Every finding on record at Missouri Slope

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 21 sampled residents (Resident #50, #61, #139, #154) and 1 supplemental resident (Resident #30) observed during cares. Failure to practice infection control standards related to glove use, hand hygiene, catheter care, equipment disinfection, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Isolation, Standard Precautions, and Enhanced Barrier Precautions occurred on 05/14/26. This policy, revised December 2025, stated, . Perform hand hygiene with hand sanitizer or soap and water upon entering and leaving a resident's room . remove gloves after use, before touching noncontaminated items and environmental surfaces and environmental surfaces . Wash hands immediately after [glove] removal to avoid transfer of microorganisms . Linen should be bagged at the point of use. Enhanced Barrier Precautions . Use gowns and gloves for high contact direct cares including . device care . examples of devices include . feeding tubes . Review of the facility policy titled Foley Catheter Care, Suprapubic Catheter Care, Drainage Bag, Leg Bag occurred on 05/14/26. This policy, revised in November 2025, stated, . Leg Bag Catheter System . Leg bags are attached directly to the catheter and are secured to the resident's leg with the Velcro straps. When drainage bag is emptied, care must be taken to avoid contamination of the spout. Keep drainage bag from touching the floor . Review of the facility policy titled Hand Hygiene, Artificial Nails occurred on 05/14/26. This policy, revised August 2025, stated, . Indications for Hand Hygiene: . Before and after resident care. After removing gloves. - Review of Resident #30's medical record occurred on all days of survey. The current care plan stated, . Resident has an indwelling medical device . Gown and gloves are used for high contact direct cares . including . device care . Resident is on Enhanced Barrier Precautions. Observation on 05/11/26 at 12:07 p.m. showed an EBP sign on Resident #30's door. A nurse (#7) entered the room, performed hand hygiene, applied gloves, flushed the resident's feeding tube with water and reattached the enteral feeding tube to the pump. The nurse (#7) failed to apply a gown prior to high-contact resident cares.- Review of Resident #50's medical record occurred on all days of survey and identified recurrent UTIs and required a Foley catheter. Observation on 05/11/26 at 12:40 p.m. showed Resident #50's urine collection bag slid along the floor as he drove his motorized wheelchair. Staff greeted the resident, but failed to secure the collection bag until the resident reached his room.During an interview on 05/14/26 at 9:46 a.m., an administrative staff member (#4) stated she expected staff to secure catheter bags to ensure the bag does not come in contact with the floor. - Observation on 05/11/26 at 11:39 a.m. showed two CNAs (#8 and #9) completed morning cares for Resident #61. The CNAs removed the soiled brief, the CNA (#8) washed the resident's perineal area, removed the soiled gloves and asked the CNA (#9) for a clean pair of gloves. Wearing soiled gloves, the CNA (#9) reached into a box of clean gloves, removed two gloves and handed them to the CNA (#8). Without performing hand hygiene, the CNA (#8) applied the new gloves, placed a barrier cream on the resident's abdominal folds and removed the soiled gloves. The CNAs (#8 and #9) completed the brief change, dressed the lower body, and transferred the resident into a wheelchair. The CNA (#8) failed to complete hand hygiene between glove changes. The CNA (#9) failed to remove the soiled gloves and complete hand hygiene prior to reaching into a clean box of gloves and failed to change the gloves after providing perineal cares and before assisting with other cares. - Observation on 05/13/26 at 9:00 a.m. showed a CNA (#5) completed morning cares for Resident #61. The CNA (#5) used three separate washcloths to cleanse the abdominal fold and perineal areas and placed each soiled washcloth directly on the bedside table. Upon completion, the CNA (#5) placed the soiled washcloths into a linen bag, set a cup of ice water on the bedside table and positioned the bedside table in front of Resident #61. The CNA (#5) failed to place soiled washcloths directly in a linen bag and failed to disinfect the bedside table after use. - Observation on 05/12/26 at 8:37 a.m. showed a CNA (#9) completed morning cares for Resident #139. The CNA (#9) cleansed the perineal area, placed the soiled washcloth on the bedside table, dried the excess water on the table with a paper towel, and moved the table next to the resident's bed. The CNA (#9) failed to place the soiled washcloths directly into a linen bag and failed to disinfect the soiled bedside table. - Observation on 05/11/26 at 4:05 p.m. showed a CNA (#10) entered Resident #154's room, performed hand hygiene and applied gloves. The CNA removed the resident's soiled brief, completed perineal care, removed the soiled gloves, applied new gloves and placed a clean brief on Resident #154. The CNA (#10) changed gloves, placed the bedside table near the resident, collected the garbage and exited the room. The CNA (#10) failed to perform hand hygiene between glove changes and failed to remove soiled gloves and complete hand hygiene prior to exiting the resident's room. During an interview on 05/13/26, an administrative staff member (#4) confirmed staff are expected to wear gowns in EBP rooms during close contact tasks, complete hand hygiene between glove changes and when moving from a dirty to a clean task, dispose of soiled laundry after use, and disinfect contaminated resident equipment.

Based on observation and staff interview, the facility failed to ensure drugs and biologicals were stored securely for 1 of 35 sampled residents (Resident #24) and 1 supplemental resident (Resident #109) with medications at the bedside. Failure to securely store medications may result in unauthorized use, adverse reactions, or ineffective treatment. Findings include: - Observation on 05/11/26 at 10:45 a.m. showed a tube of a topical analgesic (pain relief cream) on Resident #24's bedside table. - Observation on 05/12/26 at 8:15 a.m. showed three Refresh Tears eye drop bottles and one Systane eye drop bottle on Resident #24's bedside table. During an interview on 05/14/26 at 7:49 a.m., an administrative staff member (#5) confirmed nursing staff were not aware of the medications in Resident #24's room.- Observation on 05/11/26 at 11:55 a.m. showed a box of Lidocaine patches (topical pain relief patches) and Genteal eyes drops (lubricating eye drops) at Resident #109's bedside.- Observation on 05/12/26 at 10:08 a.m. showed Lidocaine patches, Genteal eyes drops, generic psyllium husk powder (fiber supplement), and generic muscle rub cream (topical pain relief) at Resident 1#09's bedside. During an interview on 05/14/26 at 10:39 a.m., an administrative staff member (#3) confirmed nursing staff were not aware of the medications in Resident #109's room.

