Every finding on record at Monterey Park Rehabilitation & Health Care Center

Based on observation, interview, and record review, the staff member working in the kitchen failed to wash their hands, providing a risk of cross contamination between objects and food. This practice potentially affected all residents who ate the food from the kitchen. The facility census was 98 residents.Review of the facility's undated Handwashing Policy and Procedure showed:-Hand washing was the most important component for preventing the spread of infection. Proper hand washing technique was to be used at all times that hand washing is indicated.-Hand washing was to be done:--When hands were visibly soiled.--Before and after eating or handling food.--After toileting or after personal grooming (combing hair).--Before starting work.--After smoking.--After coughing, sneezing, or blowing your nose.--After handling uncooked animal products such as raw meat, or fish.1. Observation on 9/25/25 from 9:30 A.M. to 12:00 P.M. during the lunch meal preparation showed:-Dietary [NAME] A grabbed the ready to eat pies in a way that his/her ungloved hand full length of his/her thumbs were touching the top of the pies when he/she moved them. -Dietary [NAME] A touched the gray garbage can lid on the large trash can without gloves on then picked up a loaf of bread, went to the three-compartment sink and then to the dishwasher without washing his/her hands. -When Dietary [NAME] A was working on the preparation line handling hamburger buns, he/she was wearing gloves but pulled up his/her pants and then went back to preparing hamburger buns without washing hands and changing gloves. During interview on 9/26/25 at 9:00 A.M. the Dietary Director said he/she was aware of staff not always washing their hands and having the risk of cross contamination and since he/she started three weeks ago he/she had already created a schedule of education topics including handwashing.

Based on interview and record review, the facility failed to notify a resident's emergency contact in a timely manner for one sampled resident (Resident #54) when on 9/11/25 at 8:10 A.M., he/she had weakened knees that buckled resulting in staff lowering him/her to ground. out 21 sampled residents. The facility resident census of 98 residents. A policy related to Notification of Change was requested not received at time of exit. 1. Review of Resident #54's admission Record form showed the resident was admitted on [DATE] with diagnoses of:-History of falls. -Cerebral Infraction (stroke happens when there is a loss of blood flow to part of the brain). -Cognitive Communication Deficit (condition where a person has difficulty with communication because of a disruption in brain function that affects thinking abilities). -The resident was his/her own person, and a family member was his/her first emergency contact. Review of the resident's Health Status Note dated 9/11/25 at 8:10 A.M, showed:-This nurse was notified by Certified Nursing Assistant (CNA) G/shower aide, that the resident was lowered to the floor in the shower room. -Upon entering, the resident was found on the floor, lying on his/her back, with both legs extended and arms to his/her sides. -The resident denied hitting his/her head. -The resident had no issue with range of motion (ROM) of his/her extremities, denied any complaints of pain.-The resident had no skin issues noted, and the resident denied pain at that time. -This nurse and staff assisted the resident up from floor into his/her wheelchair. -The nurses had notified all appropriate parties.-Note: Did not indicate who was notified. Review of the resident's Fall Investigation/Incident report dated 9/11/25 at 8:10 A.M. showed.-The resident had allegedly fallen in the shower room on 9/11/25 at 8:10 A.M. during a transfer.-Documented the resident's family member was notified on 9/11/25 at 1:26 P.M.-The resident's physician was notified of the resident incident on 9/11/25 at 2:14 P.M.Review of the resident's medical record dated 9/11/25 showed he/she did not have documentation in the progress notes that the resident's family member and emergency contact was notified immediately after the resident's fall and/or lowered to the ground. Review of the resident's late entry Health Status Note dated 9/11/2025 at 2:55 P.M., showed:-The writer was notified by the charge nurse that resident was at an appointment to oncology when a family member had called the facility stating that resident had complaints of pain in his/her knee from a prior fall that morning (9/11/25).-At the time of the fall, the resident had no complaints of pain. The resident had reported knee pain during his/her doctor appointment. -The family member decided to take the resident over to the emergency room (ER) for evaluation and treatment.Review of the resident's Fall Investigation follow-up note written by Director of Nursing (DON) dated 9/15/25 showed: -On 9/11/25 at around 8:30 A.M., the resident had a witnessed fall without injury at the time of the fall. Upon assessment by the charge nurse, no injury was noted. -On 9/11/25 while the resident was out of the facility for a doctor appointment with a family member, the resident was noted to have his/her right knee swollen. The resident had told the family member he/she had fallen on his/her knee that morning. The resident's family member took the resident to ER for a full examination. The family member reported the resident had a fracture of his/her right knee. -The resident's ER report received showed there was a closed fracture of the right tibial plateau (the top surface of the tibia (shin bone) that forms the weight-bearing part of the knee joint with the femur).-The facility was waiting on the ER x-ray and CT scan results. Review of the resident's Social Services Notes dated 9/15/25 at 4:39 P.M., showed:-The facility had informed the resident's family member that he/she was listed as the resident first emergency contact only.-The facility had no documentation stating the family member was his/her Durable Power of Attorney (DPOA).During an interview on 9/26/25 at 9:56 A.M., Licensed Practical Nurse (LPN) B said:-He/She was the nurse assigned that day and was notified by the shower aide (CNA F) that the resident had been lowered to the ground in the shower room. -He/She did not notify the resident family member immediately after the incident. -The resident had already notified his/her family member while they were at a doctor appointment that morning, before the nurse could contact the emergency contact/family member. During an interview on 9/26/25 at 11:30 A.M., Assistant Director of Nursing (ADON) B said: -The nurse assigned to the resident or the unit ADON would normally be responsible for any follow-up calls and notification family members related to the resident fall or incidents. -He/She would expect staff to document emergency contact/family notification in the resident's medical record. During an interview on 9/26/25 at 12:49 P.M., Social Services Designee (SSD) said:-The resident's family member was listed as emergency contact -The resident was listed as own responsible person at that time. -The charge nurse would be responsible for contacting the resident's family member or emergency contact with any change in condition or incidents involving the resident. During an interview on 9/26/25 at 1:27 P.M., Acting Director of Nursing (DON)/ Regional Nurse said:-The resident's family member was contacted later that same day and was noted on the fall investigation report. -The charge nurse would be responsible to notify the resident's family member/emergency contact or DPOA in timely manner of any new incident/fall or resident change of conditions. Complaint # 2619401

Based on observation, interview, and record review, the facility failed to maintain one mechanical lift in resident room [ROOM NUMBER], free from a buildup of grime and particles. This practice affected one resident who was dependent on the use of a mechanical lift. The facility census was 98 residents.Review of the facility's Undated guidelines for inspecting the mechanical lifts, entitled Inspecting Mobile lifts, showed: -Inspect all surfaces on lifts to ensure they are in good repair.-Clean as necessary and notify housekeeping.-Check battery if applicable.-Inspect the control panel.-Inspect the electrical cords.1. Observations on 9/23/25 at 11:52 A.M. and on 9/25/25 at 12:58 P.M., showed a buildup of grime on the base of the mechanical lift in the resident's room. During an interview on 9/25/25 at 12:53 P.M., Certified Nursing Assistant (CNA) A said the mechanical lift should be cleaned every shift and the facility staff who used the mechanical lift should clean the lift more often. During an interview on 9/25/25 at 1:00 P.M., CNA B said the mechanical lifts should be cleaned at night and disinfected after every use. During an interview on 9/25/25 at 1:14 P.M., the North Unit Assistant Director of Nursing (ADON) said the lift should be cleaned weekly. During an interview on 9/26/25 at 1:10 P.M., the North Unit ADON said that housekeeping staff was supposed to clean the lifts after the maintenance staff checked the lifts. During an interview on 9/25/25 at 1:20 P.M., the North Unit Side ADON the lift should be cleaned by housekeeping, and the aides should inform housekeeping when the lift needs cleaning.

Based on observation, interview, and record review the facility failed to ensure the call light was within reach for one sampled resident (Resident #18) out of 21 sampled residents. The facility census was 98 residents. A call light policy was requested and not provided at the time of exit. 1. Review of Resident #18's Significant Change Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 7/30/25 showed:-The resident was moderately cognitively impaired. -Required staff assistance with his/her activities of daily living. Review of the resident's care plan dated 9/24/25 showed:-The resident was at risk for falls related to unsteady gait and cognitive impairment with poor safety awareness.-The resident had limited physical mobility.-The resident would have interventions in place to reduce the risk for falls and/or injury r/t falls through the next review period that included:--Display a Call Don't Fall sign.--Educate resident to ask staff for assistance.--Educate resident to use the call light to ask for assistance.--Be educated to ensure the call light was clipped where the resident could easily reach it.Observation on 9/22/25 at 10:11 A.M. showed:-The resident's call light was draped across a pillow that was sitting on top of a chair in the resident's room at least 2 feet away from the resident. -A Call Don't Fall sign was posted on the wall above the resident's bed.Observation on 9/23/25 at 8:24 A.M. showed: -The resident's call light was draped across a pillow that was sitting on top of a chair in the resident's room at least 2 feet away from the resident. -A Call Don't Fall sign was posted on the wall above the resident's bed.Observation on 9/24/25 at 9:01A.M. showed:-The resident's call light was on the floor under a chair in the resident's room which was at least 2 feet away from the resident. -A Call Don't Fall sign was posted on the wall above the resident's bed.Observation on 9/24/25 at 1:39 P.M. showed:-The resident's call light was draped over a pillow that was sitting on top of a chair in the resident's room which was at least 2 feet away from the resident. -A Call Don't Fall sign was posted on the wall above the resident's bed.Observation on 9/25/25 at 10:26 A.M. showed:-The resident's call light was draped over a pillow that was sitting on top of a chair in the resident's room which was at least 2 feet away from the resident. -A Call Don't Fall sign was on the resident's bedside table which was positioned across the resident while he/she was lying in bed.Observation on 9/25/25 at 2:10 P.M. showed:-The resident's call light was draped over a pillow that was sitting on top of a chair in the resident's room which was at least 2 feet away from the resident. -A Call Don't Fall sign was on the resident's bedside table which was positioned across the resident while he/she was lying in bed.Observation on 9/26/25 at 9:16 A.M. showed:-The resident's call light was draped across the bedside table, which was near the middle of the room, 3 feet away from the resident. During an interview on 9/26/25 at 9:15 A.M. Certified Nursing Assistant (CNA) E said:-He/She knew to respond to the resident's needs by seeing if the call light was activated, regular room checks and asking the resident.-The call light should be attached to the person at all times.-The resident required total assistance.-The call light placement should be checked before leaving the resident's room.-At this time, the call light was located on the resident's beside table.--The bedside table was located 3 feet away from resident.-The call light should have been placed within the resident's reach if discovered to be out of reach. During an interview on 9/26/25 at 9:06 A.M. Licensed Practical Nurse (LPN) A said: -He/She identified that the resident was in need of assistance by the call light being activated, verbalization by the resident, the CNA or any other staff reporting it to her/him, walking by or asking the resident.-The resident was reminded to use the call light for assistance by the nursing staff, by having the call light close by, the staff verbalizing instructions, and/or displaying a Call Don't Fall sign in the room.-All call lights for all residents should be within arm's reach at all times.-All staff in the building were responsible for ensuring that call lights were within reach for all residents at all times.-Staff should ensure that call lights were within reach for residents before leaving the room. During an interview on 9/26/25 at 9:26 A.M. Assistant Director of Nursing (ADON) B said:-He/She would expect the call lights be within the residents reach at all times.-All staff including nursing, were responsible for ensuring the call lights were within reach at all times.-Staff should check that the call lights were within reach before leaving the resident's room.-If staff saw that the call light was not within reach for Resident #18, they should have moved it so it was clipped it to the resident's person within arm's reach. During an interview on 9/26/25 at 1:27 P.M. the Corporate Nurse said: -He/She would expect that call lights be within the residents reach at all times.-All staff were responsible for ensuring that the call lights were within reach at all times.-He/She would expect staff to check that the call lights were within reach before leaving the resident's room.-He/She would expect that if staff saw that a call light was not within reach, they should clip it to the resident's person placing it within arm's reach.

Based on observation, interview and record review, the facility failed to ensure infection control practices for proper placement of indwelling Foley catheter (a urinary bladder catheter inserted through urethra) tubing from dragging or touch the ground, for one sampled resident (Resident #10) who's at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system) out of 21 sampled residents. The facility census was 98 residents. Review of the facility Indwelling Foley Catheter Care policy dated 12/2024 showed: -Ensure resident to keep the catheter and tubing free of kinks. -Check drainage tubing and bag to ensure that the catheter is draining properly. 1. Review of Resident #10 admission Record showed the resident admitted to the facility with a diagnosis of obstructive and reflux uropathy (is kidney scarring caused by urine flowing backward from the bladder into a ureter and toward a kidney).Review of the resident's Catheter Care Plan dated 5/6/25 showed:-The resident required a foley catheter due to diagnosis of obstructive and reflux uropathy.-Position catheter bag and tubing below the level of the bladder.Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/8/25, showed he/she:-Was cognitively intact.-Was able to understand others and make his/her needs known.-Required total assistant from staff for all cares and transfer.-admitted with indwelling catheter. Review of the resident's Physician Order Sheet (POS) dated 9/2025 showed: -Change catheter drainage bag as needed for leaking.-Foley catheter Care - wash catheter site with soap and water every shift.Observation of the resident on 9/23/25 at 11:32 A.M., showed:-He/She was sitting in a wheelchair.-His/Her catheter drainage bag was hooked underneath his/her wheelchair in a privacy bag. -The catheter tubing had creamy thick substance in tubing. -The tubing clipped to the resident pant leg at this time. Review the resident's lab progress note dated 9/25/25 at 8:30 A.M. showed: -The resident's provider was notified of the urinalysis (UA) and culture and sensitive (C&S) results.-Awaiting return call for further instructions at that time. Observation of the resident on 9/25/25 at 10:19 A.M., showed: -The resident sat in his/her wheelchair watching television in his/her room. -The resident catheter tubing was dragging on the ground under his/her wheelchair. -The tubing had thick cloudy substances in the tubing. Observation of the resident on 9/25/25 at 1:30 P.M., showed:-The resident sat in his/her wheelchair with catheter drainage bag under the resident's wheelchair. -The Certified Nursing Assistant (CNA) C was emptying the resident catheter drainage bag.-The catheter tubing remained on the ground under the resident wheelchair.-CNA C did not attempt to reposition the catheter tubing to ensure not touching or dragging on the ground. During an interview on 9/26/25 at 9:40 A.M, CNA H said:-The resident catheter tubing should not be touching the ground and check for kinks. -While sitting in wheelchair the resident catheter bag should be positioned not touch the ground. -He/She would clean the catheter tubing and reposition the tubing so it was not touching the ground. -He/she had recent skill check off and training related to catheter care and tubing placement. During an interview 9/26/25 at 9:58 A.M, CNA B said:-Catheter tubing is placed under the resident's wheelchair and staff were to ensure the tubing was not touching or dragging on the ground. -If found a catheter tubing on the ground, he/she would clean the tubing and reposition the tubing, so it was not touching the ground. During an interview on 9/26/25 at 11:17 A.M. Licensed Practical Nurse (LPN) C said: -The resident's catheter tubing should be place underneath the resident's wheelchair and positioned so it would not drag on the ground. -The resident was at risk for urinary tract infection due to catheter usage. -The nursing and CNA staff would be responsible for ensuring the placement of the resident's catheter bag tubing, so it was not touching the ground, During an interview on 9/26/25 at 11:17 A.M., Assistant Director of Nursing (ADON) B said: -He/She would expect CNA and nursing staff to ensure the resident's catheter tubing was positioned so it was not touching the ground. -He/She would expect care staff to clean the catheter tubing if it was on the ground and reposition the resident's catheter tubing to ensure it was not touching the ground. During an interview on 9/26/25 at 1:27 P.M. Acting Director of Nursing (DON) said: -He/She would expect CNA and nursing staff to ensure the resident's foley catheter tubing was positioned under the resident's wheelchair so the tubing would not be touching or dragging on the ground.-If found tubing dragging on the ground, he/she would expect all care staff to have either replaced the drainage system or to clean the catheter tubing before repositioning the resident catheter tubing off the ground.

Based on interview and record review, the facility failed to ensure that one sampled resident (Resident #1) out of four sampled residents received medications as prescribed by the physician. On 7/9/25 Certified Medication Technician (CMT) A failed to verify the identity of the residents prior to administering medication and failed to update the resident's bed location in the electronic medication administration (eMAR) system, resulting in Resident #1 receiving Resident #2's medications. The facility census was 95 residents.On 7/21/25 the facility Administration was notified of the past noncompliance which occurred on 7/9/25. Facility staff had subsequently been educated on all facility medication administration policies. All resident bed assignments were audited. The deficiency was corrected on 7/10/25. Review of the facility's Medication Pass Tips policy dated 5/19 showed:-The five rights: right drug; right time; right resident; right dose; right route.-Prior to preparing medication, verify the resident's identity. A photo is available on the electronic medication administration record (eMAR). Another staff member who was familiar with the resident could be consulted to verify identity. Also, the resident should be called by name.-Each drug should be verified against the eMAtR. Ensure the label matched the eMAR exactly. If the resident required the medication be crushed, could this drug be crushed?-The dose in each blister should be verified against the eMAR.-The route should be verified against the eMAR. Was it via mouth, rectum, eyes, ears, nose, topical, intramuscular (IM), subcutaneously (SQ), per gastric tube (a tub inserted in the stomach to deliver nutrition), etc.?-Each medication should be administered as instructed on the eMAR and within the time-frame established by the facility. Timing was important for many medications. Directions like before, after or with meals should be noted. Review of the facility's Medical Errors and Adverse Events policy dated 12/24 showed:-When medical errors or adverse resident events were identified, the facility would:-The cause should be analyzed.-Corrective actions should be implemented to prevent future events.-Monitoring should be conducted to ensure desired outcomes were achieved and sustained. 1. Review of Resident #1's admission Record Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Hyperlipidemia, (abnormally high levels of fats in the blood).-Peripheral vascular disease, (narrowed blood vessels reduce blood flow to the limbs).-Essential hypertension, (persistent high blood pressure).-Low back pain-Depression, (persistent feelings of sadness, loss of interest and changes in sleep).-Muscle weakness. Review of the Resident's Order Summary Report dated 7/10/25 showed: -An order for Atorvastatin Calcium Oral Tablet 20 milligrams (mg) give on tablet by mouth at bedtime for cholesterol (fats in the blood) dated 7/7/25.-An order for Coreg Oral Tablet 12.5 mg give one tablet by mouth two times a day for coronary artery disease, (disease or damage in the heart's major blood vessels), ordered 7/7/25.-Gabapentin Capsule 300 mg, 1 capsule by mouth three times a day for neuropathy, (damage or disease affecting the nerves outside the brain and spinal cord), ordered 7/7/25.-None of the other medications the resident received were ordered for this resident. Review of the Medication Error Incident Report dated 7/9/25 at 7:25 P.M. showed:-Licensed Practical Nurse (LPN) B was notified by CMT B that Resident #1 had been administered the medications for Resident #2.-Medications administered to Resident #1 that were not ordered were as followed: Sulcrafate oral suspension 20 ml, (a medication that protects the lining of the stomach); Doxycycline 100 mg, (an medication used to treat infection); Famitodine 20 mg, (a medication used to reduce the production of stomach acid; Atorvastatin 40 mg (20 mg ordered) (a medication used to reduce fats I the blood); Coreg 12.5 mg, (a medication used to treat heart conditions and high blood pressure); Baclofen 10 mg, (a medication used to treat muscle spasms); Metformin 500 mg, (a medication used to help control blood sugar); Gabapentin 600 mg (300 mg ordered); Trazodone 150 mg, (an antidepressant); and Ascorbic Acid 500 mg, (Vitamin C).-It was explained to the resident what medications he/she took that were not ordered for him/her.-Resident #1 said he/she would have to be more careful about accepting medications in the future in order to ensure he/she was not given the wrong medications. He/she stated he/she needed to know more about each medication he/she took in order to catch a mistake like this.-Resident #1's vital signs were taken and the Assistant Director of Nursing, (ADON) and Director of Nursing (DON) were notified.-The physician was notified, and orders were received to hold his/her atorvastatin, gabapentin and omeprazole and that the resident's blood pressure was to be monitored every two hours for the next twelve hours.-CMT A was new to the facility and did not use the five rights to identify the resident but went by which bed he/she was in, which was wrong in the computer.-Immediate reeducation of the five rights on passing medications was given to the CMT A. Review of Resident #1's admission Record Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the Resident's Order Summary Report dated 7/10/25 showed:-An order for Atorvastatin Calcium Oral Tablet 40 mg, give on tablet by mouth at bedtime for cholesterol, dated 6/13/25.-An order for Ascorbic Acid (Vitamin-C) 500 mg, give one tablet by mouth two times a day for wound healing, dated 7/3/25.-An order for Baclofen 10 mg, give one tablet by mouth at bedtime for spasms, ordered 6/13/25.-An order for Coreg Oral Tablet 12.5 mg give one tablet by mouth two times a day for high blood pressure, ordered 6/13/25.-An order for Doxycycline Hyclate Oral Tablet 100 mg, give one tablet by mouth two times a day for wound infection until 8/8/25, ordered 6/13/25.-An order for Famotidine Oral Tablet 20 mg, give one tablet by mouth at bedtime for acid reflux, ordered 6/13/25.-An order for Gabapentin Capsule 300 mg, one capsule by mouth three times a day for neuropathy, ordered 6/13/25.-An order for Metformin HCL Oral Tablet 500 mg, give one tablet by mouth two times a day related to diabetes mellitus, ordered 6/13/25.-An order for Sucralfate Suspension 1gm/10 ml, give one gram by mouth before meals and at bedtime for gastric protection, ordered 6/17/25.-An order for Trazodone HCL Oral Tablet, give 0.5 tablet by mouth at bedtime for depression, ordered 6/13/25. Review of the Medication Error Incident Report dated 7/10/25 showed:-Resident #1 continued to have double vision and lethargy after the medication error. He/she reported double vision and feeling excessively tired.-The physician was notified of the continuation of symptoms and requested the resident be sent to the hospital if double vision persisted.-The resident was sent out to the hospital.-The resident returned to the facility at approximately 8:00 P.M. There were no new orders or negative outcomes. Review of Resident #1's hospital Patient Information Form dated 7/10/25 showed:-He/She presented to the hospital for increased lethargy.-He/She was reportedly mistakenly given his/her roommate's medications the previous night.-Those medications were Doxycycline 100 mg, Famitodine 20 mg, Atorvastatin 40 mg (20 mg ordered), Carvedilol (Coreg) 12.5 mg, Baclofen 10 mg, Metformin 500 mg, Gabapentin 600 mg (300 mg ordered), Trazodone 150 mg and Vitamin-C (Ascorbic Acid)500 mg.-He/She still received his/her night and morning medications.-Emergency Medical System (EMS) was called the previous night, who assessed the resident and noted him/her to have normal vital signs.-He/She did not want to go to the emergency department (ED) at the time, so it was written off as a refusal.-He/She reported increased fatigue so EMS was again called and resident was transported to the ED.-He/She denied any chest pain, shortness of breath, vomiting or diarrhea. During an interview on 7/21/25 at 11:00 A.M., CMT B said:-He/She was training an orientee (CMT A).-They were doing the evening medication pass.-He/She was preparing the medications and giving them to CMT A and telling him/her who to give them to.-He/She handed the medications for Resident #1 to CMT A and he/she gave them to the wrong resident.-Resident #2 was in Bed B, but the computer said Bed A.-He/She gave CMT A Resident #2's medications to give, and he/she gave them to Resident #1.-He/She did not know why the computer was not updated.-Resident #2's previous roommate had gone to another facility, so he/she moved to Bed B. He/she told someone he/she was going to move.-Then Resident #1 was put in Bed A.-Resident #1 did not know he/she was getting the wrong medications.-It was an honest mistake.-He/She did not go in the residents' room with CMT A.-He/She felt the computer should have been updated. During an interview on 7/21/25 at 12:00 P.M., Resident #1 said:-The incident with the medications happened in the evening.-A staff person (CMT A) came into the room who seemed to be in a big hurry.-CMT A gave him/her a medicine cup.-He/She looked at the cup and said, This is different.-CMT A assured him/her it was his/hers, and also gave him/her a cup with a pink liquid in it.-He/She asked what it was and CMT A said it was his/hers.-Several minutes later, CMT A came in and brought his/her roommate medications.-His/her roommate said it didn't look like his/her medicine cup and asked where the pink liquid was.-That is when he/she realized the medications had been mixed up, so he/she said something.-He/She told CMT B he/she thought the medications were mixed up.-CMT B became flustered and said he/she would be right back and left the room and did not come back right away.-After a while, he/she took a nap and later someone woke him/her up. He/she could not remember what happened.-The nurse took his/her vital signs, admitted to him/her what had happened and that they were going to send him/her to the hospital to do some testing.-The people at the ED did not see anything out of the ordinary so he/she was sent back to the facility.-Then he/she started seeing double so he/she was sent back to the ED, where it was decided he/she would stay for observation.-He/She took a long nap.-He/She was asked if he/she was still seeing double and he/she said no, that it had improved.-He/She was sent back to the facility and he/she was no longer seeing double.-He/She had never had that happen before.-He/She slept a lot after that; very deep sleep.-He/She did not think the CMT who gave him/her his medications was properly trained. During an interview on 7/21/25 at 12:40 P.M., LPN A said:-If a resident moved from one bed to another, they are admissions, discharges and transfers (ADT) in the computer and moved from whatever bed they were into whatever bed they went to.-Medications for that resident were moved from whatever drawer they were into the correct new drawer.-The CMT could move the medications.-The nurse was responsible for the ADT portion.-You would go back to the five rights.-He/She would look at the resident's picture and that they would answer to the correct name.-If he/she could not tell for sure, he/she might ask the resident some other identifying question or get some other staff who knew the resident. During an interview on 7/21/25 at 1:15 P.M., CMT A said:-He/She was shadowing CMT B for orientation.-Since it was his/her first day, he/she was following CMT B.-CMT B put the medications in the medication cups, gave them to him/her and said to give to the resident in Bed A.-After he/she gave that resident his/her medications, CMT B handed him/her the medications for Resident #2.-When he/she gave them to that resident, he/she asked where his/her pink stuff was.-He/She realized he/she had given a pink medication to Resident #1.-CMT B asked who he/she gave the medication to, he/she told him/her and they looked at the computer and realized the residents were switched around.-CMT B reported the incident to the charge nurse, checked Resident #1's vital signs and checked his/her allergies.-All of Resident #1's vital signs were normal.-Resident #1 was sent out to the hospital for observation; he/she came back the next day.-He/She did not know who did updates in the computer.-He/She was sad that the situation happened because it had never happened to him/her before. During in interview on 7/21/25 at 2:17 P.M., Physician A said:-He/She was aware that Resident #1 was given the wrong medications.-The resident did not have any long term effects from the medications.-There would not be a whole lot of side effects from just one dose of these medications.-He/She would expect that staff would check to make sure the residents were given the right dose of the right medications. During an interview on 7/21/25 at 2:20 P.M., LPN B said:-He/She was the charge nurse that day.-CMT B was passing medications and training CMT A.-The CMTs came to him/her and notified him/her that Resident #1 got Resident #2's medications due to the bed mix-up.-He/She told them they should have made sure the right medications were given to the right resident.-He/She assessed Resident #1 right away and notified the ADON, DON and the physician.-He/She followed the protocol for medication errors. -Resident #2's roommate had discharged , so he/she was switched to bed B, but the change was not made in the computer.-Admissions staff, the charge nurse or the ADON could have made the change in the computer.-He/She would have made the change, but he/she was not made aware of it.-The change should have been passed on in shift report.-After the resident was assessed and everyone appropriate notified, he/she kept monitoring Resident #1, whose vital signs remained normal the whole time.-When Resident #1 developed double vision, he/she notified the physician again who decided to send him/her to the ED.-When the paramedics came, they did an electrocardiogram (EKG) (a test which records the electrical activity of the heart), which was normal.-The EMTs kept reiterating that the hospital would just monitor the resident.-The resident initially refused to go to the hospital; the doctor was aware.-The resident did not have any vomiting, only fatigue and double vision. During an interview on 7/21/25 at 3:00 P.M., the DON said:-This incident happened on CMT A's first day working on the floor.-CMT B had trained other CMTs before.-The problem happened because the bed change was not done in the computer.-They had a quick turnover of residents in that room that day, and he/she believed that was why it didn't get done.-The charge nurse, the ADON, the DON and admissions staff could have done the bed change.-His/Her expectation was that the staff follow the five rights when giving medications and not go back room numbers.-The photo identification of a resident was also the first thing that came up on the computer screen, along with medication allergies. During an interview on 7/21/25 at 3:15 P.M., the Administrator said:-His/Her expectation is that the residents should have gotten the right medications.-Resident #1 and Resident #2 were not in the right beds.-The bed change was not done in the computer.-The admissions person was the gatekeeper of the bed and room assignments.-The ADON would have been responsible or involved for making the bed changes.-Staff should be checking and double checking the residents when giving medications. During an interview on 7/21/25 at 4:15 P.M., the ADON said:-The expectation was that the staff will know the five rights; that was step one.-Any CMT or nurse should know this, and it should be practiced with every resident and every medication.-That was the standard that should be followed.-Everyone was responsible for setting these CMTs up for success.-It was important that the person in each bed matches who the computer said was in that bed; they kind of dropped the ball on that.-The charge nurse, the ADON, the DON and the admissions staff could have made the room changes in the computer.-Resident #2 was in the first bed and moved over to the other bed.-CMTs were not always aware of bed changes.-CMT B knew the residents and not going with CMT A into the room could have contributed to the error.

