**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital record review, wound notes, facility and staff interviews, wound physician interview, observation, review of the facility policies, and National Pressure Injury Advisory Panel (NPIAP) information, the facility failed to develop and implement an accurate comprehensive and individualized pressure ulcer program to ensure necessary care and services to prevent the worsening of pressure ulcers for Resident #800 and #300. This affected two residents (#800 and #300) of two residents reviewed for pressure ulcers. The facility census was 47. This resulted in Immediate Jeopardy and serious life-threatening harm to Resident #800, who was assessed as requiring maximum assistance with bed mobility and transfers and was at risk for pressure ulcer development, on 05/04/25 when treatment orders for known pressure ulcers were not obtained timely, orders were entered incorrectly resulting in wrong treatments and pressure ulcer worsening and prevention care was not in place leading to an admission to the hospital for subsequent infection/sepsis. Resident #800 was ultimately placed on hospice due to multiple antibiotic use from worsening of pressure ulcers. This also resulted in Immediate Jeopardy and serious life-threatening harm to Resident #300, who was assessed as requiring maximum assistance with bed mobility and transfers and at risk for pressure ulcer development, on 06/24/25 when the resident was assessed to have a stage 4 (full thickness skin and tissue loss with exposed palpable fascia, muscle, tending, ligament, cartilage or done in the ulcer; slough and/or eschar may be visible) pressure ulcer to the right buttock that previously was a stage 3 (full thickness loss of skin, in which adipose [fat] is visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present; fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed) the week prior, due to medicated treatments not being placed in the orders for administration from 06/19/25 through 06/23/25. On 08/11/25 at 1:11 P.M., Administrator #41, Regional Nurse #68, Director of Nursing (DON) #40, and Regional Administrator #69 were notified Immediate Jeopardy began on 05/04/25 when the facility failed to provide any treatments as well as accurate treatments and necessary interventions to prevent worsening of pressure ulcers resulting in the hospitalization of Resident #800 for infection/sepsis from pressure ulcers. Resident #800 returned to the facility on [DATE] and was sent back to the hospital for continued inaccurate treatments and necessary interventions to prevent worsening of pressure ulcers on 06/27/25. Resident #800 returned to the facility on [DATE] and was ultimately placed on hospice due to multiple antibiotic use from worsening of pressure ulcers. Immediate Jeopardy also occurred on 06/24/25 when the facility failed to provide the medicated treatment of Leptospermum Honey and Alginate Calcium to be applied daily with a gauze island bordered dressing from 06/19/24 through 06/23/25 to a right buttock stage 3 pressure ulcer measuring 6.8 centimeters (cm) long, 5.4 cm wide and 0.2 cm in depth with moderate serous exudate and 50 percent necrotic tissue. On 06/24/25, the right buttock pressure ulcer was assessed to have worsened to a stage 4 and measured 7 cm long, 5.4 cm wide, and undetermined depth with 20 percent black necrotic(dead) eschar tissue, 50 percent devitalized necrotic tissue and 20 percent slough (dead tissue separating from living tissue). The immediate Jeopardy was removed on 08/11/25 when the facility implemented the following corrective actions: On 08/07/25, Resident #300 was assessed by Wound Care Physician #70 with orders received and followed by a licensed nurse, Assistant Director of Nursing (ADON)/Wound Nurse# 33. On 08/07/25, Resident #800 was assessed by Wound Physician #70 with new orders received and followed by a licensed nurse ADON/Wound Nurse# 33. On 08/07/25 at 10:00A.M., an in-service was completed for ADON/Wound Nurse #33 by DON #40 and Regional Nurse #68 on the policy of Pressure Injuries: assessment, prevention, and treatment and the policy of physician notification. On 08/07/25 at 11:30A.M., an in-service was completed for Minimum Data Set ( MDS) Nurse #42, Registered Nurse (RN) #34, RN #27, RN #56, Licensed Practical Nurse (LPN) #44, LPN #25, LPN # 65, LPN #30, and 26 