Based on observation, record review, review of facility policy and staff interview, the facility failed to ensure adequate assistance for 1 of 1 sampled resident (Resident #61) observed during a mechanical sit to stand lift transfer. Failure to secure the leg strap and the abdominal strap of the lift sling placed the resident at risk for falls.Findings include:Review of the facility policy titled Transfer/Locomotion occurred on 05/14/26. This policy, revised September 2025, stated, . Slings are to be placed according to proper procedure.Review of Resident #61's medical record occurred on all days of survey. Diagnosis included left sided weakness and paralysis, history of falling, unsteadiness on feet and abnormal posture. The current care plan stated, Transfers with PAL [Patient Assist Lift] with assist x 2. Per shared risk agreement, [Resident #61's name] can choose where he wants the hook strap length at and where the abdominal strap is located (prefers it above abdomen).Observation on 05/11/26 at 11:39 a.m. showed two certified nurse aides (CNAs) (#8 and #9) assisted Resident #61 to a sitting position on the edge of the bed, placed the lift sling under Resident #61's arms, and situated the mechanical lift in front of the resident. The CNA (#8) stated the resident did not want the abdominal strap buckled. Resident #61 held onto the lift with only the right hand. Without securing the abdominal strap buckle or securing the leg straps, the CNAs (#8 and #9) raised the resident to a standing position. The CNAs (#8 and #9) provided morning cares while Resident #61 stood connected to the sit to stand lift. The CNAs (#8 and #9) failed to secure the leg strap of the lift and failed to secure the abdominal strap buckle.During an interview on 05/13/26 at 1:45 p.m., an administrative nurse (#4) stated she expected staff to always buckle the abdominal safety straps on the sling and secure the leg straps on the PAL lift.

13101 42397 Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide care in a manner and environment that maintains or enhances residents' quality of life for 5 of 9 residents (Residents #3, #44, #45, #70, and #112) observed during medication administration and in 3 of 8 dining rooms (1st floor C/D wing, 2nd floor C/D wing, and 4th floor C/D wing). Failure to refer to residents by their preferred name and dispose of bags containing trash/dirty linens prior to entering dining rooms does not promote resident dignity or respect. Findings include: Review of the facility policy titled Promoting Dignity and Resident Rights occurred on 03/27/25. This policy, dated December 2024, stated, . All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . Staff members should converse with the resident while doing cares . Speak respectfully to residents . Observations of medication administration on 03/26/25 showed a medication aide (MA) (#9) using endearing terms as follows: - 8:09 a.m. Called Resident #45 [NAME], Sweetheart, [NAME]. Resident #45's current care plan stated . My preferred name: [Resident's name]. - 8:22 a.m. Called Resident #70 [NAME]. Resident #70's current care plan stated . My preferred name: [Resident's name]. - 8:32 a.m. Called Resident #112 [NAME]. Resident #112's current care plan stated . My preferred name: [Resident's name]. - 8:38 a.m. Called Resident #3 [NAME], Sweetheart. Resident #3's current care plan stated . My preferred name: [Resident's name]. -8:47 a.m. Called Resident #44 [NAME], [NAME], My Dear, Sweetie, [NAME]. Resident #44's current care plan stated . My preferred name: [Resident's name]. During an interview on 03/27/25 at 1:15 p.m., an administrative staff member (#1) confirmed she expected staff to call residents by their preferred name unless care planned otherwise. - Observation on 03/24/25 at 4:40 p.m. showed an unidentified certified nurse aide (CNA) carrying a bag of garbage, while he/she pushed Resident #126's wheelchair to the 1st floor C/D dining room and up to a table where two residents were sitting. - Observation on 03/25/25 at 8:30 a.m. showed a CNA (#3) completed Resident #4's morning cares, gathered two bags of garbage and dirty linen, and exited the room carrying the bags while she assisted the resident to a table with two residents who were eating breakfast in the 4th floor C/D dining room. - Observation during the breakfast meal on 03/25/25, showed an unidentified CNA brought an unidentified resident to the dining table in the second floor C/D dining room holding a bag of soiled linen and garbage. - Observation on 03/26/25 at 8:01 a.m. showed a CNA (#7) stood in the first floor C/D dining room next to Resident #85 holding a bag of garbage and a bag of dirty linen. Resident #85's table mate had her breakfast tray in front of her. During an interview on 03/26/25 at 11:45 a.m., a nurse manager (#4) stated she expected staff to dispose of dirty linen/garbage before taking residents to the dining room or activities. 45873

Based on observation and staff interview, the facility failed to ensure food is stored in accordance with professional standards for food service sanitation in 6 of 8 nutrition stations (first floor A/B and C/D, second floor A/B and C/D, and third floor A/B and C/D). Failure to ensure food is safe from contamination by resident ice packs has the potential to result in a foodborne illness or adverse effects for residents, visitors, and staff. Findings include: When requested, the facility failed to provide a policy for storage of ice packs. Observation of the nutrition stations on 03/24/25 showed the following items stored with food items: - 2:25 p.m. First floor A/B nutrition station freezer, two blue gel cooling packs with a resident label, alongside ice cream cups. First floor C/D nutrition station freezer, two unlabeled blue gel cooling packs alongside a box of snack breads. - 2:38 p.m. Second floor A/B nutrition station freezer, one unlabeled blue gel cooling pack alongside ice cream cups. Second floor C/D nutrition station freezer, one unlabeled blue gel cooling pack alongside ice cream cups, a piece of a resident's ice cream cake in a ziploc bag, and two dishes of what a dietary aide identified as dessert from Saturday. An administrative nurse (#5) stated staff should not store cooling packs in nourishment freezers. - 2:46 p.m. Third floor A/B nutrition station freezer, two unlabeled blue gel cooling packs alongside ice cream cups. Third floor C/D nutrition station freezer, two unlabeled blue gel cooling packs alongside ice cream cups. A staff nurse (#6) stated cooling packs are not supposed to be in there [nourishment freezers] and should be kept in the nurse's station freezer. During an interview on 03/27/25 at 1:15 p.m., an administrative staff member (#1) confirmed she expected staff to store gel packs in the nurse's station freezer designated for that purpose.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure the interdisciplinary team assessed the appropriateness to self-administer medications (SAM) for 1 of 9 residents (Resident #70) observed during medication administration. Failure to determine whether SAM is a safe practice has the potential to result in a medication error and/or harm to a resident. Findings include: Review of the facility policy titled Self-Administration of Medications occurred on 03/27/25. This policy, revised May 2024, stated, . Missouri Slope is committed to respecting resident's rights to self-administer medication, after an interdisciplinary assessment, when and if they desire and are able to. In order to facilitate this each resident will be evaluated for their ability to do so safely. Review of Resident #70's medical record occurred on 03/26/25 and identified a physician's order for Genteal Tear Solution (artificial tears) 1 drop in both eyes twice a day. The current care plan stated, . [Resident name] has impaired cognitive function/dementia . moderate to severe cognitive impairment . has an ADL [activities of daily living] self-care performance deficit & limited physical mobility. Observation on 03/26/25 at 8:22 a.m. identified a medication aide (MA) asked Resident #70 if she had taken her eye drops. The resident replied Yes. When asked about the eye drops, the MA stated, The resident keeps them in her room and puts them in herself. The MA signed off the eye drops as administered in Resident #70's medication administration record (MAR). Resident #70's medical record lacked a SAM assessment and a provider order stating the resident may keep the eye drops at bedside. During an interview on 03/27/25 at 1:45 p.m., an administrative nurse (#1) confirmed the record lacked a SAM assessment for Resident #70's eye drops.

