How many inspection deficiencies does WATERS OF BATESVILLE, THE have?

WATERS OF BATESVILLE, THE has 44 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at WATERS OF BATESVILLE, THE?

WATERS OF BATESVILLE, THE has a one-star staffing rating from CMS with 0.29 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is WATERS OF BATESVILLE, THE located?

WATERS OF BATESVILLE, THE is located in BATESVILLE, IN. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does WATERS OF BATESVILLE, THE have?

WATERS OF BATESVILLE, THE has 86 certified beds.

Who owns WATERS OF BATESVILLE, THE?

WATERS OF BATESVILLE, THE is a non profit - corporation facility and is part of the INFINITY HEALTHCARE CONSULTING chain.

What questions should families ask when visiting WATERS OF BATESVILLE, THE?

Families visiting WATERS OF BATESVILLE, THE should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does WATERS OF BATESVILLE, THE compare to other nursing homes?

WATERS OF BATESVILLE, THE has a 1-star overall rating, which is below average compared to other nursing homes in IN. Families should carefully review inspection findings and consider alternatives.

WATERS OF BATESVILLE, THE

Name: WATERS OF BATESVILLE, THE
Address: 958 E HWY 46, BATESVILLE, IN, 47006, US
Telephone: (812) 934-2436
Rating: 1.0

958 E HWY 46, BATESVILLE, IN 47006 · (812) 934-2436

Non profit - Corporation 86 Beds INFINITY HEALTHCARE CONSULTING Data: November 2025

Trust Grade

35/100

#489 of 505 in IN

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WATERS OF BATESVILLE, THE nursing home in BATESVILLE, IN - Photo 1 of 2

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Last Inspection: February 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

The Waters of Batesville nursing home has received a Trust Grade of F, indicating significant concerns about the facility's quality and care. Ranking #489 out of 505 in Indiana places it in the bottom half of the state, and it's the lowest-rated option in Ripley County, at #5 of 5. Unfortunately, the facility is worsening, with issues increasing from 4 in 2024 to 12 in 2025. Staffing is a notable concern, as they have less RN coverage than 97% of Indiana facilities, which means residents may not receive adequate supervision and care. While they have not incurred any fines, there have been specific incidents where care was lacking, such as a resident receiving medication without proper monitoring of their vital signs and another resident at risk for pressure ulcers due to inadequate assistance during personal care. Overall, the combination of low ratings, staffing issues, and care incidents suggests families should approach with caution.

Trust Score: F
In Indiana: #489/505
Safety Record: Moderate
Inspections: Getting Worse
Staff Stability: 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Indiana facilities.
Skilled Nurses: Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for Indiana. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 44 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 4 issues

2025: 12 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Indiana average (3.1)

Significant quality concerns identified by CMS

Staff Turnover: 54%

Near Indiana avg (46%)

