Inspection·June 1, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and policy review, the facility failed to ensure the physician was notified of a new skin condition. This affected one (#8) of four residents with skin impairments reviewed. The census was 21. Findings included: Medical record review for Resident #8 revealed an admission date of 04/10/20. His medical diagnoses included Parkinson's disease, muscle weakness, hypertension, hypertensive heart disease, foot drop left foot, and peripheral vascular disease. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact. His functional status was extensive assistance for bed mobility, transfers, and toileting. He was a supervision for eating. Review of wound documentation dated 04/03/23 revealed Resident #8 had an arterial wound on his left third toe that measured 1.0 centimeters (cm) by 1.5 cm by 0.1 cm that was eschar and dry. There wasn't any documentation of the left second toe in the record. Interview with Resident #8 on 05/30/23 at 10:24 A.M., revealed he stated he needed to take off his shoe because his toe hurt him. Observation and interview with Licensed Practical Nurse (LPN) #500 on 05/30/23 at 10:30 A.M., removed Resident #8's shoe and sock. On the tip of the second toe, there was an area observed to be a small black oval wound and on the tip of the third toe was a black spot. The nurse said Resident #8's wounds were something he wasn't aware of. Review of progress notes dated 05/30/23 and the morning of 05/31/23 revealed there was no documentation of a notification to the physician of the wounds. Interview with the LPN #500 on 05/31/23 at 9:53 A.M., confirmed he didn't notify the physician regarding the wound on the left second toe. Review of policy titled Change of Condition dated 09/13/22, revealed to observe, record, and report any condition change to the nurse in charge and the attending physician so proper treatment can be implemented. 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: 366415 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 366415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Cape May 175 Cape May Drive Wilmington, OH 45177 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)