Health inspection·August 29, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to complete wound care as ordered/care planned. This affected one resident (#58) of two observed for wound care. The facility identified seven residents (#2, #17, #27, #35, #45, #58, and #68) who required wound care. The facility census was 70. Residents Affected - Few Findings include: Review of Resident #58's medical records revealed an admission date of 05/01/23. Diagnoses included stage four pressure ulcer of the sacrum (tailbone) and osteomyelitis (bone infection). Review of the care plan dated 06/20/23 (revised 08/22/23) revealed Resident #58 had impaired skin integrity with a stage four pressure ulcer to the sacrum. Interventions included perform wound care as ordered. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was rarely understood and was admitted with a stage four pressure ulcer to the sacral area. Review of Resident #58's current physician orders for August 2023 revealed orders to cleanse the left lateral leg with normal saline, apply collagen powder, apply Xeroform (petroleum based gauze dressing) and cover with absorbent dressing and gauze every other day and as needed; cleanse left ischium (hip) with normal saline, apply collagen powder, and cover with border gauze daily and as needed, and cleanse sacrum with normal saline, apply collagen powder, pack loosely with silver alginate (antibacterial alginate with silver) and cover with border gauze daily and as needed. Observation on 08/28/23 at 11:25 A.M. with State Tested Nursing Assistants (STNA) #281 revealed Resident #58 had gauze dressings to both legs that were dated 08/24/23. STNA #281 stated she was unaware if Resident #58 had wounds underneath of the gauze dressings. Further observation revealed Resident #58 had an undated foam dressing to the sacrum as well as an undated foam dressing to her left hip. The dressings to the sacrum and left hip were soiled and the sacral dressing was not intact. Observation and interview on 08/28/23 at 11:42 A.M. with the Assistant Director of Nursing (ADON) revealed Resident #58 had a wound to her left leg that was supposed to be changed daily and there was no wound to Resident #58's right leg. The ADON confirmed the gauze dressings to the legs were dated 08/24/23. The ADON further stated Resident #58's sacral wound dressing was supposed to be changed daily and as needed, if soiled, and the left hip dressing was to be changed every other day and as needed. Review of Treatment Administration Record for August 2023 on 08/28/23 at 2:11 P.M. with the ADON revealed and confirmed ordered treatments were documented as being completed, however the treatments had not been performed as ordered/care planned. (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 4 Event ID: 365705 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 365705 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aventura at Walton Hills 19859 Alexander Rd Walton Hills, OH 44146 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)