Hickory Creek At Greensburg

Based on observation, record review and interview, the facility failed to have recent State survey results available and accessible for the publics review for 1 of 1 observations of right to survey results. Findings include:During an observation and record review, on 09/17/2025 at 1:32 P.M., the State Survey binder was available at the front door. Inside the binder contained a sheet of paper that indicated, .The previous 3 years of State Department of Health surveys.are available in the Administrators office. Please see the Administrator to view these reports. The last dated survey in the binder was 10/18/2022.During an interview, on 09/17/2025 at 1:38 P.M., the Administrator indicated the State Survey binder should have been up to date.During an interview, on 09/18/2025 at 9:53 P.M., the Administrator indicated they did not have a policy referencing the State Survey binder. The facility would follow the regulation related to the State Survey Results.3.1-3(b)(1)

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to indwelling urinary catheter management for 1 of 13 residents reviewed for infection control. (Resident 14) Findings include:During an observation, on 09/17/2025 at 10:24 A.M., Resident 14 was propelling himself in his wheelchair from his room and into the Main Dining Room. The tubing from the resident's indwelling urinary catheter was dragging on the floor.During an observation, on 09/17/2025 at 12:48 P.M., the resident was propelling himself in his wheelchair in the hallway and going into his room. Two to three inches of his indwelling urinary catheter tubing were dragging on the floor. During an interview and observation, on 09/18/2025 at 1:05 P.M., Licensed Practical Nurse (LPN) 2 indicated the resident required the assistance of two staff members and the use of a mechanical lift for transfers to his wheelchair. A staff member exited the resident's room followed by LPN 2 entering the room to administer a medication to the resident. Four to six inches of his urinary catheter tubing were touching the floor, and an inch of his catheter bag was touching the floor. During an observation and interview, on 09/19/2025 at 9:38 A.M., the resident was propelling himself down the hallway in his wheelchair. A mechanical lift harness was in the chair underneath him. Four to five inches of his indwelling urinary catheter tubing were dragging on the floor. The Director of Nursing (DON) indicated the tubing should not be touching the floor.The clinical record for Resident 14 was reviewed on 09/17/2025 at 2:30 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 07/09/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension and obstructive uropathy. The resident had not had a urinary tract infection in the last 30 days.The current Nursing Department Infection Control policy, with a revised date of 12/2024, was provided by the Administrator on 09/22/2025 at 12:50 P.M . The policy indicated, .nursing staff shall follow infection control guidelines to prevent the spread of infection .Urinary drainage bags should have a barrier such as a urinary drainage bag cover or a wash basin underneath them to prevent catheter bags or tubing from touching the ground . The current Infection Prevention and Control Program policy, with a revised date of 05/2023, was provided by the Administrator on 09/22/2025 at 11:36 A.M. The policy indicated, .The facility shall establish and maintain infection prevention and control program.designed to .help prevent the development .of .infections . 3.1-18(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain laboratory (lab) specimens in a timely manner for 2 of 13 residents reviewed for lab services. (Residents 3 and 1) Findings include:1.The clinical record for Resident 3 was reviewed on 09/17/2025 at 2:25 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 09/10/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, encounter for orthopedic aftercare following surgical amputation, coronary artery disease, heart failure, and respiratory failure.
The Progress Notes included, but were not limited to:
-An Interdisciplinary Team (IDT) Weekly Wound Review Note, dated 05/06/2025 at 2:00 P.M., indicated the resident had signs and symptoms of infection to the wound on their leg of Periwound (area around the wound) erythema (abnormal redness and inflammation) and heavy drainage.
A Healing Partners Skin and Wound note, dated 05/06/2025, from the Wound Nurse Practitioner (NP), indicated the resident had an arterial ulcer to his right lower extremity that was assessed. The wound was a full thickness arterial ulceration and was weeping fluid. The Wound NP spoke to the Facility NP, recommended a wound culture due to some periwound erythema and heavy drainage, and the Facility NP was in agreement.
The Lab Culture Report indicated the specimen from the resident's wound was not collected until 05/08/2025 at 10:50 A.M. The results indicated the wound was infected with bacteria.
The SURVEILLANCE LOG OF RESIDENT INFECTIONS AND ANTIBIOTIC USE for May 2025, indicated the resident was not started on an antibiotic, Levaquin 500 milligrams daily, until 05/12/2025, six days after symptom onset.
The Electronic Medication Administration Record (EMAR) for May 2025, indicated the resident received the first dose of the prescribed Levaquin on 05/12/2025 at 8:00 P.M.
During an interview, on 09/18/2025 at 9:54 A.M., the Facility Wound Nurse indicated the resident had his leg amputated due to a lack of circulation in his lower extremities. He had a wound on his shin that would not heal.
During an interview, on 09/22/2025 at 10:39 A.M., the Director of Nursing (DON) indicated when they received an order for a wound culture, the specimen could be collected and sent out in the same day. Resident 3 had an arterial wound on his shin that was infected and treated with an antibiotic.
During an interview, on 09/22/2025 at 11:26 A.M., the DON, in reference to the IDT note from May 6, 2025, indicated the IDT team was aware of the signs and symptoms of infection in the resident's wound. The facility staff could call the Wound NP anytime during the day.
2a. The clinical record for Resident 1 was reviewed on 09/17/2025 at 11:05 A.M. A Significant Change MDS assessment, dated 08/06/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, chronic kidney disease, benign prostatic hyperplasia, urinary tract infection, and malnutrition. The resident was dependent on staff for toileting hygiene and was frequently incontinent of bladder.
A Progress Note, dated 04/01/2025 at 11:48 A.M., indicated the resident was reporting of having increased frequency, burning, and hurting with urination. The resident's urine was dark yellow with foul odor. The NP was notified, and a new order was obtained for a Urinalysis with Culture and Sensitivity (UA C&S) if indicated. The resident was educated to drink more extra fluids.
A Progress Note, dated 04/03/2025 at 9:44 A.M., indicated they staff were awaiting the results of the residents UA C&S.
A Progress Note, dated 04/06/2025 at 5:09 P.M., indicated the on-call triage was notified secondary to an abnormal UA C&S results and the resident continued with burning and pain with urination. A new order was obtained for Bactrim (an antibiotic).
A UA C&S for the resident indicated it was collected on 04/02/2025 at the facility, received in the lab on 04/03/2025, and reported results to the facility on [DATE].
2b. A Progress Note, dated 08/05/2025 at 12:00 P.M., indicated the resident was voicing that he was having increased in frequency and a burning sensation with urination and only urinating small amounts. The physician was notified, and a new order was obtained for a UA C&S.
A Progress Note, dated 08/05/2025 at 4:52 P.M., indicated the resident's urine was obtained and the facility was waiting for the lab to pick it up.
