Health inspection·August 1, 2023

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, staff interviews, and review of facility policy, the facility failed to ensure staff assessed a resident's wound in a timely manner, delaying treatment. This affected one (Resident #35) of three residents reviewed for wound assessments. The facility census was 34. Residents Affected - Few Findings included: Review of the discharged medical record for Resident #35 revealed an admission date of 05/19/23. Diagnoses included difficulty with walking and muscle weakness. The resident was discharged to home on [DATE]. Review of the Minimum Data Set (MDS) assessment date 05/26/23 revealed Resident #35 was cognitively impaired. Resident #35 required extensive two person assistance with bed mobility and transfers. The resident was at risk for pressure ulcers, however the assessment indicated the resident did not have an active pressure ulcer. Review of Resident #35's most recent care plan revealed the resident had actual skin impairment to his bilateral buttock related to a Deep Tissue Injury (DTI). Interventions included: encourage good nutrition, follow protocols for treatment of injury and resident needs, and pressure reduction cushion to protect skin while up in chair. Review of shower sheets from 05/26/23 to 05/30/23 revealed nurse aides noted Resident #35 had reddened area to bottom with an open area. Review of the skin sweep completed on 05/29/23 revealed Resident #35 had intact skin. Review of the progress note dated 05/31/23 revealed Resident #35 had a pressure area to the coccyx. The wound nurse would see the resident during next rounds. An order was placed for turning and repositioning every shift and an air mattress was ordered. The resident was incontinent of stool multiple times per day due to lactulose use for increased ammonia. The lactulose was decreased. Review of the wound assessment dated [DATE] revealed Resident #35 had an unstageable DTI to the coccyx measuring 10.8 centimeters (cm) by 11 cm. Nursing staff reported the wound developed quickly due to the resident's poor nutritional intake. The following treatment was initiated: clean, pat dry, apply Medi honey alignate and foam dressing every day and as needed. On 06/05/23, the wound measured 8 cm by 9 cm. The wound was healing and no changes to the treatment were made. Review of the falsification of documentation investigation revealed on 05/29/23, Registered Nurse (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: 366263 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 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)