Inspection·June 1, 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 Based on medical record review, staff interview, and policy review, the facility failed to ensure residents who required staff assistance with bathing were bathed as scheduled/requested. This affected two (Resident #41 and #78) of three residents reviewed for Activities of Daily Living (ADL)'s. The facility identified 52 residents who needed assistance with showers. The facility census was 86. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 07/09/21. Diagnoses included depression, chronic obstructive pulmonary disease, hyperlipidemia, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/29/23, revealed Resident #41 required extensive assistance of two people for bed mobility, toilet use and hygiene, and required extensive assistance of one person for dressing. Resident #41 required assistance with bathing. The assessment indicated it was very important for Resident #41 to choose between a bed bath, tub bath and shower. Review of the care plan dated 03/30/23 revealed Resident #41 had a self-care deficit related to physical limitations. Interventions included assistance with bathing/showering as needed. Review of the shower schedule revealed Resident #41 was supposed to receive a shower on Wednesdays and Saturdays on first shift. Review of the State Tested Nurses Aide (STNA) tasks, dated 05/02/22 through 05/21/23, revealed Resident #41 had a shower on 05/16/23. There was no evidence Resident #41 received additional showers during this timeframe outside of 05/16/23. 2. Review of the medical record for Resident #78 revealed an admission date of 05/06/23. Diagnoses included heart failure, diabetes, obesity and skin cancer. Review of the comprehensive MDS assessment, dated 05/13/23, revealed Resident #78 had moderately impaired cognition. He required extensive assistance of one person for bed mobility, transfers, dressing and toilet use, and limited assistance of one person for hygiene. Resident #78 required physical help from one person with bathing. It was very important for him to choose between a bed bath, tub bath and shower. Review of the shower schedule revealed Resident #78 was supposed to receive a shower on Tuesday and Friday evenings. Review of the STNA tasks, dated 05/07/22 through 05/22/23, revealed Resident #78 was provided a bed bath on 05/09/23 and 05/16/23. There was no evidence a shower was provided to Resident #78 on 05/12/23 and 05/19/23. Interview with the Director of Nursing (DON) on 05/23/23 at 11:35 A.M. confirmed showers/bathing was not provided to Resident #41 and Resident #78 as scheduled. Review of the facility policy titled Bed Bath/Shower, dated 06/08/22, revealed showers would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 2 of 9 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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)

F 0677 scheduled to accommodate resident preferences and would occur at least weekly. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00142518. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 3 of 9 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on medical record review and staff interview, the facility failed to ensure falls were thoroughly investigated to determine the root cause of the fall and whether interventions were in place at the time of the fall. This affected one (Resident #87) of three residents reviewed for falls. The facility census was 86. Findings include: Review of the medical record for Resident #87 revealed an admission date of 04/21/23 and a discharge date of 05/05/23. Diagnoses included alcohol abuse, orthostatic hypotension, and respiratory failure. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 05/04/23, revealed Resident #87 was rarely or never understood. He required extensive assistance of one person for bed mobility, dressing and hygiene, and limited assistance of one person for toilet use. Review of the care plan, dated 04/22/23, revealed Resident #87 was at risk for falls due to weakness and cognitive deficits. Interventions included keeping his bed in a low position, commonly used articles to be in reach, and reinforcing the need to call for assistance. Review of a progress note, dated 04/23/23, revealed the resident was found on the floor in his room. He stated he fell while trying to get up. He was assisted back to bed. Resident #87 had an open area to his head from the fall. Review of the fall investigation, dated 04/24/23, revealed the fall investigation did not thoroughly investigate the root cause of Resident #87's fall on 04/23/23 and did not include information as to whether all of Resident #87's fall interventions were in place at the time of the fall including whether the bed was in a low position and the call light was in reach at the time of the fall. Interview on 05/25/23 at 5:12 P.M. with the Director of Nursing (DON) confirmed the investigation for Resident #87's fall on 04/23/23 was provided in its entirety and there was no evidence the facility thoroughly investigated the root cause of the fall and whether all of Resident #87's fall interventions were in place during the fall. This deficiency represents non-compliance investigated under Complaint Number OH00142518. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 4 of 9 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 medical record review, staff interview, observation, and policy review, the facility failed to ensure residents who were incontinent were provided incontinence care in a timely manner. This affected five (Resident #25, #33, #78, #90 and #91) out of six residents reviewed for timely incontinence care. The facility census was 86. Findings include: 1. Review of Resident #33's medical record revealed an admission date of 06/14/13 and diagnoses which included dementia, anxiety disorder, spinal stenosis cervical region and difficulty in walking. Review of Resident #33's care plan, dated 03/10/16 and reviewed 04/26/23, revealed Resident #33 had an ADL (activity of daily living) self-care deficit related to generalized weakness, impaired mobility, chronic pain and refusal to get out of bed or participate in hygiene tasks. Resident #33 would receive the assistance necessary to meet ADL needs. Interventions included to assist to bathing and shower as needed. Resident #33 had urinary incontinence related to urge incontinence, functional incontinence, chronic pain, and refusal to get out of bed. Resident #33 would be maintained in as clean and dry as well as dignified state as possible. Interventions included to provide incontinence care as needed. Review of Resident #33's Quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/14/23, revealed Resident #33 was cognitively intact. Resident #33 required extensive assistance of two staff for bed mobility, transfers, personal hygiene and toilet use. Resident #33 was always incontinent of urine and bowel. Review of Resident #33's aide charting for night shift on 05/23/23 from 11:00 P.M. through 7:00 A.M. on 05/24/23 revealed no documentation that Resident #33 was provided incontinence care. Observation on 05/24/23 at 9:10 A.M. of Resident #33 revealed she asked State Tested Nursing Assistant (STNA) #206 to assist her because she needed her incontinence brief changed. Resident #33 preferred the surveyor to stand outside the room during incontinence care. STNA #206 stated this was the first time he provided incontinence care for Resident #33 since he arrived at 7:00 A.M. because breakfast trays arrived around 7:30 A.M., and he helped pass meal trays and feed residents. STNA #206 indicated he started his incontinence rounds after breakfast was finished. After STNA #206 finished with incontinence care, he stated Resident #33's sheets and draw sheet were soiled with urine. Observation of the fitted sheet revealed it was wet with a large spot of urine and had dried urine around the edges, and the draw sheet had a large wet urine spot with dried urine on the edges. Resident #33's incontinence brief was soaked with urine and feces. STNA #206 stated due to the way Resident #33's incontinence brief, sheets, and draw sheet looked Resident #33's incontinence brief was probably not changed during the night shift. 2. Review of Resident #25's medical record revealed an admission date of 07/18/22 and diagnoses which included Huntington's Disease, anxiety disorder, and major depressive disorder. Review of Resident #25's Quarterly MDS 3.0 assessment, dated 04/20/23, revealed Resident #25 was unable to have a Brief Interview for Mental Status conducted due to Resident #25 was rarely, never (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 5 of 9 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some understood. Resident #25 required extensive assistance of two staff for bed mobility, transfers and required total dependence of two staff for toilet use. Resident #25 was always incontinent of urine and bowel. Review of Resident #25's care plan, reviewed 05/03/23, revealed Resident #25 had urinary incontinence related to immobility and had difficulty making needs known. Resident #25 would have no complications due to incontinence. Interventions included to provide incontinence care as needed. Review of Resident #25's aide charting for night shift on 05/23/23 from 11:00 P.M. through 7:00 A.M. on 05/24/23 revealed no documentation that Resident #25 was provided incontinence care. Observation on 05/24/23 at 10:29 A.M. of STNA #206 providing incontinence care for Resident #25 revealed Resident #25's incontinence brief was saturated with dark yellow urine and feces. STNA #206 stated he knew Resident #25 very well and Resident #25's incontinence brief was probably not changed all night from the way it looked. Interview on 05/24/23 at 4:52 P.M. with STNA #310 revealed she was from a staffing agency and on 05/23/23 night shift she was assigned with with STNA #311 to care for residents on the nursing unit where Resident #33 resided. STNA #310 stated she had Resident's #25 and #33 in her assignment. STNA #310 stated it was a very busy crazy night with a lot going on. STNA #310 stated eight or ten residents required two staff for incontinence care, she worked with STNA #311 to change the residents, but she might have missed a few residents including