**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, hospital record review, facility policy review, physician interview, nurse practitioner interview, and staff interviews, the facility failed to implement a comprehensive and effective pressure ulcer treatment program for one newly admitted resident (Resident #17), who was admitted with intact skin, assessed to be at risk for pressure ulcer development and dependent on staff for bed mobility and personal care. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries to Resident #17 on 11/25/22, when the facility failed to ensure adequate interventions and thorough skin assessments were performed timely and routinely for Resident #17 resulting in the development and declining condition of pressure ulcers to an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) to the left buttocks which required hospitalization and treatment with intravenous antibiotics. This affected one (Resident #17) of three residents reviewed for pressure ulcers. The facility identified two current residents with pressure ulcers in a facility census of 13. In addition, a concern that did not rise to the level of Immediate Jeopardy was identified related to the facility's failure to provide a dressing change for Resident #8's pressure ulcer in a manner to promote healing while preventing infection. On 12/23/22 at 4:22 P.M., Senior Regional Director of Operations was notified Immediate Jeopardy began on 11/25/22 when the facility failed to provide necessary care, services and interventions to prevent the development of pressure ulcers to Resident #17. On 11/25/22 Resident #17 was found with pressure ulcers to the bilateral buttocks with no staging or description assessed or documented. There was no additional assessment of the pressure ulcers for six days resulting in worsening condition of the pressure ulcers when on 12/01/22 the left buttock pressure ulcer was assessed to be unstageable with foul odor. No new interventions were implemented at that time. On 12/07/22 Resident #17 exhibited a change in condition, was hospitalized and admitted with sepsis and necrotizing fasciitis related to the pressure ulcers. As of 12/23/22 Resident #17 had not returned to the facility. The Immediate Jeopardy was removed on 12/27/22 when the facility implemented the following corrective actions: • On 12/07/22 Resident #17 was transferred to the hospital for evaluation and treatment and had not returned. • On 12/19/22 at 2:00 P.M. Director of Clinical Strategic Initiatives #401 re-educated the Director of Nursing (DON) and Clinical Manager Licensed Practical Nurse (LPN) #403 regarding dressing change procedures, pressure ulcer prevention and treatment policy, notification of change of condition, and turning and repositioning. • On 12/23/22 at 4:30 P.M. the Pressure Ulcer Prevention and Treatment policy was reviewed and updated to reflect upon identification of the pressure ulcer/pressure injury an evaluation would be performed at that time and then at least weekly and documented in the medical record. The documentation will include date the wound was observed, location, staging, size, exudate, pain, wound bed and description of wound edges and surrounding tissue. • On 12/23/22 at 4:45 P.M., Director of Clinical Strategic Initiatives #401 re-educated the DON and Clinical Manger LPN #403 on the revised policy for pressure prevention and treatment. • On 12/23/22 at 5:30 P.M., the acting Administrator notified Medical Director #400 of survey findings regarding Resident #17 and consulted with him regarding recommendations for resident skin audits, tracking and monitoring tool, staff education, replacing the facility wound nurse, and weekly QA meetings. • Beginning on 12/23/22 at 5:30 P.M., the Director of Nursing (DON)/designee began re-education of nursing personnel including two Registered Nurses (RN), 10 Licensed Practical Nurses (LPN) and 28 State Tested Nurse's Aide (STNA), on pressure ulcer prevention and treatment policy, notification of change of condition, and turning and repositioning. Education will be completed by midnight on 12/27/2022 for the 12 remaining staff members. • From 12/19/22 to 12/24/22 at 7:30 P.M., two RNs and 10 LPNS were re-educated by DON/designee on dressing change procedures including handwashing • On 12/26/22 (no time identified)- the facility acquired and retained a new wound care nurse practitioner (NP) #402. NP #402 assessed residents with impaired skin integrity via telehealth. The telehealth visit was assisted by the DON who undressed wound allowing visualization and measurement of the wound. The DON then re-dressed the wounds on 12/26/22 from 11:00 A.M. to 11:30 A.M. • On 12/27/22 at 10:00 A.M., full skin assessments were completed on all 11 