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

WATERS OF LEBANON, THE has 37 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

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

WATERS OF LEBANON, THE has a three-star staffing rating from CMS with 0.94 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 LEBANON, THE located?

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

How many beds does WATERS OF LEBANON, THE have?

WATERS OF LEBANON, THE has 64 certified beds.

Who owns WATERS OF LEBANON, THE?

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

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

Families visiting WATERS OF LEBANON, 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 LEBANON, THE compare to other nursing homes?

WATERS OF LEBANON, THE has a 2-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 LEBANON, THE

Name: WATERS OF LEBANON, THE
Address: 1585 PERRY WORTH RD, LEBANON, IN, 46052, US
Telephone: (765) 482-6391
Rating: 2.0

1585 PERRY WORTH RD, LEBANON, IN 46052 · (765) 482-6391

For profit - Corporation 64 Beds INFINITY HEALTHCARE CONSULTING Data: November 2025

Trust Grade

50/100

#400 of 505 in IN

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WATERS OF LEBANON, THE nursing home in LEBANON, IN - Photo 1 of 3

WATERS OF LEBANON, THE nursing home in LEBANON, IN - Photo 2 of 3

Photo by Lisa Suiter

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Last Inspection: September 2024

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

Overview

The Waters of Lebanon nursing home has a Trust Grade of C, indicating it is average and falls in the middle of the pack among facilities. It ranks #400 out of 505 in Indiana, which places it in the bottom half, and #6 out of 6 in Boone County, meaning there is only one local option that performs better. The facility is currently improving, having reduced its issues from 8 in 2024 to just 1 in 2025. Staffing is a relative strength, with a 3/5 star rating and a turnover rate of 40%, which is better than the state average. However, there are some concerning incidents, including improper medication storage that risks resident safety and failures in food safety practices that could lead to health risks. On a positive note, the facility has no fines on record and offers more RN coverage than 93% of Indiana facilities, which helps ensure better care.

Trust Score: C
In Indiana: #400/505
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: 40% turnover. Near Indiana's 48% average. Typical for the industry.
Penalties: No fines on record. Clean compliance history, better than most Indiana facilities.
Skilled Nurses: Each resident gets 56 minutes of Registered Nurse (RN) attention daily — more than average for Indiana. RNs are trained to catch health problems early.
Violations: 37 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★☆☆

3.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 8 issues

2025: 1 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (40%)
8 points below Indiana average of 48%

Facility shows strength in fire safety.

The Bad

2-Star Overall Rating

Below Indiana average (3.1)

Below average - review inspection findings carefully

Staff Turnover: 40%

Near Indiana avg (46%)

Typical for the industry

Chain: INFINITY HEALTHCARE CONSULTING

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 37 deficiencies on record

Jul 2025 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

Accident Prevention (Tag F0689)

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 follow safety guidelines and to provide adequate employee training resulting in a resident's wheelchair falling over during transport in a facility vehicle for 1 of 3 residents reviewed for accidents (Resident B). Findings include: On 7/30/25 at 3:20 p.m., Resident B was observed lying on the bed watching television. The bed was positioned against the wall lower to the floor and a small manual wheelchair was sitting beside the top of the bed. The resident indicated, the prior week while she was being driven to her dialysis appointment in the facility van, her wheelchair tipped over and she fell hitting her head on the floor. The van was being driven by a maintenance staff worker, not the facility's primary transportation driver. Resident B indicated she was not sure exactly what happened, but she did not think she had been properly secured in the van because when they turned a corner she fell. The resident indicated she had pain on one side of her body after the fall and was subsequently seen in the emergency room (ER) of a nearby hospital. Resident B's clinical record was reviewed on 7/30/25 at 2:00 p.m. Resident B who was admitted on [DATE] had diagnoses to include end stage renal disease (ESRD - kidney failure), difficulty walking, and dependence on renal dialysis.admission Minimum Data Set (MDS) assessments, completed on 7/26/25, assessed Resident B as being cognitively intact. The resident was dependent on staff for bed mobility, transfers in and out of bed, and transfers in and out of a car or van. The resident used a manual wheelchair for mobility. An incident report, dated 7/26/25 at 6:50 a.m., documented Resident B as having had a fall. Physician's orders for Resident B included, a. Dialysis weekly on Monday, Wednesday, and Friday.b. Apixaban (Eliquis - a blood thinner) 2.5 milligrams (mg) give 1 tablet by mouth daily.An electronic notification to providers, dated 7/26/25 at 6:50 a.m., indicated Resident B had fallen. An examination of the resident indicated she was currently taking an anticoagulant medication, was complaining of pain after the fall, and one pupil was restricted. The primary provider responded with a recommendation to send the resident to the ER for testing and x-rays. A nursing progress note, dated 7/26/25 at 8:36 a.m., indicated Resident B had an unwitnessed fall while being transported to dialysis. The resident's wheelchair fell backwards, and the resident fell flat on her back and head. The resident returned to the facility where she was assessed and found to have right pupil constriction and complaints of head and right arm pain. Resident B was sent out to the ER. An interdisciplinary team (IDT) progress note, dated 7/28/25 at 9:09 a.m., indicated Resident B had an unwitnessed fall during transport to a dialysis appointment. The resident fell backward in a wheelchair during transport, and Registered Nurse (RN) 11 who had been following the van pulled over and assessed the resident, who said she was sore. Upon return to the facility, Resident B complained of pain in her shoulder, and she was sent to the ER for evaluation. A local hospital report, dated 7/26/25, indicated Resident B who was taking Eliquis presented to the ER after a mechanical fall experience while on her way to dialysis. The resident was getting in the van and had a mechanical fall, and she stated she hit her head and her right arm. The resident complained of having a mild headache but severe right arm pain that was constant non-radiating and was worse with touch and movement. Computed tomography (CT) scans of the head, and x-rays of the right shoulder and right elbow were performed. A care plan written for Resident B after her fall on 7/26/25, indicated the resident was at risk of falls related to general weakness, and difficulty walking. Interventions included ensuring placement of seatbelts during transportation by facility staff and provide education to staff who transported the resident to outside appointments. A transportation van education sign-in sheet, dated 6/20/25, indicated 6 employees had been educated on the correct operation of a van lift, correct procedure for loading/unloading a resident on a lift, correct procedure for securing a resident with the proper tie downs, and manual operation of a van lift. Maintenance Worker 11 signed as having received the education. The facility lacked documentation the 6 employees who were providing resident transport with the facility van had been observed for competence, or that the employees had been re-educated regarding safety protocols after the incident that had occurred on the van 6/20/25.During an interview on 7/31/25 at 9:44 a.m., the Director of Nursing (DON) indicated Resident B had been admitted to the facility with orders for dialysis at a local dialysis center three times a week, and she was being transported in the facility van. On 7/26/25 while enroute to dialysis, Resident B's wheelchair tipped backwards, and the resident fell resulting in pain to her shoulder and head. Maintenance Worker 11 later indicated at the time of the incident, the front belt was off the wheelchair. The DON indicated, to her knowledge, there was nothing mechanically wrong with the van. During an interview on 7/31/25 at 10:10 a.m., the Administrator (ADM) indicated 2 months ago, an outside vendor had provided van safety education to the transportation drivers. On 7/26/25 Resident B fell on the facility bus when Maintenance Staff 11 failed to anchor her wheelchair properly on the front base of the wheelchair. Maintenance Worker 11 had attached straps to the front wheels of the wheelchair versus the front base, and the straps had come off while the van was moving down the road causing the resident's wheelchair to fall backwards. Maintenance Worker 11 had been trained on van safety last month to include how to secure a resident in the van. During an interview on 7/31/25 at 1:05 p.m., Maintenance Worker 11 indicated on 7/26/25 Resident B's wheelchair had tipped over causing the resident to fall while he was taking her to dialysis on the facility van. Maintenance Worker 11 indicated after turning a corner not far from the facility, he heard the resident yell she had fallen, and when he looked into the rearview mirror he could no longer see her sitting in her wheelchair behind him. Maintenance Worker 11 indicated he had not found out until after Resident B's fall that he had been hooking up resident wheelchairs in the van incorrectly. Maintenance Worker 11 indicated he and 5 others facility employees had been trained on van safety in June, but the group had been standing around the van in a group while the instructor demonstrated the correct procedure of hooking to the frame versus the wheels, and he had been unable to visualize the process while looking through the van windows. On 7/31/25 at 1:38pm the ADM provided a Safety During Transport - Securing Chair policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, It is the policy of this facility to secure resident wheelchair in transport vehicle to ensure resident safety during transport.9. Final check. a. Two [2] front straps 30 to 45-degree angles. Two [2] rear straps 30 to 45-degree angles.c. All straps are not attached to any adjustable or removable parts of the wheelchair. No straps are attached to the footrests, armrests, or wheels.This citation relates to Complaint 2573037.3.1-45(a)(1)3.1-45(a)(2)

Sept 2024 7 deficiencies

CONCERN (D)

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

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to ensure a resident had a self-adminstration asessment for a medication (Ventolin) stored at bedside for 1 of 12 residents (Resident 34) reviewed for medications at bedside. Findings include: On 9/10/24 at 10:12 a.m., an inhaler of Ventolin (a bronchodilator) used to treat chronic obstructive pulmonary disease (COPD) was observed on Resident 34's bedside table. Resident 34 was not observed in her room. The medication was left unattended. On 9/10/24 11:28 a.m., a record review was completed for Resident 34. She had the following diagnoses which included but not limited to COPD, heart failure, dementia, and anxiety disorder. She had an order for Ventolin HFA inhalation aerosol solution 108 (90 base) mcg/act (micrograms/actuation) (albuterol sulfate) take two puffs inhale orally every four hours as needed for shortness of breath (SOB). Residnet 34's record lacked a medication self-administration assessment. On 9/10/24 at 11:00 a.m., during an interview with the Director of Nursing, she indicated the medication should not have been left in resident's room. A policy titled, Self-Administration of Medication by Residents with a date of March 2023, was provided by the Director of Nursing (DON) on 9/10/24 at 11:52 a.m. It indicated, An interdisciplinary team determines resident's ability to self-administer medications by means of a skill assessment as follows 3.1-45(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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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Based on and interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded for 5 of 12 residents reviewed for resident assessments (Residents 6, 34, 13, 43 and 29). Findings include: 1. On 9/10/24 at 11:16 a.m., a record review was completed for Resident 6. She had the following diagnoses which included, but were not limited to, End Stage Renal Disease (ESRD- disease and degeneration of the kidneys), type 2 diabetes (an inability for the body to produce/process blood sugar), and muscle weakness. She had a physician's order, dated 1/27/24, which indicated she may attend dialysis on Monday, Wednesday, and Friday at a specific center. She had a comprehensive care plan, dated 1/26/24, which indicated she had a diagnosis of ESRD and required dialysis treatment. A Minimum Data Set (MDS) assessment, dated 8/23/24, indicated Resident 6 had not recieved dialysis treatments. 2. On 9/10/24 at 11:35 a.m., a record review was completed for Resident 34. She had the following diagnoses which included, but were not limited to, heart failure, muscle weakness, schizophrenia unspecified, and psychosis (a set of symptoms that can cause a person to lose touch with reality, making it difficult to distinguish what is real and what is not). An undated comprehensive care plan indicated she qualified for classifcation of a Level II related to her diagnosis of schizophrenia, but did not require specialized services. A MDS assessment, dated 5/28/24, was not coded to accuratly reflect her Level II status. 3. On 9/10/24 at 11:05 a.m., a record review was completed for Resident 13. He had the following diagnoses which included but not limited to heart failure, sleep apnea, major depression, chronic kidney disease, and hyperlipidemia (high cholesterol). A MDS assessment, dated 8/19/24, was coded to indicated her recieved an anticoagulant medication. Resident 13's physician orders were reviewed and laked docuemntation that he recieved an anticoagulant medication. During an interview on 9/10/24 at 11:44 a.m., the Regional MDS Consultant (MDSC) indicated, the facility should follow the RAI (Rap Assessment Instrument) for information and guidance related to anticoagulant medication coding. Resident 13 recieved an antiplatlet medication which had been miscoded as an anticogulant. 5. On 9/10/24 at 11:00 a.m., Resident 29's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of disease which affect lung tissue and capacity making breathing more difficult), congestive heart failure, and lung cancer. She had a current and active physician order, initiated 7/5/24, to receive hospice services. A nursing progress note, dated 7/6/24 at 9:10 p.m., indicated, . Resident admitted to hospice during previous shift . A comprehensive admission minimum data set (MDS) assessment, dated 7/10/24, indicated Resident 29 did not receive hospice services. During an interview on 9/10/24 at 12:09 p.m., the Regional MDS Consultant, (MDSC) indicated Resident 29's admission MDS should have coded that she received Hospice services since the MDS was dated 5 days after her Hospice services began. At that time, the MDSC indicated, there was no MDS policy, but the facility followed the RAI (Resident Assessment Instrument) guidelines. 4. On 9/11/24 at 11:41 a.m., Resident 43's record was reviewed. His diagnoses included, but were not limited to, diabetes mellitus (blood sugar disorder), essential hypertension (high blood pressure), and cerebrovascular disease (conditions that affect blood flow to the brain). His quarterly MDS assessment, dated 8/7/24, indicated Resident 43 was on an anticoagulant. His physician orders, dated 7/20/24, indicated Resident 43 had an order for aspirin 81 mg, give 1 tablet one time a day related to cerebrovascular disease and essential hypertension. An anticoagulant was not observed. During an interview, on 9/12/24 at 9:45 a.m., the Director of Nursing (DON) indicated aspirin should not have been coded on the MDS (Minimum Data Set) as an anticoagulant and the MDS Coordinator (MDSC) should have followed the RAI (Resident Assessment Instrument) Manual. During an interview, on 9/12/24 at 10:18 a.m., the Regional MDS Consultant (RMDSC) indicated she went back to the MDS record and changed the aspirin use from anticoagulant to antiplatelet use. A review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17, dated October 2019, was completed. It indicated, .Anticoagulant .Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period .Do not code antiplatelet medications such as aspirin .here

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

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 ensure a resident who was at risk for developing pressure ulcers, received a pressure reducing device for her wheelchair for 1 of 2 residents reviewed for pressure ulcers (Resident 29). Findings include: On 9/9/24 at 10:10 a.m., Resident 29 was observed. She was seated in a wheelchair (WC) with her overbed table in front of her. She rested her head in her hand with her eyes closed. No Pressure reducing cushion was observed on her WC seat at that time. On 9/9/24 at 12:33 p.m., Resident 29 was observed. She remained seated in her WC, no pressure reducing cushion was observed, as lunch trays were delivered. On 9/9/24 at 1:23 p.m., Resident 29 was observed. She remained seated in her WC and no pressure reducing cushion was observed in place. On 9/10/24 at 11:00 a.m., Resident 29's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of disease which affect lung tissue and capacity making breathing more difficult), congestive heart failure, and lung cancer. A comprehensive admission Minimum Data Set (MDS) assessment, dated 7/10/24, indicated Resident 29 was at risk for the development of pressure ulcers and required a pressure reducing device for her chair. Resident 29 had an admission comprehensive care plan, dated 7/2024, which indicated, she was at risk for the development of pressure ulcer related to her diagnoses and required interventions which included but were not limited to, follow preventative measures as ordered. During an interview on 9/11/24 at 10:00 a.m., the Director of Nursing (DON) indicated Resident 29 had not come to the facility with a WC, but shortly after her admission to Hospice, she had been evaluated by therapy and was provided a WC with a pressure reducing cushion. The DON indicated Resident 29 should have the cushion on her WC seat and she would go look for it. On 9/11/24 at 10:30 a.m., the DON indicated nursing had not been able to locate Resident 29's cushion and she did not know how long Resident 29 had gone without it. On 9/11/24 at 10:30 a.m., the DON provided a copy of Resident 29's order invoice which indicated a 16-inch gel pressure reducing cushion had been provided. On 9/11/24 at 10:30 a.m., the DON provided a copy of current facility policy titled, S-W-A-T Program, Skin Weight Assessment Team Program Meeting Guidance, dated 10/9/23. The policy indicated, .it is the intent of the facility to assess the nutritional status as well as the skin condition status of each resident and to timely address any issues or any potential for issues related to weight and/or skin. The SWAT Team will monito residents who meet the criteria on a weekly basis to ensure that measures are in place to avoid weight loss in at risk for weight loss resident; as well as to avoid skin breakdown in residents at risk for skin breakdown- based on their medical assessments an overall health status . interventions decided upon by the team will be recorded on the individual resident monitoring and record form. The appropriate disciplines will address interventions requiring a physician's order, will have that order obtained. Any new intervention will be added to the resident's care plan 3.1-40(a)

