Every finding on record at Camelot Care Center

Based on observation, interview and record review, the facility failed to ensure medication bottles were correctly labeled, refrigerated medications were safely stored, and medication carts were free of loose pills for 4 of 6 medication carts reviewed for medication storage. (vent-hall cart 1, vent-hall cart 2, boys-hall cart 2 and middle-hall cart 2) Findings include: 1. During a medication cart observation with Registered Nurse (RN) 4, on 6/27/25 at 9:30 a.m., the vent-hall cart 1 had one loose orange pill in the bottom of the second drawer and five sticky bottles for Resident 185 in the bottom drawer. The bottles contained the following medication: a. Two bottles of diazepam (for anxiety) 5 milligrams (mg)/milliliter (ml). b. One bottle of cetirizine (for allergy symptoms) 1 mg/ml. c. Two bottles of levetiracetam (for seizures) 100 mg/ml. During an interview, on 6/27/25 at 9:33 a.m., RN 4 indicated the pills should never be loose in the medication cart. The medication bottles for Resident 185 were brought in by the resident's mother. Resident 185's mother had filled the prescriptions and poured some of the medication into the bottles at their home. The resident's mother would bring in the leftover medication and the nurse would pour the new medication into the old bottles. The bottles needed directions and resident information on them. The medication bottles did not have the proper information. 2. During an observation with RN 4, on 6/27/25 at 9:40 a.m., the vent-hall cart 2 had eight bottles of liquid medication stored on the right side of the cart in a basket on the bottom drawer of the cart. The eight bottles needed to be refrigerated and were left out at room temperature. The mediations were as follows: a. erythromycin ethylsuccinate (an antibiotic) suspension for reconstitution 200 mg/5 ml. b. omeprazole (treats gastroesophageal reflux disease) solution 2 mg/ml. c. lansoprazole (treats gastroesophageal reflux disease) oral 2 mg/ml. d. amoxicillin-pot clavulanate (an antibiotic) suspension for reconstitution 400-57 mg/5 ml. e. gabapentin (treats seizures) solution 250 mg/5 ml. f. baclofen (treat muscle spasms) solution 10 mg/5 ml. g. acidophilus (promotes good bacteria in your body) capsule. h. Augmentin (an antibiotic) suspension for reconstitution 250-62.5 mg/5 ml. During an interview, on 6/27/25 at 9:44 a.m., RN 4 indicated the bottles were taken from the refrigerator and put in the medication cart around 7:35 a.m. She would use the medication and put all the bottles back into the refrigerator after she was finished with her medication pass. 3. During an observation with RN 5, on 6/27/25 at 10:40 a.m., the boys-hall cart 2 had two brown, four white and one yellow loose pill in the bottom drawer of the cart. During an interview, on 6/27/25 at 10:45 a.m., RN 5 indicated loose pills should not be left in the bottom of the cart. The loose pills would need to be destroyed in the drug buster stored in the medication room. 4. During an observation with QMA 3, on 6/27/25 at 10:56 a.m., the middle-hall cart 2 had one large white, one-half white and two orange pills loose in the bottom of the second large drawer. During an interview, on 6/27/25 at 11:05 a.m., QMA 3 indicated there should not be any loose pills in the medication cart. During an interview, on 6/27/25 at 11:30 p.m., the Administrator indicated loose pills should not be in the bottom of the medication carts. A current facility policy, titled Storing Drugs, revised 12/2017 and received from the Administrator on 6/30/25 at 9:30 a.m., indicated .Drugs and biological's will be stored in a safe, secure, and orderly manner at appropriate temperatures .Each drug must be kept and stored in the labeled dispensing container. Drugs may not be transferred from one container to another. When a permitted person is not in a drug storage area, the drug storage area and devices must be kept locked .Refrigerated medications must be stored in a refrigerator designated for medication only at a temperature of 36-46 degrees A current facility policy, titled Drug Labels, revised 12/2017 and received from the Administrator on 6/30/25 at 9:30 a.m., indicated .The pharmacist will verify the information on all tables before medication is delivered. Only the pharmacist is permitted to make changes to the prescription label. The facility must never change, modify, or affix anything to the prescription label or medication A current facility policy, titled Physician Orders, revised 4/2017 and received from the Administrator on 6/30/25 at 9:30 a.m., indicated .Never pour medication back into the bottle .The individual medication administration records (MAR's) should be reviewed at the need of medication pass to ensure all ordered medications were administered and all administered doses were documented 3.1-25(j) 3.1-25(o)

