Health inspection·March 7, 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 observation, staff interview, review of policy for incontinence, and review of staff correction form, the facility failed to ensure a resident who was dependent on staff for care, was provided incontinence care in a timely manner. This affected one (#10) of four residents reviewed for incontinence care. The census was 82. Residents Affected - Few Findings included: Review of medical record for Resident #10 revealed admission date of 08/25/20, with a readmission date of 02/17/22. The resident was admitted with diagnoses including schizoaffective disorder, bipolar disorder, muscle weakness, cognitive communication deficit and unsteady feet. Review of the minimum data set (MDS) assessment dated [DATE], revealed the resident was moderately cognitively impaired. The resident was assessed as the need for toileting as being dependent and for chair to bed or bed to chair transfer as dependent. Review of the care plan relative to the risk in decline for activity of daily living (ADL) function revealed interventions which included the use of Hoyer lift with all transfers. A care plan relative to being at risk for impaired skin integrity with interventions which included assist resident to turn and reposition as well as incontinence care at routine intervals and as needed. Observation on 03/05/24 at 9:50 A.M., revealed Resident #10 was sitting in the common areas, near the nurse's station. Resident #10 was relatedly calling out for someone to help her with her incontinence care. Licensed Practical Nurse (LPN) #303 was overheard speaking to another nurse at the nurse's station, stating she is going to write up State Tested Nurse Aide (STNA) #400 because she had told her three times to assist Resident #10. At 10:00 A.M., LPN #303 and STNA #444, took Resident #10 to her room for incontinence care. When transferring Resident #10 from her chair to her bed, Resident #10's pants were visibly soiled with urine. The incontinence pad in the chair was also saturated with urine. Resident #10 was provided incontinence care for urine and bowel movement by the staff. Interview with LPN #303 and STNA #444, at the time of the observation, verified the residents' pants in the back and front were saturated with urine and as well as the incontinence pad was saturated. LPN #303 verified STNA #400 was aware the resident was in need of incontinence care as she had instructed her several times to assist the resident. Interview on 03/05/24 at 10:35 A.M., with STNA# 400 verified she was going to take the resident to check and changed after her lunch break which was over at 10:30 A.M. STNA #400 stated the last time she had provided a check and change was at 7:15 A.M. STNA #400 stated she was unaware of how long Page 1 of 2 365453 365453 03/07/2024 Ayden Healthcare of Oregon 3953 Navarre Ave Oregon, OH 43616

F 0677 the resident had been calling out because she had been busy. Level of Harm - Minimal harm or potential for actual harm Interview on 03/07/24 at 11:00 A.M., with Director of Nursing verified STNA #400 was given a written correction action due to not performing incontinence care timely for Resident #10. Also, LPN # 303 was given a verbal counseling due to repeatedly informing STNA #400 of the resident calling out for the need of a change in clothes and for waiting which cause the resident to become more agitated and reddened buttocks. Residents Affected - Few Review of the Correction Action Form dated 03/05/24 revealed STNA #400 had a final performance issue for failure to provide resident care in a timely manner. This was verbally given on 03/05/24 and signed on 03/07/24. Review of the policy for Urinary Continence and Incontinence- Assessment and Management, dated 10/01/22, included the staff will manage individuals with incontinence with appropriate services and treatment to help residents restore or improve bladder function. The staff will provide scheduled toileting, prompted voiding, or other interventions to try and manage incontinence. This deficiency represents non-compliance investigated under Complaint Number OH00151132, Complaint Number OH00151019, and Complaint Number OH00150921. 365453 Page 2 of 2