Altercare Thornville Inc.

Review of wound grid documentation for

jeopardy to resident health or the resident was not yet at the facility.

The document stated Resident #800 had a stage 4 pressure safety ulcer to the coccyx that measured 8.9 cm by 8.7 cm by 1.8 cm.

Review of Resident #800 ' s Braden Scale for Predicting Pressure Sore Risk dated 07/07/25 revealed a score of 13 on a scale of 6 (high

the physician order for Resident #800 for 07/07/25 revealed no treatment for a sacral decubitus ulcer.

Review of the wound grid documentation for Resident #800 dated 07/08/25 at 12:45 A.M. by the FWN #33 revealed the coccyx stage 4 pressure ulcer had a wound vacuum in place with continuous suction at 125 millimeters of mercury (mm/HG).

Review of the physician order for Resident #800 dated 07/08/25 at 2:54 P.M. revealed an order entered by FWN #33 for the coccyx wound.

The order was to cleanse wound bed with normal saline, window frame outside edges of wound with adhesive film, cut black foam to fit wound bed.

Fill entire area including undermining.

Bridge with green foam using adhesive film under foam and bring it out to the left hip, attaching to port pad.

Cover the entire area with additional adhesive film.

Apply NPWT @ 125 mm/hg continuous. To be changed Sunday, Tuesday, Thursday and PRN.

Review of the medical record for Resident #800 revealed no written order for the wound vac system for the coccyx pressure ulcer, there was no date in the medical record when the wound vac arrived at the facility and when it was placed on the resident to start treatment.

Review of the wound grid documentation for Resident #800 dated 07/10/25 at 2:54 P.M. by FWN #33 revealed a coccyx sage 4 pressure ulcer measuring 8.8 cm by 7.8 cm by 0.8 cm with a wound vacuum in place with continuous suction at 125 mm/HG.

Review of the care plan revealed a plan for the pressure ulcer to the coccyx was initiated on 07/10/25.

Interventions were to perform current treatments as ordered and continue with prevention care plan measures to prevent further skin breakdown.

The care plan interventions were not implemented until 07/21/25.

Review of the wound grid documentation for Resident #800, dated 07/15/25 at 11:24 P.M. by FWN #33, revealed a coccyx sage 4 pressure ulcer measured 7.2 cm by 6.3 cm by 0.8 cm with a wound vacuum system in place with continuous suction at 125mm/HG.

Review of the wound grid documentation for Resident #800 dated 07/17/25 at 10:18 A.M. by FWN #33 revealed a coccyx sage 4 pressure ulcer measured 7.2 cm by 6.3 cm by 0.8 cm with a wound vacuum system in place with continuous suction at 125mm/HG.

Review of the wound grid documentation for Resident #800 dated 07/22/25 at 1:12 P.M. by the FWN #33 revealed a coccyx sage 4 pressure ulcer measured 7 cm by 6.2 cm by .8 cm with a wound vacuum system in place with continuous suction at 125mm/HG.

Review of the Wound Physician notes dated 07/24/25 revealed Resident #800 was seen by Wound Doctor #70. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.4 cm by 6.6 cm by 1.4 cm with moderate serous exudate and 20 percent slough tissue.

The treatment plan was a wound vacuum system with suction at 125 mm/HG, use black sponge throughout and apply three times a week. A surgical excisional debridement procedure was also completed due to removal of necrotic tissue and to establish the margins if viable tissue.

Recommendations for additional care plan items included low air-loss mattress, to offload wounds and reposition per facility protocol.

Review of the Wound Physician visit notes dated 07/31/25 revealed Resident #800 was seen by Wound Doctor #70. Resident #800 ' s coccyx stage 4 pressure ulcer measured 7.2 cm by 5.6 cm by 1.2 cm with moderate serous exudate and 20 percent slough tissue.

