**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to check the Certified Nursing Aide (CNA) Registry to ensure staff did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse and/or neglect) in accordance with the facility policy for six current employee's ([NAME] Patient Care Technician (PCT) I, student nurse intern J, Licensed Practical Nurse (LPN) K, housekeeper L, PCT M, and Health Unit Coordinator N out of seven sampled staff. The facility census was 5. 1. Review of the facility's policy titled, Patient Abuse, Neglect and Mistreatment, dated 09/11/23, showed staff were directed to do the following: -The Skilled Nursing Facility shall in accordance with regulation the Centers for Medicare and Medicaid Services 483.13 Resident Behavior and Facility Practices to ensure that all patients are not subjected to any form of abuse, neglect, harassment, exploitation, involuntary seclusion, or misappropriation of property. All employees will be screened for a past history of abuse prior to hiring. Personnel will be trained to identity events and occurrences that may constitute or contribute to abuse and neglect; -The Human Resources Department prior to hiring will screen potential employees for a history of any form of abuse, neglect, or mistreatment of patients or individuals. This includes performing a criminal background check, contacting previous employers and/or current employers, and checking with the appropriate boards and registries. 2. Review of [NAME] PCI I's personnel record showed a hire date of 06/05/23. Review showed the employee's record did not contain documentation the facility completed a CNA Registry check prior to the hire date. 3. Review of student nurse intern J's personnel records showed a hire date of 06/19/23. Review showed the employee's record did not contain documentation the facility completed a CNA Registry check prior to the hire date. 4. Review of LPN K's personnel record showed a hire date of 08/22/22. Review showed the employee's record did not contain documentation the facility completed a CNA Registry check prior to the hire date. 5. Review of housekeeper L's personnel record showed a hire date of 09/19/22. Review showed the employee's record did not contain documentation the facility completed a CNA Registry check prior to the hire date. 6. Review of PCT M's personnel record showed a hire date of 07/10/23. Review showed the employee's record did not contain documentation the facility completed a CNA Registry check prior to the hire date. 7. Review of Health Unit Coordinator N's personnel record showed a hire date of 12/08/23. Review showed the employee's record did not contain documentation the facility completed a CNA Registry check prior to the hire date. 8. During an interview on 01/18/24 at 9:09 A.M., the Human Resource Assistant Manager said he/she was responsible to completed required screenings for the CNA Registry. He/She said he/she did not know the CNA Registry was required to be checked for any staff member who had access to residents. He/She said he/she had been in the position for a few years and did not know all staff were required to check for all staff, only the employees who provided care. He/She was confused by the title CNA Registry, and did not realize the registry was to be checked for all staff, not just CNA's. He/She said he/she was responsible to ensure all required screening were completed.

Based on observation, interview, and record review, facility staff failed to conduct or complete entrapment assessments and measurements to identify areas of possible entrapment prior to the use of bed rails on admission for four residents (Resident #255, #256, #257, and #258) out of five sampled residents. The facility census was 5. 1. Review of the facility's policies showed the facility did not provide a policy for entrapment assessments. 2. Review of Resident #255's medical record showed the record did not contain a completed entrapment assessment. Observation on 01/17/24 at 4:18 P.M., showed the resident in bed with bilateral bedrails in the upright position. 3. Review of the Resident #256's medical record showed the record did not contain a completed entrapment assessment. Observation on 01/17/24 at 10:00 A.M., showed the resident in bed with bilateral bedrails in the upright position. Observation on 01/17/24 at 4:25 P.M., showed the resident in bed with bilateral bedrails in the upright position. Observation on 01/18/24 at 8:20 A.M., showed the resident in bed with bilateral bedrails in the upright position. 