Every finding on record at White Oak Health Campus

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed to self-administer medications and had Physician's Orders to self-administer medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 43) Finding includes: During an interview on 5/27/26 at 11:55 a.m., Resident 43 indicated she had kept two ointments in a drawer in her room. A tube of tacrolimus ointment (a topical medication used to treat skin conditions) was observed in the drawer. The other ointment she had used was triamcinolone (a corticosteroid used to reduce inflammation) and it had gone missing. A piece of paper posted on the chest of drawers contained instructions for the use of both the tacrolimus and triamcinolone ointments. During the interview, Resident 43 was observed scratching both of her arms.Resident 43's record was reviewed on 5/28/26 at 10:12 a.m.The admission Minimum Data Set assessment, dated 4/28/26, indicated the resident was cognitively intact.A Physician's Order, dated 4/28/26, indicated tacrolimus ointment 0.1%, one topical application every 12 hours as needed.A Physician's Order, dated 4/29/26, indicated triamcinolone acetonide cream 0.1%, one topical application every 12 hours as needed, avoiding the neck, face, skin folds, and genitals, and to be used for up to 14 days monthly.There was no self administration of medication assessment completed, nor was there a physician's order for the resident to self administer her own medications.During an interview on 5/28/26 at 10:49 a.m., RN 2 indicated she had worked with the resident during previous stays at the facility and had been assigned as her nurse for the current shift. The resident had not reported itchy skin until that morning and she had been scratching her back. The resident had one area on her back, and a cream had been applied. RN 2 indicated the resident was not permitted to have any medications at the bedside for self administration. The resident kept an unmedicated lotion at the bedside for general use. At that time, RN 2 looked inside the chest of drawers and observed a tube of tacrolimus cream. The medication had a pharmacy label that was worn off and a piece of blue tape with the word face written on it. RN 2 indicated the medication was not to be kept at the bedside. During an interview on 5/28/26 at 11:16 a.m., the Director of Nursing indicated the resident's family had been non compliant and had previously brought medications into the facility for the resident. When the resident lived in Assisted Living, she had been permitted to self administer creams. The family continued to bring the resident medications even after receiving education that nursing staff needed to be notified of any new skin issues or itching so that the resident could be properly assessed.A facility policy titled, Guidelines for Self-Administration of Medications, indicated, .1. Residents requesting to self-medicate or has self-medication as a part of their plan of care shall be assessed using the observation Trilogy-Self Administration of Medication within the electronic health record. Results of the assessment will be presented to the physician for evaluation and an order for self-medication. a. The order should include the type of medications the resident is able to self-medicate 6. A self-Medication plan of care will be initiated and updated as indicated. 7. The assessment will be reviewed quarterly, and PRN with change of condition. 8. The assessment will be documented in the EHR . 410 IAC (Indiana Administrative Code) 16.2-3.1-11(a)

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to antipsychotic medications for 1 of 16 MDS assessments reviewed. (Resident 40)Finding includes:Resident 40's record was reviewed on 5/29/26 at 12:24 p.m. The admission Minimum Data Set (MDS) assessment, dated 4/26/26, indicated the resident was cognitively intact. In the 7-day look back period, the resident had received an injection, antipsychotic, antianxiety, antidepressant, antibiotic, opioid, antiplatelet, and anticonvulsant medications. The May 2026 Physician's Order Summary indicated promethazine (Phenergan), an antiemetic drug, 25 milligrams every 8 hours as needed for nausea and vomiting. During an interview on 6/1/26 at 3:28 p.m., the MDS Coordinator indicated she had coded an antipsychotic was administered because the resident had received promethazine and that drug required an AIMS assessment along with additional monitoring. During an interview on 6/1/26 at 4:10 p.m., the Nurse Consultant indicated the MDS should not have been marked for antipsychotic medications. During a follow-up interview on 6/2/26 at 3:58 p.m., the Nurse Consultant indicated she had spoken with the Consultant Pharmacist. The Consultant Pharmacist had explained that although promethazine was similar to Compazine (a typical antipsychotic medication), the medication was not truly classified as an antipsychotic, but rather an antiemetic. 410 IAC (Indiana Administrative Code) 16.2-3.1-31(i)

