Every finding on record at Lutheran Home of the Good Shepherd

This REQUIREMENT is NOT MET as evidenced by:Based on record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #36) who was injured during van transport. Failure to provide the appropriate level of assistance ensuring Resident #36's extremities remained within the frame of the wheelchair/were supported while loading her into the van, resulted in a major injury to her left foot.Findings include:Review of the facility policy titled Safe Lift and/or Ramp Usage in the Vans occurred on 08/28/25. This policy, revised 2022, stated, . Open doors and Lower lift, Load resident with brakes on, Transfer resident into placement . The policy failed to address the need to ensure a resident's extremities remain within the frame of the wheelchair/are supported while loading him/her into the van.Review of Resident #36's medical record occurred on all days of survey. Diagnoses included laceration/nondisplaced fracture of the middle phalanx of the left lesser toe, polyneuropathy (a condition where multiple peripheral nerves throughout the body become damaged or malfunction), reduced mobility, and severe obesity. The current care plan identified, . I am at risk for falls r/t [related to] . being unaware of safety needs and inability to use my legs . Anticipate . my needs .The progress notes identified the following:* 06/28/25 at 4:00 p.m., Late Entry: This nurse was informed of [an] incident involving [the] resident during transfer into . [the] facility van. [Facility] maintenance staff (x2) [times two] and CNAs [certified nurse aides] (x2) report that [the] resident was transfered [sic] via wheelchair onto the loading platform on the back of [the] facility van. Staff completed saftey [sic] checks prior to raising [the] platform. Staff report that they ensured resident's arms and legs were in proper position. [The] Resident had gripper socks on. While raising the platform to assist [the] resident into the van staff noticed that the tip of [the] resident['s] left gripper sock was caught in between [the] platform and [the] van. [The] Sock [was] removed from [the] stuck position and [the] resident and [the] wheelchair [were] secured into the back of the van. While on the transport back to [the] facility [a] staff member noticed [the] resident's left foot 'sitting in a small pool of blood.' Staff then removed [the] resident's left sock and noted significant bleeding from [the] resident's 4th toe. Staff notifed [sic] this nurse of [the] incident and stated they were taking [the] resident back to [the] ER [emergency room] for evaluation. This nurse approved and updated [hospital] staff of [the] resident return to [the] ER.* 06/28/25 at 4:45 p.m., Late Entry: This nurse recieved [sic] [a] call from [the] [hospital] staff nurse . It was reported that [the] resident broke her 4th [forth] toe on her left foot. [A] 0.5 cm [centimeter] laceration present to top of 4th toe, 5 [five] sutures placed.A Facility Reported Incident (FRI) report, dated 06/30/25, stated, . LPN [licensed practical nurse] made the decision to have 4 staff members go with [the] [facility] transport van to pick up [the] resident. This decision was made as [the] resident is obese and is a difficult transfer . The staff then noted the resident's sock was caught in a pinch point on the platform . While driving back . [staff] noticed resident's left sock was soaked with blood. [Staff] removed her sock, noted the injury and applied pressure to the area of her left toe . Staff education provided to increase awareness with bariatric transfer . Occupational Therapy Assistant . re-evaluated the bariatric transport chair and added a foot board to the chair .A van transportation handout, dated 07/01/25, stated, . [Resident #36's] regular wheelchair will not fit on the van. The footboard and leg support is [sic] on the transport wheelchair. Make sure [the] leg rests are elevated to allow [the] wheelchair to fit on the van lift. Make sure all body parts are within the frame of the wheelchair and supported prior to lifting [the resident] and lowering [him/her] on [the] lift. Staff failed to add the transport interventions to Resident #36's care plan.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure staff followed professional standards of practice for 2 of 4 sampled residents (Resident #6 and #36) observed during medication administration. Failure to prime insulin pens correctly and failure to administer medications at the scheduled times may impede the therapeutic effectiveness of the medications.Findings include:The facility failed to provide a policy on medication administration and documentation.Review of the facility policy titled Insulin Pen Use occurred on 08/27/25. This policy, dated 2021, stated, . prime pen with 2 units of insulin pointing the pen with the needle upwards. Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 836, stated, . Ten Rights of Medication Administration . Right Documentation . Document medication administration after giving it . The record [medication administration record (MAR)] should . include the exact time of administration .-Review of Resident #36's medical record occurred on all days of survey and included physician's orders for Gabapentin (a pain medication) by mouth three times per day. The MAR listed the administration times at 7:00 a.m., 2:00 p.m., and 7:00 p.m.Observation on 08/26/25 at 4:30 p.m. showed a nurse (#7) conducted a narcotic count on the Grace Unit. Resident #36's Gabapentin narcotic record showed 2 tablets. The count showed 3 tablets of the Gabapentin remaining in the resident's medication cartridge. Resident #36's MAR reflected the nurse (#7) signed off the Gabapentin as given at 2 p.m. However, observation showed the nurse (#7) administered the Gabapentin at 4:30 p.m., resulting in late administration. During an interview on 08/27/25 at 10:05 a.m., an administrative nurse (#10) confirmed staff failed to administer the medication in a timely manner.-Review of Resident #6's medical record occurred on all days of survey. Diagnoses included type 2 Diabetes Mellitus and insulin dependence. Physician's orders included Novolog 70/30 insulin (for blood glucose control) with meals and sliding scale. Observation on 08/26/25 at 4:50 p.m. showed a nurse (#9) primed Resident #6's insulin pen pointed sideways. During an interview on 08/27/25 at 8:30 a.m., an administrative nurse (#10) confirmed the nurse failed to correctly prime the insulin pen.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 14 sampled residents (Resident #3 and #6) observed during cares. Failure to practice infection control standards related to hand hygiene and glove use has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Personal Protective Equipment occurred on 08/28/25. This policy, revised July 2022, stated, . Gloves . Perform hand hygiene before donning [applying] gloves and after removal. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another . -Observation on 08/25/25 at 1:15 p.m. showed a certified nurse aide (CNA) (#2) utilized a sit-to-stand lift to transfer Resident #3 from a wheelchair to the toilet. The CNA applied gloves, performed perineal cares, removed the soiled gloves, and transferred the resident back into the wheelchair. Without performing hand hygiene, the CNA (#2) opened the room blinds, moved the overbed table within the resident's reach, then performed hand hygiene and exited the resident's room. -Observation on 08/25/25 at 4:12 p.m. showed two CNAs (#5 and #6) performed Resident #6's perineal cares while in bed. Without changing the soiled gloves, the CNA (#5) opened the resident's nightstand drawer, removed a container of bag balm (a protective skin barrier), opened and reached into the container with a dirty gloved hand, and applied the bag balm to the resident's inner thighs. After cares were completed, the CNAs transferred the resident from the bed into a wheelchair, and without changing the soiled gloves and performing hand hygiene, the CNA (#6) adjusted the resident's necklace. The CNA (#5) failed to remove the soiled gloves, perform hand hygiene, and apply new gloves before obtaining and applying the bag balm. The CNA (#6) failed to remove the soiled gloves and perform hand hygiene prior to adjusting the resident's necklace. -Observation on 08/27/25 at 10:25 a.m. showed a nurse (#7) performed Resident #6's dressing change while in bed. The nurse performed hand hygiene, applied gloves, used gauze to pat the open skin on the resident's inner thighs, discarded the gauze, removed the soiled right glove, and without removing the soiled left glove and performing hand hygiene, exited the room. The nurse unlocked the nurse's cart, opened a cart drawer, and obtained more dressing supplies with the ungloved hand. The nurse reentered the resident's room, removed her soiled left glove, performed hand hygiene, applied new gloves, and finished the dressing change. The nurse (#7) failed to remove the soiled left glove and perform hand hygiene prior to exiting the resident's room and opening the nurse's cart/drawer and obtaining the dressing supplies. During an interview on 08/28/25 at 9:26 a.m., an administrative staff member (#4) stated she expected staff to remove gloves, perform hand hygiene, and apply clean gloves between clean and dirty tasks and remove gloves and perform hand hygiene prior to exiting resident rooms.

