Health inspection·November 22, 2023

F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. 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, hospital paperwork review, staff interview, and resident interview, the facility failed to obtain admission physician orders for the treatment of a surgical wound present on admission. This affected one (#97) of one residents reviewed for admission. The facility census was 47. Residents Affected - Few Findings include: Review of the medical record of Resident #97 revealed an admission date of 11/17/23. Diagnoses include non-ST elevation myocardial infarction, atherosclerosis of autologous artery coronary artery bypass graft with angina pectoris with documented spasm and combined systolic (congestive) and diastolic (congestive) heart failure. Review of the hospital discharge paperwork dated 11/15/23 revealed Resident #97 was status post left heart catheterization. A second document titled Cardiac Cath Discharge Instructions undated revealed you can shower after 24 hours, remove the dressing in the shower. Review of the Nursing admission assessment dated [DATE] revealed Resident #97 was cognitively intact. Review of the progress note dated 11/17/23 at 6:32 P.M., revealed the presence of a pressure dressing to the left groin. A note, written by Registered Nurse (RN) #211, revealed a note stating, Will follow-up on orders when to be removed. Interview on 11/20/23 at 9:02 A.M., with Resident #97 revealed the resident was curious as to why the dressing was still on his groin after his heart catheterization. Resident #97 stated he was reluctant to allow the surveyor to view the dressing. Interview on 11/20/23 at 2:19 P.M., with Director of Nursing (DON) provided verification related to the progress note dated 11/17/23 at 6:32 P.M., which revealed Resident #97 had a pressure dressing to the left groin upon admission. The note indicated a follow-up of when to remove the dressing will occur. She further verified no additional notes or physician orders were documented related to the pressure dressing at the left groin. Review of the progress note dated 11/20/23 at 3:03 P.M., revealed the DON received clarification orders for the left groin pressure dressing. Resident #97 had a cardiac catheterization completed on 11/15/23 and according to the Cardiac Cath Discharge instructions from the Catheterization Laboratory the dressing could have been removed 24 hours post procedure. Page 1 of 7 365232 365232 11/22/2023 Vancrest of St Mary's 1035 Hager Street St Marys, OH 45885

F 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a progress note dated 11/20/23 at 8:26 P.M., revealed the pressure dressing was removed from the left groin and no signs or symptoms of infection was noted. No drainage was noted at the time and Resident #97 tolerated the procedure well. Interview on 11/21/23 at 11:00 A.M., with the DON verified the dressing was not removed at the hospital and the facility had no orders to address the wound. The DON also verified once clarification orders were obtained the facility did not remove the dressing until five hours later. 365232 Page 2 of 7 365232 11/22/2023 Vancrest of St Mary's 1035 Hager Street St Marys, OH 45885

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately assess residents' medications for quarterly Minimum Data Set (MDS) assessments. This affected two (#23 and #36) of 16 residents reviewed for accurate assessments. The current census is 47. Residents Affected - Few Findings include: 1. Record review for Resident #23 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #23 included: fracture of femur, aftercare post-surgery, muscle weakness, chronic obstructive pulmonary disease, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Per the assessment the resident was assessed as having received an antipsychotic medication on a routine basis with no gradual dose reduction attempted. Review of Resident #23's care plans dated 08/08/23 revealed no focus for antipsychotic medication noted in the care plans. Review of Resident #23's prescribed medications dating from August 2023 to September 2023 revealed the resident had not received any anti-psychotic medications. Interview on 11/21/23 at 2:45 P.M., with MDS Licensed Practical Nurse (LPN) #310 verified when she completed the assessment, she coded the resident for antipsychotic use on routine basis even though the resident had not received an antipsychotic during the review period. 2. Record review of Resident #36 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #26 included: depression, subarachnoid hemorrhage, hypertension, aphasia, lupus, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed the resident had been coded for receiving an antipsychotic medication on a routine bases and a gradual dose reduction was attempted. Review of Resident #23's care plans dated 06/12/23 revealed no focus for antipsychotic medication noted in the care plans. Review of Resident #23's prescribed medications dating from September 2023 to October 2023 revealed the resident had not received any anti-psychotic medications. Review of Resident #23's Medication Administration Record (MAR) dated October 2023 revealed the resident had not been prescribed or received any antipsychotic medications. Interview on 11/21/23 at 2:45 P.M., with the MDS LPN #310 verified when she completed the assessment, she coded the resident for antipsychotic use on routine basis even though the resident had not received an antipsychotic during the review period. 365232 Page 3 of 7 365232 11/22/2023 Vancrest of St Mary's 1035 Hager Street St Marys, OH 45885

