Health inspection·August 29, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interview the facility failed to implement adequate skin risk interventions and treatment for Resident #5, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for turning and repositioning, to prevent the development of a pressure ulcer to the resident's left heel. Residents Affected - Few Actual harm occurred on 05/21/23 when an order for skin prep was obtained for Resident #5's heels with no corresponding assessment or information related to why. On 05/24/23 the wound Certified Nurse Practitioner (CNP) assessed Resident #5 to have a Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible) pressure ulcer to the left heel. However, treatment orders were not implemented until 05/31/23 (ten days after the ulcer was potentially first identified). This affected one resident (#5) of three residents reviewed for pressure ulcers. Facility census was 67. Finding include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included fracture of left femur, pneumonia, type 2 diabetes mellitus, embolism and thrombosis of deep veins of left lower extremity, dementia, anxiety, and chronic kidney disease. Record review revealed a plan of care dated 02/03/21 reflecting Resident #5 was at risk for skin breakdown. Interventions included to encourage resident to turn and reposition, perform skin checks and report any new areas, assist with incontinence care, pressure redistribution mattress to bed, and apply treatment as ordered. The care plan did not include any pressure related interventions for the resident's heels. A Braden Scale for Predicting Pressure Ulcer Risk dated 03/16/23 revealed Resident #5 was at very high risk for the development of pressure ulcer. Clinical suggestions included to elevate heels off the bed, turn and reposition at least every two hours while in bed. Review of the treatment administration record (TAR) revealed on 05/21/23 the record was updated to include skin prep to be applied to Resident #5's heels and the resident's heels were to be floated. However, review of skin assessments and progress notes revealed no documentation/assessment(s) pertaining to Resident #5's heels at this time or any additional information related to why this order was initiated. A wound care note by the wound CNP dated 05/24/23 revealed Resident #5 had a new Stage III pressure (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 3 Event ID: 365815 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 365815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050 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)