Inspection·April 18, 2024

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, and review of the facility policy, the facility failed evaluate, provide care and treatment, and conduct ongoing assessments to treat a resident's skin alteration. This affected one (Resident #4) of two residents reviewed for skin care and treatment. The facility census was 69. Residents Affected - Few Findings include: Review of the medical record for Resident #4 revealed an admission date of 01/22/23. Diagnoses included congestive heart failure, chronic kidney disease, type II diabetes mellitus, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact, was independent with activities of daily living, was incontinent of urine, and had no skin breakdown with no skin alterations. However, Resident #4 was at risk for skin breakdown and received the application of nonsurgical dressing. Review of the care plan dated 03/31/24 revealed Resident #4 was at risk for skin alterations due to disease process, immobility, incontinence, diabetes, heart failure and kidney failure. There was a second care plan, dated 03/31/24, for actual skin alteration to the right lower extremity due to an open blister from cellulitis. The goal for Resident #4 was to show sign of healing without complication. Interventions included to administer medications and treatments as ordered, assess, record, and monitor wound healing, obtaining measurements to include length, width, depth, the status of the wound perimeter, wound bed and healing process, monitor dressing daily to ensure intact and adhering, change as needed and enhanced barrier precautions. Review of the weekly wound care care notes from 02/27/24 to 04/01/24 revealed the resident's right lower extremity had cellulitis with an open area to the right shin, with rolled edges, with a moderate amount of serosanguineous drainage. The measurements on 04/01/24 were seven centimeters (cm) long by three cm wide by 0.1 deep. Review of the weekly skin assessments from 03/04/24 to 04/15/24 revealed Resident #4 had an open area to the right upper outer shin. The assessment on 04/15/24 revealed no signs or symptoms of infection, measurements were 2.0 cm long by 1.0 cm wide by 0.2 cm deep. Review of the current physician orders revealed an order dated 03/02/24 for weekly skin assessments every day shift on Mondays for monitoring and an order on 04/01/24 to cleanse the right lower extremity with wound cleanser, pat dry, apply border gauze, and cover with ace wrap every day and as needed. (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: 365737 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 365737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heatherdowns Rehab & Residential Care Center 2401 Cass Rd Toledo, OH 43614 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)