**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, hospital record review, toxicology report review, review of the facility admission policy, review of the facility assessment and interviews, the facility failed to ensure Resident #82 received adequate, timely and appropriate treatment and continuity of care following admission to the facility resulting in a situation of neglect. This resulted in Immediate Jeopardy and serious life-threatening harm/subsequent death beginning on [DATE] at 8:30 P.M. when Resident #82, who had been hospitalized prior to admission, arrived at the facility for placement and staff failed to obtain physician orders for medications/treatments or contact the physician/medical director regarding the resident's admission. From [DATE] through [DATE] the resident was not ordered and did not receive medications including blood pressure medication, blood thinning medication, or insulin. In addition, Resident #82 presented to the facility with a history of illegal drug use; however, the facility failed to adequately identify this history or implement comprehensive and individualized interventions to maintain the resident's safety (as it pertained to his history of drug abuse). On [DATE] at 1:39 A.M., Resident #82 activated his call light for complaints of shortness of breath. The resident's condition continued to deteriorate, and emergency medical services was called via nine-one-one (911). On [DATE] at 1:54 A.M., CPR (cardiopulmonary resuscitation) was initiated. Resident #82 was subsequently pronounced deceased by emergency medical service (EMS) staff on [DATE] at 2:19 A.M. After being pronounced deceased , the facility failed to provide timely and appropriate post-mortem care by allowing the resident's body to remain in the facility from 2:19 A.M. until 1:56 P.M. when his body was eventually transported to the morgue, as facility staff did not know how to proceed with the resident's deceased body. This affected one (#82) resident of three residents reviewed for death. The facility census was 81. On [DATE] at 2:48 P.M., the Administrator, Regional Registered Nurse (RRN) #481 and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 8:30 P.M. when facility staff admitted Resident #82 to the facility, after he had left AMA from the hospital, and neglected to notify the physician of the resident's admission to the facility and lack of admission orders to provide continuity of care to the resident with known comorbidities. Despite a known history of drug abuse, the facility did not have appropriate supervision in place to provide a safe environment. The resident experienced a rapid condition change on [DATE], which required CPR; however, the resident expired at the facility. Following the resident's death, his body remained at the facility 11 hours and 37 minutes before being transported to the morgue for further assessment and determination of his final resting place. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 2:19 A.M., Resident #82 expired at the facility. • On [DATE] at 1:56 P.M., Resident #82's body was transferred to the morgue. • On [DATE], in-person and/or by phone education was provided to the facility's 32 nurses which included 12 Registered Nurses (RN) and 20 Licensed Practical Nurses (LPN) by the DON and Staff Development Coordinator (SDC) #81 on the facility's admission policies, notification of the physician on admission, and physician orders, including medications. One-on-one education was provided to RN #15 and RN #35 as they were responsible for Resident #82's care during admission. • On [DATE], the initial Self-Reported Incident (SRI) was submitted by the Administrator based on the allegation of neglect. The admitting nurse for Resident #82, RN #35, was suspended on [DATE] at 7:30 P.M. pending the outcome of the investigation. • On [DATE], a whole house audit of 23 residents admitted within the last 30 days was conducted by the DON, RRN #481 and the Administrator to ensure physician orders were consistent with hospital discharge orders and physicians were notified of admission. The 23 residents reviewed were Resident #6, #12, #24, #25, #28, #29, #33, #43, #66, #82, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, #97 and #98 and no discrepancies were identified. Weekly, all new admissions and re-admissions will be audited by the DON or designee for four weeks to ensure physician notification and physician orders are included. • On [DATE], in person and/or by phone education was provided by the DON and/or SDC #81 to all 32 licensed nurses to communicate with facility leadership regarding changes that may occur to a resident's admission to the facility or with the hospital discharge plan, to seek further instruction and guidance; that residents with a history of drug abuse have a care plan with appropriate interventions in place; administration of an opioid reversal agent in suspected opioid overdose; the policy for postmortem care and pronouncement of death to include