Every finding on record at Avalon Springs Health Campus

Based on observation, record review and interview, the facility failed to ensure infection control measures were in place and implemented related to appropriate signage posted during a respiratory outbreak, lack of monitoring for a resident that was COVID-19 positive and lack of COVID-19 testing for a symptomatic resident for 2 of 3 residents reviewed for infection control and random infection control observations. (Residents 19 and 44)Findings include:1.On 1/8/26 at 8:35 a.m., the entrance to the facility was observed. There was no signage posted that indicated there was currently a respiratory outbreak in the facility and listed current precautions such as masking was optional or available. During the initial tour of the facility, there were resident rooms observed to have droplet precautions signs and PPE (personal protective equipment) bins outside the rooms. The staff indicated the residents on precautions had tested positive for COVID-19. The positive residents resided on the 100 and 300 halls. There was no signage that indicated those halls had a respiratory outbreak. During an interview on 1/9/26 at 2:22 p.m., the Director of Nursing indicated current infection control precautions were to make masks available, but not required, to visitors and residents. There were signs on the COVID + rooms that instructed visitors to see the nurse before entering. She indicated they did not have signs up advising visitors there was an outbreak in the facility. During an interview on 1/9/26 at 2:27 p.m., the Nurse Consultant indicated there was a sign at the entrance that indicated if visitors had signs or symptoms of the flu, they should wear a mask or defer visiting. She indicated the flu and COVID had similar respiratory symptoms. The Executive Director indicated there were signs on the COVID + rooms that instructed visitors to see the nurse before entering and posting anything elsewhere wasn't required. The facility policy, COVID-19 Identification and Management, approved date 1/7/26, indicated, .General Campus Operating Procedures. The campus will post visual alerts at the entrance and in strategic places throughout the campus. Alerts will provide information on current IPC (infection prevention control) recommendations CDC (Center for Disease Control) guidelines were retrieved on 1/9/26 from https://www.cdc.gov/covid/hcp/infection-control/index.html and indicated, .Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV Infection. Ensure everyone is aware of recommended IPC practices in the facility. Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias). These alerts should include instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations 2. Resident 19's record was reviewed on 1/12/26 at 9:47 a.m. Diagnoses included, but were not limited to, hypertension, congestive heart failure, and atrial fibrillation. A Progress Note, dated 1/7/26 at 4:38 p.m., indicated the resident was re-admitted from the hospital and had tested positive for COVID-19 while in the hospital. A Physician's Order, dated 1/8/26, indicated the resident was on contact and droplet precautions due to being COVID positive. The Medication Administration Record and Treatment Administration Record, dated 1/2026, lacked any documentation of assessment and monitoring of COVID symptoms or vital signs. The Vital Signs tab indicated the resident's vital signs had been recorded only on 1/7/26 at 5:14 p.m. and 1/11/26 at 8:02 p.m. During an interview on 1/12/26 at 11:25 a.m., the Infection Preventionist indicated COVID positive residents should be assessed once per shift/twice a day. There should have been an order in place for monitoring symptoms and checking vital signs twice a day. 3. Resident 44's record was reviewed on 1/14/26 at 9:45 a.m. Diagnoses included, but were not limited to, dementia and stroke. The admission Minimum Data Set (MDS) assessment, dated 12/13/25, indicated the resident was moderately cognitively impaired. A Physician's Order, dated 12/10/25, indicated COVID testing per current state and federal requirements, may test as needed (PRN) if resident has symptoms. A Physician's Order, dated 1/1/26, indicated the resident was in contact precautions. A Progress Note, dated 1/1/26 at 7:24 p.m., indicated the resident had rhonchi to the lung bases and a slight expiratory wheeze, no shortness of breath. The resident did not appear to be in distress. The resident stated that he had coughed up white mucous. The resident remained in contact isolation for Clostridium difficile (gastrointestinal infection, also known as c.diff). The daughter was at the bedside. The Nurse Practitioner was updated, and new orders were received for a complete blood count (CBC) and basic metabolic panel (BMP), chest x-ray in the morning, and DuoNeb nebulizer treatments every 4 hours as needed for shortness of breath and wheezing. A Point of Care (POC) Antigen COVID-19 test was completed on 1/1/26 with negative results. A Point of Care (POC) Influenza test was completed on 1/1/26 with negative results. A Progress Note, dated 1/2/26 at 6:56 a.m., indicated the resident had rhonchi, a tight congested cough and diminished breath sounds. A Progress Note, dated 1/3/26 at 4:30 p.m., indicated the resident's daughter voiced concerns about sleepiness and possible pneumonia/sepsis. The resident had coarse lung sounds with expiratory wheezes, worse on the right side. New orders were placed for doxycycline (antibiotic) 100 milligrams twice daily for 7 days and 1 liter 0.45% normal saline at 60 milliliters per hour. The chest x-ray was completed on 1/3/26 and was positive for pneumonia. A Nurse Practitioner Progress Note, dated 1/8/26 at 4:19 p.m., indicated the resident was seen for a follow-up with active c.diff infection and pneumonia. The resident had upper rhonchi lung sounds. A Progress Note, dated 1/10/26 at 3:58 p.m., indicated the resident had a non-productive cough and the lung sounds remained diminished/clear. He continued to be in contact isolation for c.diff infection. A Progress Note, dated 1/12/26 at 6:05 p.m., indicated the resident's family member called and indicated she had tested positive for COVID-19 and had been visiting with the resident recently. The resident was tested for COVID-19 and was positive with no symptoms at the time. New orders were received for Lagevrio (antiviral drug) and droplet precautions. During an interview on 1/14/26 at 12:27 p.m., the Infection Prevention (IP) Nurse Manager indicated they would normally test the resident again for COVID-19 in 48 hours if they had symptoms, however since he was being treated for pneumonia, they did not do another test because he was already on precautions. She indicated that he was only on contact precautions because he was positive for c.diff and was not on droplet precautions. The resident was symptomatic when he tested positive for COVID-19 on 1/12/26 and he had only been tested because his family who had recently visited called and indicated the family member had tested positive for COVID-19. The IP Nurse Manager indicated it was protocol to test again in 48 hours only if symptomatic. The resident was symptomatic and should have been tested again after the initial negative COVID test. A Facility Policy, revised on 6/5/23 and titled, COVID-19 Identification and Management, indicated, .Symptomatic Residents Being Evaluated for COVID-19 Infection.If using a POC (antigen test), a negative result should be confirmed by either a negative PCR test or second negative POC test taken 48 hours after the first negative test. Resident should remain in TBP until second negative test is confirmed. 3.1-18(b)

Based on observation, record review, and interview, the facility failed to document care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to flushing the PICC line for 2 of 3 residents reviewed for intravenous care. (Residents 14 and 59)Findings include:1. On 1/9/26 at 10:16 a.m. Resident 14 was observed with a PICC line to her right upper arm. She indicated she was receiving IV (intravenous) antibiotics.Resident 14's record was reviewed on 1/12/26 at 3:44 p.m. Diagnoses included, but were not limited to, bacteremia and type two diabetes mellitus.The admission Minimum Data Set (MDS) assessment, dated 12/22/25, indicated the resident was cognitively intact.A Physician's Order, dated 12/16/25, indicated piperacillin-tazobactam (an antibiotic medication) 4.5 grams intravenous every eight hours at 8:00 a.m., 4:00 p.m., and 12:00 a.m.A Physician's Order, dated 1/7/26, indicated daptomycin (an antibiotic medication) 350 mg intravenous every 48 hours at 2:00 p.m.A Physician's Order, dated 12/16/25, indicated Flush PICC with 10 cc (cubic centimeters) normal saline before and after medication twice a day, 6:00 a.m. - 10:00 a.m. and 6:00 p.m. - 10:00 p.m.The Medication Administration Record (MAR), dated 12/2025 and 1/2026, indicated there was no PICC flush documented as given before and after the administration of the 4:00 p.m. and 12:00 a.m. doses of piperacillin-tazobactam or the 2:00 p.m. dose of daptomycin.During an interview on 1/13/26 at 10:12 a.m., the Director of Nursing indicated the flush orders were put in the computer as twice a day/once per shift, but the nurses knew to flush the PICC before and after every dose of the antibiotic medication. She was unable to find any facility policy related to intravenous antibiotic medication administration. 2. On 1/9/26 at 9:17 a.m. Resident 59 was observed with a PICC line to her right upper arm. She indicated she recently had foot surgery and was receiving IV (intravenous) antibiotics.Resident 59's record was reviewed on 1/9/26 at 3:08 p.m. Diagnoses included, but were not limited to, osteomyelitis and atrial fibrillation.The admission Minimum Data Set (MDS) assessment, dated 12/22/25, indicated the resident was cognitively intact.A Physician's Order, dated 12/23/25, indicated piperacillin-tazobactam (an antibiotic medication) 3.375 grams intravenous every eight hours at 6:00 a.m., 2:00 p.m., and 10:00 p.m.A Physician's Order, dated 12/23/25, indicated daptomycin (an antibiotic medication) 483 mg (milligrams) intravenous once a day every other day 6:30 a.m.-10:30 a.m.A Physician's Order, dated 12/22/25, indicated Flush PICC with 10 cc (cubic centimeters) normal saline before and after medication twice a day, 6:00 a.m. - 10:00 a.m. and 6:00 p.m. - 10:00 p.m.The Medication Administration Record (MAR), dated 12/2025 and 1/2026, indicated there was no PICC flush documented as given before and after the administration of the 2:00 p.m. dose of piperacillin-tazobactam.During an interview on 1/13/26 at 10:12 a.m., the Director of Nursing indicated the flush orders were put in the computer as twice a day/once per shift, but the nurses knew to flush the PICC before and after every dose of the antibiotic medication. She was unable to find any facility policy related to intravenous antibiotic medication administration.3.1-50(a)

