Every finding on record at James River Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure food was protected from potential contamination when staff failed to ensure the air gap for the ice machine had the required two-inch gap between the drain in the floor and the tubing from the ice machine. The facility census was 100.1. Review of the 2013 Missouri Food Code showed an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch.Review showed the facility did not provide a policy related to the air gap.Observations on 06/16/26, at 10:13 A.M., and 06/17/26, at 9:30 A.M., showed an ice machine located in a room just outside the kitchen. Two hoses (a white and a black hose) hung down out of the bottom of the ice machine and went down into the tile floor next to the drain area. The hoses did not have the required two-inch air gap. (If the drain were to back-up the dirty water or waste could flow back into the tubing and cause the ice (a food substance) in the ice machine to become contaminated.)During an interview on 06/17/26, at 9:35 A.M. Dietary [NAME] C said he/she did not know about the required ice machine gap.During interviews on 06/17/26, at 9:36 A.M. and 2:05 P.M., the Dietary Manager said the following: -She did not know of the requirements for the air gap;-Maintenance staff were responsible for monitoring the air gap;-The drain tube from the ice machine was incorrect and placed down in the drain hole. During an interview on 06/17/26, at 9:40 A.M., the Registered Dietician (RD) said she noticed yesterday (06/16/26) of the hoses. She did not see an air gap. There should be a two-inch air gap to keep dirty water from going back into the ice machine. During an interview on 06/17/26, at 2:52 P.M., the Maintenance Supervisor said he was responsible for monitoring the air gap of the ice machine. The ice machine should have a gap about an inch and should not be down in the hole in the floor. He poured stuff in it for the gunk on a regular basis. He did that last week and maybe he did not put the hoses back into the correct place. During an interview on 06/01/26, at 1:40 P.M., the Administrator said there should be an air gap between the drain on the ice machine and the drain in the floor.

Based on observation, interview, and record review, the facility failed to establish an ongoing system of medication storage and record keeping that ensured all controlled drugs were consistently accounted for when staff failed to store medications waiting destruction behind two locks at all times, when staff failed to routinely count medications awaiting destruction, and when staff failed to destroy medications in a timely manner. The facility's census was 100.Review of the facility policy, Storage of Medication, dated [DATE] showed the following:-The facility shall store all drugs and biologicals in a safe, secure, and orderly manner;-Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers;-The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner;-The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be destroyed;-Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals 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;-Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents;-Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys. Review of the facility policy, Controlled Substances, dated [DATE] showed the following:-The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances;-Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule [NAME] controlled drugs maintained on premises;-The Director of Nursing Services will identify staff members who are authorized to handle controlled substances;-Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record;-If the count is correct, a individual resident controlled substance record must be made for each resident who will be receiving a controlled substance. Do not enter more than one prescription per page. This record must contain name of the resident; name and strength of the medication; quantity received; number on hand; name of physician; prescription number; name of issuing pharmacy; date and time received; time of administration; method of administration; signature of person receiving medication; andsignature of nurse administering medication;-Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents;-All keys to controlled substance containers shall be on a single key ring that is different from any other keys;-The charge nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers;-Unless otherwise instructed by the Director of Nursing Services, when a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given), the medication shall be destroyed and may not be returned to the container;-Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. Review of the facility policy, Discarding and Destroying Medications, dated [DATE], showed the following:-Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances;-All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of;-In Missouri, a licensed nurse and the consulting pharmacist will count, log and destroy schedule II, III and IV;-Destruction of a controlled substance must render it non-retrievable, meaning that the process permanently alters the physical or chemical properties of the substance so that it is no longer available or usable, and cannot be illegally diverted;-Any controlled substance that is considered hazardous waste will be managed in accordance with federal, state and local hazardous waste regulations, as well as the Controlled Substance Act and DEA regulations;-The medication disposition record will contain the following information the resident's name; date medication disposed; the name and strength of the medication; the name of the dispensing pharmacy; the quantity disposed; method of disposition; reason for disposition; and signature of witnesses.-Completed medication disposition records shall be kept on file in the facility for at least two years, or as mandated by state law governing the retention and storage of such records.-Staff shall contact the provider pharmacy if they are unsure of proper disposal methods for a medication. 1. Observation on [DATE], at 2:56 P.M., showed a nurse walked into the activity office, obtained a set of keys from that staff member, and proceed to unlock the DON's office. The nurse placed something in the DON's office and then left the office and returned the key to the nearby activity office staff member. Observation and review on [DATE], at 3:05 P.M., in the red filing cabinet in the Director of Nursing's (DON) office showed the following:-The cabinet was locked with a standard lock on the filing drawer;-One medication card containing one hundred-eight tablets of hydrocodone acetaminophen 10 milligram (mg)/325mg (a controlled pain medication). Staff documented the last count on [DATE], surrender of the medication on [DATE], and destruction on [DATE];-One medication card containing five patches of Fentanyl 37.5 micrograms (mcg) (a medication used for pain). Staff documented the last count on [DATE] and surrender of the medication on [DATE]. (The medication had not been destroyed.);-One medication card containing twenty-eight tablets of lorazepam 1 mg (a medication used for anxiety). Staff documented the last count on [DATE] and surrender of the medication on [DATE]. (The medication had not been destroyed.);-One medication liquid bottle containing 29.75 milliliters (ml) of morphine sulfate 20 mg/ml (a medication used for pain). Staff documented the last count [DATE] and surrender of the medication until [DATE]. (The medication had not been destroyed.);-One medication card containing fifty-six tablets of Norco 5mg/325 mg (a medication used for pain). Staff document the last count date as [DATE] and surrender date of [DATE]. (The medication had not been destroyed.);-One medication card containing ninety-six tablets of hydrocodone-APAP 10 mg/325 mg. Staff documented the last count and surrender of the medication on [DATE]. (The medication had not been destroyed.);- One medication card containing twenty-nine tables of morphine sulfate 30 mg ER (a medication used for pain, extended release). Staff document the last count on [DATE] and surrender of the medication on [DATE]. (The medication had not been destroyed.);-One medication card containing forty-five tablets of Ultram 50 mg (a controlled pain medication). Staff document the last count on [DATE] and surrender on [DATE]. (The medication had not been destroyed.);-One medication card containing twelve tablets of oxycodone/ APAP 5mg/325 mg (a medication used for pain). Staff document the last count on [DATE] and surrender on [DATE]. (The medication had not been destroyed.);- One medication liquid bottle containing 15.5 ml of morphine sulfate 20 mg/ml. Staff document the last count completed on [DATE] and surrender on [DATE]. (The medication had not been destroyed.);-Two medication liquid bottles containing a total of 52.5 ml of lorazepam 2 mg/ml.Staff documented the last count on [DATE] and surrender on [DATE]. (The medication had not been destroyed.);-One medication card containing six tablets of lorazepam 0.5 mg. Staff documented the last count on [DATE] and did not document a surrender date. (The medication had not been destroyed.);-One medication card containing eighty-nine hydrocodone-APAP 5 mg/325 mg. Staff documented the last count on [DATE] and the surrender date of [DATE]. (The medication had not been destroyed.) During an interview on [DATE], at 1:27 P.M. Licensed Practical Nurse (LPN) I said the following:-Narcotics were counted at the beginning and end of each shift;-Discontinued narcotics were kept in the DON's office;-A nurse or medication tech signs out the medication in the regular supply and the DON takes the medication and destroys with the facility pharmacy staff;-He/she was unsure of any list that is kept of destroyed narcotic medications. During an interview on [DATE], at 2:09 P.M., Certified Medication Tech (CMT) D said the following:-Narcotic's that have expired or are discontinued are kept in the double locked cabinets in the general medication room until two nursing staff can sign out of general supply;-The DON takes the discontinued or expired narcotics and destroys them;-He/she was unsure of where they were kept once the DON has possession. During an interview on [DATE], at 2:22 P.M. and 3:01 P.M., the DON said the following:-For destruction of narcotics, the expired or discontinued medications were held in her office;-The medication was placed in a red locked filing cabinet that only she had the keys to;-The DON and Assistant Director of Nursing (ADON) were the only staff that had keys to her office;-The DON did not do any other counts on the medication until their destruction:-Monthly or when the draw was full, the pharmacy would be contacted and they come on-site to destroy the medications;-A copy of the page of counts were compared with the last entry of the original count sheet on the medication card;-For liquids, they were verified with the pharmacy staff to ensure the amount matches;-All dates and amounts were verified with the last written amounts on the date of the surrender of the medication from general supply;-The medication was only destroyed with pharmacy staff present;-The pharmacy staff placed a stamp on the back of the page of the original count sheet with the destruction date;-The DON then discarded the copy of the copied count sheet;-She was not aware of any other staff members that had access to her office before today;-All narcotics should be held in a double locked cabinet and since she was the only person with the key to the cabinet, she did not count them again until destruction with the pharmacy. During an interview on [DATE] at 3:39 P.M. the Administrator said the following:-Narcotics were expected to be stored under two locks;-Narcotics should be counted and destroyed monthly;-Identified several staff that had access to the DON's office and will be implementing a new key system so that each office door has their own key and they can track better safe storage of medication.

Based on observation, interview and record review the facility failed to implement a complete infection control program when staff failed to follow Enhanced Barrier Precaution (EBP) for two residents (Resident #65 and #78) who had wounds and were care planned for EBP and when staff failed to complete proper hand hygiene while providing care for two residents (Resident #2 and #31). The facility census was 100. 1. Review of Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs (multi-drug resistant organisms - infections that are highly difficult to treat and can be dangerous), dated 04/02/24, showed the following: -MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs; -EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities; -EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO; -Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of central line (a long, flexible tube inserted into a large vein in the chest, neck, or arm, with the tip ending close to the heart), urinary catheter (a thin, flexible, indwelling urinary tube inserted through the urethra into the bladder to drain urine continuously), feeding tube (a medical device used to deliver liquid food, fluids, and medications directly to the stomach or small intestine), tracheostomy (a surgical procedure that creates an opening, called a stoma, through the neck directly into the windpipe (trachea) /ventilator (a medical machine that helps a patient breathe or fully breathes for them)and wound care of any skin opening requiring a dressing. Review of the facility policy titled Enhanced Barrier Precautions, dated August 2022, showed the following: -EBPs are used as an infection prevention and control intervention to reduce the spread of MDROs to residents; -EBPs employ 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). -PPE is changed before caring for another resident; -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use of central line, urinary catheter, feeding tube, and tracheostomy; and wound care of any skin opening requiring a dressing, but this does not include protective coverings such as transparent covering, band aids or steri-strips (thin, adhesive surgical tapes used to hold the edges of a minor cut or surgical incision together) used to keep skin flaps in place; -EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization; -EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk; -Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required; -PPE is available close to or inside of the resident rooms. 2. Review of Resident #65's face sheet showed the following: -admission date of 11/10/20; -Diagnoses included stage 3 pressure ulcer of right buttock (skin injury featuring full-thickness skin loss where the underlying fat is visible) and stage 3 pressure ulcer of left buttock. Review of the resident's quarterly Minimum Data Set (MDS – a federally mandated assessment completed by facility staff), dated 04/29/26, showed the following: -Severe cognitive impairment; -Dependent for toileting hygiene, showering, dressing, personal hygiene, oral hygiene, eating; -Two stage 3 pressure ulcers. Review of the resident's care plan, revised 04/29/26, showed the following: -Resident had stage 3 pressure wounds to bilateral buttocks and right gluteal fold; -Staff should use EBP; -Staff should administer wound healing medications as ordered. Review of the resident's physician order sheet, current as of 06/18/26, showed an order, dated 04/20/26, for EBP related to wound. Gown and gloves to be worn with high contact resident care every shift. Observation on 06/16/26, at 9:40 A.M., showed the following: -Licensed Practical Nurse (LPN) H and Certified Nurse Aide (CNA) G entered the resident's room with wound care supplies; -An EBP sign was at resident's door; -No PPE supplies were located near resident room or behind resident door; -Staff washed hands at sink and put on gloves. Staff did not apply gowns; -Staff assisted resident to roll to right side; -LPN H said the wound dressing had been removed during the resident's shower; -LPN H cleaned the wound with gauze and wound cleanser; -He/she sprayed skin prep on the surrounding skin; -LPN H removed gloves, wash his/her hands at sink, and applied new gloves. The LPN did not don a gown; -LPN H applied Santyl (prescription ointment for wound treatment), calcium alginate (used for managing moderate to heavily draining wounds), and wound dressing; -Staff repositioned resident and removed gloves and washed hands at sink. During an interview on 06/16/26, at 10:00 AM, LPN H said he/she missed a step during wound care for the resident. He/she did not put on a gown and staff were to wear gowns when working with the resident due to the stage 3 wounds. 3. Review of Resident #78's face sheet showed the following: -admission date of 11/27/15; -Diagnoses included stage 2 pressure ulcer (partial-thickness skin loss involving damage to the epidermis (outer layer) and dermis (middle layer)) of sacral region (area at the base of lower back, right above the tailbone and between the hip bones). Review of the resident's MDS, dated [DATE], showed the following: -Cognitively intact; -Use of wheelchair; -Dependent on staff for eating, oral hygiene, toileting hygiene, showering, dressing, personal hygiene, mobility; -Resident at risk for developing pressure ulcers. Review of the resident's physician order sheet, current as of 06/18/26, showed an order, dated 04/20/26, for EBP related to wound. Gown and gloves to be work with high-contact resident care every shift. Review of the resident's care plan, revised 04/20/26, showed the following: -Resident had a stage 2 pressure ulcer on sacrum; -Staff should use EBP. Observation on 06/17/26, at 11:30 A.M., showed the following: -CNA G and CNA S entered the resident's room with the Hoyer lift (mechanical lift); -The CNAs applied gloves and did not put on gowns; -CNA G and CNA S assisted the resident with peri-care, applied a brief on the resident, and assisted with changing the resident's clothes. During an interview on 06/17/26, at 1:50 P.M., CNA G said the resident had wounds, but they were not the kind that required EBP use, just gloves as far as he/she was aware. 4. During an interview on 06/16/26, at 10:00 AM, LPN H said the following: -Staff should wear PPE when caring for residents with wounds, IV's, catheters, any tubes, to protect the resident from infections; -The gowns should be on the back side of the resident doors. During an interview on 06/17/26, at 10:20 A.M., CNA M said the following: -Staff should follow EBP protocol for residents with wounds, ostomies, and catheters; -There were signs on the residents' doors and there was PPE supplies behind the door. During an interview on 06/17/26, at 1:40 P.M., CNA P said the following: -EBP required gown and gloves with residents with wounds and catheters; -The staff should use PPE any time they were involved with dressing, changing, cleaning the resident near the site involved; -The staff were not required to wear gown when transferring from bed to wheelchair. During an interview on 06/17/26, at 1:50 P.M., CNA G said the following: -There would be an EBP sign on doors of residents that require extra precautions; -Staff should have on a gown and gloves when changing or cleaning a resident on EBP. During an interview on 06/18/26, at 2:20 P.M., the Assistant Director of Nursing (ADON) said the following: -Staff should follow EBP policy for any resident with catheter, peripherally inserted central catheter (PICC - long, thin, flexible tube (a type of central line) inserted into a vein in the upper arm and threaded through larger blood vessels until the tip rests just above the heart) line, IV, and any tube that enters and exits the body; -EBP included mask if needed, gloves, and gown. During an interview on 06/18/26, at 3:50 P.M., the Director of Nursing (DON) said the following: -Staff received education related to EBP on hire and at quarterly in-services; -EBP should be followed for any resident that had a hole that God did not put there, that included any type of tubes, catheters, or wounds; -PPE should be used any time staff had high contact with patient care, including wound care, toileting hygiene, administering fluids per IV or feeding tubes, dressing and transferring residents in their room. During an interview on 06/18/26, at 3:55 P.M., the Administrator said the following: -Staff were to follow the infection control policy; -This included use of PPE during resident contact that required EBP protocol. 5. Review of facility's Hand Hygiene Policy, dated August 2015, showed the following: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Use an alcohol-based hand rub or soap and water after removing gloves; -The use of gloves does not replace hand washing; -Hand rub should be used after contact with objects in the immediate vicinity of the resident; -Single use disposable gloves should be used when in contact with blood or bodily fluids. Review of the facility policy titled, Handwashing and Hand Hygiene, dated August 2015, showed the following: -This facility considers hand hygiene the primary means to prevent the spread of infections; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; -Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; -Alcohol-based hand rub containing at least 62% alcohol or soap and water can be used before and after direct contact with residents; before and after handling an invasive device, including urinary catheters, intravenous (IV – inside a vein) access sites; before applying sterile gloves; before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after contact with blood or bodily fluids; and after removing gloves; -Hand hygiene is the final step after removing and disposing of personal protective. -The use of gloves does not replace hand washing/hand hygiene; -Glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections; -Perform hand hygiene before applying non-sterile gloves. 6. Review of Resident #2's face sheet showed the following: -admission date of 04/20/18; -Diagnoses included colostomy status (indicates that an individual has a surgically created opening in the abdomen that diverts a portion of the large intestine (the colon) to the outside of the body.). Review of the resident's Physician Order Sheet (POS), current as of 06/18/26, an order, dated 03/15/24, to empty colostomy every shift for colostomy management. Review of the resident's care plan, revised 04/27/26, showed resident had alteration in gastrointestinal status related to colostomy. Review of resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Use of ostomy; -Always incontinent; -Dependent for toileting hygiene, dressing; -Substantial to maximal assistance for personal hygiene, showering. Observation on 06/16/26, at 7:30 A.M., the following showed: -CNA R and LPN I entered the resident's room and applied gown and gloves; -CNA R prepared for emptying of colostomy; -Placed plastic container with bag inside; -Opened ostomy pouch and drained into the container; -Cleaned the ostomy seal with wet wipes; -Closed the seal; -CNA R removed gloves and applied new gloves without performing hand hygiene; -LPN I removed gloves, used hand sanitizer, and put on new gloves; -CNA R opened resident incontinent brief and wiped front private area with wet wipe; -Without changing gloves, CNA R pulled the resident's draw sheet and assisted resident to roll to left side; -CAN R Tucked the sheet under and placed a new sheet and brief under the resident with same gloved hands; -CNA R wiped the resident's buttock with wet wipe and applied barrier cream to the inner thighs; -Without changing gloves or performing hand hygiene, staff assisted resident to roll to back side and closed brief; -LPN I removed gloves and gown and washed hands at sink; -CNA R left room with soiled linen and trash and did not complete hand hygiene. 7. Review of Resident #31's face sheet showed the following: -admission date of 04/30/26; -Diagnoses included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), cellulitis (common, potentially serious bacterial infection of the skin and the deep underlying tissues) of left lower limb, and irritant contact dermatitis (itchy, non-contagious skin inflammation triggered by direct contact with a specific substance) due to friction or contact with other body fluids. Review of the resident's care plan, revised 05/04/26, showed the following: -Resident had an activities of daily living (ADL) self-care performance deficit due to weakness with cognitive impairment; -Dependent for mobility in a wheelchair; -Dependent on staff for positioning and turning in bed; -Dependent on assistance with toileting cares; -Resident had bladder and bowel incontinence related to immobility; -Resident used bariatric disposable briefs, change as required; -Staff should check as required for incontinence; -Wash, rinse and dry perineum (small area of skin and underlying tissues located between the genitals and anus). Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Always incontinent of bladder and bowel; -Dependent for toileting hygiene, mobility, transfers. Observation on 06/14/26, at 2:50 P.M., showed the following: -CNA Q and CNA M entered the resident's room; -Staff applied gloves to start incontinent care; -Staff opened the resident's brief and assisted resident to roll to left side; -CNA Q wiped resident's buttock with wet wipes to clean large bowel movement (BM) and tucked soiled sheet and brief under resident's side; -The CNA placed a clean sheet and brief and tucked under resident's side; -The CNA removed gloves and applied clean gloves without performing hand hygiene; -Staff assisted the resident to roll to the right side; -CNA M removed soiled sheets and removed gloves, left room to get new draw sheet due to BM soiled when turned resident; -CNA M entered room and applied clean gloves without performing hand hygiene; -The CNA tucked the clean draw sheet under the resident; -Staff rolled the resident back to the left side to pull the clean sheet through; -Staff assisted resident to roll onto back and pulled brief through thighs; -CNA Q wiped front private area with wet wipes and taped brief closed; -The staff pulled the blanket and cover over resident with same gloved hands; -The CNAs removed gloves and left room with soiled linens and trash; -Staff did not complete hand hygiene between glove changes and when leaving the room. 8. During an interview on 06/17/26, at 10:20 A.M., CNA M said the following: -When staff were in a resident room for incontinent care, the staff should hand sanitize, apply gloves, clean the dirty area, then remove gloves, and use hand sanitizer, then put on clean gloves; -The staff should always change gloves and clean hands between dirty to clean process. During an interview on 06/17/26, at 1:40 P.M., CNA P said the following: -Staff should wash their hands before and after incontinent cares; -The staff should change gloves especially after wiping BM and use hand sanitizer between glove changes. During an interview on 06/17/26, at 1:50 P.M., CNA G said staff should complete hand hygiene between every glove change. During an interview on 06/18/26, at 2:20 P.M., the ADON said the following: -Staff should wash and sanitize hands before applying gloves and in between glove changes; -Staff should complete proper hand hygiene before enter and exiting rooms; -Staff can only use hand sanitizer a certain number of times and then they must wash their hands. During an interview on 06/18/26, at 3:50 P.M., DON said the following: -Staff should clean their hands between dirty and clean process and with each glove change; -Staff should only use hand sanitizer up to ten uses and should then wash their hand due to sanitizer build up; -Staff are educated when to wash hands, including in an isolation room, when gloves were visibly soiled and if the hands became soiled. During an interview on 06/18/26, at 3:55 P.M., Administrator said staff were to follow the infection control policy. Staff should complete hand hygiene before entering the room, during glove changes, and when leaving the room.

