**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a dignified experience by ensuring a catheter bag that was in view of staff, visitors and residents was placed in a privacy bag for one of one resident (R25) reviewed for indwelling urinary catheter use. This had the potential to affect residents who require a catheter. Findings include: Review of R25's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE]. During an observation on 04/08/25 at 10:27 AM and on 04/09/25 at 1:05 PM, R25 was lying in bed with the indwelling urinary catheter bag hanging on the right side of the bed visible from the door. During an interview on 4/09/25 at 1:12 PM, Certified Nurse Aide (CNA)2 said it was the CNAs who placed the indwelling urinary catheter bag in a privacy bag when the resident left the room. But she stated it was a dignity issue when people can see it from the hallway and stated R25 was clearly seen from the hallway. During an interview on 04/10/25 at 9:59 AM, the Assistant Director of Nursing (ADON) said that typically during the day when the resident was in their room they did not put in a privacy bag on the catheter. But when they came out of their room they had a leg bag that was covered by clothing, During an interview on 04/10/25 at 2:46 PM, the Director of Nursing (DON) said that a indwelling urinary catheter bag should have been covered while they are in their room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update a care plan for a resident who had a change in their skin condition for one of one resident (Resident (R) 24) reviewed for accident hazards. This deficient practice has the potential to affect residents who have a change in their plan of care. Findings include: Review of R24's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis of dementia. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/25/25 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderate cognitively impaired. Review of R24's Care Plan dated 08/19/24 and located in the EMR under the Care Plan tab revealed no skin conditions related to fragile or edematous skin. Review of R24's Nurse's Note dated 03/03/25 and located in the EMR under the ''Notes'' tab written by Licensed Practical Nurse (LPN) 1 revealed, while writer and CNA [Certified Nurse Aide ] were assisting resident with transferring from the bed to the weight chair, this writer placed resident's right leg onto the foot pedal of the weight chair and a skin tear resulted to the right inner shin (ankle) area. 3cm [centimeter] by 3cm by 1cm skin Review of R24's skin assessment dated 03/03/25 revealed a skin tear to the right shin 3cm x 3cm x 0.1depth. During an interview on 04/09/25 at 7:19 PM, LPN1 stated she along with CNA3 were transferring R24 to the weight chair. She said that R24's leg was already edematous and when she picked up her leg, her hand just sunk into her leg. She said that when she touched her leg it just opened. She did not remember R24's leg hitting or touching anything during the transfer. During an interview on 04/10/25 at 9:42 AM, the Assistant Director of Nursing (ADON) stated she did not know exactly the injury occurred during the transfer but thinks it was just a result of thin skin. She said that R24's skin was fragile. The ADON confirmed R24's care plan had not been revised with some new interventions about handling residents with fragile skin while providing care. During an interview on 04/10/25 at 2:33 PM, the Director of Nursing (DON) said anytime an injury occurs when staff were proving care they should be looking at the care plan interventions and seeing what changes need to be made to the plan of care. The DON agreed there should be new interventions to R24's skin care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure a residents' safety during a transfer after Resident (R)24 sustained a laceration to her leg during a transfer that resulted in a skin tear. This had the potential to affect residents who required staff assistance during transfers. Findings include: Review of the facility's policy titled Safe Lifting and Movement of Residents dated 2001 revealed that in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Review of R24's Face Sheet located in resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/25/25 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderate cognitively impaired. Review of R24's Care Plan dated 08/19/24 and located in the residents' EMR under the Care Plan tab revealed no identified concerns with skin conditions related to fragile or edematous skin. Review of R24's Daily Charting revealed R24 assist/transfer was one person with no device. Review of R24's Nurse's Note dated 03/03/25 and located in the EMR under the ''Notes'' tab written by Licensed Practical Nurse (LPN) 1 revealed, while writer and CNA [Certified Nurse Aide] were assisting resident with transferring from the bed to the weight chair, this write placed resident's right leg onto the foot pedal of the weight chair and a skin tear resulted to the right inner shin (ankle) area, 3cm [centimeter] by 3cm by 1cm skin tear was cleansed with wound cleanser. Review of R24's Skin assessment dated 03/03/25 revealed a skin tear to the right shin 3cm x 3cm x 0.1depth. Review of R24's Incident Report dated 03/03/25 written by LPN1 and signed closed by Assistant Director of Nursing (ADON) revealed while this writer and CNA were transferring resident into weight chair, this writer placed hand on resident's leg to assist her with putting her leg onto footrest and a skin tear occurred. During an interview on 04/09/25 at 7:19 PM, LPN1 stated she along with CNA3 were transferring R24 to the weight chair. She said that R24's leg was already edematous and when she picked up her leg, her hand just sunk into her leg. She said that when she touched her leg it just opened. She did not remember R24 leg hitting or touching anything during the transfer. She was unable to explain further how the injury occurred. During an interview on 04/10/25 at 8:55 AM, CNA3 said on 03/03/25 R24 was already on the edge of the bed with her legs hanging over bed and LPN1 was in the process of trying to transfer her. She said this was the first time she ever assisted with a transfer for R24. She said she used her gait belt and put it around R24's waist while LPN1 had her legs and feet. She was standing behind the weight chair, and once they had the resident onto the chair, LPN1 was moving her feet and CNA3 observed blood on the floor. She asked what happened, and LPN1 told her R24's leg went up and she got a skin tear. CNA3 said LPN1 did not explain what or how it happened exactly. CNA3 stated that during a transfer staff should not need to grab a resident's legs with their hand and would only need to place their hand gently on the back of the resident's legs and help guide their legs onto the bed or into a chair. During an interview on 04/10/25 at 9:42 AM, the ADON stated she did not know exactly how the injury occurred during the transfer but thinks it was just a result of thin skin. She said that R24 had skin that was fragile. She was unable to remember what the nurse stated happened during the transfer because she did not get a statement or ask the staff to write anything down. She said she was not sure if there was a technique error. The physician was made aware and had no concerns. She also said she did not inservice staff about transfers or handling residents with fragile skin after the incident. During an interview on 04/10/25 at 2:33 PM, the Director of Nursing (DON) stated that anytime an injury occurs when staff are providing care, staff should be talking with residents and staff to try to figure out what occurred. She was aware that R24 sustained an injury during a transfer, but she was unsure how exactly the injury occurred. But she expected staff to do an investigation to try and determine the cause.

