Every finding on record at Todd-Dickey Nursing and Rehabilitation

Based on observation, record review, and interview, the facility failed to ensure a resident was provided proper management of the urinary catheter drainage system related to placement of the tubing and bag for 1 of 2 residents reviewed for bowel and bladder. (Resident 35) Findings include: During an observation on 6/30/25 at 8:59 a.m., Resident 35 was sitting in a wheelchair conducting a corn hole activity in the dining room. Her urinary catheter tubing, which was down the resident's left pant leg, was dragging on the floor as she moved. There was clear yellow urine in the tubing. The catheter bag was scrunched up on the left side of her wheelchair in a urinal basket. The Activity Aide was sitting to the right side of the resident, but didn't notice the tubing being on the floor. She did not notify the nurse or adjust the tubing. During an observation on 6/30/25 at 10:50 a.m., Resident 35 was sitting in a wheelchair in the dining room with the urinary catheter tubing, which was down the resident's pant leg, was dragging on the floor. The urine in the tubing was pale yellow in color. The resident kept getting her left foot caught on the tubing and would pull on the tubing to loosen it. The urinary catheter bag was scrunched up on the left side of the wheelchair in a urinal basket. As the resident rolled the wheelchair, the left front wheel was observed on top of the tubing. During an observation on 7/1/25 at 9:02 a.m., Resident 35 was sitting in a wheelchair asleep, in the dining room. The urinary catheter tubing was on the floor. The urinary catheter bag was scrunched up on the left side of the wheelchair, against the small front wheel, in a urinal basket. Two Certified Nurse Aides (CNAs) entered the dining room. As the CNAs were touching the wheelchair, CNA 5 was called out of the dining room by RN 3. CNA 5 called CNA 4 out of the dining room and they returned carrying Personal Protective Equipment (PPE). They applied the PPE and brought the resident in a wheelchair over to the recliner in the dining room. The catheter tubing was dragging the floor as the wheelchair was pushed ten feet to the recliner. CNA 5 removed the urinary catheter bag from the wheelchair, lifting it above the level of the bladder. The pale yellow urine was observed backflowing up the tubing. She tried to place the bag on the side of the recliner, but she couldn't get it to hook onto the chair. She placed it onto the floor. Both CNAs left the resident sitting in her recliner. The record for Resident 35 was reviewed on 7/1/25 at 9:48 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with foot ulcer and diabetic polyneuropathy, mild intellectual disabilities, chronic pain syndrome, hypo-osmolality and hyponatremia, hypokalemia, overactive bladder, diarrhea, neuromuscular dysfunction of the bladder, and muscle weakness. The physician's order, dated 2/4/25, indicated to change the urinary catheter and urinary drainage bag as needed for dislodgement, leakage or occlusion. The physician's order, dated 2/4/25, indicated staff were to provide urinary catheter care, make sure the catheter securement device was in place, and the nurse was to record the urine output every shift. The physician's order, dated 2/4/25, indicated to change the urinary catheter securement device weekly on Sundays. The physician's order, dated 2/4/25, indicated to change the urinary catheter securement device for dislodgement and as needed. The nurse's note, dated 3/28/25 at 12:43 p.m., indicated the resident returned from an appointment at 12:13 p.m. The nurse checked the urinary catheter per the bus driver's request. The bus driver indicated the urinary catheter was yanked, while the resident was at the appointment. Some bleeding was present on the resident's brief, with no complaints of pain. The urinary catheter was intact and patent. The Significant Change Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact. The resident was frequently incontinent of bowel. The physician's order, dated 4/16/25, indicated staff were to offer an additional 120 milliliters (mL) of fluids every shift. The nurse's note, dated 5/8/25 at 1:31 p.m., indicated the Nurse Practitioner (NP) was notified of the urinalysis (u/a) and culture results that resulted on 5/4/25. During the discussion with the NP the u/a was to have been canceled due to the urinary catheter not being removed. The nurse did not discontinue (d/c) the order so the u/a was obtained and taken to the laboratory. An antibiotic was ordered and started on 5/8/25. The NP and Director of Nursing (DON) were made aware of the situation. The resident had been afebrile and had light yellow urine with a small amount of sediment. She had no complaints of pain or discomfort in the abdomen or burning voiced over the last couple of days. The resident denied distress. The physician's order, dated 5/8/25, indicated the resident was to be given 800-160 milligrams (mg) of Bactrim Double Strength (DS) every 12 hours for 20 doses with an end date of 5/17/25 for the UTI. The care plan, dated 5/22/25 at 12:41 p.m., indicated the resident was at risk of transferring or becoming colonized with a Methicillin Resistant Organism (MDRO) and required Enhanced Barrier Precautions (EBP) due to an indwelling medical device. She had a 16 French urinary catheter with a 30 mL bulb, and an MDRO Carbapenem Resistant Enterobacterales (CRE) in which contact precautions did not apply. The interventions included, but were not limited to: dated 2/21/25, do not wear the same gloves and gown for the care of more than one person; identify the resident as needing EBP through signage and the medical record; use standard precautions including hand hygiene in addition to the EBP; and wear a gown and gloves prior to high contact resident care activities. The nurse's note, dated 5/31/25 at 1:52 p.m., indicated the resident had a tearful episode due to having to change her pants because the urinary catheter was kinked. The urinary catheter was unkinked and patient. The urinary catheter bag was changed due to a hole being present. The care plan, dated 6/9/25, indicated the resident required an indwelling urinary catheter related to a neurogenic bladder. The interventions included, but were not limited to, dated 4/23/25, staff were to record urinary output in mL; dated 2/4/25, avoid obstructions in the urinary drainage system; change the catheter per the physician's order; do not allow tubing or any part of the drainage system to touch the floor, encourage fluids; keep the urinary catheter system a closed system as much as possible; manipulate the tubing as little as possible during care; obtain labwork as ordered; position the catheter bag below the level of the bladder; provide assistance for catheter care; and report signs of a UTI. The physician's order, dated 6/11/25, indicated the resident was to receive 40 mg of furosemide twice daily. The of the culture and sensitivity report for the resident, dated 5/4/25, indicated there was greater than 100,000 colony forming units per milliliter (CFU/mL) Escherichia Coli. During an interview, on 7/1/25 at 9:12 a.m., CNA 5 indicated the urinary catheter tubing was down the resident's pant leg. The nurse told her to place the tubing there to make it easier to place on the wheelchair. She hadn't noticed the tubing dragging on the floor when she transferred the resident in her wheelchair. The tubing being on the floor would cause contamination. She had not observed the catheter bag on the floor by the recliner, either. The bag needed a new hook, which was why she didn't hang it on the recliner. During an interview, on 7/1/25 at 9:15 a.m., CNA 4 indicated she observed the tubing being down the left pant leg. The tubing being on the floor could cause contamination. She didn't notice the tubing or the catheter bag being on the floor. The resident wanted the bag on the floor. During an interview, on 7/1/25 at 9:20 a.m., RN 3 indicated the resident didn't like the catheter attached to the chair. The RN felt it would be stepped on or rolled over by the wheelchair if it was left on the floor. The tubing should not be on the floor. She had to educate the CNAs and resident to watch the tubing so that it wasn't on the floor. It depended on the day as to whether the resident understood the education to keep the tubing off of the floor. The resident had good days and bad days as far as her understanding. She felt that another leg strap could be placed around the resident's lower leg to prevent the tubing from being so long and to not be on or around the resident's foot, but the NP would have to be notified. The urinary catheter bag might be too big to prevent the tubing from dragging the floor. The bag was last changed on 6/30/25. The catheter bag should not be lifted above the resident's waste. This could cause backflow of the urine. The tubing or catheter bag being on the floor could cause infection, risk of being stepped on, or being pulled out. When the RN checked the catheter bag, the loop around the top of the catheter bag tube was not holding and came loose easily. The bag was pushed into a urinal basket. The bag being scrunched could cause the urine to backflow back up the tubing. There was 400 mL of urine in the catheter bag currently and it needed to be emptied. During an interview, on 7/1/25 at 9:35 a.m., the Director of Nursing (DON) indicated the resident's catheter tubing should not be dragging on the floor. Staff should not lift the catheter bag above the level of the bladder, because it could cause a UTI. The CNA should have placed the catheter bag into a basin, instead of placing it on the floor. The DON had placed the catheter bag into the urinal basket to hold the bag up. During an interview, on 7/1/25 at 12:39 p.m., the Executive Director (ED) indicated the facility did not have a specific policy for preventing the catheter tubing or bag from touching the floor, but she did provide the Indwelling Urinary Catheter Care, Emptying Drainage Bag and Catheter Removal training skills. During an interview, on 7/1/25 at 1:02 p.m., the DON indicated she had talked to the resident and educated her, even though the resident was cognitively unable to be educated about keeping the catheter bag off of the floor. She convinced the resident today to let staff place a leg strap catheter. Staff would have to empty the catheter bag more often and staff were educated to do this. The resident was a heavy wetter, received a diuretic, and drank a lot of fluids. 3.1-41(a)