Higher turnover may affect care consistency

Chain: INFINITY HEALTHCARE CONSULTING

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 44 deficiencies on record

1 actual harm

Feb 2025 12 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to notify the physician when a resident's blood glucose levels were out of range for 1 of 21 residents reviewed for notification of change. (Resident 29) Findings include: The clinical record for Resident 29 was reviewed on 02/05/25 at 10:44 A.M. An Annual MDS (Minimum Data Set) assessment, dated 01/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. The resident's current MD orders included an open-ended order, with a start date of 04/25/24, to administer 3 units of Humalog insulin, three times a day at 7:00 A.M., 12:00 P.M., and 5:00 P.M. The resident also had an additional open-ended order, with a start date of 04/25/24, to check the blood glucose and administer an additional dose of Humalog based on a sliding scale (the amount of insulin administered would depend on the resident's blood glucose level) three times a day at 7:00 A.M., 12:00 P.M., and 5:00 P.M. The physician was to be notified if the resident's blood glucose was greater than 351. The November and December 2024, and January and February 2025, Electronic Medication Administration Record (EMAR) and Vitals Reports were reviewed. The blood glucose levels documented when the resident received the scheduled dose of insulin were different from the blood glucose levels documented when the sliding scale insulin was administered, even though both doses of insulin would have been administered together and based off the same blood glucose level. - On 11/09/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 430, but the sliding scale blood glucose documented was 350, - On 11/16/24 at 12:00 P.M., the blood glucose documented for the scheduled insulin was 377, but the sliding scale blood glucose documented was 350, - On 11/26/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 420, but the sliding scale blood glucose documented was 340, - On 12/06/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 378, but the sliding scale blood glucose documented was 350, - On 12/07/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 358, but the sliding scale blood glucose documented was 350, - On 12/12/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 400, but the sliding scale blood glucose documented was 350, - On 12/14/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 409, but the sliding scale blood glucose documented was 350, - On 12/15/24 at 12:00 P.M., the blood glucose documented for the scheduled insulin was 563, but the sliding scale blood glucose documented was 349, - On 12/17/24 at 8:00 A.M., the blood glucose documented for the scheduled insulin was 379, but the sliding scale blood glucose documented was 350, - On 12/23/24 at 12:00 P.M., the blood glucose documented for the scheduled insulin was 551, but the sliding scale blood glucose documented was 304, - On 12/23/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 337, but the sliding scale blood glucose documented was 373, - On 12/29/24 at 7:00 A.M., the blood glucose documented for the scheduled insulin was 376, but the sliding scale blood glucose documented was 350, - On 01/04/25 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 376, but the sliding scale blood glucose documented was 350, - On 01/23/25 at 12:00 P.M., the blood glucose documented for the scheduled insulin was 435, but the sliding scale blood glucose documented was 248, and - On 02/01/25 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 415. but the sliding scale blood glucose documented was 350. There was no indication the physician was notified when the blood glucose levels were greater than 350. During an interview on 02/07/25 at 11:26 A.M., LPN 6 (Licensed Practical Nurse) indicated if a resident received sliding scale insulin with a routine insulin and the blood sugar needed to be reported to the physician due to the call parameters then she would call the physician and document in the EMAR and a progress note that the physician was notified. During an interview on 02/10/25 at 10:21 A.M., the DON (Director of Nursing) indicated if a resident had two insulin orders and one of them had parameters to call the physician then the orders should have the same blood glucose levels documented and the physician should be notified if they were outside the call parameters. The current, undated, facility policy titled, Change in Resident's Condition or Status, was provided by the DON on 02/06/25 at 9:51 A.M. The policy indicated, .It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status . 3.1-5(a)(3)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to maintain resident records in a private manner related to personal information posted in a public setting for 1 of 54 residents who resided in the building. (Resident 59) Findings include: Resident 59's room was observed on 02/04/25 at 1:17 P.M. Signage on the resident's door indicated he was in contact isolation and enhanced barrier precautions. Posted on the wall next to the door directly above the resident's name and room number was a document titled, Guidelines for addressing Candida auris. The resident's room was observed on 02/05/25 at 9:20 A.M., The signage remained, including the Guidelines for addressing Candida auris documents posted on the wall above the resident's name and room number. During an interview on 02/05/25 at 9:22 A.M., Licensed Practical Nurse 5 indicated resident information, including resident profile information, medication lists, and diagnoses information was private and confidential, and should not be out for public viewing. During an interview on 02/05/25 at 9:30 A.M., the Director of Nursing (DON) and the Regional Nurse Consultant indicated they were unaware of any documentation posted in public related to the resident's diagnosis. It should not be there and would be removed. The resident's clinical record was reviewed on 02/05/25 at 10:00 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/01/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, cancer, hypertension, and depression. The resident's current MD orders included a current open-ended order, with a start date of 02/04/25, that indicated the resident was in contact isolation for a Candida auris infection. The current, undated facility policy, titled What is HIPAA? was provided by the DON on 02/06/25 at 9:52 A.M. The policy indicated, .PROTECTED HEALTH INFORMATION .any and all health information on a resident or employee that identifies an individual . 3.1-3(o)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to follow a acquired a resident's weight related to daily weights for 1 of 4 residents reviewed for nutrition. (Resident 29) Findings include: The clinical record for Resident 29 was reviewed on 02/05/25 at 10:44 A.M. An Annual Minimum Data Set (MDS) assessment, dated 01/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. A current, open-ended physician's order, with a start date of 12/28/24, indicated the resident was to be weighed daily. The physician was to be notified if the resident had a weight gain greater than 3 pounds in a day or greater than 5 pounds in a week. The clinical record lacked daily weights on the following dates: - 12/30/24 through 01/02/25, - 01/04/25, - 01/06/25 through 01/07/25, - 01/09/25 through 01/11/25, - 01/13/25 through 01/15/25, - 01/17/25, - 01/20/25, - 01/21/25, - 01/23/25 through 02/02/25, and - 02/04/25. During an interview on 02/10/25 at 11:02 A.M., Licensed Practical Nurse (LPN) 3 indicated the resident was a daily weight. The CNAs (Certified Nurse Aides) would get the resident's weight and let the nurse know. The nurse would document the weight and call the physician if the resident was greater than a certain amount in a day. The current facility policy titled, GUIDELINES FOR OBTAINING RESIDENTS' WEIGHTS, dated 07/24/23, was provided by the DON on 02/10/25 at 1:08 P.M. The policy indicated, .Accuracy with weight measurement is essential for residents in the long-term-care setting. Weight measurement is used to calculate energy, protein, and fluid needs. Further, weight is an indicator of nutritional and health status and changes in weight can often indicate other medical changes. Inaccurate weight measurements can result in an increased number of unplanned weight changes in the facility-and can affect the plans of care for the residents .Weigh residents at the same time of the day as possible, on the same weight clothing as much as possible-each time they are weighed . 3.1-46(a)(1)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to provide Parenteral/IV (Intravenous) site maintenance for 2 of 3 residents reviewed for vascular access sites. (Residents 4 and 38) Findings include: 1. The clinical record for Resident 4 was reviewed on 02/05/25 at 2:36 P.M. An admission Minimum Data Set (MDS) assessment, dated 01/20/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, acute osteomyelitis (infection in the bone or bone marrow) of the right ankle and foot. During an interview on 02/10/25 at 8:38 A.M., the Director of Nursing (DON) indicated the resident was admitted to the facility from the hospital and had an infected heel wound with osteomyelitis. The resident had been on IV antibiotics for his wound infection since he was admitted to the facility. During an interview on 02/10/25 at 2:25 P.M., Licensed Practical Nurse (LPN) LPN 2 indicated the resident had a Midline vascular access site in his right arm. He came from the hospital with an access site but then had to have it replaced because it would not flush. Residents with a Peripherally Inserted Central Catheter (PICC) line or a Midline Catheter should have physician's orders to flush the line regularly. The PICC/MIDLINE INSERTION DOCUMENTATION record, dated 01/24/25, was provided by the Regional Nurse Consultant on 02/10/25 at 3:18 P.M. The record indicated a dual lumen PICC line had been removed, and a Midline had been inserted. The Midline was cleared for use. The clinical record indicated the resident did not receive IV medications on January 19, or 20, 2025, due to a lack of supplies. The resident did not receive IV medications on January 22, 23, or 24, 2025, due to the resident's venous access site not flushing. The clinical record lacked documentation the resident's venous access sites had been flushed on a regular basis or flushed before and after medication administration. The Electronic Medication Administration Record/Treatment Administration Record (EMAR/ETAR) for January and February 2025, was provided by the DON on 02/10/25 at 9:19 A.M. The record lacked a physician's order to flush the resident's vascular access sites to maintain patency (open and unblocked) and there was no order to flush the sites before or following the IV medication administration. 2a. The clinical record for Resident 38 was reviewed on 02/06/25 at 10:05 A.M. A Quarterly MDS assessment, dated 12/17/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, amputation, anemia, hypertension, PVD, diabetes, anxiety, depression, infection of amputation. A Progress Noted, dated 12/07/24 at 9:24 P.M., indicated the resident admitted to the facility for a right stump infection and had a PICC line in her right upper arm. A physician's order, dated 12/08/24 through 12/22/24, indicated the resident was to receive Vancomycin (an antibiotic) 1 gram, once a day for a right stump infection. A physician's order, dated 12/08/24 through 01/10/25, indicated the resident was to receive Cefepime (an antibiotic) 2 grams intravenously, twice a day for a right stump infection. A physician's order, dated 12/08/24 at 10:20 A.M., indicated the staff were to flush the IV-midline with 10 mls normal saline before and after infusions. The order had no scheduling details or assigned times to be completed. The clinical record indicated the resident did not receive the Vancomycin on the following dates: - 12/08/24 due to the medication being unavailable, - 12/09/24 due to the resident needing a new PICC line placed, and - 12/10/24 due to waiting on the PICC line verification. The clinical record indicated the resident did not receive the Cefepime medication on the following dates and times: - 12/08/24 at 8:00 P.M., due to the medication being unavailable, - 12/09/24 at 8:00 A.M., and 8:00 P.M., due to new PICC needing placed, and - 12/10/24 at 8:00 A.M., due to waiting on PICC line verification. A Vascular Access And Consultation Reports indicated the resident had a PICC/midline placed on the following dates: - 12/09/24 at 11:25 P.M., - 12/14/24 at 4:10 P.M., - 12/14/24 at 8:00 P.M., and - 01/04/25 at 3:50 P.M. The resident's PICC/midline was discontinued on 01/10/25. The clinical record lacked documentation that the resident's PICC/midline was flushed from 12/07/24 through 01/10/25. 2b. An Infectious Disease Progress Note, dated 12/20/2024 at 5:05 P.M., indicated it was recommended a referral was to be sent for the resident to get a central line (an intravenous line that is longer than a regular IV and goes all the way up to a vein near the heart or just inside the heart.) A physician's order, with a start date of 12/24/24, indicated the staff were to contact the local hospital about getting a central line placed due to difficulty with midline placement, for 5 days. A physician's order, with start date 12/26/24 and end date 12/30/24, indicated the staff were to schedule an appointment with the general surgeon for a central line for 4 days. The December 2024 EMAR and clinical record indicated the following related to the central line: - 12/24/24, the EMAR indicated to see nurse note. There was no nurse note related to the appointment, - 12/25/24 and 12/26/24, EMAR was left blank, - 12/27/24 the EMAR indicated to see a nurse note. The nurse note indicated the physician's office was closed that day, and - 12/28/24 through 12/30/24, the EMAR was left blank. The clinical record lacked any other documentation related to the central line. During an interview on 02/07/25 at 1:30 P.M., LPN 2 indicated if a resident was admitted to the facility with a PICC/Midline the medications would be delivered by pharmacy. They ran three times a day, and the nurse would need to input orders for it to be flushed. There was no reason anyone would have a PICC/Midline without flush orders. To schedule appointments, she would put it on the EMAR, and the nurse would have to check it off like a medication when it was done. If it didn't get done, then the DON would need to follow-up to make sure it was completed. During an interview on 02/10/25 at 10:03 A.M., the DON and the Regional Nurse Consultant indicated when a resident admitted to a facility with a PICC/Midline the nurse would input order for the resident to get flushes to the line. Resident 38 had an order for flushes, but the nurse didn't put in any scheduling details, so it didn't show up on the EMAR to be completed. If the physician gave orders for the pharmacy to dose a resident's medications, then the facility would follow the orders from the pharmacy. The nurse that took the order to increase the Vancomycin to 1.25 grams should have changed the order in the clinical record. Since the infectious disease NP made a recommendation for a central line the facility should have followed up with the physician to get the line placed. The current facility policy titled, Flushing a Peripheral Intravenous Catheter, dated January 2016, was provided by the DON on 02/10/25 at 1:08 P.M. The policy indicated, .Specific flush orders must be documented .Flushing is performed to ensure and maintain catheter patency, and to prevent the mixing of incompatible medications/solutions .A physician order is required for flushing of a peripheral IV catheter. The order must include: .Flushing agent .Volume .Frequency . The current facility policy titled, Flushing a Midline Catheter, dated January 2016, was provided by the DON on 02/10/25 at 1:08 P.M. The policy indicated, .Specific flush orders must be documented .Flushing is performed to ensure and maintain catheter patency, and to prevent the mixing of incompatible medications/solutions .A physician order is required for flushing of a peripheral IV catheter. The order must include: .Flushing agent .Strength/concentration .Volume .Frequency . The current, undated, facility policy titled, PHYSICIAN-ORDERS--(FOLLOWING PHYSICIAN ORDERS) was provided by the Regional Nurse Consultant on 02/07/25 at 12:15 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . 3.1-47(a)(2)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to completed assessments before and following a resident's dialysis treatments for 1 of 2 residents reviewed for dialysis. (Resident 24) Findings include: During an interview on 02/04/25 at 11:25 A.M., Resident 24 indicated she left the facility for dialysis treatments on Monday, Wednesday, and Friday. During an interview while at the Resident Council Meeting, on 02/06/25 at 2:15 P.M., the resident indicated sometimes when she got back from dialysis, she had to sit in her wheelchair with her coat on for a half an hour before staff helped her. The clinical record for Resident 24 was reviewed on 02/06/25 at 2:41 P.M. A Quarterly Minimum Data Set assessment, dated 12/15/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, renal insufficiency, and diabetes. The resident received dialysis treatments. During an interview on 02/06/25 at 3:20 P.M., the Director of Nursing (DON) indicated the facility staff were supposed to complete an assessment on the DIALYSIS/OBSERVATION COMMUNICATION FORM in the resident's dialysis binder each time the resident went to the dialysis facility for treatment. The DIALYSIS/OBSERVATION COMMUNICATION FORM records were provided by the DON on 02/06/25 at 3:55 P.M. The DON indicated the resident refuse to go to dialysis sometimes but had been to dialysis a few times in January and February. The dialysis binder only contained records for 12/13/24, 12/20/24, and 12/31/24. The dialysis provider had completed their portion of the forms. The facility failed to complete their portion of the forms which included signed assessments before and after dialysis treatments. The current Dialysis Guideline policy, with a reviewed date of 04/04/16, was provided during the Entrance Conference. The policy indicated, .Care required when a resident's disease trajectory requires hemodialysis may exceed the usual interventions provided to residents in long-term care setting .Communication between the dialysis provider and center staff should include: Written communication including review of daily weights, changes in condition or mood, response to the treatment, and evaluation of the vascular access site . 3.1-37(a)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide IV (Intravenous) antibiotics in a timely manner for 2 of 3 residents reviewed for IV antibiotics. (Residents 4 and 29) Findings include: 1. The clinical record for Resident 4 was reviewed on 02/05/25 at 2:36 P.M. An admission Minimum Data Set (MDS) assessment, dated 01/20/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, acute osteomyelitis (infection in the bone or bone marrow) of the right ankle and foot. The resident was admitted to the facility on [DATE]. During an interview on 02/10/25 at 8:38 A.M., the Director of Nursing (DON) indicated the resident was admitted to the facility from the hospital and had an infected heel wound with osteomyelitis. From admission he was on IV antibiotics. The facility had run out of IV tubing. They were out of tubing for two days. The resident was on two different IV antibiotics and missed several doses, 6 doses altogether. The pharmacy did not send tubing with the IV medications. The facility had ordered some IV tubing from a supplier who no longer carried tubing. As soon as they discovered that the supplier no longer carried tubing, they notified the pharmacy, and they delivered a box. The pharmacy delivered once early in the morning, between 2:00 A.M., and 7:00 A.M., and again, later in the afternoon, usually around 5:00 P.M., or 6:00 P.M. If staff ordered something by 3:00 P.M., they would usually have it by 7:00 A.M. the next day. They had two local pharmacies they could get supplies from in an emergency. The Electronic Medication Administration Record/Treatment Administration Record (EMAR/ETAR) for January 2025, was provided by the DON on 02/10/25 at 9:19 A.M. The record indicated the resident was to receive the following IV antibiotics daily for the acute infection in his foot: - Daptomycin 500 milligrams (mg) one time a day, at 2:00 P.M., with a start date of 01/15/25, and an end date of 02/20/25, and - Cefepime 2 grams, two times a day, at 8:00 A.M., and 8:00 P.M., with a start date of 01/16/25, and an end date of 02/21/25. The record indicated the resident did not receive the antibiotics on the following dates and times due to supplies not being available: - Daptomycin on 01/19/25, 01/20/25, at 2:00 P.M., and - Cefepime on 01/19/25 at 8:00 A.M. and 8:00 P.M., and 01/20/25 at 8:00 A.M. 2. The clinical record for Resident 29 was reviewed on 02/05/25 at 10:44 A.M. An Annual MDS assessment, dated 01/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. A Progress Note, dated 11/19/24 at 9:40 A.M., indicated the resident was positive for a UTI (Urinary Tract Infection). A new order was obtained to place a PICC line for IV Merrem (an antibiotic). A vascular access nurse was to come to the facility and place the PICC line. A physician's order, dated 11/19/24 through 11/26/24, indicated the resident was to receive Merrem, 1 gram every 8 hours for a UTI for 7 days. The November 2024 EMAR indicated the resident did not receive the antibiotics on the following dates and times: - 11/19/24 from 8:00 P.M. to 10:00 P.M., - 11/20/24 from 6:00 A.M. to 10:00 A.M., 4:00 P.M. to 6:00 P.M., and 8:00 P.M. to 10:00 P.M., - 11/21/24 from 6:00 A.M. to 10:00 A.M., 4:00 P.M. to 6:00 P.M. (there was a blank in the EMAR), and - 11/23/24 from 4:00 P.M. to 6:00 P.M. (there was a blank in the EMAR). A Progress Note, dated 11/19/24 at 11:08 P.M., indicated the Merrem medication was not administered due to waiting on the pharmacy to deliver. A Progress Note, dated 11/20/24 at 5:19 P.M., indicated the Merrem medication was not administered due to the medication being unavailable. The pharmacy stated the medication would be there that night. A Progress Note, dated 11/20/24 at 5:26 P.M., indicated the Merrem medication was not administered due to the medication being unavailable. The pharmacy stated the medication would be there that night. A Progress Note, dated 11/20/24 at 11:41 P.M., indicated the Merrem medication was not administered. The pharmacy was called and clarified that the medication had not been delivered to the facility. A Progress Note, dated 11/21/24 at 2:33 P.M., indicated the Merrem medication was not administered due to the medication being absent from the facility. During an interview on 02/07/25 at 1:30 P.M., LPN 2 indicated when a resident started on IV medication the pharmacy would send the medications. The pharmacy delivered medications three times a day. During an interview on 02/10/25 at 2:37 P.M., the ADON indicated to ensure residents received all their antibiotics the EMAR would be monitored to ensure the nurse was signing off the medication. If a physician ordered IV antibiotics, they should be delivered the next day to start the medication. During an interview on 02/10/25 at 3:11 P.M., the DON indicated the pharmacy had cut off times for ordering medications. If the staff ordered medications before 6:00 A.M., they would get there by 6:00 P.M. and vice versa. 3. The clinical record for Resident 38 was reviewed on 02/06/25 at 10:05 A.M. A Quarterly MDS assessment, dated 12/17/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, amputation, anemia, hypertension, PVD, diabetes, anxiety, depression, infection of amputation. A Progress Note, dated 12/16/24 at 10:01 A.M., indicated the pharmacy was informed of the resident's trough level for the Vancomycin. The pharmacy was increasing the dose from 1 gram to 1.25 grams. The medication was not available in the emergency drug kit and would be started when it arrived from the pharmacy. The residents December 2024 EMAR indicated the resident had received Vancomycin 1 gram on 12/17/24 and 12/18/24 and was on hold from 12/19/24 through 12/21/24. The clinical record lacked an order for the medication to be increased to 1.25 grams. The current facility policy titled, PHARMACY HOURS AND DELIVERY SCHEDULE, dated February 2017, was provided by the DON on 02/10/25 at 1:08 P.M. The policy indicated, .is open 24 hours/365 days a year. New orders and refill requests may be faxed or sent electronically at any time . The current, undated, facility policy titled, PHYSICIAN-ORDERS--(FOLLOWING PHYSICIAN ORDERS) was provided by the Regional Nurse Consultant on 02/07/25 at 12:15 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . 3.1-25(a)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to obtain blood tests for 1 of 5 residents reviewed for laboratory services. (Resident 27) Findings include: Resident 27's clinical record was reviewed on 02/06/25 at 11:00 A.M. A Quarterly Minimum Data Set assessment, dated 01/13/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, anxiety, and hypertension. The resident's current MD orders included, but were not limited to, an open-ended order, with a start date of 06/07/23, to check the resident's A1C (a blood test that measures the average blood glucose level over the past 2 to 3 months) every 3 month(s). Based on the physician's orders, the A1C blood tests should have been obtained in March, June, September, and December of 2024. The resident's A1C lab (laboratory) results for 2024 were provided by the Director of Nursing (DON). The resident's A1C was checked in March and December of 2024. During an interview on 02/07/25 at 2:24 P.M., the DON indicated the copies of the A1C labs she provided were all that were located in the resident's record. The facility missed some of the resident's required labs. The current, undated facility policy, titled LAB SCHEDULING/TRACKING, was provided by the DON on 02/10/25 at 9:19 A.M. The policy indicated, .It is the policy of the facility to ensure that laboratory tests ordered by the physician are systematically scheduled and tracked so that lab work is obtained and results are received and reported timely . 3.1-49(a)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to maintain a kitchen exterior door in good working order related to food safety for 3 of 3 kitchen observations. This deficient practice had the potential to affect 52 of 54 resident who received food from the kitchen. Findings include: During an initial kitchen observation on 02/04/25 at 10:30 A.M., an exterior kitchen door was cracked open about 1/2 to 1 inch that the outside was visible. The Dietary Manager closed the door. The bottom of the door contained a door draft stopper that was broken on the right side where the door opened to the outside. The part that was broken left an approximately 2-inch gap at the bottom of the door. During an observation on 02/04/25 at 11:01 A.M., an exterior kitchen door was cracked open about 1/2 to 1 inch that the outside was visible. The bottom of the door contained a door draft stopper that was broken on the right side where the door opens to the outside. The part that was broken left an approximately 2-inch gap at the bottom of the door. During an observation and interview on 02/10/25 at 10:44 A.M., an exterior kitchen door was cracked open about 1/2 to 1 inch that the outside was visible. The bottom of the door contained a door draft stopper that was broken on the right side where the door opens to the outside. The part that was broken left an approximately 2-inch gap at the bottom of the door. She indicated the staff knew to keep the door closed as it didn't shut properly. The broken piece in the bottom of the door had been like that for a couple weeks. She had verbally told the Maintenance Director about it. During an interview on 02/10/25 at 10:53 A.M., the Maintenance Director indicated he was notified of the door being broken in the kitchen few weeks ago. The kitchen staff were educated to make sure the door stayed closed. He had no documentation that the door needed to be fixed, and it would be fixed by the end of the day. The current facility policy titled, OTHER INFORMATION, dated 12/05/23, was provided by the Regional Director of Operations on 02/10/25 at 3:04 P.M. The policy indicated, .Maintenance Request Log .Maintenance staff will check all nurses' stations and housekeeping carts during morning rounds to pick up the Maintenance request Logs and take care of the requests as time allows. If an issue is urgent in nature, it will be addressed immediately .Work orders needed to be completed in a timely fashion .Door Inspections .Check for holes/gaps and repair as needed . 3.1-21(i)(3)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to notify the physician when a resident's blood glucose levels were out of range for 1 of 21 residents reviewed for notification of change. (Resident 29) Findings include: The clinical record for Resident 29 was reviewed on 02/05/25 at 10:44 A.M. An Annual MDS (Minimum Data Set) assessment, dated 01/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. The resident's current MD orders included an open-ended order, with a start date of 04/25/24, to administer 3 units of Humalog insulin, three times a day at 7:00 A.M., 12:00 P.M., and 5:00 P.M. The resident also had an additional open-ended order, with a start date of 04/25/24, to check the blood glucose and administer an additional dose of Humalog based on a sliding scale (the amount of insulin administered would depend on the resident's blood glucose level) three times a day at 7:00 A.M., 12:00 P.M., and 5:00 P.M. The physician was to be notified if the resident's blood glucose level was greater than 351. The November and December 2024, and January, February 2025, Electronic Medication Administration Record (EMAR) and Vitals Reports were reviewed. The blood glucose levels documented when the resident received the scheduled dose of insulin were different from the blood glucose levels documented when the sliding scale insulin was administered, even though both doses of insulin would have been administered together and based off the same blood glucose level. - On 11/09/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 430, but the sliding scale blood glucose documented was 350, - On 11/16/24 at 12:00 P.M., the blood glucose documented for the scheduled insulin was 377, but the sliding scale blood glucose documented was 350, - On 11/26/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 420, but the sliding scale blood glucose documented was 340, - On 12/06/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 378, but the sliding scale blood glucose documented was 350, - On 12/07/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 358, but the sliding scale blood glucose documented was 350, - On 12/12/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 400, but the sliding scale blood glucose documented was 350, - On 12/14/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 409, but the sliding scale blood glucose documented was 350, - On 12/15/24 at 12:00 P.M., the blood glucose documented for the scheduled insulin was 563, but the sliding scale blood glucose documented was 349, - On 12/17/24 at 8:00 A.M., the blood glucose documented for the scheduled insulin was 379, but the sliding scale blood glucose documented was 350, - On 12/23/24 at 12:00 P.M., the blood glucose documented for the scheduled insulin was 551, but the sliding scale blood glucose documented was 304, - On 12/23/24 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 337, but the sliding scale blood glucose documented was 373, - On 12/29/24 at 7:00 A.M., the blood glucose documented for the scheduled insulin was 376, but the sliding scale blood glucose documented was 350, - On 01/04/25 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 376, but the sliding scale blood glucose documented was 350, - On 01/23/25 at 12:00 P.M., the blood glucose documented for the scheduled insulin was 435, but the sliding scale blood glucose documented was 248, and - On 02/01/25 at 5:00 P.M., the blood glucose documented for the scheduled insulin was 415. but the sliding scale blood glucose documented was 350. There was no indication the physician was notified when the blood glucose levels were greater than 350. During an interview on 02/07/25 at 11:26 A.M., LPN 6 (Licensed Practical Nurse) indicated if a resident received sliding scale insulin with a routine insulin and the blood sugar needed to be reported to the physician due to the call parameters then she would call the physician and document in the EMAR and a progress note that the physician was notified. During an interview on 02/10/25 at 10:21 A.M., the DON (Director of Nursing) indicated if a resident had two insulin orders and one of them had parameters to call the physician then the orders should have the same blood glucose levels documented and the physician should be notified if they were outside the call parameters. The current, undated, facility policy titled, Change in Resident's Condition or Status, was provided by the DON on 02/06/25 at 9:51 A.M. The policy indicated, .It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status . 3.1-50(a)(2)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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2. The clinical record for Resident 29 was reviewed on 02/05/25 at 10:44 A.M. An Annual MDS assessment, dated 01/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. A current, open-ended physician's order, with a start date of 12/28/24, indicated the resident was to receive Metoprolol (a blood pressure medication) 25 mg, once a day. The staff were to hold the medication if the resident's heart rate was less than 60 or the blood pressure was less than 110/60. The December 2024, January and February 2025 EMAR indicated the resident received the medication when the vital signs were not documented for the following dates and times: - 12/28/24 through 12/31/24, no vital signs were documented, - 01/02/25 through 01/17/24, no vital signs were documented, and - 02/01/25 through 02/10/25, no vital signs were documented. The residents clinical record lacked any vital signs for the above dates. 3. The clinical record for Resident 22 was reviewed on 02/06/25 at 12:52 P.M. A Quarterly MDS assessment, dated 12/07/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, anemia, hypertension, diabetes, non-Alzheimer's dementia, depression, psychotic disorder, and respiratory failure. The current open-ended physician's order, with a start date of 04/27/23, indicated the resident was to receive Carvedilol (a blood pressure medication) 3.125 mg, twice a day. The staff were to hold the medication when the blood pressure was less than 120/70 or the heart rate was less than 60. The November and December 2024 and January, February 2025 EMAR indicated the resident had received the medication when the blood pressure was less than 120/70 or the heart rate was less than 60 on the following dates and times: - On 11/04/24 at 8:00 A.M., when the heart rate was 58 and at 8:00 P.M., when the heart rate was 58, - On 11/11/24 at 8:00 A.M., when the heart rate was 56, - On 11/19/24 at 8:00 P.M., when the blood pressure was 100/56, - On 11/20/24 at 8:00 A.M., when the blood pressure was 116/62, - On 12/09/24 at 8:00 P.M., when the blood pressure was 108/60, - On 12/14/24 at 8:00 P.M., when the blood pressure was 102/68, - On 12/16/24 at 8:00 P.M., when the blood pressure was 105/62, - On 12/17/24 at 8:00 A.M., when the blood pressure was 110/66, - On 01/15/25 at 8:00 P.M., when the blood pressure was 111/64, - On 01/20/25 at 8:00 P.M., when the blood pressure was 103/63, - On 01/21/25 at 8:00 A.M., when the blood pressure was 116/67, - On 01/26/25 at 8:00 A.M., when the blood pressure was 108/59, and - On 02/04/25 at 8:00 P.M., when the blood pressure was 114/59. 4. The clinical record for Resident 43 was reviewed on 02/06/25 at 1:37 P.M. A Quarterly MDS assessment, dated 12/26/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, stroke, hypertension, Non-Alzheimer's dementia, seizure disorder, malnutrition, anxiety, and depression. The current open-ended physician's order, with a start date of 11/24/23, indicated the resident was to be administered Midodrine 15 mg, three times a day for hypotension. The staff were to hold the medication if the systolic blood pressure was greater than 120. The November and December 2024 and January, February 2025 EMAR indicated the resident had received the Midodrine medication when their systolic blood pressure was greater than 120 on the following dates and times: - On 11/11/24 at 7:00 A.M., when the blood pressure was 133/70, - On 11/23/24 at 7:00 A.M., when the blood pressure was 124/68 and at 5:00 P.M. when the blood pressure was 126/86, - On 11/25/24 at 7:00 A.M., when the blood pressure was 132/80 at 12:00 P.M., when the blood pressure was 122/68, and 5:00 P.M., when the blood pressure was 136/76, - On 11/27/24 at 7:00 P.M., when the blood pressure was 122/76, at 12:00 P.M., when the blood pressure was 138/77, and 5:00 P.M., when the blood pressure was 122/74, - On 11/29/24 at 12:00 P.M., when the blood pressure was 123/67 and 5:00 P.M., when the blood pressure was 128/78, - On 12/02/24 at 7:00 A.M., when the blood pressure was 134/92 and at 12:00 P.M., when the blood pressure was 126/88, - On 12/03/24 at 12:00 P.M., when the blood pressure was 122/66, - On 12/05/24 at 7:00 A.M., when the blood pressure was 122/88 and 12:00 P.M., when the blood pressure was 134/74, - On 12/09/24 at 7:00 A.M., when the blood pressure was 142/76, at 12:00 P.M., when the blood pressure was 128/76, and 5:00 P.M., when the blood pressure was 134/88, - On 12/10/24 at 7:00 A.M., when the blood pressure was 135/84 and 12:00 P.M., when the blood pressure was 123/72, - On 12/11/24 at 12:00 P.M. when the blood pressure was 138/86, - On 12/13/24 at 7:00 A.M., when the blood pressure was 121/97, at 12:00 P.M., when the blood pressure was 134/86, and at 5:00 P.M., when the blood pressure was 124/82, - On 12/19/24 at 7:00 A.M., when the blood pressure was 122/84, at 12:00 P.M., when the blood pressure was 134/77, and at 5:00 P.M., when the blood pressure was 128/82, - On 12/22/24 at 5:00 P.M., when the blood pressure was 124/72, - On 12/23/24 at 7:00 A.M., when the blood pressure was 142/86, at 12:00 P.M., when the blood pressure was 132/74, and at 5:00 P.M., when the blood pressure was 132/76, - On 12/24/24 at 7:00 A.M., when the blood pressure was 128/78, - On 12/29/24 at 12:00 P.M., when the blood pressure was 123/73, - On 12/30/24 at 7:00 A.M., when the blood pressure was 142/89, at 12:00 P.M., when the blood pressure was 138/72, and 5:00 P.M., when the blood pressure was 122/84, - On 01/01/25 at 5:00 P.M. when the blood pressure was 123/78, - On 01/02/25 at 7:00 A.M., when the blood pressure was 147/106, at 12:00 P.M., when the blood pressure was 130/88, and at 5:00 P.M., when the blood pressure was 138/87, - On 01/06/25 at 5:00 P.M., when the blood pressure was 129/79, - On 01/08/25 at 7:00 A.M., when the blood pressure was 139/96, at 12:00 P.M., when the blood pressure was less than 134/88, and 5:00 P.M., when the blood pressure was 132/77, - On 01/13/25 at 7:00 A.M., when the blood pressure was 151/54, at 12:00 P.M., when the blood pressure was 136/68, and 5:00 P.M., when the blood pressure was 142/88, - On 01/15/25 at 7:00 A.M., when the blood pressure was 132/80, - On 01/16/25 at 7:00 A.M., when the blood pressure was 132/80, at 12:00 P.M., when the blood pressure was 128/74, and 5:00 P.M., when the blood pressure was 132/88, - On 01/20/25 at 7:00 A.M., when the blood pressure was 150/84, at 12:00 P.M., when the blood pressure was 138/77, and 5:00 P.M., when the blood pressure was 130/84, - On 01/22/25 at 7:00 A.M., when the blood pressure was 144/88, at 12:00 P.M., when the blood pressure was 147/83, and 5:00 P.M., when the blood pressure was 132/87, - On 01/24/25 at 12:00 P.M., when the blood pressure was 128/80, - On 01/26/25 at 7:00 A.M., when the blood pressure was 142/88, - On 01/27/25 at 7:00 A.M., when the blood pressure was 134/82, at 12:00 P.M., when the blood pressure was 122/77, and 5:00 P.M., when the blood pressure was 136/89, - On 02/03/25 at 7:00 A.M., when the blood pressure was 122/77, at 12:00 P.M., when the blood pressure was 138/80 and 5:00 P.M., when the blood pressure was 126/88, - On 02/04/25 at 7:00 A.M., when the blood pressure was 121/73, at 12:00 P.M., when the blood pressure was 132/87, and at 5:00 P.M., when the blood pressure was 127/84, - On 02/05/25 at 7:00 A.M., when the blood pressure was 134/79, at 12:00 P.M., when the blood pressure was 128/90, and at 5:00 P.M., when the blood pressure was 132/80, and - On 02/06/25 at 12:00 P.M., when the blood pressure was 128/78. During an interview on 02/07/25 at 11:26 A.M., LPN 6 indicated when a resident had hold parameters on medications, she would check the resident's vital signs prior to administering the medication. If the medication was to be held then she would not administer the medication and mark it on the EMAR that the medication was not administered with what the resident's vitals were. During an interview on 02/10/25 at 10:21 A.M., the DON indicated if a blood pressure medication had hold parameters, then the nurse should check the vitals and hold the medication based on the parameters. If there was a check mark on the EMAR, then that would mean that the medication was administered to the resident. If there was a number, then that determined the medication was not administered. The current, undated, facility policy titled, PHYSICIAN-ORDERS--(FOLLOWING PHYSICIAN ORDERS) was provided by the Regional Nurse Consultant on 02/07/25 at 12:15 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . The current facility policy titled, MEDICATION ADMINISTRATION, dated February 2017, was provided by the DON on 02/10/25 at 1:08 P.M. The policy indicated, .To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis . 3.1-37(a) Based on observation, interview, and record review, the facility failed to prime an insulin pen appropriately prior to administration, monitor blood glucose appropriately, and follow physician's orders related to medication hold parameters for 4 of 21 residents reviewed for Quality of Care. (Residents 37, 29, 22, and 43) Findings include: 1. During a medication administration observation and interview, on 02/06/25 at 10:54 A.M., Licensed Practical Nurse (LPN) 4 removed a Fiasp insulin pen from the 39 Back Medication Cart. LPN 4 indicated the pen had been opened and was for Resident 37 because they were the only resident who used that type of insulin and proceeded to write the resident's name on the pen. The resident required eight units of insulin based on the resident's blood glucose check the nurse had performed. The LPN applied the needle to the insulin pen and turned the dose knob at the end of the pen to 10 units. The LPN indicated she had done that so she could prime the pen with two units. The LPN aimed the insulin pen downwards into a plastic cup and squirted out 2 units. She donned gloves and proceeded to administer the insulin into the resident's abdomen with the door open to the room. During an interview following the procedure, LPN 4 indicated the purpose of priming the insulin pen was to ensure there was no air in the pen and she should have held the insulin pen upwards when priming the pen. The Fiasp insulin package insert was provided by the Regional Nurse Consultant on 02/10/25 at 2:00 P.M. The record indicated, .Priming your FIASP .Pen .Turn the dose selector to select 2 units .Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top .Hold the Pen with the needle pointing up. Press and hold the dose button until the dose counter shows 0 .A drop of insulin should be seen at the needle tip .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to provide the required RN coverage on duty for eight hours a day for 16 of the 21 days reviewed. Findings include: The as worked nursing schedule indicated there had not been an RN on duty for eight consecutive hours on the following dates: - Saturday 07/13/24, - Sunday 07/14/24, - Saturday 07/20/24, - Sunday 07/21/24, - Saturday 08/10/24, - Sunday 08/11/24, - Saturday 08/24/24, - Sunday 08/25/24, - Saturday 09/07/24, - Sunday 09/08/24, - Saturday 09/21/24, - Sunday 09/22/24, - Saturday 12/14/24, - Sunday 12/15/24, - Saturday 02/08/25, and - Sunday 02/09/25. During an interview on 02/10/25 at 09:52 A.M., The Director of Nursing (DON) indicated they did have issues with staffing in the previous months. The current, undated facility policy, titled Registered Nurse Coverage was provided by the DON on 02/10/25 at 9:19 A.M. The policy indicated, .It is the policy of the facility to provide the services of an RN for at least 8 consecutive hours per 24 hour day, 7days weekly . 3.1-17(b)(3)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to store medications appropriately for 3 of 3 medication carts reviewed and 1 of 1 medication rooms reviewed. (39 Back Medication Cart, Front Medication Cart, Rehab Medication Cart, and the 39 Hall Medication Room) Findings include: 1. During a medication administration observation on 02/06/25 at 10:54 A.M., Licensed Practical Nurse (LPN) 4 removed a Fiasp insulin pen from the 39 Back Medication Cart. The pen was laying loosely in the drawer of the medication cart and not in a plastic bag. The pen was labeled with an opened date of 2/1. The pen was not labeled with a resident's name or anything that would identify who the pen belonged to. LPN 4 indicated the pen had been opened and was for Resident 37 because they were the only resident who used that type of insulin. The LPN proceeded to write the resident's name on the pen and administer the insulin to Resident 37. 2. The Front Medication Cart was observed on 02/10/25 at 9:37 A.M., with LPN 3 and contained the following loose pills: - one small oval peach tablet, - one medium round gray tablet, - one medium round white tablet, - one small oval white tablet, - one small oval blue tablet, - one small oval red tablet, - one small round pink tablet, - one small round white tablet, - one medium round blue tablet, - one large oval white tablet, and - one medium orange capsule. The medication cart had a section of a drawer covered in a spilled substance and several bits of paper were scattered heavily throughout the cart. LPN 3 indicated the pharmacy occasionally came into and audited the medication carts. In-house staff usually kept the carts clean. The LPN was observed destroying the medications with a second nurse. 3. The Rehab Medication Cart was observed on 02/10/25 at 9:53 A.M., with LPN 2 and contained the following loose pills: - one small round white tablet, - one small round pink tablet, and - one large round half of a white tablet. LPN 2 indicated all insulin pens should have a resident's name on them. Per their facility policy, she had to throw the insulin pen away and she proceeded to do so. 4. The 39 Hall Medication Room was observed on 02/10/25 at 10:07 A.M. with LPN 3. The medication refrigerator contained two opened vials of Tuberculin (TB) serum, one with an opened dated of 11/07/24 that was half full and one that was undated that was half full. LPN 3 indicated the TB serum should be dated when opened. It should be discarded after 30 days. The one dated 11/07/24 should have been disposed of. LPN 3 disposed of the outdated serum vial immediately. There were no delivery dates on the serum bottles. During an interview and observation on 02/10/25 at 10:41 A.M., the Director of Nursing (DON) indicated the nurses on the floor administered the TB tests to the new admission residents. They had several new admissions in the last 30 days. This refrigerator was the only refrigerator where they kept the TB serum. The TB serum package insert was provided by the DON on 02/10/25 at 10:49 A.M. The record indicated, .A vial of TUBERSOL (TB serum) which has been entered and in use for 30 days should be discarded .Do not use after expiration date . The current MEDICATION STORAGE IN THE FACILITY policy, dated February 2017, was provided by the DON on 02/10/25 at 1:08 P.M. The policy indicated, .Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations . 3.1-25(j) 3.1-25(k)(1) 3.1-25(k)(2) 3.1-25(k)(3) 3.1-25(k)(5) 3.1-25(k)(6) 3.1-25(o)

