Health inspection·February 1, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility failed to provide Resident #6 adequate nail care prevent skin impairment. This affected one resident (#6) of three residents reviewed for quality of care. Residents Affected - Few Findings include: Review of Resident #6's medical record revealed an admission date of 07/02/23 with diagnoses including but not limited to cerebral infarction, human immunodeficiency virus (HIV) disease, type 2 diabetes mellitus with diabetic polyneuropathy, acute pulmonary edema, contusion of right upper arm, hypertension, anoxic brain damage, anxiety disorder, major depressive disorder, recurrent, severe with psychotic symptoms, and vascular dementia. Review of the care plan dated 07/02/23 revealed Resident #6 was at risk for pressure injury formation related to generalized debility and weakness as evidenced by decreased mobility in bed and wheelchair, incontinence of bowel. Interventions included an ordered dated 12/26/23 to keep nails trimmed and filed. Review of the care plan dated 07/02/23 revealed Resident #6 had an activity of daily living (ADL) self-care performance deficit related to activity intolerance, fatigue, impaired balance, limited mobility, limited range of motion (ROM) and stroke. Interventions included left palm guard to wear at all times, may take off during hygiene/grooming for skin protection. Review of Resident #6's Braden Scale for Predicting Pressure Sore Risk dated, 10/01/23, revealed Resident #6 was at risk for developing a pressure injury. Review of Resident #6's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #6 had moderate cognitive impairment. Resident #6 required extensive assistance of two staff members for bed mobility and was dependent on staff for bathing and shower assistance. Review of the progress note dated 12/25/23 at 6:05 P.M. revealed Resident #6's family visited and reported to Licensed Practical Nurse (LPN) #140 Resident #6 had a wound on her left palm. The left palm was cleansed, and palm protector put back in place and nails were trimmed, and the wound nurse practitioner (NP) was notified. Review of resident concerns for December 2023 revealed on 12/25/23 Resident #6's family had care concerns regarding a new left palm wound. Review of Resident #6's wound NP note dated 12/26/23 revealed the resident had an abrasion related wound on the left hand. Circular scab from where her finger nails have abraded her skin. Skin prep to mature scab. The wound measures 1.2 centimeters (cm) by 0.8 cm by unable to determine depth. Wound base composed of 100% scab. NO drainage and peri wound appeared normal. Treatment was ordered to apply skin prep, change and apply treatment daily and as needed. Observation on 01/30/23 at 10:16 A.M. of a LPN #140 removing Resident #6's left palm protector revealed the resident's left hand was contracted, and the left palm had a small closed area noted, with no redness, swelling or odor. LPN #140 revealed nails should be trimmed by state tested nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 2 of 8 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 366057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130 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)

F 0684 assistants unless the resident was diabetic. Resident #6 was diabetic. Level of Harm - Minimal harm or potential for actual harm Interview on 01/30/24 at 10:29 A.M. with LPN #154 confirmed Resident #6 had a wound to left palm. LPN #154 reported she was on call on 12/25/23 and received a call from the facility regarding Resident #6 family upset regarding the wounds. LPN #154 reported she spoke with Resident #6's family trying to calm her down. LPN #154 saw the left palm wound on rounds with wound NP on 12/26/23 and reported it looked macerated, had an odor, and indentation of fingernail in it. LPN #154 revealed nails should be trimmed on shower days. Residents Affected - Few Interview on 01/30/24 at 2:35 P.M. with LPN #140 confirmed resident #6's family made her aware Resident #6 had a wound to left palm. LPN #140 confirmed a wound to her left palm from her nail going into her skin, a little odor, moisture and red area noted. Interview on 01/30/24 at 4:34 P.M. with LPN #113 confirmed she worked on 12/25/23 as a state tested nursing assistant (STNA) and helped with Resident #6. LPN #113 reported Resident #6's family was upset due to finding the wound of left palm. LPN #113 reported she knows the family from working with her on the other side, so she went to help. LPN #113 reported Resident #6's nails were really long, wound smelled really bad, and nails were cutting into the palm of her hand. LPN #113 reported she cut her nails and cleansed her left palm with NS, covered with gauze and put left palm protector back on. LPN #113 reported she let LPN #140 know. LPN #113 revealed nails should be trimmed on shower days. Interview on 01/31/24 at 3:05 P.M. with Wound Nurse Practitioner (NP) #160 revealed he comes to the facility once a week to round with unit manager on wounds. Wound NP #160 reported he sees Resident #6 for wounds. Wound NP #160 reported he is concerned with all wounds he sees. Wound NP #160 reported he saw Resident #6 on 12/26/23 for an wound abrasion on left palm caused by fingernails digging into her. Wound NP #160 reported it healed pretty quickly. Interview on 02/01/24 at 1:28 P.M. with Designated Social Worker DSW#100 confirmed Resident #6's daughter was concern regarding the left palm wound. Review of the facility policy, Skin Care Program, revised 01/24/23, revealed it is the responsibility of the Center's Nursing staff to follow the plan of care (POC) and prevent and or promote healing of skin issues unless they are clinically unavoidable. When a new skin issue is noted, the nurse will measure the area initially and then every 7 days until healed. This deficiency represents non-compliance investigated under Complaint Number OH00149710. