Health inspection·April 5, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, staff interview, and facility policy review, the facility failed to comprehensively assess as well as monitor non-pressure skin areas. This affected two (Residents #13 and #14) of three residents reviewed for skin issues. The census was 50. Residents Affected - Few Findings include: 1. Review of Resident #13's medical record revealed Resident #13 was admitted to the facility on [DATE]. His diagnoses included but were not limited to Alzheimer's disease, type two diabetes, atherosclerotic heart disease, anemia, schizophrenia, vitamin D deficiency, chronic kidney disease, dementia, hypertensive heart and chronic kidney disease, and hyperlipidemia. Review of Resident #13's Minimum Data Set (MDS) assessment, dated 01/06/24, revealed Resident #13 had a severe cognitive impairment. Review of Resident #13 skin assessment, dated 03/12/24, revealed the facility documented he had no new or existing skin issues. Review of Resident #13's physician orders, dated 03/15/24, revealed he was ordered Hydrocortisone (steroid) External Cream 2.5 percent for contact dermatitis for seven days. There were no skin assessments or progress notes to support the initial diagnosis of dermatitis, and there were no ongoing skin assessments or progress notes to support monitoring of the dermatitis/rash/skin issue. Review of Resident #13 skin assessments, dated 03/19/24 and 03/27/24, revealed the facility documented he had no new or existing skin issues. Review of Resident #13's skin assessment, dated 04/02/24, revealed there was a skin issue documented, but the assessment also stated that the skin issue was not new. It did not indicate what the skin issue was, where it was located, or any description of the skin issue. Review of Resident #13 physician orders, dated 04/03/24, revealed he was ordered Permethrin External Cream five percent (medication used to treat scabies) to be spread over his whole body one time for a rash. There was no documentation indicating where the rash was located. 2. Review of Resident #14's medical record revealed Resident #14 was admitted to the facility on [DATE]. His diagnoses included but were not limited to dementia, need for assistance with personal care, dysphagia, major depressive disorder, anxiety disorder, retention of urine, single subsegmental pulmonary embolism, history of falling, long term use of anticoagulants, and hyperlipidemia. Page 1 of 3 365893 365893 04/05/2024 Berea Center 49 Sheldon Rd Berea, OH 44017

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of Resident #14's MDS assessment, dated 01/04/24, revealed he had a severe cognitive impairment. Review of Resident #14's skin assessments, dated 02/28/24, 03/06/24, 03/12/24, 03/19/24, and 03/27/24, revealed the facility documented he had no new or existing skin issues. Residents Affected - Few Review of Resident #14's physician orders, dated 03/02/24 to 03/07/24, revealed he was ordered Hydrocortisone External Cream 2.5 percent for contact dermatitis for five days. There were no skin assessments or progress notes to support the initial diagnosis of dermatitis and there were no ongoing skin assessments or progress notes to support monitoring of the dermatitis/rash/skin issue. Review of Resident #14's physician orders, dated 03/08/24 to 03/13/24, revealed he was ordered Hydrocortisone External Cream 2.5 percent for contact dermatitis for five days. There were no skin assessments or progress notes to support the initial diagnosis of dermatitis and there were no ongoing skin assessments or progress notes to support monitoring of the dermatitis/rash/skin issue. Review of Resident #14's physician orders, dated 03/14/24 to 03/21/24, revealed he was ordered Hydrocortisone External Cream 2.5 percent for contact dermatitis for seven days. There were no skin assessments or progress notes to support the initial diagnosis of dermatitis and there were no ongoing skin assessments or progress notes to support monitoring of the dermatitis/rash/skin issue. Review of Resident #14's skin assessment, dated 04/02/24, revealed there was a skin issue documented, but the assessment also stated that the skin issue was not new. It did not indicate what the skin issue was, where it was located, or any description of the skin issue. Review of Resident #14's physician orders, dated 04/03/24, revealed he had a dermatology appointment to determine the cause/extent of the skin issues that had not been resolved. Review of Resident #14's physician orders, dated 04/03/24, revealed he was ordered Permethrin