Based on record review and interview, the facility failed to develop and implement an effective system to ensure a resident's choice of code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was readily accessible to staff and documented consistently throughout the medical record for two residents (Resident #67 and Resident #12). A sample of two residents were selected for review out of a facility census of 100. Review of the facility's policy titled Advance Directive, revised [DATE] showed the following: -Advance directives will be respected in accordance with state law and facility policy; -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive; -Do Not Resuscitate (DNR) indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no cardiopulmonary resuscitation (CPR - an emergency lifesaving procedure performed when a person's heartbeat or breathing stops) be initiated. 1. Review of Resident #67's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of [DATE]; -Diagnoses included hypertension (high blood pressure); -Code status of DNR (the resident did not wish to receive CPR). Review of the resident's order summary report showed an order, dated [DATE], for a code status of full code (wished to receive CPR). Review of the resident's care plan, revised [DATE], showed the resident had a code status of full code. Review of the resident's Out of Hospital Do Not Resuscitate Form (OHDNR) showed the following: -The resident's representative signed the form on [DATE]; -The resident's physician signed the form on [DATE]. During an interview on [DATE], at 1:10 P.M., the Social Service Director (SSD) said the following: -The resident was admitted to hospice on [DATE]; -The nurses should have entered the resident's updated code status (DNR). During interviews on [DATE], at 12:38 P.M. and 1:22 P.M., the MDS/Care Plan Coordinator (MDS – Minimum Data Set – a federally mandated assessment completed by facility staff) said the following: -The resident was admitted to hospice on [DATE] and signed the DNR form on [DATE]. The resident had been a full code status; -Staff did not change the resident's full code status to DNR status until [DATE]; -When the resident's care plan was completed [DATE], the code status should have been changed from full code to DNR; -The nurse on duty should have changed the code status order when the resident was admitted to hospice on [DATE]; -On [DATE], she completed a significant change of status MDS assessment due to the resident being admitted to hospice. She should have caught the change of code status from full code to DNR. 2. Review of Resident #12's face sheet showed the following: -admission date of [DATE]; -Diagnoses included congestive heart failure (CHF - a condition in which the heart can't pump enough blood to the body's other organs), chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), and vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain); -Code status of DNR. Review of the resident's Physicians Order Sheet, current as of [DATE], showed an order dated [DATE], for DNR. Review of the resident's care plan, reviewed [DATE], showed the resident had code status of DNR. Review of the resident's care plan conference, dated [DATE], showed the following:-Physicians orders of full code (CPR); -Resident had no power of attorney on file for health care and wished to remain a full code status at the time. Observation on [DATE], at 3:00 P.M., showed a red dot on the resident's door name tag (indicating code status of DNR). 3. During an interview on [DATE], at 2:30 P.M., Certified Nurse Aide (CNA) J said the resident's code status was found on their electronic medical record. During an interview on [DATE], at 2:40 P.M., CNA L said the following: -Resident code status was located on the resident door by a red or green sticker and also in the electronic medical record; -It should be the same in all locations; -He/she would tell the nurse if he/she had any concerns. During an interview on [DATE], at 10:20 A.M., CNA M said the following: -The resident code status was located on the electronic medical record and also a red or green dot on the resident door; -The red dot meant the resident was a DNR; -The green dot meant the resident was a full code. During an interview on [DATE], at 2:45 P.M., Licensed Practical Nurse (LPN) K said the following: -Code status was found on the face sheet and could also be found in the documents tab for the physician order form; -Everything should match. During an interview on [DATE], at 4:41 P.M., LPN E said the following: -Staff can find resident code status on the resident banner in the electronic record system; -The admitting nurse was responsible for reviewing code status with residents and entered the order into the electronic record system; -The facility used to have stickers on resident doors to designate a resident's code status but did not have them anymore; -Nurse reviews code status and notifies the physician if a resident has a change of code status and changes it in the electronic record system During an interview on [DATE], at 11:33 A.M., the SSD said the following: -The admission Coordinator reviews admission paperwork and the code status with the responsible party and/or the resident upon admission; -Staff scan the signed code status form into the computer; -Nursing staff enter the code status into the electronic medical record; -Staff review code status at scheduled care plan meetings; -Resident code status should match throughout the record; -The MDS/Care Plan Coordinator develops the care plans and reviews code status orders; -Staff place the DNR forms in the physician's folder for him/her to sign when in the building; -Staff should communicate to the MDS/Care Plan Coordinator of a change of code status to update the care plan. During interviews on [DATE], at 12:38 P.M. and 1:22 P.M., the MDS/Care Plan Coordinator said the following: -The Admissions Coordinator had a form to complete and explained code status to the responsible party and/or resident upon admission; -The Admissions Coordinator uploaded the signed code status into the document section of the electronic medical record; -The admission Nurse (LPN F) entered the code status order into the electronic medical record; -She was responsible for reviewing code status orders and entered them on the care plan; -Resident code status should match throughout the medical record; -Staff review code status at every care plan meeting and complete any changes; -If a resident changes to a DNR code status, the responsible party and/or resident signs the form and staff should change the order in the electronic medical record. During an interview on [DATE], at 1:00 P.M., LPN F said the following: -A resident's code status was full code unless a DNR form is signed; -The Admissions Coordinator reviewed the code status and had the responsible party and/or resident sign the form, and placed the form in the physician's box who signs it; -The office staff uploaded completed code status forms into the electronic medical record; -He/she entered the code status orders into the computer unless the Director of Nursing (DON) or the charge nurse was able; -Resident code status should match throughout the medical record; -If a resident is admitted to hospice, the hospice nurse informed the charge nurse of a change in code status and the charge nurse should enter the updated code status order into the computer; -Staff should keep a copy of the DNR code status in the hospice chart and the electronic medical record; -Staff should enter a new code status order into the computer the same day of the change of code status. During an interview on [DATE], at 1:14 P.M., the Admissions Coordinator said the following: -admission staff review admission paperwork and discuss the code status of full code status or DNR; -Staff have an electronic code status form to sign and the physician DNR form to sign that is put in the physician's box to sign; -Staff can send the DNR form to the physician to sign; -Staff scan the signed DNR form into the computer; -The admission Nurse enters the code status orders into the computer; -Resident code status should match throughout medical record. During an interview on [DATE], at 12:12 P.M., the DON said the following: -The Admissions Coordinator reviews code status upon admission with the resident and/or responsible party; -Staff place the signed DNR form in the physician's folder who comes weekly to the facility and signs it; -The Admissions Coordinator or office staff scan the signed DNR form into the computer; -The admitting nurse entered the code status orders into the computer; -She was responsible for reviewing admission packets to ensure code status matches throughout the medical record; -The Care Plan Coordinator reviewed the admission packet and reviewed the code status, physician orders to develop and update the care plans. During an interview on [DATE], at 12:12 P.M., the Administrator said the following: -Resident code status should match throughout the medical record; -She expected staff to enter a change of code status in the medical record the same day as ordered.

Based on observation, interview, and record review, staff failed to ensure an environment free of accident hazards when staff failed to consistently implement fall preventions interventions for one resident (Resident #23) with a recent fall. The facility census was 100.Review of facility policy titled, Falls-Clinical Protocol, dated March 2018, showed the following information:-After first fall the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling;-Staff and physicians will identify pertinent interventions;-If underlying causes cannot be readily identified or corrected staff will try various interventions; -The staff and physicians will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Review of a facility's policy, Hazardous Areas, Devices, and Equipment, dated June 2017, showed the following:-A hazard is defined as anything in the environment that has the potential to cause injury;-All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible;-Assessment and analysis of hazardous areas and equipment will include resident-specific information including identification of vulnerable residents;-Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous;-Resident vulnerability is based on risk factors including the individual resident's functional status, medical condition, cognitive abilities, mood, and health treatments (e.g., medications);-Resident vulnerability to hazards may change over time. Ongoing assessment helps identify when elements in the environment pose hazards to a particular resident;-Improper or inappropriate use of equipment and devices will be identified as part of the hazard assessment and analysis;-Resident-specific interventions may include changes to the plan of care and/or increased supervision; 1. Review of Resident #23's face sheet (basic information sheet) showed the following:-admission date of 05/20/26;-Diagnoses included unspecified dementia without behaviors, anxiety, rhabdomyolysis (the rapid breakdown of muscle tissues) and spinal stenosis with claudication (narrowing of the spinal canal creating numbness and tingling and limited range of motion in lower extremities).Review of the resident's Minimum Data Sheet (MDS- a federally mandated assessment tool completed by facility staff), dated 05/29/26, showed the following:-The resident had severe cognitive impairment;-The resident had impairment of both sides of the upper and lower extremities;-The resident was maximum assist and dependent on staff for personal cares, bed mobility, and transfers. Review of the resident's fall event, dated 06/11/26, showed the following:-A fall was noted on 06/11/26 at approximately 8:00 A.M.;-The fall was unwitnessed;-Resident was restless that morning, attempting to stand from wheelchair twice. Nurse attempted redirection;-Resident was requesting to lay down;-Shower aide found resident on floor in common area. Resident fell from wheelchair attempting to stand;-Resident fell onto left arm near fish tank with forehead down on the ground;-Fall resulted in skin tear to forearm, bruising around eye, and hematoma (a closed wound where blood collects and fills a space inside the body because it cannot flow or drain out) to forehead;-Staff notified family and physician. Intervention in place to lay resident down after meals. Review of resident's care plan, dated 06/17/26, showed the following:-The resident had impaired mobility requiring dependence on staff for all activities of daily living (ADLs- activities related to personal cares including bathing, showering, dressing, getting in and out of bed or a chair, walking, toileting, and eating);-High risk for falls;-Keep call light in reach;-Lay resident down after meals.Observation on 06/16/26, at 8:02 A.M., showed the resident wheeled by staff into the sunroom and placed in front of a television. The staff member left the sunroom, leaving no staff present to supervise the resident.Observation on 06/16/26, at 9:14 A.M., showed the following:-The resident sat in his/her wheelchair in the hallway saying, I want out of here, (motioning to the wheelchair);-No staff at nursing station or near the resident;-Visible bruise to left eye and forehead. Observation on 06/17/26, at 8:30 A.M., showed the following;-The resident #23 sitting in wheelchair in sunroom stating, I'm sick of sitting here;-No staff present in sunroom. Observation on 06/17/26, at 10:53 A.M., showed the following: -The resident in bed with eyes closed;-Call light on bookshelf approximately three feet away;-Resident's door partially shut. During an Interview on 06/17/26, at 9:00A.M., Certified Nurse Aide (CNA) M said the following: -The resident liked to try and get up from wheelchair and attempt to walk. He/she liked to get close to the television;-The resident was not able to ambulate on own;-If a resident fell he/she notified the nurse right away. They would implement two hour checks;-If a resident was a high fall risk, they will have a leaf symbol on their door tag;-He/She would implement two-person lifts and make sure call light is within reach;-The resident can use the call light and they should be putting him/her to bed after eating, then getting him/her back up. During an interview on 06/17/26, at 9:04 A.M. and 10:10 A.M., CNA N said the following:-If a resident was a high fall risk, staff should set eyes on them every 15 minutes;-Interventions would be not leaving resident alone, or unattended and make sure they had a call light when in bed;-The resident tries to get out of the wheelchair a lot;-When he/she sees the resident climbing out of his/her chair staff should sit him/her back down;-Fall risk leaf icon are on the resident's door;-Fall interventions for residents are usually told to her/him by the nurse;-He/she was not aware of an interventions to lay the resident down after meals. During an interview on 06/17/26, at 12:01P.M., Registered Nurse (RN) I said the following:-The resident had a previous fall;-He/she attempted to stand up from his/her wheelchair; -The resident should go back to bed after eating;-Fall interventions depend on fall frequency, with observation of the resident's behaviors to identify risk as well as their cognition level;-Fall interventions are found in resident's care plan. During an interview on 06/18/26, at 2:21P.M., the Assistant Director of Nursing (ADON) said:-He/she expected staff to follow the care plan for interventions;-He/she expected staff to provide basic interventions immediately. During an interview on 06/18/26, at 4:06 P.M., the Director of Nursing (DON) said the following: -The resident was considered a high fall risk due to previous fall at facility. He/she attempted to stand from his/her wheelchair often;-Recent fall interventions have been implemented;-Interdisciplinary Team (IDT) met weekly to go over recent falls and decide on interventions; -He/she expect staff to know fall interventions for the residents;-He/she was responsible for evaluating the interventions and ensuring follow-through;-He/she expected staff to make rounds to ensure patient safety including ensuring call lights are in reach;-If a resident had an intervention to lay a resident down after a meal, he/she expected staff to attempt to do that, unless residents' are refusing;-If resident refused, he/she expected staff to document a refusal. During an interview on 06/18/26, at 3:15 P.M., the Administrator said the following: -She expected staff to communicate and follow the care plan for interventions regarding falls;-She expected staff to keep call lights within reach. Complaint #2980691

