Every finding on record at Waters of Rising Sun, The

Based on observation, interview, and record review, the facility failed to provide at least 80 sq (square) ft (feet) per resident for 2 of 28 resident rooms. (rooms [ROOM NUMBERS])Findings include:Review of the facility documentation of room size certification, provided by the Administrator, on 02/24/2025 at 11:18 A.M., indicated the following room sizes, as observed on facility tour, provided less than 80 square feet per resident:1. room [ROOM NUMBER], SNF/NF (Skilled Nursing Facility/Nursing Facility), was 202.5 sq ft, had the capacity for 3 beds, and equaled 67.5 sq ft per resident. During an observation of room [ROOM NUMBER] on 02/24/2026 at 11:20 A.M., each resident had adequate space to move about the room and store their belongings. The room measurements were confirmed.2. room [ROOM NUMBER], SNF/NF, was 209 sq ft, had the capacity for 3 beds, and equaled 69.6 sq ft per resident.During an observation of room [ROOM NUMBER] on 02/24/2026 at 11:22 A.M., each resident had adequate space to move about the room and store their belongings. The room measurements were confirmed.These room sizes were verified by the Administrator on 02/24/2026 at 11:25 A.M.During an interview on 02/24/2026 at 11:25 A.M., the Administrator indicated she would only use the beds as a last option and would like to continue the room waiver.410 IAC (Indiana Administrative Code) 16.2 - 3.1-19(l)(2)(A)410 IAC (Indiana Administrative Code) 16.2 -3.1-19(l)(3)410 IAC (Indiana Administrative Code) 16.2 -3.1-19(l)(8)

Based on record review and interview, the facility failed to follow physician orders related to medication administration for 1 of 13 residents reviewed for pharmacy services. (Resident C) Findings included:The clinical record for Resident C was reviewed on 03/02/2026 at 9:49 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/16/2026, indicated the resident was rarely/never understood. The resident's diagnoses included, but were not limited to, seizure disorder, glaucoma, and cerebral palsy. The resident received an opioid (pain) medication. The Nursing Progress Note, dated 11/13/2025 at 6:24 P.M., indicated Licensed Practical Nurse (LPN) 2 had prepared Resident C's 2:00 P.M. pain medication. The LPN accidentally prepared a Tramadol (pain medication) 50 milligrams (mg) for Resident C instead of the prescribed Oxycodone (pain medication) 5-325 mg. When staff were counting the medications in the medication cart at the end of the shift, the nurse realized a medication error was made. -An Interdisciplinary Team note, dated 11/13/2025 at 3:52 P.M., indicated the medication error was reviewed. The immediate intervention was for education to the nurse on medication administration. The Electronic Medication Administration Record (EMAR) for November 2025, indicated the resident had received their scheduled pain medication, Oxycodone 5-325 mg, on 11/13/2025 at 2:00 P.M. During an interview on 03/03/2026 at 1:29 P.M., the Director of Nursing (DON) indicated the resident received scheduled pain medication. LPN 2 was the nurse on duty on 11/13/2025. The nurse had prepared the Tramadol medication instead of the Oxycodone. The nurse did not give both medications. The family and the Nurse Practitioner (NP) were notified. The NP gave orders to monitor for any adverse reactions for 48 hours. The Assistant Director of Nursing (ADON) did immediate education with the nurse. The resident did not have a physician's order for Tramadol. The DON did not know which resident's tramadol medication the resident received. The current TEN RIGHTS FOR ADMINISTRATION OF MEDICATIONS policy, dated July 2024, was provided by the DON on 03/03/2026 at 2:05 P.M. The policy indicated, .The right resident .before preparing the medication, identify each resident according to .facility's policies and procedures .The right drug .verify each drug against the medication record .before administering. Verify in at least three ways, such as by the drug's size, shape, color, or label . This citation relates to intake 2790710. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(b)(7).

Based on record review and interview, the facility failed to follow a physician's order related to weight management for 1 of 2 residents reviewed for nutrition. (Resident 32)Findings include:The clinical record for Resident 32 was reviewed on 03/02/2026 at 1:17 P.M. An Annual Minimum Data Set (MDS) assessment, dated 01/14/2026, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension (high blood pressure) and diabetes. An open-ended physician's order, with a start date of 02/21/2025, indicated the resident was to be given Lasix (a water pill) as needed for weight gain greater than 3 pounds in a day and the physician was to be notified if the weight gain was greater than 3 pounds in 1 day or 5 pounds in one week. The order lacked a dosage amount. The January and February 2026 Electronic Medication Administration/Electronic Treatment Administration Record, indicated the resident had a weight gain of greater than 3 pounds on the following dates:-On 01/07/2026, the resident weighed 114.4 pounds and on 01/08/2026 the resident weighed 117.6 pounds, a 3.2 pound weight gain in one day, and- On 02/20/2026, the resident weighed 112.2 pounds and on 02/21/2026 the resident weighed 116.8, a 4.6 weight gain in one day. An open-ended physician's order, with a start date of 02/20/2025, indicated the resident was to be given Lasix 20 milligrams, as needed for a weight gain of more than 3 pounds in 1 day. The January and February 2026 EMAR/ETAR lacked documentation that the resident received the as needed Lasix medication on 01/28/2026 or 02/21/2026 when they had a weight gain of greater than 3 pounds in one day. During an interview, on 03/03/2026 at 10:30 A.M., RN 3 indicated resident daily weights would be document in the EMAR/ETAR and give medication per the physician's order. The current facility policy titled, Guidelines for Physician Orders-(Following Physician Orders) dated 06/18/2023, was provided by the Director of Nursing on 03/03/2026 at 2:20 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician.410 IAC (Indiana Administrative Code) 16.2-3.1-46(a)(1)

Based on record review and interview, the facility failed to complete assessments before and following a resident's dialysis treatments for 1 of 1 resident reviewed for dialysis. (Resident 12)Findings include:The clinical record for Resident 12 was reviewed on 03/02/2026 at 9:54 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/21/2025, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, end stage renal disease (permanent, total, or near-total kidney failure). The resident received dialysis while a resident at the facility. During an interview, on 03/03/2026 at 10:26 A.M., RN 3 indicated the resident went to dialysis three days a week. Before the resident left for their dialysis treatments, the staff would obtain his weights and vital signs, document them on a communication form and send the form with the resident to dialysis. Once the resident returned, the facility staff would check the resident's vital signs again, review the communication form and place it in the Director of Nursing's box. The resident's clinical record lacked Dialysis Communication Forms for the resident on the following dates: 01/08/2026, 01/10/2026, 01/13/2026, 01/15/2026, 01/17/2026, 01/20/2026, 01/22/2026, 01/24/2026, 01/29/2026, 02/26/2026, and 02/28/2026.During an interview, on 03/03/2026 at 1:57 P.M., the MDS Coordinator indicated she had been overseeing the Dialysis Communication Forms since the beginning of February 2026. She was unable to find the missing forms, but they should have been completed and put in the resident's clinical record. The communication forms were to be filled out by facility staff and then the dialysis staff were to complete information on the form as well. The current, undated, facility policy titled, Community Hemodialysis was provided by the Director of Nursing on 03/03/2026 at 2:20 P.M. The policy indicated, .To ensure coordination of care for residents requiring hemodialysis in the community.A dialysis communication sheet will return with the resident after the dialysis session to communicate to the facility information regarding the dialysis session.410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on record review and interview, the facility failed to notify the physician of a change in resident's condition related to blood glucose levels for 1 of 15 residents reviewed for notification of change. (Resident 12) Findings include: The clinical record for Resident 12 was reviewed on 03/02/2026 at 9:54 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/21/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, end stage renal disease, anemia, heart failure, hypertension, diabetes, anxiety, and depression. An open-ended physician's order, with a start date of 09/26/2025, indicated the resident was to take Humalog (an insulin medication) per the sliding scale and the physician was to be notified if the resident's blood glucose level was greater than 400. The clinical record lacked indication that the physician was notified on the following dates and times when the resident's blood glucose was greater than 400:-On 01/29/2026 at 8:00 P.M., when the resident's blood glucose was 459, -On 01/31/2026 at 8:00 P.M., when the resident's blood glucose was 473, -On 02/18/2026 at 11:00 A.M., when the resident's blood glucose was 481, and -On 02/25/2026 at 11:00 A.M., when the resident's blood glucose was 474. During an interview, on 03/03/2026 at 10:30 A.M., RN 3 indicated if she needed to notify the physician related to resident medications, she would call them or notify them in their facility communication system. She would then document in a progress note that the physician was notified. The current facility policy titled, Guidelines for Notification of Change in Resident's Condition/Status/Treatment dated 06/29/2024, was provided by the Director of Nursing on 03/03/2026 at 2:53 P.M. The policy indicated, .It is the intent of the facility to ensure that the resident, their attending physician, and the resident's Responsible Party/POA are notified of changes in the resident's condition, status, or treatment. This notification will be done promptly in order to obtain any orders needed for appropriate treatment and/or monitoring related to the change-as well to promote the RESIDENT RIGHTS related to the right to make choices about treatment and care preferences.410 IAC (Indiana Administrative Code) 16.2-3.1-5(a)(3)