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

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 assess on a quarterly basis to determine any improvement, decline or remained the same level with mobility and Range of Motion (ROM) for 2 of 3 residents reviewed (Resident 1 and 36). Findings include: 1. On 9/10/24 at 2:04 p.m., a record review was completed for Resident 1. He had the following diagnoses which included but not limited to type 2 diabetes, difficulty walking, heart failure, and history of falling. Resident 1 had undated care plans that indicated he required assistance with his ADLs related to a history of falls, weakness, and decreased mobility. He had an undated care plan that indicated he required a restorative program for Active Range of Motion (AROM) to restore or maintain his functional range of motion (the amount of movement a joint or body part can make, usually measured in degrees). Interventions included to evaluate and revise the program as needed and to notify nursing of decline or improvement for further evaluation, possible therapy and or MD (Medical Director) notification. He had an undated care plan indicating he required a restorative program for dressing/grooming to restore or maintain his ability to dress and undress, bathe, wash, and complete personal hygiene. Interventions included to evaluate and revise the program as needed and to notify the restorative nurse of decline or improvement for further evaluation, possible therapy or MD notification. His record lacked a comprehensive quarterly assessment to measure his extent of movement in his joints and the identification of limitations, along with any improvements, decline, or if he functionally remained at the same level of care. 2. On 9/11/24 at 11:43 a.m., a record review was completed for Resident 36. He had the following diagnoses which included but not limited to difficulty swallowing, difficult speaking, Chronic Obstructive Pulmonary Disease (COPD) (a lung disease that damages the airways and makes it hard to breathe), essential hypertension, and high cholesterol. He had a care plan, dated 3/17/21, that indicated he required a restorative program for dressing/grooming to restore or maintain his ability to dress and undress, bathe, wash and complete personal hygiene tasks. Interventions included to provide the program as scheduled, evaluate and revise the program as needed, and notify the restorative nurse of decline or improvement for further evaluation, possible therapy or MD notification. His MDS, dated [DATE], indicated he did not receive the program as indicated. His record lacked a comprehensive quarterly assessment to measure his extent of movement in his joints and the identification of limitations, along with any improvements, decline, or if he functionally remained at the same level of care. During an interview with the Regional MDS Consultant on 9/12/24 at 10:44 a.m. She indicated therapy will evaluate and recommend residents to restorative. Certified Nursing Assistants (CNA) provide the restorative programs. They document in Point of Care (POC) but the facility failed to refresh and initiate (pull) into the POC in order for information to transfer to the MDS. They were supposed to do assessments on a quarterly basis. She indicated they were working on performing assessment and checking for minutes. During an interview with the Regional Nurse Consultant on 9/10/24 at 11:44 a.m., the Regional MDS Consultant indicated they followed the Resident Assessment Instrument (RAI) manual for policies pertaining to restorative programs. 3.1-42(a)(1) 3.1-42(a)(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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident received oxygen as ordered for 1 of 1 resident reviewed for Oxygen services (Resident 29). Findings include: On [DATE] at 10:10 a.m., Resident 29 was observed. She was seated in a wheelchair (WC) with her overbed table in front of her. She rested her head in her hand with her eyes closed. An oxygen (O2) concentrator was observed against the wall with tubing in a clear plastic bag. The Nasal Canula (NC) was not in place, and the concentrator was not turned on. On [DATE] at 12:33 p.m., Resident 29 was observed. She remained seated in her WC with her eyes closed. Her O2-concentrator remained off and no O2 was applied to Resident 29. On [DATE] at 1:23 p.m., Resident 29 was observed. She remained seated in her WC with her eyes closed. Her O2 was not in place, and the concentrator remained off. On [DATE] at 10:56 a.m., Resident 29 was observed in bed with her eyes closed. Her O2 was not in place, and the concentrator remained off. On [DATE] at 12:00 p.m., Resident 29 was observed. She remained in bed, but her eyes were open and she indicated she did not feel good. Resident 29 indicated she was uncomfortable, and needed her pants pulled up. She pulled her sheet down and revealed her pants which were pulled down to the middle of her thighs, she indicated the aide forgot to pull them up after she got changed. Resident 29 indicated she was in pain. On [DATE] at 12:02 p.m., Qualified Medication Aide (QMA) 23 was notified that Resident 29 was in pain and needed assistance to pull her pants up. QMA 23 pulled Resident 29's scheduled pain medication and entered her room within five minutes. QMA 23 attempted to help Resident 29 reposition to pull up her pants, but Resident 29 struggled to roll from side to side and quickly became out of breath with her excursion. Resident 29 became frustrated and asked QMA 23 to stop and just give her the medicine. Around that time, Registered Nurse (RN) 13 entered the room to assist QMA 23. RN 13 helped the resident put her hair in a ponytail and resituated her over-bed table within the resident's reach. When Resident 29 was comfortable, RN 13 and QMA 23 left her room, and neither offered to place the oxygen on her before they left. On [DATE] at 9:08 a.m., Resident 29 was observed in bed. Her eyes were open and she indicated she felt much better than she had the day before. Her O2 NC was observed on the floor. On [DATE] at 9:10 a.m., RN 13 indicated Resident 29 had previous orders for O2 to be applied to keep her oxygen saturation level above 90, but RN 13 believed that order had been changed to as needed, since Resident 29 was often noncompliant with wearing her O2. She did not like the way it felt in her nose, and she often pulled the tubing off herself. On [DATE] at 9:15 a.m., RN 13 entered Resident 29's room. She picked up the O2 canula from the floor and detached it from the concentrator. She tidied the room a little bit before she left and pleasantly engaged with Resident 29. Upon leaving Resident 29's room, RN 13 did not offer placing a new O2 NC. On [DATE] at 11:00 a.m., Resident 29's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of disease which affect lung tissue and capacity making breathing more difficult), congestive heart failure, and lung cancer. She had a current and active physician order to apply O2 via NC every shift at 3 Liters, to maintain oxygen saturations above 90. A comprehensive admission minimum data set (MDS) assessment, dated [DATE], indicated Resident 29 received oxygen services. Resident 29 had an admission comprehensive care plan, dated 7/24, which indicated she was at risk for complications with gas exchanges related to her diagnosis of lung cancer and that she received oxygen therapy. The care plan lacked revision to include details and/or interventions for her refusals to wear the O2 or noncompliance with oxygen therapy. The care plan lacked revision to include standing or as needed clarification of her physician's order for oxygen therapy. During an interview on [DATE] at 10:00 a.m., the Director of Nursing (DON) indicated, Resident 29 had an order for oxygen therapy to be applied every shift, but it should have been changed to as needed since she did often refuse or was noncompliant with wearing her NC. On [DATE] at 10:30 a.m., the DON provided a copy of current facility policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, revised [DATE]. The policy indicated, .the comprehensive care plan will further expand on the resident's risks, foals and interventions using the Person-Centered Plan of Care approach for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs. These needs will be defined from observation, interviews, clinical medical record review with the resident, residents; family 3.1-47(a)(6)

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 record review and interview, the facility failed to label tuberculosis testing serum appropriately for 1 of 2 medications rooms reviewed (100 hall). Findings include: On 9/9/24 at 10:38 a.m., a vial of tuberculin serum was observed undated and in the specimen refrigerator. LPN 21 removed the serum from the refrigerator. The freezer was approximately 2 inches deep with ice buildup in this refrigerator. On 9/10/24 at 10:40 a.m., during an interview with the Director of Nursing (DON), she indicated the serum should have been dated when it was opened. A policy titled, Tuberculosis Testing (Mantoux Test), dated March 2023, was provided by the Director of Nursing on 9/10/24 at 11:52 a.m. It indicated, .After a physician's order is secured, acquire the dose necessary from the vial located in the medication refrigerator. If opening a new vial, it must be initiated and dated, as it is only good for 30 days after opening the vial . 3.1-25(j) 3.1-25(m) 3.1-25(n)

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, interview, and record review the facility failed to ensure effective handwashing of staff delivering lunch trays for 2 of 4 residents observed for receiving lunch trays (Residents 42 and 43). Findings include: On 9/9/24 11:56 a.m., the Social Services Director (SSD) was observed removing Resident 42's lunch tray from the mobile kitchen cart and not using hand hygiene before entering and after leaving his room. A sign on his door indicated to stop because the resident required EBP. The sign indicated, .Everyone must: Clean their hands, including before entering and when leaving the room Then, without using hand hygiene, she returned to the mobile kitchen cart and removed and provided lunch for Resident 43. During an interview, on 9/9/24 at 11:59 a.m., the SSD indicated that she thought she had gelled her hands before entering and after leaving Resident 42 and Resident 43's room. During an interview, 9/9/24 at 12:00 p.m., the Assistant Director of Nursing (ADON) indicated the SSD should have used hand sanitizer before entering and leaving Resident 42 and Resident 43's room. During an interview, on 9/12/24 at 11:27 a.m., the Director of Nursing (DON) indicated Resident 42's roommate, Resident 43, had enhanced barrier precautions because he had a suprapubic catheter (urinary drainage system). On 9/11/24 at 11:46 a.m., Resident 43's record was reviewed. His physician order, dated 7/20/24, indicated, .Enhanced Barrier Precautions ever shift for catheter A current policy, titled, Guidelines for Enhanced Barrier Precautions - (EBP), An extension of Personal Protective Equipment - (PPE), dated December 2022, was provided by the DON, on 9/11/24 at 2:10 p.m. A review of the policy indicated, .Proper hand hygiene is a critical requirement in all aspects of resident care to include any precautions such as Universal/Standard/Contact/Droplet/Airborne as well as Enhanced (EBP) 3.1-21(i)(2) 3.1-21(i)(3)

Mar 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 F0583 (Tag F0583)

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 ensure a resident's right for his medical record to be kept private and confidential when it was not discussed without the resident's permission for 1 of 3 residents reviewed for resident's rights (Resident H). Findings include: During an interview on 3/7/2024 at 10:06 a.m., Resident H's family indicated they had received clinical information from the Business Office Manager (BOM), regarding Resident H's medical condition, treatment, and services on several occasions, which included a private meeting outside of the facility property. Information provided by the BOM to Resident H's family included but was not limited to the following details: a. The facility had not provided Resident H with wound care and there were no Wound Care notes. b. The facility had not provided Resident H Physical Therapy (PT), as ordered, and there were no PT notes. c. The BOM filed reports/grievances with the Executive Director (ED) in regard to her opinion of a lack of care for Resident H and had not received a response from the ED. d. The BOM shared her opinion/assumption that Resident H had decreased mental capacity. e. The BOM indicated she overheard a telephone conversation, which occurred between a facility nurse and Resident H's dialysis center. f. The facility had not created a care plan for Resident H's wounds. During an interview on 3/7/24 at 9:40 a.m., the BOM indicated she had given permission for Resident H's family to use the above information she provided if they wanted to file a complaint regarding the resident's care. The BOM indicated she believed she was qualified to provide clinical information to Resident H's family due to her experience as a Certified Nursing Assistant (CNA). During an interview on 3/7/24 at 10:41 a.m., the Regional Nurse Consultant (RNC) indicated it was not within the scope of practice for a BOM to provide clinical information to a resident or family member. The RNC indicated the discussion of resident information outside of the facility premises would have been considered a HIPAA (Health Insurance Portability and Accountability Act) violation. The RNC indicated it would be against facility policy to provide clinical information to a family member if they were not the POA (Power of Attorney) for the resident. During an interview on 3/7/24 at 11:00 a.m., the Director of Nursing (DON) indicated only clinical staff were permitted to provide clinical information to the resident and/or the POA. The DON indicated health information was considered confidential and could only be provided to family members if the resident or POA provided prior approval for the information to be disseminated to family members. The DON indicated if information was shared without the resident or POA's permission, it was considered a HIPAA violation. On 3/7/24 at 1:00 p.m., Resident H's medical record was reviewed. He was a long-term care resident who had diagnoses which included, but were not limited to, End Stage Renal Disease (permanent kidney failure requiring dialysis), Type 2 Diabetes, and Diabetic Neuropathy (nerve damage resulting in pain or numbness). Resident H's most recent comprehensive Minimum Data Set (MDS) assessment was an admission MDS dated [DATE]. The MDS indicated Resident H was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 of 15 indicating considered normal cognition. Resident H was listed as his own responsible party and did not have a POA. The record lacked documentation of a POA and/or Guardianship authority to determine who and/or when Resident H's medical record could be discussed. On 3/7/24 at 12:02 p.m., the (RNC) provided a copy of the current, but undated, facility resident guidelines titled, Your Rights and Protections as a Nursing Home Resident. The guidelines indicated, .As a nursing home resident, you have certain rights and protections under Federal and state law . You have the right to be informed, make your own decisions, and have your personal information kept private On 3/7/24 at 1:03 p.m., the ED provided a copy of the current, but undated, facility guidelines titled, HIPAA and HiTECH Privacy. The guidelines indicated, .There should be no conversations about a resident's . personal health or health information in areas where other residents may hear or where employees without need to know may have access . It is extremely important that you never share or improperly use information with anyone who is not on a need-to-know basis . This citation relates to Complaint IN00428989. 3.1-3(o)

Jul 2023 13 deficiencies

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

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 ensure a resident's choice of code status was documented consistently in the medical record and the physician and staff were aware of the resident's choice for 1 of 2 residents reviewed for code status (Resident 196). Findings include: During a record review for Resident 196, on [DATE] at 11:16 a.m., the resident record lacked documentation for code status preferences available in a publicly accessible area. Resident 196's record was reviewed on [DATE] at 1:18 p.m. Resident 196 was admitted on [DATE] with diagnoses to include, but were not limited to, pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), and clostridium difficile [c-diff] (inflammation of the colon caused by bacteria that disrupt normal bacteria in the colon, often from antibiotic use, highly contagious, can cause severe damage to the colon, and even be fatal). Discharge Instructions from a local hospital, dated [DATE], indicated no documentation of the resident's code status orders. Review of Resident 196's record indicated there was no Indiana Physician Orders for Scope of Treatment (POST) form present for designation of the resident's preferences of attempt cardiopulmonary resuscitation (CPR) or full code, or do not attempt resuscitation/DNR indicating no code. A face sheet for Resident 196 lacked documentation of code status. Physician's orders, dated [DATE] - [DATE], lacked documentation of physician's orders for code status preferences. Interdisciplinary progress notes, dated [DATE] - [DATE], lacked documentation a discussion was had with the resident or resident representative regarding code status preferences. A care plan for Resident 196, dated [DATE], the SSD documented the resident was a full code. The goal was the resident's wishes related to her advanced directives to be honored. The intervention was to follow full code protocol. During an interview on [DATE] at 3:20 p.m., Licensed Practical Nurse (LPN) 16 indicated resident information regarding code status was supposed to be documented in the electronic medical record (EMR), staff no longer had access to hard charts containing resident information on the unit. Review of Resident 196's EMR with LPN 16 to include scanned hospital discharge orders, an admission profile, current physician's orders, resident face sheet, indicated no documentation regarding a code status. There was also no POST form observed. LPN 16 indicated, if code status information was not available, she would treat the resident as a full code. During an interview on [DATE] at 3:26 p.m., the Social Service Director (SSD) indicated she had no record of the resident's code status, it was possibly in the medical records Qualified Medication Aide's (QMA's) 17 office ready to be scanned. Medical Record QMA 17 was not available in her office, and no code status paperwork was not found on her desk. SSD then went to the Director of Nursing's (DON's) office, where a POST form for Resident 196 was found under a stack of paperwork on her desk. The POST form indicated it was prepared on [DATE] and signed by the physician on [DATE], indicated attempt CPR, full code status. During an interview on [DATE] at 9:39 a.m., the DON indicated the resident's code status should have come with the resident's orders from the hospital. If not, as soon as possible the resident should have been asked or the resident representative contacted to get the preference on her code status. The facility process was to get information of resident code status from the POST form, have the physician and resident or representative sign and date, and it was then entered into the EMR. Usually, the nurse or SSD gathered code status information upon admission. When the code status was entered into the EMR as an order, it would appear on the face sheet for nursing staff to access. The POST form was to be scanned into the EMR and could be found under the documents tab. If no code status was available, the resident would automatically be considered a full code. The DON acknowledged this was not best practices as a resident could have CPR administered against their wishes. The DON indicated, Resident 196's code status care plan had been put into the EMR by the SSD on [DATE], not sure where she got her information to put in the care plan but would ask. On [DATE] at 12:30 p.m., the Regional Nurse Consultant (RNC) provided the Advance Directives Policy and Procedure, dated [DATE], and indicated the policy was the one currently being used by the facility. The policy indicated, .The facility provides to all residents the right to accept or refuse medical and surgical treatment, and at the resident's option, formulate an advance directive .Determine upon admission whether the resident/legal representative has an advanced directive and if not, determine whether the resident/legal representative wishes to formulate an advanced directive .1. Upon admission, the facility will provide written information to the resident/legal representative concerning the resident's rights to make decisions regarding medical care including the right to accept/refuse medical treatment and the right to formulate advanced directives. 2. Upon admission, the facility must determine if the resident executed an advanced directive or has given other instructions to indicated what care is desired in case of subsequent incapacity .3. If the resident/resident legal representative has executed one or more advance directives [or executed one upon admission], copies will be obtained and incorporated in the resident medical record 3.1-4(f)(5)

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an unusual occurrence that directly affected the wellbeing and health of a resident (Resident 32) was reported to the State Department of Health. This deficient practice had the potential to effect 1 of 3 residents reviewed for accident. Findings include: On [DATE] at 11:24 a.m., Resident 32 was observed in her room. She was seated in a regular wheelchair (WC). She had poor posture and was hunched forward, unable to lift her head all the way. She indicated, on [DATE], she was in the main dining room when she all of the sudden didn't feel right and she started to choke. She did not remember anything else because she lost consciousness and was told later, staff had to perform cardiopulmonary resuscitation (CPR). During an interview on [DATE] at 9:22 a.m., Resident 32's husband indicated he had been notified of Resident 32's choking incident. Apparently, she had choked on a piece of chicken during lunch. No one was sure if her choking caused her cardiac arrest, or if a cardiac arrest caused her to choke. Either way, she became unresponsive, and the staff had to perform CPR. On [DATE] at 1:45 p.m., Resident 32's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, spinal stenosis (A narrowing of the spinal canal), idiopathic peripheral autonomic neuropathy (occurs when there is damage to the nerves that control automatic body functions) and weakness. A nursing progress note dated [DATE] at 1:30 p.m., indicated, Resident 32 indicated, I'm not ok and need air. She became unresponsive and CPR was initiated. 911 was contacted. The resident's husband was notified. CPR was continued until emergency medical staff (EMS) arrived and took over the scene. EMS transported the resident to the hospital. During an interview on [DATE] at 9:44 a.m., the Activity Director (AD) indicated, she was seated at the table with Resident 32 when she noticed, she looked kind of funny. The AC asked if she was O.K., and at first Resident 32 said, yes, but then said, no, I'm not O.K, I need air. The AC immediately signaled to the Director of Nursing (a previous nurse who was no longer at the facility) to come and assist. The AD indicated it looked like Resident 32 choked, but the nurses moved her immediately to take care of her. The AD indicated Resident 32 didn't look so good on her way out, she was a shade of purple I had never seen. During an interview on [DATE] at 10:00 a.m., the current facility Director of Nursing (DON) indicated, she was not sure if the incident had been reported, but she would check. During a follow up interview on [DATE] at 10:45 a.m., the DON indicated the incident had not been reported at the time. In review of the progress notes and investigation, the DON indicated it was an incident that should have been reported as a major accident. 3.1-28(c)