A Progress Note, dated 08/06/2025 at 1:46 A.M., indicated the lab was in the facility to obtain the resident's urine sample.
A Progress Note, dated 08/07/2025 at 12:25 P.M., indicated the resident had a new order for Cipro (an antibiotic) 500 milligrams (mg), twice a day for seven days, related to a UA.
A Progress Note, dated 08/10/2025 at 9:48 P.M., indicated the resident continued antibiotics. The resident was having burning with urination and increased frequency.
A Progress Note, dated 08/11/2025 at 1:33 P.M., indicated the NP was notified of the culture and sensitivity was not susceptible to Cipro. A new order was obtained to discontinue the Cipro and start Bactrim, twice a day for five days.
A UA C&S for the resident indicated it was collected on 08/05/2025 at the facility, received in the lab on 08/06/2025, and reported results to the facility on [DATE].
During an interview, on 09/19/2025 at 1:28 P.M., the Facility Infection Preventionist indicated when a resident had signs or symptoms of a UTI, the facility will obtain the residents vital signs and what signs and symptoms the resident was having and contact the physician. The NP was available Monday through Friday from 9:00 A.M. to 5:00 P.M., and then there was an on-call physician that was available. If the resident needed a UA or wound culture completed those would be obtained in the facility and the lab would come and pick them up. The lab recently switched to coming Monday, Wednesday, and Fridays. The other days the labs had to be sent by a mail carrier service that would get them to the lab within a few hours. The facility had access to get the results of the labs instantly as they are posted directly to the resident's record. The facility would let the NP know that the labs were available to view. The turnaround time for a UA C&S and starting and antibiotic would be three days. If the UA comes back the NP sometimes started them on an antibiotic to cover the resident until the culture results came back. Once the culture results come back then the NP would adjust if need to. She believed it would take two to three days for wound cultures to come back. She believed the Wound NP would give orders to obtain a wound culture the same day she was there for a visit if the resident was having symptoms, but she was unsure as she didn't complete wound rounds.
The current facility policy titled, Guidelines for Lab and Radiology Tracking, was provided by the Administrator on 09/19/2025 at 2:40 P.M. The policy indicated, .Daily order checks by medical records or designee will ensure all orders have been entered. The designated person will run the appropriate lab tracking report(s)daily. If any lab and/or radiology test ordered are not resulted as expected, investigate and take the necessary steps to obtain the results.
3.1-49(a)

Based on record review and interview, the facility failed to verify the accuracy of residents' healthcare physician/NP assessments related to the residents' current medical regimen for 2 of 13 resident records reviewed. (Residents 13 and 27)Findings include: 1. The clinical record for Resident 13 was reviewed on 09/18/2025 at 10:54 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 08/27/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, Chronic Obstructive Pulmonary Disease (COPD), anxiety, and depression. The Facility Nurse Practitioner (NP) Progress Note, dated 09/11/2025 at 8:35 A.M., indicated the resident resided in (name of a different facility). The progress note lacked the correct facility name the resident was currently residing in. During an interview, on 09/19/2025 at 1:15 P.M., the Director of Nursing (DON) indicated the Facility NP's progress notes were read through during their morning meeting. Resident 13 was admitted to this facility on 06/18/2025. The error in the documentation should have been caught. 2. The clinical record for Resident 27 was reviewed on 09/18/2025 at 2:01 P.M. An Annual MDS assessment, dated 07/02/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Alzheimer's disease, anxiety, aphasia, and COPD.An open-ended physician's order, with a start date of 10/10/2024, indicated the resident was to receive Xanax 1 milligram (mg), twice a day for anxiety. The Facility NP's Progress Notes, dated 08/21/2025 at 8:31 A.M., 09/04/2025 at 4:28 P.M., and 09/18/2025 at 10:43 A.M. indicated the resident's medication list included, but was not limited to, Xanax 1 mg three times a day, in her progress note documentation. During an interview, on 09/19/2025 at 1:15 P.M., the DON indicated the Facility NP's Progress Notes were read through during their morning meeting. If the Facility NP were to write a new order it would have been written on a telephone order form. The error in documentation of the wrong medication dosage should have been caught. The resident received the correct dosage of twice a day; the progress notes were inaccurate. During an interview, on 09/19/2025 at 2:02 P.M., The DON indicated the facility did not have a policy related to reviewing documentation. 3.1-22(C)(2)

Based on record review and interview, the facility failed to follow a physician's order related to wound treatments for 1 of 2 residents reviewed for pressure ulcers. (Resident 2)Findings include:The clinical record for Resident 2 was reviewed on 09/17/2025 at 1:43 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 08/13/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, unspecified open wound of lower back and pelvis subsequent encounter, obstructive uropathy, paraplegia, depression, and bipolar disorder. The resident was dependent on staff for most care.A Wound Nurse Practitioner (NP) Note, dated 06/03/2025, indicated the resident had a wound to the left ischium (hip bone). The staff were to cleanse the wound with Dakin's (an antiseptic) solution; lightly pack the wound, including the undermining (eroded), with Calcium Alginate with silver; and cover the wound with a bordered gauze dressing, once a day.A physician's order, dated 06/04/2025 through 06/11/2025, indicated the staff were to cleanse the left ischium with Dakin's solution, pack the wound with Dakin's moist fluffed gauze, and cover the wound with a boarder gauze dressing.The June 2025 Electronic Treatment Administration Record (EMTAR) documentation of the treatment from 06/04/2025 though 06/11/2024 lacked the calcium alginate with silver to the resident's wound order. During an interview, on 09/19/2025 at 10:04 A.M., the Director of Nursing (DON) indicated the resident admitted to the facility with wounds to the coccyx (tailbone) and ischium. The Wound NP came to the facility weekly to see the resident. She would let the facility staff know if there were new orders. The facility wound nurse or herself would transcribe the orders into the resident's clinical record. The nurses working the floor would then follow the orders in the ETAR. The resident's order in June should have included the calcium alginate for the left ischium.The current facility policy titled, Alterations in Skin Integrity/Wound Management, was provided by the Administrator on 09/19/2025 at 1:13 P.M. The policy indicated, .to ensure that each resident receives care, consistent with professional standards of practice, and receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection.3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to maintain a medication error rate of less than 5% related to medication errors for 1 of 4 residents observed for medication administration. (Resident 10)
Findings include:
On 10/09/24 at 8:44 A.M., Licensed Practical Nurse (LPN) 2 was observed as she prepared to administer Resident 10's medications. She removed the resident's medication blister packs from the medication cart and popped various tablets and capsules into a medication cup. She took the resident's liquid lactulose (a laxative) medication from the cart and poured it into another medication cup. The dosage marks indicated there were 15 mls (milliliters) of lactulose in the cup. She then poured the lactulose from the medication cup into a larger cup and indicated the resident preferred to take the medication from a bigger cup. She prepared the resident's Lispro (short acting) insulin pen, dialing up 25 units of insulin. The LPN indicated the resident's blood sugar was only 106 that morning and she wanted to wait and see if the resident ate all of her breakfast before she administered the insulin. The LPN entered the resident's room and determined the resident ate her breakfast. She did not recheck the resident's blood sugar. She gave the resident her oral medications including the lactulose and injected the Lispro insulin into the resident's right arm.