4. Review of Resident #257's medical record showed the record did not contain a completed entrapment assessment. Observation on 01/17/24 at 10:15 A.M., 1:27 P.M., and 2:18 P.M., showed the resident in bed with bilateral bedrails in the upright position. Observation on 01/18/24 at 8:30 A.M. and 11:22 A.M., showed the resident in bed with bilateral bedrails in the upright position. During an interview on 01/17/24 at 10:15 A.M., the resident said he/she used the upper half bedrails to help him/her move around in the bed. 5. Review of the Resident #258's medical record showed the record did not contain a completed entrapment assessment. Observations on 01/18/24 at 8:33 A.M. and 10:59 A.M., showed the resident in bed with bilateral bedrails in the upright position. During an interview on 01/17/24 at 10:48 A.M., the resident said he/she used the bedrails to transfer in and out of bed. 6. During an interview on 01/17/24 at 11:47 A.M., the Unit Nurse Manager said bed rail assessments are completed on admission by the admitting charge nurse along with obtaining a signed consent from the resident or their responsible party after explaining the risks to them. He/She said he/she is responsible to complete the entrapments and does those yearly in November on all the beds. He/She said all the beds on the unit are the same bed unless they must get a rental or bariatric bed on a special occasion. He/She said he/she has a pre-marked stick he/she uses this to gauge if the entrapment measurements on each bed are in the safe zone. Observation at this time showed the Unit Nurse Manager presented a stick which contained one end green and marked 4 3/4, the middle red, and the opposite end green and marked 2 3/8. He/She said the green ends represent the safe zone, and the red middle area represents the non-safe area. During an interview on 01/18/24 at 11:54 A.M., Registered Nurse (RN) A said the admitting charge nurse is responsible to complete the bed rail assessment and obtain a signed consent from the resident or their responsible party after they go over the risks of bed rails. He/She said all the beds on the unit have bed rails that are installed permanently. He/She said the charge nurse does not do entrapment measurements, and he/she has never done an entrapment measurement. He/She said he/she was not aware of the pre-marked stick used to complete entrapment measurements. During an interview on 01/18/24 at 12:37 P.M., the Unit Nurse Manager said he/she is responsible for completing the entrapment measurements. He/She said he/she does not do them with each new admission because the beds don't change. He/She said that a contracted company is responsible to check the beds annually for general maintenance of the bed. He/She said if staff find a bed rail loose, he/she expects staff to put a work order in for the contracted company to fix it, and to trade the bed out for another bed on the unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to attempt alternative interventions prior to the use of bedrails for six residents (Resident #2, #4, #5, #6, #7 and #202). Additionally, staff failed to obtain resident and/or guardian consent for the use of the bedrails, and failed to update the residents care plans for bedrail use. The facility census was 7. 1. Review of the facility's General Patient Care Policy, dated 12/21/21, showed one bed rail may be used. Patients will be educated on the risk of entrapment and must sign a consent form to have the bed rail up. Review of the facility's Patient Plan of Care Policy, dated 12/21/21, showed: -Developing an individualized plan of care for each patient in the Skilled Nursing Facility (SNF) unit is one of the most important tasks that is undertaken for that patient; -Planning and implementation by an interdisciplinary team will ensure the patient that his care will be coordinated and continuous; -The overall plan of care is the basis of the SNF unit's work routine; -An interim care plan is developed immediately after admission by nursing, dietary, and other disciplines as required to cover immediate needs of the patient; -The plan - will outline goals and plans developed in response to the patient's identified problems; will acknowledge the patient's preferences and/or participation when appropriate; and will be developed in coordination with the physician's orders; -The plans are the responsibility of the SNF unit supervisor or designated licensed nurse; -Time frame for reviews are weekly, with a change in level of care, or with an indicated need. 2. Review of Resident #2's Five Day Assessment Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/18/22, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required limited assistance from one staff member for bed mobility and transfers; -Does not use bedrails. Review of the resident's medical record showed it did not contain prior