Based on observation, interview, and record review, the facility failed to ensure there was a full-time qualified person responsible for food and nutrition services (FNS) when the Registered Dietitian and Dietary Services Supervisor (DSS) were employed part time and failed to provide the required number of hours for oversight of FNS. This failure resulted in a lack of oversight for food and nutrition services and had the potential to compromise the dietary and nutritional needs of the residents. (Cross reference F812) Findings: During a concurrent observation and interview on 10/7/24 at 10:44 a.m. with Dietary Aide (DA) 1, DA 1 was in the kitchen with a hair restraint on, hair was hanging out of the restraint around her ears, temples, and forehead. DA 1 stated the Dietary Services Supervisor (DSS) was off and because she had a full-time job at a different facility. During a concurrent interview and record review on 10/7/24 at 10:49 a.m. with the Assistant [NAME] (AC), the AC stated the DSS was part time and would normally come to the facility on weekends, in the evenings or early mornings. The DSS sign in sheet for 10/2024 was reviewed and indicated she was at the facility on the following dates and times: 10/1/24 5:15 a.m.-6:02 a.m. 10/2/24 4:07 p.m.-7:18 p.m. 10/3/24 5:06 a.m.-6:04 a.m., 4:28 p.m.-8:05 p.m. 10/4/24 5:32 a.m.-2:18 p.m. 10/5/24 5:14 a.m.-9:01 a.m., 9:31 a.m.-1:05 p.m. No hours were recorded for 10/6/24 or 10/7/24. During a concurrent observation and interview on 10/7/24 at 10:58 a.m. with the [NAME] (CK), the cook had a hair restraint on with hair exposed on all sides of her head. The CK stated she should have her hair completely covered because it could shed and contaminate the food while she was cooking. During an interview on 10/7/24 at 11:06 a.m. with DA 1, DA 1 stated the cart with the personal items should not have been in the kitchen. DA 1 stated the items could have cross contaminated the food. During an observation on 10/7/24 at 10:58 a.m. with DA 2, DA 2 had loose hair hanging out of the hair restraint above her ears. During an interview on 10/7/24 at 11:15 a.m. with the AC, the AC stated the FNS staff needed a full-time supervisor for oversight of the kitchen. During an interview on 10/7/24 at 12:31 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the Infection Preventionist for the facility. LVN 1 stated she would do audits weekly in the kitchen to monitor for cleanliness and expired food products. LVN 1 stated the DSS was not full time at the facility, and she was not sure what the regulations were for the hours of FNS oversight. During a concurrent interview and record review on 10/7/24 at 12:50 p.m. with the Payroll Assistant (PA) and Payroll Manager (PM), the RD's time sheets were reviewed. The PA stated the RD was a part time consultant. The RD's time sheets indicated the RD charged 6 hours weekly to the facility. The PM stated the DSS was hired part time on 8/20/23 but had not started as the DSS until 2024. The DSS' time sheets were reviewed and indicated she had worked the following hours every pay period: 6/1/24-6/15/24- 25:15 hours 6/16/24-6/30/24-36:45 hours 7/1/24-7/15/24-33:15 hours 7/16/24-7/31/24-29:00 hours 8/1/24-8/15/24-18:15 hours 8/16/24-8/31/24-37:30 hours 9/1/24-9/15/24-48.45 hours 9/16/24-9/30/24-42.45 hours The PA stated the facility was paid based a 2 week pay period and fulltime employment would be 70-80 hours per pay period. The PA stated the DSS was currently part time. During a telephone interview on 10/7/24 at 4:50 p.m. with the RD, the RD stated she was a consultant and worked for the facility six hours per week. The RD stated she was onsite every other week and remote the opposite weeks. The RD stated the DSS should be full time and part time coverage did not offer proper oversight of the FNS. The RD stated the DSS' duties included ordering the food, verifying staff met competencies, retraining staff as needed, overall discipline and inventory. The RD stated her primary responsibility was to provide overall oversight making sure the DSS was managing FNS. The RD stated she was unaware the DSS was not full time at the facility. During a telephone interview on 10/7/24 at 5:12 p.m. with the DSS, the DSS stated she was working at the facility part time. The DSS stated her duties included scheduling, inventory, monitoring the kitchen, checking food expiration dates, staff training and in-services. The DSS stated the facility should have a full time DSS since the RD was not full time. The DSS stated she tried to be at the facility most days, even if it was only for a couple hours. The DSS stated she had been part time as the DSS since 3/2024. The DSS stated she would need to be at the facility full time fulfill all her job duties. During a review of the FNS Director job description dated 2023, indicated, . Must meet the qualifications of a FNS Director as stated under State & Federal regulations . Duties and Responsibilities . schedule and supervise the Food & Nutrition Services Staff providing in-service training . Is responsible for the preparation and service of all food . Plan kitchen procedure to have food ready on time . Test cooked food by taste to determine if properly cooked and seasoned . maintaining cleanliness of kitchen equipment, and follows all department of health regulations . weekly inventory of food assuring that sufficient supplies are on hand . Make menu adjustments . with final approval of the Facility Registered Dietitian . Maintain resident diet card . Visit residents to determine food acceptance and preferences . responsible for the ordering of food and supplies, checking delivery, supervising storage, signing invoices, and keeping record of food costs . Complete Nutritional Screening form on new residents, MDS and documents all residents quarterly . Review, update, and follow policies & procedures . Attend weight variance meetings . During a review of the facility's job description titled, General Scope of Registered Dietitian's Duties, dated 2023, the job description indicated, . A qualified FNS Director . is responsible for the total operation of the Food & Nutrition Services Department . If a person is not a Registered Dietitian, they must meet the Federal and State laws and receive regular consultation from a Registered Dietitian . Responsibilities of FNS Director . Maintaining acceptable standards of sanitation and food safety . Complete resident dietary profile, nutritional screening, quarterly note, and annual review . Observe residents at mealtime . The Facility Registered Dietitian is a registered member of the Academy of Nutrition and Dietetics, (AND) and is a staff member employed full-time, part-time, or on a consultant basis, depending on the needs of the facility . HSC 1265.4 states a) A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. (b) The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food services safety when: 1. The spice storage area contained food products which were not discarded on or before the expiration dates according to facility policies. 2. There was a cart with multiple personal belongings and used items in the kitchen area. 3. Four of four staff did not have their hair properly covered by a hair restraint. These failures placed residents at risk for foodborne illness and contamination. (Cross reference F801) Findings: During an observation on 10/7/24 at 10:44 a.m. with Dietary Aide (DA) 1, DA 1 was in the kitchen and her hair restraint was not covering the hair around her ears, temples, and forehead. During an observation on 10/7/24 at 10:49 a.m. with the Assistant [NAME] (AC), the AC did not have her hair restraint on properly, exposing a large amount of hair above both ears. During a concurrent observation and interview on 10/7/24 at 10:53 a.m. with the AC, a rolling cart was observed in the kitchen, under the office window, next to the handwashing sink. The items on the cart included empty egg cartons, food in plastic resealable bags, personal bags, coffee mugs, water bottles, a pack of chewing gum, paper plates, a jar full of a milky substance and an unmarked jar of a dark fluid. The AC stated the cart with personal items should not be in the kitchen due to potential for cross contamination with the food. The AC pushed the cart out of the kitchen. During a concurrent observation and interview on 10/7/24 at 10:58 a.m. with the [NAME] (CK), the cook had a hair restraint on with hair exposed on all sides of her head. The CK stated she should have her hair completely covered because it could shed and contaminate the food while she was cooking. During an interview on 10/7/24 at 11:06 a.m. with DA 1, DA 1 stated the cart with the personal items should not have been in the kitchen. DA 1 stated the items could have cross contaminated the food. During an observation on 10/7/24 at 10:58 a.m. with DA 2, DA 2 had loose hair hanging out of the hair restraint above her ears. During a concurrent observation, interview and record review on 10/7/24 at 11:15 a.m. with the AC, a bottle of vanilla extract was on the shelf above the preparation table with an open date marked on it of 6/20/2022. The AC walked to the dry storage area and reviewed a spreadsheet of expiration dates and stated the bottle should have been thrown away 6 months after opening. There was a bottle of chili powder on the shelf with an open date of 6/20/22. The AC stated expired food could be contaminated and cause the residents to become ill. The AC stated the FNS staff needed a full-time supervisor for oversight of the kitchen. During an interview on 10/7/24 at 12:31 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the Infection Preventionist for the facility. LVN 1 stated she would do audits weekly in the kitchen to monitor for cleanliness and expired food products. LVN 1 stated she had not seen the vanilla extract and chili powder opened in 2022 during her audits. LVN 1 stated expired food products were not safe because they could grow bacteria. LVN 1 stated she was aware of the cart with personal items in the kitchen but thought it was on the far edge of the kitchen, so it was not an issue. During a telephone interview on 10/7/24 at 4:50 p.m. with the RD, the RD stated she works at the facility 6 hours weekly, onsite every other week and remotely on the opposite weeks. The RD stated she was unaware the DSS was not full time. The RD stated less than fulltime coverage by the RD was not proper oversight of the FNS. The RD stated it was important for the DSS to be full time to make sure she was ordering the food, verifying staff meet competencies, retraining staff as needed, overall discipline and inventory. The RD stated her primary responsibility was to provide over all oversight making sure the DSS was managing the FNS. During a telephone interview on 10/7/24 at 4:50 p.m. with the RD, the RD stated she worked for the facility six hours per week. The RD stated she was onsite every other week and remote the opposite weeks. The RD stated she would do a sanitation audit in the kitchen monthly, but she had not seen the vanilla extract and chili powder opened in 2022. The RD stated they should not be in the kitchen available to use. The RD stated they could cause cross contamination and illness. The RD stated hair restraints should be on and covering all hair to prevent physical contamination of the food. The RD stated the DSS should be full time and part time coverage did not offer proper oversight of the FNS. The RD stated the DSS' duties included ordering the food, verifying staff met competencies, retraining staff as needed, overall discipline and inventory. The RD stated her primary responsibility was to provide overall oversight making sure the DSS was managing FNS. During a telephone interview on 10/7/24 at 5:12 p.m. with the DSS, the DSS stated she worked at the facility part time. The DSS stated her duties included scheduling, inventory, monitoring the kitchen, checking food expiration dates, staff training and in-services. The DSS stated she was not aware there were foods on the shelf opened in 2022. The DSS stated they should have been thrown out for the resident's safety. The DSS stated she expected the staff to have the hair restraint covering all hair with none exposed so hair did not fall into the food. The DSS stated the cart with the personal belongings should not be in the kitchen and it had been an ongoing issue. The DSS stated her expectation was for the staff to keep their belongings in the breakroom. The DSS stated the cart could cause cross contamination of the food. During a review of the FNS Director job description dated 2023, indicated, . Must meet the qualifications of a FNS Director as stated under State & Federal regulations . Duties and Responsibilities . schedule and supervise the Food & Nutrition Services Staff providing in-service training . Is responsible for the preparation and service of all food . Plan kitchen procedure to have food ready on time . Test cooked food by taste to determine if properly cooked and seasoned . maintaining cleanliness of kitchen equipment, and follows all department of health regulations . weekly inventory of food assuring that sufficient supplies are on hand . Make menu adjustments . with final approval of the Facility Registered Dietitian . Maintain resident diet card . Visit residents to determine food acceptance and preferences . responsible for the ordering of food and supplies, checking delivery, supervising storage, signing invoices, and keeping record of food costs . Complete Nutritional Screening form on new residents, MDS and documents all residents quarterly . Review, update, and follow policies & procedures . Attend weight variance meetings . During a review of the facility's policy and procedure (P&P) titled Dress Code, dated 2023, the P&P indicated, . Personal Hygiene and appropriate dress are a very important part of the total appearance of the Food * Nutrition Services Department . Proper Dress . Hat for hair, if hair is short, which completely covers the hair . Hair net for hair, if hair is long . If applicable, beards and mustaches (any facial hair) must wear beard restraint .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notification of the Bed-hold notice at the time of transfer for one of three sampled residents (Resident 1), when Resident 1 was transferred to the acute care hospital (ACH) on 7/11/24 and the responsible party (RP) was not provided the written Bed-hold notice which specifies the duration of the Bed-hold policy according to federal regulations. This failure placed Resident 1 at risk for his resident rights to be violated. (Cross reference F626) Findings: During a telephone interview on 8/5/24 at 3:13 p.m. with Resident 1 ' s family member (FM) 1, FM 1 stated Resident 1 was transferred from the skilled nursing facility (SNF) to the ACH on 7/11/24. FM 1 stated the ACH had notified the Responsible Party (RP) they were ready to discharge Resident 1 back to the Skilled Nursing Facility (SNF) on 7/18/24 and the SNF had refused to readmit the resident. During an interview on 8/6/24 at 10:20 a.m. with the Administrator (ADM) and Director of Nursing (DON), the ADM stated Resident 1 was transferred to the hospital and was not readmitted to the facility. The ADM stated the family had not provided Resident 1 ' s insurance upon admission and would not pay Resident 1 ' s bill. The DON stated Resident 1 was admitted to the SNF on 6/28/24 and transferred to the ACH on 7/11/24 for diabetic ketoacidosis (DKA-serious and potentially life-threatening complication of diabetes [disease in which the body does not control the amount of blood sugar in the blood]). During a review of Resident 1 ' s admission Record (AR), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis of Type 2 diabetes mellitus with ketoacidosis without coma (a stated of deep unconsciousness), dementia with behavioral disturbance (disruptive behavior) and malignant neoplasm (cancerous tumor) of the colon (longest part of the large intestine). During an interview and record review on 8/6/24 at 11:43 a.m. with Social Services (SS), SS stated Resident 1 was transferred to the ACH on 7/11/24. SS stated she received a call from Resident 1 ' s RP after he was transferred to request a Bed-hold. SS reviewed Resident 1 ' s electronic medical record (EMR) and was unable to locate any documentation regarding her conversation with the RP. SS stated the RP had signed the Bed-hold policy during Resident 1 ' s admission to the SNF but was unable to locate documentation a written Bed-hold notice was provided at time of transfer to the ACH. SS was unable to locate any notes indicating she had spoken to the RP regarding the Bed-hold. SS stated the Business Office Manager (BOM) handled Bed-holds after a resident was admitted and she had notified the BOM of Resident 1 ' s transfer. During a concurrent interview and record review on 8/6/24 at 12:06 p.m. with the Business Office Manager (BOM), the BOM stated Resident 1 ' s RP signed the Bed-hold policy on admission. Resident 1 ' s [name of SNF] Bed Hold Policy, signed by the RP on 6/28/24, was reviewed. The policy indicated, . California Law requires . to hold a bed for up to seven (7) days for any Resident who is transferred to a General Acute Care Hospital (GACH). This is known as a Bed Hold. If the Resident ' s care is paid under the Medi-Cal program, Medi-Cal will pay for up to seven (7) day bed hold period . The BOM stated it was the family ' s responsibility to contact the facility for a Bed-hold when a resident was transferred. The BOM stated she made a courtesy call to the resident ' s RP and notified the RP they would need to pay for the Bed-hold. Resident 1 ' s progress note dated 7/18/24, at 10:22 a.m. indicated, . Late entry: Called resident ' s wife . no answer, unable to leave message. Discussed with the DON Re: [regarding] BH [bed hold] & re-admission in question since no medical [Medi-Cal] eligibility in place and for Medicare eligibility, resident has a Manage[d] Medicare Advantage Plan . The BOM stated since the Bed-hold was not paid for by the family or Medi-Cal, she had discharged Resident 1 from the facility on 7/11/24. During a telephone interview on 8/19/24 at 1:26 p.m. with the BOM, the BOM stated when Resident 1 was transferred to the hospital, the facility does not provide a written Bed-hold notice to residents. The BOM stated the facility ' s process was to provide a written Bed-hold policy during admission on ly and if a resident was transferred after admission, the notice was provided by phone. During a review of the facility ' s policy and procedure (P&P) titled Transfer and Discharge Requirements, undated, the P&P indicated, . It is the policy of this facility to permit each resident to remain in the facility and not transfer or discharge the resident unless condition or circumstances warrant . One of the following reasons must be noted in the clinical record of all transferred or discharged residents . The transfer or discharge is necessary for the resident ' s welfare and the resident ' s needs cannot be met in the facility . safety of individuals in the facility is endangered . health of individuals in the facility is endangered . The resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility . Written notice of the discharge or transfer must be given to the resident and, if known, legal representative or family member . During an interview on 8/27/24 at 3:31 p.m. the facility ' s P&P titled Transfer and Discharge Requirements was reviewed. The ADM stated the facility has residents/RPs sign a written bed hold policy on admission but does not provide a written Bed-hold policy when transferred to the ACH. The ADM stated Resident 1 ' s RP was not provided a written Bed-hold notice when he transferred to the ACH. The ADM stated, I don ' t know if the P&P was followed. During a review of the facility ' s P&P titled Bed Hold: Medical Record Readmission/Closure Policy, undated, the P&P indicated, . This policy applies irrespective as to whether a bed-hold applies . At time of transfer out . The Notice of Transfer/Discharge form and the Bed Hold Policy form must be complete . During a review of Federal Regulations for Transfer and Discharge, the regulations indicated, . Notice of Bed-Hold Policy . All facility must have policies that address holding a resident ' s bed during periods of absence, such as during hospitalization . facilities must provide written information about these policies to residents prior to and upon transfer . This information must be provided to all facility residents, regardless of their payment source . These provisions require facilities to issue two notices related to bed-hold policies . first notice could be given well in advance of any transfer . second notice must be provided to the resident, and if applicable the resident ' s representative, at the time of transfer, or in cases of emergency transfer within 24 hours .