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
record review, interview and observation, the facility failed to ensure pressure sore dressing changes were
done according to physician orders. This affected one resident (Resident #6) out of three residents
reviewed for pressure sores. The total census was 47.
Residents Affected - Few
Findings include:
Record review of Resident #6 revealed she was admitted [DATE] and had diagnoses including Parkinson's
Disease, major depressive disorder, unspecified psychosis, and diabetes. She had an order dated 06/14/23
for her left heel wound to be treated every Monday, Wednesday, and Friday with a saline cleanse, betadine,
and foam dressing. The care was documented done as ordered, including on Monday, 06/26/23. Review of
her most recent wound assessment on 06/21/23 revealed the wound was a blister acquired 05/17/23 which
progressed to an unstageable wound which appeared to be healing and measured 0.5 by 0.5 centimeters
with no drainage or odor.
Interview with Resident #6 on 06/27/23 at 11:38 A.M. revealed her wound dressing was not changed
regularly by staff.
Observation of a wound care procedure for Resident #6 on 06/28/23 at 10:38 A.M. by Licensed Practical
Nurse (LPN) #203 and Wound Physician #601 revealed the previous dressing on her left heel was dated
06/24/23 (a Saturday), and appeared to be a taped gauze dressing instead of the foam dressing ordered by
the physician. The wound measured 0.3 by 0.7 centimeters and had no drainage or odor.
Interview was conducted on 06/28/23 at 11:02 A.M. with LPN #203 who verified during the wound
observation Resident #6 did not have the correct dressing in place according to physician orders, and the
dressing had last been changed on 06/24/23 (a Saturday) which was not according to the physician orders
for every Monday, Wednesday and Friday treatments.
This deficiency represents noncompliance investigated under OH00143560.
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:
365713
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on record review, observation and interview, the facility did not ensure cold food temperatures were
being appropriately monitored to prevent risk of food born illness. This had the potential to affect all 47
residents receiving meals from the kitchen.
Findings include:
Review of the food committee minutes, dated 05/18/23, revealed a concern that cold foods were not always
served cold.
Observation on 06/27/23 at 8:06 A.M. revealed a tray full of cups of milk and orange juice was sitting at the
100 hall nursing station. The tray nor milk and orange juice cups were not on ice nor had any other obvious
method of being kept cold. Aides took drinks from the tray and put them on meal trays as they entered
resident rooms to serve breakfast. This was noted to still be ongoing as of 8:24 A.M.
Interview with Nurse Aide #201 following the above observations confirmed drinks were pre-poured and
served from an unrefrigerated tray. She said sometimes staff served it that way and sometimes they poured
drinks for one resident at a time from pitchers kept in ice.
Interview with Resident #17 on 06/27/23 at 2:52 P.M. revealed milk was sometimes not served cold.
Interview with Resident #42 on 06/27/23 at 3:04 P.M. revealed cold drinks were often served lukewarm with
meals.
Interview with Dietary Manager (DM) #302 on 06/28/23 at 7:43 A.M. revealed the facility served drinks
including milk by dispensing pitchers held in ice and sent to the units where they were then distributed by
nursing aides. DM #302 said he did not have a food temperature thermometer capable of measuring below
50 degrees Fahrenheit (F) to ensure cold foods were kept at 41 degrees or below, as the thermometer he
had did not go below 50 degrees F. DM #302 explained he began work at the facility two months ago and
during that time did not have a thermometer capable of measuring lower than 50 degrees F, so cold food
temperaturs were not being monitored. DM #302 said he had been meaning to order a thermometer that
could measure cold food temperatures.
This deficiency represents noncompliance investigated under OH00143459.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 2 of 2