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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A. Based on record review and interview, the facility failed to ensure a resident received a complete neurological assessment after an unwitnessed fall for 1of 3 residents reviewed for accidents (Resident 30). B. Based on record review and interview the facility failed to ensure a resident with a history of seizures had follow up assessments and physician notification after having seizure activity for 1 of 2 residents reviewed for quality care with catheter use (Resident 45). Findings include: A. On 7/14/23 at 11:14 a.m., Resident 30's medical record was reviewed. She had diagnoses which included, but were not limited to, unspecified psychosis (a mental disorder characterized by disconnection from reality), COPD (chronic obstructive pulmonary disease) (a group of lung disorders that block airflow and make it difficult to breathe), essential hypertension (high blood pressure), osteoarthritis (the breakdown of joint cartilage and the underlying bone), insomnia (inability to sleep), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations), heart disease, and weakness. Resident 30 had unwitnessed falls on the following dates: 1/19/23, 3/3/23, 3/6/23, 3/15/23, and 3/29/23. The record lacked documentation that neurological assessments had been completed for the falls on 1/19/23, 3/6/23, 3/15/23 and 3/29/23. During an interview on 7/13/23 at 2:10 p.m., Director of Nursing (DON) indicated she was unable to locate neurological assessments for Resident 30. She indicated she was not employed by the facility at the time of the noted falls. A policy was provided by the DON on 7/14/23 at 12:23 p.m. It indicated, .In the case of a fall, the resident will have a head-to-toe assessment to include a pain assessment and assessment as to any change in their ROM (range of motion) ability/function. Further, residents who have an unwitnessed fall must have neuro checks started and continued per policy. Neuro check will be initiated even if the resident indicates they did not hit their head in an unwitnessed fall B. On 7/11/23 at 2:16 p.m., Resident 45's closed medical record was reviewed. She admitted to the facility with diagnoses which included, but were not limited to, deficiencies of B-group vitamins, Vitamin D deficiency, epilepsy, and neoplasm (cancer) of the bladder. Resident 45 had a comprehensive care plan initiated 1/17/23 which indicated she was at risk for seizures due to her diagnoses of Epilepsy and convulsions. Interventions for the plan of care included but were not limited to; notify MD and family with each seizure. A nursing progress note dated 1/26/23 at 5:33 p.m., indicated Resident 45 was observed acting strange and noted to be very confused. She had a full body seizure that lasted approximately 30 seconds. Resident 45 was now awake but continued with confusion and garbled speech. The record lacked documentation that the MD was notified of the seizure. The record lacked documentation that a full set of vital signs or neurochecks had been obtained. A nursing progress note dated 1/26/23 at 8:11 p.m., (2 hours and 38 minutes later) indicated, Resident 45 was resting quietly in her bed with no further signs/symptoms of seizure. The note still lacked documentation of physician notification. On 1/27/23 at 1:37 a.m., a change of condition event was initiated. The event note was created months late on 6/9/23 at 2:15 p.m., made effective for the morning of 1/27/23. The event note indicated, resident has unwitnessed grand mal seizure and unwitnessed fall while in bathroom. resident observed for injury, and none found at this time, resident unresponsive. 911 was called and she was sent to the hospital. The event note indicated, the nurse attempted to call the MD on-call, but got no answer and no return call, so they left a message via text on diganotes (a communication software system for text messaging communication between providers and facilities). Further, a current set of vital sings was not obtained or documented at the time of her second seizure. Recorded vitals from 1/21/23 were attached to the event note. A nursing progress note dated 1/27/23 at 2:05 a.m., indicated, staff had been notified by Resident 45's roommate that she was having a seizure in the bathroom. Resident 45 was found on the floor lying next to the toilet with her head resting on the toilet side, she had convulsions and was unresponsive. She was moved to her side and a pillow was put under her head. 911 was called and EMS transported her to the ER. A Hospital Summary dated 1/27/23 indicated, .per staff at the Waters after having witnessed seizure twice today. Tonight around 1:00 a.m. she was sitting on toilet when she had one and hit her head on the wall. She was postictal [altered state of consciousness after an epileptic seizure] for longer than usual thus was sent in for evaluation .found to have multiple electrolyte abnormalities including hypomagnesemia, hypocalcemia, hypokalemia . she is pleasantly confused but, according to The Waters she is more oriented than this at baseline . Along with the electrolyte imbalance, she was also diagnosed with acute onset of recurrent seizures. During an interview on 7/12/23 at 9:57 a.m., LPN 14 indicated Resident 45 had a diagnosis of seizures, and although she never witnessed one, it was important to monitor her for a change of condition. If she were to have witnessed a seizure, she would immediately call for help and ensure the resident was placed safely on the floor on her side. She would immediately call the DON and on-call to get orders and instructions. If she could not reach anyone she would call 911. It would also be important to get a set of vital sings as soon as possible to have ready to give report to EMS when they got there. During an interview on 7/12/23 at 3:47 p.m., Licensed Practical Nurse (LPN) 16 indicated, she was working the night of Resident 45's first seizure. She entered the resident's room to deliver her dinner tray and noticed she was standing strange and didn't look right. She set the food tray down as Resident 45 began to seize. LPN 16 guided her into her bed so that she did not fall and turned her to her side until the seizure passed. LPN 16 indicated she did take vital signs which should have been recorded in weights/vitals. LPN 16 indicated she had also contacted the on-call but did not get any new orders, only to continue to monitor her. When she went back to check on Resident 45 later that evening, she wasn't awake or asleep, but still in a post-seizure state. She gave report to the oncoming nurse when she left so he could continue to monitor her as well. During an interview on 7/13/23 at 3:22 p.m., NP 34 indicated she had checked her call logs and text message system and did not have a record of notification related to Resident 45's seizure on 1/26/23. Although Resident 45 had several complicated medical issues, the UTI may not have necessarily caused the seizures, it was more likely that her electrolyte imbalanced caused the seizure. However, the on-call MD should have been notified immediately, and if they were unable to get an answer it would be appropriate to send her out 911 immediately, especially if her postictal state lasted longer than usual. On 7/13/23 at 11:36 a.m., the DON provided a copy of current but undated facility policy titled, Change in Resident's Condition or Status. The policy indicated, It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status . the nurse will notify the resident's attending physician when: . there is a significant change in the resident's physical, mental, or psychological status 3.1-37(a)

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary treatments and services to promote the healing of a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident 196). Findings include: On 7/11/23 at 10:44 a.m., Resident 196 was observed to be lying flat on her back in bed with the covers up to her chin. The resident was alert, talkative, and indicated her plan was to discharge to home when she was steadier and could ambulate independently again. On 7/13/23 at 9:30 a.m., Resident 196 was observed lying flat on her back in bed with the covers up to her chin. The resident's bottom with Licensed Practical Nurse (LPN) 14, resident indicated she had a sore that staff treated every day. During an observation the resident's entire buttocks was pink, dry, and had flaky skin. The coccyx/sacral area and surrounding tissue was open to air, no medication was observed. Two open areas approximately 1 centimeter (cm) circular, pink in color with white slough (dead tissue usually cream or yellow in color), were observed. There was no eschar (dry, black, hard necrotic tissue). Resident 196's record was reviewed on 7/11/23 at 1:18 p.m. Resident 196 was admitted on [DATE] with diagnoses to include, but were not limited to, pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), and clostridium difficile [c-diff] (inflammation of the colon caused by bacteria that disrupt normal bacteria in the colon, often from antibiotic use, highly contagious, can cause severe damage to the colon, and even be fatal), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar [glucose] either by not producing enough insulin, or by resisting insulin, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and severe kidney failure (long lasting disease of the kidneys leading to renal failure and a build-up of excess waste and fluid from the blood). An admission Minimum Data Set (MDS) assessment, dated 7/6/23, assessed the resident as having the ability to make herself understood and to understand others. Brief Interview for Mental Status (BIMS) indicated the resident was cognitively intact. The resident required limited assistance of 1 person physical assist for bed mobility, walking in room, dressing, toilet use, and personal hygiene. Resident 196 was at risk for acquiring pressure ulcers, admitted with one stage II (partial thickness loss of skin presenting as a shallow open ulcer with a red, pink wound bed and no slough) pressure ulcer, not present upon entry. No skin tears were listed on MDS. Hospital discharge instructions, dated [DATE], indicated wound care consult for open stage II wound to coccyx (tail bone), peeling friction areas to gluteal cleft (buttocks crack) bilaterally. Skin tears times 2 on forearm, skin candidiasis (yeast infection) bilaterally upper medical thighs and perineal area. An admission/readmission assessment, dated 7/1/23, indicated wounds to include a pressure area on the coccyx measuring 1.0 centimeter (cm) by (x) 1.0 cm x 0.2 cm, 4 areas of bruising on right antecubital (arm in front of the elbow) and bilateral hands, and 2 skin tears on back of the left hand. A care plan, dated 7/1/23, indicated the resident had has actual impairment to skin integrity of the coccyx/gluteal cleft related to fragile skin and friction. The goal was for the resident's skin injury of the gluteal/coccyx to be healed by the next review. Interventions included but not limited to monitor/document location, size and treatment of skin injury, apply weekly treatment and documentation was to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Physician assessment, dated 7/3/23, indicated resident admitted post hospitalization. Diagnoses of cellulitis of right lower limb, skin normal turgor, warm and dry, no lesions or rashes, no redness or warmth bilateral lower extremities. A care plan, dated 7/3/23 indicated the resident had skin tears to left upper extremities upon admission. The goal was to resolve without complications. Interventions included but were not limited to notify the physician and family, observe for signs or symptoms of infection, and apply treatment as ordered. A care plan, dated 7/3/23, indicated the resident had a wound present to the coccyx upon admission. The goal was for the wound to decrease in size through the next review. Interventions included diet as ordered, pressure reducing mattress/cushion in chair, skin checks weekly and as needed, and treatment as ordered. A Nurse Practitioner (NP) 31 assessment, dated 7/5/23, indicated denies new rashes, bruising, or skin breakdown. Skin warm, dry, intact, with fair turgor, no new bruising or breakdown. A Wound NP 35 visit note, dated 7/6/23, indicated a wound on the sacrum present upon admit. The plan was to apply triad paste to wound twice daily (BID) and as needed. Off load with pillows when supine (on the back face up). Original cause of wound was pressure injury. The date acquired 7/6/23. The wound was currently classified as an unstageable/unclassified wound (full thickness tissue loss in which the base of the ulcer is covered by slough and/ or eschar in the wound bed so the true depth cannot be determined). The wound measured 0.7 cm length x 0.5 cm width x 0.1 cm depth. There was a small amount of serous drainage noted. There was a large (67% - 100%) amount of necrotic tissue within the wound bed including adherent slough. The peri wound had tenderness on palpation. A physician's order, dated 7/6/23, Hydrophilic External Ointment (a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) clean coccyx wound with normal saline and apply skin prep around peri wound, apply hydrophilic ointment to coccyx wound bed topically every day shift for wound and leave open to air. Change Daily and as needed if becomes soiled, discontinue when healed. A Wound NP 35 visit note, dated 7/12/23, was not provided during the survey. On 7/14/23 at 11:54 a.m., the Director of Nursing (DON) provided an untitled document and indicated it was her wound tracking. The document indicated on 7/5/23 the sacral wound measured 0.7 cm x 0.5 cm x 0.1 cm, and on 7/12/23 the sacral pressure wound measured 0.5 cm x 0.3 cm x 0.1 cm. There was no further description of the wound. Resident record lacked documentation the resident's sacral wound worsened from a described stage II wound (skin breaks open, appears as a scrape/abrasion, blister or a shallow crater in the skin) between admission on [DATE] to an unstageable wound on 7/6/23, or that the physician and resident or resident representative were made aware. During an interview on 7/11/23 at 10:23 a.m., the DON and LPN 14 indicated Resident 196 was in isolation related to a diagnoses of c-diff. The resident was alert and oriented, and able to answer questions. The resident was continent of bowel and bladder unless she could not make it to the bedside commode timely. She required standby assistance for activities of daily living (ADL's) and had no known skin breakdown. During an interview on 7/13/23 at 12:00 p.m., Wound NP 35 indicated it was brought to her attention on 7/6/23 the resident had a wound on her sacrum that was present upon admission from the hospital, and the wound was painful. NP 35 had observed the wound on 7/6/23 and documented it as unstageable related to the slough. She could not answer as to why the resident would go from shearing or a Stage II wound to an unstageable in that short amount of time as the resident was alert and mobile. The reason could have been due to her condition before admission, and the resident might have been experiencing diarrhea before admission due to c-diff and the skin could have been compromised. Upon assessing the resident on 7/12/23, NP 35 indicated the wound on her sacrum/midline appeared to still be covered in slough and measured 0.5 cm x 0.3 cm x 0.1 cm and in her opinion improving. There was no black tissue, she considered a wound necrotic if it was covered in slough. The resident indicated the wound was still painful when laying on it but less painful than last week. During an interview on 7/14/23 at 9:46 a.m., the DON indicated the MDS Coordinator was responsible for the accuracy of information on the MDS. The original admission MDS did not indicated presence of a pressure ulcer, but when reviewed this date indicated the document had been altered last evening with correct information. DON indicated, the document had not been submitted yet, so the MDS coordinator had the option to correct until sent. During an interview on 7/14/23 at 9:51 a.m., Resident 196's record was reviewed with the DON. DON indicated, the admitting nurse assessed the resident and documented her wounds on the admission/readmission form. Wounds included bruises, skin tears, and an area on her coccyx which had measurements that was not staged but reflected a Stage II wound by description. On 7/1/23 the DON had put in care plans for the wounds with interventions. Observation of the resident record lacked documentation interventions were initiated. Wound NP documentation on 7/6/23 indicated the coccyx wound worsened to an unstageable wound with necrotic tissue and slough and gave new orders to change the treatment to twice daily. Physician's orders for wound care were not changed to twice daily and no documentation the orders were followed. Nurses were responsible for preventative wound care and making sure orders were writing and followed. On 7/14/23 at 12:30 p.m., the Regional Nurse Consultant provided a Preventative Skin Care policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, It is the intent of the facility that the facility provide preventative skin care .Responsibility: charge nurse and nursing assistants monitored by the Director of Nursing .Residents identified as being at high risk for potential breakdown shall be turned and repositioned frequently to prevent redness that does not fade or blanche . On 7/14/23 at 12:30 p.m., the Regional Nurse Consultant provided a S.W.A.T. [Skin and Weight Assessment Team] policy, undated, and indicated the policy was the one currently being used by the facility. SWAT is designed to aggressively review and address those residents exhibiting significant weight loss or skin breakdown. Those residents will be monitored through this team effort on a weekly basis . Document on SWAT form: review date (date of SWAT meeting), onset date (date of which the open area appeared), current size (the measurement of the open area most recently recorded by nursing), current stage (the most recent stage determined by nursing or the physician), odor present (putrid smell of the open area on the skin), drainage present (presence of drainage of the open area on the skin), culture/results (within normal limits). Record on treatment sheet (open area treatments need to be recorded on treatment sheet. Notifications (physician, Registered Dietician, MDS, family, and care plan). Other (needs to be checked if the resident is on skin protocol program, hydration program, appetite enhancer, six small meals, etc. Lab values (record the most current albumin and or transferring levels within 30 days of review). 3.1-40(a)(2) 3.1-40(a)(3)

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 interview and record review, the facility failed to ensure, a resident (Resident 45) with a history of electrolyte imbalance, seizures and urinary tract infections (UTIs) received ordered labs in a timely manner for a urinalysis, reported and reviewed labs in a timely manner for 1 of 2 resident reviewed for catheter use. Findings include: On 7/11/23 at 2:16 p.m., Resident 45's closed medical record was reviewed. She admitted to the facility with diagnoses which included, but were not limited to, deficiencies of B-group vitamins, Vitamin D deficiency, epilepsy, and neoplasm (cancer) of the bladder. A Physician's note dated 11/7/22 at 1:58 p.m., indicated Resident 45 was being seen for a regularly scheduled, annual assessment as well as complaints for a possible UTI. patient has concern for urinary urgency and possible getting UTI patient is getting frequent UTIs due to straight cath . [straight catheter, also called an intermittent catheter, is a soft, thin tube inserted into the bladder through the urethra used to empty urine from the body] will check UA [urinalysis] and discuss regarding routine screening measures The record lacked documentation of follow up for routine screening measures related to frequent UTIs due to Resident 45's preference to self-straight cath for urinary continence. Resident 45 had a comprehensive care plan initiated 1/17/23 which it was her preference to self-cath. However, there were no specified, person-centered risks and/or revised interventions/approaches to address her preference besides, reassess as needed A second comprehensive care plan initiated 3/28/23 indicated Resident 45 was at risk for complications related to her use and preference to self-straight cath and that she declined to allow staff to straight cath. Interventions included but were not limited to; nursing to provide education on peri care, observe In & Out cath, and ensure good peri care. The record lacked documentation of education provided to Resident 45 regarding self-straight cath risks and benefits. The record lacked documentation of nursing observations of Resident 45's ability to self-straight In & Out cath. The record lacked specification of education provided to Resident 45 regarding appropriate peri care. The record lacked documentation of initial and/or routine assessments of her ability to appropriately straight-cath herself. A nursing progress note dated 1/9/23 at 3:46 p.m., indicated, Resident 45 complained of a burning sensation while urinating and a new order was obtained for a UA & C&S (urinalysis with culture and sensitivity, a test to determine if there is the presence of a UTI and what bacteria could have caused it). A urine sample was not collected until 4 days later, on 1/13/23 at 11:47 p.m., which was provided by the resident via self-straight cath. The original order for the UA was dated 1/13/23 and indicated, UA with Culture if indicated. The results of the UA were reported on 1/16/23 at 4:22 p.m., and faxed to the facility on 1/17/23, with no specified time. Results of the UA indicated signs of a UTI as evidence by, the presence of blood, bacteria, protein, leukocytes and nitrates. The record lacked documentation of follow up on the lab results. During an interview 7/12/23 at 11:09 a.m., the DON provided a copy of a Laboratory Results Page. The report was blank. The DON indicated because different labs completely different tests for the facility, some have access to directly upload into the electronic charting system. However, other companies are unable to directly upload and can only upload via their own electronic medical record system, so a report is filed to trigger the MD/NP to log onto the particular lab for review. Highlight in the upper left corner of the blank report, was a timestamp that Nurse Practitioner (NP) 34 had not reviewed the results until 2/4/23 at 1:06 p.m. When asked about the results of the UA, the DON indicated there was some indication there could be a UTI, but it is often at the Lab's discretion if a culture should be completed, and since the original order indicated, culture as indicated, the DON said a culture may not have been completed. The record lacked documentation of follow up to see if a second UA needed to be collected or a culture should be conducted on the first sample. Resident 45's nursing progress note, physician progress notes, Medication Administration Record (MAR) and lab results all lacked documentation of follow up to the 1/20/23 UA test results. A Hospital Summary dated 1/27/23 indicated, .per staff at the Waters after having witnessed seizure twice today. Tonight around 1:00 a.m. she was sitting on toilet when she had one and hit her head on the wall. She was postictal [altered state of consciousness after an epileptic seizure] for longer than usual thus was sent in for evaluation .found to have multiple electrolyte abnormalities including hypomagnesemia, hypocalcemia, hypokalemia .likely in setting of UTI . and suffered an acute kidney injury. A re-admission Social Service Note dated 1/31/23 at 9:46 a.m., indicated, a BIMS (brief interview for mental status test) was conducted for Resident 45 as she seemed to exhibit increased confusion. Prior to hospitalization, she consistently scored 15, which indicated intact cognition. On this date, she scored a 10 which can indicate moderately impaired cognition. During an interview on 7/12/23 at 9:57 a.m., LPN 14 indicated, she had worked with Resident 45 on an occasional basis. She remembered her as being alert, oriented, particular about certain things, but overall, pleasant and cooperative. One of the things she was particular about was her preference to self-cath. As far as LPN 14 remembered, staff did not conduct additional monitoring or assessment for her ability to self-cath because that's just how she was and what she preferred. If a UA was ordered, LPN 14 would want to have collected the sample herself to ensure a sterile technique was performed to reduce the risk of contaminating the sample, and if the Resident refused, she would make a nursing note about it. During an interview on 7/13/23 at 3:22 p.m., NP 34 indicated she had access to the 1/20/23 UA lab results, NP 34 logged on and indicated there were no UA results for review from January. She was not sure at that time where the results were. She could not remember the results at the time but indicated she would not always treat with an antibiotic right away without a culture and sensitivity so that she could prescribe the appropriate medication. On 7/13/23 at 11:36 a.m., the DON provided a copy of current but undated facility policy titled, Lab Scheduling/Tracking. The policy indicated, It is the policy of the facility to ensure that laboratory tests ordered by the physician are systemically scheduled and tracked so that ordered lab work is obtained and results are received and reported timely . the Charge Nurse will monitor the scheduled labs daily to check to ensure that any collected lab results are received timely as well as to confirm that received results are reported to the physician as well as the resident's representative and that any orders received to the lab results are carried out On 7/13/23 at 11:36 a.m., the DON provided a copy of current but undated facility policy titled, Catheters. The policy indicated, It is the policy of the facility to ensure that a resident . who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible . the resident and their representative will be educated as to the use of a catheter to include: Not: this will be documented, risks and benefits . timely and appropriate assessments will be performed related to the indication and use of the catheter . Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and facility policy and procedure with adherence to infection prevention and control techniques . the resident will have ongoing monitoring of the catheter related to the potential for UTIs and recognizing, reporting and addressing significant changes 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 observation, interview, and record review, the facility failed to ensure a resident who was at risk for nutritional decline received thorough monitoring and interventions to prevent avoidable weight loss for 1 of 2 residents reviewed for nutrition (Resident 30). Findings include: During an observation and interview on 7/10/23 at 12:45 p.m., Resident 30 indicated she did not receive her weekly house shake that was ordered for Mondays. She indicated she would get it the next day. During an interview on 7/12/23 at 1:15 p.m., Resident 30 she indicated she received her house shake for the week. She indicated it had been added because she had weight loss. On 7/14/23 at 11:14 a.m., Resident 30's medical record was reviewed. She had diagnoses which included, but were not limited to, unspecified psychosis (a mental disorder characterized by disconnection from reality), COPD (chronic obstructive pulmonary disease) (a group of lung disorders that block airflow and make it difficult to breathe), essential hypertension (high blood pressure), osteoarthritis (the breakdown of joint cartilage and the underlying bone), insomnia (inability to sleep), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations), heart disease, and weakness. On 7/20/22, Resident 30 weighed 133 pounds. On 1/2/23, Resident 30 was down to 114.0 pounds. On 7/3/23 Resident 30 was weighed at 109.8 pounds. In total, Resident 30 last 14.29% of her weight between the above dates. She had physician's orders, which included, but were not limited to, a general diet with regular texture and thin liquids. An order for other supplement with meals for weight loss at lunch and dinner may substitute sherbet, and an order to change two times daily house shakes to one house shake weekly due to refusals. The record lacked documentation that during the time of her weight loss RD (Registered Dietician) had assessed or followed up with her. Resident 30 was not added to SWAT (Skin and Weight Assessment Team) to review her weights as the policy recommended. There were no interventions added during the time of this weight loss. The weight loss was not recorded on the two MDS (Minimum Data Sets) completed during the weight loss time frame of 7/20/22 through 1/2/23. Resident 30 had a care plan dated 2/21/23 indicating she had experienced weight loss and was at risk for continued weight loss. Interventions included to make a referral to MD (Medical Doctor)/RD if there is a 5% weight loss over 30 days or a 10% weight loss over 180 days, dietary health supplements as ordered: Prostat liquid (a protein supplement) and weigh resident monthly. During an interview with the MDS coordinator on 7/14/23 at 12:10 p.m., she indicated she was not employed by the facility at the time of the weight loss occurrence. During an interview with the DON (Director of Nursing) on 7/14/23 at 1:45 p.m., she indicated she was not employed by the facility at the time of the weight loss occurrence. A policy titled, S.W.A.T Program (Skin and Weight Assessment Team) was provided by the Regional Nurse Consultant on 7/14/23 at 12:33 p.m., indicated .The team will appropriately determine clinical and dietary interventions to best address each resident's needs. Any dietary intervention and/or issues in need of review by the Dietician will be listed on the Dietician referral form and addressed at routine visit. Indicators determining implementation of S.W.A.T. monitoring were 10% or more weight change (undesirable) in 180 days. On-going weekly monitoring should continue on resident of S.W.A.T until one of the following conditions has been met: new admit at 4 weeks with no concerns, weight loss- eight weeks at stable weight unless medical condition dictates otherwise, or a history of fluctuating weight is present. When weight, food consumption, and/or lab values continue to decrease or approach critical levels, alternative interventions must be reviewed by the interdisciplinary team, open areas- when the areas have healed, change of condition until a stable status achieved and tube feeding will be on-going 3.1-46