Certified Nursing Assistants (CNA) by DON #40 on the policy of pressure Injuries: assessment, prevention, and treatment policy; completing head to toe assessment and documenting on skin sheet, if resident has skin alterations; documenting the initial wound observation; and contacting House Physician #66 to obtain treatment orders if not provided from the hospital. Any staff who had not received education as of 08/11/25 will not work until education is completed. All staff had received the education as of 08/11/25. On 08/07/25 at 11:30A.M., an in-service was completed for MDS Nurse #42, RN #34, RN #27, RN #56, LPN #44, LPN #25, LPN # 65, LPN #30 by the DON #40 on notifying physician of any resident change in condition. Any staff who have not received education as of 08/11/25 will not work until education is completed. All staff have received the education as of 08/11/25. By 08/11/25, a whole facility skin sweep was completed for 48 residents to identify any skin alterations by LPN #30 and ADON/Wound Nurse #33. Any residents with new skin alterations were reviewed by the DON #40 and House Physician #66 notified. No new pressure injuries were identified during whole house skin sweep. On 08/11/25 at 11:00 A.M., treatment orders for 48 residents were reviewed by the Regional Nurse #68 to ensure that treatment orders are appropriate for any skin alterations. As of 08/11/25, a list of any residents being followed by the wound care physician will be maintained by DON #40. For newly admitted residents, based on the admission skin assessment, the resident will be added to the wound consult as applicable. For current residents, any new skin alteration identified will be reviewed and added to the wound consult as applicable. On 8/11/25, at 1:30 P.M., an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with House Physician/Medical Director #66 and facility leadership DON #40, Administrator #41, MDS/RN #42, ADON/Wound Nurse #33, Regional Administrator #69, and Regional Nurse #68 on pressure ulcer care and plan of correction. An audit to ensure pressure ulcer care is being completed per policy will be conducted for five residents three times a week for four weeks and as needed (PRN) by the DON or designee. Any concerns will be forwarded to the QAPI committee for immediate follow up. An audit to ensure wound consults are accurate on the consult sheet and orders from wound consults are entered appropriately and assigned to the correct physician will be completed once a week for four weeks and PRN by the DON or designee. Any concerns will be forwarded to the QAPI committee for immediate follow-up. An audit to ensure residents being followed by the wound care physician is being maintained by the DON, newly admitted residents are added to the wound consult list as applicable, and current residents with any new skin alterations are added to the wound consult list as applicable will be conducted once per week for four weeks and PRN by the regional nurse consultant or designee. Any concerns will be forwarded to the QAPI committee for immediate follow-up. QAPI plan completed by 08/11/25. Although the Immediate Jeopardy was removed on 08/11/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #800 revealed an admission date of 04/18/25 at 4:56 P.M. Diagnoses included weakness, cerebral infarction, atrial fibrillation, type 2 diabetes, and chronic kidney disease. Review of Resident #800 ' s hospital discharge summary that was received by the facility and dated 04/18/25, revealed a wound care order for a sacrum area to cleanse the wound with mild soap and water, rinse and pat dry. Apply triad cream at dime thickness and cover with Mepitel One, a wound dressing, to be changed every three days. The summary had no wound measurements, descriptions or classification. No other treatments or open skin areas were documented in the discharge paperwork. Review of Resident #800 ' s Braden Scale for Predicting Pressure Sore Risk, dated 04/18/25, revealed a score of 14 on a scale of six (high risk) to 23 (no risk), which indicated the resident was at moderate risk for skin breakdown. Review of the admission wound goal plan of care, dated 04/18/25, revealed to be admitted with multiple pressure areas with wound prevention and treatment approaches to include encourage to turn and re-position comfortably every two hours, check skin with daily care