**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and facility policy and procedure review, the facility failed to comprehensively assess, provide timely interventions, and implement a treatment to an existing pressure ulcer. This resulted in Actual Harm to Resident #40 on 03/20/25 when the facility failed to assess a resident's wound and obtain physician orders for wound treatments resulting in Resident #40 developing an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) to the right gluteus. This affected one (#40) of three residents reviewed for pressure ulcers. The facility census was 63. Findings include: Review of the medical record for Resident #40 revealed an initial admission date of 03/20/25. Diagnoses included pulmonary embolism, diabetes mellitus, severe protein calorie malnutrition, peripheral venous insufficiency, chronic pain syndrome, gout, anemia, gastro-esophageal reflux disease, irritable bowel syndrome, and fatty liver. Review of the resident's admission evaluation dated 03/20/25 revealed Resident #40 was admitted with no skin abnormalities. Review of the skin issues care plan contained within the admission evaluation revealed no interventions were implemented. The assessment indicated Resident #40 required extensive assistance with bed mobility and toileting. Review of the Braden scale assessment dated [DATE] revealed a score of 19 indicating Resident #40 was at risk for skin breakdown. Review of the weekly skin and wound evaluation dated 03/20/25 revealed Resident #40 was admitted to the facility with a Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.) to the right gluteus. The assessment had no measurements or description of the wound. The assessment indicated the facility implemented to cleanse the wound with normal saline, but indicated the wound had no dressing. The assessment indicated the facility implemented the interventions of nutrition/dietary supplement and turning and repositioning program. There was no baseline care plan-initiated addressing Resident #40's high risk for skin breakdown. Review of Resident #40's physician orders dated 03/20/25 revealed an order to monitor scattered bruising and scabbing to right/left hand every shift and monitor scattered bruising to bilateral lower extremities and bilateral upper extremities. There was no treatment ordered on 03/20/25 to treat the Stage II pressure ulcer identified on the weekly skin and wound evaluation. From 03/20/25 to 03/26/25, there was no evidence a nutrition/dietary supplement was ordered for Resident #40 for wound healing, no evidence of Resident #40 being on a turning and repositioning schedule, and no treatment was ordered to the Stage II pressure ulcer to the right gluteus. There was no baseline care plan in place after Resident #40 was identified to be at risk for skin breakdown and had a Stage II pressure ulcer. On 03/24/25, there was a new physician order to encourage Resident #40 to float heels while in bed. On 03/27/25, Resident #40's weekly skin and wound evaluation revealed the Stage II pressure ulcer had deteriorated to an unstageable pressure ulcer. The wound measured 2.2 centimeters (cm) in length by 1.8 cm wide and described as 100% slough. The wound had no exudate. The facility implemented the new treatment of cleansing with normal saline, apply Medi-honey to the wound bed and cover with clean dry dressing daily. The facility determined the wound had deteriorated. On 03/27/25, there were physician orders to place a low air loss mattress on the bed for pressure reduction, monitor low air loss mattress functioning and check that the settings are appropriate for the resident. Cleanse wound to right gluteus with normal saline, pat dry with gauze, apply Medi-honey to wound bed and cover with clean dry dressing daily and as needed. Enhanced barrier precautions for unstageable wound to the right gluteus and consult wound care. On 03/26/25 at 9:45 A.M., an interview with Resident #40 stated she had a wound on her right buttocks that developed while she was in the hospital. Resident #40 stated the facility was not providing any treatment to the area or turning/repositioning her. Resident #40 was positioned on her back at the time of the interview. Resident #40 stated she was applying Vaseline to the wound and off-loading with her hand to help alleviate pain. The resident rated her current pain level as a six (zero being no pain and 10 being the worst pain). On 03/27/25 at 11:27 A.M., an observation of Licensed Practical Nurse (LPN) #193 and Certified Nursing Assistant (CNA) #145 revealed they were going to observe Resident #40's pressure ulcer. LPN #193 and CNA #145 washed their hands and donned gloves and did not don a gown for enhanced barrier precautions. LPN #193 and CNA #145 pulled the resident's incontinence brief down and assisted the resident to turn back on her left side from her back. The wound bed was covered with 100% yellow slough and the surrounding tissue was dark red. LPN #193 verified the stage II pressure ulcer had deteriorated into an unstageable pressure ulcer and stated she would notify the physician for an appropriate treatment. LPN #193 stated she would obtain an order for a low air-loss mattress also. On 03/27/25 at 2:40 P.M., an interview with the Regional Nurse (RN) #153 confirmed Resident #40's stage II pressure ulcer was not comprehensively assessed and no treatment was initiated on admission [DATE]. RN #153 verified there was no treatment to Resident #40's stage II pressure ulcer seven days later 03/27/25. RN #153 verified Resident #40's stage II pressure ulcer was now an unstageable pressure ulcer. Review of the NPUAP guidelines dated 2014 revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Review of the facility policy titled Skin and Wound Guidelines dated 03/05/24 revealed the policy describes the process steps required for identification of residents at risk for the development of pressure injuries, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations. This deficiency represents non-compliance investigated under Complaint Number OH00163575.