Health inspection·May 18, 2023

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, medical record review, resident and staff interview, and facility policy review, the facility failed to ensure dependent residents received timely assistance with activities of daily living. This affected two (#10 and #36) of four residents reviewed for activities of daily living. The facility census was 50. Residents Affected - Few Findings include: 1. Review of Resident #36's medical record revealed and admission date of 09/11/20. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, acute kidney failure, benign prostatic hyperplasia without lower urinary tract symptoms, hyperlipidemia, dysphagia, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 03/16/23, revealed the resident was moderately cognitively impaired. Resident #36 required extensive one person assistance with personal hygiene. Review of the care plan, revised 05/09/23, revealed Resident #36 required assistance with personal hygiene. Observation on 05/15/23 at 11:15 A.M. revealed Resident #36 had long finger nails with the thumb and pointer finger nail appearing to have dirt under the nails. Interview with Resident #36 on 05/15/23 at 11:15 A.M., at the time of the observation, stated he asked twice on 05/13/23 and 05/14/23 to have his finger nails trimmed, and asked staff to trim his finger nails again today. Interview on 05/15/23 at 11:45 A.M. with State Tested Nurse Aide (STNA) #491 verified Resident #36's finger nails were long, dirty, and needed trimmed. 2. Review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, diabetes mellitus type II, and cataract in both eyes. Review of the most recent MDS assessment dated [DATE] revealed Resident #10 was assessed with intact cognition, and required extensive one person assistance for personal hygiene. Observation on 05/15/23 at 9:37 A.M. of Resident #10 revealed facial hair on her chin measuring (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 2 Event ID: 365498 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 365498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ottawa CO Riverview Nursing Ho 8180 W State Rt 163 Oak Harbor, OH 43449 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)