Health inspection·May 30, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to notify resident representative or guardian of the name and location of the facility where the resident was transferred, the resident's change in doctor's appointment, and of a resident's fall. This affected two (#6 and #35) of the three residents reviewed for notification of change. The facility census was 43. Finding include: 1. Review of the medical record for Resident #6 revealed an admission date of 02/19/20 with medical diagnoses of Alzheimer's disease, atherosclerotic heart disease, diabetes mellitus, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had severe cognitive impairment. Review of the nursing note, dated 12/27/22 at 9:23 A.M. revealed Residents #6's guardian was notified about the facility evacuation, and he would be updated on the location of the facility the resident was sent to when available. Further review of the medical record revealed no documentation to support Residents #6's guardian was notified of name or location of the facility Resident #6 was evacuated to on 12/27/22. Review of the nursing note, dated 04/17/23 at 12:00 P.M. stated the nurse attempted to call the urologist/neurologist's office to reschedule Resident #6's appointment from 04/11/23 and a voicemail message was left to return the facility call. There was no documentation to support Resident #6's guardian was notified of the missed appointment on 04/11/23 and no documentation to support the facility notified Resident #6's guardian of the appointment was rescheduled for 04/26/23. Interview on 05/23/23 at 9:18 A.M. with Licensed Practical Nurse (LPN) #70 stated she assisted the facility with arranging transportation for the residents in the facility. LPN #70 stated Resident #6 was usually provided transportation to his appointments by the facility van. LPN #70 confirmed there was no documentation to support Resident #6 had an appointment on 04/11/23. LPN #70 confirmed the medical record for Resident #6 did not contain documentation to support Resident #6's guardian was notified of Resident #6's appointment rescheduled for 04/26/23. Subsequent interview on 05/24/23 at 3:36 P.M. with LPN #70 confirmed Resident #6's medical record did not contain documentation to support that Resident #6's guardian was notified of the name and location of the facility Resident #6 was transferred to during the evacuation on 12/27/22. 2. Review of the medical record for Resident #35 revealed an admission date of 11/07/22 with Page 1 of 11 366236 366236 05/30/2023 Good Shepherd Village 422 North Burnett Road Springfield, OH 45503

F 0580 Level of Harm - Minimal harm or potential for actual harm medical diagnoses of cerebral infarction, bipolar disease, and aphasia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/2/23, revealed Resident #35 had severe cognitive impairment. Review of the medical record revealed Resident #35 had a fall in her room on 04/20/23 and there was no documentation to support the facility notified the resident representative of Resident #35's fall on 04/20/23. Residents Affected - Few Review of Resident #35's fall investigation report, dated 04/20/23, revealed it did not have documentation to support Resident #35's representative was notified of the fall. Review of the nursing note, dated 04/23/23 at 7:20 P.M., revealed Resident #35's daughter informed the nurse she was not notified of Resident #35's fall on 04/20/23. The note stated Resident #35 has a camera in the room and the daughter noticed the fall when reviewing the film. Interview on 05/25/23 at 3:54 P.M. with Licensed Practical Nurse (LPN) #70 confirmed the medical record did not contain documentation to support Resident #35's representative was notified of the fall on 04/20/23. Review of the facility policy titled, Change of Condition, revised February 2021, stated the facility was to notify the resident's representative when there a decision has been made to discharge the resident from the facility and the nurse would record in the resident's medical record information relative to changes in the resident's status. This deficiency represents non-compliance investigated under Complaint Number OH00142713. 366236 Page 2 of 11 366236 05/30/2023 Good Shepherd Village 422 North Burnett Road Springfield, OH 45503