Based on interview and record review, the facility failed to ensure all residents were treated in a dignified manner when one staff member (Dietary Manager) spoke in a harsh tone and showed aggression to one sampled resident (Resident #2). The facility census was 97 residents. On 7/9/25 the facility Administration was notified of the past noncompliance which occurred on 6/18/25. Facility staff had subsequently been educated on all facility medication administration policies. All resident bed assignments were audited. The deficiency was corrected on 7/7/25. A facility policy for dignity and respect was requested but not provided.1. Review of Resident #2's admission Record, showed:-The resident was admitted to the facility on [DATE].-The resident had a diagnosis of need for assistance with personal cares.-The resident had a diagnosis of dysphagia (difficulty in swallowing).-The resident had a diagnosis of cognitive communication deficit (a person has difficulty communicating because of injury to the brain that controls the ability to think).-The resident had a diagnosis of major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts).Review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/21/24, showed:-The resident was cognitively intact.-It was important to the resident to be able to make his/her own decision.-The resident required set up and clean up assistance for meals.During an interview on 7/9/25 at 11:00 A.M., the Director of Rehab said:-He/She was a witness to an incident that occurred between the resident and the previous dietary manager on 6/18/25.-The previous dietary manager was holding a resident council meeting on 6/18/25 and during the meeting the resident was expressing some concerns about his/her food.-The residents' concerns were valid and needed to be voiced to the dietary manager.-The resident started enplaning to the previous dietary manager how he/she did not like fish and was requesting an alternative be offered to her/him when fish was being served at the facility.-The dietary manager became very belligerent slammed his/her hands down very hard on the table and stated, what do you want me to do about it. -The resident began to cry after the previous dietary manager slammed his/her hands down and yelled at the resident.-During the entire resident council meeting the dietary manager was expressing frustration with the residents when they would express concerns about their meals.-The previous dietary manager no longer worked at the facility.During an interview on 7/9/25 at 11:15 A.M., the resident said:-He/She was attending a resident council meeting on 6/18/25 when the previous dietary manager got mad at him/her for expressing his/her concerns.-The previous dietary manager aggressively smacked the table with both of his/her hands and began to yell at me.-The dietary manager yelled, what do you want me to do about it when the resident expressed concerns about not liking fish and desired an alternative meal when fish was being served at the facility.-He/She was very upset and embarrassed and began to cry after the incident with the previous dietary manager.-He/She was consoled by other staff members and residents who were present at the meeting.-The previous dietary manager was pulled out of the meeting by the Administrator and separated from the residents.-The previous dietary manager was let go from the facility and no longer worked there.-He/She was pleased with how the facility handled the situation after it occurred.-He/She felt belittled when the incident occurred but felt better after the previous employer no longer worked at the facility.-He/She felt safe at the facility.During an interview on 7/9/25 at 11:34 A.M., the Business Office Manager said:-He/She was a witness to an incident that occurred between the resident and the previous dietary manager on 6/18/25.-He/She felt so uncomfortable about the way the previous dietary manager responded to the resident, that he/she left the meeting to get the administrator involved.-The resident was expressing concerns to the previous dietary manager about food when the previous dietary manager slammed both hands face down on the table hard and yelled at the resident.-He/She could tell that the resident was visibly upset about the way that the previous dietary manager handled the situation.-He/She saw the resident began to cry after the previous dietary manager yelled at the resident.-He/She left the meeting immediately and reported the incident to the administrator.-The administrator removed the previous dietary manager from the resident council meeting.-He/She witnessed the previous dietary manger being rude and disrespectful to other residents in the past.-The social services director filed a grievance on the resident's behalf.During an interview on 7/9/25 at 11:48 A.M., the Social Services Director said:-He/She filled out a grievance on the resident's behalf after the incident that occurred between the resident and the previous dietary manager on 6/18/25.-The resident was crying when he/she was recalling the story to fill out the grievance.-The resident was visibly upset and negatively affected by the previous dietary managers unprofessional behavior.-He/She has received numerous other complaints from residents regarding the previous dietary manager and the way that he/she treated the residents.During an interview on 7/9/25 at 3:02 P.M., the Director of Nursing (DON) said:-He/She was aware of the incident that occurred on 6/18/25 between the resident and the previous dietary manager.-He/She would expect all residents to be treated with dignity and respect.-The previous dietary manager no longer worked for the facility and was not re hirable.During an interview on 7/9/25 at 4:09 P.M., the administrator said:-He/She was aware of the incident that occurred between the resident and the previous dietary manager.-He/She removed the previous dietary manager from the resident council meeting shortly after he/she was rude and unprofessional to the resident and placed the previous dietary manager on suspension.-The previous dietary manager was terminated from his/her position and was not re hirable.-He/She expected all staff to treat every resident with dignity and respect.-The facility did staff training and in services on workplace violence after the incident occurred.Complaint # MO00256083

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when staff administered the wrong medications to one sampled resident (Resident #1) out of six sampled residents. The facility census was 95 residents. On 2/4/25 the Administrator and acting Director of Nursing (DON) were notified of past non-compliance which occurred on 1/31/25. On 1/31/25 the facility Administrator was notified of the incident and the investigation was started. Certified Medication Technician (CMT) A notified Licensed Practical Nurse (LPN) A of an medication error he/she had made. CMT A and all nursing staff were educated on medication administration on 1/31/25. The deficiency was corrected on 1/31/25. Review of the facility Medication Pass Tips dated 5/2019 showed: -The following is a compilation of points to keep in mind during medication pass. -Prior to preparing medications, verify the resident's identity. -A photo is available on the electronic Medication Administration Record (eMAR). -Another staff member who is familiar with the resident may be consulted to verify identity. -Also, call the resident by name. -Verify each drug against the eMAR. -Ensure the label matches the eMAR exactly. -Verify the dose in each blister against the eMAR. -Verify the route against the eMAR. -Administer each medication as instructed on the eMAR and within the timeframe established by the facility. Review of the facility's Medical Errors & Adverse Events Policy dated 12/2024, showed: -When medical errors or adverse resident events are identified, the facility will: --Analyze the cause. --Implement corrective actions to prevent future events. --Conduct monitoring to ensure desired outcomes and achieved and sustained. 1. Review of Resident #1's admission Record showed he/she was admitted to the facility with the following diagnoses: -Chronic Systolic (Congestive) Heart Failure (the heart is unable to pump blood effectively, leading to a buildup of fluid in the body). -High Blood Pressure. -Dementia (the loss of cognitive functioning- thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). -Ulcerative Colitis (a type of inflammatory bowel disease that causes inflammation and sores, called ulcers that can bleed). Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/16/25 showed the resident was severely cognitively impaired. Review of the resident's Physician's Order Sheet (POS) dated 2/1/25, showed the resident did not have orders for the following medications: -Atorvastatin (blocks enzyme that is needed by the body to make cholesterol and reduces the amount of cholesterol in the blood) 80 milligram (mg) tablet. -Baclofen (muscle relaxer) 10 mg tablet. -Apiraban (Eliquis an oral anticoagulant to prevent and treat blood clots) 5 mg tablet. -Mirtazapine (Remeron - antidepressant) 15 mg tablet. Review of the resident's Care Plan dated 3/27/24, showed: -He/She had impaired cognitive function/dementia or impaired thought process. -Administer medications as ordered. -Monitor/document/report to physician any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Review of the resident's Incident Report dated 1/31/25 at 6:15 P.M., showed: -LPN A was notified by CMT A that Resident #1 receiving the wrong medications. -Upon assessment LPN A noted the resident received Atorvastatin 80 mg, Baclofen 10 mg, Apiraban 5 mg, and Mirtazapine (Remeron) 15 mg. -Vitals signs were taken and the Nurse Practitioner (NP), Assistant Director of Nursing (ADON), family, and Hospice (end of life care) were notified of the medication error. -New order to monitor for any signs or symptoms of bleeding. -Resident was not able to state what happened. During an interview on 2/4/25 at 2:14 P.M., CMT A said: -He/She was passing medications and had just given medications to Resident #1's roommate and left the room. -He/She then started getting the medications ready for Resident #6 in the next room when he/she remembered he/she did not give Resident #1 his/her medications. -He/She set the cup of medications for Resident #6 on the medication cart and got Resident #1's medications ready and set them on the medication cart also. -He/She grabbed a cup of medications and gave them to Resident #1. -When he/she went to give Resident #6 his/her medications that is when he/she noticed that he/she had given Resident #1 Resident #6's medications. -He/She went and notified LPN A about giving Resident #1 the wrong medications. -He/She had been educated on proper medication administration on 1/31/25. During an interview on 2/5/25 at 3:58 P.M., LPN A said: -He/She was notified by CMT A that he/she had given Resident #1 Resident#6's medications. -He/She went over the medications that were given to Resident #1. -He/She assessed Resident #1 and took his/her vitals and notified the NP, ADON, and family of the medication error. -The NP gave an order to monitor the resident for any change in condition or bleeding. -Resident #1 did not have any adverse reactions to the medications he/she was given in error. During an interview on 2/6/25 at 10:55 A.M., the physician said: -Facility staff should notify the physician of the medications given in error. -The resident would be monitored for any adverse reactions. -If any reactions, he/she should be notified of the reactions and from there see if the resident would need to be sent out to the hospital. -With the resident just receiving one dose of these medications they should not cause any harm to the resident. -Staff should make sure they are giving the right medications to the right residents through the five rights as soon as getting the medications ready. -He/She was notified of the medication error on 1/31/25. MO00248924

Based on observation, interview, and record review, the facility failed to ensure appropriate transfer techniques were utilized for two sampled residents (Resident #1 and #3) out of four sampled resident. The facility census was 94 residents. Review of the facility's Transfer-One Person Skills Checklist: -Check Kardex for appropriate transfer technique. -Position chair, wheelchair, commode to resident's strong side. -Assist resident to sitting position with feet firmly on the floor. -Apply gait belt. -Have resident place their hands on you shoulders. -If transferring from chair, wheelchair, commode, have resident place hands on arm rests and push up while you pull resident up to a standing position. -Brace knees against resident's knees, or your knees on the outside of the resident's knees to block feet from sliding. -Ask resident to lean forward, count to three and ask resident to push up with legs while you pull resident to a standing position. 1. Review of Resident #1's Admission Record showed the resident was admitted on [DATE], readmitted on [DATE] with diagnoses including muscle weakness, pain in right knee, pain in left knee, and pain in left thigh. Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 4/4/24 showed the resident: -Was cognitively intact. -Used a wheelchair for mobility. -Required partial, moderate assistance for transfers. Review of the Resident's Functional Abilities and Goals assessment dated [DATE] showed he/she required partial, moderate assistance for mobility, including transfers. Review of the Resident's undated Care Plan showed: --Resident is at risk for falls, 6/28/23. --Resident wishes to wear his/her gait belt at all times and refuses to take it off, 5/1/24. --Resident required (x one) staff participation with transfers with the use of a gait belt. --Resident had limited physical mobility. --Resident required (x one) staff participation for mobility. --Resident required staff assistance with mobility. During an interview on 5/9/24 at 12:02 P.M. the resident said: -He/She was concerned about the gait belt not being used during transfers. -He/She was keeping his/her gait belt with him/her at all times to make sure staff was using it during transfers. -He/she had to constantly tell staff to use the gait belt for transfers or they would not use the gait belt with them. -He/She is fearful of falling during transfers. -When staff did not use the gait belt during transfers, the staff grab onto his/her skin and it hurt, or they grab his/her clothing causing rips and they don't replace the clothing. -Certified Nursing Assistant (CNA) A specifically did not use a gait belt for transfers, actually most of the staff did not use a gait belt for transfers. -His/Her concern about staff not using a gait belt was discussed during his/her last care plan meeting. 2. Review of Resident #3's Admission Record showed the resident was admitted on [DATE] with diagnoses including muscle weakness and lack of coordination. Review of the resident's Functional Abilities and Goals dated 12/6/17 showed the resident required supervision or touching assistance with transfers. Review of the Resident's MDS dated [DATE] showed the resident: -Was cognitively intact. -Used a wheelchair for mobility. -Required supervision, touching and steadying for transfers. Review of the Resident's undated Care Plan showed: --Resident is at risk for falls related to impaired mobility and history of falls. --Resident required (x one) staff participation with bathing, bed mobility, dressing, eating , personal hygiene and toileting. --Required (x one) assist for transfer. --Resident had limited physical mobility. --Requires assistance x one as desired/as tolerated. During an observation on 5/9/24 at 12:17 P.M. showed: -CNA A pushing the resident into his/her room. -Upon entering the room, CNA A said he/she was going to use a gait belt since other people were in the room and reached for the gait belt hanging next to the bathroom door. -As CNA A attempted to place gait belt on the resident, the resident stated he/she did not want the gait belt on because he/she cannot breathe with it on. -CNA A tossed gait belt to the foot of the bed and instructed the resident he/she would help the resident to bed. -CNA A grabbed the resident's sweat pants and bottom of the resident's sweat shirt. -The resident grabbed onto CNA A as CNA A pulled the resident from a sitting to standing position by the clothing. -CNA A pivoted the resident to the bed and lowered the resident onto the bed by the resident's clothing. -The resident laid on the bed, covered him/herself, and closed his/her eyes. 3. During an interview on 5/9/24 at 12:20 P.M. CNA A said: -He/She never uses a gait belt on Resident #3. -He/she will yell out saying he/she cannot breathe with the gait belt on. -He/She sometimes uses a gait belt with Resident #1. -The rest of the residents can stand on their own and do not need a gait belt. -Information on the transfer needs of residents can be found in therapy, unless it is in the chart. -He/She does not look in the chart, only uses the chart to document eating and bowel movements. During an interview on 5/9/24 at 12:22 P.M. the Assistant Director of Nursing (ADON) said: -CNA's are expected to look in Kardex for transfer information for all residents. -Any resident that is not using a mechanical lift should have a gait belt used when being assisted with transfers. -He/she expected CNA A to use a gait belt with the transfer. During an interview on 5/9/24 at 12:38 P.M. the Doctorate to Physical Therapy said: -He/She expects gait belts to be used during all transfers, walking, and any activity that challenges balance. -Using the wrong transfer technique can pose potential safety concerns for falls, increased pain for the resident and staff, as well as multiple other risks. -Therapy instructs staff with each new resident and their transfer needs. During an interview on 5/9/24 at 1:04 P.M. the Director of Nursing (DON) said: -Resident #3 transfers with one assist. -He/she expected staff to use a gait belt during transfers with Resident #3. -He/She was not aware of any resident refusing to use the gait belt. -It would have been nice for staff to inform him/her of the resident refusing the gait belt so it could be care planned and the resident could be switched to a lift. -Resident #1 transferred with one assist and a gait belt. -He/she was not aware Resident #1 complained of CNA A not using a gait belt for transfers. -He/she expected staff to use a gait belt when transferring Resident #1, or any resident transfers that do not require a mechanical lift. -Last in-service on gait belts was in February 2024. During an interview on 5/14/24 at 9:50 A.M. CNA A said: -He/She has completed the skills checklist. -The staff have been educated on transfers and gait belt use monthly. -He/she helped Resident #1 to the bathroom without a gait belt until about a month and a half or two months ago when the resident started wearing his/her gait belt all of the time. -He/She was not using a gait belt for transfers prior to the resident wearing his/her gait belt. MO00235286

Based on observation and interview, the facility failed to maintain the ceiling fans in the South nurses' station sitting area, free of a buildup of dust and failed to maintain the tube feeding poles in resident rooms [ROOM NUMBERS] free of debris on those poles. This practice potentially affected at least 10 residents who used the sitting area and two other residents who received tube feedings. The facility census was 92 residents. Observation on 1/5/23 at 9:45 A.M. with the Maintenance Director showed a buildup of dust on the ceiling fans over the South Nurses' station sitting area. During an interview on 1/5/23 at 9:47 A.M. the Maintenance Director said the housekeepers have extendable cleaners they can use to clean the fans. During a phone interview on 1/9/23 at 2:12 P.M., the Housekeeping Area Account Manager said he/she expected the Maintenance Personnel to clean the fans due to the height of the fans. 2. Observations on 1/2/24 at 9:46 A.M. and at 1:12 P.M., on 1/3/24 at 10:32 and A.M., and on 1/8/24 at 12:20 P.M., showed the presence of a yellow-brown substance on the base of the tube feeding pole in resident room [ROOM NUMBER]. During an interview on 1/8/24 at 12:21 P.M., Licensed Practical Nurse (LPN) B said he/she changed the resident's tube feeding bag earlier that day (1/8/24), but did not notice the debris on the tube feeding pole and the resident's tube feeding bag gets changed twice within a 24 hr. period. 3. Observations on 1/5/24 at 11:26 A.M., and on 1/8/24 at 12:09 P.M., showed the presence of a yellow-brown substance at the base of the tube feeding pole in resident room [ROOM NUMBER]. During an interview on 1/8/24 at 12:12 P.M., Assistant Director of Nursing (ADON) B said he/she expected facility staff to look at the tube feeding poles when they change the tube feeding bag and they should clean the tube feeding pole when it was soiled. During an interview on 1/8/24 at 1:33 P.M., the Director of Nursing (DON) said: - The facility staff should be looking at the poles daily to see that there was no buildup of tube feeding debris on those poles. - Any facility staff could clean the tube feeding poles. - The tube feeding poles can be cleaned at night.