External Cream five percent to be spread over his whole body one time for suspected scabies. There was no documentation to support where the rash/skin issues/suspected scabies was located. Interview with the Director of Nursing and Administrator on 04/05/24 at 12:50 P.M. confirmed there were no skin assessments, monitoring, or initial documentation of both Resident #13 and Resident #14's dermatitis/rash/skin issues. They confirmed the Residents #13 and #14 had skin issues that were found by staff and treated but were not included on the skin assessments. They confirmed Resident #14 was sent to the dermatologist and was diagnosed with and treated for suspected scabies. They also confirmed they treated Resident #13's skin issues/rash in the same manner as Resident #14 and Resident #14 was suspected of having scabies. Neither Resident #13 or Resident #14 were confirmed to have scabies since the dermatologist declined to scrape Resident #14's skin in order to confirm it was scabies and it was decided the best course of action was to treat the skin issues as if they did have scabies. Interview with Registered Nurse (RN) #102 and Licensed Practical Nurse (LPN) #103 on 04/05/24 at 1:00 P.M. revealed they were spoosed to perform skin assessments on the residents each week. If the resident had a new skin issue then they were to document it on the weekly skin assessment form. They were supposed to describe the type of skin issue, where it was, and who they contacted about the skin issue. They also revealed they were supposed to document the progression/regression of the resident's skin issues in the residents medical record, and document if/when a skin issue moves to another 365893 Page 2 of 3 365893 04/05/2024 Berea Center 49 Sheldon Rd Berea, OH 44017

F 0684 area of the body. Level of Harm - Minimal harm or potential for actual harm Interview with Nurse Practitioner #101 on 04/05/24 at 1:15 P.M. confirmed the order for hydrocortisone for Resident #14 was ordered each time because Resident #14's rash was moving to different areas. She was not sure if the facility documented where the rashes were located each time they notified her of the changes to the rash and received a new order for hydrocortisone. She confirmed she saw the rash on his back and his chest; but she confirmed she did not describe what the rash looked like each time she assessed it. Residents Affected - Few Review of the facility policy titled Scabies Management and Care, dated 07/07/17, revealed scabies was defined as a common, contagious, intensely itchy skin condition caused by a tiny, burrowing parasitic mites. Staff are to perform visual skin assessments on admission. If noted with red, raised areas with tracks or crusted, rash areas particularly on hands, fingers, toes, buttocks, and belt, sock, and bra area, contact the physician/provider. All abnormalities are noted and documented. The attending physician will be notified, as well as the attending physician of the roommate and other close contacts. The physician may order prophylactic treatment depending on each circumstance. The resident's responsible party will be notified as well. If scabies is diagnosed, notify the responsible party that those who had recent contact, including roommates with the resident, should follow up with their physician for treatment including possible prophylactic treatment to prevent spreading the mite to others. There is no effective, recommended over-the-counter treatment for scabies. The facility is to implement contact precautions. A private room is desirable, if the resident is not cognitively intact, update the care plan, obtain labs as ordered including skin scraping for identification, staff to wear appropriate PPE (personal protective equipment) when providing direct care, and discontinue contact precautions 24 hours after initial treatment. The incubation period can be two to six weeks before signs or symptoms occur. Clinical signs of infestation may include tiny vesicles or blisters where the scabies mite has penetrated the skin and tiny, slightly elevated, linear burrows, about 0.5 millimeters (mm) in diameter and three to 15 mm in length, containing the mites and their eggs. Failure to identify positive scrapings does not indicate a negative diagnosis. It is very difficult to obtain a positive scraping because only one or two mites may cause multiple lesions. Often diagnosis is made from signs and symptoms and treatment is followed without scraping sent to lab. This deficiency represents non-compliance investigated under Complaint Number OH00152194. 365893 Page 3 of 3