Health inspection·September 10, 2025

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 Based on observation, resident interview, medical record review, staff interview, and review of facility policy, the facility failed to ensure skin treatments were completed per physician order. This affected one (#48) of three residents reviewed for wound treatments. The facility census was 71.Findings include:Review of the medical record for Resident #48 revealed an admission of 02/12/25. Diagnoses included morbid obesity, psoriasis vulgaris, seborrheic dermatitis, and Type I diabetes mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/09/25, revealed Resident #48 had intact cognition. Resident #48 required moderate assistance with Activities of Daily Living (ADLs). Review of the care plan dated 03/03/23 revealed Resident #48 was at risk for chronic cellulitis. Interventions included to cleanse areas daily with soap and water and dry thoroughly. Further review of the care plan revealed Resident #48 had actual ADL self-care performance deficits and was at risk for incontinence secondary to impaired mobility, generalized weakness, and fatigue. Interventions included monitoring skin during care. Additionally, Resident #48 was at risk for potential skin breakdown related to morbid obesity, lymphedema, and cellulitis. Resident #48 had a diagnosis of psoriasis vulgaris and seborrheic dermatitis. Interventions included documenting any refusals of treatment and completing treatments as ordered.Review of the physician orders revealed an order 02/29/25 for ketoconazole external cream 2%, apply to body topically every four days for psoriasis, apply small amount during shower. Further review revealed an order dated 03/03/25 for miconazole external powder 2% (anti-fungal), apply to folds and groin topically every day and evening shift for excoriation. Lastly, Resident #48 had an order dated 07/09/25 for triamcinolone acetonide external cream 0.1%, apply topically to affected areas every day and evening shift for plaque psoriasis.Review of the Treatment Administration Record (TAR) from 09/01/25 through 09/08/25 revealed Resident #48's ketoconazole external cream, miconazole external powder, and triamcinolone acetonide external cream were documented as administered as ordered. Interview on 09/08/25 at 2:29 P.M. with Resident #48 revealed she completed her own skin treatments, including ketoconazole external cream, miconazole external powder, and triamcinolone acetonide external cream. Resident #48 stated she had been out of the treatments for three days and had told nursing staff.Interview on 09/08/25 at 3:27 P.M. with Licensed Practical Nurse/Unit Manager (LPN/UM) #528 confirmed Resident #48 applied ketoconazole external cream, miconazole external powder, and triamcinolone acetonide external cream herself, and the treatments were left in the room. LPN/UM #528 verified that Resident #48 did not have an order to self-administer her treatments or keep treatments at bedside. LPN/UM #528 confirmed the treatments were signed off as completed on the TAR; however, LPN/UM #528 stated the treatments had not been available for a long time and were not available in the medication cart. Review of the facility policy titled, Medication Administration-General Guidelines, dated 03/20/18 revealed medications were administered in accordance with written orders of the attending physician.This deficiency represents non-compliance investigated under Complaint Number 1357196. Residents Affected - Few 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: 365681 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 365681 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Lane Healthcare Center 355 Windsor Lane Gibsonburg, OH 43431 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)