Based on observation, record review, policy review, professional reference, and staff interview, the facility failed to follow professional standards of practice for medication administration for 1 of 9 resident's observed during medication administration. Failure to document medications after administration, does not reflect the actual time of administration or any refusals which may cause adverse effects for the resident. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 836, stated, . Administering Medications Safely . Document medication administration after giving it, not before. Review of the facility policy titled Medication Administration occurred on 03/27/25. This policy, dated December 2024, stated, . Proper steps for identification of medication and identification of resident should be carried out each time medications are administered. Medications should not be pre-dished for future medication passes . Right documentation . - Observation on 03/26/25 at 8:09 a.m., identified a Medication Aide (MA) (#9) administered medications to a resident in the dining room. The MA (#9) returned to the medication cart and retrieved an unlabeled cup of medications from the top drawer. The MA stated, I usually dish medications right away for residents that have pills from the narcotic drawer. When asked what narcotic the MA dished the MA stated, Die-something. A review of Resident #45's medication record identified an order for Diphenoxylate/Atropine, a controlled medication for treatment of diarrhea. The MA took the unlabeled medication cup to Resident #45's room where the resident was in the bathroom. The MA returned to the cart with the medication cup and asked a nurse what she should do with them. The nurse stated, you have to hold onto them now until the resident is available. The MA (#9) returned to Resident #45's room, waited for the resident to be available, administered the medications, and returned to the cart. Observation of the medication administration record (MAR) identified the MA already documented the medication as administered prior to administering the medications. During an interview on 03/27/25 at 1:15 p.m., an administrative nurse (#1) stated she expected staff to document medications after administration.

Based on observation, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 9 residents (Resident #44 and #70) observed during medication administration. Four medication errors occurred during staff administration of 41 medications, resulting in a nine percent error rate. Failure to properly prepare and administer medications may inhibit the effectiveness of the medication and may have a negative impact on the resident's overall health. Findings include: Review of the facility policy titled Medication Administration occurred on 03/27/25. This policy, dated December 2024, stated, . Medications included in this definition may include those administered orally . optic . c. right dosage d. right route. e. right time. f. right documentation . A resident may refuse a medication. This should be documented on the eMAR [electronic medication administration record] and the nurse notified. The physician should be notified of repeated refusals. Review of administration instructions found at Timolol Maleate Eye Drops, Solution 0.5% Novartis . Package Insert, 25 June 2020, https://www.novartis.com/sgen/sites/novartis_sg/files/TimololMaleate-Jun2020.SIN-App110920.pdf stated, . If more than one topical ophthalmic drug is being used, the drugs should be administered at least 5 minutes apart. - Review of Resident #44's medical record occurred on 03/26/25. Physician's orders included Timolol Maleate Solution (an eye drop to reduce eye pressure) 0.5% 1 drop in the right eye twice a day and Lubricant eye drops 2 drops in both eyes four times a day. Observation on 03/26/25 at 8:47 a.m. showed a medication aide (MA) (#9) administered Timolol eye drops in both of Resident #44's eyes, waited 20 seconds, and administered 1 drop of the lubricant eye drops in both eyes. When asked to confirm the dosage of the Timolol eye drops, the MA referred to the pharmacy label on the medication box which showed 1 drop in the right eye only. The MA (#9) confirmed the administration error. The MA also failed to wait the appropriate length of time before administering the lubricant drops and failed to administer 2 drops as ordered. - Review of Resident #70's medical record occurred on 03/26/25. A physician's order stated Polyethylene Glycol Powder (a laxative mixed with water) 8.5 grams by mouth once daily. Observation on 03/26/25 at 8:22 a.m. showed a MA (#9) dispensed 8.5 grams of laxative powder into a 6-ounce cup, filled it with ice water, and brought it to Resident #70. The resident stated the water was too cold and I don't want too much. The MA returned to the medication cart, wasted the medication, and placed half of the 8.5-gram dose into a plastic cup. The MA (#9) filled the glass with tap water per resident's request, administered the lower dose to the resident, and documented administration of the full dose in Resident #70's medication administration record (MAR). The MA (#9) failed to report to the charge nurse the resident's refusal of the full dose before administering a different dose. During an interview on 03/27/25 at 1:15 p.m., an administrative staff member (#1) confirmed she expected medications to be administered as ordered and report a refusal or request to the charge nurse and provider.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 14 sampled residents (Resident #116 and #164) requiring enhanced barrier precautions (EBP). Failure to practice infection control standards related to EBP and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene, Artificial Nails occurred on 03/27/25. This policy, revised December 2024, stated, . Hand hygiene is considered the single most important procedure for preventing the spread of health-care associated infections. The use of gloves does not eliminate the need for hand hygiene. Indications for Hand Hygiene . 7. After removing gloves. Review of the facility policy titled Isolation, Standard Precautions, and Enhanced Barrier Precautions occurred on 03/27/25. This policy, dated September 2024, stated, . In addition to Standard Precautions, use Enhanced Barrier Precautions when providing high contact cares for residents at increased risk of an MDRO [multidrug-resistant organism] acquisition; includes residents with . indwelling medical devices. Use gowns and gloves for high contact direct cares including . device care . examples of devices include . central line. remove PPE [personal protective equipment] and discard appropriately and perform hand hygiene before leaving room. - Review of Resident #116's medical record occurred on all days of survey. The current care plan stated, . is on Enhanced Barrier Precautions due to history of an MDRO . indwelling medical device . Observation on 03/25/25 at 8:32 a.m. showed a sign on Resident #116's door indicating enhanced barrier precautions, and the resident resting in bed. A nurse (#2) entered the resident's room, donned a gown, gloves, and a facemask, and removed the resident's oxygen mask. The nurse (#2) removed her gloves, and without performing hand hygiene, prepared a suction kit, donned the sterile gloves from the kit, and suctioned Resident #116's tracheostomy (a surgically placed airway). The nurse (#2) changed her gloves without performing hand hygiene and performed tracheostomy cares. The nurse (#2) then changed her gloves without performing hand hygiene, prepared Resident #116's nutritional supplement and tubing, changed her gloves without performing hand hygiene, flushed the feeding tube, administered medications, and connected the resident's nutritional supplement. The nurse (#2) removed her gloves, and without performing hand hygiene, retrieved a walkie talkie from her pocket to call for assistance, cleaned up the supplies, removed her gown, washed her hands, and exited the room. The nurse (#2) failed to perform hand hygiene before and after glove changes. During an interview on 03/27/25 at 10:00 a.m., an administrative nurse (#1) confirmed she expected staff to perform hand hygiene after removing gloves and before donning new gloves. - Review of Resident #164's medical record occurred on all days of survey. The current care plan stated, . is on Enhanced Barrier Precautions due to indwelling medical device, PICC [Peripherally Inserted Central Catheter] . A physician order stated, Aztreonam 2 GM [grams] [an antibiotic medication] . Infuse . intravenously [IV] . every 8 [eight] hours . Observation on 03/25/25 at 2:35 p.m. showed a sign on Resident #164's door indicating EBP. A nurse (#8) donned a mask and gloves, entered Resident #164's room, connected an antibiotic IV infusion set to the resident's PICC line, and started the antibiotic administration via an IV pump. The nurse (#8) removed her gloves and mask, performed hand hygiene, and exited the resident's room. At 3:10 p.m., the nurse (#8) donned a new mask and gloves, entered Resident #164's room, and disconnected the IV tubing from the resident's PICC line. While wearing the mask and gloves, and carrying the antibiotic infusion set, the nurse exited the resident's room. The nurse (#8) failed to wear a gown during Resident #164's PICC line IV antibiotic infusion, failed to discard the infusion set in the residents' room, and failed to remove her mask and gloves and perform hand hygiene prior to exiting the resident's room. During an interview on 03/25/25 at 4:45 p.m., an administrative nurse (#1) confirmed all nurses are trained on appropriate PPE use and medication administration for residents with PICC lines and on EBP. 45873 46964

