**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of video camera footage, ambulance report, and hospital records, and interviews with residents, power of attorney, and staff, the facility failed to provide adequate assistance to prevent a fall for Resident #9 and failed to provide timely assistance following a fall for Resident #1. This resulted in Actual Harm on 09/28/23 when Resident #9, who required maximum assistance from two staff for bed mobility, fell from the bed while a staff member was providing incontinence care resulting in Resident #9 sustaining bilateral femur fractures. At the time of the incident, the facility failed to ensure staff had adequate training on the use of a low air loss and alternating pressure mattress to provide adequate assistance with incontinence care to the resident to prevent the fall with injury. This affected two residents (#1 and #9) of three residents reviewed for accidents. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #9 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation, morbid obesity, type II diabetes mellitus, and atrial fibrillation. Review of the physical therapy Discharge summary dated [DATE] revealed Resident #9's current level of assistance required maximal assist of two staff for rolling left and right, sitting to lying, and lying to sitting. Review of the state tested nursing assistant (STNA) documentation from 07/29/23 to 08/03/23 revealed Resident #9 required extensive assistance of two staff for bed mobility, six out of the eight times bed mobility was documented. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact and required extensive assistance of two or more persons for bed mobility. Review of a nursing progress note dated 09/28/23 at 2:23 A.M. revealed Licensed Practical Nurse (LPN) #125 was called to Resident #9's room. Resident #9 was back in bed and LPN #109 was present when LPN #125 arrived. Resident #9 was crying when the left knee was touched. The left knee had an abrasion, edema, and light discoloration. Resident #9 requested an x-ray be done. Resident #9's power-of-attorney (POA) was contacted and requested Resident #9 be sent to the hospital. Resident #9 was transferred to the hospital on [DATE] at 1:45 A.M. Review of a fall scene investigation report dated 09/28/23 at 1:00 A.M. revealed Resident #9 was incontinent, in bed, and lowered by staff to the floor. A typed statement dated 09/28/23 by Licensed Practical Nurse (LPN) #109 revealed they heard staff call for assistance to Resident #9's room. Resident #9 was lying on the floor and had complaints of the pain lying on the floor. LPN #109 examined Resident #9's legs. Resident #9 was assisted back into bed. LPN #109 did not think Resident #9 was hurt due to STNA #141 stated Resident #9's feet were hanging out the left side of the bed and Resident #9's head was sliding out the right side of the bed so STNA #141 gently lowered Resident #9 to the floor. LPN #109 went to get Resident #9's nurse, LPN #125. A handwritten statement dated 09/28/23 by STNA #141 revealed Resident #9 had activated the call light. STNA #141 entered the room and found Resident #9 at a ninety-degree angle with the top part of Resident #9's body falling out of the side of the bed towards the window. STNA #141 pushed Resident #9 over and made the bed flat. STNA #141 messaged another STNA to come assist with Resident #9. STNA #141 went ahead and provided incontinence care while waiting for another STNA. STNA #141 rolled Resident #9 towards the door since Resident #9's body was in bed on the side by the window. When STNA #141 rolled Resident #9, Resident #9's feet and legs kept going out of the bed. STNA #141 called on the walkie/talkie for help as soon as possible (ASAP). STNA #141 held on to Resident #9 and jumped over the bed to lower Resident #9 onto the floor (Resident #9's knees were already on the floor). STNA #141 got Resident #9's legs out from under Resident #9 when other staff arrived at Resident #9's room. A written statement by LPN #125 revealed they heard STNA #141 call for help. LPN #109 and a STNA (unnamed) went to Resident #9's room. LPN #125 got the vital machine and went to Resident #9's room. LPN #109 came out of Resident #9's room and stated they thought Resident #9 should be sent to the hospital. Resident #9 was in bed and crying. Resident #9 would not let LPN #125 move or touch Resident #9's left knee. LPN #125 told Resident #9 they wanted to send Resident #9 to the hospital for evaluation. The facility's action plan summary revealed on 09/28/23, Resident #9 had a fall from bed during care. Resident #9 had a low air loss and alternating pressure mattress in place. Interviews revealed staff were unfamiliar with the use of the static feature (provides constant pressure redistribution and support allowing nursing to perform patient care) of the air mattress and the associated risk of falls during bed mobility while a low air loss and alternating pressure mattress was in place. On 09/28/23, only eleven of the 25 STNAs, four of the 11 LPNs and two of the seven registered nurses (RN) were provided education on the use of the static feature of the air mattress and associated risks of falls without the static feature being used. Review of the hospital Discharge summary dated [DATE] revealed Resident #9 was transferred to Cleveland Clinic Akron General from Union hospital on [DATE] for treatment of injuries reportedly sustained during a fall at extended care facility. Resident #9 underwent extensive computed tomography (CT) and x-ray imaging which revealed bilateral distal femur fractures. Orthopedic surgery was consulted, given Resident #9's non-ambulatory status and multiple co-morbidities, non-surgical treatment with bilateral knee immobilizers during transfers was recommended. Review of the plan of care revealed Resident #9 was at risk for fall/injury. An intervention dated 11/09/23 revealed staff were to verify alternating pressure mattress was in static mode prior to assisting Resident #9 with bed mobility. Review of the STNA point-of-care (POC) shift dashboard dated 12/27/23 revealed Resident #9 required assistance with eating, bed mobility, toileting/incontinence care every two to three hours and as needed, and transferring with mechanical lift. The POC did not indicate how many staff were needed for each task. Interview of 12/27/23 at 6:55 P.M. with STNA #141 revealed Resident #9 was able to roll in bed with assistance and STNA #141 was providing incontinence care for Resident #9. The air mattress went flat on one side and Resident #9's legs went over the side of the bed. STNA #141 stated they jumped over the bed and lowered Resident #9 from being on their knees beside the bed to lying flat on the floor. STNA #141 