**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview, the facility failed prevent Resident #58 from developing an in-house pressure ulcer and failed to ensure timely identification, proper treatment and interventions were initiated to promote healing. Additionally, the facility failed to ensure nursing staff completed accurate and comprehensive weekly skin assessments/checks as ordered. Actual Harm occurred on 12/04/24 when the facility failed to implement appropriate and effective interventions for Resident #58, who was at risk for developing pressure ulcers, was always incontinent of bladder, frequently incontinent of bowel, and required staff assistance for activities of daily living, to prevent the development of an in-house acquired unstageable (full-thickness tissue loss in which the base of the ulcer is covered by slough or and/or eschar making the depth/stage undetermined) pressure ulcer to the left buttocks. This affected one resident (#58) of three residents reviewed for pressure injuries/skin impairments. The facility identified five residents (#1, #17, #33, #58, and #63) with pressure ulcers. The facility census was 71. Findings include: Review of Resident #58's medical record revealed an admission date of 02/08/18 with diagnoses including type II diabetes mellitus (DM), schizophrenia, pressure ulcer of left buttock and secondary Parkinsonism. Review of a plan of care initiated on 03/09/18 revealed Resident #58 had a potential for skin breakdown related to fragile skin and impaired mobility. Interventions included Braden Scale per protocol, complete skin assessment per protocol, encourage turning and repositioning, pressure reducing mattress to bed, and pressure releasing devices as indicated. Record review revealed no documented evidence staff encouraged or provided turning and repositioning of the resident. Review of Resident #58's medical record revealed a physician's order dated 05/03/24 for skin checks weekly every day shift every Monday. Review of Resident #58's weekly skin observations/assessments dated 11/11/24 and 11/13/24 revealed the resident had no skin issues. Review of Resident #58's weekly skin observation dated 11/19/24 revealed staff documented the resident had a skin abrasion to the left buttock that measured 3.0 centimeters (cm) by 3.0 cm and documented as N/A for stage. Review of a progress note dated 11/19/24 at 10:45 P.M. revealed Resident #58 had a 3.0 cm by 3.0 cm by 0 cm abrasion on left buttock. Resident #58 had complaints of left buttock pain and as needed (PRN) medications were administered. However, the record review revealed there was no documented evidence pain medication was administered on the medication administration record (MAR) on 11/19/24. The note revealed a treatment was applied. However, there was no documented evidence of what treatment was applied. Notifications were made to the physician, Director of Nursing (DON), and family. Review of the Braden Scale for Predicting Pressure Ulcers dated 11/20/24 revealed a score of 20.0 which indicated Resident #58 was risk for developing pressure ulcers. There was no documented Braden Scale completed before 11/19/24. Review of an interdisciplinary team (IDT) progress note dated 11/20/24 revealed Resident #58 had a reddened area to the left buttock. The left buttock skin was intact but noted to be non-blanchable. Notifications were made to the physician, DON, and family. The note indicated the wound physician was notified and would follow up with the resident on the next scheduled visit. An initial intervention included to pad and protect the left buttock. No additional interventions were noted to be implemented at that time. Review of physician orders and treatment administration records (TAR) revealed from 11/20/24 to 11/22/24 an order was in place to cleanse the resident's coccyx (although the wound was on the left buttock) with normal saline (NS) and apply a clean dry dressing (CDD) every night shift (HS). A new order was obtained on 11/24/24 to cleanse the left buttock/coccyx with NS, pat dry, cover with a CDD every night shift. This order remained in place from 11/24/24 until it was discontinued on 12/03/24. Review of Resident #58's weekly skin observation dated 11/25/24 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 12/02/24 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or description of the wound. Review of a Wound Physician Note dated 12/04/24 (first visit by the wound physician) revealed Resident #58 had an unstageable pressure to the left buttock that measured 2.5 cm in length by 2.4 cm width with a depth that could not be determined (UTD). The wound bed tissue composition at the beginning of visit was 10% granulation, 10% slough, and 80% eschar. Minimal exudate and erythema were noted. A new treatment to use hydrogel gauze, cleanse wound with NS or sterile water, apply to the wound bed and cover with a dry clean dressing was noted in the progress note. Review of Resident #58's medical record revealed physician's orders dated 12/05/24 for Pro-Stat (protein supplement) two times a day (BID) give 30 milliliters (mL) for wound healing and an order for a pressure reducing cushion to the resident's wheelchair. Review of the care plan initiated 12/06/24 