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for two sampled residents (Resident #31 and #80) who had a weight loss of over 10% in the last six months; to ensure monitoring of weight loss interventions was completed to try to prevent continued weight loss for one sampled resident (Resident #80); to ensure health shake supplements were documented to show the amount consumed for three sampled residents (Resident #80, #53 and #81) and to ensure dietary orders were transcribed accurately to dietary meal tickets for two sampled residents (Resident #53 and Resident #81) out of 21 sampled residents. The facility census was 92 residents. Review of the Facility's policy titled Nutrition (impaired)/Unplanned Weight Loss- Clinical Protocol dated January 2017 showed: -The nursing staff were responsible for the monitoring and documenting of weights. -The threshold for significant unplanned weight loss was: --One month: 5% loss was significant, greater than 5% was severe. --Three months: 7.5% loss was significant, greater than 7.5% was severe. --Six months: 10% weight loss was significant, greater than 10% was severe. -The staff and physician would identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes. -The Physician will authorize, and the staff will implement appropriate general or cause-specific interventions, as indicated, with the careful consideration of the following: --Resident Choice. --Nutritional Needs. --Supplementation. --Feeding tubes. 1. Review of Resident #31's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Malignant Neoplasm of Prostate (prostate cancer). -Unspecified protein-calories malnutrition. -Cognitive Communication Deficit. -Contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity in the joints) of Left Hand. -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life. Review of the resident's weight summary on 6/4/23 showed the resident weighed 152.4 pounds (lbs.). Review of the resident's Weight Progress Note dated 8/14/23 completed by the Facility's Registered Dietician (RD) showed: -The resident's weight was down 9.2% in the last 90 days. -The resident's weight was down 11.7% in the last 180 days. -The resident was on a mechanical soft diet (any foods that can be blended, mashed, pureed, or chopped using a kitchen tool such as a knife, a grinder, a blender, or a food processor) with nectar thick liquids (easily pourable and are comparable to heavy syrup found in canned fruit). -The resident was on Remeron (Mirtazapine- used to treat depression but can also be used as an appetite stimulant) which can help with appetite. -He/she had spoken with the resident and the resident stated that he/she did not have much of an appetite. -The resident liked sweets and usually ate more around breakfast time. -The resident had Ensure (supplement) in his/her fridge. -He/she recommended Supercereal (a highly fortified porridge made of blended corn, soybean, dried skim milk and sweetener) at breakfast and Magic Cup (like ice cream when frozen but is a pudding after thawing used for adding calories and protein for those experiencing weight loss). NOTE: This was the last time the RD saw the resident. Review of a Weight Warning Note dated 10/6/23 completed by the Director of Nursing (DON) showed: -The Weight Warning showed the resident had lost more than 10% of his/her weight. -The DON wrote that the resident's weight had been stable. -The Physician and Family were aware of the resident's weight loss. -The facility would continue to monitor the weight loss. Review of the resident's Interdisciplinary Care Plan Conference Notes dated 11/7/23 showed the resident's weight and vital signs had been reviewed with no issues. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 11/12/23 showed: -The resident was cognitively intact. -The resident needed set-up or clean-up assistance (helper sets up or cleans up; Resident completes activity) only when eating. -The resident had a weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a physician-prescribed weight-loss program. -The resident had a mechanically altered diet. Review of the resident's Treatment Administration Record (TAR) dated December 2023 showed: -The resident was receiving a Glucose Control Supplement daily but did not indicate the amount the resident consumed. -The resident was receiving a Magic Cup with lunch daily but did not indicate the amount the resident consumed. -The resident was receiving the Supercereal with breakfast but did not indicate the amount the resident consumed. Review of the resident's Interdisciplinary Care Plan Conference Notes dated 12/9/23 showed the resident's weight and vital signs had been reviewed with no issues. Review of the resident's weight summary on 12/13/23 showed: -The resident weighed 133.6 lbs. on 12/13/23 which indicated a weight loss of 12.34% in six months. -The resident was last weighed on 12/13/23. -The resident's Ideal Body Weight (IBW) was between 167.0 lbs.-202.0 lbs. Review of the resident's Physician Order Sheet (POS) dated January 2024 showed: -The resident was on a regular diet with mechanical soft texture with regular liquid consistency. -An order for Glucose Control Supplement, give one time a day for weight management, give one carton. -An order for magic cup one time a day for weight management to be given at lunch. -An order for Supercereal one time a day for weight management to be given with breakfast. -An order for double portions at breakfast. -An order for Mirtazapine Oral Tablet 7.5 milligrams (mg), give 7.5 mg by mouth at bedtime for depressive disorder. During an interview on 1/3/24 at 9:36 P.M. the resident said he/she was losing weight but was unsure of what the facility was doing to prevent his/her weight loss. Observation of lunch on 1/3/24 at 12:29 P.M. showed: -The facility had started to pass the trays to the residents who stayed in their room for lunch. -The resident received his/her meal at 12:37 P.M. -The resident started eating his/her meal at 12:42 P.M. -The resident had finished his/her lunch at 1:05 P.M. -The resident had eaten 25% of the meal. -The resident had ice cream with his/her meal, but the Magic Cup was not served. -The resident was served a Boost drink and had consumed 25% of it at that point in time. -The resident had an additional Boost drink at his/her bedside and stated he/she had received it with breakfast that morning. -The resident had not been encouraged to eat throughout the meal. Review of the resident's TAR dated January 2024 showed: -The resident was receiving a Glucose Control Supplement daily but did not indicate the amount the resident consumed. -The resident was receiving a Magic Cup with lunch daily but did not indicate the amount the resident consumed. -The resident was receiving the Supercereal with breakfast but did not indicate the amount the resident consumed. Review of the resident's Nutrition-Amount Eaten documentation dated 1/8/24 showed the resident ate 51%-75% of most meals. Review of the resident's Nutrition-Snack documentation dated 1/8/24 showed the resident declined snacks about 45% of the time within the last month when a snack was offered. During an interview on 1/8/24 at 10:15 A.M. Certified Nursing Assistant (CNA) A said: -CNAs were responsible for getting residents weights every Tuesday if the resident was on weekly weights. -The nurses were the ones who monitored weight loss. -He/she was unsure of when the RD would normally come to the facility but thought he/she saw them often. -Any weight concerns that he/she may have for a resident were to be passed on to the nurse. -He/she was unsure of who was specifically responsible for getting supplements to the residents but knew it was on the TAR. -If a resident had weight loss, then the facility would put the resident on daily weights, get the physician involved, and follow whatever was ordered by the physician. -If a resident needed to be weighed more than monthly, then there would need to be an order. -All residents with weight loss should be encouraged to eat at every meal. During an interview on 1/8/24 at 10:42 A.M. CNA B said: -The resident had lost weight. -He/she was unsure of the amount of weight that the resident had lost. -He/she was unsure of what interventions were in place to prevent further weight loss for the resident. -He/she had needed to help the resident occasionally with eating. -The resident usually ate most of his/her food. -He/she was unsure of when the RD last saw the resident. -He/she thought the resident should be getting weighed two times a week. During an interview on 1/8/24 at 10:49 A.M. Registered Nurse (RN) B said: -CNAs were responsible for getting all residents weighed. -Nurses could also get a resident's weight. -He/she thought the Assistant Directors of Nursing (ADON) were responsible for monitoring resident weights. -Residents were usually weighed on Tuesdays. -He/she was unsure of when the RD usually came to the facility but had a number for the RD if a resident needed to be seen. -If he/she were to notice a resident losing weight then he/she would call the doctor, inform the ADON, see if a new dietary preference assessment needed to be completed by the kitchen manager, and follow any orders received from the doctor. -Residents who have weight loss were not required to go to the dining room for meals. -If a resident with weight loss preferred to stay in his/her room for meals, then he/she would try to sit with the resident to encourage them to eat. During an interview on 1/8/24 at 12:07 P.M. the resident said: -He/she did not always get a Magic Cup served with his/her lunch. -He/she was unsure of when he/she started getting the Boost during mealtimes. During an interview on 1/8/24 at 12:13 P.M. Licensed Practical Nurse (LPN) C said: -The resident was not on a weight watch. -Residents were usually weighed once a month but could be weighed once a week if needed. -If the resident was losing weight, then he/she would need to be put on weekly weights. During an interview on 1/8/24 at 12:19 P.M. ADON A said: -CNAs were responsible for getting the residents weighed. -He/she and the DON were responsible for monitoring resident weights. -He/she was unsure of when the resident last saw the RD. -The RD came to the facility on Mondays. -If a resident has weight loss it would be discussed in the Risk Management meeting. -The resident should be on weekly weights. -He/she was unsure if the resident had an order for weekly weights, but there would need to be one for the CNAs to get the weights. -It seemed like the resident could not stop losing weight. -He/she was aware that the resident was losing weight but was unsure of why the system had not flagged him/her. -The resident was receiving supplements and there should be a record of the amount eaten or drank in the resident's TAR. -He/she was unsure of why the documentation for the amount eaten or drank of the supplements was not showing up on the TAR. -He/she had not realized the RD had not seen the resident since August. -He/she had not realized the resident had lost over 10% of his/her weight in the last six months. -The resident had been on weekly weights previously but was unsure of why the Resident would have been taken off weekly weights. Observation on 1/8/24 at 12:42 P.M. showed the resident had received a vanilla supplement shake with lunch. During an interview on 1/8/24 at 1:00 P.M. the DON said: -He/she was unsure if the resident had been losing weight and would need to look at the resident's notes and assessments. -If the resident was losing weight, then there should have been an order for weekly weights. -He/she would not consider the resident's weight stable. -He/she was unsure why the resident had been taken off weekly weights. -He/she was unsure of what supplements the resident was on. -He/she would have expected an order to be in place for any additional supplements or replacements that the resident was receiving. -He/she was responsible for the weight management program and the ADONs were responsible for ensuring residents' weights were completed. 33409 2. Review of Resident #53 Admission Face Sheet showed he/she had diagnoses of stroke right side, dementia and dysphagia (difficulty swallowing), Hospice Care (end of life care) started on 6/9/23 due to a stroke. Review of the resident's Annual Nutrition Review, dietary note dated 5/22/23 at 6:22 P.M. showed: -The resident continues regular diet and textures, thin liquids. He/she were to utilizes a divided plate at mealtimes. -Meal intakes show 50-100% over the last month. -Current weight of 170.8 pounds. -Monitored on weekly weights. -Weights were stable for one month, and a 4.4% decrease in weight in three months and 6.25% decrease in six months. -These weight changes were not significant. -The resident's weight history reviewed, the resident appears to have had an increase and now weights were gradually trending back down. -New order for ice cream with lunch and dinner per Electronic Medical Record (EMR). -The resident's estimated needs for calories of 1613 with 78 grams of protein and 1950 milliliters of fluids. -Continue to monitor the resident's weekly weights. -Continue to encourage resident at mealtimes and provide necessary assistance. Review of the resident's Nutrition Care plan updated on 8/30/23 showed: The resident had a nutritional problem or potential nutritional problem related to stroke with dysphagia. -He/she had physician order to provide supplements drink as ordered. -Provided and serve diet as ordered. -Care staff were to provide setup assistance for meal trays with each meal. Inform the resident of what he/she was eating and where the located on his/her plate or tray. -The care plan did not show the resident had weight loss. Review of the resident's EMR showed: -On 10/3/23, his/her weight was 150.6 pounds. -On 11/7/23, his/her weight was 147 pounds. -On 12/5/23, his/her weight was 144.4 pounds. Review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was moderately cognitive impairment. -Was able to make his/her needs known. -Weight was 144 pounds. -Was not on a physician ordered weight loss regimen. -The resident was placed on Hospice care while at the facility. Review of the resident's POS dated 1/2024 showed the resident had the following physician's order: -A regular diet, regular texture, regular liquid consistency, order dated of 8/16/19. -The resident used a divided plate at all meals ordered on 2/22/23. -For ice cream at lunch and dinner two times a day for weight management ordered on 3/8/23. -For Boost Plus supplement two times a day for weight management, ordered on 10/10/23. Review of the resident's MAR dated 1/2024 showed: -For 1/1/24-1/8/24: --Physician order for Boost plus two times a day for supplement for weight management. --Documented supplement as given with (Certified Medication Technician) CMT initial and check mark, given 15 out 15 opportunities. --The resident's MAR did not have place to document the total percentage of intake of supplement drank by the resident. Review of the resident TAR dated 1/2024 showed: -For 1/1/24 to 1/8/24: --Ice cream at lunch and dinner two times a day for weight management ordered on 3/8/23. --Documented with nursing initial as given on 15 out 15 opportunities. --The resident's TAR did not have place to document the total percentage of intake of for ice cream eaten by the resident. --Note: Observation of lunch meals on 1/3/24, 1/4/24 and 1/5/24 did not have ice cream on lunch meal tray. Review of the resident's EMR showed: -On 1/2/24, his/her weight was 135.8 pounds. -The resident had 10.36 % weight loss in three months. Observation on 1/3/24 at 12:31 P.M., of the resident meal in room showed: -He/she had a divided plate with peas, potatoes and meat. -The resident was able to feed himself/herself after setup. -He/she ate around 45% of meal. -CMT B had encourage resident to eat more and he/she refused. -He/she did not have ice cream on meal tray as ordered. -There was no physician order transcribed onto the meal ticket for ice cream at lunch and dinner for weight management. Observation on 1/4/24 of the resident showed: -he/she was in his/her room. -He/she had eaten 3/4 of slice of pizza. -Supplemental drink at bedside remain full. Observation on 1/5/24 at 8:51 A.M. of the resident in room showed: -The resident was in bed. -He/she had full supplement drink at bedside. Review of the resident's lunch meal ticket dated 1/5/24 showed: -Regular diet requires a room tray. -Soup in mug for lunch and dinner. -Required a divided plate. -There was no physician order transcribed onto the meal ticket for ice cream at lunch and dinner for weight management. Observation on 1/5/24 at 12:31 P.M. of the resident showed: -He/she was up in his/her chair for the meal. -He/she had fish, broccoli, peas, roll, soup in a cup, and pineapple on a divided plate. -His/her morning supplemental drink was the on bedside table. -The resident meal tray was removed at 12:53 P.M. -He/she did not drink the shake and only took bites of fish and roll. -He/she had finished his/her cup of soup. -He/she did not have ice cream on lunch meal tray. During an interview on 1/8/24 at 10:33 A.M., Dietary Aid (DA) A said: -The resident were getting soup in a mug at lunch and dinner instead of ice cream. Review of the meal ticket sheet with DA A showed the resident did not have the prescribed physician's diet orders transcribed to meal ticket for ice cream during lunch and dinner meals. -The Dietary Manager said he/she would be responsible for review the resident's diet orders from the EMR reports to ensure they have the most current physician diet orders placed on the meal tickets. 3. Review of Resident #81's Admission Face sheet showed his/her diagnosis of Dementia (is a general term for loss of memory and other mental abilities severe enough to interfere with daily life) and Hospice Care. Review of the resident weight change note (late entry) dated 8/8/23 at 1:52 P.M. showed: -The resident's weight was taken on 8/7/23 at 2:41 P.M.: The resident had a weight warning and his/her weight was 113.6 pounds. -This was a 3.0% change from the resident's last weight and a 3.% change over 30 days. -The resident was a new admit to the facility in July 2023. -His/her hospital weight before admission was 121 pounds. -He/she was on a regular mechanical soft diet and received Boost Plus (a supplement nutritional drink) given three times a day. -A RD would review the resident's weight. -His/her physician was aware of the weight change. Review of the resident's Dietary note dated 8/14/23 at 6:31 P.M. showed: -Reviewed for resident weight loss. -His/her weight 113.6 pounds, was down 7.4 pounds or 6% loss since admission. -The resident had physician order for mechanical soft diet, fortified foods and Boost Plus three times a day. -He/she had observed the resident at lunch that day and he/she had eaten 25% meal with supervision and minimal assistance. -The resident had advanced dementia and cannot clearly communicate his/her needs or food preferences. -Weight loss may be related to advance dementia. -The resident had physician order for multivitamin and minerals. -No further recommendations. Review of the resident's Dietary Note dated 9/18/23 at 12:54 P.M. showed: -Review completed due to resident's skin breakdown risk. -The resident weighed of 123.4 pounds was stable since admission. -The resident received a mechanical soft diet. -He/she had observed resident at lunch that day. Family member was feeding the resident. -The resident's family member said the resident prefers a regular diet, but he/she cannot eat hard foods. -Recommend: adding fortified foods, no raw vegetables, multivitamin and minerals and Boost Breeze supplement three times a day with meals. Review of the resident's weight on 10/4/23 showed the resident weighed 118 pounds. Review of the resident's Dietary Note dated 10/10/23 at 11:40 A.M. showed: -The resident received a mechanical soft diet with Boost Breeze (nutritional Drink provides fruit flavored, clear liquid nutrition with 9 grams high-quality protein, 19 vitamins & minerals and 250 calories) three times a day. -He/she required assistance with feeding and consumes 51-75% of most meals. -His/her weight was 118 pounds and was down 5.4 pounds at a 4.4% loss in 30 days. -Recommend: consider changing Boost Breeze to Boost Very High Calorie nutritional drink (VHC, 8 fluid ounce (oz) serving of supplemental nutritional drink), three time a day with meals. -Boost VHC has twice as many calories and more protein compared to Boost Breeze. -Will continue to monitor the resident's weights. Review of the resident's physicians order dated 10/10/23 showed he/she had a new physician order for Boost VHC, three times a day for a supplemental drink with meals. Review of the resident's Quarterly MDS dated [DATE] showed he/she: -Was severely cognitively impaired. -Weighed 118 pounds and did not have weight loss. -Had a mechanically altered diet. Review of the resident's undated Care Plan showed there was no care plan for weight loss. Review of the resident's weights on 11/9/23 showed the resident weighed 102.4 pounds, which was a weight loss of 15.6 pounds in one month. Review of the resident's new physician order dated 11/15/23 showed he/she had physician order for a regular diet, pureed texture, regular liquid consistency and fortified foods. Review of the resident's Hospice Skilled Nursing assessment dated [DATE] showed: -The ADON had reported the resident had weight loss of 20 pounds in last 6 months. -The resident required total assist with meals. -The resident had a diet order of pureed diet and had difficulty swallowing. -The resident does not eat or drink much, only bites and sips. -The resident's weight was 102.4 pounds. Review of the resident's weight on 12/13/23 showed: -The resident was 91.7 pounds for a total weight loss for last three months of 26.3 pounds. -The resident's total percentage of weight loss of 22.29% in three months. Review of the resident's Physician Note dated 12/14/23 showed: -The resident's weight of 91.7 pounds. -A warnings noted: minus (-) 3.0% weight change from last weight. -There were no recommendations related to the weight loss from the physician. Review of the resident's MAR dated 12/1/23 to 12/31/23 showed: -A physician's order for Boost VHC three times a day for supplement with meals. -Documented with CMT initial and check mark as given and number one if refused. -The resident had refused the supplemental drink 7 out 93 opportunities. -The resident's MAR did not have place to documentation total percentage or amount consumed by the resident. Review of the resident's Certified Nursing Assistance (CNA) task showed the resident percentage of meal eaten on: -Had no documentation for 1/1/24, 1/2/24 of meals percentage eaten. -1/3/24 at 11:15 A.M. and 12:46 P.M. had 0-25% of meal. No evening meal documented. -Noted the resident had refused meal, only eaten 0-25% and no more than 50% of meals documented during look back period. Review of the resident's MAR dated 1/1/24 to 1/4/24 showed: -A physician order for Boost VHC three times a day for supplement with meals. -Documented with CMT initial and check mark as given 11 out 11 opportunities. -The resident's MAR did not have place to documentation total percentage or amount of supplement drank by the resident. Observation on 1/3/24 at 12:39 P.M., of the resident showed: -He/she was being assisted with his/her meal in his/her room by CNA G. -CNA G said the resident required to be fed for all meal. -The resident does not eat much at one a time. Observation and interview on 1/4/24 at 12:57 P.M. the resident and family member showed: -The resident was sitting in his/her Broda chair (specialized wheelchair) in room. -The resident's meal ticket sheet showed he/she had received a mechanical soft diet, include fortified mash potatoes, ravioli, green beans and a roll. -The resident's meal tray had ravioli, whole green beans, roll and a cup of fortified mashed potatoes. -He/she was being assisted with his/her meal by a family member. -The resident was feed the fortified mashed potatoes. -The resident did not have a pureed meal as physician ordered. -The family member said he/she were aware of the resident's weight loss. --He/she had been notified by facility staff of the resident's weight loss. --The resident does not eat much of meals, only a few bites at times. During an interview on 1/4/24 at 12:59 P.M., CNA G said: -The resident required feeding assistance from facility staff. -He/she would documented under task the amount the resident had eaten after each meal. -He/she would encouraged the resident to eat the meal and he/she would notify nursing staff if the resident had a decrease in meal intake or refused to eat. -The resident usually only ate small amounts of food. Observation on 1/5/24 at 12:31 P.M., of the resident showed: -The resident was sitting in his/her Broda chair in his/her room. -The CNAs had left the meal tray on his/her bedside table. He/she also had the morning health shake 3/4 full on the bedside table. -The resident lunch meal was of pureed food to include fish, peas, fortified mashed potatoes and fruit that day. -Review of the resident's meal ticket sheet dated 1/5/24 for Friday lunch showed the resident's diet orders were changed to a pureed meal. -At 12:34 P.M., CNA G entered the resident room to assist the resident with his/her meal. 4. During an interview on 1/5/24 at 12:35 P.M., CNA G said: -When he/she had assisted the resident with meal other day, he/she had noticed the resident had a mechanical soft diet. -He/she was aware the resident not able to eat the other food on meal tray, so he/she assisted feeding the resident the fortified potatoes. During an interview on 1/5/24 12:40 P.M., CMT said: -He/she provided the supplemental drinks to the resident. -He/she would offer drinks of supplement drink and then leave the rest of the supplemental drink for the resident to finish. -He/she would return check to see how much the resident drank and to ensure offer drinks of the supplement throughout the shift. -He/she would document the supplement drink intake amount in the resident's MAR. During an interview on 1/8/24 at 9:47 A.M., CNA C said: -The resident's supplemental drinks he/she provided the supplement and gives sip to the resident. -If the resident was not drinking the supplement drink, then he/she would leave the drink and come back try again. -CMTs were to document on the resident's MAR any nutritional supplement drinks were given and amount drank, if the MAR had place to document percentages of intake. During an interview on 1/8/24 at 10:27 A.M., CMT B said: -CNAs and CMTs should document the resident's meal intake after each meal in under task. -Facility staff should check each resident's meal ticket make sure received the right diet. -CMTs would administer the resident's prescribed supplemental drinks and document the percentage drank on the resident's MAR. During an interview on 1/8/24 at 10:40 A.M., LPN B said: -The CNA's and CMT would report all the weights to LPN's. -If they notice a pattern of weight loss or gain, he/she would notify the ADON, the resident's physician and the DON of any changes in the resident's weight. -Any changes in the resident diet order would be communicated to the kitchen staff. -The resident was on Hospice services who were aware of the resident's weight changes. -He/she should have been given pureed diet per the physician's orders. 5. During an interview on 1/8/24 at 12:55 P.M., DON said: -Resident #81 and Resident #53 were on Hospice care. -He/she would expect Hospice nursing to be monitoring the residents weights and intake. -The resident required assistance with meals. -He/she would expect CMTs to document the resident Boost supplement drinks when given and amount consumed on the resident MAR. -Not all of the resident's MARs had place to document the amount consumed. -The Dietary Manager would print out weekly diets and compare this to the physician diet orders report. -He/she would expect resident with weight loss be placed on weekly weights and monitor meal and supplement drink intakes. 21003 6. Review of Resident #80's Face sheet showed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia, cognitive communication deficit, depression, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), muscle weakness and pain. Review of the resident's Weight Record on 7/7/23 showed the resident weighed 111 pounds. Review of the resident's Nutritional assessment dated [DATE], showed the resident: -Was alert with confusion, and his/her current weight was 111 pounds. His/her goal weight was 115 pounds. -Received a regular diet and ate 51-75 percent at meals, and was able to feed himself/herself. -Also received a health shake supplement, one per day. -Was at risk for weight loss due to varied meal intake and dementia. -Recommendations included liberalizing the resident's diet to regular, add fortified foods and add a multivitamin with minerals daily. Review of the resident's Weight Record on 8/7/23 showed the resident weighed 101.2 pounds. Review of the resident's Physician's Telephone Order 9/11/23 showed monthly weights for weight loss. Review of the resident's Weight Record on 9/5/23 showed the resident weighed 100.4 pounds. Record review of the resident's Weight Loss Record dated 10/5/23, showed the resident weighed 101.2 pounds (a gain of 1.2 pounds in 30 days). Review of the resident's Weight Change Note dated 10/6/23, showed: -Weight warning: resident's current weight was 101.2 pounds on 10/5/23. -This showed a 7.5% weight loss. (within a month). -Notes showed the resident's weight has been stable. He/she is on a regular diet and received a weight supplement. Will continue to monitor. Physician and family were notified. Review of the resident's Physician's Telephone Order dated 10/11/23, showed a diet order for health shake supplement one carton once daily for supplement. Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert with severe cognitive incapacity. -Had functional limitations in range of motion of the resident's lower extremities. -Was dependent on staff for all transfers, toileting, bathing, was incontinent and nee

