Based on record review and interview, the facility failed to ensure restorative therapy was provided to a resident with limited ROM for one (#18) of one sampled resident reviewed for therapy services. The ADON reported 42 residents resided at the facility. Findings: A Restorative Nursing policy dated 12/2019, read in part, the facility believes that each resident will be provided with the opportunity to regain skills and abilities lost due to illness and disability. Therefore, each resident will be evaluated at move in, return from another health care facility, and after a significant change in condition for the potential benefit of participating in a restorative nursing program. Resident #18 had diagnoses which included difficulty walking and muscle weakness. A care plan focus, dated 10/11/21, documented the resident had an ADL self-care performance deficit. An associated care plan intervention, dated 01/03/25, documented the resident was to be in a restorative program for maintenance. A physician order, dated 01/10/25, documented Resident #18 was to continue restorative services two to three times a week to maintain strength, endurance and independence. On 01/22/25 at 10:44 a.m., PT #1 stated all residents were screened when admitted to the facility, transitioned from skilled to long term care, or when the need was identified for a current resident. They stated Resident #18 was to have been receiving restorative services since 01/10/25, but had not. On 01/23/25 at 9:44 a.m., PT #1 stated they had contacted RT #1 and they confirmed they had not performed any restorative services with Resident #18. PT #1 further stated there was a lapse in communication which had caused the omission of the services and training for RT #1 was required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#40) of one resident reviewed for discharge. The General Manager reported 48 residents resided in the facility. Findings: A facility policy titled discharges, revised 4/23, read in part, .Document in nursing notes time of transfer, where resident is going, condition of resident, method of transportation, disposition of all belongings and medications and that all parties are aware of the discharge . Resident #40 had diagnoses which included fracture of the third lumbar vertebra and hypertension. A 5-Day PPS assessment, dated 10/06/23, documented the resident was admitted on [DATE] and was discharged on 10/06/23. On 10/25/23 at 1:30 p.m., Resident #40's electronic health record was reviewed, a discharge summary was not located. On 10/25/23 at 1:40 p.m., the Director of Hospitality reported they did not work on 10/06/23 and they were unsure if a discharge summary was completed. On 10/26/23 at 9:20 a.m., the Assistant Chief Nursing Officer was asked if a discharge summary or other documentation of Resident #40's discharge was completed, they stated not to my knowledge.

Based on observation, record review, and interview the facility failed to ensure entrapment assessments were performed and consents for use of bed rails were obtained prior to the use of bed rails for two (#15 and #23) of two sampled residents reviewed for accidents. The General Manager reported 48 resident had bed rails attached to their beds. Findings: A Side Rails policy, review date of 05/23, read in part, .1. The resident will be assessed for the use of full side rails prior to being used/installed using the device evaluation in [product name withheld]. 2. The resident or responsible party will be informed of the risks and benefits with the use of full side rails and a consent will be obtained . 1. Resident #15 had diagnoses which included dementia and generalized muscle weakness. An annual assessment, dated 10/13/23, documented Resident #15's cognition was severly impaired and they were dependent of staff for activities of daily living. A review of Resident #15's medical records found no documentation of an entrapment assessment or consent for the use of bed rails. 2. Resident #23 had diagnoses which included generalized muscle weakness and difficulty walking. A significant change assessment, dated 09/07/23, documented Resident #23 was cognitively intact and required extensive assistance from staff for activities of daily living. A review of Resident #23's medical records found no documentation of a entrapment assessment or consent for the use of bed rails. A nurse note, dated 10/18/23 at 7:00 p.m., documented the Resident #23 was found with their knees on the floor and their head between the bed mattress and a side rail. No injuries were documented in the note. New interventions to prevent falls from the bed were noted to had been put in place at that time. On 10/23/23 at 3:02 p.m. Resident 15's room was observed for accident hazards. Bed rails were observed attached to the bed frame. On 10/24/23 at 10:35 a.m. Resident #23's bed was observed to have a bed rail attached to the bed frame. The resident stated they had slid from their bed onto the floor recently. They could not recall why they had fallen from the bed to the floor. They stated they sufferer no injuries as a result of the fall. They stated they lowered their bed and moved one side against a wall to prevent further falls. On 10/25/23 at 10:35 a.m., the Clinical [NAME] President reported bed rail assessments were not done at the facility because of the acute setting and that the rails are less than quarter rails. When informed of Resident #23's incident where their head was documented as having been found between the mattress and the bed rail the Clinical [NAME] President reported in that case an assessment should have been done. At 9:51 a.m., the Assistant Chief Nursing Officer reported to their knowledge bed rail assessments were not required. They stated there had been some assessments done but not consistently. They stated resident #23 did not have an entrapment assessment when they entered the facility or after the incident where their head was found between the bed rail and the bed mattress. At 10:16 a.m., the Clinical [NAME] President reported there was a bed rail assessment available in the electronic medical record product used at the facility but none had been completed for Resident #15 or Resident #23. On 10/26/23 at 9:03 a.m., the Assistant Chief Nursing Officer reported Resident #15 and Resident #23 had not been assessed for entrapment risk prior to their use. They further reported neither resident or their legal representative had been advised of the risks and benefits of the bed rails nor signed consents for their use which was required by their policy.

