Health inspection·February 8, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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, interview and facility policy review, the facility failed to ensure two residents (#9 and #67), who were dependent on staff for personal hygiene was shaved. This affected two (Resident #9 and #67) of three residents reviewed for personal hygiene. The facility census was 130. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #67 revealed an initial admission date of 03/27/23 with the latest readmission of 01/20/24 with the diagnoses including metabolic encephalopathy, pseudomonas, sepsis due to pseudomonas, acute and chronic respiratory failure, hydronephrosis, chronic obstructive pulmonary disease (COPD), paraplegia, neuromuscular dysfunction of bladder, paralytic syndromes, spinal stenosis of cervical region, hypertension, insomnia, benign prostatic hyperplasia, depression, chronic pain syndrome and neurogenic bowel. Review of the plan of care dated 11/29/23 revealed the resident had a self-care deficit related to weakness, decreased mobility, paralytic syndrome, spinal stenosis, chronic pain and requires electric wheelchair for mobility. Interventions included assist to bathe/shower as needed, assist with daily hygiene, grooming, dressing, oral care and eating as needed, encourage and assist to reposition frequently, therapy evaluation and treatment per physician orders, splint wear and transfer with full mechanical lift with Hoyer and two staff assist. Review of the discharge minimum data set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. Review of the mood and behavior revealed the resident displayed verbal behaviors directed towards others, however the resident rejected no care. The resident's functional abilities were not assessed. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. Review of monthly physician orders for February 2024 identified no orders related personal hygiene. Observation on 02/01/24 at 9:53 A.M. of Resident #67 revealed his shirt had crumbs on the front and had several days of facial hair growth. Interview on 02/01/24 at 11:47 A.M. with State Tested Nursing Assistant (STNA) #289 verified the resident had several days of facial hair growth. 2. Review of the medical record for Resident #9 revealed an initial admission date of 01/30/18 with the diagnoses including severe degeneration of the brain, protein calorie malnutrition, vitamin D Page 1 of 11 365272 365272 02/08/2024 Riverview 3710 Olentangy River Road Columbus, OH 43214

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few deficiency, dementia, hypertension, anemia, cerebrovascular accident (CVA), osteoarthritis, and pressure ulcer of the back. Review of the plan of care dated 01/19/23 revealed the resident had a self-care deficit related to decreased mobility, use of assistive devices, assist of staff, history of CVA, osteoarthritis, impaired decision making and safety awareness, dementia, incontinence as well as effects of medications as ordered. Interventions included bed mobility with one assist, transfers with Hoyer lift and two assist, activity as tolerated, bathing/shower as ordered and as needed per one assist, ensure call light is available to the resident on the unaffected side and assist with activities of daily living (ADL): eating, toileting, personal hygiene, bathing, bed mobility and wheelchair mobility every shift and as needed, check nail length and trim and clean on bath day and as needed. Review of the state optional MDS assessment dated [DATE] revealed the resident's cognition was not assessed. Review of the mood and behavior revealed the resident rejected no care. The resident required extensive assistance of two staff for bed mobility, transfers, eating and toilet use. The assessment indicated the resident had no unhealed pressure ulcers. Review of the resident's monthly physician orders for February 2024 identified no physician's orders related to personal hygiene. Observation on 02/01/24 at 12: 36 P.M. of Resident #9 revealed he had several days of facial hair growth. Observation on 02/05/24 at 11:40 A.M. of Resident #9 revealed the resident continued to have several days of facial hair growth. Interview on 02/05/24 at 1:26 P.M. with the Director of Nursing (DON) verified the resident has several days of facial hair growth. Review of a policy titled, Hygiene and Grooming, last revised 01/10/23 revealed it is the facility's policy to make sure the resident's needs are met regarding hygiene and grooming while addressing the resident's personal hygiene preferences and daily routine. This deficiency represents non-compliance investigated under Complaint Number OH00150547. 365272 Page 2 of 11 365272 02/08/2024 Riverview 3710 Olentangy River Road Columbus, OH 43214