Based on review of a facility reported incident (FRI) investigation, record review, review of facility policy review, and staff interview, the facility failed to ensure residents have the right to remain free from possible physical abuse/neglect for 1 of 1 sampled resident (Resident #3) with a fracture or unknown source. Failure to provide necessary service to protect residents from physical harm resulted in Resident #3 sustaining a fracture from an unknown source. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following discovery of the incident. Findings include: The surveyor determined a deficient practice existed on 05/26/25. The facility implemented corrective action immediately, completed corrective action on 05/28/25, and continues with staff education and monitoring. Review of the facility policy titled Safe Operating Procedures (Resident Transfers) occurred on 06/04/25. This policy, revised September 2023, stated, . Hoyer [full-body mechanical lift] Lift Transfer: . Use of 2 staff for all Hoyer lift transfers. Review of Resident #3's medical record occurred on June 4, 2025. Diagnoses included mild dementia, anxiety, and left-side hemiplegia and hemiparesis following cerebral infarction (stroke). The care plan stated, . Hoyer Lift for all transfers for safety. The Minimum Data Set (MDS), dated [DATE], identified a Brief Interview for Mental Status (BIMS) of 14, indicating cognitively intact, and dependent on staff for all transfers. The facility reported incident investigation, dated 05/28/25, stated, . [nurse's name] was informed by [Certified nurse aide (CNA) #1] at 9 AM on 05/25/25 that [Resident #3] was complaining about her foot hurting during a hoyer lift transfer from her bed prior to her bath and during her bath. [Nurse name] then assed [sic] resident's right ankle as the CNA notice swelling with no visible signs of bruising. Per [nurse's name] resident did not appear in any pain unless her right ankle was physically touched. [Nurse's name] did question resident at time of assessment where she thinks she may have obtained her injury. She reported to this nurse that she fell this AM. She reported a CNA had transferred her without using her correct lift and dropped her. She was unable to state how she got back to bed. She pointed at a CNA in the room [CNA #1's name]. [CNA #1] stated that she did not drop her. Upon questioning [CNA #3's name], who worked . the evening before the event . [CNA #3] stated . she assisted her [Resident #3] to bed via hoyer lift around 8:00 PM . It was validated on video that [CNA #3] did go into residents' room during the evening hours with hoyer lift and brought it out after cares. Both [CNA #3's name and CNA #1's name] were suspended . It is the facilities responsibility to have 2 staff assist with hoyer transfers. it's inconclusive of what occurred or that any willful neglect and/or abuse occurred. A physician's progress note, dated 05/27/25, stated, [Right] ankle pain [and ]swelling. New over weekend. Resident reporting possible fall but resident is a hoyer transfer [with] [left] side paralysis post CVA [stroke]. Another note dated the same day, stated, Per my review, appears to have hairline fracture of R) [right] distal fibula, as well as possible hairline fracture of proximal 5th metatarsal. During an interview on 06/04/25 at 2:50 p.m., an administrative nurse (#4) stated on the evening of 05/25/25 the CNA (#3) transferred Resident #3 to bed with the lift by herself, and the CNA (#1) on the day shift of 05/26/25 confirmed she transferred the resident with the Hoyer lift without a second staff present. The CNA (#1) denied dropping her or bumping her leg on anything. The facility failed to ensure two staff assisted while transferring Resident #3 with a mechanical lift. Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented corrective actions for all residents who may be affected by the deficient practice as follows: * Completed an investigation into Resident #3's ankle fracture. * Both CNAs were suspended from work until completion of the investigation and then terminated. * Re-education regarding following residents' care plans for method of transfer and use of two staff members for Hoyer transfers sent via Smartlinx (electronic) message to all staff and a memo to all nursing staff at nurses' stations on 05/27/25 and again on 06/03/25. * Staff required to sign they received and read the above education. * Orientation for all agency staff included resident transfer methods.