stated everyone provided incontinence care for Resident #9 with just one STNA. STNA #141 stated therapy determined how many staff members were needed for care for each resident. STNA #141 stated they started working in February 2023 and were trained to provide care without assistance for Resident #9. STNA #141 verified the report sheets or POC did not show how much assistance each resident needed. STNA #141 verified the staff had reported to management several times over the last few weeks that the air mattress to Resident #9's bed was not working properly. Interview on 12/28/23 at 9:57 A.M. with the POA of Resident #9 revealed Resident #9 told the STNA they were slipping out of the bed. The POA felt two people should have been providing care due to Resident #9 requiring a mechanical lift for transfers and was not able to assist with most of the activities of daily living care provided. The POA felt the STNA was in a hurry and did not want to wait for another staff member to come assist with care and ended up rolling Resident #9 out of bed. Interview on 12/28/23 at 10:45 A.M. with Resident #9 revealed one STNA was providing care and kept pushing Resident #9 over until Resident #9 fell out of bed. Resident #9 stated two staff members were now required to provide care. Interview on 12/28/23 at 10:48 A.M. with Therapy Program Manager #151 revealed Resident #9 had physical therapy (PT) from 04/27/23 through 05/09/23. The PT discharge summary revealed Resident #9 was a maximum assist of two persons for bed mobility/rolling and for sitting to supine positioning. Interview on 12/28/23 at 1:07 P.M. with Corporate Clinical Director #500 verified after Resident #9 fell out of the bed, it was discovered that staff were not aware of the static feature on the air mattress pump to ensure adequate support while care was being provided to a resident. Corporate Clinical Director #500 verified there was not an order for the air mattress or to check proper function of the air mattress when Resident #9 fell out of bed. Corporate Clinical Director #500 stated if the STNA POC did not specify how many staff were needed for assistance, then only one person would be required. Corporate Clinical Director #500 verified the POC did not identify that two staff were needed for mechanical lift transfer, but the staff were aware that mechanical lifts always required two staff members. Corporate Clinical Director #500 was unable to provided manufacturer instructions or recommendations for the proper use of the air mattress. 2. Review of the medical record revealed Resident #1 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, acute myocardial infarction, neuromuscular dysfunction, spinal stenosis, type II diabetes mellitus, severe morbid obesity, and mood disorder. Review of the plan of care dated 04/04/23 revealed Resident #1 required assistance from staff to meet activities of daily living needs. Interventions included assisting with toileting, transfers, and bed mobility as needed. The plan of care dated 04/14/23 revealed Resident #1 was at risk of falls. Interventions included encouraging nonskid/gripper socks when shoes were off and staff to anticipate needs. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and had impairment to one side of lower extremities. Review of the weight history revealed on 11/08/23, Resident #1 weighed 389 pounds. Review of the facility's video camera footage dated 12/15/23 (observed on 12/26/23) revealed a staff member entered Resident #1's room on 12/15/23 at 10:38 A.M. Registered Nurse (RN) #107 was observed getting a vital machine and walking to Resident #1's room at 10:44 A.M. Emergency personnel arrived on 12/15/23 at 11:31 A.M. Resident #1 was transported to the hospital at 11:58 A.M. Review of the ambulance run report revealed a call was received on 12/15/23 at 11:25 A.M. The crew arrived at the facility at 11:29 A.M. Resident #1 reported right hip pain and was transported to the hospital at 11:58 A.M. Resident #1 arrived at the hospital at 12:00 P.M. The crew was delayed on scene for lift assist and additional personnel were sent to assist. Interview on 12/21/23 at 11:09 A.M. with Resident #1 revealed they attempted to self-transfer from wheelchair to bedside commode and fell. Resident #1 stated the STNAs were upset they were not permitted to call an ambulance to assist with getting Resident #1 off the floor. Resident #1 stated due to his size, the staff were unable to get Resident #1 off the floor. Resident #1 stated RN #107 checked Resident #1's vitals and then left the room. An STNA went to the Director of Nursing (DON) and asked for an ambulance to be called. Resident #1 stated the DON did not come to assess him. Resident #1 stated he was lying on his left arm, and it was turning purple so the STNAs turned him enough to get his arm out. Resident #1 stated he started developing pain after lying on the floor so when emergency personnel arrived, Resident #1 requested to be sent to the hospital. Resident #1 believed it was an hour or more before emergency personnel arrived at the facility. Interview on 12/21/23 at 2:02 P.M. with RN #107 revealed they assessed Resident #1 after the fall on 12/15/23. RN #107 stated the DON did not want an ambulance called for emergency personnel to assist with getting Resident #1 off the floor due to the ambulance company would charge the facility for assistance. RN #107 stated the DON wanted dietary staff, maintenance, and/or therapy to assist with getting Resident #1 off the floor. Dietary staff, maintenance, and therapy all refused to assist Resident #1. Interview on 12/26/23 at 9:39 A.M. with the DON verified Resident #1 was on the floor approximately 45-minutes before an ambulance was called. The DON stated they thought a mechanical lift or additional staff might be able to get Resident #1 off the floor. The DON verified she did not go to Resident #1's room to assess Resident #1 or to assist staff. Interview on 12/26/23 at 4:02 P.M. with STNA #105 revealed the DON did not want an ambulance called. RN #107 took Resident #1's vitals and then left the room. STNA #105 stated someone finally called an ambulance to assist with getting Resident #1 off the floor. STNA #105 stated Resident #1's hand started turning purple so the STNAs rolled Resident #1 and moved Resident #1's arm from underneath him. Resident #1 started complaining of pain after lying on the floor for approximately an hour. This deficiency represents non-compliance investigated under Complaint Number OH00149296 and OH00149293.