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to Enhanced Barrier Precautions (EBP) and staff not wearing a gown during a peripherally inserted central catheter (PICC) medication administration observation. (Resident 62) Finding includes: During a medication administration observation on 5/28/26 at 12:36 p.m., RN 1 was observed preparing Resident 62's medications, which included antibiotic medication to be administered intravenously through the resident's PICC line. The resident's bathroom door had a sign that indicated EBP was to be used. RN 1 entered the resident's room, used hand sanitizer, and donned gloves. She had not donned a gown. She then proceeded to administer the intravenous medication through the PICC line. At 1:24 p.m. the antibiotic was complete and RN 1 entered the room to disconnect the medication. She used hand sanitizer, donned gloves, disconnected the tubing and flushed the PICC line. She had not donned a gown.During an interview on 5/28/26 at 1:29 p.m., RN 1 indicated she should have worn a gown when administering intravenous medication through a PICC line. During an interview on 6/1/26 at 2:29 p.m., the Infection Preventionist indicated enhanced barrier precautions should be implemented for residents with a PICC line.A facility policy, titled, Enhanced Barrier Precautions Standard Operating Procedure, received as current, indicated .1. Enhanced barrier precautions will be in place during high contact care activities for residents with the following conditions: .ii. All residents with indwelling medical devices. 1. Includes but not limited to: catheters, central lines, feeding tubes, tracheostomy tubes .2. Personal protective equipment should be used even if blood and body fluid exposure is not anticipated. a. At minimum, staff shall wear gloves and gowns during high contact care activities .410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to a build up of food debris and grease on the sides of the oven, deep fryer, floor between the oven and deep fryer, and in the bottom front of a closed warming food cart. The facility also failed to have boxes of food not stored up to the ceiling in the walk in freezer. This had the potential to affect 52 of 52 residents who resided in the facility and received food from the kitchen. (Main Kitchen) Findings include: During the Initial Kitchen Sanitation Tour on 3/3/25 at 10:53 a.m., with the Director of Food Services, the following was observed: a. There was a build up of food debris and grease on the sides of the oven. b. There was a build up of food debris and grease on the sides of the deep fryer. c. There was a build up of food debris and grease on the floor between the oven and the deep fryer. d. There was a build up of food debris and grease in the bottom front of a closed warming food cart. e. There were multiple boxes of food stored up to the ceiling in the walk in freezer. During an interview on the tour, the Director of Food Services indicated the boxes should not be stored up to the ceiling in the walk in freezer and the appliances and floors should be cleaned more often and not have a build up of food and grease. An Aides Cleaning List, provided by the Executive Director on 3/10/25, indicated the kitchen staff were responsible to sweep/mop the kitchen floors daily and clean utility carts weekly. The Executive Director could not provide any facility policies for the above concerns. 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to provide proper feeding tube (gastrostomy tube) (g-tube) care as per professional standards, related to verification of the g-tube placement not completed prior to medication administration for 1 of 1 resident reviewed for feeding tube care. (Resident 29) Finding includes: During an observation of medication pass on 3/5/25 at 12:24 p.m., RN 1 was observed preparing and administering g-tube medications to Resident 29. RN 1 prepared and crushed carbidopa-levodopa (treatment for Parkinson's disease) 25 milligram-100 milligram 2 tablets and glycopyrrolate (treatment for ulcers) 1 milligram tablet in separate medication pouches and then put them into separate medication cups after they were crushed. She washed her hands, donned a gown and gloves, and entered the resident's room. She mixed each medication with approximately 15 milliliters (ml) of water. She flushed the g-tube with 30 ml of water, milked the tubing as the water was not going down by gravity, and then pushed the plunger of the syringe to get the water to flow. She did not check for placement of the g-tube prior to administering the water flush. RN 1 then poured approximately half of the medication cup containing the carbidopa-levodopa into the g-tube. The crushed medication was not mixed in with the water. She flushed the g-tube with 30 ml of water and then administered the glycopyrrolate. She removed her gown and gloves, performed hand hygiene, and exited the room to retrieve a spoon to mix the remaining medication, leaving the medication on the resident's bedside table. She returned and administered the rest of the medication, and flushed the g-tube with water. During an interview at the time, RN 1 indicated that the policy was to check for placement once a shift, so she had checked before the morning medication pass and did not have to do check for placement again for the afternoon medication pass. During an interview on 3/7/25 at 12:15 p.m., the Director of Nursing indicated the nursing staff were to check for placement prior to every medication administration. A facility policy titled, Administering Gastric/Jejunostomy Tube Medications, and noted as current, indicated, .4. Before administering medications observe or review: e. vital signs and bowel sounds as indicated; and f. Residual volume of stomach contents .18. Perform any pre-administration assessments 23. There are multiple methods for verifying placement of the tube .a. Checking gastric residual volume (GRV) .c. pH of GRV .e. Observing changes in external length of tubing .g. For all gastric tubes, pull back gently on the syringe to aspirate stomach content .26. Administer medication by gravity flow . 3.1-44(a)(2)

Based on observation, record review and interview, the facility failed to identify or act on an irregularity in a resident's medication regimen related to a recommended lab not being completed and an accepted recommendation with no follow up for 2 of 5 residents reviewed for unnecessary medications. (Residents 16 and 8) Findings include: 1. Resident 16's record was reviewed on 3/5/25 at 8:45 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, major depression and anemia. The Quarterly Minimum Data Set assessment, dated 1/9/25, indicated the resident had severe cognitive deficits and required substantial assistance for toileting and transfers. A Pharmacy Recommendation, dated 11/19/24, indicated the resident had an order for an iron supplement for over six months and to consider checking serum iron, ferritin, TIBC and percent transferrin saturation (blood tests to determine iron iron levels) to determine if there was a continued need for supplementation. The recommendation was denied per PCP (primary care physician). There was no documentation for why the recommendation was denied. During an interview on 3/6/25 at 8:57 a.m., the Director of Nursing (DON) indicated the physician was aware of the pharmacy recommendation, but didn't want to put the resident under the stress of a blood draw for only one lab. The DON indicated the rationale had not been documented. 45666 2. Resident 8's record was reviewed on 3/6/25 at 11:18 a.m. Diagnoses included, but were not limited to, situational depression adjustment disorder with depressed mood, cerebral infarction, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 1/17/25, indicated the resident was moderately cognitively impaired for daily decision making. She required substantial staff assistance for activities of daily living (ADL) tasks including toileting, showering, and transfers. She received antidepressants, anticoagulants, diuretics, and opioid medications during the 7-day look-back period. The current March 2025 Physician Order Summary indicated the resident received 100 milligrams sertraline (antidepressant medication) daily. A Care Plan, dated 2/7/24, indicated the resident received a psychotropic drug and was at risk for developing adverse effects from the use of the antidepressant medication. Interventions included, but were not limited to, administer medication as ordered and attempt gradual dose reduction (GDR) in two separate quarters during the first year the resident received the medication. A Pharmacist Drug Regimen Review, dated 7/22/24, indicated a recommendation for the GDR of sertraline 75 milligrams (mg) to a dose of 50 mg per day. The recommendation was denied with a rationale that there was a clinical contraindication because the resident was on hospice care. A Pharmacist Drug Regimen Review, dated 1/16/25, indicated to consider a trial dose reduction of sertraline 75 mg. The recommendation was marked as accepted. The recommendation to GDR the sertraline was not implemented. During an interview on 3/7/25 at 12:05 p.m., the Director of Nursing indicated they wanted to try the GDR. The resident had been doing well lately and getting up and going to the dining room more often. The facility staff had not met with the family yet to make sure that they were in agreement with the plan of care. A care plan meeting had been set up in February, however the family did not attend. She indicated the hospice company was not in agreement for the GDR, but was unsure why the recommendation was marked as accepted. 3.1-25(i)

