Inspection·March 9, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few identified it as blood blister. STNA #128 stated she documented the condition on Resident #23's shower sheet dated 02/23/23. Interview on 03/09/23 at 8:52 A.M. with Wound Nurse Practitioner (WNP) #240 stated she was not informed of the black spot on Resident #23's right great toe. WNP #240 stated she was in the facility on 02/23/23 and on 03/02/23 and would have expected the facility to have told her about it on one of these visits. 2. Interview with Resident #23's POA on 03/06/23 at 11:02 A.M. stated Resident #23 had been having explosive diarrhea. Review of Resident #23's bowel tracker from 02/07/23 through 03/07/23 revealed there were 30 episodes of loose bowel movements in medium to large in size during that time frame. Review of progress notes from 02/07/23 through 03/07/23 revealed the physician was not notified and there were no orders to treat Resident #23's diarrhea. Interview with Licensed Practical Nurse (LPN) #331 on 03/07/23 at 9:42 A.M. stated she was not aware of Resident #23's diarrhea, but could be due to Resident #23's colon polyps. LPN #331 stated could call the physician. Observation of incontinence care for Resident #23 on 03/07/23 at 10:53 A.M. with State Tested Nurse Aide (STNA) #207 and STNA #128 revealed Resident #23's incontinence brief was saturated with liquid stool. Interview with the Nurse Practitioner (NP) #235 on 03/08/23 at 10:20 A.M. stated her protocol would be for the facility to let her know about the diarrhea, how long it had been going on, and how much. NP #235 stated she would make a determination from that information on what orders would be put into place. NP #235 stated, depending on that finding, she would order a kidney, ureter and bladder (KUB) x-radiation (x-ray) and an anti-diarrhea medication. NP #235 stated she came into the facility on [DATE] and LPN #331 reported to her there was some concerns for bowel movements for Resident #23, but the nurse reported he did not have any diarrhea, but had some history for polyps. NP #235 stated she had not been informed of Resident #23's diarrhea for the past 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 2 of 9 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 03/09/2023 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 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 observation, medical record review, staff and Power of Attorney (POA) interview, the facility failed to ensure a skin condition was assessed and a treatment was put into place. This affected one (#23) of three residents reviewed for skin conditions. The census was 47. Residents Affected - Few Findings included: Medical record review for Resident #23 revealed an admission date of 08/30/22. Medical diagnoses included pneumonia, heart failure, septicemia, Alzheimer's disease, and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. Resident #23 required extensive assistance with two person assistance for bed mobility, transfers and toilet use. Resident #23 required supervision for eating with setup help only and was assessed frequently incontinent for bowel and bladder. Interview with Resident #23's POA on 03/06/23 at 10:52 A.M. stated Resident #23 had a black spot on his toe, but was not able to identify which toe. Observation on 03/07/23 at 10:51 A.M. revealed Resident #23 had a black circle the size of a dime on the bottom of his right great toe. Review of skin assessments dated 02/23/23 at 1:13 P.M. revealed State Tested Nurse Aide (STNA) #128 identified the area on Resident #23's skin. Review of physician orders from 02/23/23 to 03/01/23 revealed there were no orders for treatment of the wound on Resident #23's right great toe. Review of Resident #23's progress notes dated 02/23/23 revealed there were no progress notes reporting the skin condition on the right great toe. Interview with Licensed Practical Nurse (LPN) #331 on 03/07/23 at 11:02 A.M. confirmed she did not know anything about the black spot on Resident #23's toe and there was not any kind of a treatment in place for it. Interview with STNA #128 on 03/07/23 at 11:45 A.M. confirmed she saw the black spot on Resident #23's right great toe, reported it to the nurse on duty, and said the nurse came and looked at it, and identified it as blood blister. STNA #128 stated she documented the condition on Resident #23's shower sheet dated 02/23/23. Interview on 03/09/23 at 8:52 A.M. with Wound Nurse Practitioner (WNP) #240 stated she was not informed of the black spot on Resident #23's right great toe. WNP #240 stated she was in the facility on 02/23/23 and on 03/02/23 and would have expected the facility to have told her about it on one of these visits. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 3 of 9 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 03/09/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #23's medical record revealed an admission date of 08/30/22. Medical diagnoses included pneumonia, heart failure, septicemia, Alzheimer's disease, and diabetes. Review of fall assessments dated 11/13/22, 12/30/22, 01/20/23 and 03/05/23 revealed Resident #23 was a moderate fall risk. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. Resident #23's functional status was assessed to require an extensive two person assistance for bed mobility, transfers and toilet use, and required supervision for eating with setup help only. Review of a progress note for Resident #23 dated 12/30/22 revealed the nurse heard a crash coming from the resident's room. Resident #23 was discovered sitting on his bottom and rolled onto his side and the bedside table was broken in half. Resident #23 was toileted by physical therapy (PT) prior and had a bowel movement in his brief. There was no injury noted and a new intervention was to place a sign in Resident #23's room to be sure to use the call light for assistance. Review of an investigation for the fall on 12/30/22 at 3:07 P.M. revealed Resident #23 was observed on the floor on his bottom then laid down and rolled to his side. Resident #23 fell onto the bedside table and broke it. Resident #23 was trying to use the bathroom and had his slipper socks on. Resident #23 had a bruise to his upper rear iliac crest. Resident #23 was oriented to person, but was confused, and had issues with his gait balance, impaired memory, and was ambulating without assistance. There were no witnesses found. Resident #23 was toileted by PT, but had bowel movement in his brief. There was no evidence a root cause analysis was completed for this fall. Interview with the DON on 03/08/23 at 8:42 A.M. stated Resident #23 used the call light in the past but agreed he had safety awareness issues. The DON confirmed she had not done a root cause analysis for this fall. During a telephone interview on 03/09/2023 at 11:15 A.M. Registered Nurse (RN) #338 stated it was his opinion that implementing a verbal reminder to use the call light after a fall was a nonsense intervention for a resident with dementia, and it was inappropriate. Observation and interview with Resident #23 on 03/09/23 at 12:43 P.M. revealed when asked if he could read the yellow sign on the wall to the right side of his bed and the orange sign on the wall in front of his bed which read, Use call light for help, Resident #23 was able to look at the sign but could not verbalize what the sign read. Review of a progress note dated 03/04/23 at 5:09 A.M. for Resident #23 revealed the resident was observed on the floor. Resident #23 wanted to get out of his bed and sit in his chair. The resident was conscious, vital signs were normal, neurological checks were normal, and there were no injuries. The immediate intervention was to place Resident #23 in his chair. Review of the investigation dated 3/4/23 revealed Resident #23 was observed sitting on the floor and he was calling for help. Resident #23 was calm, conscious, and would like to sit in his chair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 4 of 9 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 03/09/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #23's neurological assessments were completed with no concerns, and his call light was put into reach, and informed to press his call light when he needed help. There were no injuries observed. Resident #23 was confused and there were no witnesses found. The IDT collaborated and decided they would place a fall mat to the left side of Resident #23's bed. Further interventions were to encourage use of Resident #23's walker and there were signs in the room to to remind the resident to use the call light for assistance. There was not any evidence there was a root cause analysis completed for this fall. Interview with the DON on 03/0823 at 8:53 A.M. revealed she did not do a root cause analysis and felt like a fall mat was appropriate to put as a new intervention. The DON stated the IDT review falls when they happen, but confirmed there was room for improvement and would be working on a new system. 3. Review of Resident #200's medical record revealed an admission date of 02/03/23. Medical diagnoses included progressive neurological conditions, Parkinson's disease, coronary artery disease, anxiety, and depression. Review of the MDS assessment dated [DATE] revealed Resident #200 was assessed as cognitively intact. Resident #200 was assessed to require an extensive assistance of two-person assistance for bed mobility, transfers and toilet use. Resident #200 required supervision for eating with set-up help only. Review of a fall assessment dated [DATE] revealed Resident #200 was a high fall risk. Review of subsequent fall risk assessments on 02/05/23, 02/07/23, 02/12/23, and 02/16/23 revealed Resident #200 was assessed at moderate risk. Review of a progress note dated 02/12/23 revealed a nurse heard yelling and immediately ran to see what happened. The nurse observed Resident #200 on the floor on the right side of the bed. All interventions were in place and vital signs were taken with no concerns. Resident #200 was assisted back to bed and was confused and indicating she was in pain; however, the notes indicated the staff were unable to assess the pain. Review of a fall investigation dated 02/12/23 revealed Resident #200 was observed on the floor on the right side of the bed with all interventions in place. There were no witnesses to the fall and Resident #200 was oriented to person only and was confused. A fall mat was implemented as a new intervention, and the care plan was updated to reflect the new intervention. Interview with the DON on 03/08/23 at 9:02 A.M. confirmed there was not a root cause analysis for this fall for Resident #200. Review of a policy titled, Fall Reduction Policy, dated 04/29/16, revealed it is the policy of the facility to identify residents at risk for falls and to implement a fall reduction program to reduce the risk of falls and possible injury. Follow-up investigations will be done to ascertain the cause of the incident to reduce the risk of further occurrences. Based on medical record review, resident and staff interview, fall investigation review, and policy review, the facility failed to complete a root cause analysis as part of their fall investigations and implement resident appropriate fall interventions. This affected three (#16, #23, and #200) of seven residents reviewed for falls. The facility census was 47. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 5 of 9 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 03/09/2023 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 0689 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. Review of Resident #16's medical record revealed an admission date of 11/08/2022. Diagnoses included unspecified fracture of the lower right femur (12/09/2022), fracture of the left pubis (11/09/2022), displaced simple supracondylar fracture without intercondylar fracture of the left humerus (11/09/2022), repeated falls, diabetes mellitus type II, unspecified depression, adult failure to thrive, and stage III chronic kidney disease. Residents Affected - Few Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 required a two-person total assistance with bed mobility, dressing, toileting, and personal hygiene, required extensive assistance with transfers and locomotion, and required supervision with eating. Review of a care plan dated 11/09/2022 revealed Resident #16 was a high risk for falls related to a recent history of a fall with fracture prior to admission. Interventions included to keep the call light in reach and encourage use of the call light for assistance, provide a safe environment (the bed in low position, personal items within reach, call light within reach, and clutter-free), review information on past falls and attempt to determine the cause, record possible root causes of falls, and educate the resident, family, and caregivers of the causes of falls. Review of a facility investigation dated 11/28/2022 revealed Resident #16 was found sitting on the floor beside her bed with her back resting on the bed. There was no apparent injury. The investigation had no witness statements. An intervention was created for the fall as a sign would be placed on bathroom door to remind Resident #16 to call for assistance. There was no root cause analysis included in the facility's investigation which identified the cause of the fall. Review of a facility investigation dated 12/03/2023 revealed the nurse at the nurse's station heard Resident #16 scream, and when the nurse went to Resident #16's room, the nurse found Resident #16 on the floor in front of chair with her right leg bent up to her body. Resident #16 was immediately sent to hospital due to abnormal right lower extremity. There was no root cause investigation included in the facility's investigation which identified the cause of the fall. Interview on 03/07/23 at 3:31 P.M. the Director of Nursing (DON) stated they discussed root cause analysis in an interdisciplinary team (IDT) meeting after falls occurred, but there was no documentation of a root cause analysis. The DON stated the team discussed falls in IDT meetings to make sure interventions in place at the time the of the fall were appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 6 of 9 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 03/09/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident representative interviews, and medical record review, the facility failed to contact the physician and implement an order for bowel function. This affected one (#23) of two residents reviewed for bowel function. The facility census was 47. Findings included: Review of Resident #23's medical record revealed an admission date of 08/30/22. Medical diagnoses included pneumonia, heart failure, septicemia, Alzheimer's disease, and diabetes. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. Resident #23 was assessed to require an extensive two person assistance for bed mobility, transfers and toilet use. Resident #23 was assessed as frequently incontinent of bowel and bladder. Interview with the Resident #23's Power of Attorney (POA) on 03/06/23 at 11:02 A.M. stated Resident #23 had been having explosive diarrhea. Review of Resident #23's bowel tracker from 02/07/23 through 03/07/23 revealed there were 30 episodes of loose bowel movements in medium to large in size during that time frame. Review of progress notes from 02/07/23 through 03/07/23 revealed the physician was not notified and there were no orders to treat Resident #23's diarrhea. Interview with Licensed Practical Nurse (LPN) #331 on 03/07/23 at 9:42 A.M. stated she was not aware of Resident #23's diarrhea, but could be due to Resident #23's colon polyps. LPN #331 stated could call the physician. Observation of incontinence care for Resident #23 on 03/07/23 at 10:53 A.M. with State Tested Nurse Aide (STNA) #207 and STNA #128 revealed Resident #23's incontinence brief was saturated with liquid stool. Interview with the Nurse Practitioner (NP) #235 on 03/08/23 at 10:20 A.M. stated her protocol would be for the facility to let her know about the diarrhea, how long it had been going on, and how much. NP #235 stated she would make a determination from that information on what orders would be put into place. NP #235 stated, depending on that