timely notification for release of a deceased resident and notification of the police and/or coroner as necessary. • On [DATE], a whole house audit for residents with a drug abuse history diagnosis was completed by RRN #418/designee to ensure interventions were in place and care plans reflected updated interventions as needed. Staff can access the care plan and [NAME] (information regarding the resident's care) through the electronic medical record. Three residents were identified (Residents #38, #44 and #74) and had appropriate care plans. Weekly audits of care plans will be completed by the DON/designee for four weeks to ensure care plans for all residents with a history of drug abuse are appropriate. • On [DATE], audits of residents who have expired in the facility from [DATE] through [DATE] were reviewed by the DON/designee to ensure they were provided with timely and appropriate postmortem care with notifications of the coroner and police as appropriate. Weekly audits for four weeks will be completed by the DON or designee to ensure compliance. • On [DATE] at 8:15 P.M., an Ad Hoc (not scheduled) Quality Assurance and Performance Improvement Plan meeting was held with the DON, Administrator and RRN #481 in person and Certified Nurse Practitioner #493 by phone to discuss the removal plan and root cause analysis (RCA). The RCA was identified as the admission process was not followed per protocol. • On [DATE] at 9:21 P.M., the Medical Director was notified of and approved the QAPI plan. • All audits will be conducted weekly for four weeks and results will be discussed at the monthly QAPI meeting. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #82's hospital documentation (state agency requested as part of the onsite investigation) revealed the resident was admitted to the hospital on [DATE] after he had arrived at the emergency room via ambulance transport due to shortness of breath. Further review of the medical record revealed a history and physical dated [DATE] that revealed the resident experienced acute hypoxic (decreased oxygen levels) and hypercapnia (the body can't remove excess carbon dioxide from the blood so there is a buildup and the body can't maintain proper ventilation) respiratory failure, crack lung (an acute lung injury related to smoking crack cocaine and can cause lung injury, cough, difficulty breathing and even death) versus aspiration pneumonia (a substance from the stomach or mouth enters the lung and causes pneumonia) versus pulmonary edema (a condition caused by too much fluid in the lungs) exacerbation of chronic obstructive pulmonary disease, elevated troponin (a cardiac enzyme that becomes elevated when there is damage to heart muscle), suspect myocardial infarction (heart attack), acute metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic condition), hyperglycemia (blood glucose was 342 milligrams per deciliter of blood ((mg/dL)) on admission. A healthy adult blood glucose level ranges between 70-100 mg/dL), polysubstance abuse (positive for cocaine and fentanyl on admission), lung nodule in the left lower lobe (of the lung), and right renal cystic lesion. The patient required hospitalization due to acute respiratory failure in the setting of recent crack cocaine use requiring intubation and mechanical ventilation. Further review of the requested hospital record revealed a cardiology progress note dated [DATE] indicating the resident developed paroxysmal atrial fibrillation with a rapid ventricular response, multifocal atrial tachycardia and supraventricular tachycardia (all heart rhythms where the heart doesn't have a normal signaling process telling the heart when to beat and the signaling is disorganized and parts of your heart beat out of sync and may cause blood clots or compromised blood flow throughout the body). The resident also had newly diagnosed cardiomyopathy (disease that affects the heart muscle and may cause the heart muscle to become weakened, thickened, or rigid, making it difficult for the heart to pump blood effectively) with the heart ejecting only 30-35% of blood from the left ventricle. The resident was given Lasix intravenously and amiodarone (antiarrhythmic) intravenously (to treat heart failure and abnormal heart rate). Further review of the requested hospital records revealed Resident #82 was prescribed no medications prior to admission to the hospital. During Resident #82's stay at the hospital, he was prescribed medications including amiodarone 200 mg (milligrams) daily, Eliquis (blood thinner) 5 mg twice a day, Lipitor (cholesterol medication) 40 mg nightly, Plavix (antiplatelet medication that prevents platelets from clumping together into blood clots) 75 mg daily, folic acid (form of Vitamin B) 1 mg daily, Lasix (diuretic) 20 mg twice daily, insulin lispro (fast acting insulin) injection 1 to 6 units subcutaneous three times a day before meals, Lopressor (a beta-blocker that treats angina, high blood pressure and heart failure) 12.5 mg twice a day, NicoDerm