Nov 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to update a resident's plan of care related to behaviors for 1 of 5 residents reviewed for care plans. (Resident E) Findings include: A Facility Reported Incident, dated 10/23/24, indicated Resident E reported that him and another resident engaged in sexual touching in the common area. The clinical record for Resident E was reviewed on 11/12/24 at 10:55 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 08/13/24, indicated the resident was cognitively intact. The resident's diagnoses include, but were not limited to, multiple sclerosis and depression. A current care plan, with the start date of 08/06/24 and revised date of 08/22/24, indicated the resident may exhibit inappropriate behavior symptoms related to: sexually oriented, and profane or subjective remarks. The interventions included but were not limited to: dated 08/06/24, encourage resident to verbalize feelings; may refer resident to mental health services including consultations with Psychologist and psychotherapy services; validate resident's feelings and offer support and reassurance; dated 08/12/24, medication per order; dated 08/22/24, staff to monitor resident while in dining room and activities; and staff have been educated to watch for resident's whereabouts while in hall and re-direct him from female resident's rooms. A current care plan, with the start date of 08/06/24 and revised date of 8/22/24, indicated the resident had socially inappropriate behavior. The interventions included, but were not limited to: dated 08/06/24, educate the resident on what was and was not inappropriate; Psych eval as needed; validate the resident's feelings; dated 08/22/24, staff to monitor resident while in dining room and activities; and staff have been educated to watch resident's whereabouts while in hall and re-direct him from female resident's rooms. The care plans lacked any updated interventions related to the resident's behavior since 08/22/24. A progress note, dated 10/23/24 at 7:25 A.M., documented by RN 2 indicated Resident E informed a CNA that he had intimate contact with another resident (Resident F). Resident E was placed on 15-minute monitoring. During an interview on 11/12/24 at 10:10 A.M., Resident E indicated staff had told him to stay away from Resident F, but never told him why. The administrator eventually told him he needed to stay away from Resident F due to her mental disorder. A Quarterly MDS assessment, dated 09/23/24, indicated Resident F's cognition was intact. The resident's diagnoses include, but were not limited to; progressive neurological condition, aphasia (difficult to understand or express language due to damage to the brain's language center), multiple sclerosis, and manic depression. During a confidential interview from 11/11/2024 through 11/12/2024, Staff Member 3 indicated Resident E liked to hang out in the dining room. The resident liked to go into certain residents' rooms and hang out. He was inappropriate with females sometimes. Sometimes he would refuse to take his medications for the sexual behaviors. He normally targets one room. We had a stop sign across Resident F's door. All the workers know to check on them frequently. Resident E knew what he was doing, but Resident F did not understand when Resident E asked her to do certain things that it was inappropriate. During an interview on 11/12/24 at 11:51 A.M., the Social Service Director indicated that after a previous reportable when Resident E engaged in sexual behaviors with another resident, they implemented a stop sign across the female resident's door. Resident E was noncompliant to fellow residents as he was redirected often. He had an order for a medication to decrease his sexual behaviors, but he refused to take it. She was unsure if any interventions were implemented from his most recent behavior due to being on personal leave. The Administrator and DON were covering her position while she was off work. During an interview on 11/12/24 at 1:49 P.M., the DON indicated after the incident was reported to her, they implemented 15-minute checks on Resident E which were discontinued the next day, but no other interventions were put in place after Resident E's most recent behavior. The current, undated, facility policy, titled Baseline Care Plan Assessment/Comprehensive Care Plans, was provided by the Administrator on 11/12/24 at 2:30 P.M. The policy indicated, .The facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues . review of the 24-Hour reports since the prior Morning/CQI meeting are reviewed and discussed .pertinent circumstances regarding the residents. They will then see that the care plans for these residents are revised and updated as necessary . 3.1-37(a)

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to follow the physician's orders for obtaining laboratory services for 1 of 3 resident's reviewed for laboratory testing. (Resident B) Findings include: The clinical record for Resident B was reviewed on 09/30/2024 at 9:23 A.M. An admission MDS (Minimum Data Set) assessment, dated 09/11/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, Gastroesophageal reflux disease (GERD), and End Stage Renal Disease (ESRD). A physician's order, dated 09/11/24, indicated the staff were to obtain a CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), and a BNP (B-type Natriuretic Peptide). During an interview with Resident B, on 09/30/24 at 3:27 P.M., she indicated a QMA (Qualified Medical Assistant) came into get her blood and was unsuccessful. She was told another nurse would come back and try, but nobody ever came back. During an interview with the Administrator, on 09/30/24 at 2:32 P.M., she indicated that she was unable to find a laboratory (lab) report for Resident B for 09/11/24. She believed the order was transcribed wrong and fell off the orders after 24 hours. The facility had no record of it being collected or the results of the tests. During an interview with LPN (Licensed Practical Nurse) 2, on 10/01/24 at 9:37 A.M., she indicated that when a physician ordered blood work on a resident the nursing staff would go and collect it the same day, and they would call the lab to come and pick it up. There was no reason an order should not have been collected. The current undated facility policy titled, Physician Orders - (Following Physician Orders), was provided by the Administrator on 10/01/24 at 9:50 A.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . The current undated facility policy titled, Lab Scheduling/Tracking, was provided by the Administrator on 10/01/24 at 9:50 A.M. The policy indicated, .It is the policy of the facility to ensure that laboratory tests ordered by the physician are systematically scheduled and tracked so that ordered lab work is obtained . This citation related to Complaint IN00443395 3.1-49(a)

Apr 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on interview, observation, and record review, the facility failed to ensure a resident did not sustain a skin injury during therapy for 1 of 2 residents reviewed for skin wounds. (Resident B) Findings include: During an interview on 04/24/24 at 9:37 A.M., Resident B indicated he was in the facility related to issues with his back. He participated in physical therapy. A few weeks ago, he was in therapy and his back was burned while he was using the TENS (Transcutaneous Electrical Nerve Stimulation) machine (a device that used low-voltage electrical current to help with pain). The therapist wasn't sure what happened and said the machine malfunctioned. They took the patch off his back, and it had burned the first layer of his skin. The Wound NP (Nurse Practitioner) came in every week to assess and treat the wound. The burn was pretty painful. The wound treatment used to be daily, but now they only have to change it every three days. During an interview on 04/24/24 at 9:50 A.M., the DON (Director of Nursing) indicated the therapist was following the directions on the TENS unit. The resident was hooked up to the device and was doing some arm exercises. She thought the pad moved on the resident's skin with the resident's movement. During an interview on 04/24/24 at 1:23 P.M., the TDM (Therapy Department Manager) indicated he had used the TENS device five or six other times on the resident with no issues. He was familiar with the equipment; he wasn't sure what happened. There were four sticky pads that attached to the resident's skin in a criss cross fashion, with a lead wire attached to each pad. When using the machine, he would set the stimulation to an appropriate level and ask the resident to let him know when he felt the stimulation. He would adjust the level to as appropriate, so that it was high, but still comfortable. The machine ran for 15 minute cycles. The cycle was almost complete when the machine indicated check pads or something to that effect. Since the cycle was almost over, he just turned it off and went to remove the pad. When he saw the pad, it was not flat, but folded over on the resident's skin. The skin was burned where the pad was folded. The resident did not indicate he felt anything. The TDM indicated he had attached the sticky pads to the resident's back like he had done several times before. He did not think there was an issue with the machine, someone came out and inspected it once a year or so. He thought the device was fine, the pad was not on the resident properly. He put it on correctly, but it didn't stay that way. The most recent invoice for the annual safety inspection of the TENS device was provided by the DON on 04/25/24 at 9:00 A.M. The invoice indicated the device was inspected on 11/14/22 and passed inspection with no concerns. During an interview on 04/25/24 at 10:05 A.M., a representative from the device inspection company indicated when they inspected this type of device, they would check the voltage and the current, making sure levels were not too high or too low. They would make sure the leads weren't frayed. The device should be inspected annually. The facility lacked documentation the TENS device had been inspected since 11/14/22. The clinical record for Resident B was reviewed on 4/25/24 at 11:01 A.M. An admission MDS (Minimum Data Set) assessment, dated 03/20/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, arthritis, spinal stenosis, and intervertebral disc displacement. A Nursing Progress Note, dated 03/27/24 at 1:00 P.M., indicated the resident needed to be assessed. The resident was noted to have a burn on his lower back on the right side. A Skin and Wound note, dated 04/24/24 at 12:40 P.M., indicated the wound was a second degree burn on the resident's lower back that was improving. The resident reported he was wearing a TENS unit in therapy and was burned. The wound measured 3.5 cm (centimeters) x 2 cm x 0.1 cm. 75-99% of the tissue was granulation tissue (pink-red moist tissue that fills an open wound, when it starts to heal) and 25-49% of the tissue was slough (non-viable tissue that was usually moist). The wound was derided, and the wound treatment orders were changed. The resident's wound was observed with the DON on 04/25/24 at 11:09 A.M. The resident's call light was on. Upon entering the resident's room, he indicated the dressing had come off his wound. The soiled dressing was sitting on the over the bed table. A small amount of dried, bloody drainage was observed on the dressing. The resident's right lower back was observed. The wound was oval shaped, approximately 3 cm x 2 cm. The wound bed was dark pink granulation tissue. There were no signs infection. The resident indicated the wound hurt and requested pain medication. During an interview on 04/25/24 at 1:10 P.M., the TDM indicated you stay right there with a resident when using the TENS device. He didn't visually monitor the resident's skin the whole time when using the device, but he would probably look at residents' skin more often now. The current, undated facility policy, titled Low Voltage Electrical Stimulation (E-Stim) was provided by the DON on 04/25/24 at 11:40 A.M. The policy indicated, .treatments will be administered by designated personnel under the supervision and direction of a licensed therapist according to the manner directed in the therapy evaluation/plan of care .The resident is to be positioned on a treatment table/mat or chair and draped appropriately for treatment . 3.1-37(a)

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure resident medication administration records accurately reflected the administration of narcotic pain medication for 4 of 6 residents reviewed for medication administration. (Residents B, D, G, and H). Findings include: 1. The clinical record for Resident B was reviewed on 4/25/24 at 11:01 A.M. An admission MDS (Minimum Data Set) assessment, dated 03/20/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, arthritis, spinal stenosis, and intervertebral disc displacement. The resident's physician's orders included, but were not limited to, an open ended order, with a start date of 03/11/24, for Hydrocodone-Acetaminophen (narcotic pain medication) 5-325 mg (milligrams) every eight hours as needed for pain. The Controlled Drug Receipt/Record/Disposition Form for the Hydrocodone-Acetaminophen 5-325 mg medication indicated the medication was signed out as given on the following dates and times: - 03/16/24 at 6:00 A.M., - 03/16/24 at 2:00 P.M., - 03/17/24 at 6:00 A.M., and - 03/17/24 at 2:00 P.M. The March 2024 EMAR (Electronic Medication Administration Record) lacked documentation of the medication was administered on the above dates and times. 2. The clinical record for Resident D was reviewed on 4/25/24 at 11:20 A.M. An admission MDS assessment, dated 02/23/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure and polyneuropathy. The resident's physician's orders included, but were not limited to, an open ended order, with a start date of 02/15/24, for Hydrocodone-Acetaminophen 7.5-325 mg every six hours as needed for pain. The Controlled Drug Receipt/Record/Disposition Form for the Hydrocodone-Acetaminophen 7.5-325 mg medication indicated the medication was signed out as given on the following dates and times: - 02/18/24 at 1:30 P.M., - 03/05/24 at 6:00 A.M., 12:00 P.M., and 4:30 P.M., - 03/08/24 at 11:00 P.M., - 03/11/24 at 6:00 A.M., 1:00 P.M., and 5:00 P.M., - 03/14/24 at 10:00 P.M., - 03/16/24 at 6:00 A.M., and - 03/17/24 at 8:00 A.M. The March 2024 EMAR lacked documentation of the medication was administered on the above dates and times. 3. The clinical record for Resident G was reviewed on 4/25/24 at 11:26 A.M. A Quarterly MDS assessment, dated 01/12/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes and kidney disease. The resident's physician's orders included, but were not limited to, an open ended order, with a start date of 02/26/24, for Tramadol (a narcotic pain medication), 50 mg every six hours as needed for pain. The Controlled Drug Receipt/Record/Disposition Form for the Tramadol 50 mg medication indicated the medication was signed out as given on the following dates and times: - 04/04/24 at 2:00 A.M., - 04/05/24 at 1:10 A.M., and - 04/12/24 at 9:00 A.M. The April 2024 EMAR lacked documentation of the medication was administered on the above dates and times. 4. The clinical record for Resident H was reviewed on 4/25/24 at 10:26 A.M. An admission MDS assessment, dated 03/02/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, hip fracture, and seizure disorder. The resident's physician's orders included, but were not limited to, an open ended order, with a start date of 02/26/24, for Oxycodone (a narcotic pain medication) 10 mg every six hours as needed for pain. The Controlled Drug Receipt/Record/Disposition Form for the Oxycodone 10 mg medication indicated the medication was signed out as given on the following dates and times: - 02/15/24 at 6:00 P.M., - 02/16/24 at 12:00 A.M., 6:00 A.M., and 6:40 P.M., - 02/17/24 at 6:00 A.M., - 02/22/24 at 9:30 P.M., - 02/23/24 at 4:00 A.M., - 02/24/24 at 6:00 P.M., - 02/25/24 at 5:00 A.M., - 02/27/24 at 8:00 P.M., and - 03/02/24 at 8:00 P.M. The February and March 2024 EMARs lacked documentation of the medication was administered on the above dates and times. During an interview on 04/26/24 at 1:42 P.M., RN 2 indicated when a nurse administered a controlled medication it would be documented in the computer EMAR and on the paper controlled medication count sheets in the binder on the medication carts. The current facility policy, titled MEDICATION ADMINISTRATION, dated February 2017, was provided by the Director of Nursing on 04/26/24 at 10:28 A.M. The policy indicated, .administer all medications safely and appropriately .return to medication cart and document medication administration with initials in appropriate spaces on Medication Administration Record (MAR) . 3.1-50(a)(1) 3.1-50(a)(2) This citation relates to Complaint IN00431926.

