**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled Baseline Care Plan, the facility failed to implement interventions for oxygen therapy for one of seven residents (R) (R290) receiving oxygen therapy. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility's policy titled Baseline Care Plan, last review date of 5/2018 under Policy revealed, To strive to initiate a baseline care plan for a resident based upon the medical plan and nursing assessment, which includes the instructions needed to provide person-centered care and meets the professional stands of quality care. Under the section titled Procedure revealed, Number two. The baseline care plan should address the residents' immediate needs and include the minimum healthcare information necessary to properly care for the resident including, but not limited to: b. physician orders and d. therapy services. Review of the electronic medical record (EMR) revealed R290 admitted to the facility on [DATE] with diagnoses that included but not limited to dyspnea, interstitial pulmonary disease, chronic respiratory failure with hypoxia, and syncope and collapse. Review of R290's care plan indicated a focus of receiving oxygen therapy related to chronic respiratory failure with interventions that included but not limited to oxygen via nasal cannula at two liters per minute, initiated on 4/19/2024. Observation on 4/26/2024 at 10:35 am revealed R290 was observed wearing a nasal cannula and receiving oxygen via concentrator with flow meter set at three liters per minute. Observation on 4/26/2024 at 1:49 pm revealed R290 sitting up in a recliner in her room wearing a nasal cannula and receiving oxygen via concentrator with flow meter set at three liters per minute. Observation on 3/27/2024 at 8:01 am revealed R290 sitting up in her recliner eating breakfast wearing a nasal cannula and receiving oxygen via concentrator with flow meter set at three liters per minute. Observation and Interview with Licensed Practical Nurse (LPN) AA on 4/27/2024 at 8:15 am revealed R290 sitting up in recliner wearing a nasal cannula and receiving oxygen via concentrator with flow meter set at three liters per minute. LPN AA verified R290's oxygen flow meter was set at three liters per minute and that the physician order for oxygen was for two liters per minute via nasal cannula. LPN AA confirmed that it was the nurses responsibility to check and verify the flow meter was set to the setting specified by the physician orders. Interview on 4/27/2024 at 10:45 am with the Director of Nursing (DON) revealed her expectation was for the nursing staff to monitor and verify the concentrator flow rate to be set at the rate ordered by the physician. Interview on 4/28/2024 at 8:30 am with Registered Nurse (RN) Care Coordinator BB revealed that the nurses are expected to review and implement the interventions listed on the resident's care plan. Interview on 4/28/2024 at 8:45 am with RN CC revealed that the floor nurse's responsibility related to the care plan was to initiate the baseline care plan on admission, this includes review orders and family and resident requests, to assist with the development of the baseline care plan. She stated the floor nurse was expected to follow the care plan and verify the care provided was included in the care plan. She stated she usually reviewed orders and care plans prior to the start of her shift to verify and reconcile orders with the care plan. Interview with RN DD on 4/28/2024 at 9:00 am revealed the care plan was a communication tool, which opened communication with all staff, so everyone would be on the same page when providing care for each resident. She stated the care plan communicates with nurses, Certified Nursing Assistants (CNAs), and other staff what interventions are needed in relationship to the residents' orders and needs. She revealed nurses should update the care plan to include new interventions. Interview on 4/28/2024 at 9:25 am with the Assistant Director of Nursing (ADON) revealed care planning was addressed every morning during stand-up meetings. She stated the nursing supervisor rounded every morning and discussed with the floor nurses any resident concerns or needs and that they review the 24-hour report. She revealed that during the morning stand up meeting any concerns, issues, resident needs, and updates from the 24-hour report are communicated with the entire interdisciplinary team (IDT). She stated the care coordinator in the past would update the care plan immediately during this meeting as needed. She stated implementation of the care plan included addressing the Treatment Administration Record (TAR) for nurses and the task list for the CNAs. She also stated the care profile was updated and all staff were able to see this in the banner of the EMR. She stated nurses are expected to implement the interventions identified in the care plan and follow physician orders related to the oxygen flow rates. Cross Reference F695

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policies titled Person Centered, Interdisciplinary Care Planning and Care Conference, and Catheter Care, Indwelling, the facility failed to develop a person-centered care plan with interventions that addressed performing catheter care for one of three residents (R) (R24) with an indwelling urinary catheter. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility's policy titled Person Centered, Interdisciplinary Care Planning and Care Conference last revised date 10/2022, under the section titled, Policy revealed, To strive to develop, review, and revise the person-centered interdisciplinary care plan for each resident in order to identify resident needs, establish measurable goals/objectives, interventions, and timeframes to enable the resident to attain/maintain his/her optimal level of physical, mental, and psychosocial functioning. Person Centered The focus on the resident as the center of control. Each resident is supported in making his/her own choices in identifying what is important to him/her regarding daily routines, preferred activities, and a meaningful life. Under the section titled, Procedure revealed, Number five. Ensures that the interdisciplinary person-centered care plan addresses the following: Residents personal and cultural preferences, Residents' preferences and potential for future discharge. Review of the facility's policy titled Catheter Care, Indwelling last revised date 7/2022, under the section titled Procedure, Number 22 revealed, Ensure the care plan reflects the following: a. Type of catheter tubing. b. Routine care of catheter, tubing, drainage bag. c. Interventions to minimize catheter-related injury, pain, encrustation, excessive urethral tension, accidental removal, or obstruction of urine overflow. d. Outcomes and/or effects of goals and interventions. e. Complications associated with catheter usage. f. Urology consult if indicated. Review of the electronic medical record (EMR) revealed R24 was admitted to the facility with diagnoses that included but not limited to hydronephrosis with renal and ureteral calculous obstruction, urinary tract infections (UTI), methicillin resistant staphylococcus aureus (MRSA) infection, artificial openings of the urinary tract, chronic kidney disease, urethral stricture, and obstructive and reflux uropathy. Review of R24's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R24 was cognitively intact. Section GG (Functional status) revealed R24 required partial/moderate assistance during self-care admission performance of toileting. Section H (Bowel and Bladder) revealed R24 had an indwelling urinary catheter and an ostomy. Review of R24's care plan indicated a focus on bilateral nephrostomy tubes (initiated 4/1/2024) Interventions included: empty nephrostomy tubes as ordered, enhanced barrier precautions, follow up with MD (Medical Doctor) as ordered, monitor for s/sx (signs and symptoms) of infection. Further review of care plans revealed a focus for an indwelling catheter (initiated on 3/26/2024) Interventions included: monitor for s/sx of discomfort on urination and frequency, monitor/document pain/discomfort due to catheter and monitor/record/report to MD for s/sx UTI. There were no care plan interventions that addressed performing catheter care. Observation on 4/27/2024 at 9:29 am of R24 in the shower performing self-catheter care with Certified Nursing Assistant (CNA) EE standing on the other side of shower curtain observing R24 perform catheter care. Interview on 4/27/2024 at 9:24 with CNA EE revealed that R24 was documented as stand-by assist for catheter care. She stated he usually did his own catheter care while he showered. She revealed that while R24 showers she observes him performing his catheter care to verify that he completes the care correctly. She stated that if she notices him doing anything incorrectly, she redirects him in his care. She further stated once the catheter care was completed the CNA would report to the nurse and the nurse would document catheter care was completed in R24's eTAR. Interview on 4/27/2024 at 11:45 am with Licensed Practical Nurse (LPN) AA revealed she reviewed R24's care plan, latest MDS assessment, and the task tab in the EMR. She verified and confirmed she could not locate documentation that R24 had been assessed as stand-by assistance for catheter care. She verified and confirmed that the nurse document catheter care three times a day on the eTAR. She stated the CNA's have a tablet which they document in the EMR which may indicate the type of assistance R24 required for catheter care. Interview on 4/27/2024 at 11:45 am with CNA EE revealed that the tablet she uses to document care for residents listed catheter care as a task. She verified and confirmed the task did not indicate the type of assistance R24 required for catheter care. She stated she knew he was stand-by assist for catheter care because she knew R24. She stated she could not identify how the CNA determines the type of assistance R24 required for catheter care in the EMR. Interview on 4/27/2024 at 12:50 pm with the Registered Nurse (RN) Care Coordinator BB confirmed there was no care plan developed for R24 to self-perform catheter care. She stated that she runs a report everyday of new orders obtained from the physician and she develops/revises care plans based on the new orders entered in the EMRs for the facility's residents. She stated she has only been working in the facility since 4/22/2024 and was unaware R24 was performing self-catheter care. Interview with the Director of Nursing (DON) on 4/27/2024 at 12:54 pm revealed her expectation related to development of care plans was for the Care Coordinator to run a report of new orders and develop/revise care plans based upon new orders entered into resident's medical records. Cross Reference F690

Based on observations, staff interviews, record review, and review of the facility's policy titled Catheter Care, Indwelling, the facility failed to assess one out of three residents (R) (R24) with an indwelling urinary catheter for self-performance of catheter care prior to allowing the resident to perform catheter care without staff direct assistance. Findings include: Review of the facility's policy titled Catheter Care, Indwelling last revised date 7/2022 under the section titled Policy revealed, To strive to prevent contamination and catheter associated urinary tract infections and complications. Under the section titled Procedure number five revealed, Catheter care can be given during am or pm care as follows: a. Assist the resident into a supine position. b. Inspect the outside of the catheter where the catheter enters the meatus. Look for encrusted material or suppurative drainage and report any findings to the nurse. c. Inspect the tissue around the urinary meatus for irritation or swelling and report any findings to the nurse. d. Wash the meatal catheter junction and catheter tubing with soap and water, rinse and dry well. f. Draw back the foreskin, wash carefully around the catheter and replace the fore skin on the male resident. Review of R24's electronic medical record (EMR) revealed he was admitted to the facility with diagnoses that included but not limited to hydronephrosis with renal and ureteral calculous obstruction, urinary tract infections (UTI), methicillin resistant staphylococcus