Health inspection·October 12, 2022

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to complete a baseline care plan for one (Resident #262) out of the two residents reviewed for baseline care plans. The facility census was 62. Findings include: Review of the medical record for Resident #262 revealed an admission date of 09/30/22. Diagnoses included nondisplaced fracture of right femur, urinary tract infection, encephalopathy, wedge compression fracture of unspecified lumbar vertebra, diabetes mellitus, chronic atrial fibrillation, and chronic kidney disease. Review of the Nurse Designee Functional assessment dated [DATE] revealed Resident #262 required substantial/maximal staff assistance for eating, oral hygiene, and toilet hygiene. Resident #262 did not walk or transfer at the time of the assessment. Further review of the medical record revealed a Brief Interview for Mental Status dated 10/03/22 which revealed the resident had moderate cognitive impairment. Further review of the medical record revealed no documentation to support a 48-hour baseline care plan was developed and reviewed with the resident or the resident's representative Interview on 10/04/22 at 11:15 A.M. with the Director of Nursing (DON) confirmed Resident #262 did not have documentation to support a 48-hour care plan was completed and reviewed with resident or resident's representative. Review of facility policy titled, Baseline Care Plan, stated the facility is to complete Baseline Care Plan to promote the continuity of care and communication among nursing home stakeholders, increase resident safety, and safeguard against adverse events that most likely to occur right after admission. Further review of the policy revealed the 48-hour baseline care plan would be the working tool for the for the first 48 hours and would be presented to resident and/or representative prior to completion of Comprehensive Care Plan. The policy stated the facility must provide a summary of the care plan to the resident and/or representative. Page 1 of 5 365679 365679 10/12/2022 Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to update care plans to ensure plans met the resident's current level of needs. This affected two (Residents #50 and #33) of three reviewed for care planning. The facility census was 62. Findings include: 1. Medical record review for Resident #50 revealed an admission date of 07/10/22. Diagnoses included paraplegia, pain in thoracic spine, muscle wasting and atrophy, muscle spasm, and limitation of activities due to disability. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition. Resident #50 required extensive assistance of two plus persons for bed mobility, transfers, toilet use, and personal hygiene. Review of Resident #50's care plan dated 07/20/22 revealed no goals or interventions in place for Activities of Daily Living (ADLs). Interview on 10/05/22 at 11:16 P.M. with Licensed Practical Nurse (LPN) #140 verified Resident #50's care plan did not address the resident's needs for ADLs. 2. Medical record review for Resident #33 revealed an admission date of 08/04/22. Diagnoses included acute and chronic respiratory failure with hypoxia, unspecified protein-calorie malnutrition, diabetes mellitus, anemia, disorder of the kidney and ureter, and stage IV pressure ulcers to left and right buttock. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact. Resident #33 required extensive assistance of two staff members for bed mobility, transfers, dressing, toileting, bathing, and the resident did not ambulate. Further review of the MDS revealed the resident admitted with two stage IV pressure ulcers. Further review of the medical record revealed no care plan in place to address Resident #33's pressure ulcers, including no goals or interventions. Interview on 10/05/22 at 10:20 A.M. with MDS Nurse #140 confirmed Resident #33 did not have a comprehensive person-centered care plan to address Resident #33's pressure ulcers, including a lack of measurable objectives and timeframe's to meet Resident #33's medical, nursing, and psychosocial needs. Review of facility policy titled, Comprehensive Care Plans, revised date 07/19/18 revealed the MDS will be used to assess the resident's clinical condition, cognitive and functional stats and use of services. The Care Area Assessments (CAA) are used in the development of the comprehensive care plan. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS/CAA). 365679 Page 2 of 5 365679 10/12/2022 Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, dialysis contract review, and staff interviews, the facility failed to conduct ongoing assessment of a resident related complications prior to and/or post dialysis. The facility also failed to communicate the resident's vital signs and medical status with the dialysis center. This affected the one (Resident #263) resident who received dialysis. The facility census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #263 revealed an admission date of 09/27/22. The medical record for Resident #263 revealed medical diagnoses of congestive heart failure (CHF), diabetes mellitus (DM), unspecified protein-calorie malnutrition, chronic kidney disease, and dependence on renal dialysis. Review of the admission Observation dated 09/28/22 revealed Resident #263 was alert and oriented to person, place, time, and situation. The assessment revealed Resident #263 required supervision or assistance with mobility, transfers, and ambulation. Review of Resident #263's current physician orders revealed the resident had an order for hemodialysis at an outpatient dialysis facility weekly on Tuesdays, Thursdays, and Saturdays. Further review of the the medical record revealed there was no documentation