Inspection·June 13, 2019

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and record review, the facility failed to ensure a resident who was dependent on staff for fingernail care received adequate fingernail care as care planned. This affected one (#9) of one resident reviewed for activities of daily living. This had the potential to affect three residents identified by the facility who were dependent on staff assistance with personal hygiene. The facility census was 40. Residents Affected - Few Findings include: Review of Resident #9's medical record revealed an admission date of 10/15/16 with diagnoses including dementia without behavioral disturbances, Parkinson's disease and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 04/08/19, revealed Resident #9 had severely impaired cognition, did not reject any care during the look back period, and required an extensive two plus person physical assistance with personal hygiene. Review of an activities of daily living (ADL) self-care performance deficit revealed Resident #9 was to have her nail length checked, trimmed, and cleaned on bath day as necessary, and report any changes to the nurse. Review of a shower schedule for facility residents, dated 01/28/19, revealed Resident #9 was scheduled for showers on Mondays and Thursdays on second shift. Review of a shower sheet dated 06/10/19 (Monday) revealed Resident #9 was provided a shower with no concerns noted and no indication of fingernail care provided. Review of additional shower sheets from 05/30/19, 06/03/19, and 06/06/19 revealed Resident #9 received showers with no refusals of care. Review of nursing progress notes and nurse aide ADL documentation between 05/30/19 and 06/12/19 revealed no documentation of Resident #9 refusing care. Observation on 06/10/19 at 12:05 P.M. revealed a dried black substance underneath three fingernails (index, middle, and ring) on her left hand. Observations on 06/11/19 at 1:08 P.M. and 3:23 P.M., and on 06/12/19 at 10:07 A.M. revealed Resident #9's fingernails on her left hand continued to have a dried black substance underneath them. Interview on 06/12/19 3:29 P.M. with State Tested Nurse Aide (STNA) #250 stated Resident #9 was an extensive to total care assist with personal hygiene, and stated Resident #9 would not be able to clean her fingernails on her own. STNA #250 stated the facility staff does provide Resident #9 with fingernail care when it is needed, and if the fingernails were dirty they would be cleaned right away. Observation on 06/12/19 at 3:47 P.M. with STNA #250 and STNA #275, revealed Resident #9 sitting in the common area of the secure unit with her hands under a blanket. When Resident #9 was asked, she lifted her left hand from under the blanket and revealed the dried black substance under her fingernails of her left hand. STNA #250 and STNA #275 verified the dried black substance under Resident #9's fingernails and stated they would clean them right away. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365860 If continuation sheet Page 2 of 5 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 365860 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Independence House 1000 Independence Rd Fostoria, OH 44830 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on medical record review and staff interview, the facility failed to provide documentation of a rationale and an extended timeframe for extending the use of an as needed psychotropic medication beyond 14 days. This affected one (#1) of five residents reviewed for unnecessary medications with potential to affect nine residents identified by the facility with orders for as needed psychotropic medications. The facility census was 40. Findings include: Review of Resident #1's medical record revealed an admission date of 08/27/18 with diagnoses including Parkinson's disease, dementia without behavioral disturbances, cerebral infarction, major depression, anxiety and obsessive-compulsive disorder. Review of a physician order, dated 08/27/18, revealed Resident #1 was ordered the anti-anxiety medication Lorazepam 0.5 milligrams (mg.) by mouth every 12 hours as needed for anxiety. The physician order had no stop date and remained an active order as of 06/13/19. Review of a physician recommendation form, dated 09/17/18, revealed the facility pharmacy recommended the physician evaluate and update Resident #1's chart with documentation to extend the initial order for as needed Lorazepam beyond 14 days. The physician response to the recommendation was marked as other with a written notation of noted and signed by the physician on 09/21/18. There was no further instructions or orders provided on the physician recommendation form, as well as no additional physician recommendation forms related to Resident #1's order for as needed Lorazepam. Review of Resident #1's entire medical record including nursing and physician progress notes, consultation reports, physician orders, and assessments from 2018 and 2019 revealed no documented evidence of a rationale for extending Resident #1's as needed Lorazepam beyond the initial 14 days when it was ordered on 08/27/18, as well as no timeframe documented for how long the order would be extended. Interview on 06/13/19 at 10:42 A.M. with Director of Nursing (DON) #1 verified Resident #1 had an active order for an as needed anti-anxiety medication since 08/27/19, and verified the medical record contained no documented rationale for extending the physician order or a specified timeframe for the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365860 If continuation sheet Page 3 of 5 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 365860 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Independence House 1000 Independence Rd Fostoria, OH 44830 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to obtained laboratory values as ordered by the physician. This affected one (#4) of five residents reviewed for unnecessary medications with potential to affect 31 residents identified by the facility with orders to obtain laboratory values. The facility census was 40. Residents Affected - Few Findings include: Review of Resident #4's medical record revealed an admission date of 07/06/13 with diagnoses including unspecified dementia without behavioral disturbances, unspecified psychosis, anxiety, major depression, essential hypertension, and peripheral vascular disease. Review of a physician order, dated 02/16/19, revealed Resident #4 was ordered to have a complete blood count (CBC) laboratory test, which was a laboratory test to determine the overall health of a person's blood, obtained every six months with the months of March and September as the intended months to obtain Resident #4's blood. Review of the most recently obtained CBC laboratory values for Resident #4 revealed the laboratory values were obtained on 10/31/18. There were no further CBC laboratory values in the medical record for Resident #4 since 10/31/18. Interview on 06/13/19 at 10:36 A.M., with Director of Nursing (DON) #1 verified the laboratory values from 10/31/18 were the most recently collected CBC laboratory values for Resident #4. DON #1 stated Resident #4 should have had a CBC laboratory value obtained in April 2019, and verified it was done done as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365860 If continuation sheet Page 4 of 5 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 365860 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Independence House 1000 Independence Rd Fostoria, OH 44830 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of a Legionella environmental assessment form, staff interviews and policy review, the facility failed to complete a Legionella risk assessment and failed to implement a water management program with defined control measures and testing protocols based on standards from the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) and the Centers for Disease Control and Prevention (CDC) tool kit, Developing a Water management Program to Reduce Legionella Growth and Spread in Buildings, dated 06/05/17. This had the potential to affect all 40 residents residing in the facility. Residents Affected - Many Findings include Review of a Centers for Disease Control and Prevention (CDC) questionnaire for Legionella Environmental Assessment Form, dated 06/2015, utilized by the facility revealed no diagram of the water system outlining all areas of risk for Legionella. Further review of the form revealed the facility also had not specified control measures and testing protocols for Legionella based on standards from the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) and the CDC tool kit Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings dated 06/05/17. Interview on 06/14/19 at 2:15 P.M. with the Administrator revealed the facility had not conducted a Legionella risk assessment using the CDC tool kit. The Administrator revealed the facility had used a CDC Legionella Environmental Assessment Form from 2015. Interview on 06/13/19 at 3:45 P.M. with the Director of Maintenance (DOM) #120 revealed the facility had not diagrammed the water supply and identified all areas at risk using the CDC tool kit. DOM #112 revealed the facility checked the water temperatures around the building each month. DOM #112 further revealed the facility pool was tested when used. DOM #112 also revealed the water was flushed in rooms or areas not used. Review of the facility policy Maintenance and Monitoring of Water Systems, last reviewed 08/02/16, revealed the facility would perform a clinical and environmental risk assessment to determine if culturing should be performed. Further review of the policy revealed no guidelines for implementing a water management program. Further interview on 06/14/19 at 2:15 P.M. with the Administrator verified the facility policy was last reviewed in 2016. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365860 If continuation sheet Page 5 of 5