Based on record review and interview, the facility failed to ensure a peripherally inserted central catheter (PICC) intravenous (IV) access site was assessed and monitored accurately as ordered for 1 of 3 residents reviewed for parenteral/IV fluids. (Resident 41)Finding includes: Resident 41's record was reviewed on 1/14/26 at 12:36 a.m. Diagnoses included, but were not limited to, osteomyelitis (infection of the bone) and cellulitis of the right and left lower limbs (skin infection). The admission Minimum Data Set (MDS) assessment, dated 12/17/25, indicated the resident was moderately cognitively impaired. He required intermittent oxygen therapy, received intravenous (IV) antibiotic medications, and had a central IV access site. A Care Plan, dated 12/15/25, indicated the resident required IV medications related to osteomyelitis. Interventions included, but were not limited to, assess for complications of the IV every shift such as infection or dislodgment, and IV site care as ordered. A Physician's Order, dated 12/12/25, indicated PICC line dressing change every 5 days; measure external catheter length. The December 2025 and January 2026 Medication and Treatment Administration Record indicated the PICC line dressing change was completed on the following dates with external catheter measurements: -12/12/25, 25 centimeters (cm)-12/17/25, 3 cm -12/22/25, 26 cm-12/27/25, 12 cm-1/1/26, 11 cm -1/6/26, 17 cm-1/11/26, 3.5 cmDuring an interview on 1/14/26 at 2:35 p.m., the Assistant Director of Nursing indicated the resident had not had any problems with the PICC line, the staff were not all measuring the external catheter the same way so there were varying measurements documented. During an interview on 1/14/26 at 2:44 p.m., the Director of Nursing indicated she had no further information to provide and she had no policies related to PICC line care/measurements. 3.1-47(a)(2)

Based on observation, record review and interview, the facility failed to ensure fall interventions were in place for a resident with a history of falls for 1 of 1 residents reviewed for accidents. (Resident 6)Finding includes:On 1/9//26 at 9:40 a.m., Resident 6's room was observed. There was a standard size bed placed in the middle of the room with the headboard against the wall. On the right side of the bed, there was an oxygen concentrator between the bed and the wall. The resident was seated in a Broda chair near the nurse's station.The resident's record was reviewed on 1/9/26 at 9:26 a.m. Diagnoses included, but were not limited to, traumatic subdural hematoma, acute and chronic respiratory failure and Alzheimer's dementia.The Significant Change Minimum Data Set assessment, dated 12/15/25, indicated the resident had severe cognitive deficits and was dependent for transfers and toileting.An Indiana Department of Health Reportable Incident, dated 11/3/25, indicated the resident had sustained a fall on 10/31/25 and had been sent to the hospital for evaluation. He sustained a traumatic subdural hematoma to his head. The follow up indicated his care plan would be updated.An IDT (Interdisciplinary team) Note, dated 11/4/25 indicated the root cause of the fall was the resident rolled out of bed. The intervention was to place the bed against the wall.The Fall Care Plan, dated 4/18/23, indicated the resident was at risk for falls related to weakness and impaired physical functioning. Interventions included, but were not limit to, larger bed to allow for larger surface area. On 11/5/25, the intervention had been added to put the bed against the wall. During an interview on 1/13/26 at 8:40 a.m. in the resident's room, CNA 1 indicated the bed was standard size and was always in the current position, it was not pushed against the wall. During an interview on 1/13/26 at 9:30 a.m., the Director of Nursing indicated the resident's care plan had been updated the previous day, 1/12/26, and some interventions had been closed. She was made aware interventions were not in place on 1/9/26. No additional information was provided. 3.1-45(a)

Based on record review and interview, the facility failed to ensure complete and accurate information was included in Indiana Department of Health (IDOH) Reportable Incidents related to abuse allegations for 2 of 3 IDOH Reportable Incidents reviewed. (Residents 11 and 42)Findings include:1.During an interview on 1/9/26 at 11:07 a.m., Resident 11 indicated a staff member had been rude and mean to her. She indicated she did not recall who the staff member was but that she had reported it to another staff member. The resident's record was reviewed on 1/9/26 at 1:20 p.m. Diagnoses included, but were not limited to, hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following a cerebral infarction and dysphagia. The Significant Change Minimum Data Set assessment, dated 1/3/26, indicated the resident had moderate cognitive impairment. An IDOH Reportable Incident, dated 9/26/25, indicated the resident's family had reported a concern with care. The resident was assessed and no injury was noted. An investigation was initiated. Other residents who resided on the same hall were interviewed by Social Services and reported feeling safe and denied concerns with care. The Follow Up report indicated the resident continued with her usual routine, there were no concerns of psychosocial changes. A urine analysis had been completed, and the resident was found to have a urinary tract infection and currently on antibiotic therapy. Abuse could not be substantiated. There was no indication in the Reportable Incident what the concern with care had been and did not identify an abuse allegation was made. During an interview on 1/13/26 at 11:31 a.m., the Director of Nursing (DON) indicated the resident had reported someone had kicked her in the leg. The resident was unable to say if it was a staff member or another resident. She had been assessed for injury, and none was noted. The DON indicated they had been instructed to keep Reportable Incidents generic. She indicated she understood the need to accurately document the details of future IDOH Reportable Incidents. 2. On 1/9/26 at 1:22 p.m. a list of facility reportable incidents, received from the Administrator, indicated Resident 42 had reported a care concern on 7/24/25. An Indiana Department of Health (IDOH) Reportable Incident, dated 7/24/25 at 11:01 a.m., indicated Resident 42 had voiced concerns related to care. A head-to-toe assessment of the resident had been completed, and bruises had been found on her left forearm and right elbow. A CNA had been suspended pending investigation. The follow up report indicated the resident's bruises were determined to be from bumping her arms on her wheelchair while reaching for items. Other residents on the same hall had been interviewed and had no concerns. The resident had no further concerns with care. There was lack of any documentation to indicate what the resident's care concerns were or if there was any allegation of abuse. During an interview on 1/13/26 at 11:38 a.m., the Director of Nursing indicated the resident had made an allegation that the CNA was rough with care during a transfer. The actual allegation was not described in the IDOH reportable. They had worded it as a care concern as a general description of the allegation instead of documenting the exact allegation. A facility policy, titled Abuse and Neglect Procedural Guidelines, indicated, .f. Investigation .vi. Providing complete & thorough documentation of the investigation . 3.1-28(c)

