Health inspection·March 26, 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 record review, staff interview, observation, resident interview, and review of facility policy, the facility failed to ensure dependent residents received assistance with incontinence care and eating. This affected three (Residents #23, #47, #53) of 37 facility-identified incontinent residents and affected one (Resident #53) of five facility-identified residents who required physical assistance with meal consumption. The facility census was 52. Residents Affected - Few Findings include: Review of the lists provided by the facility revealed there were 37 residents (#1 #3, #4, #5, #8, #9, #10, #11, #15, #16, #17, #18, #19, #21, #22, #23, #27, #28, #30, #32, #34, #35, #36, #37, #38, #39, #41, #42, #44, #45, #46, #47, #49, #51, and #52) identified as being incontinent of bowel and/or bladder and five residents (#4, #47, #53, #44, and #49) who required physical assistance from staff for eating. 1. Review of the medical record for Resident #53 revealed an admission date of 01/30/24 with diagnoses including depression, hypertension, anxiety, and age-related cognitive decline. Review of the Minimum Data Set (MDS) assessment for Resident #53 dated 01/30/24 revealed the resident was severely cognitively impaired and was always incontinent of bowel and bladder. Review of the care plan for Resident #53 dated 02/16/24 revealed the resident had an activities of daily living (ADL) care deficit related to memory impairment and decreased mobility. Interventions included the staff should provide assistance with toileting and personal hygiene. Observation on 03/25/24 at 8:45 A.M. revealed Resident #53 was lying in bed and was wearing a urine-saturated brief. Interview on 03/25/24 at 8:45 A.M. with STNA #100 confirmed Resident #53 wearing a urine-saturated brief on and had not been provided incontinence care since prior to the beginning of the shift which began at 6:00 A.M. 2. Observation on 03/25/24 at 8:55 A.M. revealed Resident #47 was walking down the hallway with a soiled brief which caused the resident's pants to sag and to be wet with urine. Interview on 03/25/24 at 8:55 A.M. with STNA #100 confirmed Resident #47 was wearing a urine-saturated brief and had not been provided incontinence care since prior to the beginning of the shift which began at 6:00 A.M. Page 1 of 6 366202 366202 03/26/2024 Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638

F 0677 Level of Harm - Minimal harm or potential for actual harm 3. Review of the medical record for Resident #23 revealed an admission date of 12/12/23 with diagnoses including Parkinson's disease, muscle weakness, and abnormal posture. Review of the MDS assessment for Resident #23 dated 12/19/23 revealed the resident had mildly impaired cognition and was occasionally incontinent of bowel and bladder. Residents Affected - Few Review of the care plan for Resident #23 dated 12/13/23 revealed the resident was incontinent of bladder. Interventions included staff should check for incontinence as needed and provide peri-care after each incontinence episode. Interview on 03/25/24 at 9:10 A.M with Resident #23 confirmed staff did not consistently provide incontinence care every two hours, and sometimes it was several hours between incontinence changes. Observation on 03/25/24 at 9:20 A.M. revealed STNA #400 entered Resident #23's room to provide incontinence care. STNA #400 pulled Resident #23's gown up which revealed the resident was wearing two incontinence briefs. STNA #400 removed the briefs and there was a large amount of light brown urine on the brief closest to the resident's skin which emitted a strong urine odor. STNA #400 proceeded to cleanse and dry the resident's perineum and buttocks and then placed one clean incontinence brief on the resident. Interview on 03/25/24 at 9:25 A.M. with STNA #400 confirmed Resident #23 had been wearing two incontinence briefs. STNA #400 confirmed residents were only supposed to wear only one incontinence brief at a time. STNA #400 further confirmed her shift had begun at 6:00 A.M. and she had not provided incontinence care to Resident #23 prior to the observation on 03/25/24 at 9:20 A.M. STNA #400 confirmed incontinence care should be provided every two hours. Interview on 03/25/24 at 9:27 A.M with Resident #23 confirmed she had not received incontinence care on 03/25/24 on dayshift until 9:20 A.M. and the shift began at 6:00 A.M. Resident #23 further confirmed night shift staff sometimes applied two incontinence briefs at once but was unsure as to why they did this. 4. Observation on 03/25/24 at 12:27 P.M. revealed the cart containing the residents' lunch meals arrived on the secured unit. At 12:30 P.M. STNA #100 began preparing the meal trays and serve them to residents. Review of the MDS assessment for Resident #53 dated 01/30/24 revealed the resident was severely cognitively impaired and required substantial to moderate assistance of staff with eating. Review of the care plan for Resident #53 dated 02/16/24 revealed the resident had an ADL deficit related to memory impairment and decreased mobility. Interventions included the staff should provide assistance with eating and bed mobility. Observation on 03/25/24 at 12:45 P.M. revealed State Tested Nursing Assistant (STNA) #100 set up Resident #53's lunch tray on the resident's overbed table and awakened the resident and raised the head of the bed. STNA #100 then exited the room and left the resident unattended with the lunch meals. Observation on 03/25/24 at 1:01 P.M. revealed STNA #100 removed the last lunch meal tray from the cart and took it to a resident. 