Based on record review and interview, the facility failed to ensure each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being related to lack of non-pharmacological interventions used prior to giving anti-anxiety medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 252) Finding includes: Resident 252's record was reviewed on 3/4/25 at 3:40 p.m. Diagnoses included, but were not limited to, Parkinson's disease, bipolar disorder, and anxiety disorder. The admission Minimum Data Set (MDS) assessment, dated 3/2/25, was still in progress. A Care Plan, dated 2/25/25, indicated the resident was at risk for adverse consequences related to receiving anxiolytic medications. Interventions included, but were not limited to, attempt non-pharmacological interventions prior to administering as needed (PRN) anxiolytics and administer per orders. The current March 2025 Physician Order Summary indicated clonazepam (anxiolytic) 2 milligrams 1 tablet as needed for anxiety. The February and March 2025 Medication Administration Record (MAR) indicated the resident received the PRN clonazepam on 2/26 at 8:08 p.m., 2/27 at 6:41 p.m., 2/28 at 8:05 p.m., 3/2 at 7:10 p.m., 3/3 at 8:15 p.m., 3/4 at 7:45 p.m., and 3/5/25 at 1:42 a.m. The record lacked documentation of non-pharmacological interventions attempted prior to administering the PRN doses of clonazepam. During an interview on 3/7/25 at 11:53 a.m. the Director of Nursing indicated she had no further information to provide. 3.1-48(b)(2)

Based on observation and interview, the facility failed to ensure a medication was kept in a locked medication cart at all times for 1 of 8 residents observed during medication administration. (Resident 29) Finding includes: During an observation of medication pass on 3/5/25 at 12:24 p.m., RN 1 was observed preparing and administering g-tube medications to Resident 29. RN 1 prepared and crushed carbidopa-levodopa (treatment for Parkinson's disease) 25 milligram-100 milligram 2 tablets and glycopyrrolate (treatment for ulcers) 1 milligram tablet in separate medication pouches and then put them into separate medication cups after they were crushed. She washed her hands, donned a gown and gloves, and entered the residents room. She mixed each medication with approximately 15 milliliters (ml) of water. She flushed the g-tube with 30 mls of water, milked the tubing as the water was not going down by gravity, and then pushed the plunger of the syringe to get the water to flow. She did not check for placement of the g-tube prior to administering the water flush. RN 1 then poured approximately half of the medication cup containing the carbidopa-levodopa into the g-tube. The crushed medication was not mixed in with the water. She flushed the g-tube with 30 ml of water and then administered the glycopyrrolate. She removed her gown and gloves, performed hand hygiene, and exited the room to retrieve a spoon to mix the remaining medication, leaving the medication on the resident's bedside table. She returned and administered the rest of the medication, and flushed the g-tube with water. During an interview at the time, RN 1 indicated she should not have left the medication at the bedside. During an interview on 3/7/25 at 12:15 p.m., the Director of Nursing indicated the nurse should not have left the medication at the bedside. 3.1-25(m)

Based on observation, record review, and interview, the facility failed to ensure a resident's dignity was maintained, related to not placing a dignity bag over a foley (urinary) catheter drainage bag, for 1 of 1 residents reviewed for urinary catheters. (Resident 40) Finding includes: On 2/7/24 at 10:55 a.m., Resident 40 was observed in his room in bed. His catheter drainage bag was observed uncovered and draining yellow urine by gravity. On 2/7/24 at 11:26 a.m., Resident 40's catheter drainage bag was observed uncovered and draining yellow urine by gravity. Resident 40's record was reviewed on 2/7/24 at 10:28 a.m. Diagnoses included, but were not limited to, Parkinson's disease, hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the right dominant side, and obstructive uropathy (obstruction causing a blockage of the flow of urine.) The Admission Minimum Data Set (MDS) assessment, dated 1/18/24, indicated the resident was cognitively intact for daily decision making. He had an indwelling urinary catheter. A Physician's Order, dated 1/11/24, indicated indwelling urinary catheter size 16 french with a 5 cc balloon. A Care Plan, dated 1/21/24, indicated the resident used a foley catheter. Interventions included, but were not limited to, maintain a closed system with urinary bag below the resident's bladder and cover. During an interview on 2/7/24 at 11:26 a.m., RN 1 indicated the catheter bag should have had a dignity bag over it. During an interview on 2/8/24 at 2:52 p.m., the Director of Nursing (DON) indicated the catheter bag should have been covered with a dignity bag. 3.1-3(t)

Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for self-administration of medication,s and an assessment to self-administer their own medications, for 2 of 2 residents reviewed for self-administration of medication. (Residents 13 and 19) Findings include: 1. On 2/5/24 at 11:11 a.m., a bottle of Tylenol 325 milligram (mg) tablets was noted to be on Resident 13's bedside table. On 2/5/24 at 2:51 p.m., a bottle of Tylenol 325 mg tablets was noted to be on Resident 13's bedside table. The record for Resident 13 was reviewed on 2/7/24 at 12:37 p.m. Diagnoses included, but were not limited to, vascular dementia without behavioral disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 1/5/24, indicated the resident was moderately impaired for daily decision making. A Physician's Order, dated 5/30/23, indicated acetaminophen tablet 325 milligrams, 2 tablets for fever/pain every 4 hours as needed. There were no orders for self-administration or a self-administration assessment completed for the medication. During an interview on 2/7/24 at 11:23 a.m., QMA 1 indicated the resident came from assisted living, and it was a constant battle to keep her medications in the drawer. During an interview on 2/7/24 at 11:37 a.m., RN 1 indicated the resident did have a bottle of Tylenol sitting on her bedside table that morning. She did not have orders to self-administer the medication. During an interview on 2/8/23 at 2:55 p.m., the Administrator indicated she was going to provide the family education on medications at the bedside, as they continuously visited and she believed they had brought the bottle of Tylenol. 2. On 2/5/24 at 11:36 a.m., an albuterol inhaler was observed on the Resident 19's bedside table. The resident indicated she had been taking it herself as needed. On 2/5/24 at 12:09 p.m., an albuterol inhaler was observed on Resident 19's bedside table. The record for Resident 19 was reviewed on 2/7/24 at 2:01 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and chronic bronchitis. The Quarterly Minimum Data Set (MDS) assessment, dated 1/25/24, indicated the resident was cognitively intact for daily decision making. She had shortness of breath with exertion and when lying flat. She also used oxygen therapy. A Physician's Order, dated 11/20/23, indicated albuterol sulfate aerosol inhaler 90 micrograms/actuation, two puffs as needed every four hours, for shortness of breath and wheezing. May keep at bedside. The Self-Administration of Medication Assessment, dated 8/26/23 at 2:31 a.m., indicated the resident did not want to self-administer medications. The facility would set-up medications for the resident. During an interview on 2/7/24 at 11:39 a.m., RN 1 indicated the resident used to take her albuterol inhaler with her when she went on facility outings, and recently started self-administering while in the facility. During an interview on 2/8/24 at 2:51 p.m., the Director of Nursing indicated the resident had a self-administration assessment completed in 2022 which indicated she was going to self-administer the medication, however, the most recent self-administration assessment did not indicate she was going to self-administer any medications. 3.1-11(a)

Based on record review and interview, the facility failed to ensure skin odors and discolorations were assessed, monitored, and treated, for 1 of 3 residents reviewed for skin conditions (non-pressure related). (Resident 19) Finding includes: During an interview on 2/5/24 at 11:42 a.m., Resident 19 indicated she had an area of skin underneath her breasts that had a foul odor for a while and was itchy. She was unable to see if it was reddened, and indicated the facility staff were not treating the area. She was observed scratching the area and a foul odor was noted when the resident lifted her breast. The record for Resident 19 was reviewed on 2/7/24 at 2:01 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and chronic bronchitis. The Quarterly Minimum Data Set (MDS) assessment, dated 1/25/24, indicated the resident was cognitively intact for daily decision making. She had no pressure sores or skin conditions. There were no orders for a treatment or any documentation in the record related to the skin area under the breasts. The February 2024 Physician's Order Summary (POS), indicated a weekly skin assessment every Thursday. The Weekly Skin Assessment completed for February 2024, on the Treatment Administration Record, indicated the resident had no skin impairments noted on 2/1/24 or 2/8/24. During an interview on 2/8/24 at 3:50 p.m., the Director of Nursing indicated they were unaware of the skin condition, but she had the wound nurse assess the area. There was a reddened area of skin under her breasts and they were getting orders to treat the area with a powder. 3.1-37(a)