Based on observation, record review, and interview, the facility failed to ensure a resident who required maximum to dependent care received incontinence care in a timely manner, for 1 of 3 residents reviewed for incontinence care. (Resident B) Finding includes:During an observation on 10/27/25 at 10:27 a.m., Resident B was awake and lying in bed with the head of the bed elevated. The over the bed table was over the bed and the breakfast tray was on the table. The food on the tray had all been eaten. The resident indicated she was waiting on the staff to come and assist out of bed into the chair. She indicated when they brought the breakfast tray to her, they said they would be back to help her get out of bed.During an observation on 10/27/25 at 11:12 a.m., CNA 1 and CNA 2 entered the room. CNA 1 indicated the resident had incontinence care last completed at 7:30 a.m. and the resident was incontinent of large amounts of urine. The CNA's started morning care. The resident's incontinent brief was saturated, the lift sheet underneath her was soaked through to the bottom sheet on the bed and there was a large circle of wetness on the bottom sheet. CNA 1 acknowledged the saturated brief and wetness of the sheets.Resident B's record was reviewed on 10/27/25 at 10:41 a.m. The diagnoses included, but were not limited to, metabolic encephalopathy, multiple UTI's (urinary tract infections), and sepsis.A Hospital Physician's Note, dated 10/15/25 at 5:12 p.m., indicated the resident had recurrent urinary tract infections.A Care Plan, dated 4/11/25 and revised on 9/2/25, indicated there was urinary incontinence. The interventions included the resident would be offered and provided assistance to the toilet as needed and/or requested.A Quarterly Minimum Data Set assessment, dated 9/4/25, indicated a moderately impaired cognitive status, dependent for toileting hygiene and transfers, maximum assistance for hygiene, moderate assistance for bed mobility and was always incontinent of bowel and bladder.A re-admission Observation Assessment, dated 10/23/25 at 8:24 p.m., indicated the resident was oriented to person, place, and time. There was no mental impairment. She was incontinent of bowel and bladder and was unable to recognize the need to void. The Baseline Care Plan, dated 10/23/25, indicated the toilet would be offered upon rising, before and after meals, and before bedtime. The resident would be checked for incontinence and the brief would be changed as needed.During an interview on 10/27/25 at 1:58 p.m., the Director of Nursing (DON) indicated there was no facility policy for how often a resident was to be checked for incontinence. She indicated if they voided a lot, they should be checked more often. The residents were usually checked before and after meals and before bedtime.A Professional Resource, titled, Indiana State Department of Health Nurse Aide Curriculum, revised 11/19/15, Lesson #12, Activities of Daily Living (dressing and toileting), indicated residents with incontinence were to be monitored frequently for needed perineal care and change of brief.This citation relates to Intake 2645656.3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and CNA 2) when providing care to residents who were in EBP and failed to ensure a staff member (CNA 2) completed hand hygiene after the removal of soiled gloves for 2 of 3 residents reviewed for infection control. (Residents F and D)Findings include:1. During an observation on 9/16/25 at 9:24 a.m., CNA 1 entered Resident F's room and assisted the resident into the bathroom. There was a sign on the door of the room that indicated EBP was required. CNA 1 had gloves on and no gown. The Director of Nursing (DON) entered and exited the bathroom and observed CNA 1 providing care without the use of a protective gown. She indicated a protective gown should have been worn. CNA 1 exited the bathroom with a soiled brief in a clear garbage bag for disposal.During an observation on 9/17/25 at 8:23 a.m., Resident F was lying in bed. There was a mid-line IV catheter inserted and dressed on the upper left arm and a urinary catheter was present.Resident F's record was reviewed on 9/16/25 at 3:39 p.m. The diagnoses included, but were not limited to urinary tract infection and endocarditis. The Profile Guide Care Plan, dated 9/16/25, indicated EBP was required for high contact care due to the presence of an intravenous catheter line (IV) and a urinary catheter. 2. During an observation on 9/16/25 at 9:37 a.m., there was a sign on Resident D's room door that indicated EBP was required. Resident D shared the room with another resident. Resident D was sitting on the toilet and CNA 2 was assisting the resident. CNA 2 wore gloves and a mask. A protective gown was not used. The resident remained on the toilet and the CNA exited the room and indicated the urinary catheter leg bag had been leaking and a new bag was needed. She was unsure which resident in the room required EBP. CNA 2 returned to the room, applied gloves, and changed the urinary drainage leg bag. A protective gown was not used. She then exited the bathroom and the resident remained on the toilet. She exited the room with the gloves still worn, removed the gloves in the hallway and placed them in the Medication Cart Trash Bin, walked to the Nurses' Desk and began writing a note to the Nurse. When asked about hand hygiene CNA 2 indicated she had not completed the care on the resident and was going back to continue care. Resident D's record was reviewed on 9/16/25 at 3:09 p.m. The diagnoses included, but were not limited to, urinary tract infection and urinary retention.A Quarterly Minimum Data Set assessment, dated 8/2/25, indicated an intact cognitive status, required set up assistance for toileting, and an indwelling urinary catheter was present.A Care Plan, dated 6/12/25, indicated EBP was required during high-contact care related to the indwelling urinary catheter. The interventions included a gown and gloves would be utilized per the EBP policy and hand hygiene would be completed before and after care.A facility EBP policy, dated 4/2024, indicated EBP would be implemented during high-contact care activities for resident with, but not limited to, catheters and central lines. PPE was to be worn even if blood and body fluid exposure is not anticipated. High-contact care activities included, but were not limited to, morning activities of daily living care and toileting.A facility hand hygiene policy, dated 3/2027, indicated hand hygiene was to be completed before and after having direct physical contact with residents and after removal of gloves.This citation relates to Intake 2612583.3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure fall interventions were in place to prevent injury for a resident with multiple falls for 1 of 3 residents reviewed for accidents. (Resident C) Finding includes: On 2/27/25 at 10:06 a.m., Resident C was observed in bed asleep. The resident's bed was against the wall, he had bed rails, and there was a trapeze bar above the bed. The room was clean and clutter free and the call light was within reach. There were no bolsters observed on the resident's bed. On 2/27/25 at 10:25 a.m., and 1:10 p.m., the resident was observed sitting on the side of the bed. There were no bolsters on the bed. Record review for Resident C was completed on 2/27/25 at 10:36 a.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), stroke, chronic obstructive pulmonary disease (COPD), depression, and diabetes. The Significant Change in Status Minimum Data Set (MDS) assessment, dated 12/10/24, indicated the resident was cognitively impaired. The resident required substantial/maximum assistance with shower/bathing, toileting, lower body dressing, and putting on footwear. The resident was on hospice services. The resident had impairment on one side of upper and lower extremities, used a wheelchair, and required hospice services. A Care Plan, last reviewed on 1/9/25, indicated the resident was at risk for falls related to weakness and impaired physical functioning. Approaches were to provide a trapeze to assist resident with positioning, place bed against the wall, have hospice review medications, and have hospice provide bolsters to the resident's bed. The last two months were reviewed and the resident had four falls on the following dates: 1/6/25 2/9/25 2/11/25 2/26/25 A Nurses's Progress Note, dated 2/26/25 at 9:04 p.m., indicated the writer entered the room to respond to the call light, the resident was lying on the floor. The resident claimed he was trying to reposition himself in bed using the trapeze bar when he slipped and fell out of bed. A Nurses's Progress Note, dated 2/11/25 at 11:18 a.m., indicated the resident was found kneeling on the floor next to his bed. The resident claimed he was attempting to sit up in bed and began to slide out. A Nurses's Progress Note, dated 2/09/25 at 7:00 a.m., indicated the resident was found kneeling next to his bed. The resident was assessed with no signs and symptoms noted. A Nurses's Progress Note, dated 1/06/25 at 7:01 a.m., indicated the resident had turned on the call light and upon entering the room, the resident was observed sitting on the floor with his back against the bed. The resident indicated he was lying there and was not reaching for anything. The resident was assisted back to bed via Hoyer (mechanical) lift. During an interview on 2/27/25 at 1:18 p.m., RN 1 indicated the resident does not have bolsters on his bed or in his room. She could not recall the resident ever having bolsters on his bed. During an interview on 2/27/25 at 1:44 p.m., the Director of Nursing (DON) acknowledged the care plan had bolsters as an approach and she would go observe the resident. During an interview on 2/27/25 at 2:36 p.m., the DON indicated the resident did not have bolsters on his bed and she had no additional information to provide. This citation relates to Complaint IN00449145. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure urinary output was documented as ordered and an indwelling Foley (urinary) catheter collection bag was off of the floor for a resident with a history of infection for 3 of 3 residents reviewed for urinary catheters. (Residents 6, 216, and 13) Findings include: 1. Record review for Resident 6 was completed on 11/25/24 at 9:57 a.m. Diagnoses included, but were not limited to, neurogenic bladder, end stage renal disease, Alzheimer's, and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 10/22/24, indicated the resident was cognitively impaired. The resident required maximum assistance for toileting. The resident had an indwelling urinary catheter. A Care Plan, dated 10/10/22 and revised 11/11/24, indicated the resident used a Foley catheter. The resident was at risk for complications, including a urinary tract infection. An intervention included to record the resident's urinary output. The November 2024 Physician's Order Summary (POS) indicated an order to monitor urinary output every shift. The November 2024 Medication Administration Record (MAR) had the urinary output signed off as completed each shift, but lacked the amount of output. The Urinary output section of the Vital Signs had urine output documented only on day shifts for the past 30 days on the following dates: -10/26, 10/27, 10/28, 10/29, 11/2, 11/3, 11/4, 11/5, 11/8, 11/9, 11/10, 11/12, 11/14, 11/16, 11/21, 11/22, 11/23, 11/24, and 11/25/24. There was a lack of documentation to indicate the urinary output was documented on any other shift other than the day shift. During an interview on 11/26/24 at 9:26 a.m., the Director of Nursing (DON) indicated the nurses worked 12 hour shifts. There should be documentation of the urine output every shift. 32788 2. On 11/21/24 at 10:39 a.m., Resident 216 was observed seated in her wheelchair in the lounge area near the 100 Hall Nurse's Station. The urinary catheter bag was hanging from the bottom of her wheelchair and resting on the floor. On 11/21/24 at 2:34 p.m., Resident 216 was observed seated in her wheelchair in her room. The urinary catheter bag was hanging from the bottom of her wheelchair and resting on the floor. On 11/22/24 at 11:02 a.m., Resident 216 was seated in her wheelchair in her room. No urinary catheter bag was visible. Resident 216 pulled up her pant leg and a urinary catheter leg bag was observed. Resident 216's record was reviewed on 11/22/24 at 10:38 a.m. Diagnoses included, but were not limited to, chronic kidney disease, type 2 diabetes mellitus, and dementia. The Admission Minimum Data Set assessment, dated 11/12/24, indicated the resident was cognitively impaired and had an indwelling urinary catheter. The Physician's Order Summary, dated 11/2024, indicated to monitor urine output every shift. There were no orders related to the use of a urinary catheter leg bag. A care plan, updated 11/20/24, indicated the resident required a urinary catheter for neurogenic bladder. The interventions included, record urinary output. There were no interventions related to the use of a urinary catheter leg bag. The Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 11/2024, indicated the urinary output had been signed off as monitored every shift (12 hour shifts) but no amounts had been recorded. The resident had received cefdinir (an antibiotic) 300 mg (milligrams) every 12 hours from 11/8/24 through 11/11/24 for acute cystitis (inflammation of the bladder) with hematuria (blood in the urine). The vital signs urine output documentation, dated 11/8/24 through 11/22/24, indicated the urine output had only been recorded once a day on the following dates: 11/10/24 at 1:16 p.m. 11/13/24 at 1:45 p.m. 11/16/24 at 12:38 p.m. 11/17/24 at 10:56 a.m. 11/18/24 at 12:12 p.m. During an interview on 11/22/24 at 2:26 p.m., the Director of Nursing was made aware of the resident's urinary catheter bag resting on the floor. She indicated the urinary output should have been documented on each shift and there were two shifts per day. There was no specific policy related to urine output documentation, or the type of urinary catheter bag used. A policy was requested related to urinary catheter bag placement. No further information was provided. 43293 3. The record for Resident 13 was reviewed on 11/22/24 at 1:42 p.m. Diagnoses included, but were not limited to, sepsis, urinary tract infection, pneumonia, hemiplegia (paralysis on one side of the body) due to a stroke, and chronic kidney disease. The Admission Minimum Data Set (MDS) assessment, dated 11/1/24, indicated the resident was cognitively intact and had an indwelling urinary catheter. A Care Plan, updated 6/27/23, indicated the resident had an indwelling urinary catheter. An intervention indicated to monitor and document urinary output. A Physician's Order, dated 1/30/24, indicated the urinary output was to be monitored every shift, three times per day, at the following times: 7:00 a.m. - 2:00 p.m., 3:00 p.m. - 10:00 p.m., 11:00 p.m. - 7:00 a.m. The resident's record indicated urinary outputs were measured once per day on 11/14/24, 11/18/24, 11/19/24, 11/21/24, 11/22/24, 11/23/24, and 11/24/24. Urinary output was documented twice per day on 11/15/24, 11/16/24, and 11/17/24. During an interview on 11/25/24 at 10:28 a.m., CNA 1 indicated she emptied the urine bag three times per shift and documented the amount in the resident's record. During an interview on 11/25/24 at 11:13 a.m., the DON indicated the CNAs should be documenting a urine output every shift and offered no further information. 3.1-41(a)(2)

Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented, related to the correct medication administration route for 1 of 1 resident reviewed for tube feeding. (Resident 41) Finding includes: During an interview on 11/21/24 2:15 p.m., Resident 41's daughter indicated the resident received her medications sometimes through the tube and sometimes she got them by mouth. The record for Resident 41 was reviewed on 11/25/24 at 9:05 a.m. Diagnoses included, but were not limited to, colitis, dehydration, congestive heart failure, dementia, Alzheimer's disease, heart disease, Parkinson's disease, dysphagia (difficulty swallowing), peg tube (a tube inserted directly into the stomach for nutrition) The 10/21/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and had a peg tube through which she received 25% or less of nutrition. Physician's Orders, listed on the current Physician Order Summary dated 11/2024, indicated the medications of Carbidopa-Levodopa 25-250 milligrams (mg) give 1 tablet orally four times a day, and Pepcid 20 mg, give 1 tablet orally at night time. There was no order to administer the medications through the peg tube. During an interview on 11/25/24 at 11:23 a.m., RN 3 indicated she had administered the resident's medications through the peg tube, however, there was no physician's order to administer the medications through the peg tube. During an interview on 11/25/24 at 2:30 p.m., the Director of Nursing indicated the resident had received her medications orally and not through the peg tube, but since her decline, she received the medications through the peg tube. 3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure oxygen concentrators were set at the correct flow rate for 1 of 2 residents reviewed for oxygen therapy. (Resident 38) Finding includes: During random observations on 11/21/24 at 10:20 a.m. and 2:04 p.m., and on 11/22/24 at 8:30 a.m., 10:21 a.m., and 1:24 p.m., Resident 38 was observed in bed. At those times, she was wearing oxygen via nasal cannula and the oxygen concentrator was set at 2.5 liters per minute. On 11/22/24 at 2:45 p.m., LPN 1 was observed in the resident's room. At that time, she was made of the oxygen setting and immediately changed the rate to 3 liters. The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident received oxygen therapy while at the facility. The Care Plan, revised on 11/11/24, indicated the resident had the potential for complications, functional and cognitive status decline related to respiratory disease. The approach was to provide oxygen. Physician's Orders, dated 9/15/24, indicated set oxygen at 3 liters nasal cannula continuously During an interview on 11/22/24 at 2:46 p.m., LPN 1 indicated the oxygen should be on as ordered by the physician. During an interview on 11/25/24 at 2:00 p.m., the Director of Nursing was informed of the oxygen and had no additional information to provide. 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, related to enhanced barrier precautions (EBP) not in use for a resident with pressure ulcers during a wound treatment and for a resident with a peripherally inserted central catheter (PICC) line during medication pass. The facility also failed to change gloves in between pressure ulcer treatments and perform hand hygiene after glove removal during medication pass for 1 of 2 residents observed during a pressure ulcer treatment and for 1 of 8 residents observed during medication administration. (Residents 41 and 363) (Hospice CNA 1, Hospice RN 1, and RN 1) Findings include: 1. During an observation on 11/25/24 at 10:33 a.m., Hospice CNA 1 and Hospice RN 1 were observed in Resident's 41 room. At that time, Hospice CNA 1 indicated she was going to give the resident a complete bed bath and Hospice RN 1 was going to change the resident's bandages for her pressure ulcers. The CNA and RN both had performed hand hygiene and donned a pair of clean gloves to both hands and proceeded to give the resident a bed bath. Neither one of them donned a gown to provide care and give the bath. They turned the resident over on her right side and there were 5 foam bandages on the residents back side. The hospice nurse removed her gloves and washed her hands with soap and water. She donned a clean pair of gloves to both hands and removed the bandage to the sacrum. The pressure ulcer on sacrum had thick black necrotic tissue and a large amount of drainage. The RN cleaned the wound with normal saline wearing the same pair of gloves to both hands, and patted it dry. With the same gloves, she squeezed a moderate amount of Cal Zinc cream on her gloved hands and proceeded to spread the cream around the wound. She then placed a clean foam bandage over the wound. During an interview at that time, Hospice RN 1 indicated the pressure sore was much worse and she thought it was now a Kennedy ulcer (a dark, irregularly shaped sore that develops rapidly in the final stages of life) and the focus would be to prevent further breakdown, as the ulcer would need debridement. Using the same pair of gloves, she removed the bandage on the left ischium and cleaned the wound with normal saline. She patted the wound dry and squeezed a small amount of the Cal Zinc cream into the same pair of gloves and proceeded to spread the cream over the pressure ulcer on the ischium. She then placed a foam bandage over the wound. After she had finished completing the treatments, she removed her gloves and washed her hands with soap and water. At that time, there was a sign on the outside of the resident's door that indicated the resident was in EBP and a gown and gloves were needed if coming in contact with the resident. During an interview at that time, Hospice CNA 1 and Hospice RN 1 both indicated they were not aware the resident was in EBP. During an interview on 11/25/24 at 2:30 p.m., the Director of Nursing indicated the resident was in EBP and a gown was required while providing wound treatments, bathing, and turning and repositioning the resident. The current 12/31/23 Dressing Changes policy, provided by the Director of Nursing on 11/26/24 at 10:40 a.m., indicated the pressure ulcer procedure was to wash hands with soap and water and put on the first pair of gloves. Remove the soiled dressing, discard in a plastic bag or trash can and dispose of the gloves. Wash hands with soap and water and put on a second pair of disposable gloves. Follow the doctor's recommendations for treatments, apply a dressing and secure with tape. After completing the treatment, remove the gloves, discard, and wash hands with soap and water. 45666 2. During a medication pass observation on 11/21/24 at 11:31 a.m., RN 1 was observed checking Resident 363's blood sugar and administering ampicillin (antibiotic medication) via a peripheral intravenous central catheter (PICC). Upon entering the resident's room, a sign on the door indicated the resident was in Enhanced Barrier Precautions (EBP), which required staff to wear a gown and gloves while performing any high contact care with the resident. RN 1 entered the room and donned clean gloves. She did not wash her hands prior to putting on the gloves. She checked the resident's blood sugar, removed her gloves, and then donned a new pair of gloves without performing hand hygiene between glove use. She had mixed a 3 gram ampicillin vial with a 50 cc bag of 0.9% normal saline solution and then primed intravenous (IV) tubing with the medication. She placed a cap over the end of the IV tubing once it was primed. While attaching the IV tubing to the PICC line, the IV tubing was observed touching the floor. She continued to administer the medication, then removed her gloves and performed hand hygiene. During an interview on 11/21/24 at 12:14 p.m., RN 1 indicated she should have washed her hands in between glove changes each time. She was unaware the tubing had touched the floor, but she had tried to keep it off of the floor while moving the tubing around. The resident was in Enhanced Barrier Precautions (EBP), but it was only required while caring for his wound or catheter. A gown was not required for the PICC line medication administration, but it would not have hurt to have it on during care. During an interview on 11/25/24 at 2:57 p.m., the Director of Nursing indicated she had no further information to provide. A policy titled, Enhanced Barrier Precautions (EBP) Standard Operating Procedure, noted as current, indicated .1. Enhanced Barrier Precautions (EBP) will be in place during high-contact care activities for residents with the following conditions: a. Residents at an increased risk of MDRO acquisition which include: i. All residents with chronic wounds, including but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. ii. All Residents with indwelling medical devices 1. Includes but not limited to: catheters, central lines, feeding tubes, tracheostomy tubes .2. Personal protective equipment (PPE) should be used even if blood and body fluid exposure is not anticipated. a. At minimum, staff shall wear gloves and gowns during high-contact care activities .3. High-contact care activities include but are not limited to: morning and evening ADL care, toileting, and showers.: A policy titled, Guideline for Handwashing/Hand Hygiene, noted as current, indicated .1. All health care workers (HCW) shall utilize hand hygiene frequently and appropriately .3. HCW shall use hand hygiene at times such as: .c. Before/after having direct physical contact with residents. d. After removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc . 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure a resident had Physician's Order to self-administer their own medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 38) Finding includes: During random observations on 11/21/24 at 10:20 a.m. and 2:04 p.m., and on 11/22/24 at 8:30 a.m., 10:21 a.m., and 1:24 p.m., Resident 38 was observed in bed. At those times, there was a bottle of nasal saline spray on her overbed table. On 11/22/24 at 2:45 p.m., LPN 1 was observed in the resident's room. At that time, she was made aware of the nasal saline spray on the overbed table. The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident had an unplanned significant weight loss and received a therapeutic diet. The resident received oxygen therapy while at the facility. There was no Care Plan to self-administer medications. Physician's Orders, dated, 8/26/24, indicated Saline Nasal Spray 0.65%, 1 spray to each nare for dryness twice a day as needed. There was no order for the resident to self-administer the nasal spray. During an interview on 11/22/24 at 2:46 p.m., LPN 1 indicated the resident did not have any orders to leave the nasal spray in her room or to self-administer the nasal spray. During an interview on 11/25/24 at 2:00 p.m., the Director of Nursing had no additional information to provide. 3.1-11(a)

Based on record review and interview, the facility failed to ensure a physician was notified of abnormal vital signs for 1 of 5 residents reviewed for unnecessary medications. (Resident 5) Finding includes: The record for Resident 5 was reviewed on 11/22/24 at 2:17 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, heart failure, hypertensive heart disease and diabetes mellitus. The Admission MDS assessment, dated 10/11/24, indicated the resident was cognitively intact and was dependent on staff for toileting and transfers. A Physician's Order, dated 10/8/24, indicated to give carvedilol (medication used to treat hypertension) 25 milligrams (mg) twice daily for hypertension. There were no blood pressure or heart rate parameters in place indicating when to hold the medication. The October 2024 Medication Administration Record (MAR) indicated the medication had been given twice daily from 10/8/24 through 10/15/24. The resident was sent to the hospital on 10/16/24, and returned on 10/24/24. The October and November 2024 MAR indicated he received the medication twice daily from 10/24/24 through 11/11/24. It was not given once on the evening of 11/4/24, the MAR note indicated he was unavailable. A Progress Note, dated 11/12/24, indicated the Physician had assessed the resident and there was a new order to decrease the carvedilol to 12.5 mg twice daily due to low heart rate. A Physician's Order, dated 11/12/24, indicated to give carvedilol, 12.5 mg, twice daily for hypertension. There were no blood pressure or heart rate parameters in place indicating when to hold the medication. The November 2024 MAR indicated the resident received the new dose of carvedilol once on 11/12/24. He was again sent to the hospital on 11/12/24 and returned on 11/16/24. The resident received the medication twice daily from 11/17/24 through 11/24/24. It was not given once in the evening of 11/21/24, the MAR note indicated the medication was unavailable. During October and November 2024, the resident's heart rate was documented below 55 beats per minute (bpm) on the following dates: 10/11- 50 bpm 10/12- 52 bpm 10/27- 53 bpm 10/31- 53 bpm 11/1- 49 bpm 11/2- 48 bpm 11/3- 52 bpm 11/5- 53 bpm 11/10- 50 bpm 11/11- 46 bpm 11/12- 40 bpm 11/13- 49 bpm There were no additional vital signs for review on the November MAR after 11/17/24. There was no documentation the physician had been notified of the heart rates below 55 beats per minute. During an interview on 11/25/24 at 11:30 a.m., the Director of Nursing was made aware of the the lack of Physician notification of the abnormal heart rates. No additional information was provided. The guidelines for carvedilol were retrieved from the [NAME] Drug Guide website at www.drugguide.com/ddo/view/[NAME]-Drug Guide/51134/all/carvedilol on 11/25/24, and indicated, .Monitor BP and pulse frequently during dose adjustment period and periodically during therapy. Assess for orthostatic hypotension when assisting patient up from supine position. If heart rate decreases below 55 bpm, decrease dose . Implementation-PO [by mouth] Take apical pulse before administering. If < [less than] 50 bpm or if arrhythmia occurs, withhold medication and notify health care professional The policy, Physician-Provider Notification Guidelines, dated 12/17/23, indicated, .Purpose to ensure the resident's physician or practitioner (may include NP, PA or clinical nurse specialist) is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care 3.1-5(a)(2)