and bathing weekly. Report any skin concerns to the nurse/Nurse Practitioner/Physician and to record wound measurements weekly. Review of the admission initial wound grid documentation, dated 04/19/25 at 1:22 A.M., revealed a left buttock stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising; may also present as an intact or open/ ruptured blister) pressure ulcer scattered areas with moisture associated skin damage (MASD) surrounding it with no measurements. Additional initial wound grid documentation, dated 04/19/25 at 1:25 A.M., revealed a right buttock unstageable (a full thickness skin and tissue loss where the depth of the tissue damage cannot be determined because it ' s obscured by slough or eschar) pressure ulcer that measured 12 cm by 5.8 cm by 0.1cm. There was no documentation of an initial wound grid for the area on Resident #800 ' s sacrum. Review of the physician order dated 04/19/25 at 2:10 A.M. revealed for the right buttock- cleanse with mild soap and water, apply Triad cream a debriding medication) at dime thickness and cover with a Mepitel One dressing and change as needed when soiled/dislodged. This order was active until discontinued on 04/23/25 at 8:33 A.M. by FWN #33. Review of the physician orders dated 04/18/25 through 04/22/25 for Resident #800 resident revealed no wound treatment order for the sacral area as noted on hospital discharge documentation; no wound treatment order for the documented area on admission for the left buttock stage 2 pressure ulcer; and no interventions for general facility pressure ulcer injury prevention and care. Review of the Treatment Administration Record (TAR) for Resident #800 dated 04/18/25 through 04/22/25 revealed no as needed dressing change was completed for the right buttock unstageable pressure injury. Review of the initial wound consult visit by Advanced Practice Registered Nurse (APRN) #71, dated 04/22/25 with no time stamp of visit, revealed Resident #800 had several pressure ulcer areas. Identified was a right buttock unstageable pressure ulcer measuring 11.2 cm by 5.9 cm with undetermined depth with moderate serous exudate and 50 percent necrotic tissue. A treatment plan of Leptospermum Honey and Alginate Calcium to be applied daily with a gauze island bordered dressing. Another identified area was the left buttock unstageable deep tissue injury (DTI) pressure ulcer measuring 8.4 cm by 4.2 cm with undetermined depth with a treatment plan of house barrier cream twice a day. Finally, identified was a coccyx unstageable pressure ulcer measuring 4.2 cm by 1.1 cm by undetermined depth with moderate serous exudate and 100 percent slough. A treatment plan of Leptospermum Honey and Alginate Calcium to be applied daily with a gauze island bordered dressing. There were recommendations for additional care plan items including a low air-loss mattress, offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800, dated 04/23/25 at 9:34 A.M. revealed a treatment for the coccyx pressure ulcer of apply Leptospermum Honey and an island adhesive dressing daily. The treatment to include Alginate Calcium was omitted from the order. The order was discontinued on 04/29/25 at 1:29 P.M. by FWN #33. Review of the physician orders dated 04/22/25 through 04/29/25 revealed on 04/24/25, an alternating low air loss mattress was ordered, but for the left buttock unstageable DTI pressure ulcer treatment plan of house barrier cream twice a day was not ordered as well as no reposition per facility protocol and offloading of the wounds. Review of the TAR for Resident #800 dated 04/23/25 through 04/28/25 revealed the incorrect treatment order was administered for the coccyx unstageable pressure ulcer. Review of the admission Minimum Data Set (MDS) assessment, dated 04/25/25, revealed Resident #800 was alert and oriented. The resident required substantial/maximal assistance with shower/bathe self, bed mobility, toilet hygiene, and transfers and was at risk for pressure ulcer injuries. Review of Wound Physician visit notes, dated 04/29/25 with no time stamp, revealed Resident #800 was seen by APRN #71. Resident #800 to still had several pressure ulcer areas. The right buttock pressure ulcer progressed to a Stage 4 and measured 7.8 cm by 5.9 cm with undetermined depth and moderate serous exudate and 50 percent necrotic tissue. A new treatment plan was for Alginate Calcium