Inspection·April 27, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the wound Nurse Practitioner note, dated 12/08/22, revealed Resident #55's skin tear to right buttock had a bleeding wound bed. The periwound was fragile and had maroon discoloration. The note indicated to cleanse the area with soap and water, and triad cream every shift and as needed. The note further revealed the area had worsened and was 2.44 cm by 3.63 cm by 0.1 cm deep with scant serosanguinous drainage. Further review of the note revealed Resident #55's left buttock wound was worsening with a fragile periwound and maroon discoloration and measured 2.14 cm by 5.09 cm by 0.1 cm deep. The note revealed to change the treatment to cleanse with normal saline, triad cream to periwound, medihoney to open areas and cover with a dry dressing daily. Review of the wound Nurse Practitioner note, dated 12/22/22, revealed the right buttock skin tear worsened and the serous filled blister ruptured with partial thickness loss which measured 6.91 cm by 3.46 cm by 0.1 cm. The wound had worsening discoloration and blanchable erythema. The treatment was changed to cleanse with normal saline, triad cream to periwound, medihoney to open areas and cover with a dry dressing daily. The etiology was changed to a stage two (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) pressure ulcer. Further review of the note revealed the left buttock wound also worsened and measured 4.46 cm by 3.77 cm by 0.1 cm with maroon discoloration and the treatment was changed to cleanse with normal saline, triad cream to periwound, medihoney to open areas and cover with a dry dressing daily. Review of the wound Nurse Practitioner note, dated 12/26/22, revealed the right buttock skin tear worsened and measured 2.33 cm by 3.46 cm by 0.1 cm with worsening discoloration and blanchable erythema. The treatment was unchanged. The etiology was changed to a Stage II ( Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. ) pressure ulcer. Further review of the note revealed the left buttock wound also worsened and measured 5.52 cm by 5.71 cm by 0.1 cm deep with the etiology changed to evolving deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) with an open wound and small full thickness loss. Review of Resident #55's medical record revealed no evidence Resident #55's Power of Attorney was notified of the worsening skin conditions and changing treatments. Interview on 04/27/23 at 4:40 P.M. with Registered Nurse #128 verified Resident #55 had worsening wounds to her buttocks including a DTI and stage two pressure ulcer without evidence of Resident #55's Power of Attorney having been notified of the worsening wounds. The interview verified there was no evidence of Resident #55's Power of Attorney having been notified of the eye infection and pneumonia. Interview on 04/27/23 at 4:52 P.M. with Resident #55's Power of Attorney (POA) revealed she does not remember the facility calling her to let her know Resident #55 had pneumonia. She said the facility did not let her know her sister (Resident #55) had open areas on her buttocks. She revealed on 12/16/22, her sister (Resident #55) said her butt was hurting and they turned her over and Resident #55 had pressure ulcers. 2. Review of Resident #17's medical record revealed an admission date of 08/11/22 and readmission date of 03/15/23 with diagnoses including type two diabetes, gastroesophageal reflux disease, malignant neoplasm of prostrate, and traumatic subdural hemorrhage. Review of Resident #17's medical record revealed Resident #17's wife was his guardian. Review of the Impaired Skin Integrity Plan of Care, initiated 09/08/22, revealed Resident #17 had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366096 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Salem West Healthcare Center 2511 Bentley Drive Salem, OH 44460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few suspected deep tissue injury. An intervention was to educate Resident #17 on the need to turn and reposition and ensure Resident #17 was turned and positioned. Review of the wound Nurse Practitioner note, dated 03/20/23, revealed Resident #17 had a new suspected deep tissue injury to the right heel. The area measured 3.15 cm by 2.34 cm. Skin prep was ordered to be on the heel. The note indicated to ensure there was a turning protocol and to float heels. Review of the Significant Change Minimum Data Set Assessment, dated 03/23/23, revealed Resident #17 was severely impaired for daily decison making. Review of Resident #17's medical record revealed