Every finding on record at Mitchell Manor

Based on interview and record review, the facility failed to revise the care plan with new interventions after a fall for 1 of 3 residents reviewed for falls. (Resident B) Findings include: The clinical record for Resident B was reviewed on 7/15/26 at 9:00 a.m. The diagnoses included, but were not limited to, dementia, Alzheimer's disease, and reduced mobility.A quarterly Minimum Data Set (MDS) assessment, dated 6/5/26, indicated Resident B was not cognitively intact.A progress note, dated 6/20/26 at 7:11 p.m., indicated Resident B was attempting to go into another resident's room and her wheelchair wheel was stuck on the door frame. Resident B sat herself onto the floor on her bottom and attempted to scoot into the room. Resident B was assisted back up to her wheelchair.A progress note, dated 6/21/26 at 7:15 p.m., indicated Resident B lowered herself to the floor from her wheelchair. Resident B was assisted up to her wheelchair.A progress note, dated 7/6/26 at 6:15 p.m., indicated at approximately 4:55 p.m., observed Resident B move to the edge of her wheelchair. Resident B used the handrail to scoot up and lower herself to the floor.A care plan, dated 12/12/25, indicated the care plan had not been revised with new interventions for falls on 6/20/26, 6/21/26, and 7/6/26.During an interview on 7/15/26 at 11:37 a.m., CNA 1 indicated Resident B had a couple falls in the last couple months. Resident B's falls seemed to be from her pulling herself and slipping. The interventions the facility were using were to observe Resident B more often and more frequent position changes in the wheelchair.During an interview on 7/15/26 at 11:50 a.m., the Director of Nursing (DON) indicated Resident B's care plan should have been revised with the appropriate interventions. The interventions in place after her falls were more frequent observations and frequent position changes in her wheelchair.On 7/15/26 at 12:33 p.m., the Director of Nursing (DON) provided a copy of facility policy, titled Comprehensive Care Plans and Revisions, dated 8/29/25, and indicated this was the current policy used by the facility. A review of the policy indicated the facility should monitor the resident to identify changes in the resident's condition and when these changes occur the facility should review and update the plan of care to reflect the change in care delivery.This citation relates to Intakes 3075725 and 3092873.410 IAC (Indiana Administrative Code) 16.2-3.1-35(d)(2)(B)

Based on observation and interview, the facility failed to provide a safe and sanitary environment for 1 of 4 hallways for 5 of 5 days during the survey. Strong urine odors were present. (Hallway B)Findings include: On 4/27/26 at 10:10 a.m., during the initial walkthrough of the facility a strong odor of urine was noted at the beginning of Hallway B. On 4/28/26 at 11:27 a.m., a strong urine odor was noted down Hallway B. On 4/29/26 at 8:47 a.m., a strong urine odor was noted down Hallway B. On 4/29/26 at 10:00 a.m., a strong urine odor was noted at entrance of Hallway B. There were multiple residents observed to be sitting in hall at this time. On 4/30/26 at 10:21 a.m., a strong urine odor was noted down Hallway B. On 5/1/26 at 12:15 p.m., a strong urine odor was noted down Hallway B.During an interview with CNA 1 on 4/30/26 at 1:50 p.m., she indicated there was a noticeable smell of urine down Hallway B. During an interview with CNA 2 on 5/1/26 at 12:20 p.m., she indicated there is a noticeable urine odor down Hallway B.During an interview with the DON (Director of Nursing) on 5/1/26 at 12:25 p.m., she indicated they were aware of a strong odor at the entrance of Hallway B. She indicated it is the policy of the facility that all residents have the right to a clean and comfortable environment.This citation relates to Intake 3000836.410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 2 of 24 reviewed for MDS accuracy. PASSAR screenings and antidepressant medications were coded inaccurately. (Resident 64, Resident 9) 1. On 4/30/26 at 11:15 a.m., Resident 64's clinical record was reviewed. The diagnoses included, but were not limited to, anxiety and bipolar disorder. A Preadmission Screening and Resident Review (PASARR), dated 5/8/23, indicated Resident 64 had Level II screening. An annual MDS assessment, dated 1/30/26, indicated Resident B was not currently considered by the State to have a Level II PASARR screening. 2. Resident 9's clinical record was reviewed on 4/28/26 at 3:09 p.m., the diagnoses included, but were not limited to schizoaffective disorder (a mental health condition that includes symptoms of both schizophrenia and mood disorders), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (persistent, excessive, and uncontrollable worry about daily events, lasting at least six months). A physician's order, dated 6/26/25, indicated Trazodone HCl (an antidepressant medication used to treat major depressive disorder, anxiety disorders, and insomnia) Oral Tablet 50 mg (milligram), give 25 mg by mouth at bedtime for insomnia. The Quarterly MDS Assessment, dated 2/18/26, did not indicate the resident took an antidepressant medication on Item N0415. A review of the RAI, Version 3.0 User's Manual Version 1.20.1, October 2025, on 4/29/26 at 10:49 a.m., indicated .Item N0415, High-Risk Drug Classes: Use .Review the resident's medical record for documentation that any of these medications were received by the resident .during the 7-day lookback period .Code medications in Item N0415 according to the medication's therapeutic category and/or pharmacological classification, not how it is used. During an interview with the MDS Coordinator on 5/1/26 at 1:40 p.m., she indicated that the resident was taking an antidepressant at the time of the Quarterly MDS assessment, dated 2/18/26, and Item N0415C1 should have been coded yes. The MDS Coordinator indicated they do not have an MDS policy, they use the RAI tool to code MDS Assessments. 410 IAC (Indiana Administrative Code) 16.2-3.1-31(d)

Based on observation, record review, and interview, the facility failed to ensure a comprehensive plan of care was created for a resident who was a smoker, to ensure appropriate supervision and interventions were in place to prevent the potential for accidents for 1 of 4 residents reviewed for accidents. (Resident 55)Findings include: On 4/28/26 at 11:12 a.m., Resident 55 was observed to be smoking during the designated smoking time with staff supervision.On 4/29/26 at 11:00 a.m., Resident 55 was observed to be smoking during the designated smoking time with staff supervision.On 4/30/26 at 11:10 a.m., Resident 55 was observed to be smoking during the designated smoking time with staff supervision.A review of the resident smoking list, provided by the facility on 4/27/26 at 11:44 a.m., indicated that Resident 55 was a smoker.Resident 55's clinical record was reviewed on 4/30/26 at 9:46 a.m. The diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (a progressive, incurable lung disease, primarily caused by smoking, that restricts airflow, making it difficult to breathe), paranoid schizophrenia (a chronic mental health disorder characterized by intense, irrational paranoia, delusions, and auditory hallucinations), and mild neurocognitive disorder (a state of slight decline in cognitive abilities; memory, language, or thinking, that is noticeable to the individual or others but does not interfere with daily independence).Resident 55's clinical record lacked a care plan for smoking.The admission MDS (Minimum Data Set) assessment, dated 10/20/25, indicated the resident was a smoker.A review of Resident 55's progress notes on admission indicated the resident was a smoker and continued to be a smoker through present.During an interview on 5/1/26 at 9:00 a.m., the resident confirmed he was a current smoker and had smoked since he was admitted to the facility.During an interview on 5/1/26 at 11:20 a.m., the DON (Director of Nursing), indicated the resident was a smoker. She indicated they are to complete a smoking assessment on admission and then quarterly for each resident who smokes. The DON indicated the any resident who smokes should have a care plan implemented on admission.On 5/1/26 at 12:25 p.m., the DON indicated there was no care plan related to smoking for Resident 55. On 5/1/26 at 11:22 a.m., the DON provided a policy labeled Comprehensive Care Plans and Revisions, dated 8/29/25, and indicated this was a current policy used by the facility. The policy indicated, .A comprehensive care plan must be - (i) developed within 7 days after completion of the comprehensive assessment.(iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.On 5/1/26 at 12:25 p.m., the DON provided a policy labeled Facility Safety, Smoking Facility, dated 4/1/26, and indicated this was a current policy used by the facility. The policy indicated, Procedure.7. All residents who smoke will have a smoking assessment completed with the appropriate care plan interventions documented.Resident Smoking Determination.3. Once a smoking assessment is completed, the Inter-disciplinary Team (IDT) will review the resident smoking assessments and develop an individualized smoking care plan that includes, but is not limited to, smoking safety/assistance and education of smoking policy and level of understanding. 4. The DON or designee will review resident smoking assessments and care plans for accuracy and appropriateness.410 IAC (Indiana Administrative Code) 16.2-3.1-35(a)

