Health inspection·June 29, 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, interview and observation, the facility failed to ensure pressure sore dressing changes were done according to physician orders. This affected one resident (Resident #6) out of three residents reviewed for pressure sores. The total census was 47. Residents Affected - Few Findings include: Record review of Resident #6 revealed she was admitted [DATE] and had diagnoses including Parkinson's Disease, major depressive disorder, unspecified psychosis, and diabetes. She had an order dated 06/14/23 for her left heel wound to be treated every Monday, Wednesday, and Friday with a saline cleanse, betadine, and foam dressing. The care was documented done as ordered, including on Monday, 06/26/23. Review of her most recent wound assessment on 06/21/23 revealed the wound was a blister acquired 05/17/23 which progressed to an unstageable wound which appeared to be healing and measured 0.5 by 0.5 centimeters with no drainage or odor. Interview with Resident #6 on 06/27/23 at 11:38 A.M. revealed her wound dressing was not changed regularly by staff. Observation of a wound care procedure for Resident #6 on 06/28/23 at 10:38 A.M. by Licensed Practical Nurse (LPN) #203 and Wound Physician #601 revealed the previous dressing on her left heel was dated 06/24/23 (a Saturday), and appeared to be a taped gauze dressing instead of the foam dressing ordered by the physician. The wound measured 0.3 by 0.7 centimeters and had no drainage or odor. Interview was conducted on 06/28/23 at 11:02 A.M. with LPN #203 who verified during the wound observation Resident #6 did not have the correct dressing in place according to physician orders, and the dressing had last been changed on 06/24/23 (a Saturday) which was not according to the physician orders for every Monday, Wednesday and Friday treatments. This deficiency represents noncompliance investigated under OH00143560. Page 1 of 2 365713 365713 06/29/2023 Embassy of Painesville 70 Normandy Dr Painesville, OH 44077

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on record review, observation and interview, the facility did not ensure cold food temperatures were being appropriately monitored to prevent risk of food born illness. This had the potential to affect all 47 residents receiving meals from the kitchen. Findings include: Review of the food committee minutes, dated 05/18/23, revealed a concern that cold foods were not always served cold. Observation on 06/27/23 at 8:06 A.M. revealed a tray full of cups of milk and orange juice was sitting at the 100 hall nursing station. The tray nor milk and orange juice cups were not on ice nor had any other obvious method of being kept cold. Aides took drinks from the tray and put them on meal trays as they entered resident rooms to serve breakfast. This was noted to still be ongoing as of 8:24 A.M. Interview with Nurse Aide #201 following the above observations confirmed drinks were pre-poured and served from an unrefrigerated tray. She said sometimes staff served it that way and sometimes they poured drinks for one resident at a time from pitchers kept in ice. Interview with Resident #17 on 06/27/23 at 2:52 P.M. revealed milk was sometimes not served cold. Interview with Resident #42 on 06/27/23 at 3:04 P.M. revealed cold drinks were often served lukewarm with meals. Interview with Dietary Manager (DM) #302 on 06/28/23 at 7:43 A.M. revealed the facility served drinks including milk by dispensing pitchers held in ice and sent to the units where they were then distributed by nursing aides. DM #302 said he did not have a food temperature thermometer capable of measuring below 50 degrees Fahrenheit (F) to ensure cold foods were kept at 41 degrees or below, as the thermometer he had did not go below 50 degrees F. DM #302 explained he began work at the facility two months ago and during that time did not have a thermometer capable of measuring lower than 50 degrees F, so cold food temperaturs were not being monitored. DM #302 said he had been meaning to order a thermometer that could measure cold food temperatures. This deficiency represents noncompliance investigated under OH00143459. 365713 Page 2 of 2