**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observations, review of facility policy, and review of the guidelines from the National Pressure Injury Advisory Panel (NPIAP) website, the facility failed to adequately assess residents' skin, initiate prompt and timely treatment for residents' with pressure ulcers (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), provide ongoing monitoring of pressure ulcers and failed to timely implement physician ordered interventions to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers. This resulted in Actual Harm when a resident who was at risk for development of pressure ulcers and subsequently developed avoidable, facility acquired pressure ulcers which were not identified until they had reached an advanced stage. Resident #11 developed a pressure ulcer on the coccyx which was first identified as a stage IV pressure ulcer on 01/31/25 and a pressure ulcer on the left buttock which was first identified as unstageable on 01/31/25. This affected one (#11) of the three residents reviewed for pressure ulcers. The facility census was 92. Findings include: Review of the medical record for Resident #11 revealed an admission date of 09/21/23. Diagnoses included diabetes mellitus type 2, cerebral infarction, vascular dementia, and major depressive disorder. Review of the care plan dated 09/27/24 revealed Resident #11 had a potential for skin breakdown related to impaired mobility, diabetes, incontinence, and impaired cognition. Interventions included barrier ointment applied after incontinent care, instruct and assist the resident in shifting weight in wheelchair frequently, monitor nutritional status, and a pressure reduction mattress with a low-air loss mattress (LALM) to the bed. Review of a physician order dated 10/14/24, revealed Resident #11 was ordered a skin assessment weekly on Mondays every night shift (7:00 P.M. to 7:00 A.M.). Review of the January 2025 Certified Nursing Assistant (CNA) documentation survey report for Resident #11, revealed there was no documentation for rolling the resident from left to right on the following dates: 01/01/25 (day and night shifts); 01/02/25 (day and night shifts); 01/03/25 (day and night shifts); 01/04/25 (day shift); 01/05/25 through 01/14/25 (day and night shifts); 01/15/25 and 01/16/25 (night shift); 01/17/25 (day shift); 01/18/25 through 01/19/25 (day and night shifts); 01/20/25 (night shift); 01/21/25 through 01/24/25 (day and night shifts); 01/25/25 through 01/26/25 (night shift); 01/27/25 through 01/29/25 (day and night shifts); 01/30/25 (night shift); and 01/31/25 (day and night shifts). Review of the weekly skin assessments for Resident #11, revealed no documented evidence of any weekly skin assessments being completed for the month of January 2025. Review of the January 2025 Medication Administration Record (MAR) revealed all weekly skin assessments ordered for 01/06/25, 01/13/25, 01/20/25, and 01/27/25 were recorded with a nine, which indicated to see progress note. Review of the progress notes for Resident #11 dated 01/06/25, 01/13/25, 01/20/25, and 01/27/25, revealed there was no progress note related to the weekly skin observations. Review of the shower sheets for Resident #11 dated 01/21/25 and 01/24/25, revealed the shower sheets were not accurately completed and did not identify if the resident's skin was intact. Review of a progress note for Resident #11 dated 01/25/25 at 2:45 P.M., revealed the resident had a new skin concern located on the sacrum. The measurements were 5.0 centimeters (cm) in length by 4.0 cm in width. A second wound on the left buttock measured 3.0 cm in length by 2.5 cm in width. Treatments included cleaning with normal saline, pat dry, apply wound gel and cover with dry dressing. Resident #11 did not complain of pain. The physician and family were notified. Review of a physician order for Resident #11 dated 01/25/25, revealed the resident was ordered to have coccyx and left gluteal cleansed with normal saline, patted dry, wound gel applied, and covered with a dry dressing twice daily. Review of the January 2025 Treatment Administration Record (TAR) revealed Resident #11 had a nine marked on the morning treatments for 01/28/25 and 01/29/25. There was no documentation on 01/29/25 (evening treatment), 01/30/25 (morning and evening treatments), and 01/31/25 (morning treatment). Review of the progress notes for Resident #11 dated 01/28/25 and 01/29/25, revealed no documentation regarding the wound treatments marked with a nine. Review of a Wound Nurse Practitioner (WNP) progress note for Resident #11 dated 01/31/25 revealed the resident was assessed for a new skin impairment and a wound consultation. The findings included: Wound one was on the resident's coccyx and was categorized as a new, stage IV pressure ulcer. Measurements were 4.0 cm in length and 3.3 cm in width, with 50 percent (%) granulation (the formation of new connective tissue and tiny blood vessels on a wound's surface during the healing process) and 50 % slough (a layer of dead, yellow or gray tissue that separates from the underlying healthy skin), subcutaneous, adipose, and muscle tissue exposed, attached wound edges, with ecchymosis (bruising), scant amount of purulent and serosanguineous (a fluid that contains both blood and serum) drainage. Treatment plan consisted of cleansing the wound with normal saline, Dakins moistened gauze applied to the base of the wound and secured with a bordered foam twice daily and as needed. Wound two was on the resident's left buttock and was categorized as a new, unstageable pressure ulcer. Measurements were 6.2 cm in length by 0.3 cm in width by 0.5 cm in depth, with 20 % slough (a soft, yellow or white, dead tissue that accumulates on the surface of a wound or ulcer) and 80 % eschar (a thick, dry crust of dead tissue that forms over a wound), wound edges attached, erythema (redness), with scant