Based on observation, interview, and record review, the facility failed to ensure staff provided effective assistance with drinking in accordance with the plan of care and failed to implement effective interventions to prevent the spillage of hot coffee to a resident with upper extremity tremors for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in the resident spilling the hot coffee and sustaining second degree burns on right lateral chin, right and left thighs; and a third degree burn on right upper inner groin area. Findings include: On 10/1/24 at 10:35 a.m., Resident B was observed resting in bed with her eyes open and watching television. The resident was observed with tremors of persistent movement to the arms, hands, and head. The incident report, dated 9/5/24 at 7:15 a.m., indicated Resident B spilled coffee on her lap with blisters to her right upper thigh and reddened area to her bilateral legs and right lower arm. The facility preventative measures were for staff to provide the resident with a cup with a lid. The clinical record for Resident B was reviewed on 10/1/24 at 10:54 a.m. The diagnoses included, but were not limited to, dementia, anxiety, impulsiveness, and tremors. The significant status changes minimum data set (MDS) assessment, dated 8/5/24, indicated the resident's cognition was moderately impaired. The resident required staff assistance with set up for eating and drinking. The care plan, dated 7/10/24, indicated the resident was a nutritional risk related to a history of malnutrition, tremors, and self-feeding issues. The care plan lacked interventions related to tremors and self-feeding issues. The care plan, dated 7/12/24, indicated the resident required assistance with activities of daily living (ADL's) and staff were to assist Resident B with eating and drinking when needed. The care plan lacked the level of assistance needed related to the number of staff needed or how much assistance Resident B needed with eating and drinking. The nursing to therapy referral, dated 7/23/24 at 2:58 p.m., indicated the resident complained of tremors that refrained her from using eating utensils. The occupational therapy (OT) evaluation, dated 7/26/24, indicated the resident was recently referred to be evaluated by therapy. The resident had an increase in tremors and a decline in fine motor coordination which led to difficulty with self-feeding and ADL tasks. The nursing to therapy referral, dated 8/7/24 at 10:48 a.m., indicated the resident was complaining of difficulty in using her water cup at bedside due to the weight of the water in the cup. The resident continued to have tremors to her hands and arms. The resident's care plan or dietary staff notes lacked any implemented interventions related to the resident's difficulty with holding her cup, after the 8/7/24 therapy referral. The occupational therapy note, dated 9/4/24, indicated the resident and caregiver were educated on the resident's difficulties with self-feeding related to increased difficulty with scooping food onto her utensils. The Certified Occupational Therapy Assistant (COTA) 4 explained the adaptive equipment the resident could use to make self-feeding easier for the resident. The therapist will continue to observe the resident during mealtimes to assess for a scoop plate. The note lacked any documentation related to the resident's difficulties handling liquids or a cup. The progress note, dated 9/5/24 at 7:15 a.m., indicated the resident was up in the dining room and requested a cup of coffee. The resident was given the coffee and dropped the coffee on her lap. The resident was immediately taken to her room and her clothing was removed. The resident's skin was already red and showed signs of blisters (The note lacked where the redness occurred). Cool towels were applied to all the resident's red areas. The facility wound management report, dated 9/5/24 between 1:11 p.m. and 1:14 p.m., indicated the resident had acquired three burned areas related to hot coffee. - Wound 1 was a superficial burn to the resident's right lower inner arm and measured 19 cm (centimeters) in length and 8.2 cm in width with no depth. The area was pink in color with no blisters. Staff were to cleanse the area, apply a thin layer of Silvadene (a cream that treats and prevents wound infections for burns) topically and wrap with gauze twice daily. - Wound 2 was a partial thickness burn to the resident's right top thigh area and measured 39.5 cm in length and 27 cm in width with no depth. The area was blistered, moist, painful, and reddened. Staff were to cleanse the area, apply a thin layer of Silvadene topically, and wrap with gauze twice daily. - Wound 3 was a superficial burn to the resident's left top thigh area and measured 8 cm in length and 11 cm in width. The area was painful, reddened and blanched with pressure. No blisters were observed. Staff were to cleanse the area, apply a thin layer of Silvadene topically, and wrap with gauze twice daily. The clinical record lacked documentation related to a burn on the resident's right lower facial area. The physician's order, dated 9/6/24, indicated staff were to continue to cleanse all the resident's burned areas, apply a thin layer of Silvadene cream, and cover with Mepitel (a dressing used to protect the wound and skin). Then apply border gauze (a type of wound dressing that consists of three layers and was used to protect and absorb wounds) to secure. The physician's order, dated 9/11/24, indicated staff were to continue to cleanse all the resident's burned areas, apply a thin layer of Silvadene cream and cover with xeroform dressing (a dressing for low draining wounds). Then apply border gauze to secure. The wound care center history and physical note, dated 9/12/24 at 12:30 p.m., indicated Resident B presented to the wound care center with her family member related to burns acquired in the nursing home from hot coffee. The wound care center detailed assessment, dated 9/12/24 at 12:30 p.m., indicated the resident presented to the center with the following wounds: - Wound 2 involved the resident's right groin area and upper medial leg. The resident had a second-degree burn (involving the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin). The wound measured 25 cm in length, 16 cm in width with a depth of 0.2 cm, full thickness without exposed support structures. The wound had a large amount of serosanguineous (a combination of blood and serum) exudate (drainage), slough (yellow/white material in the wound bed), and with a fat layer exposed. The treatment ordered was Santyl (debriding treatment), staff were to apply a nickel thick amount to wound bed, with a Vaseline gauze over the Santyl and cover with an abdominal pad daily (ABD). The resident's right medial upper leg had a first-degree burn (involving the top layer of skin. These may present as red and painful to touch, and the skin will show mild swelling). The wound measured 2.2 cm in length, 2.4 cm in width with a depth of 0.1 cm, full thickness without exposed support structures, large amount of serosanguineous exudate and slough. The treatment ordered was bacitracin (helps prevent burns from becoming infected) to the wound bed, staff were to apply Vaseline gauze, cover with ABD pad, and secure with gauze daily. - Wound 3 involved the resident's left medial upper thigh. The resident had a second-degree burn. The wound measured 3 cm in length, 4 cm in width with a depth of 0.1 cm, full thickness without exposed support structures. The wound had a medium amount of serosanguineous exudate and with a fat layer exposed. The treatment ordered was bacitracin to wound bed, staff were to apply Vaseline gauze, cover with ABD pad, and secure with gauze wrap. - Wound 4 involved the resident's right lateral chin. The resident had a second-degree burn. The wound measured 0.3 cm in length, 0.5 cm in width with a depth of 0.1 cm, full thickness without exposed support structures, a small amount of serosanguineous exudated. The treatment ordered was bacitracin to the wound bed daily. The wound care center note, dated 9/12/24, lacked any documentation related to the resident's right lower inner arm burn that was identified on 9/5/24 as Wound 1 on the facility wound management note. The facility skin and wound note, dated 10/1/24 at 2:47 p.m., indicated the following: -Wound 2 was located on the resident's right groin area. The wound was a third-degree burn (third-degree burns penetrated the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black). The area measured 4.2 cm in length, 18 cm in width with a depth of 0.2 cm. The wound contained 80% (percent) slough with a heavy amount of serosanguineous exudate. The exposed tissues were the epithelium and dermis. A wound debridement was completed to 100% of the wound and necrotic tissue was removed. The wound was to be cleansed with wound cleanser, patted dry, apply Santyl cream and covered with ABD/bordered gauze daily. - Wound 3 was located on the resident's left thigh. The wound was a third-degree burn. The wound measured 0.5 cm in length, 1.5 cm in width with a depth of 0.1 cm with a small amount of serosanguineous exudate. The exposed tissue was epithelium. The wound was to be cleansed with wound cleanser, apply xeroform and bordered gauze daily. The facility wound note, dated 10/1/24, lacked documentation related to the resident's Wound 1 identified on the facility wound note, dated 9/5/24; or Wound 4 identified on the Wound Care Center assessment, dated 9/12/24. During an interview on 10/1/24 at 10:35 a.m., the resident's family member indicated the wound nurse had been in that morning for treatment to her family member's burn wounds. The resident had a third-degree burn to her right upper thigh and a second-degree burn to her left upper thigh. The resident had severe tremors, and the family member was unsure why there was no lid on the coffee cup to prevent spillage. On 10/1/24 at 11:00 a.m., during an observation of the coffee maker in the facility kitchen, the industrial coffee maker was observed to be set at 200 degrees Fahrenheit. The ED indicated they do not individually temp the coffee. The industrial coffee maker was set at 200 degrees Fahrenheit. The standard was between 205 to 215 degrees Fahrenheit and they set their' s below the standard at 200 degrees Fahrenheit. The industrial coffee maker was observed to be set at 200 degrees Fahrenheit. On 10/1/24 at 11.07 a.m., during an observation of the coffee temperatures in the two residents' dining rooms, the coffee being served by staff was tempted to be at 140 degrees Fahrenheit. On 10/1/24 at 11:30 a.m., a request was made for the facility policy on hot liquids. On 10/1/24 at 12:30 p.m., the Executive Director (ED) indicated the facility did not have a policy on hot liquids. The ED and Director of Nursing (DON) indicated they did not do hot liquid evaluations. The ED indicated that the resident, had always drank coffee. The DON indicated Resident B was able to eat and drink with no issues. The resident had a couple of hospital stays. After her second hospital stay, they had therapy take a look at the resident. She would not eat; she was paranoid and had mental status changes. Speech could not evaluate her because she refused. The family member could get her to eat. They sent her to neurology, and they put her on Gabapentin for her tremors. She had lethargy and increased tremors. They decreased the Gabapentin. There was no need for an evaluation as the family member was assisting the resident with meals. She was up for meals, still having tremors and staff were supervising. During an interview on 10/2/24 at 9:16 a.m., the Executive Director (ED) indicated the resident was seen by the occupational therapist assistant on 9/4/24 for assistive devices and felt at that time a lid was not needed. The facility staff were aware the resident had tremors; however, the tremors were inconsistent. The ED provided a typed noted completed on 10/2/24 and dated 9/4/24 from COTA 4. The typed noted indicated the following: The resident and resident's caregiver were educated on the different types of adaptive equipment. Adaptive equipment suggested were a scoop plate, weighted silverware, and lids on cups. The resident observed on 9/4/24 with a plastic lid on a regular cup. The resident completed drinking tasks without problems. The resident demonstrated minimum tremors during treatment session. At this time, due to the resident's alertness and minimum tremors, lids on cups were not recommended. On 10/2/24 at 9:42 a.m., an observation of the resident's wound was made with the DON and Licensed Practical Nurse (LPN) 8. The resident's area to her right groin wound (Wound 2) was observed to be 18 cm in length, 4 cm in width with a depth of 0.1 cm. Scar tissue was observed around the peri-wound. Approximately 70% of the wound was covered with yellow slough. There was no odor. The left thigh wound (Wound 3) was observed to be 2 cm in length and 2 cm in width with no depth. The wound bed was observed to be pink with no slough. Scar tissue was observed to the top of the wound. The resident denied any pain or discomfort. During an interview 10/2/24 at 9:45 a.m., Certified Nursing Aide (CNA) 5 indicated the day of the incident, she heard someone crying and another CNA 6 was taking the resident to her room. Resident B shakes really bad, and it comes and goes. She could not recall if the resident had tremors that day, but some days she had them and some days she did not. There were plenty of days that she needed a lid for her cup to prevent her from spilling the liquid. She was aware the resident had tremors. During an interview on 10/2/24 at 9:47 a.m., CNA 6 indicated it was breakfast time and CNA 7 handed Resident B a cup of coffee. The coffee was really hot that day. She heard something drop. She walked over and saw that the coffee had spilled on Resident B. She took the resident to her room, removed her clothing and put cold wash cloths on the reddened areas. Her skin was red when she removed the resident's clothing. She did not recall if the resident was having tremors that day, but she was aware the resident did have tremors. During an interview on 10/2/24 at 11:00 a.m., COTA 4 indicated she had spent time with the resident on 9/4/24. When she went in the room, the resident was abed, and her family member was at her bedside. The resident had a couple of hospital stays and after she came back from her second one, she was very paranoid. She quit eating and thought the staff were poisoning her food. On 9/4/24, when she saw the resident, she was coming out of showing signs of paranoia. The family member asked her about assistive devices, and she spoke with her about a scoop plate, weighted utensils, and a lidded cup if it came to that. On 9/4/24, the resident's tremors were minimal, and she was alert and oriented. When her lunch tray came, her cup had a lid on it. She put a straw in the top of the lid and the resident did fine drinking. She was aware the resident had tremors, and the tremors would come and go and were very inconsistent. It was a very short time when the incident occurred that the resident could feed herself. During a telephone interview on 10/2/24 at 11:09 a.m., CNA 7 indicated on the morning of the incident, they were getting the breakfast trays ready. She asked Resident B if she wanted coffee, and she said yes. She poured the resident some coffee and it was hot. She placed the coffee on the residents' table, out of the resident's reach, because it was hot. She went back to the food cart and was told the resident had spilled her coffee. She and CNA 6 took the resident to her room, got her undressed and placed cold cloths on the reddened areas. After that she left the resident's room to finish the meal service. She had never seen the resident with a lid on her cup. She had no idea how the resident reached the coffee cup or if someone else gave it to her. The resident's tremors were not as bad that day as they usually were. She was aware the resident had tremors. The resident had always gotten coffee before when she wanted it, without a lid on her cup, and she did not recall the resident ever having a lid on her coffee. On 10/2/24 at 12:38 p.m., the resident was observed resting in bed with her eyes closed and her call light in reach. Tremors were observed ongoing to the arms, hands, and head. Resident B's family member indicated the day before the incident occurred, COTA 4 came in and told her she was getting ready to put an order in for her family member to have a lid on her drinks. COTA 4 told her that her family member had eaten her meal well the day before. Her family member could not handle the weight of cups because she was shaking so badly. Burn Exposure Chart, www.antiscald.com, indicated .that a person will receive a second degree burn in 3 seconds of exposure and third degree burn in 5 seconds of exposure to water of 140 [degrees Fahrenheit] . Occupational-Therapy-Scope-of-Practice, www.research.aota.org/practice, 2024 American Occupational Therapy Association, .Occupational therapy services may be provided by two levels of practitioners: (1) the occupational therapist and (2) the occupational therapy assistant, as well as by occupational therapy students under appropriate supervision (AOTA, 2018). Occupational therapists function as autonomous practitioners, are responsible for all aspects of occupational therapy service delivery and are accountable for the safety and effectiveness of the occupational therapy service delivery process. The occupational therapy assistant delivers occupational therapy services only under the supervision of and in partnership with the occupational therapist (AOTA, 2020b). When the term occupational therapy practitioner is used in this document, it refers to both occupational therapists and occupational therapy assistants (AOTA, 2015a) . The Past noncompliance began on 9/5/24. The deficient practice was corrected by 9/12/24 after the facility implemented a systemic plan that included the following actions: All staff were educated on assist to feed which included all residents that needed assistance were assisted timely, temperature of fluids were appropriate and to resident preference, and the use of specialty cups/lids appropriately (9/11/24); Coffee temperature monitoring was implemented (9/5/24); All residents were observed to ensure no issues with cups and eating (9/5/24); Drink lids provided to all units and on hydration carts (9/8/24); Vendor completed inspection of coffee maker and ensured no temperature malfunctions (9/12/24). This Citation relates to Complaint IN00442615 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure medication errors did not occur for 1 of 3 residents reviewed for medication administration. (Resident C) Findings include: 1. The clinical record for Resident C was reviewed on 1/17/24 at 1:02 p.m. The diagnoses included, but were not limited to, congestive heart failure, depression, anxiety and hypertension. The incident report, dated 6/10/23 at 1:33 p.m., indicated Resident C had a medication error. The resident was sent to the hospital and diagnosed with a urinary tract infection. The progress note, dated 6/10/23 at 8:15 a.m., indicated QMA (Qualified Medication Aide) 4 administered the wrong medication to Resident C. The physician was notified with orders to obtain vital signs every 4 hours, check blood sugars every shift, hold the resident's morning medication, and to administer the resident's 12 p.m. medications as ordered. Review of the medication error report, dated 6/15/23, indicated QMA 4 administered Resident D's morning medications to Resident C which included the following: - Baclofen (medication for muscle spasms) 20 mg (milligrams) - Centrum Silver supplement - Divalproex (medication for convulsions) 1,500 mg - Metformin (medication for diabetes) 500 mg - Neurontin (medication used for pain) 400 mg - Oxcarbazepine (medication used for seizures) 600 mg - Paxil (antidepressant) 30 mg The clinical record lacked documentation of a physician's order for the above medications. The written statement from QMA 4, dated 6/13/23, indicated on 6/10/23, QMA 4 had two residents left to pass medications to, Resident C and Resident D. QMA 4 had both resident's medications ready. Prior to administration, QMA 4 was distracted when her aides asked her some questions along with a resident. She planned to go to Resident C's room. She grabbed Resident D's cup of medications instead of Resident C's and administered Resident D's medications to Resident C. When she returned to the medication cart, QMA 4 immediately realized the mistake and the physician was notified. During an interview on 1/17/24 at 1:19 p.m., QMA 4 indicated on the morning of 6/10/23, she only had two residents left to administer medication. She had gotten distracted when a couple of aides approached her during her medication pass. She planned to administer medication to Resident C and then Resident D. She grabbed Resident D's medications rather than Resident C's. She realized what she had done right after that. She reported to the charge nurse, DON, family and physician and followed the orders provided by the physician. On 1/18/24 at 10:49 a.m., QMA 4 indicated the 5 rights of medication administration were right person, right medication, right time, right dose and right route. On 1/18/24 at 9:40 a.m., the Executive Director provided a current copy of the document titled Medication Errors dated 11/02. It included, but was not limited to, Policy .It is the policy of this provider to ensure residents residing in the facility are free of medication errors . On 1/18/24 at 9:40 a.m., the Executive Director provided a current copy of the document titled Medication Administration dated 2/2010. It included, but was not limited to, Procedure Steps .Medications are prepared for one resident at a time .Perform the 5 rights of medication .Right Resident 2. The clinical record for Resident D was reviewed on 1/18/24 at 9:51 a.m. The diagnoses included, but were not limited to, cerebral palsy, convulsions, diabetes and depression. Review of the June 2023 medication administration record indicated the resident had the following morning medications ordered: - Baclofen 20 mg at 8:00 a.m. - Centrum Silver, one tablet between 7:00 a.m. and 11:00 a.m. - Divalproex 1,500 mg between 7:00 a.m. and 11:00 a.m. - Metformin 500 mg between 7:00 a.m. and 11:00 a.m. - Neurontin 400 mg at 8:00 a.m. - Oxcarbazepine 600 mg between 7:00 a.m. and 11:00 a.m. - Paxil 30 mg between 7:00 a.m. and 11:00 a.m. The Past noncompliance began on 6/10/23. The deficient practice was corrected by 6/15/23 after the facility implemented a systemic plan that included the following actions: All staff were educated on Medication pass policy/procedure which included the preparation of medications for one resident at a time and performing the 5 rights of medication administration of right person (6/15/23); one on one teaching and a medication pass observation completed with QMA 4. (6/15/23) 3.1-48(c)(2)

