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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff and resident interview and policy review, the facility failed to ensure quarterly care
conferences were completed. This affected one (#40) of three residents reviewed for care conferences. The
census was 54.
Findings Include:
Review of the medical record for Resident #40 revealed an admission date of 12/11/15 with diagnoses
including cerebral infarction, depression, and anxiety.
Review of the Nursing Interdisciplinary Meeting dated 08/20/19 revealed a care conference was held on
08/20/19 and the resident attended the care conference. Review of the medical record for Resident #40
revealed no care conference was held since 08/20/19.
Further review of the medical record revealed the facility completed a Quarterly Minimum Data Set
Assessment (MDS) dated [DATE] revealed Resident #40 is cognitively intact.
Interview with Resident #40 on 12/26/19 at 10:01 A.M. revealed he could not remember the last time he
had a care conference.
Interview with Social Services Designee #96 on 12/27/19 at 12:39 P.M. revealed care conferences are held
every quarter. The interview verified quarterly care conference was completed since 08/20/19 and a care
conference should have been held in November 2019.
Review of the facility policy titled Resident Education, last revised 11/2009, revealed the resident is involved
in care and care decisions through the interdisciplinary care planning process.
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 3
Event ID:
365318
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
365318
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
St Catherines Manor of Washington Court House
250 Glenn Avenue
Washington Court Hou, OH 43160
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)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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, observations and staff interview, the facility failed to staff implemented Resident #8's
skin treatments for a pressure ulcer and pressure ulcer preventative as physician ordered. This affected one
(#8) of two residents reviewed for pressure ulcers. The facility census was 54.
Residents Affected - Few
Findings include:
Record review of Resident #8 revealed an admission date of 08/15/19. Diagnoses include atherosclerotic
heart disease of native coronary artery, angina pectoris, hyperlipidemia, type 2 diabetes mellitus, transient
cerebral ischemic attack, pain, dementia without behavioral disturbance, pressure ulcer of sacral region,
pressure ulcer of left heel, and peripheral vascular disease.
Review of the modified quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident
was cognitively intact and required extensive assistance for transfer, locomotion on and off unit, toilet use
and bathing. Resident #8 required extensive assistance of two people for bed mobility, dressing and
personal hygiene. The Resident had an indwelling urinary catheter and was always incontinent of bowel.
Review of a physician order dated 08/26/19 revealed a treatment of skin prep to right heel three times a day
for prophylactic.
Review of a physician order dated 10/28/19 revealed a treatment of apply betadine to the left heel two
times a day.
Review of nursing wound documentation dated 12/26/19 revealed on 12/23/19 the left heel measurements
were 5.5 centimeters (cm) in length by 6.0 cm in width with no depth. The left heel wound was considered a
deep tissue injury pressure ulcer with eschar and no drainage. There was no pressure ulcer documentation
on the right heel.
Observation of Registered Nurse (RN) #83 completing Resident #8 dressing change on 12/27/19 at 1:36
P.M. revealed she applied skin prep to the left heel pressure ulcer and betadine to the right foot which did
not have a pressure ulcer.
Interview with RN #83 on 12/27/19 at 1:40 P.M. verified she applied skin prep to the left heel pressure ulcer
and betadine to the right foot which did not have a pressure ulcer. RN #83 verified after checking the
physician orders she did the treatments on the wrong heels.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365318
If continuation sheet
Page 2 of 3
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
365318
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
St Catherines Manor of Washington Court House
250 Glenn Avenue
Washington Court Hou, OH 43160
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)
F 0770
Provide timely, quality laboratory services/tests to meet the needs of residents.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review and staff interview, the facility failed to obtain laboratory (lab) values as
physician ordered. This affected one (#3) out of five residents reviewed for unnecessary medications. The
facility census was 54.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #3 revealed an admission date of 01/23/14. Diagnoses include
dementia, hypertension, psychosis, hyperlipidemia, and depression.
Review of physician telephone order dated 10/28/19 revealed an order to start Depakote for dementia with
behavioral disturbance and in ten days obtain a Complete Blood Count (CBC) and a Valproic Acid level.
Review of labs in medical record revealed last CBC done was on 07/09/19 and a valproic acid level only
was obtained on 11/07/19.
Interview was conducted on 12/28/19 at 2:16 P.M. with the Director of Nursing (DON) and she verified that
the CBC level was not drawn as ordered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365318
If continuation sheet
Page 3 of 3