amount of serosanguineous drainage. Treatment plan was to cleanse with normal saline, Hydrogel Calcium alginate applied to the base of wound, secured with bordered foam, and change daily as needed. Recommended ongoing and new interventions included: ongoing pressure reduction and turning/repositioning precautions per protocol, pressure reduction to the heels and all bony prominences, LALM for pressure reduction, and floating heels in bed with use of heel boots. Recommend washing peri-area with soap and water and pat dry thoroughly. Keep areas clean and dry, prevent skin to skin contact, prevent excessive moisture and apply barrier protections as needed. Review of the Five-Day Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 was not able to complete a Brief Interview for Mental Status (BIMS) because she was rarely/never understood. The resident was assessed to require substantial assistance with Activities of Daily Living (ADLS). Observation on 03/27/25 at 10:41 A.M., revealed Licensed Practical Nurse (LPN) #22 performed wound care with the assistance of Registered Nurse (RN) #30 to Resident #11's sacral and left buttock wounds. Wound bed of the sacral wound was about a softball in size with granulation tissue and slough present. LPN #22 cleansed the wound with normal saline, applied a layer of Santyl to the wound bed covered with Dakins moistened gauze to base of wound, covered with bordered foam and secured with tape. The wound bed of the left buttock was approximately the size of a quarter. LPN #22 cleansed the wound with normal saline, applied a layer of Santyl to the wound bed, covered with Dakins moistened gauze to base of wound, covered with bordered foam and secured with tape. Interview on 04/01/25 at 11:43 A.M. with the Director of Nursing (DON), verified the weekly skin assessments for Resident #11 were not completed as ordered. The DON also verified the lack of documentation for turning and repositioning a dependent resident (Resident #11). Interview on 04/01/25 at 3:19 P.M. with Wound Nurse Practitioner (WNP) #60, verified she was consulted to see Resident #11. WNP #60 stated she assessed the resident on 01/31/25 with a stage IV pressure ulcer on the resident's sacral region and an unstageable pressure ulcer to the left buttock. WNP #60 reported the wounds were pressure related and should have been avoided with proper turning and repositioning and timely incontinence care. Review of the facility policy titled, Skin Condition Assessment and Monitoring - Pressure and Non-Pressure, dated October 2024 revealed guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries, and other non-pressure skin conditions and assuring interventions were implemented. Residents identified would have a weekly skin assessment by a licensed nurse. Each resident would be observed for skin breakdown daily during care and on the assigned bath day by the certified nursing assistant (CNA). Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. Review of the NPIAP guidelines dated 2014 pages at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that included the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Review of the NPIAP website (https://npiap.com/page/PressureInjuryStages), revealed skin and soft tissue assessment is the basis of pressure injury prevention and treatment. Skin and tissue assessment is an essential component of any pressure injury risk assessment and should be conducted as soon as possible after admission and as a component of a full risk assessment. Each time the individual's clinical condition changes, a comprehensive skin and tissue assessment should be conducted to identify any alterations to skin characteristics or integrity, and to identify any new pressure injury risk factors. A comprehensive skin and soft tissue assessment consists of a head-to-toe assessment with particular focus on skin overlying bony prominence's including the sacrum, ischial tuberosities, greater trochanters and heels. In addition to comprehensive skin assessment, a brief skin assessment of the pressure points should be undertaken during repositioning. Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury is an obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. This deficiency represents non-compliance investigated under Complaint Number OH00161929.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff and resident interviews, review of facility policy and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to adequately assess residents' skin, initiate prompt and timely treatment for residents' with pressure ulcers (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), provide ongoing monitoring of pressure ulcers and failed to timely implement physician ordered interventions to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers. This resulted in Actual Harm when two Residents (#75 and #05) were admitted to the facility without pressure ulcers but were at risk for the development of pressure ulcers and subsequently developed avoidable, facility acquired pressure ulcers which were not identified until they had reached an advanced stage. Resident #75 developed a pressure ulcer on 06/04/24 which was first identified as a stage III (full-thickness skin loss in which adipose [fat] is visible) pressure ulcer on his right heel. Resident #75 developed another pressure ulcer on 08/20/24 which was first identified as a stage III pressure ulcer on his right flank. Resident #75 developed a third avoidable pressure ulcer on 09/11/24 which was first identified as a stage III pressure ulcer on the resident's sacrum. Additionally, Resident #05 was noted with skin breakdown by the licensed nurses on 07/13/24 and 07/16/24, and was not evaluated by the wound physician until 07/30/24 when Wound Care Physician (WCP) #198 diagnosed the resident with a stage III pressure ulcer on the resident's sacrum. This affected two (#75 and #05) of three residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. The facility census was 84. Findings include: 1) Review of the medical record for Resident #75 revealed the resident was admitted on [DATE]. Diagnoses included dementia, chronic kidney disease stage IV, diabetes mellitus type II and protein-calorie malnutrition. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] for Resident #75, revealed the resident was cognitively impaired, was dependent on staff for all activities of daily living (ADLs), Section M (Skin Conditions) revealed Resident #75 did not have a pressure ulcer/injury, was at risk of developing pressure ulcers/injuries and needed pressure relieving devices for the chair and bed. Review of the medical record for Resident #75 from 03/05/24 through 06/01/24, revealed no documentation of a plan of care, any skin risk assessments completed, and physician or Non-Physician Provider (NPP) visits completed for the resident. Review of a nurse progress note dated 06/01/24 for Resident #75 and authored by Licensed Practical Nurse (LPN) #410, revealed the resident had an area to the right heel measuring 7 centimeters (cm) in length by 4 cm in width by no depth. The area was dark brown in color and the surrounding tissue was red and blanchable with no warmth. The Medical Director (MD) #199 and Wound Care Nurse (WCN) #490 were notified. An order was received to apply skin prep to the resident's right heel two times a day and the doctor would be in on Monday. WCN #490 relayed the resident would be placed on the next weekly wound physician rounds. Treatment was applied, the resident was repositioned, and the family was notified. Review of a handwritten physician order dated 06/03/24 for Resident #75, located in the hard/paper chart, revealed the resident was ordered to wear bilateral heel protectors while in the bed or wheelchair. Review of a nurse progress note dated 06/04/24 for Resident #75 and authored by LPN #491, revealed the resident was seen by Wound Care Physician (WCP) #198 for a facility acquired stage III pressure injury to resident's right heel with an onset date of 06/01/24. Measurements were 2.7 centimeters (cm) in length by 2.7 cm in width by 0.1 cm in depth and minimal exudate (drainage) was present with no signs or symptoms of infection. WCP #198 gave orders for daily treatment of the wound and recommended the use of a low air loss (LAL) mattress and consult with physical therapy/occupational therapy for wound offloading needs of the resident's heels while in a wheelchair. Review of a physician order in the electronic medical record (EMR) dated 06/14/24 for Resident #75 by MD #199, revealed an order for Resident #75 to have an LAL mattress. Review of the June 2024, July 2024, August 2024 and September 2024 medication administration records (MAR) and treatment administration records (TAR) for Resident #75, revealed the daily dressing changes on the right heel were being completed as ordered. The MAR and TAR revealed no documented evidence that the heel protectors ordered on 06/03/24 and the LAL mattress ordered on 06/14/24 were ever implemented. Review of the weekly wound round visits by WCP #198, revealed Resident #75 was not assessed again by WCP #198 until 08/20/24, when the resident was evaluated for a newly acquired pressure ulcer. Review of a Wound Assessment and Plan visit note dated 08/20/24 for Resident #75 and authored by WCP #198, revealed the resident developed a new facility acquired Stage III pressure injury on his right flank which measured 21 cm in length by 14.2 cm in width by an unable to determine depth. There was 40 percent (%) granulation (new tissue), five % slough (peeling skin) and 55 % eschar (blackened/dead skin) with a moderate amount of exudate (drainage) and no signs and symptoms of infection. WCP #198 performed a sharp debridement (a medical procedure that involves removing dead, infected, or damaged tissue from a wound to help it heal) procedure to remove the eschar and slough. WCP #198 gave orders for daily treatment of the wound, weekly visits and ordered for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank). Review of a Wound Assessment and Plan visit note dated 09/03/24 for Resident #75 and authored by WCP #198, revealed the stage III pressure ulcer on the resident's right flank pressure injury measured 11.5 cm length by 8.5 cm width by 0.1 cm depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and ordered a LAL mattress for wound off-loading. Review of a Wound Assessment and Plan visit note dated 09/11/24 for Resident #75 and authored by WCP #198, revealed the resident developed a new facility acquired stage III pressure injury on his sacrum which measured 7.5 cm in length by 3.3 cm in width by 0.1 cm in depth. WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended a LAL mattress for wound off-loading. The right flank stage III pressure injury measured 8.6 cm in length by 6.2 cm in width by 0.1 cm in depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and ordered for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank). Review of Resident #75's only documented Braden Scale - for Predicting Pressure Sore Risk, dated 09/15/24, revealed the resident was at very high risk for developing pressures ulcers. Review of a Wound Assessment and Plan visit note dated 09/17/24 for Resident #75 and authored by WCP #198, revealed the resident's right flank stage III pressure ulcer measured 3.9 cm in length by 4.4 cm in width by 0.1 cm in depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. The sacrum pressure injury measured 3.2 cm in length by 4.9 cm in width by 0.1 cm in depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound. The resident had a new diabetic ulcer on her right heel which measured 0.6 cm in length by 0.6 cm in width by 0.1 cm in depth. WCP #198 gave orders for daily treatment of the wound, weekly wound care visits and recommended