Inspection·April 17, 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 Based on observation, interview, record review, and facility policy review the facility failed to change Resident #38's PICC (peripheral inserted central catheter) line dressing as ordered. This affected one resident (#38) of three residents reviewed for PICC line dressings. The facility census was 41. Residents Affected - Few Findings include: Review of the medical record for Resident #38 revealed an admission date of 03/22/24. Diagnoses included osteomyelitis of vertebra, discitis, dorsalgia, diabetes mellitus type 2, and chronic kidney disease stage 3. The admission Minimum Data Set (MDS) assessment completed 03/28/24 indicated Resident #38 had no cognitive impairment. Observation and interview on 04/17/24 at 8:39 A.M. with Resident #38 complained the facility nurses were not changing her right arm PICC line dressing as ordered. It had been about two weeks since the last change and finally it was completed the day prior, 04/16/24. The PICC dressing on Resident #38's right arm was dated 04/16/24. Review of Resident #38's physician orders revealed an order dated 03/26/24 to change PICC line dressing every seven days and an order dated 03/27/24 to change PICC line dressing to right arm as needed (PRN). Review of Resident #38's Treatment Administration Record (TAR) from 03/22/24 to 04/17/24 revealed the routine PICC line dressing change was scheduled to begin on 03/28/24 and then be completed every seven days thereafter. On 03/28/24, Resident #38's PICC line change was documented as not completed due to it being completed on 03/26/24, again on 04/04/24, it was not completed due to the previous shift, and then on 04/11/24, it was not completed due to resident care. The PRN order reflected the PICC line dressing was changed on 04/16/24. There was no documented evidence Resident #38's PICC line dressing was changed between 03/26/24 and 04/16/24. Review of the progress notes from March 2024 to April 2024 revealed no documented evidence Resident #38's PICC line dressing was changed between 03/26/24 and 04/16/24. Interview on 04/17/24 at 12:43 P.M. with Assistant Director of Nursing (ADON) #100 verified there was no documented evidence Resident #38's PICC line dressing was changed between 03/26/24 and 04/16/24, and confirmed it was not changed every seven days as ordered. Review of the undated facility policy, Dressing Change and Care of PICC revealed to reduce the risk of systemic infections and minimize contamination of the catheter system, dressings were changed (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: 366267 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 366267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare of Mayfield Village, Inc 290 North Commons Blvd Mayfield Village, OH 44143 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)