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. Page 1 of 3 366488 366488 07/30/2024 Avenue at Lyndhurst 5442 Rae Road Lyndhurst, OH 44124

F 0686 The nurse performed wound care according to the nurse practitioner orders. Level of Harm - Minimal harm or potential for actual harm This deficiency represents noncompliance investigated under Complaint Number OH00154883. Residents Affected - Few 366488 Page 2 of 3 366488 07/30/2024 Avenue at Lyndhurst 5442 Rae Road Lyndhurst, OH 44124

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure residents were regularly screened for risk of falls. This affected three residents (#15, #57, and #61) of four residents reviewed for falls. The facility census was 83. Findings include: 1. Record review of Resident #15 on 07/30/24 revealed she was admitted on [DATE] with diagnoses including diabetes, muscle weakness, and venous insufficiency. Review of her assessments revealed her last fall risk assessment was done 01/28/24 and identified her to not be at risk for falls. She had no documented falls in the last three months. 2. Record review of Resident #57 on 07/30/24 revealed she was admitted on [DATE] with diagnoses including Alzheimer's dementia, diabetes, obesity, and unspecific difficulty walking. Review of her assessments revealed her last fall risk assessment was done 11/05/23 and identified her to be at risk for falls. She had no documented falls in the last three months. 3. Record review of Resident #61 on 07/30/24 revealed he was admitted on [DATE] with diagnoses including prostate cancer, asthma, and chronic kidney disease. Review of his assessments revealed his last fall risk assessment was done 03/19/24 and identified him to be at risk for falls. He had no documented falls in the last three months. Record review of the facility's fall management policy dated 12/2022 revealed all residents were to be assessed for fall risk on admission, quarterly, and with significant change. Interview with the Director of Nursing on 07/30/24 at 8:47 A.M. confirmed the above findings. This deficiency represents noncompliance investigated under Complaint Number OH00154883. 366488 Page 3 of 3