Based on observation, record review, and interview, the facility failed to ensure proper catheter care, handling of the indwelling urinary catheter bag or tubing, and monitoring of urinary output or fluid intake for 4 of 4 residents reviewed for indwelling urinary catheters. (Residents 29, 25, 31, and 55) Findings include: 1. During an observation on 5/16/22 at 11:30 a.m., Resident 29's indwelling urinary catheter was at the bedside with 500 mL (milliliters) of tea colored urine in the catheter bag and tubing with a heavy amount of yellow [MEDICATION(S)] in the tubing but clear urine in the catheter bag. The resident indicated he had an infection and blood clots in the catheter bag. He wished the staff would take the catheter out. During an observation on 5/17/22 at 10:42 a.m., the resident was in his wheelchair participating in an activity in the dining room. The indwelling urinary catheter was hanging below the wheelchair. The catheter tubing was directly touching the floor. The urine in the bag was visible with 400 mL of yellow gold colored urine. The catheter tubing was resting directly on the floor. During an observation of catheter care for Resident 29, on 5/19/22 at 8:59 a.m., CNA (Certified Nursing Aide) 3 pulled down the resident's brief and with 3 swipes of the same area of the wipe and cleaned the crease to the right of the penis. She obtained another wipe and with 2 swipes of the same area of the wipe cleaned the right crease again. The resident was rolled onto his left side and the bowel was cleaned from the rectal area, using 2 swipes with the same area of the wipe from the testicles to the coccyx. She did this in the same manner 11 times. The resident was rolled onto his right side and the catheter bag was raised over the resident and placed onto the left side of the bed. LPN (Licensed Practical Nurse) 4, obtained a wipe and with 7 swipes with the same area of the wipe, she cleaned from the testicles to the coccyx. She obtained a wipe and cleaned the resident with 7 swipes again with the same area of the wipe from the testicles to the coccyx. She obtained a wipe and with 3 swipes with the same area of the wipe, cleaned under the testicles. She obtained a wipe and with 13 swipes with the same area of the wipe, cleaned from the testicles up the right and left creases in a back to front direction. The clinical record for Resident 29 was reviewed on 5/18/22 at 1:36 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 04/26/22 and last revised on 4/26/22 indicated the resident required an indwelling urinary catheter due to: obstructive [CONDITION(S)] related to [CONDITION(S)]. The interventions, dated 4/26/22, included, but were not limited to, avoid obstructions in the drainage, change the catheter per MD (physician's) order, do not allow tubing or any part of the drainage system to touch the floor, encourage fluids, keep catheter system a closed system as much as possible, manipulate tubing as little as possible during care, monitor urinary output, position the bag below the level of the bladder, provide assistance for catheter care, report signs of a [CONDITION(S)] (urinary tract infection), staff to record urinary output in mL, and store collection bag inside a protective dignity pouch. The Quarterly MDS (Minimum Data Set) assessment, dated 3/2/22, indicated the resident was cognitively intact. The resident was dependent with assistance for toileting. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Foley catheter care, the nurse was to record the output every shift with a start date of 4/25/22. - Document in mLs all fluids taken with medications, every shift with a start date of 11/16/18. - Urinalysis/Culture and Sensitivity Indications: complaints of pain in left lower quadrant dated 4/8/22. - Urinalysis/Culture and Sensitivity with a date of 4/11/22. - [MEDICATION(S)] capsule 300 mg (milligrams) orally every 12 hours with a start date of 4/26/22. Discontinued on 4/27/22. - [MEDICATION(S)] tablet 800-160 mg (milligrams) orally daily with a start date of 4/27/22. Discontinued on 4/27/22. - [MEDICATION(S)] 800-160 mg orally twice daily with a start date of 4/28/22 to 5/1/22. - [MEDICATION(S)] tablet 20 mg once daily starting 7/29/21. The Treatment Administration History, on 5/2/22 and 5/14/22 during the 10:00 p.m. to 6:00 a.m. shift, lacked documentation of urine output. On 5/10/22 during the 6:00 a.m., to 2:00 p.m. shift, lacked documentation of urine output. The Treatment Administration History, on 4/13/22 during the 6:30 a.m., to 2:30 p.m. shift, lacked documentation of fluid intake. The Treatment Administration History, on 3/7/22 during the 6:30 a.m. to 2:30 p.m. shift, lacked documentation of fluid intake. The nurse's note, dated 4/07/22 at 8:50 p.m., and recorded late on 4/8/22 at 12:12 a.m., indicated the resident was yelling out with complaints of pain to the left lower quadrant of the abdomen. He indicated he had a kidney stone and wanted to go to the emergency room . The nurse's note, dated 4/15/22 at 1:24 p.m., indicated the physician had reviewed the resident's recent laboratory results and ordered an appointment with a nephrologist, related to the resident's deteriorated kidney function. The nurse's note, dated 4/25/22 at 9:42 p.m., indicated the resident returned at 9:20 p.m., from a local hospital. He had a foley catheter 16 French placed and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician ordered [MEDICATION(S)] to start 4/26/22. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The follow-up call to the emergency room indicated from the information scanned, clearly revealed the patient had a foley catheter placed and it was difficult with a smaller caliber foley catheter being used. He had bacteria in his urine, which could be due to the urinary retention and not a classic [CONDITION(S)]. In either case his bacteria was present and the ER doctor started him on an antibiotic and this will continue for short time. The nurse's note, dated 4/27/22 at 09:21 p.m., indicated the resident's urine was yellow with mucous present and was started on [MEDICATION(S)] today. The nurse practitioner 30 day visit note, dated 5/02/22 at 11:50 a.m., indicated the resident went to the ER last week for a [CONDITION(S)] and urinary retention. The Urinalysis revealed 3+ blood and 4+leukocytes. The resident had a follow up appointment tomorrow with a urology center to evaluate the need for the ongoing indwelling foley catheter and/or to treat the resident for a bladder outlet obstruction. During an interview, on 5/19/22 at 9:25 a.m., CNA 3 indicated when performing catheter care she would wipe from front to back on the creases to each side of the penis, using one wipe with each downward motion. She would clean the penis in a circular motion at the tip of the penis. She would then clean down the tubing, from the penis down. 2. During an observation, on 5/18/22 at 9:42 a.m., Resident 25's indwelling urinary catheter was hanging on the left side of his bed. The catheter bag was full and the drain tube was hanging loose toward the floor. During an observation on 5/18/22 at 12:17 p.m., CNA 5 performed catheter care on Resident 25 with CNA 6, present. CNA 5, used sanitary wipes and with 3 swipes of the same area of the wipe and cleaned to each side of the penis. She obtained another wipe and with 2 swipes of the same area of the wipe cleaned down the crease to the left side of the penis. With 2 swipes of the same area of the wipe she cleaned the scrotum. She obtained a fresh wipe and with 2 swipes of the same area of the wipe cleaned the tip of the penis around the catheter tubing. The clinical record was review for Resident 25 on 5/18/22 at 8:55 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 4/26/22 and last revised on 4/26/22, indicated the resident required an indwelling urinary catheter due to neuromuscular dysfunction of the bladder. The interventions, dated 4/26/22, included, but were not limited to, avoid obstructions in the drainage, change the catheter per MD order, do not allow tubing or any part of the drainage system to touch the floor, encourage fluidsc, keep the catheter system a closed system as much as possible, manipulate tubing as little as possible during care, monitor urinary output, position the catheter bag below the level of the bladder, provide assistance with catheter care, report signs of [CONDITION(S)], staff to record urinary output in mL, and store collection bag inside a protective dignity pouch. The Quarterly MDS assessment, dated 3/9/22, indicated the resident was cognitively intact. The resident was dependent for assistance for toileting. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Foley catheter care, nurse to record output every shift every shift with a start date of 12/8/21. - Document in mLs all fluids taken with medications every shift with a start date of 1/13/21. The nurse's note, dated 3/02/22 at 6:21 a.m., indicated the resident had blood coming out of his catheter and it was leaking out from the catheter tubing. The nurse's note, dated 4/12/22 at 6:33 a.m., indicated the nurse noticed a substantial amount of blood in the urine this morning, on the last bed check. The nurse's note, dated 4/12/22 at 9:31 p.m., indicated the resident continued to have blood in urine this shift, only had 100 mL of bloody urine output this shift. The nurse's note, dated 4/13/22 at 12:09 p.m., indicated the hospice nurse was in the facility and she irrigated the catheter. The input of the solution went in easily with no return noted. She removed the foley catheter and gave orders to monitor the urine output, if no output was observed and there was no abdominal distention by 4:00 p.m. today, to call the hospice company to get further instructions and notify a hospital. The nurse's note, dated 4/13/22 at 4:07 p.m., indicated the resident voided at this time, two small bloody lines were noted, not clumped, like a clot would be, but was in a line approximately 1 cm (centimeter) long. The urine on the blanket was clear in color. The hospice nurse was notified the resident had voided. She indicated she was coming to visit him later this evening. The nurse practitioner's note, dated 4/18/22 at 11:59 a.m., indicated a recent urine culture was reviewed. [MEDICATION(S)] 800 mg, two times daily for 7 days, through 4/25/22, was ordered for a 3 organism [CONDITION(S)]. The bacteria was proteus, [CONDITION(S)] ([CONDITION(S)]), and pseudomonas (carbapenem resistant). The nurse's note, dated 4/20/22 at 7:01 p.m., indicated the hospice nurse was in this shift and an 18 French with 10 mL bulb foley catheter was inserted. The nurse's note, dated 5/07/22 at 9:29 p.m., indicated the resident had some urine leaking around the foley catheter bulb. It was deflated and only 8 mL was in the bulb and 10 mL of NS (Normal Saline) was put back in. Positive urine flow was attained and there was no complaints of pain or discomfort. The nurse's note, dated 5/11/22 at 1:32 p.m., indicated the indwelling urinary catheter was patent to bedside drain with dark yellow urine of an adequate amount. The Treatment Administration History, on 5/12/22 during the 6:00 a.m. to 2:00 p.m. shift lacked documentation of urinary output. The Treatment Administration History, on 5/13/22 during the 10:00 p.m. to 6:00 a.m. shift lacked documentation of urinary output. The Treatment Administration History, on 4/21/22 during the 10:00 p.m., to 6:00 a.m. shift lacked documented urinary output. The Treatment Administration History, on 3/2/22, 3/4/22, and 3/24/22 on the 10:00 p.m., to 6:00 a.m. shift on 3/2/22, 3/4/22, and 3/23/22 lacked documentation of urinary output. The Treatment Administration History, on 3/4/22 during the 10:00 p.m. to 6:00 a.m. shift lacked documentation of additional 240 mL of fluid intake. The Treatment Administration History, on 313/22 during the 6:00 a.m. to 2:00 p.m. shift lacked documentation of additional 240 mL of fluid intake. The Treatment Administration History, on 3/5/22, 3/8/22, 3/13/22, and 3/31/22 on the 6:00 a.m., to 2:00 p.m. shift lacked documentation of urinary output. The Treatment Administration History, on 2/25/22 on the 6:00 a.m., to 2:00 p.m., shift lacked documentation of urinary output. The Treatment Administration History, on 1/10/25, 1/21/22, 1/25/22, and 1/29/22 on the 10:00 p.m. to 6:00 p.m. shift lacked documentation of urinary output. The Treatment Administration History, on 1/22/22 on the 6:00 a.m. to 2:00 p.m., shift lacked documentation of urinary output. 3. During an observation on 5/16/22 at 10:10 a.m., the urine in the indwelling urinary catheter tubing and bag was a rusty red color for Resident 31. The resident indicated the catheter was supposed to be removed, but his appointment at the hospital appointment was cancelled. He wanted it removed, because of the discomfort. During an observation on 5/18/22 at 9:40 a.m., of the resident's indwelling urinary catheter bag and tubing, the urine in the lower half of the tubing was bloody, but the upper half of the urine in the tubing was yellow in color. There was only slight sediment in the tubing. The catheter bag was a quarter full of bloody urine. During an observation of catheter care on Resident 31, on 5/19/22 at 9:50 a.m., by CNA 7, she pulled down the brief and obtained a wipe. She cleaned the penis down the shaft to the tip of the penis. She cleaned in a downward motion, down the creases to the side of the penis. She obtained a wipe and with 2 swipes with the same area of the wipe, cleaned the right crease. She obtained a wipe and cleaned the penis down the shaft to the tip of the penis and obtained a clean wipe and cleaned down the penis to the tip again. She obtained a wipe and cleaned under the penis to the tip. She cleaned down onto the scrotum. She cleaned down the left crease, in a back to front direction. She cleaned down the shaft to the tip of the penis with 2 swipes with the same area of the wipe. She obtained a wipe and cleaned under the penis. She lifted the catheter bag above the resident, who was lying flat on his back, to remove the pajama bottoms. She folded the catheter bag to slip it down the pant leg. Orange urine with sediment was observed running back toward the urethra. She again lifted the catheter bag to slip the brief off the resident. She lifted the catheter bag again to remove the brief. She lifted the catheter bag again to put a clean brief on the resident. She lifted the catheter bag again to remove and readjust the brief. She lifted the catheter bag again to put it through the pajama bottoms, folding it in half to pull it through. Urine was observed running up and down the tubing. The clinical record for Resident 31 was reviewed on 5/16/22. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 3/28/22 and last revised on 4/13/22, indicated the resident required an indwelling urinary catheter for obstructive bladder outlet due to [CONDITION(S)] with lower urinary tract symptoms, was at risk for infection related to indwelling catheter. The interventions, dated 3/28/22, included, but was not limited to, observe for leakage, record outputs, notify the MD of any abnormal observations, avoid lying on top of tubing. measure and record intake and output, position the bag below the level of the bladder, and provide catheter care every shift and as needed. The Admission MDS assessment, dated 4/3/22, indicated the resident was cognitively intact. The resident required partial to moderate assistance for toileting. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] capsule; 500 mg orally, three times daily, with a start date of 5/16/22. - Change the foley catheter and urinary drainage bag as needed for dislodgement, leakage or occlusion, as needed with a start date of 3/28/22. - Foley catheter care, nurse to record the output every shift with a start date of 3/28/22. The Urinalysis, dated 5/15/22, indicated >100 HPF, 4+ bacteria, 4+ WBC (white blood cell) clumps, occult blood fecal positive. >100,000 cfu/ (colony forming unit) escherichia coli. A nurse's note, dated 4/14/22 at 1:46 p.m., indicated the resident's indwelling urinary catheter was patent and draining clear yellow urine to the bedside drainage bag. A physician's note, dated 5/11/22 at 11:40 p.m., indicated the resident was going to have his indwelling urinary catheter taken out tomorrow. The physician talked with the resident about his creatinine of 2.9 mg/dL (per deciliter). He discussed needing to see nephrologist with the resident. The indwelling urinary catheter was damaged and was taken out. A nurse's note, dated 5/15/22 at 6:29 a.m., indicated the resident had 600 mL (milliliters) of urine in the indwelling urinary catheter bag. The resident had a large amount of urine in his brief. The catheter was removed, and the bulb had only 3 mL of sterile water. The catheter was hardly inserted. 2 unsuccessful indwelling urinary catheter insertion attempts were performed. A second nurse made a successful insertion of the indwelling urinary catheter. The urine was cloudy and yellow upon insertion A nurse's note, dated 5/15/22 at 1:33 p.m., indicated resident had bright red blood in his brief. The bathroom was checked, and bright red blood was observed on the floor and in the toilet. The resident had a large bowel movement in the toilet and the urine in catheter bag was bloody. The resident was weak, dizzy, and shaking. His blood pressure dropped when going from a lying to a sitting position. The resident was sent to a local hospital at 10:15 a.m. The local hospital was called at 1:30 p.m., and he was being admitted to the hospital for a [CONDITION(S)]. A nurse's note, dated 5/15/22 at 9:00 p.m., indicated the resident returned from the hospital emergency room with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was given fluids while at the hospital and [MEDICATION(S)]. On 5/16/22 the resident was to start [MEDICATION(S)] 500 mg 3 times daily for 10 days for the [CONDITION(S)]. The indwelling urinary catheter was patent and draining well. The urine in the catheter bag was bloody. A nurse's note, dated 5/16/22 at 5:37 a.m., indicated the resident's indwelling urinary catheter was draining well through the night. 1000 mL of blood-tinged urine was measured. The antibiotic was started on this date for the [CONDITION(S)]. During an interview on 5/16/22 at 10:10 a.m., the resident indicated he was recovering from a bad kidney infection. The catheter was changed yesterday, and it turned bloody afterwards. His urine had been yellow before it was changed. During an interview on 5/19/22 at 10:05 a.m., CNA 7 indicated for catheter care on a male resident, she would clean the front area. She would then pull back the foreskin away from the opening and clean from the tip down. She would fold the wipe between swipes and toss it. She would clean from the outside in (creases to each side, then the penis). She would then hold the tubing and clean down it. During an interview, on 5/19/22 at 12:39 p.m., the DON, indicated the resident had e-coli (escherichia coli bacteria) in the urine when the urinalysis was completed. He was able to take himself to the bathroom for bowel movements and was educated on keeping clean. 4. During an observation, on 5/19/22 at 9:36 a.m., CNA 6 performed catheter care for Resident 55. She unfastened the brief and obtained a wipe. She cleaned down the shaft of the penis, using 2 swipes with the same area of the wipe. The bed was lowered and the catheter bag in a dignity pouch landed on the floor. The clinical record for Resident 55 was reviewed on 5/10/22 at 2:03 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 1/14/21, indicated the resident required an indwelling urinary catheter due to: [CONDITION(S)] bladder. The interventions, dated 1/14/21, included, but were not limited to, do not allow tubing or any part of the drainage system to touch the floor, encourage fluids, manipulate tubing as little as possible during care, monitor urinary output, position bag below level of bladder, provide assistance for catheter care, and staff to record urinary output in mL. The Quarterly MDS assessment, dated 3/31/22, indicated the resident was cognitively intact. He was dependent on assistance for toileting. The nurse's note, dated 3/23/22 at 11:50 a.m., indicated a family member and the renal doctor discussed the current BMP (basic metabolic panel) focusing in on the creatinine level with concern on the increase in the lab. She spoke with both the resident and the family about their wishes to not proceed with treatments to aid in lowering the level specifically [CONDITION(S)]. Both resident and family agreed that [CONDITION(S)] was not an option with the health of the resident and the NP agreed it would not improve his quality of life. Palliative care was suggested. The nurse's note, dated 3/24/22 at 10:00 a.m., indicated the resident was complaining that the foley catheter was hurting and it was, replaced without difficulty instant returning light yellow urine. The nurse's note, dated 5/11/22 at 2:24 a.m., indicated the indwelling urinary catheter changed without incident. A number 18 French catheter with 10 mL bulb anchored to the bedside with clear yellow urine. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] tablet 40 mg, orally, once a day starting on 8/30/21 - Cath orders: foley catheter care, Nurse to record output every shift, starting on 1/14/21 - Change foley catheter every 3 weeks once a day on Tuesdays, starting on 12/12/21. During an interview on 5/19/22 at 12:39 p.m., the DON indicated catheter care was ordered for every shift. Staff should perform hand hygiene and apply gloves. They should clean the creases to each side of the penis first, then the penis. They should clean in a circular motion, from the tip of the meatus of the penis and work around and down. The wipe should be discarded after each swipe, but could be folded and swiped. The tubing should then be cleaned by holding the tube at the tip of the penis and cleaning down the tube. During an interview, on 5/20/22 at 10:51 a.m., LPN 2, indicated she monitored residents for symptoms of a [CONDITION(S)], such as temperature, urinary output, sediment, urine color, pain, burning, fluid intake. The Indwellling Urinary Catheter Care, Emptying Drainage Bag & Catheter Removal, last reviewed December 2012 was provided by the Executive Director on 5/19/22 at 1:43 p.m. The policy included, but was not limited to, . 7. Using the non-dominant hand retrieve a wet soaped washcloth, cleanse the catheter in circular motion for about 10 cm (4 inches). Start where the catheter enters the meatus and down toward the drainage tube. 8. Change area on the washcloth or retrieve a new washcloth for consecutive passes along the catheter tubing. Do not rewipe the catheter . 3.1- 41(a)(1)

