Health inspection·April 26, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure preventive devices and treatments to prevent the development of pressure ulcers were in place per the resident's plan of care and physician's order. This affected one (#59) of three residents reviewed for pressure ulcers. The census was 71. Residents Affected - Few Findings include: Review of the medical record for Resident #59 revealed an admission date of 01/28/21 with diagnoses including metabolic encephalopathy, Alzheimer's disease, hypertension (HTN), and osteoarthritis (OA). Review of the Minimum Data Set (MDS) assessment for Resident #59 dated 02/21/23 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Review of the pressure ulcer risk assessment for Resident #59 dated 03/26/23 revealed the resident was at risk for the development of pressure ulcers. Review of the care plan for Resident #59 dated 01/29/21 revealed the resident had the potential for impairment of skin integrity related to poor tissue integrity, disease process, immobility, incontinence, and obesity. Interventions included to consult the nurse practitioner for evaluation and treatment as indicated, elevate heels from bed surface while in bed, monitor use of skin protective devices, assess condition of the skin over bony prominences for breakdown, educate the resident on the need to reposition, provide treatment per physician orders, and instruct on the importance of good skin care. Review of the care plan for Resident #59 dated 04/25/23 revealed the resident had a pressure ulcer related to cognitive impairment, decreased functional ability, history of skin breakdown, impaired and decreased mobility, and medical decline. Interventions included to keep heel protectors in place (added 01/12/23), keep skin clean and dry, monitor nutrition and hydration, monitor shoes to ensure they fit well, observe for reddened areas, a pressure relieving bed, protect skin from further injury, provide wound care treatments per physician orders, and reposition at least every two hours as the resident allowed. Review of the nurse progress note for Resident #59 dated 01/11/23 revealed the resident developed an unstageable pressure ulcer (unstageable full-thickness skin and tissue loss) to her right heel first identified on 01/06/23. Resident #59 was assessed by the wound physician and the pressure ulcer measured 1.8 centimeters (cm) in length by 6.2 cm in width and the depth obscured by slough tissue Page 1 of 4 366175 366175 04/26/2023 Carecore at the Meadows 11760 Pellston Court Cincinnati, OH 45240

F 0686 (non-viable yellow, tan, gray, green or brown tissue). Level of Harm - Minimal harm or potential for actual harm Review of a wound physician progress note for Resident #59 dated 03/22/23 revealed the pressure ulcer to the right heel was healed. Residents Affected - Few Review of the physician's order dated 03/27/23 for Resident #59 revealed an order dated 03/27/23 to apply skin prep, an absorbent pad, and wrap the right foot with Kerlix gauze once daily for protection. Review of the April 2023 treatment administration record (TAR) for Resident #59 revealed the treatment order to the right heel was signed off as completed. Observation on 04/25/23 at 4:23 P.M. with Licensed Practical Nurse (LPN) #345 of Resident #59 revealed the protective treatment ordered by the physician was not in place to the resident's right foot and the resident was not wearing heel protectors. A pair of heel protectors was sitting across the room from the resident. Interview on 04/25/23 at 4:34 P.M. with LPN #345 confirmed Resident #59 did not have the protective treatment to her right foot in place and the resident was not wearing the heel protectors as care planned. Observation on 04/26/23 at 6:42 A.M. with State Tested Nursing Assistant (STNA) #285 of Resident #59 revealed the protective treatment ordered by the physician was not in place to the resident's right foot and the resident was not wearing heel protectors. A pair of heel protectors was sitting across the room from the resident. Interview on 04/26/23 at 6:42 A.M. with STNA #285 confirmed Resident #59 did not have the protective treatment to her right foot in place and the resident was not wearing the heel protectors. Interview on 04/26/23 at 12:55 P.M. with the Director of Nursing (DON) confirmed Resident #59 previously had an unstageable pressure ulcer to her right heel which healed in March 2023. DON confirmed Resident #59 was at risk of the pressure ulcer reopening, and the heel protectors to both feet and the protective treatment to her right foot should be in place at all times as preventative measures. Review of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated April 2018, revealed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers such as immobility, recent weight loss, and a history of pressure ulcers. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. This deficiency represents non-compliance investigated under Complaint Number OH00142152. 366175 Page 2 of 4 366175 04/26/2023 Carecore at the Meadows 11760 Pellston Court Cincinnati, OH 45240

