Every finding on record at Brooke Haven Healthcare

Based on observations, interviews, and record review, the facility failed to assure staff treated five sampled residents (Residents #1, #11, #30, #31, and #39) in a manner that maintained their dignity during mealtimes by standing during meals, assisting multiple residents at a time, and meals being served without assistance available. The facility census was 57.Review of the facility policy titled, Resident Rights, revised December 2016, showed:- Employees shall treat all residents with kindness, respect, and dignity;- Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; d. be supported by the facility in exercising his/her rights. The facility did not provide a policy on dining assistance. 1. Observation on 02/24/26 at 11:40 A.M. to 12:15 P.M., showed:- Certified Nursing Assistant (CNA) D stood to the front and to the right of Resident #58 while he/she sat reclined back in a wheelchair. CNA D used the resident's built-up utensils (modified utensils to assist with independence with eating) to assist the resident to eat. CNA D did not cut up the noodles prior to assisting the resident to eat and the noodles dangled from the spoon and one noodle dropped onto the resident's clothing protector. CNA D picked up the noodle off the clothing protector and sat it on the side of the resident's plate;- CNA E stood to the front and to the right of Resident #11 while he/she sat wheelchair and the wheelchair was not adjusted to fit under the table. CNA E stood over the resident as he/she assisted the resident to eat. CNA E was called away from the dining area at 12:00 P.M., and did not verbalize to the resident his/her departure. CNA E returned to the dining area at 12:08 P.M. and continued to assist the resident to eat while he/she stood over the resident. No staff assisted the resident with eating during CNA E's absence. Staff did not cover the resident's plate or rewarm the food before assisting the resident to eat;- Resident #1 and Resident #31 sat at a dining table with four other residents. Three staff members assisted the other four residents with their meals while Resident #1's and Resident #31's meals sat untouched in front of the residents from 11:45 A.M. to 12:08 P.M. At 12:09 P.M., CNA I stood between Resident #1 and Resident #31 and assisted the two residents with eating. CNA I did not cut up the noodles prior to assisting Resident #31 to eat and the noodles hung off the fork and spoon while CNA I transferred the food from the plate to the resident's mouth. Staff did not cover the residents' plates or rewarm the food before assisting the residents to eat. 2. Observation on 02/24/26 at 11:49 A.M., showed:- Resident #1, Resident #30, and Resident #39 sat at the assisted table in the dining room;- CNA I stood between Resident #1 and Resident #39 and assisted both residents to eat at the same time;- CNA I assisted Resident #30 with eating after his/her meal sat untouched in front of him/her for 20 minutes while CNA I assisted the other residents to eat. Staff did not cover the resident's plate or rewarm the food before assisting the resident to eat. 3. Observation on 02/27/26 at 11:45 A.M., showed:- Resident #1, Resident #30, and Resident #39 sat at the assisted table in the dining room;- CNA D sat between Resident #1 and Resident #30 to assist the residents with eating. CNA D assisted Resident #39's with eating after his/her meal sat untouched in front of him/her for 15 minutes while CNA D assisted the other residents to eat. Staff did not cover the resident's plate or rewarm the food before assisting the resident to eat. During an interview on 02/24/26 at 12:30 P.M., CNA I said that he/she always stood while assisting to feed residents and fed two residents at a time so not to neglect any of the residents not being assisted with feeding at the time. During an interview on 02/27/2026 at 2:52 P.M., CNA L said he/she normally fed residents by standing up. It was normal to stand up and feed residents. During an interview on 02/27/26 at 5:07 P.M., the Administrator said she would expect staff to assist residents with meals sitting down and should not be standing. During an interview on 02/27/26 at 5:30 P.M., the Director of Nursing (DON) said it was expected for the staff to sit during mealtimes while assisting residents with eating. Also, staff should only assist one resident at a time with eating. During an interview on 02/27/26 at 5:32 P.M., the Assistant Director of Nursing (ADON) said staff should sit down when assisting residents to eat so it would feel homelike for the residents. If residents had food in front of them, she wanted them being fed. During a phone interview on 03/04/26 at 2:29 P.M., CNA E said when assisting with meals or feeding residents, the food should be in front of the resident. Staff should sit and feed or assist the resident. During a phone interview on 03/04/26 at 2:48 P.M., CNA D said when assisting residents in the dining room, staff encourage the residents to eat or then the staff will feed them when needed. Staff were not supposed to stand while feeding the residents and should try to face the resident towards the table. A lot of times the residents faced the staff during assistance with eating.

Based on interview and record review, the facility failed to refund resident funds within 30 days of when a resident expired for three residents (Residents #69, #71, and #72) out of three sampled residents and failed to complete a final accounting of resident personal funds within 30 days of discharge for one resident (Resident #70) out of one sampled resident. The facility census was 57.Review of the facility's policy titled, Resident Trust Fund, undated, showed:- When a resident leaves the facility with no plans to return, their Resident Trust Fund (RTF) account must be closed out;- If a resident moves to another nursing facility, it is the responsibility of the office staff to make arrangements to transfer any balance to that resident at the new facility, the office manager will first make sure that no funds are due to the facility for any reason, If there are outstanding balances with the facility, those funds remaining will be considered for use to cover such balances;- If the facility is representative payee for the resident, the facility office staff should contact the local Social Security Administration (SSA) office for directions on how and where to send the close out funds to on behalf of the beneficiary;- All notices to the SSA should happen within 10 days of any resident for whom we are representative payee change within the facility, the office manager is responsible to inform them of any move the resident would make to secure that the social security check is being disbursed to the correct facility, and in any event that our facility would no longer serve as representative payee for a beneficiary;- If a resident passes away, the funds may be considered to cover any past due balance of the beneficiary owed to the facility or any of its related organizations, if a bill is presented from a funeral home for the services of the deceased beneficiary, the facility staff may issue a payment from the resident funds directly to the funeral home, no other funeral expenses may be covered from this account, if there are funds still remaining in the account, and the resident is a Medicaid beneficiary, the funds should be sent back to the Third Party Liability (TPL) unit of the State of Missouri for the Medicaid program using the appropriate submission form completed by the facility staff;- If the facility is representative payee for the deceased resident, all conserved funds must become property of the resident's estate, if an estate is not opened at the time of disbursement, the funds may be sent back to the state of Missouri for all Medicaid beneficiaries;- Any funds received after a resident has been discharged should be returned to the resident, their responsible party, or the sending agency or individual as deemed appropriate by such sender;- If the facility receives conserved funds and benefits for a resident for whom the facility is representative payee, after the resident is discharged from the facility, the funds are to be returned to the SSA local office, the facility office staff should contact the local SSA office for direction on how the funds should be returned, whether by the facility sending those by check to the SSA directly, to another facility directly, or through a recoupment by SSA from our bank account. 1. Review of Resident #69's closed medical record showed:- The resident expired on [DATE]. Review of the facility maintained Resident Trust Fund Ledger, dated [DATE], showed:- Resident #69 had $864.90 held in the resident trust fund account as of [DATE] (806 days late). 2. Review of Resident #71's closed medical record showed:- The resident expired on [DATE]. Review of the facility maintained Resident Trust Fund Ledger, dated [DATE], showed:- Resident #71 had $705.47 held in the resident trust fund account as of [DATE] (660 days late). 3. Review of Resident #72's closed medical record showed:- The resident expired on [DATE]. Review of the facility maintained Resident Trust Fund Ledger, dated [DATE], showed:- Resident #72 had $378.87 held in the resident trust fund account as of [DATE] (469 days late). 4. Review of Resident #70's closed medical record showed:- The resident discharged to another facility on [DATE]. Review of the facility maintained Resident Trust Fund Ledger, dated [DATE], showed:- Resident #70 had $1291.00 held in the resident trust fund account as of [DATE] (29 days late). During an interview on [DATE] at 3:45 P.M., the Administrator said she was responsible for the resident trust fund. She expected the residents to have a final accounting of personal funds and to be provided the balance of those funds within 30 days after discharge as per the facility policy. Resident #70 discharged to another facility, but his/her funds deposited after the discharge, and the other residents' balances were overlooked.

Based on interview and record review, the facility failed to provide a preadmission screening and resident review (PASARR - a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder and to determine the level of care needed) for one resident (Resident #8) out of two sampled residents and one resident (Resident #52) outside the sample. The facility census was 57.The facility failed to provide a policy regarding the PASRR. 1. Review of Resident #8's medical record showed:- admitted on [DATE];- Diagnoses of stroke, schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions), aphasia (loss of ability to understand or express speech caused by brain damage), depression (a serious medical illness that negatively affects how you feel, think, and act), anxiety (persistent worry and fear about everyday situations), cognitive communication deficit (difficulty in communication), mild cognitive impairment, and vascular dementia with behavioral disturbance (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), dated 11/26/25;- No documentation of the level I and level II PASRR screening completed. 2. Review of Resident #52's medical record showed:- admitted on [DATE];- Diagnoses of schizoaffective disorder and major depressive disorder (long-term loss of pleasure or interest in life);- Determination letter, dated 06/26/17, showed the resident referred for a level II screening and had met the federal definition of serious mental illness and intellectual disability related condition but not require specialized services;- No documentation of the level I and level II PASRR screening completed. During an interview on 02/26/26 at 1:00 P.M., the Administrator said she expected the level I PASRR screening and, if required, the level II screenings be part of the resident record. During an interview on 02/27/26 at 10:37 A.M., the Social Services Director said he/she normally didn't expect to work on the level I or level II PASRR screenings unless a resident admitted from the community. There were no level II PASRR screenings currently on file for any residents in the facility. view J44.9 CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIEDNTA (2 pts)Pulmonary1/27/2022Diagnosis B 1/27/2022ptateview E11.9 TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONSNTA (2 pts)Medical Management1/27/2022Diagnosis C 1/27/2022ptateview R47.01TAPHASIASLPAcute Neurologic1/27/2022Diagnosis D 2/2/2022sblackview F25.9 SCHIZOAFFECTIVE DISORDER, UNSPECIFIED Medical Management1/27/2022Diagnosis E 2/2/2022sblackview F32.A DEPRESSION, UNSPECIFIED N/A, not an acceptable Primary Diagnosis2/16/2026Diagnosis Rank Insignificant 2/16/2026vcallahanview F01.50 VASCULAR DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY N/A, not an acceptable Primary Diagnosis12/1/2025Diagnosis Rank InsignificantDuring Stay1/21/2026twaltonview F01.518 VASCULAR DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE Medical Management11/26/2025Diagnosis Rank Insignificant 11/26/2025hannamcbrideview F41.9 ANXIETY DISORDER, UNSPECIFIED Medical Management4/13/2022Diagnosis Rank Insignificant 4/13/2022ptateview R41.841TCOGNITIVE COMMUNICATION DEFICIT N/A, not an acceptable Primary Diagnosis2/17/2022Diagnosis Rank Insignificant 4/12/2022

Based on observation, interview, and record review, the facility failed to document the type, the stage, the measurements, and the characteristics of the facility acquired pressure ulcer (areas of localized damage to the skin and/or underlying soft tissue usually over a bony prominence, generally the result of pressure, shear, and/or friction) and also failed to notify and obtain a physician order for one resident (Resident #11) out of one sampled resident with a pressure ulcer. This resulted in Resident #11's stage 1 (intact skin with non-blanchable (discoloration of the skin that does not turn white when pressed) redness of a localized area usually over a bony prominence) pressure ulcer progressing to an open wound. The facility census was 57. Review of the facility's policy titled, Pressure Injury Risk Assessment, dated March 2020, showed:- The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs);- Risk factors that increase a resident's susceptibility to develop or to not heal PIs include, but are not limited to: under nutrition, malnutrition, and hydration deficits, impaired/decreased mobility and decreased functional ability, the presence of previously healed Pl, the presence of existing Pl, exposure of skin to urinary and fecal incontinence or other source of moisture, altered skin status over pressure points, impaired perfusion, oxygenation or circulation deficits, lower extremity arterial insufficiency, conditions, such as end stage renal disease, thyroid disease or diabetes mellitus, impaired sensory perception, cognitive impairment; and resident refusal of some aspects of care and treatment;- Conduct a comprehensive skin assessment with every risk assessment;- If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin;- Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition;- Report other information in accordance with facility policy and professional standards of practice. 1. Review of the resident's medical record showed:- admission date of 10/31/25;- Diagnoses of dependence on renal dialysis (a treatment that filters waste and excess fluid from your blood when your kidneys are failing), type one diabetes mellitus (a disease that occurs when your body makes little or no insulin), pain, major depressive disorder (MDD - long term loss of pleasure or interest in life), anxiety disorder (persistent worry and fear about everyday situations), gastro-esophageal reflux disease (GERD - stomach acid being forced back into the throat region), end stage renal disease (when the kidneys are no longer able to work at a level needed for day-to-day life), spinal stenosis of the lumbar region (narrowing of the spinal canal in the lower back, specifically in the lumbar region), and dystonia (a movement disorder that causes the muscles to contract). Review of the resident's Physician Order Sheet (POS), dated February 2026, showed:- An order for Triad Paste (barrier cream) to the buttocks every shift, dated 12/31/25;- An order to turn every two hours while in bed. Due to open wounds, the resident is to be the last resident up for meals and the first one down after meals following a 30-minute period after eating to prevent aspiration (when something other than air gets into the airways, often something that's supposed to be in your stomach, like food, liquid, or stomach contents), every shift, dated 11/11/25;- No order for weekly skin assessments;- No order for a dressing or instructions for treatment of the bandage to the sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis);- No order for a pressure ulcer treatment. Review of the resident's Treatment Administration Record (TAR), dated February 2026, showed:- Triad Paste to buttocks every shift, dated 12/31/25;- Turn every two hours while in bed. Due to open wounds, resident is to be the last resident up for meals and the first one down after meals following a 30-minute period after eating to prevent aspiration every shift, dated 11/11/25;- No orders and documentation for skin and/or wound assessments;- No orders and documentation for pressure ulcer treatments;- No documentation of the type, the stage, the measurements, and the characteristics of the open wound to the resident's sacrum from 02/22/26 - 02/27/26. Review of the resident's Weekly Skin Check Assessments, dated 01/06/26 - 02/24/26, showed:- On 01/06/26, Licensed Practical Nurse (LPN) B documented a sacrum pressure ulcer/injury with non-blanchable erythema (abnormal redness) of intact skin;- On 01/13/26, LPN B documented no new skin issues found on this evaluation. Sacrum stage 1 pressure ulcer/injury with non-blanchable erythema of intact skin;- On 01/27/26, LPN B documented no new skin issues found on this evaluation. Sacrum stage 1 pressure ulcer/injury with non-blanchable erythema of intact skin;- On 02/24/26, LPN B documented no new skin issues found on this evaluation. Sacrum stage 1 pressure ulcer/injury with non-blanchable erythema of intact skin;- No documentation of weekly skin check assessments completed for 01/20/26, 02/03/26, 02/10/26, and 02/17/26;- The facility failed to complete weekly skin assessments for four missed out of eight opportunities. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 02/19/26, showed:- Severe cognitive impairment;- Dependent for all ADLs and mobility;- Always incontinent of bowel and bladder;- No pressure ulcer/injury;- At risk for pressure ulcer;- No unhealed pressure ulcers/injuries;- No other ulcers, wounds, or skin problems;- Pressure reducing device for chair and bed. Review of the resident's Braden (a tool used to assess a patient's risk of developing pressure ulcers) Scale, dated 02/23/26, showed:- Very limited sensory perception;- Occasionally moist;- Chairfast;- Resident is very limited and makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently;- Probably inadequate nutrition;- Problem with friction and shear;- Score: 12.0 which indicates the resident is a high risk for skin breakdown. Review of the resident's Care Plan, revision date 02/17/26, showed:- The resident dependent on staff for all activities of daily living (ADL);- Always incontinent of bowel and bladder and poor cognitive ability;- Pressure injuries present upon admission to the facility with interventions of: - Assess/record/monitor wound healing weekly; - Pressure relieving device on his/her bed and in his/her wheelchair; - Two hour turn and two hour reposition while up in a chair; - Follow facility policies/protocols for the prevention/treatment of skin breakdown; - Provide treatment to the area to the buttocks as ordered; - Report worsening, and signs/symptoms of infection or non-healing; - Did not address the resident's stage 1 pressure ulcer on the sacrum. Observation of the resident's incontinent care on 02/25/26, showed:- At 1:58 P.M., Certified Nursing Assistant (CNA) D performed incontinent care;- A 2 inch (in.) x 2 in. bordered foam dressing to the sacrum, dated 02/22/26, with the outside of the dressing brown in color and three sides unattached to the resident's skin. Observation of the resident on 02/25/26 at 3:02 P.M., showed:- LPN H pulled back the brown discolored dressing, dated 02/22/26, from the resident's sacral area;- The dressing had a black, dry substance on the inside which covered a nickel size open area with a white substance on the open wound;- The resident had fecal matter in his/her brief and LPN H put the same soiled dressing back in place to cover the wound, exited the room, and alerted CNAs the resident needed incontinent care.During an interview on 02/25/26 at 4:15 P.M., Licensed Practical Nurse (LPN) G said Resident #11's current treatment consisted of Triad cream to the buttocks every shift, and off-load to reduce pressure. He/She was not aware of any new skin concerns being reported for the resident but would expect it to be reported to the nurse if one was found. During an interview on 02/27/26 at 4:36 P.M., LPN B said staff had been putting a bordered gauze dressing on the resident's sacrum for protection due to it being a sensitive area and had been an open wound before. On 02/24/26, he/she completed a skin assessment, did not remove and/or change the bordered dressing, and did not assess if the resident's sacrum was open. He/She passed on in report to the oncoming nurse the dressing was not changed. During an interview on 02/27/26 at 5:07 P.M., the Administrator said if there was a wound found during care, the staff should notify the charge nurse, the Director of Nursing (DON) or the Assistant Director of Nursing (ADON), and the physician should be contacted. She would expect a resident to have a new dressing be applied to the wound and not the old dressing be put back on until after incontinent care was provided to the resident. During an interview on 02/27/26 at 5:32 P.M., the ADON said if a soiled dressing was found during incontinent care, staff should remove the soiled dressing and notify the nurse immediately for a redressing. She assessed the resident's wound after it was identified this date as opened and he/she would stage it as at least a stage 2 (damage to the skin that results in the loss of the outermost layer of and exposure of the middle layer of skin) but he/she didn't stage the wound because that was a physician's scope of practice. She said the wound care company completed the wound measurements, but she did it if the wound care company was unable to. All skin issues should be reported to the nurse or directly to her so it can be assessed, physician notified, and an order be given if needed. During a phone interview on 03/04/26 at 3:18 P.M. LPN K said he/she put the bordered foam dressing on the stage 1 to the resident's sacrum for extra protection on 02/22/26. The resident didn't have an order for the dressing, and he/she didn't notify the physician, the DON, or the ADON of the stage to the resident's sacrum. He/she didn't know if the dressing was changed or the stage 1 assessed after he/she placed the dressing on 02/22/26. He/She should have reported the stage 1 to the ADON and wasn't for sure if he/she notified the oncoming shift nurse of the stage 1 and the dressing. LPN K checked the resident's skin on the weekends, and applied the Triad Paste, but the wound opened quite frequently. LPN K said he/she did not document the dressing being placed, did not notify the physician, and did not obtain an order for the dressing. During a phone interview on 03/10/26 at 3:50 P.M., the Physician said he/she would expect staff to report redness or any other skin issues to the nurse, and the nurse to report it to the physician. There should be a physician's order to put a dressing on a resident. He/She would expect the nurse to document when he/she contacted the physician regarding a resident. For Resident #11, he/she would not have covered the area and would have expected the resident's skin to be assessed at a minimum of every shift if staff placed a dressing on a resident. He/She believed skin assessments were expected every shift. During a phone interview on 03/17/26 at 10:07 A.M., the ADON said the nurses were responsible for completing skin assessments weekly and charting them. If there were any skin issues, they should be brought to her attention and then she would contact the provider and refer to the wound care provider. LPN B would have been responsible for completing the weekly skin assessments for Resident #11 on 01/20/26, 02/03/26, 02/10/26, and 02/17/26. During an interview on 03/17/25 at 11:02 P.M., LPN B said he/she did the skin assessments on paper, and they were transcribed into the computer later. The nurse who did the skin assessment was to document it in the computer. There were days he/she did not have time to put them into the computer. If he/she was unable to put the assessment into the computer, it went to the DON or ADON to be entered. In the last couple months, he/she didn't remember not putting any weekly skin assessments into the computer, but there might have been a handful not entered.