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 observation, record review, staff interviews, review of wound notes, and facility policy review, the facility failed to accurately assess, timely notify the physician of an identified pressure area, and implement interventions to prevent a middle lumbar pressure ulcer from worsening for Resident #16. Additionally, the facility failed to comprehensively assess, notify the physician, and implement a treatment plan timely for Resident #9 and Resident #67 who were admitted to the facility with pressure ulcers/injuries. Residents Affected - Few Actual Harm occurred on 10/22/23 when Resident #16, who required extensive assistance from two staff and was incontinent, had a middle lumbar wound that was not accurately assessed as a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.) pressure ulcer which worsened to an unstageable (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound.) pressure ulcer without evidence of timely physician notification, implementation of appropriate prevention interventions, and treatment or adequate assessments of the wound area. This affected three residents (#9, #16, and #67) of three residents reviewed for pressure ulcers. The facility identified 13 residents having pressure ulcers. The facility census was 130. Findings Include: 1. Review of the medical record for Resident #16 revealed an initial admission date of 01/30/18 with diagnoses including severe degeneration of the brain, protein calorie malnutrition, vitamin D deficiency, dementia, hypertension, anemia, cerebrovascular accident, osteoarthritis, and pressure ulcer of the back. Review of the plan of care dated 01/19/23 revealed the resident had the potential for impairment to skin integrity related to decreased mobility, use of assistive devices, assist of staff, cerebral vascular accident, osteoarthritis, impaired decision making and safety awareness, dementia, anemia and incontinence. Interventions included keep skin clean and dry, use lotion on dry skin, low air loss mattress, monitor the status of resident's toenails as needed, obtain blood work as physician ordered, pressure relieving cushion to wheelchair, reposition resident for comfort as needed, turn/reposition resident regularly to relieve pressure points, use a draw sheet or lifting device to move resident and use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Review of the progress note dated 10/22/23 at 8:15 P.M. revealed the resident was found to have a reddened area with two blisters on his back. The nurse documented moisturizing cream was applied to the reddened area. Review of the resident's medical record revealed no documented evidence that the resident's primary care physician (PCP) was notified of the reddened area with two blisters on the resident's back or a treatment was initiated. Review of the primary care physician (PCP) #238 progress note dated 10/25/23 revealed no documented 365272 Page 3 of 11 365272 02/08/2024 Riverview 3710 Olentangy River Road Columbus, OH 43214

F 0686 evidence the physician was aware of the reddened area with two blisters to the resident's back. Level of Harm - Actual harm Review of the resident's physician's orders revealed an order dated 10/30/23 to cleanse wound to back with normal saline (NS), apply calcium alginate and cover with a foam dressing every Monday, Wednesday, and Friday with the special instructions to be changed by hospice nurse or staff nurse per order and as needed for wound care. Residents Affected - Few Review of the resident's medical record revealed no documented evidence that the physician ordered treatment to the resident mid lumbar spine was provided. Review of the weekly skin & wound assessment dated [DATE] revealed Resident #16 was found to have an unstageable pressure ulcer to the mid lumbar spine measuring 3.9 centimeters (cm) by 0.8 cm. The wound was described as 40% epithelial, 10% granulation and 50% slough. The wound was noted to have a light amount of serous exudate. The facility implemented the intervention to cleanse with NS, apply calcium alginate and cover with foam dressing. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 3.7 cm by 1.3 cm. The wound was described as 20% epithelial tissue, 10% granulation and 70% slough. The wound had a light amount of serous exudate with a faint odor. The surrounding tissue was macerated (wet, white, waterlogged tissue). The facility determined the wound had deteriorated. The facility changed the treatment to cleanse with NS, pat dry, apply Medi honey, apply calcium alginate to fit the wound bed and cover with a foam dressing. Review of the medical record revealed no documented evidence that the resident's power of attorney (POA) was notified of the deterioration of the unstageable pressure ulcer to the resident's mid lumbar spine. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 4.8 cm by 2.0 cm. The wound was described as 30% epithelial tissue, 10% granulation and 60% slough. The wound had a moderate amount of serosanguineous exudate with a moderate odor. The facility determined the wound was stable and made no changes to the treatment. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 4.2 cm by 1.5 cm. The wound was described as 20% epithelial tissue and 80% slough. The wound had a light amount of serous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 1.7 cm by 0.8 cm. The wound was described as 60% granulation tissue and 40% slough. The wound had a light amount of serous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the resident's November 2023 Treatment Administration Record (TAR) revealed no documented evidence the physician ordered treatment to the resident's mid lumbar spine was provided on 11/10/23, 11/13/23, and 11/27/23. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 1.8 cm by 1.4 cm. The wound was described as 30% 365272 Page 4 of 11 365272 02/08/2024 Riverview 3710 Olentangy River Road Columbus, OH 43214

