Alamo Nursing And Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure that residents received the necessary treatment and services consistent with professional standards of practice to promote healing when the facility failed to document wound care treatments for 1 of 2 (Resident #6) sampled residents reviewed for pressure ulcers. The findings include: 1. Review of the facility policy titled, Prevention of Pressure Ulcers/Injuries, dated 1/2020, revealed .The purpose of this procedure is to provide information regarding identification of pressure ulcers/injury risk factors and interventions for specific risk factors .Evaluate, report, and document changes in the skin. 2. Review of medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnosis including Pressure Ulcer Stage 3, Quadriplegia, Polyneuropathy, and Anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #6 was cognitively intact and was assessed for a Stage 3 Pressure Ulcer. Review of the Physician's Order dated 2/28/2026, revealed Tx [Treatment] : right buttock; Cleanse with DWC [Dermal Wound Cleanser], pat dry, apply collagen powder [used to stimulate tissue repair for wounds], flagyl [used to treat bacterial infections] and Alginate Calcium w/ [with] silver [antimicrobial dressing used to fight bacteria in wound care] to wound bed, skin prep [a clear, waterproof film to protect the skin] peri-wound area [skin around wound], cover with dry dressing. Change daily. Review of the Treatment Administration Record (TAR) dated December 2025, revealed that treatments were not documented as being completed on 12/5/2025, 12/9/2025, 12/23/2025, 12/24/2025 and 12/25/2025. Review of the TAR dated February 2026, revealed treatments were not documented as being completed on 2/12/2026, 2/13/2026 and 2/26/2026. Review of TAR dated March 2026, revealed treatments were not documented as being completed on 3/4/2026. During an interview on 3/11/2026 at 9:34 AM, the Director of Nursing (DON) was asked to verify the empty blanks for the buttock treatment on Resident #6's TAR. The DON reviewed the empty blanks on the TAR's. The DON was asked can you tell me if the treatments were done. The DON stated, I cannot.if the treatment was completed it should be on the TAR or documented in the progress notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to identify and eliminate all known and foreseeable accident hazards in the resident's environment for 1 of 3 (Resident #62) sampled residents reviewed for smoking. The findings include: 1. Review of the facility's policy titled, Smoking Policy-Residents, dated 10/18/2022, revealed .Any smoking-related privileges, restrictions, and concerns .are noted on the care plan .Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision . 2. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Hypertension, and Depression. Review of the Smoking Safety Evaluation dated 3/2/2026, revealed .Does Resident utilize tobacco .Yes .Supervision will be required for all Residents during designated smoking times. This evaluation will be utilized for the Resident's smoking care plan on admission and as indicated .Evaluation .Balance problems while sitting or standing .Follow the facility's policy on location and time of smoking . Review of the Baseline Care Plan dated 3/2/2026, revealed Smoking was not included. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #62 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was cognitively intact. Observation in the designated smoking area on 3/9/2026 at 4:07 PM, revealed the Staffing Coordinator was assisting residents during the smoking observation. Resident #62 was observed to have a pack of cigarettes in his front shirt pocket. Resident #62 then proceeded to pull a lighter from his front shirt pocket. The Staffing Coordinator lit Resident #62's cigarette with the lighter that he brought in. Resident #62 did not wear a smoking apron during the smoking session. CNA E asked Resident #62 if she could put his cigarettes and lighter in the facility lock box. Resident #62 stated, Yes. During an interview on 3/9/2026 at 4:28 PM, the Staffing Coordinator was asked if residents were allowed to keep cigarettes and lighter on them. The Staffing Coordinator stated, No, they are supposed to keep them locked up because if they kept them on them, they would probably smoke them. Review of the Care Plan dated 3/10/2026, revealed Resident smokes cigarettes .Apply smoking apron . During an interview on 3/10/2026 at 4:30 PM, the Director of Nursing (DON) was asked if any of the residents in the facility had independent smoking privileges. The DON stated, No, we don't have any independent smokers in the facility. The DON was asked If a resident is a smoker should that be on the care plan. The DON stated, Yes, it should be. The DON was asked if any resident should have cigarettes and lighter on their person. The DON stated, They should not . During an interview on 3/11/2026 at 11:40 AM, the DON was asked if residents should wear an apron during smoking if it is care planned. The DON stated, Yes but we do have refusals. The DON was asked if it should be documented in care plan that they refuse to wear the apron. The DON stated, Yes, it should.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored when medications were unsecure at the resident's bedside for 1 of 52 (Resident #52 ) and when 2 of 3 (South Hall and Central Supply) medication storage rooms had opened, undated, and expired medications in the medication storage rooms. The findings include: 1. Review of the facility's policy titled, Storage of Medications, dated 5/2015, revealed .nursing staff shall be responsible for maintaining medication storage.The facility shall not use.outdated.drugs or biologicals.drugs and biologicals shall be locked when not in use.such items shall not be left unattended. 2. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE], with diagnoses including Aphasia (a language disorder caused by brain damage), Atrial Fibrillation, Dysphagia (difficulty swallowing,) and Diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #52 did not have a Brief Interview for Mental Status (BIMS) assessment conducted due to the resident was rarely/never understood. Observation in Resident #52's room on 3/9/2026 at 9:13 AM, revealed a bottle of nasal mist spray and 2 bottles of lubricant eye drops on the residents beside table. Review of the current signed Physicians Orders revealed there was no order for the nasal mist spray or lubricant eye drops. During an observation and interview in Resident #52's room on 3/9/2026 at 9:17 AM, Licensed Practical Nurse (LPN) D confirmed that the bottle of nasal mist spray and 2 bottles of lubricant eye drops were left unattended in Resident #52's room on the bedside table. Nurse D was asked if nasal spray and 2 bottles of eye drops should be on the resident's bedside table. LPN D stated, No it should not. During an interview on 3/9/2026 at 9:23 AM, the Assistant Director of Nursing (ADON) was asked if Resident #52 should have nasal spray and eye drops on the bedside table, The ADON stated, .no he should not. During an interview on 3/11/2026 at 8:57 AM, the Director of Nursing (DON), was asked if a resident should have eye drops and nasal spray on the bedside table. The DON stated, .No it should not. The DON was asked where medications should be kept or stored. The DON stated, .medications should be kept at the nurse's station in a locked secure area . 3. During an observation and interview in the South Hall medication room on 3/11/2026 at 7:59 AM, revealed 1 opened and undated vial of Tuberculin (used to test for Tuberculosis skin test) in the medication refrigerator. Registered Nurse (RN) C was asked if the medication should be dated when opened. RN C stated, Yes. 4. During an observation and interview in the Central Supply Room on 3/11/2026 at 8:13 AM, revealed the following medications were expired. a. Calcium 600 milligram (mg) expiration (exp) date 2/2026 1 bottle b. Melatonin 3mg exp date 11/2025 1 bottle c. Melatonin 3mg exp date 3/2026 4 bottles RN C was asked if the above medications should have been discarded. RN C stated, Yes, prior to the expiration date. During an interview on 3/11/2026 at 9:28 AM, the DON was asked when do you expect medications to be discarded. The DON stated, by the expiration date. The DON was asked who is responsible for ensuring medications in the storage areas are within date. The DON stated, Our charge nurses are responsible for checking the medications in the storage rooms . The DON was asked should medication vials be dated with an opened date. The DON stated, Yes, ma'am.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of Center for Disease Control (CDC) guidelines, medical record review, observation, and interview, the facility failed to ensure the prevention and spread of infection during wound care and medication administration for 2 of 2 (Resident #6 and #14) sampled residents. The findings include: 1. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 10/2023, revealed .The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for Hand Hygiene .immediately before touching a resident; before performing an aseptic task [for example placing an indwelling device or handling an invasive medical device], after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching a resident's environment; before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal.Wash hands with soap and water; when hands are visibly soiled.Single use disposable gloves should be used: before aseptic procedures; when anticipating contact with blood or body fluids.The use of gloves does not replace hand washing/hand hygiene. