Health inspection·January 23, 2025

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, observation, interview, and facility policy review, the facility failed to ensure the complete physician-ordered treatment was applied to Resident #20's sacral pressure ulcer. This affected one (Resident # 20) of three residents reviewed for wound care. The facility census was 87. Residents Affected - Few Findings include: Review of the medical record for Resident #20 revealed an admission date of 07/19/24 with diagnoses including iron deficiency anemia, obesity, surgical wound, atrial fibrillation, rheumatoid arthritis, pressure ulcer of sacral region, surgical aftercare following surgery on the digestive system. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had intact cognition and had moderate depression. The resident was dependent on staff for activities of daily living. Review of the January 2025 physician's orders revealed Resident #20's had an order dated 12/02/24 for a wound dressing for a sacral pressure ulcer. The order called for the wound to be cleansed with normal saline, packed with silver alginate, covered with an absorbent pad, secured with paper tape, and changed daily. Additional instructions in the order included to apply zinc ointment around the sacral pressure ulcer daily. Review of the Treatment Administration Record (TAR) for January 2025 revealed Resident #20's sacral wound care was listed as completed daily as ordered. Review of the weekly wound assessment dated [DATE] revealed Resident #20 had a stage four pressure ulcer(indicating a full thickness wound which can extend into muscle, tendon, ligament, cartilage, or bone) to her sacrum. The assessment indicated the wound was healing. The listed treatment included cleanse the wound, apply silver alginate, cover with an absorbent pad, secure the wound with paper tape, and change daily. The assessment indicated triad cream (a zinc-oxide-based paste which can be applied to wounds to encourage healing or to intact skin to protect skin from irritation) was to be applied to the skin surrounding the wound. Observation on 01/22/25 at 2:41 PM with Licensed Practical Nurse (LPN) #288 who completed Resident #20's wound care revealed LPN #288 first prepared to change the resident's sacral wound. LPN #288 removed the old dressing, cleansed the wound with normal saline and packed the wound with silver alginate. LPN #288 then covered the wound with an absorbent pad and secured the dressing with paper tape. LPN #288 did not apply zinc or any cream or ointment to the skin surrounding the resident's wound. (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: 365845 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 365845 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145 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)