Truman Healthcare & Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to provide services per standards of practice when the facility staff did not transcribe an order for a urine analysis (UA - a routine diagnostic test that evaluates the physical, chemical, and microscopic properties of your urine. It is primarily used to screen for kidney disease, liver issues, diabetes, and urinary tract infections (UTIs)) timely, when staff did not obtain a sample for the UA timely, and when staff did not notify the physician or document the reason for the delay in obtaining the UA for one resident (Resident #1) resulting in a\\n eight day delay in obtaining the UA sample. The facility census was 104. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were reported to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required two-hour time frame when staff failed to report an allegation of employee to resident abuse when visitor reported one staff (Certified Nursing Assistant (CNA) B) yelled and cussed at one resident (Resident #1). The facility census was 100. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegation of possible abuse were thoroughly investigate when staff failed to complete a timely written investigation of an allegation of employee to resident abuse when a visitor reported one staff (Certified Nursing Assistant (CNA) B) cussed and threatened one resident (Resident #1). The facility census was 100. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment as free of accidents as possible when staff failed to provide standby and/or supervision assistance for one resident (Resident #2) resulting in the resident falling. The facility census was 100. Review of the facility policy titled, Accidents and Incidents - Investigating and Reporting, dated 2001, showed the following:-All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator;-The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident;-The following data, as applicable, shall be included on the Report of Incident/Accident form: the date/time the accident/incident took place; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meals in a timely manner in accordance with each residents' preferences when staff failed to provide a meal tray to one resident (Resident #2) during scheduled mealtimes. The facility census was 100. Review of the facility's policy titled, Frequency of Meals, dated 2001, showed the following: -Each resident shall receive at least three meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests and the plan of care;-The facility will serve at least three meals or their equivalent daily at schedule times. There will not be more than a fourteen-hour span between the evening meal and breakfast.1. Review of Resident #2's face sheet (a brief summary of the resident's medical and admission history) showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was protected from possible contamination at all times while stored, prepared, and served, when staff failed to wear hairnets appropriately while preparing resident's food and staff failed to use proper hand washing and glove use while preparing residents food. The facility census was 102.1. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Review of the facility's policy titled Code of Dress and Personal Appearance, dated 2020, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 104. Review of the facility's job description titled Director of Food Services, dated 2003, showed the following: -The primary purpose of the job position was to assist the dietician in planning organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed and served in a manner to protect against contamination and in accordance with standards of practice when staff failed to know the required temperature and sanitation levels and failed to regularly test the temperature and sanitation level and ensure the appropriate water temperature was reached on the dishwashing machine; staff failed maintain the stove, griddle, coffee pot, and the hand washing sink clean and free from debris; and when staff consumed food in the kitchen and dishwashing areas. The facility census was 104. 1. [...]

Inspectors wrote5. Review of Resident # 49's face sheet showed the following: -admission date of 12/03/19; -Diagnoses included general anxiety disorder. Review of the resident's annual MDS, dated [DATE], preferences for activities section showed the resident said it was very important to him/her to do things with groups of people, to do his/her favorite activities, and to participate in religious services. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Exhibited no behavioral symptoms; -Functional limitation in range of motion to all four extremities; -Used motorized wheelchair for mobility device; -Independent with eating; -Dependent on staff for toileting hygiene, showers, lower body dressing, and with transfers; -Required partial/moderate assistance of staff with personal hygiene; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received food and drink that was palatable, attractive and at an appetizing temperature when meals were served colder than resident preference and out of recommended service temperature range. The facility census was 104. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -Except during preparation, cooking, or cooling, time/temperature control for safety food shall be maintained at 41 degrees Fahrenheit (° F) or less; -Time/temperature control for safety food that is cooked to a temperature and for a time specified and received hot shall be a temperature of 135° F or above. Review of the facility's policy titled Food Preparation and Service, dated 2001, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the failed to establish and maintain an effective infection prevention and control program when the facility failed to ensure the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely for seven staff members (Certified Medication Technician (CMT) F, DA G, Licensed Practical Nurse (LPN) H, Certified Nursing Assistant (CNA) I, CNA J, Registered Nurse (RN) K, and Dietary Aide (DA) E) of ten sampled staff members. The facility staff also failed to wash their hands after providing catheter (a tube that is inserted into the bladder, allowing urine to drain freely) and incontinent care for one resident (Resident #4) The facility census was 104. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a system that assured full, complete, and separate accounting of each resident's personal funds when one staff (Activity Director) had the money of one resident (Resident #49) placed in his/her own personal account for resident shopping without facility maintained record keeping regarding the transactions. The resident census was 104. Review of the facility policy titled, Management of Resident's Personal Funds, revised March 2021, showed the following: -The resident may manage his or her own personal funds; -The resident may designate a representative to manage his or her personal funds; -The resident may apply to the Social Security Administration to have a representative payee designated for purposes of federal and state benefits to which he or she may be entitled; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect each resident's right to be free from abuse from staff, when a staff member continued to provide cares to a resident against the resident's wishes and refusals for one resident (Resident #17). The facility had a census of 104. Review of the facility's policy titled Abuse Prevention Program, undated, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure complete assessments regarding the appropriate use of a restraint before use when the facility failed to document an evaluation and consent for the use of a restraint, failed to obtain a physician order for restraint use, failed to care plan restraint use, and failed to document ongoing re-evaluations of the need for the restraint for one resident (Resident #77). The facility census was 104. Review of the facility's policy, titled Use of Restraints, revised April 2017, showed the following information: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when possible abuse was witnessed by staff involving two residents (Resident #32 and #57). The facility census was 104. Review of the facility's policy titled Abuse Prevention Program, undated, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were thoroughly investigated and the investigation provided to the State Survey Agency (Department of Health and Senior Services - DHSS) within five days when possible abuse was witnessed by staff involving two residents (Resident #32 and #57). The facility census was 104. Review of the facility's policy titled Abuse Prevention Program, undated, showed the following: [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure individuals were appropriately screened prior to being placed in nursing home when the facility failed to obtain and/or maintain documentation of a level one and level two Preadmission Screening and Resident Review (PASARR) for one resident (Resident #56) . The facility census was 104. Review of the document the facility provided as their policy titled Pre-admission Screening and Annual Review (PASARR), dated 04/03/25, showed the following: -A PASARR form is required in every record. The discharge planner or facility is to be advised by the person taking the inquiry that the PASARR form must be complete prior to any new admission; [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement comprehensive care plans for all residents when staff failed to care plan regarding dementia, skin integrity, and multiple medications/diagnoses for two residents (Resident #92 and #61). The facility census was 104. Review of a facility policy titled Dementia-Clinical Protocol, revised November 2018, showed the following: -As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia or otherwise impaired cognition; -For the individual with confirmed dementia, the interdisciplinary team (IDT) will identify a resident-centered care plan to maximize remaining function of life; -For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify the need for restorative therapy, failed to care plan the need for restorative therapy, and failed to provide restorative therapy services to ensure residents did not experience unavoidable reductions in range of motion and maintained maximum practical independence/range of mobility for two residents (Resident #77 and #49) who were at risk for a decline in mobility. The facility census was 104. Review of the facility's policy titled Restorative Nursing Services, revised July 2017, showed the following information: -Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services; -Residents may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment remained free of accident hazards when the facility failed to document complete and accurate smoking assessments and care plan smoking for two residents (Resident # 1 and Resident #82) and when the facility when one resident (Resident #1) was found to have multiple marijuana vape pens on his/her bedside table. The facility census was 104. Review of the facility's policy titled, Smoking- Residents, revised August 2022, showed the following information: -Prior to and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and to the extent to which the facility can accommodate their smoking or non-smoking preferences; -Resident smoking status is evaluated upon admission. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document identification and use of possible alternatives prior to the use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain a complete informed consent for the use of side rails prior to installation; failed to care plan side rails and failed to complete ongoing assessments to ensure the side rails are safe and appropriate for use for two residents (Resident #90 and Resident #92). The facility census was 104. Review of a facility policy titled Bed Safety and Bed Rails, dated August 2022, showed the following: -The use of bed rails is prohibited unless the criteria for bed rails have been met; -Regardless of mattress type, width, length, and/or depth, the bed rail, bed frame, and mattress will leave no gap wide enough to trap a resident's face or body; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication regime was free from unnecessary medications when the facility staff failed to document targeted behavioral symptoms supporting the use of an antipsychotic medication and failed to document behaviors warranting the use for one resident (Resident #75) on a physician ordered anti-psychotic medication. The facility had a census of 104. Review of the facility policy titled, Psychotropic Medication Use, dated July 2022, showed the following: -Residents will not receive medications that are not clinically indicated to treat a specific condition; -A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when staff made three errors out of 31 opportunities resulting in an 9.68% error rate affecting two residents (Resident #76 and #45). The facility had a census of 104. Review of the facility's policy titled, Administering Medications, revised April 2019, showed the following: -The Director of Nursing (DON) supervises and directs all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescriber orders, including any required time frame; -The individual administering the medication checks the label to verify the right resident, right mediation, right dosage, right time, right documentation, and right method (route) of administration before giving the medication; [...]

