Based on observation and interview, the facility failed to dispose of unlabeled and unused medications for 2 of 4 medication carts reviewed for medication storage and labeling. (Medication Cart B and Medication Cart C) Findings include: During a medication storage observation of Medication Cart B, accompanied by QMA 3 on 3/5/25 at 11:17 a.m., a loose pill was found on the bottom of the second drawer, towards the back of the cart. An additional loose pill was found at the bottom of the second drawer. QMA 3 indicated the pills should be disposed of. The medication carts were cleaned out once a week. Any loose pills would be discarded using the drug buster solution. During a medication storage observation of Medication Cart C, accompanied by QMA 3 on 3/5/25 at 11:22 a.m., a loose pill was found on the bottom of the second drawer, towards the middle of the drawer. QMA 3 indicated the pill should be disposed of. During an interview with the Corporate Nurse, during the medication cart observation, she indicated loose pills should be disposed of using the drug buster solution. A current facility policy, titled Medication Storage and Expiration, provided by the Administrator on 3/6/25 at 3:35 p.m., indicated the following: .Facility should destroy and reorder medications with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels or cautionary instructions 3.1-25(j)

Based on observation, record review, and interview, the facility failed to ensure oxygen was not titrated without a physician's order for 1 of 2 residents reviewed for respiratory care (Resident 29). Findings include: During an observation on 7/18/23 at 10:41 a.m., Resident 29 rested quietly in bed with her eyes closed. She received oxygen at 3 lpm (liters per minute) per nasal cannula. On 7/19/23 at 9:51 a.m., the resident rested in bed with her eyes closed and received oxygen at 3 lpm per nasal cannula. On 7/20/23 at 9:49 a.m., the resident rested in bed with her eyes closed. Her respirations were noisy and congested. She received oxygen at 3 lpm per nasal cannula. The resident's clinical record was reviewed on 7/19/23 at 2:54 p.m. Her diagnoses included chronic obstructive pulmonary disease, pulmonary fibrosis, heart failure, peripheral vascular disease, hypotension, and atherosclerotic heart disease of the native coronary artery without angina pectoris. Current physician's orders included morphine (opioid pain medication) concentrate solution 100 mg/5 ml: 0.25 ml every four hours (7/19/23) and admit to hospice (5/31/23). The facility clinical record lacked physician orders for oxygen therapy. A current care plan, dated 5/30/23, revised on 6/19/23, indicated the resident had the potential for impaired gas exchange related to COPD (chronic obstructive pulmonary disease). The goal, with a target date of 9/5/23, was the resident would have adequate respiratory functions as evidenced by decreased or absence of dyspnea, improved breath sounds, decreased or absence of shortness of breath, and improved oximetry results. The interventions included administer oxygen as ordered (5/31/23). A current care plan, dated 5/30/23, revised on 6/19/23, indicated the resident was at risk for ineffective tissue perfusion related to heart failure, atherosclerotic heart disease of the native coronary artery without angina pectoris, peripheral vascular disease, and hypotension. The interventions included administer oxygen as ordered (5/31/23). A Progress Note, dated 5/31/23 at 2:40 p.m., indicated the resident was admitted to the facility with an oxygen saturation of 81% on room air. Oxygen was applied at 2 lpm. A Progress Note, dated 6/8/23 at 4:28 p.m., indicated the resident received oxygen per nasal cannula at 3 lpm. A Progress Note, dated 7/9/23 at 1:48 p.m., indicated the resident's oxygen saturation was 96% with oxygen on at 3 lpm. During an interview, on 7/20/23 at 10:09 a.m., LPN 51 indicated the resident's oxygen delivery was kept around 3 lpm. They titrated the oxygen according to the oxygen saturation levels. Oxygen therapy needed to be ordered by a medical provider. She was unable to locate orders for oxygen for the resident in the facility's clinical record system. During an interview, on 7/20/23 at 10:13 a.m., LPN 52 indicated the resident should have an oxygen order. Many of the resident's medications had been discontinued recently. She was unable locate previous or current orders for the oxygen in the facility clinical record system. On 7/20/23 at 10:32 a.m., the Director of Nursing (DON) indicated the resident did not have an order for oxygen, but should have. Review of the resident's visit note report from the hospice binder, provided by the DON on 7/20/23 at 10:34 a.m., indicated the resident received oxygen at 3 lpm on 7/5/23. Review of the resident's client medication report from the hospice binder, provided by the DON on 7/20/23 at 10:34 a.m., indicated the resident had a hospice order for continuous oxygen at 2-4 lpm. The order lacked parameters for adjustment of oxygen liter flow. The hospice contract agreement with the facility, provided by the administrator during the entrance conference on 7/18/23, was reviewed, on 7/21/23 at 2:01 p.m., and indicated .Responsibilities of the Facility .Maintain an accurate medical record that includes all services and events provided. During an interview, on 7/24/23 at 3:07 p.m., the Administrator indicated the facility used a quality assurance tool for oxygen use. The tool was used to ensure oxygen use protocols were followed. The tool was completed in 1/2023 and 5/2023 and was due again 9/2023. The tool included checking for an order for oxygen. The tool completed for 5/2023 had been completed just prior to the admission of the resident. He indicated the resident had a hospice order for oxygen. This order had not been placed in the facility's orders for the resident. A current, undated facility policy, provided by the Administrator on 7/24/23 at 3:08 p.m., indicated, .Initiation of Oxygen 1) Verify physician order .4) Obtain the appropriate oxygen delivery device .7) Apply device to the patient with appropriate liter flow 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure narcotic medication was handled and accounted for according to facility policy for 1 of 6 residents reviewed for pharmaceutical