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5% with a medication error rate of 26.92% when Licensed Practical Nurse (LPN) B did not ensure all crushed medication substances in medicine cups were dissolved and given via percutaneous endoscopic gastrostomy (PEG - a tube is a procedure to place a feeding tube) for one sampled resident (Resident #76) and when Registered Nurse (RN) A did not ensure that insulin pens were primed before insulin administration for one sampled resident (Resident #24) and one supplemental resident (Resident #48) out of 21 sampled residents and four supplemental residents. The facility census was 92 residents. Review of the facility Enteral feeding Policy dated 1/22 showed: -Flush tubing with with at least 30 ml (milliners) of water or prescribed amounts before and after feedings. -No instruction for administration of medication via feeding tube. Review of the facility policy general dose preparation and medication administration 1/22 showed: -The facility staff should crush oral medication only in accordance with pharmacy guidelines or facility policy. -No instruction on providing medication via PEG-tube. Review of the facility's undated Skills Checklist titled Flex Pen Insulin Administration Skills Check showed: -Once the staff person wiped the bevel of the insulin with an alcohol pad, he/she was to then remove the seal of the needle and twist onto the insulin pen. -After the needle is in place the staff person was to prime the needle with two units of insulin, then dial the insulin to the appropriate amount of insulin. 1. Review of Resident #76's admission Face Sheet showed the following diagnoses: -Gastrostomy status (a surgical opening into the stomach. A gastrostomy may be used for feeding, usually via a feeding tube called a gastrostomy tube). -Viral Hepatitis (is an inflammation of the liver often caused by a virus). Review of the resident's Care Plan dated 3/24/23 showed: -He/she had no intervention related to medication via peg tube. -PEG-tube flushes and hydration per physician orders. -Administer medication as ordered. Review of the resident's Physician Order Sheet (POS) dated 1/2024 showed he/she: -Had a physician order to flush feeding tube with at least 30 ml of water before and after medication administration and feeding; And to flush the feeding tube with 5 ml of water between each medication, was order dated 9/10/23. -Entecavir (is used to treat liver infection caused by hepatitis B virus) 0.5 milligrams (mg) tablet, to give 1 tablet via PEG tube daily for antiviral. Nursing staff were to wear gloves when handling or crushing medication. -Atorvastatin Calcium (to lower cholesterol level in body) Oral Tablet 10 mg, to give one tablet via PEG-Tube one time a day for high cholesterol, was ordered on 7/8/23. -Aspirin Tablet Chewable 81 mg, give one tablet via PEG-tube one time a day for preventative treatment Heart Health, was ordered on 12/21/2023. -Colace Oral Capsule 100 MG (Docusate Sodium, stool softener), give one tablet via PEG-Tube one time a day for constipation, was ordered on 7/8/23. - Keppra oral solution give 2.5 ml via PEG-Tube every morning, used for managing seizures. Review of the resident's Treatment Administration Record (TAR) dated 1/1/24 to 1/31/24 showed physician's orders to flush feeding tube with at least 30 milliliters (ml) of water before and after medication administration and feeding and to flush the feeding tube with 5 ml of water between each medication, dated 9/10/23. Observation on 1/4/24 at 6:55 A.M., of the resident's PEG-tube medication pass showed: -LPN B had sanitized his/her hands prior to starting to prep medication. -He/she had already crushed the resident's antiviral medication and had placed in medicine cup (is a clear plastic medicine cup/container which hold oral medication or used measure one fluid ounce or 30 ml of liquids). -He/she prepped the other medication and placed each crushed medication in separate medicine cup for the follow medication: --Entecavir 0.5 mg one time a day. --Atorvastatin 10 mg one time a day. --Aspirin 81 mg one time a day. --Colace (stool softer) 100 mg one time a day. - Vitamin C 500 mg one time a day. -He/she had poured liquid Keppra 2.5 ml in a medicine cup. -He/she entered the resident room, washed hand with soap and water water and applied gloves to hands. -He/she added 30 ml of water into five of the medicine cup of crushed medication. -He/she did not stir to mix the crush medication, to ensure medication were dissolved prior to administering via PEG tube. -Five of medicine cups had chunks/particles of the crushed medication left in the cups. -No additional water were added to cups to obtain the not dissolved medication left in the cups. -He/she completed medication pass with water flush of the tube. -He/she threw away the five used medicine cups that had not dissolved medication left in it. During an interview on 1/4/24 at 8:29 A.M., LPN B said: -He/she should had worn gloves when handling antiviral medication. -The resident's crushed medication should had been mix to ensure all dissolved prior to administration. -When part of the crushed medication were left in medicine cup, he/she should had added a little more water and mix with spoon to ensure all medication dissolved and then given via PEG-tube. During an interview on 1/8/24 at 10:40 A.M., LPN B said he/she were not aware of any potential side effect for the resident, from not getting all his/her crushed medication including his/her antiviral medication. During an interview on 1/8/24 at 12:55 P.M., Director of Nursing (DON) said: -He/she would expect licensed nursing staff to ensure all crushed medication were dissolved prior to administration and would expect nursing staff to add additional water to any crushed medication left in a medicine cup, to ensure all medication were dissolved and given as physician ordered. -He/she would expect nursing staff to notify the physician of resident's medication were not fully given as physician ordered. 46519 2. Review of Resident #48's Face Sheet showed he/she admitted to the facility with a diagnosis of Diabetes Mellitus (DM II-- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Review of the resident's Significant Change Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 12/19/23 showed: -The resident was cognitively intact. -The resident received insulin. Review of the resident's POS dated January 2024 showed an order for Humalog (insulin lispro- a short acting insulin) Injection Solution 100 units (u)/milliliters (ml), inject six units subcutaneously with meals for DM II. Observation on 1/4/24 at 12:02 P.M. of the resident's insulin administration completed by RN A showed: -He/she placed the needle on to the insulin pen and dialed the pen to six units without priming the pen. -He/she then went into the resident's room and administered the insulin. 3. Review of Resident #24's Face Sheet showed he/she admitted to the facility on [DATE] with a diagnosis of DM II. Review of the resident's Admission MDS dated [DATE] showed: -The resident was cognitively intact. -The resident received insulin. An order for Humalog Injection Solution 100 u/ml, inject 10 units subcutaneously with meals for DMII. Observation on 1/4/24 at 12:06 P.M. of the resident's insulin administration completed by RN A showed: -He/she placed the needle on to the insulin pen and dialed the pen to five units without priming the pen. -He/she then went into the resident's room and administered the insulin. NOTE: RN A had previously asked the resident what dose of medication he/she wanted before lunch, and the resident answered five units. During an interview on 1/4/24 at 12:20 P.M. RN A said: -He/she was unsure of how the insulin administration went. -He/she would not have changed anything. -He/she never primed insulin pens before insulin administration. During an interview on 1/8/24 at 10:55 A.M. RN B said: -Insulin pens should always be primed before insulin administration. -The reason why an insulin pen needed to be primed was to ensure the resident received the full dose of insulin. -The insulin pen needed to be primed with two units of insulin. -He/she was educated upon hire about insulin pen administration. -The facility typically only used insulin pens for insulin administration. During an interview on 1/8/24 at 12:33 P.M. Assistant Director of Nursing (ADON) A said: -All insulin pens needed to be primed before insulin administration. -Priming an insulin pen ensured the resident received the full dose of insulin. -The insulin pen needed to be primed with two units of insulin. -If the nurse did not prime the insulin pen before administration, then he/she would not be certain that the resident received the full dose. During an interview on 1/8/24 at 1:00 P.M. the DON said: -Insulin pens should always be primed. -The insulin pens needed to be primed with two units of insulin before administration. -Priming an insulin pen ensured the resident received the full dose of insulin. -He/she would have expected the nurse to have primed the insulin pen. -There would be no reason for not priming an insulin pen before insulin administration. MO00229726

Based on observation, interview, and record review, the facility failed to ensure the refrigerator temperature was maintained at the appropriate temperature in the North Hall medication room which had the potential to affect all residents in the North Hall. The Facility census was 92 Rresidents. Review of the Facility's policy titled Storage and Expiration Dating of Medications, Biologicals dated 8/7/23 showed: -Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges including: --Refrigeration: 36 degrees to 46 degrees Fahrenheit (F). -Facility should monitor cold storage containing vaccines two times a day per Centers for Disease Control (CDC) guidelines. 1. Review of the North Hall's Refrigerator Temperature Log dated January 2024 showed: -The temperature on 1/1/24 was 38 degrees F. -The temperature on 1/2/24 was 38 degrees F. -The temperature on 1/3/24 was 39 degrees F. -The temperature on 1/4/24 was not legible. Observation on 1/5/24 at 12:40 P.M. of the North Hall's medication refrigerator showed the refrigerator temperature was 31 degrees F. During an interview on 1/5/24 at 12:41 P.M. Assistant Director of Nursing (ADON) B said: -The refrigerator temperatures are checked once a day during the night shift. -He/she thought the refrigerator temperature that was written on the log for 1/4/24 was 35 degrees but would double check with the nurse, Licensed Practical Nurse (LPN) A from that shift. -He/she was unsure of what temperature the refrigerator needed to be maintained at to provide appropriate medication storage. Observation on 1/5/24 at 1:02 P.M. of the North Hall's medication refrigerator showed the following medications: -Four insulin pens. -Four Intravenous (IV) antibiotics. -One solution for Tuberculosis (TB) testing. -One omeprazole and sodium bicarbonate oral solution. -One Humira pen. -One box of epinepherine injections. During an interview on 1/5/24 at 1:37 P.M. ADON B said: -He/she had double checked with the nurse who had checked the temperature on 1/4/24 and that LPN A wrote 35 degrees. -He/she assumed that the temperature had been taken before midnight indicating the temperature had been taken the previous night shift. Observation on 1/5/24 at 2:46 P.M. of the North Hall's medication refrigerator showed the refrigerator temperature was at 30 degrees F. During an interview and observation on 1/5/24 at 2:47 P.M. ADON B said: -The refrigerator temperature looked like it was between 30-32 degrees F. -He/she turned the dial in the refrigerator from medium refrigeration to minimal refrigeration. -He/she was unsure why the refrigerator temperature was low. During an interview on 1/8/24 at 1:00 P.M. the Director of Nursing (DON) said: -It was night shift's responsibility to check the refrigerator temperatures within the facility. -The nurses were responsible for checking the temperatures once during the shift. -He/he was unsure of what the refrigerator temperature needed to be maintained at for proper medication storage. -After knowing the refrigerator temperature needed to be maintained at 36 degrees F and above, he/she would have expected staff to have done extra monitoring of the refrigerator temperature to ensure the medications were being stored appropriately. -Whenever the staff needed to get a medication out of a medication refrigerator, he/she expected the staff to look at the temperature in the refrigerator to ensure that it was being maintained at the appropriate temperature. During a telephone interview on 1/8/24 at 8:03 P.M. Licensed Practical Nurse (LPN) A said: -He/she was unsure of what the temperature of the North Hall medication refrigerator had been and would need to double check what he/she wrote. -He/she had looked at the temperature log and thought he/she had written a temperature of 30 degrees F. -The refrigerator temperature varied and was usually between 30 degrees and 40 degrees F. -He/she was unsure of what the refrigerator temperature was supposed to be at for the medications that were in the refrigerator. -He/she had never been educated on what the refrigerator temperatures needed to be maintained at. -If he/she had known what the temperature of the medication refrigerator needed to be at, he/she would have adjusted the refrigerator temperature and monitored the temperature throughout his/her shift. -It was night shift staff's responsibility to check he refrigerator temperatures within the facility. -He/she normally checked the refrigerator temperatures around midnight during his/her shifts.

Based on observation and interview, the facility failed to ensure the door to the dessert fridge closed properly; to ensure the baffle (movable metal partitions used to create slotted openings along the back of the hood used to direct the air that is being exhausted out of the hood) were installed in the range hood (an open metal enclosure over cooking surfaces through which air is drawn in from the surrounding spaces to exhaust heat and grease, and to control the flow of rising hot air into the range hood and filter grease), vents did not have a heavy buildup of dust; and to ensure the upper water nozzles of the dishwasher were maintained free from debris inside those nozzles. This practice potentially affected 90 residents who received food from the kitchen. The facility census was 92 residents. 1. Observation during the initial kitchen observations on 1/02/24 from 9:03 A.M. through 9:20 A.M., showed: - The door to the dessert fridge did not close properly without closing it extra hard with the body. - A buildup of dust on the range hood baffle vents while there was food cooking under the range hood. - The presence of debris inside three upper nozzles in the automated dishwasher. 2. Observation on 1/5/24 from 6:48 A.M. through 7:58 A.M. during the breakfast meal preparation showed: - The presence of debris in the upper nozzles of the automated dishwasher. - The door to the dessert fridge did not easily close, because when it was closed it would slowly reopen on its own. During an interview on 1/5/24 at 7:51 A.M., the Dietary Account Manager said they take out the lower parts of the dishwasher water nozzles but they did not take out the upper components to remove the debris. During an interview on 1/5/24 at 7:56 A.M., the Dietary Account Manager said the door for the dessert refrigerator has not been closing well for a year. During a phone interview on 1/10/24 at 11:31 A.M., the Dietary Account Manager said: -He/she discussed with the Maintenance Department that the dietary staff would wash the baffle vents every 3-4 weeks. - A few weeks ago, one of the cooks asked the Maintenance Department to pull down the baffle vents to wash them but all of the baffle vents may not have been washed.

Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene during medication pass when passing oral medications and connecting/disconnecting an intravenous (IV) antibiotic to two sampled resident's (Resident #24 and #40) central venous catheter (CVC- a catheter placed in a large vein usually in the chest, neck, or groin to give medications, fluids, nutrition, or blood); during insulin administration for one sampled resident (Resident #24) and one supplemental resident (Resident #48); and to follow appropriate infection control practices to properly change gloves and wash or sanitize their hands during incontinence care for two sampled residents (Resident #59 and #70) out of 21 sampled residents and four supplemental residents. The facility census was 92 residents. Review of the facility's policy titled Standard Precautions-Hand Hygiene dated from 2019 showed: -Appropriate hand hygiene is essential in preventing transmission of infectious agents. -Hand hygiene continues to be the primary means of preventing transmission of infection -Gloves or the use of baby wipes are not a substitute for hand hygiene. Review of the facility undated Skills checklist sheet showed: -When providing incontinent care (peri care) wash hands and put on gloves prior to beginning care. -Remove gloves and wash hands after care. -Did not indicate to remove gloves and wash hands from a dirty to clean process. Review of the Center of Disease Control and Preventions for Hand Hygiene for Health Care Workers reviewed 1/2020 showed. -The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: --Immediately before touching a patient. --Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices. --Before moving from work on a soiled body site to a clean body site on the same patient. --After touching a patient or the patient's immediate environment. --After contact with blood, body fluids, or contaminated surfaces. --Immediately after glove removal. Review of the facility's undated Skills Checklist titled Flex Pen Insulin Administration Skills Check showed: -After explaining the procedure to the resident hand hygiene should be performed. -Once hand hygiene was performed the staff person needed to put on gloves. -After the needle is removed from the pen the staff person needed to remove his/her gloves. -Once the gloves were removed the staff person needed to wash his/her hands. 1. Review of Resident #24's Face Sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Other acute Osteomyelitis (an infection of the bone), right ankle and foot. -Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) with foot ulcer. -Coronary Artery Disease (CAD- plaque build-up in the wall of the arteries that supply blood to the heart) without Angina Pectoris (chest pain). Review of the resident's Admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 12/13/23 showed: -The resident was cognitively intact. -The resident received insulin. -The resident had an IV access site. -The resident received IV medication. Review of the resident's Physician Order Sheet (POS) dated January 2024 showed: -An order for Cefazolin (Ancef- an antibiotic) Sodium IV solution reconstituted two grams (gm) to be given once daily. -An order for Humalog (insulin lispro- a short-acting insulin) Injection Solution 100 units (u)/milliliters (ml), inject 10 units subcutaneously with meals for DMII. NOTE: There was no order indicating the resident had a CVC line site or an order for saline flushes (the method of clearing IV or CVC line of any medicine or other perishable liquids to keep the lines and entry area clean and sterile) to be given before and after IV medication administration. Observation on 1/3/24 at 8:43 A.M. of the resident's morning medication pass completed by Registered Nurse (RN) A: -Prepared the oral medication without sanitizing his/her hands. -He/she walked into the resident's room and placed the pill container on the resident's bedside table without washing/sanitizing his/her hands when entering the room. -He/she then unpackaged the IV tubing, connected the tubing to the IV bag, and began to prime (getting the tubing completely full of fluid before connecting the tubing to the resident) without washing/sanitizing his/her hands or putting on gloves. -He/she then swabbed the resident's hub (the end of the CVC that connects to the bloodlines) with an alcohol pad without washing/sanitizing his/her hands and putting on gloves. -He/she then flushed the resident's CVC site with 10 ml of a normal saline (a mixture of sodium chloride and water used for a variety of reasons) flush. -He/she then connected the IV tubing to the CVC site and started to run the infusion pump. -He/she ensured the resident had taken his/her oral medication and left the resident's room without sanitizing/washing his/her hands. During an interview on 1/3/24 at 9:03 A.M. RN A said: -He/she thought the procedure went fine. -He/she would not have done anything differently. -He/she had then realized that he/she had not washed/sanitized or worn gloves during the procedure and stated that he/she should have done that. -He/she would have washed/sanitized his/her hands before entering the resident's room. -He/she should have washed his/her hands and put on gloves before giving the resident his/her IV medication. -He/she should have sanitized/washed his/her hands when exiting the resident's room. -He/she was notorious for forgetting to perform hand hygiene during resident care. 2. Review of Resident #48's Face Sheet showed he/she admitted to the facility with the following diagnoses: -DM II. -Cerebral Ischemia (a common mechanism of acute brain injury that results from impaired blood flow to the brain). Review of the resident's Significant Change MDS dated [DATE] showed: -The resident was cognitively intact. -The resident received insulin. Review of the resident's POS dated January 2024 showed an order for Humalog Injection Solution 100 u/ml, inject six units subcutaneously with meals for DM II. Observation on 1/4/24 at 12:02 P.M. of the resident's insulin administration completed by RN A showed: -He/she did not wash or sanitize his/her hands when prepping the insulin. -He/she then entered the resident's room put on gloves. -He/she then gave the resident his/her insulin and exited the room. -He/she then returned to the medication cart, removed his/her gloves, discarded the needle, but did not wash/sanitize his/her hands before moving on to his/her next task. 3. Observation on 1/4/24 at 12:06 P.M. of Resident #24's insulin administration completed by RN A showed: -He/she had sanitized his/her hands and went to ask the resident how much insulin he/she wanted and had touched the resident's door and door handle. -He/she then went back to the medication cart and did not sanitize/wash his/her hands when prepping the insulin. -He/she entered the resident's room without washing/sanitizing his/her hands and put on gloves. -He/she gave the resident his/her insulin. -He/she then removed his/her gloves and exited the resident's room. -He/she then discarded the needle and washed his/her hands. During an interview on 1/4/24 at 12:20 P.M. RN A said: -He/she was unsure of how the procedure went. -He/she would not have done anything differently. -He/she should have performed hand hygiene before prepping the insulin pens. -He/she should have performed hand hygiene before giving the residents' their insulin. 4. During an interview on 1/8/24 at 11:00 A.M. RN B said: -Hand hygiene should be performed before and after each medication pass. -The nurse did not perform hand hygiene correctly during the IV medication administration. -He/she should have sanitized his/her hands before entering the room, given Resident #24's his/her oral medication, sanitized his/her hands before getting the IV tubing ready, washed his/her hands and put on gloves before touching the central line, given the IV medication, removed his/her gloves and washed his/her hands before exiting the Resident #24's room. -The nurse should have performed hand hygiene before prepping the insulin pens. During an interview on 1/8/24 at 12:36 P.M. Assistant Director of Nursing (ADON) A said: -Hand hygiene should be performed in between each resident and when going in and out of rooms during medication pass. -The nurse did not perform the correct hand hygiene and gloving practices when administering the IV medication. -He/she would have expected the nurse to sanitize his/her hands when prepping the medication outside of the Resident #24's room, to have sanitized his/her hands upon entry into Resident #24's room and given Resident #24 his/her oral medication, then to have sanitized his/her hands and put on gloves when handling the IV tubing, then he/she should have taken off the gloves, washed his/her hands and put on new gloves to give the IV medication, then take off his/her gloves and sanitize his/her hands when back at the medication cart. -He/she would have expected the nurse to perform hand hygiene before prepping the insulin pens. During an interview on 1/8/24 at 1:00 P.M. the Director of Nursing (DON) said: -Hand hygiene should be done before entering and exiting each resident room. -Anytime gloves are removed hand hygiene should be performed. -Hand hygiene should be performed between each resident during medication pass. -The nurse did not perform hand hygiene or gloving practices when administering the IV medication. -He/she would have expected the nurse: --To perform hand hygiene before getting the medications ready. --To have washed his/her hands after prepping the IV medication and put on gloves. before touching the central line and administering the IV medication. --To have washed his/her hands prior to exiting the resident room. -There would be no reason for the nurse to have not put on gloves when handling the CVC. -He/she would have expected the nurse to perform hand hygiene before prepping the insulin pens. 33409 5. Review of Resident #59 Admission Face Sheet showed, he/she had the following diagnoses: -Bilateral nephrostomy tubes (is a thin plastic tube that is passed from the back, through the skin and then through the kidney). -Cancer of the bone. -History of wound infections and skin infections. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 12/13/23 showed he/she: -Had a Brief Interview for Mental Status (BIMS) score of 13 out 15 and in range for cognitively intact (range 13 to 15) and he/she able to make his/her needs known. -Had history of wound infections. Observation on 1/3/24 at 1:31 P.M., of the resident's incontinence care showed: -Certified Nursing Assistant (CNA) E, CNA F and Certified Medication Technician (CMT) B had entered the resident's room and did not sanitize or wash their hands prior to resident care. -CNA E, CNA F and CMT B obtain clean gloves placed on their hands before starting cares. -CNA D had enter the resident room to assist the other CNAs with resident care. He/she preformed hand hygiene upon enter of the resident room and donned clean gloves on hands. He/she assisted in holding the resident to his/her side during care. -CNA E performed resident frontal peri area care. -With gloved hands CNA D and CNA F assisted in rolling the resident onto his/her left side and supported the resident's body during care. -CNA E continued with incontinent care for which the resident had large amount stool. -CMT B assisted holding the resident on his/her side. -CNA E completed care on had removed his/her contaminated gloves and he/she did not wash or sanitize his/her hands prior to donning new clean gloves (had stool on gloves). -CNA E continue resident's incontinent care. The resident had soiled himself/herself causing the bed sheet to be soiled. CNA E had rolled the soiled sheet so placed underneath side of the resident. -CNA E removed soiled gloves, without sanitize hands place new gloves on hands. He/she obtained clean linens for the resident and then rolled the clean bed sheet and pads underneath the rolled soiled bed sheet to be able change when CNAs turn the resident to his/her right side. -The CNAs then turned the resident to right side and CNA D completed resident care. CNA D removed his/her contaminated gloves and did not sanitizing or wash his/her hands, prior to donning clean gloves. -CNA D removed soiled bed sheets and then pulled clean sheet from underneath resident and placed clean brief under the resident. -The CNAs rolled the resident to left side then to back to finish dressing the resident. -CNA D removed contaminated gloves and washed his/her hands after care. -The CNAs assisted in making the resident comfortable, apply top sheet. -CNA E, CNA F and CMT B removed contaminated gloves and washed hands with soap and water prior to leaving the resident room. During an interview on 1/8/24 at 10:27 A.M., CMT B said: -He/she would expect care staff to wash hand before and after care, dirty to clean process and sanitize their hands between each gloves change. -He/she and the other CNAs had not sanitized or washed hand between gloves changes. During an interview on 1/8/24 at 11:42 A.M., CNA D said: -He/she should change gloves and sanitize hands when going from a dirty to clean process. -He/she should sanitize or wash his/her hands upon enter and exit residents room and sanitize hands between each glove change. During an interview on 1/8/24 at 12:06 P.M., Infection Control Preventionist (IPC) said: -He/she would expect hand hygiene should be performed before and after resident care, upon entering and exiting the resident room and from a dirty to a clean process. -He/she would expect facility care staff to wash or sanitize their hands between each glove change. -The facility had been tracking and trending the recent increased number of UTI. During an interview on 1/8/24 at 1:00 P.M. the DON said: -Hand hygiene should be done before entering and exiting each resident room. -Anytime gloves are removed hand hygiene should be performed. 21003 6. Review of Resident #40's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses including diabetes, high blood pressure, muscle weakness, osteomyelitis (infection in the bone) of the right ankle and foot, and sepsis (chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body which can cause life threatening organ dysfunction). Review of the resident's admission MDS dated [DATE], showed the resident: -Was alert and oriented without any cognitive impairment. -Needed assistance with toileting, hygiene, bathing and dressing, -Had lower extremity impairment on one side of his/her body. -Used IV medications. Review of the resident's Care Plan dated 12/6/23 showed the resident had an IV access. Nursing staff interventions showed they were to check the site daily and monitor for any signs/symptoms of infection and report this to the physician. They were also to check the site for any signs of clogging or infiltration at the site and notify the physician. Review of the resident's Physician's Order Sheet dated 1/2024 showed physician's orders for: -Piperacillin Sod-Tazobactam So Intravenous Solution Reconstituted 3.375 (3-0.375) grams (gm) three times a day for osteomyelitis (ordered 12/7/23 until 1/9/24). -Daptomycin-Sodium Chloride Intravenous Solution 1000-0.9 mg/100 milliliters (ml) one time a day for osteomyelitis (ordered 12/7/23 until 1/9/24). Observation and interview on 01/04/24 at 8:00 A.M., showed the resident was in his/her bed awake and watching television. The IV was connected to the machine but it was not on. RN B entered the resident's room, looked at the resident's IV machine as he/she asked the resident if the antibiotic was completed and whether the nurse had come in to disconnect it. The resident said the antibiotic was completed but the nurse had not come in to disconnect his/her IV. RN B then did the following: -Without washing or sanitizing his/her hands, he/she put a glove on his/her left hand and then disconnected the IV from the machine. -RN B opened an alcohol wipe and cleaned the IV opening. -He/she then removed the cap from two syringes and inserting them into the IV, he/she flushed the IV line. -RN B then opened another alcohol wipe and wiped the opening of the IV line. -He/she left the resident's room and came back with a red cap to place on the end of the IV then removed his/her gloves and washed his/her hands turning off the water with the paper towel before leaving the resident's room. During an interview on 1/8/24 at 11:35 A.M., RN B said: -Upon entering the resident's room he/she first looked at the resident's IV to see if the antibiotic was completed, then he/she should wash his/her hands and glove. -After gloving he/she should disconnect the IV, then flush the resident's IV line. -Then he/she should cleanse the IV with an alcohol wipe, place the cap back on the IV, remove and discard his/her gloves and wash his/her hands. 7. Review of Resident #70's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses including respiratory failure, muscle weakness, abnormal mobility, anemia (low iron), morbid obesity, high blood pressure, heart failure and chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's admission MDS dated [DATE], showed the resident: -Was alert and oriented with no cognitive impairment. -The resident was dependent on staff for transfers, bathing, toileting, dressing, mobility, but could perform some hygiene tasks. -Used a walker and wheelchair for mobilizing. -Received oxygen therapy. Review of the resident's Care Plan dated 11/30/23, showed the resident had a self care performance deficit and required the assistance of one to two staff for transfers, mobility, personal hygiene, bathing, toileting and transferring (transfers required two person assistance). Observation on 1/02/24 at 1:29 P.M., showed the resident was sitting in his/her wheelchair watching television with oxygen on at 2.5 liters. CNA A and CNA B came into the resident's room and asked if the resident was ready to lay down. The resident said he/she was. The following occurred: -Without washing or sanitizing their hands, CNA J and CNA H put on gloves and began attaching the resident's sling to the full body mechanical lift (an assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power). -CNA J and CNA H locked the resident's wheelchair. CNA J lifted the resident in the mechanical lift while CNA B assisted with moving and positioning the resident to his/her bed. -They disconnected the sling from the lift, then CNA J raised the resident's bed and with the assistance of CNA H, they removed the sling from under the resident. -CNA J then removed the resident's soiled brief while CNA H moved the mechanical lift away from the bed and getting the resident's clean brief. -CNA J then began cleaning the resident and CNA H assisted with turning the resident so CNA J could clean the resident's bottom. -Without degloving, washing/sanitizing their hands and re-gloving, CNA J and CNA H, using the same soiled gloves, put a clean brief on the resident. -CNA H then discarded the resident's soiled brief, took a paper towel and cleaned the seat of the resident's wheelchair and discarded the paper towel. He/She then gathered the resident's trash and put another lining in the trash can. CNA B did not remove his/her gloves or wash or sanitize his/her hands before leaving the resident's room. -CNA J using the same soiled gloves, gave the resident his/her oxygen tubing and removed the mechanical lift from the resident's room without discarding his/her gloves washing or sanitizing his/her hands. During an interview on 01/05/24 at 10:17 A.M., CNA H said: -He/she was a new employee since Oct. 2023. -When they enter the resident's room, they were supposed to turn on the water and wash their hands for 20 seconds then with the water still running, dry his/her hands and turn off the water with a paper towel, then glove and start care. -Once they clean the resident (when they are providing incontinence care) he/she would discard the gloves and then put on a new pair of gloves before moving to another body part. -After he/she is done with providing care, he/she would discard his/her gloves then wash or sanitize his/her hands before leaving the resident's room. -They have access to hand sanitizer that is available on the halls and they carry portable sanitizer. During an interview on 1/08/24 at 10:32 A.M., Licensed Practical Nurse (LPN) C said: -Nursing staff should wash their hands upon entering the resident's room then put on gloves and begin cares. -Nursing staff should remove their gloves and either wash or sanitize their hands whenever completing a soiled to clean task, whenever they touch anything soiled or if their gloves are soiled, and upon completing cares prior to exiting the resident's room. -Nursing staff should not enter the resident's room, put on gloves and complete cares without ever discarding and washing or sanitizing their hands and then leave the resident's room wearing the same gloves. During an interview on 1/08/24 at 1:00 P.M., the DON said: -He/she expected all nursing staff to wash or sanitize their hands immediately when they walk into residents room. -Nursing staff should wash or sanitize their hands when they go from dirty to clean tasks and again before they exit. -When disconnecting a resident's IV line, the nurse should wash his/her hands prior to the procedure then glove their hands, unhook the IV and then flush the IV line. -The nurse should cap the IV then after the procedure, the nurse should remove his/her gloves and wash his/her hands.

