Health inspection·July 27, 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 medical record review, staff interview, and policy review, the facility failed to ensure treatments for a pressure ulcer were provided as ordered. This affected one (Resident #8) of one resident reviewed for pressure ulcers. The facility census was 35. Residents Affected - Few Findings include: Review of the medical record for Resident #8 revealed an admission date of 01/25/23, with medical diagnoses of chronic respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, hypertension, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and required extensive staff assistance with bed mobility, transfers, incontinence cares, and bathing. Resident #8 was frequently incontinent of bowel, and had an indwelling catheter. Further review of the medical record revealed Resident #8 had a Stage IV pressure ulcer to the sacrum. Review of the Resident #8's physician's orders revealed an order dated 03/15/23 to cleanse sacrum, apply solution soaked kerlix, cover with ABD pad and secure with tape every day and every evening shift. Further review revealed the wound care order was changed on 06/28/23. Review of the March 2023 TAR revealed Resident #8 did not receive treatment to the sacrum pressure ulcer as ordered on 03/05/23, 03/09/23, 03/17/23, 03/26/23, and 03/31/23. Review of the April 2023 TAR revealed Resident #8 did not receive treatments to the sacrum pressure ulcer as ordered on 04/10/23, 04/11/23, 04/14/23, and 04/23/23. Review of the May 2023 TAR revealed Resident #8 did not receive treatments to the sacrum pressure ulcer as ordered on 05/16/23 and 05/20/23. Review of the June TAR revealed Resident #8 did not receive treatments to the sacrum pressure ulcer as ordered on 06/03/23 and 06/27/23. Further review of the medical record for Resident #8 revealed the sacrum wound was evaluated weekly by the wound physician, who documented multiple episodes of debridement of the sacral pressure ulcer from February 2023 to July 2023. Review of the wound physician note dated 07/18/23 revealed Resident #8 had a Stage IV pressure ulcer to sacrum which measured 3.5 cm by 2.7 cm x 3.5 cm and the ulcer had improved. Interview on 07/26/23 at 9:09 A.M. with the Director of Nursing (DON) confirmed Resident #8 did not receive the treatment to his sacral pressure as ordered on the dates stated above in March, April, (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 9 Event ID: 365744 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 365744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Roselawn Manor 420 East Fourth Street Spencerville, OH 45887 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)