**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of GT for one of 12 final sampled residents (Residents 12) and one nonsampled resident (Resident 13). * The facility failed to ensure Resident 12's enteral feeding formula was labeled with the time as per the facility's P&P. * The facility failed to ensure RN 2 checked for gastric residual prior to the administration of the GT medication for Resident 13, as per the facility P&P. These failures posed the risk for complications related to the use of the GT for Residents 12 and 13. Findings: Review of the facility's P&P titled Enteral Feeding, Administration revised 2/2023 showed the pump bags, syringe and tubing are to be changed every 24 hours and properly labeled with the date, time, and nurse's initials. Review of the facility's P&P titled Medication Administration Through a Feeding Tube revised 2/2023 showed medications will be administered via the feeding tube by an RN or LVN, per the physician's orders. The P&P further showed to place the continuous tube feeding on hold and check the residual and tube placement per procedure. 1. Medical record review for Resident 12 was initiated on 1/6/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's H&P examination dated 8/2/24, showed Resident 12 was GT dependent. Review of Resident 12's Active Order Sets: Dietary Orders dated 1/8/25, showed a physician's order dated 5/28/24, to administer Glucerna 1.5 (enteral feeding formula) at the rate of 50 ml/hr for 20 hours per day. On 1/6/25 at 0959 hours, Resident 12 was observed lying in bed and the GT enteral feeding was observed infusing Glucerna 1.5 at 50 ml/hr. The Glucerna 1.5 enteral feeding formula bottle was observed labeled with the date and rate, however the time was not documented on the enteral feeding bottle. On 1/9/25 at 0853 hours, Resident 12 was observed lying in bed. The GT formula feeding was observed off. The Glucerna 1.5 enteral feeding formula was observed hanging on the feeding pump pole with 850 ml of enteral feeding formula remaining in the bottle. The enteral feeding formula bottle was labeled with Resident 12's name, room, the date, and the rate, however, a time was not observed on the label. On 1/9/25 at 0955 hours, a concurrent observation and interview was conducted with LVN 3. LVN 3 stated when starting a new enteral feeding formula bottle, the enteral feeding formula should be labeled with the resident's name and room number, the date, the time the formula was started, and the infusion rate. LVN 3 further stated the enteral feeding formulas should be discarded after 24 hours. When asked when Resident 12's current enteral feeding formula was started, LVN 3 verified the above findings and stated she did not know when the enteral feeding formula was started. On 1/9/25 at 1213 hours, an interview was conducted with the DON. The DON stated when administering the enteral feeding formulas, the licensed nurses were expected to label the enteral feeding formula with the resident's name, the date and time the enteral feeding formula was started and the rate. When asked about the purpose of the labeling of the time on the enteral formula, the DON stated the enteral feeding formulas should be labeled with the time to ensure the infusion of the enteral feeding formula did not exceed 24 hours. On 1/9/24 at 1444 hours, the DON was informed and acknowledged the above findings. 2. Medical record review for Resident 13 was initiated on 1/8/25. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's Active Order Sets dated 1/8/25, showed the following physician's orders: - dated 9/20/19, to monitor the GT residual before feeding and as needed. If residual was greater than 500 ml, to hold the feeding for one hour, then reassess. - dated 12/3/24, to administer Glucerna 1.5 at the rate of 55 ml/hr for 20 hours per day via the GT. On 1/8/25 at 0825 hours, a medication administration observation was conducted with RN 2. RN 2 was observed placing her stethoscope on Resident 13's stomach and used a syringe to check Resident 13's GT placement. RN 2 was not observed checking Resident 13's gastric residual volume prior to the administration of Resident 13's medications and water flushes via the GT. On 1/8/25 at 0847 hours, an interview was conducted with RN 2. RN 2 verified she did not check for gastric residual for Resident 13 prior to the administration of medications via the GT during the medication administration observation. On 1/9/25 at 1213 hours, an interview was conducted with the DON. The DON stated for the medication administrations through the GT, the licensed nurses were expected to check the placement of the GT via auscultation and check for the gastric residual prior to the administration of the medications. On 1/9/24 at 1444 hours, the DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen utensils were air dried prior to storage. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen. Findings: Review of the facility's untitled document dated 1/6/25, showed two of 22 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Food Preparation revised 1/2023 showed non-porous cutting boards in good condition are used and sanitized between uses. Color coded cutting boards for raw meat, poultry, fish, and prepared foods, fruits and vegetables and allergies are utilized to prevent cross contamination. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. During the initial kitchen tour on 1/6/25 at 0824 hours, a concurrent observation and interview was conducted with the Dietary Director. Eight cutting boards (four white, one yellow, two red, and one purple) were observed heavily marred, discolored, and fuzzy with deep groves. The Dietary Director acknowledged the findings and stated the cutting boards should have been tossed and replaced. 2. Review of the facility's P&P titled Dish and Ware Washing/ Care of Dishmachine revised 12/2022 showed towel drying dishes is not allowed. Air drying: as the racks of dishes come from the machine, they should be allowed to air dry. If the drying space is too small to allow dishes to air dry. Allow silver to air dry by letting it stand for a few minutes after washing. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 1/6/25 at 0824 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Director. The following items were wet with visible water, and stored inside the drawer for clean utensils: - Five slotted scoops with green handles - Three scoops with green handles - Three scoops with black handles - Three slotted scoops with black handles - One scoop with blue handle The Dietary Director acknowledged the above findings and stated all the scoops should have been air dried and not stored in the clean drawer wet. 3. Review of the facility's P&P titled Dish and Ware Washing/ Care of Dishmachine revised 12/2022 showed the sanitary dishes, cooking vessels and utensils are free from visible soil, stains, greasy film, cracks and chips, and bacteria. Review of the facility's P&P titled Food Preparation revised 1/2023 showed the cooking equipment is to be clean and in good working order. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 1/6/25 at 0824 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Director. The following was observed: - Three small mesh strainers with wooden handles were deformed and discolored - One large mesh strainer with a wooden handle was deformed and discolored - Two stainless steel potato mashers had an orange/brown discoloration - One stainless steel whisk with a cracked gray handle - One stainless steel whisk with a partially melted gray handle - Two green scoops used for food portioning were worn out with peeling handles - One cream scoop used for food portioning was worn out with a discolored and peeling handle - One red scoop used for food portioning was fuzzy with a discolored handle - One white basting brush was frayed, discolored, and worn out - Six rubber spatulas with red handles were cracked, chipped at the edges, and discolored - One stainless steel slotted spatula with a brown handle was deformed and bent at one of the edges - One stainless steel spatula with a brown handle was deformed, bent at the edges and had linear black discoloration which resembled a burn mark The Dietary Director acknowledged the above findings and stated all kitchenware should have been tossed and has not been used. 4. Review of the facility's P&P titled Dish and Ware Washing/ Care of Dishmachine revised 12/2022 showed the sanitary dishes, cooking vessels and utensils are free from visible soil, stains, greasy film, cracks and chips, and bacteria. Review of the facility's P&P titled Food Preparation revised 1/2023, showed cooking equipment is to be clean and in good working order. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 1/6/25 at 0824 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Director. The following was identified: - One scoop with a blue handle, three scoops with yellow handles and one scoop with a gray handle used for food portioning were dirty, had water marks and were dry, crusted food residue - One stainless steel blue spatula was fuzzy and dirty The Dietary Director acknowledged the above findings and stated all kitchenware should have been washed. 5. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. During the initial kitchen tour on 1/6/25 at 0824 hours, a concurrent observation and interview was conducted with the Food Service Supervisor. Black dirt, grease residue was observed on the kitchen stove hood. The Food Service Supervisor verified the findings and stated the janitor was supposed to clean the stove hood every other day. The Food Service Supervisor stated it was important to clean the stove hood for air circulation to prevent smoke and grease build up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/6/25 at 0805 and 1105 hours, three linen cart covers located in the hallway in front of Room A were observed dirty, worn out and stained with black, white, and brown colors. On 1/6/24 at 1420 hours, an interview was conducted with the DSD/MDS Coordinator. The DSD/MDS Coordinator stated the covers should be clean and verified the findings. Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to prevent the development and transmission of diseases and infections. * RN 1 failed to disinfect the stethoscope after use on Resident 1 and prior to exiting the room. * RN 2 failed to disinfect the stethoscope after use on Resident 13 and prior to exiting the room. * CNA 1 failed to remove the gown and gloves and perform hand hygiene after touching Resident 1's surroundings and before touching Resident 10's environment. * Three linen cart covers were observed to be dirty, stained with black, white, and brown colors, and worn out. These failures had the potential to result in the transmission of infection to a vulnerable population of residents in the facility. Findings: Review of the facility's P&P titled Patient Equipment Use Maintenance and Cleaning dated 6/27/21, showed all reusable instruments and equipment will be thoroughly cleaned and decontaminated prior to use on a patient. 1a. On 1/7/25 at 0828 hours, during the medication administration observation for Resident 1, RN 1 was observed using a stethoscope and syringe to check for the GT placement. After completing Resident 1's medication administration, RN 1 removed the gloves and gown, washed his hands, and exited Resident 1's room. RN 1 did not disinfect the stethoscope prior to exiting Resident 1's room. On 1/7/25 at 0844 hours, an interview was conducted with RN 1. RN 1 stated the stethoscope should be disinfected after use on each resident and prior to exiting the resident's room. RN 1 verified he did not disinfect his stethoscope after using the stethoscope to check Resident 1's GT placement, and prior to exiting Resident 1's room. RN 1 stated he should have disinfected his stethoscope to prevent the transmission of organisms between residents. 1b. On 1/8/25 at 0831 hours, during the medication administration observation for Resident 13, RN 2 was observed using a stethoscope and irrigation syringe to check for the GT placement for Resident 13. After completing Resident 13's medication administration, RN 2 removed the gloves, placed the stethoscope on her workstation cart, and removed the gown. RN 2 performed hand hygiene and exited Resident 13's room. RN 2 did not disinfect the stethoscope prior to exiting Resident 13's room. RN 2 moved the stethoscope from the top of the cart to the bottom compartment of her workstation cart. On 1/8/25 at 0845 hours, an interview was conducted with RN 2. RN 2 was asked about the facility protocol for disinfection of multi- use equipment's like the stethoscope. RN 2 stated the stethoscope should be disinfected before and after use on a resident and before exiting the resident's room. RN 2 verified she did not disinfect the stethoscope after using on Resident 13, and prior to exiting Resident 13's room. On 1/8/25 at 1515 hours, an interview was conducted with the IP 1. IP 1 stated all the resident rooms, except for one room was on EBP. When asked about the facility protocol for the disinfection of the multi-use equipment on residents, IP 1 stated the staff are expected to disinfect the equipment after each use and prior to exiting the resident's room to prevent the transmission of organisms to other surfaces and residents. On 1/9/25 at 1444 hours, the DON was informed and acknowledge the above findings. 2. Review of the facility document titled Enhanced Barrier Precautions (undated), showed everyone must clean their hands, including before entering and when leaving the room. The sign showed do not wear the same gown and gloves for the care of more than one person. Medical record review for Resident 10 was initiated on 1/6/25. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Active Order Sets: Care Order/Instructions showed a physician's order dated 8/26/24, Resident 10 may have one to one feeding assistance three times per day for seven days a week with weighted spoon and grip cup during meals, per resident request. May self-feed as tolerated. On 1/6/25 at 1145 hours, a concurrent observation and interview was conducted with CNA 1 in Resident 10's room. There was an EBP sign posted outside of Resident 1 and 10's room. CNA 1 was observed wearing gloves and placed Resident 10's lunch tray on Resident 10's bedside table. CNA 1 then was observed donning a gown and with the same pair of gloves, walked by Resident 1's bed and tucked Resident 1's blanket under. CNA 1 then pulled the privacy curtain between Resident 1 and Resident 10 and was observed grabbing Resident 10's bedside table to move the table towards Resident 10. CNA did not remove his gown or gloves after contact with Resident 1's environment and before coming in contact with Resident 10's environment. CNA 1 stated he was preparing to assist Resident 10 with his lunch. CNA 1 verified he did not change his gloves and gown between touching each resident's environment. CNA 1 stated the gloves and gowns should be used for one resident and should not be used again for a different resident. CNA 1 further stated he should have removed the gloves and gown and donned a new pair of gloves before touching Resident 10's environment. On 1/8/25 at 1515 hours, an interview was conducted with IP 1. IP 1 stated all the resident rooms in the unit, except for one room was on EBP. IP 1 stated when moving from one resident to another resident in the same room, staff were expected to remove the gown and gloves, perform hand hygiene, and don a new gown and gloves. IP 1 further stated, the same gown or glove may not be worn between residents and should be removed prior to assisting the next resident. On 1/9/25 at 1213 hours, an interview was conducted with the DON. The DON stated when the staff members were in the residents' rooms providing care to a resident, the staff members were expected to doff their gown and gloves and perform hand hygiene before moving on to the next resident in the same room. The DON further stated the staff member should not wear the same gown and/or gloves for a different resident to prevent the transmission of organisms and infections to the other residents. On 1/9/25 at 1444 hours, the DON was informed and acknowledge the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to administer the pneumococcal vaccines to two of five residents reviewed for vaccinations (final sampled residents, Residents 4 and 19). This failure had the potential to cause medical complications related to pneumococcal infections for the affected residents. Findings: Review of the facility's P&P titled Pneumococcal Vaccine, Administration and Guidelines dated 1/2024 showed under section procedure, all the patients will be assessed for prior vaccination history during admission, provide the resident or legal representative with the latest edition of the vaccine information statement developed by the CDC, administer the vaccine, and document in MAR. 1. Medical record review for Resident 4 was initiated on 1/6/25. Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 4's Pneumococcal Vaccine dated 7/8/24, showed Resident 4's RP consented for the resident to receive the pneumococcal vaccine. However, there was no documented evidence the vaccine was administered to Resident 4. There was no documented evidence to explain why the pneumococcal vaccine was not administered to the resident after the consent was obtained on 7/8/24. 2. Medical record review for Resident 19 was initiated on 1/6/25. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's Pneumococcal Vaccine dated 9/30/24, showed Resident 19's RP consented for the resident to receive the pneumococcal vaccine. However, there was no documented evidence the vaccine was administered to Resident 19. There was no documented evidence to explain why the pneumococcal vaccine was not administered to the resident after the consent was obtained on 9/30/24. On 1/8/25 at 1530 hours, a concurrent interview and medical record review was conducted with the IPs 1 and 2. IPs 1 and 2 were asked if Residents 4 and 19 were offered the pneumococcal vaccine. IPs 1 and 2 stated they had offered the vaccine and obtained consents but it was not administered to the residents. IPs 1 and 2 verified the findings.