The clinical record for Resident 10 was reviewed on 10/07/24 at 1:47 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 08/13/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, hypertension, and depression. The resident had received insulin for seven of seven days during the review period.
The resident's current physician's orders were reviewed and included the following orders:
- An open-ended order, with a start date of 07/09/24, to administer lactulose,10 gm (grams) per 15 ml. Amount to administer, 30 mls, twice a day, and,
- An open-ended order, with a start date of 07/12/24, to administer insulin Lispro, 25 units, three times a day. The staff were to hold (not administer) the insulin if the resident's blood sugar was less than 120.
During an interview on 10/09/24 at 9:47 A.M., LPN 2 indicated she should have given the resident 30 mls of the lactulose. Regarding the insulin, she talked to the NP (Nurse Practitioner) the other day and she said as long as the resident ate her breakfast, ate some protein, and her blood sugar was not under 100, it was ok to give her the scheduled insulin. She didn't change the special instructions on the order in the EMAR (Electronic Medication Administration Record) to reflect the changes. She should have changed the special instructions to reflect the new order. Normally, she would have made a progress note too. It was a couple of weeks ago, she was not sure if she made any notes about it. If a resident had hold parameters for insulin, she would obtain the blood sugar and hold the medication per the order if the blood sugar was too low.
The current facility policy, titled General Dose Preparation and Medication Administration, with a revision date of 04/30/24, was provided by the DON (Director of Nursing) on 10/09/24 at 2:33 P.M. The policy indicated, .Verify each time a medication is administered that it is the correct medication, at the correct does, at the correct route, at the correct rate, at the correct time, for the correct resident .
Cross Reference F757
3.1-48(c)(1)
3.1-48(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain laboratory results and start and antibiotic in a timely manner for 1 of 2 residents reviewed for urinary tract infections. (Resident 12)
Findings include:
The clinical record for Resident 12 was reviewed on 10/09/24 at 8:50 A.M. An Annual Minimum Data Set (MDS) assessment, dated 09/25/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, cerebral infarction, Urinary Tract Infection (UTI) in the last 30 days, seizure disorder, anxiety, depression, and psychotic disorder.
A Progress Note, dated 09/01/24 at 8:47 A.M., indicated the resident's family member was in the facility and that the resident had complained of burning with urination. The staff would encourage more fluids for 24 hours. The writer assessed the resident's urine. The urine lacked odor, sediment, and was clear/yellow. The resident had indicated the burning with urination happened one time. The staff would continue to encourage more fluids and would reassess the resident in 24 hours.
A Progress Note, dated 09/03/24 at 1:47 P.M., indicated the resident was complaining of burning and pain with urination and low back pain. The Nurse Practitioner (NP) was notified that the resident had been encouraged to drink more fluids for 24 hours and was having complaints. An order was obtained for a Urinalysis (UA) and a Culture and Sensitivity (C&S).
A Progress Note, dated 09/05/24 at 10:27 A.M., indicated the resident's urine was sent with the lab technician.
A Progress Note, dated 09/09/24 at 11:03 A.M., indicated the staff were still awaiting culture and sensitivity reports at that time.
A Progress Note, dated 09/09/24 at 9:55 P.M., indicated the resident's urine had a foul odor. The resident stated, I just don't feel good. Fluids were encouraged and taken well.
A Progress Note, dated 09/11/24 at 11:31 P.M., indicated the resident's urine had a foul odor. Fluids were encouraged and taken well.
A Progress Note, dated 09/12/24 at 10:30 A.M., indicated the resident's first dose of Bactrim (an antibiotic) was pulled from the Emergency Drug Kit (EDK) that morning for an infection. The resident was encouraged and assisted with fluid intake.
A Urine Specimen, indicated the resident's urine was collected on 09/04/24, received at the lab on 09/06/24 and resulted to the facility on [DATE]. The resident's urine contained Escherichia coli (E.coli).
A physician's order, dated 09/11/24 through 09/18/24, indicated the resident was to receive Bactrim 800-160 mg (milligrams), twice a day, for a UTI.
The September 2024 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident did not receive the Bactrim medication on 09/11/24 at 8:00 P.M., due to the medication being unavailable.
The resident received the first dose of Bactrim on 09/12/24 at 8:00 A.M.
The Surveillance Log Of Resident Infections and Antibiotic Use for September 2024, indicated the resident's date of onset for UTI was 09/05/24. A Urine sample was obtained on 09/04/24 and the resident started an antibiotic on 09/11/24.
During an interview on 10/09/24 at 1:02 P.M., Licensed Practical Nurse (LPN) 2 indicated the resident used a urinal. If a resident needed a laboratory test completed the lab service would come to the facility daily at 6:00 A.M. If the resident needed a UA C&S the staff would obtain the urine and have it ready for the lab to take when they came to the facility. If the lab was missed when the laboratory staff came there was a service the facility used to come and get the sample to be tested. If a resident had an order for a UA C&S and ended up having and UTI, then the resident should have been started on an antibiotic within three days of obtaining the urine. If the facility didn't have the results of the urine, she would call the lab, request them, and document it in a progress note.
During an interview on 10/09/24 at 2:41 P.M., the Director of Nursing (DON) indicated the lab had been taking five days to get culture results back. Their lab was out of another State. The resident's final culture result was on 09/08/23 and the resident should have been started on an antibiotic sooner than he did.
The current facility policy titled, Infection Prevention and Control Program, with a revision date of 05/2023, was provided by the Administrator on 10/07/24 during the entrance conference. The policy indicated, .The facility shall establish and maintain infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections. The IPCP is comprehensive system for preventing, identifying reporting, investigating, and controlling infections and communicable diseases for all resident, staff, volunteers, visitors, and other individuals providing services under contractual arrangement .
The current facility policy titled, Guidelines for Lab and Radiology Tracking with a revision date of 4/24, was provided by the Administrator on 10/10/24 at 3:16 P.M. The policy indicated, .If any lab and/or radiology test ordered are not resulted as expected, investigate and take the necessary steps to obtain the results .
