Health inspection·June 13, 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 medical record review, observation, and staff interview, the facility failed to ensure the residents had weekly skin assessments per physician orders, failed to record skin breakdown identified during a bath, and failed to report the skin breakdown to the nurse. This affected one (Resident #57) of three residents reviewed for pressure ulcers. The facility identified seven current residents with pressure ulcers. The facility census was 58. Residents Affected - Few Findings include: Review of the medical record for Resident #57 revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus and neuromuscular dysfunction of bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively impaired. Resident #57 was dependent on staff for transfers and toileting. Review of the plan of care dated 12/16/22 revealed Resident #57 was at risk for skin breakdown related to diabetes mellitus type two, impaired mobility, weakness, incontinence, episodes from around the indwelling catheter. Interventions included to apply lotion or moisture barrier cream as needed, encourage to float heels as tolerated, house barrier cream with each incontinence episodes, observe skin for redness or open areas, pressure reducing and relieving mattress, skin assessment as needed, supplements per order, and turn and reposition every two hours as tolerated. Review of the physician order dated 01/08/23 revealed an order for Resident #57 to have weekly skin sweeps. The physician order dated 04/30/23 revealed an order to apply house barrier cream with each incontinent episode. Review of Resident #57's medical record revealed the last recorded weekly skin assessment was completed on 03/04/24. Resident #57's bath sheets dated 05/30/24, 06/04/24, 06/06/24, and 06/11/24, revealed no skin issues for Resident #57. There was a state tested nursing aides (STNA) signature at the bottom of the bath sheet, but there was no nurse signature on the bath sheets where the nurse signature was to be placed. Review of Resident #15's skin risk assessment dated [DATE] revealed Resident #57 was at moderate risk for skin breakdown. Observations on 06/13/24 from 10:20 A.M. through 10:34 A.M. revealed Resident #57 was to receive Page 1 of 2 365933 365933 06/13/2024 Buckeye Terrace Rehabilitation and Nursing Center 140 N State Street Westerville, OH 43081

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incontinence care from STNA #200. The Director of Nursing (DON) was in the room for support. There was a reddened open area on the right upper buttocks. STNA #200 confirmed Resident #57 had a skin issue. The DON confirmed Resident #57 had an open area stage two (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) on the right buttocks that measured appropriately 1.5 centimeters (cm) in length by 1.0 cm width and 0.1 cm in depth with a bright beefy pink wound bed. The DON stated she could not remember if Resident #57 was on the facility's current pressure ulcer list or if this was a new pressure ulcer found. Interview on 06/13/24 at 11:44 A.M. with Assistant Director of Nursing (ADON) #121 confirmed the last skin assessment was 03/04/24. ADON #121 confirmed there was no weekly skin assessment for Resident #57. ADON #121 stated the nurses used bath sheets as skin assessments. Interview on 06/13/24 at 2:05 P.M. with STNA #159 stated he worked on 06/11/24 and was the STNA who provided Resident #57 with a bed bath on 06/11/24. STNA #159 stated Resident #57 had a 'scratch' on her upper buttocks but could not remember if it was the left or right side. STNA #159 verified he failed to document the skin issue on Resident #57's bath sheet on 06/11/24 and never reported the skin issue to a nurse. Interview on 06/13/24 at 2:40 P.M. with Corporate Nurse #350 confirmed there was no nurse signature on Resident #57's bath sheets on 05/30/24, 06/04/24, 06/06/24, and 06/11/24. Corporate Nurse #350 verified the nurse should have signed the bath sheets when reviewing the bath sheets. Corporate Nurse #350 verified the STNA should have reported the skin issue to the nurse when he identified it during the bed bath on 06/11/24. This deficiency represents non-compliance investigated under Complaint Number OH00154287. 365933 Page 2 of 2