Health inspection·October 12, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to provide pressure ulcer wound care as ordered. This affected two (#48 and #56) of three residents reviewed for wound care. The facility identified 13 residents (#26, #46, #48, #50, #56,#57, #60, #65, #69, #80, #95, #99, and #135) with wounds. The facility census was 142. Residents Affected - Few Findings include: 1. Review of Resident #56's medical records revealed an admission date of 03/23/23. Diagnoses included wounds of the scrotum and testes and Fournier Gangrene (necrotic tissue of the genitalia). Review of Resident #56's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had intact cognition. Resident #56 required supervision with bed mobility, toileting and personal hygiene. Resident #56 had a stage four pressure ulcer (deep wound that exposes muscle or other structures). Review of Resident #56's care plan dated 07/28/23 revealed Resident #56 had a potential for skin breakdown and pressure ulcers. Interventions included administer treatments and medications as ordered. Review of current physician orders for October 2023 revealed an order to cleanse wound with normal saline, apply collagen (protein wound dressing), calcium alginate (absorbent wound treatment) and cover with a foam dressing daily and as needed. Review of the progress note dated 09/28/23 revealed Resident #56 had a stage four pressure ulcer to the ischial (hip) crease that measured 2 centimeter (cm) in length, 7 cm in width and 0.1 cm in depth. The wound was present on admission. Interview on 10/10/23 at 9:55 A.M. with Resident #56 revealed he had a wound to his buttocks and he had to beg the nurses to change the dressing and when they did change it, it was not done adequately. At time of interview State Tested Nursing Assistant (STNA) #293 and STNA #308 entered Resident #56's room stating they were going to provide incontinence care and assist Resident #56 with getting out of bed. Observation during incontinence care revealed Resident #56 had a foam dressing to his left gluteal fold that was dated 10/08/23. The dressing was not fully intact and was not covering Resident #56's wound. STNA #308 stated she had observed other resident dressings that were several days old and had also seen residents whose wounds did not have any dressings on them. Licensed Practical Nurse (LPN) #349 entered the room stating she was going to complete Resident #56's wound care. LPN #349 confirmed the foam dressing date of 10/08/23 and stated she was unsure of how often the dressing was to be changed because she worked for an agency and had not cared for Resident #56 previously. Page 1 of 5 365832 365832 10/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0686 Level of Harm - Minimal harm or potential for actual harm Observation on 10/10/23 at 9:55 A.M. revealed Licensed Practical Nurse (LPN) #349 completing Resident #56's wound care. LPN #349 did not follow standards of practice related to infection control. 2. Review of Resident #48's medical records revealed an admission date of 09/21/23. Diagnoses included osteomyelitis (bone infection) and paraplegia. Residents Affected - Few Review of Resident #48's care plan dated 09/28/23 revealed Resident #48 had stage four pressure ulcers to the right and left hip and coccyx (tailbone), stage three pressure ulcers (full thickness skin loss) to the right and left buttock and left gluteal fold, a stage two pressure ulcer (top layer of skin is broken through) to the right inner knee and an unstageable pressure ulcer (the wound is covered by a layer of dead tissue so the base of the wound cannot be seen to determine the stage) to the left heel. Review of Resident #48's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had intact cognition. Resident #48 required total assistance with transfer and extensive assistance with bed mobility, toileting and personal hygiene. Review of Resident #48's current physician orders for October 2023 revealed orders to cleanse the left and right ischium and coccyx with normal saline, apply Dakins (antiseptic solution) moistened gauze and apply an absorbent dressing every shift and every twelve hours as needed; cleanse scrotum and penis with normal saline, apply Xeroform (petroleum based wound dressing) and an absorbent dressing every night shift and every twelve hours as needed, and cleanse soles of the feet with normal saline, apply Xeroform and apply an absorbent dressing and wrap with gauze every night shift. Interview on 10/10/23 at 10:30 A.M. with Resident #48 revealed his