Resident's #25 and #33 who needed changed due to the very busy night. STNA #310 stated she did the best she could. Interview on 05/25/23 at 9:14 A.M. with STNA #311 revealed she worked on 05/23/23 night shift with STNA #310 and it was a busy night. STNA #311 indicated Resident #33 and Resident #25 were not in her assignment and STNA #310 had them in her assignment. STNA #310 told STNA #311 she was fine and did not need help changing any of her residents and STNA #311 took her word for it. STNA #311 stated she would have helped her change Resident #25 and #33 if she knew they needed their incontinence briefs changed. STNA #311 indicated she knew the residents on the hall well and if Resident #25's incontinence brief was wet that meant she was wet for a long time and probably was not changed on night shift. 3. Review of Resident #91's medical record revealed an admission date of 05/28/23 and diagnoses which included alcoholic cirrhosis of liver with ascites, major depressive disorder, and anxiety disorder. Review of Resident #91's admission Assessment and Baseline Care Plans, dated 05/28/23, revealed Resident #91 had cognitive impairment with poor decision-making skills (intermittent confusion, cognitive deficit, disoriented all the time). Review of Resident #91's care plan, dated 05/31/23, revealed Resident #91 had an ADL (activity of daily living) self-care performance deficit related to weakness, unsteady at times. Interventions included for staff to assist with completion of ADL's on a daily basis so needs are met, and provide limited assistance with toilet use. Review of Resident #91's aide charting on 05/29/23 from 11:00 P.M. until 05/30/23 at 7:00 A.M. revealed no documentation that Resident #91 was provided incontinence care during this time frame. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 6 of 9 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 05/30/23 at 4:00 A.M. of STNA #312 revealed he was sleeping in a chair, covered with a blue blanket in the common area lounge on the skilled nursing unit with the lights off. Observation on 05/30/23 at 4:07 A.M. with Registered Nurse (RN) #313 revealed she was in the skilled nursing unit hall preparing to administer medications to the residents. A call light for the resident in room [ROOM NUMBER] was activated and RN #313 answered the call light. After answering the call light, RN #313 went to the lounge, woke STNA #312 up and told him the resident in room [ROOM NUMBER] needed his assistance. Interview on 05/30/23 at 4:10 A.M. with RN #313 revealed she was from a staffing agency and this was the first night she worked in the facility. RN #313 stated she was not sure how long STNA #312 was sleeping when she woke him up to assist the resident in room [ROOM NUMBER]. RN #313 stated it was a crazy night, she was busy answering call lights and administering medications for the residents, and was not sure what STNA #312 was doing. Interview on 05/30/23 at 4:10 A.M. with STNA #312 confirmed he was sleeping, was from a staffing agency and stated he was just dozing off and on. STNA #312 proceeded to room [ROOM NUMBER] to assist the resident. Observation on 05/30/23 at 4:24 A.M. of STNA #312 revealed he was back in the common area lounge with the lights off, sitting in a chair with his head to the side, and an electronic device was on and voices could be heard. Observation on 05/30/23 at 4:33 A.M. revealed STNA #312 sitting in a chair in the common area lounge on the skilled nursing unit with the lights off and voices could be heard from an electronic device he was looking at. Observation on 05/30/23 at 4:39 A.M. revealed RN #313 walked into the common area lounge to have STNA #312 come out on the floor to assist with answering call lights. Observation on 05/30/23 from 4:39 A.M. through 5:10 A.M. revealed STNA #312 did not provide incontinence care for any residents during this timeperiod. Observation on 05/30/23 from 5:10 A.M. through 5:29 A.M. of STNA #312 revealed he answered a couple call lights and brought juice to Resident's #83 and #84, but did not provide incontinence care for any residents. Observation on 05/30/23 from 5:29 A.M. through 5:41 A.M. of STNA #312 revealed he was in the common area lounge with the lights off watching an electronic device. At 5:41 A.M., STNA #312 walked out of the lounge and to the other side of the facility. Observation on 05/30/23 at 5:49 A.M. of STNA #312 revealed he was back in the common area lounge watching his electronic device. Observation on 05/30/23 at 5:52 A.M. revealed RN #313 walked into the common area and told STNA #312 residents were requesting ice water. STNA #312 left the lounge, prepared ice water for the residents and began passing it out to the residents. STNA #312 passed ice water until 6:18 A.M. Observation on 05/30/23 from 6:18 A.M. through 6:54 A.M. revealed STNA #312 was sitting in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 7 of 9 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some common area lounge watching his electronic device. At 6:41 A.M., STNA #312 walked up and down the hall looking in resident rooms, but did not enter any