Health inspection·January 16, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews and review of facility policy, the facility failed to ensure resident room temperatures were maintained to ensure a comfortable environment for the residents. This affected two (#1 and #3) out of four residents reviewed for comfortable room temperatures. Facility census was 63. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 02/22/21. Diagnoses included cerebral infarction, anxiety, hypertension, and acute kidney injury. Review of the annual Minimum Data Set (MDS) 3.0 assessment for Resident #3, dated 11/01/23, revealed the resident had mildly impaired cognition. Review of the plan of care for Resident #3 revealed the resident had potential for altered cardiac status related to hypertension with goal to remain free from complications related to altered cardiac status. Interventions include, but not limited to, monitor for chest pain, blood pressure, nausea and vomiting, shortness of breath, diaphoresis, and edema. Note changes in sensorium: lethargy, confusion, disorientation, anxiety, and depression. Observation on 01/11/24 at 2:50 P.M. of Resident #3's room temperature, using an ambient thermometer, revealed it was 65.1 degree Fahrenheit (F). Resident #3 had on a T-shirt, a sweatshirt, with a blanket draped over her shoulders. This finding was verified with Licensed Practical Nurse (LPN) #141. Interview with Resident #3 during this observation, revealed she stated she was chilled and they had taken her heater away. 2. Review ot the medical record for Resident #1 revealed admission date of 09/18/20. Diagnoses included schizophrenia, hypertension, and chronic obstructive pulmonary disease (COPD). Review of the quarterly MDS dated [DATE] revealed the resident had impaired cognition. Review of the plan of care dated 12/26/23 revealed the resident had potential for altered cardiac status related to hypertension with goal to remain free from complications related to altered cardiac status. Interventions include, but not limited to, monitor for chest pain, blood pressure, nausea and vomiting, shortness of breath, diaphoresis, and edema. Note changes in sensorium: lethargy, confusion, disorientation, anxiety, and depression. Page 1 of 2 366099 366099 01/16/2024 Springfield Nursing & Independent Living 404 E McCreight Ave Springfield, OH 45503

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview and observation on 01/11/24 at 2:26 P.M. revealed Resident #1 was seated in the common area on the [NAME] Unit with room temperature of 70.5 degree F and stated she had on her jacket to keep warm. Interview on 01/11/24 at 3:12 P.M. with the Business Office Manager (BOM) revealed the Administrator had given a 30 day notice of resignation and had not shown up for work on the third day. The BOM stated staff learned she had locked her keys and computer in the office and would not return to the facility. The BOM stated the facility had a fire in the wiring on 01/11/24, the Fire Marshall had been in the facility, and they had to remove the space heaters that had been in use. The BOM stated the facility had one of four boilers that worked. The BOM stated they had a company that had been in to look at the boilers and she thought she understood the one boiler was sufficient to maintain the heat for the building. After review of the room temperatures the facility called a Columbus Company to install large heating units in the hallways to help with the forecasted single digit temperatures. At 4:32 P.M. the BOM reported the heating units were in route from Columbus. Interview on 01/16/24 at 8:22 A.M. with the Director of Nursing (DON), revealed the Columbus heating company brought six heat units and returned on 01/11/24 with more units. She stated a local electrician had been in the facility to update the wiring. The ADON stated the facility brought in extra blankets, sweaters, jackets, and coats. She stated they had offered to move residents to warmer areas of the facility but all declined. The DON stated they had no resident health concerns related to the temperatures. Observation on 01/16/24 between 8:26 A.M. to 8:42 A.M. during a follow-up tour of the facility, confirmed the temperatures ranged from 72.5 to 80.4 degree F. The facility had nine Salamander heaters, and 12 Herc heaters spaced throughout the hallways of the resident units. Interview on 01/16/24 at 9:47 A.M. with the Administrator, revealed the facility had been working with the boiler issues all summer. The Administrator stated they would get one thing fixed and then something else would go wrong. The Administrator stated he was not aware of concerns related to the space heaters until the wiring incident. The Administrator stated they were looking at installing packaged terminal air conditioners and heaters for each individual room. Review of a policy titled, Safe and Homelike Environment, dated February 2023, revealed the facility will maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees F. If and when a resident prefer his or her room temperature to be kept below 71 degree F, or above 81 degree F, the facility will assess the safety of this practice on the resident and the resident's roommate. This deficiency represents non-compliance investigated under Complaint Number OH00149961. 366099 Page 2 of 2