Health inspection·April 17, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital record review, staff interview, and facility policy review, the facility failed to ensure residents received the necessary treatment and services to promote healing and prevent infections for a pressure ulcer. This resulted in Actual harm when Resident #20 ' s weekly skin assessments were not completed and subsequently led to hospitalization for a wound infection and possible osteomyelitis. This affected one (Resident #20) of three residents reviewed for pressure ulcers. The facility census was 132. Residents Affected - Few Findings include: Review of the medical record for Resident #20 revealed an admission date to the facility on [DATE] and a discharge date to the hospital on [DATE], and as of 04/16/24 Resident #20 is still hospitalized . Resident #20 had a hospital diagnosis of right large heel pressure ulcer with wet necrosis with suspected superimposed infection/osteomyelitis. The resident had pertinent diagnoses of cellulitis of right upper limb, atherosclerotic heart disease of native coronary artery, type two diabetes mellitus with diabetic neuropathy, atrial fibrillation, hypertensive heart disease with heart failure, congestive heart failure, anxiety disorder, asthma, chronic kidney disease stage three, attention deficit hyperactivity disorder, restless legs syndrome, hyperlipidemia, syncope and collapse, sleep apnea, left bundle branch block, hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, insomnia, depression, and gastroesophageal reflux disease. Review of a [NAME] scale for predicting pressure sore risk assessment dated [DATE] revealed the resident had a score of 18 and was categorized as at risk for pressure ulcers. Review of a plan of care dated 01/02/24 revealed Resident #20 had impaired skin integrity to right heel with a goal of tissue injury will heal and be free from complications. Interventions included: Assess and document skin condition, notify doctor of signs of infection (redness, drainage, pain, fever), assess for pain and treat as indicated, notify physician of worsening or no improvement in wound, pressure reducing/redistributing mattress on bed, wound location: right heel and wound treatment as ordered. Review of the 03/26/24 quarterly Minimum Data Set (MDS) assessment revealed Resident #20 was cognitively intact and rejected care one to three days during the look back period. Resident #20 used a walker and wheelchair to aid in mobility and was dependent for toileting hygiene, and showering. Resident #20 required substantial to maximal assist for rolling left to right, sit tolying and lying to sitting, and sit to stand. Resident #20 had treatments in place to include pressure reducing device for chair and bed, and applications of ointments and dressings. Page 1 of 5 366120 366120 04/17/2024 Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040

F 0686 Level of Harm - Actual harm Review of outside wound clinic assessment notes dated 03/05/24 revealed multiple wounds including an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed) right calcaneus pressure ulcer injury that was open and was acquired 12/31/23 with wound measurements of 6.5 centimeters (cm) in length, 6.5 cm in width with a depth of 0.3 cm. Residents Affected - Few Review of a Physician Order dated 03/06/24 revealed to cleanse right heel wound with normal saline, apply Exufiber dressing (no silver), cover with abdominal pad and wrap with kerlix every other day and as needed per wound clinic every night shift, every other day for wound care, and as needed for wound care. Review of the outside wound clinic assessment notes dated 03/12/24 revealed an unstageable right calcaneus pressure ulcer injury with wound measurements of 6.5 cm in length, 6 cm in width, with a depth of 0.3 cm. The next appointment date was scheduled for 03/26/24. Review of the medical record revealed there were no wound measurements or assessments from 03/13/24 until a wound assessment was completed on 04/08/24. Review of the medical record revealed there was no information on the appointment for the date of 03/26/24. Review of a progress note dated 04/02/24 revealed tried to get resident ready for wound care appointment, resident too weak to sit up straight in bed, bed bath and sheets changed by aide, and educated resident on needing a stretcher for appointments. Review of the wound assessment report from the in-house wound nurse practitioner dated 04/08/24 revealed the right heel wound was unstageable 8 cm in length, by 6.5 cm in width, with a depth of 0.5 cm. There was slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) from 1-24% with a moderate amount of seropurulent exudate. Review of the Nurse Practitioner progress note dated 04/08/24 at 11:37 A.M. revealed spoke with nurse to confirm appointment at outside wound clinic for 04/09/24. Updated her on concerns for possible wound infection. Review of a progress note dated 04/09/24 at 5:45 P.M. revealed Resident #20 was being admitted to the hospital for wound infection per emergency room nurse. Interview with Registered Nurse (RN) #10 on 04/10/24 at 3:00 P.M. revealed Resident #20 did not go out to his wound clinic appointment on 03/26/24 and 04/02/24 because he was not feeling well. Interview with Director of Nursing (DON) on 04/15/24 at 12:05 P.M. verified there were no wound measurements or wound assessments from 03/13/24 until 04/08/24. Interview with Licensed Practical Nurse (LPN) #11 on 04/15/24 at 12:18 P.M. revealed she was wound certified and rounded with the wound Nurse Practitioner on Mondays. She stated they see patients weekly if they are on the caseload on her rounds. She stated she was notified on 04/08/24 that Resident #20 had missed the 04/02/24 wound appointments and was not notified of missing the 03/26/24 wound appointment. Residents usually have an order to measure wounds weekly. She verified she had not 366120 Page 2 of 5 366120 04/17/2024 Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040