Based on observation and interview, the facility failed to maintain a residents' snack refrigerator related to unlabeled items for 1 of 1 resident snack refrigerator reviewed. (Pantry Snack Refrigerator)Findings include:The Pantry Snack Refrigerator was observed with the Assistant Director of Nursing (ADON) on 03/03/2026 at 2:10 P.M., and contained the following items:- A clear, half-gallon container of soup. A resident's name was written in marker on the lid, but the container was not dated, and - A brown fast-food bag with a box that contained a burger inside. A resident's nick name was written in marker on the bag, but the bag was not dated. During an interview, on 03/03/2026 at 2:12 P.M., the ADON indicated the items were brought into the facility by the residents' families. The food should be labeled with the resident's name and the date it was brought to the facility. The current, undated facility policy, titled Food Brought Into the Facility by Friends/Family/Others (Outside Sources) for Residents, was provided by the Director of Nursing on 03/03/2026 at 2:29 P.M. The policy indicated, .Foods or beverages brought in from the outside will be labeled and dated with the resident's name, room number and date the item was brought into the facility for consumption/storage.410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately documented a resident's diagnoses (Resident 17) and a resident's discharged location (Resident 55) for 2 of 15 residents reviewed accuracy of assessments.Findings include:1.The clinical record for Resident 17 was reviewed on 02/26/2026 at 10:38 A.M. The Medications section of the resident's Quarterly MDS assessment, dated 12/31/2025, indicated the resident received insulin, antianxiety, and antidepressant medications during the assessment review period. The Active Diagnoses section of the assessment indicated the resident did not have the current diagnoses of diabetes, anxiety, or depression. The December 2025 Electronic Medication Administration Record (EMAR) indicated the resident received the following medications daily during the assessment review period: - Basaglar (a long-acting insulin), inject 20 units subcutaneously at bedtime for diabetes, - Humalog (a short-acting insulin), inject subcutaneously four times a day based on a sliding scale for diabetes,- Alprazolam, give 1 milligram (mg) by mouth at bedtime for anxiety, and- Duloxetine, 60 mg by mouth one time a day for depression. During an interview, on 03/03/2026 at 2:30 P.M., the MDS Coordinator indicated the resident's diagnoses included, but were not limited to, diabetes, depression, and anxiety. The MDS assessment should reflect the resident's current diagnoses. 2. The clinical record for Resident 55 was reviewed on 03/02/2026 at 11:00 A.M. The resident was admitted to the facility on [DATE], from the hospital. A discharge assessment, dated 01/13/2026, indicated the resident had an unplanned discharge with a return anticipated, and discharged back to the hospital. A Progress Note, dated 01/13/2026 at 3:40 P.M., indicated at 3:30 P.M., the resident's family member approached the writer that she wanted to take the resident home and care for her there due to the resident's cognitive issues. The Administrator was made aware and spoke with the family member. The family member still wished to care for the resident at home. The family member was provided with Against Medical Advice (AMA) paperwork. The family member signed the paperwork. The resident's hospital discharge paperwork was also sent with the family member. During an interview, on 03/03/2026 at 10:32 A.M., the MDS Coordinator indicated the resident was not even there for a day. The resident left AMA with her daughter. When a resident left AMA then she would document in the MDS assessment that the resident went home. The resident's discharge MDS assessment should have indicated the resident went home. There was not a facility policy for completing MDS assessments. She would follow the Resident Assessment Instrument (RAI) manual. 410 IAC (Indiana Administrative Code) 16.2-3.1-31(c)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-31(c)(8)

Based on observation, interview, and record review, the facility failed to ensure a resident that self-administered medications was appropriately assessed for self-administration prior to being left alone to administer the complete breathing treatment for 1 of 5 residents observed for medications. (Resident B)Findings include:During an observation on 02/26/2026 at 9:24 A.M., Resident B was in her room sitting up in her bed. Licensed Practical Nurse (LPN) 4 obtained the resident's blood pressure, heart rate, and oxygen saturation level. The nurse placed the nebulizer medication in the reservoir of the nebulizer, held the mask to the resident's face, and placed the straps to hold the mask around the back of the resident's head. The nurse turned the nebulizer on to start the breathing treatment and left the room. During an interview, on 03/02/2026 at 10:40 A.M., the Director of Nursing (DON) indicated there were no residents in the facility that self-administered medications.During an interview, on 03/03/2026 at 1:09 P.M., LPN 5 indicated if a resident received nebulizer breathing treatments the nurse should listen to the resident's lung sounds and obtain vital signs before and after the treatment. The resident shouldn't be left alone during the treatment. The lung sounds and vital signs were documented in the Electronic Medication Administration Record (EMAR). The resident's clinical record was reviewed on 02/26/2026 at 2:35 P.M. An Annual Minimum Data Set (MDS) assessment, dated 12/08/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included but were not limited to dementia (mental decline) and Chronic Obstructive Pulmonary Disease (COPD - a progressive, inflammatory lung disease characterized by long-term, irreversible airway obstruction that makes breathing difficult). The resident's current physician's order, with a start date of 02/23/2026, indicated Resident B was to be administered Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams (mg) four times a day for wheezes, for three days. The resident's record lacked a physician's order to self-administer medications and a medication self-administration assessment. The current facility policy, titled SELF-ADMINISTRATION OF MEDICATIONS BY RESIDENTS, with a print date of July 2024, was provided by the DON on 03/03/2026 at 2:05 P.M. The policy indicated, .Self-administration medications will be encouraged if it is desired by the resident, safe for the resident and other residents of the facility, ordered by the attending physician, and approved by the Interdisciplinary Team.The current facility policy, titled TEN RIGHTS FOR ADMINISTRATION OF MEDICATIONS with a print date of July 2024, was provided by the DON on 03/03/2026 at 2:05 P.M. The policy indicated, .The right assessment: certain medications require monitoring prior to and after administration.This citation relates to intake 2790710. 410 IAC (Indiana Administrative Code) 16.2-3.1-11(a)