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure 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, ensure pressure ulcer dressings were provided as ordered and/or prevent the risk of pressure ulcer infection for Residents #12, #38, #43, #47, #51 and #53. Actual Harm occurred on 08/11/22 when Resident #47, who was cognitively impaired, at moderate risk for pressure ulcer development, and dependent on staff for bed mobility, was found to have a deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration) pressure ulcer to the left heel and Stage III (full-thickness tissue loss into subcutaneous tissue but does not go into the muscle or bone) pressure ulcers to right buttock, right ischium, and left ischium without evidence of adequate and individualized pressure ulcer prevention interventions being in place prior to the development. Actual Harm occurred on 08/18/22 when Resident #53, who was at moderate risk for pressure ulcer development and dependent on staff for bed mobility, was found to have a Stage III pressure ulcer to the left buttock and coccyx without evidence of adequate and individualized pressure ulcer prevention interventions being in place prior to the development. Actual Harm occurred on 08/03/22 when Resident #51, who was cognitively impaired, at high risk for pressure ulcer development and dependent on staff for bed mobility was found to have a Stage III pressure ulcer to the sacrum without evidence of adequate and individualized pressure ulcer prevention interventions being in place prior to the development. Actual Harm occurred on 08/03/22 when Resident #12, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for bed mobility, was found to have a Stage III pressure ulcer to the right and left buttocks without evidence of adequate and individualized pressure ulcer prevention interventions being in place prior to the development. The resident had been identified to have an area of skin impairment on 06/23/22, however it could not be determined if the area on 08/03/22 was the same area or a different area based on the lack of assessment/monitoring. Actual Harm occurred on 08/04/22 when Resident #43, who was at high risk for pressure ulcer development and dependent on staff for bed mobility was found to have a Stage III pressure ulcer to the right ischium without evidence of adequate and individualized pressure ulcer prevention interventions being in place prior to the development. This affected six residents (#12, #38 #43, #47, #51 and #53) of six residents reviewed for pressure ulcers. Findings include: 1. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including COVID-19, acute kidney failure, atherosclerotic heart disease, diabetes, hypertension, and hypothyroidism. Review of the Clinical admission Evaluation, dated 07/15/22 revealed no evidence/documentation of Resident #47 having any skin issues/open areas/pressure ulcers present on admission. Review of the skin risk/Braden Scale Assessment, dated 07/17/22 revealed Resident #47 was assessed to be at moderate risk for developing pressure ulcers. The resident was noted to have slightly limited sensory perception, her skin was very moist, she walked occasionally, had very limited mobility, and had problems with friction and shearing which contributed to the pressure ulcer development risk. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 07/21/22 revealed Resident #47 had severely impaired cognition, required extensive assistance from two staff for bed mobility and transfers and had no pressure ulcers. Review of the July 2022 nursing assistant skin TASK documentation revealed nursing assistant staff were to check the resident's skin condition every shift during all care provided and document the presence of any scratches, red areas, discolorations or open areas. The nursing assistant was to notify the nurse of any new areas. Review of Resident #47's Skin Task documentation revealed there was no documentation of the resident's skin during care on 07/18/22, 07/19/22, 07/23/22, 07/24/22, 07/25/22, 07/26/22, 07/27/22, 07/28/22, 07/30/22 or 07/31/22. In addition, on 07/29/22 at 12:44 P.M. the documentation indicated the resident had a red area. Record review revealed no additional documentation/assessment of this area on this date. Review of the plan of care, dated 08/02/22 revealed Resident #47 was at risk for skin breakdown related to decreased mobility, diabetes, and incontinence. Interventions included to administer medications as ordered, encourage the resident to turn and reposition, staff to perform skin checks, report any new areas, assist resident with toileting as needed, provide diet as ordered, pressure redistribution mattress, and consult a wound nurse as needed. Review of a nursing progress note, dated 08/11/22 at 10:05 A.M. revealed Resident #47 was seen by the wound nurse practitioner (NP). The resident was assessed to have a Stage III pressure ulcer to her right buttock, right ischium, and left ischium. New orders were obtained to apply 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) to all areas three times daily. The note revealed the resident was also found to have a deep tissue injury to her left heel with a new order to apply skin prep, cover with an abdominal dressing and Kerlix daily. The note also revealed orders were noted at that time for a low air loss mattress to the resident's bed, use of a pressure relief cushion in the wheelchair and recliner and a protein supplements twice daily. Review of the skin grids/wound assessment, dated 08/11/22 revealed Resident #47 had a deep tissue injury to her left heel which measured 3.0 cm width by 6.0 cm length with an undetermined depth. The wound was assessed to be a dried blister. The resident was assessed to have a Stage III pressure ulcer to the right buttock which measured 0.8 cm width by 0.5 cm length with 0.1 cm depth with a small amount of serosanguinous drainage and 100 percent granulation. A Stage III pressure ulcer to the right ischium measured 0.5 cm width by 0.3 cm length with 0.1 cm in depth with a small amount of serosanguinous drainage, 30 percent slough and 70 percent granulation. A Stage III pressure ulcer to the left ischium which measured 0.5 cm width by 2.0 cm length with 0.1 cm depth with a small amount of serosanguinous drainage and 10 percent epithelial bridge, 10 percent slough and 80 percent granulation. Review of a wound NP note, dated 08/11/22 revealed a visit for an initial evaluation and management of new wounds reported for Resident #47 to the resident's buttocks and left heel. The NP note revealed the same areas as on the skin grid above with the same measurements. Review of the August 2022 physician's orders revealed the following pressure ulcer prevention measures were ordered following the development of the above pressure ulcers: Arginaid (supplement) one packet two times daily (initiated 08/17/22), 30 milliliters (ml) of Pro-Heal protein supplement twice daily (initiated 08/11/22), a pressure relieving cushion to the wheelchair and recliner (initiated 08/11/22) and a low air loss mattress to bed (initiated 08/11/22). In addition, the resident had a treatment order to apply triad paste to the left buttock three times daily (initiated 08/11/22) and an order to apply skin prep to the left heel, cover with abdominal dressing and wrap with Kerlix daily (initiated 08/11/22). Review of the August 2022 treatment administration record revealed no evidence/documentation the pressure ulcer treatments were provided as ordered to the area to the left buttock on 08/12/22 afternoon shift, or on 08/26/22 day and afternoon shift; to the area on the left ischium on 08/12/22 afternoon shift, or 08/26/22 day and afternoon shift; or to the area on the right buttock on 08/12/22 afternoon shift, on 08/15/22 at bedtime, or on 08/25/22 day and afternoon shift. On 08/31/22 at 9:37 A.M., observation with Registered Nurse (RN) #54 revealed Resident #47 had a dressing to the left heel dated 08/30/22 with a large amount of serosanguinous drainage which had leaked through the dressing. The area to the left heel was observed with a large black scab. The resident was observed with an area to her left ischium that was pinpoint in size with a pink blanchable peri wound. On 09/01/22 at 12:20 P.M. interview with Wound Nurse Practitioner #83 revealed she believed a lack of staffing lead to numerous residents, including Resident #47 with skin breakdown in August 2022. The nurse practitioner did not elaborate or provide any additional information during the interview as to how/why she had this belief. On 09/19/22 at 4:50 P.M. during an interview with Registered Nurse (RN) #54, the concern related to the development of Resident #47's pressure ulcers were discussed. The RN was unable to provide any explanation as to why/how Resident #47 was found with a deep tissue injury to the left heel and the Stage III pressure ulcers to the buttocks/ischium area on 08/11/22. RN #54 verified the lack of written evidence to reflect interventions being in place (i.e. turning and repositioning, pressure reduction devices, toileting) prior to the pressure ulcer development. The RN indicated it was good nursing practice for staff to turn, reposition and toilet residents every two hours. On 09/19/22 at 4:55 P.M. interview with Licensed Practical Nurse (LPN) #12 revealed the skin documentation section under the TASK section in the electronic medical record was for the nursing assistants to document residents skin condition(s) when they provided daily care. She indicated the nursing assistants should have been documenting the resident's condition daily. LPN #12 verified the documentation was incomplete for Resident #47 for the dates noted above. On 09/20/22 at 1:50 P.M. interview LPN #12 verified there was no follow up or skin assessment related to the nursing assistant skin task documentation of a red area for Resident #47 on 07/29/22. On 09/20/22 at 1:55 P.M. during a follow up interview with RN #54, the RN revealed she had actually been notified by therapy staff of areas of skin breakdown for Resident #47 on 08/08/22. RN #54 revealed she notified the wound nurse and received an order for a barrier cream. The RN was unable to state where these areas were on this date and verified no skin assessment had been completed for Resident #47 on 08/08/22. Review of the facility policy titled, Wound and Skin Care, dated 06/07/22 revealed the purpose of the policy was to ensure documentation, monitoring and treatment of all wounds. 2. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including heart failure, asthma, diabetes, narcolepsy, acute kidney failure, major depressive disorder, atherosclerotic heart disease, anxiety disorder, anemia, vitamin D deficiency and hypertension. Review of the Clinical admission Evaluation dated 04/28/22 revealed no evidence/documentation of Resident #53 having skin issues/open areas or pressure ulcers on admission. Review of the plan of care dated 04/29/22 revealed Resident #53 was at risk for skin breakdown related to decreased mobility, diabetes, and incontinence. Interventions included to administer medications as ordered, encourage the resident to turn and reposition, staff to perform skin checks, report any new areas, assist resident with toileting as needed, provide diet as ordered, pressure redistribution mattress, and consult a wound nurse as needed. Review of the July 2022 nursing assistant skin task documentation revealed the nursing assistants were to be checking the resident's skin condition every shift during all care provided and documenting whether the resident had any scratches, red areas, discolorations, and open areas. The nursing assistants were to notify the nurses of any new areas. Review of Resident #53's skin task documentation revealed there was no documentation of the resident's skin during care on 7/01/22, 07/02/22, 07/03/22, 07/04/22, 07/08/22, 07/09/22, 07/10/22, 07/11/22, 07/17/22, 07/24/22, 07/25/22, 07/26/22, 07/27/22, 07/29/22 or 07/30/22. On 07/28/22 at 10:11 A.M. the documentation indicated the resident had an open area. However, there was no additional assessment or information regarding this area at that time. Review of the quarterly MDS 3.0 assessment, dated 08/01/22 revealed Resident # 53 had intact cognition, required extensive assistance from two staff members for bed mobility and had no pressure ulcers. Review of a nursing progress note, dated 08/18/22 at 4:28 P.M. revealed Resident #53 had a Stage III open area to the left buttock which measured 2.0 cm width by 0.75 cm length with slough tissue present and minimal drainage, no odor. The peri wound was assessed to be reddened. The note revealed the resident also had a 2 cm round Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure area to the coccyx. The wound nurse practitioner was notified and ordered a treatment to cleanse with normal saline, apply a dime thick layer of triad paste daily and as needed, pressure relief cushion in the recliner and wheelchair, low air loss mattress and protein supplements twice daily. Review of the skin risk/Braden Scale Assessment, dated 08/19/22 revealed Resident #53 was assessed to be at moderate risk for pressure ulcer development. The resident had a very limited sensory perception, her skin was very moist, she walked occasionally, had very limited mobility, probably inadequate nutrition and had a potential problem with friction and shearing which contributed to the pressure ulcer risk. Review of the August 2022 had the following physician's orders initiated following the development of the pressure ulcer: On 08/18/22 an order was obtained for an Arginaid packet twice daily and Pro-heal supplement 30 