**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess the resident for risk of entrapment from bed rails prior to installation and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 6 of 12 (Residents #1, #5, #6, #7, #20 and #40) residents reviewed for bed rails. The facility failed to assess Residents #1, #5, #6, #7, #20 and #40 for entrapment from bed rails or obtain documentation of informed consent before using bed rails on the residents' beds. This failure could place residents at risk of injury from entrapment. Findings include: 1. Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia, lack of coordination, muscle weakness, fatigue (extreme tiredness), cognitive communication deficit (difficulty communicating due to cognitive impairment), difficulty in walking, attention and concentration deficit, abnormalities of gait and mobility, anxiety disorder, and Alzheimer's disease. Record review of Resident #1's significant change MDS assessment, dated 07/01/25, reflected a BIMS score of 99, which indicated he could not complete the assessment. It reflected he was not able to roll left to right in his bed and was not able to go from sitting to lying in his bed. Record review of Resident #1's care plan, dated 09/03/24, reflected the following: [Resident #1] has an ADL self-care performance deficit r/t Confusion, impaired balance, impaired mobility, other abnormalities of gait and mobility. [Resident #1] will receive assistance as needed with ADLs and transfers through review period. Record review of the clinical admission evaluation for Resident #1, dated 08/01/24, reflected no section related to risk of entrapment from bed rails. Record review of all assessments and evaluations for Resident #1, from 08/01/24 to 08/07/25, reflected no assessment for risk of entrapment from bed rails. Record review of all informed consent documents for Resident #1 from 08/01/24 to 08/07/25, reflected no consent for the use of bed rails. 2. Record review of Resident #5's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included abnormalities of gait and mobility, lack of coordination, muscle weakness, cognitive communication deficit (difficulty communicating due to cognitive impairment), attention and concentration deficit, fatigue (extreme tiredness), need for assistance with personal care, and depression. Record review of Resident #5's quarterly MDS assessment for Resident #5, dated 05/22/25, reflected a BIMS score of 99, which indicated she was unable to complete the assessment. It reflected she required supervision or touching assistance with rolling left to right in her bed and partial/moderate assistance with sitting on to lying in the bed. Record review of Resident #5's care plan, dated 03/01/25, reflected the following: [Resident #5] has an ADL self-care performance deficit r/t activity intolerance, impaired balance, musculoskeletal impairment. [Resident #5] will receive assistance as needed with ADLs and transfers through review period. Record review of Resident #5's clinical admission evaluation, dated 02/12/25, reflected no section related to risk of entrapment from bed rails. Record review of all assessments and evaluations for Resident #5, from 02/12/25 to 08/07/25, reflected no assessment for risk of entrapment from bed rails. Record review of all informed consent documents for Resident #5, from 02/12/25 to 08/07/25, reflected no consent for the use of bed rails. 3. Record review of Resident #6's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included neurocognitive disorder with Lewy bodies (dementia caused by protein deposits in the brain), psychotic disorder with delusions, anxiety disorder, abnormal posture, bipolar disorder, Alzheimer's disease, major depressive disorder, neuroleptic-induced parkinsonism (symptoms similar to Parkinson's disease such as tremors and muscle stiffness, brought on by use of antipsychotic medication), need for assistance with personal care, fatigue (extreme tiredness), cognitive communication deficit (difficulty communicating due to cognitive impairment), lack of coordination, abnormalities of gait and mobility, and muscle weakness. Record review of Resident #6's quarterly MDS assessment, dated 07/22/25, reflected a BIMS score of 13, which indicated intact cognition. Resident #6 required substantial/maximal assistance moving from left to right in her bed and moving from a seated to a lying position in her bed. Record review of Resident #6's care plan, dated 02/01/25, reflected the following: [Resident #6] is at risk for falls r/t Parkinson's, Imbalance, weakness. [Resident #6] will not have major or minor injury r/t a fall thru review date. Record review of Resident #6's clinical admission evaluation, dated 01/20/23, reflected no section related to risk of entrapment from bed rails. Record review of all assessments and evaluations for Resident #6, from 01/20/23 to 08/07/25, reflected no assessment for risk of entrapment from bed rails. Record review of all informed consent documents for Resident #6 from 01/20/23 to 08/07/25 reflected no consent for the use of bed rails. 4. Record review of Resident #7's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, gastrotomy status (surgical presence of a feeding tube into the digestive system), cognitive communication deficit (difficulty communicating due to cognitive impairment), fatigue (extreme tiredness), lack of coordination, anxiety disorder, muscle weakness, abnormalities of gait and mobility, and dementia. Record review of Resident #7's quarterly MDS assessment, dated 06/12/25, reflected a BIMS score of 0, which indicated severely impaired cognition. Resident #7 was completely dependent on staff to assist him with rolling left to right in his bed and did not go from sitting to lying in his bed. Record review of Resident #7's care plan, dated 07/08/25, reflected the following: Resident is at risk for falls r/t Imbalance, weakness, confusion. Resident will not have major or minor injury r/t a fall thru review date. Record review of Resident #7's clinical admission evaluation, dated 05/20/20, reflected no section related to risk of entrapment from bed rails. Record review of all assessments and evaluations for Resident #7, from 05/20/20 to 08/07/25, reflected no assessment for risk of entrapment from bed rails. Record review of all informed consent documents for Resident #7, from 05/20/20 to 08/07/25, reflected no consent for the use of bed rails. 