aureus (MRSA) infection, artificial openings of the urinary tract, chronic kidney disease, urethral stricture, and obstructive and reflux uropathy. Review of R24's most recent Minimum Data Set (MDS) assessment (Medicare five -day) dated 4/18/2024 revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R24 was cognitively intact. Section GG (Functional) revealed no functional limitations of upper and lower extremities, he was assessed to require partial/moderate assistance with toileting and lower body dressing. Section H (Bowel and Bladder) revealed R24 had an indwelling catheter and ostomy. Review of the EMR revealed physician's orders for R24 included but were not limited to flush nephrostomy tubes with 10 milliliters of normal saline daily as needed for blockage (start date 4/26/2024), clean both nephrostomy sites with warm water, pat dry, apply drain sponge to nephrostomy and cover with transparent dressing daily on Tuesday and as needed, assess for warmth, leakage, pus, breaks in tube every shift on Tuesdays (start date 4/30/2024), empty and document output from catheter and bilateral nephrostomy tubes three times a day, monitor urine output and document nephrostomy drain output three times a day (start date 4/16/24). There were no orders for R24 to perform self-catheter care. Review of the EMR revealed there was no evidence that an assessment had been completed for R24 to self-perform catheter care. Review of the April 2024 Electronic Treatment Record (eTAR) revealed documentation of urinary catheter care documented three times a day and enhanced barrier precautions documented each shift by the nurse. Observation made on 4/27/2024 at 9:29 am of R24 in the shower with Certified Nursing Assistant (CNA) EE standing outside of the curtain watching R24 self-perform catheter care. R24 used soap and water to clean the urinary meatus and catheter tubing from the meatus to the bifurcation in the tube at the balloon port and the urine drainage port. He thoroughly rinsed the area with clean water using a handheld shower head. Interview on 4/27/2024 at 9:24 am with CNA EE stated R24 was stand-by assist for catheter care. She stated he usually did his own catheter care while he showered. She stated once the catheter care was completed the CNA reported the activity to the nurse who would document the care in R24's medical record. Interview on 4/27/2024 at 11:45 am with Licensed Practical Nurse (LPN) AA revealed that R24's care plan, latest MDS assessment, and the task list located in the EMR did not specify R24 was assessed as stand-by assist for catheter care. She confirmed and verified she could not locate any documentation in the EMR that stated R24 had been assessed as stand by assist for catheter care. She stated the care was documented each shift by the nurse on the electronic Treatment Administration Record (eTAR). Interview on 4/27/2024 at 11:50 am with the Director of Nursing (DON) verified the e-TAR indicated catheter care was to be completed each shift for R24. She stated her expectation was when a resident requests to perform their own catheter care, the nurse on the floor should call the physician to request an order for self-care. She further stated that nursing should perform an assessment to verify the resident was able to perform self-catheter care. Interview on 4/27/2024 at 12:50 pm with Registered Nurse (RN) Care Coordinator BB revealed if a resident request to perform self-catheter care, the nurse should assess and educate the resident regarding signs and symptoms of infection and proper performance of catheter care. She stated the nurse should then notify the physician to obtain an order and enter the order into the EMR. She stated her first day in the facility was Monday 4/22/2024, therefore she was unaware of R24's performance of self-catheter care. A request was made for a policy related to resident assessment for self-catheter care but was not provided by the facility. Cross Reference F656

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Oxygen Administration/Safety and Use and Care of Equipment, the facility failed to follow physician's order for oxygen therapy and failed to ensure the oxygen concentrator had a filter while in use for one out of seven residents (R) (R290) who receive oxygen via the concentrator. Findings include: Review of the policy titled Oxygen Administration/Safety with review date of 10/18, revealed the policy was to strive to improve oxygenation, provide comfort to resident's experiencing respiratory difficulties and provide safety precautions during the administration of oxygen. The section titled Procedure, step number one revealed obtain a physicians' order for the use of oxygen (i.e., continuous, as needed, number of liters, etc.). Step number four stated adjust the oxygen flow as ordered by the resident's physician. Step number nine revealed check the resident and oxygen flow frequently to assure the maintenance of the correct flow rate and proper functioning of the concentrator/cylinder. Review of the policy titled Use and Care of Equipment reviewed 11/20, revealed the policy was to strive to provide clean or sterile resident care equipment in order to reduce the possibility of equipment becoming contaminated that may cause infections. Under the section titled Clean Equipment Protocols, number nine addressed Respiratory Equipment and sub-section a addressed Oxygen Materials, number five revealed oxygen concentrator filters are cleaned and or replaced weekly. Review of the electronic medical record (EMR) revealed R290 was admitted to the facility with diagnoses that included but were not limited to dyspnea, interstitial pulmonary disease, chronic respiratory failure with hypoxia, and syncope and collapse. Review of R290's EMR revealed the admission Minimum Data Set (MDS) assessment dated [DATE] was in process and had not been completed related to the resident's recent admission. Review of the EMR revealed a nursing assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated R290 was cognitively intact. Review of R290's care plan indicated a focus of care on receiving oxygen therapy related to chronic respiratory failure which included an