Health inspection·May 16, 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 observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure interventions to prevent skin breakdown were in place as ordered by the physician and per the resident plan of care. This affected two (#18 and #60) of three residents reviewed for pressure ulcers. The facility census was 86. Residents Affected - Few Finding include: 1. Review of the medical record for Resident #18 revealed an admission date of 03/06/23 with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD), osteoporosis, and mitral valve insufficiency. Review of the Minimum Data Set (MDS) assessment for Resident #18 dated 03/13/23 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Further review of the MDS assessment for Resident #18 revealed the resident was assessed with a stage four pressure ulcer (full-thickness skin and tissue loss) which was present upon admission to the facility. Review of the pressure ulcer risk assessment for Resident #18 dated 03/06/23 revealed the resident was at risk for the development of pressure ulcers. Review of the care plan for Resident #18 dated 03/06/23 revealed the resident had an alteration in skin integrity as evidenced by a pressure ulcer was present at the sacrum. Interventions included to elevate heels in bed as tolerated and as needed, encourage and assist the resident to turn and reposition as needed, provide assistance with ADLs and positioning as needed, provide the resident and family education on skin impairment and potential complications as needed, provide skin care as needed, and provide treatments per physician orders. Review of the care plan for Resident #18 dated 03/14/23 revealed the resident was at risk for alteration in skin integrity related to blood disease, cognitive impairment, dementia, incontinence, mobility impairment, and existing pressure ulcer. Interventions included that staff should encourage and assist the resident to elevate heels when in bed as needed and as tolerated, and provide assistance with ADLs and positioning as needed. Review of Resident #18's May 2023 monthly physician orders revealed an order dated 03/06/23 to encourage and assist the resident to float heels every shift. Review of the May 2023 treatment administration record (TAR) for Resident #18 revealed the order to float heels was signed off as completed daily every shift. Page 1 of 3 366251 366251 05/16/2023 Home at Hearthstone, The 8028 Hamilton Avenue Cincinnati, OH 45231

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nursing progress notes for Resident #18 dated 05/01/23 to 05/15/23 revealed no documentation of Resident #18's refusal of interventions to prevent skin breakdown including floating of heels. Observation on 05/15/23 at 9:22 A.M. of Resident #18 revealed the resident was resting in bed and her heels were not floated or elevated. There were no open areas or redness noted to Resident #18's heels at that time. Interview on 05/15/23 at 9:22 A.M. with State Tested Nurse Aide (STNA) #335 confirmed Resident #18's heels were not floated or elevated, and she was not aware of any orders to float or elevate the resident's heels. Observation on 05/16/23 at 6:55 A.M. of Resident #18 revealed resident was resting in her recliner and her heels were not floated or elevated. There were no open areas or redness noted to Resident #18's heels at that time. Interview on 05/16/23 at 6:55 A.M. with STNA #360 confirmed Resident #18's heels were not floated or elevated, and she was not aware of any orders to float or elevated the resident's heels. STNA #360 further confirmed she learned in report the night shift nurse aide got the resident up in her recliner about an hour prior to the observation. STNA #360 confirmed Resident #18's recliner did have a footrest which could be raised by staff if desired in order to elevate Resident #18's heels. Interview on 05/16/23 at 1:00 P.M. with the Administrator confirmed Resident #18 had a physician's order to float or elevate her heels every shift to prevent skin breakdown. 2. Review of the medical record for Resident #60 revealed an admission date of 09/19/22 with diagnoses including spinal stenosis, hypertension (HTN), acute kidney failure (AKF), diabetes mellitus (DM), Down's syndrome, and seizure disorder. Review of the MDS assessment for Resident #60 dated 05/03/23 revealed the resident was cognitively impaired and required extensive assistance of one to two staff with ADLs. Review of the MDS assessment for Resident #60 revealed the resident was assessed with the presence of a stage four pressure ulcer that was not present on admission to the facility. Review of the pressure ulcer risk assessment for Resident #60 dated 01/30/22 revealed the resident was at risk for the development of pressure ulcers. Review of the care plan for Resident #60 dated 12/21/21 revealed the resident was at risk for alteration in skin integrity related to apathy and lack of concern, cognitive impairment, dementia, diabetes, incontinence, mobility impairment, and obesity. Interventions included to assess for pain and provide treatment per physician orders, encourage and assist the resident to elevate heels when in bed as needed and tolerated, encourage and assist the resident to turn and reposition as needed, offloading pressure boots as tolerated to the left foot every shift and check skin when donning and doffing, provide assistance with ADLs and positioning as needed, provide the resident and family education on maintaining skin integrity and potential complications as needed, and provide skin care as needed. 366251 Page 2 of 3 366251 05/16/2023 Home at Hearthstone, The 8028 Hamilton Avenue Cincinnati, OH 45231

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the care plan for Resident #60 dated 10/05/22 revealed the resident had an alteration in skin integrity as evidenced by a pressure ulcer was present to the sacrum. Interventions included to assess for pain and provide treatment per physician order, elevate heels in bed as tolerated and as needed, encourage and assist the resident to turn and reposition as needed, provide assistance with ADLs and positioning as needed, provide the resident and family education on skin impairment and potential complications as needed, provide skin care as needed, and provide treatments per physician orders. Review of May 2023 monthly physician orders for Resident #60 revealed an order dated 01/18/23 for staff to encourage and assist the resident to float heels off the bed as tolerated every shift, and an order to apply offloading pressure boots as tolerated with skin checks completed with donning and doffing as tolerated. Review of the May 2023 TAR for Resident #60 revealed the orders to float heels and provide offloading pressure boots were signed off as completed every shift. Review of the nursing progress notes for Resident #60 dated 05/01/23 to 05/15/23 revealed there was no documentation of the resident's refusal of interventions to prevent skin breakdown including floating heels and the application of bilateral pressure boots. Observation on 05/15/23 at 9:31 A.M. of Resident #60 revealed the resident had a pressure boot on her left foot; however, Resident #60's right heel was laying directly on the mattress and neither heel was elevated. Observation of the exposed right heel revealed no redness or skin breakdown. Interview on 05/15/23 at 9:31 A.M. with Registered Nurse (RN) #300 confirmed Resident #60 had orders to float her heels and to have offloading pressure boots applied as ordered. RN #300 confirmed Resident #60's heels were not floated or elevated at the time of the observation. Review of the facility policy titled, Skin Assessment, dated September 2017, revealed the facility would provide necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. The facility would ensure interventions for preventing pressure ulcer development were defined and implemented in accordance with the resident's needs, goals, and recognized standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00139522, Complaint Number OH00135816, and Complaint Number OH00135758. 366251 Page 3 of 3