Every finding on record at Crestview Retirement Community

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys to 1 of 2 medication carts (Medication Cart #1) reviewed for drug storage and labeling.The facility failed to ensure Medication Cart #1, was locked, medications secured, and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings included:During an observation on the left side at the end of 100 hall on 06/21/2026 at 9:18 a.m., revealed Medication Cart #1 was unlocked. Med Aide B exited a room at approximately 9:23 a.m. on 100 hall and walked to Medication Cart #1. No nursing staff were observed near Medication Cart #1 on 06/21/2026 at 9:18 a.m.During an interview with Med- Aide B on 06/24/2026 at 9:30 a.m., she stated she was trained on medication storage. She stated the Nurse or Medication Aide who was working on the cart was responsible for locking the medication cart. She stated if the staff left the medication cart unlocked and unattended a resident could get into the medication cart and take medication that did not belong to them. Med-Aide B stated everyone monitored to ensure the medication carts were locked. Med-Aide B stated she was unable to view Medication Cart #1 from where she was standing in a resident's room. She stated she had been in-serviced on locking medication cart; however, she did not recall the date or time. Med-Aide B did not respond to question of reason she left the Medication Cart #1 unlocked.During an interview with the Director of Nurses on 06/24/2026 at 3:00 p.m., she stated all medication carts were expected to be locked when the Med-Aide or Nurse was not standing in front of the medication cart. She stated the Nurse or the Medication Aide who was on the medication cart was responsible for ensuring the medication cart was locked. She stated if the medication cart was left unlocked and unattended a resident could get into the medication cart and take medications. The Director of Nurses stated leadership monitored to ensure staff locked the medication cart. She stated nurse leadership were to monitor by doing observations and in-service training. She stated she did not know why Med-Aide B left the medication cart unlocked.During an interview with the Administrator on 06/24/2026 at 4:00 p.m., he stated the medication cart was to always be locked. He stated the Nurse or Medication Aide who was assigned the medication cart was responsible for ensuring the medication cart was locked. The Administrator stated if the medication cart was left unlocked and unattended a resident could take medication that was harmful to them or an employee could steal medications. He stated the DON or any management should be monitoring, by observations, to ensure the staff were locking the medication cart. He stated he did not know why Med-Aide B left the medication cart unlocked.Record review of the Facility Policy on Security of Medication Cart, Revised on April 2007, reflected The medication cart shall be secured during medication pass. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. Medication carts must be securely locked at all times when out of the nurse's view.

Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure Resident #1 was free from abuse and neglect on 05/03/2026 when CNA A verbally abused Resident #1 and neglected to give care when Resident #1 requested assistance to the bathroom. This failure placed residents at risk of abuse, neglect, trauma, and psychosocial harm.Findings included: Review of Resident #1's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety (A group of symptoms that affects memory, thinking and interferes with daily life but the exact cause is not clearly identified. It falls between mild and severe dementia in terms of impact on independence and quality of life.), difficulty with walking (can be caused by physical injuries or underlying medical conditions.), need assistance with personal care ( a person may struggle to perform ADLs independently such as: bathing, grooming, toileting and dressing), and age-related osteoporosis without fracture (a person's bones have lost density and strength due to aging, increasing future fracture risk, even though no bones are currently broken). Review of Resident #1's admission MDS dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 15 which indicated her cognition was intact. She used a wheelchair or walker for mobility. Resident #1 required partial/moderate assistance (helper does less than half the effort) with the following: eating, oral hygiene, showers, toilet transfer (ability to get on and off the toilet) and personal hygiene. She required substantial/ maximal assistance (helper does more than half the effort) for the following:lower body dressingtoileting hygieneputting on/ taking off footwearRoll left and right when in bedSit to lyingLying to sitting on side of bedSit to standChair/ bed-to-chair transferTub/shower transferReview of Resident #1's Quarterly MDS Assessment, dated 05/24/2026, reflected Resident #1's BIMS score was 99 (resident was unable to complete the interview). She was assessed to have short term memory recall. Her long-term memory was intact. She used a walker or wheelchair for mobility. Resident #1 was dependent on staff for toileting hygiene. She required substantial/maximal assistance (helper does more than half the effort) with the following:Upper and lower body dressing.Putting on /taking off footwear.Personal Hygiene.Sit to lyingLying to sitting on side of bed.Sit to standChair/bed-to-chair transfer.Toilet Transfer.Review of Resident #1's comprehensive care plan revised on 6/03/2026 reflected there was an electronic monitoring device in her room that family has consented to and was care planned on 04/13/2026. Interventions: Discuss during care plan meetings any questions/ feedback/concerns regarding monitoring. The Care Plan dated 02/20/2026 reflected Resident #1 had ADL self-care performance deficit related to activity intolerance, fatigue ( a state of extreme physical or mental weariness or lack of energy that does not improve with rest), and shortness of breath. Interventions: Toilet Use: Resident #1 required supervision with staff for toileting. She required supervision with staff to move between surfaces. The Care plan initiated on 02/20/2026 reflected Resident #1 was at risk for falls related to gait/balance problems and deconditioning (the decline in physical fitness, and muscle strength that occurs as a result of prolonged inactivity, bed rest, or a highly sedentary lifestyle.) Interventions initiated on 02/20/2026: Anticipate and meet Resident #1's needs. Ensure Resident #1's call light was in reach and encourage Resident #1 to use the call light for assistance as needed. Resident #1 needed prompt response to all requests for assistance. Resident #1 had impaired visual function and wears glasses. Intervention: Explain all care and services before providing care. Review of the video footage recorded on 05/03/2026 at 4:28 p.m. revealed CNA A entered Resident #1's room to answer call light. Resident #1 was in her bed. CNA A stated What? in a rude tone when she entered Resident #1's room. Resident #1 stated Can you please tell me how to go to the bathroom? CNA A stated I'm not taking you to the bathroom honey. Stop saying that. I'm going to change you. CNA A stated I will not assist you out of bed to go to the bathroom. You can go to the bathroom in your brief. Resident #1 stated she wanted to use the bathroom. CNA A stated to Resident #1, No ma'am. You are too weak for that, and you can do that in your diaper. CNA A stated to Resident #1 go to sleep. CNA A turned off the call light during the conversation with Resident #1. CNA A would not allow Resident #1 to express herself verbally via talking loudly when Resident #1 was attempting to talk to CNA A. Resident #1 did say she needed to go to the bathroom. CNA A was walking away from Resident #1 and stated You are too weak. We do not get up. No, I am not going to play with you. Let me know when you are finished (referring to using the bathroom in her brief). Record review of the facility investigation, began on 05/14/2026, reflectedFamily provided on 5/14/2026 of two videos dated 05/03/2026 to Director of Nursing and Social Worker ofCNA A in Resident #1's room to answer a call light. CNA A tells Resident #1that she will not assist her out of bed to go to the bathroom and to go to the bathroom in her brief. CNAA then leaves the room and tells Resident #1 to use the call light when she is done using therestroom so CNA A can return to change the brief.DON and Social Worker notified Administrator (Admin was out of town at a conference) about the meeting withResident #1's family and the content of the videos. The team agreed to initiate a self-report forneglect and to suspend CNA A.CNA A was immediately suspended on 5/14/2026 pending the results of the investigation.Administrator notified corporate team of the allegation and self-report.DON and Social Worker coordinated to begin the investigation and in-servicing. Social Worker informed Resident #1'sfamily and Medical Director of the self-report.Investigation Summary:Summary of Video 1: Length: 37 seconds - Date: 05/03/2026 CNA A entered Resident #1's room to answer call light and ask resident what theyneeded. Resident #1 is lying in her bed at this time. Resident #1 stated she wanted to go to the bathroom CNA A responded with, No ma'am. Uh-uh. No ma'am. Too weak for that. Uh-uh. You dothat in your diaper. No ma'am. Go to sleep yep. During the above statements,o CNA A turned off the call lighto Resident #1 is trying to talk to CNA A, but CNA A is talking over theresident without pausing to listen and then respond to Resident #1 once she hasfinished talking. The audio is unable to pick up the words that Resident #1 issaying, but inference can be made that she is continuing to ask about going to thebathroom. CNA A then turns off over-the-bed light and begins to walk out of the room stating: Youknow, uh-uh, we do not get up. No, I'm not going to play with you. As CNA A is leaving the room, she makes the following statements: You are too weak. Letme know when you finish. During this time, CNA A is facing towards the hallway with her back to Resident#1. CNA A closes the door to Resident #1's room after last statement is made. Video ends Summary of Video 2: Length: 36 seconds - Date: 05/03/2026 Resident #1 is lying in her bed. CNA A enters Resident #1's room and states, What? with a negative tone of voicefrom the doorway/just inside the room. Resident #1 then asks, Can you please tell me how to go to the bathroom? CNA A responds with, I'm not taking you to the bathroom honey. Stop saying that. I'mgoing to change you. CNA A approaches Resident #1 in her bed and states, I'm irritated you saidthat .***next few words were unintelligible***.you're too weak. CNA A gets to the bed and turns off the call light. CNA A then walks back across the room and enters the bathroom. CNA A can beheard saying, ***First part is hard to understand but sounds like 'Apparently two at atime'***.to go to the bathroom, no ma'am. You can hear cabinets and what sounds like CNA A gathering supplies. Video endsInterview with CNA A: DON spoke with CNA A via phone call on 05/18/2026 about the content on the videos.CNA A denied the content and the statements the DON quoted back to CNA A. DONkept reiterating to CNA A that we have videos and can clearly see and hear the content.CNA A continued to deny that she acted the way the DON described the videos. Administrator met with CNA A on 05/19/2026 in his office. Administrator explained to CNAA that he understands DON informed CNA A about the videos. CNA A confirmedthe meeting. Administrator then played both videos for CNA A and explained that we want CNAA to watch and then help us understand what was happening during this time. Halfwaythrough the second video, CNA A stated, Administrator, I understand if you need to fire me.CNA A continually stated that she does not remember that night or saying/acting the wayshe did in the videos. CNA A apologized for her behavior and statedthat she understands whatever decision the facility needs to make.Interview with Resident #1 Social Worker interviewed Resident #1 but was unable to gather viable information. Resident#1 stated that she has never had an issue with someone helping her to the bathroom.Resident Safe Surveys:Resident #2 stated he felt safe and did not feel he had been mistreated. He did suggest that we do undercoverboss with the night shift because it needs attention. When Social Worker attempted to gather more information,Resident #2 stated everything was okay, and our night shift is much better than the night shiftwhere he used to live.Resident #3 stated he felt safe and did not have any concerns. He stated he would contact the Administrator if he had any issues. Feels safe with no concerns and knows he can contact Administrator if he has an issue.Resident #4 stated she felt safe and did not have any concerns. Investigation Findings:CNA A was found to have not followed proper procedures to assist with Resident #1 going tothe bathroom. CNA A instructed Resident #1 to use the bathroom in her brief and informed Resident #1that she is too weak to get out of bed. CNA A's employment with the facility was terminatedeffective 05/20/2026 via phone call from Administrator and HR Director.Post Investigation:Administrator or designee will make random rounds on night shift to visit with staff to ensureunderstanding of in-service provided. Social Worker or designee will conduct follow-up interviews with a randomsample of residents on each floor weekly for four weeks to see if residents have any further concerns.The Interdisciplinary Team will continue to have ongoing relationship with Resident #1 family to check-in tosee if there are any concerns with care. Resident #1 family is happy with response from the facility's investigation and does not have any further concerns at this time. Record Review of Resident #1's Psychosocial Harm assessment dated [DATE] reflected Resident was not experiencing any anxiety ( feeling of worry, nervousness, or unease, typically about something with an uncertain outcome), depression ( a serious mood disorder that causes persistent sadness, loss of interest, and a lack of energy), behaviors ( observable actions, reactions, and conduct of individuals in response to their environment), distress ( a state of extreme physical or