residents by the DON/designee. No new skin areas were identified. • On 12/27/22 at 12:45 P.M., an additional Braden scale pressure ulcer risk assessment was completed on all 11 residents by the DON/designee. All 11 resident care plans were reviewed and modified as necessary. The updated Braden scale pressure ulcer risk assessments resulting in the following: one (1) resident was at no risk, four (4) residents were at low risk, five (5) residents were at moderate risk and one (1) resident was at high risk • On 12/27/22 by 7:00 P.M., the DON/designee-initiated monitoring of a minimum of eight (8) residents per day for two weeks, then eight (8) residents three (3) days per week for four (4) weeks and then at a frequency to be determined by the QA Committee to ensure residents are repositioned every 2 hours. • On 12/27/22 by 7:00 P.M. the DON/designee-initiated monitoring of a minimum of two (2) residents with wounds three (3) x per week for two (2) weeks, then two (2) residents weekly for 4 weeks and then at a frequency to be determined by the QA Committee to ensure dressing change and hand hygiene are performed appropriately. • On 12/27/22 by 7:00 P.M., the DON/designee-initiated monitoring of electronic medical record of residents with pressure injuries to ensure a description of the wound and staging is documented upon initial observation and a minimum of weekly. The audit will be conducted daily for one (1) week, then three (3) times a week for one (1) week, then weekly for 4 weeks and then at a frequency to be determined by the QA Committee. • On 12/27/22 by 7:00 P.M., the DON/designee-initiated monitoring of electronic medical records of residents with pressure injuries to ensure the facility and wound nurse practitioner is notified of changes in wound and that orders are implemented, as indicated. The audit will be conducted daily for one (1) week, then three (3) times a week for one (1) week, then weekly for 4 weeks and then at a frequency to be determined by the QA Committee. • On 12/27/22 by 7:00 P.M., the DON/designee-initiated monitoring of preventative skin measures. The DON/designee will observe a minimum eight (8) residents per day for two (2) weeks, then eight (8) residents three (3) days per week for 4 weeks and then at a frequency to be determined by the QA Committee then to ensure preventative skin measures have been implemented per physician orders/plan of care. • Beginning week of 12/26/22, a QA meeting will be held on 12/27/22 by 2:00 P.M., the QA Committee, including the Medical Director, will meet weekly times six (6) weeks then monthly x three (3) months to review audit findings and to make recommendation for improvements, as indicated. • On 12/27/22 from 1:48 P.M. to 2:19 P.M., interviews with LPN #402, LPN #405, and STNA #404 revealed the staff were knowledgeable on the education they had received on pressure ulcer in-regards to documentation, assessments, dressing change procedures, prevention and treatment of pressure ulcer, notification, and turning and repositioning. Although the Immediate Jeopardy was removed on 12/27/22, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing to educate staff and was in the process of completing and reviewing audits to determine if further action is required and monitoring to ensure on-going compliance. Findings include: 1.Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE] and discharged on 12/07/22. The resident's diagnoses included fracture of the right femur surgically repaired on 11/08/22, contusion of the right thigh, anxiety, asthma, and high blood pressure. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17's cognition was intact. The resident was assessed to be totally dependent with two or more staff physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. No pressure ulcers were identified, but a surgical wound and open lesion were noted on the assessment. Review of Resident #17's Braden scale assessment (assessment for risk factors for developing pressure ulcers) dated 11/11/22 revealed the resident had no sensory perception, was occasionally moist, chairfast, mobility was very limited, adequate nutrition, potential problem for friction and shearing. The resident scored 16.0 (at risk). The clinical suggestion section of the assessment was left blank. Review of the hospital record from the admission dated 11/11/22 revealed Resident #17 had a closed commuted intertrochanter fracture of the right femur, right thigh intermuscular hematoma. Review of Resident #17's admission assessment dated [DATE] revealed no evidence the resident had any pressure ulcer areas. Review of Resident #17's baseline care plan, dated 11/11/22 revealed to turn and reposition every two hours and pressure reduction mattress. There was no