Health inspection·May 28, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 review of the medical record, observation, staff interview, and policy review, the facility failed to ensure incontinence care was provided timely. This affected one (#85) of three residents reviewed for incontinence care. The facility census was 83. Findings include: Review of the medical record for Resident #85 revealed an admission date of 07/13/20. Diagnoses included osteoporosis, urinary incontinence, hypertension, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. The resident was always incontinent of bladder and frequently incontinent of bowel. The resident was dependent on staff for toileting. Review of the care plan last revised 01/28/25 revealed the resident had urinary and bowel incontinence related to weakness, difficulty ambulating, and cognitive deficits. Interventions included the use of incontinence briefs and incontinence care as needed. Review of the task documentation for toileting dated 05/27/25 revealed no documentation the resident had been provided incontinence care from 6:30 A.M. through 12:00 P.M. Observations on 05/27/25 at 9:13 A.M. revealed Resident #85 was sitting in the common area in a wheelchair near the nurses' station watching television. Interview on 05/27/25 at 9:17 A.M., Resident #85 revealed her incontinence brief had been changed earlier in the morning. Resident #85 revealed the staff were not checking her for incontinence during the day. Observations on 05/27/25 at 9:17 A.M., 10:01 A.M., 10:40 A.M., and 11:14 A.M., revealed the resident remained in her wheelchair in the common area in front of the television. There were no observations of staff offering to provide the resident incontinence care. Observation on 05/27/25 at 11:32 A.M., revealed Resident #85 remained in the common area in her wheelchair. There were odors of urine and stool present. Interview at 11:32 A.M. Resident #85 revealed staff had not offered to change her incontinence brief. Further observations at 11:45 A.M. and 11:59 A.M. revealed the resident remained in the common Page 1 of 2 365704 365704 05/28/2025 Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614

F 0690 area with signs of incontinence. Level of Harm - Minimal harm or potential for actual harm Interview on 05/28/25 at 11:59 A.M., Licensed Practical Nurse (LPN) #202 revealed the resident's nursing assistant was completing incontinence care rounds and had not gotten to Resident #85 yet. Residents Affected - Few Observation on 05/28/25 at 12:00 P.M. revealed Certified Nursing Assistant (CNA) #404 pushed the resident in her wheelchair down to her room. CNA #404 and CNA #232 transferred the resident to the bed using the standup lift. Further observation revealed a puddle of liquid with a urine odor in the resident's wheelchair on the seat cushion. Continued observations revealed the resident's pants were wet and had a strong urine odor. CNA #404 and CNA #232 provided incontinence care. The resident's incontinence brief was heavily saturated with urine and a small amount of stool. Further observation revealed the resident had no skin breakdown. Interview on 05/27/25 at 12:01 P.M., CNA #404 revealed her shift began at 10:30 A.M. and was not aware when Resident #85 had last received incontinence care as the prior shift nursing assistance had not let her know. CNA #404 and CNA #232 verified there was a puddle of liquid on the cushion in the resident's wheelchair. CNA #404 and CNA #232 verified the resident's pants were wet with a strong urine odor. CNA #404 and CNA #232 verified the resident had been incontinent of urine and stool and the resident's brief was heavily saturated with urine. CNA #404 and CNA #232 verified incontinence care should be provided every two hours. Interview on 05/28/25 at 2:34 P.M., the Director of Nursing (DON) revealed as a general rule incontinence care would be provided every two hours or per resident preference. Review of the undated facility policy Routine Resident Care, revealed routine daily care including incontinence care would be provided. This deficiency represents non-compliance investigated under Master Complaint Number OH00165598. 365704 Page 2 of 2