5. Record review of Resident #20's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included muscle weakness, dementia, major depressive disorder, insomnia, hemiplegia (paralysis on one side of the body), speech and language deficits, difficulty in walking, hallucinations, history of falling, and dependence on wheelchair. Record review of Resident #20's quarterly MDS assessment, dated 05/15/25, reflected a BIMS score of 08, which indicated severely impaired cognition. It reflected she was independent in rolling form left to right and going from sitting to lying in her bed. Record review of Resident #20's care plan, dated 03/13/25, reflected the following: [Resident #20] has an ADL self-care performance deficit r/t Dementia, Hemiplegia. [Resident #20] will receive assistance as needed with ADLs and transfers over the next 90 days. Record review of Resident #20's clinical admission evaluation, dated 03/01/24, reflected no section related to risk of entrapment from bed rails. Record review of all assessments and evaluations for Resident #20, from 03/01/24 to 08/07/25, reflected no assessment for risk of entrapment from bed rails. Record review of all informed consent documents for Resident #20, from 03/01/24 to 08/07/25, reflected no consent for the use of bed rails. 6. Record review of Resident #40's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included difficulty in walking, lack of coordination, muscle weakness, cognitive communication deficit (difficulty communicating due to cognitive impairment), fatigue (extreme tiredness), need for assistance with personal care, fibromyalgia (condition causing widespread body pain), lack of coordination, abnormalities of gait and mobility. Record review of Resident #40's admission MDS assessment, dated 05/15/25, reflected a BIMS score of 99, which indicated she could not complete the assessment. Record review of Resident #40's care plan, dated 04/23/25, reflected the following: [Resident #40] has an ADL self-care performance deficit r/t activity intolerance, Confusion, [Resident #40] will receive assistance as needed with ADLs and transfers through review period. impaired mobility, pain. Record review of Resident #40's clinical admission evaluation, dated 02/10/21, reflected no section related to risk of entrapment from bed rails. Record review of all assessments and evaluations for Resident #40, from 04/09/24 to 08/07/25, reflected no assessment for risk of entrapment from bed rails. Record review of all informed consent documents for Resident #40, from 04/09/24 to 08/07/25, reflected no consent for the use of bed rails. Observation on 08/05/25 at 10:00 AM revealed Resident #7 lying in bed with his covers pulled to his chest, his call button was in reach, and a peg tube connected to a feeding machine. He did not respond to efforts to interview him. His bed was furnished with 27-inch plastic side rails. Observation and interview on 08/05/25 at 10:22 AM revealed Resident #6 lying in her bed with the head of bed elevated, bed in low position, and a fall mat next to her bed. There were 27-inch plastic side rails affixed to both sides of the bed. Resident #6 stated she sometimes used the rails to move around in her bed and had never been stuck in them. She stated the facility had not talked with her about the risks and benefits of side rails. Observation and interview on 08/05/25 at 10:40 AM revealed Resident #5 seated in her wheelchair next to her bed. There were 27-inch plastic side rails affixed to both sides of the bed. She stated she did not use the rails very often and had never sustained any injuries from them. She stated she could not recall anyone from the facility discussing the risks and benefits of side rails with her. Observation on 08/05/25 at 11:02 AM revealed Resident #1 seated in his geriatric chair (specialized piece of medical equipment designed for individuals with mobility challenges, particularly the elderly) in the common area. He did not respond to efforts to interview him. Observation in his room revealed his bed was furnished with 27-inch plastic side rails. Observation and interview on 08/05/25 at 12:47 PM revealed Resident #40 seated in her wheelchair in her room having lunch next to her bed. There were 27-inch plastic side rails affixed to both sides of the bed. She stated she did not know what the side rails were for and had not noticed them. When asked if anyone from the facility had discussed the risks and benefits of side rails, she would not or could not answer and seemed confused by the question. During an interview on 08/05/25 at 12:47 PM, the private caregiver for Resident #40 stated she had never witnessed or heard about Resident #40 being injured or trapped by the side rails. She stated the facility and Resident #40's other caregivers were good at communicating any problems, so she thought she would have been notified if something like that had happened. Observation and interview on 08/05/25 at 03:04 PM revealed Resident #20 seated in a wheelchair next to her bed, which was furnished with 27-inch side rails. She stated she had never had any problems with the side rails. She stated she used them regularly to get in and out