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 3 of 8 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 366057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive pressure ulcer program to prevent the development of pressure ulcers and to ensure pressure ulcers were comprehensively assessed, properly treated, and interventions were initiated to promote healing. Residents Affected - Few Actual Harm occurred on 12/19/23 when Resident #6, who had moderate cognitive impairment, was at risk for skin breakdown and required extensive assistive from two staff for bed mobility developed a new in-house acquired unstageable (dry, leathery, brown or black necrotic (dead avascular) tissue - Eschar, full-thickness pressure injuries in which the base is obscured by slough and/or eschar due to damage of underlying soft tissue from pressure and/or shear) pressure ulcer to the left heel without evidence the area was identified prior to being unstageable and without evidence of effective and individualized interventions to prevent the development of the ulcer. This affected one resident (Resident #6) of three residents reviewed for pressure ulcers, injuries. The facility census was 56. Findings include: Review of Resident #6's medical record revealed an admission date of 07/02/23 with diagnoses including cerebral infarction, human immunodeficiency virus (HIV) disease, type 2 diabetes mellitus with diabetic polyneuropathy, acute pulmonary edema, and vascular dementia. Review of the care plan dated 07/02/23 revealed Resident #6 had potential/actual impairment to skin integrity related to fragile skin and abrasion to left gluteal fold. Interventions included weekly treatment documentation, use caution during transfers and bed mobility, complete Braden scale, and follow facility policy for treatment of injury. Review of Resident #6's Braden Scale for Predicting Pressure Sore Risk dated, 10/01/23, on a scale of at risk 15-18, moderate risk 13-14, high risk 10-12, and very high risk 9 or below revealed Resident #6 was at risk for developing a pressure injury. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #6 had moderate cognitive impairment. The assessment revealed Resident #6 required extensive assistance of two staff members for bed mobility and toilet use and Resident #6 was totally dependent on two staff members for transfers with mechanical lift. The assessment revealed the resident had no pressure ulcers or injury, no skin issues noted and was always incontinent of bowel. Review of the Weekly Skin -Total Body Evaluation completed on 11/23/23 and on 11/30/23 reflected Resident #6 did not have any wounds; however, this was identified to be inaccurate as Resident #6's medical record revealed she had a left buttock abrasion as of 11/21/23. Review of Resident #6's Braden Scale for Predicting Pressure Sore Risk dated, 12/04/23, revealed the resident was at risk of developing a pressure injury. Review of Resident #6's Braden Scale for Predicting Pressure Sore Risk dated, 12/07/23, revealed Resident #6 was at a moderate risk for developing a pressure injury. However, upon review of the Braden Scale revealed it was not completed accurately. Under the moisture section it was scored as the resident being rarely moist. Resident #6 had been assessed to be always incontinent of bowel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 4 of 8 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 366057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130 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)

F 0686 Review of Resident #6's Weekly Skin- Total Body Evaluation dated 12/14/23 revealed the resident had a wound but it did not specify type of wound or location. Level of Harm - Actual harm Residents Affected - Few a.Review of an incident report dated 12/19/23, revealed the nurse was called into resident's room due to noted new opened area to the resident's left heel. The report did not include a stage of the ulcer. The area was cleansed with normal saline solution, measured at 4.0 centimeters (cm) length by 4.0 cm width with a depth that could not be determined. The report revealed the nurse practitioner (NP) was updated and a new order was obtained for Xeroform, ABD and Kerlix, change dressing every two days and as needed. There was no further description of the wound or an identified stage. The incident report was not a part of Resident #6's medical record. Review of a late entry progress note dated 12/19/23 revealed the physician was updated about a new wound to the resident's left heel and treatment orders were obtained. The note indicated staff would provide updates as available. The medical record did not include what order was obtained or a stage of the ulcer. Review of Resident #6's TAR revealed no evidence a physician order for the left heel was transcribed for treatment. Review of Resident #6's care plan revealed on 12/19/23 pressure reduction interventions were added to include bilateral heel protectors and to encourage resident to float heels and/or wear heel boots. Review of the treatment administration records (TAR) for December 2023 revealed