Based on review of the facility reported incident and investigation reports, record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from mental and/or physical abuse for 1 of 1 sampled resident (Resident #1) who was witnessed receiving physical and verbal abuse. Failure of facility staff to immediately report a witnessed incident of staff to resident abuse to the appropriate supervisor delayed the removal of the accused abuser, the start of the facility investigation, and assessment of the resident for injury. This delay placed Resident #1 at risk for further abuse, fear, anxiety, and/or psychosocial harm and placed other residents at risk for abuse. Findings include: Review of the facility policy titled Abuse occurred on 10/15/24. This policy, reviewed September 2024, stated, . All employees receive education during orientation and at least annually throughout their employment on what constitutes abuse, neglect . and their responsibilities to protect the resident from these crimes. Abuse is defined as . intimidation, or punishment with resulting physical harm, pain, or mental anguish, or deprivation of . services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Physical abuse is defined as . controlling behavior through corporal punishment. Mental abuse is defined as . harassment, and threats of punishment . Allegations of mistreatment may be identified by anyone who witnesses or receives a report of possible mistreatment toward anyone. Review of the facility's initial investigation report, dated 10/11/24, identified on 10/11/24 a certified nurse aide (CNA) (#1) reported to the nurse manager (#2) he/she observed a CNA (#3) slap and disrespect Resident #1 on 10/10/24 during evening cares. Review of Resident #1's medical record occurred on 10/15/24. Diagnoses included anxiety disorder, dementia with mood disturbances, and Alzheimer's disease. The current care plan identified, . [Resident #1] has potential to demonstrate verbal behaviors r/t [related to] dementia. Document observed behaviors and attempted interventions in behavior log. has the potential to demonstrate physical behaviors hitting out at staff r/t dementia. document observed behaviors . When [Resident #1] becomes agitated: Intervene before agitation escalates; Guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk away calmly, and approach later. Review of Resident #1's behavior log, dated October 1-15, 2024, occurred on 10/15/24. The behavior log lacked documentation of any resident behaviors. During an interview on the morning of 10/15/24, a CNA (#1) stated, while he/she and CNA (#3) provided cares to Resident #1 on the evening of 10/10/24, the resident yelled at the CNA (#3) to, get out, and spit at her. The CNA (#1) identified hearing a spitting sound and turned around to see the CNA (#3) slap the resident in the face and cover the resident's head with a blanket. The CNA (#3) stated, This is how you calm [resident] down. When the CNA (#3) pulled the blanket down, the resident spit, and the CNA (#3) slapped the resident again, made faces, and stuck her/his tongue out at the resident. The CNA (#1) stated Resident #1 continued to yell at the CNA (#3). The CNA (#1) reported being shocked, and scared, during the abuse incident and feared retaliation from CNA #3. The CNA (#1) confirmed not reporting the incident immediately on the evening of 10/10/24 until reported to the evening nurse on 10/11/24. During an interview on 10/15/24 at 12:48 p.m., a managerial staff member (#4) stated, Education given was to [CNA #1] that [CNA #1] should have reported the incident immediately.

Based on record review, review of the facility reported incident (FRI), review of facility policy, and resident and staff interviews, the facility failed to prevent accidents for 1 of 1 sampled resident (Resident #1) who sustained a fall with fracture. Failure to utilize the whirlpool seat belt resulted in an avoidable fall and fracture for Resident #1 and placed all residents at risk for falls and/or injuries. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Bathing Procedure occured on 06/12/24. The policy, dated November 2023, stated, Resident Safety - Safety Strap Usage Whirlpool: Transfer resident to whirlpool seat. Attach seat belt around resident. Ensure seat belt does not get caught in the door when closing the door. The facility failed to provide instruction on when it is safe to remove the bath chair seat belt. Review of the FRI report, submitted to the state agency on 06/10/24, identified Resident #1 . slipped from tub chair onto the floor. Review of Resident #1's medical record occurred on 06/12/24. The current care plan stated, . has an ADL [Activities of Daily Living] self-care performance deficit & [and] limited physical mobility r/t [related to] deconditioning weakness. A progress note, dated 06/10/24, stated, . this nurse observed Resident on floor to side of tub, lateral on R [right] side, back facing tub, lying on R arm. Resident's head was on floor with blood from head. During an interview on 06/12/24 at 2:00 p.m., Resident #1 stated she [certified nurse aide (CNA)] took me out of the tub and took off the belt while I was at least 5 feet in the air. During an interview on 06/12/24 at 2:15 p.m., an administrative nurse (#1) confirmed the CNA should have kept the safety belt on as shown in training video. The facility failed to keep the appropriate device (seat belt) on Resident (#1) after exiting the whirlpool bath. This resulted in a fall with a right humerus fracture. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions for the resident affected by the deficient practice by: * Completing investigations following fall, * Determining the CNA failed to ensure adequate supervision of resident during whirlpool bath. The facility implemented measures to ensure the deficient practice does not recur by: * Educating/re-educating bath aides starting on 06/11/24 regarding utilizing the whirlpool chair seat belt while completing resident baths, * Adding Whirlpool Safety Checklist to the lead CNA's job duties, * Adding Whirlpool Safety Performance Tracker as a quality assurance measure. This surveyor determined a deficient practice existed on 06/12/24. The facility implemented corrective actions on 06/11/24 and continues with safety checks/re-educating all bath aides.

Based on record review, review of facility policy, and staff and family interviews the facility failed to provide the required specialized rehabilitative services for 1 of 6 sampled residents (Resident #156) with orders for physical therapy evaluation and treatment. Failure to provide physical therapy services as ordered for Resident #156 may result in impaired strength, impaired mobility, and increased pain. Findings include: Review of the facility policy titled Physician Orders occurred on 02/15/24. This policy, revised April 2023, stated, . It is the policy of [Facility Name] to complete physician orders in a timely manner to ensure appropriate care . Review of the facility policy titled Physical Therapy, Occupational Therapy, and Speech Therapy occurred on 02/15/24. This policy, revised April 2024, stated, . To provide therapeutic environment for residents through written communication to Nursing staff to sustain functioning and/or prevent deterioration as able. During an interview on 02/12/24 at 4:40 p.m., Resident #156's representative indicated the resident was not getting therapy to get stronger and help with his leg pain. Review of Resident #156's medical record occurred on all days of survey. Diagnoses included [NAME] Nile virus encephalitis [inflammation of the brain], myalgia [muscle ache and pain], and generalized weakness. A physician's order, dated 01/16/24, stated, PT [physical therapy] to evaluate and treat, focus on lower extremities. A physician's recertification progress note, dated 01/16/24, stated, . Needs Physical therapy with focus on the lower extremities, specifically the right lower extremity. ROS [review of systems] . Musculoskeletal: Positive for myalgias. Neurological: Positive for weakness. Physical/Results . Musculoskeletal . Comments: Significant weakness of bilateral lower extremities, right slightly greater than left. Has some contraction of right ankle noted as well. Mild pain in bilateral legs. The medical record lacked documentation of a physical therapy evaluation or treatment plan. During an interview on 02/15/24 at 11:40 a.m., an administrative nurse (#1) confirmed the facility failed to ensure physical therapy completed an evaluation and/or treatment plan for Resident #156.

