Health inspection·April 3, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure wound treatments were completed as ordered. This affected one of three residents (Resident #152) reviewed for wound treatments. The facility census was 171. Residents Affected - Few Findings Included: Review of the medical record for Resident #152 revealed an admission date of 09/06/22. Diagnoses included but were not limited to diabetes mellitus, dependence on renal dialysis, depression, pulmonary hypertension, absence of right leg below the knee, and calciphylaxis (calcium accumulates in small blood vessels of the fat and skin tissues). Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/10/24, revealed Resident #152 had intact cognition and was dependent or required maximal assistance for activities of daily living. Review of the treatment orders for April 2024 revealed an order to cleanse skin tear to right elbow once daily with normal saline, apply four by four and border gauze dressing daily, every day shift for wound care. Review of the Medication Administration Record (MAR) for February 2024 revealed documentation indicating the dressing to right elbow was completed on 02/28/24. There was no documentation the wound care was completed on 02/29/24 through 03/04/24. The MAR for April 2024 revealed no documentation the dressing change was completed on 04/01/23. Review of physician orders dated 03/03/24 revealed a new order for doxycycline 100 milligram (mg) tablet twice a day for wound infection. Review of the wound assessment dated [DATE] revealed no odor, no drainage and no signs of infection to the right elbow noted. Interview on 04/01/24 at 3:29 P.M. with Registered Nurse (RN) #450 revealed dressing changes were to be completed as ordered, usually daily, and all dressing changes were dated and initialed at time of dressing change. During an interview on 04/02/24 at 9:50 A.M. with Resident #152, Resident #152 was confused regarding the events of how she sustained the skin tear; she said she was chasing her son and fell. Resident #152 was unable to provide information regarding treatments/dressing changes. (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: 365706 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 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 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)