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, hospital paperwork review, staff interview, resident interview, and policy review, the facility failed to assess a surgical wound and obtain physician orders for the treatment of a surgical wound. This affected one (#97) of one residents reviewed for admission. The facility census was 47. Residents Affected - Few Findings include: Review of the medical record of Resident #97 revealed an admission date of 11/17/23. Diagnoses include non-ST elevation myocardial infarction, atherosclerosis of autologous artery coronary artery bypass graft with angina pectoris with documented spasm and combined systolic (congestive) and diastolic (congestive) heart failure. Review of the hospital discharge paperwork dated 11/15/23 revealed Resident #97 was status post left heart catheterization. A second document titled Cardiac Cath Discharge Instructions undated revealed you can shower after 24 hours, remove the dressing in the shower. Review of the Nursing admission assessment dated [DATE] revealed Resident #97 was cognitively intact. Review of the progress note dated 11/17/23 at 6:32 P.M., revealed the presence of a pressure dressing to the left groin. A note, written by Registered Nurse (RN) #211, revealed a note stating, Will follow-up on orders when to be removed. Interview on 11/20/23 at 9:02 A.M., with Resident #97 revealed the resident was curious as to why the dressing was still on his groin after his heart catheterization. Resident #97 stated he was reluctant to allow the surveyor to view the dressing. Interview on 11/20/23 at 2:19 P.M., with Director of Nursing (DON) provided verification related to the progress note dated 11/17/23 at 6:32 P.M., which revealed Resident #97 had a pressure dressing to the left groin upon admission. The note indicated a follow-up of when to remove the dressing will occur. She further verified no additional notes or physician orders were documented related to the pressure dressing at the left groin. Review of the progress note dated 11/20/23 at 3:03 P.M., revealed the DON received clarification orders for the left groin pressure dressing. Resident #97 had a cardiac catheterization completed on 11/15/23 and according to the Cardiac Cath Discharge instructions from the Catheterization Laboratory the dressing could have been removed 24 hours post procedure. Review of a progress note dated 11/20/23 at 8:26 P.M., revealed the pressure dressing was removed from the left groin and no signs or symptoms of infection was noted. No drainage was noted at the time and Resident #97 tolerated the procedure well. Interview on 11/21/23 at 11:00 A.M., with the DON verified the dressing was not removed at the hospital and the facility had no orders to address the wound. The DON also verified once clarification orders were obtained the facility did not remove the dressing until five hours later. Interview on 11/21/23 at 11:15 A.M. with Administrator, with review of the facility policy titled 365232 Page 4 of 7 365232 11/22/2023 Vancrest of St Mary's 1035 Hager Street St Marys, OH 45885

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admission Assessment and Follow-Up: Role of the Nurse revealed the skin should be assessed and the expectation would be to remove any dressings, unless a specific order not to, to completely assess the skin. Review of the policy titled admission Assessment and Follow Up: Role of the Nurse dated September 2012 revealed the purpose of the procedure was to gather information about the resident's physical condition upon admission for the purpose of managing the resident. One step included to conduct a physical assessment to include the skin. 365232 Page 5 of 7 365232 11/22/2023 Vancrest of St Mary's 1035 Hager Street St Marys, OH 45885

F 0760 Ensure that residents are free from significant medication errors. 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, observation, staff interview, and review of the policy, the facility failed to ensure a resident was free from significant medication error. This affected one (#97) of two residents reviewed for insulin administration. The facility census was 47. Residents Affected - Few Findings include: Review of the medical record of Resident #97 revealed an admission date of 11/17/23. Diagnosis includes diabetes mellitus type one without complications. Review of the Nursing admission assessment dated [DATE] revealed Resident #97 was cognitively intact. Review of the physician order dated 11/21/23 revealed an order for Lispro insulin to be administered seven units and per sliding scale with meals. An added instruction read Resident may self-regulate insulin sliding scale. Review of the medication administration record (MAR) and insulin administration records for November 2023 revealed the Lispro insulin ordered for 11/21/23 at 5:00 P.M., was not documented as having been administered. Interview on 11/22/23 at 8:03 A.M., with Director of Nursing (DON) while reviewing the MAR for Resident #97 provided verification the 5:00 P.M. dose of Lispro insulin was not documented as having been administered on 11/21/23 at 5:00 P.M. Telephone interview on 11/22/23 at 8:10 A.M., along with DON, with Licensed Practical Nurse (LPN) #218 provided verification the Lispro insulin was not administered on 11/21/23 at 5:00 P.M. Observation on 11/22/23 at 8:15 A.M., with LPN #219 revealed LPN #219 was observed to place a needle onto the Lispro inulin pen and dialed the knob to 3 (three) and did not prime the needle. LPN #219 administered the insulin to Resident #97. LPN #219 had failed to prime the inulin pen. Interview on 11/22/23 at 8:20 A.M., with LPN #219 provided verification she had not primed the insulin pen prior to administering the 3 (three) units of Lispro insulin to Resident #97. Review of the undated policy titled Insulin Administration Level III revealed a new pen needle will be attached and primed to remove air bubbles. It must be primed before each injection. Turn the dosage knob to the 2 (two) unit indicator with the pen pointing upward, push the knob all the way to release the air. One drop of insulin should appear, repeat the step as needed until you see a drop of insulin to ensure all of the air is out. 365232 Page 6 of 7 365232 11/22/2023 Vancrest of St Mary's 1035 Hager Street St Marys, OH 45885

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and review of policy, the facility failed to maintain hand hygiene while delivering meal trays on the 200 hall. This had the potential to affect 12 (#24, #35, #37, #95, #96, #97, #98, #99, #100, #101, #102, and #103) of 12 residents residing in the 200 hall. The facility census was 47. Residents Affected - Some Findings include: Observation, on 11/20/23 beginning at 11:20 A.M., during the lunchroom tray delivery on the 200 hall, revealed the Director of Nursing (DON) was observed to enter the room of Resident #98 and touch the resident's glasses and cell phone. DON placed the tray onto the over bed table and proceeded out of the room and began reaching for another resident tray. Interview at this time with the DON, verified she had reached for another resident's tray and stated, I should have washed my hands after touching the personal items. Observation 11/20/23 at 11:40 A.M., revealed a State Tested Nursing Assistant (STNA) #257 was observed to assist a therapist with repositioning Resident #100. STNA #257 exited the room and began reaching for a resident tray from the insulated cart. Interview at the time of the observation, with STNA #257 verified she was proceeding to grab a resident food tray and stated I did not wash my hands after repositioning him. Review of the policy titled Handwashing/Hand Hygiene dated August 2015, revealed an alcohol-based hand rub containing at least 62% alcohol, or alternatively soap and water should be used before and after direct contact with residents and assisting residents with meals. 365232 Page 7 of 7