**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure one resident (R)38 in the sample was free from accident hazards. Despite having a history of falls and an unsteady gait, the resident was ambulated without the use of a gait belt, placing her at risk for an avoidable fall and/or injury. This deficient practice has the potential to affect all residents at the facility who require assistance to ambulate. Findings include: Resident (R)38 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. Her current diagnoses include repeated falls, muscle weakness, age-related osteoporosis, and dementia. During a review of her electronic health record (EHR) it was noted that R38's last documented fall was on 06/17/23. On 08/22/23 at 10:09 AM, an observation was made of R38 being assisted back to her chair in the dining room from her room where she had gone to use the restroom. R38 was using a front-wheel walker (FWW) and was bent over slightly with a steady but awkward gait. R38 ambulated back to her chair in the dining room with a certified nurse aide (CNA) providing stand-by assistance. On 08/22/23 at 03:29 PM, on observation was done of CNA1 assisting R38 ambulate back to her chair in the dining room. R38 was bent forward at the waist, more so than the previous observation, and her gait was unsteady and a bit stumbly. Aware of her unsteadiness, CNA1 had grabbed and was guiding R38 by the back center of the elastic waistband on her loose polyester pants. Each chair that they passed, R38 asked to sit. CNA1 led her past at least two chairs, maintaining a firm grip on the back of her pants. When R38 finally made it to her seat, she plopped down and stated, my pants are too tight, it hurts! An interview with CNA1 was done at this time. When asked about the unsteadiness of R38's gait as opposed to earlier in the day, CNA1 stated it's because she is tired. When asked about using a gait belt with R38, especially when she is tired with an unsteady gait, CNA1 admitted that she should have used a gait belt. On 08/24/23 at 08:00 AM, an interview was done with the CNA Manager (CNAM) in the conference room. When asked about using gait belts for safe transfers and ambulation, CNAM stated that the physical and occupational therapists determine who needs to have a gait belt, otherwise gait belts are recommended for the safety of residents and staff, as well as comfort of the residents, and are used at the CNA's discretion. CNAM reported that her expectation is that gait belts are used for anyone determined to need extensive assistance (unless the residents refuse it), and if the CNA feels it is unsafe. CNAM agreed that using a gait belt is preferable to grabbing the resident by the back of the pants. CNAM stated that R38 requires limited to extensive assistance and is known to be more tired and unsteady on her feet in the afternoon. CNAM agreed that given R38's history of falls, she would expect to see a gait belt used when R38 has an unsteady gait. On 08/24/23 at 12:30 PM, a review of the facility's Gait Belts Nursing Protocol, last updated 09/18/22, revealed the following: Staff will use the Gait Belt as an assistive tool when transferring and ambulating residents. Not all residents require the use [sic] a Gait Belt, but to reduce possible injury, a Gait Belt is recommended during all transfers and ambulation. 2) On 08/22/23 at 11:24 AM observed R18 in the dining room. R18 was seated in a recliner and was asked if she wanted to sit in her chair. R18 was agreeable. CNA2 and CNA3 grabbed R18's pant waistband, pulled the resident up to stand, and pivoted resident to sit on a chair. There was no gait belt and the resident's pant were hiked up in the crotch area. Record review noted R18 was admitted to the facility on [DATE]. Diagnoses include but not limited to paroxysmal atrial fibrillation; age-related osteoporosis without current pathological fracture; other abnormalities of gait; and other lack of coordination. A review of the admission Minimum Data Set (MDS) with assessment reference date of 06/28/23 notes R18 requires extensive assist with one-person physical assist for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). R18 also noted to be not steady and only able to stabilize with staff assistance for moving from seated to standing position, surface-to-surface transfer (transfer between bed and chair or wheelchair). Review of R18's care plan notes she is at high risk for falls related to weakness, history of orthostatic hypotension (condition in which your blood pressure suddenly drops when you stand up from a seated or lying position), syncope (fainting or passing out caused by a temporary drop in the amount of blood that flows to the brain), and fall score of 19. R18 is also diagnoses with osteoporosis which placed her at risk for significant injury related to fall. Interventions for transfer include to instruct and remind resident to slowly transfer and give simple cues and instruction during transfer; provide limited to extensive assist with transfer; and one-man support. On the afternoon of 08/22/23, interviewed Physical Therapist (PT)1 regarding the use of gait belts when transferring residents. PT1 reported it is recommended to use a gait belt during transfers. PT1 further reported staff will determine whether a gait belt is needed. On 08/24/23 at 08:00 AM an interview was conducted with CNAM in the conference room. CNAM reported a gait belt is used for residents that require extensive assistance for transferring. Inquired which residents require the use of a gait belt, CNAM included R18 in the list. CNAM further reported gait belts are used for the safety of the residents.

Based on observation and interview the facility failed to store and label food in accordance with professional standards for food service safety. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food handling practices represent a potential source of pathogen exposure for all residents at the facility. Findings include: On 09/20/22 at 08:17 AM, the state agency (SA) did an initial tour of the kitchen with the Food Service Supervisor (FSS). SA observed several cartons of egg whites in the walk-in refrigerator with no manufacturer expiration dates. When asked, the FSM was unable to verbalize how long the egg whites are good for. On 09/23/22 at 09:55 AM, the SA conducted a follow-up tour of the kitchen with the FSM. In the outside walk-in refrigerator, the SA observed two (2) large metal trays with approximately 9 to 12 cartons of egg whites per tray. The cartons read frozen egg product. Most cartons were labeled with a handwritten date of 09/12/22, with one carton labeled 09/19/22. The FSS stated staff write the date of receipt on the cartons. Confirmed cartons were received on 09/12/22 and 09/19/22. When asked again about the expiration dates for the egg whites, the FSS was unable to verbalize an answer, stating I'm not sure .we keep them frozen in here. The SA picked up a carton and indicated that it was fully thawed. The FSS was surprised they were not frozen. The SA turned the carton to the side and observed storage instructions that read: STORAGE KEEP FROZEN Use within 3 days after thawing Keep unused portion refrigerated Do not re-freeze. Upon reading this, the FSS stated I didn't know about that suggestion. SA informed the FSS that storage instructions are not suggestions, and it is a deficient practice to not be following them. The FSS agreed and stated he would discard all the thawed cartons. On 09/23/22 at 10:15 AM, a food service worker informed the SA that the usual process of receipt for the frozen egg whites is to receive them frozen and to label each carton with the date of receipt, then place them in the freezer. Because they go through so many egg whites, they will pull whole trays and place them in the refrigerator to thaw, but unfortunately it is not their current practice to label when they are being pulled for thawing. The food service worker and the FSS both acknowledged that without labeling when they were pulled for thawing, there is no way to ensure the egg whites are being used within 3 days as per the storage instructions.