evidence Resident #17 had a care plan specific for pressure ulcer prevention and/or treatment of pressure ulcers. Review of the facility's skilled evaluation notes for Resident #17 dated 11/11/22 to 11/25/22 revealed on 11/16/22 and 11/22/22 there were comfort care concerns regarding pressure ulcers. The skilled evaluation notes indicated the resident's position was changed each shift/daily. However, the skilled evaluation notes did not provide any additional information regarding pressure ulcers or interventions. Review of Resident #17's weekly skin assessment dated [DATE] revealed no new areas since admission. Review of Resident #17's Activity of Daily Living (ADL) task dated 11/11/22 to 11/29/22 revealed on 11/23/22 a shower/bath was checked as completed but there was no shower sheet and no additional information regarding skin condition on the ADL task. The skin observations for ADL tasks sheet on 11/17/22, 11/18/22 and 11/29/22 only included the staff's initials. There was no documentation regarding Resident #17's skin condition or pressure ulcers. Further review of Resident #17's ADL task dated 11/22/22 to 12/07/22 revealed the documentation only identified bed mobility and didn't identify staff were turning and repositioning the resident. Review of the health status progress notes dated 11/25/22 at 3:31 P.M. authored by Licensed Practical Nurse (LPN) #405 revealed Resident #17 had open areas to both buttocks. The right buttock area measured four centimeters (cm) in length by three cm width and the left buttock measured five cm length by five cm width. The documentation did not include wound stage, depth, or any description of the wounds. The note revealed LPN #405 notified Nurse Practitioner (NP) #410. New treatment orders were written to cleanse areas with soap and water, apply skin prep and cover with Hydro-cellular foam dressing twice daily. Review of Resident #17's weekly skin assessment dated [DATE] revealed there were open areas noted to both buttocks. The right buttock measured four centimeters (cm) by three cm and the left buttock measured five cm by five cm. Nurse Practitioner (NP) #417 was notified. New orders were received to cleanse the wounds with soap and water, apply skin prep and cover with hydro-cellular (absorbent) foam to the sacral (documentation error) wounds. Record review revealed no additional assessment of Resident #17's pressure ulcers for six days (from 11/25/22 until 12/01/22) at which time the resident's pressure ulcers had significantly worsened in condition. Review of Wound Nurse Practitioners (NP)#410 and #411 Progress Notes dated 12/01/22 revealed at the request of the provider (NP #417), a thorough wound care assessment and evaluation was performed. Wound #1 (left buttock) was identified as an unstageable pressure ulcer measuring seven cm in length by one cm wide. The wound bed was pink with slough and blue/green exudate with a foul odor. Orders received to cleanse the area with Dakin's-soaked gauze (used to prevent and treat skin and tissue infections) and apply nickel thick Santyl (removes dead tissue from wounds so they can start to heal) to the wound bed daily and as needed and cover with a dressing. Wound #2 (right buttock) was a Stage II pressure ulcer (skin loss of epidermis, dermis, or both with no slough) measuring three cm wide by two cm in length with 0.1 cm depth. The wound bed was pink with slough and had blue/green exudate. Orders were received to cleanse the area with Dakin's-soaked gauze and apply nickel thick Santyl to wound bed daily and as needed and cover with a dressing. The note indicated a copy of the progress note would be sent to the referring physician (Physician #510). (Physician #510 was not Resident #17's physician; Physician #510 was another physician providing services at the facility). Review of Resident #17's Treatment Administration Records (TAR) for November 2022 revealed on 11/25/22 to 11/30/22 the record reflected to cleanse wounds to the right and left buttocks with soap and water and apply skin prep and cover with hydro cellular foam sacral dressing every shift for open areas. There was no evidence the treatment was completed on day or night shift on 11/30/22. Review of Resident #17's TAR for December 2022 revealed on 12/01/22 the order and treatment were to cleanse the wound sacral area with normal saline, apply Santyl ointment and cover with a dry sterile dressing. Change daily or if it becomes soiled. However, NP #410's notes indicated on 12/01/22 to cleanse with Dakin's wound wash. The order was discontinued on 12/02/22 and changed to cleanse with Dakin's wound wash, apply a layer of Santyl and cover with dry clean dressing. NP #410's order on 12/01/22 was to cleanse area with Dakin's-soaked gauze, cover