wounds had been severely infected at a previous facility and he had to be hospitalized due to the infection. Resident #48 stated due to the infection it was important that his wounds be cared for daily, and his wound care was not completed everyday. Resident #48 stated his wound care was last completed on 10/08/23. Resident #48 stated the dressings to his feet were rarely changed. Resident #48 had taken a picture of his dressings on 10/03/23 because it had been approximately a week since they had been changed and there was a large amount of black debris covering the gauze. Resident #48 showed the pictures to the nurses but felt they did not seem to care. On 10/10/23 at 1:23 P.M. Resident #48's wound care was observed with Licensed Practical Nurse (LPN) #349 and the Director of Nursing. Resident #48 had undated dressings to his left hip and upper buttocks that were not fully covering the wounds and were saturated with bloody drainage. Resident #48 had ACE wraps to both legs and the left leg ACE wrap was not fully covering the gauze dressing underneath. The exposed gauze dressing to the left leg had a large amount of yellow colored drainage to the heel and a large blackened area to the ankle. Follow up interview with Resident #48 after completion of wound care on 10/10/23 at 2:30 P.M. revealed the staff never cared for his wounds like what was observed today; he was lucky if his wound care was completed once a day. Observation on 10/11/23 at 10:15 A.M. revealed LPN #350 just completed wound care to Resident #48's hip and sacral wounds. Resident #48 stated his sacral wound dressing was not changed the previous shift; the nurse told him he needed to choose between his hip and sacral wounds or his feet wounds because she did not have time to complete both. The nurse wanted to do the dressings to his feet because they had not been done recently. 365832 Page 2 of 5 365832 10/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0686 Level of Harm - Minimal harm or potential for actual harm Interview on 10/11/23 at 12:50 P.M. with Licensed Social Worker (LSW) #203 revealed LSW #203 had spoken with Resident #48 and Resident #48 informed him about concerns related to his wound care. Resident #48 told LSW #203 his wound care was not done daily. Resident #48 also told LSW #203 the night shift nurse on 10/10/23 told him he had to choose between the hip and sacral or feet wound care because she did not have time to do both. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00146868. 365832 Page 3 of 5 365832 10/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to use appropriate infection control techniques when providing wound care. This affected two (#48 and #56) of two residents observed for wound care. The facility identified 13 residents (#26, #46, #48, #50, #56,#57, #60, #65, #69, #80, #95, #99, and #135) with wounds. The facility census was 142. Residents Affected - Few Findings include: Review of Resident #56's medical records revealed an admission date of 03/23/23. Diagnoses included wounds of the scrotum and testes and Fournier Gangrene (necrotic tissue of the genitalia). Review of Resident #56's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had intact cognition. Resident #56 required supervision with bed mobility, toileting and personal hygiene. Resident #56 had a stage four pressure ulcer (deep wound that exposes muscle or other structures). Review of Resident #56's care plan dated 07/28/23 revealed Resident #56 had a potential for skin breakdown and pressure ulcers. Interventions included administer treatments and medications as ordered. Review of Resident #56's current physician orders for October 2023 revealed an order to cleanse wound with normal saline, apply collagen (protein wound dressing), calcium alginate (absorbent wound treatment) and cover with a foam dressing daily and as needed. Review of progress note dated 09/28/23 revealed Resident #56 had a stage four pressure ulcer to the ischial (hip) crease that measured 2 centimeter (cm) in length, 7 cm in width and 0.1 cm in depth. The wound was present on admission. Observation on 10/10/23 at 9:55 A.M. revealed Licensed Practical Nurse (LPN) #349 entering Resident #56's room stating she was going to complete Resident #56's wound care. LPN #349 placed the wound care supplies on Resident #56's bedside table without placing a barrier or cleaning/disinfecting the surface of the bedside table. LPN #349 removed the old foam dressing and cleansed the area with normal saline. LPN #349 removed a pair of office scissors from her