Based on record review and interview, the facility failed to protect the residents right to be free from misappropriation of resident property for 7 out of 7 residents reviewed. The residents had money withdrawn from their accounts and placed in multiple other resident accounts. (Resident D, Resident E, Resident F, Resident G, Resident H, Resident J, and Resident K)Findings include:On 12/17/25 at 10:40 a.m., a facility incident report, dated 10/6/25, was provided by the Administrator. A review of the report indicated an allegation of possible misappropriation of funds in the resident trust account by the Business Office Manager (BOM).The report indicated on 10/6/25, the Administrator discovered a potential discrepancy involving the resident trust account. She notified the Regional Field Controller to assist with the investigation. The BOM was suspended immediately pending an investigation. During the initial investigation by the facility, it was determined the allegation was substantiated by funds that could not be accounted for and there were unauthorized withdrawals made. The Regional Field Controllers and Divisional Controller continued with ongoing audits of the resident trust accounts. The report indicated the BOM was employed on 2/20/23 and the last day the BOM worked was on 10/3/25. On 10/9/25, the BOM was officially terminated by the facility. On 12/17/25 at 11:30 a.m., the Administrator provided an audit sheet for Resident Funds Management System (RFMS) issues and Care Cost issues, no date noted, the audit indicated resident accounts that had funds withdrawn and distributed to other resident accounts. The report indicated the following:-Batch 2357 ran on 1/3/24, indicated Resident D had $52.00 withdrawn and Resident K had $41.00 withdrawn. The funds, in the amount of $93.00, were placed in Resident Y's account.-Batch 2834 ran on 12/12/24, indicated Resident J had $136.00 withdrawn. The funds, in the amount of $136.00, were placed in Resident N's account.-Batch 2857 ran on 12/18/24, indicated Resident J had $136.00 withdrawn. The funds, in the amount of $136.00, were placed in Resident N's account.-Batch 2921 ran on 1/28/25, indicated Resident H had $136.00 withdrawn. The funds, in the amount of $136.00, were placed in Resident N's account.-Batch 2957 ran on 2/11/25, indicated Resident E had $390.00 withdrawn. The funds, in the amount of $390.00, were placed in Resident N's account.-Batch 3050 ran on 4/10/25, indicated Resident G had $105.00 withdrawn. The funds, in the amount of $105.00, were placed in Resident N's account.-Batch 3081 ran on 4/22/25, indicated Resident F had $149.00 withdrawn. The funds, in the amount of $149.00, were placed in Resident N's account.-Batch 3167 ran on 5/15/25, indicated Resident D had $722.85 withdrawn and Resident E had $410.86 withdrawn. The funds were as follows; Resident N - $180.00, Resident U - $3.00, Resident W - $120.00, and Resident X - $830.71, the amounts totaled $1133.71.-Batch 3232 ran on 6/12/25, indicated Resident E had $300.00 withdrawn. The funds were as follows; Resident N - $140.00 and Resident W - $160.00, the amounts totaled $300.00.-Batch 724256 ran on 8/18/25, indicated Resident D had $551.40 withdrawn. The funds were placed as follows; Resident N - $136.00, Resident - O $86.40, Resident S - $110.00, Resident T - $24.00, Resident U - $155.00, and Resident V - $40.00, the amounts totaled $551.40.-Batch 724300 ran on 8/28/25, indicated Resident E had $799.00 withdrawn. The funds were as follows; Resident D - $83.67, Resident Q - $152.27, Resident R - $135.37, and Resident Z - $427.69, the amounts totaled $799.00.-Batch 724346 ran on 9/22/25, indicated Resident D had $1485.00 withdrawn. The funds were placed as follows; Resident L - $826.45, Resident M - $4.00, Resident N - $409.00, Resident O - 86.70, Resident P - $158.85, the amounts totaled $1485.00.The audit sheet of the RFMS Petty Cash fund was reviewed and indicated 100 transactions of various residents from February 2023 through September 2025 that did not have a verification ticket or resident/resident representative signature that were completed by the BOM.During an interview with the Administrator on 12/17/25 at 1:50 p.m., she indicated the facility utilized a combined resident funds account that was managed by a system called RFMS (Resident Funds Management System), she indicated that each resident had their own accounts within that fund. The Administrator indicated the resident funds are kept separate from the facility fund account. The Administrator indicated, on 10/6/25, it was discovered that there was a potential discrepancy with money in the RFMS handled by the facility BOM. She indicated she notified the Regional Field Controller, and an investigation was started immediately. The Administrator indicated the BOM was suspended pending investigation. She indicated the discrepancy was verified within the accounts and an audit was started on all accounts in the resident trust fund, the BOM was terminated upon verification of the discrepancy. The Administrator indicated through the investigation it was discovered that the BOM would move money from one or more resident accounts to other resident accounts in varying amounts. The Administrator indicated it was verified that seven residents had money withdrawn from their accounts by the BOM it was not replaced, according to the audit completed, this occurred from January 2024 through September 2025. The Administrator indicated the BOM had also accepted cash payments for bills from residents and/or their representatives and would not deposit the cash in the resident trust account. She indicated the BOM would keep the cash, then move money from another resident's account to cover the cash payment so no missing payments showed for those bills. On 12/17/25 at 2:15 p.m., the Administrator provided a written interview with the BOM, dated 10/9/25 at 8:30 a.m., conducted by the Regional [NAME] President (RVP) and Regional Field Controller (RFC). The document indicated the BOM was asked about unsigned receipts and a missing receipt book, according to the documentation the BOM would not provide any information at that time. The document indicated the BOM was asked about missing cash that was paid to the business office, she indicated she did not know where the money went. The document indicated that the BOM eventually told the RVP and RFC during the interview that she did take resident money, she indicated that she took no more than $500.00. The BOM then left the facility.During an interview with the Regional Field Controller (RFC) on 12/18/25 at 10:15 a.m., she indicated that on 10/6/25 she was notified by the Administrator regarding no cash in the petty cash box. She indicated the last transaction for the resident account petty cash fund showed a discrepancy. She indicated the transaction posted, date unknown, was by a resident that did not utilize the resident fund petty cash account. The RFC did not disclose the resident's name but indicated she knew the resident and the resident had an account open but never had a balance or any transactions while in the facility. She indicated she began to look into the RFMS and found multiple transactions in the petty cash fund without a ticket verification or resident/resident representative signature. She indicated she also looked into the resident liability share of cost account and there were multiple residents where money was withdrawn from their account and then posted to other resident accounts. She indicated the regional office completed an audit for the duration of employment by the BOM and found seven residents that money was taken from their liability share of cost account and posted to multiple other resident accounts. The RFC indicated, additionally, they completed an audit of the RFMS Petty Cash fund and found multiple transactions completed by the BOM without a verification ticket and/or resident/resident representative signature. She indicated that each resident who had money removed from their account either cash withdrawals or payments to the liability share of cost account were reimbursed after the audits were completed.On 12/17/25 at 2:15 p.m., the Administrator provided the facility policy, Abuse - Prevention dated 5/6/25 and indicated it was the policy currently being used by the facility. A review of the policy indicated, .It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property .This deficient practice was corrected on 10/9/25 after the facility implemented a systemic plan of correction that included the following actions: staff were in-serviced on resident funds and procedures with ongoing monitoring and audits.This citation relates to Intake 2635252.3.1-28(a)

Based on observation, interview, and record review, the facility failed to protect the residents right to be free from verbal abuse by a staff member for 1 of 3 residents reviewed for abuse. (Resident B, LPN 1)Findings include: During an interview on 12/17/25 at 11:40 a.m., Resident B indicated he had been at the facility for four months. He had a moped wreck and had broken his right leg. When asked if any staff had been verbally abusive to him, he indicated Let's just say she did not say anything I didn't say to her. On 12/17/25 at 11:45 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, multiple rib fractures, right tibia fracture, antisocial personality disorder, and seizures. A care plan, dated 8/2/25, indicated Resident B had potential to be verbally aggressive related to ineffective coping skills and antisocial personality disorder. The interventions were to analyze key times, places, circumstances, triggers, and what de-escalated behavior and document, assess resident's understanding of the situation, allow time for the resident to express self-feelings towards the situation, and when the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation, if response was aggressive, staff to walk calmly away, and approach later. A progress note, dated 11/28/25 at 11:17 a.m., indicated on 11/27/25, Resident B was in the hallway yelling and cursing because of a reduction in his pain medications. He was demanding management staff be called-in to deal with this mess. He was educated the nurse practitioner discussed with him the reduction and was weaning him off his pain medication. He was calling staff a liar. Resident B was on one-on-one supervision with another nurse and was calming down. Another nurse from another hallway approached Resident B. Staff reported a verbal altercation when the second nurse approached Resident B telling him to calm down because he was upsetting other residents. Resident B escalated again and began cursing this nurse, and staff reported the nurse cursed at Resident B. Resident B indicated they both said things they should not. During an interview on 12/17/25 at 11:57 a.m., CNA 1 indicated on 11/27/25 at around 6:30 a.m., she was sitting at the nursing station when Resident B came up to the nursing station. He was screaming F*** you, God D*** it. Staff tried to redirect him and calm him down, but he was very upset. During an interview on 12/18/25 at 10:06 a.m., CNA 2 indicated on 11/27/25 around 7:00 a.m., she was sitting at the nursing station when Resident B came up. He was upset and mad because management was not at the facility. He started screaming and cussing. He had calmed down. Licensed Practical Nurse (LPN) 1 was not Resident B's nurse. LPN 1 went up to Resident B's face and told him to quit yelling. He indicated F*** You. LPN 1 indicated F*** You. Resident B indicated I would not F*** your nasty a**. LPN 1 indicated You couldn't get lucky enough. At 12/18/25 at 10:23 a.m., LPN 2 indicated on 11/27/25 around 6:30-6:45 a.m., she was Resident B's nurse. Resident B came up to the nursing station. He was screaming and cussing, pounding on the nursing station. He wanted his pain medication. LPN 2 was unsure why his pain medication order had changed. LPN 2 was on D hall checking his medication orders during the altercation. During an interview on 10:32 a.m., Qualified Medication Aide (QMA) 1 indicated on 11/27/25, she was at the nursing station. Resident B came up to nursing station screaming. He was screaming wanting the person in charge. Resident B started to calm down. LPN 1 came from A hall. She told Resident B he needed to stop screaming. He indicated F*** you. LPN 1 indicated F*** you. Resident B indicated I wouldn't F*** your nasty a**. On 12/17/25 at 2:15 p.m., the Administrator provided the facility policy, Abuse - Prevention dated 5/6/25 and indicated it was the policy currently being used by the facility. A review of the policy indicated, .It is the policy of this facility to prevent and prohibit all types of abuse, neglect .This deficient practice was corrected on 11/28/25 after the facility implemented a systemic plan of correction that included the following actions: all staff were in-serviced on abuse policies and procedures with ongoing monitoring. This citation relates to Intake 2682268. 3.1-27(b)

