Health inspection·September 27, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, review of personnel files, review of witness statements, and review of the facility's abuse policy, the facility failed to ensure Bureau of Criminal Investigation (BCI) background checks were completed during the employees hiring process. This affected one resident (#52) of the three residents reviewed for abuse. The facility also failed to ensure their abuse policy was implemented when an allegation of resident abuse was reported. This affected one resident (#52) of three residents reviewed for abuse. The facility census was 59. Residents Affected - Few Findings Include: 1. Review of the personnel file for Housekeeper #301 revealed she was hired on 01/29/23 and terminated on 08/18/23 for violating the facility's abuse policy due to shouting at a resident. The personnel file revealed no documented evidence of a BCI background check being completed during Housekeeper #301's hiring process. A BCI background check was completed on 08/25/23 which was after Housekeeper #301 had been terminated from employment for violating the facility's abuse policy. Review of a facility document titled Level of Corrective Action Form dated 08/18/23, revealed Housekeeper #301 was terminated because she was observed by staff shouting at a resident and cursing in the dining area on the west wing. Interview with the Human Resource Director (HRD) #130 on 09/27/23 at 8:41 A.M. verified there was no documented evidence of a BCI background check being completed for Housekeeper #301 during the hiring process. HRD #130 indicated she started working at the facility on 04/10/23 and started doing audits of the personnel files and couldn't find the BCI background check for Housekeeper #301. HRD #130 instructed Housekeeper #301 to go get another background check and by the time the BCI background check was returned, Housekeeper #301 had already terminated for shouting at a resident. Review of the policy entitled Abuse, Neglect and Exploitation dated 01/01/23 revealed potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property by a background ground check reference, and credentials' checks shall be conducted on potential employees, the facility will maintain documentation of proof that the screening occurred. 2. Review of medical record for Resident #52 revealed an admission date of 06/30/23 and the resident's diagnoses included Schizophrenia. Review the admission Minimum Data Set (MDS) assessment 3.0 for Resident #52 dated 07/11/23, revealed the resident was cognitively intact. Review of a progress note dated 08/17/23 for Resident #52, revealed no documented evidence of Page 1 of 6 366099 366099 09/27/2023 Springfield Nursing & Independent Living 404 E McCreight Ave Springfield, OH 45503

F 0607 Housekeeper #301 and the resident's argument. Level of Harm - Minimal harm or potential for actual harm Review of a witness statement authored by Activities Director (AD) #62 dated 08/18/23, revealed on 08/17/23 he was on the west wing and was talking to a resident when he heard Housekeeper #301 yell someone better come get her. The witness statement revealed Housekeeper #301 was speaking to and about Resident #52. AD #62 asked Housekeeper #301 what was wrong, and Housekeeper #301 started cursing and yelling and saying Resident #52 told her she did not want her expletive room cleaned and stated this was expletive. Residents Affected - Few Review of a facility document titled Level of Corrective Action Form dated 08/18/23, revealed Housekeeper #301 was terminated because she was observed by staff shouting at a resident and cursing in the dining area on the west wing. Interview with AD #62 on 09/27/23 at 9:50 A.M. revealed on 08/17/23 at approximately 2:45 P.M. he was on the west wing of the facility and Resident #52 had returned from Bingo. He said Housekeeper #301 was coming out of the unit when Resident #52 asked her if she had cleaned her room and Housekeeper #301 indicated yes and Resident #52 said do not clean my room. AD #62 stated Housekeeper #301 was pacing back and forth and was getting worked up and had a nasty tone with Resident #52 and then started yelling at Resident #52. AD #62 asked Housekeeper #301 what was wrong when Housekeeper #301 said, I can't clean her expletive room. Housekeeper #301 then stated she was tired of this because Resident #301 said she couldn't clean her room and it needed to be cleaned. AD #62 indicated he instructed Housekeeper #301 to leave the unit and since it was time for her to go home, Housekeeper #301 clocked out for the day and left. AD #62 stated he immediately went to the Director of Nursing (DON) to report the incident. Interview with the DON on 09/27/23 at 10:05 A.M. revealed she was informed by AD #62 about the argument between Housekeeper #301 and Resident #52. The DON indicated she called her Regional Director and asked if the incident was reportable, and the Regional Director stated no and to take statements and put them in a soft file. The DON felt the argument was inappropriate but did not feel like it was directed at Resident #52 even though the resident was right there and could hear what Housekeeper #301 was saying about her. After reading the definition of verbal abuse from the facility's abuse policy, the DON agreed the argument would be considered verbal abuse. DON verified the facility didn't implement the facility's abuse policy after the verbal abuse incident. Interview with Resident #52 on 09/27/23 at 11:24 A.M. revealed the housekeeping staff was not nice to her and reported they had gotten smart with her in the past. Review of the personnel file for Housekeeper #301 revealed she was hired on 01/29/23 and terminated on 08/18/23 for violating the facility's abuse policy due to shouting at a resident. Review of the policy entitled Abuse, Neglect and Exploitation dated 01/01/23 revealed it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy indicated allegations of abuse would be thoroughly investigated. This deficiency represents non-compliance investigated under Complaint Number OH00146344. 366099 Page 2 of 6 366099 09/27/2023 Springfield Nursing & Independent Living 404 E McCreight Ave Springfield, OH 45503