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident receiving as needed oxygen had a care plan addressing the resident's oxygen use. This affected one (Resident #14) of three residents reviewed for oxygen use. The facility census was 43. Findings include: Review of Resident #14's medical record revealed the resident was readmitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with chronic kidney disease, dementia without behavioral disturbance, and Arnold Chiari Syndrome. Review of Resident #14's Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognitive status could not be evaluated related to the resident was rarely/never understood. Review of the physician orders dated 05/04/23 revealed Resident #14 had an order to monitor oxygen saturation (SPO2) every shift for shortness of breath. Resident #14 had an order dated 05/09/23 for oxygen at two to four liters per minute (LPM) via nasal cannula to maintain oxygen saturations at 90 or above. Review of the Resident #14's revised care plan dated 05/04/23 revealed Resident #14 had no care plan addressing the resident's use/need of oxygen. Interview on 05/23/23 at 10:00 A.M. with the Director of Nursing (DON) confirmed Resident #14's care plan was not revised to address the resident's ordered oxygen use. Review of the facility policy titled, Oxygen Administration, revised October 2010 revealed the purpose of this procedure is to provide guidelines for safe oxygen administration. Review the resident's care plan to assess any special needs of the resident. This deficiency represents non-compliance investigated under Complaint Number OH00142710. 366236 Page 3 of 11 366236 05/30/2023 Good Shepherd Village 422 North Burnett Road Springfield, OH 45503

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. Based on record reviews, staff interview, review of Resident Assessment Instrument Manual (RAI) 3.0, and policy review, the facility failed to conduct care plan review meetings quarterly and failed to include the resident, members of the facility interdisciplinary team (IDT), or resident representative in the review of plans of care. This affected three (#6, #20, and #35) of three residents reviewed for quarterly care plan meetings and revision of plans of care. The facility census was 43. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 02/19/20. Diagnoses included Alzheimer's disease, atherosclerotic heart disease, diabetes mellitus, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/14/23, revealed Resident #6 had severe cognitive impairment and required extensive staff assistance with bed mobility, transfers, dressing, toileting, and bathing. Review of the medical record for Resident #6 revealed no documentation to support the resident, resident representative or guardian were invited or attended care plan review meetings or were involved in care plan revisions. Interview on 05/24/23 at 11:55 A.M. with Social Service Director (SSD) #51 confirmed quarterly care conferences had not been conducted for Resident #6 as per facility policy. SSD #51 also confirmed the medical record for Resident #6 did not contain documentation to support the resident or resident representative were involved in revision of plans of care. 2. Review of the medical record for Resident #35 revealed an admission date of 11/07/22. Diagnoses included cerebral infarction, hypertension, congestive heart failure, bipolar disease, and aphasia. Review of the medical record revealed Resident #35 enrolled in hospice services on 05/11/23. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/2/23, revealed Resident #35 had severe cognitive impairment and was dependent on staff for bed mobility, toileting, eating, transfers, and bathing. Review of the medical record for Resident #35 revealed no documentation to support the resident, resident representative or guardian were invited or attended care plan review meetings or were involved in care plan revisions. Interview on 05/24/23 at 11:55 A.M. with Social Service Director (SSD) #51 confirmed quarterly care conferences had not been conducted for Resident #35 as per facility policy. SSD #51 also confirmed the medical record for Resident #35 did not contain documentation to support the resident or resident representative were involved in revision of plans of care. 3. Review of the medical record for Resident #20 revealed an admission date of 02/15/19. Diagnoses included schizophrenia, anxiety disorder, and hypertension. Review of the medical record revealed Resident #20 enrolled in hospice services on 03/20/23. Review of the significant change Minimum Data Set (MDS) assessment, dated 03/29/23, revealed 366236 Page 4 of 11 366236 05/30/2023 Good Shepherd Village 422 North Burnett Road Springfield, OH 45503

