**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.R9's Care Plan, dated 10/23/2024, documents that R9 has the potential for alteration in skin condition r/t (related to) impaired mobility/incontinence. It continues Goal: The Resident will not develop a skin injury through next review. Interventions: Administer medications as ordered and monitor for adverse effects. Administer Treatments as ordered. Weekly skin checks. It also documents the resident has the potential for pressure injury development r/t (related to) immobility / incontinence. It continues Administer medications as ordered and monitor for adverse effects. Administer treatments as ordered. R9s Minimum Data Set, dated [DATE], documents that R9 is cognitively intact, has 2 stage III pressure ulcers, and does not reject care. R9's Medication/Treatment Administration Record (MAR/TAR), dated January 2025, documents Cleanse coccyx with generic wound cleanser, pat dry, skin prep periwound, allow to dry, apply hydrocolloid 3 x (times) weekly, MWF (Monday, Wednesday, Friday), and PRN (as needed). every day shift every Mon, Wed, Fri for wound -Start Date 12/06/2024 0700 -D/C (discontinue) date 02/11/2025. There is no documentation on the TAR that R9's treatment was completed on 1/20, 1/27 and 1/29/2025. R9's Progress Notes, dated 2/11/2025 10:31 PM, documents Skin/Wound Note Text: Resident was seen on 2/10/25 by V24, Wound Nurse, for her wounds. She has a stage 3 on her coccyx with moderate serosanguinous drainage noted. It has 100% gran (granulation) tissue. Tx (treatment). of collagen and bordered gauze dressing daily and PRN (as needed). Prealbumin to be done by next visit. R9's Medication/ Treatment Administration Record, dated February 2025, documents Cleanse coccyx with generic wound cleanser, pat dry, skin prep periwound, allow to dry, apply hydrocolloid 3x weekly, MWF, and PRN. every day shift every Mon, Wed, Fri for wound -Start Date 12/06/2024 0700 -D/C Date 02/11/2025 2146. There is no documentation on the MAR/TAR that this treatment was completed on 2/5/25. R9's Medication/Treatment Administration Record, dated February 2025, cleanse coccyx with generic wound cleanser, pat dry, skin prep periwound, allow to dry, apply collagen and bordered gauze daily and PRN. every day shift for wound. -Start Date 02/12/2025 0700. There is no documentation R9 received this treatment on 2/19, 2/21, and 2/22/25. R9's Progress Note, dated 2/19/2025 at 8:36 PM, documents Skin/Wound Note Text: Resident was seen on 2/17/25 by (V24), Wound Nurse, for her wounds. She has a stage 3 on her coccyx with moderate serosanguinous drainage noted. It has 100% necrotic tissue. Tx. (treatment) of Santyl, calcium alginate and bordered gauze dressing daily and PRN. IDT, PCP, and resident updated. R9's Medication/Treatment Administration Record, dated February 2024, documents Santyl Ointment 250 UNIT/GM (Collagenase) Apply to coccyx topically everyday shift for wound Cleanse coccyx with generic wound cleanser, pat dry, skin prep periwound, allow to dry, apply Santyl, calcium alginate and bordered gauze daily and PRN. -Start Date 02/18/2025 0700 -D/C Date 02/23/2025 1802. There was no documentation that R9 received this treatment on 2/19 and 2/22 and 2/23/25. On 4/3/25 at 2:20PM, V4, (Regional Nurse Consultant), stated there have been changes since the change of ownership. V4 stated staffing is a problem, they have gotten 2-3 admissions, and management doesn't come out to help. V4 stated the wounds have gone downhill. V4 stated they have a full-time wound nurse, but she only does rounds with the wound doctor once a week, she doesn't do the wound care any other time, not even the pressure ulcers, which would help. V4 stated that with short staff this causes things to be missed. On 4/9/2025 at 4:05 PM V1, Administrator, stated that she would expect the nurses to sign off the medication/treatment record when the treatment is completed. The facility's Medication Administration policy, dated 5/2025, documents that Policy I. LEVEL OF RESPONSIBILITY: Licensed nurse (RN, LPN) may: a) prepare, b) administer, and c) record the administration of medications (prescription ointments are considered medicines) Medications shall always be prepared, administered, and recorded by the same licensed nurse or CMA. Documentation of medication administration is recorded on the Medication Administration Record (MAR.) or Treatment Record and includes the date, time, time, and