Health inspection·December 18, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, resident and staff interviews and policy review, the facility failed to ensure wound care was completed as ordered by the physician. This affected two (Residents #35 and #64) of three residents reviewed for wound care. The facility census was 67. Residents Affected - Few Findings include: 1. Review of Resident #35's medical record revealed an admission date of 11/09/23 with diagnoses that included cerebrovascular accident, diabetes mellitus and hypertension. Review of Resident #35's Minimum Data Set (MDS) 3.0 admission assessment with a reference date of 11/30/23 revealed Resident #35 had intact cognition Review of Resident #35's admission wound assessments revealed Resident #35 was admitted to the facility with bilateral stage two pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) to the bilateral heels. Review of Resident #35's physician's orders revealed on 12/01/23 wound care orders to clean the bilateral heels with wound cleanser, apply skin prep (protectant barrier), cover with an ABD (large gauze) pad and wrap with kerlix (gauze wrap) every day and as needed. Review of the Treatment Administration Record (TAR) revealed no evidence the wound care was completed as ordered by the physician on 12/02/23 and 12/12/23. The TAR indicated wound care was completed on 12/15/23, 12/16/23 and 12/17/23. Observation on 12/18/23 at 9:40 A.M. of Resident #35's bilateral heel bandages with Licensed Practical Nurse (LPN) #71 revealed bandages were in place to the bilateral heels. The left heel dressing was dated 12/14/23 and the right heel dressing was undated. Interview with LPN #71 at 9:40 A.M. revealed bilateral bandage changes are to be completed to Resident #35's heels every day. LPN #71 further verified the left heel bandage was dated 12/14/23, the right heel bandage was not dated. The LPN verified the left heel bandage had not been changed as ordered daily on 12/15/23, 12/16/23 and 12/17/23 and there was no date on the right heel dressing to indicate when the dressing had been changed. Interview with Resident #35 at 9:45 A.M. verified no wound care had been provided to his bilateral heels since 12/14/23. Interview with the Director of Nursing (DON) on 12/18/23 at 10:55 A.M. verified wound care for Resident #35 were documented as completed on 12/15/23, 12/16/23 and 12/17/23, but the observation of 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 2 Event ID: 365674 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 365674 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Minerva 400 Carolyn Court Minerva, OH 44657 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)