The treatment plan was a wound vacuum system with suction at 125mm/HG, use black sponge throughout and apply three tim

366369 09/02/2025

Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076

Review of the MAR for Resident #800 for the dates of wound pain assessment, no as needed pain medication as administered.

Interview on 08/07/25 at 2:30 P.M. with Assistant Director of Nursing (ADON) verified no medications were given prior to wound care treatments for pain which is the documentation in the progress notes that the ADON was documenting on for Resident #300 and #100, Resident 300 does not even have anything ordered as needed for pain.

Reviewed dates of all wound review templates with medication interventions not completed and no follow up after the wound treatment was completed if still in pain, the floor nurses do a pain scale every shift, but wound nurse does not follow up after and if non pharm does not work, there were two dates for interventions that included repositioning, no follow up was documented that it helped and if other treatment such as medication was needed.Interview on 08/08/25 at 11:40 A.M. with the Facility Wound Nurse #33 verified for Resident #800, there should have been wound pain assessments completed weekly from 04/22/25 through 05/13/25 and she did not verify if the resident received pain medication.

Also verified no as needed pain medication was given to this resident from 05/13/25 through 07/31/25 when the resident was assessed to have wound pain.

Review of the facility policy titled Pain Assessment and Management updated 05/01/25 revealed it is the facilities policy to assess, monitor, treat and evaluate pain to ensure effective pain management is provided.This was an incidental finding discovered during the course of this complaint investigation.

366369 09/02/2025

Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076

Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #42 was moderately impaired for daily decision-making.

Review of the electronic Physician Orders dated 09/25/25 revealed medications to be administered included chewable aspirin 81 milligrams (mg) for prophylaxis, buspirone 10 (mg) for sadness/anxiety, I-vite (vitamin and mineral) for supplement and senna plus 8.6-50,mg for bowel regimen, bupropion SR 150 (mg), celexa 40 (mg), culturelle 15 billion cell, lactulose 10 grams, aspercreme lidocaine patch, lisinopril 10mg, OsCal 500 (mg) with Vit D3, Miralax 17 gm, and Vitamin C 500 (mg). On 09/25/25 between 8:00 A.M. and 8:14 A.M., observation revealed Registered Nurse (RN) #200 prepared and administered Resident #42's morning medications including enteric coated aspirin 81 (mg), buspirone 5 (mg), and senna 8.5 (mg) and I-vite was not dispensed or administered during the observation. RN #200 was observed leaving her medication administration record open upon entering the resident's room and the electronic MAR was positioned across from the nursing station and not within eye sight of the nurse. RN #200 also left the sealed Aspercreme lidocaine patch on top of the medication cart unsupervised when she went to the resident's room to administer the other medications. At the time of the observation, RN #200 verified she left the Aspercreme lidocaine patch unattended on the top of the medication cart. On 09/25/25 at 2:46 P.M., interview with RN #200 verified she documented she had administered I-Vite to the resident; however she did not administer the medication. RN #200 verified she administered enteric coated ASA and senna to Resident #42 because that was the only form of the medications available to administer in her medication cart, and the buspirone order had been changed from 5 (mg) to 10 (mg) and the old bubble pack containing the 5 (mg) dose was left in the medication cart without a label indicating directions had been changed. RN #200 verified she had not given the ordered dose. RN #200 was observed removing the buspirone 5 (mg) bubble pack from the medication cart, closed the cart drawer, did not lock the medication cart, walked to the medication/storage room beside the nursing station with the bubble pack, unlocked the door and entered the medication/storage room with the door closing behind her. No staff were noted to be within the vicinity of the medication cart and the cart remained unlocked. RN #200 verified the cart was unlocked when she came back out of the medication/storage room.

Review of the policy: Specific Medication Administration Procedures dated May 2020 revealed medications were to be administered in a safe and effective manner, all medication storage areas including carts were to be locked at all times unless in use and under the direct observation of approved facility or pharmacy personnel. If medication instructions are changed during the course of therapy, it was the nurse's responsibility to add a direction change notation/sticker directly on the product to indicate as such.

