Health inspection·March 6, 2024

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 record review, observations, resident and staff interviews and policy review, the facility failed to provide a resident with timely incontinence care and timely assistance with the use of a bed pan. This affected one (#44) of three residents reviewed for incontinent care. The facility census was 75. Residents Affected - Few Findings include: Review of medical record for Resident #44 revealed admission date of 02/18/24. Diagnoses include diabetes mellitus type two, morbid obesity and hypertension. The resident was scheduled to be discharged [DATE] to another facility. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #44's Brief Interview Mental Status (BIMS) score was 15 indicating intact cognition. Resident #44 required maximum assistance for bed mobility, dependent for transfers and maximum assistance for eating. Review of Resident #44's admission skin assessment dated [DATE] revealed bruising to the right forearm and healed pressure area to the sacrum. Review of Resident #44's Body assessment dated [DATE] revealed Moisture Associated Skin Damage to bilateral thighs and buttocks. In the summary it was documented, Resident #44 voiced complaint of burning skin and being left on bed pan from previous shift. Administrator asked this nurse to perform skin assessment. Interview on 03/06/24 at 9:42 A.M. with Resident #44 revealed about a week or two ago, she had been left on a bed pan throughout the night and was not taken off until the morning staff came in. Resident #44 said the call light had gone unanswered. During the interview with State Tested Nursing Assistant (STNA) #320 who entered the room to provide care. Observation during incontinence care revealed several open areas on her coccyx, right and left posterior thigh. Observation on 03/06/24 at 9:48 A.M. of incontinence care for Resident #44 by STNA #320 revealed Resident #44 incontinence brief was saturated. Resident #44 was turned onto her left side and a strong urine smell filled the room. Further observation revealed a large, yellow tinged stain on Resident #44's bed blanket. Interview on 03/06/24 at 10:02 A.M. with STNA #320 revealed she had not yet provided incontinence care for Resident #44. STNA #320 stated she arrived at the facility and her shift started at 7:00 A.M. STNA #320 stated she was unsure of the last time Resident #44 was provided with incontinence care. Page 1 of 2 365876 365876 03/06/2024 Aventura at Carriage Inn 5040 Philadelphia Drive Dayton, OH 45415

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/06/24 at 10:06 A.M. with Resident #44 revealed she was unsure the last time she received incontinence care, but it had been during the night shift. Resident #44 further shared night shift would come to the door and ask if she was wet, if she said yes, they would ask if she was wet, wet. Resident #44 added she felt if she was wet at all, she wanted to be provided with care. Interview on 03/06/24 at 11:22 A.M. with STNA #350 revealed she had been informed by another STNA in report Resident #44 had been left on the bed pan all night about a week or two ago. STNA #350 acknowledged she was not working when the incident happened but added she had taken care of Resident #44 prior to the incident, and she did not have any open areas to her coccyx or thighs before the incident. Interview on 03/06/24 at 1:03 P.M. with Registered Nurse (RN) #325 revealed she had been informed in report Resident #44 had been left on the bed pan through the night. RN #325 stated she performed a skin assessment and contacted the Medical Director to provide an update and received an order for barrier cream. Interview on 03/06/24 at 4:15 P.M. with STNA #345 revealed she had arrived to work late, between 8:00 A.M. and 9:00 A.M. on 02/20/24. Resident #44 had her call light on and when she answered, Resident #44 was upset because she needed to be removed from the bed pan. STNA #345 shared the bed pan was overflowing with stool. When she removed Resident #44 from the bed pan, she could tell she had been on it a while and she had several open areas. STNA #345 stated she cleansed her and changed the bed sheet. STNA #345 stated she informed the nurse and was unsure what happened there. Review of the facility policy, Activities of Daily Living, Supporting dated 08/22 documented appropriate care and services would be provided for residents who were unable to carry them out independently. This deficiency represents non-compliance investigated under Master Complaint Number OH00151459 and Complaint Number OH00151261. 365876 Page 2 of 2