of bed and reposition herself. An attempt was made to speak with a FM for Resident #1 on 08/07/25 at 01:15 PM. A voicemail was left, but contact was not returned. During an interview on 08/07/25 at 11:33 AM, the ADON stated she had been in her position for eight months. She stated her understanding of what was required to install side rails on a resident bed was the resident should be able to get around them and not be stuck in the bed. She stated she went over the consents for all residents with side rails, and some residents had consents while others did not. She stated they had thought there was an entrapment assessment included in the clinical admission document, but it was not there. She stated she had not conducted any entrapment risk assessments herself, but the procedure was supposed to be when a new resident came in, the admitting nurse should have assessed their need for side rails and ensured their safety for the resident. She stated specifically, they needed to ensure there was no risk of the resident becoming trapped. The ADON stated the admitting nurse was responsible for completing the assessments and obtaining consents from the family, but the person responsible for oversight in that process was a unit manager who was on leave. She stated a potential negative impact on not assessing for entrapment or obtaining informed consent was the resident could become trapped and some had even suffocated in other facilities. She stated it could also take away their rights to do what they wanted if the rails kept them from getting out of bed. During an interview on 08/07/25 at 12:02 PM, the MAINT stated he was not the director of maintenance but was in charge while the director was out. He stated he did mock surveys once a month and part of that was checking the side rails on every bed. He stated he did document those checks sometimes, but he was not sure if he still had copies of them. He stated he would look for the copies and provide them if he found them. He stated he had not looked at the bed rail policy and did not know it stated he should be providing documentation of his bed rail checks to his administrator. He stated he had not done that. He stated he really only checked to make sure the bed rails were in good repair. He stated he had not found any in many months that were broken or needed maintenance. He stated he did not know anything about assessing for risk of entrapment but thought it would be important to make sure the residents did not fall out of their beds. During an interview on 08/07/2025 at 01:29 PM, the ADM stated his expectation was during the admission process the nurses would visit with the resident's family on the bed rails and determine if they were wanted. He stated their goal was to have the small assistive bars to help residents pull themselves up and move around in the bed. He stated they should have been assessing for entrapment and obtaining consents on the side rails during the admission process. He stated he had looked into consents and found a few for other residents, but for the most part, they did not have any on file. He stated the people responsible for ensuring the facility was compliant with bed rails were the ADON and DON. He stated the DON was on leave and unable to be reached by phone due to being in a no cell service area. He stated a potential negative impact of not conducting an assessment for entrapment risk or obtaining informed consent from the resident was a resident who did not need an assistive rail could be injured or have another adverse event. Record review of the facility's policy, dated August 2022, and titled Bed Safety and Bed Rails reflected the following: Policy statementResident beds meet the safety specifications established by the hospital bed safety work group. The use of bed rails is prohibited unless the criteria for use of bed rails have been met.Policy interpretation and implementation1. The resident's sleeping environment is evaluated by the interdisciplinary team.2. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment.6. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems, including potential entrapment risks.7. The maintenance department provides a copy of inspections to the administrator and report results to the QAPI committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee.Use of bed rails4. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted.5. If attempted alternatives, do not adequately meet the residence needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes:A. An evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident needsB. The resident's risk associated with the use of bed rails;C. Input from the resident and/or representative; andD. Consultation with the attending physician.6. The resident assessment to determine risk of entrapment includes, but is not limited to:A. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms;B. Size and weight;C. Sleep habits;D. Medication(s);E. Acute medical or surgical interventions;F. Underlying medical condition;G. Existence of delirium;H. Ability to toilet self safely;I. Cognition;J. Communication;K. Mobility in and out of bed; andL. Risk of falling.7. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following:A. accident hazards:(1) the resident could attempt to climb over, around, between, or through the rails, or over the footboard; and/or(2) A resident or part of his/her body could be caught between the [NAME], the opening of the rails, or between the bed rails and mattress8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consentA. The assessed medical needs that will be addressed with use of bed rails;B. The resident's risks from the use of bed rails, and how these will be mitigated;C. The alternatives that were attempted, but failed to meet the residence needs; andD. The alternatives that were considered, but not attempted and the reasons.