Health inspection·August 1, 2019

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 Based on observation, medical record review, and staff interview, the facility failed to ensure a resident received treatment for edema to bilateral lower extremities. This affected one (#47) of two residents reviewed for skin conditions. The facility identified eight residents being treated for edema. The facility census was 50. Residents Affected - Few Findings include: Review of Resident #47's medical record revealed an admission date of 07/02/19. Medical diagnoses included hypertensive heart disease with heart failure, atrial fibrillation, acute respiratory failure, pleural effusion, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, and urinary retention. Review of the Minimum Data Set (MDS) assessment, dated 07/09/19, revealed Resident #47 had moderate impairment in cognition. She required extensive assistance for dressing and hygiene. Review of the resident's nursing notes revealed documentation of two plus edema to bilateral lower extremities on 07/02/19, 07/03/19, 07/04/19, 07/06/19, 07/09/19, 07/19/19, and 07/20/19. Review of an interdisciplinary team (IDT) note dated 07/26/19 revealed the resident was reviewed by the IDT. Orders for antibiotic (left foot), change to thromboembolic disease (TED) hose (elastic stockings that compress the superficial veins in the lower limbs) , and doppler to leg. Review of the resident's physician's orders throughout the resident's admission revealed no order to address edema in the resident's right foot/ankle. Observation of the resident's bilateral feet during a dressing change to her left foot on 07/31/19 at 8:41 A.M. revealed the resident had two plus pitting edema to her bilateral feet/ankles. The resident was sitting in a wheelchair with her feet on the ground. She had no treatment to her right foot. During the observation, Licensed Practical Nurse (LPN) #120 verified the resident had no ace wrap or TED hose to her right foot. She verified the resident's right foot was edematous, with two plus pitting edema. She stated there was no order for the resident's right foot edema. She stated she was going to notify the physician to address the lack of treatment. Further observations of the resident on 07/31/19 at 10:16 A.M., 12:25 P.M., 3:09 P.M., and 5:20 P.M. revealed she was in her wheelchair and had no treatment to the right foot. Interview with the Director of Nursing (DON) on 07/31/19 at 5:25 P.M. revealed the resident's IDT note dated 07/26/19 was supposed to say Ace wraps and not TED hose for bilateral lower extremity Page 1 of 7 366221 366221 08/01/2019 Springview Manor 883 West Spring Street Lima, OH 45805

F 0684 Level of Harm - Minimal harm or potential for actual harm edema. She stated the resident had been wearing TED hose to her bilateral lower extremities prior to the development of a wound on her left foot on 07/26/19. The DON verified there was no order in place to treat the resident's edema since admission. She verified the resident still had no Ace wrap in place to the right lower extremity. Residents Affected - Few 366221 Page 2 of 7 366221 08/01/2019 Springview Manor 883 West Spring Street Lima, OH 45805

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and family and staff interview, the facility failed to ensure a splint was in place as ordered for one (Resident #1) of one residents reviewed for limited mobility. The facility identified three residents with splint devices ordered. The facility census was 50. Findings include: Review of Resident #1's medical record revealed an admission date of 02/26/14. Medical diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, dysphagia, neuromuscular dysfunction of bladder, major depressive disorder, cognitive communication deficit, unspecified dementia with behaviors, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, difficulty in walking, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 07/01/19, revealed Resident #1's cognition was severely impaired. She required extensive assistance for bed mobility, transfers, dressing, and hygiene. She had impairment of mobility to the upper and lower extremity on one side. Splint or brace assistance was coded as zero. Review of the resident's occupational therapy (OT) progress and Discharge summary dated [DATE] revealed short term goals history included prosthetic/orthotic use; the patient will demonstrate tolerance of left resting hand splint nightly to prevent contractures and protect joint integrity. Long term orthotic goal not met on 01/04/19 and noted staff will appropriately don and doff left wrist/hand orthotic with patient tolerating four plus hours and monitor skin condition for effective contracture prevention and joint protection. Analysis of functional outcome/clinical impression was patient tolerates left resting hand splint up to two hours without adverse reactions, order written for splint wear up to two hours every shift as tolerated. Patient refuses splint at times however tolerates well when in use. Caregiver training to safely manage left upper extremity splinting performance. Patient/caregiver training since last report, splinting to left upper extremity. Discharge plans and instructions were patient will remain in skilled nursing facility with staff education. Order written for left hand splinting up to two hours every shift as tolerated. Review of the resident's physician's orders revealed an order dated 01/04/19 to wear a left resting hand splint up to two hours every shift as tolerated. Review of the resident's treatment administration record revealed no documentation of splint use. Review of the resident's care plan, dated 08/15/16 and revised on 07/09/19, revealed the resident required assistance with her activities of daily living (ADLs) and was at risk for increased ADL support related to her diagnosis of cerebrovascular accident with left sided hemiparesis, heart disease, and cognitive deficit. Interventions included on 01/07/19 a left hand splint as tolerated up to two hours per shift. Observation of the resident and her room on 07/29/19 at 5:36 P.M. revealed her left hand appeared to have a range of motion deficit, with no hand splint in place, and no splint observed in the room. 366221 Page 3 of 7 366221 08/01/2019 Springview Manor 883 West Spring Street Lima, OH 45805