mental suffering, pain, or danger), etc. Resident #1 was at her baseline. Record reviews of the facility in-service on Abuse, Neglect and Exploitation, Resident Rights and Customer Service on 05/15/2026 reflected all staff employed at the facility received in-service. Record review of QA ( a structured review of care standards, safety protocols, and resident outcomes) meeting on 05/18/2026 at 9:00 a.m. reflected the investigation and CNA A was reviewed and the video of CNA A's interaction with Resident #1 was viewed by the following staff:AdministratorMedical DirectorExecutive DirectorSocial WorkerHuman Resource ManagerDONADON Observation and interview with Resident #1 on 06/24/2026 at 9:30 a.m. revealed Resident #1 in room sitting in her wheelchair. Resident #1 stated sometimes staff comes in her room and say they will be back and take care of her, however, they do not come back. Resident #1 did not respond to any further questions about the staff and her care. Interview on 06/24/2026 at 9:50 a.m. CNA B stated Resident #1 was capable of being assisted by staff to use the bathroom on the toilet in her room. She stated it was not difficult to transfer her on and off the toilet. She stated she had given care to Resident #1 numerous times. CNA B stated she did not recall the number of times she had been assigned to Resident #1. She stated she did not have any issues with Resident #1 reporting her needs. CNA B stated she had been in-serviced on abuse, neglect, resident rights and the protocol of customer service. She stated the Administrator was the abuse coordinator. CNA B stated abuse was considered hitting a resident, cussing a resident, speaking to a resident in a rude tone, etc. She stated neglect was considered refusing to assist a resident to bathroom when the resident requests, refusing to give resident their meal, refusing to give a resident a shower, etc. She stated if she observed any staff abusing or neglecting a resident she would ask the staff to leave the area and she would ensure the resident was ok and immediately report it to the Administrator, DON, and her nurse supervisor. She stated no one had reported to her not to assist Resident #1 to the bathroom due to Resident #1 being weak. CNA B stated it was on their assignments Resident #1 needed assistance to be transferred to the toilet.Interview on 06/24/2026 at 12:15 p.m. R/P of Resident #1 stated she was very satisfied with the facility's administration listening to her and investigating immediately. She stated I do not want anything like this to happen to Resident #1 or to any resident. I am very pleased with the investigation from the facility. She stated she was not worried about the care from the staff at the facility.Interview on 06/24/2026 at 2:30 p.m. CNA A stated she did view the video of the incident with Resident #1 wanting to go to the bathroom. She stated she did not recall the date or time the incident occurred during the month of May. CNA A stated I did tell [Resident #1] to use the bathroom in her brief and that she was too weak to go the toilet. I told her I was not going to play with her, and I did not mean for it to sound the way it did on the video. This is the normal way I speak, and it can be mistaken of me being rude. I explained to [Resident #1] I would come back and clean her when she finished using bathroom in her brief. I do believe this was resident neglect. [Resident #1] is capable of going to the bathroom with assistance and she did ask me to take her to the bathroom. I did what I always do and tell her to use her brief. I did not listen to [Resident #1] when she was telling me she wanted to go to the bathroom and use the toilet. I do not believe I verbally abused [Resident #1], but I can understand where someone who did not know me would believe I was talking rude to [Resident #1]. I did view the video with the Administrator, and I could not watch all the video. I was talking to my [family member] with my ear buds in my ears when I was exiting the room. I was not speaking to [Resident #1]. I was suspended and later terminated due to neglecting [Resident #1]. She stated she spoke with Administrator and the DON about the situation. She stated I cannot talk anymore at this time. I will return your call at a later date. CNA A did not return phone call. In an interview on 06/24/2026 at 3:00 p.m. the DON stated it was determined during the investigation Resident #1 was neglected by CNA A. She stated Resident #1 did request for CNA A to assist her to the restroom. The DON stated Resident #1 was expected to be assisted by staff to the bathroom anytime during the day or night. She stated Resident # 1 was physically able to go to the restroom with staff assistance. DON stated it was not the facility's protocol to ask a resident to use the bathroom in their brief. She stated the tone of voice CNA A used in the video was not the standards of the facility. DON stated the staff was expected to allow the resident to speak and to not speak over a resident and to use a calm tone when speaking. She stated CNA A was using a rude tone when speaking to Resident #1 and it could be perceived as verbal abuse. DON stated when the family showed the video to her and the Social Worker, the Administrator was contacted immediately, and they began their investigation of the incident that occurred between CNA A and Resident #1. She stated Resident #1 has remained at her baseline physically, mentally and psychosocially. DON stated they immediately began in servicing all the staff on abuse, neglect, resident rights and customer service. She stated the facility did confirm neglect by CNA A during the investigation and CNA A was terminated. She stated anytime someone abused or neglected a resident the staff would immediately be suspended until an investigation is completed and if it is determined neglect or abuse occurred the staff would be terminated immediately. She stated the police was contacted, however, they did not come to the facility for investigation. In an interview on 06/24/2026 at 3:40 p.m. LVN Charge Nurse C stated she had been giving care to Resident #1 for the past few months. She stated she did not recall how many times she had given care to Resident #1. She stated Resident #1 was capable of using the toilet with assistance of being transferred by the staff. She stated Resident #1 was assisted to the toilet by staff during the day and she was capable of being assisted to the toilet at night. LVN Charge Nurse C stated Resident #1's care did not change from daytime to nighttime. She stated Resident #1's type of care was the same 24 hours a day. LVN Charge Nurse C stated she was not aware of Resident #1 being uncooperative with care. She stated anytime a staff refuses to assist a resident to the toilet and explain to a resident to use the bathroom in their brief, this was neglect. She stated she had been in-serviced on abuse , neglect, resident rights, and customer service during the month of May 2026, however, she was unable to recall the exact date. She stated the Administrator was the abuse coordinator. LVN Charge Nurse C stated examples of abuse were when staff yelled at a resident, spoke in a rude tone, hit a resident, sexual, etc. She stated examples of neglect were refusing to give resident their medications, refusing to assist resident to the toilet, refusing to feed a resident, or give a resident their meal. She stated if she witnessed any staff neglecting or abusing a resident she would immediately ask the staff to leave the room and ensure the staff was assisted by another staff to an office or private area. She stated the resident needed to be assessed immediately for any injuries or their mental and emotional status. LVN Charge Nurse C stated she would immediately contact the Administrator, DON, Physician and the responsible party of the resident. She stated the resident had a right to be free from abuse and neglect, had a right to voice their grievances without worrying about any retaliation. In an interview with the Administrator on 06/24/2026 at 4:00 p.m. the Administrator stated it was determined after watching the video of CNA A's interaction with Resident #1 the CNA did neglect Resident#1. He stated Resident #1 did request to be assisted to the bathroom and CNA refused and explained to Resident #1 to use the bathroom in her brief. The Administrator stated CNA A would speak at the same time Resident #1 was attempting to speak to CNA A. He stated during the QA meeting and the facility investigation it was determined CNA A did neglect Resident #1. He stated Resident #1's family was having a care plan conference meeting, and this is when she showed the video to the Social Worker and the Director of Nurses. He stated the event occurred on 05/03/2026. He stated the facility administration did not know about the incident until 05/14/2026. The Administrator stated an investigation began immediately and CNA A was suspended after the video was reviewed. He stated in-services began on abuse, neglect, resident rights and customer service. The Administrator stated the physician and police were notified immediately. He stated the Police did not come to the facility and the facility did not receive a police report. The Administrator stated CNA A did degrade Resident #1 by speaking down to her. He stated he meant degraded Resident#1 by the words and tone of voice CNA A used when speaking to Resident #1. He stated this would be considered verbal abuse by her tone of voice and stating to Resident #1 I'm not going to be playing with you. He stated CNA A also said to Resident #1 we don't get up ( in a rude tone) when Resident #1 was requesting to go to the toilet to use the bathroom. The Administrator stated CNA A denied the accusations until she viewed the video. He stated CNA A refused to view the entire video. He stated they followed their abuse /neglect protocol and followed HHSC provider letter pertaining to abuse and neglect. He stated other residents were interviewed and no one had any issues with CNA A. The Administrator stated Resident #1 has remained at her baseline. Record review of CNA A's Personnel Action Form reflected CNA A was terminated on 05/20/2026 and her last day to work was on 05/14/2026 when she was suspended. CNA A was terminated related to a video of CNA A explaining to a resident( Resident #1) to urinate in her brief instead of taking the resident to the bathroom. Record review of the Facility's Policy on Abuse, Neglect , Exploitation and Misappropriation Prevention Program, revised on April 2021, reflected Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual orphysical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and ImplementationThe resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment andresource allocation to support the following objectives:1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including,but not necessarily limited to:a. facility staff;b. other residents;c. consultants;d. volunteers;e. staff from other agencies; f. family members;g. legal representatives;h. friends;i. visitors; and/orj. any other individual. 2. Develop and implement policies and protocols to prevent and identify:a. abuse or mistreatment of residents;b. neglect of residents; and/orc. theft, exploitation or misappropriation of resident property.