wound bed with nickel thickness Santyl, and cover with dry clean dressing. Interview on 12/28/22 at 2:36 P.M. with the Director of Nursing (DON) confirmed there was no evidence Resident #17's treatment for the pressure ulcers was completed on day or night shift on 11/30/22. The DON reported she received a verbal order on 12/01/22 to cleanse the wounds with normal saline, however she didn't have the signed order. The DON verified the order written on 12/02/22 did not include to use Dakin's-soaked gauze or nickel thick Santyl per NP #410's progress note. Review of an invoice dated 12/01/22 for Resident #17 revealed a hospital service delivered a single zone direct low air loss mattress. Review of the weekly skin note, dated 12/02/22 and authored by LPN #412 revealed the LPN indicated there were open areas on the resident's sacrum (the documentation did not include measurements, wound stage, or any description of the wounds). Physician #400 was notified on 12/01/22 at noon. The treatment was changed on 12/01/22 by NP #410 to apply Santyl to the open areas and apply clean dry dressing daily and as needed. Review of the nutritional note authored by Dietitian #413 dated 12/02/22 at 10:35 A.M., for Resident #17 revealed the dietitian was notified of a sacral open area. November's weight was 149.6 pounds (#), daily protein needs were 75-81 grams (gm) per day. Recommend obtaining new weight. Noted resident receiving Pro stat 30 milliliter (ml) three times a day, providing 300 kilocalorie (kcal) and 45-gr protein daily and was accepting appropriately per medication administration record. Magic cup twice a day, also providing additional support with 290 kcal each/9 gr protein each. Mechanical soft diet continued with assistance at meals, intakes ranged from 25-50%. Given the poor intakes at meals recommend continuing current supplementation as scheduled to meet protein needs and to aid in skin healing. The note indicated continue to monitor. Review of a Health Status Note dated 12/06/22 at 6:40 A.M. revealed, LPN #415 wrote she changed and cleansed the wound on the coccyx. The odor coming out of this wound is too much. Cleansed with normal saline (NS), applied Santyl cream, and ABD pad. The resident stated she had some pain and was medicated. There was no evidence Resident #17's physician or NP were updated on the status of the resident's pressure ulcers at that time. Review of the nursing progress note authored by LPN #416 dated 12/07/22 at 9:12 A.M., revealed Resident #17 was noted to be slow to respond and not answering questions appropriately during speech this A.M. The nurse assessed Resident #17 and the resident was refusing to eat, and very weak. NP #417 was notified, and new orders for STAT labs, IV with IV fluids, and new treatment orders were obtained. The resident's husband was notified. Review of the nursing progress note authored by LPN #416 dated 12/07/22 at 12:20 P.M. revealed a peripheral 22 gauge intravenously (IV) was inserted to left antecubital with Resident #17 tolerating it well, IV fluids running as ordered. STAT labs drawn and pending at this time. At 2:13 P.M. Resident #17's husband was at the bedside speaking with NP #417 and updated on resident's new orders, husband wants resident transported to the hospital for an evaluation. Order given for transport. Critical care called and transported resident. The husband was to meet the resident at the hospital. Review of the hospital documentation by emergency room Physician #500 dated 12/07/22 revealed Resident #17 had a history of Alzheimer's dementia, hypertension and presented to the hospital from a rehabilitation facility after a recent fixation of a right hip fracture. At the facility, the patient was noted to be having worsening generalized weakness, poor appetite, and worsening sacral decubitus ulcers. As such, the patient was sent to our facility for further evaluation. Resident #17 does not participate in the history given her Alzheimer's and history was provided almost entirely by her husband, whom was at the bedside. The husband stated that over the past three (3) to four (4) days the patient has had a significant decrease in her appetite. The husband states sacral decubitus ulcers had been worsening over time as well. To his and the facility's knowledge the patient has not had a fever. The hospital documentation from emergency room Physician #500 identified Resident #17 had a large area on her lower back/sacrum with skin breakdown consistent with a sacral decubitus ulcer, likely at least a Stage III (full thickness skin loss involving damage or necrosis of the subcutaneous tissue) or IV. The ulcer was foul-smelling with some scant purulent drainage. The area around the wound was tender and mildly erythematous. Clinical