Based on observation and interview, the facility failed to ensure a resident's privacy was maintained related to the electronic medication record (EMR) left open and unlocked in the hallway during medication pass for 1 of 8 residents observed during medication pass. (Resident 363) Finding includes: On 11/21/24 at 12:21 p.m., RN 1 was observed disconnecting an intravenous medication for Resident 363. She had the electronic medication record open on the computer as she gathered her supplies from the 300 Hall cart and then walked towards the resident's room to disconnect the medication and flush the line. The computer screen was left open and on, leaving the residents medications and personal information available to view. At 12:28 p.m., RN 1 was observed returning to the 300 Unit Nurses' Station where she sat down. The 300 Hall cart computer was still open and could be viewed in the hallway. During an interview on 11/21/24 at 12:28 p.m., RN 1 indicated she did not realize she had left the screen open, but the screen should always be locked when not in use. She proceeded to close the computer so that the record could no longer be seen in the hallway. During an interview on 11/25/24 at 2:57 p.m., the Director of Nursing indicated the computer screen should have been locked when the nurse walked away from the computer. 3.1-3(p)(2)

Based on record review and interview, the facility failed to ensure residents were involved in decisions about their care related to new medications and ensuring a resident attended and participated in care planning conferences for 2 of 2 residents reviewed for participation in care planning. (Residents 38 and 49) Findings include: 1. During an interview on 11/21/24 at 10:18 a.m., Resident 38 indicated she was not always informed of new medications, laboratory tests or treatments. The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. A Physician's Order, dated 11/14/24, indicated Remeron (an antidepressant medication) 15 milligrams (mg), give 1/2 tablet at bedtime. A Nurse's Note, dated 8/26/24 at 10:09 a.m., indicated the resident's daughter was made aware of the new order for Remeron. Physician's Orders, dated 10/1/24, indicated Complete Blood Count (CBC) and Complete Metabolic Panel (CMP) and Magnesium levels to be drawn. A Nurse's Note, dated 10/1/24 at 2:36 p.m., indicated the resident's daughter was notified of the new orders for the labs of CBC, CMP and Magnesium levels to be drawn. There was no documentation the resident was made aware of the new medications and lab draws. During an interview on 11/25/24 at 2:30 p.m., the Director of Nursing indicated the resident should have been notified of the change in medication and of the labs to be drawn. 2. During an interview on 11/21/24 at 2:27 p.m., Resident 49 indicated he had not attended or been invited to a care plan conference and was not always kept informed of medication changes. The record for Resident 49 was reviewed on 11/22/24 at 10:54 a.m. Diagnoses included, but were not limited to, right knee replacement, acute kidney failure, hypertensive chronic kidney disease, type 2 diabetes, heart disease, falls, bradycardia, and anemia. The 9/29/24 Admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The Scheduled 5 day MDS assessment, dated 10/29/24, indicated the resident was moderately impaired for daily decision making. The 9/30/24 Care Plan, indicated the resident demonstrated moderate cognitive impairment which was anticipated to progress due to the intrinsic nature of the disease process. The approaches were to encourage the resident to participate in familiar activities and daily tasks. A Physician's Order, dated 11/1/24, indicated Protonix 40 milligrams (mg) give 1 tablet two times a day. A Nurse's Note, dated 11/1/24 at 5:31 p.m., indicated the resident's wife was made aware of the new order for Protonix and draw the resident's blood on Monday. A Physician's Order, dated 11/20/24, indicated Doxycycline 100 mg twice a day. A Nurse's Note, dated 11/20/24 at 3:09 p.m., indicated the resident's wife was notified of the new order for the antibiotic of Doxycycline. Care Plan conference documentation, dated 11/11/24 at 1:00 p.m., indicated the resident's spouse and daughter were in attendance and plans were discussed regarding discharge. There was no documentation the resident was notified of the new medications or the lab draws. There was also no documentation if the resident was invited or attended the care conference. During an interview on 11/25/24 at 2:00 p.m., the Director of Nursing had no additional information to provide. During an interview on 11/26/24 at 8:55 a.m., the Administrator indicated the resident was invited to the care plan conference, however, the family did not want the resident there. They did not hold a separate conference with only the resident. 3.1-35(d)(2)(B)

Based on observation, record review and interview, the facility failed to ensure a resident's pain was managed and monitored for 1 of 2 residents reviewed for pain. (Resident 157) Finding includes: On 11/21/24 at 3:18 p.m., Resident 157 was observed sitting in his wheelchair in his room. He was grimacing, shifting in his chair, and complaining of back pain rated 7 out of 10 for severity. The resident indicated his back pain was not well controlled and he felt like he needed new or changed pain medications. On 11/25/24 at 9:26 a.m., the resident was observed fidgeting and attempting to reposition himself in bed. He indicated he was having back pain and the Fentanyl (an opioid pain medication) patch and Norco (an opioid pain pill) he had received were not controlling his pain. The resident's record was reviewed on 11/25/24 at 10:32 a.m. Medical diagnoses included, but were not limited to, cellulitis of the legs, heart failure, chronic kidney disease, atrial fibrillation, depression, spinal stenosis, and opioid use. The Admission Observation and Data Collection, dated 11/17/24, indicated the resident had moderate cognitive impairment, and was able to make needs known. The current Pain Care Plan indicated a goal that the resident's pain would be at a tolerable level with interventions. Interventions included, but were not limited to, observe for and record verbal and non-verbal signs of pain, administer medications as ordered, and attempt non-pharmacological interventions. The November 2024 Medication Administration Record (MAR) indicated the resident could receive diclofenac gel (a topical anti-inflammatory) as needed for pain, but he had not received it. There was no indication any non-pharmacological interventions had been attempted to manage the resident's pain. During an interview on 11/25/24 at 2:00 p.m., RN 2 indicated the non-pharmacological interventions for pain were rest and repositioning, and the resident did that himself. The resident was never given the diclofenac gel because he did not ask for it, but she did not know if he knew he could have it. QMA 1 then got the diclofenac gel from the medication cart, and went into the resident's room. On 11/25/24 at 2:15 p.m., the resident indicated he was glad the QMA applied the diclofenac to his back as he had not tried it before, and did not know it was available to him. During an interview on 11/26/24 at 10:35 a.m., the Director of Nursing was informed of the pain concerns and no further information was received. A facility policy, titled, Guidelines for Pain Observation and Management, received from the Administrator as current, indicated, . Procedures . 5. Educate the resident / family / caregivers on the pain management interventions . 6. Implement the care plan approaches to assist with pain management. 7. Evaluate the effectiveness of pain management interventions and modify as indicated. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a peripherally inserted central catheter (PICC) line was maintained related to bandage changes for 1 of 1 resident reviewed for infections. (Resident 363) Finding includes: During an interview on 11/21/24 at 11:15 a.m., Resident 363 indicated he had received intravenous (IV) antibiotics for a wound infection in his foot. The PICC line bandage had not been changed since he had been at the facility and one of the ports did not work. The white split gauze sponge under the clear tegaderm was observed with brown dried blood. There was no date on the bandage of the PICC line. On 11/21/24 at 3:20 p.m., the resident was sitting up in his wheelchair inside his room. The PICC line bandage remained the same as above. During an interview on 11/22/24 at 8:25 a.m., the resident indicated the nurse had changed his PICC line bandage that morning. The record for Resident 363 was reviewed on 11/22/24 at 10:27 a.m. Diagnoses included, but were not limited to, absence of the right foot, osteomyelitis, abscess of the right foot, type 2 diabetes, arteriosclerosis, peripheral vascular disease, heart disease, heart failure, depression, and anxiety. The resident was admitted to the facility on [DATE]. The 11/13/24 Admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making, received an antibiotic, and had an IV. The Care Plan, dated 11/8/24, indicated the resident required IV medication. The approaches were IV site care as ordered. Physician's Orders, dated 11/7/24, indicated change PICC dressing every 5 days and measure external catheter length. The Treatment Administration Record (TAR) for the month of 11/2024, indicated the PICC line dressing change was not signed out as being completed on 11/12 and 11/17/24. The first time it was signed out as being completed was on 11/22/24. There was no documentation on 11/12 or 11/17/24 the PICC line bandage was changed. During an interview on 11/25/24 at 2:00 p.m., the Director of Nursing had no additional information to provide. The current and revised 12/2015 Catheter Insertion and Care policy, provided by the Assisted Living Director as current on 11/25/24 at 3:15 p.m., indicated the midline catheter dressing was to be changed at specified intervals or when needed to prevent catheter-related infections. The midline catheter was to be changed every five to seven days, or if it was wet, dirty, not intact, or compromised in any way. 3.1-47(a)(2)

