related LVN J would have made the appointment. During an interview on 05/03/25 at 2:12 PM, LVN R stated she had noticed a decline in Resident #1's wounds the day before he was sent to the hospital, which was a weekend. LVN R stated LVN J was at the facility brining some treatment supplies, when she notified her that Resident #1's wound looked worse and had an odor. LVN R stated LVN J stated she would assess the wound tomorrow during her normal working hours. LVN R stated she did not report the wound decline or odor to the doctor but thought the treatment nurse would have handled it. Record review of revised physician order policy dated 1/12/20 indicated, Policy: 1. The licensed nurse will receive and transcribe the physician's orders according to Practice Guidelines. 2. The licensed nursing staff will provide residents with medications and treatments as ordered by his/her physician . Record review of an undated DON O job description indicated, .Job Summary: The Director of Nursing position is to direct the provision of nursing services to facility residents. DON O will oversee the development and implementation of resident care plans and assure the provision of the best available quality of care for facility residents. Key Responsibilities (list specific job duties): A. Maintains appropriate nursing service obligations, goals, and standards of nursing practices consistent with licensure requirements and the Nurse Practice Act. B. Oversees, directs, and coordinates nursing staff to provide proper resident care consistent with standard nursing practices. C. Participates in screening prospective residents as well as ongoing assessment of resident needs . Record review of an undated charge nurse job description indicated, .Job Summary: The Charge Nurse position participates in and oversees the assurance of the provision of resident care services consistent with accepted standards of care and as prescribed by the attending physician. This position also provides direct resident care and assigns duties to LVN's and/or Nursing Assistant as appropriate. Key Responsibilities (list specific job duties): A. Assure resident care according to accepted standards. B. Observes, assesses, and reports resident condition/changes and documents. C. Administers medication/treatments as prescribed. D. Receive, transcribe, implement physician's orders . This was determined to be an Immediate Jeopardy (IJ) on 05/04/25 at 11:00 AM. The Administrator and DON were notified. The Administrator was provided the IJ template on 05/04/25 at 11:15 AM. The following plan of removal [TRUNCATED]