Independence House

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure physician orders were followed regarding wound care. This affected one (#33) of three residents reviewed for wounds. The facility census was 32.Findings include:Review of medical record for Resident #33 revealed an admission date of 12/05/25 and discharge date of 01/07/26 with diagnoses including but not limited to atrial fibrillation, psoas muscle abscess, heart failure, chronic gout, bacteremia, osteomyelitis of vertebra lumbar region, neoplasm of uncertain behavior of cerebral meninges, type two diabetes, non-pressure chronic ulcer of other part of right foot with fat layer exposed and hypertension.Review of minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact.Review of physician orders revealed treatment to coccyx triad cream with optifoam daily ordered from 12/06/25 through 12/12/25, sacrum wound cleanse with normal saline (NS) apply Santyl nickel thick, calcium alginate and apply silicone border foam dressing from 12/12/25 through 12/19/25, and mid thoracic back wound treatment cleanse with NS, apply silver alginate cover with ABD and secure with tape daily from 12/12/25 through 12/24/25, back incision cleanse with NS cover with gauze and ABD pad secure with tape daily from 12/06/25 through 12/10/25, sacrum wound cleanse with NS apply Santyl nickel thick, calcium alginate, xtrasorb and cover with tape daily from 12/20/25 through 12/24/25, miconazole external powder two percent (%) apply to affected skin areas topically twice daily for skin rash, bilateral heels apply derma prep and cover with mepilex every three days from (12/09/25 through/ 12/24/25, and right heel wound cleanse with NS apply skin prep and cover with silicone bordered foam dressing on Tuesday, Thursday, and Saturday daily.Review of treatment administration record (TAR) for December 2025 revealed the treatment to coccyx triad cream cover with optifoam was not signed off on 12/11/25, treatment to sacrum was not signed off for 12/16/25, mid thoracic back wound treatment was not signed off on 12/16/25 and 12/18/25, miconazole external powder two % twice daily was not signed off at bedtime on 12/11/25 and 12/12/25 and upon rising on 12/16/25, right heel wound cleanse with NS apply skin prep and cover with silicone bordered foam dressing on Tuesday, Thursday, Saturday was not signed off on 12/16/25, back incision cleanse with NS cover with gauze and ABD pads secure with tape daily was not signed off on 12/11/25, and bilateral heels apply derma prep and cover with mepilex every three days was not signed off on 12/11/25.Review of after visit summary dated 01/03/26 revealed orders to pack coccyx wound with Dakin's soaked kerlix and then apply sacral foam border to hold in place, paint bilateral heels with iodine and place mepilex over unstageable wounds daily, and back incision dressing check operative dressing at least once a shift and change dressings postoperative day three and then as needed moving forward. Postoperative day three is 01/05/26.Review of physician orders for January 2026 revealed heel inspection twice daily from 01/03/25 through 01/08/26, Dakin's soaked kerlix one quarter strength to sacral wound daily from 01/07/26 through 01/20/26, left heel paint with betadine cover with mepilex daily start date of 01/08/26 and discharge date of 01/08/26. No order was noted for monitoring the back incision every shift or to change the postoperative dressing until 01/06/26. No sacral treatment noted from 01/03/26 through 01/07/26.Review of TAR for January 2026 revealed heel inspection twice daily was not signed off on 01/05/26, left heel paint with betadine cover with mepilex daily was started on 01/08/26 after discharge. Review of wound documentation for 12/11/25 and 12/18/25 revealed the wounds to the mid thoracic, sacrum, and bilateral heels were improving from admission.Interview on 02/12/26 at 3:08 P.M. with the Administrator revealed they verified the discharge orders for 01/03/26 was to paint bilateral heels with iodine and place mepilex over the unstageable wounds daily and back incision dressing check operative dressing at least once per shift and change the dressing postoperative day three and then as needed moving forward, sacral wound was pack with Dakin's soaked kerlix daily. administrator verified there was no order to change the postoperative dressing on 01/05/26 or an order to monitor the dressing once a shift. Administrator located a physician order placed under other to apply ABD to back incision on 01/06/26 and it did not show up on the physician order due to not needing any documentation. Verified there was no order for sacral wound until 01/07/26 or paint bilateral heels upon discharge on [DATE] and no order in place until 01/08/26. Administrator verified the treatments not signed off in December as listed above.Review of policy titled Wound Treatment Management dated 12/01/2021 revealed to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.This deficiency represents non-compliance investigated under Complaint Number 2705856.