Based on observation, interview, and record review, the facility failed to ensure medicine kept in a resident room was properly stored; to ensure there was a physician's order for self-administration of medication, and to ensure the resident was assessed to be able to self-administer medications for one sampled resident (Resident #21) and one supplemental resident (Resident #27) out of 21 sampled residents and 4 supplemental sampled residents. The facility census was 92 residents. Review of the Facility's policy titled Storage and Expiration Dating of Medications, Biologicals dated 8/7/23 showed: -Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. -Facility should store bedside medications or biologicals in a locked compartment within the resident's room. 1. Review of Resident #27's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 12/23/23 showed he/she: -Was cognitively intact. -Had moisture-associated skin damage (MASD, is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture). Review of the resident's Treatment Administration Record (TAR) dated 1/1/24 to 1/31/24 showed: -Physician order for Nystatin powder (for treatment of yeast infections) to apply under resident's right breast topically every shift for yeast infection (a common fungal infection caused by a yeast called Candida), order dated 9/28/23. -Treatment were documented as given on 1/1/24, 1/2/24,1/3/24 for the morning and night shift by nursing initials. -No documentation of a physician order or nursing assessment that the resident could self-administer medication or treatments. Observation on 1/2/24 at 8:56 A.M., of the resident room showed he/she had a prescription bottle with a medicine cup over the cap. The bottle was Nystatin powder. Observation and interview on 1/4/24 at 11:15 A.M., of the resident showed: -He/she had a prescription bottle of Nystatin left on his/her nightstand. -The resident said he/she does apply the Nystatin powder as needed. -He/she had complaint of soreness under his/her right breast. - His/her right breast showed a slight odor, reddened shiny area under his/her breast. There was a dried/moist white substance under his/her breast. -He/she said the facility nursing staff were assessing his/her skin and have apply Nystatin powder as needed. Review of the resident's Physician Order Sheet (POS) with wound nurse on 1/4/24 at 11:18 A.M., showed: -A physician order dated 9/28/23, for Nystatin powder to apply to under the resident's right breast topically every shift for a yeast infection. -The resident did not have physician order for self-administration and did not have a self-medication assessment completed or ordered. During an interview on 1/4/24 at 11:19 A.M., Wound Nurse said: -The resident did not have a physician order to self-administered medication or treatments. -He/she would expect the resident to have a physician order to keep the medication at bedside. -He/she would expect the Certified Medication Technician (CMT) or nursing staff to ensure the removal of the Nystatin powder after treatment. During an interview on 1/4/24 at 11:20 A.M., Licensed Practical Nurse (LPN) B said: -He/she had assessed the resident skin in past and was aware of the prescription treatment. -He/she would have expected nursing staff apply the powder as needed. -Nystatin powder should not be left at resident's bedside without a physician order for self -administration. -The resident did not have physician order for self-administer medication or treatments. During an interview on 1/8/24 at 12:55 P.M., Director of Nursing (DON) said: -He/she would expect resident's medication not to be left at bedside. -He/she would expect a physician order and self administration assessment be completed before a resident allowed to keep medication or treatment at bedside. -The facility administration run a new physician orders report monthly and check for accurate orders and documentation. -Nursing staff and CMT should be monitoring for medication left at bedside. -The resident's Self- Administration assessment should be completed by nursing staff and reassessed quarterly for the resident ability to perform prescribed treatment and ability for self-administration of medication. 46519 2. Review of Resident #21's Face Sheet showed the resident was admitted to the facility with the following diagnoses: -Acute on Chronic Congestive Heart Failure (CHF- a weakness of the heart that leads to the build-up of fluid in the lungs and surrounding tissue). -Chronic Kidney Disease (CKD- a long standing kidney disease based on kidney damage or decreased kidney function for three or more months). -Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Review of the resident's Quarterly MDS dated [DATE] showed he/she was cognitively intact. Review of the resident's POS dated January 2024 showed: -No order for Robitussin (Dextromethorphan- a medicine used to treat a cough) Cough Syrup. -No order for self-administration for Robitussin. Note: A complete review of all the resident's past orders was done and no order for Robitussin was found. Observation on 1/2/24 at 11:38 A.M. showed the resident had two bottles of Robitussin Cough Syrup sitting on his/her nightstand. Review of the resident's Electronic Medical Record (EMR) on 1/4/24 showed no assessment for self-administration of the Robitussin cough syrup. Observation on 1/4/24 at 10:25 A.M. showed the resident still had the Robitussin Cough Syrup sitting in the same exact location as the previous observation. During an interview on 1/4/24 at 10:27 A.M. the resident said: -He/she had not used the cough syrup in a while. -He/she had a sinus infection about a month prior and was using the cough syrup then. -The facility knew he/she had the medication at his/her bedside and stated that it was okay for him/her to have it. -The facility had not watched him/her take the cough syrup in the past and was unsure if a self-administration assessment had been completed. During an interview on 10/4/24 at 12:25 P.M. Registered Nurse (RN) A said: -He/she could not find an order for Robitussin Cough Syrup in the resident's POS. -He/she thought the cough syrup should have been removed from the resident's room because there was no order for the medication, or someone should have obtained an order for the medication. -He/she did not provide care for the resident, so he/she was unsure if the resident would be able to self-administer the cough syrup. During an interview on 1/8/24 at 9:16 A.M. CMT A said medications should never be left at bedside and he/she would always wait at the door to ensure all residents took their medication. During an interview on 1/8/24 at 10:56 P.M. RN B said: -Medication should never be left at the bedside unattended. -The resident should have had an order for the medication. -The resident should have had a self-administration assessment completed to ensure the resident would be able to keep the cough syrup at the bedside. -Once the assessment was completed then an order should have been put in place for the resident to have the medication at bedside. -He/she thought that cough syrup was not allowed to be kept at residents' bedsides in general. During an interview on 1/8/24 at 12:34 P.M. Assistant Director of Nursing (ADON) A said: -The cough syrup should not have been left at the resident's bedside. -The resident should have had an order for the medication itself. -Residents need to have an assessment completed to ensure self-administration is appropriate and there should also be an order in place. -The facility does not let residents keep cough syrup at their bedside. -The cough syrup should have been taken away from the resident's bedside before now. -The resident's family had supplied the cough syrup to the resident. -The resident did not tell the facility that he/she had the cough syrup. -The resident had been educated on medication storage and the cough syrup was taken away from the resident. During an interview on 1/8/24 at 1:00 P.M. the DON said: -Medications should never be left at bedside without an order. -The resident should have had an order for the cough syrup. -The resident should have had an assessment for self-administration completed and an order in place for the cough syrup to be at bedside. -The resident's family had brought the medication to the resident.

Based on observation, interview and record review, the facility failed to perform a safe transfer for one sampled resident (Resident #80) who needed assistance with transfers and was unable to bear weight, and to ensure the resident was not left sitting up in his/her wheelchair unattended in his/her room to prevent falls out of 21 sampled residents. The facility census was 92 sampled residents. Review of the facility Fall Management policy and procedure revised 9/17/19, showed the purpose of the fall management program was to develop, implement, monitor and evaluate an interdisciplinary team fall prevention approach and manage strategies and interventions that foster resident independence and quality of life. The fall management program promotes safety, prevention and education of both staff and residents. -The fall policy did not include documentation showing how residents should be transferred using a gait belt or with one or two person assistance. -The fall policy did not show documentation regarding how fall interventions should be followed to prevent further falls. 1. Review of Resident #80's Face sheet showed the resident was admitted on [DATE] and readmitted on [DATE], with diagnoses including dementia, cognitive communication deficit, depression, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), muscle weakness and pain. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 10/12/23, showed the resident: -Was alert with severe cognitive incapacity. -Had functional limitations in range of motion (ROM - the range on which a joint can move) of the resident's lower extremities. -Was dependent on staff for all transfers, toileting, bathing, was incontinent and needed substantial assistance with dressing and supervision with hygiene and eating. -Used a wheelchair for mobility. -Had a history of falls and had falls within the look behind assessment period. Review of the resident's undated Care Plan showed the resident had a self-care performance deficit and was at risk for falls. Interventions showed: The resident required one to two persons for turning and bed mobility, dressing, toileting, transferring, and required one person assistance for eating and hygiene. -The resident was receiving restorative services for active and passive range of motion for his/her upper and lower extremities, to include transfer training for stand and pivot transfers with one to two persons assisting. During an observation and interview on 1/03/24 at 1:16 P.M., showed the resident was sitting in his/her recliner, reclined with glasses on and was dressed for the weather with socks on. The resident had some contracture (a fixed tightening of muscle, tendons, ligaments, or skin. It prevents normal movement of the associated body part) to his/her feet and toes (lack of flexibility in the resident's ankles). Certified Nursing Assistant (CNA) B entered the resident's room, and asked if the resident if he/she was ready to lay down and the resident said he/she was. CNA B did the following: -He/she put on gloves, positioned the resident's wheelchair in front of the recliner and locked the wheels. -Without using a gait belt, CNA B placed his/her hands on each side of the waistband of the resident's pants, he/she lifted the resident while the resident held onto to the CNA and transferred the resident into his/her wheelchair. The resident was not bearing his/her own weight. -CNA B then unlocked the resident's wheelchair and moved the resident to the side of his/her bed. -While the resident held onto CNA B's waist, CNA B again lifted the resident by the waist band of the resident's pants and transferred the resident to his/her bedside. The resident laid down on his/her bed and CNA B lowered the resident's bed to the ground. During an interview on 1/03/24 at 1:21 P.M., CNA B said: -They usually use a gait belt with the resident when completing a one-person transfer. -He/she knew he/she was supposed to use a gait belt, but he/she did not have one available at the time. -The resident really did not bear any weight, but they usually did not transfer him/her with more than one person because the resident was so small and light weight. -They did not have a physician's order to use a mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone ) to transfer the resident and the rehabilitation staff had never trained them to use a mechanical lift with the resident. During an interview on 1/08/24 at 9:40 A.M., Licensed Practical Nurse (LPN) C said: -The resident has to be transferred with one to two persons with a gait belt because he/she cannot transfer himself/herself. -The resident was not transferred with a mechanical lift. -The nursing staff should always use a gait belt when transferring the resident and should not use the resident's pants to lift him/her. During an interview on 1/08/24 at 10:16 A.M., the Director of Rehabilitation said: -The Physical Therapist evaluated the resident for ambulation, strengthening and transfers due to falls on 11/14/23. -Currently the resident receives one to two person assistance with a gait belt for all transfers. -The resident is currently on a restorative program for range of motion for mobility, muscle extensibility and transfer training for all surfaces. -The rehabilitation staff have trained the nursing staff on using a gait belt to transfer the resident with either one or two persons. -Nursing staff should always use a gait belt when transferring the resident with one or two persons. During an interview on 1/08/24 at 1:00 P.M., the Director of Nursing (DON) said: -Nursing staff should use a gait belt when transferring any resident who was not transferred with a mechanical lift. -He/she was aware that the resident was transferred without a gait belt and that should not have happened. Review of the resident's Fall Investigation Report dated 9/6/23, showed: -The nursing staff notified the writer that the resident was sitting on the floor. The nurse observed the resident sitting on the floor at 3:05 P.M., next to his/her bed and wheelchair. The resident was trying to transfer himself/herself into his/her bed and said he/she slid out of his/her wheelchair. The resident was alert and denied pain. The resident's skin was intact and there were no new injuries or bruising noted at this time. Nursing staff assisted with transferring the resident into his/her bed. He/She did not use his/her call light to call staff for assistance with transferring. Nursing staff initiated neurological checks (evaluation of the nervous system which includes level of consciousness, ability to move extremities, eye responses and change in pupils) that were within normal limits and his/her vital signs (temperature (t), pulse (p), respirations (r), blood pressure (bp) and oxygen (o) level)ere within normal limits. Nursing staff notified the resident's physician and supervisor. -Nursing notes showed post fall follow up documentation for 72 hours after the resident's fall did not show any changes in the resident's condition. Review of the resident's Fall Risk assessment dated [DATE], showed a score of 30 (a score above 10 represented high risk for falls). Review of the resident's undated Care Plan showed the resident had a self-care performance deficit and was at risk for falls. Interventions showed: -Staff was to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. -Staff was to educate the resident/family/caregivers about calling for assistance prior to cares and what to do if a fall occurs. -Staff was to ensure that the resident was wearing appropriate footwear when ambulating or mobilizing in his/her wheelchair. -The resident was to be placed on a low bed (when in bed). -Staff was to bring the resident to the nurses' station or common area when the resident was restless to have closer monitoring. -Staff was to encourage the resident to remain in the common area to watch television or activity until bedtime. -Staff was to offer to lay the resident down in the evening. -An undated post fall intervention showed staff took the resident to the nurses' station for close monitoring. It showed staff would follow up with laboratory work due to the resident's increased confusion. -An undated post fall follow up showed the resident's Melatonin (medication for sleep) was discontinued and Nursing staff was to ensure the resident wore non-skid socks. -Staff was educated to check in on the resident during meals. -Staff was educated to ensure rounds were being completed timely with resident being checked and offered toileting. Review of the resident's Physician's Telephone Order dated 11/14/23, showed a physician's order for a physical therapy evaluation after a recent fall. Skilled physical therapy services is not required. Recommendation is for one to two person assistance for transfers and close supervision when out of bed to reduce self-transfers. Review of the resident's Fall Risk assessment dated [DATE], showed a score of 32 (high risk of falls). Review of the resident's Fall Investigation dated 12/11/23, showed: -On 12/11/23 the nursing staff notified the nurse at 6:09 P.M., that the resident was on the floor. Upon entering the resident's room, the resident was lying flat on his/her back with his/her legs straight out on the floor at his/her bedside. The resident was dressed in a shirt and brief and his/her shirt and linen was wet from juice served with dinner. The resident was last seen in his/her wheelchair eating dinner prior to the fall. The resident was unable to indicate what happened. Nursing staff assessed the resident for injury with none noted, his/her skin was intact. The resident was alert and oriented to person only. The resident's neurological checks, vital signs and range of motion was within normal limits. Nursing staff assisted the resident to a standing position with two staff assistance and then placed into his/her bed. The nursing staff notified the resident's responsible party, physician and Assistant Director of Nursing (ADON). -The fall summary did not show the interventions that were in place for the resident at the time of his/her fall (the intervention that nursing staff checked on the resident during his/her meal and the time the staff last saw the resident prior to his/her fall or whether the resident was restless). -Nursing Notes showed post fall follow up documentation for 72 hours showed the resident had no change in condition. Review of the resident's Care Plan showed no additional fall interventions were documented. During an observation and interview on 1/03/24 at 1:16 P.M., showed the resident was sitting in his/her recliner with glasses on and was dressed for the weather with socks on. The resident had some contracture to his/her feet and toes (lack of flexibility in the resident's ankles). CNA B said: -The resident, due to having several falls, was on a low bed, but he/she continued to climb out of his/her bed and onto the floor. -They have to show each time he/she climbs out of bed onto the floor as a fall, but it was a behavior. -The resident was confused and does not remember that he/she cannot walk. -The resident does not remember to use a call light so they have to check on the resident frequently if he/she is up. -They (nursing staff) place the resident in his/her recliner in the reclined position when he/she is in his/her room and he/she will stay in the recliner and not try to get out. -The resident was placed in his/her recliner for meals. -He/she was unaware of the resident falling out of his/her recliner. -Nursing staff was not supposed to leave the resident up in his/her wheelchair, because he/she will slide out of the wheelchair. -The resident was left up in his/her wheelchair and slid out of it when the resident fell on [DATE]. During an observation on 1/05/24 at 10:35 A.M., showed the resident was sitting up in his/her wheelchair in the small dining/community area with peers watching television. Nursing staff was sitting in the community area with the resident, supervising. During an interview on 1/08/24 at 9:40 A.M., LPN C said: -The resident has Parkinson's disease and will sometimes also become agitated and move around a lot while up in his/her wheelchair. -When they see the resident moving around a lot, they will put him/her either in his/her recliner or in bed if he/she is in his/her room. -The resident has had several falls, most have been from his/her bed which is why it is in the lowest position because he/she will put himself/herself onto the floor. -He/she was aware that the resident had fallen from his/her wheelchair in December 2023. -They were allowed to keep the resident up in his/her wheelchair during meals when he/she ate in his/her room and this fall was at that time. -They tried to check on the resident frequently when he/she was up in his/her room due to his/her fall risk. -They have allowed the resident to sit in his/her recliner to eat and the resident is usually okay and has not had any falls from his/her recliner. During an interview on 1/08/24 at 10:16 A.M., the Director of Rehabilitation said: -The Physical Therapist evaluated the resident on 11/14/23, for ambulation, strengthening and transfers due to the resident falls before and up to 11/14/23. -When the resident is sitting up he/she tends to move around and eventually will slide down out of his/her wheelchair due to his/her Parkinson's diagnosis. -Physical Therapy staff recommended that when the resident was up in his/her room, he/she should be placed in his/her recliner in a reclined position with the foot/leg rests up to help block the resident from sliding. -It was not recommended that the resident be left up in his/her wheelchair without supervision. During an interview on 1/8/24 at 1:00 P.M., the (Director of Nursing) DON said: -The resident has had several falls from his/her bed and wheelchair and they have implemented several interventions to try to prevent the resident from falling. -They had the rehabilitation department evaluate the resident and look at his/her positioning. -The resident could be in his/her wheelchair and he/she was appropriate to sit in his/her wheelchair for meals. -If nursing staff put the resident in his/her wheelchair, staff was to take the resident to the common area or nursing station so the resident can be supervised/observed. -If the resident is restless while up in his/her wheelchair, the nursing staff should bring the resident to the nursing station so the nurse can observe him/her. -Nursing staff should not leave the resident up in his/her wheelchair in his/her room without monitoring him/her.

