**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of avoidable pressure ulcers, timely identify areas of new skin impairment, promote optimal healing, ensure pressure ulcer dressings were provided as ordered and/or prevent the risk of pressure ulcer infection. Actual Harm occurred beginning on 11/19/24 when Resident #54, who had moderate cognitive impairment and was at high risk for pressure ulcer development, was assessed to have a Stage II (partial-thickness skin loss with exposed dermis) pressure ulcer to the right buttocks that originated from Moisture Associated Skin Damage (MASD). Due to a lack of individualized and effective interventions, on 11/26/24 Resident #54's right buttock pressure ulcer expanded to a bilateral buttock pressure ulcer. On 12/03/24 the pressure ulcer progressed to a Stage III (full-thickness tissue loss into subcutaneous tissue but does not go into the muscle or bone) bilateral buttock pressure ulcer without evidence of adequate and individualized pressure ulcer prevention interventions being in completed prior to the deterioration/progression. Actual harm occurred on 10/29/24 when Resident #163 who had severe cognitive impairment, was dependent on staff for toileting and transfers, was assessed and documented to be at high risk for pressure ulcer development but had no individualized plan developed to prevent pressure ulcers was identified to have of an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer to the sacrum. The facility failed to create and implement an individualized plan to prevent the pressure ulcer resulting in the development and identification of the unstageable ulcer. Actual harm occurred on 08/13/24 when Resident #89, who was at high risk for pressure ulcer development and had a history of unstageable pressure ulcers, developed a new Stage III pressure ulcer to the right ischium. On 08/08/24, the resident's prescribed air mattress malfunctioned and was replaced with a regular bed and a gel overlay, which failed to provide adequate pressure relief. On 08/12/24, a new air mattress was ordered, but documentation on 08/13/24 indicated the replacement air mattress also malfunctioned, causing the resident's buttocks to come into direct contact with the metal bed frame. This resulted in tissue breakdown and the development of the new Stage III pressure ulcer. The facility failed to ensure timely replacement and proper functioning of pressure-relieving equipment, resulting in the development of the Stage III pressure ulcer. This affected three residents (#54, #89, and #163) of five residents reviewed for pressure ulcers. The facility census was 109. Findings include: 1.Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including a wedge compression fracture of thoracic (T)11-T12 vertebra, chronic respiratory failure, urinary tract infection (UTI), unspecified combined systolic and diastolic heart failure, benign prostatic hyperplasia with lower urinary symptoms, atrial fibrillation, hypertension (HTN), left bundle-branch block, low back pain, bilateral primary osteoarthritis of first carpometacarpal joints, malignant neoplasm of prostate, vitamin D deficiency, presence of cardiac pacemaker, repeated falls, hyperlipidemia, major depressive disorder, constipation, wedge compression fracture of first lumbar vertebra, chronic obstructive pulmonary disease (COPD), tinea unguium, and psoriasis vulgaris. Review of the skin risk/Braden Scale Assessment (a tool used to assess a resident's risk of developing pressure ulcers), dated 7/10/24 revealed Resident #54 was assessed to be at mild risk for pressure injury. Review of a nursing progress note dated 07/10/24 at 7:48 P.M. revealed Resident #54 admitted to the facility with an excoriating skin rash all over back area down to coccyx and blisters on the coccyx. Zinc oxide cream and Triad paste (a zinc oxide based hydrophilic paste for light to moderate levels of wound exudate/drainage used to help maintain an optimal wound healing environment) were to be applied on rash twice daily. Review of the physician orders revealed the following orders were in place: Zinc Oxide External cream 10% apply to lower back topically two times a day for excoriating rash with a start date of 7/11/24. Ammonium lactate external cream 12% apply to upper and lower back topically as needed for soilage with a start date of 07/12/24 and an end date of 07/19/24. Review of the Medication Administration Report (MAR) for Resident #54 revealed no evidence the physician orders for Ammonium lactate external cream 12% was administered at all during incontinence episodes during this time period. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/29/24 revealed Resident #54 had moderately impaired cognition, required moderate (staff) assistance with toileting, moderate (staff) assistance with upper extremity dressing, maximum (staff) assistance with lower extremity dressing, maximum (staff) assistance with putting on and taking off footwear, and had no pressure ulcers. A skin risk/Braden Scale Assessment completed on 11/01/24 which revealed a high risk for pressure injury development. Review of the comprehensive care plan for Resident #54 revealed a focus on potential alterations in skin integrity. The goal was to prevent skin breakdown through comprehensive review. Interventions included (on 07/10/24) educate resident/family on skin breakdown risk factors and preventative measures, encourage floating heels while in bed, pressure-reducing cushion to the chair, pressure-reducing mattress to the bed, assist with hygiene, including peri-care as needed and barrier cream during showers and after incontinent episodes. A plan of care (dated 08/08/24) revealed the resident had current area of skin impairment to the right buttock. The goal was to heal the existing impairment and prevent further skin breakdown and infection with a target date of 10/08/2024. Interventions included (on 08/08/24) to initiate wound treatment, continue as ordered by the medical director or nurse practitioner, observe and document wound character weekly, and monitor for clinical changes such as infection or worsening of the wound, (on 11/08/24) encourage repositioning as tolerated, (on 11/19/24) apply barrier cream after each incontinent episode and encourage repositioning with pillows as tolerated, (on 12/04/24) air mattress to bed, monitor for proper functioning, and (12/17/24) encourage resident to allow staff to reposition every two hours. Review of Bed Mobility task documentation from 11/24/24 to 12/23/24 for Resident #54 revealed staff documented the resident was totally dependent on staff for bed mobility during this time period. The resident had orders for Triad Hydrophilic wound dress external paste (wound dressings) apply to bilateral buttocks topically every shift for wound care with a start date of 09/11/24 and an end date of 10/30/24. Triad Hydrophilic wound dress external paste (wound dressings) apply to bilateral buttocks topically as needed for incontinence with a start date of 09/11/24 and an end date of 10/30/24. Triad Hydrophilic wound dress external paste (wound dressings) apply to bilateral buttocks topically as needed for soilage with a start date of 10/17/24 and an end date of 12/17/24. Review of a nursing progress note dated 10/09/24 revealed Resident #54 returned to the facility with a skin tear on the right arm and a reddish spot on the buttock with no open area. Review of the skin assessments from contracted Wound Provider #1050 for Resident #54 revealed the following information: 10/16/24: Initial assessment: Wound on the right buttock diagnosed as Moisture-Associated Skin Damage (MASD) 9.0 centimeters (cm) length by (x) 3.5 cm width x <0.1 cm depth. Irritant contact dermatitis due to fecal, urinary, or dual incontinence. Treatment orders: Cleanse area, pat dry, apply zinc barrier cream (20% or greater) every shift and as needed (PRN). No new interventions or changes to the resident's plan of care were noted at this time. 10/30/24: Right buttock pressure ulcer still diagnosed as MASD. 12.0 cm length x 10 cm width x <0.1 cm depth. Additional treatment: Triad paste to buttocks every day and PRN. However, record review revealed no documented evidence of the Triad paste being provided as needed after incontinence episodes between July and 10/30/24. 11/19/24: Right buttock pressure injury progressed to a Stage II pressure ulcer (related to exposed dermis) 11 cm length x 9.0 cm width x 0.1 cm depth. Irritant contact dermatitis due to fecal, urinary, or dual incontinence. Record review revealed no additional interventions were implemented to address the resident's fecal/urinary/dual incontinence to prevent skin breakdown. 11/26/24: Right buttock pressure injury remained at Stage II, 13 cm length x 11 cm width x 0.1 cm depth, treatment orders remained the same on this date. 12/03/24: Right buttock worsened to a Stage III (full thickness) pressure ulcer, 9.0 cm length x 13 cm width x 0.1 cm depth with 90% granulation and 10% slough. Treatment remained the same. Record review revealed no additional or new interventions were implemented to prevent additional skin breakdown and/or to promote healing. 12/10/24: Right buttock pressure ulcer remained at Stage III, 8.0 cm length x 5.0 cm width x 0.1 cm depth with 100% granulation. Irritant contact dermatitis due to fecal, urinary, or dual incontinence. Resident agreeable to air mattress. Wound physician measured the entire wound region, reporting eight pressure ulcers with skin bridges and MASD resolved. Treatment orders: Triad paste open to air, reapply triad paste as needed, air mattress in place. 12/17/24: Right buttock pressure ulcer remained at Stage III, 8.0 cm length x 4.5 cm width x 0.1 cm depth with 100% granulation. Comments and treatment remain the same. Review of the Medication Administration Report (MAR) for Resident #54 revealed no evidence the physician orders for Triad Hydrophilic wound dress external paste (wound dressings) was administered at all during incontinence episodes from July 2024 to December 2024. On 12/19/24 at 1:54 P.M., observation of Resident #54's Stage III pressure ulcer to the right buttocks revealed the wound bed was red with active bleeding on the incontinence brief. Further observation revealed the physician ordered treatment of Triad following each incontinence episode was not in place. Interview with Registered Nurse (RN) Wound Nurse #500 during the time of the observation verified the resident was provided incontinence care prior to entering the room for the wound observation and the physician ordered treatment of Triad was not in place. Interview on 12/18/24 at 2:35 P.M. with the Wound Doctor (WD) #122 verified Resident#54's wound started as MASD and turned to an open Stage II pressure ulcer wound on 11/19/24. He