Health inspection·August 8, 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 Based on medical record review, staff interview, review of shower schedules, and review of a facility policy, the facility failed to ensure residents were provided with scheduled bathing. This affected three (#9, #50, and #68) of three residents reviewed for bathing. The facility census was 76. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 01/06/23. Diagnoses include chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, oral dysphagia, stage three chronic kidney disease, generalized muscle weakness, need for assistance with personal care, anorexia, anxiety disorder, dementia, and depression. Review of the annual Minimum Data Set (MDS) assessment, dated 07/05/24, revealed Resident #9 was severely cognitively impaired, was dependent for showering and bathing, and required substantial/maximal assistance with personal hygiene. Review of a facility shower schedule revealed Resident #9 was scheduled for showers every Wednesday and Saturday on second shift. Review of Resident #9's shower documentation for 07/10/24 through 08/08/24 revealed Resident #9 was scheduled to be bathed nine times during that time frame. Further review revealed Resident #9 only received bed baths on 07/17/24, 07/20/24, and 07/24/24, with a shower refusal documented on 07/10/24. 2. Review of the medical record for Resident #50 revealed an admission date of 07/15/24. Diagnoses include Alzheimer's disease, lumbar spinal stenosis, dizziness and giddiness, hyperlipidemia, and hypertension. Review of the admission MDS assessment, dated 07/22/24, revealed Resident #50 was moderately cognitively impaired and required setup or clean-up assistance for showering and bathing as well as all personal hygiene. Review of a facility shower schedule revealed Resident #50 was scheduled for showers every Monday and Thursday on first shift. Review of Resident #50's shower documentation for 07/15/24 through 08/08/24 revealed Resident #50 was scheduled to receive five showers during that time frame. Further review revealed Resident #50 only received showers on 07/17/24, 07/25/24, and 08/01/24. 3. Review of the medical record for Resident #68 revealed an admission date of 03/24/24. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia, schizoaffective disorder, anxiety, hypertension, and atrial fibrillation. Page 1 of 2 365907 365907 08/08/2024 Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the MDS assessment, dated 08/02/24, revealed Resident #68 was severely cognitively impaired and was dependent for showering/bathing as well as all personal hygiene. Review of a facility shower schedule revealed Resident #68 was scheduled for showers every Monday and Thursday on first shift. Review of Resident #68's shower documentation for 07/10/24 through 08/08/24 revealed Resident #68 was scheduled to be bathed nine times during that time frame. Further review revealed Resident #68 only received bed baths on 07/15/24, 07/18/24, and 07/22/24. Interview on 08/08/24 at approximately 11:00 A.M. with the Director of Nursing (DON) revealed the facility was in the process of converting their shower documentation from shower sheets to their electronic medical record (EMR). Interview on 08/08/24 at approximately 2:30 P.M. with the DON and the Administrator verified Resident #9, Resident #50, and Resident #68 were not bathed according to their scheduled bathing times. The DON and the Administrator verified Resident #9 was bathed on three of nine scheduled opportunities between 07/10/24 and 08/08/24, verified Resident #50 received three of the five scheduled showers between 07/15/24 through 08/08/24, and verified Resident #68 received three of the nine scheduled showers between 07/10/24 through 08/08/24. Review of facility policy titled, Resident Showers, dated 11/17, revealed residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. This deficiency represents non-compliance investigated under Complaint Number OH00156323 and represents continued non-compliance from the survey dated 06/13/24. 365907 Page 2 of 2