Based on observation, interview, and record review, the facility failed to ensure proper storage of nasal cannulas (plastic tubing placed in the nostrils to provide supplemental oxygen) when not in use for two residents (Residents #4 and #38) and failed to follow oxygen orders for two residents (Residents #38 and #52) out of four sampled residents. The facility census was 57.Review of the facility's policy titled, Oxygen Administration, revised October 2010, showed:- Verify there is a physician's order for this procedure;- Review the physician's orders or facility protocol for oxygen administration;- Assemble the equipment and supplies as needed;- Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter);- Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered;- Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened, be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through;- Did not address proper storage of the nasal cannula. 1. Review of Resident #4's medical record showed: - admission date of 05/23/22;- Diagnoses of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), systolic congestive heart failure (CHF - an inability of the heart to pump sufficient blood flow to meet the body's needs). Review of the resident's Physician Order Sheet (POS), dated February 2026, showed:- An order for oxygen at 2-4 liters per minute (L/min) per nasal cannula continuously due to shortness of breath and maintain oxygen saturation (measures the percentage of oxygen-carrying hemoglobin in the blood, indicating how well oxygen is being delivered to the tissues) above 90 percent, dated 01/19/26. Observation of the resident on 02/24/26 at 11:27 A.M., showed: - The resident lay in bed with the oxygen concentrator on at 2.5 L/min at the bedside;- The resident's nasal cannula, dated 02/21/26, lay on the floor and the prongs touched the floor;- The resident's oxygen saturation was 89 percent without oxygen;- The nasal cannula for the portable oxygen tank, undated, hung from the wheelchair brake without a sealed container. Observation of the resident on 02/24/26 at 2:23 P.M., showed: - The resident lay in bed with the oxygen concentrator on at 2.5 L/min at the bedside;- The resident's nasal cannula, dated 02/21/26, wrapped around his/her forehead;- The nasal cannula for the portable oxygen tank, undated, hung from the wheelchair brake without a sealed container. Observation of the resident on 02/25/26 at 3:36 P.M., and 02/26/26 at 4:02 P.M., showed: - The resident lay in bed with the oxygen concentrator on at 2.5 L/min at the bedside;- The nasal cannula, dated 02/21/26, lay under the resident's sheet; - The nasal cannula for the portable oxygen tank, undated, hung from the wheelchair brake without a sealed container. Observation of the resident on 02/27/26 at 8:45 A.M., showed: - The resident lay in bed with the oxygen concentrator on at 2.5 L/min at the bedside and with the nasal cannula in place;- The nasal cannula for the portable oxygen tank, undated, hung from the wheelchair brake without a sealed container. 2. Review of Resident #38's medical record showed:- admission date of 10/17/25;- Diagnosis of acute and chronic respiratory failure with hypoxia (a sudden, dangerous worsening of breathing in a patient with an existing, long term lung disease). Review of the resident's POS, dated February 2026, showed;- An order for oxygen continuously to maintain oxygen saturations above 90 percent, dated 02/09/26. Observation of the resident on 02/24/26 at 1:55 P.M., showed:- The resident lay in bed with the oxygen concentrator on at 3 L/min at the bedside;- The nasal canula, dated 02/21/26, was sideways on the resident's face and inserted in only one nostril;- The nasal cannula for the portable oxygen tank, undated, lay in the floor without a sealed container. Observation of the resident on 02/26/26 at 8:28 A.M., and 4:04 P.M., showed:- The resident lay in bed with the oxygen concentrator on at 3 L/min at the bedside;- The nasal cannula for the portable oxygen tank, undated, lay in the floor without a sealed container. Observation of the resident on 02/27/26 at 8:29 A.M., 12:09 P.M., 1:51 P.M., and 5:55 P.M., showed:- The resident lay in bed with the oxygen concentrator off at the bedside;- The nasal cannula attached to the oxygen concentrator, undated, lay in the floor without a sealed container;- The nasal cannula for the portable oxygen tank, undated, lay in the floor without a sealed container;- The resident did not have oxygen on as ordered. During an interview on 02/27/26 at 8:30 A.M., Resident #38 said he/she didn't know why the concentrator was off, but it was turned off a while ago. 3. Review of Resident #52's medical record showed:- admission date of 03/14/25;- Diagnoses of COPD and unspecified systolic CHF. Review of the resident's POS, dated February 2026, showed:- An order for oxygen as needed, resident may self-maintain, oxygen via nasal cannula to maintain oxygen saturation above 90 percent, dated 11/21/25;- An order to check oxygen saturation daily due to diagnosis of COPD, dated 07/19/25;- An order to titrate oxygen as needed to maintain saturation above 90 percent, dated 01/20/25; - An order for portable oxygen via nasal cannula for when resident is not in room, may titrate to maintain oxygen saturation above 90 percent, dated 01/20/25. Observation of the resident on 02/24/26 at 2:18 P.M., showed:- The resident lay in bed with the oxygen concentrator on at 2.5 L/min at the bedside;- The nasal cannula, dated 02/21/26, hung coiled outside of a container from the nightstand drawer;- No portable oxygen supplies were available. During an interview on 02/24/26 at 2:18 P.M., Resident #52 said he/she could use the portable oxygen for trips outside his/her room to the dining area and other areas of the facility. Staff had mentioned providing the portable equipment, but he/she hadn't heard anything else lately. Observation of the resident on 02/25/26 at 2:29 P.M., showed: - The nasal cannula, dated 02/21/27, hung coiled outside of a container from the nightstand drawer;- The resident was outside of the room. Observation of the resident on 02/26/26 at 8:23 A.M., and 02/27/26 at 1:51 P.M., showed: - The resident lay in bed with the oxygen concentrator on at 2.5 L/min at the bedside and with the nasal cannula, dated 02/21/26, in place;- No portable oxygen supplies were available. During an interview on 02/27/26 at 2:19 P.M., Licensed Practical Nurse (LPN) B said the residents should have their oxygen on as ordered. The nasal cannula should be in the resident's nose and not on their forehead. The concentrator should be on the correct L/min as ordered. If the nasal cannula wasn't on the resident, it should be placed back on them. The oxygen was checked by a certified nursing assistant (CNA). If the portable oxygen was not in use, the cannulas should be placed in a bag. The oxygen saturation should be checked if they were not wearing the oxygen. During an interview on 02/27/26 at 2:27 P.M., LPN A said the storage bags should be dated, but not the nasal cannula. The portable nasal cannula should never be on the floor. The tubing should be placed in a bag when not in use. During an interview on 02/27/26 at 2:34 P.M., CNA N said when checking on a room with oxygen, there should be a bag on the concentrator for placing the nasal cannula in and it should not be on the floor. The nasal cannula should be changed out weekly and should be aligned properly in the resident's nose. The portable oxygen nasal cannula on a wheelchair should be in a bag. The oxygen order should be followed and if it was for continuous oxygen, it should be on all the time. During an interview on 02/27/26 at 2:39 P.M., CNA M said the oxygen concentrator should be checked to see if it was on and the nasal cannula should be positioned and aligned with the nostrils. The nasal cannula for portable oxygen should be coiled up and stored in a bag. The nasal cannula should not be on the floor. The nasal cannula should be dated with staff initials. If there was an order for continuous oxygen, it should be on the resident. During an interview on 02/27/26 at 2:52 P.M., CNA L said the nasal cannula should be aligned in the nose properly and connected. The portable oxygen should have a gauge, and the nasal cannula should be in a plastic storage bag. The resident should be wearing it all the time if the order was for continuous oxygen. During an interview on 02/27/26 at 5:07 P.M., the Administrator said oxygen orders should be followed. The CNA should let the charge nurse know if there were problems. During an interview on 02/27/26 at 5:32 P.M., the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) said residents with oxygen should be checked. If the residents weren't wearing the nasal cannula, their oxygen saturation level should be checked. If it was low, the resident needed to be encouraged to put the nasal cannula on. If the oxygen saturation was good and in range, the nasal cannula should be stored in a plastic bag on the concentrator. If the nasal cannula was on the floor, it should be changed.

:Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 25 opportunities with two errors made, resulting in an error rate of 8% for two residents (Residents #13 and #54) out of seven sampled residents. The facility's census was 57.Review of the facility's policy titled, Administering Medications, revised April 2019, showed:- Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so;- Medications are in accordance with prescriber orders, including any required time frame;- Insulin pens containing multiple doses of insulin are for single resident use only;- Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident;- Each nurse's station has manufacturer's instructions or user's manuals related to any medication administration devices kept with the devices or at the nurses' station. Review of the insulin aspart (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen (insulin in a pen-type device) instructions, revised July 2023, showed:- To prime the pen, turn the dose knob to select two units;- Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect airbubbles at the top;- Continue holding the pen with the needle pointing up. Push the dose knob in until it stops, and number zero is seen in the dose window. Hold the dose knob in and count to five slowly;- Insulin should be seen at the tip of the needle. If you do not see insulin, repeat the steps;- Turn the dose knob to select the number of units you need to inject and administer the insulin. 1. Review of Resident #13's Physician Order Sheet (POS), dated February 2026, showed:- An order for insulin aspart Pen subcutaneous (an injection just below the skin) inject 6 units plus sliding scale before meals. Sliding scale for blood sugars of 181-220 = 4 units, 221-260 = 6 units, 261-300 = 8 units, 301-350 = 10 units, 351-400 = 12 units, if blood sugar is 140 or below no sliding scale just 6 units, dated 09/17/25.Observation of the resident's insulin administration on 02/27/26 at 10:35 A.M., showed:- Licensed Practical Nurse (LPN) B administered six units of insulin aspart subcutaneously as ordered for a blood sugar of 140 with the resident's insulin aspart Pen;- LPN B failed to prime the insulin aspart Pen per the manufacturer's instructions prior to the administration to the resident.2. Review of Resident #54's POS, dated February 2026, showed:- An order for insulin aspart Pen inject 12 units subcutaneously before meals, dated 12/20/25.Observation of the resident's insulin administration on 02/27/24 at 10:30 A.M., showed;- LPN B administered six units of insulin aspart subcutaneously as ordered with the resident's insulin aspart Pen;- LPN B failed to prime the insulin aspart Pen per the manufacturer's instructions prior to the administration to the resident. During an interview on 02/27/26 at 4:20 P.M., LPN B said he/she had recently moved from out of state and in the previous state he/she lived in, they did not prime insulin pens. During an interview on 02/27/26 at 5:20 P.M., the Administrator said she expects staff to follow policy and procedure regarding insulin administration. During an interview on 02/27/26 at 5:25 P.M., the Assistant Director of Nursing (ADON) said it was expected to prime the insulin pens with two units of insulin. During an interview on 02/27/26 at 5:30 P.M., the Director of Nursing (DON) said it was expected the staff prime insulin pens by wasting two units of insulin before administering the full dose.

Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) and follow appropriate infection control practices with hand hygiene and glove changes when staff performed wound care for three residents (Residents #2, #20, and #58) out of four sampled residents, and during incontinent care for three residents (Residents #11, #31, and #58) out of four sampled residents. The facility also failed to correctly screen three residents (Residents #20, #51, and #68) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents as required by state regulation 19 CSR 20-20.100. The facility census was 57. Review of the facility's policy titled, Wound Care, dated October 2010, showed:- Wipe nozzles, foil packed, bottle top, with alcohol before opening;- Use disposable cloth to establish clean field on resident's overbed table;- Wash and dry hands thoroughly;- Wash and dry hands after removing dressing and glove again;- Be certain all clean items are on clean field;- Wipe reusable supplies with alcohol as indicated. Review of the facility's policy titled, Enhanced Barrier Precautions, dated August 2022, showed:- EBP are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDRO) to residents;- EBP employs targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply;- Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room);- Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.), and wound care (any skin opening requiring a dressing). Review of the facility's policy titled, Personal Protective Equipment - Using Gloves, revision dated September 2010, showed:- Wash hands after removing gloves. Note: Gloves do not replace handwashing. Review of the facility's policy titled, Screening Residents for Tuberculosis, dated August 2025, showed:- This facility shall screen all residents for TB infection and disease. Individuals identified with active TB disease shall be isolated from other residents and ancillary staff, and transported to an appropriate care facility as soon as possible;- The admitting nurse will screen referrals for admission and readmission for information regarding exposure to or symptoms of TB;- Screening of new admissions or readmissions for TB infection and disease is in compliance with State regulations. Review of the facility's policy titled, Cleaning and Disinfection of Resident Care Items and Equipment, date revised October 2018, showed:- Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Act (OSHA) bloodborne pathogens standard. 1. Observation of Resident #58's incontinent care on 02/24/26 at 11:13 A.M., showed:- EBP signage on the door;- Certified Nursing Assistant (CNA) E and CNA F entered the room, did not perform hand hygiene, put on gloves, and did not put on a gown;- CNA E used a disposable wipe to clean fecal material from the resident's buttocks with the same area of the disposable wipe two times instead of using a clean area of the disposable wipe with each wipe, changed gloves, and performed hand hygiene;- CNA F removed the wet incontinent pad from under the resident, did not change gloves, did not perform hand hygiene, touched the closet handle, touched the resident's clean shorts, touched the drawer handle, touched the clothing inside the drawer, removed gloves, did not perform hand hygiene, and exited the room;- CNA F reentered the room, did not perform hand hygiene, did not put on a gown, put on gloves, and assisted CNA E with the transfer of the resident to the wheelchair. 2. Observation of Resident's #58's wound care on 02/24/26 at 11:40 A.M., showed:- EBP signage on the door;- Licensed Practical Nurse (LPN) B gathered supplies, entered the room, and put supplies on the resident's dresser without a clean barrier;- LPN B did not perform hand hygiene, put on gloves, and did not put on a gown;- LPN B removed resident's shoe and sock, did not perform hand hygiene, did not change gloves, cleaned the open wound to the resident's right heel with gauze saturated with wound cleanser, did not change gloves, and did not perform hand hygiene;- LPN B opened the skin prep wipe, wiped the surrounding skin of the open wound, did not change gloves or perform hand hygiene, opened and placed a bordered foam dressing (a type of dressing) to the open wound on the right heel, did not change gloves or perform hand hygiene, and placed the sock and shoe on the resident's right foot. 3. Observation of Resident #31's incontinent care on 02/25/26 at 1:41 P.M., showed:- CNA D and CNA E entered the room, performed hand hygiene, put on gloves, and transferred the resident from the wheelchair to the bed;- CNA E removed gloves, performed hand hygiene, and exited the room;- CNA D removed the resident's urine saturated pants and dropped them on the floor, did not change gloves or perform hand hygiene, used a disposable wipe to clean the outer left leg, covered the urine-soaked resident with bed linens, changed gloves, and performed hand hygiene;- CNA E entered room with disposable wipes, did not perform hand hygiene, and put on gloves;- CNA D unfastened and removed the resident's urine saturated brief and did not change gloves or perform hand hygiene;- CNA D placed a clean brief at the resident's buttock area and the brief touched the resident's skin soiled with urine;- CNA D assisted the resident to turn on his/her back, cleaned the resident's middle groin with the same area of the disposable wipe three times. CNA D retrieved a clean disposable wipe, cleaned the left side of the groin with the same area of the disposable wipe six times, and with a new area of the same wipe, cleaned the right side of the groin with the same area of the disposable wipe seven times. CNA D did not change gloves, did not perform hand hygiene, assisted the resident to turn to the side, cleaned the resident's right rear thigh and buttock with the same area of the disposable wipe six times, changed gloves, and performed hand hygiene;- CNA E fastened the urine soiled brief and did not change the urine soiled incontinent pad from under the resident;- CNA E and CNA D used the soiled incontinent pad to reposition the resident in bed, and CNA D covered the resident with the urine soiled bed linens. 4. Observation of Resident's #11's incontinent care on 02/25/26 at 1:58 P.M., showed:- EBP signage on the door;- CNA D performed hand hygiene and put on a gown and gloves;- CNA D cleaned the resident's left groin with the same area of a disposable wipe three times, cleaned the left groin with another area of the of the disposable wipe two times, retrieved a new disposable wipe and cleaned the upper middle groin area, did not clean the lower groin area, did not change gloves, and did not perform hand hygiene;- CNA D used the incontinent pad to turn the resident onto the right side, cleaned the buttocks, the sacrum (a large, inverted triangular bone at the base of the lumbar spine) had a dressing discolored brown and dated 02/22/26, removed the brief soiled with fecal material, did not change gloves, and did not perform hand hygiene;- CNA D placed a clean brief under the resident, pulled the resident's pants up, removed gloves, did not perform hand hygiene, and touched the bed control. 5. Observation of Resident #11 on 02/25/26 at 3:02 P.M., showed:- EBP signage on the door;- LPN H entered the room, did not perform hand hygiene, put on gloves, and did not put on a gown;- LPN H unfastened and lowered the resident's brief and exposed the resident's dressing on his/her sacrum;- LPN H pulled back the brown discolored dressing, dated 02/22/26, from the resident's sacrum;- The dressing had a black, dry substance on the inside which covered a nickel size open area with a white substance on the wound;- The resident had fecal matter in his/her brief and LPN H put the same soiled dressing back in place over the wound, removed the gloves, performed hand hygiene, exited the room, and went to get staff to perform incontinent care. 6. Observation on 02/27/26 at 8:05 A.M., of Resident #20's wound care showed:- EBP signage on door;- LPN A gathered supplies; entered the room; put the bandage supplies on a clean tray on the bed; put scissors, a box of gloves, wound cleanser, and tape on the resident's bed without a clean barrier; exited the room; and pushed the resident into the room in a wheelchair from the dining room;- LPN A did not perform hand hygiene, put on gloves, and did not put on a gown;- LPN A sprayed gauze with wound cleanser and cleaned the wounds to the left lower leg, did not perform hand hygiene, and did not change gloves; - LPN A sprayed gauze with a wound cleanser and cleaned the wounds to the right lower leg; - LPN A lay the soiled gauze on the floor;- LPN A changed gloves, did not perform hand hygiene, picked up the scissors off of the resident's bed, cut the calcium alginate (a type of wound dressing) with scissors, placed the calcium alginate on the open wounds to the left leg, did not change gloves, and did not perform hand hygiene;- LPN A put Xeroform (a type of wound dressing) on the open wounds to the right leg, did not change gloves, and did not perform hand hygiene;- LPN A put Kerlix (gauze bandage roll) around the left leg, did not perform hand hygiene, did not change gloves, put an ABD (large absorbent dressing) pad and a gauze roll around the right leg, did not perform hand hygiene, and did not change gloves;- LPN A picked up the trash off the floor and threw it away;- LPN A removed gloves, performed hand hygiene, and pushed the resident back to the dining room;- LPN A placed the wound cleanser, tape, scissors, and a box of gloves from the resident's bed into the treatment cart without sanitizing them. 7. Observation on 02/27/26 at 8:20 A.M., Resident #2's wound care showed:- EBP signage on the door;- LPN A gathered supplies, entered the room, put the supplies on a clean tray on the bedside table, and placed the soiled scissors used during Resident #20's wound care on the bedside table;- LPN A did not perform hand hygiene and put on a gown and gloves;- LPN A removed the dressings from the resident's right hip, left hip, and the sacrum;- LPN A did not perform hand hygiene, did not change gloves, cleaned the left hip wound, did not perform hand hygiene, did not change gloves, applied Xeroform, applied a border gauze, did not perform hand hygiene, and did not change gloves;- LPN A rolled the resident to the left side, cleaned the right hip wound, sat the wound cleanser bottle on the resident's bed without a clean barrier, did not perform hand hygiene, and did not change gloves;- LPN A cleaned the sacrum wound, did not perform hand hygiene, did not change gloves, applied metronidazole powder (an antibiotic medication) to the right hip wound, inserted calcium alginate with silver rope (a type of wound care treatment) with a cotton applicator, covered with a sterile gauze pad cut with the soiled scissors, sat the scissors on the resident's bed without a clean barrier, secured the gauze pad with a border gauze, did not perform hand hygiene, and did not change gloves;- LPN A placed metronidazole and calcium alginate with silver rope into the sacral wound, covered with border gauze, did not perform hand hygiene, and did not change gloves;- LPN A moved the wound cleanser bottle and scissors from the bed to a bookcase; - LPN A removed gloves and gown, performed hand hygiene, exited the room, put the scissors and wound cleanser bottle into the treatment cart without sanitizing them. 8. Review of Resident #20's medical record showed;- admitted on [DATE];- Step one Tuberculosis Skin Test (TST), dated 01/08/26, with a result of 0 millimeters (mm) and no read date;- Step two TST, dated 01/22/26, with a result of 0 mm and no read date. 9. Review of Resident #51's medical record showed:- admitted on [DATE];- Step one TST, dated 01/12/26, with a result of 0 mm and no read date;- Step two TST, dated 01/26/26, and no result. 10.Review of Resident #68's medical record showed:- admitted on [DATE];- Step one TST, dated 02/20/26, with a result of 0 mm and no read date. During an interview on 02/25/26 at 4:15 P.M., LPN G said hand hygiene should be performed upon entering and exiting a resident's room, when moving from dirty to clean task/care, gloves should be changed when moving from dirty to a clean task. EBP consisted of a gown and gloves and should be worn while providing care when a resident had wounds, catheters, ports (a central line that gives medicine and fluid into your veins), intravenous line (IV - a soft, flexible tube placed inside a vein), tracheostomy tube (a hollow tube that goes through the hole and into your windpipe to help you breathe), or a gastrostomy tube (G-tube - a tube inserted through the abdomen that brings nutrition directly to the stomach). When performing incontinent care, clean front to back, use one wipe and throw it away or fold it over to a clean area. Soiled items should not be placed on the floor, they should be put in a bag and taken to soiled utility, then hands should be washed. During an interview on 02/26/26 at 3:57 P.M., LPN B said should perform hand hygiene before and after resident care, after disposing of soiled linens and trash, and between dirty and clean tasks. Should put on gloves after hand hygiene and change gloves between dirty and clean tasks. EBP was to wear a gown and gloves when doing in contact direct care, such as incontinent care, and dressing changes on residents with wounds and/or lines, drains, or tubes not naturally occurring from the resident's body. Incontinent care should be completed front to back and include the genitals. Should not use the same area of the wipe multiple times. Should wipe, fold, wipe, dispose of wipe, and use a new wipe until the area was clean. During an interview on 02/27/26 at 5:07 P.M., the Administrator said she would expect staff to follow policy and procedures regarding maintaining infection control during care to include handwashing, glove changes, wound care, and such. It was expected that staff complete resident TST per policy and procedures. During an interview on 02/27/26 at 5:32 P.M., the Assistant Director of Nursing (ADON) said staff should wear a gown and gloves for care for those residents who were on EBP protocol. Staff should sanitize hands before care, with glove changes, at the end of care, and anytime they question if they needed to, or their hands became visibly soiled. Glove changes should occur when moving from one area of the body to another or moving from soiled to clean during care, or if gloves become visibly soiled. Supplies should be placed on a barrier and sanitized in between residents if used for more than one. Scissors should be sanitized between wounds and residents. Trash and discarded wound care items should not be placed on the floor. It was expected that staff complete resident TST per policy and procedures. During an interview on 02/27/26 at 5:52 P.M., the Director of Nursing (DON) said staff should follow policy and procedure for infection control, handwashing, glove changes, wound care, and basic standards. Trash should not be placed on the floor. EBP policies should be utilized for care for those residents on it. It was expected that staff complete resident TST per policy and procedures. During a phone interview on 03/04/26 at 2:29 P.M., CNA E said hand hygiene should be completed upon entering the resident's room, then put on gloves, perform care, remove gloves, perform hand hygiene, and then perform hand hygiene again at the nurse's station after disposing of soiled items and trash. Hand hygiene with glove changes going from dirty to clean tasks. Soiled items should not be on the floor, they should be placed in a trash bag. When performing incontinent care, it should be one swipe per wipe and throw it away. EBP consisted of using a gown and gloves during care for a resident with a wound, catheter, or peripherally inserted central catheter (PICC - a thin, flexible tube that delivers treatments through a vein) line. During a phone interview on 03/04/26 at 2:48 P.M., CNA D said hand hygiene should be performed when you enter a resident's room, with glove changes, and when finished up with care. Change gloves and perform hand hygiene when moving from a dirty to clean task or area. When performing incontinent care, use a new cloth with each wipe. EBP consisted of the gown and gloves and should be used when providing care for a resident with open wounds, active infection, or an IV. During a phone interview on 03/04/26 at 3:04 P.M., CNA F said should perform hand hygiene and put on gloves when going into a room, change gloves and perform hand hygiene when moving from dirty to clean care, and perform hand hygiene before leaving the room. Soiled items go in a bag, not on the floor. When performing incontinent care, get a new wipe with each wipe. EPB was wearing gown and gloves to protect the resident with open wounds, catheters, and IVs.

