Health inspection·March 27, 2025

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** 2. Review of the medical record revealed Resident #108 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic pain, metabolic encephalopathy, peripheral vascular disease, adult failure to thrive, dementia, dysphagia, insomnia, hypertensive heart disease, anxiety disorder, bullous pemphigoid, protein-calorie malnutrition, vitamin D deficiency, major depressive disorder, syncope and collapse, and hyperlipidemia. Residents Affected - Few Review of the March 2025 medication administration record revealed Resident #108 had an order for the nurse to use adhesive removal when changing the dressing to the sacrum every shift dated 01/27/25 and was signed off as completed twice daily. Review of the March 2025 physician orders revealed Resident #108 had an order to cleanse the sacral wound with Hibiclens, pat dry, apply iodoform, and cover with bordered foam dressings every shift and as needed dated 03/17/25 and a nurse to use adhesive removal when changing dressing to sacrum dated 01/27/25. Observation of wound care on 03/26/25 at 8:00 A.M. revealed LPN #280 provided wound care to Resident #108. LPN #280 started to remove the border foam from the sacrum of Resident #108 and the resident voiced expressions of pain numerous times while LPN #280 removed the treatment. On 03/26/25 at 12:30 P.M. an interview with the Director of Nursing (DON) stated she does not know why Resident #108 still had an order for adhesive remover because she thought it was discontinued. The DON stated at one time Resident #108 had a dressing that was irritating the skin around her sacrum so they got an order of adhesive remover so it would be easier on her. On 03/26/25 at 11:21 A.M. an interview with LPN #280 confirmed she did not use the adhesive remover prior to removing the border foam dressing from the sacrum of Resident #108. LPN #280 stated she did not know Resident #108 had an order for adhesive remover. Review of the undated facility policy titled, Skin Care and Wound Management Overview, revealed the facility strives to prevent resident skin impairment and to promote the healing of exiting wounds. The interdisciplinary team works with the resident and for family to identify and implement interventions to prevent and treat potential skin integrity issues. This deficiency represents non-compliance investigated under Complaint Number OH00162412. Based on observation, medical record review, resident and staff interview, review of shower sheets, and policy review, the facility failed to ensure pressure ulcer treatments were implemented as Page 1 of 6 365727 365727 03/27/2025 Pebble Creek Healthcare Center 670 Jarvis Rd Akron, OH 44319

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ordered and failed to ensure pressure ulcers were properly identified and addressed in a timely manner. This affected two (#9 and #108) of four residents reviewed for pressure ulcers. The facility census was 148. Findings included: 1. Review of Resident #9's medical record revealed an admission date of 01/25/24. Diagnoses included hepatic encephalopathy, type two diabetes mellitus, dysphagia, and congestive heart failure. Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had moderate cognitive impairment. Resident #9 was dependent for toileting hygiene, bathing, and lower body dressing. Resident #9 required partial to moderate assistance with personal hygiene. Resident #9 was always incontinent of urine and bowel. Resident #9 was at risk of developing a pressure ulcer but did not have a pressure ulcer or injury. Resident #9 did not reject care during the seven-day assessment look-back period. Review of Resident #9's Braden scale observation tool dated 03/11/25 revealed Resident #9 was at low risk for developing a pressure ulcer. Review of Resident #9's progress notes dated 02/05/25 at 1:40 A.M. revealed Resident #9 was transported to the local hospital. Review of Resident #9's progress notes dated 02/10/25 at 4:03 P.M. revealed Resident #9 was readmitted to the facility and had three pressure ulcers with treatments ordered. Resident #9 was placed on a low air loss mattress and Resident #9's son was notified. Review of Resident #9's wound assessment report dated 02/12/25 revealed Resident #9 had a stage two pressure ulcer (partial-thickness skin loss with exposed dermis) to the sacrum present on admission with measurements of 2.0 centimeters (cm) long by 1.0 cm wide by 0.2 cm deep. Treatment initiated to cleanse the wound with normal saline, apply Triad cream (a zinc oxide-based paste used for managing wounds), and a bordered foam dressing daily and as needed. Resident #9 had a stage one pressure ulcer (non-blanchable erythema of intact skin) to the mid-back on admission with measurements of 1.0 cm long by 1.5 cm wide with no measurable depth. Treatment was initiated to cleanse the wound with wound cleanser, apply skin prep and a bordered foam dressing three times a week and as needed. Resident #9 also had a stage one pressure ulcer to the right lateral ankle present on admission with measurements of 1.0 cm long by 1.0 cm wide with no measurable depth. Treatment was initiated to cleanse the wound with normal saline, apply skin prep and a bordered foam dressing three times per week and as needed. Review of Resident #9's wound assessment report dated 02/19/25 included Resident #9's right lateral ankle stage one pressure injury was resolved. Review of Resident #9's wound assessment report dated 02/26/25 included Resident #9's sacral stage two pressure ulcer was resolved. Review of Resident #9's wound assessment report dated 03/05/25 included Resident #9's stage one pressure ulcer to the mid-back was resolved. Review of Resident #9's progress notes and assessments dated 03/05/25 through 03/25/25 did not 365727 Page 2 of 6 365727 03/27/2025 Pebble Creek Healthcare Center 670 Jarvis Rd Akron, OH 44319

