Health inspection·February 15, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and facility policy review, the facility did not keep an accurate record of skin wound assessments in the medical record for one (Resident #101) out of three residents with skin wounds. The facility census was 87. Findings include: Review of the medical record for Resident #101, revealed an admission date of 01/18/24. Diagnoses included metabolic encephalopathy, bacteremia, vascular dementia, and type 2 diabetes. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 4 out of 15 which indicates severe cognitive impairment. The resident was determined to not have a pressure ulcer but at risk for developing them. Review of the nursing admission assessment dated [DATE] for Resident #101 revealed no skin alterations for his left and right buttock and his groin area. Review of the skin observation dated 01/21/24 for Resident #101 revealed skin was intact with no new areas opened. Review of Resident #101's assessment for skin grid pressure dated 01/22/24 revealed a reddened area to the right buttock with scant amount of blood measuring 8 centimeters (cm) by 11 cm by .01 cm. Review of twice a day skilled nurse notes for day shift for Resident #101 dated 01/22/24 revealed skin assessment as: other open lesion. Review of the progress note for Resident #101 dated 01/23/24 revealed a clarification was added by the Director of Nursing (DON) stating the area was moisture associated skin damage (MASD) noted to the middle right inner buttocks to anus measuring 3 cm by 3 cm by 0.1 cm. Review of twice a day skilled nurse notes for day shift for Resident #101 dated 01/23/24 revealed skin assessment as other open lesion. Review of Resident #101's assessment of skin grid non-pressure dated 01/23/24 revealed the MASD area noted to be found on 01/22/24 and was the left buttock measuring 3 cm by 3 cm by 0.1 cm and was described as MASD to buttocks and groin area opened and measured about right buttocks, surrounding area blanches, and had scar tissue visible and wound status as improved. Page 1 of 3 365644 365644 02/15/2024 Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the weekly skin observation dated 01/23/24 for Resident #101 revealed skin was not intact, previous area identified, dressing dry and intact and no new areas noted with MASD to right buttock and groin with no measurements. Review of twice a day skilled nurse notes for night shift for Resident #101 dated 01/23/24 and 01/26/24 revealed skin was within normal limits. Review of twice a day skilled nurse notes for Resident #101 revealed the dates for: 01/27/24 day and night shift and 01/28/24 day shift skin assessment as other: open lesions. Review of twice a day skilled nurse notes for Resident #101 revealed the date of 01/30/24 as the skin assessment being within normal limits. Review of Resident #101's assessment of weekly skin grid non-pressure dated 01/30/24 revealed the MASD area noted to be found on 01/22/24 and was the left buttock measuring 2 cm by 1 cm by 0.1 cm and was described as MASD to buttocks and groin area opened and measured about right buttocks, surrounding area blanches and also has scar tissue visible and wound status as improved. Review of Resident #101's assessment of weekly skin grid non-pressure dated 01/31/24 revealed the MASD area noted to be found on 01/22/24 and was the left buttock measuring 2 cm by 1 cm by 0.1 cm and was described as MASD to buttocks and groin area opened and measured about right buttocks, surrounding area blanches and also has scar tissue visible and wound status as improved. Review of twice a day skilled nurse notes for Resident #101 dated 01/31/23 day shift, 02/01/24 day shift, 02/05/24 night shift, and 02/06/24 day shift documented skin assessment as other: open lesion. Review of twice a day skilled nurse notes for Residents #101 dated 02/02/24 and 02/03/24 for day shifts revealed skin assessment with: other concerns, see narrative note below with no notes. Review of Resident #101's assessment of weekly skin grid non-pressure dated 02/07/24 revealed the MASD are noted to be found on 01/22/24 and was the left buttock measuring 6.5 cm x 2.5 cm x 0.1 cm and was described as MASD to the left buttock, surrounding area blanches and also has scare tissue visible. Moisture around surrounding skin and wound status has improved. Review of weekly skin observation dated 02/07/24 for Resident #101 revealed skin was not intact and the left buttock was a sore wound. Review of the twice a day skilled nurses notes for Resident #101 dated 02/07/24 day shift revealed skin assessment was within normal limits. Interview on 02/13/24 at 11:43 A.M. with the Regional Nurse revealed when nurses are charting on skilled documentation's it should reflect their current skin status and verified since admission, Resident #101's twice a day skilled nurses notes have not reflected his actual skin assessments during his stay. Verified the resident also has never had a pressure ulcer to the right buttock, but a left MASD skin issue, despite the documentation on the weekly skin-grids documenting buttocks and groin. Interview on 02/14/23 at 1:00 P.M. with the Regional Nurse revealed for Resident #101's skin documentation's throughout his entire stay are not consistent and accurate and immediate education with be 365644 Page 2 of 3 365644 02/15/2024 Embassy of Winchester 36 Lehman Dr Canal Winchester, OH 43110

F 0842 started for the issues and are not following facility policy. Level of Harm - Minimal harm or potential for actual harm Observation on 02/14/24 at 10:23 A.M. for Resident #101 revealed the residents skin issue is to the left buttock only with clean dressing applied per Assistant Director of Nursing (ADON) #888. Residents Affected - Few Review of the facility policy titled Charting and Documentation revised July 2017 revealed documentation in the medical record will be objective (not opinionated, or speculative), complete, and accurate. This deficiency represents non-compliance investigated under Master Complaint Number OH00150749. 365644 Page 3 of 3