Health inspection·July 20, 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 interview and record review the facility failed to ensure wound care was provided as ordered by the physician for Residents #4, #11, and #18. This affected three residents (#4, #11, and #18) of three residents reviewed for wound care. The facility census was 33. Residents Affected - Few Findings include: 1. Review of Resident #4's medical record revealed an admission date of 09/20/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, chronic viral hepatitis c, protein-calorie malnutrition, epilepsy, hypertension, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had impaired cognition. The resident required extensive assistance with bed mobility and toileting and required total dependence for bathing and transfers. Review of the care plan dated 11/13/22 revealed Resident #4 had multiple skin impairments. Interventions included provide wound care as ordered. Review of Resident #4's physician orders for May 2023 revealed wound treatment to left anterior hip to clean with normal saline, pat dry, apply calcium alginate/silver (an effective barrier to bacterial penetration in moderately to heavily exudating wounds) and Medihoney (aides in healing wounds through its anti-inflammatory effects) to wound bed and apply border gauze twice a day and as needed (PRN). Wound treatment to right buttock and sacrum clean with cleanser of choice, pat dry and apply calcium alginate with silver and cover with foam border daily and PRN every night shift. Wound treatment to stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed), left lower medial knee to clean with cleanser of choice, pat dry, apply Dakin's (antiseptic) soaked gauze (1/4 strength) and cover with border gauze island dressing daily every night shift and PRN. Wound treatment to right elbow stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling), clean with wound cleanser of choice, pat dry, apply calcium alginate with silver, cover with gauze island with border daily and PRN every night shift. Wound treatment stage III to left anterior shoulder clean with wound cleanser of choice, pat dry, apply Dakin's-soaked gauze (1/4 strength) to peri wound bed, apply zinc ointment border, cover with gauze island border dressing daily and PRN. Wound treatment left hip clean with normal saline, pat dry, Dakin's-soaked gauze, cover with island border dressing daily and night shift. Wound treatment to left upper buttock clean with cleanser of choice, pat dry, apply Dakin's-soaked (1/4 strength) gauze to wound bed and cover with border gauze island dressing daily and PRN and night shift. Wound treatment left anterior shoulder Page 1 of 5 366377 366377 07/20/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stage III, cleanse with wound cleanser of choice, pat dry, apply Dakin's-soaked gauze to wound bed and apply zinc ointment to peri wound and cover with border island dressing daily, PRN, and nightly. Wound treatment right distal medial foot, stage III, cleanse using wound cleanser of choice, pat dry, apply Skin-Prep (liquid film-forming dressing that helps reduce friction during removal of tapes and films) to wound bed then cover with border gauze island dressing every night shift and PRN. Wound treatment right anterior shoulder, unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to clean with cleaner of choice, pat dry, apply oil emulsion (nonadherent gauze mesh impregnated with white petrolatum in an oil emulsion blend) to wound bed and cover with border gauze island dressing every two days and PRN. Wound treatment skin tear, right anterior shoulder, clean with wound cleaner of choice, apply oil emulsion to wound bed cover with border gauze island dressing every two days and PRN. Wound treatment to right hip, stage IV, clean with cleanser of choice, pat dry, apply Dakin's-soaked gauze to wound bed border foam daily on night shift. Wound treatment to right medial knee, stage III cleanse with cleanser of choice, pat dry, apply MediHoney, cover with border gauze island daily and PRN on night shift. Wound treatment to right lower back, unstageable, cleanse with wound cleanser of choice, pat dry, apply Dakin's-soaked gauze to wound bed, apply border gauze island dressing daily and PRN on night shift. Review of Resident #4's Treatment Administration Record (TAR) for May 2023 revealed no documented evidence wound care was provided on 05/04/23, 05/06/23, 05/09/23, 05/10/23, 05/12/23, 05/14/23, 05/15/23, 05/18/23, 05/19/23, 05/21/23, 05/22/23, 05/23/23. Review of Resident #4's TAR for June 2023 revealed no documented evidence wound care was provided on 06/03/23, 06/04/23, 06/06/23, 06/07/23, 06/12/23, 06/13/23, and 06/19/23. Review of Resident #4's TAR for July 2023 revealed no documented evidence wound care was provided on 07/07/23, 07/11/23, 07/12/23, 07/17/23, and 07/20/23. 2. Review of Resident #11's medical record revealed an admission date of 03/14/23. Diagnoses included chronic obstructive pulmonary disease (COPD), dysphagia, unspecified psychosis, dementia, moderate with other behavioral disturbance, type two diabetes mellitus (DM), and hypertensive heart disease with heart failure. Review of the MDS assessment dated [DATE] revealed Resident #11 had impaired cognition, and required extensive assistance for bed mobility, transfers, and dressing and required two staff assistance with toileting. Resident #11 required total dependence with two plus assistance for bathing and extensive assistance of one for eating and hygiene. Review of the care plan dated 06/11/23 revealed Resident #11 had a stage IV pressure ulcer to the coccyx. Resident#11 had multiple skin impairments. Interventions included provide wound care as ordered. Review of the physician orders for July 2023 revealed an order to apply moisture barrier cream to buttocks after each incontinence episode and every shift for moisture associated skin damage (MASD) every shift. Review of the TAR for May 2023, revealed no documented evidence wound care was provided on 05/30/23 and 05/31/23. Review of TAR for June 2023, revealed no documented evidence wound care was provided on 06/03/23, 06/07/23, 06/08/23 and 06/22/23. Review of TAR for July 2023 revealed no documented evidence wound care was provided on 07/03/23, 07/05/23, 07/08/23, 07/10/23, 07/11/23, and 07/17/23. 