**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and facility policy review, the facility failed to assess, develop and implement a comprehensive and individualized prevention program to prevent the development of avoidable pressure ulcers, ensure pressure ulcer dressings were provided as ordered and/or prevent the risk of pressure ulcer infection for Resident #43 and #49. Actual harm occurred on 02/05/25 when Resident #43 was readmitted to the facility following an acute care hospital stay, was determined to be at high risk for skin breakdown, dependent on staff for bed mobility and with known pressure ulcers that were found not to have a comprehensive assessment of the known pressure ulcers upon readmission to the facility. Additionally, the resident's physician ordered treatments for pressure ulcers that were not provided as ordered. Furthermore, the resident was sent to the local acute care hospital on [DATE] following a physical examination of stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) pressure ulcer to the sacrum for suspected infection in need of surgical intervention, non-staged pressure ulcer to the right outer ankle and a new unidentified wound to the right outer fifth digit to the right foot. Additionally, Actual Harm occurred on 01/10/25 when Resident #49, who was cognitively impaired, was at high risk for pressure ulcer development, dependent on staff for bed mobility and had known pressure ulcers and was found to have a stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) pressure ulcer to the left ischium without evidence of adequate and individualized pressure ulcer prevention interventions being in place prior to the development. Furthermore, the resident readmitted to the facility on [DATE] with no readmission assessment and no physician ordered treatments to the unstageable, known but not stageable due to coverage of wound bed by slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed), and/or eschar (Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound), pressure ulcer to the sacrum/coccyx, left ischium and stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also be present as an intact or open/ruptured blister.) pressure ulcer to the left heel. This affected two (Resident #43 and #49) of three residents reviewed for pressure ulcers. The facility census was 67. Findings Include: 1. Review of the medical record for Resident #43 revealed an initial admission date of 01/22/25 with the latest readmission of 02/05/25 with the diagnoses including but not limited to cellulitis of right lower limb, pressure induced deep tissue damage of sacral region sacral region, hypertension, neurogenic bowel, benign prostatic hyperplasia neuromuscular dysfunction of bladder, anemia, bipolar disorder, anxiety disorder, post-traumatic stress disorder, osteoarthritis, gastro-esophageal reflux disease, retention of urine, edema, pain, Rhabdomyolysis, insomnia, spondylosis lumbar region, obesity, colostomy status and polyneuropathy. Review of the resident's admission evaluation dated 01/22/25 revealed the resident was admitted from an acute care hospital for wounds and weakness. The assessment indicated the resident had edema to bilateral lower extremities. The resident had an indwelling urinary catheter on admission. The assessment indicated the resident had a skin impairment of a blister. Review of the Braden scale contained within the assessment revealed a score of 15 indicating the resident was at high risk for skin breakdown. Review of the wound evaluation dated 01/22/25 revealed the resident had an unstageable pressure ulcer to his left gluteal fold measuring 4.0 centimeters (cm) by 8.0 cm by 0.1 cm. The wound was described as 20% granulation tissue with scant sanguineous exudate and 80% slough. The peri-wound was described as pink. Review of the wound evaluation dated 01/22/25 revealed the resident had an unstageable pressure ulcer to his right gluteal fold measuring 7.0 cm by 6.25 cm by 0.1 cm. The wound was described as 20% granulation tissue with scant sanguineous exudate and 80% slough. The peri-wound was pink. Review of the wound evaluation dated 01/23/25 revealed the resident had an unstageable pressure ulcer to his coccyx measuring 13/5 cm by 9.5 cm by 0.1 cm and the wound was described as 90% slough with a scant amount of serosanguineous exudate. The peri-wound was pink. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident was dependent for bed mobility and toileting. The assessment indicated the resident had an indwelling urinary catheter and an ostomy. The assessment indicated the resident was at risk for skin breakdown and was admitted with one stage II and three stage III pressure ulcers. The assessment indicated the resident had an infection to his foot, other lesion to his foot and open lesions. The facility implemented a pressure reducing device to bed, pressure ulcer/injury care, application of ointments/medications other than to feet and application of dressings to feet. Review of the progress note dated 01/25/25 at 9:33 A.M. revealed the resident was shaking all over stating that he was freezing. The resident requested to be sent to the