room. Interview on 05/30/23 at 6:50 A.M. of RN #313 revealed she had to keep going in the common area lounge to get STNA #312 and it would be better if he stayed in the hall where the residents resided so he could hear if something happened and residents needed his assistance. RN #313 stated STNA #312 spent a lot of time in the lounge during the 11:00 P.M. to 7:00 A.M. shift. Interview on 05/30/23 at 5:54 A.M. of STNA #312 revealed he stated he provided incontinence care for residents at 5:30 A.M. even though there were no observations of this having occurred. STNA #312 stated the surveyor could check residents and it did not make me no difference. STNA #312 gathered his personal belongings and left the facility without waiting for the day shift aide to give report. Observation on 05/30/23 at 7:05 A.M. of STNA #314 providing incontinence care for Resident #91 revealed Resident #91 had two incontinence briefs on. STNA #314 removed the two incontinence briefs and stated Resident #91 should not have been wearing two incontinence briefs. Further observation revealed Resident #91's sheets were soiled with brown marks, which appeared to be feces, and STNA #314 stated Resident #91 required a complete bed strip. STNA #314 stated STNA #312 worked night shift, left the facility, and did not give her report before he left. Interview on 05/30/23 at 7:30 A.M. with the Director of Nursing revealed STNA #312 should not have been sleeping and staff found sleeping were terminated. 4. Review of Resident #90's medical record revealed an admission date of 05/22/23 and diagnoses which included sepsis, hydrocephalus, major depressive disorder, and neuromuscular dysfunction of the bladder. Review of Resident #90's admission Assessment and Baseline Care Plans, dated 05/22/23, revealed Resident #90 had cognitive impairment with poor decision-making skills (intermittent confusion, cognitive deficit, disoriented all the time). Resident #90 had an indwelling catheter. Review of Resident #90's care plan, dated 05/23/23, revealed Resident #90 had an ADL self-care deficit related to physical limitations, weakness, unsteady gait, and cognitive deficits. Resident #90 would receive assistance necessary to meet ADL needs. Interventions included to assist with daily hygiene, grooming, dressing, oral care and eating as needed. Review of Resident #90's aide charting on 05/29/23 at 11:00 P.M. through 05/30/23 at 7:00 A.M. revealed there was no evidence Resident #90 was provided incontinence care during this timeperiod. Observation on 05/30/23 at 7:20 A.M. of STNA #314 providing incontinence care for Resident #90 revealed Resident #90 had a large brown bowel movement. Observation of Resident #90 revealed the feces was dried on his buttocks and STNA #314 had to wipe the area multiple times to get the feces off. Resident #90's buttocks were red and STNA #314 stated the bowel movement was not fresh and had been there awhile. 5. Review of Resident #78's medical record revealed an admission date of 05/06/23 and diagnoses which included permanent atrial fibrillation, aftercare following surgery for neoplasm, and heart failure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 8 of 9 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 365691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #78's admission MDS 3.0 assessment, dated 05/13/23, revealed Resident #78 had moderate cognitive impairment. Resident #78 required extensive assistance of one staff member for bed mobility, transfers, and toilet use. Resident #78 was frequently incontinent of urine and always incontinent of bowel. Review of Resident #78's care plan, dated 05/08/23, revealed Resident #78 had an ADL self-care deficit related to physical limitations weakness, unsteady at times, recent surgery. Resident #78 would receive assistance necessary to meet ADL needs. Interventions included to assist with daily hygiene, grooming, dressing, oral care and eating as needed. Review of Resident #78's aide charting from 05/29/23 at 11:00 P.M. through 05/30/23 at 7:00 A.M. revealed no evidence Resident #78 was provided incontinence care during this timeframe. Interview on 05/30/23 at 9:30 A.M. of Nurse #216 and STNA #314 revealed they had just changed Resident #78's incontinence brief and Resident #78 was drenched with urine and needed to have his entire bed linens changed because all the linens including two blankets were saturated with urine. Nurse #216 stated it was very evident STNA #312 did nothing on night shift. Observation on 05/30/23 at 9:30 A.M. of Resident #78's bed linens and incontinence brief revealed Resident #78's gown, two bath blankets, fitted sheet, and incontinence brief were soaked with urine. Review of facility policy titled Incontinence Care, reviewed 06/08/22, revealed the purpose was to keep skin clean, dry, free from irritation and odors, to identify skin problems as soon as possible so treatment could be started, and to prevent skin breakdown and infection. This deficiency represents non-compliance investigated under Complaint Number OH00142518. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365691 If continuation sheet Page 9 of 9