Based on observation, review of manufacturer's instructions, and staff interview, the facility failed to follow infection control standards for 3 of 3 residents (Resident #7, #8, and #41) observed during blood glucose testing. Failure to properly disinfect glucometers may result in the spread of bloodborne pathogens between residents. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 07/08/24 at 5:55 p.m. The IJ resulted from a staff member improperly cleaning a glucometer and attempting to use it with another resident. This finding placed residents in immediate danger due to the potential for exposure to bloodborne pathogens. *07/08/24 at 6:27 p.m., The survey team notified the administrator and director of nursing of the IJ situation, provided the IJ template, and requested a plan for removal of the IJ. *07/09/24 at 9:44 a.m., The survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: *Immediate disinfection of all glucometers using an approved method (i.e., Sani-Cloths) *Ensured all residents requiring blood glucose checks (accuchecks) were assigned individual glucometers *Education provided to all staff who complete accuchecks on proper disinfecting process *07/09/24 at 10:04 a.m., The survey team verified the implementation of the removal plan as of 07/08/24 and the IJ removal. The deficient practice remained at a D scope and severity following the removal of the IJ. Findings include: Review of the manufacturer's instructions for the Assure Prism blood glucose meter (glucometer) identified, . Cleaning and Disinfecting . The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood-borne pathogens. The meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed. We have validated . PDI Super Sani-Cloth Germicidal Disposable Wipe for disinfecting the Assure Prism multi meter. Only wipes with EPA [Environmental Protection Agency] registration numbers listed in the previous tables have been validated for use in cleaning and disinfecting the meter. The manufacturer's instructions did not list isopropyl alcohol wipes as an approved cleaner/disinfectant. - Observation on 07/08/24 at 4:06 p.m. showed a nurse (#4) checked Resident #8's blood sugar with a glucometer labeled with the resident's name. The nurse then cleaned the meter with an alcohol wipe and placed it back in the case. The nurse stated she normally used a Sani-Cloth to clean the meter but there were none in the cart, and each resident had their own individual glucometer. - Observation on 07/08/24 at 4:18 p.m. showed a nurse (#4) checked Resident #41's blood sugar with a glucometer labeled with the resident's name. The nurse then cleaned the meter with an alcohol wipe and placed it back in the case. - Observation on 07/08/24 at 4:27 p.m. showed a nurse (#4) attempted to check Resident #7's blood sugar using Resident #8's glucometer. The nurse stated, She's [Resident #7] not one we do routinely [check blood sugars], so we use someone else's [glucometer]. Observation showed the nurse took Resident #8's glucometer from the medication cart and attempted to enter Resident #7's room. The surveyor intervened and requested the nurse disinfect the glucometer with a Sani-Cloth. During an interview on the afternoon of 07/08/24, an administrative nurse (#1) stated she expected staff to clean glucometers with Sani-Cloths and not share meters between residents.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the care plans to reflect residents' current status for 1 of 12 sampled residents (Resident #24). Failure to review and revise the care plan limited staff's ability to communicate needs, ensure continuity of care, and may negatively impact the care provided to the resident. Findings include: Review of the facility policy titled Care Plans occurred on 07/09/24. This policy, dated August 2022, stated, . Care plans are revised as changes in the resident's condition dictates. Review of Resident #24's medical record occurred on all days of survey. The current care plan stated, Transfers with supervision. I like to ambulate throughout the wing but will often refuse staff to walk with me. EZ stand with leg strap. It is recommended that I use a walker to stabilize my gait . I ambulate with a stumped over posture and shuffled gait . Encourage me to take rest periods after walking as I will walk aimlessly. The Minimum Data Set (MDS) dated [DATE], identified the resident utilized wheelchair for mobility. Observations on all days of survey showed Resident #24 in a wheelchair, moving herself throughout the unit using her feet. During an interview on the afternoon of 07/09/24, an administrative staff member (#1) confirmed the facility failed to update Resident #24's care plan regarding the mobility status.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled residents (Resident #15) observed receiving a topical medication and 1 supplemental resident (Resident #6) observed during medication administration. Failure to obtain a physician's order and to properly administer medications may result in a resident receiving an ineffective dose and/or experiencing adverse reactions. Findings include: Review of the facility policy titled Administration of Medications occurred on 07/10/24. This policy, dated March 2023, stated, 1. Medication administration must safely be performed according to the six rights of administration. e. The medication is given by the right route. 3. Physician orders are obtained through faxing or calling physician for either written or verbal orders. Mosby's 2023 Nursing Drug Reference, 36th ed., Elsevier, Inc., Missouri, page 1046, stated, . Administer Drugs Safely, Accurately, and Professionally . Do not break, crush, or chew ext [NAME] [extended release] tabs [tablets] . - Observation on 07/09/24 at 8:54 a.m., showed a medication aide (#3) applied Nystatin powder to Resident #15's perineal area while completing cares. Review of Resident #15's medical record occurred on 07/09/24. The record lacked a physician's order for Nystatin powder. The medication aide (#3) applied a topical medication without an order. - Observation on 07/10/24 at 8:23 a.m., showed a nurse (#2) crushed and administered a Potassium Chloride tablet in pudding to Resident #6. Review of Resident #6's medical record occurred on 07/10/24. A physician's order stated, Potassium Chloride ER [extended release] oral tablet . give 1 tablet by mouth one time a day . During an interview on the afternoon of 07/10/24, an administrative staff member (#1) confirmed the nurse (#2) administered the tablet incorrectly, and confirmed that all medications should have a physician's order.

1. Based on observation and staff interview, the facility failed to ensure an environment free from accident hazards on 1 of 1 special care unit. Failure to ensure residents do not have access to laundry and soiled utility rooms placed them at risk for exposure to chemicals and other accident hazards. Findings include: - Observation on 07/08/24 at approximately 2:10 p.m. showed Resident #23 opened the door to an unlocked laundry room on the special care unit, and the door closed behind her. A few minutes later, an unidentified staff member entered the laundry room to redirect the resident. Observation showed containers of bleach and laundry detergent next to the washing machine. A cupboard contained other laundry detergents, Sani-Cloth disinfecting wipes, and hair spray. Observation on 07/08/24 at 4:08 p.m. showed this door remained unlocked. During an interview on the morning of 07/09/24, an administrative nurse (#1) reported the laundry room door, when closed tightly, should automatically lock. -Observations on 07/08/24 from 4:07 p.m. until 5:37 p.m. showed the door of the soiled utility room on the special care unit unlocked. The room contained Comet disinfecting cleaner with bleach, Clorox urine remover, mop detergent, four bottles of antibacterial liquid hand soap, two containers of hand sanitizer, and Sani-Cloth germicidal disposable wipes. On 07/09/24 at 8:25 a.m., observation showed the soiled utility room door locked. A housekeeping staff member (#7) stated the door should always be locked. During an interview on 07/09/24 at 4:04 p.m., an administrative staff member (#8) stated she expected staff to keep the soiled utility room door locked at all times. 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate assistance and/or assistive devices for 1 supplemental resident (Resident #25) observed during a toileting transfer. Failure to use a gait belt and provide appropriate assistance during a transfer placed residents at risk for accidents, falls, and/or injuries. Findings include: Review of the facility policy titled Transfers with use of Transfer Belts/Mechanical Lifts occurred on 07/10/24. This policy, dated January 2018, stated, . If a resident needs hands on assistance of trained staff for balance or lifting and maintaining standard position, transfer belt/gait belt must be used, unless otherwise care planned. -Review of Resident #25's medical record occurred on 07/10/24. The care plan stated, . Will ambulate but requires walker, staff using gait belt with hands on assist. Transfers with one assist and FWW [front wheeled walker]. Observation on 07/08/24 at 4:15 p.m. showed two certified nurse aides (CNAs) (#5 and #6) assisted Resident #25 from the wheelchair to a standing position by lifting under the resident's arms and transferred the resident to the toilet without the use of a gait belt. After toileting the resident, both CNAs (#5 and #6) lifted Resident #25 under the arms, and without the use of a gait belt, transferred Resident #25 back to the wheelchair. During an interview on the afternoon of 07/10/24, an administrative staff member (#1) confirmed staff should be following policy and resident care plans. 46477

