Health inspection·July 30, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure wound care was ordered and documented according to nurse practitioner orders. This affected one resident (#15) of three residents reviewed for wound care. The facility census was 83. Residents Affected - Few Findings include: Record review of Resident #15 revealed she was admitted [DATE] with diagnoses including a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) and diabetes. She had an as-needed order dated 07/19/24 for wound care, but no scheduled time or days when wound care was to be done. Review of her treatment administration record (TAR) revealed no wound care procedures were documented as completed in 07/2024. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had mild or no cognitive impairment and had a stage III pressure sore present on admission. Record review of Resident #15's wound nurse practitioner notes revealed an assessment on 07/05/24 identified the resident as having a stage III pressure sore to her sacrum measuring 2.1 centimeters (cm) by 0.9 cm with a depth of 0.1 cm. The orders called for daily application of calcium alginate and a clean dry dressing. Their assessment on 07/25/24 noted the wound was improving and measured 1.8 cm by 0.7 cm by 0.2 cm and called for a silver alginate dressing to be applied daily. Interview with Resident #15 on 07/29/24 at 10:02 A.M. revealed she received daily wound care, had the wound prior to admission, and was seen weekly by the wound nurse practitioner. She had no concerns with her wound care. Interview with Wound Nurse Practitioner #501 on 07/29/24 at 4:08 P.M. revealed Resident #15 was to receive daily wound care of silver alginate with a dry dressing. She knew of no concerns with wound care not being done. Interview with the Director of Nursing (DON) on 07/29/24 at 4:20 P.M. confirmed the above findings, including that wound care was to be done daily and was not documented through 07/2024. She said that due to the location on the sacrum the wound became easily soiled with incontinence care, so staff regularly changed the dressing despite the lack of scheduled orders. Observation of wound care for Resident #15 on 07/30/24 at 9:18 A.M. revealed her previous dressing was dated 07/29/24. The wound appeared clean and without clear evidence of negligence or infection. (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: 366488 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 366488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Lyndhurst 5442 Rae Road Lyndhurst, OH 44124 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)