Based on observation, record review, review of facility policy and staff interview, the facility failed to follow standards of infection control for 1 of 1 sampled resident (Resident #138) observed for medication administration via feeding tube and 1 of 1 sampled resident (Resident #91) on transmission-based precautions (TBP). Failure to follow infection control standards during medication administration and with TBP has the potential to transmit infections to residents, staff, and visitors. Findings include: MEDICATION ADMINISTRATION Review of the facility policy titled Medication Assistant Scope of Practice occurred on 02/14/24. This policy dated February 2023, stated, . If a medication is dropped, it should be discarded. Observation on 02/13/24 at 12:04 p.m., showed a staff nurse (#11) prepared medication for Resident #138. The staff nurse (#11) dropped a Guaifenesin tablet on the top of the cart. Using bare hand contact, picked up the pill, placed it into the medication cup, and administered it to the resident. TRANSMISSION BASED PRECAUTIONS Review of the facility policy titled Isolation occurred on 02/15/24. This policy, revised January 2024, stated, . Transmission Based Precautions will be used for the care of persons with infections from highly transmissible . pathogens that cannot be controlled with Standard Precautions. It includes . Enteric Contact . Procedure: . 2. Gloves . wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. B. Remove gloves after use, before touching noncontaminated items . C. Wash hands immediately after removal to avoid transfer of microorganisms . 4. Gown/Apron . B. Remove a soiled gown/apron as promptly as possible and wash hands to avoid transfer of microorganisms . Review of the facility policy titled C-diff (Clostridium Difficile) - GI [gastrointestinal] (Enteric) Isolation occurred on 02/15/24. This policy, revised February 2024, stated, .GI (Enteric precautions are taken to prevent infections that are transmitted primarily by direct or indirect contact with fecal material. Procedure: . 3. Handwashing is the most important preventative measure. Hand sanitizer is not effective against C-Diff. Wash hands with soap and water prior to leaving the resident's room. Review of the facility policy titled Hand Hygiene, Artificial Nails occurred on 02/15/24. This policy, revised November 2023, stated, . Hand hygiene is considered the single most important procedure for preventing the spread of health-care associated infections . A. Indications for Hand Hygiene: . 8. Soap and water should be used . after caring for a patient with known or suspected C. difficile. Review of Resident #91's medical record occurred on all days of survey. Diagnoses included C. Difficile. A nursing progress note, dated 01/24/24 at 1:22 p.m., stated, . Resident had the suprapubic catheter placed today. Observation on 02/12/24 at 12:48 p.m. showed an isolation sign on Resident #91's door. The sign stated, . Gastrointestinal (Enteric) . Wear gloves when entering room . Wear gown when entering room . Remove PPE [personal protective equipment] and wash hands with soap and water before leaving room . Observation on 02/14/24 at 9:25 a.m., showed a nurse (#8) entered the room in a gown and gloves. The nurse (#8) removed the soiled dressing from the suprapubic site, removed gloves, and performed hand hygiene. The nurse (#8) donned clean gloves, cleansed suprapubic catheter site and suprapubic tube with gauze sponge moistened with soap and water, and without removing gloves or performing hand hygiene, placed a new split gauze, reached into the pocket of her uniform top, removed a roll of tape, pushed up glasses, taped the split gauze, and placed the tape back in her uniform pocket. The nurse (#8) removed her gloves, washed her hands with soap and water, removed her isolation gown, performed hand hygiene with hand sanitizer, and left the room. The nurse (#8) failed to remove her soiled gloves and perform hand hygiene after cleaning the suprapubic catheter site and tube, and before touching other items. The nurse failed to remove all PPE at once and wash her hands with soap and water before exiting Resident #91's room. During an interview on 02/14/24 at 3:25 p.m., an administrative nurse (#1) stated she expected staff to change gloves and perform hand hygiene when moving from dirty to clean tasks, and remove all PPE at one time, then wash hands with soap and water prior to exiting Resident #91's room. 42397

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 1 of 2 sampled residents (Resident #286) who received an as needed (PRN) psychotropic. Failure to limit PRN psychotropic use to 14 days unless reevaluated by a practitioner placed the resident as risk of receiving unnecessary medications and experiencing adverse drug effects. Findings include: Review of the facility policy titled Medications-Psychotropic and Antipsychotic Medication Use occurred on 02/15/24. This policy, dated August 2023, stated, . The attending or prescribing health care provider must document the diagnosed specific condition and indication for the PRN medication in the medical record. When the extended use of a PRN psychotropic mediations is indicated (beyond 14 days), additional orders must be obtained. Nursing staff will automatically send Health Care Provider a pre-made PRN Psychotropic Fax prior to day 14 if indication for use continues and there is no specific time frame for the PRN. Review of Resident #286's medical record occurred on all days of survey. A physician's order, dated 01/27/24, included Ativan (antianxiety) 0.25 milligrams every four hours as needed for agitation. The physician renewed the order for the prn Ativan on 02/13/24 (4 days late). During an interview on 02/15/24 at 10:30 a.m., an administrative nurse (#1) confirmed Resident #286's PRN Ativan failed to be reevaluated within 14 days.

