Health inspection·May 10, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, hospital documentation review, and staff interview, the facility failed to ensure surgical wound and wound drainage care was provided as ordered by a physician following re-admission to the facility. This affected one (#52) of three residents reviewed for wounds. The facility census was 93. Residents Affected - Few Findings include: Review of Resident #52's medical record identified admission to the facility occurred on 11/16/23 with medical diagnoses including bipolar disorder, urine retention, multiple sclerosis, Alzheimer's disease, and neoplasm of the genital organs. Further review of the medical record revealed Resident #52 required hospitalization from 04/29/24 through 05/07/24 for a scrotal abscess that required incision and drainage surgery. Review of Resident #52's hospital discharge documentation dated 05/07/24 revealed physician orders, under the section for drain and tube care, for the resident to have a nurse change the Kerlix dressing (antimicrobial rolled dressing) twice a day with wet to dry and maintain a Penrose drain (a soft, flexible rubber tube that drains fluid away from a wound) to allow for continued discharge. Review of Resident #52's re-admission nursing assessment dated [DATE] at 5:48 P.M., revealed, under the skin condition section, revealed instructions for staff to indicate all body marks such as old and recent scars (surgical or other). Further review of the assessment revealed no assessment or indication the resident had a scrotal surgical wound or Penrose drain. Observation of Resident #52 occurred on 05/09/24 at 10:14 A.M. with assistance from State Tested Nurse Aide (STNA) #200. Resident #52 was observed in bed at the time of the observation and Resident #52's scrotal area was observed with a Penrose drain in place with no covering or dressing noted to the site. Review of Resident #52's treatment administration record (TAR) for May 2024 and current physician orders dated 05/07/24 following hospital discharge revealed no evidence of any dressing changes to the Penrose drainage tube. Interview with Licensed Practical Nurse (LPN) #400 on 05/09/24 at 10:32 A.M. stated she was told in report that morning Resident #52 had a sacral abscess and there was no mention of a drainage tube. LPN #400 confirmed there are no physician orders for a Penrose drain or dressing. LPN #400 also confirmed the Penrose drain was in the resident's scrotal area not sacral area. (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 3 Event ID: 366477 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 366477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at North Ridgeville 6200 Lear Nagle Road North Ridgeville, OH 44039 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)