**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review, and policy review, the facility failed to ensure the medical record of one (Resident (R) 39) of 13 residents reviewed in the sample was complete and accurately documented. The inaccurate documentation of use of a left-hand edema glove had the potential to cause a delay in receipt of a new glove or inaccurate assessment of edema and effectiveness of the intervention for R39. Findings include: Review of R39's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with diagnoses including flaccid hemiplegia on the left side, muscle weakness, history of stroke, and lymphedema. Review of R39's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/31/23, located in the MDS tab of the EMR, revealed he scored 10 out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. He had impaired range of motion in his upper extremity on one side. Review of R39's 06/21/23 physical therapy Discharge Summary, located in the Miscellaneous tab of the EMR, revealed a recommendation for, Glove on left hand during the day, off at bedtime. Review of R39's EMR under the Orders tab revealed an order, which originated on 05/10/23, for, Left arm edema glove, on AM, off PM every day shift related to flaccid hemiplegia affecting left nondominant side. Review of R39's 06/07/23 Care Plan, located in the Care Plan tab of the EMR, revealed documented, I need assistance with ADL's [activities of daily living], I have had a flaccid hemiplegia affecting left nondominant side. The resident's goal was, I will maintain current level of function through the review date. The interventions included: see task for assistance required. Review of R39's Tasks tab of the EMR revealed, Special Equipment: left hand edema glove on in AM [morning] and off at HS [bedtime] - lotion hand upon removal. Review of R39's POC [Point of Care] Response History for 07/04/23 to 08/03/23 addressing use of a left-hand edema glove daily, located in the Tasks tab of the EMR, revealed an answer of Yes to the question Is the resident wearing the device? on: -07/04/23 at 1:38 PM and 3:23 PM; -07/06/23 at 6:23 PM; -07/07/23 at 9:43 AM and 7:09 PM; -07/08/23 at 10:41 AM and 4:40 PM; -07/09/23 at 2:29 PM; -07/12/23 at 10:19 AM and 3:15 PM; -07/14/23 at 3:16 PM; -07/16/23 at 2:52 PM; -07/21/23 at 1:49 PM and 6:23 PM; -07/22/23 at 2:14 PM; -07/23/23 at 3:53 PM; -07/24/23 at 1:55 PM and 7:00 PM; -07/26/23 at 3:07 PM; -07/27/23 at 3:55 PM; -08/01/23 at 4:00 PM; and -08/03/23 at 7:26 PM. Review of R39's Notes tab in the EMR revealed the Orders - Administration Notes from 08/03/23 to 07/04/23 revealed the resident's left hand edema glove was not available. In an observation of R39 in his room on 08/01/23 at 1:03 PM, he was seated in his recliner with no glove on his left hand. R39's left hand was curled into a loose fist. R39 stated he was unable to move his left arm or hand. He stated he did not have a glove to wear. In observations on 08/02/23 at 10:12 AM and 2:20 PM, 08/03/23 at 9:41 AM and 3:30 PM, and 08/04/23 at 10:10 AM in R39's room, he was observed seated in his recliner without a glove on his left hand. In an interview on 08/04/23 at 10:22 AM, Certified Nurse Aide (CNA) 1 stated the resident's glove had been lost and a new one had been ordered; there was no glove to apply for R39 at the moment. In an interview on 08/04/23 at 10:32 AM, CNA2 stated R39 did not have a glove, and stated she believed it had not been available for over a month. She stated she did not know why Yes would be checked on the POC Response History as the glove was not available. In an interview on 08/04/23 at 10:37 AM, the Director of Nursing (DON) stated R39 was on his third glove, as the first glove was torn and the second glove did not fit properly. She stated a new glove was currently on order but had not been delivered yet. The DON stated the CNA's documentation on the POC Response History should not reflect yes to the question whether the glove was on, as it was not available. In an interview on 08/04/23 11:37 AM, the DON stated the CNAs on the evening shift were documenting, Yes on POC Response History; however, the Yes meant the glove was not on, even though the question was Is the resident wearing the device? She stated the question in the task should be changed to reflect accurately that he did not have the glove on. Review of the ADL Documentation policy, dated 2023, revealed, Accuracy in documentation is critical to highlight changes [and] generate the appropriate referrals . Code for actual elder performance [and] actual support provided.

Based on observations and interviews, the facility failed to ensure staff used gloves when breaking up medication for one resident (Resident (R) 39) and when transferring medication from one cup to another for R3 to prevent possible cross contamination, from a sample of four residents observed during medication pass. Findings include: During medication observation for R39 on 08/02/23 at 9:10 AM with Certified Medication Aide (CMA) 1, revealed that CMA 1 obtained one pill of calcium antacid 500 milligrams (mg) from the over the counter (OTC) medication drawer on the medication cart. CMA 1 placed the calcium antacid in her bare hands and broke into four pieces, then placed it into the medication cup with other medications for R39. During medication observation for R3 on 08/02/23 at 9:16 AM with CMA 1, revealed while preparing R3's medications, CMA 1 said that R3 likes all of her larger pills (one dull yellowish/orangish round thick pill of potassium chloride 10 milliequivalent (meq), one thick oblong while pill of Gabapentin 600 mg, one thick white oblong pill of Metformin 1000 mg, and one thick white oblong pill of oyster shell 500 mg) in one cup and the other pills into a separate cup. CMA 1 was observed attempting to pour the larger pills from one medication cup to another; however, the pills were not transferring. Then CMA 1 picked up all five of the pills and placed them into the second medication cup with her bare hands. During this transfer, CMA 1 said I know I'm not to do this, but and continued to transfer pills with her bare hands. Interview with the Infection Preventionist (IP) on 08/03/23 at 1:35 PM, she confirmed that at no time should a nurse or CMA be touching medications with their bare hands.