intervention but was not limited to oxygen settings: Oxygen via nasal cannula at two liters per minute (initiated on 4/19/2024). Review of R290's EMR revealed physician's orders that included but was not limited to oxygen at two liters per minute via nasal cannula (started 4/18/2024). Review of the EMR revealed nurses documented on the electronic medication administration record (eMAR) oxygen saturations twice a day ranging from 94 to 98 percent on oxygen via nasal cannula. Observations and Interview on 4/26/2024 at 10:35 am of R290 working with physical therapy in her room. R290 was wearing nasal cannula with oxygen infusing from the concentrator at three liters per minute. R290 revealed she had worn her oxygen continuously since her admission into the facility. She revealed prior to admission, she only wore oxygen when walking because she became short of breath easily. Observation on 4/26/2024 at 12:30 pm revealed R290's oxygen concentrator was missing the filter on the back of the machine. Observations on 4/26/2024 at 1:49 pm revealed R290 sitting up in a recliner in her room wearing a nasal cannula and the flow meter on the oxygen concentrator was set at three liters per minute with the filter missing from the back of the concentrator. Observations made on 4/27/2024 at 8:01 am observed R290 sitting up in a recliner in her room wearing a nasal cannula and eating breakfast. The oxygen concentrator flow meter was set at three liters per minute with the filter missing from the back of the oxygen concentrator. Observation and interview on 4/27/2024 at 8:15 am with Licensed Practical Nurse (LPN) AA, confirmed R290's orders for oxygen at two liters via nasal cannula. LPN AA observed and confirmed R290's oxygen concentrator flow meter was set at three liters per minute in addition to the oxygen concentrator not having a filter. She revealed that all oxygen tubing and humidifier bottles were changed weekly on night shift. She stated she thought filters were cleaned one to two times a week but was not sure. She stated she was not sure which night this task was completed on but when tubing and humidifier bottles are changed the nurse should label them with the date. She further stated she was not sure where this task was documented because it was not on her eMAR. Interview on 4/27/2024 at 10:05 am with the Director of Nursing (DON) confirmed R290 had physician orders for oxygen at two liters per minute via nasal cannula. She confirmed the admitting nurse should obtain the oxygen concentrator for newly admitted resident and verify the filter was in place and clean before placing the concentrator in use. She stated oxygen tubing should be changed on Sunday nights. She revealed the admission nurse should initiate the change tubing orders and when tubing was changed, the nurse should document this on the eMAR. She stated each disposable component of the oxygen concentrator (nasal cannula and humidifier bottle) should be labeled with the date it was changed. She stated her expectation of staff was upon admission if a resident has an order for oxygen to initiate oxygen by obtaining a concentrator with a clean filter and set up with a nasal cannula and humidifier if needed and to label each component and the date initiated. She stated she expected the flow meter to be set on the rate ordered by the physician. She also stated she expected during nursing rounds the nurses should be checking the flow meter rate and verifying the rate was set at the physician's ordered rate. She stated she expected the night shift nurse on Sundays to change the tubing set up and clean the filter each week. Cross Reference F655

Based on record review, staff interview, and review of the facility policy titled, Psychotropic Medications, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for one Resident (R) (R#28) reviewed for unnecessary medications. Specifically, the facility failed to ensure a stop date was implemented for antianxiety medication ordered as needed (PRN) for R#28. Findings Include: A review of the medical record revealed that R#28 was admitted to the facility with a past medical history of right femur fracture, hypokalemia, dementia with behaviors, HTN, heart disease, CHF, and abdominal aortic aneurysm. A review of the facility policy, Psychotropic Medications, number M-04.16, revised 10/2022, revealed the use of a psychotropic medication ordered on an as needed (PRN) basis was limited to 14 days, except when the prescribing practitioner believed it was appropriate for the order to be extended and documented the rationale and duration in the health record. A review of the Medical Doctor (MD) orders dated 12/22/2022 at 4:15 p.m. revealed R#28, the MD ordered Lorazepam Solution 2 MG/ML, lorazepam Solution 2 MG/ML, 0.5 (Milliliters) ml intramuscularly (IM) every six hours as needed for refusing care, hitting, kicking, or attempting to elope. The order had a start date of 12/22/2022, but the order had no stop date. A review of the Medication Administration Record (MAR) dated 1/27/2023 at 11:56 p.m., revealed R#28 was administered 0.5 milligrams of Lorazepam IM. A review of the Nursing Notes dated 1/27/2023 at 11:56 p.m. revealed staff administered Lorazepam Solution 2 MG/ML, 0.5 ml intramuscularly (IM) to R#28 for refusing care, hitting, kicking, and attempting to elope. The resident was screaming and combative. The staff had R#28 speak with his daughter by phone, and he would not calm down. The staff could not get him to return to his room and watch a ballgame on TV. He declined an offer to go on a walk. He could not be re-directed, called staff slang names, and struck out at staff. During an interview with the Nursing Supervisor (NS) AA on 2/11/2023 at 2:07 p.m., she stated that the consultant pharmacist reviewed all resident medications, and any recommended changes or modifications were sent to the Nursing Home Administrator (NHA) and the Director of Nursing (DON). NS AA stated the DON would notify the physician and alert them to any medication changes. NS AA acknowledged R#28's lorazepam, 0.5 mg IM, every six hours, as needed, should have been assigned a 14-day end date, and the medication did not have one.

