Every finding on record at Bethel Pointe Health and Rehab

Based on interview and record review the facility failed to ensure a resident was free from a significant medication error for 1 of 1 resident reviewed for medication errors (Resident B). This deficient practice resulted in Resident B's hospitalization in the intensive care unit for bradycardia (abnormally slow heart rate), hypotension (low blood pressure) and subsequent cardiogenic shock (heart cannot pump enough blood to meet the body's needs). This deficient practice was corrected on 7/16/26, prior to the start of the survey, and was therefore past noncompliance. Findings include: Resident B's clinical record was reviewed on 7/20/26 at 11:49 a.m. Diagnoses included chronic respiratory failure with hypoxia, heart failure, anemia, iron deficiency anemia, essential (primary) hypertension, and Parkinson's disease without dyskinesia, with fluctuations. Current medications included aspirin 81 mg daily; nitrofurantoin monohydrate/macrocrystals (antibiotic) 50 mg daily at bedtime; hydrocodone-acetaminophen (opiate pain reliever) 5-325 mg twice daily; metoprolol tartrate (for high blood pressure) 12.5 mg twice a day; and carbidopa-levodopa (for Parkinson's) 25-100 mg, four tablets three times daily. An SBAR (Situation, Background, Assessment, and Recommendation) note, dated 7/16/26 at 10:30 a.m., indicated the resident was administered an amiodarone (for irregular heartbeat) 200 mg tablet, a citalopram (antidepressant) 10 mg tablet, a Certa Vite/Antioxidants (vitamin) tablet, a clopidogrel bisulfate (blood thinner) 75 mg tablet, a Floranex (probiotic dietary supplement) tablet, an omeprazole (decreases stomach acid production) tablet, an apixaban (blood thinner) 5 mg tablet, a buspirone (antianxiety) 5 mg tablet, and a metoprolol 25 mg tablet. The resident also received a regular scheduled dose of hydrocodone-acetaminophen 5-325 mg. The resident was alert and oriented, at baseline, and exhibited no distress or complaints. The nurse practitioner (NP) ordered vital signs to be obtained every 30 minutes. The resident and his representative were notified. At 12:00 p.m., his vital signs were blood pressure 100/60 mm/Hg (millimeters of mercury), pulse 30 beats per minute, temperature 97.6 degrees Fahrenheit, and oxygen saturation was 92 percent on 2 liters of oxygen per nasal cannula. A new order was received from the NP directing that the resident be sent to the hospital for evaluation. A hospital emergency department history and physical document, dated 7/16/26 at 12:52 p.m., indicated the history of the present illness was an accidental overdose. Emergency medical services administered one milligram of atropine (for slow heart rate) due to the resident's heart rate being in the 30s enroute to the hospital. The resident received epinephrine (for slow heart rate when atropine and pacing are ineffective) 4 mg in 250 milliliters of 0.9 percent normal saline intravenously. The assessment included accidental ingestion of medication, bradycardia, and hypotension. His condition was described as guarded, and he was admitted to the intensive care unit (ICU). A hospital history and physical, dated 7/20/26, indicated Resident B had inadvertently been given another resident's medications prior to admission. In the emergency department, he was found to be bradycardic and hypotensive and was transferred to the ICU on intravenous epinephrine. The ICU team experienced difficulty in weaning him off the epinephrine, and the regimen was completed 7/19/26. His encephalopathy (malfunction of the brain that alters mental state) slowly improved, and he returned to baseline. He was stable for transfer to the hospitalist service (no longer required intensive care unit). The assessment and plan included: 1. Accidental overdose with subsequent cardiogenic shock, now improved; 2. cardiogenic shock, resolved; 3. Bradycardia, improving; and 4. toxic metabolic encephalopathy due to the above issues and urinary tract infection (UTI), improving with waxing and waning mentation. During an interview, on 7/20/26 at 12:34 p.m., the Director of Nursing (DON) indicated Qualified Medication Aide (QMA) 3 was suspended related to the medication error involving Resident B. QMA 3 had completed three medication administration in-services and a medication pass check-off since a prior medication error committed on 5/22/26. RN 4 was on the nursing unit during the medication error on 7/16/26 and assisted with the reporting of it. Review of QMA 3's inservice record indicated the following:On 5/22/26, QMA 3 received a review of the facility's medication administration policy.On 5/22/26, QMA 3 participated in a medication administration audit.On 5/22/26, QMA 3 attended an all-staff education regarding medication administration.On 6/25/26, QMA 3 attended an all-staff education regarding medication administration. During an interview, on 7/20/26 at 1:31 p.m., the DON indicated Resident B received Resident C's medications on 7/16/26. RN 4 had asked QMA 3 to assist with completion of the morning medication pass for two residents (Resident B and Resident C). RN 4 wanted Resident C to receive her medications prior to leaving for an appointment. QMA 3 informed RN 4 that the medications for the pass were not present. Both RN 4 and QMA 3 searched through Resident C's entire roll of medication packets and were unable to find the morning packet. RN 4 then looked in the brown paper bag taped to the cart, which was used to dispose of the empty medication packets, and found Resident C's empty morning packets. They then realized Resident B's medications remained in the cart. The medication error was reported immediately to her DON, who became highly involved in monitoring and transferring Resident B to the hospital. The DON indicated Resident B's and Resident C's medication storage compartments were adjacent to each other in the medication cart. A review of the Medication Error Report, provided by the Administrator on 7/20/26 at 2:25 p.m., indicated on July 16 at 10:30 a.m., Resident B was given amiodarone 200 mg, citalopram 10 mg, CertaVite, clopidogrel bisulfate 75 mg, Floranex, omeprazole 40 mg, apixaban 5 mg, buspirone 5 mg, metoprolol 25 mg, and his scheduled hydrocodone-acetaminophen 5/325 mg. He was administered the wrong medications, experienced changes in vital signs, and was sent to the emergency department per physician order. The error was self-reported. QMA 3's handwritten statement, signed 7/16/26, and provided by the Administrator on 7/20/26 at 2:25 p.m., indicated QMA 3 assisted RN 4 with completing the morning medication pass. RN 4 asked her to pass Resident B's morning medications while RN 4 completed another medication pass. QMA 3 reached into the second drawer of the cart and retrieved what she believed were Resident B's medications. She removed his narcotic medication and indicated she had to move around frequently because RN 4 was also using the cart. She crushed the medications and administered them to Resident B. A few minutes later, when she attempted to administer Resident C's medication, she realized Resident C's morning medications were missing and notified RN 4. RN 4's printed text and undated, signed statement, provided by the Administrator on 7/20/26 at 2:25 p.m., indicated, at 10:10 a.m., QMA 3 arrived to assist with the medication pass. RN 4 had sent a resident to the hospital for chest pain and was running late with medication administration. Resident B's and Resident C's medications remained to be administered. Because Resident C was not in her room, RN 4 asked QMA 3 to give Resident B his medication. She signed out of the electronic tablet and provided QMA 3 the medication cart keys. RN 4 then went to the nurses' station. QMA 3 later sat down at the nurses' station, and RN 4 asked if Resident C had received her medication due to her upcoming appointment. QMA 3 searched for Resident C's medication and indicated she could not find it. Both RN 4 and QMA 3 were unable to locate the morning medication packets for 7/16/26. QMA 3 then indicated Resident B's 7/16/26 morning medication packet remained in the cart. RN 3 checked the brown paper bag containing empty medication packets and located Resident C's empty packets for that morning. RN 4 asked QMA 3 whether she had checked Resident B's medications before administering them. QMA 3 replied, Supposedly. RN 4 retrieved Resident C's morning medication list to find what medications were erroneously given to Resident B and told QMA 3 that Resident B's vitals signs needed obtained. RN 4 immediately reported the medication error to her supervisor. During a phone interview, on 7/20/26 at 2:08 p.m., QMA 3 indicated she arrived at the unit at 10:00 a.m. on 7/16/26. RN 4 directed her to assist with passing medications. RN 4 was still using the medication cart and had a resident's medication administration record (MAR) opened on the electronic tablet. QMA 3 did not check the MAR and acknowledged she committed another medication error. At 11:00 a.m., she checked Resident C's medications and realized they were missing. She indicated she should have paid more attention and could not believe that she had committed another medication error. She prepared and administered the medications, believing they were Resident B's, but administered Resident C's medications instead. During an interview, on 7/20/26 at 2:40 p.m., RN 4 indicated, around 10:10 a.m. on 7/16/26, QMA 3 arrived on the unit. RN 4 was running late due to addressing another resident's chest pain. RN 4 informed QMA 3 that two residents remained due for their morning medications. RN 4 signed out of the electronic tablet and handed QMA 3 the cart keys. RN 4 went to the nurses' station. QMA 3 later joined her at the nurses' station. RN 4 asked if Resident C had received her medication due to her appointment. QMA 3 left, then Resident C approached the medication cart setting in front of the nurses' station. QMA 3 asked RN 4 to look for Resident C's medication packet for that morning. RN 4 used the next day's morning medication packet for Resident C due to her appointment. QMA 3 then said Resident B's medication packet remained in the cart. RN 4 asked whether QMA 3 had checked Resident B's medications before administration, and QMA 3 replied, Supposedly. RN 4 located Resident C's empty morning medication packets in the brown bag and reported the error immediately to her supervisor. She did not pass medications at the medication cart at the same time as QMA 3. During an interview, on 7/21/2026 at 3:35 p.m., the DON indicated she observed Resident C's empty medication packets and believed QMA 3 mistakenly administered those medications, resulting in Resident B's subsequent hospital admission. A current facility policy, revised on 11/11/24, titled Medication Administration, provided by the Administrator, on 7/21/26 at 1:00 p.m., indicated the following: Policy Explanation and Compliance Guidelines.10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage.11. Review MAR to identify medication to be administered 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. The deficient practice was corrected by 7/16/26 after the facility implemented a systemic plan that included the following actions: education of all working nurses and qualified medication aides on the Seven Rights of Medication Administration and minimizing distractions during a medication pass, observations of medication administration, and implementation of an ongoing quality improvement plan. Cross reference F726. This citation relates to Intake 3096409 and Intake 3097017. 410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure staff had the competencies and training to administer medication according to facility policy to prevent medications errors for 1 of 4 residents reviewed for medication administration (Resident B). This deficient practice resulted in Resident B's hospitalization in the intensive care unit for bradycardia (abnormally slow heart rate), hypotension (low blood pressure) and subsequent cardiogenic shock (heart cannot pump enough blood to meet the body's needs). Finding includes: Review of an Indiana Department of Health (IDOH) intake, submitted 7/16/26, indicated a resident had been hospitalized after he was administered medications intended for another resident. The staff member who administered the medication had made a similar medication error in the past month, which resulted in another resident requiring hospitalization.A hospital emergency department history and physical document, dated 7/16/26 at 12:52 p.m., indicated Resident B's history of present illness was an accidental overdose. Emergency medical services administered one milligram of atropine (for slow heart rate) due to the resident's heart rate being in the 30s enroute to the hospital. The resident received epinephrine (for slow heart rate when atropine and pacing are ineffective) 4 mg in 250 milliliters of 0.9 percent normal saline intravenously. The assessment included accidental ingestion of medication, bradycardia, and hypotension. His condition was described as guarded, and he was admitted to the intensive care unit (ICU).During an interview, on 7/20/26 at 12:34 p.m., the Director of Nursing (DON) indicated Qualified Medication Aide (QMA) 3 was suspended related to the medication error involving Resident B. QMA 3 had completed three medication administration in-services and one medication pass check-off since a prior medication error committed on 5/22/26. During an interview, on 7/20/26 at 1:31 p.m., the DON indicated she believed QMA 3 retrieved Resident C's medications and administered them to Resident B. Resident C's medications were stored adjacent to Resident B's medications in the medication cart. The medication packets had the residents' names listed on them, and she believed QMA 3 could not have checked the packets prior to preparing and administering the medications. Review of a facility document, titled Ad Hoc QAPI Form, dated 7/16/26, provided by the Administrator on 7/20/26 at 2:25 p.m., included the following:Summary of the Event: Resident B was given Resident C's medication by accident.Immediate Actions Taken: The QMA was immediately removed from passing medications and suspended pending investigation.Root Cause Analysis: Failure to correctly verify resident identification and medication packaging prior to medication administration during a hand-off of medication pass responsibilities. The nurse transferred responsibility for the final two residents' morning medication to the QMA while responding to another resident's care needs. At the time of the hand-off, medications for the two residents remained on the medication cart. The QMA selected the incorrect medication packet, prepared the medications, and administered them to the wrong resident. During interview, the QMA was unable to identify any environmental distractions, equipment issues, packaging defects, or other contributing factors that led to the error. The investigation determined that the QMA did not complete the required medication administration process, including confirming the resident name on the medication packet against the resident receiving the medications, prior to administration. Contributing factors included failure to follow the established rights of medication administration, specifically verification of the correct resident and correct medication prior to administration. No evidence indicated a packaging error, physician order error, transcription error, or equipment malfunction. The event was determined to be preventable and resulted from failure to adhere to established medication administration procedure. During an interview, on 7/20/26 at 2:08 p.m., QMA 3 indicated RN 4 was administering medications from the cart at the same time QMA 3 was attempting to administer medications to Resident B. QMA 3 did not verify the medications before administering them because RN 4 had another resident's medication administration record (MAR) open on the cart's electronic tablet. She should have taken 10 seconds to check both the MAR and the medication packets. She prepared and administered the medication, believing they belonged to Resident B, but they were Resident C's medications. She indicated she had been a QMA for two years without prior issues until recently and attributed the errors to not paying attention. During an interview, on 7/20/26 at 2:40 p.m., RN 4 indicated she had signed off the electronic tablet, provided the medication cart keys to QMA 3, and left to complete other tasks. She was not present at the cart during QMA 3's medication administration and discovered the error after finding Resident C's empty medication packets. During an interview, on 7/21/26 at 11:26 a.m., RN 5 indicated the MAR should always be checked against medications in the packets. She verified medication packets with the MAR and checked that she delivered the right medication to the correct person. During an interview, on 7/21/26 at 11:35 a.m., LPN 6 indicated she always verified with the MAR when administering medications. She worked on the rehabilitation unit and would often have a new resident tell her their name and date of birth as able, or the hospital armband if recently admitted . She paid close attention and verified the medication packets with the MAR. During an interview, on 7/21/26 at 2:05 p.m., RN 4 indicated when she administered medications, she reviewed the MAR, checked the resident name matched the MAR and the packet, and confirmed the pills in the packet matched the MAR. During an interview, on 7/21/26 at 2:12 p.m., RN 7 indicated when he passed medications, he opened the MAR, obtained the medication packet, checked each pill individually, ensured no additional or missing medications were present, and verified the name and room number on the packet matched the MAR. During an interview, on 7/21/26 at 3:35 p.m., the DON indicated she believed QMA 3 administered the wrong medications to Resident B. The DON had observed Resident C's empty medication packets on the day of the error. QMA 3 should have verified she was giving the right medication to the right person and followed the rights of medication administration. Review of the facility's 6/18/26 intake survey Statement of Deficiencies (2567) indicated the facility failed to ensure medications were administered according to facility policy to prevent medication errors when QMA 3 administered the incorrect medications to a resident, resulting in the resident requiring evaluation at the emergency department on 5/22/26 for lethargy and worsening vital signs. Review of QMA 3's facility in-service record indicated the following:On 5/22/26, QMA 3 received a review of the facility's medication administration policy.On 5/22/26, QMA 3 participated in a medication administration audit.On 5/22/26, QMA 3 attended an additional all-staff education regarding medication administration.On 6/25/26, QMA 3 attended an all-staff education regarding medication administration. A current facility policy, revised on 11/11/24, titled Medication Administration, provided by the Administrator, on 7/21/26 at 1:00 p.m., indicated the following: Policy Explanation and Compliance Guidelines.10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage.11. Review MAR to identify medication to be administered 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Cross reference F760. This citation relates to Intake 3096409 and Intake 3097017. 410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure wound treatments were implemented and consistently completed to promote healing for 2 of 4 residents reviewed for wound care. (Resident B and Resident E) This deficient practice resulted in delayed treatment for a chronic wound to Resident B's toe that was later surgically amputated. Findings include:1.Resident B's clinical record was reviewed on 7/13/26 at 9:24 a.m. Diagnoses included type 2 diabetes mellitus with foot ulcer, other osteomyelitis, unspecified sites, skin graft (allograft) (autograft) infection, non-pressure chronic ulcer of other part of left foot with unspecified severity, peripheral vascular disease, local infection of the skin and subcutaneous tissue, and acquired absence of other toe(s), unspecified side. A cytology hospital surgical report, dated 6/16/26, indicated he had a left first toe and left first metatarsal excision (removal/amputation). A hospital discharge report, dated 6/27/26, indicated to start linezolid (antibiotic) 600 milligram (mg) twice daily through 7/27/26, metronidazole (antifungal) 500 mg twice daily through 7/27/26, thiamine (supplement) 100 mg daily, folic acid (supplement) 1 mg daily, and nitroglycerin paste to the amputation site. The Wound Vacuum Assisted Closure (VAC) dressings were to remain clean, dry, and intact until the resident's first follow-up appointment. An admission assessment, dated 6/27/26, indicated he had a surgical incision to his left toe(s) and his dressing to his left foot was intact, clean and dry. The wound nurse was to follow the resident. A 6/29/26 surgical wound care plan indicated he had complications related to diabetes and infection. His interventions included treatment as ordered (6/29/26). A 6/29/26 care plan indicated he had an infection in his surgical graft wound due to bacteria/osteomyelitis. Interventions included applying his treatment(s) as ordered (6/29/26). A 6/30/26 revised care plan indicated he had two surgical wounds with failed grafts. Interventions included staff would apply his treatment as ordered (6/29/26). A nurses note, dated 6/29/26 at 10:35 a.m., indicated a new skin issue to his left dorsum first digit amputation site, six staples were present, there was increased exudate (drainage) and an odor. A nurses note, dated 6/29/26 at 1:36 p.m., indicated an order was received to cleanse the left foot surgical site with wound cleanser and pat dry. Apply moist to dry dressing to site, cover with super absorbent dressing, change twice daily and as needed. He was to have appointment with the wound clinic on 6/30/26. An initial wound evaluation and management summary, dated 7/2/26, indicated the resident had a post-surgical wound of his left medial foot. A new order was given for the primary dressing of calcium alginate (wound treatment) with silver daily and as needed, and a secondary dressing for gauze sponge and gauze wrap for 30 days. And he had a diabetic wound to his (now remaining) first toe on his left foot. His (now remaining) first toe was described as intact with purple/maroon discoloration. A new order was given for betadine (antiseptic) daily and as needed for 30 days. The July Treatment Administration Record (TAR) lacked the new 7/2/26 wound care orders. A nurses note, dated 7/8/26 at 9:27 a.m., indicated the second digit on his left foot was dark in color. The wound center was notified, and orders were received for a surgical evaluation appointment on 7/14/26. A wound evaluation and management summary, dated 7/9/26, indicated the resident was seen for a post-surgical wound of his left medial foot. New orders included leptospermum honey (medical grade honey for wound treatment) daily and as needed for 30 days, to continue alginate calcium with silver daily and as needed for 23 days. He was also seen for a diabetic wound of his left foot, first toe and it was described as 100% thick adherent devitalized necrotic (dead) tissue and to continue the order for betadine daily and as needed for 23 days. His July TAR lacked the new and continued wound treatment orders. On 7/13/26 at 1:16 p.m., Resident B was sitting in a wheelchair. He had an elastic bandage around his left foot that was slightly loose at the back of his heel. The resident indicated the treatment to his left foot had not been completed for three days. He was experiencing anxiety related to whether or not he was having surgery the next day. He indicated that his toe was black as the ace of spades, and started after he admitted to the facility. On 7/13/26 at 1:27 p.m., Wound Nurse 6 indicated the wound doctor had already been into the facility and Resident B's treatment had already been completed. On 7/13/26 at 1:30 p.m., LPN 17 indicated, after observing Resident B's dressing, it did not look like his treatment had been completed. During a wound care observation for Resident B, on 7/13/26 at 4:07 p.m., Wound Nurse 6 indicated that she had already changed the dressing to his left foot. The tape on the elastic bandage was dated 7/13/26 at 2:00 p.m. A nurses note, dated 7/14/26 at 2:54 p.m., indicated the nurse practitioner spoke with the nurse at the wound center and indicated that the resident was sent to the emergency room for a STAT (immediate) surgery for the amputation of his left foot second toe. During an interview, on 7/14/26 at 10:45 a.m., Wound Nurse 6 indicated she completed resident wound care treatments Monday through Friday. She completed rounds with the wound doctor on Mondays and Thursdays. The wound doctor gave verbal orders during wound rounds, and they communicated with one another during the week. The wound doctor's progress notes were scanned into the electronic health records automatically. She was not sure who reviewed the wound doctor's progress notes, but thought that the Unit Manager may review them. Resident B admitted to the facility on a Friday or Saturday after the amputation of his great toe, and she saw him on the first Monday he was there. The Wound Nurse received the order for the wound cleanser wash on 6/29/26 from the hospital and the order should not have been discontinued on 7/1/26. She normally looked at the orders but did not catch that it was discontinued. Resident B's second toe on his left foot was noticed on 7/8/26 and a wound appointment was made. A Peripherally Inserted Central Catheter (PICC) line was placed, and he received Intravenous (IV) antibiotics for a wound infection. A culture was obtained and they were awaiting the results. 2. Resident E's clinical record was reviewed on 7/13/26 at 12:17 p.m. Diagnoses included paraplegia, stage 4 (full thickness wound exposing all skin layers down to underlying muscle, bone, or tendon) pressure ulcer of right buttock, and non-pressure chronic ulcer of the back with unspecified severity. A 4/29/26 revised care plan indicated she had a stage 4 pressure ulcer to her spine. Interventions included she would receive her treatment as ordered (2/27/26). A 4/29/26 revised care plan indicated she had a stage 4 pressure ulcer to her right ischial tuberosity (lower part of pelvis that supports body when seated). Interventions included she would receive her treatment as ordered (4/29/26)June 2026 TAR orders included the following: Cleanse right ischium with wound wash, pat dry apply calcium alginate to wound cover with super absorbent dressing secure with coverall, change daily and as needed.Cleanse the lower spine with wound wash, rinse with saline. pack with black foam to fit inside wound and run vacuum continuously at 150 millimeters of mercury (mmHG) change every Monday, Wednesday, Friday and as needed. The June 2026 TAR lacked documentation for completed treatments for her right ischium on 6/24, 6/25, and 6/30, and for her lower spine on 6/24. The July 2026 TAR lacked documentation for completed treatments for her right ischium on 7/1, 7/6, and 7/7, and for her lower spine on 7/1 and 7/6.During an interview, on 7/14/26 at 10:45 a.m., Wound Nurse 6 indicated Resident E admitted to the facility with pressure ulcers and was currently on intravenous antibiotics for an infection to her wounds. An x-ray was completed and osteomyelitis (bone infection) was suspected. A wound culture was obtained, and they were awaiting the results. She normally completed her wound VAC treatment. She worked on the dates that lacked signatures on the MAR for June and July and the treatments were completed. The nurses documented the treatments after the Wound Nurse completed them. During an interview, on 7/14/26 at 11:37 a.m., LPN 14 indicated Wound Nurse 6 normally completed Resident E's treatments. Wound Nurse 6 would either tell her, or she would see her completing the treatments and she documented in the MAR when Wound Nurse 6 completed the treatments. During an interview, on 7/14/26 at 11:57 a.m. RN 22 indicated she asked Wound Nurse 6 if she completed the wound treatments or Wound Nurse 6 would tell her what to document. During an interview, on 7/14/26 at 1:34 p.m., Unit Manager 32 indicated she did not review the wound doctor's progress notes nor document the orders from him. Wound Nurse 6 completed rounds with the wound doctor and entered the treatment orders. When Wound Nurse 6 completed rounds she would tell the nurses that the treatments were completed and what the wound looked like and then the nurses would document it. During an interview, on 7/14/26 at 2:35 p.m., the DON indicated Wound Nurse 6 should document in the clinical record when she completed the treatments. A 12/21 revised current facility policy, titled Administrative Transcription of Physician's Orders, provided by the Administrator on 7/14/26 at 3:53 p.m., indicated the following: .admission Protocol or Return From Hospital Stay Within 15 Days.2. Transcription of physician order: a. Carefully, review transfer record and discharge summary from the hospital.c. After each order is entered in the Physician Order tab of the chart, check that ll orders were entered correctly.7. Medication and treatment orders are to be transcribed in the physician order tab of the electronic medical record. A 4/24 revised current facility policy, titled Following Physician Orders/Parameters, provided by the Administrator on 7/14/26 at 3:26 p.m., indicated the following: .Policy.8) After performing the activity, the licensed healthcare personnel will document administration and/or response to the procedure in the MAR or TAR. An undated current facility polity, titled Wound Treatment Management, provided by the Administrator on 7/14/26 at 3:12 p.m., indicated the following: .Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. This citation relates to Intake 4074283. 410 Indiana Administrative Code (IAC) 16.2-3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a staff member spoke to a resident in a dignified and respectful manner for 1 of 5 residents observed during medication administration. (QMA 15 and Resident E) Findings include:During a medication observation, on 6/17/26 at 11:52 a.m., QMA 15 prepared medication for Resident E and entered the resident's room. Resident E sat in her wheelchair, holding baby doll. QMA 15 approached the resident with the medication and indicated she had her medicine and asked the resident if she wanted to show how big of a girl she was by taking her medication. QMA 15 attempted to administer the resident's medication and the resident pulled back. QMA 15 attempted again, and the resident took the spoon. QMA 15 guided the resident's hand holding the spoon to her mouth. After the resident took the medication QMA 15 stated Look at her, she's a big girl, good job.During an interview, on 6/17/26 at 12:04 p.m., QMA 15 indicated she spoke to the resident in a childlike manner because that was how the resident responded. During an interview with the Administrator present, on 6/17/26 at 12:57 p.m., the DON indicated Resident E was care planned for having a baby doll and speaking to the doll as though it were a real person.Resident E's clinical record was reviewed on 6/18/26 at 8:31 a.m. Diagnoses included severe intellectual disabilities and aphasia.A 3/25/26 quarterly Minimum Data Set assessment indicated she was rarely/never understood.A current 10/4/21 care plan indicated the resident preferred to have her baby doll or stuffed dog with her daily. She had difficulty communicating at times and responded best to questions with yes or no answers.A current 12/12/25 care plan indicated she had a communication deficit as evidenced by severe intellectual disability and she was generally non-verbal. Her interventions included she would be able to effectively communicate her wishes by gestures such as shaking her head yes or no (12/12/25) and responded best to questions requiring yes/no responses (12/12/25).A current facility policy, dated 11/29/23 and titled Promoting/Maintaining Resident Dignity, provided by the Administrator on 6/17/26 at 1:34 p.m. indicated the following: .Compliance Guidelines: 1. All staff member are involved in providing care to residents to promote and maintain resident dignity and respects resident rights. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(a)

