Kingswood Senior Living

Inspectors wroteBased on interview and record review, the facility failed to meet the medical needs of one sampled resident (Resident #1) out of four sampled residents, who admitted to the facility on [DATE] from the hospital with an indwelling foley catheter (a tube placed to drain the bladder). On 07/09/26, the resident's Urologist (medical doctor and surgeon specializing in diagnosing and treating conditions of the urinary tract) removed the indwelling foley catheter and ordered the resident to be monitored for urinary retention. The facility failed to document any monitoring for post void retention (PVR - urinary output) per policy and as ordered. The facility failed to timely assess the resident's change of condition when the resident had increased confusion, diarrhea with no evidence of urinary output and consult, or collaborate with the resident's medical durable power of attorney (DPOA). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the cleanliness of the floors around and under equipment in the main kitchen and around the counters in Satellite Kitchen #3; failed to ensure in the main kitchen the bins that contained dried items (sugar, flour, and cereal) did not have grime and debris on them; failed to ensure in Satellite Kitchen #3 there was not a black substance potentially mold in the juice machine around the tops of the juice nozzles, coffee debris around the coffee nozzles, and dried spills on both sides of the serving station walls. This practice potentially affected all residents. The facility census was 56 residents. The facility did not provide a sanitation policy. 1. Observation on 6/16/25 at 2:41 P.M., of the initial main kitchen showed the following: [...]

Inspectors wrote3. Review of Resident #5's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Moderate cognition impairment. -Required assistance from staff with his/her activities of daily living (ADL bathing, transfers, toileting, mobility). -No pain indicated. -Application of medications other than to feet. -Application of dressings to feet. Review of the resident's POS dated June 2025 showed: -Enhanced Barrier Precautions. -Wound treatment three times a week and as needed if dressing becomes soiled or if the dressing comes off. --Open area to mid back. Review of the resident's Medication Administration Record (MAR) dated June 2025 showed: -Calcium Alginate (brown seaweed and used in various applications due to its unique properties. [...]

Inspectors wrote2. Review of Resident #28's quarterly MDS dated [DATE], section N0415 showed: -The resident was taking an anticoagulant (medication that prevents the blood from clotting). -The resident was taking an antiplatelet (medication that prevents the platelets in blood from collecting and forming clots). Review of the resident's Medication Administration Record (MAR) dated 6/18/25, showed: -There were no orders for anticoagulant medications. -There were no orders for antiplatelet medications. - A physician's order, for Aspirin (nonsteroidal anti-inflammatory drug NSAID) 81 milligram (mg) tablet, delayed release enteric coated (EC a barrier to prevent the gastric acids in the stomach from dissolving or degrading drugs after you swallow them) once daily by mouth (po) for prophylaxis (as a preventative measure) dated 3/7/25. --This drug is an NSAID by class. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure weekly skin checks were completed and documented; failed to communicate new pressure injury to physician and dietician; failed to ensure that wound care treatments were in place, completed and documented, for one sampled resident (Resident #28) out of 14 sampled residents. The facility census was 56 residents. A review of the facility's policy titled Pressure Ulcer/Skin Breakdown Clinical Protocol dated April 2018 showed: -The nurse shall describe, document, and report the following: --Full assessment of pressure sore including location, stage, length, width, depth, presence of exudates or necrotic tissue. --Pain assessment. --Resident's mobility status. --Current treatments including support surfaces. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately treat pain for one sampled resident (Resident #163) who expressed pain out of 14 sampled residents. The facility census was 56 residents. Review of the facility's Pain policy and procedure dated October 2022, showed the physician and staff will identify individuals who have pain or who are at risk for having pain. Policy and procedures showed: -The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, when there is an onset of new pain or worsening of existing pain. -The staff will identify the characteristics of pain such as location, intensity, frequency, pattern and severity. -The nursing staff will identify any situations where an increase in pain may be anticipated; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure complete orders for dialysis (a medical procedure that filters and cleanses the blood of patients whose kidneys are not functioning properly), were on the Physician Order Sheet (POS) and documented in the care plan for one sampled resident (Resident #163) out of 14 sampled residents. The facility census was 56 residents. Review of the facility Dialysis policy and procedure dated February 2023, showed there was no documentation or procedure regarding physician's orders for residents who receive dialysis and what the physician's order should include. 1. Review of Resident #163's Face Sheet showed the resident was admitted on [DATE], with diagnoses including hip fracture, bladder cancer, kidney disease, acute kidney failure, and acute pain due to trauma. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the large fan in the laundry room free of a heavy buildup of dust which caused the fan to blow dust towards the laundry staff and the folding area of the laundry. The facility census was 56 residents. 1. Observation on 6/17/25 at 2:23 P.M., showed a heavy buildup of dust on the blades of the fan in the laundry. During an interview on 6/17/25 at 2:24 P.M., Maintenance Assistant B said he/she did not know the last time the fan was cleaned.