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 9/2022, revealed .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA [Occupational Safety Health Administration] Bloodborne Pathogens Standard.Non-critical items are those that come in contact with intact skin but not mucus membranes.Non-critical environmental surfaces include bedside tables.Non-critical items require cleaning followed by either low or intermediate level disinfection following manufacturers' instructions. Disinfection is performed with an EPA [Environmental Protection Agency]-registered disinfectant labeled for use in healthcare settings . Review of the facility's policy titled, Administering Medications, dated 12/2012, revealed .Staff should follow established infection control procedures [.handwashing, antiseptic technique, gloves.] when these apply to the administration of medications. 2. Review of the CDC website article titled, Hand Hygiene For Healthcare Workers, dated 2/27/2024, revealed .Know when to wear [and change] gloves.Gloves are not a substitute for hand hygiene.If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings.Always clean your hands after removing gloves.When to change gloves and clean hands.If gloves become damaged. If gloves become soiled with blood or body fluids after a task. If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs.If they look dirty or have blood or body fluids on them after completing a task. Before exiting a patient room. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Pressure Ulcer Stage 3, Depression, Quadriplegia, and Anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. Resident #6 was dependent on staff to perform activities of daily living (ADLs) and was assessed for a Stage 3 facility acquired pressure ulcer. Review of the Physician's Order dated 2/28/2026, revealed Tx [Treatment] : right buttock; Cleanse with DWC [Dermal Wound Cleanser], pat dry, apply collagen powder [used to stimulate tissue repair for wounds], flagyl [used to treat bacterial infections] and Alginate Calcium w/ [with] silver [antimicrobial dressing used to fight bacteria in wound care] to wound bed, skin prep [a clear, waterproof film to protect the skin] peri-wound area, cover with dry dressing. Change daily. During an observation in the Resident's room on 3/10/2026 at 11:02 AM, revealed the Wound Physician present with Licensed Practical Nurse (LPN) A preparing to perform Resident #6's wound care. The Wound Physician performed hand hygiene, donned a gown, and 2 pair of gloves. LPN A placed a barrier on the over the bed table, donned a gown, performed hand hygiene, and donned sterile gloves. The Wound Physician removed his phone from his left pocket prior to initiating wound care. Then without changing gloves or performing hand hygiene, the Wound Physician removed the soiled dressing from the resident's right buttock, wiped the wound with dry 4x4 gauze, inserted the contaminated, gloved right index finger into the resident's wound bed, cleansed the wound with wound cleanser moistened gauze, measured the wound. The Wound Physician removed the top layer glove from his right hand and applied a skin graft to the wound bed. The Wound Physician removed his PPE (Personal Protective Equipment) and exited the resident's room. LPN A resumed Resident #6's wound care, LPN A applied Flagyl via (by way of) q-tip (cotton tip applicator) to the peri-wound edges and over the graft to wound. LPN A applied collagen powder to a bordered foam dressing and covered the wound and then applied skin prep to the peri-wound skin. LPN A discarded the sharps in the sharps container, removed PPE, performed hand hygiene, sanitized the over the bed table and bottles of cleanser with a sani wipe, and performed hand hygiene. The Wound Physician failed to perform proper hand hygiene during Resident #6's wound care. 4. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Anxiety, Diabetes Mellitus, and Depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #14 scored a 14 on the BIMS assessment, indicating she was cognitively intact, and was assessed as receiving insulin. Review of the Physician's Order dated 12/23/2025, revealed Lantus (long-acting insulin used to treat Diabetes) 70 units subcutaneous (under the skin) two times a day. During an observation and interview during medication administration on 3/10/2026 at 8:45 AM, revealed LPN B was on the [NAME] Hall Medication Cart preparing medication for Resident #14. LPN B obtained a Lantus insulin vial from the medication cart, cleansed the vial hub with an alcohol pad, and prepared an insulin syringe with 70 units. LPN B entered Resident #14's room and placed the insulin syringe and alcohol pad on the over the bed table without a barrier. LPN B donned gloves, cleansed Resident #14's abdomen with the alcohol pad and administered the Lantus 70 units subcutaneous. LPN B discarded the insulin syringe in the sharps container, removed her gloves and exited the resident's room without performing hand hygiene. LPN B was asked if she had completed all tasks related to Resident 14's medication administration. LPN B stated she was done. LPN B was asked if she should perform hand hygiene after the removal of gloves. LPN B stated, Yes. LPN B was asked if she should have placed the alcohol pad and insulin syringe on the over the bed table without a barrier prior to the administration of the medication. LPN B stated, No ma'am, it should have a barrier. During an interview on 3/11/2026 at 9:28 AM, the Director of Nursing (DON) was asked if staff should place medications on an over the bed table without a barrier during medication administration. The DON stated, No, ma'am. The DON was asked when do you expect staff to perform hand hygiene. The DON stated, Before entering the resident's room, exiting the room, before giving medications, if hands are visibly soiled, after performing procedure, and after the removal of gloves. The DON was asked should providers follow infection control measures when providing care to residents. The DON stated, Yes, they should follow infection control measures. The DON was asked if does double gloving replaces hand hygiene. The DON stated, No, ma'am. During an interview on 3/11/2026 at 12:58 PM, the Wound Physician was asked should you perform hand hygiene after the removal of a soiled dressing before performing clean technique dressing. The Wound Physician stated, No, that is why I had on 3 pairs of gloves. The Wound Physician was asked should double gloving replace the use of hand hygiene. The Wound Physician stated, Yes, I was already scrubbed in, and you want to keep as sterile as possible even though it is not a sterile procedure. The Wound Physician was asked about his phone being taken out of his pocket prior to starting the treatment. The Wound Physician stated, That's why I had on 3 sets of gloves so I could remove a pair of gloves after taking a picture of the wound. The Wound Physician was asked if he was familiar with the facility's infection control policies and procedures. The Wound Physician stated, Yes, I am.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure a medication administration rate of less than 5% (percent) when 1 of 4 nurses (Licensed Practical Nurse (LPN) B ) failed to sign out 19 out of 25 medications after administration for 2 of 2 sampled residents (Resident #30 and #39) observed during medication administration. This resulted in a medication administration error rate of 76%.
The findings include:
1. Review of the facility policy titled Administering Medications, dated 11/2017, revealed .The individual administering the medication is logged into the resident's EMR [Electronic Medical Record] the signature will be attached after giving the medication .As required .for a medication, the individual administering the medication will record in the resident's medical record .The signature and title of the person administering the drug .
2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Edema, Depression, Glaucoma and Pain.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that Resident #30 was cognitively intact.
Observation in Resident #30's room on 2/11/2025 at 8:21 AM, revealed Resident #30 was administered Trilogy ( asthma treatment), Iron (supplement), Gabapentin (nerve pain treatment), Tramadol (pain treatment), Gemtesa (overactive bladder treatment), Singular (asthma treatment), Meloxicam (arthritis treatment), Bethanechol (urinary retention treatment), Famotine (antacid), Duloxetine (anti-anxiety) Sertraline (anti-depression), Lansoprazole (intestinal ulcers), Mucus Relief, Topiramate (seizure treatment) and Olopatadine (itchy eyes treatment). LPN B did not sign the medications out before administering medications to the next resident.
3. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE], with diagnoses including Cerebral Vascular Disease, Lack of Coordination, Difficulty Walking, and Anxiety.
Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated that Resident #39 was cognitively intact.
Observation in Resident #39's room on 2/11/2025 at 8:15 AM, revealed Resident #39 was administered Amlodipine (high blood pressure treatment), Clopidogrel (prevent clotting), Aspirin (cerebral infarction treatment) and Labetalol (high blood pressure treatment). LPN B did not sign the medications out before administering medications to the next resident.
