Health inspection·August 1, 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 medical record review, staff interviews, and review of facility policy, the facility failed to ensure staff assessed a resident's wound in a timely manner, delaying treatment. This affected one (Resident #35) of three residents reviewed for wound assessments. The facility census was 34. Residents Affected - Few Findings included: Review of the discharged medical record for Resident #35 revealed an admission date of 05/19/23. Diagnoses included difficulty with walking and muscle weakness. The resident was discharged to home on [DATE]. Review of the Minimum Data Set (MDS) assessment date 05/26/23 revealed Resident #35 was cognitively impaired. Resident #35 required extensive two person assistance with bed mobility and transfers. The resident was at risk for pressure ulcers, however the assessment indicated the resident did not have an active pressure ulcer. Review of Resident #35's most recent care plan revealed the resident had actual skin impairment to his bilateral buttock related to a Deep Tissue Injury (DTI). Interventions included: encourage good nutrition, follow protocols for treatment of injury and resident needs, and pressure reduction cushion to protect skin while up in chair. Review of shower sheets from 05/26/23 to 05/30/23 revealed nurse aides noted Resident #35 had reddened area to bottom with an open area. Review of the skin sweep completed on 05/29/23 revealed Resident #35 had intact skin. Review of the progress note dated 05/31/23 revealed Resident #35 had a pressure area to the coccyx. The wound nurse would see the resident during next rounds. An order was placed for turning and repositioning every shift and an air mattress was ordered. The resident was incontinent of stool multiple times per day due to lactulose use for increased ammonia. The lactulose was decreased. Review of the wound assessment dated [DATE] revealed Resident #35 had an unstageable DTI to the coccyx measuring 10.8 centimeters (cm) by 11 cm. Nursing staff reported the wound developed quickly due to the resident's poor nutritional intake. The following treatment was initiated: clean, pat dry, apply Medi honey alignate and foam dressing every day and as needed. On 06/05/23, the wound measured 8 cm by 9 cm. The wound was healing and no changes to the treatment were made. Review of the falsification of documentation investigation revealed on 05/29/23, Registered Nurse Page 1 of 4 366263 366263 08/01/2023 Grace Brethren Village 1010 Taywood Road Englewood, OH 45322

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (RN) #400 completed a skin sweep document for Resident #30, stating the resident's skin was intact. RN #400 admitted to the Director of Nursing (DON) she did not complete an actual skin assessment for Resident #30. Further investigation verified nurse aides reported the resident's wound on shower sheets on 05/26/23 and 05/30/23 and verbally notified RN #400. Interview on 07/19/23 at 2:30 P.M. with the Administrator revealed RN #400 admitted she did not perform a skin assessment for Resident #35 on 05/29/23, as indicated on the skin sweep document. Interviews with nurse aides revealed they informed RN #400 Resident #35 had a reddened area and open wound. The Administrator further verified the resident's treatment was delayed due to RN #400 not properly assessing the resident. Interview on 08/01/23 at 9:30 A.M. with State Tested Nurse Aide (STNA) #202 verified she initially noticed Resident #35's buttocks were red and notified RN #400, who did not look at the resident, but advised STNA #202 to start applying zinc. A few days later when STNA #202 showered Resident #35 again, she noticed the resident's buttock was bloody and choppy looking, which was reported to a nurse. STNA #202 further reported Resident #35 was having frequent loose stools during this time and was resistive to care needs. Resident #35 did not turn himself in bed, but did scoot up and down in the bed. Resident #35 rarely let staff turn and reposition him, or use pillows and just wanted to return home with his son. Once the resident developed the wound, he was more willing to allow staff to reposition him. Interview on 08/01/23 at 10:43 A.M. with the Medical Director (MD) revealed Resident #35's pressure area was unavoidable due to many comorbidities such as diabetes, Urinary Tract Infection (UTI) with Methicillin-resistant Staphylococcus aureus (MRSA), pneumonia with antibiotic use, and use of lactulose, which increased chances of diarrhea. The MD further reported Resident #35 had decreased mobility and required two staff assistance with transfers using a Hoyer life. Prior to the development of the pressure ulcer, the facility was unable to get an air mattress. Review of the policy titled, Pressure Ulcer Injury Risk Assessment, dated 03/20 revealed staff would complete a comprehensive skin assessment and document findings on a facility approved skin assessment tool. This deficiency represents non-compliance investigated under Complaint Number OH00143584. 366263 Page 2 of 4 366263 08/01/2023 Grace Brethren Village 1010 Taywood Road Englewood, OH 45322

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 record review, staff interview, review of a personnel file, and review of facility policy, the facility failed to ensure staff did not falsify medical records. This affected one (Resident #35) of three residents reviewed for falsifying medical records. The facility census was 34. Findings included: Review of the discharged medical record for Resident #35 revealed an admission date of 05/19/23. Diagnoses included difficulty with walking and muscle weakness. The resident was discharged to home on [DATE]. Review of the Minimum Data Set (MDS) assessment date 05/26/23 revealed Resident #35 was cognitively impaired. Resident #35 required extensive two person assistance with bed mobility and transfers. The resident was at risk for pressure ulcers, however the assessment indicated the resident did not have an active pressure ulcer. Review of Resident #35's most recent care plan revealed the resident had actual skin impairment to his bilateral buttock related to a Deep Tissue Injury (DTI). Interventions included: encourage good nutrition, follow protocols for treatment of injury and resident needs, and pressure reduction cushion to protect skin while up in chair. Review of shower sheets from 05/26/23 to 05/30/23 revealed nurse aides noted Resident #35 had reddened area to bottom with an open area. Review of the skin sweep completed on 05/29/23 revealed Resident #35 had intact skin. Review of the progress note dated 05/31/23 revealed Resident #35 had a pressure area to the coccyx. Review of the wound assessment dated [DATE] revealed Resident #35 had an unstageable DTI to the coccyx. Review of the falsification of documentation investigation revealed on 05/29/23, Registered Nurse (RN) #400 completed a skin sweep document for Resident #30, stating the resident's skin was intact. RN #400 admitted to the Director of Nursing (DON) she did not complete an actual skin assessment for Resident #30. Interview on 07/19/23 at 2:30 P.M. with the Administrator revealed RN #400 admitted she did not perform a skin assessment for Resident #35 on 05/29/23, as indicated on the skin sweep document. Interviews with nurse aides revealed they informed RN #400 Resident #35 had a reddened area and open wound. The Administrator further verified the resident's treatment was delayed due to RN #400 not properly assessing the resident. Interview on 08/01/23 at 9:30 A.M. with State Tested Nurse Aide (STNA) #202 verified she initially noticed Resident #35's buttocks were red and notified RN #400, who did not look at the resident, but advised STNA #202 to start applying zinc. 366263 Page 3 of 4 366263 08/01/2023 Grace Brethren Village 1010 Taywood Road Englewood, OH 45322

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of RN #400's personnel file revealed discipline on file related to falsifying records. RN #400 was terminated on 06/01/23 due to falsifying records. Review of the policy, Charting and Documentation, dated 07/17 revealed all services provided to the resident, or any changes in the resident's medical condition, shall be documented in the resident's medical record. Documentation in the medical record will be objective, completed, and accurate. This deficiency represents non-compliance investigated under Complaint Number OH00143584. 366263 Page 4 of 4