Based on observation, interview, and record review, the facility failed to operate the facility van lift safely and appropriately for 1 of 3 residents reviewed for accidents. (Resident D)Findings include:During an interview, on 11/20/2025 at 10:13 A.M., Resident D indicated recently she was getting out of the facility van with a staff member when the van lift felt like it gave out and went straight to the ground. Her wheelchair tipped back, and she fell to the ground. There wasn't a staff member standing on the lift when it went down. She didn't hit her head when she fell, but she did hurt her upper back that now has some bruising, and she was very sore. She did have to go to the hospital, but she didn't break any bones or have any bleeding anywhere. Just the bruising to her back. During an observation, on 11/20/2025 at 10:44 A.M., two staff members went into Resident D's room to assist her with repositioning. The resident was rolled to her right side. She had a baseball sized bruise to her upper left back. During an interview, on 11/20/2025 at 11:00 A.M., Activities/Transport Driver 2 indicated she was not the staff member that was operating the van at the time of the incident with Resident D. She wasn't sure what happened, but she had a video call with a representative with the van lift company on Monday. When they spoke with him, he indicated that the lift would not have been able to drop the resident like they said it did. The lift had been working correctly ever since the incident and was put back into service. During an observation and interview, on 11/20/2025 at 11:05 A.M., Activities/Transport Driver 2 demonstrated that the van lift was operational without issue. There was a safety belt on the back of the lift and Activities/Transport Driver 2 indicated it was to prevent residents from going out of the lift or falling backwards. During an interview, on 11/20/2025 at 11:09 A.M., the Administrator indicated on 11/15/2025 Activities/Transport Driver 3 was taking Resident D out of the van using the van lift when she backed her out on the lift and the lift just went down. They attempted to recreate the event and the only time they were able to get the lift to drop down was when the lift wasn't flush with the van. They believe the incident was a user error. They had annual training for staff with a representative from the van lift company and he was contacted on Monday, 11/17/2025. He told them there were only two situations that would have caused the lift to drop fast and that was that the resident was either pushed out, or the lift wasn't positioned where it needed to be. The staff that operate the van lift have been in-serviced since the incident occurred. During an interview, on 11/20/2025 at 12:17 P.M., the representative for the van lift company indicated he spoke with the facility on Monday, 11/17/2025. He wasn't quite sure what happened as he wasn't there when the incident occurred. He was told that the transport person rolled the resident's wheelchair onto the lift and the lift dropped suddenly to the ground. The lift safety belt was not in place. He informed them that it was not possible for the lift to drop to the ground suddenly without the hydraulics going out of the lift. The lift would not be back into operation with the hydraulics going out if they didn't get them repaired. The lift was fully operational when he observed it through a video call on Monday. During an interview, on 11/20/2025 at 12:22 A.M., the Maintenance Director indicated he was the weekend manager on Sunday, 11/16/2025. When he came in the staff informed him that the van lift had broken the previous day and a resident had fell to the ground. He was told that Activities/Transport Driver 3 was pushing Resident D out of the van onto the lift when the lift suddenly went to the ground, causing both the resident and staff member to fall to the ground. The safety belt on the lift was not in place at the time of the transfer and should be in place before the lift was even folded down. He performed monthly inspections of the van and lift without any concerns from the last two months. The only documented inspections for the van lift provided were dated 10/15/25 and dated 11/12/25. During an interview, on 11/20/2025 at 1:04 P.M., RN 4 indicated she was the nurse on duty on 11/15/2025 when Activities/Transport Driver 3 came into the facility for help because Resident D was on the ground outside. When she went outside Resident D was lying on the ground on her right side. The resident's wheelchair was sitting on the van lift on its back with the lift all the way on the ground and the lift strap not in place. Activities/Transport Driver 3 had told her she didn't have time to put the strap in place before the lift went to the ground. The resident was complaining of back and right elbow pain at the time. She assessed the resident and started neurological assessments. She made the resident comfortable and someone called 911. The resident was transported to the local hospital. The resident had no abnormal findings and was sent back to the facility. The clinical record for Resident D was reviewed on 11/20/2025 at 10:35 A.M. A Quarterly Minimum Data Set assessment, dated 10/20/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, heart failure, hypertension, renal insufficiency, anxiety, and depression.A Progress Note, dated 11/15/2025 at 3:21 P.M., indicated the writer was notified by the facility's transporter that Resident D was on the ground outside. The writer went to the parking lot, and the resident was lying on her right side on the ground at the back of the van. The staff member was transferring the resident and when she was putting the resident onto the lift from the van the hydraulics failed causing the lift, staff member, and the resident to quickly lower to the ground and they both fell off the lift. A head-to-toe assessment was completed; neurological assessments were completed. The resident was alert and complained of back and head pain. An ambulance was called, and the resident was sent to the local emergency room for evaluation and treatment. A Progress Note, dated 11/16/2026 at 2:04 A.M., indicted the resident returned from the hospital and the x-rays were negative. The hospital records for the resident lacked abnormal findings related to the fall. The current, undated, facility policy titled, Vehicle Lift Safety, was provided by the Regional Director of Operations on 11/20/2025 at 12:57 P.M. The policy indicated, .Resident will be secure and safe during use of transport vehicle lift.Secure seat belt.The current facility policy titled, GUIDELINES FOR INCIDENTS/ACCIDENTS/FALLS, dated 06/30/2023, was provided by the Regional Director of Operations on 11/20/2025 at 12:57 P.M. The policy indicated, .The facility will ensure that incidents and accidents that occur involving residents are identified, reported, and resolved.3.1-45(a)(1)3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide at least 80 sq (square) ft (feet) per resident for 2 of 28 resident rooms. (rooms [ROOM NUMBERS]) Findings include: Review of the facility documentation of room size certification, provided by the Administrator, on 01/03/25 at 11:15 A.M., indicated the following room sizes, as observed on facility tour, provided less than 80 square feet per resident: 1. room [ROOM NUMBER], SNF/NF (Skilled Nursing Facility/Nursing Facility), was 217 sq ft, had the capacity for 3 beds, and equaled 79.3 sq ft per resident. During an observation of room [ROOM NUMBER] on 01/09/25 at 1:20 P.M., each resident had adequate space to move about the room and store their belongings. The room measurements were confirmed. 2. room [ROOM NUMBER], SNF/NF, was 224 sq ft, had the capacity for 3 beds, and equaled 74.6 sq ft per resident. During an observation of room [ROOM NUMBER] on 01/09/25 at 1:21 P.M., each resident had adequate space to move about the room and store their belongings. The room measurements were confirmed. These room sizes were verified by the Administrator on 01/09/25 at 1:15 P.M. During an interview on 01/09/25 at 1:15 P.M., the Administrator indicated she would only use the beds as a last option and would like to continue the room waiver. 3.1-19(l)(2)(A) 3.1-19(l)(3) 3.1-19(l)(8)

