Health inspection·February 27, 2023

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to obtain authorization and a third-party witness to manage their finances for Residents #30 and #41. This affected two residents (#30 and #41) of five reviewed for funds. The facility census was 47. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 03/16/21 with diagnoses including heart failure, hypothyroidism, and Alzheimer's disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was severely cognitively impaired. He had a power of attorney for finances. Review of Resident #30's financial records revealed no authorization for resident funds or witness to such authorization available for review. 2. Review of the medical record for Resident #41 revealed an admission date of 06/05/21 with diagnoses including dementia, post-traumatic stress disorder (PTSD), depression, and anxiety. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #41 had moderate cognitive impairment. He had a power of attorney for finances. Review of Resident #41's financial records revealed no authorization for resident funds or witness to such authorization available for review. Interview on 02/27/23 at 1:47 P.M. with the Administrator confirmed no authorization for resident funds or witness to such authorizations were available for Resident's #30 and #41. Review of the facility policy titled Resident Funds, dated January 2017, revealed the facility would not manage resident funds without authorization from the resident, and the authorization would be witnessed by a person not affiliated with the facility in any way. Page 1 of 13 365460 365460 02/27/2023 Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the facility self-reported incident (SRI), and facility policy review the facility failed to follow their policy for abuse when they did not thoroughly investigate an incident of staff to resident verbal abuse for Resident #26. This affected one resident (#26) of three residents reviewed for abuse and had the potential to affect all 47 residents in the facility. Residents Affected - Few Findings include: Review of the medical record for Resident #26 revealed an admission date of 12/12/22 with diagnoses including diabetes, anxiety, hypertension, and hyperlipidemia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 was cognitively intact. He required supervision of one staff for bed mobility, hygiene, eating, dressing, and toilet use and was independent in transfers. He had no behavioral concerns. Review of the facility SRI tracking number 231391 dated 01/24/23 revealed Resident #26 reported State Tested Nurse Aide (STNA) #479 looked at him with a mean look, told him to leave, asked why he was still at the facility, and would not give him things he asked for. Interview on 02/23/23 at 8:09 A.M. with the Administrator confirmed the investigation revealed other employees reported STNA #479 used rough talk with residents, had a rough tone of voice, and was stern. Her employment was terminated as a result of the investigation for not following the employee Code of Conduct. The Administrator further confirmed the SRI was complete but did not contain all the information necessary for the investigation to be considered thorough. She confirmed non-interviewable residents were not assessed and all staff working at the time of the incident were not interviewed. Review of the facility policy for Resident Abuse Prevention Practices, dated October 2022, revealed the facility would thoroughly investigate all allegations of abuse. 365460 Page 2 of 13 365460 02/27/2023 Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the facility self-reported incident (SRI), and facility policy review the facility failed to thoroughly investigate on incident of staff to resident verbal abuse for Resident #26. This affected one resident (#26) of three residents reviewed for abuse and had the potential to affect all 47 residents in the facility. Residents Affected - Few Findings include: Review of the medical record for Resident #26 revealed an admission date of 12/12/22 with diagnoses including diabetes, anxiety, hypertension, and hyperlipidemia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 was cognitively intact. He required supervision of one staff for bed mobility, hygiene, eating, dressing, and toilet use and was independent for transfers. He had no behavioral concerns. Review of the facility SRI tracking number 231391 dated 01/24/23 revealed Resident #26 reported State Tested Nurse Aide (STNA) #479 looked at him with a mean look, told him to leave, asked why he was still at the facility, and would not give him things he asks for. Interview on 02/23/23 at 