Based on observation, interview and record review, the facility failed to ensure staff followed the physician's order for medications given through a gastrostomy tube (a feeding tube inserted through the abdominal wall directly into the stomach) for 3 of 3 residents reviewed for medication administration. (Resident 46, 33 and 72) Findings include: 1. During an observation, on 6/26/25 at 10:57 a.m., Qualified Medication Aide (QMA) 2 indicated the resident received her medication through her gastrostomy tube (g-tube). QMA 2 poured 120 milliliters (ml) of water into a plastic cup and 130 ml into another plastic cup. She pulled Resident 46's medication out of the cart and crushed the pills. She put the crushed pills into the cup with 130 ml water. She took the two cups into the resident's room. The QMA checked the resident's residual and attached the piston to the g-tube. QMA 2 poured the medication into the piston and then poured 120 ml of water. QMA 2 did not flush before the medication was given and flushed the medication with 120 ml of water after the medication. The clinical record for Resident 46 was reviewed on 6/27/25 at 11:35 a.m. The diagnoses included, but were not limited to, gastrostomy tube (g-tube) and dysphagia (difficulty swallowing). A physician's order, dated 11/22/22, indicated to check placement of the g-tube prior to giving medications and to flush the gastrostomy tube with 30 ml of water before and after the medication was given. During an interview, on 6/26/25 at 11:10 a.m., QMA 2 indicated she was not aware of the resident's order for a water flush, and she used this amount most of the time. 2. During an observation, on 6/26/25 at 11:47 a.m., QMA 2 indicated Resident 33 received her pills through her gastrostomy tube (g-tube). QMA 2 poured 130 ml of water into a plastic cup and 120 ml into another plastic cup. She pulled Resident 46's pills out of the medication cart and placed them in a plastic sleeve. She crushed all the pills and poured the crushed pills into the cup with 130 ml water. She took the two cups into the resident's room. QMA 2 poured the medication into the piston and followed with 120 ml of water. The clinical record for Resident 33 was reviewed on 6/27/25 at 11:55 a.m. The diagnoses included, but were not limited to, gastrostomy tube (g-tube) and dysphagia (difficulty swallowing). A physician's order, dated 8/6/22, indicated to administer 30 ml of water into the g-tube before and after medication was administered. During an interview, on 6/26/25 at 12:01 p.m., QMA 2 indicated she was not aware of the correct amount of water the resident had ordered for a flush. 3. During an observation, on 6/30/25 at 10:26 a.m., QMA 2 crushed all Resident 72's pills and put them in 120 ml of water. Then she poured another cup of 90 ml of water for the flush. She poured all 120 ml of water with the crushed pills and followed it with 90 ml of water for a flush. QMA 2 did not flush the g-tube with 30 ml of water before and after giving the medication. The clinical record for Resident 72 was reviewed on 6/30/25 at 11:35 a.m. The diagnoses included, but were not limited to, gastrostomy tube (g-tube) and dysphagia (difficulty swallowing), severe intellectual disabilities, feeding difficulties, neuromuscular scoliosis, and gastrostomy status. A physician's order, dated 10/12/23, indicated to administer 30 ml of water by g-tube before and after medication was given. During an interview, on 6/30/25 at 11:40 a.m., QMA 2 indicated she knew the order was to flush with water before and after the medication was given. A current facility policy, titled Physician Orders, revised 10/2017 and received from the Administrator on 6/30/25 at 9:30 a.m., indicated .Facility nursing personnel will ensure clear, accurate and complete physician's orders A current facility policy, titled Tube Feedings (Naso-gastric or Gastrostomy tube), revised 10/2014 and received from the Administrator on 6/30/25 at 9:30 a.m., indicated .Physician Orders .Flush with 5 cc water between each medication .Thirty (30) cc of water flush before and after medication administration 3.1-44(a)(2)

Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in 1 of 33 resident rooms reviewed. (room [ROOM NUMBER]) Findings include: During the initial facility observation, on 6/26/25 at 1:12 p.m., room [ROOM NUMBER] was found to have three beds. room [ROOM NUMBER] had 3 beds and was 237.9 square feet. This was 79.3 square feet for each resident. During the entrance conference, the Regional Director provided a copy of the Indiana Department of Health recommendation, dated 11/7/24, to approve the room size waiver for room [ROOM NUMBER]. 3.1-19(l)(2)(A)