Based on interview, medical record review and facility P&P review, the facility failed to take immediate action to prevent further potential abuse after the allegation of verbal and physical abuse was reported for one of two sampled residents (Resident 1). * The facility failed to immediately remove CNA 1 (alleged perpetrator) from the resident care assignment after the allegation of abuse was reported by Resident 1. The failure had the potential to negatively impact Resident 1's well- being. Findings: Review of the facility's P&P titled Abuse Recognition/ Reporting: Elder/Dependent Adult, reviewed on 2/2024 showed Protection/Reporting- if the incident is not witnessed but reported by a resident, take measures to protect the resident immediately. Remove/separate the resident from the area or ask the individual in question to leave the room or the area. On 11/17/24 at 1420 hours, an interview was conducted with RN 1. RN 1 stated on 10/27/24 between 2100 to 2130 hours, Resident 1 reported being physically and verbally abused by CNA 1. CNA 1 was removed from Resident 1's assignment after RN 1 received a call from the DON on 10/28/24 approximately 0400 hours, seven hours after the alleged abuse was reported. RN 1 further stated CNA 1 should have been immediately removed when Resident 1 made the allegations. On 11/7/24 at 1057 hours, an interview was conducted with CNA 1. CNA 1 stated she was removed from Resident 1's assignment at 0400 hours when the supervisor decided to report the alleged abuse. On 11/7/24 at 1605 hours, an interview was conducted with the Clinical Educator/Acting DON. The Clinical Educator/Acting DON acknowledged CNA 1 was removed at 0400 hours (seven hours after reporting the alleged abuse) instead of immediately after the alleged abuse was reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the written information regarding the rights to accept or refuse the medical or surgical treatments and formulate the advance directive for one of 14 final sampled resident (Resident 19). In addition, the facility did not have a written policy on advance directives. These failures had the potential for the residents' decision regarding the resident's healthcare and treatment options not being honored. Findings: According to the Code of Federal Regulations, Section § 483.10(g)(12), the facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident ' s option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. 1. Medical record review for Resident 19 was initiated on 1/8/24. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 2/16/23, showed Resident 19 was alert and oriented. Review of Resident 19's POLST dated 2/16/23, showed no documented evidence as to whether Resident 19 had an advance directive. Review of Resident 19's medical record failed to show an advance directive on file or if the advance directive information was provided to Resident 19. On 1/9/24 at 1514 hours, an interview and concurrent medical record review was conducted with the Social Worker. The Social Worker verified Resident 19 did not have an advance directive and acknowledged there was no documented evidence Resident 19 received the advance directive information and education. 2. On 1/9/24 at 1541 hours, a copy of the facility's P&P for advance directive was requested from the facility. On 1/9/24 at 1640 hours, review of the facility's P&P titled POLST revised 12/2023, showed no written policy on advance directives. On 1/10/24 at 1004 hours, a follow-up interview was conducted with the Resource Nurse. When asked regarding the facility's P&P for advance directives, the Resource Nurse verified the facility did not have policy for advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the plans of care for two of 14 final sampled residents (Resident 6 and 10) were developed, resident centered, and with measurable goals. This failure posed the risk of not providing appropriate, individualized care to Residents 6 and 10. Findings: Review of the facility's P&P titled Care Planning reviewed 10/23 showed in part, Purpose: to ensure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident, Procedure: 4. (d) Problem statements should be followed with a related to or secondary phrase which relates to the problem when appropriate. (e) Objectives/goals are expectations, within the resident's abilities, which can be reached realistically. Each problem should have an objective/goal that is simple, specific and measurable within a specified time frame. 1. Medical record review for Resident 6 was initiated on 1/9/24 at 1408 hours. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's care plan titled Altered Nutrition showed on 4/24, 6/26, and 7/25/23, a problem of unintended weight gain with a goal of gradual weight loss. Another Resident 6's care plan dated 1/4/24, showed a care plan problem addressing the resident's altered nutrition regarding the unintended weight loss with a goal of gradual weight gain. On 1/10/24 at 0821 hours, an interview and concurrent medical record review regarding Resident 6's Altered Nutrition care plan was conducted with RDs 1 and 2. RDs 1 and 2 confirmed they were responsible to create and update the resident's nutrition care plan. When asked what it meant for a problem and goal of gradual weight gain or loss, RDs 1 and 2 stated gradual referred to not significant weight gain or loss. When asked where the resident's problem of weight gain or loss and goal weight was documented, RD 1 stated the weight loss or gain problem and weight goal were documented in the nutrition assessment. RDs 1 and 2 confirmed the problems and goals of gradual weight gain or loss on Resident 6's Altered Nutrition care plan were not specific or measurable. 2. Medical record review for Resident 10 was initiated on 1/8/24. Resident 10 was admitted to the facility on [DATE], with a diagnosis of chronic respiratory failure. Review of Resident 10's MDS dated [DATE], showed Resident 10 needed oxygen therapy, tracheostomy (a surgical opening in the trachea and a tube placed into the opening to assist with for breathing) care, and mechanical ventilator. Review of the Sub Acute Unit: Physicians Orders for January 2024 showed a physician's order dated 12/23/23, for Resident 10's mechanical ventilator set to mode of AC rate of 14, tidal volume of 500, PEEP of 5, and 40% FiO2, cool aerosol 35% during the day, keep the ventilator at bedside and place on ventilator every night. Review of Resident 10's Care Plan for respiratory condition revised 1/2024, showed the care plan did not address Resident 10's specific physician's order for cool aerosol 35% during the day, keep the ventilator at bedside, and place on ventilator every night. On 1/9/24 at 1453 hours, an interview and concurrent medical record review for Resident 10 was conducted with RT 1. RT 1 stated Resident 10 was able to eat, so they turned off the ventilator and connected the tracheostomy with oxygen for the rest of the day. RT 1 was asked to review the comprehensive care plan for Resident 10's respiratory condition. RT 1 verified there was no care plan for the specific setting of the mechanical ventilator and for the changing to the oxygen administration including turning off the ventilator and connecting to cool aerosol. RT 1 stated there should have been a care plan for the respiratory care interventions. On 1/11/24 at 1509 hours, an interview and concurrent medical record review for Resident 10 was conducted with the DON. The DON was informed and verified the above findings. The DON stated the care plan should have been formulated for the respiratory care of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive plans of care for two of 14 final sampled residents (Residents 7 and 10) were revised to reflect the residents' current care needs and interventions. * The facility failed to revise the comprehensive plan of care for Resident 7's use of the bilateral knee braces. * The facility failed to revise the comprehensive plan of care for Resident 10's use of PICC line. These failures posed the risk of not providing the residents with individualized and person-centered care. Findings: 1. On 1/8/24 at 1048 hours, during the initial tour of the facility, Resident 7 was observed in bed with a rolled pillowcase on his left hand. Also observed during the tour were the knee braces stored on the cabinet. Medical record review for Resident 7 was initiated on 1/8/24. Resident 7 was admitted to the facility on [DATE]. On 1/10/24 at 1328 hours, an interview and concurrent medical record review for Resident 7 was conducted with RN 1. Review of Resident 7's plan of care showed a care plan problem dated 3/28/22, addressing a risk for alteration on ADL functioning. RN 1 verified the knee braces were not included on the care plan interventions. RN 1 verified the plan of care should have been revised to reflect Resident 7's use of bilateral knee braces. Cross reference to F688. 2. On 1/8/24 at 0854 hours, during the initial tour of the facility, Resident 10 was observed in bed and had a PICC line on the right upper arm with a dry dressing dated 1/6/24. Medical record review for Resident 10 was initiated on 1/9/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's plan of care showed a care plan problem dated 12/22/23, addressing a risk for infection, bleeding, and malfunction related to the use of PICC line. However, the interventions did not show specific intervention of measuring the catheter length and arm circumference. On 1/9/24 at 1334 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified the plan of care should have been revised to reflect the interventions related to Resident 10's PICC line use. Cross reference to F694.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent and worsening of pressure injuries for one of 14 final sampled residents (Resident 13). * The facility failed to ensure the licensed staff were trained and followed the manufacturer's guidelines on the LAL mattress settings. * The facility failed to ensure Resident 13 was repositioned every two hours per the physician's order. These failures put Resident 13's pressure injuries to reoccur and not heal. Findings: Medical record review for Resident 13 was initiated on 1/8/24. Resident 13 was admitted to the facility on [DATE]. The resident had a diagnosis of respiratory failure, traumatic brain injury, seizure disorder, and diabetes. a. Review of the facility's P&P titled Skin Integrity section Support Surfaces for Prevention and Treatment of Pressure Ulcers revised 3/2021 showed the nurses should consult manufactures guidelines for bedding needs. On 1/8/24 at 0832 hours, during the initial tour, Resident 13 was observed lying in bed with tracheostomy tube (a tube inserted into the windpipe in front of the neck to assist in breathing) present, indwelling urinary catheter in place draining to a dark red urine in tubing, and GT connected to a feeding machine that was turned off. The resident was on a LAL (low air loss) mattress and had a sign above the resident's bed showing two arrows up. Resident 13 was nonverbal upon conversation initiation. On 1/9/24 at 0830 and 0917 hours, Resident 13 was observed lying on his back. On 1/9/24 at 0918 hours, an interview with CNA 1 was conducted. CNA 1 was asked how the LAL mattress are set. CNA 1 stated, I always ask for help because I don't know how to use the machine. During the concurrent observation and interview with CNA 1, Resident 13's LAL setting was observed to be in the middle #9, between soft and firm. An instruction manual was observed behind the LAL machine in Resident 13's room, and CNA was asked to show the manual. The Quick Reference Guide-Functions manual showed, Set air pressure based on patient height and weight (HT/WT) method. On 1/9/24 at 1144 hours, an interview and concurrent observation for Resident 13 was conducted with RN 2. RN 2 was asked how the LAL mattress was set up, RN 2 stated when the LAL mattress was first set up, they would enter the Resident's height and weight, then the machine would calculate the settings. RN 2 verified the LAL mattress setting for Resident 13 was set at a height of four feet and 10 inches and weight was set at 100 pounds. On 1/10/24 at 1020 hours, an interview with RN 3 was conducted. RN 3 stated Resident 13 has a Stage 4 pressure injury on the sacral area that had reopened; and prevention measures consisted of repositioning the resident every two hours, and skin check sheets were documented on shower days. On 1/10/24 at 1125 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was asked if she had any knowledge of Resident 13 having any pressure injuries. RN 1 stated Resident 13 had a Stage 4 on the sacral area that reopened. When asked RN 1 what measures were in place for the prevention