Inspection·September 22, 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, observation, resident interview, and staff interviews, the facility failed to ensure Resident #5's sacral pressure ulcer wound care was completed per the physician's order. This affected one (Resident #5) of three residents reviewed for pressure ulcers. The facility census was 99. Residents Affected - Few Findings include: Review of Resident #5's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dislocation of the left hip with encounter for other orthopedic aftercare, muscle weakness and difficulty in walking. Review of Resident #5's admission assessment dated [DATE] revealed the resident's skin was intact (with the exception of a surgical hip wound the resident was admitted with). Review of Resident #5's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and required extensive two person assist for bed mobility and toilet use as well as extensive one person assist for dressing, personal hygiene, and bathing. Review of Resident #5's weekly skin check dated 08/02/23 revealed the resident had a recent left hip surgical site with a wound vac in place and was followed by the wound team. The resident did not have a pressure ulcer to the sacral area on this date. Review of Resident #5's initial wound track form dated 08/08/23 revealed the resident had a stage three sacral pressure wound (full-thickness skin loss with fat exposed) which measured 4.3 cm (centimeters) length by 7.6 cm width by 0.2 cm depth acquired 08/08/23. Current pressure prevention interventions included turning and repositioning the resident. New pressure prevention interventions included to elevate heel, low air-loss mattress and roho cushion to the wheelchair. Review of Resident #5's Wound Nurse Practitioner (NP) progress note dated 08/08/23 indicated the NP was consulted for evaluation of a pressure injury to the sacrum. Per the facility staff, the patient was non-compliant with skin checks, skin care and turning. Upon exam, the stage 3 pressure injury noted to the sacral region, contiguous with the bilateral buttocks, revealed a shallow, full thickness wound comprised primarily of red, moist tissue with some yellow, adherent tissue noted to the dermal layer as well. Review of Resident #5's skin integrity care plan dated 08/08/23 revealed the resident had a stage 3 pressure ulcer to the sacrum and interventions included to elevate the heels while in bed, a low air loss mattress with a perimeter overlay, moisture barrier after each incontinent episode, roho (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: 365865 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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)