Health inspection·December 18, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, resident and staff interviews and policy review, the facility failed to ensure wound care was completed as ordered by the physician. This affected two (Residents #35 and #64) of three residents reviewed for wound care. The facility census was 67. Residents Affected - Few Findings include: 1. Review of Resident #35's medical record revealed an admission date of 11/09/23 with diagnoses that included cerebrovascular accident, diabetes mellitus and hypertension. Review of Resident #35's Minimum Data Set (MDS) 3.0 admission assessment with a reference date of 11/30/23 revealed Resident #35 had intact cognition Review of Resident #35's admission wound assessments revealed Resident #35 was admitted to the facility with bilateral stage two pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) to the bilateral heels. Review of Resident #35's physician's orders revealed on 12/01/23 wound care orders to clean the bilateral heels with wound cleanser, apply skin prep (protectant barrier), cover with an ABD (large gauze) pad and wrap with kerlix (gauze wrap) every day and as needed. Review of the Treatment Administration Record (TAR) revealed no evidence the wound care was completed as ordered by the physician on 12/02/23 and 12/12/23. The TAR indicated wound care was completed on 12/15/23, 12/16/23 and 12/17/23. Observation on 12/18/23 at 9:40 A.M. of Resident #35's bilateral heel bandages with Licensed Practical Nurse (LPN) #71 revealed bandages were in place to the bilateral heels. The left heel dressing was dated 12/14/23 and the right heel dressing was undated. Interview with LPN #71 at 9:40 A.M. revealed bilateral bandage changes are to be completed to Resident #35's heels every day. LPN #71 further verified the left heel bandage was dated 12/14/23, the right heel bandage was not dated. The LPN verified the left heel bandage had not been changed as ordered daily on 12/15/23, 12/16/23 and 12/17/23 and there was no date on the right heel dressing to indicate when the dressing had been changed. Interview with Resident #35 at 9:45 A.M. verified no wound care had been provided to his bilateral heels since 12/14/23. Interview with the Director of Nursing (DON) on 12/18/23 at 10:55 A.M. verified wound care for Resident #35 were documented as completed on 12/15/23, 12/16/23 and 12/17/23, but the observation of the Page 1 of 2 365674 365674 12/18/2023 Arbors at Minerva 400 Carolyn Court Minerva, OH 44657

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dressing revealed no wound care had been provided since 12/14/23. Further interview with the DON also verified there was no documented evidence of bilateral heel wound care was provided on 12/02/23 and 12/12/23. 2. Review of Resident #64's medical records revealed an admission date of 10/11/23 with admission diagnoses that included right femur fracture, chronic obstructive pulmonary disease and hypertension. Review of Resident #64's physician's orders revealed wound care orders on 12/06/23 for care of treatment of the right lateral malleolus and bilateral heels with wound cleanser, pat dry, apply skin prep, cover with ABD pad and wrap with kerlix every day and as needed. Review of Resident #64's wound assessments revealed Resident #64 was admitted to the facility with unstageable pressure wounds (known but unstageable due to coverage of wound bed by slough or eschar) to the bilateral heels and right lateral malleolus. Review of Resident #64's TAR revealed no evidence of wound care for the right lateral malleolus and bilateral heels completed as ordered by the physician on 12/15/23 and 12/16/23. Interview with the DON on 12/18/23 at 10:55 A.M. verified wound care was not documented as provided for Resident #64's bilateral heels and right lateral malleolus on 12/15/23 and 12/16/23. Review of the facility policy Wound Treatment Management with a revision date of 10/26/23 indicated wound treatments will be provided in accordance with physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00149087. 365674 Page 2 of 2