Based on interview and record review, the facility failed to provide a safe environment per the resident's assessed level of need, when Resident #21 received a second degree (a burn that damages the epidermis and dermis, the two layers of skin) burn from the spilled coffee in his/her lap after a Certified Nursing Assistant (CNA) handed the resident hot coffee in a coffee cup without a lid for one sampled resident. The census was 69. The facility did not provide a policy regarding accidents/incidents. 1. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 11/19/24, showed: - Diagnoses of non-traumatic brain injury (brain injury that occurs due to internal factors, rather than an external force to the head), dementia ( general term for a group of neurological conditions that cause a decline in mental abilities that affects daily life), and anxiety ( a feeling of fear, dread, and uneasiness that can be a normal reaction to stress); - Cognition severely impaired; - No speech and not understandable; - Does not understand others; - Partial/Moderate assist with eating with mechanically altered diet; - Dependent for all activities of daily living (ADL's) and mobility; - No skin conditions. Review of the resident's care plan, last reviewed on 11/19/24, showed: - On a pureed, fortified diet and used Kennedy cups (spill proof cup with a lid and straw); - Poor safety awareness. Review of the resident's December 2024 Physician Order Sheet (POS) showed: - An order to cleanse the burn with wound cleanser, apply silvadene (topical antimicrobial drug indicated as an adjunct for the prevention and treatment of wound sepsis in patients with second degree burns) and cover with an island dressing two times a day for burn, discontinue once healed, dated 11/20/24 and discontinued 11/23/24; - An order for silvadene cream 1% apply topically to the left hip two times daily for burn until healed, then discontinue, dated 11/20/24, discontinued 11/23/24, due to allergic; - An order to cleanse burn with wound cleanser and apply triple antibiotic ointment and cover with island dressing two times a day for burn, discontinue once healed, dated 11/23/24, discontinued 11/29/24; - An order to cleanse burn with wound cleanser, apply Xeroform gauze (a fine mesh gauze occlusive dressing for use on low exudating wounds) and cover with ABD (a large absorbent dressing) pad and island dressing two times a day for burn, discontinue once healed and as needed for burn, dated 11/29/24. Review of the resident's nurse's notes showed: - On 11/19/24 at 12:25 P.M., a Braden scale assessment (used for predicting pressure ulcer risk) evaluation with sensory perception slightly limited; - On 11/20/24 at 7:28 P.M., silvadene wasn't available, waiting on pharmacy since it was a new order. Did not cover burn as ordered; - On 11/21/24 at 11:25 A.M., the dressing on the left leg/hip was dry and intact. Silvadene not available; - On 11/22/24 at 1:12 A.M., cleaned and covered burn with dressing without silvadene cream due to being unavailable; - On 11/22/24 at 7:37 A.M., area was cleansed and redressed. No silvadene available due to resident possibly allergic; - On 11/28/24 at 6:22 P.M., resident had a dressing change at 3:45 P.M.; - On 11/29/24 at 5:02 P.M., order to cleanse burn with wound cleanser, apply Xeroform gauze and cover with ABD pad and island dressing as needed for burn; - On 12/05/24 at 3:54 A.M., assessed the wound to left thigh. Treatment completed as ordered by wound physician. The wound was healing. No complaint of pain or discomfort to wound area or signs or symptoms of infection; - On 12/05/24 at 9:52 A.M., resident had a 20 centimeter (cm) by 6 cm burn area on the left distal (away from the center) thigh. The lower 10 cm part of the burn had pink closed tissue. The upper 10 cm tissue was pink but open. No eschar (dead tissue) noted. Burn was progressively healing; - On 12/06/24 at 2:16 A.M., assessed the wound to left thigh. Treatment completed as ordered by wound physician. Wound was healing with no complaint of pain or discomfort to wound area. No signs or symptoms of infection this shift. Review of the facility incident report, dated 11/19/24, completed by the Director of Nursing (DON), showed: - On the morning of 11/19/24, Resident #21 received a cup of coffee without a lid, handed to the resident by a CNA not familiar with the resident which resulted in the resident spilling coffee in his/her lap. - Two CNAs immediately took the resident and changed him/her and notified the nurse. An assessment was completed by the CNAs and nurse with no redness or open areas noted. Later that week on the night of 11/22/24, Licensed Practical Nurse (LPN) reported a large blister to the leg. On 11/27/24, the blister opened and began weeping. The wound was assessed that day by Physician K, wound provider. New wound orders were given at this time and the primary physician was notified of the extent of the injury. Staff education was done. Family notified of the situation; - The physician was notified, nurse's notes reviewed, orders reviewed, staff interviewed, pain and skin assessment completed, and resident was unable to be interviewed; - Upon completion of the investigation, it was determined the injury was unintentional, and the CNAs and nurse took the proper steps in immediately changing the resident and assessing the site. Education provided to nursing staff. During an interview on 12/05/24 at 8:30 A.M. CNA I and CNA J said the unit night shift CNA got the resident up on 11/19/24, and gave him/her coffee which the resident spilled on himself/herself. The night shift CNA didn't know the resident should have a lid, even though the resident was care planned for it. CNA I and CNA J saw the thigh the morning of 11/20/24, and it was red with a small blister up at the top. The next day, on it was a way larger blister. During an interview on 12/06/24 at 11:50 A.M., Physician K said he/she wasn't made aware of the burn until a week from when it happened. He/She heard multiple different stories, but in the end, the resident spilled hot coffee on him/herself. He/She would have came to the facility and assessed him/her that day or at least the next had he/she known. When he/she saw it on 11/28/24, there was a large amount of drainage which was concerning regarding his/her fragile state and possible electrolyte issues. Per the facility, the drainage had decreased. Seeing him/her this week, the drainage had stopped and the burn was healing. The facility should be able to care for it now as long as they keep infection from it. Physician K was very upset and would have sent the resident to the emergency room had he/she known of the burn to ensure the electrolytes stayed good. During an interview on 12/06/24 at 12:15 P.M., the Director of Nursing said the silvadene never came in because the resident had a sulfa allergy. The pharmacy caught the allergy and didn't fill the script. She was notified on the morning of 11/19/24, of the accident. The CNAs and nurse found no skin issues. However, there was no follow up skin assessment documented after 11/19/24, and there should have been documentation showing the area was assessed daily. The wound physician was followed up with on 11/28/24, to let him/her know the progress of the injury.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 69. The facility did not provide a policy regarding the kitchen. 1. Observation on 12/03/24 at 9:34 A.M., and 12/05/24 at 11:38 P.M., of the kitchen showed: - No cleaning logs; - Two unlabeled white plastic food bins with clear unlabeled lids near the gas range with white sugar and brown sugar; - A metal backsplash behind the gas range with a 2 foot (ft.) diameter (dia.) area with dark brown carbon build-up; - The commercial style can opener with an oily film on the base and blade; - One 3 ft. by 4 ft. diffuser (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surfaces and between the ventilation louvers outside the water heater closet door; - The floor below the reach-in freezer, the reach-in refrigerator, gas range, deep fryer, mixer, and food preparation counters with scattered debris and oily film; - The walk-in freezer with a 12 inch (in.) dia. area of 1 in. thick frost build up left of the fan louvers, one small clear prepackaged bag of vegetables, a serving dish, and scattered debris lay on the floor; - The walk-in refrigerator with scattered food debris and liquid on the floor approximately 1 in. deep in the back left corner, a black substance on the right wall between the middle food shelves, and a gray build up on the ventilation louvers; - Three 24 cup muffin pans with black carbon build up inside the cups and on the top cooking surface; - One 18 in. and two 12 in. skillets with dark brown carbon build up on the interior cooking surfaces; - The floor below the ice machine with scattered debris and gray grime build-up, two non-intact vinyl floor tiles, and the plastic drain with no visible air gap. 2. Observation on 12/03/24 at 9:34 A.M., of the dry food storage room showed: - One tray with nine bowls of toasted oats, eleven bowls of fruit rings, and nine bowls of bran flakes, undated and unlabeled; - One tray with 10 covered bowls of apple crisp desert, undated and unlabeled; - One tray with eight wrapped graham crackers with peanut butter cups, undated and unlabeled; - One partially full clear plastic bin of corn flakes, labeled with an expiration date of 05/15/24; - One partially full clear plastic storage bin with bran flakes, undated or labeled; - One partially full clear plastic storage bin with fruit rings, undated or labeled; - One partially full clear plastic storage bin with toasted oats, undated or labeled; - One partially full white plastic storage bin with hot wheat cereal, undated or labeled; - One partially full white plastic storage bin with hot oatmeal, undated or labeled; - One 30 count cardboard box with paper towels and one 1000-piece cardboard box with 10 ounce disposable bowls lay on the floor; - Scattered food debris lay on the floor along the walls below the food shelves. During an interview on 12/03/24 at 10:04 A.M., Dietary Aide F said there were no cleaning schedules. The last time he/she remembered the walk-in cooler being cleaned was back in February 2024. There was a black substance between the food shelves that needed to be cleaned. During an interview on 12/05/24 at 12:27 P.M., the Dietary Manager said the said facility did not keep cleaning logs but should. It was expected that dietary staff keep the kitchen area clean. A maintenance repair crew was called in to repair the freezer on 12/03/24. The dishwasher had been out for over one month, a dishwasher part was being specially made and had created a delay on the repair, and the dishwasher was not being used. Food items should be labeled and dated. Disposable bowls should not be stored on the floor. Appliances and floors should be clean, and cookware should not have carbon build up. During an interview on 12/05/24 at 2:10 P.M., the Administrator said the facility should be keeping dietary cleaning logs but did not at this time. There were several cleaning and food storage issues that would need to be corrected. The walk-in freezer should not have frost build up. The food should be labeled in the dry storage area and disposable food containers should not be stored on the floor. The floor under the kitchen appliances and storage shelving should be kept clean. The appliances and can opener should be clean. The wall space behind the gas range should be clean and dust free. The walk-in refrigerator should be clean and not have grime build up on the wall between the shelving. There should not be food left on the floor in the freezer. The ice machine drain should have an air gap and the floor should be clean and intact beneath. The dishwasher was being repaired and taking longer than expected.

Based on observation, interview, and record review, the facility failed to ensure the narcotic reconciliations (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) were accurate when on-coming and off-going staff failed to document narcotic medications as they were administered for two residents (Residents #21 and #46) which resulted in the inaccuracy of the narcotic counts. The facility census was 69. The facility did not provide a policy for the narcotic count. 1. Review of the 100/200 Certified Medication Technician's (CMT's) cart Controlled Drug Receipt-Record Disposition form on 12/05/24 at 9:45 A.M., showed: - A count of 22 tablets for Resident #21's hydrocodone (a narcotic pain medication) 5/325 milligram (mg) by mouth two times a day for pain, dated 06/13/24; - A count of seven tablets for Resident #46's eszopichlone (a hypnotic medication used to help a person sleep) 3 mg by mouth at night, dated 04/23/24. Observation on 12/05/24 at 9:45 A.M., of the 100/200 CMT's medication cart showed: - A count of 20 tablets for Resident #21's hydrocodone 5/325 mg two times a day for pain in the medication card; - A count of six tablets for Resident #46's eszopichlone 3 mg by mouth at night in the medication card; - The facility staff did not document the administration of Resident #21 and Resident #46's medications on the Controlled Drug Receipt-Record Disposition forms. During an interview on 12/05/24 at 9:50 A.M., CMT H said the night nurse gave the Resident #46's eszopichlone and didn't sign it out on the narcotic book, but signed it on the resident's MAR. He/She was not sure what happened with the Resident #21's hydrocodone count. He/She counted at the start and end of his/her shift, even if it's with him/herself. During an interview on 12/06/24 at 12:30 P.M., the Director of Nursing (DON) and the Administrator said staff should always make time to do narcotic counts when changing shifts. Staff should document both on the MAR and the narcotic book when administering narcotic medications.

Based on observation, interview, and record review, the facility failed to follow physician orders for one resident (Resident #118) out of six sampled residents when the facility failed to administer the correct amount of insulin (a hormone that helps regulate blood sugar levels by moving glucose from the bloodstream into cells for energy). The facility also failed to follow Registered Dietician (RD) recommendations for one resident (Residents #22) out of four sampled residents. The facility census was 69. Review of the facility's policy titled, Administering Medications, dated April 2019, showed: - Medications are administered in a safe and timely manner and as prescribed; - Medications are administered in accordance with prescriber orders, including any required time frame. The facility did not provide a policy regarding RD recommendations. 1. Review of Resident #22's medical record showed: - Diagnosis of cerebral palsy (a group of neurological disorders that affect a person's ability to move, balance, and maintain posture); No documentation regarding the RD's recommendation documented on the Nutrition Note, dated 10/21/24. Review of the resident's Physician Order Sheet (POS), dated December 2024, showed: - An order enteral feed (a method of providing nutrition to the body through a feeding tube that delivers liquid food directly to the stomach or small intestine) one time a day, replace kangaroo bag (the bag that holds the formula for enteral feeding) every day, dated 07/09/24. Review of the resident's Medication Administration Record (MAR), dated December 2024, showed: - Enteral feed order one time a day Osmolite (therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding for patients) 1.5 42 milliliters (ml)/hour for 23 hours for a total of 960 ml, dated 03/24/24; - Enteral feed order one time a day for cerebral palsy replace kangaroo bag every day, dated 07/09/24. Review of the resident's Nutrition Note, dated 10/21/24, and weights showed: - Resident's weight increasing gradually and gained 20 pounds (lbs) in the past six months. Tube feed was unchanged and tolerated well. Received Osmolite 1.5 at 42 ml/hour continuously, did receive 100 ml water flush three times a day with bag replaced daily. Suggest to reduce to 35 ml/hour to stabilize weight as continued gain would not be beneficial. This reduction would be approximately 200 calories less per day than currently receiving; - On 04/07/24, weight of 152 lbs; - On 10/16/24, weight of 165 lbs; - On 10/23/24, weight of 166 lbs, - On 11/05/24, weight of 167 lbs, - On 12/05/24, weight of 169 lbs. 2. Review of Resident #118's POS, dated December 2024, showed: - Diagnosis of diabetes mellitus (a chronic disease that causes high blood sugar levels); - An order for Insulin lispro (medication used to lower blood sugar) 100 units/milliliters, inject per sliding scale for blood sugar 341-380=14 units, blood sugar 381-420=administer 16 units, blood sugar between 421-460=administer 18 units, dated 12/05/24. Review of the resident's MAR, dated December 2024, showed: - Insulin lispro 100 units/milliliters, inject per sliding scale for blood sugar 341-380=14 units, blood sugar 381-420=administer 16 units, and blood sugar between 421-460=administer 18 units; - On 12/06/24 at 11:00 A.M., blood sugar result documented as 425 and 18 units insulin administered. Observation on 12/05/24 at 11: 30 A.M., of Resident #118's blood sugar and insulin administration showed: - Registered Nurse (RN) G obtained the resident's blood sugar with a result of 425 and wrote it on a piece of paper on top of nurse cart; - RN G went and obtained two other resident's blood sugars and administered one other insulin prior to returning to Resident #118; - RN G obtained Resident #118's Insulin lispro and looked at the resident's sliding scale; - RN G said Resident 118's blood sugar was 373 and required 14 units of insulin; - RN G dialed the Insulin lispro pen to 14 units and picked up an alcohol pad; - RN G said the resident's blood sugar was 373 and not 425 as he/she looked at the 425 written under the resident's name on the piece of paper he/she documented Resident 118's blood sugar on; - RN G said 14 units of insulin would be correct. RN G opened the top drawer of the medication cart, looked again, and said a blood sugar of 373 required 14 units of insulin; - RN G administered 14 units of insulin to Resident #118; - RN G administered the incorrect amount of insulin. Resident #118 should have received 18 units of insulin due to a 425 blood sugar. During an interview on 12/06/24 at 11:30 A.M., RN G said Resident #118's blood sugar result was 373 and should receive 14 units of insulin. During an interview on 12/07/24 at 1:00 P.M., the Director of Nursing (DON) and Administrator said nurses should document the residents' blood sugar results in the electronic record as they were obtained so the medication administered would be accurate. They would expect the appropriate amount of insulin to be administered. They would also expect RD recommendations to be followed through on, especially a tube feeding. 46521

Based on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of the residents' personal funds) for at least one and one-half times the average monthly balance of the residents' personal funds for the last twelve consecutive months from October 2023 to September 2024. The facility census was 69. The facility did not provide a policy for the surety bond. 1. Review of the residents' personal funds account on 12/05/24, for the last twelve consecutive months from October 2023 to September 2024, showed: - The facility's current approved bond amount equaled $100,000.00; - The average monthly balance for the residents' personal funds equaled $68,621.10; - An average monthly balance of $68,621.10 required a bond of at least $103,500. During an interview on 12/05/24 at 11:07 A.M., the Business Office Manager (BOM) said the surety bond should be one and one-half times the amount on the residents' trust balance. During an interview on 12/05/24 at 11:20 A.M., the Administrator said the surety bond amount should be one and one-half times the amount of the resident trust balance to meet the regulatory requirement.

Based on observation, interview and record review, the facility failed to ensure a urinary catheter (a tube inserted into the bladder to drain urine) drainage bag and tubing was kept off the floor for one resident (Resident #31) out of two sampled residents. The facility census was 69. Review of the facility policy titled, Catheter Care, Urinary, Revised August 2022, showed: - Be sure the catheter tubing and drainage bag are kept off the floor. Review of Resident #31's Physician Order Sheet (POS), dated December 2024, showed: - An order for urinary catheter care every shift for urinary retention (an inability to empty the bladder of urine), dated 11/26/24; - An order for a 16 French (FR - size of catheter) catheter with 10 cubic centimeter (cc) bulb one time a day every one month starting on the 15th for 28 days, dated 11/26/24; - An order for a 16 FR catheter with 10 cc bulb for occlusion or leakage as needed, dated 11/26/24; - An order to empty the catheter drainage bag and chart the output every shift, dated 11/27/24. Observation of the resident showed: - On 12/04/24 at 9:33 A.M., and 10:39 A.M., the resident lay in bed and the catheter drainage bag lay on the floor between the bed frame and a wheelchair with a privacy cover attached to the catheter drainage bag; - On 12/04/24 at 9:41 A.M., Certified Nursing Assistant (CNA) A and CNA B entered the resident's room, the catheter drainage bag lay on the floor between the bed frame and a wheelchair, talked to the resident, and exited the room; - On 12/05/24 at 8:02 A.M., the resident lay in bed, the catheter drainage hung from the bed frame with the bottom of the catheter drainage bag touching the front right wheel of a wheelchair, and a privacy cover in place. During an interview on 12/05/24 at 3:01 P.M., Licensed Practical Nurse (LPN) C said the catheter drainage bag should be hung below the bladder. The drainage bag and tubing should be off the floor, not touching the wheels of a wheelchair, and a privacy cover should be in place. During an interview on 12/05/24 at 3:30 P.M., the Director of Nursing (DON) said if a resident lay in bed, the catheter drainage bag should be hung on a non-moving piece of the bed. It should be hung lower than the bladder. The catheter drainage bag and tubing should not be on the floor, dragging the floor, and not touching the wheel of the wheelchair. During an interview on 12/06/24 at 12:30 P.M., CNA B said the catheter drainage bag and tubing should not lay on the floor and should not drag the floor. The catheter drainage bag should have a privacy cover in place and should be hung on the bed frame if in bed. During a phone interview on 12/12/24 at 4:37 P.M., CNA A said the catheter drainage bag should be hung on the bed frame. The drainage bag and tubing should not touch or drag the floor.

