**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, hospital record review, review of facility policy and interview the facility failed to ensure effective and timely ongoing monitoring and assessments were completed for a non-pressure related skin impairment to Resident #132's right forearm. Actual Harm occurred on 01/02/24 at 1:14 P.M. when Registered Nurse (RN) #612 identified a previous open area to Resident #132's right forearm contained thick black necrotic eschar (dead tissue) and was significantly larger in size measuring 12 centimeters (cm) in length by ten cm width. The resident was transferred to the hospital where she required surgical debridement to the fascia (layer of connective tissue that surrounds the cells, nerves, joints, and tendons) and treatment for a venous thrombosis (blood clot) at the lateral ventral aspect of the arm. Prior to 01/02/24 there was no previous documentation Resident #132's right forearm open area was being assessed/monitored and/or measured except on the admission assessment dated [DATE] (almost three weeks) when the area measured 3.0 cm in length by 4.5 cm in width and was described as cyanotic (bluish/ purplish) in color around the open area. This affected one resident (#132) of three residents reviewed for non-pressure skin impairment. The facility identified six current residents (#4, #18, #33, #66, #71, and #79) who had non-pressure skin impairments. The facility census was 125. Findings Include: Review of the closed medical record for Resident #132 revealed an admission date of 12/13/23 with diagnoses including left femur fracture, diabetes, and dementia. Record review revealed the resident was discharged to the hospital on [DATE] and did not return to the facility. Review of the admission Packet-V12 dated 12/13/23 and completed by Registered Nurse (RN) #612 revealed Resident #132 had an open area to her right forearm that measured 3.0 cm in length by 4.5 cm in width. The area was cyanotic around the open area. She also had a laceration to her left elbow and surgical area to her left hip. Review of the physician's order dated 12/13/23 revealed Resident #132 had an order to cleanse her right forearm with normal saline, apply oil emulsion, abdominal (ABD) pad and secure with Kerlix gauze every day and as needed. Review of the care plan dated 12/14/23 revealed Resident #132 had actual impaired skin integrity related to surgical incision to her left hip, open area to right forearm, and laceration to her left elbow. Interventions included complete skin documentation per facility policy, monitor for signs of infection, notify physician of deterioration of wound, provide wound care per orders, refer to wound physician as needed, and skin assessment per policy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #132 had impaired cognition as her brief interview for mental status (BIMS) score was a one of 15. She was dependent on her activities of daily living (ADL) including toileting, dressing, and showers. Review of the Skin Assessment Weekly/ Return/ ER/ LOA dated 12/26/23 and completed by RN #610 revealed Resident #132's skin was assessed. The assessment revealed she had a surgical wound, and that there were no new areas identified. There was no follow up documentation of the open area to her right forearm including assessment and/ or measurements. Review of the nursing notes dated from 12/13/23 to 01/02/24 revealed there was no documentation regarding any follow up assessment, and/or measurements of Resident #132's open area to the right forearm until it was found to be black and necrotic with significant increase in size as it measured 12 cm in length and 10 cm in width on 01/02/24. Review of the Skin Assessment Weekly/ Return/ ER/ LOA dated 01/02/24 and completed by Wound Licensed Practical Nurse (LPN) #600 revealed Resident #132's right forearm had thick black eschar that was firmly adhered, and the area measured 12 cm in length by 10 cm in width. Review of the nursing note dated 01/02/24 at 1:14 P.M. and completed by RN #612 revealed she noticed the dressing on Resident #132's right forearm became loose. During the assessment she noticed the area was black and necrotic. She was able to obtain a pulse under the resident's armpit but not the wrist area. Resident #132 had no complaints of pain. She notified Primary Care Physician (PCP)/ Medical Director #606 who ordered to send the resident to the hospital. Review of Emergency Physician #622's progress note dated 01/02/24 revealed Resident #132 was evaluated in the emergency room with a right arm wound which she stated started several days ago and progressively worsened. The note revealed she had necrosis on her right forearm and was admitted with diagnoses that included skin necrosis and right arm wound. Review of the Hospital History and Physical dated 01/03/24 and completed by Physician #623 revealed Resident #132 presented to the emergency room with a right black necrotic lesion to her forearm. The note revealed initially the wound was small (at the facility) and now was getting larger. The area was necrotic with surrounding