Inspection·June 18, 2024

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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to follow the physician's order for a resident's pressure ulcer treatment. This affected one (Resident #65) of three residents reviewed for pressure ulcers. The facility census was 106. Residents Affected - Few Findings include: Review of the medical record revealed Resident #65 was admitted on [DATE]. Diagnoses included surgical amputation, cognitive communication deficit, acquired absence of below the knee, type two diabetes mellitus, end stage renal disease, dependent on renal dialysis, and chronic pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively impaired. Resident #65 was dependent on staff for transfers, toileting, bathing, and personal hygiene. Review of the plan of care dated 05/28/24 revealed Resident #65 had pressure ulcer and had potential for pressure ulcer development related to immobility, incontinence, and disease process. Resident #65 was admitted on [DATE] with stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed.) to sacrum. Interventions included to administer medication as ordered, administer treatments as ordered, and follow policies and protocols for the preventions and treatment of skin breakdown. Review of the physician order dated 06/18/24 for Resident #65 revealed an order to cleanse sacrum with derma cleanse, apply triad paste, and leave open to air every shift. Observations on 06/24/24 from 12:07 P.M. through 12:25 P.M. revealed State Tested Nursing Aide (STNA) #239, and License Practical Nurse (LPN) #229 were assisting in incontinence care for Resident #65. Resident #65 had a dressing on his coccyx that was covered with feces. LPN #229 took off old dressing off and threw it away. STNA #239 had asked LPN #204 to come in Resident #65's room while receiving incontinence care. LPN #204 who was Resident #65's nurse for the day, had directed LPN #229 to perform the treatment on Resident #65's coccyx. LPN #204 directed LPN #229 to cleanse the coccyx area, then apply triad and leave open to air. LPN #204 handed STNA #239 the wound treatment supplies. STNA #239 then cleansed Resident #65 coccyx with wash cloth with soap and water. STNA #239 then patted dry the coccyx with a dry towel. LPN #229 took a dressing and applied triad on dressing and applied directly to Resident #65's coccyx. Interview on 06/24/24 at 12:45 P.M. with STNA #239 confirmed that she did wash Resident #65's coccyx with a washcloth and soap and water only. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365551 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clovernook Health Care and Rehabilitation Center 7025 Clovernook Avenue Cincinnati, OH 45231 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)