services. (Resident B) Findings include: A review of Resident B's clinical record was completed on 7/20/23 at 11:04 a.m. Diagnoses included cerebral atherosclerosis, spastic quadriplegic cerebral palsy, and generalized anxiety disorder. A physician's order, dated 6/7/23 and discontinued on 6/20/23, indicated lorazepam (to treat anxiety) 0.5 mg (milligram) administer 1 mg every four hours for generalized anxiety disorder. During an interview on 7/20/23 at 11:45 a.m., the ADON indicated the medication count on 6/14/23 had been over for lorazepam 0.5 mg during the narcotic count the morning of 6/14/23. The night shift nurse (LPN 6) had administered baclofen (a muscle relaxer) instead of lorazepam. The baclofen medication card had been placed in the narcotic box in error. When LPN 6 arrived the next morning, QMA 3 told her something was off with the count. At that time, it was determined the baclofen had been given instead of lorazepam. The ADON contacted the NP regarding the error. The four Lorazepam tablets were destroyed by the ADON with QMA 3 as a witness. The ADON notified the DON and the Administrator and was counseled for destroying the medication instead of documenting the medication error. During an interview on 7/20/23 at 12:01 p.m., the DON indicated the facility paid for the four destroyed tablets to be replaced. She immediately educated the ADON on the appropriate way to handle a miscount of medications. LPN 6 would not confirm if she gave the baclofen or just skipped the lorazepam doses. During an interview on 7/20/23 at 12:07 p.m., the Administrator indicated he was made aware of the medication error and the inappropriate correction of the lorazepam count. The ADON was educated immediately regarding the policy for disposal of medications and medication errors. Review of a narcotic count sheet for June 2023, provided by the ADON on 7/20/23 at 12:28 p.m. indicated a handwritten notation of count corrected, initialed by the ADON on 6/14/23. A Medication/Treatment Error Report dated 6/14/23 at 9:00 a.m., received from the ADON 7/23/23 at 12:00 p.m., indicated lorazepam 1 mg (two 0.5 mg tablets) not given at 12:00 a.m. and 4:00 a.m. The NP was notified on 6/14/23 at 8 a.m. and Resident B's family was notified on 6/14/23 at 8:30 a.m. The DON was notified by the ADON on 6/14/23 at 9:00 a.m. Measures taken to prevent recurrence included .education and med pass observation. LPN 6, who made the error, refused to sign the Medication/Treatment Error Report and quit her job. The document was signed by the DON on 6/15/23. A document titled Drug Disposition Form dated 6/14/23 at 8:30 a.m. and received from ADON on 7/20/23 at 12:00 p.m. indicated RX # 604434560, drug Lorazepam (Ativan) 0.5 mg, quantity 4, reason for destruction code 5 (dropped/ruined), and method of destruction code D (other - drug buster), was signed by the ADON and QMA 3. A document titled Record of Facility Inservice dated 6/14/23 and received from DON on 7/20/23 at 12:28 p.m. indicated the in-service focused on counting narcotics at shift change and included a summary indicating Nurses and QMA's need to count prior to handing off cart keys to anyone. Every shift, every time. The DON provided a Quality Assurance Tool on 7/24/23 at 2:51 p.m The document was undated. During an interview on 7/24/23 at 2:51 p.m., the DON indicated the date should have been recorded as 6/30/23. The assessment tool was completed by the Regional Director of Clinical Services (RDCS).The document indicated the suspected drug diversion was immediately reported to the DON and/or Administrator, an investigation of the diversion was started immediately and an interview of all staff involved was completed. Human Resources was notified of the drug diversion with potential recommendations followed. The narcotic count sheets were reviewed for the entire facility for discrepancies or unusual activity and indicated no other discrepancies were observed. Individual controlled records were reviewed for each resident for discrepancies and no other discrepancies were observed. The facility cameras were reviewed as needed or available. All narcotics were counted and accuracy was verified for the entire building including the Emergency Drug Kits. The shred boxes were investigated for potential missing card/sheets. A soft file was kept with Administrator/DON regarding investigation with summary of findings typed up. Narcotic storage and destruction was occurring per policy. Staff education was provided for any areas of opportunity. A current Medication Errors policy with a revision date of 11/2018, was provided by the DON on 7/21/23 at 3:01 p.m., and indicated the following: .Policy - It is the policy of this provider to ensure residents residing in the facility are free of medication errors and the facility maintains a medication error rate of less than 5%. Procedure - When a suspected medication error is identified, the nurse will immediately assess the condition of the affected resident and notify the physician of the event. The responsible party/family will be notified of the error. The DON will be notified of the error, resident condition. The charge nurse will correct findings contributing to the error (i.e. destroy/return discontinued meds, correcting transcription errors, etc.) to prevent further errors. The charge nurse will complete a medication error report, including a brief summary of findings. Documentation in the medical record will include physicians/family notification, type of error, and assessment of resident. The licensed nurse/QMA responsible for the error will be required to meet with the DON/designee to review the medication error report. Education/Disciplinary actions are determined based on the medication error and the individual staff member's past performance errors. Medication errors resulting in outcomes that require medical treatment beyond an ER/Physician evaluation or monitoring of vital signs will be reported to IDOH and reviewed as needed in facility QAPI meetings The deficient practice was corrected by 7/3/23, prior to the start of the survey, and was therefore past noncompliance. The facility had completed assessments, audits, and education related to the facility's Medication Errors protocol. This Federal tag relates to complaint IN00412174. 3.1-25(n)