Inspection·April 17, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based medical record, staff interview, and facility policy, revealed facility failed to obtain clarifying orders for a wound vacuum and provide care and treatment to a wound. This affected one (#74) of three residents reviewed for wounds. Facility census was 72. Residents Affected - Few Findings included: Review of Resident #74's medical record revealed an admission date on 03/31/23 and discharged [DATE] to the hospital. Resident #74's diagnoses included surgical infection, type two diabetes, end stage renal disease, sepsis, and acquired absence of left toes. Review of Minimum Data Set assessment dated [DATE] revealed Resident #74 had no Brief Interview of Mental Status (BIMS) finished. Resident #74 required for assistance extensive one-person for bed mobility and toilet use. Review of plan of care dated 03/31/23 revealed Resident #74 was at risk for infection related to chronic disease, dialysis port, history of infections, and wound. Interventions included administering oxygen as ordered, aerosols as ordered, isolation per order, pulse oximetry as ordered, report signs and symptoms of infection, and treatments as ordered. Review of hospital Discharge summary dated [DATE] for Resident #74 revealed there was a discharge order stating needs wound vacuum (vac) placement at the facility. The order did not have the suction setting stated for the wound vac. Review of physician orders date from 03/31/23 through 04/01/23 revealed no physician order for the wound vac. Review of progress notes and assessment from 03/31/23 through 04/01/21 revealed there was no evidence of a wet to dry dressing to the left foot or mention of wound vac till 04/02/23 with physician order. Review of physician orders date from 03/31/23 through 04/03/23 revealed Resident #74 had no physician order for wet to dry dressing treatment to left foot if wound vac was not placed or not intact. Review of physician order dated 04/02/23, documented by Licensed Practical Nurse (LPN) #300, revealed Resident #74 had an order to have a wound vac at the suction rate of 125 pressure applied to left foot every Monday, Wednesday, and Friday. Review of progress noted dated 04/02/23, documented by LPN #300, stated Resident #74 asked this nurse to remove wound vac this morning after placing at 12:00 A.M. on 04/02/23. Resident #74 was (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: 365515 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 365515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439 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)