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 3 kitchens (main kitchen) reviewed for food safety. 1. The facility failed to ensure the ED and DRM wore a hair restraint while in the kitchen on 08/05/25. 2. The facility failed to ensure the DM wore gloves while preparing prepared ham sandwiches in the kitchen. These failures could place residents at risk of food-borne illness. Findings include: 1. Observation on 08/05/25 at 09:20 AM revealed the ED, who had short hair, and the DRM, who had shoulder length hair, standing in the kitchen and speaking to the cooks. Neither of them wore a hairnet or hair restraint. They both walked out of the kitchen and the DRM returned less than a minute later with a hairnet on. During an interview on 08/05/25 at 09:27 AM, the DRM stated she was required to wear a hairnet in the kitchen. She stated she did not know why she was in the kitchen not wearing one. She stated she was in a hurry and forgot to apply the hairnet. She stated residents could have gotten hair in their food. 2. Observation on 08/05/25 at 11:12 AM revealed the DM on the food preparation line making several ham sandwiches at once. He was handling bread, lettuce, and deli ham with his bare hands and not wearing gloves. He said out loud as if to himself, That's how you know the rookie is on the line. I'm not a chef! He then washed his hands, retrieved and donned gloves, and resumed his food preparation. During an interview on 08/06/25 at 12:20 PM, the LD stated all staff needed to wear hairnets when they entered the kitchen. She stated this was because they did not want hair falling into the food. She stated the DM and all staff who prepared food were to wear gloves while handling the food. She stated the purpose of wearing gloves was to prevent bacteria from going into the food and making residents sick. She stated she performed audits in the kitchen to ensure compliance, and if she saw noncompliance with food safety rules, and in-serviced the staff if she saw issues, but she had not done training with the ED, the DRM or the DM. During an interview on 08/14/25 at 01:01 PM, the DM stated he had been the manager of the facility kitchen for about two and a half years. He stated the kitchen served both the assisted living and the nursing facilities in the building. He stated he had done the food safety training courses and knew he was supposed to wear gloves while handing food directly. He stated he knew better than to try to do 800 things at once and had overlooked putting gloves on as a result. He stated his expectation was all staff wore hairnets in the facility kitchen. He stated the potential negative impacts to residents of his failure was cross contamination and food borne illnesses and even contamination with his own blood if he were to cut himself. He stated he did not provide any training for the ED, because the ED was his boss and had been at the facility for something like 30 years. He stated he worked for a contracted entity, and it would not have been appropriate for him to train the ED. He stated he did train the DRM to wear hairnets in the kitchen. He stated he had been somewhat concerned about some of the activities personnel and volunteers performing food service tasks and thought it would be a good idea to broaden their in-service audience. During an interview on 08/07/2025 at 01:29 PM, the ADM stated his expectation was any staff in the kitchen should have worn a proper hair restraint and staff should have worn gloves during food preparation. He stated he ensured that happened by making random rounds through the kitchen and by running around the facility all the time and looking at what was going on. He stated the responsibility for oversight on food safety compliance was on the dining and kitchen supervisor. He stated the potential negative outcome of breaches in food safety was poor sanitation. Record review of the facility's policy, dated January 2025, and titled Uniform Dress reflected the following: Policies: personal cleanliness and need appearance are essential for the food service worker. In addition to this policy, associates must follow facilities appearance guidelines.Procedures:Associates working with foodWhere the approved hair restraint when on duty, regardless of length or presence of hair. The only exception is to remove hair restraints when delivering trays to patients/residents. Record review of the facility's policy, dated January 2024, and titled Disposable Glove Use reflected the following: Policies: disposable, non-latex gloves must be warm at the following times:When handling ready to eatIn most cases, when serving food or assembling patient meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater when the facility had a medication error rate of 36.36% based on 16 errors of 44 opportunities, which involved 2 of 5 residents (Resident #8 and Resident #10) observed during medication administration. 