Inspection·September 5, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of Resident #87's Skin Grid Non-Pressure of the left buttock dated 08/09/23 revealed the skin impairment was a new non-pressure area. The area was first observed on 08/08/23 and measurements were length 2 centimeters (cm) and width 2 cm. The area was described as MASD, partial thickness skin loss, color was red, epithelialization (light pink with a shiny pearl appearance) occuring, and no exudate (pus). Residents Affected - Few Review of Resident #87's Skin Grid Non-Pressure of the right buttock dated 08/09/23 revealed the skin impairment was new non-pressure area. The area was first observed on 08/08/23 and measurements were length 9 cm and width was 4 cm. The area was described as MASD, partial thickness skin loss, color was red, epithelialization occuring, and no pus. Interview on 08/30/23 at 10:39 A.M. of Family Member (FM) #426 revealed she complained to the staff because they did not use the potty chair which was delivered on 08/03/23, and Resident #87 was lying in feces. FM #426 stated Resident #87 could pivot and sit on the potty chair. FM #426 stated Licensed Practical Nurse (LPN ) #384 worked on 08/03/23 when Resident #87 was admitted to the facility and worked on 08/08/23 when two new wounds were found on Resident #87's buttocks. FM #426 stated when Resident #87 was admitted to the facility she had a dime size wound on her coccyx, but no wounds on her buttocks. FM #426 indicated Resident #87 wore pull ups and developed open sores on her bilateral buttocks because she was not changed and she was not put on the potty chair. FM #426 stated the family wanted to use their personal surveillance camera , but it did not work with the facility's system. FM #426 stated she had a conversation with ADON #402 and he admitted the facility dropped the ball. FM #426 stated she was very upset and angry Resident #87 developed two new wounds on her buttocks. FM #426 stated family was at the facility on 08/04/23 and 08/05/23 and gave staff instructions regarding Resident #87's care. FM #426 stated on 08/06/23 Resident #87 did not have bilateral buttock wounds. FM #426 stated the new wounds looked like a burn on Resident #87's skin. Interview on 08/30/23 at 2:42 P.M. of ADON #402 revealed Resident #87 was admitted with an unstageable pressure wound to the coccyx. ADON #402 indicated Resident #87 had poor mobility, the family told him Resident #87 could be toileted using the bedside commode, but for safety reasons she was made a check and change while she resided in the facility. ADON #402 revealed on 08/08/23 HN #427 brought it to his attention that Resident #87 had new skin impairments on her buttocks. ADON #402 stated the bilateral buttock wounds looked like a cross between shearing and MASD. ADON #402 stated HN #427 arrived around 11:30 A.M. but did not report the bilateral buttock wounds until she had been at the facility for a couple hours. ADON #402 indicated it could not be determined when the bilateral buttock wounds first occurred, but on 08/06/23 FM #426 provided care for Resident #87 and the buttock wounds were not present. ADON #402 stated FM #426 was upset about Resident #87's bilateral buttock wounds and the staff was also upset Resident #87 developed the buttock wounds. ADON #402 stated an investigation was conducted and the nurses and aides who cared for Resident #87 did not notice any new wounds on her buttocks. Interview on 08/31/23 at 11:44 A.M. of State Tested Nursing Assistant (STNA) #406 revealed on 08/08/23 she had Resident #87 in her assignment from 7:00 A.M. to 9:00 A.M. STNA #406 stated she checked Resident #87's incontinence brief, it was dry so she did not change the incontinence brief or see Resident #87's bottom during that time. STNA #406 did not know if Resident #87 had bilateral buttock wounds. Interview on 08/31/23 at 12:54 PM. of Licensed Practical Nurse (LPN) #384 revealed on 08/03/23 she admitted Resident #87 to the facility for a five day respite stay. LPN #384 stated when she did her evaluation, Resident #87 was not able to stand and pivot and LPN #384 felt it was a safety concern (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 2 of 3 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 365811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwestern Healthcare Center 570 North Rocky River Drive Berea, OH 44017 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and thought it would be better if Resident #87 had her incontinence brief checked and changed while she was in bed. LPN #384 stated Resident #87 was admitted with a pressure wound to her coccyx that needed packed, but had no wounds on her buttocks. LPN #384 stated on 08/08/23 when Resident #87's bilateral buttock wounds were found HN #427 was with Resident #87 a long time assisting her with ADL's. LPN #384 indicated HN #427 came out of Resident #87's room after providing care for her and told her Resident #87 had two new wounds, one on each buttock. LPN #384 stated the wounds on each buttock looked fresh, like they just happened, but HN #427 stated the wounds were there when she provided care. LPN #384 revealed she immediately reported the wounds to ADON #402. Interview on 08/31/23 at 1:33 P.M. of ADON #420, HN #427 and Hospice Supervisor #428 revealed HN #427 provided care for Resident #87 on 08/08/23. HN #427 stated Resident #87's skin tears on her buttocks were discovered during the visit sometime between 11:00 A.M. and 1:00 P.M. HN #427 stated she found one large skin tear to the right buttocks and one small skin tear to the left buttocks. HN #427 stated she did not notice the skin tears before she took Resident #87 to the bedside commode, and did not look at Resident #87's bottom before she had her use the bedside commode. HN #427 stated Resident #87's facility aide helped her pivot Resident #87 to use the bedside commode. HN #427 stated Resident #87 was steady, was a two person assist, and did not fall to the side when she sat down. HN #427 stated she spoke to the hospice aide who took care of Resident #87 on 08/07/23 and the aide told her Resident #87 did not have bilateral buttock wounds. Interview on 08/31/23 at 2:43 P.M. of STNA #375 revealed on 08/08/23 at 9:00 A.M. she was assigned to care for Resident #87. STNA #375 stated she checked Resident #87's incontinence brief, it was dry and she did not remove the brief or see Resident #87's bottom. STNA #375 indicated HN #427 arrived to care for Resident #87, and she assisted her to place Resident #87 on the bedside commode. STNA #375 indicated she did not see Resident #87's bottom because she was standing in front of Resident #87 and did not have a view of her bottom. STNA #375 stated HN #427 did not say Resident #87 had new wounds on her buttocks when they transferred her to the bedside commode. This deficiency represents non-compliance investigated under Complaint Number OH00145718. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365811 If continuation sheet Page 3 of 3