milliliters two times daily. In addition, on 08/18/22 orders were obtained for a pressure relief cushion in the wheelchair and recliner and a low air loss mattress to the bed. On 08/26/22 an order was obtained for skin prep to the bilateral heels, leave open to air and an order (initiated 08/25/22) to cleanse left buttock with normal saline (NS), apply dime thick layer of triad paste three times daily and as needed Review of a Wound NP note, dated 08/25/22, revealed an initial evaluation and management of new wounds reported to the left buttock and coccyx for Resident #53. The resident was assessed to have a Stage III pressure ulcer to the coccyx which measured 1.5 cm width by 0.3 cm length with scant serosanguinous drainage. The wound bed had 100 percent viable tissue. The resident was also assessed to have a Stage III pressure ulcer to the left buttock which measured 1.5 cm width by 1.0 cm length by 0.1 cm depth with scant serosanguinous drainage, 30 percent slough tissue and 70 percent granulation. The resident's bilateral heels were assessed to be soft, blanchable. The note revealed the resident was at high risk for breakdown and orders were provided to apply skin prep to heels, leave open to air, offload heels and obtain a pressure relieving cushion for her chair. On 08/31/22 at 10:15 A.M. observation with RN #54 revealed Resident #53 had a nickel size open area to her left buttock. The wound bed was reddened, and the peri wound was pink. The resident was observed to have a low air loss mattress to her bed at the time of the observation. An interview at the time of the observation revealed Resident #53 stated her left buttock hurt. On 09/01/22 at 12:20 P.M. interview with Wound Nurse Practitioner #83 revealed she believed a lack of staffing lead to numerous residents, including Resident #53 with skin breakdown in August 2022. The nurse practitioner did not elaborate or provide any additional information during the interview as to how/why she had this belief. On 09/19/22 at 3:50 P.M. interview Resident #53 revealed she believed the pressure wounds she had were due to laying in bed all the time. The resident revealed she required staff to assist her out of bed and turn/reposition in bed and denied receiving this assistance. On 09/19/22 at 4:50 P.M. during an interview with Registered Nurse (RN) #54, the concern was shared related to the development of Resident #53's pressure ulcers. The RN was unable to provide an explanation as to why/how Resident #53 was found with the Stage III pressure ulcers on 08/18/22. RN #54 verified the lack of written documentation to reflect interventions being in place (i.e. turning and repositioning, pressure reduction devices, toileting) prior to the Stage III pressure ulcer developing. The RN indicated it was good nursing practice for staff to turn, reposition and toilet residents every two hours. On 09/19/22 at 4:55 P.M. interview with Licensed Practical Nurse (LPN) #12 revealed the skin documentation section under the TASK section in the electronic medical record was for the nursing assistants to document residents skin condition(s) when they provided daily care. She indicated the nursing assistants should have been documenting the resident's condition daily. She verified the documentation was incomplete for Resident #53 for the dates noted above. On 09/20/22 at 1:50 P.M. interview LPN #12 verified there was no follow up or skin assessment related to the nursing assistant skin task documentation of an open area for Resident #53 on 07/28/22. Review of the facility policy titled, Wound and Skin Care, dated 06/07/22 revealed the purpose of the policy was to ensure documentation, monitoring and treatment of all wounds. 3. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage, diabetes, hypertension, acute respiratory failure, disease of the pancreas, anxiety disorder, schizoaffective disorder, vascular dementia, and vitamin D deficiency. Review of the Clinical admission Evaluation, dated 04/21/22 revealed no evidence documentation of Resident #51 having skin issues/open areas/pressure ulcers present on admission. Review of the plan of care, dated 04/22/22 revealed Resident #51 was at risk for skin breakdown related to decreased mobility, diabetes, and incontinence. Interventions included to administer medications as ordered, encourage the resident to turn and reposition, staff to perform skin checks, report any new areas, assist resident with toileting as needed, provide diet as ordered, pressure redistribution mattress, use lift sheet/pad for bed mobility and consult a wound nurse as needed. Review of the Braden Scale, dated 05/08/22 revealed Resident #51 was assessed to be at high risk for developing pressure ulcers. The assessment revealed the resident had very limited sensory perception, his skin was very moist, he was chair fast, had very limited mobility, probably inadequate nutrition and had a problem with friction and shearing which contributed to the pressure ulcer risk. Review of the quarterly MDS 3.0 assessment, dated 07/28/22 revealed Resident #51 had severely impaired cognition, required total assistance from two staff for bed mobility, transfers, dressing and toilet use. The MDS assessment revealed the resident was always incontinent of bladder and bowel and did not have a pressure ulcer. Review of the weekly Skin Observation document, dated 07/29/22 revealed Resident #51 had a new skin area noted. However, record review revealed no additional assessment/staging/description of the wound was completed on this date. Review of a nursing progress note, dated 07/31/22 at 3:24 P.M. revealed Resident #51 had an open area to the left side of the coccyx which measured 3.0 cm width by 3.1 cm length with 0.1 cm depth. The note did not include a stage of the ulcer at that time. The area was noted to have a red/pink wound bed. The wound nurse was notified and order to cleanse the areas with normal saline, apply triad paste and a foam dressing. Review of the July 2022 nursing assistant skin task documentation revealed the nursing assistants were to be checking the resident's skin condition every shift during all care provided and documenting whether the resident had any scratches, red areas, discolorations, and open areas. The nursing assistant was to notify the nurse of any new areas. Review of Resident #51's Skin task documentation revealed there was no documentation of the resident's skin during care on 7/04/22, 07/05/22, 07/10/22, 07/23/22, 07/24/22, 07/26/22, 07/30/22 or 07/31/22. Review of a wound NP note, dated 08/04/22 revealed a visit for an initial evaluation and management of a new wound reported to the sacrum of Resident #51. The resident was assessed to have a Stage III pressure ulcer to the sacrum