Health inspection·March 13, 2024

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 record review, observation and interview, the facility failed to develop and implement an effective and individualized pressure ulcer prevention program for Resident #101 to prevent the development of a facility acquired pressure ulcer to the back of the resident's neck. Residents Affected - Few Actual Harm occurred on 02/27/24 when Resident #101, who was cognitively impaired, ventilator dependent, at risk for pressure ulcer development and required total dependence on staff for bed mobility and all activities of daily living, was assessed on 02/27/24 by Wound Nurse Practitioner (NP) #703 to have a Stage IV (full thickness skin and tissue loss) facility acquired pressure ulcer with correction of the staging completed on 03/05/24 to an unstageable (full thickness loss of tissue completely covered by dead tissue) pressure ulcer to his rear neck found under his tracheostomy ties. The pressure ulcer measured 2.0 centimeters (cm) in width by 1.2 cm in length with no depth noted with the pressure ulcer having 100 percent eschar (dead tissue) to the wound bed with no undermining (tissue loss under the wound margins), tunneling, nor drainage or odor present. The facility failed to ensure adequate interventions/care including skin monitoring were provided to prevent the development of the ulcer and failed to timely identify the ulcer prior to it being a Stage IV/unstageable pressure ulcer. This affected one resident (#101) of three residents reviewed for ventilator dependence and pressure ulcers. The facility census was 96. Findings include: Review of the medical record for Resident #101 revealed an original admission date of 01/12/24 with subsequent hospital stays dated 01/13/24 to 01/16/24, 01/20/24 to 01/25/24, 01/31/24 to 02/06/24, and 02/29/24 to 03/06/24 with diagnoses including sepsis, diabetes mellitus, acute respiratory failure with hypoxia, ventilator dependent with tracheostomy, moderate protein calorie malnutrition, hypertension, fractures of the right and left tibias, injury to thoracic spinal cord, traumatic subarachnoid hemorrhage, fracture of facial bones, right shoulder dislocation, right ulna fracture, dislocation of right humerus, multiple bilateral rib fractures, and paraplegia. The most recent hospitalization on 02/29/24 was due to pneumonia for which he was treated in the hospital with antibiotics. Review of the Nursing admission Evaluation for Resident #101 dated 01/12/24, revealed Resident #101 was admitted to the facility with multiple wounds. Wounds to his scalp, face and several toes were from being struck by an automobile while crossing the street. Two wounds to his upper and lower back were surgical wounds and four wounds to his right and left buttock, right gluteal fold and occipital head were caused from pressure prior to admission to the facility. There was no wound identified to the resident's back/rear neck under tracheostomy (Trach) ties at the time of admission. Review of the Medicare five-day Minimum Data Set (MDS) 3.0 assessment, dated 02/13/24, revealed Resident #101 had severely impaired cognition, and was dependent on staff for all activities of daily living (ADLs) including bed mobility, turning, and repositioning, bowel incontinence care, and management of a suprapubic catheter. Review of the plan of care for Resident #101, initiated 01/12/24, revealed Resident #101 had potential or actual impairment to skin integrity related to fragile skin. Interventions included to supply education to the resident, family and caregivers of causative factors and measures to prevent skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365795 If continuation sheet Page 2 of 5 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 365795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis Center for Rehabilitation and Healing 850 East Midlothian Blvd Youngstown, OH 44507 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 Residents Affected - Few injury, ensure good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, keep skin clean and dry, use lotion on dry skin, monitor and document location, size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, and maceration to the physician. In addition the plan of care included Resident #101 was ventilator dependent with interventions to include monitor, document and report as needed any pressure ulcers. Preventative measures included turning at least every two hours, use pressure relief mattress or turning bed if indicated, follow prevention of pressure ulcer plan of care and maintain nutritional needs. The disciplines responsible were listed as the licensed nurses. Review of the weekly skin and wound evaluations dated 02/07/24, 02/13/24, and 02/15/24 revealed there were no new open areas identified on Resident #101's body. Review of the Skin and Wound