Based on observation, review of professional reference, and staff interview, the facility failed to label medications in accordance with professional standards for 2 of 4 supplemental residents (Resident #8 and #22) observed during medication pass. Failure to ensure appropriate labeling of medications placed residents at risk for medication errors. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 834, stated, . Check Three Times for Safe Medication Administration . First Check . Read the MAR [medication administration record] and remove the medication(s) from the client's drawer. Verify that the client's name and room number match the MAR. Page 838 stated, . Compare the label of the medication container or unit-dose package against the order on the MAR or computer printout. Rationale: This is a safety check to ensure that the right medication is given. If these are not identical, recheck the prescriber's written order in the client's chart. If there is still a discrepancy, check with the pharmacist. - Observation on 07/08/24 at 4:06 p.m. showed a nurse (#4) prepared medications for Resident #8. The nurse removed a bottle of artificial tears from the drawer. The box/bottle lacked a label with identifying information (such as the resident's name). The nurse administered the eye drops to Resident #8. - Observation on 07/09/24 at 8:27 a.m. showed a nurse (#9) removed nasal spray from the medication cart for Resident #22. The label on the medication identified two sprays to each nostril twice daily; however, the MAR and the physician's order identified two sprays each nostril once daily. During an interview on the morning of 07/09/24, an administrative nurse (#1) identified she would clarify the nasal spray order, and staff should label over the counter medications with the resident's name and the date they opened the medication.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure the residents' rights to request, refuse, and/or discontinue treatment for 1 of 13 sampled residents (Resident #30) reviewed for advance directives. Failure of staff to ensure a resident's legal representative (Power of Attorney) signed documentation regarding his/her wishes limited the facility's ability to communicate to direct care staff and emergency personnel the resident's/representative's wishes in the event of a medical emergency. Findings include: Review of the facility policy titled Advance Directives occurred on 01/20/22. This policy, revised October 2017, stated, . The facility will . approach the . legal representative if the resident is determined not to have decision making capacities. During the care planning process, the facility will review with the . legal representative whether they desire to make any changes related to the Advanced directives. - Review of Resident #30's medical record occurred on all days of survey and showed a family member versus the power of attorney signed the code status form on file. The record lacked evidence of a discussion with the power of attorney regarding what his/her current wishes entailed regarding Resident #30's code status. During an interview on 01/20/22 at 1:30 p.m., an administrative staff member (#1) acknowledged staff failed to ensure Resident #30's power of attorney signed the code status form.

Based on record review, review of facility policy, and staff and family interviews, the facility failed to notify the resident's representative (family/legal guardian) of a change in condition for 1 of 1 resident (Resident #4) reviewed for a fall with injury. Failure to notify the resident's representative of a change in condition does not allow the representative to be fully informed of the resident's status and limits their ability to make informed decisions regarding their medical care. Findings include: Review of the facility policy titled Incident and Accident occurred on 01/20/22. This policy, dated March 2016, stated, . Notify family of accident, status and orders for care. If incident occurs between 8:00 AM and 10:00 PM the family/legal guardian will be notified in a timely manner as the situation allows. If incident occurs after 10 PM and does not require immediate medical attention, the family will be notified the next morning . Family/Legal guardian must be notified immediately on falls occurring after 10pm requiring immediate medical attention; this would include falls with a head injury . Review of Resident #4's medical record occurred on all days of survey. Nursing progress notes, dated 01/17/22 at 4:45 a.m. stated, Resident found on floor at [4:45 a.m.] bed alarm in place and on at time of fall. CNA [Certified Nursing Assistant] found resident on floor. Upon entering room author noted resident lying on right side next to bed. Blood noted on floor. Resident wearing gripper socks on feet bilat. [bilaterally]. Neuro [Neurological] assessment initiated. PERRLA [Pupils equal, round, reactive to light and accomodation]. Hand grasps strong. speech unchanged. Author noted large bump on right side of forehead. Small cut noted in center of bump. Bleeding ceased with pressure. During an interview on 01/19/22 at 11:39 a.m., Resident #4's Power of Attorney (POA)/Emergency contact stated she came to visit Resident #4 on Monday 01/17/22 and noticed a gash on the resident's forehead. The POA asked staff about the injury's origin and staff informed her of Resident #4's fall earlier that morning. The POA expressed frustration with not being notified of the fall prior to the visit. The medical record lacked evidence staff notified the resident representative of Resident #4's fall. During an interview on 01/20/22 at 1:19 p.m., an administrative staff member (#1) confirmed staff failed to notify the resident representative of Resident #4's fall with injury.

Based on observation, review of facility policy, review of narcotics records, and staff interview, the facility failed to ensure an accurate count for 2 of 2 residents' (Resident #40 and #43) controlled medications. Failure to account for missing controlled medications in a timely manner increases potential for medication error, loss, or diversion. Review of the facility policy titled Controlled Drug Count occurred on 01/20/22. This policy, revised October 2021, stated, . To maintain an accurate count of the controlled drugs in the facility . scheduled 2, 3, 4 and 5 drugs . will be counted every shift by the oncoming and off going nurse . each nurse will mark the count and sign the appropriate place on the form . any discrepancies will be resolved immediately, if unable to resolve, contact the Resident Care Coordinator or the Director of Nursing . - Observation of the Peace medication room on 01/19/22 at 11:46 a.m., showed Resident #40's medication cartridge labeled [MEDICATION(S)] 50 mg [milligrams] take 1 tablet PO [oral] daily at 12 noon. The narcotic count log showed one tablet missing from 12/20/21 to 01/19/22 and staff failed to report the missing narcotic. - Observation of the Peace medication room on 01/19/22 at 11:48 a.m., showed Resident #43's medication cartridge labeled [MEDICATION(S)] 75 mg 1 tablet TID [three times a day] at 1900 [7 PM]. The narcotic count log showed one tablet missing from 12/20/21 to 01/19/22 and staff failed to report the missing narcotic. During an interview on 01/20/22 at 10:29 a.m., a nurse administrator (#1) confirmed staff are expected to immediately report any controlled medication discrepancies.

Based on observation, review of facility policy and staff interview, the facility failed to label and date 4 of 4 opened multi-dose insulin pens and correctly prime 2 of 4 insulin pens observed during medication administration. Failure to correctly label and date insulin pens when opened and correctly prime insulin pens increases the risk of residents receiving outdated medications with reduced efficacy and inaccurate doses of medications. Findings include: Review of the facility policy titled Insulin Pen Storage and Labeling occurred on 01/20/22. This policy, revised October 2021, stated, .To assure appropriate storage and labeling of pens . Insulin pens will be dated and initialed when first opened . Review of the facility checklist titled Insulin Pen Competency checklist occurred on 01/20/22. This checklist, revised July 2021, stated, . prime pen with 2 units pointing the pen with the needle upwards . - Observation on 01/19/22 at 4:15 p.m., showed opened multi-dose insulin pens for Resident #2, #3, #11, and #28 without an open date or initials. During an interview on 01/20/22 at 11:02 a.m., an administrative nurse (#1) confirmed the insulin pens lacked an open date and initials. - Observation during medication administration on 01/19/22 at 4:38 p.m., a nurse (#2) prepared an insulin pen with 22 units of Novolog 70/30 to administer to Resident #28 at the evening meal. The pen was primed in a horizontal position. - Observation during medication administration on 01/19/22 at 4:48 p.m., a nurse (#2) prepared an insulin pen with 12 units of Novolog 70/30 to administer to Resident #2 at the evening meal. The pen was primed in a horizontal position. During an interview on 01/20/22 at 11:02 a.m., an administrative nurse (#1) confirmed the insulin pens should be primed in a vertical position.

Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control standards for 1 of 4 residents (Resident #1) and 6 supplemental residents (Resident #5, #6, #7, #8, #9 and #10) on isolation precautions related to positive COVID-19 status. Failure to place visible isolation signage, cohort residents, close doors, and properly utilizing personal protective equipment (PPE) for residents on isolation/transmission based precautions has the potential to spread the COVID-19 virus to other residents, personnel, and visitors. During the infection control survey on November 16, 2020, the team determined a potential Immediate Jeopardy (IJ) situation existed. The IJ potential resulted from observations of PPE use and staff interviews. These showed residents were placed in immediate dangerous situations due to improper use of PPE, open doors to positive patient rooms and lack of staff education. These situations failed to protect residents from the potential spread of the COVID-19 virus. * 11/16/20 at 5:30 p.m. - The survey team contacted the management staff at the State Survey Agency (SSA) to report the findings and to discuss a potential IJ situation. * 11/17/20 at 3:45 p.m.- The survey team notified the facility's administration (administrator, director of nursing (DON), and infection preventionist (IP)) of the IJ situation and requested they develop a plan for abatement of the immediate jeopardy. * 11/17/20 at 6:30 p.m. - The SSA notified the regional office of the immediate jeopardy situation. * 11/18/20 at 12:18 p.m. - The facility provided a written plan of correction for the IJ. * 11/18/20 at 1:15 p.m. - The survey team reviewed and accepted the facility's written plan. * 11/18/20 at 3:45 p.m. - The survey team determined the IJ situation at a scope/severity of K was abated and reduced to a scope/severity of E. * 11/18/20 at 5:46 p.m. - The SSA notified the regional office of the removal of the immediate jeopardy situation. Findings Include: Review of the facility policy titled Novel-[MEDICAL CONDITION] Prevention and Response occurred on 11/17/20. This policy, revised October 2020, stated, . 5. d. Educate staff on proper use of personal protective equipment and application of contact, droplet and airborne precautions, including eye protection. e. Promote easy and correct use of proper personal protective equipment (PPE). 6. e. Promote easy and correct use of personal protective equipment (PPE) by: i. Posting signs on the door or wall outside of the resident room that clearly describe the type of precaution needed and required PPE. ii. Make PPE, including face mask, eye protection, gowns, and gloves available immediately outside of the resident's room. Observations on 11/16/20 of resident's testing positive for COVID-19 showed the following: * 12:20 p.m. - Resident #5's room door wide open with plastic sheet hanging on the side of alcove entrance to resident's door. * 12:25 p.m. - Resident #6's room door wide open with plastic sheet hanging on the side of alcove entrance to resident's door. * 12:15 p.m. - Resident #7, #8 and #9's room doors wide open with plastic sheets hanging across the alcove with multiple vertical strips cut for openings. * 12:35 p.m. - Resident #1's room door wide open and no visible sign for droplet precautions. * 3:55 p.m. - Resident #7, #8, and #9's room doors remain wide open with plastic sheets hanging across the alcove with multiple vertical strips cut for openings. During an interview on 11/16/20 at 12:31 p.m., a certified nursing assistant (CNA) (#7) stated staff received instructions to wear the same N95 (respirator mask) for their entire shift (between negative and positive rooms). During an interview on 11/16/20 at 1:15 p.m., a CNA (#9) stated she does not wipe off her face shield when going from a positive resident's room to a negative resident's room. The CNA (#9) also stated staff received instructions to wear a N95 mask with a surgical mask over it and to remove the surgical mask prior to going into the negative resident's room. During an interview on 11/16/20 at 3:50 p.m., a CNA (#10) stated she does not wipe/disinfect her face shield between positive and negative resident's rooms and she does not recall receiving staff education to do that. During an interview on 11/16/20 at 4:00 p.m., a CNA (#8) stated staff have not been provided education regarding changing N95 or surgical masks when leaving a positive residents room and entering a negative residents room. The CNA (#8) also stated the resident across the hall (Resident #10) was currently on isolation. Observation showed no droplet precautions sign and/or PPE available outside Resident #10's room. The facility failed to prevent the potential transmission of COVID-19 by the lack of placing visible signs outside the residents' rooms indicating the type of precautions required, close resident's room doors, and educate/monitor staff on the appropriate PPE use and/or disinfecting face shields.

Based on observation, review of facility policy/procedure, and staff interview, the facility failed to ensure food was served under sanitary conditions, in 1 of 4 kitchens (Angel Road) used to prepare food for residents. Failure to safely handle food has the potential to result in foodborne illness to residents, staff, and visitors. Finding include: Review of the facility policy titled, Glove Usage occurred on 03/11/20. This policy, revised January 2018, stated, . Gloves must be changed when switching between tasks . Glove use is not a replacement for hand washing. Review of the policy titled, When, where and how to wash hands occurred on 03/11/20. This policy, revised February 2018, stated, . Hands should be washed in the following situations . Every time an employee enters the kitchen. Observation in the Angel Road Kitchen showed the following: * 03/09/20 at 11:00 a.m. - A dietary staff member (#1) wore gloves while plating food for meal service, delivered plates, and retrieved items from the fridge and cabinets while wearing the same pair of gloves. The kitchen staff member then handled ready to eat foods for residents while wearing the same gloves. * 03/10/20 at 8:28 a.m., - A dietary staff member (#2) wore gloves while plating food for meal service, delivered plates, and retrieved items from the fridge and cabinets while wearing the same pair of gloves. The kitchen staff member then handled ready to eat foods for residents while wearing the same gloves. The dietary staff members (#1 and #2) failed to follow the facility policy and change gloves when switching tasks. During an interview on 03/11/20 at 10:06 a.m., a dietary manager (#2) stated she expected staff to wash their hands when entering the kitchen and change gloves when switching tasks.

Based on observation, review of the facility's policy, and staff interview, the facility failed to ensure staff followed appropriate infection control practices for 1 of 1 sampled resident (Resident #53) observed during wound care. Failure to follow appropriate infection control practices and hand hygiene/glove use may result in the spread of infection within the facility. Findings include: Review of the facility policy titled Hand washing occurred on 03/11/20. This policy, dated January 2015, stated, . facility personnel must wash their hands for 20 seconds under the following conditions . After contact with blood, body fluids . or non-intact skin . Review of the facility policy titled Wound Dressing Change occurred on 03/11/20. This policy, revised August 2008, stated . Remove soiled dressing . Discard dressing . dispose of gloves . Cleanse hands . Put on gloves and cleanse wound as necessary, apply and secure dressings . Dispose of gloves . Cleanse hands . Observation of wound assessment on 03/10/20 at 08:51 a.m. showed a nurse (#5) enter Resident #53's room with gloved hands and holding a plastic wound measurement device. The nurse examined, touched, and measured the wound. The nurse (#5) left the resident's room prior to removal of the gloves and performing hand hygiene. Observation of a wound dressing change on 03/11/20 at 10:55 a.m. showed a nurse (#5) preparing to perform a dressing change to Resident #53's foot. The nurse (#5) performed hand hygiene, donned gloves, removed the soiled dressing, removed the gloves, donned a new pair of gloves, and applied the sterile dressing to the wound. The nurse (#5) failed to perform hand hygiene after removing the gloves, which were in contact with the soiled dressing, prior to donning a new pair of gloves to complete wound care and prior to exiting the resident's room. During an interview on the afternoon of 03/11/20, an administrative nurse (#4) confirmed staff should have followed the facility's policy when performing wound care/hand hygiene and prior to exiting the resident's room.

