Health inspection·March 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 medical record review, staff interviews, and review of the facility policy, the facility failed to ensure a resident's pressure ulcer was assessed and monitored and the treatment to the pressure ulcer was administered as physician ordered. This affected one (Resident #100) of three residents reviewed for pressure ulcer care. The facility census was 135 Residents Affected - Few Findings include: Review of the closed medical record for Resident #100 revealed an admission date of 02/15/24. Diagnoses included encephalopathy, lack of coordination, muscle weakness, dementia, chronic kidney disease, and sacrococcygeal Deep Tissue Injury (DTI) (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). The resident was discharged on 02/24/24 to the hospital. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had severe cognitive impairment. Resident #100 was dependent on staff for toileting, upper and lower body dressing, and personal hygiene. Review of resident's initial nursing assessment dated [DATE] revealed there was no assessment of Resident #100's DTI on the sacrococcygeal. There was no description or measurements of the wound during Resident #100's stay at the facility. Review of Resident #100's care plan dated 02/22/24 revealed support and interventions for self-care deficit and actual and potential for impaired skin integrity related to fragile skin and DTI. Interventions for potential and actual skin impairment included to follow facility protocols for treatment of injury, monitor, document location size, and treatment of skin injury. Review of Resident #100's physician orders dated 02/16/24 revealed an order for the sacrococcygeal DTI blister: paint with betadine-soaked gauze over blistered/open area then apply zinc-based barrier ointment to general area four times daily and as needed (PRN) and an order for lower thoracic- lumbar spine: hydrocolloid dressings to protect prominent spinal bones every shift for protection. Review of Resident #100's Treatment Administration Record (TAR) from 02/17/24 to 02/23/24, revealed the physician ordered treatment to the sacrococcygeal DTI blister was not documented as being completed (blank signatures) ten times out of 28 opportunities on 02/20/24 at 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M.; on 02/21/24 at 9:00 A.M., 1:00 P.M., and 5:00 P.M. and 02/22/24 at 9:00 A.M., 1:00 P.M., and 5:00 P.M Further The physician ordered treatment to the lower thoracic-lumbar spine (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 6 Event ID: 365272 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 365272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview 3710 Olentangy River Road Columbus, OH 43214 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)