8:09 A.M. with the Administrator confirmed the investigation revealed other employees reported STNA #479 used rough talk with residents, had a rough tone of voice, and was stern. Her employment was terminated as a result of the investigation for not following the employee Code of Conduct. The Administrator further confirmed the SRI was complete but did not contain all the information necessary for the investigation to be considered thorough. She confirmed non-interviewable residents were not assessed and all staff working at the time of the incident were not interviewed. Review of the facility policy for Resident Abuse Prevention Practices, dated October 2022, revealed the facility would thoroughly investigate all allegations of abuse. 365460 Page 3 of 13 365460 02/27/2023 Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure residual of a residents continuous tube feeding was checked prior to administering medications. This affected one resident (#34) of two residents observed for tube feeding medication administration. The facility identified six residents (#13, #21, #32, #34, #35, and #356) with a feeding tube. The facility census was 47. Findings include: Review of Resident #34's medical record revealed an admission date of 07/27/22 with diagnoses including stroke, dysphagia (difficulty swallowing), and altered mental status. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had impaired cognition and required extensive assistance with toileting and personal hygiene. Resident #34 was dependent on staff for eating as he received nothing by mouth (NPO) and had a feeding tube. Review of the care plan dated 01/18/23 revealed Resident #34 was NPO and required a feeding tube (tube inserted through the abdomen into the stomach) for nutrition and medication administration. Interventions included check for tube placement and residual volume and prior to use. Review of the physician orders for February 2023 revealed to check tube feeding placement before initiation of formula and medication administration. There were no orders related to a feeding tube dressing or checking for residual. Observation of medication administration for Resident #34 on 02/23/23 at 8:05 A.M. with Licensed Practical Nurse (LPN) #415 revealed the resident had a feeding tube. Observation revealed LPN #415 prepared the residents medications by crushing them to administer via his feeding tube. LPN #415 did check for placement but did not check for residual prior to administering the resident's medications. Interview with LPN #415 revealed she should have checked residual prior to administering the medications. Further observation revealed Resident #34 had a gauze dressing around the feeding tube insertion site that was dated 02/21/23 and was soiled with what appeared to be the tube feed substance. Interview with LPN #415 at time of observation confirmed the soiled dressing and stated the dressing should have been changed when soiled. Review of the facility policy titled Medications trough N/G (nasogastric, feeding tube inserted through the nose into the stomach) or G-Tube (gastrostomy tube, feeding tube inserted through the abdomen into the stomach), Administration Of, revised 06/2017, stated once medications are ready for administration, the nurse will stop the feeding, disconnect the feeding administration tubing and check for placement, then flush briskly with 30 cubic centimeters (cc) of warm water. If the resident has an order to check the residual stomach contents: insert feeding syringe into the feeding tube and aspirate the stomach contents gently. Follow any established physician orders for administration of the feeding. If there are no specific physician orders: • For 50 cc's or less of residual, return aspirate to the stomach and administer the feeding as prescribed. 365460 Page 4 of 13 365460 02/27/2023 Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504

F 0693 • Level of Harm - Minimal harm or potential for actual harm For 50-100 cc's of residual, return aspirate to the stomach, subtract the amount from the feeding to be administered. Residents Affected - Few • For 100 cc's or more, return the aspirate to the stomach, hold the feeding, and notify the physician. 