Based on interview, observation, and record review, the facility failed to identify pressure ulcers in a timely manner for 1 of 3 residents reviewed for pressure ulcers. (Resident 10) Findings include: During an interview on 01/02/25 at 12:45 P.M., Resident 10 indicated she had a wound on her right elbow and a wound on the right side of her right thigh above her knee. The resident pulled up her pant leg to reveal an uncovered nickel size wound that had a reddened defined edge and was two to three millimeters deep. She indicated it was from her leg rubbing on the arm rest support on her wheelchair when she propelled herself. The resident had limited mobility in her right arm. During an interview on 01/08/25 at 10:28 A.M., the Assistant Director of Nursing (ADON) indicated the CNAs reported any redness or alterations in skin integrity on the shower sheets or, if they noticed areas when they were providing care for residents, they would notify the nurse on duty. When a wound was identified, the nurse should complete a wound assessment in the computer, even for areas of redness. The wound evaluations would include all of the resident's wounds. The wounds should be assessed, and the assessment should be documented weekly until the wounds were healed. During an interview on 01/09/25 at 10:19 A.M., the resident indicated the staff helped her to change her clothes. They cleaned her wounds when she got a shower twice a week. They had already changed the dressing on her elbow that day. They had a pillow they wanted her to use under her elbow. The pillow was nowhere in sight and the resident did not know where it was. She had gotten the pillow after the wound was found on her elbow. During an interview on 01/09/25 at 10:31 A.M., Certified Nurse Aide (CNA) 2 and CNA 3 indicated it took two staff members to assist the resident on and off the toilet. The resident's left leg had a metal rod in it and was always straight. They changed her clothes every morning. The resident needed help getting dressed. She used to be able to put her own shirt on but had declined and needed staff assistance with dressing for the last six months. During an interview on 01/09/25 at 2:34 P.M., the ADON indicated the resident's wound on her elbow, a pressure ulcer, was first observed on 12/24/24. It was unstageable (obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough, non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture, or eschar, dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like). It was dark and scabbed initially. This resident had progressed quite quickly with her wounds. Yesterday they found a new area on her right thigh, and it was scabbed. They determined the wound on her thigh was caused by rubbing on the wheelchair. They tried to put a pillow under her right arm after the wound developed but the resident indicated it kept falling out and the ADON felt it was an infection control issue. The thigh wound was being treated with Medihoney. The elbow was being treated with Santyl, a debriding medication. The elbow had slough on the wound bed the day before. Both of the wounds, the thigh and the elbow, had depth. The wounds should have been noticed before they were unstageable. The resident's clothes were changed daily, and she was toileted frequently. The dressing change to the resident's right elbow and right thigh were observed on 01/09/25 at 11:00 A.M., with RN 8. The right elbow wound was the size of a nickel with a red border. The wound bed was covered in slough and approximately three millimeters deep. The RN indicated they were treating it with Medihoney. The right thigh wound was the size of a dime with a red border. One third of the wound bed was covered in yellow slough. Two thirds were covered with a dark red/black scab. The RN indicated they were treating it with Santyl. The clinical record was reviewed on 01/06/25 at 12:20 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/12/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, anxiety, and depression. The resident was at risk for pressure ulcers but had no unhealed pressure ulcers. The Weekly Wound Evaluation record for the wound on the resident's right elbow was provided by the ADON on 01/08/24 at 4:12 P.M. The record indicated the resident's wound was first identified on 12/24/24, was unstageable and measured 1 centimeter (centimeter) x (by) 1.5 cm x 0.25 cm. The wound had a small amount of thick sanguineous (pale red to pink) drainage. The wound bed was 100% covered in necrotic (dead) black tissue. The wound edges were red and defined. The current preventative interventions included a pressure redistribution mattress and a wheelchair cushion. The Braden Scale For Predicting Pressure Sore Risk, with an effective date of 12/08/24, was provided by the Director of Nursing (DON) on 01/09/25 at 3:05 P.M. The record indicated the resident's score was 16 and was categorized as being at Low Risk for developing pressure sores. The current GUIDELINES FOR PREVENTION/TREATMENT OF PRESSURE INJURIES policy, dated 10/09/23, was provided by the DON on 01/09/25 at 4:30 P.M. The policy indicated, .based on resident assessment, the facility will ensure .A resident receives care, consistent with professional standards of practice; to prevent pressure ulcers .A Risk Assessment is considered the starting point for prevention of pressure injury .It is important to note and at risk resident can develop a pressure injury within hours of the onset of pressure. For this reason, the at risk resident must be identified, and have specific interventions put promptly in place and care planned in an effort to prevent formation of a pressure injury . 3.1-40(a)(2)

Based on observation and interview, the facility failed to follow appropriate guidelines related to the use of hairnets in the kitchen for 2 of 3 staff observed for food procurement. (Dietary Aides 4 and 5) Findings include: During a tour of the kitchen on 01/08/25 at 11:38 A.M., Dietary Aide (DA) 4's hairnet was on the back of her head with three inches of her bangs exposed while she was in the food preparation area. During an observation on 01/09/25 at 9:23 A.M., DA 4 was pushing a hall tray food cart out the kitchen door, three inches of her bangs were not covered by her hairnet. During a kitchen observation on 01/09/25 at 1:16 P.M., DA 4 had three inches of her bangs that were not covered by her hairnet and DA 5 had two inches of her hair around her face that was not covered by her hairnet. During an interview on 01/09/25 at 1:19 P.M., DA 4 indicated hairnets should cover the entire head and all their hair. The current Hair Restraints policy, dated 2017, was provided by the Assistant Director of Nursing on 01/09/25 at 2:34 P.M. The policy indicated, .Staff shall wear hair restraints in all food preparation, dishwashing, and serving areas. 3.1-21(i)(3)

Based on record review and interview, the facility failed to treat a resident for a Urinary Tract Infection (UTI) in a timely manner for a resident who had a history of UTIs for 1 of 6 residents reviewed for UTIs. (Resident B) Findings include: The clinical record for Resident B was reviewed on 01/06/25 at 12:37 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/01/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, cancer, septicemia, and the resident had a UTI in the last 30 days. The resident had received intravenous (IV) medications. The INFECTION CONTROL LOG for October and December 2024, were provided by the Director of Nursing (DON) on 01/09/25 at 4:05 P.M., and indicated the resident received the following antibiotics for UTIs: - Meropenem IV, four times a day for 12 days, with a start date of 10/27/24 and a resolved date of 11/08/24, and - Macrobid 100 milligrams, twice a day for 14 days, with a start date of 12/16/24, and a resolved date of 12/30/24. The Order Details record, dated 12/06/24, was provided by the DON on 01/09/25 at 4:05 P.M., and indicated the Medical Director had ordered the facility to obtain a urine specimen for a Urinalysis/Culture and Sensitivity (UA/C&S) related to the resident having an increase in behaviors. The order was put in the Electronic Health Record with a start date of 12/08/24, and an end date of 12/09/24. The Lab Results Report, dated 12/13/24, was provided by the DON on 01/09/25 at 4:05 P.M., and indicated the urine sample was collected on 12/08/24, received by the lab on 12/09/24, and reported on 12/13/24 at 4:32 P.M. The resident's urine sample tested positive for Escherichia coli and Extended-spectrum beta-lactamase (ESBL). The Electronic Medication Administration Record for December 2024, indicated the resident had a urine specimen collected for a UA/C&S on 12/08/24. The resident was not started on an antibiotic for a UTI until 12/16/24 on night shift, eight days later. During an interview on 01/09/25 at 1:35 P.M., the Assistant Director of Nursing (ADON) indicated she writes the order to collect the urine sample the night before the lab was scheduled to pick up specimens on Mondays. For a UA sent on a Monday, the facility should have the results back by Wednesday evening at the latest. The lab results are sent back to the facility at any time of the day. If she doesn't receive the results she would call the lab. When the facility received the lab results, they contact the doctor. When they get the order from the doctor, the resident should be started on the medication within six hours. The facility staff can contact the doctor on the weekends. The resident was sent out to the hospital recently. She was lethargic, had a UTI, she had ESBL, and was in kidney failure. She came back to the facility on IV antibiotics. The facility can call the Infectious Disease Nurse Practitioner (ID NP) anytime of the day or night, even on the weekends. The Medical Director will often have the facility staff call the ID NP for infections and ordering antibiotics. During an interview on 01/09/25 at 1:48 P.M., the ADON indicated the resident should have been started on an antibiotic sooner for the UTI she had in December. During an interview on 01/09/25 at 4:05 P.M., the DON indicated they had issues with the Lab recently. The resident's lab order was dated 12/06/24. The lab comes on Mondays, so the specimen would have been collected on Sunday, the 8th, and the lab would have picked it up on the 9th. In her professional opinion, between the lab taking a long time and the MD and NP, she did not feel it was best practice to wait to treat the resident for the UTI for that many days. The current undated Change in Resident's Condition or Status policy was provided by the ADON on 01/09/25 at 2:24 P.M. The policy indicated, .The nurse will notify the resident's attending physician when .Any result of a specifically ordered diagnostic test/evaluation that is outside normal parameters .If the resident's physician does not respond to calls of a resident condition status change, the facility Medical Director will be notified to obtain orders, and this will be documented . The current GUIDELINES FOR OBSERVING AND IMPLEMENTING - RESIDENT RIGHTS policy, dated 07/12/23, was provided by the ADON on 01/09/25 at 2:24 P.M. The policy indicated, .Residents are to have their well-being and self-esteem and self-worth enhanced during all care and services interactions . This citation relates to Complaint IN00447592 . 3.1-41(a)(2)