During an interview on 2/11/2025 at 9:34 AM, the Regional Nurse Consultant confirmed that medications should be signed out after they are administered.
During an interview on 2/12/2025 at 8:01 AM, the Director of Nursing confirmed that medications should be signed out right after they are administered.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored when a medication was left unattended in a resident's room for 1 of 1 sampled residents (Resident #37).
The findings include:
1. Review of the facility's policy titled storage of Medications, dated 5/2015, revealed .The facility shall store all drugs and biologicals in a safe, secure and orderly manner .Drugs shall be stored in an orderly manner in cabinets, drawers, carts .or holding area to prevent possibility of mixing medications .
2. Observation in the resident's room on 2/09/2025 at 9:55 AM, revealed Resident #37 had an unsecured Heparin Flush (to maintain patency of an indwelling intravenous catheter) syringe on the over the bed table on the unoccupied side of the room that was left unattended.
During an interview on 2/09/2025 at 3:02 PM, Licensed Practical Nurse (LPN) F was asked if the medication should have been left unattended at the bedside. He stated, .No, she no longer has the midline .
During an interview on 2/09/2025 at 3:07 PM, Registered Nurse (RN) G confirmed that the medication should not have been left unattended at the bedside.
During an interview on 2/12/2025 at 8:09 AM the Director of Nursing (DON) confirmed that medications should not be left unattended at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Centers for Disease Control guidelines, policy review, record review, observation, and interview, the facility failed to ensure infection control practices to prevent the spread of infection when 1 of 4 (Licensed Practical Nurse (LPN) A) staff failed to perform hand hygiene during medication administration and when 2 of 2 (Certified Nurse Assistants (CNA) D and (CNA) E) failed to wear Personal Protective Equipment (PPE) during a transfer of a resident on Enhanced Barrier Precautions.
The findings include:
1. Review of the Centers for Disease Control (CDC), Clinical Safety: Hand Hygiene for Healthcare Workers, revealed .Clinical Safety: Hand Hygiene for Healthcare Workers .CDC provides the following recommendations for hand hygiene in healthcare settings .Know when to clean your hands .Immediately after glove removal .
Review of the facility's policy titled, Enhanced Barrier Precautions, dated August 2022, revealed .Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .Gloves and gown are applied prior to performing the high contact resident care activities (as opposed to before entering the room) .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .transferring .device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator .wound care (any open skin requiring a dressing) . EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .
Review of the facility's policy titled, Handwashing/Hand Hygiene, dated October 2023, revealed .This facility considers hand the primary means to prevent the spread of healthcare-associated infections .All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, visitors .Hand hygiene is indicated .after contact with blood, body fluids, or contaminated surfaces .immediately after glove removal .The use of gloves dose not replace hand washing/hand hygiene .
2. Observation at the North Medication Cart on 2/10/2025 at 3:14 PM, revealed LPN A entered Resident #213's room and failed to perform proper hand hygiene before and after administering medications.
Observation at the [NAME] Medication Cart on 2/11/2025 at 3:19 PM, revealed LPN A entered Resident #113's room and did not perform hand hygiene between donning and doffing of gloves.
During an interview on 2/11/2025 at 3:38 PM LPN A was asked if she should have done hand hygiene between glove changes. LPN A stated, .yes .
During an interview on 2/12/25 at 8:00 AM, the Director of Nursing (DON) confirmed the staff should perform hand hygiene between donning and doffing of gloves.
3. Review of medical record revealed Resident #113 was admitted on [DATE], with diagnoses including, Bladder-neck obstruction, Gastrostomy status, Retention of urine, and Aphasia.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident #113 was moderately cognitively impaired.
Review of the Physician's Order dated 2/6/2025, revealed Enhanced barrier precautions related to peg tube every shift.
Review of the Physicians Order dated 2/8/2025, revealed Enhanced barrier precautions related to foley catheter.
A random observation in Resident #113's on 2/11/2025 at 9: 45 AM, revealed CNA E entered Resident #113's room and failed to put on a gown and failed to perform hand hygiene before donning gloves. CNA D was observed in the resident's room holding the resident's catheter bag in her gloved hand but did not have on a gown. CNA E left the resident's room with gloved hands and entered another resident's room with the same gloves on and returned to the resident's room with a gait belt. CNA E failed to remove the gloves and perform hand hygiene before exiting the room and failed put on a gown. CNA E placed and secured the gait belt around the resident's waist. CNA D continued to hold the resident's catheter bag without a gown while CNA E and C NA D transferred the resident to another wheelchair. CNA E took the catheter bag and placed it inside a black plastic catheter bag cover and then placed it on the lower part of the resident's wheelchair. CNA D failed to remove gloves, perform hand hygiene and put on a gown before connecting the resident's peg tubing to peg site and turning on the feeding pump. CNA D exited the room and failed to remove the gloves and perform hand hygiene. CNA E failed to remove gloves and perform hand after handling the resident's catheter bag and preceded to place the resident's bed pillow on the head on the bed, and pulled the resident's bed covers from the end of bed. CNA E removed gloves, failed to perform hand hygiene before exiting the resident's room.
During an interview on 2/12/2025 at 8:41 AM, the Infection Control Preventionist (ICP) confirmed staff should wear a gown and gloves when transferring a resident who is on Enhanced Barrier Precautions. The ICP confirmed staff should remove gloves and perform hand hygiene after touching potentially contaminated items. The ICP confirmed staff should not exit a resident's room with gloved hands on and enter another resident's room with same gloved hands, and staff should remove gloves and perform hand hygiene before exiting a resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided related to showering for 2 of 2 sampled residents (Resident #39 and #114) reviewed for ADLs.?
The findings include:
1. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, dated 03/2018, revealed .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .?
2. Medical record revealed Resident #39 was admitted to the facility on [DATE], with diagnoses including Cerebral Vascular Disease, Lack of Coordination, Difficulty Walking, and Anxiety.
Review of the care plan dated 8/26/2022, revealed Resident bathing preference fluctuates but prefers daytime bath.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that Resident #39 was cognitively intact. Upper impairment on one side and both lower sides impaired. Uses wheelchair for mobility.
Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated that Resident #39 was cognitively intact. Substantial to maximal assist needed for shower/bath. Impairment on both lower extremities.
Review of the task: Documentation Survey Report . dated November 2024, revealed .ADL-BATHING Resident preference is to have a whirlpool twice a week and bed bath 5 times a week . Resident #39 did not receive a bath 11/4/2024, 11/7/2024, 11/9/2024, 11/12/2024, 11/13/2024, 11/14/2024, 11/18/2024, 11/19/2024, 11/21/2024, 11/27/2024 and 11/27/2024.
3. Medical record revealed Resident #114 was admitted to the facility 12/6/2022, and readmitted [DATE], with diagnoses including Spinal Stenosis, Congestive Heart Failure, Anxiety and Depression.
Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated Resident #114 was cognitively intact. The Resident was dependent on staff for bathing.
Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated Resident #114 was cognitively intact. Resident was dependent on staff for bathing.
Review of the task: Documentation Survey Report . dated November 2024, revealed .ADL-BATHING resident preference is to have a whirlpool twice a week and bed bath 3 times a week . Resident #114 did not receive a bath or shower 11/3/2024 11/7/2024, 11/10/2024, 11/21/2024, 11/23/2024, 11/26/2024 and 11/30/2024.
During an interview on 2/12/2025 at 8:11 AM, the Director of Nursing (DON) confirmed that Residents should be receiving a bath of some sort daily or documented if it is refused.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to ensure a resident was provided Oxygen consistent with professional standards of practice when the facility failed ensure an order for the continued use of Oxygen and failed to monitor and document the effectiveness of the Oxygen, for 1 of 2 resident (Resident #41) sampled for Oxygen.
