Inspection·February 21, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in-house acquired deep tissue injury (DTI) pressure wound and the site was documented as the left heel with the type indicating it was a vascular non-pressure wound acquired 01/12/24 which measured 2.5 cm length by 4.3 cm width by no depth. Review of Resident #18's Podiatrist Wound Evaluation form dated 01/29/24 revealed the resident had a left heel venous non-pressure wound with 100% epithelial tissue which measured 2.5 cm wound length, 4.3 cm wound width with no depth. The wound was purple and non-blanchable. The venous duplex was reviewed which demonstrated compressibility of the deep veins with no evidence of thrombosis. Per the primary physician, the resident's left heel sore was related to her venous stasis. Review of Resident #18's Wound Assessment form dated 02/05/24 revealed the resident had a left heel in-house acquired DTI pressure wound and the site was documented as the left heel with the type indicating it was a vascular non-pressure wound acquired 01/12/24 which measured 2.5 cm length by 3.5 cm width by no depth. Review of Resident #18's Wound Assessment form dated 02/13/24 revealed the resident had a left heel in-house acquired DTI pressure wound and the site was documented as the left heel with the type indicating it was a vascular non-pressure wound acquired 01/12/24 which measured 2.5 cm length by 3.5 cm width by no depth. Review of the Podiatrist Wound Evaluation form dated 02/13/24 revealed the resident had a left heel venous ulcer non-pressure wound with 100% epithelial tissue bed with no drainage which measured 2.5 cm length by 3.5 cm width with no depth. The wound was purple and non-blanchable. Review of Resident #18's physician progress note authored by Physician #865 dated 02/19/24 indicated the resident had an area of eschar on her left heel with a heel wound. The resident had venous stasis with a history of severe leg edema where she required diuresis. The discoloration of her lower extremity was consistent with venous stasis and venous dermatitis. Observation on 02/20/24 at 6:20 A.M. of Resident #18's left heel wound care with Licensed Practical Nurse (LPN) #826 revealed the resident's left leg and heel were extremely dry with skin observed flaking onto the bed. The left heel did not have an open area and no drainage was noted. A darker area was observed on the left heel. The top aspect of Resident #18's foot appeared edematous with no drainage noted. Interview with LPN Wound Nurse #812 revealed Resident #18 had a left heel wound which Wound Nurse Practitioner (NP) #868 had assessed as a SDTI. LPN Wound Nurse #812 indicated Podiatrist #866 also assessed the wound on Resident #18's left heel and determined the wound was SDTI. Interview on 02/20/24 at 7:53 A.M. with Wound NP #868 stated she had assessed Resident #18's left heel one time and determined it was a SDTI. She stated Podiatrist #866 took over after that assessment. Observation on 02/20/24 at 8:58 A.M. with Podiatrist #866 and LPN Wound Nurse #812 of Resident #18's left heel wound revealed the wound measured 2.0 cm length by 3.3 cm width with no drainage. Interview on 02/20/24 at 10:07 A.M. with Podiatrist #866 indicated she had assessed Resident #18 on 01/22/24 for a left heel discoloration and determined the resident had a SDTI to the left heel which was purple and non-blanchable. She stated she ordered a noninvasive vascular study in relation to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366275 If continuation sheet Page 2 of 3 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 366275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067 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 0842 Level of Harm - Minimal harm or potential for actual harm the left heel wound and did not determine the wound was vascular in nature. She indicated that she received a text message from the DON on 01/25/24 which stated Resident #18's primary care physician (Physician #865) had reclassified the left heel wound as a vascular ulcer instead of a pressure. She stated at that point (01/29/24, 02/05/24, 02/13/24 and 02/20/24), she changed her documentation to vascular instead of pressure as she was a consulting physician and not the primary physician. Residents Affected - Few Interview on 02/20/24 at 10:37 A.M. with the DON and Registered Nurse (RN) Regional #867 indicated the DON did not recall talking to or sending Podiatrist #866 a text. She stated she called Physician #865 and asked him if the resident had any vascular issues. She confirmed Physician #865 indicated Resident #18 had venous stasis and the area to the resident's left heel was vascular. Telephone interview on 02/20/24 at 11:59 A.M. with Physician #865 with the DON present indicated he had known Resident #18 for 30 years and the resident had venous stasis. He stated he told the DON that she had venous stasis with kidney problems and had a mixed etiology which could compromise wounds. He indicated he was aware of Resident #18's vascular and arterial studies and thought the left heel wound could be vascular or it could be pressure and he was not sure. Interview on 02/20/24 at 12:09 P.M. with the DON indicated she texted LPN Wound Nurse #812 that Physician #865 thought Resident #18's left heel wound could be vascular, but she did not talk or text Podiatrist #866. Telephone interview on 02/21/24 at 9:54 A.M. with RN Regional #867 confirmed Physician #865 had assessed Resident #18 on 02/18/24 and determined the resident had a left heel vascular wound. She was unsure why Resident #18's wound documenting inaccurately reflected both pressure and non-pressure on the wound skin grids. Review of the Pressure Ulcer Prevention and Assessment policy dated 12/17/13 revealed it was the facility policy to prevent the development of pressure ulcers to the greatest extent possible and as allowed by the resident's compliance, cognition and/or physical function. This deficiency represents non-compliance investigated under Complaint Number OH00150445. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366275 If continuation sheet Page 3 of 3