Every finding on record at Missoula Health & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen by ensuring staff with facial hair wore beard coverings while working in the kitchen. The deficient practice had the potential to affect all residents who received food prepared in the facility's kitchen by increasing the risk of hair contamination in the food. Findings include:During an observation on 3/23/26 at 1:56 p.m., staff member L was observed with facial hair and was not wearing a beard cover while working in the kitchen.During an interview and observation on 3/25/26 at 11:51 a.m., staff member M was observed working in the kitchen with facial hair and was not wearing a beard cover. Staff member M stated he should have been wearing a beard covering because of his facial hair.During an interview on 3/25/26 at 11:53 a.m., staff member L stated staff with facial hair are required to wear beard coverings while working in the kitchen.Review of the facility's policy titled, Personal Hygiene Standards, updated June 2021, showed, .2. The following standards have been adopted by the FANS (Food and Nutrition Services) Departments:.k. For those employees with beards, beard guards are worn.

Based on observation, interview, and record review, the facility failed to ensure temperatures were monitored daily by staff for a refrigerator that contained stored medications and vaccines. This failure placed residents who had or used refrigerated medications and vaccines at risk for experiencing adverse effects. Findings include: During an observation and interview on 3/26/26 at 8:51 a.m., staff member Q stated the two refrigerators in the provider office were used to store medications and supplements. Staff member Q stated the night shift nurse was supposed to check the refrigerator temperatures during their shift. Staff member Q stated he could see some temperatures were missing from the log sheets with daily temperature monitoring displayed on both refrigerators. The refrigerator had multiple types of medications and biologicals, including Tubersol (for tuberculin skin testing) boxes and influenza vaccine (FLUAD) boxes.Review of a facility document titled, Temperature Log for Refrigerator - Fahrenheit, dated 3/26, showed two pages of logs for temperatures for March 2026. One page showed temperatures for days 1-15, and the second page had temperatures for days 16-31. On the days of March 20 and 21 (2026), there were no staff initials, times, or temperatures noted on the log.Review of a facility policy titled, Storage of Medication, dated 1/25, showed: . Medications and biologicals are stored properly. to keep their integrity and to support safe, effective drug administration. 11. Medications requiring refrigeration or temperatures between . 36 F and . 46 F. are kept in a refrigerator with a thermometer to allow temperature monitoring. A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. If no vaccines are stored in the refrigerator, document temperature checks at least once daily.

Based on observation, interview, and record review, the facility failed to ensure it had an effective process in place for the most current code status on POLST (Physician Orders for Life-Sustaining Treatment) forms and advance directives to be readily accessible in the electronic medical record, and available to staff, in the event of an emergency, for 2 (#s 30 and 31) of 22 sampled residents. Findings include:During an interview on [DATE] at 1:16 p.m., staff member R stated resident POLST forms and advance directives were kept at the nurses station in hard copy only. Staff member R stated the forms were not kept in the electronic medical record because of the need to have them available and to update for recent changes, in case of an emergent situation.During an observation and interview on [DATE] at 1:26 p.m., staff member S walked to the nurses station and requested to use the binder which held resident POLST forms and advance directives. Staff member S stated she did have to come up to the nurses station to check on resident code statuses. Staff member S looked for resident information in the binder and passed the binder back to the surveyor.During an interview on [DATE] at 8:14 a.m., staff member R stated POLST forms for residents were kept in a binder at the nurses station and not scanned into their medical record. Staff member R stated it had been like that since the facility went to electronic records from paper charts in 2012. Staff member R stated nurses have an SBAR (Situation, Background, Assessment, and Recommendation) form they can use for entering a resident's code status in the medical record. 1. Review of resident #30's POLST, dated [DATE], showed the form was completed by his medical power of attorney, with a selection of Do Not Attempt Resuscitation (DNR), no artificial nutrition by tube, and treatment options to include comfort measures only. Review of resident #30's care plan showed an admission date of [DATE], with a pertinent diagnosis of intractable epilepsy with status epilepticus, and did not include information regarding resident #30's code status or advance directives. Review of resident #30's medication and treatment administration record for [DATE] showed no listed physician's orders for code status. The section for Advance Directive showed, For Advance Directives and Code Status and/or POLST, see Disaster Recovery binder at nursing station. Review of resident #30's electronic medical record showed a document for a funeral trust was uploaded to the documents section under the category Advance Directives. The section displayed under the resident's name titled, Code Status: Advance Directives, showed: For Advance Directives and Code Status and/or POLST, see Disaster Recovery binder at nursing station.2. Review of resident #31's POLST, dated [DATE], showed the form was completed by his medical power of attorney, with a selection of No CPR, no artificial nutrition by tube, and medical interventions to include selective treatment, and showed, I want him to have oxygen always if needed! Review of resident #31's care plan showed an admission date of [DATE], with a pertinent diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and did not include information for resident #31's code status or advance directives. Review of resident #31's medication and treatment administration record for [DATE] showed no listed physician orders for code status. The section for Advance Directive showed, For Advance Directives and Code Status and/or POLST, see Disaster Recovery binder at nursing station. Review of resident #31's electronic medical record showed no advance directives or POLST forms were uploaded to the documents section under the category Advance Directives. The section displayed under the resident's name titled, Code Status: Advance Directives, showed: For Advance Directives and Code Status and/or POLST, see Disaster Recovery binder at nursing station. Review of a facility policy titled Advance Directives, revised [DATE], showed: . 2. During the admission process, the facility identifies if the resident has an advance directive or medical orders related to life sustaining treatment. If the resident does, a copy is requested and kept in the resident's medical chart, accessible to the physician and care staff. 10. The resident's comprehensive care plan is reviewed and updated routinely in order to incorporate the resident's choices regarding these rights into treatment, care and services. Review of an online reference, located at https://boards.bsd.dli.mt.gov/medical-examiners/provider-orders-life-sustaining-treatment/faq and accessed on [DATE], showed: . The Provider Orders for Life-Sustaining Treatment (POLST) form represents a way of summarizing wishes of an individual regarding life-sustaining treatment. The form is intended for any individual with an advanced life-limiting illness. The form accomplishes two major purposes: it is portable from one care setting to another and it translates wishes of an individual into actual medical orders. The POLST form facilitates the process of translating end-of-life discussions with patients into actual treatment decisions, and provides security for the individual and physician that the expressed wishes will be carried out. There is no other form that streamlines the process in this way. If you have a signed POLST form, The Department of Public Health & Human Services and Board of Medical Examiners recommends you also have an advanced directive, though it is not required. You may obtain more information about advanced directives from your provider.

Based on interview and record review, the facility failed to ensure the Brief Interview for Mental Status (BIMS) was completed correctly on the Minimum Data Set Assessment, and failed to conduct the required staff assessment for the resident's mental status when the resident was unable to participate in the Brief Interview for Mental Status (BIMS) for 1 (#7) of 22 sampled residents. The failure resulted in an inaccurate representation of the resident's cognitive status and placed the resident at risk for inappropriate care planning and interventions. Findings Include:During an interview on 3/25/26 at 2:07 p.m., staff member D stated resident #7 was Out of it, when he was admitted to the facility. Staff member D said that when she completed Section C, the Brief Interview for Mental Status (BIMS), resident #7 either didn't respond to the interview questions or the resident provided nonsensical responses during the entire interview. Staff member D stated that a staff assessment should have been completed due to resident #7's inability to meaningfully participate.Review of resident #7's admission Minimum Data Set, with an assessment reference date of 3/6/26, showed:Section B (Hearing, Speech, and Vision): resident #7 was coded as usually making himself understood and usually understood others.Section C (Cognitive Patterns): Brief Interview for Mental Status Score (C0500) coded as 00, a severe cognitive impairment. No staff assessment was completed.There was no documentation to support the Brief Interview for Mental Status interview that met criteria for a completed interview, nor was there evidence that the required staff assessment was initiated after an incomplete interview.Review of the CMS RAI Version 3.0 Manual, Section C (Cognitive Patterns) showed:A BIMS interview is considered complete only if the resident: Attempts and provides relevant responses to at least four items (C0200-C0400)The interview must be stopped if: Responses are nonsensical, irrelevant or no response was provided.If the interview is incomplete, staff must: Code 99 in C0500, Code 1 (Yes) in C0600 (Staff Assessment Required), and complete the Staff Assessment for Mental Status (C0700-C1000).The manual further clarified that nonsensical responses or lack of responses to four or more items constitute an incomplete interview, requiring a staff assessment.Resident #7 did not provide meaningful or relevant responses during the Brief Interview for Mental Status, as revealed in staff member D's interview on 3/25/26. The facility coded a completed score of 00 rather than 99 (unable to complete). The facility failed to trigger and complete the required staff assessment.

