Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
record review, staff interview, and review of facility policy, the facility failed to provide the residents with
wound care as physician ordered. This affected two (Residents #6 and #45) of three residents reviewed for
wound care. The facility census was 54.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #6 revealed an admission date of 05/01/23. Diagnoses
included cellulitis right lower leg, sepsis, and dementia.
Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6
was cognitively impaired and required extensive assistance of one staff for toilet use. Resident #6 was
always incontinent of bowel and bladder. Resident #6 had no identified skin breakdown but was identified at
risk and used a pressure reduction device for the bed.
Review of the care plan dated 05/03/23 revealed Resident #6 was at risk for skin breakdown due to
immobility. The goal identified skin integrity will be maintained. Interventions included treatments to be
administered as ordered.
Review of the care plan updated on 05/22/23 revealed Resident #6 had actual skin impairment with
moisture associated skin damage (MASD) related to incontinence. Interventions included to follow facility
protocols for treatment injury, monitor, document location, size and treatment of skin injury.
Review of a wound care note dated 05/22/23 revealed Resident #6 had MASD of partial thickness to the
right and left buttock. Wound size for the right buttock MASD was 2.5 centimeters (cm) long by 1.0 cm wide
by 0.01 cm deep and for the left buttock, 2.0 cm long by 1.0 cm wide and 0.01 cm deep. The treatment plan
included alginate calcium with silver once daily and cover with silicone foam border. The wound care note
dated 05/29/23 revealed the MASD of the right buttock resolved and the left buttock measured 6.0 cm long
by 1.5 cm wide by 0.01 cm deep.
Review of Resident #6's physician orders written 05/29/23 revealed an order to cleanse the left buttock with
wound cleanser, pat dry, cover with alginate calcium with silver daily and cover with foam silicone border.
Barrier cream to be applied around the wound with treatments to start on 05/30/23.
Review of the treatment administration records from 05/30/23 to 07/04/23 revealed there were 13 missed
treatments record for Resident #6 on the following dates: 05/30/23, 06/02/23, 06/03/23, 06/04/23, 06/08/23,
06/09/23, 06/10/23, 06/12/23, 06/13/23, 06/16/23, 06/23/23, 06/24/23, and 07/03/23.
(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 3
Event ID:
366410
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
366410
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/05/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
St Clare Commons
12469 Five Point Road
Perrysburg, OH 43551
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the weekly wound notes dated 06/05/23, 06/12/23, 06/19/23 and 06/26/23 revealed the left
buttock MASD had improved with measurements on 06/26/23 of 0.5 cm long by 0.4 cm wide by 0.01 cm
deep.
Interview with the Director of Nursing on 06/29/23 at 4:00 P.M. verified the wound care treatments for
Resident #6 were not completed as physician ordered on 05/30/23, 06/02/23, 06/03/23, 06/04/23, 06/08/23,
06/09/23, 06/10/23, 06/12/23, 06/13/23, 06/16/23, 06/23/23, 06/24/23, and 07/03/23.
2. Review of the medical record for Resident #45 revealed an admission date of 04/07/22 with a
readmission date of 04/21/23. Diagnoses included hemiplegia and hemiparesis following a cerebral
infarction affecting left, non-dominant side, type II diabetes mellitus, morbid obesity, and chronic
osteomyelitis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed
Resident #45 was cognitively intact.
Review of the care plan dated 04/21/22 revealed Resident #45 had a pressure ulcer to the sacrum. Goals
included for the wound to show signs of healing without complications and interventions included to provide
treatments as ordered.