to confirm the facility provided ongoing monitoring of Resident #263 for dialysis related complications such as bleeding, access site infection or hypotension prior to or post dialysis. Further review of the medical record revealed no documentation to confirm collaboration of care and communication between the facility and the dialysis center. Interview on 10/04/22 at 10:00 A.M. with Licensed Practical Nurse (LPN) #165 confirmed Resident #263's medical record did not contain documentation to support the facility conducted ongoing monitoring for dialysis related complications prior to or post dialysis. LPN #263 stated the staff did not complete pre-dialysis or post dialysis assessments for Resident #236. LPN #263 further confirmed Resident #263's medical record did not contain documentation to support collaboration of care and communication between the facility and the dialysis center. Interview on 10/04/22 at 3:37 P.M. with Director of Nursing (DON) confirmed the staff did not complete pre-dialysis or post dialysis assessments to monitor for dialysis related complications for Resident #263. The DON verified the medical record for Resident #263 did not contain documentation to support collaboration and communication between the facility and dialysis center. Review of a contract titled, Long Term Care (LTC) outpatient Dialysis Services Coordination Agreement, revealed mutual obligations by both entities for collaboration of care. The agreement revealed both entities shall ensure that there is documented evidence of collaboration of care and communication between the facility and dialysis center. 365679 Page 3 of 5 365679 10/12/2022 Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete laboratory (lab) orders as directed. This affected one (Resident #22) of three residents reviewed for physician orders. The facility census was 62. Findings include: Medical record review for Resident #22 revealed an admission date of 11/10/20. Diagnoses included chronic obstructive pulmonary disease (COPD), muscle wasting and atrophy, type II diabetes, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. The resident required supervision for bed mobility, transfers, walk in room, walk in corridor, toilet use, and personal hygiene. The resident received antianxiety, antidepressant, and opioid medications. Review of physician orders dated 07/23/22, start date 07/25/22, revealed a one time order for the following labs: basic metabolic panel (BMP), complete blood count (CBC) with differential, Hemoglobin A1C, and thyroid stimulating hormone (TSH). Further review of the medical record revealed no documentation ordered labs were completed. Interview on 10/05/22 at 2:54 P.M. the Director of Nursing verified there were no lab results documented for the ordered lab draws. 365679 Page 4 of 5 365679 10/12/2022 Signature Healthcare of Fayette County 375 Glenn Avenue Washington Court Hou, OH 43160

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to properly practice proper infection control procedures when providing wound care. This affected one (Resident #46) out of four residents reviewed for infection control procedures during wound care. The facility census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #46 revealed she was admitted to the facility on [DATE] with diagnoses of congestive heart failure, muscle wasting and atrophy, atrial fibrillation, type II diabetes, urinary tract infection, and chronic respiratory failure. Review of the Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact. Resident #46 required assistance from staff for all activities of daily living and was totally dependent upon staff for maintaining personal hygiene. Resident #46 a stage IV pressure ulcer on her left heel. Review of the care plan dated 08/19/22 revealed Resident #46 was at risk for impaired skin related to advanced disease process, weakness, pain, malnutrition, muscle wasting and atrophy, shortness of breath, morbid obesity, resident refuses skin checks, resident refuses treatments, resident refuses showers, and resident refuses peri-care. Interventions included to see current physician's orders for current treatment as ordered by physician, weekly skin assessments, report changes in skin status to physician. Review of the physician's orders dated 10/05/22 revealed the following wound care orders: Wash left heel with wound wash, pat dry, paint open area with betadine, cover with non-adherent pad, and wrap with Kerlex. Change daily and as needed. Observation on 10/05/22 at 1:00 P.M. of wound care for Resident #46 provided by Licensed Practical Nurse (LPN) #126 and Registered Nurse (RN) #173 revealed LPN #126 washed her hands before donning gloves and removed Resident #46's old, dirty, dressing. LPN #126 continued to clean Resident #46's wound with wound wash. LPN #126 continued with the same gloves and started to clean the pressure cite with betadine. The surveyor had to intervene and ask LPN #126 if she changed her gloves. LPN #126 reported she was going to change her gloves after cleaning the pressure cite with betadine. LPN #126 changed her gloves and proceeded with wound care (after surveyor intervention). Interview with the Director of Nursing (DON) on 10/05/22 at 1:15 P.M. confirmed LPN #126 should have changed her gloves after removing the old, dirty dressing from Resident #46's foot and before she used the betadine on the pressure area. Review of the facility policy titled, Handwashing/Hand Hygiene, dated 08/2019 revealed hand hygiene should be used before handling clean or soiled dressings, gauze pads, etc. Before moving from a contaminated body site to a clean body site during resident care. After contact with blood or bodily fluids. 365679 Page 5 of 5