initials of the licensed nurse or CMA who administered the medication. II. ADMINISTRATION OF MEDICATIONS: Medications must be administered in accordance with a physician's order, e.g., the right resident, right medication, right dosage, right route, and right time. The facility's Pressure Ulcer Prevention policy, dated 5/2025, documents that the purpose is to prevent and treat pressure sores/pressure injury. Based on interview and record review, the facility failed to assess and identify a residents impaired skin integrity, failed to document weekly skin assessments, and failed to follow physician orders for pressure ulcer treatment for 3 of 4 residents (R7, R9, R14) reviewed for pressure ulcers in a sample of 29. This failure resulted in R7 developing pressure ulcer that upon identification was classified as an unstageable/stage 4, required significant debridement on multiple occasion, osteomyelitis and 7-day hospital stay. The Immediate Jeopardy began on 2/27/25 when the facility failed to assess and treat a high-risk resident who was readmitted on [DATE] without any pressure injuries, resulting in R7 developing a facility acquired unstageable/stage 4 pressure ulcer that was identified on 02/27/25 on her ischial tuberosity with infection present. V6, Crisis Administrator, V32, Mobile Administrator, and V2, Director of Nurses was notified of the Immediate Jeopardy on 4/30/25 at 2:16 PM. The surveyor confirmed by record review and interview that the Immediate Jeopardy was removed on 5/2/2025 but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: 1.R7's Face sheet documents R7 was admitted on [DATE] with a readmission date of 4/7/25 with diagnoses of Type 2 Diabetes, other symptoms and signs involving cognitive function and awareness, hydronephrosis, enterococcus, pulmonary embolism, sacrococcygeal disorders, not elsewhere classified, and presence of urogenital implants. R7's Braden scale dated 9/20/2022 obtained during admission assessment, documented a score of 17 indicating R7 is at risk for developing pressure ulcer. R7's Minimum Data Set (MDS) dated [DATE] documented that R7 is moderately cognitively impaired, no pressure ulcer/injury on admission. The MDS further documents R7 is at risk of developing a pressure ulcer with skin treatments recommended including a pressure reducing device for chair and for bed. R7 is at risk for developing a pressure injury and had no pressure ulcers present. R7's MDS dated [DATE] documents R7 remains at risk for pressure injury but currently has no unhealed pressure wounds. R7's MDS dated [DATE] documented that R7 is severely cognitively impaired, dependent on staff for all activities of daily living (ADL)'s. The MDS documents R7 is incontinent of bladder and bowel and is at risk for pressure ulcers and has one stage 4 pressure ulcers. R7's MDS dated [DATE] documents R7 as moderately impaired cognition and dependent on staff for all ADL's, including turning and repositioning. The section regarding skin conditions documented yes to the question resident has pressure ulcer/injury, a scar over bony prominence, or non-removable dressing, unhealed pressure ulcer. R7's MDS dated [DATE] documents R7's cognition as (left blank), short-term memory ok, no behaviors or inattention, disorganized thinking or altered level of consciousness. R7's MDS further documents R7 is dependent on staff for ADL's, including turning and repositioning. R7's Social Service Note dated 3/6/25 documented R7 has clear speech, understands verbal content with severe impairment memory to recall after 5 minutes. R7's Care Plan dated 10/4/22 documented R7 has the potential for pressure injury development related occasional incontinence and decreased mobility. The goal is the resident will have intact skin, free of redness, blisters, or discoloration. Interventions include to apply skin barrier as needed, educate the resident and family on the causes of skin breakdown, educate the resident/family on the importance of change in position for prevention of pressure injuries, encourage appropriate hydration, encourage increased activity, if the resident refuses positioning, talk with the resident regarding the importance of positioning, maintain clean and dry skin, monitor nutritional status, and document/report changes in skin appearance and color. R7's care plan dated 12/11/2024 documents a potential for pressure injury development. The goal is that she will have intact skin and be free