Based on interview and record review, the facility failed to ensure a PRN (as needed) psychotropic medication was not ordered beyond 14 days or the attending physician documented their rationale in the resident's medical record to indicate the duration for the PRN order for 1 of 5 residents reviewed for unnecessary medications. (Residents 62) Finding includes: The clinical record for Resident 62 was reviewed on 8/9/24 at 1:44 p.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure, dependence on a ventilator (machine to move air in and out of your lungs), tracheostomy, seizure, anxiety disorder, post-traumatic stress disorder, and major depressive disorder. A physician's order, dated 2/14/24, indicated to give one (1) lorazepam (an anxiety medication) 1 milligram (mg) tablet by gastrostomy tube (a tube inserted through the abdomen directly to the stomach). The facility may administer up to 2 tablets in 24 hours as needed (PRN). A care plan, dated 4/2/24, indicated the resident required the use of an anxiety medication. The interventions included, but were not limited to, administer medication as ordered and observe for changes in mood or behavior. During an interview, on 8/9/24 at 9:14 a.m., the Administrator indicated if the resident had an order for PRN lorazepam the medication would need to have a stop date after 14 days. A current policy, titled PRN Medications, dated as revised 9/2017 and received by the Clinical Support Nurse on 8/9/24 at 2:17 p.m., indicated .Residents shall not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs shall be limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. 3.1-48(a)(2) 3.1-48(b)(2)

Based on observation, interview and record review, the facility failed to keep medications within eyesight or stored in a location not accessible to residents or unauthorized personnel for 3 of 3 residents' medications randomly observed for medication storage. (Residents 70, 33 and 74) Finding includes: During an observation, on 8/8/24 at 3:46 p.m., the following medications were found on top of the medication cart: a. One plastic container which contained Erythromycin Benzoyl ointment (used for acne) for Resident 70. b. A bottle of Lansoprazole (a medication used to treat stomach acid) and a bottle of Topiramate (an anticonvulsant medication) for Resident 33. c. A bottle of Cefpodoxime (an antibiotic medication) for Resident 74. There were no staff observed in the hallway. Resident 22 was observed on multiple occasions wandering the halls. During an interview, on 8/8/24 at 3:46 p.m., QMA 3 indicated the medications were from the refrigerator and she should have put them back. A current policy, titled Storing Drugs, received from the Clinical Support Nurse on 8/9/24 2:20p.m., indicated .drug and biologicals will be stored in a safe, secure and orderly manner at appropriate temperatures and accessible only to licensed nursing and pharmacy personnel or staff members lawfully authorized to administer medications 3.1-25(m)

Based on observation, interview and record review, the facility failed to ensure staff covered their clothing with personal protective equipment while providing catheter care for 1 of 1 resident observed for catheter care and Enhanced Barrier Precautions. (Resident K) Finding includes: During an observation, on 8/9/24 at 10:29 a.m., LPN 2 donned a disposable yellow gown and did not tie the gown at the neck or the waist. The gown fell to LPN 2's elbows as she was leaning over the bed to provide catheter care, and her shirt was not covered by the gown. LPN 2 then indicated the gown was bothering her and she removed the gown and put on a new disposable yellow gown. She did not tie the second gown at the neck or the waist. She continued to provide catheter care, and the gown fell off her shoulders and down to her elbows. Her shirt was not covered by the gown and the gown was laying on the resident's bed instead of covering the shirt of LPN 2. During an interview, on 8/9/24 at 10:36 a.m., LPN 2 indicated she should have tied the gown. The clinical record for Resident K was reviewed on 8/9/24 at 10:40 a.m. The diagnoses included, but were not limited to, cerebral palsy, tracheostomy status, gastrostomy status, adult failure to thrive, and cystostomy (surgical opening in the bladder) with a suprapubic catheter. During an interview, on 8/9/24 at 10:54 a.m., the Regional Director indicated the staff should tie the disposable gowns. A current policy, titled Enhanced Barrier Precautions, dated 10/2019 and received from the Administrator at entrance, indicated .Enhanced Barrier Precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated. These precautions entail the use of gown and gloves during 'high contact' resident care activities that provide opportunities for transfer of MDROs [multi drug resistant organisms] to staff hands and clothing to address the continued risk of transmission from residents with MDRO colonization, which can persist for long periods of time (e.g., months), and result in the silent spread of MDROs. A current Center for Disease Control (CDC) procedure, not dated and provided by the Clinical Support Nurse on 8/9/24 at 2:17 p.m., indicated .Sequent for putting on personal protective equipment .GOWN .Fully cover torso from neck to knees, arms to end of wrists, and [NAME] around the back .Fasten in back of neck and waist This citation relates to Complaint IN00440500. 3.1-18(b)(1)

Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft) per resident in 1 of 33 resident rooms reviewed. (Rooms 16) Finding includes: During the initial facility observation, on 8/5/24 at 11:45 a.m., room [ROOM NUMBER] was found to have three beds. room [ROOM NUMBER] had 3 beds and was 237.9 square feet. This was 79.3 square feet for each resident. During the entrance conference, the Regional Director provided a copy of the Indiana Department of Health recommendation, dated 7/13/23, to approve the room size waiver for room [ROOM NUMBER]. 3.1-19(l)(2)(A)

Based on observation, record review and interview, the facility failed to provide at least 80 square feet (sq. ft) per resident for 1 of 33 resident rooms in the facility. (Rooms 16) Finding includes: During the initial facility observation, on 5/3/23 at 11:45 a.m., room [ROOM NUMBER] was found to have three beds. Facility documentation of room size certification, requested on 5/3/23, and provided by the Administrator on 5/5/23 upon entrance, indicated the following: 1. room [ROOM NUMBER], 3 beds/NF 237.9 Sq.ft./79.3 sq.ft. for each resident. During an interview, on 5/5/23 at 10:30 a.m., the Administrator indicated a room size waiver had been requested in the past and was granted. 3.1-19(l)(2)(A)

Based on record review, observation and interview, the facility failed to provide at least 80 square feet (sq. ft) per resident in 1 of 33 resident rooms in the facility. (Room 16). Finding includes: During the initial facility observation, on 6/9/22 at 11:30 a.m., Room #16 was found to have three beds. Measurement of Room #16 indicated the following: Room #16 had 3 beds/237.3 square feet/79.1 square feet per resident. During an interview, on 6/9/22 at 12:30 p.m., the Administrator indicated a room size waiver had been requested in March of 2020 and was granted. 3.1-19(l)(2)(A)

Based on interview and record review, the facility failed to notify the physician when a medication was not available or administered for 1 of 21 residents reviewed for physician notification (Resident B). Finding includes: The record for Resident B was reviewed on 02/20/2020 at 10:37 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A review of the October 2019 Medication Administration Record [REDACTED] The Respiratory Therapy (RT) Notes indicated on 10/24/19 and 10/29/19 the [MEDICATION NAME] was not given because the facility was waiting on prior authorization approval from the insurance company. A prior authorization request form was sent to the insurance company on 10/11/19. From 10/11/19 to 11/11/19, the medication was not given and there was no documentation the physician or family were notified. On 11/11/19, a telephone physician's orders [REDACTED]. During an interview, on 02/20/20 at 3:02 p.m., the Minimum Data Set (MDS) Coordinator indicated prior authorization was sent to the insurance company on 10/11/19 and a response from the insurance company was not located in the resident's medical records. The MDS Coordinator indicated she contacted the insurance company on 02/20/2020 and requested a response from the insurance company. A current facility policy, titled Notification of Change, dated 10/14, received from the Administrator on 02/20/2020 at 4:15 p.m., indicated .Facility personnel shall immediately inform the resident, consult with resident's physician; and, if known, notify the resident's legal representative or an interested family member when there is: .a need to alter treatment significantly (i.e., a need to discontinue an existing form or treatment due to adverse consequences, or to commence a new form of treatment) .Any response received from the physician must be documented in the clinical record (e.g., new orders received, no new orders received, etc.) .All attempted notification(s), as well as successful notification(s) of physician(s) and family member(s)/legal representative are to be documented in the clinical record This Federal tag relates to Complaint IN 153. 3.1-5(a)(3)

Based on interview and record review, the facility failed to complete the state prescribed Notice of Transfer or Discharge form and failed to notify the ombudsman of the transfer to the hospital for 2 of 6 reviewed for hospitalization s (Residents B and 51). Findings include: 1. The record for Resident B was reviewed on 02/20/2020 at 10:37 a.m. [DIAGNOSES REDACTED]. The resident was transferred to the emergency roiagnom on [DATE]. The Notice of Transfer or Discharge form was not completed. During an interview, on 02/20/2020 at 3:06 p.m., the Director of Nursing indicated the Notice of Transfer and Discharge was not completed and should have been completed. 2. The record for Resident 51 was reviewed on 02/17/20 at 4:50 p.m. [DIAGNOSES REDACTED]. A review of the transfer/discharge log for November 2019 indicated Resident 51 was transferred to the emergency roiagnom on [DATE]. During an interview, on 2/19/20 at 10:39 a.m., the Social Service Director (SSD) indicated the transfer/discharge log was sent via email to the ombudsman each month, but she was unable to provide the ombudsman notification for November 2019. During an interview, on 2/20/20 at 2:58 p.m., the Director of Nursing (DON) indicated the SSD had failed to send the notification of transfers/discharges to the ombudsman's office for November 2019. A current facility policy, titled Transfer/Discharge, dated 1/2015, provided by the MDS Coordinator on 02/20/20 at 5:23 p.m., indicated .the facility must, on a form prescribed by the state department, do the following: (A) Notify the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner that the resident understands. The health facility must place a copy of the notice in the resident's clinical record and transmit a copy to the following: (i) The resident, (ii) A family member of the resident if known, (iii) The The resident's legal representative if known, (iv) The local long term care ombudsman program (for involuntary relocations or discharges only) 3.1-12(a)(6)(A)(iii) 3.1-12(a)(6)(iv)

