Health inspection·June 20, 2023

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 record review, observation, staff interview, review of the facility policy, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin and failed to timely identify the resident's pressure ulcers until it reached an advanced stage. This resulted in Actual Harm to Residents #03 and #65 who were at risk for pressure ulcers and the facility found Resident #03's pressure ulcer as an unstageable pressure ulcer (Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) and Resident #65's pressure ulcer as a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed). This affected two (#03 and #65) of three residents reviewed for pressure ulcers. The facility census was 64. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #03 revealed an admission date of 11/05/19. Diagnoses included malignant neoplasm of female breast, atherosclerotic heart disease, Alzheimer's disease, and cardiomegaly. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #03 was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs.) Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #03 was at moderate risk for the development of pressure ulcers. Review of the care plan last updated 04/13/23 revealed Resident #03 was at risk for impaired skin integrity related to impaired mobility, generalized weakness, peripheral vascular disease (PVD) and diabetes mellitus (DM), and incontinence of bowel and bladder. Interventions included the following: complete a pressure ulcer risk assessment per facility policy, complete weekly skin inspection, keep pressure off of heels, provide pressure relieving boots or float heels while resident is in bed, observe skin under braces, prosthetics, splints, cast for breakdown, provide pressure reducing wheelchair cushion, provide pressure reduction/relieving mattress, provide thorough skin care after incontinent episodes and apply barrier cream, skin assessment to be completed per facility policy toileting plan, treatments as ordered, turning and repositioning schedule per assessment, and weekly wound assessment. Review of the weekly skin checks for Resident #03 dated 05/24/23 and 05/31/23 revealed there were no new skin issues noted. Page 1 of 5 365277 365277 06/20/2023 Bradford Place Care Center 1302 Millville Avenue Hamilton, OH 45013

F 0686 Level of Harm - Actual harm Residents Affected - Few Review of the nurse progress note for Resident #03 dated 06/05/23 revealed the hospice nurse notified the staff that the resident had a new open area to her sacrum. Hospice nurse said she would order a low air loss mattress for the resident. Review of the initial wound assessment for Resident #03 dated 06/06/23 per the wound Nurse Practitioner (NP) revealed Resident #03 had a facility acquired unstageable pressure ulcer (Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) to her sacrum. The ulcer measured 2.2 centimeters (cm) in length by 1.0 cm in width by 0.2 cm in depth. There was a small amount of serous drainage from the wound and adherent slough tissue was observed to the wound bed. Review of the wound assessment for Resident #03 dated 06/13/23 per wound NP revealed the unstageable pressure ulcer to the resident's sacrum was slightly larger and measured 2.1 cm in length by 1.5 cm in width by 0.3 cm in depth. There was a small amount of serous drainage from the wound with no granulation tissue in the wound bed and a large amount of necrotic tissue in the wound bed including adherent slough. Review of the June 2023 monthly physician orders for Resident #3 revealed an order dated 06/06/23 to cleanse the wound with normal saline, apply Medihoney to the wound bed, and cover with a dry dressing twice daily and as needed. Observation of wound care for Resident #03 on 06/16/23 at 10:45 A.M. per Licensed Practical Nurse (LPN) #235 revealed Resident#03 had a dime sized pressure ulcer to her sacrum. The wound bed was covered with yellow slough and there was a moderate amount of serosanguinous drainage from the wound. Interview on 06/16/23 with LPN #235 confirmed Resident #3 had developed an unstageable pressure ulcer to her sacrum which was first identified on 06/05/23 by the hospice nurse. Interview on 06/16/23 at 2:30 P.M. with the Director of Nursing (DON) confirmed residents' skin was to be thoroughly inspected by a licensed nurse once weekly and documented in the resident's medical record. DON confirmed Resident #3 developed a facility acquired unstageable pressure ulcer which was identified by the hospice nurse on 06/05/23. The DON confirmed the pressure ulcer for Resident #03 was not identified until the wound had reached an advanced stage. 2. Closed record review for Resident #65 revealed an admission date of 12/12/22 with diagnoses including Fournier gangrene, benign prostatic hypertrophy (BPH), obstructive uropathy, chronic obstructive pulmonary disease (COPD), colostomy, anxiety disorder, and acquired absence of left leg below knee. Resident #65 discharged from the facility on 03/31/23. Review of the care plan dated 12/20/22 revealed Resident #65 was at risk for the development of pressure ulcers due to Braden scale score lower than 18 and a diagnosis of diabetes mellitus (DM.) Interventions included the following: complete Braden scale (standardized pressure ulcer risk assessment tool) per facility policy, do not massage over bony prominences, observe diabetic foot, podiatry consult as needed, provide pressure relieving wheelchair cushion, provide pressure relieving mattress, and skin assessment to be completed per facility policy. Review of the Minimum Data Set (MDS) assessment for Resident #65 dated 03/21/23 revealed Resident #65 was cognitively impaired and required limited assistance with ADLs. Resident was coded as positive for the presence of a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may 365277 Page 2 of 5 365277 06/20/2023 Bradford Place Care Center 1302 Millville Avenue Hamilton, OH 45013