on 12/21/23 an order was transcribed for a treatment to cleanse left heel with normal saline (NS), apply xeroform, ABD, kerlix every tree (3) days and PRN, every day shift every Tuesday, Thursday, and Saturday. The treatment was documented as being completed on 12/21/23 and 12/23/23. Review of the facility concern log for December 2023 revealed on 12/25/23 Resident #6's family had care concerns regarding the resident's left heel dressing changes not being completed. Review of the investigation documents completed on 12/26/23 regarding Resident #6's family concerns on 12/25/23 revealed Licensed Practical Nurse (LPN) #140 received a written warning for failure to carry out job responsibilities. The investigation revealed on 12/21/23, LPN #140 signed the TAR indicating she had completed a left heel dressing change, however on 12/25/23 it was observed the left heel dressing on Resident #6 was dated 12/19/23. Further review of the investigation documents completed on 12/26/23 revealed Registered Nurse (LPN) #148 received a written warning for failure to carry out job responsibilities. The investigation revealed on 12/23/23, RN #148 signed the TAR indicating she completed a left heel dressing change. However, on 12/25/23 it was observed the left heel dressing on Resident #6 was dated 12/19/23. Review of the Wound Care assessment dated [DATE] revealed an initial evaluation of Resident #6's left heel. The wound was assessed to be an unstageable pressure injury wound, with circular black eschar with surrounding callus, no drainage, no signs of infection, measuring 4.2 cm by 3.1 cm with an undetermined depth. There was 40% eschar and the wound based was also composed of 60% white callus. Treatment included to apply skin prep, cover with ABD pad and wrap with Kerlix, change and apply treatment daily and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 5 of 8 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 366057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130 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)

F 0686 Level of Harm - Actual harm Residents Affected - Few Review of Resident #6's physician orders dated 12/27/23, revealed orders maintain dressing to left heel each shift. Cleanse left heel with normal saline, pat dry apply skin prep to wound bed and cover with ABD and Kerlix. Change every Tuesday, Thursday, Saturday, and as needed (PRN). Review of the Resident #6's TAR for December 2023 revealed on 12/28/23 a treatment was in place to cleanse left heel with normal saline (NS), pat dry, apply skin prep to wound bed and cover with ABD and kerlix, change daily and PRN every day shift for wound healing. Review of the TAR for Resident #6 for January 2024 revealed on January 10, 2024, a treatment was in place to cleanse left heel with normal saline (NS), pat dry, apply skin prep to wound bed and cover with ABD and kerlix, change every Tuesday, Thursday, and Saturday and PRN every day shift for wound healing. Review of the TAR for January 2024 for Resident #6 revealed an order to monitor and maintain dressing to left heel each shift. Record review revealed no evidence this order was completed on 01/07/24 second shift, 01/09/24 first shift, 01/16/24 first shift, or 01/16/24 first shift as the nurse failed to document the completion of the order. Review of Resident #6's Wound Care evaluation dated 01/30/24 revealed the unstageable pressure injury located on the left heel was improved/healing and measured 2.2 cm x 1.3 cm x with and undetermined depth at this time. The wound base was composed of 100% necrotic patch. Observations beginning on 01/30/24 at 10:04 A.M. and continuing at intermittent intervals throughout the onsite survey revealed Resident #6 had only one heel protector in place, to the left heel. A left heel dressing was in place and dated 01/30/24. Interview on 01/30/24 at 2:35 P.M. with LPN #140 revealed on she saw a dressing in place to Resident #6's left foot on 12/21/23. LPN #140 confirmed she received a written warning on 12/26/23 for not completing a dressing change on 12/21/23 as the dressing on left heel on that date was noted to have been from 12/19/23. Interview on 01/30/24 at 2:55 P.M. with the Director of Nursing (DON) revealed nurses could assess and measure wound(s), then the unit manager does the comprehensive initial assessment of wound(s) the next day. The unit manager was expected to take a picture per policy, have a baseline for that area, measure the wound, and if the wound was really bad notify the wound NP to see if they could come in that day, or get a different order. The DON stated she was not sure how/why the left heel pressure ulcer was identified as an unstageable wound the first time assessed. Interview on 01/30/24 at 4:34 P.M. with LPN #113 confirmed she worked on 12/25/23 as a State Tested Nursing Assistant (STNA) and helped with Resident #6. LPN #113 reported Resident #6's had a dressing to left heel she believed was dated 12/19/23. LPN #113 reported she changed it immediately and let LPN #140 know to document it. Interview on 01/31/24 at 10:38 A.M. with the DON confirmed the Braden Scale for Predicting Pressure Sore Risk dated, 12/07/23 was not accurately completed for the resident. The moisture section was scored as rarely moist when Resident #6 was always incontinent of stool. The DON reported she should have scored the moisture section as occasionally moist due to the resident being always incontinent of bowel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 6 of 8 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 366057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130 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)

