Health inspection·July 7, 2023

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 observation, record review, interview, and facility policy review the facility failed to ensure Resident #3's left lower leg (LLE) surgical wound dressing was completed per the physician order and failed to ensure the medical record accurately reflected Resident #3's LLE surgical wound care. This finding affected one resident (#3) of three residents reviewed for wounds. Residents Affected - Few Findings include: Review of Resident #3's medical record revealed she was admitted on [DATE], discharged out to the hospital on [DATE], and returned to the facility on [DATE] with diagnoses including displaced bicondylar fracture of the left tibia, unspecified fall, and unspecified fracture of the left patella. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited intact cognition. Review of Resident #3's physician orders revealed an order dated 06/29/23 to change the dressing to the left lower leg (LLE) every other day and as needed. Keep the knee straight for four weeks with a brace. Review of Resident #3's treatment administration record (TAR) dated 06/29/23 revealed Licensed Practical Nurse (LPN) #814 documented she had completed the LLE surgical wound care. Review of Resident #3's TAR dated 07/01/23 revealed LPN #815 documented she had completed the LLE surgical wound care. Review of Resident #3's progress note dated 07/02/23 at 12:46 A.M. revealed the resident refused the leg treatment because she was sleeping. Review of Resident #3's TAR dated 07/03/23 revealed LPN #815 documented she had completed the LLE surgical wound care. Observation on 07/06/23 at 3:52 P.M. with LPN #809 and the Director of Nursing (DON) of Resident #3's LLE surgical wound care revealed the DON held up the LLE while LPN #809 unwrapped the ace wrap and cast type dressing from the leg, removed her gloves, washed her hands, replaced her gloves, and placed abdominal pads and Kerlix gauze around the sutures to Resident #3's LLE. Interview on 07/06/23 at 4:05 P.M. with LPN #809 revealed the facility did not have the cast type dressing which she had removed from Resident #3's LLE during the surgical wound care dressing change, Page 1 of 2 365748 365748 07/07/2023 White Oak Manor 1926 Ridge Avenue Warren, OH 44484

F 0684 and the dressing on Resident #3's LLE was the original surgical dressing. Level of Harm - Minimal harm or potential for actual harm Interview on 07/06/23 at 4:14 P.M. with the DON confirmed LPN #814 documented on Resident #3's TAR that she had completed the LLE surgical wound care on 06/29/23, LPN #815 documented on Resident #3's TAR that she had completed the LLE surgical wound care on 07/01/23 and 07/03/23. The DON confirmed the wound care was not completed as ordered and she would launch an investigation into the concern. Residents Affected - Few Interview on 07/06/23 at 4:16 P.M. with Resident #3 confirmed staff had not changed her LLE surgical wound dressing since her return to the facility on [DATE]. Telephone interview on 07/07/23 at 2:49 P.M. with the DON revealed she called Resident #3's surgeon, and he did not use the type of dressing which was removed from Resident #3's leg on 07/06/23 by LPN #809. She stated she also called LPN #815 who told her that she completed Resident #3's wound care on 07/03/23. The DON confirmed she did not provide evidence of the completion of the wound care including staff statements or phone numbers because the facility had a surprise admission. Review of the undated Wound Care policy indicated dry dressing protection was to follow the order or per nursing judgement and use house stock dry dressing, Kerlix gauze, abdominal dressing, or four by four dressings. This deficiency represents non-compliance investigated under Master Complaint Number OH00143723. 365748 Page 2 of 2