Health inspection·March 5, 2020

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** 2. Medical record review revealed Resident #43 was admitted to the facility 09/07/16 with diagnoses including dementia without behavioral disturbance. Review of the MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Observations on 03/02/20 at 10:16 A.M., on 03/03/20 at 8:37 A.M., and on 03/04/20 at 8:38 A.M. revealed Resident #43 in her wheelchair in the dining room. Her wheelchair had two strips of pink tape and one strip of blue tape with her first initial of her first name, and full last name taped to the back of her chair. Interview on 03/04/20 at 11:35 A.M. with State Tested Nursing Assistant (STNA) #211 confirmed Resident #43 had two strips of pink duct tape and one strip of blue painter's tape with her first initial of her first name, and full last name on her wheelchair. The STNA confirmed it was not dignified to have tape on the back of Resident #43's wheelchair with her name on it. Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to promote dignity by not providing privacy during one Resident (#42) of one observed during wound care and incontinence care. The facility also failed to provide privacy for one Resident (#43) of one observed with their name taped to a wheelchair. The facility census was 45. Findings include: 1. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including dementia without behavior disturbances, and Parkinson's disease. Review of Resident #42's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was significantly cognitively impaired. The resident required extensive assistance of two people Activities of Daily Living (ADLs). Observation of incontinence care and pressure ulcer wound care for Resident #42 with Licensed Practical Nurse (LPN) # 223 and assisted by LPN #312 on 03/04/20 at 11:24 A.M., revealed LPN #223 removed the resident's clothing. Resident #42's window had blinds, which were opened. There was a person observed walking around outside near the window. The wound was cleansed and care provided as ordered. LPN #223 then put a new brief and clothes on the resident. Interview with LPN #223 on 03/04/20 at 11:37 A.M. confirmed the window blind was up and the Page 1 of 3 365047 365047 03/05/2020 First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident was exposed the whole time during incontinence and wound care. LPN #223 revealed the blind is normally always down, however she forgot to shut it. She confirmed there was a person walking around outside near the window of Resident #42's room. Review of the facility policy titled Privacy and Confidentiality, dated August 2013, revealed full visual privacy will be maintained during resident care and treatment to include pulling privacy curtains, closing doors and window coverings. 365047 Page 2 of 3 365047 03/05/2020 First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, review of facility policy and procedures, the facility failed to implement their Water Management Plan to reduce the risk, growth and spread of the Legionella Disease. This had the potential to affect all 45 residents of the facility. Residents Affected - Many Findings include: Interview on 03/03/20, at 11:12 A.M. with the Maintenance Supervisor (MS) #368 revealed he took resident rooms water temperatures daily, however, did not keep a record of the temperatures. Interview on 03/03/20, at 2:36 P.M. with MS #368 and Executive Director (ED) #376 revealed they did not flush systems that had standing water. The ED revealed they had a contracted company who tested their water systems two times a year for the Legionella infection. Interview on 03/04/20, at 11:30 A.M. with the Executive Director #376 confirmed they do not have documentation of performing the required maintenance measures listed in their Water Management Plan. Review of the Legionella Policy-Environmental Policy and Procedure (February 2018) revealed the mission of the facility is to maintain environmental and clinical policies and procedures to ensure that when a Legionella infection is identified, actions are taken to identify the source of the organism, if possible and to reduce the risk of Legionella infection by managing water systems in accordance with the policy. Review of the Water Management Plan (02/18) revealed the facility should be monitoring and recording distal temperatures, chlorine levels, flush low use points, flush eye wash stations, check storage tank temperatures to maintain a temperature of 140 F and drain expansion tanks monthly. 365047 Page 3 of 3