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure physician orders were followed as ordered. This affected one (#33) of three residents reviewed for physician orders. The facility census was 32.Findings include:Review of medical record for Resident #33 revealed an admission date of 12/05/25 and discharge date of 01/07/26 with diagnoses including but not limited to atrial fibrillation, psoas muscle abscess, heart failure, chronic gout, bacteremia, osteomyelitis of vertebra lumbar region, neoplasm of uncertain behavior of cerebral meninges, type two diabetes, non-pressure chronic ulcer of other part of right foot with fat layer exposed and hypertension.Review of minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact.Review of the hospital discharge orders dated 12/05/25 revealed ergocalciferol 50,000 units by mouth weekly.Review of physician orders dated 12/05/25 revealed ergocalciferol tablet give 5,000 units by mouth weekly on Monday for vitamin D deficiency, daily weights first thing in the morning if weight is up three pounds in 24 hours, or five pounds in one week notify the physician, cyclobenzaprine 5 milligrams (mg) twice daily for muscle relaxer until 12/15/25, gabapentin 400 mg by mouth four times daily.Review of medication administration record (MAR) for December 2025 revealed ergocalciferol 5000 units was given on Mondays (not the 50,000 as documented in hospital discharge paperwork), daily weights were not obtained on 12/06/25, 12/08/25 through 12/13/25, 12/15/25 through 12/18/25, 12/20/25, and 12/23/25, cyclobenzaprine was not administered on 12/05/25 in the evening, gabapentin 400 mg was not signed off as administered on 12/05/25 in the evening.Interview on 02/12/26 at 3:40 P.M. with the Administrator revealed the daily weights were not obtained on the above dates. The Administrator verified the ergocalciferol order was transcribed incorrectly on 12/05/25 and the resident received three doses weekly since admission. The Administrator verified that cyclobenzaprine and gabapentin was not signed off on 12/05/25 for the evening shift.Review of policy titled, Medication Administration, revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection and sign the MAR after medication is administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident's care plan was revised for advanced directive orders. This affected one (#12) of 13 residents reviewed for care planning. The facility census was 37.
Findings include:
Review of the medical record for Resident #12 revealed an admission date of 10/10/23. Diagnoses included end stage renal disease, polyneuropathy, and hypertension.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition.
Review of the plan of care, initiated 10/12/23 and revised on 10/26/23, revealed Resident #12 had elected a full code (cardiopulmonary resuscitation) status.
Review of the physician orders revealed dated 08/15/24 revealed the resident's code status orders were changed from Full Code to Do Not Resuscitate Comfort Care (DNRCC).
Review of a DNR order form dated 08/15/24 revealed Resident #12 had elected DNRCC.
Review of a nurse's note dated 08/14/24 at 9:04 A.M., revealed Resident #12 had changed her code status from full code to DNRCC.
Interview on 09/04/24 at 12:49 P.M. with Licensed Practical Nurse (LPN) #212 verified Resident #12's care plan had not reflected the code status changed from full code to DNRCC.
Review of the facility policy titled Care Plan -- Comprehensive dated 05/15/15 revealed the care plan would be updated when there was a significant change in resident condition, when a desired outcome was not met, when the resident had been readmitted to the facility from a hospital stay and at least quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, observations, and policy review, the facility failed to timely obtain physician orders for a wound dressing change and complete wound dressing changes as physician ordered. This affected one (#23) of one resident reviewed for skin conditions. The facility census was 37.
Findings include:
Review of the medical record for Resident #23 revealed an admission date of 06/26/23. Diagnoses included hypertension, chronic obstructive pulmonary disease, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had impaired cognition.