During an interview on 10/10/24 at 2:51 P.M., the Administrator indicated the facility did not have any other policies related to lab services.
3.1-41(a)(2)

Based on interview and record review, the facility failed to provide the required RN (Registered Nurse) on duty for eight consecutive hours a day for 12 of 29 days reviewed.
Findings include:
During an interview on 10/09/24 at 1:24 P.M., the Director of Nursing (DON) indicated they were the only RN working in the facility at this time so sometimes there was not an RN on duty for eight consecutive hours a day.
During an interview on 10/11/24 at 10:31 A.M., the Regional Director of Clinical Services indicated the payroll was completed by the facility staff then the corporate Manager of Financial Operations compiled the information and reported the Payroll-Based Journal (PBJ).
During an interview on 10/11/24 at 10:38 A.M., the Manager of Financial Operations indicated, based on their records for Fiscal Year Quarter 3 (April 1, through June 30), the facility had one day with zero RN hours, and 21 days with less than 8 RN hours.
The nursing as-worked weekend schedules for April, May, and June 2024, were provided by the Administrator on 10/07/24 at 12:40 P.M. The records indicated an RN was not on duty for eight consecutive hours on the following dates:
- 04/13/24,
- 04/14/24,
- 04/19/24, and
- 05/25/24.
The nursing as-worked weekend schedules for September and October 2024, were provided by the DON on 10/09/24 at 3:15 P.M. The records indicated an RN was not on duty for eight consecutive hours on the following dates:
- 09/01/24,
- 09/07/24,
- 09/14/24,
- 09/15/24,
- 09/22/24,
- 09/28/24,
- 09/29/24, and
- 10/06/24.
The Facility Assessment, with an approval date of 08/01/24, was provided by the Administrator on 10/10/24 at 12:20 P.M. The record indicated the average number of RNs needed for direct care/facility staff was four.
During an interview on 10/10/24 at 2:52 P.M., the Administrator indicated they did not have a facility policy related to RN coverage.
3.1-17(b)(3)

Based on record review and interview, the facility failed to follow a physician's order related to hold parameters for insulin for 1 of 5 residents reviewed for unnecessary medications. (Resident 10)
Findings include:
The clinical record for Resident 10 was reviewed on 10/07/24 at 1:47 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 08/13/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, hypertension, and depression. The resident had received insulin for seven of seven days during the review period.
The current physician's order, with a start date of 07/12/24, indicated the resident was to receive insulin lispro, 25 units, three times a day. The staff were to hold (not administer) the insulin if the resident's blood sugar was less than 120.
The July, August, and September EMAR/ETAR (Electronic Administration Record/Electronic Treatment Administration Record) indicated the resident received the insulin when their blood sugar was less than 120 on the following dates and times:
- 07/25/24 at 7:00 A.M., when the resident's blood sugar was 118,
- 08/12/24 at 7:00 A.M., when the resident's blood sugar was 107,
- 08/14/24 at 7:00 A.M., when the resident's blood sugar was 79,
- 08/17/24 at 7:00 A.M., when the resident's blood sugar was 73,
- 08/23/24 at 7:00 A.M., when the resident's blood sugar was 111 and 5:00 P.M., when the blood sugar was 105,
- 09/14/24 at 7:00 A.M., when the resident's blood sugar was 111,
- 09/20/24 at 7:00 A.M., when the resident's blood sugar was 106,
- 09/23/24 at 7:00 A.M., when the resident's blood sugar was 82,
- 09/25/24 at 7:00 A.M., when the resident's blood sugar was 113,
- 09/29/24 at 7:00 A.M., when the resident's blood sugar was 96, and 12:00 P.M., when the blood sugar was 110, and
- 10/07/24 at 7:00 A.M., when the resident's blood sugar was 106.
During an interview on 10/09/24 at 9:47 A.M., Licensed Practical Nurse (LPN) 2 indicated she normally would check the resident's blood sugar and hold the insulin until she was done eating and then administer it. She had messaged the Nurse Practitioner (NP) the other day and had not changed the instructions on the order to reflect the new order. It had been a couple weeks since she talked to the NP. She would normally make a progress note related to talking with the NP. If a resident had hold parameters on an insulin, she would obtain the blood sugar and hold the medication per the physician's order.
The current facility policy, titled General Dose Preparation and Medication Administration, with a revision date of 04/30/24, was provided by the DON on 10/09/24 at 2:33 P.M. The policy indicated, .Verify each time a medication is administered that it is the correct medication, at the correct does, at the correct route, at the correct rate, at the correct time, for the correct resident .
3.1-48(a)(6)

Based on interview and record review, the facility failed to implement interventions to address a resident's dementia care needs related to wandering into other resident's personal space for 1 of 4 residents reviewed for dementia care. (Resident C)
Findings include:
A progress note, dated 08/28/23 at 6:00 P.M., indicated a nursing staff member entered Resident B's room and observed Resident C touching Resident B inappropriately. The residents were immediately separated. Resident B was assessed and there were no injuries observed. The resident's family, physician, and police were notified.
The clinical record for Resident B was reviewed on 09/27/23 at 10:30 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/21/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, diabetes, Alzheimer's disease, anxiety, and depression.
During an interview on 09/27/23 at 9:52 A.M., LPN (Licensed Practical Nurse) 2 indicated on 08/28/23 she went to Resident B's room to check her blood sugar and give the resident her evening medications. The door was closed to the room. She knocked, no one answered, so she cracked the door open. Resident B was laying on her bed and her shirt was pulled up to her neck. Resident C was standing next to the bed and he had his hands on Resident B's bare breasts. Both residents just froze when they saw her. She escorted Resident C out of the room and had another staff member take him to his own room. She conducted a head to toe assessment on Resident B and asked her if she was okay. The resident did not seem upset about what happened. Resident C was upset, he denied he did anything and couldn't understand why LPN 2 asked him to go to his room. LPN 2 indicated they had to keep an eye on Resident C. In the last week or so leading up to the incident, he had been going into Resident B's room and Resident B had been sharing her snacks with him. Staff would escort him out of the room when they caught him in there. Before this incident, Resident C had gone into Resident D's room and made her uncomfortable. This started within a day or two of his admission to the facility. Resident D and Resident G shared a room. He had been asked to stay out of their room. He was trying to be friendly with Resident D, but it was making her uncomfortable. He had been making inappropriate suggestions. Resident G would turn on the call light to get staff into the room and tell Resident D to tell staff what Resident C said to her. Resident C needed frequent redirection. The Administrator, Social Services Director, and DON (Director of Nursing) all talked to him about it. It lasted a few weeks, but then he stopped going in their room, it seemed like he got the hint that Resident D wasn't interested.