Based on observation, interview, and review of facility policy titled, Holding Hot and Cold Potentially Hazardous Foods the facility failed to maintain hot food items on the portable steam table above 135 degrees to prevent food borne illness. This deficient practice affected 10 of 14 residents on the Reflections Hall consuming a regular textured diet. Findings included: Review of the facility policy titled Holding Hot and Cold Potentially Hazardous Foods revised 11/2013 revealed that for hot foods held for service, all hot potentially hazardous food should be 135F or above before placing the food out for service. Observation on 2/11/2023 at 12:35 p.m. of the portable steam table on the Reflection Hall revealed the grilled chicken breasts had a temperature of 115 degrees and the special request order of fried chicken tenders had a temperature of 116 degrees. Temperatures were obtained by the Certified Dietary Manager (CDM) using the facilities calibrated thermometer. During an interview on 2/11/2023 at 12:35 p.m. the CDM confirmed that the grilled chicken breast was at 115 degrees and the special order of fried chicken tenders were at 116 degrees. The CDM stated that food items should be held on the portable steam table above 135 degrees.

Based on observation, interviews, and review of facility policy titled, Personal Food in Willowbrooke Court the facility failed to ensure that a policy regarding resident personal food included procedure for safe consumption/safe reheating to prevent food borne illness. The deficient practice had the potential to affect 60 of 60 residents receiving an oral diet. Findings include: Review of the fcility policy titled, Personal Food in Willowbrooke Court dated 2/2017 revealed directions for food storage. The policy had no guidelines regarding safe consumption of hot foods if re-heated. Interview on 2/11/2023 at 11:45 a.m. with the Director of Dietary Services (DDS) revealed that he was not sure about a policy that included safe consumption or reheating of food items bought in from outside. The DDS stated that he would expect staff to re-heat to 165 degrees. During an interview on 2/11/2023 at 12:45 p.m. the Certified Dietary Manager (CDM) confirmed that the current policy regarding personal food brought in the facility did not cover safe consumption/reheating procedure. The CDM revealed that she had conducted a quick stand-up in-service a few months ago with some nursing staff on using the microwave for re-heating food items brought in the facility, but did not have staff sign an in-service form due to the information was presented on the spot. The CDM revealed that she did not educate all nurses and all shifts about re-heating foods properly. Observation on 2/11/2023 at 1:20 p.m. of all four resident nourishment areas revealed no food thermometer found for staff to use when reheating resident food items. During interview on 2/11/2023 at 1:20 p.m. the CDM confirmed that there are no food thermometers in any of the resident nourishment areas for staff to use when reheating resident food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that one resident (R) #30 received chopped meats at the lunch meal on two of three days of the survey. This affected one of six residents who were observed for dining. Findings include: Record review revealed that R#30 was admitted on [DATE] with diagnoses to include Type II diabetes, hypertension and dementia. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of seven indicating that the resident was cognitively impaired, the resident was assessed as needing set-up help and supervision only for eating. Review of Physician's Orders dated 9/23/2020 documented R#30's diet to be mechanical soft/chopped meat. Review of the Registered Dietician's (RD) Note for the resident, dated 4/30/2021, revealed a recommendation for a mechanical soft/chopped meat. Review of the resident's care plan revealed that the resident was care planned for mechanical soft diet with chopped meats. Review of an electronic Rehab Screen, dated 6/24/2021, documented an evaluation was recommended for coughing with a meal. An observation of R#30 on 6/21/21 at 12:50 p.m. while eating in the main dining room revealed the resident coughing several times while eating a hot dog which was slice length wise but not chopped along with pinto beans. An observation and family interview on 6/23/21 at 11:25 a.m. revealed the resident sitting in a wheelchair in his room with his spouse visiting. The spouse revealed that the resident chokes sometimes while eating because he puts too much on his fork. An observation on 6/23/21 at 12:41 p.m. revealed R#30 at table a table, in the dining room, with his spouse. The resident was served asparagus soup, approximately quarter size breaded fried whole shrimp, not chopped, sweet potatoes, and cranberry juice. The resident was observed to experience some difficulty eating the food, recovered by self and was able to answer questions asked by the nurse who noticed his difficulty eating. Observation on 6/24/21 at 5:41 p.m. of the resident seated at a table and was served mashed sweet potatoes, chopped brussels sprouts, chopped pork with sauce, applesauce, cranberry juice, chocolate ice cream. No observation of coughing or choking. An interview on 6/23/21 at 1:10 p.m. with the Rehabilitation Director OO revealed that she was familiar with R#30 for physical therapy and that the resident was on a mechanical soft with chopped meats due to moderate dysphagia. She had not been aware of the resident having difficultly eating over the last year. She revealed that if this had been reported by nursing, a speech therapy screen would have been completed. An interview with Licensed Practical Nurse (LPN) II on 6/23/21 at 2:43 p.m. revealed that she is familiar with the resident and