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 (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: 366275 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 12/30/2024 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)