Based on observation, interview, and record review, the facility failed to follow physician's orders for supplemental oxygen therapy for two residents (Residents #39 and #62) out of two sampled residents, and failed to ensure proper tracheostomy (trach - incision in the windpipe to relieve an obstruction to breathing) care for one resident (Resident #39) out of one sampled resident. The facility census was 69. The facility did not provide an oxygen policy. Review of the facility's policy titled, Tracheostomy Care, revised August 2023, showed: - The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas; - Aseptic technique must be used: during cleaning and sterilization of reusable tracheostomy tubes; during tracheostomy tube changes, either reusable or disposable; - Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures; - Remove old dressings. Pull soiled glove over dressing and discard into appropriate receptacle; - Wash hands; - Clean the removable inner cannula: - Open tracheostomy cleaning kit; - Set up supplies on sterile field; - Maintain sterile field, pour equal parts hydrogen peroxide and normal saline in one compartment of opened kit. Pour normal saline in another compartment; - Open four gauze pads and saturate with hydrogen peroxide; - Open two gauze pads and saturate with antiseptic solution; - Open two gauze pads and saturate with sterile saline; - Open two gauze pads, keep them dry; - Put on gloves; - Secure the outer neck plate with non-dominate gloved hand; - Unlock the inner cannula with gloved dominate hand; - Gently remove the inner cannula, rotating counterclockwise while lifting away from the resident; - Soak the cannula in hydrogen peroxide/saline mixture; - Clean with brush. Rinse with saline and dry with pipe cleaners; - Remove and discard gloves into appropriate receptacle; - Wash hands and put on fresh gloves; - Replace the cannula carefully and lock in place; Site and Stoma Care: - Apply clean gloves; - Clean the stoma with two peroxide-soaked gauze pads (using a single sweep for each side); - Rinse the stoma with saline-soaked gauze pads (using a single sweep for each side); - Wipe with dry gauze (using a single sweep for each side); - Disinfect the stoma with the antiseptic-soaked gauze pads (using a single sweep for each side). Allow to air dry or wipe with clean, dry gauze; - Remove neck ties and replace with clean ones; - Apply a fenestrated (having an opening) gauze pad around the insertion side; - Replace supplemental oxygen mask over tracheostomy; - Remove gloves and discard into appropriate receptacle; - Wash hands; - Document the procedure, condition of the site, and the resident's response; Resident self-performance of Trach Care per Resident preference: - Assure resident is competent by completion of an annual competency observed by charge nurse; - Assure resident has supplies available to complete procedure; - Staff to assist Resident as resident allows and when needed. 1. Review of Resident #39's medical record showed: - Diagnoses of malignant neoplasm of supraglottis (a cancerous growth located in the supraglottis, which is the upper part of the larynx (voice box) and tracheostomy status; - An order for #6 Shiley Fenestrated replaceable inner cannula (a tube within the outer tracheostomy tube), dispense 1 unit with 5 refills to be replaced every day, #6 Shiley Fenestrated uncuffed tracheostomy tube (a type of tracheostomy tube used to maintain an open airway) dispense 1 unit with 5 refills. Does self trach care, one time a day, dated 03/14/23; - An order to change suction container and [NAME] (type of suctioning tube) tubing one time a day every Sunday, dated 01/18/24; - An order to wipe down the oxygen concentrator, dated & tape zip-lock bags for tubing. Change oxygen tubing and trach hood, clean black filter weekly, one time a day every Sunday, dated 01/18/24; - No order for oxygen; - No documentation of the resident's competency for tracheostomy cleaning. Review of the resident's untitled document, dated 11/06/24, showed: - Resident wished to perform suctioning and self-care of tracheostomy; - Resident demonstrated and understood the steps to suctioning and care of tracheostomy; - Tracheostomy Care: gather supplies; wash hands with soap and water; position a mirror and lighting so you can see airway; prepare you new tracheostomy tube for insertion; remove inner cannula and insert the obturator (used to insert a tracheostomy tube) - coat with K-Y Jelly (a water-based lubricant) - place the Velcro or twill ties through one side of the flange holes; insert the new tracheostomy tube (with the obturator in place) approaching your stoma from the side; once the tube is inserted about an inch, turn the tube so it curves downward and insert the rest of the way until the flange is sitting against your neck; remove the obturator and replace the inner cannula; secure the Velcro or twill ties; - Did not address the procedure for cleaning of tracheostomy; - Did not address if the resident understood and could perform the tracheostomy self care. Observation on 12/03/24 at 10:30 A.M., showed the resident sat in a recliner with oxygen attached to the trach at 2 liters per minute. Observation on 12/05/24 at 8:04 A.M., of the resident's self-care of the tracheostomy showed: - The resident entered the bathroom where a tracheostomy care kit, two gauze pad packages, one split sponge package, and a trach collar package was set out on the left sink area unopened; - The resident washed hands; - The resident opened the tracheostomy care kit, set drape sheet to the right of the kit container, left folded, attempted to put on sterile gloves, set sterile gloves aside on the right sink area because they were too small, retrieved clean, non-sterile gloves from the box of gloves behind the bathroom door, removed the trach collar and split gauze from the trach site; - The resident did not change gloves or perform hand hygiene, picked up the trachea tube brush from the kit, cleaned the outer cannula under running tap water at the sink, sat the outer cannula on top of the folded drape sheet; - The resident did not change gloves or perform hand hygiene, opened the new trach collar, threaded the collar through the outer cannula, removed glasses, pulled the collar with the outer cannula attached over his/her head, did not change gloves or perform hand hygiene, picked up the gauze the trach collar sat on and wiped the trach site, inserted the outer cannula, tightened the collar, removed the gloves, gathered the used supplies and put into the trash can; - The resident did not perform hand hygiene, did not put on gloves, opened a new split sponge, and placed around the trach site under the outer collar; - Resident did not insert the inner cannula of the tracheostomy; Observation on 12/06/24 at 11:30 A.M., of the resident showed: - Sat in the recliner with the outer tracheostomy cannula in place; - The inner cannula of the tracheostomy sat on the bedside table. During an interview on 12/05/24 at 8:15 A.M., Resident #39 said he/she always used water from the sink to clean the trach collar. He/She didn't use the inner cannula because it was hard to breath with it in. During an interview on 12/05/24 at 9:45 A.M., Licensed Practical Nurse (LPN) C said Resident #39 had the inner cannula. The resident did most stuff him/herself. The resident had been educated on the importance of handwashing, keeping everything sterile, and used sterile water to clean the obturator and for cleaning the cannula too. The resident cleaned the cannula and changed the Shiley inner cannula daily, then let staff know it was done. The resident used the inner cannula sometimes, but at times took it out because he/she said it was hard to breath. The facility had tried another inner cannula and the resident said it got hung up, and changed to the current one. During an interview on 12/05/24 at 10:00 A.M., the Director of Nursing (DON) said nurses did competency checks and monitored trach care. The competency checks were completed twice a year by the DON or charge nurse. Nurses got the trach care supplies for the resident, and they were kept in the resident's room. Resident #39 performed his/her own trach care and communicated with the nurse when it was done for the day. The he inner cannula should always be in place, tap water should not be used, and the obturator could come out, but did not think it should come out daily. The tracheostomy cleaning should be completed using sterile technique, using sterile gloves, cleaned with normal saline and hydrogen peroxide, and then changed to new sterile gloves when retrieving the new inner cannula from the package and inserting. 2. Review of Resident #62's medical record showed: - admitted [DATE]; - Diagnosis of chronic obstructive pulmonary disease (COPD - a group of lung diseases that causes restricted airflow and breathing problems). Review of the resident's Physician Order Sheet (POS), dated December 2024, showed: - An order for oxygen at 2 liters per minute by nasal cannula (NC - a flexible tube inserted into the nose to administer supplemental oxygen) as needed for shortness of breath, dated 11/18/24. Observation of the resident on 12/03/24 at 9:40 A.M., showed the resident sat in a recliner in his/her room with oxygen on at 4 liters per minute via NC. During an interview on 12/05/24 at 3:30 P.M., the DON said the order for oxygen should be followed. 47445

Based on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for one resident (Resident #31) with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts to the event) out of one sampled resident. The facility's census was 69. The facility did not provide a PTSD policy. 1. Review of Resident #31's medical record showed: - admitted [DATE]; - Diagnoses of PTSD, depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), and anxiety disorder (persistent worry and fear about everyday situations); - Trauma Informed Care Assessment, dated 11/06/24, showed resident triggered for PTSD. Review of the resident's Physician Order sheet (POS), dated December 2024, showed: - An order for alprazolam (an antianxiety medication) 0.25 milligrams (mg) by mouth every 8 hours as needed for anxiety, dated 09/17/24; - An order for Cymbalta (an antidepressant medication) delayed release 30 mg by mouth two times a day for depression, dated 11/06/24; - An order for Seroquel (an antipsychotic medication) 50 mg by mouth one time a day for cognitive communication deficit, dated 11/06/24; - An order to refer to behavioral healthcare, dated 10/24/24. Review of the resident's comprehensive care plan, dated 08/19/24, showed: - PTSD not addressed; - No goals to maintain the resident's psychosocial and mental health; - No documentation of the resident's past trauma, or any triggers that would cause the resident trauma; - No interventions for how the facility would address the behaviors if they occurred or how the facility would provide support to the resident. During an observation and interview on 12/03/24 at 10:53 A.M., Resident #31 said he/she had PTSD and replayed the images in his/her mind of that day. The resident was tearful, spoke with a quivering voice while he/she talked about his/her past trauma. He/She did have triggers with a train whistle being one of them. During an interview on 12/05/24 at 11:45 A.M., the Administrator said the resident had just started talking about his/her past trauma, but PTSD should be addressed on the resident's care plan. During a phone interview on 12/06/24 at 12:17 P.M., the Social Service Designee (SSD) said Resident #31 had recently started to. talk about his/her PTSD.

Based on observation and interview, the facility staff failed to post the required daily nurse staffing information which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, in a prominent location readily accessible to residents and visitors for three out of four days. The facility census was 69. The facility did not provide a policy regarding posting of nurse staffing. Observation on 12/04/24 at 9:30 A.M., 12/05/24 at 11:00 A.M., and 12/06/24 at 12:00 P.M., of the facility's Staff Posting Sheet, located on a bulletin board beside the nurse's station showed: -The Staff Posting Sheet, dated 12/02/24; -The facility did not post the required daily nurse staffing information for 12/04/24, 12/05/24, and 12/06/24. During an interview on 12/06/24 at 2:00 P.M., the Administrator and Director of Nursing (DON) said nurse staffing should be posted on the Nurse Staffing board daily.

Based on interview and record review, the facility failed to limit the use of an as needed (PRN) order for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medication to 14 days for one resident (Resident 29), failed to attempt a gradual dose reduction (GDR) for one resident (Resident #7), and failed to ensure an appropriate diagnosis for the use of a psychotropic medication for two residents (Residents #31 and #43) out of nine sampled residents. The facility census was 69. Review of the facility policy titled, Tapering Medications and GDR, revised April 2007, showed: - Within the first year after a resident is admitted on an antipsychotic (a class of medications used to treat psychosis) medication or after the resident has been started on an antipsychotic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between attempts), unless clinically contraindicated; - After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated. The facility did not provide a policy regarding appropriate diagnosis of a psychotropic medication and PRN orders. 1. Review of Resident #7's medical record showed: - An admitted [DATE]; - Diagnoses of unspecified dementia (changes in memory, thinking, and behavior) and major depressive disorder (persistent depressed mood or loss in interest) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (persistent worry and fear about everyday situations); - An order for Rexulti (an antipsychotic medication) 1 milligram (mg) daily, dated 04/12/24; - No documentation of a GDR. Review of the manufacturer's safety information for Rexulti, undated, showed the warning and precautions included increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at increased risk of death. Rexulti is not approved for the treatment of patients with dementia-related psychosis without agitation associated with dementia due to Alzheimer's disease. 2. Review of Resident #29's medical record showed: - An admitted [DATE]; - Diagnosis of dementia; - An order for clonazepam (an antianxiety medication) 0.25 mg by mouth every 24 hours PRN (as needed) for agitation, dated 02/21/24, and no stop date; - The facility failed to provide a 14 day stop date order for the clonazepam PRN order. 3. Review of Resident #31's medical record showed: - An admitted [DATE]; - Diagnoses of depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety disorder, post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event), and cognitive communication deficit; - An order for Seroquel (an antipsychotic medication) 50 mg daily for cognitive communication deficit, dated 11/06/24; - No documentation of an appropriate diagnosis for Seroquel. Review of the manufacturer's safety information for Seroquel, undated, showed the warning and precautions included increased mortality in elderly patients with dementia-related psychosis. Seroquel is not approved for elderly patients with dementia-related psychosis. 4. Review of Resident #43's medical record showed: - An admitted [DATE]; - Diagnoses of unspecified dementia with mild mood disorder; - An order for Seroquel 50 mg one tablet daily for dementia, dated 05/20/24; - An order for Seroquel 100 mg one tablet at bedtime for dementia, dated 08/16/24; - No documentation of an appropriate diagnosis for Seroquel. During an interview on 12/06/24 at 4:00 P.M., the Pharmacist Consultant said Seroquel use was discouraged, but it was used for dementia. Psychotropic medications were not effective at treating dementia but they were used to manage symptoms. There should be GDR's when they were used. PRN meds should have a stop date. Pharmacy asked an initial PRN order to be discontinued after 14 days, then the provider should clarify if they could add in their own recommendation for the duration of the medication with an acceptable diagnosis. During an interview on 12/06/24 at 12:30 P.M., the Assistant Director of Nursing (ADON) said no staff in the facility were responsible for auditing chart orders to check for appropriate diagnoses. The facility utilized a consultant pharmacist monthly medication reviews. He/She normally received the pharmacy recommendations. During an interview on 12/06/24 at 12:45 P.M., the Administrator and Director of Nursing (DON) said all PRN psychotropic medications should have a 14 day stop date. All medications should have the appropriate diagnosis linked to it. Anyone putting medications into a resident's chart, should ensure it's linked to the appropriate diagnosis, and if there wasn't one, then the physician should be notified. The ADON ensured pharmacy recommendations were followed.