Based on interview and record review, the facility failed to submit MDS (minimum data set) assessments timely for 2 of 2 residents reviewed for transmitting MDS assessments (Residents 4 and 2). Findings include: 1. The record for Resident 4 was reviewed on 2/19/2020 at 10:19 a.m. [DIAGNOSES REDACTED]. [MEDICAL CONDITION], convulsions and asthma. A quarterly MDS assessment was completed on 1/13/2020. The quarterly MDS assessment, dated 1/13/2020, had not been submitted. 2. The record for Resident 2 was reviewed on 2/19/2020 at 10:19 a.m. [DIAGNOSES REDACTED]. [MEDICAL CONDITION], convulsions and [MEDICAL CONDITION]. The quarterly MDS assessment was completed on 12/31/19. The quarterly MDS assessment, dated 12/31/19, had not been submitted. During an interview, on 2/18/2020 at 3:20 p.m., the MDS Coordinator indicated Resident 4's quarterly MDS assessment had not been submitted yet and it should have been. Resident 2's MDS assessment was submitted on 2/12/2020 and was submitted late. During an interview, on 2/18/2020 at 3:20 p.m., the Corporate Clinical MDS indicated the facility did not have a policy on MDS and used the RAI manual. 3.1-31(d)(3)

Based on interview and record review, the facility failed to ensure a resident was accurately assessed for a Significant Change Minimum Data Set (MDS) assessment for 1 of 21 residents reviewed for accurate MDS assessments (Resident 57). Finding includes: The record for Resident 57 was reviewed 02/18/20 at 2:29 p.m. [DIAGNOSES REDACTED]. On 06/03/2019, the resident weighed 117 pounds. A reweight from 12/03/19 indicated the resident weighed 125 pounds and on 12/24/19 the resident weighed 124 pounds. A Significant Change MDS assessment, dated 12/25/19, indicated the resident weighed 124 and had a 5% weight loss in the last month or 10% in the last 6 months. The resident's weights did not indicate a weight loss of 10% in 6 months or 5% in one month. During an interview, on 02/20/20 at 11:26 a.m., the MDS Clinical Support nurse indicated the Significant Change MDS dated [DATE] was incorrect and the facility followed the requirements of the Resident Assessment Instrument (RAI) manual. A policy was requested on 02/20/20 at 11:30 a.m. and at the time of exit, none was provided. 3.1-31(d)

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for 1 of 18 residents reviewed for care plans (Residents 71). Findings include: The record for Resident 71 was reviewed on 02/17/20 at 4:45 p.m. [DIAGNOSES REDACTED]. During an observation, on 02/17/20 at 01:13 p.m., Resident 71 was sitting up, in her customized wheelchair, in the activity area. A wander guard bracelet was attached to her wheelchair. During an interview, on 02/20/20 at 11:00 a.m., CNA 4 indicated Resident 71 was out of the facility today for the regular school based program. She indicated the resident had a wander guard bracelet on her wheelchair. A social service progress note, dated 01/31/12, indicated a discussion took place with the resident's mother about the placement of the wander guard bracelet on the resident's wheelchair and the mother voiced no concerns. A physician's orders [REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, dated 01/16/20, indicated the resident used the a wander guard bracelet daily. An elopement risk assessment, dated 2/17/20, indicated the resident had the ability to propel her own wheelchair, she had a history of [REDACTED]. The resident had not expressed a desire to leave the facility nor did she exhibit exit-seeking behavior i.e walk toward exits, manipulate doors, handles. The resident was determined to be at risk for elopement so a wander guard was in use. A care plan related to the risk of elopement or the use of a Wanderguard bracelet was not located. A current facility policy, titled Care Plan Development and Review, dated as revised on 9/2017 and provided by the Executive Director (ED) on 02/19/20 at 10:00 a.m., indicated .5. The comprehensive care plan shall then be developed and shall describe the following: The services that are to be furnished to attain and maintain the resident's highest practicable physical, mental and psychosocial well-being .6. the comprehensive care plan shall be: Prepared by an interdisciplinary team, that includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff 3.1-35(a)

