Health inspection·July 13, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation, record review, and staff interview, the facility failed to ensure the appropriate disciplines were notified per the plan of care, after a resident was observed in the dining room choking. This affected one (#37) of eight residents observed eating in the dining room. The census was 56. Findings include: Review of Resident #37's medical record revealed an admission date of 05/12/22, with diagnoses including metabolic encephalopathy, cerebral infarction, dementia, gastro-esophageal reflux disease. Review of physician orders dated 06/03/22 revealed speech therapist to treat Resident #37, five times per week for four weeks to address deficits and dysphagia, regular-sodium precautions diet, regular texture, and thin liquids consistency. Review of plan of care dated 06/08/22 revealed Resident #37 had a swallowing problem related to complaints of difficulty or pain with swallowing. Interventions included to monitor, document, and report to nurse, dietician, and physician for difficulty swallowing, holding food in mouth and prolonged swallowing time, coughing, throat clearing, drooling, or pocketing food in mouth. Refer to speech therapist for swallowing evaluation. Review of the progress note dated 07/01/22 revealed Resident #37 had new order for speech therapy three times per week for four weeks. Observation on 07/05/22 at 11:32 P.M., with Stated Tested Nurses Aid (STNA) #506 revealed Resident #37 was eating his lunch in the dining room. Resident #37 was served a regular diet which included a cheeseburger. Observation revealed Resident #37 took a bite of the cheeseburger. Resident #37's face became deep red, resident back up his wheelchair, leaned forward, drooling, and not talking. Resident #37 coughed hard and was able to get the food up. STNA #506 went to get the nurse. Review of progress notes dated from 07/01/22 through 07/09/22 revealed no documentation notifying physician or speech therapist of choking incident on 07/05/22. Interview on 07/07/22 at 2:27 P.M., with Director of Nursing (DON) verified there was no documentation in the chart regarding choking incident on 07/05/22. The DON verified the physician or speech therapist were not notified the of choking incident, Resident #37, that occurred in the dining room on 07/05/22. The DON confirmed that the Physician and speech therapist should of been notified after the choking incident. Page 1 of 7 366194 366194 07/13/2022 Bennington Glen Nursing & Rehabilitation Center 825 State Route 61 Marengo, OH 43334

F 0580 Level of Harm - Minimal harm or potential for actual harm Interview on 07/07/22 at 2:28 P.M., with Speech therapist (ST) #599, revealed Resident #37 had been upgraded from thickened liquids to thin liquids but kept for cognitive treatment this started June ninth, making sure he was tolerating and continuing with swallowing exercises. The ST #599 confirmed she did not know of choking episode on 07/05/22 and thinks she should have been notified unless it was just a strong cough. Residents Affected - Few Interview on 07/07/22 2:39 P.M., with Stated Tested Nurses Aid (STNA) #506 revealed she was passing trays on 07/05/22 and witnessed Resident #37 coughing hard with mucous coming out of his nose. Interview on 07/07/22 at 3:12 P.M., with DON #522 revealed she would have expected RN #598 to notify speech therapy and the physician of the choking episode and to document incident in the medical chart. Interview on 07/07/22 at 3:15 P.M., with Registered Nurse (RN) #598 revealed STNA #506 had come and got her and said Resident #37 was choking. RN #598 revealed Resident #37 wasn't choking at time she went to him. RN #598 revealed she was not aware speech therapy was working with Resident #37. RN #598 verified she did not notify speech therapy or the doctor because she did not see resident choking, just thought he was having a coughing spell. 366194 Page 2 of 7 366194 07/13/2022 Bennington Glen Nursing & Rehabilitation Center 825 State Route 61 Marengo, OH 43334

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 record review, observation, staff interviews, policy review and review of information from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to accurately assess, and timely obtain a treatment when a resident was re-admitted to the facility with a pressure wound. This affected one (#40) of three reviewed for pressure ulcers. Facility census was 56. Residents Affected - Few Findings include: Review of Resident #40's medical record revealed an admission date of 03/20/18 and readmission date of 07/01/22. Diagnoses for Resident #40 included atrial flutter, aphasia, kidney failure, and hemiplegia and hemiparesis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was cognitively intact. The resident required extensive assistance of two for bed mobility and transfer. Resident #40 had a Stage III (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia) pressure ulcer. Review of the electronic facility form titled Admit/Readmit Screener form dated 07/01/22 (and signed as completed on 07/06/22) revealed Resident #40 had a Stage II pressure ulcer to the right heel measuring 2 cm long, 2 cm wide, and was 0.2 cm deep. Review of physician orders dated 07/01/22 to 07/04/22 revealed no orders to treat the right heel. Review of the Weekly Skin Integrity assessment dated [DATE] revealed Resident #40 had a Stage III pressure ulcer to right inner heel with deterioration to the peri wound. The pressure ulcer measured 2.6 cm long, 3 cm wide, and was 0.2 cm deep. Review of physician orders dated 07/05/22, revealed an ordered for a foam boot to the right heel at all times, and the right inner heel was to be cleansed with wound cleaner, patted dry, Calcium Alginate (for moderate to heavily exudative wounds) added, and covered with foam border dressing every day, and the resident may be followed by the in-house wound doctor. Review of the treatment administration record (TAR) revealed the foam boot was applied to Resident #40's right heel the evening of 07/05/22. Further review of the TAR, revealed there was no documentation of a treatment to the right heel from 07/01/22 to 07/04/22. Review of a physician order dated 07/06/22 revealed Resident #40 was ordered the right inner heel to be cleansed with wound cleanser, patted dry, and covered with foam border dressing every day. Review of the TAR revealed a treatment to Resident #40's right inner heel was started on 07/06/22. Review of the plan of care dated 07/06/22 revealed Resident #40 had a Stage IV pressure ulcer to right inner heal. Interventions included the treatment to be completed as ordered. Review of a Skin/Wound note dated 07/06/22 at 1:09 P.M., revealed Resident #40 was seen by the wound doctor. 366194 Page 3 of 7 366194 07/13/2022 Bennington Glen Nursing & Rehabilitation Center 825 State Route 61 Marengo, OH 43334