Based on observation, record review, and interview, the facility failed to ensure blood pressure medication was administered as ordered according to parameters for 1 of 1 resident reviewed for blood pressure parameters and for 1 of 5 residents reviewed for unnecessary medications. (Residents 38 and 5) Findings include: 1. The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident received oxygen therapy while at the facility. Physician's Orders, dated 12/22/22, indicated Hydralazine (a medication used to lower the blood pressure) 25 milligrams (mg) twice a day and to hold if systolic blood pressure was less than 110 and the heart rate was less than 60. Metoprolol succinate (a medication used to lower the blood pressure and heart rate) extended release 25 mg once a day and hold if systolic blood pressure was less than 110 and/or the heart rate was less than 60. The 9/2024 Medication Administration Record (MAR) indicated the Hydralazine was administered on following dates: 11:00 a.m.-1:30 p.m.: - 9/12/24 and the blood pressure was 108/61. - 9/20/24 and the blood pressure was 109/69. - 9/25/24 and the blood pressure was 109/64. 6:30 p.m.-10:30 p.m. - 9/1/24 and the blood pressure was 99/59. - 9/5/24 and the blood pressure was 89/44. - 9/7/24 and the blood pressure was 99/54. - 9/10/24 and the blood pressure was 98/58. - 9/18/24 and the blood pressure was 102/70. The 9/2024 MAR indicated the Metoprolol was administered on following dates at 11:00 a.m.-1:30 p.m.: - 9/2/24 and the heart rate was 57. - 9/8/24 and the heart rate was 59. - 9/12/24 and the blood pressure was 108/61. - 9/15/24 and the blood pressure was 102/68. - 9/20/24 and the blood pressure was 106/69. - 9/24/24 and the blood pressure was 97/57 and the heart rate was 59. - 9/25/24 and the blood pressure was 109/64. The 10/2024 MAR indicated the Hydralazine was administered on the following dates: 11:00 a.m.-1:30 p.m. - 10/10/24 and the blood pressure was 100/54. - 10/30/24 and the blood pressure was 107/61. 6:30 p.m.-10:30 p.m. -10/8/24 and the blood pressure was 106/65. The 10/2024 MAR indicated the Metoprolol was administered on the following dates at 11:00 a.m.-1:30 p.m. -10/10/24 and the blood pressure was 100/54. -10/30/24 and the blood pressure was 107/61. The 11/2024 MAR indicated the Hydralazine was administered on the following dates at 11:00 a.m.-1:30 p.m.: - 11/6/24 and the blood pressure was 84/56. - 11/14/24 and the blood pressure was 97/51. - 11/16/24 and the blood pressure was 104/63. - 11/19/24 and the blood pressure was 104/62. - 11/22/24 and the blood pressure was 106/62. The 11/2024 MAR indicated the Metoprolol was administered on the following dates at 11:00 a.m.-1:30 p.m.: - 11/6/24 and the blood pressure was 84/56. - 11/14/24 and the blood pressure was 97/51. - 11/16/24 and the blood pressure was 104/63. - 11/19/24 and the blood pressure was 104/62. - 11/20/24 and the blood pressure was 95/64. - 11/22/24 and the blood pressure was 106/62. During an interview on 11/22/24 at 2:46 p.m., LPN 1 indicated a QMA had passed the medications on her unit. She was told by the QMA that she held the Metoprolol for the resident and did not administer it. She indicated the medication was to be administered according to the parameters. During an interview on 11/25/24 at 2:30 p.m., the Director of Nursing indicated the medication should have been administered as ordered by the Physician. 32582 2. The record for Resident 5 was reviewed on 11/22/24 at 2:17 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, heart failure, hypertensive heart disease and diabetes mellitus. The Admission MDS assessment, dated 10/11/24, indicated the resident was cognitively intact and was dependent on staff for toileting and transfers. A Physician's Order, dated 10/8/24, indicated to give carvedilol (medication used to treat hypertension) 25 milligrams (mg) twice daily for hypertension. There were no blood pressure or heart rate parameters in place indicating when to hold the medication. The October 2024 Medication Administration Record (MAR) indicated the medication had been given twice daily from 10/8/24 through 10/15/24. The resident was sent to the hospital on 10/16/24, and returned on 10/24/24. The October and November 2024 MAR indicated he received the medication twice daily from 10/24/24 through 11/11/24. It was not given once on the evening of 11/4/24, the MAR note indicated he was unavailable. A Progress Note, dated 11/12/24, indicated the Physician had assessed the resident and there was a new order to decrease the carvedilol to 12.5 mg twice daily due to low heart rate. A Physician's Order, dated 11/12/24, indicated to give carvedilol, 12.5 mg, twice daily for hypertension. There were no blood pressure or heart rate parameters in place when to hold the medication. The November 2024 MAR indicated the resident received the new dose of carvedilol once on 11/12/24. He was again sent to the hospital on 11/12/24 and returned on 11/16/24. He received the medication twice daily from 11/17/24 through 11/24/24. It was not given once in the evening of 11/21/24, the MAR note indicated the medication was unavailable. During October and November 2024, the resident's heart rate was documented below 55 beats per minute (bpm) on the following dates: 10/11- 50 bpm 10/12- 52 bpm 10/27- 53 bpm 10/31- 53 bpm 11/1- 49 bpm 11/2- 48 bpm 11/3- 52 bpm 11/5- 53 bpm 11/10- 50 bpm 11/11- 46 bpm 11/12- 40 bpm 11/13- 49 bpm There were no additional vital signs for review in the November MAR after 11/17/24. During an interview on 11/25/24 at 11:10 a.m., the Director of Nursing indicated holding the medications would depend on the patient, if a heart rate was in the 40's it should probably be held. A policy was requested but not provided. The guidelines for carvedilol was was retrieved from the [NAME] Drug Guide website at www.drugguide.com/ddo/view/[NAME]-Drug Guide/51134/all/carvedilol, on 11/25/24, indicated, .Monitor BP and pulse frequently during dose adjustment period and periodically during therapy. Assess for orthostatic hypotension when assisting patient up from supine position. If heart rate decreases below 55 beats/min, decrease dose . Implementation-PO Take apical pulse before administering. If < [less than] 50 bpm or if arrhythmia occurs, withhold medication and notify health care professional 3.1-37(a)

Based on record review and interview, the facility failed to monitor weekly weights and nutritional intake for meals and supplements as ordered for a resident with significant weight loss for 1 of 2 residents reviewed for nutrition. (Resident 38) Finding includes: The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and weighed 78 pounds. The resident had an unplanned significant weight loss and received a therapeutic diet. The revised Care Plan, dated 11/12/24, indicated the resident was malnourished/ at risk for malnutrition related to inadequate nutrient/ energy intakes, and/or metabolic demands. The approaches were to provide diet, supplements, medications, and adaptive equipment as ordered. A Physician's Order, dated 3/3/23 and on the current Physician Order Statement dated 11/2024, indicated point of care tasks: check breakfast, lunch and dinner. A Physician's Order, dated 5/14/24, indicated regular fortified foods with meals. A Physician's Order, dated 8/16/24, indicated med pass (nutritional supplement) 90 milliliters (ml) daily. The resident's weight was 77 pounds on 7/11/24 and on 8/2/24 she weighed 70 pounds. The resident's current weight on 11/14/24 was 78 pounds. A Registered Dietitian (RD) Note, dated 8/15/24 at 11:46 a.m., indicated the resident had a significant weight loss of 8.2% in the last 30 days. The RD suggested adding med pass supplement of 90 ml daily and obtaining weekly weights times four weeks. There was no documentation the weekly weights were completed for 4 weeks. The consumption of the of the med pass supplement was not documented as being administered on 10/6, 10/7, 10/10, 10/11, 10/15, 10/17, 11/9, 11/14, 11/15, and 11/21/24. The meal consumption log indicated there was no documentation for the breakfast meal on 9/2, 10/11, 11/1, 11/3, 11/5, 11/7, 11/12, and 11/19/24 The meal consumptions indicated there was no documentation for the lunch meal on 9/2, 10/11, 11/1, 11/3, 11/5, 11/19, and 11/21/24. The meal consumptions indicated there was no documentation for dinner meal on 9/2, 9/5, 9/9, 9/14, 9/18, 9/22, 10/1, 10/5, 10/9, 10/11, 10/14, 10/18, 10/21, 10/23, 10/26, 11/1, 11/5, 11/8, 11/10, 11/14, 11/17, 11/18, and 11/19/24. During an interview on 11/25/24 at 2:20 p.m., the Director of Nursing indicated the meal and supplement consumptions were incomplete. During an interview on 11/26/24 at 9:10 a.m., the Director of Nursing indicated the weekly weights were not completed. 3.1-46(a)

Based on record review and interview, the facility failed to ensure a resident received adequate fluids orally and assessments were completed to ensure a resident did not exhibit clinical signs of possible dehydration, which resulted in one resident requiring intravenous (IV) fluid to be given for hydration (Resident #B), for 2 of 3 residents reviewed for dehydration risks, in a total sample of 5. (Resident #B and #C) Findings include: 1. Resident #B's record was reviewed on 02/23/15 at 1:45 p.m. The resident's [DIAGNOSES REDACTED]. The resident was [AGE] years old. The Annual Minimum Data Set Assessment, dated 11/27/14, indicated the resident was severely cognitively impaired, required extensive assistance of two for bed mobility and transfers, and required extensive assistance for eating. A Monthly Nursing Assessment & Data Collection, dated 01/07/15, indicated the resident was 65 inches and weighed 144 pounds, mucous membranes were pink and moist, and skin turgor had been left blank. A Professional Resource, titled, "Indiana Diet Manual 6th Edition", indicated the resident's fluid intake should be approximately 1963 ml (milliliter)/ 24 hours. (allow 30 ml per kilogram of actual body weight per day for resident's over [AGE] years of age with no history of [MEDICAL CONDITION] or [MEDICAL CONDITION]) The resident's care plan, dated 12/08/14, indicated the following problems and interventions: The resident required assistance with care. The interventions included to provide set up for meals and encourage independent eating. The resident had dysphagia and was a risk for choking and aspiration. The interventions included to provide the resident with diet as recommended by Speech Therapy. The resident had nausea at times. The interventions included to encourage to drink plenty of fluids, provide with ordered diet and fluids and document my consumption. There was no care plan to indicate the resident was a risk for hydration. A physician's orders [REDACTED]. The Nurses' Note, dated 12/22/14 at 8 p.m., indicated the facility received an order from the Physician for a BMP and an urinalyses to be completed on 12/23/14, related to possible dehydration. There was no assessment of the resident's hydration status (oral mucosa color and moisture, skin turgor, fluid intake) completed to and no documentation oral fluids had been encouraged. The Nurses' Notes, dated 12/22/14 at 11 p.m. and 12/23/14 at 12:30 a.m., indicated an assessment for the resident's hydration status had not been completed and oral fluids had not been encouraged. The noted indicate an external catheter had been applied to assist in obtaining an urine specimen. The Nurses' Notes, dated 12/23/14 at 4 a.m., indicated the resident consumed 60 ml of thickened water and a scant amount of urine was present in the external catheter. A Nurses' Note, dated 12/23/14 at 5:30 a.m., indicated the urine specimen could not be obtained due to no urine in the external catheter. The BMP results were received on 12/23/14 at 2:14 p.m., the sodium was 142 (normal 135-147), potassium 3.9 (3.5-5.0), BUN (kidney function) 21 (normal 7-22), and creatinine (kidney function) 0.7 (0.4-1.5). The Physician documented on the results the resident was well hydrated. The next Nurses' Notes were dated 12/24/14 at 10 a.m. and 12/24/14 at 8 p.m. The Nurses' Notes indicated an assessment of the resident's hydration status had not been completed and extra oral fluids had not been offered to the resident. The next Nurses' Notes, dated 12/26/14 at 5 p.m., indicated an assessment of the resident's hydration status had not been completed and extra oral fluids had not been offered to the resident. The next Nurses' Notes, dated 12/28/14 at 6 p.m., indicated an assessment of the resident's hydration status had not been completed and extra oral fluids had not been offered to the resident. A Resident First Conference Notes form, dated 12/29/14, indicated the nutritional status and hydration concerns was left blank, the residents overall status had declined due to exacerbation of a medical condition and natural aging process, the areas of decline included ADL's (activities of daily living) and cognition. The Care giver comments, indicated, "From therapy-his eating has been poor...expecting his eating behavior to decline further...If we are able to see if hydration changes condition to see if his intake improves..." The Resident/responsible party comments indicated, "...(Daughter's Name) 'I want him hydrated w/ (with) IV hydration with (Resident) is an issue; someone has to offer him water constantly every couple of hours offer him a few sips." A physician's orders [REDACTED]. The results for the BMP ordered on [DATE] were received by the facility on 12/30/14 at 4:43 p.m., which indicated, sodium 149 (high), potassium 3.8, BUN 36 (high), and Creatinine 1.1. A physician's orders [REDACTED]. A Physician's Progress Note, dated 12/30/14, indicated the resident had been having increasing issues with taking food and liquids and overall had decreased intakes and last week the resident was well hydrated and now the labs currently showed dehydration and the resident was started on IV fluids. The note indicated the resident was still struggling with oral intake and the plan was to IV hydrate for now and to discuss future plans with feeding and hospice related to advanced dementia and dysphagia. There were no further Nurses' Notes from 12/28/14 at 6 p.m. until 12/30/14, no date documented, indicated an assessment of the resident's hydration status had not been completed and extra oral fluids had not been offered to the resident. The BMP results for 12/31/14 (after the first three liters of fluid were infused), were received by the facility on 12/31/14 at 12:13 p.m. The resident's sodium was 150 (high), potassium 4.1, Chloride 115 (normal 99-109), BUN 27 (high), and Creatinine 0.8. A physician's orders [REDACTED]. The Nurses' Note, dated 12/31/14, no time documented, indicated the resident complained of nausea and was medicated and resident was offered 120 ml (milliliters) of cranberry juice was consumed. The note indicated an assessment of the resident's hydration status had not been completed. Further in the Nurses' Notes, dated 12/31/14 at 11:30 a.m. and 12/31/14 at 6:45 p.m., 11:35 p.m., and 11:45 p.m. there was no assessment of the resident's hydration status and no documentation extra oral fluids were offered. The BMP, dated 01/02/15, indicated the resident's sodium was 142, potassium 4.2, chloride 107, BUN 19, and Creatinine 0.9 (all within normal range). There were no further Nurses' Notes until 01/04/15 at 12:30 p.m., which there was still no documentation of the resident's hydration status. There was no dehydration assessments located on the Change in Condition Form, dated 12/31/14 at 11:30 a.m. through 01/03/15, 7 a.m. to 3 p.m. shift. During an interview on 02/24/15 at 8:30 a.m. with the Executive Director and the Director of Healthcare Services (DHS), the DHS indicated there were no assessments for the resident's hydration status. She indicated lab tests were done. She indicated intakes could be on the care tracker and she would print them. As of exit from the facility on 02/24/15 at 1 p.m., the DHS had not provided the care tracker information to provide fluid intake records for the resident. 2. Resident #C's record was reviewed on 02/24/15 at 10:35 a.m. The resident's [DIAGNOSES REDACTED]. A BMP results, dated 01/26/15 at 5:07 p.m., indicated the resident's sodium was 143 (normal 135-147), potassium 4.3 (normal 3.5-5.0), chloride 110 (normal 99-109), BUN 41(normal 7-22), and Creatinine 3.0(normal 0.4-1.5). The Physician documented on the results , "Please encourage oral hydration". The Nurses' Notes, dated 1/22/15 at 11:05 a.m., 01/31/15 at 8:30 a.m., and the last note in the record, dated 01/31/15 8:50 a.m., indicated an assessment of the resident's hydration status had not been completed and extra oral fluids had not been offered to the resident. During an interview on 02/24/15 at 11:30 a.m. with the ED and DHS, the DHS indicated there were no hydration assessments completed. This Federal Tag relates to complaint IN 926. 3.1-46(b)