Based on observation, record review, and interview, the facility failed to ensure accuchecks (blood glucose level monitoring) were performed as ordered, and insulin pens were primed prior to administration of insulin for 2 of 3 residents reviewed for insulin administration. (Residents 258 and 9) Findings include: 1. During an observation on 5/17/22 at 8:42 a.m., LPN (Licensed Practical Nurse) 1 dispensed medications for Resident 258. She prepared [MEDICATION(S)] 5 mg (milligrams), [MEDICATION(S)] 2 mg, [MEDICATION(S)] 40 mg, [MEDICATION(S)] 10 mg, [MEDICATION(S)] 5 mg, and [MEDICATION(S)] 7.5 mg, by removing the medications out of the packaging and placing them directly into her bare, ungloved hand, and then placing the medication into a clear medication cup with bare fingers. The resident's order for an accucheck to be completed at 7:00 a.m. was highlighted in red as late. During an interview 5/17/22 at 8:45 a.m., LPN 1 indicated the Unit Manager had performed her accuchecks for her. She did not know if Resident 258 had received her accucheck and insulin, she would have to ask the unit manager if she had completed the task. During an interview on 5/17/22 at 8:48 a.m., the Unit Manager indicated she had not completed Resident 258's accucheck or administered her insulin. During an observation on 5/17/22 at 8:52 a.m., the Unit Manager obtained supplies and tested Resident 258's blood glucose level. The resident indicated during this time she had already eaten her breakfast. The resident's blood glucose level was 152 mg/dL. During an observation on 5/17/22 at 9:00 a.m., the Unit Manager attached the pen needle to Resident 258's tujeo insulin pen and dialed the pen to 35 units and administered the insulin to the resident's left upper quadrant. She did not prime the pen prior to the administration. The clinical record for Resident 258 was reviewed on 5/20/22 at 10:55 a.m. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 5/17/22 at 8:55 a.m., the Unit Manager indicated she didn't realize the resident had an accucheck due. Typically the nurses did their accuchecks, and she was not necessarily responsible for them, but the nurse was the only nurse on the hall and they decided the Unit Manager would do the accuchecks for her to give some relief to the nurse. 2. During an observation on 5/17/22 at 11:37 a.m., The Unit Manager checked Resident 9's blood glucose level. The resident's blood glucose level registered as 216 mg/dL (milligrams per deciliter). The unit manager indicated the resident would receive her sliding scale insulin as well as the routine insulin. During an observation on 5/17/22 at 11:40 a.m., the Unit Manager applied a disposable needle to Resident 9's [MEDICATION(S)] Kwikpen and dialed the pen to 20 units. She did not prime the needle or perform an air shot. She entered Resident 9's room, and administered 20 units of [MEDICATION(S)] subcutaneously to the resident's left upper quadrant. The clinical record for Resident 9 was reviewed on 5/20/22 at 10:09 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, initiated on 11/10/21 and last revised on 2/21/22, indicated the resident was at risk for adverse effects of [CONDITION(S)] or [CONDITION(S)] related to use of glucose lowering medications and or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] If Blood Sugar is less than 60, call MD. If Blood Sugar is 0 to 150, give 0 Units. If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 300, give 6 Units. If Blood Sugar is 301 to 400, give 8 Units. If Blood Sugar is 401 to 450, give 10 Units. If Blood Sugar is 451 to 500, give 12 Units. If Blood Sugar is greater than 500, call MD three times daily at 7:00 a.m., 11:00 a.m., and 4:00 p.m. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 5/20/22 at 9:56 a.m., the DON (Director of Nursing) indicated Resident 9's accucheck had been performed late by the Unit Manager because the order for the accu check had not been put on the correct flowsheet. When the resident admitted , it had been put in her medications flowsheet instead of the diabetic flowsheet. Her accu check order being on the wrong flow sheet was the root cause of the late administration. If an administration was scheduled for 7:00 a.m., they had from 6:00 a.m. to 8:00 a.m. to administer it. An hour after the administration time it would turn red, and when it turned red it indicated the medication was late. Nursing staff had been instructed to prime insulin pens prior to use. Priming insulin pens was a standard of practice and the pharmacy had instructed them on how to do the priming when the pens first came out. During an interview on 5/20/22 at 10:33 a.m., the DON indicated she did not have a policy on the timing of accu checks, however she would expect staff to adhere to the same standards of medication administration for timing. If it was an accucheck for sliding scale insulin, the accucheck would be obtained before meals. The Insulin Pen Administration Skills Competency Procedure Steps, last reviewed 10/2019, provided on 5/17/22 at 2:11 p.m. by the DON, included, but was not limited to, . 8. Attach pen needle by twsting the needle onto the end of the insulin pen. 9. Pull off and remove outer pen needle protective cap and cover. 10. Prime the pen by dialing 2 units. (A small drop of insulin should be visible. If insulin does not appear, repeat) . 3.1-37(a)

Based on observation, and interview, the facility failed to ensure the nurse staffing informaatiion was posted daily for 4 of 5 survey days. Findings include: The following observations were made between 5/16/22 and 5/20/22: The staff posting could not be located on 5/17/22 at 9:30 a.m. The ED (Executive Director) indicated the location was in the hall by the DON (Director of Nursing). The holder was empty. The staff posting on 5/18/22 at 9:00 a.m., and 12:00 p.m., indicated a date of 5/17/22. The staff posting on 5/19/22 at 8:50 a.m., and 11:10 a.m., indicated a date of 5/17/22. The staff posting on 5/20/22 at 9:48 a.m. indicated a date of 5/19/22. During an interview on 5/20/22 at 11:15 a.m., the ED indicated the scheduler was responsible for posting the daily staff schedule. During an interview on 5/20/22 at 11:38 a.m., the DNS indicated the scheduler had worked the night shift and posted yesterday's staffing schedule that night, so she couldn't get the schedule out during the day. The Posted Nurse Staffing Data and Retention Requirements policy, dated July, 2019, was provided by the DON on 5/20/22 at 11:38 a.m. The policy included, but was not limited to, . The facility must post the following information at the beginning of each shift . 11. The nurse staffing data must be posted in a prominent place readily accessible to residents and visitors. 12. The Nursing Staffing Data should be updated each shift if there are changes to the daily posting . 3.1-17(b)