stated he doesn't remember seeing blisters on his initial assessment. WD #122 stated they were doing zinc barrier and then collogen. He stated there were multiple open areas and the wound changed to a bilateral wound on 11/26/24, but stated there was not a wound on the left buttock only multiple wounds on the right buttock. WD#122 stated he did not measure each area. During the interview, the WD revealed the wound was not being offloaded so it would not heal properly. He stated the Triad paste should be applied on during changes and soilage and stated there were eight separate wounds but since they were in the same area he measured the wounds as one big area. He stated the Triad paste and leaving the areas open to air was the current treatment. Additionally, WD #122 stated the area around the wound wasn't MASD so he didn't want adhesive on the skinned area around the wound. Review of the medical record revealed the facility did not implement the wound/skin prevention interventions as listed in the care plan for Resident #54. The care provided to Resident #54 was also not consistently delivered as planned, resulting in the progression of the MASD to a Stage III pressure ulcer. Despite the progression of Resident #54's skin alteration from Moisture-Associated Skin Damage (MASD) to a Stage II pressure ulcer and then Stage III pressure ulcer, no changes were made to the wound treatments implemented for the resident. The wound, was initially assessed as MASD on 10/16/24, progressed to Stage II on 11/19/24 and later to Stage III on 12/03/24, yet the same treatment plan was followed without modification. Specifically, the use of zinc barrier cream and Triad paste was continued, even after the wound had deepened and required more advanced management. No adjustments were made in the frequency or nature of wound care, nor was the offloading of pressure more rigorously addressed. As a result, the wound failed to heal properly and worsened in severity. 2. Review of the medical record for Resident #163 revealed an initial admission date of 09/23/24 with a latest readmission of 12/01/24 with diagnoses including gastrostomy malfunction, asthma, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, syncope and collapse, repeated falls, cerebrovascular accident (CVA) with left sided hemiplegia, anxiety disorder, dysphagia, aphasia, hypertension, and hypothyroidism. Review of the resident's plan of care dated 10/12/24 revealed the resident had the potential for pressure ulcer development related to CVA with hemiparesis. Interventions included follow facility policies/protocols for the prevention/treatment of skin breakdown, incontinence care check and change for incontinence on a routine basis and as needed, turn and reposition as ordered and use lifting device to reduce friction. Review of the resident's readmission admission assessment with baseline care plan dated 10/17/24 revealed the resident was re-admitted on [DATE] with no pressure ulcers. Review of a revised plan of care (originally dated 10/17/24) revealed the resident had an actual area of skin impairment related to pressure to sacrum and unstageable pressure ulcer to the resident's left elbow that was present on admission from the hospital and resident prefers to lay on his back most of the day. Interventions included air mattress as ordered on 10/29/24, encourage to reposition as tolerated, evaluate for pain and provide pain relieving interventions as ordered, initiate wound treatment, continue treatment as ordered by the physician/nurse practitioner (NP), limit time out of bed, nursing to observe the wound dressing daily to ensure that the dressing remains intact and that there are no signs/symptoms of infection or increased drainage, observe for clinical changes, such as infection and/or worsening of wound, pressure reducing cushion to chair, refer to dietician to determine need/no need for dietary intervention and skin observation and document on bath/shower days, charge nurse to notify the wound nurse, physician and family of any new areas. Review of the resident's Braden scale dated 10/24/24 revealed a score of 15 indicating the resident was at risk for skin breakdown. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident was dependent on staff for bed mobility, toileting and transfers. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had no skin issues. The facility implemented a pressure reducing device to his bed. Review of the progress note dated 10/29/24 at 7:54 A.M. revealed the nurse performed a weekly skin assessment and discovered an open area to sacrum measuring 2.0 centimeters (cm) by 2.0 cm. The area was cleansed with normal saline (NS) and pad and protect order initiated. The physician and wound nurse were made aware of the wound. Review of the skin observation dated 10/29/24 revealed the resident was found to have a pressure ulcer to his sacrum measuring 2 cm by 2 cm. The observation contained no description or staging of the wound. Review of the facility's incident report dated 10/29/24 revealed the nurse performed an ordered weekly skin assessment and discovered open area to sacrum. The resident was unable to verbalize when the area started or how the area occurred as the resident was unaware of the area. The area was cleansed with NS and pad and protect order initiated. The physician and wound nurse were made aware of the wound. Review of the weekly