finding, she would order a kidney, ureter and bladder (KUB) x-radiation (x-ray) and an anti-diarrhea medication. NP #235 stated she came into the facility on [DATE] and LPN #331 reported to her there was some concerns for bowel movements for Resident #23, but the nurse reported he did not have any diarrhea, but had some history for polyps. NP #235 stated she had not been informed of Resident #23's diarrhea for the past 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 7 of 9 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 03/09/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and facility policy review, the facility failed to obtain resident weights as ordered and failed to provide alternates when meal intakes were below desired levels. This affected one (#300) of four residents reviewed for nutrition. The census was 47. Residents Affected - Few Findings include: Review of Resident #300's medical record revealed an admission date of 09/27/22. Diagnoses included diabetes mellitus type II, atherosclerotic heart disease, hypertension, cervicalgia, muscle weakness, colostomy status, fusion of the spine, dysphagia, hyperlipidemia, ischemic cardiomyopathy, and bradycardia. Review of his Minimum Data Set (MDS) assessment, dated 01/06/23, revealed Resident #300 was cognitively intact. Review of Resident #300's orders revealed he was to have weekly weights taken, for the first four weeks, which was dated from 09/28/22 to 10/24/22. Further review of the orders revealed, beginning on 10/19/22, the order was continued for weekly weights. The was to continue until 01/19/23. Review of Resident #300's weights, dated 09/28/22 to 02/01/23, revealed Resident #300 weighed 164.4 pounds on 10/04/22, weighed 154.8 pounds on 10/08/22, weighed 163.4 pounds on on 11/17/22, weighed 164.8 pounds on 11/22/22, weighed 159.0 pounds on 12/01/22, weighed 159.4 pounds on 12/04/22, weighed 159.4 pounds 12/14/22, weighed 149.9 pounds on 01/11/23, weighed 146.8 pounds on 01/18/23, weighed 150.8 pounds on 01/31/23, and weighed 150.8 pounds on 02/01/23. The facility did not take an initial weight for Resident #300 until six days after admission. There was a significant weight decrease from 10/04/22 to 10/08/22, and no re-weight was taken to verify the weight loss. Also, there was a significant weight increase from 10/08/22 to 11/17/22, and a re-weight was not taken until five days later. There was a significant weight decrease from 12/14/22 to 01/11/23, and there was no re-weight taken until seven days later. Finally, there were multiple entries missing to meet the order of taking weekly resident weights from 09/28/22 to 01/19/23. Review of Resident #300 nutritional care plan revealed the facility is to obtain weights per order. Also, the facility staff will offer a substitute if the resident eats less than 75% of his meals. Review of Resident #300 meal intake documentation and meal substitutes offered documentation, dated 11/10/22 to 02/01/23, revealed Resident #300 ate less than 75% of meals and was not offered a substitute 59 different times. Interview with Dietary Technician (DT) #400 on 03/08/23 at 2:20 P.M. confirmed the facility had a challenge with getting weights in a timely manner and as ordered, but have been working better at obtaining resident weights. DT #400 confirmed Resident #300's weights were no taken as ordered, and confirmed if Resident #300 ate less than 75% of meals, the electronic medical record would automatically generate another question as to whether a substitute was offered. DT #400 stated the facility staff would have to answer and document if a substitute was offered each time it was required. Interviews on 03/09/23 at 9:01 A.M. with Licensed Practical Nurse (LPN) #216, at 9:14 A.M. with LPN #337, and at 9:32 A.M. with Director of Nursing (DON) confirmed staff should be entering substitutes and the amount of the substitute the resident ate in the electronic medical records. All three (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 8 of 9 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 03/09/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff members also confirmed they are to follow physician and nutritional orders for taking resident weights. DON confirmed the facility had an issue with getting weights obtained timely a couple months ago, but they have worked to do better. Review of a facility weight policy, dated March 2017, revealed weight is an indicator and method of monitoring resident nutritional status. Resident weight will be monitored on a monthly basis, or more frequently when indicated. This data will be used to identify those residents with significant weight variance and as an indicator of nutritional risk. All weight orders are to be written as follows: weights weekly for four weeks and then monthly and as needed unless otherwise ordered or specified. An in-house weight will be obtained within 24 hours of admission and recorded in the resident health record. Residents will be reweighed in 24 hours if their weight change meets the following criteria: resident weight less than 150 pounds with a three pound (or more) weight change or resident weight more than 150 pounds with a five pound (or more) weight change. This deficiency represents non-compliance investigated under Master Complaint Number OH00137211 and Complaint Number OH00136526. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365318 If continuation sheet Page 9 of 9