Inspection·August 23, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to timely notify residents and responsible parties of a change in condition. This affected two (#10 and #80) of three residents reviewed for wounds. The facility census was 47. Findings include: 1. Review of Resident #10's medical record revealed the resident was admitted to the facility with 06/02/23 with diagnoses that include chronics respiratory failure, pneumothorax, need for assistance with personal care, and chronic venous hypertension with ulcer of the left lower extremity. Review of the weekly wound tracking logs for July and August 2023 for Resident #10 revealed on 07/07/23 Resident #10 had a stage two pressure ulcer (partial-thickness skin loss with exposed dermis) to the left buttocks that resolved on 07/14/23. Further review revealed Resident #10 had a stage two pressure ulcer on the coccyx beginning 07/24/23 and continued until 08/11/23 when the wound healed. On 08/18/23, Resident #10 was again documented to have a stage two pressure ulcer on the coccyx. Review of physician orders revealed Resident #10 was prescribed to have the left buttocks wound cleansed with normal saline, pat dry, and apply a dry dressing every Tuesday, Thursday, and Saturday for wound care dated 07/06/23. Review of Resident #10's medical record revealed Resident #10's skin changes and physician orders related to her wounds were not documented as communicated with Resident #10 or the resident's responsible party. 2. Review of Resident #80's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including diabetes type two, anxiety, sepsis, and morbid obesity. Review of weekly wound tracking logs for July and August 2023 revealed Resident #80 had moisture associated skin dermatitis on the coccyx on 08/04/23. On 08/11/23, Resident #80 was assessed with an unstageable wound (obscured full-thickness skin and tissue loss) to the coccyx. On 08/18/23, Resident #80 was assessed to have a stage three pressure ulcer (full-thickness skin loss) to the coccyx and a stage two pressure ulcer to the right heel. Review of Resident #80's physician orders revealed Resident #80 was ordered zinc cream to wounds on the coccyx every shift dated 07/23/23, orders for wound care to the coccyx wound dated 07/28/23 and 08/09/23, and orders for treatment to Resident #80's right heel wound on 07/28/23 and 08/18/23. (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 5 Event ID: 365605 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 365605 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milcrest Nursing Center 730 Milcrest Drive Marysville, OH 43040 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)