**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, review of a facility self-reported incident (SRI), and interviews with staff and the coroner, the facility failed to ensure Resident #145 was provided adequate and necessary care and services during the provision of personal care to prevent an accident/injury. Actual harm occurred on [DATE] when Resident #145, who had right hemiplegia/hemiparesis and was dependent on staff for bed mobility and personal care sustained a significantly displaced acute proximal right humeral neck fracture with medial angulation during care provided by staff. The resident displayed increased pain as a result of the incident and required orthopedic surgical follow-up. This affected one resident (#145) of three residents reviewed for accident hazards. The facility census was 75. Findings include: Review of the closed medical record for Resident #145 revealed an admission date of [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the right dominant side, osteopenia, atrial fibrillation, chronic pain, and convulsions. Review of the plan of care dated [DATE] revealed Resident #145 was at risk for impaired functional range of motion related to inability to move extremities independently, potential for contractures, and weakness due to history of stroke. Interventions included if the resident refused offer again later in the day and administer medications as ordered for pain. An activities of daily living (ADL) care plan related to activity intolerance, fatigue, pain and history of stroke revealed interventions including providing care based on the residents' usual performance. The care plan revealed the resident was dependent on staff for toileting, personal hygiene, rolling left to right, and transferring. Resident #145 was to always wear a gown per family. The care plan included to instruct Resident #145 to use grab bars on the bed to assist with bed mobility. Staff to assist with the completion of activities of daily living (ADLs), two people assist for all care and encourage Resident #145 to fully participate. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #145 had impaired cognition. The assessment revealed Resident #145 was dependent on staff for transfers, bed mobility (rolling left and right) and toileting. Resident #145 had impairment on one side of both lower and upper extremities. Review of a facility SRI tracking number 258571 revealed on [DATE], Resident #145 had redness and swelling on the right upper extremity. An x-ray results showed a proximal right humerus neck fracture. The SRI revealed staff were unaware of any falls or other injuries. Staff stated Resident #145 was able to roll to the right and hold the grab bar with her left hand for assistance. Following this incident, the facility initiated a new intervention for two-persons assistance with care to be provided to Resident #145. Review of the radiology report dated [DATE] at 9:30 P.M. of right shoulder revealed a significantly displaced acute proximal right humeral neck fracture with medial angulation. Greater than one shaft width displacement. The right humeral head remains in articulation with the glenoid with advanced degenerative changes of the joint space. Moderate degenerative change of the acromioclavicular joint. Reactive soft tissue swelling. Review of the physician orders dated [DATE] revealed an order for Tramadol (narcotic pain medication to treat moderate to severe pain) 50 milligrams (mg) one tablet every six hours as needed to treat the resident's pain. On [DATE], an additional order for routine pain medication was added (Tramadol 50 mg two times daily; then discontinued on [DATE]) On [DATE], Oxycodone (narcotic pain medication to treat moderate to severe pain) five mg one tablet every six hours for pain was ordered. Review of an orthopedic surgery note dated [DATE] revealed Resident #145 was seen by the physician for acute pain of right shoulder and displaced fracture of proximal end of right humerus. Review of hospital records revealed Resident #145 was transferred to the hospital on [DATE] related to hypoxia (body does not receive enough oxygen) and was treated for pneumonia. Resident #145 received comfort measures in the hospital and expired on [DATE]. Interviews on [DATE] at 10:14 A.M. with Registered Nurse (RN) #300; at 10:38 A.M. with RN #301, at 11:10 A.M. with Licensed Practical Nurse (LPN) #302; at 11:15 A.M. with Certified Nursing Assistant (CNA) #303; at 3:12 P.M. with CNA #304; at 3:16 P.M. with #305; and at 3:27 P.M. with CNA #306 revealed Resident #145 had a contracture to her right arm/shoulder and was unable to move her arm more than a few inches. Interview on [DATE] at 3:36 P.M. with RN #307 revealed she was Resident #145's nurse the weekend of [DATE], and she worked day shift. RN #307 denied knowledge of any swelling of redness to Resident#145's right arm/shoulder. The RN revealed she did not know of any injury until she came back in to work on Sunday morning. She was told the resident had a fracture of her humerus and her arm was in a sling. The resident had an order for pain medications and needed an orthro appointment made. Interview on [DATE] at 10:38 A.M. with RN #301 revealed she worked on [DATE] from 7:00 A.M. to 7:00 P.M. as the nursing supervisor. The floor nurse notified her on the evening of [DATE] that Resident #145 had redness and swelling of the right upper arm and it was warm not hot. RN #301 stated she did not see anything else out of the ordinary. Interview on [DATE] at 2:29 P.M. with the Director of Nursing (DON) revealed Resident #145 right humerus fracture must have been sustained during care (as the resident was dependent on staff for care and had an inability to move her right arm/shoulder more than a few inches). However, the DON revealed she was unable to determine how Resident #145 sustained the fracture. Interview on [DATE] at 9:50 A.M. with CNA #318 revealed he was the CNA assigned to care for Resident #145 on [DATE]. He stated during the shift on [DATE], he did not believe Resident #145 acted any different than her normal. During the interview, CNA #318 denied knowledge of any swelling in Resident #145's hand or arm, and no bruising or discoloration noted. Interview on [DATE] at 10:03 A.M. with Coroner #402 revealed the preliminary findings for cause of Resident #145's death was contributed to heart disease, pneumonia, and a right arm fracture. Coroner #402 stated there was a bruise on the arm where the fracture was, and a small bruise on the back of the resident's hand. The coroner revealed resident had osteopenia prominently and it would not have taken much to break her arm. The coroner revealed the break likely could have occurred when staff were providing care. This deficiency represents non-compliance investigated under Control Number OH00164638 and Complaint Number OH00164284.