Health inspection·January 3, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility did not ensure a safe, functional, sanitary, and comfortable shower room. This affected two residents (#42 and #82) out of two residents reviewed for the accommodation of showers and had the potential to affect all 17 residents (#2, #12, #23, #32, #34, #39, #41, #42, #47, #60, #61, #62, #71, #77, #78, #79, #82) residing on the secured unit. The facility census was 93. Findings included: 1. Review of the medical record for Resident #82 revealed an admission date of 10/17/23 with diagnoses including traumatic brain injury with loss of consciousness, dementia, psychosis, history of falling, and intellectual disabilities. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had impaired cognition. He was dependent on staff assistance with his showers. Review of the care plan dated 10/17/23 revealed Resident #82's bathing preference was to have a shower. Interventions included encourage him to voice his personal preferences, to request changes as needed, and provide a shower. Observation on 01/03/24 at 8:55 A.M. revealed State Tested Nursing Assistant (STNA) #608 and STNA #613 assisted Resident #82 with his shower in the secured unit shower room. They started the water and proceeded to transfer him from his wheelchair to a shower chair and undressed him. STNA #608 proceeded to wash Resident #82's body and hair. During the shower the water was observed to rise on the floor, move towards the hallway, and not drain properly. STNA #608 continued to bathe Resident #82 as he stood in tennis shoes in approximately one inch of water (dirty). STNA #608 verified, at least an inch I feel sometimes gets higher that he had to stand in while showering residents. After the shower they proceeded to use bath blankets to soak up the excess water that was standing on the floor. 2. Review of the medical record for Resident #42 revealed an admission date of 08/10/23 with diagnoses including psychosis, mood disorder, and bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #42 had intact cognition. She required supervision/ touching assistance with her showers and was independent with dressing. Review of the care plan dated 10/26/23 revealed Resident #42's bathing preference was to have a shower. Interventions included encouraging the resident to voice her personal preferences, to request Page 1 of 3 366015 366015 01/03/2024 Carecore at Mentor 8881 Schaefer St Mentor, OH 44060

F 0921 changes as needed, and provide a shower. Level of Harm - Minimal harm or potential for actual harm Interview on 01/03/24 at 9:09 A.M. with Resident #42 revealed she takes showers independently in the shower room on the secured unit as she does not want staff to assist her. She revealed she stood in water during her showers, it is a mess, does not drain right. Residents Affected - Some Interview on 01/03/24 from 7:58 A.M. to 8:04 A.M. with Licensed Practical Nurse (LPN) #609 and STNA #608 verified Resident #42 independently takes her showers in the shower room on the secured unit. STNA #608 verified it was a fall risk for Resident #42 to independently be in the shower room due to the water not properly draining, but Resident #42 refused to have staff assistance. 3. Interview on 01/03/24 at 5:12 A.M. with STNA #603 revealed when she provided showers on the secured unit the water gets all over the floor and comes into the hallway. She revealed if staff assist with providing a shower, they must stand in inches of water as the drain does not drain correctly. She revealed, I feel the drain is not big enough or something. She revealed it had been like that since September 2023 when she started at the facility. Interview on 01/03/24 at 7:58 A.M. with STNA #608 revealed the secured unit shower room flooded all the time. He revealed he had to put down bath blankets for the water not to come out into the hallway. He revealed it was standing water that does not go down the drain properly. He revealed it was a safety issue, and it had been like that for several months. He revealed he stands in water when he provides a shower, and his shoes get soaked with the dirty water causing concerns with infection control. He revealed he had reported it to the Administrator and Maintenance Director #612 multiple times who always replied, too expensive to fix. He revealed Maintenance Director #612 stated the shower room had been like that for a long time, and he refused to fix it. Interview on 01/03/24 at 8:04 A.M. with LPN #609 verified she had witnessed the shower room flood many times when staff gave showers as she had seen water come out into the hallway from the shower room. Interview on 01/03/24 at 10:05 A.M. with Maintenance Director #612 revealed the secured unit shower room had drained like that for years. He revealed when they built the shower room they did not pitch (angle) the floor correctly towards the drains as the floor does not slope causing the water to accumulate and not drain properly. He verified he had seen the water a few inches high and the water flow towards the hallway. He verified staff had brought it to his attention several times, but he stated, I do not have a solution for it. He revealed unless the facility breaks up the concrete and re-does the floors to slant them correctly, which he stated they were not going to do, there really was nothing that could be done. Interview on 01/03/24 at 11:45 A.M. with the Administrator verified she was notified approximately three weeks prior regarding the shower not draining properly in the secured unit shower room. She revealed she had a company come out and gave the facility a quote to correct the issue. She verified she had not placed any interventions regarding the safety/ fall risk for staff/ residents including Resident #42 who independently showers in the secured unit shower room. She also verified she had not implemented any interventions regarding the standing water potentially causing an infection control concern. Review of the facility policy labeled, Accommodation of Needs, dated March 2021, revealed the facility's environment and staff behaviors were directed toward assisting residents in maintaining and/ 366015 Page 2 of 3 366015 01/03/2024 Carecore at Mentor 8881 Schaefer St Mentor, OH 44060

F 0921 or achieving safe independent functioning, dignity, and well-being. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00149152. Residents Affected - Some 366015 Page 3 of 3