Health inspection·December 28, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure clean bed linens were provided to the residents. This affected one (#4) of three residents reviewed for clean and sanitary bed linens. The facility census was 61. Findings include: Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), peripheral vascular disease, contracture left and right knee, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had moderate cognitive impairment, dependent on staff with activities of daily living, continent of bladder, and incontinent of bowel. Review of the nursing plan of care dated 09/07/23 revealed Resident #4 had an activity of daily living self care performance deficit related to impaired cognition, weakness, and pain. Interventions included toileting assistance with perineal hygiene, required substantial/maximal assistance with hygiene, and bathing/showering. Observation and interview on 12/27/23 at 8:37 A.M. revealed Resident #4 was in bed. Interview with State Tested Nurse Aide (STNA) #200 at the time revealed Resident #4 was last checked and repositioned at the beginning of the shift at approximately 6:00 A.M. During the observation, STNA #200 provided Resident #4 with a bed bath and discovered the resident's bed linen to be soiled with dried urine. The stain soaked through a folded bath blanket onto the fitted sheet under the resident. The top sheet was also discovered with dried urine stains. STNA #200 indicated she was unaware of the stains until the 8:37 A.M. bed check. This deficiency represents non-compliance investigated under Complaint Number OH00149103. 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: 365163 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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)