CQ 21 mg/24 hours transdermal daily, MiraLAX (laxative) 17 grams twice daily, Seroquel (antipsychotic) 25 mg twice daily, and Xopenex (bronchodilator) 1.25 mg/0.5 ml nebulizer solution every 6 hours when needed. Review of the hospital Discharge summary dated [DATE] revealed Resident #82 was going to leave the hospital against medical advice (AMA) because his dog had a tumor on his face. The physician presented at the bedside and discussed this would be against medical advice, discussed the risks including worsening heart failure, cardiovascular accident (CVA), ACS (acute coronary syndrome), hypoxia, ischemia (restriction in blood flow) and death. Resident #82 expressed understanding. He signed out AMA on [DATE]. Review of Resident #82's facility closed medical record revealed he was admitted on [DATE]. Diagnoses included metabolic encephalopathy, respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), pulmonary edema, substance abuse, prediabetes and cardiomyopathy. Further review revealed no documentation of any admission orders or communication with the medical director for Resident #82 during the resident's stay at the facility. The resident discharged from the facility on [DATE]. Review of the admission baseline care plan dated [DATE] revealed the resident was at risk for elopement and negative health outcomes related to continued substance use while at the facility. Interventions included encourage to participate in activities of interest and medications per orders. Review of the progress notes dated [DATE] at 10:04 P.M. revealed Resident #82 showed no signs and symptoms of distress, is able to make needs and wants known, no concerns noted. Resident is on continued monitoring. Review of the progress notes dated [DATE] at 10:49 P.M. revealed Resident #82 was resting in bed, respirations are even and unlabored, lung sounds are clear bilaterally, denies pain and is able to make his needs known. Resident #82 is on continued monitoring. Review of the admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed the resident's cognition was not assessed. He was independent with eating, required setup or clean-up assistance for oral hygiene, toileting, shower/bathing and dressing. He was always continent of urine and always incontinent of bowel. cognition was not assessed. He was independent with eating, required setup or clean-up assistance for oral hygiene, toileting, shower/bathing and dressing. He was always continent of urine and always incontinent of bowel. Review of the progress notes, dated [DATE] at 1:39 A.M and authored by RN #15, revealed at 1:15 A.M. Resident #82 told this nurse that he was going to get snacks from the vending machine, and the nurse offered (to) help, but he refused. Resident #82 came back to his room; the nurse assisted him in bed. Further review of the progress notes revealed at 1:39 A.M., he turned on his call light, this nurse went to the patient's room, and he told the nurse that he was having shortness of breath but denied chest pain. Resident #82 was on oxygen with the head of the bed elevated, his vitals were Blood Pressure (BP) 119/68 millimeters of Mercury (mmHg) [normal 120/60 mmHg], pulse (rate) 85 (normal 60-90 beats per minute), respiration 18 (normal 12-20 breaths per minute), oxygen saturation (measures the oxygenation of the blood) was 95 % (92-100 % is normal) and temperature 97.8 Fahrenheit. A decline was noticed in his condition while in his room. Further review of the [DATE] progress notes revealed at 1:40 A.M., 911 was called while in the room with Resident #82, and he was put on a non-rebreather mask (provides more oxygen than a nasal cannula), at 1:47 A.M. the nurse recalled 911 because the resident's condition was declining. At 1:48 A.M., his vitals were BP 112/65, pulse 90, respiration 20, temperature 97.9 and oxygen saturation 90 %. At 1:50 A.M., 911 arrived BP 100/62, pulse 50, respiration 12, temperature 97.7 and oxygen saturation was 86%. Further review of the progress notes, dated [DATE], revealed at 1:54 A.M., 911 started chest compressions on patient. At 2:19 A.M., Resident #82 was pronounced deceased . The DON, Med One (the on-call medical provider service) and the patient's family/friend were notified about the incident. A crack pipe, (with) residue and a lighter were found in the patient's shoe. Further review of the progress notes dated [DATE] at 1:56 P.M. and authored by RN #71 revealed Resident #82's body transported from the facility at 1:36 P.M. by the coroner's office. Review of the Coroner's Report: Finding of Facts and Verdict, dated [DATE], revealed the immediate cause of death was cardiomyopathy as a consequence of recent and chronic cocaine use, the manner of death was accidental. Toxicology testing showed benzoylecgonine (cocaine metabolite that can be detected for several days after use of cocaine), nicotine and cotinine (nicotine metabolite). Drug paraphernalia at the scene was positive for cocaine. On [DATE] at 12:03 P.M., an interview