that he usually does very well with his meals of mechanical soft with chopped meats. LPN II further revealed that it was unusual for him to cough during meals as he did today. LPN II further revealed that the resident had been screened by Speech Therapy in the past because he eats fast and will put a lot of food in his mouth at one time. Due to his dementia, the resident needs to be reminded to eat slower and take smaller bites. An interview Dietary Manager (DM) AA on 6/24/21 at 9:43 a.m. revealed that the resident is on a mechanical soft diet with chopped meats. DM AA further stated on 6/21/21 the resident had a hot dog we would have cut it lengthwise. DM AA revealed on 6/23/21 that the resident had the shrimp, and it should have been chopped although it is a resident right to have the food the way he wants it. The process is we have host round sheets, are posted in the kitchen and a notebook for Certified Nursing Assistants (CNA's) which is kept by the coffee machine. The dietary aide is responsible to ensure it was chopped but he probably would not have eaten it. The DM AA further revealed it is all staff's responsibility to ensure it is the right consistency. DM AA further revealed that if a resident prefers to not have the ordered consistency that there is a waiver which should be signed. An interview with Dietary Aide (DA) NN on 6/24/21 at 10:08 a.m. revealed that the type of diet the resident is on is posted on a sheet hanging on the bulletin board in the kitchen and is visible so all kitchen staff can see it. DA NN revealed that R#30's diet is mechanical soft with chopped meat and confirmed that on 6/23/21 the resident's meat was not chopped. An interview with the Director of Nursing (DON) on 6/24/21 at 10:38 a.m. revealed that the facility does not have a waiver form for refusing chopped meats for R#30. An interview with CNA MM on 6/24/21 at 10:57 a.m. revealed that she is aware that R#30 is on mechanical soft with chopped meets. CNA MM revealed that she worked with the resident on 6/20/21 and that the resident had flounder, it was broken into small pieces and that the resident did not cough or choke while eating lunch that day. CNA MM further revealed that the resident's diets are posted on a list at the kitchen station or staff can asked and if the food consistency is not correct, they should have it remade. An interview with the Dietary Manager AA on 6/24/21 at 12:05 p.m. revealed that the shrimp was looked at as mechanical soft although the shrimp should have been chopped. An interview with the DON on 6/24/21 at 4:25 p.m. revealed that any agency staff are oriented by a CNA and are educated on how to determine what type of diet the resident is on and were to find that information. A telephone interview with CNA JJ on 6/24/21 at 4:54 p.m. revealed that she worked for an agency and was working with R#30 on 6/23/21. She was aware of where to find what type of diet the residents are on although she could not recall if the shrimp served to R#30 were chopped. A telephone interview with the Registered Dietitian (RD) on 6/24/2021 at 7:41 p.m., revealed that she is familiar with R#30 and is aware of his eating history and he is monitored quarterly. The RD confirmed that both the hot dog and the shrimp should have been chopped before serving them to R#30. She revealed that staff had not reported any issues with eating difficulties for this resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interviews and review of the facility policy titled Side Rail/Bed Rail Usage, the facility failed to assess for the risk of entrapment from bed rails, for two residents (R) (#48) and (R#4); and failed to obtain informed consent, Physician Orders and attempt alternative methods for 36 of 39 residents prior to the use of assist rails (R#1, R#2, R#6, R#7, R#8, R#10, R#12, R#13, R#15, R#16, R#17, R#19, R#20, R#22, R#23, R#25, R#26, R#27, R#28, R#29, R#30, R#33, R#37, R#38, R#40, R#41, R#43, R#45, R#46, R#51, R#52, R#57, R#58, R#59, R#610, and R#613). The findings include: Review of the Facilities Policy titled Side Rail/Bed Rail Usage, revised 6/2018, revealed to strive to ensure that a side/bed rail is used only as necessary, and if used is installed correctly and routinely maintained. All residents will be assessed for the use of side rails upon move-in to the community. The community will attempt to offer side rail alternatives prior to using or installing a side rail. Review the risks and benefits of side/bed rail with the resident or resident's representative. Provide written documentation describing the risks/benefits and safety of side rail use. Look for risk of entrapment from the side (bed) rails at the time of the installation and ongoing with the use of one or more rails. 1. A review of the clinical record revealed R#48 was re-admitted to the facility on [DATE] with diagnosis including unspecified fracture of upper end of right humerus, other specified fracture of right pubis, dementia, major depressive disorder, Alzheimer's disease, essential hypertension, chronic diastolic heart failure, and acute kidney failure. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed R#48 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident was also assessed to require limited assistance of one person with bed, transfer and toileting. Observations of R#48 on 6/22/21 at 11:00 a.m., 6/22/21 at 3:30 p.m., 6/23/21 at 1:35 p.m. and 6/24/21 at 11:30 a.m. revealed the resident laying in her bed sleeping with bed rails in the up position. The bedrails can pivot to an upright position (grab bar) then pivoted for use as a side rail, the staff reference this position as down. Review of Physician Orders, and Progress Notes, for R#48 between admission through 6/24/2021 revealed no documentation related to the use or need for assist/bedrails. Further review revealed there were no Physician Orders, no documented informed consent and no evidence that alternatives or risk for bedrail entrapment were completed prior to the installation of bed rails. An interview on 6/24/21 at 9:50 a.m. with Certified Nursing Assistant (CAN) EE revealed that side rails stay down (pivoted for use as a side rail) when the resident is in bed in order to prevent resident's from failing and for safety. CNA EE stated that a lot of residents on the locked Alzheimer's/Dementia unit have them for safety. CNA EE revealed that she does not know of another use the side rails except to ensure safety of the resident. CNA EE stated the days she provides care to R#48 she enters the resident's room and asks her of she's ready to get up and if the resident is ready to get up, she lifts (pivots) the bed rail and places it in the locked-up position and assists R#48 with transferring from her bed to her wheelchair. CNA EE stated she assists R#48 with toileting and then takes her to breakfast. CNA EE revealed that that after the resident eats she always insists on returning to her bed. CNA EE stated that staff try to encourage R#48 to stay and interact with staff and other resident's but R#48 prefers to be in her bed. CNA EE stated when she returns the resident to her bed, she assists with transferring the resident to the bed, puts bed in low position and puts side rail in place. CNA EE stated she always places the call within reach but admitted that R#48 does not know what the call light is. CNA EE revealed that not all residents use bed rails but the ones that do it is for safety. CNA EE stated that all staff know that the rails are for safety and to prevent falls. CNA EE stated staff have discussed rails but that she is unaware of any in-service or training related to bedrail safety. An interview with Registered Nurse (RN) FF on 6/24/21 t 10:29 a.m. revealed that side rails are used for safety on the locked unit. RN FF revealed that when residents are out of bed, the side rails are in the up position (pivoted to grab bars) and when residents are in bed they are in the down position (pivoted to side rail position). RN FF stated that during admission a bedrail assessment is completed for all residents but is unsure of how often they are completed after admission or of any ongoing assessments. RN FF stated that she is not sure if any of the residents that currently have bedrails have an active Physician's Order for side rails because she has never been told to check for one. RN FF stated that the resident has bedrails on her bed currently and that they should always be in the down position (side rail position) when she is in the bed. RN FF stated that the resident is not compliant and will try to get out of bed without assistance and therefore the bed rails are there to keep her safe and is not able to release them by herself. RN FF stated they are not used for grab bars for the resident because she is unable to use them to pull herself or for repositioning. RN FF stated that she monitors the locked unit throughout her shift to ensure when residents, including R#48, are in bed and that the bed rails are in the down position (side rail position). 2. A review of the clinical record revealed Resident (R)#4 was re-admitted to the facility on [DATE] with a diagnosis of but not limited to altered mental status, unspecified, Alzheimer's disease with late onset, traumatic subdural hemorrhage, unspecified injury of head, subsequent encounter. A review of the admission MDS, dated [DATE], revealed R#4 had a BIMS score of 10, indicating moderately cognitive impairment. The resident was also assessed to require extensive assistance of two person with bed mobility, transfer and toileting. The resident was assessed as having a history of falls prior to admission to the facility. An observation on 6/23/21 at 1:35 p.m. revealed R#4 lying in the bed with her eyes closed with a removeable mesh side rail covering the length of the bed and the bed was pushed against the wall on the other side. An observation on 6/24/2021 at 10:21 a.m. with RN PP revealed that the resident was unable to independently remove the mesh side rail on command throughout the observation without assistance from the RN. Review of the Physician Orders for R#4 dated 4/1/21 through 6/24/21 revealed no documented Physician Order for the use of the removable mesh side rail. Further review of the progress notes for the resident dated 4/8/21, 5/13/21, and 6/10/21 revealed no documentation to use or need for the removable mesh side rail. Review of the document Side Rail Assessment dated 6/162021 revealed no documented evidence of appropriate alternatives to the removable mesh side rail use were attempted. An interview was conducted on 6/24/21 at 12:26 p.m. with the Administrator and Director of Nursing (DON) both confirmed that a Physician Order is not obtained for the use of side rails. The DON stated R#4 has not been assessed for the removable mesh side rail and does not have a Physician Order for the use of the removable mesh side rail. Record Review of medical records for residents R#1, R#2, R#6, R#7, R#8, R#10, R#12, R#13, R#15, R#16, R#17, R#19, R#20, R#22, R#23, R#25, R#26, R#27, R#28, R#29, R#30, R#33, R#36, R#37, R#38, R#40, R#41, R#43, R#45, R#46, R#51, R#52, R#57, R#58, R#59, R#610, and R#613 revealed no documented evidence of appropriate alternatives for bed rail use were attempted prior to a bedrail being assigned. Further review revealed no assessment for risk of entrapment, no documentation of a benefits verses risk analysis being completed, no documented signed informed consent by either the resident or the resident's representative prior to installing bedrails. And lastly there were no Physician Orders for bedrails for any of these residents.