Review of the current physician orders dated 05/02/23 revealed an order to for the right heel to clean daily
and as needed with wound cleaner, pat dry and leave open to air. Review of the treatment administration
record (TAR) from 05/02/23 to 06/30/23 revealed the treatment was not completed as physician ordered 23
times on the following dates: 05/03/23, 05/05/23, 05/08/23, 05/12/23, 05/13/23, 05/14/23, 05/22/23,
05/23/23, 05/26/23, 05/29/23, 06/02/23, 06/03/23, 06/04/23, 06/08/23, 06/09/23, 06/10/23, 06/12/23,
06/13/23, 06/16/23, 06/20/23, 06/24/23, 06/27/23, and 06/29/23
Review of the current physician orders dated 05/02/23 revealed an order for the right hip to clean with
wound cleanser, pat dry, pack surgical incision with roll gauze moistened in Dakin's solution, cover with five
inch by nine-inch dry dressing and secure with tape daily and as needed. Review of the TAR from 05/02/23
to 06/30/23 revealed the treatment was not completed as physician ordered 24 times on the following
dates: 05/03/23, 05/05/23, 05/08/23, 05/12/23, 05/13/23, 05/14/23, 05/22/23, 05/23/23, 05/26/23, 05/29/23,
06/02/23, 06/03/23, 06/04/23, 06/08/23, 06/09/23, 06/10/23, 06/11/23, 06/12/23, 06/13/23, 06/16/23,
06/19/23, 06/20/23, 06/24/23, and 06/29/23.
Review of the current physician orders dated 05/02/23 revealed an order for the coccyx to cleanse with
wound cleaner, pat dry, pack wound with roll gauze moistened with Dakin's solution, cover with calcium
alginate, cover with Opti foam dressing daily and as needed. Review of the TAR from 05/02/23 to 06/30/23
revealed the treatment was not completed as physician ordered 22 times on the following dates: 05/03/23,
05/05/23, 05/08/23, 05/12/23, 05/13/23, 05/14/23, 05/22/23, 05/26/23, 05/29/23, 06/02/23, 06/03/23,
06/04/23, 06/08/23, 06/09/23, 06/10/23, 06/11/23, 06/12/23, 06/13/23, 06/16/23, 06/20/23, 06/24/23, and
06/29/23.
Review of the current physician orders dated 05/02/23 revealed an order for the scrotum to cleanse with
wound cleaner, pat dry, apply Medi honey and cover with nonadherent dressing and brief daily and as
needed. Review of the TAR from 05/02/23 to 06/30/23 revealed the treatment was not completed as
physician ordered 23 times on the following dates: 05/03/23, 05/05/23, 05/08/23, 05/12/23, 05/13/23,
05/14/23, 05/22/23, 05/23/23, 05/26/23, 05/29/23, 06/02/23, 06/03/23, 06/04/23, 06/08/23, 06/09/23,
06/10/23, 06/11/23, 06/12/23, 06/13/23, 06/16/23, 06/20/23, 06/24/23, and 06/29/23.
Review of the current physician orders dated 05/02/23 revealed an order for the left heel to clean
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366410
If continuation sheet
Page 2 of 3
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
366410
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/05/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
St Clare Commons
12469 Five Point Road
Perrysburg, OH 43551
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
Level of Harm - Minimal harm
or potential for actual harm
with wound cleanser, pat dry, cover with calcium alginate and roll gauze daily and as needed. Review of the
TAR from 05/02/23 to 06/30/23 revealed the treatment was not completed as physician ordered 22 times on
the following dates: 05/03/23, 05/05/23, 05/08/23, 05/12/23, 05/13/23, 05/14/23, 05/22/23, 05/23/23,
05/26/23, 05/29/23, 06/02/23, 06/03/23, 06/04/23, 06/08/23, 06/09/23, 06/10/23, 06/12/23, 06/13/23,
06/16/23, 06/24/23, 06/27/23, and 06/29/23
Residents Affected - Few
Interview with the Director of Nursing on 06/29/23 at 4:00 P.M. verified Resident #45 had several missing
wound treatments to the right heel, right hip, coccyx, scrotum, and left heel between 05/02/23 to 06/30/23.
Review of the facility policy titled Wound Treatment Management, dated October 2010, stated to promote
wound healing evidenced-based treatments will be provided in accordance with current standards of
practice and physician orders, including the cleansing method, type of dressing and frequency of the
dressing change.
This deficiency represents non-compliance investigated under Complaint Number OH00142936.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366410
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the July 5, 2023 survey of ST CLARE COMMONS?
This was a inspection survey of ST CLARE COMMONS on July 5, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ST CLARE COMMONS on July 5, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.