Inspection·June 6, 2023

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 observations, staff and resident interviews, and record review, the facility failed to ensure wound care treatments for pressure ulcers were completed as ordered. This affected one resident (#03) of three residents reviewed for wound care. The facility census was 159. Residents Affected - Few Findings included: Review of the medical record for Resident #03 revealed an admission date of 10/05/22 with diagnoses including, but not limited to, end stage renal disease, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #03 was cognitively intact. Review of the wound care notes dated 05/23/23 for Resident #03, revealed the resident had a stage 3 pressure wound on the left ankle which was facility acquired on 05/23/23. Notes indicated the left heel wound was documented as a stage 4 pressure ulcer and present on admission. The notes indicated the both wounds were improving without complications. Review of the wound care notes dated 05/30/23 for Resident #03, revealed both left leg wounds (one on ankle and one on the calf) to be improving without complications. Review of the physician orders dated 06/01/23 for Resident #03, revealed the resident was ordered to have the left ankle and left outer calf area cleansed with normal saline, patted dry, calcium alginate applied to the wound bed and covered with rolled gauze daily and as needed. Review of the June 2023 Treatment Administration Records (TAR) for Resident #03, revealed no documented evidence the resident's left leg dressing changes were performed on 06/04/23 and 06/05/23. Interview on 06/06/23 at 10:20 A.M. with Resident #03, revealed the staff did not change the dressing to on left foot as ordered. Observation at same time revealed the dressing was marked 6/3. Resident #03 verified that the dressing had not changed since 06/03/23. Resident #03 stated he was seen by a wound care specialist; however, his dressing was ordered to be changed daily and as needed, but they did not change it every day. Resident #03 denied any other skin breakdown issues other than the dressings to his bilateral lower extremities. Observation of Resident #03's dressing to his left foot on 06/06/23 at 10:25 A.M. with Licensed Practical Nurse (LPN) #200, revealed the resident's dressing was dated 06/03/23. LPN #200 verified the date and stated the dressing should have been changed on 06/04/23 and 06/05/23 as ordered. (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: 365396 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 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 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)