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #20 had moderately impaired cognition and required supervision with bed mobility and transfers, limited staff assistance with toileting, and extensive staff assistance with bathing. Review of the medical record for Resident #20 revealed no documentation to support the resident, resident representative or guardian were invited or attended care plan review meetings or were involved in care plan revisions. Interview on 05/24/23 at 11:55 A.M. with Social Service Director (SSD) #51 confirmed quarterly care conferences had not been conducted for Resident #20 as per facility policy. SSD #51 also confirmed the medical record for Resident #20 did not contain documentation to support the resident or resident representative were involved in revision of plans of care. Review of the Resident Assessment Instrument (RAI) Manual 3.0 pages four to 11 stated the resident's care plan must be reviewed after each assessment and revised based on changing goals, preferences and need of the resident and in response to current interventions. The interdisciplinary team (IDT) with the input from the resident, family or resident representative is needed to determine when a problem or potential problem needs to be addressed in the resident's care plan. Review of the facility policy titled Resident Participation- Assessment/care plans, revised February 2021, stated the resident or resident representative are encouraged to participate in the development and implementation of resident's care plans and informed, in advance, of any changes to the plan of care. This deficiency represents non-compliance investigated under Complaint Number OH00142713. 366236 Page 5 of 11 366236 05/30/2023 Good Shepherd Village 422 North Burnett Road 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, staff interview and review of the facility policy, the facility failed to obtain physician orders for a resident readmitted to the facility with an indwelling urinary catheter and failed to provide timely colostomy care to a resident. This affected one (#14) of two residents reviewed for an indwelling urinary catheter and one (#6) of two residents reviewed for colostomy care. The facility identified two residents with indwelling catheters. The facility census 43. Findings include: 1. Review of Resident #14's medical record revealed the resident was readmitted to the facility on [DATE]. Diagnoses included Parkinson's disease, dementia without behavioral disturbance, and neurogenic bladder. Review of Resident #14's Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognitive status could not be evaluated related to the resident was rarely/never understood. Review of the hospital discharge report dated 04/30/23 revealed Resident #14 was discharged to the facility with an indwelling urinary catheter. Review of the care plan dated 04/04/23 and revised on 05/23/23, revealed Resident #14 had an indwelling urinary catheter related to neurogenic bladder that can increase risk for infection. Interventions included catheter 18 French gauge with 10 milliliter balloon to continuous drainage related to urinary retention. Monitor/record/report to the physician for signs or symptoms of urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, increased pulse, increased temperature, foul smelling urine, change in behavior and change in eating patterns. Notify the physician and family of any changes in condition. Provide catheter care each shift and as needed. Review of the May 2023 physician orders revealed Resident #14 had no orders for the indwelling urinary catheter. Review of Resident #14's May 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no information/documentation related to the resident's indwelling urinary catheter. Observation on 05/22/23 at 12:35 P.M. revealed Resident #14 was observed to have an indwelling urinary catheter. Interview on 05/30/23 at 10:30 A.M. with the Director of Nursing (DON) confirmed Resident #14 did not have physician orders for the indwelling urinary catheter. The DON stated Resident #14 had previous orders for the catheter prior to her hospitalization on 04/25/23 and the order was not updated when the resident returned to the facility on [DATE]. Review of the facility's undated policy titled admission Policy (Catheter) revealed preliminary resident information shall be documented upon a resident's admission to the facility. When a resident is admitted to the nursing unit, the admitting nurse must document the following information (as each may apply) in the nurses' notes, admission form, or other appropriate place, as designated by the facility protocol (the time the physician's orders were received and verified the presence of a 366236 Page 6 of 11 366236 05/30/2023 Good Shepherd Village 422 North Burnett Road Springfield, OH 45503

F 0690 catheter, dressings, etc). Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #6 revealed an admission date of 02/19/20. Diagnoses included Alzheimer's disease and schizophrenia. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/14/23, revealed Resident #6 had severe cognitive impairment and required extensive staff assistance with dressing and toileting. Review of the behavior care plan, dated 03/06/20, revealed Resident #6 removes colostomy bag and throws it. Resident #6 also had a plan of care for an alteration in gastrointestinal status due to resident having a colostomy with an intervention noted to change colostomy bag as needed and monitor skin around site. Review of the physician orders for Resident #6 revealed an order dated 01/01/23 to change the colostomy wafer every three days and as needed. However, Resident #6 did not have a physician's order to change the colostomy bag. Interview on 05/24/23 at 1:08 P.M. with State Tested Nursing Assistant (STNA) #78 stated she brought Resident #6 to the bathroom on 05/24/23 around 11:15 A.M. to allow Resident #6 to void prior to his family picking him up for an outing. STNA #78 stated she observed a large amount of dried feces on Resident #6's skin around the wafer and the feces were so caked on the skin and wafer that she had to use over a half of bag of wipes to clean Resident #6's skin around the wafer. Interview on 05/24/23 at 1:19 P.M. with Licensed Practical Nurse (LPN) #70 stated she was alerted to Resident #6's room on 05/24/23 due to Resident #6's guardian yelling at STNA #78 regarding the dried feces around Resident #6's colostomy wafer and on his skin around the wafer. LPN #70 confirmed the medical record for Resident #6 did not contain documentation to support the facility changed Resident #6's colostomy bag. LPN #70 also confirmed the May 2023 treatment administration record (TAR) revealed Resident #6's colostomy wafer was changed daily. LPN #70 stated Resident #6's colostomy wafer was not changed daily, and the order was entered into the system incorrectly. LPN #70 could not provide a date for the last time Resident #6's colostomy wafer or bag was changed or when colostomy care was last provided. Review of the facility policy titled Colostomy/Ileostomy Care, revised October 2010, revealed staff are to provide date/time of colostomy care, name of individual who provided the care, any breaks in skin, and how resident tolerated the procedure. The policy also stated staff are to discard the old drainage bag and replace it with a new drainage bag. This deficiency represents non-compliance investigated under Complaint Number OH00142713 and Complaint Number OH00142710. 366236 Page 7 of 11 366236 05/30/2023 Good Shepherd Village 422 North Burnett Road Springfield, OH 45503

