Health inspection·July 6, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, review of facility fall policy, and staff interviews, the facility failed to ensure fall interventions were in place for a resident at risk for falls. This affected one (Resident #55) of three residents review for falls. The facility census was 103. Findings include: Review of Resident #55's medical record identified admission to the facility occurred on 03/21/23 with medical diagnoses including; dementia, chronic kidney disease (CKD) and Alzheimer's disease. Resident #55 was receiving hospice services since admission. Review of Resident #55's admission fall risk assessment dated [DATE] revealed the resident was at high risk for falling and had multiple falls prior to admission. A care plan was developed with interventions in place to prevent falls. Review of Resident #55's progress note dated 06/10/23 at 5:43 A.M., revealed the resident was found on the floor after falling in the bathroom. The facility documented an intervention of non-skid strips to be placed on the bathroom floor. The intervention of non-skid strips to the bathroom floor was added to the resident's care plan on 06/10/23. Observation on 07/05/23 at 8:40 A.M. revealed Resident #55 walked into his bathroom independently and was standing at the sink running his hands under water. There were no non-skid strips located on the resident's bathroom floor. Interview and observation on 07/05/23 at 9:44 A.M. with Registered Nurse (RN) #200 revealed Resident #55's bathroom did not have non-skid strips placed on the floor as listed in the resident's care plan. RN #200 verified Resident #55 fell in his bathroom on 06/10/23 due to him flooding the bathroom, by plugging the sink. Review of the facility's fall policy dated 01/02/23, revealed staff would identify specific interventions related to the resident's risks to try to prevent falls. This deficiency represents non-compliance investigated under Complaint Number OH00143186. Page 1 of 2 365976 365976 07/06/2023 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

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. Based on observations, medical record review, and staff interviews, the facility failed to ensure a resident had an anchor device in place for the resident's catheter (a device that attaches to the resident's leg to secure a catheter to prevent tugging). This affected one (Resident #103) of three residents reviewed for catheter care. The facility census was 103. Findings include: Review of Resident #103's medical record identified admission occurred on 01/11/23 with medical diagnoses including; morbid obesity, dementia, bipolar disorder and enlarged prostate. Further review revealed Resident #103 was admitted to the facility with a urinary catheter. Review of the resident's care plan revealed an intervention to, Secure my catheter to my thigh to decrease trauma and bladder spasms. Observation on 07/05/23 at 7:08 A.M. revealed State Testing Nurse Aides (STNAs) #205 and #206 providing catheter care to Resident #103. Resident #103's catheter did not have an anchor device to secure the catheter to his thigh, per his care plan. STNAs #205 and #206 verified Resident #103 had no anchor device for his catheter. Further observation revealed Resident #103 had a small amount of bloody drainage to the tip of his penis, however this was not unusual for the resident. STNAs #205 and #206 verified the facility had anchoring devices available and would get one placed. Review of the facility's urinary catheter care policy, last updated 05/10/23, revealed the policy did not address the use of urinary catheter anchors to decrease the potential for trauma. This deficiency represents non-compliance investigated under Complaint Number OH00143186. 365976 Page 2 of 2