Based on observation, document review, interview, and policy review, the facility failed to ensure staff were taking meal temperatures to ensure they were served at safe temperatures before each meal was served. This had the potential to affect all residents who consumed food from the kitchen. Findings include: Review of the facility ' s policy titled Food Preparation and Service dated 2001 revealed that Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Proper hot and cold temperatures are maintained during food distribution and service. Foods that are held in the temperature danger zone are discarded after 4 hours. The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff. Observation on 04/09/25 at 5:00 PM of the tray line revealed there was no documentation that food temperatures had been taken at that time. Review of the food temperature logs provided by the Dietary Manager (DM) revealed for the time period from 01/01/25 until 04/10/25 revealed temperatures were not documented for all three meals or all the hot food items prepared for each meal. During an interview on 04/09/25 at 5:15 PM the DM said food temperatures were not being taken consistently. She said she had taken them prior to them serving but had not written them down yet. During an interview on 04/10/25 at 2:19 PM, the Director of Nursing (DON) said she expected that foods temperature was obtained and served at the appropriate temperature before it left the kitchen and was served to residents. She was not aware of any concerns. During an interview on 04/10/25 at 2:23 PM, the Administrator stated he expected that staff would take the temperature of foods to ensure that residents were served food at safe temperatures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of facility policy, the facility failed to prepare and administer medications according to the pharmacy label and as ordered by the physician for 1 of 27 observed opportunities during medication administration. Specifically, Registered Nurse (RN)1 crushed and administered an extended-release medication, a significant med error, which placed Resident (R)25 at risk for complications of a rapid release of potassium into the stomach and bloodstream. Findings include: Review of a Policy Statement, revised April 2018, documented, Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders .1. The medical director and director of nursing services, in conjunction with the consultant pharmacist, shall identify appropriate indications and procedures for crushing medications. Review of R25's Detailed Summary documented R25 was admitted to the facility on [DATE] with diagnoses that included but was not limited to; congestive heart failure and hypokalemia (low level of potassium in the blood). Review of R25's Physicians Orders documented an order dated 07/06/23 . May give meds crushed/whole in applesauce per pharmacy or physician order, except time released .Klor-Con M20 mEq tablet, extended release [Potassium chloride]- 1 TAB by mouth Once daily for abnormal finding of blood chemistry. Review of a red sticker on the pharmacy label for R25's Klor-Con medication, located in the medication cart, documented . Do not chew or crush before swallowing. Review of an undated document titled Medications Not To Be Crushed located in the narcotic notebook on the medication cart, documented potassium chloride .Klor-Con. During an observation on 07/26/23 at 8:30 AM, revealed RN1 poured R25's morning medications, including potassium Cl (chloride) ER (extended release) 20 MEQ (milliequivalents), into a medicine cup then proceeded to place it into a sleeve and crush. This Surveyor advised RN1 to double check to ensure all the medications could be crushed. RN1 said it was not necessary as the computer would alert her if the medication could not be crushed. RN1 put the crushed medications into yogurt and administered to R25. During an interview on 07/26/23 at 10:00 AM, RN1 confirmed the potassium extended-release medication should not have been crushed. During a phone interview on 07/26/23 at 11:22 AM, the Staff Pharmacist said the most immediate effect of the crushed extended-release potassium could be irritation to the throat or esophagus. The Staff Pharmacist said the resident could also experience a rapid heartbeat due to a quick release of potassium into the blood stream. The Staff Pharmacist said all medications that cannot be crushed have a red alert sticker on the pharmacy label and each of the medication carts had an extensive list of medications that should not be crushed. During an interview on 07/26/23 at 11:35 AM, R25 said she has never had throat irritation, upset stomach, or rapid heartbeat after taking morning medications.

Based on observation, interview and record review, the facility failed to ensure accurate labeling and dating of foods and removal of expired foods from the Production Cooler. Findings include: Review of facility policy titled, Policy & Procedure Manual: Food Storage revealed Refrigerated food storage:. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed for their safe use by dates, or frozen (where applicable), or discarded. During observation on 07/25/23 at 11:19 AM, the Production Cooler contained opened, unlabeled cream cheese and two pieces of unlabeled cheese. There were 7 pieces of expired Boursin Garlic and Fine Gourney Cheese 5.2 pounds that had an expiration date of 05/2023. There was one expired 5-pound container of pimento spread with an expiration date of 06/03/23. Interview on 07/25/23 at approximately 12:11 PM with the Certified Dietary Manager (CDM), revealed storage and labeling duties are completed by the receiver and all staff that utilize the storage areas. Interview on 07/25/23 at approximately 12:15 PM with the Executive Chef revealed, the receiver is responsible for receiving items, dating items, and rotating items. All staff that uses the storage area are responsible for rotating and discarding items. Interview on 07/26/23 at 11:21 AM with the Receiver revealed they are responsible for receiving incoming items, rotating items, updating items, and discarding expired and spoiled items. When items are in storage, and they are not dated, he puts the date that he sees the items. Staff from different areas utilize the storage area as well, and therefore some of those staff maybe not be labeling the items.