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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, staff interview, and policy review, the facility failed to follow physician orders to ensure a resident was assessed each shift to determine the resident's need for oxygen. This affected one (Resident #14) of three residents reviewed for oxygen use. The facility census was 43. Residents Affected - Few Findings include: Review of Resident #14's medical record revealed the resident was readmitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus with chronic kidney disease, dementia without behavioral disturbance, and Arnold Chiari Syndrome. Review of Resident #14's Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognitive status could not be evaluated related to the resident was rarely/never understood. Review of the physician orders dated 05/04/23 revealed Resident #14 had an order to monitor oxygen saturation (SPO2) every shift for shortness of breath. Resident #14 had an order dated 05/09/23 for oxygen at two to four liters per minute (LPM) via nasal cannula to maintain oxygen saturations at 90 or above. Review of Resident #14's May 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR), revealed no information/documentation of the resident's SPO2 being monitored every shift for the need for oxygen Interview on 05/23/23 at 10:00 A.M. with the Director of Nursing (DON) confirmed the Resident #14's SPO2's was not being obtained to determine the resident's need for oxygen. Review of the facility policy titled Oxygen Administration, revised October 2010, revealed the purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess any special needs of the resident. Before administering oxygen, assess arterial blood gases and oxygen saturation, if applicable. Document all assessment data obtained before, during, and after the procedure. This deficiency represents non-compliance investigated under Complaint Number OH00142710. 366236 Page 8 of 11 366236 05/30/2023 Good Shepherd Village 422 North Burnett Road Springfield, OH 45503

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. Based on medical record review, staff interview, and policy review, the facility failed to ensure medications were given as physician ordered. This affected two (#6 and #35) of the three residents reviewed for medication administration. The facility census was 43. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 02/19/20. Diagnoses included Alzheimer's disease, atherosclerotic heart disease, diabetes mellitus, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/14/23, revealed Resident #6 had severe cognitive impairment. Review of the physician orders for Resident #6 revealed orders dated 12/31/22 for abilify (antipsychotic) 10 milligram (mg) by mouth two times a day for schizophrenia, atorvastatin 40 mg by mouth every evening for hyperlipidemia, famotidine 20 mg by mouth two times a day for stomach acid production, sucralfate 1.0 gram by mouth three times per day for acid reflux, levetiracetam (anticonvulsant) 500 mg by mouth two times per day for convulsions, ranolzine extended release packet 1,000 mg by mouth for angina and an order dated 01/01/23 tamsulosin 0.4 mg by mouth daily for kidney disease. Review of the March 2023 Medication Administration Record (MAR) revealed Resident #6 did not receive the following medications on 03/29/23 and 03/30/23 as ordered: atorvastatin 40 mg, tamsulosin 0.4 mg, abilify 10 mg, famotidine 20 mg, levetiracetam 500 mg, ranolazine extended release (antianginal) 1,000, and sucralfate 1.0 gram. Interview on 05/24/23 at 2:55 P.M. with Licensed Practical Nurse (LPN) #70 confirmed Resident #6 did not receive his medications as ordered on 03/29/23 and 03/30/23 and confirmed Resident #6's medical record did not contain documentation to support why the medication was not given. 2. Review of the medical record for Resident #35 revealed an admission date of 11/07/22. Diagnoses included cerebral infarction and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0, dated 04/20/23, revealed Resident #35 was severely cognitively impaired. Review of the physician order dated 03/09/23 revealed Resident #35 had an order for buspirone (antianxiety) 10 mg by mouth three times a day for anxiety. Review of the April 2023 medication administration record (MAR) revealed there was no documentation to support the buspirone was administered as physician ordered on 04/21/23 or 04/25/23. The May 2023 MAR had no documentation to support the buspirone was administered as physician ordered on 05/02/23, 05/03/23, 05/05/23, 05/07/23, and 05/09/23. Review of the nursing note, dated 05/05/23 at 1:49 P.M., revealed the nurse was informed by another nurse that Resident #35 had been without buspirone 10 mg for a couple of weeks. The note stated the nurse attempted to re-order several times and the pharmacy notified the facility a 30-day supply had been filled on 04/11/23 and the medication had been received and signed for by a nurse at the facility. The note stated the nurse was unable to locate the medication. The note continued to state the pharmacy sent a five-day supply of the medication at the facility's expense. 366236 Page 9 of 11 366236 05/30/2023 Good Shepherd Village 422 North Burnett Road Springfield, OH 45503