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, hospital record review, policy and procedure review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent and timely identify bilateral heel pressure ulcers for Resident #165. Actual harm occurred on 01/31/23 when Resident #165, who was cognitively impaired required extensive/dependence on staff for bed mobility and activities of daily living (ADL) care, was found to have an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer to the right heel and a suspected deep tissue injury (SDTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. The ulcers deteriorated and on 05/23/23 the resident's daughter requested the resident be sent to the emergency room related to the condition of the heel ulcers, the ulcers had moderate amounts of copious drainage with a foul odor noted. The resident was subsequently admitted to the hospital and diagnosed and treated for heel ulcer wound infection. This affected one resident (#165) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #165's closed medical record revealed the resident was admitted to the facility on [DATE], discharged to the hospital on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE]. Resident #165 had diagnoses including essential hypertension, muscle weakness and adult failure to thrive. A plan of care dated 12/20/22 revealed the resident had the potential for altercation in skin integrity due to a diagnosis of failure to thrive (FTT), easily bruising, history of a skin tear due to fragile skin condition, abnormal labs, decreased circulation/oxygenation, vitamin deficiency, mood/behavior status and being at risk for malnutrition and incontinence. Interventions included to administer medications as ordered, administer treatments as ordered, Braden score quarterly and as needed, diet per recommendations, monitor for bruising, monitor labs, offload heels as tolerated, pressure redistribution cushion to chair. An intervention dated 01/04/23 indicated to implement a low air loss mattress to the bed. Review of Resident #165's admission assessment and baseline care plans form dated 12/30/22 revealed Resident #165 was at high risk for skin breakdown and no skin concerns or pressure areas were identified on the document. Review of Resident #165's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment and required extensive two person assist for bed mobility and toilet use. The assessment also revealed the resident required total dependence with two-person assist for transfers and toilet use as well as total dependence one person assist for dressing, personal hygiene, and bathing. Review of Resident #165's medication administration records (MAR) and treatment administration records (TAR) from 01/01/23 to 01/31/23 revealed the low air loss mattress was implemented on 01/03/23. Review of Resident #165's Shower Sheet Forms dated 01/16/23, 01/19/23 and 01/23/23 did not reveal skin concerns or evidence of pressure ulcers. Review of Resident #165's progress note dated 01/25/23 at 2:26 P.M. revealed no new skin issues identified. Review of Resident #165's Shower Sheet Form dated 01/26/23 revealed her right and left heels were dry, and her shower sheet form dated 01/30/23 revealed nothing new was documented on the form. Review of Resident #165's progress note authored by Registered Nurse (RN) Wound Nurse #817 dated 01/30/23 at 11:15 A.M. revealed the resident was alert and responsive. Resident #165 required extensive assistance from one person for bed mobility and extensive assist from one person for transfers and toilet use. The note documented the resident's skin was within normal limits (WNL) and a treatment was in place. However, the progress note did not identify the type of treatment or the location of the treatment. Review of Resident #165's shower sheet form dated 01/31/23 revealed no skin issues were noted on the form. Review of Resident #165's progress note dated 01/31/23 at 7:39 A.M. revealed the resident had a SDTI (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) to the left heel and the wound bed was not visible with no drainage noted. The note also reflected the resident had a right heel pressure ulcer with the wound bed partially visible, 50% granulation tissue and scant drainage. (The right heel pressure ulcer was not staged by the facility per this note and the facility did not document wound measurements at this time). Review of Resident #165's Skin Alteration Incident Report Dated 01/31/23 at 11:02 A.M. indicated the son was notified on 02/01/23 at 1:05 P.M. and Certified Nurse Practitioner (CNP) #601 was notified on 01/31/23 at 1:05 P.M. of the new pressure ulcers. Review of Resident #165's facility Weekly Ulcer/Wound Documentation form dated 02/01/23 revealed a left heel SDTI measuring 5.1 centimeters (cm) length by 7.1 cm width with no cm depth which was a dark colored, non-blanching area. Resident #165 also had a right heel unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) which measured 2.3 cm by 6.1 cm by 0.1 cm depth. Resident #165 was noted to have 50% granulation tissue and 50% dark discolored area with