Based on observation, record review and interview, the facility failed to assess and monitor wounds that required treatment changes and failed to provide treatment as ordered during wound care for 1 of 5 residents reviewed for pressure ulcers. (Resident 12) Findings include: 1. On 1/24/23 at 10:09 a.m., Resident 12 was observed seated in her room in a recliner. She indicated she had sores on her bottom that were uncomfortable and the nurses were doing treatments to them. On 1/27/23 at 8:45 a.m., the resident's wound care was observed with LPN 2. There were two open areas on the right buttocks, each approximately 1.5 centimeter (cm) x 1 cm, one on the left buttock approximately 2 cm x 1 cm and the coccyx approximately 0.5 cm x 0.5 cm. The resident's record was reviewed on 1/24/23 at 3:00 p.m. The resident had been hospitalized and readmitted on [DATE]. Diagnoses included, but were not limited to, C.diff. (clostridium difficile, an infectious intestinal disease that causes loose stools) and sepsis. The Admission Minimum Data Set assessment, dated 1/11/23, indicated the resident was admitted with 2 unstageable pressure ulcers. A Progress Note, dated 1/7/23, indicated resident had been readmitted from hospital with a pressure ulcer to left buttock measuring 4 centimeters (cm) x 2 cm, and right buttock 6 cm x 3 cm. A Progress Note, dated 1/12/23, was entered by the Wound Nurse. The right buttock measured 3 cm x 1.5 cm and the left buttock was 1.5 x 1 cm. Because the wounds were not on a bony prominence, and on the fatty portion of the buttock and the resident was having frequent loose stools, the wounds would not be classified as pressure, but as MASD (moisture-associated skin damage). A Progress Note, dated 1/15/23, indicated wounds to fatty portion of buttocks remained. Treatment in place with frequent dressing changes due to frequent loose stools. There was a new open area to the resident's coccyx. There were no measurements or assessment of the new area to the coccyx. There were no additional measurements of the right or left buttocks in progress notes. A Physician's Order, dated 1/7/23, indicated to apply Medihoney and foam dressing to right and left buttocks every three days. A Physician's Order, dated 1/14/23, indicated to cleanse right and left buttock with would cleanser or normal saline, apply skin prep around the wound, apply calcium alginate to wound bed and cover with foam dressing every three days and as needed. A Physician's Order, dated 1/15/23, for coccyx was to cleanse with wound wash or normal saline, apply skin prep around wound and apply foam dressing every three days A Physician's Order, dated 1/25/23, indicated to to cleanse coccyx, right and left buttock with wound wash or normal saline, apply skin prep around wounds, apply collagen to wound beds and cover with foam dressing every three days and as needed. There was no indication in the progress notes as to why the treatments had been changed, or if the wounds had improved or worsened. Interview with Nurse Consultant 1 on 1/26/23 at 12:57 p.m., indicated if a wound wasn't pressure it did not require it to be monitored in wound rounds or measured weekly. It would be monitored by nursing staff and the Wound Nurse would assess it weekly. Consistent nursing staffing was planned to monitor improvement or worsening. The wounds were being considered moisture associated skin damage (MASD). Interview with LPN 2 on 1/27/23 at 9:15 a.m., indicated she was unsure if there had been two open areas on the resident's right buttock before, one of the areas might be new, it had been about a week since she had last observed the wounds. She indicated the resident no longer had C.diff or loose stools. 2. On 1/27/23 at 8:45 a.m., Resident 12's wound care was observed with LPN 2. There were two open areas on the right buttocks, each approximately 1.5 cm x 1 cm, one on the left buttock approximately 2 cm x 1 cm and the coccyx approximately 0.5 cm x 0.5 cm. The LPN cleansed the area with wound wash and patted gently with gauze. She then applied a piece of collagen to the open area on the left buttock. She then covered the entire area with a large foam dressing. A Physician's Order, dated 1/25/23, indicated to to cleanse coccyx, right and left buttock with wound wash or normal saline, apply skin prep around wounds, apply collagen to all wound beds and cover with foam dressing every three days and as needed. Interview with the LPN, on 1/27/23 at 9:15 a.m., indicated she was not aware she had done the treatment incorrectly and she would re-do it. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a Physician Order was in place for a resident receiving oxygen for 1 of 1 residents reviewed for respiratory care. (Resident 12) Finding includes: On 1/24/23 at 10:09 a.m., Resident 12 was observed seated in her room. She had a nasal cannula in place and oxygen was flowing at 2 liters per minute (lpm) via oxygen concentrator. The resident's record was reviewed on 1/24/23 at 3:00 p.m. Diagnoses included, but were not limited to, acute respiratory failure and sepsis. There was no Physician's Order for oxygen. A Respiratory Care Plan, dated 1/17/23, indicated the resident had the potential for shortness of breath when laying flat due to respiratory failure. Interview with LPN 1 on 1/25/23 at 9:45 a.m., indicated she was unable to locate a Physician's Order for oxygen and would contact the physician to clarify. 3.1-37(a)(6)