Based on record review and interview, the facility failed to follow the physician's orders related to medication administration parameters for cardiac medications for 2 of 6 residents reviewed for medications (Residents 12 and 29) Findings include: 1. The clinical record for Resident 12 was reviewed on 01/07/25 at 1:43 P.M. A Significant Change Minimum Data Set (MDS) assessment, dated 11/15/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anemia, cirrhosis, diabetes, hypotension, and hypertensive heart disease. The resident's current physician's orders included an open-ended order, with a start date of 11/21/24, for midodrine (a medication used to treat low blood pressure) 5 milligrams three times a day (8:00 A.M., 11:00 A.M., and 4:00 P.M.). The special instructions indicated the medication was to be held for a systolic blood pressure (sbp) > (greater than) 130 or a diastolic blood pressure (dbp) > 90. The November and December 2024 and January 2025 Electronic Medication Administration Record (EMAR) indicated the resident had received the medication when the systolic blood pressure was greater than 130 or the diastolic blood pressure was greater than 90 on the following dates and times: - On 11/21/24, the 11:00 A.M. blood pressure was 146/79, - On 11/23/24, the 11:00 A.M. blood pressure was 159/80, - On 11/24/24, the 4:00 P.M. blood pressure was 148/82, - On 11/27/24, the 4:00 P.M. blood pressure was 135/74, - On 11/30/24, the 4:00 P.M. blood pressure was 138/74, - On 12/05/24, the 4:00 P.M. blood pressure was 134/74, - On 12/06/24 the 8:00 A.M. blood pressure was 158/85, the 11:00 A.M. blood pressure was 158/85, and the 4:00 P.M. blood pressure was 140/89, - On 12/09/24, the 11:00 A.M. blood pressure was 152/69, - On 12/10/24, the 4:00 P.M. blood pressure was 136/68, - On 12/24/24, the 8:00 A.M. blood pressure was 146/69, the 11:00 A.M. blood pressure was 152/71, and the 4:00 P.M. blood pressure was 135/75, - On 12/28/24, the 11:00 A.M. blood pressure was 144/62, - On 12/29/24, the 11:00 A.M. blood pressure was 155/73, - On 01/01/25, the 4:00 P.M. blood pressure was 152/68, - On 01/02/24, the 11:00 A.M. blood pressure was 140/80, - On 01/04/24, the 8:00 A.M. blood pressure was 139/100, and - On 01/07/24, the 11:00 A.M. blood pressure was 136/74 and the 4:00 P.M. blood pressure was 140/74. During an interview on 01/09/25 at 1:42 P.M., Licensed Practical Nurse (LPN) 6 indicated some medication orders included administration parameters. Sometimes a medication was to be held if the resident's blood pressure or pulse was too low or too high. She would check the resident's blood pressure and if it was out of range, she would not administer the medication. She would mark held on the EMAR and put in a progress note that indicated why the medication was held. 34232 2. The clinical record for Resident 29 was reviewed on 01/06/25 at 12:01 P.M. An Annual MDS assessment, dated 12/05/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, dementia, depression, and hypertension. The resident's current physician's orders included an open-ended order, with a start date of 09/12/24, for Metoprolol 25 mg, give one tablet two times a day (8:00 A.M. and 5:00 P.M.) for hypertension. The medication was to be held for a heart rate (HR) of less than 60. The October, November, and December 2024, EMAR was provided by the Director of Nursing on 01/09/25 at 4:30 P.M., and indicated the resident had received the medication when the HR was less than 60 on the following dates and times: - On 10/03/24, the 8:00 A.M. HR was 55, - On 10/08/24, the 8:00 A.M. HR was 55, - On 11/13/24, the 5:00 P.M. HR was 50, - On 11/15/24, the 5:00 P.M. HR was 54, - On 11/18/24, the 8:00 A.M. HR was 58, - On 11/26/25, the 5:00 P.M. HR was 56, and - On 12/11/24, the 5:00 P.M. HR was 51. A Care Plan, with an initiated date of 12/29/23, indicated the resident was at risk for elevated blood pressure related to a diagnosis of hypertension. The interventions included, but were not limited to, administer medications as ordered by the physician. The current MEDICATION ADMINISTRATION policy, dated February 2017, was provided by the Assistant Director of Nursing on 01/09/25 at 2:45 P.M. The policy indicated, .Review the resident's Medication Administration Record .Read each order entirely .Read and follow special instructions .Obtain and record any vital signs as necessary prior to medication administration . 3.1- 48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a care planned fall intervention was in place for 1 of 3 residents reviewed for Quality of Care. (Resident 12) Findings include: During an observation Resident 12 was observed in his room on 01/02/25 at 11:35 A.M. The resident was sitting on the side of his bed. The resident denied concerns with the environment and denied falling in the facility. There was pale yellow tape wrapped around the resident's call light. There were no non-skid strips on the resident's floor near his bed or anywhere else on his side of the room. The clinical record for Resident 12 was reviewed on 01/07/25 at 1:43 P.M. A Significant Change Minimum Data Set (MDS) assessment, dated 11/15/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anemia, cirrhosis, diabetes, hypotension, and hypertensive heart disease. The resident had not experienced a fall since the last assessment. A Progress Note, dated 12/06/24 at 1:49 P.M., indicated the resident was found on the floor near his bed on 12/06/24 at 2:35 A.M. The resident did not remember what he was trying to do at the time. The resident was experiencing weakness due a recent decline in health and was receiving hospice services. The resident was not injured. An intervention to place non-skid strips on the floor beside the resident's bed was to be implemented. The resident's care plan was updated to include the intervention. A Progress Note, dated 12/16/24 at 11:47 A.M., indicated the resident experienced a fall on 12/13/24 at 5:31 P.M. The resident was incontinent and attempted to go to bathroom without assistance. The resident was not injured. The resident's call light was in reach, his bed was in the lowest position, and he had proper footwear on. There was no mention of any non-skid strips on the floor near the resident's bed. An intervention to place florescent tape on the resident's call light was implemented. A Progress Note, dated 1/06/25 at 3:53 P.M., indicated the resident experienced a fall on 01/05/25 at 2:02 A.M. The resident was attempting to get out of bed to go to the bathroom and fell . The resident was not injured. An intervention to ensure the resident's bed was in the lowest position while he was in bed was implemented. During an interview on 01/08/25 at 9:53 A.M., Certified Nurse Aide (CNA) 7 indicated the resident hadn't had any falls recently that she was aware of. He had a cane, but he didn't like to use it. They would put non-skid socks on his feet, and he would just take them off. The resident's room was observed with the Assistant Director of Nursing (ADON) on 01/09/25 at 2:50 P.M. There were no non-skid strips on the floor near the resident's bed. The ADON indicated the resident was supposed to have non-skid strips on the floor, she remembered when they discussed the intervention. The resident's Fall Care Plan was provided by the Director of Nursing (DON) on 01/09/25 at 3:05 P.M. The care plan indicated an intervention was initiated on 12/06/24 to place non-skid strips on the floor by the resident's bed. The current facility policy, titled GUIDELINES FOR INCIDENTS/ACCIDENTS/FALLS, dated 06/30/23, was provided by the DON on 01/09/25 at 3:05 P.M. The policy indicated, .All falls will have a site investigation .to define root cause of the fall .Each fall needs a new care plan interventions rolled out . 3.1-37(a)