The findings include:
1. Review of the facility's policy titled, Oxygen Administration, dated 4/2014, revealed .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration .Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following as applicable .Oxygen tubing should be replaced weekly as well as humidifier bottles if not already replaced. It should be labeled with a resident identifier and date .After completing the oxygen setup or adjustment, the following information may be recorded in the resident's electronic medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow and route. 4. The reason for p.r.n. (as necessary) administration. 5. Any assessment data obtained before, during, and after the procedure if applicable
2. Medical record revealed Resident # 41 was admitted to the facility on [DATE], with diagnoses including of Chronic Obstructive Pulmonary Disease, Anxiety, and Peripheral Vascular Disease.
Review of the annual Minimum Data Set, dated [DATE], revealed a Brief Interview for Mental Status score of 15, which indicated Resident #41 had intact cognition.
Review of the Physician Orders revealed Resident #41 had no order for Oxygen(O2).
Observation in Resident #41's room on 2/10/2025 at 9:40 AM, at 4:51 PM, and 1:47 PM on 2/12/2025 at 8:49 AM, revealed the resident had O2 via nasal canula at 3 Liters.
Observation on 2/10/2025 at 1:52 PM revealed the O2 tubing was on Resident #41's dresser, not in a bag.
Observation on 2/11/2025 at 4:20 PM revealed the O2 tubing was on the resident's bed, not in a bag.
During an observation and interview on 2/12/2025 at 8:55 AM, Practical nurse (LPN H) entered confirmed Resident #41's room and confirmed the resident had O2 via nasal canula set on 3 Liters. LPN H confirmed no awareness Resident #41 received O2, looked in the computer and confirmed Resident #41 had no order for the O2.
During an interview on 2/12/2025 at 9:46 AM, the Director of Nursing was asked about orders for Oxygen. The DON stated, .the order should be in the computer .should be monitored . be on the MAR [medication administration record] .checking the O2 sat [saturation] to make sure right amount of O2 . The DON confirmed Resident #41 did not have an order in the computer for Oxygen use, and Resident O2 saturation was not monitored to ensure adequate amount of O2 was delivered to maintain acceptable safe levels.

Based on policy review, observation, and interview, the facility failed to ensure that medication records were in order and that an account of all controlled medications were maintained and reconciled for 1 of 3 Medication Carts (North Medication Cart) medication carts.
The findings include:
1. Review of the facility policy titled Administering Medications, dated 11/2017, revealed .The individual administering the medication .the signature will be attached after giving the medication .As required .for a medication, the individual administering the medication will record in the resident's medical record .The signature and title of the person administering the drug .
2. Observation and interview at the North Medication Cart on 2/11/2025 at 8:52 AM, revealed Licensed Practical Nurse (LPN) B was asked to review Resident #5's narcotics. Review of the NARCOTIC INVENTORY SHEET for Resident #5 revealed, .Tramadol [for pain] 50 MG [milligrams] .Doses Left .2 . Review of Resident #5's narcotic card revealed 1 tablet remained. LPN B was asked about the difference in the number remaining, I did not sign it out she confirmed it should have been signed out when it was administered.
Observation and interview at the North Medication Cart on 2/11/2025 at 8:55 AM, revealed Licensed Practical Nurse (LPN) B was asked to review Resident #11's narcotics. Review of the NARCOTIC INVENTORY SHEET for Resident #11 revealed, .Gabapentin [for nerve pain] 300 MG [milligrams] .Doses Left .3 . Review of Resident #11's narcotic card revealed 2 tablets remained. LPN B was asked about the difference in the number remaining, I did not sign it out she confirmed it should have been signed out when it was administered.
Observation and interview at the North Medication Cart on 2/11/2025 at 8:58 AM, revealed Licensed Practical Nurse (LPN) B was asked to review Resident #24's narcotics. Review of the NARCOTIC INVENTORY SHEET for Resident #24 revealed, .Lorazepam [for anxiety] 0.5 MG [milligrams] .Doses Left .8 . Review of Resident #24's narcotic card revealed 7 tablets remained. LPN B was asked about the difference in the number remaining, I did not sign it out she confirmed it should have been signed out when it was administered.
During an interview on 2/11/2025 at 9:34 AM the Regional Nurse Consultant confirmed that narcotics should be signed out in the narcotic book after they are administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to ensure a resident's medication regimen was free of unnecessary medications when the facility failed to ensure as needed (prn) psychotropic medications were discontinued after 14 days, failed to ensure monitoring related to the use of an anticoagulant (blood thinner), and failed to follow a provider's order for 1 of 5 residents (Resident #6) sampled for unnecessary meds.
The findings include:
1. Review of the facility's undated policy titled, Psychotropic Medication Use, revealed .A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior .Anti-anxiety medications; and .PRN orders for psychotropic medications are limited to 14 days .For psychotropic medications that ARE antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication .
Review of the facility's policy titled, Anticoagulation - Clinical Protocol, dated 2/2014, revealed .The staff and physician will identify and address potential complications .The staff and physician will monitor for possible complications .
2. Review of the medical record revealed Resident # 6 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Kidney Disease, Atherosclerotic Heart Disease, Anxiety, and Depression.
Review of the annual Minimum Date Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated Resident #6 had severe cognitive impairment and received antidepressants, and antianxiety medications.
Review of the Physicians Order dated 10/17/2024, revealed Eliquis [an anticoagulant-blood thinner] Oral Tablet 5 MG [milligrams] (Apixaban) Give 1 tablet by mouth two times a day for PVD [Peripheral Vascular Disease].
Review of the Physician Order dated 11/10/2024, revealed Promethazine [medication for nausea and vomiting] HCl Oral Tablet 25 MG (Promethazine HCl) Give 25 mg by mouth every 8 hours as needed for nausea/vomiting. The as needed Promethazine order had no end date.
Review of the Physician Order dated 11/18/2024, revealed Ativan [an antianxiety medication] Oral Tablet 0.5 MG (Lorazepam) .Give 0.5 mg by mouth every 4 hours as needed The as needed order for Ativan had no end date.
Review of a Pharmacist Communication/Recommendation sheet revealed [named Provider] signed and dated to discontinue Promethazine (a medication used for nausea and vomiting) on 2/4/2025.
During an interview on 2/12/2025 at 10:10 AM, the Director of Nursing (DON) confirmed Resident #6 had an as needed (prn) order for Ativan dated 11/18/2024 with no end date. The DON confirmed a review of the facility's policy would be necessary before questions related to the as needed order for Ativan could be answered. The facility failed to discontinue the prn psychotropic medication order after 14 days and failed to present documented rationales for the continued use of the prn psychotropic medication. The DON confirmed the facility failed to monitor Resident #6 for bleeding and bruising related to the use of Eliquis and it should have been completed every shift. The DON confirmed the facility failed to discontinue Promethazine as ordered by the provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to honor a resident's preferences for bathing for 1 of 1 sampled resident (Resident #35) reviewed for choices.
The findings include:
1. Review of the facility's policy titled, .Resident Rights Policy, dated 11/2016 revealed .The nursing home shall establish .implement .the rights of residents .preservation of dignity, individuality .must treat each resident with respect and dignity and care for each resident in a manner .that promotes .enhancement of his or her quality of life, recognizing each resident's individuality .
2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE], with the diagnoses of Non-Traumatic Brain Dysfunction, Hypertension, and Alzheimer's Disease.
Review of the Quarterly Minimum Date Set dated 2/8/2024, revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment with no behaviors exhibited. The resident did not reject evaluation or care. Functional Limitation in Range of Motion showed no impairment.
Review of the Care Plan dated 2/12/2024, for Resident #35 revealed, ADL [activities of daily living] limitations r/t [related to] functional and cognitive factors such as dx [diagnoses] of Alzheimer's ds [disease] with dementia, memory disturbances, need for assist with ADL's, psychotropic meds. Resident has a tendency to wear clothes multiple days in a row and refuses to allow staff to take to laundry at times. Bathing: Prefers shower or sponge bath in early morning. Requires up to extensive assistance with bathing task. Personal Grooming: Provide limited to extensive assistance .
Review of the undated document titled, .NORTH BATH/SHOWER/WHIRLPOOL LIST, revealed Resident #35 was to receive showers on Mondays, Wednesdays, and Fridays.
Review of the facility's report titled, .Documentation Survey Report . revealed Resident #35 did not receive a shower on 1/1/2024, 1/3/2024, 1/8/2024, 1/10/2024, 1/12/2024, 1/15/2024, 1/17/2024, 1/19/2024, 1/22/2024, 1/26/2024, 1/29/2024, and 1/31/2024 on his scheduled days in January.
Review of the facility's report titled, .Documentation Survey Report . revealed Resident #35 did not receive a shower on 2/2/2024, 2/5/2024, 2/7/2024, 2/9/2024, 2/12/2024, 2/16/2024, 2/19/2024, 2/21/2024, and 2/23/2024 on his scheduled days in February.
Review of the facility's report titled, .Documentation Survey Report . revealed Resident #35 did not receive a shower on 3/4/2024, and 3/6/2024. Resident #35 did not receive his shower on his scheduled days in March.
Observations in Resident #35's room on 3/11/2024 at 8:48 AM, revealed the bed was in low position, resident was dressed and resting in bed. At 1:55 PM, the resident was in the bed and appeared to be asleep.
During an interview on 3/11/2024 at 3:21 PM, Resident #35 was asked about bathing and showers, Resident #35 confirmed that he gets 1 shower a week, and he would prefer them daily.
Observations on 3/13/2024 at 8:23 AM, revealed Resident #35 said he received a shower yesterday and he was mad cause they took his jeans to wash. He confirmed he only has one pair.
During an interview on 3/15/2024 at 9:45 AM, Certified Nursing Aide (CNA)#2 was asked should CNA's follow the shower schedule. CNA # 2 stated, Yes .we are supposed to document the reason they did not get a shower and we are to report it to the nurse .
During an interview in the Central Supply room on 3/15/2024 at 11:05 AM, Certified Nursing Assistant (CNA) #1/Staffing Coordinator confirmed that if a resident is on the list for a shower on Monday, Wednesday, and Friday they should be getting one. She was asked that if a resident wanted a shower 5 days a week should they be able to get one. CNA #1 stated, Yes. She was asked if a resident refused, should there be documentation. CNA #1 stated, The nurse should document something in the progress note .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to convey the funds to the estate of a deceased resident within the 30 days requirement for 1 of 2 (Resident #322) residents reviewed for personal funds account.
The findings include:
1. Review of the facility's policy titled, Refunds, dated 12/2006, revealed .within thirty (30) days of a resident's death, the facility will provide the resident's personal funds and a final accounting of those funds to the resident's representative or to the probate administering the resident's estate .
2. Review of the medical record revealed Resident #322 was admitted to the facility on [DATE] with diagnoses of Alzheimer's, Depression, Anxiety, and Dysphagia.
Review of the facility's Discharge Summary, dated 1/2014, revealed Resident #344 expired on [DATE]. The refund check reimbursement was issued on [DATE].
The refund was 93 days after the resident expired.
During an interview on [DATE] at 2:34 PM, the Receptionist was asked for a copy of a refund check to the estate of a deceased resident. The Receptionist stated, I have [named Resident #322] oh, but hers was held up. Let me find you another one that was refunded . The Receptionist was asked what the timeframe for the check is to be refunded to the estate after a death. The Receptionist stated, .I have to wait until corporate sends me the ok to send one out .usually within one to two weeks, sometimes takes longer .as for a certain amount of time to get them out, I don't know anything about that .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide information regarding residents' right to formulate an advanced directive for 6 of 24 (Resident #22, #28, #29, #52, #62 and #270) sampled residents reviewed for advance directives.
The findings include:
1. Review of the facility's policy titled, Advanced Directives dated 10/2022, revealed .The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment .prior to or upon admission of a resident .the resident or representative is provided with written information .and to formulate an advance directive if he or she chooses to do so .the facility will offer assistance in establishing advance directives .
2. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease, Anxiety, Dysphagia, Diabetes, Traumatic Subarachnoid Hemorrhage, and Seizures.
Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #22 had severe cognitive impairment.
Review of Resident #22's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his legal representative was informed of/or provided written information regarding his right to formulate an advanced directive. During the survey the facility provided an advance directive document that was dated 3/12/2024.
3. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Pain, Diabetes, Anxiety, and Anemia.
Review of the quarterly MDS dated [DATE], revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment.
Review of Resident #28's medical record revealed an advanced directive dated 5/25/2021, with neither the yes or no circled, and had no signature.
4. Review of the medical record revealed Resident #29 was admitted on [DATE], with diagnoses of Atrial Fibrillation, Hypertension, Anxiety Disorder, and Depression.
Review of the quarterly MDS dated [DATE], revealed Resident #29 had a BIMS score of 13 which indicated she was cognitively intact.
Review of Resident #29's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his legal representative was informed of/or provided written information regarding his right to formulate an advanced directive.
5. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE], with diagnoses of Spinal Stenosis, Osteoarthritis, Anxiety, Urinary Retention and Depression.
Review of the annual MDS dated [DATE], revealed Resident #52 had a BIMS score of 9 indicating the resident had moderate cognitive impairment.
Review of Resident #52's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his legal representative was informed of/or provided written information regarding his right to formulate an advanced directive.
6. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Insomnia, Dementia, Anxiety, Atrial Fibrillation, and Diabetes.
Review of the quarterly MDS dated [DATE], revealed Resident #62 had a BIMS score of 14, which indicated he was cognitively intact.
Review of Resident #62's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his legal representative was informed of/or provided written information regarding his right to formulate an advanced directive.
7. Review of the medical record revealed Resident #270 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease, Seizures, Anxiety, Depression, and Dementia.
Review of the annual MDS dated [DATE], revealed Resident #270 had a BIMS score of 6, which indicated he had severe cognitive impairment.
Review of Resident #270's medical record revealed there was no advance directive and there was no documentation that upon admission the resident or his legal representative was informed of/or provided written information regarding his right to formulate an advanced directive.
8. During an interview on 3/15/2024 at 10:57 AM, the Administrator was asked when an advance directive should be completed. The Administrator stated, On admission and the Administrator confirmed the advance directives were not completed until during the survey on 3/12/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation and interview the facility failed to meet Professional Standards of Quality when Registered Nurse (RN #1) prepared medications for administration and Licensed Practical Nurse (LPN #1) administered the medications to the residents.
The finding include:
1. Review of the facility's policy titled Administering Medications, dated December 2012 revealed .Medications shall be administered in a safe and timely manner .The individual administering medications must check the label to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication .As required or indicated for a medication, the individual administering the medication will record in the resident's medical record .the date and time the medication was administered . The signature and title of the person administering the drug .
Review of the facility's policy titled, Administering Medications dated December 2012, revealed .Medications must be administered in accordance with the orders, including any required time frame .Medications must be administered within one (1) hour before .or within one (1) after their prescribed time .
Review of Understanding the Basics of Medication Administration, revealed, .Proper preparation and medication administration .Although there may be instances in which more than one healthcare provider may be required to administer a single medication, such as in a code, it is not generally acceptable practice to prepare any type of medication for another person to administer. Nor is it acceptable practice to administer a medication that another has prepared. The reasons for this strict rule are numerous. First and foremost, because preparation and administration are fraught with potential for error, relying on another nurse to prepare a medication that you administer is dangerous at best . Understanding the basics of medication administration | Nurse.com
2. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses of Dementia, Diabetes, Chronic Kidney Disease and Depression.
Review of the quarterly MDS dated [DATE] revealed Resident #19 had a BIMS score of 12, which indicated moderate cognitive impairment.