Based on observation, record review, review of professional literature, and staff interview, the facility failed to ensure 1 of 7 sampled residents (Resident #16) received the care and services necessary to attain the highest degree of safety possible while being fed in the dining room. Failure to ensure staff provided proper positioning prior to giving foods and liquids placed Resident #16 at risk for aspiration. Findings include: Nancy B. Swigert, The Source for Dysphagia: Third Edition, LinguiSystems, Inc (2007), page 9 and the educational handouts, identified, . During the oral intake of . liquids, it is optimal for a patient to be seated at a 90 degree angle, whether in a bed or in a chair . Even a slightly reclined position while eating greatly increases the risk of premature loss of food over the back of the tongue . Review of Resident #16's medical record occurred all days of survey. [DIAGNOSES REDACTED]. The current care plan addressed Resident #16's need for assistance during meals and stated, . Drinks at meals . Ensure 240 ml (milliliters) @ (at) all meals . The care plan failed to provide any guidance regarding appropriate positioning for safe oral intake. Observation showed the following: * Observation on 03/11/19 at 11:30 a.m., showed an unidentified certified nursing assistant (CNA) assisting Resident #16 with the noon meal while the resident was in a broda chair, with the chair reclined to a 50 degree angle. * Observation on 03/13/19 at 7:15 a.m., showed a CNA (#4) assisting Resident #16 with breakfast while the resident was in a broda chair, with the chair reclined to a 60 degree angle. The CNAs failed to ensure Resident #16 was seated as close to 90 degrees as possible prior to offering her foods or liquids. During an interview on 03/13/19 at 11:45 a.m., an administrative nurse (#3) agreed residents should be seated as close to 90 degrees as possible prior to being offered food or liquids.

Based on facility policy, record review, observation, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 2 of 7 sampled residents (Resident #6 and #16) requiring staff assistance for transfers and toileting. Failure to consistently provide assistance with toileting may result in skin breakdown, agitation, and pain. Findings include: Review of facility policy titled Bowel and Bladder/Toileting occurred on 03/13/19. This policy, revised 09/03/14, stated, . The CNA's (certified nursing assistants) will toilet the residents as outlined on their individual . care plan. Residents on a check and change program will be checked for incontinence every 2-3 hour . - Review of Resident #6's medical record occurred on all days of survey. The annual Minimum Data Set (MDS), dated [DATE], identified the resident is at risk of developing pressure ulcers, requires extensive assist with transfers and toileting, frequent bowel and bladder incontinence, pressure relieving device to wheelchair and bed, and severely impaired cognition. Resident #6's care plan stated, . I am frequently incontinent of bowel and bladder but still will void on the toilet. Assist me to the bathroom . I require extensive to total assist with most ADL's (activities of daily living) r/t (related to) my progressing [MEDICAL CONDITION]. anticipate her needs . I have the potential for skin breakdown . Observation on 03/12/19 showed the following: * 8:08 a.m. to 11:49 a.m., Resident #6 seated in a wheelchair. *1:12 p.m., showed Resident #6 in bed. Failure to toilet a resident for over four hours may result in skin breakdown, agitation and pain. - Review of Resident #16's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified the resident at risk for developing pressure ulcers, dependent assist for toileting and transfers, always incontinent of bowel and bladder, pressure relieving device to wheelchair and bed, and severely impaired cognition. Resident #16's care plan stated, . Check and change q (every) 2-3 hrs (hours) and prn (as needed) for incontinence per facility protocol. I am incontinent of bowel and bladder. extensive to total assist with most ADL's. Hoyer lift for transfers at all times . I have the potential for skin breakdown . Anticipate needs . A Braden Scale Assessment, dated 12/26/18, identified Resident #16 as High Risk for pressure ulcers. Observation on 03/12/19 showed Resident #16 seated in a broda chair (adjustable positioning chair) from 8:08 a.m. to 11:29 a.m. Failure to check and change a resident for over four hours may result in skin breakdown, agitation and pain. During and interview on 03/12/19 at 1:03 p.m., a CNA (#5) confirmed that Resident # 6 and #16 had not been toileted and/or checked and changed since before breakfast. The facility failed to toilet/check and change Resident #6 and #16 for over four hours. During an interview on 03/13/19 at 11:50 a.m., an administrative nurse (#3) stated she would expect staff to toilet/check and change residents per care plan and facility policy.

Based on observation and staff interview, the facility failed to follow infection control standards on 1 of 3 days of survey (03/12/19). Failure to wear gloves when touching ready to eat food (Resident #4) and properly sanitize resident care equipment (Resident #44) has the potential to spread illness/infection to residents in the facility. Findings include: The facility failed to provide a policy addressing disinfection of the lift equipment. - Observation on 03/12/19 at 11:41 a.m. showed a staff member (#1) assisted Resident #4 with eating. The staff member rubbed her nose and picked up Resident #4's sandwich with her bare hands to offer the resident a bite. Throughout the meal, the staff member continued to touch the resident's sandwich with her bare hands. - Observation on 03/12/19 at 1:09 p.m. showed a CNA (#5) transfer Resident #44 from the wheelchair to the recliner using the mechanical stand lift. Following the transfer, the CNA placed the lift in the storage area and failed to disinfect it. - Observation on 3/12/19 at 2:09 p.m. showed a CNA transfer Resident #44 from his recliner to the bathroom and then to his wheelchair using a mechanical stand lift. Following the transfer, the CNA placed the lift in the storage area and failed to disinfect it. Both observations showed disinfecting wipes available for staff to use on the stand lift. During an interview on the afternoon of 03/12/19, two supervisory staff members (#2 and #3) stated staff should not touch ready to eat food with their bare hands, and should use gloves. During an interview on 03/13/19 at 11:40 a.m., an administrative nurse (#3) stated she would expect staff to disinfect the stand lift equipment after each use.

