Inspection·August 30, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain an accurate medical record related to skin wounds. This affected two residents (#62 and #67) of three residents reviewed. Findings include: Interview 08/30/23 at 11:31 A.M. with the Administrator revealed the facility had an incident when two residents developed maggots in their skin wounds. Record review for Resident #67 revealed the resident was admitted to the facility on [DATE] and a 08/28/23 readmission with diagnoses including acute osteomyelitis of the right femur, paraplegia, weakness, abnormal posture, dysphasia, need for assistance with personal care, osteomyelitis of the sacrum, schizophrenia, bipolar disorder, unspecified psychosis, muscular dysfunction of bladder, reduce mobility, hypertension, insomnia, colostomy, abscess of the left testicle, irritable bowel syndrome with diarrhea, indwelling urinary catheter nephrostomy, delusional disorder, paranoid disorder, and acute kidney failure. Review of the 07/17/23 quarterly Minimum Data Set Assessment (MDS) assessment revealed the resident was moderately impaired for daily decision making, experienced daily rejection of care, delusions, verbal and physical behaviors. The resident required extensive assist of two for bed mobility, transfers, dressing, toilet use, bathing and personal hygiene. The resident had one Stage 3 pressure ulcer and one Stage 4 pressure ulcer. Review of the treatment administration records (TAR) revealed the resident had an order for a right ischium dressing cleanse with normal saline, pat dry, cover with foam dressing once a day for wound care. The resident refused a dressing change on 08/11/23 through 08/14/23. Interview on 08/28/23 at 2:03 P.M. with Registered Nurse (RN) #80 revealed while passing medications on 08/15/23 she saw a maggot on the bedding of Resident #67. She removed it with a washcloth and took it to management. They joined her in the room and when she pulled back the covers she saw approximately 10 more on the bedding. When she removed the dressing to Resident #67's right ischium there may have been 100 maggots. The nurse practitioner happened to be in the building and gave orders for a hibiclens shower. The nurse practitioner consulted with the wound consultant and then ordered a Dakin's dressing also. The resident allowed the shower but refused the Dakins dressing. No other maggot activity has been found on Resident #67. Review of the progress notes revealed the 08/15/23 at 2:44 P.M. a nurse note written by the (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 3 Event ID: 365612 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 365612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summit Acres Nursing Home 44565 Sunset Road Caldwell, OH 43724 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)