Based on observation, interview and record review, the facility failed to ensure residents with oxygen had physician's orders documented for two sampled residents (Resident #70 and # 83); to ensure oxygen nasal cannulas (a thin flexible tube that gives you additional oxygen through your nose), face masks and tubing was kept covered when not in use for one sampled resident (Resident #83) and ensured free standing oxygen containers were secured in an oxygen stands for two sampled residents (Resident #70 and #83) out of 21 sampled residents. The facility census was 92 residents. Review of the facility's Oxygen Administration policy and procedure dated 1/2027, showed: -Verify that there is a physician's order for this procedure of oxygen administration. -After completing the oxygen set up or adjustment the following should be documented in the resident's medical record: the rate of oxygen flow rate, frequency and duration of treatment, and the reason for as needed administration. -There was no documentation that showed how nasal cannulas, tubing, face masks and other oxygen equipment should be stored when not in use. -There was no documentation showing how oxygen tanks should be stored. 1. Review of Resident #70's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses including respiratory failure, muscle weakness, abnormal mobility, anemia (low iron), morbid obesity, high blood pressure, heart failure and chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's Care Plan dated 11/30/23 showed the resident had altered respiratory status and difficulty breathing related to respiratory failure and COPD. Interventions showed the nursing staff was to: -Administer medication as ordered and monitor the effectiveness. -Elevate the resident's head of bed to alleviate shortness of air when lying flat. -Monitor and document changes in orientation, restlessness, anxiety and air hunger. -Monitor for signs and symptoms of respiratory distress. -Monitor for abnormal breathing patterns and report to the physician. -Position the resident with proper body alignment for optimal breathing. -Provide oxygen as needed. -The care plan did not show the resident was on continuous oxygen and did not show the amount of oxygen needed. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 12/3/23, showed the resident: -Was alert and oriented with no cognitive impairment. -The resident was dependent on staff for transfers, bathing, toileting, dressing, mobility, but could perform some hygiene tasks. -Used a walker and wheelchair for mobilizing. -Received oxygen therapy. Review of the resident's Physician's Order Sheet (POS) dated 1/2024, showed physician's orders for: -Ipratropium-Albuterol Solution 0.5-2.5 milligrams (mg)/milliliters (ml), inhale 3 ml orally every 4 hours as needed for shortness of breath or wheezing via nebulizer (a device for producing a fine spray of liquid, used for inhaling a medication) (ordered 11/29/23). -Change nebulizer and nebulizer tubing weekly every night shift on Sunday (ordered 11/29/23). -There were no physician's orders for oxygen to include the frequency or amount of oxygen the resident was to use. Observation on 1/02/24 at 9:37 A.M., showed the resident was not in his/her room, but there was an oxygen concentrator (a medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen) sitting beside the resident's bed without any tubing connected. There was also a oxygen tank that was standing across from the resident's bed against the wall what was not in an oxygen stand. Observation and interview on 1/02/24 at 1:23 P.M., showed the resident was sitting in his/her room in his/her wheelchair with his/her oxygen on at 2.5 liters per minute. There was a portable oxygen tank across from the resident standing freely by the wall and was not in an oxygen stand. The resident said: -He/She came to the facility from the hospital after being unresponsive at home and was here for rehabilitation. -He/She wore oxygen continuously. Observation on 1/03/24 at 10:22 A.M., showed the resident was in his/her bed with oxygen on at 2.5 liters. The oxygen tank was no longer free standing across from the resident's bed. It was in a sleeve on the back of the resident's wheelchair. Observation and interview on 1/04/24 at 7:46 A.M., showed the resident was sitting up in his/her bed wearing his/her oxygen at 2.5 liters while finishing his/her breakfast. The resident said: He/She wore his/her oxygen continuously and only sometimes removed it. -His/Her oxygen was supposed to be on 3 liters per minute and he/she started wearing oxygen continuously when he/she came into the facility. -He/She was wearing oxygen while he/she was in the hospital also. -He/She wore portable oxygen when he/she was out of his/her room and the portable oxygen tank was usually on the back of his/her wheelchair. 2. Review of Resident #83's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including muscle weakness, abnormal mobility, low iron, fall history, and unsteadiness on his/her feet. Review of the resident's admission MDS dated [DATE], showed the resident: -Was alert and oriented with few cognitive incapacities. -Needed substantial assistance with bathing, dressing, toileting, mobility and used a wheelchair for mobility. -It did not show the resident received any oxygen therapy during the lookback period nor did it show the resident received any type of respiratory care and treatment. Review of the resident's Care Plan dated 12/7/23, showed the resident had a self-care deficiency and needed assistance with transfers, bathing, dressing, toileting and mobility, but there was no documentation showing the resident had any respiratory difficulties, diagnoses or used oxygen for any condition. Review of the resident's POS dated 1/2024, showed physician's orders to: -Obtain oxygen saturation and report to the physician if saturation levels are below 90 (ordered 12/21/23). - Ipratropium-Albuterol Solution 0.5-2.5 mg/ml, inhale 3 ml every 4 hours as needed for shortness of breath or wheezing via nebulizer (ordered 12/28/23). -There were no physician's orders for oxygen use. Observation on 1/02/24 at 2:23 P.M., showed the resident was sitting up in his/her recliner. There was an oxygen tank standing by the resident's closet that was not in an oxygen stand and there was a oxygen cord and nasal cannula coiled around the cannister that was uncovered. The resident was not wearing oxygen. Observation on 1/03/24 at 9:10 A.M., showed the resident was in the bathroom receiving assistance with toileting and grooming. The resident's oxygen tank was standing beside the resident's closet with the nasal cannula and oxygen tubing coiled around it, uncovered. The oxygen tank was not in an oxygen stand. It was not in use at this time. Observation on 1/03/24 at 1:10 P.M., showed the resident was sitting in his/her wheelchair in his/her room eating lunch. He/She was not wearing oxygen. The oxygen tank was standing next to the resident's closet without being in a oxygen stand and the nasal cannula and tubing was still coiled around the top of the oxygen tank. Observation and interview on 1/08/24 at 9:19 A.M., showed the resident was sitting in his/her recliner receiving a breathing treatment. The oxygen cylinder was sitting in front of his/her closet and was in an oxygen stand. The nasal cannula and tubing was coiled around the top of the oxygen tank, uncovered. The resident said: -He/She did not use oxygen and did not know why the oxygen cylinder was in his/her room, but it had been in there for a long time. -He/She asked nursing staff to remove the oxygen tank from his/her room, but they will not. During an interview on 1/08/24 at 9:36 A.M., Certified Nursing Assistant (CNA) B said: -He/She had not seen the resident use oxygen and did not know why the oxygen tank was in the resident's room. -The resident has breathing treatments for shortness of breath, but not oxygen. -All oxygen nasal cannulas, tubing, face masks and breathing treatment mouth pieces should be kept in a bag and covered when not in use. -The oxygen tubing on the oxygen tank should have been covered (placed in a bag) and the oxygen tank should always be in an oxygen stand. -Usually the resident should have an order for oxygen if they are to receive oxygen. 3.During an interview on 1/08/24 at 9:40 A.M., Licensed Practical Nurse (LPN) C said: -The resident has the oxygen tank in his/her room because when they take his/her oxygen level, if it is below 90 they are to administer oxygen to the resident at 2 liters per minute. -The physician's order for 2 liters per minute was a standard order since the resident only used oxygen as needed. -There should be a physician's order for oxygen for the resident. -(After looking at the resident's physician's orders) he/she saw the order for taking the resident's oxygen saturation level and to notify the physician if the resident's saturation was below 90, but he/she did not see a physician's order to administer oxygen at 2 liters as needed to the resident. -The nurse who received the order for oxygen was responsible for ensuring the order was on the resident's POS. -All residents who have oxygen continuously or as needed should have a physician's order stating this and how much oxygen the resident should receive. -Nursing staff was to change the oxygen tubing and oxygen supplies out weekly. -All oxygen tubing, nasal cannulas and face masks should be kept covered in a bag when not in use. -Any portable oxygen tanks should be stored in an oxygen stand if not on the back of the resident's wheelchair. During an interview on 1/08/24 at 1:00 P.M., the Director of Nursing (DON) said: -Oxygen nasal cannulas, facemasks and mouthpieces should be stored in a plastic bag and dated when they are not in use. -All oxygen supplies were usually changed weekly on the night shift. -Nursing staff should be checking when entering the resident's room to ensure all nasal cannulas, tubing facemasks and mouth pieces were in a bag when not in use. -There should be no free-standing oxygen tanks in the resident's room. The oxygen tanks should either be in the storage containers or in the oxygen storage room. -All residents with oxygen should have a physician's order that should show the frequency and amount of oxygen. -The nursing management staff have clinical meetings where they look at the physician's orders at least monthly to ensure the orders are on the resident's POS and are correct and current. -He/She was not aware that the physician's orders for oxygen had not been transcribed to the resident's POS.

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #3) out of four sampled residents was free from abuse when Resident #4 slapped Resident #3 in the head. The facility census was 89 residents. Record review of the facility's abuse policy dated as revised October 2022 showed: -Each resident had the right to be free from abuse. -The facility prohibited abuse of residents. -Resident behaviors would be monitored and strategies implemented to prevent occurrences of abuse. -Resident to resident abuse included willful actions when the individual's actions were deliberate and not accidental. The Administrator was notified on 2/2/23 of Past Non-Compliance which occurred on 1/24/23. On 1/24/23, facility administration was notified of Resident #4 slapping Resident #3, began the facility investigation and began facility staff in-services on abuse. The facility was completed with obtaining statements, in-services and the investigation on 1/26/23. 1. Record review of Resident #4's significant change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning dated 12/4/22 showed the following staff assessment of the resident: -Had severely impaired cognition. -Had no behaviors. -Used a wheelchair. -Was totally dependent upon staff for locomotion on the unit. -Had a diagnosis of anxiety disorder (psychiatric disorders that involve extreme fear, worry and nervousness). Record review of Resident #4's care plan updated 12/16/22 showed: -The resident had impaired cognitive function. -The resident had a mood problem related to anxiety. -An update on 1/24/23 that the resident had a behavior problem which included having an altercation with another resident. -Interventions for behaviors included redirection, anticipating and meeting needs and having a private room. Record review of Resident #3's care plan revised on 9/19/21 showed the resident had impaired cognitive function. Record review of Resident #3's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Was moderately cognitively impaired. -Was independent with walking. -Had a diagnosis of dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes). Record review of Resident #4's notes dated 1/24/23 at 1:15 A.M. showed: -Resident #4 was agitated, was yelling at staff, wouldn't allow anyone to help him/her, had his/her bag packed and was asking for his/her spouse to come and get him/her and was seeing spiders. -Staff were unable to redirect Resident #4. -Resident #4 was given Hydroxyzine (an antihistamine used for the treatment of itchiness, anxiety and tension) 25 milligram (mg) intramuscularly (IM-an injection given into a muscle). Record review of Resident #4's notes dated 1/24/23 at 1:35 A.M. showed a Certified Nursing Assistant (CNA) reported to the nurse that Resident #4 slapped Resident #3. Record review of Resident #4's discharge MDS dated [DATE] showed the resident was discharged with return anticipated to an acute hospital. During an interview on 2/1/23 at 9:30 A.M. Resident #3 said: -He/she did not remember being hit. -He/she had no injuries. -He/she did not know who Resident #4 was. -He/she was not afraid of any residents. During an interview on 2/1/23 at 10:55 A.M., CNA D said: -Resident #4 was already agitated when he/she arrived at 10:00 P.M. on 1/24/23. -Resident #4 received a shot for his/her agitation that night. -He/she was walking with Resident #4 and brought Resident #4 to the sitting area. -Resident #4 was behind Resident #3. -He/she was with Resident #4 and Resident #4 just slapped Resident #3 on the back of his/her head with the palm of his/her hand for no apparent reason. During an interview on 2/2/23 at 11:35 A.M., the Administrator with the Assistant Director of Nursing (ADON) present (the Director of Nursing was not at the facility that day) acknowledged Resident #4 hitting Resident #3 was considered abuse. During an phone interview on 2/9/23 at 8:08 A.M., the resident's primary care physician said: -The resident came to the facility from the hospital on hospice (end of life care). -They weaned the resident off some of his/her medications and over time he/she got better and discharged off of hospice. -Then the resident began to have symptoms of dementia such as agitation and paranoia. -The resident's behaviors would go away and then come back again. -The resident typically did better when he/she was out around people. -The facility did not have a locked memory care unit, which is what the resident needed so the was discharged to another facility that had a memory care unit. MO00213033

Based on interview and record review, the facility failed to implement and follow policies and procedures for medication reconciliation by not filling out the Shift Verification Count Sheets/Packages correctly and completely, resulting in 23 tablets of Oxycodone (a narcotic medication for pain) missing for one sampled resident (Resident #1). The facility census was 91 residents. Record review of the facility's undated but revised 2/21 (February 2021) Controlled Substance Policy that was included in the facility's investigation showed: -Controlled substances in Schedules II, III and IV were subject to special handling, storage, disposal and record-keeping requirements. Such drugs were to be accessible only to authorized nursing and pharmacy personnel. The Director of Nurses (DON) was responsible for the control of such drugs. -Drugs listed in Schedules II, III and IV were to be stored under double-lock conditions. The medication nurse on duty at the time would maintain possession of the key to the locked storage area that housed the drugs listed in Schedules II, III and IV. The key must have remained in the possession of the licensed nurse that completed the count at all times during their shift. -The authorized person who received and checked in a drug in Schedules II, III and IV was to prepare a controlled substance proof of use record form for that medication, if one was not provided by the pharmacy. A physical inventory of the medication would be made at the change of each nursing shift. Shift Verification Count Sheets/Packages should be completed at the change of each shift. -All controlled substances should be counted every shift. The count should be performed by the on-coming licensed nurse and the off-going licensed nurse. The oncoming nurse would be responsible for looking at the medication to verify the amount of medication present at the time of the count. The off-going nurse would be responsible for viewing the Controlled Substance Proof of Use Record to verify the amount on the record at the time of the count. Both nurses sign on the Narcotic Sign In and Out Sheet that the count was completed. -Any discrepancy in the inventory of a controlled substance was to be reported to the DON immediately. The Director of Nurses was responsible for investigating and making a reasonable effort to reconcile all reported discrepancies. The discrepancy of a controlled substance was to be reported to the Administrator and the Regional Nurse immediately. If a discrepancy was not reconciled, the DON was to document the details on the audit record, including the possible shift or persons responsible for the discrepancy and the efforts made to reconcile it. -The Controlled Substance Proof of Use record is to be kept in the Controlled Medication Book. Record review of the facility's undated but revised 10/22 (October 2022) Controlled Substance Policy emailed to Senior Regulatory Auditor on 10/31/22 showed: -Controlled substances in Schedules II, III and IV were subject to special handling, storage, disposal and record-keeping requirements. Such drugs were to be accessible only to authorized nursing and pharmacy personnel. The DON was responsible for the control of such drugs. - Drugs listed in Schedules II, III and IV were to be stored under double-lock conditions. The medication nurse or Certified Medication Technician (CMT) on duty at the time would maintain possession of the key to the locked storage area that housed the drugs listed in Schedules II, III and IV. The key must have remained in the possession of the licensed nurse or CMT that completed the count at all times during their shift. -The authorized person who received and checked in a drug in Schedules II, III and IV was to prepare a controlled substance proof of use record form for that medication, if one was not provided by the pharmacy. A physical inventory of the medication would be made at the change of each nursing shift. Shift Verification Count Sheets/Packages should be completed at the change of each shift. -All controlled substances should be counted every shift. The count should be performed by the on-coming licensed nurse or CMT and the off-going licensed nurse or CMT. The oncoming nurse or CMT would be responsible for looking at the medication to verify the amount of medication present at the time of the count. The off-going nurse or CMT would be responsible for viewing the Controlled Substance Proof of Use Record to verify the amount on the record at the time of the count. Both nurses or CMTs sign on the Narcotic Sign In and Out Sheet that the count was completed. -Any discrepancy in the inventory of a controlled substance was to be reported to the DON immediately. The Director of Nurses was responsible for investigating and making a reasonable effort to reconcile all reported discrepancies. The discrepancy of a controlled substance was to be reported to the Administrator and the Regional Nurse immediately. If a discrepancy was not reconciled, the Director of Nurses was to document the details on the audit record, including the possible shift or persons responsible for the discrepancy and the efforts made to reconcile it. -The Controlled Substance Proof of Use record is to be kept in the Controlled Medication Book. Record review of the DON checklist showed the DON was supposed to review controlled counts weekly. 1. Record review of Resident #1's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Other acute osteomyelitis, right ankle and foot (inflammation or swelling of bone tissue). -Chronic kidney disease and heart failure (When the kidneys don't work well, more stress is put on the heart. When someone has Chronic Kidney Disease, their heart needs to pump harder to get blood to the kidneys. This can lead to heart disease.) Record review of the resident's Physician's Order Sheet dated 10/26/22 showed he/she was prescribed Oxycodone HCI Capsule 5 milligrams (mg) Give 1 capsule by mouth every 6 hours as needed pro re nata (PRN) for moderate to severe pain with a start date of 9/15/22. Record review of the resident's Admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 9/21/22 showed the resident had a BIMs (brief interview for mental status) of 14, indicating the resident was cognitively intact. Record review of the resident's Oxycodone 5 mg Controlled Drug Receipt/Record/Disposition Form showed: -28 tablets were added to the resident's supply on 10/4/22. -On 10/7/22 at 11:00 A.M., one tablet was given to the resident, making the total count 23. -No further documentation after 10/7/22 at 11:00 A.M. Record review of the resident's October Medication Administration Record (MAR) showed the resident received Oxycodone HCI Capsule 5 mg on: -10/7/22 at 11:09 A.M. administered by Registered Nurse (RN) B. -10/8/22 at 8:51 A.M. administered by Assistant Director of Nursing (ADON) A's initials but reported as being Agency Licensed Practical Nurse (LPN) A. -10/9/22 at 12:30 A.M. administered by LPN B. Record review of the facility investigation dated 10/12/22 showed: -No evidence of injury. -Misappropriation of resident property. -No witnesses. -Resident not aware of any pain medications missing and received pain medications when he/she asked for them. -Staff nurses interviewed and drug tested . -Agency nurses not required to be drug tested by agency. -Agency opened own investigation. -New drug count sheets in place. -All nursing staff and CMT in-serviced on reporting missing narcotics and how to use correct shift count sheets. -Abuse Investigation Questionnaires for RN B, RN A, Agency LPN A, Agency RN C and LPN B. -RN B, Agency LPN A, Agency RN C and LPN B were unaware of the missing narcotics. -RN A found the resident's narcotic sheet sitting on the side of the narcotics bin and no sheet in the narcotics box. -10 Resident Incident Questionnaires indicated the residents felt safe, felt their things were safe and staff treated them well. -In-Service Sign-In Sheet dated 10/12/22 with the topic of controlled substance policy. CMT A, RN A, RN B and agency staff did not sign that they attended the inservice. -Updated Shift Verification Count Sheets/Packages document. -A letter from the agency stating Agency LPN A did not complete the drug test and Agency RN C had some type of interference with his/her drug test and it was invalidated. Record review of the facility's Shift Verification Count Sheet/Package showed: -On 10/7/22 at 0600, there were 11 sheets of narcotics. The number 12 was crossed through with the number 11 written underneath. RN A and RN B signed as the ongoing/offgoing nurses/CMTs. -On 10/7/22 at 10:00 A.M., 1 sheet of narcotics was subtracted for an unknown reason and the number of sheets showed 10. RN B and RN D signed as the ongoing/offgoing nurses/CMTs. -On 10/7/22 at 1:00 P.M., 1 sheet of narcotics was added as a new sheet and the number of sheets showed 10. RN D signed as the only outgoing/incoming nurse/CMT. -No documentation of any other narcotic sheet counts on 10/7/22. -On 10/8/22 at 7:00 A.M., 2 sheets of narcotics were subtracted for a resident discharge and the number of sheets showed 9. The name appeared to be Agency LPN A as the only ongoing/offgoing nurse/CMT. -On 10/8/22 at 6:00 P.M., there were 7 sheets of narcotics. One of the ongoing/offgoing nurse/CMT's names appeared to be Agency LPN A and the other name was unable to be read clearly. -No documentation of any other narcotic sheet counts on 10/8/22. -On 10/9/22 at 6:00 A.M., 1 sheet of narcotics was added as a new refill and the number of sheets showed 8. The only ongoing/offgoing nurse/CMT's name was unable to be read clearly. -On 10/9/22 at 2:00 P.M., 4 sheets of narcotics were subtracted for a resident discharge and the number of sheets showed 4. The only ongoing/offgoing nurse/CMT's name was unable to be read clearly. -On 10/9/22 at 2:00 P.M., there were 4 sheets of narcotics. One of the ongoing/offgoing nurses/CMTs was CMT A and the other name was unable to be read clearly. -On 10/9/22 at 6:00 P.M., there were 4 sheets of narcotics. The only ongoing/offgoing nurse/CMT's name was CMT A. -On 10/10/22 at 6:00 A.M., there were 4 sheets of narcotics. Agency LPN F signed as one ongoing/offgoing nurse/CMT and the other ongoing/offgoing nurse/CMT's name was unable to be read clearly. -On 10/10/22 at 6:00 P.M., 1 sheet of narcotics was added as a new sheet and the number of sheets showed 5. Agency LPN F signed as one ongoing/offgoing nurse/CMT and the other ongoing/offgoing nurse/CMT's name was unable to be read clearly. -On 10/11/22 at 6:00 A.M., there were 5 sheets of narcotics. RN A signed as one ongoing/offgoing nurse/CMT and the other name was unable to be read clearly. -On 10/11/22 at 6:00 P.M., there were 5 sheets of narcotics. Both ongoing/offgoing nurse/CMT's names were unable to be read clearly. -On 10/11/22 at 10:00 P.M., there were 5 sheets of narcotics. RN A signed as one ongoing/offgoing nurse/CMT and the other name was unable to be read clearly. During an interview on 10/25/22 at 12:03 P.M., Resident #1 said: -There was a weekend and a couple of days where staff didn't have his/her pain medication available. -First they said they were waiting on the pharmacy and then said the medication had disappeared. -This is the only time he/she was aware that his/her pain medications had been missing. During an interview on 10/25/22 at 3:13 P.M., RN B said: -He/she gave Resident #1 an Oxycodone out of the narcotic box on 10/7/22. -He/she put both the narcotic sheet and the resident's Oxycodone 5 mg Controlled Drug Receipt/Record/Disposition Form back where they belonged. -He/she usually worked on the other unit and was just filling in that day. -He/she was off 10/8/22 and 10/9/22 and came back to work on 10/10/22. -He/she found out that Resident #1 was missing a narcotic sheet sometime after he/she came back to work. -The narcotic count was correct at 6:00 P.M. on 10/7/22. -He/she and the oncoming nurse counted the narcotics and documented that the narcotics had been counted on 10/7/22. -The nurses going off shift counted narcotics with the nurses coming on shift. -The nurses going off shift had the paperwork and the nurses coming on shift counted the pills and number of sheets. -The nurse coming on shift said the name and number of each narcotic and counted the number of narcotic sheets in the locked box. -The nurse going off shift filled out the form that verified the number of narcotic sheets. During an interview on 10/25/22 at 3:37 P.M., ADON A said: -The Controlled Drug Receipt/Record/Disposition Form should be in the locked box with the narcotic sheets. -Resident #1's Controlled Drug Receipt/Record/Disposition Form wasn't in the locked box so nurses would not have known Resident #1 was supposed to have the narcotic sheet that was missing. -The Shift Verification Count Sheets/Packages was updated because the form that was being used was not being used correctly. During an interview on 10/26/22 at 9:08 A.M., LPN B said: -He/she worked overnight on 10/7/22, 10/8/22 and 10/9/22. -He/she did not remember seeing Resident #1's narcotic sheet Friday night but the sheet could have been there. -Resident #1 did not ask for his/her pain pill over the weekend while he/she was working. -He/she did not remember seeing Resident #1's refilled sheet with 23 pills left at all but that didn't mean it wasn't there. -He/she did not have a very good memory. -He/she counted the narcotics and the number of sheets at the beginning and end of all of his/her shifts and documented it. -The counts of narcotics and sheets were all correct. -The nurse coming on shift said the name and number of each narcotic sheet and the nurse going off shift checked it against the documents. -The nursing coming on shift counted the number of narcotic sheets and told the nurse going off shift. -They did receive a new document to keep track of narcotic sheets and it was more user-friendly. -When he/she came on shift on 10/9/22, he/she did the narcotics count with a CMT, who had the keys to the narcotics box from 2:00 P.M. to 6:00 P.M. -The facility did an in-service about narcotics. During an interview on 10/26/22 at 9:23 A.M., Agency RN C said: -He/she worked from 6:00 A.M. to 2:00 P.M. on 10/9/22. -He/she counted all narcotics with another nurse when she came on shift. -He/she documented on the form showing how many narcotic sheets were in the box. -He/she counted with someone when he/she went off shift and signed the form. -The incoming nurse counted the pills and sheets and the outgoing nurse filled out the paperwork. -All of the counts were correct. During an interview on 10/26/22 at 10:54 A.M., ADON A said: -There weren't any CMTs on Resident #1's unit. -He/she had documentation that Agency RN C worked until 6:00 P.M. on 10/9/22. -He/she didn't know who would've had the keys from 2:00 P.M. to 6:00 P.M. on 10/9/22. -He/she audited narcotics on 100, 300 and 500 halls. During an interview on 10/26/22 at 11:04 A.M., CMT A said: -He/she did have the keys to the narcotic box on 10/9/22 from 2:00 P.M. until 6:00 P.M. -He/she counted the narcotics with the nurse leaving and the nurse coming on. -One person had the paperwork and one person said the resident's name and how many pills they had and then they verified it all together. -There was another document that had how many narcotic sheets there were and he/she filled that out too. -All of the counts were accurate. -Only nurses gave out PRN narcotics. -He/she gave out scheduled pain medication. -Only nurses add or subtract from the narcotics box. During an interview on 10/28/22 at 12:15 P.M. RN A said: -He/she was going to give Resident #1 his/her pain medication. -He/she couldn't find the narcotic sheet. -He/she found Resident #1's Controlled Drug Receipt/Record/Disposition Form outside the narcotics box in the drawer. -He/she called ADON A and told him/her about the missing narcotics. -ADON A went to the facility and started the investigation. -Resident #1's Oxycodone was there when he/she left for two days and it was there when he/she came back. -He/she gave Resident #1 his/her Oxycodone almost every night. -The nurse coming in counted the pills and sheets and the nurse going out handled the paperwork. -Then both nurses signed the sheet showing how many narcotic sheets were left. -All of the counts were correct when he/she was working. -He/she thought there had been an in-service about narcotics since then. During an interview on 10/28/22 at 3:15 P.M., ADON A said: -He/she was the acting DON at the time the narcotic sheet went missing. -All nursing staff who had access to the narcotic box were drug tested and they all came back negative. -RN D would have had access to the narcotics box too when CMT A had the keys so RN D could pass out PRN medication. During an interview on 11/3/22 at 3:18 P.M., ADON A said: -He/she was not working on 10/8/22, even though his/her initials were on Resident #1's MAR. -The agency nurse who was supposed to work that day was replaced by a different nurse without the facility's knowledge. -When an agency nurse worked for the first time, they had to get the agency nurse access to the electronic health system from their corporate office. -Since the agency nurse was at the facility without access, he/she wouldn't have been able to do or see anything. -The agency nurse used his/her identification (ID) so the agency nurse could do his/her job. During an interview on 11/4/22 at 10:51 A.M., ADON A said: -The facility replaced the missing narcotics. -The two agency nurses cannot come back to work at the facility. -The failure was the Shift Verification Count Sheet/Package form because it was not being filled out correctly. -The process in place was to audit the narcotics and paperwork to ensure everything is correct and filled out correctly three times a week. -The process prior to this incident was unknown. -The audits just needed to be done. -He/she did not know when the last audit prior to this incident had been completed. -There was no policy on auditing narcotics but there was a DON checklist that showed audits needed to be completed. -He/she had no documentation of prior audits. -The number of narcotic sheets in the locked box should be noted at the beginning of a shift on the verification form. -If a medication was added to or taken out of the narcotic box, the number of narcotic sheets should not change on the same line where the addition or subtraction was documented. -The next time the narcotic sheets were counted, either for an addition or subtraction of a sheet or the beginning or end of a shift, that's where the previous change in number of narcotic sheets should be seen. -Agency LPN F signed the narcotics verification form on 10/10/22. -The facility put their staffing needs online through a local agency and a nurse responded. -That was how Agency LPN F came to work at the facility. -There was no number or contact information for the local agency. During an interview on 11/4/22 at 1:02 P.M., RN D said: -He/she thought he/she remembered the weekend he/she was responsible for giving PRN narcotics because a CMT had the keys to the narcotics box. -He/she did not have to pass any PRN medication. -He/she did not know who Resident #1 was. -He/she was not familiar with Resident #1 or his/her medications. -Incoming nurses counted pills and narcotic sheets and outgoing nurses did the paperwork. -Nurses usually counted the narcotics and not CMTs but he/she did not remember if he/she counted the narcotics or if the CMT counted the narcotics. -If a narcotic sheet was added to the narcotic box, the total number of narcotic sheets would change on the next line and not on the line where the addition was documented. During an interview on 11/4/22 at 1:46 P.M., RN B said: -He/she did not look at the Shift Verification Count Sheet/Package form to see how many narcotic sheets there were on 10/7/22. -He/she did not know if the wrong number was written down or what happened. -When a narcotic was added or subtracted, the updated number was supposed to show up on the next line and not the line where the addition or subtraction was documented. During an interview on 11/4/22 at 2:20 P.M., Agency LPN A said: -He/she only worked at the facility for one day. -He/she couldn't remember which day she worked at the facility. -He/she didn't think his/her login worked so he/she had to use the acting DON's login. -He/she did not remember if he/she had to get anything out of the Cubex (automated medication dispensing system). -He/she remembered a resident discharged and another nurse helped him/her discharge the resident with one or two narcotics sheets. -He/she remembered the narcotic counts, including the number of pills and the number of narcotic sheets, were all correct. -The oncoming nurse counted the pills and the narcotics sheets and the outgoing nurse did the paperwork. -Then both nurses signed the form that showed how many narcotics sheets were there. MO00208305

