Health inspection·October 3, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review, and policy review, the facility failed to ensure Resident #25's bedside commode was emptied in a timely manner. This affected one (Resident #25) of three residents reviewed for physical environment. The facility census was 65. Findings include: Review of the medical record for Resident #25 revealed she was admitted to the facility on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease, and chronic kidney disease. Review of the admission Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #25 was alert and oriented to person, place and time and required supervision or touching assistance for toileting. Review of the care plan dated 08/20/24 revealed Resident #25 was at risk for bladder incontinence and had a self-care performance deficit with interventions including provide incontinence care with care rounds every shift and toilet assistance of one staff member. Observation and interview on 09/30/24 at 7:55 A.M. with Resident #25 revealed a bedside commode adjacent to the left side of the bed, positioned against the wall. Observation revealed a yellow liquid substance in the bottom of the bedside commode. Resident #25 revealed she urinated inside the bedside commode and needed it to be emptied. During an interview on 09/30/24 at 8:07 A.M. with Licensed Practical Nurse (LPN) #819 revealed she was made aware of Resident #25 bedside commode needing emptied. Follow-up observation and interview on 10/01/24 at 8:45 A.M. with Resident #25 revealed her bedside commode had not been emptied for two days. Resident #25 revealed staff always forgot to change her bedside commode of urine and feces. Resident #25 revealed she informed the staff that her bedside commode needed emptied. Observation revealed a yellow liquid substance in the bottom of the bedside commode and an odor of urine. Observation and interview on 10/01/24 at 8:47 A.M. with the Assistant Director of Nursing (ADON) #910 revealed a yellow liquid substance in the bedside commode. The ADON was informed by Resident #25 that her bedside commode needed emptied for the last two days and that she had told staff. ADON #910 confirmed and verified Resident #25 bedside commode was filled with urine and needed emptied. Page 1 of 2 366471 366471 10/03/2024 Avenue at Broadview Heights 1201 Akins Road Broadview Heights, OH 44147

F 0584 Level of Harm - Minimal harm or potential for actual harm Review of the facility document titled Activities of Daily Living (ADLs) dated March 2023, revealed the facility had a policy in place to provide assistance with residents regarding toileting and elimination. This deficiency represents noncompliance as an incidental finding during investigation of Complaint Number OH00157803. Residents Affected - Few 366471 Page 2 of 2