Inspectors wroteBased on observation and interview, the facility failed to ensure there was negative air flow in the 1st floor soiled utility room. The facility census was 56 residents. 1. Observation on 6/17/25 at 2:05 showed the absence of negative air flow from the 1st floor as required in a soiled utility room as evidenced by using two different tissue papers to check if the vent was drawing the paper up. During an interview on 6/17/25 at 2:07 P.M., the Director of Facility Operations said he/she was not sure how long that soiled utility room was without negative air flow.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1) was treated with dignity and respect when on 5/14/25 Registered Nurse (RN) A grabbed the resident's arm, held it in place while the resident was resisting care resulting in a moon shaped skin tear out of three sampled residents. The facility census was 55 residents. The Administrator was notified on 5/22/25 at 5:12 P.M. of the past noncompliance which began on 5/14/25. The facility in-serviced all staff on the facility's resident rights, abuse and neglect policies. RN A was terminated on 5/16/25. The deficiency was corrected on 5/14/25. Review of the facility Resident Rights Policy dated 2001, revised in 2/2021 showed: -Employees shall treat all residents with kindness, respect, and dignity. -These rights include but not limited to: --A dignified existence. [...]

Inspectors wroteBased on interview and record review, facility staff failed to follow facility policy for using mechanical lifts for one sampled resident, (Resident #1) out of five sampled residents. Facility staff failed to use two staff to transfer the resident using a Hoyer lift (a medical device used to assist lifting and transferring individuals with limited mobility) and failed to inspect the lift sling for safety on 2/26/25. During the transfer, the sling strap broke and the resident fell to the floor. The resident sustained a subdural hematoma (a type of bleeding that occurs inside the skull in the outermost membrane surrounding the brain) and a fractured right hip and was admitted to the hospital intensive care unit (ICU). The facility census was 59 residents. The Director of Nursing (DON) was notified on 3/4/25 at 5:12 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician, Administrator, Director of Nursing (DON) and/or the resident representative of one resident's (Resident #1) changes in skin condition resulting in a delay in treatment out of four sampled residents. The facility census was 67 residents. Review of the facility Change in a Resident's Condition or Status dated 2/2021 showed: -Our facility promptly notifies the resident, his/her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. -The nurse will notify the resident's attending physician or physician on call when there has been a(n) significant change in the resident's physical, emotional, or mental condition and the need to alter the resident's medical treatment significantly. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were reviewed, updated and/or revised for two sampled residents (Residents #1 and #3) out of four sampled residents. The facility census was 67 residents. Review of the facility Care Plans, Comprehensive Person-Centered dated 03/2022 showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident physical, psychosocial and functional needs is developed and implemented for each resident. -The comprehensive, person-centered care plan: --Includes measurable objectives and timeframe's. --Describes the services that to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. --Reflects currently recognized standards of practice for problem areas and conditions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure weekly skin/wound assessments, wound assessments included a detailed description and measurements of the pressure ulcer/injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), and to notify the resident's physician of a new pressure ulcer to obtain treatment orders in a timely manner for one sampled resident (Resident #1) out of four sampled residents. The facility census was 67 residents. Review of the facility Pressure Injury Risk assessment dated 3/2020 showed: -The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Dietitian (RD) was in the facility to perform dietary assessments and to consult with dietary staff in the kitchen. This practice affected two sampled residents (Residents #1 and #2) who needed dietary assessments during the time span when there was no RD coming to the facility out of four sampled residents. The facility census was 67 residents. Review of the facility Dietitian policy dated 11/2022 showed: -A qualified dietitian or other clinically qualified nutrition professional will help oversee food and nutrition services provided to the residents. -The dietitian or nutrition professional may be a full time or part time consultant or an employee depending on the current requirements of the facility. --The requirements are based on: ---Assessments and care plans of resident nutritional needs. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the ceiling tiles, light fixtures, and sprinkler heads, which were over the food preparation table and the dishwasher area, free of a dust buildup. This practice potentially affected all residents who ate food prepared in the kitchen. The facility census was 58 residents. 1. Observation on 9/25/23 at 9:42 A.M., showed a buildup of dust on the sprinkler head on the ceiling close to the food preparation area. Observation on 9/25/23 at 9:43 A.M., showed a dust buildup on the ceiling tiles and on the light fixtures over the food preparation table. Observation on 9/25/23 at 9:47 A.M., showed a buildup on the ceiling tiles and on the light fixtures over the dishwasher area. [...]

