Health inspection·January 7, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provided timely incontinence care to the residents. This affected two (Residents #10 and #74) of three residents reviewed for incontinence care. The facility census was 110. Findings include: 1. Record review for Resident #10 revealed an admission date of 11/06/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and muscle weakness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was moderately cognitively impaired. Resident #10 had impairment on one side of the upper and lower extremities, was frequently incontinent of urine and always incontinent of bowel. Resident #10 required substantial/maximal assistance with toileting hygiene, personal hygiene, and was dependent on staff for transfers. Review of the care plan dated 12/23/24 revealed Resident #10 had bowel incontinence due to impaired mobility and physical limitations. Resident #10 also had bladder frequent incontinence due to impaired mobility and physical limitations. Interventions included to check resident, if she was continent, offer to assist with toileting. If she was incontinent, remove wet or soiled clothing, briefs; provide incontinent care; apply protective barrier after each incontinent episode; and maintain resident dignity during incontinent care. Observation and interview on 01/06/25 at 12:53 P.M. revealed Resident #10 was sitting up in her chair. Resident #10 stated she had been incontinent and asked the Certified Nursing Assistant (CNA) to change her since 10:00 A.M. Interview on 01/06/25 at 12:57 P.M. with CNA #335 confirmed she was Resident #10's CNA. CNA #335 stated she needed two people to transfer Resident #10 to her bed to change her so she would do it at 2:00 P.M. Interview on 01/06/24 at 2:22 P.M. with CNA #335 stated she was not ready yet to change Resident #10, she needed to wait for another staff member to assist her with the transfer. CNA #335 stated Resident #10 was a mechanical lift and required two persons to transfer her. The night shift placed her in the chair, unsure what time but it was before 7:00 A.M., and Resident #10 has not been laid back down or checked and changed since night shift got her up. CNA #335 stated she did not have enough Page 1 of 2 365033 365033 01/07/2025 Cedarwood Plaza 12504 Cedar Road Cleveland Heights, OH 44106

F 0690 hands to do it all. Level of Harm - Minimal harm or potential for actual harm Observation on 01/06/25 at 2:30 P.M. revealed Licensed Practical Nurse (LPN) #312 assisted CNA #335 to transfer Resident #10 to her bed. Observation during incontinence care revealed Resident #10's brief was completely saturated front and back with urine and stool. Residents Affected - Few 2. Record review for Resident #74 revealed an admission date of 11/25/24. Diagnoses included spondylosis with myelopathy cervical region, overflow incontinence and muscle weakness. Review of the Medicare five-day MDS assessment dated [DATE] revealed Resident #74 was cognitively intact. Resident #74 required supervision or touch assistants with toileting hygiene and transfers. Resident #74 was occasionally incontinent of bowel and bladder. Review of the care plan revealed Resident #74 had bladder incontinence related to impaired mobility. Interventions included to check the resident if he/she was incontinent, remove wet or soiled clothing, briefs; provide incontinence care; and apply protective barrier after each incontinent episode. Observation and interview on 01/06/25 at 1:03 P.M. revealed Resident #74 was sitting up in his chair next to his bed. Observation revealed the sheets on top of Resident #74's bed were saturated from one side of the bed to the other with a large dried yellow ring on the edges. The room had a strong odor of urine. Resident #74 stated he was up on his chair since 8:45 A.M. Resident #74 stated he had not been changed yet and asked for assistance to get changed a few hours ago. Resident #74 stated he often had to wait to get changed and he was wet now. Interview on 01/06/25 at 1:10 P.M. with CNA #402 stated each of her residents were checked and changed two times a shift, in the morning and at the end of her shift. CNA #402 stated the shift began at 7:00 A.M. until 3:00 P.M. Observation and interview on 01/06/25 at 1:19 P.M. with CNA #403 confirmed Resident #74's sheets were saturated with urine and the room had a strong urine odor. CNA #403 stated Resident #74 used a urinal, he was incontinent sometimes but if he needed help he would ask, otherwise she did not need to check on him for incontinent care needs. CNA #403 stated she changed other incontinent residents twice a shift, in the morning and at the end of her shift. CNA #403 confirmed she worked from 7:00 A.M. until 3:00 P.M. Interview on 01/06/25 at 1:38 P.M. with CNA #461 stated she could not take residents to the bathroom or provide incontinence care during meal time which included passing the meal trays, feeding residents and picking up the trays. Interview on 01/06/24 at 3:20 P.M. with Regional Director #476 revealed residents were checked and changed on an individualized bases but at least every two hours, some residents may require it more often and as needed. Review of the facility policy titled ADL Care (Activity of Daily Living) dated 11/30/23 included the purpose was to meet the resident's physical and mental needs. Assist resident with toilet activities and provide incontinence care as needed. This deficiency represents non-compliance investigated under Complaint Number OH00161188. 365033 Page 2 of 2