cellulitis displayed. There were no signs of an insect bit and/ or she was not on anticoagulant medications. She started on intravenous antibiotics and a surgical wound care consult was ordered for wound debridement. Review of the general surgery progress note dated 01/04/24 and completed by Surgeon #621 revealed Resident #132 while in the hospital had her right extremity debrided due to necrotizing soft tissue infection. He performed a sharp debridement of the necrotic tissue until viable tissue was seen. The wound was down to fascia (layer of connective tissue that surrounds the cells, nerves, joints, and tendons) and there was a venous thrombosis at the lateral ventral aspect that was tied off. After the procedure the area measured 18 cm in length by 10 cm in width. Interview on 01/24/24 at 9:03 A.M. with Resident #132's daughter revealed she was upset as did not understand how her mother's skin tear/ open area to her right forearm got so bad without anyone noticing. She revealed she had spoken with Assistant Director of Nursing (ADON)/ LPN #608 regarding her concern and was told she would investigate the issue and get back to her. She revealed ADON/ LPN #608 had left her a message that Resident #132's dressing was changed on night shift and the nurses that had worked the few days prior to 01/02/24 when it was found to be black and necrotic were not the nurses who usually worked the 100-unit. She revealed the nurses had not seen Resident #132's right forearm previously; therefore, did not know what her baseline was. She revealed she felt this was an unacceptable response so did not call her back as any nurse should know that the resident's arm did not look good and needed to be addressed. Interview on 01/24/24 at 9:12 A.M. with Wound LPN #600 revealed Resident #132 was admitted to the facility with a skin tear like open area to her right forearm. She revealed she saw the area on admission, 12/13/23, and then not again until the day the resident was sent to the hospital on [DATE]. She revealed on admission it looked red with granulating healthy tissue, no signs of infection and with no necrosis. She revealed she did not follow skin tears unless there was a concern as they usually healed right up. She revealed as far as she knew the facility did not measure or document weekly on skin tears and/or other open areas that were not pressure related. She verified she did not have any documentation regarding the status of the skin tear (open area) while Resident #132 was at the facility including appearance and measurements except what was on admission, 12/13/23 and on the assessment completed the day the resident was sent out on 01/02/24. Interview on 01/24/24 at 2:46 P.M. with Assistant Director of Nursing (ADON)/ LPN #608 revealed Resident #132 had a skin tear/open area to her right forearm when she was admitted on [DATE] and on 01/02/24 RN #612 changed the dressing and noticed it was significantly larger in size, black, and necrotic. She revealed they sent Resident #132 to the hospital for evaluation. She revealed Resident #132's daughter was upset about the significant change, and she had told the daughter that she would investigate the issue. She revealed the dressing was changed on night shift, and the nurses who were on the previous days before RN #612 discovered it were not usually assigned to the 100 unit. She revealed the nurses had never seen Resident #132's forearm prior to know what her baseline was. She revealed it was possible the nurses would not know that it had declined. She revealed she had left Resident #132's daughter a message regarding her findings but had not received a call back. Interview on 01/25/24 at 9:33 A.M. with RN #610 revealed he worked 7:00 P.M. to 7:30 A.M. on 12/28/23 and had completed Resident #132's dressing change to her right forearm. He revealed he had seen her arm throughout her stay at the facility and on 12/28/23 he did not feel it looked any different. Interview on 01/25/24 at 9:39 A.M. with LPN #611 revealed she was assigned the 100 unit on 12/31/23 from 7:00 P.M. to 7:30 A.M. and completed Resident #132's right forearm treatment. She revealed she could not remember what her arm looked like when she changed her wound dressing. She revealed she could not say if the wound was necrotic or not. She revealed she had never seen her wound before as that was the first time she cared for Resident #132, so she was unable to say if there was any change. Interview on 01/25/24 at 9:45 A.M. with RN #612 revealed she admitted Resident #132 to the facility on [DATE] and stated the resident had an open area to her right forearm. She revealed the area measured 3.0 cm in length by 4.5 cm in width, was red, beefy, with no signs of infection and/or signs of necrosis. She revealed the resident's treatment was scheduled on night shift, so she had not seen the open area to her right forearm until 01/02/24 when she noticed her dressing partially coming off. She revealed she had then noted a significant change as the area was large, necrotic, and completely covered with dry eschar. She stated, How that happened crazy