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain relief and failed to update his pain management care plan to include leg pain for 1 of 1 residents reviewed for pain management (Resident 8). Findings include: On 7/11/23 at 1:46 p.m., Resident 19's record was reviewed. He was initially admitted on [DATE]. His diagnoses included, but were not limited to, chronic pain disorder, low back pain, peripheral vascular disease (PVD), and rhabdomyolysis (break down of muscle tissue resulting in kidney damage). A care plan, dated 6/13/23, indicated Resident 8 was taking anticonvulsants medication related to low back pain. The intervention indicated to carry out the medication management regimen as prescribed. A care plan, dated 6/25/23, indicated Resident 8 had pain related to a previous humerus (upper arm bone) fracture. An intervention indicated to give medication as ordered. A care plan, dated 6/26/23, indicated Resident 8 had compression hose for his left leg related to varicose veins. An intervention indicated to wearing them during the day and remove them at night. A care plan, dated 6/25/23, indicated Resident 8 would have not have adverse effects from opioid use. An intervention indicated to give the medication as ordered. A care plan, dated 6/26/23, indication Resident 8 had potential for complication, discomfort, related to a diagnoses of muscle wasting and atrophy due to a history of rhabdomyolysis. On 7/13/23 at 2:42 p.m., Resident 8's physician orders, indicated to: a. Provide thigh high compression hose, dated 6/19/22, for left leg for symptomatic varicose veins (painfully, enlarged veins). On in AM (during the day) off at HS (bedtime). b. Provide oxycodone 50 mg, dated 5/6/23, every 6 hours for moderate to severe pain related to low back pain. c. Provide ibuprofen 600 mg, dated 11/8/22, every 8 hours as needed for pain. d. Provide Tylenol 325 mg, dated 6/26/23, every 6 hours as needed for breakthrough pain. On 7/12/23 at 1:50 p.m., Resident 8 was observed walking in the hall with his walker. Once he sat down in his room, he indicated his left leg hurt all the time. In a scale of 1 - 10, it hurts at level 7. He indicated he was still getting his narcotic pain killers. His indicated he preferred the compression stockings; they work well to relieve the leg pain. The facility provided compression stockings, but no one measured his legs to get the right size and the ones they provided did not work because they were too small and rolled down his thighs. He indicated his leg pain was horrible, it was enough to almost make him cry. He has told the nursing staff about this issue. On 7/13/23 at 2:35 p.m., Resident 8 indicated he took the oxycodone for his back and leg pain. Tylenol just did not do the trick. On 7/13/23 at 2:19 p.m., the Director of Nursing (DON) indicated the facility needed to provide different compression hose until he can get to his vascular appointment later this month. On 7/13/23 at 3:30 p.m., the DON indicated Resident 8's legs were measured and the facility already had the correct size compression stockings in their supplies. He was given the correct size stocking this afternoon. On 7/14/23 at 1:14 p.m., the DON indicated if a resident complained of pain regarding the fitting of compression stockings, the nursing staff should have followed up and let the physician know. Resident 8 had already told them he was having leg pain. A current policy, titled, Management of Pain, with no date, was provided by the Regional Nursing Consultant (RNC), on 7/14/23 at 12:42 p.m. A review of the policy indicated, .Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our resident the means to received necessary comfort, exercise greater independence, and enhance dignity and life involvement .Using non-pharmacological and Complimentary and Alternative Medicine when appropriate .Initiate an interdisciplinary plan of care based on the initial assessment and development of pain relieving strategies. Include both pharmacological and complimentary intervention in the care plan 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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Based on record reviews and interviews the facility failed to properly reconcile and account for medications that were sent home with a resident who discharged from the facility for 1 of 2 residents reviewed for discharge (Resident 44). Findings include: A comprehensive record review was completed on 7/11/23 at 11:23 a.m. Resident 44 had the following diagnoses, but not limited to ASHD (arteriosclerotic heart disease, a thickening and hardening of the walls of the coronary arteries), essential hypertension (high blood pressure), chronic pain syndrome, fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness and insomnia), restless leg syndrome (uncomfortable sensations in the legs and the urge to move them in order to relieved the sensations, typically occurring in the evening or at night and often interfere with sleep), and diabetes mellitus, type 2 (elevated blood sugars). Resident 44 discharged from the facility on 5/20/23. A progress note, dated 5/20/23 at 12:50 a.m., indicated that Resident's daughter wanted to have her mother discharged home with family. The physician gave an order to discharge to home with medications including narcotics. Resident had orders for the following medications: a.) acetaminophen extra strength 500mg (a pain medication) b.) amlodipine besylate 10mg (for ASHD) c.) aspirin 81mg (a pain reliever used for blood thinning) d.) atorvastatin 40mg (used for elevated cholesterol) e.) buprenorphine buccal film 600mg (a narcotic medication used to treat pain) f.) clopidogrel bisulfate 75mg (used to prevent heart attacks and strokes) g.) docusate sodium 100mg (used to treat constipation) h.) duloxetine delayed release sprinkle 60mg (used to treat depression and peripheral neuropathy (nerve damage) i.) ferrous sulfate 325mg (used to treat anemia) j.) gabapentin 600mg (used to treat fibromyalgia) k.) isosorbide mononitrate 30mg (used to treat hypertension) l.) Jardiance 25mg (used to treat diabetes) m.) metformin 500mg (used to treat diabetes) n. metoprolol succinate 50mg (used to treat hypertension) o.) oxycodone 5mg (used to treat pain) p.) pantoprazole sodium 40mg (used to treat stomach conditions, such as ulcers) q.) sucralfate 1 gram (used to treat stomach conditions, such as ulcers), r.) tizanidine 4mg (used to treat neuropathy). On 7/13/23 at 2:15 p.m., the DON (Director of Nursing) provided a copy of a drug disposition for oxycodone. Resident 44 signed and acknowledged receipt of 22 tablets upon discharge. The DON indicated the facility did not have to reconcile and account for the number of non-controlled medications for residents at the time of discharge. A policy titled; Controlled Substance Disposition was provided by the DON on 7/13/23 at 10:05 a.m. The policy discussed disposition of controlled substances but not non-controlled medications. 3.1-25(a) 3.1-25(b)(l) 3.1-25(c)

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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2. A comprehensive record review was completed on 7/11/23 at 11:26 a.m. Resident 15 had the following diagnoses but not limited to osteoarthritis (degeneration of joint cartilage and the underlying bone), essential hypertension (high blood pressure), hyperlipidemia (high cholesterol), GERD (gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting the mouth and stomach), presence of cardiac pacemaker, dysphagia (difficulty swallowing), type 2 diabetes mellitus (high blood sugar), sleep apnea, and chronic renal failure (kidney failure). Resident 15 had a medication order for carvedilol 12.5mg (a drug used to treat high blood pressure and certain heart problems) was ordered on 4/1/23 to administer one time daily on Tuesday, Thursday, Saturday, and Sunday for essential hypertension. The order had parameters to hold if SBP (systolic blood pressure (how much pressure the blood placed against the artery walls while the heart pumps)) less than 110 and to hold if the DBP (diastolic blood pressure (the pressure in the arteries when the heart rests between beats)) was less than 50. Do not give on dialysis (a procedure used for people that have renal failure). Resident 15 had an evening medication order for carvedilol 12.5mg, take 1 tablet daily for essential hypertension. The evening order for carvedilol lacked parameter instructions for administration. On 7/1/23 on dayshift, Resident 15's blood pressure was 108/77. His carvedilol was administered despite being below the administration parameter of 110 or less. A policy for medication errors was requested on 7/14/23 at 9:30 a.m. but was not provided at the time of exit on 7/14/23. 3.1-48(c)(2) Based on observation, interview, and record review, the facility failed to prevent a significant medication error related to administering a potassium extended release tablet dissolved in water with an indication of do not crush (Resident 16) for 1 of 29 residents observed for medication administration, and failed to hold a hypertensive medication Coreg per manufactures guidelines related to a low blood pressure reading (Resident 15) 1 of 29 residents observed for medication administration Findings include: 1. During a random observation of medication administration to Resident 16 on 7/13/23 at 7:30 a.m., Licensed Practical Nurse (LPN) 14 was observed to place a potassium chloride ER (extended release) tablet in a plastic medication cup with water and spend over 15 minutes smashing the tablet with a spoon until totally dissolved. The medication was then administered to the resident. LPN 14 indicated the resident received the medication twice daily and would not take it whole. She knew she was not supposed to crush the medication so she would dissolve it in water every day. The physician had not been notified of the resident refusal to take the medication whole. Resident 16's record was reviewed on 7/12/23 at 11:51 a.m. Diagnoses on Resident 16's profile included, but were not limited to, schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder such as depression or bipolar disease), bipolar disorder (episodes off mood swings ranging from depressive lows to manic highs), and hypo-osmolality and hyponatremia (serum is produced by retention of water, by loss of sodium or both). A physician's order for Resident 16, dated 5/19/23, indicated potassium chloride ER give 10 meq by mouth twice daily (BID) for hypokalemia (low blood potassium levels that can result in fatigue, muscle cramps, and abnormal heart rhythms). A medication administration record (MAR), dated July 2023, indicated the resident was documented as receiving her potassium chloride twice daily as ordered. A laboratory results document, date 5/23/23, indicated potassium level, dated 5/23/23, results 3.6 meq/L (normal 3.5-5.3). The resident record lacked current orders for future labs to include potassium. A care plan for Resident 16, dated 6/1/23, indicated she was at risk for development of low potassium levels related to daily use of non-potassium sparing diuretic. The goal was for the resident to be free from signs or symptoms of low potassium levels and maintain a normal potassium level through next review. The interventions included observe for signs or symptoms of low potassium levels such as nausea/vomiting, muscle cramps, or weakness. Weight as ordered and notify the physician of weight gains or losses. Labs to be drawn as ordered with all labs reported to the doctor and family. Receive meds as ordered. During an interview on 7/14/23 at 9:30 a.m., the Director of Nursing (DON) indicated potassium was not supposed to be crushed, LPN 14 should have asked for the medication to be ordered in a different form. Being newer to the facility, she was unsure of what continuing education the nurses and Qualified Medication Aides (QMA's) had received. There were do not crush lists provided inside the narcotic books on the medication carts for staff reference. Medication pharmacy labels may also state to not crush. DON indicated, ultimately it was her responsible for making sure the staff were educated and residents received their medications properly. On 7/13/23 at 3:00 p.m., the DON provided an Oral Dosage Forms That Should Not Be Crushed 2016 list, and indicated the list was the current on used by the staff. The form was available to the staff by being kept in the front of the narcotic binder on the medication carts. The do not crush list included, potassium slow release tablets. FDA (2013): K-TAB (potassium chloride extended-release tablets) is a solid oral dosage form of potassium chloride containing 8 meq (milliequivalents), 10 meq and 20 meq of potassium chloride, USP, equivalent to 600 mg, 750 mg and 1500 mg of potassium, respectively, in a film-coated [not enteric-coated], wax matrix tablet. These formulations are intended to slow the release of potassium so that the likelihood of a high localized concentration of potassium chloride within the gastrointestinal tract is reduced. The expended inert, porous, wax/polymer matrix is not absorbed and may be excreted intact in the stool. ISMP (Institute for Safe Medication Practices): Enteric-coated potassium extended-release pills should not be dissolved to administer. Enteric-coated pills are designed to dissolve in the small intestine, not in the stomach. Dissolving them can destroy the drug's protective coating and cause the medication to be absorbed too quickly or too slowly, which can be harmful. In general, avoid crushing or dissolving controlled-delivery, controlled-release, delayed-release, enteric-coated, and extended-release pills.

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident, (Resident 32) received a pneumococcal vaccination upon her admission and written consent for 1 of 5 residents reviewed for vaccination status. Findings include: On [DATE] at 11:24 a.m., Resident 32 was observed in her room. She was seated in a regular wheelchair (WC). She had poor posture and was hunched forward, unable to lift her head all the way. She was alert, oriented and pleasant. When asked if she had any concerns, she indicated, she wanted to get off her all-liquid diet. When asked why she was on a full liquid diet, Resident 32 indicated, on [DATE] she was in the main dining room when she all of the sudden didn't feel right and she started to choke. She did not remember anything else because she lost consciousness and was told later, staff had to perform cardiopulmonary resuscitation (CPR). Resident 32 indicated she had a type of neuropathy that affected more than just her extremities and her esophagus was twisted and narrow which may have caused her to choke. She indicated, she had also been treated for pneumonia and had still been a little weak from the infection. During an interview on [DATE] at 9:22 a.m., Resident 32's husband indicated he and Resident 32 had given permission and consent for her to receive the flu and pneumonia vaccinations. As far as he was aware, she had received them. When asked about cardiac arrest and choking incident on [DATE], he indicated, he had been on the way to visit her when the facility called and told him what happened. When he got the hospital, she was in bad shape. She was on a ventilator, and it was unclear if she would recover. He indicated, Resident 32 had previously been treated for pneumonia, but they thought it had been resolved. She had some residual shortness of breath and weakness. On [DATE] at 1:45 p.m., Resident 32's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, spinal stenosis (A narrowing of the spinal canal), idiopathic peripheral autonomic neuropathy (occurs when there is damage to the nerves that control automatic body functions) and weakness. Upon a readmission, Resident 32 signed a Vaccination Consent Form, dated [DATE], and requested the pneumonia vaccine. The record lacked documentation that the vaccine had been administered. Nursing progress notes were reviewed and revealed the following: On [DATE] at 10:44 a.m., Resident 32 received Doxycycline (an antibiotic medication) for congestion. On [DATE] at 5:19 p.m., Resident 32 complained of shortness of breath and wheezing. She was given breathing treatment and felt better. On [DATE] at 8:50 p.m., Resident 32 continued on antibiotic therapy for respiratory infection. On [DATE] at 12:33 p.m. a new order for a chest x-ray was placed and on [DATE] at 8:08 p.m., the x-ray results were reviewed and showed signs of pneumonia. The on call Medical Doctor (MD) was contacted and new ordered were received to schedule albuterol treatments every 6 hours and continue her antibiotic. During an interview on [DATE] at 12:38 p.m., the Director of nursing, (DON) indicated, she was not yet hired at the time of Resident 32's readmission, but standard nursing practice would indicate, if a resident signed consent to receive a vaccination, then it should be administered during the next round of vaccines. Since Resident 32's consent was signed upon her admission and in the middle of the flu season, she should have gotten the vaccine as soon as possible. On [DATE] at 12:30 p.m., the DON provided a copy of current, but undated facility policy titled, Guidelines for Pneumococcal Vaccination. The policy indicated, It is the intent of the facility to minimize the risk of residents acquiring, transmitting and/or experiencing complication s from Pneumococcal pneumonia. This policy will assure that each resident and/or their representative/(POA) is informed . and that each resident has the opportunity to receive the vaccine