Review of the Medication Administration Record (MAR) for March 2024 revealed that Resident #19 had the following medications scheduled at 8:00 AM and were signed out by RN #1:
a. LEVOTHYROXINE (for hypothyroidism) 75 mcg (micrograms)
b. Aspirin Tablet (for Heart Disease) 81 mg (milligrams)
c. FUROSEMIDE (diuretic) 40 mg
d. Glycol Powder (used for constipation) 17 grams
e. Lantus Subcutaneous Solution (to lower blood glucose) 5 units Subcutaneous Injection
f. Losartan Potassium (to lower blood pressure) 25 mg
g. Potassium CL (Chloride) ER (Extended Release) (used for low potassium) 20 MEQ milliequivalent)
h. Carvedilol (used to lower blood pressure) 3.125 mg
i. OXYCODONE .(for pain) .325 mg.
Observations on the [NAME] Hall on 3/13/2024 at 09:27 AM, RN #1 was pulling medications from the medication cart and then handing the mediations to LPN #1 to administer the medications to Resident #19. LPN #1 went in the room with medication cup full of pills and syringe to administer medications while RN #1 started gathering medications for the next resident.
Observations on the [NAME] Hall on 3/13/2024 at 9:36 AM, RN #1 and LPN #1 were at the medication cart. LPN #1 walked away to wash her hands and had her back to RN#1, not observing RN #1 pulling medications.
During an interview on 3/13/2024 at 9:45 AM, RN #1 was asked How do you know the resident is receiving the medications. [Named LPN #1] stated, She tells me, and I trust her.
During an interview on 3/13/2024 at 9:47 AM, LPN #1 was asked, How do you know the medications you are administering are for the correct resident. LPN #1 stated, I watch her. I told her that I observed her go into the resident's room and that RN #1 started pulling medications for the next resident. LPN #1 then stated, I trust her. I then asked who was signing the medications out on the MAR. RN #1 stated she is the one signed into the Electronic Medical Record [EMR], so she is signing them out since she is logged in. I asked if this was common practice and they both stated it was not. They said they were short staffed and to make medication pass faster, since they are not used to passing medications, they would do it together .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure fall interventions were implemented for 1 of 4 (Resident #7) sampled residents reviewed for accidents. The facility's failure to implement a fall intervention resulted in Actual Harm when Resident #7 had a fall that resulted in a head laceration [a deep cut] and was sent to the Emergency Room.
The findings include:
1. Review of the facility's policy titled, Assessing Falls and Their Causes, dated 10/2010, revealed .After a Fall .If a resident has just fallen, or is on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities .If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid .Nursing staff will observe for delayed complications of a fall after an observed or suspected fall, and will document findings in the medical record .An incident report must be completed for resident falls .
Review of the facility's policy titled, Neurological Assessment, dated 10/2010, revealed .The purpose of this procedure is to provide guidelines for a neurological assessment .upon physician order .when following an unwitnessed fall .subsequent to a fall with a suspected head injury .when indicated by resident condition .Perform neurological checks with the frequency as ordered or per falls protocol .
2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses of Dementia, Osteoporosis, Glaucoma, Anxiety, and Diabetes.
Review of the Annual Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment, and 2 or more falls with no injuries.
Review of the Fall Risk assessment dated [DATE], revealed Resident #7 was a high risk for falls with a score of 24.
Review of the medical record revealed Resident #7 had 5 falls from 5/8/2023 through 7/13/2023 with no documented injuries.
Review of the Quarterly MDS dated [DATE], revealed Resident #7 had a BIMS score of 5, which indicated the resident had severe cognitive impairment.
Review of the Care Plan dated 10/27/2023, revealed .Falls; risk for related to history of falls, dementia, osteoarthritis, osteoporosis, confusion, psychotropic medication use, muscle weakness, incontinence, cardiac dx [diagnosis], tendency to get up unassisted at times and remove non skid socks, refuse to use call light for assistance at times, and tends to hold on to furniture when ambulating instead of walker .
Review of the Incident Note dated 11/7/2023 at 11:10 PM, revealed Notified to the resident's room by aide. Resident sitting on the floor between the wheelchair and the front of the toilet. Wheelchair not locked. Resident back to left side of toilet wall legs stretched out in front of her with feet touching the opposite wall. Resident alert and oriented to person, place, and time [The MDS indicated the resident had severe cognitive impairment]. Resident complaining of left arm pain. Head to toe assessment done. Knot to back of head noted upon initial assessment. This nurse with another aide used gait belt to assist resident back in wheelchair to get resident back in the bed. Further assessment showed redness to lower resident back and skin tear to left forearm. Neuro checks initiated. Cleaned area with Dermal wound cleanser, applied TAO [triple antibiotic ointment, used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns] and bandage. On call notified. RP [Responsible Party] [named daughter] called x [times] 3 no answer. [Named daughter] called .very grateful to be notified and wants mother to be watched but not sent out to hospital. Intervention 30 min.[minute] visual check-initiated times 3 days .
There was no documentation the facility implemented other interventions after the 3 days of every 30 minute checks were completed.
Review of the Incident Note dated 1/10/2024 at 12:30 AM, revealed Notified to the room by staff. Resident noted sitting on the restroom floor back against the wall to the right of the toilet, legs stretched out in front of her with brief down to her knees. Toilet seat twisted toward her on the floor and wheelchair laying down. Head to toe assessment completed. Resident assisted on to the toilet then to wheelchair with gait belt and 2 person assist. This nurse and staff assisted resident on to the bed where this nurse completed another head to toe assessment. Bruises noted to bilateral lower legs, skin tear to left leg below the knee to the right. Skin tear cleansed, triple antibiotic ointment applied with band aid. Redness to the upper back no new open spots .[Named daughter] notified about incident. She thanked us for notifying her and asked could we increase monitoring her tonight since she is in isolation [Droplet precaution for 10 days related to Covid]. [Named Nurse Practitioner] called and notified of no anticoagulants [medication that prevent blood clots] taken and with order to start neuro checks. Neuro checks started. Fall precautions in place and being followed. Intervention increased level of observation every 30 min times three days. Resident encouraged to use call light when needing any assistance .
The interventions for this fall was to provide resident checks every 30 minutes for 3 days and to encourage resident (who has cognitive impairment) to use the call light.
Review of the quarterly MDS dated [DATE], revealed Resident #7 had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #7 had two or more falls with injury that were not major. Resident #7 received antianxiety, antidepressant, antibiotic, and hypoglycemic medications.
Review of the Incident Note dated 1/23/2024 at 6:15 PM, revealed This nurse was called to resident's room by CNA [certified nursing assistant]. Upon entering room, wheelchair noted in front of bathroom facing hallway. Resident lying on left side at the end of roommate's bed. Full skin assessment completed. Resident assisted to bed and vital signs obtained. Scattered bruising noted to bilateral arms, tx [treatment] remains in place .No complaints of pain or discomfort at his time. Resident noted to be drowsy. RP notified. DON [Director of Nursing] notified. MD [Medical Doctor] notified. MD notified of administration of Meclizine [med used for nausea, dizziness, and vertigo] due to resident complaining of dizziness. MD stated Meclizine can cause drowsiness .Staff educated to assist resident back to bed after administration of Meclizine. One on one supervision for the half-life [half-life of Meclizine is 6-8 hours] of medication after administration to assess for side effects such as drowsiness.
There was no documentation the intervention of 1:1 monitoring for the half-life of the Meclizine was implemented for Resident #7.
