Health inspection·March 11, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, observations, staff interviews, interview with Wound Physician #500, and review of facility policy, the facility failed to timely assess, monitor, and implement treatments for Resident #43, who was admitted to the facility with a pressure ulcer on the coccyx. This resulted in Actual Harm when Resident #43 was assessed upon admission on [DATE] with a pressure ulcer to the coccyx but the staff failed to accurately assess the wound to include measurements/description and the staff failed to notify the physician to obtain/implement treatment orders. Subsequently, Resident #43's coccyx pressure ulcer was assessed by the wound physician on 03/04/25 to be unstageable with necrosis and the coccyx pressure ulcer required excisional debridement (surgery) on 03/04/25 and again on 03/06/25. This affected one (#43) of three residents reviewed for pressure ulcers. The facility census was 76. Residents Affected - Few Findings include: Review of medical record for Resident #43 revealed an admission date of 02/18/25. The resident was admitted with diagnoses including spinal stenosis, cord compression, malignant neoplasm of bone and protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The assessment indicated the resident was dependent on two-assist for activities of daily living care. Resident #43 had one pressure ulcer which was unstageable. Review of the risk assessment dated [DATE] revealed the resident was at risk for skin breakdown. Review of the hospital discharge record on 02/18/25 revealed the resident had a non-blanchable purple wound on the coccyx found in the hospital on [DATE]. Review of the care plan dated 02/18/25 revealed Resident #43 had impaired skin integrity related to recent surgical procedure, pressure area to coccyx on admission, and immobility. Individualized interventions included consult nurse practitioners for evaluation and treatment as indicated, and turn and reposition per protocol with measurable goals. Review of the medical record revealed a skin observation tool assessment was completed for the dates of 02/18/25 and 02/25/25, which indicated a surgical wound and pressure wound to the coccyx; however, there was no further assessment of Resident #43's wounds including no wound measurements, and no wound stage. Further review of the medical record revealed the physician was not notified and no treatment orders were initiated for the coccyx pressure ulcer. Page 1 of 3 365202 365202 03/11/2025 Carecore at Lima 599 South Shawnee Street Lima, OH 45804

F 0686 Level of Harm - Actual harm Residents Affected - Few Review of Resident #43's weekly physician notes from the dates of 02/18/25 to 03/03/25 revealed wound assessments were completed for a post-surgical wound of the back. However, there was no documented assessment of the pressure area on Resident #43's coccyx. Review of the Treatment Administration Record (TAR) from 02/18/25 through 03/03/25 revealed there was no treatment for the coccyx wound. Review of a nurse's note dated 02/28/25 at 4:03 A.M. revealed Resident #43 had an unstageable pressure ulcer to the sacrum measuring 6.2 centimeters (cm) by 6.9 cm by 0.3 cm. The wound bed had 50 percent (%) slough and 50% eschar. The wound bed was macerated with the peri-wound being red. The wound was noted to be close to the rectum. The manager was updated. The note lacked notification to the physician and or any treatments being implemented. Review of the shower sheets for Resident #43 revealed on 02/28/25 a bed bath was given and the resident was noted to have an unstageable pressure area to the coccyx. Review of the wound monitoring sheets dated 03/04/25 noted as the first evaluation revealed Resident #43 had a wound which was an unstageable pressure ulcer to the coccyx with necrosis. The wound was measured as being 7.0 cm by 7.20 cm, and a depth of 1.40 cm. The wound bed was undefined with treatments which were Alginate calcium once daily and hydrogel with silver once daily. The wound monitoring sheets were reviewed from January 2025 to 03/06/25 and lacked documentation of Resident #43 being assessed or documented for any type of wound. Review of the VOHRA Initial Wound Evaluation and Management Summary, dated 03/04/25 revealed Resident #43 had a wound on the coccyx. The wound examination of the coccyx revealed the wound was unstageable due to necrosis. The duration was greater than 14 days (it was noted to be present upon admission). The wound measured at 7.0 cm by 7.2 cm by 1.4 cm. The wound had exudate moderate serous with thick adherent devitalized necrotic tissue of 100 percent (%). This wound had undergone a surgical excisional debridement procedure. The wound was surgically excised of devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 1.5 cm. The non-viable tissue in the wound bed decreased from 100% to 95%. Further review, revealed on 03/06/25, the coccyx wound measured 7 cm by 7.2 cm by 1.4 cm with undermining at 3o'clock measuring 3 cm. The wound had moderate serous exudate with thick adherent devitalized necrotic tissue being 100% of the wound. Another surgical excisional debridement procedure to remove necrotic tissue and establish the margins of viable tissue. The surgical procedure excised the devitalized tissue and necrotic muscle level tissue was removed to a depth of 3.3 cm. The non-viable tissue in the wound bed decreased from 100% to 75%. Observation on 03/11/25 at 6:00 A.M. with Wound Nurse #207 of the treatment to Resident #43's pressure ulcer revealed the wound to the coccyx had a foul odor with dark necrotic tissue. The coccyx wound measured 6.5 cm by 5.4 cm by 3 cm. The wound nurse verified the wound was an unstageable pressure ulcer and was unable to confirm the full depth of the wound due to necrotic tissue present. Interview on 03/11/25 at 12:10 P.M. with the Administrator and Regional Nurse #400 verified lack of documentation in the medical record from 02/28/25 to 03/04/25 of orders for treatments to the coccyx, which was noted upon admission, and notification to the physician. Interview with Wound Physician #500 on 03/11/25 at 2:15 P.M. verified the coccyx wound for Resident #43 was not observed until 03/04/25. There was a consultation on 02/25/25 but the physician did not see the resident due to resident being seen by general surgery. The wound physician was not aware 365202 Page 2 of 3 365202 03/11/2025 Carecore at Lima 599 South Shawnee Street Lima, OH 45804

F 0686 Level of Harm - Actual harm of the status of the coccyx wound until 03/04/25. The wound physician performed a debridement but was unable to remove all the necrotic tissue due to the procedure causing the resident pain. The nurse practitioner had to return two days later and perform another surgical procedure to remove more of the necrotic tissue. Residents Affected - Few Review of the facility's policy, Documentation of Wound Treatments dated 10/10, revealed the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Wound assessments are documented upon admission, weekly, and as needed if resident or wound condition deteriorates. The following elements are documented as part of a complete wound assessment; type of wound, and anatomical location, stage of the wound, measurements (height, width, depth, undermining or tunneling. The description of the wound should include the color of the wound, type of tissue in the wound, condition of peri-wound, presence, amount, and characteristics of wound drainage, presence or absence of odor, and presence of pain. Additional documentation shall include notification to physicians. Review of the facility's policy, Pressure Injury Risk Assessment dated 03/20, revealed the purpose for this procedure is to provide guidelines for the structured assessment and identification of residents at risk for developing new pressure injuries or worsening of existing pressure injuries. The following information should be recorded in the resident's medical record: the condition of the skin (the size, location and description) if any identified areas are present. Initiation of pressure or non-pressure form related to the type of skin alteration and documentation addressing the physician notification. This deficiency represents non-compliance investigated under Complaint Number OH00163267. 365202 Page 3 of 3