emergency room (ER) for an evaluation. Review of the progress note dated 01/25/25 at 5:50 P.M. revealed the resident was admitted to the hospital for the diagnoses of influenza A, dehydration and cough. Review of the progress note dated 02/05/25 at 6:10 P.M. revealed the resident was readmitted to the facility at 6:00 P.M. Review of the medical record revealed a comprehensive readmission assessment was not completed until 02/07/25. Further review revealed the assessment was still in progress. The resident was admitted from the hospital for wound care. The resident had an ostomy as well as an indwelling urinary catheter. The assessment indicated the resident was admitted with pressure ulcer and blisters. The Braden scale contained within the evaluation revealed a score of 14 indicating the resident was at risk moderate for skin breakdown. Review of the medical record revealed no documented comprehensive assessment of the resident's pressure ulcers to the sacrum, left gluteus, right gluteus, right out ankle and surgical wound to left shin. Review of the resident's monthly physician orders for February 2024 identified orders dated 01/22/25 encourage and assist with frequent offloading, heel medic boots bilaterally to assist with offloading, cleanse wound to sacrococcygeal region with wound cleanser, pat dry, apply barrier cream daily and as needed, 01/23/25 enabler bars to enhance bed mobility, bilateral ischial tuberosities-cleanse wounds with wound cleanser, pat dry, apply calcium alginate to wound bed and cover with comfort foam border dressing daily and 01/24/25 cleanse wounds to bilateral lower legs and feet with wound cleanser, pat dry, apply Xeroform to wounds wrap with Kerlix starting at base of toes working up the knee and secure with tape, change daily and as needed. On 02/11/25 at 1:34 P.M., observation of Licensed Practical Nurse (LPN) #180 provide the physician ordered treatment to the resident's wounds revealed the LPN donned a gown and gloves for enhanced barrier precautions (EBP). The LPN placed a barrier on the bedside table consisting of a clear trash bag. She then set up the required supplies on the barrier. The dressings to the bilateral lower extremities (BLE) were dated 02/09/25. LPN #180 verified the dressing changes were physician ordered as daily and had not been changed since 02/09/25. The LPN removed the soiled dressing to the resident's left lower extremity (LLE) then removed the soiled dressing to the right outer ankle using the same gloves. The LPN placed the soiled dressings on the clear trash bag used as a barrier on the bedside table next to the clean treatment supplies. The LPN then cleansed the wounds to his LLE and right outer ankle. The LPN then washed her hands and donned a pair of gloves. The LPN then removed a piece of gauze used to cleanse the wound to the left lower extremity and placed a piece of Xeroform to the wound. She then placed multiple 4 X 4 on the Xeroform and wrapped the resident's left lower extremity with Kerlix. Using the same gloves the LPN placed a piece of Xeroform to the pressure ulcer on the right outer ankle, covered with a 4 X 4 and wrapped with Kerlix. The LPN removed the barrier from the bedside table and EBP to obtain the supplies to provide treatment to the left and right ischium wounds and the sacral wound. The LPN set-up the required supplies on the bedside table with no barrier. The resident was assisted onto his right side by a Certified Nursing Assistant (CAN) with difficulty due to the parameter mattress being too small for the resident's size. The dressing to the resident's sacrum was dated 02/08/25. The dressing was saturated with blood-tinged drainage and a foul odor was noted. LPN #180 verified the dressing changes were daily and had not been changed since 02/08/25. The LPN removed the soiled dressings to the left ischium, right ischium and sacrum using the same gloves. The LPN then cleansed all three wounds using wound cleanser and 4 X 4. The LPN then washed her hands, donned a pair of gloves and placed calcium alginate to all wound beds and covered with multiple 4 x 4. The LPN then covered all three wounds with two ABD pads and secured with tape. On 02/11/25 at 2:00 P.M., an interview with LPN #180 confirmed the resident's bed was too small limiting the resident's ability to turn and reposition to achieve off-loading to the pressure ulcers and would require a bariatric bed. The LPN confirmed the resident was not provided with an air mattress despite the stage IV pressure ulcer to the sacrum. On 02/11/15 at 3:25 P.M., interview with the Licensed Nursing Home Administrator (LNHA) and the Regional Nurse revealed the contracted wound company was supposed to start in March 2025. The LNHA and Regional Nurse was made aware of no admission assessment, no comprehensive assessment of the resident's wounds, the resident's left and right ischium wounds and sacral/coccyx wound treatments had not been completed since 02/08/25 and 02/09/25. The LNHA and Regional Nurse was made aware of the resident's bed was not large enough to accommodate his size to off-load pressure to the wounds. On 02/13/25 at 9:05 A.M., an interview with the resident's