Based on observation, interview and record review, the facility failed to ensure medications were administered according to facility policy to prevent medication errors and failed to ensure medications were prepared and administered according to physician orders and facility policy for oral and inhaled medications. (Residents C, B, F, and E) Findings include:1.A 5/23/26 anonymous intake submitted to the Indiana Department of Health (IDOH) indicated a resident had been administered medications intended for another resident, resulting in hospitalization.Resident C's clinical record was reviewed on 6/17/26 at 10:28 a.m. Diagnoses included essential (primary) hypertension, acute on chronic diastolic (congestive) heart failure, obstructive and reflux uropathy, and dizziness and giddiness.His medications included buspirone (treat anxiety) 5 mg, paroxetine (treat depression) 40 mg, quetiapine (antipsychotic) 12.5 mg, and tramadol (opiate pain medication) 100 mg.A progress note, dated 5/22/26 at 10:32 p.m., indicated Resident C was administered baclofen (muscle relaxer) 10 mg, melatonin (treat insomnia) 5 mg, levetiracetam (treat seizures) 1000 mg, quetiapine 300 mg in addition to routine medications. He had no allergies to the medications. He was alert and oriented, and at his baseline. Vitals were obtained, and the on-call physician ordered to monitor vital signs every two hours, implement enhanced fall precautions, and to report any decline in condition.An SBAR (Situation, Background, Assessment, and Recommendation) note, dated 5/23/26 at 2:50 a.m., indicated the resident exhibited jumbled speech, inability to form a sentence, hallucinations, and a blood pressure of 86/54 millimeters of mercury (mm Hg). Orders were received to send him to the emergency room for an evaluation and treatment. A nurses note, dated 5/23/26 at 9:45 a.m., indicated the resident returned to the facility from the emergency room following an evaluation for a medication error resulting in lethargy and worsening vital signs. A new order was received to hold his metoprolol for one day. He was transferred from transport cart to bed without awakening and continued to appear sedated/lethargic.A nurses note, dated 5/23/26 at 2:50 p.m. indicated he had a decline in condition following return from the emergency room. He remained nonresponsive and was not able to be aroused to verbal and tactile stimuli. He had intermittent periods of apnea (breathing stopped) lasting approximately 15-20 seconds with gurgling respirations. He had urinary retention and had not voided in over 12 hours. A bladder scan was performed showing approximately 660 milliliters of urine. A new order was received to send him to the emergency room for further evaluation and treatment.A nurses note, dated 5/23/26 at 8:10 p.m., he returned from the hospital with a new order for cephalexin (antibiotic) and a urinary catheter.During an interview, on 6/17/26 at 1:20 p.m. QMA 33 indicated, on 5/22/26, it had been busy, and she was stressed and flustered. She knocked over a medication cup while preparing Resident D's medication, and pills spilled on top of the medication cart and two fell on the floor. She placed the two pills from the floor and the pills from the top of the medication cart back into the medication cup. When she looked at the MAR (Medication Administration Record), it displayed Resident C's name, and she got confused and thought that she was preparing Resident C's medication. She prepared and placed Resident C's medication in the cup that was intended for Resident D. She administered Resident D's medication and Resident C's medication to Resident C between 9:30 p.m. and 9:45 p.m. About five minutes later, she realized she had given Resident C and Resident D's medication to Resident C. She immediately reported the error to the nurse.2.During the initial tour of the facility, on 6/17/26 at 9:21 a.m., Resident B was observed sitting on the side of her bed receiving a nebulizer treatment via mask without licensed staff present. CNA 17 entered Resident B's room, assisted her with a pillow behind her back, and exited the room.At 9:26 a.m., RN 24 entered Resident B's room, removed the nebulizer, and checked her oxygen saturation. RN 24 indicated that her oxygen level was low, and applied oxygen via nasal cannula. RN 24 exited Resident B's room. During an interview at the time of the observation, RN 24 indicated the resident's oxygen saturation was 90% but came up to 94%. Resident B had orders for oxygen but refused to wear it. Resident B did not have an order to self-administer her nebulizer treatment and RN 24 would normally stay with the resident during the treatment. Resident B's clinical record was reviewed on 6/17/26 at 9:36 a.m. Diagnoses included unspecified dementia, acute respiratory failure with hypoxia (low oxygen level), and COPD (chronic obstructive pulmonary disease).Current orders included ipratropium-albuterol solution (bronchodilator) 3 ml (milliliters), inhale 3 ml orally daily to be administered by a clinician.A Social Services Assessment and Plan, dated 6/15/26, indicated she had moderate cognitive impairment.Her clinical record lacked a self-administration assessment.3. During a medication administration, on 6/18/26 at 9:10 a.m., RN 24 obtained Resident F's blood pressure, pulse, and oxygen saturation level. RN 24 prepared Resident F's medication and entered his room. After administering his pills, she removed his T-piece nebulizer from the plastic bag hanging on his overbed table and placed the contents of a vial of ipratropium-albuterol solution into the chamber. She handed the resident the nebulizer and turned on the nebulizer machine. Once the treatment was completed, she took the nebulizer from his hand and returned it to the plastic bag. RN 24 exited the resident's room and began preparing another resident's medication.During an interview, on 6/18/26 at 9:38 a.m., RN 24 indicated she had not yet listened to Resident F's breath sounds and she normally placed the nebulizer in the plastic bag.Resident F's clinical record was reviewed, on 6/18/26 at 10:11 a.m. Diagnoses included COPD with (acute) exacerbation.Current orders included ipratropium-albuterol solution 3 ml, inhale 3 ml orally four times daily, breath sounds chart C for clear, W for wheezes, D for diminished, CR /F for fine crackles, and CR/C for coarse crackles (Respiratory treatment) four times daily.4. During the medication observation, on 6/17/26 at 11:52 a.m., QMA 15 indicated Resident E received nectar thick liquids. QMA 15 poured 17 grams of polyethylene glycol powder (treat constipation) into an 8-ounce medication cup, filled the cup one-quarter full (approximately 60 ml) of nectar thick water and stirred. She administered the resident's pills and then administered the polyethylene glycol through a straw.Resident E's clinical record was reviewed on 6/18/26 at 8:31 a.m. Diagnoses included constipation and dysphagia.Current orders included polyethylene glycol powder 17 grams daily and to dissolve in fluids.During an interview, on 6/17/26 at 12:04 p.m., QMA 15 indicated she did not remember the required amount of fluid for polyethylene glycol administration and would guess it to be 280 ml. She indicated the less water used was better because the resident did not like water. After checking the label of the polyethylene glycol bottle, QMA 15 indicated there was supposed to be eight ounces (240 ml) of water added to the polyethylene glycol.On 6/18/26 at 11:45 a.m., the Administrator provided QMA 33, RN 24, QMA 15's education on medication administration, each dated 5/22/26.A current facility policy, reviewed on 11/11/24, titled Medication Administration, provided by the Administrator, on 6/18/26 at 11:45 a.m., indicated the following: Policy Explanation and Compliance Guidelines.10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage.11. Review MAR to identify medication to be administered.17. Administer medication as ordered in accordance with manufacturer specifications. a. Provide appropriate amount of food and fluid.A current facility policy, revised 8/25/25, titled Nebulizer and Aerosol Generating Procedure Therapy, provided by the Administrator on 6/17/26 at 1:34 p.m. indicated the following: .Procedure.4. Stay with the resident during delivery of the medication unless the resident has been deemed appropriate to self-administer by the IDT (Interdisciplinary Team) and has an order to self-administer.9. Listen to lung sounds with a stethoscope. (Include in assessment: Sp02, heart rate, respiratory rate, and post treatment evaluation.).12. Disassemble the nebulizer and T-piece and rinse with tap water. Reassemble nebulizer and place in plastic bag that is clean and dated. This citation relates to Intake 3022941. 410 IAC (Indiana Administrative Code) 16.2-3.1-14(i)