F 0686 granulation tissue and 70% slough. The wound had no exudate. The facility determined the wound was stable and made no changes to the treatment. Level of Harm - Actual harm Residents Affected - Few Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 5.7 cm by 2.4 cm by 0.2 cm. The wound was described as 100% slough. The wound had a light amount of serosanguineous exudate with no odor. The facility determined the wound had had improved despite the increased size, depth and the wound being 100% slough. The facility made no changes to the treatment. Review of the medical record revealed no documented evidence that the resident's POA was notified of the deterioration of the wound. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 3.6 cm by 2.0 cm. The wound was described as 90% granulation tissue and 10% slough. The wound had a light amount of serosanguineous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 4.1 cm by 1.6 cm by 0.2 cm. The wound was described as 70% granulation tissue and 30% slough. The wound had a moderate amount of serosanguineous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the resident's December 2023 TAR revealed no documented evidence the physician ordered treatment to the resident's mid lumbar spine was provided on 12/10/23. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 2.5 cm by 1.8 cm by 0.2 cm. The wound was described as 70% granulation tissue and 30% slough. The wound had a moderate amount of serosanguineous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 2.6 cm by 2.1 cm by 0.2 cm. The wound was described as 70% granulation tissue and 30% slough. The wound had a moderate amount of serosanguineous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 1.9 cm by 1.5 cm by 0.2 cm. The wound was described as 80% granulation tissue and 20% slough. The wound had a light amount of serosanguineous exudate with a faint odor. The facility determined the wound was stable and the treatment was changed to cleanse with Dakin's solution, apply calcium alginate and cover with a foam dressing. Review of the medical record revealed no documented evidence the resident's POA was notified of the change in treatment. Review of the plan of care dated 01/18/24 revealed the resident was at risk for pressure injury formation related to generalized debility and weakness as evidenced by decreased mobility in bed and wheelchair, incontinence of bowel and bladder, requires assistance from staff with incontinence care, turning and repositioning, Braden score less than 17 and pressure ulcer to lumbar and right lateral mid foot. Interventions included Braden scale to be completed per facility protocol, cushion to 365272 Page 5 of 11 365272 02/08/2024 Riverview 3710 Olentangy River Road Columbus, OH 43214

F 0686 Level of Harm - Actual harm Residents Affected - Few wheelchair daily, encourage and assist as needed to turn and reposition per policy, use assistive devices as needed, encourage intake of 75 to 100% of diet and fluids daily, Registered Dietician (RD) to assess dietary needs quarterly and with significant changes, encourage resident to float heels and/or wear heel boots, monitor skin daily during care and for redness, excoriation or breakdown, skin evaluation weekly, weekly nursing skin evaluations with shower, notify primary care physician and wound care nurse of any skin changes. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 2.5 cm by 1.6 cm by 0.2 cm. The wound was described as 80% granulation tissue and 20% slough. The wound had a moderate amount of serosanguineous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 2.7 cm by 2.0 cm by 0.2 cm. The wound was described as 80% granulation tissue and 20% slough. The wound had a moderate amount of serosanguineous exudate with no odor. The facility determined the wound was improving and made no changes to the treatment. Review of the resident's January 2024 TAR revealed no documented evidence the physician ordered treatment to the resident's mid lumbar spine was provided as ordered on 01/22/24 on the day shift and on 01/25/24 on the day shift. Review of the resident's February 2024 TAR revealed no documented evidence the physician ordered treatment to the resident's mid lumbar spine was provided as ordered on 02/02/24 on the night shift. Review of the monthly physician orders for February 2024 identified orders (initiated 03/16/23) for barrier cream to peri-area and buttocks