Health inspection·June 23, 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 interview, observation, record review, and facility policy review the facility did not ensure Resident #3 received timely incontinence care. This affected one resident (#3) out of three residents reviewed for incontinence care. This had the potential to affect 41 residents (#2, #3, #8, #10, #11, #12, #14, #17, #19, #20, #22, #23, #24, #27, #28, #29, #31, #33, #34, #36, #38, #41, #45, #46, #47, #48, #50, #51, #52, #54, #57, #58, #60, #63, #71, #72, #74, #77, #78, #80, and #83) who were identified by the facility as incontinent. Residents Affected - Few Findings include: Review of the medical record for Resident #3 revealed an admission date of 09/09/18 with diagnoses including Lennox-Gastaunt Syndrome (LGS) with status epilepticus (type of seizure disorder with multiple different types of seizures), fracture of upper end of the left humerus, and cerebral palsy. Review of the undated care plan revealed Resident #3 had urinary incontinence related to impaired mobility, physical limitation, cognitive deficits, and resistance to care at times. Interventions included adjust toileting times to meet the resident's needs, apply skin moisturizer and barrier creams as needed, provide incontinence care as needed, and use absorbent products as needed. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition. He required extensive assistance of two staff with bed mobility, dressing, personal hygiene, and toileting. He was totally dependent of two staff for transfers. He was frequently incontinent of urine and always incontinent of bowel. Observation of incontinence care on 06/23/23 at 8:19 A.M. and completed by State Tested Nursing Assistant (STNA) #600 and STNA #601 revealed Resident #3 had two incontinence briefs on and both briefs were saturated in urine. Observation revealed he was lying on two bath blankets folded as draw sheets underneath the briefs and both bath blankets were saturated with urine resulting in urine that soaked all the way through both bath blankets to his bottom fitted sheet. Observation revealed Resident #3's bottom fitted sheet had dried yellow round urine spots. Interview on 06/23/23 at 8:35 A.M. with STNA #600 and STNA #601 revealed when they came on duty on 06/23/23 at 7:00 A.M. the two STNA's from 11:00 P.M. to 7:00 A.M. shift had already left and that they did not get anything in report regarding Resident #3 refusing care and/or a reason why he had not been changed. They revealed they were supposed to do walking rounds with the off-going STNA's to check for incontinence but since the aides from the previous shift had left, they had not, and they were unsure when Resident #3 was changed last. They verified by the condition Resident #3 was found in he had not been changed for a long period of time and felt it was much longer than two hours. They Page 1 of 2 365691 365691 06/23/2023 Mentor Hills Post Acute 8200 Mentor Hills Drive Mentor, OH 44060

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few asked Resident #3 when the last time he was changed while they were changing him but Resident #3 was unable to recall when he was changed last. Interview on 06/23/23 at 9:57 A.M. with STNA #603 revealed she primarily worked day shift and at times she had come in and found residents saturated in urine as their briefs as well as their sheets were urine soaked, and she felt staff from the 11:00 P.M. to 7:00 A.M. shift had not changed the residents as they should have been every two hours. She revealed they were supposed to do rounds with off going STNA's but most the time the staff just left without doing the rounds. Re-interview on 06/23/23 at 10:11 A.M. with STNA #600 revealed Resident #3 more than likely had urinated four or five times by the time they had changed him on 06/23/23 at 8:19 A.M. She revealed he had to have urinated four or five times because he had two incontinence briefs on that were soaked and then stated he had an inch thick of bath blankets underneath the two incontinence briefs that the urine had soaked all the way through both bath blankets then all the way down to the fitted sheet which then also was soaked. She revealed it appeared in her opinion that Resident #3 had not been changed almost all 11:00 P.M. to 7:00 A.M. or if he was changed it was at the beginning of that shift but that he had gone several hours without being changed. Interview on 06/23/23 at 11:56 A.M. with the Director of Nursing revealed Resident #3 should not have had two incontinence briefs in place. She revealed she had contacted Agency STNA #608 regarding the condition Resident #3 was found in. She revealed it was Agency STNA #608's first time at the facility and that Agency STNA #608 stated Resident #3 was sleeping on her last set of rounds prior to her leaving and that she had not attempted to awake him to provide incontinence care as per his plan of care. The Director of Nursing verified Resident #3 was incontinent of urine and was to be checked and changed every two hours and provided incontinence care as needed. She revealed she was unsure when Resident #3 was changed last on 06/23/23 prior to being changed at 8:19 A.M. but stated, obviously she did not do incontinence care and it was over two hours by how he was found. Review of the facility policy labeled Incontinence Care, dated 06/08/22, revealed the purpose of the policy was to keep resident's skin clean, dry, and free of irritation and odor. There was nothing in the policy regarding the frequency of incontinence care. This deficiency represents non-compliance investigated under Complaint Number OH00143579. This deficiency is an example of continued noncompliance to the survey completed on 06/01/23. 365691 Page 2 of 2