Dec 2023 11 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to notify the appropriate physician of laboratory results for 1 of 20 residents reviewed for notification of change. (Resident 24) Findings include: During an observation and interview on 12/06/23 at 1:40 P.M., Resident 24 indicated she currently had a bad UTI. She was on IV (Intravenous) antibiotics. The IV antibiotic was running at the time. The clinical record for Resident 24 was reviewed on 12/12/23 at 9:38 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 11/11/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure, hypertension, neurogenic bladder, seizure disorder, and depression. An Infectious Disease Physician's Progress Note, dated 08/01/23 at 6:21 P.M., indicated the resident had cloudy urine and was not on antibiotics. A recommendation was made for staff were to obtain urine for a U/A (Urinalysis) C&S (Culture and Sensitivity) and to please email or call with the results. A UA result, dated 08/03/23, indicated the resident had positive nitrate, 2+ leukocytes, rare bacteria, and increase white blood cell, which were all noted as abnormal. A Culture result final report, verified 08/06/23, indicated the residents urine contained the following bacteria: - Proteus Mirabilis, - Escherichia Coli ESBL (E.Coli), and - Providencia Stuartii. There was no indication in the clinical record that the Infectious Disease NP (Nurse Practitioner) had been provided with the results of the UA C&S. An Infectious Disease Physician's Progress Note, dated 08/10/23 at 9:50 P.M., indicated the resident had cloudy urine and was not receiving any antibiotics. A recommendation was made for staff to obtain urine and for U/A C&S and to please email or call with results. A UA result, dated 08/12/23, indicated the resident had positive nitrate, 1+ leukocytes, rare bacteria, and increase white blood cell, which were all noted as abnormal. A Culture result final report, with a verified date of 08/14/23, indicated the residents urine contained the following bacteria: - Proteus Mirabilis, and - Escherichia Coli ESBL (E.Coli). There was no indication in the clinical record that the Infectious Disease NP had been provided with the results of the UA C&S. During an interview on 12/13/23 at 9:43 A.M., LPN (Licensed Practical Nurse) indicated if the Infectious Disease NP would order a U/A C&S then she would notify both the facility NP and the Infectious Disease NP with the results. The Infectious Disease NP's number was hanging at the nurses station. During an interview on 08/13/23 at 5:00 P.M., the Infectious Disease NP indicated it was really hard to getv the laboratory results from the facility she usually had to hunt them down herself. They don't send any of them to her. She had asked for access to the lab system so she could just log in and see them herself. The facility said they would scan them into the resident electronic record, but they were usually not in the system. She always emails the DON (Director of Nursing) or ADON (Assistant Director of Nursing) with her recommendations, but they sometimes don't get done. She had tried entering the orders in herself, but because they used an outside lab the order doesn't go to them. She would be fine with the facility NP getting the results as long as they treat the UTI (Urinary Tract Infection), a lot of times they don't use the correct antibiotic for the UTI. If she had asked for a UA C&S on 08/01/23 and then again on 08/10/23 then she would not have received the results from the 08/01/23 UA. The current facility policy titled, Change in Resident's Condition or Status, was provided by the DON on 12/14/23 at 10:21 A.M. The policy indicated, .It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status . 3.1-5(a)(3)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to follow infection control guidelines and follow physician orders for 2 of 8 residents reviewed for pressure ulcers. (Residents 14 and 18) Findings include: 1. During an observation on 12/06/23 at 12:24 P.M., LPN (Licensed Practical Nurse) 5 retrieved Resident 14's treatment supplies from a treatment cart and stopped outside the resident's room. She placed the supplies on top of cart outside the room. She donned a gown, gloves, and a face mask. She picked up the supplies and went into the resident's room. She placed a paper towel on an over bed table and placed the supplies on top. She removed the resident's sheet, and the resident lifted his right stump. She removed an undated dressing and placed it in a garbage can. The dressing had heavy drainage. She removed a gauze from a package, sprayed it would wound cleanser, and cleansed the wound. She removed a collagen sheet and placed it over the wound with both hands, covered the wound with an abdominal pad. She misplaced her tape and found some on a bedside table that was stuck to a Dorito bag. She grabbed the tape with her gloved hands and removed the part that was stuck to the bag and removed some more tape and taped the wound dressing. She then proceeded to change a dressing to the left buttock/thigh using the same gloves. She did not wash her hands prior to the treatment and her gloves were not changed until both wound treatments were complete. A Quarterly MDS (Minimal Data Set) assessment, dated 10/31/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension, diabetes, depression, and bilateral amputee. The resident had pressure ulcers. A Skin and Wound Note, dated 12/07/23, indicated the resident's right thigh wound had seropurulent drainage and continued to worsen. After consulting with the primary care physician, a wound culture was planned. A Wound Culture Result, with a verified date of 12/12/23, indicated the resident had the following bacteria in the wound: - Moderate Proteus Mirabillis, - Few Klebsiella Pneumoniae ESBL, - Few Escherichia coli, - Few Providencia stuartii, and - Few Streptococcus agalactiae. The resident was started on an antibiotic that was susceptible to the bacteria. During an interview on 12/14/23 at 10:06 A.M., LPN 6 indicated when performing a dressing change, she wound gather her materials and go to the resident room. She would put the supplies on a clean surface, wash her hands, and don gloves. She would change her gloves and wash her hands after removing old dressing and before moving onto another dressing if the resident had multiple. She would never touch anything in the resident's room during a dressing change, if she did, she would change her gloves. During an interview on 12/14/23 at 10:38 A.M., LPN 6 indicated the resident had a wound culture in the right leg wound and had started on an antibiotic. The current, undated, facility policy titled, Non-Sterile Dressings was provided by the DON (Director of Nursing) on 12/14/23 at 12:50 P.M. The policy indicated, : .8. Wash hands and don gloves .11. Remove soiled dressing and place in plastic trash bag .12. Remove soiled gloves and place in plastic trash bag .13. Wash hands .14. [NAME] new gloves . 2. The clinical record for Resident 18 was reviewed on 12/11/23 at 10:44 A.M. A Quarterly MDS assessment, dated 11/11/23, indicated the resident was moderately cognitively impaired. The diagnosis included, but was not limited to, hypertension. A Wound Assessment, dated 10/19/23, indicated the resident had a Stage 3 (Full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) pressure ulcer to the coccyx. The wound measured 2.4 cm (centimeters) X (by) 2.9 cm X 0.2 cm. The treatment order was to cleanse the wound with wound cleanser, apply medical grade honey, and cover with a bordered foam, daily and as needed. A Wound Assessment, dated 12/07/23, indicated the resident had a Stage 3 pressure ulcer to the coccyx. The wound measured 0.9 cm X 0.5 cm X 0.1 cm. The treatment remained the same as 10/19/23. The Electronic Treatment Administration Record for October and November 2023 were reviewed and indicated the medical grade honey treatment had not started until 11/11/23. The ETAR lacked documentation that the treatment was completed on 11/19/23, 11/21/23, 11/22/23, and 11/27/23. During an interview on 12/14/23 at 12:07 P.M., the ADON (Assistant Director of Nursing) indicated at the time of the wound re-developed on 10/19/23 they were using a paste to the coccyx. The treatment order should have changed to the medical honey. During an interview on 12/14/23 at 12:17 P.M., the Interim DON (Director of Nursing) indicated if there was a blank in the EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) it would indicate the mediation or treatment was not done. The current, undated, facility policy titled, Physician Orders--(Following Physician Orders) was provided by the Interim DON on 12/13/23 at 2:53 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . The current facility policy, titled Guidelines for Prevention/Treatment if Pressure Injuries and dated 10/09/23, was provided by the Interim DON on 12/14/23 at 12:50 P.M. The policy indicated, .It is the intent of the facility to recognize the following information and to act on it in such a way as to practice evidence-based recommendations for the prevention/treatment of pressure injuries to the residents who reside in the facility . 3.1-40(a)(2)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to treat a UTI (Urinary Tract Infection) appropriately for 1 of 2 residents reviewed for UTI. (Resident 24) Findings include: During an observation and interview on 12/06/23 at 1:40 P.M., Resident 24 indicated she currently had a bad UTI. She was on IV (Intravenous) antibiotics. The IV antibiotic was running at the time. A Quarterly MDS (Minimum Data Set) assessment, dated 11/11/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure, hypertension, neurogenic bladder, seizure disorder, and depression. A UA (Urinalysis) result, dated 09/27/23, indicated the resident's urine was positive for nitrates, had 2+ leukocytes, increased white blood cell count, 3+ bacteria, and increased red blood cells, which were all abnormal. A Physician Progress Note, dated 09/28/23 at 12:19 P.M., indicated the resident was seen due to UA that was positive for a UTI. The resident reported fatigue and malaise over the past couple days. The resident had a history of an indwelling catheter and was noted with strong urine odor. The residents preliminary culture results were positive for proteus mirabilis and would start the resident on IV Cefazolin (an antibiotic). A Culture final report, with a verified date of 09/30/23, indicated the resident had the following bacteria in her urine: - Proteus Mirabilis, - Escherichia Coli (E.coli) ESBL, and - Providencia Stuartii. The culture indicated the antibiotic medication Cefazolin was only susceptible to the proteus mirabilis and not to the E. Coli and Providencia stuartii. The resident was to administer the Cefazolin from 09/27/23 through 10/05/23. The clinical record lacks indication that the physician or NP (Nurse Practitioner) did not want to change the antibiotic, just that they were aware of the culture results. A UA result, dated 10/09/23, indicated the resident's urine was positive for nitrite, 2+ leukocytes, increased white blood cells, 3+ bacteria, and increased red blood cells, which were all abnormal. A Culture final report, with a verified date of 10/12/23, indicated the resident had the following bacteria: - E.coli ESBL, - Pseudomonas aeruginosa and - E. Coli ESBL #2. A Physician Progress Note, dated 10/12/23 at 5:40 P.M., indicated the resident was being seen for re-evaluation following a recent diagnosis of UTI, follow-up UA was consistent with persistent UTI. The plan was to restart the IV antibiotics. The resident was administered Cefazolin from 10/12/23 through 10/18/23. The Culture final result, with a verified date of 10/12/23, indicated the bacteria were resistant to Cefazolin. A Progress Note, dated 10/19/23 at 1:40 P.M., indicated the resident's PICC line to the left upper arm was removed per the MD orders. A UA result, dated 10/22/23, indicated the resident was positive for nitrite, 2+ leukocytes, increased white blood cells, and 2+ bacteria which were all abnormal. A Culture result, with a verified date of 10/24/23, indicated the resident had the following bacteria in her urine: - E. Coli ESBL and - Proteus Mirabilis. There was no indication in the clinical record that the physician or NP had been notified of the UA C&S (Culture and Sensitivity) result. An Infectious Disease Physician Progress Note, dated 11/15/23, indicated the resident was being seen with complaints of pain around the indwelling catheter and the urine in the indwelling catheter was dark yellow and there was a moderate amount of white sediment lining the catheter tubing. She was recently treated with an antibiotic. A recommendation was made for a UA C&S. A UA result, dated 11/16/23, indicated the resident's urine was positive for nitrites, 2+ leukocytes, amorphous, increased white blood cell count, and 1+ bacteria, which were all abnormal. A Culture final result with a verified date of 11/18/23, indicated the resident's urine contained the following bacteria: - Proteus Mirabilis, - Providencia Stuartii, and - E.coli ESBL. A Progress Note, dated 11/19/23 at 10:21 P.M., indicated the UA results were sent to the MD. A Physician Progress Note, dated 11/21/23 at 9:09 A.M., indicated the resident was seen for an indwelling catheter with complaints of urinary leakage around the catheter and dysuria. The plan was to start Imipenem (an antibiotic) for 14 days. The antibiotic was susceptible to the bacteria. During an interview on 12/13/23 at 9:43 A.M., LPN (Licensed Practical Nurse) 4 indicated when a resident had an order for a UA C&S, she would obtain the urine and get it to the lab as soon as possible. When the results came, she would call them to the MD and make sure they got them and see if they wanted to start them on an antibiotic. If the resident had already been started on an antibiotic, then she would make sure they were aware and the results of the culture in case the medication needed to be changed. If the infectious disease NP ordered the UA, then she would call her and the facility NP with the results. She would document everything in the progress notes. During an interview on 12/13/23 at 11:42 A.M., NP 5 indicated if she would have seen the residents culture results then she would have changed the antibiotics to the appropriate one. During an interview on 12/13/23 at 11:57 A.M., the Interim DON indicated when UA C&S results were received, they would be sent to the MD/NP or the Infectious Disease NP if they were the ones that ordered the UA. The facility tracked infections and the Infection Preventions would determine if the antibiotic was appropriate. If the antibiotic was not appropriate, then the MD would be notified, and a progress note would be made if the medication was going to be changed or not. The current facility policy, titled Antibiotic Stewardship with a revised date of 03/14/23, was provided by the Interim DON on 12/13/23 at 1:16 P.M. The policy indicated, .The facility focuses on improving antibiotic use through Antibiotic (Antimicrobial) Stewardship Program (ASP) to ensure appropriate antibiotic usage practices are in place, to promote optimal therapeutic and cost-effective care for our residents, and ultimately, reduce the likelihood of developing multi-drug resistant organisms . 3.1-41(a)(2)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to follow a physician's order related to daily weights for 1 of 3 residents reviewed for nutrition. (Resident 48) Findings included: A Quarterly MDS (Minimum Data Set) assessment, indicated Resident 48 was cognitively intact. The diagnoses included, but were not limited to, anemia, heart failure, hypertension, and depression. An open-ended physician order, with a start date of 10/11/23, indicated the resident was to be weighed daily and to notify the MD or NP (Nurse Practitioner) of weight gain of greater than 5 pounds in 3 days. A Physician Note, dated 10/12/23 at 3:56 P.M., indicated the resident was seen. The plan was to continue daily weights and notify provider if greater than 3 pounds in 24 hours or 5 pounds in 1 week. The clinical record lacked that the order was changed to reflect the MD notification of weight gain greater than 3 pounds in 24 hours of 5 pounds in 1 week. The resident had the following weight gains or no weight was provided with no indication that the physician was notified: - On 10/14/23 the weight was 204.4 and 10/15/23 the weight was 210.4, a 6 pound weight gain - On 10/21/23 no weight was recorded, - On 10/29/23 the weight was 197.6 and 10/30/23 the weight was 212, a 14.4 pound weight gain, - On 11/04/23 the weight was 197.8 and 11/05/23 the weight was 209, a 11.2 pound weight gain, - On 11/09/23 no weight was recorded, - On 11/11/23 no weight was recorded, - On 11/22/23 no weight was recorded, - On 11/25/23 the weight was 204 and 11/26/23 the weight was 208.4, a 4.4 pound weight gain, and - On 11/29/23 no weight was recorded. During an interview on 12/13/23 at 9:43 A.M., LPN (Licensed Practical Nurse) 4 indicated if the was a daily weight and had a weight gain then she would call the MD and document in a progress note. During an interview on 12/14/23 at 12:04 P.M., LPN 6 indicated when the NP/MD came into see a resident they would give the nurse verbal orders or input their own orders. The nurse working the floor is who would transcribe the order. The current facility policy titled, Guidelines for Obtaining Residents' Weights dated 07/24/23, was provided by the Clinical Support Nurse on 12/14/23 at 2:55 P.M. The policy indicated, .Accuracy with weight measurements is essential for residents in the long-term care setting. Weight measurement is used to calculate energy, protein, and fluid needs. Further, weight is an indicator of nutritional and health status and changes in weight can often indicate other medical changes. Inaccurate weight measurements can result in an increased number of [unplanned] weight changes in the facility-and can affect the plans of care for the residents . 3.1-46(a)(1)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to coordinate care related to the physician's dialysis form to decrease a resident's medication for 1 of 2 residents reviewed for dialysis. (Resident 42) Findings include: A Quarterly MDS (Minimum Data Set) assessment, dated 11/10/23, indicated Resident 42's cognition was moderately impaired. The resident's diagnoses included, but were not limited to, renal insufficiency and diabetes. The resident received dialysis treatments while a resident. The Dialysis Communication binder was reviewed on 12/12/23 at 9:09 A.M. A Physicians Order Sheet with a note, dated 11/22/23, indicating the resident's Nifedipine medication was to be decreased from 90 mg (milligrams) to 60 mg daily per the Dialysis NP (Nurse Practitioner) 2. The EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) for November and December 2023, was provided by the Interim DON (Director of Nursing) on 12/12/23 at 12:09 P.M. The record indicated the resident had a current order, with a start date of 10/12/23, for Nifedipine 90 mg by mouth at bedtime. During an observation of the Physician's Order Sheet, on 12/12/23 at 11:47 A.M., LPN 3 indicated the orders were reviewed by the nurse on the floor upon the resident's return from dialysis. The nurse on the floor should have received the paperwork and put the new orders in the computer. The undated Community Hemodialysis Policy and Procedure was provided by the Interim DON on 12/12/23 at 12:09 P.M. The policy indicated, .Purpose .To ensure coordination of care for residents requiring hemodialysis in the community .All residents that are admitted to the facility with needs for hemodialysis will have coordination of services between the facility and the hemodialysis unit .A dialysis communication sheet will return with the resident after the dialysis session to communicate to the facility information regarding the dialysis session . The current Guidelines For Physician Orders policy and procedure, dated 06/18/23, was provided by the Interim DON on 12/12/23 at 12:09 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician .All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received . 3.1-37(a)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to follow physician orders related to medication hold parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 24) Findings include: The clinical record for Resident 24 was reviewed on 12/12/23 at 9:38 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 11/11/23, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, neurogenic bladder, seizure disorder, and depression. An open-ended physician's order, with a start date of 04/05/23, indicated the staff were to administer Metoprolol Tartrate (a blood pressure medication) 12.5 mg (milligrams), twice a day, for hypertension. The medication was to be held if the resident's systolic blood pressure (top number) was less than 110. The medication was not held the following dated and times when the resident's systolic blood pressure was less than 110: - 09/16/23 at 8:00 A.M., when the resident's blood pressure was 103/60, - 09/17/23 at 8:00 P.M., when the resident's blood pressure was 104/62, - 09/29/23 at 8:00 A.M., when the resident's blood pressure was 107/64, - 10/22/23 at 8:00 A.M., when the resident's blood pressure was 105/62, - 11/08/23 at 8:00 P.M., when the resident's blood pressure was 107/74, - 12/07/23 at 8:00 A.M., when the resident's blood pressure was 103/63, and - 12/09/23 at 8:00 A.M., when the resident's blood pressure was 93/61. An open-ended physician's order, with a start date of 07/07/23, indicated the staff were to administer Midodrine, 5 mg, three times a day, for low blood pressure. The medication was to be held if the resident's systolic blood pressure was greater than 130. The medication was not held on the following dates and times: - 09/19/23 at 11:00 A.M., when the resident's blood pressure was 160/80, - 09/22/23 at 4:00 P.M., when the resident's blood pressure was 139/82, - 09/25/23 at 11:00 A.M., when the resident's blood pressure was 135/82, - 09/27/23 at 11:00 A.M., when the resident's blood pressure was 137/75, - 09/30/23 at 4:00 P.M., when the resident's blood pressure was 146/85, - 10/01/23 at 11:00 A.M., when the resident's blood pressure was 155/84, - 10/14/23 at 7:00 A.M., when the resident's blood pressure was 140/80, - 10/28/23 at 7:00 A.M., when the resident's blood pressure was 143/86, - 10/29/23 at 11:00 A.M., when the resident's blood pressure was 134/66, - 11/01/23 at 7:00 A.M., when the resident's blood pressure was 142/76, - 11/05/23 at 11:00 A.M., when the resident's blood pressure was 139/78, - 11/06/23 at 11:00 A.M., when the resident's blood pressure was 133/72, and 4:00 P.M., when the blood pressure was 138/78, - 11/10/23 at 7:00 A.M., when the resident's blood pressure was 152/87, and 11:00 A.M., when the blood pressure was 136/80, - 11/11/23 at 7:00 A.M., when the resident's blood pressure was 149/72, 11:00 A.M., when the blood pressure was 137/84, and 4:00 P.M., when the resident's blood pressure was 136/70, and - 11/17/23 at 7:00 A.M., when the resident's blood pressure was 134/77. During an interview on 12/13/23 at 9:43 A.M., LPN (Licensed Practical Nurse) 4 indicated if a medication had hold parameters then the medication would be held based on the parameters. She would mark on the EMAR (Electronic Medication Administration Record) that the medication was not administered and input a progress note. The current, undated, facility policy titled, Physician Orders--(Following Physician Orders) was provided by the Interim DON (Director of Nursing) on 12/13/23 at 2:53 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . 3.1-48(a)(3)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure a resident received the prescribed significant medications upon admission for 1 of 20 residents reviewed. (Resident 53) Findings include: An admission MDS (Minimum Data Set) assessment, dated 09/14/23, indicated the Resident 53 was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, hypertension, septicemia, anxiety, and respiratory failure. A Progress Note, dated 09/08/23 at 4:27 P.M., indicated the resident arrived to the facility via EMT (Emergency Medical Technician). A Progress Note, dated 09/21/23 at 2:28 P.M., indicated the nurse found four prescriptions from the admitting hospital infectious disease doctor that were written on 09/06/23 for antibiotics and labs. The resident had not received them. She would follow up with the MD tomorrow. The hospital discharge scripts, dated 09/06/23 indicated the resident was to receive the following: - IV (Intravenous) Penicillin (an antibiotic) 3 million units, six times daily, until 09/15/23 for possible neurosyphilis, - IV Ertapenem 1 gram daily until 09/12/23, for Enterobacter Bacteremia, - PICC Care and please remove PICC at the completion of IV antibiotics, - [NAME] Blood Cell, Platelet Count, BUN/Creatin, hepatic function panel, weekly while on antibiotics. During an interview on 12/13/23 at 9:43 A.M., LPN (Licensed Practical Nurse) 4 indicated when a resident admitted to the facility from the hospital all their medication orders were to transcribe to the electronic health record. The nurse was to go through the hospital paperwork. If there were any written prescriptions, they would be entered and faxed to the pharmacy. During an interview on 12/13/23 at 1:49 P.M., the Interim DON (Director of Nursing) indicated when a resident admitted from the hospital the nurse would process all the orders as indicated. The nurse would review the paperwork. If the resident came with written prescriptions, then they would be faxed to the pharmacy. Medication orders should be put in as soon as possible or within 24 hours. The current, undated, facility policy titled, Medication Administration Errors, was provided by the Interim DON on 12/14/23 at 10:21 P.M. The policy indicated, .A medication error is any preventable event that may cause or lead to inappropriate medication use . The current, undated, facility policy titled, admission Orders was provided by the Interim DON on 12/13/23 at 2:53 P.M. The policy indicated, .Upon admission/readmission, orders for care of the resident are received from the physician, placed on physician's order sheet and filed in the health record . The current, undated, facility policy titled, Physician Orders--(Following Physician Orders) was provided by the Interim DON on 12/13/23 at 2:53 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . 3.1-48(c)(2)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