Based on observation, record review, and interview, the facility failed to ensure timely administration of medication for 2 of 34 administrations observed. (Residents 257 and 33) Findings include: 1. During an observation of medication administration on 5/17/22 at 8:37 a.m., LPN (Licensed Practical Nurse) 1 administered [MEDICATION(S)] 5 mg, [MEDICATION(S)] 1 mg, and four tablets of primodone 50 mg to Resident 257. The medications were scheduled to be given at 7:00 a.m. and were highlighted in red in the EMAR (electronic medication record) as late. The clinical record for Resident 257 was reviewed on 5/20/22 at 11:15 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. During an observation of medication administration on 5/17/22 at 9:16 a.m., LPN 1 administered [MEDICATION(S)] 300 mg, [MEDICATION(S)] 5 mg, and [MEDICATION(S)] 50 mg to Resident 33 The medications were scheduled to be given at 7:00 a.m. and were highlighted in red in the EMAR (electronic medication record) as late. The clinical record for Resident 33 was reviewed on 5/20/22 at 11:11 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .m The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview, on 5/17/22 at 9:27 a.m., LPN 1 indicated she was the only nurse on the hall and had to administer medications to 26 to 28 residents. She typically ran late when she had that patient load. During an interview, on 5/20/22 at 9:56 a.m., the DON (Director of Nursing) indicated they tried to use four hour time frames for medications but if the medication had a specific time of administration, such as 7:00 a.m., they had to be administered within an hour before or after the scheduled time. One hour after the scheduled time it would turn red on the EMAR, which indicated the medication was late. The most current Medication Pass Procedure policy, last reviewed 12/2016, provided on 5/17/22 at 2:11 p.m., by the DON, included, but was not limited to, . Procedure Steps . 1. Medications administered within 60 minutes before and/or after time ordered . 3.1-48(c)(1)

Based on observation, record review, and interview, the facility failed to ensure documentation on the Narcotic Count Sheet of administered narcotics for 11 of 19 residents (Residents 50, 40, 21, 29, 38, 5, 23, 13, 27, 30, and 14) and 3 of 3 observations of medication storage (200, 300, and 400 hall medication carts). Findings include: 1. During an observation on 11/20/19, beginning at 10:47 a.m., of the 200 hall medication carts one and two, the following were observed: a. Resident 50's [MEDICATION NAME] 0.5 mg (milligram) the Controlled Substance Record sheet indicated the resident had a count of 12 tablets left. The resident's medication card contained 11 tablets of [MEDICATION NAME]. The last dose signed out on the Controlled Substance Record sheet was on 11/19/19 at 4:00 p.m. A clinical record review on 11/20/19 at 1:00 p.m., of the physician's orders [REDACTED]. The review of the resident's MAR (Medication Administration Record) indicated the resident's last dose of [MEDICATION NAME] 0.5 mg was administered on 11/20/19 at 8:00 a.m. b. Resident 40's [MEDICATION NAME] 600 mg the Individual Narcotic Count Sheet indicated the resident had a count of 26 tablets left. The resident's medication card contained 25 tablets of [MEDICATION NAME]. The last dose signed out on the Individual Narcotic Count Sheet was on 11/19/19 at 8:00 p.m. The clinical record review on 11/20/19 at 1:05 p.m., of the physician's orders [REDACTED]. The review of the resident's MAR indicated [REDACTED] c. Resident 21's [MEDICATION NAME] Immediate 10 mg the Controlled Substance Record sheet indicated the resident had a count of 19 tablets left. The resident's medication card contained 18 tablets of [MEDICATION NAME] Immediate. The last dose signed out on the Controlled Substance Record sheet was on 11/20/19 at 2:43 a.m. The clinical record review on 11/20/19 at 1:10 p.m., of the physician's orders [REDACTED]. The review of the resident's MAR indicated [REDACTED] Resident 21's [MEDICATION NAME] 600 mg the Individual Narcotic Count Sheet indicated the resident had a count of 20 tablets left. The resident's medication card contained 19 tablets of [MEDICATION NAME]. The last dose signed out on the Individual Narcotic Count Sheet was on 11/19/19 at 4:00 p.m. The physician's orders [REDACTED]. The review of the resident's MAR indicated [REDACTED] d. Resident 29's [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg the Controlled Substance Record sheet indicated the resident had a count of 28 tablets left. The resident's medication card contained 27 [MEDICATION NAME] tablets. The last dose signed out on the Controlled Substance Record sheet was on 11/19/19 at 8:00 a.m. The clinical record review on 11/20/19 at 1:15 p.m., of the physician's orders [REDACTED]. The review of the resident's MAR indicated [REDACTED] e. Resident 38's [MEDICATION NAME] 2 mg the Controlled Substance Record sheet indicated the resident had a count of 14 tablets left. The resident's medication card contained 13 [MEDICATION NAME] tablets. The last dose signed out on the Controlled Substance Record sheet was on 11/19/19 at 8:00 p.m. The clinical record review on 11/20/19 at 1:20 p.m., of the physician's orders [REDACTED]. The review of the resident's MAR indicated [REDACTED] f. Resident 5's [MEDICATION NAME] 5-325 mg the Controlled Substance Record sheet indicated the resident had a count of 10 tablets left. The resident's medication card contained 9 [MEDICATION NAME] - [MEDICATION NAME] tablets. The last dose signed out on the Controlled Substance Record sheet was signed out on 11/19/19 at 8:00 a.m. The clinical record review on 11/20/19 at 1:25 p.m., of the physician's orders [REDACTED]. The review of the resident's MAR indicated [REDACTED] g. Resident 23's [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg the Controlled Substance Record sheet indicated the resident had a count of 1 tablet left. The resident's medication card contained 0 [MEDICATION NAME] tablets. The last dose signed out on the Controlled Substance Record sheet was signed out on 11/19/19 at 8:30 a.m. The clinical record review on 11/20/19 at 1:30 p.m., of the physician's orders [REDACTED]. The review of the resident's MAR indicated [REDACTED] During an interview on 11/20/19 at 12:50 p.m., LPN (Licensed Practical Nurse) 9 indicated We are supposed to sign out our narcotics when we pop them out of the container. 2. During an observation on 11/20/19 at 10:21 a.m., of the 300 hall medication cart with LPN 8, the following discrepancies were observed: h. Resident 13's [MEDICATION NAME] 300 mg (milligram) Individual Narcotic Count Sheet indicated the resident had a count of 4 tablets left. The resident's medication card only contained 3 tablets of [MEDICATION NAME]. The last dose signed out on the Controlled Substances Record sheet was on 11/19/19 at 8:00 p.m. During the clinical record review on 11/20/19 at 12:40 p.m., the resident's MAR indicated [REDACTED] The physician's orders [REDACTED]. During an interview on 11/20/19 at 10:22 a.m. LPN 8 indicated he had given the medication at 7:45 a.m. i. Resident 27's [MEDICATION NAME] 0.5 mg Controlled Substances Record Sheet indicated the resident had a count of 13 tablets left. The resident's medication card only contained 12 tablets of [MEDICATION NAME]. The last dose signed out on the Controlled Substances Record sheet was on 11/19/19 at 8:00 p.m. During the clinical record review on 11/20/19 at 12:44 p.m., the resident's MAR indicated [REDACTED] The physician's orders [REDACTED]. During an interview on 11/20/19 at 10:24 a.m., LPN 8 indicated he had given the medication at 8:25 a.m. 3. During an observation on 11/20/19 at 10:25 a.m., of the 400 hall medication cart with LPN 8 the following discrepancies were observed. j. Resident 30's [MEDICATION NAME] HCL 50 mg Individual Narcotic Count Sheet indicated the resident had a count of 22 tablets left. The resident's medication card only contained 20 tablets of [MEDICATION NAME]. The last dose signed out on the Individual Narcotic Count Sheet was on 11/19/19 at 8:00 p.m. During the clinical record review on 11/20/19 at 12:46 p.m., the resident's MAR indicated [REDACTED] The physician's orders [REDACTED]. During an interview on 11/20/19 at 10:27 a.m. LPN 8 indicated he had given the resident's medication at 9:00 a.m. k. Resident 14's [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg Controlled Substances Record sheet indicated the resident had a count of 6 tablets left. The resident's medication card only contained 5 tablets of [MEDICATION NAME]-[MEDICATION NAME]. The last dose signed out on the Controlled Substances Record sheet was on 11/19/19 at 7:00 p.m. During the clinical record review on 11/20/19 at 12:48 p.m., the resident's MAR indicated [REDACTED] The physician's orders [REDACTED]. During an interview on 11/20/19 at 10:30 a.m., LPN 8 indicated he had given the resident's medication at 8:30 a.m. He had gotten busy and had not signed the narcotics out, but had planned on getting to them. Narcotics were supposed to be signed out when removed from the package. The General Dose Preparation and Medication Administration policy dated 12/1/07, last revised on 1/1/13, provided on 11/20/19 at 12:40 p.m., by the Corporate DON (Director of Nursing) included, but was not limited to, . 5. During medication administration . 5.5 Document the administration of controlled substances in accordance with Applicable Law . 3.1-25(3)

Based on observation and interview, the facility failed to ensure residents were provided privacy during 2 of 4 observations of personal care. (Residents 21 and 50) Findings include: 1. During an observation of incontinence care on 11/19/19 at 12:59 p.m., Resident 21 was provided care by CNAs (Certified Nursing Aides) 5 and 6. The CNA's provided the entire incontinence care with the privacy curtains open the length of the foot of the bed and each side of the bed. The entry door to the room was left open during care. Review of the resident's clinical record on 11/19/19 at 1:59 p.m., indicated the resident's [DIAGNOSES REDACTED]. The Significant Change in Status MDS (Minimum Data Set) assessment, dated 9/10/19, indicated the resident was cognitively intact. 2. During an observation of suprapubic catheter care on 11/19/19 at 1:19 p.m., Resident 50 was provided care by CNAs 5 and 6. The CNA's provided the entire catheter care procedure with the privacy curtains open the entire length of the bed, facing the entry door. Review of the resident's clinical record on 11/20/19 at 1:12 p.m., indicated the resident's [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 10/21/19, indicated the resident was cognitively intact. During an interview on 11/20/19 at 9:21 a.m., CNA 4 indicated during care she would provide privacy by pulling the privacy curtains, shutting the door, and keeping the top and bottom of the resident covered. During an interview on 11/20/19 at 12:49 p.m., Resident 21 indicated it would upset him if someone walked in during care and the door and curtains were open. During an interview on 11/20/19 at 12:54 p.m., the DHS (Director of Health Services) indicated when providing privacy, staff should close the blinds and the door. The privacy curtain should be pulled to completely enclose the area. The review of the Perineal Care policy reviewed on 03/2012 included, but was not limited to, . 2. Provide for privacy . 3.1-3(t)

