Every finding on record at Harrison Trail Health Campus

Based on record review and interview, the facility failed to ensure staff accurately documented when medications were held from being administered and the rationale for holding the medication, which affected 1 (Resident #2) of 5 residents reviewed for unnecessary medications. The facility census was 54.Findings included:An Resident Face Sheet indicated the facility admitted Resident #2 on 04/01/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of ST elevation myocardial infarction of unspecified site (heart attack) permanent atrial fibrillation, hypertensive heart disease with heart failure, end stage renal disease, and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/04/2026, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment.Resident #2's Care Plan revealed a problem statement initiated on 04/04/2024, that indicated the resident was at risk for cardiovascular distress related to diagnoses of hypotension, atrial fibrillation, myocardial infarction, and hypertension. Interventions directed staff to obtain vital signs as ordered and to administer medications as ordered (initiated 04/04/2026).Resident #2's physician Orders included an active order, dated 12/28/2025, for midodrine (a miscellaneous cardiovascular agent) 5 milligrams (mg), one tablet by mouth twice a day, with instructions to hold the medication if the resident's systolic blood pressure (SBP; the top number in a blood pressure reading) was greater than 130 millimeters of mercury (mmHg). The Orders also included an active order, dated 12/27/2025, for metoprolol tartrate (a beta blocker) 25 mg tablet, one half tablet (12.5 mg) by mouth twice a day, with instructions to Hold for SBP less than 100 HR [heart rate] less than 55.Resident #2's December 2025 Medications Administration History revealed staff documented that midodrine 5 mg was administered to the resident when the resident's SBP was greater than 130 mmHg on the following dates and times: - 12/06/2025- 6:00 AM to 10:00 AM- Licensed Practical Nurse (LPN) #3 documented the medication was administered; the resident's SBP was documented as 133 mmHg.- 12/15/2025- 6:00 AM to10:00 AM- LPN #3 documented the medication was administered; the resident's SBP was documented as 144 mmHg.- 12/15/2025- 6:00 PM to10:00 PM- LPN #7 documented the medication was administered; the resident's SBP was documented as 131 mmHg. - 12/17/2025- 6:00 PM to 10:00 PM- LPN #7 documented the medication was administered; the resident's SBP was documented as 145 mmHg.- 12/30/2025- 6:00 PM-10:00 PM- LPN #7 documented the medication was administered; the resident's SBP was documented as 133 mmHg.Resident #2's December 2025 Medications Administration History revealed staff documented metoprolol tartrate 12.5 mg was administered when the resident's SBP was less than 100 mmHg or their heart rate was less than 55 beats per minute (bpm) on the following dates and times:- 12/01/2025- 6:00 AM to 10:00 AM, LPN #3 documented the medication was administered; the resident's SBP was documented as 98 mmHg.Resident #2's January 2026 Medications Administration History revealed staff documented that midodrine 5 mg was administered to the resident when the resident's SBP was greater than 130 mmHg on the following dates and times: - 01/01/2026- 6:00 AM to 2:00 PM- LPN #7 documented the medication was administered; the resident's SBP was documented as 135 mmHg. - 01/16/2026- 6:00 PM to 10:00 PM- LPN #7 documented the medication was administered; the resident's SBP was documented as 131 mmHg.- 01/30/2026- 6:00 PM to 10:00 PM- LPN #7 documented the medication was administered; the resident's SBP was documented as 131 mmHg.Resident #2's February 2026 Medications Administration History revealed staff documented that midodrine 5 mg was administered to the resident when the resident's SBP was greater than 130 mmHg on the following dates and times:- 02/04/2026- 6:00 PM to 10:00 PM- LPN #7 documented the medication was administered; the resident's SBP was documented as 131 mmHg. - 02/11/2026- 6:00 PM to 10:00 PM- LPN #7 documented the medication was administered; the resident's SBP was documented as 131 mmHg.Resident #2's record revealed no evidence of the medications being held on the dates and times referenced.During an interview on 02/26/2026 at 10:00 AM, LPN #7 stated she checked the resident's blood pressure when there were parameters given. She stated that if the medication had to be held, then she took it out of the packaging and discarded it. LPN #7 stated she was familiar with Resident #2 and knew the resident's medications well. LPN #7 stated she worked fast and sometimes clicked the prep button and forgot to go back and change it to indicate that it was not given. During an interview on 02/26/2026 at 10:50 AM, LPN #3 stated she checked Resident #2's blood pressure and looked at parameters to see if medications were to be given. She stated that if a medication was held, it would be documented on the medication administration record (MAR). LPN #3 stated she was very familiar with Resident #2, and she worked with the resident at least once a week. She stated that sometimes she accidentally hit prepped and signed it out but forgot to go back to document the medication was not given.During an interview on 02/26/2026 at 11:25 AM, the Director of Health Services (DHS) stated she expected the nurses to follow the parameters in the order. She stated if a medication should be held, then staff held it and notified the doctor as ordered. The DHS stated she expected medication with blood pressure readings outside the parameters to be marked as not given in the electronic medical record.