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the wound doctor note dated 07/06/22 revealed Resident #40 had a Stage III pressure ulcer to right heel that measured 3 cm long, 3.5 cm wide, and 0.3 cm deep. There was a moderate amount of serous (thin clear serum) drainage. A correction note dated 07/06/22 revealed Resident #40 pressure ulcer to the right heel was a Stage IV. Interview on 07/07/22 at 9:06 A.M., with Wound Nurse #545 verified she was not working when Resident #40 returned from the hospital on [DATE]. Wound Nurse #545 stated if a resident had a wound, the expectation was for an order to be obtained and treatment to started. Wound Nurse #545 verified she assessed Resident #40's pressure ulcer on 07/05/22 and put orders in at that time. Wound Nurse #545 verified she did not know if a dressing had been put on or changed since Resident #40 return from the hospital on [DATE]. The dressing that was on the wound was all bunched up when she assessed the wound; so she was unable to see if the dressing was dated. Wound Nurse #545 verified the wound doctor assessed Resident #40 on 07/06/22 and stated the pressure ulcer was now a Stage IV. Interview on 07/07/22 at 10:49 A.M., with Registered Nurse (RN) #550 verified she was working when Resident #40 returned from the hospital on [DATE]. RN #550 stated a Mepilex (absorbent foam) dressing was in place to Resident #40's pressure ulcer and was sticking to the wound, so it was not removed. RN #550 verified she wanted the wound nurse to see the wound and did not remove the dressing that was in place when Resident #40 returned from the hospital on [DATE]. Observation on 07/11/22 at 10:09 A.M., of wound care for Resident #40 by Wound Nurse #545 revealed the right heel had approximately 50-percent brown/yellow slough (dead skin tissue that may have a yellow or white appearance) in the center of the wound bed. The surrounding tissue had some white maceration, and a moderate amount of serous drainage was noted. Interview on 07/11/22 at 4:05 P.M., with Wound Nurse #545 verified she had changed documentation of the admitting nurse on the Admit/Readmit Screener dated 07/01/22 from a Stage II pressure ulcer that measured 2 cm long, 2 cm wide, and 0.2 cm deep; the documentation now revealed Resident #40 was admitted with a Stage IV pressure ulcer that measured 3 cm long, 3.5 cm wide, and 0.2 cm deep. Wound Nurse #545 verified she did not observe the wound until 07/05/22. Wound Nurse #545 also verified she changed her own documentation on the Weekly Skin Integrity assessment dated [DATE] from a Stage III pressure ulcer to right inner heel with deterioration to the peri wound (skin surrounding the wound) that measured 2.6 cm long, 3 cm wide, and 0.2 cm deep to a Stage IV with measurements of 3 cm long, 3.5 cm wide, and 02. cm deep. Wound Nurse #545 verified the previous documentation was not available. The documentation was changed because the wound had deteriorated, and she did not agree with the documentation by the admitting nurse on 07/01/22 or her own previously documented observation on the wound on 07/05/22. Review of the policy titled Pressure Ulcer Assessment and Prevention, dated 10/04/21 revealed the purpose was to assess residents' potential for development of pressure ulcers so that prevention techniques can be implemented. Nursing staff will follow guidelines from the NPIAP. Review of information from the NPIAP revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin 366194 Page 4 of 7 366194 07/13/2022 Bennington Glen Nursing & Rehabilitation Center 825 State Route 61 Marengo, OH 43334

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few overlying bony prominence's including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Staff should ensure that the heels are free from the bed, use heel offloading devices or polyurethane foam dressings on individuals at high-risk for heel ulcers. The implementation of a treatment for an existing pressure ulcer is essential to promote healing of the wound. Wound status could change rapidly. Wound improvement or deterioration indicated by change in wound dimensions, change in tissue quality, an increase or decrease in wound exudate, signs of infection or other complications all provided indications of the effectiveness of the current management plan. Further review of the NPIAP revealed a Stage II pressure injury is partial-thickness skin loss with exposed dermis. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage III pressure injury is full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage IV pressure injury is full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. 366194 Page 5 of 7 366194 07/13/2022 Bennington Glen Nursing & Rehabilitation Center 825 State Route 61 Marengo, OH 43334