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.

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 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 [DATE] 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 [DATE] at 5:55 PM and discard [DATE] at 5:55 PM. 1 metal tray labeled Fish, Salmon 6oz, opened [DATE] at 5:55 PM and discard [DATE] at 5:55 PM, which contained 38 individually wrapped pieces of fish. 1 plastic bag labeled Fish, Salmon Fillet Raw opened [DATE] at 6:20 PM and discard [DATE] 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 [DATE] at 12:42 PM and discard [DATE] 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 [DATE] at 3:06 PM and discard [DATE] at 3:06 PM. Observation on [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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, XXX,d+[DATE].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 ,d+[DATE].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

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 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.

Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervisions and assistive devices for 1 of 8 Residents (Resident #17) reviewed for accidents and hazards, in that: Facility failed to adequately supervise and ensure staff checked the coffee temperature prior to serving to residents which resulted in Resident #17 spilling a pot of coffee over his lap resulting in 1st and 2nd degree burns to his bilateral thighs and down his legs to his ankles. On 05/31/2023 at 2:40 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/02/2023, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of accidents due to lack of supervision. Findings included: Review of Resident #17's Face Sheet, and health record information dated 06/02/2023 reflected an [AGE] year old male admitted on [DATE] with diagnoses which included dementia in other diseases with mood disturbance (refers to the presence of disturbed mood, behavior or thought confusion), psychotic disorder with delusions, acute heart failure, lack of coordination, muscle wasting and atrophy(loss of muscle leading to its shrinking and weakening.), gastro-esophageal- reflux disease without esophagitis, sick sinus syndrome ( abnormal heart beat), presence of pacemaker( machine to stabilize heart rate, major depressive disorder (a common mental disorder, It is characterized by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), fractured( cracked) right hip. Review of Resident #17's Significant change MDS dated [DATE] revealed a BIMS score that was not determined indicating severe cognitive impairment. Resident #17 was assessed to require partial/ moderate assistance status for the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Review of Resident #17's care plan dated 05/24/2023 revealed Resident #17 to have dementia and poor nutritional intake requiring assistance supervision and/or cueing at each mealtime as indicated. Observation on 05/30/2023 and 5/31/2023 revealed no coffee outside of the satellite kitchen on the first or second floor dining room areas. Review of the facility reported incident completed by Administrator dated 05/27/2023 reflected Resident #17 was in the dining room prior to breakfast and went to get a cup of coffee. Resident #17 dropped the pot of coffee all in his lap. Resident #17 complained of pain and was sent to ER. Review of Resident #17's Hospital Records dated 05/27/2023 reflected Patient presents to emergency room from nursing home with reports that he had some hot coffee spilled on his legs. He has some 1st and 2nd degree burns to both thighs .after examination the patient has approximately 2-3% second-degree burns (Second -degree burns, or partial thickness burns, are more severe than first-degree burns. They affect the outer layer of skin, called the epidermis, and part of the second layer of skin, called the dermis), with small amount of 1st degree burns (First-degree burns affect only the top layer of skin (the epidermis). patient with dementia and does recall that he spilled hot coffee on his legs. Review of an in-service provided to nursing staff by the DON dated 05/27/2023 reflected Hot beverages such as coffee and tea are available to our residents throughout the day The liquids are very hot and can cause significant burns. Make sure lids are screwed tightly on the pot .observe for cracks, chips, etc.Keep in mind our residents have the right to drink coffee and we should have it accessible to them, just keep an eye on them and make sure they are being safe . The in-service training did not address testing the temperature of the coffee. In an interview on 05/31/2023 at 10:55 AM the Administrator stated the facility did keep a metal coffee pot on the bar in the dining room area with coffee in it for the residents to self-serve. He stated they removed the coffee from the bar after the incident and now it is only in the satellite kitchen. He stated the facility did not have a policy for testing the temperature of the coffee before serving it or putting it out. In an interview on 05/31/2023 at 09:45 AM RN A stated while staff were getting residents up, Resident #17 was trying to get his own coffee. RN A was alerted by a dietary aide of Resident #17 having an accident spilling hot coffee on himself. RN A stated as she arrived at the scene of the incident, she observed a coffee lid and coffee pot placed separately on the floor so it looked like the coffee lid was not on correctly but that was only her assumption since she was not present at the scene. RN A stated when Resident #17 was bought back to his room, she noticed bright redness on both of thighs. RN A called the doctor for Resident #17 to be sent to the ER. RN B stated ER reported that Resident #17 had 2nd degree burns. RN A stated when he returned to the facility, she noticed he had blisters. RN stated Resident #17's doctor has him on Xero foam Gauze currently. RN A stated the coffee pots have been removed and are currently not accessible to the residents. RN A stated that the facility probably did an Inservice earlier this week, but she was not present since today is her first day back. RN A stated that since the incident coffee is no longer allowed to be self-served by the residents. Staff has removed the coffee pots. RN A stated that current policy for the facility is if residents want coffee, they need to alert staff to get it ready for them. When asked who is required to check the temperature for coffee pots, she stated she is unsure, that it should be the kitchens duty. In an interview on 05/31/2023 at 10:58 AM, Dinning Supervisor (DS) B stated she was working on the day Resident #17 spilled his coffee on his lap. She stated she was in the satellite kitchen on the first floor. She stated she did not test the temperature of the coffee before placing the coffee out for residents. DS B further stated they did not routinely test the coffee and there was not a policy to test the temperature of the coffee before serving. When asked what the possible outcome of not a policy having to check the Coffee temperature prior to serving to the residents she stated it could result in burns to the residents. Observation on 05/31/2023 at 09:40 AM Resident #17 was observed resting in bed with blankets over the resident. When woken up, Resident #17 stated he is alright just having pain that comes and goes. In an interview on 05/31/2023 10:24 AM Resident #17's FM stated he felt Resident #17 is doing fine now. Resident #17's FM reported his only concern is how a resident like him, confused and weak got access to a coffee pot. Resident #17's FM stated that if the facility can remove access for Resident #17 to self-serve his own coffee, then he was fine with facility providing care to him. Observation on 05/31/2023 at 10:30 AM revealed no coffee pots in the dining room that residents could access. Surveyor witnessed coffee pots stored in the kitchen. Observation on 06/01/2023 at 1:41 PM revealed Resident #17 in room in bed. LVN J in room to perform wound care. LVN J removed Resident #17 dressing to left leg to reveal extensive 1st and 2nd degree burns to his left posterior (further back in position; of or nearer the rear or hind end), and anterior (front position) thigh and down his leg extending to his ankle with areas appearing to be 3rd degree (Third-degree burns are a severe burn that reaches the third layer of your skin burns) to his inner left thigh. Continued observation of Resident #17's burns revealed extensive 1st and 2nd degree burns to posterior and anterior right thigh with areas on the inner thigh extending down to his right ankle. In an interview on 06/02/2023 at 9:40 AM the DDS stated that the coffee does come from the main kitchen and the temperature of the machine was set at 200 degrees to go to satellite kitchens. He stated the coffee would lose some heat during transport but was probably served from the satellite kitchens at 175 or 180 or so once it got to the residents. Review of the facility's policy Food and Coffee Safety not dated, provided to Surveyor on 05/31/2023 reflected The community will serve coffee to resident preference. Unless otherwise requested by the resident the coffee will be served between the temp of 160-175 degrees. Coffee service stations will be set up to brew or serve coffee at the designated temperature range . This was determined to be an Immediate Jeopardy (IJ) on 05/31/2023 at 2:40 PM. The Administrator was notified. The Administrator was provided with the IJ template on 05/31/2023 at 3:01 PM. The following Plan of Removal was accepted on 06/01/2023 at 11:57 AM and included: IJ Plan of Removal - Crestview Retirement Community - 05/31/2023 Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on May 31, 2023, for failing to ensure hot liquid temperatures are monitored. The 46 residents of the facility had the potential to be affected by this alleged deficient practice. A. Corrective Action: Dining Services staff immediately removed the coffee pots from the dining room areas and therefore eliminated further access for residents to pour their own cup of coffee. A coffee dispenser that has an external digital temperature readout for the internal liquids has been ordered and will arrive on Tuesday, 06/06/2023. Plan for self-serving coffee dispensers will be to serve at a temperature range of 130-150 degrees Fahrenheit. Temperature range was determined by reviewing published information from the National Institutes of Health - National Library of Medicine for Calculating the optimum temperature for serving hot beverages. Ad Hoc QAPI meeting was held in Administrator's office on 05/31/2023 around 3:15PM with the following in attendance: Administrator, Medical Director, DON, RN Corporate Nurse, Executive Director, AL Director, and Dining Services Director. Community Plan for Removal developed and initiated from this meeting. In-servicing initiated on 05/31/2023 with Dining Services regarding taking and recording temperatures of coffee prior to service. Dining Services staff members will be in-serviced prior to working their next shift and serving residents by the Dining Director and/or designee. In-servicing finished on 05/31/2023. AL Director (Also a current Licensed Nursing Home Administrator) completed the in-servicing with Dining Staff present in the building on 05/31/2023 Administrator in-serviced Dining Director on 05/31/2023. Dining Director in-serviced 11 additional Dining Services staff members via individual telephone calls on 05/31/2023. o Administrator was present in the building on 06/01/2023 prior to breakfast service and verified with two Dining Staff members, that were not present on 05/31/2023, received the phone in-service on 05/31/2023. B. Identification: Nursing department conducted resident hot liquid evaluations on the 46 residents of the facility on 05/31/2023 to determine resident directed interventions, if needed, for individual residents. Interventions put in place on 05/31/2023 to serve coffee at 140 degrees Fahrenheit. Self-service coffee has been temporarily suspended until new coffee dispensers that display the internal temperature of liquids on the outside of the dispenser arrive. Hot liquid evaluations completed on 05/31/203 each resident to determine who is at risk to safely handle hot liquids o On 06/01/2023, facility staff are interviewing residents determined to be at risk to identify individual preferences. The goal of the facility is to serve hot liquids to the preference of the resident while ensuring their safety to handle these liquids. o Resident care plans will be updated to identify resident preference for hot liquids. C. Preventative Measures: Dining Services Servers that work in the SNF satellite kitchens will obtain and record temperatures of hot liquids on a log sheet prior to serving at 140 degrees Fahrenheit at meal times that hot liquids are served. Dining Services will add training regarding hot liquids to new hire orientation for new staff members hired after 05/31/2023 and ongoing to ensure each new staff members are trained on hot liquid safety. Responsible: Dining Services Director and/or on Duty Supervisor Training completed on 05/31/2023 for currently employed staff New staff hired in the future will be trained during orientation starting 05/31/2023 D. Monitoring: Dining Services Director and/or designee will review temperature logs daily for two weeks beginning on 06/01/2023 to ensure compliance. Dining Services Director and/or designee will review temperature logs weekly beginning on 06/15/2023 and report to the community QAPI committee meetings for six months unless otherwise determined by the QAPI committee. Medical Director was present in the building when community was informed of the Immediate Jeopardy on 05/31/2023. Administrator informed Medical Director after community was informed on 05/31/2023. Monitoring for the Plan of Removal was completed from 06/01/2023 through 06/02/2023 as follows Review of the facility's in-service conducted on 05/31/2023 through 06/02/2023 reflected serving hot liquids above 140 degrees has the potential to cause burns in the elderly population. Hot liquids are to be checked and temperature logged prior to serving. Review of the signatures on the in-service reflected all dietary, and dinning staff were in-serviced. Observation on 06/01/2023 and 06/02/2023 revealed no coffee outside of the satellite kitchen on the first or second floor dining room areas. Review of the facility's revised policy provided on 06/01/2023 reflected Safety of Hot liquids, Residents will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission and on change of condition .The potential for burns from hot liquids is considered an ongoing concern among residents .Once risk factors for injury from hot liquids are identified, appropriate resident centered interventions will be implemented to minimize the risk from burns. Such interventions may include (a.) Maintaining a hot liquid serving temperature of not more than 140 degrees Fahrenheit. (b.) serving hot beverages in a cup with a lid .(c.) providing protective lap coving or clothing to protect skin from accidental spills . Review of the Sampled Resident EMRs on 06/01/2023 and 06/02/2023 for Resident #2, 95, 24, 20,19, 11, and 15 reflected all had a Hot liquid evaluations completed. In an interview on 06/01/23 at 1:42 PM DA D stated staff are to get the coffee from the main kitchen, check the temperature. DA D stated if the temperature is over 140 F, staff should wait for coffee to cool down to less than 140 F. DA D stated that staff should put up the coffee warmer when the dining is not serving food in the kitchen. DA D stated staff needed to put up coffee heater to prevent residents from being burned. In an interview on 06/01/23 at 1:55 PM DS C stated that the DDS went over training with her yesterday. DS C stated that staff was in services about checking temperature of coffee before being served. DS C stated that if temperature was above 140 F, then staff should re check until it has cool down to less than 140 F. DS C stated, for now, we are to leave the coffee heater behind the counters in the kitchen. DS C stated nurses and/or dining services can only have access to the coffee maker. This is all done to ensure safety for residents and avoid further accidents from happening. In an interview on 06/01/23 at 2:04 PM the DDS stated that before coffee is to be served it must be bought down to 140 or below. They must sign off on the temperature sheet before serving coffee. DDS stated that coffee heater is not accessible to residents anymore because to prevents burns on residents' skin. DDS stated that the facility switched to coffee heaters that are pumps, meaning the cover will not unlock and spill, in case a resident were to get access. Observation and interview on 06/01/23 at 2:15 PM DA G showed surveyor sign in sheet of Coffee Temperature before it is to be served. DA G stated staff are required to log in temperature before serving coffee to residents. She stated temperature must be below 140 F before serving. In an interview on 06/02/2023 at 9:40 AM the DDS stated that the coffee does come from the main kitchen and the temp of the machine is set at 200 degrees to go to satellite kitchens. He stated the coffee would lose some heat but was probably served at 175 or 180 or so once it got to the residents. The DDS stated he in-serviced all staff in dining to ensure the coffee is checked to ensure it is not more than 140 when served to the residents. In an interview on 06/02/2023 at 2:30 PM DA H stated that currently on the floors no coffee can be available for residents to self-serve. DA H quoted We keep the coffee heaters in the back of the kitchen where the residents will not be able to access them. DA H stated staff members are required to take temperature of coffee two times before serving to residents. DA H said that temps are documented immediately upon brewing and another time right before serving when temp is 140 F or below. On 06/02/2023 at 2:30 PM, the Administrator was notified that the Immediate Jeopardy (IJ) was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. 46735

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 [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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

