Inspection·October 16, 2024

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/16/24 at 10:30 A.M. with the Director of Nursing verified treatments orders need to be followed as written and further verified if the treatments are not documented as completed then they were not completed. The Director of Nursing further verified treatments were not completed to the right heel pressure wound on 09/01/24, 09/13/24, 09/16/24, 09/22/24, 09/24/24, 09/25/24, 09/27/24, 09/28/24, 10/01/24, 10/08/24, 10/09/24, 10/10/24 and 10/14/24 to the left heel pressure wound on 09/13/24, 09/16/24, 09/22/24, 09/24/24, 10/08/24, 10/10/24, and 10/14/24 for Resident #60. 2. Review of the medical record for Resident #64 revealed an admission date of 07/15/24, diagnoses included paraplegia, pressure ulcer stage 4 (sacral region) pressure ulcer right buttock, stage 4, depression, osteomyelitis, and hypertension. Review of the comprehensive MDS dated [DATE] revealed Resident #64 was cognitively intact, had functional impairment to bilateral lower extremities, was dependent for toilet hygiene, bathing, dressing and transfers. Resident #64 was incontinent of bladder and bowel and had two stage 4 unhealed pressure ulcers requiring the application of dressings. Review of the care plan dated 07/18/24 revealed Resident #64 had a pressure injury, interventions included for medications and treatments to be administered as ordered, assess, record and monitor wound healing, monitor nutritional status, pressure reducing mattress to bed and cushion to chair, and to treat pain. Review of a physician order dated 07/18/24 required the right thigh pressure wound to cleansed with wound wash, collagen to be applied to wound bed and the wound was to be covered with Silver Alginate and drainage pad daily. The order was discontinued on 10/16/24 and new order for the right thigh pressure wound to be cleansed with wound wash, apply collagen, cover with silver alginate and a border foam dressing daily. Resident #64 also had a treatment order written on 07/18/24 for the coccyx pressure wound to be cleansed with wound wash, collagen applied and for the pressure wound to be covered with silver alginate and a drainage pad daily. This order was also discontinued on 10/16/24 with a new order to cover with a border gauze rather than the drainage pad. Review of the treatment administration records for Resident #64 revealed in July 2024 the pressure wound treatment to the right thigh was not completed as ordered on 07/22/24, 07/24/24, 07/25/24, 07/27/24, 07/28/24, 07/29/24 an 07/31/24. For August 2024 treatments were not provided on 08/01/24, 08/02/24, 08/04/24, 08/08/24, 08/09/24, and 08/17/24. Review of the September 2024 treatment record, treatments were missed on 09/01/24, 09/02/24, 09/19/24, 9/22/24, 09/27/24, and 09/30/24 and for October 2024 treatments were not provided on 10/01/24 and 10/02/24. Review of the treatment records for July 2024, August 2024, September 2024 and October 2024 for the management of the pressure wound to the coccyx of Resident #64 revealed missing treatments on the following dates: 07/27/24, 07/28/24, 07/29/24, 07/31/24, 08/01/24, 08/02/24, 08/04/24, 08/08/24, 08/09/24, 08/18/24, 09/01/24, 09/02/24, 09/22/24, 09/27/24, 09/31/24, 10/01/24, and 10/02/24. Interview on 10/16/24 at 8:45 A.M. with Resident #64 revealed concerns related to the care and treatment of the pressure wounds. Resident #64 stated the treatments being provided do not match the wound care physician orders. Observation on 10/16/24 at 9:32 A.M. of Unit Manager #157 completing Resident #64's dressing changes to the right thigh and coccyx revealed the wounds were cleansed with wound wash, patted dry followed by an application of collagen to the wound beds and each of the wounds were covered with silver (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365737 If continuation sheet Page 2 of 4 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 10/16/2024 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)

F 0686 alginate and border foam. Level of Harm - Minimal harm or potential for actual harm Interview with Unit Manager #157 on 10/16/24 at 10:10 A.M. verified Resident #64 has an order for a drainage pad to be placed over the wounds and Unit Manager #157 used border gauze. Unit Manager #157 stated the drainage pads hold moisture, and the border gauze does not and due to Resident #64 being incontinent, border foam is used to pull the moisture away from the wounds. Residents Affected - Few Interview on 10/16/24 at 10:30 A.M. with the Director of Nursing verified treatments orders need to be followed as written and further verified if the treatments are not documented as completed then they were not completed. 3. Review of the medical record for Resident #8 revealed an admission date of 06/19/24 with a readmission on [DATE], diagnoses included a fracture of the right acetabulum, neuromuscular dysfunction of bladder, atrial fibrillation, and Alzheimer's disease. Review of the comprehensive MDS dated [DATE] revealed Resident #8 was cognitively impaired, was at risk for pressure injuries and had no unhealed pressure wounds. Review of the care plan dated 07/01/24 revealed Resident #8 was at risk for skin alteration with potential for pressure ulcer development related to disease process and immobility. Interventions included to administer medications, treatments and preventative treatments as ordered, follow facility policies and procedures for the prevention of skin breakdown and to monitor, document and report and changes in skin condition. Review of the physician orders for Resident #8 revealed orders written on 07/09/24 for preventive skin preparation to be applied to bilateral heels every morning and at bedtime, weekly skin review every Tuesday and on 08/06/24 an order for preventative heel boots were ordered. Review of the treatment administration records for July 2024 and August 2024 for Resident #8 revealed preventative skin preparation was not applied as ordered on 07/12/24, 07/17/24, 07/24/24, 08/12/24, and 08/13/24. Review of the weekly nursing skin assessment completed on 08/06/24 revealed an unstageable pressure wound to the left heel of Resident #8 measuring 3.1 centimeters (cm) in length by 1.9 cm in width and 0.1 cm in depth. The care plan updated on 08/06/24 at 3:53 P.M. revealed Resident #8 had an unstageable left heel injury related to immobility, end stage cardiovascular disease and dementia. Interventions included administer medications and treatments as ordered, heel boots, and pain management. Further review of the treatment administration record for August 2024 revealed Resident #8 did not have heel boots in place on 08/16/24, 08/18/24 and 08/21/24. Interview on 10/16/24 at 10:30 A.M. with the Director of Nursing verified Resident #8 was at risk for pressure ulcers and preventative treatments were not documented as being implemented on 07/12/24, 07/17/24, 07/24/24, 08/12/24, and 08/13/24. The Director of Nursing verified if treatments are not documented then they were not completed. The Director of Nursing further verified Resident #8 developed a facility acquired pressure wound to the left heel on 08/06/24. Additionally, the Director of Nursing verified a physician ordered intervention for heel boots were not implemented on 08/16/24, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365737 If continuation sheet Page 3 of 4 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 10/16/2024 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)

F 0686 08/18/24 and 08/21/24. Level of Harm - Minimal harm or potential for actual harm Review of the undated facility policy titled, Physician Order System, stated orders are implemented as written. Residents Affected - Few Review of the undated facility policy titled, Skin Care, stated the facility will provide the care necessary to decrease the risk of a resident developing a pressure injury. Review of the facility policy titled, Wound Care, dated 08/2022 provided guidelines for the care of wounds to promote healing and included the verification of the physician order and documentation of the completed treatment in the electronic medical record. This deficiency represents non-compliance investigated under Complaint Number OH00158518. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365737 If continuation sheet Page 4 of 4