**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of three sampled residents, was free from significant medication error. Staff administered Resident #1 another resident's (Resident #3's) 8:00 A.M. scheduled medications\and then following the error, administered Resident #1's scheduled 8:00 A.M. medications. Resident #1 experienced low blood pressure, lethargy, increased weakness, and required intravenous (IV) fluids. The facility census was 78. Review of the facility policy Administration of Medications, dated 9/16/24, showed the following: -The facility would ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms; -Significant medication error meant one which caused the resident discomfort or jeopardized his/her health and safety. Significance may be subjective or relative depending on the individual situation and duration; -Medication administration was the responsibility of those individuals who through certification and licensure were authorized to administer mediations in a facility; -Staff who are responsible for medication administration will adhere to the 10 rights of medication administration; -Right drug. Every drug administered must have an order from the provider. Compare the order with medication administration record (MAR) for accuracy. Compare the label on the drug to the information on the MAR three times, before removing the container from the drawer, as the drug is removed from the container and at the bedside before administering it to the resident. Do not prepare unmarked drug containers or illegible containers; -Right resident. Use two identifiers; -Right dose. Check the MAR and the physician's order before medications are administered; -Right to refuse. Give the resident enough autonomy to refuse the medication after thoroughly explaining the effects. Medication refusals should be documented on the MAR with the reason for the refusal and follow up from the licensed professional; -All verbal orders and telephone orders must be read back and verified to ensure accuracy; -Any order that is incomplete, illegible or unclear, should be clarified; -Be aware of high-alert and hazardous medications. Review of the facility policy Resident Medication Rights, dated 6/1/24, showed the following: -Document when a resident refuses a medication or treatment; -Discuss the health and safety consequences of refused medications or treatments with the resident and/or representative as appropriate; -Notify the physician of a resident's refusal of treatment. Physician notification should include resident refusal of medications for periods greater than 24 hours. Facility should notify physician immediately if refused medication could affect the health or safety of the resident; -Wasted single doses of medication for disposal should be disposed of in a manner that limited access to them by unauthorized personnel or residents. 1. Review of Resident #1's Physician Order Sheet (POS), dated 2/3/25, showed the following: -Diagnoses of anxiety, depression, sleep apnea, chronic obstructive pulmonary disease (COPD, a group of lung diseases that cause airflow obstruction and breathing difficulties), lymphedema (swelling of the lymph tissue causing fluid filled tissue in the lower extremities), interstitial pulmonary disease (lung disease causing difficulty breathing), chronic respiratory failure with hypoxia (severe difficulty breathing with low oxygen levels), congestive heart failure (inability of the heart to pump blood effectively resulting in swelling of the tissues, shortness of breath, weakness, fatigue and chest pain), chronic kidney disease stage 2 (decline of the kidney function), atrial fibrillation (irregular heart rhythm) high blood pressure, pulmonary hypertension (a type of high blood pressure that affected the arteries in the heart and lungs), cardiomegaly (enlarged heart); -Lexapro (antidepressant medication) 20 milligrams (mg) daily; -Jardiance (medication used to treat heart failure and other diseases) 10 mg daily; -Cyanocobalamin (vitamin B-12 supplement) 2500 micrograms (mcg) daily; -Furosemide (medication used to treat fluid retention caused by congestive heart failure and other illnesses) 80 mg daily; -Gabapentin (medication used to treat nerve pain) 300 mg twice daily; -Isosorbide (medication used to treat chest pain in coronary heart disease) Extended Release (ER) 30 mg daily; -Macrobid (antibiotic medication) 100 mg daily; -Metoprolol (medication used to treat high blood pressure) ER 50 mg daily; -Namenda (mediation used to treat dementia) 10 mg daily; -Spironolactone (medication used to treat fluid retention and high blood pressure) 25 mg daily. Review of the resident's Care Plan dated 2/4/25 showed the following: -At risk for adverse effects from medications. The resident will have o serious or life-threatening complications related to the use of medications. Administer medications as ordered, monitor for serious or life-threatening complications such as respiratory distress, facial [NAME], chest pain and report to the physician; -The resident had congestive heart failure. The resident will have no complications related to CHF. Check breath sounds, observe for labored breathing, offer small frequent feedings, give cardiac medications as ordered, inform physician or any insomnia or anxiety, observe and report any signs or symptoms of CHF, swelling of the legs and feet, swelling about the eyes, shortness of breath upon exertion, cook skin, dry cough, weakness, weight gain unrelated to intake, crackles and wheezes of lung sounds, increased heart rate, lethargy, difficulty breathing when lying down flat; -The resident had hypertension. Goal ro remain free of complications related to hypertension. Administer medications as ordered, notify the physician of swelling, observe for abnormal urine output; -At risk for ineffective communication due to cognitive deficit and hearing deficit. Make basic needs known on a daily basis. Anticipate and meet need, allow time to respond, repeat as necessary, observe for physical/nonverbal indicators of discomfort or distress and follow-up as needed; -At risk for fluid volume deficit related to diuretic use. The resident will be free of symptoms of dehydration. Administer medications as ordered, vital signs as ordered per protocol and record. Notify physician or significant abnormalities; -The resident had COPD. Observe and report any signs or symptoms of respiratory infection, difficulty breathing, anxiety, confusion, restlessness, shortness of breath at rest; -Supplemental oxygen. Review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 2/6/25 showed the following: -Moderately impaired cognition; -Short of breath with exertion (such as walking, bathing, transferring) and at rest and when lying flat; -Received antipsychotic, antidepressant and diuretic medications. Review of the resident's nurses' notes showed staff documented the following the following: -On 2/10/25 at 9:00 A.M. blood pressure 172/83 (normal 120/80) and at 8:19 P.M. blood pressure 131/58; -On 2/11/25 at 10:06 A.M. blood pressure 110/60; -On 2/12/25 at 10:29 A.M. blood pressure 175/91; -On 2/13/25 at 9:31 A.M. blood pressure 162/86 and at 8:17 P.M. blood pressure 133/69; -On 2/14/25 at 8:25 A.M. blood pressure 148/73. Review of the resident's MAR dated 2/14/25 showed Certified Medication Technician (CMT) A documented he/she administered the following medications at 8:00 A.M.: -Lexapro 20 mg; -Jardiance 10 mg; -Cyanocobalamin 2500 mcg; -Furosemide 80 mg; -Gabapentin 300 mg; -Isosorbide ER 30 mg; -Macrobid 100 mg; -Metoprolol ER 50 mg; -Namenda 10 mg daily; -Spironolactone 25 mg. Review of the resident's nurses note, dated 2/14/25 showed at 9:42 A.M., Licensed Practical Nurse (LPN) B documented the CMT reported he/she gave the resident the wrong medications, and resident also received his/her scheduled medications. The resident was alert and oriented, denied feeling dizzy or lightheaded. Physician notified and instructed staff to monitor the resident's blood pressure. Review of the resident's MAR, dated 2/14/25 at 11:00 A.M., showed staff documented the resident's blood pressure was 117/65. Review of the resident's nurses note dated 2/14/25, showed at 11:51 A.M. LPN B documented the resident came out of the shower and said he/she did not feel well, complained of feeling dizzy. Blood pressure 72/44. Physician notified. New order received for intravenous (IV) fluids. IV (needle and catheter inserted into the vein to administer medications or fluids directly into the vein and circulatory system) started, 500 ml administered with blood pressure of 92/62. Physician notified of changes, orders received to continue IV fluids for one more bag, blood pressure now 120/64. Review of the resident's POS, dated 2/14/25, showed the following: -Monitor blood pressure and pulse every two hours for 24 hours; -Sodium chloride (normal saline fluid) 0.9 percent intravenous solution, 1000 ml intravenously over one hour for low blood pressure followed by 1000 ml intravenously at 150 ml per hour. Review of the resident's MAR dated 2/14/25 at 1:00 P.M., showed staff documented the resident's blood pressure was 110/58. Review of the resident's nurses note dated 2/14/25, showed at 12:58 P.M., the Director of Nursing (DON) documented she was notified by LPN B the physician wanted to start IV fluids due to low blood pressure. IV started, normal saline 0.9 percent ran in at 999 ml/hour 1000 ml bag. Physician notified 1000 ml bag was finished and blood pressure was 120/64. New order received to start IV fluids at 150 ml/hour, 1000 ml bag until finished. Resident sat up in bed, communicating. Review of the resident's MAR, dated 2/14/25, showed staff documented the following: -At 3:00 P.M. blood pressure was 82/48; -At 5:00 P.M. blood pressure was 98/58; -At 7:00 P.M. blood pressure was 90/50; -At 9:00 P.M. blood pressure was 95/56; -At 11:00 P.M. blood pressure was 90/60. Review of the resident's MAR, dated 2/15/25, showed staff documented the following: -At 1:00 A.M. blood pressure was 92/62; -At 3:00 A.M. blood pressure was 96/64; -At 5:00 A.M. blood pressure was 100/70; -At 7:00 A.M. blood pressure was 98/52; -At 9:00 A.M. blood pressure was 98/56. Review of the resident's nurses note, dated 2/15/25, showed Registered Nurse (RN) E documented the following: -At 1:34 P.M. blood pressure 98/58; -At 4:06 P.M. nurse called to resident's room by CNA, who said the resident felt dizzy and family member wanted the nurse. The resident sat in the wheelchair and complained of shakiness, awake and oriented. Blood pressure 96/56. Staff assisted the resident to bed, transferred without difficulty. Nurse Practitioner (NP) updated, the family questioned more IV fluid administration. NP declined IV fluids, did not want to overload the resident with his/her CHF diagnosis. Review of the resident's nurses notes showed staff documented the following: -On 2/15/25 at 9:27 P.M. blood pressure 137/53; -On 2/16/25 at 9:31 A.M. blood pressure 92/52; -On 2/16/25 at 10:32 P.M. blood pressure 138/83; -On 2/17/25 at 8:42 A.M., the resident had trouble breathing, physician notified and orders received for x-ray and laboratory tests; -On 2/17/25 at 9:24 A.M., blood pressure 115/70, lung sounds coarse respirations even and unlabored, occasional cough noted, complained of shortness of breath, weakness noted; -On 2/17/25 at 10:14 A.M., resident continued to complain of shortness of breath, increased weakness, NP aware and ordered chest x-ray and laboratory tests; -On 2/17/25 at 12:15 P.M., resident complained of increased shortness of breath while eating, oxygen saturation level 86 - 90 percent (normal greater than 92 percent), resident agreed to hospital transfer. Transported to local hospital by ambulance. Review of the resident's Emergency Department Physician's Note, dated 2/17/25, showed the following: -Complaints of shortness of breath, low blood pressures on Friday (2/14/25) with 1500 ml of IV fluid ordered; -Acute hypoxic respiratory failure; -Pneumonia (lung infection); -Acute on chronic renal failure (acute kidney failure with underlying chronic kidney failure). IV fluids given in emergency department; -Transfer to nephrology (kidney specialist) unit at a regional hospital. 2. Review of Resident #3's POS dated 3/25/24 showed the following: -Diagnoses of dementia and obstructive uropathy (swelling of the urinary system causing difficulty with urination and urine retention), hypertension (high blood pressure), retention of urine, and prostate cancer; -Prozac (antidepressant medication) 10 mg daily; -Seroquel (antipsychotic medication) 50 mg two times daily; -Amlodipine (antihypertensive medication given for high blood pressure and chest pain) 5 mg daily; -Bethanechol (medication used to treat urinary retention or trouble urinating) 10 mg three times daily; -Lisinopril (antihypertensive medication) 10 mg daily; -Propranolol (beta-blocker medication used to treat high blood pressure, heart rhythm disorders, chest pain and other heart or circulatory conditions) 20 mg three times daily; -Tamsulosin (medication used to treat enlarged prostate) 0.4 mg daily. Review of the resident's MAR dated 2/14/25 showed the following: -Prozac (antidepressant medication) 10 mg at 8:00 A.M. not administered, the resident refused; -Seroquel (antipsychotic medication) 50 mg at 8:00 A.M. not administered, the resident refused; -Amlodipine (antihypertensive medication given for high blood pressure and chest pain) 5 mg at 8:00 A.M. not administered, the resident refused; -Bethanechol (medication used to treat urinary retention or trouble urinating) 10 mg at 8:00 A.M. not administered, the resident refused; -Lisinopril (antihypertensive medication) 10 mg at 8:00 A.M. not administered, the resident refused; -Propranolol (beta-blocker medication used to treat high blood pressure, heart rhythm disorders, chest pain and other heart or circulatory conditions) 20 mg at 8:00 A.M. not administered, the resident refused; -Tamsulosin (medication used to treat enlarged prostate) 0.4 mg at 8:00 A.M. not administered, the resident refused. 