Based on record review, policy review, and resident and staff interview, the facility failed to provide care and services to control pain for 1 of 3 sampled residents (Resident #17) investigated for pain management. Failure to administer pain medication as scheduled may have contributed to Resident #17 experiencing increased and/or unresolved pain. Findings include: Review of the facility policy titled Medication Administration occurred on 02/15/24. This policy, dated December 2023, stated, . Scheduled medications may be given up to 1 hour before and 1 hour after the designated time. Review of Resident #17's medical record occurred on all days of survey. The admission Minimum Data Set (MDS), dated [DATE], identified intact cognition and frequent pain rated 5 on a 0-10 scale, which affected her sleep and day to day activities occasionally and interfered with therapy activities almost constantly. Resident #17's care plan stated, . potential for pain R/T [related to] chronic back pain, diabetes, PVD [peripheral vascular disease]. Resident's pain score goal is 0 [on a scale of 0-10]. Administer analgesic as per orders & [and] monitor for relief obtained. Monitor/document for probable cause of pain. Remove/limit causes where possible. Physician orders included: * 01/28/24, HYDROCO/APAP [hydrocodone/acetaminophen] [narcotic and non-narcotic analgesic combination] TAB [tablet] 5-325MG [milligram] TAKE 1 TABLET BY MOUTH EVERY 6 HOURS AROUND THE CLOCK FOR SEVERE PAIN (Related Diagnoses: FIBROMYALGIA [a disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue and sleep disturbances] * 02/07/24, Gabapentin [treats nerve pain] Oral Capsule 100 MG . Give 1 capsule by mouth three times a day related to FIBROMYALGIA During an interview on 02/12/24 at 2:50 p.m., Resident #17 stated, Sometimes my meds [medications] are given late, like up to an hour late, and my pain meds wear off. The resident complained of hip, back, and shoulder pain and restless legs, and stated, I can wait up to two hours to get my pain meds. A report provided by an administrative nurse (#1) on 02/15/24 at 2:14 p.m. showed the exact time staff administered a medication and revealed the following: * February 1-15, hydrocodone/apap given between 62 minutes to 133 minutes after the scheduled time on 11 of 58 occasions * February 7-15, Gabapentin given between 63 to 117 minutes after the scheduled time on nine of 23 occasions During an interview on 02/15/24 at 2:18 p.m., an administrative nurse (#1) stated she expected staff to administer medications 60 minutes before/after their scheduled administration time.

Based on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to provide respiratory care for 1 of 11 sampled residents (Resident #163) receiving oxygen by nasal cannula. Failure to administer oxygen according to the physician's order may result in complications and compromise the residents' respiratory status. Findings include: Review of a policy/procedure titled Oxygen occurred on 02/15/24. This policy/procedure, revised December 2023, stated, . Turn the oxygen on as ordered by the physician . Review of Resident #163's medical record occurred on all days of survey and identified a diagnoses of dependence on supplemental oxygen. A physician's order, dated 11/14/23, stated, Oxygen continuously at 1 LPM [liters per a minute] to maintain saturations above 88%. Observations on 02/12/24 at 11:11 a.m., 02/13/24 at 4:14 p.m., and 02/14/24 at 12:15 p.m. showed Resident #163 in a recliner without oxygen. During an interview on 02/12/24 at 11:14 a.m., Resident #163 reported facility staff removed their continuous oxygen on the morning of 02/12/24 and did not notify the resident of the reasoning. During an interview on 02/13/24 at 4:28 p.m., an administrative staff member (#9) confirmed Resident #163 should be on continuous oxygen per physician's orders.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate and sufficient supervision for 2 of 6 sampled residents (Resident #135 and #166) observed for safe transfers. Failure to provide appropriate and sufficient supervision during mechanical lift transfers (Resident t#166) and follow fall interventions (Resident #135) placed residents at risk for accidents, falls, and/or injuries. Findings include: Review of the facility policy titled Transfer/Locomotion occurred on 02/15/24. This policy, dated November 2023, stated, . 4. Always use 2 staff during transfer. Review of the facility policy titled Fall (Resident) Guidelines occurred on 02/15/24. This policy, revised June 2023, stated, . The nurse should make changes to the care plan and Kardex as determined by the team to prevent further incidents of fall. - Review of Resident #166's medical record occurred on all days of survey and included a diagnoses of dementia. The current care plan stated, TRANSFER: hoyer [full body mechanical lift] for all transfers. Observation on 02/14/24 at 8:13 a.m. showed one certified nurse aide (CNA) (#3) transferred Resident #166 to the wheelchair utilizing the ceiling lift [full body mechanical lift]. The CNA (#3) failed to ensure two staff completed the lift transfer. During an interview on the afternoon of 02/15/24 an administrative staff member (#1) confirmed he/she expected staff to follow facility policy when using the ceiling lift. - Review of Resident #135's medical record occurred on all days of survey. A care plan intervention, dated 01/10/24, stated, . Wheelchair within reach at all times. A Fall Note, dated 01/22/24, stated, . Wheelchair and walker were not within reach and resident may have been self-transferring. Observation on the afternoon of 02/12/24, during early afternoon showed Resident #135's wheelchair not within reach. Without staff present, the resident ambulated per self from the recliner to the wheelchair. Observations on 02/12/24 at 4:35 p.m. and on 02/12/24 at 4:20 p.m. showed Resident #135 resting in the recliner. Staff failed to place the wheelchair within the resident's reach. During an interview on 02/15/24 at 12:45 p.m. an administrative staff member (#1) confirmed he/she expected facility staff to implement fall interventions as care planned. 47896