366202 Page 2 of 6 366202 03/26/2024 Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 03/25/24 at 1:07 P.M. revealed Resident #53 was slumped over to the left side with her head resting against the wall. The resident held a roll in her hand which she was attempting to eat. The remainder of the resident's lunch meal was on the overbed table but was out of the resident's reach. The resident was unable to reposition herself in the bed. Interview on 03/25/24 at 1:11 P.M. with STNA #100 confirmed Resident #53 was slumped over in bed unable to reach her lunch meal tray as she was unable to reposition herself. STNA #100 further confirmed Resident #53 required assistance with eating and she had not provided assistance to the resident. Review of the facility policy titled Incontinence Management Standard of Care undated revealed the facility would promote intact skin, maintain dryness, and respect the resident's standard and individualized interventions and right to dignity by implementing appropriate interventions. Interventions included routine rounding every two hours with turning and repositioning, provision of personal hygiene and skin care after each incontinence episode, and evaluation for and implementation and the proper use of incontinence products. Review of the facility policy titled Assisting the Resident with In-Room Meals dated December 2013 revealed for meal consumption residents should be positioned so their head and upper body are as upright as possible with the head tipped slightly forward. If the resident was served their meal in bed staff should use wedges and pillows to achieve a nearly upright position. Staff should assist the resident with eating as necessary. This deficiency represents noncompliance investigated under Complaint Number OH00152025. 366202 Page 3 of 6 366202 03/26/2024 Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on record review, staff interview, observation, resident interview, and review of facility policy, the facility failed to ensure there were sufficient staff present to provide care and services to residents. This affected three (Residents #23, #47, #53) of 37 facility-identified incontinent residents and affected one (Resident #53) of five facility-identified residents who required physical assistance with meal consumption. The facility census was 52. Findings include: Review of the lists provided by the facility revealed there were 37 residents (#1 #3, #4, #5, #8, #9, #10, #11, #15, #16, #17, #18, #19, #21, #22, #23, #27, #28, #30, #32, #34, #35, #36, #37, #38, #39, #41, #42, #44, #45, #46, #47, #49, #51, and #52) identified as being incontinent of bowel and/or bladder and five residents (#4, #47, #53, #44, and #49) who required physical assistance from staff for eating. Observation on 03/25/24 at 8:25 A.M. revealed there were two licensed nurses and three State Tested Nursing Assistants (STNAs) present in the facility to provide care for 52 residents. Interview on 03/25/24 at 8:27 A.M with Registered Nurse (RN) #600 confirmed there were only three STNAs working due to one STNA calling off work for the day. RN #600 confirmed the nurses were busy administering medications to residents and did not have time to help the STNAs provide personal care. RN #600 confirmed it was hard to provide needed care and services to residents present in the facility when there were only three STNAs. Interview on 03/25/23 at 8:35 A.M. with STNA #100 confirmed they were the only employee currently present on the secured unit of the facility. The two nurses and two other STNAs were providing care to the residents outside of the secured unit. STNA #100 confirmed some of the residents on the secured unit required assistance from two staff members with activities of daily living (ADLs) due to behaviors and their physical needs. STNA #100 confirmed some residents on the secured unit were currently soiled with urine as there had not been time to complete incontinence care for any residents on the unit since the shift had begun at 6:00 A.M. on 03/25/24. 1. Review of the medical record for Resident #53 revealed an admission date of 01/30/24 with diagnoses including depression, hypertension, anxiety, and age-related cognitive decline. Review of the Minimum Data Set (MDS) assessment for Resident #53 dated 01/30/24 revealed the resident was severely cognitively impaired and was always incontinent of bowel and bladder. Review of the care plan for Resident #53 dated 02/16/24 revealed the resident had an activities of daily living (ADL) care deficit related to memory impairment and decreased mobility. Interventions included the staff should provide assistance with toileting and personal hygiene. Observation on 03/25/24 at 8:45 A.M. revealed Resident #53 was lying in bed and was wearing a urine-saturated brief. Interview on 03/25/24 at 8:45 A.M. with STNA #100 confirmed Resident #53 wearing a urine-saturated brief on and had not been provided incontinence care since prior to the beginning of the shift which 366202 Page 4 of 6 366202 03/26/2024 Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638