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, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing and, mental and psychosocial needs for 1 (Resident #34) of 12 reviewed for care plans in that: The facility failed to ensure Resident #34's Comprehensive Care Plan was revised for oral care for Resident #34 after Resident #34 could not use routine oral care techniques. This failure placed residents at risk of not having their individualized needs met in a timely manner and communicated with providers and could result in an injury, a decline in physical well-being and in quality of life. Findings included: Record review of Resident #34's face sheet, dated 03/24/2022, revealed Resident #34 to be a [AGE] year old female admitted to the facility 02/22/2022 with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #34's MDS Assessment, dated 03/01/2022, revealed Resident #34 had a BIMS score of 09 to indicate moderately impaired cognition and Resident #34 required feeding via PEG tube for greater than 51% of Resident #34's total caloric intake . The MDS assessment further revealed Resident #34 required one person assistance for ALD care. Record review Resident #34's care plan, dated 02/24/2022, revealed Resident #34 required tube feeding (PEG tube) related to Dysphagia post [CONDITION(S)], NPO and malnutrition. There were no further interventions regarding oral care for Resident #34 identified on the care plan . Record review of Resident #34 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #34 was also ordered on 03/08/2022 puree nectar thick diet for trials only with Speech Therapy and diet to remain NPO outside of these trials. An observation and interview on 03/22/2022 at 1:15 PM reflected Resident #34 to have stringy white saliva in her mouth with white [MEDICATION(S)] built up on her upper and lower teeth. Resident #34's upper and lower lip observed to have cracks and white [MEDICATION(S)] dried on her lips . Resident #34 stated she felt good and had no needs. When asked about the [MEDICATION(S)] in her mouth, she did not know what was being referred to in her mouth . When asked about brushing her teeth, Resident #34 was unable to answer. An observation on 03/23/2022 at 11:41 AM revealed Resident #34 had dry lips and had a [MEDICATION(S)] coating built up on her upper and lower teeth. In an interview on 03/23/2022 at 11:44 AM with LVN D stated Resident #34 was not resistant to care of her mouth. When asked about Resident #34's oral care LVN D stated Resident #34 sucked on the oral swabs and since Resident #34 was NPO they don't use them at the risk of Resident #34 choking on them. She stated the facility ordered a suction toothbrush for Resident #34, but they did not have it yet. When asked about [MEDICATION(S)] swab use for Resident #34 oral care, LVN D stated they had not tried them. An observation on 03/24/2022 at 9:50 AM reflected Resident #34 sleeping with mouth open, breathing through her mouth. Resident #34 was observed to not have the gumminess and build up in her mouth as previously observed. Resident #34's lips were observed to be cracked with pieces of tissues peeling off. In an interview on 03/24/2022 at 9:55 AM LVN B stated she examined Resident #34 this morning and her mouth looked better than usual. She said they had to clean it frequently as Resident #34 had a lot of saliva. She stated when Resident #34 was first admitted to the facility she was diagnosed with thrush of the mouth and had three days of anti-fungal medication administered and the thrush resolved. She said the therapy department ordered and received suction toothbrushes that would help with cleaning her mouth, but they had not been implemented yet. She did not know why they had not been implemented yet. She said they used pink swabs to clean Resident #34's mouth but Resident #34 tried to eat the swab and it could be unsafe. She said the nurses and CNAs would be trained on using the suction toothbrushes for Resident #34's care plan. She said there had not been other interventions put into place by the facility that she knew of for Resident #34. She said they did use lip moisturizer/protectant as needed for her lips. In an interview on 03/24/2022 at 10:05 AM LVN G stated she did oral care this morning for Resident #34. She said she used the pink swabs and was careful not to let Resident #34 bite the swab off at the risk of swallowing it. She stated she put lip protectant on her as needed. In an interview on 03/24/2022 at 10:15 AM REHAB DIR stated they had a plan to improve Resident #34's oral care but it had not been implemented . She said her care plan was not updated with the plan. She said they ordered and received the suction toothbrushes and OTA H would attempt to use them today. She said OTA H had been off work and had not had a chance to try the new toothbrushes. In an interview on 03/24/2022 at 10:20 AM OTA H stated she helped with oral care for Resident #34 when Resident #34 bit off the pink swab. OTA H said she had to sweep her mouth to prevent Resident #34 from swallowing the swab and possibly choking. She said the pink swab could be dangerous as a swallow hazard. She stated water could not be used to clean Resident #34's mouth because Resident #34 could not swallow water because of dysphagia and Resident #34 would start coughing and choking. She said they would implement the suction tooth brushes that would hopefully help and that would be done at least twice per day. She stated the oral care issue, and the intervention should have been added to Resident #34's care plan. Record review of occupational therapy progress note, dated 03/13/2022, revealed Resident #34 given oral swab, however Resident #34 bit into it and required therapist to sweep foam from mouth, nursing aware. In an interview on 03/24/2022 at 11:25 AM RN E, MDS and Care Plan Coordinator, stated Resident #34's care plan should have been updated regarding her oral care needs and the need for suction toothbrushes for oral care. She stated she would have updated the care plan once therapy instructed her on the new plan for oral care for Resident #34. She stated it was not done as therapy had not implemented the new plan. She stated the care plan should have been updated when a problem with the swabs was noticed and the plan for suction toothbrushes was developed. Record review of Routine Dental Care policy, dated April 2007, revealed the facility's routine dental care included daily dental and oral hygiene plan of care to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth and to prevent oral infection. Staff were to review the resident's care plan to assess for any special needs of the resident.

Based on interviews and record reviews, the facility failed to ensure residents who received [CONDITION(S)] medications PRN were limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication in 1 (Resident #37) of 12 residents reviewed for unnecessary medication and [CONDITION(S)] medication use. The facility failed to follow-up on consultant pharmacist recommendations and a physician's letter that the medication [MEDICATION(S)] was not recommended for the use by Resident #37 and the physician would need to check labs such as CMP and magnesium, an EKG and most other antipsychotics would be preferred over this one for the resident. The facility failed to have a completed consent with justification of the appropriateness of the medication for Resident #37. These failures place all residents at risk of adverse effects of psychoactive medications. Findings included: Record review of face sheet dated 03/24/2022 for Resident #37 revealed Resident #37 to be an [AGE] year old male admitted to the facility 01/03/2022 with a diagnoses of traumatic subdural hemorrhage (pool of blood between the brain and its outer most covering), [CONDITION(S)] (rare type of cancer in which too many abnormal white blood cells are made and crowd out healthy blood cells), chronic myeloproliferative disease (type of blood cancer associated with [CONDITION(S)]), dementia (a group of thinking and social symptoms that interferes with daily functioning) and high blood pressure. Record review of Resident #37's significant change MDS Assessment, dated 03/07/2022, revealed Resident #37 to have severely impaired cognition as designated by staff members MDS Assessment revealed Resident #37 to have an active psychiatric diagnosis for anxiety disorder and depression. MDS Assessment further revealed Resident #37 to receive antipsycotic medications and antidepressant medications seven days per week. Resident #37 also received hospice services . Record review of Resident #37's care plan, dated 03/24/2022, revealed Resident #37 received sedative/hypnotic medication [MEDICATION(S)] for a sleep disorder or [MEDICATION(S)]. The care plan further revealed Resident #37 used antidepressant medication [MEDICATION(S)] 25 MG one time a day related to depression. Record review of Resident #3'7's physician's orders, dated 02/01/2022, revealed Resident #37 had an order for [MEDICATION(S)] 20 MG (antipsychotic medication used to treat [CONDITION(S)] and the manic symptoms of [CONDITION(S)] disorder) twice daily for [CONDITION(S)] with no end date. Record review of Resident #37's Drug Regimen Review, dated 02/02/2022, revealed the consultant pharmacist documented [do not recommend use of [MEDICATION(S)] - 1) New form 3713 (Consent form for antipsychotic medication) is required 2) Would need to check labs such as CMP and Mg, and possibly even EKG to ensure he not at risk for QTc prolongation . Most other antipsychotics would be preferred over this one for resident.] Record review of Resident #37's Drug Regimen Review Physician Letter, dated 02/02/2022, revealed [Resident #37] is a new admit with a transfer order from [hospital] for [MEDICATION(S)] 20 MG twice daily for [CONDITION(S)]. The resident was noted to have had a low magnesium level in the hospital. Due to the risk of QTc prolongation it is not recommended in geriatrics. Please consider a short-term use with another antipsychotic if the [CONDITION(S)] has not subsided by now. If the [MEDICATION(S)] is to continue 1) Please add a stop date 2) Recommend an EKG, CMP and Mg level . Record review of Resident #37 Drug Regimen Review Physician response letter, dated 03/01/2022, revealed the physician disagreed with the pharmacist recommendation and wrote the following, patient on hospice now, will defer to hospice team for medication regimen and behaviors, please check with them and was signed by the nurse practitioner. An additional note written by the hospice physician on 03/04/2022 revealed, [MEDICATION(S)] was already decreased to once daily on 02/28/2022. It will be stopped in a few days if his symptoms remain controlled. Record review of Resident #37 physician's orders, dated 02/28/2022, revealed Resident #37 ordered [MEDICATION(S)] 20 MG once daily with a stop date of 03/08/2022. Record review of Resident #37's Consent for Antipsychotic Medication Treatment, dated 03/03/2022, revealed Resident #37 required the [MEDICATION(S)] for [CONDITION(S)] , subdural hematoma and dementia and had combative behaviors while hospitalized [DATE] - 02/01/2022. The form was signed by the nurse practitioner on 03/03/2022 and by Resident #37's responsible party on 03/09/2022. In an interview on 03/24/2022 at 11:30 AM the ADON stated she was responsible for the drug regimen review follow-up with the attending physician and completion of order changes if needed for residents at the facility. She stated she was responsible for ensuring consents for medications were completed. She stated Resident #37 returned from the hospital on 02/01/2022 with the [MEDICATION(S)] prescribed by the hospital physician. She stated the hospital did not complete a consent with the resident or his responsible party for the use of the antipsychotic medication. She said until 03/09/2022 the facility did not have a completed consent for the use of the medication. She said they should have had the consent upon his re-admission to the facility on the [MEDICATION(S)]. She said she received the pharmacist's review and recommendations for Resident #37 by the pharmacist on 02/02/2022 and sent the paperwork to Resident #37's physician for review and signature. She said there was confusion over who would sign the medications and orders because Resident #37 was transitioning to hospice care and the consent and changes were not completed as required . She said normally when they received pharmacist recommendations, they tried to make the change or have an answer within a day or two of the recommendations. She said they tried to have the consent for antipsychotics completed as soon as possible or within a week of the prescription . Record review of Pharmacy Consultant Inservice for facility staff on Antipsychotic in our Patients (undated) revealed Form 3713 was the new consent for antipsychotic use and the form must be completed within seven days of the prescribed antipsychotic. Record review of Medication Regimen Reviews, dated May 2019, revealed the consultant pharmacist provides a written report to the attending physician within 24 hours of the Medication Regimen Review. The attending physician documents in the medical record that the irregularity (refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice) has been reviewed and what (if any) action was taken to address it.

