Health inspection·June 29, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on observation, record review, facility policy review and interview the facility failed to ensure timely assessments were completed, wound care was completed as ordered and adequate interventions were implemented to prevent the development of pressure ulcers for Resident #33 and Resident #51. The facility census was 58. Residents Affected - Few Actual Harm occurred on 04/03/23 when Resident #33, who required extensive to total dependence from staff for activities of daily living (ADL) including bed mobility, toileting and transfers, was found to have an unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to his right trochanter (hip). On 04/18/23 Resident #33 was identified with another unstageable pressure ulcer to his left trochanter. There was no evidence adequate interventions and monitoring was in place to prevent the development of these wounds or to ensure the wounds were identified prior to being unstageable. Actual Harm also occurred on 05/17/23, when Resident #51 who required extensive assistance from staff for ADL care including bed mobility, transfers, and toileting, was found to have an unstageable pressure ulcer to his right buttock/ upper posterior thigh. There was no evidence adequate interventions and monitoring was in place to prevent the development of this wound or to ensure the wound was identified prior to being unstageable. This affected two residents (#33 and #51) of three residents reviewed for pressure ulcers. Findings included: 1. Review of medical record for Resident #33 revealed an admission date of 08/30/22 with diagnoses including acute kidney failure, hypertension, cerebral infarction, and dementia. Review of care plan dated initiated on 01/24/23 (last revised on 06/07/23) revealed Resident #33 had actual impaired skin integrity related to the coccyx, right hip, and left hip areas. Interventions included to administer medication and treatments as ordered, to assess and document status of the wounds, to complete skin checks per protocol, to monitor nutritional status,to turn and reposition as indicated, and to use pressure relieving devices as indicated to bed and wheelchair. Review of Braden Scale Pressure Ulcer Risk Assessment completed on 02/24/23 by Registered Nurse (RN) #616, revealed Resident #33 was at moderate risk for developing pressure ulcers due to the following risk factors: occasionally moist, chairfast, very limited with mobility, inadequate nutrition, and a problem with friction and shear. Review of care plan, revised 03/30/23, revealed Resident #33 had an activities of daily living Page 1 of 6 366441 366441 06/29/2023 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0686 Level of Harm - Actual harm Residents Affected - Few (ADL) self-care deficit related to impaired cognition and mobility. Interventions included assist with ADL's including dressing, grooming, toileting, and feeding, assist with one staff with bed mobility, assist with two staff with toileting, and transfer with two staff assist with a mechanical lift. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/30/23 revealed Resident #33 was rarely and/or never understood. He required extensive assist of two staff with bed mobility and was totally dependent of two staff with transfers. He required extensive assist of one staff with toileting and was unable to ambulate. He was at risk for pressure ulcers but had no pressure ulcers at the time of the assessment. Review of nursing notes dated from 03/01/23 to 04/03/23, for Resident #33, revealed there were no skin impairments/ pressure ulcers identified to his right trochanter area prior to 04/03/23 when the Wound Nurse Practitioner (NP) #615 found an unstageable pressure ulcer during wound rounds. Review of Wound Evaluation progress note dated 04/03/23 and completed by Wound NP #615 revealed Resident #33 had a new pressure wound to his right trochanter that was found as unstageable. The wound measured 1.8 cm in length, 1.2 cm in width and unable to determine depth due to slough. The note revealed the wound contained 100 percent slough. Review of Weekly Wound Assessment V1-V5 dated 04/04/23 and completed by Former Registered Nurse (RN) #617 revealed Resident #33 had an unstageable in house acquired pressure ulcer to his right trochanter hip. The pressure ulcer measured a length of 1.8 cm, width of 1.2 cm and unable to determine depth due to the slough. The wound was described with a small amount of serous (this watery fluid) drainage and the wound bed contained