to me as it was a small skin tear/open area on admission that turned to a large black area. She stated that there was no way, in her opinion, that it happened overnight and could not understand if the dressing was being done every night how someone did not notice the significant change. Interview on 01/25/24 at 10:27 A.M. with RN #614 revealed she worked on 01/01/24 from 7:00 P.M. to 7:30 A.M. and was assigned the 100 unit. She revealed she also had two other units (700-unit and [NAME] Court Unit) as there were only two nurses in the facility. She revealed there were medication technicians on these units as well, but they could do treatments and/or assessments. She revealed it was a hectic night trying to get everything done and stated, the whole night was a blur. She revealed if she signed off the treatment then she did the treatment but honestly could not remember anything about what the resident's right forearm looked like, including if it was necrotic. She revealed she had never seen Resident #132's arm previously as she had never taken care of her, so would not know what her arm had looked like before to compare to. Interview on 01/25/24 at 11:54 A.M. and 12:29 P.M. with the Director of Nursing (DON) verified Resident #132 was admitted on [DATE] with an open area to her right forearm that was measured on admission as 3.0 cm in length by 4.5 cm in width. She verified there was no other documentation that the open area was assessed and measured until it was documented on 01/02/24 as 12 cm in length by ten cm in width and was described as black and necrotic. She revealed Wound LPN #600 should have been tracking all open areas not just pressure ulcers and documenting at least weekly on the open area by utilizing a skin grid non-pressure form so that Wound LPN #600 would identify if there was a change as well as a nurse could reference when they were doing a treatment if there was any change in the appearance and/or measurement. Interview on 01/25/24 at 12:38 P.M. with LPN #613 revealed she was assigned the 100 unit on 12/30/23. She revealed she usually worked (Nora's Unit) and only occasionally worked the 100 unit. She revealed Resident #132 she had a large area on her right arm that was dark in color, and it was dry. She revealed she could not remember exactly as she had a lot of treatments that night and that she had never seen Resident #132's arm previously, so could not say if it had declined as she was unsure what her arm had looked like on admission. Interview on 01/25/24 at 1:53 P.M. with Primary Care Physician/ Medical Director #606 revealed he was aware Resident #132 had a fractured leg but was not aware of any open area on her right forearm. He revealed that he was not aware that she had a necrotic area to her arm and stated, I just do not recall. Review of the undated facility policy labeled, Skin Measurement/ Skin Grid revealed the facility would maintain an active record as upon admission or identification of a skin condition the licensed nurse would complete a wound treatment progress record. The policy revealed once the treatment was initiated the licensed nurse would monitor for progress of healing and it was expected that healing should be noticeably visible within two weeks. The policy revealed if there were no visible signs of healing the physician would be contacted and treatment re-evaluated. The policy noted that examples of types of wounds that would receive a skin measurement/ skin grid included pressure ulcers, burn injuries, skin tears, and surgical wounds. The policy revealed every seven days assessments would be completed. This deficiency represents non-compliance investigated under Master Complaint Number OH00150274 and Complaint Number OH00150145.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview, the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of pressure ulcers for Resident #79 and Resident #124. Actual Harm occurred on 11/30/23 (six days after admission) when Resident #79, who was cognitively impaired and required total dependence from staff for activities of daily living (ADL) including bed mobility, toileting, and transfers was found to have a Stage III (full thickness loss of skin where adipose (fat) was visible in the ulcer) pressure ulcer to her right buttock. The pressure ulcer was assessed to deteriorate to an unstageable pressure ulcer on 12/07/23. Actual Harm occurred on 12/14/23 when Resident #124, who was a paraplegic and was dependent on staff assistance with bed mobility and transfers was found to have a Stage III pressure ulcer to his right buttock extending to his sacral area. There was no evidence adequate interventions and monitoring were in place to prevent the development of Resident #79 and Resident #124's pressure ulcers or to ensure the wounds were identified prior to being assessed to be Stage III pressure ulcers. This affected two residents (#79 and #124) of three residents reviewed for pressure ulcers. The facility identified five residents (Resident #10, #71, #77, #79, and #124) who currently had facility acquired pressure ulcers. Findings Include: 1. Review