interventions attempted prior to bedrail use. Review of the Physician Order Summary (POS), undated, showed it did not contain an order for bedrails or assistive devices. Review of the care plan, dated 8/12/22, showed it did not contain direction for staff in regard to bedrail use for the resident. Review of the Side Rails Informed Consent and Release form, dated 8/22/22 at 2:40 P.M., showed staff documented the bedrails are used as a mobility aid and not a physical restraint. Further review, showed staff documented the resident was informed of the benefits and risks of the use of siderails. Observation on 8/22/22 at 11:16 A.M., showed the resident in bed with an assist bar up on both sides. Observation on 8/23/22 at 10:46 A.M., showed the resident's bed with an assist bar up on both sides. Observation on 8/23/22 at 2:09 P.M., showed the resident's bed with an assist bar up on both sides. 3. Review of Resident #4's Five Day MDS dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had diagnoses of Lung cancer, anemia and anxiety; -Required assistance from one staff member for bed mobility and transfers; -Had no limitations in range of motion; -Does not use bedrails. Review of the resident's medical record showed it did not contain interventions attempted prior to bedrail use. Review of the resident's POS, dated 8/22/22, showed it did not contain an order for bedrails or assistive devices. Review of the resident's Care Plan, dated 8/10/22, showed it did not contain direction for staff in regard to bedrail use for the resident. Review of the resident's Side Rails Informed Consent and Release Form, dated 8/22/22, showed staff documented the bedrails are used as a mobility aid and not as a physical restraint. Further review showed the form was signed by the resident. Observation on 8/22/22 at 11:30 A.M., showed the resident had bedrails up on both sides of the bed. Observation on 8/23/22 at 8:10 A.M., showed the resident had bed rails up on both sides of the bed. 4. Review of Resident #5's Medical Record dated 8/11/22, showed staff assessed the resident: -admitted on [DATE]; -Cognitively intact; -Had diagnoses of pelvic fractures, dilated cardiomyopathy (type of heart muscle disease that cause the hear chambers to thin and stretch growing larger), and chronic coronary artery disease ( coronary arteries struggle to supply the heart with enough blood, oxygen, and nutrients). -Did not contain prior interventions attempted prior to bedrail use. Review of the residents signed Side Rail Informed Consent and Release Form, dated 8/22/22 at 3:00 P.M., showed staff documented the bed rails are used as a mobility aid and not as a physical restraint. Review of the resident's POS, dated 8/11/22, showed it did not contain an order for bedrails or assistive devices. Review of the resident's care plan, dated 8/11/22, showed it did not contain direction for staff in regard to bedrail use for the resident. Observation on 8/22/22 at 11:50 A.M., showed the resident's bed with side rail up on both sides. Observation on 8/22/22 3:00 P.M., showed the MDS coordinator obtained verbal consent from the resident for the use of the bedrails Observation on 8/23/22 at 8:00 A.M., showed the resident in bed with bedrails up on both sides. During an interview on 8/22/22 at 2:05 P.M., the resident said he/she did not use the bedrails. 5. Review of Resident #6's Medical Record, dated 8/15/22 showed staff assessed the resident: -admitted on [DATE]; -Cognitively intact; -Had a diagnosis of Necrotizing Cellutlitus of the perineum (an infection that causes severe tissue destruction). -Did not contain prior interventions attempted prior to bedrail use. Review of the resident's Side Rail Informed Consent and Release Form, dated 8/22/22 at 2:33 P.M., showed staff documented the bedrails are used as a mobility aid and not as a physical restraint. Review of the resident's physicians orders, dated 8/15/22, showed it did not contain an order for bedrails or assistive devices. Review of the resident's care plan, dated 8/15/22, showed it did not contain direction for staff in regard to bedrail use for the resident. Observation on 8/22/22 at 12:11 A.M., showed the resident's bed with bedrails up on both sides. Observation on 8/22/22 at 2:22 P.M., showed the resident in bed with bedrails up on both sides. Observation on 8/23/22 at 1:45 P.M., showed the resident in bed with bedrails up on both sides. During an interview on 8/22/22 at 2:22 P.M., the resident said he/she used the bedrails for bed mobility and transfers. 