Based on interview and record review, the facility failed to ensure documentation of ongoing monitoring and assessment of a resident who was at risk to develop pressure ulcers (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) for one sampled resident (Resident #1), which resulted in a new unidentified pressure ulcer to his/her left lower leg discovered when the resident was admitted to the hospital after his/her orthopedic Controlled Ankle Movement (CAM) boot was removed, out six sampled residents. The facility census of 83 residents. Record review of the facility policy Wound Care System Requirements revised 3/2021 showed: -The facility has a designated Wound Care Nurse who completes weekly assessment and documentation. -Standardized Pressure ulcer/Pressure Injury Risk Assessment Tool in use - Braden Scale (a pressure sore risk assessment instrument), completed upon admission, weekly x 4 weeks, and then quarterly or with any significant change. -Certified Nursing Assistants (CNAs) will observe residents' skin during care daily. Any changes will be reported to the licensed nurse for follow up. -Skin checks by licensed staff weekly for all residents. -Monthly 100% Skin Audits of all residents by the Director of Nursing (DON) and administrative nurse team completed by the 10th of each month. -Weekly wound assessment is being completed, with individual documentation. -A Pressure Ulcer/Pressure Injury Worksheet will be completed each time an in-house acquired pressure ulcer/pressure injury is identified. -Physician will be notified of findings from Pressure Ulcer/Pressure Injury Worksheet, as needed, for further physician review. -Weekly Pressure ulcer/Pressure Injury reports are generated and distributed to the appropriate team members. -Weekly Care Management System Meetings are being held with appropriate attendance and input. -Collaborate with therapy to initiate therapeutic interventions (adjunct treatments) to prevent occurrence or progression of the pressure ulcer/injury. -The physician and family are notified timely when wounds are identified and with any significant change in status. -Treatments are being completed as ordered, and are changed if no progress is noted in two weeks. -Treatment orders are consistent with the protocols, unless contraindicated. -Care Plans and MDS reflect the current wound status, risk factors, and individualized approaches/interventions. -Current and ongoing employee education on Prevention, Treatment, Healing and Responsibilities by the wound care nurse. Record review of the facility pressure wound reports from 12/1/21 to 1/3/22 showed Resident #1 was not listed on wound report as having a pressure ulcer or any other skin issue. 1. Record review of Resident #1's hospital Progress Note dated 12/23/21 showed he/she: -Had a splint in place to his/her left lower leg. -Hospital staff had placed the resident in a medium tall CAM boot onto his/her left lower leg. -Continue to be non-weight bearing of the left lower leg for five more weeks. --NOTE: The resident did not have a noted pressure ulcer on his/her left leg at that time. Record review of the resident's facility record of Hospital Discharge instruction, order and records dated 12/24/21 showed: -The resident had been admitted to skilled nursing care facility for therapy services. --NOTE: The resident did not have a noted pressure ulcer on his/her left leg at that time. Record review of the resident's Admission Face Sheet showed he/she was admitted to the facility on [DATE] and had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Orthopedic aftercare and a displaced trimalleolar fracture of left lower leg. -Left ankle Pain. -The resident was discharged to hospital on 1/3/22. Record review of the resident's nursing Admission Data Collection assessment dated [DATE] at 2:58 P.M. showed the resident skin integrity section as follows: -Braden score of 14 which score greater than 10 was high risk impaired skin issue and pressure injury. -Scattered bruising across abdomen, scattered bruising on bilateral upper extremities. -Coccyx was slight pink in color. -No documentation related to the skin under the resident CAM boot. -No detail documentation related any other skin issue. Record review of the resident's Physician Order Sheet (POS) and Treatment Administration Record (TAR) from 12/24/21 to 1/3/22 showed the resident: -Did not have any physician orders for staff to assess, provide care, or monitor his/her skin under the left ankle CAM boot. -No physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] -No documentation on the resident's TAR staff assessed, provided care, or monitored his/her skin under the left ankle CAM boot. Record review of the resident's undated CNA care sheet for skin integrity and resident care showed the resident: -Required assist of one to two staff to reposition and turn the resident in bed. -Required CNA during resident care to inspect and check the resident body daily and report any abnormal skin issue to the nurse staff. -Required assist of two staff members with transfer with the use of mechanical lift. The resident was non-weight bearing to left lower leg and had a CAM boot in place. Record review of the resident's Daily Skilled Nursing Notes dated 12/25/21 to 1/3/22 showed: -The resident required skilled services for Physical Therapy (PT)/ Occupational Therapy (OT) and nursing care related to his/her left ankle fracture surgical repair. -The resident had no new skin issues documented. -No documentation of the monitoring of his/her skin under the CAM boot or dressing. Record review of the resident's care plan for skin integrity dated 12/27/21 showed the resident: pressure ulcer. -Interventions include but not limited to: --Administer treatment as physician ordered and monitor for effectiveness or changes to the resident skin. --Heels were to be floated while in bed as tolerated. --Facility staff were to place a pressure redistributing mattress (is to help treat or prevent pressure ulcers by providing two sets of air cells that expand and contract on an alternating basis so as to continually shift pressure) on the his/her bed and pressure cushion while up in his/her wheelchair. Record review of the resident's Admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 12/30/21 showed he/she: -admitted to the facility on [DATE] from acute hospital. -Had Brief Interview for Mental Status (BIMS) of 13 out 15 and was cognitively alert. -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Had recent surgery requiring active skilled nursing care services. -Had a repair of a fracture ankle. -Was at risk to develop pressure ulcers. -No documented pressure ulcer at the time of admission. -Did have ointment or creams applied to skin other than his/her feet. Record review of the resident's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -Distal pulse (a pulse felt at a location distant from the heart, such as wrist or foot) intact. -Nursing were to monitor the wound for signs of infection, odor or drainage -Resident was to continue with physical and occupational therapy. -Required follow-up with consults appointments. -White cell count was elevated as well. (Possible signs of infection in the body) -No documentation related to assessment of the skin under the resident left ankle CAM boot. Record review of the resident's nursing weekly skin assessment dated [DATE] at 2:48 P.M. showed: -No changes in the resident skin this week. -No documentation in the skin impairment section. -No documentation related to skin under the left CAM boot. -No documentation changes to the resident buttocks area. Record review of the resident's nursing notes dated 1/3/22 at 2:00 P.M. showed: -The resident had been sent to hospital by ambulance for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] -No documentation related to the resident's skin under the left CAM boot. Record review of the resident's care plan for skin integrity and general care was updated on 1/3/22 showed the resident: -Required assist of two staff members with transfer with the use of mechanical lift, due to the resident was non-weight barring to left lower leg and had a CAM boot in place. -Facility care staff were to assist him/she with toileting, incontinence (having no or insufficient control over urination or defecation) care and perineal care (peri-care area, surface area between the thighs extending from the pubic bone to the tail bone). Facility care staff were to apply moisture barrier cream to peri-area after care. -Facility care staff and nursing staff were check all of resident body for any skin breakdown and treat promptly as ordered by the resident physician. -Facility care staff were to monitor the resident skin, document and report to nursing staff and his/her physician as needed, for any signs and symptoms of infection to any open areas on the his/her skin, such as redness, pain, heat, swelling or pus formation. Record review of resident's hospital Medical Record dated 1/3/22 showed the resident: -Had a CAM boot upon admission to the hospital. -Had a nursing note dated 1/3/22 the resident was admitted with a moisture skin impairment of the buttock area, which had a bilateral [CONDITION(S)] (is a type of skin rash caused by injured or irritation) of pink, red and skin was intact. Record review of the resident's hospital consult note by Nurse Practitioner (NP) dated 1/5/22 showed the resident: -The resident had a boot on his/her left lower extremity. (Boot, meaning a medical devices to secure the ankle). -The resident's hospital nursing notes documented they had found a wound to his/her foot and lower leg once hospital staff had removed the resident's left lower leg CAM boot. Record review of the resident's hospital nursing progress note dated 1/5/22 showed: -Nursing had documented the resident had a left lower pressure injury present at time of admission to the hospital. -The last dressing change to lower left leg was on 1/5/22 at 2:41 P.M. -The hospital nursing staff did not measurement the wounds. -The resident's dressing was intact. Record review of resident hospital Consult dated 1/6/22 showed: -The reason for the resident's consult was due to wound on his/her left calf. -The resident had been non-weight bearing in a CAM boot. -The resident had recently admitted to hospital for other medical issue. -He/she had bruising and skin breakdown over the posterior (back) aspect of the mid-calf. --Hospital nursing instructed to dress the ulceration on the posterior calf with special dressing. -Nursing were to keep the resident's CAM boot off at that time, to prevent progression of calf wound. During an interview on 2/2/22 at 10:33 A.M., the resident said: -He/she could not remember if he/she had other wounds. -His/her bottom area had been tender when he/she sat or lying down on back to long. -Was not aware and did not remember if the facility nursing staff had assessed, provided dressing changes or had been monitored his/her left lower leg and surrounding skin while at the facility. During an interview on 2/3/22 at 11:10 A.M. CNA A said: -He/she remembered the resident had some irritation on his/her coccyx (tailbone) area and had some soreness on both side buttocks. -During personal care the CNA's would have applied barrier cream to the resident bottom area. -He/she did not see any open areas on buttocks at that time. -The resident had no complaints about his/her left lower leg, -The CNA's provide baths and general cares for the resident and would report any skin changes to the nursing staff. -He/she would have document any resident care and skin issue in the resident Electronic Medical Record (EMR) under CNA notes section. During interview on 2/3/22 at 11:25 A.M., Licensed Practical Nurse (LPN) A said: -Record review of the resident medical record with the LPN A showed he/she could not find physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -Nursing were to document any wound assessment in the resident's progress notes or in the resident TAR. During interview on 2/3/22 at 1:15 A.M., the DON said: -The facility had not been tracking and monitoring for any changes in resident's skin under the CAM boot for any new or worsening skin changes. -The resident had been sent to hospital on 1/3/22 due to a new medical issue. -He/she would have expected facility nursing staff to obtain physician's orders for ongoing monitoring and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident's daily skilled nursing notes from 12/25/21 to 1/3/22 showed the resident had no new skin issue. -The facility nursing notes, did not have any detail documentation of the resident skin under the left CAM Boot or coccyx area. During an interview on 2/3/22 at 1:50 P.M., the Assistant Director of Nursing (ADON) said: -He/she thought the resident had a soft cast and was covered with ace wrap (stretch roll bandage to help secure dressing) to left lower leg. -Upon admission he/she would expect nursing staff to monitor and document the resident's skin under the CAM boot every shift. -He/she would have expected detailed documentation to include the type of dressing, a splint or cast in place and appearance of the surround skin. -He/she would had expected nursing staff to ensure the resident had physician's orders for treatment or monitoring of the resident skin and wound site. During an interview on 2/3/22 at 2:50 P.M., Previous ADON said: -He/She no longer worked at this facility, he/she was the ADON until the first of January 2022. -He/She would have been responsible for completing wounds rounds with the facility contracted wound physician. -He/She did not remember if the resident had been included in the wound rounds. -He/she had been in charge of the rehab unit. The nursing staff and CNAs assigned to the rehab unit would notify him/her of any changes to the resident's skin including the resident's surgical site. During an interview on 2/4/22 at 11:30 A.M., the resident's surgeon said: -The surgical office had lost track of the patient after discharge from the hospital on 12/24/21. They did not know where the resident went, if he/she went home or to a facility. -The resident had not showed up for any his/her follow-up appointments while at the facility. -Routinely he/she does order a boot or a splint post-operative for the residents. -He/she would have expected the resident to have physician's orders at discharge from the hospital, to include written physician's orders for Physical therapy or occupational therapy to remove or open the resident's boot to exam the skin at the surgical site area and surrounding skin. -On 2/1/22, the surgeon examined the resident and found the resident had horrible wounds on his/her left lower extremity. -The resident had pretty edematous lower extremities. -He/she feels as though the wounds are from the resident's leg hitting a wheelchair. -He/she does not know if the resident may lose his/her leg or not. -The wounds are really infected, and the patient had been on antibiotics prior to appointment. -Routinely he/she would have order a boot or a splint after surgery. -Typically in his/her experience, if a pressure ulcer develops from these appliances, it develops on the heel. During an interview on 2/8/22 at 10:30 A.M., CNA C said. -He/she obtains information on how to care for the resident by CNA reports at shift change or by the nursing staff. -Depending on the resident's physician orders and the CNA's Care Sheet, he/she would ensure that the resident with a CAM boot or a splint on his/her leg, was positioned with pillows supporting the lower left leg and to had evaluated the left leg on pillows. -He/she would monitor and clean the foot area and report to the nursing staff of any changes in the resident skin or changes in his/her vital signs. -He/She would report to the nursing staff or the ADON of any of the resident complaints of pain or discomfort. -The CNAs document in the resident's EMR under task any care provided for the resident and any changes resident's skin. -He/she did not work with Resident #1. During an interview on 2/8/22 at 10:45 A.M., CNA B said: -He/she obtains information on how to care for the resident on the CNA Care sheets or by reports from the nursing staff. he/she would have positioned the resident's CAM boot as needed. During interview on 2/8/22 at 10:50 A.M., Registered Nurse (RN) A said: -The facility night nursing would be responsible for completing the resident skin assessments. -During the assessment, he/she would look for any open areas, check the resident's circulation, and monitor the skin. If noted a change in skin. -He/she would have notified the resident's physician or surgeon. -During the day shift, if nursing noted any changes, they would have assessed the resident and documented in the resident nursing progress notes. During an interview on 2/8/22 at 11:00 A.M., NP A said: -He/She would expect nursing staff to remove or open the resident's CAM boot, and to assess the resident surgical site and surrounding skin. -He/She would expect nursing staff to document the findings in the resident's EMR. -He/She would expect nursing staff to complete a detailed assessment and description of the resident's resident skin upon admission. During an interview on 2/8/22 at 11:10 A.M., RN B said: -He/she would assess the resident with a CAM boot daily by opening CAM boot and then assessing the surrounding skin and surgical site for any redness, drainage, or bruising. -He/She would document the findings in the resident's nursing progress notes or TAR. During an interview on 2/8/22 at 11:15 A.M., the Physical Therapy Assistant (PTA) Director said: -Resident #1 had a CAM boot in place. -The physical therapy help monitor the resident pain and provided physical therapy and occupational therapy. -Review of PT/OT physician orders for Resident #1 did not have order to remove or assess the resident skin under the CAM boot. -Resident #1 was non-weight bearing on his/her left ankle. -Resident #1 had swelling of the left lower leg from the knee to toes. -Was unable to assess the skin underneath the CAM boot. -Resident #1's pain evaluation of his/her left ankle had a pain scale range of 6 to 8 out of 10. -Resident #1 had no documentation of any drainage noted and had no skin to visualize since he/she had CAM boot in place. -If the facility nursing had question related to the care of the resident's CAM boot, he/she would have expected the facility nursing to contact the resident's physician or hospital to clarify orders. -PT department had no documentation found related to providing education or recommendation for the care of the resident to the facility nursing care staff. During interview on 2/8/22 at 11:28 A.M., the ADON said: -He/she was not aware the resident had a new pressure injury to left lower leg. -He/she would expect the nursing staff to have physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 2/8/22 at 11:35 A.M., the MDS Coordinator said: -He/she was not aware the resident had presented with a pressure ulcer upon admission to the hospital on 1/3/22. -The MDS assessment information obtained by the nursing notes and physician orders. -Under the wounds showed the resident had a surgical wound and had other ointments applied to other then feet. -The resident care plan had interventions for monitoring of the resident's surgical site for signs of infection -Nursing care staff were to apply barrier cream to bottom area after personal care and report any changes of skin to resident's physician. -He/she would have expected the resident to have a physician's order for the monitoring and assessment of skin including under the CAM boot. -Facility care staff would have documented in the resident's EMR under task and to know how to care for the resident been on the resident's CNA kardex (type of care needed sheet). During a phone interview on 2/8/22 at 11:52 A.M., NP B said: -He/she was not aware the resident had developed a pressure injury under his/her CAM boot. -If admitted with no discharge order for wound care, he/she would expect nursing staff to call and obtain general surgical orders for the monitoring and care of the surgical site. -He/She would have expected the nursing staff to obtain orders for the monitoring of the skin under the CAM boot. During an interview on 2/8/22 at 12:15 P.M. DON said: -He/she was not aware the resident had been admitted to the hospital with a pressure ulcer to his/her left lower leg. -He/she was not aware of any documentation by nursing staff of the resident left lower leg at time of discharge on 1/3/22. -If nursing found the resident had a CAM boot, he/she would expect nursing staff to open up the CAM boot (do not remove) and assess dressing, the skin surrounding surgical site. -The resident should have had skin assessment weekly to include detail of the surgical site and the skin underneath the CAM boot. Complaint #MO 703