no evidence Resident #17's guardian was notified of Resident #17's new pressure ulcer to the right heel. Interview on 04/27/23 at 6:28 P.M. with the Director of Nursing verified there was no evidence of Resident #17's guardian having been notified of the new pressure ulcer to the right heel. Review of the facility policy titled Notification of Change in Condition, undated, revealed the center must inform the resident, consult with the resident's physician and/or notify the residents' representative, authorized family member, or legal power of attorney/guardian when there is a change requiring such notification. Circumstances requiring notification included the potential to require physician intervention and a new treatment. When a change in condition is noted, the nursing staff will contact the resident representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366096 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Salem West Healthcare Center 2511 Bentley Drive Salem, OH 44460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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, staff interview, and policy review, the facility failed to ensure wound dressing were changed appropriately and failed to ensure wound treatments were completed as ordered. This affected two (Residents #6 and #17) out of three residents reviewed for pressure ulcers. The facility census was 52. Residents Affected - Few Findings include: 1. Review of Resident #6's medical record revealed an admission date of 10/29/21 with diagnoses including but not limited to multiple sclerosis and pressure ulcer of the right buttock unstageable. Review of Resident #6's Impaired Skin Integrity Plan of Care, initiated 09/27/22, revealed the resident had impaired skin integrity and was at risk due to multiple sclerosis, weakness, need for assistance with activities of daily living, pain, history of pressure ulcers, poor nutrition, and excoriation to right and left elbows. Review of the quarterly Minimum Data Set Assessment (MDS), dated [DATE], revealed Resident #6 was independent for daily decision-making. Resident #6 was at risk for developing pressure ulcers with an unhealed unstageable (Full thickness tissue loss in which actual. depth of the ulcer is completely obscured by slough and/or eschar in the wound bed) pressure ulcer at the time of the assessment. Review of Resident #6's wound documentation, dated 04/26/23, revealed the resident had a right gluteal unstageable pressure ulcer which measured 1.24 centimeters (cm) by 0.77 cm by 0.5 cm with 2.5 cm tunneling deepest at 10-11 o'clock. The pressure ulcer was worsening with moderate serosanguinous malodorous drainage. A culture was ordered. The treatment was changed to Dakins moist to dry and border foam. Review of Resident #6's wound documentation, dated 04/26/23, revealed Resident #6 had an inhouse acquired left gluteal fold Stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) which reopened on 04/26/23. The pressure ulcer had scant serosanguinous drainage and was 0.95 cm by 1.29 cm by 0.1 cm deep. The treatment order was to cleanse the wound with normal saline daily and apply Santyl and border foam. Observation of Resident #6's pressure ulcer dressing change on 04/27/23 at 10:45 A.M. with Licensed Practical Nurse (LPN) #76 revealed LPN #76 brought in the supplies for the dressing change and laid them on her overbed table without cleaning the table off and wiping it down. The overbed table had a bag of popcorn on it, a glass of chocolate milk, two partially full water glasses, an electric toothbrush, glasses, a lidded thermal handled mug, a bowel of salad with a lid on it, a styrofoam cup, mail and a knife and fork. The nurse picked up a container of deodorant off the floor and placed it on the overbed table as well as a manual toothbrush. LPN #76 washed her hands and put on new gloves, and rolled the resident to her left side and removed the dressings from the coccyx, and right and left gluteal fold, including packing from the right gluteal fold. LPN #76 opened the gauze four by four's and normal saline. She cleansed the coccyx wound, right gluteal fold, then left gluteal fold, all while wearing the same pair of gloves. The LPN stated they sent a culture of Resident #6's right gluteal fold the day prior. She removed her gloves and donned another pair without handwashing. She applied Triad cream to the coccyx with the gloved fingers and applied a foam pad dressing. She went (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366096 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Salem