Based on observation, interview and record review, the facility failed to dispose of an expired medication and failed to label pre-drawn syringes for a medication pass in 2 of 4 medication carts reviewed (Girl's Hall Carts 1 and 2). Findings include: 1. During an observation, on [DATE] at 9:51 a.m., the girls' hall medication cart 1 had one bottle of [MEDICATION NAME] liquid for Resident 14, dated [DATE] with an expiration date of ,[DATE]. During an interview, on [DATE] at 9:55 a.m., LPN 3 indicated the staff should have disposed of the expired medication. The record for Resident 14 was reviewed on [DATE] at 4:40 p.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. 2. During an observation, on [DATE] at 9:58 a.m., the girls' hall medication cart 2 had two syringes with liquid medications in them and no resident's name or identification of the medication in the syringes. During an interview, on [DATE] at 9:59 a.m., LPN 3 indicated she had filled the syringes with [MEDICATION NAME] (an antacid) and dairy aid (enzyme for breaking down lactose in dairy products) for Resident 8. She prepared the syringes earlier in the day for the 11:00 a.m. medication pass and should have labeled the syringes. The record for Resident 8 was reviewed on [DATE] at 4:50 p.m. [DIAGNOSES REDACTED]. A current facility policy, titled STORING DRUGS, dated ,[DATE] and received from the Executive Director on [DATE], indicated .Drugs and biologicals will be stored in a safe, secure, and orderly manner at appropriate temperatures and accessible only to licensed nursing and pharmacy personnel or staff members lawfully authorized to administer medications .Each drug must be kept stored in the labeled dispensing container .Any outdated, contaminated, or deteriorated drugs, or those drugs that have containers that are cracked, soiled, or without secure closures must be removed from stock and destroyed according to policy 3XXX,[DATE](k)(1) 3XXX,[DATE](o)

Based on observation, interview and record review, the facility failed to use proper hand hygiene for 1 of 4 residents reviewed for [MEDICAL CONDITION] care (Resident 35). Finding includes: The record for Resident 35 was reviewed on 02/17/20 at 5:00 p.m. [DIAGNOSES REDACTED]. During an observation of [MEDICAL CONDITION] (trach) care, on 02/19/20 at 10:47 a.m., the respiratory therapist (RT) 2 removed the soiled split gauze from around [MEDICAL CONDITION]. He removed his gloves and discarded them. He did not wash his hands prior to donning his sterile gloves or before cleaning around [MEDICAL CONDITION]. During an interview, on 02/19/20 at 11:14 a.m., RT 2 indicated he should have either used alcohol based rub (ABR) or soap and water to wash his hands before donning his sterile gloves. A facility policy, titled [MEDICAL CONDITION] Care,dated 10/2014, provided by the Executive Administrator (ED) on 02/19/20 at 12:10 p.m., indicated .12. Gently remove the soiled gauze dressing around the stoma and under the [MEDICAL CONDITION] tie and discard. 13. Wash hands and don sterile gloves 3.1-18(l)

Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft) per resident in 4 of 33 resident rooms in the facility (Rooms 1, 6, 18, and 19). Findings include: During the initial facility observation, on 02/17/2020 at 10:33 a.m., rooms [ROOM NUMBERS] were found to have three beds and rooms [ROOM NUMBERS] were found to have four beds. Facility documentation of room size certification, not dated, provided by the Administrator on 02/20/2020 at 3:00 p.m., indicated the following: 1. room [ROOM NUMBER]: 3 beds/NF 238.8 Sq.ft./79.6 sq.ft. for each resident. 2. room [ROOM NUMBER]: 3 beds/NF 237.9 Sq.ft./79.3 sq.ft. for each resident. 3. room [ROOM NUMBER]: 4 beds/NF 319.6 Sq.ft./79.9 sq.ft. for each resident. 4. room [ROOM NUMBER]: 4 beds/NF 319.6 Sq.ft./79.9 sq.ft. for each resident. During an interview, on 02/17/2020 at 3:00 p.m., the Administrator indicated a room size waiver had been requested in the past and granted. 3.1-19(1)(2)