365460 Page 5 of 13 365460 02/27/2023 Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure pain assessments were documented prior to and after narcotic pain medications were administered. This affected three residents (#16, #47 and #353) of three residents reviewed for narcotics. The facility census was 47. Residents Affected - Few Findings include: 1. Review of Resident #16's medical records revealed an admission date of 06/20/15 with diagnoses including quadriplegia, chronic pain syndrome, contractures, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had intact cognition and required extensive assistance with bed mobility, toileting, and personal hygiene. Review of the care plan dated 02/08/23 revealed Resident #16 was at risk for acute and chronic pain related to medical conditions. Interventions included administer medications as ordered and assess pain type and intensity using a scale of 1-10 before and after intervention and evaluate the effectiveness of pain interventions. Review of the physician orders for February 2023 revealed Resident #16 had an order for Oxycodone (narcotic pain medication) 10 milligrams (mg) every four hours as needed. Review of the narcotic sign out sheets for January and February 2023 revealed Oxycodone had been signed out on the narcotic sheets on 01/27/23 at 5:30 P.M., 01/29/23 at 5:00 P.M., 01/31/23 at 11:35 A.M., 02/03/23 at 12:00 A.M., 02/03/23 at 11:00 A.M., 02/04/23 at 8:00 A.M., 02/04/23 at 2:00 P.M., 02/05/23 at 12:00 P.M., 02/11/23 at 12:00 P.M., 02/11/23 at 5:30 P.M., 02/12/23 at 12:00 P.M., 02/12/23 at 5:30 P.M., 02/14/23 at 11:00 A.M., 02/18/23 at 12:20 A.M., 02/18/23 at 5:00 A.M., 02/18/23 at 11:35 P.M., 02/19/23 at 10:00 A.M. and 02/19/23 at 8:00 P.M. Review of the Medication Administration Record (MAR) revealed the medication had not been signed off as administered and no pain assessment of evaluation for effectiveness was documented. Interview on 02/21/23 at 12:34 P.M. with Resident #16 revealed she could not recall if she had received all of her doses of pain medication. 2. Review of Resident #47's medical records revealed an admission date of 09/21/22 with diagnoses including cervical cancer and chronic pain. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #47 had intact cognition, was independent for ambulation and required supervision with toileting and personal hygiene. Review of the care plan dated 12/26/22 revealed Resident #47 was at risk for chronic and acute pain related to cancer diagnosis. Interventions included administer medications as ordered, evaluate the effectiveness of pain interventions, record and monitor pain characteristics using scale of 1-10. Review of the physician orders for February 2023 revealed Resident #47 had an order for Oxycodone 20 mg every four hours as needed for pain. Review of the narcotic sign out sheets from January and February 2023 revealed Oxycodone had been 365460 Page 6 of 13 365460 02/27/2023 Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504

F 0697 Level of Harm - Minimal harm or potential for actual harm signed out on the narcotic sheets on 02/05/23 at 5:00 P.M., 02/06/23 at 9:00 A.M., 02/06 23 at 6:42 P.M., 02/08/23 at 6:20 P.M. 02/10/23 at 1:50 P.M., 02/12/23 at 9:00 A.M., 02/13/23 at 9:00 A.M., 02/15/23 at 7:30 P.M., 02/17/23 at 1:50 P.M., 02/18/23 at 9:00 A.M., 02/19/23 at 9:00 A.M., 02/20/23 at 9:00 A.M. and 02/22/23 at 6:45 P.M. Review of the MAR revealed the medication had not been signed off as administered and no pain assessment of evaluation for effectiveness was documented. Residents Affected - Few 3. Review of Resident #353's medical record revealed an admission date of 02/16/23 with diagnoses including spinal fusion and chronic pain syndrome. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #354 had intact cognition. The resident's functional assessment was in progress. Review of the care plan dated 02/16/23 revealed no care plan related to pain. Review of the physician orders for February 2023 revealed Resident #353 had an order for Oxycodone 15 mg every four hours as needed and Methadone (narcotic pain medication) 10 mg every eight hours as needed. Review of narcotic sign out sheets for February 2023 revealed Oxycodone was signed out on 02/19/23 at 1:00 P.M., 02/19/23 at 7:30 P.M., 02/20/23 at 2:00 P.M., and 02/22/23 at 4:10 A.M. Review of the MAR revealed the medication had not been signed off as administered and no pain assessment of evaluation for effectiveness was documented. Review of the MAR for February 2023 revealed Oxycodone had been signed off as administered on 02/17/23 at 4:17 A.M., 02/17/23 at 1:52 P.M., 02/22/23 at 3:24 P.M. and 02/22/23 at 7:46 P.M. Further review revealed no documented evidence on the narcotic sign out sheet of the medication having been signed out. Review of the narcotic sign out sheet for February 2023 revealed Methadone was signed out on 02/18/23 at 4:30 A.M. and 02/20/23 at 2:00 P.M. Review of the MAR revealed the medication had not been signed off as administered and no pain assessment of evaluation for effectiveness was documented. Interview on 02/23/23 at 9:53 A.M. the Director of Nursing (DON) stated a pain assessment as well as follow up for effectiveness of pain medications were to be documented in the MAR before and after a pain medication was administered. Review of the facility policy titled Medication Administration, revised 05/22, revealed medications were to be charted in the MAR. This deficiency represents non-compliance investigated under Complaint Number OH00136547. 