Inspection·July 18, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Review of the Braden Scale dated 07/14/23 for Resident #7 revealed that sensory perception was very limited due to responds only to painful stimuli, that cannot communicate discomfort except by moaning or was restless or has sensory impairment which limited the ability to feel pain or discomfort over half of body. Degree to which skin exposed to moisture was occasionally moist that required an extra linen change approximately once a day. Resident #7 was at moderate risk of skin breakdown. Residents Affected - Few Review of the stated tested nursing aide (STNA) [NAME] for Resident #7 dated 07/18/23 revealed the STNAs were given the information that Resident #7 used disposable briefs. Resident #7 was incontinent of bowel and bladder. Resident #7 required extensive assistance with two staff members for toileting. Continuous observations on 07/18/23 from 10:33 A.M. through 12:03 P.M. revealed Resident #7 was in her Broda chair in the activity room asleep watching television. Resident #7 had a blanket over the top of her lower abdomen and lower extremities, while sitting in her Broda chair. No staff member had come into the activity room to check Resident #7 her for incontinence care during this time. Observations on 07/18/23 at 12:03 P.M. revealed STNA #201 took Resident #7 from the activity room to the dining room for lunch. STNA #201 did not check for incontinence at this time. From 12:04 P.M. to 1:46 P.M., Licensed Practical Nurse (LPN) #650 assisted Resident #7 with her meal in the dining room. At 1:47 P.M., STNA #70 took Resident #7 from the dining room back to her room in the Broda chair. Observation and interview on 07/18/23 from 1:51 P.M. to 1:59 P.M. with STNAs #270 and STNA #282 revealed they transferred Resident #7 with a Hoyer lift from the Broda chair to her bed. STNA #282 verified the black cushion in Resident #7's Broda chair was saturated with urine. Observation on 07/18/23 at 1:52 P.M. through 1:56 P.M. revealed Resident #7 was in her full clothes on her bed. STNAs #270 and #282 verified Resident #7 had a strong malodorous odor before removing clothes and incontinent brief. STNA #270 verified Resident #7's pants were saturated with urine. STNA #282 laid out a clean pair of pants next to Resident #7's bed. At 1:59 P.M., Resident #7's incontinent brief was observed with heavy saturated dark urine. Resident #7 had bowel movement when wiped down with disposable wipes. When Resident #7 was turned to her right side, she had a round red skin issues that estimated 1.5-2.5 inches circular on bilateral buttocks. There was a small red opened area of blood on the right buttocks. STNA #282 verified Resident #7's brief was heavily saturated of urine. Interview on 07/18/23 at 2:03 P.M. with STNA #270 stated the last time he changed Resident #7 was after breakfast between 8:30 A.M. and 9:00 A.M. Interview on 07/18/23 at 2:49 P.M. with STNA #201 stated for residents who were incontinent and confused, she would provide incontinence care every two to three hours. Interview on 07/18/23 at 2:51 P.M. with the Director of Nursing (DON) stated incontinence care was to be completed every two to three-hours. The DON verified Resident #7 should have been taken before lunch for incontinence care. At 2:56 P.M., the DON stated the staff typically check and change a resident after breakfast, then lay the resident down and then check and change the resident before lunch to make sure the resident was dry. Interview on 07/18/23 at 2:58 P.M. with STNA #217 stated she had taken care of Resident #7 before and would check and change her after breakfast, laying her down, and before lunch. STNA #217 stated lunch was served after 12:15 P.M. in the dining room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366301 If continuation sheet Page 2 of 3 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 366301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritagespring Healthcare Center of West Chester 7235 Heritagespring Drive West Chester, OH 45069 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Subsequent interview on 07/18/23 at 4:33 P.M. with the DON stated Resident #7's video footage revealed that STNA #270 had entered Resident #7's room on 07/18/23 at 9:13 A.M. and left Resident #7's room at 9:24 A.M. The DON stated Resident #7 was checked and changed at that time. The DON stated the video footage was reviewed at the facility. Interview with the Administrator on 07/18/23 at 4:12 P.M. revealed the facility changed their policy to check and change residents every two to four hours for incontinence. The Administrator stated the policy was changed due to staffing shortages. The Administrator stated the blanket lying on Resident #7's lap covered up urine smell and LPN #650 who fed Resident #7 her lunch did not identify any odor. Review of the facility policy titled Urinary Incontinence Management, dated 03/2016, revealed routine or scheduled toileting should be offered to incontinent residents on a consistent basis. Caregiver will take the resident to void every two to four hours, including at night. The goal was to keep the resident dry. This deficiency represents non-compliance investigated under Complaint Number OH00144029. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366301 If continuation sheet Page 3 of 3