Based on observation, interview, and record review, the facility failed to ensure timely assessment, implementation of appropriate wound care orders, and coordinated follow-up after a skin concern was initially identified by the therapy department for 1 (#7) of 22 sampled residents. This failure resulted in delayed assessment and treatment of a developing pressure injury, placing the resident at risk for worsening skin breakdown and impaired healing. Findings include:During an observation on 3/23/26 at 2:48 p.m., resident #7 was observed in his room, seated in his wheelchair in a reclined position. During an observation on 3/24/26 at 4:44 p.m., resident #7 was observed in his room, asleep in his wheelchair in a reclined position. During an observation on 3/25/26 at 1:40 p.m., resident #7 was observed in the common area in his wheelchair in a reclined position. During an interview on 3/25/26 at 10:12 a.m., staff member B stated that when a skin concern was identified, the wound nurse is responsible for assessing and staging (determining severity) the wound, notifying the provider, and obtaining physician orders, which are then implemented on the medication and treatment administration record until the wound is resolved. Staff member B reported she was notified by the therapy department on 3/24/26 while resident #7 was assisted with toileting. Staff member B stated she did not approve of resident #7 being up in the chair for prolonged periods, noting, He's up almost all day in that chair, and stated the resident would benefit from being repositioned in bed to reduce pressure (on skin). She further stated the therapy department had been directing the resident's daily positioning and care. Staff member B said she was not aware of the skin concern before 3/24/26 and had not been informed of the initial identification on 3/19/26, after the skin concern was first identified. During an interview on 3/25/26 at 10:31 a.m., staff member K stated the skin concern for resident #7 was initially identified by the therapy department the previous week, at which time the area was described as dry and reddened. Staff member K further reported that by the day prior (3/24/26), the area had progressed to being open and peeling, revealing a decline in skin integrity. Staff member K said they have been trying to keep resident #7 up in his chair in the mornings and lay him down after lunch. This information demonstrates that the skin concern was identified days before the skin opened, yet a timely follow-up assessment and interventions were not implemented to prevent progression. During an interview on 3/25/26 at 10:43 a.m., staff member P said resident #7's daily routine was to be up in his chair for all meals and then lie down after meals, Because of his bottom. During an interview on 3/25/26 at 1:25 p.m., NF2 said she had mixed messages from staff related to the wound on resident #7's buttock. NF2 stated, Some people have said yes, something is going on, and some people say nothing is going on, related to resident #7's buttock wound. During an observation on 3/25/26 at 1:32 p.m., staff members F and G provided peri-care for resident #7. When resident #7's brief was removed, the resident had a large circular basketball-sized reddened area around his gluteal area with a circular imprinted dimpled area around the circumference of the reddened area. The reddened area was blanchable. Inside the reddened area was a large padded dressing covering the intergluteal cleft (the crack between the buttocks), the coccyx, and the gluteal region. The dressing was dated 3/24/26. Staff member H entered the room to perform wound care for resident #7. When staff member H removed the dressing, there was an open area of skin, which was approximately one centimeter (the size of a pencil eraser) circular wound with partial thickness skin loss exposing the dermis. The open area appeared bright red and shallow, with no drainage. Staff member H cleansed the wound and reapplied a large white dressing to the area. There were no measurements obtained by staff member H during the observation. During an interview on 3/25/26 at 3:11 p.m., staff member H stated she was notified of resident #7's wound/skin area yesterday (3/24/26) during morning cares. She stated the area was opened yesterday, and she cleansed the site and applied a dressing. She stated she did not obtain any measurements or assessments of the area since she was not as familiar with the staging of pressure injuries. She stated she had notified staff member B since the wound care nurse was out on leave. She stated she would normally notify the wound care nurse and the provider of any new pressure areas noted on a resident. Staff member H stated she felt the open area on resident #7's buttocks would heal quickly with barrier cream. Review of resident #7's Physical Therapy Treatment Encounter Note, dated 3/19/26, showed, .It also became apparent that patient was beginning to demonstrate signs of breakdown. Nurse is notified and she is able to place both cream and protective barrier. Review of resident #7's electronic health record showed the following: - Daily Skilled Evaluation for Falls/Weakness note, dated 3/19/26, .Noted gluteal skin reddened, risk for breakdown. Cleansed, barrier cream and prophylactic dressing applied. Therapy x2 assisted with brief change. - Daily Skilled Evaluation for Falls/Weakness note, dated 3/24/26, .Left gluteal wound cleansed and dressing applied. Barier cream applied on peri-area. [sic] - Daily Skilled Evaluation for Falls/Weakness note, dated 3/25/26, .Left gluteal shear wound care done, note no drainage, or signs of infection, no pain. - Weekly Skin Evaluation, dated 3/25/26, .Wound site: Buttock Right, Wound is described as shearing of skin dry flake, Length in centimeters: 5, Width in centimeters: 5, Depth in centimeters: 0, Shape of wound: oval .This is the first observation of this wound. The weekly skin evaluation dated 3/25/26 inconsistently identified the wound as the first observation and located it on the right buttock, reflecting discrepancies in the documentation and delayed recognition of the wound's progression. Review of resident #7's medication and treatment administration record for March 2026 showed the following orders: -Weekly Skin Audit every day shift every Mon Nurse Initials - Head to Toe Skin Evaluation completed. If new skin impairment is found, document in Progress Notes, notify Medical Provider, and initiate Weekly Skin Evaluation. Start Date- 03/09/2026 6:00 a.m. - Left gluteal wound - cleanse with wound wash, pat dry and cover with dry dressing once daily and PRN one time a day for wound care -Start Date- 03/24/2026 10:00 a.m. The medication and treatment administration record showed wound care orders were not initiated until 3/24/26, despite identification of skin breakdown on 3/19/26. This demonstrates a failure to ensure timely follow-up, accurate assessment, and consistent documentation after initial identification of skin breakdown, resulting in progression of the wound. Review of the facility's policy titled, Skin Integrity, updated January 2026, showed, Policy Statement: It is the policy of this center that a resident who enters the center without pressure ulcer/injury does not develop pressure ulcer/injury unless the individual's clinical condition demonstrates that they were unavoidable and a resident having pressure ulcer/injury receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. 4. For new skin impairment identified, the LN completes the following: a. Documents the skin impairment that includes measurements of location, size, color, presence of odor, exudate, and presence of pain associated with the skin impairment. [sic]

Based on observation, interview, and record review, the facility failed to follow professional standards and practices to ensure a resident's electronic medical record contained accurate information for the administration of a medication for 1 (#44) of 22 sampled residents. Findings include:Review of resident #44's list of physician orders showed: .Order: busPIRone HCI Oral Tablet 15 MG (Buspirone HCI), Directions: Give 1.5 tablet by mouth two times a day, Category: Pharmacy, Status: Active, Start Date: 3/18/26, Revision date: 3/23/26.Supply Date Dispensed: 3/18/26, Date Received: 3/18/26, Status: on hand, Medication: busPIRone HCI 15 MG Tablet, Directions: Take 1 & 1/2 tablet (22.5 MG) by mouth twice daily for hypertension.During an interview on 3/25/26 at 7:56 a.m., resident #44 stated her medications were previously messed up, but the staff had straightened them out. Resident #44 stated that Buspirone is for her anxiety. During an interview on 3/25/26 at 7:59 a.m., staff member B stated that when a resident arrives at the facility, the ADON enters the medication orders, and the DON double-checks them. Staff member B stated she did not know why the order showed hypertension and did not know how it was entered that way. Staff member B stated she had done an audit and noticed it had the wrong diagnosis and changed it immediately. During an observation and interview on 3/25/26 at 10:10 a.m., staff member N stated the rationale for resident #44's buspirone was hypertension, according to the label on the medication card. Staff member N pulled out the medication card and showed this surveyor. The medication card for resident #44's buspirone showed .for hypertension. Staff member N stated the medication administration record is the same as the medication card from the pharmacy.During an interview on 3/25/26 at 4:16 p.m., staff member O stated buspirone does not have any hypertensive agents but could be used to reduce anxiety and, as a result, reduce hypertension.During an interview on 3/26/26 at 8:49 a.m., NF3 stated she was not sure how hypertension got attached to resident #44's buspirone order. NF3 stated, She (resident #44) has a history of depression and anxiety, but the medication is definitely not for hypertension. NF3 stated she (resident #44) does see psych services, and she came to the facility on that medication. Review of a facility document titled Medication Administration General Guidelines dated 1/25, showed: Policy: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices.3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to label if directions have changed from the current label.

Based on observation, interview, and record review, the facility failed to maintain a comfortable temperature for 5 (#s 1, 9, 20, 26, and 89) of 14 sampled residents throughout the facility; and failed to repair the sheet metal covering on a base board heater in a community area. This deficient practice had the potential to cause cold induced stress, and injure a resident ambulating in the affected area. Findings include: 1. During an observation on 2/12/25 at 3:50 p.m., the base board heater at the end of the North Hall, by the nurses' station, had sheet metal that was detached, and a sharp edge was protruding out on both ends of the heater. During an interview on 2/13/25 at 9:38 a.m., staff member C stated the protruding sheet metal on the base board heater was a tripping hazard for residents. A review of a facility policy titled, Preventative Maintenance, with a published date of July 2008, showed: Policy Statement: This manual defines and establishes procedures for the implementation of the Center's preventative maintenance program. The intent of this program is to establish a building where the environment is safe and comfortable, essential utilities are delivered without interruption and mechanical systems and equipment operate safely, accurately, and reliably. Procedure: . 2. All areas of the Center and equipment therein, are inspected and maintained in accordance with the scheduled maintenance system . 45447 2. During an observation and interview on 2/12/25 at 11:00 a.m., the nurses station temperature read 66 degrees Fahrenheit. Staff member C stated he had put plastic on the windows to help keep the building warm, but residents liked to poke holes in the plastic. Staff member C stated the facility provided blankets to the residents when they were cold, and stated the facility did not have a blanket warmer. Staff member C stated the building ran on a boiler for heat in the North Hall rooms, so those rooms were colder than the South Hall rooms. Staff member C stated he did not document the temperatures in the resident rooms or public areas because he did not have a sheet designated to document the temperatures. Staff member C stated the low temperatures in the building, .just happen when it gets this cold . There is nothing in the works to help improve the temperature issues . During an observation and interview on 2/12/25 at 12:28 p.m., resident #1 was lying in bed with blankets covering her. Resident #1 stated she was so cold that day, her hands turned blue, and she could not get warm. Resident #1's room was on the South Hall. During an observation on 2/12/25 at 12:30 p.m., the temperature on the South Hall read 68 degrees Fahrenheit. During an interview on 2/12/25 at 12:32 p.m., resident #20 stated she kept her door shut because otherwise her room would get cold. Resident #20's room was on the South Hall. During an observation on 2/12/25 at 12:48 p.m., the temperature on the North Hall read 65 degrees Fahrenheit. 49554 3. During an interview on 2/12/25 at 10:55 a.m., staff member J stated the facility was old and was often cold. During an interview on 2/12/25 at 3:05 p.m., resident #26 stated, The facility is cold every winter. The staff keeps the temperature low. It is warmest in the dining room near the baseboard heaters. During an observation and interview on 2/12/25 at 3:19 p.m., resident #9 was wrapped up in blankets in her bed. Resident #9 stated, I just got out of the shower. Resident #9 was shivering and had goose bumps on her arms; her lips were purple in color. Resident #9 stated, It is cold in here. I normally have lots of blankets on me. One hallway will be warm one week and cold the next. During an interview and observation on 2/12/25 at 3:25 p.m., staff member I stated, I don't think it's cold in here. Staff member I was wheeling resident #89 down the hall in her wheelchair. Resident #89 stated, I'm cold; could I get a blanket? Staff member I went and got a blanket for resident #89. At this time resident #89 already had a blanket around her and now had two blankets on.

