Inspection·March 13, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policy reviews, the facility failed to provide assistance with activities of daily care for a resident dependent on staff for assistance. This affected two (#20 and #49) of three residents reviewed for assistance with care needs. The facility census was 137. Residents Affected - Few Findings include: 1. Review of medical record for Resident #20 revealed admission date of 12/04/17. The resident was admitted with diagnoses including congestive heart failure, stroke and Crohn's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed he was rarely understood and had a long-term memory problem with modified independence cognition. He required maximum assistance for eating, and was dependent with bed mobility, transfers and toileting. He was always incontinent of bowel and bladder. Observation on 03/13/24 at 2:27 P.M., of Resident #20 revealed a layer of thick plaque to his top teeth and his nails were noted to extend approximately 0.6 centimeters beyond his fingertips. [NAME] material was also observed under his nails. Interview with the Director of Nursing, at the time of the observation, verified the observation. 2. Review of medical record for Resident #49 revealed admission date of 10/02/15 with a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. The resident was admitted with diagnoses including peripheral vascular disease, dementia, bipolar disease and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed she required set up assistance for eating, maximum assistance for bed mobility, toileting hygiene and not applicable for transfers. It was documented she was always incontinent of bowel and bladder. Observation was made on 01/13/24 at 9:27 A.M., of incontinence care for Resident #49. State Tested Nursing Assistant (STNA) #102 assisted Resident #49 onto her back and loosened the tape to both sides of the incontinence product. When she pulled down the product a strong smell of urine filled the room. The incontinence product was observed to be saturated with dark urine. Resident #49 was unsure about the last time she had been provided care. Interview immediately after incontinence care on 03/13/24 at 9:33 A.M., revealed STNA #102 did not receive report from the previous shift. She stated there was no STNA on the floor when she arrived at 7:00 A.M. She was unsure the last time Resident #102 had been provided incontinence care. She (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: 365278 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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)