for the resident to have a LAL mattress. Review of a Wound Assessment and Plan visit note dated 09/24/24 for Resident #75, and authored by WCP #198, revealed the resident's right flank pressure injury measured 6.9 cm in length by 1.3 cm in width by 0.1 cm in depth (an increase in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and ordered for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. The resident's right heel diabetic ulcer measured 3.6 cm in length by 3.4 cm in width by 0.1 cm in depth (an increase in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended the resident to have a LAL mattress. The sacrum pressure injury measured 6.3 cm in length by 1.3 cm in width by 0.1 cm in depth (an increase in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended the resident to have a LAL mattress. Review of a Wound Assessment and Plan visit dated 10/01/24 for Resident #75 and authored by WCP #198, revealed the resident's right flank pressure injury measured 4.9 cm in length by 1.6 cm in width by 0.2 cm in depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and ordered for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. The right heel diabetic ulcer measured 2.1 cm in length by 1.5 cm in width by 0.1 cm in depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for the resident to have an LAL mattress. The sacrum pressure ulcer measured 6.3 cm in length by 1.3 cm in width by 0.1 cm in depth (no changes). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended the resident to have a LAL mattress. Review of a Wound Assessment and Plan visit dated 10/08/24 for Resident #75 and authored by WCP #198, revealed the resident's right flank pressure injury measured 4.5 cm length by 1.7 cm width by 0.2 cm depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. The right heel diabetic ulcer measured 2.3 cm length by 0.7 cm width by 0.1 cm depth (an increase in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended the resident to have a LAL mattress. The sacrum wound was healed. A preventative wound recommendation was for the resident to have a LAL mattress. Review of a Wound Assessment and Plan visit dated 10/15/24 for Resident #75 and authored by WCP #198, revealed the resident's right flank pressure injury measured 4.1 cm in length by 1.4 cm in width by 0.2 cm in depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. The right heel diabetic ulcer was healed. Review of a physician order dated 10/17/24 for Resident #75, revealed the resident was ordered to have weekly skin assessments every Wednesday and notify the physician for any new impairments. Review of a Wound Assessment and Plan visit note dated 10/22/24 for Resident #75 and authored by WCP #198, revealed the resident's right flank pressure injury measured 2.1 cm in length by 1.1 cm in width by 0.2 cm in depth (decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. Review of a Wound Assessment and Plan note dated 11/05/24 for Resident #75 authored by WCP #198, revealed the resident's right flank pressure injury measured 2.0 cm in length by 1.0 cm in width by 0.1 cm in depth (decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. Interview with MDS Coordinator #395 on 11/06/24 at 10:35 A.M., revealed she assisted in updating the residents' care plans. MDS Coordinator #396 verified she never placed any specific off-loading interventions on Resident #75's plan of care and if the staff needed to know of any specific interventions for Resident #75, they would have to go into the physician's orders to view them. MDS Coordinator #395 indicated the facility did not utilize any type of quick reference [NAME] system. MDS Coordinator #395 verified there was no LAL mattress, or bilateral heel protectors assessed on the MDS. Interview with LPN #420 on 11/06/24 at 11:35 A.M. who reported being Resident #75's regular nurse, revealed she had no knowledge of the order dated 06/14/24 for Resident #75 to have a LAL mattress. LPN #420 stated she was aware of the bilateral heel protectors for the resident because the order was reflected on the MAR. LPN #420 verified the LAL mattress was not in place on Resident #75's bed when the resident developed the stage III pressure ulcers. Observation of Resident #75's room on 11/06/24 at 11:45 A.M. with CNA #575, revealed the resident was seated in a wheelchair with no heel protectors in place and the resident's bed did not have a LAL mattress in place. Interview with CNA #575 at the same time revealed she was unaware Resident #75 had physician orders for a LAL mattress and bilateral heel protectors. Interview with the Interim Director of Nursing (DON) on 11/06/24 at 1:33 P.M., revealed Resident #75 was ordered to have bilateral heel protectors on 06/03/24 and there was no documented evidence that the bilateral heel protectors were ever implemented. The Interim DON verified the resident was ordered to have a LAL mattress on 06/14/24 which wasn't implemented until 11/06/24 when the surveyor questioned it. The Interim DON verified Resident #75 developed an avoidable facility acquired stage III pressure ulcer on the right heel on 06/04/24 and was not assessed again by WCP #198 until 08/20/24 when the resident developed another facility acquired stage III pressure ulcer on the resident's right flank. The Interim DON verified Resident #75 developed a third stage III pressure ulcer on the resident's sacrum on 09/11/24. The Interim DON acknowledged Resident #75's pressure ulcers should have been identified before they had reached an advanced stage. The Interim DON stated the facility did not have a [NAME] type system in place for the staff to use as a quick reference for any physician ordered care interventions for the residents. The Interim DON stated the staff would have to access the physician orders in order to find out if there were any ordered interventions in place for the residents. The Interim DON stated the CNAs did not