Based on interview and record review, the facility failed to honor a resident's activity preference for going outside when the weather was comfortable, for 2 (#s 9 and 24) of 14 sampled residents. This deficient practice increased the risk of the resident's of a decline in mood or well-being. Findings include: During an interview on 2/11/25 at 8:22 a.m., NF1 stated she had asked facility staff shortly after resident #24 was admitted to the facility, when would she be able to go outside, and was told resident #24 could go out with the smokers. The smokers went outside five times a day. NF1 further stated the residents could go months and months without going outside. During an interview on 2/11/25 at 2:21 p.m., resident #9 stated she had not been outside the facility except to go to appointments. Resident #9 stated, I would like to go outside when it's not cold and they haven't taken us outside, they're busy. A review of resident #9's Annual MDS assessment, with an ARD of 3/15/24, showed section F: Preferences for Customary Routine & Activities, . How important is it to you to go outside to get fresh air when the weather is good? . Response: somewhat important. A review of resident #24's Admission MDS assessment, with an ARD of 10/16/24, showed for section F: Preferences for Customary Routine & Activities, . How important is it to you to go outside to get fresh air when the weather is good? . Response: very important. During an interview on 2/12/25 at 9:36 a.m., staff member E stated he did not conduct any outside activities for the residents since starting in his position in the middle of July 2024. Staff member E stated he had not utilized the facility's outside courtyard since he had been here. Staff member E further stated he had not felt comfortable taking any residents outside until sometime around September 2024. A review of the facility's monthly activities calendar, listing activities for each day of the month, for April, May, August, September, and October 2024, failed to show any outside activities scheduled. The activities calendars for June and July 2024 were requested, but not received prior to the end of the survey. A review of a facility policy titled, Activity Program, updated July 2015, showed: Policy Statement: The Center provides an ongoing program of activities designed to meet the interests as well as physical, mental, and psychosocial well-being of each resident. Procedure: 1. The activity program: a. Is multifaceted to reflect the entire resident population's needs and interests. b. Is varied to provide stimulation or solace. c. Promotes physical, cognitive, and/or emotional well-being. d. Enhances to the extent practical each resident's physical. mental. and psychosocial status. [sic]

Based on interview and record review, the facility failed to complete a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences within 14 days of admission, for 1 (#89) of 14 sampled residents. Findings include: Review of resident #89's medical record showed resident #89 was admitted to the facility on [DATE]. The ARD for the completion of the comprehensive Admission MDS assessment was 1/27/25. The comprehensive Admission MDS assessment was open and showed 'in progress.' This assessment should have been completed and submitted within 14 days of the resident's admission to the facility. The comprehensive Admission MDS was 15 days late as of the last day of the survey period. During an interview on 2/12/25 at 1:39 p.m., staff member H stated she completed Admission assessments within 14 days of a resident's admission.

Based on observation, interview, and record review, the facility staff failed to provide regular showers for 4 (#s 9, 20, 26, and 89) of 14 sampled residents, which made the residents feel dirty and or upset. Findings include: 1. a. During an observation and interview on 2/10/25 at 12:05 p.m., resident #9 was lying in her bed eating her lunch. Resident #9 was in her nightgown, and her hair looked greasy and unkempt. Resident #9 stated she had not had a shower in quite a few days. During an observation on 2/12/25 at 11:03 a.m., resident #9's hair was greasy and matted to her head. During an observation and interview on 2/12/25 at 3:19 p.m., resident #9 was in her bed, and her hair was wet and pulled back in a ponytail. Resident #9 stated, I am supposed to get a shower every three days, but it doesn't always happen. Sometimes it's once a week or longer. I just went two weeks without a shower. It made me feel dirty, and my head was itchy. b. During an observation and interview, on 2/10/25 at 12:12 p.m., resident #20 was sitting on the side of her bed. Resident #20's hair looked greasy and unkempt. Resident #20 had a substantial amount of facial hair. Resident #20 stated, We don't get our showers often. It's usually one shower every three weeks. I feel dirty. c. During an observation on 2/10/25 at 3:37 p.m., resident #89 was sleeping in her wheelchair, at a table, in the dining room. Her hair looked unkempt. During an observation on 2/11/25 at 8:15 a.m., resident #89 was sitting at the dining room table waiting for breakfast. Her hair was unkempt. d. During an observation and interview on 2/10/25 at 3:27 p.m., resident #26 was lying in her bed; and her hair appeared greasy. Resident #26 stated, I get a shower once a week, usually. Sometimes it's longer than that. The staff tell me I don't stink, so I don't need a shower. It makes me upset; I would prefer a shower more often. During an interview on 2/12/25 at 10:46 a.m., staff member G stated, CNAs are responsible for doing baths. There are times they don't get them done if they are short-staffed or have call-offs. The baths are documented in PCC and on the Care Team Assignments sheets at the nurse's station. When the aides do the baths, they cross it off the list and initial it. If a bed bath was conducted, it would be documented as well . If I went two weeks without a shower, I would feel gross. It would affect your mental health. Review of the bathing task documentation in PCC and Care Team Assignment sheets showed: Resident #89 went 14 days without a shower (1/25/25 - 2/8/25). Resident #20 went 22 days without a shower (1/14/25 - 2/5/25). Resident #9 went 12 days without a shower (1/31/25 - 2/11/25). Resident #26 went 12 days without a shower (1/31/25 - 2/11/25). A request was made for a bathing policy on 2/11/25 at 4:15 p.m. The facility failed to provide one by the end of the survey period.

Based on observation, interview, and record review, the facility failed to provide residents with group and individual activities to meet their interests and support their physical, mental, and psychosocial well-being for 2 (#s 9 and 26) of 14 sampled residents. Resident #26 stayed in her room most of the time, and neither resident participated often in group activities. 1. During an observation and interview on 2/10/25 at 3:27 p.m., resident #26 was lying in her bed in the dark. Resident #26 stated, They don't have activities that interest me. They do bingo all the time, but I don't like bingo. I stay in my room most of the time. During an observation on 2/12/25 at 3:05 p.m., resident #26 was in her room lying in her bed in the dark. Review of resident #26's activities participation record showed participation in two activities in the 30-day look-back period. 2. During an observation and interview on 2/10/25 at 12:05 p.m., resident #9 was lying in her bed eating lunch. Resident #9 stated, I don't have much to do. I don't like most of the activities scheduled. During an observation and interview on 2/12/25 at 3:19 p.m., resident #9 was lying in her bed. Resident #9 stated, I have to be in the right mood to participate in group activities. The staff have never offered me things to do in my room. I wish they did. They have a lot of stuff for my roommate to do, but not me. I guess I should tell them that I like to color too. Review of resident #9's activities participation record showed participation in one activity in the 30-day look-back period. During an interview on 2/12/25 at 9:36 a.m., staff member E stated he met with the residents continually throughout their stay to get to know them. He was responsible for care planning the residents' preferences. Staff member E stated, I don't always record refusals when residents refuse to participate in group activities. The facility just hired an assistant, so I'm hoping documentation will be better. I haven't been documenting as much as I should be. I haven't been documenting one-on-one time spent with residents. During an interview on 2/13/25 at 10:00 a.m., staff member K stated activities documentation was identified as an issue about three weeks ago. The Activities Director was not documenting any of the activities. Review of a facility document titled, Activity Program, updated on 7/2015 showed: 1. The activity program: a. Is multifaceted to reflect the entire resident population's needs and interests . d. Enhances to the extent practical each resident's physical, mental, and psychosocial status. 2. The Activity Director is responsible for overall supervision, direction, and management of the activity program, including: a. Reviewing activities and attendance monthly . 5. Activities include individual, small and large group, one-on-one, and independent activities to meet residents' needs, abilities, and interests.