of open areas related to pressure. The interventions include air loss mattress with safety cover bolsters, air pressure redistribution, administer treatments as ordered, assist with position changes on rounds, barrier cream as directed, elevate/float heels while in bed, encourage to avoid lying or sitting on affected area, offer toileting assistance before and after meals, requires pressure relieving reduction devices on bed and chair. R7's Shower sheet dated 2/3/25 documented dry flaky skin but no wounds. R7's Shower sheet dated 2/9/25 documented no wounds. There is no other documentation in R7's Clinical records of R7's skin assessment. R7's progress notes dated 2/27/25 at 10:57 am documented a Certified Nursing Assistant (CNA), came to nurse this morning, and notified nurse of a right-side coccyx wound/ulcer. Nurse went in to see the coccyx, cleaned it, and covered it. wound nurse notified and informed to look at it. change in condition assessment completed and doctor as well a family updated. R7's progress notes dated 2/27/25 The Change in Condition (CIC) documented a skin wound. The skin status evaluation documented a pressure ulcer/injury. R7 was reported to have pain with the wound. Nursing observations, evaluation, and recommendations are open wound/ulcer on coccyx. R7's Situation, Background, Assessment, Recommendation (SBAR) Summary for Providers dated 2/27/25 at 10:25 AM documents Situation: The Change in Condition/s reported on this CIC Evaluation are/were Skin wound or ulcer. R7's Wound Assessment Details dated 2/27/25 documents: site left ischial tuberosity, active, pressure, ulceration, facility acquired, unstageable, tissue: necrotic soft, adherent 100%, probable decline, size: 5.5 centimeters (cm) x 6.5cm x 0cm, area: 35.75cm, exudate: moderate serosanguineous, odor: yes, signs of infection present: unable to determine. R7's Specialized Wound Management Physician Notes dated 3/3/25 document Wound Evaluation and Management Summary. Chief complaint: R7 has a wound on her left ischium and a rash. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today .Past Medical History: atherosclerotic heart disease of native coronary artery with angina pectoris, essential(primary) hypertension, anemia, hyperlipidemia, Type 2 Diabetes mellitus with diabetic neuropathy. Genitourinary- intermittent incontinence, appetite fair, supplements none, no medication found to be affecting wound healing in clinical context. Oriented to person, place, time, and situation, calm and cooperative. Etiology- pressure, MDS 3.0 stage: 4, Duration: greater than one day, Wound size: 9.5 x 7 x not measurable cm, Depth: unmeasurable due to presence of nonviable tissue and necrosis, Surface area: 66.50 cm, Peri wound radius: odor, Exudate: heavy serous, Thick adherent devitalized necrotic tissue: 80%, Granulation tissue: 20%. Additional Wound detail: R7 states she has some type of cancer, dg(diagnosis) not found, not enough information in R7 chart; pending notes from PCP (primary care physician) or oncology; on exam today, no mass noticed on her back, sacrum, or legs. Expanded Evaluation Performed: The development of this wound and the context surrounding the development were considered in greater detail today. Relevant conditions including anemia, malnutrition, infection was considered and addressed through treatment changes or investigations. Thorough review of history performed, including speaking with Nursing staff for further information. Coordination of care and plan for this wound discussed with Nursing staff for further information. Dressing Treatment Plan: Primary dressing(s): sodium hypochlorite solution (Dakin's) and apply twice daily for 30 days; Dakin's sol (solution) ¼ strength; gauze apply twice daily for 30 days. Secondary Dressing(s) Gauze Island with border apply twice daily for 30 days. Plan of care reviewed and addressed: Recommendations Off load wound; reposition per facility protocol; air cell wheelchair cushion; low air loss mattress. Indication for Procedure: Remove necrotic Tissue and Establish the margins of Viable tissue. Procedure Note: The wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade, pick-ups were used to surgically excise 26.60cm of devitalized tissue and necrotic muscle level tissues were removed at a depth of 1.2cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 80% to 40%. Hemostasis was achieved and a lean dressing applied. Post operative recommendations