Based on observation, record review, and interview, the facility failed to ensure residents who required extensive to dependent care received incontinent care in a timely manner, for 3 of 3 residents reviewed for incontinent care. (Residents G, F, and L) Findings include: 1. The following was observed for Resident G on 7/28/22: At 8:31 a.m., he way lying in bed and awake. There was a faint urine smell in the room. At 8:56 a.m., there was a urine smell in the hallway outside of the room. At 8:59 a.m., CNA 3 and CNA 4 entered the room. CNA 3 indicated there was a urine smell in the room. She indicated they started the shift at 6 a.m. They proceeded to start care on the resident. There was a wetness under the brief and a dried brown ring. There was incontinence of bowel and a large amount of wetness in the incontinent brief observed. CNA 4 indicated he was probably last checked for incontinence around 4 or 5 a.m. and he had not been checked since the beginning of the shift at 6 a.m. The bowel movement on the skin is dried. The wetness on the bottoms sheet went from the middle back to the middle thigh. There was no redness or excoriation to the buttock area. Incontinent care was completed and the bottom sheet was changed. Resident G's record was reviewed on 7/28/22 at 9:10 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) assessment, dated 7/6/22, indicated a severely impaired cognitive status, required extensive assistance of two for bed mobility, transfers, and toileting, and was always incontinent of bowel and bladder. A Care Plan, dated 1/27/22, indicated moisture related skin damage to the buttock. The interventions included to keep clean and dry. A Care Plan, dated 4/12/22, indicated an impairment of functional status in regards to bed mobility, transfers, toileting, and eating. The interventions included extensive assistance was needed for toileting. A Care Plan, dated 10/6/21, indicated there were episodes of incontinence. The interventions included assistance was needed for toileting as needed and incontinent care as needed. 2. The following was observed for Resident F on 7/28/22: At 9:47 a.m., Resident F was sitting in a Broda (high back reclining chair) chair in front of the TV in the lounge. At 12 p.m., she was in the Dining Room sitting in the Broda chair. At 1:30 p.m., she was in the lounge sitting in the Broda chair by the Nurses' Station. At 1:47 p.m., CNA 3 and CNA 5 assisted the resident to her room and transferred her manually to the bed. CNA 3 indicated the resident had been checked and incontinent care had been given around 7 -7:30 a.m. when she was assisted out of bed. CNA 5 indicated residents were usually checked for incontinency in the morning, after breakfast, and before lunch. She had been in activities this morning so she had not been checked. The incontinent brief was wet. There was a pin point open area observed to the right buttock. Incontinent care was completed. No barrier cream was used. A new incontinent brief was applied. Resident F's record was reviewed on 7/28/22 at 5:03 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS assessment, dated 7/8/22, indicated a short and long term memory problem, required extensive assistance of two for transfers, bed mobility, and toileting, and was always incontinent of bowel and bladder. A Care Plan, dated 7/12/22, indicated incontinence. The interventions included assistance with toileting would be offered and incontinent care would be completed as needed. An interview on with the Administrator on 7/28/22 at 5:36 p.m., indicated the resident was in a group reading activity from 8:15 a.m. to 8:30 a.m. and received an one on one activity in the lounge by the Nurses' Station from 8:30 a.m. to 8:45 a.m. The Administrator indicated on 7/28/22 at 5:38 p.m., the resident had not been activities all morning and could have been toileted. 3. During an observation on 7/28/22 at 1:33 p.m., CNA 3 and CNA 5 assisted Resident L from the wheelchair to the bed with the use of a mechanical lift. The incontinent brief was saturated with urine. CNA 3 indicated the last check for incontinence was around 8:30 a.m. Incontinent care was completed. There was a small open area observed on the right buttock and the right buttock had an area which was pink. Resident L's record was reviewed on 7/29/22 at 12:50 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS assessment, dated 5/27/22, indicated a severely impaired cognitive status. Required extensive assistance of two staff for bed mobility, transfers, and toileting, was frequently incontinent of bowels and always incontinent of bladder. A Care Plan, dated 11/25/20 and reviewed on 6/8/22, indicated episodes of incontinence. The interventions included offers and assistance with toileting would be provided as needed. A Care Plan, dated 11/25/20 and reviewed on 6/8/22, indicated a risk for skin breakdown. The interventions included to keep clean as possible and minimize skin exposure to moisture. The Administrator was informed of the observation on 7/28/22 at 5:38 p.m. This Federal tag relates to Complaint IN 857. 3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to ensure treatments and care was provided in accordance with professional standards of practice, related to treatments of medicated ointments completed without a Physician's Order, dressings applied without a Physician's Orders, and assessments of the areas not completed, for 2 of 11 residents reviewed for quality of care. (Residents K and E) Findings include: 1. During an interview on 7/28/22 at 11:25 a.m., RN 6 indicated Resident K had a PICO (single use negative pressure wound therapy system that runs for seven days and shuts off) on the surgical site located on the buttocks. She indicated the PICO had stopped running and they were applying Santyl (debridement agent) to the area and packing the wound with gauze. She indicated there was no Physician's Order for this treatment. They had been using this treatment prior to PICO usage. She indicated the Wound Nurses thought this would be the best treatment until another PICO could be obtained. She indicated the PICO had been off for a few days. During an observation on 7/28/22 at 11:41 a.m., there was no dressing on the upper buttock wound. RN 6 indicated the dressing had come off. She indicated the wound had slough and there was an infection in the wound. She then cleaned the wound with normal saline, placed Santyl in the wound and indicated a nickel thick amount was to be applied. She then packed the wound with gauze and placed a foam dressing over the area. She then indicated she was going to look to see if there was another PICO in the building that could be used. A Physician's Order, dated 7/23/22, indicated the Santyl had been discontinued. A Physician's Order, dated 7/26/22 as a one time order, indicated the PICO dressing was to be changed and the PICO would shut down either 7/26/22 or 7/27/22 automatically. The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's order for a treatment due to the PICO not being on was not obtained until 7/28/22 at 9:38 p.m. and indicated to loosely pack the area with collagen and cover with a dressing every four days. There was no documentation in the Nurses' Progress Notes that indicated when the PICO was discontinued and what treatment was in place when the PICO was no longer used. During an interview on 7/29/22 at 2:30 p.m., the Director of Nursing (DON) indicated there was no documentation on what the facility had done or when the PICO was discontinued. The Corporate RN indicated on 7/26/22 the area was packed loosely with [MEDICATION(S)] (antimicrobial dressing). The area was to be re-assessed so a decision could be made if the PICO needed to be replaced. During an interview on 7/29/22 at 2:51 p.m., LPN 7 indicated another nurse had packed the wound and applied a foam dressing. She was unsure what it was packed with. She indicated she packed the wound with normal saline gauze. There had not been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She thought the other nurse had notified the Physician. There had not been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. During an observation on 7/28/22 at 4:14 p.m., Resident E had a dressing on the back of his left hand dated 7/28/22. He indicated the dressing was changed daily. Resident E's record was reviewed on 7/28/22 at 2:04 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Event Form, dated 7/15/22 at 7:06 p.m., indicate a skin tear to the back of the left hand due to a fall. A border dressing was applied. The area measured 1.5 cm by 1.5 cm, was shallow with a moderate amount of blood. The skin tear had irregular edges. There was no Physician's Orders for a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no further assessment of the skin tear. During an interview on 7/28/22 at 4:17 p.m., the Director of Nursing indicated there was no Physician's Order for the dressing and when to change the dressing. There were no further assessments of the skin tear area since the area was first found. A facility policy for skin tear assessment guidelines, dated 5/10/16 and received from the Director of Nursing as current, indicated a weekly follow-up assessment may be completed to ensure the skin tear is resolved or in the process of healing. This Federal tag relates to Complaint IN 857. 3.1-37