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion were provided appropriate assistance and positioning to maintain or improve mobility for 2 (#s 15 and 27) of 14 sampled residents. Findings include: 1. During an interview on 2/10/25 at 1:08 p.m., resident #27 stated she had a recurring wound on her coccyx area that would open and then heal. Resident #27 stated she worked with physical therapy three times a week, but would like to work more on her mobility. During an interview on 2/11/25 at 6:19 p.m., NF3 stated they feel resident #27 was left in bed too long when they visited the facility, and had not seen a staff member rotate resident #27. NF3 stated if resident #27 was moved it was just to bed. NF3 stated she would talk to resident #27 on the phone every day, and talk her through her physical therapy exercises. NF3 stated feeling more physical therapy or restorative therapy would be beneficial for resident #27, and felt the facility was short staffed at times, which might have led to less mobility and potentially more pain for resident #27. Review of resident #27's EHR showed the task: Did you turn and reposition? Resident #27 was repositioned once during the day shift on 2/10/25 (at 9:31 a.m.) and once on 2/11/25 (at 10:58 a.m.). No other times were documented for turning or repositioning during the day shifts on 2/10/25 or 2/11/25. During the following observations on 2/12/25, resident #27 was sitting in her wheelchair in the main dining room area: - 8:31 a.m. - 9:24 a.m. - 11:10 a.m. - 1:23 p.m. - 2:48 p.m. - 4:38 p.m. During an interview on 2/12/25 at 4:38 p.m., resident #27 stated her legs felt tired and she had not moved from her wheelchair all day. Review of resident #27's EHR showed a physician's order: Have CNA check resident Q 2 hours Put on side to side . every night shift . [sic]. Review of resident #27's EHR showed the task: Did you turn and reposition? In the past 30 days, there were no times where resident #27 was repositioned consistently throughout the night shift. 2. During an interview on 2/10/25 at 12:44 p.m., resident #15 stated he would get sores on his coccyx area from sitting long periods of time. Resident #15 stated his day would consist of sitting in the wheelchair for twelve hours, and at night he would then lay in bed for twelve hours. Review of resident #15's EHR showed a nursing rehab/restorative intervention: Assist resident, using gait belt, to stand and pivot into w/c to sit up for every meal. 3-5 times a week. [sic] The follow up question on this task was: Amount of minutes spent training and skill practice in transfer. Below, resident #15's activity in the past 30 days, is reflected: - 1/24/25; 10 minutes documented - 1/31/25; 10 minutes documented - 2/1/25; 15 minutes documented - 2/6/25; 25 minutes documented - 2/8/25; 15 minutes documented - 2/12/25; 15 minutes documented - All other days showed: Not Applicable During an interview on 2/12/25 at 9:34 a.m., staff member E stated they were trying to encourage other staff to keep residents out of bed more. During an interview on 2/12/25 at 1:16 p.m., staff member P stated they would complete restorative duties when CNA duties were done.

Based on observation, interview, and record review, the facility failed to ensure sufficient pain medication was provided for a resident who stated she had pain consistently throughout the day, for 1 (#27) of 14 sampled residents. Findings include: During an interview on 2/10/25 at 1:08 p.m., resident #27 stated, My legs hurt so bad. Resident #27 stated her legs would hurt consistently throughout the day. She stated she would lose the call light and be unable to call a staff member to request a pain medication. She stated staff did not ask her what her pain rating was very frequently. Review of resident #27's EHR showed her pain was documented as a 0/10 for the day and evening shifts on 2/10/25. Review of resident #27's TAR showed: - Monitor Pain, every shift indicate pain level and location if applicable, - Document Non-Pharmacological pain interventions, 1. Rest, 2. Repositioning, 3. None . NA for 0 pain. - From 12/1/24 to 2/10/25, there were 14 out of 216 opportunities that resident #27 was documented to have pain and an intervention provided. All other days were documented as NA. During an interview on 2/11/25 at 6:19 p.m., NF3 stated when they were at the facility, pain was a constant problem. NF3 stated resident #27 would say comments like, I hurt so bad, and, My legs are bugging me. NF3 stated they called resident #27 daily, and resident #27 would often say her legs hurt. NF3 stated telling #27 to push her call button, but she often could not find it. NF3 voiced concerns related to the staff not assessing resident #27's pain often enough. NF3 stated they did not see staff reposition or do range of motion exercises with her, and it seemed like the staff kept her in bed too long, and felt this could have been a contributing factor to resident #27's pain. NF3 stated, the facility staff did not move or reposition the resident, but instead would put resident #27 to bed. During an interview on 2/12/25 at 11:18 a.m., staff member N stated no different pain interventions were needed for resident #27. During an interview on 2/12/25 at 4:38 p.m., resident #27 stated her legs were very tired, sore, and hurt from sitting in the same position all day.

Based on observation, interview, and record review, the facility failed to dispose of expired over the counter medications; and administer medications per physician order, for 2 (#s 10 and 11) of 14 sampled residents; and failed to appropriately document medication administration. Findings include: 1. During an observation on 2/11/25 at 1:20 p.m., staff member N administered Tylenol 1000 mg to resident #10. Resident #10's medications were not crushed during the observation or when given to the resident. Review of resident #10's MAR showed: Crush medication put in apple sauce per ST three times a day for CVA. 2. During an interview on 2/11/25 at 1:32 p.m., staff member L stated medications needed to be disposed of when the expiration date was reached. During an observation on 2/11/25 at 2:00 p.m., the South Hall medication cart had two expired medications: Vitamin B Complex (expired 1/8/25) and Colace (expired 10/24/24). During an interview on 2/11/25 at 2:20 p.m., staff member Q stated medications were kept until the expiration date. During an observation on 2/11/25 at 2:20 p.m., the North Hall medication cart had one expired medication: Vitamin C (expired 1/25). 3. Review of resident #11's MAR showed Carafate was scheduled and administered at 6:30 a.m. During an observation and interview, on 2/12/25 at 8:31 a.m., staff member L prepared the medication Carafate 1000 mg for resident #11. Resident #11 had previously been eating at the dining room table and walked up to the medication cart with staff member L. Staff member L administered the Carafate. Staff member L stated the Carafate had been checked off on the MAR earlier because the facility could be flexible and they stated taking the Carafate later was the resident's preference. Staff member L stated they had not thought about getting a physician's order clarifying the resident's preference or changing the scheduled time of the medication. Review of resident #11's physician orders showed: Carafate Tablet (Sucralfate) Give 1000 mg by mouth two times a day for gerd . give before meals. [sic] During an interview on 2/13/25 at 9:58 a.m., NF5 stated the medication Carafate had the best efficacy when administered an hour before meals, and the purpose of the Carafate was to coat the stomach before eating for residents with GERD. NF5 stated if a resident ate prior to the Carafate medication administration, the effectiveness would decrease, and if it was given late, then it should be given two hours after a resident had eaten. NF5 also stated over the counter medications should be thrown out after the expiration date. Review of the facility policy, titled Medication Administration, dated 1/2025, showed: - . 1. Medications are administered in accordance with written orders of the prescriber, - . 3. Medication administration timing parameters include the following: a. Medications to be given on an empty stomach or before meals are to be scheduled for administration 30 minutes to 2 hours prior to meals. [sic] - . Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given.

Based on observation, interview, and record review, the facility failed to provide dental services for 1 (#26) of 14 sampled residents. Findings include: During an observation and interview on 2/10/25 at 3:27 p.m., resident #26 was lying in her room, and she was observed to be missing all her teeth. Resident #26 stated, I used to have dentures, but they did not fit right. The staff haven't ever asked me if I wanted dentures; they just cut my meat up for me. During an interview on 2/12/25 at 10:55 a.m., staff member J stated she had asked resident #26 if she wanted to go to the dentist and would look for that documentation. During an interview on 2/12/25 at 4:04 p.m., staff member J stated resident #26 was alert and oriented. Staff member J stated she could not find any supporting documentation of offering dental services. During the QAPI meeting with facility staff held on 2/13/25 at 10:00 a.m., staff member J stated they had identified a documentation issue with resident #26 and her dental care. Review of resident #26's care plan showed: Problem: The resident has oral/dental health problems (no teeth) r/t Poor oral hygiene. Goal: The resident will be free of infection, pain or bleeding in the oral cavity by review date. The resident will comply with mouth care at least daily through review date. Interventions/Tasks: Coordinate arrangements for dental care, transportation as needed/as ordered. [sic] Review of a facility document titled, Dental Services - Dentures, with a published date of 10/2017 showed, Policy Statement: The Center assists the resident with dental services when loss or damage to dentures occurs. Procedure: 1. The Center assists residents as necessary or requested upon notification and confirmation of lost or damaged dentures: a. Arranging for transportation to and from dental services location. b. Within 3 days of notification and confirmation, refers residents with lost or damaged dentures for dental services and documents the referral in the medical record. [sic] A request was made for dental notes pertaining to resident #26's dentures on 2/12/25 at 2:46 p.m. The facility did not provide any dental notes for resident #26 by the end of the survey period.

Based on observation, interview, and record review, the facility failed to ensure the staff used gloves when handling a resident's food, for 1 (#88) of 14 residents sampled. This deficient practice increased the risk of foodborne illness. Findings include: During an observation on 2/11/25 at 8:30 a.m., staff member D picked up slices of cooked bacon from resident #88's plate with bare hands, and placed the slices on a half piece of toast on the resident's plate. During an interview on 2/11/25 at 8:32 a.m., staff member D stated when staff served food plates, they were to use hand sanitizer first. Staff member D stated the kitchen staff used gloves when plating the food. Staff member D stated, I was not supposed to touch the food (on resident #88's plate), that was wrong. During an observation on 2/11/25 at 8:35 a.m., staff member D stood by the kitchen door to wait. Staff member D did not remove resident #88's plate with the contaminated food. Resident #88 proceeded to eat his toast. During an interview on 2/11/25 at 8:36 a.m., staff member D stated he was standing by the kitchen to get an egg for resident #88's breakfast sandwich, and was not getting the resident new food. Staff member D then stated he would get resident #88 new food. During an observation on 2/11/25 at 8:39 a.m., staff member D gave resident #88 a new plate of food, and placed the hashbrowns from the previously contaminated plate onto the new plate with the egg and bacon sandwich. During an interview on 2/11/25 at 12:32 p.m., staff member A stated she would have to check the hand washing policy for specifics on food handling. Staff member A stated staff member D usually worked on the night shift. Staff member A stated CNAs were not supposed to touch residents' food. Review of the facility's policy, Glove Use, revised December 2021, showed, Bare hand food contact is prohibited.

