Health inspection·January 23, 2025

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 medical record review, observation, interview, and facility policy review, the facility failed to ensure the complete physician-ordered treatment was applied to Resident #20's sacral pressure ulcer. This affected one (Resident # 20) of three residents reviewed for wound care. The facility census was 87. Residents Affected - Few Findings include: Review of the medical record for Resident #20 revealed an admission date of 07/19/24 with diagnoses including iron deficiency anemia, obesity, surgical wound, atrial fibrillation, rheumatoid arthritis, pressure ulcer of sacral region, surgical aftercare following surgery on the digestive system. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had intact cognition and had moderate depression. The resident was dependent on staff for activities of daily living. Review of the January 2025 physician's orders revealed Resident #20's had an order dated 12/02/24 for a wound dressing for a sacral pressure ulcer. The order called for the wound to be cleansed with normal saline, packed with silver alginate, covered with an absorbent pad, secured with paper tape, and changed daily. Additional instructions in the order included to apply zinc ointment around the sacral pressure ulcer daily. Review of the Treatment Administration Record (TAR) for January 2025 revealed Resident #20's sacral wound care was listed as completed daily as ordered. Review of the weekly wound assessment dated [DATE] revealed Resident #20 had a stage four pressure ulcer(indicating a full thickness wound which can extend into muscle, tendon, ligament, cartilage, or bone) to her sacrum. The assessment indicated the wound was healing. The listed treatment included cleanse the wound, apply silver alginate, cover with an absorbent pad, secure the wound with paper tape, and change daily. The assessment indicated triad cream (a zinc-oxide-based paste which can be applied to wounds to encourage healing or to intact skin to protect skin from irritation) was to be applied to the skin surrounding the wound. Observation on 01/22/25 at 2:41 PM with Licensed Practical Nurse (LPN) #288 who completed Resident #20's wound care revealed LPN #288 first prepared to change the resident's sacral wound. LPN #288 removed the old dressing, cleansed the wound with normal saline and packed the wound with silver alginate. LPN #288 then covered the wound with an absorbent pad and secured the dressing with paper tape. LPN #288 did not apply zinc or any cream or ointment to the skin surrounding the resident's wound. Page 1 of 2 365845 365845 01/23/2025 Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 1/22/25 at 3:00 P.M. with LPN #288 verified she did not apply zinc around the sacrum wound. LPN #288 confirmed the physician's order called for zinc to be applied, but stated if zinc was applied, the tape wound not adhere to the resident's skin. Review of the policy titled Wound Care, revised October 2010, revealed to verify that there is a physician's order for the procedure, and to ensure that the physician order matches the wound Nurse Practitioner (NP) order. This deficiency represents non-compliance investigated under Master Complaint Number OH00161530. 365845 Page 2 of 2