pocket and without cleaning or disinfecting the scissors cut a piece of collagen and calcium alginate. LPN #349 placed the collagen and calcium alginate on the wound and covered the wound with a foam dressing. Review of Resident #48's medical records revealed an admission date of 09/21/23. Diagnoses included osteomyelitis (bone infection) and paraplegia. Review of Resident #48's care plan dated 09/28/23 revealed Resident #48 had stage four pressure ulcers to the right and left hip and coccyx (tailbone), stage three pressure ulcers (full thickness skin loss) to the right and left buttock and left gluteal fold, a stage two pressure ulcer (top layer of skin is broken through) to the right inner knee and an unstageable pressure ulcer (the wound is covered by a layer of dead tissue and the base of the wound cannot be observed to determine the stage) to left heel. Review of Resident #48's MDS assessment dated [DATE] revealed Resident #48 had intact cognition. Resident #48 required total assistance with transfer and extensive assistance with bed mobility, 365832 Page 4 of 5 365832 10/12/2023 University Manor Health & Reha 2186 Ambleside Rd Cleveland, OH 44106

F 0880 toileting and personal hygiene. Level of Harm - Minimal harm or potential for actual harm Review of Resident #48's current physician orders for October 2023 revealed an order to cleanse the left and right ischium and coccyx with normal saline, apply Dakins (antiseptic solution) moistened gauze and apply an absorbent dressing every shift and every twelve hours as needed. An order to cleanse scrotum and penis with normal saline, apply Xeroform (petroleum based wound dressing) and an absorbent dressing every night shift and every twelve hours as needed and cleanse bilateral soles of feet with normal saline, apply Xeroform and apply an absorbent dressing and wrap with gauze every night shift. Residents Affected - Few Observation of wound care for Resident #48 on 10/10/23 at 1:23 P.M. with LPN #349 and the Director of revealed LPN #349 clearing a small area on Resident #48's bedside table. LPN #349 did not place a barrier, clean, or disinfect the bedside table prior to opening the wound care supplies and placing them on the bedside table. LPN #349 removed the dressing to Resident #48's left hip and cleansed the area with normal saline. LPN #349 picked up gauze that had been previously placed in Dakins solution and used office scissors that were not cleaned or disinfected prior and cut a section of the gauze. LPN #349 packed the Dakins soaked gauze into Resident #48's left hip wound and placed an absorbent dressing over the wound. LPN #349 did not change her gloves or wash her hands after cleansing the wound and before applying the new dressing. LPN #349 proceeded to remove Resident #48's dressing to his sacral area wearing the same gloves. LPN #349 cleansed the sacral wound with normal saline, using the same office scissors that had still not been cleaned or disinfected LPN #349 cut a piece of Dakins soaked gauze which she used to pack Resident #48's sacral wound. Wearing the same gloves, LPN #349 rolled Resident #48 onto his back and removed a piece of Xeroform from the resident's penis. LPN #349 cleaned Resident #48's penis with normal saline and changed her gloves prior to applying a new piece of Xeroform. LPN #349 proceeded to apply normal saline to remove a dressing to the right side of Resident #48's groin area. LPN #349 cleansed Resident #48's groin with normal saline and placed a section of Dakins soaked gauze to the area and applied an absorbent dressing to the wound. LPN #349 then proceeded to roll Resident #48 to his left side and remove a dressing to the right hip. LPN #349 cleansed Resident #48's right hip with normal saline and obtained a new package of Dakins soaked gauze and using the office scissors cut a section of the dressing, placed the Dakins soaked gauze into the wound and applied an absorbent dressing to the right hip. Interview with LPN #349 immediately after completion of the wound care confirmed she did not clean or disinfect Resident #48's or Resident #56's bedside tables prior to placing the supplies on the tables. LPN #349 confirmed she did not clean or disinfect the scissors prior to using them during wound care and stated she had located the scissors at the nurses station. LPN #349 further confirmed she had not changed her gloves in between dirty and clean portions of the wound care/dressing change. This deficiency represents non-compliance investigated under Complaint Number OH00146868. 365832 Page 5 of 5