Based on observation, interview, and record review, the facility staff failed to provide protective oversight for a resident, who remained outside in the facility courtyard, unattended by a staff member for approximately one hour when the outside temperature was 97 degrees Fahrenheit, which resulted in the resident to have a severe sunburn with blisters to his/her body, the resident's body temperature was 106 degrees Fahrenheit, the resident was having a seizure while outside which resulted in the resident to be transported to the hospital emergency room for treatment for [REDACTED].#3); and to safely transfer a resident into a wheelchair, which caused a laceration to the resident's left lower leg, for one sampled resident (Resident #2); out of eight sampled residents. The facility census was 88 residents. 1. Record review of the Resident #3's Admission Record showed he/she: -admitted to the facility on [DATE], then readmitted on [DATE]; -admitted with the following medical Diagnoses: [REDACTED]. --[DIAGNOSES REDACTED](irregular heart rhythm); --Pulmonary hypertension (increased pressure in the lungs resulting from heart failure); --Heat stroke (results from prolonged exposure to high temperatures, usually in combination with dehydration, which leads to failure of the body's temperature control system; It is the most serious form of heat injury and is considered a medical emergency); --Cardiomegaly (enlarged heart); --Generalized edema (fluid retention); --Dysphagia (inability to swallow or chew) and --Congestive heart failure (CHF- inability of the heart to circulate blood supply). Record review of the resident's Activities of Daily Living (ADL) Self Care Deficit Care Plan, revised 4/11/16, showed he/she required extensive assistance from one staff member with transfers. Record review of the resident's Impaired Thought Processes Care Plan, revised on 12/23/15, showed: -The resident would remain oriented to person, place, situation, and time and -Discuss concerns about confusion, disease process, and placement in the nursing home with the resident and family members. Record review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment tool used to assess the resident's care needs for a specific time period and to establish an appropriate plan of care for the individual resident), dated 5/24/16, showed he/she: -Was not cognitively impaired; -Could make his/her needs known to others; -Used a wheelchair for mobility; -Required assistance from one nursing staff member to perform activities of daily living (ADL) to include: --Transfers -Had active medical [DIAGNOSES REDACTED].>--Anemia (a decrease in hemoglobin in the blood to levels below the normal range); --Heart Failure (the heart's pumping power is weaker than normal and the blood is circulated at a slower rate throughout the body); -Was on a scheduled pain medication and also on PRN (as needed) pain medication; -Had complaint of pain almost constantly and -Had pain that affected his/her day to day activities. Record review of the resident's Progress Note, dated 7/21/16 at 3:15 P.M., showed the resident attended a medical appointment at a local hospital and was seen by one of his/her Physicians. New order was obtained to increase the resident's salt and fluid intake. Lasix (a loop diuretic medication) to be held until blood tests are performed on 7/25/16. Record review of the facility's recapitulation of events that occurred to the resident for the date of 7/24/16, showed: -At 9:00 A.M., after eating breakfast, the resident stated that he/she was cold and requested to go outside to the facility courtyard area (a perimeter-enclosed area in the center of the facility that was open to air and unprotected from actual weather conditions/elements, with concrete walkways, and living plants, trees, and shrubbery); -At 10:00 A.M., the resident returned back inside the facility from the courtyard area; -At 11:00 A.M., Licensed Practical Nurse (LPN) A took the resident and two other residents, back outside to the courtyard in a tree-shaded area. The resident made multiple statements that the facility temperature inside felt cold and the resident enjoyed being outside in the warmth and sunlight; -At 11:20 A.M., LPN A and the other two residents came back inside the facility. The resident stated that he/she wanted to remain outside. LPN A informed the resident come inside the facility in 15 minutes for lunch. The resident stated that he/she would return inside by opening the courtyard door (handicapped accessible doorway that was armed with an alarm setting when opened without a security code). LPN A stated that a staff member would reset the alarm after the resident came back inside (as staff had done in the past when a courtyard door was opened without a security code entered); -At 12:10 P.M., Certified Nursing Assistant (CNA) A saw the resident outside in the courtyard area, flailing his/her extremities and having jerking movements of his/her body. CNA A brought the resident inside and informed LPN A of the resident's condition. The resident was assessed and striped of his/her clothing to cool the resident's temperature; -At 12:32 P.M., Emergency Medical Services (EMS) was called for the resident; -At 12:44 P.M., EMS arrived at the facility and due to the resident's condition; additional time was needed by EMS personnel to prepare the resident to be transported to the hospital; -At 12:53 P.M., EMS left the facility and transported the resident to a local acute care hospital. Record review of the resident's Nursing Home to Hospital Transfer Form, dated 7/24/16 at 12:39 P.M., showed he/she: -Was sitting outside and found convulsing in a wheelchair; -Had been outside since 11:00 A.M.; -Had a body temperature of 106 degrees Fahrenheit and - Had cool cloths applied and his/her temperature had decreased to 105 degrees Fahrenheit. Record review of the resident's Progress Note, dated 7/24/16 at 2:51 P.M., showed: -The resident ate breakfast then around 9:00 A.M., he/she requested to go outside in the courtyard because he/she was cold. The resident returned from the courtyard around 10:00 A.M. LPN A then took the resident back outside into the courtyard between 10:45 A.M.-11:00 A.M., along with two other residents, and the resident propelled himself/herself to approximately the center of the courtyard to a location with partial shade. LPN A and the other two residents began to walk towards the door to go back inside the facility. One witness asked the resident if he/she was ready to go back inside and the resident replied that he/she was not ready. The resident had stated that the warmth outside made him/her feel sleepy. LPN A told the resident to come inside the facility in about 15 minutes because lunch would be served shortly. LPN A informed the resident to come to the door or come inside. The resident replied by stating that he/she could open the door but the alarm would sound. LPN A told the resident that the alarm would be reset by a staff member. LPN A went inside the facility and started performing blood glucose testing for other residents and formula feedings. At 12:10 P.M. or so, CNA A came to the door and stated that he/she had seen the resident outside in the courtyard with uncontrolled whaling of all extremities and did not respond to spoken commands. LPN A immediately went to the resident's room, began applying moist towels to cool the body, removed the resident's clothing while the CNA gathered equipment to assess the resident. The resident did have a pulse and was breathing at that time. Sternal rub was performed and the resident tried to open his/her eyes and the nurse began speaking to the resident. The resident's body temperature was 106 degrees Fahrenheit (normal body temperature is 98.6 degrees), blood pressure was slightly elevated, 20 breaths per minute (bpm- normal is 14-20 bpm), oxygen saturation (the fraction of oxygen-saturated hemoglobin relative to total hemoglobin (unsaturated + saturated) in the blood) was 89% (normal is greater than 90%), oxygen was applied at two liters via nasal cannula. The resident was transferred into his/her bed with the head of bed elevated. A few minutes passed, then resident attempted to vomit but nothing was expelled. The resident appeared to be nauseated. At that time, another charge nurse notified EMS to request their assistance and paperwork was copied for the resident to be transferred to a hospital for evaluation. The resident's temperature began to decrease to 105 degrees, then to 104 degrees. EMS was notified at 12:32 P.M. and arrived at the facility at 12:44 P.M. The resident's family was notified that the resident would be transferred to the hospital for evaluation. The resident's temperature was 103 degrees before leaving the facility with EMS personnel. EMS and the resident left the facility at 12:53 P.M. The medical director of the facility was notified of the resident's condition at 12:50 P.M. The resident had gone outside in the courtyard in the past on several occasions and always came up to the door or opened the door, causing the alarm to sound, to re-enter the facility. LPN A documented that he/she believed that the resident may have fallen asleep outside and did not realize how hot he/she had gotten. Review of www.accuweather.com <http://www.accuweather.com>, for weather conditions, dated 7/24/16, showed the outside temperature for the facility location, showed the actual high temperature at 97 degrees Fahrenheit. Record review of the resident's Assessment and Plan, dated 7/24/16, documented by the admitting Physician at the hospital, showed: -Heat Stroke. The resident's body temperature had returned to normal after cooling efforts were implemented and the resident's mentation had improved; -Seizure. The cause of the resident's seizure was most likely a seizure from the resident's high body temperature. The resident denied any previous history of seizures. The resident would be consulted by Neurology and would continue receiving seizure medication; -Burns to both thighs with skin tears. The resident would be given Silvadene cream( a topical medication used to treat burns of the skin) for the open areas of skin and continue with offloading on the anterior thighs. Condition could be due to sunburn and the resident would be monitored for developing Cellulitis (inflammation of the skin); -Skin tears. The resident had skin tears to his/her left knee, which appeared superficial and very raw looking, similar ones on his/her right ankle and anterior thighs bilaterally and -There are some fluid filled blisters that had developed, that area felt very warm and was tender to touch. Record review of the resident's Progress Notes, dated 7/25/16 at 10:33 A.M., showed a call was placed to the hospital that morning at 9:20 A.M. and facility staff spoke with the resident's nurse in the Intensive Care Unit (ICU), who confirmed the resident was a full admission for treatment services at the hospital. Record review of the resident's Neurology Consult, dated 7/25/16, from the hospital, showed: -Assessment and Plan: The resident had obvious heat issues yesterday. He/she certainly would fit the definition of suffering a heat stroke, given the high temperature and central nervous system dysfunction, namely his/her seizure. The resident had already been effectively cooled. The resident's renal (kidney) failure was being treated with gentle hydration due to his/her heart failure. If the resident's seizures had continued then seizure medication would be continued. No further treatment was needed at that point. The resident would not need anti-seizure medication prescribed. Record review of the resident's Progress Notes, dated 7/26/16 at 4:08 P.M. showed: -The facility Social Services Designee (SSD) and the Director of Nursing (DON) met with the resident's family member to clarify the incident that took place on 7/24/16 before the resident was transported to the hospital; -The family member was concerned for the resident and the care that the facility could provide; -The family member and staff discussed the importance of the resident's safety and what measures would put into place to help prevent this type of incident from reoccurring; -The family member felt that the facility staff had forgotten about the resident outside and -The facility staff assured the resident's family member that a full investigation for the incident would be completed by the facility staff. Record review of the resident's Discharge Summary, dated 7/31/16, from the hospital showed: -Discharge [DIAGNOSES REDACTED].>--Heat stroke; --Seizures secondary to heat stroke; --Multiple burns versus skin tears on the resident's bilateral lower extremities; --Acute renal failure on top of chronic kidney disease, stage four; --Anemia; -The resident was consulted by Neurology and Nephrology; -The resident underwent [REDACTED]. --Chest x-ray; --Thoracentesis (removal of fluid from within the lung field); --Renal ultrasound; --CT scan of the head; -Blood cultures and fluid cultures showed no growth to date and -The resident to be discharged from the hospital and return to the long term care facility. Record review of the resident's Mobility Care Plan, revised on 7/31/16, showed the resident had limited physical mobility that required physical assistance from one staff member. Record review of the resident's Potential for Skin Breakdown Care Plan, revised on 8/1/16, showed: -The resident had multiple open heat blisters to bilateral lower extremities and a treatment was ordered for care and -If the resident refused the treatment then staff should re-educate the resident and confer with the resident's family member and Interdisciplinary Team to try alternative measures to gain compliance. During an interview on 8/8/16 at 4:00 P.M., the Facility Administrator said: -The hospital medical records described a different scenario then what had occurred at the facility; -At the time of incident, the resident had been wearing jeans and rarely does a person get sunburnt through clothing material as thick as jeans; -The resident had been in the shade while outside in the courtyard on 7/24/16; -The resident's body temperature was 103 degrees at the facility on 7/24/16; -The resident's skin tears were most likely caused during transporting the resident; -EMS personnel had great difficulty when starting intravenous fluids for the resident, prior to transporting the resident to the emergency room ; -Facility staff can't make a resident do something that he/she doesn't want to do; -Resident rights had to be respected; -Some of the resident's rooms at the facility did have sliding glass doorways that opened to the courtyard area and -The room that the resident resided in did have a sliding door that opened to the courtyard. During an interview on 8/8/16 at 4:46 P.M., the DON, said: -No internal investigation for the incident had been completed due to the type of incident that had occurred. Type of incident did not prompt staff to complete an incident report in the facility computer system and -The resident had a history of [REDACTED]. Record review of the resident's Pharmacy Consultation Report, dated 8/9/16, showed: -Review of the resident's prescribed medications showed the following: --Atorvastatin (anti-lipid/heart medication) (2% risk) and cyclobenzaprine (antibiotic medication) (rare risk), are medications that may cause a photosensitivity reaction; --Azithromycin (antibiotic medication) also had a low risk for photosensitivity reaction (less than 1% risk); -The following precautions are recommended for individuals taking a medication which may cause a photosensitivity reaction, if prolonged sun exposure was expected, or if a history of reaction had occurred: --Limit sun exposure during peak hours of intensity for ultraviolet rays (10:00 A.M.-3:00 P.M.); --Apply minimum SPF 30 sunscreen, 30 minutes before outdoor activity or exposure; --When outdoors, attempt to keep as much of the body covered, as possible; -Consider implementing these precautions in an effort to minimize the potential for a photosensitivity reaction for the resident, if exposure will be prolonged and/or as Physician feels necessary and -The resident's risk for photosensitivity is very low, related to the resident's current medication regimen. During a phone interview on 8/9/16 at 4:00 P.M., CNA A said: -He/she had been working at the facility since 12/3/15; -He/she had went to assist a resident in efforts to help a fell ow CNA with their work load on 7/24/16; -Observed the resident outside through the glass door while in another resident's room; -The resident's body was, jerking; -He/she ran outside and the resident would not respond to verbal stimuli, so he/she brought in the resident inside the facility via the resident's wheelchair; -The resident was taken to his/her room and LPN A was informed of the resident's situation and asked to come to the resident's room; -LPN A was located in the main dining room at that time; -The resident had on a sweater, slacks, and a ski cap on his/her head; -He/she assisted the nurse in removing the resident's clothing to help cool the resident down and transferred the resident to the bed; -The resident's skin was warm to touch and pink in color; -When the resident was put in his/her bed, his/her body was no longer jerking and extremities were no flailing around as before; -The resident's temperature resulted at 106 degrees when it was first taken; -No staff member informed him/her that the resident was outside or to go check on the resident; An observation on 8/9/16 at 2:25 P.M., of the resident's skin showed: -The resident had multiple blistered skin areas, reddened skin was noted from the resident's groin to the resident's knee (thigh area) on both legs, and reddened skin above both feet to mid shin area; -Open blistered skin (heat blisters) were treated with normal saline for cleansing then Santyl applied for debriding the skin areas, then covered with a dry dressing; -Wound care was performed once a day by the nursing staff; -The resident refused any pain medication prior to the wound care being performed; -The resident grimaced and verbalized pain/tenderness when the Wound Nurse removed the old dressings to the resident's thigh areas; -After removing the dressings the resident then fell back to sleep for the remainder of the wound care procedure; -The multiple skin tear areas were noted to be scabbed over and were ordered to be left open to air; -Location of skin tears were noted to the resident's left outer thigh and near the right ankle; -The Wound Nurse stated that the wounds were improving since re-admission to the facility; -The Wound Nurse confirmed that the heat blisters, skin tears, and reddened skin areas were not present prior to 7/24/16. During an interview on 8/9/16 at 3:30 P.M., the resident said: -When the resident was asked what month it was, he/she replied, December; -The resident did not know what day it was; -When asked what year it was, the resident responded with, 19 ., and did not finish the year; -The resident could not identify who the current President of the United States was; -When the resident was asked if he/she could recall what happened, he/she stated, I was left outside for an hour and -The resident described his/her location when the incident occurred as, I was under a shady tree but it wasn't too shady then the resident fell asleep. During a phone interview on 8/9/16 at 5:45 P.M., LPN A said: -He/she did not complete an incident report for the incident that occurred with the resident on 7/24/16 because he/she was not aware that a report needed to be completed; -He/she stated that he/she had been a licensed nurse since 1981; -He/she had worked at the facility for nine months; -He/she only worked on Saturday and Sunday at the facility each week; -He/she was assigned to care for the resident on 7/24/16; -The resident had been wearing a long-sleeved shirt, long pants, and a cap on 7/24/16; -The resident had asked to go outside in the courtyard earlier that morning around 9:00 A.M.; -The resident requested to go outside again around 11:00 A.M. and he/she accompanied the resident, along with two other residents outside; -The resident self-propelled himself/herself in the wheelchair to the center of the courtyard in a shady area; -After 15 minutes, the residents and LPN A began to walk towards the doorway in to the facility and asked the resident if he/she was ready to go back inside; -The resident stated that he/she was not ready to go inside yet; -LPN A instructed the resident to only remain outside for 15 minutes or so because the lunch meal would be served soon and the resident said ok; -LPN A began to do his/her nursing tasks for other residents at that time; -LPN A did not go back to check on the resident or inform any other staff member that the resident was outside; -At 12:10 P.M., CNA A came to get LPN A and said that the resident was flailing his/her arms and having a seizure; -LPN A began removing the resident's clothing after assessing the resident's condition as being heat related; -LPN A took the resident's body temperature and resulted at 106 degrees Fahrenheit; -Cool damp cloths were placed on the resident's body to help cool the resident; -The resident was placed in his/her bed and the resident tried to vomit but nothing came up; -EMS was called by another nurse who got the resident's paperwork for transfer ready; -The resident's body temperature started to come down to 105 degrees, then 104 degrees, and was 103 degrees when EMS arrived and -LPN A felt very upset that the incident had occurred. Record review of a Social Services Progress Note, dated 8/10/16 at 1:28 P.M., showed: -The Social Worker had visited with the resident, while sitting in the shaded area of the courtyard on several different occasions during the past month; -The resident sat in the shaded area of the courtyard while wearing a stocking cap and a jacket; -Social Services would inform the resident on really warm days, due to the resident's decision to wear excessive/inappropriate clothing, not to remain outside for long periods and the resident would reply that it felt good because he/she was always so cold and -The resident stated that he/she felt just fine and would come inside the facility when he/she needed to. During an interview on 8/10/16 at 2:20 P.M., Social Worker A said: -Prior to the incident on 7/24/16, the resident's cognitive status was not impaired and the resident could make his/her own decisions and -After the resident was re-admitted to the facility on [DATE], the resident's cognitive status was assessed as being impaired. During an interview on 8/10/16 at 2:30 P.M., LPN B said: -He/she had cared for the resident in the past; -The resident would often request to go outside in the courtyard area in the past and -He/she would often set an alarm on his/her phone to remind him/her self to check on the resident to ensure that the resident came back inside the facility, when the resident chose to remain outside. During a phone interview on 8/10/16 at 3:09 P.M., the Medical Director of the facility said: -He had been notified of the incident that occurred to the resident on 7/24/16; -He assessed the resident while the resident was hospitalized after the incident had occurred; -He felt that the incident/situation that had occurred to the resident could have been prevented; -He stated that on extremely hot days the residents shouldn't be allowed to be outside for long periods; -He stated that the resident's medical comorbidities had not been a causative factor for the incident on 7/24/16; -He felt that the facility staff should lock the courtyard doors on extremely hot days so that the residents could not go out into the courtyard, when unattended by staff and -He stated that the resident did have a history of staying outside despite education and requests made by the staff members to come inside. During an interview on 8/10/16 at 4:00 P.M., the Administrator said: -The resident had a care plan intervention that said the resident requested to go outside in the courtyard despite staff instructing resident of dangers of exposure to high temperatures outside; -When the resident was re-admitted to the facility on [DATE], that care plan intervention was accidentally deleted by a staff member; -The regional nurse consultant for the facility had been contacted on the day that the incident occurred; -The regional nurse consultant informed the Administrator that the incident did not need to be reported to the State Agency in Missouri; -The facility staff had determined the cause of the incident and determined that the incident was not alleged abuse and neglect to the resident and Note: The facility staff failed to notify the State Agency of the incident that caused injury to the resident, to present date, as of 8/24/16. 2. Record review of resident #2's Admission Record showed he/she: -Was admitted to the facility on [DATE], then re-admitted on [DATE]; -Had medical [DIAGNOSES REDACTED].>-Cognitive communication deficit; -Generalized muscle weakness and -Generalized edema. Record review of the resident's ADL Self Care Performance Deficit, revised on 7/17/16, showed: -The resident required a slide board and participation from one or two staff members with transfers and -The resident required assistance from two staff members specifically to perform transfers. Record review of the resident's Discharge MDS Assessment, dated 7/17/16, showed the resident: -Had mild cognitive impairment; -Transferred with extensive assistance and required physical assistance from two staff members; -Had no impairment of his/her upper and lower extremities for ROM; -Used a wheelchair for a mobility device; -Had no identified skin tears or skin wounds identified and -Had no previous history of any falls since being admitted to the facility. Record review of the facility's Occurrence Report, dated 7/21/16 at 11:40 A.M., showed: -Type of occurrence: Skin issue; -Location of occurrence: The resident's room; -Activity: Resident transfer; -Witnesses of the occurrence: CNA B and CNA C -Reported by: Registered Nurse (RN) A; -The resident's Physician was notified, the resident's Durable Power of Attorney (DPOA) was notified of the incident on 7/21/16; -An ambulance was called on 7/21/16 at 12:05 P.M. and arrived at the facility at 12:20 P.M.; -The resident was sent to the hospital on [DATE] at 12:20 P.M.; -The residents vital signs were taken by nursing staff at the time of incident and the resident's cognition was assessed as being oriented to person, place, and time; -Injury that occurred to the resident included: --A left lower leg laceration occurred on 7/21/16 at 11:40 A.M.; --The laceration was to the resident's left lower anterior calf; -Immediate actions taken by the nursing staff included: --A pressure dressing was applied to the resident's left lower leg; --The resident was transferred safely into a wheelchair; --The resident reported no pain when the range of motion (ROM) was assessed in the left leg; --The dressing was secured to the resident's lower leg and --The resident's wheelchair wheels were locked for safety. Record review of the resident's Nurse's Note, dated 7/21/16 at 12:51 P.M., showed: -CNA B approached the nurse's station and said to RN A, We need you down here. The resident is bleeding really bad; -RN A went to the resident's room and observed CNA C holding pressure to the resident's left lower leg, using an incontinence pad as a barrier to observe excess blood; -A small pool of blood on the floor was observed at the resident's left foot; -RN A removed the pad to assess the injury and observed a large L shaped laceration of the resident's skin, that extended down into the resident's outer layer of skin; -RN A applied a sterile pressure dressing to the resident's left lower leg to control the bleeding; -The resident's Physician, the resident's DPOA, the DON, and then EMS were notified in that order by telephone call; -The resident's statement of what had happened included, The aides were moving me and my leg got caught on the wheelchair. I told the aides to stop, but they kept going; -The CNA's statement of what had happened included, they were transferring the resident from the bed to a wheelchair using a gait belt and the resident's leg got caught on the wheelchair; -Further assessment of the resident's condition and wound showed: --The resident complained of moderate burning pain to the left lower leg; --The base color of the skin laceration was red; --Drainage from the laceration was a heavy amount of blood and --The outer layers of the resident's skin were affected. Record review of the resident's Scheduled Five Day MDS Assessment, dated 7/23/16, showed he/she: -Had mild cognitive impairment; -Had no behaviors or refusal of cares; -Transferred with extensive assistance and required physical assistance from two staff members; -Had no impairment of the upper or lower extremities in ROM; -Had no previous history of falls since being admitted to the facility -Had skin tears, a surgical wound, and a sore caused by pressure to a prominent body/skin area that was present on admission to the facility and -Used a wheelchair and a walker for mobility devices. Record review of the resident's Occurrence Follow Up Report, dated 7/28/16, showed: -Conclusion: As staff transferred the resident, using a gait belt for safety, from the bed to a wheelchair, a metal piece on the wheelchair caused a laceration to the resident's left lower leg/calf; -The nursing staff were not aware that the resident was usually transferred by using a slide board (board to slide from surface to surface), until the resident's DPOA notified the staff of the resident's preferred technique for transfers; -Root cause: Documented as, No fault; -No abuse was suspected; -Actions implemented included: --CNA B and CNA C were both re-educated on proper techniques to transfer a resident; --A physician's orders [REDACTED]. --Slide board transfer was added to the resident's care plan. A telephone call was placed to CNA B on 8/9/16 at 2:36 P.M. and a voicemail was left requesting a return phone call when possible. CNA B did not return a phone call; A telephone call was placed to CNA C on 8/9/16 at 2:39 P.M. and a voicemail was left requesting a return phone call when possible. CNA C did not return a phone call. During an interview on 8/10/16 at 1:30 P.M., the DON said: -The wheelchair that was used for the resident's transfer was a facility owned wheelchair; -The leg/calf brace on the wheelchair was made of plastic and the resident's leg became caught on it during the transfer and ultimately caused the laceration; -That specific wheelchair could not be located for observation purposes; -The wheelchair did not have a metal piece that caused the laceration on the resident's leg; -That wheelchair was an older model wheelchair; -The aides who witnessed the transfer were re-educated on proper transfer techniques; -The resident did not return to the facility and was no longer a resident; -No in-service was performed regarding safety with resident's who take blood thinning medications; -The staff did not notify the St