Inspection·December 28, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview and facility policy review, the facility failed to maintain infection control practices during dressing changes. This affected one (#21) of three residents reviewed for pressure ulcers. The facility census was 85. Residents Affected - Few Findings include: Review of the medical record for Resident #21 revealed an initial admission date of 07/01/22 with the latest readmission of 07/14/23 with diagnoses including sepsis due to methicillin resistant staphylococcus aureus, acute and chronic respiratory failure with hypoxia, diabetes mellitus, chronic obstructive pulmonary disease (COPD), neuromuscular dysfunction of bladder, congestive heart failure, polyneuropathy, hypertension, encounter for palliative care, osteoarthritis, benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, necrotizing fasciitis, anemia and cardiomyopathy. Review of the resident's admit/readmit assessment dated [DATE] revealed the resident was admitted to the facility with a Stage III (Full thickness tissue loss). Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) pressure ulcer to left buttocks measuring 3.0 centimeters (cm) by 1.8 cm by 0.1 cm, a vascular wound to the left groin measuring 2.0 cm by 2.0 cm by 0.1 cm. The assessment also indicated the resident has an indwelling urinary catheter. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident has not cognitive deficit. The resident had an indwelling urinary catheter and was always incontinent of bowel. The assessment indicated the resident was at risk for skin breakdown and had one Stage III pressure ulcer present on admission. The facility implemented pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, surgical wound care, application of nonsurgical dressings and applications of ointments/medications other than to feet. Review of the weekly skin observation dated 12/26/23 revealed the Stage III pressure ulcer to the left ischium measured 2.9 centimeters (cm) by 1.3 cm by 2.5 cm with undermining (the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface) present at 12 o'clock at the depth of 2.7 cm. The wound was describes as being beefy red with a large amount of serosanguinous drainage. The facility determined the wound had improved. Review of the weekly observation dated 12.26.23 revealed incision and drainage of abscess wound 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: 365295 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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)