4. During an interview on 2/19/25 at 11:50 A.M. CMT A said the following: -On 2/14/25 he/she was running behind passing morning medications. Resident #3 refused to take his/her 8:00 A.M. medications from CMT A. LPN B said he/she would try to give Resident #3 his/her cup of medications. While LPN B tried to administer Resident #3's 8:00 A.M. medications, CMT A prepared Resident #1's 8:00 A.M. medications and sat the cup of medications on the medication cart. Resident #3 refused to take the medications from LPN B. LPN B handed Resident #3's cup of 8:00 A.M. medications back to CMT A. CMT A sat Resident #3's cup full of medications on the med cart, picked up the wrong cup and administered Resident #3's 8:00 A.M. medications to Resident #1; -CMT A immediately told LPN B he/she had given Resident #1 the wrong medication. LPN B said to go ahead and give Resident #1 his/her 8:00 A.M. medications. CMT A administered Resident #1's 8:00 A.M. medications. The resident took all of his/her regularly scheduled 8:00 A.M. medications after taking the cup of Resident #3's 8:00 A.M. medications; -He/She needed to stay more focused while preparing and administering resident medications to prevent medication errors. He/She should not prepare more than one resident's medications at a time. During interview on 2/19/25 at 10:50 A.M. and 2:30 P.M., LPN B said the following: -On 2/14/25 at about 8:30 A.M., CMT A informed LPN B of a medication error. CMT A gave Resident #3's 8:00 A.M. medications to Resident #1. The medications included bethanechol chloride 10 mg, Seroquel 50 mg, Prozac 10 mg, propranolol 20 mg, amlodipine 50 mg, lisinopril 10 mg and Flomax 0.4 mg; -LPN B called the physician and explained the medication error and the medications administered. LPN B read the list of Resident #1's routine 8:00 A.M. medications as well as the list of medications given to Resident #1 in error. The physician said to give Resident #1 his/her 8:00 A.M. medications. LPN B hollered down the hall and told CMT A to go ahead and administer Resident #1's 8:00 A.M. medications; -LPN B did not question the physician regarding administration of Resident #1's 8:00 A.M. medications including additional blood pressure and cardiac medications after the resident received other medications in error; -LPN B then informed the Director of Nurses (DON) of the medication error; -LPN A attempted to administer Resident #3's 8:00 A.M. medications after the resident refused to take the medications from CMT A. When Resident #3 refused his/her morning medications, LPN B should have destroyed the medications and not given the full medication cup back to CMT A. During an interview on 2/20/25 at 8:40 A.M. RN E said he/she was aware a medication error occurred with Resident #1 on 2/14/25. Resident #1's routine morning medications included cardiac and blood pressure medications. The charge nurse and CMT involved should have consulted the DON, stopped and figured out the situation and clarified clearly with the physician before proceeding. The resident required IV fluids in response to the drop in blood pressure. The medication error should not have occurred. The staff member passing medications should not prepare more than one resident's medications at a time. During an interview on 2/19/25 at 3:00 P.M. RN/Staff Development Coordinator D said on 2/17/25 the DON asked her to provide nursing staff education on the seven rights of medication administration for all staff who administered resident medications. She had not provided CMT A any in-service education regarding medication administration since 2/14/25. The in-service education also included CMT staff should inform the charge nurse if a resident refused medication. The charge nurse should intervene, talk to the resident and notify the physician of refused medications. She did not educate staff on destroying medications if the medications were refused and did not educate staff to avoid preparing more than one resident's medications at a time. Errors occurred when staff was not focused on one resident's medications at a time. She did not know the circumstances of the 2/14/25 medication error and did not know what medications were given in error. The charge nurse should communicate effectively with the physician and review the situation again if any concerns occurred. Any concerns should be addressed with the physician and DON before administration of multiple medications following a known medication error. During an interview on 2/19/25 at 12:30 P.M., the DON said the medication error led to the resident's change in condition. The resident required IV fluids for treatment of low blood pressure. The physician and NP were notified multiple times of the resident's change in condition on 2/14/25, 2/15/25 and 2/16/25. Family was present and declined transfer to the hospital until 2/17/25 when the resident's condition worsened. During an interview on 2/19/25 at 3:45 P.M., the NP said the medication error should not have occurred. The error led to a change in condition and need for the resident to receive IV fluids due to a drop in blood pressure. Communication with the physician and NP was very important to ensure complete understanding of the situation. During an interview on 2/19/25 at 1:00 P.M. the resident's physician said he was aware of the medication error involving Resident #1 on 2/14/25. He understood the nurse who called him to say staff had administered Resident #1's morning routine medications prior to the medication error. The nurse gave him the list of medications the resident received. If he had understood staff had not administered Resident #1's 8:00 A.M. medications, he would have told staff to hold the medications and not administer Resident #1's 8:00 A.M. medications on top of the medications given in error. This was a major medication error and caused the resident's blood pressure to drop and the resident's decline in condition. The resident required IV fluids in response to the low blood pressure. If a resident refused their medications staff should destroy the medications immediately and avoid preparing multiple residents' medications at the same time. During an interview on 2/19/25 at 1:30 P.M. the administrator said CMT A made a significant medication error. The resident's blood pressure dropped and required IV fluids for treatment. He expected staff to communicate clearly with the physician when explaining a resident's condition. Staff should ensure the physician understood the situation clearly and correctly. Staff should follow the medication pass policy and if a resident refused medications, destroy the refused medications immediately. Staff preparing more than one resident's medications at a time increased the risk of errors. MO 249731 MO 249733

Based on interview and record review of a sample of seven residents, the facility failed to ensure one resident (Resident #6 ), received care according to professional standards when staff failed to obtain and administer medications per physician's orders upon admission for Resident #6, with a tracheostomy (surgical opening into the trachea or windpipe from outside the neck which allows breathing through a tube inserted into the opening), including breathing treatments, injectable medication to prevent blood clots, and medications to stimulate the resident to stay awake. The facility also failed to ensure the resident received the prescribed dosage of heart failure medication and cholesterol medication. The resident developed severe respiratory issues and required emergent treatment in the hospital. Staff also failed to adequately assess one resident (Resident #4's) skin condition following a fractured humerus (upper arm bone), and application of a partial cast when the resident developed an open, draining wound in the axilla (armpit). The facility census was 90. Review of the facility policy Physician Orders, dated 3/10/23, showed the following: -A physician must provide orders for the resident's immediate care and ongoing care of the resident. The facility was obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines; -The receiving nurse immediately entered telephone or verbal orders into the clinical software; -Physician orders included medications and treatments, and special medical procedures required for the safety and well-being of the resident. Review of the facility admission Policy, dated 8/9/23, showed the following: -The facility must establish and implement an admissions policy; -The health referral form submitted by the attending physician would contain medical findings, diagnoses, treatment to follow, prescribed diet, medication and treatment orders, functional state, and signed orders for immediate care. These should be available at the time of admission. Review of the facility policy titled Skin Integrity and Pressure Ulcer/Injury Prevention and Management, revised 8/25/21, showed the following: -The policy provides licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards; -A comprehensive skin assessment on admission and readmission may identify pre-existing signs of possible tissue damage already present; -Skin observations also occur throughout the point of care provided by staff during bathing, dressing, incontinent care, etc. Any changes are reported to the nurse; -A skin assessment should be preformed weekly by a licensed nurse; -A resident's risk may increase due to an acute illness or condition change and may require additional evaluation. 1. Review of Resident #6's care plan, dated 11/24/23, showed the following: -admission date of 11/24/23; -Diagnoses of chronic obstructive pulmonary disease (COPD, a lung disease that blocks airflow and caused breathing difficult), tracheostomy, gastrostomy (surgical opening into the stomach which allowed feeding and medication administration through a tube inserted through the opening into the stomach), pneumonia (infection of the lung), encephalopathy (declining ability to reason and concentrate, causes may include infection or stroke), dysphagia (difficulty swallowing), cognitive communication deficit, hemiplegia (paralysis of one side of the body usually caused by a stroke), stroke, aphasia (loss of ability to understand or express speech, caused by brain damage), and muscle weakness; -The resident required staff assistance to maintain or attain his/her highest level of function. He/She had impaired cognitive ability and impaired thought processes. Staff should assist with Activities of Daily Living (ADLs). Review of the resident's hospital discharge orders, dated and signed by the physician on 11/24/23, showed the following: -Caffeine (medication used as an alertness aid to keep awake) 200 mg (milligram) daily; -Doxazosin (medication used to treat urinary problems caused by an enlarged prostate) 4 mg daily; -Coreg (medication used to treat heart failure and high blood pressure) 12.5 mg, administer 6.25 mg (half tablet) twice daily; -Hydrochlorothiazide (medication used to treat fluid retention and high blood pressure) 25 mg daily; -Modafinil (stimulant medication used to treat excessive sleepiness) 200 mg daily; -Baclofen (medication used to treat pain and muscle spasms) 10 mg three times daily; -Lovenox (injectable medication used to prevent blood clots) 40 mg/0.4 milliliters (ml) injection subcutaneous (SQ, administered just beneath the skin) daily at bedtime; -Brovana (medication inhaled used to relax muscles to the airways and improve breathing) inhalation 15 micrograms (mcg) 2 ml twice daily; -Albuterol (medication inhaled to relax muscles in the airways and increase air flow to the lungs) 2.5 mg/3 ml every 1 hour as needed (PRN); -Albuterol 2.5 mg/3 ml four times daily; -Albuterol-ipratropium (medication inhaled to prevent bronchospasm and improve breathing) 2.5 mg-0.5 mg/3 ml inhalation every 2 hours PRN; -Pulmicort (medication inhaled to reduce swelling and inflammation in the lungs and improve breathing) 0.5 mg/2 ml inhalation twice daily; -Rosuvastatin (medication used to lower cholesterol) administer 20 mg daily at bedtime. Review of the resident's nurses' notes, dated 11/24/23 at 3:59 P.M., showed staff documented the resident was admitted to the facility via ambulance with diagnoses of COPD and stroke, non-verbal, unable to make wants and needs known, total assist of two staff members with ADLs. Review of the resident's Physician Order Sheet (POS), dated 11/24/23, showed the following: -Nothing by mouth due to external feed (feeding by gastrostomy tube) and tracheostomy; -Oxygen at 10 liters continuously per tracheostomy mask (breathing mask fitted over the tracheostomy tube); -Keep oxygen saturation rates (level of oxygenation in the blood) above 92 percent (normal reading is above 92 percent); -Suction resident every two hours and as needed; -Caffeine 200 mg daily through gastrostomy tube for encephalopathy; -Doxazosin 4 mg daily through gastrostomy tube for enlarged prostate; -Coreg 12.5 mg give 1 tablet two times daily (hospital discharge order was 6.25 mg twice daily) through gastrostomy tube for hypertension; -Hydrochlorothiazide 25 mg daily through gastrostomy tube for hypertension; -Modafinil 200 mg daily through gastrostomy tube for encephalopathy; -Baclofen 10 mg three times daily through gastrostomy tube for pain; -Lovenox 40 mg/0.4 ml injection subcutaneous daily at bedtime to prevent blood clots; -Brovana inhalation 15 mcg/2 ml twice daily breathing treatment through tracheostomy for COPD; -Albuterol 2.5 mg/3 ml every 1 hour through tracheostomy as needed for shortness of breath; -Albuterol 2.5 mg/ 3 ml four times daily through tracheostomy for COPD; -Albuterol-ipratropium 2.5 mg-0.5 mg/3 ml inhalation through tracheostomy every 2 hours as needed for COPD; -Pulmicort 0.5 mg/2 ml inhalation through tracheostomy every 12 hours for COPD; -Rosuvastatin 10 mg daily through gastrostomy tube (hospital discharge order was 20 mg daily at bedtime) at bedtime. Review of the resident's admission collection tool, dated 11/24/23, showed staff documented the following: -Impaired cognitive, speech, sensation and range of motion status; -Alert, unable to make self-understood, understood others; -Swelling of the right leg and left arm; -Irregular respiratory