Inspection·August 10, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and interview the facility failed to adequately monitor Resident #50 related to non-pressure skin ulcers and failed to ensure wound care was completed as ordered. Residents Affected - Few Actual harm occurred on 07/04/23 when staff identified a decline in the resident's non-pressure skin ulcer to the left foot with an increase in drainage, necrosis (dead tissue) and slough (dead tissue, usually cream or yellow in color that impeded healing and increases the potential for infection) to the wound without evidence the physician or wound clinic were notified of the decline. The facility also had no evidence of wound monitoring, especially after the identified decline in the status of the wound. The resident was subsequently admitted to the hospital in serious condition on 07/16/23 with cellulitis to the left lower extremity and possible sepsis. This affected one resident (Resident #50) of four sampled residents. Findings include: Review of Resident #50's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, atrial fibrillation, high blood pressure, peripheral vascular disease, end stage renal disease with hemodialysis and lower extremity wounds. The resident was discharged to the hospital on [DATE] and did not return to the facility. Review of the physician's orders revealed Resident #50 had an order for Doxycycline (antibiotic) 100 milligrams twice day for infection dated 05/10/23. He took the medication twice a day until he was admitted to the hospital on [DATE]. Review of the facility wound Nurse Practitioner (NP) #500 notes dated 05/10/23 revealed Resident #50 had a vascular wound to the left lower extremity which measured 20 centimeters (cm) in length by 13 cm in width by 0.1 cm in depth with moderate amount for serous (clear fluid drainage) drainage. A wound to the foot (left or right not documented) which measured 1.2 cm in length by 0.3 cm in width by 0.2 cm in depth with a moderate amount of serosanguinous (fluid with some blood cells noted) drainage. A diabetic wound to the right planter foot which measured 6.5 cm in length by 5.3 cm in width by 0.0 cm in depth with a moderate amount of serosanguinous drainage. The wound bed was 100 percent covered in slough and the wound had a mild odor present. The last wound documented was a diabetic wound to the left lateral foot that had full thickness loss. The wound measured 15.2 cm in length by 4.0 cm in length by 0.3 cm in depth with moderate serosanguinous drainage. The wound bed was covered by 50 percent slough and had a mild odor. The wounds to the bilateral feet needed debridement; however the resident expressed he did not want the NP to do the debridement because he had his own physician who would do it for him. He was educated on the appearance and that debridement would help heal the wounds. The resident stated he spoke to his wife, and she told him to do what he felt was best. (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 7 Event ID: 365269 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 365269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Court 1076 Coshocton Ave Mount Vernon, OH 43050 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)