Based on observations, interviews, and record reviews, the facility failed to ensure a medication cart was not left unlocked and unattended for 2 of 5 medication administration observations (North Medication Cart) and medication was not left unattended on top of a medication cart for 2 of 5 medication administration observations. (Center Medication Cart) Findings include:1. On 6/17/26 at 11:52 a.m., QMA 15 prepared medication for Resident E. She walked down the hall and administered the medication in the resident's room while leaving the North Hall medication cart unlocked and unattended at the nurse's station.At 12:04 p.m., QMA 15 returned to the unlocked cart. During an observation, accompanied by QMA 15, the medication cart contained eye drops, prefilled insulin pens, insulin needles, lancets, prepackaged medication, nebulizer vials, nose spray, antacid medication, liquid and powdered medication. During the observation, QMA 15 indicated that she normally locked the cart when she walked away from it but she was nervous and accidentally forgot to lock it.2. On 6/18/26 at 9:30 a.m., RN 24 prepared medication for Resident G. She indicated the omeprazole (treat stomach acid) 20 mg (milligram) and bupropion (treat depression) 150 mg from the prepackaged pack were discontinued and were not on the resident's medication administration record. She placed the pills back in the package, wedged the side of the package under a box of gloves located on top of the medication cart and entered the resident's room and closed the door.At 9:38 a.m., RN 24 returned to the medication cart. She indicated she would not normally leave the medication unattended on top of the medication cart. On 6/18/26 at 11:45 a.m. the Administrator provided QMA 15 and RN 24's skills competency reviews that indicated the following:On 5/23/26 and 6/8/26, the DON performed a medication skill competency related to medication pass procedure and included locking the medication cart for QMA 15.On 5/22/26 and 6/8/26, the DON performed a medication skill competency related to medication pass procedure and included returning container/card to proper area in cart for RN 24.A current facility policy, revised 4/16/24, titled Medication Storage, provided by the Administrator on 6/18/26 at 1:34 p.m. indicated the following: . General Guidelines: a. All drugs and biologicals will be stored in locked compartments.c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. This citation relates to Intake 3022941. 410 Indiana Administrative Code (IAC) 16.2-3.1-25(m)

Based on observation, interview, and record review, the facility failed to obtain a physician's order for wound treatment in a timely manner and failed to implement physician's orders promptly to promote healing of a diabetic ulcer for 1 of 3 residents reviewed for skin conditions. (Resident 5) Findings include: Resident 5's clinical record was reviewed on 2/11/26 at 11:00 a.m. Diagnoses included primary hypertension, type 2 diabetes mellitus, and generalized muscle weakness.A current, 1/13/26, pressure ulcer care plan indicated Resident 5 had a stage 3 (full-thickness pressure injury) wound to the right lateral foot. Interventions included the following: treatment as ordered (1/13/26), report signs/symptoms of infection such as increased redness, warmth, induration at or near wound edges, foul odorous drainage (1/13/26), and initiate pain care plan interventions (1/13/26).A 1/21/26, admission, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired and had a stage 3 pressure injury.A 1/31/26 readmission Evaluation assessment indicated Resident 5 had a right lateral diabetic foot ulcer.A 2/1/26 Skin Issues assessment indicated Resident 5 had a right lateral foot pressure ulcer upon admission. The wound was 0.83 centimeters(cm) length (L) x 0.62 cm width (W) with 100% slough (soft white or yellow nonviable tissue), and light serosanguineous (thin, watery, and light red or pink) drainage. The treatment was listed as follows: generic wound cleanser, an antimicrobial dressing, and a composite dressing.A 2/2/26 readmission Skin Observation note indicated Resident 5 had a right lateral foot pressure area. The dressing was clean, dry, and intact.A 2/4/26 Daily Skilled Progress note indicated Resident 5 had a diabetic ulcer, without drainage.A 2/4/26 Weekly Skin Observation note indicated Resident 5 had a right lateral foot pressure area with a dry and intact dressing.A 2/6/26 wound center note indicated Resident 5 had a diabetic ulcer to his right lateral foot acquired on 1/3/25. The wound was 0.6 cm (L) x 0.7 cm (W) x 0.1 cm (D). The treatment was as listed as follows: Cleanse wound to right foot with Vashe (wound cleanser), pat dry, apply a slightly moist with saline Prisma (a collagen wound dressing) dressing and cover with a dry dressing and wrap with gauze once daily, every Monday, Wednesday, and Friday for wound healing.A 2/8/26, Daily Skilled Progress note indicated Resident 5 had a diabetic ulcer without drainage.A 2/11/26, Skin Issues assessment indicated Resident 5 had a stage 3 pressure ulcer to the right lateral foot on admission. The wound was 0.64 cm (L) x 0.8 cm (W) with 10% eschar (dead tissue), and light serous (clear watery fluid) drainage. The treatment was listed as follows: generic wound cleanser, Prisma, foam, and a compression wrap.Current treatment orders, dated 2/11/26, indicated to cleanse wound to right foot with Vashe (wound cleanser), pat dry, apply a slightly moist with saline Prisma (a collagen wound dressing) and cover with a dry dressing and wrap with gauze once daily, every Monday, Wednesday, and Friday for wound healing.The clinical record lacked an active wound treatment order from 1/31/26 - 2/11/26. During a wound observation, on 2/12/26 at 3:23 p.m., the Wound Nurse removed Resident 5's dressing from his right lateral foot. The dressing was dated 2/11/26. The wound was circular, pale, and white, with a raised border. The wound was roughly the size of a jumbo #2 yellow pencil eraser. There was no drainage present.During an interview, at the time of the observation, the Wound Nurse indicated this resident had a pressure ulcer to his right lateral foot. He had recently returned from a hospital stay and was seen at the wound center on 2/6/26 and had returned with a wound treatment order. She indicated she had forgotten to enter the treatment order until the evening of 2/11/26. Treatment orders should be obtained and started immediately or as soon as possible when a wound was identified.During an interview, on 2/13/26 at 11:45 a.m., the DON indicated that when a resident admitted or returned to the facility, the nurse should complete a skin assessment. The nurse should document any skin conditions or wounds and contact the physician to obtain an order for treatment. The nurse should enter any orders and implement the treatment. Resident 5 should have had a treatment order upon his return to the facility. The nursing staff should follow all physicians' orders as given.A current facility policy, implemented 11/29/23, titled, Skin Integrity-Foot Care, provided by the DON on 2/13/26 at 10:17 a.m., indicated the following: .It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. This policy pertains to maintaining the skin integrity of the foot.1a. The facility will utilize a systemic approach for the prevention and management of [NAME] ulcers, including efforts to identify risk: stabilize, reduce, or remove underlying risk factors; monitor the impact of the interventions; and modify the interventions as possible. 2a. Licensed nurses will conduct pressure injury risk assessments and skin assessments in accordance with facility policy for those assessments.3c. Evidence-based treatment will be provided for all residents who have a foot ulcer.i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, or diabetic ulcers.5a. The attending physician will be notified of the presence, progression towards healing, or lack of healing of any foot ulcers, or any changes in a resident's medical condition. b. Interventions will be modified in a resident's plan of care as needed. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP) during high contact care activities for a resident with an indwelling medical device for 1 of 4 residents reviewed for EBP. (Resident 47) Findings include:Resident 47's clinical record was reviewed on 2/11/26 at 3:19 p.m. Diagnoses included presence of left artificial knee joint, infection and inflammatory reaction due to internal left knee prosthesis, and disruption of external operation (surgical) wound.Current physician's orders included: Enhance Barrier Precautions (EBP) due to PICC (peripherally inserted central catheter) line and history of MRSA/VRE (Methicillin-Resistant Staphylococcus Aureus/Vancomycin-Resistant Enterococci) (antibiotic resistant bacteria), daptomycin (antibiotic) 500 milligram one time a day for knee joint infection, and non-weight bearing to left lower extremity.A current care plan, revised on 2/9/26, included the following: I require enhanced barrier precautions related to PICC line and history of MRSA/VRE. Interventions included: Staff will follow enhanced barrier precautions with my care as needed and you will provide my treatments as ordered.A 2/9/26 nurse's note indicated new orders were received from the physician to initiate enhanced barrier precautions related to PICC line and history of MRSE/VRE.During a random observation on 2/9/26 at 2:40 p.m., EBP signage was located on the right side of Resident 47's doorway. The signage read as follows: Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. A personal protective equipment (PPE) cart was also observed to the right of her bedside.During a dressing change observation on 2/12/26 at 1:37 p.m., the Wound Nurse performed hand hygiene prior to entering Resident 47's room. She indicated EBP was not required for this dressing change because the site was a closed surgical wound. She donned gloves and removed the resident's knee immobilizer (during which her jacket brushed against the right edge of the resident's bed and the resident's left bare thigh). Hand hygiene was performed and new gloves were donned, the area was cleaned, and a new dressing was applied (during which her jacket again brushed against the right side of the resident's bed, left thigh, and shirt). RN 4 removed the gloves and, with her bare hands, replaced the resident's knee immobilizer.During an interview on 2/13/26 at 11:18 a.m., the DON indicated residents who required EBP had signage on their door. A gown and gloves must be worn during any type of resident care. If a resident had a closed wound and a PICC or another medical device, EBP would still be required.During an interview on 2/13/26 at 11:29 a.m., the Infection Preventionist indicated a resident required EBP when they had an open wound that required treatment or if they had medical devices. If staff were providing care for the resident, a gown and gloves must be worn.A current facility policy, titled, Enhanced Barrier Precautions, revised 2/5/25, indicated the following: .Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.a. The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO [multi-drug resistant organism] that is not currently targeted by CDC but may be considered epidemiologically important.4. High-contact resident care activities include:.Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters, h. Wound care: any skin opening requiring a dressing.9. Additional epidemiologically important MDROs may include, but are not limited to: a. Methicillin-resistant Staphylococcus aureus (MRSA).c. Vancomycin-resistant Enterococci (VRE).10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.3.1-18(a)