Based on interview and record review, the facility failed to ensure all residents received trauma-informed care per standards of practice when staff failed to document a complete trauma assessment, failed to care plan specification triggers, and failed to ensure all staff were aware of the resident's triggers and trauma related 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 about the event). The facility census was 100.Review of the facility policy, Trauma-Informed and Culturally Competent Care, dated August 2022, showed the following:-Purpose is to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice;-For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization;-Triggers are highly individualized. Some common triggers may include experiencing a lack of privacy or confinement in a crowded or small space; -Develop an organizational culture that supports all trauma-informed and resilience oriented ([NAME]) including universal and early screening and assessment; resident-centered care and services; and educated and responsive staff;-Staff should perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events;-Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant and sensitive;-Utilize initial screening to identify the need for further assessment and care;-Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers;-Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate;-Identify and decrease exposure to triggers that may re-traumatize the resident;-Recognize the relationship between past trauma and current health concerns. 1.Review of resident #31's face sheet (brief information sheet about the resident) showed the following:-admission date of 04/30/26;-Diagnoses included PTSD. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 05/05/26, showed the following:-Moderate cognitive impairment;-Diagnosis of PTSD. Review of the resident's social services assessment, dated 04/30/26, showed the following:-Mood diagnoses and any related physician orders associated with mood included PTSD, sertraline (prescription for depression and PTSD)) 100 milligram (mg), and divalproex sodium (used to treat seizures and manage bipolar disorder) 500 mg;-When the resident is having a bad day thinking of spouse helps;-No verbal or physical behaviors since admission;-Will PTSD/trauma be address in the care plan was marked no.-The identify possibly triggers portion was not complete. Review of the resident's current Physician's Order Sheet (POS) showed the following:-An order, dated 04/30/26, for divalproex sodium oral tablet delayed release 500 mg, give one tablet by mouth two times daily related to PTSD;-An order, dated 04/30/26, for sertraline HCI oral tablet 100 mg, give one tablet by mouth in the morning related to PTSD;-An order, dated 04/30/26, for trazodone HCI (antidepressant) oral tablet 150 mg, give one tablet by mouth at bedtime related to PTSD. Review of the resident's care plan, dated 05/04/26, showed the following:-Resident used psychotropic and anticonvulsant medications to treat/manage her target behaviors PTSD;-The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension (low blood pressure), gait disturbance, constipation/impaction, or cognitive/behavioral impairment;-Attempt non pharmaceutical interventions as follows: Check for pain, constipation, positioning, incontinence; -Encourage out of room activities;-Target behavior symptoms (little interest in anything, self-isolation) and document;-Resident reports feeling lonely or socially isolated at times;-Arrange for roommate compatibility. Introduce to other residents with similar cognitive abilities and interests;-Encourage, and facilitate if needed, continued contact/phone calls/visits with familyand friends. Review of the resident's nursing progress notes showed staff documented the following:-On 05/02/26, at 12:24 P.M., resident resting in bed, refusing to get out of bed, and yelling at therapy when in the room;-On 05/12/26, at 3:13 P.M., guardian provided verbal consent for the resident to be seen and treated by the psychologist. Review of the resident's medical record, dated 05/12/26 to 06/15/26, showed staff did not document regarding a psychologist appointment or related to the resident's diagnosis of PTSD. During an interview on 06/15/26, at 2:30 P.M., the resident said the following:-He/she was abused by a family member previously;-He/She did not know if he/she was taking any medications or seeing a physician for PTSD, but was aware that it was listed as a diagnosis on his/her chart;-His/Her roommate had a friend (another resident) that came and visited in the room often and it bothered him/her. He/She was not comfortable with the other resident being in the room;-He/She was not always clothed appropriately for other residents to be in the room;-He/she did not like confrontation. During an interview on 06/17/26, at 1:50 P.M., Certified Nursing Assistant (CNA) G said he/she would know a resident had PTSD if it was in the care plan. Any known triggers and cares to be provided should be in the care plan. During an interview on 06/17/26, at 2:45 P.M., the Social Services Director (SSD) said the following:-Residents with PTSD diagnosis have information on their care plan and she would visit the residents on a routine basis;-The resident would also be seen by the psychiatrist;-The resident had a diagnosis of PTSD;-She had tried to visit with the resident, but the resident was hard to warm up to;-She did not know the resident's history of trauma or possible trauma triggers;-She did not complete a trauma care assessment for the resident;-She did not locate any notes from the psychiatrist in the resident's chart and the resident was not on the psychiatrist schedule. During an interview on 06/18/26, at 10:45 A.M., Registered Nurse (RN) I said the following: -If a resident had PTSD the information would be found in the care plan;-He/She was unaware of the history of the resident's PTSD and was unsure what triggers could be an issue for the resident;-He/She was unaware of any assessment form that was complete for trauma care. During an interview on 06/18/26, at 11:00 A.M., Licensed Practical Nurse (LPN) H said the following:-He/She was unsure of the process for screening residents with a PTSD diagnosis;-The care plan should include possible triggers to help prevent a re-occurrence of trauma symptoms, like too much noise or something physical would cause stress;-He/she wanted to be notified of PTSD triggers in order to educate staff on shift;-Staff should be calm and try to assist a resident if there were PTSD concerns. During an interview on 06/18/26, at 1:10 P.M., the MDS/Care Plan Coordinator said the following: -Social services completed the PTSD assessment and would add the information to the care plan on admission;-There was a tab in the electronic medical record for PTSD and other trauma related concerns;-If a resident was prescribed a medication related to a PTSD diagnosis that information would be in the care plan. During an interview on 06/18/26, at 2:20 P.M., the Assistant Director of Nursing (ADON) said the following: -Residents with a PTSD diagnosis should be provided with mental health services as needed;-If a resident was prescribed medications due to a mental health diagnosis they should follow up with a mental health provider;-The care plan addresses diagnoses and the expectations of staff. During an interview on 06/18/26, at 3:50 P.M., the Director of Nursing (DON) said the following: -Residents with PTSD should be referred to the psychiatrist if they are willing;-Staff should monitor the resident and the care plan should include possible triggers for staff to avoid. During an interview on 06/18/26, at 3:55 P.M., the Administrator said she would expect PTSD information to be in the care plan for staff guidance.

Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for three residents (Resident #1, #2, and #3). The facility census was 96.1. Review of Resident #1's face sheet (a general information sheet) showed the following:-admission date of 03/14/24;-Diagnoses included type 2 diabetes, morbid obesity, and chronic kidney disease.Review of the resident's quarterly Minimum Data Set (MDS - federally mandated assessment instrument completed by facility staff), dated 10/02/25, showed the following:-No cognitive impairment;- Partial/moderate assistance with shower/bathing;-Supervision/touching assistance with shower/bath transfer.Review of the resident's October 2025 shower sheets showed the resident received a shower on the following dates: -On 10/03/25;-On 10/09/25 (six days after the prior shower);-On 10/22/25 (13 days after the prior shower):-On 10/27/25.Review of the resident's October 2025 nursing notes showed staff did not document any additional showers or any shower refusals by the resident. Review of the resident's most current care plan, as of 11/04/25, showed the following:-Resident had an activities of daily living (ADL) self-care performance deficiency due to limited mobility;-Resident was partial/moderate assist with one staff with showering;-Resident preferred to shower on Monday and Thursday.Observation and interview on 11/04/25, at 10:34 A.M., showed the following: -The resident's hair appeared oily;-The resident said he/she feels dirty, and his/her head is starting to itch; -He/she should receive two showers per week;-Resident received his/her last shower eight days ago (10/27/25);-He/she has not received two showers per week in the last month;-Resident would like to have a shower daily;-The facility does not have staff to assist with showers.2. Review of Resident #2's face sheet showed the following:-admission date of 10/25/22;-Diagnoses included congestive heart failure (CHF - is a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply), type 2 diabetes, morbid obesity, and anxiety.Review of the resident's annual MDS, dated [DATE], showed the following:-No cognitive impairment;-Partial/moderate assistance with shower/bathing;-Supervision/touching assistance with shower/bath transfer.Review of the resident's October 2025 shower sheets showed the resident received a shower on the following dates: -On 10/02/25;-On 10/09/25 (seven days after the prior shower);-On 10/14/25;-On 10/22/25 (eight days after the prior shower);-On 10/28/25.Review of the resident's October 2025 nursing notes showed staff did not document any additional showers or any shower refusals by the resident.Review of the resident's most current care plan, as of 11/04/25, showed the following:-Resident had an ADL self-care performance deficit due to limited mobility with morbid obesity;-Supervision of one staff when bathing or showering;-Resident prefers bathing/showering on Monday, Thursday, and as needed.Observation and interview on 11/04/25, at 9:48 A.M., showed the following: -The resident's hair appeared oily;-The resident said he/she felt dirty;-The resident preferred to have regular shows as he/she has cellulitis (skin infection) and the skin under his/her stomach fold starts to crack;-He/she normally received one shower per week;-The resident had not bathed in seven days (10/28/25).3. Review of Resident #3's face sheet showed the following:-admission date of 09/30/22;-Diagnoses included type 2 diabetes, morbid obesity, schizoaffective disorder-depressive type (a mental health condition that combines symptoms of schizophrenia and a mood disorder), and borderline intellectual functioning. Review of the resident's quarterly MDS, dated [DATE], showed the following:-No cognitive impairment;-Partial/moderate assistance with shower/bathing;-Substantial/maximum assistance with shower/bath transfer.Review of the resident's October 2025 shower sheets showed the resident received a shower on the following dates: -On 10/03/25;-On 10/08/25;-On 10/10/25;-On 10/14/25;-On 10/27/25 (13 days after the prior shower).Review of the resident's October 2025 nursing notes showed staff did not document any additional showers or any shower refusals by the resident. Review of the resident's most current care plan, as of 11/04/25, showed the following:-Resident had an ADL self-care performance deficit due to limited mobility;-Partial/moderate assist with showers;-Resident preferred bathing/showering on Tuesday, Friday, and as needed.During an interview on 11/04/25, at 11:39 A.M., the resident said the following:-Resident said he/she was supposed to receive two showers per week, but normally only received one;-The resident was active and felt like he/she needed at least two showers per week;-When the resident only received one shower per week, he/she started to feel dirty and itchy. 4. During an interview on 11/04/25, at 9:57 A.M., Certified Nursing Assistant (CNA) A said the following;-He/she was the shower aide for the 200 hall;-Two weeks ago, he/she started driving resident transportation;-The 300 hall had a shower aide, but he/she quit approximately two weeks ago;-He/she helped with showers when he/she was not at an appointment with a resident;-Residents are supposed to received two showers per week, however he/she was unsure how many residents receive;-Residents have voiced concerns to him/her about not receiving showers;-He/she notifies the aide on the floor if a resident has a shower concern. During an interview on 11/04/25, at 11:21A.M., CNA B said the following:-He/she is the shower aide for the 100 hall;-He/she gets pulled to the floor to work as an aide, which has occurred more recently;-Residents did not receive showers when he/she was pulled to the floor;-Residents should receive two showers per week;-Residents on halls 200 and 300 are not receiving two showers per week;-Residents have voiced concerns and management is aware. During an interview on 11/04/25, at 11:32 P.M., CNA C said the following:-Residents are supposed to receive two showers per week;-Residents are not receiving two showers per week, and some residents have not had a shower in over a week;-Residents have voiced concerns about not getting enough showers;-The facility used to have a shower aide for each hall;-Management is aware of the resident's shower concerns. During an interview on 11/04/25, at 11:55 A.M., Licensed Practical Nurse (LPN) D said the following:-Residents voice concerns occasionally about not receiving showers;-Due to staffing changes, the aides are having to play catch up with showers and try to pick one or two residents a shift to shower;-Residents receive one shower per week, but staff try to provide two per week;-He/she was unsure how many showers residents receive per week. During an interview on 11/04/25, at 12:05 P.M., LPN E said the following:-Residents are supposed to receive two showers per week;-He/she was unsure if they receive two showers;-Management reviews the shower sheets. During an interview on 11/04/25, at 12:14 P.M., the Social Service Director (SSD) said the following:-Residents have voiced concerns about not receiving frequent showers;-Residents are supposed to receive two showers per week;-He/she was unsure if residents receive two showers per week;-The facility had encountered staffing challenges.During an interview on 11/04/25, at 12:35 P.M., LPN E said the following:-Residents should receive two showers per week;-Floor staff provide showers, as there has been turnover with the shower aides;-He/she was unsure if residents received two showers per week;-Management provided showers to residents when needed;-Management reviews the shower sheets.During an interview on 11/04/25, at 2:00 P.M., the Director of Nursing (DON) said the following: -Residents should receive at least one shower per week;-Residents should be offered two showers per week;-Residents, on average, receive two showers per week;-The facility had a change in staffing at the end of September/beginning of October;-The facility is transitioning to assigning aides to complete a number of showers per shift, as they are phasing out shower aides.Complaint #2649642

Based on observation, interview, and record review, the facility failed to follow standards of practice and keep food safe from potential contamination or bacterial growth when staff failed to ensure cups and glasses were air dried before being stored. The facility census was 101. Review showed the facility did not provide a policy regarding drying of dishes. Record review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. 1. Observations on 07/23/24, at 8:46 A.M., showed 53 small water and juice cups/glasses stored/stacked upside down on a the tray in a manner that trapped water and did not allow for airflow for drying. Observations on 07/26/24, at 11:55 P.M., showed 49 small water and juice cups/glasses stored/stacked upside down on a the tray in a manner that trapped water and did not allow for airflow for drying. During an interview on 07/29/24, at 2:40 P.M., Dietary Aide (DA) W said the following: -He/she was not aware that the dishes had to be dried before they could be stacked/placed upside down trapping water; -he/she was told glasses must be completely dry before putting them away. During an interview on 07/29/24, at 2:50 P.M., DA X said the following: -He/she was told dishes could not be stored away while still wet; -He/she said they were told that it can cause bacteria to grow. During an interview on 07/29/24, at 3:00 P.M., the Dietary Manager (DM) said he/she was not aware that drinking glasses were being placed upside down in a manner that trapped water and prevented air drying. During an interview on 07/29/24, at 2:40 P.M., the Administrator said the following: -Staff have looked for a policy regarding air drying dishes before storing, but are unable to locate anything related; ought liners that they thought would work to line the trays; -He/she did not realize there was not enough of an air gap to allow for airflow and drying.

Based on observation and interview, the facility failed to properly store all drugs in locked compartments when three medication carts were observed unlocked while unattended by staff. The facility census was 101. Review showed the facility did not provide a policy pertaining to storage of medication. 1. Observation on 07/26/24, at 11:30 A.M., showed Licensed Practical Nurse (LPN) U positioned a medication cart in the hallway outside a resident's room. The cart was facing the resident's doorway and adjacent wall, approximately two feet away. The LPN dispensed the resident's medications, did not lock the cart, and entered the resident's room to administer the medications. The Assistant Director of Nursing (ADON) R approached the cart and depressed the lock. Observation on 07/29/24, at 1:42 P.M., showed a medication cart positioned with its back against the half-wall of the nurses' station, facing a resident lounge area. Two unidentified residents were in the lounge area, and two staff passed down the hall pushing residents in wheelchairs. The cart was not attended by staff and was not locked. The Director of Nursing (DON) approached the cart and depressed the lock. Observation on 07/24/24, at 1:02 P.M., showed a medication cart positioned against the wall facing toward resident room [ROOM NUMBER] and left unattended. The medication cart contained several cards of medication. Several residents and staff, including housekeeping and LPN T passed by the cart. At 1:04 P.M., Certified Mediation Technician (CMT) V came out of room [ROOM NUMBER] and locked the medication cart. During an interview on 07/26/24, at 9:39 A.M., Certified Nursing Assistant/ Certified Medication Technician (CNA/CMT) F said that medication carts should be locked when staff are not present. During an interview on 07/30/24, at 12:15 P.M. the Admissions Nurse said all medication carts should be locked when staff is walking away from them. During an interview on 07/30/24, at 1:33 P.M., with the Administrator, Director of Nursing (DON), Clinical Nurse Consultant, and Director of Operations, the DON said staff should lock the medication carts when they are not with the cart. 50185