Inspectors wrote2. Review of Resident #44's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including shortness of breath, respiratory failure, chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure, kidney disease, fluid overload and cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). Review of the resident's annual MDS dated [DATE], showed the resident: -Was alert and oriented. -Needed extensive assistance with bathing and hygiene, limited assistance with dressing and toileting. -Needed supervision with ambulation and was able to mobilize in a wheelchair. -Had no skin problems or other wounds. -Received ointment treatments and application of dressings to his/her feet and other areas (other than feet). [...]

Inspectors wroteBased on observation and interview, the facility failed to do or maintain the beauty shop ceiling vent free from a dust buildup; to maintain the floor in the 1st floor east kitchenette free from a buildup of rust and water; maintain the restroom ceiling vent in resident room [ROOM NUMBER] free from a buildup of dust; to maintain resident rooms [ROOM NUMBERS] free from a buildup of cobwebs; to maintain the floor in the 2nd floor west kitchenette free from a a buildup of debris; failed to maintain hot water temperatures at or close to 105 ºF (degrees Fahrenheit) in resident rooms 123, 114, 212, 223 and 216 for two days of the survey. This practice potentially affected at least 35 residents who resided in or used those areas. The facility census was 58 residents. 1. Observation on 9/26/23 with the Director of Facility Operations showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document a comprehensive assessment for a suprapubic (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) stoma (surgical opening) site weekly for two sampled residents (Resident #23 and #35); to document a suprapubic catheter change on 8/1/23 and on 9/1/23 for one sample resident (Resident #23); to ensure a dignity bag (a bag that the drainage bag is placed into to prevent contamination and other people seeing the urine) was placed for three sampled residents (Resident #19, #4, and #35); to complete physician's ordered cares to the catheter for three sampled residents (Resident #19, #4, and #35); to ensure the drainage bag was managed appropriately to prevent infection for two sampled residents (Resident #35 and #4); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment was properly stored for four sampled residents (Resident #44, #10, #35, and #20), and failed to care plan the use of respiratory equipment for three sampled residents (Resident #44, #35, and #20) out of 15 sampled residents. The facility census was 58 residents. Review of the facility's policy, titled Continuous Positive Airway Pressure (CPAP-a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing)/Bilevel Positive Airway Pressure (BiPap-a type of device that helps with breathing) Support dated March 2015, showed: -Staff were to clean Cpap and BiPap masks with warm, soapy water for five minutes, rinse with warm water, and allow it to air dry. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide justification for re-implementing an elopement risk device (a bracelet that the resident wears that is used to keep track of resident and provides the facility an additional layer of security that allows sensors on doors to alarm when the resident attempts to exit) and to care plan the device for one sampled resident (Resident #46) out of 15 sampled residents. The facility census was 58 residents. Review of the facility's undated elopement risk device policy and procedure showed: -Wander guard placement was determined by resident assessment, history of wandering or getting lost or turned around. -Assessments should be done quarterly or as needed. -Residents were provided a bracelet by the facility. -Wander guard placement would be care planned. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to include the amount of $4,281.75 in the reconciliation (the process of verifying two sets of records to ensure consistency and accuracy) calculations which were completed in June 2023 for one discharged resident (Resident #500) and to obtain a resident signature or other evidence of the resident's approval for a check written for $375.00 for one sampled resident (Resident #2) account. This practice affected one discharged resident (Resident #500) and one sampled resident (Resident #2) out of two sampled residents who allowed the facility to hold funds. The facility census was 58 residents. 1. Review of Resident #500's discharge records showed he/she moved away from the facility on 1/10/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit a Third Party Liability (TPL) form within 30 days of death, to Missouri Health Net for one deceased resident (Resident #501). The facility census was 58 residents. 1. Review of Resident #501's medical records showed the resident passed away on [DATE], which was 113 days prior to the resident fund review on [DATE]. During an interview on [DATE] at 11:23 the Director of Finance said: -The resident received Medicaid as a part of his/her funding for his/her stay at the facility. - A TPL form should have been filled out since the resident passed away.