Review of the Incident Note (for the 2/18/2024 fall) dated 2/19/2024 at 5:02 AM, revealed CALLED TO RESIDENT'S ROOM BY CNA. OBSERVED RESIDENT FACE DOWN ON FLOOR BY HER BED WITH HEAD TOWARD BED A. HER HEAD WAS BY HER ROOMMATES W/C [wheelchair] WHEEL AND IT HAD BLOOD ON IT. SHE WAS BARE FOOT. HER PJ [pajama] BOTTOMS WERE DOWN AROUND HER THIGHS. HER BRIEF WAS DRY. HER SHEET WAS BY HER FEET/LEGS ON THE FLOOR. ROOM LIGHTS WERE OFF. ONLY LIGHT WAS HALL LIGHTS ILLUMINATING THE ROOM. FLOOR WAS DRY AND FREE OF ANY TRIPPING HAZARDS. RESIDENT'S W/C WAS BY HER NIGHT STAND AND OUT OF THE WAY. BED ALARM DID NOT SOUND AND CNA DISCOVERED THAT THE ALARM SWITCH IN THE HALLWAY WAS TURNED OFF, SO STAFF WAS NOT ALERTED TO RESIDENT GETTING OOB [out of bed]. THERE WAS A POOL OF BLOOD UNDER HER HEAD AND ALL IN HER HAIR. RESIDENT COULDN'T RECALL WHAT SHE WAS DOING WHEN SHE FELL. THIS CN [charge nurse] AND 3 CNAS, ASSESSED RESIDENT FROM HEAD TO TOE. ONLY INJURY OBSERVED WAS TO HER FOREHEAD. AT THAT TIME, WE PICKED UP RESIDENT AND MOVED HER ONTO HER BED. RESIDENT WAS TALKING AND C/O [complain of] HEAD REALLY HURTING. THIS CN AND AIDES CLEANED BLOOD FROM RESIDENT'S FACE AND HAIR & [and] NOTED A 3/4 [inch] INDENTED LACERATION TO FOREHEAD, JUST BELOW HAIRLINE, WITH A 2.5 AREA OF BRUISING AND SWELLING DEVELOPING AROUND THAT. APPLIED PRESSURE TO STOP BLEEDING. CLEANED WITH WOUND CARE SPRAY AND COVERED WITH A NON-STICK DRESSING. HAD CNA SIT WITH RESIDENT AND TAKE VITALS PER PROTOCOL. NEURO CHECKS WERE INITIATED. CONTACTED ON-CALL [named Nurse Practitioner] AND WAS GIVEN AN ORDER TO SEND RESIDENT TO ER [Emergency Room] FOR EVAL [evaluation] AND TX [treatment]. NOTIFIED RP/DAUGHTER .AND SHE STATED SHE WOULD MEET HER AT THE ER. NOTIFIED EMS [Emergency Medical Service] FOR TRANSPORT. NOTIFIED [named DON] ABOUT INCIDENT. INTERVENTION IS TO MAKE SURE RESIDENT HAS ON NON-SKID SOCKS AND TO VERIFY THAT ALARM IS ON AND WORKING PROPERLY EVERY SHIFT.
Review of the Care Plan revealed on 2/18/2024 the interventions of chair and bed alarm were implemented, and on 2/19/2024 the intervention of the wall alarm was implemented.
Review of the Emergency Department (ED) Triage assessment dated [DATE] at 10:48 PM, revealed . Brought by EMS [Emergency medical services] from SNF [Skilled Nursing Facility] for fall .was found in the floor, no one witnessed the fall. Pt [patient] unable to recall what happened. Head laceration noted. Pt complains of head pain .Upon arrival pt was in a fib w/ rvr [Atrial Fibrillation with rapid ventricular rate] .heart rate at 146 [beats per minute] .Orientation Assessment: Identifies self, Not oriented to situation .Primary Pain Location: Head .Moderate pain .Irregular Cardiac Rhythm : Atrial fibrillation . History of Falling Immediate or Within Last 3 Months : Yes .Mental Status Fall Risk Morse : Forgets limitations .Skin abnormality .Head .laceration .
Review of the ED Computerized Tomography (CT) Scan dated 2/18/2024 at 11:24 PM, revealed .IMPRESSION .No CT evidence for acute intracranial process or acute intracranial injury is identified. Some mild soft tissue swelling seen at the left forehead. Bones intact .
Review of the ED physician's Medical Screening Examination (MSE) documentation dated 2/18/2024 at 11:00 PM, revealed .The patient presents following fall .Preceding symptoms dizziness. Associated symptoms: Tachycardia. Additional history: Patient is DNR [Do Not Resuscitate] with comfort measures .Family was upset that she was even brought to the ER in the 1st place, as she is on comfort measures .Skin: Warm, dry, 3 centimeter laceration on left forehead .Crystalloid bolus [intravenous solution of water, salt, and minerals] given mild dehydration .Sutures refused. Steri-Strips applied to laceration on forehead. Family agreed to single dose of amiodarone for atrial flutter .Amiodarone bolus given with improvement of patient's heart rate .Okay for discharge back to nursing facility .
Review of the ED laboratory results dated [DATE], revealed, .BEDSIDE GLUCOSE: 275 mg/dL [milligrams per deciliter] -- Normal range between (70 and 110) .BUN (BLOOD UREA NITROGEN) [measures amount of urea nitrogen in the blood]: 45 mg/dL -- Normal range between (7 and 17) .LACTIC ACID [measures the level of lactic acid in the body made by muscle tissue and red blood cells]: 5.3 mEq/L [milliequivalents per liter] -- Normal range between (0.7 and 2.1) .TROPONIN I [measures damage to the heart] : 0.178 ng/mL [nanograms per milliliter]-- Normal range between (0.000 and 0.033) .
Review of the ED medical record revealed Resident #7 was discharged back to the nursing home on 2/19/2024 at 9:30 AM with the diagnoses of Accidental fall; Atrial flutter; Dementia; Elevated troponin; Forehead contusion; Forehead laceration.
Review of the significant change MDS dated [DATE], revealed Resident #7 had severe cognitive impairment. Resident #7 had one fall with injury. Resident #7 received antianxiety, antidepressant, opioid, and antibiotic medications.
Review of the care plan dated 3/7/2024 revealed ADL [Activities of Daily Living] limitations r/t cardiac dx, osteoporosis and osteoarthritis, muscle weakness, psychotropic medication use, occasional incontinence, pain, hx [history] of SOB [shortness of breath] with exertion, hx of falls, dependent on staff for ADL's .
Observations in Resident #7's room on 3/12/2024 at 4:57 PM, revealed a CNA in the resident's room trying to keep resident from getting out of bed. Resident #7 was saying, I want to get up .Get me up. The CNA would tell her you can't get up by yourself you might fall and break a bone. Then the roommate began to say she wanted to get up also. The CNA stayed in the room with them until the nurse came back with someone to assist them. The bed was in a low position and the alarm was on.
Observation in Resident #7's bathroom on 3/13/2024 at 8:53 AM, revealed Resident #7 was sitting on the toilet, no staff was present at the time, and no alarm was sounding.
During an interview on 3/12/2024 at 9:45 AM, the MDS Coordinator was asked about the decline Resident #7 has had. MDS Coordinator stated, .recently had a fall and since the fall had a decline in ADL function and cognitive status. She was made comfort measures. She could not answer questions like she used to .
During a telephone interview on at 3/13/2024 at 3:02 PM, LPN #4 stated, I work at least 2-3 days [during] the week. Whenever, I was doing 4-5 o'clock med pass, she [Resident #7] got Meclizine. It has side effect of drowsiness and after dinner she fell out of wheelchair frontwards. Her roommate called for help when she fell .They paged me to the room. No injuries .I believe the intervention was 1 on 1 for first hour after Meclizine given .