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to ensure medications were stored properly in 2 of 2 medication carts, and 2 of 2 treatment carts reviewed for medication storage (100 hallway, and 200 hallway). Findings include: During a random observation of the 100 hallway medication cart with Registered Nurse (RN) 9, on 7/10/23 at 10:09 a.m., the following was observed to be unbagged, not stored separately, or treatments in the medication cart among oral medications, a. Top right drawer was observed to be a catch-all of items to include, but were not limited to, a bottle of Johnson's baby shampoo without a resident label, 3 prefilled syringes of 0.9% sodium chloride injection with no resident label, an opened bottle of COVID -19 Ag reagent, 2 pill crushers soiled with unidentified white powder, AA batteries, [NAME] hand lotion, and 2 cigarette lighters. b. Bottom drawer had an opened tube of Biofreeze (topical analgesic) belonging to Resident 40, a glucagon pen (emergency injection to treat sever low hypoglycemia) with Resident 15's name on the outside of the box, and an opened bottle of Povidone iodine 10% with Resident 43's name written on the bottle without a resident specific label for directions, all stored among vital sign equipment of stethoscopes and blood pressure cuffs. c. Top left drawer was observed to have the following medication stored randomly to include Resident 5's opened and undated bottle of Azelastine (antihistamine) nasal spray 0.1 %, Resident 31's bottle of Azelastine 0.05% eye drops (antihistamine) opened and undated, Resident 16 Systane nighttime eye ointment (lubricant) 3.5 grams (gm) opened and undated, and Resident 32 a Symbicort 160/4.5 (corticosteroid) micrograms (mcg) 10.2 gm inhaler opened and undated. d. Bottom drawer contained a can of value scents citrus air freshener deodorizer opened and stored among medications to include Resident 5 a tube of triamcinolone cream (topical corticosteroid used to treat swelling and itching) 0.1% opened and undated, and a bottle of Azelastine 0.1% nasal spray opened and undated, and Resident 19 a tube of Diclofenac sodium topical gel (antifungal) 1% opened and undated. The 100 hallway medication room was observed with RN 9, the sink, counter, and floor were observed to be heavily soiled with unidentified substances, dirt, paper debris, lime build up in the sink and around the faucet, and when turned on the water sprayed out of the faucet to the left side onto the counter. There was no paper towel. On 7/10/23 at 10:28 a.m., the 100 hallway treatment cart was observed with RN 9, the following treatments were observed to be stored randomly together and unbagged, among 6 containers of wound cleaner and a can of aerosol sunscreen, a. Top drawer Resident 5, 2 bottles of Nystatin powder opened and undated, Resident 36 a bottle of Nystatin powder opened and undated, Resident 43 a bottle of Povidone iodine 10% with no resident specific label opened and undated, Resident 146 a bottle of Nystatin powder opened and undated, Resident 39 a tube of Biofreeze opened and undated, Resident 40 a tube of Aquaphor cream (moisturizes dry, chapped, or irritated skin) with no resident specific label opened and undated, Resident 26 a bottle of Nystatin powder opened and undated, and Resident 15 a bottle of Nystatin powder opened and undated, a bottle of selenium anti-dandruff shampoo opened and undated, and a bottle of renew skin repair without a resident specific label, and Resident 16 a bottle of baby shampoo with no resident specific label, and a tube of hydrophilic wound dressing (absorbs excess fluids from wounds while maintaining a moist healing environment) opened, undated, and no resident specific label. On 7/11/23 at 9:51 a.m., the 200 hallway treatment cart was observed with Licensed Practical Nurse (LPN) 28, the following treatments were observed to be stored randomly together and unbagged, a. Second drawer Resident 18 a bottle of Nystatin powder opened and undated, Resident 5 a bottle Ketoconazole 2% shampoo (antifungal) opened unbagged with red liquid leaking out of the lid and dried on the side of the bottle, and a container of c-bactra-nyst-znox 1:1:1 ointment (combination ointment used to treat fungal infections) not bagged and undated, Resident 33 a tube of Ketoconazole cream 2% opened and undated, Resident 12 a tube of Aquaphor ointment opened and undated, Resident 13 a container of Proctofoam 1% (rectal foam that helps relieve swelling and itching in the anal region) opened and undated, Resident 29 a tube of Diclofenac sodium topical gel 1% opened undated, Resident 1 a tube of Biofreeze 4% gel opened undated, Resident 2 a bottle of Ketoconazole shampoo 2% opened undated, Resident 3 a bottle of ammonium lactate 12% (lubricant) opened and undated with the cap not closed, Resident 9 a bottle of Nystatin powder opened and undated stored among the containers wound cleaners, and Resident 23 had 2 containers of Eucerin cream opened and undated. There was a tube of Dermaphor ointment (moisturizer to treat or prevent dry, rough, scaly, itch skin, and minor skin irritation) and tube of Venelex wound dressing ointment (topical wound dressing for management of chronic and acute wounds and ulcers) both opened unbagged with no resident specific label or name. b. Third drawer Resident 2 a tube of Biofreeze opened and undated, and Resident 33 a tube of Lidocaine 4% cream opened and undated. c. Fourth drawer Resident 24 Aquaphor ointment butt cream opened and undated stored among 11 tubes of house stock calmoseptine, and an opened tube of medihoney with no resident specific label stored with wound dressings. The 200 hallway medication refrigerated top shelf was observed to have the majority of the shelf covered in a dark dried unidentified substance with resident medications laying on top of it. Observation of the 200 hallway medication cart with LPN 28, a. Resident 14 a bottle of Latanoprost solution 0.005% eye drops (used to treat glaucoma) opened and undated, Resident 2 a Symbicort inhaler opened undated, and Resident 197 a tube of aspercreme 10% (topical analgesic) opened undated and not bagged stored among the oral medications. On 7/11/23 at 10:18 a.m., a second observation of the 100 hallway medication cart indicated concerns from the prior day of opened and unbagged treatments being stored in the medication cart among oral medications, and undated opened medications continued. On 7/11/23 at 10:52 a.m., a second observation of 100 hallway medication room. Sink and counter observed to be heavily soiled with unidentified substances, lime build up in sink and around faucet, water sprays to the left side when turned on and still no paper towel. The floor was littered with paper debris, heavily soiled with unidentified dark and red dried substances. The DON indicated it was the nurse's responsibility to clean up the medication room, or to monitor housekeeping so they could clean. During a random observation on the 100 hallway medication cart on 7/13/23 at 9:25 a.m., sitting halfway down the hallway in front of room [ROOM NUMBER]. On top of the medication cart was a cup of unidentified crushed medications, an inhaler, IV bag of clear medication, and a plastic water glass with pink liquid. The medication cart was unsupervised as LPN 14 was observed on another hallway taking a resident back to his room, and 2 unidentified resident were observed sitting near the cart conversing. At 9:36 a.m., LPN 14 was observed returning to the medication cart and administering the medications to Resident 32 at the end of the hallway. During an interview on 7/11/23 at 10:13 a.m., LPN 28 indicated, it was the responsibility of the nurse using the cart to maintain the carts in a neat and orderly manner, and date medications when opened. The contracted wound nurse used the treatment carts also, but it was still the nurses responsible for maintaining medication and treatment carts. During an interview on 7/14/23 at 9:25 a.m., the Director of Nursing (DON) indicated, being newer she was unsure of what continuing education the nurses and Qualified Medication Aides (QMA's) had received at the facility. There were do not crush lists provided inside the narcotic books on the medication carts for staff reference. Medication pharmacy labels may also state to not crush. DON indicated, ultimately it was her responsible for making sure the staff were educated and residents received their medications properly. The nurses were responsible for assuring the medication and treatment carts and medication rooms were clean, organized, and medications dated when opened, with management oversight. On 7/14/23 at 12:30 p.m., the Regional Nurse Consultant provided a Medication Storage in The Facility policy, dated May 2019, and indicated the policy was the one currently being used by the facility. The policy indicated, Policy: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations .3. Medication rooms, carts, and medication supplies are locked or attended by person with authorized access: a. License Nurses, b. Consultant Pharmacist, c. Pharmacist Technician, d. Individual lawfully authorized to administer drugs, e. Consultant Nurses. 4. Drugs for internal use are kept separate from externally used medications. 5. Eye drops, ointments, drops, and inhalers to be kept separately from floor stock medications. 6. Medications labeled for individual residents are stored separately from floor stock medications. 7. External medications including ointments for skin irritations and medication for application to wounds should be kept in a treatment cart, or in a separate drawer in the medication cart which is labeled as such. 8. Potentially harmful substances [e.g. urine test reagent tablets, household poisons, cleaning supplies, disinfectants] are stored in a locked area separately from medications .15. Mediation storage areas are kept clean, well lit, and free of clutter .16. Medication and treatment carts are a property of the pharmacy; the facility is required to keep the carts clean and damage free . 3.1-25(j) 3.1-25(k) 3.1-25(m) 3.1-25(o)

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure all kitchen foods were covered, hand washing was correctly completed in the kitchen and dining room (Resident 7 and 10), and failed to clean to fryer in a timely manner for 2 of 2 days of observations. These deficient practices had the potential to effect 43 of 43 residents who received food from the kitchen. Findings include: 1. On 7/10/23 at 10:45 a.m., 2 large, pre-cooked turkey breasts were observed, uncovered, sitting on the stainless steel counter top. The Dietary Manager (DM) indicated the internal temperature of the turkey breasts were 83.4 degrees F. She indicated the danger zone for food sitting-out was 70 degrees F. The DM indicated she took them out of the refrigerator at 8:30 a.m. and set them on top of the oven. The oven was on and set at 350 degrees Fahrenheit (F). At 9:00 a.m., she set them on the kitchen counter and went to morning meeting. On 7/10/23 at 11:00 a.m., the DM indicated that was not how the kitchen usually handled food. She indicated it was after breakfast, and she was getting ready to prepare the turkey for lunch. She was going to grind it up and add barbeque sauce. Normally, she would have taken it out of the refrigerator, ground it up, added the barbeque sauce right away and placed it into the oven. But, she was cooking breakfast this morning. and just, made a mistake. The turkey breasts were covered with foil while on top of the oven. When she put them on the counter, she took the foil off. She indicated she should have left the foil on the pan. 2a. On 7/10/23 at 11:26 a.m., Dietary Aide (DA) 8 was observed to wash her hands, she turned the water faucet off with her bare hands, then dried them on paper towels. She removed two steam table lids, drained them in the sink and placed them on top of the oven. On 7/10/23 at 11:27 a.m., Dietary Aide 8 was observed to wash her hands, she turned the water faucet off with her bare hands then dried them on paper towels. She acquired the temperature of the foods on the steam table and started serving food on plates for the residents. On 7/12/23 at 10:52 a.m., [NAME] 29 was observed preparing pureed foods. She washed her hands, turned the faucet off with her bare hands then dried them on paper towels. 2b. On 7/10/23 at 11:52 a.m., Certified Nursing Assistant (CNA) 4 sat down between Resident 7 and Resident 10. She pulled the chair up with her bare hands and did not use hand hygiene. She mixed a pat of butter into Resident 10's mashed potatoes, then mixed butter into Resident 7's mashed potatoes. She did not perform hand hygiene between residents. During a continuous observation, from 11:54 a.m., to 11:57 a.m., CNA 4 was observed going back and forth between the two residents providing several bites of food to each resident without using hand hygiene. On 7/10/23 at 11:57 a.m., CNA 4 provided a bite of mashed potatoes to Resident 10. Then, she reached down to her lap and pulled up a small blanket. She did not use hand hygiene before providing a bite of food to Resident 7. On 7/10/23 at 11:58 a.m., CNA 4 readjusted Resident 7's clothing protector and did not perform hand hygiene before proving Resident 10 a bite of food. During a continuous observation, from 11:58 a.m., to 12:02 p.m., CNA 4 was observed going back and forth between the two residents providing several bites of food to each resident without using hand hygiene. On 7/10/23 at 12:02 p.m., CNA 4 was observed rubbing her right shoulder with her left hand. She did not use hand hygiene before providing Resident 7. On 7/10/23 at 12:03 p.m., CNA 4 was observed to lay both her hands flat on her thighs. She did not hand wash before providing food to Resident 10. On 7/10/23 at 12:04 p.m., CNA 4 was observed to lay both her hands flat on her thighs. She did not hand wash before providing food to Resident 7. On 7/10/23 at 12:07 p.m., CNA 4 touched her hair, did not use hand hygiene, and provided food for Resident 10. On 7/10/23 at 12:10 p.m., CNA 4 touched her hair, did not use hand hygiene, and provided a drink for Resident 10. During an interview, on 7/14/23 at 1:18 p.m., the DON indicated staff should use hand gel between touching themselves or other surfaces. For assisting residents with eating, the CNAs should only assist one resident at a time. The facility had enough staff for the resident's to received one on one care with eating. A current policy, titled, Hand Hygiene, with no date, was provided by the DON, on 7/12/23 at 11:36 a.m. A review of the policy indicated, .wet hands .apply generous amount of soap to hands and run hands together vigorously for at least 20 seconds dry thoroughly with a disposable towel .rinse hands with warm water .Use towel to turn off faucet and exit ad the area A current policy, titled, Stop Germs! Wash Your Hands, with no date, was provided by the DON, on 7/14/23 at 2:10 p.m. A review of the policy indicated, .Keeping hands clean is one of the most important things we can do to stop the spread of germs and stay healthy 3. On 7/10/23 at 11:25 a.m., the front of the fryer was observed with oil streaks down the front of it, the inside had a thick ring of very brown crumbs at and above the oil line with a slightly burned odor. Dietary Aide (DA) 8 indicated the kitchen staff were unable to clean the fryer because the grease dumpster behind the kitchen was full. The last time it was cleaned was June 27th. On 7/12/23 at 10:51 a.m., the front of the fryer was observed with oil streaks down the front of it, the inside had a thick ring of very brown crumbs at and above the oil line with a slightly burned odor. On 7/12/23 at 11:18 a.m., the Dietary Manager (DM) indicated the grease dumpster outside was overflowing. We have new grease for the fryer once we can empty it. We called the Maintenance man (MM) twice. The MM calls the company to come out to empty the grease dumpster. We fry chicken tenders and french fries every day. as always available food. A current policy, titled, Cleaning Instructions: Fryer, with no date, was provided by the DON, on 7/12/23 at 11:36 a.m. A review of the policy indicated, .fryer will be cleaned on a routine basis 3.1-18(l) 3.1-21(i)(2) 3.1-21(i)(3)

CONCERN (F) 📢 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

Safe Environment (Tag F0921)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure compliance with Indiana Department of Environmental Management's (IDEM) requirement to submit documentation of a fully certified Water Distribution Manager to comply with the Safe Drinking Water Act. Further, the facility failed to ensure a Plan of Correction was submitted after an onsite inspected which resulted in deficient practice on [DATE]. These deficient practices had the potential to effect 43 of 43 residents who resided in the facility. Findings include: During an interview on [DATE] at 12:14 p.m., the Section Chief for the IDEM Drinking Water Field Inspection, (SC), indicated, IDEM did not have documentation to satisfy the requirement of a designated water safety operator. Additionally, an onsite inspection had been conducted on [DATE], and the facility failed to submit a formal Plan of Correction for the cited deficiencies at that time. On [DATE], a second letter of noncompliance was submitted which requested these requirements to be addressed. The SC submitted a copy of the letter of noncompliance for review. A Noncompliance Letter on IDEM letterhead, dated [DATE] indicated, On [DATE], representatives of IDEM, Office of Water Quality, conducted a second review of the Waters of Lebanon .a summary of the review is provided below: .according to our records . The Waters of Lebanon is without a certified operator in responsible charge . it also states that a written notice is to be submitted to the Commissioner no later than 30 days after the occurrence of a change in the person serving as the certified operator in responsible charge . On [DATE] at 1:55 p.m., the SC provided a copy of the first noncompliance letter dated [DATE], which stated the same information as above. Further, the SC submitted a summary of prior Sanitary Survey results, where were reviewed on [DATE] at 12:30 p.m. A Sanitation Survey was conducted on [DATE] which resulted in a System Management & Operation Deficiency, DSS FSO certification for [Maintenance Director] expired on [DATE] . [MD] needs to become DSS certified or have another person become certified as the Facility Specific Operator . During an interview on [DATE] at 1:30 p.m., the Maintenance Director indicated he believed he was DSS certified and provided a copy of his certificate. A copy of the Maintenance Director's DSS certificate was reviewed, although it was undated, an accompanying letter dated [DATE] indicated instruction for the DSS examination. A review of the Indiana State License and Certification website on [DATE] at 1:35 p.m., revealed the Maintenance Director's DSS certification was Inactive. A review of the IDEM website for Operator Requirement and Qualifications indicated, Once certified, an operator must get their required continuing education hours and renew their license(s) triennially (every three years). Secondly, the Sanitary Survey report submitted by the SC indicated, a Sanitation Survey was conducted on [DATE] and cited 7 deficiencies, with no resolved dates. During an interview on [DATE] at 1:37 p.m., the Maintenance Director indicated he was not responsible for writing or submitted plan or correction reports. That was his Regional Supervisor's responsibility. During an interview on [DATE] at 1:45 p.m., The Maintenance Director Regional Supervisor (RMD) indicated, he could not remember when or who he submitted a plan of correction to, but that he was sure it had been completed. On [DATE] at 2:00 p.m., the Maintenance Director provided a copy of his notes on the corrections that were made for the [DATE] sanitation survey. The report was 11 pages long and contained pictures of deficient equipment/areas. The MD indicated, next to the pictures were his handwritten notes of the corrections that had been completed. The report lacked documentation of who completed the repairs, and/or how the deficiency would be monitored/maintained as to not repeat the deficiency. The Maintenance Director and the RMD were unable to provide a copy of a formal plan of correction. On [DATE] at 2:30 p.m., the Maintenance Director provided a copy of current, but undated facility policy titled, Water Systems- Legionella Risk Prevention. The policy indicated, It is the policy of the facility to ensure that microbial growth is inhibited in the water system. The facility will provide a safe, sanitary and comfortable environment to include practices in place to help prevent the development and transmission of communicable disease and infection . If you qualify for a Water Management Program, make a building specific list (for the building for which the Water Management Program is being devised) taken from the Mater [NAME] as to areas/equipment that need to be monitored . program review needs to take place at least annually This federal/state tag relates to Complaint IN00412867. 3.1-19(b)