revealed Resident #58 had actual skin breakdown related to mobility deficit. Resident #58 had an unstageable deep tissue injury (DTI) (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 buttock (12/03/24). Interventions initiated on 12/06/24 (following the identification of the pressure ulcer) included consulting a wound consultant and follow up as needed (PRN), encourage turning and repositioning every two hours while in bed, low air loss mattress, minimizing exposure to excessive moisture or stool, nutritional interventions as ordered, and wound care as ordered. The care plan was updated on 12/31/24 to reflect the pressure ulcer was a Stage III (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) pressure ulcer. Review of Resident #58's medical record revealed a physician's order dated 12/06/24 for a low air loss mattress. Review of Resident #58's weekly skin observation dated 12/09/24 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or description of the wound. Review of Resident #58's weekly skin observation dated 12/16/24 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or a description of the wound. Review of the Wound Physician Note dated 12/18/24 revealed Resident #58 had a pressure injury on the left buttock that measured 2.5 cm by 2.4 cm by width UTD. The wound bed tissue composition was 10% granulation, 10% slough, and 80% eschar. Minimal exudate and erythema were noted. The treatment was to include 0.25% Dakin's moistened gauze every day and PRN. The healing status stated declined. Review of Resident #58's weekly skin observation dated 12/20/24 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 12/23/24 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or a description of the wound. Review of Resident #58's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #58 had intact cognition. She had no behaviors of rejection of care and had limitations to range of motion of the upper and lower extremities bilaterally. The assessment revealed the resident required supervision or touching assistance with toileting hygiene, showers, rolling left to right and transfers. She required partial to moderate assistance with lower body dressing and personal hygiene and was dependent on staff for putting on/taking off footwear. The assessment revealed the resident was always incontinent of bladder and frequently incontinent of bowel, was at risk for pressure ulcer development and had a Stage III pressure ulcer. Review of Resident #58's weekly skin observation dated 01/06/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or a description of the wound. Review of Resident #58's weekly skin observation dated 01/13/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or a description of the wound. Review of Resident #58's weekly skin observation dated 01/20/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or a description of the wound. Review of Resident #58's weekly skin observation dated 01/27/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or description of the wound. Review of Resident #58's weekly skin observation dated 01/29/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or a description of the wound. Review of Resident #58's weekly skin observation dated 02/05/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or description of the wound. Review of Resident #58's weekly skin observation dated 02/10/25 revealed the resident had a left buttock pressure ulcer; however, there were no measurements or description of the wound. Review of Resident #58's weekly skin observation dated 02/14/25 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 02/17/25 revealed the resident had a left buttock pressure; however, there were no measurements or description of the wound. Review of Resident #58's weekly skin observation dated 02/19/25 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 02/20/25 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 02/24/25 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 03/03/25 revealed the resident had a left buttock other, wound; however, there were no measurements or a description of the wound. Review of Resident #58's weekly skin observation dated 03/10/25 revealed no skin issues were documented on the form. Review of Resident #58's weekly skin observation dated 03/17/25 revealed no skin issues were documented on the form. Record review revealed during this time period, the resident was being seen by the Wound Physician who did include measurements of the wound when the resident was seen. On 03/19/25 at 2:24 P.M. an interview with Regional Director of Clinical Operations (RDCO) #400 verified weekly skin observations were to be done every week, and the form was to be completed accurately to include the type of skin/pressure ulcer and the measurements of the pressure ulcer/wound. On 03/19/25 at 3:00 P.M. an interview with Wound Nurse (WN)/Assistant Director of Nursing (ADON) #205, who was new to the position, verified weekly skin observations were to be done every week by the nurses working the floor, despite the Wound Physician's weekly assessments, and the form was to be completed accurately to include the type of skin/pressure ulcer and the measurements. WN/ADON #205 verified weekly skin observations