yellow slough. Review of nursing notes dated, 04/04/23 to 04/18/23, revealed no evidence Resident #33 had any skin impairments/ pressure areas to his left trochanter prior to 04/18/23 when former RN #617 documented she had found the unstageable pressure ulcer. Review of Weekly Wound Assessment V1-V5 dated 04/18/23 and completed by former RN #617 revealed Resident #33 had an unstageable in house acquired pressure ulcer to his left trochanter hip that measured 7.3 cm in length, 5.5 cm in width and had a depth of .1 cm. The wound was described as having small amount of serosanguineous (containing fluid and clear fluid) drainage and the wound bed was yellow. Review of Wound Evaluation progress note dated 04/26/23 and completed by Wound NP #615 revealed Resident #33 had a left trochanter pressure ulcer that was unstageable. The note revealed the wound measured 4 cm in length, .8 cm in width and unable to determine depth due to slough. The note revealed there was a small open area in the above measurement that was .5 cm in length, .5 cm in width and 100 percent slough with surrounding dark purple tissue. Review of Treatment Administration Record (TAR) dated May 2023 revealed Resident #33's treatment order to his right trochanter was to cleanse his wound with wound cleanser, apply Xeroform, and cover with border foam three times a week and as needed. There was no documentation the treatment order was completed on 05/16/23 or 05/23/23. The treatment record also revealed Resident #33's treatment order to his left hip that was to cleanse his left hip with wound cleanser, apply Xeroform, cover with border foam every Tuesday, Thursday and Saturday. There was no documentation the treatment was completed on 05/16/23, 05/23/23, or 05/25/23. 366441 Page 2 of 6 366441 06/29/2023 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0686 Level of Harm - Actual harm Residents Affected - Few Review of physician's orders from June 2023 revealed Resident #33 had an order dated 04/04/23 to cleanse right trochanter wound with wound cleanser, apply Xeroform, and cover with border foam three times a week and as needed; and an order dated 05/03/23 cleanse left hip with wound cleanser apply Xeroform, cover with border foam every Tuesday, Thursday and Saturday on night shift and side to side turned every two hours. Review of TAR for June 2023 revealed Resident #33's treatment to his left hip was not documented as completed on 06/01/23. Review of Wound Evaluation progress note dated 06/21/23 completed by Wound NP #615 revealed Resident #33 continued to have unstageable pressure ulcers to his right and left trochanter. The right trochanter measured a length of 1.5 cm in length and a width of 1 cm with 100 percent slough. The left trochanter pressure ulcer measured 5 cm in length and 8 cm in width with also 100 percent slough. Interview on 06/28/23 at 9:14 A.M. and at 2:22 P.M. with Licensed Practical Nurse (LPN)/Wound Nurse #614 revealed she had only been the wound nurse approximately for three weeks. She verified, after review of the documentation, that Resident #33's right trochanter was found as an unstageable pressure ulcer on 04/03/23, per the Wound NP #615 notes from the wound rounds, as that was the first the wound was documented. She also verified Resident #33's left trochanter pressure ulcer was also found as unstageable on 04/18/23. She verified Resident #33 required extensive to total dependence of staff for his bed mobility, toileting, and transfers. She verified the wounds should have been detected prior to being found unstageable. She verified the identified treatments were not documented as completed on the TAR for May 2023 and June 2023 as noted above. She verified if the treatments were not documented on the TAR, then most likely they were not done. She revealed she completed all the wounds treatments every Wednesday on the wound rounds. When she first started, she noted several times when treatments were not completed as ordered. She stated that when went to complete the treatment, the same treatment was in place that she had completed days prior. She verified the floor nurses were not doing the treatments as ordered. Observation on 06/28/23 at 11:41 A.M. of wound care completed by LPN/ Wound Nurse #614 and Wound NP #615 revealed Resident #33's right trochanter had an unstageable pressure ulcer that measured 1.5 cm in length, one cm in width and contained 100 percent slough with a small amount of serosanguineous drainage. The observation revealed Resident #33's left trochanter was an unstageable pressure