Health inspection·July 26, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to consistently ensure Resident #66's wound treatment was maintained and Resident #75's dressing to prevent skin breakdown was maintained. This affected two of three residents reviewed for pressure ulcers. The facility census was 97. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #75 was admitted on [DATE] with diagnoses including nontraumatic subarachnoid hemorrhage, cerebral infarction (stroke), chronic respiratory failure, neuromuscular dysfunction of bladder, hydrocephalus epilepsy and anemia. Resident #75's physician order dated 05/11/23 indicated to cleanse Resident #75's sacral wound with normal saline, pat dry, apply 50/50 mix triad and calmoseptine and then cover the wound with a foam dressing once a day for wound care. Resident #75's Treatment Administration Record (TAR) dated 07/01/23 to 07/31/23 indicated Resident #75's wound treatment was applied to the sacral area during the night shift hours from 11:00 P.M. to 7:00 A.M. on 07/24/23. Resident #75's plan of care dated 04/25/23 indicated Resident #75 had actual/potential impairment of skin integrity related to lack of mobility, respiratory failure and muscle weakness. Interventions on the plan of care included to follow facility protocols for treatment of skin injury. An observation of Resident #75's sacral wound on 07/25/23 at 4:50 P.M. revealed there was no wound treatment in place on Resident #75's sacral wound. State Tested Nursing Assistant (STNA) # 102 and Licensed Practical Nurse (LPN) #103 entered Resident #75's room to provide incontinence care for Resident #75. When Resident #75's bed linens were removed Resident #75's incontinence brief was soaked with urine and leaked on the under pad on Resident #75's bed. When STNA #102 and LPN #103 removed Resident #75's incontinence brief there was no wound treatment present on Resident #75's sacral area. Resident #75's sacral area had a white colored scarred area with a small reddened center approximately the size of a 50 cent piece coin. At the time of the observation on 07/25/23 at 4:50 P.M. both STNA #102 and LPN #103 verified there was no wound treatment present on Resident #75's sacral/coccyx area. 2. Resident #66 was admitted on [DATE] with diagnoses including osteomyelitis of lumbar vertebra, discitis, escherichia coli infection, severe protein calorie malnutrition, diabetes mellitus, alcoholic cirrhosis of the liver with ascites, spinal stenosis, chronic viral hepatitis C, retroperitoneal abscess, neuromuscular dysfunction of the bladder, high blood pressure, need for assistance with personal care, limitation of activities due to disability and reduced mobility. Resident #66's wound assessment dated [DATE] indicated a stage four pressure ulcer was located on the coccyx measuring 4.2 centimeters (cm) long by 3.4 cm wide by 1.6 cm deep with undermining at the 10 o'clock and 12 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 365115 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae-Ann Westlake 28303 Detroit Rd Westlake, OH 44145 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)