The clinical record for Resident C was reviewed on 09/27/23 at 9:30 A.M. An admission MDS assessment, dated 07/12/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, non-Alzheimer's dementia, seizure disorder, and depression. The resident exhibited wandering behavior during the assessment review period.
Resident C's admission records, that included, but were not limited to, a psychiatric evaluation follow up, dated 05/15/23, were provided by the Administrator on 09/28/23 at 1:30 P.M. The evaluation indicated staff reported the resident has had some difficulty with making sexual remarks towards females but he had not been physical with anyone. Staff also reported the resident had increased confusion in the evening which appeared to be sundowning. The medication review indicated the resident received 10 mg (Milligrams) of Provera daily for sexual aggression.
An IDT (Interdisciplinary Team) Behavior Review Note, dated 07/10/23 at 3:14 P.M., indicated Resident C was wandering into peers' rooms. The resident was redirected. The root cause of the resident's behavior expression was determined to be related to their dementia. The resident's care plan was updated, and preventative interventions included, but were not limited to, the following: redirect the resident, offer an activity of interest, ensure basic needs were met, and engage in conversation.
During an interview on 09/28/23 at 1:50 P.M., Residents D and G indicated there were times that a resident might wander in their room, but they would eventually leave, it wasn't a big deal. Resident G indicated Resident D did have a problem with a male resident a few months ago, but the resident was no longer in the facility. Resident D indicated a male resident would come into her room. He was inappropriate with her. She told a nurse about it, and they handled it.
During an interview on 09/28/23 at 2:17 P.M., the Administrator indicated Resident C went back to the facility he was at before he was admitted here. She was unaware of any issues with Resident C and Resident B before the incident occurred. She was unaware of any incidents with Resident C and any other residents in the facility.
The current facility policy, titled Behavior Management, with a revision date of 08/22, was provided by the Administrator on 09/28/23 at 1:51 P.M. The policy indicated, .It is the policy .to provide behavior interventions for residents with problematic or distressing behaviors .
This Federal tag relates to Complaint IN00416303.
3.1-37(a)

Based on observation, interview, and record review, the facility failed to administer medications for a Urinary Tract Infection for 1 of 14 residents reviewed. (Resident 17)
Findings include:
During an observation and interview on 08/06/23 at 11:32 A.M., Resident 17 was sitting on the side of her bed. The resident indicated she has had a lot of UTI's (urinary tract infections).
A Significant Change MDS (Minimum Data Set) assessment, dated 06/21/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anemia, hypertension, renal insufficiency, diabetes, depression, and bipolar.
A Progress Note, dated 02/16/23 at 11:03 A.M., indicated the resident had a new order for cephalexin (an antibiotic) for a UTI.
A Urine Culture, dated 02/14/23, indicated the resident's urine culture organism contained Escherichia Coli (E.coli).
A physician's order, dated 02/16/23 through 02/23/23, indicated the staff were to administer the resident's cephalexin 500 mg (milligrams) every 8 hours.
The February 2023 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident had not received the antibiotic medication on the following dates and times:
- 02/19/23 at 7:00 A.M.,
- 02/21/23 at 11:00 P.M., and
- 02/22/23 at 11:00 P.M.
A UTI Care Plan, dated 02/16/23, indicated staff were to administer the resident's antibiotics as ordered.
A Progress Note, dated 03/09/23 at 8:28 A.M., indicated the resident had a new order for amoxicillin 500 mg, three times a day, for a UTI with E.coli.
A physician's order, dated 03/09/23 through 03/15/23, indicated the staff were to administer the resident's amoxicillin 500 mg, three times a day.
The March 2023 EMAR/ETAR indicated the resident had not received the antibiotic medication on 03/15/23 at 7:00 A.M.
During an interview on 08/10/23 at 10:04 A.M., the ADON (Assistant Director of Nursing) indicated when a medication was given it would have the nurse's initials on the EMAR.
During an interview on 08/10/23 at 10:15 A.M., the DON (Director of Nursing) indicated the blank in the EMAR signified a missed medication dose.
The current facility policy titled, General Dose Preparation and Medication Administration, with a revised date of 01/01/22, was provided by the DON on 08/10/23 at 1:10 P.M. The policy indicated, .should comply with Applicable Law and the State Operations Manual when administering medications .Document necessary medication administration/treatment information [e.g., .when medications are given .]
3.1-25(b)(2)

Based on observation, interview, and record review, the facility failed to ensure the identified fall intervention, of a trapeze bar, was accessible for 1 of 4 residents reviewed for accident hazards. (Resident 22)
Findings include:
The clinical record for Resident 22 was reviewed on 08/09/23 at 2:00 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/14/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, anemia, heart failure, hypertension, non-Alzheimer's dementia, hemiplegia or hemiparesis, and depression. The resident required extensive assistance of two or more staff members with bed mobility and transfers.
A Fall Event, dated 07/04/23 at 12:55 P.M., indicated the resident had an unwitnessed fall. The resident was found sitting on the floor next to the bed. The resident stated he was trying to scoot himself up in bed.
An IDT (Interdisciplinary Team) Note, dated 07/05/23 at 12:41 P.M., indicated the resident had an unwitnessed fall, he was observed sitting beside the bed. The resident was trying to scoot back in the bed and slid out of the bed. An intervention was put into place for a trapeze bar to assist in positioning.
An at-risk fall Care Plan, with a start date of 10/24/22 and a revised date of 08/09/23, indicated the intervention, with a start date of 07/05/23, was for the resident to have a trapeze bar to assist the resident with positioning himself in bed.
During an observation on 08/09/23 at 2:25 P.M., the resident was lying in bed on his back. The triangle trapeze grab bar over the resident's bed was hung to high and not accessible by the resident.
During an observation on 08/10/23 at 10:03 A.M., the resident was lying in bed on his back. The triangle trapeze grab bar over the resident's bed was hung to high and not accessible by the resident.
During an interview and observation on 08/10/23 at 10:43 A.M., CNA (Certified Nurse Aide) 4 indicated the resident was able to stand when he first came to the facility. He had recently not been able to stand. A trapeze bar was added to his bed a couple of days ago to help him position himself. She confirmed that the trapeze bar was not down at that time to be accessible by the resident.
During an observation and interview on 08/10/23 at 10:46 A.M., Resident 22 was lying in bed. He indicated he was able to reposition himself with the trapeze bar when it was down, but the staff left it up and he couldn't reach it.
The current facility policy titled, Fall Management, with a revised date of 8/2022, was provided by the DON on 08/09/23 at 3:34 P.M. The policy indicated, .to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .Residents who are categorized as moderate to high risk should have fall interventions implemented based on resident specific risk factors .The resident care specific requirements will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet .
3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure appropriate interventions were in place for a resident at risk for pressure ulcers that currently had a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. (Resident 25)
Findings include:
Resident 25 was observed in her room in bed on 08/06/23 at 1:15 P.M. The resident was wearing a pressure reducing boot on her right foot. The resident was not wearing a boot on her left foot. The resident's left foot was not elevated, and her heel was resting on the mattress.
On 08/07/23 at 9:36 A.M., the resident was observed in a common area. The resident was sitting in a broda (positioning wheelchair) chair. A pressure reducing boot was on the resident's right foot. The resident was wearing a nonskid sock on her left foot. Her left heel was resting on the chair footrest.
On 08/08/23 at 9:50 A.M., the resident was observed in her room in her chair. The chair was in a reclined position, with the resident's legs extended and her feet up on the footrest. The resident was wearing a pressure reducing boot on her right foot and a non-skid sock on her left. The resident's left heel was in contact with the chair footrest.
On 08/08/23 at 10:54 A.M., the resident's right heel wound was observed with the ADON (Assistant Director of Nursing). The resident was in her room in her chair. The chair was reclined, with the resident's legs extended and her feet were up on the footrest. The resident was wearing a pressure reducing boot on the right foot and a non-skid sock on the left. The resident's left heel was in contact with the chair footrest. The ADON removed the boot and sock from the resident's right heel. A golf ball sized wound was observed on the resident's right heel. The wound bed was dry and dark brown in color. There was no drainage or signs of infection.
During an interview on 08/08/23 at 10:55 A.M., the ADON indicated the resident has had the wound on the right heel for less than two months. The wound started out as intact blister. The resident did not wear pressure reducing boots before the wound developed. The ADON indicated she was the facility wound nurse. The resident was to wear the boot while she was up in her chair. The resident's left heel was resting on the footrest of the chair. The resident was not wearing a pressure reducing boot on the left foot. She was not sure why she wasn't wearing a boot on the left foot. She had looked before, and couldn't find another boot in the resident's room, she thought it might have been in the laundry.
A Significant Change MDS (Minimum Data Set) assessment, dated 06/21/23, indicated the resident was severely cognitively impaired. The resident required extensive to total staff assistance for all ADLs (Activities of Daily Living). The resident's diagnoses included, but were not limited to, stroke, dysphagia, hemiplegia, malnutrition, and depression. The resident was at risk for pressure ulcers and had one, unhealed Stage 2 (Partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer. The wound bed was viable, pink, or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer at the time of the assessment. The resident received hospice services.
On 08/09/23 at 8:49 A.M., the resident was observed in her room in her chair. The chair was in a reclined position, with the resident's legs extended and her feet up on the footrest. The resident was wearing a pressure reducing boot on her right foot and a non-skid sock on her left. The resident's left heel was in contact with the chair footrest.
On 08/09/23 at 10:10 A.M., the resident was observed in her room in her chair. The chair was reclined, with the resident's legs extended and her feet up on the footrest. The resident was wearing a pressure reducing boot on her right foot and a non-skid sock on her left. The resident's left heel was in contact with the chair footrest.
On 08/09/23 at 1:29 P.M., the resident was observed in the common area near the television. The resident's chair was reclined, with the resident's legs extended and her feet up on the footrest. The resident was wearing a pressure reducing boot on her right foot and a non-skid sock on her left. The resident's left heel was in contact with the chair footrest.
On 08/09/23 at 2:09 P.M., the resident was observed in the common area near the television. The resident's chair was reclined, with the resident's legs extended and her feet up on the footrest. The resident was wearing a pressure reducing boot on her right foot and a non-skid sock on her left. The resident's left heel was in contact with the chair footrest.
On 08/10/23 at 9:20 A.M., the resident was observed in her room in her chair. The chair was reclined, with the resident's legs extended and her feet up on the footrest. The resident was wearing a pressure reducing boot on her right foot and a non-skid sock on her left. The resident's left heel was in contact with the chair footrest.
A Wound Management Detail Report indicated the resident's Stage 2 pressure wound was first observed on 06/27/23 at 11:23 A.M. The wound measured 4 cm (centimeters) x 3.5 cm. The depth could not be measured. The comments section indicated the wound was an intact blister on the resident's right heel that was pale in color and firm to touch. A liquid skin protectant treatment was ordered to be administered twice a day and the resident was to wear pressure reducing boots to both heels while in bed.
The resident's Plan of Care was reviewed on 08/08/23 at 11:40 A.M., and included a Risk for Skin Breakdown Care Plan, with a start date of 05/22/23. The interventions included, but were not limited to, the following:
- Foam boots to bilateral feet while in bed, with a start date of 06/27/23, and
- Foam boot to right heel at all times, with a start date of 07/27/23.
The current MD orders included, but were not limited to the following:
- An open-ended order, with a start date of 06/26/23, to float the resident's heels as much as she tolerates,
- An open-ended order, with a start date of 07/06/23, for the resident to wear foam boots on both feet while in bed, and
- An open-ended order, with a start date of 07/27/23, for a foam boot to be in place on her right heel at all times.
During an interview on 08/10/23 at 1:36 P.M., the DON (Director of Nursing) indicated the interventions in place for the resident included the foam boots that started on 06/27/23. One boot stayed on her heel at all times. The resident was to wear both of them when she was in bed. Sometimes she kicked the boot off. If a resident refused to wear boots, nursing staff should document the refusal in the resident's record. It would not hurt to have the boot on the left foot while she was up in the chair.
The resident's clinical record lacked documentation the resident refused to wear the pressure reducing boots.
During an interview on 08/10/23 at 2:59 P.M., CNA (Certified Nurse Aide) 5 indicated she worked second shift and was familiar with the resident. She assisted the resident into bed. Pressure reducing interventions they had implemented for the resident included turning and repositioning the resident every 2 hours. The resident liked to lean on her left side, so they tried to keep pressure off that side. The resident wore a pressure reducing boot on her right foot because she had a pressure ulcer on her right heel. They did not put a pressure reducing boot on her left foot, and she didn't wear a pressure reducing boot on her left foot when she was in bed. There were two boots in her room, but they were both for the right foot in case one of them was soiled.
The current facility policy, titled SKIN MANAGEMENT PROGRAM, with a most recent revision date of 05/22, was provided by the DON on 08/10/23 at 2:24 P.M. The policy indicated, .a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing .
3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to complete neurological assessments after a fall for 1 of 4 residents reviewed for accidents. (Resident 22)
Findings include:
During an observation on 08/08/23 at 9:59 A.M., Resident 22 was in his wheelchair. A staff member was assisting the resident to go outside for some fresh air.
