Inspection·October 16, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews and review of facility policy, the facility failed to ensure interventions and treatment orders were in place for a resident admitted to the facility with a stage three pressure ulcer to the coccyx. This resulted in the Actual Harm when Resident #10's stage three pressure ulcer, present upon admission, did not receive timely treatment and there was deterioration of the pressure ulcer to a stage four (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer. Additionally, the facility also failed to ensure skin assessments were completed as ordered for Resident #14 who was at risk for pressure ulcer development and who developed an unavoidable pressure ulcer, this placed the resident at potential risk for more than minimal harm for Resident #14. This affected two (#10 and #14) of four residents reviewed for skin breakdown. The facility census was 113. Residents Affected - Few Findings included: 1. Review of medical record for Resident #10 revealed an admission date of 09/28/23. Diagnoses include right tibia fracture, diabetes mellitus type two, colostomy, reflux, depression, anxiety and alcohol induced pancreatitis. Review of Resident #10's care plan revealed the resident had a pressure ulcer to the sacrum. The care plan was initiated on 09/28/23 with interventions which included to assess/monitor/record wound healing frequency; measure length, width and depth when possible; assess the wound perimeter, wound bed and healing process; report improvements and declines to the physician; and encourage frequent repositioning and encouragement to turn side to side in bed when tolerated. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10's Brief Interview for Mental Status (BIMS) score was 15 out 15 indicating intact cognition. Resident #10 was independent with eating, dependent for toileting, and transfers were not attempted. Resident #10 had an indwelling catheter and ostomy present. Resident #10 had a stage three pressure ulcer present upon admission. Review of the admission assessment/orders for Resident #10 revealed the resident had a documented stage three (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) pressure ulcer. On 09/27/23, the area measured 4.0 centimeters (cm) by (x) 3.5 cm x 0.5 cm. Wound surface area was 14 cm. The admission wound care order was to apply Vashe (wound cleanser) moistened gauze and border foam dressing to change daily and as needed. Review of Resident #10's physician orders revealed there were no admission orders entered for the treatment of a stage three pressure ulcer. Review of the admission skin assessment dated [DATE] revealed an open wound was documented to the coccyx. There was no identification, or measurements of the wound. Review of the progress notes for Resident #10 revealed no documentation the physician was contacted for treatment orders for an open wound to the coccyx. Review of Resident #10's September 2023 Treatment Administration Record (TAR) revealed there was no documentation or treatment for coccyx wound care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 2 of 4 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 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)

F 0686 Level of Harm - Actual harm Review of Resident #10's skin assessment dated [DATE] revealed documentation of a coccyx wound was described as an unstageable pressure wound. Peri wound noted with intact edges, moderate serosanguinous drainage noted with foul smelling odor, wound bed red and moist. The physician was notified, and a new treatment order was obtained. Residents Affected - Few Review of Resident #10's physician orders dated 10/02/23 revealed an order to cleans the coccyx with wound cleanser, pack with calcium alginate (wound), then cover with xeroform then apply foam dressing twice daily and as needed. Review of Resident #10's October 2023 TAR revealed there was no documentation for coccyx wound care until 10/02/23 on the night shift. Review of Resident #10's wound physician notes dated 10/03/23 documented coccyx wound to be a stage four (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer. Measurements were 5.0 cm x 4 cm x 0.5 cm. Wound surface area was 20.0 cm. with 30 percent (%) slough (nonviable tissue). Observation of Resident #10's coccyx dressing change with Licensed Practical Nurse (LPN) #42 on 10/11/23 at 12:33 P.M. revealed wound care was completed as ordered and per standards of care. Resident #10's old dressing was removed from the coccyx which revealed drainage was minimal with no signs of infection, no odor present. Resident #10's coccyx wound base appeared beefy red, and wound perimeters were intact without concern for infection. Resident #10 denied pain when asked. The area was described as a healing stage four pressure ulcer. Interview on 10/16/23 at 1:44 P.M. with the Director of Nursing (DON) revealed Resident #10's admitting nurse was a Licensed Practical Nurse (LPN) who cannot stage a wound. The DON acknowledged Assistant Director of Nursing (ADON) #09 and weekend nurse managers were each Registered Nurses. The DON verified measurements were not taken of the coccyx wound upon admission and the wound treatment admission orders were not initiated as ordered and caused a delay in the treatment of a stage three pressure injury. The DON confirmed Resident #10's coccyx pressure ulcer deteriorated from a stage three to a stage four. 2. Review of medical record for Resident #14 revealed an admission date of 08/04/23 and admitted to hospice on 09/01/23. Diagnoses include vertebrogenic low back pain, second lumbar and sacrum fracture, anxiety, delusions, anemia and scoliosis. Resident #14 was receiving hospice services. Review of the significant change MDS assessment dated [DATE] revealed Resident #14 had a BIMS score of five out of 15 which indicated significant cognitive impairment. Resident #14 required extensive two-person assistance for bed mobility, transfers, toileting and one person assistance for eating. Resident #14 had no pressure ulcers documented. Review of Resident #14's skin assessment dated [DATE] revealed the resident's skin was intact. There was no further skin assessment until 09/12/23. Review of Resident #14's September 2023 TAR revealed an order to complete a head-to-toe assessment and note any current and new area under skin observation assessment. The start date was 08/05/23; however, there was no documentation of completion of a skin assessment until 09/20/23. Review of Resident #14's Wound Physician note dated 09/12/23 revealed documentation of a pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 3 of 4 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 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)

F 0686 ulcer to the coccyx. The area measured 1.7 cm x 1.9 x 0.1 cm. Treatment was collagen sheet daily cover with gauze island with foam border. Level of Harm - Actual harm Residents Affected - Few Review of the September 2023 TAR revealed an order to wash coccyx area and pat dry, cover with collagen and cover with gauze island with border dressing daily with a start date of 09/17/23. Review of Resident #14's Wound Physician note dated 09/19/23 revealed documentation of a pressure ulcer to the coccyx. The area measured 2.0 cm x 1.5 x 0.1 cm. Improved as evidenced by a 7.1 % decrease in surface size. No change in treatment. Interview on 10/16/23 at 1:44 P.M. with the DON verified skin assessments had not been done weekly or as ordered for Resident #14. The DON confirmed Resident #14 was at risk for pressure ulcer development and weekly skin assessments should have been done/documented for the resident. The DON shared a new position for a treatment nurse had recently been filled and an admission nurse position had recently been approved and was hopeful this would allow the floor nurses to have more time to ensure assessments were provided as ordered. Review of the facility policy titled Pressure Ulcer/Skin Breakdown last revised 04/2018 revealed the nurse shall describe and document a full assessment of pressure sore including location, stage, length, width, depth and presence of exudate of necrotic tissue. This deficiency represents non-compliance investigated under Complaint Number OH00147182. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 4 of 4