**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interviews, and review of the resource from the National Pressure Injury Advisory Panel titled Best Practices for Prevention of Medical Device-Related Pressure Injuries in Long Term Care, the facility failed to monitor a resident's leg where a brace was applied. This resulted in actual harm when the resident developed a Deep Tissue Injury (DTI) later resulting in a stage four pressure ulcer (deep wound that may impact muscle, tendons, ligaments, and bone) that ultimately required two surgical debridements in an attempt to promote wound healing. This affected one (#9) of three residents reviewed for pressure wounds. The facility census was 39. Findings include: Review of medical record for Resident #9 revealed an admission date of of 11/29/24 with diagnoses including but not limited to occlusion and stenosis of right carotid artery, muscle weakness, periodic breathing, fracture of lower end of right femur, cervical disc disorder with myelopathy, peripheral vascular disease, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of current physician orders revealed wound treatment to right upper lateral calf was to cleanse with soap and water, pat dry and apply calcium alginate to the wound bed, cover with abdominal (ABD) pad and wrap with kerlix, weight bearing as tolerated (WBAT) to right lower extremity while in knee brace with walker (03/19/25-04/16/25), liquid protein 30 milliliters (ml) daily for wound healing. Review of the care plan dated 03/26/25 revealed the resident is at risk for skin breakdown related to increased need for assistance with bed mobility and transfers, neuropathy, peripheral vascular disease, and right lateral calf pressure. Interventions included apply lotion/moisture barrier cream as needed, can transition out of brace, WBAT to right lower extremity with walker, encourage to float heels as tolerated, observe skin for redness or open areas notify the nurse, skin assessment as needed, supplements per order, and turn and reposition every two hours as tolerated. Review of a general progress note dated 02/19/25 at 2:02 P.M. revealed the resident returned from an orthopedic appointment with order indicating okay to put right foot down for balance. Continue physical therapy (PT) and occupational therapy (OT). No Range of Motion (ROM) to right knee. Continue brace. Follow up in one month. Review of a general progress note dated 03/19/25 at 1:42 P.M. revealed the resident returned from an orthopedic appointment with new order to begin Weight Bearing as Tolerated (WBAT) to right lower extremity in the knee brace. Okay for ROM to right knee and continue PT/OT. Review of a general progress note dated 04/16/25 at 3:00 P.M. revealed the resident returned from an orthopedic appointment with new order to transition out of knee brace. WBAT to right lower extremity with walker. Continue with PT/OT. Review of a general progress note dated 04/17/25 at 11:58 A.M. revealed Certified Nursing Assistant (CNA) reported the resident had a skin tear on the outer right calf caused by the brace. Resident is to transition out of the brace and therapy is working with the resident towards that goal. Steristrips applied. Review of a general progress note dated 04/20/25 at 8:41 P.M. revealed this order was updated to cleanse and apply border foam to right outer calf. This nurse went to treat the area and found that the skin flap is slothing off and area had opened. Area measured 4.7 centimeters (cm) by 5.4 cm, area warm, seeping and plus two pitting edema compared to left leg at plus one pitting edema. Daughter present in room and explained they will await treatment plan and the resident could be seen by the in-house wound physician. Review of the wound physician note dated 04/21/25 revealed an unstageable wound to right upper lateral calf full thickness. Wound was a pressure wound. Wound measured 7.0 cm length by 5.9 cm width with a non measurable depth. Surface area 41.30 cm squared. Periwound surrounding deep tissue injury (purple/maroon). Moderate serous exudate. Thick adherent black necrotic tissue 60 percent (%), granulation tissue 40% with no pain or signs of infection. Treatment plan santyl apply once daily and as needed if saturated, soiled, or dislodged for 30 days and cover with gauze island with border dressing once daily and as needed. Reason for no sharp debridement chronic stable wound with insignificant amount of necrotic tissue and no signs of infection. Monitor for now. Recommended lower extremity arterial Doppler. Review of wound physician note dated 04/28/25 revealed a stage four pressure wound to the right upper lateral calf full thickness. Per note patient had a fractured femur for which the resident was wearing a brace. The pad of the brace created a pressure wound on the calf. Wound measured 7.0 cm length by 6.0 cm width by depth is unmeasurable due to presence of non-viable tissue and necrosis. Surface area 42.00 cm squared. Periwound induration and maceration. Light serous exudate. 