Based on record review and interview, the facility failed to provide/offer showers according to the resident's preferences to maintain proper hygiene for 1 of 3 residents reviewed for activities of daily living. (Resident B)Finding includes: Resident B's closed clinical record was reviewed on 1/22/26 at 11:16 a.m. The resident discharged from the facility on 1/7/26. Diagnoses included major depressive disorder, syncope and collapse, general muscle weakness, difficulty in walking, other abnormalities of gait and mobility, and a history of falling.An 11/11/25, admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. He used a walker and wheelchair for mobility. The resident required substantial staff assistance for lower body dressing, footwear donning, bathing, and shower transfers. He was dependent on staff assistance for toileting hygiene. Resident B required partial staff assistance to stand and transfer to the toilet. He occasionally had incontinence of urine. The resident had bowel incontinence. The resident had unhealed pressure ulcers, a surgical wound, and moisture acquired skin damage (MASD). Skin interventions included a pressure reducing device for the chair, nutrition/hydration, pressure injury care, surgical wound care, application of non-surgical dressings, and applications of ointments/medications. Resident B's care plans included the following:An 11/8/25 problem of required assistance with activities of daily living. Interventions included the following: I require assistance from one staff for a.m. and p.m. care (11/8/25), I require assistance of one staff for getting dressed (11/8/25), I require assistance of one staff for bathing (11/8/25).An 11/10/25 specific choices care plan. Interventions included the resident's preference to have his showers on Tuesday and Friday day shifts (11/10/25). The care plan lacked any indication that the resident was not compliant with bathing.An 11/11/25 problem of impaired skin integrity impairment related to MASD (moisture associated dermatitis) to the buttocks related to incontinence and excessive moisture. Interventions included resident education and reminders as needed regarding skin on skin, good hygiene, and changing of clothing and undergarments daily (11/11/25).A progress note, dated 12/15/25, indicated the resident attended an appointment in the community on this date.Review of the facility's clinical schedules indicated CNA 3 was on duty for the resident on 12/15/25, when the resident went out to the community for his appointment.Review of a grievance form, filed 12/18/25, indicated Resident B's representative reported concerns of the resident having the same clothes on for two days. The resident was sent to an appointment in the community, messy with feces, and without a brief.The facility investigation in response to the grievance indicated interviews with the nurse and CNA 3. CNA 3 went in prior to the resident's appointment to change clothes, clean up, and put a new brief on the resident. Resident B declined needing changed because he was in a clean brief and told CNA 3 his clothes were fine as he just wore them for one day prior. The investigation conclusion indicated an explanation was given to the representative that the resident was able to make his own decisions. Corrective action if necessary: Staff will notify the representative if the resident refuses to change briefs or clothes again.Date resolved: 12/18/25. Resident/representative response to resolution: The resident and representative agreed with the resolution with no further concerns.Review of Resident B's bathing documentation indicated the following information:On Tuesday, 11/25/25, the resident refused, On Friday, 11/28/25, the resident received a bed bath and shampoo,On Tuesday, 12/2/25, the resident refused, On Friday, 12/5/25, the resident refused,On Tuesday, 12/9/25, the resident refused, On Friday, 12/12/25, the resident received a shower and shampoo,On Tuesday, 12/16/25, the record lacked any bathing information,On Friday, 12/19/25, the record lacked any bathing information,On Tuesday, 12/23/25, the resident refused,On Friday, 12/26/25, the record lacked any bathing information,On Tuesday, 12/30/25, the record lacked any bathing information,On Friday, 1/2/26, the record lacked any bathing information, [NAME] Tuesday, 1/6/26, the record lacked any bathing information.The clinical record lacked any additional attempts, education, nurse notification, or family notification to engage the resident in bathing on the dates recorded as refusals. During an interview on 1/22/26 at 1:43 p.m., CNA 3 indicated he was familiar with Resident B. The resident was pleasant and cooperative with care assistance. The resident was compliant with toileting and always willing to get cleaned up and dressed every day. CNA 3 was uncertain if the resident refused showers. On 1/22/26 at 3:32 p.m., the Administrator indicated the facility reached out to the resident representative regarding feedback left on the resident portal and initiated a grievance. Staff indicated the resident had refused care prior to the appointment. The resident denied refusal of care. After the solution was provided to the representative, she was unaware of any further hygiene concerns. On 1/22/26 at 4:15 p.m., the DON indicated the facility was no longer required to chart the morning and evening care and the assistance the resident received for dressing each day. These items were a normal standard of care. She did not have any information to show the resident had been assisted with dressing each day.On 1/22/26 at 4:48 p.m., QMA 4 indicated residents were required to provide/offer bathing according to the resident's preference each week. When a resident refused bathing, the staff were required to reapproach the resident three times to encourage bathing. After three refusals, then the refusal was reported to the nurse and documented in the clinical record and on the shower sheets. The shower sheet refusals were signed by the nurse notified and the CNA who offered the showers. It was not acceptable practice to leave the residents' bathing or refusals uncharted.On 1/22/26 at 4:54 p.m., QMA 5 indicated she was familiar with Resident B. The resident was cooperative with care. He required assistance from one staff member for toileting. None of the CNAs had reported any concerns to her about shower refusals nor noncompliance with incontinence care for Resident B. The resident did not bring any concerns to her attention. On 1/22/26 at 5:01 p.m., the DON indicated she was unable to provide any further information regarding the resident's bathing. The clinical record lacked any notification for shower refusals to the nurse or the resident's family. Resident B's bathing information was left blank on 12/16/25, 12/19/25, 12/26/25,12/30/25, 1/2/26 and 1/6/26. One could not identify the resident was offered bathing because it was not in the clinical record. Residents have the right to be provided/offered showers according to their preference.A current facility policy, dated 11/29/23, titled Resident Showers, provided by the DON on 1/22/26 at 5:05 p.m., indicated the following: Policy: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice.This citation relates to Intake 2697020.3.1-38(a)(2)3.1-38(b)(2)3.1-38(f)

Based on interview and record review, the facility failed to provide services for a resident with a feeding tube to prevent complications for 1 of 1 resident reviewed for tube feeding. (Resident 47) Finding includes: During an interview on 3/17/25 at 4:02 p.m., Resident 47 indicated she had a feeding tube as a result of a stroke. She recently began to have a pureed diet with thickened liquids for nutrition. She continued to receive her medications every day through her feeding tube. Resident 47's clinical record was reviewed on 3/18/25 at 2:29 p.m. Diagnoses included cerebral infarction without residual deficits, gastrostomy status, dysphasia, pharyngoesophageal phase, moderate protein-calorie malnutrition, and generalized muscle weakness. A current physician order, dated 2/20/25, indicated to change the enteral tube for splits/cracks in the tube, plugged, and/or dislodgement as needed. The clinical record lacked orders for gastrostomy tube site care. An admission Minimum Data Set (MDS) assessment, dated 2/25/25, indicated the resident was cognitively intact. The resident required substantial assistance from staff for toileting, bathing, and lower body dressing. She required partial assistance from staff for transfers supervision for personal hygiene. Eating assistance from staff was marked not applicable. Nutritional approached included a feeding tube on admission and while a resident. A current care plan, dated 2/20/25, indicated the resident had a gastrostomy tube related to moderate protein calorie malnutrition. Interventions included, the resident will receive her feedings as ordered (2/20/25), observe the resident for any changes in breathing or increased coughing (3/4/25), check for placement of the feeding tube prior to administration of medications or feedings (3/4/25). The care plan lacked interventions for feeding tube site care. During an observation on 3/20/25 from 3:22 p.m. to 3:33 p.m., accompanied by LPN 6 , the resident's feeding tube site had a clean and dry T-drain sponge in place, dated 3/20/25. During an interview at the time of observation on 3/20/25 at 3:34 p.m., LPN 6 indicated the residents' clinical records with feeding tubes typically had an order for feeding tube site care every shift. She was unaware how to determine if site care had been performed every shift because she was unable to find the information in the resident's clinical record. It was the duty of every nurse to identify necessary orders and request orders that were lacking from the provider. During an interview on 3/21/25 at 12:42 p.m., Resident 47 indicated staff had not cleaned her feeding tube site and changed the dressing every shift ,nor every day. It had been cleaned intermittently, but she no longer received feedings through it. During an interview on 3/21/25 at 12:56 p.m., LPN 7 indicated Resident 47 was cooperative with her care. The clinical record for residents with feeding tubes typically included orders on the Treatment Administration Record (TAR) for feeding tube site care and T-drain sponge dressing changes. The orders provided prompts for nursing in the TAR when they were due. In the event a clinical record lacked an order for feeding tube site care, it was necessary to contact the provider for an order. During an interview on 3/21/25 at 1:17 p.m., the Corporate Nurse Consultant indicated a resident's tube site was assessed every day. The site would have been cleaned if it was dirty. The facility lacked information to show the resident's feeding tube site care had been performed. The clinical record lacked an order for feeding tube site care. A current facility policy, dated 11/27/23, titled Care and Treatment of Feeding Tubes, provided by the DON on 3/21/25 at 9:55 a.m., indicated the following: Policy: It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: .3. The resident's plan of care will address the use of feeding tube, including strategies to prevent complications 3.1-44(a)(2)

Based on observation and interview, the facility failed to ensure insulin (a medication to treat diabetes mellitus) vials and pens were dated when opened and disposed of when expired for 2 of 5 carts reviewed for medication storage. (East and Center hall carts) Finding includes: 1. During a medication storage observation of the East hall cart, accompanied by RN 4 on [DATE] at 10:58 a.m., the following was observed: One open vial of Glargine (long-acting) insulin, undated; the vial contained approximately 90 units, and One open vial of Lispro (short-acting) insulin, dated [DATE], [DATE] and [DATE]; the vial contained approximately 80 units. During an interview at the time of the observation, RN 4 indicated the East hall cart provided medications for eight diabetic residents, and insulin was good for 28 days from opening. During an interview, at the time of the observation, the DON indicated the insulin with three dates was misdated and if the staff were unsure of the open date on insulin, it would need to be disposed of properly. 2. During a medication storage observation of the Center hall cart, accompanied by LPN 5 on [DATE] at 11:16 a.m., the following was observed: One open Lantus (long- acting) Solostar insulin pen, undated; the pen contained approximately 220 units, and One open vial of Lispro insulin, with illegible markings, the vial contained approximately 50 units. During an interview, at the time of the observations, LPN 5 indicated the Center hall cart provided medications to 5 diabetic residents. The insulin was good for 28 days from opening and if it the open date was illegible the insulin would not be appropriate to provide to a resident and would need to be disposed of. During a follow-up interview, on [DATE] at 11:13 a.m., the DON indicated the expectation for staff was insulin was to be dated when opened. This date was to be reviewed with each dose of insulin given to ensure the medication was not given after the 28 day expiration. A current facility policy, revised ,d+[DATE] and titled Labeling of Medications and Biological's, provided by the DON on [DATE] at 2:26 p.m., indicated the following: All medications and biological's used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications .2. Medication labels must be legible at all times .8. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed (needle-punctured); b. All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial . A current facility policy, revised ,d+[DATE] and titled Product Expiration Dates, provided by the DON on [DATE] at 2:26 p.m., indicated the following: . Insulin vials expire 28 days after opening . Insulin pens expire at manufacturers date unless opened and then 28 days . 3XXX,d+[DATE](j) 3XXX,d+[DATE](k)

