Health inspection·May 18, 2023

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 interview, and policy review, the facility failed to ensure peripherally inserted central catheter (PICC) line needleless connectors and PICC line dressings were changed weekly and as needed. This affected three (#90, #91, and #92) of three residents reviewed for PICC lines. The facility census was 80. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #90 had an admission date of 11/15/22 and a discharge date of 12/08/22. Diagnoses included osteomyelitis right tibia and fibula, methicillin resistant staphylococcus aureus infection, respiratory failure with hypoxia, type two diabetes mellitus, depression, hypothyroidism, and a nondisplaced tri-malleolar fracture of left lower leg, and subsequent encounter for closed fracture with routine healing. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had intact cognition and received intravenous (IV) therapy. Review of the physician orders dated 11/16/22 revealed an order to change Resident #90's PICC line dressing every week. There were no orders to change the PICC line needleless connectors. Review of the treatment administration record (TAR) dated 11/16/22 through 12/08/22 revealed Resident #90's PICC line dressing change was completed weekly; however, there was no documentation the needleless connectors were changed. Interview on 05/17/23 at 10:12 A.M., with the Director of Nursing (DON) stated the needleless connectors would be changed weekly when the PICC line dressing was changed, and verified there were no orders to change the needleless connectors. The DON stated the facility never had separate orders for changing the needleless connectors. 2. Medical record review for Resident #91 revealed an admission date of 03/13/23 and a discharge date of 04/04/23. Diagnoses included pressure ulcer of the sacral region stage four, chronic osteomyelitis with draining sinus, vascular dementia, pressure ulcer of the right heel, pressure ulcer of the left heel, peripheral vascular disease, and chronic obstructive pulmonary disease. Review of the admission MDS assessment revealed Resident #91 had intact cognition. Review of the medical record revealed Resident #91 had a PICC line for IV therapy and the resident was received IV therapy. (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: 365645 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 365645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northridge Health Center, The 35990 Westminster Ave North Ridgeville, OH 44039 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)