impression as of 12/07/22 sacral region, Stage III. The emergency room Physician #500 identified Resident #17's white blood cell (WBC) count was markedly elevated and as such patient was started on broad-spectrum antibiotics. Also, lactate was elevated and will be given a gentle liter bolus and will be reassessed. A full 30 ml/kilogram (kg) of crystalloid fluid may cause more harm than benefit given the patient's age and potential for fluid overload. emergency room Physician #500 revealed Resident #17 will be admitted to the hospital for further work-up and treatment. She has been evaluated by the hospitalist for admission, plain films returned demonstrating some gas in the tissues. This may be secondary to the patient's decubitus ulcer however it was noted by the radiologist that this could also be secondary to gas-forming organisms. On-call surgeon was consulted, and he recommended having the resident's physician serving evaluate the patient and ordering a computer tomography (CT) for further evaluation. emergency room Physician #500 identified Resident #17 required 35 minutes of critical care for metabolic crisis, sepsis, and circulatory failure. The hospital history and physical identified the wound to the sacrum: present upon admission unstageable pressure injury; the wound extends onto the left buttock but would be considered one wound. The wound bed was 80% black eschar with 20% firm yellow slough; the surrounding tissue was red and moist in appearance. There was superficial skin breakdown noted on the right buttock as well, which appears to be more moisture related versus pressure. The hospital history and physical revealed recommended and performed the following treatment to the sacrum wound: wash with normal saline and pat dry; apply Triad paste (controls light to moderate exudate and creates an ideal healing environment to allow for natural debridement) in a dime size thickness over area to promote autolytic debridement. Cover with 4 by 4 gauze or abdominal (ABD) pad to secure Triad on patient and off the linens. Change every three days and when needed. If soiled prior to that, dab away soiled area and reapply. On 12/19/22 at 11:55 A.M. and 12/22/22 at 3:00 P.M., interview with Licensed Practical Nurse (LPN) #22 revealed when Resident #17 was admitted she had no open areas and she had developed the areas afterwards. LPN #22 reported she was not the one who found them but did change the dressing when she was on duty. Per LPN #22, the wound nurse was providing the wound care and was aware of the odor. During the interview, LPN #22 revealed when staff turned Resident #17 on her side she would roll right back. On 12/22/22 at 2:31 P.M., interview with NP #410 revealed even though there was a foul odor present, she did not believe there were signs of infection on 12/01/22. The facility started cleansing the area with Dakin's solutions and applying Santyl ointment nickel to the wound bed and covered it with a dressing. NP #410 stated the resident had an odor to the wound on 12/01/22 but no fever, no signs of infection, or notification of abnormal labs (Review of Resident #17's laboratory (labs) results dated 11/11/22 to 12/07/22 revealed the resident only had labs collected on 12/07/22, the day she went to the hospital). On 12/22/22 at 2:42 P.M. interview with facility NP #417 revealed she had not seen Resident #17's wound until 12/07/22 due to wound NP #410 providing care and observing. NP #417 reported when she visited the facility Resident #17 was typically up in the dining room or had visitors. NP #417 reported she was called by facility on 12/07/22 at 9:12 A.M. and notified the resident's wound had an odor, the condition of the wound had changed in the last 24 hours, since the NP came in. NP #417 was in the facility, observed the area and noted it looked bad, and she could tell it was infected. NP #417 revealed she had a long conversation with the resident's husband and gave him treatment options. The husband wanted the resident comfortable and talked about hospice and the resident was started on an IV for antibiotics and fluids. NP #417 gave the husband a choice to send the resident to emergency room (ER). Later he chose to send the resident to ER. Resident #17 was sent out at 2:13 P.M. On 12/23/22 at 11:51 A.M., interview with the Medical Director (Physician #400) revealed he was not aware Resident #17's pressure ulcers had a foul odor on 12/01/22. Physician #400 reported he could not tell the surveyor what he would have done because he did not see the wound. According to Physician #400, he believed the treatment order given was appropriate by the NP. The NP did however let him know afterwards Resident #17 was sent out to the hospital and the condition of the wound. On 12/28/22 