Health inspection·October 12, 2023

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few policies/protocols for prevention/treatment of skin breakdown, monitor nutritional status and obtain/monitor/report laboratory/diagnostic work as ordered, a pressure reduction cushion to wheelchair at all times, and a pressure reducing mattress to bed. Review of the treatment administration record (TAR) from 09/01/23 through 09/08/23 revealed the triad paste treatments were completed as ordered to the bilateral posterior thighs and the bilateral buttocks until discontinued on 09/08/23. There was no documentation of treatment or assessment for the coccyx pressure ulcer. Review of Nurse Practitioner's (NP) #300's wound assessment dated [DATE] revealed the resident had a stage three pressure ulcer to the posterior distal right thigh. The wound measured 2.7 centimeters (cm) in length, 1.2 cm in width, with a depth of 0.20 cm with exposed subcutaneous tissue. The wound had 100% granulation tissue, with intact surrounding skin, moderate serosanguineous exudate and no odor. A treatment was ordered to cleanse wound with wound cleanser, calcium alginate and hydrocolloid, change three times per week. The resident also had a deep tissue injury to the right proximal posterior thigh measuring 4.5 cm length by 4.5 cm in width and zero depth with 100% epithelial tissue, attached wound edges, no exudate and no odor. A treatment was ordered to cleanse with wound cleanser, zinc oxide paste twice a day and leave open to air. The resident had an unstageable pressure ulcer to the right buttock measuring 1 cm in length by 2 cm in width by 0.20 cm depth with 1-24% granulation tissue and 75% to 99% slough, no eschar, exposed subcutaneous tissue, unattached wound edges, intact surrounding skin and moderate serosanguineous drainage with no odor. A treatment was ordered to cleanse with wound cleanser, calcium alginate and hydrocolloid three times per week. The resident also had an unstageable pressure ulcer to the left buttock measuring 0.7 cm in length by 1 cm in width by 0.10 cm in depth. The wound had exposed subcutaneous tissue, unattached wound edges, moderate serosanguineous drainage with no odor and the surrounding skin was intact. A treatment was ordered to cleanse with wound cleanser, treat with calcium alginate and hydrocolloid three times per week. There was no evidence these orders were written on the date of the assessment. Review of a physician order dated 09/08/23 at 7:00 P.M. revealed to cleanse the right posterior thigh-proximal with normal saline, pat dry, apply zinc oxide paste twice a day and as needed every day and night shift. An order to cleanse with normal saline, pat dry, apply zinc oxide paste twice daily and as needed was also initiated and completed but there was no documentation where the treatment was to be applied. Review of the TAR revealed the treatment was completed once on 09/08/23 and twice daily from 09/09/23 through 09/15/23. Review of physician order dated 09/09/23 revealed to cleanse the right and left buttock with normal saline, pat dry, apply calcium alginate and cover with hydrocolloid, change three times per week and as needed on Tuesdays, Thursdays and Saturdays. Also orders to cleanse the right posterior distal thigh with normal saline, pat dry, apply calcium alginate and cover with hydrocolloid change three times per week and as needed on Tuesdays, Thursdays and Saturdays. Review of the TAR revealed the treatments were completed on 09/09/23, 09/12/23 and 09/14/23. Interview on 10/12/23 at 11:35 A.M. the Director of Nursing (DON) verified upon admission a complete wound assessment including wound measurements and wound staging was not completed for the resident. The DON verified there were no physician orders for wound treatments for the pressure ulcer to the coccyx other than triad paste cream to the bilateral buttocks and thighs initiated upon admission. Further interview with the DON revealed WNP #300 saw the resident on 09/07/23, however no orders for wound treatments were received until 09/08/23. The DON verified the wound to right posterior thigh pressure ulcer was not treated until after 7:00 P.M. on 09/08/23. The DON revealed the treatments (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 2 of 3 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for the pressures ulcers on the left and right buttocks and right distal thigh were not initiated until first shift on 09/09/23. Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised 03/2014, revealed the nurse would describe, document and report a full assessment of pressure sore including location, stage, length, width, depth and presence of exudate or necrotic tissue, pain assessment, resident's mobility status, current treatments, including support surfaces; and all active diagnoses. This deficiency represents non-compliance investigated under Complaint Number OH00146689. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 3 of 3