pressure skin grid dated 10/30/24 revealed the resident was found to have a Stage III pressure ulcer to the sacrum measuring 1.6 centimeters (cm) by 1.4 cm by 0.2 cm with the wound bed being 100% slough. The peri-wound was within normal limits. The wound had a moderate amount of serosanguineous drainage. The facility implemented the treatment cleanse, apply Santyl, cover with normal saline (NS) soaked gauze. Review of the weekly pressure skin grid dated 11/05/24 revealed the Stage III was now classified as an unstageable pressure ulcer measuring 1.0 cm by 1.5 cm with the depth being unable to determine due to the wound bed being 100% slough. The wound had a moderate amount of serous exudate. No changes to the treatment were made at this time. Review of the weekly pressure skin grid dated 11/12/24 revealed resident had an unstageable pressure ulcer measuring 1.0 cm by 1.0 cm with the depth being unable to determine due to the wound bed being 100% slough. The wound had a moderate amount of serosanguineous exudate. There were no changes to treatment at this time. The resident was discharged to an acute care hospital on [DATE] and re-admitted to the facility on [DATE]. Review of the resident's monthly physician orders for December 2024 identified orders dated 11/11/24 cleanse right sacrum with normal saline, pat dry, apply nickel thick Santyl to wound bed, cover with saline moistened gauze then cover with a clean dry dressing daily and as needed, 11/13/24 air mattress to bed, ensure proper functioning every shift and 12/04/24 enhanced barrier precautions (EBP) every shift due to wound. Review of the skin observation dated 12/01/24 revealed the resident was re-admitted to the facility with a previously identified wound to the sacrum. Further review revealed no comprehensive assessment (measurements/description) of the pressure ulcer was completed upon re-admission to the facility. Review of the readmission pressure skin grid dated 12/02/24 revealed the unstageable pressure ulcer to the resident's sacrum measured 1.5 cm by 1.5 cm with the depth being unable to determine due to the wound bed being 100% slough. The wound had a minimal exudate. The facility resumed the previous treatment to cleanse wound, apply Santyl and cover with NS soaked gauze. Review of the re-admission pressure skin grid dated 12/03/24 revealed the unstageable pressure ulcer to the resident's sacrum measured 1.3 cm by 1.3 cm with the depth being unable to determine due to the wound bed being 100% slough. The wound had a minimal exudate. The facility did not determine if the wound had improved, declined or remained unchanged. The facility made no changes to the treatment. Review of the re-admission pressure skin grid dated 12/10/24 revealed the unstageable pressure ulcer to the resident's sacrum measured 1.3 cm by 1.0 cm with the depth being unable to determine due to the wound bed being 100% slough. The wound had a minimal exudate. The facility determined the wound had improved and made no changes to the treatment. Review of the re-admission pressure skin grid dated 12/17/24 revealed the unstageable pressure ulcer to the resident's sacrum measured 1.2 cm by 1.0 cm with the depth being unable to determine due to the wound bed being 100% slough but able to see tips of granulation. The wound had a minimal exudate. The facility determined the wound had improved and made no changes to the treatment. On 12/18/24 at 9:32 A.M., observation of Registered Nurse Wound Nurse (RNWN) #500 and Unit Manager (UM) #214 provide the physician ordered treatment to the resident's unstageable pressure ulcer revealed RNWN #500 donned personal protective equipment (PPE) (gown), entered the room washed their hands and donned gloves. RNWN #500 cleansed the resident's bedside table with a sani-wipe, washed her hands and donned gloves. She then placed a barrier on the table and set-up the required supplies. RNWN #500 removed the soiled dressing to the sacral wound. The wound was quarter sized with pink edges and a yellow center. She then washed her hands and donned a pair of gloves and cleansed the wound with NS and a 4X4, pat dry. RNWN #500 then washed her hands and donned gloves. She then used a tongue depressor and placed Santyl on the center of the wound, covered the wound with a NS soaked gauze and covered the wound with a bordered gauze dressing. On 12/18/24 at 1:39 P.M., interview with the Interim Director of Nursing (IDON) and Registered Nurse Wound Nurse (RNWN) #500 revealed the sacral wound was actually an unstageable pressure ulcer when the wound was discovered, however the wound physician documented the wound as a Stage III pressure ulcer. The IDON and RNWM #500 revealed they were unaware of why the staff had not identified the pressure ulcer prior to an unstageable pressure ulcer. The facility provided no evidence of an individualized skin breakdown prevention program for the resident. 