Apr 2023 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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide additional nursing assessments for an unresponsive resident who ended up in the hospital Intensive Care Unit (ICU) for 1 of 1 resident reviewed for nursing assessments (Resident B) Finding include: On 4/13/23 at 10:00 a.m., Resident B's record was reviewed. His diagnoses included, but were not limited to left-sided hemiplegia and hemiparesis (paralysis and weakness), chronic obstructive pulmonary disease (COPD), cerebrovascular disease, diabetes mellitus (DM) (blood sugar disorder), Personal history of traumatic brain injury, major depressive disorder, schizophrenia (disordered thought process with delusions), dementia (degenerative and progressive brain disease), and constipation (unable to have bowel movements). Physician's orders indicated Resident B was on Cymbalta (antidepressant) daily for depression, Risperdal (antipsychotic) and Depakote sprinkles (anticonvulsant) daily for schizoaffective disorder, bipolar type. He had Zofran, as needed for nausea/vomiting. He was a full code. A nursing progress note, dated 4/6/23 at 9:09 p.m., indicated Resident B vomited a large volume after dinner. A nursing progress note, dated 4/8/23 at 10:35 p.m., indicated Resident B had a change in condition. Licensed Practical Nurse (LPN) 11 did nursing rounds right after report. Resident was lethargic, only responding to a hard sternal rub. Unable to follow commands, unable to grip. His VS were BP 133/75, HR 101, O2 saturation 90% on room air, respirations were even and unlabored at 20, and his temperature was 98 degrees Fahrenheit (F). His physician was notified and received an order to send him out. Emergency Medical Services (EMS) arrived and resident was noted to have a small seizure during that time that lasted approximately 30 seconds. Resident B was sent to a local hospital. A follow-up call with an ER nurse, she indicated Resident B had 3 more seizures in route to the hospital, Keppra (anticonvulsant) was given and the seizures stopped. However, he remained responsive only to a sternal rub and they planned to admit him. A nursing progress note, dated 4/8/23 at 11:00 p.m., indicated Resident B's neurological status evaluation was an altered level of consciousness and seizure. His change in condition warranted an order to be set to ER for further evaluation. His change in condition form, dated 4/8/23, indicated he had an altered mental status with new neurological signs, seizure, and unresponsiveness. His vital signs VS) were blood pressure 133/75, pulse 101, temperature 98 degrees F, and oxygen (O2) saturation 90%. He was a full code. The resident evaluation indicated altered level of consciousness, sudden change in level of consciousness or responsiveness, and new onset seizure. Left eye drooping and only aroused with hard sternal rub. Evening nurse stated he was lethargic at dinner time but was able to consume 100% of dinner and drink all fluids without issue. Change in condition warranted an order to be sent to ER for further evaluation. A bowel and bladder incontinence screener, dated 3/7/23, indicated Resident B was always incontinent of bladder and incontinent of bowel 4 to 6 times a week. He was not appropriate for structured bowel and bladder program. He would be placed on a check and change program/standard of care. A risk for constipation care plan, dated 2/9/22, indicated Resident B was at risk for constipation related to his impaired mobility and medication, with a goal to have a bowel movement (BM) at least every 3 days. A nursing approach indicated he needed his medications as order and his BMs monitored by staff to assure he didn't become constipated. A toileting care plan, dated 2/9/22, indicated Resident B needed varied assistance for toileting for bowel and bladder incontinence. An antipsychotic care plan, dated 4/15/22, indicated Resident B had schizoaffective disorder/schizophrenia/mania. A nursing approach indicated he needed his antipsychotic medications as ordered and routine psych visits as needed. During an interview, on 4/13/23 at 2:30 p.m., Registered Nurse (RN) 10 indicated she worked the night shift. Report during change of shifts, LPN 11 indicated the resident was more sleepy than usual after dinner, he did not seem right and he had been vomiting earlier that week. RN 10 indicated after report, she went to Resident B's room first. His room was dark, when she turned on the light, he did not wake up. She grabbed his arm, but he did not respond. He was unable to grip her hands. He was breathing normally, but his left eye was droopy and he could not open it further. She requested LPN 11 to get his VS. They were within normal limits (WNL). LPN 11 did a hard sternal rub (knuckle pressure on the sternal bone to effect a response from a patient who does not respond to verbal stimuli). He did not respond. RN 10 indicated she got on Diagnotes (email system to reach the nurse practitioner (NP) or medical doctor (MD) to share information about residents) and indicated Resident B was unresponsive and needed to be sent out (to the hospital). She could not find a phone number for the MD. She believed the doctor on-call should have been available to call in an emergency situation. She would have preferred to call the MD instead of waiting for Diagnotes to email her back. The other nurse assisting her was RN 13. We were taking turns in the resident's room. Certified Nursing Aide (CNA) 12 was in the room, so the resident was still being monitored when the nurses were out of the room. RN 10 indicated while she prepared the resident's paperwork, RN 13 called 911. When EMS arrived Resident B had a seizure in his bed, prior to being transferred to the EMS cart. She indicated he was jerking and his arm was up and shaking (his left side was paralysis due to a previous stroke). The seizure lasted about 30 seconds. On 4/14/23 at 9:10 a.m., the Administrator provided a copy of the emailed information through Diagnotes: a. At 9:40 p.m., from LPN 10: Resident B was extremely lethargic. Only responded to a hard sternum rub. VS all WNL. Glucose 156. Request to send out. b. At 9:43 p.m., from Diagnotes, RN 9: Family was requesting? c. At 9:44 p.m., from LPN 10: No, do you want me to ask family? d. At 9:52 p.m., from Diagnotes, RN 9: Was seeking clarification as to who was requesting. e. At 9:52 p.m., from LPN 10: He is a full code. f. At 9:53 p.m., from Diagnotes, RN 9: Did he take narcotics? g. At 9:54 p.m., from LPN 10: Facility was requesting he be sent out because of a change in condition. h. At 9:56 p.m., from LPN 10: He takes tramadol (for moderate to severe pain). i. At 9:59 p.m., from Diagnotes, RN 9: You may ask family. j. At 10:24 p.m., from LPN 10: We send him out. He started seizing. Unable to reach family. During an interview, on 4/14/23 at 2:40 p.m., RN 13 indicated her assignment that night was on a different hall, but RN 11 requested her help at 10:30 p.m. with Resident B's change in condition. He was not at baseline, he had a significant change in condition. She assessed his level of consciousness. He was unresponsive to a sternal rub, he said an unintelligible word, but his VS and blood sugar (BS) were stable. RN 13 indicated to RN 11 that she should call 911 right away. It is normal for the on-call person to be responding with the NP. We have a number we can call, but we routinely use Diagnotes. Recommended the nurse to communicate on Diagnotes and prepare the resident for transfer. We had been told to use Diagnotes to get a faster response from the providers. The communication from Diagnotes indicated to contact the family. I don't know why the information from Diagnotes wanted us to contact the family. During an interview, on 4/17/23 at 10:59 a.m., CNA 14 indicated she sat with him while the nurses were in and out of the room. He looked like he was in a deep sleep and his breathing seemed normal. The nurse indicated he looked like he had a stroke because his left eye was drooping. During an interview, on 4/17/23 at 1:54 p.m., LPN 11 indicated she was Resident B's nurse on the evening shift. He got up for dinner and ate in the dining room. A CNA assisted him with eating and he ate 100 % of his meal and drank all the fluids. He was talking, but seemed a little drowsy from being woken up. They lay him down between meals and he was asleep before dinner. He was transferred via a Hoyer lift. As the evening drew longer, at the end of the shift, he laid down and fell back asleep, around 8:00 p.m. The last time she saw him was around 5:30 - 6:00 p.m. She gave him roommate medication around 7:00 or 8:00 p.m., and she noticed he was asleep. She indicated he was more sleepy that usual, but his VS and BS were WNL. She was still at the facility when the night nurse found him unresponsive. He would not respond to verbal stimuli, she did a sternal rub. RN 10 indicated she was going to send him out and LPN 11 agreed with her. During her shift, she did not notice any neurological changes, no tremors or shaking. One of his eyes was normally a little droopy. If she was the nurse when the resident was found unresponsive she would have immediately contacted Diagnotes and then called 911. She would not have waited 1.25 hours before contacting 911. It was a change in condition, he was a different person During an interview, on 4/14/23 at 4:17 p.m., the Nurse Consultant indicated Resident B was very dependent on staff. During an interview, on 4/14/23 at 4:18 p.m., the Administrator indicated the daughter indicated in the hospital notes that she doesn't visit him very often. During an interview, on 4/14/23 at 4:20 p.m., the Director of Nursing (DON) indicated if a resident had a change in condition, the staff should have seen the symptoms, do VS, contact the person on Diagnotes, and wait for their response. If the resident was non-responsive, the staff should have contacted the DON or administrator. Then, complete a change in condition form. An assessment included VS and blood sugar if needed. Vital signs were the main thing to do. She would have called another nurse to help. The nurse would have been on Diagnotes, get the paperwork ready, and calling the family. The time goes by fast. All the steps that have to be done to send a resident out correctly. If the first set of VS were WNL, even if the resident was unresponsive, that would have been enough. [NAME] County EMS document titled, Patient Care Report, dated 4/8/23, was provided by Medical Records 15 at [NAME] Hospital, on 4/18/23 at 2:10 p.m. A review of the document indicated dispatch was notified at 10:59 p.m. Advanced Life Support (ALS) was at the resident's side at 11:06 p.m., where he was found unresponsive. At 11:08 p.m., his BP was 90 palpated (systolic pressure taken by hand), pulse 100, and respirations 24. His Glasgow Coma Scale (GCS) (measure of a person's level of consciousness after a brain injury) was 5 (severe). At 11:14 p.m., his GCS was down to 4. Resident B's O2 saturation was 88%, O2 at 2 lpm (liters per minute) was added via nasal cannula (NC). Patient had sudden onset jerking consistent with a tonic clonic seizure lasting 10-15 seconds. This seizure-like activity happened 3 times within 5 minutes of each other. Patient was moved from the bed to the stretcher. Upon the third bout of seizure-like activity, patient was given 5 mg Midazolam (versed) (benzodiazepine -slows activity in the brain) IM (intramuscular injection). A current policy, titled, Assessments, was provided by the Nurse Consultant, on 4/14/23 at 5:00 p.m. A review of the policy indicated, .It is the policy of this facility to ensure that assessments of the resident take place timely, at the appropriate time and are accurate .Appropriate assessment can with will be completed at time based on the event .Nurses and other qualified health professionals will perform appropriate assessment of the resident as indicated based on the routine schedule as well as when a change in condition or circumstances and/or an event takes place that required ?assessment? by a qualified medical professional This Federal tag relates to Complaint IN00406257. 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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for 6 of 6 random call light observations (Resident C, D, F, G, H, and K). Findings include: Starting on 4/13/23 at 11:10 a.m., random call lights were observed. -Resident K was in bed with his eyes closed, the call light was hanging out of reach away from the side of his bed. -Resident F was in bed with eyes closed. His call light was clipped on the wall behind his bed, it was out of his reach. Starting on 4/14/23 at 1:10 p.m. random call lights were observed. -Resident H was in bed with eyes closed. The call light was observed to be clipped to the wall, behind the bed, out of reach. -Resident G was in bed with eyes closed. His call light was observed to be clipped to the wall, out of reach. -Resident C and D shared a room. Both were asleep in chairs in their rooms. Both call lights were observed on the floor out of reach of the residents. -Resident K was in bed with eyes closed. The call light was observed out of reach, under the edge of the bed. During an interview, on 4/14/23 at 4:29 p.m., the Director of Nursing (DON) indicated the call lights should be answered in less than a minute, but the staff could be working short staffed if it takes longer. Call lights should not be on the floor. There was a clamp attached to the call light so that it can be pinned to the resident and should be within their reach. A current policy, titled, Call Lights, was provided by the Nursing Consultant, on 4/14/23 at 4:39 p.m. A review of the policy, indicated, .Always place the call light in an accessible location to where the resident is located in their room This Federal tag relates to Complaint IN00406257. 3.1-19(u)

Mar 2022 13 deficiencies

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure a call light was within reach for 1 of 8 dependent residents reviewed for call light placement (Resident 17). Findings include: On 3/21/22 at 2:06 p.m., Resident 17 was observed sitting in his reclining wheelchair at beside with a television remote in his hand attempting to find a channel. The resident's call light was observed to be laying on the floor between a floor fan and chair, out of reach of the resident. Resident 17 indicated if he needed the staff, he supposed he would use the call light, and while pointing at the call light he indicated the call light was over there on the floor. On 3/22/22 at 2:49 p.m., Resident 17 was observed lying in bed with his eyes closed. The resident's call light was observed laying on a chair at the head of the bed on the resident's right side, out of reach of the resident. On 3/23/22 at 11:07 a.m., Resident 17 was observed sitting in his wheelchair at bedside watching television. The resident's call light was observed to be on the floor in front of the resident, out of reach. Resident 17 indicated he got the staff's attention by yelling. On 3/24/22 9:07 a.m., Resident 17 was observed in his wheelchair at beside watching television. The resident's call light was observed to be on the floor in front of the resident, out of reach. On 3/24/22 9:52 a.m., observation of Resident 17 sitting in his wheelchair at bedside as Licensed Practical Nurse (LPN) 5 administered the resident's medications. LPN 5 acknowledged the resident's call light on the floor and indicated the call light should have been clipped to the resident's lap throw within his reach. Resident 17's record was reviewed on 3/22/22 at 1:39 p.m. Diagnoses on Resident 17's profile included, but were not limited to, hemiplegia and hemiparesis following a cerebrovascular disease affecting left non-dominant side, personal history of traumatic brain injury, and dependence on wheelchair. A Physician's order for Resident 17, dated 4/7/21, indicated resident to sit up in Broda chair (type of reclining wheelchair) daily. An Annual MDS (Minimum Data Set) assessment, completed on 1/26/22, assessed Resident 17 as requiring extensive assistance of two person physical assist for bed mobility, dressing, toileting, and personal hygiene. He required extensive assistance of one person physical assist for eating, and total assistance of two person physical assist for transfers and locomotion on and off the unit. Care Plans for Resident 17 indicated he required assistance for all ADL's (activities of daily living) related to impaired mobility, left side hemiparesis/hemiplegia, schizophrenia, contractures, dysphagia, pain, and obesity. On 3/24/22 at 11:30 a.m., the Director of Nursing (DON) provided a Use of Call Light policy, dated 2006, and indicated the policy was the one currently being used by the facility. The policy indicated, .8. When providing care to residents be sure to position call light conveniently for the resident to use .11. Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand 3.1-3(v)(1)

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure a resident's reclining wheelchair was properly cleaned and the cushioned arm padding was free of frayed material for 1 of 2 residents reviewed for equipment in good repair (Resident 17). Findings include: On 3/21/22 at 10:06 a.m., Resident 17 was observed propped up in bed drinking a health shake. The resident was alert, responsive to conversation, with difficulty forming sentences. A reclining wheelchair at bedside was observed to be heavily soiled with unidentified white and brown substances. On 3/21/22 at 12:20 p.m., Resident 17 was observed being brought into the main dining room in his reclining wheelchair and fed by a staff member. The resident was alert, talkative, and asking visitors to marry him. His reclining wheelchair frame, arm rests, cloth straps on the back side of the back rest, and wheels were heavily soiled with an unidentified white substance, chunks of brown substances were on the back side of the wheelchair metal frame, and the material on the back side of the cloth arm cushions were frayed. On 3/22/22 at 10:49 a.m., Resident 17 was observed sitting in his reclining wheelchair watching television, his wheelchair continued to be heavily soiled with unidentified substances. On 3/23/22 at 10:15 a.m., Resident 17 was observed sitting in his reclining wheelchair at bedside, the wheelchair continued to be heavily soiled. On 3/24/22 at 9:52 a.m., Resident 17 was observed sitting in his heavily soiled reclining wheelchair at bedside as Licensed Practical Nurse (LPN) 5 administered the resident's medications. LPN 5 acknowledged the soilage of the resident's wheelchair and indicated there was no wheelchair cleaning schedule to her knowledge. She did not think any one person had been assigned responsibility for assuring resident wheelchairs were cleaned. On 3/25/22 at 11:23 a.m., Resident 17's reclining wheelchair was observed at bedside. It continued to be heavily soiled with unidentified substances. Resident 17's record was reviewed on 3/22/22 at 1:39 p.m. Diagnoses on Resident 17's profile included but were not limited to hemiplegia and hemiparesis following a cerebrovascular disease affecting left non-dominant side, personal history of traumatic brain injury, and dependence on wheelchair. A Physician's order for Resident 17, dated 4/7/21, indicated the resident was to sit up in the Broda chair (type of reclining wheelchair) daily. Care Plans indicated Resident 17 required assistance for all ADL's (activities of daily living). A 10/7/21 care plan indicated Resident 17 was to sit up in a Broda chair for positioning daily when out of bed. The goal was for the resident to have no injuries related to Broda chair use. Interventions included adjust positioning for comfort as needed, assure proper positioning while up in Broda chair, and use a mechanical lift and at least assistance of 2 for all transfers in and out of the Broda chair. On 3/22/22 2:54 p.m., Certified Nursing Assistant (CNA) 9 indicated she had worked the hall and been assigned to Resident 17's room. Resident wheelchairs and durable medical equipment were washed in the shower room on the resident's shower day. A shower binder indicated Resident 17 was assigned to have a shower on Wednesday and Saturday evenings. Maintenance request slips, dated February and March 2022, indicated no documentation related to the disrepair of the padded arm cushions on Resident 17's wheelchair. On 3/22/22 at 2:52 p.m., CNA 8 indicated aides received their work assignments daily from the nurse. On 3/23/22 at 10:57 a.m., CNA 10 indicated resident assignments were written out on a paper at the desk daily. Agency aides were given report from each other and that was how they knew what resident care was needed. To her knowledge the night shift was responsible for cleaning resident wheelchairs and walkers, but if her resident had a dirty wheelchair, she would have cleaned it. On 3/23/22 at 11:00 a.m., LPN 7 indicated she had never seen a resident assignment sheet for the aides or a cleaning schedule for durable medical equipment to include walkers or wheelchair. She had just assumed it was a night shift responsibility, or the staff cleaned as needed routinely. On 3/23/22 at 11:05 a.m., CNA 9 indicated there was no specific work list for cleaning resident equipment such as wheelchairs or walkers, she cleaned her residents' wheelchairs on their shower days. A Wheelchair/Walker Cleaning Schedule-Night Shift form, undated, indicated Resident 17's wheelchair was scheduled to be cleaned on Saturday nights. On 3/25/22 at 1:10 p.m., the Administrator (ADM) provided a Cleaning DME (Durable Medical Equipment) Wheelchairs/Mechanical Lifts/Stand Up Lifts/Shower Chairs/Bedside Commodes/Walkers/Other policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, It is the policy of the facility to ensure that DME [Durable Medical Equipment] is clean and in good repair. Procedure: [For equipment belonging to the resident] 1) Designated staff will examine the equipment for obvious soiling/spills prior to use. A mild detergent with water can be used to clean the affected area .On a monthly basis, personal DME will be thoroughly cleaned in a nearby shower area using a mild detergent and water .5) The upholstery will be checked for cracks/tears - these will be reported to the maintenance staff for repair/replacement 3.1-19(f)

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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Based on observation, interview, and record review, the facility failed to ensure a resident's dressings were changed according to her physician's orders and failed to ensure proper infection control measures were followed during a treatment observation for 1 of 2 residents reviewed for non-pressure skin conditions (Resident 15). Findings include: On 3/21/22 at 11:08 a.m., Resident 15 was observed asleep in her wheelchair (WC), in her room. She woke easily to verbal stimuli. She indicated her biggest concern was her legs, they hurt all the time. At this time her legs were observed to be bandaged from her toes to her knees. No date or nurse initials were visible on the bandages to determine the last time her dressing was changed. Resident 15 indicated they were supposed to be changed daily. On 3/21/22 at 2:09 p.m., Resident 15 was observed. She remained in her WC. She indicated her bandages had not been changed yet. On 3/22/22 at 9:29 a.m., Resident 15 was observed. She was sitting up in her WC and wore the same gown as she was observed in the previous day. Her bandages were the same, although at this time were observed to be discolored with light yellow/green soilage and there was a strong wound odor. Resident 15 indicated she did not know when they would be changed, but she hoped soon, because they hurt and itched like crazy. Resident 15 pressed her hand to the discolored area of the bandage and indicated they were damp, as her legs often leaked through. On 3/22/22 at 2:05 p.m., Resident 15 was observed. She remained in her WC. Her bandages were noted unchanged, the room was warm, and the smell was pungent. On 3/23/22 at 11:41 a.m. Resident 15 was observed. She wore a new gown, and indicated she had a shower. Her bandages had been changed and the date and initials of 3/23/22 at 11:00 a.m. were observed on fresh clean bandages. Resident 15 indicated she felt much better and was glad to have the dressings changed because, when they go for days like that, they get that nasty green slush. On 3/23/22 at 3:54 p.m., Resident 15's medical record was reviewed. She had current diagnoses which included but were not limited to chronic osteomyelitis (inflammation or swelling that occurs in the bone) and cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of right and left lower limbs. As of 3/23/22, she had current physician orders which included but were not limited to: a. Amoxicillin (an antibiotic medication) 500 mg (milligrams) every 12 hours for 14 days for her chronic osteomyelitis. b. Doxycycline (an antibiotic medication) 100 mg twice a day for 14 days for her wounds. c. Wound Treatment: cleanse bilateral lower extremities with normal saline (NS). Apply protective cream to peri-wound. Cover wound beds with 2 layers of silver alginate. Cover with ABD pads and wrap from toes to base of knees with kerlix. On 3/23/22 at 3:54 p.m., Resident 15's Treatment Administration Record (TAR) was reviewed and lacked documentation that her wound treatments had been completed on 3/22/22. Further, the TAR indicated 9 coded on 3/21/22, which was an indication to see nursing notes, however, there was no corresponding documentation in the nursing notes. On 3/24/22 at 9:15 a.m., Resident 15 was observed. She sat on the edge of her bed with her over-bed table and breakfast try in front of her. The bandages had been removed from her legs, so that her legs were bare, and her wounds were visible. There were multiple, large, irregularly shaped wounds that covered her legs from the bottom of her knees to her ankles. The wound beds could not be visualized through layers of purulent green slough. A plastic trash bag was observed on the floor with the soiled dressings, also noted to be copiously saturated with green drainage. On 3/24/22 at 9:30 a.m., the Wound Nurse Practitioner (W-NP) entered Resident 15's room for a weekly wound assessment. At the end of her assessment the W-NP indicated overall her wounds were stable, but not improving. She did not make any new recommendations at this time and indicated the facility wound nurse could re-dress the legs. During a continuous observation on 3/24/22 from 10:00 a.m. until 11:00 a.m. the Wound Nurse (WN) completed Resident 15's wound treatment. The WN began by gathering supplies and set up a clean station at the foot of Resident 15's bed by placing a new plastic trash bag down to set her supplies on top. She taped a second plastic bag to the end of the resident's bed for discarded/soiled supplies. The WN gathered supplies from several places including the treatment cart, her scrubs pockets, and from the resident's drawers. When she was ready to begin, the WN did not complete hand hygiene by washing with soap and water or using hand gel she simply placed on the first pair of gloves. With her 1st pair of gloves, the WN began by spraying the open areas of Resident 15's left leg with NS. Then used gauze to wipe the wound beds, which removed copious amounts of green slough. She removed the pair of gloves, and without performing hand hygiene, placed on a second pair of gloves. When the WN was ready to place the ABD pad over the alginate, she dropped the clean pad which fell onto Resident 15's right foot. She continued to place the ABD pad on the residents left leg. The WN placed on a new pair of gloves and while she waited for Resident 15 to reposition herself in bed, the WN leaned against the footboard of the resident's bed, using her right gloved hand for support. When the resident was ready, the WN continued the treatment without hand hygiene or a new pair of gloves after touching the resident's bed. The WN removed a pair of gloves and needed to gather additional supplies. She used her bare hands to pull the privacy curtain back and forth, rummaged through the treatment cart, and reached into her scrubs pocket again for scissors. She returned to the dressing treatment and put on a new pair of gloves without performing hand hygiene. When completing the dressing treatment, the WN ripped off two sections of tape with her bare hand and placed them on her bare forearm. She put on a new pair of gloves, without performing hand hygiene, and wrapped Resident 15's legs with kerlix. She used the tape from her forearm to secure the kerlix in place. During an interview on 3/24/22 at 11:05 a.m., the WN indicated she usually had an aid to help her with the treatments since Resident 15 could not lift her legs. It was helpful to have that second pair of hands to help steady and lift her legs so she could focus on doing the treatment thoroughly. On 3/24/22 at 12:09 p.m., the Director of Nursing provided a copy of current, but undated facility policy titled, Dressing Change-Clean Guidelines. At this time the DON indicated the policy was pretty general, but in review of Resident 15's treatment observation, the WN should have limited her contact with the resident's environment/surfaces and performed hand hygiene anytime she put on a new pair of gloves. The policy indicated, . to prevent infection and [the] spread of infection . perform hand hygiene 3.1-37(a)