and maintenance of the pressure injuries, RN 1 stated a LAL was ordered, and to set with the weight of the resident. When asked who was responsible to set the LAL bed, RN 1 stated the nurse or treatment nurse. Review of the resident's medical record with RN 1 showed documentation on 1/5/24, that Resident 13's current height and weight were five feet and six inches and 157 pounds. On 1/10/24 at 1338 hours, after the wound care observation for Resident 13 was conducted, LVN 1 was asked how to determine the LAL mattress setting. LVN 1 stated she did not know how to set the LAL mattress, and the machine was delivered pre-set. RN 3 was observed outside Resident 13's room and was asked if she knew how to set the LAL mattress. RN 3 stated the bed arrived set, and she did not know how to set the LAL mattress. On 1/11/24 at 1358 hours, an interview with RNA 1 and CNA 2 was conducted. When asked RNA 1 and CNA 2 how to set the LAL mattress settings, both stated the LAL mattresses were set by the supplier and the staff did not know how to set the LAL mattress for the residents. On 1/11/24 at 1538 hours, an interview with the DON was conducted. When the DON was asked who was responsible to set the LAL mattresses, the DON stated the company that delivered the LAL beds came and did not provide the training to the staff for the LAL beds. The DON acknowledged the company needed to be called to provide an in-serviced for the staff. b. Review of the National Pressure Injury Advisory Panel's (NPIAP) Clinical Practice Guideline titled Prevention and Treatment of Pressure Ulcers/Injuries dated 2019 showed repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure is multifaceted; however, by definition, pressures cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage. Typically, a painful stimulus caused by the pressure on the tissue will motivate the individual to change position. Therefore, two primary concerns are the individual's ability to feel pain, and the person's actual physical ability to move or reposition. Repositioning involves a change in position of the lying or seated individual undertaken at regular intervals, with the purpose of relieving or redistributing pressure and enhancing comfort. Mobilization involves assisting or encouraging a person to move or shift into a new position. Individuals who cannot reposition themselves will require assistance in this activity. Review of the facility's P&P titled Skin Integrity Turning and Repositioning revised 3/2021 showed to reposition the resident as frequently as the resident can tolerate, minimally every two hours. Review of Resident 13's Physician's Orders for the month of January 2024 showed to turn or reposition the resident every or within two hours of the last turn, start date 11/28/23. Review of Resident 13's care plan problem addressing the resident's risk for skin breakdown and/or pressure ulcer dated 12/26/22, showed to turn and reposition every two hours and as needed. On 1/9/24 at 0918 hours, an interview and concurrent medical record review was conducted with CNA 1. CNA 1 was asked if Resident 13 had any known pressure injuries. CNA 1 stated Resident 13 had a wound dressing on his backside to protect his bottom. When CNA 1 was asked what preventative measures were in place to prevent pressure injuries, CNA 1 stated to turn the resident every two hours. CNA 1 was asked when the resident was last turned, CNA 1 stated Resident 13 was last turned at 0600 hours. CNA 1 stated, we try to turn every two hours, but not always on time, so he was supposed to be turned now. Upon record review in the EPIC charting system (an electronic medical record), CNA 1 showed the Flowsheets for Resident 13's repositioning documentation. The Flowsheets for repositioning showed Resident 13 was turned at 0200, 0400, and 0600 hours; and CNA 1 verified the 0800 hours reposition was missed, and stated she would turn the resident now. On 1/9/24 at 1144 hours, an interview with RN 2 was conducted. RN 2 was asked how often Resident 13 received wound care. RN 2 stated Resident 13 was provided wound care to a sacral wound today and received wound care once daily and as needed. RN 2 was asked what preventative measures were in place to prevent worsening of Resident 13's wound. RN 2 stated repositioning every two hours, keeping area dry, and clean due to the location of the wound and bowel movements. RN 2 stated Resident 13's wound healed before, but it had reopened. On 1/11/24 at 1538 hours, an interview with the DON was conducted. The DON was asked what preventative measures were in place to prevent or worsening of pressure injuries. The DON stated the staff tried their best to turn every two hours and conduct skin observations on the shower days. On 1/11/24 at 1611 hours, an interview with the DON was conducted regarding documentation of repositioning. The DON was asked when the documentation should be inputted, at the time the task was completed or at the time it was supposed to be completed? The DON stated the documentation should show when the task was actually completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to ensure the treatment was provided to one of 14 final sampled residents (Resident 7) to prevent a decline in the ROM functions. * The facility failed to follow a physician's order to apply a knee brace to Resident 7's both knees. This failure had the potential for Resident 7 to sustain a decline in ROM functions, leading to muscle atrophy and decrease in functioning. Findings: On 1/8/24 at 1048 hours, during the initial tour of the facility, Resident 7 was observed in bed with a rolled pillowcase on his left hand. Also, the knee braces were observed on the cabinet. Medical record review for Resident 7 was initiated on 1/9/24. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Physician's Order dated 4/30/23, showed to apply knee braces to Resident 7's both knees eight hours daily, once a day five times per week as tolerated, with routine skin checks every two hours. Another physician's order showed for the RNA to assist the resident with the PROM to both lower extremities once a day five times a week as tolerated. On 1/9/24 at 0957 hours, an observation and concurrent interview was conducted with RT 1. Resident 7 was observed in his wheelchair in the activity room. RT 1 was with Resident 7 and was asked if Resident 7 was wearing his knee braces on both knees. RT 1 verified Resident 7 was not wearing knee braces. On 1/10/24 at 0924 hours, an observation and concurrent interview was conducted with CNA 3. Resident 7 was observed resting in bed. No braces were observed on Resident 7's both knees. CNA 3 was asked if Resident 7 was supposed to wear a knee braces. CNA 3 stated the RNA put the braces on Resident 7's both knees. CNA 3 verified Resident 7 was not wearing braces. On 1/10/24 at 1008 hours, an interview and concurrent medical record review was conducted with RNA 3. RNA 3 confirmed Resident 7 had an order for the RNA to assist with Resident 7's knee braces application eight hours per day or as tolerated. RNA 3 stated the skin checks every two hours was done when the knee braces was applied and documented in the RNA notes. Reviewed RNA Flowsheets for the month of January 2024 showed the initials of the staff. However, RNA 3 was asked for the documentation of skin checks every two hours, RNA 3 verified there was no documentation. On 1/10/24 at 1328 hours, an interview and concurrent medical record review for Resident 7 was conducted with RN 1. RN 1 verified there was a physician order for Resident 7 application of the knee braces. RN 1 was informed and verified the above findings. RN 1 stated the licensed nurses should make sure the order for devices should have been followed for the benefit of the resident. On 1/11/24 at 1507 hours, the DON was informed and verified the above findings. Cross reference to F657, example #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of the 14 final sampled residents (Resident 22). * The facility failed to ensure Resident 22's bed alarm was on. This failure had the potential for the resident to sustain another fall. Findings: Review of the facility's P&P titled Fall Prevention/Reduction Program revised 02/2016 showed in part, to implement a program that prevents falls and /or reduces the number of times a resident falls .under the section Policy, showed an individualized interdisciplinary fall prevention/reduction plan of care will be developed and implemented for each resident identified as a fall risk and the plan of care for each resident will be accelerated post fall, as indicated, to enhance the preventive measures a decrease the risk of further falls in a manner that meets the individual needs of the resident. Medical record review for Resident 22 was initiated on 1/8/24. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Nursing Note dated 12/1/23, showed Resident 22 was found on the floor. Review of Resident 22's Fall Risk assessment dated [DATE], showed Resident 22 was a high risk for fall. Review of Resident 22's Care Plan showed a care plan problem initiated on 12/1/23, addressing an actual fall on 12/1/23, with the following interventions: - bed at the lowest position; - patient with yellow fall risk arm band; - fall risk sign by the patient door; - bed alarm turned on; and - floor mat for safety. On 1/10/24 at 1515 hours, an observation and concurrent interview was conducted with RNA 1 in Resident 22's room. RNA 1 verified Resident 22's bed alarm was not turned on. On 1/11/24 at 1408 hours, an observation and concurrent interview was conducted with CNA 2 in Resident 22's room. CNA 2 verified Resident 22's bed alarm was not turned on. On 1/11/24 at 1455 hours, an interview and concurrent review of Resident 22's Care Plan addressing an actual fall on 12/1/23, was conducted with RN 1. RN 1 verified and acknowledged Resident 22's bed alarm should be turned on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to follow the physician's order for the indwelling urinary catheter (a tube placed in the body to drain and collect urine from) maintenance for one of 14 final sampled residents (Resident 13). This failure had the potential for not providing the necessary care and services to prevent adverse complications of obstruction or infections for residents with an indwelling urinary catheter. Findings: Medical record review for Resident 13 was initiated on 1/8/24. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's care plans showed the resident had UTI on 7/9/23, 10/21/23, 12/8/23, and 1/9/24. Resident 13's care plan showed a care plan problem addressing the alteration in urinary function related to the use of indwelling urinary catheter. The interventions dated 3/31/23, included to flush the indwelling urinary catheter with 60 ml of normal saline every four hours. Review of Resident 13's Physician's Order for January 2024 showed Resident 13 had an indwelling urinary catheter size 16 Fr/10 ml. The physician's order also showed an order dated 12/6/23, to flush the indwelling urinary catheter with 60 ml sterile water every four hours. Review of Resident 13's January 2024 Treatment Record showed the documentation for the flushing of the resident's indwelling urinary catheter very four hours were blank on 1/1, 1/2, and 1/3/24 at 0800, 1200, 1600, and 2000 hours. Review of Resident 13's Flowsheet showed the resident's urine color was amber and present with sediment on 1/6/24 through 1/7/24; and on 1/8/24, the resident's urine color was red, cloudy sediment, and malodorous. On 1/8/24 at 0832 hours, during the initial tour, Resident 13 was observed lying in bed with an indwelling urinary catheter connected to a urinary drainage bag draining dark red urine. Resident 13 was nonverbal upon conversation initiation. ON 1/9/24, at 1135 hours, interview with CNA 1 was conducted. CNA 1 verified Resident 13 had pink color urine with sediments in the indwelling urinary catheter drainage bag. On 1/9/23 at 1144 hours, an interview with RN 2 was conducted. RN 2 stated the resident had a history of kidney stones and a current urinary tract infection that started two days ago, and the physician was aware of the resident's blood drainage in the indwelling urinary catheter. RN 2 stated the laboratory tests were drawn with currently pending culture and sensitivity results for a medication regimen to be implemented. RN 2 stated the indwelling urinary catheter was changed monthly and the drainage bag was changed weekly by the treatment nurse. On 1/10/24 at 1049 hours, an interview and concurrent medical record review was conducted with RN 3. The document titled January 2024 Treatment Record dated 12/6/24, showed to flush the resident's indwelling urinary catheter with 60 ml of sterile water every four