Based on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner when opened insulin was found undated in the medication cart, failed to ensure the medication cart was locked while unattended, and the facility failed to ensure resident safety by leaving medication in one resident's (Resident #31) room, unattended out of one sampled resident. This had the potential to affect all residents. The facility census was 69. Review of the facility policy titled, Storage of Medications, dated April 2007, showed: - The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; - The nursing staff shall be responsible for maintaining medication storage; - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals; - Compartments containing drugs shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Review of the facility policy titled, Administering Medications, dated April 2019, showed: - The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. The facility did not provide a policy regarding medications being stored in a resident's room. Review of the manufacturer's recommendations for Lantus (a long-acting type of insulin), dated June 2023, showed the medication was to be discarded 28 days after opening. Review of the manufacturer's recommendations for lispro insulin pen (a fast acting type of insulin), dated 2023, showed the medication was to be discarded 28 days after opening. Review of the manufacturer's recommendations for Fiasp insulin pen (a fast acting type of insulin), dated June 2023, showed the medication was to be discarded 28 days after opening. 1. Review of Resident #31's Physician Order Sheet (POS), dated December 2024, showed: - An order for diltiazem extended release (ER) (blood pressure medication) 180 milligram (mg) by mouth three times a day, for atrial fibrillation (irregular heart beat), dated 10/25/24; - An order for gabapentin (used to treat nerve pain) 300 mg by mouth three times a day, dated 11/21/24. Observation on 12/04/24 at 1:15 P.M., showed one diltiazem ER 180 mg tablet and one gabapentin 300 mg tablet in a medication cup sat on Resident #31's bedside table; - On 12/04/24 at 2:09 P.M., a housekeeper entered the room with the one diltiazem ER 180 mg tablet and one gabapentin 300 mg tablet in the medication cup sat on the resident's bedside table; - On 12/04/24 at 2:11 P.M., Resident #31 took the one diltiazem ER 180 mg tablet and one gabapentin 300 mg tablet medications. During an interview on 12/04/24 at 1:15 P.M., Resident #31 said he/she didn't have any water to take his/her medication with. The resident had spilled the water earlier and it had not been replaced. During an interview on 12/05/24 at 3:15 P.M., Certified Medication Technician (CMT) E said he/she placed Resident 31's one diltiazem ER 180 mg tablet and one gabapentin 300 mg tablet medications in a cup and the resident had their own water in their room. CMT E normally watched the resident take their medication before leaving the room. Medications should never be left with a resident. 2. Observation on 12/05/24 at 7:33 A.M. - 7:40 A.M., of the 400 Hall nurse medication cart showed: - The medication cart sat against the wall to the right of the nurse station facing the hallway and unlocked. 3. Observation on 12/05/24 at 7:48 A.M. - 7:59 A.M., of the 400 Hall nurse medication cart showed: - At 7:48 A.M., the medication cart sat against the wall to the right of the nurse station facing the hallway and unlocked; - At 7:50 A.M., three staff walked past the unlocked medication cart; - At 7:52 A.M., Licensed Practical Nurse (LPN) D walked past the unlocked medication cart; - At 7:53 A.M., LPN D walked to the unlocked medication cart, opened the top drawer, did not lock the medication cart, left, and walked down the hall; - At 7:55 A.M., three staff walked past the unlocked medication cart; - At 7:59 A.M., a staff locked the medication cart. 4. Observation on 12/05/24 at 10:10 A.M., of the 200 Hall nurse medication cart showed: - One labeled and opened Lantus insulin pen, dated 09/25/24, when opened; - One labeled and opened Lantus insulin pen, not dated when opened; - One labeled and opened insulin Fiasp insulin pen not dated when opened; - Two labeled and opened insulin lispro insulin pens not dated when opened. 5. Observation on 12/05/24 at 3:40 P.M., showed: - The 400 Hall nurse's medication cart sat against the wall to the right of the nurse station facing the hallway unlocked, the keys hung out of the lock, with no staff present, and five residents sat in wheelchairs in front of the nurse station; - The 200 Hall nurse cart sat against the wall to the left of the nurse station facing the hallway unlocked, with no staff present, and five residents sat in wheelchairs in front of the nurse station; - At 3:50 P.M., LPN D walked to the 200 Hall nurse's medication cart and opened it. The 400 Hall nurse's medication cart remained unlocked and the keys hung out of the lock. During an interview on 12/05/24 at 10:15 A.M., LPN C said insulin pens should be dated when opened. During an interview on 12/05/24 at 3:22 P.M., LPN C Medications shouldn't be left in room unattended. Whoever administers it should watch the resident take it and not leave the medication in the room. Someone else could take the medication. During an interview on 12/06/24 at 11:00 A.M., LPN D said insulin pens should be dated when opened. Medication carts should be locked when left unattended. During an interview on 12/06/24 at 12:45 P.M., the Director of Nursing (DON) and Administrator said insulin pens should be dated when opened. Medication carts should always be locked when left unattended. Keys to the medication carts should never be left hanging from the cart's lock. Medications should never be left unsupervised in a room with a resident.

Based on observation, interview, and record review, the facility failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpster. This failure had the potential to affect all residents. The facility census was 69. The facility did not provide a policy regarding the dumpster. 1. Observations on 12/03/24 at 10:17 A.M., 12/05/24 at 11:33 A.M., and 12/06/24 at 8:53 P.M., of the outside trash dumpster located near the kitchen entrance showed one 6-yard (yd.) dumpster partially filled with two plastic lids completely opened. During an interview on 12/05/24 at 2:10 P.M., the Administrator said the dumpster should be closed when it was unattended and not being filled by the facility staff. During an interview on 12/06/24 at 8:56 A.M., the Assistant Maintenance Director said the trash dumpster should remain closed when it was not being filled. Most of the facility staff were expected to throw trash in the dumpster. The staff had been trained to close the lid on the dumpster but it didn't always get closed.

Based on interview and record review, the facility failed to complete a comprehensive discharge summary for two residents (Residents #58 and #66) out of two discharged residents. The facility's census was 69. The facility did not provide a policy regarding a discharge summary or recapitulation. 1. Review of Resident #58's closed medical record showed: - Resident discharged home on 11/25/24; - No documentation of a recapitulation or completed discharge summary. 2. Review of Resident #66's closed medical record showed: - Resident discharged home on 09/19/24; - No documentation of a recapitulation or completed discharge summary. During an interview on 12/07/24 at 2:00 P.M., the Administrator and Director of Nursing (DON) said the discharging nurse was responsible for completing the discharge summary. The discharge summary and the recapitulation should be completed prior to the discharge of a resident.