1. The facility failed to hold Resident #10's medication due to low heart rate. 2. The facility failed to ensure Resident #8's extended release (ER) medications were not crushed and the resident received the full dose of her medications. These failures could place residents at risk of unwanted side effects and not receiving therapeutic dosage of medications. Findings include: 1.Review of Resident #10's face sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), thrombocytopenia (low platelet levels), bradycardia (heart rate lower than 60 beats per minute), hypertension (elevated blood pressure) and edema (build-up of fluid in the body's tissues). Review of Resident #10's Quarterly MDS assessment, dated 06/19/2024, reflected a BIMS score of 99 indicating resident was unable to complete the assessment. Review of Resident #10's physician orders reflected the order for Metoprolol (heart medication for blood pressure, which can lower heart rate) 50mg daily, hold for heart rate less than 60. Observation on 07/24/2024 at 07:11 AM revealed LVN A check the vital signs for Resident #10 (HR 54, BP 141/62 ) LVN A then crushed and administered Metoprolol 50mg via PEG tube for Resident #10 when his heart rate was 54. In an interview on 07/24/2024 at 09:25 AM, LVN A stated the Nurse Practitioner verbally told her (date/time unknown) to give Resident #10's metoprolol dose if the HR was above 50. LVN A acknowledged the current order in the chart reflected hold for heart rate less than 60 and she should have had the order changed before administering the medication. LVN A acknowledged the potential for adverse effects such as the heart rate dropping too low. 2. Review of Resident #8's Face Sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of type 2 diabetes (condition in which the body has trouble regulating blood sugar), atrial fibrillation (irregular, often very rapid heart rhythm), history of cerebral infarction (stroke), speech and language deficits, and dementia (a group of symptoms affecting memory, thinking and social abilities). Review of Resident #8 's Comprehensive MDS assessment, dated 03/07/2024, reflected a BIMS score of 10 indicating moderate cognitive impairment. MDS further reflected resident requires some partial assistance with functional abilities. Review of Resident #8's Comprehensive Care Plan reflected a problem with resident refusing medications at times, dated 07/24/2024. Interventions included to find out why resident refused and adjust scheduling to encourage a positive outcome. Care Plan also reflected resident had a problem with hypertension (high blood pressure) and heart disease, dated 03/13/2024, and should have anti-hypertensive medications and cardiac medications administered as ordered. Observation on 07/24/2024 at 07:37 AM, MA B administered medications to Resident #8. MA B crushed all 12 of the medications (Eliquis, Sodium Bicarb, Aspirin, Vit B-12, Glipizide ER, Metformin, Amlodipine, Bupropion ER, Farxiga, Folic Acid, Metoprolol ER, and Finerenone) and mixed them together with one spoonful of pudding in a small cup. Resident #8 was able to swallow one bite of medications with the pudding. When MA B gave Resident #8 the second bite followed by a sip of water, she held the pudding/medications in her mouth and then spit them out into a cup. Resident #8 received approximately half of the medications. MA B documented in the chart that the resident only received half of her medications and notified LVN A. In an interview on 07/24/2024 at 09:45 AM, MA B stated she always crushes Resident #8's medications and mixes them together with pudding. MA B stated the resident often refuses her medications and the doctors are aware she does not get them all the time. MA B further stated she always charts when Resident #8 refuses or does not receive all of her medications. In an interview and observation on 07/24/2024 at 12:30 PM, Resident #8 stated she usually takes her medications crushed. Resident #8 stated she never receives any of her medications whole. Resident #8 stated she was having difficulty swallowing the medications this morning, so she spit them out. Resident #8 was observed sitting up in chair watching television with no signs of acute distress. In an interview on 07/25/24 at 02:55 PM, DON stated the MAs sometimes crush the medications and mix them together, it just depends on the resident and the situation . The DON stated for residents that sometimes spit out the medication, it would be better to administer the critical ones separately to ensure they know how much and which ones the resident actually received. The DON stated she would expect staff to follow the orders in the chart because you can't verify verbal orders. In an interview on 07/25/24 at 03:27 PM, Administrator stated a pharmacy consultant comes in monthly and reviews medication administration and reports any errors and also provides training to the staff. The Administrator stated he expects the staff to follow the orders as written and the order for Resident #10's Metoprolol should have been changed to reflect the appropriate holding parameters prior to administering the medication. Review of training records dated 02/14/2023 reflect MA B was trained on medication administration and proper technique for crushing medications. Review of Adverse Consequences and Medication Errors facility policy, dated 2001, reflected a medication error defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its residents were free of any significant medication errors for one (Resident #8) of five residents reviewed for significant medication errors. The facility failed to ensure Resident #8's extended release (ER) medications, including Glipizide 2.5mg ER, Bupropion 300mg ER, and Metoprolol Succinate 50mg ER were not crushed prior to administration and that Resident # 8 received the full dose of her medications. These failures could place residents at risk of unwanted side effects, not receiving therapeutic dosage of medications, and ineffective disease management. Findings include: Review of Resident #8's Face Sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of type 2 diabetes (condition in which the body has trouble regulating blood sugar), atrial fibrillation (irregular, often very rapid heart rhythm), history of cerebral infarction (stroke), speech and language deficits, and dementia (a group of symptoms affecting memory, thinking and social abilities). Review of Resident #8's Comprehensive MDS assessment, dated 03/07/2024, reflected a BIMS score of 10 indicating moderately cognitive impairment. MDS further reflects resident requires some partial