Based on observation, record review, and interview, the facility failed to ensure care was provided to assist in preventions of pressure ulcers, related to incontinence care and repositioning, for 2 of 2 residents reviewed for pressure ulcers. (Residents F and L) Finding includes: 1. Resident F was observed on 7/28/22 sitting in a Broda (high back recliner) chair from 9:47 a.m. through 1:47 p.m. At 1:47 p.m., CNA 3 and CNA 5 assisted the resident to her room and transferred her manually to the bed. CNA 3 indicated the resident had been checked and incontinent care had been given around 7 -7:30 a.m. when she was assisted out of bed. CNA 5 indicated residents were usually checked for incontinency in the morning, after breakfast, and before lunch. She had been in activities this morning so she had not been checked. The incontinent brief was wet. There was a pin point open area observed to the right buttock. Incontinent care was completed. Resident F's record was reviewed on 7/28/22 at 5:03 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS assessment, dated 7/8/22, indicated a short and long term memory problem, required extensive assistance of two for transfers, bed mobility, and toileting, was always incontinent of bowel and bladder, and had no pressure ulcers. A Care Plan, dated 7/12/22, indicated a risk for skin breakdown. The interventions included, assistance in repositioning would be provided as needed, she would be kept dry and clean, risk for moisture would be minimized on the skin and a barrier cream would be used as needed. An Event Form, dated 7/28/22 at 2:26 p.m., indicated there was an open area to the upper right coccyx area. It was round, red, and had scant serosanguinous drainage. The area measured 0.1 centimeters (cm) by 0.1 cm with a depth of less than 0.1 cm. A Wound Assessment Progress Note, dated 7/29/22 at 11:04 a.m., indicated the wound presented as moisture associated skin damage. The Physician and Representative were notified and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. During an observation on 7/28/22 at 1:33 p.m., CNA 3 and CNA 5 assisted Resident L from the wheelchair to the bed with the use of a mechanical lift. The incontinent brief was saturated with urine. CNA 3 indicated the last check for incontinence was around 8:30 a.m. Incontinent care was completed. There was a small open area observed on the right buttock and the right buttock had an area which was pink. Resident L's record was reviewed on 7/29/22 at 12:50 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS assessment, dated 5/27/22, indicated a severely impaired cognitive status. Required extensive assistance of two staff for bed mobility, transfers, and toileting, was frequently incontinent of bowels, always incontinent of bladder, and no pressure ulcers. A Care Plan, dated 11/25/20 and reviewed on 6/8/22, indicated a risk for skin breakdown due to incontinency. The approaches included, moisture barrier products as needed, assist to reposition, keep skin clean and dry, and minimize skin exposure to moisture. A Nurse's Progress Note, dated 7/28/22 at 3:42 p.m., indicated an open area to right upper outer coccyx was found. The area was cleaned. The resident was placed on her left side. The Representative and the Physician were notified. A Nurse's Progress Note, dated 7/29/22 at 11 a.m., indicated the wound was assessed on the buttock and presented as moisture associated skin damage due to incontinence. Skin barrier cream was ordered twice a day. A facility policy for pressure prevention, dated 12/1/21, and received from the Corporate RN as current, indicated the skin was to be kept clean, dry and free of body wastes. 3.1-40(1)

Based on observation, record review, and interview, the facility failed to ensure a resident received use of assistive devices to decrease her chance of accidents, related to a resident who was care planned for a mechanical lift transfer being transferred manually, for 1 of 2 residents observed for transfers. (Resident F) Finding includes: During an observation on 7/28/22 at 1:47 p.m., CNA 3 and CNA 5 transferred Resident F from the Broda chair (high back reclining chair) to the bed. They each placed an arm under the resident's arm/shoulder area and used the back of the resident's pants to assist her to a standing position, then pivoted her to the bed and assisted her into a lying position. A Care Plan, dated 6/14/21, indicated a risk for falls and a mechanical lift could be used for transfers. The CNA Profile Care Guide, dated 3/23/22, indicated she was dependent for transfers and a mechanical lift was to be used for transfers. During an interview on 7/28/22 at 5:22 p.m., the Corporate RN indicated the CNA's should use the Care Guide for resident care and acknowledged a mechanical lift should have been used for the transfer. 3.1-45(2)