F 0686 reveal evidence Resident #9 had reddened or open areas on her back and coccyx. Level of Harm - Minimal harm or potential for actual harm Review of Resident #9's medication administration record and treatment administration record dated 03/05/25 through 03/26/25 did not reveal treatment orders were provided for Resident #9's back, buttocks, or coccyx areas. Residents Affected - Few Review of Resident #9's nurse aide assignment sheets dated 03/20/25, 03/21/25, and 03/25/25 revealed Certified Nurse Aide (CAN) #253 was assigned to care for Resident #9. Review of Resident #9's shower sheet revealed the documented month was March 2025, but the specific date was unable to be determined. Further review revealed there was an area of concern over Resident #9's right buttock. Review of Resident #9's shower sheet dated 03/20/25 and 03/22/25 revealed there was a mark placed over the drawing of a back on the shower sheet indicating there was an area of concern. Observation and interview during incontinence care on 03/26/25 at 8:30 A.M. with CNA #215 revealed Resident #9 had three areas of injury on the skin including one to her mid-back which was red, non-blanchable, and the size of a deck of cards; one to her coccyx which was reddened, open, approximately 0.1 cm deep, and the size of a dime; and the third area was over slightly to the right of the coccyx wound on the right buttock which was the size of a pencil eraser, and was reddened and non-blanchable. Further observation by the surveyor determined the areas identified were pressurerelated. CNA #215 verified the three areas of injury on the resident's skin at the time of the observation. Interview on 03/26/25 at 1:22 P.M. with Nurse Practitioner (NP) #412 revealed she evaluated Resident #9 today on 03/26/25 and Resident #9 had two areas of MASD on her coccyx. Interview on 03/26/25 at 12:00 P.M. with CNA #253 revealed Resident #9 had red areas on her back and coccyx for a while. CNA #253 stated she told the nurse a couple days ago about Resident #9's red areas on her back and coccyx, but she did not remember what day it was or which nurse she told. CNA #253 stated the areas were reddened and were not open the last time she cared for Resident #9. 365727 Page 3 of 6 365727 03/27/2025 Pebble Creek Healthcare Center 670 Jarvis Rd Akron, OH 44319

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure fall interventions were in place as care planned to prevent falls. This affected one (#111) of three residents reviewed for falls. The facility census was 148. Findings include: Review of Resident #111's medical record revealed an admission date of 06/02/23 and diagnoses included hemiplegia affecting the right dominant side, acute respiratory failure with hypoxia, and vascular dementia. Review of Resident #111's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 did not have a Brief Interview for Mental Status (BIMS) completed due to Resident #111 being rarely or never understood. Resident #111 was dependent for toileting hygiene, bathing, personal hygiene, and lower body dressing. Resident #111 required partial to moderate assistance for the ability to roll from lying on her back to the left and right side and return to lying on her back on the bed. Resident #111 was always incontinent of urine and bowel. Review of Resident #111's fall risk observation tool dated 11/02/24 revealed Resident #111 was at risk for falls. Review of Resident #111's care plan revised 04/22/24 included Resident #111 was at risk for falls related to diagnoses with a goal Resident #111 would not sustain a major injury related to falls through the review date. Interventions included Dycem (non-slip pad) to chair as ordered; move Resident #111 closer to the nurses station when available; and an intervention initiated 11/12/24 revealed to place Dycem between Resident #111 and the Hoyer (mechanical lift) pad. Review of Resident #111's progress notes dated 02/01/25 at 12:30 P.M. revealed the nurse heard Resident #111 start yelling, when she checked on her she was found in the common area on the floor in front of her chair. A head-to-toe assessment was completed and no injuries or pain was noted. Resident #111 was assisted back to her chair using a mechanical lift with the assistance of three staff. Neurological checks were started and an intervention was documented for extra Dycem in the resident's chair to prevent future falls. Review of Resident #111's fall risk observation tool dated 02/02/25 revealed Resident #111 was at risk for falls. Interview on 03/25/25 at 2:07 P.M. with Licensed Practical Nurse (LPN) #221 revealed when Resident #111 fell on [DATE] she was sitting in her padded tilt-in-space wheelchair and had recently been checked and changed for incontinence. LPN #221 stated she did not see the fall, she heard yelling, and ran to where the yelling was. LPN #221 stated Resident #111 slid out of her chair and she did not know how it happened. LPN #221 stated she saw Resident #111 about five minutes before she experienced the fall and she was fine. LPN #221 stated she could not remember the position of Resident #111's tilt-in-space wheelchair when she had the fall. There was no evidence she had a seizure, and sometimes Resident #111 moved around a bit in the chair. 365727 Page 4 of 6 365727 03/27/2025 Pebble Creek Healthcare Center 670 Jarvis Rd Akron, OH 44319