with an onset date of 08/03/22. Nursing staff reported the resident slides down in the wheelchair causing shearing. The note revealed the resident was placed on an air mattress yesterday. Resident #51's sacral wound measured 3.0 cm width by 3.5 cm width with 0.1 cm depth and a small amount of serosanguinous drainage. The wound had 20 percent slough tissue with 80 percent granulation tissue present. Review of the August 2022 physician's orders revealed following the development of the pressure ulcers, Resident #51 had orders to encourage to turn and reposition (initiated 08/30/22), float heels as tolerated while in bed (initiated 08/30/22), cleanse sacrum with normal saline, apply a dime-thick layer of triad paste, cover with foam dressing daily and as needed, pressure relieving cushion in the chair (initiated 08/04/22), and a low air loss mattress to the bed (initiated 08/04/22). Review of the progress note, dated 08/23/22 at 4:28 P.M. revealed Resident #51 had a 2.0 cm by 1.0 cm blister to his right heel which was dark red in color. The skin around the blister was dark pink. A new order was received to apply skin prep, an abdominal (ABD) dressing and wrap in Kerlix daily. Review of the August 2022 TAR revealed no evidence the treatment to the sacrum was completed as ordered on 08/18/22, 08/20/22, 08/23/22, 08/25/22 or 08/28/22. On 08/31/22 at 10:00 A.M. observation and interview with RN #54 revealed Resident #51 had a quarter size open area to his coccyx. The wound bed was reddened. There was not a dressing to the area at the time of the observation. The resident also had a nickel size dried blister to his right outer heel. On 09/01/22 at 12:20 P.M. interview with Wound Nurse Practitioner #83 revealed she believed a lack of staffing lead to numerous residents, including Resident #51 with skin breakdown in August 2022. The nurse practitioner did not elaborate or provide any additional information during the interview as to how/why she had this belief. On 09/19/22 at 4:50 P.M. during an interview with Registered Nurse (RN) #54, the concern related to the development of Resident #51's pressure ulcer to the sacrum was shared. The RN was unable to provide an explanation as to why/how Resident #51 was found with a Stage III pressure ulcer on 08/03/22. RN #54 verified the lack of written documentation to reflect interventions being in place (i.e. turning and repositioning, pressure reduction devices, toileting) prior to the Stage III pressure ulcer developing. The RN indicated it was good nursing practice for staff to turn, reposition and toilet residents every two hours. On 09/19/22 at 4:55 P.M. interview with Licensed Practical Nurse (LPN) #12 revealed the skin documentation section under the TASK section in the electronic medical record was for the nursing assistants to document resident skin condition(s) when they provided daily care. She indicated the nursing assistants should have been documenting the resident's condition daily. LPN #12 verified the documentation was incomplete for Resident #51 for the dates noted above. Review of the facility policy titled, Wound and Skin Care, dated 06/07/22 revealed the purpose of the policy was to ensure documentation, monitoring and treatment of all wounds. 4. Review of the medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including major depression, anxiety, adult failure to thrive, amnesia, osteoarthritis, and high blood pressure. Review of the admission MDS 3.0 assessment, dated 05/27/22 revealed the resident had severely impaired cognition, required extensive assistance from two staff members for bed mobility, transfers, dressing and toilet use and extensive assistance from one staff member for personal hygiene. The MDS assessment revealed no evidence the resident had any type of skin breakdown/wounds present on admission. Review of the plan of care, dated 05/27/22 revealed Resident #12 was at risk for breakdown related to decreased mobility and incontinence. Interventions included to administer medications as ordered, encourage the resident to turn and reposition, staff to perform skin checks, report any new areas, assist resident with toileting as needed, use a lift sheet/pad for bed mobility, provide diet as ordered, pressure redistribution mattress, and consult a wound nurse as needed. Review of the skin risk/Braden Assessment Scale dated 06/08/22 revealed Resident #12 was at high risk for developing pressure ulcers. The assessment revealed the resident had very limited sensory perception, her skin was very moist, she was chair fast, had very limited mobility, probably inadequate nutrition and had a problem with friction and shearing which contributed to the pressure ulcer risk. Review of a nursing progress note, dated 06/23/22 at 2:05 P.M. revealed during a skin assessment Resident #12 was found to have a 0.25 centimeter (cm) superficial open area to the left inner buttock. The area was not staged and did not contain any additional description/assessment. The note did document the resident refused to get out of bed often. There was an order for barrier cream to the resident's bilateral buttocks three times daily, however the note indicated the order would be changed to Chamosyn with Manuka Honey to bilateral buttock three times daily and as needed. Record review revealed no additional information or assessments were provided related to the identification of the superficial area to the left inner buttock or of monitoring of the area following the identification. In addition, there was no evidence the facility implemented additional pressure ulcer prevention or interventions at that time. Record review revealed no evidence the facility developed a plan of care related to the resident refusing to get out of bed. Review of a physician's order, dated 06/23/22 revealed Resident #12 had a treatment order for Chamosyn with Manuka Honey to bilateral buttock three times daily and as needed. Record review revealed from 06/24/22 to 08/02/22 there were no skin assessments or monitoring of the resident's skin by a licensed nurse or evidence of monitoring of the area to the left inner buttock first noted on 06/23/22. Review of the July 2022 nursing assistant skin task documentation revealed the nursing assistants were to be checking the resident's skin condition every shift during all care provided and documenting whether the resident had any scratches, red areas, discolorations, and open areas. The nursing assistants were to notify the nurse of any new areas. Review of Resident #12's Skin task documentation revealed there was no documentation of the resident's skin during care on 07/02/22, 07/09/22, 07/10/22, 07/14/22, 07/16/22, 07/19/22, 07/23/22, 07/24/22, 07/25/22, 07/26/22, 07/27/22, 07/29/22, 07/30/22 