Health inspection·January 30, 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 record review, resident, family, and staff interview and review of facility policy, the facility failed to timely treat and assess the resident's pressure wounds. This affected two Residents (#10 and #12) of three residents reviewed for wounds. The facility census was 43. Residents Affected - Few Findings include: 1) Review of medical record for Resident #10 revealed an admission date of 01/25/24. Diagnoses included end stage renal disease, congestive heart failure, diabetes mellitus type II, and chronic venous insufficiency. The resident was hospitalized on [DATE] and did not return. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had cognitive impairment. Resident #10 was dependent on staff for toileting hygiene, bed mobility, and transfers. Review of the care plan revealed potential for wounds or pressure ulcer development related to end stage renal disease, venous insufficiency and a past history of pressure ulcers. Interventions included to administer treatments as ordered and monitor effectiveness and weekly treatment documentation to include the measurement of each area of skin breakdown's width, depth, type of tissue and exudate. Record review revealed upon the return of her hospitalization on 08/01/24, the admission skin assessment documented a pressure wound to her coccyx measuring four centimeters (cm) length by (x) one cm wide x 0.7 cm. depth. Pressure area staging documentation was blank. The wound assessment dated [DATE] revealed no documentation of the coccyx wound. The progress note dated 08/05/24 revealed documentation the wound nurse practitioner had been unable to assess the coccyx wound due to Resident #10 being in a dialysis chair. The skin assessment dated [DATE] revealed documentation of a sacral wound measuring 3.4 cm in length x 1.2 cm. wide and no depth was documented. The area type was specified as other and described as open area. The wound assessment dated [DATE] revealed documentation of coccyx wound measuring 7.5 cm in length x 3.5 cm wide x 0.1 cm. in depth. The wound was documented as pressure and staging was documented as 'not applicable'. The progress note dated 08/12/24 revealed the wound nurse practitioner provided a telehealth visit. Orders were given for Triad cream to coccyx twice daily and as needed. Review of Resident #10's physician orders and treatment administration records revealed there were no treatment orders for the coccyx and or sacral wound from 08/01/24 until 08/12/24. (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 4 Event ID: 365936 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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)