Based on observation, interview, and record review, the facility failed to post complete nurse staffing information daily for residents and visitors. This deficiency had the potential to affect 103 of 103 residents in the facility. Finding includes: During an observation on 3/18/25 at 8:57 a.m., the facility nurse staffing for first shift, dated 3/18/25, was posted in a frame beside the restroom in the main hallway. The posting lacked the nurse staffing information for second and third shifts. Nurse staffing, dated 3/18/25, included the following: Census: 103 Shift: 6:00 a.m. to 2:00 p.m. Registered Nurse: five staff at 8 hours = 40 actual hours Licensed Practical Nurse: eight staff at 8 hours = 64 actual hours Certified Nurse Aide: 9.5 staff at 7.5 hours = 71.25 actual hours During an observation on 3/18/25 at 4:28 p.m., the facility nurse staffing for first shift, dated 3/18/25, remained unchanged and posted in the hallway near the restroom. First shift ended at 2:00 p.m. During an observation on 3/19/25 at 1:09 p.m., the facility nurse staffing for first shift, dated 3/19/25, was posted in a frame beside the restroom in the main hallway. The posting lacked the nurse staffing information for second and third shifts. Nurse staffing, dated 3/19/25, included the following: Census: 99 Shift: 6:00 a.m. to 2:00 p.m. Registered Nurse: four staff at 8 hours = 32 actual hours Licensed Practical Nurse: eight staff at 8 hours = 64 actual hours Certified Nurse Aide: ten staff at 7.5 hours = 75 actual hours During an observation on 3/19/25 at 3:11 p.m., the nurse staffing sign remained unchanged. First shift ended at 2:00 p.m. During an observation on 3/20/25 at 9:32 a.m., the facility nurse staffing for first shift, dated 3/20/25, was posted in a frame beside the restroom in the main hallway. The posting lacked the nurse staffing information for second and third shifts. Posted nurse staffing, dated 3/20/25, included the following: Census: 98 Shift: 6:00 a.m. to 2:00 p.m. Registered Nurse: four staff at 8 hours = 32 actual hours Licensed Practical Nurse: eight staff at 8 hours = 64 actual hours Certified Nurse Aide: nine staff at 7.5 hours = 67.5 actual hours During an observation on 3/20/25 at 4:00 p.m., the nurse staffing sign remained unchanged. First shift ended at 2:00 p.m. During an observation along with the DON on 3/21/25 at 9:55 a.m., the facility nurse staffing for first shift, dated 3/21/25, was posted in a frame beside the restroom in the main hallway. The posting lacked the nurse staffing information for second and third shifts. During an interview at the time of observation, the DON indicated the second and third shift postings were in behind the first shift posting and not visible for residents and visitors. The nurse staffing was not posted in any other locations. Typically, they changed the nurse staffing posting at the beginning of each shift. She was unaware it had not been changed each day at the beginning of each shift 3/18/25 through 3/20/25. When nurse staffing posting was not changed at the beginning of each shift, one could not determine how many staff were on duty for the specific shifts. Posted nurse staffing, dated 3/21/25, included the following: Census: 101 Shift: 6:00 a.m. to 2:00 p.m. Registered Nurse: four staff at 8 hours = 32 actual hours Licensed Practical Nurse: eight staff at 8 hours = 64 actual hours Certified Nurse Aide: nine staff at 7.5 hours = 67.5 actual hours A current facility policy, last revised 8/21/2024, titled Nurse Staffing Posting Information, provided by the DON on 3/21/25 at 12:22 p.m., indicated the following: Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census d. The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. 3. The information posted will be: a. Presented in a clear and readable format. b. In a prominent place readily accessible to residents, and visitors

Based on record review and interview, the facility failed to complete ordered wound treatments and assessments for 2 of 3 residents reviewed for wound care. (Residents B and C) Findings include: 1. The clinical record for Resident B was reviewed on 9/4/24 at 10:34 a.m. Diagnoses include multiple sclerosis, dementia, malnutrition, and type II diabetes. A current physician's order, dated 7/2/24, indicated to cleanse the area on the right shin with wound wash and pat dry. Apply wound gel to the wound bed and cover with gauze. Change daily and as needed if soiled or dislodged. A review of the electronic treatment administration record (eTAR) lacked documentation of the treatment being completed on 7/4/24, 7/11/24 to 7/14/24, and on 7/18/24. A current physician's order, dated 6/26/24 and discontinued 7/27/24, indicated to cleanse the right heel with wound wash and pat dry. Apply hydrogel to wound bed and cover with an abdominal pad and secure with gauze wrap. Change daily and as needed. A review of the eTAR lacked documentation of treatment being completed on 7/4/24, 7/11/24, 7/12/24, 7/13/24, and 7/18/24. A current physician's order, dated 6/26/24 and discontinued 8/2/24, indicated to document drainage amount of right heel wound, daily as N=none, S=scant, M=moderate, C=copious, N/A=not applicable. A review of the eTAR lacked documentation of drainage amount for 7/4, 7/11/24, 7/12/24, 7/13/24, and 7/18/24. 2. The clinical record for Resident C was reviewed on 9/4/24 at 12:10 p.m. Diagnoses include Alzheimer's disease, malnutrition, and iron deficient anemia. A current physician's order, dated 8/20/24, indicated to cleanse the area on left ankle with wound wash and pat dry. Apply betadine to area and cover with bordered gauze, daily. A review of the electronic treatment administration records (eTAR) lacked documentation of the treatment being completed on 8/17/24, 8/18/24, and 8/20/24. A current physician's order, dated 8/20/24, indicated to cleanse the area on left ankle with wound wash and pat dry. Apply betadine to area and cover with bordered gauze, at bedtime. A review of the electronic treatment administration records (eTAR) lacked documentation of the treatment being completed on 8/20/24, 8/23/24, 8/26/24, 8/29/24, and 8/30/24. A current physician's order, dated 8/20/24, indicate drainage amount of left ankle wound at bedtime as N=none, S=scant, M=moderate, C=copious, N/A=not applicable. A review of the eTAR lacked documentation of drainage amount for 8/20/24 through 8/31/24. During an interview on 9/6/24 at 12:05 p.m., the DON indicated all treatments should be completed and documented per physician's order. The prompt for the wound description was not documented as indicated and several dressing changes lacked documentation of being completed. A current facility policy, revised 3/2020, titled, Following medication-Physician Orders/Parameters, provided by the DON on 9/6/24 at 12:43 p.m., indicated: Purpose: To administer medications in a safe and effective manner and following physician ordered parameters Procedures: .L. After administration, return to cart, replace medications container (if-multi-dose and doses remain), and document administration in the MAR or TAR, and controlled substance sign out record, if indicated. This citation relates to Complaint IN00441065. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure medications were stored securely and disposed of according to policy and compliance regulations. (Residents E, F, G, H, J, K, L, M, N, O, P, Q, R, S, T, and U) Findings include: On 7/11/24 at 11:09 a.m., during an observation of the Wound Nurse's office with the Administrator present, a small, unlocked two-drawer file cabinet was located behind the desk and contained the following: Twenty-four tablets of ondansetron (antiemetic) 4 mg for Resident E with an order date 6/19/24. The resident still resided in the facility. Eleven capsule of hydroxyzine pamoate (antihistamine) 25 mg for Resident F, who discharged from the facility on 1/26/24. There were the following medications for Resident G: seven finasteride (prostate medication) 5 mg tablets, six Floranex (supplement) tablets, seven lisinopril (anti-hypertensive) 10 mg tablets, six pioglitazone HCL(diabetic) 15 mg tablet, nine atorvastatin calcium (cholesterol reduction) 20 mg tablets, thirteen methazolamide (anti-glaucoma) 25 mg oral tablets, seven fosinopril sodium (anti-hypertensive) 10 mg tablets, seven glimepiride (diabetic) 1 mg oral tablets, and seven losartan potassium (anti-hypertensive) 50 mg tablets. The resident discharged from the facility on 6/24/24. Resident H's medications included two torsemide (diuretic) 20 mg tablets, two potassium chloride (supplement) 10 milliequivalents (mEq), one metoprolol tartrate (anti- hypertensive) 50 mg tablet, one sertraline (anti depressant) 50 mg tablet, and one warfarin sodium (anticoagulant) 2.5 mg tablet. The resident discharged from the facility on 1/12/24. Resident J's medications included thirty-six acetaminophen (analgesic) 325 mg tablets, two atorvastatin calcium (cholesterol reduction) 40 mg tablets, three clopidogrel bisulfate (antiplatelet) 75 mg tablets, three folic acid (supplement) 1 mg tablets, two meclizine (antihistamine) 25 mg tablets, four magnesium oxide (supplement) 400 mg tablets, one metoprolol tartrate (anti hypertensive) 25 mg tablets, one omeprazole (acid reducer) 40 mg capsule, three potassium chloride (supplement) 20 mEq capsules, and thirty prochlorperazine maleate (antipsychotic/antiemetic) 5 mg tablets. The resident discharged from the facility 5/23/24. Twenty-four hydroxyzine (antihistamine) 25 mg tablets for Resident K. The resident discharged from the facility on 5/24/24. One open bottle of Pancreatin (supplement) 2000, with an open date of 5/28/24. The resident still resided in the facility. Resident M's medications included six Eliquis (anticoagulant) 5 mg tablets, seven pantoprazole (acid reducer) 20 mg tablets, seven potassium chloride 20 mEq capsules, seven propranolol (anti-hypertensive) 10 mg tablets, four quetiapine fumarate (antipsychotic) 400 mg tablets, three colchicine (anti-gout) 0.6 mg tablets, three levothyroxine (hormone supplement) 175 mcg tablets, three Torsemide (diuretic) 10 mg tablets, and one Cefadroxil (antibiotic) 500 mg capsule. The resident discharged from the facility on 6/15/24. One Cefepime (antibiotic) 2 mg IV injection vial, dated 6/5/24. The resident still resided in facility. Resident P's medications included one bottle of nitroglycerin (anti-hypertensive) 0.4 mg tablets and twenty-six acetaminophen (analgesic) 325 mg tablets. The resident discharged from the facility on 11/15/23. Resident Q's medications included one intravenous bag of vancomycin (antibiotic) solution 1.75 mg, dated 6/3/24, and another dated 6/25/24. The resident discharged from the facility on 6/15/24. Resident R's medications included seven atorvastatin 40 mg tablets, seven aspirin 81 mg tablets, fourteen doxycycline (antibiotic) 100 mg tablets, seven donepezil (for dementia) 5 mg tablets, seven escitalopram (antidepressant) 10 mg tablets, seven Floranex tablets, fourteen propranolol (anti-hypertensive) 20 mg tablets, and seven Vitamin B-12 (supplement) 1000 mcg tablets. The resident discharged from the facility on 6/6/24. Resident S's medications included twenty-six acetaminophen 325 mg tablets, seven ferrous sulfate (supplement) 325 mg tablets, seven furosemide (diuretic) 10 mg tablets, twenty-six loperamide (antidiarrheal) 2 mg tablets, three melatonin (sleep supplement) 3 mg tablets, two metoprolol (anti hypertensive) 100 mg tablets, seven pantoprazole 40 mg tablets, one spironolactone (anti hypertensive) 50 mg tablet, and seven Ursodiol (gallstone dissolution agent) 300 mg capsules. The resident discharged from the facility on 6/25/24. One partially used bottle of Novolog (diabetic) insulin for Resident T. The resident discharged from the facility on 7/1/24. Resident U's medications included seven atorvastatin (cholesterol reduction) 20 mg tablets, seven multivitamin tablets, seven clopidogrel 75 mg tablets, seven Floranex tablets, seven levothyroxine 50 mcg tablets, seven lorsartan 50 mg tablets, seven tamsulosin (alpha blocker- diuretic) 0.4 mg capsules, and seven Vitamin B-2 (supplement) 1000 mcg tablets. The resident discharged from the facility on 6/6/24. During an interview on 7/11/24 at 11:09 a.m., the Administrator indicated the medications found in the Wound Nurse's office should not have been there and were not stored properly. During an interview on 7/11/24 at 12:17 p.m., the Wound Nurse indicated medications should not be stored in her office. Then medications should have been destroyed or sent with the resident upon discharge. During an interview on 7/11/24 at 12:38 p.m., RN 1 indicated medications were to be sent with residents upon discharge. If the resident transferred and did not return, the family would be called and asked if they wished to pick up the medications, otherwise, the medications should be destroyed. RN 1 did not know how long the facility would hold medications before they were destroyed. During an interview on 7/11/24 at 12:41 p.m. RN 2 indicated discharged residents were sent home with their medications. If the resident discharged to a hospital and did not return to the facility, the medication would be sent back to the pharmacy if possible and/or destroyed. During an interview on 7/12/24 at 8:28 a.m., the ADON indicated medications were not to be stored in any office. All medications were to be stored in the medication carts or in the medication rooms. If the medications were not sent home with discharged residents, they were kept for 7 days and then destroyed. During an interview on 7/12/24 at 8:40 a.m., the Rehab Unit Manager indicated she shares the office with the Wound Nurse. The Rehab Unit Manager was aware the medication were being stored in the office. She indicated the reason the medications were kept in the office was because they were waiting for families to come get them. She indicated the medications should have been kept in the medication room, not have been stored in the office. If the families did not pick them up, the medications should be sent back to pharmacy or destroyed. A current facility policy, dated 11/1/2023 and provided by the Administrator on 7/12/24 at 10:02 a.m., titled Medication Storage indicated the following: Policy Explanation and Compliance Guidelines a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. 8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. Theses medication are destroyed in accordance with our Destruction of Unused Drugs Policy A current facility policy, dated 10/23 and last revised on 7/24, titled Drug Disposition indicated the following: General Guidelines: 1. Non-unit dose drugs not qualifying for return to the issuing pharmacy and drug left by residents discharged from this facility shall be destroyed. 2. Non-controlled and scheduled V controlled drugs must be destroyed in the presence of two (2) licensed nurses or one (1) licensed nurse and pharmacist. 4. All medications, including narcotics and Duragesic/Fentanyl patches, are to be placed into the designated medication disposal container. 5. Discontinued, outdated, or deteriorated medication shall not be maintained or used in the facility. Medications shall be disposed of in compliance with federal, state, and local laws. 6. All unused portions of nay properly tabled medications, including controlled substances, shall be released to the discharged resident, along with instructions for their use, upon written order of the physician. 7. Unopened or unexposed medication may be returned to the issuing pharmacy for credit to the appropriate party. 8. Unused portions of medications not released with the resident or returned for credit shall be destroyed on the premises within seven (7) days by the consultant pharmacist or licensed nurse with a witness. This citation relates to Complaint IN00437074. 3.1-25 (m) 3.1-25(o) 3.1-25(p) 3.1-25(q) 3.1-25(r)