QAPI Program (Tag F0867)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to demonstrate that ongoing corrective actions were in place to address unresolved quality deficiencies related to pressure ulcers, that were previously cited on the last annual survey, for 1 of 13 care areas reviewed. (Pressure Ulcers) Findings include: During the Annual Recertification and complaint survey, from 12/06/23 to 12/14/23, one deficiency was a repeated citation from the last annual survey, F686. The facility's Quality Assurance Committee did not implement on-going appropriate measures to correct identified issues or prevent deficiencies as follows: 1. Pressure Ulcers: 2 residents did not received appropriate infection control measures and physician orders followed. During an interview on 12/14/23 at 12:33 P.M., the Administrator indicated the QAPI involved their entire IDT (Interdisplinary Team). They invite Certified Nurse Aides and Nurses because the want the entire building involved to help things flow. They meet monthly. They usually always review wounds, infections, medications, discharges, turnover, admissions, marketing, resident council, dietary, medical record reviews, and billing. They try to go over everything. All departments focus on something in their department. If there was an area of concern then they decide if they need to make an action plan for it. They are supposed to bring audits to QAPI and the IDT reviews them to see if things need to change. They had a QAPI for pressure ulcers from May through August 2023. She was able to find some audit forms from May and June but it obviously didn't work if there was still a problem if it was being cited again. The current Quality Assurance/Performance Improvement Program (QAPI) was provided by the Administrator on 12/08/23 at 12:34 P.M. The policy indicated, .To provide a process that will enhance the care and experience for all residents, improve the work environment for stakeholders, and quality of all services provided by the facility . Cross reference F686 3.1-52(b)(2)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to appropriately track and monitor a resident's urinary track infections for 1 of 2 residents reviewed for UTI's. (Resident 24) Findings include: 1. A Quarterly MDS (Minimum Data Set) assessment, dated 11/11/23, indicated Resident 24 was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, neurogenic bladder, seizure disorder, and depression. A UA (Urinalysis) result, dated 09/27/23, indicated the resident's urine was positive for nitrates, had 2+ leukocytes, increased white blood cell count, 3+ bacteria, and increased red blood cells, which were all abnormal. A Physician's Progress Note, dated 09/28/23 at 12:19 P.M., indicated the resident was seen due to UA that was positive for a UTI. The resident reported fatigue and malaise over the past couple days. The resident had a history of indwelling catheter and had a strong urine odor. The residents preliminary culture results were positive for proteus mirabilis and they would start the resident on IV Cefazolin (an antibiotic). A Culture final report, with a verified date of 09/30/23, indicated the resident had the following bacteria in her urine: - Proteus Mirabilis, - Escherichia Coli (E.coli) ESBL, and - Providencia Stuartii. The culture indicated the antibiotic medication Cefazolin was only susceptible to the proteus mirabilis and not to the E. Coli and Providencia stuartii. The resident was administered Cefazolin from 09/27/23 through 10/05/23. The clinical record lacked indication that the physician or NP (Nurse Practitioner) did not want to change the antibiotic just that they were aware of the culture results. A UA result, dated 10/09/23, indicated the resident's urine was positive for nitrite, 2+ leukocytes, increased white blood cells, 3+ bacteria, and increased red blood cells, which were all abnormal. A Culture final report, with a verified date of 10/12/23, indicated the resident had the following bacteria: - E.coli ESBL, - Pseudomonas aeruginosa and - E. Coli ESBL #2. A Physician's Progress Note, dated 10/12/23 at 5:40 P.M., indicated the resident was being seen for re-evaluation following a recent diagnosis of UTI, follow-up UA was consistent with persistent UTI. The plan was to restart the IV antibiotics. The resident was administered Cefazolin from 10/12/23 through 10/18/23. The Culture final result, with a verified date of 10/12/23, indicated the bacteria were resistant to Cefazolin. During an interview on 12/13/23 at 11:42 A.M., NP 5 indicated if she would have seen the resident's culture results then she would have changed the antibiotics to the appropriate one. During an interview on 12/13/23 at 11:57 A.M., the Interim DON (Director of Nursing) indicated when UA C&S results were received, they would be sent to the MD/NP or the Infectious Disease NP if they were the ones that ordered the UA. The facility tracked infections and the Infection Preventions would determine if the antibiotic was appropriate. If the antibiotic was not appropriate, then the MD would be notified, and a progress note would be made if the medication was going to be changed or not. All infections would be tracked in the infection control log. Resident 24's EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated she had received the following antibiotics: - Cefazolin from 09/28/23 through 10/05/23 and - Imipenem from 11/24/23 through 12/07/23. The Infection Control Tracking and Trending was provided by the Interim DON on 12/13/23 at 3:30 P.M. The October and November 2023 Tracking logs indicated the resident was on antibiotics for the above infections. The current facility policy, titled Antibiotic Stewardship with a revised date of 03/14/23, was provided by the Interim DON on 12/13/23 at 1:16 P.M. The policy indicated, .The facility focuses on improving antibiotic use through Antibiotic (Antimicrobial) Stewardship Program (ASP) to ensure appropriate antibiotic usage practices are in place, to promote optimal therapeutic and cost-effective care for our residents, and ultimately, reduce the likelihood of developing multi-drug resistant organisms .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide COVID-19 booster immunizations in a timely manner for 2 of 6 residents reviewed for immunizations. (Residents 10 and 53) Findings include: 1. The clinical record for Resident 10 was reviewed on [DATE] at 10:14 A.M. The resident was admitted on [DATE]. A Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes and chronic obstructive pulmonary disease. The Informed Consent - Vaccination - COVID-19 record, signed by the resident and the resident's representative on [DATE], indicated the resident had received a copy of the most current COVID-19 Fact Sheet as published by the CDC (Centers for Disease Control), the resident understood the benefits and risks associated with the vaccine and consented to receive the vaccination as determined by current CDC guidelines. The resident had received the following COVID-19 immunizations: - dated [DATE], - dated [DATE], - dated [DATE], and - dated [DATE], prior to admission. The clinical record lacked documentation the resident had received a COVID-19 booster vaccine since [DATE] or following admission on [DATE]. The Infection Control Log was provided by the Interim DON (Director of Nursing) on [DATE] at 8:35 A.M. The record indicated the resident tested positive for COVID-19 on [DATE]. The Progress Notes, from [DATE] to present, lacked documentation the resident had been offered a COVID-19 booster vaccine. The current, completed, and discontinued physician's orders, from [DATE] to present, lacked orders for a COVID-19 booster vaccine. 2. The clinical record for Resident 53 was reviewed on [DATE] at 10:25 A.M. The resident was admitted on [DATE]. An admission MDS assessment, dated [DATE], indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to heart failure, anxiety, and respiratory failure. The Informed Consent - Vaccination - COVID-19 record, signed by the resident on [DATE], indicated the resident had received a copy of the most current COVID-19 Fact Sheet as published by the CDC, the resident understood the benefits and risks associated with the vaccine and consented to receive the vaccination as determined by current CDC guidelines. The resident had received the following COVID-19 immunizations: - dated [DATE], - dated [DATE], and - dated [DATE], prior to admission. The clinical record lacked documentation the resident had received a COVID-19 booster vaccine since [DATE] or following admission on [DATE]. The Infection Control Log was provided by the Interim DON on [DATE] at 8:35 A.M. The record indicated the resident tested positive for COVID-19 on [DATE]. The Progress Notes, from [DATE] to present, lacked documentation the resident had been offered a COVID-19 booster vaccine. The current, completed, and discontinued physician's orders, from [DATE] to present, lacked orders for a COVID-19 booster vaccine. During an interview on [DATE] at 11:58 A.M., the Interim DON indicated they had called the Regional Nurse Consultant, and they did not know when the last COVID-19 vaccine clinic was conducted in the building. During an interview on [DATE] at 3:16 P.M., the Administrator indicated they were working on scheduling a clinic for the new booster. A CDC (Centers for Disease Control) press release, dated [DATE], indicated, . Updated COVID-19 vaccines from Pfizer-BioNTech and Moderna will be available later this week. Vaccination remains the best protection against COVID-19-related hospitalization and death. Vaccination also reduces your chance of suffering the effects of Long COVID, which can develop during or following acute infection and last for an extended duration. If you have not received a COVID-19 vaccine in the past 2 months, get an updated COVID-19 vaccine to protect yourself this fall and winter . The current Moderna COVID-19 Vaccine - Standing orders for Administering Vaccine policy dated [DATE], was provided by the Interim DON on [DATE] at 2:44 P.M. The policy indicated, .Purpose .To reduce morbidity and mortality from coronavirus disease 2019 (COVID-19) by vaccinating persons who meet the criteria established by the Centers for Disease Control and Prevention's Advisory Committee on immunization Practices (ACP) . The current GUIDELINES FOR POST COVID-19 PHE (Public Health Emergency) Which Ended [DATE] .as related to Nursing Homes policy, with an effective date of [DATE], was provided by the Interim DON on [DATE] at 1:41 P.M. The policy indicated, .testing requirements expired with the PHE on [DATE]. However, the nursing home will be mindful of accepted standard of practice related to Covid-19 according to CDC and this will be maintained .This nursing home will continue to educate and offer the Covid-19 vaccine to residents beyond the end of the PHE as part of the Requirements of Participation, through [DATE] . 3.1-18(b)(1)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to provide the required RN coverage on duty for eight hours a day for 5 of the 16 days reviewed. Findings include: The as worked nursing schedule indicated there had not been an RN on duty for eight consecutive hours on the following dates: - Saturday 11/04/23, - Sunday 11/05/23, - Saturday 11/25/23, - Saturday 12/09/23, and - Sunday 12/10/23. During an interview on 12/14/23 at 2:51 P.M., the Administrator indicated the facility did not have an RN on duty for eight consecutive hours for the days reviewed and they did not have any nurse waivers. The facility did not have a policy for RN coverage, they followed State and Federal regulations. 3.1-17(b)(3)