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy and procedure review, the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #8. Actual harm occurred on 11/19/22 when Resident #8, who was at risk for skin breakdown was identified to have a Stage III (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer to his sacrum. There was no evidence the facility had adequate interventions in place to prevent the development of the ulcer and to promote healing once the ulcer was identified. The facility failed to ensure the pressure ulcer was timely identified prior to being found as a Stage III, failed to comprehensively assess the pressure ulcer initially and weekly subsequently and administer the treatment as physician ordered. This affected one resident (#8) of three residents reviewed for pressure ulcers. The facility census was 61. Findings Include: Review of the medical record for Resident #8 revealed an initial admission date of 05/13/22 with the latest readmission of 01/10/23. Diagnoses included Parkinson's disease dementia with agitation, chronic obstructive pulmonary disease (COPD), diabetes mellitus, chronic kidney disease, obstructive and reflux uropathy, schizoaffective disorder, bipolar disorder, urine retention, anemia, insomnia, psychosis, overactive bladder, chronic pain syndrome, hypertension, major depressive disorder, and hyperlipidemia. Review of plan of care dated 05/26/22 revealed the resident was at risk for skin breakdown. Interventions included apply lotion to dry skin, assess skin daily during care, attempt to keep heels off mattress, encourage to turn and reposition frequently as tolerated, assist as needed, if resident is alert instruct why repositioning was important and how to do it, incontinence care as needed, monitor skin and clothing for wetness, pressure reduction cushion and pressure reduction mattress. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was discharged to an acute care hospital. The assessment indicated the resident was at risk for skin breakdown and had no unhealed pressure ulcers. Review of the Braden Scale dated 11/14/22 revealed a score of 13 indicating the resident was at risk for skin breakdown. Review of the progress note dated 11/19/22 at 10:00 P.M. revealed a State Tested Nursing Assistant (STNA) notified the nurse the resident had a sore on his buttock area. The nurse noted a Stage III pressure injury to the sacrum measuring 3.0 centimeters (cm) by 2.0 cm with no description of the wound. No signs or symptoms of infection were noted to site. New orders were obtained for an air mattress to promote skin integrity, cleanse site with NS, pat dry, apply calcium alginate to wound bed, cover with dry clean dressing daily and refer to wound Certified Nurse Practitioner (CNP). Review of the medical record failed to identify a comprehensive assessment detailing the Stage III pressure ulcers appearance. Review of the plan of care dated 11/21/22 revealed the resident has actual pressure ulcer formation related to resident had pressure ulcer unstageable to sacrum with risk for delayed healing secondary to progressing comorbidities, debility and generalized weakness with decreased physical mobility and bowel/bladder incontinence daily. Interventions included cushion to wheelchair, check placement prior to transfer, frequent turning and repositioning, house liquid protein as ordered, monitor wound for any significant changes, preventive skin care post incontinence daily/as needed, provide surface support and pressure redistribution, position changes and offloading daily and provide wound care as ordered by physician and wound consult recommendations. Review of the November 2022 Treatment Administration Record (TAR) revealed the physician ordered treatment was not administered on 11/20/22, 11/21/22 and 11/29/22. Review of the medical record revealed the Stage III pressure ulcer was not assessed again until 12/01/22 when the wound CNP completed a thorough wound care assessment and evaluation. The assessment indicated the wound was now an unstageable measuring 2.5 cm by 1.5 cm with slough covering the wound bed. The CNP changed the treatment to cleanse the wound, cover the wound bed with a nickel size thickness of Santyl (removes dead skin tissue and aides in wound healing) and cover with a dry clean dressing daily and as needed. Review of the medical record revealed no documented evidence the now unstageable pressure ulcer to the resident's sacrum was assessed on 12/08/22 and 12/15/22. Review of the wound CNP wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's sacrum measured 3.0 cm by 2.0 cm by 0.1 cm with 75% pink tissue and 25% slough. The treatment to the wound remained unchanged. The assessment did assess for improvement or deterioration of the wound. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 15. Review of the mood and behavior revealed the resident displayed verbal behaviors directed towards others. The resident required extensive assistance of one with bed mobility, transfers, toilet use and was non-ambulatory. The assessment indicated the resident had an indwelling urinary catheter and was frequently incontinent of bowel. The assessment indicated the resident was at risk for skin breakdown and had non unhealed unstageable pressure ulcer that was not present on admission. The facility implemented the interventions pressure reducing device to bed/chair, nutrition, or hydration intervention to manage skin problems and pressure ulcer/injury care. Review of the wound CNP wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's sacrum measured 3.0 cm by 2.0 cm by 0.1 cm with 75% pink tissue and 25% slough. The treatment to the wound remained unchanged. The assessment did assess for improvement or deterioration of the wound. Review of the TAR for December 2022 revealed the physician ordered treatment was not administered on 12/01/22, 12/03/22, 12/04/22, 12/08/22, 12/17/22, 12/18/22, 12/25/22 and 12/31/22. Review of the wound CNP wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's sacrum measured 1.0 cm by 1.6 cm by 0.1 cm with 75% pink tissue and 25% slough. The treatment to the wound remained unchanged. The assessment did assess for improvement or deterioration of the wound. Review of the baseline admission evaluation dated 01/10/23 revealed the resident was readmitted to the facility with a 2.0 cm by 0.5 cm sacral ulcer. The assessment failed to identify the staging or the appearance of the wound. Review of the wound CNP wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's sacrum measured 2.0 cm by 2.0 cm by 0.1 cm with the wound bed being slough. The treatment to the wound remained unchanged. The assessment did assess for improvement or deterioration of the wound. Review of the TAR for January 2023 revealed the physician ordered treatment was not administered on 01/01/23, 01/11/23, 01/13/23, 01/14/23, 01/14/23, 01/15/23 and 01/16/23. Review of the physician's orders identified an order dated 01/16/22 cleanse wound with NS, pat dry with gauze, apply Santyl, cover with dry clean dressing daily and as needed. On 01/17/23 at 2:15 P.M. interview with the Director of Nursing (DON) revealed she felt the physician ordered treatments were provided but not documented as being administered. The DON verified the lack of documented evidence the physician ordered treatments were administered, comprehensive initial and subsequent weekly assessments were completed. Review of the facility policy titled, Dressing Change: Clean, last revised 09/11/13 revealed document the treatment in the TAR and additional progress notes if necessary. This deficiency substantiates Complaint Number OH00139308.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, family interview, and staff interview, the facility failed to ensure staff were aware a resident had a nephrostomy bag when transferring the resident from her wheelchair to bed resulting in the nephrostomy tube being dislodged. This affected one (Resident #58) of three residents reviewed for indwelling urinary catheters/ nephrostomies. Actual harm occurred to Resident #58 when her nephrostomy tube (a surgically inserted catheter tube inserted into the kidney to drain urine and sutured in place) was pulled out of her right lower back resulting in pain and requiring the resident to be sent to the hospital for reinsertion of the nephrostomy tube. Findings include: A review of Resident #58's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included tubulo-interstitial nephritis, hydronephrosis with uteretopelvic junction obstruction, obstructive and reflux uropathy. Her diagnoses was updated on 10/31/22 to reflect there had been a displacement of a nephrostomy catheter. A review of Resident #58's physician's orders revealed the resident had orders for maintaining an indwelling urinary catheter and the care associated with it. She also had orders in place for the treatment of her nephrostomy site. A review of Resident #58's admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was able to make herself understood and was usually able to understand others. She was cognitively intact and was not known to display any behaviors or reject care. She was dependent on two for transfers. She was identified on the MDS as having both an indwelling urinary catheter and an ostomy to include a urostomy. A review of Resident #58's active care plans revealed she had a care plan in place for an alteration in elimination related to an indwelling urinary catheter related to obstructive uropathy. The care plan did not identify her as having a nephrostomy bag. The interventions did include nephrostomy tube care as ordered along with urinary catheter care per facility policy. Her activities of daily living care plan identified only an indwelling urinary catheter. It did not identify the resident as having the use of a nephrostomy bag. A review of Resident #58's [NAME] (a care plan for the aides to identify a resident's care needs) revealed the resident was not identified as having the use of a nephrostomy bag. The section for bladder and bowel revealed they were to provide catheter care and monitor the output every shift (12 hours). They were also to check for catheter anchor and to provide urinary catheter care per facility protocol. There was nothing under that section to alert the aides that the resident