Inspection·March 6, 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 interview and policy review, the facility failed to assess and implement a physician ordered treatment for a resident admitted with a pressure ulcer to the coccyx. This affected one (#72) of three residents reviewed for pressure ulcer care. Facility census was 71. Residents Affected - Few Findings Include: Record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including diabetes, heart failure, Parkinson's, malnutrition and Stage IV (full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, including undermining and tunneling) pressure ulcer to the coccyx. Resident #72 was discharged on 02/03/24. Record review revealed there was no comprehensive Minimum Data Set (MDS) completed for Resident #72 due to the residents short stay at the facility. Additionally, there was no documentation of a Braden Scale being completed for Resident #72. Review of Resident #72 base line plan of care initiated 02/02/24 revealed interventions of daily treatments and assessments, for Stage IV pressure ulcer. Review of Resident #72 admission nurses note dated 02/01/24 revealed the resident had a jejunostomy tube (j tube used for nutrition) and a pressure ulcer on the coccyx. Review of Resident #72's medical record revealed there was no further documentation including no description, measurements or assessment of Resident #72's pressure ulcer to the coccyx. The notes failed to mention if a dressing was intact, appearance, or drainage. Review of Resident #72's physicians orders dated 02/01/24 revealed a daily treatment for the coccyx pressure ulcer. Review of the Treatment Administration Record (TAR) for February 2024 revealed no signature or initials that the treatment was provided and no description of the coccyx pressure ulcer. Interview with the Director of Nursing (DON) on 03/05/24 at 2:30 P.M. revealed the nurses would be expected to assess and document what a wound or pressure ulcer looked like upon admission. The DON confirmed Resident #72's coccyx pressure ulcer was not assessed upon admission and the physician ordered treatment was not completed. The DON confirmed there was no Braden Scale completed for Resident #72 and its the facility policy to complete Braden Scales upon admission. Review of the facility policy for Pressure Ulcers dated 07/07/23 revealed the admitting nurse is to (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: 365277 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 365277 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bradford Place Care Center 1302 Millville Avenue Hamilton, OH 45013 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)