Based on observation, interview, and record review, the facility staff failed to maintain proper infection control when administering medication for two residents (Residents #254 and #8) and failed to properly disinfect glucometers (medical device for determining glucose in the blood) during tests performed for three residents (Residents #74, #22, and #14). The facility census was 101. 1. Review of the facility policy titled Administering Oral Medications, dated October 2010, showed staff should not touch medications with their hands. Review of Resident #254's face sheet (gives basic profile information), showed the following information: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), respiratory failure, encephalopathy (brain disease that alters brain function or structure), and dysphagia (difficulty swallowing). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 06/08/24, showed the following information: -Cognitively intact; -Takes antianxiety (medications that are used to treat anxiety disorders), antidepressants (medications that are used to treat depressive disorders), anticoagulants (medications that prevent and treat blood clots), opioids (pain reducing medications), and hypoglycemics (a group of drugs that help lower blood sugar levels). Review of the resident's physician order sheet, dated 07/30/24, showed the following: -Diltiazem (antihypertensive drug that treats high blood pressure) HCI (added salt to help the medication dissolve or be absorbed in the bloodstream) 90 milligram (mg) tablet, give one tablet via g-tube (tube used for medication nutrition when resident cannot do so by mouth) three times a day; -Gabapentin (anticonvulsant that treats pain and nerve pain and seizures) 100 mg capsule, give one capsule via peg-tube (g-tube) three times a day; -Oxycodone (narcotic that treats moderate to severe pain) HCI 5 mg tablet, give one tablet via peg-tube every four hours as needed. Observation on 07/24/24, at 1:09 P.M., showed Licensed Practical Nurse (LPN) T obtained diltiazem from the medication card, crushed it, then placed it into a medication cup. LPN T obtained gabapentin from the medication card and emptied the capsule into the same medication cup as diltiazem. LPN T obtained oxycodone from the medication card, crushed it, then placed the medication into the same medication cup as the diltiazem and gabapentin. LPN T emptied all medications into a bigger cup and added 30 milliliters (ml) of water into the cup. After adding water to the cup LPN swirled the medication. The medication continued to have some clumping of medications. LPN T took his/her gloved finger and stirred the medications. LPN T apologized and said he/she did not have a spoon with him/her. LPN T then poured the medications into the resident's peg-tubing via a 60 ml syringe. During an interview on 07/26/24, at 9:39 A.M., Certified Nursing Assistant/Medication Technician (CNA/CMT) F said it was not acceptable to stir medications with one's fingers, gloved or not. During an interview on 07/26/24, at 9:50 A.M., LPN G said that he/she would not stick his/her finger in medications to stir them. The expectation is to use a spoon. He/she would consider stirring medications with a finger, gloved or not as cross contamination and an infection control issue. During an interview on 07/30/24, at 12:08 P.M., the Admissions Coordinator said it is not acceptable to stir medications with one's finger, gloved or not. During an interview on 07/30/24, at 1:33 P.M., the Director of Nursing (DON) and Administrator said it would not be acceptable for staff to stir medications with their fingers. 2. Review of Resident #8's face sheet showed the following: -admitted [DATE]; -Diagnoses included anemia, congestive heart failure (CHF - inability for heart to pump blood to the body as needed), renal insufficiency (kidney issues), pain, dementia, high cholesterol, and thyroid disorder. Review of the resident's significant change MDS, dated [DATE], showed the following: -Severely impaired cognition; -Received antipsychotic and antiplatelet (helps prevent blood clots) medications on a routine basis. Review of the resident's care plan, last updated 07/24/24, showed the following: -Resident has congestive heart failure. Administer cardiac medications as ordered; -Resident has impaired cognitive function/dementia or impaired thought processes. Administer medications as ordered; -Resident uses psychotropic medication. Administer psychotropic medications as ordered by physician; -Resident has chronic pain. Anticipate the resident's need for pain relief; -Resident has chronic renal failure related to kidney disease stage 3. Administer medications as ordered by physician. Observation on 07/29/24, at 9:18 A.M., showed CMT M the following: -The CMT used hand sanitizer before preparing the resident's medications; -The CMT punched medications from bubble packed cards into a medication cup: -The CMT dispensed medications from bottles by pouring pill into the lid and then into the medication cup: -The CMT entered the resident's room and placed the medication cup on top of a tapestry runner covering a dresser. The cup tipped over, spilling out multiple pills. The CMT used a plastic spoon to scoop the pills up and put them back into the cup and said, At least they didn't hit the floor. The CMT gave the cup of pills to the resident with a drink. During an interview on 07/30/24, at 1:33 P.M., with the Administrator, DON, Clinical Nurse Consultant, and Corporate Director of Operations, the DON said staff should follow all infection control guidelines. They should discard dropped pills and re-dispense them. 3. Review of the undated manufacturer's manual titled Glucocard, the glucometer used, showed the following disinfecting procedures: -Wear appropriate protective gear such as disposable gloves; -Open the cap of the disinfectant container and pull out one towelette and close the cap; -Wipe the entire surface of the glucometer three times horizontally and three times vertically using a new towelette to remove blood borne pathogens; -Dispose of the used towelettes in the trash; -Allow exteriors to remain wet for the corresponding contact time for each disinfectant; -After disinfection, the users gloves should be removed to be thrown away and hands washed before proceeding to the next patient. 4. Review of Resident #74's face sheet showed the following information: -admitted [DATE]; -Diagnoses include type two diabetes. Review of the resident's current care plan showed the resident to receive diabetic medications and fasting blood glucose levels as ordered by the doctor. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact and resident received insulin injections seven days a week. Observation on 07/29/24, at 11:56 A.M., showed LPN T completed another resident's accucheck and placed the glucometer into a sani-wipe (without wiping or thoroughly wetting the glucometer) and placed the glucometer onto medication cart next to a second wrapped glucometer. LPN T sanitized his/her hands, donned gloves, obtained a test strip and placed it into the 2nd glucometer that he/she obtained from the top of the medication cart that had been wrapped in a sani-wipe. LPN T obtained an alcohol wipe and prepped the resident's finger. LPN T obtained a lancet, obtained blood from the resident's finger, and placed it onto the test strip. LPN T obtained a sani-wipe from its container and wrapped the glucometer (without wiping or thoroughly wetting the glucometer) and placed it on the medication cart. 31464 5. Review of Resident #22's face sheet showed the following: -admitted [DATE]; -Diagnoses included diabetes mellitus. Review of the resident's significant change MDS, dated [DATE], showed resident's cognition intact and received insulin on seven of the previous seven days. Review of the resident care plan, last updated 07/23/24, showed the following information: -At risk for pain related to disease process; -Resident had diabetes mellitus. Staff to obtain fasting blood sugar as ordered by doctor. Observation on 07/26/24, at 11:40 A.M., showed LPN V used hand sanitizer and prepared supplies to perform an accucheck for the resident. LPN V unwrapped glucometer #2 (the same machine used to complete the previous accucheck for the previous). The LPN did not wipe the machine with a sani-cloth and did not allow time for the machine to air dry, and completed the Accucheck. 6. Review of Resident #14's face sheet showed the following: -admitted [DATE]; -Diagnoses included diabetes mellitus. Review of the resident's quarterly MDS, dated [DATE], showed resident had severely impaired cognition and received insulin on seven of the previous seven days. Review of the resident's care plan, last updated 05/25/24, showed resident had diabetes mellitus and staff to obtain fasting serum blood sugar as ordered by doctor. Observation on 07/26/24, at 12:12 P.M., showed LPN G used hand sanitizer and donned gloves to perform an accucheck for the resident. LPN G wrapped the glucometer in a sani-wipe without first wiping it clean and placed the machine on top of the treatment cart. 7. During an interview on 07/29/24, at 1:40 P.M., LPN T said upon finishing an accucheck, he/she wrapped the glucometer in a sani-wipe and let it sit for five minutes, after that, the glucometer is sanitized and he/she goes on using it. 8, During an interview on 07/30/24, at 12:08 P.M., the Admissions Coordinator said glucometers should be sanitized with sanitizing wipes. The glucometers must actually be wiped down and then let dry before they are considered sanitized. 9. During an interview on 07/30/24, at 1:33 P.M., with the Administrator, DON, Clinical Nurse Consultant, and Corporate Director of Operations, the DON said staff should follow all infection control guidelines. 41787

Based on observation, interview, and record review, the facility failed to treat all residents with dignity and respect when staff used an inappropriate tone of voice and a public location to discuss concerns with one resident (Residents #22) and when one staff member (Certified Nurse Aide (CNA) A) cursed and used a disrespectful name in the presence of a resident, transferred a resident in a rough manner, and tossed a draw sheet while assisting a resident for one resident (Resident #19). The facility census was 101. A sample of 27 residents was reviewed; the facility census was 101. Review of a facility's policy titled Dignity, revised 02/2021, showed the following: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; -Residents are treated with dignity and respect at all times; -Honor resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay; -Individual needs and preferences of the resident are identified through the assessment process; -Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice. Review of the facility policy titled Resident Rights, dated December 2016, showed the following: -Federal and state laws guarantee certain basic right to all residents of this facility; -These rights include the resident's right to be treated with respect, kindness, and dignity. 1. Review of Resident #22's face sheet (gives basic profile information) showed the following: -admitted [DATE]; -Diagnoses included multiple sclerosis (MS - disease causing nerve damage which disrupts communication between the brain and the body; may result in impaired movement, vision loss, pain, and fatigue), muscle wasting and weakness, left femur (leg) fracture, diabetes, muscle spasm and pain of lower back, anemia (low red blood cell count), depressive disorder, urinary incontinence, high blood pressure, history of mini-stroke, and generalized anxiety disorder. Observation on 07/23/24, at 4:40 P.M., showed the resident sat in his/her power chair in the facility's library room. The library was approximately 10 feet by 8 feet in size with a large windows on adjacent sides that allowed visibility into the room. The room's door was closed. Certified Nursing Assistant (CNA) K, CNA N, and CNA O sat in chairs surrounding the resident. Licensed Practical Nurse (LPN) L stood approximately three feet in front of the resident, leaning into him/her. The LPN shook his/her splayed hands out to his/her front/sides and loudly demanded, What do you want us to do?! CNA K came out of the room and went to talk to Assistant Director of Nursing (ADON) R. The ADON entered the library at that time and began talking to the resident. During an interview on 07/23/24, at 4:55 P.M., the resident said during the event in the library, he/she was frustrated, saying We weren't getting anywhere! It was just a 'he said/she said' argument. The staff wasn't listening to me, and they said I wasn't hearing them! The resident said following a disagreement with the CNAs in his/her room, the nurse said they would go to the library to discuss the situation. The resident said he/she was upset, so he/she went into the room of another resident to briefly talk to them. While in that room, the door accidentally closed, and the resident was unable to re-open it due to his/her power chair. LPN P knocked on the door and loudly called out, Come on, we're waiting on you! During an interview on 07/25/24, at 9:37 A.M., the resident said he/she felt like the four staff were ganging up on me during the discussion in the library on 07/23/24. The resident said he/she felt intimated. During an interview on 07/24/24, at 3:50 P.M., CNA N said the group discussion in the library was due to a disagreement between the resident and aides regarding the prioritizing/timing of residents' cares, resulting in the resident telling all of the aides to just leave the room. LPN L came and took the CNAs and resident into the library. During the conversation, CNA K told CNA N the discussion wasn't productive and left the room to get ADON R. CNA N said LPN L and the resident was trying to work it out, but it was just a 'he said/she said' argument. CNA N said he/she wasn't comfortable with the situation and thought management should have been involved. During an interview on 07/24/24, at 4:05 P.M., CNA O said he/she, CNA K, and CNA N had a disagreement with the resident regarding the prioritizing of residents' cares. When the aides said they didn't want to argue about it, the resident told them all to leave his/her room. LPN L suggested they all go to the library to avoid talking in front of the resident's roommate. CNA O said the aides didn't really talk much, LPN L and then later ADON R, did the talking. The resident was a bit upset, insisting I needed to lay down, but you kept taking care of everyone else! The staff was explaining the need to prioritize care. CNA K went to get ADON R, who sat down across from the resident to explain the aides' actions. CNA K and CNA N apologized to the resident, who then allowed them to assist him/her to bed without telling them to leave. During an interview on 07/25/24, at 4:05 P.M., LPN L said staff should help residents maintain their dignity and a dignified appearance. The LPN said on 07/24/24, at around 4:00 P.M., he/she sent staff to put the resident in bed. When the aides reported to LPN L that the resident had sent them all out of the room, LPN L went to the resident, who was then out in the hall, and asked him/her the reason. The resident said it was because they told her they weren't going to put up with my talking about another resident's care. LPN L said he/she wanted to talk about what was said and how the resident interpreted it. LPN L started to take the three staff into the resident's room to discuss the situation, but the resident didn't want to talk in front of the roommate. LPN L suggested they go to the library. The LPN said nobody raised their voices, and the staff wasn't trying to intimidate the resident by all of them being present. LPN L said he/she suggested the library because the resident likes it in there. The LPN said he/she had not noticed that the discussion was audible and visible to anyone who was in the front lobby area and maybe he/she should have better managed the issue by talking to the resident one-to-one instead of with all of the aides there. During an interview on 07/26/24, at 2:22 P.M., the Director of Nursing (DON) said staff should treat residents in a dignified manner. If there is a need to discuss a resident's concerns, needs, or a situation regarding the aides, the charge nurse, not a group of staff, should remove the aides from the situation and speak calmly with the resident one-to-one. During an interview on 07/26, 24, at 3:00 P.M., the Administrator said staff should not stand over a resident or have a group of staff confronting the resident to discuss a disagreement; that might be appear to be undignified and possibly intimidating to the resident. Appropriate staff (the charge nurse, DON or Administrator) should meet with the resident one-to-one to de-escalate the situation. 2. Review of Resident #19's face sheet showed the following: -admitted [DATE]; -Diagnoses included multiple sclerosis (chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) without behavioral disturbance, Alzheimer's disease with late onset (progressive disease that destroys memory and other important mental functions) , generalized anxiety disorder, and age-related physical debility (the state of being weak in health or body). Review of the resident's care plan, last updated 02/05/24, showed the following: -The resident lacked the capacity to understand and make decision regarding healthcare; -The resident has an ADL self-care performance deficit; -The resident required extensive assistance of one staff for toilet use; -The resident required substantial/maximum assistance by two staff for all transfers; -The resident had limited physical mobility; -The resident was totally dependent on one staff for locomotion using wheelchair; -Staff should provide supportive care and assistance with mobility as needed; -When resident became agitated staff to interview before agitation escalated; guide away from source of distress; and engage calmly in conversation. If response was aggressive, staff should walk calmly away and approach later; -The resident had impaired cognitive function/dementia or impaired thought process, -Staff should engage in conversation about a pleasant topic before initiating care; -Staff should use positive approach techniques including approach resident from the front and use a wave and extend your hand for a handshake. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 07/04/24, showed the following: -Severe cognitive impairment; -Resident required substantial/maximal assistance for toileting hygiene; -Resident required partial/moderate assistance for dressing; -Resident required use of a wheelchair for mobility. Review of the resident's nursing progress note dated 07/21/24, at 3:19 P.M., showed during the course of the day, there was an alleged incident of verbal abuse from a staff member. Statements were gathered and the event was reported to the Director of Nursing (DON) and Administrator. Staff informed physician, family member, and on-call nurse for hospice. The staff member was released from duty pending the investigation. Nurse completed head to toe assessment with no finding. The resident was alert to self only and could not make any statement about the incident. Review of the interview statement, dated 07/22/24, completed by the Administrator and an Assistant Director of Nursing (ADON) with CNA B, showed the following: -CNA B went to the shower room. CNA A and the resident were already present. The resident was screaming help. CNA A stood the resident up and CNA B pulled down the resident's pants. CNA A pivot transferred the resident to the toilet by throwing him/her. The Administrator and ADON asked CNA B to demonstrate the transfer. From CNA B's description, the resident was not thrown, but transferred in a rough manner. -CNA A then left to collect a fresh brief and pants. While CNA A was gone the resident stated, I'm not getting a shower. CNA B reassured the resident that he/she was only getting cleaned up. -CNA B put the brief and pants around the resident's leg. CNA A stood the resident up. The resident had another bowel movement. CNA B cleaned the resident up again. -CNA C entered the room. CNA A pivot transferred the resident back to the chair. During the transfer CNA A said to the resident, you sound like a fucking [NAME] goat. After the transfer, CNA B took the foot pedals back to the room. CNA B went to the charge nurse and reported the incident. Review of the written statement, dated 7/21/24, completed by CNA A showed the following: -While working with CNA B, they took the resident to the shower room to change his/her brief. CNA C came in to talk with CNA B. The resident was yelling, and CNA A said to both co-workers that the resident sounded like a [NAME] goat. CNA B and CNA A then stood the resident and pulled up his/her pants. CNA A took the resident to his/her room. -CNA C and CNA A both were in the resident room when CNA A transferred the resident. When CNA A pulled the blankets down, he/she tossed the stained pull sheet out in the hallway, covered the resident up, and pushed the wheelchair to the hallway. During an interview on 07/25/24, at 1:23 P.M., CNA A said the following: -The resident was upset in the hallway and was trying to climb out of his/her chair. The resident was crying loud pitch noises which was not his/her normal. The resident said he/she wanted to go to bed. He/she took the resident to the big bathroom in the hallway, toileted the resident, and then took the resident back to his/her room and transferred to him/hr to bed. CNA A said that he/she tossed the dirty pull sheet to the hallway. He/she did not put another draw sheet because the resident was anxious; -In the shower room, he/she said to another co-worker that when the resident was crying he/she sounded like a baby [NAME] goat. The aide said this to the coworker in a low voice. The resident was in the room, but was hard of hearing. CNA A said that he/she should not have done that. The aide said he/she was not rough with transfer; -CNA A said that he/she was going to lay down the resident, but knew he/she needed changed first. The resident was a two-person transfer to the toilet, the aide said that he/she assisted the resident to stand up and CNA B pulled up the resident's pants. CNA A pivoted the resident and sat him/her back down, this was not rough or hard. Review of the written statement, dated 07/21/24, completed by CNA B showed the following: -CNA A took the resident in the main shower room on 300 hall. CNA A picked the resident up and threw him/her on the stool. CNA A said I am mad. CNA B said okay, I'm sorry. CNA A went and got the resident's pants. CNA A stood the resident up and CNA B wiped the resident. CNA C was in the room now. As they were cleaning the resident CNA A said I'm going to start calling you a fucking goat. Then he/she threw the resident in his/her chair. CNA A was cussing about Registered Nurse (RN) D and saying this is not how you treat your aides; -CNA A is frequently rude to residents and always cussing. During an interview on 07/26/24, at 9:05 A.M., CNA B said he/she did not feel CNA A mean to intentionally do anything to the resident, he/she was having a bad day. Review of the written statement, dated 07/21/24, completed by CNA C showed the following: -When CNA C walked into the shower room, CNA C was looking for CNA B and was told that was where he/she was. -When CNA C walked in CNA B was cleaning up the resident and CNA A said the resident sounded like a fucking goat. -CNA C grabbed the chair and CNA A put the resident in the chair roughly. CNA C then followed CNA A and CNA B to the resident's room. CNA B left and CNA A started to put the resident into bed and he/she proceeded to throw the dirty pull sheet out into the hallway. During an interview on 07/26/24, at 8:50 A.M., CNA C said the following: -On Sunday, 07/21/24, he/she walked into the shower room and two aides were giving care to the resident. CNA A was holding up the resident and CNA B was cleaning the resident. He/she moved the wheelchair closer and asked what the resident was yelling about. CNA A looked at the resident and said you shit yourself. CNA A then pivoted the resident to the wheelchair, but instead of sitting the resident into the wheelchair, he/she just dropped the resident into the wheelchair and the resident had a rough landing. CNA A grabbed the wheelchair to take back to his/her room. -The resident said something about not being clean or not being done. CNA A was argumentative, so CNA C said let's just get the resident back to his/her room for now. CNA B left the room. CNA C and CNA A went into the resident room. -As the staff got the resident into his/her bed there was a stain or dirty mark on the draw sheet, CNA A threw the sheet out into the hallway. CNA A said the resident sounded like a fucking [NAME] goat. He/she was looking at the resident when he/she said this. During an interview on 07/23/24, at 3:50 P.M., the resident's roommate, Resident #67, said CNA A was rude and hateful. Resident #67 said he/she asked CNA A for wash rags and towels and the aide told the resident that he/she did not have time for that. During an interview on 07/24/24, at 3:15 P.M., Resident #17 said that he/she had seen CNA A be rude and rough with the resident. During an interview on 07/24/24, at 12:10 P.M., CNA K said he/she had worked with CNA A and had seen CNA A have a rude tone and attitude to staff and residents. During an interview on 07/25/24, at 1:43 P.M., RN D said the following: -CNA B and CNA C reported to him/her that the resident was transferred roughly and verbal abuse occurred, including general cursing. He/she then contacted the DON and was told to escort CNA A out of the building. He/she completed a full assessment on the resident. He/she asked questions of the resident with no response. The resident was at his/her baseline and was not fearful. The RN contacted the family and the physician and hospice and no new orders were received. The RN had witnessed CNA A's attitude but not to any one person; -he RN said that Resident #17 mentioned that he/she had witnessed CNA A move the resident roughly before; -The RN said he/she would tell the DON if any resident stated that staff were rude. During an interview on 07/25/24, at 3:45 P.M., LPN L said that it was not appropriate for staff to call resident names even to each other. During an interview on 07/26/24, at 9:15 A.M., CMT M said it was not appropriate for staff to call any resident disrespectful names while standing over the resident or with the resident in the room. If needed, staff should talk to co-worker in a private area. During an interview on 07/25/24, at 2:03 P.M., the DON said the following: -Was made aware of allegation of abuse when CNA B sent a text; -The DON called RN D and he/she said the aides just came to him/her and he/she went to make sure the resident was safe; -It was not appropriate to call a resident a [NAME] goat, even if not talking to the resident; -Staff should not talk over residents to talk each other and should not call residents derogatory names. This was not dignified behavior. During an interview on 07/26/24, at 3:00 P.M., the Administrator said the following: -Was notified on Sunday, 07/21/24, of an incident and then came into the building and took some staff interviews; -It is not appropriate for staff to call residents disrespectful names. The residents have rights and they have names. MO00239286 41787