3. Review of the medical record revealed Resident #89 was admitted on [DATE] and readmitted on [DATE], with diagnoses including paraplegia, epilepsy, heart failure, atrial fibrillation, hypertension, muscle weakness, and a colostomy and indwelling catheter in place. Resident #89 was admitted (on 04/03/24) with a Stage III pressure ulcer to the right ischium which measured 4.5 cm in length X 1.5 cm in width, and 1.5 cm in depth. The pressure ulcer healed on 06/04/24. On 07/10/24, a skin risk/Braden Scale Assessment indicated the resident was at mild risk for pressure injury development. However, a follow-up skin assessment conducted on 11/01/24 identified the resident as being at high risk for pressure injury development. Review of the comprehensive care plan for Resident #89 revealed a focus on skin integrity, specifically addressing areas of skin impairment related to pressure on the sacrum and right ischium, as well as non-pressure concerns on the right second toe. The goal was to heal the current impairment and prevent further skin breakdown. Interventions included on 04/04/24 pressure reducing cushion to chair, Prevalon boots to bilateral lower extremities as tolerated, monitor for pain and provide pain-relieving interventions as ordered. On 04/24/24 check function of air mattress every shift was added and revised on 11/19/2024. On 04/27/24 ask resident about pain level prior to dressing change procedure, medicate if needed and air mattress as ordered. On 08/08/24 the care plan was updated to include observe and document the character of the wound weekly, observe for clinical changes, such as infection and/or worsening of wound, and initiate wound treatment as ordered by the medical director (MD)/Nurse practitioner (NP). On 11/08/24 encourage repositioning as tolerated, and on 12/13/24 apply shoes for outside doctor appointments were added. The care plan also had a focus on enhancing the overall management of skin integrity, including interventions initiated on 04/04/24 of daily skin observation and documentation on bath/shower days, on 11/19/24 padding to the right lateral wheelchair, on 12/04/24 to limit time out of bed, and implement enhanced barrier precautions due to wound and colostomy. On 12/17/24 encouraging the resident to allow staff to reposition every two hours was added to the resident's plan of care. Review of the 10/01/24 Minimum Data Set (MDS) 3.0 assessment revealed Resident #89 was cognitively intact and required extensive (staff) assistance with personal care, including bed mobility, transfers, toileting, and sitting to lying positions. a.Review of a nursing progress note on 08/08/24 at 10:36 A.M. noted Resident #89's air mattress was noted to be malfunctioning and per the nurse practitioner discontinue the air mattress and order gel mattress. An order was placed with a medical supply company. Review of a nursing progress note on 08/13/24 at 10:46 A.M. noted the wound nurse conducted a weekly wound assessment for Resident #89 on this date. A new pressure injury was identified on the resident's right ischium. The wound bed presented with 100% granulation tissue, measuring 5.0 cm in length by 1.5 cm in width with 0.1 cm depth. A new order was provided to cleanse the wound with normal saline (NS) or wound cleanser (WC), pat dry, apply Calcium Alginate to the wound bed, and cover with a foam dressing. The dressing was to be changed daily (QD) and as needed (PRN). Additionally, the assessment revealed an issue with the air mattress placed beneath the resident. The mattress was noted to be deflated at the buttocks area, causing pressure on the metal frame, which was not detected by the pump's alarm for low pressure. The resident, who was alert and oriented (A&O x 4) was paraplegic and unable to feel sensations below the waist. A new order was provided to replace the malfunctioning air mattress. The resident was assisted out of bed and into a wheelchair. The medical supply company was contacted and requested to replace the air mattress. The mattress was replaced, and the new air mattress was confirmed to be functioning properly. Interview with Resident # 89 on 12/23/24 at 8:13 A.M. revealed he could feel when the air mattress failed as he was able to feel it on his back and he felt with his hands that the bed was deflated. He stated he alerted the staff, and it took approximately an hour for them to respond. The resident stated the bed had no audible alarm or any other type of notification that he was aware of when it malfunctioned. During the interview, the resident voiced concerns that staff did not actually observe his skin during repositioning. Interview on 12/24/24 at 12:10 P.M. with Wound Nurse #500 confirmed on 08/08/24 she found the resident's air mattress was losing air, so the Certified Nurse Practitioner (CNP) ordered a gel overlay to put on a regular mattress. Wound Nurse #500 noticed the gel overlay was dispersing but not offloading for the wound, so she ordered a new air mattress that came on 08/12/24. That bed malfunctioned on 08/13/24 and a new bed was ordered. The resident was on regular mattress with a gel overlay for four days. The resident developed a Stage III pressure ulcer as a result. b. In addition, review of the care provided to Resident #89 related to pressure ulcers revealed the following concerns with treatments not completed as ordered: Santyl External Ointment 250 Unit/GM (Collagenase) with orders to apply to right ischium topically every day shift for wound care was not completed on 10/04/24,10/06/24, 10/08/24, 10/21/24, 11/07/24, 11/12/24 or 11/14/24. Right Ischium: Cleanse with NS, pat dry. Apply Santyl (nickel thick) to wound bed then moistened gauze and cover with clean dry dressing daily and as needed was not completed on 10/04/24, 10/08/24, 10/21/24, 10/24/24 or 11/06/24. Monitor Right Ischium, Bilateral buttocks, left 2nd toe for s/s of infection. If noted, report to NP/MD & management/wound nurse every shift was not completed on 10/17/24, 11/07/24 or 12/11/24. Interview on 12/23/24 at 3:44 P.M. with Wound Nurse #500 verified the dates of the missed wound treatments and interventions and stated there was no justification for the missed wound care and treatments. c. Review of the skin grid pressure assessments and wound provider assessment for Resident #89 revealed the following: 10/16/24 Skin grid assessment: Wound assessed as unstageable, measuring 1.7 cm length x 1.7 cm width x unable to determine depth; described as healing, the wound was documented to have 40 % slough and 60 % granulation tissue. MD #610 was documented as the practitioner who assessed the wound. 