Based on observation, interview, and record review, the facility failed to ensure hospice orders were clarified for accuracy and appropriately followed for 1 (#10) of 14 sampled residents. Findings include: During an interview on 2/12/25 at 9:43 a.m., staff member O stated they did not provide any different care for hospice residents. Staff member O stated the main difference (between hospice and non-hospice residents) was hospice would come in and do baths more frequently if a resident was on hospice. During an interview on 2/12/25 at 11:18 a.m., staff member N stated resident #10 was on hospice due to the failure to thrive. Staff member N stated if a resident was on comfort care, the facility would mostly care for the resident, but if a resident was on hospice, then hospice would take over. Review of resident #10's physician orders showed current comfort care orders as of 11/24/24. Review of resident #10's physician orders showed the resident was placed on hospice on 12/16/24. Review of resident #10's EHR showed a nursing note, dated 2/5/25 which included: Lorazepam Oral Tablet 1MG; Give 1 mg by mouth every 6 hours as needed for anxiety, restlessness for 180 Days activated from comfort care order set . [sic] Review of resident #10's EHR showed a nursing note, dated 2/7/25, which included: Morphine Sulfate(Concentrate) Solution 20 MG/ML Give 0.5 ml by mouth every 2 hours as needed for pain and dyspnea activated from comfort care order set . [sic] Review of a facility document, titled Comfort Care Order Set, dated 11/8/24, showed resident #10 was still following some of the comfort care orders in the Resident Disaster and Recovery Binder. During an interview on 2/12/25 at 11:35 a.m., staff member L stated if there was a change to a medication for a resident on hospice, the hospice physician would sign the order change. During an interview on 2/12/25 at 3:23 p.m., staff member B stated resident #10's physician orders were different than the hospice orders because the resident was not actively passing. Staff member B stated the primary physician had wanted this resident to be on the facility's comfort care orders. During an interview and observation on 2/12/25 at 4:05 p.m., staff member M stated they felt it was odd that a resident was on hospice and not following the hospice orders specifically. Staff member M stated they did not know why the orders were different, but stated they would ask staff member B those types of questions. During the observation of resident #10's morphine medication package, that was locked in the medication cart, showed the hospice order (0.25 ml sublingual to be given as needed every 15 minutes). Review of resident #10's hospice orders showed: morphine 100 mg/5 ml; give 0.25-1 ml SL every 15 minutes as needed. Review of resident #10's EHR current physician orders showed: morphine, give 0.125 ml every 2 hours as needed. During an interview on 2/13/25 at 10:30 a.m., NF4 stated they heard there was a discrepancy at the facility concerning resident #10's morphine. NF4 stated they were under the impression the facility was following the hospice orders. NF4 stated [entity name] had their own comfort care orders along with hospice orders.

Based on observation and interview, the facility failed to ensure staff were properly handling resident medications for 2 (#s 11 and 22) of 14 sampled residents, which increased the risk of negative outcomes for the residents if infection control prevention measures were not upheld. Findings include: During an observation on 2/11/25 at 1:32 p.m., staff member L was administering the medication gabapentin to resident #22. Staff member L touched this medication with bare hands and put the medication in the medication cup. Staff member L administered the gabapentin to resident #22. During an observation on 2/12/25 at 8:31 a.m., staff member L was administering the medication clonazepam to resident #11, and the medication fell on the medication cart. Staff member L touched the medication with bare hands and put the medication in the medication cup. Staff member L then administered clonazepam to resident #11. During an interview on 2/12/25 at 2:54 p.m., staff member M stated touching medications with bare hands was unacceptable, and this was a basic skill learned in nursing school, due to the transmission of germs to a resident, and the potential of the medication absorbing into the skin if improperly handled. Review of a facility document, titled Medication Administration, dated 1/25 showed: . hands are washed with soap and water and gloves applied prior to handling tablets .

Based on observations, interviews, and record review, the facility failed to remove expired items for disposal for one medication room and two medication carts; and properly store food items used for medication administration, keeping it off the floor, in one medication room. These failures increased the risk of expired items being or food being used, when stored unsafely, for resident care, if taken from the identified medication room and carts. Findings include: 1. During an observation on 2/13/24 at 10:43 a.m., with staff member B, in the medication room, the following items were found: - One case of Prostat packets, on the floor. - One case of individual serving, vanilla pudding cups, on the floor. - One case of individual applesauce cups, on the floor. 2. Stock of multi-resident use medications: - Senna, two bottles, expired 12/20 - Senna, four bottles, expired 7/20 - Omeprazole, one bottle, expired 11/18 - Milk of magnesia, one bottle, expired 5/19 - Ferrous Gluconate, expired 1/24 - Fleet pads, opened 7/24/20 - Slow-release Iron, expired 12/23 - Two Sodium Chloride 0.9% 250 mL bags, expired 11/30/23 During an interview on 2/13/24 at 10:45 a.m., staff member B stated she was not aware of the expired medications. Staff member B stated the pharmacy was responsible for checking of expiration dates. Staff member B stated she tried to get into the medication room to also check out dates, monthly, but had not done so in several months. During an observation on 2/13/24 at 12:15 p.m., staff member E had the following items on the medication cart: - Aspirin, 81 mg, expired 1/24 - Multivitamin expired 1/24 During an observation on 2/13/24 at 11:55 a.m., staff member F had the following item on the medication cart: - Metrix blood glucose test strips, bottle of 50 strips, expired 5/31/23 Review of the facility's procedure, Did you Know The Steps to Perform an Internal Expired Med Inventory Audit?, no date, reflected: - . Enact a system to regularly check meds for correct expiration dates and to remove expired drugs. - Perform this internal inventory inspection at least monthly .

Based on observations, interviews, and record review, the facility failed to ensure residents had knowledge of the grievance process and access to grievance forms to file a grievance, to include anonymously; and, the facility failed to ensure all grievances were investigated, resolved, and that residents were made aware of the outcome of the grievance, for 2 (#s 11 and 20) of 19 sampled residents. Findings include: During an observation and interview on 2/12/24 at 1:15 p.m., resident #13 verbally notified the CNAs that she did not like the lunch served and to take it away. Resident #13 stated she was upset the food was not edible. Resident #13 stated she had reported her grievances verbally several times (and on this day) to staff and management, but nothing was ever done. She continued to receive the foods she did not want. Resident #13 stated another resident repeatedly entered her room and took her things. She stated the facility did not do anything about that either. Resident #13 stated, It's been going on for months (lack of follow up of grievance concerns) and no one does anything. She stole my shoes last night, and staff had to get them back from her. It happens all the time, and all they say is they are trying to find her a new home. That's not my problem, I've lost so much stuff to her stealing. Grievances just go unanswered. Resident #13 stated she did not know how to access a grievance form to file a grievance. Resident #13 stated she had verbally notified many people (of her grievances), including staff member C and the kitchen, but they did not have a grievance form to complete. Resident #13 stated no one ever came back to tell her what a plan was to address her concerns. During an interview on 2/12/24 at 1:16 p.m., resident #20 stated she did not know how to file a grievance or where to locate grievance forms in the event she needed one. During an interview on 2/12/24 at 1:17 p.m., staff member F stated he did not know where to get grievance forms, or what to do, when a resident had a complaint or grievance. Staff member F stated, Let me get my DON, because I just don't know. During an interview on 2/12/24 at 1:20 p.m., staff member B stated grievances are given to staff member C, and she addresses them. Staff member B stated, Well usually they (staff) just go get [staff member C], if there was a grievance concern. Staff member B showed the surveyor a box at the nursing station, located on the wall, where grievance forms would be kept. No forms were available in the box as it was empty. In addition, the grievance box at the nurses' station was not accessible to residents unless they asked a staff member to retrieve the form. Due to this, obtaining and submitting an anonymous grievance would be difficult. Staff member B took the surveyor the South Hall, to another grievance form box, by where the survey results book was kept. Staff member B stated there was a grievance box there as well, but that box was now missing. Staff member B stated the residents could file a grievance during resident council, and staff member C filled a form out for those complaints or grievances. Staff member B stated most grievances at resident council were about food. Staff member B stated, residents who did not attend resident council could ask a staff member for a grievance form. There was no process in place for a resident to file a grievance anonymously. During an interview on 2/12/24 at 2:04 p.m., staff member Q, R, S, and T were at the nursing station. The staff were unable to explain where grievance forms were located. Staff member T stated, if a resident had a grievance, If it's abuse, we tell [staff member A]. Staff member Q, R, and S did not have an answer for what they would do if a resident had a grievance. During an interview on 2/15/24 at 9:04 a.m., resident #11 stated she did not know how to file a grievance or where to locate forms to file a grievance. Resident #11 stated she just told staff member C when she was not happy. A review of the facility's policy, Grievance Procedure, dated November 2016, showed: - .4. Staff are trained at orientation and periodically on the Center's grievance procedure, including: - .d. What to do with grievances. - .e. When to put a grievance in writing. - .5. The Center makes Grievance Forms and this policy readily available to residents, family members, representatives, visitors, and staff members. - .10. The person with the grievance has the right to a written decision regarding his/her grievance.