of the medical record for Resident #79 revealed an admission date of 11/24/23 with diagnoses including fracture to her right humerus (arm), chronic obstructive pulmonary disease, and hypertension. Review of the admission Packet- V12 dated 11/24/23 and completed by Registered Nurse (RN) #612 revealed Resident #79 was confused and disoriented. RN #612 completed a skin assessment and noted skin tears to her right knee, left knee, and left toe. There was no documentation Resident #79 had any pressure ulcer or skin breakdown to her right buttock. The admission packet included a Braden Scale for Predicting Pressure Sore Risk that revealed Resident #79 was at risk for developing pressure ulcers as she was occasionally moist, bedfast, limited with mobility, her nutrition was probably inadequate, and she had a potential problem with friction and shearing. Review of the undated care plan revealed Resident #79 required (staff) assistance with activities of daily living (ADL) related to cognitive impairment and weakness. Interventions included transfer with mechanical lift, weight bearing assistance including holding lifting and supporting of trunk and limbs for dressing, personal hygiene, bed mobility, and she was totally dependent of staff assist with transfers, bathing, and toileting. Review of the undated care plan revealed Resident #79 was at risk for impaired skin integrity and pressure ulcers related to failure to thrive, malignant neoplasm of the skin and dermatitis. Interventions included elevate heels off mattress, inspect skin during routine daily care, lift sheet for positioning, lotion to skin, pillows for positioning, pressure reduction devices, turn and reposition as ordered and skin assessment and treatments as ordered. Review of the nursing note dated 11/30/23 at 10:15 A.M. and completed by RN #619 revealed the treatment nurse was notified Resident #79 had an area to her right buttock. Resident #79 was encouraged to reposition self every two hours to prevent skin breakdown and she verbalized understanding. Review of the Skin Grid Pressure 3.0- V2 dated 12/01/23 and completed by Wound Licensed Practical Nurse (LPN) #600 revealed on 11/30/23 Resident #79 was noted to have a Stage III right buttock pressure ulcer that measured 4.0 centimeter (cm) in length by 2.0 cm in width by 0.2 cm in depth. She described the area: full thickness dark red wound bed with moderate serous (clear to yellow) drainage. Review of the initial Wound Evaluation dated 12/07/23 and completed by Wound Nurse Practitioner (NP) #609 revealed Resident #79 had an unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to her right buttock that measured a 3.5 cm in length by 1.5 cm in width by the depth was unable to be determined. The wound contained 30 percent granulation tissue and 70 percent slough. (The note incorrectly identified this area was present on admission). Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 has impaired cognition as her Brief Interview for Mental Status (BIMS) revealed she was rarely and/or never able to understand. She was dependent on staff assistance for toileting, dressing, rolling left and right, and transfers. She was always incontinent of bowel and bladder. She was at risk for pressure ulcers and had one unstageable pressure ulcer that was not present on admission. Review of the Wound Evaluation dated 01/18/24 and completed by Wound NP #609 revealed Resident #79's right buttock pressure ulcer was now a Stage III and measured 0.4 cm in length by 0.6 cm in width by 0.2 cm in depth. The wound responded well to debridement and had a smaller wound bed of 100 percent granulation tissue. An attempted interview on 01/24/24 at 9:27 A.M. with Resident #79 revealed she was cognitively impaired and unable to provide any information regarding her pressure ulcer. Interview on 01/25/24 at 8:19 A.M. with Wound LPN #600 revealed Resident #79 was not admitted to the facility with any pressure areas including to her right buttock. She verified on 11/30/23 Resident #79 was found to have a Stage III pressure ulcer to her right buttock measuring 4.0 cm in length by 2.0 cm in width by depth of 0.2 cm. She verified Resident #79 was dependent on staff assistance with bed mobility, transfers, and toileting. She revealed she could not say why the pressure area was found at Stage III just that it was. Observation of wound care on 01/25/24 at 9:51 A.M. for Resident #79 and completed by Wound NP #609 and Wound LPN #600 revealed Resident #79 was completely dependent on staff to roll her to her side during the wound care. She continued to have a pressure ulcer to her right buttock that measured 2.6 in length by 1.8 cm in width by 0.1 cm in depth. The wound bed contained pink- red moist granulated tissue. 