Health inspection·September 7, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 interview, and policy review, the facility failed to ensure pressure ulcer prevention interventions were implemented for residents with known pressure ulcers as per their physician's orders and plan of care. This affected two residents (#3 and #52) of three residents reviewed for pressure ulcers. Residents Affected - Few Findings include: 1. A review of Resident #3's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia with behavioral disturbances, low back pain, obesity, restlessness and agitation, and muscle weakness. A review of Resident #3's quarterly Minimum Data Set (MDS) completed on 08/16/23 revealed the resident had unclear speech and rarely/ never made herself understood. She was sometimes able to understand others. She had short and long term memory impairment. Her cognitive skills for daily decision making was severely impaired. She did not display any behaviors during the seven day assessment period, nor was she known to reject care. She required an extensive assist of two for bed mobility. Transfers occurred only once during that assessment period and ambulation did not occur. She was identified as being at risk for pressure ulcers, but was not identified as having any unhealed pressure ulcers at that time. A review of Resident #3's care plans revealed she had a care plan in place for being at risk for skin breakdown related to impaired mobility, impaired cognition, incontinence, and friction/ shearing concerns. The care plan was initiated on 10/28/21. The interventions included encouraging/ assisting the resident to float heels as tolerated. Her care plans also included a care plan for having a pressure ulcer to her right heel that was a deep tissue injury (DTI), which is defined as purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/ or shear. That care plan was initiated on 08/28/23. The interventions included continuing with preventative care plan measures to prevent further skin breakdown. A review of Resident #3's physician's orders revealed she had an order in place for the use of pressure relief boots to her bilateral feet. That physician's order was initiated on 08/23/23. A review of Resident #3's wound assessments revealed she developed a facility acquired DTI to her right heel that originated on 08/22/23. The area measured 4.5 centimeters (cm) x 5 cm. The area was purple/ maroon in color. The pressure ulcer was assessed weekly and remained when it was last assessed on 09/04/23. The wound measured 6 cm x 4.5 cm that last time it was measured. Page 1 of 3 365481 365481 09/07/2023 Altercare Newark North Inc. 151 Price Road Newark, OH 43055

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/05/23 at 2:02 P.M., an observation of Resident #3 noted her to be lying in bed slightly over on her left side with a pillow behind her back. She had an air mattress on the bed and her bilateral heels were noted to be in direct contact with the mattress. She was not wearing pressure relief boots to her bilateral feet and her heels were not floated to offload pressure as per her physician's orders and plan of care. On 09/05/23 at 2:15 P.M., the Director of Nursing was asked to assist in assessing Resident #3's right heel. She confirmed the resident did not have pressure relief boots to her bilateral feet as ordered by the physician. She also confirmed the resident's heels were not being floated and were in direct contact with the mattress. She verified the pillow that was in place under her upper calves/ knee area was not effective in alleviating any pressure off her heels. She removed the resident's right sock and took a dressing off that was covering her right heel. A small amount of bloody drainage was noted on the old gauze pad that was secured with Kerlix wrap. She stated the dressing was in place to provide additional padding. The right heel did have a dark purplish-maroon colored DTI to it with a small open area where the drainage was coming from. A review of the facility's policy on Pressure Injuries: Assessment, Prevention, and Treatment undated revealed it was the policy of the facility to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries, and provide care for existing pressure injuries. The interventions included floating heels (keep heels off the bed) and to implement preventative measures as indicated. They were also to provide treatments per the physician's orders. 2. A review of Resident #52's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a history of a stroke, muscle weakness, abnormal posture, aphasia, multiple contractures, and morbid obesity. A review of Resident #52's quarterly MDS assessment dated [DATE] revealed the resident had no speech and was rarely/ never able to make herself understood. She was sometimes able to understand others. She had short and long term memory impairment and her cognitive skills for daily decision making was severely impaired. She was totally dependent on two for bed mobility, transfers, and toilet use. She was at risk for pressure ulcers and was indicated to have had two unhealed stage III pressure ulcers that were not present upon her admission. A review of Resident #52's care plans revealed she had a care plan in place for being at risk for skin breakdown related to impaired mobility, impaired cognition, and incontinence. The care plan was initiated on 06/24/21. Her interventions included encouraging/ assisting the resident with floating her heels as tolerated. That intervention had been in place since 06/24/21. Her care plans were updated to include a care plan for an existing pressure ulcer to her left ischium. The interventions included to continue with preventative care plan measures to prevent further skin breakdown. That care plan was initiated on 06/07/23. On 09/05/23 at 2:07 P.M., an observation of Resident #52 noted her to be lying in bed in a supine position with the head of bed up. Her bed had a regular pressure reduction mattress on it that was not an air mattress. Her heels were not noted to be offloaded as per her plan of care and in direct contact with the mattress. On 09/05/23 at 2:35 P.M., an interview with LPN #100 revealed Resident #52 had a pressure ulcer on her buttocks. She was asked what they were doing to help prevent additional pressure ulcers from 365481 Page 2 of 3 365481 09/07/2023 Altercare Newark North Inc. 151 Price Road Newark, OH 43055

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few developing. She stated the resident's heels were to be floated off the mattress with use of a pillow. She verified the resident did not have a pillow under her feet to raise her heels off the bed. She found the pillow on top of the resident's nightstand. She indicated the wound doctor was in that day and likely removed it. She stated the facility's Assistant Director of Nursing (ADON) accompanied the wound doctor during his rounds. She indicated the ADON should have replaced the resident's pillow under her feet, after they were done looking at her, to prevent pressure on her heels. She obtained the pillow and placed it under the resident's feet to alleviate pressure off her heels. On 09/05/23 at 2:40 P.M., an interview with State Tested Nursing Assistant #125 revealed she was not aware of Resident #52 having any skin issues. She was asked what they were doing to prevent the resident from developing pressure ulcers. She stated they were turning the resident side to side, checked and changed her every hour, and had a pillow under her feet. She confirmed the wound doctor was in earlier that day and checked the resident's skin. She suspected he must have removed the pillow that was in place when checking the resident's skin and did not put it back in place. She verified the facility's ADON did rounds with him and it was around 1:00 P.M. to 1:30 P.M. when that occurred. She agreed the ADON should have put the pillow back in place under the resident's heels (after they checked the resident), as it was one of her skin prevention interventions. This deficiency represents non-compliance investigated under Complaint Number OH00145717. 365481 Page 3 of 3