Based on observation, interview and record review, the facility failed to ensure a gastrostomy tube ([DEVICE]) was flushed prior to medication administration (Resident 23) for 1 of 8 residents observed for medication administration. Finding includes: During a medication administration observation, on 12/12/18 at 11:08 a.m., Licensed Practical Nurse (LPN) 1 was observed to prepare medications for Resident 23. She went into the resident's room, connected a 50 mL (milliliter) syringe to the gastrostomy tube ([DEVICE]), checked for residual, and poured a liquid medication into the [DEVICE] without the [DEVICE] being flushed first. The record for Resident 24 was reviewed on 12/13/18 at 10:21 a.m. The [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. During an interview, on 12/12/18 at 11:21 a.m., LPN 1 indicated she forgot to flush the [DEVICE] before giving medications. During an interview, on 12/12/18 at 3:43 p.m., the Director of Nursing indicated she expected nursing staff to follow Physician order [REDACTED]. A current facility policy titled, Tube Feedings (Naso-Gastric or Gastrostomy Tube), dated 10/2014, received from the Corporate Nurse on 12/12/18 at 12:42 p.m., indicated .Medication Administration via Gastrostomy Tube: .12. Flush the tube with approximately 30 cc (cubic centimeters) of water 3.1-35(g)(1)

Based on interview and record review, the facility failed to provide a clinical rationale for not following a pharmacy recommendation to gradually reduce [MEDICAL CONDITION] medications for 1 of 6 resident's reviewed for unnecessary medications (Resident 22). Finding include: The record for Resident 22 was reviewed on 12/11/18 at 10:22 a.m. [DIAGNOSES REDACTED]. The Physician Orders, started on 05/04/18, included, but were not limited to, 0.3 mg (milligrams) of [MEDICATION NAME] HCl (sedative), 60 mg of [MEDICATION NAME] (antidepressant) and 20 mg of [MEDICATION NAME] (antidepressant). A care plan for antidepressant use, last revised 10/10/18, indicated the resident required antidepressant use to treat mood, anxiety and [MEDICAL CONDITION]. Interventions included, but were not limited to .Attempt gradual dose reduction per policy A Note to Attending Physician/Prescriber, dated 08/17/18, indicated a gradual dose reduction (GDR) of [MEDICATION NAME] needed to be considered. The GDR indicated to reduce the medication as advised by the pharmacy. The signed physician response indicated worth a try and was dated 08/24/18. At the bottom of the GDR was a hand written note, Mom notified on this date and refused any GDR or any meds (medications) to be changed regarding dose reduction unless (pediatric specialty hospital) Doctor's make the decrease will document this. A Social Service Progress Note, dated 08/24/18 at 1:15 p.m., Reported to writer by DON that a recommendation was made by the pharmacy to GDR [MEDICATION NAME] PCP (primary care physician) agreed. Mother declined GDR. Mother requests no med changes be made unless they are reviewed by resident's doctors at (pediatric specialty hospital) . A Note to Attending Physician/Prescriber, dated 10/15/18, indicated a GDR of [MEDICATION NAME] needed to be considered. The Medical Doctor's (MD) response to the GDR was to not reduce the medication as the mother refuses GDR of any Meds and was signed by the doctor on 10/19/18. A Note to Attending Physician/Prescriber, dated 11/16/18, indicated a GDR of [MEDICATION NAME] needed to be considered. The MD response was to not reduce the medication because the mom opposed and was signed and dated 11/30/18. During an interview, on 12/11/18 at 3:13 p.m., the Director of Nursing indicated the facility never notified the pediatric specialty doctors and that they should have been asked to review the resident's medication list to see if the GDR was acceptable or clinically contraindicated. A current facility policy, titled Antipsychotic Medication/Gradual Dose Reduction, revised 09/17, received from the Executive Director on 12/11/18 at 1:13 p.m., indicated .For any individual who is receiving a [MEDICAL CONDITION] medication to treat a disorder other than expressions of indications of distress related to dementia (for example, [MEDICAL CONDITIONS] mania, depression with psychotic features, or other medical condition, other than dementia, which may cause [MEDICAL CONDITION]), the GDR may be considered clinically contraindicated for reasons that include, but that are not limited to: The continues use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why an attempted dose reduction would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder; or The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder 3.1-48(b)(2)