2. Review of the medical record for Resident #124 revealed an admission date of 01/10/22 with diagnoses including spina bifida, chronic kidney disease, seizures, and paraplegia. Review of the undated care plan revealed Resident #124 required assistance with his ADL care related to spina bifida, paraplegia, impaired mobility, and muscle weakness. Interventions included a mechanical lift with all transfers, he was totally dependent and does not participate in any aspect of transferring, and he required weight bearing assistance including holding lifting or supporting trunk and limbs with bed mobility, dressing, toileting, personal hygiene, and bathing. Review of the undated care plan revealed Resident #124 had actual impaired skin integrity as he had Stage III pressure areas to his bilateral buttocks. Interventions included custom built cushion to his wheelchair, low air loss mattress to his bed, turn and reposition in routine intervals, wound physician as needed, and notify the physician of deterioration of wounds. Review of the quarterly Braden Scale for Predicting Pressure Sore Risk dated 09/22/23 revealed Resident #124 was at risk for pressure ulcers as he was very limited with his sensory perception, was chair fast, very limited with his mobility, and he had a potential problem with friction and shearing. Review of the quarterly MDS dated [DATE] revealed Resident #124 had intact cognition. He required partial to moderate assistance with toileting. He was dependent on staff to roll left and right, and transfers. He was unable to go from a sitting position to lying or lying to a sitting position and he was unable to ambulate. He was at risk for pressure ulcers but had no pressure ulcers. Review of the Treatment Administration Record (TAR) for December 2023 revealed Resident #124 had an order to clean his bilateral buttocks with normal saline, pat dry, and place calcium alginate on the wound bed and cover every day. Review of the TAR revealed no evidence the treatment was completed as ordered on 12/21/23, 12/22/23, and 12/27/23. Review of the nursing note dated 12/14/23 at 9:54 A.M. and completed by Wound/ LPN #600 revealed a new open area was noted to Resident #124's right buttock during routine dressing change with Wound NP #609 and new orders were received. Review of the Wound Evaluation dated 12/14/23 and completed by Wound NP #609 revealed Resident #124 had a Stage III pressure wound to his right buttock extending to his sacral area. The area was 5.0 cm in length by 2.9 cm in width by 0.2 cm in depth. He was also seen for his pressure ulcer to his left buttock. Review of the Skin Grid Pressure 3.0-V2 dated 12/15/23 and completed by Wound Nurse/ LPN #600 revealed on 12/14/23 a Stage III pressure ulcer was found on Resident #124's right buttock that measured 5.0 cm in length by 2.9 cm in width by 0.2 cm in depth. Review of the Wound Evaluation dated 01/18/24 and completed by Wound NP #609 revealed Resident #124 continued to have a Stage III pressure area to his right buttock as she noted per the progress note larger measurements with two areas measured as one wound. The area was 3.1 cm in length by 4.5 cm in width by 0.2 cm in depth. The wound bed was composed of 60 percent granulation tissue and 40 percent scar tissue. Interview on 01/24/24 at 8:19 A.M. with Wound/ LPN #600 revealed they had been treating a pressure ulcer to Resident #124's left buttock and during wound rounds with Wound NP #609 they had found Resident #124 to have a Stage III pressure ulcer to his right buttock. She revealed she was not sure why the pressure ulcer was not found and/or reported at an earlier stage. She revealed staff responded thought you knew about it especially since we were already treating the area to his left buttock. She verified Resident #124 was dependent on staff assistance on most all his ADL including bed mobility and transfers. Interview on 01/24/24 at 11:13 A.M. with Resident #124 revealed he had a pressure ulcer to his bottom. He revealed since he had the pressure ulcers, he was trying to work hard on healing the area by making sure he turned every two hours as well as have staff assist with placing a wedge under him which had been helping. He revealed his dressing was to be changed once a day and occasionally the nurse did not complete the dressing change daily. Observation of wound care on 01/25/24 at 8:53 A.M. completed by Wound NP #609 and Wound LPN #600 revealed the resident's left buttock pressure ulcer was now considered healed and his right buttock pressure ulcer had improved measuring 0.4 cm in length by 0.9 cm in width by 0.1 cm in depth. Interview on 1/25/24 at 9:04 A.M. with Wound NP #609 revealed on 12/14/23 when she was in evaluating the pressure ulcer to Resident #124's left buttock they had found a Stage III pressure ulcer to his right buttock. She verified on 12/14/23 the pressure ulcer to the right buttock measured 5.0 cm in length by 2.9 cm in width by 0.2 cm in depth when it was found. Review of the undated facility policy labeled, Pressure Ulcer Prevention and Risk Identification revealed the facility would assess each resident for the risk of pressure ulcer development to establish measures to prevent the development of pressure ulcers. The policy revealed interventions would be implemented as indicated by the physician and as determined by the interdisciplinary team. This deficiency represents non-compliance investigated under Complaint Number OH00150145.