10/16/24 Wound provider assessment: Wound assessment and plan: Unstageable pressure wound, 2.0 cm length x 1.7 cm width x depth unknown, 40% granulation and 60% slough in wound bed, noted as healing. Treatment cleanse wound with normal saline or sterile water, Santyl nickel thick layer- cover with moist gauze and cry clean dressing every day and PRN. Assessment documented by MD #610. 11/05/24 Skin grid assessment: Wound classified as Stage III, measuring 0.2 cm length x 0.2 cm width x <0.1 cm depth; noted as improved the wound was documented to have 100 % epithelial tissue present with a new treatment ordered and WD #122 was documented as the practitioner who assessed the wound. 11/05/24 Wound provider assessment: Wound assessment and plan: Stage IV wound, 0.2 cm length x 0.2 cm width x <0.1 cm depth, noted as healing. Full thickness with exposed underlying structure. 100% epithelial tissue in wound bed. Treatment Barrier cream twice daily and as needed. Assessment completed by WD #122. 12/03/24 Skin grid assessment: Wound became unstageable, measuring 2.0 cm length x 1.5 cm width x unable to determine depth; noted decline by facility assessment, the wound was documented to have 70 % slough and 30% granulation tissue present and to continue with the current treatment. WD #122 was documented as the practitioner who assessed the wound. 12/03/24 Wound provider assessment: Wound assessment and plan: Stage 4 pressure wound, 2.0 cm length x 1.5 cm width x 0.2 cm depth, 30 % granulation and 70 % slough in wound bed. Wound documented as same/stable. No documentation present why stage was changed from Stage 3 to Stage 4. Assessment completed by WD #122. Interview on 12/24/24 at 10:15 A.M. with the Regional Nurse #504 and Interim Director of Nursing (IDON) #506 revealed there were discrepancies between the wound nurse and wound physicians' assessment. They stated the wound nurse and wound physician should be communicating those differences and additionally verified the wound nurse and wound physician are not communicating their differences in assessment. Review of the Skin and Wound Management Policy dated October 2024 revealed the purpose of the Skin and Wound Management policy was to provide an approach in the prevention and management of pressure injuries and skin alterations using the nursing process and other strategies to assist in identifying residents at risk for developing pressure injuries. This approach was in accordance with State and federal regulations. Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. The physician would assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.). The physician would order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. The physician would guide the care plan as appropriate, especially when wounds were not healing as anticipated or new wounds develop despite existing interventions. The deficiency identifies non-compliance with Complaint Number OH00160119.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to maintain a safe accident free environment and prevent a fall with injury for Resident #20. Actual Harm occurred on 05/03/24 when Resident #20 sustained a fracture of metatarsal bone and talus as a result of a fall sustained when the resident stepped from the transportation bus onto an unstable milk crate placed by facility staff, when exiting the transportation bus. Following the incident, Resident #20 complained of left knee and right foot pain and bruising was noted on her right ankle. Nursing noted Resident #20 had right extremity swelling, bruising, and uncontrolled pain, rating her pain an eight on a scale of one to 10 prior to her being sent to the hospital for evaluation and treatment. This affected one resident (#20) of three residents reviewed for accidents. The facility census was 108. Findings include: Record review for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses including age-related osteoporosis, anemia, pain in left hip, history of falls, and stroke. Review of the physical therapy (PT) treatment notes dated 02/05/24 revealed Resident #20 was discharged from physical therapy (PT) with safe functional mobility throughout facility with and without an assistive device. Resident #20 could safely ambulate unlimited distances using a front wheeled walker on uneven surfaces with modified independence. Review of the care plan dated 02/22/24 revealed Resident #20 was at risk for fall related to injury due to history of falls and medication use. Interventions included keeping the call light within reach and observe medication use for side effects that may increase fall risk, therapy screens, and update physician as indicated regarding change in condition/treatment needs. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had intact cognition. The assessment revealed Resident #20 required partial assistance from staff with mobility and sit-to-stand. Review of Fall Risk evaluation assessment dated [DATE] revealed Resident #20 was at low risk of falls. The assessment revealed Resident #20 was ambulatory, had normal balance, and had no reported falls within the past three months. Review of a progress notes dated 05/03/24 revealed the facility received a call from the dialysis center regarding a fall Resident #20 encountered during transfer off the bus. Resident #20 complained of left knee pain and bruising was noted on her right ankle. This resident was sent to the hospital after returning from dialysis for further evaluation related to injuries. Review of an incident report dated 05/03/24 revealed Resident #20 was complaining of pain to her right foot. Predisposing factors revealed uneven surface and lost balance. Nursing noted Resident #20 had right extremity swelling, bruising, and uncontrolled pain. The resident was sent to hospital for x-rays related to injury. Pain was noted at eight out of ten (with 10 being the most severe pain). Review of the hospital records dated 05/03/24 for Resident #20 revealed the resident was admitted due to complaint of right ankle injury from fall. This injury was sustained after stepping out of facility transportation bus onto a milk carton placed by their bus driver. This milk carton was unstable and flipped over under Resident #20's feet. The hospital records noted Resident #20 complained of pain rated a 10 out of 10. The physical exam revealed right ankle swelling present, tenderness over lateral malleolus, base of fifth metatarsal, and anterior [NAME]-fibular ligament. The x-ray report dated 05/03/24, revealed partially visualized fractures at the fifth metatarsal base, fourth metatarsal, third metatarsal, and second metatarsal. Probable avulsion type fracture arising from the anterior process of the talus. Resident #20 was hospitalized until 05/07/24 when she was discharged back to the facility. Review of the physician order dated 05/08/24, revealed Resident #20 was ordered non-weight bearing to right leg due to fracture of right foot. There was also a dressing order for the right foot/leg dressing to be changed every shift. Interview on 06/18/24 at 7:36 A.M. with Resident #20 revealed prior to the incident (on 05/03/24), she had no issues getting off the bus. On 05/03/24, she was stepping down off the bus, the facility transport assistant placed a milk crate under her to help with the step. After placing her second foot on the crate it flipped out from underneath her. When she fell, she was assisted up, and she stated she had refused to go to the hospital until after she received dialysis. When finished with dialysis, she was transported to the facility where nursing staff sent her out to the hospital. Resident #20 stated she was in tremendous pain due to the fall. Interview on 06/18/24 at 8:48 A.M. with Transport Driver #328 confirmed Resident #20 fell due to an unstable crate that he had placed at the steps of the transport bus. Transport Driver #328 indicated the milk crate had not been used previously as a transfer aide, and he confirmed the milk crate was not an appropriate transfer device. Interview on 06/18/24 at 10:38 P.M. with Licensed Practical Nurse (LPN) #252 confirmed prior to Resident #20's fall, she was independent with ambulation and required no assistance with getting on and off the bus. LPN #252 confirmed the dialysis center called the facility on 05/03/24 due to the reported incident of fall. LPN #252 stated Resident #20 told her she fell when stepping off the bus onto an unstable milk crate. Interview on 06/18/24 at 11:32 A.M. with Director of Nursing (DON) #224 confirmed Resident #20 fell due to stepping onto an unstable milk crate. Interview on 06/18/24 at 11:20 A.M. with the Administrator revealed he was notified of Resident #20's fall. The Administrator stated he spoke with Transportation Driver #328 about the incident, where he was informed to never use inappropriate transfer devices for ambulation. The Administrator confirmed the crate should not have been placed to use as a step for the resident. This deficiency represents non-compliance investigated under Complaint Number OH00154301.

Based on closed medical record review, staff interviews, and policy review, the facility failed to assess Resident #196's newly identified pressure ulcers and implement interventions/treatments to aid in the healing of existing pressure ulcers. Actual Harm occurred on 11/14/22 when the facility failed to provide assessment and treatment to the resident's pressure ulcer resulting in the pressure ulcer declining to a Stage III pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) to the coccyx. This affected one resident (#196) of three residents reviewed for pressure ulcers. Findings include: Review of the closed medical record for Resident #196 revealed an admission date of 10/12/22 with medical diagnoses of diabetes mellitus (DM) with neuropathy, right below the knee amputation (BKA), morbid obesity, end stage renal disease (ESRD) and dependence on dialysis. The medical record revealed Resident #196 discharged from the facility, against medical advice, on 12/06/22. Review of the medical record for Resident #196 revealed