Health inspection·April 18, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, and review of the facility policy, the facility failed evaluate, provide care and treatment, and conduct ongoing assessments to treat a resident's skin alteration. This affected one (Resident #4) of two residents reviewed for skin care and treatment. The facility census was 69. Residents Affected - Few Findings include: Review of the medical record for Resident #4 revealed an admission date of 01/22/23. Diagnoses included congestive heart failure, chronic kidney disease, type II diabetes mellitus, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact, was independent with activities of daily living, was incontinent of urine, and had no skin breakdown with no skin alterations. However, Resident #4 was at risk for skin breakdown and received the application of nonsurgical dressing. Review of the care plan dated 03/31/24 revealed Resident #4 was at risk for skin alterations due to disease process, immobility, incontinence, diabetes, heart failure and kidney failure. There was a second care plan, dated 03/31/24, for actual skin alteration to the right lower extremity due to an open blister from cellulitis. The goal for Resident #4 was to show sign of healing without complication. Interventions included to administer medications and treatments as ordered, assess, record, and monitor wound healing, obtaining measurements to include length, width, depth, the status of the wound perimeter, wound bed and healing process, monitor dressing daily to ensure intact and adhering, change as needed and enhanced barrier precautions. Review of the weekly wound care care notes from 02/27/24 to 04/01/24 revealed the resident's right lower extremity had cellulitis with an open area to the right shin, with rolled edges, with a moderate amount of serosanguineous drainage. The measurements on 04/01/24 were seven centimeters (cm) long by three cm wide by 0.1 deep. Review of the weekly skin assessments from 03/04/24 to 04/15/24 revealed Resident #4 had an open area to the right upper outer shin. The assessment on 04/15/24 revealed no signs or symptoms of infection, measurements were 2.0 cm long by 1.0 cm wide by 0.2 cm deep. Review of the current physician orders revealed an order dated 03/02/24 for weekly skin assessments every day shift on Mondays for monitoring and an order on 04/01/24 to cleanse the right lower extremity with wound cleanser, pat dry, apply border gauze, and cover with ace wrap every day and as needed. Page 1 of 2 365737 365737 04/18/2024 Heatherdowns Rehab & Residential Care Center 2401 Cass Rd Toledo, OH 43614

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few There was no mention of skin issues on Resident #4's left leg in the medical record including the weekly wound care notes, weekly skin assessments, physician orders, or progress notes. Observation on 04/18/24 at 8:00 A.M. of Resident #4 revealed there was redness and swelling to both of the lower extremities. The right lower leg had an intact clean and dry gauze wrap in place, dated 04/17/24 and a nonskid sock. The left leg, had an irregular shaped scab to the front of the shin, approximately two cm in length by one cm in width. Interview on 04/18/24 at 8:00 A.M. with Resident #4 revealed the scabbed area to the left lower leg had been present for a while. Resident #4 denied any no treatments being completed to the area. Resident #4 stated no one has looked or inquired about the scab on left lower leg. Resident #4 verified daily treatments were occurring to the open area on the right leg. Observation and interview on 04/18/24 at 1:55 P.M. of Resident #4's lower extremities with the Director of Nursing (DON) verified Resident #4 had a scabbed area to the left lower extremity. The DON reviewed Resident #4's medical record and verified the medical record contained no information regarding the scabbed area to Resident #4's left lower extremity. The DON verified the scab to the left lower extremity should have been captured and recorded in Resident #4's medical record in both the nurse's weekly skin assessments and in the wound care notes to ensure ongoing monitoring and any needed treatment. Review of the facility policy titled Skin Care, dated 06/02/23, revealed the policy was developed to ensure skin care and skin assessments are provided to residents. Skin evaluations will be completed upon admission and the weekly to identify new and or evaluate existing skin alterations. This deficiency represents non-compliance investigated under Complaint Number OH00152567. 365737 Page 2 of 2