Health inspection·September 5, 2019

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 medical record review, resident and staff interview, and review of facility policies, the facility failed to ensure the physician and dialysis center were notified of a change in a resident's condition. This affected one (Resident #15) of one resident reviewed for dialysis. The facility identified only one resident receiving dialysis. The facility census was 54. Findings include: Review of Resident #15's medical record revealed an admission date of 05/22/19. Medical diagnoses included aftercare for fracture left femur, hypertensive heart and chronic kidney disease with heart failure, dependence on renal dialysis, rheumatoid arthritis, and insomnia. Review of the resident's Minimum Data Set assessment dated [DATE] revealed mild impairment in cognition. The resident received anticoagulant medication three days during the assessment period. Review of the resident's physician's orders revealed an order dated 05/22/19 for hemodialysis Tuesday, Thursday, and Saturday. On 05/23/19, an order was written to monitor for signs and symptoms of bleeding and increased or abnormal bruising, and to notify physician if symptoms occur. The resident had an order dated 06/14/19 for clopidogrel (blood thinner) and an order dated 06/20/19 for apixaban (anticoagulant). Review of the resident's dialysis care plan dated 06/14/19 revealed interventions included coordinating care with the dialysis center. If bleeding from shunt site, apply pressure, call physician. If excessive bleeding, call nine-one-one (911). Review of the resident's care plan dated 06/20/19 for resident's risk for excessive bleeding and bruising related to medications included interventions to notify the physician of abnormal bruising and or bleeding. Review of the resident's nursing notes dated 08/22/19 revealed the resident was sent to the hospital due to uncontrolled bleeding from her right arm arteriovenous (AV) fistula following dialysis. The resident returned to the facility on [DATE]. There were no further notes indicating bleeding issues until 09/04/19 at 4:58 A.M. The note revealed the resident called the nurse in to look at her right arm. She had pulled off her cotton ball and tape from dialysis and it was bleeding. Bruit and thrill were present. The area was cleaned and a band-aid was applied. Approximately an hour later, the resident called the nurse back in and the bleeding had not stopped. The nurse documented she applied and island dressing and wrapped kerlix around to apply pressure. She rechecked the resident at 4:30 A.M. and the bleeding had stopped. On 09/04/19 at 5:26 P.M. it was documented the resident continued to have excess bleeding from fistula at this time. This nurse cleaned the area and covered it with a dressing and secured with coban to apply pressure. Continued review of the nursing notes revealed (continued on next page) 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 10 Event ID: 366464 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 366464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs of Lima The 370 North Eastown Road Lima, OH 45807 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)