Based on observation, interview, and record review, the facility failed to provide a clean, safe, and comfortable homelike environment for all residents when when staff failed to repair a stained ceiling, and failed to keep the floor free from debris for one resident (Resident #70); when staff failed to repair wall damage for one resident (Resident #30); and when staff failed to maintain wall outlets for one resident (Resident #49). The facility census was 101. Review of the facility policy titled Homelike Environment, dated February 2021, showed the following: -Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; -The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting including a clean, sanitary and orderly environment. 1. Review of Resident #70's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke) affecting left non-dominant side, spondylosis of thoracolumbar region (natural wearing down in the mid-back), repeated falls, and generalized anxiety disorder. Review of the resident's care plan, last updated 04/02/24, showed the resident had an activities of daily living (ADL) self-care performance deficit related to weakness. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 05/27/24, showed the resident cognitively intact and use of manual wheelchair. Observation and interview on 07/25/24, at 11:03 A.M., showed the following: -The resident said there was trash under the bed and under the recliner that the housekeeping staff would not clean up. There were also several stains on the ceiling; -Observation showed multiple pieces of trash and debris, including food crumbs, medication cups, paper, tissue, under the resident's bed and behind the bedside recliner; -Observation showed stained area on the ceiling directly above the resident's bed approximate 6-inch diameter stain with a black ring, pink ring, and brown discoloration in the stain; -Observation showed two stained appearance spots around smoke detector above the resident's dresser area that were brown discoloration in appearance and extended around the smoke detector about two inches round; -The resident said that the stains and trash were bothersome and made him/her feel that the room was dirty. Review of the Maintenance Request Log at the 300 hall nurses' station showed the following: -On 05/26/24, leak by the smoke detector. The entry was initialed by someone other than the current Maintenance Director; -No entry documented regarding ceiling damage above the bed. 31464 2. Review of Resident #30's face sheet showed the following information: -admitted [DATE]; -Diagnoses included anemia (low red blood cell count), paraplegia (loss of muscle function in the lower half of the body), left above-knee amputation (AKA) with phantom limb pain, high blood pressure, obstructive uropathy (causes impaired urinary elimination), chronic obstructive pulmonary disease (COPD - breathing disorder), and respiratory failure. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Utilized a motorized wheelchair; -Dependent on staff for transfers between chair/bed. Review of the resident's care plan, last updated 05/23/24, showed the resident had capacity to understand and make decisions and resident has limited physical mobility related to left above the knee amputation and right leg brace for foot drop; Observation and interview on 07/24/24, at 12:50 P.M., showed the following: -The resident pointed out wall damage to the corner of the wall next to the closet. He/she said staff had driven his/her power chair into it on occasion, knocking off the clear plastic protective covering and leaving the metal drywall corner bracket revealed. Observation at the time of the interview confirmed the damage. -The resident said the peeled portion of the wall/wallpaper above his/her bed looked like (the shape of) a pregnant woman. I needed to move my plant over there to cover it up! Observations at the time of the interview confirmed the peeling wall paper. -The resident said the new maintenance staff was working hard to make repairs that had been needed for quite a while. Review of the Maintenance Request Log at the 300 hall nurses' station showed the no entries documented regarding wall damage. 3. During an interview on 07/26/24, at 9:05 A.M., Certified Nursing Assistant (CNA) B said that if he/she had any environment concerns, he/she would notify the maintenance staff, and there was a maintenance log at the nursing station that information could be added to. He/she had not been told by any residents of environment concerns. He/she had seen holes and tears in the walls of various resident rooms. 4. During an interview on 07/26/24, at 9:15 A.M., Certified Medication Technician (CMT) M said that any environment concerns should be written on the maintenance log that was located on the 100/200 hall nurse desk. He/she was not aware of any residents with complaints of room repairs needed. 5. During an interview on 07/26/24, at 10:25 A.M., Licensed Practical Nurse (LPN) G said that staff should notify the maintenance staff any time concerns in any resident rooms or common areas. He/she was not aware of any resident room concerns. 6. During an interview on 07/26/24, at 10:35 A.M., Registered Nurse (RN) D said that staff should notify the maintenance staff of damage in resident rooms. He/she was not aware of stained ceiling or resident rooms not cleaned. 7. During an interview on 07/26/24, at 11:10 A.M., the Maintenance Director said staff should write any maintenance concerns on the log at the nurses' stations, or they could verbally notify him. He was currently trying to fix holes in walls, closets, and doors, and would assist with the current process involving new floors in the 400 hall. He was aware of some large holes in various rooms, but not aware of any damage on the 300 hall at that time. 8. During an interview on 07/26/24, at 3:00 P.M., the Administrator said that resident rooms should not have large holes in walls, doors, or closets. The rooms should not have stained ceilings. The maintenance staff was trying to catch up on facility repairs. Staff should notify the Maintenance Director for repairs or damage to resident rooms. 9. Review showed the facility did not provide a policy regarding electrical outlet monitoring. Review of Resident #49's face sheet showed the following: -admitted [DATE]; -Diagnoses included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), dependence on wheelchair, acquired absence of right leg and left leg above the knee (limb was amputated), chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), chronic respiratory failure a with hypoxia (condition not have enough oxygen in the tissues in the body), and obstructive and reflux uropathy (urine cannot drain through the urinary tract, and may back up into the kidneys). Review of the resident's significant change in status Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/07/24, showed the following: -Cognitively intact; -Required substantial to maximal assistance with showering/bathing; -Dependent on staff for transfers. Review of the resident's care plan, last reviewed 07/18/24, showed the following: -The resident had an activities of daily living (ADL) self-care performance deficit related to bilateral above the knee amputation. Observation and interview on 07/25/24, at 10:53 A.M., showed the following: -The resident said the electrical outlet behind the small bedside table in his/her room was significantly loose. He/she said that no plug would remain plugged in without being propped up by the bedside table. The resident said he/she cannot plug his/her cell phone into the outlet because it will not stay plugged in. He/she said that he/she had notified staff several times; -Observation of the outlet showed the resident's CPAP machine (continuous positive airway pressure - machine that uses mild air pressure to keep breathing airways open while sleeping) plugged into the outlet with most of the silver prongs visible and loosely hanging into the outlet. The back of the bedside table was touching the electrical cord. During interview on 07/26/24, at 11:10 A.M., Maintenance Director said the following: -He checked electrical outlets for receptacle retention tests and was not aware of any outlets that are loose at this time; -Staff should notify maintenance of items in need of repair or write on the maintenance log at the nursing station; -Plugs should not be hanging out of the wall or propped up by furniture. During an interview on 07/26/24, at 2:20 P.M., the DON said outlets should not have furniture propping up plugs and staff should notify maintenance for repair. During an interview on 07/26/24, at 11:46 A.M., the Administrator said plugs should not be supported by furniture to stay in the outlet.

Based on interview, observation, and record review, the facility failed to facilitate and support each resident's right to self-determination when staff failed to provide baths/showers to two residents (Resident #46 and #49) as requested and care planned. A sample of 27 residents was reviewed in a facility census with a census of 101. Review showed the facility did not provide a policy related to showers/bathing of residents. 1. Review of Resident #46's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses include: cerebral infarction (stroke), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), systemic lupus erythematosus (SLE - an autoimmune disease, the immune system of the body mistakenly attacks healthy tissue), cognitive communication deficit, and congestive heart failure (CHF - condition in which the heart cannot pump enough blood to the body's other organs). Review of the resident's care plan, last reviewed on 03/08/24, showed the following: -The resident had an activities of daily living (ADL) self-care performance related to weakness and non-ambulatory status; -Staff should offer two baths/showers per week and as needed; -Resident required extensive assistance of one staff for bathing/showering. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/04/24, showed the following: -Moderate cognitive impairment; -Required partial to moderate assistance with showering/bathing; -Independent with transfers. Review of the resident's ADL sheet titled Bathing Monday & Thursday & PRN (as needed), dated 06/01/24 to 07/29/24, showed staff documented the following: -On 06/05/24, the resident received a shower; -On 06/12/24, the resident received a shower (seven days after the previous shower); -On 06/19/24, the resident received a shower (seven days after the previous shower); -On 06/24/24, the resident received a shower; -On 07/08/24, the resident received a shower (14 days after the previous shower); -On 07/18/24, the resident received a shower (10 days after the previous shower); -On 07/29/24, the resident received a shower (11 days after the previous shower). Observation and interview on 07/23/24, at 1:15 P.M., showed the resident said he/she would like showers more often. He/she only get a shower once per week. He/she felt dirty and tired when not clean. He/she was scheduled for showers on Monday and Thursdays. He/she said when received, showers twice week was good enough, but that once per week was not enough. The resident's hair was uncombed and dull. 2. Review of Resident #49's face sheet showed the following: -admitted [DATE]; -Diagnoses included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), dependence on wheelchair, acquired absence of right leg and left leg above the knee (limb was amputated), chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), chronic respiratory failure a with hypoxia (condition not have enough oxygen in the tissues in the body), and obstructive and reflux uropathy (urine cannot drain through the urinary tract, and may back up into the kidneys). Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Required substantial to maximal assistance with showering/bathing; -Dependent on staff for transfers. Review of the resident's care plan, last reviewed 07/18/24, showed the following: -The resident had an ADL self-care performance deficit related to bilateral above the knee amputation; -The resident preferred bathing/showering on Monday, Thursday, and as needed; -The resident required extensive assistance of one staff for bathing/showering; -The resident required extensive assistance of two staff for bed mobility; -The resident required mechanical lift, Hoyer, with two staff assistance for transfers. Review of the resident's ADL sheet, titled Bathing Monday & Thursday & PRN, dated 06/01/24 to 07/29/24, showed staff documented the following: -On 06/11/24, the resident received a bed bath (at least 11 days after the previous bath/shower); -On 06/13/24, the resident received a shower; -On 06/25/24, the resident received a shower (12 days after the previous shower); -On 07/24/24, the resident received a shower (one month after the previous shower); -On 07/28/24, the resident received a bed bath. Observations and interview on 07/23/24, at 11:16 A.M., showed the resident said he/she had not had any shower or bed bath since 07/03/24, when came off hospice. The resident's hair had a greasy, oily, and dull appearance. The resident said he/she needed a shower. He/she felt crusty, dirty, nasty, and smelled without a shower. The resident said he/she had agreed to a full shower one to two times per month because he/she did not tolerate the Hoyer lift (mechanical device with a sling attached to lift and transfer a non-ambulatory resident) well with skin issues on the back side. He/she thought at one time the physician ordered for him/her to receive bathing/shower five times per week, but he/she would settle for twice per week. During an interview on 07/26/24, at 12:30 P.M., Certified Nurse Aide (CNA) S said residents on hospice services should be offered showers from the facility staff as well. The resident just came off hospice and the resident's hospice staff was great about getting him/her cleaned. The resident took two showers per month and the rest of the time had bed baths. He/she did not provide showers last week as the resident was still on hospice. 3. During an interview on 07/26/24, at 10:25 A.M., Licensed Practical Nurse (LPN) G said that showers are done by shower aides with the schedule they had. He/she had not seen any residents not appear clean or heard of no shower for weeks. 4. During an interview on 07/26/24, at 12:30 P.M., CNA S said that he/she had a shower list and that residents should be offered two showers per week. Some residents only take one per week. 5. During an interview on 07/26/24, at 2:20 P.M., the Director of Nursing (DON) said staff should offer two showers/baths per week, even if on hospice service. Staff should communicate in report if a resident was no longer on hospice although nothing should change because staff should already be offering two shower/baths per week. Residents should not have to wait 20 days to have a shower/bath. 6. During an interview on 07/26/24, at 3:00 P.M., the Administrator said staff should offer residents showers/baths two times per week even if on hospice. Residents should not have to wait three weeks for shower.

Based on observation, interview, and record review, the facility failed to ensure each resident's personal privacy was protected when staff failed to shut the door for one resident (Resident #6) while providing personal care exposing him/her to anyone passing the room. The facility census was 101. Review of the facility's policy titled Dignity, last revised in February 2021, showed the following information: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; -Residents' private space and property are respected at all times; -Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of the Resident #6's face sheet showed the following information: -admitted [DATE]; -Diagnoses include diabetes, obesity, Alzheimer's disease, chronic kidney disease, and major depressive disorder. Review of the resident's quarterly Minimum Data Sheet (MDS - a federally mandated assessment tool filled out by facility staff), dated 05/01/24, showed the following information: -Moderate cognitive impairment; -Dependent on staff for all personal cares and mobility; -Incontinent of bowel and bladder. Review of the resident's care plan, last revised on 10/17/22, showed extensive assist of two staff required for personal care. Observation on 07/25/24, at 10:37 A.M., showed the resident's room door open with the the resident's unclothed back of his/her body visible from the hall. The resident was laying on his/her left side facing toward Certified Nursing Assistant (CNA) E. The resident was undressed from the waist down. CNA said oh, sorry, I should have pulled this. CNA E left the side of the resident and pulled the curtain to provide privacy. CNA E said he/she was performing incontinence care and had just finishing up. During an interview on 07/26/24, at 9:15 A.M., the resident said he/she did not particularly like his/her whole body shown to the hall, but his/her roommate likes the door open, so it is often left open during care. During an interview on 07/26/24, at 9:39 A.M., Certified Nursing Assistant/Certified Medication Technician (CNA/CMT) F said a resident's bare body should never be seen from the hallway. Staff should provide privacy for the resident prior to providing care. The resident's roommate has claustrophobia (a fear of confined spaces), so he/she does not like the door to be closed often. But, in that case, staff should still pull the privacy curtain. During an interview on 07/26/24, at 9:50 A. M., Licensed Practical Nurse (LPN) G said he/she expected staff to provide privacy during care by closing the curtain around them. There should never be any instance when walking down the hall should you see an unclothed resident. During an interview on 07/30/24, at 12:08 P.M., the Admissions Coordinator said it is never acceptable to be able to see an exposed resident from the hallway. During an interview on 07/30/24, at 1:33 P.M., the Director of Nursing (DON) and Administrator agreed and said that residents' doors and curtains should not be open while incontinent care is being performed.

Based on observation, interview, and record review, the facility failed to complete the required Preadmission Screening and Resident Review (PASARR - a two level tool used to screen each resident in a nursing facility for mental disorder or intellectual disability prior to admission) prior to or upon admission to the facility for one resident (Resident #14). The facility census was 101. Review of the facility's policy titled Admission Criteria, dated March 2019, showed the following information: -All new admissions and readmissions are screened for mental disorders, intellectual disabilities, or related disorders per the PASARR process; -The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a mental disorders, intellectual disabilities, or related disorders; -If the level I screen indicates that the individual may meet the criteria for a mental disorders, intellectual disabilities, or related disorders, he/she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process; -Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he/she needs, and whether placement in the facility is appropriate; -The state PASARR representative provides a copy of the report to the facility; The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation; -Once a decision is made, the state PASARR representative, the potential resident, and his/her representative are notified. 1. Review of Resident #14's face sheet (brief overview of resident information) showed the following information: -admitted [DATE]; -Diagnoses include dysphagia (difficulty swallowing), intellectual disabilities, cognitive communication deficit, visual loss in both eyes, and dementia. Review of the resident's care plan, last revised on 05/12/21, showed the following information: -Required extensive assistance with two staff for toileting, mobility, dressing, and transfers related to intellectual disabilities; -Visual and hearing disablement; -Lacked capacity to understand and make decisions regarding healthcare. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 05/25/24, showed the following information: -Resident rarely or never understood; -Substantial to maximum assist from staff for personal care and mobility; -Incontinent of bowel and bladder. Review of the resident's record on 07/23/24, at 2:28 P.M., showed no Level I or II PASARR completed. During observation and interview on 07/25/24, at 12:43 P.M., the MDS Coordinator said she is responsible for PASARR's. Level I PASARR's are completed at the hospital prior to admission to the facility. If the resident comes from home, then the facility will complete it. A Level II is only completed if the resident has had a recent behavioral, psychiatric, or impatient stay at the hospital. If a resident does require a level II, the facility contacts Bock Associates and they will come and complete it for the facility. She does not believe this resident would trigger a Level II. The resident has been at the facility for a long time, so he/she should have a completed PASARR. The MDS Coordinator reviewed the resident's electronic medical record (EMR) and said she could not find one. The MDS Coordinator said the Medical Records Nurse might have record of his/her PASARR in paper form. During an interview on 07/26/24, at 1:42 P.M., the Medical Records Director said they were unable to find the resident's PASARR in the facility's records due to him/her being at the facility so long. During an interview on 07/30/24, at 1:33 P.M., the Director of Nursing (DON) and Administrator said, a PASARR Level I should be completed prior to admission to the facility. If they don't have one, the MDS Nurse is responsible for completing them. The resident hasn't had any behavioral admissions, so they do not believe he/she would require a Level II, but he/she should at least have had a Level I completed.