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 3 of 5 residents observed during 4 medication pass observations. 3 errors in medications were observed during 26 opportunities for errors in medication administration. This resulted in a medication error rate of 11.53. (Residents N, O, & P) Findings includes: 1. RN 6 was observed on 7/28/22 at 8:10 a.m. She was preparing Resident N's morning medications. She placed the following medications in the plastic medication cup: aspirin 81 mg (milligrams), 1 tablet B12, one tablet cranberry 450 mg, one tablet [MEDICATION(S)] (cognitive enhancer) 5 mg, two half tablets [MEDICATION(S)] sulfate (iron), 325 mg, one tablet [MEDICATION(S)] ([CONDITION(S)]) 50 micrograms, one tablet loratadine (allergy) 10 mg, one tablet [MEDICATION(S)] (losartan, blood pressure) 25 mg, one tablet potassium 10 milliequivalent, one tablet [MEDICATION(S)] (antidepressant), 50 mg, one tablet vitamin C 250 mg, one tablet. She indicated there were 12 tablets in the cup, then proceeded into the resident's room and administered the medications. The resident requested a pain medication at that time, the pain was assessed, and then a [MEDICATION(S)] (pain) 7-325 mg tablet was given. Resident N's record was reviewed on 7/29/22 at 10 a.m. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The losartan had not been administered. 2. During an observation on 7/28/22 at 11:02 a.m., RN 6 prepared Resident O's intravenous (IV) of [MEDICATION(S)] (antibiotic) 1 gm (gram). The [MEDICATION(S)] was mixed with 50 milliliters (ml) of 0.9% normal saline. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . of dextrose. RN 6 indicated the pharmacy recommended normal saline be used for the infusion and had not clarified this with the Physician as of that time. She indicated normal saline had been used for the infusion since the medication was ordered on 7/18/22. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. During a medication pass observation on 7/29/22 at 10:32 a.m., the Corporate Regional RN administered 1.8 mg of [MEDICATION(S)] (antidiabetic) subcutaneous via pen to Resident P. Resident P's record was reviewed on 7/29/22 at 11:15 a.m. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A Medication Administration policy, dated 11/2018 and received from the Administrator as current, indicated, the five rights of medication administration were to be followed, the five rights included, right drug, right dose, and right time. Medications were to be administered in accordance with the written orders of the prescriber. This Federal tag relates to Complaint IN 857. 3.1-25(b)(9) 3.1-48(c)(1)

Based on record review and interview, the facility failed to ensure a resident was provided with laboratory service related to a laboratory blood test not completed as ordered for 1 of 3 residents reviewed for laboratory services. (Resident G) Finding includes: Resident G's record was reviewed on 7/28/22 at 9:10 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse's Progress Note, dated 6/13/22 at 3:41 p.m., indicated the laboratory company was unable to obtain the blood for the CBC and CMP on 6/10/22 and on 6/13/22. The laboratory specimen would be attempted on the next laboratory draw day. There was no documentation that indicated the Physician had been notified about the test not completed. There was no documentation that indicated the test was attempted on the next laboratory draw day. A CBC and CMP was completed on 6/20/22. During an interview on 7/28/22 at 2:37 p.m., the Director of Nursing (DON) indicated the normal laboratory draw days are Monday, Wednesday, and Friday. She indicated the laboratory test had not been completed on those days. She indicated the Physician had also not been notified the tests were not completed as ordered. This Federal tag relates to Complaint IN 857. 3.1-49(c)

Based on record review and interview, the facility failed to ensure outside resources were used as ordered, related to a resident with a consult appointment to see a Neurosurgeon not provided transportation to the appointment for 1 of 3 residents reviewed for outside resources visits. (Resident E) Finding includes: Resident E's record was reviewed on 7/28/22 at 2:04 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation to indicate the resident had gone to the appointment. A Nurse's Note, dated 6/23/22 at 4:18 p.m., indicated the resident said he would arrange his own transportation to the appointment on 7/7/22. There was no follow up with the resident to ensure he was able to find his own transportation to the appointment. During an interview on 7/28/22 at 4:17 p.m., the Administrator indicated she was not sure if he went to the appointment on 7/7/22. The appointment had been written on the calendar but it did not indicate if he went to the appointment. RN 6 had indicated to the Administrator she was unsure if the resident had gone to the appointment on 7/7/22. The resident informed the Administrator he had not gone to the appointment but he was unsure why he didn't go. No one was sure why he did not go to the appointment. She indicated the bus was available for him to take. The Nurses' should document when residents left and returned from appointments or why they were not going to the appointments. She indicated she would call the Physician's Office to see if he went to the appointment or not. During an interview on 7/29/22 at 11:22 a.m., the Administrator indicated she notified the Physician's office and he had not gone to the appointment. She was still unsure why, but indicated the appointment had been rescheduled. This Federal tag relates to Complaints IN 754 and IN 857. 3.1-13(m)