Based on interview and record review, the facility failed to ensure that the facility's medical director or his/her designee attended the QAPI meetings, and failed to meet at least quarterly to for one of one facility, reviewed for QAPI, in that: The facility did not ensure the Medical Director attended all quarterly QAPI meetings. The facility failed to ensure they held quarterly QAPI meetings. This failure placed residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings include: Review of the facility's QAPI meeting sign in sheets reflected QAPI meetings were held on 03/01/2021, 08/27/2021, November 2021 and 02/25/2022. There was no documented evidence a meeting was held in May 2021. Further review of the QAPI meetings sign in sheets reflected the Medical Director did not attend the 08/27/2021 QAPI meeting. In an interview on 03/24/22 at 12:12 PM the Administrator stated he did not start working at the facility until August 2021. The Administrator stated he did realize they were not having quarterly QAPI meetings. The Administrator also stated the Medical Director was not at the 8/27/2021 QAPI meeting. He stated the QAPI meetings should be held quarterly with the Medical Director in attendance. He stated moving forward they were going to have QAPI meetings monthly. Review of the facility's policy Quality assurance and performance improvement plan (not dated) reflected, .QAPI will provide a proactive approach to continually improving the way we care for and engage with our residents, caregivers and other partners .The committee will meet no less than quarterly

Based on observation, interview and record review the facility failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for one (Resident #34) of residents reviewed for ADL's in that: The facility failed to ensure Resident #34 received adequate oral care to prevent buildup of [MEDICATION(S)] on her teeth. This deficient practice could place all residents who are dependent on ADL care at risk for reduced self-worth and well-being. Findings included: Record review of Resident #34 face sheet dated 03/24/2022 revealed Resident #34 to be a [AGE] year old female admitted to the facility 02/22/2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #34 MDS assessment dated [DATE] revealed Resident #34 had a BIMS score of 09 to indicate moderately impaired cognition and Resident #34 required feeding via PEG tube for greater than 51% of Resident #34's total caloric intake . The MDS assessment further revealed Resident #34 required one person assistance for ALD care. Record review Resident #34 care plan dated 02/24/2022 revealed Resident #34 required tube feeding (PEG tube) related to Dysphagia post [CONDITION(S)], NPO and malnutrition. There were no further interventions regarding oral care for Resident #34 identified on the care plan . Record review of Resident #34 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #34 also ordered 03/08/2022 puree nectar thick diet for trials only with Speech Therapy and diet to remain NPO outside of these trials. An observation on 03/22/2022 at 1:15 PM reflected Resident #34 to have stringy white saliva in her mouth with white [MEDICATION(S)] built up on her upper and lower teeth. Resident #34's upper and lower lip observed to have cracks and white [MEDICATION(S)] dried on her lips. In an interview on 03/22/2022 at 1:16 PM, Resident #34 stated she felt good and had no needs. When asked about the [MEDICATION(S)] in her mouth, she did not know what was being referred to in her mouth . When asked about brushing her teeth, Resident #34 was unable to answer. An observation on 03/23/2022 at 11:41 AM revealed Resident #34 had dry lips and had a [MEDICATION(S)] coating built up on her upper and lower teeth. In an interview on 03/23/2022 at 11:44 AM with LVN D stated Resident #34 was not resistant to care of her mouth. When asked about Resident #34's oral care LVN D stated Resident #34 sucked on the oral swabs and since Resident #34 was NPO they don't use them at the risk of Resident #34 choking on them. She stated the facility ordered a suction toothbrush and did not know when it was ordered for Resident #34, but they do not have it yet. When asked about [MEDICATION(S)] swab use for Resident #34 oral care, LVN D stated they had not tried them. An observation on 03/24/2022 at 9:50 AM reflected Resident #34 sleeping with mouth open, breathing through her mouth. Resident #34 was not observed to have the gumminess and build up in her mouth as previously. Resident #34's lips were observed to be cracked with pieces of tissues peeling off. In an interview on 03/24/2022 at 9:55 AM LVN B stated she examined Resident #34 this morning and her mouth looked better than usual. She said they had to clean it frequently, possibly every two hours as Resident #34 had a lot of saliva. She stated when Resident #34 was first admitted she was diagnosed with thrush of the mouth and had three days of anti-fungal medication administered and the thrush resolved. She said the therapy department ordered and received suction toothbrushes that would help with cleaning her mouth, but they had not been implemented yet . She did not know why they had not been implemented yet. She said they used pink swabs to clean Resident #34's mouth but Resident #34 tried to eat the swab and it could be unsafe. She said they do use lip moisturizer/protectant as needed for her lips. In an interview on 03/24/2022 at 10:05 AM LVN G stated she did oral care this morning for Resident #34. She said she used the pink swabs and was careful not to let Resident #34 bite the swab off at the risk of swallowing it. She stated she put lip protectant on her as needed. In an interview on 03/24/2022 at 10:15 AM REHAB DIR stated they had a plan to improve Resident #34's oral care but it had not been implemented . She said they ordered and received the suction toothbrushes and OTA H would attempt to use them today. She said OTA H had been off work and had not had a chance to try the new toothbrushes. In an interview on 03/24/2022 at 10:20 AM OTA H stated she helped with oral care for Resident #34 when Resident #34 bit off the pink swab. OTA H said she had to sweep her mouth to prevent Resident #34 from swallowing the swab and possibly choking. She said the pink swab could be dangerous as a swallow hazard. She stated water could not be used to clean Resident #34's mouth because Resident #34 could not swallow water because of dysphagia and Resident #34 would start coughing and choking. She said they would implement the suction tooth brushes that would hopefully help and that would be done at least twice per day . Record review of occupational therapy progress noted 03/13/2022 revealed Resident #34 given oral swab, however Resident #34 bit into it and required therapist to sweep foam from mouth, nursing aware. Record review of Routine Dental Care policy dated April 2007 revealed our facility's routine dental care includes daily dental and oral hygiene plan of care to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth and to prevent oral infection. Staff were to review the resident's care plan to assess for any special needs of the resident.

Based on observation, interview, and record review the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and include the appropriate expiration dates to preserve their integrity for medications stored three of three residents (Resident #9, #19 and #37) reviewed for medication storage. The facility failed to date a multi-use product (eye drops) when the product was first opened according to manufacture and professional standards and failed to label the multi-use products with resident names. These failures place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication. Findings Included: Review of Resident #9's Face Sheet, dated 03/24/2022, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Quarterly MDS assessment, dated 12/24/2021, reflected she had a BIMS score of 10 indicating moderate cognitive impairment. Resident #9 was assessed to have impaired vision. Review of Resident #9's Consolidated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #19's Face Sheet, dated 03/24/2022, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on ,d+[DATE] with the following diagnoses, [CONDITION(S)] (irregular heartbeat) altered mental status and hypertension (high blood pressure). Review of Resident #19's Quarterly MDS, dated [DATE], reflected he was assessed to have a BIMS score of 8 indicating moderate cognitive impairment. Resident #19 was further assessed to have moderately impaired vision. Review of Resident #19's Consolidated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's Face Sheet, dated 03/24/2022, reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, Dementia, Hypertension, and traumatic subdural hemorrhage. Review of Resident #37's Significant change MDS assessment, dated 03/07/2022, reflected the resident did not have a BIMS assessment conducted indicating severe cognitive impairment. Resident #37 was assessed to have moderately impaired vision. Review of Resident #37's Consolidated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 03/23/2022 at 1:30 PM revealed the first-floor medication aide cart with 1 vial of [MEDICATION(S)] eye drops, 1 vial of artificial tears and 1 vial of refresh eye drops not labeled with an open date or labeled with a resident name. In an interview on 03/23/2022 at 1:33 PM LVN B, the unit supervisor, stated the eye drops should be labeled with the resident's name and date opened by whoever opens the vial. LVN B removed the eye drops from the cart. Observation on 03/23/2022 at 1:45 PM revealed the second-floor medication aide cart with 1 vial of [MEDICATION(S)] eye drops and 1 vial of artificial tears not labeled with an open date or labeled with a resident name. In an interview on 03/23/2022 at 1:47 PM RN A stated the eye drops should be labeled with the resident's name and date opened. RN A removed the eye drops from the cart. RN A stated she did not know who the eye drops belonged to. In an interview on 03/23/2022 at 4:00 PM the DON stated eye drops should be dated when opened and should have a resident name, so they were not used on anyone else. In an interview on 03/24/2022 at 10:50 AM MA F stated eye drops should be dated with the date opened and labeled with a resident name. He stated he passed medications on both floors and did not know why the vials were not dated with an open date or resident name. In an interview on 03/24/2022 LVN B stated the eye drops on first floor cart belonged to Resident #9 ([MEDICATION(S)] Gel), Resident #19 (Artificial Tears) and Resident #37 (Artificial Tears). Review of the facility's policy Administering Medications, dated April 2019, reflected Medications are administered in a safe and timely manner, and as prescribed .The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container