Based on observation, interview, and record review, the facility failed to ensure an apical pulse was obtained prior to the administration of digoxin for 1 of 8 residents observed during medication administration (Resident 58). Finding includes: During a medication administration observation, on 6/6/24 at 8:33 a.m., RN 3 checked Resident 58's medications with the medication administration record. She opened plastic packages containing the medications. This included aspirin 81 mg, a multivitamin, cetirizine 5 mg (allergy symptoms), digoxin 125 mcg (micrograms) (heart failure/irregular heart rhythm), Eliquis 2.5 mg (blood thinner), Floranex (probiotic), furosemide 20 mg (diuretic), hydrochlorothiazide (blood pressure/diuretic), losartan 25 mg (blood pressure), metoprolol succinate extended release 100 mg (blood pressure/heart failure), potassium extended release 10 mEq (milliequivalents), and vitamin D3 50 mcg, and placed them in a medication cup. She took the medication cup and a Trelegy Ellipta inhaler into Resident 58's room. She instructed Resident 58 to take a puff from the inhaler, take a sip of water, and swish, then spit the water into a cup. She gave the medication cup containing the pills to the resident, and the resident swallowed the medications. She did not obtain the resident's pulse prior to the medication administration. Resident 58's record was reviewed on 6/6/24 at 2:34 p.m. Diagnoses included atrial fibrillation (irregular heartbeat). Her physician's orders included digoxin 125 mcg daily (3/30/21). The order lacked parameters for when to hold the medication or notify the physician. The Pulse Summary indicated the pulse was 62 on 6/2/24, 85 on 5/17/24, and 70 on 5/2/24. The record lacked additional pulses from 5/2/24 through 6/6/24 . During an interview, on 6/6/24 at 4:39 p.m., RN 3 indicated she had not obtained a pulse on the resident. She had used the pulse obtained by the night shift nurse obtained earlier that day. During an interview, on 6/6/24 at 4:46 p.m., LPN 4 indicated when a resident received digoxin, the pulse and blood pressure were checked. Generally, if the resident's pulse was below 60, the digoxin was held, the physician was notified and would check if the physician wanted to add parameters for the pulse. During an interview, on 6/6/24 at 4:49 p.m., LPN 5 indicated a resident who received digoxin would have digoxin levels checked and should have orders to check pulse and blood pressure routinely with administration. During an interview, on 6/6/24 at 4:57 p.m., RN 3 indicated the resident's pulse had been taken at 5:30 a.m. by the night shift nurse, and she had forgotten to document it in the resident's record. She had the pulse written down on the Report Sheet. During an interview, on 6/7/24 at 1:05 p.m., the DON indicated physician's orders should be followed when giving medications. She would expect a pulse to be obtained prior to the administration of digoxin. [NAME]'s Drug Guide website, https://www.drugguide.com/ddo/view/[NAME]-Drug-Guide/51218/all/digoxin#9, accessed on 6/06/24 at 4:01 p.m., indicated the following: .Monitor apical pulse for 1 full min before administering. Hold dose and notify health care professional if pulse rate is <60 bpm [beats per minute] in an adult, <70 bpm in a child, or <90 bpm in an infant. Notify health care professional promptly of any significant changes in rate, rhythm, or quality of pulse A current facility policy, dated 2/1/18, provided by the Administrator on 6/7/24 at 9:03 a.m., titled Medication Administration, indicated the following: .perform any pre-administration checks/parameters (i.e. pulse, blood pressure) prior to prepping medication(s) for ingestion 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure an indwelling catheter and tubing was positioned properly to avoid contamination for 1 of 1 residents reviewed with urinary catheter (Resident C). Finding includes: During an observation, on 6/4/24 at 10:12 a.m., Resident C was lying on her right side. Her catheter drained dark yellow urine with a large amount of sediment in the tubing. During an observation, on 6/5/24 at 10:10 a.m., the resident was lying on her right side in bed, with her covered catheter bag hanging off the bed frame and touching the floor mat along with the catheter tubing towards the door. During an observation, on 6/5/24 at 10:43 a.m., LPN 9 stopped, looked into the resident room then continued to walk to the nurse's station. During an observation, on 6/5/24 at 11:11 a.m., the resident's covered catheter bag and tubing remained laying on the fall mat on the floor towards the door. During an observation, on 6/5/24 at 11:13 a.m., CNA 10 entered the resident's room after applying a gown and gloves. During an observation, on 6/5/23 at 11:17 a.m., CNA 10 exited the resident's room. During an observation, on 6/5/23 at 11:23 a.m., the resident was lying on her left side. The covered catheter bag and catheter tubing laid on the fall mat on the floor towards the door. During an observation, on 6/5/24 at 12:10 p.m., LPN 9 checked on Resident C and asked if she would like something else to eat. The resident indicated she would eat some soup. LPN 9 walked down the hall toward the kitchen. The covered catheter bag and catheter tubing laid on the fall mat on the floor towards the door. During an observation, on 6/5/24 at 12:29 p.m., the resident was sitting up in bed, she had eaten her soup. The covered catheter bag and tubing laid on the fall mat on the floor towards the door. Resident's C clinical record was reviewed on 6/4/24 at 3:57 p.m. Diagnoses included personal history of urinary tract infections, chronic kidney disease, stage 3, age-related debility, and unspecified dementia. Current physician orders included 16 French foley catheter with 10 mL bulb for neurogenic bladder initiated 4/19/24, Catheter care every shift and as needed every shift for preventative and as needed. A significant change Minimum Data Set (MDS) assessment on 4/18/24 indicated the resident was severely cognitively impaired. She was dependent on staff for toileting, showering, lower body dressing, personal hygiene, moving from sitting to lying position, moving from lying to sitting position, and transfers. She required substantial/maximal assistance rolling left and right. A care plan, initiated on 4/28/24, indicated the resident had an indwelling catheter related to the pressure injury on her sacrum and urinary retention. A Nurse Note, dated 5/15/24 at 7:05 p.m., indicated the catheter was flowing with dark yellow urine. During an interview, on 6/7/24 at 10:58 a.m., CNA 7 indicated for catheter care she made sure the catheter bag was in a privacy bag, the tubing was not in a knot, and the catheter bag and tubing were not laying on the floor. During an interview, on 6/7/24 at 11:05 a.m., LPN 5 indicated as she walked by residents' rooms who had catheters, she checked the catheter bags were in privacy bags, the tubing was not kinked and patent. She also checked to make sure the catheter bag and tubing were below the bladder and not on the floor. During an interview, on 6/7/24 at 11:45 a.m., the DON indicated the catheter bags and tubing should not be resting on the floor and expected staff to monitor that. A current facility policy, dated 11/27/23, provided by the DON on 6/7/24 at 12:38 p.m., titled Catheter Care, indicated the following: .It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care

Based on observation, interview, and record review, the facility failed to provide monitoring of a pressure injury and to develop and implement interventions to promote the healing of a pressure injury for 1 of 3 residents reviewed for pressure injuries (Resident C). Findings include: During an observation, on 6/4/24 at 10:12 a.m., Resident C was lying on her right side on a low air loss mattress at a 30-degree angle. During an observation, on 6/5/24 at 12:29 p.m., the resident was sitting up in bed. During an observation, on 6/6/24 at 3:34 p.m., the resident was lying on her right side on a low air loss mattress. Resident C's clinical record was reviewed on 6/4/24 at 3:57 p.m. Her diagnoses included age-related debility, disorientation, cauda equina syndrome, unspecified dementia unspecified severity with psychotic disturbance, chronic right heart failure, chronic kidney disease, and unspecified severe protein-calorie malnutrition. Current physician's orders included Allevyn adhesive external pad (wound dressing) - apply to left buttock topically every day shift (4/19/24) and Dakins (1/4 strength) external solution - apply to left buttock topically every day shift. Cleanse the wound to the left buttock with Dakin's solution, pack wound with Dakin's soaked kerlix, then cover with Allevyn. Change daily and as needed for soilage or displacement (4/20/24). A quarterly Minimum Data Set (MDS) assessment on 1/18/24 indicated the resident was moderately cognitively impaired. She required substantial/maximal assistance of staff for toileting, lower body dressing, personal hygiene, rolling to right and left, moving from sitting to lying position, moving from sitting to standing position, transfers to and from the toilet, and transfers to and from the tub/shower. The resident was frequently incontinent of bowel and bladder. She was at risk for a pressure injury. A care plan focus, initiated 12/22/23, revised 5/1/24, indicated the resident was at risk for developing more pressure ulcers related to requiring assist with bed mobility and incontinence. Interventions, initiated on 12/22/23, included the following: I will rest on a pressure redistribution surface, I will turn and reposition frequently and ask for assistance as needed, and You will give incontinence care to me and apply barrier cream as needed. The care plan lacked interventions initiated after 12/22/23. A care plan focus, initiated 4/28/24, indicated the resident had an unstageable pressure ulcer related to skin failure. Interventions, initiated 4/28/24, included the following: I will rest on a pressure reducing mattress, I will receive my treatment as ordered, I will report and you will observe for signs/symptoms of infection such as increased redness, warmth, induration at or near wound edges, foul odorous drainage. A Physiatry Progress Note, dated 1/22/24 at 3:04 p.m., indicated the resident was having some sacral discomfort from her pressure sore. The resident's clinical record lacked a wound assessment or a treatment of the resident's pressure injury between 1/22/24 and 1/30/24. The Wound Consultant Note, dated 1/30/24, indicated the resident was being seen for assessment of a pressure injury located on the coccyx. Previous wound treatments included barrier products. The wound was staged as a stage 3 (Full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.) pressure injury to the left gluteal with a length of 0.6 cm by a width of 0.8 cm with less than a 0.1 cm depth. The wound bed was 50% granular (red, bumpy tissue that is healing) and 50 % slough (nonviable tissue). The plan was a return visit in one week. Current treatment included a hydrocolloid dressing. On the same assessment, a stage 1 (Observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence) pressure injury was located on the coccyx with measurements of 0.5 cm long by 0.5 cm wide by less than 0.1 cm deep. The tissue was epithelial (Appears pink or pearly white and wrinkles when touched. Occurs in the final stage of healing when the wound is covered by healthy epithelium.). A Skin & Wound assessment, dated 2/1/24, indicated the resident had a new stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising.) pressure injury to the sacrum with a length of 1.4 cm, a width of 1.1 cm, and a depth of 0.1 cm. The wound bed was 70% filled with eschar and 30% filled with slough. The wound had a moderate amount of serous (clear to yellow fluid) drainage. The resident had continuous pain to the area. A Nurse Note, dated 2/1/24 at 5:06 p.m., indicated the resident had received a new physician order for Medihoney - apply to the coccyx every day shift for wound healing. A Skin & Wound assessment, dated 2/8/24 at 11:42 a.m., indicated the resident had a stage 2 pressure injury to the sacrum that measured 0.9 cm long by 0.6 cm wide by 0.1 cm deep. The wound bed was 50% filled by granulation and 50% filled by slough. The resident's clinical record lacked a wound assessment between 2/8/24 and 2/16/24. A Skin & Wound assessment, dated 2/16/24 at 11:45 a.m., indicated the resident had a stage 2 pressure injury to the sacrum that measured 2.2 cm long by 1.7 cm wide by 0.1 cm deep. The wound bed was 50% filled by granulation and 50% filled by slough. The resident's clinical record lacked a wound assessment between 2/16/24 and 2/25/24. A Skin & Wound assessment, dated 2/25/24 at 10:06 a.m., indicated the resident had a stage 2 pressure injury to the sacrum that measured 1.4 cm long by 2.0 cm wide by 0.1 cm deep. The wound bed was 10% filled by granulation, 70% filled by slough, and 20% filled by eschar. A Skin & Wound assessment, dated 3/28/24 at 10:01 a.m., indicated the resident had an unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.) pressure injury to the sacrum that measured 3.9 cm long by 3.9 cm wide and depth not applicable. The wound bed was 10% filled by granulation, 20% filled by slough, and 70 % filled by eschar. A Nurse Note, dated 4/12/24 at 5:11 p.m., indicated the resident returned from the hospital on hospice care and had an unstageable pressure injury to the sacrum. A Skin & Wound assessment, dated 4/25/24 at 11:16 a.m., indicated the resident had an unstageable pressure injury to the sacrum that measured 2.4 cm long by 4.0 cm wide by 1.4 cm deep. The wound bed was 90% filled by granulation and 10% filled by slough. A Skin & Wound assessment, dated 5/30/23 at 11:32 a.m., indicated the resident had a stage 3 pressure injury to the sacrum that measured 2.0 cm long by 1.8 cm wide and depth not applicable. The wound bed was 100% filled by granulation. During a wound treatment observation, on 6/6/24 at 10:53 a.m., the Wound Nurse while wearing gown and gloves removed the wound dressing and packing from the resident's sacral area on the left buttock. The wound was cleansed, packed, and a new dressing was applied. The wound bed was beefy red. The wound length was the diameter of a quarter, the width of the diameter of a nickel, and the depth of the diameter of a dime. During an interview, on 6/6/24 at 3:41 p.m., the Wound Nurse indicated the first assessment she did on the resident's sacral pressure injury was performed on 2/1/24. She was unaware of the Physician Assistant note completed on 1/22/24 indicated the resident had a pressure sore that caused her sacral discomfort. During an interview, on 6/7/24 at 10:57 a.m., CNA 7 indicated anytime she changed someone she looked for pressure areas and reported them to the nurse immediately. She checked the interventions on the computer for the residents. For Resident C she made sure she was turned every two hours. During an interview, on 6/7/24 at 11:11 a.m., the DON indicated she was unable to locate an assessment done on the pressure sore indicated by the Physiatry Physician Assistant (PA) note on 1/22/24. She was unaware the 1/30/24 Wound Consultant Note indicated the resident had a wound on her left gluteal. The CNAs were supposed to mark on the shower sheets when the residents had a new area. The shower sheets for the time period did not show a new area. She deferred to the Wound Nurse about pressure injury staging and characteristics. During an interview, on 6/7/24 at 11:41 a.m., the Wound Nurse indicated the on admission the resident had a previously healed stage 1 pressure injury but was uncertain what the Wound Consultant was referring to in her note. She was uncertain why the facility had not received additional notes from the Wound Consultant. She was going to request to see if there were additional notes the facility had not received. She had left a message with the Wound NP. During an interview, on 6/7/24 at 12:31 p.m., the PA indicated in her documentation when she wrote pressure sore the area would not have been open, or she would have written ulcer. If she wrote sore, then she would have been there during care and saw the resident had a red, tender area. During an interview, on 6/7/24 at 1:16 p.m., the Wound Nurse indicated she had a picture of the wound on 2/1/24. The wound had dark tissue on wound base and a yellow area from 2 to 6 using a clock. She had documented the area was eschar but thought now it was dried blood when she looked at it. If the wound had slough or eschar would be a stage 3 wound. She had mistakenly called the wound bed eschar and slough. The wound picture did not clearly identify the wound bed as dried blood or the yellow area as denuded (loss of epidermis) skin. A current facility policy, dated 11/29/23, provided by the DON on 6/7/24 at 12:38 p.m., titled Pressure Injury Prevention and Management, indicated the following: Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcers/injuries .4. Interventions for Prevention and to Promote Healing . d. Evidence based treatment in accordance with current standards of practice will be provided for all residents who have a pressure injury present .ii. Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate (if present), presence of pain, signs of infection, wound bed, wound edge, and surrounding tissue characteristics . 5. Monitoring a. The Wound Nurse, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record This citation is related to conplaint IN00433981. 3.1-40(a)(2)