365460 Page 7 of 13 365460 02/27/2023 Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interview, the facility failed to have a Registered Nurse (RN) working in the facility for eight consecutive hours each day of the week. This had to potential to affect all 47 residents in the facility. Findings include: Review of the schedule for 01/22/23 through 02/26/23 revealed the facility did not have an RN working for eight consecutive hours on 01/22/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23, 02/11/23/ 02/12/23, 02/18/23, 02/19/23, 02/25/23 and 02/26/23. Interview on 02/22/23 at 6:52 A.M. with Licensed Practical Nurse (LPN) #409 revealed she had no knowledge of any RN's working for the facility except for the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #456. Interview on 02/23/23 at 8:09 A.M. with the Administrator confirmed no RN worked eight consecutive hours on the dates listed above. 365460 Page 8 of 13 365460 02/27/2023 Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure narcotic pain medications were properly documented and accounted for. This affected three residents (#16, #47 and #353) of three residents reviewed for narcotics. The facility census was 47. Findings include: 1. Review of Resident #16's medical records revealed an admission date of 06/20/15 with diagnoses including quadriplegia, chronic pain syndrome, contractures, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had intact cognition and required extensive assistance with bed mobility, toileting, and personal hygiene. Review of physician orders for February 2023 revealed Resident #16 had an order for Oxycodone (narcotic pain medication) 10 milligrams (mg) every four hours as needed. Review of narcotic sign out sheets for January and February 2023 revealed Oxycodone was signed out on 01/27/23 at 5:30 P.M., 01/29/23 at 5:00 P.M., 01/31/23 at 11:35 A.M., 02/03/23 at 12:00 A.M., 02/03/23 at 11:00 A.M., 02/04/23 at 8:00 A.M., 02/04/23 at 2:00 P.M., 02/05/23 at 12:00 P.M., 02/11/23 at 12:00 P.M., 02/11/23 at 5:30 P.M., 02/12/23 at 12:00 P.M., 02/12/23 at 5:30 P.M., 02/14/23 at 11:00 A.M., 02/18/23 at 12:20 A.M., 02/18/23 at 5:00 A.M., 02/18/23 at 11:35 P.M., 02/19/23 at 10:00 A.M. and 02/19/23 at 8:00 P.M. Review of the Medication Administration Record (MAR) revealed the Oxycodone was not signed off as administered. Interview on 02/21/23 at 12:34 P.M. with Resident #16 revealed she could not recall if she had received all of her doses of pain medication. 2. Review of Resident #47's medical records revealed an admission date of 09/21/22 with diagnoses including cervical cancer and chronic pain. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #47 had intact cognition, was independent for ambulation, and required supervision with toileting and personal hygiene. Review of the physician orders for February 2023 revealed Resident #47 had an order for Oxycodone 20 mg every four hours as needed for pain. Review of the narcotic sign out sheets from January and February 2023 revealed Oxycodone was signed out on 02/05/23 at 5:00 P.M., 02/06/23 at 9:00 A.M., 02/06/23 at 6:42 P.M., 02/08/23 at 6:20 P.M. 02/10/23 at 1:50 P.M., 02/12/23 at 9:00 A.M., 02/13/23 at 9:00 A.M., 02/15/23 at 7:30 P.M., 02/17/23 at 1:50 P.M., 02/18/23 at 9:00 A.M., 02/19/23 at 9:00 A.M., 02/20/23 at 9:00 A.M. and 02/22/23 at 6:45 P.M. Review of the MAR revealed the medication was not signed off as administered. 3. Review of Resident #353's medical records revealed an admission date of 02/16/23 with diagnoses including spinal fusion and chronic pain syndrome. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #353 had intact cognition. Resident 365460 Page 9 of 13 365460 02/27/2023 Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504

