Inspection·April 17, 2024

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 medical record review, hospital record review, staff interview, and facility policy review, the facility failed to ensure residents received the necessary treatment and services to promote healing and prevent infections for a pressure ulcer. This resulted in Actual harm when Resident #20 ' s weekly skin assessments were not completed and subsequently led to hospitalization for a wound infection and possible osteomyelitis. This affected one (Resident #20) of three residents reviewed for pressure ulcers. The facility census was 132. Residents Affected - Few Findings include: Review of the medical record for Resident #20 revealed an admission date to the facility on [DATE] and a discharge date to the hospital on [DATE], and as of 04/16/24 Resident #20 is still hospitalized . Resident #20 had a hospital diagnosis of right large heel pressure ulcer with wet necrosis with suspected superimposed infection/osteomyelitis. The resident had pertinent diagnoses of cellulitis of right upper limb, atherosclerotic heart disease of native coronary artery, type two diabetes mellitus with diabetic neuropathy, atrial fibrillation, hypertensive heart disease with heart failure, congestive heart failure, anxiety disorder, asthma, chronic kidney disease stage three, attention deficit hyperactivity disorder, restless legs syndrome, hyperlipidemia, syncope and collapse, sleep apnea, left bundle branch block, hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, insomnia, depression, and gastroesophageal reflux disease. Review of a [NAME] scale for predicting pressure sore risk assessment dated [DATE] revealed the resident had a score of 18 and was categorized as at risk for pressure ulcers. Review of a plan of care dated 01/02/24 revealed Resident #20 had impaired skin integrity to right heel with a goal of tissue injury will heal and be free from complications. Interventions included: Assess and document skin condition, notify doctor of signs of infection (redness, drainage, pain, fever), assess for pain and treat as indicated, notify physician of worsening or no improvement in wound, pressure reducing/redistributing mattress on bed, wound location: right heel and wound treatment as ordered. Review of the 03/26/24 quarterly Minimum Data Set (MDS) assessment revealed Resident #20 was cognitively intact and rejected care one to three days during the look back period. Resident #20 used a walker and wheelchair to aid in mobility and was dependent for toileting hygiene, and showering. Resident #20 required substantial to maximal assist for rolling left to right, sit tolying and lying to sitting, and sit to stand. Resident #20 had treatments in place to include pressure reducing device for chair and bed, and applications of ointments and dressings. (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 5 Event ID: 366120 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 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040 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)