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 58 residents. 1. Review of the facility maintained Resident Trust Reconciliation on 9/29/23, showed an average monthly balance of $ 7,894.03. During an interview on 9/26/23 at 10:42 A.M., the Director of Finance said the surety bond was updated two years ago and he/she would really have to look at the balances. Review of the facility's Surety Cancellation and Nonrenewal Notice on 10/19/23, showed the Notice was dated 7/1/23, received by the Department of Health & Senior Services on 8/3/23 and cancelled the surety bond effective 10/2/23, making the surety bond insuffiecient by $12,000.

Inspectors wroteBased on interview and record review, the facility failed to provide restorative therapy (therapy given to either reach a higher level or maintain a current level of functioning) services as ordered for one sampled resident (Resident #48) out of 15 sampled residents. The facility census was 58 residents. Review of the facility's policy, titled Restorative Nursing Services dated July 2017, showed: -Restorative therapy may or may not be accompanied by formal rehabilitation services such as Physical Therapy (PT-therapy that is used to preserve, enhance, or restore movement and physical function impaired by disease, injury, or disability), Occupational Therapy (OT-therapy that is used to promote independence in activities of daily living), and Speech Therapy (ST-therapeutic treatment of impairments related to communication and swallowing). 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete and document a comprehensive initial assessment of the resident's leg wounds and comprehensive ongoing assessments of the resident's leg wounds; to care plan the resident had cellulitis that was being treated; and to use proper skin issues and treatments for one sampled resident (Resident #44) out of 15 sampled residents. The facility census was 58 residents. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident prior to and after dialysis (a mechanical way to filter the blood and remove waste when the kidneys stop functioning) for one sampled resident (Resident #20) out of 15 sampled residents. The facility census was 58 residents. Review of the facility's undated policy, titled Pre/Post dialysis Nursing Assessment showed: -Staff were to create and fill out the Dialysis Nursing Pre/Post Assessment, print it out, and send it with the resident to dialysis. -Staff were to retrieve the form when the resident returned from dialysis and place it in the communication book. 1. Review of Resident #20's face sheet showed he/she was admitted with the following diagnoses: -End Stage Renal Disease (the kidneys no longer work as they should to meet the body's needs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain dental services, care plan dental problems, and accurately record dental problems on the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for one sampled resident (Resident #48) out of 15 sampled residents. The facility census was 58 residents. Review of the facility's undated policy titled Dental Services showed: -Staff were to ensure residents received routine and emergency dental services. -The Social Services Designee (SSD) was to assist residents with arranging appointments, transportation, and reimbursement of dental services, if eligible. -Staff were to record all dental services provided in the resident's medical record. Review of the facility's policy, titled Goals and Objectives, Care Plans dated April 2009, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the mechanical soft chicken was maintained at or close to a temperature of 120 ºF (degrees Fahrenheit) for one supplemental resident (Resident #9) on the steam table and at the time of service. This practice affected one resident. The facility census was 58 residents. 1. Review of Resident #9's face sheet showed diagnoses which included hemiplegia (paralysis on one side of the body), aphasia (having difficulty with their language or speech. It's usually caused by damage to the left side of the brain (for example, after a stroke), diabetes mellitus (when the body can't produce enough of a hormone called insulin, or the insulin it produces isn't effective in order to digest carbohydrates), generalized weakness, Review of the resident's Nutrition Risk assessment dated [DATE] showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to label foods in the resident use refrigerator, with the name of the resident(s) those foods belonged to. This practice potentially affected two residents who had food in that resident use refrigerator. The facility census was 58 residents. Review of the facility's policy entitled Foods Brought by Family/Visitors dated 7/17, showed: -Policy Statement: Food brought to the facility by visitors and family was permitted. Facility staff would strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. -Family members and visitors were requested to inform nursing staff of their desire to bring foods into the facility. -Foods brought by family/visitors for individual residents may not be shared with or distributed to other residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to prevent the presence of gnats (small flies) around the condiment area on a food storage shelf and under the dishwashing sink. This practice affected the kitchen. The facility census was 58 residents. 1. Observation on 9/25/23, showed the following: -At 9:29 A.M., many gnats flew around the shelf where the condiments were stored and containers of cider vinegar with several gnats in the cider vinegar -At 11:22 A.M., many gnats flew around the area under the dishwasher area, where there was grime on the pipes and a 1 foot (ft.) by long by 1 ft. wide opening in the wall under the dishwashing sink. During an interview on 9/25/23 at 1:07 P.M., the Director of Dining Service said he/she was not sure of the last time that area under the dishwasher was treated for gnats. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the shift change narcotic (a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions) count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 52 residents. 1. Record review of the facilities Control Substances (a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) Policy revised December 2012 showed: -Nursing staff would count controlled medications at the end of each shift. -The nurse coming on duty and the nurse going off duty would make the count together. -They would document the count and reported and discrepancies to the Director of Nursing (DON). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 26 observed medication opportunities, five errors occurred resulting in an error rate of 19.23%. One medication involved crushing contents of a timed release capsule (Resident #20); one error involved an inhaler medication (Resident #1), one error involved an eye drop medication (Resident #45), one error involved insulin administration (Resident #12) and one error involved time of administration (Resident #43). The facility census was 52 residents. Record review of eye drop and inhaler administration information from the Certified Medication Technician (CMT) Student Manual, revised 2008 showed: -Hold the lower eye lid away from the eye to form a pouch. -Instill the eye drop into the pouch. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure breathing inhalers were labeled with resident's name on the inhaler; to ensure eye drop vials were dated and labeled when opened; to monitor the medication refrigerator temperatures to ensure temperatures were maintained at appropriate levels for one medication refrigerator out of two medication refrigerators and to ensure acidophilus (a supplement that is used to help maintain the number of healthy bacteria) was refrigerated after opening for one sampled resident, (Resident #1). The facility census was 52 residents. Record review of facilities policy on Labeling of Medication Containers revised April of 2019 showed all medications maintained in the facility were properly labeled in accordance with current state and federal guidelines and regulations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: refrigerate open condiment containers; maintain in a sanitary condition a manual countertop can opener; keep cutting boards in good repair; keep spice containers clean an up-to-date; store foods covered, labeled and dated; ensure there were lids on trash cans available to use; and to ensure all kitchen food preparation employees were wearing hair restraints. These deficient practices of not practicing good hygienic and sanitation techniques and procedures, could potentially, promote microorganisms and bacterial growth which could adversely affect the health and well-being of the residents and staff who partook of the meals prepared by the dietary staff. The facility census was 52 residents at the time of the survey. 1. Observations on 4/18/22 between 5:35 A.M. and 8:38 A.M., in the kitchen, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative(s) in writing of a transfer or discharge to a hospital, including the reasons for the transfer and to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for one sampled resident (Resident #9) out of 13 sampled residents and one closed record (Resident #49) out of two closed records. The facility census was 52 residents. 1. Record review of Resident #9's Profile Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the facility investigation dated 12/21/21 showed the resident was sent to the hospital after stepping off a sit to stand lift (are designed to assist patients who have some mobility but need help to rise from a sitting position. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative in writing of the facility bed hold policy at the time of transfer for one sampled resident (Resident #9) out of 13 sampled residents and one closed record (Resident #49) out of two closed records. The facility census was 52 residents. Record review of the facility's undated Bed Hold Policy showed: -If a resident was absent for up to 18 days, no additional costs would be charged. -The residence (bed) would be held for 18 days. 1. Record review of Resident #9's Profile Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the facility investigation dated 12/21/21 showed the resident was sent to the hospital after stepping off a sit to stand lift (are designed to assist patients who have some mobility but need help to rise from a sitting position. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure completion of one resident's (Resident #20) left hip pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) treatment and to clarify/discontinue a treatment for the resident's right hip once the wound was healed, out of 13 sampled residents. The facility census was 52 residents. Record review of the facility Pressure Ulcer/Skin Breakdown - Clinical Protocol, revised April 2018 showed: -The licensed nurse would document all current treatments. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors. One medication error occurred involving failure to properly prime an insulin pen (priming means removing the air from the needle and cartridge and ensures the pen is working correctly - if the pen is not primed before each injection, too little or too much insulin may be injected) prior to administration of insulin for one sampled resident (Resident #12). The facility census was 56 residents. Record review of the facility Insulin Administration policy, revised September 2014 showed: -The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. -Forms of insulin delivery included insulin pens. [...]