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 03/25/25 at 2:32 P.M. of Resident #111 with Unit Manager (UM) #230 revealed she was lying in bed with her eyes open. A fall mat was observed on the floor next to her bed and the bed was in the lowest position. Resident #111 told UM #230 she wanted to get out of bed. UM #230 instructed Certified Nurse Aide (CNA) #292 and CNA #293 to assist Resident #111 out of her bed into her padded tilt-in-space wheelchair. CNA #292 and CNA #293 assisted Resident #111 to her padded wheelchair using a mechanical lift. Observation on 03/25/25 at 4:40 P.M. of UM #230 and LPN #270 revealed they assisted Resident #111 to her bed using a mechanical lift to check her for incontinence. Observation revealed there was Dycem located on the wheelchair cushion, but there was no Dycem between Resident #111 and the mechanical lift pad. The Dycem that was supposed to be between Resident #111 and the mechanical lift pad was observed laying on Resident #111's bedside table. UM #230 and LPN #270 confirmed the Dycem was not placed between Resident #111 and the mechanical lift pad and should have been. Review of the undated facility policy titled, Fall Prevention and Management, revealed fall prevention and management was the process of identifying risk factors that could minimize the potential for falls and also a process to manage a resident's care if a fall occurred. If the resident was identified to be at risk for falls, a care plan should be initiated that included a plan to potentially diminish the risk for falls. The care plan should be reviewed and updated as needed with each change of condition. 365727 Page 5 of 6 365727 03/27/2025 Pebble Creek Healthcare Center 670 Jarvis Rd Akron, OH 44319

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure incontinence care was completed timely. This affected one (#15) of three residents reviewed for incontinence. The facility census was 148. Findings include: Review of Resident #15's medical record revealed an admission date of 11/15/24 and diagnoses included congestive heart failure, type two diabetes mellitus with diabetic peripheral angiopathy without gangrene, and chronic kidney disease. Review of Resident #15's care plan revised 03/18/25 revealed Resident #15 had impaired skin integrity or was at risk for altered skin integrity. Resident #15 would have improved or maintain current skin status through the next review date. Interventions included to provide peri-care as needed to avoid skin breakdown due to incontinence. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact. Resident #15 was dependent for toileting hygiene and lower body dressing. Resident #15 was dependent for the ability to transfer to and from a bed to a chair or wheelchair. Resident #15 was always incontinent of urine and frequently incontinent of bowel. Observation and interview on 03/24/25 at 2:48 P.M. of Certified Nurse Aide (CNA) #289 and CNA #417 revealed they transferred Resident #15 back to her bed. Resident #15 stated she was put in her chair around 10:00 A.M. and she was unable to be put back to bed until now because there is no care during meals and you might as well forget it if you need something. Resident #15 stated she had to wait until the lunch meal was finished. Observation of Resident #15's incontinence care revealed her left and right buttocks had large red areas on them. Resident #15's left buttock was more reddened than her right buttock. Resident #15 stated she had a huge bowel movement that morning that was not diarrhea, and it took at least two hours for her to be changed because it happened during the breakfast meal. CNA #289 confirmed Resident #15 had reddened areas on the right and left buttocks. CNA #289 stated she was not working at the time of the lunch meal and just came to work. CNA #417 confirmed residents often had to wait for care during meal times because the staff was passing out meal trays and feeding residents. Review of the undated facility policy titled, Perineal Care Male or Female, revealed the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. It was the policy of the facility to provide resident care that met the psychosocial, physical, emotional needs and concerns of the the residents. Providing personal care services promoted a sense of well-being and met hygiene standards of care. Perineal care was performed on residents who were unable or unwilling to maintain body cleanliness and, or who were incontinent of bowel and bladder. 365727 Page 6 of 6