Life Care Center Of Waynesville

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

shall be relayed with little or no delay to the ordering physician) to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnoses and treatment, and the facility is responsible for the quality and timeliness of services whether services are provided by the facility or outside resource. 6. Review of Resident #3's admission MDS, dated [DATE REDACTED], showed the facility assessed the resident cognitively intact with diagnoses of chronic kidney disease - stage four, peripheral vascular disease (circulation disorder where blood vessels outside the heart become narrowed, blocked, or weakened), high blood pressure , diabetes, fibromyalgia (widespread pain, fatigue, and other symptoms, such as problems with sleep, thinking, and memory) and schizophrenia (chronic mental health disorder that affects a person's ability to think, feel, and behave, leading to a distorted perception of reality). Review of

the resident's POS, dated 09/26/25, showed the physician directed staff to administer Macrobid (antibiotic used to treat and prevent urinary tract infections) two times a day for five days. Review of the resident's Medication Administration Record (MAR), dated 09/26/25 showed staff did not document the resident received Macrobid on 09/26/25. Review of the resident's nurses note, dated 9/19/2025 at 1:49 P.M., showed staff documented the resident had bloody discharge in his/her brief with no foul odor. Staff received an order for a urinalysis due to concerns. Review showed the nurses notes did not contain documentation staff obtained the urine. Review of the resident's nurses note, dated 9/21/25 at 11:24 P.M., showed staff documented the urine specimen was collected, labeled and stored in lab fridge for lab pickup. Review of the resident's nurses note, dated 9/26/25 at 1:19 P.M., showed staff documented they received results of the resident's urinalysis and resident was diagnosed with a urinary tract infection, faxed results and received an order to start resident on Macrobid 100 mg twice a day for five days. Order noted and staff contacted pharmacy. During an interview on 11/24/25 at 12:18 P.M., the DON said the physician ordered for the resident to have a urinalysis on 9/19/25, the collection was delayed and not collected until 9/21/25 and the lab did not receive the urine specimen until 9/22/25. He/She said he/she does not know why the urine specimen was not collected on 9/19/25, he/she expects urine specimens to be collected when the urinalysis is ordered. He/She said final culture for urine analysis is seventy-two hours. He/She the staff was notified of the diagnoses and treatment on 09/26/25 and treatment should not have been delayed because

the medication was in the facility's emergency kit. He/She said his/her expectation is to start treatment right away. He/She said he/she does not know why the medication was delayed. Complaint# 2631457 and Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Waynesville

700 Birch Lane Waynesville, MO 65583

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #6's medication ezetimibe (treats high cholesterol), simvastatin (manage high cholesterol and reduce the risk of heart attacks and strokes), Vistaril (treats anxiety), or trazodone (treats major depression) to Resident #5. The facility census was 76.1.Review of the facility Administration of Medications, reviewed 09/09/25, showed the facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medication in a skilled nursing facility. Staff who are responsible for medication administration will adhere to the 10 rights of medications administration - Right Resident: use two identifiers. Ask the resident his/her full name and compare it to the name on the medication or treatment administration record (MAR/TAR) and compare the resident's photo to the resident.

1. 2. Review of Resident #5's admission minimum data set (MDS), a federally mandated assessment tool,

dated 10/21/25, showed staff assessed the resident as severely cognitively impaired with diagnoses of Parkinsons (progressive brain disorder causing movement issues like tremors, stiffness and slowness).

Review of the resident's progress notes, dated 11/5/2025 12:25 A.M., showed staff documented the resident received incorrect medication tonight from Certified Medication Technician (CMT) on shift, gave roommates meds instead. Resident took ezetimibe, simvastatin, Vistaril, or trazodone. Resident attempted to ambulate to restroom, he/she is quite sedated from trazodone. Resident was educated on fall risk and agreed to call for assistance with transfers. Attempted to notify residents family but phone line has been disconnected, number not in service. Physician notified, directed to continue to monitor resident through the night. Review of the resident's physician order sheet (POS), dated November 2025, did not contain an order for ezetimibe, simvastatin, Vistaril, or trazodone.Review of the facility investigation, dated 11/04/25, showed CMT C administered another resident's medication to Resident #5 because he/she administered medications that were prepared by another staff member and there was confusion. CMT C's statement, dated 11/04/25, showed he/she documented I gave a med cup to the wrong resident. I had gotten done passing meds on my hall and went to go help. The nurse had popped the meds into a med cup and handed

it to me. There was a miscommunication, and I gave the meds to the wrong resident in the room.During an

interview on 11/24/25 at 11:19 A.M., the Director of Nursing (DON) said Resident #5 had a medication error when the resident was given his/her roommates medications. He/She said the physician was notified and

the resident was tired but had no other side effects. During an interview on 11/24/25 at 11:49 A.M., the resident said he/she does not know how he/she got the wrong medication or what medication he/she got but said he/she was so tired and had a lot of weird dreams after the error. He/She said staff came to check

on him throughout the night.During an interview on 12/09/25 at 4:08 P.M., CMT B said the facility was short

a nurse and an agency nurse came in late to help. He/She said he/she finished his/her medication pass and went to help the nurse because he/she was behind. He/She said the nurse gave him/her a pill cup to take to a resident, he/she said he/she was unfamiliar with the residents on that hall and there were two residents in the room and he/she gave the medication to the wrong resident. He/She said he/she told the nurse immediately and the nurse took it from there and called the department heads and the physician.

He/She said he/she has not seen the nurse since and was educated by the DON on medication administration. He/She said he/she is aware he/she should never pass medications that he/she did not prepare but he/she tried to help to get the residents their medications on time. Complaint # 2675499

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet