Inspection·June 27, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews with facility staff and the nurse practitioner, review of open and closed medical records, review of skin assessments, review of wound assessment reports, review of physician orders, review of treatment administration records, and policy review, the facility failed to ensure a resident's skin impairment was timely identified and treatment provided. This resulted in Actual harm to Resident #88 on 05/13/24 when the facility failed to develop and implement a care plan that included skin integrity monitoring with the use of an abdominal binder and failed to assess and monitor the resident's skin every shift that resulted in Resident #88 developing a Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) caused by the abdominal binder the resident was required to wear. Additionally, the facility failed to ensure Resident #34, identified at risk for skin breakdown on admission [DATE]), and who was assessed with excoriation/incontinence erosion to the coccyx area, received appropriate treatment and services to prevent the area from worsening by failing to document the initial wound assessment describing the wound, including measurements in accordance with facility policy, from 06/14/24 until the nurse practitioner evaluated the wound on 06/24/24. Furthermore, Resident #34 had no documented treatment in place for the coccyx until 06/20/24, six days after admission, placing the resident at risk for potential skin breakdown at a Severity Level 2 (no actual harm with the potential for more than minimal harm). This affected two (#88 and #34) of three residents reviewed for pressure ulcers. The facility census was 86. Residents Affected - Few Findings include 1. Review of the closed medical record for Resident #88 revealed an admission date of 03/21/24. The resident was discharged to the hospital on [DATE] and had not returned to the facility. Diagnoses included hemiplegia and hemiparesis affecting right dominant side, stage four pressure ulcer of the sacrum, hypertension, type two diabetes mellitus, gastrostomy, tracheostomy, and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment. The resident was admitted with one Stage 4 pressure ulcer and one Unstageable pressure ulcer. The resident was dependent on staff for toileting, hygiene, and bed mobility. Review of the pressure ulcer risk assessments dated 03/21/24, 03/29/24, 04/11/24, and 04/18/24 revealed the resident was at very high risk for developing pressure ulcers. Review of the care plan initiated 03/26/24 revealed the resident was at risk for skin break down related to weakness, impaired mobility, history of cerebral vascular accident with right sided weakness, incontinence status, diuretic medication use, diabetes mellitus and anticoagulant use. (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 4 Event ID: 365339 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 365339 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Terrace Rehabilitation Center 2735 Darlington Rd Toledo, OH 43606 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)