primary care physician (PCP) #200 revealed he was scheduled to see Resident #43. The resident's PCP was unaware the facility had no contracted wound company, and the resident was not referred to a wound clinic, the physician ordered treatments were not being rendered as ordered and the resident was not on a specialized mattress. Review PCP #200's progress note dated 02/13/25 revealed the resident was being seen for evaluation of multiple wound and recent hospitalization for influenza A. On 01/30/25 the resident underwent surgical incision and drainage of a left calf abscess a right ankle wound, a sacral wound and ischial wounds. An examination revealed a deep stage IV pressure wound to the coccyx with significant slough and some odor indicative of an underlying infection. The wounds needed immediate debridement which could not be delayed for the wound physician's visit in the next six days. The physician's plan was to send to the hospital for further evaluation, management and treatment. The physician documented the risk of osteomyelitis was high and required surgical intervention. Review of the progress note dated 02/13/25 at 4:12 P.M. revealed the resident was admitted to the local acute care hospital for the evaluation and treatment of wounds. The facility failed to provide any documented evidence that the readmission assessment, comprehensive wound assessment and the physician ordered treatments were completed. 2. Review of the medical record for Resident #49 revealed an initial admission date of 12/27/24 with the latest readmission of 02/11/25 with the diagnoses including but not limited to cerebrovascular accident with right sided hemiplegia, respiratory failure, asthma, chronic respiratory failure with hypoxia, severe protein calorie malnutrition, systemic lupus, dysphagia, dysphonia, neuromuscular dysfunction of bladder, gastrostomy status, cardiomyopathy, anemia, anxiety disorder, gastro-esophageal reflux disease, hyperlipidemia, hypertension, fibromyalgia and major depressive disorder. Review of the admission evaluation dated 12/27/24 revealed the resident was admitted with an indwelling urinary catheter and was incontinent of bowel. The assessment indicated the resident was a two person assist with toileting and bed mobility. The assessment indicated the resident was admitted to the facility with pressure to the sacrum/coccyx being described as a large open deep wound with tunneling, measuring 6.0 centimeters (cm) by 7.2 cm by undefinable depth. The resident also had a wound to her right ischium measuring 1.3 cm x 1.5 cm by 0.3 cm. The assessment had no description of the tissue of the wounds. Review of the wound evaluation dated 12/27/24 revealed the resident had an open wound to the sacrum/coccyx measuring 8.0 cm by 12.0 cm by undefinable depth. The wound had tunneling at 12 o'clock, 3 o'clock and 9 o'clock. The wound was described as 60% slough with a heavy purulent exudate. The peri-wound was described as pink. Review of the plan of care dated 12/29/24 revealed the resident had impaired skin integrity. Interventions included assisting resident with turning and repositioning as needed, complete skin inspection every seven to 10 days and as needed, complete wound evaluation to monitor the progress of the resident's skin condition and treatments per physician orders. Review of the resident's readmission assessment dated [DATE] revealed the resident was admitted to the facility with an indwelling urinary catheter and was incontinent of bowel. The assessment indicated the resident was a two person assist with toileting and bed mobility. The assessment indicated the resident was readmitted to the facility with pressure ulcers. The assessment contained no location, staging or description of the pressure ulcers. Review of the skin inspection dated 01/10/25 revealed the resident had skin issues as follows and were present on admission: • Sacrum/coccyx wound measured 0.8 centimeters (cm) by 12.0 cm by undefinable depth with bone involvement. The wound was described as 60% tan slough with 40% granulation tissue, bone was visible at the center of the wound. The wound also had tunneling/undermining present at 3 o'clock, 6 o'clock and 9 o'clock with heavy malodorous brown wound drainage. The wound edges were uneven, and the peri-wound was pink. • Right Ischium open wound measured 0.3 cm with a 0.1 cm depth. The wound bed was not described and had no drainage. The peri-wound was described as dark purple-maroonish. • The left ischium open area was from shearing measuring 0.3 cm by 0.8 cm by 0.1 cm with no description of the wound bed. The wound edges were uneven, and the peri-wound was pink. • Left heel open wound measured 1.5 cm by 3.0 cm by 0.1 cm with no description of the wound bed. The wound edges were uneven, and the peri-wound was dark purple maroonish in color. Review of the wound evaluation dated 01/11/25 revealed the resident was readmitted to the facility with an unstageable pressure ulcer to her sacrum/coccyx measuring 8.0 cm by 12.0 cm by undefinable. The wound had tunneling and/or undermining at 3 o'clock, 6 o'clock and 9 o'clock. The wound was described as 30% epithelial tissue, 