Based on record review and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #138) reviewed for restorative therapy received the services developed by the therapy staff. Failure to follow up on a request to the provider for restorative nursing/therapy services may adversely affect the resident's ability to maintain range of motion (ROM), strength, and mobility. Findings include: Review of Resident #138's medical record occurred on all days of survey. Diagnosis included hemiplegia. The current care plan stated, . impaired functional mobility as evidenced by Inability to achieve full functional ROM, Decreased ability to self-perform ADLs [activities of daily living] R/T [related to] intracranial injury. A quarterly Minimum Data Set [MDS] dated 11/22/23 identified bilateral functional limitation in range of motion to upper and lower extremities. Random observations of cares during all days of survey showed Resident #138's knees in a bent position. Progress notes identified the following: * 01/20/24 at 1:57 p.m.: Update of resident's status given to wife. She requested his restorative therapy program be resumed due to his stiffness. Fax sent to [provider] with request for therapy. * 02/02/24 at 6:06 p.m.: Late Entry: Order request sent to [provider name] office requesting an order for PT [physical therapy] to evaluate resident for Restorative therapies per wife request [wife's name]. * 02/14/24 at 6:08 p.m.: Another request for PT evaluation placed in file for resident to be evaluated by PT for Restorative therapies. During an interview on 02/14/24 at 5:28 p.m., an administrative nurse (#1) confirmed the resident is currently not receiving restorative therapy. The medical record lacked evidence of an order for restorative therapy for Resident #138.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure appropriate care and services for 1 of 1 sampled resident (Resident #379) with orders for a knee immobilizer. Failure to follow physician's orders and the care plan for application, and report refusals of application, placed Resident #379 at risk for falls and discomfort/pain. Findings include: Review of the facility policy titled Care Plans (Plan of Care) occurred on 02/15/24. This policy, revised August 2023, stated, . develop and implement a baseline and/or comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events . Review of Resident #379's medical record occurred on all days of survey. Diagnoses included left patellar (kneecap) fracture. The current physician's orders stated, . Keep immobilizer in place to LLE [left lower extremity] until cleared by ortho [orthopedics] . The current care plan stated, . alteration in musculoskeletal status R/T [related to] left patellar fracture . Resident has immobilizer in place to L leg . An orthopedic daily progress note, dated 02/06/24, stated, . fell on to his left knee sustaining a closed nondisplaced vertically oriented left patella fracture. Plan: . Weight bearing: as tolerated with knee immobilizer in place. Review of the treatment administration record for February 12 - 15, 2024, showed staff documented the knee immobilizer in place on all days during all shifts. The medical record lacked documentation by staff of the resident's refusal to wear the knee immobilizer. Observations of Resident #379 showed the following: * 02/13/24 at 7:58 a.m., seated in wheelchair without a knee immobilizer to the left leg. * 02/13/24 at 12:27 p.m., laying in bed without a knee immobilizer to the left leg. * 02/13/24 at 3:53 p.m., two certified nurse aides (CNAs) (#5 and #6) transferred the resident from the bed to wheelchair with a mechanical sit to stand lift. The CNAs (#5 and #6) failed to place the left knee immobilizer on Resident #379's left leg. During an interview on 02/13/24 at 3:53 p.m., the CNAs (#5 and #6) stated they were unsure about placement of the knee immobilizer for Resident #379. One CNA (#6) stated, I did see it on him yesterday, he should be wearing it. Both CNAs reported access to the care plans on either the tablet or on the computers in the hallway. During an interview on 02/13/24 at 4:00 p.m., a certified occupational therapy aide (#7) stated Resident #379 refused to wear the knee immobilizer on two occasions. During an interview on 02/13/24 at 4:55 p.m., an administrative nurse (#4) stated she expected staff to place the immobilizer to Resident #379's left knee as ordered and care planned, and communicate/document any resident refusals.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 2 of 36 sampled resident (Resident #69 and #138). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled, Care Plan (Plan of Care), occurred on 02/15/24. This policy, dated August 2023, stated, . The plan of care is reviewed at least monthly by nursing, quarterly with completion of MDS [Minimum Data Set] assessment and annually at interdisciplinary care conferences. Nursing plans of care are to be kept current by licensed staff members and remain consistent with the attending physician's plan of medical care, and the changing needs of the residents. - Review of Resident #138's medical record occurred on all days of survey. Diagnoses included hemiplegia. The current care plan identified the following: . Restorative therapy to Assist to move through tolerated range, supporting joints above & [and] below area: Lower Extremity exercises 6x's/ [times per] week. During an interview on 02/14/24 at 5:28 p.m., an administrative nurse (#1) confirmed the facility discontinued restorative therapy for Resident #138 and failed to remove it from the care plan. - Review of Resident #69's medical record occurred on all days of survey and identified diagnoses of depressive episodes and insomnia. Current physician's orders, dated 01/28/22 and 05/16/23, stated, DULoxetine HCl Capsule Delayed Release Particles [an antidepressant]. Trazadone [an antidepressant] tab [tablet] 50mg [milligrams]. The current care plan identified the following: . uses psychotropic medications R/T [related to] depression, and anxiety. Hx [history] of insomnia. Educate resident's family/caregivers about risks, benefits and the side effects and/or toxic symptoms. Monitor/record/report to MD [medical doctor] prn [as needed] side effects and adverse reactions of psychoactive medication. The facility failed to identify some serious side effects staff should observe for when taking multiple antidepressants on Resident #69's care plan. During an interview on 02/15/24 at 2:19 p.m. a licensed nurse (#4) confirmed Resident #69's care plan failed to address the side effects related to the use of antidepressants. During an interview on 02/15/24 at 2:53 p.m. a medication assistant (MA) (#2) failed to verbalize the side effects/symptoms Resident #69 could experience related to antidepressants. During an interview on 02/15/24 at 3:00 p.m. a nurse (#3) failed to verbalize the side effects/symptoms Resident #69 could experience related to antidepressants. 47896

Based on review of information provided by the complainant, facility reported incident investigation, record review, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 1 sampled resident (Resident #167) who failed to receive an ordered medication on multiple days. Failure to administer medication according to a physician's order may have contributed to high sodium levels and resulted in the resident's hospitalization . This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Information provided by the complainant indicated the facility failed to obtain and administer medication which resulted in Resident #167's hospitalization and cancellation/delay of a scheduled radiology test and appointments with specialists in another city. The facility reported incident investigation, dated 11/15/22, stated, Resident did not receive his Desmopressin [antidiuretic hormone] from 11/10/22 - 11/13/2022. Resident went for preplanned MRI (Magnetic Resonance Imaging) with anesthesia on 11/15/2022. Pre-procedure lab work showed a Na [sodium] of 156. Resident was sent to ER [emergency room ] for evaluation and was admitted for high Na and pneumonia. Review of Resident #167's medical record occurred on all days of survey. Diagnoses included diabetes insipidus (condition in which your body produces too much urine and isn't able to properly retain water). An order, dated 10/12/22, stated, Desmopressin tab 0.1mg [milligram], take 1 tablet by mouth every day (Related Diagnoses: Diabetes Insipidus.) The dose frequency was increased to twice daily on 10/25/22. The November 2022 Medication Administration Record (MAR) for Desmopressin (due at 8:00 a.m. and 8:00 p.m.) identified staff charted a 9 on each entry from November 10 at 8:00 a.m. through November 14 at 8:00 a.m. Staff documented the Desmopressin administered on November 14 at 8:00 p.m. The Chart Codes on the MAR stated 9=Other/See Nurse Notes. Staff failed to document a reason in the nurses' notes for not administering the nine doses of Desmopressin. The Emergency Department record, dated 11/15/2022 at 10:01 a.m., stated, . Patient presents with Hypernatremia [elevated sodium level]. Na of 156. According to wife, over the last 4 days during the snowstorm, patient had not received any of his DDAVP [Desmopressin] as he had run out. Today she noticed that he was confused and sleepy, really would not wake up to answer any questions, 'like he gets when his sodium is high.' He has had limited oral intake over the last couple days. He had evaluation by anesthesia for MRI earlier today, who obtained labs with sodium 156. He was sent to the ED for further evaluation. Results for orders placed or performed during the hospital encounter of 11/15/22 . Sodium 154 (H) [high] [Range] 136 - 145 meq/L [milliequivalents per Liter] . Resident #167's nurses' notes stated: * 11/10/2022 at 12:08 p.m., Received a phone call from pre admissions at [local hospital] regarding resident's upcoming MRI scheduled for Tuesday 11-15 -22 at 0630 AM. NPO [nothing to eat/drink] after midnight except sips of water until 0430 [4:30 a.m.]. Hold AM medication. * 11/15/2022 at 3:05 p.m., Call received from [emergency room staff], updated me regarding resident's status. Left for MRI at 5:30am, lab results came in while having the MRI, Na at 156 and resident was brought to the ER. Labs redrawn at the ER, Na was at 154 as of 10am . CXR [chest x-ray] was done that revealed pneumonia of the left lower lobe . Resident is admitted for hypernatremia and pneumonia. * 12/6/2022 at 12:38, . returned from the hospital . During an interview on 02/16/23 at 2:22 p.m., a nurse administrator (#1) stated nursing staff followed the process to order the Desmopressin, making several attempts. The pharmacist was not in building due to the storm. In follow-up with pharmacy, the pharmacist stated if they knew the significance of the medication, they would have had the on-call pharmacist come in. Since this incident, pharmacy stocked Desmopressin in the emergency kit. This nurse described education provided, interventions put in place, and monitoring conducted to ensure delivery of ordered medications. Based on the following information, non-compliance at F760 is considered past non-compliance. The facility implemented the corrective action for the resident affected by the deficient practice by: * Completing an investigation by 11/18/22 after conducting interviews of staff involved with ordering and dispensing of medication. * Determining the investigation showed the Desmopressin was unavailable to the resident even though nursing staff followed the process for ordering medication (sending order through the electronic health system, pulling the label from medication card and faxing pharmacy), and partly due to unfortunate factors (needing a new prescription order from the provider and the winter storm affecting pharmacy/provider availability). * Stocked Desmopressin in the FirstDose emergency medication kit on 11/15/22. * Placing a reminder on the MAR that the resident cannot miss a dose of Desmopressin, to order it promptly when noted a low amount of medication in the vial (provider changed Desmopressin to injectable form), to call the on-call pharmacist if needed, and reminder of an extra vial available in the FirstDose emergency kit. The facility addressed measures put in place and implemented systemic changes to ensure the deficient practice does not recur by: * Providing face-to-face re-education on November 14-25, 2022 with each nurse by the 1st floor Unit Director on the importance of following up on reordered medications that do not arrive and providing re-education on Desmopressin. * One of the Unit Directors began review of reorders on all floors each day to ensure reorders have been transmitted to pharmacy as expected and as needed. * Reviewing the reorder process with the pharmacy manager, including reorders through the electronic health system and faxing, and the process pharmacy uses to request medication refills from providers. The pharmacy manager re-educated staff to look for rejected medication refill requests and timing of refills. * Continuing with a Medication Reorder audit to check if ordered medications arrived as requested. The survey team determined a deficient practice existed on 11/10/22. The facility implemented corrective action on 11/14/22 and completed nursing education on 11/25/22.