Based on observation, interview, and record review, the facility failed to ensure all residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene when staff failed to provide peri-care and change urine soaked items for one resident (Resident #42). The facility census was 101. Review of the facility's policy titled Urinary Incontinence- Clinical Protocol, last revised April 2018, showed staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. Review showed the facility did not provide a policy regarding incontinent care and/or performing incontinent care. 1. Review of the Resident #42's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses include chronic kidney disease, overactive bladder, muscle wasting and atrophy (loss of muscle tissue, size, and strength), and diabetes mellitus. Review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 06/25/24, showed the following information: -admitted [DATE]; -Cognitively intact; -Dependent on staff for mobility; -Substantial to maximum assistance from staff needed for personal hygiene; -Incontinent of bladder. Review of the resident's care plan, last revised on 07/24/24, showed the following information: -Frequent bladder incontinence; -Staff to check as required for incontinence. Staff to wash, rinse, and dry perineum (sensitive skin between genitals). Staff to change clothing as needed after incontinence episodes; -Staff to monitor for signs and symptoms of infection; -At times resident refused to allow staff to change him/her. Puddles of urine have been under his/her chair and resident remains non-compliant with allowing staff to change him/her. Observation on 07/24/24, at 3:37 P.M., showed the following: -The resident sat in his/her wheelchair in his/her room with the call light on. He/she said they were waiting for staff to return to provide care. -Certified Nursing Assistant (CNA) I entered the room at 3:40 P.M. and said he/she would be performing care as soon as he/she found some help. At 3:48 P.M., CNA I , CNA H, and the Assistant Director Of Nursing (ADON) entered the room. CNA I, CNA H, and ADON donned (put on) gowns. At 3:50 P.M., CNA J knocked on the resident's door and entered with a Hoyer lift (mechanical lift). -CNA I and CNA H donned gloves. CNA I obtained the Hoyer lift and positioned it in front of the resident. CNA I and CNA H both obtained Hoyer sling (sling that goes under the resident and hooks to the lift) straps from under the resident and hooked them up to the lift. CNA I operated the Hoyer lift and lifted the resident into the air, while CNA H guided the resident's legs. While aides were doing so, urine was seen on the resident's wheelchair pad that he/she was sitting on and dripping onto the floor from the point of the resident's wheelchair to the bed. -Once the resident was over the top of the bed, CNA I lowered the lift and resident onto the bed with CNA H guiding. CNA I and CNA H unlatched the Hoyer sling from the lift. The ADON prepped brief and laid it on the bed for the aides and then obtained a towel and began cleaning up urine spill on the floor with his/her shoe. -CNA H and CNA I pulled down the resident's pants and took off the resident's shoes. CNA I and CNA H pulled down the resident's dirty brief and exposed the resident. CNA I doffed (took off) gloves and donned new gloves. CNA I handed wipes to CNA H. CNA H wiped under the resident's pannus (excess skin and fat that hang down from the stomach) and down each side of the residents' inner thighs with the same wipe change. The CNAs did not provide peri-care (washing of genitals and anal area). The resident then rolled toward CNA H and CNA I wiped the resident's bottom three times with one wipe. -With no hand hygiene or glove change, CNA I obtained and placed a clean brief under the resident. The wet Hoyer sling was not changed and remained under the resident. Resident rolled toward CNA I and CNA H, pulled out that side of the resident's brief. Resident rolled back onto his/her back. CNA H and CNA I latch the clean brief around the resident and asked the resident if he/she would like them to change his/her pants. The resident said no. CNA H and CNA I did not tell the resident that his/her pants were urine soaked. CNA I and CNA H pulled the residents pants back up. -CNA H and CNA I doffed gloves. CNA H washed hands and CNA I did not. CNA I obtained the Hoyer lift and put it over the top of the resident. CNA I and CNA H latched the Hoyer sling to the Hoyer lift. CNA I operated the Hoyer lift, while CNA H guided the residents' legs. CNA H locked the resident's wheelchair, and CNA I lowered the Hoyer lift and resident down onto the urine-soaked pad in the wheelchair. Before unhooking the resident from the lift, the surveyor asked the aides if they had checked to see if the pad in the resident's wheelchair was urine-soaked. Both aides did not check and unhooked the Hoyer sling from the lift. During an interview on 07/26/24, at 9:39 A.M., CNA/Certified Medication Tech (CMT) F said to provide incontinent care staff must, provide privacy, gather all necessary supplies, and perform hand hygiene and don gloves prior. Staff should let the resident know what they are going to be doing. Staff would cleanse front to back, one side of the privates at a time, then down the middle at the end. One wipe per swipe. At the end of that care, staff may apply barrier cream then put the residents' clothes/brief back on. Staff should wash your hands and don clean gloves before and after care, and anytime they go from a dirty surface to a clean one. It would never be acceptable to not change out soiled clothing/linens. During an interview on 07/26/24, at 9:50 A. M., Licensed Practical Nurse (LPN) G said for incontinent care, he/she expected staff to wash their hands, don gloves, remove any dirty items, take off gloves, wash hands, and don new gloves prior to starting care. After cleansing, staff should change wash their hands, don new gloves, then move onto the resident's backside, one wipe per swipe. It is never acceptable to not change out soiled clothing/linens. During an interview on 07/30/24, at 12:08 P.M., the Admissions Coordinator said that staff should always wash their hands, especially when going from a dirty surface to a clean one. Staff should also not leave a resident in soiled clothing or linens. During an interview on 07/30/24, at 1:33 P.M., the Director of Nursing (DON) and the Administrator said there should be two staff for providing incontinent care. Hand hygiene should be performed, the curtain should be pulled, and staff should explain what they are doing. The staff should don gloves and proceed to performing care. One staff member should assist with getting the resident positioned. The second staff should pull down the resident's brief and obtain three wipes. One wipe per side, and one wipe for the middle, utilizing one wipe per swipe. After that, staff should doff their dirty gloves, perform hand hygiene, and don clean gloves, otherwise everything is contaminated. Staff should make sure all linens and clothing being put back on the resident are clean.

Based on observation, record review, and interview, the facility failed to ensure that one resident's (Resident #46) code status (type of emergent treatment a person would or would not receive if their heart or breathing were to stop) matched throughout the medical record out of a sample of 27 residents. The facility census was 101. Review of the facility policy titled Advance Directives, dated [DATE], showed the following information: -Advance directives will be respected in accordance with state law and facility policy; -Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so; -Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members or legal representative, about the existence of any written advance directives; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive; -The Interdisciplinary Team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record; -Changes or revocations of a directive must be submitted in writing to the administrator. The care plan team will be informed of such changes so that appropriate changes can be made in the resident assessment and care plan. 1. Review of Resident #46's face sheet (brief information sheet about the resident), current as of [DATE], showed the following: -admitted on [DATE]; -Diagnoses included cerebral infarction (stroke), altered mental status, chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure with hypoxia (condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen levels or chronically high carbon dioxide levels), and systemic lupus erythematosus (SLE - an autoimmune disease. In this disease, the immune system of the body mistakenly attacks healthy tissue); -Code status of do not resuscitate (DNR - if a person's heart or breathing stops the healthcare team will not try to restart it). Review of the resident's care plan, last revision on [DATE], showed the following: -Code status is full code (the resident wished to receive cardiopulmonary resuscitation (CPR - an emergency life-saving procedure completed when someone's breathing or heartbeat has stopped); -Staff should make sure that the full code is listed as the resident's code status on the resident profile/face sheet; -Staff should provide opportunity for the resident to discuss feeling and ask questions related to end of life decision as needed; -Staff should review code status with the resident/responsible party quarterly or as needed. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated [DATE], showed resident cognitively intact. Review of the resident's Social Services - Assessment and Note, dated [DATE], showed the following: -Quarterly assessment; -Code status of full code; -Code status care plan if the resident's heart stops beating or the resident stops breathing CPR will be initiated per the resident's/responsible party's wishes; -Check to make sure that full code is listed as the resident's code status on the resident profile/face sheet; -Review code status with the resident/responsible party quarterly and as needed. Review of the resident's physician's order sheet, active as of [DATE], showed an order dated, [DATE], for DNR. During an interview and observation on [DATE], at 3:00 P.M., the resident said that he/she would want CPR started if his/her heart or breathing stopped. The care plan inside the resident's closet door showed resident as full code. During an interview on [DATE], at 3:40 P.M., Certified Nurse Aide (CNA) N said that a resident's code status could be found on the top of the screen in the electronic medical record (EMR) and in the resident's closet care plans. During an interview on [DATE], at 9:05 A.M., CNA B said that resident code status was located in the EMR and in each resident's closet care plan. The information should match. During an interview on [DATE], at 9:15 A.M., Certified Medication Technician (CMT) M said staff could locate a resident's code status by looking in the EMR and inside a resident's closet door. He/she said the information should match and thought someone checked that monthly. During an interview on [DATE], at 3:55 P.M., Licensed Practical Nurse (LPN) L said that code status for residents can be found on the resident's face sheet in the EMR, as well as in the resident's closets, and this information should match. During an interview on [DATE], at 10:08 A.M., LPN U said he/she would look in the EMR for a resident's code status. During an interview on [DATE], at 10:25 A.M., LPN G said that resident code status was located in the EMR on the face sheet, medication administration record, and the physician orders. The information was also located inside the resident closets on a posted paper care plan. The information should match. He/she was unsure who audits charts for accuracy. During an interview on [DATE], at 10:35 A.M., Registered Nurse (RN) D said that resident code status could be found in the resident medical record and on the care plan posted in residents' closets. The information should match and he/she thought that social services audited for accuracy. During an interview on [DATE], at 10:15 A.M., the Social Service Director (SSD) said the staff would notify him/her when a code status should be changed in the care plan. He/she did not have access to enter information on the face sheet. He/she thought the Administrator audited the charts. During an interview on [DATE], at 2:08 P.M., the Admission Coordinator said that he/she reviewed initial admission code status with residents. When a resident returned from the hospital the nursing staff reviewed if any changes have been made. The nursing staff should audit to ensure the code status is accurate and matched throughout chart. During an interview on [DATE], at 2:20 P.M., Director of Nursing (DON) said resident code status should match throughout the chart. The admission nurse entered the code status information and then the next day on match back the orders should all be checked. (Match back is the chart audit 24 hours after orders are entered.) The resident's care plan and outside hospital orders should all match. When a resident leaves and returns from the hospital the nurses should ensure and update information and ensure it all matches throughout the record. At times the hospital might make someone a DNR at hospital even though the resident has not signed the DNR form. The closet care plan should be updated and accurate, however, it is a guide. Staff should always verify the electronic record. Usually, social services ensured that charts were accurate when doing the quarterly care plan updates. During an interview on [DATE], at 3:00 P.M., the Administrator said that the admission nurses should enter resident code status and then there is a match back to ensure orders match. Code status audits are done every three months with care plan meetings and in-between as needed. The information can be located on the top banner of the EMR, in physician orders, signed documents, and care plan. Staff should notify nurses changes in care plan or EMR are needed. Any nurse can make changes to the care plan, as well as social services. All resident code status should match through their chart. Social Services Director completes quarterly care plan. Inaccuracies should be caught during match back even on readmission from hospital.

Based on observation, record review, and interview, the facility failed to ensure catheter (a sterile tube inserted into the bladder to drain urine) use per standard of practice when one resident's medical record (Resident #47) failed to have a diagnosis to show why the resident had a catheter. The facility census was 101. Review of the facility policy Catheter Care, Urinary, revised, August 2022, showed the following information: -To prevent urinary catheter associated complications, including urinary tract infections (UTI's) staff will review the resident's care plan to assess for any special needs and review and document the clinical indications for catheter use prior to inserting. 1. Review of Resident #47's face sheet (a brief look at the residents personal, incoming information), showed the following information: -admitted [DATE] -Diagnoses included kidney complications. Review of the resident's progress note dated 05/22/24, at 5:18 P.M., showed the resident arrived to facility with a catheter in place. (Staff did not document the diagnosis that warranted the catheter use.) Review of the resident's admissions Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 05/31/24, showed the following information: -Cognitively moderately impaired; -Resident required a catheter; -Diagnoses showed resident has had UTI's. (The MDS did not show a diagnosis associated with need of a catheter.) Review of the resident's physician's orders, dated 07/07/24, showed the following information: -An order, dated 05/26/24, for Foley catheter output documented every shift for health maintenance. (The order did not include the diagnosis that warranted the catheter use.) -An order, dated 06/03/24, for foley catheter to be changed 22nd of every month and as needed. (The order did not include the diagnosis that warranted the catheter use.) -An order, dated 06/03/24, for Foley cath care every shift and as needed. (The order did not include the diagnosis that warranted the catheter use.) Review of the resident's care plan, dated 07/07/24, showed the following information: -The resident had an indwelling catheter; -The resident will be/remain free from catheter-related trauma; -The resident will show no signs or symptoms of urinary infection; -Monitor and document intake and output as per facility policy; -Monitor for signs and symptoms of discomfort on urination and frequency; -Monitor/document for pain/discomfort due to catheter. (Staff did not care plan the diagnosis that warranted the catheter use.) Review of the resident's July 2024 Treatment Administration Record (TAR) showed staff did not document the diagnosis that warranted the catheter use. Review of the resident's progress note dated 07/22/23, at 10:19 A.M. showed catheter changed per physician orders. (Staff did not document the diagnosis that warranted the catheter use.) During an interview on 07/30/24, at 11:15 A.M., the Infection Control Nurse said there should be a diagnosis as to why a resident would require a catheter. Someone should have questioned why there was no diagnosis for the catheter. During an interview on 07/30/24, at 1:35 P.M., the Admissions Coordinator said the following: -He/she usually made sure the diagnoses are included in the physician's orders; -A resident requiring a catheter should definitely have a diagnosis as to why they would need it. During an interview on 07/30/24, at 2:10 P.M., the Director of Nursing (DON) and Administrator said the following: -There should be a diagnosis for why the resident would need a catheter; -This is important because physician orders come from diagnosis' and must be followed. 41787

Based on observation, interview, and record review, the facility failed to ensure respiratory care consistent with standards of practice when staff failed to obtain a physician's order for staff to administer continuous positive airway pressure machine (CPAP - machine used to deliver constant and steady air pressure while sleeping) for the treatment for obstructive sleep apnea (breathing repeatedly stops and starts during sleep) at bedtime as care planned for one resident (Resident #49) with a CPAP machine at bedside. The facility census was 101. Review of the facility policy titled CPAP Support, dated March 2015, showed the following information: -Purpose to provide the spontaneously breathing resident with continuous airway pressure machine with or without supplemental oxygen; to improve oxygenation in residents with respiratory insufficiency, obstructive sleep apnea or restrictive/obstructive lung disease; and to promote resident comfort and safety; -Review the physician's order to determine the oxygen concentration and the pressure for the CPAP machine; -Review and follow the manufacturer's instructions for CPAP machine setup and oxygen delivery; -Document in the resident's medical record the time CPAP therapy was started and the duration of therapy; the mode and settings for the CPAP; and how the resident tolerated the treatment. 1. Review of Resident #49's face sheet showed the following: -admitted [DATE]; -Diagnoses included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), acquired absence of right leg and left leg above the knee (limb was amputated), congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), and chronic respiratory failure a with hypoxia (condition not have enough oxygen in the tissues in the body). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 07/07/24, showed the following: -Cognitively intact; -Use of supplemental oxygen; -Staff did not mark use of CPAP treatment. Review of the resident's care plan, last reviewed 07/18/24, showed the following: -The resident had altered respiratory status/difficulty breathing related to sleep apnea; -Staff should apply auto titrating CPAP at 9-15 cwp (centimeters of water pressure (setting to be ordered by the physician)) with heated humidifier; -Staff should monitor, document, and report abnormal breathing pattern to the physician. Review of the resident's June 2024 and July 2024 Treatment Administration Record (TAR) and Medication Administration Record (MAR) showed no order for CPAP placement, pressure setting, or monitoring. Review of the resident's physician order sheet, current as of 07/26/24, showed no order for application or use of CPAP therapy at bedtime. During observation and interview on 07/23/24, at 11:14 A.M., showed the resident's CPAP was on the bedside table. The resident said that the CPAP mask was not always applied by staff at night or machine turned on. The resident said he/she falls asleep and forgets to tell the staff and did not want to bother staff. He/she said that he/she would use the CPAP if staff helped him/her at night. During an interview on 07/25/24, at 3:45 P.M., Licensed Practical Nurse (LPN) L said that CPAP treatment would populate on the nursing TAR during the night shift. The resident did not want his/her CPAP on at night. He/she thought the resident's family took the CPAP out of the room. During an interview on 07/26/24, at 10:08 A.M., LPN U said that the nursing TAR showed what treatments are required for each resident during the shift. He/she did not know if CPAP was on the TAR. During an interview on 07/26/24, at 10:35 A.M., Registered Nurse (RN) D said that treatments and medications populate on the MAR and TAR for each resident. He/she would expect there was an order for a resident with CPAP therapy. During an interview on 07/26/24, at 2:20 P.M., the Director of Nursing (DON) said that the nurses are responsible for CPAP treatment for residents and there should be an order for use. The CPAP should be in the care plan and there should be an order for nurses to apply the CPAP including the pressure settings. The nurses could communicate with aides for CPAP application. During an interview on 07/26/24, at 3:00 P.M., the Administrator said there should be an order for all treatments, including CPAP therapy. The nurses were responsible to ensure the CPAP was started for the resident.

Based on observation, record review, and interview, the staff failed to ensure correct installation and maintenance of all bed rails when the bed rails of one resident (Resident #49) could be moved by the resident back and forth several inches in each direction. The facility had a census of 101. Review showed the facility failed to provide a policy regarding side rail use, installation, and monitoring. 1. Review of Resident #49's face sheet showed the following: -admitted [DATE]; -Diagnoses included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), dependence on wheelchair, acquired absence of right leg and left leg above the knee (limb was amputated), chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), chronic respiratory failure a with hypoxia (condition not have enough oxygen in the tissues in the body), and obstructive and reflux uropathy (urine cannot drain through the urinary tract, and may back up into the kidneys). Review of the resident's significant change in status Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/07/24, showed the following: -Cognitively intact; -Required substantial to maximal assistance with showering/bathing; -Dependent on staff for transfers. Review of the resident's care plan, last reviewed 07/18/24, showed the following: -The resident had an activities of daily living (ADL) self-care performance deficit related to bilateral above the knee amputation; -The resident had enable bars (side rails) to left upper and right upper sides of bed to increase bed mobility and assist with positioning during staff assisted ADLs due to bilateral below the knee amputations; -The resident was informed of risks and benefits of enable bars and consent form signed by resident; -Side rail assessment performed to ensure appropriateness of halo bars for resident; -Side rail zone measurements every monthly and with every significant change; -Assessment of side rail use dated 4/4/23. Observation and interview on 07/25/24, at 10:53 A.M., showed the following: -The resident seated upright in bed with bilateral (both sides) half side rails on the bed; -The resident said that the right-side rail was very loose and that he/she used the bed rail throughout the day to move him/herself in the bed; -The resident grabbed the right-side rail and pulled with the rail several inches back and forth and side to side when he/she pulled on the rail. The resident said that he/she had notified staff of the rail being this loose. During an interview on 07/26/24, at 11:10 A.M., the Maintenance Director said the following: -He installed enabler bars when notified that therapy had done an evaluation. He checked the measurements, ensured they are installed tightly and securely, and educated the resident on the use of the bar. He checked monthly to ensure nothing was loose or broken; -He visually inspected all bed rails every month, but did not keep a log of this check. -Staff should notify maintenance of items in need of repair or write on the maintenance log at the nursing station. During an interview on 07/26/24, at 2:20 P.M., Director of Nursing (DON) said the following: -Side rail assessments should be reviewed by all management teams; -The maintenance staff should monitor for measurements and safety quarterly or when changes in resident condition; -Staff should notify maintenance if there is something wrong with the bed rail so it can be fixed quickly. During an interview on 07/26/24, at 11:46 A.M., the Administrator said that the Maintenance Director was given a list of all side rails once per month to ensure they were intact and not loose. There was nothing other than a check mark for this check. All items should be repaired any time found or notified loose. Staff should notify maintenance of any needed repairs or damage.

