Health inspection·February 12, 2020

F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident and staff interview, and medical record review, the facility failed to follow up on recommendations from the physician. This affected one (#56) of four reviewed. The census was four. Residents Affected - Few Findings include: Review of Resident #56's medical record revealed an admission date of 02/07/20. Diagnoses included depression, peripheral artery disease, vitamin D deficiency, chronic kidney disease, insomnia, and chronic diastolic heart failure. Review of a physician order dated 02/09/20 revealed Resident #56 was ordered a basic metabolic panel (BMP) blood test. Review of results of the BMP revealed Resident #56's blood glucose was elevated measuring 126 milligrams per deciliter (mg/dL). The facility laboratory set a normal range for blood glucose levels between 74 and 99 mg/dL. Review of a physician visit progress note dated 02/09/20 revealed the physician identified Resident #56 with a focused problem area of type two diabetes mellitus with peripheral neuropathy and documented Resident #56 would be placed on rapid blood glucose finger checks (Accu-Cheks) with insulin coverage. The progress note was signed by the physician on 02/09/20 at 11:54 A.M. Review of Resident #56's medical record between 02/10/20 and 02/12/20 revealed no further blood glucose laboratory values and no finger stick blood glucose levels were obtained, no physician orders were initiated for Accu-Cheks or insulin, and no additional progress notes were documented related to the physician's recommendation for Accu-Cheks with insulin coverage. Review of a progress note dated 02/12/20, written by Registered Nurse (RN) Clinical Coordinator #100, revealed the physician was contacted for clarification of his recommendation on 02/09/20 for Resident #56 to have Accu-Cheks and insulin, and the physician verified he wanted Resident #56 on a medium dose sliding scale insulin with Accu-Cheks before meals and at bedtime. Observations on 02/10/20 at 7:52 A.M., at 10:49 A.M., at 2:21 P.M.; on 02/11/20 at 1:03 P.M., 2:39 P.M., and at 3:52 P.M.; and on 02/12/20 at 8:24 A.M. revealed Resident #56 was calm and free from distress. Resident #56 did not display any lethargy or signs of an altered mental state, and her overall health condition remained unchanged. Interview on 02/11/20 at 4:02 P.M. with Resident #56 stated she had no concerns about the current status of her health and verified she had not experienced any significant changes with her health since she was admitted to the facility. (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: 365807 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 365807 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitional Care Unit 200 St Clair Street Saint Marys, OH 45885 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)