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were hospitalized were permitted to return to the facility for one of three sampled residents (Resident 1) when the facility refused to take Resident 1 back after Resident 1 was medically cleared (when a patient no longer needs to receive inpatient care) to return to the facility from the acute care hospital (ACH). This failure placed Resident 1 at risk for psychosocial harm by not allowing the resident to return to the skilled nursing facility (SNF) near his home and caused him to be transferred to a SNF in a different city. This caused a hardship for Resident 1 ' s spouse when she had to decrease the frequency of her visits to the resident. (Cross reference F625) Findings: During a telephone interview on [DATE] at 3:13 p.m. with Resident 1 ' s family member (FM) 1, FM 1 stated Resident 1 was transferred from the skilled nursing facility (SNF) to the ACH on [DATE]. FM 1 stated the ACH had notified the responsible party (RP) they were ready to discharge Resident 1 back to the SNF on [DATE] and the SNF had refused to accept the resident. FM 1 stated the facility would not provide a clear answer why they refused to allow the resident to return. FM 1 stated the facility was close to Resident 1 ' s home and moving the resident to a facility in another city created a hardship for the family and placed stress on the resident due to diagnosis of dementia (loss in function of thinking, remembering, and reasoning interfering with daily life) and confusion. FM 1 stated Resident 1 ' s spouse was unable to visit the resident as often. During an interview on [DATE] at 10:20 a.m. with the Administrator (ADM) and Director of Nursing (DON), the DON stated Resident 1 was admitted to the SNF on [DATE] and transferred to the ACH on [DATE] for diabetic ketoacidosis (DKA-serious and potentially life-threatening complication of diabetes [disease in which the body does not control the amount of blood sugar in the blood]). The ADM stated Resident 1 was not allowed to return to the SNF because he was private pay and had not paid the bill. The ADM stated Resident 1 ' s seven-day Bed-hold had expired. The ADM stated Resident 1 was also not allowed to return because he had behaviors the facility considered dangerous to the other residents. During a review of Resident 1 ' s admission Record (AR), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis of Type 2 diabetes mellitus with ketoacidosis, dementia with behavioral disturbance (disruptive behavior) and malignant neoplasm (cancerous tumor) of the colon (longest part of the large intestine). During a concurrent interview and record review on [DATE] at 11:20 a.m. with LVN 1, Resident 1 ' s Nurse ' s Note (NN), dated [DATE] at 10:11 a.m. was reviewed. The NN indicated, . Resident appeared clammy and noted with labored breathing. Resident was unable to be aroused with verbal or physical stimuli . BS [blood sugar] 446 . [name of physician] notified via phone and gave order to send to [name of ACH] ER [emergency department] . LVN 1 stated Resident 1 ' s blood sugar results while in the facility ranged between 125 and 450 prior to hospitalization. LVN 1 stated Resident 1 ' s medication had been adjusted as needed to control his blood sugar. Resident 1 ' s MAR dated 7/2024 for behavior monitoring was reviewed and indicated Resident 1 had 10 behaviors on [DATE], one behavior on [DATE], and one behavior on [DATE]. LVN 1 stated Resident 1 ' s behaviors mostly consisted of yelling and did not place other residents in danger. LVN 1 stated the facility was able to provide the necessary care to other residents with diabetes and/or behaviors. LVN 1 stated she was not sure why Resident 1 was not allowed to return to the facility but was told there were issues with billing. During an interview and record review on [DATE] at 11:43 a.m. with Social Services (SS), SS stated after Resident 1 was transferred to the ACH she received a phone call from Resident 1 ' s (responsible party) RP requesting a Bed-hold. SS reviewed Resident 1 ' s electronic medical record (EMR) and was unable to locate any documentation regarding her conversation with the RP. SS stated Resident 1 ' s wife did not agree to pay for a Bed-hold, and she had told the RP to follow up with the Business Office Manager (BOM). SS stated the facility held an Interdisciplinary Team (IDT-) meeting on [DATE] to discuss Resident 1 ' s return and the IDT had determined the resident required a higher level of care. SS was unable to clarify if Resident 1 was discharged due to the Bed-hold expiring or needing a higher level of care. SS responded, I believe it was both. SS stated Resident 1 required total care and had behaviors which also contributed to the resident to returning to the SNF. SS stated there were other residents in the facility who had behaviors and the facility provided care to them. During a concurrent interview and record review on [DATE] at 12:06 p.m. with the Business Office Manager (BOM), the BOM stated Resident 1 ' s RP signed the Bed-hold policy on admission. Resident 1 ' s [name of SNF] Bed Hold Policy, signed by the RP on [DATE], was reviewed. The policy indicated, . California Law requires . to hold a bed for up to seven (7) days for any Resident who is transferred to a General Acute Care Hospital (GACH). This is known as a Bed Hold. If the Resident ' s care is paid under the Medi-Cal [public health insurance program] program, Medi-Cal will pay for up to seven (7) day bed hold period . The BOM stated it was the family ' s responsibility to contact the facility for a Bed-hold when a resident was transferred. The BOM stated she made a courtesy call to Resident 1 ' s RP and notified the RP they would need to pay for a Bed-hold. Resident 1 ' s progress note dated [DATE], at 10:22 a.m. indicated, . Late entry: Called resident ' s wife . no answer, unable to leave message. Discussed with the DON Re: [regarding] BH [bed hold] & re-admission in question since no medical [Medi-Cal] eligibility in place and for Medicare [eligibility, resident has a Manage[d] Medicare Advantage Plan . The BOM stated since the Bed-hold was not paid for by the family or Medi-Cal, she had discharged Resident 1 from the facility when he was transferred to the hospital on [DATE]. The BOM stated the SNF was responsible to take their residents back after hospitalization. During an interview on [DATE] at 12:31 p.m. with the DON, the DON stated Resident 1 was transferred to the ACH because his blood sugar was out of control. Resident 1 ' s Interdisciplinary Team (IDT) note dated [DATE], at 9:48 a.m. was reviewed. The IDT note indicated, . IDT team met to discuss resident possibly returning to the facility after acute [ACH] stay. It appears resident needs a higher level of care then [than] the facility is able to provide, and readmission isn ' t possible at this time . The DON stated it was the facility ' s responsibility to allow residents to return after they are hospitalized . The DON stated Resident 1 needed a higher level of care because she was worried, he would go into a diabetic coma. The DON stated, his blood sugars were sporadic, kept shooting up to 400. The DON stated Resident 1 ' s blood sugar was scary for us. The DON stated, we usually have no problem taking residents back. If they have a condition we can manage, we do take [them] back. The DON stated the facility had other diabetics they were able to care for. The DON stated Resident 1 had behaviors, but they were not the reason he was not allowed to return. During a telephone interview on [DATE] at 2:55 p.m. with the RP, the RP stated the day after Resident 1 was admitted to the ACH she spoke with SS and was told Resident 1 ' s bed was placed on hold. The RP stated the BOM called her the next day on [DATE] and asked if she had Resident 1 ' s Medi-Cal number but did not notify her they had not placed the resident ' s bed on Bed-hold. The RP stated on [DATE] the ACH case manager called to notify her Resident 1 was ready for discharge, but the facility would not allow him to return. During a review of Resident 1 ' s ACH document titled Face Sheet, dated [DATE], the FS indicated, . Coverage Information . 1. [name of Medicare plan] . 2. Medi-Cal/Medi-Cal Share of Cost . During a review of Resident 1 ' s Financial Arrangements, dated [DATE], the document indicated, . Beginning on [DATE] . we will provide routine nursing and emergency care and other services to you in exchange for payment . At the time of admission, payment for the care we provide to you will be made by . Resident (Private Pay) [checked] . Medi-Cal [checked] . During a telephone interview on [DATE] at 1:42 p.m. with SS, SS stated She had checked the box for Medi-Cal on the Financial Arrangements because the family had stated Resident 1 had Medi-Cal. SS stated Resident 1 ' s bed was not placed on hold because the family had not provided the Medi-Cal information. During an interview on [DATE] at 3:31 p.m. with the ADM, the ADM the federal regulations indicate if the facility was able to provide care for the resident, they had to allow the resident to return. The ADM stated the DON had decided the Resident needed a level of care the facility could not provide. During a review of Resident 1 ' s ACH document titled Initial Care Coordination Note, dated [DATE], the note indicated, . Expected Discharge Disposition . Skilled Nursing Facility . Patient/Family Goals . Wife want[s] pt [patient] placed in LTC [long term care] . Has recently been at [name of SNF] for rehab to LTC but the facility is not willing to accept him back . During a review of Resident 1 ' s ACH document titled ED to Hosp [hospital]-Admission, dated [DATE], the document indicated, . Assessment and plan . Altered level of consciousness . Septic shock present on admission . Diabetic ketoacidosis . Urinary tract infection . Plan Admit to ICU . During a review of Resident 1 ' s ACH document titled Initial Care Coordination Note, dated [DATE], the note indicated, . Expected discharge date : [DATE] . Patient/Family Goals: Back to [name of SNF] . During a review of Resident 1 ' s ACH document titled Initial Care Coordination Note, dated [DATE], the note indicated, . Known to CM [case manager] d/t [due to] prior admissions. Has recently been at [name of SNF] for rehab to LTC [long term care] butt [sic] the facility is not willing to accept him back . During a review of the facility ' s policy and procedure (P&P) titled, Bed Hold: Medical Record Readmission/Closure Policy, undated, the P&P indicated, . This policy applies irrespective as to whether a bed-hold applies . There may be times that it would be better served to close a record of a resident on bed hold irrespective of whether a resident is on a bed hold or not. This addendum allows a chart to be closed and new record reopened on re-entry on a case-by-case basis with the review of the Director of Nursing Services . The record of a resident transferred/discharged to an acute care facility may be closed and completed as a discharged record if the resident does not return to the facility within: [left blank] days or [left blank] days of transfer/discharge to an acute care facility . At time of transfer out . The transfer order from the physician will include the reason for transfer . The transfer form will be completed, including resident specific information current on transfer . The transfer form and the licensed nurse ' s note will contain the specific reason for transfer . During a review of the facility ' s P&P titled, Transfer and Discharge Requirements, undated, the P&P indicated, . Transfer and discharge includes movement of a resident to a bed outside of the certified facility . One of the following reasons must be noted in the clinical record of all transferred or discharged residents . Transfer or discharge is necessary for the resident ' s welfare and the resident ' s needs cannot be met in the facility . transfer or discharge is appropriate because the Resident ' s health has improved . safety of individuals in the facility is endangered . health of individuals in the facility is endangered . the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility . facility ceases to operate .

2. During an observation and interview on 6/18/24, at 10:28 a.m., with Resident 128, inside Resident 128's room, Resident 128's urinary catheter bag containing urine was hung to her wheelchair uncovered. Resident 128 stated she was not aware that it should be covered at all times to preserve her dignity. During a concurrent observation and interview on 6/18/24, at 11:00 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 128's room, LVN 1 validated the urinary catheter bag has urine and was not covered. LVN 1 stated Resident 128's urinary catheter bag should have been placed in a dignity bag to ensure privacy. During an interview on 6/20/24, at 9:48 a.m., with the Director of Nursing (DON), the DON stated the urinary catheter bag should have been covered to ensure resident dignity was maintained. The DON stated the facility failed to follow the facility's policy on maintaining Resident 128's dignity at all times. During a review of Resident 128's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 6/20/24, the AR indicated, Resident 128 was admitted from an acute care hospital on 6/6/24 to the facility, whose diagnoses included Malignant Neoplasm of Bladder (bladder cancer), Hypertension (high blood pressure), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Constipation. During a review of Resident 128's Nursing Careplan (CP), dated 6/8/24 was reviewed. The CP indicated, . The resident has Left nephrostomy tube . Interventions . Foley bag should be placed below the bladder and placed in a privacy bag Resident prefers to use Foley bag to drain urine . During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2/21, the P&P indicated . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered . Based on observation, interview and record review, the facility failed to ensure two of 12 sampled residents (Resident 128 and 19) were treated with dignity and respect when: 1. Resident 19 was assisted with lunch by Certified Nursing Assistant (CNA) 1, CNA 1 did not engage in conversation and did not inform the resident when she was providing beverages, spoons with food or wiping her face. This failure resulted in Resident 19 not being provided a respectful and dignified dining experience which could further enhance resident's quality of life. 2. Resident 128's urinary catheter (a flexible tube inserted through a narrow body opening into the bladder and used for draining urine) bag was left uncovered. Findings: 1. During an observation on 6/19/24 at 12:20 p.m. in the facilities dining room, CNA 1 was seated next to Resident 19 assisting her with her lunch. Resident 19 was nonverbal; her eyes were closed, fists clenched, and she was unable to feed herself. Resident 19 had a white cloth fastened around her neck covering the front of her chest area. CNA 1 was placing spoons of food and up to Resident 19's mouth, when Resident 19's lips would part CNA 1 would put the spoon in Resident 19's mouth. Resident 19 would grimace after each spoon full of food. CNA 1 would place the beverage up to Resident 19's mouth and when her lips would part CNA 1 would pour the beverage in her mouth without informing her it was liquid. CNA 1 would take the cloth around Resident 19's neck and wipe her face without warning her. CNA 1 was calling out to other residents in the dining room, engaging in conversation with Licensed Vocational Nurse (LVN) 1 but did not engage in conversation with Resident 19, while assisting her. During an interview on 6/19/24 at 12:25 p.m. with CNA 1, CNA 1 stated she would not want to be fed the way she was feeding Resident 19. CNA 1 stated Resident 19 should have been her only focus, she should have been informing her what she was attempting to put in her mouth and identify between beverage or food. CNA 1 stated she should have warned her prior to wiping her face as to not startle Resident 19. CNA 1 stated she was not feeding Resident in a dignified manner, and she was not following the facility policy or meeting the facilities expectations. During an interview on 6/19/24 at 12:29 p.m. with LVN 1, LVN 1 stated she was present in the dining room at the time of the incident. LVN 1 stated CNA 1 was not assisting Resident 19 per the policy or facility expectations. LVN 1 stated CNA 1 should have been focused on Resident 19 and not engaged in conversations with other residents and staff including herself. LVN 1 stated she would not like to be fed the way CNA 1 was feeding Resident 19. LVN 1 stated she would feel embarrassed or even scared not knowing what was happening. During an interview on 6/19/24 at 10:11 a.m., with the Director of Nurses (DON), the DON stated CNA 1 did not treat Resident 19 with dignity or respect when she did not engage with the resident and did not inform her what she was putting in her mouth. The facility expects staff to always follow policy and procedure, all residents are to be always treated with respect and dignity. During a review of Resident 19's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 6/20/24, the AR indicated, Resident 19 was admitted from an assisted living facility on 9/15/22 with diagnosis of, Dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Anemia (lack of healthy red blood cells), hypothyroidism (happens when the thyroid gland doesn't make enough thyroid hormone), and Vitamin D deficiency. During a review of Resident 19's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/31/24, the MDS section C indicated Resident 3 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 19 had severe cognitive impairment During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2/21, the P&P indicated . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . 5. When assisting with care, residents are supported n exercising their rights . e. provided with a dignified dining experience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide services which met professional standards of practice for 17 of 25 sampled residents (Residents 1, 2, 3, 4, 6, 10, 11, 12, 13, 14, 15, 17, 18, 19, 21, 127, and 128) when: 1. LVN 1 failed to explain the medication name and indication to Resident 1, 13, 18, 21, 127, and 128 during medication administration. This failure had the potential to place Residents 1, 13, 18, 21, 127, and 128 at risk of receiving the wrong medication and experience unnecessary side effects. 2.The facility failed to have a Licensed Nurse confirm the lunch meal tray matched residents' dietary orders for Residents 2, 3, 4, 6, 10, 11,12, 13, 14, 15, 17, 18, 19, and 21. This failure had the potential to place Residents 2, 3, 4, 6, 10, 11,12, 13, 14, 15, 17, 18, 19, and 21, at risk of receiving the wrong meal, choking, allergic reactions and weight loss. Findings: 1. During a medication pass observation on 6/18/24, at 11:01 a.m., inside Resident 127's room, LVN 1 administered Gabapentin (medication for nerve pain or inflammation) 100 MG (milligram, unit of measurement) capsule without explaining the medication and indication to Resident 127. During a review of Resident 127's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 6/21/24, the AR indicated, Resident 127 was admitted from an acute care hospital on 5/28/24 to the facility, whose diagnoses included Hypertension (high blood pressure), Anemia (low iron), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Neuralgia (pain cause by damage nerves) and Neuritis (inflammation of nerves). During a review of Resident 127's Medication Administration Record (MAR), dated 6/24, the MAR indicated, . Gabapentin oral capsule 100 MG. Give 1 capsule by mouth three times a day for nerve pain . Order date 5/28/24 . During a medication pass observation on 6/18/24, at 11:05 a.m., inside Resident 1's room, LVN 1 administered Gabapentin 100 MG, 2 capsules (200 MG) without explaining the medication and indication to Resident 1. During a review of Resident 1's AR, dated 6/21/24, the AR indicated, Resident 1 was admitted from an acute care hospital on 5/8/24 to the facility, whose diagnoses included Hypertension, Anemia, Major Depressive Disorder, Neuropathy and Constipation. During a review of Resident 1's MAR, dated 6/24, the MAR indicated, . Gabapentin oral capsule 100 MG. Give 2 capsules by mouth three times a day for Neuropathy . Order date 6/14/24 . During a medication pass observation on 6/18/24, at 11:21 a.m., inside Resident 18's room, LVN 1 administered Gabapentin 300 MG capsule without explaining the medication and indication to Resident 18. During a review of Resident 18's AR, dated 6/21/24, the AR indicated, Resident 18 was admitted from an acute care hospital on 5/4/24 to the facility, whose diagnoses included Cerebrovascular Disease (stroke), Atrial Fibrillation (Afib, is an irregular and often very rapid heart rate), Anemia, and Restless Leg Syndrome (RLS, a condition that causes a very strong urge to move the legs) and Major Depressive Disorder. During a review of Resident 18's MAR, dated 6/24, the MAR indicated, . Gabapentin oral capsule 300 MG. Give 1 capsule by mouth three times a day for pain . Order date 5/16/24 . During a medication pass observation on 6/18/24, at 11:26 a.m., inside Resident 13's room, LVN 1 administered Ferrous Sulfate (iron supplement) 325 MG tablet without explaining the medication and indication to Resident 13. During a review of Resident 13's AR, dated 6/21/24, the AR indicated, Resident 13 was admitted from an acute care hospital on 1/5/22 to the facility, whose diagnoses included Fracture of Right Femur (hip), Type 2 Diabetes Mellitus (abnormal or high blood sugar), Heart Failure (weakness in the heart where fluid accumulates in the lungs), Anemia, Hypertension and Major Depressive Disorder. During a review of Resident 13's MAR, dated 6/24, the MAR indicated, . Ferrous Sulfate 325 MG. Give 1 tablet by mouth three times a day for supplement . Order date 6/13/24 . During a medication pass observation on 6/18/24, at 11:26 a.m., outside the activity room, LVN 1 administered Ferrous Sulfate 325 MG, Sodium Bicarbonate (used to relieve heartburn) 650 MG, and NovoLog (insulin, used to lower blood sugar) without explaining the medications and indications to Resident 21. During a review of Resident 21's AR, dated 6/21/24, the AR indicated, Resident 21 was admitted from an acute care hospital on 6/16/23 to the facility, whose diagnoses included Type 2 Diabetes Mellitus, Huntington's Disease (cause the brain to decay overtime, causing uncontrolled body movements), Chronic Obstructive Pulmonary Disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow of the lungs), Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Gastro-Esophageal Reflux Disease (GERD - condition where acid comes up from the stomach into the throat) and Anemia. During a review of Resident 21's MAR, dated 6/24, the MAR indicated, . Ferrous Sulfate 325 MG. Give 1 tablet by mouth three times related to Iron Deficiency/Anemia . Order date 7/5/23 . Sodium Bicarbonate tablet 650 MG. Give 1 tablet by mouth three times a day related to Gastro-Esophageal Reflux Disease . Order date 6/16/23 . NovoLOG injection Solution . Inject 7 unit subcutaneously three times a day related to Type 2 Diabetes Mellitus . Order date 11/9/23 . During a medication pass observation on 6/18/24, at 11:40 a.m., inside Resident 128's room, LVN 1 administered Ferrous Sulfate (iron supplement) 325 MG tablet without explaining the medication and indication to Resident 128. During a review of Resident 128's AR, dated 6/21/24, the AR indicated, Resident 128 was admitted from an acute care hospital on 6/6/24 to the facility, whose diagnoses included Malignant Neoplasm of Bladder (bladder cancer), Hypertension, Major Depressive Disorder and Constipation. During a review of Resident 128's MAR, dated 6/24, the MAR indicated, . Ferrous Sulfate 325 MG. Give 1 tablet by mouth three times a day for supplement . Order date 6/13/24 . During an interview on 6/18/24, at 11:45 a.m., with LVN 1, LVN 1 stated she did not explain the medications and indications when she gave the medications to Residents 127, 1, 18, 13, 21, and 128. LVN 1 stated facility Residents had the right to know the medications they are receiving, and she failed to inform them (residents). During an interview on 6/20/24, at 10:02 a.m. with the Director of Nursing (DON), , the DON stated LVN 1 should explain the medications and their use prior to medication administration. The DON stated facility Residents have the right to know the medications they are receiving at all times. The DON stated LVN 1 failed to follow the facility's expectations and assigned responsibilities during medication pass. During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, undated, the document indicated, . Duties and Responsibilities . The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures . 4. Prepare and administer medications and prescribed treatments . During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/19, the P&P indicated . Medications are administered in a safe and timely manner, and as prescribed . 5. Medication administration times are determined by resident need and benefit . c. honoring resident choices and preferences, consistent with his or her care plan . During a review of the facility's P&P titled, Resident Rights Guidelines for All Nursing Procedures, dated 10/10, the P&P indicated . For any procedure that involves direct resident care, follow these steps . d. Introduce yourself to the resident . g. Explain the procedure to the resident. Answer any questions he/she may have h. Ask permission to implement the procedure . 2. During an observation on 6/19/24 at 12:10 p.m. in the facilities dining room, the lunch carts with the resident's meal trays arrived in the dining room. Residents were seated at designated tables waiting for their meal. The Certified Nursing Assistants (CNA), CNAs 1, 2, and 3 approached the meal cart and started taking meal trays to residents in the dining room. There were no licensed staff present to verify the meals the residents were receiving matched the ordered meal. During an observation on 6/19/24 at 12:15 p.m. CNA 4 was observed taking meal trays into rooms [ROOM NUMBERS] before the trays were checked by the Licensed Nurse, (LN). During an interview on 6/10/24 at 12:20 p.m. with CNA 4, CNA 4 stated he delivered the meal trays without having a LN checking them. CNA 4 stated, Kitchen staff is supposed to check the meal tray for accuracy. LVNS don't check resident's meal tray and I am not aware that nurses were supposed the tray before serving meals. During an interview on 6/21/24 at 10:12 a.m. with the DON, the DON stated, Licensed Nurses were required to check the trays prior to handing them out. The DON stated, The lunch is an order and licensed staff have to verify the order was followed by the kitchen prior to giving to the resident. During a review of Resident 2's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 6/20/24, the AR indicated, Resident 2 was admitted from an acute care hospital on 4/18/24 to the facility, whose diagnoses included Hypertension (high blood pressure), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Peripheral Vascular Disease (PVD - a disorder that involves narrowing of the peripheral blood vessels),osteomyelitis (infection of the bone) to the left ankle and foot, Heart Failure (HF -the heart muscle doesn't pump blood as well as it should), and presence of Pace Maker (a small device that is inserted under the skin of your chest to help the heart beat in a regular rhythm). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/25/24, the MDS section C indicated Resident 3 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 2 was cognitively intact. During a review of Resident 3's AR dated 6/20/24, the AR indicated Resident 3 was admitted from an acute care hospital on 7/14/21 to the facility, whose diagnoses included Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Dysphagia (trouble swallowing), Depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities), Anxiety (Feeling of being worried, tense or afraid), Dysphagia, Anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), Hypertension, muscle weakness, and history of falling. During a review of Resident 3's MDS section C dated 4/24/24 the MDS indicated, Resident 3 had a BIMS score of 3 indicating Resident 3 had severe cognitive impairment. During a review of Resident 4's AR dated 6/20/24, the AR indicated Resident 4 was admitted from an acute care hospital on 1/25/19 to the facility, whose diagnoses included Diabetes Mellitus (DM - A disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine), Iron Deficiency Anemia, Intercranial Hemorrhage (type of stroke where blood pools between brain and skull preventing oxygen from reaching the brain), and Hypertension. During a review of Resident 4's MDS section C dated 5/7/24 the MDS indicated, Resident 4 had a BIMS score of 4 indicating Resident 4 had severe cognitive impairment. During a review of Resident 6's AR dated 6/2024, the AR indicated Resident 6 was admitted from an acute care hospital on [DATE] to the facility, whose diagnoses included Acute Respiratory Failure (a serious condition that makes it difficult to breathe on your own), Acute kidney failure (where your kidneys suddenly stop working properly), Atrial Fibrillation ( a quivering or irregular heartbeat, or arrhythmia), Anemia, Hypertension, Encephalopathy (damage or disease that affects the brain), and history of falls. During a review of Resident 6's MDS section C dated 4/27/24 the MDS indicated, Resident 6 had a BIMS score of 12 indicating Resident 6 had mild cognitive impairment. During a review of Resident 10's AR dated 6/2024, the AR indicated Resident 6 was admitted from an acute care hospital on [DATE] to the facility, whose diagnoses included Dementia, Depression, Anxiety, and repeated falls. During a review of Resident 10's MDS section C dated 5/6/24 the MDS indicated, Resident 10 had a BIMS score of 00 indicating Resident 10 had severe cognitive impairment. During a review of Resident 11's AR dated 6/20/24, the AR indicated Resident 11 was admitted from her private residence on 8/02/23 to the facility, whose diagnoses included Depression, Neuropathy (nerve damage interfering with spinal cord), Anemia, Osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), and repeated falls. During a review of Resident 11's MDS section C dated 5/17/24 the MDS indicated, Resident 11 had a BIMS score of 15 indicating Resident 11 had no cognitive impairment. During a review of Resident 12's AR dated 6/20/24, the AR indicated Resident 11 was admitted from her private residence on 8/02/23 to the facility, whose diagnoses included DM, Anemia, Anxiety, Hypertension, Heart Failure (occurs when the heart muscle doesn't pump blood as well as it should), Atrial Fibrillation, and Morbid obesity (weight more than 80 to 100 pounds above their ideal body weight), due to excess calories. During a review of Resident 12's MDS section C dated 4/16/24 the MDS indicated, Resident 12 had a BIMS score of 14 indicating Resident 12 had no cognitive impairment. During a review of Resident 13's AR dated 6/20/24, the AR indicated Resident 13 was admitted from an acute care hospital on 8/02/23 to the facility, whose diagnoses included DM, Atrial Fibrillation, Heart Failure, Acute Kidney Failure, Hypertension, Acute Respiratory Failure, Anemia, Vitamin D Deficiency, muscle weakness, During a review of Resident 13's MDS section C dated 5/15/24 the MDS indicated, Resident 13 had a BIMS score of 14 indicating Resident 13 had no cognitive impairment. During a review of Resident 14's AR dated 6/20/24, the AR indicated Resident 14 was admitted from a skilled nursing on 3/07/23 to the facility, whose diagnoses included Respiratory Failure, Acute Kidney Failure, Depression, Obesity, Cirrhosis (a condition in which the liver is scarred and permanently damage) of Liver, muscle weakness, Anemia, and repeated falls. During a review of Resident 14's MDS section C dated 5/09/24 the MDS indicated, Resident 14 had a BIMS score of 4 indicating Resident 14 has severe cognitive impairment. During a review of Resident 17's AR dated 6/20/24, the AR indicated Resident 17 was admitted from a skilled nursing on 01/05/22 to the facility, whose diagnoses included Dementia, Anemia, Vitamin D deficiency, Osteoarthritis to right hip, Anxiety, muscle weakness, and history of falling. During a review of Resident 17's MDS section C dated 5/22/24 the MDS indicated, Resident 17 had a BIMS score of 3 indicating Resident 17 has severe cognitive impairment. During a review of Resident 18's AR dated 6/20/24, the AR indicated Resident 18 was admitted from an acute care hospital on [DATE] to the facility, whose diagnoses included Depression, Atrial Fibrillation, Hypertension, Hemiplegia (paralysis that affects one side of your body) right side of body, Anemia, and history of falls. During a review of Resident 18's MDS section C dated 5/12/24 the MDS indicated, Resident 18 had a BIMS score of 15 indicating Resident 18 has no cognitive impairment. During a review of Resident 19's AR dated 6/20/24, the AR indicated Resident 19 was admitted from an assisted living home on 9/15/22 to the facility, whose diagnoses included Dementia, Hypertension, Vitamin D Deficiency, and Breast Cancer. During a review of Resident 19's MDS section C dated 5/31/24 the MDS indicated, Resident 19 had a BIMS score of 00 indicating Resident 19 has severe cognitive impairment. During a review of Resident 19's AR dated 6/20/24, the AR indicated Resident 19 was admitted from an assisted living home on 9/15/22 to the facility, whose diagnoses included Dementia, Hypertension, Vitamin D Deficiency, and Breast Cancer. During a review of Resident 21's AR dated 6/20/24, the AR indicated Resident 21 was admitted from an acute care hospital on 6/18/23 to the facility, whose diagnoses included DM, Depression, Huntington's Disease (The disease attacks areas of the brain that help to control voluntary (intentional) movement, as well as other areas), Anemia, and Dementia. During a review of Resident 21's MDS section C dated 3/25/24 the MDS indicated, Resident 21 had a BIMS score of 8 indicating Resident 21 has moderate cognitive impairment. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services, dated 10/2017, indicated, . Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs . Nursing staff will ensure that assistive devices are available to residents as needed . During a review of Cal. Code Regs. Tit. 22, § 72309 - Nursing Service dated 3/10/22, Cal. Code Regs. Tit. 22, § 72309 - Nursing Service indicated, . 72311. Nursing Service-General . (a) Nursing shall include, but not be limited to, the following . (1) Planning of patient care, which shall include at least the following . (C) Licensed nursing personnel shall ensure that patients are served the diets as ordered by the attending licensed healthcare practitioner acting with the scope of his or her professional licensure .

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program to prevent the development and transmission of diseases for seven of 18 sampled resident (Resident 128, 8, 1, 9 177, 16, and 19) when: 1. Resident 177 was on contact precautions and isolations gowns were not stocked and available outside the room for staff to use. 2. Certified Nurse Assistant (CNA) 1 did not use an alcohol-based hand rub (ABHR-an alcohol containing liquid, gel or foam rubbed on hands that kill microorganisms) when passing out breakfast trays for five of seven residents (Resident 128, 8, 1, 9, 177). 3. CNA 1 failed to use an ABHR prior to and after feeding two of two residents (Resident 16, 19). This failure had the potential to result in the transmission of infection between residents. Findings 1. During an observation on 6/18/24 at 10:51 a.m. outside Resident 177's room, there was an orange sign on the left side of the door that indicated Resident 177 was on contact isolation (a patient with a contagious disease that can spread by touch). Below the sign, an isolation cart (a container of gloves, gowns, and other protective coverings used for residents with infectious diseases) was missing isolation gowns (a protective gown worn by staff to prevent infections). During a concurrent observation and interview on 6/18/24 at 10:58 a.m. with Laundry Staff (LF) 1 in front of Resident 177's room, LF 1 stated, there should have been gowns stocked in the cart. During a concurrent observation and interview on 6/18/24 at 11:01 a.m. with CNA 2 outside Resident 177's room, CNA 2 stated, Resident 177 had shingles (a viral [a very small, disease-causing organism] disease that causes painful skin rashes). CNA 2 stated, there were no gowns in the cart and should have been re-stocked because Resident 177 was in contact isolation. CNA 2 stated, it's important to wear isolation gowns to prevent infections from spreading. During an interview on 6/20/24 at 10:26 a.m. with Infection Preventionist (IP), IP stated, Resident 177 was on contact isolation for shingles. IP stated, the isolation gowns outside Resident 177's room should have been stocked because the use of gowns and other protective equipment can help prevent the spread of infections. During an interview on 6/21/24 at 9:59 a.m. with the Director of Nursing (DON), the DON stated, the carts should have been stocked with gowns. The DON stated, Resident 177 had shingles and was in contact isolation. The DON stated, whenever a resident is on contact isolation, staff should always wear gowns, gloves, and other necessary protective equipment to ensure diseases do not spread to other residents. During a review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment-Using Gowns, dated October 2010, the P&P indicated, Objectives 1. To prevent the spread of infections; 2. To prevent soiling of clothing with infectious material .use of a gown is indicated, all personnel must put on the gown before treating or touching the resident. During a review of the facility's P&P titled, Isolation-Categories of Transmission-Based Precautions, dated 2001, the P&P indicated, Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room . 2. During an observation on 6/20/24 at 7:52 a.m. outside Resident 128's room, CNA 1 did not use an ABHR before or after when passing out the breakfast tray. During an observation on 6/20/24 at 7:54 a.m. outside Resident 8 room CNA 1 did not use an ABHR before or after entering the room when passing out the breakfast tray. During an observation on 6/20/24 at 7:55 a.m. outside Resident 1's room, CNA 1 did not use an ABHR before or after entering the room when passing out the breakfast tray. During an observation on 6/20/24 at 7:57 a.m. outside Resident 9's room, CNA 1 did not use an ABHR before or after entering the room when passing out the breakfast tray. During an observation on 6/20/24 at 7:58 a.m. outside Resident 177's room, CNA 1 did not use an ABHR before or after entering the room when passing out the breakfast tray. During an interview on 6/20/24 at 8:08 a.m. with CNA 1, CNA 1 stated, she didn't use an ABHR when she was passing out the trays because she didn't touch the residents. CNA 1 stated, they only use ABHRs when they touch the resident. During an interview on 6/20/24 at 8:15 a.m. with CNA 3, CNA 3 stated, every time CNAs go into each room and pass a tray, the must use an ABHR before and after. CNA 3 stated, if it was my mom, I'd want them [staff] to do that [use ABHR]. During an interview on 6/20/24 at 10:26 a.m. with IP, IP Nurse stated, CNA 1 should have used an ABHR for each resident whenever passing out trays. IP stated whenever a staff enters a room, they are expected to use an ABHR before entry, before care, after care, and before exiting the room. IP stated the use of ABHRs is important because it helps prevent the spread of pathogens (disease causing organisms) from one resident to the next. During an interview on 6/21/24 at 10:03 a.m. with the DON, the DON stated, it is expected for staff to use an ABHR whenever they are passing out food trays. The DON stated, even if staff just enters the room and hands out the tray, they must use an ABHR. The DON stated, the use of an ABHR is important because it's an infection control issue; it [ABHR] is used to help prevent infection and transmission of pathogens. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated August 2019, the P&P indicated, All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing transmission of healthcare-associated infections, . All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread o the infections to other personnel, residents, and visitors, . Use an alcohol-based hand rub .before and after direct contact with residents .after contact with objects .in the immediate vicinity of the resident .before and after eating or handling food .before and after assisting a resident with meals . 3. During an observation on 6/20/24 at 8:01 a.m. outside Resident 16's room, CNA 1 did not use an ABHR before proceeding to help Resident 16 eat breakfast. During an observation on 6/20/24 at 8:04 a.m. inside Resident 19's room, CNA 1 did not use an ABHR before starting to feed Resident 19 after feeding Resident 16. During an interview on 6/20/24 at 10:26 a.m. with IP, IP Nurse stated CNA 1 should have washed her hands or used an ABHR prior to feeding Resident 16 and Resident 19. IP stated the use of ABHRs is important because it helps prevent the spread of pathogens (disease causing organisms) from one resident to the next. During an interview on 6/21/24 at 10:03 a.m. with the DON, the DON stated, it is expected for staff to use an ABHR whenever they are passing out food trays. The DON stated, even if staff just enters the room and hands out the tray, they must use an ABHR. The DON stated, the use of an ABHR is important because it's an infection control issue; it [ABHR] is used to help prevent infection and transmission of pathogens. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated August 2019, the P&P indicated, All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing transmission of healthcare-associated infections, . All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread o the infections to other personnel, residents, and visitors, . Use an alcohol-based hand rub .before and after direct contact with residents .after contact with objects .in the immediate vicinity of the resident .before and after eating or handling food .before and after assisting a resident with meals .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 20) was free from physical restraints when Resident 20 had a self-releasing seat belt with alarm and the initial physical restraint evaluation had not been performed to determine the need for the seat belt. This failure resulted in Resident 20 to be unnecessarily restrained and kept her from getting up or moving freely due to the self-releasing seat belt. Findings: During an observation on 9/20/22, at 11:40 a.m., in front of room [ROOM NUMBER], Resident 20 was sitting in her wheelchair with a belt across her lap. During a review of Resident 20's Face Sheet, undated, the Face Sheet indicated, Resident 20 was admitted to the facility on [DATE] and had a primary diagnosis of osteoarthritis (occurs when the cartilage that cushions the ends of bones in joints gradually deteriorate), osteoporosis (a disease in which bones become fragile and more likely to break), and difficulty walking. During a review of Resident 20's Minimum Data Set assessment (MDS-an evaluation of a resident's cognitive, functional, behavioral, and care needs), dated 8/19/22, the MDS indicated, Resident 20 required the use of a wheelchair (w/c) and needed extensive staff assistance when transferring. The MDS indicated, Resident 20's Brief Interview for Mental Status (BIMS-assessment of cognitive status-memory function) score was a 4 out of 15 indicating severe cognitive impairment (have a very hard time remembering things, making decisions, concentrating, or learning). During a review of Resident 20's Order Summary Report (Orders), dated 9/23/22, the Orders indicated, Resident 20 had an order on 8/4/22 for self-releasing seat belt alarm while up in w/c [wheelchair] for safety every shift. During a review of Resident 20's Progress Notes (Notes), dated 8/5/22, the Notes indicated, at 6:39 p.m., the resident was found by [Licensed Vocational Nurse (LVN) 2] at 1804 [6:04 p.m.] on 8/5/22 on the floor as result of unwitnessed fall . assessed the resident and she denied any pain and was able to move both legs and arm . needed to change the seat belt on [Resident 20] w/c from a basic seatbelt to a sensor seat belt . During a concurrent observation and interview on 9/22/22, at 11:18 a.m., with Certified Nursing Assistant (CNA) 3, in the hallway near Resident 20's room, Resident 20 had a belt across her lap while sitting in her w/c. CNA 3 stated Resident 20 had fallen many times. CNA 3 stated the self-releasing belt was ordered to be applied when Resident 20 was in her w/c due to Resident 20 being a high risk for falls. CNA 3 stated not all residents knew how to take the self-releasing belt off. CNA 3 stated the seatbelt was a form of physical restraint but was ordered by the physician. CNA 3 stated he checked the belts each shift to make sure they were working properly. CNA 3 stated Resident 20 was not able to release the belt. CNA 3 stated Resident 20 has removed the belt several times before and Resident 20 now has a self-releasing belt with an alarm that goes off when the belt was released. CNA 3 stated when the alarm was set off, the resident was already up and could potentially fall so once he heard an alarm going off, he would stop what he was doing and go to the resident as soon as possible to prevent the resident from falling. CNA 3 stated the alarms could not prevent falls, but it could alert the staff that a resident was attempting to or had already gotten out of their w/c. CNA 3 stated the risks of using seatbelts with residents in a w/c was if the resident leaned forward, the w/c could tip forward. CNA stated he had seen this happen two times before in the past. During a concurrent interview and record review on 9/23/22, at 4:04 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 20's Order Summary Report (Orders), dated 9/23/22, Resident 20's Care Plan (CP), dated 9/23/22, and MDS (Minimum Data Set), dated 8/19/22 was reviewed. The MDSC stated the Orders indicated, Resident 20 had new orders for self-releasing belt with sensor alarm on 8/4/22. The MDSC stated the CP indicated Resident 20 had a fall on 8/5/22. The MDSC stated Resident 20 was able to release the belt herself and there were no risks of using the self-releasing belt. The MDSC stated she was not sure if a risk assessment was completed prior to applying the self-releasing belt. The MDSC stated the purpose of the restraint was to prevent falls for Resident 20. The MDSC stated the MDS indicated Resident 20 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) of 4 and a score of 0-7 indicated a severe impairment in cognition. The MDSC stated, based on Resident 20's BIMS, she was not able to release the seat belt on her own and the seat belt was considered a restraint. During a review of Resident 20's Restraint-Physical (Initial Evaluation), dated 9/23/22, the Initial Evaluation indicated, Resident 20 had not been assessed for physical restraint use prior to the self-releasing seat belt being applied to Resident 20 which was ordered on 8/4/22. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, dated 4/2017, the P&P indicated, . Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls . Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body . if the resident cannot remove a device in the manner in which the staff applied it given that resident's physical condition . and this restricts his/her typical ability to change position or place, that device is considered a restraint . prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Licensed Nurses have the competencies necessary to meet the needs of the residents for ten of ten sampled residents (Residents 1, 4, 5, 7, 10, 13, 14, 15, 16, and 222) and Licensed Vocational Nurse (LVN) 2 and Director of Staff Development DSD/IP did not have training and competencies on the proper use of bed rails when: 1. Resident 7 had four bed rails raised. Prior to the use of the four bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the four bed rails. 2. Resident 16 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 3. Resident 15 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. 4. Resident 13 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 5. Resident 10 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 6. Resident 4 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 7. Resident 222 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 8. Resident 5 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. 9. Resident 14 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. 10. Resident 1 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. After prompting from surveyor, the consent, physician order and care plan were implemented on 9/22/22. These failures had the potential to place Resident 1, 4, 5, 7, 10, 13, 14, 15, 16, and 222 at risk for decreased freedom of movement, entrapment and/or injury. Findings: 1. During an observation on 9/20/22, at 9:06 a.m., in Resident 7's room, Resident 7 was lying in bed with two bed rails up. During an observation on 9/21/22, at 9:06 a.m., with Resident 7, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/15/22, the MDS indicated, Resident 7's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 0 out of 15 indicating severe cognitive impairment (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills] ,8-12 moderate cognitive impairment, and 13-15 cognitively intact). During a concurrent observation and interview on 9/21/22, at 9:30 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. CNA 1 stated Resident 7 had four bed rails up to keep pillows in place. CNA 1 stated she placed pillows between Resident 7 and the bed rail. CNA 1 stated Resident 7 constantly moved in bed causing her leg to go through the side rail. CNA 1 stated Resident 7 would not be able to lower the side rail due to requiring extensive assistance and cognitive status. CNA 1 stated she had witnessed Resident 7's foot through the bed rail in the past. During a concurrent interview and record review on 9/21/22, at 2:15 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 7's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 7 did not have a consent or entrapment risk assessment in place for bed rails. LVN 1 stated pillows were implemented in between the bed rail because Resident 7 constantly moved in bed causing her arm or leg to go through the bed rail. LVN 1 stated the pillows were placed to prevent injury from the bed rail. LVN 1 stated it was the licensed nurses responsibility to develop a care plan once an intervention was started such as the bed rail. During a review of Resident 7's care plan dated 7/14/22 was reviewed. The care plan indicated, . High risk for falls . History of falls . Unaware of safety needs . large pillows to be used while resident is in bed to prevent resident from injuring self . During an interview on 9/22/22, at 9:39 a.m., with LVN 1, LVN 1 stated bed rails can cause strangulation and injury. 2. During an observation on 9/20/22, at 2:02 p.m., in Resident 16's room, Resident 16 was lying in bed with two bed rails up. During a review of Resident 16's MDS dated [DATE], the MDS indicated Resident 16's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 1:57 p.m., with CNA 1, in Resident 16's room, Resident 16 was lying in bed with two bed rails up. CNA 1 stated Resident 16 had two side rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/21/22, at 2:47 p.m., with LVN 1, Resident 16's clinical record was reviewed. LVN 1 reviewed the care plans. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 16 did not have a consent or entrapment risk assessment in place for bed rails. 3. During an observation on 9/20/22, at 10:54 a.m., in Resident 15's room, Resident 15 was lying in bed with two bed rails up. During a review of Resident 15's MDS, dated 7/29/22, the MDS indicated, Resident 15's BIMS score was 7 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/22/22, at 11:35 a.m., with CNA 3, in Resident 15's room, Resident 15 was lying in bed with two bed rails up. CNA 3 stated Resident 15 had two bed rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/23/22, at 10:31 a.m., with LVN 1, Resident 15's clinical record was reviewed. LVN 1 stated, Resident 15 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 15 had bed rail use prior to 9/22/22. 