Based on observations, interviews and record reviews the facility failed to follow professional standards of practice when a certified medication technician (CMT) incorrectly administered Resident #2's medications, which included controlled opioid narcotics, to Resident #1 on 2/8/13. As a result of this medication error, Resident #1 became lethargic, had a low oxygen level, and abnormal vital signs that included slowed and irregular respirations. The resident required the administration of a total of eighteen subcutaneous doses of [MEDICATION NAME] (a medication that reverses the effects of opioid-based medications) on 2/8/13 and 2/9/13. Twelve residents were selected for medication reviews in the facility with a census of 107. 1. According to the 2001 CNA training manual, the normal ranges for pulse, respirations and blood pressures, in adults are as follows: -Pulse, 50-100 beats per minute; -Respirations, 14-20 breaths per minute; -B/P, Systolic (top number) between 100 to 150 mm Hg (millimeters of mercury); - B/P - Diastolic (bottom number) between 60 to 90 mm Hg. 2. According to Mosby's Manual of Diagnostic and Laboratory Tests, normal pulse oximetry value in the elderly should be equal to or greater than 95% and a critical pulse oximetry value when equal to or less than 75%. 3. Record review of the facility policy on the General Administration of Medications showed the following information: -Drugs and biologicals may be administered only by licensed physicians, licensed registered or practical nursing personnel, or by other personnel who are duly authorized to perform such services under state law; -Medications must be administered by the same person preparing the doses for administration; -Medications may not be prepared in advance and must be administered within one (1) hour of preparation; -Medications must be charted immediately following the administration by the person administering the drugs. The date, time administered, dosage, etc, must be entered in the medical record and signed by the person entering the data; -Should there be any doubt as to the correct identification of a resident, medication may not be administered to that resident until positive identification has been made; -Should there be any doubt concerning the administering of medication, the physician's orders must be verified before the medication is administered; -Medications ordered for one resident may not be administered to another resident; -Incidents related the resident's refusal of medications and/or treatments will be recorded in the resident's medical record. 4. Record review of the facility's policy on medication errors showed the following information: -Procedure: -A medication error is a discrepancy between what the physician orders and what is administered. Medication errors include: -Omissions; -Unauthorized drugs (drugs administered without a physician's order); -Wrong dose; -Wrong route of administration; -Wrong dosage form; -Wrong time; -Any medication error must immediately be reported to the resident's attending physician, charge nurse and Director of Nursing (DON). -A medication error form will be filled out by the medication nurse for each medication or treatment error. -The medication nurse will document in the medical record, and record the incident on a 24 hour report form. -Reporting and documentation: -Report any abnormal or unusual findings to the charge nurse. -Document the appropriate information in the resident's medical record. 5. Mosby's 2013 Nursing Drug Reference showed the treatment for [REDACTED]. 6. Record review of the Resident #1 medical record showed the following information:-Admission to the facility 3/29/12; -[DIAGNOSES REDACTED]. -Staff assessed the resident as needing extensive assistance in bed mobility, transfers, dressing and personal hygiene; -Care plan dated 1/28/13, showed the resident is terminal and for staff to keep communication with resident and family to support their wishes and answer questions or concerns, and work with hospice, if ordered. Resident identified with cognition loss with expected continued decline. Care plan also showed staff to administer medications per physician orders. Resident identified at risk for falls and to have non-self release seat belt on for safety and positioning; -On 2/4/13, diet changed to pureed and honey thickened liquids; -On 2/8/13, documented resident given [MEDICATION NAME] inadvertently. Record review of the medication error report dated 2/8/13 regarding the resident, showed the following information:-Date and time of error, 2/8/13 at 6:30 A.M.; -Error, "resident received another resident's medications at 6:30 A.M. and then received his/her own medications at 8:30 A.M. Resident became lethargic, with garbled speech, a gurgling quality to throat, decreased oxygen saturation, decreased blood pressure and was diaphoretic (sweaty). Physician notified and [MEDICATION NAME] 0.4 mg/dl (used for reversal of opioid depression including respiratory depression, IV preferred route, also given IM, intratracheal and subq) ordered to give now and to monitor every 15 minutes with vital signs taken; -Date and time reported to DON, 2/8/13 at 9:30 A.M.; -Date and time physician notified, 2/8/13 at 9:30 A.M.; -Wrong medications (ordered for Resident #2 and administered to Resident #1) administered to Resident #1 at 6:30 A.M. included: -[MEDICATION NAME] 20 mg (antidepressant); -[MEDICATION NAME] 25 mg (beta blocker); -[MEDICATION NAME] 0.5 mg (diuretic); -[MEDICATION NAME] 10 mg ([MEDICATION NAME]); -[MEDICATION NAME] 100 mg (stool softener); -[MEDICATION NAME] 17 gm mixed in 4-8 oz of fluid (fiber); -[MEDICATION NAME] tablet (a supplement); -[MEDICATION NAME] 20 mg (used in treatment of [REDACTED]. -[MEDICATION NAME] 30 ml (laxative); -[MEDICATION NAME] 225 mcg ([MEDICAL CONDITION] product); -[MEDICATION NAME] mg (sustained release controlled opioid narcotic); -[MEDICATION NAME] 15 mg (immediate release controlled opioid narcotic). Record review of the 2/1-28/2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. included: -[MEDICATION NAME] 0.5 mg (controlled antianxiety scheduled for 7:00 A.M., signed out at 8:00 A.M. on the controlled drug record); -[MEDICATION NAME] 10 mg (antidepressant scheduled for 7:00 A.M.); -[MEDICATION NAME] 60 mg (calcium channel blocker scheduled for 6:00 A.M.); -KCL 10 mEq (electrolyte supplement scheduled for 7:00 A.M.); -[MEDICATION NAME] 20 mg (diuretic scheduled for 7:00 A.M.); -[MEDICATION NAME] 12.5 mg (beta blocker scheduled for 7:00 A.M.); -MVI (vitamin); -[MEDICATION NAME] 75 mg (antiplatelet agent scheduled for 7:00 A.M.); -[MEDICATION NAME] 600 mg ([MEDICATION NAME]); -[MEDICATION NAME] 300 mg (antibiotic used in treatment of [REDACTED]. -[MEDICATION NAME] 150 mg (antifungal agent); -[MEDICATION NAME] 600 mg (antibiotic scheduled for 7:00 A.M.); -On 2/8/13, physician ordered [MEDICATION NAME] 0.4 mg/ml 1 ml subcutaneous (subq) one dose now showed administered at 11:15 A.M. (emergency box secured drugs showed it taken for the resident at 11:00 A.M.); -On 2/8/13, order for [MEDICATION NAME] 0.4 mg/ml subq every two hours as needed for drowsiness for 48 hours administered at 1:15 P.M.; -On 2/8/13 order for [MEDICATION NAME] 0.4 mg/ml subq every hour starting at 2:00 P.M., administered at 2:00 P.M., 3:00 P.M., 4:00 P.M., 5:00 P.M., 6:00 P.M., 7:00 P.M., 8:00 P.M., 9:00 P.M., 10:00 P.M.; -On 2/8/13 order starting at 11:00 P.M. for [MEDICATION NAME] 0.4 mg/ml 1 ml subq every two hours until 8:00 A.M. on 2/9/13, administered at 11:00 P.M. 2/8/13 and then on 2/9/13 at 1:00 A.M., 3:00 A.M. 5:00 A.M., and 7:00 A.M.; -On 2/9/13, order for [MEDICATION NAME] 0.4 mg/ml subq now administered at 11:00 A.M.; -On 2/9/13, order for [MEDICATION NAME] 0.4 mg/ml subq now administered at 5:00 P.M.; -On 2/8/13, order for [MEDICATION NAME] opth sol 2 drops sublingual (sl) (under the tongue) every 2 hours as needed for secretions administered at 11:20 A.M. and 1:20 P.M.; -Order for oxygen at 3 liters (L) per nasal cannula as needed to keep oxygen sats above 90%. On 2/8/13 at 9:00 A.M. staff documented the resident complained of shortness of breath and had an oxygen sat at 82% on room air and resident started on oxygen at 3 L. -On 2/8/13 order for [MEDICATION NAME] to both lower extremities to be applied in the morning and removed at bedtime; -On 2/8/13 order for [MEDICATION NAME] 0.5 mg/3 cc NS breathing treatment every four hours for four times administered at 2:00 P.M., 6:00 P.M., 10:00 P.M. and on 2/9/13 at 2:00 A.M. and then the order changed to breathing treatment four times a day; -On 2/8/13 order for [MEDICATION NAME] (controlled narcotic) 20 mg/ml 0.5 ml/sl every 30 minutes as needed for pain/dyspnea to be started on 2/9/13. Record review of the nurses' notes regarding the resident showed the following information: -On 2/7/13 at 1:45 P.M., staff documented the resident continues on antibiotic (for) pneumonia. Resident's rash continues to entire body. No temperature. Non productive cough noted. -On 2/8/13 at 9:50 A.M. staff documented the resident was brought out of dining room that morning with increased shortness of breath, head hyper-extended (head up and back with neck extended). Pulse ox (oxygen saturation) 82-86% on room air, oxygen placed at 3 L per nasal cannula, pulse ox increased to 94%, shortness of breath continued. Head of bed elevated, lungs coarse, increased secretions noted. Eyes glazed, responded appropriately. Resident praying to God to take him/her. Blood pressure 143/67, pulse 97, respirations 10 and irregular, temperature 96.7 axillary. Resident was given medications twice, medications unknown. Reported to the physician and orders obtained one dose [MEDICATION NAME] 0.4 mg/ml 1 ml subq now. Also an order for [REDACTED]. -On 2/8/13 at 11:30 A.M., staff documented resident awakening and talking with staff appropriately. Monitoring often. Shortness of breath resolved. Resident continues on oxygen at 3 L. Call placed to durable power of attorney (DPOA) office at 9:55 A.M. and spoke with secretary. The secretary was updated regarding resident and condition, and stated would try to catch DPOA and call back. The secretary did call back and he/she stated spoke with the DPOA and he/she stated to do whatever medical personnel felt was necessary. -On 2/8/13 at 12:15 P.M., received call from physician and orders were received for [MEDICATION NAME] 0.4 mg/ml 1 ml subq every 2 hours for drowsiness for 48 hours. Resident continues to be alert and talking with staff, will get out of bed. Call placed to pharmacy for immediate medication. -On 2/8/13 at 1:35 P.M., resident with increased secretions and drowsiness, [MEDICATION NAME] and [MEDICATION NAME] administered. -On 2/8/13 at 2:00 P.M., physician here to see resident. New orders noted. Resident with 8 second apnea (absence of breathing) and mottling (discoloration) to feet and toes. Bilateral lower extremities cool to touch. [MEDICATION NAME] MMTX (breathing treatment) administered, oxygen continues at 3 L per nasal cannula. [MEDICATION NAME] administered as ordered. Will continue to monitor. -On 2/8/13 at 3:00 P.M., staff documented [MEDICATION NAME] administered. Resident mottled at this time and has Cheyne-Stokes (irregular breathing that frequently occurs prior to death) breathing. Resident unresponsive. Will continue to monitor. -On 2/9/13 at 1:00 A.M., staff documented resident status essentially unchanged. Resident did bite his/her lip. Resident is drowsy, somnolent (sleepy), unresponsive to stimuli, pupils non reactive to light. [MEDICATION NAME] administered. -On 2/9/13 at 7:00 A.M., staff document resident opens eyes when spoken to, pupils are non reactive to light. [MEDICATION NAME] 1 ml given per order. -On 2/9/13 at 11:00 A.M., physician updated on resident's condition with a new order received and noted. -On 2/9/13 at 5:00 P.M., staff documented the resident was awake off and on. Pupils remain non-reactive. Resident saying words, but sleeping most of the time. -On 2/9/13 at 5:30 P.M., the resident was up in highback wheelchair, awake and saying words. More alert, up to desk in wheelchair. -On 2/9/13 at 6:30 P.M., resident remains up in wheelchair. Resident ate ? cup yogurt and drank 12 oz of fluids. Resident becoming more alert the longer he/she sits up. No signs or symptoms of pain or discomfort. -On 2/9/13 at 8:25 P.M., staff documented the resident continues on antibiotics for pneumonia with no adverse effect noted. Resident up in wheelchair talking to staff, resident alert and confused. Will monitor. (no nurse' notes again until the next day at 4:45 P.M.) Record review of CNA vital signs log for the resident showed the following information: -On 2/6/13 6-2 shift, blood pressure (BP) 123/72, pulse (P) 77, respirations (R) 18, temperature (T) 98.4, PO2 (pulse oximetry value) at 94. -On 2/7/13 on 10-6 shift, T at 98.2 and PO2 at 91%. -On 2/8/13 on 6-2 shift, T at 96.7 axillary and PO2 at 94%. -On 2/8/13 on 2-10 shift, BP 122/86, P 127, R 22, T 96, PO2 at 97%. -On 2/8/13 on 10-6 shift, BP 98/68, P 130, R 14, T 96.9, PO2 at 97%. -On 2/9/13 on 6-2 shift, BP 123/68, P 110, R 12, T 97.8, PO2 at 96%. -On 2/9/13 on 10-6 shift, BP 132/87, P 128, R 18, T 97.1, PO2 at 96%. Record review of the physician history and physical for the resident dated 2/8/13, showed the following information: -Today, resident was given [MEDICATION NAME] inadvertently and given [MEDICATION NAME] and it wore him/her down and then decreased his/her responsiveness. I have given the resident 0.4 mg of [MEDICATION NAME] subcutaneously two times and then I have given two more doses here and his/her respiratory rate has improved. The resident is coughing a little bit more. This resident is frail with dementia and weakness normally. Resident was last discharged from the hospital and felt to be terminal in regards to his/her aspiration pneumonia. The resident is looking better with the increase in [MEDICATION NAME] and his/her color is better and definitely more awake. -Resident's skin after the extra [MEDICATION NAME] is warm and dry. Lungs have increased expiratory phase with upper airway rhonchi. Heart is irregularly irregular in rate and rhythm. Abdomen is soft. Extremities have 1+ [MEDICAL CONDITION] with some coolness. -I have been sitting in the room for hours watching the resident and staff have been checking on the resident closely. We will ultimately be able to stop the [MEDICATION NAME] and the goal is to make sure we keep him/her comfortable without heroics. We will make sure hospice is notified at this point. Resident's [MEDICATION NAME] will not start until tomorrow and I will make sure we do have it as the resident is declining. -Addendum: I rechecked on the resident and it is about 5:00 now and he/she is breathing more comfortable. Lungs actually sound clear. Skin is warm and dry. Resident has been getting the [MEDICATION NAME] every hour. Respiratory rate has been staying good. I have been watching the resident over the last 2-3 hours and he/she seems to be doing better. I spoke with the administrator and DON. Record review of physician telephone orders regarding the resident showed on 2/13/13, physician ordered hospice of choice for the resident. During interviews on 3/13/13 at 9:30 A.M. with CMTs E and G; staff said the following: CMT E said he/she had worked in full time capacity since January 2013, CMT G said today was his/her first day doing medications and he/she had been working as an aide at the facility for the past three weeks, CMT E said he/she was teaching medication administration to CMT G this day. Observations in the dining room on 3/13/13 at noon, showed CMT E and CMT G working at one medication cart. CMT E administered medications to residents while CMT G remained at the cart getting more medications ready for another resident. During this time, observation showed CMT E administered medications with a spoon to a resident at the dependent feeding assistance table. He/she did not have any water for the resident to drink after administering the medications nor were there any fluids on the table for the resident to drink after the administration of the medications. Observations during a medication administration pass on 3/14/13 at 1:00 P.M. showed CMT E made three errors. During an interview at this time CMT E said he/she would fill out two medication error forms, he/she did not understand the third error (failed to take a residents blood pressure as directed by the Physician prior to the administration of the heart medication). When asked if he/she had ever had to fill out a medication error form before he/she said, " yes, about a month ago". CMT E said he/she gave wrong medications to Resident #1 and it caused the resident to be lethargic. CMT E said he/she was counseled by the Administrator and the Director of Nursing (DON) after the error. During an interview on 3/14/13 at 3:20 P.M., the Administrator said, CMT E talked with Registered Nurse (RN) A and he/she was very upset. The Administrator was made aware of the errors made on CMT E's medication pass. The Administrator said we are human and "with medications, will always be making errors", but we try to minimize them. She said in her eighteen years she had not seen a medication error rate of "zero." The prior medication report form for CMT E's medication error was in another office along with requested missing medical records from Resident #1's chart. Review of the 2/8/13 medication error form showed Resident #1 received Resident #2's medications at 6:30 A.M. At 8:30 A.M., Resident #1 received his/her own ordered medications. The measure taken to prevent recurrence, showed CMT E was counseled and given written counseling. The written counseling showed the CMT will ensure that the proper medications are given to the correct resident and if an error of this magnitude happened again it would result in termination of employment. The Administrator said the DPOA for Resident #1 did not want the resident sent out to the hospital. She said the resident's Physician came in the facility that day to see the resident. At 4:50 P.M., the Administrator said CMT E had been terminated. (Record review of the employee file for CMT E, showed full time employment began on 1/28/13) During an interview on 3/16/13 at 3:25 P.M., licensed practical nurse (LPN) C said he/she worked the next day, Saturday, after he/she was told Resident #1 got the wrong medications. That day he/she administered [MEDICATION NAME] all day to the resident. The resident would wake up at times and was gurgling at times. LPN C said the resident was given [MEDICATION NAME] for the secretions and they watched him/her closely. LPN C said the resident's Physician came in the day of the incident to see the resident. LPN C said he/she had concerns about CMT E and told RN A. RN A said he/she would take care of it. During an interview on 3/16/13 at 3:55 P.M., CNA F said on the evening shift on 2/8/13, the resident had trouble breathing and he/she was not responsive. An interview and a review of a provided statement and documentation on 3/18/13 at 1:40 P.M., showed the following information regarding Resident #1's DPOA and his/her secretary: -On 2/8/13, LPN B called the DPOA's office to ask permission to send the resident to the hospital due to taking medications, not sure what they were, oxygen level dropped and his/her vital signs not being normal.(documented time on the phone call 10:27 A.M.). -DPOA's secretary called the DPOA to relay the message and the DPOA said "yes" and that he/she previously had told the folks at the facility to do whatever the doctor advised in these situations. -DPOA's secretary called LPN B after talking with the DPOA and relayed his/her instructions. Facility sending the resident to the hospital. -On 2/11/13, LPN B called the DPOA and left a message they didn't send the resident to the hospital. LPN B said they gave the resident medicine to counter act his/her symptoms. The resident came out of it and is doing fine. (Documented time on the phone call 11:37 A.M.) During an interview on 3/19/13 at 2:35 P.M., LPN B said he/she worked the 6-2 shift on 2/8/13 (Friday), when Resident #1 received some wrong medications. LPN B said about 6:30 A.M. to 6:45 A.M., he/she observed CMT E with Resident #1 in the dining room. LPN B told CMT E the resident was to have honey thickened liquids as CMT E had water for the resident after administering his/her medications. After breakfast, about 8:00 A.M., restorative aide (RA) D took the resident to the nurses' station for LPN B to assess. RA D reported CMT E had given the resident crushed medications at breakfast when the resident's head was in a hyper-extended position. LPN B noted the resident's neck was hyper-extended and he/she notified the DON the resident may have been given wrong medications. The resident was short of breath and staff started oxygen, took vital signs, and he/she was placed in bed. The physician was notified. The physician's first option was to send the resident to the emergency room . LPN B called the DPOA's office with the message and then received a message back from the DPOA's office for the resident to be sent to the emergency room . LPN B said they waited about an hour to see what the DPOA said and then the physician gave orders to keep the resident at the facility and to start the [MEDICATION NAME]. The facility had two doses of [MEDICATION NAME] in the facility emergency kit at the facility, they used both for the resident and notified the pharmacy for an immediate order for additional doses. LPN B said the vital signs should be recorded on the CNA flow sheets or in the nurses' notes. LPN B said he/she did not know what wrong medications had been given and did not know which resident did not get their ordered medications. LPN B left the facility about 2:30 P.M. that day. LPN B said he/she returned to work on the next Monday and called the resident's DPOA with a follow up report on the resident. LPN B said the facility has not had any inservices regarding this medication error. During an interview on 3/19/13 at 3:10 P.M., the DON said on 2/8/13, LPN B said he/she thought Resident #1 got the wrong medication. The DON said she did the initial notification of the resident's physician. The DON said they administered [MEDICATION NAME] to the resident from the facility emergency kit after they received the physician order. She said the resident had been on hospice at the hospital. The DON was not sure on the times that day, but said it should be in the nurses' notes and other records. During an interview on 3/19/13 at 3:30 P.M., the Administrator said he/she heard LPN B and the DON discussing the medication incident involving the resident on 2/8/13. She said it was all speculative at first. The Administrator said from the facility video, they found Resident #1 received the medications ordered for Resident #2. The Administrator said Resident #1 was not on hospice care. She said it was her understanding the staff told the circumstances of the medication incident to the DPOA and the DPOA said to keep the resident at the facility. The administrator said when staff make a medication error, they fill out a medication error form and if it was their first error they are counseled. During an interview on 3/20/13 at 9:50 A.M., the DON said after CMT E's medication error on 2/8/13, RN A observed him/her during medication passes off and on and RN A did not observe any medication error. During an interview on 3/20/13 at 10:30 A.M., RN A (RN supervisor for the resident's hall) said it was reported to him/her by LPN B on 2/8/13, (unknown time) the physician ordered [MEDICATION NAME] for the resident and the first dose was taken from the facility emergency kit. RN A said the DPOA for the resident did not want him/her sent out to the emergency room . RN A said LPN B contacted the resident's DPOA. RN A said the procedure varies when a resident gets the wrong medications and this was the first time in his/her eighteen years at the facility, he/she did not see the resident sent to the emergency room for [MEDICATION NAME] treatment. RN A said the Administrator reviewed the facility videos with CMT E about 9:00 A.M. that morning, and CMT E identified whose medications had been given to the resident. RN A said CMT E was very nervous after the error, but continued passing medications for his/her shift. He/she said this was a serious mistake and CMT E needed to learn the residents. RN A said staff were written up when a medication error occurred. RN A said the action taken depended on the situation. RN A said the staff should take vitals every 15 to 30 minutes for the first couple of hours following a medication error. RN A said he/she did not know if Resident #2 received his/her ordered medications that morning after they had mistakenly been administered to Resident #1. He/she said if the error was found early enough Resident #2 should have received his/her ordered morning medications. RN A said the resident's physician came to the facility that day and stayed with the resident for about two hours, he/she said the physician told him/her the resident was doing better than expected. During an interview on 3/20/13 at 1:00 P.M., RA D said on 2/8/13, he/she was assisting in the dining room and observed CMT E administering medications in applesauce to the resident when his/her head was backwards. RA D said the resident was on a pureed diet with honey thick liquids. He/She said the resident was not eating well. RA D said he/she took the resident to see LPN B and told LPN B about the observation with CMT E. LPN B told RA D that the resident had already had his/her medications earlier that morning. The resident remained at the nurses' station and then staff laid him/her down. RA D said previously he/she had noted CMT E was quick. During an interview on 3/20/13 at 3:30 P.M., the DON said their pharmacy consultant specified the medication administration times on the resident MARs. The staff have one hour prior until one hour after the specified time to administer the medication. If it is noted to have a blood pressure or pulse also, the CMT should have it documented prior to the medication being administered. If information is not documented it is not done. CMTs can check the nurses' log of accuchecks or the aides log of vitals prior to administration of the medication. You "can't be 100% positive they looked unless it is written down". During an interview on 3/25/13 at 10:47 A.M., hospice staff said the resident was admitted to hospice care on 2/14/13 and he/she passed away on 3/9/13. During an interview on 3/25/13 at 2:11 P.M., the resident's Physician said he/she was notified by LPN B the morning of 2/8/13 regarding the resident receiving wrong medications. The Physician said a [MEDICATION NAME] overdose is a challenge to treat. The Physician said 90 mg of [MEDICATION NAME] a significant error, and the resident was already compromised with pneumonia. The Physician said the first choice was to send the resident to the emergency room . The Physician said the DPOA was contacted about sending the resident to the emergency room and it was relayed to him/her the DPOA did not want to send the resident out. The Physician said he/she ordered the [MEDICATION NAME] both routine and as needed and the staff followed the resident closely. The Physician said he/she cannot answer why the first [MEDICATION NAME] dose was not administered until 11:15 A.M. The physician said he/she sat in the resident's room for awhile that day. The Physician said it would have been easier for the resident to go to the hospital for twelve to twenty-four hours, the goal was to have the resident do as well as possible. The physician said the [MEDICATION NAME] was given when the resident was drowsy. He/she said the staff were to monitor the resident's vitals and do a visual assessment too, for the first 24-36 hours. The Physician said the resident was back to his/her baseline in a week. The Physician said he/she also talked with the Administrator and the DON the day of the medication error. When asked about Resident #2 being monitored, the Physician said he/she should have received the missed medications but he/she said it is unknown to him/her if the resident received them as he/she was focused on Resident #1. (record review of the controlled drug record regarding [MEDICATION NAME] mg for Resident #2 showed it was signed out at 8:00 A.M. and circled not given to him/her, and not signed out again until the next scheduled dose in 12 hours at 8:35 P.M.) Complaint #MO 812