Based on observation, interview, and record review, the facility failed to ensure a resident with a weight loss was monitored for 1 of 3 residents reviewed for nutrition. (Resident C)Findings include: On 12/17/25 at 2:25 p.m., Resident C's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, Parkinson's disease, chronic kidney disease, muscle weakness, dysphagia (difficulty swallowing), and mood disorder. A care plan, dated 8/22/25, indicated Resident C had a nutritional problem or a potential nutritional problem. The interventions were to provide and serve diet as ordered and the registered dietician to evaluate and make diet change recommendations as needed. A Care Management Note, dated 8/8/25 at 10:31 a.m., indicated Resident C was a new admission and the admission weight was 158.3 pounds. A Dietary Note, dated 8/8/25 at 10:53 a.m., indicated Resident C's weight was 180 pounds. His ideal body weight was 150 pounds. He had no significant weight change in the last 30/180 days. A weight variance was anticipated due to swelling, fluid balance, medications, and diagnoses. Resident C had diagnosis of dementia and was at risk for appetite, intake, and/or weight changes as disease progressed. The nutritional interventions were to serve diet as ordered by physician, to honor food preference, and monitor weights. On 8/14/25 at 10:33 a.m., the Weights and Vitals Summary indicated Resident C weighed 178 pounds. A Care Management Note, dated 8/15/25 at 1:56 a.m., indicated Resident C's weight was 178 pounds. He was on a regular diet. The note lacked documentation of this weight being inaccurate or he had a 19.7 pound increase. The clinical record lacked documentation of weight or a care management note from 8/17/25 through 8/23/25. On 8/24/25 at 4:45 p.m., the Weights and Vitals Summary indicated Resident C weighed 165 pounds. A Care Management Note, dated 8/29/25 at 11:24 a.m., indicated Resident C's weight was 165 pounds on 8/24/25. He was on a regular diet. The note lacked documentation of weight of 178 being inaccurate. On 9/3/25 at 10:22 a.m., the Weights and Vitals Summary indicated Resident C weighed 166.9 pounds. A Care Management Note, dated 9/5/25 at 1:37 p.m., indicated Resident C's weight was 166.9 pounds on 9/3/25. He had an 11 pounds weight loss in 30 days compared to the weight of 178 pounds on 8/14/25. His weight had been stable for 3 weeks. He was on a regular diet. His weights continued to be monitored. The note lacked documentation the weight of 178 was inaccurate or of any weight loss interventions. A Dietary Note, dated 9/5/25 at 2:13 p.m., indicated Resident C weight was 166.9 pounds. Resident C had a significant weight loss of 11.1 pounds which was a 6.2 percent weight loss in 30 days. He was noted to be on a diuretic. His interventions were to continue to monitor weights. The clinical record lacked documentation of weight or a care management note dated 9/7/25 through 9/13/25. A Care Management note, dated 9/19/25 at 7:46 a.m., indicated Resident C remained on enhanced barrier precautions related to indwelling catheter. The note lacked documentation of monitoring for weight loss. On 9/22/25 at 6:56 a.m., Resident C was yelling in pain from his indwelling catheter. The Nurse Practitioner ordered pain medication and to send him to the hospital for evaluation. On 9/28/25 at 4:13 p.m., the Weights and Vitals Summary indicated Resident C weighed 105 pounds. A Dietary Note, dated 10/3/25 at 11:07 a.m., indicated Resident C was a readmission. His weight was 166 pounds (weight was used from the 9/3/25 related to possible weight error on readmission). His ideal body weight was 154 pounds. No documented significant weight loss in 30/180 days. The most recent weight from readmission was 105 pounds (weight loss of 60 pounds) was likely inaccurate. The hospital records indicated weight was 156 pounds. Resident C had diagnosis of dementia and was at risk for appetite, intake and/or weight changes as disease progresses. The interventions were to provide diet as order by physician and to monitor weight and labs. The note lacked documentation of any health shakes supplements being ordered twice a day. A Care Management Note, dated 10/3/25 at 1:46 p.m., indicated Resident C had an indwelling catheter in place because of urinary retention. The note lacked documentation of 9/28/25 weight of 105 pounds being inaccurate, an order for weekly weights or any new supplements orders. A Communication Note to the Physician, dated 10/9/25 at 12:00 a.m., indicated Resident C was in significant distress and was shouting for help and was holding his abdomen. The nurse practitioner indicated to send Resident C to the emergency room for evaluation and treatment. A readmission Dietary Note, dated 10/17/25 at 9:36 a.m., indicated Resident C's weight was 166 pounds. The weight was used from most recent hospital record because the previous facility weight of 105 pounds was likely an error. His ideal body weight was 154 pounds. No documented significant weight change in 30/180 days. The most recent weight from readmission of 105 pounds (weight loss of 60 pounds) was likely inaccurate. The hospital record indicated on admission to the hospital his weight was 156 pounds. He had a diagnosis of dementia and was at risk for appetite, intake, and/or weight changes as his disease progressed. The interventions were diet as ordered by physician and monitor weights. A Care Management Note, dated 10/20/25 at 11:06 a.m., indicated Resident C returned from the hospital with urinary catheter in place. The note lacked documentation of any monitoring of Resident C's weights since his return from the hospital on [DATE]. On 10/23/25 at 1:07 p.m., the Weights and Vitals Summary indicated Resident C weighed 103.6 pounds. A Care Management Note, dated 10/24/25 at 8:04 a.m., indicated Resident C's weight was 103.6 pounds on 10/23/25. This weight was triggering a 7.5% weight loss on compared to 8/14/25 which was 178 pounds. He had a recent hospital stay weight loss. The interdisciplinary team recommended to add med-pass (nutritional supplement) and fortified foods. The clinical record lacked documentation of weight or a care management note dated 10/26/25 through 11/1/25. A Dietary Note, dated 10/31/25 at 9:59 a.m., indicated Resident C's current weight was 103.6 pounds. He had a significant weight loss of 74.4 pounds which was 41.8% in 180 days. He was started on med-pass and mirtazapine (antidepressant for weight loss) 7.5 milligrams daily. He had dramatic weight fluctuations over the past 6 months and hospitalization. His weights were trending between 100 - 105 pounds. He was observed to be lying in bed and appeared in bed cachectic (condition causes significant weight loss and muscle loss) with global muscle and fat wasting. A care plan, dated 10/31/25, indicated Resident C had an unplanned/unexpected weight loss related to poor food intake and recent hospitalization. The interventions were to evaluate any weight loss; determine percentage lost and follow facility protocol for weight loss; give supplements as ordered; and to offer substitutes as requested. On 11/6/25 at 10:48 a.m., the Weights and Vitals Summary indicated Resident C weighed 104 pounds. A Care Management Note, dated 11/7/25 at 11:45 a.m., indicated Resident C required assistance to eat. His weight on 11/6/25 was 104 pounds which triggered a 10% weight loss in 180 days compared to 8/14/25 weight of 178 pounds. This was a loss of 74 pounds. His weight loss was attributed to recent illness and hospitalizations. His diet was regular with easy to chew texture and med pass three times a day. The interdisciplinary recommended weekly weights until stable. A Care Management Note, dated 11/14/25 at 8:18 a.m., indicated Resident C's weight, on 11/13/25, was 104 pounds which triggered a 10% weight loss in 180 days compared to 8/14/25 weight of 178 pounds. He had a recent hospitalization and returned with a readmission weight of 103.6 pounds. His weight was stable for 3 weeks. He received med pass 3 times a day. A Dietary Note, dated 11/14/25 at 1:48 p.m., indicated Resident C's current weight was 104 pounds. He had a significant weight loss of 74 pounds which was 41.6% in 180 days. He was on med-pass and mirtazapine 7.5 milligrams daily. He had dramatic weight fluctuations over the past 6 months and hospitalization. His weights were stable between 100 - 105 pounds. On 11/19/25 at 4:08 p.m., the Weights and Vitals Summary indicated Resident C weighed 105.1 pounds. A Care Management Note, dated 11/21/25 at 11:33 a.m., indicated Resident C's weight, on 11/19/25, was 105 pounds. His weight was stable since 9/28/25. The comparison weight of 165 pounds which was a loss of 59.9 pounds. He was on a regular mechanically altered diet, med pass three times a day, and mirtazapine as an appetite stimulant. His weight loss was from acute illness and hospitalization. The clinical record lacked documentation of weekly weight or care management note dated 11/23/25 through 11/29/25. The clinical record lacked documentation of weekly weight or care management note dated 11/30/25 through 12/6/25. On 12/1/25 at 1:41 a.m., the Weights and Vitals Summary indicated Resident C weighed 102 pounds. A Care Management Note, dated 12/12/25 at 1:45 p.m., indicated Resident C's weight was 102 pounds which triggered a 7.5% weight loss compared to the weight of 166.9 pounds on 9/3/25. This was a loss of 64.9 pounds. His weight loss was attributed to acute illness and hospitalizations. His weight loss had been stable since 9/28/25. He was on pureed diet and nectar thickened liquids. He returned from the hospital on [DATE]. During an interview on 12/18/25 at 11:25 a.m., Licensed Practical Nurse (LPN) 3 indicated Resident C had been sick quite a bit. She was unsure if he had weight loss. During an interview on 12/18/25 at 11:30 a.m., CNA 3 indicated Resident C required assistance with eating meals. During an interview on 12/18/25 at 1:10 p.m., the Director of Nursing (DON) indicated a new admission was weighed on the day of admission or the day after and then weekly for 4 weeks. The IDT met weekly for four weeks after admission, and if stable would discharge from the IDT monitoring. On 12/18/25 at 2:20 p.m., the DON provided a physician's order which indicated health shakes twice a day for weight loss. The order was entered into the electronic health record on 12/18/25 but dated for 9/30/25. On 12/18/25 at 3:29 p.m., the DON provided the facility policy, Resident at Risk [RAR] Policy dated 5/6/25 and indicated it was the policy currently being used by the facility. A review of the policy indicated, .1. The facility establishes a consistent method of weighting residents, verifying weights upon admission, monitoring weights over time to identify weight loss/gain, verifying weights when changes occur, determining interventions, and reassessing interventions when appropriate .2. Residents newly admitted to the facility are weighed weekly for the first 4 weeks after admission to establish baseline and stability. This citation relates to Intake 2650504. 3.1-46(a)(1)

Based on interview and record review, the facility failed to ensure a resident was supervised while riding on the facility transportation van during a scheduled doctor's appointment for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: Resident B's clinical record was reviewed on 8/18/25 at 10:48 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease and depression. A nursing progress note, dated 7/28/25 at 8:32 p.m., indicated the resident's family and physician were notified of an alleged incident. No new orders received. No signs or symptoms of acute distress noted at this time. The clinical record lacked documentation of the alleged incident. A Fall/Accident Interview Statement, dated 7/29/25, indicated on 7/28/25, a staff member took Resident B to a doctor's appointment in the facility transportation van. The staff member bought his wife lunch, took it to her at the hospital, and admitted ly left Resident B in the vehicle with the window rolled down. The staff member indicated he should not have left the resident unattended in the vehicle. During an interview on 8/18/25 at 10:35 a.m., the Administrator indicated the transportation driver drove Resident B to an appointment and on the way back decided to stop at a restaurant drive through and get lunch for himself, his wife, and the resident. He then stopped at the nearby hospital and exited the vehicle to take his wife lunch. The transportation van had air-conditioning, however, Resident B indicated he rolled down the window and turned the van off. After approximately 15 minutes, Resident B left the vehicle and went into the hospital to try and locate the drive. A security guard from the hospital met her, provided a wheelchair, and sat with her until the transportation driver returned. When the transportation driver returned, he asked Resident B not to say anything because he had bought her lunch. The Administrator indicated Resident B did not report the incident for over a week. During an interview on 8/18/25 at 11:20 a.m., the DON indicated she was not sure of the exact date the above incident occurred because Resident B did not report it for over a week. The resident had an appointment on 7/24/25 at 9:15 a.m. and she believed it happened on that date during lunchtime. The Weather Underground website at www.wunderground.com, indicated during the week of 7/24/25 through 7/28/25, the average high temperature was 90 degrees. Resident B was out of the facility and unavailable for interview during the survey period. On 8/18/25 at 10:49 a.m., the Administrator provided the policy titled, Transportation Coordination and Services with a revised date of 5/15/25, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Procedure: 3. The facility will ensure that safety and infection prevention procedures are followed in accordance to state and federal guidance .This citation relates to Complaint 2574607.3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the carpets were not worn and free of stains for 63 of 63 residents residing in the facility and failed to ensure a homelike environment for 2 of 16 residents reviewed for environment. (Hallway A, Hallway B, Hallway C, Hallway D, Resident 33 and Resident 16) Findings include: 1. On 2/24/25 at 11:00 a.m., during an initial tour, the carpet on Hallway A, Hallway B, Hallway C, and Hallway D were observed to be worn and to have multiple stains throughout. 2. On 2/26/25 at 10:02 a.m., a sign was observed to be on the wall in Resident 33's room which indicated to put dentures in denture cup before picking up meal tray or stray Kleenex. On 2/28/25 at 12:15 p.m., the above sign was observed to still be on the wall in Resident 33's room. 3. On 2/26/25 at 10:12 a.m., a sign was observed to be on the wall in Resident 16's room which indicated his turning schedule from 8 a.m. until 6 p.m. On 2/28/25 at 2:24 p.m., the above sign was observed to still be on the wall in Resident 16's room. During an interview on 2/28/25 at 12:30 p.m., the Director of Nursing (DON) indicated the hallway carpets were in need of being replaced and the signs in Resident 33 and Resident 16's rooms would need to come down because they listed private information meant for staff convenience only. On 2/28/25 at 1:50 p.m., the DON provided the facility's policy, Housekeeping with a reviewed date of 6/12/2024, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . The resident has a right to a safe, clean, comfortable and homelike environment . 3.1-19(f)