Based on record review and interview, the facility failed to monitor food cooking and holding temperatures to ensure safe temperatures were maintained in the kitchen and on the steam table during meal service. The General Manager reported 48 residents resided in the facility. Findings: A facility policy titled Food, Revised 04/23, read in part, .The temperatures of food items served to elders will be tested and recorded before the delivery of food to the units/neighborhoods, at the time serving begins, at least once during serving if serving lasts longer than thirty (30) minutes, and at the conclusion of serving . The lunch temperature log, dated 10/23, did not document any food temperatures had been recorded between 10/18/23 and 10/24/23. The dinner temperature log, dated 10/23, did not document any food temperatures had been recorded between 10/18/23 and 10/24/23. On 10/24/23 at 12:00 p.m., [NAME] #2 was asked why no temperatures were documented between 10/18/23 and 10/24/23 they stated temperatures were not done. They also stated the chef on duty for the meal was responsible for ensuring staff documented temperatures on the temperature log.

2. Resident #35 had a diagnosis of urinary tract infection. Resident #35 had a physician's order, dated 04/04/22, for Amoxicillin Tablet 875 mg to be administered twice a day for a UTI. The MAR documented to start the medication on 04/05/22 at 8:00 a.m. The MAR progress notes, dated 04/05/22, documented the morning and evening doses of Amoxicillin were not available. On 04/06/22 at 10:10 a.m., Resident #35 was asked if she currently was being treated for a UTI. She stated she was and started an antibiotic yesterday morning. She was asked if she had any symptoms of a UTI. She stated she had confusion. At 10:16 a.m., LPN #1 was asked how she ensured new medications were available to be administer as ordered by the physician. She stated the pharmacy was called to make sure they received the medication. She stated the Amoxicillin had not been delivered. 3. Resident #153 had a diagnosis of atrial fibrillation. Resident #153 had a physician's order, dated 04/01/22, for aspirin 81 mg to be given one time a day for anticoagulant. The MAR documented to start the medication on 04/02/22 at 8:00 a.m. The MAR progress notes, dated 04/02/22, 04/03/22, 04/04/22, 04/05/22, and 04/06/22, documented the medication was not available. On 04/06/22 at 9:12 a.m., LPN #2 was asked what the facility protocol was if a resident did not have medication available. She stated they documented the medication was not available and ordered them from pharmacy. She stated they ordered medications on Monday, Wednesday, and Friday. Based on interview and record review, the facility failed to ensure medications were available for three (#42, #35 and #153) of nine sampled residents who were reviewed for medication availability. The DON identified 50 residents who received medications in the facility. Findings: 1. Resident #42 had diagnoses which included neuropathy, hyperlipidemia, mild pain, anxiety, hypertension, and depression. Physician's orders, dated April 2022, documented the resident was ordered the following medications: ~ Atorvastatin 20 mg by mouth at bedtime for hyperlipidemia, ~ Duloxetine 60 mg by mouth daily for depression, ~ Losartan 25 mg by mouth daily for hypertension, ~ Olanzapine 2.5 mg by mouth at bedtime for anxiety, ~ Tylenol 650 mg three times a day for mild pain, and ~ Gabapentin 300 mg by mouth four times a day for neuropathy. Review of the MAR, dated April 2022, documented the resident was not administered Atorvastatin from 04/02/22 through 04/05/22, Duloxetine on 04/02/22, Losartan on 04/04/22, Olanzapine on 04/02/22, Tylenol on 04/02/22 at 8:00 a.m. and 2:00 p.m., and Gabapentin from 04/02/22 at 8:00 p.m. through 04/04/22 at 8:00 p.m. Review of the clinical record documented the medications were not available in the facility. On 04/04/22 at 1:45 p.m., the resident's family stated the resident had missed some doses of their medication. On 04/06/22 at 9:12 a.m., LPN #2 was asked why all ordered medications were not available for resident #42. She reviewed the clinical record and stated she had noticed on 04/03/22 the resident only had one pill of Gabapentin left and placed an order to the pharmacy at that time. On 04/06/22 at 9:20 a.m., the DON was asked how medications were monitored to ensure they were available. She stated medications were reordered three times a week. She was asked why resident #42 had not had the above listed medications available in April 2022. She stated she would need to check with the ADON and follow up with the pharmacy. On 04/06/22 at 9:57 a.m., ADON #2 reviewed the resident's MAR and stated they ordered medications on Monday, Wednesday, and Friday but did not see any documentation in the clinical record the medications had been reordered for the resident.

Based on observation and record review, the facility failed to ensure medication error rate of less than 5% during medication administration for two (#153 and #35) of three sampled residents observed during medication pass. The facility had two errors out of 35 opportunities, resulting in a 5.71% medication error rate. The DON identified 50 residents received medications. Findings: 1. Resident #153 had a physician's order for aspirin 81 mg to be administered daily. 2. Resident #35 had a physician's order for Invokana 100 mg two tablets one time a day. On 04/06/22 at 7:27 a.m., LPN #1 was observed to prepare medication for resident #153. She stated that the aspirin was not in the facility. At 7:43 a.m., LPN #1 was observed to prepare medication for resident #35. She was observed to administer Invokana one tablet to the resident. The medication administration observation error rate was calculated to be 5.71%.