and Santyl daily with a gauze island dressing. A surgical excisional debridement was performed due to removal of necrotic tissue and to establish the margins of viable tissue. The left buttock unstageable DTI pressure ulcer measured 7.3 cm by 4.2 cm with undetermined depth. A new treatment plan was for Alginate Calcium and Santyl daily with a gauze island dressing. The coccyx pressure ulcer measured 3.9 cm by 0.9 cm with undetermined depth and moderate serous exudate and 100 percent slough. The new treatment plan was for Alginate Calcium and Santyl daily with gauze island dressing. Recommendations for additional care plan items included to offload wounds and reposition per facility protocol. Review of the physician orders dated 04/29/25 through 05/03/25 revealed the left buttock pressure ulcer treatment of Alginate Calcium and Santyl daily with a gauze island dressing from APRN #71 was not ordered as well as no reposition per facility protocol and offloading of the wounds. The interventions for the risk for skin breakdown dated 04/18/25 were not started until 05/01/25 and included to assist resident with turning and repositioning frequently while in bed and an air mattress. Review of the progress note for Resident #800, dated 05/04/25 at 10:49 A.M., documented the resident was confused and delusional, and the nurse spoke to the 24/7 on call physician line and obtained an order to send resident to the hospital. The resident left the faciity on [DATE] at 11:02 A.M. Review of the hospital documentation for Resident #800 ' s admission on [DATE] revealed cellulitis of decubitus ulcer to the sacral region confirmed by a computed tomography (CT) scan image. Treatment included surgical debridement of the site and broad-spectrum antibiotics for the area. Resident #800 was discharged back to the facility on [DATE] with intravenous antibiotics, but no wound care instructions, measurements, descriptions and classification of any skin areas. Review of the progress note dated 05/09/25 at 5:11 P.M. revealed Resident #800 returned to the facility from the hospital. Review of the admission initial wound grid documentation dated 05/09/25 at 5:39 P.M. revealed a coccyx unstageable pressure ulcer measured 14 cm by 8 cm by 0.6 cm. Review of the admission wound goal plan of care dated 05/09/25 for Resident #800 revealed resident admitted with a high wound risk, with wound prevention and treatment approaches to include encourage to turn and re-position comfortably every two hours. Review of Resident #800 ' s Braden Scale for Predicting Pressure Sore Risk dated 05/09/25 revealed a score of 14 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at moderate risk for skin breakdown. Review of the active care plan initiated on 04/18/25 from original admission for Resident #800 revealed at risk for skin break down with no new approaches added since 05/01/25 and included to assist resident with turning and repositioning frequently while in bed and an air mattress. Review of treatment orders for Resident #800 revealed for the coccyx unstageable pressure ulcer, no treatment was in place until 05/10/25 at 12:58 P.M. when the floor nurse obtained an order from Physician #66. This order was discontinued on 05/12/25 at 1:11 A.M. by FWN #33. Review of the physician orders for Resident #800 revealed a written treatment order written by FWN #33 from Wound Doctor #70 entered on 05/12/25 at 1:13 A.M. for the coccyx pressure ulcer to apply a nickel thick layer of Santyl to wound bed and cover with a comfort foam border dressing every three days. This order was discontinued on 05/13/25 at 12:51 P.M. by the FWN #33. Review of the TAR dated 05/12/25 revealed Resident #800 received a treatment completed to the coccyx unstageable pressure ulcer. Review of the medical record revealed no written order from Wound Physician #70 for the coccyx unstageable pressure ulcer to apply nickel thick layer of Santyl to wound bed and cover with a comfort foam border dressing every three days that was written by FWN #33 and entered on 05/12/25. Review of the active physicians ' orders dated 05/09/25 through 05/16/25 for this resident revealed the only intervention for pressure ulcer injury prevention and care was an alternating low air loss mattress. Review of Wound Physician Visit notes revealed Resident #800 was seen by APRN #71 on 05/13/25. Resident #800 had