F 0725 began at 6:00 A.M. because there were not enough staff. Level of Harm - Minimal harm or potential for actual harm 2. Observation on 03/25/24 at 8:55 A.M. revealed Resident #47 was walking down the hallway with a soiled brief which caused the resident's pants to sag and to be wet with urine. Residents Affected - Few Interview on 03/25/24 at 8:55 A.M. with STNA #100 confirmed Resident #47 had not been provided incontinence care since prior to the beginning of the shift which began at 6:00 A.M. because there were not enough staff. Interview on 03/25/24 at 9:05 A.M. with STNA #300 confirmed they were working on the middle unit of the facility (outside of the secured unit) and they were not able to help the STNA on the secured unit because there were not enough staff. 3. Review of the medical record for Resident #23 revealed an admission date of 12/12/23 with diagnoses including Parkinson's disease, muscle weakness, and abnormal posture. Review of the MDS assessment for Resident #23 dated 12/19/23 revealed the resident had mildly impaired cognition and was occasionally incontinent of bowel and bladder. Review of the care plan for Resident #23 dated 12/13/23 revealed the resident was incontinent of bladder. Interventions included staff should check for incontinence as needed and provide peri-care after each incontinence episode. Interview on 03/25/24 at 9:10 A.M with Resident #23 confirmed staff did not consistently provide incontinence care every two hours, and sometimes it was several hours between incontinence changes. Observation on 03/25/24 at 9:20 A.M. revealed STNA #400 entered Resident #23's room to provide incontinence care. STNA #400 pulled Resident #23's gown up which revealed the resident was wearing two incontinence briefs. STNA #400 removed the briefs and there was a large amount of light brown urine on the brief closest to the resident's skin which emitted a strong urine odor. STNA #400 proceeded to cleanse and dry the resident's perineum and buttocks and then placed one clean incontinence brief on the resident. Interview on 03/25/24 at 9:25 A.M. with STNA #400 confirmed Resident #23 had been wearing two incontinence briefs. STNA #400 confirmed residents were only supposed to wear only one incontinence brief at a time. STNA #400 further confirmed her shift had begun at 6:00 A.M. and she had not provided incontinence care to Resident #23 prior to the observation on 03/25/24 at 9:20 A.M. STNA #400 confirmed incontinence care should be provided every two hours. Interview on 03/25/24 at 9:27 A.M with Resident #23 confirmed she had not received incontinence care on 03/25/24 on dayshift until 9:20 A.M. and the shift began at 6:00 A.M. Resident #23 further confirmed night shift staff sometimes applied two incontinence briefs at once but was unsure as to why they did this. Interview with STNA #300 on 03/25/24 at 11:01 A.M. confirmed there were a lot of residents who were incontinent and had behaviors and it was hard to provide care timely when there were only three STNAs present. STNA #300 stated two night shift STNAs had stayed over until approximately 8:30 A.M. and helped pass out breakfast trays but did provide any residents with incontinence care between 6:00 A.M. and 8:30 A.M. before they left. 366202 Page 5 of 6 366202 03/26/2024 Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638

F 0725 Level of Harm - Minimal harm or potential for actual harm Interview with STNA #200 on 03/25/24 at 12:10 P.M. confirmed incontinence care was to be provided every two hours but there were times when there were not enough staff present to do so. 4. Observation on 03/25/24 at 12:27 P.M. revealed the cart containing the residents' lunch meals arrived on the secured unit. At 12:30 P.M. STNA #100 began preparing the meal trays and serve them to residents. Residents Affected - Few Review of the MDS assessment for Resident #53 dated 01/30/24 revealed the resident required substantial to moderate assistance of staff with eating. Review of the care plan for Resident #53 dated 02/16/24 revealed the resident had an ADL deficit related to memory impairment and decreased mobility. Interventions included the staff should provide assistance with eating and bed mobility. Observation on 03/25/24 at 12:45 P.M. revealed State Tested Nursing Assistant (STNA) #100 set up Resident #53's lunch tray on the resident's overbed table and awakened the resident and raised the head of the bed. STNA #100 then exited the room and left the resident unattended with the lunch meals. Observation on 03/25/24 at 1:01 P.M. revealed STNA #100 removed the last lunch meal tray from the cart and took it to a resident. Observation on 03/25/24 at 1:07 P.M. revealed Resident #53 was slumped over to the left side with her head resting against the wall. The resident held a roll in her hand which she was attempting to eat. The remainder of the resident's lunch meal was on the overbed table but was out of the resident's reach. The resident was unable to reposition herself in the bed. Interview on 03/25/24 at 1:11 P.M. with STNA #100 confirmed Resident #53 was slumped over in bed unable to reach her lunch meal tray as she was unable to reposition herself. STNA #100 further confirmed Resident #53 required assistance with eating and she had not provided assistance to the resident. STNA #100 confirmed there was not enough staff available to timely deliver residents' meals and remain with residents who needed assistance with meal consumption. Interview with Licensed Practical Nurse (LPN) #500 on 03/25/24 at 2:10 P.M. confirmed nurses typically did not have time to assist the STNAs in providing resident care due to being busy administering medications and performing other tasks. Interview with Resident #30 on 03/26/24 at 8:25 A.M. confirmed there was often an extended wait time for staff to provide care and assistance and incontinence care was not routinely provided every two hours. Interview with Resident #28 on 03/26/24 at 8:34 A.M. confirmed the facility needed more staff as it sometimes took a long period of time to receive needed care. Review of the facility policy titled Staffing dated 09/202 revealed the facility should provide sufficient and competent staff to meet the care and service needs of all residents. This deficiency represents noncompliance investigated under Complaint Number OH00151811. 366202 Page 6 of 6