4. During an observation on 9/21/22, at 9:13 a.m., in Resident 13's room, Resident 13 was lying in bed with two bed rails up. During a review of Resident 13's MDS, dated 7/22/22, the MDS indicated, Resident 13's BIMS score was 4 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 9:34 a.m., with CNA 2, in Resident 13's room, Resident 13 was lying in bed with two bed rails up. CNA 2 stated Resident 13 had two bed rails up which were used for protection to prevent fall. During a concurrent interview and record review on 9/21/22, at 2:42 p.m., with LVN 1, Resident 13's clinical record was reviewed. LVN 1 stated, Resident 13 did not have a consent, physician order or entrapment risk assessment in place for bed rails. 5. During an observation on 9/21/22, at 9:39 a.m., in Resident 10's room, Resident 10 was lying in bed with two bed rails up. During a review of Resident 10's MDS, dated 7/27/22, the MDS indicated, Resident 10's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 10:13 a.m., with CNA 1, in Resident 10's room, Resident 10 was lying in bed with two bed rails up. CNA 1 stated Resident 10 had two bed rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/21/22, at 2:27 p.m., with LVN 1, Resident 10's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 10 did not have a consent or entrapment risk assessment in place for bed rails. 6. During a concurrent observation and interview on 9/21/22, at 1:50 p.m., with CNA 1, in Resident 4's room, Resident 4 was lying in bed with two bed rails up. CNA 1 stated Resident 4 had two bed rails up which were used to prevent falls. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/21/22, at 2:44 p.m., with LVN 1, Resident 4's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 4 did not have a consent or entrapment risk assessment in place for bed rails. 7. During a concurrent observation and interview on 9/21/22, at 1:54 p.m., with CNA 1, in Resident 222's room, Resident 222 was lying in bed with two bed rails up, CNA 1 stated Resident 222 had two bed rails up. During a concurrent interview and record review on 9/21/22, at 3:21 p.m., with LVN 2, Resident 222's clinical record was reviewed. LVN 2 stated there was no care plan for bed rail use and no physician order. LVN 2 stated Resident 222 did not have a consent or entrapment risk assessment in place for side rails. LVN 2 stated she did not get an in-service training for bed rails. LVN 2 stated, it was a nursing measure to have two bed rails and there was no requirement to have physician order, consent, or care plan. LVN 2 stated she was unaware of the entrapment risk assessment and had not seen it at the facility. LVN 2 stated she did not recall the last time she had seen the facility policy regarding side rail use. 8. During a concurrent observation and interview on 9/22/22, at 11:40 a.m., with CNA 3, in Resident 5's room, Resident 5 was lying in bed with two bed rails up. CNA 3 stated Resident 5 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 7/8/22, the MDS indicated, Resident 5's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/23/22, at 10:33 a.m., with LVN 1, Resident 5's clinical record was reviewed. LVN 1 stated, Resident 5 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 5 had bed rail use prior to 9/22/22. 9. During a concurrent observation and interview on 9/22/22, at 11:50 a.m., with CNA 3, in Resident 14's room, Resident 14 was lying in bed with two bed rails up. CNA 3 stated Resident 5 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 7/28/22, the MDS indicated, Resident 14's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/23/22, at 10:34 a.m., with LVN 1, Resident 14's clinical record was reviewed. LVN 1 stated, Resident 14 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 14 had bed rail use prior to 9/22/22. 10. During an interview on 9/21/22, at 3:21 p.m., with LVN 2, LVN 2 stated she had not had an in-service training for side rails. LVN 2 stated, it was a nursing measure to have two side rails and there was no requirement to have physician order, consent, or care plan. LVN 2 stated she was unaware of the entrapment risk assessment and had not seen it at the facility. LVN 2 stated she did not recall the last time she had seen the facility policy regarding side rail use. During a concurrent observation and interview on 9/22/22, at 11:52 a.m., with CNA 3, in Resident 1's room, Resident 1 was lying in bed with two bed rails up. CNA 3 stated Resident 1 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 8/11/22, the MDS indicated, Resident 1's BIMS score was 0 out of 15 indicating severe cognitive impairment. During an interview on 9/22/22, at 3:18 p.m., with Maintenance (MN), MN stated he did not conduct routine preventative maintenance for bed rails. MN stated he addressed bed rails as needed when facility staff would report an issue. During a concurrent interview and record review on 9/22/22, at 9:43 a.m., with Director of Staff Development/Infection Preventionist (DSD/IP), the facility policy titled, Proper Use of Side Rails, dated 12/2016 was reviewed. The policy indicated, . When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . DSD/IP stated the policy only applied when the bed rails were considered a restraint. DSD/IP reviewed her in-service binders and stated there were no in service training for bed rails. DSD/IP stated the bed rails were used as mobility devices therefore the policy did not pertain when only two bed rails were used. DSD/IP stated there was a risk for entrapment when bed rails were in use. During a concurrent interview and record review on 9/22/22, at 10:01 a.m., with Director of Nursing (DON), the facility policy titled, Proper Use of Side Rails, dated 12/2016, was reviewed. The policy indicated, . When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . DON stated it was the facility policy to include all the components as outlined in the policy prior to bed rail use. DON stated the bed rails were in use for safety but can be a risk for entrapment. DON stated it was the responsibility of Licensed Nurses to develop a care plan for bed rail use to maintain continuity of care. During an interview on 9/22/22, at 11:56 a.m., with DON, the DON stated the Interdisciplinary Team (IDT) consisted of multidisciplinary staff. The DON stated the IDT meetings were held daily except for weekends. DON stated she did not recall when or if bed rails were discussed in the IDT meetings. During a concurrent interview and record review on 9/23/22, at 10:29 a.m., with LVN 1, Resident 1's clinical record was reviewed. LVN 1 stated, Resident 1 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 1 had bed rails use prior to 9/22/22. During a review of the facility job description titled, Director Of Staff Development undated, was reviewed. The job description indicated, . Participates in Quality Assurance meetings to identify training needs . Provides resources for licensed staff In-services in clinical skills development . Participates as a member of Safety Committee to identify training needs of staff . Participates in Care Plan Conferences to monitor for training needs . During a review of the facility job description titled, Charge Nurse undated, was reviewed. The job description indicated, . The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with the current existing federal and state regulations and established company policies and procedures . Assist in writing and updating Resident Assessment and Comprehensive Care Plans . During a review of the facility policy and procedure titled, Proper Use of Side Rails, dated 12/2016, was reviewed. The policy indicated, . The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Documentation will indicate if less restrictive approaches are no successful, prior to considering the use of side rail . The risk and benefits of side rails will be considered for each resident . Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefit and risks . The resident will be checked periodically for safety relative to side rail use . When side rail usage Is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being use) . Facility staff, in conjunction with the Attending Physician, will assess and document the resident's risk for injury due to neurological disorders or other medical conditions . During a review of professional reference from the FDA- Food and Drug Administration titled, A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts retrieved from https://www.fda.gov/medical-devices/hospital-beds/guide-bed-safety-bed-rails-hospitals-nursing-homes-and-home-health-care-facts dated 12/11/17, indicated, . Today there are about 2.5 million hospital and nursing home beds in use in the United States. Between 1985 and January 1, 2009, 803 incidents of patients* caught, trapped, entangled, or strangled in beds with rails were reported to the U.S. Food and Drug Administration. Of these reports, 480 people died, 138 had a nonfatal injury, and 185 were not injured because staff intervened. Most patients were frail, elderly or confused . Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient's health care team will help to determine how best to keep the patient safe . Potential risks of bed rails may include: Strangling, suffocating, bodily injury, or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. Feeling isolated or unnecessarily restricted. Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet .

Based on observation, interview, and record review, the facility failed to ensure the Dietary Services Supervisor (DS) possessed the appropriate competencies and skills set to carry out the functions of the food and nutrition services department in accordance with the DS job description when: 1. The DS did not provide the necessary oversight of food safety, sanitation, and storage in the kitchen: 1a. Dietary staff were not implementing or accurately documenting safe food cool down process. 1b. Dietary staff did not label food and did not dispose expired food. 1c. The DS did not have the required certification or education to meet the needs of the DS position. These failures had the potential to place residents who consumed meals prepared from the kitchen to be at risk for foodborne illnesses related to growth of microorganisms (bacteria or fungus that cause nausea, vomiting, and diarrhea), weight loss, and malnutrition. (cross reference F812) Findings: 1a. During an interview on 9/21/22, at 12:09 p.m., with [NAME] 1, [NAME] 1 stated she did not prepare food the day before to cut down time on preparation of meals. [NAME] 1 stated when chicken or tuna salad was the main dish, she prepared it the same day. [NAME] 1 stated the tuna and seasonings were stored in the dry storage area while the rest of the ingredients were stored in the refrigerator. [NAME] 1 stated once all the ingredients were mixed, she placed the salad in the refrigerator and prior to serving the salad, she checked the temperature. [NAME] 1 stated when preparing pudding from powder, she added milk and followed the directions on the package. [NAME] 1 stated once she was done preparing the pudding, she placed the pudding in serving bowls and placed them into the refrigerator and the temperature was checked prior to serving the pudding to the residents. During an interview on 9/21/22, at 3:40 p.m., with [NAME] 2, [NAME] 2 stated when chicken or tuna salad was on the menu, the salad was made the same day. [NAME] 2 stated most of the ingredients were from the refrigerator except for the seasonings. [NAME] 2 stated after she mixed all the ingredients, she labeled and covered the salad and placed it in the refrigerator. [NAME] 2 stated she never checked the temperature prior to placing the salad in the refrigerator but she did check the temperature prior to serving the salad. During an interview on 9/22/22, at 9:30 a.m., with the DS, the DS stated the cool down process started when the food was at 140 degree (°) Fahrenheit (F-unit of measurement) and she had six hours to cool the food to 41°F. The DS stated every two hours the temperature of the food was checked and logged in the Cool Down Log. The DS stated if the temperature was dropping every two hours and by the sixth hour if the temperature was 41°F the cool down process was complete and it did not matter what the temperature was, two hours into the cooling process. During a concurrent observation and interview on 9/22/22, at 10:05 a.m., with the DS, in the walk-in refrigerator, there were several leftovers in containers to include: chicken noodles dated 9/20/22 and used by date 9/23/22, beef dated 9/20/22 and used by date 9/23/22, chicken dated 9/21/22 and used by date 9/24, salad dated 9/21/22 and used by date 9/24/22, corn slaw dated 9/20/22 and used by date 9/23/22 and chicken dated 9/19/22 and used by date 9/22/22. The DS validated the food in the containers were leftovers. During a concurrent interview and record review on 9/22/22, at 10:10 a.m., with the DS, the facility's document Cooling/Chilling Temperature Control Log (Log), dated 12/2021, 1/2022, 2/2022, 3/2022, 4/2022, 5/2022, 6/2022, 7/2022, 8/2022 and 9/2022, and the facility's P&P titled, Food Preparation . Cool Down, dated 2018 was reviewed. The DS stated, the Logs indicated there had not been any entries made for the month of 1/2022, 4/2022, 5/2022, 6/2022, 7/2022, 8/2022 and 9/2022. The DS stated, the 9/2022 Log indicated there were no entries for the leftovers that were in the refrigerator. The DS stated the P&P indicated, . Food that is cooked and will not be used for immediate service will be cooled to the appropriate temperatures within the allotted time to prevent microbial growth [an increase in the number of bacteria] . A cool down log will be maintained to ensure standards are met . Food must be cooled to 70°F within two hours and then to 41°F within the next four hours . During a concurrent interview and record review, on 9/22/22, at 10:18 a.m. with the DS, the Kitchen In-Service Binder, undated was reviewed. The DS stated she had not provided any in-services or education on the Cool Down process since 3/2022, when she became the DS and there had not been any education or in-services logged in the Kitchen In-Service Binder since 1/2021 pertaining to the Cool Down process. The DS stated her expectations were for cooks to prepare everything in the kitchen properly and use the Cooling Logs when appropriate. The DS stated the importance of the cool down process was to make sure the food was properly cooled to prevent bacteria from growing on the food which could cause residents to get sick if they consumed the food that was not cooled down properly. During an interview on 9/23/22, at 1:29 p.m., with the Registered Dietitian (RD), the RD stated kitchen staff should be using the cool down process. The RD stated the importance of using the cool down process was to make sure the food was cooled as quick as possible to prevent the food from staying in the temperature danger zone which was between 41°F to 135°F. The RD stated food that stayed in the temperature danger zone could cause bacterial growth and foodborne illnesses which could be bad for residents. The RD stated her expectations were for kitchen staff to start using the cool down log when food products needed to be cooled. During a review of the facility's P&P titled, Food Preparation . Calibrating and Sanitizing Thermometers, dated 2018, the P&P indicated, . Two Tiered Cooling: Internal temperature of food must be reduced from 140°F to 70°F in 2 hours and cooled from 70°F to 41°F in 4 hours . During a review of the facility document titled, Job Description: Dietary Service Supervisor (DSS), undated, the DSS Job Description indicated, . responsibilities . provide a sanitary and infection free environment . Supervise food preparation and service . Observe for over-production of food and improper preparation of foods . 1b. During an observation on 9/20/22, at 9:12 a.m., in the dry storage area, there were multiple food items or products that did not have used by dates and dates indicating the food product or item were expired. During an interview on 9/22/22, at 10:20 a.m., with the DS, the DS stated the kitchen staff who stocked the dry storage area were responsible for checking expiration dates and labeling of new food products or items. The DS stated the received date and the used by date should be written on all the items in the dry storage area. The DS stated she made sure food items were not expired and everything was labeled appropriately. The DS stated the residents could become ill if they consumed expired food. During an interview on 9/23/22, at 1:30 p.m., with the RD, the RD stated her expectations were for kitchen staff to dispose of expired food items and make sure everything was labeled and dated to prevent wasting of food. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control . Canned and Dry Goods Storage, dated 2018, the P&P indicated, . All open food items will have an open date and use-by-date per manufacturer's guidelines . new stock must be placed behind the old stock so oldest items will be used first. Products should be dated to assure FIFO-First In-First Out. Food items will be labeled and dated when placed into containers . Bins holding dry goods such as flour, sugar, bean, etc. must be clearly labeled, dated on the lid or front of the container and dated when product was put into bin . During a review of the facility's P&P titled, Food Receiving and Storage, dated 2014, the P&P indicated, . All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . Food items and snacks kept on the nursing units must be maintained as indicated below: a. All food items to be kept below 41 degrees Fahrenheit (F-a unit of measurement) must be placed in the refrigerator located at the nurses' station and labeled with a use by date . 1c. During an interview on 9/22/22, at 9:30 a.m., with the DS, the DS stated she had been in her position as the Dietary Services Supervisor (DS) since March 2022. The DS stated she had been a cook prior to taking on her new role as the DS. The DS stated she did not have the training to be a DS but was trained by the previous DS on the basic stuff and there was no documentation of her training by the previous DS. The DS stated her training may have been 30 hours of hands-on training with the previous DS. The DS stated she was not sure what certifications or training she needed to be a DS. During an interview on 9/23/22, at 1:35 p.m., with the RD, the RD stated the DS should have certified dietary manager training because there was no full time RD at the facility. The RD stated she was aware the DS had not completed the required training to be a DS. The RD stated due to the DS not being trained appropriately, she could potentially expose the residents in the facility to food borne illnesses and potential weight loss. The RD stated her expectations for the DS was to start looking for programs and start working her way to becoming certified. During a review of the DS's Employee File, undated, the Employee File indicated, the DS had an American National Standards Institute (ANSI) eFoodHandler Basic Safety Course issued on 11/3/2020 and expiration date of 11/3/2023. The Employee File indicated, the DS did not have any other certifications. During an interview on 9/23/22, at 5:27 p.m., with the Administrator (ADM), the ADM stated she was aware the DS did not have the qualifications to be a DS. The ADM stated the DS had a brief orientation with the previous DS. The ADM stated the residents could lose weight if the therapeutic diets ordered by the physician were not followed through and the residents could potentially be exposed to food borne illnesses because the DS was not certified. The ADM stated her expectations of the DS were to check new admissions, make recommendations, oversee residents' health and nutrition, provide in-services on infection control and safety in the kitchen, and labeling of food products which had been an ongoing problem. During a review of DS's Competency Checklist for Employee for Department of Nutrition and Food Services (Competency), dated 5/28, the Competency indicated the DS needed improvement on the topic of Temperature Danger Zone: 39-140 degrees Fahrenheit. The Competency indicated the DS did not have the Orientation, Inservice, & Personnel Management . Job Skills Evaluation, signed off by herself or the previous DS. During a review of the facility document titled, Job Description: Dietary Service Supervisor (DSS), undated, the DSS Job Description indicated, . Education: Graduation from a course in food service supervision which meets the standards established by the American Dietetic Association or a graduate of another course in food service supervision with 90 or more hours in classroom instruction with on-the-job counseling by a dietitian . knowledge of and ability to meet regulations of ADA [Americans with Disabilities Act], state, infection control, health department, and OSHA [Occupational Safety and Health Administration] .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan for ten of ten sampled residents (1, 4, 5, 7, 10, 13, 14, 15, 16, and 222) when: 1. Resident 7 had four bed rails raised. Prior to the use of the four bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the four bed rails. 2. Resident 16 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 3. Resident 15 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. After prompting from the surveyor, the consent, physician order and care plan were implemented on 9/22/22. 4. Resident 13 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 5. Resident 10 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 6. Resident 4 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 7. Resident 222 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 8. Resident 5 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. 9. Resident 14 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. 10. Resident 1 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. These failures had the potential to place Resident 1, 4, 5, 7, 10, 13, 14, 15, 16, and 222 at risk for decreased freedom of movement, entrapment and/or injury. Findings: 1. During an observation on 9/20/22, at 9:06 a.m., in Resident 7's room, Resident 7 was lying in bed with two bed rails up. During an observation on 9/21/22, at 9:06 a.m., with Resident 7, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/15/22, the MDS indicated, Resident 7's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 0 out of 15 indicating severe cognitive impairment (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills] ,8-12 moderate cognitive impairment, and 13-15 cognitively intact). During a concurrent observation and interview on 9/21/22, at 9:30 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. CNA 1 stated Resident 7 had four bed rails up to keep pillows in place. CNA 1 stated she placed pillows between Resident 7 and the bed rail. CNA 1 stated Resident 7 constantly moved in bed causing her leg to go through the side rail. CNA 1 stated Resident 7 would not be able to lower the side rail due to requiring extensive assistance and cognitive status. CNA 1 stated she had witnessed Resident 7's foot through the bed rail in the past. During a concurrent interview and record review on 9/21/22, at 2:15 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 7's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 7 did not have a consent or entrapment risk assessment in place for bed rails. LVN 1 stated pillows were implemented in between the bed rail because Resident 7 constantly moved in bed causing her arm or leg to go through the bed rail. LVN 1 stated the pillows were placed to prevent injury from the bed rail. LVN 1 stated it was the licensed nurses responsibility to develop a care plan once an intervention was started such as the bed rail. During a review of Resident 7's care plan dated 7/14/22 was reviewed. The care plan indicated, . High risk for falls . History of falls . Unaware of safety needs . large pillows to be used while resident is in bed to prevent resident from injuring self . During an interview on 9/22/22, at 9:39 a.m., with LVN 1, LVN 1 stated bed rails can cause strangulation and injury. 