Based on observation, record review and interview the facility failed to implement appropriate interventions to prevent additional falls for one resident (Resident #8), who had a history of [REDACTED]. Staff failed to appropriately assess in order to identify signs of a fracture after one resident (Resident # 12) sustained a fall and fracture of the hip. Staff moved the resident after the fall in a wheelchair placing the resident at risk for further injury and delayed calling the physician for nealy two hours. The resident required surgery and hospitalization to repair the displaced hip fracture. Fourteen residents were sampled out of a facility census of 81. Record review of the facility's policy entitled "Falls-Clinical Protocol" revised October 2010, showed in part the following information: -The nurse shall assess and document/report: vital signs; recent injury, especially fracture or head injury; changes in range of motion, weight bearing; neurological status; pain; frequency and number of falls; -Falls should be identified as witnessed or unwitnessed events; -For a resident who has fallen, staff should attempt to define possible causes within 24 hours of the fall; -Based on the assessment, the staff and physician should identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling; -If interventions have been successful in preventing falling, the staff should continue with current approaches or reconsider whether these measures are still needed if the problem that required the interventions has resolved; -If the resident continues to fall, the staff and physician should re-evaluate the situation and consider other possible reasons for the resident falling and will re-evaluate the continued relevance of current interventions; -As needed the physician will document the presence of uncorrectable risk factors including why any additional search for causes is unlikely to be helpful. Record review of the facility's policy entitled "Managing Falls and Fall Risk" revised December 2007, showed in part the following information: -Based in previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -The staff, with input from the physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of the resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions; -If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant; -If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable; -In conjunction with the physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling; Record review of the facility's policy entitled "Monitoring Subsequent Falls and Fall Risk" revised December 2007, showed in part the following information: -The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling; -The staff and/or physician will document the basis for conclusion that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. 1. Record review of Resident #8's admission face sheet showed the following information: -Staff admitted the resident to the facility on [DATE]; -A [DIAGNOSES REDACTED]. Record review of the care plan developed on 07/10/11, showed the following information: -Progression of dementia; -Altered thought process; -Alert and oriented to self and family, is confused, usually unable to reorient and lacks insight to safety; -Gait is at times unsteady; -Resident is non compliant with staff assisting and has fallen twice since admission; -Has personal safety alarm (PSA) in place but removes it; -Needs minimal assist with activities of daily living (ADLs); -Non complaint with PSA and waiting for staff to walk with him/her; -Staff identify the resident was at risk for falls; -Goal: to have fewer falls. Record review of the quarterly minimum data set (MDS), a federally mandated comprehensive assessment instrument required to be completed by facility staff, dated 10/01/11, showed the following information: -Cognition severely impaired; -Required limited assistance by one staff for transfers, walking, locomotion, dressing and personal hygiene; -Locomotion: Ambulated with walker -Not steady, only able to stabilize with staff assistance while moving from a seated to standing position, moving on and off the toilet and transferring between the bed and chair or wheelchair; -Had a fall prior to admission; -Had one fall with injury (not major). Record review of the nurses notes beginning from the resident's admission to the 11/24/11 fall showed the resident had multiple falls and the interventions put into place were the PSA and BSA. Record review of the facility's fall risk evaluation dated 11/24/11, showed the following information: -The resident's cognition was impaired; -The resident had a balance problem while walking; -The resident had three or more falls in the past three months -Staff documented a score of 16 that indicated the resident was at high risk for falls. Record review of the nurses notes dated 11/24/11 showed the following information: -The resident's spouse was in the hall calling for help; -Staff found the resident on the floor, head bleeding and unconscious. -RN L documented the resident was awake but could not recognize spouse or where he/she was; -Staff notified the physican and orders were given to send the resident to the hospital. Record review of the resident's hospital discharge summary dated 11/24/11, showed the following information: -Head injury with a subdural hematoma (a collection of blood occurring inside the brain). -and subarachnoid hemorrhage (bleeding between certain structures of the brain). -Spinous process fracture of the T1 (The boney protrusion of the first thorasic spine, high in the upper back). Record review of a facility form entitled, "Report of Incident, Accident or Event", dated 11/24/11, showed the following information: -Fall occurred at 12:40 A.M.; -Description of event: the resident's spouse came into the hall, aide went into resident's room. The resident was on the floor with his/her head bleeding. The resident was unconscious. The aide notified the charge nurse. The nurse called the physician and received orders to send the resident to the hospital; -Nursing interventions: the resident was barefooted. Staff wrote non-slip socks or slipper. Leave light on in room, call light to ask for assistance. (Staff did not update the care plan with these additional interventions so all staff would be aware since this document is not available to all staff for review.) -Staff did not indicate if the resident's safety alarm had been in place and sounding at the time of the fall; -The report was signed by the DON on 1/29/12. Record review of the care plan showed staff did not update the care plan with additional interventions to try to prevent further falls. Record review of the nurses notes dated 11/29/11 showed the following information: -At 1:35 A.M., the resident's spouse was in the hall calling for help; -Staff found the resident sitting on the floor next to the bed; -The resident said he/she slipped out of bed and did not hit his/her head. -Staff assessed the resident, emphasized the need for the resident to call for help, placed the BSA under the mattress and left the room door open; -Staff documented to continue to monitor. Record review of the facility's form entitled, "Neurological Flow Sheet", showed the staff began neurological checks on 11/29/11 at 9:00 A.M. (approximately seven and half hours after the resident's fall). During an interview on 02/09/12, at 1:00 A.M., RN L said the following: -When a resident had a fall, he/she assessed the resident to see if the resident needed to go to the hospital. Staff should check vital signs, assess for pain and notify the physician; -If a resident had an unwitnessed fall, staff should begin neurological checks for three days; -He/she recalled the resident returning from the hospital after a fall on 11/25/11when the resident injured his/her head; -He/she was on shift when the resident had the unwitnessed fall on 11/29/11; -The resident said he/she had not hit his/her head, but the fall was unwitnessed; -Staff should have started neurological checks (record review showed RN L was the charge nurse when the fall occurred on 11/29/11); -"I know we should have started neurological checks" but if it is not documented then "I just don't know". Record review of the nurses notes dated 11/29/11 showed the following information: -At 11:00 A.M., the resident's PSA was sounding and staff found the resident urinating in the bathroom sink; -At 6:30 P.M., the resident was vomiting; -At 7:40 P.M., the resident was having projectile vomiting (projectile vomiting can be a sign of increased intracranial pressure within the brain); -At 7:45 P.M., staff notified the physician and orders were given to send the resident to the hospital; Record review of a facility form entitled "Report of Incident, Accident or Event", dated 11/29/11, showed the following information: -Fall occurred at 1:35 A.M.; -Description of event: the resident's spouse came into the hall and said the resident fell . Staff entered the room. The resident was sitting on the floor and stated, "Just slid out of bed". The resident said he/she did not hit his/her head. The resident had turned off the BSA and put it on the table; -Nursing interventions: attach and hide bed alarm. Door kept open. Check on resident every hour, offer urinal, toileting, non-slip socks to sleep in (staff noted the socks as an intervention on 11/24/11, as well). Reinforce teaching for call light use (Staff noted the resident had progressive dementia with moderately impaired cognitive decision-making skills.); -(Staff did not update the care plan with these additional interventions so all staff would be aware since this document is not available to all staff for review.) -Staff did not document they started the neurological checks on the resident at the time of the fall; -Staff notified the physician and the resident's family at 6:15 A.M.. (The facility had just readmitted the resident on 11/25/11, with bleeding and bruising on the resident's head). Record review of the nurses notes, dated 11/30/11, showed the following information: -At 1:00 A.M., the resident returned from the hospital and walked from the gurney to his/her bed; -At 3:30 P.M., the resident's BSA was sounding and the resident was on the edge of the wheelchair seat and slid off into the floor; -Noted no injury; family and physician notified. Record review of a facility form entitled, "Report of Incident, Accident or Event", dated 11/30/11, showed the following information: -Fall occurred at 1:00 P.M.; -Description of event: as the aide walked by, the BSA began to sound. The resident was sitting on the edge of the wheelchair and slid out onto the floor; -Nursing interventions: staff did not document any interventions Record review of the care plan showed staff did not update the care plan with additional interventions to try to prevent further falls. Record review of the nurses notes dated 12/04/11 showed the following information: -At 1:05 P.M., The resident's call light was on; -Staff entered the room and the resident was sitting in his/her wheelchair, the floor and bed were wet; -The resident could not tell the staff what happend; -The resident's spouse said the resident fell ; -The resident said he/she hit his/her head but did not remember what part of head he/she hit; -Then, the resident said he/she did not hit his/her head; -Staff notified physican and family and both decided not to send the resident to the hospital. -Staff notified physician and family and neurological checks were initiated. Record review of the significant change MDS assessment dated [DATE], showed the following information: -Cognition severely impaired; -Required extensive assistance by two staff for locomotion, dressing, toileting and bathing; -Required limited assistance by one staff for transfers, walking, and personal hygiene; -Locomotion: Ambulated with walker and wheelchair -Not steady, only able to stabilize with staff assistance while moving from a seated to standing position, moving on and off the toilet and transferring between the bed and chair or wheelchair; -Had a fall prior to admission. -Had two or more falls after admission with no injury. Record review of the nurses notes, dated 12/08/11, at 3:10 P.M., showed the following information: -The resident's PSA sounded; -Staff found the resident on the floor just inside the doorway to room and wheelchair tipped over; -Staff notified physician and family and neurological checks were initiated. Record review of a facility form entitled, "Report of Incident, Accident or Event", dated 12/8/11, showed the following information: -Fall occurred at 11:37 A.M.; -Description of event: staff heard the PSA sound, found resident on the floor of the room just inside the doorway. The resident attempted to get up without assistance and fell pulling the wheelchair over with him/her; -Staff notified the physician and received new orders to send the resident to the hospital if condition worsened; -Nursing interventions: staff did not document any interventions; -The report was signed by the DON on 1/10/12 (32 days after fall occurred). Record review of the nurses notes, dated 12/11/11, showed the following information: -At 11:45 P.M., certified nurse assistant (CNA) reported that when he/she transferred the resident from the bed to the wheelchair, the resident fell and hit back of head on the telelvision; -Staff notified physician and family and neurological checks were initiated. Record review of the care plan reviewed on 12/15/11, showed the following information: -Altered thought process due to dementia; -Cognition continues to decline; -Gait is unsteady; -Alert and oriented to self and family but disoriented to to surroundings and forgetful; -Shared a room with spouse who also has cognition problems and will turn his/her alarms off so spouse can get up; -Both lack insight to safety; -PSA and bed safety alarm (BSA) in place but he/she or spouse will remove it; -Has had several falls lately due to unsteady gait and not allowing staff to assist with transfers; -Needs limited to extensive assist for ADLs; -Staff failed to indicate problems, goals and approaches to address the resident having a fall which resulted in the subdural hematoma and subarachnoid hemorrhage; -Staff failed to indicate problems, goals and approaches to address the resident having a spinal fracture; -Staff failed to indicate problems, goals and approaches to address any new interventions regarding the residents multiple falls. Record review of the facility's fall risk evaluation dated 01/03/12, showed the following information: -The resident's cognition was impaired; -Mobility - had a balance problem while walking; -The resident had three or more falls in the past three months -Staff documented a score of 16 that indicated the resident was at high risk for falls. Record review of the nurses notes dated 01/13/12, showed the following information: -At 2:50 A.M., the resident was on knees facing the bed with hands on the bed. The resident said the floor was slick; -Staff assisted the resident back into bed and the resident warned his/her spouse to be careful, that floor was slick. -At 8:45 P.M., staff found the resident on the floor in the bathroom sitting on buttocks with knees flexed. -Staff documented; continue to monitor. Record review of a facility form entitled, "Report of Incident, Accident or Event", dated 1/13/12, showed the following information: -Fall occurred at 2:50 A.M.; -Description of event: staff found the resident facing the bed with both knees and hands on the bed. The resident had on socks. Staff did not document if the resident was wearing non-slip socks; -Staff did not document if the resident's safety alarm had been in place and sounding at the time of the fall; -The form did not have a section for staff to note nursing interventions. Record review of the nurses notes, dated 01/16/12, showed the following information: -Staff found the resident on the floor next to bed lying on his/her back; -Abrasion noted on left inner arm; -Staff notified family and DON; -Staff documented; continue to monitor. Record review of a facility form entitled, "Report of Incident, Accident or Event," dated 1/16/12, showed the following information: -Fall occurred at 9:00 P.M.; -Description of event: staff found the resident on the floor by the bed laying on his/her back; -Nursing interventions: Turned BSA on. The alarm had been switched to the off position since the aide put the resident to bed at 7:30 P.M. Record review of the nurses notes, dated 02/01/12, showed the following information: -The resident's BSA sounded; -Staff found the resident on the floor on buttocks with legs stretched out in front and a puddle of urine found on floor under resident. -Staff notified physician and family and neurological checks were initiated. Record review of a facility form entitled, "Report of Incident, Accident or Event", dated 2/1/12, showed the following information: -Fall occurred at 8:15 P.M.; -Description of event: staff responded to the BSA sounding. The resident was on the floor on his/her buttocks with legs outstretched in front of him/her and a puddle of urine under him/her; -Nursing interventions: staff did not document any interventions. Observations beginning on 02/06/12 at 3:30 P.M., showed the following information: -The resident had a PSA attached to the wheelchair and the back of his/her shirt and was turned to the on position; -The resident's spouse or staff propelled the resident to and from any activity or to the dining room for meals; -The resident had a BSA pad on the bed and was turned to the on position; (The bed was approxiamentely two-two and half feet in height). -The PSA and BSA were the only precautions in place due to the residents fall risk. During an interview on 02/08/12, at 10:15 A.M., CNA N said the resident has a regular bed and it cannot be lowered. The electric beds can be adjusted. The resident wears a PSA while in his/her wheelchair and a BSA while in bed for safety due to falls. Interview and observation beginning on 02/09/12, at 12:00 A.M., showed the following information: -At 12:07 A.M., the resident's alarm sounded and nurse aide (NA) M assisted the resident to the bathroom; -At 12:15 A.M., NA M said the resident's alarm was going off and staff have to get to him/her quick or he/she will slip and fall. The resident's alarm goes off at least five times during the NA's shift. The resident will get up if he/she needs to use the bathroom. There have been times that the resident has transferred self from the bed to the wheelchair before he/she could get there. The NA said the resident falls a lot and the only thing in place as a precaution was the PSA on his/her wheelchair and a BSA on the bed. -The NA gets report when coming on shift and looks in the care plan book to see how to care for each resident. During an interview on 02/09/12, at 12:42 A.M., CNA O said the following: -The staff get report verbally when coming on shift, and have a care plan book to look in for ADL cares, falls, behaviors, how a resident eats and toileting a resident. -Resident #8 was pleasantly confused and does not comprehend the alarms or why they are making the loud sound; -The staff have to explain to the resident that the alarms sounds and lets the staff know the resident needs help getting up; -The resident's alarm sounds three to six times during this shift; -The only interventions in place for the residents falls are the two alarms, the one on the wheelchair and the one on the bed. -The resident tries to stand on his/her own and transfers self from the bed to the wheelchair and then slips and falls; -The resident cannot stand by him/herself; -The resident is cognitive enough to know he/she needs to go to the bathroom but not cognitive enough to ask for help from staff. During an interview on 02/09/12, at 10:37 A.M., CNA P said staff get information regarding a resident's care during verbal report when coming on shift and from the care plan. Resident #8's alarm sounds at least five to six times during his/her shift. Staff have to listen for the alarm and get the resident to the bathroom. The CNA said the only precautions to prevent the resident's falls are the PSA and BSA. During an interview on 02/09/12, at 1:00 A.M., RN L said the following: -Resident #8 seems to be alert but then forgets; -Staff placed alarms on the resident's wheelchair and bed; -There was no special care, "Just make sure he/she doesn't fall". -The resident was up three to four times during the nightshift; -There have been so many falls; -He/she said staff had talked about the need for something else to be done to prevent the resident's falls "because one day something is going to happen". Observation and interview on 02/09/12, beginning at 9:02 A.M., showed the following information: -The resident sat in his/her wheelchair in room; -At 9:02 A.M., the resident stood up, the PSA sounded and the resident transfered to the bed before the staff arrived; -LPN I entered the room and said the resident's alarms sound three to four times on the day shift and sometimes as much as ten times. It is even worse on the evening shift. -The resident doesn't comprehend the alarms and the staff have to keep reminding him/her to use the call light; -It is the facility policy that an RN assess the resident after a fall; -Neurological checks begin for any unwitnessed falls; - LPN I said he/she has been working when the resident has fallen; -LPN I said one fall resulted in a brain bleed; -The PSA and BSA are the only precautions in place to prevent the resident from falling; -"Sometimes we get really busy and cannot get to the resident in time, he/she is really fast". During an interview on 02/09/12, at 12:45 P.M., the care plan coordinator (CPC) Q and CPC R said the following: -Staff complete MDS assessments as scheduled, then complete the care plan using the information gathered from the MDS; -Staff review the resident's medical record, interview residents, staff and family to gather additional information for the care plan; -RN S (rehabilitation nurse on the care plan; -They told staff the care plan was an ongoing process and if there were changes with the resident, staff should add those changes to the care plan; -Staff should document any injuries, falls, pain and/or behaviors on the resident's care plan; -Staff have a weekly fall meeting to discuss residents with falls and what interventions were in place; -Resident #8 currently had alarms in place. Staff had discussed other interventions but did not document it. During an interview on 02/09/12, at 1:45 P.M., RN S said the following: -He/she completes the fall section on the MDS; -Staff meet once weekly to discuss any resident care issues that include falls or injuries; -Falls are discussed in morning report to include any recent falls interventions in place and the need for new interventions; -He/she uses the fall sheet and will document on the care plan any updates, added falls and/or any new interventions; -Resident #8 has had mutilple falls and is alert to self with a bit of confusion; -The resident has an urgency to urinate and cannot remember to use the call light when he/she wants to get up; -The resident has a PSA and a BSA in place as an intervention for falls; -Staff discussed other interventions such as a low bed and mats on the floor but failed to document these discussions. During an interview on 02/09/12, beginning at 2:05 P.M., the Director of Nursing (DON) said the following: -The care plan team meets weekly and discuss how issues with residents were resolved or not resolved from the prior week and if there are other interventions that staff need to implement. -RN S was responsible for falls and addressing any resident who has had a fall; -If a resident has a fall staff should assess the resident, notify the physician, the family and administrative staff. Staff should fill out an event report and document in the nurse ' s notes. -If the fall was un-witnessed, staff should initiate neurological checks. -Staff should document any resident changes in the care plan; -She said staff has spent many hours discussing Resident #8 ' s falls and toileting. -Staff has discussed interventions like the low bed and mats on the floor but the safety of the resident ' s spouse was a concern; -Staff did not document any of these discussions; -The current interventions are the PSA and BSA. -Staff should document any interventions that they discussed and whether they tried the intervention; -The DON said if a resident was at risk for falls then it should be care planned but she would not expect staff to write every fall on the care plan. 2. Record review of Resident #12's quarterly MDS assessment dated [DATE], showed the following information: -Long and short-term memory problems;-Moderately impaired cognitive decision-making skills;-Extensive staff assistance for mobility, transfer, toileting and personal hygiene -Supervision and oversight for transfers and ambulation; -One fall with no injury;-One fall with injury (not major). Record review of the nurse's notes showed the following information: -On 12/17/11 at 11:30 A.M., the resident was standing beside a chair in the dining room when he/she tripped on the skirt under the Christmas tree. The resident landed on the floor sitting on his/her buttock. The resident denied pain, no bruising or deformity noted. Range of motion to all extremities. Assisted to chair for noon meal. Vital signs obtained. Physician and family notified; -Staff did not document on the resident between 12/17/11 at 11:30 A.M., to 12/18/11 at 1:25 A.M.;-On 12/18/11: -At 1:25 P.M., staff found the resident on the floor in another resident's room. No obvious injuries but resident complained of pain to left hip. Staff moved the resident to the bed via wheelchair. Tylenol given. The charge nurse did not document any further assessment in the notes regarding range of motion, any noted deformity or internal or external rotation of the extremity (signs of a fractured hip). The charge nurse did not document he/she examined the resident's head for injury or that staff started neurological checks (the fall was not witnessed by staff). The charge nurse did not document he/she notified the resident's physician at the time of the fall when the resident complained of left hip pain;-At 3:15 P.M., (next entry) the resident still complained of pain, refused to get up states, "I can't walk". The nurse called the physician who ordered x-rays and notified the Director of nursing (DON). The charge nurse did not document any further assessment in the notes regarding range of motion, any noted deformity or internal or external rotation of the extremity. The charge nurse did not document he/she examined the resident's head for injury or that staff started neurological checks; Record review of the facility form entitled "Report of Incident, Accident or Event" dated 12/18/11, showed RN A noted the following information: -Date of event 12/18/11 at 1:25 P.M.;-Description of event: aide standing in hall, heard noise, entered room and found resident on the floor;-[DIAGNOSES REDACTED]. Tylenol given;-Physician notified at 3:15 P.M., (almost two hours after fall occurred); -Responsible party notified at 3:45 P.M., (approximately two hours after the fall occurred). -Investigation: RN A noted the aide was standing in the hall, heard a noise, went into a room and found the resident on the floor. RN A had just entered the unit and went to assess the resident. The nurse found no obvious signs of injury (above noted the resident had pain with movement of left leg). Assisted the resident to the wheelchair, returned to his/her room. In bed to rest. Went back to check on the resident, the resident refused to get up, stated "I can't walk" . Staff called the physician, x-rays were ordered. Record review of the nurse's notes showed the following:-At 4:20 P.M., x-ray technician here. Will call results;-At 6:45 P.M., (approximately five hours after the fall occurred) staff called the resident's family at 3:45 P.M., (approximately two hours after the fall occurred). The resident's hip was fractured. The resident was sent to the emergency room . Record review of the hospital history and physical dated 12/19/11, showed the following information: -History of present illness: he/she was at the facility yesterday and fell at noon. Staff finally brought him/her in about 7:00 P.M., with the inability to walk. X-rays in the emergency room showed that he/she had a 100 percent displaced subcapital fracture (dislodged from its position and can disrupt the normal blood supply to the ball of the femur) of his/her left hip;-Physical examination: ~General: He/she was essentially non-responsive, he/she will look you in the eyes but will not respond verbally; ~Extremities: He/she had shortening and external rotation deformity;-Diagnostic studies: x-rays were reviewed and showed that he/she had 100 percent displaced subcapital fracture; -Plan: prosthesis (artificial hip replacement) of the left hip.During an interview on 2/9/12 at 12:07 A.M., the night shift charge nurse LPN B said the following: -When a resident had a fall, staff should assess the resident and check for any pain, changes in level of consciousness and check range of motion;-When completing range of motion, check for internal and external rotation. If the resident had any pain, staff should stop and call the physician;-LPN B said he/she would not move the resident, he/she would leave the resident on the floor until he/she called the physician. If he/she received orders to send the resident to the emergency room , he/she would leave the resident on the floor until the ambulance arrived;-He/she would then document the assessment in the notes and completed a fall incident report, contact the family and Director of nursing (DON) During an interview on 2/14/12 at 2:11 P.M., RN A said the following information: -When a resident had a fall, staff should complete an assessment of the resident checking range of motion for shortening and/or rotation of the leg and if the resident complained of pain;-Staff should try to move the resident to the bed to make them more comfortable and administer pain medications as ordered;-Staff should complete the fall incident report and make a note in the nurse's notes. Staff should document their assessment in the notes and on the report;-Staff should notify the physician and the resident's family of the fall;-When a resident had a fall, staff would continue to document on the resident every shift for several days; -Regarding Resident #12, RN A said he/she did check for shortening and rotation. When RN A palpated and moved the resident's leg, the resident complained of pain;-RN A said he/she was a new nurse. He/she did receive orientation and was trained on how to complete the fall incident report;-RN A said this was the first fall he/she had experienced. He/she knows his/her documentation was not that good and has gotten a better grasp on it now;-He/she should have noted his/her full assessment in the resident's record;-He/she should have called the physician sooner, he/she knows that now;-RN A said he/she would not leave the resident on the floo