hours. The treatment record for the flushing entry showed blank documentation on 1/1/, 1/2, and 1/3/24 at 0800, 1200, 1600, and 2000 hours. RN 3 verified the documentation was blank. When RN 3 was asked what the blank documentation indicated, RN 3 stated if it was not documented, it was not done. On 1/10/24 at 1208 hours, the DON acknowledged the missing documentation for Resident 13's January 2024 Treatment Record to flush the resident's indwelling urinary catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the physician's orders were clarified for one of 14 final sampled residents (Resident 13) for head of bed (HOB) elevation for aspiration precautions when the resident received a feeding tube. This failure had the potential to cause the resident to experience adverse reactions from GT feeding Findings: Medical record review for Resident 13 was initiated on 1/8/24. Resident 13 was admitted to the facility on [DATE]. The resident had a diagnosis of respiratory failure, traumatic brain injury, seizure disorder, and diabetes. On 1/8/24 at 0832 hours, during an initial tour, Resident 13 was observed lying on a LAL mattress in bed with tracheostomy tube, indwelling urinary catheter connected to a urinary drainage bag, and GT connected to a feeding pump. Resident 13 was nonverbal upon conversation initiation. On 1/10/24 at 1338 hours, LVN 1 was observed providing wound care to Resident 13. After completion of care, LVN 1 raised the HOB and resumed the GT feeding. During the observation, the Resident 13's HOB was low. When LVN 1 was asked how to identify the correct bed position was, LVN 1 showed the degree settings underneath the bed. LVN 1 verified the setting was at 25 degrees. LVN 1 was asked what was the prescribed setting, LVN 1 stated 30 degrees, then she proceeded to elevate the bed to 30 degrees. On 1/10/24 at 1428 hours, a concurrent medical record review and interview was conducted with LVN 1 and RN 3. Review of the Physician's Orders for January 2024 showed two orders with different instructions: - on 12/26/22, aspiration precaution-elevate HOB 35 degrees at all times - on 11/28/23, elevate HOB 30 degrees until discontinued RN 3 proceeded to look at another one of her assigned residents, which also showed the same two physician's orders. When LVN 1 and RN 3 were asked how they knew which order to go by, RN 3 stated the orders would need to be clarified with the physician. On 1/10/24 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there were two active physician's orders for Residents 13's bed to be elevated. When asked how they knew which order to go by, the DON responded that it would be the most recent order. When asked about the process if there were two orders that differ from one another, the DON stated the process would be to discontinue one of the orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 14 final sampled residents (Resident 10). In addition, the facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 10. These failures had the potential to delay the identification of catheter related complications for the resident. Findings: Review of the facility's P&P titled Peripherally Inserted Central Line (PICC): Maintenance and Discontinuation with a revised date on 7/18 showed the care and maintenance should be performed by qualified persons knowledgeable of the risk for PICC line. Dressing changes every seven days, and document in medical records including the catheter integrity and arm circumference. Medical record review for Resident 10 was initiated on 1/9/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's PICC Line Insertion Procedure dated 12/22/23, showed a double lumen catheter was inserted to the right upper extremity with the catheter length of 38 cm and arm circumference of 33 cm. Review of the physician's order dated 12/29/23, showed Resident 10's PICC line dressing was ordered to change every seven days and as needed if dressing becomes loose, soiled, or moist. However, further review of the physician's order showed there was no specific order for the assessment of the PICC line site area including the measurement of the length of the catheter and arm circumference. Review of Resident 10's PICC line Flowsheet Record for December 2023 and January 2024 showed the resident had a PICC line catheter and the dressing was changed. However, the medical record failed to show the measurement of the length of the external catheter and arm circumference above the insertion site were obtained upon providing care to the PICC line site. On 1/9/24 at 1334 hours, an interview and concurrent medical record review for Residents 10 was conducted with RN 2. RN 2 verified Residents 10's medical record showed the PICC line external catheter and arm circumference measurements were documented when the PICC line was placed. RN 2 stated the PICC external catheter line and resident's arm circumference measurements were served as a baseline measurement for future reference. RN 2 verified there was no documentation of the measurement of the length of the catheter and arm circumference of Resident 10. RN 2 stated the assessment should have been done and a physician's order should have been obtained. On 1/11/24 at 1509 hours, an interview and concurrent medical record review for Residents 10 was conducted with the DON. The DON verified the above findings. The DON stated there should have been an accurate assessment and measurement of the resident's PICC line site. Cross reference to F 657, example #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the completion of side rails assessments for two of 14 final sample residents (Residents 6 and 8). * Resident 6 did not have two quarterly entrapment assessments completed. * Resident 8's assessments for bed side rails use were not completed. These failures posed the risk for the residents' safety associated with bedrails usage. Findings: Review of the facility's P&P titled Bed Rail Entrapment Assessment revised 5/2021 showed all residents are required to have fall and entrapment assessment upon admission to facility, followed by quarterly and as needed basis. The Bed Entrapment Risk Assessment tool consist of seven Safety Alert Zones approved by Food and Drug Administration. Zone 1: within the rail Zone 2: between the top of the compressed mattress and the bottom of the rail, between rails ports Zone 3: between the rails and mattress Zone 4: between the top of the compressed mattress and the bottom of the rail, at the end of the rails Zone 5: between the split bed rails Zone 6: between the end of the rail and the side edge of the head or foot board Zone 7: between the head or foot board and the end of the mattress Review of the facility's P&P titled Restraints, Physical Guidelines for Use and assessment dated 02/23 showed, all residents will be assessed upon admission, quarterly and as needed during their facility stay for physical and behavioral triggers/symptoms, which may necessitate the use of restraints for their safety and well-being. This failure to perform Entrapment Assessment jeopardize the safety and wellbeing of the resident and violates the facility's policy and procedure. On 1/8/24 at 1114 hours, Resident 6 was observed with bilateral upper and lower padded side rails, padded board above head, and HOB elevated approximately 35 degrees. Resident 6 had a towel roll in his left hand and appeared to be comfortable. On 1/10/24 at 1052 hours, Resident 6's medical record review was initiated. Review of Resident 6's medical record showed a signed consent dated 4/1/19, for the bilateral full side rails. However, two quarterly entrapment risk assessments were missing for September and December 2023. On 1/10/24 at 1345 hours, an an interview and concurrent medical record review was conducted with the DON. The DON stated the Bed Entrapment Risk Assessment was to be done upon admission, quarterly, and as needed to ensure the resident was safe and free from entrapment risk. The DON also confirmed the above findings. 2. On 1/8/24 at 1057 hours, an observation was conducted in Resident 8's room. Resident 8 was observed with elevated bilateral upper, bilateral lower padded side rails, and padded headboard. Medical records review for Resident 8 was initiated on 1/8/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 6/9/23, showed Resident 8's active problem list including seizure disorder (a sudden, uncontrolled electrical disturbance in the brain). Review of Resident 8's Active Order Sets showed a physician's order dated 1/1/22, for bilateral padded full rails up to prevent fall from bed with presence of involuntary body movements and diagnosis of seizure disorder with recurrent seizure activity. Review of Resident 8's Subacute Unit Bedside Rail and Assist Bar Evaluation and Physical Device Reassessment and Redirection Tool showed Resident 8 was assessed for bilateral padded full side rails use on: - 9/12 and 12/12/22; and - 3/9, 6/8, and 9/8/23. Further review of Resident 8's medical record did not show an assessment was done for the bilateral padded full side rails use upon admission on [DATE], and quarterly assessments for March and June 2022, and December 2023. On 1/11/24 at 1015 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the missing bed side rails assessments and acknowledged Resident 8 should have been assessed for the use bilateral padded full side rails upon admission and quarterly thereafter. Cross reference to F909, example #3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Medication Administration Times dated 02/16 showed the nurse must verify the order by physician and encourage to ask for pharmacist input when scheduling medications to coincide with tube feeding schedule. This effort is to promote safety with medication administration process. Medical review for Resident 6 was initiated on 1/9/24. Resident 6 was admitted to the facility on [DATE]. Review of the physician's orders dated January 2024 showed an order dated 6/1/22, to administer aspirin (a blood thinner medication) chewable table 80 mg per GT daily for stroke prophylaxis to be given with food; and an order dated 10/24/23, to administer ferrous sulfate (iron supplement) 300 mg per GT three times a day with meals for supplement. The physician's orders also showed an order dated 1/4/24, for an enteral feeding via GT of Jevity 1.2 (enteral feeding formula) at 50 ml/hr for 20 hours, on at 1100 hours and off at 0700 hours or until dose is infused. Review of the MAR from 1/1/24 to 01/10/24 showed the aspirin and ferrous sulfate medications were signed off as given; however, the time given was not coincide with the enteral feeding schedule order. On 1/10/24 at 1405 hours, an interview was conducted with the pharmacist. When asked about the medication order with food and meals, he stated it was referring to the feeding formula. When the GT enteral feeding order was shown to the pharmacist, he verified the feeding order was to be off at 0700 hours. He stated the nurses were to turn on the feeding when the medication was to be given. Later on, the pharmacist verified he should have discussed that during his medication regimen review and give recommendation to coincide with the tube feeding. He verbalized that he failed to look at the tube feeding order and only reviewed the medications. The pharmacist stated he would call the physician to clarify the order. Based on interview, medical record review, and facility P&P, the facility failed to ensure the pharmaceutical services were provided to meet the residents' needs for two of 14 final sampled residents (Residents 6 and 16). * The nursing staff failed to ensure the physician's order not to crush paroxetine (antidepressant medication) tablet was clarified with the pharmacist or physician to obtain an alternate form of medication to administer via GT for Resident 16. * The medications ordered to administer with meals were administered when the GT feeding was not on for Resident 6. These failures had the potential to cause the adverse reactions due to improper medication administration to the residents. Findings: 1. Review of the facility's P&P titled Medication Administration revised on 5/16 showed medications shall be reviewed for appropriateness of crushing (see List of Medications Which Should Not Be Crushed or Chewed). Specific questions should be addressed to the pharmacist. Any medication which appears on the List of Medications Which Should Not Be Crushed or Chewed that cannot be provided in another form and cannot be administered without crushing or chewing, requires a specific physicians order authorizing its administration by crushing or chewing. Medical record review for Resident 16 was initiated on 1/8/24. Resident 16 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Physicians