Based on record review and interview, the facility failed to accurately complete MDS (Minimum Data Set) assessments related to residents' discharge status and diagnoses for 4 of 14 residents reviewed for accuracy of assessments. (Residents 49, 7, 38, and 50) Findings include: 1. The clinical record for Resident 49 was reviewed on 02/22/24 at 10:21 A.M. A Discharge MDS assessment, dated 12/18/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, anxiety, malnutrition, and heart failure. The assessment indicated this was a planned discharge and the resident's return was not anticipated. The discharge status section indicated the resident was discharged to a short-term general hospital. The resident's discharge summary in the EHR (Electronic Health Record) indicated the resident discharged from the facility on 12/18/23 to another nursing home. The resident's family provided transportation. During an interview on 02/22/24 at 11:12 A.M., the Social Services Director indicated the resident moved to a different facility that was closer to her family. During an interview on 02/22/24 at 11:16 A.M., the MDS Coordinator indicated the assessment should have indicated the resident discharged to another nursing home, not to a hospital. 2. The clinical record for Resident 7 was reviewed on 02/20/24 at 10:30 A.M. A Quarterly MDS assessment, dated 01/29/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anemia, heart failure, and COPD (Chronic Obstructive Pulmonary Disease). The Infections segment of the diagnosis section of the assessment indicated the resident had not had a UTI (Urinary Tract Infection) in the last 30 days. Urinalysis Culture and Sensitivity lab test results, dated 01/10/24, were provided by the MDS Coordinator on 02/22/24 at 11:43 A.M. The test results indicated the resident had greater than 100,000 CFU/ml (colony forming units per milliliter) of Escherichia coli (a bacteria). The resident was placed on an antibiotic. An INFECTION - UTI (McGeer Criteria) document, dated 01/11/24, indicated the resident's urinalysis results and complaints of dysuria or pain met McGeer's criteria for infection. During an interview on 02/22/24 at 11:20 A.M., the MDS Coordinator indicated the resident's urinalysis results did meet criteria for infection. The MDS should have indicated the resident had a UTI in the last 30 days of the assessment review period. The facility followed the RAI (Resident Assessment Instrument) manual. 34232 3. The clinical record for Resident 38 was reviewed on 02/22/24 at 1:32 P.M. A Significant Change MDS assessment, dated 02/05/24, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, Alzheimer's disease and obstructive uropathy. The resident had an indwelling urinary catheter and had not had a UTI in the last 30 days. During an interview on 02/22/24 at 3:07 P.M., the MDS Coordinator indicated for a UTI to be documented on the MDS assessment it had to meet McGeer's Criteria and have over 100,000 organisms on the Culture and Sensitivity lab test. Culture and Sensitivity lab test results, dated 01/20/24, were provided by the MDS Coordinator on 02/22/24 at 3:13 P.M. The test results indicated the resident had greater than 100,000 CFU/ml of Proteus mirabilis and Psuedomonas aeruginosa and was placed on an antibiotic. The MDS Coordinator indicated the UTI should have been documented on the MDS assessment. 33613 4. The clinical record for Resident 50 was reviewed on 02/20/24 at 8:58 A.M. A Discharge - Return Anticipated MDS assessment, dated 12/01/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes and a fall at home. The resident was returning to the community. The Resident Discharge Summary, dated 12/01/23, indicated the resident was returning home to the community. A progress note, dated 12/01/23 at 11:21 A.M., indicated the resident left the facility with her son and daughter-in-law. During an interview on 02/22/24 at 1:38 P.M., the MDS Coordinator indicated the assessment for Resident 50 should have been a discharged - return not anticipated.

Based on record review and interview, the facility failed to notify the physician of a resident's weight changes for 1 of 17 residents reviewed for notification of change. (Resident 16) Findings include: The clinical record for Resident 16 was reviewed on 02/22/24 at 11:06 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 01/09/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure and renal insufficiency. A current physician's order, with a start date of 07/13/23, indicated the staff were to weigh the resident daily and were to call the MD for a weight gain greater than 2 lbs. (pounds) in a day and greater than 5 lbs. in a week. The December 2023, January and February 2024 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record). The records either lacked a documented weight or the physician had been notified of the following weight gains: - 12/04/23, no weight documented, - 12/09/22, no weight documented, - 12/15/23 through 12/18/23, no weight documented, - 12/20/23, no weight documented, - 12/22/23, no weight documented, - 12/24/23, no weight documented, - 12/25/23, no weight documented, - 12/30/23, no weight documented, - 01/11/24, no weight documented, - 01/20/24, no weight documented, - 01/22/24, the weight was 343.8 lbs. and 01/23/24 the weight was 346 lbs., a 2.2 lb. weight gain, - 01/24/24, the weight was 346 lbs. and 01/25/24 the weight was 348.8 lbs., a 2.8 lb. weight gain, - 01/27/24, through 01/29/24, no weight documented, - 02/01/24, the weight was 352.6 lbs. and 02/02/24 the weight was 362 lbs., a 9.4 lb. weight gain, - 02/03/24, no weight documented - 02/04/24, the weight was 362.2 lbs. and 02/05/24 the weight was 365 lbs., a 2.8 lb. weight gain, - 02/10/24, the weight was 365.4 lbs. and 02/11/24 the weight was 367.7 lbs., a 2.3 lb. weight gain, and - 02/18/24, no weight documented. During an interview on 02/22/24 at 3:18 P.M., the ADON (Assistant Director of Nursing) indicated if the resident had a weight gain of greater than 2 pounds in 24 hours the MD should have been notified. The nurses were to document the weight daily and notification of the physician in the clinical record. If the resident refused to be weighed it would be documented as a refusal. The current, undated, facility policy titled, Change in Resident's Condition or Status was provided by the Regional Nurse Consultant on 02/22/24 at 4:06 P.M. The policy indicated, .It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status .The nurse will notify the resident's attending physician when: .There is a need to alter the resident's treatment plan significantly . 3.1-5(a)(3)

Based on record review and interview, the facility failed to follow physicians' orders for hold parameters related to blood pressures and heart rates for 2 of 17 residents reviewed for quality of care. (Residents 42 and 17) Findings include: 1. The clinical record for Resident 42 was reviewed on 02/20/24 at 10:06 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 02/08/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension, neurogenic bladder, seizure disorder, anxiety, and depression. A current physician's order, with a start date of 05/10/23, indicated the resident was to get Midodrine 5 mg (milligrams), three times a day, for hypotension. The staff were to hold the medication if the residents systolic (top number) blood pressure was greater than 140. The clinical record that included the January and February 2024 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident had received the medication when the blood pressure was greater than 140 or the blood pressure was not obtained on the following dates and times: - 01/06/24 at 5:00 P.M., the blood pressure was 144/76, - 01/12/24, at 5:00 P.M., the blood pressure was not documented and lacked indication the resident received the medication, - 01/16/24 at 5:00 P.M., the blood pressure was 175/79, - 01/22/24 at 8:00 A.M., the blood pressure was 156/67, - 01/26/24 at 1:00 P.M., the blood pressure was 188/61, - 02/11/24 at 5:00 P.M., the blood pressure was not documented and lacked indication the resident received the medication, and - 02/19/24 at 5:00 P.M., the blood pressure was not documented and lacked indication the resident received the medication. During an interview on 02/22/24 at 10:03 A.M., RN 3 indicated if there were hold parameters on a resident's medication, then she would obtain the vitals. If the vitals were outside of the parameters, the medication wouldn't be administered. She would document the vitals in the EMAR and that the medication was held. 33613 2. The clinical record for Resident 17 was reviewed on 02/21/24 at 9:57 A.M. A Quarterly MDS assessment, dated 11/14/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, diabetes, renal insufficiency, hypertension, and a stroke. A current physician's order, with a start date of 08/29/23, indicated the resident was to get Atenolol 25 mg, one time a day, for hypertension. The staff were to hold the medication if the resident's heart rate was less than 60. The clinical record that included the January and February 2024 EMAR/ETAR indicated the resident had received the medication when the heart rate was not documented on the following dates: - 01/02/24, - 01/03/24, - 01/06/24 through 01/31/24, and - 02/05/24 through 02/14/24. During an interview on 02/22/24 at 10:49 A.M., the Assistant Director of Nursing indicated if a resident's medication had hold parameters for the heart rate, the heart rate should be obtained prior to the medication being given. If the heart rate was outside of the parameters, the medication shouldn't be administered, and the Medical Director and the family should be notified. The current, undated, facility policy titled, Physician Order-(Following Physician Orders) was provided by the Regional Nurse Consultant on 02/22/24 at 10:56 A.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . The current facility policy titled, Medication Administration dated February 2017, was provided by the Regional Nurse Consultant on 02/22/24 at 10:56 A.M. The policy indicated, .To administer medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis .Read and follow any special instructions written on labels .Obtain and record any vital signs as necessary prior to medication administration . 3.1-37(a)