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure medical records were maintain with accurate documentation of a resident's condition. This affected two (#37 and #40) of 25 residents medical records reviewed. The census was 56. Findings include: 1. Review of Resident #37's medical record revealed an admission date of 05/12/22, with diagnoses including metabolic encephalopathy, cerebral infarction, dementia, gastro-esophageal reflux disease. Review of physician orders dated 06/03/22 revealed speech therapist to treat Resident #37, five times per week for four weeks to address deficits and dysphagia, regular-sodium precautions diet, regular texture, and thin liquids consistency. Observation on 07/05/22 at 11:32 P.M., with Stated Tested Nurses Aid (STNA) #506 revealed Resident #37 was eating his lunch in the dining room. Resident #37 was served a regular diet which included a cheeseburger. Observation revealed Resident #37 took a bite of the cheeseburger. Resident #37's face became deep red, resident back up his wheelchair, leaned forward, drooling, and not talking. Resident #37 coughed hard and was able to get the food up. STNA #506 went to get the nurse. Review of progress notes dated from 07/01/22 through 07/09/22 revealed no documentation of the choking incident or notifying physician or speech therapist of choking incident on 07/05/22. Interview on 07/07/22 at 2:27 P.M., with Director of Nursing (DON) verified there was no documentation in the chart regarding choking incident on 07/05/22. 2. Review of Resident #40's medical record revealed an admission date of 03/20/18 and readmission date of 07/01/22. Diagnoses for Resident #40 included atrial flutter, aphasia, kidney failure, and hemiplegia and hemiparesis. Review of a narrative nurse note dated 07/01/22 at 2:27 P.M., revealed Resident #40 was readmitted to the facility. The resident had an area to right heel that measured 2 centimeters (cm) long and 2 cm wide. The wound bed was red, and no slough was noted. The wound edges were attached and a scant amount of serosanguinous (blood and serum) drainage was noted. Review of the facility form titled Admit/Readmit Screener form dated 07/01/22 revealed Resident #40 had a Stage II pressure ulcer to the right heel measuring 2 cm long, 2 cm wide, and was 0.2 cm deep. Review of the Weekly Skin Integrity assessment dated [DATE] revealed Resident #40 had a Stage III pressure ulcer to right inner heel with deterioration to the peri wound. The pressure ulcer measured 2.6 cm long, 3 cm wide, and was 0.2 cm deep. Interview on 07/07/22 at 10:49 A.M., with Registered Nurse (RN) #550 verified she was working when Resident #40 returned from the hospital on [DATE]. RN #550 stated a Mepilex (absorbent foam) dressing was in place to Resident #40's pressure ulcer and was sticking to the wound, so it was not 366194 Page 6 of 7 366194 07/13/2022 Bennington Glen Nursing & Rehabilitation Center 825 State Route 61 Marengo, OH 43334

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few removed. RN #550 verified she wanted the wound nurse to see the wound and did not remove the dressing that was in place when Resident #40 returned from the hospital on [DATE]. Observation on 07/11/22 at 10:09 A.M., of wound care for Resident #40 by Wound Nurse #545 revealed the right heel had approximately 50-percent brown/yellow slough (dead skin tissue that may have a yellow or white appearance) in the center of the wound bed. The surrounding tissue had some white maceration, and a moderate amount of serous drainage was noted. Interview on 07/11/22 at 4:05 P.M., with Wound Nurse #545 verified she had changed documentation of the admitting nurse on the Admit/Readmit Screener dated 07/01/22 from a Stage II pressure ulcer that measured 2 cm long, 2 cm wide, and 0.2 cm deep. The documentation now revealed Resident #40 was admitted with a Stage IV pressure ulcer that measured 3 cm long, 3.5 cm wide, and 0.2 cm deep. Wound Nurse #545 verified she did not observe the wound until 07/05/22. Wound Nurse #545 also verified she changed her own documentation on the Weekly Skin Integrity assessment dated [DATE] from a Stage III pressure ulcer to right inner heel with deterioration to the peri wound (skin surrounding the wound) that measured 2.6 cm long, 3 cm wide, and 0.2 cm deep to a Stage IV with measurements of 3 cm long, 3.5 cm wide, and 02. cm deep. Wound Nurse #545 verified the previous documentation was not available. The documentation was changed because the wound had deteriorated, and she did not agree with the documentation by the admitting nurse on 07/01/22 or her own previously documented observation on the wound on 07/05/22. Interview on 07/11/22 at 4:29 P.M., with the Director of Nursing verified documentation should not be changed where the previous documentation was not available. If an error was noted, an addendum or clarification should be documented. 366194 Page 7 of 7