Review of a nursing progress note dated 08/22/24 at 12:05 P.M., revealed dietary staff reported Resident #23 got bit by something in the dining room during lunch. The resident's left forearm was noted to have a raised reddened area. The physician was notified and gave a verbal order for Benadryl 25 milligrams every six hours as needed.
Review of a nurse's note dated 09/02/24 at 5:11 P.M. revealed the physician was notified of a new skin issue on left forearm. Awaiting response. Review of a wound assessment dated [DATE] revealed the resident had drainage from a wound on her left forearm. Review of a wound assessment dated [DATE] revealed the resident had a skin tear on her left forearm.
Observation and interview on 09/03/24 at 8:39 A.M. revealed Resident #23 had a gauze dressing applied to her left forearm. Resident #23 slid the dressing down and there was a nonadherent dressing underneath covering a wound with two steri-strips in place. The dressing was not dated. Resident #23 stated she thought she got bit by a bug and the facility had been placing a dressing on her left forearm for three to four days.
Review of the physician orders on 09/03/24 at 1:00 P.M. revealed there were no orders in place for the dressing to Resident #23's left forearm. Review of the treatment administration record (TAR) revealed no documentation of the dressing applied to the wound.
Review of a physician order dated 09/03/24 at 3:00 P.M. revealed an order for antibacterial ointment to the left arm wound and tear topically two times a day for wound care.
Observation on 09/04/24 at 7:41 A.M., revealed Resident #23 told Licensed Practical Nurse (LPN) #200 the wound dressing to her left arm was too tight. LPN #200 unwrapped a layer of self-adherent wrap then a layer of gauze wrap from around the left forearm revealing a nonadherent dressing covering a skin tear closed with two steri-strips. LPN #200 then cleansed the wound with normal saline, applied a new nonadherent dressing before wrapping the wound with new gauze and a self-adherent wrap.
Interview on 09/04/24 at 7:53 A.M. with LPN #200 verified she had removed an undated wound dressing from Resident #23's left forearm. LPN #200 verified she had not checked for a physician order prior to applying the dressing. LPN #200 then checked the physician orders and verified there was no order in place for a wound dressing to the resident's left forearm. LPN #200 verified there was an order for antibacterial ointment to be applied to the wound. LPN #200 verified she had not applied the ordered antibacterial ointment. LPN #200 revealed she would call the physician for an order for the wound dressing.
Interview on 09/05/24 at 7:02 A.M. with the Director of Nursing (DON) revealed she called the physician last night and clarified orders for the wound dressing. The DON stated a nurse had received wound care orders from the physician but forgot to enter the orders. The DON revealed the nurses applying the resident's wound dressing should have first ensure there was an order in place before changing the wound dressing and they should have documented the completion of the wound dressing change.
Review of the policy titled Skin Care and Ulcer Prevention dated 05/11/21 revealed the physician would be notified to obtain treatment orders for skin impairments. Daily monitoring of the wound dressing and site around wound as well as the wound if visible would be completed.

Based on review of a Legionella environmental assessment form, staff interviews and policy review, the facility failed to complete a Legionella risk assessment and failed to implement a water management program with defined control measures and testing protocols based on standards from the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) and the Centers for Disease Control and Prevention (CDC) tool kit, Developing a Water management Program to Reduce Legionella Growth and Spread in Buildings, dated 06/05/17. This had the potential to affect all 40 residents residing in the facility.
Findings include
Review of a Centers for Disease Control and Prevention (CDC) questionnaire for Legionella Environmental Assessment Form, dated 06/2015, utilized by the facility revealed no diagram of the water system outlining all areas of risk for Legionella. Further review of the form revealed the facility also had not specified control measures and testing protocols for Legionella based on standards from the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) and the CDC tool kit Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings dated 06/05/17.
Interview on 06/14/19 at 2:15 P.M. with the Administrator revealed the facility had not conducted a Legionella risk assessment using the CDC tool kit. The Administrator revealed the facility had used a CDC Legionella Environmental Assessment Form from 2015.