every shift, cushion to wheelchair, check and change frequently, encourage lotion to all dry areas, encourage to clip and file nails every shift, ammonium lactate lotion 12% to bilateral lower extremities every shift; on 07/10/23 house med pass supplement 240 milliliters (ml) three times a day; on 10/20/23 house liquid protein 30 ml twice daily for wound healing, encourage resident to float bilateral heels while in bed, skin evaluation weekly; on 01/17/24 cleanse wound to mid lumbar spine with Dakin's solution, pat dry, apply calcium alginate (cut to fit wound bed), and cover with foam dressing twice daily and as needed; on 01/18/24 cleanse right lateral foot with Dakin's solution soaked gauze, pat dry, apply calcium alginate (cut to fit wound bed), then cover with foam dressing daily and as needed; on 01/24/24 apply betadine to right first digit and leave open to air and on 01/25/24 apply foam to left posterior knee for protection every two days. Observation on 02/05/24 at 11:40 A.M. of the physician ordered treatment to mid lumbar spine by the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #268 revealed upon entry to the room the required supplies were set-up on a disposable barrier on the resident's bedside table. The staff washed their hands. The resident was then positioned on his left side and the LPN removed the soiled dressing to his back. The LPN then cleansed the wound with Dakin's soaked 4 X 4 and changed her gloves. The wound was quarter size with a pink wound bed. The wound also had slough present around the edges of the wound. The LPN then applied a 2 X 2 piece of calcium alginate without cutting to fit the wound bed and applied a foam dressing. Interview on 02/05/24 at 4:02 P.M. with the DON verified the wound to the mid lumbar spine was not accurately assessed, there was no timely notification to the physician of the identified pressure area or evidence comprehensive, effective and individualized interventions were implemented to prevent 365272 Page 6 of 11 365272 02/08/2024 Riverview 3710 Olentangy River Road Columbus, OH 43214

F 0686 the ulcer from deteriorating to an unstageable pressure ulcer on 11/01/23. Level of Harm - Actual harm Review of the facility policy titled, Skin Care Program, last revised 01/14/23 revealed a Stage II pressure ulcer was defined a partial thickness skin loss involving epidermis, dermis, or both. The ulcer was superficial and presents clinically as an abrasion, blister, or shallow crater. Upon admission the residents would have their skin assessed from head to toe by a professional nurse. Each area would be documented by the professional nurse on the illustrations of documentation and measurements of skin area form. This information would be entered as appropriate into the electronic medical record (EMR). Notify the physician for orders and notify the authorized representative of the skin condition and orders accordingly. Weekly a professional nurse needs to measure each skin issue and enter the resident's EMR. Update the residents' plan of care as needed. When a new skin issue was noted, the nurse would measure the area initially and then every seven days until healed. All information would be entered into the EMR. Notify the physician for orders and notify the authorized representative of the new skin condition and orders accordingly. Weekly measurements need to be entered into the resident's EMR. Update the plan of care as needed. Residents Affected - Few 2. Review of the medical record for Resident #67 revealed an initial admission date of 03/27/23 with the latest readmission of 01/20/24 with diagnoses including metabolic encephalopathy, pseudomonas, sepsis due to pseudomonas, acute and chronic respiratory failure, hydronephrosis, chronic obstructive pulmonary disease (COPD), paraplegia, neuromuscular dysfunction of bladder, paralytic syndromes, spinal stenosis of cervical region, hypertension, insomnia, benign prostatic hyperplasia, depression, chronic pain syndrome and neurogenic bowel. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. Review of the mood and behavior revealed the resident had not rejected any care. The assessment indicated the resident required substantial/maximal assistance for toileting, dressing, personal hygiene, and dependent for bathing. The resident required moderate assistance for bed mobility and was dependent with transfers. The assessment indicated the resident had an indwelling urinary catheter and was frequently incontinent of bowel. The assessment indicated the resident was at risk for pressure ulcers and had no unhealed pressure ulcers. However, the resident had moisture associated skin damage (MASD). The facility implemented the interventions pressure reducing device to bed/chair and applications of ointments/medications other than to feet. Review of the state optional MDS assessment dated [DATE] revealed the resident's cognition was not assessed. Review of the mood and behavior revealed the resident rejected no care. The resident required extensive assistance of two staff for bed