Health inspection·August 18, 2022

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 observation, record review, and interview the facility failed to ensure Resident #27's skin interventions for edema were completed as ordered. This finding affected one (Resident #27) of one resident reviewed for non-pressure skin conditions. The facility census was 74. Residents Affected - Few Findings include: Review of Resident #27's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, Parkinson's disease, and difficulty in walking. Review of Resident #27's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited severe cognitive impairment. Review of Resident #27's physician orders revealed an order dated 11/09/21 for bilateral TED hose (anti-embolism stockings) on in the morning and off at night every shift for bilateral lower extremity edema. Review of Resident #27's care plan dated 10/21/21 indicated the resident had impaired circulation related to dependent edema and an intervention was implemented dated 11/10/21 for bilateral knee hi TED hose on the morning and off at bedtime. Review of Resident #27's medication administration records (MAR) and treatment administration records (TAR) from 08/01/22 to 08/18/22 revealed the bilateral TED hose were implemented per the order. Observation on 08/18/22 at 9:05 A.M. with Licensed Practical Nurse (LPN) #801 revealed the left heel wound care treatment was completed and Resident #27 was sitting up in his room in a modified Broda (specialty chair) with a table across his lap. Resident #27 was in his room watching television at the time of the observation. The bilateral TED hose were not implemented at the time of the observation; however, the TED hose were signed off as completed on the MAR and TAR. Interview on 08/18/2 at 9:20 A.M. with Unit Manager Registered Nurse (RN) #802 confirmed Resident #27's bilateral TED hose were not implemented as ordered; however, the TED hose were signed off on the MAR and TAR on 08/18/22 as completed. 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: 365715 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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)