2. During an observation on 9/20/22, at 2:02 p.m., in Resident 16's room, Resident 16 was lying in bed with two bed rails up. During a review of Resident 16's MDS dated [DATE], the MDS indicated Resident 16's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 1:57 p.m., with CNA 1, in Resident 16's room, Resident 16 was lying in bed with two bed rails up. CNA 1 stated Resident 16 had two side rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/21/22, at 2:47 p.m., with LVN 1, Resident 16's clinical record was reviewed. LVN 1 reviewed the care plans. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 16 did not have a consent or entrapment risk assessment in place for bed rails. 3. During an observation on 9/20/22, at 10:54 a.m., in Resident 15's room, Resident 15 was lying in bed with two bed rails up. During a review of Resident 15's MDS, dated 7/29/22, the MDS indicated, Resident 15's BIMS score was 7 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/22/22, at 11:35 a.m., with CNA 3, in Resident 15's room, Resident 15 was lying in bed with two bed rails up. CNA 3 stated Resident 15 had two bed rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/23/22, at 10:31 a.m., with LVN 1, Resident 15's clinical record was reviewed. LVN 1 stated, Resident 15 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 15 had bed rail use prior to 9/22/22. 4. During an observation on 9/21/22, at 9:13 a.m., in Resident 13's room, Resident 13 was lying in bed with two bed rails up. During a review of Resident 13's MDS, dated 7/22/22, the MDS indicated, Resident 13's BIMS score was 4 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 9:34 a.m., with CNA 2, in Resident 13's room, Resident 13 was lying in bed with two bed rails up. CNA 2 stated Resident 13 had two bed rails up which were used for protection to prevent fall. During a concurrent interview and record review on 9/21/22, at 2:42 p.m., with LVN 1, Resident 13's clinical record was reviewed. LVN 1 stated, Resident 13 did not have a consent, physician order or entrapment risk assessment in place for bed rails. 5. During an observation on 9/21/22, at 9:39 a.m., in Resident 10's room, Resident 10 was lying in bed with two bed rails up. During a review of Resident 10's MDS, dated 7/27/22, the MDS indicated, Resident 10's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 10:13 a.m., with CNA 1, in Resident 10's room, Resident 10 was lying in bed with two bed rails up. CNA 1 stated Resident 10 had two bed rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/21/22, at 2:27 p.m., with LVN 1, Resident 10's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 10 did not have a consent or entrapment risk assessment in place for bed rails. 6. During a concurrent observation and interview on 9/21/22, at 1:50 p.m., with CNA 1, in Resident 4's room, Resident 4 was lying in bed with two bed rails up. CNA 1 stated Resident 4 had two bed rails up which were used to prevent falls. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/21/22, at 2:44 p.m., with LVN 1, Resident 4's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 4 did not have a consent or entrapment risk assessment in place for bed rails. 7. During a concurrent observation and interview on 9/21/22, at 1:54 p.m., with CNA 1, in Resident 222's room, Resident 222 was lying in bed with two bed rails up, CNA 1 stated Resident 222 had two bed rails up. During a concurrent interview and record review on 9/21/22, at 3:21 p.m., with LVN 2, Resident 222's clinical record was reviewed. LVN 2 stated there was no care plan for bed rail use and no physician order. LVN 2 stated Resident 222 did not have a consent or entrapment risk assessment in place for side rails. LVN 2 stated she did not get an in-service training for bed rails. LVN 2 stated, it was a nursing measure to have two bed rails and there was no requirement to have physician order, consent, or care plan. LVN 2 stated she was unaware of the entrapment risk assessment and had not seen it at the facility. LVN 2 stated she did not recall the last time she had seen the facility policy regarding side rail use. 8. During a concurrent observation and interview on 9/22/22, at 11:40 a.m., with CNA 3, in Resident 5's room, Resident 5 was lying in bed with two bed rails up. CNA 3 stated Resident 5 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 7/8/22, the MDS indicated, Resident 5's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/23/22, at 10:33 a.m., with LVN 1, Resident 5's clinical record was reviewed. LVN 1 stated, Resident 5 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 5 had bed rail use prior to 9/22/22. 9. During a concurrent observation and interview on 9/22/22, at 11:50 a.m., with CNA 3, in Resident 14's room, Resident 14 was lying in bed with two bed rails up. CNA 3 stated Resident 5 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 7/28/22, the MDS indicated, Resident 14's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/23/22, at 10:34 a.m., with LVN 1, Resident 14's clinical record was reviewed. LVN 1 stated, Resident 14 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 14 had bed rail use prior to 9/22/22. 10. During an interview on 9/21/22, at 3:21 p.m., with LVN 2, LVN 2 stated she had not had an in-service training for side rails. LVN 2 stated, it was a nursing measure to have two side rails and there was no requirement to have physician order, consent, or care plan. LVN 2 stated she was unaware of the entrapment risk assessment and had not seen it at the facility. LVN 2 stated she did not recall the last time she had seen the facility policy regarding side rail use. During a concurrent observation and interview on 9/22/22, at 11:52 a.m., with CNA 3, in Resident 1's room, Resident 1 was lying in bed with two bed rails up. CNA 3 stated Resident 1 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 8/11/22, the MDS indicated, Resident 1's BIMS score was 0 out of 15 indicating severe cognitive impairment. During an interview on 9/22/22, at 3:18 p.m., with Maintenance (MN), MN stated he did not conduct routine preventative maintenance for bed rails. MN stated he addressed bed rails as needed when facility staff would report an issue. During a concurrent interview and record review on 9/22/22, at 9:43 a.m., with Director of Staff Development/Infection Preventionist (DSD/IP), the facility policy titled, Proper Use of Side Rails, dated 12/2016 was reviewed. The policy indicated, . When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . DSD/IP stated the policy only applied when the bed rails were considered a restraint. DSD/IP reviewed her in-service binders and stated there were no in service training for bed rails. DSD/IP stated the bed rails were used as mobility devices therefore the policy did not pertain when only two bed rails were used. DSD/IP stated there was a risk for entrapment when bed rails were in use. During a concurrent interview and record review on 9/22/22, at 10:01 a.m., with Director of Nursing (DON), the facility policy titled, Proper Use of Side Rails, dated 12/2016, was reviewed. The policy indicated, . When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . DON stated it was the facility policy to include all the components as outlined in the policy prior to bed rail use. DON stated the bed rails were in use for safety but can be a risk for entrapment. DON stated it was the responsibility of Licensed Nurses to develop a care plan for bed rail use to maintain continuity of care. During an interview on 9/22/22, at 11:56 a.m., with DON, the DON stated the Interdisciplinary Team (IDT) consisted of multidisciplinary staff. The DON stated the IDT meetings were held daily except for weekends. DON stated she did not recall when or if bed rails were discussed in the IDT meetings. During a concurrent interview and record review on 9/23/22, at 10:29 a.m., with LVN 1, Resident 1's clinical record was reviewed. LVN 1 stated, Resident 1 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 1 had bed rails use prior to 9/22/22. During a review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the policy indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . During a review of the facility job description titled, Charge Nurse, undated was reviewed. The job description indicated, . The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with the current existing federal and state regulations and established company policies and procedures . Assist in writing and updating Resident Assessment and Comprehensive Care Plans . During a review of the facility policy titled, Proper Use of Side Rails, dated 12/2016, the policy indicated, . The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Documentation will indicate if less restrictive approaches are no successful, prior to considering the use of side rail . The risk and benefits of side rails will be considered for each resident . Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefit and risks . The resident will be checked periodically for safety relative to side rail use . When side rail usage Is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being use) . Facility staff, in conjunction with the Attending Physician, will assess and document the resident's risk for injury due to neurological disorders or other medical conditions . During a review of professional reference from the FDA- Food and Drug Administration, titled, A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts retrieved from https://www.fda.gov/medical-devices/hospital-beds/guide-bed-safety-bed-rails-hospitals-nursing-homes-and-home-health-care-facts dated 12/11/17, indicated, . Today there are about 2.5 million hospital and nursing home beds in use in the United States. Between 1985 and January 1, 2009, 803 incidents of patients* caught, trapped, entangled, or strangled in beds with rails were reported to the U.S. Food and Drug Administration. Of these reports, 480 people died, 138 had a nonfatal injury, and 185 were not injured because staff intervened. Most patients were frail, elderly or confused . Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient's health care team will help to determine how best to keep the patient safe . Potential risks of bed rails may include: Strangling, suffocating, bodily injury, or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. Feeling isolated or unnecessarily restricted. Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure ten of ten Residents (Residents 1, 4, 5, 7, 10, 13, 14, 15, 16, and 222) were assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered position) prior to installation and had no consent (form signed by resident or family explaining the risks of side rail use), physician order, indication for use, and care plans prior to the use of side rails when: 1. Resident 7 had four bed rails raised. Prior to the use of the four bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the four bed rails. 2. Resident 16 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 3. Resident 15 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. After prompting from the surveyor , the consent, physician order and care plan were implemented on 9/22/22. 4. Resident 13 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 5. Resident 10 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 6. Resident 4 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 7. Resident 222 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 8. Resident 5 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. After prompting from surveyor, the consent, physician order and care plan were implemented on 9/22/22. 9. Resident 14 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. After prompting from surveyor, the consent, physician order and care plan were implemented on 9/22/22. 10. Resident 1 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. After prompting from surveyor, the consent, physician order and care plan were implemented on 9/22/22. These failures had the potential to place Resident 1, 4, 5, 7, 10, 13, 14, 15, 16, and 222 at risk for decreased freedom of movement, entrapment and/or injury. Following the identification of the deficient practices related to bedrails, the facility developed and implemented care plans, assessed residents for risk of entrapment and obtained consents for all ten residents . Findings: 1. During an observation on 9/20/22, at 9:06 a.m., with Resident 7, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. During an observation on 9/21/22, at 9:06 a.m., with Resident 7, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/15/22, the MDS indicated, Resident 7's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 0 out of 15 indicating severe cognitive impairment (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, and 13-15 cognitively intact). During a concurrent observation and interview on 9/21/22, at 9:30 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. CNA 1 stated Resident 7 had four bed rails up to keep pillows in place. CNA 1 stated she placed pillows between Resident 7 and the bed rail. CNA 1 stated Resident 7 constantly moved in bed causing her leg to go through the side rail. CNA 1 stated Resident 7 would not be able to lower the side rail due to requiring extensive assistance and cognitive status. CNA 1 stated she had witnessed Resident 7's foot through the bed rail in the past. During a concurrent interview and record review on 9/21/22, at 2:15 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 7's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 7 did not have a consent or entrapment risk assessment in place for bed rails. LVN 1 stated pillows were implemented in between the bed rail because Resident 7 constantly moved in bed causing her arm or leg to go through the bed rail. LVN 1 stated the pillows were placed to prevent injury from the bed rail. LVN 1 stated it was the licensed nurses' responsibility to develop a care plan once an intervention was started such as the bed rail. During a review of Resident 7's care plan dated 7/14/22 was reviewed. The care plan indicated, . High risk for falls . History of falls . Unaware of safety needs . large pillows to be used while resident is in bed to prevent resident from injuring self . During an interview on 9/22/22, at 9:39 a.m., with LVN 1, LVN 1 stated bed rails can cause strangulation and injury. 2. During an observation on 9/20/22, at 2:02 p.m., in Resident 16's room, Resident 16 was lying in bed with two bed rails up. During a review of Resident 16's MDS dated [DATE], the MDS indicated Resident 16's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 1:57 p.m., with CNA 1, in Resident 16's room, Resident 16 was lying in bed with two bed rails up. CNA 1 stated Resident 16 had two side rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/21/22, at 2:47 p.m., with LVN 1, Resident 16's clinical record was reviewed. LVN 1 reviewed the care plans. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 16 did not have a consent or entrapment risk assessment in place for bed rails. 3. During an observation on 9/20/22, at 10:54 a.m., with Resident 15, in Resident 15's room, Resident 15 was lying in bed with two upper bed rails raised up. During a review of Resident 15's MDS dated [DATE], the MDS indicated Resident 15's BIMS score was 7 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/22/22, at 11:35 a.m., with CNA 3, in Resident 15's room, Resident 15 was lying in bed with two bed rails up. CNA 3 stated Resident 15 had two bed rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/23/22, at 10:31 a.m., with LVN 1, Resident 15's clinical record was reviewed. LVN 1 stated, Resident 15 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 15 had bed rail use prior to 9/22/22. 4. During an observation on 9/21/22, at 9:13 a.m., in Resident 13's room, Resident 13 was lying in bed with two bed rails up. During a review of Resident 13's MDS, dated 7/22/22, the MDS indicated, Resident 13's BIMS score was 4 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 9:34 a.m., with CNA 2, in Resident 13's room, Resident 13 was lying in bed with two bed rails up. CNA 2 stated Resident 13 had two bed rails up which were used for protection to prevent fall. During a concurrent interview and record review on 9/21/22, at 2:42 p.m., with LVN 1, Resident 13's clinical record was reviewed. LVN 1 stated, Resident 13 did not have a consent, physician order or entrapment risk assessment in place for bed rails. 5. During an observation on 9/21/22, at 9:39 a.m., in Resident 10's room, Resident 10 was lying in bed with two upper bed rails raised up. During a review of Resident 10's MDS, dated 7/27/22, the MDS indicated, Resident 10's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 10:13 a.m., with CNA 1, in Resident 10's room, Resident 10 was lying in bed with two upper bed rails raised up. CNA 1 stated Resident 10 had two bed rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/21/22, at 2:27 p.m., with LVN 1, Resident 10's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 10 did not have a consent or entrapment risk assessment in place for bed rails. 6. During a concurrent observation and interview on 9/21/22, at 1:50 p.m., with CNA 1, in Resident 4's room, Resident 4 was lying in bed with two upper bed rails raised up. CNA 1 stated Resident 4 had two bed rails up which were used to prevent falls. During a review of Resident 4's MDS, dated 7/4/22, the MDS indicated, Resident 4's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/21/22, at 2:44 p.m., with LVN 1, Resident 4's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order . LVN 1 stated Resident 4 did not have a consent or entrapment risk assessment in place for bed rails. 7. During a concurrent observation and interview on 9/21/22, at 1:54 p.m., with CNA 1, in Resident 222's room, Resident 222 was lying in bed with two upper bed rails raised up, CNA 1 stated Resident 222 had two upper bed rails raised. During a concurrent interview and record review on 9/21/22, at 3:21 p.m., with LVN 2, Resident 222's clinical record was reviewed. LVN 2 stated there was no care plan for bed rail use and no physician order. LVN 2 stated Resident 222 did not have a consent or entrapment risk assessment in place for side rails . LVN 2 stated she had not had an in service training for bed rails. LVN 2 stated, it was a nursing measure to have two bed rails and there was no requirement to have physician order, consent, or care plan. LVN 2 stated she was unaware of the entrapment risk assessment and had not seen it at the facility. LVN 2 stated she did not recall the last time she had seen the facility policy regarding side rail use. 8. During a concurrent observation and interview on 9/22/22, at 11:40 a.m., with CNA 3, in Resident 5's room, Resident 5 was lying in bed with two upper bed rails raised up. CNA 3 stated Resident 5 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 7/8/22, the MDS indicated, Resident 5's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/23/22, at 10:33 a.m., with LVN 1, Resident 5's clinical record was reviewed. LVN 1 stated Resident 5 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 5 had bed rail use prior to 9/22/22. 9. During a concurrent observation and interview on 9/22/22, at 11:50 a.m., with CNA 3, in Resident 14's room, Resident 14 was lying in bed with two upper bed rails raised up. CNA 3 stated Resident 5 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 7/28/22, the MDS indicated, Resident 14's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/23/22, at 10:34 a.m., with LVN 1, Resident 14's clinical record was reviewed. LVN 1 stated Resident 14 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 14 had bed rail use prior to 9/22/22. 10. During a concurrent observation and interview on 9/22/22, at 11:52 a.m., with CNA 3, in Resident 1's room, Resident 1 was lying in bed with two upper bed rails raised up. CNA 3 stated Resident 1 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 8/11/22, the MDS indicated, Resident 1's BIMS score was 0 out of 15 indicating severe cognitive impairment. During an interview on 9/22/22, at 3:18 p.m., with Maintenance (MN), MN stated he did not conduct routine preventative maintenance for bed rails such as checking for loose side rails. MN stated he addresses bed rails as needed when facility staff would report an issue. During a concurrent interview and record review on 9/22/22, at 9:43 a.m., with the Director of Staff Development/Infection Preventionist (DSD/IP), the facility policy titled, Proper Use of Side Rails, dated 12/2016, was reviewed. The policy indicated, . When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . The DSD/IP stated the policy only applied when the bed rails were considered a restraint (limiting freedom of movement. The DSD/IP reviewed her in-service binders. The DSD/IP stated there were no in-service training for bed rails. The DSD/IP stated the bed rails were used as mobility devices therefore the policy did not pertain when only two bed rails were used. The DSD/IP stated there was a risk for entrapment when bed rails were in use. During a concurrent interview and record review on 9/22/22, at 10:01 a.m., with the Director of Nursing (DON), the facility policy titled, Proper Use of Side Rails, dated 12/2016, was reviewed. The policy indicated, . When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . The DON stated it was the facility policy to include all the components as outlined in the policy prior to bed rail use. The DON stated the bed rails were in use for safety but can be a risk for entrapment. The DON stated it was the responsibility of Licensed Nurses to develop a care plan for bed rail use to maintain continuity of care. During an interview on 9/22/22, at 11:56 a.m., with the DON, the DON stated the Interdisciplinary Team (IDT) consisted of multidisciplinary staff. The DON stated the IDT meetings were held daily except for weekends. The DON stated she did not recall when or if bed rails were discussed in the IDT meetings . During a concurrent interview and record review on 9/23/22, at 10:29 a.m., with LVN 1, Resident 1's clinical record was reviewed. LVN 1 stated Resident 1 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 1 had bed rails use prior to 9/22/22. During a review of the facility policy titled, Proper Use of Side Rails, dated 12/2016 was reviewed. The policy indicated, . The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Documentation will indicate if less restrictive approaches are no successful, prior to considering the use of side rail . The risk and benefits of side rails will be considered for each resident . Consent for side rail use will be obtained from the resident or legal representative,after presenting potential benefit and risks . The resident will be checked periodically for safety relative to side rail use . When side rail usage Is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being use) . Facility staff, in conjunction with the Attending Physician, will assess and document the resident's risk for injury due to neurological (disorders or other medical conditions . During a review of the facility job description titled, Charge Nurse, undated, was reviewed. The job description indicated, . The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with the current existing federal and state regulations and established company policies and procedures . Assist in writing and updating Resident Assessment and Comprehensive Care Plans . During a review of professional reference from the FDA Food and Drug Administration, titled, A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts retrieved from https://www.fda.gov/medical devices/hospital beds/guide bed safety bed rails hospitals nursing homes and home health care facts dated 12/11/17, indicated, . Today there are about 2.5 million hospital and nursing home beds in use in the United States. Between 1985 and January 1, 2009, 803 incidents of patients* caught, trapped, entangled, or strangled in beds with rails were reported to the U.S. Food and Drug Administration. Of these reports, 480 people died, 138 had a nonfatal injury, and 185 were not injured because staff intervened. Most patients were frail, elderly or confused . Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm,such as falling. Assessment by the patient's health care team will help to determine how best to keep the patient safe . Potential risks of bed rails may include: Strangling, suffocating, bodily injury, or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. Feeling isolated or unnecessarily restricted. Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet .

Based on observation, interview, and record review, the facility failed to ensure food was stored and/or prepared in accordance with professional standards for food services safety when: 1. Food products stored in the dry storage area and refrigerator contained food items that were not labeled and dated and discarded on or before the expiration dates. 2. Shelled eggs prepared for residents were not pasteurized eggs. 3. Kitchen staff did not follow the facility's policy for Cool Down. These failures placed residents at risk for foodborne illness and food contamination. Findings: 1. During a concurrent observation and interview on 9/20/22, at 9:01 a.m., with the Dietary Supervisor (DS), in a refrigerator in the kitchen, there were two diet cakes in circular pans with a label adhered to the plastic covering on each cake, and there were no dates written on the label. The DS stated, I made those cakes last night, I put the labels on the cakes but forgot to write down the date. During an observation on 9/20/22, at 9:07 a.m., in the kitchen, there were five clear bins filled with assorted dry goods. The bins were labeled with: flour, received date: 2/4/22, opened date: 2/4/22 and used by date: 2/4/23; pinto beans, received date: 4/2/22 and no used by date; rice, opened: 8/25/22 and used by date: 8/23; sugar, 8/22 and no used by date; and thickener, dated: 8/25/22 with used by date: 8/23. During a concurrent observation and interview on 9/20/22, at 9:12 a.m., with the DS, in the dry storage area, there were dry goods that had expired dates and some food products did not have all the components labeled on each food product to include the received date, opened date, and used by date. This list included: Brand Name pretzels received on 2/25/22 on the plastic container, inside the plastic container was a resealable plastic bag with pretzels inside dated 5/11/22 and no used by date; Bread Crumbs in a resealable plastic bag with received date of 7/30/21 and no used by date; A container of Ground Cumin with no labeling; Four containers of Italian Seasoning with no labeling; Four containers of Dill Weed with received date of 7/2/21 and used by date of 7/2/22; Diet Jello Powder packets in a plastic bin labeled received date of 9/2021 and no used by date; Assorted Gelatin packets in a plastic bin labeled opened on 3/19/21 and used by date of 3/19/22; Lemon Instant Pudding & Pie filling mix packets is in a plastic bin, but label reads Chocolate & Vanilla Pudding with received date of 10/2/21 and another date 11/3/21; Tapioca Pudding packets in a plastic bin labeled with received date of 8/5/21 and used by date of 8/5/22; and Box with a bag of prunes labeled opened on 7/1/22 and used by 8/8/22. The DS stated the containers of Ground Cumin, Italian Seasoning, and Dill weed needed to be thrown out and was observed getting placed in the trash receptacle. During an interview on 9/22/22, at 10:15 a.m., with the DS, the DS stated, kitchen staff who were stocking the dry storage area were responsible for checking the expirations dates and labeling of food products. The DS stated, the received date and the used by date should be written on all the items in the dry goods storage area. The DS stated the importance of labeling food products was to use the food products before the expiration date. The DS stated, residents could become ill if they consumed expired food. The DS stated from now on she would make sure food products were not expired and everything was labeled appropriately by checking the dry storage area on Fridays when stocking was completed. During an interview on 9/23/22, at 10:24 a.m., with the Registered Dietitian (RD), the RD stated her first time at the facility was on 9/13/22. The RD stated she toured the kitchen and found spices past their used by date and the DS was supposed to dispose of the expired spices and order new spices. During an interview on 9/23/22, at 1:30 p.m., with the RD, the RD stated the DS should have ordered new spices and should have disposed the expired spices. The RD stated most of the residents in the facility were immunocompromised (the immune system's defense are low, affecting its ability to fight off infections and diseases) due to their age and pre-existing conditions, which placed the residents at a higher risk to develop food borne illnesses especially if they consumed food past their expiration date. The RD stated the DS should ensure all food products were labeled. The RD stated the kitchen staff should label all food items and products with the received date and when a food item or product was opened, kitchen staff should label the food items with an open date and a used by date. The RD stated it was important to ensure all food items and products were labeled with the date it was received, when it was opened, and a used by date for kitchen staff to be made aware when a food item was about to expire to prevent wasting food. The RD stated kitchen staff should practice the First In First Out (FIFO) method and to use the food items or products that were going to expire first then the newer food items that were just delivered. The RD stated, her expectations were for kitchen staff to continue to carry out and improve the process of labeling, dating, and disposing of expired food products. During a concurrent observation and interview on 9/23/22, at 2:05 p.m., with Licensed Vocational Nurse (LVN) 1, in the medication room where the resident snack refrigerator was located, three of 12 assorted juices were not labeled with a date and there was a sandwich with a date and no used by date was observed. LVN 1 stated there were some juices without dates in the refrigerator and the sandwich should have a used by date which was usually three days from the opened date. LVN 1 stated Licenses Nurses (LN) were responsible for checking the food items in the refrigerator and was usually done at night on the NOC (a period of time during the night in which a person is scheduled to work) shift which was from 10:30 p.m. to 7 a.m. LVN 1 stated the kitchen staff should be labeling the dates on food items in the refrigerator. LVN 1 stated the importance of labeling was to let everybody know if the food product was about to expire or if it was expired. LVN 1 stated residents could become ill if they consumed expired food products. During an interview on 9/23/22, at 5:27 p.m., with the Administrator (ADM), the ADM stated her expectations were for the DS to oversee the labeling of food products which has been an ongoing problem. The ADM stated the facility was ensuring labeling was done by having the DS check as well as the Director of Staff Development (DSD) perform a walkthrough of the kitchen to see if anything was forgotten or not completed. The ADM stated the cooks were also responsible for labeling, dating, and checking for expiration dates and to use the first in first out method to prevent wasting of food products. During a review of the facility document titled, Job Description: Dietary Service Supervisor (DSS), undated, the DSS Job Description indicated, . responsibilities . provide a sanitary and infection free environment . supervise the receiving and storage of food . During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control . Canned and Dry Goods Storage, dated 2018, the P&P indicated, . All open food items will have an open date and use-by-date per manufacturer's guidelines . new stock must be placed behind the old stock so oldest items will be used first. Products should be dated to assure FIFO-First In-First Out. Food items will be labeled and dated when placed into containers . Bins holding dry goods such as flour, sugar, bean, etc. must be clearly labeled, dated on the lid or front of the container and dated when product was put into bin . During a review of the facility's P&P titled, Food Receiving and Storage, dated 2014, the P&P indicated, . All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . Food items and snacks kept on the nursing units must be maintained as indicated below: a. All food items to be kept below 41 degrees Fahrenheit (F-a unit of measurement) must be placed in the refrigerator located at the nurses' station and labeled with a use by date . 2. During an interview on 9/21/22, at 10:26 a.m., with [NAME] 1, [NAME] 1 stated shell eggs were used for fried eggs that morning. [NAME] 1 stated all the fried eggs were fully cooked and over easy or runny eggs were not served to residents. During an interview on 9/21/22, at 3:40 p.m., with [NAME] 2, [NAME] 2 stated the fried eggs served to residents were fully cooked and she ensured the eggs were fully cooked by checking the temperature of the eggs which should be 155°F . [NAME] 2 stated the eggs used for fried eggs were shell eggs and she knew they are pasteurized eggs by the P stamped on the eggs. During an interview on 9/22/22, at 9:23 a.m., with [NAME] 1, [NAME] 1 stated she knew the eggs were fully cooked when she checked the temperature, and the temperature was 155°F or higher. [NAME] 1 stated she knew the eggs were pasteurized by looking at the box the eggs came in which stated the eggs were pasteurized. During a review of the facility's menu Good For Your Health Menus, dated 9/19-25/22, the menu indicated on 9/21/22, fried eggs was served for breakfast. During a concurrent observation and interview on 9/22/22, at 9:30 a.m., with the DS, in the walk-in refrigerator, a box of eggs was observed, and the DS stated the box did not indicate the eggs were pasteurized. The DS stated she knew the eggs she purchased were pasteurized because her order stated the eggs ordered were pasteurized eggs. The DS stated she did not know why eggs had to be pasteurized. During an interview on 9/22/22, at 12:10 p.m., with Resident 2, Resident 2 stated he preferred his fried eggs over easy and that was how he ordered his eggs. During a concurrent interview and record review on 9/22/22, at 3:31 p.m., with the DS, the facility's invoice titled, Customer's Original Invoice Confidential Property of Sysco, dated 9/9/22 and the website titled, shop.sysco.com, undated was reviewed. The invoice indicated, three cases of 15 dozen WHLFIMP EGG SHELL MED WHT AA was purchased by the facility. The DS stated, the invoice did not indicate the eggs purchased were pasteurized eggs. The DS stated the website where the eggs were purchased did not indicate the eggs were pasteurized eggs. The DS stated, the website indicated pasteurized eggs had a P stamped on the eggshell, verifying the eggs were pasteurized eggs. The DS stated now that she knew the website carried pasteurized eggs, moving forward she would start purchasing pasteurized eggs instead of the unpasteurized eggs. During an interview on 9/23/22, at 1:25 p.m., with the RD, the RD stated the importance of using pasteurized eggs in long term care facilities was to prevent foodborne illnesses to the immunocompromised population who resided at the facility. The RD stated her expectations of the facility was to use and purchase pasteurized eggs from now on and she would ensure the DS was educated on the importance of pasteurized eggs and following through with purchasing pasteurized eggs. During an interview on 9/23/22, at 5:27 p.m., with the ADM, the ADM stated the use of pasteurized eggs were safer for the residents than unpasteurized eggs and therefore, the facility should be using pasteurized eggs. The ADM stated her expectations were for the facility to use pasteurized eggs based on the recommendations of the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA). During a review of the facility's P&P titled, Food Preparation . Food Cookery, dated 2018, the P&P indicated, . Pasteurized eggs (shelled or liquid) must be used . During a professional review of the Centers for Medicare and Medicaid Services guidance titled, Advance Copy of Revised F371; Interpretive guidance and Procedures for Sanitary Conditions, Preparation of Eggs in Nursing Homes, dated 5/20/14, the guidance indicated, . Skilled nursing and nursing facilities should use pasteurized shell eggs or liquid pasteurized eggs to eliminate the risk of residents contracting Salmonella Enteritidis [(SE)-a common cause of food poisoning]. The use of pasteurized eggs allows for resident preference for soft-cooked, undercooked or sunny-side up eggs while maintaining food safety . if unpasteurized eggs contaminated with SE are eaten raw or undercooked the bacterium [bacteria] can cause illness and death particularly in the elderly, infants, and those with impaired immune systems . 3. During an interview on 9/21/22, at 10:39 a.m., with the DS, the DS stated there was usually no leftovers, so the facility did not need to use the cool down log. During an interview on 9/21/22, at 12:09 p.m., with [NAME] 1, [NAME] 1 stated she did not cook food a day ahead, instead she prepared chicken or tuna salad the same day if it was a main dish. [NAME] 1 stated the tuna and spices were stored in the dry goods storage area and the rest of the ingredients were from the refrigerator. [NAME] 1 stated after preparing the salad, she placed the salad in the refrigerator and checked the temperature prior to serving the salad. [NAME] 1 stated when she prepared pudding from powder form, she followed the directions on the package and as soon as the pudding was prepared, she poured them into individual serving bowls, covered the bowls, placed them in the refrigerator and the temperature was checked before serving to residents. During an interview on 9/21/22, at 12:18 p.m., with [NAME] 2, [NAME] 2 stated when she prepared dinner, she made just enough food so there were no leftovers. [NAME] 2 stated she would use the cool down process for the leftover spaghetti from lunch by placing the spaghetti into smaller containers, label with the date, kept the containers on the counter for a couple hours or sometimes she would use ice to help cool the food down then placed it in the refrigerator. [NAME] 2 stated she would check the temperature before placing the spaghetti inside the refrigerator and it could be used for up to 3 days. During an interview on 9/21/22, at 3:40 p.m., with [NAME] 2, [NAME] 2 stated the temperature of the spaghetti should be 40°F before she placed it in the refrigerator. [NAME] 2 stated when chicken or tuna salad was on the menu, the salad was made the same day. [NAME] 2 stated most of the ingredients were from the refrigerator except the seasonings. [NAME] 2 stated after she mixed all the ingredients, she would label the salad, cover it, and then placed the salad in the refrigerator. [NAME] 2 stated she never checked the temperature before placing the salad into the refrigerator, but she did check the temperature prior to serving the salad. During an interview on 9/22/22, at 9:23 a.m., with [NAME] 1, [NAME] 1 stated she started the cool down process by placing food items in a bag or smaller container then placed it on top of an ice bath, let it sit and check the temperature every two hours, the first temperature should be 138°F or below, next temperature in two hours should be 41°F or below and she has six hours total for the food item to be 41°F or below. During an interview on 9/22/22, at 9:30 a.m., with the DS, the DS stated she started the cool down process when the temperature of the food items reached 140°F and she had six hours to cool the food down to 41°F. The DS stated every two hours she would check the temperature and log the temperature on the Cool Down log. The DS stated the temperature should be dropping from 140°F, if the temperature was dropping every two hours and by the sixth hour if the temperature was 41°F, then she had completed the Cool Down process and at that time she would place the food item in the refrigerator. During a concurrent observation and interview on 9/22/22, at 10:05 a.m., with the DS, in the walk-in refrigerator, there were several leftovers in containers to include: chicken noodles dated 9/20/22 and used by date 9/23/22, beef dated 9/20/22 and used by date 9/23/22, chicken dated 9/21/22 and used by date 9/24, salad dated 9/21/22 and used by date 9/24/22, corn slaw dated 9/20/22 and used by date 9/23/22 and chicken dated 9/19/22 and used by date 9/22/22. The DS validated the food in the containers were leftovers. During a concurrent interview and record review on 9/22/22, at 10:10 a.m., with the DS, the facility's document Cooling/Chilling Temperature Control Log (Log), dated 12/21, 1/22, 2/22, 3/22, 4/22, 5/22, 6/22, 7/22, 8/22 and 9/22, and the facility's P&P titled, Food Preparation . Cool Down, dated 2018 was reviewed. The DS stated, the Logs indicated there had not been any entries made for the month of 1/22, 4/22, 5/22, 6/22, 7/22, 8/22 and 9/22. The DS stated the P&P indicated, . Food that is cooked and will not be used for immediate service will be cooled to the appropriate temperatures within the allotted time to prevent microbial growth [an increase in the number of bacteria] . A cool down log will be maintained to ensure standards are met . Food must be cooled to 70°F within two hours and then to 41°F within the next four hours . During a concurrent interview and record review, on 9/22/22, at 10:18 a.m. with the DS, the Kitchen In-Service Binder, undated was reviewed. The DS stated she had not provided any in-services or education on the Cool Down process since 3/2022 , when she became the DS and there had not been any education or in-services logged in the Kitchen In-Service Binder since 1/2021 pertaining to the Cool Down process. The DS stated her expectations were for cooks to prepare everything in the kitchen properly and use the Cooling Logs when appropriate. The DS stated the importance of the cool down process was to make sure the food was properly cooled to prevent bacteria from growing on the food which could cause residents to get sick if they consumed the food that was not cooled down properly. During an interview on 9/23/22, at 1:29 p.m., with the RD, the RD stated kitchen staff should be using the cool down process. The RD stated the importance of using the cool down process was to make sure the food was cooled as quick as possible to prevent the food from staying in the temperature danger zone which was between 41°F to 135°F. The RD stated food that stayed in the temperature danger zone could cause bacterial growth and foodborne illnesses which could be bad for residents. The RD stated her expectations were for kitchen staff to start using the cool down log. During a review of the facility's P&P titled, Food Preparation . Hazard Analysis of Critical Control Points (HACCP) for Food Preparation, dated 2018, the P&P indicated, . Each facility should develop HACCP procedures to assure that foods produced and consumed will be safe . Food Handling and Preparation-Do the employees have directions for handling, storing and reheating leftovers? Are temperature control logs being utilized for potentially hazardous foods? Are prepared foods monitored throughout the day for time and temperature? . During a review of the facility's P&P titled, Food Preparation . Calibrating and Sanitizing Thermometers, dated 2018, the P&P indicated, . Two Tiered Cooling: Internal temperature of food must be reduced from 140°F to 70°F in 2 hours and cooled from 70°F to 4°F in 4 hours .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan that provided direction for individualized care of the resident) for three of 22 sampled residents (Resident 17, 18 and 10) when: 1. Resident 17's communication problem care plan did not have a hearing aid appliance intervention for use specific to resident needs. This failure placed Resident 17 at risk for lacking sensory interaction (hearing) and potential decrease in quality of life. 2. Resident 18's care plan was not developed for use of an indwelling urinary catheter (A flexible plastic tube inserted into the bladder to provide continuous urinary drainage). This failure placed Resident 18 at risk for indwelling catheter care procedures to be unmet placing the resident at risk for care provided not up to standards of practice. 3. Resident 10's nutritional care plan intervention to prepare and serve honey thickened liquids was not followed during a lunch meal observation. This failure placed Resident 10 at risk for choking and lung infections. Findings: 1. During a Resident Council meeting observation on 1/21/20, at 2:20 p.m., Resident 17 stated while cupping both ears, I could not hear you well. During a concurrent observation and interview on 1/23/2020, at 9:30 a.m., with Resident 17, Resident 17 was in his room and stated he had a problem with his hearing. Resident 17 stated, I cannot hear well while cupping both of his ears. Resident 17 stated he had been examined by a hearing doctor before and his ears were cleaned. During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool used to identify resident care needs) assessment dated 11/26/19, the assessment indicated a Brief Interview for Mental Status (BIMS) score of 14 of 15 which indicated Resident 17's cognition (mental action or process) was intact. The MDS assessment, section B, indicated, Hearing aid or other hearing appliance used .[yes]. During a concurrent interview and review of Resident 17's clinical record, on 1/23/2020, at 9:47 a.m., with the Social Service Designee (SSD), Resident 17's Communication problem [related to] hearing deficit care plan dated 5/22/17, indicated, Focus: The resident has a communication problem r/t (related to) Hearing Deficit. 11/25/19 Resident [17] has hearing aids for both ears .Goal . resident [17] will maintain current level of communication function . The care plan did not have interventions specific to Resident 17's hearing aid use and needs that would improve the resident's hearing function and communication. The SSD stated she documented Resident 17's hearing aids in the care plan on 11/25/19. The SSD validated she failed to put in place interventions to ensure staff assisted Resident 17 with the use of his hearing aid to improve his hearing function. The SSD stated she should have documented person-centered interventions for the use of Resident 17's hearing aids and she did not do that. During an interview on 1/23/2020 at 2:40 p.m., with the Director of Nursing (DON), the DON stated the SSD should have included care plan interventions to ensure Resident 17 would be assisted by staff in offering and putting in hearing aid device to improve the resident's quality of life. 2. During a concurrent interview and record review on 1/23/2020, at 4 p.m., with Medical Records Department (MRD) 2, Resident 18's clinical records were reviewed. Resident 18's face sheet (document containing resident demographic information) undated indicated Resident 18 was admitted to the facility on [DATE] with diagnoses which included Unspecified Hydronephrosis (the swelling of a kidney due to a build-up of urine) and Retention of Urine (inability to completely empty the bladder). Resident 18's physician's order dated 1/23/2020 indicated, Indwelling catheter 16fr (French-size of lumen) for Hydronephrosis date . 2/13/19. MRD 2 reviewed Resident 18's clinical record and was unable to find documented evidence a comprehensive care plan was developed for Resident 18's use of an indwelling urinary catheter. MRD 2 stated a comprehensive care plan was not developed for Resident 18's use of the indwelling urinary catheter and one should have been developed. During a concurrent interview and clinical record review for Resident 18 on 1/23/2020 at 4:20 p.m., with the Minimum Data Set Coordinator (MDSC), the MDSC reviewed Resident 18's clinical record and was unable to find documented evidence of a care plan for Resident 18's use of an indwelling urinary catheter. The MDSC stated a care plan for the indwelling urinary catheter should have been developed and it was not. During a concurrent interview and clinical record review for Resident 18 on 1/24/2020, at 1:20 p.m., with the DON, the DON reviewed Resident 18's clinical record and stated there should have been a comprehensive care plan developed for Resident 18's use of the catheter to meet the resident's care needs and it was not. 3. During a concurrent lunch observation and interview on 1/21/2020, at 12:20 p.m., with Certified Nursing Assistant (CNA) 1, Resident 10's lunch tray included a 4 ounce (oz) glass of cranberry juice, a 4 oz glass of milk and a 4 oz glass of water. CNA 1 repeatedly assisted Resident 10 in drinking the cranberry juice in between bites of pureed food. The glasse of milk and water were a thickened consistency and the cranberry juice was watery. CNA 1 stated Resident 10's diet was fortified pureed with honey thickened liquids. CNA 1 lifted, tilted and shook the watery cranberry juice in a glass. CNA 1 stated the cranberry juice was watery in consistency and compared the glass of cranberry juice with the glasses of thickened milk and water served to the resident. CNA 1 stated Resident 10's milk and water were thickened and the cranberry juice was not. CNA 1 stated the dietary department prepared all thickened liquids and nursing staff was responsible to check the accuracy of the consistency of the liquids. CNA 1 stated she should have checked and ensured Resident 10's thickened liquids were honey thickened according to the physician's order and she did not do that. CNA 1 stated she should not have given the watery cranberry juice to Resident 10 because of the danger of choking or aspiration (inhalation) of liquids to her lungs. During a review of Resident 10's Diet care plan dated 6/27/19, indicated, Focus: Diet: .[serve] Honey liquids. Goal: [section of the care plan was left blank] Interventions. Diet as ordered - specify; .[serve] Honey thick liquids. [by] CNA, LPN [license Practical Nurse], RN [Registered Nurse] . During a concurrent interview on 1/23/2020, at 3:20 p.m., with the Dietary Services Supervisor (DSS) and the Registered Dietician (RD), the DSS and the RD stated the CNA should have asked the dietary department for thickened liquids if the fluids served to the residents were not thickened according to their diet cards. The DSS stated this practice was to ensure the physician's diet order and the care plans were followed and that did not occur. During a concurrent interview and review of Resident 10's Diet care plan on 1/24/2020 at 1:35 p.m., with the DON, the DON reviewed Resident 10's Diet care plan and stated Resident 10's comprehensive person-centered care plans should have measurable goals and it did not. The DON stated the care plan interventions should have been implemented and should have included for CNAs to serve resident's thickened liquids safely according to the physician's order and in accordance with a person-centered care plan and it was not. During a review of the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual dated 10/19 indicated, . Care Planning . the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical mental, and psychological well- being. The care plan is driven not only by identified resident issues and /or conditions but also by a resident's unique characteristics, strengths, and needs, a care plan is based on thorough assessment, effective clinical decision making and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services that met professional standard of quality for three of four sampled residents (Resident 12, 17 and 20) when: 1. Licensed Vocational Nurse (LVN) 1 had not notified Resident 12's physician that Resident 12 had a change in condition, abnormally low blood pressure. This failure placed Resident 12's health and safety at risk when the physician was not notified of the resident's change of condition. 2. Resident 17 and Resident 20 did not have a physician's order for the use of an indwelling urinary catheter (a tube which is inserted into the bladder and left in place in drain urine). This failure placed Resident 17 and 20 at risk for undetected complications from the indwelling urinary catheter and could adversely affect resident's health. Findings: 1. During a concurrent medication administration observation and interview on 1/22/2020, at 9:10 a.m., with LVN 1 in Station 1, South Wing, LVN 1 took Resident 12's blood pressure (BP - the pressure of the blood within the arteries), using a digital blood pressure monitor. LVN 1 obtained the BP values of 82/50 mmHg (millimeter of mercury) at 9:18 a.m. LVN 1 took Resident 12's BP again at 9:50 a.m., with values of 88/58 mmHg. LVN 1 informed Resident 12 that her blood pressure was unusually low and (LVN 1) would hold (not administer) her Lisinopril (medication used to treat high blood pressure). Resident 12 was observed to be sluggish in speech, slow in response and sleepy. LVN 1 informed Resident 12 she would take the BP manually later and would contact the physician about her low blood pressure. LVN 1 administered the other scheduled morning medications by spooning the pill to the resident's mouth one at a time while Resident 12 sipped water from the cup with a straw. Resident 12 dropped one pill from her mouth onto the bed. LVN 1 stated Resident 12 was taking a long time to swallow the medications. LVN 1 then lowered the head of Resident 12's bed and exited the room. During a concurrent interview and record review on 1/23/2020, at 9:20 a.m., with LVN 1 at the nurse's station, LVN 1 reviewed Resident 12's progress noted dated 1/22/2020 which indicated, Lisinopril Tablet 20 milligrams (mg-unit of measure) held d/t (due to) BP 88/58. Resident 12's Weights and Vitals Summary form dated 1/7/2020 through 1/22/2020 had three low BP values recorded: Resident 12's BP was 96/62/mmHG on 1/13/2020; 96/52 mmHG on 1/15/2020; and 88/58 mmHg (lowest) on 1/22/2020. LVN 1 stated she took Resident 12's BP manually on those dates but was unable to find documentated evidence in the clinical record. LVN 1 was unable to find documented evidence Resident 12's physician was informed of the resident's change in B/P's and sluggish response and sleepiness. LVN 1 reviewed Resident 12's Progress notes dated 1/7/19 through 1/22/20 and was also unable to find documented evidence Resident 12's change of condition was monitored during her shift. During a concurrent interview and record review on 1/23/2020, at 10 a.m., with the Director of Nursing (DON), the DON reviewed Resident 12's Progress notes dated 1/7/2020 through 1/22/2020 and stated LVN 1 should have notified Resident 12's physician promptly about the resident's low BP and change in condition. The DON stated LVN 1 should have taken Resident 12's BP every half hour to one hour before the shift ended to conduct ongoing assessments of Resident 12's BP condition and for endorsement to the next shift and that did not occur. During a review of the facility's policy and procedure (P&P) titled, Change in Resident Condition or Status dated 12/16, indicated, Policy Statement: Our facility shall promptly notify . his or her Attending Physician . for changes in the resident's medical/mental condition and or status . 2. During a concurrent observation and interview on 1/21/2020, at 4:35 p.m., with Resident 17, in the hallway, Resident 17 had an indwelling urinary catheter. Resident 17 stated he had the indwelling catheter because he was unable to urinate. During a review of Resident 17 admission record (demographic information of the resident) dated 1/23/2020, indicated Resident 17 was admitted on [DATE] with diagnoses of Benign Prostatic Hyperplasia (prostate gland enlargement causing difficulty urinating) and Urinary retention (the inability to empty the bladder completely). During a concurrent interview and record review on 1/23/2020, at 8:05 a.m., with LVN 1, LVN 1 reviewed Resident 17 and Resident 20's physician's orders dated 1/23/2020 and was unable to find a physician's order for the use of indwelling urinary catheters for Resident 17, and Resident 20. LVN 1 stated an order should have been obtained when the indwelling catheters were initiated for Resident 17 and Resident 20 and that did not occur. During a review of Resident 20's admission record dated 1/23/2020, the admission record indicated, Resident 20 was admitted on [DATE] with diagnoses of Retention of Urine and Benign prostatic Hyperplasia. During concurrent interview and record review, on 1/23/2020, at 9:21 a.m., with the Minimum Data Set Coordinator (MDSC), the physician's order for Resident 17 and Resident 20 was reviewed. The physician's order for Resident 17 and Resident 20, indicated there were no indwelling urinary catheter orders. The MDSC stated there was no physician's orders for an indwelling urinary catheter for Resident 17 or Resident 20. The MDSC stated Resident 17 and Resident 20 should have had a physician's order for the use of the indwelling urinary catheters. During a review of the facility's P&P titled, Medication Orders and treatment, Dental Services dated 4/07, indicated, .1. all orders for treatment of the resident must be in writing and signed . 3. All orders must be charted and made a part of the resident's medical records and care plan . During a review of the facility P&P titled, [brand name] Catheter Insertion, Male Resident dated 10/2010, indicated, .1. Verify that there is a physician's order for this procedure .