mobility, transfers, eating and toilet use. The assessment indicated the resident had no unhealed pressure ulcers. Review of the readmission assessment dated [DATE] revealed the resident's bilateral buttocks/coccyx was reddened with dark red areas and superficial open areas. The resident also had a dark skin scab like area to the back of his heel. Review of the progress note dated 11/22/23 at 10:00 P.M., authored by Registered Nurse (RN) #338 revealed the resident was readmitted back to the facility with coccyx/buttocks reddened with dark red area scattered on buttocks and coccyx. Scabbed areas noted to bilateral shins and posterior left calf. Right heel with darkened red areas. The facility implemented the treatment of hydrogen peroxide and povidone iodine. The facility implemented the interventions of heel suspension/protection device, mattress with pump, moisture barrier, moisture control and turning and repositioning program. 365272 Page 7 of 11 365272 02/08/2024 Riverview 3710 Olentangy River Road Columbus, OH 43214

F 0686 Review of the medical record revealed no documented evidence the described areas to the coccyx/bilateral buttocks were assessed, physician notified, or a treatment put in place to prevent a decline of the areas. Level of Harm - Actual harm Residents Affected - Few Review of the skin and wound evaluation dated 11/24/23 revealed the resident had a Stage II pressure ulcer to his coccyx measuring 3.8 cm by 1.7 cm and was described as 100% epithelial tissue. The wound had no exudate. The facility implemented the following interventions, heel protectors, incontinence management, mattress with pump, moisture barrier, moisture control, repositioning devices and turning/repositioning program. The assessment indicated the resident was notified despite the resident having a severe cognitive impairment and a power of attorney (POA) on file. Review of the plan of care dated 11/29/23 revealed the resident was at risk for further alteration in skin integrity related to actual skin impairment, weakness, decreased mobility, multiple wounds present, COPD with head of bed elevated, use of Bi-pap and oxygen, overall decline in condition, anemia, functional quadriplegia, abnormal labs, variable by mouth intakes, bowel incontinence, use of indwelling urinary catheter, chronic sacral wound (suspected Kennedy ulcer) with status post debridement, pressure injuries to left heel times two, right heel, right lateral foot, right ankle, left lateral foot, arterial ulcers to right and left shin. Interventions included administer treatment per physician orders, air mattress to bed, barrier cream to peri area/buttocks as needed, coordinate wound care and treatments with wound care provider, diet and supplements per physician order, elevate heels as able, encourage and assist as needed to turn and reposition, use assistive devices as needed, encourage fluids, float heels while in bed, observe skin condition with activities of daily living (ADL) care daily and report abnormalities, obtain labs as ordered and report results to physician, podiatric care as needed, pressure redistributing device bed/chair, provide preventative skin care routinely and as needed and use pillows/position devices as needed. Review of the weekly skin and wound evaluation dated 12/01/23 revealed the Stage II pressure ulcer to the resident's coccyx had no measurements and the wound was described as 90% epithelial tissue and 10% granulation tissue. The wound had a light amount to serous exudate, the surrounding skin was dry and flaky. The treatment remained to cleanse with normal saline (NS), apply calcium alginate and cover with a foam dressing. The facility determined the wound was stable. Review of the weekly skin and wound evaluation dated 12/06/23 revealed the Stage II pressure ulcer to the resident's coccyx measured 5.0 cm by 1.0 cm and described as 80% epithelial tissue and 20% granulation tissue. The wound had no exudate. The facility determined the wound had improved. Review of the weekly skin and wound evaluation dated 12/13/23 revealed the Certified Nurse Practitioner (CNP) #345 classified the wound as moisture associated skin dermatitis (MASD) to the resident's coccyx measuring 11.6 cm by 7.6 cm and described as 20% epithelial tissue and 80% granulation tissue. The surrounding tissue was described as fragile and at risk for skin breakdown and macerated. The wound had no exudate. The facility determined the wound had improved. Review of the weekly skin and wound evaluation dated 12/20/23 revealed CNP #345 continued to classify the wound as MASD to the resident's coccyx measuring 8.4 cm by 4.1 cm and described as 20% epithelial tissue and 80% granulation tissue. The surrounding tissue was macerated. The wound had no exudate. The facility determined the wound was stable. Review of the weekly skin and wound evaluation dated 12/27/23 revealed the MASD was now unstageable measuring 8.4 cm by 4.1 cm. The wound was described as 80% granulation tissue and 20% slough. The 365272 Page 8 of 11 365272 02/08/2024 Riverview 3710 Olentangy River Road Columbus, OH 43214