Based on observation, record review, and interview, the facility failed to follow appropriate infection control guidelines related to perineal and suprapubic catheter care for 3 of 4 residents observed for infection prevention. (Resident 21, 50, and 49). Findings include: 1. During an observation on 11/19/19 at 12:59 p.m., of incontinence care on Resident 21 by CNAs (Certified Nursing Aides) 5 and 6, wipes were obtained. CNA 5 cleaned the scrotum first. Then with 5 swipes, with the same area of the wipe, cleaned the tip of the penis. The shaft was not cleaned. The resident was rolled onto his left side and with 2 swipes with the same area of the wipe, the anal area was cleaned. The resident's clinical record was reviewed on 11/19/19 at 1:59 p.m. The resident's [DIAGNOSES REDACTED]. The Significant Change in Status MDS (Minimum Data Set) assessment, dated 9/10/19, indicated the resident was cognitively intact. The resident's current care plan, dated 11/14/18 and revised on 09/20/19, indicated the Resident requires assistance with toileting and is incontinent due to: [MEDICAL CONDITION], incomplete, chronic pain, anxiety, depression, [MEDICAL CONDITION], decreased mobility. Interventions included, Assess and document skin condition weekly and as needed. Assist with elimination. Assist with incontinent care as needed. Check every 2 hours for incontinence. Document any abnormal findings and notify MD (physician). Observe for signs of urinary tract infection: decreased output, concentrated urine, abdominal/flank pain, difficult/painful urination, frequency, change in mental status, fever, increase in incontinence. 2. During an observation on 11/19/19 at 1:19 p.m., suprapubic catheter care was provided on Resident 50 by CNAs 5 and 6. CNA 5 applied soap to the wet washcloth and using 7 swipes with the same area of the cloth, the skin around the tubing insertion site was cleaned. She obtained another wet washcloth and applied soap and using 5 swipes with the same area of the cloth, cleaned the area around the tubing again. She folded the washcloth and swiped 36 times, one inch up and then down the tubing. She obtained a wet washcloth, and using 9 swipes with the same side of the cloth, rinsed the area around the tubing and patted the area dry with a dry washcloth. The resident's clinical record was reviewed on 11/20/19 at 1:12 p.m. The resident's [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 10/21/19, indicated the resident was cognitively intact. The resident's current care plan, dated 11/12/2015 and revised on 11/12/19, indicated the Resident requires a suprapubic catheter related to [MEDICAL CONDITION] bladder due to [DIAGNOSES REDACTED]. Assess the drainage every shift. Record the amount, type, color, odor. Observe for leakage. Avoid obstructions in the drainage . Keep catheter system a closed system as much as possible. Manipulate tubing as little as possible during care . Report complications/UTI (e.g., acute confusion, bladder spasms, low back/flank pain, malaise, nausea, emesis, chills, fever, foul odor, concentrated urine, blood in urine, obstruction, tissue trauma at site, dislodgment of catheter, bowel perforation). Store collection bag inside a protective dignity pouch. 3. During an observation of incontinence care on 11/20/19 at 9:08 a.m., on Resident 49 by CNAs 4 and 7, the basin of water had been filled and soap was added to the basin. CNA 4 cleaned the creases to each side of the labia, swiping 2 times with the same area of the cloth. CNA 7 dried the creases with 2 swipes of the same area of the towel. The resident was rolled onto the left side and CNA 7 cleaned the anal area using 3 swipes with the same area of the washcloth. The resident urinated and the bedding was removed. The peri care was provided again with CNA 7 swiping 3 times with the same area of the cloth on the anal area. She obtained another washcloth and swiped the anal area 2 times with the same area of the cloth. The resident's clinical record was reviewed on 11/20/19 at 10:11 a.m. The resident's [DIAGNOSES REDACTED]. The resident's current care plan, dated 8/7/17 and revised on 11/18/19, indicated the Resident requires assistance with toileting and is incontinent due to left above the knee amputation d/t (due to) [MEDICAL CONDITIONS] r/t (related to) chronic cardiac d/o (disorder), hx (history of) [MEDICAL CONDITION](cardiovascular accident) with left sided weakness, type II diabetes with [MEDICAL CONDITION], chronic pain, history of falls, dizziness, unsteady gait, decreased mobility. Interventions included, Assess and document skin condition weekly and as needed. Assist with elimination. Assist with incontinent care as needed. Check every 2 hours for incontinence. Document any abnormal findings and notify MD. Observe for signs of urinary tract infection: decreased output, concentrated urine, abdominal/flank pain, difficult/painful urination, frequency, change in mental status, fever, increase in incontinence. Toilet resident upon rising, before and after meals, at bedtime and as needed. During an interview on 11/20/19 at 9:21 a.m., CNA 5 indicated for incontinence care she wound obtain multiple rags, test the water, open the brief, fold the rag between swipes, then clean with a new rag. During an interview on 11/20/19 at 12:54 p.m., the DON (Director of Nursing) indicated the staff shouldn't use the same area of the cloth. They should use a new wipe or fold the cloth and use the corner. They should clean from the center outward. Suprapubic catheter care would be the same as for the indwelling urinary catheter. They should clean 4 inches down the tubing. The review of the Indwelling Urinary Catheter Care, Emptying Drainage Bag & Catheter Removal policy last reviewed on 12/2012, included, but was not limited to, .cleanse the catheter in circular motion for about 10 cm (centimeters) (4 inches). Start cleansing where the catheter enters the meatus and down toward the drainage tube. Change area on the washcloth or retrieve a new washcloth for consecutive passes along the catheter tubing. Do not rewipe the catheter . The review of the Perineal Care policy reviewed on 03/2012 included, but was not limited to, .Use a clean area of the wash cloth with each wipe. Do not rewipe area, unless using a clean area of the wash cloth. Change wash cloth as needed . Males: Wash and rinse tip of penis in circular motion, starting at urethra moving outward . Continue washing down the penis to the scrotum outward . Clean anal area from front to back, using a clean area of wash cloth with each wipe . 3.1-18(a)

Based on record review and interview, the facility failed to develop a care plan which addressed the resident's noncompliance with refusal to wear her stump shrinker stocking to the left Above the Knee Amputation for 1 of 12 residents reviewed for care plans. (Resident 29). Findings include: A review of the clinical record for Resident 29, on 10/31/18 at 10:23 a.m., indicated the resident's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, dated 10/23/18, indicated the resident was alert and oriented. On 10/31/18 at 11:35 a.m., a review of the physician's orders [REDACTED]. A record review, on 10/3/18 at 2:18 p.m., indicated the clinical record lacked documentation related to the resident's noncompliance and refusal to wear her stump shrinker stocking. During an interview, on 10/31/18 at 11:43 a.m., the resident indicated, I only wear my shrinker at the most nine hours a day. I don't like to wear it all the time and I refuse to put it on. During an interview, on 10/31/18 1:56 p.m., the O.T. (Occupational Therapist) indicated, The resident doesn't want to wear her stump shrinker. In the beginning it was for shaping and protection. Now it is ordered for protection. When I see her she will have it on sometimes and sometimes she will tie her pant leg over it. During an interview, on 10/31/18 at 2:12 p.m., the DON (Director of Nursing) indicated, The resident is noncompliant with wearing her stump shrinker. She is supposed to wear it twenty four seven. Because she is noncompliant she should have had a care plan. During an interview, on 11/01/18 at 10:44 a.m., RN 5 indicated the resident should of had a care plan for noncompliance related to the stump shrinker. A current Care Plan policy was provided by LPN 6 on 10/31/18 at 2:18 p.m., and included, but was not limited to, .The care plan will include resident-centered goals and interventions relative to resident needs and preferences to promote the residents highest level of functioning including medical, nursing, mental and psychosocial needs . 3.1-35(a) 3.1-35(b)(1)

Based on observation, record review, and interview, the facility failed to ensure the physician's orders were followed related to a stump shrinker stocking for an Above the Knee Amputation for 1 of 4 residents reviewed for prosthetic devices. (Resident 29) Findings include: A review of the clinical record for Resident 29, on 10/31/18 at 10:23 a.m., indicated the resident's [DIAGNOSES REDACTED]. On 10/31/18 at 11:35 a.m., a review of the physician's orders, for (MONTH) (YEAR), indicated the resident was to wear a STtump (sp) shrinker stocking to Left AKA (Above the Knee Amputation) at all times. (MONTH) remove for showers or baths every shift . During an observation, on 10/29/18 at 10:32 a.m., Resident 29 had a sign above her bed stating, (resident) is to wear stump shrinker 24/7 (twenty four hours/seven days). Remove only for showers. If it is soiled DO NOT send it to laundry. Hand wash/dry or give to therapy. The resident was observed without her stump shrinker on her left AKA. During an observation, on 10/30/18 at 10:34 a.m., the resident was in her room sitting in her wheelchair. The resident was not wearing her left AKA stump shrinker. During an observation, on 10/31/18 at 11:43 a.m., the resident was resting quietly in bed. The resident did not have her left AKA stump shrinker on while in bed. Record review, on 10/31/18 at 07:47 p.m., indicated the clinical record lacked documentation related to the resident's refusal to wear her stump shrinker as ordered by the physician. On 10/31/18 at 11:43 a.m., during an interview Resident 29 indicated I only wear my shrinker at the most nine hours a day. I don't like to wear it all the time and I refuse to put it on. On 10/31/18 at 1:46 a.m., during an interview LPN (Licensed Practical Nurse) 3 indicated, If she (Resident 29) gets a rash or anything like that, she will refuse to put it on. Right now her rash has healed. Most of the time she won't wear it in bed, but she will put it on while she is up in the wheelchair. She is not compliant with wearing it. On 10/31/18 at 1:56 p.m., during an interview the O.T. (Occupational therapist) indicated, The resident doesn't want to wear her stump shrinker. In the beginning it was for shaping and protection. Now it is ordered for protection. When I see her, she will have it on sometimes and sometimes she will tie her pant leg over it. On 10/31/18 at 2:12 p.m., during an interview the DON (Director of Nursing) indicated, The resident is noncompliant with wearing her stump shrink. She is supposed to wear it twenty four seven. On 11/01/18 at 10:44 a.m., during an interview RN 5 indicated, We should have called the doctor and had the order changed, because that was when she first had her leg amputated. A current Nursing Admission or Return Admission Procedure policy dated (MONTH) (YEAR) was provided by LPN 6 on 10/31/18 at 2:18 p.m., and included but was not limited to, .procedures will be followed for all admissions including physician's orders . 3.1-47(a)(8)

Based on observation and interview, the facility failed to follow appropriate infection control guidelines related to catheter bags and tubing for 1 of 3 residents with urinary catheters. (Resident 3). Findings include: During an observation on 10/29/18 at 12:30 p.m., Resident 3's indwelling urinary catheter tubing was dragging on the floor while in the resident was in a wheelchair in his room. On 10/30/18 at 09:56 a.m., the resident's tubing and the catheter bag inside a dignity bag was dragging the floor as the resident was pushed in his wheelchair to the hair salon. The dignity bag dragging the floor had a white powdery substance on the bottom of the bag. During an observation, on 10/30/18 at 11:03 a.m., the resident was observed sitting in the dining room in his wheel chair. The tubing of his catheter was laying on the floor. On 10/30/18 at 12:52 p.m., the review of Resident 3's [DIAGNOSES REDACTED]. The review, on 10/30/18 at 12:57 p.m., of the Care Plan, with a started date of 06/06/17 and a revised date of 08/02/18, indicated, Resident requires an indwelling urinary catheter R/T (related to) [MEDICAL CONDITIONS] and [MEDICAL CONDITION] at risk for infection. Interventions, dated 10/23/17, indicated Do not allow tubing or any part of the drainage system to touch the floor . On 10/30/18 at 01:09 p.m., the review of the physician's orders [REDACTED]. During an interview, on 11/01/18 at 09:19 a.m., CNA (Certified Nursing Assistant) 2 indicated she would make sure the tubing wasn't too tight and was hanging under the chair in a cover and would drain well. The tubing had a squeeze clamp to make sure the tubing doesn't touch the floor. During an interview, on 11/01/18 at 01:16 p.m., the DON (Director of Nursing) indicated the catheter bag and tubing should not touch the floor. Even when it was in a dignity bag, it should not drag the floor. On 11/01/18 at 1:52 p.m., the DON provided a copy of the last Record of Facility Inservice, dated 08/06/18 thru 08/08/18, included, but was not limited to, .Cath (catheter) care & dignity bags *no tubing or bag on floor. Nursing and CNA signatures were documented as in attendance. 3.1-18(a)

Based on observation and interview, the facility failed to follow appropriate handwashing or hand sanitizer during contact with food and residents for 1 of 16 residents in the Main Dining Room. (Resident 6) and 3 of 13 residents in the Restorative Dining Room. (Residents 33, 36 and 61) Findings include: 1. During a lunch observation on 10/9/17 at 12:10 p.m., LPN (Licensed Practical Nurse) 1 was observed to cut up Resident 6's sandwich with a knife and her hand on top of the bun. She then picked the sandwich up and handed it to the resident so she could feed herself. 2. During lunch observation on 10/10/17 at 11:20 a.m., the following was observed: a. CNA (Certified Nursing Assistant) 1 with bare hands picked up Resident 36's bun lid, placed mayonnaise on it, and held the sandwich to be cut with a knife. b. CNA 1 picked up Resident 61's bun to put tomatoes and lettuce on the sandwich with her bare hands. She then cut the sandwich in half, picked up half the sandwich and fed it to the resident. After answering a call light and washing her hands, she gently shook Resident 33 to awaken him to eat. She then picked up Resident 61's sandwich again to feed him. She put it down to open the sandwich to take the tomato off, adjusted his chair back and then sat down and continued to feed him his sandwich. During an interview on 10/11/17 at 1:30 p.m., CNA 2 indicated To cut up a sandwich, I would use the knife and fork utensils. To butter bread, I would butter half while leaving half still in the bag. Don't want to touch it with my hands. During an interview on 10/12/17 at 8:55 a.m., CNA 3 indicated Protocol is to grab gloves or use utensils to cut up a resident's sandwich if it needed to be. CNA 1 agreed with CNA 3 that utensils were to be used. On 10/16/17 at 9:00 a.m., the Director of Nursing indicated Staff should be using silverware to butter bread and to pick up the top piece of bread or bun when fixing a sandwich. Staff should use a fork to feed a resident a sandwich and should not be using their hands. 3.1-21(i)(2) 3.1-21(I)(3)

Based on interview and record review, the facility failed to report an allegation of abuse to the Indiana State Department of Health and other agencies for 1 of 3 residents reviewed for abuse. (Resident B) Findings include: The clinical record for Resident B was reviewed on 5/22/17 at 10:20 a.m. [DIAGNOSES REDACTED]. The initial MDS (Minimum Data Set) assessment, dated 4/14/17, indicated the resident had severely impaired cognition. During a telephone interview on 5/22/17 at 11:48 a.m., a family member indicated Resident B told her a man at the nursing home tried to hurt and rape her. During a telephone interview on 5/22/17 at 12:56 p.m., a family friend of Resident B indicated she told her a man had tried to hurt her and raped her and it was reported to facility staff. During an interview on 5/22/17 at 2:10 p.m., CNA (Certified Nursing Assistant) 3 indicated Resident B's friend reported to her that the resident said she had been raped, and she reported the incident to her nurse. CNA 3 could not remember the date or time of the incident. During an interview on 5/22/17 at 2:20 p.m., LPN (Licensed Practical Nurse) 4 indicated it was reported to her, by CNA 3, that the resident said she had been raped, and she reported the incident to the Director of Nursing. LPN 4 could not remember the date or time of the incident. During an interview on 5/22/17 at 2:46 p.m., the DON (Director of Nursing) who was unsure of the date and time, she indicated she spoke with Resident B's friend who told her the resident said she was raped. She spoke with Resident B who denied the allegation, and the resident showed no signs of trauma or fearfulness. I thought at the time I had handled the incident since the resident told me nothing had happened. I did not handle it right and should have reported the incident. The DON indicated she did not notify the Administrator. On 5/22/17 at 10:05 a.m., the Administrator provided a copy of the document titled Abuse Prohibition, Reporting, and Investigation, dated August 2016. It included, but was not limited to, the following: .It is the policy .to protect residents from abuse including .sexual abuse .Policy/Procedure .will not permit residents to be subjected to abuse by anyone, including .other residents .All abuse allegations .must be reported to the Executive Director immediately and to the resident's representative .within 24 hours of the report .The Executive Director/designee will report all unusual occurrences, which include allegations of abuse .to the Long Term Care Division of the Indiana State Department of Health. Upon completion of the investigation, which must occur within 5 working days of the reporting of an occurrence, a report of the investigation must be forwarded to the Long Term Care Division of the Indiana State Department of Health. Copies of the completed investigation must also be sent to Adult Protective Services, Ombudsman, and Director of Operations . This Federal tag relates to Complaint IN 008 3.1-28(b)(2)