West Healthcare Center 2511 Bentley Drive Salem, OH 44460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm to the treatment cart in the hall and obtained additional supplies. She removed her gloves, washed her hands, and regloved. She applied Santyl to the open area on the left buttock and a foam dressing. She took off her gloves and put on new gloves but did not wash her hands. She cut the gauze in half and used half Dakins and water to pack the right gluteal fold and covered it with a foam dressing. She positioned the resident, took off her gloves, and washed her hands. Residents Affected - Few Interview on 04/27/23 at 12:42 P.M. with LPN #76 verified she did not place the dressing supplies on a clean barrier. She verified she had the same gloves on when cleaning all three pressure ulcers. She also verified she did not consistently wash her hands between changing gloves. 2. Review of Resident #17's medical record revealed an admission date of 08/11/22 and a readmission date of 03/15/23 with diagnoses including but not limited to type two diabetes, malignant neoplasm of prostrate, and traumatic subdural hemorrhage. Review of Resident #17's Impaired Skin Integrity Plan of Care, initiated 09/08/22, revealed the resident had a suspected deep tissue injury. An intervention was to educate resident on need to turn and reposition and ensure resident is turned and positioned. Review of Resident #17's wound Nurse Practitioner note, dated 03/20/23, revealed Resident #17 had a new suspected deep tissue injury to the right heel. The area measured 3.15 cm by 2.34 cm. Skin prep was ordered to be on the heel. Review of Resident #17's Significant Change Minimum Data Set Assessment, dated 03/23/23, revealed the resident was severely impaired for daily decison making. Review of Resident #17's Treatment Administration Record (TAR) revealed Resident #17's treatment to apply skin prep to right heel and pad and protect was not signed off as completed on 03/24/23, 04/01/23 or 04/02/23. Further review of the TAR revealed on 04/06/23, the order was changed to apply a calcium alginate border gauze in the morning for skin care. The treatment was not signed off as completed on 04/06/23 and 04/07/23. Review of Resident #17's wound documentation, dated 04/26/23, revealed Resident #17's right heel pressure ulcer measured 1.24 cm by 0.99 cm and was classified as a stage two pressure ulcer. Observation on 04/27/23 at 12:28 P.M. of Resident #17's pressure ulcer dressing change revealed Resident #17 was in a low bed with the left side against the wall and fall mats on the floor. The resident was turned on his left side with a pillow behind his back and buttocks. The resident had slipper socks on. Licensed Practical Nurse (LPN) #76 removed the dressing items from the cart and placed them on the residents bedside table. LPN #76 pulled down the residents slipper sock and removed the foam pad from his heel. There was a dark area which was approximately 1.0 cm by 1.0 cm. and the perimeter of the dark area was dry. LPN #75 stated the wound nurse pulled off the dried layer of scab over the skin that was over the heel. LPN #75 washed her hands and gloved. LPN #75 opened four by four gauze pads in order to cleanse the right heel and threw the gauze on the residents fitted mattress pad near his feet without a barrier. LPN #75 picked up the gauze off the mattress pad and held it to the residents right heel until she ran saline down the heel. She then wiped the right heel with the gauze pad that had been on the fitted mattress pad. Interview on 04/27/23 at 12:44 P.M. with LPN #75 verified when she was performing the dressing change she placed the gauze pad on the fitted mattress pad which was not a clean surface. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366096 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Salem West Healthcare Center 2511 Bentley Drive Salem, OH 44460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/27/23 at 6:28 P.M. with the Director of Nursing verified Resident #17's treatments to the right heel had not been signed as completed 03/24/23, 04/01/23, 04/02/23, 04/06/23 and 04/07/23. Review of the facility's undated Uncomplicated Dressing Change Procedure revealed to prepare a clean hard surface work area using EPA disinfectant wipes and remove gloves and perform hand hygiene before donning gloves again. This deficiency represents non-compliance investigated under Complaint Number OH00139125. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366096 If continuation sheet Page 6 of 6