Based on record review and interview, the facility failed to complete a significant change assessment after hospice admission for 1 of 1 residents reviewed for hospice. (Resident 44) Findings include: The clinical record for Resident 44 was reviewed on 5/5/23 at 11:04 a.m. The resident's diagnosis included senile degeneration of the brain. He had a physician order to admit to hospice on 12/12/22. The resident had a Quarterly Minimum Data Set (MDS) assessment, dated 12/15/22, which lacked indication of hospice services. During an interview on 5/8/23 at 11:29 a.m., the MDS coordinator indicated the assessment done on 12/15/22 should have been a (comprehensive) significant change assessment related to the resident's new hospice admission. During an interview on 5/9/23 at 11:13 a.m., the MDS coordinator indicated she used the RAI (Resident Assessment Instrument) manual as the policy and procedure for completing MDS assessments. She had access to the online manual. Review of the current online RAI manual (April 25, 2023) retrieved from www.cms.gov on 5/9/23, indicated the following: .significant change in status assessment (SCSI) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home 3.1-31(d)(1)

Based on record review and interview, the facility failed to include activities of daily living needs in a baseline care plan for 1 of 3 residents reviewed for activities of daily living. (Resident 159) Findings include: The clinical record for Resident 159 was reviewed on 5/5/23 at 9:42 a.m. Diagnoses included stroke, hemiplegia of the left side, and depression. The resident admitted on [DATE] from an acute care hospital following a stroke. An admission Minimum Data Set (MDS) assessment, dated 4/20/23, indicated the resident was cognitively intact and required extensive assistance of two staff for bed mobility, transfer, dressing, toileting, and bathing. The clinical record lacked a baseline health care plan regarding the resident's needs for staff assistance for his activities of daily living (ADLs). The comprehensive care plan for ADLs was developed/revised on 4/26/23, six days after admission. During an interview on 5/9/23 at 10:14 a.m., the DON indicated the resident's baseline care plan had not included his specific needs regarding safe ADL care. This should have been included in the baseline care plan. A current facility policy, revised 10/2022, titled, Care Planning, provided by the DON on 5/9/23 at 10:41 a.m., indicated the following: .Procedure: .Baseline Plan of Care: 4. A Baseline plan of care will include at a minimum and will be completed within 48 hours of admission . 5 .c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility 3.1-30(a)

Based on observation, record review, and interview, the facility failed to ensure a call light was placed within reach of a dependent resident for 1 of 3 residents reviewed for activities of daily living. (Resident 159) Findings include: During a random observation on 5/8/23 at 10:44 a.m., Resident 159 was observed seated in his wheelchair, to the right of the lower end of his bed. His call light button was clipped to his bedsheet, to the left of his wheelchair. He indicated he had urinated on himself and his left arm was sore and in the wrong position, but he had been unable to get the staff's attention. The resident indicated he was unable to reach the call light due to his inability to move his left arm and inability to reach the call light button with his right arm. During an interview on 5/08/23 at 10:48 a.m., CNA 7 indicated the call light button was attached to the resident's bed in a place the resident was unable to reach. The clinical record for Resident 159 was reviewed on 5/5/23 at 9:42 a.m. Diagnoses included stroke, hemiplegia to his left side, and depression. An admission Minimum Data Set (MDS) assessment, dated 4/20/23, indicated the resident was cognitively intact, required extensive assistance for bed mobility, transfer, dressing, toileting, and bathing. During an interview on 5/9/2 at 10:18 a.m., the DON indicated the resident's call light button should be placed so the resident can use it to call staff for assistance. A current facility policy, last revised 10/2022, titled, Resident Call System, provided by the DON on 5/9/23 at 10:41 a.m., indicated the following: .Guidance: .The call light should be within reach of the resident whether in bed, sitting in a chair in their room, in the toilet and bathing areas. The intent of this requirement is that residents, when in their rooms, toilet and bathing areas, have a means of directly contacting caregivers 3.1-3(v)(1)

Based on interview and record review the facility failed to ensure staff used a gait belt during transfers for 1 of 3 residents reviewed for accidents. This deficient practice resulted in the resident falling during a transfer and sustaining a fractured left hip that required surgical repair. (Resident B and CNA 1) Findings include: Review of the facility reportable and investigation indicated on [DATE]20 at 6:00 p.m., Resident B was being transferred from the wheelchair to the bed and fell . During the transfer the resident and the CNA (Certified Nursing Assistant) (CNA 1) lost their balance and the CNA lowered the resident to the floor. The investigation lacked any documentation of a gait belt being used during the transfer. The clinical record for Resident B was reviewed on 1/30/2020 at 11:10 a.m. [DIAGNOSES REDACTED]. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 10/16/2019, indicated the resident was cognitively intact. Review of a Fall Risk Evaluation, dated 12/9/2019, indicated the resident was a high risk for falls. Review of a fall risk care plan dated 11/15/2018. Interventions included, but were not limited to, I need up to extensive physical assistance of staff for transfers, dated [DATE]. An intervention added on 1/30/2020 indicated the resident was to be transferred with two staff members and a gait belt was to be utilized. Review of a progress note, dated [DATE]20 at 9:35 p.m., indicated at 6:10 p.m., the resident was being transferred by one staff member (CNA 1) from the wheelchair to the bed. During the transfer, the resident's weight shifted causing both the resident and the CNA to become unstable. The CNA was able to lower the resident to the floor. The note indicated the resident stated her shoe had been slipping off. Review of a progress note, dated 1/11/2020 at 5:59 p.m., indicated the resident complained of lower left extremity pain. The pain was rated 7 out of 10. The resident was medicated with [MEDICATION NAME] (pain medication) 5-325 mg, one tablet per physician order. Review of a stat left hip x-ray, dated 1/12/2020, indicated the resident sustained [REDACTED]. Review of a progress note, dated 1/13/2020 at 7:59 a.m., indicated on 1/11/2020 at 6:10 p.m.,. the resident began complaining of left hip pain. A stat x-ray was ordered and obtained on 1/12/2020. The resident was sent to the hospital for evaluation and treatment resulting in being admitted for surgical hip repair. The resident was readmitted to the facility on [DATE]. During an interview on 1/30/2020 at 10:49 a.m., Resident B indicated she told CNA 1 her knee was giving out and the CNA assured her she had a hold on her. She indicated she still fell but the CNA was able to prevent her from falling hard. She indicated the CNA did not use a gait belt for the transfer. During an interview on 1/30/2020 at 1:13 p.m., Resident B's family member indicated they had been present at the time of the fall on [DATE]20. The family member indicated the resident usually transferred with one staff member using a turn and pivot maneuver. The resident's knee gave out and both the resident and the staff member fell . The family member indicated the staff member did not use a gait belt for the transfer. During an interview on 1/30/2020 at 2:41 p.m., LPN 2 indicated she had been on duty on [DATE]20. LPN 2 indicated when she arrived in Resident B's room a family member was present. She indicated the resident was a one person assist for transfers at the time of the fall. She indicated CNA 1 had not used a gait belt during the transfer and that it was a facility expectation for staff to use gait belts for transfers. LPN 2 indicated she gave CNA 1 a teachable moment for not using a gait belt during the resident transfer. During an interview on 1/30/2020 at 3:10 p.m., CNA 3 indicated staff are supposed to use gait belts for all transfers except hoyer lifts. During an interview on 1/30/2020 at 3:25 p.m., the Director of Nursing (DON) indicated it was the expectation of the facility that gait belts were to be used for transfers. The DON was unable to find a policy specifically for transfers to the bed, but indicated the transfer to chair would be the same procedure. Review of a current facility procedure dated 3/2015 and revised 3/2017, titled Resident Care Procedure #25: Transfer To Chair was provided by the DON on 1/30/2020 at 3:25 p.m. The procedure indicated the following: .1. Assist resident to sit on edge of bed. Encourage resident to sit for a few seconds to become steady. Check for dizziness. 2. Place belt around resident's waist with the buckle in front (on top of resident's clothes) and adjust to a snug fit ensuring that you can get your hands under the belt. Position one hand on the belt at the resident's side and the other hand on the belt at the resident's back. 3. Assist the reside to stand on count of three. 4. Allow resident to gain balance. Ask the resident if dizzy. 5. Stand to side and slightly behind resident while continuing to hold onto belt. 6. Walk at residents pace. 7. Return resident to chair or bed and remove belt. This federal tag relates to Complaint IN 529. 3.1-35(g)(2)

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors resulting in the admittance of a resident to the hospital with a [DIAGNOSES REDACTED]. (Resident C) Findings include: The clinical record of Resident C was reviewed on 2/2/16 at 2:43 p.m. [DIAGNOSES REDACTED]. Review of a nursing note, dated 1/27/16, indicated Resident C had received the following medications intended for another resident (Resident D) at 7:30 p.m.: [MEDICATION NAME]-Levadopa([MEDICAL CONDITION]) 25-100 mg, [MEDICATION NAME] (antipsychotic) 20 mg, [MEDICATION NAME] (anticonvulsant) 300 mg, [MEDICATION NAME] (laxative) 100 mg, [MEDICATION NAME] (antipsychotic) 10 mg and [MEDICATION NAME] (anticonvulsant) 2 mg. The physician was notified and ordered Resident C be monitored and sent to the hospital for any symptoms and severe sedation, confusion or abnormal bleeding. Review of a nursing note, dated 1/28/16 at 2:30 a.m., indicated Resident C was found on the floor in his room. The nursing note also indicated Resident was alert to self and seemed to be alert to surroundings at time but was unable to make it voiced due to resident slurring words. Resident C was sent to the hospital for evaluation and treatment. Review of the hospital Pre-Arrival Summary dated 1/28/16 indicated Resident C was to arrive to the emergency department via ambulance due to being lethargic due to wrong medications. Review of the ED physician progress notes [REDACTED]. At 5:49 a.m. Resident C's reevaluation indicated pt (patient) is still very lethargic. Plan will be to admit him. Impression and Plan: Alteration of consciousness, Accidental drug overdose, [MEDICAL CONDITION], Fall. Resident C's blood pressure was 192/79. Review of the inpatient hospital Discharge Summary, dated 1/30/16 at 3:05 p.m., indicated Resident C had been discharged with the following Diagnoses: [REDACTED]. During an interview on 2/3/16 at 3:00 p.m., LPN #6 indicated she had asked another nurse to administer medication to Resident D on the skilled care unit. LPN #6 indicated she had pre-set the medications and gave them to the other nurse to administer to Resident D. I know I'm not supposed to but I pre-set his (Resident D) meds (medications) and gave them to (RN #5) to give. During an interview on 2/3/16 at 2:50 p.m., RN #5 indicated she had received pre-set medications for Resident D from LPN #6. I popped his (Resident C) meds to give it to him. Another resident distracted me and I handed his (Resident C) meds to the orientee. I gave her the wrong meds. I had another resident's medications because I was passing his (Resident D) meds for another nurse. We aren't supposed to pre-set meds and I never do. Guess it was some bad decisions. I know I'm not supposed to give meds pulled by another nurse, but I was just trying to help out. RN #5 indicated she was going to watch the orientee give the medications to Resident C, but the orientee had given the medications by the time she arrived to the resident's room. During an interview on 2/3/16 at 3:05 p.m., the DON (Director of Nursing) indicated the medication error had been reported and investigated. The investigation report was provided for review at this time. The report indicated Resident C had been given the wrong medications and immediate steps taken. We inserviced the staff on medication administration and accepted professional practice. The DON indicated it was against facility policy for nursing staff to administer medications prepared by another staff member and it was not accepted professional practice to pre-set medications. During an interview on 2/3/16 at 3:05 p.m., the ADON (Assistant Director of Nursing) indicated it was not acceptable professional practice to pre-set medications or give medications prepared by another nurse. That's nursing 101. We were taught not to do that. After this incident we included it as part of the nursing orientation. This federal tag relates to Complaint IN 403. 3.1-25(b)(9) 3.1-48(c)(2)