have access to the physician orders and would have no way of knowing about any specific interventions unless the nursing staff relayed the information. Observation of Resident#75's room on 11/06/24 at 3:45 P.M., revealed the resident was in bed and had a LAL mattress on the bed and was wearing bilateral heel protectors. Review of a Wound Assessment and Plan visit note dated 11/27/24 for Resident #75 and authored by WCP #198, revealed the resident's right flank pressure injury wound measured 2.7 cm in length by 11.3 cm in width by 0.1 cm in depth (decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank). Attempted interview with WCP #198 on 12/02/24 at 3:23 P.M. and again on 12/04/24 at 9:05 A.M. with no success. Interview with Regional Director of Rehabilitation (RDR) #800 on 12/04/24 at 1:04 P.M. revealed the facility had been through three different therapy providers since June 2024 with the most recent change in therapy providers taking place on 11/11/24. RDR #800 verified WCP #198 had ordered physical therapy/occupational therapy to be consulted for Resident #75's wound offloading needs. RDR #800 verified there was no documented evidence Resident #75 had been evaluated by therapy for the off-loading needs. Follow-up interview with the Interim DON on 12/04/24 at 4:42 P.M., verified Resident #75 was ordered to have a therapy consultation for off-loading needs on 08/20/24 by WCP #198. Interim DON verified the facility did not have any therapy records for Resident #75 prior to the 11/11/24 transition because the therapy records did not transition over to the new therapy provider. The Interim DON stated the facility recently parted ways with WCP #198 due to several issues and it was not an amicable departure. 2) Review of the medical record for Resident #05 revealed the resident was admitted on [DATE]. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included cerebral infarction (stroke) with hemiplegia affecting dominant side, left femur fracture, and displaced fracture of second cervical vertebrae. Review of the admission History and Physical dated 06/14/24 for Resident #05 revealed the only identified skin impairment was a surgical incision for a repaired left femur fracture. Review of the MDS five-day assessment dated [DATE] for Resident #05, Section M (Skin Conditions) revealed the resident did not have a pressure ulcer/injury, was at risk of developing pressure ulcers/injuries and needed pressure relieving devices for the bed and chair due to a surgical incision. Review of the plan of care dated 06/20/24, revealed Resident #05 had a focus area for skin impairments due to impaired mobility, recent left hip replacement, and osteoarthritis. Interventions included, but not limited to, pressure reduction cushion to wheelchair per facility protocol, apply moisture barrier cream after incontinent care, turn and reposition frequently, follow facility policies/protocols for the prevention/treatment of skin breakdown, instruct/assist to shift weight in wheelchair frequently, and LAL mattress to bed and check placement and function per facility protocol. Review of the June 2024, July 2024, August 2024 and September 2024 MARs and TARs revealed no documented evidence Resident #05 had an order for a LAL mattress or had one in place. Review of a nurse progress note dated 07/05/24 at 6:00 P.M. for Resident #05 and authored by LPN #499, revealed the resident readmitted to the facility from the hospital at 1:30 P.M. There was an area to the resident's coccyx, pink in color, measured 3.0 cm in length by 1.5 cm in width by 0 cm in depth. A dry dressing was applied after cleaning with normal saline. There is no documented evidence that the physician or other provider was notified of the new area identified on the resident's coccyx. Review of the hospital Continuity of Care discharge form dated 07/05/24, revealed when Resident #05 was discharged from the hospital, the only wound present was a surgical incision to the left hip. Resident #05 was hospitalized from [DATE] to 07/05/24 due to acute respiratory failure with hypoxia. Review of the re-admission History and Physical dated 07/08/24 for Resident #05, revealed the only documented skin impairment, was a surgical incision for the repaired left femur fracture. Review of a nurse progress note dated 07/13/24 at 7:00 A.M. for Resident #05 authored by RN #397, revealed Resident #05 was alert, oriented, had normal breathing with no shortness of breath reported and no other complaints. Dressing to left hip continued with no breakthrough drainage noted. Resident #05 noted with skin breakdown to coccyx area which measured 5 cm in length by 3 cm in width and a dressing was applied. The Foley catheter was patent and draining dark colored urine. Review of a nurse progress note dated 07/16/24 for Resident #05 authored by RN #396 revealed the resident was resting in bed with normal vital signs. The nurse was called to the resident's room to observe the skin breakdown on the resident's coccyx area. The color was pink and dark/scabbed in some places which were noted on admission. The area was cleansed with normal saline. The resident reportedly had three episodes diarrhea. Nurse Practitioner (NP) called and ordered for the resident to have a one-time dose of Imodium (anti-diarrhea). The resident's daughter was notified of the diarrhea and the medication. There was no documented evidence of the NP being notified of the skin breakdown. Review of the nurse progress notes from 07/17/24 to 07/30/24 for Resident #05, revealed no additional documentation of the resident's skin breakdown on his coccyx. Review of the weekly skin assessments from 07/17/24 to 07/30/24 for Resident #05 revealed no documented evidence of any skin assessments being completed. Review of a physician order dated 07/17/24 for Resident #05, revealed the resident was ordered to have weekly skin assessments and to notify physician if a