Evaluation V7.0 document, dated 02/27/24 and authored by Wound NP #703 revealed while completing treatment to a wound on the occipital (back of head) portion of Resident #101's head, there was a (new) pressure area found under the resident's trach ties. The wound was documented to be an in house acquired Stage IV pressure ulcer measuring 2.0 centimeters (cm) width by 1.2 cm length with no depth noted and with 100 percent eschar (dead tissue). There was no undermining or tunneling; there was no drainage or odor present. Review of a progress note dated 03/05/24 by Wound NP #703 revealed a correction in the staging of Resident #101's rear neck wound from a Stage IV to an unstageable due to wound bed having 100% eschar tissue. Review of the physician's orders dated January 2024, February 2024 and March 2024 revealed an order dated 01/19/24 for trach ties to be changed weekly on Fridays or as needed, head of bed elevated to no less than 30 degrees, low air loss mattress to bed at all times. An order for wound care, dated 02/28/24 for the wound on the resident's neck to be cleaned with normal saline, apply skin prep to the perimeter and then apply Medi honey to the wound bed and cover with a foam dressing everyday shift for wound management and as needed was also noted. At the time this order was received, it was noted that Resident #101 was also receiving daily wound treatments to a wound on the back of his head (for a pressure ulcer present on admission) that was above the new Stage IV/unstageable pressure ulcer first identified on 02/27/24. Review of the February 2024 Treatment Administration Record (TAR) for Resident #101 revealed trach ties were to be changed every Friday. The February TAR indicated the trach ties had been changed on 02/09/24, 02/16/24, and 02/23/24. Wound treatments to the rear neck pressure ulcer were completed every dayshift beginning on 02/28/24. Review of the Braden Scale risk assessment dated [DATE] revealed Resident #101 was at a high risk for developing pressure ulcers. Review of the Braden Scale risk assessment dated [DATE] revealed Resident #101 was at a moderate risk for developing pressure ulcers. Review of a typed statement dated 03/12/24, authored by Primary Care Physician (PCP) #900 and submitted via email correspondence to the surveyor on 03/12/24 revealed PCP #900 enclosed a pressure injury audit and wrote the area on his rear neck that was caused by the trach tie was in my opinion unavoidable. The physician included the wound, in the PCP's opinion was unavoidable not only due to the resident's extensive comorbidities but also due to the resident requiring a ventilator and trach (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365795 If continuation sheet Page 3 of 5 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 365795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis Center for Rehabilitation and Healing 850 East Midlothian Blvd Youngstown, OH 44507 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 ties to hold trach in place with the trach tie a medical necessity to sustain life. The head of the resident's bed elevated due to continuous tube feeding. The resident being completely immobile, sliding down in bed and requiring staff to turn him. Fecal incontinence requiring staff to frequently provide incontinence care. And the resident being bedfast with several functional limitations in range of motion. Residents Affected - Few Review of the Pressure Injury Audit, dated 03/12/24, authored by PCP #900 revealed Resident #101 had a nosocomial (health care associated) existing pressure ulcer to his rear neck measuring 2.72 cm length by 1.92 cm depth and unstageable. Eschar or slough was present, and no signs of infection. Comments included: New area to rear neck found on 02/27/24. Resident was struck by an automobile, admitted with multiple wounds and multiple fractures. Resident has been to the hospital 4 times since 1/12/24. Resident has an unstageable pressure area to the rear neck from his trach tie. Trach tie is a medical necessity. Resident cannot survive without ventilator support. Curawound nurse practitioner will see on a weekly basis. Intermittent observations were conducted of Resident #101 in his room from 03/06/24 to 03/11/24 and revealed the resident was in bed lying on a low air loss mattress on his right side or back and had an enteral tube feed pump infusing enteral feeding continuously via PEG (percutaneous enterogastric) tube with the head of his bed elevate to approximately 30 degrees. Resident #101's eyes were open, but no meaningful attempts to communicate were made from him upon greetings. Interview on 03/05/24 at 1:00 P.M. with Respiratory Therapist (RT) #701 revealed NP #703 called and notified him on 02/27/24 of the new pressure ulcer found on the back of his neck and under the trach ties which was due to the trach ties being too tight. He