Based on record review and interview, the facility failed to ensure a resident with a urinary tract infection was followed-up on in a timely manner to ensure prompt treatment of [REDACTED]. (Resident #B) Findings include: The clinical record for Resident #B was reviewed on 2/26/14 at 2 p.m. [DIAGNOSES REDACTED]. The clinical record indicated the resident received outpatient [MEDICAL TREATMENT] services three times a week on Mondays, Wednesdays, and Fridays. A quarterly Minimum Data Set assessment, dated 1/21/14, indicated Resident #B was severely cognitively impaired, required extensive assistance from the staff for toileting, and was occasionally incontinent of bowel and bladder. A nursing note, dated 1/11/14 at 12:11 p.m., indicated the resident's family was concerned about her and requested a urine test for possible infection. The facility contacted the physician and an order was obtained for a urinalysis and culture and sensitivity (u/a and C&S). An in and out catheterization was done and "rusty colored, cloudy" urine was obtained and sent to the lab for testing. A laboratory report, dated 1/11/14 at 9:21 a.m., indicated multiple abnormal results including the presence of blood, bulirubin, protein, and "few bacteria". A nursing note, dated 1/11/14 at 1:21 p.m., indicated the resident's family and physician were notified of the u/a report. The note indicated the physician was awaiting the C&S results. The C&S report, dated 1/14/14, indicated the urine was positive for [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE). The report indicated the organism was only sensitive to the antibiotics Linezolid and Quinupristin/Dalfopristin. A nursing note, dated 1/14/14 at 5:49 p.m., indicated the physician had been notified of the report and no new orders were received at that time. The physician wanted the reports to be faxed to his office in the morning for further review. A nursing note, dated 1/15/14 at 4:03 p.m., indicated a new order had been received for a one time only dose of [MEDICATION NAME] 250 mgs (milligrams) and the staff were to send the u/a and C&S reports to [MEDICAL TREATMENT] for nephrology to review and order treatment due to the resident's renal status. The next nursing note related to any follow-up from the C&S report was dated 1/21/14 at 3 p.m. The note indicated "Spoke with (name of [MEDICAL TREATMENT] employee) at [MEDICAL TREATMENT] clinic and updated on resident status as we had sent lab results to clinic and had received no response at this time [MEDICAL TREATMENT] clinic asked that lab results be sent again and states 'we do not typically treat an infection unless at the access site'. Explained to (name of [MEDICAL TREATMENT] employee) that (name of doctor) had given a initial dose of antibiotic but was hesitant to treat further due to renal function and would like the nephrologist to be made aware of the results as well." A nursing note, dated 1/21/14 at 3:08 p.m., indicated contact had been made with the resident's nephrologist and he was "updated on urinalysis positive for VRE and physician requesting nephrologist notified and concern for kidney function with treatment. (name of nephrologist) states 'he does not need to worry about renal function as hers is gone he should only renally dose her medications and treat her.' No further orders received at this time...." A nursing note, dated 1/21/14 at 3:31 p.m., indicated the resident's physician was notified of the nephrologist's comments. No new antibiotic orders were received at that time. An SBAR (Situation, Background, Assessment, Recommendation) report, dated 1/22/14 at 1:19 p.m., indicated the resident had returned from her [MEDICAL TREATMENT] treatment at 11:30 a.m. and had been "somewhat lethargic" at that time. Her accucheck at that time was 98. The assessment indicated the resident developed increased confusion, decreased consciousness, and needed more assistance with activities of daily living. The note indicated an accucheck taken at 1 p.m. indicated the resident's blood sugar was 30. [MEDICATION NAME] (a medication that increases the blood sugar) was given. The assessment indicated the resident's family arrived and requested the resident be transported to the ER. An emergency room "Progress Note", dated 1/22/14 at 3:25 p.m., included, but was not limited to, the following: ...History of Present Illness The patient presents with altered mental status, confusion as well as [DIAGNOSES REDACTED]. The onset was 2 weeks ago. The course/duration of symptoms is fluctuating in intensity.... ...Additional history: ...Patients daughter, who is her POA (power of attorney) states that over the last 2 weeks patient has been increasingly confused and has been refusing physical therapy at the nursing home. On Jan. 11th she had a UA and UC (urine culture) done in view of her waxing and waning LOC (level of consciousness) and was found to have VRE in her urine which was only sensitive to Linezolid...." The emergency room progress note also indicated the "Differential Diagnosis" was "dementia, urinary tract infection, [MEDICAL CONDITION], possibly hepatic [MEDICAL CONDITION], not confusion". Multiple lab tests had been completed in the emergency room . Her urinalysis showed "many" bacteria. Her blood ammonia level was also elevated. The note indicated the resident would need to be admitted in view of elevated ammonia levels and urinary tract infection. The note indicated Linezolid and [MEDICATION NAME] (a medication given to decrease blood ammonia levels) treatment had been started. The note indicated an intravenous treatment of [REDACTED]. The Administrator and DoN were interviewed on 2/28/14 at 10:50 a.m. Additional information was requested related to the delay in obtaining medical treatment for [REDACTED]. The [MEDICAL TREATMENT] center was to be contacted for treatment at the request of the resident's physician on 1/15/14. The clinical record lacked any contact with the [MEDICAL TREATMENT] center until 1/21/14. This indicated a time period of six days from the date the physician requested the [MEDICAL TREATMENT] center order treatment for [REDACTED]. The DoN, Assistant DoN (ADoN) and RN Consultant were interviewed on 2/28/14 at 3:40 p.m. The ADoN indicated she had reviewed the unit calendar (not part of the clinical record) which indicated contact had been made with the [MEDICAL TREATMENT] center on January 15, 16, and 17, 2014 related to urinalysis follow-up, but no orders had been received. She indicated she called the nephrologist herself (instead of going thru the [MEDICAL TREATMENT] center) on 1/21/14 and had then relayed the nephrologist's response to the resident's attending physician. This indicated a delay in six days before treatment information was obtained from the nephrologist as requested by the resident's attending physician on 1/15/14. Review of the current facility policy, revised 5/2012, provided by the DoN on 2/28/14 at 3:45 p.m., titled "Laboratory - Test Processing and Reporting", included, but was not limited to, the following: "Purpose: To assure physician-ordered diagnostic tests are performed, and to assure that test results are promptly reported to the physician. ...Standards: ...4. A nurse is responsible for monitoring all test results received...." This federal tag relates to Complaint IN 481. 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure a resident with ear drainage was monitored and assessed and medications to treat an ear infection with drainage were started promptly after ordered by the physician to prevent potential pain and allow for the resident with hearing loss to return to wearing her hearing aide, for 1 of 1 resident reviewed with purulent ear drainage. (Resident #41) Findings include: The clinical record for Resident #41 was reviewed on 11/27/12 at 10:30 a.m. [DIAGNOSES REDACTED]. The clinical record indicated the resident was admitted to the facility on [DATE]. An Internal Medicine history and physical, dated 10/18/12, indicated the resident had been seen due to difficulty with gait and bilateral lower extremity [MEDICAL CONDITION]. The note also indicated the resident was having a problem with left ear pain which had improved following treatment with antibiotic ear drops. An admission Minimum Data Set assessment, dated 10/25/12, indicated the resident was severely cognitively impaired, required a hearing aide for adequate hearing, and required extensive assistance with all activities of daily living. The clinical record indicated the resident was not receiving any ear drops at the time of admission to the facility. A nursing note, dated 11/18/12 at 6:12 p.m., indicated a CNA had called the nurse to the resident's room due to left ear drainage being noted. The note indicated the resident had tan-yellow drainage in outer ear and this was cleaned with a gauze square. The note indicated the resident's husband told the nurse the resident had had problems with drainage in her ears for "some time". The note indicated the husband took the resident's hearing aid home and she was not wearing one at the present time. The resident's temperature was taken and was within normal limits. The next nursing note, dated 11/19/12 at 1:34 p.m., indicated "Resident's husband stated that she has some drainage out of her left ear. He said that in the past, it was treated with ear gtts (drops), but he did not know what kind they were. He said he brought some from home and wanted to know if he could put them in. Nurse explained to him that (name of physician) would need to order the medication. Nurse spoke with (name of physician) and he stated that he looked at resident's ears last week and did not see any drainage at that time. He stated he would look again tomorrow when he does rounds." The note lacked any assessment by the nurse related to ear drainage, possible ear pain, and/or vital signs having been taken. There were two nursing note entries for 11/20/12 and they both pertained to a blood blister on the resident's left lower leg. There were no assessments for ear drainage, abnormal vital signs, and/or possible ear discomfort noted in the nursing notes for 11/18, 11/19, and 11/20/12. A physician's progress note, dated 11/21/12 at 12:25 p.m., indicated the physician had visited the resident and noted copious purulent drainage from the left external canal. His "assessment" indicated she had "external otitis, possible related to the use of a hearing aid." The note indicated [MEDICATION NAME] otic (ear) drops (an anti-[MEDICAL CONDITION]/antibiotic ear drop) were ordered four times daily for ten days and the resident would be re-evaluated at that time. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the resident's husband on 11/27/12 at 3:10 p.m., he indicated he had concerns related to his wife's ear drainage. He indicated he had talked to the staff and the physician about it and thought ear drops were supposed to have been ordered. He indicated his wife was not receiving any ear drops and the drainage problem continued. He indicated he had taken his wife's hearing aid in for cleaning/repair due to the ear drainage, but she could not wear it again until the ear drainage problem was resolved. He indicated her hearing was extremely poor without the hearing aide. He indicated she had a long history of ear problems. During an interview on 11/27/12 at 3:40 p.m. with LPN #4, additional information was requested related to any ear drops having been ordered for Resident #41. On 11/27/12 at 4:05 p.m., LPN #3 provided a physician's orders [REDACTED]. A nursing note, dated 11/27/12 at 2:10 p.m., indicated "(name of physician) was approached by QMA stating husband would still like resident to have ear drops. (name of physician) stated he previously had written that in notes last week. Progress note had not been noted. (name of physician) aware and said to start ear drops today...." This indicated a delay of six days from the date the order was first received until the ear drops would be initiated. There were no nursing notes for 11/22, 11/23, 11/24, 11/25, and 11/26/12. The clinical record lacked any nursing assessment related to possible ear drainage and/or ear pain or assessment of the resident's vital signs on those dates noted above. During an interview with the Director of Nursing on 11/29/12 at 1:00 p.m., additional information was requested related to the lack of monitoring and timely initiation of treatment for [REDACTED]. The facility failed to provide any additional information as of exit on 11/30/12. Review of the current facility policy, dated 1/12, titled "ADMINISTRATIVE physician's orders [REDACTED]. "Purpose: To provide general guidelines when receiving, transcribing, notification, and care planning physician's orders [REDACTED]. Performed by: Licensed Nursing... ...5. Following a physician visit, a licensed nurse will: Check for any orders that require verification. The orders will be verified by the nurse and the instructions for the order will be completed. Check the paper chart for any new written physician orders [REDACTED]." 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident was not left unattended on the toilet resulting in a fall and fracture (Resident #92), failed to ensure a safety alarm was in place at the time of a resident's fall (Resident #14), and failed to ensure a fall risk assessment was completed (Resident #29) to identify a resident at risk for falls for 3 of 7 residents reviewed who met the criteria for falls and/or fracture in a Stage 2 Sample of 34. Findings include: 1.) The clinical record for Resident #92 was reviewed on 12/1/11 at 11:15 a.m. [DIAGNOSES REDACTED]. A 6/14/11 "Transfer Assessment" indicated the resident could not bear weight and had a limitation of upper body strength. An admission nursing assessment, dated 6/14/11 at 1:20 p.m., indicated the resident had a contracture of the right hand, needed the assistance of 2 for transfers, and needed the assistance of 2 for ambulation and mobility needs. A nursing note, dated 6/14/11 at 2 p.m., indicated the resident had fallen within the last 60 days prior to coming to the nursing home. A nursing note, dated 6/15/11 at 1:23 p.m., indicated the resident needed total assistance for transfers, extensive assistance of ambulation, bed mobility, toileting, dressing and grooming. The note indicated the resident had an unsteady gait and balance problem and weakness to right upper and lower extremities. The only injuries documented at the time of the fall was a 0.5 centimeter (cm) by 2 cm "bump knot" noted to the top of right cranial area. A Falls Investigation Worksheet", dated 6/16/11, indicated the resident had an unwitnessed fall on 6/15/11 at 4 p.m. The worksheet indicated the resident was sitting on the toilet in the bathroom at the time of the fall. The note indicated current interventions in place to help reduce falls were a chair pad alarm and a low bed with mat. The root cause analysis section indicated "Resident left alone and sitting balance not good. Corrective action given to CNA...." A nursing note, dated 6/19/11 at 3:59 p.m., indicated "(name of doctor) notified of resident's bruising on right shoulder and increased reports of pain. Order received for x-ray of right shoulder...." An right shoulder X-ray report, dated 6/19/11, indicated the resident had an acute distal clavicle fracture. A nursing note, dated 6/19/11 at 5:25 p.m., indicated the physician was notified of the X-ray report and an order for [REDACTED]. The note indicated the resident was to have a followup orthopedic consult. During an interview with the Administrator and Director of Nursing (DoN) on 12/1/11 at 4:20 p.m., the DoN indicated Resident #92 should not have been left on the toilet unattended prior to the resident's fall on 6/15/11. 2.) The clinical record for Resident #14 was reviewed on 12/2/11 at 2:00 p.m. Resident #14's current [DIAGNOSES REDACTED]. Resident #14 had a "Fall Risk Assessment", dated 5/28/11, which indicated the resident was at a high risk for falls. The clinical record indicated the resident had a history of [REDACTED]. Resident #14 had a healthcare plan, dated 7/6/11, which indicated the resident had a problem listed as, potential for falls related to psychotropic medication use, confusion and a history of falls. Interventions for this problem included, bed pad alarm, chair pad alarm, and motion sensor alarm. A nursing note entry, dated 9/3/11 at 3:39 p.m., indicated, called to room by housekeeping staff, observed resident sitting on floor bedside her bed, no alarms sounding. During an interview with the Director of Nursing on 12/2/11 at 3:20 p.m. she indicated at the time of Resident #14's fall on 9/3/11 the alarms were not in place and were not sounding. She further indicated she had done a "teachable moment" with the staff related to the alarms not being in place as indicated in the plan of care. 3.) The clinical record for Resident #29 was reviewed on 12/1/11 at 9:55 a.m.. Resident #29's current [DIAGNOSES REDACTED]. Resident #29 had a healthcare plan, dated 9/6/11, which indicated the resident had a problem listed as, the resident has a potential for falls related to decreased mobility, weakness, psychotropic medication use, incontinence, and narcotic analgesic use. Interventions for this problem included, low bed with mats, personal alarms to bed and chair and hipsters. The clinical record indicated the resident had a "Fall Risk Assessment" completed on 6/11/11. The clinical record lacked any documentation of any "Fall Risk Assessment" having been completed following 6/11/11. The clinical record indicated the resident had a history of [REDACTED]. During an interview with the RN consultant on 12/1/11 at 2:45 p.m. she indicated a "Fall Risk Assessment" should be completed at a minimum of "quarterly". She further indicated Resident #29 should have had a "Fall Risk Assessment" completed in the month of September 2011. She indicated the nursing staff had not completed a quarterly "Fall Risk Assessment" as indicated in the facility policy. 4.) Review of the current facility policy, dated 8/2009, titled "FALL RISK AND POST FALL INVESTIGATION," was provided by the Director of Nursing on 12/5/11 at 8:30 a.m., included, but was not limited to, the following: "Purpose: 1. To identify treatable conditions and improve overall quality of life for the resident. 2. To conduct appropriate assessments prior to and after falls. 3. To intervene when possible to "break" a fall. 4. To detect reversible causes of falls and to identify supportive aides to prevent falls. 5. To identify high-risk residents and institute interventions to reduce falls and the consequences of falls. Policy: 1. A Fall Risk and other assessment forms will be completed on each resident: a. On Admission b. Quarterly c. When a Significant Change Occurs 2. Any resident scoring a "10" or above on the Fall Risk Assessment form will be placed in the "High Risk for potential falls" category.... ...Performed By: Nursing staff and all interdisciplinary team members. Procedure 1. Conduct Fall Risk Assessment as stated under "Policy" above. Rationale 1. Staff should regularly monitor residents for changes which might increase chances for falling.... ...Possible Interventions... ...2. Physical... ...Bed 1. Personal Bed Alarm Chair 1. Personal Alarm... ...5. Staff will assist resident with ADLs and ambulation if needed.... ...8. A resident who is at high-risk and incapable of voluntary movement may have the following interventions used: a. Total assistance will be used in all transfers...." 3.1-45(a)(2)