Based on observations, staff interviews, and policies Operational Standards Storeroom and Date Marking Ready-to-Eat Foods reviewed, the facility failed to discard expired food items in the freezer, label and date items in the main kitchen pantry, label and date items in the resident's pantry, and keep the ice machine clean. These deficient practices had the potential to affect 58 of 59 residents receiving an oral diet. Findings include: Review of Operational Standards Storeroom policy, dated 6/1990, revised 2/2017 revealed procedure is all items are organized for easy inventory, foods are stored properly, ensuring opened containers are properly sealed and labeled with the date of opening and the use-by date (month, day and year), all foods are stored in the delivery box with the delivery date or individually with a delivery date on the individual food item, and items that have a manufacture's expiration date do not need additional dating unless it is required by stated regulations. Review of Date Marking Ready-to-Eat Foods policy, dated 12/2007, revised 2/2017 revealed the procedure is for all ready-to-eat foods will be labeled to include the following information: product name and date (month, day and year) the product was prepared or opened and the date the product should be used by. Further review revealed the procedure is to label all ready-to-eat, potentially hazardous foods that are prepared on-site with date of three days from the date it was prepared. Continued review revealed the procedure is to label any processed, ready-to-eat, potentially hazardous foods when opened with a use-by-date based on the Food Storage Chart. 1. During initial tour observation of the main kitchen accompanied by the Sous [NAME] (SC) on 6/21/21 at 11:20 a.m. of walk-in freezer #2, revealed, an opened, one gallon of Tartar Sauce was without a received date or use by label. During continued observation tour of the main kitchen in the dry food storage pantry on 6/21/21 at 11:30 a.m. revealed three, seven pound cans of hot fudge topping with an expiration date of 3/2/2020 on the label. Continued observation of the pantry revealed a 16 oz. jar of honey was open, unlabeled, and half of the contents were consumed and a 16 oz jar of unsalted almond butter was open, half of the contents were consumed and a label with an expiration date of March 2020 was on the lid. On 6/21/21 at 11:30 a.m. the SC verified the tartar sauce was missing the appropriate label, the hot fudge topping had expired on 3/2/2020, the jar of honey was unlabeled, and the jar of almond butter had expired in March 2020. An interview conducted with the SC on 6/22/21 at 11:30 a.m. revealed the process for rotating food in the main kitchen is to rotate most recent dated items to the front and when new food items are received they are placed in the back on the shelf. He stated once food items are received, a label will be created and the received date and discard date are noted before placing the food on the shelf or in the freezer. SC continued to state it is his responsibility to ensure the food items are used or discarded on or before the discard date. An interview conducted with Dietary Manager (DM) on 6/24/21 at 5:00 p.m. revealed she has provided in-service training on Date Marking for the kitchen staff to ensure the process of rotating food is followed. 2. During observation of the first floor kitchen on 6/22/21 at 10:00 a.m. the Dietary Aid (DA), revealed the ice machine has a black, wet substance located inside, underneath the door opening. Continued observation revealed one, 5.5 oz (ounce) pack of 6, V8 vegetable juice is unlabeled. Further observation of the first floor pantries on 6/22/21 at 10:15 a.m. with the DA revealed: Pantry #1 had one snack basket missing a use by label. Pantry #2 had an opened pitcher of lemonade in the refrigerator with a use-by 6/20/21 label. Observation and interview on 6/22/21 at 10:20 a.m. the DA verified the black substance located in the ice machine, the vegetable juice was missing the appropriate label, the snack basket was missing the use by label and the lemonade in the refrigerator had expired on 6/20/21. An interview conducted with DM on 6/23/21 at 10:30 a.m. revealed that the facility has a contract with a repair service company to come into the building and clean the ice machines quarterly.