new skin impairment developed. Review of a Wound Assessment and Plan note dated 7/30/24 for Resident #05 and authored by WCP #198 revealed the resident was evaluated and diagnosed with a new facility acquired stage III pressure ulcer on his sacrum. The new pressure ulcer measured 3.4 cm in length by 2.0 cm in width and unable to determine depth. The wound had 20 % granulation, 70 % slough, 10% eschar, minimal exudate, and no signs and symptoms of infection. The resident's wound was debrided to remove excess eschar and slough tissue. Post debridement wound bed had 35 % slough and eschar remaining and post debridement wound bed measurement 3.3 cm in length by 2.2 cm in width by 0.5 cm in depth. WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended the resident to have a LAL mattress. Review of a nurse progress note dated 07/31/24 for Resident #05 and authored by WCN #490, revealed the resident was seen by WCP #198 during the weekly wound care rounds on 07/30/24. The resident had a stage III sacrum pressure injury which measured 3.4 cm in length x 2.0 cm in width and unable to determine depth. Resident was ordered to have his sacrum cleansed with normal saline, hydrogel gauze applied, covered with dry dressing and changed daily and as needed. The resident and family are aware of the new orders and voiced understanding. Review of the physician orders dated 07/31/24 for Resident #05, revealed an order to cleanse the resident's sacral wound with normal saline, apply hydrogel gauze to wound bed, cover with dry dressing, change daily every night shift and as needed. Review of a Wound Assessment and Plan for Resident #05 dated 08/06/24, 08/13/24 08/20/24 08/27/24, 09/03/24, 09/11/24, 09/17/24, 09/24/24, 10/01/24, 10/08/24, 10/15/24, 10/22/24, and 11/05/24 and authored by WCP #198, revealed the resident was ordered to have a LAL mattress. Review of a physician order dated 10/22/24 for Resident #05, revealed the resident was ordered a LAL mattress due to resident being a high-risk for skin breakdown. Interview with the Interim DON on 11/06/24 at 3:00 P.M., revealed the staff had to look at the physician orders or the MARs and/or TARs to view any specific resident care interventions which was not practical. The Interim DON stated the CNAs did not have access to the physician's orders to view any specific interventions ordered for the residents. Observation on 11/18/24 at 12:10 P.M. revealed Resident #05 was in bed and had an LAL mattress in place. Interview with the Interim DON on 11/18/24 at 12:16 P.M. verified Resident #05 was at risk for developing pressure ulcers and was diagnosed with a facility acquired stage III pressure injury located on the resident's sacrum on 07/30/24. The Interim DON verified the pressure ulcer was not identified until it had reached a stage III. The interim DON verified Resident #05's LAL mattress was ordered on 07/30/24 by WCP #198 and not put in place until 10/22/24. Interview with WCN #490 on 11/18/24 at 12:33 P.M., verified Resident #05 was at risk for developing pressure ulcers when the resident developed a facility acquired pressure ulcer on his sacrum and it was not identified until it reached a stage III. WCN #490 verified WCP #198 ordered a LAL mattress on 07/30/24 and it was not put in place until 10/22/24. Interview via phone with RN #396 on 12/02/24 at 7:51 P.M. verified there was no documented evidence that the physician or the facility administration was notified when she observed Resident #05's skin breakdown on the coccyx. RN #396 stated she had no recollection of the resident's wounds. Interview via phone with LPN #499 on 12/02/24 at 8:03 P.M. verified there was no documented evidence that the physician or the facility administration was notified when she observed Resident #05's skin breakdown on the coccyx. LPN #499 stated she had no recollection of the resident's wounds. Interview via phone with RN #397 on 12/03/24 at 2:28 P.M. verified there was no documented evidence that the physician or the facility administration was notified when he observed Resident #05's skin breakdown on the coccyx. RN #397 stated he had no recollection of the resident's wounds. Review of the facility policy titled, Skin Condition Assessment and Monitoring-Pressure and Non-Pressure, last updated October 2024, revealed the purpose of the policy is to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. Guidelines include pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record. The facility policy also states that residents identified will have a weekly skin assessment completed by a licensed nurse. Review of the NPIAP, 2019 edition, pages 75 to 81, indicate skin and soft tissue assessment is the basis of pressure injury prevention and treatment. Skin and tissue assessment is an essential component of any pressure injury risk assessment and should be conducted as soon as possible after admission, as a component of a full risk assessment (see the guideline chapter on Risk Factors and Risk Assessment). Each time the individual's clinical condition changes, a comprehensive skin and tissue assessment should be conducted to identify any alterations to skin characteristics or integrity, and to identify any new pressure injury risk factors. Finally, a comprehensive skin and soft tissue assessment should be conducted on discharge, to ensure that an appropriate pressure injury prevention and treatment plan is in place. A comprehensive skin and soft tissue assessment consists of a head-to-toe assessment with particular focus on skin overlying bony prominence's including the sacrum, ischial tuberosities, greater trochanters and heels. In addition to comprehensive skin assessment, a brief skin assessment of the pressure points should be undertaken during repositioning. Check the pressure points on which the individual has been positioned to identify any alterations in condition and to evaluate the effectiveness of the repositioning regimen. Presence of persistent erythema can indicate a need to increase frequency of repositioning. Check pressure points onto which the individual will be repositioned to ensure that the skin and tissue has fully recovered from previous loading. The NPIAP Pressure Injury Stages, revealed if necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). This deficiency represents noncompliance investigated under Complaint Number OH00158062 and Complaint Number OH00160225.