Health inspection·October 5, 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 closed record review, facility policy review and interview the facility failed to ensure routine assessment/skin monitoring was completed and failed to prevent the development of an avoidable pressure ulcer injury for Resident #68. Following the development of the pressure ulcer, the facility failed to ensure treatments were completed as ordered. Residents Affected - Few Actual Harm occurred on 07/19/23 when Resident #68, who was assessed to be at risk for pressure ulcer development was found to have an open wound (to the left lateral foot) with no evidence of any type of treatment being initiated. On 07/20/23 the area was assessed to be unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer. This affected one resident (#68) of three reviewed for wounds. The facility census was 61. Finding include: Review of the medical record for Resident #68 revealed an admission date of 01/24/23 with diagnoses including chronic kidney disease, type II diabetes, adult failure to thrive, and neuromuscular dysfunction of the bladder. Record review revealed the resident was transferred to the hospital on [DATE]. The resident did not return to the facility. Review of the weekly skin computer assessments from 06/01/23 through 07/20/23 revealed only one weekly skin check was completed on 06/01/23. Review of the Treatment Administration Record (TAR) for June 2023 revealed weekly skin checks were documented as completed on 06/07/23, 06/14/23, 06/21/23 and 06/27/23. Review of the TAR for July 2023 revealed weekly skin assessments were documented as being completed on 07/05/23, 07/12/23, and 07/19/23. Review of the shower sheets for July 2023 revealed there was no shower documented as completed on scheduled shower days 07/04/23, 07/08/23, 07/11/23, 07/15/23, 07/18/23, 07/25/23, 07/25/23, and 07/29/23. Showers were refused on 07/12/23 and 07/19/23. The resident received a shower on 07/22/23. Review of the quarterly Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #68 had intact cognition. The assessment revealed the resident required limited assistance with toilet use and hygiene. The resident was continent of bowel and bladder. The assessment indicated the resident was at risk for pressure ulcers. Page 1 of 5 365784 365784 10/05/2023 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0686 Level of Harm - Actual harm Residents Affected - Few Review of the care plan dated 07/18/23 revealed Resident #68 was at risk for pressure injury, rash, cellulitis, and skin tears due to limited mobility. Interventions included weekly skin assessments to report irregularities, protect skin from moisture, and to elevate heels off the bed as tolerated. The care plan stated the resident was resistive to care related to failure to thrive. The care plan documented the resident refused showers. Review of the pressure ulcer risk assessment dated [DATE] revealed the resident was at moderate risk for the development of pressure ulcers. Review of the skilled charting documentation dated 07/19/23 at 1:59 A.M. revealed a left lateral wound was identified with scant drainage and granulated, healing, tissue. There was no evidence that a treatment was put in place. Review of the wound physician assessment report dated 07/20/23 revealed the resident had a left lateral foot unstageable pressure wound that measured 4.5-centimeter (cm) length by 4.5 cm width and depth unable to be determined. The wound had 50 percent (%) to 74% slough, a mass of dead tissue, and 1% to 24% eschar, dried dead tissue, with a moderate amount of drainage. A new treatment order was put in place at this time. A treatment was ordered to cleanse the wound with normal saline, apply hydrogel (promotes the removal of infected or necrotic tissue), calcium alginate (highly absorbent dressing), abdominal (ABD) pad, and wrap with Kerlix rolled gauze daily and as needed. Review of the July 2023 physician's orders revealed orders dated 07/28/23 for an ultrasound to bilateral lower extremities and change the dressing to the left lateral foot to cleanse with normal saline solution, pat dry, apply adaptic oil emulsion dressing (non-adherent dressing) cut to fit exposed bone/tendon, pack wound with Dakin's (antiseptic) saturated four by four gauze, cover with an ABD pad and secure with Kerlix rolled gauze, change twice daily and as needed. Review of the July 2023 TAR revealed the treatments to the left lateral foot were not documented as completed as ordered on 07/28/23, 07/29/23, and 07/30/23. Review of the medical record revealed ultrasound results dated 08/02/23 revealed no occlusion, and the resident received an order for an antibiotic, Doxycycline. Review of the medical record revealed an order dated 08/25/23 to send the resident to the local hospital on Monday, 08/28/23, for a MRI (magnetic resonance imaging) to rule out worsening wound. On 08/28/23, the resident was diagnosed with cellulitis and osteomyelitis (infection of the bone) and was ordered to continue Doxycycline and begin Keflex (antibiotic) for 14 days. Review of the medical record revealed the resident was sent to the local hospital on [DATE] and admitted with a diagnosis of osteomyelitis. Interview on 10/04/23 at 7:00 A.M. with Licensed Practical Nurse (LPN) #272 revealed on 07/19/23 she was orientating with another nurse who identified the wound. The wound was about the size of a quarter. She could not recall if a dressing was put into place. The nurse would not allow her to document the assessment. Interview on 10/04/23 at 12:45 P.M. with the Director of Nursing (DON) verified Resident #68's weekly skin assessments and showers were not completed. There was no evidence a wound treatment was administered on 07/19/23 when the wound initially identified. The DON also verified treatments to the 365784 Page 2 of 5 365784 10/05/2023 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0686 left lateral foot were not documented as completed per physician's orders on 07/28/23, 07/29/23, and 07/30/23. Level