one pressure ulcer area to the coccyx. The area was a stage 4 and measured 11.4 cm by 8.7 cm by 2.4 cm with moderate serous exudate and 30 percent necrotic tissue. The treatment plan was sodium hypochlorite solution (Dakin ' s solution), pack wound with soaked gauze and apply daily abdominal dressing. A surgical excisional debridement procedure was also completed due to removal of the necrotic tissue to establish the margin of viable tissue. There were recommendations for additional care plan items including a low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 05/13/25 at 12:56 P.M. entered by the FWN #33 and discontinued on 05/19/25 at 11:41 A.M. by the FWN #33, revealed a treatment for the coccyx stage 4 pressure ulcer for Leptospermum Honey to fill and cover all open areas and cover all areas with Alginate Calcium, cover with an abdominal pad daily. The APRN #71 ' s treatment plan on 05/13/25 was for sodium hypochlorite solution (Dakin ' s solution) to pack wound with soaked gauze and apply daily with abdominal dressing. Review of Resident #800s TAR dated 05/13/25 through 05/18/25 revealed an incorrect treatment completed for the coccyx stage 4 pressure ulcer. Review of the physician order dated 05/16/25 revealed to turn and repositioned every two hours along with the alternating low air loss mattress, but no other pressure ulcer preventions and care. Review of the physician order for Resident #800 dated 05/19/25 at 11:41 A.M. revealed a treatment order for the coccyx stage 4 pressure ulcer to pack wound with Dakin ' s solution-soaked gauze, cover with an abdominal dressing daily. This is the order from 05/13/25 the APRN #71 originally ordered on 05/13/25. This order was discontinued on 06/13/25 at 7:38 A.M. by FWN #33. Review of Wound Physician notes dated 05/20/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 11.2 cm by 0.4 cm by 3.2 cm with moderate serous exudate and 30 percent necrotic tissue. The treatment plan was to continue sodium hypochlorite solution (Dakin ' s solution), pack wound with soaked gauze and apply daily with an abdominal dressing. A surgical excisional debridement procedure was also completed due to removal of the necrotic tissue to establish the margin of viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of Wound Physician notes dated 05/27/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.1 cm by 6.4 cm by 3 cm with moderate serous exudate and 20 percent necrotic tissue. The treatment plan was to continue sodium hypochlorite solution (Dakin ' s solution) to pack wound with soaked gauze and apply daily with an abdominal dressing. A surgical excisional debridement procedure was also completed due to removal of the necrotic tissue to establish the margin of viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of Wound Physician notes dated 06/03/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.1 cm by 6.2 cm by 2.6 cm with moderate serous exudate and 40 percent slough tissue. The treatment plan was to continue sodium hypochlorite solution (Dakin ' s solution) to pack wound with soaked gauze and apply daily with an abdominal dressing. A surgical excisional debridement procedure was also completed due to removal of thick adherent eschar and devitalized tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of Wound Physician notes dated 06/10/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 6.7 cm by 5.6 cm by 2.4 cm with moderate serous exudate and 20 percent necrotic tissue. The treatment plan was changed to alginate calcium with leptospermum honey apply daily three times a week with a foam border dressing. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish the margins if viable tissue. Recommendations for additional care plan items included: low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 06/10/25 and 06/11/25 revealed the order APRN #71 gave on 6/10/25 to change the treatment to alginate calcium with leptospermum honey apply daily three times a week was not entered. Review of the TAR for Resident #800 for 06/10/25 and 06/11/25 revealed the treatment of Dakin ' s solution was done for the coccyx stage 4 pressure ulcer. Review of Wound Physician notes dated 06/12/25 revealed Resident #800 was seen by Wound Doctor #70. The coccyx stage 4 pressure ulcer measured 7.2 cm by 8.4 cm by 2.4 cm with moderate serous exudate and 20 percent slough tissue. The treatment plan was changed to alginate calcium apply daily three times a week with a foam border dressing. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish the margins if viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 06/12/25 revealed the new order from Wound Doctor #70 was not entered. The current treatment was still the Dakin ' s solution-soaked gauze. Review of the TAR for Resident #800 dated 06/12/25 revealed the treatment of Dakin ' s solution was done. Review of the physician order dated 06/13/25 at 7:41 A.M. revealed a treatment order for the coccyx stage 4 pressure wound to be filled with generous amount of Leptospermum Honey and apply Alginate Calcium and cover with a foam border dressing daily. This was not the order from Wound Doctor #70 ' s visit on 06/12/25. This order was discontinued on 06/25/25 at 6:45 A.M. by Facility Wound Nurse (FWN) #33. Review of the TAR for Resident #800 dated 06/13/25 through 06/18/25 revealed the incorrect treatment completed for the coccyx stage 4 pressure ulcer. Review of Wound Physician notes dated 06/19/25 revealed Resident #800 was seen by Wound Doctor #70. Resident #800 ' s coccyx stage 4 pressure ulcer measured 5.6 cm by 3.4 cm by 1.8 cm with moderate serous exudate and 20 percent slough tissue. The continued treatment plan was for Alginate Calcium, apply daily three times a week with a foam border dressing. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish the margins if viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 06/19/25 through 06/24/25 revealed a treatment order for the coccyx stage 4 pressure ulcer wound to be filled with generous amount of leptospermum honey and apply alginate calcium and cover with a foam border dressing daily. This was not the order from Wound Doctor #70 ' s visit on 06/19/25. Review of the TAR for Resident #800 dated 06/19/25 through 06/23/25 revealed incorrect treatments completed for the coccyx stage 4 pressure ulcer. Review of Wound Physician notes dated 06/24/25 revealed Resident #800 was seen by APRN #71. Resident #800 ' s coccyx stage 4 pressure ulcer measured 8.9 cm by 8.7 cm by 1.8 cm with moderate serous exudate and 60 percent necrotic tissue. The treatment plan was changed to Alginate Calcium and Leptospermum Honey, apply daily with a foam border dressing. A surgical excisional debridement procedure was also completed due to removal of thick adherent eschar and devitalized tissue. Recommendations for additional care plan items included a low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the physician orders for Resident #800 dated 06/24/25 revealed the treatment order was correct. Review of the physician order for Resident #800 dated 06/25/25 at 6:51 A.M. entered by the FWN #33 revealed a treatment for the coccyx stage 4 pressure ulcer to apply a nickel thick layer of Santyl and cover with Alginate Calcium and apply a foam border dressing daily. This order was not consistent with the order from APRN #71 ' s visit on 06/24/25. Review of the TAR for Resident #800 dated 06/25/25 through 06/27/25 revealed incorrect treatments ordered were administered for the coccyx unstageable pressure ulcer. Review of the progress note for Resident #800 dated 06/27/25 at 7:59 P.M. revealed the resident had a critically low hemoglobin with a blood pressure of 90/41 blood pressure, pulse 123, a temperature of 97.3 degrees Fahrenheit (F) and oxygen saturation of 97 percent on room air. The nurse spoke to the on-call physician and Resident #800 was sent to the emergency room. Resident #800 left the facility at 8:00 P.M. Review of the hospital documentation for Resident #800 ' s admission revealed a low hemoglobin and severe sepsis. During the hospital stay, a CT scan revealed the sacral decubitus wound extended to the underlying bone with osteomyelitis. The wound culture of the sacral decubitus wound was performed and was positive for Bacteroides fragilis, a rare gram-positive cocci and white blood cells. Intravenous antibiotics were administered throughout Resident #800 ' s stay and surgical debridement of the sacral decubitus wound was completed. The hospital discharge diagnosis was severe sepsis without septic shock from osteomyelitis (infection of the bone) from sacral decubitus wound. Resident #800 discharged back to the facility on [DATE] with oral antibiotics ordered as well as an order