100% thick adherent black necrotic tissue. No pain or signs of infection observed. Debridement procedure completed to remove necrotic tissue and establish the margins of viable tissue, remove thick adherent eschar and devitalized tissue, and remove hematoma. Post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a stage 4 pressure injury. This is not a wound deterioration. Lower extremity arterial Doppler left and right performed on 04/28/25 with mild to moderate peripheral vascular disease without occlusion in the right lower leg. Review of the wound physician note dated 05/05/25 revealed a stage four pressure wound to the right upper lateral calf full thickness measuring 6.8 cm length by 5.8 cm width by 0.7 cm in depth with moderate serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased necrotic tissue and decreased surface area. No pain or signs of infection. Review of the wound physician note dated 05/12/25 revealed a stage four pressure wound to the right upper lateral calf full thickness measuring 7.0 cm length by 5.6 cm width by 0.4 cm depth with moderate serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased depth. No pain or signs of infection. Review of the wound physician note dated 05/19/25 revealed stage four pressure wound to the right upper lateral calf full thickness measuring 6.9 cm length by 5.0 cm width by 0.3 cm depth with moderate serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased depth. No pain or signs of infection. Review of the wound physician note dated 05/26/25 revealed stage four pressure wound to the right upper lateral calf full thickness measuring 6.5 cm length by 4.5 cm width by 0.2 cm depth with light serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased depth. No pain or signs of infection. Review of the wound physician note dated 06/02/25 revealed stage four pressure wound to the right upper lateral calf full thickness measuring 5.8 cm length by 3.8 cm width by 0.1 cm depth with moderate serous exudate. 3% thick adherent devitalized necrotic tissue and 97% granulation tissue. Wound progress improved evidenced by decreased depth. No pain or signs of infection. Surgical excisional debridement completed. The wound was cleansed with normal saline and anesthesia was achieved using topical bensocaine. Curette was used to surgically excise devitalized tissue and necrotic tissue subcutaneous level tissues were removed to a depth of 0.1 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 3% to 0%. Hemostasis was achieved and a clean dressing was applied. Interview on 06/04/25 at 8:39 A.M. with the Director of Nursing (DON) revealed the resident's brace came off every night at bedtime. The DON stated the nurses would look at the residents skin then. The DON stated that two days prior to the wound being discovered, she treated a skin tear. The DON stated she then treated another skin tear by cleaning the wound and applying Steristrips and kerlix. The DON stated that approximately two days later she was notified that the area was open and bleeding. The DON stated that when she cleaned the skin tear she thought the wound looked weird as the skin appeared to be darker. The DON stated the wound doctor saw the resident the next day and he removed what they thought was a big clot. Further review of the medical record revealed no evidence the facility was removing the brace at night and checking the skin around the brace on a daily basis. Interview on 06/04/25 at 3:18 P.M. with the DON and Assistant Director of Nursing (ADON #403) revealed they both verified the wound was caused by the brace. ADON #403 stated if you lined up the brace the wound was located where the dial of the brace was located. The DON verified they could have padded the area that the dial was on had they realized it would or was causing pressure. The DON verified the wound was staged by the wound physician. The DON verified the weekly wound documentation prior to the discovery of the deep tissue injury did not contain any lesions or open areas to the right lower extremity and on 04/20/25 there was documentation of a skin tear to the area. The DON verified there was no supporting documentation regarding the removal of the brace for care or skin assessments under the brace. Review of the resource from the National Pressure Injury Advisory Panel titled Best Practices for Prevention of Medical Device-Related Pressure Injuries in Long Term Care, dated February 2020, indicates, in part, the following: Inspect the skin under and around the device at least daily (if not medically contraindicated); Cushion and protect the skin with dressings in high risk areas; Be aware of edema under the device(s) and potential for skin breakdown; and Educate staff on correct use of devices and prevention of skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interviews, review of hospital documentation, revealed of fall investigations, review of manufacturer's guidelines, and review of a facility policy, the facility failed to ensure residents dependent for transfers and activities of daily living were kept free from falls. This resulted in actual harm when Resident #10 sustained a fall during a mechanical lift transfer on 06/12/24 which was being completed by one staff member and Resident #2 sustained a fall on 06/07/24 when the resident was left unattended in bed after it was elevated to perform incontinence care. Consequently, Resident #10 suffered a fractured left femur requiring surgery and Resident #2 suffered fractures to both femurs. This affected two (#2 and #10) of three residents reviewed for falls. The census was 41. Findings include: 1. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included wedge compression of vertebrae, obesity, chronic obstructive pulmonary disease, and embolisms. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had mildly impaired cognition and was an extensive assist with transfers. Review of Resident #10's care plans revealed a focus for falls. Interventions dated 11/03/23 included to anticipate needs, keep the call light within reach, educate the resident on safety, follow fall protocols, therapy evaluation, review information post fall and attempt to determine cause of falls, record root cause of falls, and alter or remove potential causes if possible. A revised intervention dated 06/06/24 included the use of a walker for ambulation and transfers. Further review of Resident #10's care plans revealed there were no revised interventions added to the care plans regarding lifts used for transfers post fall on 06/12/24. Review of Resident #10's physical therapy notes dated 04/15/24 revealed the therapist documented the resident required a maximum heavy assist with two staff for a stand lift bed-chair with the wheelchair for proper technique and safety. There were no other assessments for lifts or equipment noted in the medical record. Review of Resident #10's physician orders dated June 2024 revealed no physician ordered interventions for prevention of falls were noted in the records. Review of Resident #10's progress notes dated 06/13/24 at 10:58 A.M., late entry, revealed the resident had a fall witnessed by a nurse aide. Per the note, the resident fell to her knees onto the floor while being assisted with a sit-to-stand lift. Resident #10 was lowered to the floor and complained of pain to the left knee and left hip. Resident #10 was assessed by the nurse and emergency medical services (EMS) were called with the resident being sent to the hospital on [DATE] at 9:00 P.M. Review of Resident #10's fall investigation revealed on 06/12/24 at 8:30 P.M., the nurse aide was transferring Resident #10 back to bed using a sit-to-stand mechanical lift. Per the investigation, the nurse aide was in the room with the resident and her family member. The nurse aide documented the resident slid out of the stand lift and fell to floor. Per the nurse aide's written interview, the nurse aide had taken the resident to the shower room, bathed her, and was transferring the resident back into bed from a wheelchair using the sit-to-stand lift. The nurse aide attempted to stop Resident #10 from falling, but was unable to, and lowered her to the ground. The nurse aide called for help and two nurses responded. Per the nurse aide's written interview, EMS was called, and the resident was transported to the hospital. Review of Resident #10's hospital paperwork dated 06/12/24 revealed the resident was admitted to the emergency room (ER) on 06/12/24 at 9:04 A.M. when the first set of vital signs were recorded in the documentation. Per the documentation, Resident #10 sustained a left distal femur fracture which required surgery to repair the fracture and the resident was returned to the facility on [DATE]. Interview on 06/25/24 at 2:00 P.M. with Resident #10 revealed there was one nurse aide with her in the bathroom on 06/12/24, the day of her fall. Resident #10 stated she was brought back to her room and the nurse aide was using the sit-to-stand lift to get her back into bed from the wheelchair. Resident #10 stated she was weak, her foot slipped on the floor during the transfer, and the nurse aide could not keep her from falling to her knees on the floor. Resident #10 stated she could not recall who the nurse aide was, but stated there was only one nurse aide assisting her with her bathing and transfer. Resident #10 stated she suffered a broken bone in her leg and had surgery to repair it. Interview on 06/25/24 at 7:55 P.M. with Licensed Practical Nurse (LPN) #200 revealed the nurse was present in the building at the time Resident #10 fell on [DATE]. Per LPN #200, she heard the nurse aide calling for help to Resident #10's room and stated she and another nurse responded quickly to the room. LPN #200 stated the resident was lying on the floor and the nurse aide was holding her to prevent her from falling further and hurting herself more. Per LPN #200, the nurses began to assess Resident #10 for injuries and the resident stated her leg hurt. LPN #200 stated a staff member called EMS and the resident was transferred to the hospital within one hour of the fall. LPN #200 verified there was to be two staff members performing the transfers with lifts and at the time of Resident #10's fall there was only one nurse aide in the room providing care and using the lift. Interview on 06/26/24 at 2:30 P.M. with Assistant Director of Nursing (ADON) #275 and Regional Nurse #595 verified the facility fall policy revealed all lifts are to be used by two staff members. Regional Nurse #595 stated the nurse aide who witnessed Resident #10's fall was following the manufacturer's guidelines and not the facility's policy. During a follow-up interview on 06/27/24 at 9:20 A.M. with Regional Nurse #595 and ADON #275 verified there was no full clinical assessment of Resident #10's condition and suitability to use the sit-to-stand lift per manufacturer's guidelines. Review of the facility policy titled, Lifting Machine Using a Mechanical, dated 07/2017, revealed per the policy at least two nursing assistants are needed for all transfers using a lift. Review of the manufacturer's guideline dated 11/2014, for the mechanical sit-to-stand lift used during Resident #10's fall on 06/12/24, revealed per the guidelines, prior to using the lift each resident must have a full clinical assessment and his/her condition and suitability must be completed by a qualified person. 2. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure with hypoxia, dysphagia, impulse disorder, intellectual disabilities, and cognitive communication deficit. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #2 had impaired cognition and was dependent for assistance with activities of daily living (ADLs). Review of Resident #2's care plans dated 10/31/19 revealed Resident #2 was at risk for falls. Interventions include to keep the call light within reach, keep personal items within reach, perimeter mattress to the bed, and maintain the bed in a low position. An intervention was added to the revised care plan on 06/08/24 for staff to take the bedside table out of the room with books and hat and return after care had been provided. Review of Resident #2's fall investigation dated 06/07/24 revealed one nurse aide was providing care for Resident #2 and raised the bed to waist level. Per the investigation, the nurse aide turned to leave the room and was in the doorway to retrieve the lift in the hallway, when the resident reached out of his bed for items on his bedside table and fell out of the bed landing on his face down on the floor. Per the investigation, the resident sustained femur fractures to bilateral legs. Observation on 06/25/24 to 06/27/24 at random times throughout the survey revealed Resident #2 was wearing bilateral leg braces. Interview on 06/25/24 at 5:00 P.M. with Resident #2 revealed the resident did not recall specific details regarding the fall. Resident #2 stated he fell out of bed and hurt his legs but could not give details on the incident. Resident #2 stated his legs were uncomfortable and hurt sometimes. Resident #2 denied pain at the time of the interview. Interview on 06/25/24 at 6:50 P.M. with LPN #200 revealed, per the nursing report, there was one nurse aide in Resident #2's room providing care when the resident rolled out of the bed and sustained the fractures to his legs. Interview on 06/26/24 at 4:00 P.M. with Regional Nurse #595 and ADON #275 verified State Tested Nurse Aide (STNA) #350 raised Resident #2's bed to provide incontinence care to the resident and did not lower the bed prior to leaving the room. ADON #275 stated STNA #350 was close to the bed when she turned to go out to the hallway to ask for another staff to help her with the lift. ADON #275 stated, per the fall investigation, the lift was in the hallway at the time of the incident and verified the resident did reach out of the bed to his bedside table, which was out of reach, fell out of the waist high raised bed, and sustained the bilateral femur fractures. ADON #275 verified Resident #2's care plans and the interventions were not followed by STNA #350 at the time of the fall. This deficiency represents non-compliance investigated under Master Complaint Number OH00155120, Complaint Number OH00155118, Complaint Number OH00154905, and Complaint Number OH00154469.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and policy review, the facility failed to assess newly identified skin breakdown, implement interventions/treatments to aid in the healing of the existing skin breakdown, and conduct ongoing monitoring of the skin breakdown. This resulted in Actual Harm when Resident #32 was found to have a Stage III pressure ulcer to coccyx on 11/14/22 and deep tissue injuries (DTI) to right lateral foot and right lateral fifth toe. This affected one (#32) of one resident reviewed for pressure ulcers. There were a total of two residents identified by the facility with pressure ulcers. The facility census was 38. Findings include: Review of the medical record for Resident #32 revealed an admission date of 09/03/22 with medical diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes mellitus with diabetic neuropathy, atrial fibrillation, osteoarthritis, hyperlipidemia, Major Depression, and hypothyroidism. Review of the medical record for Resident #32 revealed a Minimum Data Set (MDS) dated [DATE] which revealed Resident #32 had severe cognitive impairment. The MDS revealed Resident #32 required extensive staff assist with bed mobility, transfers, ambulation, dressing, toileting, and bathing. Review of the medical record for Resident #32 revealed the resident enrolled in Hospice services 09/16/22 and changed Hospice providers on 11/14/22 per family request. Review of the medical record for Resident #32 revealed a shower sheet dated 10/24/22 that had documentation that Resident #32 had a sore that was open and red to the resident's right buttock/coccyx area. Review of the medical record revealed no documentation to support the wound was assessed or a treatment initiated. Review of the medical record for Resident #32 revealed a weekly skin assessment completed 10/26/22 which documented Resident #32 had a pressure ulcer to the coccyx but did not have documentation of the wound measurement. Further review of the medical record for Resident #32 did not have documentation to support the staff assessed the wound or contacted the physician regarding the pressure ulcer for treatment orders. Review