Health inspection·January 8, 2024

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 observation, staff interviews, record review, and policy review, the facility failed to ensure pressure ulcer treatments were completed as prescribed and failed to ensure pressure ulcer assessment were completed. This affected two (Residents #10 and #12) of three residents reviewed for pressure ulcers. The facility census was 73. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 02/20/23. Diagnoses included peripheral vascular disease and cognitive communications deficit. The resident was cognitively impaired. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 required assistance with eating, toileting, bed mobility, and transfers. Review of the 12/13/23 wound evaluation revealed a Suspected Deep Tissue Injury (SDTI) (purple or maroon localized area of discolored intact skin due damage of underlying soft tissue from pressure) on the left proximal foot measuring 1.5 centimeters (cm) by (x) 1.5 cm and left proximal foot SDTI measuring 2.3 cm x 1.1 cm. Documents revealed Physician #114 was contacted. Review of the weekly wound assessments revealed no documentation a weekly assessment was completed on 12/20/23 for the left distal or proximal left foot wounds. Review of physician orders revealed an order with a start date of 12/21/23 to cleanse with normal saline, pat dry, apply xeroform and cover with dry, clean dressing every day shift. Review of the December and January Treatment Administration Record (TAR) revealed no documentation the treatment was provided as ordered on 12/12/23, 12/28/23, or 01/03/24. Interview on 01/09/24 at 3:30 P.M. with the Director of Nursing verified there was no documentation of a wound assessment for the distal and/or proximal wound to the left foot on 12/20/23. 2. Review of the medical record for Resident #12 revealed an admission date of 12/07/23. Diagnoses included rhabdomyolysis, type two diabetes mellitus, and anxiety. The resident was cognitively impaired. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 required assisstance with activities of daily living. Further review revealed the resident had two stage Page 1 of 2 365876 365876 01/08/2024 Aventura at Carriage Inn 5040 Philadelphia Drive Dayton, OH 45415

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few four pressure ulcers and three unstageable pressure ulcers all of which were documented present upon admission. Review of the admission skin assessment revealed wounds were documented to right elbow, left elbow, coccyx and left trochanter. There was no documentation of the type of wound, measurements, and/or staging of the wounds. Interview on 01/09/24 at 12:17 P.M. with the Administrator verified there was no description, staging and/or measurements of Resident 12's wounds upon admission. Review of the Prevention of Pressure Injuries policy revised 09/22 revealed to assess the resident upon admission for existing pressure injury risk factors, and to identify any signs of developing pressure injuries. Review of the Wound Care policy revised 09/22 revealed documentation which should be included in the resident record all assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound. This deficiency represents non-compliance investigated under Complaint Number OH00149752. 365876 Page 2 of 2