Inspectors wroteBased on record review and interview, the facility staff failed ensure all residents were free of significant medication errors when staff administered one resident's (Resident #76) high blood pressure medication against physician orders by not following perimeters included on the order. The facility was census of 104. Review of the facility's policy titled, Administering Medications, revised April 2019, showed the following: -The Director of Nursing (DON) supervises and directs all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescriber orders, including any required time frame; -The individual administering the medication checks the label to verify the right resident, right mediation, right dosage, right time, right documentation, and right method (route) of administration before giving the medication; [...]

Inspectors wroteBased on interview and record review, the facility failed to protect residents from misappropriation of personal property when a staff member took two narcotic pain medication tablets from Resident #5's supply and when Resident #6, had over $700 of fraudulent purchases on his/her debit card made by a facility employee. The effected two sampled residents. The facility census was 98. Review of the facility policy titled, Abuse Prevention Program, dated 1999, showed the following: -Objective: Zero tolerance of verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property, by employees, family members, or other residents; -To develop and implement a system for identifying, preventing, and reporting any incident, or suspected incident, of abuse, neglect, mistreatment, or misappropriation of resident property; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the highest quality of care and ensure that all residents receive treatment and care in accordance with professional standards of practice when the facility failed to document care and treatment refusals for one resident (Resident #2) with skin concerns, that ultimately led to infection. The facility census was 98. Review of the facility's undated policy, titled Wound and Skin Care Protocols, showed the following information: -The Director of Nursing (DON) will be responsible for reviewing weekly wound reports and monitoring progress/decline of any wound and assuring compliance with current standards of would care practice; -The interdisciplinary plan of care will address problems, goals, and interventions directed toward the prevention and/or treatment of impaired skin integrity/pressure injuries. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the highest quality of care when the facility failed to accurately and completely monitor and document wounds on the skin assessments and care plan pressure ulcers/injuries (skin injuries caused by prolonged pressure, friction, or shear, resulting in tissue damage) for one resident, Resident #1. The facility census was 98. Review of the facility's undated policy, titled Wound and Skin Care Protocols, showed the following information: -The Director of Nursing (DON) will be responsible for reviewing weekly wound reports and monitoring progress/decline of any wound and assuring compliance with current standards of would care practice; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when Certified Medication Technician (CMT) D brought narcotic pain medication tablets into the facility and placed them into the bubble pack medication card for one resident (Resident #5) and a staff member subsequently administered one dose of the medication to the resident. The facility census was 98. 1. Review of Resident #5's face sheet showed: -admitted to the facility on [DATE]; -Diagnoses of chronic pain, low back pain, anxiety disorder, major depression, and stroke. Review of the resident's care plan revised on 05/25/25, showed: -Resident is at risk for increased pain and discomfort related to a diagnosis of chronic pain; -Follow up with the resident's physician and pain management as needed; -Medication provided as prescribed; [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified Director of Food and Nutrition services. Failure to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, created the potential for the 93 residents to receive insufficient nutrition services. Review of the job description for the Dietary Manager position was not provided by the facility. 1. Interview during the initial tour of the facility kitchen on 07/11/23, at 10:17 AM, showed the dietary staff stated that they had been without a Dietary Manager for the past three months. During an interview on 07/13/23, at 3:45 P.M., the Administrator stated the Dietary Manager quit on 04/27/23 and that she and the Office Manager were overseeing the kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one of four halls, the secured dementia care unit. The failure created the potential for an undesirable living situation for the 25 residents residing on the secured unit. Review of the facility Maintenance Service Policy, dated 12/09, revealed the following: -Maintenance service shall be provided to all areas of the building, grounds, and equipment; -The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include, but are not limited to maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; maintaining the building in good repair and free from hazards; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance through a communication system at all times when the facility did not ensure all residents had working call lights at all times. Review of the facility's policy titled, Call System/Light Policy, dated 09/22, showed the residents call system remains functional at all times. If visual communication is used, the lights remain functional. 1. Review of Resident #53's Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) with an Assessment Reference Date (ARD) of 04/18/23, showed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident cognitively intact. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program, regarding flies, for the entire facility of 93 residents. Review of the facility's Pest Control Contract, showed the contract, dated 12/12/13, was for monthly service for pest management program designed to provide solution to the common pests found around the outside foundation environment including roaches, ants, house spider, mice/rats, millipedes, centipedes, [NAME] and pill bugs, crickets, silverfish, earwigs. There was no identification of fly treatment or service to the blue light, bug zappers. 1. Observations of the facility, by four surveyors, during the survey of 07/11/23 to 07/14/23, showed an excessive number of flies. The flies were all throughout the facility including the kitchen, dining rooms, on residents' food, persons, and equipment. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure two of 19 residents (Resident #19 and #76), in a total sample of 42 residents, was afforded the opportunity to be included in all aspects of person-centered care planning. Review of the facility's policy titled, Resident Participation - Assessment/Care Plan, revised February 2021, showed the resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. Spouses and other members of the family may participate in the resident assessment and development of the person-centered care plan with the resident's permission. 1. Review of Resident #19's Face Sheet, provided by the facility, showed the following: -admission date of 06/05/13; [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure one of one sampled resident (Resident 51) had a physician's order in the medical record and was assessed and care planned for the self-administration of medications. This failure increased the risk of incomplete or inaccurate administration of medication for the resident. Review of the facility-provided policy titled Self-Administration of Medication, revised 02/21, showed the following: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe; -If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan; -Self-administered medications are stored in a safe and secure place, which is not accessible by other residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to have a process in place to identify and address weight loss for one resident (Resident #25) of one resident with possible weight loss, in a sample of 42 residents. Review of the facility's policy titled, Resident Participation - Assessments/Care Plans, revised on February 2021, showed the following regarding care planning process: -Facilitates the inclusion of the resident and/or representative; -Includes an assessment of the resident's strengths and his/her needs; -Incorporates the residents personal and cultural preferences in establishing goals of care. 1. Review of the Resident #25's Face Sheet, showed the following: -admission date of 03/17/23; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one resident (Resident #30) of one resident in the sample of 43 received appropriate and timely assistance and his/her pain was controlled when he/she fell out of bed during the night shift. Review of Lippincott Nursing Procedures, eighth edition, Wolters Kluwer 2019: Pain Management pp. 570-572, showed the following: -To assess pain properly, staff need to consider the resident's description and staff's observations of the resident's physical and behavioral response; -Ask the resident to rank the pain on a scale from 0-10, with 0 denoting lack of pain and 10 denoting the worst pain possible; -Reassess and respond to the resident's pain by evaluating the response to treatment and progress toward pain management goals; -Document each step of the nursing process; [...]

Inspectors wroteBased on record review and interivew, the facility failed to ensure that the Facility Assessment listed all the services provided by the facility, inlcuding tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) care. This affected one of 93 residents (Resident #64). 1. Review of Resident #64's paper medical record Face Sheet revealed showed the following: -admission date of 09/17/20; -Diagnoses included traumatic brain injury (TBI), tracheostomy, and seizures. Review of the resident's paper medical record Physician Orders for July 2023 showed the resident was to have tracheostomy changed out as needed, suction airway as needed, tracheostomy care each shift, and change tracheostomy every month on the 15th. Review of the form titled, Facility Assessment Tool, dated 03/21/23, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect food from possible contamination when the staff failed to complete hand hygiene or change gloves between tasks; failed to dry dishes properly and stacked dishes wet; and when staff stored dented cans on the shelf to be used in food preparation. The facility census was 92. 1. Record review of the 2013 Food Code, issued by the Food and Drug Administration, showed the following: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food. - Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to document completion of measurements to ensure the there were no gaps that's could potentially cause injury or entrapment for ten residents (Resident #8, #19, #27, #29, #44, #47, #57, #77, #80, and #85). Staff failed to obtain physician's orders for, care plan, or obtain signed consent for the use of side rails for one resident (Resident #29). The facility census was 92. Record review of the facility's policy titled Bed Safety, dated December 2007, included the following information: -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure the medication error rate was less than five percent when facility staff failed to administer medications according to the physician's orders and standards of practice resulting in 18 medication errors out of 26 opportunities. This practice affected five residents (Resident #54, #59, #74, #80, and #238). The medication error rate was 69.23%. The facility census was 92. Record review of the facility's Administering Medications Policy, dated April 2019, showed the following: -The Director of Nursing (DON) Services supervises and directs all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescriber orders, including any required time frame; [...]

Inspectors wroteBased on interview and record review, the facility failed to assure administer antibiotics (medications to treat infections) as ordered for one resident (Resident # 29) and failed to follow-up with a physician's orders to recheck a urinalysis sample after treatment with an antibiotic for one resident (Resident # 80), both who had UTIs (urinary tract infection). Staff failed to update the care plans of two residents (Resident #29 and #80) regarding recent UTIs. The facility census was 92. Record review of the facility's Urinary Tract Infections/Bacteriuria (bacteria in the urine) - Clinical Protocol Policy, dated April 2018, showed the following: -The physician and nursing staff will review the status of individuals who are being treated for a UTI and adjust treatments accordingly. Record review of the facility's Antibiotic Stewardship Policy, dated December 2016, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to properly disinfect glucometers (small hand-held devices that check blood glucose levels in residents) when collecting blood glucose (sugar that the bloodstream carries to all cells in the body to supply energy) levels on residents and failed to protect the glucometer test strips from potential contamination. This practice affected two residents (Resident #51 & #238). The facility census was 92. Record review of the Centers for Disease Control and Prevention (CDC) website showed the following information: -Blood glucometers approved for use for more than one person must be cleaned and disinfected. [...]