Health inspection·December 30, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, facility policy review, and interview, the facility failed to ensure accurate documentation of skin tear treatments were completed for Resident #51. This affected one (Resident #51) of three residents review for wound treatments. The facility census was 50. Finding include: Review of the closed medical record for Resident #51 revealed an admission date of 11/13/24. Diagnoses included end stage renal disease, anxiety, anemia, fracture of right femur, dependence on dialysis and depression. The resident was discharged from the facility on 12/04/24. Review of the care plan dated 11/13/24 revealed Resident #51 Resident had a skin tear to the left forearm due to limited mobility. Interventions included to monitor for signs of infection and provide wound treatments. Review of the admission assessment dated [DATE] revealed Resident #51 had intact cognition and had a skin tear to the left forearm. Record review Resident #51's physician's orders revealed an order dated 11/21/24 for a treatment to a left forearm skin tear. The order read to clean the area with normal saline, pat dry, apply oil emulsion, cover with an absorbent pad and wrap with gauze. The treatment was to be changed daily and as needed. Review of Resident #51's Treatment Administration Record (TAR) for December 2024 revealed treatments were not documented on 12/02/24, 12/03/24 and 12/04/24. There was no evidence in the medical record the treatment were documented as administered. Review of the skin assessment dated [DATE] revealed a left forearm skin tear measuring three centimeters (cm) by two (cm) signed by Licensed Practical Nurse (LPN) #200. Interview on 12/30/23 at 9:55 A.M. with LPN #200 stated he assessed Resident #51 left forearm skin tear on 12/03/24 and applied the dressing. LPN #200 stated he documents treatments after they completed however it was a busy and may have forgotten to document the treatment application. Interview on 12/30/24 at 10:05 A.M. with LPN #100 stated she changed Resident #51's left forearm dressing on 12/02/24 in the morning prior to her scheduled dialysis treatment. LPN #100 states she always documents treatments after they are administered, however she could have been distracted and Page 1 of 2 366275 366275 12/30/2024 Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067

F 0842 forgotten to document the treatment application. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 12/30/34 at 12:22 P.M. verified treatment for the left forearm were not signed on 12/02/24, 12/03/24 and 12/04/24. The DON stated nurses are expected to document and sign off all treatments. Residents Affected - Few Review of the facility's policy titled Wound Care revised October 2010, revealed documentation of wound care should include the name and title of person along with the date and time. This deficiency represents non-compliance investigated under Complaint Number OH00160401. 366275 Page 2 of 2