Inspection·December 18, 2019

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interviews, policy review and review of McGeer's criteria, the facility failed to ensure their antibiotic protocols were implemented when a resident was treated with an oral antibiotic. This affected one (#42) out of five residents sampled for unnecessary medications. Facility census was 52. Residents Affected - Few Findings include: Review of Resident #42's medical record identified admission to the facility occurred on 06/21/19. Diagnoses include cerebral vascular accident, major depression, muscle weakness, dysphasia, dementia, chronic kidney disease, diabetes mellitus and protein calorie malnutrition. Review of the progress notes dated 10/21/19, identified Resident #42 was noted with a change in mood past couple of days, combative at times, sleeping a lot, urine with odors. Progress notes dated 10/23/19 identified Resident #42 had foul smelling urine and a urine sample was obtained. The records identified no fevers, complaints of pain or other symptoms of an infection. The notes identified a urine sample was obtained and sent to the laboratory for testing. Review of the urinalysis test results dated 10/25/19 identified Resident #42 had two bacteria growing but was identified with less than 70,000 colony forming units (cfu's). The record identified Resident #42 received Augmentin (antibiotic) 875-125 milligrams (mg) from 10/26/19 through 11/02/19. Review of the facilities policy titled review for UTI without indwelling catheter, undated identified for a resident to be treated for infections criteria should be met and or the physician must identify why there is an exception. The listed criteria included fever of 100 degrees Fahrenheit (F) or two repeated temperatures of 99 degrees F and at least an additional symptom. The policy identified if criteria is met an antibiotic is recommended. The policy identified if the minimum criteria was not met than increase in fluids, monitor vital signs and monitor for increased symptoms would occur. The record identified Resident #42 was evaluated on 10/30/19 and identified she did not met the criteria to initiate an antibiotic. The record additionally did not identify the physician was notified the resident did not meet the criteria at the time of the antibiotic initiation. Interview with the Director of Nursing (DON) occurred on 12/17/19 at 9:10 A.M. confirmed Resident #42 did not meet the criteria to initiate an antibiotic and the physician was not notified of this and therefore Resident #42 received and completed an antibiotic. Review of an online resource titled Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria revealed for residents without an indwelling catheter (both (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 2 Event ID: 365575 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 365575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Catherine's C C of Fostoria 25 Christopher Dr Fostoria, OH 44830 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)