ulcer that measured three cm in length, four cm in width and contained in the wound bed 100 percent slough. The treatment was completed according the the current order. Interview on 06/28/23 at 11:41 A.M. with Wound NP #615 verified, upon review of her notes, that Resident #33's pressure ulcer to his right trochanter was found on wound rounds as unstageable on 04/03/23. She revealed Resident #33's left trochanter pressure ulcer, that she evaluated on 04/26/23, was previously identified, according to the documentation on 04/18/23, as unstageable. The facility was unable to provide evidence adequate interventions had been implemented and were in place prior to the developed and failed to ensure skin monitoring was being completed to prevent the development of these wounds and to ensure the wounds were identified prior to being unstageable 2. Review of medical record for Resident #51 revealed an admission date of 06/29/21 with diagnoses including peripheral vascular disease, failure to thrive, lymphedema, chronic kidney disease, heart failure and diabetes. 366441 Page 3 of 6 366441 06/29/2023 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0686 Level of Harm - Actual harm Residents Affected - Few Review of care plan dated 06/29/21 revealed Resident #51 had a self-care deficit. Interventions included Resident #51 required staff assistance with dressing, grooming, and toileting, bed mobility of one staff assist, toileting of two staff assist, and transfers with two staff assist. Review of care plan dated 06/29/21 (with a revision date of 08/02/22) revealed Resident #51 had a potential for skin breakdown related to impaired mobility and incontinence. The interventions included to turn and repositioned as indicated, apply pressure relieving devices as indicating including ROHO cushion and air mattress, and to complete skin assessments per protocol. Review of annual MDS 3.0 assessment, dated 03/09/23 revealed Resident #51 had intact cognition. He required extensive assist of one person with bed mobility, transfers, dressing, toileting, and personal hygiene. He was unable to ambulate. Review of Wound Evaluation progress note dated 03/29/23 and completed by Wound Nurse Practitioner (NP) #615 revealed Resident #51 had moisture associated skin damage (MASD) to his left buttock. There were no documented concerns regarding his right buttock/ posterior thigh area. Review of physician's orders from 01/01/23 to 06/28/23 revealed an order dated 05/17/23, that was discontinued on 06/14/23, to cleanse wound to right buttocks with wound cleanser, apply Xeroform, cover with bordered foam and change daily. There was another order dated 06/14/23 to apply triad to right buttocks/ upper thigh area, cover with border foam and change daily and as needed, turn and reposition every two hours, and apply pressure reducing cushion to wheelchair. There were no other wound care treatment orders prior to 05/17/23 for his right buttock/ upper posterior thigh region. Review of Wound Evaluation progress note dated 05/17/23 and completed by Wound NP #615 revealed Resident #51 had a new unstageable pressure ulcer to his right buttock/ posterior upper thigh that measured a length of five centimeter (cm), width of 2.5 cm and a depth that was unable to be determined due to slough. The note revealed the wound had serosanguinous drainage and contained 100 percent slough. Review of Weekly Wound Assessment V1-V5 dated 05/17/23 and completed by former RN #617, revealed Resident #51 had an unstageable in house acquired pressure ulcer to his right buttock that measured a length of 5 cm, width 2.5 cm and the depth was unable to be determined as there was slough. The assessment revealed the date the wound was identified was 12/07/22 but subsequent interview with Licensed Practical Nurse (LPN)/ Wound Nurse #614 verified this was inaccurate as the date should have been 05/17/23. The assessment revealed the wound had a small amount of serosanguinous drainage and the wound bed was yellow and red. Review of quarterly MDS 3.0 assessment, dated 06/09/23 revealed Resident #51 had intact cognition and required limited assist of one person with bed mobility and extensive assist of one person with transfers, toileting, and personal hygiene. He was unable to ambulate. Review of Wound Evaluation progress note dated 06/14/23 and completed by Wound NP #615 revealed on assessment Resident #51's unstageable pressure ulcer to his right buttock/ upper thigh was healed with 100 percent epithelial tissue. Review of Wound Evaluation progress note dated 06/21/23 and