Health inspection·January 2, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy for wound care, this facility failed to ensure residents assessments were accurate to refect a pre-existing skin injury during admission assessments. This affected one (Resident #141) of four residents reviewed for skin care and prevention. The facility census was 70. Residents Affected - Few Findings include: Review of the medical record for Resident #141 revealed an initial admission date of 07/23/23, and re-entry date of 11/29/23, and a discharge date of 12/13/23. Diagnoses included acute respiratory failure with hypoxia, altered mental status, and sepsis unspecified organism. Review of the plan of care dated 11/30/23 revealed Resident #141 was at risk for skin breakdown and has skin breakdown. Interventions include to apply triad cream twice a day after incontinence episode as needed, assist with repositioning and or turning at frequent intervals to provide pressure relief, keep skin clean and dry, assist with skin care based on residents limitations, and report changes in skin integrity to the nurse. Review of Resident #141's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident had an intact cognition for daily decision making abilities. Resident #141 required supervision assistance for personal hygiene and was dependent on staff for toileting, dressing, and transfers. Resident #141 was noted to be free of any skin injuries or pressure wounds during this assessment review. Review of Resident #141's physician orders for December 2023 revealed the following: -Apply triad cream to buttocks/coccyx area every day and night shift for redness. Start on 11/29/23. -Monitor bruising to left and right forearm every shift for monitoring until healed. Review of weekly skin observations for Resident #141 from 11/29/23 through 12/13/23 revealed the resident was free of any skin injuries or pressure wounds. Interview on 12/27/2023 at 11:38 A.M. with the Assistant Director of Nursing (ADON) #172 revealed Resident #141 was admitted to the facility with a red area to her buttocks and she got a order for cream for redness. She thought she out a progress note in the residents medical record but could not find it anywhere. Normally this would have been documented under weekly skin assessments or pressure (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 7 Event ID: 365485 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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)