Based on record review and interview, the facility failed to ensure the Discharge MDS (Minimum Data Set) assessment was completed within allotted timeframe for 1 of 4 residents reviewed for resident assessment. (Resident 48) Finding includes: On 2/27/25 at 2:07 p.m., Resident 48's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, anxiety, and major depressive disorder. The MDS assessments indicated there was no Discharge MDS assessment completed. The last MDS assessment completed was the Quarterly MDS Assessment, on 9/10/24. A progress note, dated 10/1/24, indicated the resident was discharged to another facility. A review of the Resident Assessment Instrument (RAI),Version 3.0 User's Manual, 10/2023, on 2/28/25 at 10:00 a.m., indicated the Discharge MDS assessment must be completed within 14 calendar days after the discharge date and must be submitted within 14 days after the MDS completion date. During an interview with the MDS nurse on 2/28/25 at 10:40 a.m., she indicated the Discharge MDS assessment was not completed upon discharge of the resident and should have been completed within 14 calendar days of the discharge date . She indicated the facility did not have a resident assessment policy and they used the RAI tool criteria for timeframe of completion.

Based on record review and interview, the facility failed to ensure an accurate assessment of active diagnoses for 2 of 4 residents reviewed for resident assessment. (Resident 20, Resident 57) Findings include: 1. On 2/26/25 at 1:25 p.m., Resident 20's clinical record was reviewed. The diagnoses included, but were not limited to, Parkinson's disease (a chronic brain disorder that causes movement problems), dementia, and benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland). The Quarterly MDS (Minimum Data Set) assessment, dated 2/10/25, was not marked for a diagnosis of UTI (urinary tract infection) in the last 30 days. The resident's laboratory results, dated 1/23/25, indicated the resident had Aerococcus urinae (Gram-positive bacterium associated with urinary tract infections) present on a urine culture. The resident's MAR (Medication Administration Record), indicated the resident received Ceftriaxone Sodium (a medication used to treat bacterial infections), 1 gram intramuscularly one time only for UTI on 1/24/25. A review of the Resident Assessment Instrument (RAI),Version 3.0 User's Manual, 10/2023, on 2/26/25 at 2:00 p.m., indicated for Item I2300 Urinary tract infection (UTI), the UTI has a look-back period of 30 days for active disease instead of 7 days. During an interview with the MDS nurse on 2/28/25 at 2:00 p.m., she indicated the resident was diagnosed with a UTI on 1/23/25. The MDS nurse indicated the Quarterly MDS assessment, dated 2/10/25, was marked no for a diagnosis of UTI and it should have been marked yes. The MDS nurse indicated the facility did not have a MDS policy and they utilized the RAI tool to complete MDS assessments. 2. On 2/27/25 at 10:02 a.m., Resident 57's clinical record was reviewed. The diagnoses included, but were not limited to, bipolar disorder (a mental illness that involves extreme shifts in mood) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Admission MDS assessment, dated 12/20/24, indicated bipolar disorder was not marked as an active diagnosis. The resident's MAR indicated, the resident had an active order on 12/16/24 for Depakote Delayed Release Tablet (medication to treat seizures and bipolar disorder) 250 mg (milligrams), for bipolar disorder. A review of the RAI, Version 3.0 User's Manual, 10/2023, on 2/27/25 at 11:00 a.m., indicated for section I5900, Bipolar Disease, Diagnosis status: Active or Inactive is a 7-day look-back period. During an interview with the MDS nurse on 2/28/25 at 2:00 p.m., she indicated the resident had an active diagnosis of bipolar disease on 12/16/24. The MDS nurse indicated the Admission MDS assessment, dated 12/20/24, was marked no for diagnosis of bipolar disease and it should have been marked yes. The MDS nurse indicated the facility did not have a MDS policy and they utilized the RAI tool to complete MDS assessments. 3.1-31(d)

Based on interview and record review, the facility failed to develop a care plan for a resident's preference for 2 of 2 residents reviewed for choices. (Resident 24, Resident 49) Findings include: 1. During an interview on 2/24/25 at 11:52 a.m., Resident 24 indicated her shower days were on Tuesday and Friday. On 2/27/25 at 10:52 a.m., Resident 24's clinical record was reviewed. The diagnoses included, but were not limited to, low back pain and muscle weakness. The Resident ADL (Activities of Daily Living) Preferences, dated 12/30/24, indicated Resident 24 preferred showers on Tuesday and Friday. The form lacked documentation of preference updated on the care plan. The Admission MDS (Minimum Data Set) assessment, dated 1/3/25, indicated it was very important for Resident 24 to choose between a tub bath, bed bath, and sponge bath. During an interview on 2/27/25 at 11:28 a.m., the MDS nurse indicated Resident 24 should have had a preference care plan after the Admission MDS assessment. During an interview on 2/27/25 1:30 p.m., the Director of Nursing (DON) indicated Resident 24's clinical record lacked documentation of a care plan for preferences. 2. During an interview on 2/24/25 at 11:57 a.m., Resident 49 indicated her shower days were on Tuesday and Friday. On 2/27/25 at 11:25 a.m., Resident 49's clinical record was reviewed. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and muscle weakness. The Resident ADL Preferences, dated 1/2/25, indicated Resident 49 had no preference on what shower days, but preferred them on evening shift. The form lacked documentation of preference updated on the care plan. The Admission MDS assessment, dated 1/7/25, indicated it was not very important for Resident 49 to choose between a tub bath, bed bath, and sponge bath. During an interview on 2/27/25 at 11:28 a.m., the MDS nurse indicated Resident 49 should have had a preference care plan after the Admission MDS assessment. During an interview on 2/27/25 1:30 p.m., the Director of Nursing (DON) indicated Resident 49's clinical record lacked documentation of a care plan for preferences. On 2/28/25 at 3:15 p.m., the DON provided the facility's policy, Comprehensive Care Plans and Revisions, dated 9/11/24, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . (i). Developed within 7 days after completion of the comprehensive assessment . 3.1-35(a)

Based on observation, interview, and record review, the facility failed to label the Over the Counter (OTC) medications with resident's name for 2 of 2 medications cart observed. (B Wing Back Hall, B Wing Front Hall) Findings include: On 3/25/24 at 10:20 a.m., the back hall B wing medication cart was observed to have OTC bottles of calcium tablets, probiotic, fish oil, vitamin B 1, and sodium chloride with no resident's name. At that time, the Director of Nursing (DON) indicated the OTC medication bottles were to have resident name on them. On 3/25/24 at 11:09 a.m., the front hall B wing medication cart was observed to have an OTC bottles of acetaminophen (pain reliever), loperamide (antidiarrheal), and milk of magnesia with no resident's name. At that time, Registered Nurse (RN) 1 indicated the OTC bottles lacked residents name. On 3/25/24 at 2:34 p.m., the DON provided the facility's policy, House Stock Items, revision date of 1/1/22 and indicated it was the policy being used by the facility. A review of the policy lacked documentation of labeling OTC medication bottles. 3.1-25(l)(1)

Based on observation, interview, and record review, the facility failed to ensure food was served in a palatable and attractive manner for 1 of 1 test tray obtained from a hall cart. (Resident 43, Resident 5, Resident 23, Resident 13, Resident 14, Resident 33, Resident 44, Resident 35, Resident 30, Resident 24, Resident 7, Resident 25) Findings include: On 3/20/24 at 9:59 a.m., Resident 43 indicated the food did not taste good and the food was often served to her room at a cold temperature. On 3/20/24 at 10:52 a.m., Resident 5 indicated the food did not taste good. On 3/21/24 at 10:49 a.m., Resident 23 indicated the food did not taste good. On 3/21/24 at 11:13 a.m., Resident 13 indicated the food was not good and was served at a cold temperature when they delivered to the room. On 3/21/24 at 11:36 a.m., Resident 14 indicated the meat was tough. On 3/21/24 at 11:41 a.m., Resident 33 indicated the meat was tough. On 3/25/24 at 10:45 a.m., a resident council meeting was held. Resident 44, Resident 35, Resident 30, Resident 24, Resident 7, and Resident 25 were all in attendance. When asked about food palatability, all residents began to shake their heads No, which indicated they did not like the taste of the food. Resident 24 indicated the food was not good and he suggested the kitchen staff needed new recipes and the menus should be changed around to offer more variety. Resident 25 indicated the facility would often serve fish multiple times a week. Resident 7 indicated the meat was very tough. On 3/25/24 at 11:23 a.m., a test tray was obtained from the B hall meal cart. The meal consisted of beef stew poured over a biscuit, cubed potatoes, a side salad, and an apple crisp dessert. The appearance of the meal tray was not immediately identifiable nor attractive to sight. The beef stew meat was gristly making it difficult to cut and chew. The potatoes were hard in texture which indicated they were undercooked. The side salad contained brown, wet, and wilted lettuce, which indicated it was not fresh. The apple crisp had very little flavor and the apples had a mushy texture which indicated they were not fresh. The following resident interviews took place after the test tray was obtained: - On 3/25/24 at 11:33 a.m., Resident 14 indicated the beef stew meat was very tough to cut up. He was able to cut it up into a bunch of pieces and was able to eat it. He further indicated the meat would be easy for someone to choke on. - On 3/25/24 at 11:34 a.m., Resident 33 indicated he sent his food back because it was too tough to eat. - On 3/25/24 at 11:45 a.m., Resident 43 indicated the beef in the beef stew was tough and she could not chew it. - On 3/25/24 at 12:38 p.m., Resident 5 indicated the beef in the beef stuff was tough. - On 3/25/24 at 4:24 p.m., Resident 13 indicated he didn't eat any of the lunch because it looked gross and would not even try to eat it, so he sent it back. Resident 12 indicated he had never seen meatloaf on a biscuit before which was different. He further indicated the meat was too tough to eat, so he ate around it. During an interview on 3/25/24 at 11:35 a.m., the Administrator attempted to cut up the beef stew meet with a fork and indicated the meat on the test tray was difficult to cut and therefore chew. On 3/25/24 at 4:44 p.m., the Director of Nursing provided the facility policy, Resident Satisfaction with Food and Dining, revised on 4/25/23, and indicated it was the current policy being used. A review of the policy indicated, . Each resident receives and the facility provides - Food prepared by methods that conserve . flavor, and appearance . Food and drink that is palatable, attractive . 3.1-21(a)(1) 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to provide a homelike environment free of damage and disrepair for of 7 of 9 residents reviewed for environmental concerns (Resident 19, Resident 23, Resident 14, Resident 33, Resident 28, Resident 36, and Resident 43). Findings include: 1. On 3/20/24 at 10:00 a.m., the light in Resident 43's shower was observed to not function. During an interview on 3/20/24 at 10:01 a.m., Resident 43 indicated the shower was dark and would like to have a light in the shower that worked. 2. On 3/20/24 at 10:05 a.m., an electrical outlet sized hole was observed in the wall behind Resident 36's bed. 3. On 3/20/24 at 11:33 a.m., Resident 19's call light pull was observed to be approximately 1 inch long and difficult to grasp. There were holes in the netting of the privacy curtains observed in the room. 4. On 3/21/24 at 10:48 a.m., the paint on the wall at the head of Resident 23's bed was observed to be scraped, revealing the bare drywall. 5. On 3/21/24 at 11:04 a.m., the door of Resident 28's closet was observed to be off the guide rails. The wall behind the bed was observed to be dirty and scuffed. 6. On 3/21/24 at 11:38 a.m., Resident 14 and Resident 33's room was observed to be missing baseboards, revealing scraped and scuffed drywall. During an interview on 3/25/24 at 12:58 p.m., the Physical Plant Director indicated the aforementioned environmental concerns existed and required repair. On 3/25/24 at 2:55 p.m., the facility Administrator provided the Resident Rights, undated, and indicated these were the Resident Rights currently utilized by the facility. A review of the Resident Rights indicated, .the resident has the right to a safe, clean, comfortable, and homelike environment . 3.1-19(f)

