Health inspection·December 28, 2019

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. Page 1 of 3 365318 365318 12/28/2019 St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160

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. 365318 Page 2 of 3 365318 12/28/2019 St Catherines Manor of Washington Court House 250 Glenn Avenue Washington Court Hou, OH 43160

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. 365318 Page 3 of 3