Based on observation, interview, and record review the Pharmacy Consultant (PC) failed to identify irregularities during his drug regimen review for one of six sampled residents (Resident 17) when Resident 17's medication to treat high blood pressure was not administered at the prescribed times. This failure had the potential to place Resident 17's health and safety at risk for the side effect of a medication not administered in accordance with the physician ordered administration time. Findings: During a concurrent medication administration observation on 1/22/2020, at 10:03 a.m., with Licensed Vocational Nurse (LVN) 1 in Station 1, South Wing, LVN 1 took Resident 17's blood pressure (Bp - is the pressure of the blood within the arteries). LVN 1 reviewed Resident 17's physician's order, medication administration record (MAR) and the medication bubble pack (device that contains designated sealed compartments, or spaces for medication pills to be taken at particular times of the day) for Carvedilol (medication for high blood pressure). LVN 1 administered Carvedilol 6.25 milligram (mg-unit of measure) one tablet by mouth at 10:12 a.m., and Resident 17 swallowed the pill. During a concurrent interview and record review on 1/22/2020, at 2:37 p.m., with LVN 1, LVN 1 reviewed Resident 17's Physician's order and the MAR dated 1/22/2020 which indicated, Carvedelol tablet 6.25 mg Give 1 tablet by mouth two times a day for [high blood pressure] .start date 4/6/16. Resident 17's Carvedelol bubble pack pharmacy label instruction indicated, . Take 1 tab by mouth twice daily with breakfast and dinner for [high blood pressure]. LVN 1 stated Resident 17's MAR indicated to administer Carvedilol at 9 a.m. and 9 p.m. LVN 1 stated the physician order and pharmacy medication prescription indicated to administer Carvedilol medication with breakfast and dinner and that had not occurred. LVN 1 stated breakfast was served at 7:30 a.m., and dinner was served at 6 p.m. During a concurrent interview and record review, on 1/22/2020, at 3:40 p.m., with the Medical Records Designee (MRD) 2, Resident 17's drug regimen review conducted by the Pharmacy consultant (PC) was reviewed. The MRD 2 stated Resident 17's drug regimen review for the last six months had not included documented evidence the PC had identified the irregularity in the time of administration of the medication Carvedilol. During a telephone interview on 1/23/2020, at 8:11 a.m., with the PC, the PC stated he conducted monthly audits of Resident 17's drug regimen. The PC stated during review he would check Resident 17's physician's order and the MAR but did not check the medication bubble packs. The PC stated he missed the discrepancy in the time of administration of the Carvedilol for Resident 17 on the MAR. The PC stated Carvedilol should have been administered with breakfast and dinner according to the physician order, pharmacy prescription label instruction and the manufacturer's specification. During a review of the facility's policy and procedure titled, Medication Regimen Review dated 2017 indicated, . Procedure . 4. The facility should ensure that the Consultant Pharmacist had access to . Physician/Prescriber progress notes , nurses' notes, and other documents which may assist Consultant Pharmacist in making a professional judgement as to whether or not irregularities exist in the medication regimen .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the medication error rate did not exceed 5 percent or greater when there were 30 medication pass opportunities for error and two errors resulting in a medication error rate of 6.67 percent for two of 22 sampled residents (Resident 20 and Resident 17). These failures resulted in medication errors for Resident 20 and Resident 17 and placed Resident 20 and Resident 17 at risk for the side effects of the medications not administered in according with the physician's order and the pharmacy prescription label instruction. Findings: 1. During a concurrent medication administration observation and interview on 1/22/2020, at 9:58 a.m., with the Licensed Vocational Nurse (LVN 1) in Station 1, South Wing, LVN 1 reviewed Resident 20's Physician's order, the Medication Administration Record (MAR) and the medication bubble packs as she prepared each medication. LVN 1 entered Resident 20's room at 10 a.m., and administered Resident 20 the scheduled medications which included Tamsulosin HCL (hydrochloric acid - medication that relaxes the muscles in the prostate [a gland surrounding the neck of the bladder in male] and bladder neck, making it easier to urinate) capsule 0.4 milligram (mg - unit of measurement). During a concurrent interview and record review, on 1/22/2020, at 2:26 p.m., with LVN 1, LVN 1 reviewed Physician's order and MAR dated 1/22/2020 indicated, Flomax capsule 0.4 mg (Tamsulosin HCL) Give 1 capsule by mouth one time a day for urinary retention 1 hour after breakfast. Resident 20's medication bubble pack indicated, Take 1 cap[[NAME]] .one hour after breakfast. LVN 1 stated the time of administration in Resident 20's MAR was at 9 a.m. LVN 1 stated she thought she had 1 hour after the scheduled time and that was why she administered the Flomax at 10 a.m., LVN 1 stated Resident 20 was usually served breakfast in his room at 8 a.m. and Flomax was administered at 10 a.m. LVN 1 stated she should have administered the medication Tamsulosin HCL with breakfast in accordance with the physician's order. During a concurrent interview and record review on 1/22/2020, at 2:45 p.m. with the Director of Nursing (DON), the DON reviewed the Mealtime schedule and stated breakfast was served at 8 a.m., for residents eating in their rooms. The DON stated Resident 20's Flomax should have been administered by LVN 1 with breakfast according to the physician's order. During a telephone interview on 1/23/2020, at 8:11 a.m. with the Pharmacy Consultant (PC), the PC stated Flomax should be administered no later than 1 hour after breakfast 9 a.m., following the physician's order and the pharmacy prescription label instruction. During a record review the facility's policy and procedure (P&P) titled, Administering Medications dated 12/12 indicated, Medication shall be administered in a safe and timely manner, and as prescribed . 3. Medication must be administered in accordance with the orders including any required time frames. 4. Medication must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 2. During a concurrent medication administration observation and interview on 1/22/2020, at 10:03 a.m. with LVN 1 in Station 1, South Wing, LVN 1 prepared Resident 17's scheduled morning medication. LVN 1 reviewed Resident 17's physician's order, the MAR and the medication bubble packs as she prepared each medication. LVN 1 took Resident' 17's blood pressure and then administered his morning medications at 10:12 a.m., including Carvedilol (medication for hypertension [abnormally high blood pressure]). During a concurrent interview and record review on 1/22/2020, at 2:37 p.m. with LVN 1, LVN 1 reviewed Resident 17's Physician's order and the MAR dated 1/22/20 indicated, Carvedelol tablet 6.25 mg Give 1 tablet by mouth two times a day for hypertension [high blood pressure]. Resident 17's Carvedilol bubble pack prescription indicated, .Take 1 tab by mouth twice daily with breakfast and dinner for hypertension. Resident 17's MAR indicated, Carvedelol tablet 6.25 mg Give 1 tablet by mouth two times a day at 9 a.m. and 9 p.m. LVN 1 stated Carvedilol should have been scheduled at 8 a.m. during breakfast time and at 6 p.m. at dinner time. LVN 1 stated she followed the 9 a.m. schedule and thought she had one hour after the scheduled medication time of 9 a.m. to administer the medication and that was the reason she administered the medication at 10:12 a.m. LVN 1 stated Resident 17's Carvedilol should have been scheduled with meals at 8 a.m. and 6 p.m. according to the pharmacy prescription label instruction and the physician's order. During a concurrent interview and record review on 1/22/2020, at 2:50 p.m. with the DON, the DON reviewed the Mealtime schedule and stated the mealtime schedule for breakfast was 8 a.m. and dinner schedule was 6 p.m. The DON stated Carvedilol should have been scheduled at breakfast time 8 a.m. and at dinner time 6 p.m. so that carvedilol would be administered following the physician's order and pharmacy prescription label instruction. During a telephone interview with the Pharmacist Consultant (PC) on 1/23/2020, at 8:11 a.m., the PC stated Resident 17's Carvedilol should have been scheduled during mealtimes following the physician's order and pharmacy prescription label instruction. During a review of professional reference titled, Carvedilol - https://www.google.com/search?safe=active&ris= com.microsoft%3Aen-US%3AIE-Addr dated 1/27/20 indicated, Low blood pressure warning: Carvedilol can cause dangerously low blood pressure which may cause you to lose consciousness. To decrease the risk of this happening, take Carvedilol with food . During a review of the facility's policy and procedure titled, . Sample Medication Administration Schedule (undated) indicated, . Medication ordered administered with meals should be given between the first bite of a meal . During a review of the facility's P&P titled, Administering Medications, dated 12/12 indicated, Medication shall be administered in a safe and timely manner, and as prescribed . 3. Medication must be administered in accordance with the orders including any required time frames. 4. Medication must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .

Based on observation, interview, and record review, the facility failed to follow the planned lunch menu served on 1/21/2020 as posted. This failure had the potential for residents to receive repetitive food items which could lead to disinterest of meals and result in weight loss. Findings: During a concurrent observation and record review, on 1/21/2020, at 12:05 p.m., in the dining room, the facility document title Good for your Health Menus(menu for the whole week), dated 1/20 - 26, 2020, was posted on the dining room wall. The good for your health menu indicated for 1/21/2020 lunch meal menu Italian Lasagna, Broccoli with Tarragon, garlic bread, peanut butter cup pudding was going to be served. The residents in the dining room were served their lunch meal. Resident 23's food tray contained Italian Lasagna, Brussels sprouts, garlic bread and peanut butter cup pudding and no broccoli with tarragon. Resident 20's food tray contained Italian Lasagna, Brussels sprouts, garlic bread and peanut butter cup pudding and no broccoli with tarragon. Resident 28 and Resident 26' food trays contained Italian Lasagna, Brussels sprouts, garlic bread and peanut butter cup pudding and no broccoli with tarragon. During a concurrent interview and record review, on 1/21/2020, at 12:10 p.m., with the Dietary Services Supervisor (DSS), the DSS reviewed the facility menu dated 1/20 - 1/26, 2020 which indicated on 1/21/2020 lunch menu was Italian Lasagna, Broccoli with Tarragon, garlic bread, peanut butter cup pudding. The DSS stated the cook change broccoli to brussels sprouts because the kitchen did not have broccoli available. The DSS stated she the cook did not inform her of the brussel sprouts substitution for the lunch meal. The DSS stated when the meal menu was changed, they change the menu posted in the dining room, notify the Registered Dietician (RD) and notify residents about the changes. The DSS checked the menu posted in the dining wall and no changes were documented on the menu. The DSS stated she did not notify the RD of the meal substitute. During an interview on 1/21/2020, at 12:20 p.m., with Resident 26, Resident 26 stated she was not notified about the changes of the broccoli to Brussels sprouts. During an interview on 1/21/2020, at 12:25 p.m., with Resident 28, Resident 28 stated he was not notified about the changes from broccoli to Brussels sprout. Resident 28 stated he likes vegetables. During an interview with Resident 20, on 1/21/2020, at 12:30 p.m., Resident 20 stated he was not notified about the substitutions for broccoli to Brussels sprouts. During a concurrent interview and record review, on 1/22/2020, at 9:10 a.m., with the DSS, the DSS reviewed the facility policy titled Menu Substitution dated 2012 which indicated .menu substitutions be noted on the posted weekly and daily menus throughout the facility so resident/patients and nondietary staff are aware of substitutions .5 Menu substitution .should be approved and signed off by the Registered Dietician. The DSS stated they did not follow the Meal Substitute policy. During an interview on 1/22/2020, at 9:20 a.m., with the Cook, the [NAME] stated they did not have broccoli available and used brussels sprouts as the substitute. The [NAME] stated she substituted a green vegetable to another green vegetable which has the same vitamins so it would be okay. The [NAME] stated she forgot to notify her supervisor DSS of the substitution changes. During a concurrent interview and record review, on 1/22/2020, at 9:30 a.m., with the Registered Dietician (RD), the facility policy titled Menu Substitution dated 2012 was reviewed. The RD stated he was aware of the changes done on the menu yesterday when the DSS called him and notified him about the food substitution after the lunch meal was served. The RD reviewed the policy and stated the changes should be posted on the weekly menu and daily menus throughout the facility so resident were aware of the substitution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assure therapeutic diets were served in accordance with the physician prescribed diet for one of two sampled residents (Resident 10), when Resident 10 was served and consumed unthicken cranberry juice during lunch meal served on 1/21/2020. This failure had the potential to place Resident 10 at risk for choking and/or aspiration (inhalation) of liquids into resident's lungs. Findings: During a concurrent lunch observation and interview, on 1/21/2020 at 12:20 p.m., with Certified Nursing Assistant (CNA) 1, Resident 10's lunch meal included 4 ounces (oz) glass of cranberry juice, 4 oz glass of milk and 4 oz of water. CNA 1 repeatedly assisted Resident 10 in drinking the cranberry juice in between bites of pureed (mashed) food. The glasses of milk and water were observed to be a thickened consistency. The cranberry juice was a watery consistency and not thickened. CNA 1 stated Resident 10's prescribed diet was fortified pureed with honey thickened liquids. CNA 1 lifted, tilted and shook the remaining cranberry juice in the glass. CNA 1 stated the cranberry juice was watery in consistency when she compared the glass of cranberry juice with the thickened milk and water served to the resident. CNA 1 stated Resident 10's was served thickened milk and water, but the cranberry juice was not thickened. CNA 1 stated the dietary department prepared the thickened liquids and she was responsible to check and ensured the Resident 10's liquids were a honey thickened consistency in accordance with the physician's prescribed diet. CNA 1 stated she should not have given the watery cranberry juice to Resident 10 because Resident 10 was in danger of choking or aspiration of liquids to her lungs. During a review of Resident 10's Nutrition Risk Assessment assessment dated [DATE], indicated, Fluid consistency, Honey thick . Physical [and] Mental Functioning . Feeding ability - Dependent on staff for all foods and fluids . Chewing and swallowing ability- delayed swallow . During a concurrent interview and record review, on 1/22/2020, at 3:20 p.m., with the Dietary Service Supervisor (DSS) and the Registered Dietician (RD), DSS reviewed Resident 10's physician diet order dated 1/22/2020 which indicated, Honey consistency. DSS reviewed Resident 10's diet card which indicated . HTL (Honey Thick Liquids). The DSS stated the kitchen staff thickens resident fluids using Instant Food Thickener Suggested Usage Chart undated which indicated, . 1 T (tablespoon+ 1/2 tsp (teaspoon - portion measurement to prepare honey thick liquids) The DSS stated dietary aides should have thickened Resident 10's cranberry juice to a honey thick consistency in accordance to the physician's prescribed diet and Resident 10's diet card to prevent potential aspiration of liquids. The RD stated dietary staff should have followed the physician's prescribed therapeutic diet order of liquid thickening and for Resident 10 the cranberry juice was missed and not thickened. The RD stated the Instant Food Thickener suggested usage chart was available in the kitchen for all dietary staff to use. The RD stated he and the DSS should have made spot checks on how the dietary staff thickened the liquids to monitor the staff competency for compliance. During an interview on 1/24/2020 at 1:35 p.m., with the Director of Nursing (DON), the DON stated the dietary staff should have thickened Resident 10's cranberry juice in accordance with the physician's prescribed diet order. The DON stated the dietary staff should have followed the food thickener suggested usage chart for Resident 10's swallowing safety. During a review of the facility's policy and procedure titled Nutrition Care dated 2012, indicated, . Diet orders for New Admissions, Diet Changes, NPO (Nothing by Mouth), or Hold Meals. Procedures: . The facility will serve diets as ordered by the physician and in accordance with the approved diet manual . During a review of the facility's policy and procedure titled Nutrition Care dated 2012, indicated, Policy: Thickened foods and liquids are provided to residents /patients with swallowing disorder to ensure a safe consistency for adequate nutrition and hydration and to decrease the probability of aspiration . Subject: THICKENED LIQUIDS Procedures: . 4. Manufacturer's instruction will be followed when using thickening agents to provide the ordered consistency of liquids. The Nursing staff and Dietary Service Supervisor will monitor staff competency for compliance as part of the quality assurance .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain complete medical records for one sampled resident (Resident 3) when Resident 3 who was a known smoker did not have a smoking assessment completed. This failure potentially placed Resident 3 at risk for injury from unassessed smoking safety needs. Findings: During an interview on 1/24/2020, at 10:10 a.m., the Social Service Director (SSD) stated Resident 3 was a smoker and was provided with supervised smoking sessions by a CNA each time Resident 3 requested a smoke break. During a concurrent interview and record review, on 1/24/2020, at 10:15 a.m., with the Medical Records Director (MRD) 2, the MRD looked through Resident 3's clinical record in search of a smoking assessment. The MRD reviewed Resident 3's face sheet (document with personal identifiable information) indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's nursing admission progress note dated 11/13/17, indicated Resident 3 was a smoker. Resident 3's Minimum Data Set (a resident assessment tool used to identify resident care needs) dated 3/8/19, indicated Resident 3 used tobacco. The MRD 2 looked through Resident 3's clinical record and stated there was no documented smoking assessments in Resident 3's electronic medical record. During an interview on 1/24/2020, at 1:20 p.m., with the Minimum Data Set Coordinator (MDSC), the MDSC validated Resident 3 did not have a smoking assessment and should have had one completed. During an interview on 1/24/2020, at 2 p.m. with the Director of Nursing (DON), the DON stated the facility did not have a smoking assessment in PCC and there should have been. The DON stated the facility did not have a policy and procedure to follow for the completion of smoking assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to review and revise comprehensive person-centered care plans (a plan that provides direction for individualized care of the resident) for one of 22 sampled residents (Resident 3) when: 1. Resident 3 did not have a care plan developed for Restorative Nursing Assistant (RNA) exercise program services. This failure had the potential to place Resident 3's range of motion and mobility care needs at risk of not being met. 1b. Resident 3's smoking care plan was not reviewed, revised and updated on an ongoing basis to reflect changes in Resident 3's smoking needs. This failure placed Resident 3's Behavioral/Emotional related to smoking care needs at risk of not being met. Findings: 1. During a concurrent interview and record review on 1/24/2020, at 10:15 a.m., with Medical Record Director (MRD) 2, MRD 2 reviewed Resident 3's face sheet (document with personal identifiable information) which indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included Hemiplegia (paralysis of one side of the body) and Hemiparesis (partial weakness of one side of the body) following Cerebral Infarction (stroke- damage to the tissue or brain). MRD 2 stated Resident 3 was placed on Restorative nursing assistant (RNA- exercises program to gain or maintain resident's highest possible functioning level). MRD 2 reviewed Resident 3's physician order dated 5/10/19 which indicated, RNA program for QD [daily] 3x/week cont[inue] for strengthening exercises. MRD 2 stated Resident 3 did not have a care plan developed for RNA program services prescribed by the physician for the past eight months. MRD 2 stated a care plan should have been developed. During a concurrent interview and review of Resident 3's care plans on 1/24/2020, at 2 p.m., with the Minimum Data Set Coordinator (MDSC), MDSC stated Resident 3 did have a care plan for the RNA program and the care plan had not been reviewed and/or updated to reflect Resident 3's current functional state. The MDSC stated the resident's care plan should have been reviewed, revised and updated every three months to meet the resident's care needs. During an interview on 1/24/2020, at 1:20 p.m., with the DON, the DON stated Resident 3's care plans should have included the RNA services and should have been reviewed, revised and updated every three months or as needed to meet the residents needs and that did not occur. 1b. During a concurrent observation and interview on 1/24/2020 at 10:10 a.m., with Resident 3 in her room, with MRD 2, Resident 3 stated she stopped smoking 12 months ago. During a concurrent interview and record review on 1/24/19, at 9:47 a.m., with MRD 2, MRD 2 reviewed Resident 3's Behavioral/Emotional care plan dated 2/20/18 which indicated, .Resident becomes anxious, agitated when unable to smoke. Threatens to stand by herself to go out to smoke. Paces (wheeling self-back and forth) in halls in w/c (wheelchair) looking for someone to go with her. Started on Nicoderm [nicotine] patch for smoking cessation [to quit smoking]. On 5/30/18 Resident 3 started smoking again. MRD 2 stated Resident 3's smoking care plan had not been reviewed, revised or updated from 5/30/18 through 1/24/2020 to reflect Resident 3's current smoking status for the past 19 months. MRD 2 stated Resident 3 was still smoking. During a concurrent interview and record review on 1/24/2020, at 1:45 p.m., with the MDSC, the MDSC validated Resident 3's care plan did not contain ongoing review and updates. The MDSC stated Resident 3's smoking care plan should have been reviewed, revised and updated every three months or as needed to reflect Resident 3s current smoking status and it was not. During a concurrent interview and clinical record review on 1/24/2020, at 1:20 p.m., with the DON, the DON stated Resident 3 was smoking on and off for periods of time. The DON reviewed Resident 3's smoking care plan and stated the care plan should have been reviewed and updated to reflect Resident 3's smoking status and it did not. During a review of the Center for Medicare and Medicaid (CMS) RAI (Resident Assessment Instrument) Version 3.0 Manual dated 10/19 indicated, The plan of care must be reviewed and revised periodically, and the services provided must be consistent with each resident's written plan of care.