Based on interview and record review, the facility failed to ensure accurate reconciliation and accounting for narcotic medications was implemented for 1 of 1 residents reviewed. (Resident 13) Findings include: Resident 13's clinical record was reviewed on 3/25/24 at 10:35 a.m. The diagnoses included, but were not limited to, depression and anxiety. Physician orders included, but was not limited to: Clonazepam (anti-anxiety medication) oral tablet 0.5 mg (milligram) give 0.25 mg by mouth two times a day for anxiety . The Controlled Substance Record for Resident 13's clonazepam was reviewed on 3/25/24 at 12:00 p.m. The record indicated 60 tablets were delivered on 3/13/24 at 9:26 a.m. The count indicated the following: - On 3/16/24 at 9:00 a.m., 1 tablet was given making the count 59. - On 3/16/24 at 8:00 p.m., 1 tablet was given making the count 58. - On 3/17/24 at 9:00 a.m., 1 tablet was given making the count 57. - On 3/17/24 at 8:00 p.m., 1 tablet was given making the count 56. - On 3/18/24 at 8:00 a.m., 1 tablet was given making the count 55. - On 3/18/24 at 8:00 p.m., 1 tablet was given making the count 54. - On 3/19/24 at 8:00 a.m., 1 tablet was given making the count 53. On 3/19/24 at 7:00 p.m., during the narcotic count for clonazepam for Resident 13, the count indicated 51 tablets were remaining which indicated 2 tablets were unaccounted for. During an interview on 3/20/24 at 9:51 a.m., the Administrator indicated the clonazepam count for Resident 13 was off on 3/19/24 at the 7:00 p.m. shift change. The nurse had believed she counted wrong because there were usually 6 tablets in a packet and she counted for 6 however, there were only 4 tablets in the packet after all. During an interview on 3/25/24 at 11:04 a.m., Registered Nurse 1 indicated she counted the missing clonazepam for Resident 13 however she believed she had counted wrong. She was not sure what happened exactly. She only gave 1 clonazepam tablet to the resident during her shift and no one else had access to her cart. 3.1-25(e)(2)

Based on observation, interview, and record review, the facility failed to ensure a urinary drainage bag and tubing was positioned off the floor for 1 of 1 residents reviewed for urinary catheter. (Resident 52) Findings include: On 3/19/24 at 12:39 p.m., Resident 52 was observed to be sitting in his wheelchair in the dining room. The urinary drainage tubing was observed to be touching the floor. On 3/21/24 at 1:17 p.m., Resident 52 was observed to be rolling around the hallway in his wheelchair. The urinary drainage tubing was observed to be dragging on the floor. On 3/21/24 at 3:06 p.m., Resident 52 was observed to be sitting in his wheelchair in his room. The urinary drainage tubing was observed to be touching the floor. On 3/22/24 at 12:41 p.m., Resident 52 was observed to be sitting in his wheelchair in his room. The urinary drainage bag and tubing were observed to be touching the floor. On 3/25/24 at 10:26 a.m., Resident 52 was observed to be rolling around the hallway in his wheelchair. The urinary drainage tubing was observed to be dragging on the floor. On 3/25/24 at 1:32 p.m., Resident 52 was observed to be rolling around the hallway in his wheelchair. The urinary drainage tubing was observed to be dragging on the floor. On 3/25/24 at 4:34 p.m., Resident 52 was observed to be sitting in his wheelchair at the end of the hall. The urinary drainage tubing was observed to be touching the floor. Resident 52's clinical record was reviewed on 3/22/24 at 10:20 a.m. The diagnosis included, but was not limited to, benign prostatic hyperpiesia with lower urinary tract symptoms. During an interview on 3/25/24 at 1:19 p.m., Certified Nursing Assistant (CNA) 1 indicated the urinary drainage bag and tubing should be positioned off the floor. During an interview on 3/25/24 at 4:35 p.m., CNA 2 indicated the urinary drainage bag tubing for Resident 52 was currently touching the floor. On 3/25/24 at 2:34 p.m., the Director of Nursing provided the facility's policy,Indwelling Urinary Catheter [Foley] Management with a reviewed date of 8/24/23, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . General Urinary Catheter Maintenance Guidelines . 2. Maintain unobstructed urine flow . b. keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor . The policy did not mention the urinary drainage bag tubing. 3.1-18(b)(1)

Based on observation and interview, the facility failed to ensure the staff posting information sheets were posted in a prominent place readily accessible to residents and visitors, presented in a clear and readable format, and included actual hours worked for 4 of 4 staff posting sheets reviewed. Finding include: On 3/25/24 at 2:50 p.m., the staff posting information sheet was located behind the nurses' station among other posted papers. The paper was not easily located nor identifiable as it was posted in among past and future staff posting sheets. The posted sheets for the dates of 3/22/24, 3/23/24, 3/24/25, and 3/25/24 did not contain the actual hours worked or the shift times. During an interview on 3/25/24 at 2:55 p.m., the Administrator indicated the staff posting sheets had always been posted behind the nurses station and the actual hours worked were updated in the computer system the next day. She indicated the posted staffing sheets did not contain the actual hours worked or the specific shift times. On 3/25/24 at 4:44 p.m., the Director of Nursing provided the policy, Staffing, revised on 8/7/23, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . The facility must post the following information on a daily basis . actual hours worked by . staff directly responsible for resident care per shift . 2. The facility posts daily staffing information in a clear readable format in a prominent place that is easily accessible to residents and visitors at any time .

Based on interview and record review, the facility failed to ensure a resident was free from a significant medication error for 1 of 3 residents reviewed. A resident received the wrong dose of fast acting insulin. (Resident B, Resident C) Finding includes: During an interview on 7/21/23 at 11:03 a.m., Resident B indicated he received too much insulin from LPN 1 (Licensed Practical Nurse) a few weeks ago. LPN 1 informed Resident B he had administered 30 units of insulin. LPN 1 also told Resident B he administered the wrong insulin. During an interview on 7/21 23 at 1:18 p.m., LPN 1 indicated on 6/29/23 he administered Resident C's fast acting insulin dose to Resident B by mistake. LPN 1 walked past Resident C's room and into Resident B's room by mistake because the power went out during a storm. LPN 1 administered sugary drinks and snacks to help keep Resident B's blood sugar from dropping. The insulin LPN 1 administered to Resident B was from Resident C's insulin pen that was already opened and used for Resident C. LPN 1 took the insulin pen back to the medication cart, removed the needle, replaced the cap, and placed the pen back in the medication cart. The clinical record for Resident B was reviewed on 7/21/23 at 10:31 a.m. The diagnoses included, but were not limited to, diabetes and long term use of insulin. A quarterly MDS (Minimum Data Set) assessment, dated 6/26/23, indicated Resident B was cognitively intact. The Physician's orders included, but were not limited to: - Insulin lispro solution (fast acting insulin that should be administered by injection within 15 minutes before meals or right after eating a meal) 100 units/ml (milliliters). Inject as per sliding scale: if blood sugar is 141-180 give 2 units; 181-220 give 4 units; 221-260 give 6 units; 261-300 give 8 units; 301-340 give 10 units; 341-380 12 units; 381-420 give 14 units; 421-460 give 16 units; 461-482 give 18 units. Administer insulin subcutaneously, before meals, and call the physician if blood sugar is 482 or greater, initiated 3/23/23. The June 2023 Medication Administration Record indicated: On 6/29/23 at 4:30 p.m., Resident B's blood sugar was 234. Resident B should have received 6 units of insulin lispro. A progress note, dated 6/29/23 at 9:12 p.m., indicated Resident B's blood sugar results were reported to the Nurse Practitioner for the evening of 6/29/23. The blood sugar results at 7:00 p.m., 101, at 8:00 p.m., 96, at 9:00 p.m., 62, and at 9:30 p.m., 116. The clinical record for Resident C was reviewed on 7/21/23 at 10:19 a.m. The diagnoses included, but were not limited to, diabetes and cancer. A quarterly MDS assessment, dated 4/21/23, indicated Resident C was cognitively intact. The Physician's orders included, but were not limited to: - Insulin aspart solution (fast acting insulin that should be administered by injection within 10 minutes before eating a meal) pen-injector 100 units/ml. Inject 30 units subcutaneously before meals, initiated 10/27/22. An incident report, dated 6/29/23 at 5:02 p.m., indicated Resident B was given insulin dose in error. Resident B was given sugary snacks to counteract effects. The Director of Nursing educated LPN 1 on 6 rights. On 7/20/23 at 2:30 p.m., the Director of Nursing provided a copy of a facility document, titled Insulin Administration Competency Checklist, dated 6/29/23, and indicated this was the competency that was reviewed with LPN 1. A review of the competency indicated ask permission to enter the resident's room and identify the resident. This Federal Tag relates to Complaint IN00413267. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure infection control practices were followed for 1 of 3 residents reviewed. A resident was administered another resident's used insulin pen. (Resident B, Resident C) Finding includes: During an interview on 7/21/23 at 11:03 a.m., Resident B indicated LPN 1 told Resident B he had administered the wrong insulin. During an interview on 7/21 23 at 1:18 p.m., LPN 1 indicated on 6/29/23, he administered Resident C's fast acting insulin dose pen to Resident B by mistake. The insulin pen LPN 1 administered to Resident B was from Resident C's insulin pen that was already opened and used for Resident C. An incident report, dated 6/29/23 at 5:02 p.m., indicated Resident B was given insulin dose in error. Resident B was given sugary snacks to counteract effects. The Director of Nursing educated LPN 1 on 6 rights. On 7/26/23 at 9:30 p.m., the Regional Director of Nursing provided a copy of a facility policy, titled Guidance for Using Insulin Products, dated 2021, and indicated this was the current policy used by the facility. A review of the policy indicated pens and needles should never be used between residents. This Federal Tag relates to Complaint IN00413267. 3.1-18(b)(1)