Interview on 06/13/19 at 3:45 P.M. with the Director of Maintenance (DOM) #120 revealed the facility had not diagrammed the water supply and identified all areas at risk using the CDC tool kit. DOM #112 revealed the facility checked the water temperatures around the building each month. DOM #112 further revealed the facility pool was tested when used. DOM #112 also revealed the water was flushed in rooms or areas not used.
Review of the facility policy Maintenance and Monitoring of Water Systems, last reviewed 08/02/16, revealed the facility would perform a clinical and environmental risk assessment to determine if culturing should be performed. Further review of the policy revealed no guidelines for implementing a water management program.
Further interview on 06/14/19 at 2:15 P.M. with the Administrator verified the facility policy was last reviewed in 2016.

Based on medical record review and staff interview, the facility failed to provide documentation of a rationale and an extended timeframe for extending the use of an as needed psychotropic medication beyond 14 days. This affected one (#1) of five residents reviewed for unnecessary medications with potential to affect nine residents identified by the facility with orders for as needed psychotropic medications. The facility census was 40.
Findings include:
Review of Resident #1's medical record revealed an admission date of 08/27/18 with diagnoses including Parkinson's disease, dementia without behavioral disturbances, cerebral infarction, major depression, anxiety and obsessive-compulsive disorder.
Review of a physician order, dated 08/27/18, revealed Resident #1 was ordered the anti-anxiety medication Lorazepam 0.5 milligrams (mg.) by mouth every 12 hours as needed for anxiety. The physician order had no stop date and remained an active order as of 06/13/19.
Review of a physician recommendation form, dated 09/17/18, revealed the facility pharmacy recommended the physician evaluate and update Resident #1's chart with documentation to extend the initial order for as needed Lorazepam beyond 14 days. The physician response to the recommendation was marked as other with a written notation of noted and signed by the physician on 09/21/18. There was no further instructions or orders provided on the physician recommendation form, as well as no additional physician recommendation forms related to Resident #1's order for as needed Lorazepam.
Review of Resident #1's entire medical record including nursing and physician progress notes, consultation reports, physician orders, and assessments from 2018 and 2019 revealed no documented evidence of a rationale for extending Resident #1's as needed Lorazepam beyond the initial 14 days when it was ordered on 08/27/18, as well as no timeframe documented for how long the order would be extended.
Interview on 06/13/19 at 10:42 A.M. with Director of Nursing (DON) #1 verified Resident #1 had an active order for an as needed anti-anxiety medication since 08/27/19, and verified the medical record contained no documented rationale for extending the physician order or a specified timeframe for the order.

Based on observation, staff interview and record review, the facility failed to ensure a resident who was dependent on staff for fingernail care received adequate fingernail care as care planned. This affected one (#9) of one resident reviewed for activities of daily living. This had the potential to affect three residents identified by the facility who were dependent on staff assistance with personal hygiene. The facility census was 40.
Findings include:
Review of Resident #9's medical record revealed an admission date of 10/15/16 with diagnoses including dementia without behavioral disturbances, Parkinson's disease and anxiety.
Review of the Minimum Data Set (MDS) assessment, dated 04/08/19, revealed Resident #9 had severely impaired cognition, did not reject any care during the look back period, and required an extensive two plus person physical assistance with personal hygiene.
Review of an activities of daily living (ADL) self-care performance deficit revealed Resident #9 was to have her nail length checked, trimmed, and cleaned on bath day as necessary, and report any changes to the nurse.
Review of a shower schedule for facility residents, dated 01/28/19, revealed Resident #9 was scheduled for showers on Mondays and Thursdays on second shift.
Review of a shower sheet dated 06/10/19 (Monday) revealed Resident #9 was provided a shower with no concerns noted and no indication of fingernail care provided. Review of additional shower sheets from 05/30/19, 06/03/19, and 06/06/19 revealed Resident #9 received showers with no refusals of care.
Review of nursing progress notes and nurse aide ADL documentation between 05/30/19 and 06/12/19 revealed no documentation of Resident #9 refusing care.