Based on record review and interview the facility failed to assure staff did not make a significant medication error when a Registered Nurse (RN) failed to follow professional standards of practice to familiarize him/herself on dosage administration when giving a medication for the first time. The RN gave one hospice resident (Resident #1) who had a severe, compromising lung disease, 10 times the physician's orders [REDACTED]. Staff did not recognize the medication error for over four hours and nurses did not adequately monitor the resident during this time. The narcotic severely depressed the resident's respirations causing [MEDICAL CONDITION] (decreased oxygen to vital tissue) requiring an emergency medication (a narcotic antagonist) and transfer to the hospital emergency room . The resident did not fully recover and died within 24 hours. A sample of six hospice residents was reviewed out of a facility with a census of 88. 1. Record review of Resident #1's Interdisciplinary Progress Notes dated [DATE] at 11:35 A.M. showed: -The resident was readmitted to the facility from the hospital. -The admitting [DIAGNOSES REDACTED].) -The nurse documented the resident was alert and oriented to person, place and time. -Vital signs were: blood pressure (B/P) ,[DATE] (normal blood pressure for the healthy elderly is between ,[DATE] to ,[DATE]) temperature 98.2, pulse 72(normal: 60 - 100 beats per minute), respirations 22 (normal: 12 to 15 respirations per minute for a healthy elderly person), pulse oximetry 97% (a measure of how well the blood is [MEDICATION NAME]; normal: 90 - 100%) on 4 liters of oxygen. Record review of Social Services Note dated [DATE] showed the family requested hospice services. Record review of the Activity Notes, dated [DATE] showed: -The resident was admitted to hospice services with comfort measures. -During the activity person's visit the resident was alert, stated he/she was glad to be back home, and wanted the television on so he/she could watch his/her favorite show. Record review of the Hospice record, dated [DATE] at 1:55 P.M. showed: -The resident was able to sign his/her first name on his/her Hospice consent and benefit election form, Medicaid authorization form, and Do Not Resuscitate order. -Review of the comprehensive Hospice assessment showed the resident's condition was poor and rapidly declining. The family requested hospice so the resident could be as comfortable as possible. -The resident had [DIAGNOSES REDACTED]. enough blood to meet the body's needs), polymyalgia rheumatic (chronic disease that primarily causes inflammation in the large arteries in the muscles, causing pain and stiffness) and [MEDICAL CONDITION] ([MEDICAL CONDITION]- reduced blood flow in the vessels outside the heart and brain). -The family and resident verbalized knowledge and prognosis of the disease process although the resident had intermittent episodes of not following the conversation. -The resident did not express that he/she had any symptoms of pain at time of admission to the Hospice services. -The resident was alert to person, place and time, was occasionally incontinent of bowel and bladder. - Respiratory status showed the resident was on oxygen, heart sounds were regular, and the lungs sounds had coarse and rattling sounds. Record review of the Hospice assessment/care plan update, dated [DATE] (no time recorded) showed: -The resident is total assist, alert and oriented to person place, and time but was forgetful and had frequent confusion during the visit. He/she does have a [DIAGNOSES REDACTED]. -He/she denied pain at time of the assessment, but was very anxious. -The resident's lungs were congested. -He/she could get get up to the bathroom, and was occasionally incontinent. Record review of the facility's Medication Administration Policy (not dated) showed: -Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. -Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Record review of the physician order [REDACTED]. -On [DATE] at 2:30 P.M., orders from a physician per RNFNP (Registered Nurse Family Nurse Practitioner) C to give: -[MEDICATION NAME] ([MEDICATION NAME] - narcotic) 20 mg(milligram)/ml(milliliter) give 5 to 10 mg per mouth (PO) or SL (sublingual-under the tongue) every 1 hour as needed for pain or air hunger. Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -[MEDICATION NAME] 20 mg/ml; 5 mg by mouth every hour as needed for pain or air hunger, dated [DATE]. -[MEDICATION NAME] 20 mg/ml; 5 mg by mouth Sublingual every hour as needed for pain or air hunger, dated [DATE]. -[MEDICATION NAME] 20 mg/ml; 10 mg by mouth every hour as needed for pain or air hunger, dated [DATE] -[MEDICATION NAME] 20 mg/ml; 10 mg per mouth Sublingual every hour as needed for pain or air hunger, dated [DATE]. Record review of the Nurse Narrative, dated [DATE] showed: -At 1:30 P.M., RN A documented the resident's respirations were even, and he/she was alert and oriented to person, place and time. -At 2:55 P.M., RN A documented the resident was resting in his/her bed with no complaints of pain, breathing was difficult, with rales (abnormal respiratory sound) and wheezing in the lungs with an occasional nonproductive cough. His/her heart rate was strong and irregular. The resident had attempted to climb out of bed multiple times. The nurse documented he/she would continue to monitor the resident. -At 4:35 P.M., the resident requested pain medication because his/her back hurt. The resident reported that on a scale of 1 to 10 (1 being the least pain to 10 being severe pain) his/her pain level was an 8 to 10. -At 5:15 P.M., staff administered [MEDICATION NAME] (no amount or dosage noted). -6:00 P.M. (45 minutes after the medication was given) the record showed the resident was trying to climb out of bed. (According to Nursing 2010 Drug Handbook, adverse reactions can be agitation and restlessness as well as circulatory and respiratory depression.) -6:30 P.M. documentation showed the resident was in bed with his/her eyes closed and no signs or symptoms of distress were noted. Record review of the MAR indicated [REDACTED] -On [DATE] at 5:15 P.M., RN A documented that he/she gave the resident [MEDICATION NAME] 20 mg/ml; 5 mg by mouth. (This was the first dose staff administered to the resident.) -The RN documented on the reverse side of the MAR, he/she gave the [MEDICATION NAME] because of pain. -At 6:30 P.M., the RN documented the resident had no complaints of pain and was resting. During an interview [DATE] at 1:10 P.M., RN A said [DATE] was the first day that he/she had worked with Resident #1. The resident was oriented to self and knew that he/she was in a nursing home. The resident was having labored breathing and had been put on Hospice. An aide came and told RN A and RN B that Resident #1 was in pain. RN A and RN B pulled the [MEDICATION NAME] from the emergency kit. RN A said that he/she looked at the order and thought it said 5 ml. (The order was for 5 mg. The concentration was 20 mg/ml; 5 ml = 100 mg or 20 times the dose.) RN A poured 5 ml (100 mg [MEDICATION NAME]) from the medicine cup into the resident's mouth at 5:15 P.M. At 6:00 P.M. an aide came and told him/her that resident was trying to climb out of bed. RN A went to the resident's room and asked what was wrong and the resident said "I want to go home; get out of my way." RN A and the aide assisted the resident back into bed. RN A did not know if this was usual behavior for this resident. RN stated, he/she "did not take any vitals, the aides take vitals at the beginning of the shift and the RN or LPN charts them." RN A did not know he/she had made a medication error. RN A went back to see the resident at 6:30 P.M. and the resident was lying in bed with his/her eyes closed. The resident's breathing was normal and the resident was not struggling to breathe. Record review of the Nurse Narrative, dated [DATE] showed: -At 9:30 P.M. (4 hours and 15 minutes after receiving the [MEDICATION NAME]) the resident was in bed, eyes closed, with shallow breathing. The nurse did not document any other assessment or vital signs. During an interview [DATE] at 1:10 P.M., RN A said he/she peeked in on the resident at 9:30 P.M.. The aides said, "Shhh, the resident is finally asleep". The resident's breathing was non-labored and shallow. RN A said he/she should have gotten a set of vitals but didn't. The RN said that he/she still did not know that he/she had made a mistake. -RN A said he/she started giving report to the next shift at 10:45 P.M.. Resident #1 was the last resident that he/she gave report on and it was a good ,[DATE] minutes before giving report on Resident #1. RN A told RN G (the on-coming nurse) that he/she gave Resident #1, 5 ml of [MEDICATION NAME] at 5:15 P.M. and the resident had been resting. RN B said, "Tell me you gave 5 mg" and RN A said, "No, I gave 5 ml; I put it in a medicine cup and gave 5 ml to the resident". One of the other RNs said, "Let's hope the resident is still breathing." RN A and RN G went to the resident's room and took his/her vitals. The resident's heart rate was 71 and respirations were one per minute. RN A asked, "Shouldn't we get an order for [REDACTED]. The other two nurses said we needed to do something. RN A called the physician on call and told him/her about the medication error. The physician gave the order for the [MEDICATION NAME]. The physician said to give five doses to the resident every three to four minutes. Record review of the Nurse Narrative for [DATE] at 11:00 P.M. showed nursing staff called the physician on call for orders. Orders were obtained to give [MEDICATION NAME]. Record review of the physician's orders [REDACTED]. -an order for [REDACTED]. -If the resident continues to be unresponsive send to the emergency room . (Documentation at 10:45 P.M., showed one respirations per minute and the resident was unresponsive.) Record review of the October [DATE] for [DATE] showed staff wrote the following on the reverse side of the MAR: -At 11:05 P.M. [MEDICATION NAME] IM, resident unresponsive, respiration 1, heart rate 70, no results; -At 11:10 P.M., [MEDICATION NAME] IM, unresponsive, respiration 1, heart rate 60, no results; -At 11:15 P.M. [MEDICATION NAME] IM unresponsive, respirations 2, heart rate 48, no results; -At 11:19 P.M., [MEDICATION NAME] IM, unresponsive, respirations 2, heart rate 31, no results; -At 11:23 P.M., unresponsive, respirations 5 heart rate 51, no results. Record review of the Nurse Narrative for [DATE] showed: -Staff administered 5 injections of [MEDICATION NAME] from 11:05 PM. to 11:23 P.M. After three injections, the nurse called the ambulance, and reported to the local emergency room . The nurse administered two more injections of [MEDICATION NAME], before the ambulance arrived. At 11:30 P.M. the resident was transferred to the emergency room . During an interview [DATE] at 1:10 P.M., Registered Nurse (RN) A stated RN A said RN G gave the last dose as the ambulance arrived. The resident was still alive when the ambulance left Record review of the hospital emergency room report, dated [DATE] at 12:48 P.M. showed the resident arrived unresponsive, pupils were constricted (abnormal closing or reduction in the size of the pupil), skin was cool and dry and cyanotic (bluish discoloration of the skin caused by lack of oxygenation), respirations were 6 to 8 per minute and shallow. The physician was at the bedside. At 1:00 A.M., the hospital documented they were waiting for the resident to be transferred back to the nursing home per family request. Record review of the Nurse Narrative for [DATE] showed: -The resident returned from the emergency room , per ambulance at 1:25 A.M. -At 3:15 A.M. the resident's respirations were shallow and 32 per minute. The lung sounds were coarse. -Staff documented at 6:15 A.M., the resident was resting comfortably continues to be unresponsive to stimuli, respirations shallow and 14 per minute, apical heart rate 72. Addendum (staff did not date or time when addendum was made), resident opens eyes when name called. -At 5:35 P.M., staff was called to resident's room. Resident was unresponsive, no respirations, no apical (pulse rate closest to the heart) or carotid (pulse rate that can be felt at the front of the neck) pulses, family at bedside. -Staff documented-Hospice notified of the resident's death at 5:40 P.M. and stated they would notify the physician and funeral home. During an interview [DATE] at 2:30 P.M., LPN D stated when he/she gives a narcotic he/she checks on the resident within the hour to see if pain/symptoms were relieved. If pain persists, he/she follows up with more medications or other treatment. If this is a medication the resident has never taken, he/she would check the resident every 15 minutes. He/she would not rely on an aide as they do not have the training to assess the resident properly. If he/she gave the medication, especially if it was a narcotic/pain medication, it would be his/her responsibility to monitor and assess. The LPN stated that he/she was taught in Nursing School that you always verify with another nurse when administering insulin or narcotic medications. During an interview on [DATE] at 3:20 P.M., LPN E stated; -"I would assess the resident for change of behavior, grimacing, thrashing around, vital sign changes and if the resident told me they were in pain." - The LPN would check the physician's orders [REDACTED]. If he/she did not have any medication, the LPN would call the physician or nurse practitioner for an order to relieve the resident's pain. If the resident had never received the pain medication, he/she would check the resident in thirty minutes. "I would assess them myself to assure the resident did not have an allergic reaction and if the pain was relieved. I would not rely on the aides to assess the resident." During an interview [DATE] at 1:10 P.M., RN A stated he/she had never administered the narcotic [MEDICATION NAME](generic-[MEDICATION NAME]). RN A graduated from nursing school in [DATE] and had been employed at the local emergency room for approximately five months. RN A had given 5 ml (milliliters-measure of volume) of [MEDICATION NAME] through IV (intravenous) in the emergency room . He/she would have monitored a patient every 30 minutes to check vitals and check that respirations stayed within normal limits. RN A said it was the first day that he/she had worked with Resident #1. RN A stated that RN B and the Registered Nurse Family Nurse Practitioner (RNFNP) told him/her that the resident had only 72 hours to live due to his/her [MEDICAL CONDITION] diagnosis. RN B was RN A's preceptor (someone who trains another). RN A was outside on break with RN B on [DATE] when an aide came and told them that Resident #1 was in pain. RN B called the pharmacy to get permission to pull out [MEDICATION NAME] from the emergency kit (he/she stated that there was a facility rule that pharmacy had to give permission to pull medications from the emergency kit). RN B was talking on the phone with the physician and the physician insisted that the medication be pulled even without pharmacy permission. He/she did not want his/her patient in any pain. RN A and RN B pulled the emergency kit and then RN pulled the [MEDICATION NAME] medication out. RN B went to fax the pharmacy. RN A said that he/she looked at the order and he/she could "swear" it said 5 ml (not 5 mg) of [MEDICATION NAME]([MEDICATION NAME]). RN A opened the box of [MEDICATION NAME] and did not notice the dropper in the box ([MEDICATION NAME] is dispensed by a dropper to control the dose.) RN A got a medicine cup and glanced at the order again; and still thought it said 5 ml. RN A stated that SL means sub-lingual; under the tongue. The RN said he/she poured 5 ml from the medicine cup into the resident's mouth. The resident took two sips; RN A gave three teaspoons of apple juice to the resident. RN A showed surveyor on a medicine cup how much [MEDICATION NAME] he/she put in the cup not using dropper or syringe to measure. RN A showed where he/she filled the medicine cup to the 5 ml line. RN A, again, stated "I swear it said 5 ml" (on the MAR). RN A went back to see the resident at 6:30 P.M. and the resident was lying in bed with his/her eyes closed; the resident's breathing was normal and the resident was not struggling to breathe. If the resident had not previously tried to climb out of bed the RN stated he/she would not have checked on the resident until 7:00 P.M.; the aides check on the residents. RN A called Hospice and told them what happened (after the medication error was discovered) and called the emergency room and gave them a report on the resident. He/she called the Administrator of the facility and gave report. The RN said "I feel like I killed Resident #1." The RN was in the medication room when she poured the medicine cup; no one watched him/her. When he/she first started working there he/she went to another nurse to have an insulin checked and that nurse told him/her that "we don't do that here." Since this incident it has been changed to all strong medications and insulin will be checked before given by a second nurse. During an interview [DATE] at 5:30 P.M. RN B stated as a preceptor he/she does not watch the nurse in orientation give medications after the first day. RN A had been on orientation for two weeks. RN B would expect a licensed RN to know how to administer medications. The resident's dose of [MEDICATION NAME] was 5 mg to 10 mg. RN B told RN A to give the smaller dose of [MEDICATION NAME] to the Resident and RN A never asked for any further instructions on giving the medication. RN B said that as a preceptor, he/she helps the new RN with facility paperwork; shows how to do new admits; paperwork for physician orders; where the policy book is located; acquaints RN's with residents; shows treatments for residents and goes over treatment book with the new RN; where the Oxygen Storage room is located; where refrigerated medications are stored; how to check medication out of the emergency kit and shows him/her where the narcotic medications are located. During an interview on [DATE] at 4:30 P.M. the director of nursing (DON) stated that the company puts nurses on the floor in a two to three week program to follow a preceptor in learning paperwork; how medications are ordered; and policies on different medications. The DON expected a graduate nurse to know how to do an assessment and day-to-day documentation. Communications is taught by the preceptor on how to get in touch with the physicians and on-call physicians. The preceptor orientation program also includes acclimating him/her to the nurses station, policy and procedure manual, all paperwork procedures; Medicare A and Medicare B policies; phone numbers, paperwork and all communications within the facility dealing with laboratory and pharmacy, x-ray, etc. The preceptor's duties for orientation of new nurses includes communications within the facility, understanding how the facility is run; knowledge of resident names, likes and dislikes, comfort calls for short-stay residents; and admission, transfer and discharge paperwork. The DON expected the RN to already know the difference between ml and mg. The DON expected the RN to know that [MEDICATION NAME] is given sub-lingual; would expect the RN to follow the instructions of the dosage form on the box and that the RN would not put the medication in a medicine cup and have the resident drink the [MEDICATION NAME]. The DON asked RN A why he/she gave 5 ml when there was a 1 ml dropper in the container. RN A was very distraught and stated that he/she did not know why he/she did that. The DON expected anyone who saw a 1 ml dropper in a box with a medication that they would take a second look before giving 5 ml to a resident. That is filling the dropper 5 times. The DON said, "This is an error that should not have occurred. I would have expected closer monitoring of a resident who is being given a new medication or being given [MEDICATION NAME]." The DON would have been concerned about a resident climbing out of bed an hour after being given [MEDICATION NAME]. RN A should not have had to have a preceptor watching over him/her giving medications; he/she should have had the knowledge as a Registered Nurse; besides having worked in the emergency room for the past several months and administering medications there. The DON stated the resident came back to the facility with a different level of awareness and could not say it was due to the medication error or the disease process. During an interview by phone on [DATE] at 2:40 P.M. with the facility medical director stated: -He/she felt the the resident had received way too much [MEDICATION NAME]. -If the [MEDICATION NAME] was swallowed, the absorption rate would be slower, than if it was given sublingual. The medication would make the resident breath less effectively. If the resident had been left at the nursing home without further treatment at the hospital the resident would have died . -He/she felt the [MEDICATION NAME] "severely effected him/her", and the appropriate thing to do was to give the [MEDICATION NAME]. -He/she had read the laboratory reports from the hospital and they showed the resident was hypoxic. During an interview on [DATE] at 12:35 P.M. the facility medical director stated that an RN should be expected to know how to administer medications. He/she thought the RN would have reassessed sooner for pain symptoms after giving [MEDICATION NAME]. He/she felt there should be a protocol for following up on narcotic medications but was reluctant to give a time frame as to how often a resident should be reassessed in a nursing facility. He/she said the family's decision to "not resuscitate" in the emergency room may have led the resident to an early death or the medication error could have led to his/her death--we will never know."