Health inspection·June 11, 2024

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, medical record review, staff interview, and policy review, the facility failed to complete adequate wound assessments and failed to ensure pressure-reducing interventions were in place as ordered. This affected one (#11) of three residents reviewed for pressure ulcers. The facility census was 58. Residents Affected - Few Findings include: Review of the medical record for Resident #11 revealed admission date of 04/24/24. The resident was admitted with diagnoses including congestive heart failure, type two diabetes mellitus, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Resident #11 required required moderate assistance for transfers, maximum assistance for bed mobility, was dependent for toileting hygiene, and required supervision for eating. Resident #11 was assessed at risk for pressure ulcers, but none were observed at the time of the assessment. Review of a progress note by Licensed Practical Nurse (LPN) #108 dated 05/23/24 documented a wound on Resident #11's right great toe. A treatment for antibiotic ointment was initiated and the Director of Nursing was contacted. There were no measurements or further description of the wound documented until it was seen by Wound Physician (WP) #99 on 06/04/24. Record review of Resident #11's May 2024 treatment administration record (TAR) revealed the treatment for triple antibiotic to the right great toe twice daily was completed as ordered. Review of the physician orders revealed an order for bilateral heel boots or float heels on pillows while in bed with a start date of 06/04/24. Review of WP #99's progress note dated 06/04/24 revealed Resident #11's wound was documented a stage three pressure ulcer (full-thickness skin loss) to the right great toe measuring 0.5 centimeters (cm) long by 0.7 cm wide by 0.1 cm deep. Observation on 06/10/24 at 11:04 A.M. of Resident #11 revealed he did not have heel boots on while lying on his low air loss mattress in bed. Observation on 06/10/24 at 12:33 P.M. revealed Occupational Therapy Assistant (OTA) #106 was overheard asking LPN #101 if Resident #11 was supposed to have his heel boots on. LPN #101 answered that if the resident was in bed, he needed them on. OTA #106 stated she would apply them. (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 2 Event ID: 365238 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 365238 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wapakoneta Manor 1010 Lincoln Ave Wapakoneta, OH 45895 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)