A Quarterly MDS (Minimum Data Set) assessment, dated 07/14/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, anemia, heart failure, hypertension, non-Alzheimer's dementia, hemiplegia or hemiparesis, and depression. The resident required extensive assistance of two or more staff members with bed mobility and transfers.
A Fall Event, dated 02/02/23, indicated the resident had an unwitnessed fall at 9:30 P.M. He was found lying on the floor face up on his back. The resident indicated he had leaned too far off the bed and fell on his back. The resident was assessed with no injuries. His vital signs were stable and neurological checks were initiated.
A Neurological Assessment, dated 02/02/23, lacked documentation to indicate the resident's neurological checks were completed on the following dates and times:
- 02/02/23 at 9:45 P.M., 10:00 P.M., 10:15 P.M., 11:15 P.M., 11:45 P.M., and
- 02/03/23 at 1:15 A.M., 2:15 A.M., 3:15 A.M.
During an interview on 08/09/23 at 1:51 P.M., LPN (Licensed Practical Nurse) 2 indicated the resident currently had used a mechanical lift for transfers due to some recent falls. If a resident had an unwitnessed fall the nurse was to assess the resident, obtain their vitals, and assist the resident up. If the fall was not witnessed the nurse should initiate neurological checks. The neurological checks were completed on paper. Once they were complete, she would file them in the resident's file or put them in the DON's box.
The current facility policy titled, Fall Management, with a revised date of 8/2022, was provided by the DON on 08/09/23 at 3:34 P.M. The policy indicated, .to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .Post fall .any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided. A neurological assessment will be initiated on all un-witnessed falls .
A current, undated, Neurological Assessment procedure form was provided by the DON on 08/09/23 at 3:34 P.M. The form indicated neurological assessment documentation should included, .Date .Time .Q [every] 15 min [minutes] x [times] 1 hr [hour] .Q 30 min x 2 hr .Q 1 hr x 4 hr .Every eight hours x 72 hours .
3.1-37(a)

Based on observation, interview, and record review, the facility failed to store dry foods in a sanitary manner related to the dry storage room. This deficient practice had the potential to affect all 30 residents who reside in the facility.
Findings include:
During an initial kitchen and dry storage observation on 08/06/23 at 10:42 A.M., the following was observed:
- a watermelon sat inside a plastic container that contained ranch dressing packets,
- a cardboard box of disposable lids and a cardboard box of plastic bowls sat on the floor under the middle rack, and
- there was a white powdered substance along the back wall behind the middle rack of dry goods that measured approximately 3-4 feet long and 6 inches wide, and
- 4 small Styrofoam bowls, a tea bag, a clear plastic bowl, and a coffee creamer were laying on the floor under the storage racks.
- two rodent traps with no visible rodent droppings.
On 08/06/23 at 11:24 A.M., The Daily Cleaning Schedule for the kitchen were reviewed with Dietary Aide 6 , the August 2023 cleaning logs lacked documentation that the dry storage room was cleaned on 08/04/23, 08/05/23 and 08/006/23. It was noted a copy of the schedule was needed.
The Daily Cleaning Schedule was reviewed on 08/06/23 at 1:34 P.M., with [NAME] 7, the logs were now signed with a staff member's initials to indicated the Dry Storage Room was cleaned on 08/04/23, 08/05/23, and 08/06/23.
During a dry storage observation on 08/06/23 at 1:41 P.M., the following was observed:
- a cardboard box of disposable lids and a cardboard box of plastic bowls sat on the floor under the middle rack, and
- there was a white powdered substance along the back wall behind the middle rack of dry goods that measured approximately 3-4 feet long and 6 inches wide, and
- 4 small Styrofoam bowls, a tea bag, a clear plastic bowl, and a coffee creamer were laying on the floor under the storage racks.
- two rodent traps with no visible rodent droppings.
During an observation and interview of the dry storage room with the Social Services Director on 08/08/23 at 9:20 A.M., the following was observed:
- a cardboard box of plastic bowls sat on the floor under the middle rack, and
- there was a white powdered substance along the back wall behind the middle rack of dry goods that measured approximately 3-4 feet long and 6 inches wide, and
- 4 small Styrofoam bowls, a tea bag, a clear plastic bowl, and a coffee creamer were laying on the floor between the bread rack and another storage rack.
- two rodent traps with no visible rodent droppings.
The Social Service Director, who was assisting with managing the kitchen, indicated the dry storage room should be cleaned daily and deep cleaned once a week. The daily cleaning schedule log was observed and indicated the dry storage room had been cleaned, swept, and mopped, daily, since 08/06/23. She indicated the staff should not have signed the log if it had not been cleaned.
The current facility policy titled, Cleaning Schedules with a revised date of 05/23, was provided by the DON (Director of Nursing) on 08/09/23 at 12:13 P.M. The policy indicated, .The culinary staff will maintain the sanitation of the culinary department through compliance with a written, comprehensive cleaning schedule .The cleaning schedule will be posted for all cleaning tasks, and employees will initial tasks once completed .The Culinary Manager is responsible to ensure all cleaning tasks are completed timely and thoroughly .
3.1-21(i)(3)

2. During an observation on 08/09/23 at 8:31 A.M., LPN 2 gathered Resident 3's Lispro insulin pen from a medication cart. She removed the pen from a clear reusable plastic bag, removed the cap from the pen, and attached a needle to the pen. She did not cleanse the hub of the pen with alcohol before attaching the needle. She primed the insulin pen and dialed up the dose needed for the resident. She assisted the resident into the bathroom, used an alcohol pad to cleanse the resident's skin, and injected the medication.
During an interview on 08/09/23 at 8:43 A.M., LPN 2 indicated she should have cleansed the pen before attaching the needle.
During an interview on 08/10/23 at 3:00 P.M., the Regional Director of Clinical Services indicated the insulin pen should have been cleansed with alcohol before the needle was attached.
The current facility policy, titled Insulin Pen Administration, with a reviewed on date of 10/2019, was provided by the DON on 08/10/23 at 2:24 P.M. The policy indicated, .wipe top of insulin pen with alcohol swab/pad if instructions indicated .
3.1-18(b)
Based on observation and interview, the facility failed to follow infection control guidelines for 1 of 2 wound observations (Resident 12) and 1 of 2 insulin administrations (Resident 3).
Findings include:
1. During and observation on 08/08/23 at 2:58 P.M., Resident 12 was lying in his bed on his right side. LPN (Licensed Practical Nurse) 2 indicated the resident had just received a shower. The LPN donned gloves from a box, gathered dry wash cloths and placed them directly in the resident's bathroom sink. She wet the cloths with water and applied soap to a few of them. After the cloths were wet, she placed them on a pad at the end of the resident's bed. She removed her gloves and sanitized her hands. The resident was positioned, and the nurse used the cloths to wash and rinse the resident's wound to the bilateral groin area. The wounds showed no signs of infection, and no odor was present.