Based on interview and record review the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 of 1 residents reviewed and 1 of 1 investigation reports reviewed for neglect. ( Residents #1) The facility failed to submit the Provider Investigation Report for the Resident #1's unwitnessed fall reported on 09/14/2021 within 5 working days 09/21/2021. This failure could place residents at risk for neglect and further injury from falls without appropriate corrective actions being taken. Findings include: Review of Resident #1's face sheet dated 10/21/2021 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 99 indicating severe cognitive impairment. Resident #1 was assessed to require extensive to dependent assist with all ADLs. Resident #1 was further assessed to not have falls during the assessment look back period. Review of Resident #1's Comprehensive Care Plan dated 05/24/2021 reflected Resident #1 was at risk for falls related to imbalance, weakness, confusion and poor safety awareness. Interventions included fall mats in place and if resident does fall to follow the facility protocol. Review of the facility's incident investigation worksheet for intake # 4 reflected the incident was reported to the state 09/14/2021. The intake noted that Resident #1 was found on the floor of his room laying on his left side/ face down with a left antecubital (upper forearm) skin tear, hematoma (internal bruising) to the top of his scalp, and bruising to the left side of his face. Review of the state reporting database on 10/21/2021: TULIP (Texas Unified Licensure Information Portal) for incident reflected the 3613-A, provider investigation report had been submitted on 10/21/2021 after surveyor intervention. The provider investigation report was due no later than 09/14/2021. In an interview on 10/21/2021 at 11:50 AM, the SW stated she was responsible for conducting the facility investigations and turning in the PIR reports. The SW stated she thought since the state was in the building after the incidents that she did not have to do the 5-Day reports. She stated it was her mistake and she would turn the PIR's in. In an interview on 10/21/2021 at 12:02 PM, the Administrator stated he had been at the facility since August. He stated the SW was responsible for turning in the PIRs. The Administrator stated he was not aware that the PIRs for the intakes had not been turned in but agreed the incident was reportable.

Based on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR for one (Resident #1) of 44 residents reviewed for advanced directives, in that: Resident #1 was found unresponsive in his room and nursing staff did not have Resident #1's correct code status in Resident #1's EMR and performed CPR on resident. Resident #1 was revived and sent by ambulance to the hospital where he was intubated until his RP was contacted and told the hospital to cease all life saving measures per the DNR. Resident #1 passed in the hospital that same afternoon. This failure affected placed residents at risk of not having their wishes known, respected, and implemented in emergency. Findings include: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old male with an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's EMR revealed the residents advanced directive was DNR status . Further review of the resident's advanced directives in the EMR revealed an attachment of a physician signed DNR dated [DATE]. Record review of Resident #1's EMR progress note dated [DATE] at 11:25 AM revealed Note Text: CNA notified nurse the patient was unresponsive in room. Nurse entered room patient in w/c slouched over, no pulse found, Crestview staff transferred patient to bed CPR started on patient, ambu bag used, EMS arrived, daughter notified, daughter made nurse aware DNR form was in works of being completed had spoken to social worker, nurse notified daughter patient would be transferred to ST Joseph ER due to obtaining a pulse, daughter stated she would head that way. DON notified. Interview on [DATE] at 11:00 AM ADM stated he expected the procedure of changing a code status to be performed as soon as possible. He stated the process would be better explained by the Social Worker because she was the one that handles the changes with the families and with the physician. Interview on [DATE] at 11:15 AM, SW stated Resident #1 was newly admitted . She stated the previous facility did not have an advance directive for the resident . She stated she spoke with the resident's RP at admission on [DATE] and they stated they wanted a DNR order . She stated the RP came to the facility on [DATE] and signed the DNR paperwork. She stated the facility physician signed the DNR on [DATE]. She stated in the morning meeting on [DATE] she notified Charge Nurse A the newly signed DNR order needed to be updated in the EMR. She stated Charge Nurse A took the physical copy of the DNR form and stated he would make the necessary change in the EMR. She stated since she is not a nurse, she could not make the order change in the EMR . When asked if this is typically how Code Status changes are handled, she stated it was. She stated the process: Family will sign the DNR with her, she leaves it with the charge nurse to give to the physician, the physician review's the resident's chart and signs off if she agrees. Once the physician signs the order, the Physician gives the SW the signed DNR and the SW updates the Code Status Binder with the most current information; then gives the form to the charge nurse on duty to update the EMR. Record review on [DATE] at 11:30 AM of 44 resident's code status in the EMR was compared with the Code Status Binders on both floors of the facility and they were all accurate and accounted for. Interview on [DATE] at 1:00 PM with RP stated she received a phone call from Charge Nurse A informing her that her father was found unresponsive, had CPR administered, and he was being sent to the hospital by EMTs. She stated she told Charge Nurse A that her father had a signed DNR and he should not have been revived. She stated her father was intubated and placed on a vent at the hospital. She stated she had to direct the hospital to stop all life support after she got to the hospital. She stated she spoke with the SW and the Administrator about the event and was not happy about how the situation was handled. Interview on [DATE] at 2:00 PM with Nurse B stated if a resident was unresponsive, she would check the Code Status Binder for current code status. She stated she was trained to check the binder first because it can take time for the Charge Nurse to update the EMR. Interview on [DATE] at 2:45 PM with Nurse C stated she was trained to always use the Code Status Binder for resident code status. She stated she needs to see the hard copy of the DNR to determine code status. She stated the certified copies of the DNR's are in the Code Status binder with the resident's face sheet. She stated sometimes it can take a few hours or more to have a code status changed in the EMR, so she does not rely on the EMR for code status. Interview on [DATE] at 11:15 AM Charge Nurse A stated he did remember SW handing him Resident #1's DNR in the morning meeting to update the EMR. He stated shortly after the morning meeting he was on the second floor doing rounds and was alerted by a CNA that Resident #1 was unresponsive. Charge Nurse A stated he went to the EMR to check the code status, saw it was 'Full Code' and proceeded performing CPR on Resident #1 and had staff call 911 to dispatch paramedics. Charge Nurse A stated, in the heat of the moment I totally forgot this was the resident that needed his code status changed. Charge Nurse A stated that had he changed the code status in the computer immediately after leaving the meeting he would not have performed unwanted life saving measures on Resident #1. He stated he was trained to check the binder first and the PCC if there was a question. He stated he did not check the Code Status Binder before performing CPR. Record review of facility's policy for cardiopulmonary resuscitation, revised in [DATE], reflected in part . Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Record review of facility's Policy for Advance Directives, revised in [DATE], reflected in part .The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. Record Review of facility's investigative report dated [DATE] revealed the physician signed the DNR between 8AM and 9AM on [DATE]. At 9AM the SW brought the DNR to the facility's morning meeting and handed it to Charge Nurse A. Less than three hours later, Resident #1 was found in his room unresponsive. Charge Nurse A checked the DNR book and PCC and did not find evidence of a DNR so began CPR and called 911. Resident #1 was transported to a local hospital. After Resident #1 was transported, Charge Nurse A remembered the DNR on his desk. The facility initiated the following corrective action. Facility will add to the procedure of updating the EMR for code status change to include the Social Worker safeguarding the form and standing at the Nurse's station until the EMR has been changed by the Nurse on duty.

Based on observation, interview and record review the facility failed to store, distribute and serve food in accordance with professional standards for one (1) of three (3) kitchens. A. The facility failed to properly label and store food. B. The facility failed to use proper sanitation procedures on the food serving line table when the cook touched potato salad with soiled gloves. C. The facility failed to maintain a proper temperature for cold foods on the serving line table. The deficient practice placed residents who were served from the kitchen at risk for foodborne illnesses and health complications. Findings included: Observation in the main kitchen on 02/03/2020 at 9:25 AM revealed a plastic container of ham on the food prep table not covered or labeled. Observation in the main kitchen on 02/03/2020 at 9:28 AM revealed leftover bread, rolls and hamburger buns on a cart not labeled or dated. Observation of the walk-in freezer in the main kitchen on 02/03/2020 at 9:33 AM revealed a large package of English muffins, bagels, rye bread, ravioli and flour tortillas not in the original package without a label or a date. Observation in the walk-in freezer further revealed leftover jalapeno dinner rolls not in the original package and without a label or a date. Observation of the walk- in freezer in the main kitchen on 02/03/2020 at 9:40 AM revealed six (6) individual cups of ice cream stored on the floor. Two (2) large containers (two Gallons each) of left over ice cream not labeled or dated. Observation of the main kitchen on [DATE]20 at 11:05 AM revealed a container of potato salad on the serving line table was 46 degrees and a container of slaw 42 degrees. Observation of the main kitchen on [DATE]20 at 11:10 AM revealed the cook dropped the thermometer on the kitchen floor. The cook was wearing gloves when she picked up the thermometer and the gloves touched the floor. Furthermore, the cook didn't change gloves and touched the potato salad on the serving line table. The potato salad was on the cook's gloves. In an interview on 02/03/2020 at 9:44 AM the Dietary Manager stated, The ham on serving line table wasn't going to be used for meals. Ham is to be covered and labeled. All foods not in original packaging does require a label and a date. Any leftover foods also required to have a label and a date. Storage of food is to be on shelves and not on floor anywhere in the kitchen, including freezer. In an interview on [DATE]20 at 11:15 AM the Dietary Manager stated, This is cross contamination when the cook touched the floor wearing gloves and then touched the potato salad. I expect all staff to change gloves and wash hands when needed. In an interview on [DATE]20 at 11:22 AM the Cook stated, I should have changed gloves and washed hands after I touched the floor. I did touch the potato salad with the dirty gloves. Review of Facility policy on Sanitation and Infection Control Receiving and Storage dated 01/2016 reflected Items are stored a minimum of 18 inches from the ceiling and 6 inches from the floor. Review of Facility Policy on Sanitation and Infection Control Labeling and Dating dated on 01/2016 reflected All foods are labeled, dated and securely covered and use-by dates are monitored and followed. Review of Facility Policy on Sanitation and Infection Control Food Safety dated 01/2016 reflected Cold foods are to be he held at 40 degrees or below. Review of Facility Policy on Sanitation and Infection Control Disposable Glove Use reflected Disposable gloves shall be worn while handling food ready to eat foods that do not require further cooking. Gloves shall be discarded after each use and if they are soiled, torn or contaminated. At no time shall the use of gloves be considered as a replacement for proper and frequent hand washing.

