Health inspection·January 21, 2026

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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEYBased on record review, interview and policy review, the facility failed to ensure residents were assessed for alterations in skin integrity upon admission. This deficient practice affected one resident (Resident #89) out of two residents reviewed for alterations in skin integrity. The facility census was 88.Findings include: Review of Resident #89 ' s medical record revealed an admission dated 12/23/25 and a discharge date [DATE] against medical advice (AMA) with diagnoses including but not limited to urinary tract infection (UTI), spina bifida, asthma, dysphagia, and dependence on wheelchair for mobility.Review of Resident #89 ' s physician orders revealed an order dated 12/23/25 to encourage/assist to turn and reposition as tolerated every shift, a treatment order dated 12/23/25 for Mupirocin External Ointment 2% apply to chronic wounds topically every shift for chronic wounds and an order dated 12/26/25 to evaluate and assess pressure area with dressing located at coccyx every shift. Assess status of dressing, the status of the surrounding area that is visible without removing the dressing for the presence of complications such as infection, and pain as it pertains to the wound.Review of Resident #89 ' s assessments revealed an admission assessment dated [DATE] with Resident #89 ' s skin marked as being warm and dry. There was no further skin assessment completed on 12/23/25. Further review revealed a skin assessment dated [DATE] completed by the facility wound nurse Licensed Practical Nurse (LPN) #327 with a pressure area being noted to the coccyx measuring 1.5 centimeters (cm) by 1.0 cm by 0.2 cm with a small amount of serosanguineous drainage, a red wound bed, and maceration on the wound edges.Review of Resident #89 ' s Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15 which indicated intact cognition, had bilateral extremity impairment, and had an unhealed pressure area to coccyx.Interview on 01/21/26 at 2:13 P.M. with the facility wound nurse/LPN #327 confirmed Resident #89 did not have an admission skin assessment completed on admission [DATE] and the only skin assessment completed was on 12/26/25 when LPN #327 completed a skin assessment as the wound nurse. LPN #327 stated the admitting nurse should be completing the initial admission skin assessment and then as the wound nurse a second assessment will be completed and a review of the admission orders will be completed for treatment orders.Review of the facility ' s policy titled Skin Assessment revised 03/15/24 revealed it is the intent of the facility to provide necessary care to prevent the development of pressure injuries unless the resident ' s clinical condition demonstrates that the development is unavoidable. Residents with pressure injuries shall receive necessary treatment and services to promote healing, prevent infection, and prevent new injuries from developing consistent with professional standards of practice.Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of 01/06/26.On 12/29/25 the facility implemented interventions to ensure the completion of admission skin assessment by using a Residents Affected - Few Page 1 of 2 366024 366024 01/21/2026 Sycamore Run Nursing and Rehab Ctr 6180 State Route 83 N Millersburg, OH 44654

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Skin/Wound Best Practice Checklist.On 12/31/25 all newly admitted residents ' records were audited to ensure completion of admission skin assessments, treatments orders, and for accuracy of documentation.On 12/31/25 admission skin assessments were added to the Quality Assurance Performance Improvement (QAPI) to audit all new admissions for skin assessments and admission treatment orders weekly for two weeks. Audits being completed on 01/07/26 and 01/15/26 with no negative findings.From 12/29/25 to 01/06/26 all nurses were educated to policies for new admission/re-admission skin assessments and treatment orders.Interview conducted on 01/21/26 at 2:36 P.M. with LPN #305 stated she was educated on 12/29/25 for the completion of an admission skin assessment completed upon admission and to review admission paperwork for treatment orders.This deficiency demonstrates noncompliance identified under allegations contained in Complaint Number 2707271. 366024 Page 2 of 2