rate, short of breath, labored, noisy breathing and had shortness of breath or trouble breathing when sitting at rest and when lying flat; -Coarse breath sounds throughout lung fields; -Tracheostomy present; -Required total staff assistance with all ADLs; -Nebulizer (breathing treatments) therapy, supplemental oxygen at 10 liters/minute by mask and tracheostomy care required. Review of the resident's Medication Administration Record (MAR), dated 11/24/23 at 8:00 P.M.,. showed staff documented the following: -Lovenox 40 mg/0.4 ml not administered, medication not available from pharmacy; -Brovana 15 mcg/2 ml not administered, not available from pharmacy; -Coreg 12.5 mg administered (hospital discharge order was 6.25 mg); -Rosuvastatin 10 mg daily at bedtime administered (hospital discharge order was 20 mg daily at bedtime). Review of the resident's MAR, dated 11/25/23 at 8:00 A.M., showed staff documented the following: -Modafinil 200 mg not administered, medication not available from pharmacy; -Albuterol inhalation 2.5 mg/3 ml not administered, medication not available from pharmacy; -Baclofen 10 mg not administered, medication not available from pharmacy; -Caffeine 200 mg not administered, medication not available from pharmacy; -Coreg 12.5 mg administered (hospital discharge order was 6.25 mg); -Doxazosin 4 mg not administered, medication not available from pharmacy; -Hydrochlorothiazide 25 mg not administered, medication not available from pharmacy; -Brovana 15 mcg/2 ml not administered, medication not available from pharmacy, physician aware (no additional documentation regarding physician instructions); -Pulmicort 0.5 mg/2 ml not administered, medication not available from pharmacy. Review of the resident's MAR, dated 11/25/23 at 12:00 P.M., showed staff documented Albuterol inhalation 2.5 mg/3 ml not administered, medication not available from pharmacy. Review of the resident's nurses notes, dated 11/25/23 at 12:40 P.M., showed staff documented the resident was alert, non-verbal, responded to stimuli, unable to make wants and needs known. Medications given via gastrostomy tube. Tracheostomy in place, suctioned every two hours with thick mucus noted, breathing treatment had not arrived from pharmacy at this time. Resident able to cough mucus up. Required total care by staff. There was no documentation found in the resident's record staff notified the physician about the resident's medications not being administered as ordered. Review of the resident's MAR, dated 11/25/23 at 2:00 P.M., showed staff documented Baclofen 10 mg not administered, medication not available from pharmacy. Review of the resident's MAR, dated 11/25/23 at 4:00 P.M., showed staff documented Albuterol inhalation 2.5 mg/3 ml not administered, medication not available from pharmacy. Review of the resident's MAR, dated 11/25/23 at 8:00 P.M., showed staff documented the following: -Lovenox 40 mg/0.4 ml not administered, medication not available from pharmacy; -Coreg 12.5 mg administered (hospital discharge order was 6.25 mg); -Brovana 15 mcg/2 ml not administered, medication not available from pharmacy; Review of the resident's nurses' notes, dated 11/26/23 at 4:30 A.M., showed staff documented humidified oxygen attached to tracheostomy, suctioned every two hours for thick and copious (abundant in supply or quantity) secretions. Received breathing treatment per tracheostomy. Gastrostomy tube used for feeding and medications, flushed easily. There was no documentation found in the resident's record staff notified the physician about the resident's medications not being administered as ordered. Review of the resident's MAR, dated 11/26/23 at 8:00 A.M.,. showed staff documented the following: -Modafinil 200 mg one time daily not administered, medication not available from pharmacy; -Caffeine 200 mg not administered, medication not available from pharmacy; -Coreg 12.5 mg administered (hospital discharge order was 6.25 mg); Review of the resident's nurses' notes, dated 11/26/23 at 10:20 A.M., showed staff documented resident alert, non-verbal, responds to stimuli, continues with medications as ordered via gastrostomy tube. Tracheostomy in place, suctioned every two hours with thick mucus noted, breathing treatment administered. Review of the resident's MAR, dated 11/26/23 at 8:00 P.M., showed staff documented Coreg 12.5 mg administered (hospital discharge order was 6.25 mg). Review of the resident's care plan, updated 11/27/23, showed the resident had potential for dehydration and fluid deficit, required tube feeding due to swallowing problem, received sedatives and pain medication and had a tracheostomy due to history of respiratory failure. Staff should administer medications as ordered, assess and report any change in hydration status, provide tube feedings as ordered, observe for adverse reactions to pain medication and report to physician, observe for changes in level of consciousness, mental status and lethargy, suction as necessary and observe respiratory rate, depth and quality. Review of the resident's MAR, dated 11/27/23 at 8:00 A.M., showed staff documented the following: -Modafinil 200 mg one time daily not administered, medication not available from pharmacy; -Caffeine 200 mg not administered, medication not available from pharmacy; -Coreg 12.5 mg administered (hospital discharge order was 6.25 mg). Review of the resident's nurses notes, dated 11/27/23 at 5:44 P.M., showed staff documented the resident responded at times by nodding his/her head. Tracheostomy suctioned with minimal amounts of mucus coughed or suctioned. Review of the resident's MAR, dated 11/27/23 at 8:00 P.M., showed staff documented Coreg 12.5 mg administered (hospital discharge order was 6.25 mg). Review of the resident's MAR, dated 11/28/23 at 2:56 A.M., showed staff documented Albuterol 2.5 mg/3 ml breathing treatment administered for shortness of breath. Unknown if the treatment was effective. Review of the resident's nurses notes, dated 11/28/23, showed staff documented the following: -At 3:56 A.M. temperature 99.8 degrees (normal is 98.6 degrees) with no fever earlier in the shift. Respirations increased to 30 breaths per minute (normal 10 to 16 per minute) and oxygen saturation levels between 86 percent and 90 percent (normal above 92 percent). Lung sounds coarse (congested). Resident pointed to his/her head when staff assessed the resident. Tylenol (medication used for pain and fever reducing) and a breathing treatment given. Notified the on-call physician. Orders received to send resident to the emergency room by ambulance; -At 6:40 A.M. staff added the resident was suctioned every two hours with a tint of green sputum noted, lung sounds coarse before and after breathing treatment. Review of the emergency room records dated 11/28/23 showed the resident's admitting diagnoses were pneumonia and respiratory failure. During an interview on 11/30/23 at 2:20 P.M. LPN D said the following: -Resident #6's medication orders were faxed to the pharmacy on 11/24/23. Staff should call the on call pharmacist if orders were faxed later in the day to ensure the orders were received and filled the same day. Staff should ensure residents received medications as ordered and did not miss medications due to pharmacy delay. A local pharmacy was also available for delivery of medications if needed. Lovenox 40 mg was available in the emergency kit. The emergency kit did not contain the resident's breathing treatment medications; During interview on 11/30/23 at 12:05 P.M. Licensed Practical Nurse (LPN) A said he/she was the resident's charge nurse on 11/25/23. The resident was lethargic that morning with thick mucus. LPN A suctioned the resident frequently. The resident's medications had not arrived from the pharmacy and there were no breathing treatments for administration. The pharmacy delivered the resident's medications that afternoon. After starting the breathing treatments the resident's secretions thinned and the resident improved in the afternoon. He/She notified the physician that the resident's medications had not arrived from the pharmacy and reported the resident's condition. The on-call physician said to call back if the resident's condition changed. During interview on 11/30/23 at 3:45 P.M. LPN E said on 11/24/23, the day of Resident #6's admission, he/she was the charge nurse. The resident had arrived prior to 5:30 P.M. when LPN E arrived to work. The resident was coherent, non-verbal with a functioning tracheostomy. He/She suctioned the resident every two hours or more often. The resident was on humidified supplemental oxygen and was congested with a lot of sputum, light green/yellow in color. The resident's oxygen saturation rates were 97 percent on 8 to 10 liters of oxygen. The physician discharge orders were put into the electronic system and he/she pulled medications and gave whatever he/she could find in the emergency kit. LPN E did not fax the resident's medication orders to the pharmacy. He/She borrowed an Albuterol from another resident and administered it to Resident #6. The resident was very congested. He/She did not give Brovana breathing treatment or the Lovenox injection, as those medications were not in the emergency kit and pharmacy did not deliver the resident's medications that night. LPN E was not aware how to obtain stat (at once or right away) medications. During an interview on 11/30/23 at 2:35 P.M. the Nurse Practitioner said she followed Resident #6's care and was not aware the resident had not received all of his/her medications, including breathing treatments and Lovenox injections as ordered. She expected staff to obtain and administer resident's medications as ordered starting the day of admission. Missed breathing treatments and medications could have negatively affected the resident's respiratory status. The resident's history was significant and included respiratory failure. The facility should have a system to obtain medications without delay. Delaying medication administration for 24 hours or longer could have a negative impact on a resident's condition. Staff should notify the physician or nurse practitioner if medications were not administered and obtain further instructions for care. During an interview on 11/30/23 at 2:00 P.M. and 12/4/23 at 4:00 P.M. the Administrator said the following: -He/She was not aware staff had not administered Resident #6's medications and had not received all the resident's medications from the pharmacy the day of admission. On admission, staff should fax the medication orders to the contract pharmacy and call the on call pharmacist if after hours to ensure the medications were filled and delivered the day of admission. Staff should pull medications from the emergency kit if available. The breathing treatment would have improved the resident's respiratory status. 2. Review of the resident's annual Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff ), dated 7/17/23 showed the following: -Moderately impaired cognition; -Required substantial staff assistance with mobility (staff provided more than half the effort); -Required substantial staff assistance with dressing upper and lower body. Review of Resident #4's care plan, updated 6/19/23, showed the following: -Diagnoses of stroke with hemiplegia (paralysis of one side of the body) of the right side, unsteadiness on feet, contracture (limited mobility of the joints) of the right shoulder, elbow and hand; -The resident was at risk for skin breakdown due to limited mobility. Staff should monitor skin and report any abnormal findings and perform weekly skin assessments. Review of the resident's skin assessment, dated 10/16/23, showed staff documented the resident's skin was intact. Review of the resident's nurses' notes showed staff documented the following: -On 10/17/23 at 11:24 P.M. the resident fell to the ground and staff heard the resident's right arm snap. The right arm appeared broken, was cold with no radial (wrist) pulse. Emergency services called and the resident was transported to the hospital; -On 10/18/23 at 8:22 A.M. the resident returned to the facility from the hospital following a fall with right humerus fracture (broken right upper arm bone). The resident's right arm was in a cast, wrapped with ace wrap and a sling was in place. Review of the resident's physician order sheet (POS), dated 10/18/23, showed keep the splint/cast to the resident's right arm dry and right arm in a sling related to right humerus fracture. Review of the resident's Braden score (assessment for predicting pressure sore risk), dated 10/18/23, showed staff documented the following: -Skin occasionally moist; -Chairfast; -Very limited mobility; -Score of 17, indicating mild risk for pressure ulcer development. Review of the resident's care plan, updated 10/18/23, showed the resident had a fractured right arm. Staff should keep the cast clean and dry and ensure resident wore the right arm sling as ordered. There were no instructions for staff regarding assessing the resident's skin with a cast. Review of the resident's POS, dated 10/27/23, showed an order to not remove the right humerus brace. Check for skin integrity at right shoulder and right elbow every shift. Review of the resident's Treatment Administration Record (TAR) from 10/27/23 through 10/31/23 showed staff documented the right humerus brace was not removed, and the right shoulder and right elbow were checked for skin integrity every shift. Review of the resident's nurses' note, dated 11/6/23 at 10:36 A.M., showed staff documented they called the physician regarding the resident's complaint of pain in the right arm. Tramadol (pain medication) continued and the resident continued to wear the splint to the right arm. Review of the resident's TAR from 11/1/23 through 11/10/23 showed staff documented the right humerus brace was not removed, and the right shoulder and right elbow were checked for skin integrity every shift. Review of the resident's skin assessment, dated 11/8/23, showed staff documented the resident's skin was intact. There was no documentation regarding the condition of the resident's skin on his/her right