Based on observation, interview and record review, the facility failed to ensure medications were locked and secure in 2 of 6 medication carts observed during medication storage review (The Girls Hall and Ventilator Hall). Finding includes: 1. During an observation, on 12/11/18 at 11:14 a.m., the medication cart on the ventilator hallway was unlocked and unattended. During an interview, on 12/11/18 at 11:17 a.m., LPN 2 indicated she should have locked her cart before she entered a resident's room. During an interview, on 12/12/18 at 9:04 a.m., the Executive Director (ED) indicated the nurse should have locked her cart before she walked away from it. 2. During an observation, on 12/12/18 at 11:08 a.m., the medication cart on the girls hall was unlocked and left unattended while LPN 1 was observed to administer medications. During an interview, on 12/12/18 at 11:16 a.m., LPN 1 indicated she should have locked her cart before she entered the room to administer medications. A current facility policy, titled Storing Drugs, dated 12/2017, received from the ED, on 12/12/18 at 9:05 a.m., indicated .Drugs and biologicals will be stored in a safe,secure,and orderly manner at appropriate temperatures and accessible only to licensed nursing and pharmacy personnel or staff members lawfully authorized to administer medications .When a permitted person is not in a drug storage area, the drug storage areas and devices must be kept locked 3.1-25(m)

The facility failed to ensure appropriate, professional standards were followed by staff during intermittent catheter care which resulted in the necessity for surgical catheter removal in a acute care facility. This deficient practice affected 1 of 2 residents reviewed for urinary catheter care. (Resident #66) Findings include: The record review for Resident #66 was completed on 11/12/15 at 10:00 a.m. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Nurse's documentation dated 10/14/15 at 9:30 p.m., indicated the RN #2 attempted to catheterize with a 8 french catheter which was unsuccessful. The RN indicated she thought the catheter was clogged, so she cut off the end of the catheter, altering the medical device and allowing the catheter to migrate into the penis/urethra. During an interview with RN#1 (who came into the room to assist RN #2) on 11/12/15 at 11:45 a.m., she indicated she attempted to remove the catheter, she was unsuccessful. She notified the physician on call. The resident was sent to the emergency room for evaluation. A review of the a hospital Operative note from 10/15/15, indicated Resident #66 was given general trachea anesthesia and the catheter was removed from the bladder with a rigid cystoscope. During an interview with the DON on 11/9/15 at 2:00 p.m., she indicated the nurse did not follow physician orders [REDACTED]. A review of the policy titled Catherization Male Intermittent, Straight dated 10/2014, indicated . Purpose : Catherization will relieve bladder distention and/or provide a means to obtain a sterile urine specimen for diagnostic analysis . Policy: Catherization will be performed by licensed personnel as per physician's orders [REDACTED]. Carefully withdraw the catheter and immediately notify physician 3.1-35(g)(1)

The facility failed to ensure appropriate Catheter care was provided to a resident which resulted in the necessity for surgical catheter removal in an acute care facility. This deficient practice affected 1 of 2 residents reviewed for urinary catheter care. (Resident #66) Findings include: The record review for Resident #66 was completed on 11/12/15 at 10:00 a.m. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Nurse's documentation dated 10/14/15 at 9:30 p.m., indicated the RN # 2 attempted to catheterize with a 8 french catheter which was unsuccessful. The RN indicated she thought the catheter was clogged, so cut off the end of the catheter, causing the catheter to migrate into the penis/urethra. During an interview with RN#1 (who had came into the room to assist RN # 2) on 11/12/15 at 11:45 a.m., she indicated she attempted remove the catheter, she was unsuccessful. She notified the physician on call. The resident was sent to the emergency room for evaluation. A review of the hospital Operative note from 10/15/15, indicated Resident #66 was given general trachea anesthesia and the catheter was removed from the bladder with a rigid cystoscope. During an interview with the DON on 11/9/15 at 2:00 p.m., she indicated the nurse did not follow physician orders [REDACTED]. During an observation of an in and out catherization of Resident #66 on 11/13/15 at 11:50 a.m., LPN # 2 gathered her supplies and checked the orders and entered the resident's room. She set up her supplies on the bedside table without cleaning the field. She used an alcohol based hand cleaner, donned gloves and open and prepared her supplies. With the same gloves she positioned the Resident, his blankets and began the procedure by holding his penis in one hand and cleaning with the [MEDICATION NAME] swabs. With the same gloved hands, she retrieved the in and out catheter and inserted it into the penis to drain the urine from the Resident's bladder. The LPN did not wash her hands during the procedure or when completed after she cleaned up the supplies and exited the room. A review of the policy titled Catherization Male Intermittent, Straight dated 10/2014, indicated . Purpose : Catherization will relieve bladder distention and/or provide a means to obtain a sterile urine specimen for diagnostic analysis . Policy: Catherization will be performed by licensed personnel as per physician's orders [REDACTED]. Carefully withdraw the catheter and immediately notify physician 3.1-41(a)(2)