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/24/23 at 2:55 P.M. with Licensed Practical Nurse (LPN) #70 confirmed Resident #35 did not receive buspirone as physician ordered on 04/21/23, 04/25/23, 05/02/23, 05/03/23, 05/05/23, 05/07/23, and 05/09/23. LPN #70 confirmed the medical record for Resident #35 had documentation which stated the buspirone was not available on those days due to it not being reordered from the pharmacy. Review of the facility policy titled Medication Administration, revised April 2021, revealed medications are to be administered in a safe and timely manner and as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00142713 and Complaint Number OH00142170. This deficiency represents ongoing noncompliance from the survey dated 05/08/23. 366236 Page 10 of 11 366236 05/30/2023 Good Shepherd Village 422 North Burnett Road Springfield, OH 45503

F 0880 Provide and implement an infection prevention and control program. 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, staff interviews, resident representative interview, and review of the facility policy, the facility failed to follow infection control procedures when completing colostomy care. This affected one (#6) of two residents reviewed for colostomy care. The facility census was 43. Residents Affected - Few Findings include: Review of the medical record for Resident #6 revealed an admission date of 02/19/20. Diagnoses included Alzheimer's disease and schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/14/23, revealed Resident #6 had severe cognitive impairment and required extensive staff assistance with dressing and toileting. Review of the physician orders for Resident #6 revealed an order dated 01/01/23 to change the colostomy wafer every three days and as needed. Interview on 05/24/23 at 12:50 P.M. with Resident #6's guardian via telephone stated he went to the facility on [DATE] around 11:00 A.M. to pick up Resident #6 to go on an outing and he observed dried feces on Resident #6's abdomen around the wafer. Resident #6's guardian stated State Tested Nursing Assistant (STNA) #78 provided colostomy care by cleaning around the wafer with cleansing wipes. Resident #6's guardian stated STNA #78 was unable to locate a new colostomy bag, so STNA #78 rinsed out the old colostomy bag, with feces present in the bag, in Resident #78's sink. Interview on 05/24/23 at 1:08 A.M. with STNA #78 confirmed she washed Resident #6's old colostomy bag out in Resident #6's bathroom sink due to she was unable to locate a new colostomy bag. STNA #78 stated Licensed Practical Nurse (LPN) #70 was present when the colostomy care was provided. Interview on 05/24/23 at 1:19 P.M. with LPN #70 confirmed STNA #78 rinsed Resident #6's old colostomy bag out in Resident #6's bathroom sink and re-applied the old bag. LPN #78 confirmed Resident #6's roommate does use the shared bathroom sink. Review of the policy titled Colostomy/Ileostomy Care, revised October 2010, stated staff were to remove the old drainage bag, provide appropriate skin care, and replace with clean drainage bag. Review of the facility policy titled Infection Prevention and Control Program, revised October 2018, stated the staff are to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable disease and infections. This deficiency is based on incidental findings discovered during the course of this complaint investigation. This deficiency represents ongoing noncompliance from the survey dated 04/05/23. 366236 Page 11 of 11