Health inspection·November 29, 2023

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 medial record review, staff interview, and review of facility policy, the facility failed to complete pressure ulcer treatments as ordered. This affected three (#1, #4, and #5) of three residents reviewed for pressure ulcer care. The census was 69. Residents Affected - Few Findings include: 1. Review of Resident #1's medical record revealed an admission date of 03/09/22. Diagnoses listed included type two diabetes mellitus, hypertension, congestive heart failure, chronic kidney disease, and stage four pressure ulcer of sacral region. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and had a stage four pressure ulcer. Review of wound physician documentation dated 10/30/23 and 11/20/23 revealed Resident #1 had a stage four pressure ulcer to the sacrum. Review of physician orders dated 11/21/23 revealed an order dated 11/21/23 for cleanse sacrum with normal saline (NS) or wound cleanser. Pat dry and pack wound lightly with calcium alginate with silver (absorbent antimicrobial wound treatment) and also apply to the top of the wound. Cover with a bordered foam dressing every day and night shift. An order dated 11/21/23 for cleanse sacrum with NS or wound cleanser. Pat dry and pack wound lightly with calcium alginate with silver and cover with a bordered foam dressing every day and night shift. Review of treatment administration records (TAR's) revealed wound treatments were not documented as being completed on 11/07/23 and 11/24/23 dayshift. On 11/25/23 the nightshift treatment was not documented as completed. 2. Review of Resident #4's medical record revealed an admission date of 10/10/13. Diagnoses listed included paraplegia, chronic pain syndrome, breast cancer, chronic kidney disease, type two diabetes mellitus, stage four pressure ulcer, and major depressive disorder. Review of an annual MDS assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and had a stage four pressure ulcer. Review of physician orders revealed an order dated 10/23/23 for cleanse coccyx with wound cleanser, pat dry, lightly pack with calcium alginate with silver and cover with foam dressing every day and night shift. Page 1 of 4 366178 366178 11/29/2023 Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of TAR's revealed wound treatments were not documented as being completed on 11/25/23 and 11/26/23 dayshift. On 11/26/23, 11/27/23, and 11/28/23 the nightshift treatments were not documented as completed. 3. Review of Resident #5's revealed an admission date of 10/02/23. Diagnoses listed included hypotension, constipation, type two diabetes mellitus, atrial fibrillations, stage four pressure ulcer, atherosclerotic heart disease, and metabolic encephalopathy. Review of quarterly MDS assessment dated [DATE] revealed Resident #5 was severely cognitively impaired and had a stage four pressure ulcer. Review of wound physician documentation dated 10/30/23 and 11/20/23 revealed Resident #4 had a stage four pressure ulcer to the sacrum. Review of physician orders revealed an order dated 10/23/23 for cleanse wound to coccyx with wound cleanser, pat dry and lightly pack wound with collagen sheet (wound bed treatment) and wound cleanser moistened Kerlix (gauze) including the undermined area from 10 o'clock to 3 o'clock and cover with foam border dressing every day shift. Review of TAR's revealed the wound treatments were not documented as being completed on 11/15/23, 11/16/23, 11/18/23, and 11/24/23. During an interview on 11/29/23 at 10:15 A.M. the Director of Nursing (DON) confirmed wounds treatments for Resident #1, #4, and #5 were not documented as completed for the above listed dates. Review of the facility's policy titled Wound Care dated August 2023 revealed after completion of a wound treatment staff should document the treatment was completed in the electronic medical record. This deficiency represents non-compliance investigated under Complaint Number OH00148162. 366178 Page 2 of 4 366178 11/29/2023 Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medial record review and staff interview, the facility failed complete urinary catheter care as ordered. This affected three (#1, #4, and #5) of three residents reviewed for urinary catheters. The census was 69. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 03/09/22. Diagnoses listed included type two diabetes mellitus, hypertension, congestive heart failure, chronic kidney disease, and stage four pressure ulcer of sacral region. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and had a stage four pressure ulcer. Review of physician orders revealed an order dated 07/19/23 was for Foley (urinary catheter) two times as day and as needed (PRN) for preventative. Review of treatment administration records (TAR's) revealed Foley care was not documented as being completed on two times a day 11/07/23, 11/11/23, 11/15/23, 11/16/23, 11/18/23, and 11/21/23. 2. Review of Resident #4's medical record revealed an admission date of 10/10/13. Diagnoses listed included paraplegia, chronic pain syndrome, breast cancer, chronic kidney disease, type two diabetes mellitus, stage four pressure ulcer, and major depressive disorder. Review of an annual MDS assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and had a stage four pressure ulcer. Review of physician orders revealed an order dated 07/26/23 for Foley care every day and night for prevention. An order dated 07/26/23 was to monitor Foley output every day and nightshift. Review of TAR's revealed Foley care was not documented as being completed on dayshift 11/17/23, 11/24/23, 11/25/23,11/25/23, and 11/31/23. Nightshift Foley care was not completed on 11/02/23, 11/04/23, 11/06/23, 11/07/23, 11/08/23, 11/13/23, 11/14/23, 11/15/23, 11/18/23, 11/20/23, 11/21/23, 11/22/23, 11/26/23 and 11/27/23. Foley output was not documented on dayshift 11/05/23, 11/09/23, 11/17/23, 11/19/23, 11/24/23, 11/2523, 11/26/23, 11/27/23, and 11/31/23. Nightshift Foley output was not documented on 11/02/23, 11/04/23, 11/06/23, 11/07/23, 11/08/23, 11/13/23, 11/14/23, 11/15/23, 11/18/23, 11/20/23, 11/21/23,11/22/23, 11/26/23, and 11/27/23. 3. Review of Resident #5's revealed an admission date of 10/02/23. Diagnoses listed included hypotension, constipation, type two diabetes mellitus, atrial fibrillations, stage four pressure ulcer, atherosclerotic heart disease, and metabolic encephalopathy. Review of quarterly MDS assessment dated [DATE] revealed Resident #5 was severely cognitively impaired and had a stage four pressure ulcer. Review of physician orders revealed an order dated 12/16/22 to check Foley place every shift. 366178 Page 3 of 4 366178 11/29/2023 Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of TAR's revealed Foley placement was not documented as being checked on dayshift 11/07/23, 11/15/23, 11/16/23, 11/18/23, and 11/24/23. Foley placement was not documented as being completed on nightshift 11/11/23. During an interview on 11/29/23 at 10:15 A.M. the Director of Nursing (DON) confirmed urinary catheter care for Resident #1, #4, and #5 were not documented as completed for the above listed dates. This deficiency represents non-compliance investigated under Complaint Number OH00148162. 366178 Page 4 of 4