Based on interview and record review, the facility failed ensure a resident's right to be free from sexual abuse for 1 of 3 residents reviewed for sexual abuse. A cognitively intact male resident placed his hands down in the pants of a cognitively impaired female resident. (Resident C, Resident D) Finding includes: During an interview on 8/25/22 at 2:19 p.m., the Regional Director of Nursing indicated that CNA 1 reported Resident C had his hand in Resident D's pants. Resident D was cognitively impaired and would not have been able to consent. During an interview on 8/25/22 at 2:47 p.m., the SSD (Social Service Director) indicated on 8/19/22 at approximately 6:00 p.m., a CNA reported she saw Resident C with his hand down Resident D's pants. Resident C was cognitively intact, but Resident D was not. The clinical record for Resident C was reviewed on 8/26/22 at 8:19 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 6/3/22, indicated Resident C was cognitively intact, had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) on 1-3 days during the look back period. A care plan, dated 8/19/22 and current through 12/1/22, indicated Resident C with occasional inappropriate statements of a sexual nature to associates, and an incident of sexual nature involving a resident. The interventions, all dated 8/19/22, included, but were not limited to, placed on 1:1 staff supervision and administer medications as ordered that are prescribed to decrease inappropriate sexual behaviors. A psychoactive medication consent form, dated 6/4/22, indicated Resident C was taking [MEDICATION(S)] for sexual behaviors. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (an anti-depressant medication) 10 mg (milligrams), every day for sexual disorder, initiated 6/1/22. A Psychiatry Progress note, dated 8/8/22, indicated sexual dysfunction stable, continue [MEDICATION(S)] ([MEDICATION(S)]) 10 mg daily as ordered 5/31/22. Resident has utilized this in past with effectiveness. Facility to monitor and document incidence of inappropriate behaviors. Progress notes included, but were not limited to: On 8/19/22 at 9:23 p.m., Resident C was noted by CNA 1 to have his hand in Resident D's pants earlier this shift. Resident C's wrist was holding Resident D's gown up. When CNA 1 noted the incident, she asked Resident C what he was doing, and he stated Nothing. CNA 1 could not tell if his hand was in Resident D's brief. She could only see that it was in her pajama pants. On 8/20/22 at 2:40 a.m., received order to send Resident C to neuro-psych hospital, related to incident this day, sexual behavior noted around 6:00 p.m. on 8/19/22, Resident C has been one on one since incident. The clinical record for Resident D was reviewed on 8/26/22 at 9:16 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 6/29/22, indicated Resident D had severe cognitive impairment. A care plan, dated 3/9/21 and current through 12/14/22, indicated the resident had impaired cognitive ability/impaired thought processes related to Alzheimer's dementia. The interventions included, but were not limited to, allow extra time for resident to respond to questions and instructions, and administer medications as ordered. The Progress Notes included, but were not limited to: On 8/19/22 at 9:39 p.m., Resident C noted by CNA 1 to have his hand in Resident D's pants earlier this shift. CNA 1 did not know if Resident C's hand was inside the brief. Resident D did not appear to be in any distress at that time. CNA 1 asked Resident C what he was doing and Resident C said Nothing. CNA 1 took Resident D by the hand and walked her directly to the nurse on duty. On 8/19/22 at 10:22 p.m., the SSD observed Resident D sitting at nurse's station with nurse after an incident occurred earlier today when CNA 1 reported that Resident C was sexually inappropriate with Resident D. During an interview 8/26/22 at 9:41 a.m., CNA 1 indicated she was walking on the education hall toward the nurse's station. She could hear Resident D making weird noises, but not talking. She saw Resident C's left arm up, his hand was in her pants and her gown was resting on his left wrist. Resident C's left arm was moving back and forth very quickly. She rushed to Resident C and Resident D and asked Resident C what he was doing. Resident C jumped and pulled his hand out of Resident D's pants. Resident C turned red, became very agitated and said nothing. Then he turned his head. This took place on 8/19/22 at approximately 5:53 p.m. On 8/26/22 at 12:00 p.m., the facility was unable to provide a policy on sexual abuse. 3.1-27(a)(1)

Based on interview and record review, the facility failed to implement appropriate interventions and monitoring for substance use disorder for 1 of 1 residents reviewed for substance use disorder. A resident with a history of [MEDICATION(S)] abuse and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in the resident requiring 2 doses of [MEDICATION(S)] (a medication used to treat an overdose of narcotics in an emergency situation) administration after he became unresponsive on 6/21/22. The resident was found with methamphetamines again on 8/9/22. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 6/15/22 at approximately 8:00 a.m., when the facility failed to implement interventions and monitoring for a resident with a history of [MEDICATION(S)] abuse and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 8/12/22 at 11:40 a.m. The Immediate Jeopardy was removed on 8/12/22 at 5:00 p.m., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: During an interview on 8/11/22 at 8:55 a.m., LPN 1 (Licensed Practical Nurse) indicated, Resident B had been on 1 on 1 supervision because he was caught possessing and possibly using illegal drugs. During an interview on 8/11/22 at 9:23 a.m., Resident B indicated he had used methamphetamines before being admitted to the facility and admitted methamphetamines had been found in his room two times since his admission to the facility. The clinical record for Resident B was reviewed, on 8/11/22 at 9:30 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 8/1/22, indicated Resident B was cognitively intact. A care plan, dated 8/9/22 and current through 10/30/22, indicated resident visitor bringing in what is believed to be illegal substances. The interventions included, but were not limited to, facility contacted police on 8/9/22 removal of substances by (Name of) Police Department. The hospital inpatient discharge instructions, dated 6/2/22, indicated Resident B was diagnosed with [MEDICATION(S)] abuse and polysubstance abuse. An undated, handwritten nurse's report from the hospital to the facility indicated Resident B was alert with behaviors, was homeless, tested positive for methamphetamines upon admission to the hospital, and family and friends would bring illegal drugs. The Progress Notes included, but were not limited to: On 6/15/22 at 7:46 a.m., at approximately 7:00 a.m., Resident B had reported a man came into Resident B's room and was there for less than a minute and the man gave Resident B a pack of cigarettes. The cigarette box felt empty to the nurse and when the nurse looked inside the box it contained a small bag with a white substance tied up in the box. Resident B was hollering out for staff to give the drugs back because that was his livelihood and that was how he supplemented his income. On 6/15/22 at 5:15 p.m., police in this shift and talked with Resident B about substance that was found on him. The officer believed the substance to be crystal [MEDICATION(S)] and was taking it to the station to test it. On 6/21/22 at 12:23 p.m., Resident B went unresponsive while working with therapy. The NP (Nurse Practitioner) was notified, and gave new orders to administer [MEDICATION(S)] (a medication used to treat overdose from narcotics in an emergency situation) and to repeat dose in 15 minutes if Resident B was still unresponsive. First dose administered at 9:30 a.m. and second dose administered at 9:45 a.m., Resident B was still not responsive even with sternal rub. Contacted Resident B's daughter to inform her of what was going on and his daughter requested to have Resident B sent to the emergency room . Called 911 to send Resident B to the emergency room . When the emergency medical team arrived, Resident B became responsive and started talking. Resident B was able to answer questions appropriately and refused to go to the hospital. On 7/17/22 at 6:19 a.m., while this nurse entered residents room to check morning blood sugar found residents mouth open and one pill was laying on his tongue in two pieces. This nurse took it off with resident's permission. Noted that resident has taken [MEDICATION(S)] (a narcotic pain medication) 5 mg (milligrams)/325 mg from his own on hand supply. Resident does not have [MEDICATION(S)] ordered, DON notified. On 7/17/22 at 6:41 a.m., resident was asked from where he obtained [MEDICATION(S)] 5 mg/325 mg. Resident refused to answer. Will notify social services. Oncoming nurse is aware. No social service follow up documented. On 8/9/22 at 9:07 p.m., when the CNA (Certified Nursing Aide) went into Resident B's room to do a bed check, Resident B was asleep with a straw in his hand and a metal vial with white powder residue was found lying on the floor, next to his bed. Resident B did not have any visitors that evening. On 8/10/22 at 3:00 a.m., staff were unable to locate the straw in Resident B's room. This nurse phoned police department and an officer came to facility and took the metal vial with the white residue into his possession which did test positive for crystal [MEDICATION(S)]. A behavior monitoring log, dated August 2022, indicated Resident B was being monitored for agitation and danger to self. The interventions included, but were not limited to, 1 on 1 supervision, redirect, monitor visitors for suspicious behavior, and report any non-prescribed/illegal drug use. Resident B did not have any behaviors on the following night shifts: 8/3/22, 8/4/22, 8/5/22, 8/6/22, 8/7/22, 8/9/22, 8/10/22, and 8/11/22. The behavior monitoring log lacked documentation for day and evening shifts for those days. During an interview on 8/11/22 at 9:58 a.m., the Director of Nursing indicated Resident B was found with methamphetamines on 8/9/22 at approximately 9:00 p.m., RN 1 (Registered Nurse) found a metal vial lying next to Resident B's bed. The metal vial had a white substance residue in it. Resident B was asleep with a short straw in his hand. A staff member called the police, and the police officer tested the substance and it did test positive for methamphetamines. The staff monitored Resident B through the night and started 1 on 1 observation with a staff member the next morning of 8/10/22. The DON indicated there was another time when Resident B was found with a white substance in a cigarette pack back in June. At that time, the police department came but did not test the substance at the facility. The officer indicated he was going to return to the police station and test the substance there. The facility staff were never made aware of what the white substance was. During an interview on 8/11/22 at 1:58 p.m., The Director of Nursing indicated the facility staff did not call the police department to follow up on the results of the testing of the white substance. She didn't think the facility needed to call the police to follow up because if the substance were an illegal drug the police would have notified the facility. She was aware of Resident B refusing his medications yesterday, but that was the only behavior she was aware of for Resident B. During an interview on 8/12/22 at 8:43 a.m., an officer from the local police department indicated the white substance that was found in a cigarette pack on 6/15/22 did test positive for methamphetamines. During an interview on 8/12/22 at 9:59 a.m., RN 1 indicated she was the nurse that worked with Resident B on 8/9/22. The CNA found a vial on the floor in Resident B's room, next to his bed. The vial had a white powder residue. RN 1 assessed the resident and he was okay. RN 1 indicated she notified the DON and Administrator via text message. She was instructed via text message, that the Nurse Practitioner was still in the facility so she might want to ask her if she wanted to give any orders such as [MEDICATION(S)]. The Administrator said she wasn't sure if the facility could do anything since the vial was empty, and to monitor Resident B, notify his daughter, and wanted to know if he had a visitors. During an interview on 8/12/22 at 10:21 a.m., RN 2 indicated Resident B was unresponsive during her shift back in June, she tried a sternal rub on Resident B, and he wouldn't come back around. The DON called the Nurse Practitioner, and the Nurse Practitioner gave orders to administer [MEDICATION(S)]. RN 2 administered the first dose and 15 minutes later the DON administered the second dose. RN 2 indicated the reason why they used [MEDICATION(S)] was because of Resident B's drug abuse history, and he was found with a white substance previously in the facility. Before Resident B went unresponsive, he was not making any sense nor acting like himself. During an interview on 8/14/22 at 8:42 a.m., the SSD (Social Service Designee) indicated that she had been notified that Resident B had a [MEDICATION(S)] pill in his mouth. She notified the DON and the DON indicated the DON would take care of it. The DON indicated she did not want the SSD involved. The SSD indicated that was why there was no social service follow-up to the incident with Resident B having a [MEDICATION(S)] pill that was not prescribed to him. On 8/11/22 at 10:00 a.m., the DON provided a copy of a facility policy, titled Behavior Health Management, dated 5/9/22, and indicated this was the current policy used by the facility. A review of the policy indicated The facility must provide the necessary behavioral health care and services which include ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's . safety. On 8/12/22 at 8:55 a.m., the DON provided the Facility Assessment, revised 7/18/22. The Facility Assessment indicated the facility was unable to provide care and services for residents with drug use or abuse (alcohol dependence/substance dependence). The Immediate Jeopardy, that began on 6/15/22 was removed on 8/12/22 when the facility inserviced the facility staff on substance use disorders, interventions, monitoring, and care, but the noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This Federal tag relates to Complaint IN 006. 3.1-37(a)