Orders for the month of January 2024 showed an order dated 7/27/23, for paroxetine 10 mg via GT daily for depression as manifested by crying. The order also showed, hazardous Drug. DO NOT CRUSH OR CUT TABLETS/CAPSULES. Contact Pharmacy a liquid formulation is needed. Review of Resident 16's Care Plan showed a care plan problem addressing the resident's alteration in ADL including dysphagia and GT. The interventions included tube feeding as ordered. On 1/10/24 0856 hours, an interview and concurrent medical record review with LVN 2 was conducted. When LVN 2 was asked how Resident 16's medications were administered, LVN 2 stated all the medications for Resident 16 were tablets which were crushed and given via GT. Review of the MAR for January 2024 showed Paxil (brand name for paraxetine) was a tablet. LVN 2 stated she must crush medication to administer to Resident 16. When asked if Paxil can be crushed, LVN stated, let me go see because I forgot. It says do not crush but I heard you can crush or put in water and let melt. When LVN 2 was asked if there a liquid alternative, LVN stated, yes, we have some patients that have liquid here. On 1/10/23 at 1009 hours, an interview with RN 3 was conducted. RN 3 stated the pharmacist was contacted and stated the Paxil medication was a medication that can be crushed, but the warning on the physician's order cannot be removed. On 1/10/24 1154 hours, an interview with the pharmacist was conducted. The pharmacist stated Paxil is immediate release and the physician was notified and stated ok to give via GT. The pharmacist stated the medications were based on the facility assessment conducted for the medication to determine if Paxil can be crushed and was based on the National Institute for Occupational Safety and Health (NIOSH) list of medications, which did not show Paxil was on the list provided. When asked how a tablet be given to the resident via GT if it was not crushed, the pharmacist stated it could not be given whole and had to be crushed. When asked for documentation stating the MD was notified and the medication could be crushed. He stated he would return with the documentation. On 1/10/24 at 01:53 hours, a follow-up interview and concurrent medical record review was conducted with the pharmacist. When asked, how the nurses knew when the medications were safe to crush and what medications are on the NIOSH list, the pharmacist stated the nurses would not know if it was safe to crush or what was listed on the NIOSH list. Review of the document given by the pharmacist titled Handling Hazardous Drugs in the Healthcare Setting <USP 800> Policy/Procedures showed, Addendum B-due to facility risk of assessment, many hazardous medications were removed from the hazardous list because they are deemed not hazardous to the handlers only to the recipients. The pharmacist verified the physician's order showed, do not crush and the responsibility of the pharmacist would be to notify the resident's physician to obtain a separate physician's order that the medication would be safe to crush for administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure the necessary care and services were provided to prevent adverse reactions of a medication for experiencing active bleeding from multiple sources while receiving enoxaparin (a medication used to thin the blood) for one of 14 final sampled residents (Resident 13). This failure had the potential to result in Resident 13 to have more or active bleeding in his urine, and bleeding from his tracheostomy tubing (a tube inserted into the windpipe in front of the neck to assist in breathing). Findings: On 1/8/24 at 0832 hours, during an initial tour, Resident 13 was observed lying in bed with tracheostomy tube, indwelling urinary catheter in place draining dark red urine in tubing, and GT. Resident 13 was nonverbal upon conversation initiation. Medical record review for Resident 13 was initiated on 1/8/24. Resident 13 was admitted to the facility on [DATE]. The resident had a diagnosis of respiratory failure, traumatic brain injury, seizure disorder, and diabetes. Review of Resident 13's Flowsheet showed the resident's urine color was amber with sediment from 1/6/24 through 1/7/24. On 1/8/24, the Flowsheet showed the resident's urine color was red, cloudy sediment, and malodorous. Medical Record review for Resident 13 showed a change of condition was initiated 1/8/24, for tracheal bleeding. Review of the Physicians Orders for January 2024 showed an order dated 12/13/23, to administer enoxaparin syringe 40 mg Subcutaneous daily, by deep subcutaneous injection to the left or right anterolateral or posterolateral abdominal wall for DVT prophylaxis. Review of the MAR showed Resident 13 was administered with enoxaparin syringe 40 mg daily from 12/31/23-1/9/24. On 1/9/24 at 1135 hours, an interview with CNA 1 was conducted. CNA 1 was asked when a resident was on blood thinners, what type of monitoring do you provide, CNA 1 responded monitoring for bruises, and bleeding and report to nurse or charge of any findings. CNA 1 verified the urinary bag has pink urine present. 01/9/24 at 1144 hours an interview and concurrent medical record review was conducted with RN 2. RN 2 stated when residents were on blood thinners, residents were monitored for bleeding, bruising, blood in the urine, and tracheal bleeding. RN 2 stated Resident 13 started to exhibit bleeding in the urine two days ago, and the physician was aware; laboratories were ordered, and currently pending results. RN 2 stated Resident 13 had a medical history of renal stones and hematuria (blood in the urine), and had a current infection of Influenza B, tracheal bleeding with a medical history of a granuloma in trachea. RN 2 stated Resident 13 currently had some small amount bleeding in urinary catheter and stated the physician was aware. On 1/10/24 at 1016 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 stated Lovenox should be monitored for bleeding, bruising, and labs. RN 3 stated Resident 13's urine bleeding was started on 1/7/24. The nurse practitioner was notified and laboratory orders were ordered. RN 3 was asked if the resident was still receiving Lovenox, RN 3 verified Resident 13 had been continuing to receive the Lovenox medication. RN 3 stated the primary physician was aware and knew the resident had a history of reddish urine. Further review of Resident 13's medical record showed Resident 13 had a history of a urinary tract infection with bleeding, and Lovenox was discontinued by the physician for the duration of the bleeding, then resumed. However, the medical record did not show the physician was notified of the resident continuing to receive Lovenox with the current episode of urinary bleeding and tracheal bleeding or that the physician addressed continuation or discontinuation of Lovenox. According to Lexicomp, enoxaparin (Lovenox): Nursing Physical Assessment/Monitoring: Check ordered labs and report any abnormalities. Obtain weight; dosing is weight based. Monitor patient for signs and symptoms of bleeding (bruising or bleeding that is not normal, changes in menstrual periods like lots of bleeding, spotting, or bleeding between cycles, nosebleeds that won't stop, bowel movements that are red or black like tar, throwing up blood or liquid that looks like coffee grounds) and neurological impairment (midline back pain, sensory defects, motor defects, bowel dysfunction, and bladder dysfunction). Educate patients on bleeding precautions including avoiding invasive procedures, activities that could cause injuries, and how to handle bleeding emergencies. Monitor for signs and symptoms of thrombocytopenia after therapy initiation. On 1/11/24 at 1537 hours, the DON acknowledged Resident 13 was receiving Lovenox while having active bleeding via the indwelling urinary catheter and tracheal bleeding. After the DON was notified, the DON presented a document showing the physician discontinued the use of Lovenox on 1/11/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 19) was free from the unnecessary psychotropic medications (medication that affects the brain activity). * The facility failed to provide non-pharmacological interventions to Resident 's 19's crying and constantly crying episodes due to depression and severe anxiety. * The facility failed to ensure a GDR was attempted for Resident 19's buspirone (medication to treat anxiety) and escitalopram (medication to treat depression) use. These failures had the potential for the physician to not have the necessary information and the residents to receive the unnecessary medications. Findings: Review of the facility's P&P titled Psychotropic Drug Therapy Monitoring revised 12/2023 showed patients who have psychotropic medication drug therapy initiated shall receive a comprehensive assessment to assure that psychotropic medication drug therapy is necessary to treat a specific condition rather than use as a chemical restraint. Under section Routine Order, showed a plan for psychotropic reduction and/or eventual withdrawal of the drug will be attempted at least quarterly . and upon monthly review of resident medical records, the Pharmacist/IDT will make recommendations for dosage reduction/adjustment of psychotropic medications for resident in accordance with CMS regulations and guidance. Medical record review for Resident 19 was initiated on 1/8/24. Resident 19 was admitted to the facility on [DATE]. Review of the facility's document titled Medication for Resident 19's escitalopram showed a physician's order dated 7/8/23, to administer escitalopram 20 mg via GT daily for depression. Further review of the facility's document for Resident 19's escitalopram medication use showed Resident 19 had been on the same escitalopram dosage and frequency since 2/17/23. Review of the facility's document titled Medication for Resident 19's buspirone showed a physician's order dated 7/8/23, to administer buspirone 15 mg via GT every eight hours for anxiety. Further review of the facility document for Resident 19's buspirone medication showed Resident 19 had been on the same buspirone dose and frequency since 2/22/23. a. Review of Resident 19's November 2023 Treatment Record showed for the use of escitalopram medication, Resident 19 was monitored for episodes of depression manifested by crying every shift tally by hash mark. Resident 19 had two crying episodes in the morning shift on 11/20/23. Review of Resident 19's November 2023 Dietary Administration Record showed for the use of Buspar medication, Resident 19 was monitored for episode of severe anxiety manifested by constantly crying every shift and tally by hash mark. Resident 19 had one constantly crying episode in the morning shift on 11/20 and 11/21/23. Review of Resident 19's medical record did not show Resident 19 was provided with any non-pharmacological interventions when Resident 19 manifested the episodes of crying. On 1/11/24 at 1457 hours, an interview and medical record review was conducted with RN 1. RN 1 verified Resident 19 was not provided with the non-pharmacologic interventions for episodes of crying. On 1/11/24 at 1615 hours, an interview was conducted with the DON. The DON was made aware of the above findings and acknowledged Resident 19 should have been provided with non-pharmacological interventions for episodes for crying. b. Review of Resident 19's Treatment Record on monitoring for episodes of depression manifested by crying every shift tally by hash mark for escitalopram medication use showed the following: - for October 2023, Resident 19 had no crying episodes; - for November 2023, Resident 19 had two crying episodes; and - for December 2023, Resident 19 had no crying episodes. Review Of Resident 19's Dietary Administration Record on monitoring for episode of severe anxiety manifested by constantly crying every shift and tally by hash mark for buspirone use showed the following: - for October 2023, Resident 19 had no constantly crying episodes; - for November 2023, Resident 19 had two constantly crying episodes; and - for December 2023, Resident 19 had one constantly crying episode. Review of Resident 19's Psychotropic Medication in Subacute for 2023 reviewed by the Pharmacist on 8/15, 8/21, 8/31, 9/18, 10/6, 10/13, 11/3, 11/17, and 11/24/23, showed Resident 19 was on buspirone 15 mg via GT every eight hours for manifestation by verbalization of feeling anxious, and escitalopram 20 mg via GT for depression manifested by crying. Review of Resident 19's Psychiatric Progress Notes dated 11/17, 12/1, 12/15, and 12/29/23, and 1/5/24, showed Resident 19's current medications including buspirone 15 mg via GT every eight hours and escitalopram 20 mg via GT daily. Further review of the documents showed the plan to continue Lexapro (brand name for escitalopram) to help with depression and Buspar (brand name for buspirone) to help with anxiety. Review of Resident 19's Interdisciplinary Plan of Care Conference dated 9/19, 10/24, 11/21, and 12/19/23, showed Resident 19's scheduled medication for buspirone 15 mg via GT every eight hours continue as prescribed and escitalopram 20 mg via GT daily continue as prescribed. Review of Resident 19's medical record did not show the facility attempted a GDR on Resident 19's buspirone and escitalopram use. On 1/11/24 at 1543 hours, an interview and concurrent Psychotropic Medication document review was conducted with the Pharmacist. The Pharmacist verified and acknowledged there were no attempts of GDR for Resident 19's buspirone and escitalopram use. On 1/11/24 at 1615 hours, an interview and medical records review was conducted with the DON. The DON verified and acknowledged there were no attempts of GDR for Resident 19's buspirone and escitalopram use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly and failed to discard the expired supplies. * Medication Cart A had one open and unlabeled Lantus pen (an insulin medication to treat high blood sugar), and three expired supplies. * The facility failed to monitor the temperature of Medication room [ROOM NUMBER]. * Medication Cart B had two expired supplies. These failures posed the risk for negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Floor Stock revised 10/2019 showed the policies and procedures are designed to ensure the safe and accurate dispensing of medications throughout the hospital . under the section Floor Stocks, showed medication contained in floor stock are stored under the condition listed by the medication manufacturer to ensure stability. Review of the facility's P&P titled Automated Medication Dispensing System revised 9/2020 under the section Patient-Specific Medications, showed patient-specific medications such as inhalers, ointments, eye drops, ear drops, and non-formulary medications are normally not stocked in the automated dispensing system. The Pharmacy Department will dispense these items, labeled with the patient's information, to the patient care unit. These items are then stored separately in a safe and locked area. 1. On [DATE] at 0943 hours, an inspection of Medication Cart A and Medication room [ROOM NUMBER] was conducted with LVN 5. a. Medication Cart A contained Lantus pen labeled with an opened date of [DATE], and expired date of [DATE]. However, the Lantus pen was not labeled with the resident name. LVN 5 verified and unable to determine which resident it belonged to. b. Medication Cart A contained the following: - one piece of BioPatch Protective Disk (an IV access dressing) with CHG (Chlorhexidine Gluconate - a substance that stops or slow down growth of microorganism) had expired on [DATE]; - one piece of Guard [NAME] (an IV access dressing) with CHG had expired on [DATE]; and - one piece of LNCS Neo (neonatal/adult pulse oximeter adhesive sensor) had expired on [DATE]. LVN 5 verified the above expired supplies. On [DATE] at 1615 hours, an interview was conducted with the DON. The DON acknowledged the medication carts should not contain the expired supplies. c. Medication Cart A containing the residents' medications and an ADS machine (automated medication dispensing system) containing IV hydration bags, and medical supplies were located inside Medication room [ROOM NUMBER]. Medication room [ROOM NUMBER] was observed with no thermometer to measure the room temperature. LVN 5 verified there was no thermometer inside the room and unable to provide the temperature log for Medication room [ROOM NUMBER]. LVN 5 stated the Engineering Department checked the temperature of the subacute unit daily. On [DATE] at 1130 hours, an interview and concurrent document review was conducted with the Director of Plant Operations. Review of the Sub-Acute Unit/Room Temperature Checks showed the columns for date, temperature of the hallway, room [ROOM NUMBER] and room [ROOM NUMBER], time, and initial. However, the temperature log failed to show the temperature for Medication room [ROOM NUMBER]. The Director of Plant Operations stated he performed random hallway temperature checks including the Nurses Station but not Medication room [ROOM NUMBER]. 2. On [DATE] at 1133 hours, an inspection of Medication Cart B was conducted with LVN 1. Medication Cart B contained the following: - one bottle of Skintegrity Hydrogel (used to maintain moist wound environment) had expired on 4/2022; and - one pack of SureStep (post foley catheter insertion wipes) had expired on [DATE]. LVN 1 verified the above expired supplies. On [DATE] at 1615 hours, an interview was conducted with the DON. The DON acknowledged the medication carts should not contain the expired supplies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary adaptive equipment was provided for one of 14 final sampled residents (Resident 10). * Resident 10 was not provided with a plate guard, non-slip table mat, and a suction cup as per the physician's order. This failure had the potential for Resident 10 not having an appropriate assistive device to consume her food and drinks. Findings: Review of the facility's P&P titled Nursing Care Restorative and Supportive revised 5/2016 showed the provision of supplies and equipment to support self-care of the residents. Restorative and supportive care includes the assessment of self-feeding skills, providing adaptive devices, and retraining program based on resident needs and capabilities. On 1/8/24 at 1156 hours, and 1/9/24 at 1157 hours, a concurrent observation and interview for Resident 10 with RNA 2 was conducted. Resident 10 was observed in bed and assisted by RNA 2 for the set up of Resident 10's food tray. There was no adaptive equipment for eating such as the plate guard, non-slip table mat, and suction cup observed on the food tray of Resident 10. RNA 2 was asked if Resident 10 had an adaptive equipment to use for eating. RNA 2 verified there were the plate guard and special spoon in the drawer at the bedside. RNA 2 added they offered the assistive devices when Resident 10 wanted to eat by himself. Medical record review was initiated for Resident 10 on 1/8/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Physicians Order for the month of January 2024 showed Resident 10's use of a plate guard, non-slip table mat, and suction cup for drinking assisted by the RNA in self-feeding program. Review of Resident 10's plan of care showed a care plan problem with an initiation date 10/14/23, addressing Resident 10's ADL functioning. The interventions included for the RNA to assist the resident with self-feeding using the right hand during mealtimes, using a plate guard, non-slip table mat and suction cup as tolerated. Review of Resident 10's Occupational Therapy Initial assessment dated [DATE], showed the recommendation of the OT for RNA feeding program for Resident 10, to encourage the use of the unaffected right upper extremity for self feeding using a plate guard, and non-slip table mat, as well as a suction cup to prevent spills during self-initiated feedings. Review of Resident 10's MDS dated [DATE], showed Resident 10 needed assistance in eating. On 1/9/24 at 1425 hours, an interview was conducted with RNA 2. RNA 2 verified there was an order for Resident 10's assistance in eating. RNA 2 verified there was no adaptive equipment for eating was available on Resident 10's food tray. On 1/10/24 at 0843 and 0932 hours, an interview and concurrent medical record review for Resident 10 was conducted with the Rehabilitation Director. The Rehabilitation Director verified there was a physician's order for the RNA assistance in feeding of Resident 10. The Rehabilitation Director stated the adaptive equipment for eating should have been with the food tray for the resident use. On 1/11/24 at 1029 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was a physician's order for Resident 10 to use an adaptive equipment for eating. The DON stated the adaptive equipment for eating should have been placed on the resident's food tray for use in eating.

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility's P&P for dating foods was not followed. * The staff was not performing handwashing between soiled and clean tasks. * The food preparation equipment was not clean when stored. * The food preparation equipment was not air dried. * A handwashing sink was used for purposes other than handwashing. These failures posed the risk to cause food borne illnesses in a highly susceptible resident population of three residents who consumed food prepared in the kitchen. Findings: Review of the facility's matrix showed three of 21 residents consumed food prepared in the kitchen. 1. Review of the facility's P&P titled Food Labeling and Dating revised 8/2023 showed in part, 3. Stored foods are labeled to indicated type of product and dated prepared or dated the product is to be discarded .5. Prepared pudding .meat, tuna .are discarded after three days .16 .Non-perishable foods (flour, sugar, rice, beans and pasta) that are received without an expiration date, are dated with the date received and used within one year. Review of the facility's P&P titled Thawing of Potentially Hazardous Food revised 12/22 showed in part, 3.Fish, lamb, poultry and pork are held no more than two days after thawing. During the initial tour of the kitchen on 1/8/24 at 0805 hours, an observation of the walk-in refrigerator and concurrent interview was conducted with the DNS. Two bags of completely thawed chicken were observed without a date. When asked about the thawing process the facility followed, the DNS stated the meats were dated when they were transferred from the freezer to the refrigerator. The DNS stated she was not sure how long meats could be stored in the refrigerator once transferred from the freezer. On 1/8/24 at 0827 hours, an interview was conducted with the Chef. The Chef stated once meat was transferred to the refrigerator from the freezer, it should be used within three days. The Chef stated the chicken was removed from the freezer on 1/5/24, but was not dated. a. On 1/8/24 at 0827 hours, an observation of the walk-in refrigerator and concurrent interview was conducted with the Chef. 30 pounds of pork and 32 pounds of flap meat were observed with a pack date of 1/4/24. The Chef stated a pack date was the date the food company packed the product. The Chef confirmed the pork and flap meat should have a date which showed when it was received by the facility. b. During the initial tour of the kitchen on 1/8/24 at 0805 hours, an observation of a bin of rice and concurrent interview was conducted with the DNS. The bin of rice was not labeled or dated. The DNS confirmed the rice bin should be labeled and dated. 2. Review of the facility P&P titled Handwashing revised 12/2022 showed in part, indications for handwashing includes, but is not limited to the following: 1 .Prior to engaging in food preparation including working with clean equipment and utensils .9. After working the dirty side of the dish machine. On 1/9/24 at 0908 hours, an observation of the dishwashing process and concurrent interview was conducted with DA 1 and the Kitchen Supervisor. DA 1 touched the dirty dishes with gloved hands, then donned a new pair of gloves without washing his hands. DA 1 was observed to change his gloves two more times after touching soiled areas prior to touching clean dishes, without washing his hands between glove changes. DA 1 and the Kitchen Supervisor confirmed DA 1 should have washed his hands between glove changes. 3. Review of the facility's P&P titled Dish and Ware Washing/Care of Dish machine revised 12/2022 showed sanitary dishes, cooking vessels and utensils are free from visible soil, stains, greasy film, cracks and chips, and bacteria. During the initial tour of the kitchen with the DNS on 1/8/24 at 0805 hours, a frying pan stored with the clean equipment was observed with food residue on the cooking surface. The DNS confirmed the frying pan was not clean. The DNS removed the pan and stated it would be washed. 4. Review of the facility's P&P titled Dish and Ware Washing/Care of Dish machine revised 12/2022 showed in part, C. Operating the dishwashing machine: 3. Air Drying: As the racks of dishes come from the machine, they should be allowed to air dry. During the initial tour of the kitchen with the DNS on 1/8/24 at 0805 hours, a blender was observed stored wet with the top on. The DNS confirmed the blender should be air dried. 