for a wound vaccuum system for the sacral decubitus ulcer. Further review of the hospital documentation revealed no orders for the settings of the wound vac and there were no hospital measurements or description of the decubitus ulcer. Review of the progress note dated 07/07/25 at 8:55 P.M. revealed Resident #800 arrived at the facility for readmission. Review of the admission information dated 07/07/25 for Resident #800 revealed no initial wound grid documentation for a sacrum decubitus ulcer by the admitting floor nurse. Review of wound grid documentation for Resident #800, was created on 07/09/25 at 12:42 A.M. by FWN #33 for 07/07/25 at 12:41 A.M., when the resident was not yet at the facility. The document stated Resident #800 had a stage 4 pressure ulcer to the coccyx that measured 8.9 cm by 8.7 cm by 1.8 cm. Review of Resident #800 ' s Braden Scale for Predicting Pressure Sore Risk dated 07/07/25 revealed a score of 13 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at moderate risk for skin breakdown. Review of the physician order for Resident #800 for 07/07/25 revealed no treatment for a sacral decubitus ulcer. Review of the wound grid documentation for Resident #800 dated 07/08/25 at 12:45 A.M. by the FWN #33 revealed the coccyx stage 4 pressure ulcer had a wound vacuum in place with continuous suction at 125 millimeters of mercury (mm/HG). Review of the physician order for Resident #800 dated 07/08/25 at 2:54 P.M. revealed an order entered by FWN #33 for the coccyx wound. The order was to cleanse wound bed with normal saline, window frame outside edges of wound with adhesive film, cut black foam to fit wound bed. Fill entire area including undermining. Bridge with green foam using adhesive film under foam and bring it out to the left hip, attaching to port pad. Cover the entire area with additional adhesive film. Apply NPWT @ 125 mm/hg continuous. To be changed Sunday, Tuesday, Thursday and PRN. Review of the medical record for Resident #800 revealed no written order for the wound vac system for the coccyx pressure ulcer, there was no date in the medical record when the wound vac arrived at the facility and when it was placed on the resident to start treatment. Review of the wound grid documentation for Resident #800 dated 07/10/25 at 2:54 P.M. by FWN #33 revealed a coccyx sage 4 pressure ulcer measuring 8.8 cm by 7.8 cm by 0.8 cm with a wound vacuum in place with continuous suction at 125 mm/HG. Review of the care plan revealed a plan for the pressure ulcer to the coccyx was initiated on 07/10/25. Interventions were to perform current treatments as ordered and continue with prevention care plan measures to prevent further skin breakdown. The care plan interventions were not implemented until 07/21/25. Review of the wound grid documentation for Resident #800, dated 07/15/25 at 11:24 P.M. by FWN #33, revealed a coccyx sage 4 pressure ulcer measured 7.2 cm by 6.3 cm by 0.8 cm with a wound vacuum system in place with continuous suction at 125mm/HG. Review of the wound grid documentation for Resident #800 dated 07/17/25 at 10:18 A.M. by FWN #33 revealed a coccyx sage 4 pressure ulcer measured 7.2 cm by 6.3 cm by 0.8 cm with a wound vacuum system in place with continuous suction at 125mm/HG. Review of the wound grid documentation for Resident #800 dated 07/22/25 at 1:12 P.M. by the FWN #33 revealed a coccyx sage 4 pressure ulcer measured 7 cm by 6.2 cm by .8 cm with a wound vacuum system in place with continuous suction at 125mm/HG. Review of the Wound Physician notes dated 07/24/25 revealed Resident #800 was seen by Wound Doctor #70. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.4 cm by 6.6 cm by 1.4 cm with moderate serous exudate and 20 percent slough tissue. The treatment plan was a wound vacuum system with suction at 125 mm/HG, use black sponge throughout and apply three times a week. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish the margins if viable tissue. Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol. Review of the Wound Physician visit notes dated 07/31/25 revealed Resident #800 was seen by Wound Doctor #70. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.2 cm by 5.6 cm by 1.2 cm with moderate serous exudate and 20 percent slough tissue. The treatment plan was a wound vacuum system with suction at 125mm/HG, use black sponge throughout and apply three tim