Warren Barr South Loop

health records. V2 said all orders entered will show in the resident's TAR and the wound care nurse will document or sign the TAR if treatment is done. V2 said that if it's not signed off, it's not an active order. V2 further stated that skin care plan is revised as needed and if any new skin issue occurs. It needs to be revised based on the current condition of the resident. V2 said that the care plan is resident specific and individualized, and the purpose of the care plan is to make sure staff is following the plan of care of the residents. V2 stated that the resident's needs, conditions, outcomes, and interventions should all be included in the care plan.The facility's Skin Care Regimen and Treatment Formulary policy dated 7/3/25 documents in part: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown.

Charge nurses must document in the Electronic Health Record any skin breakdown upon assessment and identification.

Furthermore, treatment must be obtained from the patient's physician. TAR Nursing Documentation includes: a) Routine wound care completed by wound care nurse or designee. b) Ostomy care completed by the wound care nurse or designated nurse.

Refer any skin breakdown to the skin care team and physician including wound physician/NP for further review and management as indicated.The facility's Care Plan policy dated 6/30/25 documents in part: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations.

After the comprehensive assessment (state/federal-required MDS) is completed, the facility will put in place person-centered care plans outlining care for the resident within 7 days.

These will be periodically reviewed and revised by a team of qualified person after each assessment.

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