Based on interview and record review, the facility failed to implement written policies and procedures regarding abuse as evidenced by failure to report an abuse allegation to the Indiana State Department of Health and other agencies for 1 of 3 residents (Resident B) reviewed for abuse. Findings include: The clinical record for Resident B was reviewed on 5/22/17 at 10:20 a.m. [DIAGNOSES REDACTED]. The initial MDS (Minimum Data Set) assessment, dated 4/14/17, indicated the resident had a severely impaired cognition. On 5/22/17 at 11:48 a.m. during a telephone interview, a family member indicated Resident B told her a man at the nursing home tried to hurt and rape her. On 5/22/17 at 12:56 p.m. during a telephone interview, a family friend of Resident B indicated she told her that a man had tried to hurt her, and raped her and the allegation was reported to facility staff. On 5/22/17 at 2:10 p.m. during an interview with CNA (Certified Nursing Assistant) 3, she indicated Resident B's friend reported to her that the resident said she had been raped, and she reported the incident to her nurse. CNA 3 could not remember the date or time of the incident. On 5/22/17 at 2:20 p.m. during an interview with LPN (Licensed Practical Nurse) 4, she indicated it was reported to her by CNA 3 that the resident said she had been raped, and she reported the incident to the Director of Nursing. LPN 4 could not remember the date or time of the incident. On 5/22/17 at 2:46 p.m. during an interview with the DON (Director of Nursing) who was unsure of the date and time, she indicated she spoke with Resident B's friend who told her the resident said she was raped. She spoke with Resident B who denied the allegation, and the resident showed no signs of trauma or fearfulness. I thought I had handled the incident since the resident told me nothing had happened. I did not handle it right and should have reported the incident. She did not notify the Administrator. On 5/22/17 at 10:05 a.m., the Administrator provided a copy of the current document titled Abuse Prohibition, Reporting, and Investigation, dated August 2016. It included, but was not limited to, the following: .It is the policy .to protect residents from abuse including .sexual abuse .Policy/Procedure .will not permit residents to be subjected to abuse by anyone, including .other residents .All abuse allegations .must be reported to the Executive Director immediately and to the resident's representative .within 24 hours of the report .The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed. In the absence of the Executive Director, this responsibility will be delegated to the Director of Nursing .The Executive Director/designee will report all unusual occurrences, which include allegations of abuse .to the Long Term Care Division of the Indiana State Department of Health. Upon completion of the investigation, which must occur within 5 working days of the reporting of an occurrence, a report of the investigation must be forwarded to the Long Term Care Division of the Indiana State Department of Health. Copies of the completed investigation must also be sent to Adult Protective Services, Ombudsman, and Director of Operations .A comprehensive record of the abuse investigation is to be kept by the facility Executive Director and/or Director of Nursing Services .It is the responsibility of every employee of .to not only report abuse situations, but also suspicion of abuse .to his/her immediate supervisor and to the Executive Director .Resident-To-Resident Abuse .Procedure .If resident-to-resident abuse is identified, or there is suspicion of resident-to-resident abuse, the following guidelines will be followed .The Executive Director .will be notified immediately of the report and the initiation of the investigation .The charge nurse will assess .residents involved to determine if physical injuries have occurred .a. Residents will be questioned (if alert and competent) about the nature of the incident .The attending physician will be notified .The family of the resident (s) and/or responsible party will be notified .9. Follow up assessments will be completed/documented every shift .It is the responsibility of the Administrator/Director of Nursing to report the abuse, or allegations of abuse, immediately to the Indiana State Department of Health .The Administrator/Director of Nursing will report the final results of the investigation to the Indiana State Department of Health within five working days . This Federal tag relates to Complaint IN 008 3.1.28(a)

Based on interview and record review, the facility failed to follow procedure for fall management related to a fall event on a resident (Resident E) who sustained a fall for 1 of 3 residents reviewed for accidents. Findings include: The clinical record for Resident E was reviewed on 11/16/16 at 12:00 p.m. [DIAGNOSES REDACTED]. The incident report, dated 10/2/16, included, but was not limited to, the following: .(Resident E's name) .Brief Description of Incident .It was reported on 10/2/16 that resident fell on [DATE] in her room .Follow up .10/06/2016 .The investigation confirmed there was not any knowledge or report of a fall involving the resident . The written statement from CNA (Certified Nursing Assistant) 2, undated and untimed, included, but was not limited to, the following: Went to help (CNA 3's first name) with resident (sic) Resident was in bathroom (sic) had walker but couldn't get around to walk (sic) (CNA 3's first name) said to me (sic) get the chair. I got the chair (sic) we finally got her in the chair (sic) went to get her up. We got her turn (sic) around and was getting her in bed (and sign) her legs give (sic) out on her. We tried to lift her in the bed (and sign) she wouldn't move. She started to go down (and sign) we grap (sic) her pants (and sign) tried to lift her up. We knew we couldn't do it so we lower (sic) her to the floor. We got a good grip (and sign) then we got her back in the bed . The written statement from from the Director of Nursing (DON), indicated as verbal confirmation per telephone conversation from CNA 3, dated 10/3/16 and untimed, included, but was not limited to, the following: .(10p-6a 10/2) .During a transfer from w/c (wheelchair) to bed, she (plus sign) (and) (CNA 2's first name) had to sit her on the ground due to she would not bear wt (weight) - dead weight. Took a rest (plus sign) (and) assistd (sic) her back to bed . The clinical record lacked documentation of the fall. During an interview with the DON on 11/18/16 at 11:25 a.m., she indicated Resident E did have a fall and the nurse working was aware of it and a fall event should have been completed. On 11/18/16 at 12:45 p.m., the DON provided a current copy of the document titled Fall Management Program, dated 7/2016. It included, but was not limited to, the following: .Procedure .Post Fall .1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided .3. The physician will be contacted .4. The family will be notified .5. A fall event will be initiated as soon as the resident has been assessed and cared for .The report must be completed in full in order to identify possible root causes of the fall and provided immediate interventions .6. All falls will be discussed by the Interdisciplinary team (IDT) .The fall event will be reviewed by the team .IDT note will be written .The care plan will be reviewed and updated, as necessary . This Federal tag relates to Complaint IN 871 3.1-45(a)(2)

Based on interview and record review, the facility failed to withhold administering an anti-anxiety medication when interventions were documented as effective and failed to ensure non-pharmacological interventions were attempted prior to administering an anti-anxiety medication for 1 of 3 residents reviewed for unnecessary medications. (Resident E) Findings include: The clinical record for Resident E was reviewed on 11/16/16 12:00 p.m. [DIAGNOSES REDACTED]. The care plan for Resident E included, but was not limited to, the following: .Problem .Behavioral Symptoms .Resident has episodes of increased anxiousness .Approach .Intervention #1 Assure that all needs will be met .Intervention #2 Assure she has pen and paper to write down her needs .Intervention #3 Meds. (sic) per orders . The Controlled Drug Record, dated 9/29/16, included, but was not limited to, the following: .(Resident E's name) .[MEDICATION NAME] 0.5 mg (milligram) (anit-anxiety medication) tablet .Give 1 tablet by mouth 3 times a day as needed . The record indicated the medication was administered on 9/30/16 at 3:00 p.m. and 10/1/16 at 11:00 a.m. During an interview on 11/18/16 at 11:25 a.m., the Director of Nursing indicated she could not locate the behavior flowsheet for September 2016. The September 2016 Medication Administration Record [REDACTED].PRN (as needed) Medications Flowsheet: (Resident E's name) .[MEDICATION NAME] .tablet .0.5 mg .Three Times A Day - PRN .Generalized anxiety . The September 2016 MAR indicated [REDACTED] The behavior flowsheet for October 2016 included, but was not limited to, the following: .(Resident E's name) .Behavior: Resident has episodes of increased anxiousness .Sa 1 (October 1) .Day .Y .# of bx (behavior) episodes .1 .Interventions tried .1 (#1) .Effective Y/N .Y .Eve (evening) .Y .# of bx episodes .2 .Interventions tried .1,2 .Effective .Y The nurses note, dated 10/1/16 at 1:24 p.m., included, but was not limited to, the following: .Gave her a [MEDICATION NAME] ([MEDICATION NAME]) with some effect . During an interview on 11/16/16 at 2:32 p.m., the Director of Nursing indicated she did not know why the [MEDICATION NAME] was given if the interventions were effective. On 11/16/16 at 3:06 p.m., the Administrator provided a current copy of the document titled [MEDICAL CONDITION] Management Policy, dated 1/2016. It included, but was not limited to, the following: .Policy: It is the policy of American Senior Communities to ensure that a resident's [MEDICAL CONDITION] medication regimen helps promote the resident's highest practicable mental, physical and psychosocial well-being .Procedure .3. Prior to initiating a [MEDICAL CONDITION] medication, an assessment will be made of the resident .6. All residents who are taking antipsychotic .sedative/hypnotic .are required to have a behavior monitoring program in place .as well as personalized non pharmacological interventions . The Federal tag relates to Complaint IN 871 3-1.48(a)(4) 3-1.48(a)(3)

Based on observations and interviews, the facility failed to ensure resident bedrooms had full visual privacy in that curtains were too short when pulled around the resident beds, curtains were missing off the window to the hall, and/or the ceiling track did not allow the curtain to be pulled around the bed. This deficient practice affected 7 of 8 resident rooms observed. (Rooms #401, #403, #404, #405, #406, #407 and #408). Findings include: 1. During initial room observations and interviews on 9/20/16 starting at 10:53 a.m., the following was observed: a. In Room #407 the privacy curtain on the wall by the window, which looked out into the hall, was missing. The resident indicated They said they are going to be renovating my room soon, but they took the curtain down sometime ago though. b. In Room #405 both Bed A's and Bed B's curtains were two feet too short to provide privacy when fully extended. c. In Room #403 Bed A's privacy curtain was two feet too short when fully extended and Bed B's ceiling track would not allow the curtain between the beds to come around the bed to provide visual privacy. 2. During room observations, on 9/21/16 starting at 9:41 a.m., the following was observed: a. In Room #404 Bed B's ceiling track would not allow the curtain between the beds to come around the bed to provide full visual privacy. b. In Room #401 both of Bed A's and B's curtains were one and a half feet too short when fully extended to provide full visual privacy. c. In Room #406 B the ceiling track would not allow the curtain between the beds to come around the bed to provide full visual privacy. d. In Room #408 Bed A's and B's curtains were one and a half feet too short when fully extended to provide visual privacy. On 9/23/16 at 11:25 a.m., an environmental tour was conducted with the Administrator, Director of Environmental Services, and the Corporate Consultant. During an environmental tour and interview, on 9/23/16 at 11:25, the Administrator and Director of Environmental Services indicated the curtains in the rooms observed were too short and some of the ceiling tracks did not allow for the residents visual privacy. 3.1-19(l)(6)

Based on observation, interview and record review, the facility failed to ensure proper infection control practices and standards were maintained related to incontinence care for 2 of 3 residents observed. (Residents # 7 and 12) Findings include: 1. During an observation on 09/22/16 at 1:35 p.m., CNA (Certified Nursing Assistant) #1 and CNA #3 were providing incontinence (perineal) care for Resident #7. CNA #3 obtained a wet wipe, and using a front to back motion, cleaned the labial area, folding, then swiping again. Another wet wipe was obtained and CNA #3 swiped several times with the same area of the wipe on the crease to the right of the labia, then the crease to the left of the labia. They rolled the resident to the left side. CNA #3 obtained a wet wipe and cleaned the buttocks and then the rectal area with the same area of the wipe, using a front to back motion. 2. During an observation on 09/23/16 at 9:25 a.m., CNA #1 and CNA #2 were providing incontinence (perineal) care for Resident #12. CNA #2 obtained a wet wipe, and using a front to back motion, cleaned the labial area, folding, then swiping again. Another wet wipe was obtained and she swiped the crease to the right of the labia three times using the same area of the wipe and twice to the crease to the left of the labia, with the same wipe. After use of the wet wipe the resident's perineal area was not dried. During an interview on 09/23/16 at 9:55 a.m., CNA #1 indicated for perineal care you should start in the labial area first and work outwards to the creases, using a front to back motion with the wet wipes. Next the resident would be rolled over and the rectal area would be cleaned first using a front to back motion. A clean area of the wipe or a new wipe would be used with each swipe. On 09/23/16 at 10:01 a.m., the DON (Director of Nursing) indicated she would use a clean area of the wet wipe or obtain a new wipe with each swipe during perineal care. On 09/21/16 at a.m., the DON provided a copy of the Perineal Care Policy & Procedure for both female and male, which indicated, but was not limited to, .Use a clean area of the wash cloth with each wipe. Do not re-wipe area, unless using a clean area of the wash cloth. Change wash cloth as needed .Gently pat area dry in same direction as when washing. 3.1-18(a)