arm. Review of the resident's record showed no documentation staff completed a weekly skin assessment between 10/16/23 and 11/8/23. Review of the resident's nurses' note, dated 11/10/23 at 8:19 P.M., showed staff documented the resident was noted with drainage on shirt when staff assisted with clothing change. The drainage was light yellow with odor noted to armpit area, slough (dead cells accumulated in the wound bed with drainage) noted to wound in armpit around the top of the splint. Open area 5 centimeters (cm) in length and 0.25 cm deep. The area was hard to measure due to fracture and resident unable to fully extend his/her arm. Staff removed the splint to assess the area. The physician was notified and orders received to send the resident to the emergency room for evaluation and treatment. Review of the resident's hospital emergency room medical records dated 11/10/23 showed the following: -Stage 2 (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured blister) pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) of the right axilla; -Measured 5 centimeters (cm) long by 3 cm wide and 1 cm deep. Review of the resident's POS showed the following new orders from the physician: -On 11/10/23, cleanse right axilla with wound cleanser, apply xeroform (wound treatment dressing to promote healing), cover with absorbent dressing and wrap, monitor area for change every shift. Do not put brace on due to open area, only wear sling, monitor right arm for skin integrity change. Monitor blister to back of right arm every shift; -On 11/11/23, wound check once daily, irrigate (the process of flushing a wound with a gentle stream of a specific liquid to remove dead tissues) right axilla wound with saline (cleansing solution) and cover with xeroform, apply absorbent dressing and wrap. Bactrim (antibiotic medication) 800-160 mg twice daily for right axilla wound for 7 days. During an interview on 11/30/23 at 1:05 P.M. Certified Nurse Aide (CNA) B said the resident had a cast on his/her right arm. The cast was solid to the back of the arm from the resident's wrist and into the armpit and was wrapped in place with an ace wrap. During an interview on 11/30/23 at 1:15 P.M. and 12/4/23 at 11:30 A.M. LPN C said the following: -The resident had a fractured right arm and was in a partial cast wrapped with an ace wrap. The hard cast extended under the arm tight into the axilla and rubbed the resident's arm causing an open area about two to three inches in length. Staff sent the resident to the emergency room after the wound was discovered. This wound occurred from the cast rubbing on the skin; -Staff should complete weekly skin assessments. There were no weekly skin assessments documented for the resident from 10/16/23 until 11/8/23. During an interview on 11/30/23 at 2:45 P.M. the Director of Nursing said the following: -Resident #4's cast was in the armpit. Staff said they assessed the resident's arm and skin condition. The wound, when found, was 5 cm in length and caused by the cast rubbing in the armpit. Staff should conduct thorough assessments and ensure the resident's skin was intact around the cast; During an interview on 11/30/23 at 2:00 P.M. and 12/4/23 at 4:00 P.M. the Administrator said the following: -Resident #4 fell and fractured the right humerus. Staff sent the resident to the hospital and he/she returned with a partial cast secured with an ace wrap from the wrist to the axilla. The cast went up to the resident's arm pit. Staff documented assessment of the resident's skin and axilla area every shift. Staff were unaware the resident had a wound until drainage was noted 11/10/23. The wound was caused by the cast rubbing. He expected staff to complete thorough assessments. #MO00228015 #MO00227243

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure one resident (Resident #18), a resident with diagnosis of muscular dystrophy, was free from misappropriation of medication when 46 of his/her oxycodone tablets (narcotic pain medication), were exchanged for 46 loratadine (allergy medication) tablets. The resident did not receive his/her ordered pain medication as a result for an undetermined amount of time from 4/11/23 (admittance to the facility) until 4/25/23. The resident reported he/she was not getting pain relief and his/her pain was not under control with the current dose of oxycodone. The facility census was 96. Review of the facility policy Abuse-Protection of Residents, Misappropriation of Property and Exploitation, dated 10/4/22 showed: -Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent; -Examples of resident property include money, theft of resident's personal belongings and missing prescription medications or diversion of a resident's medications, including but not limited to controlled substances for staff use or personal gain. Review of the facility policy Resident Rights, last reviewed 10/6/22, showed the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. 1. Review of Resident #18's face sheet showed the following: -The resident admitted to the facility on [DATE]; -The resident had diagnoses that included muscular dystrophy (a group of diseases that cause progressive weakness and loss of muscle mass), unsteadiness on feet, periodic limb movement disorder, repeated falls, lack of coordination and abnormal posture. Review of the resident's physician order sheet (POS) showed an order dated 4/11/23 for oxycodone 5 milligrams (mg) by mouth every six hours as needed for pain related to muscular dystrophy. Review of the resident's progress notes and comments, dated 4/11/23, Pharmacist H wrote the following: -The resident's medications were verified; -All appear to be as labeled; -Lisinopril (blood pressure medication) 20 milligram bottle; two different shapes/colors were in the bottle - both are lisinopril; -As needed pain reliever; two different shapes/colors were in the bottle - both are as labeled; -The note was signed by Pharmacist H. Review of the resident's care plan, dated 4/12/23, showed the following: -The resident expressed frequent pain due to his/her diagnosis of muscular dystrophy; -Administer pain medications as ordered; -Report any uncontrolled pain to the physician; -Perform pain assessments as per facility protocol. Review of the resident's pain assessment, dated 4/16/23, showed: -The resident said lying in the same position for long periods of time caused pain; -Repositioning and oxycodone as needed made the pain better. Review of the resident's pain assessment, dated 4/18/23, showed: -The resident said everything, especially movement made the pain worse; -Medication made the pain better; -The resident said the pain was constant. Review of the resident's progress notes, dated 4/18/23 at 11:18 A.M., showed the resident had pain all over. Review of the resident's progress notes, dated 4/18/23 at 1:50 A.M., showed the following: -The resident voiced his/her pain was not under control with the current dose of oxycodone; -The resident asked the nurse practitioner for an increase in his/her oxycodone. Review of the resident's progress notes, dated 4/18/23 at 4: 41 P.M., showed the resident's physician increased his/her oxycodone order to one or two tablets every six hours as needed. Review of the resident's POS showed an order dated 4/18/23 for oxycodone 5 mg by mouth, may have one or two tablets by mouth every six hours as needed for pain. Review of the facility Time Line of Events for Resident #18, dated 4/25/23, showed the following: -At 6:46 P.M. during change of shift narcotic reconciliation, medication didn't appear uniform to Licensed Practical Nurse (LPN) A and LPN E. Notification to the Director of Nursing (DON) and the administrator; -At 7:00 P.M., regional and divisional staff were notified, local police notified, statements from staff obtained; -Resident #18's oxycodone was removed from commission and medication used from the emergency box until verification and proper packaging secured; -On 4/26/23 Pharmacist I conducted a facility audit on medication carts. No gaps in process found. Review of a note signed by Pharmacist I on the local pharmacy letterhead, dated 4/26/23, showed all narcotics, controlled and liquid medications were verified at the facility on 4/26/23 During an interview on 4/26/23 at 9:47 A.M., LPN D said the following: -He/She and LPN E were counting the resident's oxycodone on 4/25/23 at evening shift change; -LPN E noticed a difference in some of the pills while they were counting; -The two nurses compared the pills and found there were different markings on some of the pills; -The nurses looked online to find out what the pills were. Forty-six of the pills were loratadine and 35 of the pills were oxycodone; -After finding the discrepancy in the pills they called the administrator and the DON. The DON told them to separate the pills and to lock them up. The resident was to begin receiving oxycodone from the emergency kit. -He/She did not take the pills and did not know who switched them; -He/She had not noticed a difference in any of the resident's medications before this day. During an interview on 4/26/23 at 12:39 P.M., LPN E said the following: -He/She counted the resident's oxycodone with LPN D; -He/She noticed the pills looked a little bit different and began looking at them closer; -After looking more closely at the pills he/she observed they had different markings on them; -The two nurses looked up the markings and found that 35 pills were oxycodone and 46 pills were loratadine; -After finding the discrepancy, the nurses called the administrator and the DON. -He/She did not switch the pills and did not know who switched them; -He/She had not noticed a difference in any of the resident's medications before this day. Observation on 4/26/23 at 9:47 A.M., of the resident's medication showed: -The oxycodone pill bottle contained 35 oxycodone 5 milligram pills that had the numbers 03 52 marked on one side of each pill and a M inside a square marked on the other side of each pill; -46 loratadine pills sealed in a plastic bag that had the numbers 439 marked on each pill. During an interview on 4/26/23 at 6:45 P.M., the resident said the following: -He/She was not getting pain relief with the oxycodone 5 mg; -Sometimes the resident would wake up with the shakes and that is when he/she knew it was time for more medication. During an interview on 4/26/23 at 9:03 A.M. and 5/18/23, the DON said the following: -The resident's oxycodone was filled at the local pharmacy and it was brought to the facility in a prescription bottle; -When the resident was admitted to the facility the local pharmacist came to the facility, took the resident's medications to the pharmacy, verified the medications and returned them to the facility before the resident received oxycodone at the facility; -The pharmacy did not bubble pack the resident's oxycodone and she was not sure why; -LPN D and LPN E found a discrepancy in the resident's oxycodone last night at shift change during the narcotic counts; -The nurses called her and the physician and police were notified; -She did not know who switched the pills out. During an interview on 5/15/23 at 3:34 P.M., the administrator said the following: -He expected 100% honesty from his staff; -He expected staff to count narcotics at each shift change and when administering the medications; -The pharmacist verified the oxycodone when the resident was admitted to the facility; -He does not know how the oxycodone pills got switched with the other pills. During an interview on 5/18/23 at 9:08 A.M., Pharmacist I said the following: -If a nursing home resident had a home medication that was filled at the pharmacy they would bubble pack it and send it back to the pharmacy for it to be administered to the resident instead of from a pill bottle; -He/She was at the facility on 4/26/23 and verified there were oxycodone in the resident's medication bottle; -The facility staff had already taken the other pills out of the oxycodone bottle and placed them in a plastic bag separate from the oxycodone. During an interview on 5/18/23 at 3:42 P.M., Pharmacist H said the following: -The facility brought the resident's medications to the pharmacy (4/11/23) for review about five minutes before closing time and the facility driver returned them to the facility after he/she reviewed them; -He/She can't 100% say if the oxycodone was reviewed. If he/she reviewed the oxycodone and there was a discrepancy in the pills he/she should have noted it in the progress note; -The pharmacist remembered he/she reviewed lisinopril, an over the counter generic Tylenol PM, multiple vials of testosterone and many blood thinners; -At the time the resident's medications were reviewed the pharmacy did not have a policy to bubble pack controlled substances for the nursing home; -When he/she verified the resident's medications on 4/11/23 and made note of one medication having two different pills it was probably because the resident had two different refills by different manufacturers mixed together. MO217558