F 0686 Level of Harm - Actual harm wound had a light amount of serosanguineous exudate. The surrounding tissue was fragile and at risk of skin breakdown. The assessment documented CNP #345 resolved the MASD to an unstageable area with redden, darken areas. The area was not resolved and to see new assessment labeled pressure, [NAME]-sacrum. The assessment indicated the resident's POA was notified of the decline in the wound. Residents Affected - Few Review of the weekly skin and wound evaluation dated 01/03/24 revealed CNP #345 classified the wound as a Kennedy terminal ulcer and measured 9.4 cm by 6.8 cm. The wound was described as 20% granulation tissue, 40% slough and 40% eschar. The wound had light serosanguineous exudate. The surrounding skin was fragile and at risk of breakdown. CNP #345 recommended hospice services at that time. Review of the weekly skin and wound evaluation dated 01/10/24 revealed the Kennedy terminal ulcer measured 12.4 cm by 11.6 cm. The wound was 90% eschar with serosanguineous odorous exudate. The facility determined the wound had deteriorated. Review of the medical record revealed the resident was discharged from the facility to an acute care hospital from [DATE] to 01/20/24 where he was treated for an infection to the ulcer which was assessed to be a Kennedy terminal ulcer. Review of the admission/re-admission evaluation dated 01/20/24 revealed the resident was readmitted to the facility with a pressure wound to the coccyx, pressure wounds to bilateral heels and left and right shin wounds. The assessment failed to indicate the staging of the pressure wounds, measurements, and description of the wounds. The wound was described as 40% granulation and 60% slough. The wound had bone exposed and had a moderate amount of serosanguineous odorous exudate. Review of the medical record revealed the first comprehensive assessment of the wound to the coccyx was on 01/24/24. The Kennedy terminal ulcer was classified as unstageable and measured 19.1 cm by 16.2 cm by 1.0 cm with undermining. The assessment failed to indicate where the undermining was located within the wound. The facility implemented the treatment to cleanse with Dakin's solution, pat dry, apply Santyl to wound bed and cover with Dakin's moisten gauze and foam dressing every shift and as needed. Review of the weekly skin & wound assessment dated [DATE] revealed the Kennedy terminal ulcer was now classified as a Stage IV (full thickness tissue loss with exposed bone,tendon,or muscle)pressure ulcer measuring 14.6 cm by 10.0 cm by 1.0 cm. The wound was described as 60% granulation tissue, 20% slough, and 20% eschar with serosanguineous exudate. The facility determined the wound had deteriorated. Review of the resident's monthly physician orders for February 2024 identified orders (initiated on 11/23/23) for a regular mechanical soft diet, resident is to be fed for meals, house liquid protein 30 ml by mouth twice daily, weekly skin evaluation; on 12/30/23 barrier cream to buttocks every shift and as needed; on 01/24/24 cleanse sacrum wound with Dakin's solution, pat dry, apply Santyl to wound bed and cover with Dakin's moistened gauze and cover with foam dressing every shift and as needed; and on 01/26/24 house nutritional juice drink twice daily for additional calories, Review of the resident's progress notes revealed the resident was admitted to the local acute care hospital on [DATE] for confusion. Interview on 02/05/24 at 1:26 P.M. with the DON revealed the resident had MASD that was resolved in October 2023. The DON revealed the MASD weekly skin and wound assessment was supposed to be closed 365272 Page 9 of 11 365272 02/08/2024 Riverview 3710 Olentangy River Road Columbus, OH 43214

F 0686 Level of Harm - Actual harm as resolved in October 2023 but was not. She revealed CNP #345 documented the assessment on the MASD instead of the Stage II assessment. She revealed the MASD was closed, and the assessments were combined. The DON verified the lack of a comprehensive assessment of the wounds detailed on the 11/22/23 and 01/20/24 admission/re-admission evaluation. Residents Affected - Few Review of the facility policy titled, Skin Care Program, last revised 01/14/23 revealed a Stage II pressure ulcer was defined a partial thickness skin loss involving epidermis, dermis, or both. The ulcer was superficial and presents clinically as an abrasion, blister, or shallow crater. Upon admission the residents would have their skin assessed from head to toe by a professional nurse. Each area would be documented by the professional nurse on the illustrations of documentation and measurements of skin area form. This information would be entered as appropriate into the electronic medical record (EMR). Notify the physician for orders and notify the authorized representative of the skin condition and orders accordingly. Weekly a professional nurse needs to measure each skin issue and enter the resident's EMR. Update the residents' plan of care as needed. When a new skin issue was noted, the nurse would measure the area initially and then every seven days until healed. All information would be entered into the EMR. Notify the physician for orders and notify the authorized representative of the new skin condition and orders accordingly. Weekly measurements need to be entered into the resident's EMR. Update the plan of care as needed. 