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 (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: 365691 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 06/23/2023 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)