F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the medical record, staff interview, and policy review, the facility failed to ensure a resident's care
plan was revised for advanced directive orders. This affected one (#12) of 13 residents reviewed for care
planning. The facility census was 37.
Findings include:
Review of the medical record for Resident #12 revealed an admission date of 10/10/23. Diagnoses included
end stage renal disease, polyneuropathy, and hypertension.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had
intact cognition.
Review of the plan of care, initiated 10/12/23 and revised on 10/26/23, revealed Resident #12 had elected a
full code (cardiopulmonary resuscitation) status.
Review of the physician orders revealed dated 08/15/24 revealed the resident's code status orders were
changed from Full Code to Do Not Resuscitate Comfort Care (DNRCC).
Review of a DNR order form dated 08/15/24 revealed Resident #12 had elected DNRCC.
Review of a nurse's note dated 08/14/24 at 9:04 A.M., revealed Resident #12 had changed her code status
from full code to DNRCC.
Interview on 09/04/24 at 12:49 P.M. with Licensed Practical Nurse (LPN) #212 verified Resident #12's care
plan had not reflected the code status changed from full code to DNRCC.
Review of the facility policy titled Care Plan -- Comprehensive dated 05/15/15 revealed the care plan would
be updated when there was a significant change in resident condition, when a desired outcome was not
met, when the resident had been readmitted to the facility from a hospital stay and at least quarterly.
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
Page 1 of 3
Event ID:
365860
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
09/05/2024
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, resident and staff interviews, observations, and policy review, the facility failed to
timely obtain physician orders for a wound dressing change and complete wound dressing changes as
physician ordered. This affected one (#23) of one resident reviewed for skin conditions. The facility census
was 37.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #23 revealed an admission date of 06/26/23. Diagnoses included
hypertension, chronic obstructive pulmonary disease, and depression. Review of the quarterly Minimum
Data Set (MDS) assessment dated [DATE] revealed Resident #23 had impaired cognition.
Review of a nursing progress note dated 08/22/24 at 12:05 P.M., revealed dietary staff reported Resident
#23 got bit by something in the dining room during lunch. The resident's left forearm was noted to have a
raised reddened area. The physician was notified and gave a verbal order for Benadryl 25 milligrams every
six hours as needed.
Review of a nurse's note dated 09/02/24 at 5:11 P.M. revealed the physician was notified of a new skin
issue on left forearm. Awaiting response. Review of a wound assessment dated [DATE] revealed the
resident had drainage from a wound on her left forearm. Review of a wound assessment dated [DATE]
revealed the resident had a skin tear on her left forearm.
Observation and interview on 09/03/24 at 8:39 A.M. revealed Resident #23 had a gauze dressing applied to
her left forearm. Resident #23 slid the dressing down and there was a nonadherent dressing underneath
covering a wound with two steri-strips in place. The dressing was not dated. Resident #23 stated she
thought she got bit by a bug and the facility had been placing a dressing on her left forearm for three to four
days.
Review of the physician orders on 09/03/24 at 1:00 P.M. revealed there were no orders in place for the
dressing to Resident #23's left forearm. Review of the treatment administration record (TAR) revealed no
documentation of the dressing applied to the wound.
Review of a physician order dated 09/03/24 at 3:00 P.M. revealed an order for antibacterial ointment to the
left arm wound and tear topically two times a day for wound care.
Observation on 09/04/24 at 7:41 A.M., revealed Resident #23 told Licensed Practical Nurse (LPN) #200 the
wound dressing to her left arm was too tight. LPN #200 unwrapped a layer of self-adherent wrap then a
layer of gauze wrap from around the left forearm revealing a nonadherent dressing covering a skin tear
closed with two steri-strips. LPN #200 then cleansed the wound with normal saline, applied a new
nonadherent dressing before wrapping the wound with new gauze and a self-adherent wrap.
Interview on 09/04/24 at 7:53 A.M. with LPN #200 verified she had removed an undated wound dressing
from Resident #23's left forearm. LPN #200 verified she had not checked for a physician order prior to
applying the dressing. LPN #200 then checked the physician orders and verified there was no order in
place for a wound dressing to the resident's left forearm. LPN #200 verified there was an order for
antibacterial ointment to be applied to the wound. LPN #200 verified she had not applied the ordered
antibacterial ointment. LPN #200 revealed she would call the physician for an order for the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365860
If continuation sheet
Page 2 of 3
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
09/05/2024
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 0684
wound dressing.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 09/05/24 at 7:02 A.M. with the Director of Nursing (DON) revealed she called the physician last
night and clarified orders for the wound dressing. The DON stated a nurse had received wound care orders
from the physician but forgot to enter the orders. The DON revealed the nurses applying the resident's
wound dressing should have first ensure there was an order in place before changing the wound dressing
and they should have documented the completion of the wound dressing change.
Residents Affected - Few
Review of the policy titled Skin Care and Ulcer Prevention dated 05/11/21 revealed the physician would be
notified to obtain treatment orders for skin impairments. Daily monitoring of the wound dressing and site
around wound as well as the wound if visible would be completed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365860
If continuation sheet
Page 3 of 3