of Harm - Actual harm Residents Affected - Few Interview on 10/04/23 at 3:30 P.M. with State Tested Nursing assistant (STNA) #281 stated the resident refused showers but would wash up in his room. Resident #68 was able to wash the upper portion of his body but needed assistance with his legs and feet. STNA #281 stated he was always wearing socks and she would just wash his legs. STNA #281 stated she never took off his socks to look at his feet. STNA #281 stated when she provided a shower, she does not do a thorough skin check or check the bottom of feet. Interview on 10/04/23 at 3:57 P.M. with Registered Nurse (RN) #215 stated the computer program does not always prompt to complete weekly skin assessments. RN #215 kept a list of residents and days they were scheduled to receive weekly skin checks to ensure they were completed. Review of the facility policy titled Pressure Ulcers and Skin Breakdown, revised April 2018, revealed the nurse shall describe and document a full assessment of a pressure sore including location, stage, length, width and dept, presence of exudate or necrotic tissue. Review of the facility policy titled Bath, Shower or Tub, revised February 2018, revealed the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. This deficiency represents non-compliance investigated under Master Complaint Number OH00146836. 365784 Page 3 of 5 365784 10/05/2023 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

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 observations, staff interviews, record review, and facility policy review the facility failed to provide adequate supervision to prevent elopement of Resident #10. This affected one resident (#10) of one resident reviewed for elopement. The facility census was 61. Finding include: Review of Resident #10's medical record revealed he was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, vertigo, heart failure, psychotic disorder, schizophrenia, muscle weakness, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had impaired cognition, no wandering behaviors, and could wheel 150 feet in a wheelchair. The resident required supervision for activities of daily living and with movement off the unit. Review of the elopement risk assessment dated [DATE] revealed Resident #10 was at a low risk for wandering. Review of Resident #10's care plan dated 02/13/23 revealed the resident was care planned for impaired thought process. Review of the nurses' progress noted dated 09/16/23 revealed at 5:30 P.M. a neighbor reported a male resident from the facility was down the street and appeared to be confused. The nurse picked up the resident and his wheelchair and returned to the facility. The Assistant Director of Nursing (ADON) #232 was notified. Interview on 09/27/23 at 10:42 A.M. with Resident #10 stated maybe he left the facility. Interview on 09/27/23 at 5:10 P.M. with ADON #232 stated she could not remember if she was notified of the elopement and would have to check her notes. The ADON stated she had epilepsy and had difficulty remembering. Interview on 09/27/23 at 5:20 P.M. with License Practical Nurse (LPN) #236 stated she received a call from a neighbor stating a resident from the facility was down the street. LPN #236 got into her car and picked up Resident #10 and brought him back to the facility. Resident #10 was assessed and had no injury. LPN #236 stated the last time she saw Resident #10 was between 4:30 P.M. and 5:00 P.M. eating dinner at the table. He was alert, orientated, and smiled at her. LPN #238 stated Resident #10 was gone less than 30 minutes. Interview on 09/27/23 at 6:05 P.M. with State Tested Nursing Assistant (STNA) #204 worked the unit on 09/16/23, where Resident #10 resided. STNA #204 last saw Resident #10 at 5:00 P.M. eating dinner. Interview with Director of Nursing (DON) on 10/27/20 at 4:13 P.M. revealed she was off for several days. ADON #232 did not inform her that Resident #10 had left the facility. 365784 Page 4 of 5 365784 10/05/2023 Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 09/28/23 at 8:45 A.M. of the facility and surrounding area revealed the Resident #10 wheeled out of the parking lot turned left and was picked up about 200 feet from the entrance of the facility. Interview on 09/28/23 at 1:23 P.M. with STNA #281, stated she was assigned to Resident #10 when he went off the unit. Earlier in the day, Resident #10 asked if he could go outside because he was tired of staying in his room. STNA #281 stated it was his choice. STNA #281 last saw Resident #10 at 3:00 P.M. She was unaware Resident #10 left until she returned from her break. Interview on 10/02/23 at 1:06 P.M. with MDS Nurse #260 revealed the ADON #232 notified him to update the Resident #10's care plan for elopement. Interview with the Administrator 10/03/23 at 2:00 P.M. stated she was not informed by ADON #232 that Resident #10 left the facility and was brought back. Interview on 10/03/23 at 2:00 P.M. with Registered Nurse (RN) #287 stated she was an agency nurse assigned to Resident #10 the day he left the unit. RN #287 was unaware Resident #10 was off the unit until he returned to the facility. RN #287 stated it was her first day at the facility she could not recall the last time she saw Resident #10. Review of daily historical temperatures on accuweather.com revealed on 09/16/23 a high temperature of 72 degrees Fahrenheit (F) and low temperature of 42 degrees F. Review of sunset times on timeanddate.com revealed sunset on 09/16/23 was at 6:51 P.M. Follow up interview 11:30 A.M. with the DON on 10/04/23 stated Resident #10 left the facility through the back door. The DON stated Resident #10 often spent time with his wife on the patio next to the back door. Review of the facility policy titled Wandering and Elopement, revised March 2019, revealed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintain the least restrictive environment for residents. The following deficiency is based on an incidental finding discovered during the course of the complaint investigation. 365784 Page 5 of 5