366369 09/02/2025

Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076

Review of the medical record for Resident #100 revealed a skin alteration occurred on 06/02/25 at the facility per facility wound grid documentation.Further review revealed no Wound Physician visits in her closed record to review.Interview on 08/04/25 at 12:02 P.M. with the Director of Nursing (DON) revealed Resident #100 saw the Wound Physician group a few times during her stay and will get the visit notes from the Facility Wound Nurse #33 as they were not in her chart. 2.

Review of the medical record for Resident #300, revealed an admission date of 05/20/25.

Diagnoses included but were not limited to metabolic encephalopathy, altered mental status, muscle weakness, and cerebral infarction.

Review of the most recent MDS 3.0 assessment dated [DATE] revealed resident had intact cognition with a BIMS of 14 out of 15.

Review of the medical record for Resident #300 revealed a skin alteration on admission per facility wound grid documentation.Further review revealed no Wound Physician visits in the record to review.Interview on 08/06/25 at 11:09 A.M. with the Facility Wound Nurse #33 verified Resident #300 did not have any of her Wound Physician visits in her current medical record and should be uploaded after each visit.3.

Review of the medical record for Resident #800, revealed an admission date of 04/18/25.

Diagnoses included but were not limited to weakness, cerebral infarction, atrial fibrillation, type 2 diabetes, and chronic kidney disease.

Review of the most recent MDS 3.0 assessment dated [DATE] revealed resident with intact cognition with a BIMS of 14 out of 15.

Review of the medical record for Resident #800 revealed a skin alteration on admission per facility wound grid documentation.Further review revealed no Wound Physician visits in the medical record to review.Interview on 08/06/25 at 1:50 P.M. with Regional Nurse #68 verified Resident #800 did not have the Wound Physician Consultant notes uploaded into their charts and had to access them on the consultant's server, but it is the expectation that the Facility Wound Nurse #33 be uploaded after each visit to keep the residents' chart up to date and current for care.This was an incidental finding discovered during the course of this complaint investigation.

366369 09/02/2025

Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076

residents (#701 and #802), but has the potential to affect all 47 residents residing in the facility.

to be preparing medications for Resident #701.

She put on a glove to her right hand and proceeded to touch the cart, the residents' medications and the computer all with the same glove on.

Once the medications were in the cup, she removed the glove, did not sanitize her hands after locking the cart and entering Resident #701's room.

She took Resident #701's blood pressure and pulse ox with a machine she brought into the room.

She then administered the residents' medications and proceeded to leave the room without sanitizing her hands and cleaning off the equipment.

She returned to the cart at 8:48 A.M. and proceeded to prepare Resident #802's medications following the same steps.

She put on a glove to her right hand, proceeded to touch the cart, medications and computer with the same glove, then removed her glove, locked the cart and did not sanitize her hands before entering Resident #802's room to administer medications.

She took Resident #802's blood pressure and pulse ox with the same machine she carried into the rooms and did not sanitize them before or after use.

She administered Resident #802's medications and left the room without sanitizing her hands.Interview on 08/05/25 at 9:00 A.M. with Registered Nurse #27 verified she should have changed her glove once she touched anything other than Resident #701 and #802's medications, she should have sanitized her hands before and after entering the resident's rooms and she verified she never cleaned the blood pressure and pulse ox equipment before and after each resident.Review of the facility policy titled Hand Washing-Hygiene no date, revealed it is the facility's policy for employees to conduct proper hand hygiene that will aid in the prevention and transmission of infectious diseases.

Alcohol/Antimicrobial hand rub may be used in the following situations: before donning gloves, after removing gloves and before preparing or handling medications.

Review of the facility policy titled Cleaning of Equipment no date revealed the facility will utilize general disinfecting procedures to prevent and control infection.This was an incidental finding discovered during the investigation for Complaint Number 1385838.