with RRN #481 revealed Resident #82 had left the hospital AMA and just showed up here at the facility without any paperwork (A friend dropped him off) but the facility had scheduled to admit him. The facility had called the hospital and asked for discharge paperwork, but the hospital refused to give the facility any instructions due to him leaving AMA. Further interview revealed the facility received the hospital discharge summary on [DATE] and the directive given were to use his home medications (written on the AMA discharge summary). The nurses did not follow through with obtaining the orders, but they were disciplined (RN #15 and #35) and we put a plan in place, so it wouldn't happen again. On [DATE] at 2:35 P.M., an interview with Coroner #486 revealed an autopsy was not completed but an external examination, toxicology and the preliminary drug screen was positive. The coroner's office was treating the case as a drug overdose. He was pronounced dead at 2:19 A.M. and laid there (in the facility) almost 12 hours before they called me, and they collected all the evidence and moved it (referencing the crack pipe). The police were not called so Coroner #486 directed the facility to call the police. On [DATE] at 2:32 P.M., a follow-up interview with Coroner #486 revealed when she arrived at the facility for the assessment of Resident #82, rigor had set in, and his body was very stiff. She confirmed the resident's body was moved to the morgue from the facility. On [DATE] at 9:44 A.M., an interview with the DON revealed the reason Resident #82's body remained at the facility so long was because of a lack of knowledge from staff and they should have called the police. She stated the staff were waiting for the funeral home to open, as they shared with her, they had contacted the funeral home, but the message provided indicated the funeral home didn't open until 10:00 A.M. The DON verified she contacted the police and the coroner. The police had come but the coroner's office took all the drug paraphernalia, so there was nothing for them to take. The nurse on duty the night of the resident's admission said she called the hospital and was told he had left AMA, and the hospital wouldn't give the facility discharge instructions and none of the nurses followed up. The DON verified the staff should not have accepted the resident due to him leaving the hospital AMA. On [DATE] at 1:34 P.M. an interview with RRN #481 verified the facility had no documentation the medical director was contacted by the facility, and the facility did not have a policy for accepting residents with a drug abuse history. On [DATE] at 1:38 P.M. an interview with Social Service Director (SSD) #339 revealed admissions from the hospital are handled by Central Intake and the Admissions Department. SSD #339 revealed she was unaware Resident #82 was admitted until on [DATE]. On [DATE] at 1:41 P.M. an interview with Admissions Director (AD) #332 revealed she was not aware Resident #82 left the hospital AMA as he was a planned discharge at 6:00 P.M. on [DATE]. The AD stated she had left for the day at 5:30 P.M. ([DATE]) and found out about his admission and leaving the hospital AMA on [DATE]. The AD stated the hospital did not notify the facility the resident left AMA, but the facility was not to admit residents that leave the hospital AMA. The plan was either family or a taxi was to bring him to the facility. The hospital did not let the facility know he left AMA. The AD stated the facility did an onsite visit with the resident while he was in the hospital and the facility's expectations would be discussed with the resident by the hospital liaison. The AD verified the nurse should have contacted the medical director about the resident's admission, or the facility has central admission staff available 24 hours a day. On [DATE] at 1:53 P.M. an interview with the DON revealed she was not aware until Monday ([DATE]) that Resident #82 was admitted to the facility. There was no communication from the hospital he left AMA, but the nurse should have called the medical director. On [DATE] at 2:26 P.M. an interview with RN liaison #400 revealed she had gone to the hospital to see Resident #82 either [DATE] or [DATE] and discussed the facility no smoking, no drug, no alcohol policy and he said, don't worry I don't smoke. On [DATE] at 4:08 P.M. an interview with Risk Management RN #400 from the hospital where Resident #82 was a patient prior to admission to the facility, revealed the hospital did not contact the facility to let them know that the patient left AMA but it was on a Friday late ([DATE]), and it appeared that it was after the Case Manager or Social Worker left for the day or was not aware of the resident leaving AMA. The weekend team would not have known to follow up as he would have been out of the hospital (documentation) system. She verified the hospital was not planning on the resident discharging that day ([DATE]) since he was not medically cleared to discharge but