Health inspection·January 3, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, review of wound clinic notes, and review of facility policy, the facility failed to ensure new wound treatment orders were timely obtained and implemented. This affected one (#40) of three residents reviewed for pressure ulcers. The facility census was 86. Residents Affected - Few Findings include: Review of the medical record for Resident #40 revealed an admission date of 09/26/23. Diagnoses included metabolic encephalopathy, status post surgical repair of the left fibula, polyosteoarthritis, and generalized muscle weakness. Resident #40 had no unhealed pressure ulcers upon admission to the facility. Review of the Medicare 5-day Minimum Data Set (MDS) assessment, dated 10/02/23, revealed Resident #40 was moderately cognitively impaired. Additionally, Resident #40 was not identified to refuse care or have any behaviors. Resident #40 required one person assistance with performance of daily care tasks and transfers. He was not recorded to have any unhealed pressure ulcers but was identified to be at risk for pressure ulcer development. Review of the plan of care revealed Resident #40 was at risk for alteration in skin integrity due to a cognitive impairment, fragile skin, incontinence, mobility impairment, and non-compliance with therapeutic skin regimen. The care plan additionally noted on 10/11/23, Resident #40 had a pressure ulcer present. Interventions included to maintain a low-air loss mattress, provide assistance with activities of daily living and positioning, and provide treatments per physician's orders. Review of a progress note, dated 11/20/23, revealed Resident #40 was seen by the in-house wound nurse practitioner, who ordered an outside wound clinic consult due to a non-healing pressure ulcer. Resident #40's daughter was updated on the resident's wound status and order for wound clinic consult. Review of Resident #40's physician's orders revealed a treatment order, dated 11/28/23, for the right heel wound to be cleanse with normal saline, pat dry, and apply hydrofera blue (a type of dressing to promote wound healing and wicking of drainage from the wound bed), cover with a abdominal (absorbent) pad and wrap with kerlix (gauze roll), change daily on day shift. The wound order was discontinued on 12/15/23. On 12/15/23 a new treatment was ordered for Resident #40's right heel pressure ulcer to be cleanse with normal saline or betadine, apply gauze moistened with betadine, cover with an abdominal pad and wrap with kerlix, to be changed daily on day shift. Review of a progress note, dated 12/07/23, revealed Resident #40 went out to an appointment at a (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 2 Event ID: 366446 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 366446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Grove Transitional Care 5919 Blue Star Drive Grove City, OH 43123 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)