assistance with functional abilities. Review of Resident #8's Comprehensive Care Plan reflected a problem with resident refusing medications at times, dated 07/24/2024. Interventions included to find out why resident refused and adjust scheduling to encourage a positive outcome. Care Plan also reflected resident had a problem with hypertension (high blood pressure) and heart disease, dated 03/13/2024, and should have anti-hypertensive medications and cardiac medications administered as ordered. Observation on 07/24/2024 at 07:37 AM, MA B administered medications to Resident #8. MA B crushed all 12 of the medications, including 3 extended-release tablets (Glipizide 2.5mg ER (for diabetes), Bupropion (antidepressant) 300mg ER and Metoprolol Succinate 50mg ER (heart medication for blood pressure control), and mixed them together with one spoonful of pudding in a small cup. Resident #8 was able to swallow one bite of medications with the pudding. MA B gave her the second bite followed by a sip of water, Resident #8 held the pudding/medications in her mouth and then spit them out into a cup. Resident #8 only received approximately half of the medications. MA B documented in the resident electronic medical chart that Resident #8 only received half of her medications and notified LVN A. In an interview on 07/24/2024 at 09:25 AM, LVN A stated that MA B should not have crushed the ER tablets because Resident #8 would get a large dose at one time which could drop her blood pressure. LVN A stated she was told by MA B that she administered the ER tablets whole with pudding and crushed the rest because Resident #8 pockets the tablets if they are not crushed. In an interview on 07/24/2024 at 09:45 AM, MA B stated she always crushes Resident #8's medications and mixes them together with pudding. MA B stated she normally crushes the extended-release tablets. MA B said she should not have crushed the ER tablets. In an interview on 07/24/24 at 10:00 AM, the DON stated MA B should not have crushed the ER tablets for Resident #8 and they notified the pharmacist and the doctor and will monitor her throughout the day for any side effects , such as low heart rate, low blood sugar and low blood pressure. The DON provided a copy of a drug regimen review, dated 07/24/2024, from the pharmacist to the physician which reflected orders to change the ER tablets to immediate release tablets. The DON provided in-service training completed 07/24/2024 for MA B which reflected training regarding the negative outcomes that can occur by crushing ER medications. In an interview and observation on 07/24/2024 at 12:30 PM, Resident #8 stated she usually takes her medications crushed. Resident #8 stated she never received any of her medications whole. Resident #8 stated she was having difficulty swallowing the medications this morning, so she spit them out. Resident #8 was observed sitting up in chair watching television with no signs of acute distress. In an interview on 07/24/2024 at 02:00 PM, the Medical Director stated she was notified by several people from the facility regarding the ER medication error for Resident #8. The Medical Director was aware the ER tablets were crushed with all of the resident's medications and that she spit out most of them. The Medical Director stated the potential adverse effects of crushing ER tablets were, it essentially changes the ER to immediate release. No expected harm with the medications she received. The Medical Director stated her 3rd year medical resident was at the facility at the time of the incident and evaluated the resident with no concerns. The Medical Director stated she was at the facility around lunch time and checked on the resident as well with no adverse effects noted. She also stated the resident's primary physician, and the pharmacist were notified, and the orders were changed to immediate release tablets. The Medical Director stated the potential negative impact from switching medication was, there aren't really any, they just give the medication twice a day instead of once a day. She stated this has never happened before and usually the MA's are very proactive and notify her if the ER order needs to be changed. The Medical Director stated she was not aware of any adverse effects from medication errors in the facility in the last 6 months. In an interview on 07/25/24 at 03:10 PM, MA C stated the nurses and MAs are trained regularly on medication administration and the MAs have taken the medication administration course. She stated ER medications should not be crushed because the resident would receive all of the medication at one time and it should be released over a period of time. In an interview on 07/25/24 at 03:27 PM, the Administrator stated the ER medications should not be crushed because it takes away the extended-release action and could result in severe consequences to the resident. The Administrator stated a pharmacy consultant comes in monthly and reviews medication administration and reports any errors and also provides training to the staff. Review of Adverse Consequences and Medication Errors facility policy, dated 2001, reflected a medication error defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles. to include crushing a do not crush medication. Review of training records dated 02/14/2023, reflected MA B was trained on 02/14/2023 in medication administration and proper technique for crushing medications. Review of the Institute for Safe Medication Practices ISMR Long-Term Care Advise, dated 2017, reflected As a general principle, any tablet that is labeled extended-release or sustained release should not be crushed or split. This is because crushing or splitting will damage the tablets' properties, causing immediate release of a large dose of medication that would otherwise have been released over a longer period of time.