was planning to discharge the next day ([DATE]) and the facility was aware of him coming the next day. The RN verified there was no record of the facility calling the hospital requesting the discharge paperwork or a report. The RN stated Resident #82 reported that he had an extensive substance abuse history to the hospital licensed social worker. On [DATE] at 11:01 A.M. an interview with RN #35 revealed when Resident #82 showed up at the facility, she was not aware he had left the hospital AMA. She had looked through his bag and found no discharge paperwork, so she called the hospital and spoke to the charge nurse on the floor he was on, but the hospital didn't have anything to provide. She verified she did not call the medical director but said she called and texted the Assistant Director of Nursing (ADON) #91 but never received any response. The RN stated she only worked on [DATE] but had no problems with Resident #82 (that night). On [DATE] at 11:04 A.M. an interview with the Medical Director revealed she was not aware, and no one contacted her team to notify anyone on her team that Resident #82 was admitted to the facility and did not find out until [DATE]. Her expectation would be for the facility to contact her (or her team) regarding admission. Further interview revealed when a resident who is admitted to a facility with a known history of drug abuse, generally they are already through the withdrawal window so usually all they (the facility) do is supportive care because this is their home. She also shared the facility was not a drug rehabilitation facility, so the facility didn't provide any type of supervision (related to drug use prevention). On [DATE] at 9:43 A.M. an interview with Records Manager #500 at the Columbus Police Department (CPD) revealed the facility called the CPD at 12:42 P.M. regarding drug paraphernalia. The CPD did not arrive at the facility until 3:40 P.M. and the call was cleared at 3:42 P.M. The records manager verified there was no report to review. Review of the Facility Assessment, revised [DATE], revealed the facility was able to provide care for residents with drug use or abuse (alcohol dependence/substance dependence). Review of the facility admission Policy, dated [DATE] and revised [DATE], revealed a physician must personally approve, in writing, a recommendation that an individual be admitted to the facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. Review of the facility Abuse: Identification of Types policy and procedure, issued [DATE] and revised [DATE], revealed it is the policy of this facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to identifying and understanding the different types of abuse and possible indicators. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. a. Neglect of goods or services may occur when staff are aware, or should be aware, of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as lack of training to perform an intervention (e.g., suctioning, transfers, use of equipment), lack of sufficient staffing to be able to provide the services, lack of supplies, or staff lack of knowledge of the needs of the resident. This deficiency demonstrates non-compliance investigated under Complaint Number OH00163381.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital record review, policy review for Prevention of Pressure Injuries, review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, and staff interviews, the facility failed to implement a comprehensive and effective pressure ulcer treatment program for one newly admitted resident (Resident #84). This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries on 09/14/22, when the facility failed to ensure Resident #84 had admission physician orders for wound treatments transcribed to the medical record and implemented, and failed to ensure thorough skin assessments were performed timely and routinely, resulting in the development of new unstageable pressure ulcers and the declining condition of the existing pressure ulcers to an unstageable pressure ulcer which required hospitalization, with intravenous antibiotics and surgical debridement of the wounds. This affected one (#84) of three residents reviewed for pressure sores. The facility identified nine current residents with pressure ulcers in a facility census of 83. On 10/31/22 at 4:40 P.M., the Administrator was notified Immediate Jeopardy began on 09/14/22, when Resident #84 had an identified buttock shearing and the right and left calf, and right and left hip had open areas which appeared to be pressure and/or cellulitis, were not provided physician ordered treatments. There were no assessments or measurements of the wounds completed upon admission. When the wounds were first assessed, the right hip had declined to unstageable, with slough and eschar. There were discharge orders from the hospital for wound dressings of the lower extremities and right hip, that were not put into place for the treatment and care of the wounds. No