Inspection·July 2, 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 record review, interview and facility policy review, the facility failed to document treatments completed on two pressure ulcers for one resident (#111) of three residents reviewed. The facility census was 96. Residents Affected - Few Findings include: Review of the medical record for Resident #111, revealed an admission date of 09/29/20. Diagnoses included but were not limited to schizophrenia, other reduced mobility pressure ulcer of left buttock 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. Often includes undermining and tunneling) and dependence on other enabling machines and devices. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated cognitive intactness. The resident was assessed to require dependence on toilet hygiene, partial/moderate assistance with transfers and independent with bed mobility. The resident was also assessed to have two stage IV pressure ulcers on readmission/reentry with no refusal of care behaviors. Review of Resident #111's active care plans revealed a focus of an actual area of skin impairment related to stage IV pressure to left and right ischial with interventions including but not limited to: treatment order to left and right ischial changed per Nurse Practitioner and treatment as ordered. Review of physician's orders dated for 04/16/24 with a discontinued date of 05/06/24 for Resident #111 revealed two wound orders: cleanse wound to left ischium with normal saline, irrigate wound, pat dry, pack wound with collagen sheet, follow with packing and gauze and secure twice a day and as needed every shift for wound care and cleanse wound to right ischium with normal saline, irrigate wound, pat dry, pack wound with collagen sheet, follow with packing and gauze and secure twice a day and as needed every shift for wound care. Further review of this resident's physicians orders dated for 05/07/24 with a discontinuation date of 06/10/24 revealed two orders: Mupirocin external ointment 2 % apply to left ischium topically every shift for wound care cleanse wound to left ischium with normal saline (irrigate) pat dry, pack wound with Mupirocin covered gauze, cover with dressing, twice a day and as needed and Mupirocin external ointment 2 % apply to right ischium topically every shift for wound care cleanse wound to right ischium with normal saline (irrigate) pat dry, pack wound with Mupirocin covered gauze, cover with dressing, twice a day and as needed. (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: 365435 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 365435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Logan 300 Arlington Avenue Logan, OH 43138 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)