Based on record review and interview, the facility failed to prevent a DTI (Deep Tissue Injury) (Persistent non-blanchable deep red, maroon, or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) pressure ulcer for 1 of 4 residents reviewed for pressure ulcers. (Resident 16) Findings include: During an interview on 02/19/24 at 11:11 A.M., Resident 16 indicated she had developed a wound to her left heel after coming to the facility. The wound was currently healed, but she continued with wearing heel boots at night while she was in bed. The clinical record for the resident was reviewed on 02/22/24 at 11:06 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 01/09/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anemia, heart failure, hypertension, renal insufficiency, diabetes, anxiety, and depression. A Weekly Skin Observation, dated 11/19/23 and 11/26/23, indicated the resident did not have any new skin conditions. The CNA (Certified Nurse Aide) Bath/Shower Checklist for November and December 2023, lacked indication the resident had any new skin conditions. A Wound NP (Nurse Practitioner) Assessment, dated 12/06/23, indicated the resident had a Deep Tissue Injury to the left heel that measured 1.5 cm (centimeters) by 1.5 centimeters. A Wound NP Assessment, dated 01/24/24, indicated the resident's left heel wound had healed. During an interview on 02/21/24 at 10:28 A.M., the Wound NP indicated the resident had chronic knee pain and would push her foot directly on the foot pedal of her wheelchair and caused the DTI to the left heel. The resident's wound healed well. They initiated boots for the resident to wear at all times, but she no longer needed them. The wound was a DTI when it was found. During an interview on 02/22/24 at 10:03 A.M., RN 3 indicated the nurses assessed the resident's skin weekly. If a resident had a new skin impairment, she would complete a skin risk management assessment and notify the appropriate management staff, MD, and family. The aides were to come to the nurse and let them know if they saw any skin impairments with daily care. During an interview on 02/22/24 at 10:21 A.M., CNA 5 indicated she looked at the resident skin anytime she was assisting them with care. She made sure to check bony prominences and high-pressure areas. If the resident had a new skin impairment, she would let the nurse know right away. During an interview on 02/22/24 at 2:57 P.M., the ADON (Assistant Director of Nursing) indicated the resident was alert and oriented. The resident was a diabetic. The resident developed a wound to her left heel from pushing her foot onto her foot pedal even after education and encouragement to not do so. When the wound developed the resident was given boots to wear at all times. She had recently started to not want to wear them while up in the wheelchair, but still wore them while she was in bed. The wound was a deep tissue injury when it was found. The staff should have noticed redness before and alerted her before it was a deep tissue injury. The current facility policy titled Guidelines for Prevention/Treatment of Pressure Injuries dated 10/09/23, was provided by the Regional Nurse Consultant on 02/22/24 at 4:06 P.M. The policy indicated, .It is the intent of the facility to recognize the following information and to act on it in such a way as to practice evidence-based recommendations for the prevention/treatment of pressure injuries to the residents who reside in the facility .In accordance with Federal Regulations-and based on resident assessment, the facility will ensure: A resident received care, consistent with professional standards of practice; to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable . 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure appropriate catheter care was provided related to the positioning of an indwelling urinary catheter drainage bag and tubing for 1 of 5 residents reviewed for indwelling catheters. (Resident 17) Findings include: The clinical record for Resident 17 was reviewed on 02/21/24 at 9:57 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 11/14/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, diabetes, renal insufficiency, hypertension, and a stroke. The resident required substantial/maximal assistance with ADLs (Activities of Daily Living). During an observation on 02/21/24 at 11:24 A.M., Resident 17 was sitting in his wheelchair in the hallway between the nurse's station the main dining room. His urinary catheter bag was half full and approximately two inches of the bag was touching the floor. There were several staff members in the immediate area walking past him. During an observation on 02/21/24 at 11:44 A.M., Resident 17 propelled himself into the main dining room with his urinary catheter bag dragging on the floor. During an observation on 02/21/24 at 11:54 A.M., Resident 17 was sitting in the main dining room with his urinary catheter bag touching the floor. During an observation on 02/21/24 at 12:17 P.M., Resident 17 was removed from the main dining room and propelled down the hall to his room by CNA (Certified Nurse Aide) 4. The urinary catheter bag was dragging the floor. During an observation on 02/21/24 at 12:33 P.M., CNA 4 returned Resident 17 to the main dining room. His urinary catheter bag continued to drag the floor. During an observation on 02/22/24 at 12:19 P.M., Resident 17 was sitting in his wheelchair in the main dining room with two inches of his urinary catheter bag touching the floor. A current physician's order, with a start date of 02/16/24, indicated the resident received Macrobid (an antibiotic) 100 mg (milligrams), twice a day for nine days for a UTI (urinary tract infection). During an interview on 02/22/24 at 10:52 A.M., CNA 5 indicated a resident's urinary catheter tubing or bag should never touch the floor. During an interview on 02/22/24 at 11:15 A.M., the Regional Nurse Consultant indicated the facility did not have a policy related to keeping the urinary catheter bag and tubing off the floor, but the urinary catheter bag and tubing should never touch the floor. 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure a resident was free from a transcription error of a significant medication. This deficient practice resulted in the resident developing mouth sores, low platelet counts, critical laboratory values, hospitalization , and death resulting in immediate jeopardy for 1 of 5 residents reviewed for medications. (Resident D) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility failed to ensure a resident was free from a transcription error of a significant medication. This deficient practice resulted in the resident requiring hospitalization for critical laboratory values and death. The Administrator was notified of the Immediate Jeopardy on [DATE] at 03:40 P.M. The immediate jeopardy that began on [DATE] was removed, and the deficient practice corrected, on [DATE], prior to the start of the survey and was therefore Past Non-Compliance. Findings include: The clinical record for Resident D was reviewed on [DATE] at 10:32 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. The resident was hospitalized on [DATE] for treatment of [REDACTED]. The Resident remained in the facility until [DATE], when she was sent to the local hospital emergency room . The resident was subsequently transferred to another hospital where she was admitted on [DATE] and remained until her death on [DATE]. The hospital records for Resident D were reviewed on [DATE] at 08:14 A.M. The records indicated the resident was admitted to the hospital on [DATE] and died on [DATE] at 9:35 A.M. [DIAGNOSES REDACTED].Active problems: [MEDICATION NAME] toxicity, accidental or unintentional, initial encounter .[MEDICAL CONDITION] .Pancytopenia (reduction in the number of red and white blood cells as well as platelets) due to antineoplastic [MEDICAL CONDITION] .[MEDICAL CONDITION] in stage 4 [MEDICAL CONDITION] .[MEDICAL CONDITION] arthritis of multiple sites without organ or system involvement with positive [MEDICAL CONDITION] factor .Debility .MRSA ([MEDICAL CONDITION]-Resistant Staphyloccus Aureus) bacteremia (presence of bacteria in the blood) .Lower gastrointestinal hemorrhage (an escape of blood from a ruptured blood vessel, especially when profuse) .