and updates to the plan of care are documented in the Assessment and plan section below. Deep swab technique performed on stage 4 pressure wound of the left ischium on 3/3/25. Procedure Today: surgical excisional debridement was performed today on this wound. Additional Recommendations related to performed expanded evaluation: lab name: white blood count (WBC), Deep wound culture, prealbumin. R7's Skin/Wound Note dated 3/3/25 documents: Resident was seen by V24, Wound Physician on 3/3/25 r/t (related to) her wound. R7 has a stage 4 to her left buttock with heavy serous drainage noted. It has 80% necrotic tissue and 20% gran tissue. Treatment of Dakin's moistened kerlix lightly packed in wound, abdominal (ABD) pad and secure with tape twice daily (BID) and as needed (PRN), glycated hemoglobin (HBA1C), prealbumin, complete blood count (CBC), hemoglobin (HGB) and [NAME] Blood Count (WBC) to be done for next visit. Interdisciplinary team (IDT), primary care physician (PCP), power of attorney (POA) and resident aware. R7's Skin/Wound Note dated 3/3/25 documents: Tetracycline 500 milligrams (mg) 1 tab PO twice BID for 14 days and wound culture to be done. R7's Physician orders dated 3/3/25 documented treatment of Dakin's moistened kerlix lightly packed in wound, ABD pad and secure with tape BID and PRN, tetracycline 500mg BID and labs including a wound culture. R7's Physician order dated 3/3/25 at 9:44 PM documented orders also to apply Santyl ointment to left buttock topically every day and evening shift for wound to left buttocks. Cleanse with normal saline apply Santyl ointment, calcium alginate and bordered gauze BID and PRN. R7's March Treatment Administration Record (TAR) did not document R7 received treatments on 3/6/25(evening), 3/7/25 (morning), 3/8/25 (evening), 3/12/25 (morning) and 3/13/25 (evening). Treatment orders consisted of Apply Dakin's ¼ strength to left buttock topically every day and evening shift for wound. Cleanse left buttock with generic wound cleanser, pat dry, skin prep peri wound, allow to dry, pack wound lightly with Dakin's moistened kerlix, ABD pad and secure with tape BID and PRN. R's Physician orders dated 3/3/25 documented an order for a wound culture. R7's Wound Assessment Details dated 3/7/25 documents: site: left ischial tuberosity, active, pressure, ulceration, facility acquired, date identified: 2/27/25 healed stage 4, tissue: bright beefy red; 20%, necrotic soft, adherent 80%, has been debrided: no, probable decline, size: 9.5cm x 7.0cm x 0cm, area: 66.5cm, exudate: heavy serosanguineous, odor: yes, signs of infection present: yes. Is patient on antibiotic: no. Although R7's physician Order Sheet documents R7 was on antibiotic. R7's Specialized Wound Management Physician Notes dated 3/10/25 document Wound Evaluation and Management Summary. Chief complaint: R7 has a wound on her left ischium and a rash. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today .Past Medical History: atherosclerotic heart disease of native coronary artery with angina pectoris, essential(primary) hypertension, anemia, hyperlipidemia, Type 2 Diabetes mellitus with diabetic neuropathy. Genitourinary- intermittent incontinence, appetite fair, supplements none, no medication found to be affecting wound healing in clinical context. Oriented to person, place, time, and situation, calm and cooperative. Focused Wound Exam (Site 1) Stage 4 Pressure wound of the left ischium full thickness: Etiology- pressure, MDS 3.0 stage: 4, Duration: greater than 8 days, Wound size: 9.5 x 6.5 x not measurable cm, Depth: unmeasurable due to presence of nonviable tissue and necrosis, Surface area: 62.70 cm, Exudate: heavy serous sanguinous, Thick adherent devitalized necrotic tissue: 70%, Granulation tissue: 30%. Additional Wound detail: Recommend increase protein intake with each meal and addition supplements three times a day, pending notes from PCP or oncology, importance of performing the dressing as per order discussed with rounding nurse. Expanded Evaluation Performed: The development of this wound and the context surrounding the development were considered in greater detail today. Patient not following reposition or offloading recommendations and counseling provided. Impaired nutritional status discussed with patient, family, nursing staff and/or dietician. Recommend consult/reconsult with dietician to review current nutritional status. Reviewed offloading surfaces and discussed surfaces