10% granulation and 60% slough with a heavy serous exudate. The peri-wound was described as pink. Review of the wound evaluation dated 01/16/25 revealed the resident stage IV pressure ulcer to the coccyx measured 12 cm by 7.0 cm by 1.3 cm. The wound was described as 70% granulation tissue and 30% slough with a moderate amount of serosanguineous exudate. The peri-wound was described as pink, and the facility determined the wound had remained unchanged. Review of the wound evaluation dated 01/16/25 revealed the shearing wound was now a stage III pressure ulcer to the left ischium measuring 6.0 cm by 3.0 cm by 0.1 cm and described as 70% granulation and 30% slough with a small amount of serosanguineous exudate. The assessment indicated the resident was admitted with stage III pressure ulcer. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive impairment. The resident was dependent on staff for toileting. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. The assessment indicated the resident was at risk for skin breakdown and was admitted with one stage II pressure ulcer, one stage III pressure ulcer and one stage IV pressure ulcer. The facility implemented pressure reducing devices to bed/chair, turning/repositioning program, nutrition or hydration intervention to manage skin problems and pressure ulcer/injury care. Review of the wound evaluation dated 01/22/25 revealed the resident stage IV pressure ulcer to the coccyx measured 10 cm by 6.5 cm by 1.3 cm. The wound was described as 70% granulation tissue and 30% slough with a moderate amount of sanguineous exudate. The peri-wound was described as pink, and the facility determined the wound had remained unchanged. Review of the wound evaluation dated 01/22/25 revealed the resident had a stage III pressure ulcer to the left ischium measuring 6.0 cm by 3.0 cm by 0.1 cm and described as 70% granulation and 30% slough with a small amount of sanguineous exudate. The assessment indicated the resident was admitted with stage III pressure ulcer. Review of the medical record revealed no documented evidence the wounds to the right ischium and the left heel were assessed every seven days as required. Review of the residents' January 2025 Treatment Administration Record (TAR) revealed a treatment was not implemented for the wound to the resident's left heel, left ischium until 01/17/25. The physician ordered treatment was not provided for the left ischium wound on 01/19/25 and 01/30/25. Further review revealed the physician ordered treatment to the sacral/coccyx wound was not provided as ordered on 01/16/25, 01/19/25 and 01/30/25. Additionally, the air mattress was not implemented until 01/28/25. Review of the progress note dated 02/01/25 at 9:05 A.M. revealed the resident was displaying an altered mental status. The resident was sent to the local emergency room (ER) for an evaluation. Review of the progress note dated 02/01/25 at 11:01 P.M. revealed the resident was admitted to the acute care hospital for altered mental status, possible urinary tract infection (UTI) and acute metabolic encephalopathy. Review of the progress note dated 02/11/25 at 8:27 P.M. revealed the resident was readmitted to the facility. Review of the medical record revealed no documented evidence a readmission assessment or wound assessment was completed. Review of the resident's monthly physician orders for February 2025 identified orders dated 02/12/25 enhanced barrier precautions (EBP) related to wound, tube feeding and tracheostomy. Further review revealed no orders for the treatment of the sacral/coccyx wound, left ischium wound, the right ischium wound and the left heel wound. Review of the first documented wound evaluation following survey request revealed on 02/13/25 the unstageable pressure ulcer to the sacral/coccyx measured 10.0 cm by 6.5 cm by 1.3 cm and described as 30% slough and 70% granulation tissue. The wound had a heavy amount of serosanguineous exudate. The peri-wound was described as pink. Review of the first documented wound evaluation following survey request revealed on 02/13/25 the unstageable pressure ulcer to the left ischium measured 6.0 cm by 1.3 cm by 0.1 cm and described as 30% slough and 70% granulation tissue with a small amount of serosanguineous exudate. The peri-wound was described as pink. Review of the first documented wound evaluation following survey request revealed on 02/13/25 the stage III pressure ulcer measuring 6.0 cm by 1.3 cm by 0.1 cm with the wound being described as 30% slough and 70% granulation tissue with a small amount of serosanguineous exudate. The peri-wound was described as pink. Review of the resident's February 2024 Treatment Administration Record (TAR) revealed a treatment to the unstageable pressure ulcer to the sacrum/coccyx and left ischium and the stage II pressure ulcer to the left heel was not implemented until 02/13/24. On 02/13/25 at 9:05 A.M., an interview with the resident's PCP #200 revealed he was scheduled to see Resident #49 and revealed he was unaware the resident had no treatment in place for the multiple pressure ulcers. On 02/13/25 at 2:45 P.M., an interview with the Director of Nursing (DON) verified the resident