Based on record review and staff interview, facility staff failed to follow the plan of care for 1 of 1 discharged resident (Resident #10) who experienced a fall with major injury. Failure to follow a resident's plan of care may be neglect if staff do not follow identified care interventions and result in compromising the residents quality of life. Findings include: Review of the closed medical record for Resident #10 occurred on (MONTH) 28, - (MONTH) 1, (YEAR). Resident #10's [DIAGNOSES REDACTED]. A Transfer Assessment, dated 04/19/17, and the care plan stated, Transfer with Hoyer lift 2 assist. Nursing progress notes identified the following: * 10/20/17 at 10:16 p.m., (6:40 p.m.) Called to (Resident #10's) room. Upon entering room, observed resident lying on her back on the floor besides her bed. Her head was at the foot of the bed. CNA (certified nurse aide) stated that she had been transferring resident to bed and (the resident) slid out of the lift sheet. CNA had tried to catch resident and had ahold of (resident's) butt but she con't (continued) to fall. CNA stated that resident did not hit her head, and that she had landed on her left shoulder. CNA also stated that she heard a crack when resident landed. assessed resident. Is alert and responding to yes or no questions appropriately. ROM (range of motion) to LEs (lower extremities) within normal limits and denied pain. ROM to right arm within normal limits. Left arm is almost flaccid. Shoulder feels displaced. Attempted slight vertical ROM with almost instantaneous 'Ow' from resident and grimace. Also heard grinding noise. no further ROM attempted. no other injuries observed at this time. (vital signs taken) . Daughter . notified of fall and impending transfer to (hospital) . agreeable to transfer. (7:00 p.m.) . DON, notified of fall. (7:05 p.m.) . Administrator, notified of fall. 911 called. (Hospital) called and informed of impending arrival of resident and updated on her condition. (ambulance) here . left arm secured to body to prevent further movement. Scoop used to lift to cot with 4 assist. (7:23 p.m.) Left per (ambulance) . (8:55 p.m.) Received call from (Hospital). Informed that resident did have fx (fracture) of left shoulder and probably will be coming back to facility tonight. (9:00 p.m.) Daughter, (name), called facility to let us know what (Hospital) said and to let us know resident coming back tonight. * 10/20/17 11:09 p.m., Resident returned from (Hospital) (at) 10:55 (p.m.) Fracture to L (left) proximal humerus (sic). Immobilizer in place to L shoulder. Orders received for [MEDICATION NAME] 50 mg (milligrams) po (by mouth) q (every) 4-6 hrs. (four to six hours) PRN (as needed). * 10/21/17 Addendum 2:02 p.m., . CNA was educated at the time of fall about proper placement of lift sheet, going over care guides, and requesting assistance when needed. * 10/21/17 10:15 p.m., Alert. (Resident #10) is in pain when we turned her to changed (sic) the product. PRN [MEDICATION NAME] given. Immobilizer on at all times. * 10/22/17 5:47 p.m., . Minimal discomfort observed to left shoulder. assessed right leg again . no change from this morning. (5:15 p.m.) PRN [MEDICATION NAME] given. * 10/23/17 10:02 a.m., Residents O2 (oxygen) sat (saturation) 85% was started on oxygen (at) 2 L (liters) per nasal canal. Daughter . called and informed of oxygen use. Will continue to monitor. Sat up to 93% after 15 minutes. * 10/24/17 2:28 p.m., Res. (Resident) c/o (complains of) left sided rib pain and right sided hip pain. No outward rotation of hip noted. Also sats drop to low 80's without oxygen. Sats up to 93% with O2 on (at) 3l/nc (three liters per nasal cannula). MD (medical doctor) notified and did say only left shoulder x-rays were completed. Orders received for x-rays hips and chest x-ray. Radiology reports of the 10/24/17 hip and chest x-rays showed: * Hip: . No evidence of fracture or loosening. * Chest: . There is a [MEDICAL CONDITION] 4th rib poterolaterally (sic). No additional rib fracture is apparent . Review of the facility fall investigation, dated 10/20/17 at 8:30 p.m., showed: * The CNA was on orientation at the time of Resident #10's fall. The fall occurred due to the hoyer sling not being positioned properly. Resident did slide out of the sling because lift sheet was not crossed at the legs. The CNA did admit to not being familiar with the mechanical lift and reported she had not used a lift sling that crossed between the resident's legs before. * Interviews with two CNAs who assisted with the involved CNA's orientation identified she had not worked with this specific lift prior to the fall. * At the time of the fall, the nurse on duty, educated the CNA on the importance of reading the resident's care guides and understanding how to use a Hoyer lift. The nurse then removed the CNA from working without her orientating CNA. * On the night of the fall the DON educated the CNA demonstrating on the specific lift used including appropriate placement of the sheet to prevent sliding and signs the resident may be shifting in the sling. The DON also educated the CNA on the importance of reading care guides for directions on each resident's method of transfer and directed her to ask for assistance if she has not worked with a piece of equipment before. During interviews on 03/01/18 at 8:23 a.m. and 1:10 p.m., an administrative nurse (#1) identified and documented the steps the facility took to prevent another resident from falling from a sling/transfer sheet: * The DON observed the involved CNA as she completed a transfer competency evaluation on 10/20/17. * Nursing staff observed facility CNAs complete transfer competency evaluations beginning 10/21/17, as the staff were on duty, completing most evaluations by 10/31/17. As part time or travel staff worked since the fall nursing staff observed as they completed transfer competency evaluations. * The facility provided education on 11/28/17 and 11/29/17 for all nurses and CNAs on the use of mechanical lifts. * Staff changed care plans for all residents using a Hoyer lift to two person assist. Prior to the fall, if care planned, one person could use the portable Hoyer lift for a transfer. * The facility programed the CNA kiosks, on 10/21/17, to show a resident's mode of transfer upon opening the resident's task page. CNAs no longer need to go to the nurse's station to obtain this information. * The nurse (#1) stated the facility monitors the continued implementation of competency evaluations as part of the facility's quality improvement plan. The survey team determined a deficient practice existed on 10/20/17. The facility implemented corrective action on 10/20/17 and completed facility wide nursing staff education on 11/29/17. At the time of the survey, the facility maintained an ongoing education program and quality assurance plan to prevent reoccurrence of a similar fall.