5. According the USDA Food Code 2022 Section 2-301.15 Where to Wash showed, food employees shall clean their hands in a handwashing sink .and may not wash their hands in a sink used for food preparation or ware washing. On 1/9/24 at 0908, an observation of the dishwashing process and concurrent interview was conducted with DA 1 and the Kitchen Supervisor. DA 1 was observed to wash his hands in a sink where soiled dishes were rinsed prior to being put in the dish machine. The Kitchen Supervisor stated the employees who worked in the dish room washed their hands in the sink used to rinse soiled dishes because there was no other handwashing sink nearby.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility P&P review, the facility failed to ensure the facility staff responsible for handling food brought for residents from the outside and visitors who brought food for residents from the outside were educated on safe food handling procedures. These failures posed the risk for food borne illness for residents who consume food from the outside. Findings: Review of the facility's P&P titled Outside Food for Patients/Residents revised 1/2023 showed the following: * Food may be brought in from home or other sources to improve nutritional intake or provide supportive care. * For a patient to receive food from an outside source, a physician/LIP order is required and be compatible with the diet order and texture. * Food supplied to patients from outside sources must be stored in a manner which complies with infection control and food safety guidelines. * If perishable food is brought in but eaten right away it must be stored in the refrigerator with the following guidelines: C. Food may be dispensed from a container with a clean utensil onto a serving plate or closed/covered container should be returned to the refrigerator. On 1/9/24 at 0836 hours, an interview was conducted with LVN 3. LVN 3 stated if a resident wanted food brought from the outside, there must be a doctor's order. LVN 3 stated once the food was opened, it was discarded especially if the food had been in the resident's room. LVN 3 was asked if she had received any safe food handling education. LVN 3 stated the only training she received regarding food brought from the outside was to label the food. On 1/9/24 at 0849 hours, an interview was conducted with the DON. The DON was asked how the visitors who brought food from the outside for residents were informed of safe food handling practices. The DON stated the visitors were told what type of diet the resident was on and what food was allowed. The DON stated the visitors were told to buy food in sealed containers and food cooked at home was not allowed. The DON stated there was one resident (Resident 19) who currently received food from the outside and the resident's visitor had been educated on proper feeding procedures. Medical record review of Resident 19 was initiated on 1/9/24 at 0904 hours. Resident 19 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure. Review of Resident 19's physician's order dated 4/17/23, showed okay for the resident to have food from home. Resident 19's care plan dated 5/8/23, showed Resident 19's family member brought in food from the outside. The care plan did not show education was given to the family member on safe food handling practices. On 1/9/24 at 0940 hours, a telephone interview was conducted with Resident 19's family member. Resident 19's family member was asked if he had received education on safe food handling regarding food brought from the outside. Resident 19's husband stated he was only instructed on how to safely feed Resident 19 but nothing regarding safe food handling. On 1/09/24 at 1003 hours, an interview was conducted the DSD. The DSD confirmed she had not provided staff or visitors education on safe food handling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident 16 was initiated on 1/8/24. Resident 16 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 16's H&P examination dated 7/10/23, showed the resident had a history of seizures. Review of the resident's Physician's Orders for January 2024 showed postural supports for positioning, safety, and balance aide: padded bed side rails x 4 for seizure precaution and poor trunk control. Review of Resident 16's Subacute Unit Bed Entrapment Assessment Risk assessment dated [DATE] showed, no responses for any gaps in-between all railings for zones one through seven. On 1/8/24 at 0832 hours, during the initial tour, Resident 16 was observed lying in bed with all four side rails up. The resident's head was at the foot of bed. On 1/8/24 at 1149 hours, Resident 16 was observed lying in bed and putting both legs over the side rails. On 1/10/24 at 0756 hours, an interview and concurrent record review with RN 1 was conducted regarding the use of side rails and entrapment assessment. RN 1 stated the current census was 21 out of 22 beds. When asked, out of 21 residents, how many residents utilize side rails, RN 1 stated about 15-16 residents used the side rails, and the side rails were used for positioning and for residents with seizure disorders. Review of the Entrapment Assessment provided by the facility did not show an accurate assessment, and there was no responses for the assessment items for Zones 1 through 7. RN 1 verified the findings. On 1/10/24 0844 hours, Resident 16 was observed lying at the foot of the bed with all padded side rails up. On 1/10/24 at 0931 hours, an observation of Resident 16's bed showed a gap inbetween the foot and head of bed. 3. Review of the FDA - Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 5/10/06, showed the Table 3 Summary of FDA Hospital Bed Dimension Limit Recommendations as follows: - less than 4 and 3/4 inches in Zone 1: within the rails; - less than 4 and 3/4 inches in Zone 2: under the rail, between rail supports or next to a single rail support; - less than 4 and 3/4 inches in Zone 3: between rails and mattress; and - less than 2 and 3/8 inches in Zone 4: under the rails, at the ends of the rail. On 1/8/24 at 1057 hours, an observation was conducted in Resident 8's room. Resident 8 was observed with elevated bilateral upper and bilateral lower padded side rails and padded headboard. Medical records review for Resident 8 was initiated on 1/8/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 6/9/23, showed Resident 8's active problem list including seizure disorder. Review of Resident 8's Active Order Sets showed a physician's order dated 1/1/22, for bilateral padded full rails up to prevent fall from bed with presence of involuntary body movements and diagnosis of seizure disorder with recurrent seizure activity. Review of Resident 8's Subacute Unit Bed Entrapment Risk assessment dated [DATE], 1/1, 1/2 and 1/3/22, showed the reason for use of bilateral padded side rails was to prevent fall from bed with presence of involuntary body movement and diagnosis of seizure disorder. The form showed to indicate Yes or No response on the zones for 72 hours: - Zone 1 gap within side rails less than 4 and 3/4 inches; - Zone 2 side gap under or between rails supports and mattress less than 4 and 3/4 inches; - Zone 3 gap on between rail and mattress less than 4 and 3/4 inches; - Zone 4 gap under the rails at the ends of the rails less than 2 and 3/8 inches; - Zone 5 gap between the split bed rail- neck/chest entrapment; - Zone 6 gap on sides between the end of rails and head or foot board; and - Zone 7 gap between end of mattress and head or food board. Review of the staff responses on Resident 8's Subacute Unit Bed Entrapment Risk Assessment upon admission and for 72 hours, showed, No to all Zones. Review of Resident 8's quarterly Subacute Unit Bed Entrapment Risk Assessment showed Resident 8 was assessed for entrapment on 3/20, 6/12, and 9/12/22. Further review of Resident 8's medical record showed four quarterly entrapment assessments were without dates and no quarterly assessment for December 2022 and all quarterly assessments for 2023. On 1/11/24 at 1015 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 8's quarterly bed entrapment assessments were incomplete, and RN 1 was not able to determine when the assessments were done for the quarterly assessments without dates. On 1/11/24 at 1024 hours, an interview and concurrent medical record review was conducted with RNs 1 and 3. When asked regarding Resident 8's Bed Entrapment Risk Assessment document performed upon admission and for 72 hours, RNs 1 and 3 acknowledged the staff did not answer the form properly and Resident 8's bed entrapment risk assessment was inaccurate. Based on observation, interview, medical record review, facility document interview, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete including the measurements during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for four of 14 final sampled residents (Residents 5, 7, 8, and 16). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the facility's P&P titled Bed Side Rail and Entrapment Assessment revised 5/21, showed all residents will be assessed for fall and entrapment risk upon admission to the facility. Residents will be all be reviewed/reassessed quarterly; post fall, and as needed thereafter upon a significant change in condition of the resident by the IDT. Complete the resident Fall Risk Assessment, Bed Side Rail & Assist Bar Evaluation, and Bed Entrapment Risk Assessment upon Admission. The Bed Side Rail Entrapment Risk Assessment tool consist of the FDA Safety Alert zones as shown below: Zone 1 - Within the rail; Zone 2 - Between the top of the compressed mattress and the bottom of the rail, between rails ports; Zone 3 - Between the rail and the mattress; Zone 4 - Between the top of the compressed mattress and the bottom of the rail, at the end of the rails; Zone 5 - Between the split bed rails; Zone 6 - Between the end of the rail and the side edge of the head or foot board; and Zone 7 - Between the head or foot board and the end of the mattress. 1. On 1/8/24 at 1058 hours, and 1/9/24 at 1034 hours, Resident 5 was observed lying in bed with four bed side rails up and padded. Medical record review for Resident 5 was initiated on 1/9/24. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's Physicians Orders for January 2024 showed a physician's order dated 4/21/22, for full padded side rails for safety secondary to seizure disorder. Review of Resident 5's Bed Entrapment Risk assessment dated [DATE], showed the bilateral side rails for postural support, positioning, and safety. Further review of the entrapment assessment showed the staff assessed for the entrapment zones with a response of a yes or no. However, the document failed to show the specific measurements of the entrapment zones. Review of Resident 5's Bedside Rail and Assist Bar Evaluation dated 4/16/23, showed Resident 5 used full side rails for safety. On 1/10/24 at 0745 hours, an interview for Resident 5 was conducted with CNA 3. CNA 3 stated Resident needed total assist on all ADL cares and unable to reposition himself in bed. CNA 3 stated Resident 5 had all four side rails elevated and padded when in bed due to seizure. On 1/10/24 at 0756 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 1. RN 1 verified there was a physician's order for side rails use of Resident 5. RN 1 stated the charge nurses were responsible for side rail assessment including the entrapment assessment. RN 1 verified there were no specific measurements on the entrapment zones of the bed. 2. On 1/8/24 at 1052 hours, and 1/9/24 at 0824 hours, Resident 7 was observed lying in bed with both upper bed side rails up and padded. Medical record review for Resident 7 was initiated on 1/9/24. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Physicians Orders for January 2024 showed a physician's order dated 3/29/22, for bilateral upper padded side rails for safety secondary to seizure disorder. Review of Resident 7's Bed Entrapment Risk assessment dated [DATE], showed the bilateral side rails for postural support, positioning, and safety. Further review of the entrapment assessment showed the staff assessed for the entrapment zones with a response of a yes or no. However, the document failed to show the specific measurements of the entrapment zones. On 1/10/24 at 0756 hours, an interview and concurrent medical record review for Resident 7 was conducted with RN 1. RN 1 verified there was a physician's order for side rails use of Resident 7. RN 1 stated the charge nurses were responsible for side rail assessment including the entrapment assessment. RN 1 verified there were no specific measurements for the entrapment zones of the bed. On 1/11/24 at 1505 hours, an interview and concurrent medical record review for Residents 5 and 7 was conducted with the DON. The DON was informed and verified the above findings. The DON stated the bed side rails assessment should have been clarified and the staff should be educated for completing the document.

