Inspection·September 4, 2024

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 medical record review, observation, staff interview, and review of the facility policy, the facility to ensure staff provided timely incontinence care. This affected one (Resident #29) of three residents reviewed for incontinence care. This had the potential to affect 26 facility-identified incontinent residents. The facility census was 48 residents. Findings include: Review of medical records for Resident #29 revealed an admission dated 06/15/23 with diagnoses including dementia, depression, osteoporosis, atrial fibrillation, type two diabetes, chronic diastolic heart failure, and anxiety disorder. Review of Minimum Data Set (MDS) assessment for Resident #29 dated 07/18/24 revealed the resident was cognitively impaired and was dependent upon staff assistance with bathing and hygiene. Review of the care plan for Resident #29 dated 07/19/24 revealed the resident had bowel and bladder incontinence. Interventions included the following: be aware of changes in urinary elimination, inspect for skin breakdown and intervene when needed, obtain vital signs, provide incontinence care every two hours and as needed, apply house moisture barrier cream as ordered. Review of the care plan for Resident #29 dated 07/26/23 revealed the resident had a potential for alteration in skin integrity related to bowel and bladder incontinence. Interventions included the following: educate family and resident on skin breakdown, encourage to float heels while in bed, encourage to turn and position every two hours and as needed, pressure reducing mattress to bed, provide assistance with hygiene, including peri care as needed, use barrier cream with showers and with incontinent episodes. Observations on 09/03/24 from 10:45 A.M. through 1:42 P.M. revealed Resident #29 was sitting in her Geri chair in the common area during this time frame, and no staff approached the resident to offer incontinence care. Interview on 09/03/24 at 1:40 P.M. with State Tested Nurse Aide (STNA) #206 confirmed Resident #29 was incontinent of bowel and bladder and was confused and should be checked for incontinence every two hours and changed as needed. STNA #206 confirmed she had not checked the resident for incontinence and offered care since 09/03/24 at 10:20 A.M. Observation of incontinence care on 09/03/24 at 1:48 P.M. for Resident #29 per STNA #206 revealed the resident's incontinence brief was saturated with urine and there was feces smeared in the brief. (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: 366043 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 366043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlisle Manor Health Care Inc 730 Hillcrest Drive Carlisle, OH 45005 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)