Based on interviews and record review, the facility failed to follow professional standards of practice when a certified medication technician (CMT) incorrectly administered six of one resident's medications to another resident (Resident #7). Resident #7 began to experience side effects from the medications and staff sent the resident to the hospital. The resident remained in the hospital for five days for the treatment of [REDACTED]. The facility failed to assure staff administered medications correctly when a licensed practical nurse (LPN) incorrectly administered 22 units of of 70/30 insulin to one resident (Resident #6) instead of the physician ordered 10 units of 70/30 insulin. A sample of seven residents was reviewed out of a facility with a census of 111. 1. Review of Lippincott's Nursing Procedures Fifth Edition, 2009, showed before the administration any medication, always compare the practitioner's order with the order on the patient's medication record. Then mentally check off the first five "rights" of drug administration: right patient, right drug, right dose, right route and right time. 2. Record review of the facility's current policy and procedure to ensure proper administration of medications showed the policy and procedure stated, in part: -Should there be any doubt as the correct identification of a patient, medication may not be administered to that patient until positive identification has been made. -Should there be any doubt concerning the administering of medications, the physician's orders [REDACTED]. -Medications ordered for one patient may not be administered to another patient. 3. Record review of the facility's form for Medication Errors showed the form stated the following: -Procedure performed by: certified medication technician/certified medication aide (CMT/CMA), licensed practical nurse (LPN) or registered nurse (RN); -Procedure: A medication error is a discrepancy between what the physician orders [REDACTED]. -Omissions; -Unauthorized drugs (drugs administered without a physician's orders [REDACTED]. -Wrong dose; -Wrong route of administration; -Wrong dosage form; -Wrong time. -Any medication error must immediately be reported to the patient's attending physician, charge nurse or DON. -A Medication Error form will be filled out by the medication nurse for each medication or treatment error. -The medication nurse will document in the medical record, and record the incident on a 24 hour report form. -Reporting and Document: -Report any abnormal or unusual findings to the charge nurse. -Document the appropriate information in the patient's medical record. 4. Record review of Resident #7's November 2012 physician order [REDACTED].M., the resident received another resident's medication. Those medications were as follows: [MEDICATION NAME] .5 mg (for anxiety), [MEDICATION NAME] 15 mg. (for antianxiety/sedative), Trazadone 50 mg. (antidepressant and can cause sedation), [MEDICATION NAME] 5 mg. (antipsychotic), [MEDICATION NAME] 5 mg. (opiate pain medication) and [MEDICATION NAME] 300 mg. (often used for nerve pain). Record review of the residents medical record showed the following Diagnoses: [REDACTED]. Record review of the medication error report dated 11/15/12, at 6:00 P.M., showed CMT G administered all of another resident's 6:00 P.M. medications to Resident #7. The report showed the physician was notified and CMT G notified the charge nurse immediately. The error report showed the resident was sent to the hospital. The form states what precautions can be taken to prevent similar errors: ask someone when these two patients are together. Record review of the physician order [REDACTED]. concerning the medication error and to send the resident to the hospital for evaluation and observation if ok with the resident's family. The physician also ordered, if the resident goes to the hospital, notify Hospice services to discontinue the resident's care through hospice. Staff indicated they called hospice with the information. Record review of the facility resident information for transfer/referral for the resident showed the resident to be sent to the local hospital. The reason for the transfer due to resident receiving wrong medications. Vitals signs - blood pressure 158/72, pulse 84, respirations 16, temperature 97.4 and pulse ox 87-90 %. The resident's mental condition was listed as confused, the resident was incontinent of bowel and bladder, and the resident required assist with ambulation with no devices used. Staff documented the resident was sleepy. Record review showed the staff documented the error in the resident's nursing notes on 11/15/12. Staff contacted the hospital on [DATE], and checked on the status of the resident. The resident admitted to the hospital with [REDACTED]. The resident returned to the facility on [DATE]. Record review of the EMS notes showed the resident talked to the EMS staff onsite at the facility but enroute to the hospital only responded to painful stimuli. EMS staff gave the resident 1 mg of [MEDICATION NAME] (an opiate antidote that can reverse an opioid overdose) while in route to the hospital with no change in condition. Record review of the resident's hospital records (history and physical dated 11/15/12) showed the hospital admitted the resident on 11/15/12, with signs and symptoms of somnolence (extreme drowsiness), lethargy and remained hypotensive (low blood pressure) despite receiving two normal saline [MEDICATION NAME] (intravenous fluids). Record review of the hospital's history and physical showed acute [MEDICAL CONDITION] (disorder or disease of the brain)/decreased mental status secondary to unintentional overdose, [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] and receiving wrong medications. The resident's vital signs at the hospital on [DATE] were as follows: -6:48 P.M., BP 141/59, P 77, R 16, O2 96% on room air; -7:23 P.M., BP 144/86, P 88, R 16, O2 93% on room air; -7:53 P.M., BP 80/38, P 78, R 16, O2 91% on room air; -8:23 P.M., BP 64/28, P 76, R 16, O2 92%on room air; -From 9:38 P.M. through 10:08 P.M., BP never above 96/46, R between 64 and 62, P remained at 60 and O2 99% to 96% on room air; -From 10:23 P.M. through 11:12 P.M. BP ranged from 73/34 to 80/39, R between 56 to 60, P 15 to 16 and O2 96% and 97% on room air. -On 11/16/12, at 7:15 A.M., hospital staff documented the resident was unresponsive to questions and sedated due to overdose. During an interview on 11/28/12, at 8:50 A.M., CNA A said the resident goes from being lethargic to awake and the resident is not interviewable. During an interview on 11/28/12, at 9:10 A.M., the administrator said that CMT G administered the wrong medications to the resident on 11/15/12. CMT G immediately knew she had given the wrong medication and reported it to the charge nurse and nurse practitioner in the building at the time of the error. Staff notified the resident's physician who encouraged family to have the resident sent to the hospital. The administrator said the last inservice related to medication administration and medication errors was 3/15/12. During an interview on 11/28/12, at 9:35 A.M., the DON said Resident #7 and the resident whose medications Resident #7 received look very similar. She said CMT G received a disciplinary action. The CMT just needed to sign it. The DON said staff do not necessarily report medication errors to the family, but in this case staff did. During an interview on 11/28/12, at 2:45 P.M., CMT G said she had worked at the facility about a month. She said she started popping out medications for the other resident and turned from the medication cart. The CMT said when she turned back around, Resident #7 stood there. CMT G said Resident #7 and the other resident look similar and she continued to pop out medications from the cards and administered the medications to Resident #7. At that time she heard the other resident yell out and at that time realized she had made a medication error. CMT G immediately told LPN F who spoke to the Nurse Practitioner (NP) in the building at the time. The NP told the staff to monitor the resident, until the staff reported exactly what medications Resident #7 received. At that time the physician was contacted and family and the physician told staff to encourage family to send the resident to the hospital. CMT G said staff took the resident to the dining room. Staff were directed not to let the resident eat because EMS had been called and was on the way. At the time the EMS staff arrived the resident had begun to get sleepy but fought with the EMS staff when they attempted to put the resident's coat on. CMT G was called into the administrative office and thanked for being honest. CMT G denied getting a disciplinary action. She said she was told to slow down, read cards more carefully, and if in doubt, ask. CMT G said the narcotic card is now initialed with a date when each pill is given, and said as soon as she signs it, she immediately pulls the medication from the drawer. CMT G said during orientation she followed another CMT for about a week and then the next week she administered medications and the other CMT watched her.. CMT G said she had no specific orientation on medication administration or how medication errors are handled. On 11/30/12, at 3:30 P.M., LPN F said she had worked at the facility about a year. She said when the medication error occurred with Resident #7, CMT G immediately notified her and she spoke with the NP in the building at the time. LPN F called the physician and family. The physician gave an order to send the resident to the ER. LPN F said from the time the medications were given until the time the resident left was about 45 minutes. LPN F said the resident had begun to become lethargic. 5. According to the 2001 certified nurse aide (CNA) training manual, the normal ranges for pulse, respirations and blood pressures (BP), in adults are as follows: -Pulse - 50-100 beats per minute; -Respirations(R) - 14-20 breaths per minute; -B/P - Systolic (top number) between 100 to 150 mm Hg (millimeters of mercury); -B/P - Diastolic (bottom number) between 60 to 90 mm Hg. 6. Record review of Mosby's Diagnostic and Laboratory Test Reference, 2nd edition, showed normal oxygen saturation levels (O2) for an adult is 95-100% on room air. 7. Record review of Resident #6's care plan dated 9/27/12, showed staff identified the resident had a potential for hypo/hyperglycemic (low vs high blood sugars) due to the diabetes. Staff were directed to administer medications, do accuchecks (blood sugar testing)per physician orders [REDACTED]. Signs and symptoms may include diaphoresis (excessive sweating), increased thirst, increased urination, change in condition or lethargy. Record review of the resident's physician order [REDACTED]. and 4:30 P.M. and [MEDICATION NAME] 70/30 10 units every A.M. and [MEDICATION NAME] 70/30 four units every P.M. Record review of the nursing notes and medication administration records (MAR) showed no indication on the insulin or accucheck record that the resident received 22 units of [MEDICATION NAME] 70/30 on 11/17/12, instead of the physician ordered 10 units. Records did show an accucheck at 8:50 A.M on 11/17/12, of 208 (Normal blood glucose level is between 80 and 120). Record review of the resident's nursing notes showed no documentation on 11/17/12 or 11/18/12 and no vital signs were taken per vital sign sheets on 11/17/12 or 11/18/12, after the error occurred on 11/17/12, at 6:30 A.M. Record review of the medication error report dated 11/17/12, for the medication error on 11/17/12, showed the physician was notified at 7:00 A.M. by LPN D who made the error. The form states what precautions can be taken to prevent similar errors: Double check dose prior to administering the dose. Record review of the resident's medical chart showed the resident had type II diabetes. During an interview on 11/28/12, at 1:55 P.M., LPN D (who administered the incorrect dosage of insulin) said he/she just gave the wrong amount. The LPN thought he/she immediately called the physician. LPN D said he/she did a accucheck and the blood sugar level was 180. LPN D said he/she immediately gave the resident a glass of orange juice or milk, he/she could not remember. The LPN said the resident had no side effects. See Complaint Number MO 574