Based on interview and record review, the facility failed to ensure the food services staff had appropriate competencies and safely to effectively carry out the functions of food services department when [NAME] 1, Assistant cook (AC) and dietary aide (DA)1 were not able to verbalize the process for food cool down. This failure had the potential for untrained staff to place residents at risk of exposure to foodborne illnesses. Findings: During an interview on 1/22/2020, at 10:30 a.m., with the [NAME] and the Dietary Services Supervisor (DSS), [NAME] 1 was asked to verbalize the kitchens food cool down process. [NAME] 1 stated she would place the hot food in a tray of ice to cool down. [NAME] 1 stated she did not know the cool down process. The DSS stated [NAME] 1 was not able to verbalize the cool down process. During an interview on 1/22/2020, at 10:35 a.m., with Dietary Aide (DA)1, DA verbalized the hot food cool down process. DA 1 stated to start the cooling down process for hot foods the temperature of the food should reach 135 degrees Fahrenheit (F) and then continue cooling down every two hours and the hot food is cool. DA 1 was unable to verbalize the foot food cool down process. During an interview on 1/22/2020, at 10:38 a.m., with the Assistant [NAME] (AC), AC stated she does not know the hot food cooling down process. During a concurrent interview and record review, on 1/22/2020, at 10:41 a.m., with the DSS, the DSS reviewed the cool down process policy and procedure and stated the hot food cool down process should start when food temperature drops to 135 Degrees F, then cool down to 70 F within two hours and then continue for 4 hours until hot food reaches 41 degrees F. The DSS validated the cook, AC and DA 1 were unable to verbalize the food cooling down process. The DSS stated it was important to know the food cooling down process to prevent growth of bacteria and prevent residents from becoming sick. During an interview on 1/22/2020, at 10:45 a.m., with the Registered Dietician (RD), in the DSS office, the RD stated the dietary staffs needs to know how to perform the food cool down process to prevent residents from food borne illness. During a review of the facility's policy and procedure titled, Food Preparation dated 2012, indicated .2. Food must be cooled to 70 F within two hours and then 41 F within the next four hours . During a review of the Professional Reference titled, Food Code U.S. Public Health Services, FDA [Federal Food and Drug Administration] U.S. food & Drug administration dated 2017, indicated, Using improper cooling and holding temperature activities, directly relate to food safety concerns and food borne illness risk factors. To effectively reduce the occurrence of food-borne risk factors, food service operators develop and implement food safety management systems to prevent, eliminate or reduce the occurrence of food-borne illness risk factors. The FDA Food Code identified a preventative rather than a reactive approach to food safety through a continuous system of monitoring and verification. Control measures essential to food safety, such as proper cooking, cooling, refrigeration, includes time/temperature control for foods. For example, within two hours of cooking, the internal food temperature shall reach 70 degrees Fahrenheit or less and 41 degrees F or less after an additional four hours.

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food services safety when: 1. Food storage bins were not kept clean and sanitary. 2. Foods stored in the refrigerator were not labeled and dated. 3. Dry and canned goods in the dry good storage were not labeled and dated. 4. Multiple kitchen spices lids and containers were found dusty, sticky and with dried spillage. These failures had the potential to result in unsafe food storage, food handling and unsanitary practices that could lead to food contamination, growth of microorganism (bacteria) and forborne illness to the residents receiving meals from the kitchen. Findings: 1. During an observation on 1/21/2020, at 10:15 a.m., in the kitchen with the Dietary Services Supervisor (DSS), five large food storage bins each containing thickener, flour, rice, sugar and beans had covers with sticky, black substance and dust on the covers. The DSS validated the bin covers had sticky substance and were dusty. During an interview on 1/22/2020, at 3:05 p.m., with the Dietary Aide (DA) 3 at the dietary department, DA 3 stated looked at the big storage bins and stated the food storage bins were dirty and everybody was expected to clean the bins. DA 3 stated Nobody was given the responsibility to clean the bins and we all thought somebody would clean the bins, but no one did. DA 3 stated the storage bins should have been cleaned at least once a week. DA 3 stated nobody had checked the storage bins regularly to ensure the storage bins were cleaned and sanitary. During a concurrent interview on 1/22/2020, at 3:20 p.m., with the DSS and the Registered Dietician (RD) in the dietary department, the DSS stated the storage bins should have been cleaned regularly for cleanliness and sanitation. The RD stated the cleaning of the bins was his responsibility and the DSS should have spot check the kitchen storage sanitation more often. During a review the facility's policy and procedure titled, Sanitation and Infection Control dated 2012 indicated, Cleaning Schedules/Procedures .1. Cleaning schedules will be developed by the Dietary Service Supervisor .The Registered Dietician will check the cleanliness of the kitchen and dining area .and make recommendations to the facility as needed to maintain a sanitary environment. 2. During an observation on 1/21/2020 at 11 a.m., in the walk-in freezer in the kitchen with Dietary Aide (DA) 2 the following items were observed: a. An opened, unlabeled and undated three-gallon Rocky Road ice cream container did not have a cover on the container and was readily available to be served to residents. b. An opened, unlabeled and undated three-gallon Strawberry ice cream container was readily available to be served to residents. c. An opened half full plastic container with Pull meat was unlabeled and undated d. An opened 1/3 full bag of mixed vegetables was unlabeled and undated. During an interview on 1/21/2020, at 11:10 a.m., with the DA 2 in the Dietary Department, DA 2 stated food should have been labeled and dated with open date before in was stored in the refrigerator or the dry storage room and that did not occur. During an interview on 1/21/2020, at 11:15 a.m., with the DSS, the DSS stated all food stored in the kitchen should have been labeled and dated with open date by the dietary staff before the food were stored in the refrigerator or freezer. During a review of the facility's policy and procedure titled, Sanitation and Infection Control dated 2012 indicated, Subject: Freezer Storage. Procedures: . 6. Frozen food should be labeled with the date it was placed in the freezer . 3. During an observation on 1/21/20, at 11:52 a.m., in dry storage room with the DSS the following items were observed: a. An open, unlabeled, undated container with Lentil beans was in the dry storage and readily available to be used for resident consumption. b. An opened box containing 500 tartar sauce in individual packet was not labeled and not dated. c. An opened box containing 2000 sugar packet was not labeled and not dated. During a concurrent interview and record review, on 1/22/2020, at 3:35 p.m., with the DSS and the RD at the Dietary Department, the DSS stated all dry foods and canned foods should have been labeled and dated before they were stored in the dry goods storage. The RD stated the dry lentil beans should have been labeled, dated and transferred to a covered closed container before the Lentils were stored in the dry storage area. During a review of the facility's policy and procedure titled, Sanitation and Infection Control dated 2012 indicated, Subject: Canned and Dry Goods Storage. Procedures . 5. New stocks must be placed behind the old stocks so oldest items will be used first. Products should be dated to assure FIFO - First In- First Out . 7. Metal, plastic containers (with tight fitting lids and NSF approved) or resealable plastic bags will be used for staples and opened packages of items such as pastas, rice, dry cereals etc. Food items will be labeled and dated when place into containers. 4. During a concurrent observation and interview, on 1/22/2020, at 10:05 a.m., with the DSS in the kitchen, the kitchen Spices rack containing different spices had the following: ground black pepper lid and container were sticky, Paprika container and lid were dusty with reddish color dust, Worcestershire sauce with dried spilled sauce on the container, Red wine vinegar container was found dust on the lid, Italian Seasoning container dusty with crumbs on the lid and the Chili red powder container had red dust on the lid with crumbs. The DSS stated the Assistant [NAME] (AC) was assigned to clean the spices shelves/rack weekly and that did not occur because the spices were dusty and sticky. During a review of the facility's policy and procedure titled Sanitation and Infection Control dated 2012, indicated .1. All storage area (cupboards, shelves, drawers, storeroom) will be clean and dry .15. Bins holding dry goods such as flour, sugar, beans, etc. must be clearly labeled on the lid .and need to be cleaned each time they are used. 16. Storage area will be cleaned . During a review the facility's policy and procedure titled, Sanitation and Infection Control dated 2012 indicated, Cleaning Schedules/Procedures .1. Cleaning schedules will be developed by the Dietary Service Supervisor .The Registered Dietician will check the cleanliness of the kitchen and dining area .and make recommendations to the facility as needed to maintain a sanitary environment .

Based on interview, and record review, the facility failed to address physical plant condition necessary to keep residents safe when the facility assessment did not include a water management plan for the detection of Legionella (water borne bacteria which can cause life threatening pneumonia)(lung pneumonia) or other waterborne bacteria in the facility water system. This practice failed to establish an individualized facility assessment to meet the requirement for water management plan which had the potential for waterborne bacteria exposure to all residents including Legionella. Findings: During an interview on 1/23/2020, at 2 p.m., with Maintenance Supervisor (MS), and Asst. Maintenance supervisor (AMS) in the Administrator's (ADM) office, the MS stated he had been working in the facility since it opened. The MS stated he was not aware of the requirement to develop and implement a water management plan. The AMS stated he heard about it from another Skilled Nursing Facility (SNF) but he was not aware if the facility had a water management plan for the detection of Legionella. The MS stated the facility had no water management plan. During a concurrent interview and record review on 1/23/2020, at 2:30 p.m., , the ADM stated the facility did not develop or implement a water management plan for detection of Legionella or water borne bacteria. The ADM reviewed the Annual Facility Assessment Tool undated and stated the facility assessment did not include information regarding the facility needs for a water management program. During a review of Professional references, CMS (Centers for Mediacare and Medicaid Services) Quality, Safety & Oversight (QSO) letter dated and revised 7/16/18, indicated, Expectation for Healthcare Facilities: CMS expects Medicare/Medicaid certified facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1) conducts a facility risk assessment to identify where Legionella and other opportunistic water borne pathogens .could grow and spread in the facility water system. 2) Develops and implements water management program that considers the [American Society of Heating, Refrigeration and Air-Conditioning] ASHRAE industry standard and the [Center for Disease Control] CDC tool kit. 3)Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are maintained. 4) Maintains compliance with other applicable Federal, State and local requirements.

Based on interview and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program when the QAPI program did not address the development and implementation of a water management plan as part of the infection Control Program. This failure resulted in the facility not having a water management program in place to reduce the risk of water borne illnesses including Legionella (a water borne disease that may cause a severe form of pneumonia which is a lung infection). Findings: During an interview on 1/23/2020, at 2 p.m., with Maintenance Supervisor (MS), and Asst. Maintenance supervisor (AMS) in the Administrator (ADM)'s office, the MS stated he had been working in the facility since it opened. The MS stated he was not aware of the requirement for a water management plan. The AMS stated he heard about a water management plan from another Skilled Nursing Facility (SNF) but he was not aware if the facility had a water management plan for the detection of Legionella. The MS stated the facility had no water management plan. During a concurrent interview and record review, on 1/23/2020, at 2:30 p.m., with the ADM, the facility document titled Quality Assurance and Performance Improvement, undated was reviewed. The ADM stated she was not aware of the requirement for a water management plan and the facility had not developed and implemented the water management plan for the detection of Legionella. The QAPI committee had not addressed the need to develop a water management program in their facility QAPI infection control program. The ADM stated he had not implemented measures to ensure the facility developed and implemented a water management program. During a review of Professional references, CMS (Centers for Mediacare and Medicaid Services) Quality, Safety & Oversight (QSO) letter dated and revised 7/16/18, indicated, Expectation for Healthcare Facilities: CMS expects Medicare/Medicaid certified facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1) conducts a facility risk assessment to identify where Legionella and other opportunistic water borne pathogens .could grow and spread in the facility water system. 2) Develops and implements water management program that considers the [American Society of Heating, Refrigeration and Air-Conditioning] ASHRAE industry standard and the [Center for Disease Control] CDC tool kit. 3)Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are maintained. 4) Maintains compliance with other applicable Federal, State and local requirements.

2. During an interview on 1/23/2020, at 2 p.m., with the Administrator (ADM), Maintenance Supervisor (MS), and the Assistant Maintenance Supervisor (AMS), the MS stated he was not aware of the requirements to establish a water management program. The AMS stated he knew about the requirements to establish a water management program for the prevention of water borne bacteria from another Skilled Nursing Facility (SNF). The AMS stated he did not know if the facility had a water management plan for the detection of Legionella (a water borne bacteria that can cause lung infections). The MS stated the facility did not have a water management plan for the detection of water borne bacteria. During an interview on 1/23/2020, at 2:30 p.m., with the ADM, the ADM stated the facility did not develop or implement a water management plan for detection of Legionella or other water borne bacteria. The QAPI committee did not address the need to develop a water management program in their facility QAPI infection control program. The ADM stated she did not implement measures to ensure the facility developed and implemented a water management program. During concurrent interview and record review, on 1/24/2020, at 9:20 a.m., with the Director of Staff Development (DSD), the DSD reviewed the infection control manual dated 2009. The DSD stated she had a policy for Legionnaires Surveillance and Detection, dated 7/2017 inside her infection control manual but was not able to implement a surveillance program. The DSD stated the facility did not implement the policy for legionnaires because the facility don't have water management program developed as part of the infection control program. During a review of the CMS Quality, safety & Oversight (QSO) letter dated and revised 7/16/18, indicated, Expectation for Healthcare Facilities: CMS expects Medicare/Medicaid certified facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1) conducts a facility risk assessment to identify where Legionella and other opportunistic water borne pathogens .could grow and spread in the facility water system. 2) Develops and implements water management program that considers the [American Society of Heating, Refrigeration and Air-Conditioning] ASHRAE industry standard and the [Center for Disease Control] CDC tool kit. 3)Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are maintained. 4) Maintains compliance with other applicable Federal, State and local requirements. Based on observation, interview and record review, the facility failed to ensure facility infection prevention and control program were implemented for three of six sampled residents (Resident 12, 14 and 17) when 1. Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene before and after medication administration and did not disinfect the blood pressure cuff before and after use. These failures placed Resident 12, 14 and 17 at risk of infections. These failures potentially placed Resident 12, 14 and 17 at risk for the spread of avoidable infections. 2. The facility did not develop or implement a water managment plan for the detection of water borne bacteria. This failure potentially placed all of the residents at risk for infections from unidentified water born bactera such as Legionella (an infection that can cause respiratory illness) and lead to respiratory failure. Findings: 1. During a concurrent medication administration observation and interview on 1/22/20, starting at 9:08 a.m., with LVN 1 in Station 1, LVN 1's medication cart did not have hand sanitizer for use during the medication pass. LVN 1 stated Residents 14, 12 and 17 were prescribed blood pressure medications and she routinely obtained the blood pressure prior to administering the medication. LVN 1 applied the blood pressure cuff first to Resident 14, followed by Resident 12 and lastly Resident 17. The blood pressure cuff was not disinfected prior to or after use for each of the residents. LVN 1 did not sanitize her hands prior to or after each of the medication administrations for Residents 14, 12 or 17. During an interview on 1/22/20, at 4 p.m., with LVN 1, she stated the medication cart did not have hand sanitizer for use during the medication pass. LVN 1 stated a hand sanitizer should have been available for use during the medication pass. LVN 1 stated she did not perform hand hygiene during the medication pass and after direct contact with Resident 12, 14 and 17. LVN 1 stated she should have performed hand hygiene. LVN 1 stated she did not disinfect the BP cuff in between use with Resident 12, 14 and 17 and should have. During an interview on 1/22/20, at 4:15 p.m., with the Director of Nursing (DON), the DON stated she expected LVN 1 to perform hand hygiene in between resident contact. The DON stated LVN 1 should have had hand sanitizer available when performing a medication pass. The DON stated LVN 1 was required to disinfect the BP cuff after each use and before storage. During a review of the facility's policy and procedure titled, Infection Control Guidelines for all Nursing Procedures indicated, .General Guidelines . 3. Employees must wash their hands for 10 to 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents . 4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based containing 60-95% ethanol or isopropanol for all the following situations. a. Before and after direct contact with residents . During a review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment date 7/14 indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Center for Disease Control and Prevention) recommendation for disinfection and the OSHA (Occupational Safety and Health Administration) Blood borne Pathogens Standard. Policy Interpretation and Implementation .c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident care items include . blood pressure cuffs . computers) . Intermediate and low-level disinfectant for non-critical items include: a. Ethyl or isopropyl alcohol. b. Sodium Hypochlorite (5.25-6. 15% diluted in 1:500 or per manufacturer's instructions). c. Phenolic germicidal detergents and d. Iodophor germicidal detergents and e. Quaternary ammonium-germicidal detergents (low-level disinfection only).