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain appropriate infection control practices while providing suprapubic (SP) catheter care to 1 (Resident #5) of 2 residents observed for suprapubic catheter care. The facility census was 54.Findings included:A facility policy titled, Suprapubic Catheter Care, dated 12/16/2024, revealed, Overview: To prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. The policy revealed, 3. To perform the procedure: a. Cleanse around the catheter site (Note: If the resident has a drainage sponge around the stoma [a surgically created opening on the abdomen where a tube is placed to divert urine outside the body] site, remove the drainage sponge before washing,) Wash the outer part of the catheter tube.During an interview on 02/26/2026 at 1:09 PM, the Infection Preventionist (IP) stated the procedure and standard practice for cleaning a stoma was to start at the stoma site and clean in a circular motion away from the stoma. She also stated that the procedure and standard practice for cleaning the catheter tubing was to hold the base of the tubing at the stoma site and clean by moving the washcloth down the tubing away from the stoma site. A Resident Face Sheet revealed the facility admitted Resident #5 on 02/20/2026. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of acute cystitis without hematuria, obstructive and reflux uropathy, urinary tract infection, benign prostatic hyperplasia without lower urinary tract symptoms, and the need for assistance with personal care.An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/02/2026, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for toileting hygiene (which included wiping the opening of an ostomy/stoma) and had an in-dwelling catheter (which included a suprapubic catheter) during the assessment look-back period. Resident #5's Care Plan included a focus area initiated on 02/23/2026, that indicated the resident had an active diagnosis of Urinary Tract Infection (UTI). Interventions directed staff to use proper infection control precautions as indicated and per policy when providing toileting, incontinence care, or catheter care (initiated 02/23/2026).Resident #5's Physician Order Report for orders dated 01/01/2026 through 02/24/2026, revealed an active order dated 02/20/2026 to provide suprapubic catheter care which included cleansing with soap and water with activity of daily living care, twice a day.During an observation of suprapubic catheter care on 02/25/2026 at 11:22 AM, Registered Nurse (RN) #9 and RN #6 stopped outside Resident #5's room, donned personal protective equipment (PPE) including a gown and gloves, and entered the room. The observation revealed that the resident was sitting in a wheelchair and RN #9 asked the resident if it was okay for them to provide catheter care while the resident was sitting in the wheelchair, and the resident agreed. The observation revealed that RN #9 wet a washcloth in a basin of warm water, added body wash to the cloth, and cleansed the stoma site for the suprapubic catheter by wiping back and forth (in an up and down scrubbing motion) over the stoma site. RN #9 then wet a clean cloth and rinsed the stoma site in the same up/down scrubbing motion, then proceeded to dry the stoma with a clean, dry cloth in the same manner. RN #9 then held onto the base of the tubing and wiped up and down the tubing, starting at the insertion site, going down the tubing approximately three inches and back up the tubing toward the stoma. RN #9 then wet a clean washcloth, rinsed the tubing with the same back and forth motion, and used a dry cloth to pat the tubing dry. During an interview on 02/26/2026 at 10:12 AM, RN #9 stated that the process was to use a soapy cloth to clean around the stoma site and tubing and use the same process for rinsing and drying. RN #9 stated that she was supposed to clean near the stoma site then outward. For the tubing, RN #9 stated that she was supposed to hold the tubing and clean down the tube, away from the insertion site. She stated she usually liked to have Resident #5 positioned in the bed for suprapubic catheter care. However, RN #9 stated that the resident was already in a wheelchair, and the resident was really hard to transfer. RN #9 said she tried to go under the catheter as well as she could; however, she stated that it was not done correctly and stated the resident should have been in bed for better positioning. During an interview on 02/26/2026 at 1:09 PM, the IP stated it was never okay to clean urinary catheter tubing by wiping a washcloth up and down the tubing. She stated RN #9 did not use the correct procedure for cleaning Resident #5's stoma site and tubing. During an interview on 02/26/2026 at 10:51 AM, the Director of Health Services (DHS) stated the procedure for cleaning a stoma site was to start from the inside. Per the DNS, staff should clean the tubing by going from the insertion site down the tubing away from the patient. She stated it was not appropriate to scrub up and down over the stoma site. During an interview on 02/26/2026 at 11:03 AM, the Interim Administrator stated that he did not know the catheter care policy verbatim, but knew there was a right way to provide catheter care. He stated he expected the nurses to provide catheter care per facility policy.