Nov 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to complete wound treatments as ordered by the physician for 1 of 5 residents reviewed for quality of care. (Residents D) Findings include: 1. The clinical record for Resident D was reviewed on 11/13/23 at 11:00 A.M. An admission MDS (Minimum Data Set) assessment, dated 08/31/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hip and knee replacement, hypertension, renal insufficiency, diabetes, anxiety, and depression. a. A physician's order, dated 09/01/23 through 09/27/23, indicated the staff were to cleanse the resident's right third toe with wound cleanser, apply bacitracin (an antibiotic ointment), and cover with a Band-Aid every day shift. The September 2023 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident's right third toe treatment was not completed on 09/15/23, 09/16/23, 09/24/23, 09/26/23, and 09/27/23. b. A physician's order, dated 09/08/23 through 10/02/23, indicated the staff were to cleanse the left lower abdomen with wound cleanser, apply bacitracin, and cover with a bordered gauze dressing every day shift. The September 2023 EMAR/ETAR indicated the resident's left lower abdomen treatment was not completed on 09/15/23, 09/16/23, 09/24/23, and 09/26/23, c. A physician's order, dated 08/26/23 through 10/02/23, indicated the staff were to apply a Mepilex (foam absorbent) dressing to the open area on the left shin every three days on day shift. The September 2023 EMAR/ETAR indicated the resident's left shin treatment was not completed on 09/13/23 and 09/16/23. d. A physician's order, dated 08/26/23 through 10/02/23, indicated the staff were to apply a Mepilex dressing to the open area on the top of the right foot every three days on day shift. The September 2023 EMAR/ETAR indicated the resident's top of the right foot treatment was not completed on 09/13/23 and 09/16/23. e. A physician's order, dated 08/28/23 through 10/04/23, indicated the staff were to apply Balsam Peru Castor Oil External Ointment to the bilateral buttocks and gluteal cleft every shift. The September 2023 EMAR/ETAR indicated the resident's bilateral buttocks and gluteal cleft treatments were not completed on night shift 09/14/23, on day shift 09/15/23, on day shift 09/16/23, on night shift 09/20/23, and on day shift 09/24/23, and f. A physician's order, dated 09/05/23 through 10/04/23, indicated the staff were to apply Miconazole Nitrate Powder (antifungal powder) to the gluteal cleft, groin, peri-area, abdominal folds, and under the bilateral breasts twice a day. The September 2023 EMAR/ETAR indicated the resident's gluteal cleft, groin, peri-area, abdominal folds, and under the bilateral breasts treatments were not completed on night shift 09/14/23, on day shift 09/15/23, on day shift 09/16/23, on night shift 09/20/23, and on day shift 09/24/23. During an interview on 11/14/23 at 9:18 A.M., Agency LPN (Licensed Practical Nurse) 5 indicated when administering treatments she would mark that it was completed or input a number indicating the reason why it wasn't completed on the EMAR/ETAR and document in a progress note why it was not administered. If there was a blank in the EMAR/ETAR then it might indicate the treatment was not completed. There shouldn't be any blanks in the EMAR/ETAR. There should always be an explanation as to why something wasn't completed. The current, undated, facility policy titled, PHYSICIAN ORDERS-(FOLLOWING PHYSICIAN ORDERS) was provided by the Administrator on 11/14/23 at 10:39 A.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . This tag relates to Complaint IN00418816. 3.1-37(a)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure hospice medications were administered as ordered by the physician for 1 of 4 residents reviewed for medication administration. (Resident M) Findings include: The clinical record for Resident M was reviewed on 11/14/23 at 10:15 A.M. The resident's diagnoses included, but were not limited to, secondary malignant neoplasm of retroperitoneum and peritoneum, dehydration, weakness, and malignant neoplasm of hypopharynx. A Progress Note, dated 11/08/23 at 8:35 P.M., indicated the hospice nurse came to the facility with morphine (a pain medication) and Ativan (an antianxiety medication) for the resident. New orders were received. The hospice nurse indicated the resident was in the end stages of life. The November 2023 EMAR/ETAR indicated the resident had the following physician orders with no documentation the medications were administered on the following dates and times: - A physician's order, with a start date of 11/09/23 at midnight, indicated the resident was to receive Lorazepam (an antianxiety medication) 0.25 ml (milliliters) every 4 hours for hospice. The medication was not administered on 11/09/23 at midnight and 4:00 A.M., - A physician's order, with a start date of 11/09/23 at midnight, indicated the resident was to receive Morphine Sulfate (a liquid pain medication) 0.5 ml every 4 hours for hospice. The medication was not administered on 11/09/23 at midnight and 4:00 A.M. During an interview on 11/14/23 at 9:18 A.M., Agency LPN (Licensed Practical Nurse) 5 indicated when administering medications she would mark that it was completed or input a number indicating the reason why it wasn't completed on the EMAR/ETAR and document in a progress note why it was not administered. If there was a blank in the EMAR/ETAR then it might indicate the medication was not given. There shouldn't be any blanks in the EMAR/ETAR. There should always be an explanation as to why something wasn't administered. If the hospice nurse brought medication into the facility and there was an order for the medication, then it would be available to give. The current facility policy titled, MEDICATION ADMINISTRATION, dated February 2017, was provided by the Administrator on 11/14/23 at 10:39 A.M. The policy indicated, .To administer all medications safely and appropriately to aid residents to overcome illness, relieve, and prevent symptoms, and help in diagnosis .Return to the medication cart and document medication administration with initials in appropriate spaces on Medication Administration Record [MAR] .Circle initials on MAR if medication is not administered as ordered and record reason in the PRN [as needed]/Omission Medication section of the MAR . This tag relates to Complaint IN00418816. 3.1-25(a)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines for residents who were under isolation precautions for Covid-19. (Residents L and H) Findings include: 1. During an observation on 11/13/23 at 2:28 P.M., CNA (Certified Nurse Aide) 2 went to answer a call light for Resident L's room. The CNA donned an N-95 mask from an isolation cart sitting in the hallway and entered Resident L's room. The CNA failed to don a gown, gloves, or clean his hands. He wore his own glasses. The sign posted on the outside of the room door indicated the resident was in Droplet/Contact Isolation and prior to entering the room staff were to clean their hands, don a gown, gloves, mask, and eye protection. The resident was sitting near the door to the room watching a television that sat on a small dresser. During an interview on 11/13/23 at 2:30 P.M., CNA 2 indicated if they were going into an isolation room, just to shut off the call light or bring in ice water and not providing patient care, he wore a mask and gloves. If he was providing patient care he wore a gown, mask, face shield, and gloves. He believed it was just the resident in the first bed, Resident L, who was positive for Covid-19, at that time. During an observation on 11/13/23 at 2:39 P.M., CNA 2 was wearing an N-95 mask and gathering trash from Resident L's room. The trash was in a clear bag and the CNA was placing it in a red isolation bag. The CNA was not wearing a gown or face shield. The clinical record for Resident L was reviewed on 11/14/23 at 11:25 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 09/28/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, cancer, fracture, anxiety, and depression. The current list of residents who had recently tested positive for Covid-19 indicated Resident L had tested positive on 11/09/23, and would be out of isolation on 11/20/23. 2. During an observation and interview on 11/14/23 at 9:11 A.M., with the Administrator, a group of residents were sitting outside the window to the Administrator's office on the front patio of the facility smoking. CNA 3 was sitting with the residents and wearing an N-95 mask as she assisted the residents. The CNA wore no gown, gloves, or face shield. The Administrator identified the residents as Resident H, Resident L, and Resident K, all of which were currently positive for Covid-19. CNA 3 was holding new cigarettes in between her bare fingers for the residents, passing them out, and lighting them. The CNA and residents were all within six feet of one another. During an observation on 11/14/23 at 12:50 P.M., a sign posted on the front of the exterior door to the facility indicated the facility was in outbreak status and had 19 residents and 10 staff members who were currently positive for Covid-19. The isolation precaution signs posted on the residents' room doors who were positive for Covid-19 were provided by the RDO (Regional Director of Operations) on 11/14/23 at 10:55 A.M. The signs indicated the residents were in Droplet/Contact Isolation and prior to entering the room staff were to clean their hands, don a gown, gloves, mask, and eye protection. During an interview on 11/14/23 at 11:00 A.M., the RDO indicated for residents in Contact/Droplet Isolation who had tested positive for COVID-19, the staff should don a gown, gloves, N-95 mask, and a face shield, glasses, or goggles prior to entering the residents' rooms. The current list of residents who had recently tested positive for Covid-19 indicated Resident H had tested positive on 11/13/23, and would be out of isolation on 11/24/23. The current Post Public Health Emergency - Standard and Guidelines policy, with an effective date of 05/23/23 was provided by the RDO on 11/14/23 at 11:03 A.M. The policy indicated, .The facility will follow CDC [Centers for Disease Control] guidelines including prompt detection, triage and isolation of potentially infectious residents to prevent unnecessary exposures of COVid-19 [sic] .The facility will provide education and visual alerts (signs, posters) to ensure everyone is aware of recommended IPC [Infection Prevention Control] practices in the facility. This includes making everyone entering the facility aware of the recommended action to prevent transmission .HCP (Health Care Providers) who enter the room of a resident with suspected or confirmed SARS-CoV-2 [Covid-19] infection will follow Transmission Based Precautions and use a NIOSH [National Institute for Occupational Safety and Health] Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection . 3.1-18(b)(2)

Sept 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to clarify the physician's order and administer wound treatments for 1 of 3 residents reviewed for skin impairments. (Resident J) Findings include: The clinical record for Resident J was reviewed on 09/14/23 at 2:00 P.M. An admission MDS (Minimum Data Set) assessment, dated 08/18/23, indicated the resident was admitted to the facility from an acute hospital on [DATE]. The resident was cognitively intact. The diagnoses included, but were not limited to, diabetes and peripheral vascular disease. The resident had a recent amputation of their right leg above the knee. The physician's order for the resident's treatment of the surgical wound from the discharging hospital indicated the wound dressing was to be changed daily. The wound was to be cleansed with saline and gauze. Saline soaked gauze was to be packed into the wound. Alginate (a type of wound dressing), an absorbent pad, and gauze wrap were to be applied to the wound. If the wound was too wet, the wound was to be packed with alginate. A Nursing Progress Note, dated 08/13/23 at 12:17 A.M., indicated the resident was resting in bed. The resident's right above the knee amputation was clean and dry. There was no dressing intact. There were no complaints of pain or signs of infection. A facility admission Skin Assessment, dated 08/13/23 at 2:19 A.M., indicated the resident had an AKA (above the knee amputation) of the right leg. The wound measured 20 cm (centimeters) x 0.2 cm. The assessment lacked any further documentation regarding the wound, including the number of sutures present. The resident's August 2023 ETAR (Electronic Treatment Administration Record) included, but was not limited to, the following physician's orders: - An order, with a start date of 08/14/23 and a discontinued date of 08/22/23, to cleanse the area with a wound cleanser and leave the wound open to air every shift (twice a day) for the right AKA. Monitor for signs of infection. The ETAR lacked documentation the wound treatment was administered on 08/14/23, and on day shift on 08/15/23. A progress note, dated Tuesday, 08/15/23 at 12:32 P.M., indicated a call was placed and a message was left at the vascular center for a return call regarding wound care. The Wound NP (Nurse Practitioner) assessed the resident's wound on 8/17/2023. The assessment indicated the wound measured 25 cm x 1.5 cm. 50 to 74% of the wound was covered in eschar (dead tissue). There were 24 visible sutures, but some may have been covered in eschar. The skin near the lateral aspect of the wound was light purple in color. There was a scant amount of serosanguinous (pale red to pink, thin and watery) drainage. The Wound NP recommended the resident follow up with the vascular surgeon ASAP for close monitoring of the wound. On 09/15/23 at 12:30 P.M., the Administrator provided a statement taken by the ADON (Assistant Director of Nursing) during a telephone interview from LPN (Licensed Practical Nurse) 2 on 09/05/23. The statement indicated LPN 2 was the nurse that admitted Resident J to the facility. The wound care orders needed to be clarified, and she did not receive a call back from the MD on her shift. During an interview on 09/15/23 at 2:37 P.M., the DON indicated LPN 2 asked for clarification on the wound treatment orders from the hospital but it didn't seem to get passed on to the day shift nurse. The day shift nurse didn't know she needed clarification on the orders. The resident was admitted to the facility on the weekend, and when they came in on Monday, they called and got clarification on the orders. The current, undated facility policy, titled PHYSICIANS ORDERS--(FOLLOWING PHYSICIAN ORDERS) was provided by the Administrator on 09/15/23 at 2:00 P.M. The policy indicated, .Orders that accompany the resident on admission will be clarified by the physician through action of the nurse who will contact the physician for clarification upon the resident's admission . The current, undated facility policy, titled Policy and Procedure Surgical Wounds was provided by the Administrator on 09/15/23 at 2:00 P.M. The policy indicated, .To ensure that a resident with a surgical wound has appropriate assessment and treatment .if sutures or staples are present the number should be documented in the medical record .Upon identification of the change of the resident's surgical wound the nurse will conduct an assessment of the resident utilizing the SBAR assessment form . This Federal tag relates to Complaint IN00416922 3.1-37(a)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to obtain a urinalysis in a timely manner for a resident with signs and symptoms of a urinary tract infection for 1 of 3 residents reviewed for urinary tract infections. (Resident E) Findings include: A Nursing Progress Note, dated 02/12/23 at 6:10 A.M., indicated the resident's blood sugar was elevated and the resident had not eaten or drank anything on the 10:00 P.M. to 6:00 A.M. shift. The resident's urine is like light brown sludge. Will pass information on to day shift. A Nursing Progress Note, dated 02/13/23 at 9:54 A.M., indicated the MD was updated on the resident's urine and sediment. A new order was given, and the responsible party was updated. A Nursing Progress Note, dated 02/17/23 at 1:03 P.M., indicated the resident's urine was obtained as ordered for a UA (urinalysis) and was sent to the local hospital lab by courier. A Nursing Progress Note, dated 02/18/23 at 2:15 A.M., indicated there were no results from the hospital on the resident's UA at that time. A Nursing Progress Note, dated 02/21/23 at 6:38 P.M., indicated the resident's UA results were received and the MD was updated. A new order was received for Augmentin (an antibiotic) 875 mg (milligrams) twice a day for seven days. The resident's family and the DON (Director of Nursing) were updated. During an interview on 09/14/23 at 2:29 P.M., LPN (Licensed Practical Nurse) 4 indicated if a resident was suspected to have a UTI (urinary tract infection), nursing staff were to call the MD and get an order for a UA. After the sample was obtained, they would call the hospital lab and let them know to pick up the sample. They would come the same day, usually within a few hours. The initial test results were faxed to the facility. The culture and sensitivity results would take another day or two, and then they would be faxed to the facility. The nurse would call the MD with the results. If an antibiotic was ordered, the order would be entered into the computer. The pharmacy would see the order when the nurses put it in the computer. The medication would usually be delivered with the next pharmacy delivery, but a lot of medications were in the Cubex (the automated drug dispensing system) in the facility, and they could pull the medication from there. During an interview on 09/15/23 at 10:21 A.M., LPN 3 indicated if a resident had signs or symptoms of a UTI, you would call the MD and get an order for a UA. The sample should be obtained the same day. This resident had an indwelling urinary catheter. The catheter would need to be changed and then the sample would be obtained. The hospital had a courier that picked up the samples during the day. If the courier wasn't available, facility staff could take the sample to the hospital laboratory. Resident E's urinalysis results indicated the urine sample was collected on 02/17/23 at 2:09 P.M. (five days after symptoms). The preliminary report, dated 02/18/23 at 9:11 A.M., indicated the sample contained 50,000 cfu/ml (colony forming unit per milliliter) of Proteus mirabilis (a bacteria). The susceptibility results were to follow. The final report that included the list of antibiotics the bacteria were susceptible to was finalized on 02/19/23 at 6:50 A.M. and faxed to the facility. During an interview on 09/15/23 at 2:45 P.M., the Administrator indicated the facility did not have a policy specific to obtaining a urinalysis. There was a policy related to following MD orders. The current, undated facility policy, titled PHYSICIANS ORDERS--(FOLLOWING PHYSICIAN ORDERS) was provided by the Administrator on 09/15/23 at 2:00 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . This Federal tag relates to Complaint IN00416922. 3.1-41(2)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medications were available for administration and follow physician's orders for 1 of 4 residents reviewed for medications. (Resident C) Findings include: An admission MDS (Minimum Data Set) assessment, dated 07/12/23, indicated the resident was admitted to the facility from a hospital on [DATE]. The resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, bipolar disorder, and enterocolitis due to Clostridium difficle (C.diff, a bacteria). The resident's July 2023 EMAR (Electronic Medication Administration Record) was reviewed on 09/12/23 at 2:00 P.M. The EMAR indicated the resident had a physician's order, with a start date of 07/07/23, for vancomycin (an antibiotic) oral solution, 25 mg/ml (milligrams per milliliter). Give 5 ml by mouth four times a day for infection for 7 days. The first dose of the medication was scheduled to be administered on 07/07/23 at 8:00 P.M., with subsequent doses scheduled at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. for the next seven days. The resident's EMAR indicated the following: - On 07/07/23 the medication was not administered at 8:00 P.M., - On 07/08/23 the medication was administered at 8:00 A.M., and not administered at 12:00 P.M., 4:00 P.M., and 8:00 P.M., and - On 07/09/23 the medication was administered at 8:00 A.M., not administered at 12:00 P.M., administered at 4:00 P.M., and not administered at 8:00 P.M. An EMAR Medication Administration note, with an effective date of 07/08/23 at 6:54 P.M., indicated the vancomycin medication was not available. An EMAR Medication Administration note, with an effective date of 07/08/23 at 6:57 P.M., indicated the vancomycin was unavailable. An EMAR Medication Administration note, with an effective date of 07/08/23 at 9:50 P.M., related to the vancomycin indicated awaiting delivery. An EMAR Medication Administration note, with an effective date of 07/09/23 at 3:34 P.M., related to the vancomycin indicated the nurse spoke to someone at the pharmacy and the medication would be delivered that evening. The MD was made aware. An EMAR Medication Administration note, with an effective date of 07/10/23 at 3:34 P.M., related to the vancomycin indicated they were waiting on the pharmacy to deliver the medication, the pharmacy was aware of the need. During an interview on 09/15/23 at 1:19 P.M., the ADON (Assistant Director of Nursing) indicated the times on the EMAR that she indicated the medication was administered on 07/08/23 and 07/09/23 were mistakes. She was the nurse that documented the medication administration, and she did not administer the antibiotic because it was not available. She did request the medication from the pharmacy (as indicated in the resident's EMAR notes). The pharmacy staff delivered medications to the facility twice a day. There have been problems getting medications timely. Further review of the EMAR considering the three times the medication was documented as administered when it wasn't indicated the resident missed 9 doses of the medication. During an interview on 09/15/23 at 1:46 P.M., the Administrator and DON (Director of Nursing) indicated they did find a bottle of vancomycin in the resident's drawer, but they were not aware of when the medication came into the facility. They usually did an inventory of items when a resident arrived at the facility. This resident had family that came in and out and they weren't sure when the medication was brought into the facility, and it hadn't been refrigerated so they couldn't use it. The facility documentation lacked an inventory of personal items for Resident C. Resident C's physician's orders included an order, with a start date of 07/07/23, for Xanax (a medication used to treat anxiety and panic disorders), 0.5 mg by mouth as needed everyday for anxiety. The order was put on hold from 07/11/23 until 07/12/23 when it was discontinued. The resident had not received the as needed medication since his admission to the facility. A Physician's Progress Note, dated 07/11/23 at 6:31 P.M., indicated the resident's bipolar disorder was stable on medications. The MD ordered a decrease in the resident's Xanax from 0.5 mg by mouth daily PRN (as needed) for 14 days to 0.25 mg by mouth daily as needed for 14 days. A physician's order, with a start date of 07/12/23, and an end date of 07/19/23 was entered into the resident's record for Xanax 0.25 mg. Give 0.25 mg by mouth one time a day for anxiety for 14 days. The medication was scheduled to be administered daily at 11:00 A.M. Documentation in the resident's EMAR indicated the medication was not administered on 07/12/23, 07/13/23, and 07/14/23. An EMAR Medication Administration note, with an effective date of 07/12/23 at 11:38 A.M., indicated the Xanax medication was on order. An EMAR Medication Administration note, with an effective date of 07/13/23 at 10:38 A.M., indicated the Xanax medication was not available. An EMAR Medication Administration note, with an effective date of 07/14/23 at 13:57 A.M., indicated the facility was waiting on delivery of the medication. The pharmacy was called, and the medication would arrive that night. The MD was aware. The resident's EMAR indicated the resident received the Xanax 0.25 mg routinely on 07/15/23, 07/16/23, and 07/17/23. The resident refused the medication on 07/18/23, and the order was changed from routine administration to as needed on 07/19/23. The current facility policy, titled 1.6 PHARMACY HOURS AND DELIVERY SCHEDULE, and dated February 2017, was provided by the Administrator on 09/15/23 at 12:31 P.M. The policy indicated, .[the pharmacy] is open 24 hours/365 days a year. New orders and refill requests may be faxed or sent electronically at any time .New orders communicated to the .Pharmacy after the cut off time will automatically go into the next regular delivery for the facility .An emergency delivery can be requested by sending the order to the .Pharmacy, contact the pharmacy by phone to alert them you sent a STAT order . The current, undated facility policy, titled PHYSICIANS ORDERS--(FOLLOWING PHYSICIAN ORDERS) was provided by the Administrator on 09/15/23 at 2:00 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . This Federal tag relates to Complaint IN00413257. 3.1-25(a)