an admission Minimum Data Set (MDS) assessment, dated 10/19/22, which indicated Resident #196 was cognitively intact. The MDS revealed Resident #196 required extensive staff assistance with bed mobility, dressing, toileting and Resident #196 was dependent upon staff for transfers and bathing. The MDS also indicated Resident #196 was admitted with surgical wound and had no other skin issues. Review of the medical record for Resident #196 revealed a potential for impaired skin care plan, dated 10/25/22, due to diabetes mellitus and reduced bed mobility. Interventions included apply cushion to wheelchair, assist resident with turning and repositioning on routine rounds and as needed, and assist with toileting and incontinence care on routine rounds and as needed. Review of the care plans for Resident #196 revealed no documentation to support the facility had a care plan to address Resident #196's pressure ulcer or treatment to the wound. Review of the medical record for Resident #196 revealed a nurse's note dated 10/12/22 at 6:13 P.M. which stated Resident #196 admitted with a surgical wound to right BKA. The note also stated Resident #196 had an area to the buttock (not identified right or left buttock) measuring 1.2 centimeters (cm) by 2.2 cm and an area to the gluteal crest measuring 6 cm by 2 cm. The two areas had no staging documented. Review of the medical record for Resident #196 revealed a physician order dated 10/12/22 to clean areas to right buttock and gluteal crest fissure with soap and water and apply barrier cream every shift, after incontinence episodes, and as needed. Further review of the medical record for Resident #196 revealed a nurse's note dated 10/29/22 at 10:03 A.M. which documented the dressing was changed to Resident #196 coccyx per Resident 196's request. Review of the medical record for Resident #196 revealed no documentation to support a physician order for dressing to be applied to coccyx. Review of the medical record for Resident #196 revealed a nurse's note dated 11/14/22 at 8:24 P.M. which stated Resident #196 was seen at the wound clinic for a weekly check and evaluation and new orders were received for the wound to buttocks. A nurse's note dated 11/15/22 at 11:23 A.M. stated the facility wound nurse was notified that Resident #196 had a new pressure ulcer to his coccyx. The note continued to state Resident #196 refused to allow the facility wound nurse to assess the wound due to the wound was assessed by a doctor on 11/14/22 at the clinic. Review of the medical record for Resident #196 revealed a wound observation evaluation dated 11/14/22 which stated Resident #196 had a Stage III pressure ulcer to coccyx, measuring 3.5 cm by 1.5 cm by 0.1 cm and slough was present in the wound bed. Further review of the medical record for Resident #196 revealed Resident #196 refused wound observation evaluations of the coccyx wound to be completed on 11/21/22 and 11/28/22 and Resident #196 was not available for wound observation evaluation on 12/05/22. Review of the medical record for Resident #196 revealed no documentation to support the facility assessed the areas to buttocks and gluteal crease fissure from 10/12/22 through 11/13/22. Further review of Resident#196's physician orders revealed an order dated 11/15/22 for treatment to the right buttock and gluteal crease fissure to cleanse wound to buttocks with saline or soap and water, pat dry, place medi honey alginate to wound bed and cover with bordered dressing daily. Review of the medical record for Resident #196's revealed the October 2022 and November 2022 treatment administration record (TAR) revealed no documentation to support the facility provided the treatment to right buttock and gluteal crest fissure as ordered from 10/12/22 through 11/14/22. Review of the November 2022 TAR revealed treatment dated 11/15/22 to cleanse wound to buttocks with saline or soap and water, pat dry, place medi honey alginate to wound bed and cover with bordered dressing daily. Further review of Resident #196's November 2022 TAR, revealed no documentation to support the treatment to the buttocks was completed on 11/17/22, 11/18/22, and 11/22/22. Interview on 12/29/22 at 8:15 A.M. with Director of Nursing (DON) confirmed Resident #196's medical record did not have documentation to support treatment was provided to the area on the buttock and gluteal crease from 10/12/22 to 11/14/22. The DON confirmed the facility did not complete assessments of the area on the buttock or gluteal grease from 10/12/22 until 11/15/22. The DON confirmed a new treatment was ordered on 11/15/22 after the area developed into a Stage III pressure ulcer. The DON also confirmed the medical record did not contain a care plan to address the pressure ulcer or treatment. Review of facility policy titled Pressure Surveillance, revised 04/01/22, revealed the purpose of the policy is to prevent, identify, report, and investigate any new or worsened pressure injuries in the facility. The policy stated registered nurses and licensed practical nurses would participate in surveillance through assessment of residents and reporting changes in condition to the resident physicians and management staff. The policy stated surveillance activities include pressure injury/wound assessments and medication and treatment records. This deficiency represents non-compliance investigated under Complaint Number OH00138198.