Based on interview and record review, the facility failed to ensure it received medication from the pharmacy at the ordered dose and failed to ensure the medication was administered to the resident at the physician's prescribed dose, for 1 of 1 resident reviewed for a medication incident, resulting in overnight hospitalization of the resident. Resident #62 Findings include: The clinical record of Resident #62 was reviewed on 7/11/12 at 10 A.M. [DIAGNOSES REDACTED]. During the clinical record review, a physician order [REDACTED]...3 ml (milliliters) tid (three times a day)..." A MAR (medication administration record) dated June 2012 indicated the following: "Diazepam (valium) 5 mg/5 ml solution...give 3 ml ...3 times a day..." Documentation indicated the resident received 3 doses every day of the medication for the month, with the exception of 6/25, where Resident #62 received only one dose of diazepam. A physician communication and progress note, dated 6/25/12, indicated the following: "...instead of 3 mg 3 x (times) daily, he (Resident #62) has been getting 15 mg 3 x day d/t (due to) pharmacy sent Valium Intensol with same instructions." On 7/12/12 at 9:30 A.M., the DON (Director of Nursing) was interviewed. She indicated the following: The pharmacy sent a box of diazepam solution with a pharmacy sticker placed mostly over the manufacturer's medication identification and concentration information on the front of the box. The pharmacy sticker indicated the following: "Diazepam 5 mg/5 ml solution. Give 3 ml (3 mg)...3 times a day." The DON indicated the documentation on the back of the medication box, indicated the concentration of this medication as 5 mg per 1 ml. She indicated the pharmacy had placed a label with an incorrect concentration of (3 mg per 3 ml) on the front of the box, covering the actual, more concentrated solution of 5 mg per 1 ml. She indicated their investigation of this incident indicated this was a pharmacy error, and the pharmacy accepted their error. During this same interview, the DON provided a photo copy of the back of the box, which has a picture of the dispensing dropper in the bottle. This photo indicated 1 ml (milliliter) of medication was equal to 5 mg (milligrams) of medication. The DON indicated at this time, the actual dropper only had the identifying markings of ml and not the milligram dose. The DON also provided a photo copy of the end flap of the box, which indicated the box had been opened on 6/22/12. The DON was unsure of the number of doses of this medication the resident received on 6/22/12 from this vial. She indicated the resident received 3 doses of this concentrated medication on 6/23 and 6/24. She indicated the resident received 1 dose of the concentrated medication on 6/25 before being transferred to the hospital for evaluation. She indicated the resident was admitted to the hospital as "observation" status overnight and was discharged home the next day. During this same interview, the DON provided copies of the history and physical of the resident's admission to the hospital on [DATE]. This documentation included, but was not limited to, the following: "...with [DIAGNOSES REDACTED] with severe [DIAGNOSES REDACTED]...According to the patient's adoptive mother, the patient normally is very calm and is able to talk. However, today the patient was very agitated. He has been very restless...The emergency room did receive a call...that the patient has been receiving 15 milligrams of valium tid (3 times a day). This was an accidental overdose and the patient's orders are for him to receive 3 milligrams tid...Assessment: 1. Benzodiazepine overdose 2. Urinary Tract Infection...Plan: It is possible that the patient is having a paradoxical reaction to overdose of Valium and instead of being sedated, the patient is in fact, agitated. Patient also has some mild laboratory indices of urinary tract infection, which could also be playing a role. We will observe the patient and hopefully as the valium comes out of his system, he will become less agitated. We will also treat with Cipro for urinary tract infection..." On 7/12/12 at 11:10 A.M., the DON was interviewed. She indicated the label which pharmacy applies to the bottles/vials sometimes covers the manufacturer label already on the bottle/vial. The DON indicated the nurses would know the dosing instructions from the label, which pharmacy applies to the bottle/vial. The DON indicated because the pharmacy applied label partially covered the manufacturer's label, this is the reason the nurses didn't see the actual concentration on the bottle. The DON indicated when the nurse receives the medications from pharmacy and checks them in, the following is done: the nurses compares the quantity of each medicine received to the list of medications and quantity received from pharmacy. On 7/12/12 at 2:25 P.M., the DON was interviewed. She indicated on 6/25/12 at 5:45 A.M., the resident had pulled a fingernail off to his right, third digit. She indicated this was not typical behavior for this resident. She indicated the resident's mother was notified of this incident and came in the morning of 6/25/12 to see the resident. The DON indicated the mother requested the resident be sent to the hospital as he wasn't acting normally for himself. On 7/13/12 at 9:15 A.M. a copy of the following drug information was obtained from the facility copy of the 2013 Lippincott's Nursing Drug Guide, which included but was not limited to, the following: drug classes: anxiolytic and benzodiazepine; available forms: oral solution: 1 mg/ml and 5 mg/ml. On 7/13/12 at 9:20 A.M., the DON provided a copy of the facility policy and procedure for "LTC (Long Term Care) Facilities Receiving Pharmacy Products and Services from Pharmacy." This policy was dated May 2010. This policy included, but was not limited to, the following: "Document any delivery discrepancies (...labeling error...)." At this time also, the DON provided a copy of the "Narcotic count Record" for the resident. This form indicated the Diazepam 5 mg/5 ml was received on 6/14/12. This form also indicated the first dose of this concentration of diazepam was given on 6/22/12 at 6 A.M. On 7/13/12 at 11:20 A.M., the DON was interviewed. She indicated that 90% of the front of the original box was covered by pharmacy labels placed on it. She also indicated that the pharmacy is to notify the facility if a medication is dispensed in a different concentration that was ordered by the physician. She indicated the pharmacy should get clarification of the order before dispensing. On 7/13/12 at 11:30 A.m. the DON was interviewed. She indicated the actual bottle/vial of liquid Valium had a pharmacy label on it but she doesn't know the actual placement of the label as to what was and was not visible. She indicated they disposed of the bottle as it was a narcotic. She indicated the label affixed by the pharmacy includes the resident name, medication and dosage on the bottle. 3.1-25(g)

Based on interview and record review, the facility failed to ensure a resident received respiratory treatments as ordered by the physician, resulting in re-hospitalization for respiratory distress, for 1 of 1 residents reviewed with physician orders [REDACTED]. Resident A Findings include: 1. The clinical record of Resident A was reviewed on 7/13/11 at 12:00 P.M. [DIAGNOSES REDACTED]. The resident was readmitted to the facility following hospitalization on [DATE]. A hospital discharge summary, dated 12/29/10, indicated: "...Diagnoses: [REDACTED]. Secondary left lower lobe pneumonia 3. Multifactorial [MEDICAL CONDITION] requiring mechanical ventilation 4. [MEDICAL CONDITION] dysphagia (difficulty swallowing)...requiring...gastrostomy tube (PEG) placement (feeding tube)...Medications on Transfer to the Facility:[MEDICATION NAME] nebulizer (breathing treatment) therapy q (every) 4 hours. 13. [MEDICATION NAME] nebulizer therapy q 8 hours...." A hospital respiratory treatment record, dated 12/29/10, indicated Resident A last received a [MEDICATION NAME] and [MEDICATION NAME] respiratory treatment at 3:38 P.M. admission orders [MEDICATION NAME] mini neb (nebulizer) Q 4 (hours). [MEDICATION NAME] nebulizer Q 8 (hours)." Nursing Progress Notes included the following notations: 12/29/10 at 8:00 P.M.: "Resting quietly abed. I have checked rsd (resident) frequently. (No) resp (respiratory) distress...." 12/29/10 at 11:00 P.M.: "Res (resident) placed on her Rt side...No resp distress noted." 12/30/10 at 12:30 A.M.: "Res experiencing resp. difficulty...O2 sat (saturation) 50% on humidifier 28% [MEDICAL CONDITION] 3L/m. Res unresponsive...suctioned per trach...12:40 A.M. (Name of physician) notified. Order rec'd...1:15 A. Res transported to (name of hospital) in (name) ambulance." A Respiratory Treatment Record, undated, included: "1. [MEDICATION NAME] mini neb Q 4 (hours) 6a-10a-2p-6p-10p-2a. 2. [MEDICATION NAME] nebulizer Q 8 (hours) 8a-4p-12am." The treatment record was blank, and indicated no treatments were administered. Documentation was lacking in the clinical record that the resident received either the [MEDICATION NAME] or [MEDICATION NAME] breathing treatments. On 7/13/11 at 1:45 P.M., during interview with the Director of Nursing (DON), she indicated since the resident was not admitted to the facility until 5:30 P.M., the breathing treatment medications would not have been delivered by the pharmacy until 3:00 A.M. The DON indicated the facility did have a back-up pharmacy, and that the nurse would have had to tell the pharmacy which medications she would want delivered immediately. 2. On 7/14/11 at 10:00 A.M., the DON provided the current facility policy on "Receipt of Interim/Stat/Emergency Deliveries," dated May 2010. The policy included: "...Facility should immediately notify Pharmacy when Facility receives from a Physician/Provider a medication order that may require an interim/stat/emergency delivery. 2. If a necessary medication is not contained within Facility's interim/stat/emergency supply, and Facility determines that an interim/stat/emergency delivery is necessary, Facility should arrange either: With Pharmacy to include the interim/stat/emergency supply medication(s) in an earlier scheduled delivery or a special delivery, as required, or For delivery by contract courier, or For the medication to be dispensed and delivered by a Third Party Pharmacy to ensure timely receipt...." This Federal tag relates to Complaint IN 421. 3.1-35(g)(2)

Based on interview and record review, the facility failed to ensure a resident with a [DIAGNOSES REDACTED]. Resident A Findings include: 1. The clinical record of Resident A was reviewed on 7/13/11 at 12:00 P.M. [DIAGNOSES REDACTED]. The resident was readmitted to the facility following hospitalization on [DATE]. A hospital discharge summary, dated 12/29/10, indicated: "...Diagnoses: [REDACTED]. Secondary left lower lobe pneumonia 3. Multifactorial [MEDICAL CONDITION] requiring mechanical ventilation 4. [MEDICAL CONDITION] dysphagia (difficulty swallowing)...requiring...gastrostomy tube (PEG) placement (feeding tube)...Medications on Transfer to the Facility:[MEDICATION NAME] nebulizer (breathing treatment) therapy q (every) 4 hours. 13. [MEDICATION NAME] nebulizer therapy q 8 hours...." A hospital respiratory treatment record, dated 12/29/10, indicated Resident A last received a [MEDICATION NAME] and [MEDICATION NAME] respiratory treatment at 3:38 P.M. admission orders [MEDICATION NAME] mini neb (nebulizer) Q 4 (hours). [MEDICATION NAME] nebulizer Q 8 (hours)." A Nursing Comprehensive Admission Data Collection and Assessment, dated 12/29/10 at 5:30 P.M., indicated, "...admitted from (name of hospital)...Respiration: Unlabored, Breath Sounds: Diminished Rt (right) Lt (left), Inability to breath (sic) lying down Yes...Trach: (yes), Suctioning: Yes...." Nursing Progress Notes included the following notations: 12/29/10 at 8:00 P.M.: "Resting quietly abed. I have checked rsd (resident) frequently. (No) resp (respiratory) distress...." 12/29/10 at 11:00 P.M.: "Res (resident) placed on her Rt side...No resp distress noted." 12/30/10 at 12:30 A.M.: "Res experiencing resp. difficulty...O2 sat (saturation) 50% on humidifier 28% [MEDICAL CONDITION] 3L/m. Res unresponsive...suctioned per trach...12:40 A.M. (Name of physician) notified. Order rec'd...1:15 A. Res transported to (name of hospital) in (name) ambulance." Documentation was lacking in the clinical record that the resident received either the [MEDICATION NAME] or [MEDICATION NAME] breathing treatments. An EMS (emergency medical service) patient assessment, dated 12/30/10 and untimed, indicated: "...Treatment by [MEDICATION NAME] x 2, Atrovent x 1...." A hospital nursing patient record, dated 12/30/10 at 1:55 A.M., indicated, "...Chief complaint: Resp Distress/Asthma/URI (upper respiratory infection)...SOB (short of breath) (Yes)...Mild Distress (Yes)...Crackles: Bil (bilaterally)...." A Emergency Physician Record, dated 12/30/10 at 3:20 A.M., indicated, "...Chief complaint: dyspnea (shortness of breath)...Treatment [MEDICATION NAME][MEDICATION NAME] therapy, treatments given: 3...." A hospital "Observation Summary," dated 12/31/10, indicated, "...This individual had been discharged to (name of facility) on 12/29/10 and I was contacted in the early morning hours of 12/30/10 by the staff indicating that she was poorly responsive, significantly hypoxemic (short of breath) and congested. Reports from EMS and from the Emergency Department staff indicated that she required significant suctioning but after this had been performed she appeared to return to baseline status...The patient's chest x-ray showed no new infiltrates...." On 7/13/11 at 1:45 P.M., during interview with the Director of Nursing (DON), she indicated since the resident was not admitted to the facility until 5:30 P.M., the breathing treatment medications would not have been delivered by the pharmacy until 3:00 A.M. The DON indicated the facility did have a back-up pharmacy, and that the nurse would have had to tell the pharmacy which medications she would want delivered immediately. The DON indicated she did not know if the medications were in the emergency drug kit (EDK). The DON indicated the resident's lung sounds would have been assessed before and after receiving the breathing treatments. On 7/14/11 at 10:00 A.M., the DON provided a listing of the contents in the EDK box. The contents did include [MEDICATION NAME] for the [MEDICATION NAME] treatment. The DON indicated she inserviced nursing on 7/13/11 regarding receiving medications from the back-up pharmacy. This Federal tag relates to Complaint IN 421. 3.1-47(a)(6)