Inspection·August 24, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure pressure ulcer wound care was completed as ordered. This finding affected two (Residents #38 and #68) of three residents reviewed for pressure wounds. Residents Affected - Few Findings include: 1. Review of Resident #38's medical record revealed the resident was admitted on [DATE] with diagnoses including end stage renal disease, peripheral vascular disease and need for assistance with personal care. Review of Resident #38's physician orders revealed an order dated 07/20/23 to irrigate the sacral pressure wound with normal saline (NS), pat dry, apply calcium alginate (soft, comfortable, highly absorbent dressing) and silicon to the wound bed and cover with a bordered foam dressing every night shift. Review of Resident #38's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #38's Skin and Wound Evaluation form dated 08/17/23 revealed the resident had a stage 3 sacral pressure ulcer (affects the top two layers of skin, as well as fatty tissue) present upon admission measuring 1.0 centimeters (cm) length by 1.1 cm width by 0.2 cm depth. Review of Resident #38's medication administration records (MARS) and treatment administration records (TARS) from 08/01/23 to 08/23/23 revealed no evidence pressure ulcer wound care was completed on 08/04/23 and 08/07/23. Interview on 08/24/23 at 9:11 A.M. with the Director of Nursing (DON) confirmed the wound care was not completed on Resident #38's sacral pressure ulcer on 08/04/23 and 08/07/23 as ordered by the physician. 2. Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses including acute and subacute endocarditis, diabetes and end stage renal disease. Review of Resident #68's physician orders revealed an order dated 08/03/23 to irrigate the right heel/achilles with NS, pat dry, pad and protect with an abdominal pad (ABD) and wrap with Kerlix one time a day. This order was discontinued on 08/05/23 and a new order was placed on 08/05/23 to irrigate the right heel/achilles with NS, pat dry, pad and protect with an ABD and Kerlix daily every day (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: 365718 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 365718 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Streetsboro 1645 Maplewood Dr Streetsboro, OH 44241 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)