had a nephrostomy bag or what care if any was to be provided. A review of a CNA (Certified Nursing Assistant) Task List Assignment that was what the aides documented in the electronic health record (EHR) under the task tab as having been provided to Resident #58. There was no identification under the task tab of the resident having a nephrostomy bag. There was only documentation required for them performing indwelling urinary catheter care every shift. A review of Resident #58's nurses' progress notes revealed a nurse's note by Agency Registered Nurse (RN) #26 documented on 09/11/22 at 9:58 P.M. revealed the resident's nephrostomy bag came out by accident. The resident's husband was indicated to be at the bedside at the time of the incident. A physician order was received to send the resident to the hospital for replacement. She was transferred out to the hospital around 9:00 P.M. A nurse's progress note dated 09/14/22 at 6:44 P.M. revealed Resident #58 returned to the facility from the hospital. The resident had her right nephrostomy tube replaced after it was dislodged on 9/11/21. Her indwelling urinary catheter was replaced that day too per hospital report. A review of Resident #58's hospital records for her hospitalization between 09/11/22 and 09/14/22 revealed the resident was sent to the hospital for a nephrostomy tube dislodgement. The nephrostomy tube had been replaced on 09/12/22 before being returned to the facility on [DATE]. On 11/21/22 at 11:00 A.M., an interview with Resident #58 confirmed she had both an indwelling urinary catheter and a nephrostomy bag to her right lower back. She reported having it for about three months now and confirmed she had it when she was admitted to the facility on [DATE]. She confirmed there had been one incident that occurred where the nephrostomy tube was pulled out of her back during a transfer. She recalled a larger sized female aide assisting her with a transfer from her wheelchair to her bed. She thought the incident occurred sometime in August or September of 2022. The resident reported it did hurt when the nephrostomy tube had been pulled out. She stated she cried at the time and rated the pain an 8 on a 1-10 scale. She further indicated she had more pain while at the hospital when it had to be reinserted. On 11/21/22 at 12:30 P.M., an interview with Resident #58's husband confirmed he was there when the resident was transferred to bed and the nephrostomy tube was pulled out. He recalled a female aide that was larger in size had transferred the resident from her wheelchair to bed. The aide got her arms around the resident to lift her and, as she was pivoting her around to sit her on the bed, the nephrostomy bag got hung up on the wheelchair causing the tubing to pulled out during the transfer. He stated the aide was careless and should have been aware of the resident having a nephrostomy bag, in addition to her indwelling urinary catheter, before transferring her from the wheelchair to bed. On 11/21/22 at 12:54 P.M., an interview with Agency Aide #8 revealed she was one of two aides present at the time Resident #58 was transferred on 09/11/22 and her nephrostomy tube came out. She thought the other aide was State Tested Nurse Aide (STNA) #13. She reported they positioned the resident's wheelchair by the bed and she stood in front of the resident while the other aide was behind the resident. Both had assisted the resident with weight bearing assistance. Agency Aide #8 reported she managed the resident's indwelling urinary catheter during the transfer, but they did not know she had a nephrostomy bag too. With the way the resident was in her wheelchair, the nephrostomy bag was not visible. It had slipped down between the side of the wheelchair seat. When they stood her up and began to turn the resident around, they heard a snap. That was when they realized she had a nephrostomy tube and it had been pulled out of the her back. She reported she was an agency aide and the other aide that assisted her was a facility employee. She denied the other aide was aware she had a nephrostomy bag either as she did not secure it properly during the transfer. The nephrostomy bag was half tucked down in the side of the wheelchair. She reported that was the first time she worked she had taken care of the resident. She was asked how the residents' care needs and appliances were communicated to the aides. She stated that information would be available in the facility's computer software program in the care plans and on their [NAME]. On 11/21/22 at 2:37 P.M., an interview with the Director of Nurse (DON) confirmed Resident #58's care plans, [NAME] and tasks (where the aides document their care) only identified the resident as having a urinary catheter. She confirmed there was nothing that identified the resident as having a nephrostomy tube that the aides had access to. She acknowledged the concerns of staff transferring the resident without knowledge of her having a nephrostomy bag that resulted in the accidental dislodgement of the nephrostomy tube during the transfer. She confirmed the resident was sent to the hospital on [DATE] to have her nephrostomy tube reinserted. She also acknowledged the resident complained of pain of an 8 on a 1-10 scale, when the nephrostomy tube was dislodged and reported having additional pain when the nephrostomy tube had to be re-inserted at the hospital. This deficiency is cited as an incidental finding to Complaint Number OH00137616.