Health inspection·September 13, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wide, and 0.1 cm deep. The second and third wounds were documented as identified on 08/07/24. There were no physician written to implement a treatment order for the three non-pressure wounds on 08/06/24 or 08/07/24. A progress note dated 08/06/24 at 11:59 A.M. by the facility Certified Nurse Practitioner (CNP) revealed Resident #21 had open areas to abdomen and back with treatments in place. Resident #21 had a history of yeast under folds with treatment that included Fluconazole and nystatin. The wound team was to follow up with Resident #21 on 08/07/24. Review of the wound nurse practitioner notes dated 08/07/24 revealed Resident #21 presented with a chronic non-healing non-pressure chronic ulcer of the center midline abdomen. The wound measured 1.15 cm long, 1.96 cm wide, and 0.1 cm deep. A treatment was ordered to cleanse the wound with saline solution and pat dry with gauze. Then tertracyte (topical antibiotic for bacterial infections) was to be applied to the wound bed, followed by calcium alginate, and covered with bordered gauze daily and as needed. Resident #21 also presented with a non-healing non-pressure chronic ulcer of right distal groin. The wound measured 0.96 cm long, 2.37 cm wide, and 0.1 cm deep. A treatment was ordered to cleanse wound with saline solution and pat dry with gauze. Then tertracyte was to be applied to the wound bed, followed by calcium alginate, and covered with bordered gauze daily and as needed. Resident #21 also had a chronic non-healing non-pressure ulcer of the right lateral groin. The wound measured 1.14 cm long, 2.72 cm wide, and 0.3 cm deep. A treatment was ordered to cleanse the wound with saline solution and pat dry with gauze. Then tertracyte applied to the wound bed, followed by calcium alginate, and covered with bordered gauze daily and as needed. However, there were no physician orders written on 08/07/24. Review of the treatment administration record (TAR) revealed there were no treatment orders or treatment completed on 08/07/24, 08/08/24, and 08/09/24. A nursing note dated 08/07/24 by LPN #200 revealed wound nurse practitioner saw Resident #21 for initial visit. Treatment orders were clarified and in place. However there were no physician orders written on 08/07/24 and were not written until 08/10/24 Review of the physician orders dated 08/10/24 revealed Resident #21 was ordered the center midline abdomen wound to be cleansed with saline, patted dry, tertracyte applied to wound bed, calcium alginate applied to the wound bed, and covered with border dressing daily and as needed. On 08/10/24, Resident #21 was also ordered the right distal groin wound to be cleansed with saline, patted dry, tertracyte applied to wound bed, calcium alginate applied to the wound bed, and covered with border dressing daily and as needed. On 08/10/24, Resident #21 was ordered the right lateral groin wound to be cleansed with saline, patted dry, tertracyte applied to wound bed, calcium alginate applied to the wound bed and covered with border dressing daily and as needed. Review of the TAR revealed treatments to Resident #21's midline abdomen, right distal groin, and right lateral groin were started on 08/10/24. Interview on 09/13/24 at 11:04 A.M. with LPN #200 verified a head-to-toe skin assessment was completed by LPN #200 when Resident #21 was admitted , and Resident #21 had no skin concerns. Interview on 09/13/24 at 2:46 P.M. with the Director of Nursing (DON) verified Resident #21 had an area to midline abdomen and two areas to the groin that were identified on 08/06/24 and treatments were not ordered or put in place until four days later on 08/10/24. The DON verified there was no documentation of nystatin being ordered or administered to Resident #21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 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 366418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dublin Post Acute 4075 West Dublin-Granville Road Dublin, OH 43017 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 This deficiency represents non-compliance investigated under Complaint Number OH00157135. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 3 of 3