Health inspection·January 9, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and medical record review, the facility failed to provide wound treatment according to physician orders. This affected one (#67) of three residents reviewed for wound care. The facility census was 161. Residents Affected - Few Findings Include: Review of Resident #67's medical record revealed an admission date of 06/01/22. Diagnoses included hemiplegia, right heart failure, and unspecified malnutrition. Review of a wound physician assessment, dated 01/03/24, revealed Resident #67 had moisture associated skin damage (MASD) to the buttocks, which had improved since its development on 12/27/23, and measured 3 centimeters (cm) by 1.5 cm with a depth of 0.2 cm. The assessment called for a treatment of honey alginate (a mesh dressing mixed with honey gel) covered by a foam dressing to be changed daily. Review of a physician order dated 12/27/23 confirmed there was an active order in place for this treatment. Observation of wound care for Resident #67 by Licensed Practical Nurse (LPN) #501 on 01/09/24 at 10:45 A.M. revealed she performed the dressing care by washing the wound with normal saline, drying it with gauze, applying Medihoney gel, then a foam dressing. The wound itself appeared consisted of a small pink area with a very small open red area within with no obvious drainage or sign of infection. Observation of the Medihoney gel container revealed no evidence it contained alginate. Interview with LPN #501 on 01/09/24 at 11:01 A.M. confirmed she did not use honey alginate on the wound as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00149356. Page 1 of 3 365046 365046 01/09/2024 Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, staff interview and review of a fall investigation, the facility failed to provide appropriate monitoring during personal care to prevent a fall. This affected one (#114) of three residents reviewed for falls. The facility census was 161. Findings Include: Review of Resident #114's medical record revealed an admission date of [DATE]. Diagnoses included encephalopathy, chronic kidney disease, and unspecified dementia. Resident #114 was admitted to hospice on [DATE] and expired in the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #114 was severely cognitively impaired, was dependent on staff for toileting assistance, and needed substantial assistance with turning in bed. Review of a plan of care focus area, revised [DATE], revealed Resident #114 had an activities of daily living (ADLs) self-performance deficit related to impaired mobility. Interventions included extensive one to two person staff assistance with bed mobility. Review of a fall risk assessment, dated [DATE], revealed Resident #114 was at high risk for falls. Review of a progress note, dated [DATE], revealed Resident #114 fell during personal care when a nurse aide left to get a towel and came back to see the resident sliding off the bed. Resident #114 was noted to have hit his head and had a small abrasion above the eye with slight swelling and no bleeding. Hospice was notified. Follow-up vital signs and neurological assessments revealed no further injury. Review of the fall investigation revealed a written statement, dated [DATE], by State Tested Nursing Aide (STNA) #601. The statement indicated STNA #601 was changing Resident #114, left to get more towels, returned and began to wet the towels, then heard a noise and saw Resident #114 was falling. STNA #114 tried to catch the resident but he was too heavy and slid to the floor. Further review of the investigation revealed the intervention noted was to educate staff to bring all supplies before entering rooms and to lay residents flat before leaving their side. Interview on [DATE] at 11:03 A.M. with Licensed Practical Nurse (LPN) #502 revealed she was involved with the investigation and follow-up to Resident #114's fall. LPN #502 stated STNA #601 begun providing incontinence care and left Resident #114 on his side to retrieve more supplies, and when she returned he was seen sliding from the bed. She confirmed staff was not to leave residents alone on their side when giving care and the aide should have rung for assistance or returned him to a supine position before leaving. LPN #502 stated STNA #601 was reeducated following the event. Interview on [DATE] at 2:05 P.M. with STNA #601 confirmed she was the aide giving care when Resident #114 fell. STNA #601 stated she lowered the bed during care and left the room to get more towels. While wetting a towel in the sink, STNA #601 stated she hear Resident #114 shout and found him hanging on to the railing with his legs out of the bed. STNA #601 stated she tried to catch the resident's lets legs but he was too heavy and she assisted him to slide out of the bed. STNA #601 denied 365046 Page 2 of 3 365046 01/09/2024 Daughters of Miriam Center for Nursing & Rehabilit One David N Myers Parkway Beachwood, OH 44122

F 0689 leaving Resident #114 on his side, but acknowledged he was close to the edge of the bed. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Master Complaint Number OH00149666. Residents Affected - Few 365046 Page 3 of 3