Health inspection·May 25, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, review of the facility policy on dressing changes and record review, the facility did not ensure Resident #3's treatment and wound care was documented accurately as completed per physician orders. This affected one resident (Resident #3) out of three residents (Resident #3, #42, and #72) reviewed for the accuracy of treatment/ wound care documentation . The facility census was 110. Findings included: Review of medical record for Resident #3 revealed an admission date of 01/10/23 and diagnoses included injured in motor vehicle accident, morbid obesity, chronic pain syndrome, and pressure ulcers to his sacral region. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had intact cognition. He required extensive assistance of two people with bed mobility, dressing, and personal hygiene. He was totally dependent on two staff for transfers. He was at risk for pressure ulcers and had unhealed pressure ulcers. Review of May 2023 Treatment Administration Record (TAR) revealed Resident #3 had the following order: change midline dressing to right upper extremity weekly and as needed. The TAR revealed there was no documentation that this was completed as scheduled on 05/03/23 from 7:00 A.M. to 7:00 P.M. as the TAR was blank. The TAR also had an order to dress skin graft to left ankle with bacitracin topically followed by xeroform, ABD pad and kerlix daily until follow up with plastic surgeon. The TAR revealed there was no documentation that this was completed as scheduled 7:00 A.M. to 7:00 P.M. on 05/03/23, 05/09/23, 05/12/23, and 05/13/23 as the TAR was blank. The TAR revealed he had an order to cleanse his right chest/ axilla area with normal saline, pat dry and apply mepilex foam every three days. The TAR revealed there was no documentation that this was completed as scheduled 7:00 A.M. to 7:00 P.M. on 05/03/23, 05/09/23, and 05/12/23 as the TAR was blank. The TAR revealed he had an order to cleanse his right hip with normal saline, pat dry, and apply topically calcium aquacel with mepilex foam every two days. The TAR revealed there was no documentation that this was completed as scheduled 7:00 A.M. to 7:00 P.M. on 05/03/23, 05/09/23, and 05/13/23 as the TAR was blank. The TAR revealed he had an order to cleanse his right lateral knee with normal saline, pat dry, apply topically Medi honey to site and cover with mepilex foam every two days. The TAR revealed there was no documentation that this was completed as scheduled 7:00 A.M. to 7:00 P.M. on 05/03/23, 05/09/23, and 05/13/23 as the TAR was blank. The TAR revealed he had an order to cleanse his sacrum and medial/ lower buttocks with normal saline, pat dry, apply calcium aquecel advantage with mepilex foam daily. The TAR revealed there was no documentation that this was completed as scheduled 7:00 A.M. to 7:00 P.M. on 05/03/23, 05/09/23, 05/12/23, 05/13/23, 05/22/23, and 05/23/23 as the TAR was blank. Review of care plan last revised 05/12/23 revealed Resident #3 had actual area of skin impairment to his sacrum, right buttock, and left buttock that were present on admission. Interventions included initiating wound treatment and continuing treatment as ordered, limit time out of bed, and pressure reducing mattress. Interview on 05/24/23 at 1:17 P.M. with Resident #3 revealed his wound care and treatment orders were completed as ordered every day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365306 If continuation sheet Page 2 of 3 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 365306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Health Care 7600 S Ridge Rd Madison, OH 44057 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 05/25/23 at 7:48 A.M. revealed Assistant Director of Nursing (ADON)/ Licensed Practical Nurse (LPN)/ Wound Nurse #346 and with the assistance of LPN #383 completed Resident #3's wound care with no concerns as the old dressing was dated appropriately. Interview on 05/25/23 at 9:15 A.M. with ADON/ LPN/ Wound Nurse #346 revealed she completed the wound care almost daily Monday through Friday. She verified on May 2023's TAR for Resident #3 the TAR had the above blanks. She revealed she completed the treatments and wound care as ordered, but most likely forgot to sign off the treatments as being completed. Interview on 05/25/23 at 9:40 A.M. with Administrator verified the treatments were not documented as completed per Resident #3's TAR as mentioned above. She revealed she had talked to him, and he was cognitively intact and had stated his treatments were completed daily. She revealed the treatments were completed but instead it was a documentation issue that the nurses had not documented after they had completed the treatment. She verified after the completion of a treatment the nurse was to document on the TAR. Review of facility policy labeled, Dressing Change, Dry/ Clean dated November 2015 revealed the documentation of the treatment should be documented in the resident record. This deficiency represents noncompliance investigated under Master Complaint Number OH00140036. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365306 If continuation sheet Page 3 of 3