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen reviewed for sanitation. The facility failed to discard of food products in the walk-in freezer that were past their facility indicated use by date. The facility failed to label and date food products in the walk-in freezer. The facility failed to clean their industrial can opener. These failures could place residents at risk of cross contamination, loss of nutritional value, and foodborne illness. Findings included: Observation on 07/23/2024 at 8:29 AM, of the facility's walk-in freezer revealed the following food products that were past their displayed use by date or were not labeled: 1 metal tray covered with plastic wrap that was labeled breaded cod, opened 07/14/24 at 5:55 PM and discard 07/17/24 at 5:55 PM. 1 metal tray labeled Fish, Salmon 6oz, opened 06/27/24 at 5:55 PM and discard 07/17/24 at 5:55 PM, which contained 38 individually wrapped pieces of fish. 1 plastic bag labeled Fish, Salmon Fillet Raw opened 07/05/24 at 6:20 PM and discard 07/08/24 at 6:20 PM. The bag contained small pieces of fish, some of which had visible ice crystals on them. 1 plastic wrapped food product labeled Pork opened 07/04/24 at 12:42 PM and discard 07/07/24 at 12:42 PM. 1 metal tray with 2 sealed plastic bags that contained what appeared to be chicken wings but had no identification label or dates on them. 1 metal tray with 2 plastic wrapped food products labeled, Veal, Liver Raw 07/18/24 at 3:06 PM and discard 07/21/24 at 3:06 PM. Observation on 07/23/2024 at 8:39 AM, of an industrial can opener mounted to a prep table at the back of the kitchen revealed a sticky substance on and around the cutting blade. Interview and observation on 07/23/2024 at 8:51 AM, the Dietary Manager stated the facility's refrigerators and freezers were supposed to be checked daily by the supervisors to ensure there were not out of date or expired food products present. The Dietary Manager checked the freezer and stated that the observed out of date items should have been discarded. The Dietary Manager stated even if they were incorrectly labeled their discard dates had been reached and they should not have been present. The Dietary Manager stated the two unlabeled plastic bags did contain chicken wings and that they should have been labeled as such with the date in and a discard by date. The Dietary Manager stated labeling of food in important to ensure that staff know what the food product is. The Dietary Manager stated failure to properly discard of expired food products could result in a resident getting sick, loss in nutritional value, and possible freezer burn. The Dietary Manager stated the industrial can opener is inspected and replaced by a company, but they should be cleaning it daily. The Dietary Manager stated failure to properly clean the industrial can opener could result in contamination. Interview on 07/23/2024 at 9:01 AM, the Chef stated their industrial can opener not being properly cleaned could lead to food product contamination. The Chef stated any food products in the facility's freezers and refrigerator that are past their use by date should be discarded immediately. The Chef stated that service of out-of-date food products could result in a loss of nutritional value, affect taste, and appearance. The Chef stated he and everyone who works in the kitchen is responsible for labeling and storage of food products and should ensure that out of date food products are discarded. Interview on 07/25/2024 at 8:30 AM, the Lead [NAME] stated items placed in the freezer needed to be labeled to identify the product as well as have the date in and a discard date. The Lead [NAME] stated the date to discard for frozen items can be different for them but that if it is past the displayed date it must be discarded. The Lead [NAME] stated everyone in the kitchen is responsible for ensuring that food products are properly labeled, dated, and discarded when past their use by date. The Lead [NAME] stated service of expired food products could result in a resident become sick or the food losing nutritional value. Follow-up interview on 07/25/2024 at 8:37 AM, the Chef stated he did not have an in-service training for labeling and storage he could provide but stated they do discuss it in morning meetings. Interview on 07/25/2024 at 3:14 PM, the Administrator stated he expects food products in the kitchen to be labeled and dated appropriately. The Administrator stated nothing should be present in the kitchen that is past the use by or manufacturer's expiration date. The Administrator stated even if a product was dated it error it should still be discarded because, better safe than sorry. The Administrator stated failures in labeling and storage could result in illness for a resident that consumes it. Review of the facility's Food Safety and Quality Assurance Standards Manual dated 10/01/2022 revealed, 5.3 DATING & LABELING OF FOOD IN PRODUCTION. Standard - All foods, including prepared items, bulk foods, frozen foods, and ingredients present in a [facility] must be labeled at all times. - [Facility] foods requiring a date mark shall be labeled with the common name, preparation date, discard date, and associate initials. 5.4 FOOD EXPIRATION & ROTATION. Stock must be rotated to ensure that older foods are used first, this method is often called FIFO or First In, First Out. Standard - Foods that have expired must be discarded and not used or served. This includes both manufacturer and unit-labeled food expiration dates on dry, refrigerated and frozen foods. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 1of 16 residents reviewed with limited range of motion (Resident #2), received appropriate treatment and services to prevent a decline in range of motion. The facility failed to ensure Resident #2 had interventions in place for her right- and left-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her right and left hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: Review of Resident #2's Face Sheet dated 06/02/2023 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Multiple Sclerosis (A disease that affects central nervous system. The immune system attacks the myelin, the protective layer around nerve fibers and causes Inflammation and lesions. This makes it difficult for the brain to send signals to rest of the body), Contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen), and Hypertension ( High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache). Review of Resident #2's Quarterly MDS dated [DATE] reflected Resident #2 was assessed to have a BIMS score of 1 indicating severe cognitive impairment. Resident #2 was assessed to require extensive assist with all ADLs. Resident #2 was further assessed to have limitation in range of motion for both upper extremities. Review of Resident #2's Comprehensive Care Plan (not dated) reflected a problem for limited physical mobility related to contractures. Interventions did not include palm protectors. Review of Resident #2's Consolidated Physician orders dated 06/02/2023 reflected no orders for contracture management or palm protectors. Observation on 05/30/2023 at 10:25 AM revealed Resident #2 in room in bed alert but confused. Resident #2 was observed to have contractures of her bilateral hands. Resident #2's right hand had tissue paper between her fingers and her palms. Resident #2's fingernails were long. Observation of Resident #2's left hand revealed her fingers curled into her palm. Resident #2's fingernails were long and digging into her palm. Resident #2 was not able to open her hand. Observation on 06/01/2023 at 1:00 PM revealed Resident #2 in room in bed. Observation of Resident #2's hand revealed no palm protectors in resident's hands and fingernails remained long. In an interview on 06/02/2023 at 10:01 AM LVN E examined Resident #2's hand and stated that Resident #2 hand was contracted, and Resident #2 should have palm protectors in place. LVN E further stated Resident #2's fingernails were long, and they were digging into her palms. LVN E stated Resident #2 needed her fingernails trimmed and palm protectors in place to prevent Resident #2 from getting skin breakdown in her hands. LVN E stated it was not only the responsibility of hospice staff, but the facility nurses and CNAs to ensure the care was provided for Resident #2 . In an interview on 06/02/2023 at 10:11 AM CNA F stated she was not aware of any devices for Resident #2's hands to treat Resident #2's contractures. CNA F stated, Resident #2's hands are contracted, I don't know why they do not have palm protectors for her, but they should . In an interview and observation on 06/02/2023 at 11:35 AM the DON stated hand rolls or palm protectors should be used for residents with contractures. After the DON reviewed Resident #2's care plan she stated there were no interventions listed for contracture devices . The DON stated the nurses are responsible for ensuring care is provided and to ensure nail care is done. The DON stated the residents' nails should have been trimmed because it could lead to pressure ulcers or infection. Review of the facility policy Resident Mobility and Range of Motion dated July 2017 reflected Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .the care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in one of one walk in refrigerator. The facility failed to label and date leftover, opened foods in the walk-in refrigerator in the kitchen. This failure could place the residents at risk of foodborne illness and decreased quality of life. Findings included: In an observation on 05/30/2023 at 10:05 AM in the main kitchen in the walk-in refrigerator revealed an uncovered rolling shelve with meat on metal trays not covered or dated; one full metal tray of barbeque chicken; one full metal tray of baked chicken, on metal tray with a pork tenderloin not covered, dated, or labeled. Further observation revealed a rolling shelve with metal trays with 4 pies on a rack not covered, dated, or labeled. In an interview on 05/30/2023 at 10:08 AM the Chef stated the chicken in the walk-in refrigerator was from the night before and the pork loin was cooked on 05/30/2023 and was cooling to be cut. The Chef stated the meat should be covered, dated, and labeled. He stated not labeling and dating the food could result in food being kept past the date it was safe. The Chef further stated the food not being covered could lead to contamination of the meat from airborne contaminates. The Chef stated the pies should also be dated, labeled, and covered. In an interview on 06/02/2023 at 9:40 AM the Director of Dinning Services (DDS) stated the meat and pies in the walk-in refrigerator should be dated and labeled and covered. The DDS stated failure to do so could lead to contaminated food or expired food being served to residents which could cause food borne illness. In an interview on 06/02/2023 at 11:35 AM the Administrator stated it was his expectation that food in the refrigerator be covered dated and labeled, the Administrator stated, it goes without saying, it is for the safety of the residents. Review of the facility policy Storage of Food and Supplies dated 12/15/2020 reflected .All food non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Cover, label and date .complete all sections on a universal date label .Refrigerated Foods .Cover foods stored on ladder/speed racks to prevent contamination from airborne contaminants as well as from dripping condensation. Either use a bag that covers the entire cart or cover each tray individually