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to failed to provide a wheelchair and a lift sling to accommodate one resident (Resident #38) and failed to ensure call lights were in reach for three residents (Resident #28, #63, and #147), in a review of 20 sampled residents. Resident #38 was unable to transfer from his/her bed as the sling used with the facility's mechanical lift caused severe pain, cutting into his/her legs. Additionally, the facility did not have a wheelchair that fit the resident's physical needs. As a result, the resident's movements were restricted to his/her room for over two years, contributing to the resident feeling depressed and unsafe. The facility census was 92. Review of the facility policy Resident Rights last reviewed 10/6/22 showed a facility must care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The resident has the right to receive the services and/or items included in the plan of care. Review of the facility policy Resident Call System last revised 1/4/23 showed the following: -The facility must be adequately equipped to allow residents to call for assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities; -The call light should be positioned within reach of the resident; -The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room; -The call system must be accessible to the resident at each toilet and bath or shower facility 1. Review of Resident #38's face sheet showed the resident's diagnosis include bipolar disorder (drastic mood swings from depressed to elated), anxiety, depression, cellulitis both lower extremities, deep vein thrombosis (blood clots), arthritis, lymphedema (swelling in an arm or leg caused by a lymphatic system blockage), and morbid obesity. Review of the resident's Care Plan, last reviewed 6/24/21, showed the following: -Requires hoyer lift (mechanical lift) for transfers, but has been unable to transfer due to complaints of pain when getting out of bed; -The resident chooses to stay in bed at all times; -He/She cannot exit his/her bed without total assist of staff and is refusing to get out of bed. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 2/16/23, showed the following: -Cognitively intact; -Required extensive assistance from two or more staff for bed mobility, -Transfers and locomotion did not occur; -Functional limitation in range of motion to both lower extremities; -No mobility devices; -He/She weighed 412 pounds (lbs). Observation on 4/12/23 at 9:30 A.M., showed the following: -The resident lay in a bariatric bed; -The resident's bed was visibly wider than the doorframe to the resident's room; -The resident's weight was primarily in his/her lower body related to lymphedema; -His/Her legs went from one side of the bed to the other side of the bed, with very little room left at the edge of the bed; -The resident's legs were swollen and weeping (fluids leaking from the skin); -The resident did not have a sling for a mechanical lift or a full size sheet in his/her room. During an interview on 4/12/23, at 11:28 A.M., Licensed Practical Nurse (LPN) Q said the following: -The resident had not been weighed in quite a while; -He/she refuses because the hoyer lift sling hurts him/her; -He/She thought occupational therapy was working to get a wheelchair for the resident but hadn't heard anything about it in a while. During an interview on 4/12/23, at 11:38 A.M., the resident said the following: -He/She had been in his/her room in his/her bed for three years, except for a hospitalization, and once to get his/her hair dyed; -He/She was to be weighed daily, but staff had not weighed him/her in about a year because the sling hurt his/her legs too much to be lifted with the mechanical lift; -The staff say he/she refuses to get up, but the sling the facility has cuts into his/her legs; -The hoyer lift hurts so bad he/she does not want to get up in the hoyer lift; -His/Her lymphedema got worse and his/her legs got bigger. The wheelchair he/she had was not safe, it would tip forward; -The occupational therapist had him/her measured for a custom wheelchair, but the company went out of business and he/she has not heard anything else; -He/She would like to play cards or games everyday, he/she really enjoys games; -He/She would love to paint, but the facility doesn't allow the residents to have paint in their rooms now; -He/She can't leave his/her room so he/she does not feel safe if there is a fire or tornado, he/she does not feel emotionally safe at the facility. During an interview on 4/12/23, at 1:25 P.M., Certified Nurse Assistant (CNA) MM said the following: -The facility had slings for the hoyer lift that were rated for 440 lbs; -All the lift slings go around the resident's legs; -The facility does not have slings that are solid under the resident's whole body. During interviews on 4/12/23, at 1:30 P.M. and 2:15 P.M., LPN/Infection Preventionist (IP) QQ said the corporate approved brand of hoyer lifts does not make a full body solid sling, so the resident would have to use the sling that goes between his/her legs with the lift. During an interview on 4/12/23, at 2:37 P.M., Physical Therapy Assistant (PTA) RR said the following: -Occupation therapy was working with a company to get a custom wheelchair for the resident; -About four months ago, the company went out of business; -They have not been able to find another company to make the resident a custom wheelchair; -A regular bariatric chair would be so uncomfortable; -Therapy has tried to get the resident out of bed with the hoyer lift, but the facility does not have a sling that will fit around the resident's legs; -Therapy tried the facility's slings three to four times, and the last time the resident had cuts into his/her legs; -The hoyer lift sling hurts the resident. During an interview on 4/12/23, at 2:51 P.M., the Director of Nursing said the following: -The resident does not have a wheelchair that fits him/her; -His/Her legs got too big for his/her wheelchair, and the facility had not been able to get him/her a custom chair, therapy was working on it and the company went out of business; -He/She did not know if the resident was over the weight limit of the hoyer lift because they have not been able to weigh the resident. During an interview on 4/12/23 at 5:25 P.M., the Administrator said the following: -He did not know if the facility had a lift or sling that fit the resident; -The therapy staff tried to get a custom chair for the resident but there was a problem with the company. 2. Review of Resident #63's care plan, last revised 2/15/23, showed the following: -The resident was at risk for seizures; -The resident will occasionally press his/her call light when he/she believes he/she is having a seizure or is about to have a seizure; -Keep the call light within reach and encourage the resident to ask for assistance as needed. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 4/5/23, showed the following: -Severely impaired cognition; -Required extensive assistance from two staff for bed mobility and transfers; -Required extensive assistance from one staff for locomotion on and off unit; -Used a wheelchair. Observation on 4/10/23 at 9:27 A.M. showed the following: -The resident lay in his/her bed; -His/Her soft touch call light lay on the floor on the right side of the bed, out of the resident's reach. Observation on 4/11/23 at 4:50 P.M. showed the following: -The resident sat in his/her wheelchair to the left side of his/her bed; -The resident said he/she was cold; -The resident's call light lay on the floor on the right side of the bed; -The resident's roommate put on his/her call light for the resident, and said he/she saw the resident's call light on the floor a lot. Observations on 4/18/23 showed the following: -At 11:25 A.M., the resident sat in his/her wheelchair to the left side of the bed. The resident's soft touch call light lay on the floor to the right side of the bed. -At 6:10 P.M., the resident lay in bed with the head elevated. The call light was attached to siderail (which was lowered) and rested on the floor (on the right side of the bed), out of the resident's reach. 3. Review of resident #147's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Always incontinent of bowel and bladder; -Required extensive assistance from two staff for bed mobility, dressing and personal hygiene. Review of the resident's care plan, last revised 3/6/23, showed the following: -Diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning); -Assist with bed mobility, dressing and personal hygiene; -Ensure the resident's safety at all times; -Keep call light in reach. During interview on 4/11/23 at 3:00 P.M., the resident's family member said a few days ago the resident phoned to say he/she could not reach/find the call light. The family member called the facility at 9:00 A.M., spoke with an unknown staff and informed them that the resident could not reach the call light and needed attention. At 10:30 A.M., he/she spoke with the resident and no one had responded, so he/she called the facility again and this time he/she spoke with LPN D who responded right away. 4. Review of Resident #28's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included Alzheimer's disease and dementia; -Required extensive assistance from two staff for bed mobility, transfers, and toileting; -Used a wheelchair. Review of the resident's care plan, dated 4/4/23, showed the following: -The resident had limited mobility and activity of daily living (ADL) function due to Alzheimer's dementia, congestive heart failure and adult failure to thrive; -He/She was at risk for falls due to his/her limited mobility, unsteadiness, muscle weakness and history of falling with poor safety awareness; -The resident required extensive assistance from two staff for dressing, personal hygiene, toileting and transferring; -The resident was unable to ambulate at this time due to unsteadiness and weakness; -He/She used a wheelchair for his/her primary mode of locomotion and was dependent on staff to propel his/her wheelchair; -Keep call light within reach and encourage the resident to ask for assistance as needed. Observation on 4/10/23 at 9:40 A.M., showed the resident lay in bed on his/her back. The call light hung on the wall and was not in the resident's reach. Observation on 4/12/23 at 8:35 A.M., showed the resident sat on the side of his/her bed. The resident's call light hung on the wall and was not in the resident's reach. 5. During interview on 4/20/23 at 4:00 P.M. the Director of Nursing (DON) and the regional vice president said they expected call lights to be within the resident's reach at all times whether they were in the bed or up in a chair. During interview on 4/20/23 at 4:00 P.M., the administrator said call lights should be in the resident's reach at all times when they are in their rooms. MO216336

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #38), a resident with a past history of abuse and diagnoses including post traumatic stress disorder and depression, in a review of twenty sampled residents, was free from mental and emotional abuse. The resident was totally dependent on staff and was bed bound as a result of facility failure to ensure he/she had appropriate transfer equipment. The resident had not been able to leave his/her room in at least two years and participate in any activity outside of his/her room. The resident was alert and oriented. The resident reported staff were mean and hateful in their interactions with him/her, he/she felt ignored and an inconvenience for staff. Staff accused him/her of crying wolf and wasting his/her body. The resident relayed this made him/her feel humiliated and treated in a way that made him/her feel like staff did not like him/her. As a result of staff treatment, relative to her diagnoses and past experiences, the resident verbalized wanting to go home to heaven because no one would pick on him/her there. The facility census was 92. Review of the facility's policy Abuse Identification, dated 10/4/22, showed the following: -It is the policy of this facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to identifying and understanding the different types of abuse and possible indicators. -The facility will apply the following definitions to identify abuse, neglect, and exploitation. -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are residents from abuse. necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Involuntary seclusion is defined as separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the resident representative; -Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. -Willful is defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation; -Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse include, but are not limited to: o Harassing a resident; o Mocking, insulting, ridiculing; o Yelling or hovering over a resident, with the intent to intimidate; o Threatening residents, including but limited to, depriving a resident of care or withholding a resident from contact with family and friends; and o Isolating a resident from social interaction or activities. -Literature indicates that the most prevalent psychosocial outcomes of abuse are depression, anxiety, and posttraumatic disorder; -Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. o Neglect of goods or services may occur when staff are aware, or should be aware, of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as lack of training to perform an intervention (e.g., suctioning, transfers, use of equipment), lack of sufficient staffing to be able to provide the services, lack of supplies, or staff lack of knowledge of the needs of the resident. -Involuntary seclusion occurs when separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the resident representative o Involuntary seclusion may take many forms, including but not limited to the confinement, restriction or isolation of a resident. o Involuntary seclusion may be a result of staff convenience, a display of power from the caregiver over the resident or may be used to discipline a resident for wandering, yelling, repeatedly requesting care or services, using the call light, disrupting a program or activity, or refusing to allow care or services such as showering or bathing to occur. 1. Review of Resident #38's Preadmission Screening and Resident Review (PASRR) (a federally mandated screening process), dated 11/17/16, obtained by the state agency showed the following: -Psychiatric diagnosis: bipolar disorder (mental condition marked by alternating periods of elation and depression), anxiety, adjustment disorder (a group of symptoms, such as stress, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event, reaction to the event are stronger than expected for the type of event that occurred), depressive disorder post traumatic stress disorder (PTSD) (a mental health condition that's triggered by a terrifying event. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), borderline intellectual functioning, borderline personality disorder (a mental illness that severely impacts a person's ability to regulate their emotions. This loss of emotional control can increase impulsivity, affect how a person feels about themselves, and negatively impact their relationships with others), dependent personality disorder (a mental disorder that cause one to often feel helpless, submissive or incapable of taking care of themselves), blindness at birth (corrected with glasses); -Symptoms to support diagnosis: anxiety, depression, poor judgment, poor impulse control and history of suicidal ideation, inpatient stay July 2016; -Physical abuse by step parent; -Hospital stay July 2016 due to suicidal ideation after his/her children were removed from his/her care, (this is second hospitalization this year); -Records note history of labile mood, nightmares, and flashbacks related to past abuse; -Depressed over this hospitalization because he/she has not had thoughts of hurting himself/herself this admission; -Current symptoms include: anxiety, depression and poor impulse control; -Current psychiatric support/services: medication therapy administration and monitoring, psychiatric service provider, and safety precautions; -Recommend ongoing psychiatric care and treatment, implementation of systematic plans to change inappropriate behavior, medication therapy and monitoring, structured environment, ADL programs to increase independence and self-determination, development of personal support networks; -Would benefit from guardianship, family support/education, nutritional evaluation, art/music therapy, pet therapy, recreational therapy, grief/loss/adjustment counseling/emotional support, medication education/counseling, financial assistance/eligibility evaluation, medical follow up ongoing, and medication review ongoing. Review of the resident's Care Plan, last reviewed 2/1/23, showed the following: -Resident has a diagnosis of depression and is prescribed antidepressant medication; mood and cognition fluctuate due to his/her bipolar disorder, and is at risk for change in mood and behavior related to medical condition; -Resident has anxious/tearful and attention seeking behaviors at times that are not always easily redirected and makes untruthful statements to gain attention, resident has a history of manipulative behaviors and is at risk for being manipulated by others due to cognitive level/functioning; -Goal: resident will remain free of signs and symptoms of depression, anxiety or sad mood, and the resident will not harm self or others through next review; -Always treat any resident with dignity and respect; -Consult with the resident on preferences regarding customary routine; -Encourage resident to express feelings; -Offer one on one conversations, visiting with other residents, visits from facility pets, likes to color in adult color books, phone calls with family and friends; -Observe for and report any signs and symptoms of depression including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health related complaints, tearfulness, mood changes, making untruthful statements, and attention seeking behaviors; -When this resident makes untruthful statements, let the resident know that this behavior is not appropriate; -Allow resident to vent/share in a nonjudgmental way; -Assist/encourage/support the resident to set realistic goals; -Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears; -Encourage participation from the resident who relies on others to make decisions and to participate in facility life of choice; -Increase communication between resident/family/caregivers about care and living environment; -Observe for resident's usual response to problems. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff), dated 2/16/23, showed the following: -Diagnosis included bipolar, anxiety, and depression, -The resident has not been evaluated by Level II PASRR (an assessment completed on those residents identified during the Level I screening who are known or suspected to have a serious mental illness (such as schizophrenia, dementia, major depression, etc., mental retardation (MR) or related MR conditions to determine the need for specialized service); -Cognitively intact; -Moderately severe depression signs and symptoms; -Nearly everyday the resident has little interest or pleasure in doing things, feels down, depressed, or hopeless; feels tired or having little energy; poor appetite or overeating; -Several days: feels bad about self or that he/she has let self or your family down; -No behaviors or rejection of care; -Preferences: It is somewhat important to have snacks between meals; -Activities that are very important to the resident included: music; he/she likes pets, keeping up with the news, doing favorite activities, going outside is important -but can't, or no choice, religious activities and it is somewhat important to do things with groups of people; -Requires extensive assistance of two or more staff for bed mobility, toilet use, and bathing; -Transfers and locomotion did not occur; -Functional limitation in range of motion to both lower extremities; -No mobility devices; -Scheduled and PRN (as needed) pain medications; -Pain frequently, makes it hard to sleep at night, limits day to day activities and rates pain a 10 on a scale of 0-10; -Incontinent of bowel and bladder. During an interview on 4/10/23, at 12:27 P.M., the resident said the following: -The nurse aides aren't nice to him/her; -He/She pushed his/her call light and Certified Nurse Assistant (CNA) O came in; -CNA O's reply to his/her request was anger and that the he/she would need to ask the nurse first; -A while had passed and he/she didn't know if CNA O was coming back, so he/she turned his/her light back on because the window was open and he/she was getting cold; -CNA O came back and said, You knew I was coming right back, I hope you don't ask for anything else through the night; -CNA H works nights and is snappy and rude; CNA H does not wake the resident up to change him/her; -CNA P works nights and is also rude, snooty, mean, hateful, and snobby; -The resident said he/she asked to be moved off the hall because of the way staff treat him/her; -Registered Nurse (RN) BB and Licensed Practical Nurse (LPN) R are rude and snappy; -LPN R was supposed to put the resident on the list to see his/her physician tomorrow. LPN R won't do this, he/she never does; -LPN R did not come back and look at his/her leg after CNA Z and CNA EE reported that it was still bleeding; he/she won't, he/she never comes in when staff report things; -The resident said he/she feels ignored, like he/she isn't good enough to exist, and some staff make him/her feel like an inconvenience, but he/she cannot get out of bed or go get anything himself/herself; -Resident said he/she has told the administrator all of this before; he says he will check into it and never tells the resident anything afterwards. During an interview on 4/11/23 at 10:16 A.M., the resident said the following: -The nurse last night, LPN FF, told him/her he/she cries wolf and makes allegations that aren't true. LPN FF took forever to bring him/her a pain pill; -Last night, CNA CC said, Go to sleep, he/she was tired of coming in my room. Observation on 4/11/23, at 10:23 A.M., showed the Social Service Director (SSD) came into the resident's room. The resident began to cry, and said, I'm so glad you're here. I need a friend. I just want to go home to heaven. I will be so much happier there. No one will pick on me there. The SSD comforted the resident while in the room, but did not document or report to nursing the resident's concerns. During an interview on 4/12/23, at 11:38 A.M., the resident said the following: -The administrator came and interviewed him/her on 4/11/23 and he/she told the administrator all of his/her concerns about how staff are treating him/her; -The staff say he/she refuses to get up, but the sling the facility uses for the mechanical lift cuts into his/her legs, and that is why he/she doesn't want to get up. He/She does want to get out of bed and out of his/her room; -CNA CC usually responds to him/her by saying, What do you want, in a hateful way when he/she uses the call light and asks for ice or water; -Last time he/she asked CNA CC for ice and water around 10:00 P.M., the CNA said, You will have to wait until I pass ice at 11:30 P.M., which he/she thinks is a long time to be thirsty; -He/She has been physically or emotionally abused his/her whole life; -Registered Nurse (RN) BB once made him/her wait three hours for a pain pill; RN BB always has an attitude; -He/She reported to CNA O one time that he/she was in pain and CNA O told him/her to, Suck it up buttercup, you asked for this; -CNA H would tell the nurses he/she (the resident) refused to get changed, but he/she (CNA H) just wouldn't wake him/her up. If CNA H was mad at him/her, he/she (CNA H) would say he/she would report to the nurse that he/she (the resident) refused to be changed; -The Director of Nurses (DON) said they interviewed LPN FF and the reason he/she said the resident cried wolf is because the resident had asked for pain medication but when he/she came in the room he/she said the resident was on the phone laughing; -The resident said he/she may have not been in extreme pain when lying flat, but it was almost time for the staff to change him/her and that causes extreme pain; -It really hurts his/her feelings when staff are so mean and rude to him/her; -He/She has asked the staff What did I ever do to you; -CNA CC will say things like, If you want to waste your body away, that's on you; -The resident said, The way they treat me makes me depressed; -The resident said, I want to go home to heaven; in heaven no one would pick on me. During an interview on 4/27/23, at 2:02 P.M., CNA O said the following: -One nurse, LPN PP, was snappy with residents all the time -Staff have reported to the Director of Nurses (DON), the DON said he/she would take care of it, but there have been no changes; -He/She has witnessed Licensed Practical Nurse (LPN) PP be rude and mean to residents including Resident #38; -Before Resident #38's fluid restriction was discontinued, LPN PP would be snappy about the fluid restriction or what Resident #38 was eating; -LPN PP brags about being hateful; -Resident #38 gets his/her feelings hurt often, sometimes as a result of staff's tone of voice; -LPN PP has lectured Resident #38 multiple times about food and drink; -He/She reported it to the charge nurse on 200/400 halls but nothing was done. During an interview on 4/27/23, at 3:15 P.M. LPN FF said the following: -He/She has had staff be rude and snappy with Resident #38. The resident will make up things at times; -The resident asks why does everybody hate her? LPN FF has told the resident that some staff are concerned or scared to take care of him/her. The resident will tell people little lies. The resident once called him/her a liar. He/She has not called the resident a liar; -Resident #38 asked him/her why staff do not like him/her, and he/she explained to the resident the staff feel like he/she will make up stories or turn things around on staff, and it makes staff leery to go into his/her room; -CNA CC would not always wake Resident #38 up to change him/her and say he/she did; CNA CC is no longer able to go in Resident #38's room; -CNA CC and Resident #38 have a clash of personalities, it's possible CNA CC was rude to Resident #38, or for him/her and the resident to go back and forth with each other. During an interview on 4/27/23, at 5:09 P.M., CNA H said the following: -LPN PP, has gotten snarky with residents; -LPN PP is rude and will argue with residents, this is a common occurrence; -He/She has witnessed LPN PP be rude and almost yelling at Resident #38; -He/She has reported to the administrator and he has not done anything about the report. He will say the nurse is short tempered or didn't do or say it out of malice and try to justify the actions. During an interview on 4/12/23, at 2:51 P.M., the DON said the following: -She did not feel Resident #38 was abused; -The resident was sensitive to what staff say to him/her; -The resident has behaviors. During an interview on 4/11/23, at 5:37 P.M., and 4/20/23, at 4:00 P.M. the administrator said the following: -Staff are expected to speak to residents with dignity and respect, and should not use a loud tone or be short with a resident; -Staff should not be rude to residents; -Staff are expected to report any concerns reported by a resident; -To decide if a report was abuse or a dignity issue, he would consider if the resident was alert and oriented, and how the resident received it; -Should consider how actions made the resident feel; -He did not believe the allegations made by Resident #38 were true.