Inspection·August 7, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and review of facility policy, the facility failed to implement interventions and treat a resident for constipation. This affected one resident (#29) of five reviewed for unnecessary medications. The facility census was 131. Residents Affected - Few Findings include: Review of Resident #29's medical record revealed an admission date of 05/04/19 with diagnoses including Lewy body dementia, toxic encephalopathy, dysthymic disorder, and depression. Review of Resident #29's care plan dated 05/15/19 revealed the resident was at risk for constipation due to impaired mobility and medication usage. The goal was for the resident to have a medium to large bowel movement every two to three days. Intervention included if no bowel movement in three days to assess for nausea, vomiting, abdominal distention, pain, bowel sounds, monitor bowel patterns and notify the physician if needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had severe cognitive impairment and was noted to have occasional bowel incontinence. Review of Resident #29's Bowel and Bladder Summary report dated 07/09/19 through 07/23/19 revealed the resident did not have a bowel movement from 07/09/19 to 07/13/19 (five days). The resident did not have a bowel movement from 07/18/19 through 07/23/19 (six days). There was no evidence the physician was notified, or any treatment for constipation relief was completed. Interview with the Director of Nursing (DON) on 08/07/19 at 9:47 A.M. revealed the bowel log for each resident was monitored each morning and reviewed. If there was a resident who had not had a bowel movement after three days they looked at it for further intervention. The DON revealed interventions were to administer medication based on the physician orders. The DON verified Resident #29 did not have a bowel movement from 07/09/10 to 07/16/19 (five days) and from 07/18/19 to 07/23/19 (six days). Interview with Licensed Practical Nurse (LPN) #200 on 08/07/19 at 1:30 P.M. revealed if a resident had not had a bowel movement for two days she would use the physician standing orders and administer milk of magnesium (MOM) or just contact the physician. Interview with the DON on 08/07/19 at 1:37 P.M. revealed the facility did not have any standing orders in relation to bowel and bladder and was unsure why a note was not entered for Resident #29 during the times she had no bowel movement. (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 5 Event ID: 365077 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 365077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monterey Care Center 3929 Hoover Road Grove City, OH 43123 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)