treatment was provided until 09/21/22, resulting in the right hip declining in condition, developing drainage and an odor. Nurse Practitioner #400 ordered an antibiotic and stat (immediate) wound consult at the clinic. The facility failed to immediately initiate the antibiotic and made an appointment for a week later with the wound clinic, resulting in Resident #84 being sent to the hospital with the diagnosis of septic shock (a life-threatening condition caused by a severe localized or system-wide infection that requires immediate medical attention) due to necrotizing fasciitis (a rare bacterial infection that spreads quickly in the body and can cause death). The Immediate Jeopardy was removed on 11/01/22 when the facility implemented the following corrective actions: • On 09/26/22, Resident #84 was transferred and admitted to the hospital. • On 10/31/2022, Registered Nurse (RN) Staff Development Coordinator #600 and/or designee in-serviced the nursing staff and rehabilitation personnel, on the facility ' s Skin Integrity and Pressure Ulcer/Injury Prevention and Management and Area of Focus: Basic Skin Management Policy. • On 10/31/22, a house audit of all resident ' s skin will be completed by RN Staff Development Coordinator #600 and/or designee to ensure all wounds have been assessed and treatments obtained as needed. • On 10/31/22, an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the interdisciplinary team and the plan of removal was reviewed and approved by the QAPI team. • On 10/31/22, the Medical Director reviewed and approved the plan of removal. • Beginning on 11/01/22, weekly audits will be completed by the Director of Nursing (DON) or designee to assure the ordered treatments are being completed, wounds are assessed and monitored three times a week for 12 weeks. Any issues identified will be addressed immediately and will be reviewed at the monthly QAPI meeting. • On 11/01/22, the DON will educate all nursing and rehabilitation staff on the facility ' s Skin Integrity & Pressure Ulcer/Injury Prevention and Management and Area of Focus: Basic Skin Management Policy. • On 11/01/22, the agency Licensed Nurse that was assigned the admission for Resident #84 was reported to the nursing agency and has not return to the facility. • Beginning on 11/01/22, all agency staff and new hires will be in-serviced on the Skin Integrity & Pressure Ulcer/Injury Prevention and Management & Area of Focus: Basic Skin Management Policy prior to first working shift by RN Staff Development Coordinator #600 and/or designee. Although the Immediate Jeopardy was removed on 11/01/22, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing to educate staff and was in the process of completing and reviewing audits to determine if further action is required and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #84 revealed an admission date of 09/14/22 and a discharged date to the hospital on [DATE]. Diagnoses for Resident #84 included: bilateral primary osteoarthritis of hip, end stage renal disease, difficulty in walking, cellulitis of left lower limb, morbid obesity, bipolar disorder, anxiety disorder and bullous disorder (a rare skin condition that causes large, fluid-filled blisters). Review of the admission skin assessment dated [DATE] for Resident #84 revealed the abdominal folds red, buttock shearing, right and left calf and right and left hip open; appears to be pressure or cellulitis. No measurements or staging of wounds were documented. Review of the admission pressure ulcer risk dated 09/14/22 revealed Resident #84 was a mild risk for pressure ulcer. Review of a pressure ulcer assessment dated [DATE] revealed Resident #84 was at moderate risk for pressure ulcer. Review of the Aftercare Visit Summary, dated 09/14/22 for Resident #84, revealed wound care instructions included the following: for lower extremity wounds, irrigate wound with ¼ strength of Dakin ' s (solution used to clean wound and regulate pH of wound); cover wounds with duoderm (hydrocolloid dressing for dry to lightly exuding wounds) or hydrogel if available; cover with abdominal (ABD) pad; wrap with kerlix and secure with Medi pore tape. For the right hip, cleanse wound with sterile saline; cover with large hydrofera ready blue border dressing (powerful antibacterial wound dressing); please keep in place five days or until you see white drainage on dressing. There was a new patient visit for Wound Care East Hospital for 09/16/22 at 2:45 P.M. Review of the skin assessment revealed bullae or blisters have expanded on medial left and right leg, with small tense bullae on arms but not in any particular distribution. Review of nurse ' s progress notes dated 09/17/22, for Resident #84, revealed the nurse performed a wound dressing change on the lateral right of resident ' s leg. Wound draining with foul smell. Also, wound team needs to evaluate resident wound and put treatment plan in place. As of now, there is no treatment plan in place for resident ' s wound. This nurse changed the dressing, cleansed with normal saline, and applied abdominal pad. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #84 revealed she was assessed as being cognitively intact. She had behaviors which include rejection of care which occurred one to three days a week. She required extensive assistance of two-person physical assist for toileting, bed mobility and transfer. She was occasionally incontinent of urine and always incontinent of bowel. The resident had one unstageable pressure ulcer which was present upon admission. She also received dialysis. Review of the Treatment Administration Record (TAR) for September 2022, for Resident #84, revealed no documentation of any wound treatments being completed from 09/14/22 through 09/21/22 for the hip, thigh, legs, or buttocks wounds. Review of the wound progress note dated 09/21/22, revealed the resident was seen for the side of the right thigh pressure area. The wound was an unstageable, slough and eschar. There was slough tissue present (yellow, tan, stringy) 100 percent (%) of wound bed, serosanguineous, measuring 20 centimeters (cm) by 10 cm by 0 cm and had a foul odor. Resident has pain of moaning with intervention of pain medications and repositioning. The current treatment plan is for the right hip cleanse wound with sterile saline cover with large hydrofera ready blue border dressing (please keep in place 5 days or until you see white drainage on dressing). For the right lower leg front pressure slough/eschar necrotic tissue 100% no drainage 3 cm by 3 cm by 0 cm. To the lower extremity wounds irrigate wound with 1/4 strength Dakin ' s. Cover wounds with duoderm or hydrogel if available. Cover with an ABD, wrap with Kerlix and secure with Medi pore tape. A wound of left lower leg with cellulitis slough 20% small amount of drainage serosanguineous measuring 2 cm by 2 cm by 0 cm. The treatment is for lower extremity wounds irrigate wound with 1/4 strength Dakin ' s. Cover wounds with duoderm or hydrogel if available. Cover with an ABD, wrap with Kerlix and secure with Medi pore tape. This is the first observation by the wound team, and the doctor and family were notified. Review of the physician ' s order dated 09/21/22, revealed for the right hip: to cleanse wound with sterile saline; cover with large hydrofera ready blue boarder dressing every shift and please keep in place five days or until you see white drainage on dressing. This order was discontinued on 09/23/22 and a new order was written. Review of the physician ' s order dated 09/23/22 (with an end date of 10/01/22), revealed for the right hip: to cleanse wound with sterile saline cover with large hydrofera ready blue boarder dressing twice per day. Review of the progress notes dated 09/22/22 at 3:39 P.M., revealed Nurse Practitioner (NP) #550 was notified the resident ' s wound has drainage and odor. An order was given to start doxycycline one tablet by mouth twice a day for wound infection for ten days. Also, there was a stat (immediately) order for a wound clinic visit at hospital. Review of the physician ' s orders dated 09/22/22, revealed for the lower extremity wounds to irrigate wound with 1/4 strength Dakin ' s; cover wounds with duoderm or hydrogel if available; cover with an ABD pad; wrap with Kerlix and secure with Medi pore tape every dayshift. Review of an order dated 09/22/22, revealed an order for Doxycycline Hyclate Tablet (antibiotic) 100 milligrams (mg) to give one tablet by mouth two times a day for wound infection for 10 Days. Review of the Medication Administration Record (MAR) for Resident #84 revealed she had an entry dated 09/22/22 for Doxycycline Hyclate Tablet 100 milligram (mg) to be given one tablet by mouth two times a day for wound infection for 10 days. There were no signatures indicating the medication was ever administered to the resident. Review of the physician order dated 09/23/22, revealed Resident #84 had an appointment scheduled with wound care at the hospital on [DATE] at 10:00 A.M. Review of the progress note dated 09/23/22 at 5:03 P.M., revealed the hip wound dressing was completed with foul malodor from wound, and 100 % tan slough to wound bed. Pocket of pus was noted draining from the wound. Patient currently on by mouth Doxycycline and is scheduled for an appointment at the wound clinic on Friday (09/30/22). Will continue scheduled wound care. Review of the progress note dated 09/26/22 at 7:15 A.M., revealed this nurse was completing resident ' s dressing change and the wound had a foul odor with green fluid coming out of it. The DON was called, and the resident was sent out to hospital. Review of the plan of care dated 09/26/22 (day of discharge to hospital) revealed Resident #84 was admitted with an unstageable pressure ulcer to her left outer thigh area, cellulitis, and blisters to her bilateral lower extremities (BLE). The plan of care noted risk for infection, pain and delayed healing with interventions which included her wounds will show signs