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 2 of 2 sampled residents (Resident #8 and #12) identified affected adversely by a medication error. Failure to ensure residents received the correct medications resulted in Resident #8's experiencing a fall with an injury, a severe drop in blood pressure, and a temporary decline in mental and physical status, and had the potential for Resident #12 to experience avoidable discomfort. Findings included: Review of the facility policy titled Medication Error occurred on 02/23/16. This policy, dated 09/07/14, stated, Medication error: . Significant medication error caused (sic) the resident discomfort or jeopardizes his or her health and safety. Examples are: 1. Omissions 2. Unauthorized drugs (drugs administered without a physician's order). Any medication error must be reported to the resident's attending physician, A medication Error Form completed and the DON (Director of Nursing) notified. Procedure 1. If the error or errors is significant, notify the DON ASAP (as soon as possible).3. Depending on the severity of the error, the medications the resident should have received may be held until the physician is updated. - Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] (blood thinner) 2 mg (milligrams) daily, [MEDICATION NAME] (pain medication) 50 mg two times a day, Tylenol Ex-Str (extra strength) 1000 mg and [MEDICATION NAME] (to lower blood pressure) 50 mg two times a day. During an interview on 02/22/16 at 5:02 p.m. an administrative nurse (#1) stated before Resident #8 sustained a fall on 11/30/15 a medication error occurred. The medical record lacked documentation of the medication error. (Refer to F514) During an interview on 02/23/15 at 08:15 a.m. an administrative nurse (#1) stated on 11/30/15 at approximately 8:00 p.m. Resident #8 received Resident #12's medications. The medications orally administered to Resident #8 included: * Trazadone (antidepressant) 300 mg, * MS ER ([MEDICATION NAME] sulfate-extended release narcotic pain medication) 30 mg * Senna (laxative) 3 tablets The administrative nurse (#1) also stated at 9:16 p.m. Resident #8 sustained a fall. A nursing staff member on duty informed this administrative nurse (#1) at 9:30 p.m. of the medication error and the fall. The nursing staff member failed to notify the DON of the medication error ASAP. Neurocheck Assessment worksheets identified the following on 11/30/15: * 9:30 p.m. blood pressure (B/P) 114/55 - Pulse (P) 89 - Respirations (R) 20 - Comments: Complain of dizziness, #6 pain (pain scale of 1-10) back of her head and lower back pain. * 9:45 p.m. B/P 77/47 - P 80 - R 18 * 10:00 p.m. B/P unable to obtain - P 61 - R 20 - Comments: . BP unreadable, (local hospital) notified (name of nurse practitioner) (NP) aware. Still c/o (complain of) #6 dizziness and lower back and back of head pain, Offered Ice pack, resident refused stating 'It will go away.' The medical record lacked orders/instructions received from the NP. The staff notified the NP approximately two hours after the nurse discovered the medication error. * 10:15 p.m. B/P unable to obtain - P 82 - R 20 - Comments: . B/P 64/45 Notified (name of NP), she said to continue monitor Vitals and call (local hospital) if any unusual results. * 10:30 p.m. B/P 64/45 - P 83 - R 20 - Comments: . Able to get B/P reading of 64/45, (name of NP) notified and suggested to forced (sic) fluids (sic) intake. The record lacked evidence of a telephone order. * 11:00 p.m. B/P unable to obtain - P 86 - R 20 - Comments: . unable to get BP reading, started on water orally. * 11:30 p.m. B/P unable to obtain- P 79 - R 20 - Comments: . denies pain and started on 7-up. Staff failed to notify the NP of any unusual results in vitals for two hours (10:30 p.m. to 12:30 a.m.). Neurocheck Assessment worksheets identified nursing staff did not ensure the stability of Resident #8's blood pressure to ensure normal readings for a period of six hours on 12/01/15: * 12:30 a.m. B/P 105/70 - P 59 - R 26 - Comments: . notified (name of NP) stated to continue oral fluids . * 1:30 a.m. B/P unable to obtain P 79 R 16 Comments: . No BP reading, gave another can of diet 7-up. Denies pain * 2:30 a.m. B/P 76/45 - P 74 - R 18 * 3:30 a.m. B/P 72/44 - P 79 - R 20 * 7 :30 a.m. B/P 110/60 - P 60 - R 20 Nursing progress note stated the following: * 12/1/2015 1:58 AM - (On 11/30/15 at 9:15 p.m.) - CNA (certified nursing assistant) was calling this nurse over handset to go to resident room. Observed resident in supine position and stated that she got up and was about to lower her window blinds when she felt dizzy and lost her balance, she added she hit the back of her head. Room is crowded with furniture and resident has gripper socks on. No swelling or redness back of her head (sic), ROM (range of motion) ok, upper and lower extremities has no pain upon moving and equal in length. Voiced #6 pain to back of head and lower back pain and with some dizziness. Removed some furniture from bedroom to accommodate the Hoyer lift (full body lift), use Hoyer lift for transfer and made comfortable in bed. Pain pill was given an hr. (hour) before the fall. Started on neuro (neurological) check per protocol. Dr. (Name) was notified about resident status and about BP (blood pressure) that is unable to obtain. 2230 (10:30 p.m.) BP 64/45. Advised to forced (sic) fluid intake and watch on (sic) any abnormal vitals. Resident is alert, speech clear and strength equal to bilateral hands. No SOB (shortness of breath) and refused ice pack for back of her head. Family will be notified in the morning. Monitor. * 12/1/15 9:52 a.m. lethargy. Res. (Resident) was very tired this am (a.m.) and was not going to eat BF (breakfast) so did hold insulin. * 12/1/2015 at 11:00 a.m. Res very lethargic. She does respond, but is very slow to respond. Her speech is slurred. Pupils are pinpoint and very sluggish. Hand grasps are equal and strong bilat. (bilateral). 'I'm just so tired ' Dr. (name) made aware of the above. Orders received to get CT (cat scan) of head. * 12/1/2015 4:19 p.m. Denies pain . Res. alert but still sleepy and able to answer questions. * 12/1/2015 10:19 p.m. Resident still very lethargic and confused about the date. BS (blood sugar) 179, and went right back to sleep. * 12/2/2015 1:41 a.m. Resident alert, tired and feels 'shot (sic) circuited' but no confusion now. * 12/2/2015 2:57 p.m. Res is still very sleepy today. * 12/02/2015 10:15 p.m. Resident remains very lethargic. Has difficulty getting up but stands well and holds on to bars well in BR (bathroom). Once back in bed, sleeps immediately. * 12/3/2015 9:43 a.m. Resident is alert and oriented. Still c/o (complain of) mild pain to top of head from fall. Very tired. Had breakfast tray in room and is back in bed resting. The November 2015 Medication Administration Record [REDACTED]. A physician progress notes [REDACTED]. Apparently fell and bumped her head. She had CTs (cat scan) of the C- (cervical) spine and brain yesterday that were basically normal. Mild concussion. Resident #8 received Resident #12's medications which resulted in a fall sustaining a mild concussion, an unstable condition noted by low blood pressure readings, and lethargy for approximately three days. In addition, staff failed to: * notify the NP until approximately two hours after the medication error occurred. * notify the NP when unable to obtain a BP reading for two hours * monitor blood pressures to ensure normal readings for a period of six hours on 12/01/15. * document telephone order regarding orders received. * ensure documentation of the event in the medical record to ensure proper follow-up monitoring/communication. - Review of Resident #12's medical record occurred on 02/24/16. Record review identified the resident received scheduled [MEDICATION NAME] (pain medication) two times a day for chronic pain, and Trazadone (antidepressant) on a daily basis for [MEDICAL CONDITION]. On the evening of 11/30/15 nursing staff failed to ensure Resident #12 received these two medications after an event with another resident. Failure to administer Resident #12's scheduled medications could adversely affect this resident's pain level and ability to rest.