During a telephone interview on 3/13/2024 at 3:52 PM, LPN #3 was asked about Resident #7's fall on 2/18/2024. LPN #3 stated, I was working that night. She has alarms on the bed and hooked to the alarm on wall outside the room. So, we hear from bed and chair alarm. They did not go off that night someone had turned it off. It [fall] happened right as we got on shift. Within first hour or so when we got there. The alarm had not been checked and we come in on 7 PM, on weekends. We work 12 hours on weekends. Once they did rounds, I was doing med pass, aides sit on the hallway, and the CNA was sitting on the hall outside her door. I hear someone say help. I asked the CNA, said did you hear something, and CNA went to the door and found her on the floor. CNA said oh there is blood everywhere, she was facedown with a pool of blood around her head. She is sort of blind but can see shadows, checked BP [blood pressure] and turned her over, she wasn't answering questions like normal she was loopy, so we applied pressure to her head I felt all her joints and watched her facial expressions we picked her up on a sheet and put her on the bed. At that time, she was making a little more sense. A CNA got a cloth to wash her hair to see if she only had the one wound .one area on forehead, sent CNA to get [vital signs] and 1 CNA sat with her while I called the doctor. I don't remember her [CNA] name. Holding pressure to her head. I put a bandage on her head I knew she was going out. Order from physician. Waited on EMS, called RP, DON, EMS picked her up and took her to [NAME]. Yes, she is different since fall. She hollers more, seems to say she has Headaches, she doesn't want me to leave her room, wants someone to stay with her. She has declined cognitively and ADLs also a definite decline. One of the aides [CNA #6] peeked around the corner and said the alarm is turned off. It has to be manually cut off. So, we didn't hear her until she yelled help. We would have been in there if alarm had been on. We could hear them easily. When they start moving around, they go off. She is slow and not cognitive enough to use the call light, her roommate used the call light. [Named Resident #7] can't use call light.
During a telephone interview on 3/13/2024 at 4:21 PM, CNA #7 was asked about Resident #7's fall on 2/18/2024. CNA #7 stated, I did work that night with [named CNA #6 and CNA #8]. I was sitting by her door in hall, I guess someone on the 7a-7p [7:00 AM-7:00 PM] shift turned off the alarm. We didn't hear the alarm, we heard 'help' it was coming from [named Resident #7's] room I went running in there and there was blood on the floor, I yelled for [named LPN #3] told her she fell, and we tried to figure out why the alarm didn't go off. [Named CNA #6] said alarm was turned off. Nurse did [an] assessment, we tried to see how she hit her head; she hit her head on the roommate's walker, on [the] edge, we tried to get her up, put [her] in bed, and took vital signs. I was keeping her awoke [awake]. Did not return on our shift [after Resident #7 was transferred to the ED]. We usually hear her alarm. We were right by her door, she would never have fell if alarm had worked .
During an interview on 3/13/2024 at 4:48 PM, the DON was asked about the Resident #7's fall with the laceration on 2/18/2024. The DON stated, She had a fall early .when I got here Monday morning I started investigating and in the report it stated the alarm had been turned off. So, when I saw that, I went to the room myself to check alarm to see if it was malfunctioned. The bed alarm and the chair are both connected to the doorbell in hall. Then I went back to look at documentation to look into when .[the] last time she was changed, toileted, offered a snack, hydrated, anything in room that could cause fall. I checked the orders in PCC [Point Click Care- computer system program used by the facility] to see who all was on alarm orders, to see who all had alarms. Made sure they had an order and the nurse marks on MAR [Medication Administration Record] alarm is functioning. Made that an audit, to make sure that was being done. [Named Resident #7] returned between 10 and 11 AM [on 2/19/2024]. Her daughter was present at that time, her daughter was concerned with being comfort measures and sent out to ER anyway. I explained with a fall with an injury we called provider and they felt she needed to go out for treatment. Had sutures [steri strips] put in. After explaining why she was sent out per orders, she was better with it. ISNP [Institutional-Equivalent Special Needs Plan] is a [an] extra provider that oversees care with a resident. They round on resident couple times a week. We try to keep them in the loop. This was an emergent situation. I checked her vitals and made sure they had no other concerns. I then, on 2/21/2024, did in-service with nurses for incidents for appropriate documentation is captured so we could get whole picture. It was important for us to know. Important to check alarms at beginning of shift and throughout the shift. To get in habit of checking them not necessarily documenting it. Initially she was not herself, was more drowsy, not getting out of the room, or up in the wheelchair. But is back to more like herself, eating, drinking better. The alarm was properly working. It does manually have to be turned on and off. I did in-service on 2/21/2024 with nurses on that day I did verbally go over the in-service . and on the 2/19/2024 with the nurse on at the time of the fall, [Named LPN #3]. I feel like with the history of her falls we have really had to dig in, a huge factor is her vision and she is very quick when she gets up, the alarm is there to alert staff to get there much quicker to assist her. Can't say realistically that it would have prevented fall. Fell again last night, alarm was functioning, she got up out of bed, [Charge Nurse #2] found her sitting on floor on her bottom. Wheelchair was beside her to left and nightstand to the right of her she said she was going to bathroom putting her hand on nightstand to get in wheelchair it was not locked and appears wheelchair rolled. No immediate injury last night complained of left arm pain. Not aware of results x-ray was here this morning. Anti-tippers applied to wheelchair.
During a telephone interview on 3/13/2024 at 5:33 PM, CNA #8 was asked about the night Resident #7 fell and lacerated her head. CNA #8 stated, I was working on my shift. I don't remember times exactly. It was around 9 PM, we had 3 aids [CNAs] on the [NAME] Hall and 1 nurse on West. [Named CNA #6] and I walked to nurses' station to get a cannula for a resident .when we walked back on hall we saw LPN #3 walking quickly into [named Resident #7's] room and when we got up there, [Resident #7] was lying on the floor. One of the things I did was check bed alarm that was connected to box in the hall and it was turned off. We got vitals and cleaned her up and everything .If alarm had been on it would not have been a problem. It was the first thing I did was check alarm, we would have got to her in time. After the fall her head was hurting, her demeanor was not changed, but she was in pain. She does not get up as fast as she did, she still tries to get up. I have not noticed a change in cognition, I only work on the weekends. She has had falls prior to this, yes, that's why she has bed alarm. There was nothing on the floor she could have tripped over .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and observation, the facility failed to ensure a medication administration error rate of less than 5 percent (%) when 1 of 6 nurses (Licensed Practical Nurse (LPN) #1) failed to properly administer medications for 1 of 6 (Resident #37) sampled residents observed during medication administration with 12 errors out of 33 opportunities. This resulted in a medication administration error rate of 36.36 %.
The findings include:
1. Review of the facility's policy titled, Administering Medications dated December 2012, revealed .Medications must be administered in accordance with the orders, including any required time frame .Medications must be administered within one (1) hour before .or within one (1) after their prescribed time .
2. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE], with diagnoses of Atherosclerotic Heart Disease, Shortness of Breath, Depression, Cardiomegaly, and Angina.
Review of the Medication Administration Record for March 2024, revealed the following medications were to be administered at 8:00 AM:
a. BUSPIRONE HCL (used for anxiety) 15 MG (Milligrams).
b. HYDROCHLOROTHIAZIDE (for high blood pressure) 25 MG.
c. ISOSORBIDE MONO ER [Extended Release] (widens the blood vessels) 30 MG.
d. LOSARTAN POT [Potassium](for high blood pressure) 100 MG.
e. Ativan Oral Tablet (for anxiety) 0.5 MG.
f. FUROSEMIDE (treats fluid retention) 20 MG.
g. Gemtesa Oral tablet (for urinary Frequency) 75 MG.
h. Lactobacillus Capsule (used for diarrhea).
i. Potassium Tablet (treatment for low potassium) 10 mEq (milliequivalents).
j. Thera-M Tablet (Supplement for added nutrition).
k. CARVEDILOL (for high blood pressure) 6.26 MG.
l. Tylenol 8 Hour Arthritis Pain Tablet Extended Release (for pain) 650 MG.
Observations on 3/13/2024 at 9:52 AM, revealed LPN #2 administered the above listed medications approximately 52 minutes past the time frame for 8:00 AM medications to be administered by. Failure to administer medications timely in accordance with the facility policy and resulted in a medication error rate greater than 5%.