Based on record review and interview, the facility failed to ensure the an unavoidable pressure ulcer developed related to a resident, identified as having staff assist with his bedpan use, developed a suspected deep tissue injury in the shape of a bedpan for 1 of 3 residents reviewed for wounds in the sample of 7. (Resident #G) Findings include: The closed record for Resident #G was reviewed on 12/16/13 at 10:40 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident was discharged from the facility on 11/13/13. The 9/16/13 Minimum Data Set (MDS) admission assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was (5). This score indicated the resident's cognitive patterns were impaired. The assessment also indicated the resident required extensive assistance ( resident involved in activity with staff providing weight bearing support) of two plus persons for bed mobility and dressing. The assessment indicated the resident required extensive assistance of one person assist for toilet use and personal hygiene. The assessment also indicated the resident had one Stage I (intact skin with non blanchable redness) pressure ulcer and no other ulcers, wounds or skin problems. A "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" report was initiated on 10/23/13. The report indicated the resident had a "Suspected Deep Tissue Injury" noted on his buttock. The section on the report labeled "Anatomical Location" had two body diagrams on it to indicate where the skin areas were located. On the diagram of the posterior side of the resident's body the facility had marked a "U" shaped line which started at the waist on the left side and continued down the resident's left buttock, across to the right buttock and up the buttock to the right waist area. The area was measured as 52 cm (centimeters) in length and 1.4 cm in width and the color was noted to be "purple." The following measurement of the above area were documented on the report. 10/30/13: 15.1 cm x 1 cm 11/06/13: 8.4 cm x 0.3 cm 11/13/13: 6.4 cm x 0.3 cm There was no Skin Impairment Circumstance, Assessment, and Intervention form completed related to the development of the suspected deep tissue injury area. When interviewed on 12/17/13 at 11:35 a.m. the Director of Nursing indicated a Skin Impairment Circumstance form should have been initiated when the suspected deep tissue injury was first observed to the resident's buttock areas. The Director of Nursing indicated Nursing assessment of the area were to be completed once a shift for 72 following the observation of the new wound. When interviewed on 12/16/13 at 12:15 p.m., the Director of Nursing indicated the resident developed a suspected deep tissue area to the buttock on 10/23/13. The Director of Nursing indicated the night shift informed her of the area at approximately 6:00 a.m. on 10/23/13 and she was in the facility at this time. The Director of Nursing indicated she interviewed the CNA at this time and the CNA indicated the resident was not on the bed pan. When asked if the area was caused by a bed pan the Director of Nursing replied "it could have been." The Director of Nursing indicated the Wound Nurse/Unit Manager at the time interviewed the staff caring for the resident for the past 72 hours and no staff reported putting the resident on the bed pan. When interviewed on 12/16/13 at 3:00 p.m., the facility Administrator indicated she was aware the resident had pressure ulcers but had not been informed the area discovered on 10/23/13 had an irregular shaped as noted on the wound sheet. The Administrator indicated she should have been informed of the area. When interviewed on 12/17/13 at 1:15 p.m., the facility Administrator indicated she would have looked at the investigation of the area if she had been informed. The Administrator indicated she was not aware of any inservices or education/training done related to the development of the area. The Administrator indicated there were bedpans in the facility for residents to use. When interviewed on 12/17/13 at 1:25 p.m.,LPN #1 was in the supply room and he indicated he was familiar with items in the supply store room. The LPN indicated there were two types of bed pans usually available and one is a small fracture pan and the other is plastic larger one which is about 2-3 inches high all around. When interviewed on 12/17/13 at 1:30 p.m., the Director of Nursing indicated one of the staff interviewed did indicate the resident used the bed pan at times but she did not recall which employee that was. When interviewed on 12/17/13 at 1:35 p.m., LPN #2 indicated he worked on the hall Resident #G had resided on. The LPN indicated he worked the 3:00 p.m. to 11:00 p.m. shifts at the time and the resident rarely got out of bed on this shift. The LPN indicated he had heard in change of shift report that the resident apparently may have been left on the bed pan. LPN #2 indicated he never had placed the resident on the bed pan but did recall seeing a bed pan in a plastic bag in the resident's room. The LPN indicated it was the big one. The LPN indicated he talked with the CNA's on his hall and one CNA did indicate the resident used the bedpan at times. The LPN indicated in the past the resident would ask for the urinal and was able to use to the urinal. LPN #2 indicated he did not feel the resident would be able to put himself on or off the bed pan. When interviewed on 12/17/13 at 1:40 p.m., CNA #3 indicated she usually worked the day shift on the hall Resident #G resided on and she had taken care of the resident. The CNA indicated she had put the resident on the bedpan at times and he would have a bowel movement. The CNA indicated she used the smaller pan. CNA #3 indicated the resident required assistance to turn to his side. The CNA indicated the resident's bedpan was kept in a bag in the bathroom and it was the midnight shift CNA's responsibility to change them out on Mondays. The CNA indicated the night shift Nurse told her about the area at the change of shift when she came on the day it happened. The CNA indicated she did not put the resident on the bedpan after that. The CNA indicated the resident's condition had declined and she would ask him if he wanted to use the bedpan but he would decline. CNA #3 indicated she saw the area on the day it was observed and it looked like a "bruise" and was "right where a bedpan would go." When interviewed on 12/17/13 at 1:55 p.m., CNA #4 she worked on the 100 hall and had taken care of Resident #G. The CNA indicated the resident was incontinent of bowel and bladder. The CNA indicated she had never placed the resident on the bedpan. The CNA indicated there was a bedpan in the resident's room but she was not aware of any Nurses or CNA's using the bedpan. When interviewed on 12/17/13 at 2:00 p.m. the Director of Nursing indicated there were other residents in the facility who used bedpans and no other resident's ever had any skin issues from the bedpan. The Director of Nursing indicated they did not interview any other residents who used bedpans and did not complete any monitoring or audits of bed pan use at the time to determine if there we other identified concerns. The facility policy titled "Guidelines for Circumstance and Reassessment Forms" was reviewed on 12/17/13 at 11:35 a.m. There was no date on the policy. The Administrator provided the policy and indicated the policy was current. The policy indicated the purpose of the form was "to provide a mechanism for investigation, assessment, care plan update, interdisciplinary team review and follow up for specific episodes." The policy indicated the appropriate Circumstance and Reassessment Form" was to be used as applicable to each episode. The policy indicated the top portion of the form was to be completed to determine the circumstance and investigation of the occurrence. New interventions or approaches were to be evaluated and added to the care plan. The policy also indicated the interdisciplinary team was to review the completed form in the daily stand up meetings. The review was to include the thoroughness of the investigation, circumstance and the approach/interventions response. A blank "Skin Impairment Circumstance Investigation" form was reviewed. Sections on the form include listing the type of impairment, Environmental and Equipment Inspections, and Prevention Updates. There was also a section on the form for IDT (Interdisciplinary team) review and recommendations. The form was to be signed by the IDT members who reviewed it. The facility policy titled "Accident and Incident Reporting Guidelines" was reviewed on 12/17/13 at 3:00 p.m. The policy was dated 11/2010. the Nurse Consultant provided the policy and indicated the policy was current. The Policy indicated all accidents and incidents including injuries of unknown sources were to be reported to the department supervisor. Investigative action was to be initiated by the attending Nurse or Nursing Supervisor by completing a "Circumstance and Reassessment" form and the completed form was to be brought to the daily stand up meetings for review. Administrative staff were to complete the investigation by completing the "Interdisciplinary Team" section. This Federal tag relates to Complaint IN 215. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview the facility failed to ensure a Medication Error was accurately identified and addressed in the Quality Assessment and Assurance committee meeting related to numerous Nurses failing to follow the policy for checking medication orders prior to administering medications for 1 resident in the sample of 7. (Resident #D) (Nurse #4, #5, #6, and #7) Findings include: The record for Resident #D was reviewed on 12/16/13 at 1:30 p.m. The resident's [DIAGNOSES REDACTED]. Review of the 10/2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The order was originally written on 5/3/2012. The [MEDICATION NAME] medication was signed out as administered to the resident daily form 10/1/13 through 10/13/13 and 10/15/13 through 10/19/13. The [MEDICATION NAME] was not resumed until 10/28/13. The above medication was initialed as given by approximately (4) different staff members. Those staff members were Nurse #4, #5, #6, and #7. A "Medication Error Circumstance, Assessment, and Intervention" report was completed on 10/20/13. The report indicated the medication error was found on 10/201/3 at 7:00 a.m. on the MAR (Medication Administration Record). The nature of the error indicated a medication was given every day instead of every other day as transcribed. The medication was identified as [MEDICATION NAME] ( [MEDICATION NAME]) 20 milligrams. The resident's Physician and his Responsible Party were notified. On the 10/20/13 Medication Error Circumstance, Assessment, and Intervention report there was a section titled "Prevention Update." In this section there were spaces to check if any Nursing Education, Nursing Counseling, ongoing chart review for medication accuracy , or monitoring of side effects had been completed. These areas in the "Prevention Update" section were all blank. The section was signed by an LPN. There was another section on the 10/20/13 Medication Error Circumstance, Assessment, and Intervention report titled "IDT (Interdisciplinary Team) Review." This section contained areas to mark if the IDT reviewed the above Prevention Update and agreed with the plan to maximize safety. This section was not completed. Five IDT team members signed the above sheet with the noted blanks. A "Change in Condition" form was initiated on 10/24/13 (no time listed). The form indicated the resident was noted to have "abnormal labs-dehydration." The Physician response was for the resident to receive IV fluids of 0.9% normal saline at 150 ml's (millimeters) an hour x 3 liters and to obtain a BMP (laboratory test) after the fluids were administered. The October 2013 Physician orders [REDACTED]. 10/20/13- Patient to have BMP on 10/21/13. 10/22/13 - Hold [MEDICATION NAME] x 2 days (10/23/13 and 10/24/13), push oral hydration every shift, repeat BMP on 10/24/13, and obtain a renal ultrasound. 10/24/13- Resident to receive 0.9 % Normal Saline via IV at 150 milliliters per hour for a total of (3) liters 10/26/13- Continue to hold [MEDICATION NAME] and push fluids. The 9/2013 and the 10/2013 laboratory test results were reviewed ad the following results were recorded; 09/03/2013 BUN (Blood Urea Nitrogen): 37 (normal level 7-22) Creatanine: 1.8 (normal level .4-1.5) 10/01/2013 BUN: 43 (normal level 7-22) Creatatine: 1.8 (normal level .4- 1.5) Sodium : 146 (normal level 135-147) Potassium: 4.0 (normal level 3.5-5.0) 10/03/2013 BUN: 51 (normal level 7-22) Creatatine: 1.9 (normal level .4- 1.5) 10/21/2013 BUN: 74 (normal level 7-22) Creatanine 2.3 (normal level .4-1.5) The 2010 Nursing Spectrum Drug Handbook indicated adverse reactions to [MEDICATION NAME] included, dehydration and [MEDICAL CONDITION]. The Handbook also indicated BUN laboratory levels were to be monitored. When interviewed on 12/16/13 at 3:05 p.m., the Director of Nursing indicated the medication error was found by a Nurse during medication pass. The diuretic medication was being administered once a day instead of every other day. The Director of Nursing indicated no Nursing staff inservicing or staff education was completed related to the above medication error. The Director of Nursing indicated other charts on the unit were audited at this time. The DON indicated the facility had Nurses reviewing the monthly orders and as a result of the above error they assigned a Manager to review the monthly orders. The DON indicated there were no Nursing inservices or education completed related to the medication errors the Nurses were making when they gave the medication daily instead of every other day as the order was written on the Medication Administration Record. The facility policy title "Med Pass Procedures & Error Prevention" was reviewed don 12/17/13 at 11:40 a.m. The Director of Nursing provided the policy and indicated the policy was current. The policy indicated during medication administration pass the staff were to triple check the medications for accuracy three times. The times three times were to be as the medication was identified, as the medication was prepared, and as the medication container was put back. When interviewed on 12/17/13 at 11:38 a.m., the facility Administrator indicated the Quality Assessment and Assurance team consists of the Administrator, DON, ADON, MDS Nurse, Unit Manager, and the Medical Director. The Administrator indicated there are standard quality measures covered at each meeting. These measures included Medication Errors. The Administrator indicated at the 11/20/13 Quality Assessment and Assurance meeting it was determined there were transcription errors. The plan that was put into place was to have a Department manager review and sign the monthly Physician orders [REDACTED]. The Administrator indicated the plan did not address the issue of the 10/2013 Medication Errors for Resident #D in which the errors occurred by Nurses not following the policy to verify the order written on the MAR (Medication Administration Record) prior to administering medications to the resident rather then a transcription error. This Federal tag relates to Complaint IN 215. 3.1-52(b)