Based on observation, interview, and medical record review, the facility failed to ensure the proper infection prevention and control measure as evidenced by: * Lack of surveillance, tracking and mapping of suspected and confirmed infection cases. The summary of the monthly infection snapshot did not reflect the accuracy of the actual McGeer's tool for individual resident assessments. The facility did not include the residents who did not meet the McGeer's criteria in the discussion during the quarterly infection control meeting. * The facility failed to provide a system in place to protect the residents, staff, guests, and outside vendors free from possible exposure to infectious diseases by comingling the isolation and non-isolation residents' soiled laundry throughout the facility. These failures posed the increased risk for spread of infectious diseases. Findings: 1. On 1/11/24 at 0901 hours, an interview with the Director of Performance Improvement was conducted. He stated his responsibilities included overseeing the quality assurance, patient safety, and regulatory compliance. Infection control meeting was held quarterly, which included the PI and medical staff (MD, pharmacist, and nurses). The next meeting was scheduled on 3/6/24, for the 4th quarter. On 1/11/2024 at 0930 hours, an interview and concurrent Infection Control Binder review was conducted with two IPs, DON and exiting DON. The two IPs verified the subacute unit did not have a surveillance log but only had the McGeers binder. The IPs provided a log titled McGeers Criteria Monthly Summary which included residents' names, type of infection, date and antibiotic ordered and whether the McGeer's criteria was met or not. Review of the Infection Control Binder dated for July 2023 showed Resident 16's infection not meeting McGeer's criteria but no explanation on the summary what criteria was not met. Review of the Infection Control Binder dated for September 2023 showed Resident 1's infection not meeting McGeer's criteria but no explanation on the summary what criteria was not met. Review of Infection Control Binder dated for October 2023 showed Resident 15 was listed as meeting the McGeer's criteria but had a note showing microbiologic data did not meet McGeer's criteria. Review of Infection Control Binder dated November 2023 showed Resident 18 did not meet McGeer's criteria and antibiotic was prescribed for UTI without urine culture collection. However, review of the Infection control meeting minutes failed to include the discussion of the four residents who did not meet the McGeer's criteria during the review period of July through December 2023. Both IPs confirmed lack of documentation and surveillance and will improve their process from hereon. 2.a. Review of the CDC's guidelines for Environmental Infection Control in Health-Care Facilities, Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics showed bags containing contaminated laundry must be clearly identified with labels, color-coding, or other methods so that health-care workers handle these items safely, regardless of whether the laundry is transported within the facility or destined for transport to an off-site laundry service. On 1/11/24 at 1132 hours, an inspection of the laundry room was conducted with the Activity Coordinator. While walking through the double locked doors to the laundry room, five laundry hampers (with blue bag) with lids filled with linens were placed in the hallways. One blue laundry bag filled with linens was observed on top of the hampers. On 1/11/24 at 1132 hours, an interview with the Activity Coordinator was conducted. The Activity Coordinator showed where the laundry room was. She stated the laundry room was used for the residents' personal soiled clothes, and the linens and sheets were picked up by an outside vendor. When asked where they left the soiled linens for pick up, the Activity Coordinator stated the soiled laundry were left in hallways, and the vendor would come several times a day to pick up the soiled laundry. On 1/11/24 at 1143 hours, an interview and observation was conducted with the Housekeeping. The Housekeeping stated the linens in the hallway were picked up by the contracted linen company. When asked how often the vendor came to pick up the laundry, the Housekeeping stated twice in the morning. The Housekeeping stated the company came to pick up the laundry two to three times daily. The Housekeeping further stated the process for the soiled laundry was to bring the laundry from the resident's room, take the laundry out, and put the laundry in the hallway. On 1/11/24 at 1150 hours, an interview with the Relief Staff Housekeeping and Housekeeping was conducted in the clean linens room. The Relief Staff Housekeeping was asked about the process of isolation versus non isolation residents' soiled laundry, he stated they all placed in a blue bag throughout the entire facility. The Relief Staff Housekeeping stated there were no separation between isolation versus non isolation linens. The Relief Staff Housekeeping and Housekeeping confirmed the isolation linens were all being placed with non isolation liens, and no separate bags or bins were used to distinguish between isolation versus non isolation linens. b. On 1/11/24 at 1138 hours, during an interview with CNA 4, when asked what the soiled and clean laundry rooms were for, CNA 4 stated it was currently being used for trash. On 1/11/24 at 1143 hours, an interview and observation was conducted with the Housekeeping. The soiled laundry room was observed with one large bin with trash overfilled. The Housekeeping acknowledged the trash was overfilled.

Based on observation, interview, and facility document review, the facility failed to ensure two of two ice machines were not clean and maintained as per the manufacturer's guidelines. This failure posed the risk of ice contamination and equipment to not function in the way it was intended. Findings: 1. Review of the ice machine manufacturer guidelines located on the interior panel of the ice machine located in the kitchen showed, Cleaning and Sanitizing instructions, Cleaning solution, [Hoshizaki scale away] 9.6 ounces diluted with 1.6 gallons warm water . Sanitizing solution, 2.5 ounces of a sodium hypo-chlorite solution with five gallons of warm water. On 1/8/24 at 1356 hours, an observation of the facility's ice machine located in the kitchen and concurrent interview was conducted with IMTs 1 and 2. IMT 1 stated he used the ice machine cleaner and sanitizer produced by [Nu-Calgon] company to clean and sanitize all ice machines in the facility. IMT 1 stated some hard water deposits could not be removed. The interior of the ice chute (the part of the ice machine where ice was dispensed into the ice storage bin) was wiped with a clean white towel. A large amount of white crusty residue was removed. IMT 1 confirmed the ice machine was not clean. IMT 2 stated he mixed three ounces of the ice machine cleaner produced by [Nu-Calgon] with one gallon of water and eight ounces of the ice machine sanitizer produced by [Nu-Calgon] with five gallons of water to clean all parts of the facility's ice machines. On 1/8/24 at 1426 hours, an interview was conducted with the DPO. The DPO stated regular service was more important than correct chemicals used to clean the ice machine. The DPO stated as long as the components of the ice machine cleaning and sanitizing solutions were the same, it was fine to use the generic brand. 2. Review of the manufacturer guidelines located on the interior panel of the ice machine located in the clean utility room of the subacute unit showed in part, Cleaning and Sanitizing, 2. Dilute approximately 9.6 ounces recommended cleaner [Lime Away] with 1.6 gallons of water. 12. Dilute approximately .82 ounces of a 5.25% sodium hypochlorite solution with 1.6 gallons of water. On 1/8/24 at 1442 hours, an observation of the ice machine located in the clean utility room of the subacute unit and concurrent interview was conducted with IMT 1 and the DPO. The ice chute had a gray residue. IMT 1 stated he would replace the ice chute part.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure two of 12 final sampled residents (Residents 16 and 17) and one nonsampled resident (Resident 4) remained free from accident hazards. * The facility failed to ensure the residents' side rails were padded as ordered by the physician and as care planned. These failures posed the risk for the residents to become entrapped or injured by the side rails. Findings: Review of the FDA issued safety alert titled Entrapment Hazards with Hospital Bed Side Rails showed the residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. 1. On 1/3/23 at 0911 hours, Resident 4 was observed lying in bed with four full side rails elevated. Three side rails were observed padded; however, the upper left side rail was not padded. Medical record review for Resident 4 was initiated on 1/3/23. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's Care Order/Instruction dated 7/20/17, showed to implement padded full side rails to prevent fall/injury secondary to seizure disorder with recurrent seizure activities and the behavior of bouncing back and forth while sitting in bed. Review of Resident 4's plan of care showed a care plan problem revised date 1/3/21, addressing the resident's risk for fall/injury, attempting to get out of the bed by scooting to the end of the bed, and found sitting at the edge of the bed. The interventions were to pad all of the side rails. On 1/3/23 at 1048 hours, Resident 4 was observed sitting in bed rocking back and forth. Four full side rails were elevated with only three side rails padded; the upper left side rail was not padded. On 1/3/23 at 1052 hours, an interview was conducted with RN 1. RN 1 verified the findings and stated all the side rails had to be padded to prevent Resident 4 from injuring herself since she had seizure disorder and moved around in bed. 2. On 1/3/23 at 0912 and 1052 hours, Resident 16 was observed lying in bed with four full side rails elevated. Three side rails were observed padded; however, the upper left side rail was not padded. Medical record review for Resident 16 was initiated on 1/3/23. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's Care Order/Instruction dated 9/7/22, showed to implement four padded side rails for seizure precaution and poor trunk control. Review of Resident 16's plan of care showed a care plan problem dated 1/10/22, addressing the resident's risk for fall/injury. The interventions included to pad the four elevated side rails due to seizure activity. On 1/3/23 at 1052 hours, an interview was conducted with RN 1. RN 1 verified the findings and stated all the side rails had to be padded to prevent Resident 16 from injuring herself since she moved around in bed. 3. On 1/3/23 at 0904 and 1058 hours, Resident 17 was observed lying in bed with four full side rails elevated. Three side rails were observed padded; however, the lower left side rail was not padded. Medical record review for Resident 17 was initiated on 1/3/23. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Care Order/Instruction dated 12/29/22, showed to implement padded bilateral upper side rails for safety secondary to seizure disorder and to aid in bed mobility. Review of Resident 17's plan of care showed a care plan problem dated 12/13/22, addressing the resident's risk for fall/injury. The interventions included to implement four padded side rails. On 1/3/23 at 1105 hours, an interview was conducted with LVN 3. LVN 3 verified the findings and stated all the side rails had to be padded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The medication error rate was 6.9%. * One of four licensed nurses (RN 2) failed to ensure Resident 11 received the correct doses of medications administered via GT. This failure had the potential for the resident to experience decreased drug efficacy. Findings: Medical record review for Resident 11 was initiated on 1/4/23. Resident 11 was admitted to the facility on [DATE], with a GT. On 1/4/23 at 0958 hours, an observation of the medication administration for Resident 11 was conducted with RN 2. The following medications were administered via GT to Resident 11: - Keppra (for seizure control) 500 mg/5 ml solution two solution containers; - lacosemide (for seizure control) syringe 200 mg (50 mg/5 ml) four syringes (5 ml each syringe); - clonazepam (for seizure control) 1 mg one tablet; - Thera M plus (supplement) one tablet; - Eliquis (a blood thinner medication that reduces blood clotting) 2.5 mg one tablet; - culturelle (probiotic supplement) one capsule; - lansoprazole (stress ulcer prevention) 30 mg one capsule; - bromocriptine (for post traumatic brain injury [an injury that affects how the brain works] treatment to improve wakefulness) 2.5 mg two tablets; - propranolol (medication for high blood pressure) 10 mg one tablet; - vitamin D3 (supplement) 25 mcg 1000 IU two tablets; and - Pro-Stat (supplement) sugar-free liquid 30 ml; RN 2 was observed crushing medications and putting the crushed medications in separated medicine cups. RN 2 placed the liquid medications in separated medicine cups. RN 2 administered each medication one by one via the GT to Resident 11 and flushed the GT with 20 ml of water with each administration. However, after administering the medications via the GT, there were significant amounts of crushed medications left in two medication cups (Thera M plus and bromocriptine). During a follow-up interview with RN 2 after administration of the medication, RN 2 verified the leftover medications were from the medications administered to Resident 11. RN acknowledged to make sure the complete dose of medication was given, put additional water to the medication cup, make sure crushed medication was dissolved, and medication cup was clear. LVN 2 acknowledged two of Resident 11's medication cups had significant crushed medication residue and Resident 1 did not receive the full dose of his medications.

Based on observation, interview, and facility document review, the facility failed to ensure the menu was followed for three out of three residents on a pureed diet. * The [NAME] failed to follow the recipe for the preparation of mashed potatoes. This posed the risk of the residents' nutritional needs not being met. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 1/3/23, showed three residents in the subacute unit received mechanically altered diets including pureed and all chopped foods. Review of the facility's recipe for mashed potatoes showed to mix 5.25 quarts of water with 2.375 pounds of dry potato granules. On 1/4/23 at 1041 hours, an observation and concurrent interview was conducted with the Cook. The [NAME] stated he was preparing the mashed potatoes. The [NAME] measured one gallon (equivalent to four quarts) of hot water and poured it into a container. The [NAME] then poured an unmeasured amount of the dry potato granules directly from its packaging into the water. The [NAME] verified he did not measure or weigh the dry potato granules as per the recipe, and just added enough so the mixture was not too thick or too runny. On 1/4/23 at 1155 hours, an interview and concurrent facility document review was conducted with the Food Service Supervisor. The Food Service Supervisor stated the recipe yielded 50 portions, but the [NAME] should have reduced the amount of the ingredients while maintaining its ratio to follow the recipe. On 1/5/23 at 0837 hours, an interview was conducted with the RD. The RD verified the [NAME] should have followed the recipe to ensure standardized portion sizes and the nutritive values of each portion.

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the resident refrigerators/freezers were only used for resident foods. This had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility's P&P titled Refrigerators/Freezers: Care of dated 12/15/22, showed resident refrigerators are used only for resident foods. Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility and dated 1/3/23, showed three residents in the subacute unit received foods prepared in the kitchen. On 1/3/23 at 0810 hours, during the initial tour of the kitchen with the Food Service Supervisor, an employee's iced coffee was observed stored inside the resident's freezer. The Food Service Supervisor verified employee foods were not supposed to be stored in the resident refrigerators or freezers to prevent cross contamination.