F 0686 Level of Harm - Actual harm Interview on 01/31/24 at 3:05 P.M with Wound Nurse Practitioner (NP) #160 revealed he comes to the facility once a week to round with unit manager on wounds. Wound NP #160 reported he sees Resident #6 for wounds. Wound NP #160 reported he usually orders both heel protectors, not just one. Residents Affected - Few Review of Resident #6's [NAME] dated 01/30/24 revealed Resident #6 was to wear bilateral heel protector. Interview on 02/01/24 at 7:57 A.M. with Resident #6's daughter revealed she did not know about the resident's left heel wound until 12/19/23 and at that time none of the nurses or aides knew anything about it. On 12/25/23 she saw the resident had a heel dressing in place that was dated 12/19/23. Interview on 02/01/24 at 10:04 A.M. via telephone with RN #148 confirmed she received a write up (disciplinary action) for not completing a dressing change on 12/23/23. RN #148 reported she signed the TAR indicating she did the dressing change. The RN confirmed the dressing on the left heel was dated 12/19/23. Interview on 02/01/24 at 1:33 P.M. with the DON confirmed the treatments/orders were not completed on the dates noted above as ordered when nursing staff failed to document the completion. Interview on 02/01/24 at 8:32 A.M. with Regional Quality Assurance Nurse (RQAN) #139 confirmed the [NAME] (nursing worksheet that includes patient information) dated 01/30/24 showed the resident was to use bilateral heel protectors. On 01/31/24, RQAN #139 changed the [NAME] to reflect only the use of a left heel protector. b. In addition, review of an incident report dated 11/21/23 revealed two open areas noted to the left buttock of Resident #6. The medical record contained no evidence of the wound being assessed until 11/28/23. Review of the Weekly Skin -Total Body Evaluation completed on 11/23/23 and on 11/30/23 reflected Resident #6 did not have any wounds. Review of the wound note, completed by Wound Nurse Practitioner (NP) #160, dated 11/28/23 revealed the resident was seen for a left buttock abrasion that measured 6.2 centimeter (cm) long by (x) 11.0 cm wide x 0.1 cm deep. Wound bed composed of 80% granulation tissue and 20% shallow pink tissue. Elipitical shaped area of shearing type injury. Treatment was ordered to apply zinc oxide cream, change, and apply treatment every shift and as needed (PRN). The NP did not stage the ulcer at that time. Review of the physician orders for Resident #6, dated 11/2023 revealed no orders were in place for the treatment of the left buttock. Review of the Treatment Administration Record (TAR) for November 2023 revealed the treatment for left gluteal fold medial (left buttock abrasion) was not completed as ordered by Wound NP #160. Review of Resident #6's TAR for December 2023 revealed a treatment to Resident #6's left buttock was not completed until 12/27/23. Review of the physician orders dated 12/27/23 revealed orders for left gluteal fold medial to cleanse with normal saline, pat dry, apply zinc oxide to wound bed every shift and PRN for abrasion (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 7 of 8 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 366057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130 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)

F 0686 healing. Level of Harm - Actual harm Review of the December TAR 2023 revealed on 12/27/23 a treatment was in place for left gluteal fold medial to cleanse with normal saline, pat dry, apply zinc oxide to wound bed every shift and PRN for abrasion healing. Residents Affected - Few Review of Resident #6's Wound Care evaluation dated 01/30/24 revealed the left superior buttock abrasion was improving/healing and measured 0.5 cm x 0.7 cm x 0.1 cm with shallow pink tissue seen at the wound base as of this date. Interview on 01/31/24 at 10:38 A.M. with the DON confirmed the Weekly Skin -Total Body Evaluation completed on 11/23/23 and on 11/30/23 reflected Resident #6 did not have any wounds which she stated was not accurately completed. The DON confirmed Resident #6 had a left buttock wound on 11/21/23. Interview on 01/31/24 at 2:35 P.M. with DON and Regional Quality Assurance Nurse (RQAN) #139 confirmed there were no orders in place for the left buttock treatment from the development of the wound on 11/21/23 through 12/27/23. RQAN #139 reported the orders were never completed and therefore did not come across to the TARS. Interview on 01/31/24 at 3:05 P.M. with Wound Nurse Practitioner (NP) #160 via phone revealed he comes to the facility once a week to round with unit manager on wounds. Wound NP #160 reported he sees Resident #6 for wounds. Wound NP #160 reported he was not aware the treatment to Resident #6's buttocks was not completed as ordered. Wound NP #160 confirmed he saw Resident #6 on 11/28/23 for the wound to left buttock and treatment provided at that time. Review of the facility policy, Skin Care Program, revised 01/24/23, revealed it is the responsibility of the Center's Nursing staff to follow the plan of care (POC) and prevent and or promote healing of skin issues unless they are clinically unavoidable. When a new skin issue is noted, the nurse will measure the area initially and then every 7 days until healed. This deficiency represents non-compliance investigated under Complaint Number OH00149710. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 8 of 8