Thorne Crest Retirement Center

During an interview on 9/18/25 at 9:51 a.m., receptionist (R)-A stated the ADON told her that R1 needed a ride to the clinic for an eye appointment, so she called the transport driver (TD)-A and asked him to bring R1 in.

During an interview on 9/18/25 at 11:05 a.m., TD-A stated he got a call from R-A, and she told him R1 needed a ride to the clinic for an eye appointment. TD-A stated normally when he takes a resident to an appointment, they send paperwork with. TD-A stated he had no paperwork for R1 and assumed R1 had an eye appointment.

TD-A stated he got him to the clinic at the eye part and the girl at the clinic put his name in the kiosk and said she didn't think R1 had an appointment. TD-A thought the girl at the clinic would take R1 to his appointment, so he left. TD-A stated when he got back to the facility, he found out he was supposed to have taken R1 to the ED, he stated he felt terrible about the mix up.

During an interview on 9/17/25 at 3:38 p.m., DON indicated she was not aware that R1 was left unattended at the ED on 9/10/25, while he was in a manual wheelchair and stated it was not safe for R1 because he was immobile in the manual wheelchair. DON was unsure if R1 was ever assessed for safety in a manual wheelchair and normally used his specialized electric wheelchair that he was independent with mobility in.Facility policy for transporting residents to outside appointments was requested and not received.

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Thorne Crest Retirement Center 1201 Garfield Avenue Albert Lea, MN 56007

During an

assistant (PA) that saw R1 had ordered oral and eye antibiotics on 9/5/25 and wanted them to start

per the provider order on 9/5/25, rather were started on 9/6/25 and was unsure why. LPN-A stated this would be considered a medication error. LPN-A stated the process for a medication error was to fill out a paper medication error form and notify the resident, the director of nursing (DON) and the provider and follow whatever the direction they give you.

The medication error should also be documented in risk management.

During an interview on 9/18/25 at 1:19 p.m., assistant director of nursing (ADON) stated R1's oral and eye drop antibiotics were supposed to be started on 9/5/25 and were not actually started until 9/6/25 and indicated this would be a medication error because the providers orders were not followed. ADON stated when a medication error was identified we use a paper medication form that would be filled out and documented in risk management. ADON stated the resident would be assessed, notify the resident, family, DON and provider and follow provider direction. ADON stated the DON would be responsible to investigate the medication error to look for the root cause to put a prevention plan in place to prevent it from occurring again.

During an interview on 9/18/25 at 1:39 p.m., DON stated R1 had a telehealth visit on 9/5/25 and was ordered oral and eye drop antibiotics that were to be started that day and indicated they were not started until 9/6/25.

DON stated this would be a medication error for not following the providers orders. DON further stated the facility process for a medication error would be to document the event in risk management and the facility staff should not be using a paper form. DON stated with a medication error you would assess the resident, notify the resident, family, provider and follow any orders given. DON indicated she would be the one to investigate the medication error to look for a root cause and place interventions for prevention of future medication errors. DON stated she was not aware of R1's medication error until this surveyor pointed it out.

Review of Facility policy, Medication Error copyright 2025, identified It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors.

Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services.

Policy Explanation and Compliance Guidelines: 1.

The facility shall ensure medications will be administered as follows: a.

According to physician's orders. b.

Per manufacturer's specifications regarding the preparation, and administration of the drug or biological. c. In accordance with accepted standards and principles which apply to professionals providing services. 8. If a medication error occurs, the following procedure will be initiated: a.

The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible. b.

Monitor and document the resident's condition, including response to medical treatment or nursing interventions. c.

Document actions taken in the medical record. d.

Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report.Review of facility paper Medication Error Report form, revised 5/2000, identified Part 1 description of error, outcome to resident, corrective action taken and measures to prevent the reoccurrence of similar errors.

Part 2-Assessment and Summary of error that included type of error, and reason for error.

Further identified a disnature and date was needed for person making the error, person finding the error, DON, attending physician, medical director, pharmacist and administrator.Facility policy does not identify resident or resident representative notification or documentation of resident assessment.

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Thorne Crest Retirement Center 1201 Garfield Avenue Albert Lea, MN 56007

precautions are also used in situations when a resident is experiencing wound drainage, fecal

even before a specific organism has been identified. 6.

The individual on contact precautions is placed

various risks associated with other resident placement options (e.g., cohorting, placing with a low-risk roommate). 7.

Staff and visitors wear gloves (clean, non-sterile) when entering the room. a.

While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). b.

Gloves are removed and hand hygiene performed before leaving the room. c.

Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 8.

Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.Facility policy, Equipment and Supplies Used During Isolation, revised October 2018, identified appropriate infection prevention and control equipment and supplies are obtained, stored and used in accordance with current guidelines and manufacturer instructions. 1.

All equipment and supplies needed to implement transmission-based (isolation) precautions are obtained from an approved vendor. 2.

Infection prevention and control supplies are stored and maintained in accordance with current guidelines and manufacturer's recommendations. 3.

The infection preventionist (or designee) oversees the availability and inventory of infection prevention and control supplies.The facility policy did not identify where PPE carts should be placed for a resident on contact precautions.Facility policy, Standard Precautions revised September 2022, identified Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status.

Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents.

Policy Interpretation and Implementation 1.

Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. 2.

Personnel are trained in the various aspects of standard precautions to ensure appropriate decision-making in various clinical situations. 3.

Residents and family members are provided with information pertaining to standard precautions and the prevention of infection upon the resident's admission to the facility. 4.

Visitors are reminded and encouraged to maintain hand hygiene and follow instructions regarding infection prevention and control while in the facility.

Standard precautions include the following practices: 1.

Hand hygiene a.

Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of alcohol-based hand rub (ABHR), which does not require access to water. b.

Hand hygiene is performed with ABHR or soap and water: (1) before and after contact with the resident.(4) after contact with items in the residents room.