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident (Resident #28), of 20 sampled residents, had a nutritional assessment completed on admission, received weights per facility protocol, and failed to ensure his/her feeding tube was connected as ordered for continuous feeding to ensure he/she received adequate nutrition. The resident had a 9.5 pound (-7.68%) weight loss in ten days. The facility also failed to re-evaluate interventions to prevent weight loss for effectiveness, carry through recommendations from the Registered Dietitian, notify physician and dietitian with further weight loss, failed to update the resident's care plan timely when new weight loss was identified and take action to prevent further weight loss, or identify possible need for adaptive equipment for one sampled resident (Resident #64), which resulted in a 31.6% significant weight loss and severe protein-calorie malnutrition. The facility census was 92. Review of facility policy, Weight Monitoring, Long-Term Care, revised: August 19, 2022, showed the following: -Introduction: -Following a routine weighing schedule helps detect weight changes; -Unless otherwise specified, a resident's weight should be recorded at the time of admission, weekly for 4 weeks, and then monthly; -Unplanned weight loss in residents is associated with increased mortality; a decrease in weight of 5% or more in a month or of more than 10% in 6 months should be reported to the practitioner for further evaluation; -Compare the resident's current weight with previous measurements to assess for trends in weight gain or loss; -If you note a weight change, assess the resident to help determine a possible cause of the weight change; -Notify the practitioner if weight changes are beyond the expected range; -Documentation associated with weight monitoring includes: a. Resident's weight, according to your facility's documentation format; b. Assessment findings; c. Date and time that you notified the practitioner of significant weight changes; d. Prescribed interventions; -The facility has approved the following information as an addendum to the Lippincott procedure: a. Follow facility protocol to determine who is assigned to obtain residents' weights and heights; b. Maintain consistency when obtaining repeated weights (i.e., weigh at the same time of day, with the same equipment, with the resident wearing similar clothing); c. Notify the nurse if the weight obtained is significantly different from the prior weight (2.3 lbs. for a weekly weight; 2.5 lbs. for a monthly weight); d. Re-weigh as needed; e. The unit manager/designee should review and verify the weights on the day they are obtained to ensure there is no unexplained significant variance from the prior weight by utilizing the weight reports in Point Click Care (PCC) (residents' electronic record). Review of facility policy, Nutrition Assessment, revised 12/16/21 and reviewed: 04/27/22, showed the following: -Policy: -A representative from the Food and Nutrition Services department visits all residents upon admission and routinely thereafter. Food preferences, nutritional history and a visual assessment are documented; - Each resident receives a comprehensive nutrition assessment to determine nutritional needs on admission, annually and when the resident becomes at risk for compromised nutritional status; -The Director of Food and Nutrition Services/ RD or designee completes the Nutrition Data Collection section and food and beverage preference list; -The Registered Dietitian reviews the information and completes the RD portion of the nutrition assessment on the next visit or per state regulation; -The Director of Food and Nutrition Services/ designee reviews the medical record and notes the relevant physician's orders and history/transfer information; -The nutrition data collection includes at least feeding, chewing and swallowing ability - from visual observation; -The Nutrition Data Collection/Assessment is completed on admission, annually and whenever the Comprehensive Minimum Data Set (MDS) is completed; -The Director of Food and Nutrition Services or designed visits each resident within 72 hours of admission; -The resident's nutritional status is updated as it changes, but no less than quarterly; -The Registered Dietitian assesses the resident to determine nutritional needs by reviewing the information and completing the RD portion of the nutrition assessment. If there is a contract RD, it will be completed on the next visit or per state regulation; -Nutrition assessment includes an estimate of calorie, nutrient and fluid needs. Approximate needs are compared with approximate intake to determine if present intake is adequate to meet those needs; -A systematic approach will be used to optimize a resident's nutritional status. The process includes identifying and assessing each resident's nutritional status and risk factors, evaluating/analyzing the assessment information, developing and consistent implementing pertinent approaches and monitoring the effectiveness of interventions and revising them as necessary. 1. Review of Resident #28's face sheet showed the resident was NPO (nothing by mouth) and received continuous tube feedings of Jevity 1.5 (nutritional formula). Review of the resident's physician order summary, dated 3/01/23 - 4/30/23, showed the following: -Diagnoses of Alzheimer's disease, adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition) and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function); -Enteral (nutrition received through an opening in the stomach through a tube), feed order every shift Jevity 1.5 Cal at 60 ml/hour (milliliters per hour) continuous feeding via pump. Flush with 100 ml water every 2 hours; -Verify percutaneous endoscopic gastronomy (PEG) (a tube through the skin and the stomach wall) tube placement by checking gastric residual volume (GRV) and observing changes in external length of tubing; -No order documented for obtaining the resident's weight. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff,dated 4/3/23, showed the following: -Date of admission: [DATE]; -The resident has severe cognitive impairment; -His/Her diagnoses include Alzheimer's disease, dementia, malnutrition, and depression; -The resident had coughing or choking during meals or when swallowing medications; -The resident had complaints of difficulty or pain with swallowing; -The resident's admission weight was 134 pounds on 3/30/23; -He/She has a feeding tube; -The resident receives 51% or more total calories through feeding tube; -The resident receives an average of 501 cubic centimeter (cc) ( fluid volume measurement) /day or more fluid by feeding tube. Review of the resident's care plan dated 4/4/23, showed the following: -The resident has impaired cognitive ability and impaired thought processes related to Alzheimer's dementia; -The resident receives all fluids and nutrients via tube and he/she is at risk for weight fluctuations due to a history of congestive heart failure; -Administer the tube feedings and flushes as ordered; -Follow the NPO diet as ordered; -Obtain his/her weight per protocol; -Refer to the dietician as needed; -The resident is at risk for aspiration due to dysphagia; -Monitor the resident for any signs or symptoms of aspiration pneumonia after any episodes of coughing or choking while eating or drinking (fever, cough, wet breath sounds, lethargy, etc) and report to the primary care physician; -He/She asks for drinks frequently and does not follow his/her NPO status; -Provide oral care as needed and remind him/her or his/her NPO status. Review of the resident's medical record showed no weight documented for the week of 4/2/23 through 4/8/23. Review of the resident's medical record showed the resident weighed 135.4 pounds on 4/9/23. Observation of the resident on 4/10/23 at 9:40 A.M., showed the resident's tube feeding pump was turned off and the resident was not connected to the feeding pump to receive his/her ordered Jevity. Observation of the resident on 4/12/23 at 8:35 A.M., showed the following: -The resident sat on the side of the bed; -The resident was hooked up to tube feeding; -The tube feeding formula bag was empty, pump read error, and air was in the line approximately 14 inches leading from the pump; -The resident's pants looked to be several sizes too big. Observation of the resident on 4/12/23 at 9:30 A.M., showed the resident was outside smoking and was not connected to the tube feeding pump. Review of the nursing progress note, dated 4/12/23 at 2:47 P.M., showed the following: -Whenever staff is in the room the resident will ask for a drink and says he/she is thirsty; -At times when this nurse is in the room giving medications via PEG tube, the resident will lean down to attempt to drink from the syringe the medications are in; -When the resident reports he/she is thirsty, this nurse will give him/her swabs to wet his/her mouth and that typically satisfies the resident for a short period. Observation of the resident on 4/13/23 showed the following: -At 12:50 P.M., the resident in his/her bed and not connected to the tube feeding pump; -1:35 P.M., the resident sat at the nurses' station and not connected to the tube feeding pump; -2:00 P.M., the resident outside smoking and not connected to the tube feeding pump; -2:20 P.M., the resident sat at the nurses' station and not connected to the tube feeding pump; -2:45 P.M. the resident sat at the nurses' station and not connected to the tube feeding pump; -3:15 P.M., the resident outside smoking and not connected to the tube feeding pump; -3:30 P.M., the resident lay in his/her bed and not connected to the tube feeding pump; -3:35 P.M., Licensed Practical Nurse (LPN) A reconnected the resident to the feeding pump; -The resident had been off of his/her feeding pump two hours and forty five minutes, (the resident was to receive his/her tube feeding continuously per pump). During an interview on 4/13/23 at 3:35 P.M., LPN A said the resident asked to be unhooked from his/her tube feeding to go outside and smoke. When the Certified Nurse Assistants (CNA)s bring the resident back from smoking they let him/her know the resident is ready to be connected to his/her tube feeding. The CNA told him/her the resident was back in his/her room after being outside for smoke break. Review of the resident's nursing progress note, dated 4/16/23 at 3:22 A.M., showed staff documented the resident was found by this nurse up at the sink with the water running and water on the floor and his/her shirt. The resident had his/her feeding tube stretched to its capacity from the pole. The resident was educated on the importance of not drinking due to being NPO at this time and it was not safe. Review of the resident's nursing progress note, dated 4/17/23 at 1:18 P.M., showed staff documented the resident is saying frequently he/she is thirsty. Review of speech therapy treatment encounter note dated 4/17/23, showed the following: - NPO; -Resident educated about the severe risk of aspiration with thin liquids. Patient let speech therapist know that he/she realizes he/she should not have thin water, but was so thirsty. Observation of the resident on 4/18/23 showed the following: -At 1:20 P.M., the resident sat at the nurses' station and not connected to the tube feeding pump; -1:34 P.M., the resident outside smoking and not connected to the tube feeding pump; -2:00 P.M., the resident sat at the nurses' station and not connected to the tube feeding pump; -3:06 P.M., the resident sat at the door that leads outside to the smoking area and was not connected to the tube feeding pump; -5:11 P.M., the resident lay in bed and was not connected to the tube feeding pump; -5:43 P.M., the resident lay in bed and was not connected to the tube feeding pump; -5:55 P.M., the resident hooked up to his/her tube feeding pump; -The resident was off of his/her feeding pump four hours and thirty five minutes. Review of the resident's nursing progress note, dated 4/19/23 at 12:56 A.M., showed staff documented the resident requested water frequently. Review of nutrition assessment, dated 4/19/23, showed the following: -NPO; -Total amount of water received from enteral feeding and water flushes 2294 ml; -What percent of the estimated fluid need does the enteral feeding and water flushes provide?100%; -Admit assessment body weight 135 with body mass index (BMI) (a measure of body fat based on height and weight) 18.4 (underweight) and diagnosis of protein-calorie malnutrition. Nutrition needs based on weight gain/muscle maintenance. Goal is weight maintenance and tube feeding tolerance; -The nutrition assessment was completed 20 days after the resident's admission and after the surveyor interview inquiring about the assessment. Observation of the resident on 4/19/23 showed the following: -At 10:40 A.M., the resident sat in his/her room and not connected to the feeding pump; -12:10 P.M., Licensed Practical Nurse (LPN) A reconnected the feeding pump for the resident; -The resident had been off of his/her feeding pump one hour and thirty minutes. Observation on 4/19/23 at 1:32 P.M., showed the following: -Certified Nurse Aide (CNA) NN weighed the resident while the resident sat in his/her wheelchair. The weight obtained was 168.6 pounds; -CNA NN weight the resident's wheelchair and obtained a weight of 43.6 pounds; -The resident weighed 125.0 pounds; -The resident had lost 9.5 pounds (-7.68%) in ten days. Observation on 4/19/23 at 1:30 P.M., showed LPN A unhooked the resident from tube feeding pump so he/she could go outside to smoke. During an interview on 4/19/23 at 1:25 P.M., CNA NN said he/she brings resident in from smoking and puts him/her in his/her room and then notifies the nurse so he/she can reconnect feeding tube. During an interview on 4/19/23 at 12:10 P.M., LPN A said CNA staff obtain a resident's weight on admission and reweigh the resident every day for three days, then weigh resident once weekly for four weeks and then weight the resident once monthly. During an interview on 4/19/23 at 1:52 P.M., LPN A said he/she had cleared the pump settings and does not chart the resident's input from the feeding pump. During an interview on 4/19/23 at 12:45 P.M., the Infection Preventionist said that staff obtain a resident's weight on admission and reweigh the resident every day for three days, then weigh once weekly for four weeks and then weight the resident once monthly. The dietician will complete a nutrition assessment on all new admissions within one week. There was currently no system in place for monitoring if the dietician had seen a new admission. During an interview on 4/20/23 at 4:00 P.M., the Director of Nursing (DON) said new admission weights should be obtained so a baseline weight is obtained, then weigh the resident every day for three days, then weigh the resident once weekly for four weeks until stable. The registered dietician assessments are done on admission, then quarterly and with changes. The dietician works remotely. The nutrition assessment usually starts within 24 hours after admission and is completed within seven days. The registered dietician should calculate the caloric need and rates for a new admission in the first week. Staff should follow physician orders for continuous tube feeding. If the resident is taken off the pump, he/she should not be off for extended periods of time. The physician should be notified if a resident is taken off a feeding pump for an extended period of time. If the resident is off of feeding pump for an extended period of time it could contribute to weight loss. If the resident did have weight loss, the staff would need to let the physician and