[MEDICAL CONDITION] (condition where abnormally low levels of platelet are observed) due to platelet alloimmunization (the immune response present on the platelet's surface) .Coagulation defect .Preliminary Cause of Death .[MEDICATION NAME] toxicity resulting in severe pancytopenia and likely DIC (Disseminated Intravascular Coagulation; a condition where blood clots are excessively formed in the body's blood vessels), resulting in acute hemorrhagic shock and septic shock . During an interview on [DATE] at 12:44 P.M., NP (Nurse Practitioner) 4 indicated Resident D was one of her patients. Resident D had been hospitalized at the end of (MONTH) 2019 and treated for [REDACTED]. The NP was in the facility and reviewed Resident D's physician orders [REDACTED]. She viewed the medications and the dosages in the EHR. She did not open and view the orders to review the frequency of each medication. She assumed the orders were going to be transcribed as ordered from the hospital. She will change the way she looks at the medications and look at the dosage frequency in the future. If someone received an excessive dose of [MEDICATION NAME] they could have mouth sores, low platelets, and liver problems. When she was made aware of the medication error she told the staff at the facility that this was a very serious drug and they needed to get labs right away. When they received the lab results she gave an order to send the resident to the hospital. She told the staff at the facility to make sure they let the hospital know about [MEDICATION NAME] the resident had received in the facility. During an interview on [DATE] at 11:45 A.M., the DON (Director of Nursing) indicated on [DATE] the resident had complained of mouth sores. The NP was in the building, assessed the resident, and ordered [MEDICATION NAME] (an antifungal medication) to treat the sores in her mouth. A short time later, LPN (Licensed Practical Nurse) 3 mentioned to the ADON (Assistant Director of Nursing) that maybe the mouth sores could be from a new medication. Nursing staff reviewed Resident D's medications and discovered the [MEDICATION NAME] (an antimetabolite medication that suppresses the immune system) had been given incorrectly. They notified the NP and she gave an order to hold the [MEDICATION NAME]. Other than the mouth sores, the resident was asymptomatic at that time. During an interview on [DATE] at 12:02 P.M., LPN 3 indicated she assessed Resident D's mouth on [DATE]. She observed a few blister type sores with a small amount of blood on the inside of both sides of the resident's mouth. LPN 3 thought the sores could be from a new medication and she told the resident she would review her medications. Resident D was appreciative because the sores hurt, and were making it hard for her to eat. LPN 3 and the ADON reviewed Resident D's medication and found the [MEDICATION NAME] medication error. They notified the NP, and the NP gave an order to hold the medication on [DATE]. She did not order any labs (laboratory tests) at that time. During an interview on [DATE] at 1:30 P.M., the DON indicated on [DATE], Resident D had a nose bleed, and complained of stomach pain and of a sore mouth. The resident was noted to have had a medium sized bowel movement with dark/black stool but she did take iron supplements that would cause dark stools and she had a history of [REDACTED]. When the lab results came back, they sent the resident to the local hospital emergency department. During an interview on [DATE] at 12:28 P.M., LPN 2 indicated during the week, the DON or ADON usually put the orders in the computer for an admission or readmission. Resident D came back on [DATE], which was a Saturday. LPN 2 put the orders in herself. She thought she entered the [MEDICATION NAME] order in the EHR (electronic health record), to be administered once weekly, but she must have clicked the wrong button and selected administer daily. She needed clarification on a different medication order for potassium, so she didn't enter that order in the EHR. She asked the DON to review the potassium order and get clarification on the following Monday. A Progress Note, dated [DATE] at 3:58 P.M., indicated the DON had spoken to the nurse at the discharging hospital and gotten clarification for Resident D's potassium order. A PROVIDER PROGRESS NOTE, dated [DATE], was provided by the Administrator on [DATE] at 3:09 P.M. The note indicated Resident D was seen by NP 4. The record indicated the NP had reviewed the physician's orders [REDACTED]. No further orders were noted regarding the medication [MEDICATION NAME]. The progress note was signed by the NP and dated [DATE]. The EMAR (Electronic Medication Administration Record) for Resident D, was provided by the Administrator on [DATE] at 3:15 P.M. The EMAR for (MONTH) and (MONTH) 2019 included the following orders: [MEDICATION NAME] 2.5 mg (milligram) tablet. Give 1 tablet by mouth, one time a day, every Thursday for [MEDICAL CONDITION] arthritis. The start date was [DATE] at 8:00 A.M. The discontinue date was [DATE] at 2:10 P.M. [MEDICATION NAME] 2.5 mg tablet. Give 1 tablet by mouth, one time a day, for [MEDICAL CONDITION] arthritis. The start date was [DATE] at 8:00 A.M. The discontinue date was [DATE] at 5:53 P.M. The EMAR indicated Resident D received [MEDICATION NAME] 2.5 mg, daily, on (MONTH) 31, 2019 and (MONTH) 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10, 2019. The Lab Reports for Resident D were provided by the Administrator on [DATE] at 3:15 P.M. The report indicated the resident had the following lab values on the following dates, (normal range listed in parenthesis): [DATE] -WHITE BLOOD CELL COUNT - 6.9 (4XXX,[DATE].8 K/cmm) per thousand of cells per cubic millimeter of blood -RED BLOOD CELL COUNT - 2.91 (3XXX,[DATE].40 M/cmm) per million of cells per cmm of blood -HEMOGLOBIN - 8.8 (12XXX,[DATE].0 g/dL) grams per deciliter -HEMAT[NAME]RIT - 26.5 (36XXX,[DATE].0%) -PLATELET - 228 (,[DATE] K/cmm) [DATE] -WHITE BLOOD CELL COUNT - 1.5 (4XXX,[DATE].8 K/cmm) -RED BLOOD CELL COUNT - 2.38 (3XXX,[DATE].40 M/cmm) -HEMOGLOBIN - 7.0 (12XXX,[DATE].0 g/dL) -HEMAT[NAME]RIT - 21.6 (36XXX,[DATE].0%) -PLATELET - 45 (,[DATE] K/cmm) A physician order, prescribed by NP 4, dated [DATE] at 17:54 (5:54 P.M.), was provided by the Administrator on [DATE] at 3:09 P.M. The order indicated under order summary, .[MEDICATION NAME] Tablet 2.5 MG (milligrams) ([MEDICATION NAME] Sodium) Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] arthritis . The medication was discontinued at 5:53 P.M. The reason listed was Transcription error. A physician order, prescribed by NP 4, dated [DATE] at 17:55 (5:55 P.M.), was provided by the Administrator on [DATE] at 3:09 P.M. The order indicated under order summary, .[MEDICATION NAME] Tablet 2.5 MG .Give 1 tablet by mouth one time a day every Fri (Friday) for R.A. ([MEDICAL CONDITION] Arthritis) . The undated, Verbal Orders / Admission / Readmission orders [REDACTED].M. The policy indicated, .After transcription of orders .Recheck your transcription word for word to make sure that it was transcribed correctly .Knowledge of Medications being given .Side-effects to be expected . The Past Non-Compliance Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed, and deficient practice corrected by [DATE] after the facility implemented a systemic plan that included the following: Residents' charts were reviewed to ensure all medications were transcribed as ordered and that the correct medication and dose was on hand. The EHR documentation was reviewed to ensure medication orders were transcribed accurately, and included medication, dosage, and frequency. All staff educated and inserviced on order entry and medication transcription. DON/ADON will validate all transcribed MEDICATION ORDERS FOR [REDACTED]. An admission/readmission checklist will be filled out for every admission, and require two nurses to verify and sign off on all physician orders. The pharmacy had implemented a flagging system for all high alert medications. This Federal tag relates to complaint IN 416 3XXX,[DATE](a)(1)