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure a resident who was severely hard of hearing received ancillary audiology services, was care planned for her hearing loss, and failed to identify and replace lost hearing aids in a timely manner for 1 of 1 resident reviewed for vision/hearing (Resident 6). Findings include: On 3/21/22 at 10:42 a.m., Resident 6 was observed as she laid in bed. Upon entrance into her room, she was very tearful, and held a tissue to her nose as she cried. The head of her bed (HOB) was elevated, and Resident 6 was slouched down and leaned to the right. Resident 6 was very hard of hearing (HOH) and was only able to answer questions once they were typed out in large font across a computer screen. During an interview on 3/21/22 at 3:16 p.m., Resident 6's family member was in for a visit. She sat in a visitor's chair with a dry-erase white board and indicated it was a communication device she used so she didn't have to yell at the top of her lungs to Resident 6. Fortunately, Resident 6 could see good with her glasses, and she understood the written conversation. Resident 6's family member indicated she used to have a pair of hearing aids that helped but they had been lost for a long time. Resident 6 was asked at this time if she would like a new pair of hearing aids and she indicated, I'm too old to spend money on anything like that. Resident 6 indicated if she did not have to pay for them then it would be nice to try a new pair. Hearing aids might help her and the staff from becoming frustrated that she was so hard of hearing. On 3/22/22 at 9:41 a.m., Resident 6 was observed in her bed, but slouched down and complained that she was uncomfortable. Her call light was on for only a few minutes before Certified Nursing Assistants (CNA) 8 and 9 entered the room to help reposition her. They did not ask what was wrong, they did not explain the procedure of how they would reposition her and Resident 6 just shrugged and indicated she could not hear them when they spoke to her. The aids used the pad under the resident to pull/hoist her upward. Resident 6 called out and cried that it hurt all over to be moved. During an interview on 3/25/22 at 11:15 a.m., the Social Service Director, (SSD) indicated she had only worked with Resident 6 for 4 weeks and was unaware that she had a pair of hearing aids that had gone missing. She called the former SSD and spoke with Resident 6's family. Resident 6's room was searched as well. They were unable to locate the hearing aids. During an interview on 3/25/22 at 2:10 p.m., the Administrator (ADM) indicated, upon resident 6's admission she had a private audiologist. The ADM was unsure when Resident 6 stopped seeing that audiologist and indicated someone from the facility should probably have followed up with Resident 6 or her family about pursuing ancillary audiology services through the facility. At this time the ADM provided a text conversation between an unnamed staff member and Resident 6's family member. The text thread indicated the staff member contacted the family member to let them know the last set of batteries had been placed in Resident 6's husbands hearing aids. The family member asked how Resident 6's batteries were and the staff member indicated she would need new batteries too. Resident 6's family member indicated they would provide batteries. On 3/23/22 at 11:55 a.m., Resident 6's medical record was reviewed. The most recent comprehensive assessment was a quarterly Minimum Data Set (MDS) assessment, dated 12/9/21, which indicated Resident 6 was severely hearing impaired and required the assistance of hearing aids or appliances. Resident 6 had an admission personal item inventory, dated 2/12/20, which indicated she had two hearing aids. A nursing progress note dated 2/12/20 at 2:40 p.m., indicated, Resident 6 admitted to the facility, she was hard of hearing and had two hearing aids in place. A nursing progress note dated 3/30/20 at 12:26 p.m., indicated Resident 6 was hard of hearing and used hearing aids. The record lacked any further documentation of Resident 6's hearing aids. The record lacked documentation of a comprehensive care plan that outlined the extent of her hearing loss and or any interventions in place to communicate with her such as the dry-erase white board, which ear she was most able to hear from, and/or if any additional appliances or devices were available if needed. The record lacked documentation of any audiologist appointment for routine or as needed assessment and treatment. On 3/25/22 at 2:30 p.m., the ADM provided a copy of current, but undated facility policy tiled, Vision and Hearing Services. The policy indicated, .It is the standard of the organization to ensure that residents receive the proper treatment and assistive devices to maintain hearing and vision abilities 3.1-39(a)

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the development of an avoidable stage I pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident 6). Findings include: On 3/21/22 at 10:42 a.m., Resident 6 was observed as she laid in bed. Upon entrance into her room, she was very tearful, and held a tissue to her nose as she cried. The head of her bed (HOB) was elevated, and Resident 6 was slouched down and leaned to the right. Resident 6 was very hard of hearing (HOH) and was only able to answer questions once they were typed out in large font across a computer screen. At this time, Resident 6 indicated she was upset because her legs and feet hurt. She indicated her legs were broken from a fall, and she was unable to move herself in bed to get comfortable. Resident 6 pulled her bed sheet up so that her feet were visible. Her left foot was observed to have a protruding bunion (a bony bump that forms on the joint at the base of the big toe) that pressed into the mattress. During an interview on 3/21/22 at 3:16 p.m., Resident 6 was observed to have a family member in for a visit. At this time Resident 6 was observed lying in bed in the same position as noted above. At this time an interview was conducted with the family member. The family member indicated the resident's legs had not been broken in a fall, but she had a spinal cord injury many years ago that left her mostly paralyzed. She was unable to move herself in bed and often complained that her legs, and feet hurt. The slightest touch would cause her a great deal of pain. In order to communicate with Resident 6, her family member used a dry-erase board and wrote out questions. Resident 6's feet were observed when her family member pulled the sheets back, her left foot was pressed against the mattress. On 3/22/22 at 9:41 a.m., Resident 6 was observed in the same position as noted above. The HOB of her bed was elevated, but Resident 6 was slouched down and leaned to the right and her head rested on the bed rail. Resident 6 indicated she wanted to be repositioned she was uncomfortable. Her call light was on for only a few minutes before Certified Nursing Assistants (CNA) 8 and 9 entered the room to help reposition her. The aids used the pad under the resident to pull/hoist her upward. Resident 6 called out and cried that it hurt all over to be moved. On 3/23/22 at 11:15 a.m., Resident 6 was observed in the same position as noted above. She was upset and cried into a tissue. She indicated her toe hurt and she could not move it. Her foot was observed, her bunion was pressed into the mattress. Resident 6's call light was initiated, and CNA 10 entered the room. Resident 6 continued to cry out that her toe hurt. CNA 10 took two spare pillows from a visitor chair in the room and placed them under the resident calves to elevate her feet. On 3/23/22 at 11:38 a.m., Licensed Practical Nurse (LPN) 7 entered to room to assess Resident 6's feet due to her pain. An area to her bunion, at the base of her left big toe was observed. It was approximately the size of a half dollar, red, and tender to touch. When LPN 7 pressed the area, there was a delayed blanch response. LPN 7 described the area as a definite pressure area but would leave it to the wound nurse to stage. LPN 7 indicated there was delayed blanche response and her feet would need to be elevated to relieve the pressure. After several minutes of elevation, Resident 6 indicated it felt much better. On 3/23/22 at 11:55 a.m., Resident 6's medical record was reviewed. Resident 6 had active diagnoses which included but were not limited to, contracture of the left and right knee (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and foot drop (difficulty lifting the front part of the foot). A hospital Discharge summary, dated [DATE], with a PT (physical therapy) initial summary indicated, .strict elevation of heels The most recent pressure ulcer risk assessment was a Braden scale assessment, dated 1/4/22, which indicated Resident 6's score was 9. A score of 9 or less is very high risk. Resident 6 had a current comprehensive care plan which indicated she was at risk for skin breakdown due to her impaired mobility. Interventions for this plan of care included, but were not limited to, ensure she was turned and repositioned at least every 2 hours. A 30 day look back report for Turn and Repositioning indicated only 6 entries that Resident 6 had been repositioned. A nursing progress note, dated 3/23/22 at 3:48 p.m., indicated Resident 6 had a new area to the medial side of the ball of her foot which measured 1.0 centimeter (cm) by (x) 0.6 cm. It was blanchable. The NP was notified and a new order for skin prep twice a day was added. On 3/25/22 at 1:34 p.m., the Director of Nursing (DON) provided a copy of current but undated facility policy titled, Preventative Skin Care. the policy indicated, .It is the intent of the facility that the facility provide preventative skin care through careful washing, rinsing, and drying to keep residents clean, comfortable, well-groomed and free from pressure sores . residents identified as being at high risk for potential breakdown shall be turned and repositioned frequently to prevent redness that does not face or blanche . positioning pillows and or specialty devices may be used between two skin surfaces or to slightly elevate bony prominences/pressure areas off the mattress . pillows may be used to float heels to prevent potential pressure sores on those residents identified to be high risk 3.1-40(a)(1)

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 observation, interview, and record review, the facility failed to ensure a resident with significant weight loss was monitored for the effectiveness of a new intervention for 1 of 3 residents reviewed for nutrition (Resident 6). Findings include: On 3/21/22 at 10:42 a.m., Resident 6 was observed in bed with a breakfast tray in front of her on the bedside table. Resident 6 was tearful, and only about 10% of her breakfast had been consumed. Resident 6 indicated sometimes she just didn't want to eat anymore. During an interview on 3/21/22 at 3:16 p.m., Resident 6's family member indicated Resident 6 had lost a lot of weight. The family member indicated Resident 6 complained a lot about the food, and that it just didn't taste good anymore. On 3/23/22 at 11:55 a.m., Resident 6's medical record was reviewed. As of 3/23/22, she had a current comprehensive care plan for a mechanically altered diet due to her diagnosis of dysphagia. On 9/2/2021, Resident 6 weighed 132.8 lbs. On 3/2/22, she weighed 118.6 pounds which was a -10.69 % weight loss. The record lacked a care plan which outlined Resident 6's weight loss and interventions in place to prevent further weight loss. Resident 6 had a current physician order for a regular diet with the texture altered to mechanical soft, and chocolate milk with meals. A dietary progress note, dated 1/31/22 at 7:33 p.m., indicated Resident 6 had some weight loss which was attributed to her recent diagnosis of COVID-19. It was suggested to add Resident 6 to SWAT (Skin and Weight Assessment Team) to monitor her more closely, monitor weekly weights, and add interventions or supplements as needed. A dietary progress note, dated 3/21/22 5:22 p.m., indicated a follow up note of Resident 6 due to weight loss. Resident 6 had remained stable in the last 60 days. Chocolate milk with meals had been changed to Carnation Instant Breakfast. Her current physician orders as of 3/23/22 did not reflect the change from chocolate milk to Carnation Instant Breakfast. Resident 6 had an additional physician order, dated 2/14/22, to monitor her weights once a week for 4 weeks. The record lacked documentation her weights had been recorded on 2/21/22, 3/7/22, and 3/14/22. Over those 4 weeks, Resident 6 was weighed on 2/16/22 at 120 lbs. Her most recent weight on 3/2/22 she weighed 118. She had a 2-pound weight loss after a new intervention was put in place. During an interview, on 3/25/22 at 1:20 p.m., the Registered Dietician (RD), indicated anything over 10% over 180 days and 5% in 30 days would be considered a significant weight loss. Because Resident 6 had experienced a significant weight loss, the RD added a new intervention of Carnation Instant Breakfast and weekly weights for 4 weeks to monitor the new intervention. It was important to get regular weights for residents with weight loss in order to measure the appropriateness of the interventions and determine if new interventions should be put in place or not. On 3/24/22 at 12:00 p.m., the Director of Nursing (DON) provided a copy of current, but undated facility policy titled, S.W.A.T. Program. The policy indicated, Purpose: to identify those resident at nutritional risk for related medical concerns . on-going weekly monitoring shall continue on each resident of SWAT . weight management, continue interventions: please check when current interventions are appropriate, and the team will continue to monitor until next review 3.1-46(a)(1)

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failure to ensure CPAP (continuous positive airway pressure machine) and BiPap (alternating positive pressure machine for inhalation and expiration) masks were covered and not open to the air for 3 of 3 residents observed for CPAP and BiPAP mask use (Resident 24, 92, and 22). Findings include: 1. On 3/22/22 at 10:51 a.m., Resident 24's CPAP mask was observed uncovered on his bedside table. On 3/23/22 at 12:21 p.m., Resident 24's CPAP mask was observed uncovered on his bedside table. On 3/23/22 at 2:42 p.m., Resident 24's CPAP mask was observed uncovered on his bedside table. On 3/24/22 at 11:56 a.m., Resident 24's record was reviewed. His diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) (lung disease that blocks airflow and makes it difficult to breathe), chronic respiratory failure with hypercapnia (high levels of carbon dioxide), and obstructive sleep apnea. A physician's order, dated 3/11/22, indicated Resident 24 used a CPAP at bedtime via nasal pillows (nasally applied mask) with 2 L (liters) of oxygen, every night for sleep apnea (temporary cessation of breathing during sleep). A respiratory care plan indicated the resident had altered respiratory status with COPD and difficulty breathing related to and obstructive sleep apnea that may cause shortness of breath. 2. On 3/21/22 at 12:32 p.m., Resident 92's BiPap mask was observed uncovered on his bedside table. On 3/22/22 at 10:53 a.m., Resident 92's BiPap mask was observed uncovered on his bedside table. On 3/23/22 at 12:35 p.m., Resident 92's BiPap mask was observed uncovered on his bedside table. On 3/25/22 at 1:12 p.m., Resident 92's record was reviewed. His diagnoses included, but were not limited to, COPD, sleep apnea, and morbid obesity. His respiratory care plan indicated he was at risk to experience periods of shortness of breath and/or low oxygen saturations related to his diagnosis of COPD and morbid obesity. 3. On 3/23/22 at 12:40 p.m., Resident 22's BiPap mask was observed uncovered on his bedside table. On 3/22/22 at 2:39 p.m., Resident 22's record was reviewed. Her diagnoses included, but were not limited to, COPD, chronic respiratory failure with hypoxia (low oxygen levels), and obstructive sleep apnea. On 3/25/22 at 1:41 p.m., the Administrator indicated the facility policy indicated to follow the manufacturer's recommendations, and the recommendations indicated masks did not need to be covered when not in use. On 3/25/22 at 1:33 p.m., the Director of Nursing (DON) provided the manufacturer's instructions for the CPAP ([NAME]) and BiPAP (ResMed) machines. The [NAME] CPAP instructions indicated, .It is vitally important to keep everything as clean as possible, as hoses/tubing and masks can be a prime breeding ground for bacteria and mold The ResMed instructions indicated, .You should clean the device weekly as described. Refer to the mask user guide for detailed instructions on cleaning your mask A current policy, titled, Bipap/Cpap, with no date, was provided by the Administrator, on 3/25/22 at 1:12 p.m. A review of this policy, indicated, .to provided non-invasive breathing support for residents who are diagnosed with obstructive sleep apnea ([NAME]), COPD and neuromuscular disease .Manufacturer's recommendations should be followed 3.1-47(a)(6)

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 ensure facility and dialysis written communication was completed for each dialysis visit for 1 of 2 residents reviewed for dialysis communication (Resident 32). Findings include: During an interview, on 3/21/22 at 2:46 p.m., Resident 32 indicated he went to dialysis three times a week on Tuesday, Thursday, and Saturday. On 3/24/22 at 9:44 a.m., Resident 32's record was reviewed. His diagnoses included, but were not limited to, end stage renal (kidney) disease, diabetes mellitus (blood sugar disorder), chronic obstructive pulmonary disease (COPD) (breathing disorder). His dialysis care plan indicated he, .will go to dialysis on my scheduled days and will not experience any adverse effects During an interview, on 3/24/22 at 10:43 a.m., Licensed Practical Nurse (LPN) 6 indicated the facility did not have a dialysis binder for Resident 32. She indicated the facility did not get any information from the dialysis center of any resident changes or new orders. She had informed the Director of Nursing (DON) of the lack of communication. On 3/24/22 at 11:28 a.m., the DON indicated the facility had a dialysis binder for Resident 32 and would provide it. On 3/25/22 at 1:59 p.m., the Administrator indicated the facility did have a dialysis binder for Resident 32 and would provide it. As of the exit conference on 3/25/22, a dialysis binder was not provided by the facility. A current policy, titled, Community Hemodialysis, with no date, was provided by the DON, on 3/24/22 at 12:00 p.m. A review of the policy indicated, .All residents that are admitted to the facility with needs for hemodialysis will have coordination of services between the facility and the hemodialysis unit prior to admission .Special consideration will be given to residents going to dialysis to coordinate therapy .Resident will be weighed pre and post dialysis by the dialysis center to evaluate removal of fluid and waste products .The resident will be assessed by the dialysis unit RD (Registered dietician) with special dietary recommendations relayed to the facility for implementation .A dialysis communication sheet will return with the resident after the dialysis session to communicate to the facility information regarding the dialysis session 3.1-37(a)

