Health inspection·April 3, 2024

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 and staff interview, the facility failed to provide wound care as ordered. This affected one (Resident #20) of three reviewed for wounds. The facility census was 47. Residents Affected - Few Findings include: Review of the medical record for Resident #20 revealed an admission date of 01/25/24 with diagnoses including but not limited to displaced bimalleolar fracture (ankle) of right lower leg, fracture of upper end of right tibia (larger bone in lower leg, shinbone), type one diabetes, major depressive disorder, syncope and collapse, other specified disorders of bone density and structure to right thigh, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Resident #20 required extensive assistance for Activities of Daily Living (ADLs) and had surgical wounds. Review of the care plan dated 02/01/24 revealed Resident #20 had actual impairment to skin integrity of the right lower leg related to surgical wound. Interventions included but not limited to follow facility protocols for treatment and injury, keep skin clean and dry, use lotion on dry skin, monitor for side effects of medications, pressure reducing device as ordered, and weekly skin screen. Review of physician orders for Resident #20 revealed orders for nursing staff to change wound vac every Wednesday and Friday, place bridge between wounds and place suction in the middle of the bridge per wound clinic and wound clinic to change dressings. Review of the nursing note dated 03/05/24 revealed Resident #20 returned from the hospital per transport. Resident #20 complained of pain to right leg and ankle. Wound vac in place and draining. Order received from wound clinic to change wound vac on Thursday and Saturday this week. Review of the Treatment Administration Record (TAR) for March 2024 revealed no order put in to change wound vac on Thursday (03/07/24) and Saturday (03/09/24) therefore wound vac was not signed off as being changed. Wound vac was signed off as held on 03/06/24. Starting 03/11/24, wound vac started to be changed by the wound clinic on Monday, Wednesday, and Friday. Interview on 04/03/24 at 4:33 P.M. with the Director of Nursing (DON) verified the order was not put in for the wound vac change on Thursday 03/07/24 and Saturday 03/09/24, therefore it was not completed. (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: 365953 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 365953 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein St Marys Retirement Community 11230 State Route 364 St Marys, OH 45885 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)