F 0686 Level of Harm - Actual harm Residents Affected - Few measured Resident #20 ' s wound from 03/13/24 to 04/08/24. LPN #11 stated if a new wound pops up and whoever does the treatment would measure it and assess the wound. She stated they quit following Resident #20 ' s wound back in February when they realized he was going out to a podiatrist at a wound clinic, and then switched over to a different wound provider. She revealed they called the wound clinic on 04/08/24 and talked to a nurse and the doctor, because the Nurse Practitioner was thinking the right heel had osteomyelitis and it had an odor. Review of the hospital records from admission date on 04/09/24 revealed Resident #20 had a wound culture that showed Methicillin Resistant Staphylococcus Aureus, Escherichia coli, and possibly extended spectrum beta lactamase. A fungus culture grew Candida Albicans. There was a right heel pressure ulcer with wet necrosis with suspected superimposed infection/osteomyelitis. The right foot x-ray showed erosion of the posterior right calcaneus compatible with osteomyelitis. Resident #20 was receiving intravenous daptomycin antibiotic. The MRI (Magnetic Resonance Imaging) for osteomyelitis was still pending. Review of the facilities skin management policy dated 10/01/19 revealed residents will have a skin assessment completed upon admission and no less than weekly by the licensed nurse in an effort to assess overall skin condition, integrity, and skin impairment. This deficiency represents non-compliance investigated under Complaint Number OH00152801. 366120 Page 3 of 5 366120 04/17/2024 Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure medication error rates were less than 5% when they administered incorrect medications for Resident #30 and Resident #75 and failed to administer a medication for Resident #75. This affected two Residents (#30 and #75) of three Residents reviewed for medication administration. There was three errors out of 26 opportunities for a medication error of 11.5%. The facility census was 132. Residents Affected - Few Findings include: 1. Record review of Resident #30 revealed an admission date of 07/23/18 with pertinent diagnoses of: hypertensive heart disease, gastrointestinal hemorrhage, left ventricular failure, unspecified vitamin deficiency, and unspecified nutritional deficiency. Review of a Physicians Order dated 04/08/24 Calcium Carbonate Vitamin D-Mineral Oral Tablet 600-400 milligrams (mgs)-unit (Calcium Carbonate-Vitamin D with Minerals). Give one tablet by mouth two times a day for supplement. Observation of a medication administration pass on 04/10/24 at 8:25 A.M. revealed Registered Nurse (RN) #10 passing medications to Resident #30. Medications administered included calcium 600 milligrams one tab by mouth. Interview with RN #10 on 04/10/24 at 10:40 A.M. verified she did not give calcium 600 mgs with 400 milligrams vitamin D. She verified she only gave calcium 600 mgs. 2. Record review of Resident #75 revealed an admission date of 02/28/22 with pertinent diagnoses of: acute kidney failure, type two diabetes mellitus, hypertension, and pain. Review of a Physicians Order dated 03/13/24 Polysaccharide Iron Complex Oral Tablet (Polysaccharide Iron Complex) Give 180 mg by mouth one time a day every other day for deficiency. Review of a Physicians Order dated 03/16/24 Senna-S Oral Tablet 8.6-50 mgs (Sennosides-Docusate Sodium) Give two tablet by mouth two times a day for constipation. Observation of a medication administration pass on 04/10/24 at 9:00 A.M. revealed Licensed Practical Nurse (LPN) #15 administered medications of colace 100 mg two tabs, aspirin 81 mgs, Tylenol 325 mg, norvasc 10 mgs, folic acid 400 mcg, plavix 75 mgs, metoprolol 25 mgs, vitamin B complex, and lasix 40 mgs. Interview with LPN #15 on 04/10/24 at 10:45 A.M. verified she did not give the 180 mgs Polysaccharide Iron Complex with the morning medications as ordered, and verified she gave colace 100 mgs two tabs instead of the ordered senna-S 8.6 mgs-50 mgs. Review of the facility policy titled administration procedures for all medications dated 08/01/20 revealed prior to removing the medication package/container from the cart/drawer to check the medication administration record for the order. 366120 Page 4 of 5 366120 04/17/2024 Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040

F 0759 This deficiency represents non-compliance investigated under Complaint Number OH00152801. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366120 Page 5 of 5