and symptoms of healing through review date and medications per orders. Review of the progress note dated 09/28/22 at 1:54 P.M. with MDS Nurse #500, revealed orders written on 09/22/22 for the Doxycycline were entered into electronic medical record (EMR) but were not clarified so the medication was never started as prophylactic medication. Interview with MDS Nurse #500 at the time of the review, verified the Doxycycline orders were not clarified and never started for Resident #84. Review of the physician ' s orders dated 10/02/22, revealed for the right hip: to cleanse wound with sterile saline cover with large hydrofera ready blue boarder dressing twice per day; document on the wound bed (if not applicable: N/A; Wound Bed-G=granulation, S=slough, E=eschar, Ep epithelization; Odor-Y=yes, N=no; Drainage-S=serous, Se=serosanguineous, B=bloody, P=purulent; Surrounding skin-P=pink, R=red, I=indurated, W=Warm; Wound Outcome-U=unchanged, I=improved, D=deteriorated). This order was written after the resident was discharged on 09/26/22, by Regional Nurse #600. Interview on 10/31/22 at 2:00 P.M. with Regional Nurse #600, revealed she was on vacation until the week of 10/21/22. She came to the facility and had initiated all residents with wounds to be reviewed. Regional Nurse #600 stated therefore Resident #84 did not have any wound measurements until this date. Regional Nurse #600 stated this is why the resident (Resident #84) slipped through the cracks due to lack of oversight with the facility not having a DON at the time. Review of the Emergency Department (ED) Provider Note, visit date 09/26/22, revealed patient presents with wound infection. Patient is hypotensive of 86 systolic and 38 diastolic on ED arrival. The patient was made a sepsis alert related to wound and hypotension. Resident #84 was admitted to the Intensive Care Unit (ICU) for further medical treatment and evaluation of sepsis, wound infections and hypotension. Review of the Operative Report dated 09/26/22 at 2:49 P.M., revealed Resident #84 was diagnosed with necrotizing soft tissue infection of the right hip with the operative procedure being excision of large necrotizing soft tissue of right hip. The history of the wound was described as a wound on her right hip that has been present for an unknown length of time. She presents with increased pain. On examination, she had an area of soupy necrosis on the hip where the skin is obviously necrotic, and the area preoperatively measures probably 20 cm by 30 cm. Computerized tomography (CT) scan confirmed subcutaneous air, and she has obvious drainage and malodorous smell. Review of the Brief Post Operative Note dated 09/26/22, revealed the procedure was for incision and drainage right upper hip for necrotizing fasciitis. The debridement of right lateral thigh/hip necrotizing fasciitis measuring 35 cm by 35 cm debrided. Wound packed with four saline-dampened kerlix rolls, covered with total of six ABD pads and tape. The right thigh wound was not debrided but was just covered with kerlix roll wrap to protect skin. The description of the wounds included: a right pre-tibial and left pre-tibial unstageable deteriorating non-healing eschar covered wound with a small amount of foul purulent drainage; an acute deep tissue pressure injury (DTPI) to the mid sacral area which is non-healing and had a small amount of foul-smelling serosanguineous drainage; and an acute left and right buttock DTPI, which was non-healing with a moderate amount of serosanguineous drainage. The wound cultures grew proteus, pseudomonas, Providencia, Bacteroides, [NAME], Citrobacter, klebsiella and Escherichia coli. Review of the policy titled Prevention of Pressure Injuries, revised April 2020, revealed the resident should be assessed on admission for existing pressure injury risk factors, repeating the risk assessment weekly, and upon any changes in condition. Staff should conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment as indicated according to the resident's risk factors, and prior to discharge. Staff should inspect the skin daily when performing or assisting with personal care or activities of daily living and inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). The staff should evaluate, report, and document potential changes in the skin, and review the interventions and strategies for effectiveness on an ongoing basis. The nurses are required to complete a skin assessment to be performed weekly. Review of the NPIAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes 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. Further review revealed an unstageable pressure injury is obscured full-thickness skin and tissue loss. 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 three or Stage four 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 noncompliance under Master Complaint Number OH00137161 and Complaint Numbers OH00136726 and OH00136249 and is an example of continued noncompliance from the survey dated 09/15/22.