Based on observation, record review, and interview, the facility staff failed to ensure a malfunctioning refrigerator, which held resident medications, was monitored adequately to identify temperature concerns which had been ongoing, for the replacement or repair of the refrigerator, for stored and refrigerated medications. This failure involved medications for 12 (#s 3, 4, 6, 11, 12, 20, 22, 24, 26, 31, 33, and 35) of 24 sampled and supplemental residents, in which the medication efficacies were unable to be determined once the temperature of the refrigerator was out of range. This also had the potential to affect all other residents who received, or might receive, medications that were required to be stored in the medication refrigerator. On 7/12/18 at 5:13 p.m., the facility Director of Clinical Services, Executive Director and Director of Nursing Services were notified that an immediate jeopardy existed in the area of F755 for pharmacy services and F761 for storage of drugs and biologicals. The facility submitted an acceptable plan to remove the immediacy on 7/13/18 at 1:16 p.m. The severity and scope was identified at a level K. After the plan was accepted the severity and scope was reduced to an E. Findings include: During an observation on 7/11/18 at 3:00 p.m., the medication refrigerator had leaked water on the shelves below the freezer portion of the refrigerator where numerous resident insulin pens, insulin vials, vaccines, antibiotic wound wash, liquid anti-anxiety medications, eye drops, and the facility emergency e-kit were stored. The temperature of the medication refrigerator was documented at 32 degrees. These medications were required to be stored in the refrigerator at temperatures between 36 and 46 degrees. The medications in the refrigerator included: - Resident #3 had a 10 ml vial of Humalog insulin, and ten Humalog kwik pens, - Resident #4 had a 30 ml bottle of [MEDICATION NAME], - Resident #6 had one vial of [MEDICATION NAME] insulin, - Resident #11 had a 30 ml bottle of [MEDICATION NAME], - Resident #12 had a 30 ml bottle of [MEDICATION NAME], - Resident #20 had a 10 ml vial of [MEDICATION NAME] insulin, - Resident #22 had one Basaglar insulin kwik pen, - Resident #24 had a 30 ml bottle of [MEDICATION NAME], - Resident #26 had a 30 ml bottle of [MEDICATION NAME], - Resident #31 had a one liter bottle of Genta 80 mg/Neosp antibiotic wound wash, - Resident #33 had a 30 ml bottle of [MEDICATION NAME], - Resident #35 had a bottle of [MEDICATION NAME] 0.005% eye drops. Included in the medication refrigerator were four stock single dose vials of [MEDICAL CONDITION] vaccination, one stock bottle of influenza vaccination, eight Prevnar thirteen injections, one single dose [MEDICATION NAME] injection, and the facility e-kit. The facility e-kit contained two 10 ml vials of [MEDICATION NAME], two 10 ml vials of [MEDICATION NAME], a 2 mg vial of Alteplase, a 10 ml vial of [MEDICATION NAME], two vials of 2 mg/ml [MEDICATION NAME], one [MEDICATION NAME] 0.005% eye drops, one 10 ml vial of [MEDICATION NAME] N, four [MEDICATION NAME] 25 mg suppositories, two vials of Humalog, one vial of 10 ml [MEDICATION NAME] 70/30, one [MEDICATION NAME] 30 ml bottle, and one 10 ml vial of [MEDICATION NAME] insulin. A review of the manufacturers recommendations for the refrigerated medications showed the medications should have been stored between 36 and 46 degrees and the manufacturer was not able to account for the efficacy of the medications once the medications were stored out of the required temperature ranges. During an interview on 7/12/18 at 7:49 a.m., NF3 stated she could not attest to the efficacy of the medication stored in the refrigerator and would refer to the manufacturer's recommendations on the efficacy of the medications. Record review of the (MONTH) (YEAR) thru (MONTH) (YEAR) medication refrigerator temperatures showed the following: - In (MONTH) there were fifteen of thirty-one days the temperature of the medication refrigerator was not taken and/or was below 36 degrees. - In (MONTH) there were twenty-eight of twenty-eight days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were twenty-seven of thirty-one days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were nine of thirty days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. -In (MONTH) there were twenty-five of thirty-one days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were twenty-seven of thirty days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were ten days out of 11 that the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. During an interview on 7/12/18 at 9:50 a.m., staff member B stated there were no maintenance work orders. She stated staff filled them out, the maintenance department fixed the problem and gave the work orders to her, she signed off on the work order, and then shredded them. Review of the policy for the consultant pharmacist, titled ORGANIZATIONAL ASPECTS IA2: CONSULTANT PHARMACIST SERVICES PROVIDER REQUIREMENTS, showed the following information under procedures: Section C. The consultant pharmacist agrees . 2) Evaluating the process of receiving and interpreting prescriber's orders; acquiring, receiving, storing . Section F . 3) Checking emergency medication supply at least monthly to ascertain that is is properly sealed and stored . Checking the medication storage areas routinely, and the medication carts routinely, for proper storage and labeling of medications . During an interview on 7/11/18 at 3:00 p.m., NF3 stated she did not check the mediation refrigerator temperatures when she comes to the facility. During an interview on 7/12/18 at 11:55 a.m., staff member E stated he had adjusted the temperature on the medication refrigerator on 7/9/18. He stated he was informed by one of the licensed staff members that the refrigerator had not been running right. He stated he turned the refrigerator down and did not return to check on the temperature of the medication refrigerator. During an interview on 7/13/18 at 11:57 a.m., staff member NF2 stated she was not sure if the improperly stored medications would affect the residents.