had no readmission assessment, readmission wound assessments and treatments for the multiple pressure ulcers. Review of the facility policy titled, Wound Care, dated 09/21 revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Verify there is a physician's order for the procedure. Review of the facility policy titled, Pressure Reducing and Relieving Devices, not dated revealed the purpose of the procedure was to provide guidelines for the assessment of the appropriate reducing and relieving devices for residents at risk of skin breakdown. Redistributing support surfaces are to promote for bed or chairbound residents to prevent skin breakdown, promote circulation and provide pressure relief or reduction. Mattresses are chosen for the residents based on Braden scale pressure ulcer risk. Residents at risk for developing pressure ulcers should be placed on a redistribution support surface such as foam, gel, static, air, alternating air or air loss or gel when lying in bed. This deficiency represents noncompliance investigated under Complaint Number OH00162365.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital progress notes, staff interview, observation, resident interview, and review of the facility policy, the facility failed to ensure a resident received medication timely and as ordered by the physician. Actual Harm occurred when the facility failed to administer two scheduled doses of Suboxone (a medication used for opioid withdrawal) resulting in Resident #52 experiencing nausea, diaphoresis (sweating), and discomfort and resulted in the resident being transported to the hospital and admitted for opioid withdrawal symptoms. This affected one (Resident #52) of three residents reviewed for medication administration. The facility census was 72 residents. Findings include: Review of the medical record for Resident #52 revealed the resident was admitted on [DATE] with diagnoses including a history of intravenous (IV) drug use. Review of the physician's orders for Resident #52 revealed an order dated 09/12/24 for eight milligrams (mg) of Suboxone every twelve hours for opioid dependence. Review of the Medication Administration Record (MAR) for Resident #52 dated 09/12/24 revealed the staff documented the resident was not administered the evening dose of Suboxone as ordered by the physician. There was no documentation in Resident #52's record regarding the rationale for omission of the evening dose of Suboxone nor was there documentation of physician notification of the missed dose. Review of the MAR for Resident #52 dated 09/13/24 revealed the staff documented the resident was not administered the morning dose of Suboxone as ordered by the physician. There was no documentation in Resident #52's record regarding the rationale for omission of the morning dose of Suboxone nor was there documentation of physician notification of the missed dose. Review of the hospital progress note for Resident #52 dated 09/13/24 revealed the resident presented to the emergency room complaining of withdrawal symptoms due to not receiving scheduled doses of Suboxone at the facility and was admitted to the hospital. The resident was documented to have been receiving Suboxone since May of 2024 for the treatment of substance abuse. Interview with Licensed Practical Nurse (LPN) #200 on 09/13/24 confirmed Resident #52 was admitted during the afternoon on 09/12/24 and had not received scheduled doses of Suboxone on the evening of 09/12/24 or the morning of 09/13/24 due to the medication not being available. Observation on 09/13/24 at 12:40 P.M. of Resident #52 revealed the resident was lying on her left side and was curled into a ball. The resident was sweating and appeared to be uncomfortable. Interview on 09/13/24 at 12:40 P.M. with Resident #52 confirmed she was sweating, nauseous, and very uncomfortable. Resident #52 confirmed she had not received the scheduled doses of Suboxone ordered by the doctor since being admitted to the facility the day prior. The resident stated she had received the last dose of Suboxone in the hospital at 8:00 A.M. on 09/12/24 and did not receive scheduled doses the evening of 09/12/24 or the morning of 09/13/24. The resident stated she believed she was beginning to experience withdrawal symptoms due to missing scheduled medication doses. Telephone interview on 09/13/24 at 1:46 P.M. with Nurse Practitioner (NP) #500 confirmed Resident #52 was likely experiencing withdrawal symptoms due to not receiving scheduled doses of Suboxone on 09/12/24 and 09/13/24. NP #500 confirmed staff should have notified the physician or NP of the medication not being available for administration. Interview on 09/13/24 at 2:05 P.M. with Licensed Practical Nurse (LPN) #20 confirmed Resident #52 had been transferred to the hospital for evaluation due to complaints of nausea, sweating, and not feeling well due to missing scheduled doses of Suboxone. Review of the facility policy titled Medication Administration dated September 2018 revealed medications were to be administered in accordance with written orders of the prescriber. This deficiency represents noncompliance investigated under Complaint Number OH00156868.