Observation on 06/10/19 at 12:05 P.M. revealed a dried black substance underneath three fingernails (index, middle, and ring) on her left hand. Observations on 06/11/19 at 1:08 P.M. and 3:23 P.M., and on 06/12/19 at 10:07 A.M. revealed Resident #9's fingernails on her left hand continued to have a dried black substance underneath them.
Interview on 06/12/19 3:29 P.M. with State Tested Nurse Aide (STNA) #250 stated Resident #9 was an extensive to total care assist with personal hygiene, and stated Resident #9 would not be able to clean her fingernails on her own. STNA #250 stated the facility staff does provide Resident #9 with fingernail care when it is needed, and if the fingernails were dirty they would be cleaned right away.
Observation on 06/12/19 at 3:47 P.M. with STNA #250 and STNA #275, revealed Resident #9 sitting in the common area of the secure unit with her hands under a blanket. When Resident #9 was asked, she lifted her left hand from under the blanket and revealed the dried black substance under her fingernails of her left hand. STNA #250 and STNA #275 verified the dried black substance under Resident #9's fingernails and stated they would clean them right away.

Based on observation, staff interview, and medical record review, the facility failed to provide a dignified dining experience while assisting a resident with eating. This affected one (#12) of 14 residents observed dining on the secured unit. The facility identified Resident #12 as the only resident on the secured unit who required feeding assistance. The facility census was 40.
Findings include:
Review of Resident #12's medical record revealed an admission date of 04/18/16 with diagnoses including unspecified dementia without behavioral disturbances, dysphagia, lack of coordination, muscle weakness and disorientation.
Review of an activities of daily living care plan dated 04/04/18 revealed Resident #12 required reminding, prompting, cueing, and assistance to eat.
Review of the most recent Minimum Data Set (MDS) assessment, dated 04/04/19, revealed Resident #12 had short and long term memory issues with severely impaired cognitive skills for daily decision making. Resident #12 was assessed as requiring extensive one person physical assistance for eating.
Observation on 06/10/19 at 11:45 A.M. of the lunch time meal revealed residents on the secured unit seated in the common dining area. On 06/10/19 at 11:48 A.M., State Tested Nurse Aide (STNA) #215 was observed standing on the right side of Resident #12 and was noted to be placing food items on a spoon and lifting the spoon to Resident #12's mouth. STNA #215 was also observed lifting cups to Resident #12's lips to take drinks of fluids. The observation continued until 12:15 P.M. on 06/10/19 and STNA #215 was observed standing to assist Resident #12 during the lunch meal the entire observation. At no time did STNA #215 attempt to locate a chair to sit one once she began assisting Resident #12.
Interview on 06/10/19 at 12:23 P.M. with STNA #215 verified she stood to assist Resident #12 throughout lunch, and stated she normally sits to assist residents with feeding. However, there were no additional chairs available for her to sit on.

Based on medical record review and staff interview, the facility failed to obtained laboratory values as ordered by the physician. This affected one (#4) of five residents reviewed for unnecessary medications with potential to affect 31 residents identified by the facility with orders to obtain laboratory values. The facility census was 40.
Findings include:
Review of Resident #4's medical record revealed an admission date of 07/06/13 with diagnoses including unspecified dementia without behavioral disturbances, unspecified psychosis, anxiety, major depression, essential hypertension, and peripheral vascular disease.
Review of a physician order, dated 02/16/19, revealed Resident #4 was ordered to have a complete blood count (CBC) laboratory test, which was a laboratory test to determine the overall health of a person's blood, obtained every six months with the months of March and September as the intended months to obtain Resident #4's blood.
Review of the most recently obtained CBC laboratory values for Resident #4 revealed the laboratory values were obtained on 10/31/18. There were no further CBC laboratory values in the medical record for Resident #4 since 10/31/18.
Interview on 06/13/19 at 10:36 A.M., with Director of Nursing (DON) #1 verified the laboratory values from 10/31/18 were the most recently collected CBC laboratory values for Resident #4. DON #1 stated Resident #4 should have had a CBC laboratory value obtained in April 2019, and verified it was done done as ordered.