St Ottos Care Center

In the surveyor’s words

From the most serious findings on record at St Ottos Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF730Nov 10, 2022

  Based on interview, and record review, the facility failed to complete a performance review every 12 months for 2 of 3 nurse aides (NA-D & NA-E) reviewed for performance reviews. Findings include: NA-D's Employee Evaluation revealed her last performance review was completed on 08/30/19. NA-E's Employee Evaluation revealed his last performance review was completed on 06/01/18. On 11/10/21, at 9:00 a.m. the Director of Nursing (DON) verified last performance review was completed 8/30/19 for NA-D and 6/01/18 for NA-E. DON stated she was aware the performance reviews were late prior to the start of survey. Review of the undated Employee Performance Evaluations policy revealed it is the facility's policy to complete performance evaluations annually.

• No harm, potential for more than minimal, isolatedF646Nov 8, 2024

  Based on interview and document review, the facility failed to notify the county (designated State Mental Health Authority (SMHA)) for 1 of 1 resident (R76) with new onset mental illness. Findings include: R76's Census Record indicated admission on 4/17/24. R76's quarterly Minimum Data Set (MDS) dated [DATE], identified R76 had intact cognition and required assistance with all activities of daily living (ADL)'s. R76's diagnoses included hypertension, urinary tract infection, diabetes mellitus, hyperlipidemia, depression, chronic obstructive pulmonary disease (COPD), hypothyroidism, polyarthritis, and major depressive disorder. MDS also indicated R76 hallucinated and had delusions. R76's prior MDS's had no identification of a psychotic disorder. […]

• No harm, potential for more than minimal, isolatedF684Nov 8, 2024

  Based on interview and document review, the facility failed to ensure provider orders were processed for 1 of 1 resident (R76) reviewed for change in mental status. Findings include: R76's quarterly Minimum Data Set (MDS) dated [DATE], identified R76 had intact cognition and required assistance with all activities of daily living (ADL)'s. R76's diagnoses included hypertension, urinary tract infection, diabetes mellitus, hyperlipidemia, depression, chronic obstructive pulmonary disease (COPD), hypothyroidism, polyarthritis, and major depressive disorder. PHQ9 score was 13. […]

• No harm, potential for more than minimal, isolatedF688Nov 8, 2024

  Based on interview, and document review, the facility failed to implement interventions to prevent further development of decreased range of motion for 2 of 3 residents (R5 and R10) reviewed for positioning and mobility. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was admitted to the facility on [DATE] and had a moderate cognitive impairment and diagnoses of diabetes. R5's physical therapy (PT) discharge summary dated 7/14/21 through 8/13/21, indicated lower extremity (LE) exercises, LE ROM, and LE bike to maintain current level of performance, and prevent decline were recommended. […]

• No harm, potential for more than minimal, isolatedF758Nov 8, 2024

  Based on observation, interview, and document review, the facility failed to implement and monitor orthostatic blood pressures and obtain a baseline AIMS (abnormal involuntary movement scale) with the initiation of an antipsychotic medication for 1 of 3 residents (R76) reviewed for antipsychotic medications. Findings include: R76's quarterly Minimum Data Set (MDS) dated [DATE], identified R76 had intact cognition and required assistance with all activities of daily living (ADL)'s. R76's diagnoses included hypertension, urinary tract infection, diabetes mellitus, hyperlipidemia, depression, chronic obstructive pulmonary disease (COPD), hypothyroidism, polyarthritis, and major depressive disorder. PHQ9 score was 13. MDS also indicated R76 hallucinated and delusions. […]