were not completed correctly for Resident #58. During the interview, she was also unable to provide a reason why some of the nurse's weekly skin observations showed no wounds when Resident #58 did in fact have a pressure ulcer to the left buttocks. In addition, during the interview WN/ADON #205 also revealed she would not expect an abrasion to turn into an unstageable pressure wound before additional interventions were implemented. No investigation was conducted by the facility to determine how the left buttock abrasion deteriorated from an abrasion to an unstageable pressure ulcer without staff knowledge before it became unstageable. WN/ADON #205 verified Resident #58's pressure ulcer to the left buttock was an in-house acquired unstageable pressure ulcer identified by the wound physician on 12/04/24. Observation on 03/20/25 at 12:47 P.M. of wound care revealed Licensed Practical Nurse (LPN) #211 performed hand hygiene, gathered supplies, donned personal protective equipment (PPE), knocked on door and entered. LPN #211 disinfected the over the bed tray and applied a barrier. Gloves were removed, hand hygiene performed, and new gloves applied. Resident #58 was in bed, and LPN #211 assisted in removing the resident's pants and brief. LPN #211 removed the resident's old dressing which had moderate dry drainage noted. An open area with some darkness was observed to the left buttock. LPN #211 cleansed with wound normal saline, patted the wound dry, applied collagen alginate with silver and covered with a dressing with date and initials. LPN #211 assisted Resident #58 with reapplying her brief and pants and assisted her to her chair. Infection control was maintained throughout the procedure, and Resident #58 tolerated with no complaints. LPN #211 doffed PPE before exiting the room. Review of the facility policy, Pressure Ulcer/Injury Risk Assessment, revised 07/2017, revealed the purpose of this procedure was to provide guidelines for the structures assessment and identification of residents at risk of developing pressure ulcers/injuries. The purpose of the risk assessment was to identify all risk factors and determine which could be modified, which could not, or which could be immediately addressed. Review of the facility policy, Pressure Ulcer/Injury Care and Management, revised 08/2022, revealed residents would receive care consistent with professional standards of practice, to prevent pressure ulcer/injury. Residents would receive necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. This deficiency represents non-compliance investigated under Master Complaint Number OH00163632.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #54, who was cognitively impaired and required extensive assistance from two persons for transfers was transferred safely via a mechanical (Hoyer) lift to prevent a fall with injury. Actual Harm occurred on 12/12/19 when Resident #54 sustained a fall from the Hoyer lift resulting in a laceration to her head requiring transport to the emergency room. This affected one resident (#54) of one resident review for accidents. Findings Include: Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, type two diabetes and unspecified intellectual disabilities. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 was severely cognitively impaired and required extensive assistance for activities of daily living including two person assistance for transfers. Review of the nurse's note authored by Licensed Practical Nurse (LPN) #50 dated 12/12/19 at 8:09 A.M. revealed LPN #50 was notified by maintenance of an emergency in Resident #54's room. Upon arriving into Resident #54's room LPN #50 discovered Resident #54 laying supine (facing upward) on top of the Hoyer lifts legs. State Tested Nursing Assistant (STNA) #120 explained to LPN #50 that while STNA #120 and another STNA were transferring the resident the hoyer lift malfunctioned and Resident #59 fell hitting her head on the Hoyer lift. Resident #54 was sent out to the hospital after assessment revealed a posterior (back) head wound. Review of the fall investigation, dated 12/12/19 revealed the hydraulic lift system of the Hoyer malfunctioned and subsequently caused the fall for Resident #54. Following the incident, a review a Lift Preventative Maintenance Inspection, dated 12/12/19 revealed under the section titled Shift Handle a visual/functional inspection of the lift used for Resident #54 revealed the lift needs cross; Support & Hardware. The lift was taken out of service as it was not in proper working order but failed to include information as to specifically why or how the lift malfunctioned as noted in the nursing progress note and investigation. The facility failed to identify the lift was not in proper working order prior to the the incident on 12/12/19 in which Resident #54 sustained an injury when she fell out of the lift during a staff assisted transfer. During the onsite survey, the facility failed to provide evidence of effective preventative maintenance to ensure the proper functioning of all lift devices to prevent resident falls with injury. Interview with the Director of Nursing on 12/17/19 at 2:05 P.M. verified the events of the fall and findings of the fall investigation as noted above.