of the medical record for Resident #32 revealed a Hospice nursing aide note dated 10/27/22 which indicated Resident #32 had a new skin issue on his bottom and the Hospice aide reported the skin issue. Review of the medical record for Resident #32 revealed a Hospice progress note dated 10/28/22 which documented the Hospice nurse was notified by facility staff that Resident #32 had several open areas on his buttocks and an area above the crease of the buttock was open. Review of the medical record revealed the Hospice nurse ordered a treatment to the wounds and stated Hospice would access the wounds with the next nurse visit. Review of the medical record for Resident #32 revealed a nurse's note dated 10/28/22 at 5:36 P.M. which documented the nurse notified Resident #32's daughter of dressing change orders due to two new areas of skin breakdown on Resident #32's bottom. Review of the medical record for Resident #32 did not contain documentation to support an assessment or measurement of the wounds were completed. Review of the medical record for Resident #32 revealed a physician order dated 10/28/22 for treatment to open areas to buttocks and coccyx. Further review of the medical record revealed the treatment order was changed on 11/01/22. Review of the Hospice aide visit note dated 10/31/22 revealed the Hospice aide reported Resident #32's wound to his bottom was worse than last report. Review of the Hospice note dated 11/01/22 revealed Resident #32 had a large open area to left buttock, no drainage noted. Further review of the medical record for Resident #32 revealed a Hospice aide visit note dated 11/03/22 which documented Resident #32 had a dressing over the wound to bottom. Review of the medical record for Resident #32 did not have documentation to support assessment/monitoring of wounds. Continued review of the medical record for Resident #32 revealed a Hospice nurse aide visit note dated 11/10/22 revealed Resident #32 had an area to outer right foot and nurse was notified. Review of the medical record for Resident #32 revealed a physician order dated 11/11/22 for skin prep to right outer foot. Review of the medical record did not contain documentation to support the assessment or measurement of the wound to the right lateral foot. Review of the medical record for Resident #32 revealed a progress note dated 11/10/22 at 4:00 P.M. which documented the DTI to coccyx area had U-shaped area of granulation tissue and measured 8 x 6. The note did not specify the unit of measurement used to measure the wound. Further review of the medical record for Resident #32 did not contain documentation to support the wound to the coccyx or left buttock was assessed or monitored from 10/28/22 to 11/10/22. Review of the medical record for Resident #32 revealed a Hospice assessment completed 11/14/22 which revealed the resident had a Stage III pressure ulcer to coccyx with measurements of 5 centimeters (cm) width x 4 cm length x 0.1 cm depth. The Hospice assessment did not contain documentation to support any wounds to Resident #32's right foot. An observation on 11/15/22 at 2:15 P.M. with Licensed Practical Nurse (LPN) #305 was made while LPN #305 completed a dressing change to Resident #32's wound to the coccyx. The wound was observed to be a round area on the coccyx with dark purple color on the edges of the wound and pink area inside the wound. Continued observation of Resident #32's dressing change revealed blood was noted to the old dressing. LPN #305 confirmed Resident #32's old dressing contained blood. LPN #305 confirmed the wound measurements were 5 cm x 4 cm x 0.1 cm. Interview on 11/15/22 at 9:29 A.M. with the Director of Nursing (DON) revealed the facility had not been monitoring or assessing Resident #32's coccyx wound due to the resident receiving Hospice services. The DON stated she believed the Hospice provider was assessing, monitoring, and measuring Resident #32's wound. Observation on 11/16/22 at 2:02 P.M. of State Tested Nursing Assistant (STNA) #337 examining Resident #32's right foot revealed a dressing to resident's right lateral fifth toe. The observation also revealed a dark purplish-black circle, the size of a nickel, to Resident #32's lateral right foot. Observation on 11/16/22 at 2:39 P.M. of the DON examining Resident #32's right foot revealed a dark purplish-black area, the size of a nickel, to resident's right lateral foot. Further observation included observing the DON remove the dressing to Resident #32's fifth toe on his right foot which revealed a one inch oblong dark purplish-black area to right lateral fifth toe. Review of the medical record did not have documentation to support a treatment order for the area to Resident #32's right lateral fifth toe. Interview on 11/16/22 at 2:41 P.M. with the DON confirmed Resident #32 did not have an order for treatment to the wound on the right lateral fifth toe. The DON also confirmed the facility had not completed assessments or monitored the wounds to Resident #32's lateral right fifth toe or right lateral foot. The DON stated Resident #32's wounds to his right foot looked to be DTIs based on her observation. Review of the Prevention of Pressure Ulcer/Injuries policy revealed the facility was to evaluate, report, and document potential changes in skin and to review the interventions and strategies for effectiveness on an ongoing basis.