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, physician interview, and review of the hospital records, the facility failed to monitor a resident's lack of bowel movements, implement interventions to prevent a fecal impaction, and assess a resident with signs of fecal impaction. This resulted in Actual Harm when Resident #16 had no bowel movements for four days, no assessment of the resident was completed, no interventions were provided, physician ordered as needed laxatives were not administered, and the physician was not notified. Subsequently, Resident #16 experienced abdominal pain, vomiting, and was admitted to the hospital with a large fecal impaction which required treatment with medications, enemas, and a nasogastric tube. This affected one (#16) of two residents reviewed for hospitalization. In addition, the facility failed to ensure timely treatment for a diabetic ulcer was implemented. This affected one (#57) of two residents reviewed for skin conditions. The census was 90. Findings include: 1. Review of the medical record review revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included sepsis, diabetes, malnutrition, depression, metabolic encephalopathy, and acute cystitis without hematuria. Review of the significant change Minimum Data Set (MDS) assessment, dated 03/17/22, revealed Resident #16 had severely impaired cognition. Resident #16 required extensive assistance for bed mobility with two staff members and total assistance for transfers, toilet use and eating. Resident #16 had an indwelling urinary catheter and was always incontinent of bowel. Resident #16 has a gastrostomy tube and received nutritional support daily. Review of the plan of care, dated 11/22/21, revealed Resident #16 was at risk for constipation related to impaired mobility, history of constipation, medications, diabetes mellitus, and degenerative neurological disorder. Interventions included administer laxatives/stool softeners as ordered, dietary consult as needed, encourage physical activity as tolerated, follow facility bowel protocol for bowel management, monitor medication for side effects of constipation, keep physician informed of any problems, monitor bowel movement patterns, and monitor/document/report as needed signs and symptoms of complications related to constipation such as: change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation, bradycardia, abdominal distention and vomiting, new onset of small loose stools, fecal smearing, bowel sounds, diaphoresis, abdomen tenderness, guarding, rigidity, and fecal compaction. Review of the physician's orders for December 2021 revealed Resident #16 had an order dated 11/19/21 for polyethylene glycol 510 grams (gm) mix 17 gm with juice or water and take by mouth nightly. There was also an order dated 11/18/21 for docusate sodium 100 mg soft gel take one capsule by mouth daily as needed. Review of the facility look back summary for bowel movements, dated 12/01/21 through 01/07/22, revealed Resident #16 had a large bowel movement on 12/23/21. There was no recorded bowel movements on 12/24/21 and the summary had no entries on 12/25/21, 12/26/21, 12/27/21. An entry dated 12/28/21 revealed a medium soft formed bowel movement occurred at 2:57 P.M. Resident #16 had a small bowel movement on 12/30/21 was recorded at 2:19 A.M. No bowel movement was recorded on 12/31/21. Review of the Medication Administration Record (MAR) for December 2021 revealed docusate sodium 100 mg soft gel as needed was not administered during the month of December 2021. Review of the department notes on 12/31/21 at 11:35 A.M. revealed Resident #16 was complaining of abdominal pain. The physician was notified and advised to send the resident to the emergency room for further evaluation. Review of the department notes on 12/31/21 at 5:51 P.M. revealed Resident #16 was admitted to the hospital for a fecal impaction. Review of the emergency room note for Resident #16 dated 12/31/21, revealed the reason for the visit was altered mental status. History and physical noted the resident complaining about some pain on the side of his head, abdominal pain and difficulty pooping. Physical examination revealed abdomen diffusely firm with some tenderness to palpation. Resident #16 was admitted to the hospital for further evaluation and management of altered mental status and stercoral colitis (chronic constipation leading to fecal impaction). Review of the hospital imaging studies report, dated 12/31/21, revealed a computed tomography (CT) scan was administered with contrast (dye to highlight areas of the body being examined). The CT scan results revealed Resident #16 had a large amount of stool present with the greatest amount in the rectum. Additionally, a large rectal stool ball was evident measuring up to nine centimeters (cm) in diameter with mass effect on the bladder. The impression listed a large amount of stool with a large rectal stool ball and possible stercoral colitis. Study impression and plan of care revealed a large stool burden. Recommendation included saline, mineral oil, and glycerin (SMOG) enema two times a day and start Golytely if able to take by mouth. Review of hospital progress notes, dated 01/01/22, revealed Resident #16 presents to the hospital with worsening abdominal pain. Resident #16 has increasing nausea, emesis, abdominal pain and distention. In emergency room department the resident was found to have