Nov 2022 11 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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2. The clinical record for Resident 36 was reviewed on 11/15/22 at 11:41 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 09/28/22, indicated the resident was rarely/never understood. The diagnoses included, but were not limited to, stroke, hypertension, neurogenic bladder, diabetes, non-Alzheimer's dementia, hemiplegia/hemiparesis, seizure disorder, depression, and tracheostomy status. The resident required extensive assistance of two or more staff for most ADLs. She was at risk for developing pressure ulcers, and had one, unhealed facility acquired Unstageable pressure ulcer at the time of the assessment. An NP Wound Assessment, dated 08/01/22, indicated the resident had a Stage 2 pressure ulcer to the right upper buttock that measured 2.44 cm x 2.53 cm x 0.5 cm. There was a scant amount of sanguineous drainage. The wound had 100% epithelial tissue. The treatment was to apply Triad (a hydrophilic wound paste that absorbed moderate levels of wound exudate) paste and leave the area open to air. An NP Wound Assessment, dated 08/15/22, indicated the resident's wound to the right upper buttock was healed. The Triad treatment was discontinued when the wound healed. No new interventions were put into place after the wound healed. An NP Wound Assessment, dated 09/08/22, indicated the resident had an Unstageable pressure ulcer to the right upper buttocks that measured 1.22 cm x 1.33 cm x 0.10 cm. There was a moderate amount of serosanguinous drainage. The treatment was to cleanse the wound, apply Medi honey, and cover with bordered gauze. Pressure and Offloading interventions included to ensure compliance with turning protocol and a specialty bed. An NP Wound Assessment, dated 09/29/22, indicated the resident had an Unstageable pressure ulcer to the right upper buttock that measured 0.53 cm x 1.26 cm x 2.0 cm with 5.0 cm tunneling at 9 o'clock. The wound was covered in 100% slough/eschar with a moderate amount of serosanguinous drainage. The wound treatment changed to cleanse the wound, apply iodoform gauze packing and cover with a bordered gauze. An NP Wound Assessment, dated 10/20/22, indicated the resident had an Unstageable pressure ulcer to the right upper buttocks that measured 0.38 cm x 0.78 cm x 1.5 cm with 4.0 cm tunneling at 9 o'clock. The wound was covered in 100% granulation with a moderate amount of purulent drainage. The wound treatment remained the same. An NP Wound Assessment, dated 11/10/22, indicated the resident had an Unstageable pressure ulcer to the right upper buttocks that measured 0.55 cm x 0.49 cm x 2.0 cm with 4.0 cm tunneling at 9 o'clock. The wound was covered in 100% granulation tissue with a moderate amount of purulent drainage. The wound treatment remained the same. The clinical record lacked the MD notification of the resident's wound increasing in size and wound drainage. A Complete Care Plan was provided by the DON on 11/16/22 at 1:20 P.M. The Care Plan contained the following: - Altered Skin Integrity to the right buttock, interventions included, monitor daily for increase in size, notify MD and family as needed, and treatment per order. -At risk for skin breakdown due to diagnosis CVA (cerebrovascular accident) with weakness, incontinence of bowel, and use of a urinary catheter. Interventions included, but were not limited to, Braden scale quarterly and as needed, ensure toileting at least every 2 hours, float heels every shift, keep clean and dry, pressure relieving mattress per facility policy, preventive measures as needed, skin assessment per facility policy, supplements per order. The August 2022 ETAR indicated the resident had received the Triad paste daily from 08/04/22 through 08/15/22. During an interview on 11/16/22 at 3:37 P.M., the ADON/Wound Nurse indicated the resident's wound first started as a Stage 2 pressure on 08/01/22 and healed on 08/15/22. The wound had reopened on 09/08/22 as an unstageable. Her interventions included, a low air loss mattress, turning and reposition per protocol, t-time (toileting time). The staff noticed the resident had a wound and brought it to her attention. 3. During an observation on 11/16/22 at 02:01 P.M., Resident 13 had an area to her coccyx that was pencil eraser size with measurable depth. The wound was pink with no drainage noted. The resident's clinical record was reviewed on 11/15/22 at 9:41 A.M. A Quarterly MDS Assessment, dated 10/18/22, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, anemia, heart failure, hypertension, malnutrition, depression, and psychotic disorder. The resident required extensive assistance of 2 or more staff members with most ADLs. The resident was a risk for pressure ulcers with no pressure ulcer at the time of the assessment. A Progress Note, dated 08/31/22, indicated the resident had an open area to her coccyx and a new order was obtained to cleanse the wound, apply Medi honey, and cover with a bordered gauze every night shift. The September, October, and November 2022 ETAR lacked documentation the treatment was provided the following dates: - 09/02/22, - 09/03/22, - 09/04/22, - 09/09/22, - 09/12/22, - 09/17/22, - 09/19/22, - 09/22/22, - 09/23/22, - 09/25/22, - 10/05/22, - 10/08/22, - 10/19/22, - 10/22/22, - 10/29/22, - 11/06/22, and - 11/13/22. No weekly wound assessments could be provided for the wound. No wound staging was documented in the resident's clinical record. During an interview on 11/15/22 at 2:01 P.M., the ADON/Wound Nurse indicated wound assessments were completed weekly by the NP and she was unsure why the resident had been getting a dressing change to her coccyx. During an interview on 11/15/22 at 3:06 P.M., LPN 5 indicated it was a night shift dressing change and she was unsure what the resident had going on. During an interview on 11/16/22 at 9:04 A.M., LPN 6 indicated the resident stayed in bed per her choice most of the time. She was incontinent of her bowel and bladder. The resident had developed a wound on her bottom that had a treatment completed on night shift. During an interview on 11/16/22 at 2:30 P.M., the DON indicated a nurse had notified the NP of the resident having a wound and obtained treatment orders. The wound should be assessed weekly, and the resident did not have weekly wound assessments. During an interview on 11/16/22 at 3:09 P.M., the DON indicated the resident treatments should be signed out in the ETAR. If there was a blank in the ETAR then it meant it wasn't done. 4. On 11/10/22 at 9:59 A.M., Resident 70 was observed sitting in a chair in his room. The resident indicated he was at the facility short term after a hospitalization and would be going home soon. The resident did have a wound on his bottom, he was not sure when it developed. There was a current treatment for the wound, but it was almost healed. The resident deferred an observation of the wound. The resident's clinical record was reviewed on 11/16/22 at 2:46 P.M. An admission MDS assessment, dated 08/28/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension, atrial fibrillation, renal insufficiency, seizure disorder, urinary tract infection in the last 30 days, and COPD (Chronic Obstructive Pulmonary Disease). The resident was at risk for pressure ulcers but had no unhealed pressure ulcers during the assessment review period. The resident utilized a pressure reducing device for his bed. The Facility admission Assessment, dated 08/24/22, indicated the resident had no skin impairments. A Wound NP Assessment, dated 08/29/22, indicated the resident had a sacrococcygeal (sacrum and coccyx area) pressure ulcer, staged as a suspected DTI (Deep Tissue Injury, a non-blanchable deep red, purple or maroon area of intact skin, non-intact skin, or blood-filled blisters caused by damage to the underlying soft tissues) that measured 5.79 cm x 3.85 cm x 0.05 cm. There was a scant amount of thin, serous (thin, watery fluid) drainage. The wound tissue type was 100% epithelial tissue, wound colors were listed as pink (5.19 cm 2), black (7.70 cm 2), and red (1.55 cm 2). The treatment was to cleanse the wound and apply a hydrocolloid dressing. The dressing was to be changed every three days. Current preventative interventions included the use of a pressure redistribution mattress, wheelchair cushion, and a specific turning and repositioning program. The August and September 2022 EMARs and ETARs lacked documentation that the hydrocolloid dressing treatment was ever administered. A Wound NP Assessment, dated 09/15/22, indicated the resident had a sacrococcygeal wound that was previously classified as an evolving DTI, but was now classified as an Unstageable pressure ulcer. The wound measured 3.05 cm x 2.55 cm and was 100% covered in slough/eschar (dead skin). There was a moderate amount of serous drainage. The treatment was to cleanse with a wound cleanser, apply Medihoney and a bordered gauze. The September 2022 ETAR contained a physician's order, with a start date of 09/24/22, to cleanse the area with wound cleanser, apply Medihoney and cover with a bordered gauze every day shift for wound care to the coccyx. The treatment was administered as ordered. The ETAR lacked documentation of a wound treatment before 09/24/22. During an interview on 11/16/22 at 2:24 P.M., the ADON indicated the wound was present on admission, it started as a suspected DTI. She was unsure as to why the wound treatments weren't on the ETARs, the orders must have been missed. A Wound NP Assessment, dated 09/29/22, indicated the resident had a sacrococcygeal wound that was previously identified as an unstageable wound, and was determined to be a Stage 3 pressure ulcer that measured 1.15 cm x 0.65 cm x 1.20 cm. The wound was 70% granulation tissue and 30% slough/eschar. There was moderate serous drainage. The treatments were daily dressings with Medihoney and calcium alginate. The resident was discharged home from the facility on 11/16/22. The current, undated facility policy, titled S.W.A.T.---Skin Weight Assessment Team---Guidelines Pressure Ulcers was provided by the Administrator on 11/16/22 at 4:19 P.M. The policy indicated, .It is the policy of the facility to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable .a resident .receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing .ensure all assessments are timely and accurate .monitor treatments for efficacy . 3.1-40(a)(2) 3.1-40(a)(3) Based on observation, interview, and record review, the facility failed to prevent residents from acquiring in house pressure ulcers and weekly assessments of a pressure ulcers for 4 of 6 residents reviewed for pressure ulcers. This deficient practice resulted in one resident's pressure ulcer being identified at a Stag 3 and two residents' wounds identified with deep tissue injuries. (Residents 15, 36, 13, and 70) Findings include: 1. During an observation on 11/16/22 at 2:53 P.M., the Wound Nurse and QMA (Qualified Medication Aide) 9 entered Resident 15's room and explained they were going to change the dressing on her buttocks. They each washed their hands and donned gloves. QMA 9 assisted the resident in turning onto her right side. The Wound Nurse removed the old dressing, removed her gloves and donned clean gloves. The wound was approximately 9 cm (centimeters) x (by) 11 cm x 2 cm deep. The wound bed was pink and red with a half dollar sized amount of slough (yellowish colored dead tissue) in the center. The wound was cleaned with wound cleanser, packed with hydrogen peroxide soaked gauze, covered with an absorbent dressing and secured with tape. The clinical record was reviewed on 11/14/22 at 11:22 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/30/22, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, anemia, heart failure, diabetes, stroke, anxiety, and respiratory failure. The resident required extensive assistance of two staff members for ADLs (Activities of Daily Living). The resident was at risk for pressure ulcers. The CNA (Certified Nurse Aide) Bath Checklist, dated 05/25/22, was provided by the DON on 11/16/22 at 9:28 A.M. The checklist indicated the resident had no open areas were documented. The Weekly Skin Check record, dated 05/29/22, was provided by the DON on 11/16/22 at 9:28 A.M. The skin check indicated the resident had no new loss of skin integrity. A Wound NP assessment, dated 05/30/22, indicated the resident had a Stage 3 (full thickness tissue loss) pressure ulcer, measuring 2.8 cm x 1.1 cm x 0.1 cm depth, to her right buttocks. A Wound NP assessment, dated 06/13/22, indicated the right buttocks wound measured 6.2 cm x 4.7 cm and was covered with 100% slough. A wound culture was obtained on 06/13/22. The culture results, dated 06/16/22, indicated there was Heavy Proteus mirabilis (a bacteria) in the wound. The resident was started on Keflex (an antibiotic) for the positive wound culture. A Progress Note, dated 06/16/22 at 9:00 A.M., indicated the resident was sent to the hospital for a change in condition. The emergency room note, 6/16/22, indicated the resident presented with altered mental status with positive wound culture. History of UTI, non-ambulatory, bed bound, medical decision indicated sever sepsis. The wound was foul in smell and most likely the source of the patient's infection. During an interview on 11/16/22 at 3:14 P.M., the Wound Nurse indicated the pressure ulcer on the buttocks, from 06/13/22, wasn't identified until after the shoulder was healed, It just popped up'. The resident's skin was fragile.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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2. Resident 39 was observed in her room on 11/09/22 at 11:40 A.M. The resident was in bed with the head of her bed somewhat elevated. The resident was wearing oxygen and indicated she was waiting for lunch. There were no signs or symptoms of discomfort or distress. The resident's clinical record was reviewed on 11/16/22 at 3:00 P.M. A Quarterly MDS assessment, dated 10/10/22, indicated the resident was moderately cognitively impaired. The resident required extensive staff assistance with most of her ADLs (Activities of Daily Living). Both of the resident's lower extremities were impaired, and she used a wheelchair. The diagnoses included, but were not limited to, stroke, diabetes, and heart failure. The resident's current physician's orders included an open-ended order, with a start date of 01/03/22, to obtain the resident's weight, daily. Staff were to call the MD if the resident gained more than 3 pounds a day. The resident's weights were not obtained, and the spaces were blank in the ETAR for August, September, and October 2022 on the following days: - 08/03/22, - 08/04/22, - 08/05/22, - 08/10/22, - 08/13/22, - 08/16/22, - 08/17/22, - 08/18/22, - 08/27/22, - 08/29/22, - 09/01/22, - 09/02/22, - 09/05/22, - 09/10/22, - 09/13/22, - 09/15/22, - 09/16/22, - 09/17/22, - 09/19/22, - 09/20/22, - 09/22/22, - 09/24/22, - 09/28/22, - 09/29/22, - 09/30/22, - 10/01/22, - 10/02/22, - 10/03/22, - 10/04/22, - 10/06/22, - 10/07/22, - 10/08/22, - 10/09/22, - 10/10/22, - 10/11/22, - 10/12/22, - 10/19/22, - 10/23/22, - 10/27/22, and - 10/28/22. During an interview on 11/17/22 at 10:15 A.M., LPN (Licensed Practical Nurse) 5 indicated the resident had orders to be weighed daily, and they were supposed to notify the MD if she gained more than 3 pounds in one day. The staff would weigh her when she would allow it. She didn't like to get weighed in the morning; she would usually let staff weigh her around 1:00 P.M. because she would be up for the smoke break. If a resident refused to be weighed, they would document the refusal. If it became a pattern that the resident refused, they would notify the MD. The resident's current Care Plans included a care plan that indicated the resident had a diagnosis of Congestive Heart Failure. The care plan was initiated on 08/11/19. The current interventions included, but were not limited to, an intervention with a start date of 09/16/19 to obtain the resident's weight daily. Staff were to notify the MD if the resident gains more than 3 pounds in one day. The current, undated facility policy, titled PHYSICIAN ORDERS--(FOLLOWING PHYSICIAN ORDERS) was provided by the Administrator on 11/16/22 at 4:19 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . 3.1-37(a) Based on interview, observation, and record review, the facility failed to administer prescribed wound treatments and obtain weights for 2 of 19 residents reviewed for quality of care. (Residents 27 and 39) Findings include: 1. During an interview and observation on 11/09/22 at 11:48 A.M., Resident 27 indicated she had open areas on her lower legs that seeped. The dressings were to be changed daily. The dressing had not been changed since Sunday, 11/06/22. The resident unzipped her compression sock on her right leg and the date written on the 4 (inch) x (by) 4 dressing, located on her shin, was 11/06/22. During an interview on 11/10/22 at 11:25 A.M., the resident indicated the staff had changed the dressing on her leg last night and today. The dressing change to the resident's right shin was observed on 11/15/22 at 10:44 A.M., with the ADON (Assistant Director of Nursing). When the dressing was removed, a large amount of yellow exudate was noted on the old dressing. The ADON indicated the calcium alginate dressing pads turn yellow from exudate. The dressing contained both calcium alginate and silver alginate. During an interview on 11/15/22 at 11:07 A.M., the ADON indicated dressing changes were documented on the EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) . During an interview on 11/16/22 at 10:12 A.M., LPN (Licensed Practical Nurse) 5 indicated the resident had cellulitis in her lower legs in August. The Infection Control Log for August 2022, was provided by the DON (Director of Nursing) on 11/16/22 at 2:30 P.M. The record indicated the resident had cellulitis, with an onset date of 08/16/22, and was treated with the antibiotic Cephalexin until 08/23/22. The EMAR/ETAR for September, October, and November 2022, was provided by the Regional Director of Operations on 11/16/22 at 4:14 P.M., and included, but was not limited to, the following physician's order for the wound treatment: - Cleanse area with wound cleanser, apply calcium/silver alginate, secure with border gauze every day shift for wound, BLE (Bilateral Lower Extremities) scattered open areas, with a start date of 08/25/22 and a discontinued date of 11/06/22. The records lacked documentation the dressing changes had been completed on the following dates: - September 14, - September 16, - September 22, - October 3, - October 6, - October 8, - October 9, - October 11, and - October 23. The November record indicated the dressing frequency had been changed to every other day with a start date of November 7, 2022.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure residents' safety related to unauthorized medications at the bedside for 1 of 17 residents observed. (Resident 40) Findings include: During an observation and interview on 11/16/22 at 11:40 AM., Resident 40 was sitting in her wheelchair in her room self administering her medications from a medicine cup that contained 13 pills of various sizes and colors. The resident indicated they had left for an appointment that morning and she did not get their medications prior to leaving. The staff told her they would hold them for her until she returned from her appointment. The staff usually left her medications at her bedside but they were not supposed to now because State was in the building. No staff were observed near the the resident's room. They staff were down the hall at the nurse's station. During an interview, down the hall near the nurse's station, on 11/16/22 at 11:41 A.M., QMA (Qualified Medication Aide) 9 indicated the resident did not have an assessment to self administer her medications. She had just given the resident her the medications and thought she had taken them. During an interview on 11/17/22 at 10:02 A.M., the Administrator indicated she did not think their medication administration policy specified that the nurse had to stay in the presence of the residents while they were taking their medications. No current residents were permitted to self administer their medications. The clinical record was reviewed on 11/17/22 at 2:40 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 09/18/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, hypertension, anxiety, depression, and history of stroke. The EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) for November 2022, was provided by the Regional Director of Operations on 11/16/22 at 4:14 P.M. The record indicated the resident had current physician orders that included, but were not limited to, the following medications to be administered in the morning: - Allopurinal 100 mg (milligrams) for gout, - Amlodipine Besylate 5 mg for hypertension, - Lasix 40 mg for edema, - Levothyroxine 88 mcg (micrograms) for hypothyroidism, - Lisinopril 10 mg for hypertension, - Lisinopril 5 mg for hypertension (for a total of 15 mg), - Loratadine 10 mg for allergies, - Paroxetine 40 mg for depression, - Paroxetine 10 mg for depression (for a total of 50 mg), - Potassium Chloride 20 meq (milliequivalent), - a prenatal vitamin, - Prilosec 20 mg for GERD (Gastroesophogeal Reflux Disease), - Vitamin D3 20 mcg for osteopenia, - Iron 325 mg for anemia, and - Gabapentin 100 mg, 2 capsules, for neuropathy. The current undated Medication Administration policy was provided by the Administrator on 11/16/22 at 4:19 P.M. The policy indicated, .Purpose .To ensure that resident medication are administered in a timely manner and documentation is completed to substantiate administration . The current undated Medication Self Administration policy was provided by the Administrator on 11/16/22 at 4:19 P.M. The policy indicated, .Purpose .To provide procedures for determining if the resident can safely self-administer and store medications in their room . 3.1-45(a)(2)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to follow the physician's orders related to a PICC dressing for 1 of 1 resident reviewed for PICC (Peripherally Inserted Central Catheter) line. (Resident 29) Findings include: During an observation and interview on 11/09/22 at 1:04 P.M., Resident 29 was lying in bed. She indicated she had an infection recently. There was a PICC inserted in the resident's right upper arm. The dressing was all bunched up. The date had a 10 written on it and the rest was unreadable due to the dressing being folded over. During an observation and interview on 11/09/22 at 1:34 P.M., LPN (Licensed Practical Nurse) 6, assessed the resident's dressing covering her PICC in the right arm. She folded the dressing over and the date was visible and dated 10/17. She indicated the dressing should have been changed since 10/17. The dressing was to be changed weekly. The clinical record for Resident 29 was reviewed on 11/15/22 at 10:48 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 11/04/22, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, anemia, hypertension, hip fracture, seizure disorder, anxiety, and depression. The resident had received IV (intravenous) medications during the last 14 days of the assessment. A Progress Note, dated 10/17/22, indicated a urine culture and sensitivity was received from the laboratory. The MD was updated, and a new order was received to discontinue the resident's oral antibiotic medication and start Invanz (an intravenous) medication, every day, for 10 days. The facility may place a midline/PICC line. The Assistant Director of Nursing and the resident were notified. The pharmacy IV department was updated to come to the facility to place a midline/PICC. A Midline/PICC Insertion Documentation Form, dated 10/17/22, indicated the PICC for Resident 29 was placed on 10/17/22. An open-ended physician's order, with a start date of 10/25/22, indicated staff were to change the IV-PICC transparent dressing weekly and as needed. The resident had not suffered any ill effects from the PICC dressing not being changed. The current, undated, facility policy titled, PICC Catheter Needleless Access Device Change, was provided by the DON (Director of Nursing) on 11/09/22 at 2:44 P.M. The policy indicated, .To decrease the risk of catheter associated infections .PICC catheter needleless access devices are change at the following times: at least every 7 days . 3.1-47(a)(2)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to follow infection control guidelines for 1 of 1 resident reviewed for tracheotomy care (Resident 36), and failed to appropriately manage residents' respiratory needs related to dating equipment for 2 of 3 residents reviewed for respiratory care. (Residents 40 and 27) Findings include: 1. During an observation on 11/17/22 at 11:19 A.M., LPN (Licensed Practical Nurse) 2 entered Resident 36's room. She placed a towel over the resident and explained the procedure. She washed her hands, applied gloves, and set up her supplies on the bedside table. She doffed her gloves and donned sterile gloves, retrieved the tracheotomy kit with her left sterile gloved hand and opened it with her right sterile gloved hand. She took the sterile field drape and opened it onto the bedside table, removed all the supplies with her right hand and placed them on the drape. She mixed peroxide and normal saline into the empty package and doffed her gloves. She donned new sterile gloves, removed the resident's oxygen covering the trach, removed the trach cannula with her right hand, retrieved a gauze pad soaked in peroxide with normal saline and cleansed around the trach using her right hand. She retrieved a dry gauze pad and wiped around the tracheostomy with her right hand while hold the trach in place with her left hand. She removed the old collar, put a new collar in place with both gloved hands, and placed a new cannula with her right hand. The oxygen was replaced. During an interview on 11/17/22 at 1:33 P.M., LPN 2 indicated when providing tracheostomy care she should have never touched the supplies with her contaminated gloved hand. She should always have a clean hand and a dirty hand during the procedure. The clinical record for Resident 36 was reviewed on 11/15/22 at 11:41 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 09/28/22, indicated the resident was rarely/never understood. The diagnoses included, but were not limited to, stroke, hypertension, neurogenic bladder, diabetes, non-Alzheimer's dementia, hemiplegia/hemiparesis, seizure disorder, depression, and tracheostomy status. The resident had received levofloxacin for an upper respiratory infection from 09/21/22 through 10/01/22. The current, undated, facility policy titled Respiratory: Tracheostomy Care, was provided by the DON (Director of Nursing) on 11/17/22 at 1:23 P.M. The policy indicated, .To describe a recommended method for cleaning a tracheostomy site and tube-keeping site and tube free from mucus build-up, maintaining tube patency-reducing risk of infection and maintain skin integrity at stoma site .Establish sterile field on over-bed table and maintain during procedure .open packages to reveal supplies-using insides of packages to form sterile field .Add items to the field by properly dropping items onto the field being sure to keep package between the items to be used and hands .Put on sterile latex free gloves and personal protective equipment [gown, goggles-if indicated]Remember when performing tracheostomy care keep dominate hand sterile [usually right hand] and non-dominate hand clean [usually left hand] . 2. During an interview and observation on 11/09/22 at 11:55 A.M., Resident 40 indicated she had not had water for her oxygen since September and staff had not changed the tubing in a really long time. The resident was sitting in her room on the side of her bed. She had an oxygen concentrator machine at the end of her bed with an attached water reservoir humidification bottle and tubing. The water bottle was dated 09/28/22 and was dry and empty. There was no date on the tubing indicating when it had been put into service. There was a one inch piece of tape on the tubing that had dirty black flecks of debris, dust, and hair stuck to the tape. No date was written on the tape. During an interview and observation on 11/10/22 at 11:25 A.M., the resident indicated their oxygen tubing had been changed last night. The resident's tubing was dated appropriately, the water bottle was two thirds full, and was dated 11/09/22. During an interview on 11/16/22 at 3:41 P.M., the DON indicated oxygen tubing was changed weekly on Wednesday nights. During an interview on 11/17/22 at 2:17 P.M., LPN 5 indicated oxygen tubing and humidification bottles both should be dated. They were changed weekly on Wednesday and documented in the EMAR/ETAR (Electronic Medication Administration Record / Electronic Treatment Administration Record). The clinical record was reviewed on 11/17/22 at 2:40 P.M. A Quarterly MDS assessment, dated 09/18/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, hypertension, anxiety, depression, and history of stroke. The EMAR/ETAR for September and October 2022, were provided by the Regional Director of Operations on 11/16/22 at 4:14 P.M. The record indicated the resident had current physician orders that included, but were not limited to, the following: - Oxygen at 2 liters per minute per Nasal Cannula as needed for shortness of breath with a start date of 5/25/21, - Change oxygen tubing and humidifier every Wednesday on night shift, date both tubing and water with a start date of 05/26/21, a discontinued date of 10/11/22, and a start date of 10/12/22. The September record indicated the oxygen tubing and water bottle had been changed on September 28, 2022. The October record lacked documentation the oxygen tubing and water bottle had been changed on the following dates: - October 5, - October 19, and - October 26. The resident had not had a respiratory infection recently. 3. During an interview on 11/09/22 11:57 A.M., Resident 27 indicated the facility utilized agency nurses because they did not have enough nurses. They used to change the oxygen tubing on Wednesday nights, but they didn't anymore. The clinical record was reviewed on 11/17/22 at 2:49 P.M. A Significant Change MDS assessment, dated 08/24/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, arthritis, anxiety, depression, and lymphedema. The EMAR/ETAR for September and October 2022, were provided by the Regional Director of Operations on 11/16/22 at 4:14 P.M. The record indicated the resident had current physician orders that included, but were not limited to, the following: - may apply oxygen per Nasal Cannula as needed for shortness of breath with a start date of 02/07/21, - Change oxygen tubing and humidifier (if needed) every Wednesday on night shift, date both tubing and water with a start date of 05/26/21, a discontinued date of 10/10/22, and a start date of 10/12/22. The September record lacked documentation the oxygen tubing had been changed on the following date: - September 21. The October record lacked documentation the oxygen tubing and water bottle had been changed on the following dates: - October 5, - October 19, and - October 26. The resident had not had a respiratory infection recently. The current undated Oxygen Administration policy was provided by the Administrator on 11/16/22 at 4:19 P.M. The policy indicated, .Tubing, humidifier bottles .will be changed, cleaned and maintained no less that [sic] weekly .Each will be labeled with date, time and initialed by staff completing this service to equipment . 3.1-47(a)(6)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide the required RN (Registered Nurse) on duty for eight hours a day for 2 of the 17 days reviewed. Findings include: During an interview on 11/17/22 at 1:57 P.M., the DON (Director of Nursing) indicated she was usually here Monday through Friday. The DON and RN 12 were the only two RNs currently working in the facility. When neither herself nor RN 12 were working, a corporate RN would usually comes to the facility. They did not currently have any nursing waivers. The as worked nursing schedule indicated there had not been an RN on duty for eight consecutive hours on Saturday, 11/05/22 and Sunday, 11/06/22. During an interview on 11/17/22 at 3:23 P.M., the DON indicated the facility did not have a policy for RN coverage, They followed state and federal regulations. 3.1-17(b)(3)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to post nurse staffing daily for the survey time period 11/09/22 through 11/17/22. Findings include: During an observation on 11/09/22 at 2:44 P.M., the nurse staffing was posted by the therapy gym and dated for 11/08/22. During an observation on 11/10/22 at 9:20 A.M., the nurse staffing was posted by the therapy gym and dated for 11/09/22. During an observation on 11/14/22 at 11:00 A.M., the nurse staffing was posted by the therapy gym and dated for 11/13/22. During an observation on 11/14/22 at 3:59 P.M., the nurse staffing was posted by the therapy gym and dated for 11/13/22. During an observation on 11/15/22 at 9:04 A.M., the nurse staffing was posted by the therapy gym and dated for 11/13/22. During an observation on 11/15/22 at 12:25 P.M., the nurse staffing was posted by the therapy gym and dated for 11/13/22. During an observation on 11/15/22 at 4:10 P.M., the nurse staffing was posted by the therapy gym and dated for 11/13/22. During an observation on 11/16/22 at 9:30 A.M., the nurse staffing was posted by the therapy gym and dated for 11/15/22. During an observation on 11/16/22 at 1:29 P.M., the nurse staffing was posted by the therapy gym and dated for 11/15/22. During an interview on 11/16/22 at 1:30 P.M., the DON (Director of Nursing) indicated LPN (Licensed Practical Nurse) 2 was responsible for the posting the staffing. It should be posted at the beginning of each day. During an interview on 11/17/22 at 5:05 P.M., LPN 2 indicated she had been posting the staffing for the previous day to reflect which staff had acutely worked. During an interview on 11/17/22 at 9:36 A.M., the DON indicated the facility had no specific policy for staff posting, they follow the federal regulations.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to label medications appropriately for 1 of 2 medication storage rooms reviewed (39 Hall Medication Room), and label insulin pens for 1 of 3 medication carts reviewed (77 Front Medication Cart) . Findings include: On 11/17/22 at 2:30 P.M, the 39 Hall Medication Storage Room was observed with LPN (Licensed Practical Nurse) 5. The medication refrigerator contained the following: - 2 nearly empty vials of Tubersol serum, with no opened-on date, - 1, 3/4 full vial of Tubersol serum, with no opened-on date, and - 1, 1/5 full bottle of Acetylcysteine 20% Inhalation Solution for Resident 36, with no opened-on date. During an interview, LPN 5 indicated all medications should be labeled with an opened-on date. The TB serum was good for 30 days. During an observation on 11/17/22 at 2:45 P.M. with RN 3, the 77 Front medication cart contained the following insulin medications with no opened-on dates: - 1 Novolog insulin pen for Resident 23 that was 3/4 full, and - 1 Lantus insulin pen for Resident 52 that was 3/4 full. RN 3 indicated she gave Resident 52 insulin from the unlabeled Lantus insulin pen that morning. No residents suffered any ill effects from using the unlabeled medications. The current pharmacy recommendations for storage of select medications, dated September 2022 was provided by the Administrator on 11/17/22 at 4:15 P.M. The recommendations indicated the following, .Tubersol .Discard vials in use after 30 days .Novolog .use within 28 days of initial use .Lantus .use within 28 days of initial use . The current, undated facility policy, titled MEDICATION STORAGE IN THE FACILITY was provided by the Administrator on 11/17/22 at 4:10 P.M. The policy indicated, .Medications .are stored safely, securely, and properly following the manufacturer or supplier recommendations 3.1-25(j) 3.1-25(o)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to hold food at appropriate temperatures on the serving table for 1 of 2 food temperature observations. Findings include: During an observation on 11/15/22 at 11:00 A.M., [NAME] 8 had lunch prepared on the steam/cold table on ice. The food temperatures were as followed: - Egg Salad at 46.6 egress, - Chilled Beets at 50.2 degrees, - Pureed Egg Salad at 35.9 degrees, and - Pureed Chilled Beets at 33.5 degrees. Cook 8 indicated, the egg salad had been sitting in the refrigerator for 2 hours before she removed it and sat it in ice. She would serve it to the residents when the temperature was between 40-45 degrees. She proceeded to plate the food for the residents to deliver to their rooms. During an interview on 11/15/22 at 11:13 A.M., the Dietary Manager indicated the cold food holding temperatures should be at 40 degrees or below. She wasn't sure why the food was temping warmer than 40 degrees because the egg salad had been in the refrigerator for 2 hours and the beets had been in them since that morning. She was unsure of what the facility procedure was, and she would find out. The concerns were brought to the Administrator's attention on 11/15/22 at 11:20 A.M. She had gone to the kitchen to address the concern. During an interview on 11/15/22 at 11:32 A.M., the Administrator indicated the food was not served to any residents and was replaced. The current facility policy, titled Monitoring Food Temperatures for Meal Service, dated 2010, was provided by the Administrator on 11/15/22 at 11:52 A.M. The policy indicated, .Cold foods and beverages which are not 41 degrees or below will be chilled on ice or in the freezer . 3.1-21(a)(2)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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3. During an interview on 11/09/22 at 1:20 P.M., Resident 10 indicated sometimes the food wasn't good. She never got a menu. She never knew what she was getting until her tray came to her room. There were some alternate choices, but she couldn't choose those until she saw the tray and then would order an alternate. During an observation and interview on 11/15/22 at 1:57 P.M., Resident 10 was sitting in her room and indicated the lunch was good that day, but she had not received a menu to choose what she wanted. During an observation and interview on 11/16/22 at 11:37 A.M., Resident 10 had just received her lunch tray. She indicated she didn't get to choose what she wanted. A form sat on the tray that indicated what was for lunch, with a list of alternates food choice of grilled cheese, peanut butter and jelly, or a hamburger. She indicated a menu would be nice so she can choose something before the tray came. The clinical record for Resident 10 was reviewed on 11/15/22 at 3:31 P.M. A Quarterly MDS Assessment, dated 10/05/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, multiple sclerosis, anemia, hypertension, neurogenic bladder, anxiety, and depression. During an interview on 11/16/22 at 9:16 A.M., LPN 6 indicated the residents did not get menus to choose what they wanted to eat. The get their meal and then if they wanted something different the staff would go to the kitchen and order them something else. During an interview on 11/16/22 at 3:30 P.M., the Activities Director indicated the residents used to get a menu for the day in the daily packet they would distribute in the mornings, but it had faded out and not been in the packets anymore. During an interview on 11/17/22 at 3:51 P.M., the Administrator indicated the resident menu was posted daily in the dining room for the residents to view. They could always ask what was on the menu for the day. When the resident received their tray, and they didn't like what was on it then they could ask the staff to get them something else. The kitchen staff usually knew what the residents liked and disliked. They did not have a facility policy related to menus. 3.1-21(a)(1) 3.1-21(a)(2) 3.1-21(a)(4) Based on interview and observation, the facility failed to provide menus and palatable meals for 3 of 24 residents reviewed. (Residents 27, 40, and 10) Findings include: 1. During an interview and observation on 11/09/22 at 11:41 A.M., Resident 27 indicated the chicken did not taste like chicken. They had a lot of pork. The food tastes poor. If you got a grilled cheese they would lay it on top of the vegetables. They had not gotten a menu for at least a year. They used to give out a menu for the week. They do not know what they are having until their meal is served. If they wanted something different it took a long time to get it and you may not get it at all. They were supposed to be able to get a salad if they wanted it but they cannot get it anymore. The soup had no taste. It was just like water. The resident received her lunch tray and her grilled cheese was laying on top of her vegetables and was limp. The resident indicated it was greasy and soggy. During an interview on 11/17/22 at 2:33 P.M., the DM (Dietary Manager) indicated residents got a daily packet with activities and the menu for the day. It just showed what was on the menu for the day. The residents do not get a menu the day before for what is available for the next day. The residents do not get a monthly menu. When they get their tray, if they don't like what they get, they can send one of the nurses down to ask the kitchen staff for something else. The clinical record was reviewed on 11/17/22 at 2:49 P.M. A Significant Change MDS (Minimum Data Set) assessment, dated 08/24/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, arthritis, anxiety, depression, and lymphedema. 2. During an interview on 11/09/22 at 12:07 P.M., Resident 40 indicated she had gotten her teeth pulled to get a partial plate. They were supposed to bring her soft foods but they didn't. They say they don't have cottage cheese or pudding. They do not get menus anymore. They got a paper on their tray when their meal was served saying what was on their plate. The clinical record was reviewed on 11/17/22 at 2:40 P.M. A Quarterly MDS assessment, dated 09/18/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, hypertension, anxiety, depression, and history of stroke.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to demonstrate ongoing corrective actions were in place to address unresolved quality deficiencies related to pressure ulcers, that were previously cited on the last annual survey for 1 of 11 care areas reviewed. (pressure ulcers) Findings include: The current facility policy, titled Quality Assurance / Performance Improvement Program (QAPI), was provided by the Administrator on 11/17/22 at 4:08 P.M. The policy indicated, .It is the intent of this facility to conduct an on-going Quality Assurance / Performance Improvement (QAPI) program designed to systematically monitor, evaluate, and improve the quality and appropriateness of resident care . During the Annual Recertification and complaint survey, from 11/09/22 to 11/17/22, one deficiency was a repeated citation from the last annual survey, F686. The facility's Quality Assurance Committee did not implement on-going appropriate measures to correct identified issues or prevent deficiencies as follows: Pressure Ulcers: Four residents acquired pressure ulcer wounds that the facility failed to prevent, identify, and appropriately administer treatments to. Cross reference F686 During an interview on 11/17/22 at 4:28 P.M., the Administrator indicated the findings from last survey were addressed in their Plan of Correction. They conducted audits and monitored the issues for a least 6 months. The DON (Director of Nursing) indicated they currently had a QAPI in place for wounds and falls. They started one in June for falls, and May for wounds. They were self-identified concerns when the DON started working in the facility. At 4:56 P.M., the Administrator indicated the DON started in her position in May, put the QAPI into place, but it hadn't been updated as it should have been. Moving forward, it would be addressed. There were issues with communication between the floor staff and management. The FACILITY PLAN OF ACTION / CONTINUOUS QUALITY IMPROVEMENT record for in house pressure wounds was provided by the DON on 11/17/22 at 5:00 P.M. The record's last documented date was 05/23/22. 3.1-52(b)(2)