F 0686 be visible but bone, tendon or muscle is not exposed) which was not present upon admission. Level of Harm - Actual harm Review of the weekly skin checks for Resident #65 dated 03/21/23 revealed there were no new skin issues noted. There was no skin breakdown identified on Resident #65's coccyx. Residents Affected - Few Review of the wound physician visit note for Resident #65 dated 03/21/23 at 2:30 P.M. revealed the physician identified a new stage III pressure ulcer to the resident's coccyx which measured 1.5 centimeter (cm) in length by 0.4 cm in width by 0.1 cm in depth. The physician provided sharp debridement of the devitalized tissue to the wound which included slough tissue and noted the drainage from the wound had a foul odor. Review of the wound physician visit note for Resident #65 dated 03/28/23 revealed the stage III pressure ulcer coccyx measured 0.7 cm in length by 0.2 cm in width by 0.1 in depth. The physician provided sharp debridement of the devitalized tissue to the wound which included slough tissue. Interview on 06/16/23 at 4:47 P.M. with the Director of Nursing (DON) confirmed Resident #65 was at an outpatient appointment with the wound physician on 03/21/23. The DON confirmed the wound physician identified a stage III pressure ulcer to the resident's coccyx which required sharp debridement. The DON confirmed the pressure ulcer to Resident #65's coccyx was not identified until it reached an advanced stage. Review of the facility policy titled Skin and Wound Care Management Program, dated 02/01/20, revealed the facility would prevent the development of pressure ulcers and a licensed nurse would perform a head-to-toe skin check of the resident and would document the findings. Review of the NPUAP guidelines dated 2014 revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents non-compliance investigated under Complaint Number OH00143206. 365277 Page 3 of 5 365277 06/20/2023 Bradford Place Care Center 1302 Millville Avenue Hamilton, OH 45013

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interviews, and review of the facility policy, the facility failed to ensure wound care was performed in a clean and sanitary manner. This affected one (Resident #3) of three residents reviewed for pressure ulcers. The facility census was 64. Residents Affected - Few Findings include: Review of the medical record for Resident #3 revealed an admission date of admitted [DATE] with diagnoses including malignant neoplasm of female breast, atherosclerotic heart disease, and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs.) Review of the weekly wound assessment for Resident #3 dated 06/13/23 revealed the unstageable pressure ulcer (Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) to the resident's sacrum was slightly larger from the previous week and measured 2.1 centimeter (cm) in length by 1.5 cm in width by 0.3 cm in depth. There was a small amount of serous drainage from the wound with no granulation tissue in the wound bed and a large amount of necrotic tissue in the wound bed including adherent slough. Review of the physician orders for Resident #3 revealed an order dated 06/06/23 to cleanse the wound with normal saline, apply Medihoney to the wound bed, and cover with a dry dressing twice daily and as needed. Observation of wound care for Resident #3 on 06/16/23 at 10:45 A.M. by Licensed Practical Nurse (LPN) #235 revealed Resident #3 had a dime sized pressure ulcer to her sacrum. The wound bed was covered with yellow slough and there was a moderate amount of serosanguineous drainage from the wound. LPN #235 washed her hands, donned gloves, and removed and discarded the soiled dressing from the resident's sacrum. LPN #235 then donned a new pair of gloves without washing or sanitizing her hands first. LPN #235 then cleansed the wound with gauze soaked with normal saline and doffed gloves. LPN #235 donned a new pair of gloves without washing or sanitizing her hands first, and applied Medihoney to the wound bed. LPN #235 doffed the gloves and donned a new pair of gloves without washing or sanitizing her hands first and applied a dry dressing to cover the wound. Interview on 06/16/23 at 11:05 A.M. with LPN #235 confirmed she changed gloves during wound care for Resident #235 three times: after removing the soiled dressing, after cleansing the wound which had a moderate amount of drainage, and after applying Medihoney directly to the wound bed. LPN #235 confirmed she did not wash or sanitize her hands after removing the contaminated gloves and prior to donning new gloves. Interview on 06/16/23 at 4:47 P.M. with the Director of Nursing (DON) confirmed in order to provide proper wound care and reduce the risk of wound infection, nurses should wash or sanitize their hands after removing contaminated gloves and prior to donning new gloves. Review of the facility policy titled Dry Clean Dressing Change, dated September 2013, revealed the nurse should remove gloves, wash hands, and don clean gloves after removing the dressing, after cleaning the wound, and after applying the ordered treatment. 365277 Page 4 of 5 365277 06/20/2023 Bradford Place Care Center 1302 Millville Avenue Hamilton, OH 45013

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Handwashing/Hand Hygiene, dated August 2019, revealed the facility considered hand hygiene the primary means to prevent the spread of infections. Staff should wash or sanitize their hands after handling used dressings, after contact with blood or body fluids, and after removing gloves. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00143206. 365277 Page 5 of 5