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, related to the improper use of flex pens for insulin administration, and opening of extended release potassium capsules listed on the do not crush list for 3 of 48 medications observed during medication administration resulting in an error rate of 6.25% (Residents 8, 11, and 29). Findings include: 1. On 3/23/22 8:05 a.m., Licensed Practical Nurse (LPN) 5 was observed to open 2 capsules of Potassium Chloride 10 meq (milliequivalents) and mix the medication into a cup of crushed medications in applesauce. LPN 5 indicated Resident 8 had required her medications to be crushed for an extended period to assure she was swallowing them. Resident 8's record was reviewed on 3/25/22 at 2:47 p.m. Diagnoses on Resident 8's profile included, but were not limited to, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, hyperlipidemia, hypo-osmolality and hyponatremia. A physician's order for Resident 8, dated 9/8/21, indicated Potassium Chloride ER (extended release) capsule 10 meq give 2 capsules by mouth one time a day for supplement. The resident record lacked documentation to indicate an order was obtained to open the potassium caps for administration. On 3/23/22 8:25 a.m., LPN 5 indicated, Resident 8's potassium was extended relief and should not have been opened as it defeated the purpose of being extended relief. Resident 8's medication should have been changed to a different form due to the need for her medications to be crushed. On 2/24/22 at 9:01 a.m., the Director of Nursing (DON) provided an Institution for Safe Medication Practices document, titled Oral Dosage Forms That Should Not Be Crushed 2016, and indicated this was the current do not crush list. The document indicated potassium slow-release and effervescent tablets were listed as do not crush. 2. On 3/23/22 at 9:00 a.m., LPN 7 was observed to not prime a Lantus insulin flex pen before administering the dose to Resident 11, and while administering held the pen in the arm for less than 4 seconds. Resident 11's record was reviewed on 3/25/22 at 2:36 p.m. Diagnoses on Resident 11's profile included, but were not limited to muscular dystrophy, and type II diabetes mellitus. A physician's order for Resident 11, dated 1/3/22, indicated Lantus Solution 100 UNIT/ML (units per milliliter) inject 40 unit subcutaneously one time a day related to type 2 diabetes mellitus. 3. On 3/24/22 at 9:12 a.m., LPN 5 was observed to not prime a Levemir insulin flex pen before administering the dose to Resident 29. LPN 5 indicated flex pens were primed when opened and used for the first time, it was her understanding pens did not need to be primed after the initial dose. Resident 29's record was reviewed on 3/25/22 at 2:51 p.m. Diagnoses on Resident 29's profile included but were not limited to Alzheimer's disease and type II diabetes mellitus. A physician's order for Resident 29, dated 4/28/21, indicated Levemir FlexTouch Solution Pen-injector 100 UNIT/ML inject 37 unit subcutaneously two times a day related to type 2 diabetes mellitus with diabetic neuropathy. On 3/25/22 at 3:10 p.m., the DON indicated flex pens from the pharmacy came in clear sealable bags and did not include instructions for use. She was not aware flex pens had to be primed with every use. It was the responsibility of the DON to educate nurses on the proper administration of medications. A Novolog Manufactures instructions, dated 8/8/18, indicated prime the flex pen before each use to assure the proper dose was delivered. If the pen was not primed, air may have become trapped in the chamber and the pen may deliver an inaccurate dose. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears. On 3/24/22 at 9:01 a.m. the DON provided a Medication Administration Policy and Procedure, undated, and the policy was the one currently being used by the facility. The policy indicated, To ensure that resident medications are administered in a timely manner and documentation is completed to substantiate administration . On 3/24/22 at 11:50 a.m., the DON provided an Insulin Pen Policy and Procedure, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, Procedure .4. Remove the cap and cleans the insulin pen hub with alcohol, 5. Screw on a new pen needed, 6. Turn the knob on the end of the pen to the number of units needed, 7. Administer the insulin affording privacy. Cleanse the skin with an alcohol prep and insert the needed into the skin .8. Press the button on the end of the pen to deliver the dose, 9. Count to 6 and remove from the skin . 3.1-48(c)(1) 3.1-48(c)(2)

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 observation, record review, and interview, the facility failed to ensure a medication was administered by manufacturer's specifications for not altering a potassium extended release capsule during 1 of 48 medications observed administered (Resident 8). Findings include: On 3/23/22 8:05 a.m., Licensed Practical Nurse (LPN) 5 was observed to open 2 capsules of Potassium Chloride 10 meq (milliequivalents) and mix into a cup of crushed medications in applesauce. LPN 5 indicated Resident 8 had required her medications to be crushed for an extended period to assure she was swallowing them. Resident 8's record was reviewed on 3/25/22 at 2:47 p.m. Diagnoses on Resident 8's profile included, but were not limited to, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, hyperlipidemia, hypo-osmolality and hyponatremia. A physician's order for Resident 8, dated 9/8/21, indicated Potassium Chloride ER (extended release) capsule 10 meq give 2 capsules by mouth one time a day for supplement. The resident record lacked documentation to indicate an order was obtained to open the potassium caps for administration. On 3/23/22 8:25 a.m., LPN 5 indicated, Resident 8's potassium was extended relief and should not have been opened as it defeated the purpose of being extended relief. Resident 8's medication should have been changed to a different form due to the need for her medications to be crushed. Nursing 2021 Drug Handbook, dated April 2021, indicated do not crush, chew, break, or suck on an extended-release tablet. Swallow the pill whole. Breaking or crushing the pill may cause too much of the drug to be released at one time. Sucking on a potassium tablet can irritate your mouth or throat. Common side effects of potassium chloride are nausea, vomiting, gas, abdominal pain or discomfort, and diarrhea. Serious side effects of potassium chloride include upper and lower gastrointestinal conditions including obstruction, bleeding, ulceration, and perforation. On 2/24/22 at 9:01 a.m., the Director of Nursing (DON) provided an Institution for Safe Medication Practices document, titled Oral Dosage Forms That Should Not Be Crushed 2016, and indicated this was the current do not crush list. The document indicated potassium slow-release and effervescent tablets were listed as do not crush. On 3/24/22 at 9:01 a.m. the DON provided a Medication Administration Policy and Procedure, undated, and the policy was the one currently being used by the facility. The policy indicated, To ensure that resident medications are administered in a timely manner and documentation is completed to substantiate administration 3.1-48(c)(1) 3.1-48(c)(2)

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to ensure medications and biologicals were labeled, and stored properly for 2 of 2 medications carts, 2 of 2 medication refrigerators, and 1 of 2 specimen refrigerators observed for medication and biological storage (Residents 4, 5, 6, 7, 9, 11, 14, 15, 18, 21, 22, 23, 33, 92, 194). Findings include: 1. On [DATE] at 8:42 a.m., during the morning medication pass with LPN 6, the following treatment medications were observed stored in the bottom drawer of the front hallway 100 medication cart stored among oral medications, a. Resident 92, a tube of Diclofenac Sodium Gel (nonsteroidal anti-inflammatory) 1% opened and unbagged. b. Resident 22, 4 tubes of Diclofenac Sodium Gel 1% opened and unbagged. On [DATE] at 9:10 a.m., during the morning medication pass with Licensed Practical Nurse (LPN) 7, the following treatment medications were observed stored in the bottom of the front hallway 200 medication cart stored among oral medications, a. An oxygen mask with tubing, a roll of trash bags, an unbagged tube of Dimethicone Skin Protectant (silicone skin protectant) with no label containing a resident name or directions for use, a tube of Renew Repair Cream (moisture barrier) with no label containing a resident name or directions for use, and a tube of Mupirocin Ointment 2% (Bactroban antibacterial) with no label containing a resident name or directions for use. b. An opened unlabeled bottle of Acetic Acid 0.25%, LPN 7 indicated was used to irrigate the yeast in Resident 15's body folds. c. Resident 33, 2 tubes of Triad Hydrophilic Wound Dressing (corticosteroid) opened and unbagged, and a bottle of T/[NAME] Neutrogena 3% shampoo opened and unbagged. d. Resident 9, a tube of Triad Hydrophilic Wound Dressing opened and unbagged. e. Resident 23, a tube of barrier cream and a tube of Biofreeze both without a label, opened and unbagged. d. Resident 14, a tube of Diclofenac Sodium Gel 1% opened and unbagged. e. Resident 4, a tube of Calgonate 2.5% (calcium protectant ointment) gel and 2 bottles of Nystatin Powder (antifungal) both opened and unbagged. f. Resident 7, 3 tubes of A & D Ointment (protective barrier) and 2 tubes of Nystatin topical (antifungal) all opened and unbagged. g. Resident 21, a tube of Triad Hydrophilic Wound Dressing, 2 tubes of Diclofenac Sodium Gel 1%, and a bottle of Ketoconazole shampoo 2% (antifungal) all opened and unbagged. h. Resident 194, a tube of Biofreeze (pain relief) gel opened and unbagged. i. Resident 18, a bottle of Nystatin Powder and a tube of Antifungal Cream 1% both opened and unbagged. j. Resident 11, a tube of Nystatin topical cream opened and unbagged. k. Resident 15, a tube of Metronidazole Vaginal Gel 1% (antibacterial) and a tube of Zinc Oxide 1% (protectant) both opened and unbagged. l. Resident 6, a bottle of Head and Shoulders shampoo and a bottle of Selsun Blue shampoo both opened and unbagged. m. Resident 5, a bottle of antidandruff shampoo opened and unbagged. On [DATE] at 8:25 a.m., Licensed Practical Nurse (LPN) 5 indicated treatments were supposed to be stored in the treatment cart not on the medication carts. On [DATE] 8:45 a.m., LPN 6 indicated she considered Diclofenac Sodium Gel 1% an analgesic versus a treatment, so it was kept in the medication cart to be administered during medication pass as needed. On [DATE] at 9:27 a.m., LPN 7 indicated treatment medications had always been stored on the medication cart. The treatment cart had never been used to her knowledge as there was tape over the lock, were no keys and no way to lock it. 2. On [DATE] at 8:49 a.m., the 100 hallway medication room refrigerator temperature was observed with LPN 6 to be 48 degrees Fahrenheit (F). LPN 6 indicated the medication refrigerator should have been below 40 F. The 100 hallway specimen refrigerator temperature was observed to be 26 F, LPN 6 indicated the temperature should have been above 30 F. On [DATE] at 8:51 a.m., Daily Freezer/Refrigerator Temperature Logs in the 100 hallway medication room, dated [DATE], indicated lack of daily documentation of temperatures for the medication and specimen refrigerators. LPN 6 indicated, there were no refrigerator logs available for February or [DATE]. On [DATE] at 8:54 a.m., LPN 5 indicated the night shift nurses were responsible for monitoring the temperatures for the medication room refrigerators. On [DATE] 9:31 a.m., a vial of Tubersol (Tuberculin Purified Protein), dated [DATE], was observed in the 200 hallway refrigerator. LPN 7 indicated the Tubersol was outdated and should have been discarded as it was considered expired after being opened for 30 days. On [DATE] at 9:32 a.m., the specimen refrigerator in the 200 hallway medication room was observed to have 2 opened cartons of med pass, and 1 opened carton of thickened lemon water. LPN 7 indicated the specimen refrigerator was used to store specimens such as urine, feces and blood, there should not have been resident supplements used with oral medication pass in the refrigerator. On [DATE] at 9:34 a.m., Daily Freezer/Refrigerator Temperature Logs in the 200 hallway medication room, dated [DATE], indicated lack of daily documentation of temperatures for the medication and specimen refrigerators. LPN 7 indicated, there were no refrigerator logs available for February or [DATE], and she was not sure what the refrigerator and freezer temperatures were supposed to be. Instructions on the Daily Freezer/Refrigerator Temperature Logs for medication and specimen refrigerators indicated, This log will be maintained for each refrigerator and freezer in the facility. The night shift nursing staff will record the time, temperature and their initials. If corrective action is required on any, circle the date in the first column and explain the action taken on the back of the form. Refrigerators should be between 36 degrees F and 41 degrees F. Freezers should be between -10 F and 0 F. On [DATE] at 9:01 a.m. the Director of Nursing (DON) provided a Medication Storage in The Facility policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, Medication and biological are stored safely, securely, and properly following the manufacturer or supplier recommendations .4. Drugs for internal use are kept separate from externally used medications .6. Medications labeled for individual residents are stored separately from floor stock medications. 7. External medications including ointments for skin irritation and medications for application to wounds should be kept in a treatment cart, or in a separate drawer in the medication cart which is labeled as such .11. Medications requiring [refrigeration] or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator .18. Facility staff will assure that the multidose via is stored following manufacturer's suggested storage conditions . 3.1-25(j) 3.1-25(k) 3.1-25(m)

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure food was dated with open and expiration dates, refrigerator and freezer temperature logs were completed, dented cans were removed from the dry storage area for 44 of 44 residents served food from the kitchen and pureed food was prepared according to the recipe and hands were washed prior to pureed foods being prepared for 3 of 3 residents on pureed diets. Findings include: 1. On 3/21/22 at 9:55 a.m., the Dietary Manager (DM) provided a tour of the kitchen. Opened foods were found with no open date or expiration date. a. In the three-door freezer, an open plastic bag of chicken tenders had no open date or expiration date. b. The walk-in freezer had a plastic bag of diced chicken and a plastic bag of pork patties. Both without open and expiration dates on them. c. The walk-in refrigerator had a small open plastic bag of diced chicken with no open or expiration date. A current policy titled, Labeling and Dating of Foods, dated March 2017, was provided by the Administrator, on 3/22/22 at 1:30 p.m. A review of the policy indicated, .All foods stored will be properly labeled and dated .Date marking for refrigerated storage food items .Once opened, all ready to eat, potentially hazardous food will be re-dated with the date the item was opened and a use by date according to safe food storage guidelines .Date marking for freezer storage food items .Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines 2. The three-door freezer, one-door freezer, walk-in freezer, and walk-in refrigerator were observed to have no temperature logs posted. On 3/22/22 at 11:05 a.m., the DM of a sister facility (DM 2) indicated when she arrived there were no temperature logs posted on any refrigerators or freezers, so she posted them. On 3/23/22 at 11:11 a.m., the Director of Nursing (DON) indicated the kitchen did not have any refrigerator or freezer temperature logs for March 2022. A current policy, titled, Refrigerator/Freezer Temperatures, with no date, was provided by the Director of Nursing (DON), on 3/23/22 at 10:28 a.m. A review of the policy indicated, .In order to ensure all perishable food stuff stays fresh and palatable, temperatures will be recorded on all refrigerators and freezers in use .Dining Services will be responsible for taking temperatures on all kitchen refrigerators and freezers, and recording temperatures on temperature report logs daily, during each shift 3. A large, dented can of pears, 106 ounces, was observed on the slanted shelving unit. It was the next canned fruit to be used. 4. On 3/22/22 at 11:05 a.m., the Assistant Dietary Manager (ADM) was observed when she pureed resident food. She did not follow a recipe and did not measure the chicken broth for the pureed egg noodles. She added Thick and Easy thickener powder. The recipe did not call for it. On 3/24/22 at 10:55 a.m., the ADM opened the locked kitchen door with her bare hand, did not wash her hands before she prepared pureed food for 3 residents. On 3/24/22 at 10:59 a.m., the ADM indicated she should have washed her hands before she pureed the food. A current policy, titled, Pureed Food Preparation, dated March 2017, was provided by the Administrator, on 3/25/22 at 1:12 p.m. A review of the policy indicated, .Pureed foods will be prepared using standardized recipes to ensure quality flavor and maximum nutritive value .Food thickener will be used only in accordance with a specific recipe A current policy, titled, Hand Hygiene Guidelines, with no date, was provided by the Director of Nursing (DON), on 3/24/22 at 12:00 p.m. A review of the policy indicated, .When hands are visibly soiled, exposure to a spore forming organism has been suspected or proven, before and after eating, and after using the restroom hands should be washed with a non-microbial or anti-microbial soap .When criteria above have not been met it is appropriate to use a waterless alcohol-based agent On 3/21/22 at 10:30 a.m., the DM indicated the open food should have had open and expiration dates. The kitchen refrigerators and freezers should have had temperature logs. There should not have been a dented can in the dry storage area. 3.1-21(a)(1) 3.1-21(i)(2) 3.1-21(i)(3)

CONCERN (E)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to ensure 2 of 2 crash carts (or code carts, a cart designated for the transportation and dispensing of emergency medication/equipment at site of medical/surgical emergency for life support protocols to potentially save someone's life) were checked off daily to ensure emergency supplies were readily available in case of an emergency. This deficient practice had the potential to effect 19 of 44 residents who had full code advance directive wishes. Findings include: On 3/21/22 at 12:15 p.m., a crash cart was observed in the corner of the main dining room. A clipboard on top of the cart indicated the cart had last been checked off/inspected on 11/1/21. The policy behind the check off sheet indicated the cart should be checked weekly. During an interview on 3/21/22 at 12:19 p.m., Licensed Practical Nurse (LPN) 7 indicated there were 2 crash carts, one in the dining room and one at the 100 hall nurses' station. LPN 7 indicated she did not know when, how often, or who was responsible for checking on the carts to ensure equipment was readily available. On 3/21/22 at 12:25 p.m., a crash cart was observed at the 100 hall nurses' station. A clipboard on top of the cart indicated the cart had last been checked off/inspected on 3/15/22 (with no documentation of additional checks for March) with a note that indicated there was no suction machine. As of the observation on 3/21/22, there was still no suction machine. On 3/23/22 at 2:00 p.m., both crash carts were observed a second time and lacked documentation that daily checks/inspections had been completed. A suction machine had been replaced on the 100 hall cart. On 3/25/22 at 11:54 a.m., both crash carts were observed a third time and lacked documentation that daily checks/inspections had been completed. On 3/25/22 at 1:10 p.m., the Administrator, (ADM) indicated, the crash carts should be checked off at least weekly to ensure appropriate supplies were available in case of an emergency. At this time the ADM provided a copy of current, but undated facility policy titled, Crash Cart. The policy indicated, Policy: To ensure that emergency supplies are available to provide care and services to residents in accordance with Advance Directives that have been discussed with the resident or resident's legal representative of medical emergencies including medical interventions used to restore circulation and respiratory function. Procedure . 2. The Crash Cart will be stocked with supplies according to the Crash Cart Checklist . 4. the crash cart will be locked at all times to ensure that all supplies are available during the course of a medical emergency . 5. The crash cart will be unlocked weekly, and all supplies will be verified to be present and intact The Crash Cart Checklist indicated the Nurse on the 11-7 (night shift) should sign for verification. 3.1-19(bb)

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 major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most Indiana facilities.
• 40% turnover. Below Indiana's 48% average. Good staff retention means consistent care.

Concerns

• 37 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade C (50/100). Below average facility with significant concerns.

Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.

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About This Facility

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

CMS assigns WATERS OF LEBANON, THE an overall rating of 2 out of 5 stars, which is considered 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 Lebanon, The Staffed?

CMS rates WATERS OF LEBANON, THE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 40%, compared to the Indiana average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Waters Of Lebanon, The?

State health inspectors documented 37 deficiencies at WATERS OF LEBANON, THE during 2022 to 2025. These included: 37 with potential for harm.

Who Owns and Operates Waters Of Lebanon, The?

WATERS OF LEBANON, THE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by INFINITY HEALTHCARE CONSULTING, a chain that manages multiple nursing homes. With 64 certified beds and approximately 37 residents (about 58% occupancy), it is a smaller facility located in LEBANON, Indiana.

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

Compared to the 100 nursing homes in Indiana, WATERS OF LEBANON, THE's overall rating (2 stars) is below the state average of 3.1, staff turnover (40%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

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

Based on this facility's data, families visiting should ask: "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?"

Is Waters Of Lebanon, The Safe?

Based on CMS inspection data, WATERS OF LEBANON, 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 2-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 Lebanon, The Stick Around?

WATERS OF LEBANON, THE has a staff turnover rate of 40%, which is about average for Indiana nursing homes (state average: 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 Lebanon, The Ever Fined?

WATERS OF LEBANON, 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 Lebanon, The on Any Federal Watch List?

WATERS OF LEBANON, 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: 64
Avg. Residents: 37
Occupancy: 58.4%
Ownership: For profit - Corporation
Chain: INFINITY HEALTHCARE CONSULTING
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
37 Deficiencies: -10
Final Score: 50/100

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 155211