Based on record review and interview, the facility failed to ensure resident's remained free of significant medication error related to a diuretic medication given daily instead for every other day as ordered by the Physician which resulted in the resident requiring the administration of IV (intravenous) fluids for 1 of 3 residents reviewed for dehydration in the sample of 7. (Resident #D) Findings include: The record for Resident #D was reviewed on 12/16/13 at 1:30 p.m. The resident's [DIAGNOSES REDACTED]. Review of the 9/28/13 Minimum Data Set (MDS) quarterly assessment indicated resident had received a diuretic medication on (7) days during the last (7) days. A care plan initiated on 4/4/13 indicated the resident was at risk for alterations in nutrition and hydration. The care plan was last updated on 9/27/13. Care plan interventions included for staff to administer medications as ordered by the Physician. Review of the 10/2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The order was originally written on 5/3/2012. The [MEDICATION NAME] medication was signed out as administered to the resident daily form 10/1/13 through 10/13/13 and 10/15/13 through 10/19/13. The [MEDICATION NAME] was not resumed until 10/28/13. A "Medication Error Circumstance, Assessment, and Intervention" report was completed on 10/20/13. The report indicated the medication error was found on 10/201/3 at 7:00 a.m. on the MAR (Medication Administration Record). The nature of the error indicated a medication was given every day instead of every other day as transcribed. The medication was identified as [MEDICATION NAME] ( [MEDICATION NAME]) 20 milligrams. The resident's Physician and his Responsible Party were notified. On the 10/20/13 Medication Error Circumstance, Assessment, and Intervention report there was a section titled "Prevention Update." In this section there were spaces to check if any Nursing Education, Nursing Counseling, ongoing chart review for medication accuracy , or monitoring of side effects had been completed. These areas in the "Prevention Update" section were all blank. The section was signed by an LPN. There was another section on the 10/20/13 Medication Error Circumstance, Assessment, and Intervention report titled "IDT (Interdisciplinary Team) Review." This section contained areas to mark if the IDT reviewed the above Prevention Update and agreed with the plan to maximize safety. This section was not completed. Five IDT team members signed the above sheet with the noted blanks. A "Change in Condition" form was initiated on 10/24/13 (no time listed). The form indicated the resident was noted to have "abnormal labs-dehydration." The Physician response was for the resident to receive IV fluids of 0.9% normal saline at 150 ml's (millimeters) an hour x 3 liters and to obtain a BMP (laboratory test) after the fluids were administered. The October 2013 Physician orders [REDACTED]. 10/20/13- Patient to have BMP on 10/21/13. 10/22/13 - Hold [MEDICATION NAME] x 2 days (10/23/13 and 10/24/13), push oral hydration every shift, repeat BMP on 10/24/13, and obtain a renal ultrasound. 10/24/13- Resident to receive 0.9 % Normal Saline via IV at 150 milliliters per hour for a total of (3) liters 10/26/13- Continue to hold [MEDICATION NAME] and push fluids. The 9/2013 and the 10/2013 laboratory test results were reviewed ad the following results were recorded; 09/03/2013 BUN (Blood Urea Nitrogen): 37 (normal level 7-22) Creatanine: 1.8 (normal level .4-1.5) 10/01/2013 BUN: 43 (normal level 7-22) Creatatine: 1.8 (normal level .4- 1.5) Sodium : 146 (normal level 135-147) Potassium: 4.0 (normal level 3.5-5.0) 10/03/2013 BUN: 51 (normal level 7-22) Creatatine: 1.9 (normal level .4- 1.5) 10/21/2013 BUN: 74 (normal level 7-22) Creatanine 2.3 (normal level .4-1.5) The 2010 Nursing Spectrum Drug Handbook indicated adverse reactions to [MEDICATION NAME] included, dehydration and [MEDICAL CONDITION]. The Handbook also indicated BUN laboratory levels were to be monitored. When interviewed on 12/16/13 at 3:05 p.m., the Director of Nursing indicated the medication error was found by a Nurse during medication pass. The diuretic medication was being administered once a day instead of every other day. The Director of Nursing indicated no Nursing staff inservicing or staff education was completed related to the above medication error. The Director of Nursing indicated other charts on the unit were audited at this time. The DON indicated the facility had Nurses reviewing the monthly orders and as a result of the above error they assigned a Manager to review the monthly orders. The DON indicated there were no Nursing inservices or education completed related to the medication errors the Nurses were making when they gave the medication daily instead of every other day as the order was written on the Medication Administration Record. The facility policy title "Med Pass Procedures & Error Prevention" was reviewed on 12/17/13 at 11:40 a.m. The Director of Nursing provided the policy and indicated the policy was current. The policy indicated during medication administration pass the staff were to triple check the medications for accuracy by comparing the ancillary label, the resident label, and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This Federal tag relates to Complaint IN 215. 3.1-48(c)(2)