Based on observation, interview and record review the facility failed to ensure PRN (as needed) orders for psychoactive drugs were limited to 14 days unless the prescribing practitioner documented their rationale in the resident's medical record indicating the duration for the PRN order for two of five residents reviewed for unnecessary medications (Residents #10 and #14). A. The facility failed to have documented clinical rationale to continue Resident #10's [MEDICATION NAME] as needed for [MEDICAL CONDITION] ordered on [DATE] and [MEDICATION NAME] as needed for Anxiety ordered 01/12/2020 when they continued to be available for administration for greater than 14 days. B. The facility failed to have documented clinical rationale for Resident #14's PRN [MEDICATION NAME] as needed for panic attacks related to Anxiety dated initiated on 01/06/2020 and failed to have an acceptable [DIAGNOSES REDACTED]. These failures could lead to residents being sedated which could lead to decreased intake of food and fluid, decreased socialization and a lower quality of life for those residents on psychoactive medications. Findings included; A. Review of Resident #10's Face Sheet reflected she was an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Admission MDS dated [DATE] reflected a BI[CONDITION] score of zero which indicated severe cognitive impairment. Her mood assessment reflected two to six days out of 14 Resident #10 was tired, spoke slowly and was easily annoyed. Resident #10 required moderate assistance of one or two staff for all her ADLs. Review of her [DIAGNOSES REDACTED]. The MDS reflected she had taken an antipsychotic medication and an antidepressant every day of the observation period and an antianxiety medication three of seven days. Review of Resident #10's undated care plan reflected she was limited in her ability to communicate and participate in activities due to her [MEDICAL CONDITION] progression. The care plan further reflected she had anxiety and could be physically aggressive. Observation of Resident #10 on 02/03/20 at 03:55 PM revealed she was in a bed in low position with an alarm enabled. Resident could be wakened but she did not open her eyes for a while. She spoke to surveyor but was extremely calm, quiet with little self-initiated movement while nurse aide turned her side to side. Observation of Resident #10 on 02/03/20 at 12:36 PM revealed Resident was very calm and quiet with little self-initiated movement while being fed by her husband. She kept her eyes mostly shut while she had mechanical soft foods. Review of Resident #10's Order Summary Report dated printed on 02/05/2020 reflected she had an order for [REDACTED]. Orders reflected she was admitted to Hospice services on 11/01/2019. Review of Resident #10's Medication Administration Record [REDACTED]. Review of Resident #10's MAR indicated [REDACTED]. An anti-psychotic; [MEDICATION NAME] was discontinued on 01/17/2020. Review of Resident #10's Pharmacy Consultant recommendations fax dated 01/02/2020 reflected; This hospice resident has an order for [REDACTED].). The responding clinician wrote; Please clarify with Hospice and signed and dated it on [DATE]20. An additional copy of the same recommendation was faxed to the Hospice and the response, Stop [MEDICATION NAME], no other orders was signed 01/17/2020. The clinicians did not address the PRN [MEDICAL CONDITION] medications that were available for administration since November 2019 without clinical rationale for continuing the medication. B. Review of Resident #14's Face Sheet reflected she was an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's Admission MDS dated [DATE] reflected a BI[CONDITION] score of seven which indicated severe cognitive impairment. Her mood assessment reflected two to six days out of 14 Resident #14 was tired, spoke slowly and felt bad about herself or having let her family down. She required assistance of one or two staff for her ADLs. Resident #14 had received an antipsychotic and an antidepressant seven of seven days of the observation period. Review of Resident #14's undated care plan reflected she had a stroke and it caused overall weakness but affected the left side more. A care plan for potential medication side effects from psychoactive drugs reflected she took antidepressant, antianxiety, and antipsychotic medications. Review of Resident #14's Order Summary dated 02/05/2020 reflected orders for; [MEDICATION NAME] 0.25 mg one tablet by mouth every eight hours as needed for panic attacks related to Anxiety dated initiated on 01/06/2020. She also had orders for [MEDICATION NAME] 25 mg (an Anti-psychotic) one at bedtime for Anxiety (which is not a [MEDICAL CONDITION]) initiated on 1[DATE]19, [MEDICATION NAME] 100 mg once daily for Major [MEDICAL CONDITION], and [MEDICATION NAME] 100 mg one daily for Depression. Review of Resident #14's 01/01/2020 - 01/31/2020 MAR indicated [REDACTED]. Review of Resident #14's Pharmacy Consultant recommendations fax dated 01/02/2020 reflected; Resident has orders for both [MEDICATION NAME] and [MEDICATION NAME] 25 mg every night for restless legs. As [MEDICATION NAME] is an antipsychotic med and can increase fall risk, recommend (stop) [MEDICATION NAME] at this time. The consultant did not mention the facility needed a review and rationale for continuing the PRN [MEDICATION NAME]. Observation/interview of Resident #14 on 02/03/20 at 3:12 PM revealed Resident #14 was in the lobby in a fully reclined geri chair. Her mouth was visibly dry, (a potential side effect of medications) and she replied Yes, please when asked if she wanted a drink. Medication aide G gave her a full cup of water and then she was able to talk better. Resident #14 stated she does not feel excessively medicated or too sleepy. She conversed slowly in a very low voice without attempting to rise and stated the only thing she needed was chocolate. She was able to raise her right foot. In an interview on 02/05/2020 at 4:00 PM the DON stated [MEDICAL CONDITION] was not the correct [DIAGNOSES REDACTED]. She further stated Anxiety was not a correct [DIAGNOSES REDACTED]. The DON further stated she did not know the 14 day PRN rule applied to residents on Hospice and Resident #10 was on Hospice services. The DON stated the facility should have Resident #10 and Resident #14's PRN [MEDICAL CONDITION] medications reviewed and discontinued or have a physician's documented rationale for the continuation of the drug. Review of the policies provided by the facility reflected the facility did not have a policy which reflected the current guidelines for PRN [MEDICAL CONDITION] medication procedures. The facility provided a policy Tapering Medications and Gradual Drug Dose Reduction dated April 2007 which reflected; 1. After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. 5. The Physician will review periodically whether current medications are still necessary in their current doses; for example, whether an individual's conditions or risk factors are sufficiently prominent or enduring that they require medication therapy to continue in the current dose . or a lower dose. Review of the policy Antipsychotic Medication Use dated December 2016 reflected; 7. Antipsychotic medications shall generally be used only for the following [DIAGNOSES REDACTED].[MEDICAL CONDITIONS] disorder, Schizophreniform disorder, Delusional disorder, [MEDICAL CONDITION] disorder, depression with psychotic features, Refractory [MEDICAL CONDITIONS] in the absence of dementia, medical illnesses with psychotic symptoms, [MEDICAL CONDITION]'s disorder, [MEDICAL CONDITION]'s, Hiccups, or Nausea and Vomiting associated [MEDICAL CONDITION] or [MEDICAL CONDITION].

Based on interview and record review, the facility failed to ensure residents have a right to have a regular resident group meeting for eight (8) of eight (8) residents reviewed for resident council. (Residents #23, #30, #4, #3, #12, #20,#29 and #31). The facility failed to follow activity calendar to provide monthly resident council meetings. The deficient practice could place residents attending Resident Council meetings at risk of decreased confidence with administration, decreased resident rights and a decreased quality of life. Findings included: Record Review of the past years Resident Council Minutes reflected Resident Council met seven (7) out of twelve (12) months in the past year. The Resident Council did not meet during the months of : January 2019, February 2019, March 2019 , August 2019 and September 2019. Record Review of the past year Activity Calendars reflected Resident Council was on the calendar for each month of January 2019 through January 2020. In an interview on [DATE]20 at 10:05 AM Members of the Resident Group stated, We want to have Resident Council Meetings every month. We want to discuss different things in a group meeting. In an interview on [DATE]20 at 1:35 PM the Lifestyle Enrichment Coordinator stated I have given you all the Resident Council Minutes. We are to meet every month and it is on the monthly activity calendar. The Coordinator further stated it was his responsibility to ensure the meetings were conducted and recirded. In an interview on 02/05/2020 at 8:37 AM the Administrator stated Resident Council is on the monthly activity calendar and to meet every month. If Resident's do not want to meet on a particular day it can be rescheduled for another day in the same month. Review of Facility's Policy of Resident Council on 04/2017 reflected Council meetings are scheduled monthly or more frequently if requested by residents. The date, time and location of the meetings are noted in the Activity Calendar.