care plan. Thorough review of history performed, including speaking with Nursing staff for further information. Coordination of care and plan for this wound discussed with Nursing staff for further information. Dressing Treatment Plan: Primary dressing(s): sodium hypochlorite solution (Dakin's) and apply twice daily for 23 days; Dakin's sol (solution) ¼ strength; gauze apply twice daily for 23 days. Secondary Dressing(s) Gauze Island with border apply twice daily for 23 days. Plan of care reviewed and addressed: Recommendations Off load wound; reposition per facility protocol; pillow cushion; low air loss mattress. Site 1: Surgical Indication Debridement Procedure: Indication for procedure: Remove necrotic Tissue and Establish the margins of Viable tissue. Procedure Note: The wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade, pick-ups were used to surgically excise 25.08cm of devitalized tissue and necrotic muscle level tissues were removed at a depth of 1.5cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 70% to 30%. Hemostasis was achieved and a clean dressing applied. Post operative recommendations and updates to the plan of care are documented in the Assessment and plan section below. Investigations: Recommended and/or Reviewed: Deep wound culture pending on pressure wound of the ischium as of 3/10/25. R7's Skin/Wound Note dated 3/10/25 documents: Resident was seen by V24 on 3/10/25 r/t (related to) her wound. R7 has a stage 4 to her left buttock with heavy serous drainage noted. It has 70% necrotic tissue and 30% gran tissue. It has improved. Tx. Of Dakin's moistened kerlix lightly packed in wound, ABD pad and secure with tape IDT, PCP, and POA and resident aware. There is no documentation regarding the wound culture. R7's Wound Assessment Details dated 3/13/25 documents: site: left ischial tuberosity, active, pressure, ulceration, facility acquired, date identified: 2/27/25 healed stage 4, tissue: bright beefy red; 30%, necrotic soft, adherent 70%, has been debrided: no, probable improvement, size: 9.5cm x 6.6cm x 0cm, area: 62.7cm, exudate: heavy serosanguineous, odor: yes, signs of infection present: yes. Is patient on antibiotic: no. R7's shower sheet dated 3/13/25 documents R7 did not have any wounds. R7's Specialized Wound Management Physician Notes dated 3/17/25 documented Wound Evaluation and Management Summary. Chief complaint: R7 has a wound on her left ischium and a rash. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today .Past Medical History: atherosclerotic heart disease of native coronary artery with angina pectoris, essential(primary) hypertension, anemia, hyperlipidemia, Type 2 Diabetes mellitus with diabetic neuropathy. Genitourinary- intermittent incontinence, appetite fair, supplements none, no medication found to be affecting wound healing in clinical context. Oriented to person, place, time, and situation, calm and cooperative. Focused Wound Exam (Site 1) Stage 4 Pressure wound of the left ischium full thickness: Etiology- pressure, MDS 3.0 stage: 4, Duration: greater than 15 days, Wound size: 9.5 x 6.3 x not measurable cm, Depth: unmeasurable due to presence of nonviable tissue and necrosis, Surface area: 59.85 cm, Exudate: heavy serous sanguinous, Thick adherent devitalized necrotic tissue: 50%, Granulation tissue: 50%. Additional Wound detail: Wound culture not performed yet, discussed with rounding nurse . Dressing Treatment Plan: Primary dressing(s): sodium hypochlorite solution (Dakin's) and apply twice daily for 16 days; Dakin's sol (solution) ¼ strength; gauze apply twice daily for 16 days. Secondary Dressing(s) Gauze Island with border apply twice daily for 16 days. Plan of care reviewed and addressed: Recommendations Off load wound; reposition per facility protocol; air cell wheelchair cushion; low air loss mattress. Site 1: Surgical Indication Debridement Procedure: Indication for procedure: Remove necrotic Tissue and Establish the margins of Viable tissue. Procedure Note: The wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade, was used to surgically excise 17.96 cm of devitalized tissue and necrotic periosteum and bone were removed at a depth of 1.6cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 50% to 20%. Hemostasis was achieved and a clean dressing applied. Post operative recommendations and updates to the plan of care are documented in the Assessment and plan section below. Investigations: Recommended and/or