completed by Wound NP #615 revealed Resident #51's wound to his right buttock/ upper thigh had reopened and was classified as a Stage III (full thickness skin loss in which adipose tissue (fat) is visible in the ulcer) measuring a length 366441 Page 4 of 6 366441 06/29/2023 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0686 of 16 cm, width of eight cm, and a depth of 0.1 cm. The note revealed he had scattered open areas and 40 percent of the scattered areas had epithelia tissue with purple discoloration. Level of Harm - Actual harm Residents Affected - Few Review of Weekly Wound Assessment V1-V5 dated 6/21/23 and completed by Licensed Practical Nurse (LPN)/ Wound Nurse #614 revealed Resident #51 had an in-house acquired Stage III pressure ulcer to his right buttock/ upper posterior thigh that measured a length of 16 cm, width of eight cm, and was 0.1 cm in depth. The assessment noted the wound had moderate amount of serosanguinous drainage and the wound bed was red. Review of Review of Wound Evaluation progress note dated 06/28/23 and completed by Wound NP #615 revealed Resident #51 continued to have a Stage III pressure ulcer to his right buttock/ posterior upper thigh area that measured 11 cm in length, two cm in width and 0.1 cm in depth. The note revealed he had 100 percent granulated tissue to the scattered open areas with moderate serosanguinous drainage. Interview on 06/28/23 at 1:11 P.M. with Wound NP #615 verified Resident #51, on 05/17/23 during wound rounds was found to have an unstageable pressure ulcer to his right buttock/ posterior thigh region. She revealed she did not have in her notes that he had any skin issues to his right buttock just his left from 01/01/23 to 05/17/23. She revealed the unstageable pressure ulcer resolved on 06/14/23 but reopened and was found at a Stage III on 06/21/23. Interview on 06/28/23 at 2:22 P.M. with LPN/ Wound Nurse #614 revealed she had only been the wound nurse approximately for three weeks. She revealed upon review of the Weekly Wound Assessment V1-V5 dated 05/17/23 Resident #51's pressure ulcer to his right buttock/ posterior thigh area was found as an unstageable. She verified that the date on the assessment was dated as 12/07/22 as the date when identified but she revealed this had to be inaccurate as on review Resident #51 had not received any treatments for his right buttock/ posterior thigh region from 01/01/23 to 05/17/23 and/or that she had any documentation he had any issues. She also revealed he had a pressure ulcer to his left buttock that was identified on 12/07/22 and felt the previous nurse had mixed up the dates on the assessments. She verified that Resident #51 needed staff assistance with his activities of daily living including with toileting as he was incontinent. She verified since he required assistance most likely his pressure ulcers should have been detected at a prior stage than unstageable/ Stage III. She verified the unstageable pressure ulcer healed on 06/14/23 but then was found at a Stage III on 06/21/23. Observation on 06/29/23 at 10:28 A.M. of wound care for Resident #51 completed by LPN #607 revealed Resident #51 had a Stage III to his right buttock that was red. She applied the treatment as ordered. There was no evidence adequate interventions were in place prior to the development of the unstageable pressure ulcer. In addition, there was no evidence of ongoing monitoring to prevent the development of this wound or to ensure the wound was identified prior to being unstageable. During the onsite investigation, the facility identified 19 residents, Resident #2, #3, #4, #5, #7, #11, #14, #17, #27, #33, #34, #36, #37, #47, #48, #49, #51, #57, and #58 with pressure ulcers. Review of facility policy labeled, Skin and Wound Care Best Practices dated 06/10/22 revealed the purpose of the policy was to provide evidence based preventative skin care and wound treatment to prevent unavoidable skin complications. The policy revealed prevention included provide pressure 366441 Page 5 of 6 366441 06/29/2023 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0686 Level of Harm - Actual harm Residents Affected - Few reduction and redistribution for those at risk including reposition at a frequency determined by risk assessment. The policy revealed educating the nursing aide staff on the importance of basic care such as bathing, repositioning, toileting, skin care and nutrition. This deficiency represents non-compliance investigated under Master Complaint Number OH00143562 and Complaint Number OH00143520. 366441 Page 6 of 6