Health inspection·October 4, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, and review of a shower list, the facility failed to offer alternatives to meet a resident's preference for bathing. This affected one (#1) of three residents reviewed for activities of daily living. The census was 82. Findings include: Review of Resident #1's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, right pubis fracture, asthma, dysphagia, hypertension, end stage renal disease, dependence on renal dialysis, aggressive periodontitis, secondary hyperparathyroidism of renal origin, neurofibromatosis, rhabdomyolysis, and anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was assessed with intact cognition, was dependent on staff for the completion of activities of daily living (ADLs), was occasionally incontinent of urine, continent of bowel, had no skin breakdown, and received dialysis. Review of a nursing plan of care dated 08/21/23 addressed Resident #1's ADLs self-care performance deficit related to fracture of the pubis, asthma, protein calorie malnutrition, falls, end stage renal disease, hyperparathyroidism, neurofibromatosis, rhabdomyolysis, anemia, convulsions, hypertension, radiculopathy, hypoosmolality and hyponatremia, anxiety, weakness, hypothyroidism, and dependence on renal dialysis. Interventions included to assist with ADLs (i.e., dressing, grooming, personal hygiene, locomotion, oral care, etc.) as needed, with two person assist with transfer and bed mobility. Review of the undated facility shower list noted Resident #1 was assigned showers during night shift on Monday and Thursday. The shower list noted if the resident refused a shower three times, have the nurse ask the resident, and then document. Review of Resident #1's weekly bath and skin report from September 2023 through 10/02/23 noted a bath was documented on 09/04/23. There were documented refusals on 09/07/23, 09/11/23, 09/14/23, 09/18/23, 09/21/23, 09/25/23, 09/28/23, and 10/02/23. Further review revealed no documentation contained in Resident #1's medical record indicating the resident was offered additional attempts on bath days or alternative bathing options (bed bath). Interview on 10/04/23 at 7:34 A.M., with Resident #1 stated she had not received bathing opportunities as scheduled, and was informed facility staff were documenting she refused. Resident #1 (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: 365745 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 365745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Swanton Valley Rehabilitation and Healthcare Cente 401 W Airport Hwy Swanton, OH 43558 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)