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on medical record review, staff and resident interview, review of witness statements, review of the facility's self-reported incidents (SRIs) and review of the facility's abuse policy, the facility failed to ensure an allegation of verbal abuse was reported to the state agency. This affected one resident (#52) of three residents reviewed for abuse. The census was 59. Findings include: Review of medical record for Resident #52 revealed an admission date of 06/30/23 and the resident's diagnoses included Schizophrenia. Review the admission Minimum Data Set (MDS) assessment 3.0 for Resident #52 dated 07/11/23, revealed the resident was cognitively intact. Review of a progress note dated 08/17/23 for Resident #52, revealed no documented evidence of an argument between Housekeeper #301 and the resident. Review of the SRI's submitted by the facility revealed no documented evidence of an SRI being initiated to the state agency for an allegation of staff to resident abuse on 08/17/23. Review of a witness statement authored by Activities Director (AD) #62 dated 08/18/23, revealed on 08/17/23 he was on the west wing and was talking to a resident when he heard Housekeeper #301 yell someone better come get her. The witness statement revealed Housekeeper #301 was speaking to and about Resident #52. AD #62 asked Housekeeper #301 what was wrong, and Housekeeper #301 started cursing and yelling and saying Resident #52 told her she did not want her expletive room cleaned and stated this was expletive. Review of a facility document titled Level of Corrective Action Form dated 08/18/23, revealed Housekeeper #301 was terminated because she was observed by staff shouting at a resident and cursing in the dining area on the west wing. Interview with AD #62 on 09/27/23 at 9:50 A.M. revealed on 08/17/23 at approximately 2:45 P.M. he was on the west wing of the facility and Resident #52 had returned from Bingo. He said Housekeeper #301 was coming out of the unit when Resident #52 asked her if she had cleaned her room and Housekeeper #301 indicated yes and Resident #52 said do not clean my room. AD #62 stated Housekeeper #301 was pacing back and forth and was getting worked up and had a nasty tone with Resident #52 and then started yelling at Resident #52. AD #62 asked Housekeeper #301 what was wrong when Housekeeper #301 said, I can't clean her expletive room. Housekeeper #301 then stated she was tired of this because Resident #301 said she couldn't clean her room and it needed to be cleaned. AD #62 indicated he instructed Housekeeper #301 to leave the unit and since it was time for her to go home, Housekeeper #301 clocked out for the day and left. AD #62 stated he immediately went to the Director of Nursing (DON) to report the incident. Interview with the DON on 09/27/23 at 10:05 A.M. revealed she was informed by AD #62 about the argument between Housekeeper #301 and Resident #52. The DON indicated she called her Regional Director and asked if the incident was reportable, and the Regional Director stated no and to take statements and put them in a soft file. The DON felt the argument was inappropriate but did not feel like it 366099 Page 3 of 6 366099 09/27/2023 Springfield Nursing & Independent Living 404 E McCreight Ave Springfield, OH 45503