Reviewed: Deep wound culture pending on pressure wound of the ischium as of 3/17/25. R7's progress note dated 3/17/25 at 9:31 pm documented resident was seen by V24 on 3/17/25 related to her wound. She has a stage 4 to her left buttock with heavy serous drainage noted. It has 50% necrotic tissue and 50% granulated tissue. It has improved. Treatment. of Dakin's moistened kerlix lightly packed in wound, ABD pad and secure with tape BID. There is no documentation for the wound culture. R7's Wound Assessment Details dated 3/20/25 documents: site: left ischial tuberosity, active, pressure, ulceration, facility acquired, date identified: 2/27/25 healed stage 4, tissue: bright beefy red; 50%, necrotic soft, adherent 80%, has been debrided: no, probable improvement, size: 9.5cm x 6.3cm x 0cm, area: 59.85cm, exudate: heavy serosanguineous, odor: yes, signs of infection present: yes. Is patient on antibiotic: no. R7's Dietary note dated 3/21/25 documents Diet: Low Concentrated Sweet (LCS), Regular, Thin; fortified ice cream four times per day (QID); liquid protein Intake: 50-100% Skin: Stage 4 wound on left ischial tuberosity Review: Resident is eating 50-100%of meals. Stage 4 wound noted, receiving liquid protein and fortified ice cream for wound as of 3/21/25. R7's Specialized Wound Management Physician Notes dated 3/24/25 document Wound Evaluation and Management Summary. Chief complaint: R7 has a wound on her left ischium and a rash. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today .Past Medical History: atherosclerotic heart disease of native coronary artery with angina pectoris, essential(primary) hypertension, anemia, hyperlipidemia, Type 2 Diabetes mellitus with diabetic neuropathy. Genitourinary- intermittent incontinence, appetite fair, supplements multivitamins, protein, no medication found to be affecting wound healing in clinical context. Oriented to person, place, time, and situation, calm and cooperative. Focused Wound Exam (Site 1) Stage 4 Pressure wound of the left ischium full thickness: Etiology- pressure, MDS 3.0 stage: 4, Duration: greater than 22 days, Wound size: 9.5 x 8 x not measurable cm, Depth: unmeasurable due to presence of nonviable tissue and necrosis, Surface area: 76.00 cm, Peri wound radius: odor, Exudate: heavy serous sanguinous, Thick adherent devitalized necrotic tissue: 40%, Granulation tissue: 40%. Other viable tissues: 20% (bone) Additional Wound detail: Wound culture report never received. Performed another one today. Expanded Evaluation Performed: The progress of this wound and the context surrounding the progress were considered in greater detail today counseling offered to optimize wound healing and relevant conditions (or possible conditions) were addressed through management changes or investigation regarding conditions including anemia, noncompliance, malnutrition. Patient not following reposition or offloading recommendations and counseling provided. Impaired nutritional status discussed with patient, family, nursing staff and/or dietician. Recommend consult/reconsult with dietician to review current nutritional status. Medications affecting wound healing reviewed and considered. Reviewed offloading surfaces and discussed surfaces care plan. Coordination of care and plan for this wound discussed with Nursing staff for further information. Dressing Treatment Plan: Primary dressing(s): sodium hypochlorite solution (Dakin's) and apply twice daily for 9 days; Dakin's sol (solution) ¼ strength; gauze apply twice daily for 9 days. Secondary Dressing(s) Gauze Island with border apply twice daily for 9 days. Plan of care reviewed and addressed: Recommendations Off load wound; reposition per facility protocol; air cell wheelchair cushion; low air loss mattress. Site 1: Surgical Indication Debridement Procedure: Indication for procedure: Remove necrotic Tissue and Establish the margins of Viable tissue. Procedure Note: The wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade, pick-ups were used to surgically excise 7.60cm of devitalized tissue and necrotic periosteum and bone were removed at a depth of 1.6cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 40% to 30%. Hemostasis was achieved and a clean dressing applied. Post operative recommendations and updates to the plan of care are documented in the Assessment and plan section below. Investigations: Recommended and/or Reviewed: Deep wound culture technique cancelled on stage 4 pressure