dietician know so the feedings could be recalculated. During a phone interview on 5/2/23 at 2:10 P.M., the Regional Dietician said the following: -Nutritional assessments are performed through chart review and not in person; -Ideally a new admission nutrition assessment should be completed within 14 day; -A new admission who is on a feeding tube should have a nutrition assessment completed sooner than 14 days; -The consultant dietician runs reports to see if there are new admissions once weekly; -There is no system currently in place to monitor nutrition assessments for new admissions; -The facility should contact the dietetic service to advise them if there is a missed assessment for a new admission; -According to best practice, a new admission should be weighed once a week for the first four weeks; -If a resident is disconnected from a feeding pump it would decrease his/her caloric intake; -She was not aware the resident was being disconnected from his/her feeding; -The resident's charts are reviewed once monthly to see if there is any significant weight loss. 2. Review of Resident #64's care plan, updated 5/18/22, showed the following: -Resident has a history of weight loss and low body max index (BMI) related to chronic obstructive pulmonary disease (COPD) with air hunger, adult failure to thrive and a diagnosis of severe protein calorie malnutrition, dementia, and dysphagia (difficulty swallowing); -Goal, resident will increase his/her weight to an normal BMI of 25 to 28 over the next 90 days; -Document meal percentages per protocol and report any poor appetite to the charge nurse; -Ensure oxygen is in place to prevent dyspnea (shortness of breath) with eating; -Allow for frequent breaks during eating; -Follow residents food like and dislike listing; -Obtain weight per protocol; -Offer snacks in between meals as needed; -Prefers to eat meals in room; -Provide diet as ordered; -Provide food substitutes and always available menu items as needed; -Provide resident meal assist with meal set up and cueing as needed; -Provide supplements as ordered; -Refer to dietitian as needed; -Refer to speech therapy as needed. Review of the resident's physician's orders, dated August of 2022, showed the following: -Regular diet; -Med Pass (concentrated nutritional supplement, may use 2 Cal if Med Pass not available) 60 milliliters (ml) two times daily. Review of the resident's registered dietitian note, dated 8/19/22, showed the following: -Resident is at 113.6 lbs. with weight gain noted, change desirable; -Recommended weight range 117-143 lbs.; -Diagnosis of COPD, chronic respiratory failure, severe protein calorie malnutrition, and adult failure to thrive; -Estimated needs determined and met; -Continued gain is desirable; -Diet order remains appropriate; -Receives Regular Diet with 60 ml Med Pass two times daily. Review of the resident's weight record showed the following: -On 11/3/22, the resident weighed 117.8 pounds (lbs.); -On 12/4/22, the resident weighed 115.4 lbs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -admission to facility 3/16/21; -Diagnosis include chronic respiratory failure with hypoxia (lack of oxygen), dementia, malnutrition, dysphagia, essential tremor, chronic pain, and failure to thrive, -Vision impaired can see large print; -Cognitively intact; -Requires set up and supervision for eating; -115 lbs. (pounds), on a physician prescribed weight gain program; -Does not have a condition or disease that may result in life expectancy of less than six months. Review of the resident's weight record, dated 1/1/23-1/23/23, showed the following: -1/3/23 88.4 lbs; -1/5/23 86.4 lbs; -1/8/23 87.2 lbs; -1/22/23 88.6 lbs. Review of the resident's medical record showed no notifications to the dietitian or physician with the resident's weight loss from 1/3/23-1/23/23. Further review showed no new interventions, or orders in the resident's medical record during this time to prevent further weight loss. Review of the resident's registered dietitian note, dated 1/24/23, showed the following: -Weight Loss Note: Current body weight is 87 lbs., reweights obtained; -Weight is down from 115 lbs. in one month which is a 24% weight loss; -Weight is down from 117 lbs. in three months, which is a 26% weight loss; -Weight is down from 106 lbs. in six months which is 18% weight loss; -Tolerating regular textures; -2 Cal or Med Pass 60 ml two times daily; -Recommend: House shake two times daily to provide: 400 kilocalories, 12 grams of protein to promote weight gain; -Registered dietitian to follow up as needed. Review of the resident's physician's orders did not show a new order for house shakes two times daily. Review of the resident's weight record, dated 1/29/23, showed the resident weighted 86.2 lbs. The facility did not document notification to the dietitian or physician with further weight loss. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Requires supervision and one staff member physical assist for eating; -86 lbs, significant weight loss not on a physician prescribed weight loss plan. Review of the resident's weight record, dated 2/8/23, showed the resident weighs 81.4 lbs. Review of the resident's nurses notes, dated 2/10/23, showed the following: -Weight on 1/29/23 86.2 and weight 2/5/23 81.4, weight loss of 4.8 lbs.; -Continues regular diet with 2 cal med pass 60 ml two times daily; -Requires staff assist with meal set up, cueing, and encouragement to increase intake; -Staff continues to offer food substitutes, always available menu items, and snacks in between meals as needed; -Have discussed weight loss and refusal to eat or drink supplements at times with resident; -Will need to have meeting with family in regards to continued weight loss; -No new labs to review or interventions to be added at this time. Review of the resident's weight record showed the following: -2/12/23, the resident weighs 82.4 lbs; -2/16/23, showed the resident weighs 84.8 lbs. Review of the resident's medical record showed no notifications to the dietitian or physician with significant weight changes from 1/29/23-2/26/23. Further review showed no new interventions, or orders in the resident's medical record during this time to prevent further weight loss. The house shakes recommended by the registered dietitian on 1/24/23 were not ordered or documented as administered. The staff did not recommend trying any other supplements, therapy evaluations for feeding/swallowing/oxygen conservation techniques, textures to make chewing take less effort, possible adaptive equipment, or smaller meals at a higher frequency. Review of the resident's care plan, updated 2/28/23, showed the following: -2/1/23 actual weight loss; -Resident likes Fig Newtons. The recommended house shakes were not added to the resident's care plan. The registered dietitian did not document a review of the resident's weight loss in February. Review of the resident's weight record, dated 3/1/23-3/7/23, showed the following: -3/3/23 83.6 lbs.; -3/5/23 85.7 lbs. Review of the resident's registered dietitian note, dated 3/8/23, showed the following: -Monthly Weight Note: current weight 84 lbs.; -Weight is up from 81 lbs in the last month, 3.7% gain; -Weight is down from 112 lbs. in six months, 25% weight loss; -Receiving Med Pass 60 ml two times daily (240 kcals, 10 g protein); -Meeting estimated nutrition needs with meals, snacks, and supplements, goal is weight gain; -Registered Dietitian to follow up as needed. The note did not include the previous recommendation for house shakes, or that the recommendation was not followed, and did not recommend any further interventions. Review of the resident's weight record, dated 3/12/23, showed the resident weighed 80.0 lbs., 37 lbs. weight loss from 117 lbs 11/3/22, 31.6% weight loss in four months. The facility did not document dietitian or physician notification with further weight loss. Review of the resident's weight record, dated 3/9/23-4/10/23, showed the following: -3/19/23 81.6 lbs.; -3/26/23 82.2 lbs.; -4/1/23 83.6 lbs. Review of the resident's medical record showed no notifications to the physician with significant weight changes from 1/3/23-4/10/23. Further review showed no new interventions, or orders in the resident's medical record during this time to prevent further weight loss. The house shakes recommended by the registered dietitian on 1/24/23 were not ordered or documented as administered. The staff did not recommend trying any other supplements, therapy evaluations for feeding/swallowing/oxygen conservation techniques, textures to make chewing take less effort, possible adaptive equipment, or smaller meals at a higher frequency. Review of the resident's registered dietitian note, dated 4/11/23, showed the following: -Monthly Wound/Weight note: Current weight is 83.4 lbs; -Weight stable for one month with fluctuations noted; -Weight down from 87 lbs in three months 4.6 % weight loss; -Weight is down from 117 lbs. in six months for 29% weight loss, the resident is under ideal body weight; -Skin: Abrasion to left outer ankle; -Receiving Med Pass 60 ml two times daily; -Meeting nutrition needs with meals, supplements, snacks at this time; -Goal is weight maintenance; -Registered Dietitian to follow up as needed. Observation on 4/18/23, at 12:14 P.M.-12:45 P.M., showed the following: -The resident in his/her wheelchair in the dining room with his/her oxygen on via nasal cannula (tube to deliver oxygen through the nose); -Staff served the resident chicken, squash, baked beans, cornbread, cake with whipped cream, red drink, yellow drink, and coffee/tea; -Resident fed himself/herself; -The resident's hands had tremors when loading his/her utensils making food fall off of his/her fork and/or spoon, and food fell of the side of his/her plate when he/she attempted to scoop his/her food onto his/her fork. The resident did not have adaptive equipment (plate guard, weighted silverware); -The resident consumed a few bites of chicken; -At 12:20 P.M. the resident was short of breath and moved his/her plate to the side and stopped eating; -At 12:29 P.M., CNA U placed a clothing protector on the resident, did not cue or assist the resident to eat, and walked away; -At 12:45 P.M., CNA Z sat down to assist the resident (31 minutes after the resident was served); -CNA Z fed the resident a few bites of chicken and beans, the resident visibly short of breath, and said it doesn't taste good, cold; -The CNA did not offer to heat up the resident's meal; -The resident consumed less than 25% of his/her meal. During an interview on 4/18/23, at 1:45 P.M., CNA Z said the following: -The resident has never consumed large amounts at meals; -The resident used to be able to feed himself/herself but now has more trouble with tremors, and he/she gets winded while eating; -The resident had lost weight; -Most days he/she eats in his/her room and staff assist him/her; -He/She gets tired when eating and does not eat very much; -Staff are expected to offer to heat up a resident's meal if they request it; -The resident might do well with several small meals, he/she cannot tolerate eating for a long period of time. During an interview on 4/19/23, at 9:30 A.M., LPN QQ said the following: -The registered dietitian monitors weight loss through the electronic health record; he/she (the RD) is in a different state; -He/She was not sure why Resident #64's health shakes were not added; -Resident #64 has not had therapy evaluations for tremors or oxygen conservation that he/she knew of; -If there is weight loss the facility weighs the resident weekly and reviews the weights weekly; -The physician and dietitian can review weights in the electronic medical record; -When new interventions are added they would be added to the resident's care plan. During an interview on 4/18/23, at 3:20 P.M., the Director of Nursing said the following: -When a resident triggers for weight loss his/her weight is monitored weekly; -The facility tries to have weekly meetings to review weight loss, but this doesn't always happen; -If a resident has continued weight loss would attempt new interventions; -New interventions would be added to the care plan; -Staff are expected to notify the physician and dietitian of new or worsening weight loss; -She did not know Resident #64 has worsening tremors and shortness of breath while eating; -LPN QQ is expected to carry through dietitian recommendations timely and document if there is a reason they are not carried through; -CNA's are expected to assist residents timely and offer to heat food if it gets cold; -Therapy can be consulted to work on adaptive equipment, oxygen conservation techniques and swallowing issues. She did not know if Resident #64 has had therapy for those issues; -The facility does not have consumption logs for Resident #64. During an interview on 5/23/23, at 9:50 A.M., the Registered Dietitian (RD) said the following: -She was located in another state and would review residents remotely; -The facility did not include her in meetings about weight loss; -The facility did not notify her of weight loss, she would have to find it on review of the medical records; -She expected the facility to carry through recommendations; -She feels like the facility needed a dietitian that could be in the facility to assist with recommendations; -For weight loss there are many things you can try if you can see if a resident is struggling in one area; -She was unable to make meaningful recommendations because of the lack of communication with the facility. During an interview on 4/19/23, at 9:30 A.M., LPN QQ said the following: -The registered dietitian monitors weight loss through the electronic health record; he/she (the RD) is in a different state; -Not sure why Resident #64's health shakes were not added; -Resident #64 has not had therapy evaluations for tremors or oxygen conservation that he/she knows of; -If there is weight loss the facility weighs the resident weekly and reviews the weights weekly; -Physician and dietitian can review weights in the electronic medical record; -When new interventions are added they would be added to the resident's care plan.