St. Catherines Manor of Washington Court House

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure food was stored in a manner to protect against potential contamination and spoilage. This had the potential to affect all 43 residents in the facility that receive food from the kitchen. The facility identified three (#9, #36, and #55) residents with active orders for nothing by mouth. The facility census was 46.

Inspectors wroteBased on observation, review of a facility Legionella plan and testing and monitoring documents, medical record review, and staff interview, the facility failed to ensure measures to address and prevent Legionella growth within the facility were maintained and conducted as required and failed to ensure infection control measures were maintained following urinary catheter care for a resident (#6). This had the potential to affect all 46 residents residing in the facility. The census was 46.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, facility failed to ensure a resident room was set to a comfortable temperature. This affected one (#9) of 16 residents reviewed for environmental issues during the initial sample. The facility census was 46.

Inspectors wroteBased on medical record review, resident and staff interview, and policy review, the facility failed to ensure residents were properly assessed for appropriateness before being placed on the secured memory care unit. This affected one (#49) of one resident reviewed for restraints. The facility census was 46.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to monitor behaviors with psychotropic medication use. This affected two (#2 and #56) of five residents reviewed for psychotropic medications. The facility census was 46.

Inspectors wroteBased on medical record review, resident and staff interview, and policy review, the facility failed to ensure care conferences were completed in a timely manner. This affected two (#2 and #35) of four residents reviewed for care conferences. The facility census was 46. 1. Review of the medical record for Resident #2 revealed an admission date of 09/04/18. Diagnoses included type II diabetes mellitus, heart failure, dementia, Parkinson's disease, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. The resident was assessed to require supervision with eating, and was dependent with toileting, bathing, dressing, and transfers. [...]

Inspectors wroteBased on medical record review, resident representative interview, and staff interview, the facility failed to provide showers to residents who were dependent on staff for assistance. This affected one (#8) of four residents reviewed for activities of daily living. The facility census was 46.

Inspectors wroteBased on observation, staff interview, medical record review, and policy review, the facility failed to ensure timely implementation of a therapy recommended splint and failed to ensure orders were followed regarding contractures. This affected one (#9) of one residents reviewed for range of motion. The facility census was 46.

Inspectors wroteBased on observation, staff interview, medical record review, and policy review, the facility failed to check for placement of a gastronomy tube prior to administering medications through the tube. This affected one (#36) of six residents reviewed for medication administration. The facility census was 46.

Inspectors wroteBased on observation, staff interview, medical record review, and policy review, the facility failed to ensure medications were ingested during medication administration prior to leaving the resident's room. This affected one (#14) of six residents reviewed for medication administration. The facility census was 46.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure timely follow-up on pharmacy recommendations during monthly medication reviews. This affected one (#24) of five residents reviewed for unnecessary medications. The facility census was 46.

Inspectors wroteBased on observation, medical record review, staff interview, review of food preparation menu and instructions, and policy review, the facility failed to prepare pureed food to a form that was safe and appropriate. This affected three (#20, #29, and #30) of three residents who had puree diet ordered. The facility census was 46.

Inspectors wroteBased on observation, staff and resident representative interview, and medical record review, the facility failed to timely notify a physician or nurse practioner when a change in a resident's condition was identified. This affected one (#23) of three residents reviewed for skin conditions and one (#23) of two residents reviewed for bowel function. The facility census was 47.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.