was informed of the new orders in place. Interview on 03/05/24 at 2:00 P.M. with the Director of Nursing (DON) revealed the wound to the back of Resident #101's neck under the trach ties was found on 02/27/24 by Wound NP #703. A phone interview on 03/06/24 at 12:53 P.M. with Wound NP #703 revealed Resident #101 was found on 02/27/24 with an unstageable pressure wound to the back of his neck caused by the trach ties. Wound NP #703 then stated she was not comfortable with speaking on the phone and provided no further information about the wound. Interview on 03/06/24 at 1:25 P.M. with RT #701 revealed trach ties on any ventilator dependent resident should not cause pressure ulcers to the back of a resident's neck. RT #701 revealed Resident #101's wound was avoidable because the trach ties should be checked daily when staff provided care to ensure at least two fingers could be slipped under the ties to ensure the ties were not too tight on the resident's body. RT #701 confirmed the respiratory therapist was the only staff person who would change trach ties and the trach ties were dated when put on Resident #101 and last changed on 02/23/24. RT #701 revealed the nurses signed off the tie changes on the TAR whereas the RT documented it on the ventilator shift assessment. Observation was conducted on 03/07/24 at 11:00 A.M. of Resident #101 receiving wound care by Licensed Practical nurse (LPN) #717 and LPN #718 who was the facility wound care nurse. State Tested Nursing Assistant (STNA) #709 and STNA #716 were also in the room to help position the resident. The observation revealed Resident #101 was difficult to position on his side, he was on a low air loss mattress, tube feeding was placed on hold and the head of the bed was lowered to complete treatment to the wound on the back of his neck. LPN #718 performed hand hygiene, applied gloves, loosened trach ties, and removed the old dressing dated 03/06/24. The wound dressing had no excessive drainage, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365795 If continuation sheet Page 4 of 5 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 365795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis Center for Rehabilitation and Healing 850 East Midlothian Blvd Youngstown, OH 44507 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 Residents Affected - Few wound bed was 100% eschar with pink wound edges without undermining and no signs of infection in the wound. LPN #718 performed hand hygiene and applied new gloves, cleansed the area with normal saline, applied skin prep to the perimeter and then applied Medi honey to the wound bed and covered with a foam dressing and then retightened the trach ties placing two fingers underneath the trach ties to ensure they were not too tight causing additional pressure. The resident was repositioned in bed on his back, he was alert but not responsive to the staff speaking to him. The head of bed was again elevated to at least 30 degrees, tube feeding was turned back on and was running at the appropriate settings. LPN #718 verified these findings at the time of the observation. Interview on 03/11/24 at 1:12 P.M. with the facility wound care nurse, LPN #718 revealed resident was on a low air loss mattress and all other wound care orders were followed. She stated the wound to the back of Resident #101's neck was avoidable, could have been monitored better, and were caused by the trach ties being too tight. LPN #718 indicated Resident #101's PCP #900 does not follow the wounds because there was a physician with the wound care team if any orders were needed, and Wound NP #703 came to the building weekly to assess the wounds in the facility, to do measurements, do treatments and to write any new orders if necessary. PCP #900 verified in a written statement Resident #101, who was dependent on staff for all of his care needs, was found to have a pressure ulcer to the back/rear of his neck that was unstageable at the time of development. Although the physician expressed in writing it was his opinion the ulcer was unavoidable, interviews with RT #701 and LPN #718 identified the pressure ulcer was avoidable and caused by the resident's trach ties being too tight. In addition, the facility's identification of the resident's co-morbidities and increased care needs should have resulted in a more effective and individualized plan of care and pressure ulcer prevention program in accordance with the facility policy to prevent the development of this pressure ulcer. Review of the facility policy titled, Prevention of Pressure Injuries, last revised in April 2020 revealed the purpose of this procedure was to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. This deficiency represents noncompliance identified under Complaint Number OH00151700. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365795 If continuation sheet Page 5 of 5