Based on information provided by the complainant, record review, review of facility policy, and staff interview, the facility failed to follow professional standards for medication administration for 1 of 1 resident (Resident #3) who required hospitalization as a result of a significant medication error. Failure of staff to administer medications using professional standards and facility practice resulted in a significant medication error which required an avoidable hospitalization for Resident #3. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Information provided by the complainant indicated nursing staff administered the wrong medications to a resident. Review of the facility policy titled Medication Errors occurred on 05/11/22. This policy, revised September 2021, stated, . It is the policy of [Facility Name] to provide protections for the health, welfare and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. 3. [Facility Name] will consider factors indicating errors in medication administration as A. Not being given in accordance with providers orders, examples include . incorrect medication. Review of the facility policy titled Medication Administration occurred on 05/11/22. This policy, revised April 2022, stated, . 6. Proper steps for identification of medication and identification of resident should be carried out each time medications are administered. Medications should not be pre-dished for future medication passes. Review of Resident #3's medical record occurred on 05/11/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing progress notes identified the following: * 04/13/22 at 10:51 p.m., Resident was administered incorrect medications. Phone call placed to [Provider Name], on call NP [nurse practitioner]. directed to call poison control. Poison control directed to send to ER [emergency room ] immediately. 911 called for transfer to [Hospital Name]. VS [vital signs] obtained, stable at this time. Resident AOX3 [alert oriented times three], baseline at this time. Updated [Provider Name] on transfer. Updated [power of attorney] via phone of incident and transfer, verbal okay to hold bed and transfer. Medications administered not ordered for resident: [MEDICATION(S)] [anti-psychotic medication] 400 mg [milligram], [MEDICATION(S)] [anti-[CONDITION(S)] medication] 1000 mg, [MEDICATION(S)] [anti-psychotic medication] 600 mg. Stable at discharge from facility. Report given to ER nurse at [Hospital Name]. * 04/14/22 at 10:33 p.m., [Name] from [Hospital Name] called. EKG's [electrocardiogram shows electric signals in the heart] done throughout the night resident is stable and is projected to return tomorrow. * 04/15/22 at 12:25 p.m., Spoke with [POA Name] this a.m. re: the incident on the 13th. Answered questions she had about the incident and discussed [Resident #3's] current condition. Review of Resident #3's hospital history and physical (H&P) occurred on 05/11/22. This H&P, dated 04/13/22, stated, . presented to the ER of our facility today after accidental ingestion of another patient's medications. Patient was given another patient's medications including 400 mg of [MEDICATION(S)], 1 g [gram] of [MEDICATION(S)] and 600 mg of [MEDICATION(S)]. Patient was also given his nighttime medications including [MEDICATION(S)] [supplement for sleep], [MEDICATION(S)] [antidepressant], [MEDICATION(S)] [antidepressant], potassium chloride [potassium supplement] and [MEDICATION(S)] [antidepressant]. Patient seen and examined in the ER. Patient very somnolent [drowsy]. Responds to verbal command however immediately goes back to sleep therefore no history could be obtained. In the ER patient's blood pressure was 108/59, respiratory rate 20, pulse 87, temperature 98 and O2 [oxygen] saturation 92% on room air. Labs were significant for potassium of 3.4 and BUN [blood urea nitrogen showing kidney function 7-20 normal range] of 24. EKG showing a normal sinus rhythm with nonspecific intraventricular conduction delay . Poison control was contacted and was advised to monitor the patient for 6 hours. Patient was given potassium chloride 20 mEq [milliequivalent] IV [intravenous] x1 and [MEDICATION(S)] 1 g IV x1 in the ER. Patient admitted for observation. Hospital physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] * 04/14/22 at 3:51 a.m., . Poison control called to follow-up with patients [sic] EKG. QRS was noted to be greater than 130 ms so they recommended 1 amp [ampoule] of [MEDICATION(S)] [[MEDICATION(S)] used to shorten QRS interval] to be given and repeat EKG to be obtained. Poison control recommended repeating EKG at 6 AM . * 04/15/22 at 11:00 a.m., . Starting to wake up but still somnolent; tolerated CLD [clear liquid diet] . * 04/16/22 at 10:30 a.m., . Improved alertness, mumbling . A physician discharge summary, dated 04/19/22 at 11:03 a.m., stated, . was admitted . due to acute [CONDITION(S)] in the setting of accidental polypharmacy. Condition on discharge stable. Review of the facility incident investigation report, dated 04/20/22 stated, MAII [medication aide two] pre-dished medications for Resident #3 and another resident. Accidentally gave the other resident's medications to Resident #3. MAII received corrective action with re-education on proper medication administration. Seven shift monitoring log will be completed to ensure re-education was understood. During an interview on 05/11/22 at 2:45 p.m., an administrative nurse (#2) agreed the MAII failed to follow facility policy by pre-dishing medications and not performing the five rights of medication administration prior to administering medications to Resident #3. Based on the following information, non-compliance at F760 is considered past non-compliance. The facility implemented the corrective action for the resident affected by the deficient by: * Educated the staff member involved in the error on 04/14/22 at 10:00 a.m. * Educated all staff who administer medications to residents on 04/15/22. * Extended the orientation period for travel medication aides from four hours to eight hours. * Updated the facility policy titled Medication Administration. * Began audits of medication administration on 04/18/22. The survey team determined deficient practice existed on 04/13/22. The facility implemented corrective action on 04/14/22, provided staff education on 04/15/22, and audited medication administration beginning on 04/18/22 through 05/28/22.