Park Health Center

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, policy review, review of video footage, and interview the facility failed to ensure a resident was treated with respect and dignity. This affected one resident (#22) of four residents reviewed for change

in condition. The facility census was 86.Findings include:Record review revealed Resident #22 was re-admitted to the facility on [DATE REDACTED] with diagnoses including unspecified intracapsular fracture of right femur, muscle wasting and atrophy, and need for assistance with personal care. Review of a minimum data set (MDS) dated [DATE REDACTED] revealed Resident #22 had impaired cognition, no behaviors, was dependent on staff for transfers, and had occasional pain of five.Review of an Authorization for Electronic Monitoring in Resident Room form dated 05/12/25 revealed Resident #22's power of attorney installed a fixed position video camera with recording in her room.Review of a video provided by Resident #22's family dated 07/04/25 at 10:51 A.M. revealed Registered Nurse (RN) #162 exiting Resident #22's bathroom, raise her hand to block her face from the camera, walk over to the camera and stand in front of it, obscuring the view of Resident #22 when she was brought out of the bathroom. The camera was motion activated and due to being blocked, had stopped recording.Review of an education training document dated 07/11/25 revealed RN #162 received education on Electronic Monitoring policy and stated I put my hand up because the light turns color when it starts recording and it was a reaction to that because I hate cameras.Interview on 08/19/25 at 10:15 A.M. with Director of Nursing (DON) #141 confirmed the video of RN #162 blocking Resident #22's camera. Review of a policy titled Electronic Monitoring in Resident Rooms dated 03/23/22 revealed the facility will not intentionally obstruct, tamper with, or destroy any electronic monitoring device or any recording made by an electronic monitoring device.This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2583102.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Health Center

100 Pine Avenue St Clairsville, OH 43950

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 0676

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, policy review, review of video footage, and interview, the facility failed to ensure a resident was provided the opportunity for urination in the bathroom versus being told to urinate in her incontinence brief. This affected one resident (#22) of four residents reviewed for change in condition. The facility census was 86.Findings include:Closed record review revealed Resident #22 re-admitted to the facility on [DATE REDACTED] with diagnoses including unspecified intracapsular fracture of right femur, muscle wasting and atrophy, and need for assistance with personal care. Review of a minimum data set (MDS) assessment dated [DATE REDACTED] revealed Resident #22 had impaired cognition, no behaviors, required moderate assistance for transfers, and was frequently incontinent of bladder and bowel.Review of a care plan dated 04/28/25 revealed Resident #22 had an alteration in elimination related to hip fracture and revision, back pain, dementia, stroke, diabetes, overall decline in mobility, falls, and bowel and bladder incontinence. The goal was for Resident #22 to be clean, dry and odor free. Interventions included but were not limited to toileting program, monitor and provide hydration as needed, monitor and record bowel movements every shift, provide incontinence care as needed, and monitor for signs and symptoms of a urinary tract infection.Review of video footage (provided by Resident #22's family and shared with the Administrator and Director of Nursing) dated 06/18/25 at 9:38 P.M. revealed Resident #22 was in her room and asked Certified Nursing Assistant (CNA) #189 if she could go to the bathroom. CNA #189 responded, we'll get you cleaned up. Resident #22 was then being transferred to her bed and stated, I need to go to the bathroom. CNA #189 stated, it's hard to go on the toilet when your leg's been busted up. CNA #189 did not assist Resident #22 to the bathroom.Interview on 08/20/25 at 3:40 P.M. with CNA #189 revealed he had received education on incontinence care recently. CNA #189 stated Resident #22 was forgetful and he did not redirect the resident appropriately, instead opting to instruct her to go (urinate) in her (incontinence) brief because he was about to change her anyway and would get her cleaned up. Interview on 08/20/25 at 4:00 P.M. with the Administrator revealed he personally educated CNA #189 about incontinence care after being made aware of the footage of him declining to take Resident #22 to the bathroom. This deficiency represents non-compliance investigated under Complaint Number 2583102.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Health Center

100 Pine Avenue St Clairsville, OH 43950

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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

OS #230 stated it was fairly hard to dislocate a hip because you had to really twist the leg around somehow to get it to come out. OS #230 stated Resident #22 does have dementia, so she could've had an unwitnessed event which was the cause of the dislocation (however, the exact circumstance of how the dislocation had occurred could not be determined). OS #230 stated people with dementia express their pain in different ways or sometimes can't at all, but it would be a painful injury for most people to have.

Interview on 08/18/25 at 1:20 P.M. with RN #127 revealed she worked with Resident #22 often during the resident's stay in the facility. Resident #22's baseline was confused and did not have a lot of behaviors. RN #127 stated she recalled 07/21/25 and when she came in that morning, nightshift staff were reporting the resident had yelled out in pain all night and pain medication had been administered but did not seem to be effective. RN #127 stated she asked about the right hip and the nurse (LPN #113) had stated she thought it looked aligned to her, but it had taken three staff to get her out of bed (which was not the resident's normal). RN #127 inquired about how therapy went and was told Resident #22 would scream and had to be sat down. RN #127 stated while Resident #22 was sitting in her wheelchair, she was fine and did not have signs of distress. The only time Resident #22 was transferred during RN #127's shift was to lay her down for

the x-ray. RN #127 stated she called the resident's RP and let her know Resident #22 was having pain and did not do well in therapy. RN #127 stated when the x-ray tech was present, she asked her to come to Resident #22's room to see the picture and they were able to tell the right hip was out. RN #127 stated she obtained orders to send Resident #22 to the emergency [TRUNCATED]

Event ID:

Facility ID:

If continuation sheet