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Resident #1's family member on 07/30/19 at 9:26 A.M. revealed he was not sure what the facility was doing for the resident's left hand. He stated he thought she might have had a splint, but was not sure if she was wearing it or not. Further observations on 07/30/19 at 2:30 P.M. and 07/31/19 at 10:15 A.M. and 12:04 P.M. revealed Resident #1 did not have a splint in place to her left hand. Interview with State Tested Nursing Assistant (STNA) #150 on 07/31/19 at 10:59 A.M. revealed she was not aware of any splint for Resident #1. She stated there was no place in the STNA care tracker for her to document splint use for the resident. Interview with Licensed Practical Nurse (LPN) #130 on 07/31/19 at 12:05 P.M. revealed she was not aware of a splint for the resident. LPN #130 verified there was an order for a resting hand splint two hours per shift as tolerated. She verified there was no documentation indicating the resident was wearing the splint. After the interview, LPN #130 went in Resident #1's room and found two left hand splints in the closet. Interview with Regional Nurse #200 on 07/31/19 at 12:36 P.M. verified there was no STNA documentation of the resident's splint use. She stated she had began educating the STNA staff on the resident's splint use. 366221 Page 4 of 7 366221 08/01/2019 Springview Manor 883 West Spring Street Lima, OH 45805

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident received medication as ordered. This affected one (Resident #47) of five residents reviewed for medication. The facility census was 50. Findings include: Review of Resident #47's medical record revealed an admission date of 07/02/19. Medical diagnoses included hypertensive heart disease with heart failure, atrial fibrillation, acute respiratory failure, pleural effusion, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, and urinary retention. Review of Resident #47's Minimum Data Set (MDS) assessment, dated 07/09/19, revealed moderate impairment in cognition. Review of the resident's laboratory results dated [DATE] revealed a potassium level of 2.9 millimoles per liter (mmol/L) (normal 3.5-5.3). The physician was notified and responded on 07/11/19 with an order for potassium supplement 40 milliequivalents (mEq) by mouth now, then potassium 40 mEq twice daily on 07/12/19. Review of the resident's July Medication Administration Record (MAR) revealed Licensed Practical Nurse (LPN) #110 did not administer the morning dose of potassium 40 mEq on 07/12/19. She documented it was not available. Further review of the medical record revealed no indication LPN #110 notified the physician the potassium was not available. Interview with Regional Nurse #200 on 07/31/19 at 5:25 P.M. revealed LPN #110 was an as needed nurse. She stated she contacted LPN #110 via telephone, who stated she could not find the resident's potassium on 07/12/19 and did not administer it. Regional Nurse #200 verified LPN #110 should have notified the physician and attempted to obtain the medication. 366221 Page 5 of 7 366221 08/01/2019 Springview Manor 883 West Spring Street Lima, OH 45805

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to follow their isolation policy for a resident with a drug resistant infection. This affected one (Resident #47) of two residents reviewed for infections. The facility census was 50. Residents Affected - Few Findings include: Review of Resident #47's medical record revealed an admission date of 07/02/19. Medical diagnoses included hypertensive heart disease with heart failure, atrial fibrillation, acute respiratory failure, pleural effusion, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, and urinary retention. Review of the Minimum Data Set (MDS) assessment, dated 07/09/19, revealed Resident #47 had moderate impairment in cognition. Review of the resident's laboratory results revealed a urine culture reported on 07/14/19 with results of vancomycin resistant enterococcus faecium (VRE). Continued review revealed no further urine cultures. Review of the resident's physicians orders revealed an order dated 07/15/19 for contact isolation. Review of an interdisciplinary team (IDT) note dated 07/15/19 at 8:09 A.M. revealed the resident was in contact isolation for VRE in urine. Review of the resident's care plan dated 07/16/19 revealed the resident had a need for isolation related to active infectious disease (VRE) in urine. The goal of the resident's isolation was to reduce the spread of the infectious agent and minimize the transmission of the infection. Interventions included following the facility's infection control policies/procedures when cleaning/disinfecting room, handling soiled and/or contaminated linen, disinfecting equipment, etc. Have adequate personal protective equipment available for staff and visitors. Practice good handwashing, teach residents and caregivers chain of infection/methods of transmission, and use principles of infection control and standard precautions. Observation of the resident on 07/31/19 at 8:41 A.M. with Licensed Practical Nurse #120 and State Tested Nursing Assistant #150 revealed the resident was in the bathroom on the toilet. There was also a bedside commode in the bathroom. The resident had a roommate. Interview with the Director of Nursing (DON) on 07/31/19 at 5:25 P.M. verified Resident #47 had a roommate who did not have a diagnosis of VRE. She stated they had placed the bedside commode in the room for Resident #47's use. She verified Resident #47 should not have been cohorted with a resident who did not have VRE per the facility policy. She verified the resident did not have an order for a repeat urine culture. She stated she had called the physician and obtained an order to get a repeat urine culture on 08/01/19. She stated the facility had no other residents with VRE and the resident's roommates was not having any VRE symptoms. She stated they were going to move the resident's roommate so Resident #47 would have her own room. Review of a facility policy titled Guidelines for Management of Residents with Vancomycin Resistant Enterococcus, reviewed 05/22/18, revealed it was recommended the resident be placed in contact 366221 Page 6 of 7 366221 08/01/2019 Springview Manor 883 West Spring Street Lima, OH 45805

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few precautions. The nursing staff will follow the physician orders for follow up cultures. If the screens are negative, remove the resident from contact precautions. When possible, the resident should be given a private room or blocked multi-resident room until the screen/culture results are obtained. When a resident's screen/culture is positive for VRE, the resident shall be placed in a private room or cohorted with residents with like organisms. Contact precautions will be continued unless all of the following are identified: symptoms are resolved, antibiotic therapy discontinued, negative culture is obtained. The physician and/or the infection control committee will evaluate timing for reculture. 366221 Page 7 of 7