wound of the left ischium on 3/24/25 (R7's record did not document the 3/3/25 orders result and thus cancelled on 3/24/25) Prealbumin recommended on 3/24/25. Deep swab technique performed on stage 4 pressure wound of the left ischium on 3/24/25. R7's progress note dated 3/24/25 at 9:57 pm documented R7 was seen by V24 on 3/24/25 related to her wound. She has a stage 4 to her left buttock with heavy serous drainage noted. It has 40% necrotic tissue, 20% bone and 40% granulation tissue. It has exacerbated. R7 is noncompliant with off-loading wound and with wound care. Treatment of Dakin's moistened kerlix lightly packed in wound, ABD pad and secure with tape BID and PRN. Prealbumin and a deep swab performed and collected to be done for next visit. R7's progress notes dated 3/26/25 documents R7 received intravenous infusion of Derma IV-DRIPT IV therapy infusion (500.9% normal saline with 5 gm Vitamin C, B Complex, biotin 10 mg, Arg 300 mg, Om150mg, [NAME] 150mg, Cit 150 mg and zinc 10 mg.) due to Acute/Chronic Wounds It continues to document R7 received intravenous (IV) infusion d/t acute/chronic wounds. No adverse reaction noted upon post IV infusion. no bruising noted at IV site. R7's Wound Assessment Details dated 3/29/25 documents: site: left ischial tuberosity, active, pressure, ulceration, facility acquired, date identified: 2/27/25 healed stage 4, tissue: bright beefy red; 50%, necrotic soft, adherent 50%, has been debrided: no, probable improvement, size: 9.5cm x 7.0cm x 0cm, area: 66.5cm, exudate: heavy serosanguineous, odor: yes, signs of infection present: yes. Is patient on antibiotic: no. R7's shower sheet 3/31/25 documents shower given and no wounds present. R7's Specialized Wound Management Physician Notes dated 3/31/25 document the patient visit had been rescheduled. R7 not in the facility currently. R7's Specialized Wound Management Physician Notes dated 4/7/25 document the patient not seen due to wound related hospitalization since last visit. R7's Wound Assessment Details dated 4/10/25 documents: site: left ischial tuberosity, active, pressure, ulceration, facility acquired, date identified: 2/27/25, unstageable, tissue: slough non adherent 10%, necrotic soft, adherent 90%, has been debrided: yes, probable decline, size: 10cm x 6.0cm x 0cm, area: 60.00cm, exudate: heavy purulent and malodorous , odor: yes, signs of infection present: yes. Is patient on antibiotic: no. R7's Laboratory Report dated 4/1/25 documents a wound culture with gram stain was collected on 3/25/25 with final report of heavy growth of proteus mirabilis and light growth of enterococcus faecalis. The Sensitivity report to medications does not indicate tetracycline, that was ordered for R7 on 3/3/25, as medication of choice sensitive to organisms. R7's Progress notes dated 3/25/25 document R7 making loud moaning sound. Upon entering room, observe pt lying in bed with pillows surrounding her, lifted slightly off left hip. Call bell in reach. R7 stated Why won't anyone help me? Writer instructed that R7 has not used her call bell to alert any staff that she wanted or needed any help. R7 looked directly at call bell that was laying by her right hand on the bed and stated, I'm so weak Offered pain medication and R7 opened her mouth as in wanting pill dropped in. Asked R7 why she wasn't holding the pill cup and R7 stated I'm so weak in my legs. R7's Progress notes dated 3/26/25 documents R7 continues to hold on to call bell but instead is hollering out and becomes agitated that no one answers her. Writer has explained on each occasion that she should be using call bell because staff cannot always hear her yells. R7's Progress note dated 3/26/25 documents R7 received IV infusion d/t acute/chronic wounds. No adverse reaction noted upon post IV infusion. no bruising noted at IV site. R7's Follow up assessment post fall note dated 4/1/25 documents R7 is alert and orientated. R7 has sad worried facial expression. Pain scale 3 of 10, R7 has chronic pain though nights d/t hip wound. R7 has preexisting wound to hip. R7's IDT note dated 4/1/25 documents Late entry: Root cause for fall on 4/1: R7 restless in bed due to pain. R7 sent to hospital per R7 and family request for pain control brief Interview for Mental Status (BIMS) 12. Care plan updated. Medical Doctor (MD) and POA aware. R7's Nursing Note dated 4/1/25 documents R7 grandson came to writer and reported that he overheard a female not talking very k[TRUNCATED]