Based on observation, interview, and record review, the facility failed to ensure medications that were required to be refrigerated were stored at the appropriate temperature for an extended period of time. This failure involved 12 (#s 3, 4, 6, 11, 12, 20, 22, 24, 26, 31, 33, and 35) of 24 sampled and supplemental residents, who had medications stored in the malfunctioning refrigerator, and all other residents who received or might receive medications that were required to be stored in the medication refrigerator. On 7/12/18 at 5:13 p.m., the facility Director of Clinical Services, Executive Director and Director of Nursing Services were notified that an immediate jeopardy existed in the area of F755 for pharmacy services and F761 for storage of drugs and biologicals. The facility submitted an acceptable plan to remove the immediacy on 7/13/18 at 1:16 p.m. The severity and scope was identified at a level K. After the plan was accepted the severity and scope was reduced to an E. Findings include: During an observation on 7/11/18 at 3:00 p.m., the medication refrigerator had leaked water on the shelves below the freezer portion of the refrigerator where numerous resident insulin pens, insulin vials, vaccines, antibiotic wound wash, liquid anti-anxiety medications, eye drops, and the emergency e-kit were stored. During an interview on 7/12/18 at 11:55 a.m., staff member E stated he had adjusted the temperature on the medication refrigerator on 7/9/18. He stated he was informed by one of the licensed staff members that the refrigerator had not been running right. He stated he turned the refrigerator down and did not return to check on the temperature of the medication refrigerator. Medications stored in the refrigerator included: - Resident #3 had a 10 ml vial of Humalog insulin, and ten Humalog kwik pens, - Resident #4 had a 30 ml bottle of [MEDICATION NAME], - Resident #6 one vial of [MEDICATION NAME] insulin, - Resident #11 had a 30 ml bottle of [MEDICATION NAME], - Resident #12 had a 30 ml bottle of [MEDICATION NAME], - Resident #20 had a 10 ml vial of [MEDICATION NAME] insulin, - Resident #22 had one Basaglar insulin kwik pen, - Resident #24 had a 30 ml bottle of [MEDICATION NAME], - Resident #26 had a 30 ml bottle of [MEDICATION NAME], - Resident #31 had a one liter bottle of Genta 80 mg/Neosp antibiotic wound wash, - Resident #33 had a 30 ml bottle of [MEDICATION NAME], - Resident #35 had a bottle of [MEDICATION NAME] 0.005% eye drops. Included in the medication refrigerator were four stock single dose vials of [MEDICAL CONDITION] vaccination, one stock bottle of influenza vaccination, eight Prevnar thirteen injections, one single dose [MEDICATION NAME] injection, and the facility e-kit. The facility ekit contained two 10 ml vials of [MEDICATION NAME], two 10 ml vials of [MEDICATION NAME], a 2 mg vial of Alteplase, a 10 ml vial of [MEDICATION NAME], two vials of 2 mg/ml [MEDICATION NAME], one [MEDICATION NAME] 0.005% eye drops, one 10 ml vial of [MEDICATION NAME] N, four [MEDICATION NAME] 25 mg suppository, two vials of Humalog, one vial of 10 ml [MEDICATION NAME] 70/30, one [MEDICATION NAME] 30 ml bottle, and one vial 10 ml vial of [MEDICATION NAME] insulin. The temperature of the medication refrigerator was documented at 32 degrees. These medications were required to be stored in the refrigerator at temperatures between 36 and 46 degrees. A review of the manufacturers recommendations for the refrigerated medications showed the medications should have been stored between 36 and 46 degrees and the manufacturer was unable to account for the efficacy of the medications once they had been stored out of the proper range. Record review of the (MONTH) (YEAR) thru (MONTH) (YEAR) medication refrigerator temperatures showed the following: - In (MONTH) there were fifteen of thirty-one days the temperature of the medication refrigerator was not taken and/or was below 36 degrees. - In (MONTH) there were twenty-eight of twenty-eight days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were twenty-seven of thirty-one days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were nine of thirty days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. -In (MONTH) there were twenty-five of thirty-one days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were twenty-seven of thirty days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were ten days out of eleven that the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. A review of the temperature sheets showed the refrigerator temperatures should have been maintained between 36 and 46 degrees. During an interview on 7/12/18 at 7:15 a.m., staff member P stated she was not sure what temperature the medications should be stored at. She stated she assumed the medications should not freeze or go over 40 degrees. Staff member P had checked the refrigerator temperatures in the past. During an interview on 7/12/18 at 7:20 a.m., staff member D stated the medications should be stored at temperatures between 35 and 41 degrees. During an interview on 7/12/18 at 7:30 a.m., staff member O stated the temperatures should be above 32 degrees and not above 40 degrees. During an interview on 7/12/18 at 7:49 a.m., NF3 stated she could not attest to the efficacy of the medication stored in the refrigerator and would refer to the manufacturer's recommendations on the efficacy of the medications. During an interview on 7/12/18 at 8:35 a.m., staff member C stated if the temperatures in the medication refrigerator were out of range, the staff were to notify staff member E. Staff member C stated she conducted a random audit the week before survey and noticed one day when the temperature had been out of range and notified staff member E. Staff member C stated the night nurse checks the refrigerator temperatures. During an interview on 7/12/18 at 9:50 a.m., staff member B stated there were no maintenance work orders. She stated staff filled them out, the maintenance department fixed the problem and gave the work orders to her, she signed off on the work order, and then shredded them. During an interview on 7/12/18 at 4:27 p.m., NFI stated he was not aware the medication refrigerator temperatures had been out of the recommended range for (MONTH) through (MONTH) (YEAR). He stated this was unacceptable. He stated there should have been checks and balances in place to identify a problem like this with the temperatures. He stated he had been told the new refrigerator had been put in place but it did not address the months of inconsistencies. During an interview on 7/13/18 at 11:57 a.m., with NF2 she stated was not aware of the number of days the medication refrigerator temperatures had been out of the proper range for storing medications. She stated she did not know what the efficacy of the medications would be due to not being stored properly. During an interview on 7/13/18 at 2:49 p.m., staff member B stated the facility had not identified refrigerator temperatures as a problem.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program, which included: preventing, identifying, and controlling a communicable disease for all residents, staff, and family. The facility failed to utilize precautions correctly, notify family of the gastroenteritis, follow a policy and procedure in a timely manner, use proper hand hygiene, provide education to staff and residents, and prevent the spread of the infection through laundry. The failure affected 5 (#s 1, 4, 8, 9, and 11 ) out of 15 sampled and supplemental residents, but had the potential to affect everyone in the facility. The findings included: 1. Precautions Upon entry to the facility on [DATE] at 9:25 a.m., staff member A stated the facility had an outbreak of gastrointestinal and respiratory related concerns; nausea, vomiting, diarrhea, and coughing with and without a fever. She stated the staff were treating the gastrointestinal and respiratory symptoms with either contact, or droplet PPE precautions. The staff member stated the medical director, and the Infection Control consultant had advised not to test the residents. She stated there were no confirmed cases of influenza or Norovirus in the community. Staff member A stated the facility staff members were following precautions for those residents with gastrointestinal or respiratory symptoms to prevent the spread of symptoms. The facility did not test for the type of infection(s), in order to appropriately treat the infection(s). During an observation on 3/20/17 at 12:35 p.m., staff member G was delivering room trays. Staff member G entered resident #8's room with a lunch tray. The door had a droplet precaution sign on it. There was a cart with PPE outside the door of the resident's room. Staff member G entered the room with the room tray, and did not don PPE prior to entering the room. Staff member G left the room without washing or sanitizing her hands. During an observation on 3/20/17 at 12:45 p.m., staff member X entered resident #9's room. The door had a contact precaution sign on it. There was a cart with PPE outside the door of the adjacent room which was used by the staff member. The staff member donned a clean gown, but did not wash, or sanitize her hands, or don clean gloves prior to entering the resident's room. During an observation on 3/20/17 at 12:57 p.m., staff member X exited resident #9's room. The staff member walked up to the meal cart that contained meal trays, selected one, and went back into the resident's room. Staff member G entered the room with staff member X. Staff member G donned a clean gown, but did not wash, or sanitize her hands, or don gloves prior to entering the resident's room. During an observation and interview on 3/20/17 at 3:10 p.m., staff member J and staff member L walked into resident #4's room, which had a contact precaution sign on the door. The staff members did not put on masks, gloves, or a gown. They asked resident #4 if she would like to lay down. This surveyor asked if the room was no longer on contact precautions. The staff members stated no and walked out of the room and put on gloves. They did not put on a mask or a gown. The staff members did not follow the correct precautions. During an observation on 3/20/17 at 3:15 p.m., staff member G entered resident #4's room, which had a contact precautions sign on the door. Staff member G wore a mask and gloves, and no gown. She sat on the resident's bed, and painted her nails. The staff member did not follow the correct precautions. During an observation on 3/20/17 at 3:40 p.m., staff member L responded to a call light for residents #1 and #4. The door had a contact precaution sign on it. There was a cart with PPE outside the door of the resident's room. Staff member L entered the room, and did not don PPE. Staff member L quickly left the room without washing his hands. During an observation on 3/20/17 at 3:47 p.m., staff member G donned a gown and gloves, and entered resident #4's room. The door had a contact precaution sign on it. Staff member G sat on the resident's bed, and provided nail care. Proper precautions were not taken. During an interview on 3/21/17 at 8:45 a.m., staff member B stated they took residents off precautions after they were symptom free for 24 hours. During an interview on 3/22/17 at 12:15 p.m., staff member C stated The CDC states that precautions are not needed after 24 hours of no active symptoms. Review of the facility's Norovirus Prevention and Control policy showed the following during outbreaks, residents with Norovirus gastroenteritis are placed on Contact Precautions for a minimum of 48 hours after the resolution of symptoms. 2. Family notification During an observation and interview on 3/22/17 at 8:00 a.m., resident #11's family member was seated in his room, next to his bed, and held his hand. The family member did not have on gloves, a gown, or a mask. The room had a contact precautions sign on the door, related to recent nausea and vomiting from resident #11. Resident #11's family member then left the room to refill the resident's water pitcher. She stated she had not been informed about the recent gastroenteritis outbreak in the building. She stated that she had been sick the previous week with nausea, vomiting, and diarrhea for three days. A staff member took the water pitcher, refilled it, and gave it back to the family. She was then seen back in the resident's room without a gown, gloves, or a mask. During an interview on 3/22/17 at 12:15 p.m., staff member B stated resident #11's family member had been there the past two days. She did not know why the facility did not think to notify her about the resident's illness. Review of the facility's Norovirus Prevention and Control policy showed the following, If it is necessary to have continued visitor privileges during outbreaks, visitors with symptoms consistent with Norovirus infection are screened and excluded. All visitors comply with hand hygiene and Contact Precautions. 3. Hand hygiene During an interview on 3/21/17 at 8:45 a.m., staff member B stated that hand sanitizer was used by staff most of the time. She stated soap and water was not encouraged over hand sanitizer at any time. During an interview on 3/22/17 at 3:22 p.m., staff member J stated was not aware of any specific time to use hand soap instead of hand sanitizer, unless his hands were visibly soiled. Review of the facility's Norovirus Prevention and Control showed the following, during outbreaks, use soap and water for hand hygiene after providing care or having contact with residents suspected or confirmed with Norovirus gastroenteritis. Review of the facility's Help Prevent the Spread of Norovirus (Stomach Bug) educational handout from their infection control book, showed the following, wash your hands thoroughly with soap and water, hand sanitizers may not be effective against Norovirus. During an observation on 3/23/17 at 11:47 a.m., staff member Z wiped dining room tables with a wet towel. During an interview on 3/23/17 at 11:53 a.m., staff member Z stated the cleaner used for cleaning the dining room tables was regular table sanitizer, without bleach. 4. Staff education During an interview on 3/22/17 at 3:22 p.m., staff member J stated he was not aware of any specific time to use hand soap instead of hand sanitizer, unless his hands were visibly soiled. He stated he was sick last week with nausea, vomiting, and diarrhea. He worked the next day. 5. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #1 required total assist with all of her transfers, and activities of daily living. Resident #1 was under contact precautions for gastrointestinal symptoms. During an observation on 3/21/17 at 7:25 a.m., staff member U and V assisted the resident with dressing and perineal care. Staff member U sanitized her hands, and donned gloves. Staff member U provided perineal care, log rolled the resident, applied a clean brief, and pulled up the resident's pants. Staff member U then removed her gloves. Staff member U did not remove her gloves immediately after providing perineal care. Staff member V sanitized her hands, and donned gloves. Staff member V assist the resident with dressing, oral care, and transferring to her wheel chair from the bed. Staff member V removed her gloves, and did not sanitize her hands. During an interview on 3/21/17 at 7:40 a.m., staff member U stated she should have removed her gloves after completing the perineal care. Staff member V stated staff is taught to remove their gloves, and when working with body fluids to sanitize their hands. Staff member V stated staff was taught to sanitize when coming into a resident's room and to remove gloves, and sanitize when leaving the room. During an interview on 3/21/17 at 9:10 a.m., staff member B stated the facility staff used hand washing if hands were visibly soiled. Otherwise, staff used hand sanitizer. During an observation on 3/21/17 at 2:00 p.m., staff member V assisted resident #1 with a transfer from her wheelchair to her bed. Staff member V sanitized her hands, and donned gloves. Staff member V lowered the resident's pants, and removed her brief. Staff member V provided perineal care. Staff member V did not remove her gloves, and applied a clean brief. Staff member V continued to wear the contaminated gloves, and pulled up the resident's pants while log rolling her on the bed. Staff member V then removed her gloves, and sanitized her hands. Resident #1 was on contact precautions for a gastrointestinal illness. Staff member V left the resident's room without washing her hands. 6. Laundry During observations and interviews on 3/20/17 at 11:40 a.m., the laundry in the lower level of the facility was inspected. Staff member S was asked if the door between the soiled sorting room and the washing machine area was ever closed while sorting. She stated that she was not told to close the door. The door was being held open by a 5-gallon bucket of detergent. Also, the corridor door to the laundry room had a coat hung over the door preventing the door from closing and latching in case of an emergency. Staff member P removed the coat from the door and placed it on a pile of clean linen. He was instructed that personal clothing goes into lockers and not on clean linen. He again removed the coat and placed it in another room. During an observation on 3/20/17 at 2:30 p.m., the laundry room was again inspected. Red bags containing soiled linen were scattered on the floor directly in front of the handwash sink. The sink was not available for handwashing. The laundry chute was checked for proper latching. There were three red bags containing soiled laundry in the chute, which dumped out into a sink below. One of the bags had rips in the bag. The chute room on first floor was inspected. The room was small and a garbage can had been placed directly infront of the chute opening preventing the chute door from fully opening. The limited opening caused bags to be ripped when stuffed through the chute door. During an observation on 3/21/17 at 7:45 a.m., the laundry area was again inspected. The same coat was again placed over the corridor door to the laundry room. During an interview on 3/21/17 at 8:30 a.m., staff member Q stated that the door to the soiled sorting room would remain closed during sorting. He stated that all facility staff that work in laundry had been retrained on the afternoon of 3/20/17. He stated that the garbage can had been relocated in the chute room. 7. Activities During an interview on 3/23/17 at 9:30 a.m., staff member Y stated 25 residents, including #3, #5, and #6 had attended group activities on 3/17/17. She stated a Saint Patrick's Day party, and a musical activity, was held in the main dining area from 2:00 p.m. to approximately 4:30 p.m. A review of the facility's Activities Participation Form for March 2017 showed residents #3, #5, #6, #12, #13, #15, and #16 attended the Saint Patrick's Day party on 3/17/17. A review of the facility's Skilled Nursing Room Roster showed: 3/15/17 - resident #1 had vomiting, diarrhea, and a fever. - resident #3 had respiratory symptoms. - resident #12 had diarrhea. - resident #13 had diarrhea. - resident #14 had nausea. These residents were having their symptoms and vital signs monitored. 3/16/17 - resident #7 had a fever. - resident #8 had a sore throat, and a fever. - resident #9 had diarrhea. - resident #13 still had diarrhea. - resident #14 still had nausea. These residents were having their symptoms and vital signs monitored. 3/18/17 - resident # 15 had nausea and diarrhea The residents was having his symptoms and vital signs monitored. 3/19/17 - resident # 14 had diarrhea The resident was having his symptoms and vital signs monitored. During an interview on 3/21/17 at 8:35 a.m., staff member B stated several residents had gastrointestinal complaints on 3/15/17. The staff member stated symptomatic residents should have been confined to their room, and staff should have been using PPE precautions when in contact. 8. Mechanical Lift use During an observation on 3/20/17 at 3:30 p.m., staff members J and L transfered resident #7 from his bed to his wheelchair using a sit-to-stand lift. The resident was taken to the Tub room on the south hall and lowered onto the toilet. The lift sling, and straps were left on the resident while he used the toilet. At 4:10 p.m., resident #7 was taken back to his room and transfered from his wheelchair back to his bed using the sit-to-stand lift. Staff member L wheeled the sit-to-stand lift from the south hall, and put it into a storage room on the north hall. The lift was not cleaned. During an interview on 3/20/17 at 4:16 p.m., staff member L stated the lifts were cleaned by the night shift staff. The staff member was not sure whom, or when the lifts were cleaned. A review of the facility's Standard Precautions policy, initiated 5/2015, read, 5. Resident-Care Equipment .b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriatley cleaned and reprocessed and single use itmes are properly discareded. 9. Policy A policy was requested that the facility used for a gastroenteritis or Norovirus outbreak during the following times: -3/20/17 at 5:00 p.m. -3/22/17 at 5:35 p.m. During an interview on 3/21/17 at 8:45 a.m., staff member A stated she would provide the facility's Norovirus policy. During an interview on 3/21/17 at 12:15 p.m., staff member C stated the facility did not follow a policy for a gastroenteritis outbreak, but rather they called their infectious disease and control consultant. She stated she could ask the consultant to type a policy and procedure for the facility. During an interview on 3/22/17 at 5:09 p.m., NF1 stated he did not provide the facilities with policy and procedures, or the CDC guidelines. He stated his role as a consultant was to answer any questions the facility had over the phone. NF1 stated he had spoken to the facilty but did not remember exactly what was going on at the facility. During an interview on 3/23/17 at 7:55 a.m., staff member C stated NF1 never sent the policy and procedure for Norovirus outbreak. During an interview on 3/23/17 at 11:23 a.m., staff member C stated the facility's policy and procedure was on-line. She stated the facility did not print one off to follow, they looked at it on the computer. The facility did not follow any policy or procedure to help stop the spread of the infection in their facility.