a treatment in place. Review of the treatment administration records for February 2023 revealed no evidence the treatments were provided as ordered for the left heel on 02/06/23 or for the right heel on 02/06/23, 02/10/23, 02/14/23 or 02/28/23. Prior to the development of the pressure ulcers, there was no documented evidence of offloading for the resident's bilateral heels or turning and repositioning. Following the development of the bilateral heel pressure ulcers, the facility implemented the use of heel lift suspension boots to be used at all times. The use of the heel boots was reflected on the administration records. Record review revealed the facility completed weekly wound measurements from 02/01/23 through 05/23/23. Review of Resident #165's wound Certified Nurse Practitioner (CNP) #601's Wound Note form dated 02/14/23 revealed a left heel SDTI and a right heel unstageable pressure ulcer. The Weekly Wound Note, dated 03/28/23 at 11:27 A.M. revealed the resident had a left heel unstageable pressure ulcer which measured 5.0 cm length by 5.5 cm width with no depth and a right heel unstageable pressure ulcer which measured 2.6 cm length by 3.8 cm width with no depth which had 90% slough/necrosis present and a scant amount of thin, straw-colored drainage. Review of Resident #165's facility Weekly Ulcer/Wound Documentation form dated 05/23/23 revealed the CNP was in to assess and treat. The left heel was noted to have an unstageable pressure ulcer which measured 2.5 cm by 4.4 cm by 0.3 cm depth. Resident #165 also had a right heel unstageable pressure ulcer which measured 2.2 cm by 2.8 cm by 0.4 cm. Both heels were debrided at that time. Review of Resident #165's CNP #601's Weekly Wound Note dated 05/23/23 at 2:49 P.M. indicated the resident had an unstageable pressure ulcer to the left heel which measured 2.5 cm by 4.4 cm by 0.3 cm with a wound base of 50% granulation tissue and 50% slough/necrotic tissue with a scant amount of thin, straw-colored drainage and a debridement (a procedure to remove debris or infected/dead tissue from a wound) was completed. Resident #165 also had an unstageable right heel pressure ulcer which measured 2.0 cm by 2.8 cm by 0.4 cm with a wound base which was 100% slough/necrosis with a moderate amount of thin, straw-colored drainage and a debridement was completed. Review of Resident #165's progress note dated 05/23/23 at 10:08 P.M. indicated the resident's daughter requested the resident to be sent to the emergency room due to the ulcers to her heels. Wound care was provided, and moderate amounts of copious drainage was noted with a foul odor. Review of Resident #165's progress note dated 05/24/23 at 7:19 A.M. indicated the resident was admitted to the hospital for an infection. Review of Resident #165's emergency room visit note dated 05/24/23 at 1:46 A.M. indicated during an exam, Resident #165 was noted to have approximately grade three ulcerations of her bilateral heels, with the left worse than the right. There was foul smelling, purulent discharge with antibiotics initiated. No systemic symptoms or evidence of sepsis and radiographs showed no evidence of osteomyelitis or other deep space infection. Interview on 06/16/23 at 10:07 A.M. with CNP #601 indicated Resident #165's bilateral heels did have an odor but she did not feel it was an infectious odor but rather the odor of necrotic tissue. There was no evidence the resident's heel ulcers had ever been cultured while the wounds were being treated in the facility. Interview on 06/28/23 at 1:29 P.M. with the Director of Nursing (DON) revealed she believed Resident #165's bilateral heels were offloaded and the resident was being turned and repositioned prior to the development of the left heel SDTI heel pressure ulcer as well as the right heel unstageable pressure ulcer, although staff were not required to document the offloading or turning and repositioning in the resident's medical record. The DON confirmed Resident #165's hospital paperwork reflected the resident, upon admission to the hospital had purulent, foul-smelling drainage to her bilateral heels and she was hospitalized with a diagnosis of infection. Interview on 06/29/23 at 9:54 A.M. with Registered Nurse (RN) Wound Nurse #817 revealed the treatment in place that she documented in the progress note on 01/30/23 was barrier cream used to the resident's buttocks associated with incontinence. Interview on 06/29/23 at 11:46 A.M. with Resident #165's power of attorney (POA) for care revealed wound care concerns. The POA revealed there were multiple times the family would visit the resident and her heels would be directly on the bed and multiple times the dressings were not changed as ordered. He stated Emergency Contact #2 had visited Resident #165 prior to her discharge from the facility (on 05/24/23), and the resident's bilateral feet had a foul odor. The POA indicated the facility neglect was the reason why the resident did not return following her most recent hospitalization. Interview on 06/29/23 at 12:31 P.M. with the DON confirmed the facility did not obtain a culture of Resident #165's bilateral heel pressure wounds at any point following the development of the ulcers. Review of the facility policy titled Pressure Ulcer Prevention Protocols/Risk Assessment, dated 06/08/22, revealed a resident's level of risk for pressure ulcer development would initially be determined at the time of admission or readmission taking into consideration the nature of risk to include underlying causes. Residents were considered HIGH risk when admitted with any pressure ulcers, any history of pressure ulcers, any pressure ulcer wounds which the resident has physician order(s) addressing treatment(s), or a Braden Scale score less than or equal to 12. Pressure ulcer preventative/supportive precautions would be implemented including to offloading the resident's heels. This deficiency represents non-compliance investigated under Complaint Numbers OH00144100 and OH00143241.