from 9:15 A.M. to 12:28 P.M., interview with Director of Clinical Strategic Initiatives #401 revealed a low air loss mattress was ordered on 11/30/22, however the physician did not write the order until 12/01/22. The hospital service delivered the low air mattress on 11/30/22. Director of Clinical Strategic Initiatives #410 reported Wound NP #410 saw Resident #17 on 12/01/22, however NP #411 signed off on the progress note. The Director of Clinical Strategic Initiatives #410 reported the facility does not document turning, and repositioning of residents, it was just considered a part of resident care. Director of Clinical Strategic Initiatives #410 verified comfort care documentation dated 11/16/22 and 11/22/22 on the skilled evaluation indicted the resident was at risk for pressure ulcers. Review of the facility undated policy titled Pressure Ulcer/Injury Prevention and Treatment revealed the following: • It was the facility's policy to provide care to promote the prevention of pressure ulcer/pressure injury development and promote the healing of existing pressure ulcers (PU)/pressure injuries (PI). • Residents would be reviewed to identify resident at risk for developing PU/PI and resident with existing or new onset of PU/PI. Upon admission, a skin check would be completed to identify existing skin issues. Skin checks will be completed weekly and as needed. Upon admission a Braden scale would be completed and then quarterly and as needed. • If new pressure ulcers/pressure injury was observed the nurse would notify the physician and obtain orders for treatment. The nurse will notify the resident and resident representative on new onset of the PU/PI and will provide regular updates. The interdisciplinary team would make referrals to the dietician, wound nurse practitioner and/or therapy as appropriate. Intervention would be updated as needed and care plans to include interventions to heal/prevent PU/PI and address pain. • An evaluation of the PU/PI would be performed at least weekly, and this evaluation would be documented in the medical record. The documentation would include the date observed, location and staging, size, exudate, pain, wound bed and description of wound edges and surrounding tissue. • The PU/PI would be monitored by the nurse and if the PU/PI fails to show some evidence of the progress toward healing within 2-4 weeks, the area and resident's overall condition would be reassessed, and current interventions communicated observation to the practitioner and review changes to treatment and interventions. Review of the facility's policy titled Braden Scale (undated) revealed the Braden scale was used to assess for risk factors for developing pressure ulcers. After the nurse completed the Braden scale an analysis of risk factors and skin concerns would occur. A care plan would be developed or updated based on the analysis of the risk factors. 2. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, anxiety, hemiplegia and hemiparesis, hypertensive heart disease, incontinence, and heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively impaired and totally dependent on staff for bed mobility, transfers, dressing and toilet use. The assessment revealed the resident had an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) deep tissue injury (DTI) pressure ulcer. Review of the physician's orders dated 12/17/22 revealed an order to cleanse coccyx/sacral area with normal saline, pat dry, apply Santyl (a debriding agent that works by helping to break up and remove dead skin and tissue) to dark areas, cover with calcium alginate and island dressing. The dressing change was to be completed every day and when necessary. On 12/19/22 at 10:15 A.M. Licensed Practical Nurse (LPN) #22 was observed completing Resident #8's wound care/dressing change. The LPN washed her hands and put on gloves. LPN #22 then removed the resident's old dressing, which had a moderate amount of drainage on it. LPN #22 then removed her gloves and washed her hands. She then placed new gloves and cleansed the coccyx wound with normal saline. Wearing the same gloves, LPN #22 opened the calcium alginate, cut a piece off, placed it into the wound bed and applied Optifoam dressing. On 12/19/22 at 10:25 A.M. interview with LPN #22 verified she had not changed her gloves or washed her hands after cleansing the wound and before applying a new/clean dressing. Review of the facility policy and procedure titled Hand Hygiene dated 11/22/19 revealed to complete hand washing after contact with blood, body fluids, visibly contaminated surfaces or after contact with objects in the resident's room. This deficiency represents non-compliance investigated under Master Complaint Number OH00138617 and Complaint Number OH00138446.