Based on staff interview, policy review, and record review, the facility staff failed to follow professional standards of quality for medication administration for 1 (#9) of 12 sampled residents. Findings include: Record review revealed resident #9 received resident #5's medication on 12/2/12 at approximately 9:15 p.m. Resident #9 received [MEDICATION NAME] 500 mg (milligrams), [MEDICATION NAME] 600 mg, and [MEDICATION NAME] 150 mg. Resident #9 was sent to the emergency roiagnom on [DATE] at 11:30 p.m., and admitted to the hospital. During an interview with staff member E on 12/12/12 at 2:00 p.m., she stated that she was training staff member F the night of 12/2/12 when the medication error occurred. Staff member E stated she had prepared resident #5's medications and gave them to staff member F to administer. Staff member E stated when staff member F went into resident #5's room the resident was not in the room and staff member F gave the medications to resident #9 by mistake. Staff member E stated resident #5 came up to the cart about a half an hour later. Staff member E stated resident #5 asked for her medications. Staff member E and staff member F then realized that resident #9 had received resident #5's medications. Staff member F was interviewed on 12/12/12 at 5:15 p.m. She stated that 12/2/12 was her first night on shift at the facility. She stated staff member E was training her that evening. Staff member F stated staff member E had prepared resident #5's medications and asked her to administer them to resident #5. Staff member F stated she took the medications and went into resident #5's room. Staff member F stated she gave the medications to the resident who was in the room after she awakened resident #9.? She stated she did not ask the resident her name. Staff member F stated that it wasn't until later (about a half an hour later) when resident #5 came to the medication cart and asked for her medications that she (staff member F) and staff member E realized that staff member F had given resident #9 resident #5's medications. Staff member E stated that at that point she notified the physician and guardian of the incident. Staff member E received order to monitor the residents vitals signs every two hours and send to the emergency room if the vital signs decline. Resident #9 was monitored by facility staff per the physician orders [REDACTED]. Resident #9 was sent to the emergency room at approximately 11:30 p.m. on 12/2/12 via ambulance. Documentation from the emergency room indicated resident #9 was unresponsive upon arrival at the emergency room and required intubation. Resident #9 was admitted to the intensive care unit and returned to the facility on [DATE]. Staff members B and C stated after the medication error they had provided education to all the licensed staff in regards to proper medication administration and random medication administration audits were performed. The surveyor was provided documentation of the education provided to staff. Staff member C stated the facility management is in the process of writing a policy and procedure for identifying residents. The facility policy for General Dose Preparation and Medication Administration was reviewed on 12/13/12 at 9:35 a.m. Documented in Section 3 - Prior to Medication Administration "3.1 Facility staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident"... ?Standards for nursing practice for administration of medication provide, in pertinent part that: Medications must be accurately administered and documented. Accurate administration includes transcribing the drug order correctly, delivering the correct drug, to the correct resident, by the correct route, in the correct dose. Accurate documentation involves recording information on the drug administered, including the client's response to the medication. See generally: Lipin, Nursing Drug Guide, 1998 (Lipin) and Perry & Potter, Clinical Nursing Skills & Techniques; 1998, (Perry & Potter).

Based on clinical record review, facility policy review, and staff interviews, 1 (#9) of 12 sampled residents incurred significant medication errors. Findings include: Record review revealed resident #9 received resident #5's medications on 12/2/12. Resident #9 received [MEDICATION NAME] 500 mg (milligrams), [MEDICATION NAME] 600 mg, and [MEDICATION NAME] 150 mg. Resident #9 was sent to the emergency roiagnom on [DATE] at 11:30 p.m., and admitted to the hospital. During an interview with staff member E on 12/12/12 at 2:00 p.m., she stated that she was training staff member F the night of 12/2/12 when the medication error occurred. Staff member E stated she had prepared resident #5's medications and gave them to staff member F to administer at approximatley 9:15 p.m. Staff member E stated when staff member F went into resident #5's room the resident was not in the room and staff member F gave the medications to resident #9 by mistake. Staff member E stated resident #5 came up to the cart about a half an hour later. Staff member E stated resident #5 asked for her medications. Staff member E and staff member F then realized that resident #9 had received resident #5's medications. Staff member E stated that at that point she notified the physician and the guardian of the incident. Staff member E received order to monitor the residents vitals signs every two hours and send to the emergency room if the vital signs decline. Resident #9 was monitored by facility staff per the physician orders [REDACTED]. Resident #9 was sent to the emergency room at approximately 11:30 p.m. on 12/2/12 via ambulance. Documentation from the emergency room indicated resident #9 was unresponsive upon arrival at the emergency room and required intubation. Resident #9 was admitted to the intensive care unit and returned to the facility on [DATE]. Staff member F was interviewed on 12/12/12 at 5:15 p.m. She stated that 12/2/12 was her first night on shift at the facility. She stated staff member E was training her that evening. Staff member F stated staff member E had prepared resident #5's medications and asked her to administer them to resident #5. Staff member F stated she took the medications and went into resident #5's room. Staff member F stated she gave the medication to the resident who was in the room after she awakened her. She stated she did not ask the resident her name. Staff member F stated that it wasn't until later ( about a half an hour later) when resident #5 came to the medication cart and asked for her medications that she (staff member F) and staff member E realized that staff member F had given resident #9 resident #5's medications. Staff member F stated that staff member E then called the physician and guardian. Staff member F stated she left the facility shortly after that. The facility policy for General Dose Preparation and Medication Administration was reviewed on 12/13/12 at 9:35 a.m. Documented in Section 3 - Prior to Medication Administration "3.1 Facility staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident"... Staff members B and C stated after the medication error they had provided education to all the licensed staff in regards to proper medication administration and random medication administration audits were performed. The surveyor was provided documentation of the education provided to staff. Staff member C stated the facility management are in the process of writing a policy and procedure for identifying residents during medication administration.