3. Review of Resident #18's medical record revealed an admission date of 06/19/23. Diagnoses 366377 Page 2 of 5 366377 07/20/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included Multiple Sclerosis (MS), major depressive disorder, neuromuscular dysfunction of bladder, obstructive and reflux uropathy cognitive communication deficit, age-related osteoporosis, quadriplegia, and dysphagia oropharyngeal. Review of the care plan dated 09/04/15 revealed Resident #18 had a Deep Tissue Injury (DTI) (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue) to the right buttocks. Interventions included provide wound care as ordered. Review of the MDS assessment dated [DATE] revealed Resident #18 had intact cognition. Resident #18 required extensive assistance of two plus staff for bed mobility, dressing, toileting, hygiene, and total dependence of two plus staff for bathing. Review of the physician orders for July 2023 revealed to an order to apply barrier cream as indicated every shift, may use after each incontinent episode. Review of the TAR for June 2023 revealed no documented evidence wound care was provided on 06/28/23. Review of TAR for July 2023 revealed no documented evidence wound care was provided on 07/08/23. Interview on 07/19/23 at 1:53 P.M. with the Director of Nursing (DON) declined to provide an explanation of the missing documentation on the TARs for Residents #4, #11, and #18's wound care treatments. Interview on 07/19/23 at 2:34 P.M. with the DON reported she had no documentation available to indicate staff provided dressing changes as ordered. The DON further stated, blank spots on TARs; I would assume they didn't do it because they didn't sign it off. This deficiency represents non-compliance investigated under Complaint Numbers OH00144500 and OH00144299. 366377 Page 3 of 5 366377 07/20/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility investigation review, and facility policy review the facility failed to ensure the care plan was followed to prevent a fall for Resident #15. This affected one resident (#15) of three residents reviewed for accidents. Findings include: Review of Resident #15's medical record revealed an admission date of 10/29/22. Diagnoses included Multiple Sclerosis (MS), morbid (severe) obesity, need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility. Review of the care plan dated 11/02/22 revealed Resident #15 required assistance with ADL related to decreased mobility, generalized weakness, and MS. Interventions included bathing, bed mobility, and transfer with full sling Hoyer (mechanical) lift with two-person assistance which was revised on 06/06/23. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. Resident #15 required extensive assistance of two plus staff for bed mobility, transfers, dressing, toileting, and total dependence for bathing with two plus staff assists. Review of the progress noted dated 06/11/23 at 8:35 P.M. authored by Registered Nurse (RN) #171 revealed she was notified by State Tested Nurse Aide (STNA) #183 regarding Resident #15 fell out of bed while being provided care with one assist for bathing. RN #171 did an assessment and notifications and treated skin abrasion to the right knee and assisted Resident #15 back to bed via Hoyer lift with two-staff assistance. Review of the investigation report dated 06/11/23 revealed Resident #15 received care by one staff and fell out of bed. RN #171 assessed Resident #15 and he was Hoyer lifted back into bed with two staff assist. RN #171 did notifications. Resident #15 sustained an abrasion to his right knee with treatment provided. Summary of findings included caregiver provided ADL care to Resident #15 with one assist, and the resident fell out of bed. Root cause: Staff was not following care plan; the resident required two-person assist with ADL and bathing. Interventions with on-the-spot education provided to caregiver. Interview on 07/18/23 at 12:15 P.M. with the Director of Nursing (DON) confirmed Resident #15 had a fall during bed bath with only one staff present, and Resident #15 required two staff per the care plan. Telephone interview on 07/20/23 at 9:06 A.M. with STNA #183 revealed he was giving Resident #15 a bed bath when the resident fell out of bed. STNA #183 confirmed Resident #15 required two staff assist for bed bath and he was the only staff giving the bed bath. Interview on 07/20/23 at 10:34 A.M. with RN #171 confirmed Resident #15 was to have two staff assistance for all ADL, and on 06/11/23 had only one staff was providing a bed bath when the resident fell. 366377 Page 4 of 5 366377 07/20/2023 Tranquility of Richmond Heights 562 Richmond Road Richmond Heights, OH 44143

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy, Falls and Fall Risk, Managing, revised March 2018, revealed based on previous evaluations and current date, the staff will 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 Complaint Numbers OH00144500 and OH00144299. 366377 Page 5 of 5