severe stool overload from unclear reasons. The resident was given SMOG enemas with placement of nasogastric tube (NG) and Golytely prep. The resident had massive results with extensive bowel movements and decompression. Resident #16 was diagnosed with stercocral colitis, severe constipation, and positive for Covid-19. Review of the hospital progress notes, dated 01/04/22, for revealed no acute events overnight and the resident continued to have large explosive bowel movements. Review of the physical exam revealed mildly distended abdomen with bowel sounds diminished. Review of the hospital progress notes, dated 01/05/22, revealed no acute events overnight and Resident #16 continued to have large explosive bowel movements. Review of the physical exam revealed mildly distended abdomen with bowel sounds diminished. Interview on 05/24/22 at 12:33 P.M., Licensed Practical Nurse (LPN) #178 stated nurses should check the electronic health record and review the residents on the assignment to ensure no laxatives were needed. LPN #178 verified residents with no bowel movements in three days should have received a laxative per the bowel protocol. Interview on 5/25/22 at 10:24 P.M., State Tested Nursing Assistant (STNA) #152 stated when a resident has a bowel movement the aides record it in the electronic health record. STNA #152 stated she did not know how to look back to see if a resident had a bowel movement on any other shift other than the one she was entering. STNA #152 stated the nurse will look up a resident's bowel movements if we have any problems. Interview on 05/25/22 at 3:17 P.M., the Regional Registered Nurse (RN) #225 stated the facility does not have a policy related to constipation. The expectation was if a resident did not have a bowel movement after three days a laxative was given. RN #225 verified there were multiple days on the look back assessment for bowel movement monitoring that was blank during the 12/01/21 through 01/07/22 time period for Resident #16 and no as needed laxative medication given. Interview on 06/02/22 at 12:09 P.M., LPN #227 stated she was assigned to care for Resident #16 on 12/31/21. LPN #227 verified she did not complete any abdominal assessment for the resident on the day that he was discharged . Resident #16 was yelling out in pain, vomiting, and wanted to go to the hospital. LPN #227 stated she got his vital signs and called 911 for the transfer. LPN #227 stated she was working as an agency nurse for the facility and was unable to access the electronic health record at that time. The STNAs would let her know if a resident needed a laxative and no one had said anything. LPN #227 stated she did not have access to the bowel monitoring at the time of Resident #16's transfer and was not told by staff that he needed a laxative. Interview on 06/03/22 at 4:45 P.M., the facility Medical Director #251 stated she was not notified Resident #16 did not have a bowel movement for four days in December 2021 prior to being hospitalized for a fecal impaction. Medical Director #251 stated if she had been notified she would have ordered an abdominal radiography (x-ray) test to determine if the resident had a problem. The results of the x-ray would determine the next step in treatment. Interview on 06/06/22 at 8:40 A.M., Dietician #206 stated Resident #16 had a diagnosis of constipation but it was an old one from the hospital. Dietician #206 was not aware of any problems since he had been in the facility and there were no specific dietary interventions in place. Dietician #206 stated he was not asked to consult on any dietary interventions for Resident #16. Interview on 06/06/22 at 8:53 A.M., LPN #177, who was assigned to care for Resident #16 on 12/26/21, stated she would have charted a laxative on the medication administration record if she had provided one. LPN #177 stated the STNA would let the nurses know if a resident needed to have a bowel movement. The agency staff working at the facility have had difficulty documenting in the electronic health record. 2. Medical record review for Resident #57 revealed an admission dated 04/28/21. Diagnoses included cancer, heart failure, coronary artery disease, renal insufficiency, diabetes, anxiety, and depression. Review of the MDS dated [DATE] revealed Resident #57 was cognitively intact. The resident required extensive assistance for bed mobility, transfers, and toilet use. The resident was independent for eating. She was frequently incontinent for bowel and bladder. Review of the physician note dated 04/28/21 revealed no mention for a treatment to Resident #57's toe. Review of progress notes dated 04/29/21 revealed there was an area to the right foot second toe. Review of the Treatment Administration Record (TAR) for Resident #57 from 04/28/21 through 04/30/21 revealed the TAR was missing from the chart. Review of the progress notes dated 05/03/21 revealed Resident #57 was admitted with a diabetic ulcer to the right second toe dorsal surface. New order was for betadine moistened gauze to ulcer and cover with dry gauze, twice daily and Aquaphor, to left toes daily, wound specialist visit weekly at the facility. Review of the physician orders dated 05/03/21 revealed an order for right foot second toe to cleanse with normal saline, apply betadine moistened gauze and cover with dry dressing twice a day. Interview with Resident #57 on 05/23/22 at 10:29 A.M. revealed she didn't get her dressing changes on her right foot second toe like she should have been Interview with Licensed Practical Nurse (LPN) #118 on 05/26/22 at 11:05 A.M. revealed she was the admitting nurse for Resident #57 and admitted she did not put a treatment in place for the resident's toe. She said normally when a new admission came into the facility the unit manager would look at the wound the next day and call the physician for a treatment. She said the unit manager no longer worked at the facility.