Based on interview and record review, the facility failed to ensure antibiotic peak and trough levels were implemented to adequately monitor a high risk medication prescribed to a resident which resulted in a hospitalization for [MEDICATION NAME] poisoning and an acute kidney injury for 1 of 3 residents reviewed for intravenous (IV) antibiotic medication use (Resident B). Findings include: On 4/18/19 at 11:00 a.m., Resident B's closed clinical record was reviewed. [DIAGNOSES REDACTED]. A review of Resident B's March, 2019, physician's orders [REDACTED]. -On 1/29/19 the resident was ordered [MEDICATION NAME] (an antibiotic medication) 2 grams IV every 12 hours for 38 days, for left hip infection. -On 1/29/19, the resident was ordered [MEDICATION NAME] (an antibiotic medication) 1500 milligrams IV every 24 hours for 38 days, for left hip infection. A review of Resident B's February, 2019, Medication Administration Record [REDACTED]. A review of Resident B's laboratory results indicated the following: -On 1/31/19 at 6:32 a.m., the resident's GFR (glomerular filtration rate. A test used to check how well the kidneys are working.) was 73. A range of 60-89 indicated mildly decreased kidney functioning. -On 2/5/18 at 7:00 a.m., the resident's GFR was 56. A range of 45-59 indicated mildly to moderately decreased kidney functioning. -On 2/12/19 at 4:12 a.m., the resident's GFR was 52. A range of 45-59 indicated mildly to moderately decreased kidney functioning. -On 2/26/19 at 4:21 a.m., the resident GFR was 40. A range of 30-44 indicated moderately to severely decreased kidney functioning. Resident B's clinical record lacked documentation of having monitored a peak and trough for the [MEDICATION NAME]. The trough level is the lowest concentration of the drug in the bloodstream and peak level is the highest concentration of a drug in the bloodstream. A review of the Wolters Kluwer Nursing (YEAR) Drug Handbook, 36th edition, copyright (YEAR), Nursing Consideration included: Patients with renal (kidney) dysfunction need dosage adjustment. Monitor blood levels to adjust I.V. dosage requirements . Resident B was admitted to the hospital on [DATE], due to a decline in health status. A hospital Nephrology Staff Consult report, dated 3/4/19, indicated the following, [MEDICATION NAME] (level) 44.1 (critical high (normal range 10.0-15.0)) . Assessment/Plan: 1. AKI (acute kidney injury) due to #2 ([MEDICATION NAME] poisoning) and [MEDICAL CONDITION] (low blood pressure) . 2. [MEDICATION NAME] poisoning. 3. Metabolic acidosis (when the kidneys are not removing enough acid from the body) from AKI . 4. [DIAGNOSES REDACTED] (low potassium level) . 5. [MEDICAL CONDITION] (low sodium level) . During an interview, on 4/17/19 at 1:30 p.m., the Director of Nursing indicated Resident B was admitted to the nursing facility late on a Friday evening and had not been admitted with orders for peak and troughs to be drawn for her IV [MEDICATION NAME]. An order was not obtained and [MEDICATION NAME] peak and troughs had not been drawn. The resident was sent out (on 3/3/18) when her nurse found her unresponsive. During an interview, on 4/18/19 at 12:15 p.m., the Medical Doctor indicated the resident was admitted , on 1/29/19, from the hospital with orders for IV [MEDICATION NAME]. It was important to monitor [MEDICATION NAME] levels, peak or trough levels, as [MEDICATION NAME] is a very strong antibiotic. On 4/18/19 at 1:12 p.m., the Director of Nursing provided the facility policy, Medications Dosed by Lab Values, undated, and indicated it was the policy currently being used. A review of the policy indicated, Always check the lab book and this flow sheet before giving a dose of [MEDICATION NAME] to determine if any Peak and Trough is needed and has been completed . 3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure they developed and implemented a policy and procedure to effectively evaluate and establish parameters for the administration of [MEDICATION NAME], which included monitoring labs and communicating abnormal lab results related to [MEDICATION NAME] therapy to the attending physician, for 1 of 3 residents reviewed for IV medications, in that a resident was given IV [MEDICATION NAME] (antibiotic), after lab results showed he had critical levels of the medication and pharmacy recommended the medication be held, resulting in the resident experiencing acute kidney injury most likely secondary to [MEDICATION NAME] and requiring [MEDICAL TREATMENT]. Resident A The Immediate Jeopardy began on 7/28/11 when Resident A's lab results concerning his [MEDICATION NAME] therapy was high, not reported to the physician or orders obtained and the medication again administered on 7/29/11, resulting in kidney injury and [MEDICAL TREATMENT]. The Administrator and Director of Nursing were notified of the Immediate Jeopardy at 1:30 P.M. on 8/15/11. The immediate jeopardy was removed on 8/16/11, but noncompliance remained at the lowered scope and severity of isolated, no actual harm, with potential for more than minimal harm, that is not immediate jeopardy. Findings include: Resident A's clinical record was reviewed on 8/15/11 at 10:30 A.M. The resident's [DIAGNOSES REDACTED]."(infection of the bone) A Physician order, dated 7/21/11, indicated "[MEDICATION NAME] 800 mg IV every 8 hrs (hours) x's (times) 6 weeks dx (diagnosis) osteo[DIAGNOSES REDACTED]...Vanc ([MEDICATION NAME]) peak and trough with every 3rd dose..." Another telephone physician order, dated 7/21/11, indicated "pharmacy to titrate vanc ([MEDICATION NAME]) doses." A [MEDICATION NAME] trough level dated 7/23/11, indicated a level of 16.7. A Pharmacist Dosing Recommendations form, dated 7/23/11, indicated "...Current IV Medication- [MEDICATION NAME] 800 mg Q8H (every 8 hours)...Change to dose recommended below: Recommended dose: 1500 mg Q12H (every 12 hours). **Obtain Trough level prior to 4th dose** Please consult with physician on the recommendation and fax a telephone order to the IV Department with theses changes...." The form indicated for [MEDICATION NAME] trough, the range of 16 to 20 was appropriate for osteo[DIAGNOSES REDACTED]. A Physician order, dated 7/23/11, indicated "[MEDICATION NAME] (antibiotic) 1500 mg per IV q (every) 12 hrs (hours) draw vanc ([MEDICATION NAME]) trough after 3rd does (1/2 hr after admin (administration))." A Pharmacist Dosing Recommendation form, dated 7/25/11, indicated "Current IV Medication Order: [MEDICATION NAME] 1.5 gm q 12h. Lab results: Trough: 22.8...DC (discontinue) current order. Change to recommendation below. New IV order: [MEDICATION NAME] 1.5 gm (gram) qd (everyday). Obtain Trough level ([MEDICATION NAME]) prior to 7/28 does. Thursday..." The Nurses Notes, dated 7/25/11 at 5:00 P.M., indicated "Received results of [MEDICATION NAME] trough. Trough level 22.8. (Name) NP (Nurse Practitioner) notified. New order received to d/c (discontinue) current vanco ([MEDICATION NAME]) order et (and) start [MEDICATION NAME] 1.5 gm (grams) IV qd (everyday). Obtain [MEDICATION NAME] trough prior to 7/28 dose." A Physician order, dated 7/25/11, indicated "[MEDICATION NAME] 1.5 gm (grams) IV qd (everyday). Obtain [MEDICATION NAME] trough level prior to 7/28 dose." A Pharmacist Dosing Recommendations form, dated 7/28/11, indicated "...Current IV Medication Order: [MEDICATION NAME] 1.5 gm qd. Lab results: Trough: 35. DC current order. New IV order: Obtain a random level 7/29/11 AM..." The MAR (Medication Administration Record,) dated July 2011, indicated the [MEDICATION NAME] was not administered at 8 A.M. The Nurses Notes, dated 7/28/11 at 3:30 P.M., indicated "[MEDICATION NAME] trough level drawn from PICC line by (name) RN. Taken to (name) lab." A Physician order, dated 7/28/11, indicated "Redraw [MEDICATION NAME] trough on 7/29/11." The Nurses Notes, dated 7/28/11 at 9:00 P.M., indicated "Dr (name) in to see. Resident's right leg very red up to groin warm et resident states is painful to the touch...New orders received..." Telephone physician orders, dated 7/28/11, included orders for a venous doppler and cough medication written by the attending physician and an order to redraw [MEDICATION NAME] trough on 7/29/11 from the Nurse Practitioner, NP #1. A progress note, dated 7/28/11, written by the attending physician, indicated "asked to eval by nurse, worsening leg, cough, occasionally refuses [MEDICATION NAME] (antibiotic). The progress note did not include any information concerning the [MEDICATION NAME] or lab results. The Nurses Notes, dated 7/29/11 at 8:30 A.M., indicated "Vanc ([MEDICATION NAME]) trough drawn via PICC line and sent to (name) lab. Continues IV antibiotics for tx (treatment) osteo[DIAGNOSES REDACTED]..." The July 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., LPN # 3 had given [MEDICATION NAME] 1.5 gm IV. The Nurses Notes, dated 7/29/11 at 11:30 A.M., indicated "Vanc trough at 38.0 pharm (pharmacy) and NP aware. Orders to stop vanc dc (discontinue) at this time. Random vanc Monday AM Chem 7 stat after [MEDICATION NAME] (antibiotic) dose infused." The Nurses Notes, dated 7/29/11 at 1:30 P.M., indicated "Chem 7 drawn via PICC and sent to (name) lab via (name) p/u (pick up)." The Nurses Notes, dated 7/29/11 at 4:10 P.M., indicated "Called lab levels from Chem 7 to NP due to BUN at 31 (normal range 9 -20) Creat (creatinine)5.5 (normal range 0.8 to 1.5). NP to consult Dr (name) and return call." The Nurse Notes, dated 7/29/11 at 4:30 P.M., indicated "New orders from NP due to elevated bld (blood) levels sent to (name) ER (emergency room ) via ambulance. Report called to (name) in ER. DON (Director of Nursing) aware of orders. (Name) ambulance here to p/u (pick up) resident at 4:55 P.M." A hospital History and Physical, dated 7/29/11, indicated "...On 07/21/2011 BUN was 9, creatinine 0.9. The patient was found to have on 07/29/2011 at Mitchell Manor a BUN of 31, and creatinine 5.5. I note on 07/28/2011, a [MEDICATION NAME] tough level was 35.8. [MEDICATION NAME] trough level on 07/29/2011 was 38. I do not have any other [MEDICATION NAME] levels. It is unclear if they were done. He was initially on [MEDICATION NAME] 800 IV every 8 hours from 07/21/2011 to 07/23/2011 and 1.5 grams IV every 12 hours from 07/24/2011 to 07/25/2011. I believe he has continued to receive [MEDICATION NAME] from this, but it is difficult to figure it out from records sent...Acute kidney injury, most likely secondary to [MEDICATION NAME]. Discussed with the patient he will need to be initiated on [MEDICAL TREATMENT], both for his creatinine clearance, as well as for removal of his [MEDICATION NAME], which is significantly elevated still. He will undergo daily [MEDICAL TREATMENT]. I discussed with him hopefully this will be temporary but there is a chance this could be long-term..." The ADON (Assistant Director of Nursing) provided an investigation, which she indicated was conducted after discovering Resident A had received [MEDICATION NAME] IV on 7/29/11. A time line labeled "Resident A" included: "7/28/11, 1.) (name of LPN #1) talked with (name of pharmacy) about increased vanc ([MEDICATION NAME]) level 35.8 (name of pharmacy) requested to hold Vanc and get redraw thought it might be contaminated. 2.) 2:06 p.m.-recommendation came through fax machine. 3.) RN #2 redrew Vanc level in afternoon. 4.) During report from days to evenings (Name of LPN #1) reported to oncoming nurse (LPN #2) Vanc was held and to redraw level. 5.) Dr (residents primary care physician) in at 11 p.m. -saw resident-2nd shift nurse told him vanc was on hold -Nurse practitioner was present- he said ok. 6.) 7/29/11 day shift nurse reported upon receiving vanc level from the blood draw that levels have increased-Nurse practitioner (NP) notified-NP stated to (name of LPN #3) Vanc on hold -LPN #3 had given the 8 a.m. dose there was nothing written on the MARs (Medication Administration Record) to hold med no physician order to hold medication, no documentation on chart from day shift on the 28th, Chem 7 was drawn after [MEDICATION NAME] (antibiotic) dose infused at 1:30 p.m.-results received 3:30 p.m. increased BUN and creatinine levels (kidney functions levels), NP notified-sent to ER 4:55 p.m. received 8-2-11 H & P from Hospital [DIAGNOSES REDACTED]. Implemented 1-(name of LPN #1) suspended 7/29/11 for no documentation of res condition...8/3/11 terminated (name LPN #1) terminated related to no documentation and MD notification." During interview with the ADON on 8/15/11 at 11:30 A.M., she indicated LPN #1 had not documented anything for her shift on 7/28/11. She indicated the lab and pharmacy had phoned and spoke with LPN #1 with nothing documented that day at all. ADON further indicated the 24 hour shift report did not include any information concerning the resident's [MEDICATION NAME] levels. A written statement from LPN #1, dated 7/29/11, included: "spoke with pharmacy, [MEDICATION NAME] level 35.8. IV department thought maybe level was incorrect as last level was lower and medication dose had been reduced...spoke to second shift nurse, asked her to finish orders for resident that RN #1 would draw lab for her. That MD was returning that evening and would need to see labs and give orders for antibiotics. Nurse stated she would. Returned to nurses station and attached note to MD resident list asking for ATB orders...." A written statement from LPN #2, dated 7/29/11, indicated " on 7/28/11 I came to work at approximately 2:20 p.m. ...LPN #1 stated that (name of Resident A) [MEDICATION NAME] trough was 35.8 and I asked 'so his vanc's on hold' she stated yes and told me that his trough needed redrawn that afternoon 7/28 and for me to grab RN #1 ...also stated Resident A refused his [MEDICATION NAME] and that Dr (primary care Dr) was coming in and to make sure that I had his vitals and chart ready when Dr came in that night...lab specimen obtained and sent to lab...at approximately 9 p.m. Dr (primary care Dr) was in the building. I approached him and asked him to see Resident A because of his leg, stated he would see him...I went to desk Dr still charting in chart and (Name of Nurse practitioner) NP 1, had came in as well. Dr asked about [MEDICATION NAME] informed Dr and NP1 that resident's trough was 35.8 and vanc on hold. Asked if they wanted the vanc and trough done on 7/29/11 as per pharmacy recommendation had said. NP 1 stated to draw it on 7/29/11. I wrote the order to draw vanc trough on 7/29/11 and put it on the MARs...I gave report to LPN #4...told her trough of 35.8 and that NP1 said to redraw vanc trough on 7/29/11 before administering next dose..." During interview with LPN #3, on 8/15/11 at 1:00 P.M., she indicated on 7/29/11 she only received in report that Resident A was ok. Nothing was passed on to her about the [MEDICATION NAME] level. She indicated she administered the [MEDICATION NAME] IV and then received the high lab results from the [MEDICATION NAME] trough that a.m. LPN #3 indicated she called the pharmacy for recommendations as NP1 in the past had requested they call pharmacy first and then let her know what pharmacy said. LPN #3 indicated the pharmacy told her they had recommended the drug not be given the day before. LPN #3 indicated she then called NP1 who indicated the medications should not have been given. LPN #3 indicated there was no system where nurses would check the last lab on titrated antibiotics before giving the medication. During phone interview with Nurse Practitioner 1, NP1, on 8/15/11 at 1:15 p.m., she indicated she had heard LPN #2 state on 7/28/11 while she was in facility with the attending physician the [MEDICATION NAME] was on hold. NP1 indicated she had spoke with the physician about this following the event and neither her nor the attending physician was told of the high [MEDICATION NAME] level from 7/28/11, nor asked what to do with the [MEDICATION NAME]. She indicated when she heard the nurse state it was on hold she assumed the physician had been asked what to do and ordered the medication held. NP1 further indicated the medication should not have been given with the labs that high. On 8/15/11 at 11:15 A.M., RN # 2 provided an inservice she had done with the nursing staff on 8/3/11. The inservice was titled Physician notification of Pharmacy Recommendations. The inservice indicated "...Pharmacy notifications must be reported to the physician with (sic) 24 hours, as usual. The exception to this would be if the notification were for HOLDING a med (medication) or STOPPING a med due to lab values. This instance would again be IMMEDIATE notification because it represents a need to alter treatment AND a significant change." RN # 2 indicated this inservice was done as a walking inservice. She indicated she had spoke individually with each nurse. On 8/15/11 at 11:15 A.M., RN # 2 provided the policy and procedure, " Blood Sampling for Peak and Trough Values," dated 3/3/10. She indicated this is available to all nurses in the The Nurses' Infusion Manual for Long Term Care Facilities. The policy indicated "...Many medications must remain within a certain therapeutic range in the bloodstream in order to achieve desired effects. In some cases the level of medication in the blood may go beyond an acceptable limit and symptoms attributable to drug toxicity can develop. Therefore, monitoring certain drug levels is important...Proper dosing of aminoglycoside drugs and [MEDICATION NAME] is important to achieve sustained serum concentrations and to prevent resistance, progression of infection and mortality...The "trough" is a measurement of drug in the blood right before the next dose and at its lowest level of concentration in the blood. Ideally just prior to infusion...Verify physician order/pharmacy recommendations for blood sampling...." The facility drug book, 2011 Lippincott's Nursing Drug Guide, was provided by the Assistant Director of Nursing, on 8/15/11 at 1:30 P.M. The book indicated "[MEDICATION NAME] patients or patient with [MEDICAL CONDITION]. Monitor dosage and serum levels very carefully..." The Immediate Jeopardy that began on 7/28/11 was removed on 8/16/11, when the facility demonstrated policies and procedures had been put in place to ensure staff were knowledgeable of the need to monitor labs and notify the physician., but noncompliance remained at the lowered scope and severity of isolated, at no actual harm, with potential for more than minimal harm, that is not immediate jeopardy. \ This federal tag relates to Complaint IN 593. 3.1-48(a)(3)