Based on observation, interview, and review of facility policy, the facility failed to ensure Enhanced Barrier Precaution (EBP) guidelines were followed for all residents that required EBP. This affected four (Residents #5, #27, #36, #255) of five reviewed for EBP. The facility census was 49. Findings include: 1. Review of the medical record for Resident #36 revealed an admitted [DATE]. Diagnoses included sepsis, urinary tract infection, atrial fibrillation, Parkinson's disease, chronic diastolic (congestive) heart failure, and use of indwelling urinary catheter. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had intact cognition. Resident #36 required use of a urinary catheter. Observation of Resident #36's room on 05/20/24 at 9:20 A.M. revealed no signage for EBP. The room had no gowns or gloves specified for EBP. Interview on 05/20/24 at 9:40 A.M. with Resident #36 revealed he has never been in EBP. Interview with the Infection Control Preventionist (ICP) #317 on 05/20/24 at 11:00 A.M. revealed the facility had not put EBP in place. 2. Review of the medical record for Resident #255 revealed an admitted [DATE] Diagnoses included chronic kidney disease with heart failure, cirrhosis of liver, portal hypertension, diabetes mellitus with diabetic neuropathy, and the resident had a dialysis port and required dialysis three times weekly. Review of the Admission MDS assessment dated [DATE] revealed Resident #255 was cognitively intact and required assistance with care. Review of the physician orders for 05/24 revealed no orders for EBP until 05/20/24. Observation of Resident #255 on 05/20/24 at 9:00 A.M. revealed no signage was posted to inform staff of EBP near the resident's room. Interview with the Infection Control Preventionist (ICP) #317 on 05/20/24 at 11:00 A.M. revealed the facility had not put EBP in place. 44083 3. Record review of Resident #5 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #5 included encephalopathy, respiratory failure, cerebral palsy, quadriplegia due to cerebral palsy, depression, myalgia, dysphagia, congenital dilatation of esophagus, and hip contracture. Review of the MDS assessment dated [DATE] revealed the resident had intact cognition and required extensive assistance for Activities of Daily Living (ADLs), including mobility dressing and transfers. Record review of Resident #5 revealed the resident had an abdominal tube with a physician order to flush the tubing with 30 milliliters (ml) of water twice a day, cleanse tube site with water and split sponge twice a day and check for residual every shift. Review of physician orders dated 05/20/24 at 1:52 P.M. revealed staff to use EBP, wearing gowns and gloves at minimum, during high contact care activities. Observation on 05/20/24 at 8:45 A.M. revealed Resident #5 was observed to have no signage or other notification of EBP. Interview on 05/20/24 at 8:45 A.M. Licensed Practical Nurse (LPN) #416 verified Resident #5 had no order for EBP until 05/20/24 and there was no notification of EBP in the resident room. LPN #416 verified Resident #5 had an abdominal tube and should have had EBP in place. Interview on 05/21/24 at 3:35 P.M. LPN #400 verified Resident #5 did not have an order for EBP and there had been no signage and notification of EBP until 05/20/24. LPN #400 verified Resident #5 had an abdominal tube and should have had EBP in place. Interview on 05/22/24 at 2:57 P.M., State tested Nurse Aide (STNA) #300 verified Resident #5 had no EBP signage or notification in the STNA plan of care until the afternoon of 05/20/24. STNA #300 verified staff are required to wear gowns and gloves when providing direct contact care to residents with abdominal tubes. 50007 4. Record review for Resident #27 revealed an admitted [DATE]. Diagnoses included sepsis, cystitis without hematuria, displacement of nephrostomy catheter, and peritoneal abscess. The resident had a nephrostomy. Review of the most recent quarterly MDS assessment dated [DATE] revealed the Resident #27 had intact cognition and was independent for all care. Review of the treatment record for Resident #27 revealed Normal Saline Flush (sodium chloride 0.9 %) syringe amount 5 ml, flush left nephrostomy with 5 ml of normal saline two times daily. Review of the monthly physician orders for 05/24 revealed no orders for EBP until 05/20/24 after it was brought to the facility's staff attention. Review of treatment record dated 05/20/24 for Resident #27 revealed staff to use EBP, wearing a gown and gloves at minimum during high-contact care activities twice a day. Observation on 05/20/24 at 9:14 A.M. of Resident #27's room revealed no EBP signage. Interview with LPN #416 on 05/20/24 at approximately 9:30 AM confirmed no EBP signage in Resident #27's room. Review of the facility policy, Enhanced Barrier Precautions, dated 04/02/24 revealed the facility would identify residents with central lines, urinary catheters, feeding tubes, hemodialysis catheters and tracheotomy/ventilator status regardless of Multi drug-resistant Organisms (MDRO) colonization status. High contact resident care activities requiring gown and glove use included but were not limited to tracheotomy/ventilator care. Residents identified with MDRO, wound, and or indwelling medical devices would have an EBP sign noting the Personal Protective Equipment (PPE) needed and the high contact care activities.