F 0755 #353's functional assessment was in progress. Level of Harm - Minimal harm or potential for actual harm Review of the physician orders for February 2023 revealed Resident #353 had an order for Oxycodone 15 mg every four hours as needed and Methadone (narcotic pain medication) 10 mg every eight hours as needed. Residents Affected - Few Review of the narcotic sign out sheets for February 2023 revealed Oxycodone was signed out on 02/19/23 at 1:00 P.M., 02/19/23 at 7:30 P.M., 02/20/23 at 2:00 P.M., and 02/22/23 at 4:10 A.M. Review of the MAR revealed the Oxycodone was not signed off as administered. Review of the MAR for February 2023 revealed Oxycodone was signed off as administered on 02/17/23 at 4:17 A.M., 02/17/23 at 1:52 P.M., 02/22/23 at 3:24 P.M. and 02/22/23 at 7:46 P.M. Further review revealed no documentation on the narcotic sign out sheet of the medication having been signed out. Review of the narcotic sign out sheet for February 2023 revealed Methadone was signed out on 02/18/23 at 4:30 A.M. and 02/20/23 at 2:00 P.M. Review of the MAR revealed the Methadone was not signed off as administered. Observation of medication administration on 02/22/23 at 8:12 A.M. with Licensed Practical Nurse (LPN) #465 revealed Resident #353 requested pain medication. LPN #465 informed the resident she would look at her orders and see what she was able to have. LPN #465 checked the orders and informed the resident she was able to receive her ordered Oxycodone, and the resident was agreeable. LPN #465 proceeded to obtain the medication from the narcotic drawer, and there was one Oxycodone left in the medication card. LPN #465 removed the medication, and she removed the used medication card. LPN #465 proceeded to document the removal of the medication card on the narcotic sign out sheet. LPN #465 stated the narcotic card count was off by one. LPN #465 stated the narcotic card count sheet stated there were a total of ten medication cards; however, only there were only nine medication cards in the narcotic drawer. LPN #465 was unable to state why the count was off and stated she would inform the Director of Nursing (DON). LPN #465 proceeded to document administering Resident #353's Oxycodone and stated the medication was signed out in the narcotic sign out sheet on 02/22/23 at 4:10 A.M.; however, the MAR stated the medication last administered on 02/21/23 at 4:32 P.M. LPN #465 stated narcotics were to be signed out on the narcotic sign out sheet as well signed off as administered on the MAR. Interview on 02/22/23 at 2:48 P.M. with the DON revealed she was informed of the narcotic discrepancy by LPN #465 and stated she investigate into the situation. The DON denied being aware of concerns related to narcotic discrepancy previously. Interview on 02/23/23 at 9:53 A.M. the DON stated she investigated the situation regarding the narcotic discrepancy. At 10:56 A.M. the DON returned with narcotic sign out sheets; however, she was unable to specify why the narcotic card count was not accurate. Review of the narcotic sign out sheets with the DON at time of interview revealed on 11/01/22 the narcotic count was identified as having six cards; however, the correct number should have been seven. The DON stated a nurse made an error and that had caused the count to be off by one. The DON stated the error should have been caught sooner; however, the nurses who had performed the daily narcotic count did not identify the error. Interview with the DON further revealed the narcotic medications were to be signed out on the narcotic sign out sheets as well as in the MAR. Review of the facility policy titled Controlled Drug Count, dated 11/16, revealed two nurses were 365460 Page 10 of 13 365460 02/27/2023 Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to complete a physical inventory of controlled substances at change of each shift, ensure proper record keeping, no more than one prescription for a controlled drug was to be entered on an individual controlled drug sheet and if the count was not accurate, the off going nurse was to remain on duty until the count could be reconciled and all discrepancies were to be reported to the DON immediately. Review of the facility policy titled Medication Administration, revised 05/22, revealed medications were to be charted in the MAR. This deficiency represents non-compliance investigated under Complaint Number OH00136547. 365460 Page 11 of 13 365460 02/27/2023 Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504

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** 2. Review of Resident #34's medical records revealed an admission date of 07/27/22 with diagnoses including stroke, dysphasia (difficulty swallowing), and altered mental status. Residents Affected - Few Review of the MDS 3.0 assessment dated [DATE] revealed Resident #34 had impaired cognition and required extensive assist with toileting and personal hygiene. Review of the physician orders for February 2023 revealed Resident #34 was ordered Omeprazole (medication used to treat heartburn) 40 milligrams (mg) to be administered via the residents feeding tube. Observation of medication administration on 02/23/23 at 8:05 A.M. with Licensed Practical Nurse (LPN) # 415 for Resident #34 revealed LPN #465 had obtained the residents Omeprazole capsule. LPN #465 proceeded to break open the capsule with an ungloved hand and had poured the contents of the capsule into a medication cup. Interview with LPN #415 at time of observation confirmed she should have been wearing gloves prior to opening the capsule. Based on observation, record review, and interview the facility failed to follow infection control policies and procedures for wound care and medication administration. This affected one resident (#5) of one resident reviewed for wound care and one resident (#34) of one resident reviewed for medication administration. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #5 was initially admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis, type II diabetes mellitus with diabetic neuropathy, hypothyroidism, pleural effusion, acute kidney failure, hyperkalemia, and stage IV pressure ulcer (full-thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed) as of 09/30/22 with wound infection. Review of the five-day Minimum Data Set (MDS) 3.0 assessment of 01/31/23 revealed Resident #5 was cognitively impaired with periods of confusion, was totally dependent on two staff for activities of daily living, was always incontinent of bowel and bladder, and had developed a Stage IV pressure ulcer after admission to hospital on [DATE]. Review of the care plan of 01/18/23 revealed a care area for actual impairment to skin integrity related to pressure area to the sacrum. The care plan also noted Resident #5 was at increased risk for further impairment to skin integrity related to impaired cognition, diabetes, incontinence, impaired mobility, and generalized weakness. Interventions included wound care to evaluate and treat as needed, assessing, recording, and monitoring wound healing, turning, air mattress, pressure reducing cushion to wheelchair, monitoring diet as ordered and intake, and repositioning frequently with rounds and as needed. Review of Resident #5's progress notes for wound care from 09/30/22 through 02/26/23 revealed a wound to the sacrum was discovered on admission after hospital stay on 09/30/22. Review of Resident #5's physician's orders dated February 2023 revealed orders for turn an 365460 Page 12 of 13 365460 02/27/2023 Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few repositioning every two hours and as needed using pillows to offload buttocks, barrier cream to bilateral buttocks after each incontinence episode, weekly skin checks every Tuesday on night shift, cleanse sacral wound with normal saline, pat dry, apply nickel thick layer of Santyl (ointment that removes dead tissue from wounds to aide in healing) to the wound bed, apply Dakin's solution (antiseptic) to dampen sterile gauze, lightly pack wound, and cover with a foam dressing twice a day and as needed due to drainage or incontinence. Observations on 02/27/23 at 9:00 A.M. and 11:30 A.M. revealed Resident #5 was repositioned after two hours, air mattress was in place, resident was lying her left side by using pillows to offload buttocks. Pressure reducing cushion to wheelchair was observed to be in place. Observation on 02/27/23 at 12:00 P.M. of Resident #5's right sacral area revealed a stage IV pressure ulcer. The wound bed was pink in color in the center and was red around the edges. There was a moderate amount of bluish-green drainage on the old dressing. Registered Nurse (RN) #456 stated Resident #5's wound deteriorated after an admission to the hospital with return to the facility on [DATE]. RN #456 gathered wound care supplies and brought them into the resident's room where a floor nurse was checking Resident #5's blood pressure, and there was a break in infection control when RN #456 placed all dressing supplies on tray table without disinfecting surface. There was a glass of water and medication cup that the floor nurse had placed on tray table and other items belonging to Resident #5. RN #456 then placed a protective barrier on the tray table again without disinfecting the tray table and did not put any of the dressing supplies on the barrier. RN #456 proceeded with wound care, repositioned the resident for comfort during wound care, removed the old dressing, completed hand hygiene, cleansed the wound with normal saline, applied Santyl to 0.125 percent Daskins solution-soaked gauze, and covered with foam dressing. Resident was then repositioned again for comfort with pillows for offloading. Interview on 02/27/23 at 12:30 P.M. with Resident #5 revealed she stated wound care was completed as ordered multiple times a day due to drainage or incontinence. 365460 Page 13 of 13