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on medical record review, observation, staff interview, and review of the facility, policy the facility failed to ensure fall prevention devices were in place per the resident's plan of care and physician's order. This affected one (#59) of three residents reviewed for falls. The census was 71. Findings include: Review of the medical record for Resident #59 revealed an admission date of 01/28/21 with diagnoses including metabolic encephalopathy, Alzheimer's disease, hypertension (HTN), and osteoarthritis (OA). Review of the Minimum Data Set (MDS) assessment for Resident #59 dated 02/21/23 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Review of the fall risk assessment for Resident #59 dated 03/26/23 revealed the resident was at risk for falls. Review of the care plan for Resident #59 dated 09/06/22 revealed the resident had the potential for injuries and falls related to balance deficit, cognitive deficits, disease progression, history of falls, impulsivity, poor communication and comprehension, wandering, weakness, and a fall on 08/25/22 with a laceration to the eye. Interventions included to assist in position for comfort as needed, anticipate needs as able, encourage to ask and use the call light for assistance, keep call light within reach, frequent orientation to room, bathroom, call light, and facility, keep hydration cup to bedside, maintain uncluttered environment, monitor safety and preventative devices for application, instruct on use of adaptive equipment as needed, and observe and report unsafe conditions. Review of the April 2023 monthly physician's orders revealed an order dated 09/07/22 for a fall mat to be placed to the left side of Resident #59's bed while in bed for fall prevention. Review of the April 2023 treatment administration record (TAR) for Resident #59 revealed the fall mat to the left side of the bed was signed off as completed. Observation on 04/25/23 at 4:23 P.M. with Licensed Practical Nurse (LPN) #345 of Resident #59 revealed the resident was resting in bed with the right side of the bed pushed against the wall. There was no fall mat in place to the left side of the bed. No fall mats were observed anywhere in the resident's room. Interview on 04/25/23 at 4:34 P.M. with LPN #345 confirmed Resident #59 did not have a fall mat in place to the left side of her bed. LPN #345 confirmed she was not aware of an order for the resident to have a fall mat. Observation on 04/26/23 at 6:42 A.M. with State Tested Nursing Assistant (STNA) #285 of Resident #59 revealed the resident was resting in bed with the right side of the bed pushed against the wall. There was no fall mat in place to the left side of the bed. No fall mats were observed anywhere in the resident's room. 366175 Page 3 of 4 366175 04/26/2023 Carecore at the Meadows 11760 Pellston Court Cincinnati, OH 45240

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/26/23 at 6:42 A.M. with STNA #285 confirmed Resident #59 did not have a fall mat in place to the left side of her bed. STNA #285 confirmed she did not think the resident was supposed to have a fall mat. Observation on 04/26/23 at 11:06 A.M. with STNA #280 of Resident #59 revealed the resident was resting in bed with the right side of the bed pushed against the wall. There was no fall mat in place to the left side of the bed. No fall mats were observed anywhere in the resident's room. Interview on 04/26/23 at 11:06 AM. with STNA #280 confirmed Resident #59 did not have a fall mat in place to the left side of her bed. STNA #280 confirmed she did not think the resident was supposed to have a fall mat. Interview on 04/26/23 at 12:55 P.M. with the Director of Nursing (DON) confirmed Resident #59 was at risk for falls and experienced falls with injury in the facility in the past. DON confirmed Resident #59 had a physician's order to have a fall mat placed to the left side of her bed to with the right side of the bed pushed against the wall to maximize room space. DON confirmed the purpose of the fall mat was to minimize risk of injury if the resident fell out of bed. Review of the undated facility policy titled, Fall Risk Management, revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. This deficiency represents non-compliance investigated under Master Complaint Number OH00142152, Complaint Number OH00141851, and Complaint Number OH00141822. 366175 Page 4 of 4