Inspection·March 22, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review, observations staff and resident interviews and policy review the facility failed to ensure a residents dressing changes were completed per physician orders. This affected one (#20) out of three residents reviewed for skin breakdown. The facility census was 70. Residents Affected - Few Findings include: Record review of Resident #20 revealed an admission date of 12/20/23. Diagnoses included complete traumatic amputation of left great toe, spina bifida, inflammatory polyneuropathy, paraplegia, osteomyelitis, non-pressure chronic ulcer, adult failure to thrive, gastro-esophageal reflux disease, pressure ulcer of unspecified site, major depressive disorder, opioid dependence, anorexia and stimulant abuse. Review of the Minimum Data Set (MDS) assessment completed on 01/01/24 revealed Resident #20 with a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 indicating the resident was cognitively intact. Functional imitation in range of motion revealed no impairment both upper extremities, and impairment to both lower extremities. Further review of Resident #20's medical record revealed the resident had an order for the left 2nd toe to cleanse with saline, apply medihoney, then calcium algnate, cover with foam every day shift for wound care; an order for the right hip to cleanse with saline, apply medihoney, then calcium algnate, cover with foam every day shift for wounds; an order for the left foot to cleanse with saline, apply xeroform and foam dressing every day shift for wound care, an order for the left ischium to cleanse with saline, apply medihoney, calcium alginate, cover with foam every day shift for wound; and order for the right ishium to cleanse with saline, apply medihoney, calcium algnate, cover with foam every day shift. Review of Resident #20's treatment administration record (TAR) for March 2024 revealed the treatments for the right ischium, left ischium, left foot, right hip and left 2nd toe dressing were not done and not initialed off as being completed on 03/21/24. Observation and interview on 03/22/24 at 10:27 A.M. with Resident #20 revealed multiple dressings were dated 03/20/24. Resident #20 stated her dressing changes were to be changed daily. The observations revealed dressings on right ischium dated 03/20/24, left ischium dated 03/20/24, left foot dated 03/20/24, right hip dated 03/20/24, and left 2nd toe dated 03/20/24. Interview on 03/22/24 at 10:32 A.M. with the Assisted Director of Nursing (ADON) #9 confirmed dressings on Resident #20 were last changed on 03/20/24 and the treatment record did not reflect the dressing were changed on 03/21/24. Interview with ADON #9 also confirmed she would ensure the dressings (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365202 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Lima 599 South Shawnee Street Lima, OH 45804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)