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most Indiana facilities.

Concerns

• 44 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• Grade F (35/100). Below average facility with significant concerns.

Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Waters Of Batesville, The's CMS Rating?

CMS assigns WATERS OF BATESVILLE, THE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Indiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Waters Of Batesville, The Staffed?

CMS rates WATERS OF BATESVILLE, THE's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 54%, compared to the Indiana average of 46%. RN turnover specifically is 57%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Waters Of Batesville, The?

State health inspectors documented 44 deficiencies at WATERS OF BATESVILLE, THE during 2022 to 2025. These included: 1 that caused actual resident harm and 43 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Waters Of Batesville, The?

WATERS OF BATESVILLE, THE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by INFINITY HEALTHCARE CONSULTING, a chain that manages multiple nursing homes. With 86 certified beds and approximately 53 residents (about 62% occupancy), it is a smaller facility located in BATESVILLE, Indiana.

How Does Waters Of Batesville, The Compare to Other Indiana Nursing Homes?

Compared to the 100 nursing homes in Indiana, WATERS OF BATESVILLE, THE's overall rating (1 stars) is below the state average of 3.1, staff turnover (54%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Waters Of Batesville, The?

Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Waters Of Batesville, The Safe?

Based on CMS inspection data, WATERS OF BATESVILLE, THE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Indiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Waters Of Batesville, The Stick Around?

WATERS OF BATESVILLE, THE has a staff turnover rate of 54%, which is 8 percentage points above the Indiana average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Waters Of Batesville, The Ever Fined?

WATERS OF BATESVILLE, THE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Waters Of Batesville, The on Any Federal Watch List?

WATERS OF BATESVILLE, THE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 86
Avg. Residents: 53
Occupancy: 61.6%
Ownership: Non profit - Corporation
Chain: INFINITY HEALTHCARE CONSULTING
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
1 Actual Harm citation: -5
44 Deficiencies: -10
Final Score: 35/100

Nearby Alternatives

ST ANDREWS HEALTH CAMPUS 5-star SILVER MEMORIES HEALTH CARE 4-star RIPLEY CROSSING 3-star

View all in BATESVILLE →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 155233