During an interview on 08/10/23 at 11:01 A.M., the DON (Director of Nursing) indicated the resident's wounds were to be washed with soap and water. Staff should have held the wash cloths in their clean gloved hand while wetting them and putting soap on them. Then the staff should have placed them in a bag at the foot of the resident's bed, so they didn't touch anything. Staff should never sit clean wash cloths in the resident's sink to get them wet.
During an interview on 08/10/23 at 1:44 P.M., CNA (Certified Nurse Aide) 4 indicated when she gave a resident a bath, she would get a bath basin and place wash cloths in it, to get them wet. She would never place clean wash cloths directly in the resident's bathroom sink.
The current facility Skills Competency-Nursing Policy & Procedure, titled, Dressing Change Clean Technique with a revised date of 06/2021, was provided by the DON on 08/10/23 at 2:24 P.M. The policy indicated, .Prepare a clean work surface or place a clean barrier such as clean towel or paper towel to ensure easy access to supplies during procedure .Set up clean field with dressing change supplies and other necessary equipment .

Based on interview and record review, the facility failed to monitor/assess a resident's fistula following dialysis treatments for 1 of 1 resident reviewed for dialysis. (Resident 24)
Findings include:
During an interview on 08/06/23 at 11:21 A.M., Resident 24 indicated he left the facility for dialysis treatments on Mondays, Wednesdays, and Fridays, at around 10:00 A.M. He returned around 2:30 P.M.
During an interview on 08/10/23 at 9:21 A.M., the ADON (Assistant Director of Nursing) indicated, for residents who received dialysis treatments outside of the facility, the staff checked their vital signs before they left and when they came back. They were weighed when they came back. The dialysis treatment facility weighed them before and after treatments, but the facility still did their own weight when they come back to ensure it was correct. The resident had a fistula (dialysis access port) in his arm. When he returned from having a dialysis treatment the staff at the facility checked his fistula for a bruit and thrill. They checked the bruit and thrill every day each 12-hour shift, but upon return from dialysis it was checked to make sure it was not bleeding or swollen. They also reviewed his dialysis binder when he returned from treatments. The dialysis center put information in the binder that the facility staff needed to review. Facility staff documented the assessments of the resident before and after dialysis treatments under Events in the EHR (Electronic Health Record). The resident had not been sent out to the hospital in the last three months. The facility did not fill out any paper on the post dialysis assessment. The post dialysis assessments were in the computer.
During an interview on 08/10/23 at 9:36 A.M., the DON (Director of Nursing) indicated there should be a dialysis Event for every day the resident received dialysis treatments.
The Event History document was provided by the ADON on 08/10/23 at 9:39 A.M The record lacked a post dialysis assessment for the following dates:
- 07/28/23,
- 07/19/23,
- 07/17/23,
- 07/12/23,
- 07/05/23,
- 07/03/23,
- 06/30/23,
- 06/19/23, and
- 06/16/23.
The Progress Notes were provided by the DON on 08/10/23 at 10:28 A.M., and included, but were not limited to, the following:
- A note, dated 06/23/23 at 2:07 P.M., indicated the resident had returned from the dialysis center early due to his fistula infiltrating during his session. His left lower forearm was noted with slight swelling from the infiltration.
The resident's clinical record lacked a nursing assessment post dialysis of shunt cite after the resident returned to the facility after receiving dialysis on the above listed dates that he had received treatments.
The facility provided the dialysis center's post vitals, however the resident's clinical record lacked a facility document shunt assessment once the resident arrived back at the facility.
During an interview on 08/10/23 at 10:36 A.M., the DON indicated on 06/23/23, the Dialysis center had sent back paperwork indicating the resident's fistula had infiltrated and the staff here at the facility were to monitor the fistula site. The resident had a port in his chest they had used for dialysis treatments prior to him getting the fistula in his arm. They had tried to place a fistula in his arm before and it had been unsuccessful, so they had continued to use the port in his chest for a while. He had gotten a new fistula in his arm this year. On 06/23/23 the fistula was in his arm, the same fistula they were currently using. She had not seen the fistula when it had infiltrated.
The clinical record was reviewed on 08/07/23 at 1:51 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 05/24/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension, obstructive uropathy, and renal insufficiency. The resident received dialysis treatments.
The current Dialysis Care policy, with a reviewed date of 11/2017, was provided by the DON on 08/10/23 at 10:28 A.M. The policy indicated, .For .residents receiving dialysis at a certified dialysis facility: .An assessment of the resident will be completed upon return from each dialysis visit to include vital signs and assessment of the site including bruit and thrill (if applicable), drainage, and general condition .A dialysis event will be initiated in EMR [Electronic Medical Record] to include time of transfer and completed on return to the unit .
3.1-37(a)

Based on record review and interview, the facility failed to follow the physician's order to discontinue a medication after a pharmacy recommendation for 1 of 5 residents reviewed for unnecessary medications. (Resident 21)
Findings include:
Resident 21's clinical record was reviewed on 08/09/23 at 1:48 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/12/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure, renal insufficiency, and diabetes with diabetic kidney complication.
A Pharmacy Consultation Report, dated 06/19/23, indicated the resident received Farxiga (a diabetic medication)10 mg (milligrams) daily. The resident had an eGFR (estimated glomerular filtration rate, a test that measured kidney function) of 44 ml/min (milliliters per minute). The manufacturer stated to avoid this medication in patients with an eGFR of less than 45. The pharmacist recommended considering discontinuing the medication. The physician response indicated the MD accepted the recommendation to discontinue the medication on 06/23/23.
The resident's current medication orders included, but were not limited to, an open ended order, with a start date of 04/19/23, to administer Farxiga 10 mg once a day. The June, July, and August 2023 EMAR (Electronic Medication Administration Record) indicated the resident received the medication every day.
During an interview on 08/09/23 at 2:50 P.M., the DON (Director of Nursing) indicated the medication should have been discontinued when the MD accepted the pharmacy recommendation, and it was not discontinued. The resident continued to receive the medication daily.
The current facility policy, titled Medication Regimen Reviews and Pharmacy Recommendations, dated 10/2018, was provided by the DON on 08/09/23 at 2:57 P.M. The policy indicated, .Pharmacy recommendations should be reviewed with follow up by the physician within 30 days of the facility receiving .
The current facility policy, titled MatrixCare Physician Orders Policy, with a most recent revision date of 02/14/22, was provided by the DON on 08/09/23 at 12:12 P.M. The policy indicated, .orders will be entered into MatrixCare Physician Orders by the Nurse receiving the order .
3.1-48(a)(5)