or 07/31/22. Review of a nursing progress note, dated 08/02/22 at 2:35 P.M. revealed Resident #12 received a bed bath and the wound on her bottom was starting to open and bleed. However, record review revealed no additional assessment or care provided on this date. A physician's order, dated 08/04/22 (two days later) revealed an order to cleanse bilateral buttocks with normal saline and apply dime-thick layer of triad paste three times daily and as needed. Review of a nursing progress note, dated 08/04/22 at 12:13 P.M. revealed the wound nurse practitioner (NP) visited. Resident #12 was assessed at that time (by the NP) to have a Stage III pressure ulcer to her left and right buttocks. A new order was received to cleanse areas with normal saline and apply a dime-thick amount of triad cream three times daily and as needed. The progress note also revealed to implement a low air loss mattress to bed, a pressure relief cushion to wheelchair and recliner and a protein supplement twice daily. Review of the skin grid/wound assessment, dated 08/04/22 revealed Resident #12 had a Stage III pressure ulcer to the left buttock which measured 1.0 centimeter (cm) in width by 1.0 cm in length with 0.1 cm in depth with 100 percent granulation and a small amount of serosanguinous drainage and a Stage III pressure ulcer to the right buttock which measured 0.9 cm width by 1.5 cm length with 0.1 cm depth with 30 percent slough tissue and 70 percent granulation with a small amount of serosanguinous drainage. Review of the Wound NP note, dated 08/04/22 revealed NP visited for an initial evaluation and management of new wounds reported for Resident #12 to the bilateral buttocks with an onset of 08/03/22. The NP note reflected the same measurements and description from the skin grid/wound assessment dated [DATE]. Review of August 2022 treatment administration record (TAR) revealed no evidence the treatment to the bilateral buttocks was completed as ordered on 08/18/22 afternoon shift, 08/20/22 day and afternoon shift, 08/23/22 day and afternoon shift or on 08/24/22 afternoon shift. On 08/31/22 at 10:45 A.M. observation of Resident #12's skin revealed an open area to the right buttock with granulation tissue present. The resident's skin was pink surrounding peri wound. On 09/01/22 at 12:20 P.M. interview with Wound Nurse Practitioner #83 revealed she believed a lack of staffing lead to the numerous residents, including Resident #12 with skin breakdown in August 2022. The nurse practitioner did not elaborate or provide any additional information during the interview as to how/why she had this belief. On 09/19/22 at 4:50 P.M. during an interview with Registered Nurse (RN) #54, the concern was shared related to the identification of Stage III pressure ulcers to Resident #12's bilateral buttocks. The RN was unable to provide an explanation as to why/how Resident #12 was found with a Stage III pressure ulcer on 08/04/22. RN #54 verified the lack of written documentation to reflect interventions being in place (i.e. turning and repositioning, pressure reduction devices, toileting) prior to the Stage III pressure ulcer developing. The RN indicated it was good nursing practice for staff to turn, reposition and toilet residents every two hours. On 09/19/22 at 4:55 P.M. interview with Licensed Practical Nurse (LPN) #12 revealed the skin documentation section under the TASK section in the electronic medical record was for the nursing assistants to document resident skin condition(s) when they provided daily care. She indicated the nursing assistants should have been documenting the resident's condition daily. She verified the documentation was incomplete for Resident #12 for the dates noted above. Review of the facility policy titled, Wound and Skin Care, dated 06/07/22 revealed the purpose of the policy was to ensure documentation, monitoring and treatment of all wounds. 5. Review of the medical record reve[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure one resident (Resident #152) was provided the necessary care and services to prevent the development of unstageable pressure ulcers. This affected one resident (#152) of three residents reviewed for hospitalization. Actual Harm occurred on 02/12/19 when Resident #152, who was identified to be at moderate risk for pressure ulcers, complained of increased pain to the right ankle and was subsequently identified to have developed three unstageable pressure ulcers when assessed by an orthopedic physician. Prior to the orthopedic identification of the pressure ulcers, the facility failed to adequately monitor the resident's skin and implement appropriate pressure relieving interventions to prevent the development of three unstageable pressure ulcers. Findings include: Review of Resident #152's medical record revealed an admission date of 01/31/19 with diagnoses including status post right ankle fracture with surgical repair, polyneuropathy (disease or damage affecting the peripheral nerves on both sides of the body), diabetes and heart failure. Review of the admission nursing assessment, dated 01/31/19 revealed no skin alterations were noted on admission except shearing to the resident's scrotum. The resident's skin was warm and dry. No skin alteration interventions were noted on the admission assessment. Review of the Braden Assessment for Predicting Pressure Ulcer Development, dated 01/31/19 revealed a score of 14 indicating the resident was at moderate risk for pressure ulcer development. Review of the physician's orders revealed orders to ice and elevate leg every shift (which leg not specified) dated 01/31/19, keep splint to right ankle clean, dry and intact dated 02/01/19 and enabler bars to bilateral bedside to encourage turning and repositioning dated 02/04/19. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 02/07/19 revealed the resident was cognitively intact and required extensive assistance of two staff with bed mobility, transfers and toilet use. The resident also required extensive assistance of one staff with dressing and personal hygiene. The resident was identified at risk for pressure ulcer development but did not have pressure ulcers, diabetic ulcers, venous or arterial ulcers upon admission. Review of the progress note, dated 02/11/19 at 9:53 P.M. revealed the resident had a skin check and the resident did not have any new skin issues documented to be addressed at this time. Review of an orthopedic progress note, dated 02/12/19 revealed the resident presented to the office with right ankle pain. The note revealed the resident was initially seen in consultation at the hospital on [DATE] after a fall that resulted in an obvious deformity of the right ankle. The resident was brought to the emergency department. X-rays revealed an ankle fracture and a fibula fracture. The resident had an open reduction, internal fixation of the right ankle on 01/25/19. The resident presented to the office on 02/12/19, non-weight bearing and with a knee immobilizer. There was an area of necrotic tissue on the right forefoot on the lateral side as well as a plantar ulcer. There was also an area of eschar (dark area) over the patella, likely a pressure sore from the knee immobilizer. The resident was taken out of the ankle orthotic splint and placed in a tall walker boot. The note indicated the resident would remain in this only to come out for daily range of motion exercises. The resident would remain non-weight bearing for the next four weeks and no longer needed to wear the knee immobilizer. It was suggested the resident see the podiatrist due to necrotic tissue on the lateral side of his right forefoot and a plantar ulcer that needed assessed. The area of eschar on the patella also needed assessed and the areas needed monitored by the facility to ensure they were not progressing to infection. Review of the progress note, dated 02/14/19 at 11:19 A.M. revealed a facility skin assessment was completed and two areas of eschar were observed on the resident's right knee and the ball of the right foot and an area of discoloration to the right lateral bottom of the foot measuring 4.7 centimeters by 2.3 centimeters was also noted. The note revealed the Wound Certified Nurse Practitioner would follow starting the following week. An order was obtained to cleanse the right knee with normal saline and apply A&D ointment, cover with border foam dressing every other day and as needed. The area measured 3.5 cm by 3.0 cm. Preventative measures revealed the resident was non-weight bearing to the right foot and the resident was currently working with therapy. Review of a podiatry progress note, dated 02/15/19 revealed the resident had an ungradeable ulcer to the right (location not specified) without signs or symptoms of infection. Orders were written for wound care. Review of the physician's orders revealed to cleanse the ball of the right foot and right knee with normal saline, pat dry and apply A&D ointment and cover with border foam, change every other day and as needed written 02/16/19. Review of the medical record revealed a weekly skin integrity review, dated 02/18/19 indicating necrotic areas to the bottom and lateral of the right foot. No measurements were documented at that time. Review of the Patient Visit Record, dated 02/19/19 revealed Resident #152 was evaluated by Certified Nurse Practitioner #500 due to wounds to the right lower extremity. The CNP evaluated the wound to the right knee with an etiology of abrasion/pressure and measuring 3.1 centimeters (cm) in length by 2.9 cm width with 0.1 cm depth. The visit record documentation revealed the right foot plantar area was identified as an unstageable pressure ulcer with 100% stable eschar with the wound measuring 2.4 cm in length by 3.0 cm width with 0.1 cm depth. The visit record documentation revealed an unstageable pressure ulcer to the right lateral foot measuring 3.1 cm in length by 4.5 cm width with 0.1 cm depth. The order obtained for all three areas was silver alginate, abdominal pad, gauze wrap three times a week and as needed. Record review revealed the resident had a current plan of care related to the risk for skin breakdown due to decreased mobility that was first initiated on 07/05/19. Interventions documented on the care plan included an air mattress (dated 03/15/19), encourage resident to turn and reposition (dated 02/21/19), staff to perform skin checks and report any new areas (dated 02/21/19) and pressure ulcer management program dated 02/21/19. Each of these interventions were noted to have been implemented after the resident was assessed to develop the unstageable pressure ulcers on 02/12/19. On 11/26/19 at 6:06 P.M. interview with Licensed Practical Nurse (LPN) #27 revealed the resident was admitted to the facility with post-operative surgical needs and had no skin alterations on admission but was wearing a splint/boot to the right foot and ankle. LPN #27 revealed the resident was to receive weekly skin assessments but verified the wounds were not identified by the facility until 02/14/19, two days after the alterations were identified by the orthopedic physician. LPN #27 verified the first facility pressure ulcer assessments were dated 02/14/19. LPN #27 stated the resident's boot should have been removed daily for bathing and a skin assessment and circulation check should have been completed daily due to the resident's potential to develop a pressure ulcer from the splint/boot. LPN #27 verified the resident developed three unstageable pressure ulcers to the right foot and knee from the right ankle splint and pressure was identified as the etiology by CNP #500. LPN #27 verified the resident was seen by the podiatrist on 02/15/19 but the podiatrist did not indicate the etiology or location of the unstageable wounds during his evaluation. Further interview verified no wound treatments were written the date the podiatrist visited. Lastly, the LPN verified the resident was identified to be at moderate risk for pressure ulcer development using the Braden assessment tool however, a plan of care was not implemented until 07/05/19. The plan of care included interventions that were dated before the plan of care was developed and the care plan was initiated well after the pressure ulcers were first identified. The LPN verified there was no evidence of pressure relieving interventions prior to the identification of the pressure ulcers on 02/14/19 or immediately after the ulcers were identified. Review of the Wound and Skin Care Policy, dated 09/23/1996 and revised 06/07/16 revealed all new admissions and readmissions would be placed on a skin program for four weeks. For new admissions who do not have a pressure area/ulcer, the resident's skin would be monitored weekly through the nurses' skin assessments. Identified issues would be followed through the skin program. If a pressure area/ulcer was present, the resident would be placed on the pressure ulcer monitoring program (PUMP) and the area would be measured/tracked weekly and as needed until the area was resolved. Further review revealed an unstageable pressure ulcer had an unknown depth. An unstageable pressure ulcer was defined as a full thickness loss where the base of the ulcer was covered with slough and/or eschar (dead tissue) in the wound bed. The stage could not be determined and the depth could not be obtained. All wounds would be assessed for etiology using predisposing factors, anatomic location, wound characteristics and resident assessment.