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was directed at Resident #52 even though the resident was right there and could hear what Housekeeper #301 was saying about her. After reading the definition of verbal abuse from the facility's abuse policy, the DON agreed the argument would be considered verbal abuse and should have been reported to the state agency via an SRI. Review of the personnel file for Housekeeper #301 revealed she was hired on 01/29/23 and terminated on 08/18/23 for violating the facility's abuse policy due to shouting at a resident. Review of the policy entitled Abuse, Neglect and Exploitation dated 01/01/23 revealed it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy indicated allegations of abuse would be thoroughly investigated and reported to the state agency within the specified timeframes. This deficiency represents non-compliance investigated under Complaint Number OH00146344. 366099 Page 4 of 6 366099 09/27/2023 Springfield Nursing & Independent Living 404 E McCreight Ave Springfield, OH 45503

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interviews and policy review the facility failed to ensure incontinence care was provided correctly. This affected two residents (#11 and #31) of three residents reviewed for incontinence care. The census was 59. Findings include: 1. Review of medical record for Resident #11 revealed an admission date of 01/08/21 with diagnoses of seizures, aphasic, and cerebrovascular attack (stroke). Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 07/01/23 for Resident #11, revealed the resident had severely impaired cognition. The resident required extensive assistance for toileting was always incontinent of bowel and bladder. Review of the care plan for Resident #11 dated 07/09/23 revealed the resident exhibited episodes of incontinence for bowel and bladder due to impaired cognition. Observation of incontinence care provided by State Tested Nursing Aide (STNA) #124 for Resident #11 on 09/27/23 at 2:36 P.M. revealed STNA #124 stood the resident up in the bathroom and took a couple of wipes out of the package and wiped in a downward motion over the penis and the scrotum and then wiped his anal area with a new wipe. 2. Review of medical record for Resident #31 revealed an admission date of 07/20/12 with diagnoses of psychosis, aphasic, and non-Alzheimer's dementia. Review of Resident #31's MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required extensive assistance for toileting was always incontinent of bowel and bladder. Review of the care plan dated 07/09/23 for Resident #31 revealed the resident had bowel and bladder incontinence related to impaired cognition, impaired communication, and decreased awareness of bowel and bladder needs. Observation of incontinence care by STNA #124 for Resident #31 on 09/29/23 at 2:41 P.M. revealed she stood the resident up in the bathroom and took a couple of wipes out of the package and wiped in a downward motion over the penis and the scrotum and then wiped his anal area with a new wipe. Interview with STNA #124 on 09/29/23 at 2:45 P.M., revealed she did not follow the correct procedure when providing incontinence care for residents (#11 and #31). STNA #124 stated the correct procedure for providing incontinence care would be to use the wipes to pull back the skin of the penis and clean in a circular motion and to wipe the scrotum off too. STNA #124 verified she did not perform the correct procedures for providing incontinence care. Review of policy titled Perineal Care dated 10/2022 revealed it is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin 366099 Page 5 of 6 366099 09/27/2023 Springfield Nursing & Independent Living 404 E McCreight Ave Springfield, OH 45503

F 0690 breakdown. For males the procedure for incontinence care included the following: Level of Harm - Minimal harm or potential for actual harm a. Assist resident to supine position (unless contraindicated), b. Gently raise penis and place bath towel underneath. Residents Affected - Few c. Wet washcloth and apply perineal cleanser. If using prepackaged products, open the package and obtain the wet cloth. d. Gently retract the foreskin if applicable. e. Hold the shaft of the penis with one hand and with the other, begin cleansing tip of penis at urethral meatus using a circular motion and working outward. f. Replace foreskin, if applicable. g. Cleanse the shaft of the penis, using downward strokes toward the scrotum. Use separate sections of washcloth or new disposable wipe with each stroke. h. Cleanse the scrotum, using a clean portion of the washcloth, new washcloth, or new disposable wipe with each stroke and pat dry. i. Clean and dry the bottom of the scrotum and the anal area. This deficiency represents non-compliance investigated under Complaint Number OH00146344. 366099 Page 6 of 6