Health inspection·October 14, 2025

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 observation, record review, staff interview, review of protective cream labels, and review of facility policy, the facility failed to ensure a Stage 3 pressure ulcer present upon admission received treatment and failed to ensure proper linens were used with a pressure reducing mattress to promote healing of the pressure ulcer for one (Resident #3) of three residents reviewed for pressure ulcers. The facility census was 52. Findings include:Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnosis included hypertensive chronic kidney disease and peripheral vascular disease. Review of the Wound Management note dated 09/23/25 revealed Resident #3 had a Stage 3 pressure ulcer to the coccyx measuring 3 centimeters (cm) by 2 cm by 0.2 cm deep. The wound had serosanguineous drainage and the surrounding skin was a dark purple or rusty discoloration.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and was assessed to have a stage 3 pressure ulcer. Review of the care plan dated 09/30/25 revealed Resident #3 had a pressure ulcer. Interventions included pressure reducing mattress, treatment per physician order, and notify physician if treatment not effective. Review of the Physicians Orders revealed an order dated for 09/23/25 to cleanse skin with personal cleanser and apply protective ointment/cream as needed after each incontinence episode twice a day. On 10/01/25 an order was provided for treatment to coccyx wound cleanse with wound cleanser or normal saline, pat dry, apply skin prep to periwound, apply hydrogel, and cover with foam, change dressing as needed. Observation on 10/14/25 at 3:00 P.M. of Resident #3's wound care with Assistant Director of Nursing (ADON) #10 revealed the resident was observed on a low air loss mattress covered with a fitted sheet, a cloth bed pad for repositioning and wearing an incontinence brief. Observation of the wound revealed no drainage, surrounding tissue appeared red and the center of the wound had a yellow discoloration. The ADON's wound measurements revealed 1.0 cm long by 0.7cm wide. The surrounding redness measured 2.5 cm. Review of the Thera Calazinc Body Shield (protective cream) revealed a warning label which read Do not use on deep or puncture wounds. Review of the low air loss mattress user manual titled Med Aire Plus 10 Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System by Drive Medical, revealed under the heading Recommended Linen: Drive DeVilbiss Healthcare bed support surfaces are designed to be used with appropriate linens. Deep pocketed fitted or flat sheets are recommended. Multiple layering of linens or under pads beneath the patient should be avoided, when possible, for the prevention and treatment of pressure injuries. Interview on 10/14/25 at 3:30 P.M. with ADON #10 revealed on 09/23/25 Resident #3 was admitted with a Stage 3 pressure ulcer. The treatment ordered was a barrier cream. ADON #10 verified the order to treat the pressure ulcer on 09/23/25 was for a protective cream that was still in place to use with incontinent care. ADON #10 verified the wound on admission was a stage 3 pressure ulcer with depth and that would be a deep wound. ADON #10 stated the protective cream is a routine order and ordered at admission and no dressing was used to cover the pressure ulcer until 10/01/25. ADON #10 Residents Affected - Few Page 1 of 2 366492 366492 10/14/2025 Norwich Springs Health Campus 4680 Library Way Hilliard, OH 43026

F 0686 Level of Harm - Minimal harm or potential for actual harm confirmed the SR#3 had multiple layers between wound and low air loss mattress and the user manual recommends avoiding multiple layers.This deficiency represents non-compliance investigated under Complaint Number 2637068. Residents Affected - Few 366492 Page 2 of 2