3. Review of the medical record for Resident #9 revealed an initial admission date of 08/23/23 with diagnoses including pressure ulcer to the left heel, convulsions, asthma, chronic kidney disease, hypothyroidism, disorder of thyroid, dementia, obesity, diabetes mellitus, hypertension, and depression. Review of the baseline admission evaluation dated 08/23/23 revealed the resident was admitted with deep tissue injury (DTI) (purple or maroon localized area of discolored intact skin or blood filled blister) to right outer ankle and left heel. The assessment contained no description of the wound. The assessment also indicated the resident had a sore on the left and right buttocks. Review of the plan of care dated 08/24/23 revealed the resident had potential/actual impairment of skin integrity of the left leg and knee related to pressure of left heel, history of left femur fracture and incontinence of bowel and bladder. Interventions included pressure relieving/reducing mattress, complete Braden scale per facility protocol, encourage good nutrition and hydration in order to promote healthier skin, encourage resident to not scratch and keep hands and body parts from excessive moisture, keep fingernails short, encourage resident to turn and reposition regularly, encourage skin to be clean and dry, use lotion to dry skin, encourage to float heels from bed, encourage to use a draw sheet for lifting device to move resident, monitor/document location size and treatment of skin injury, report abnormalities, obtain blood work as ordered by physician, weekly treatment documentation to include measurement of each area of skin breakdown, width, length, depth, type of tissue, exudate and any other notable changes of observations. Review of the weekly skin & wound assessment dated [DATE] revealed the resident had a deep tissue injury to her left heel measuring 2.1 cm by 0.7 cm and was purple in color. The facility implemented the treatment of cleanse with normal saline and paint with betadine and cover with a foam dressing. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had an unhealed unstageable pressure ulcer present on admission. The facility implemented pressure reducing device for 365272 Page 10 of 11 365272 02/08/2024 Riverview 3710 Olentangy River Road Columbus, OH 43214

F 0686 bed, nutrition, or hydration intervention to manage skin problems, pressure ulcer/injury care and application of dressing to feet. Level of Harm - Actual harm Residents Affected - Few Review of the state optional MDS assessment dated [DATE] revealed the resident had a moderate cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. The assessment indicated the resident was at risk for skin breakdown and had an unhealed unstageable pressure ulcer. The facility implemented pressure reducing device for bed, nutrition, or hydration intervention to manage skin problems, pressure ulcer/injury care and application of dressing to feet. Review of the most recent weekly skin and wound assessment dated [DATE] revealed the resident's wound was a Stage III (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle is not exposed, slough may be present) pressure ulcer measuring 1.5 cm by 1.1 cm by 0.2 cm. The wound was described as 70% granulation and 30% slough and had a light amount of serosanguineous drainage. The treatment implemented was cleanse with normal saline, apply calcium alginate, Medi honey and cover with a foam dressing. The facility determined the wound had improved. Review of the resident's monthly physician orders for February 2024 identified orders (initiated on 09/22/23) for house nutritional drink six ounces daily, house med pass supplement 237 milliliters (ml); on 10/05/23 skin evaluation weekly; on 01/03/24 cleanse left heel with NS, pat dry, apply Medi honey to wound bed, cover with calcium alginate, cut to fit wound bed and secure with bordered foam dressing daily and as needed; and on 01/17/24 apply barrier cream to left and right buttocks after each incontinence episodes. Interview on 02/05/24 at 4:02 P.M. with the DON verified Resident #9's left heel wounds were not comprehensively assessed on admission to the facility. Review of the facility policy titled, Skin Care Program, last revised 01/14/23 revealed a Stage II pressure ulcer was defined a partial thickness skin loss involving epidermis, dermis, or both. The ulcer was superficial and presents clinically as an abrasion, blister, or shallow crater. Upon admission the residents would have their skin assessed from head to toe by a professional nurse. Each area would be documented by the professional nurse on the illustrations of documentation and measurements of skin area form. T 365272 Page 11 of 11