6. Review of Resident #7's Medical Record, dated 8/18/22 showed staff assessed the resident: -admitted on [DATE]; -Cognitively intact; -Had diagnoses of Osteoporosis (A condition in which bones become weak and brittle) and Right Intertrochanteric (part of hip) hip fracture with nail fixation. -Did not contain prior interventions attempted prior to bedrail use. Review of the resident's Side Rail Informed Consent and Release Form, dated 8/18/22, showed staff documented the bed rails are used as a mobility aid and not as a physical restraint. Review of the POS, dated 8/18/22, showed it did not contain an order for bedrails or assistive devices. Review of the resident's care plan, dated 8/15/22, showed it did not contain direction for staff in regard to bedrail use for the resident. Observation on 8/22/22 at 11:17 A.M., showed the resident in bed with bedrails up on both sides. Observation on 8/23/22 at 8:06 A.M., showed the resident in bed with bedrails up on both sides. During an interview on 8/22/22 at 11:17 A.M., the resident said he/she used the bedrails for bed mobility and transfers. 7. Review of Resident #202's medical record showed had not completed an MDS completed. Review of the resident's face sheet showed: -admitted on [DATE]; -Had diagnoses of a seizure disorder, hyponatremia (the level of sodium in the blood is too low), chronic obstructive pulmonary disease (a type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), history of stroke with left-sided weakness, obstructive sleep apnea (repeatedly stop and start breathing while sleeping). Review of the resident's medical record showed it did not contain prior interventions attempted prior to bedrail use. Review of the POS, undated, showed it did not contain an order for bedrails or assistive devices. Review of the care plan, dated 8/12/22, showed it did not contain direction for staff in regard to bedrail use for the resident. Review of the Side Rails Informed Consent and Release Form, dated 8/22/22 at 2:30 P.M., showed staff documented the bedrails are used as a mobility aid and not as a physical restraint. Further review, showed staff documented the resident was informed of the benefits and risks of the use of side rails. Observation on 8/22/22 at 11:59 A.M., showed the resident in bed with an assist bar up on both sides. Observation on 8/23/22 at 10:52 A.M., showed the resident's bed with an assist bar up on both sides. Observation on 8/23/22 at 2:07 P.M., showed the resident in bed with an assist bar up on both sides. 8. During an interview on 8/23/22 at 2:11 P.M., the MDS Coordinator and Registered Nurse (RN) A said the care plans should be updated nightly by the night shift nurses. They said the charge nurse is responsible for auditing the care plans for accuracy. RN A said the care plans do not address bedrails. During an interview on 8/23/22 at 2:18 P.M., RN C said the nurses are responsible for updating the care plans. He/She said the MDS coordinator and nurses are responsible for ensuring the care plans is are up to date. He/She said the nurses should evaluate the care plans every shift and assess the resident's interventions and progress. He/She said he/she would not expect to find bedrails on a care plan or physician orders. He/She said all the nurses, the MDS coordinator, and the nurse manager have access to the care plans. During an interview on 8/23/22 at 2:32 P.M., the Director of Nursing (DON) said the nurses and MDS nurse are responsible for ensuring care plans are up to date. He/She said he/she would expect bedrails addressed on the care plan, even if the patient did not use them or if they had been discontinued. He/she said he/she expects there to be a physicians order for bed rails. He/She said all nursing staff and providers can access the care plans. During an interview on 8/25/22 at 3:48 P.M., RN A said the admitting nurse should get the bedrail consent form signed by the resident. He/She said the consent forms are printed with the admission packet, so the forms should be signed upon admission. He/She said the resident consent forms were signed after the surveyors asked to review them, because he/she did not see them in the residents medical records. He/she said physician orders are not required for the use of bed rails. He/She said there are no interventions attempted prior to the use of the bed rails. He/She said the bedrails are permanently attached to the bed, but can be lowered if there is a concern of risk to the resident. He/She said there has not been an audit system in place for the past year to ensure the consent forms were signed. During an interview on 8/25/22 at 4:09 P.M., the DON said there should be a physician's order for bed rail use. He/she said he/she did not know who would be responsible for obtaining the physician's order for the bed rails. He/She said he/she did not know when the consent forms should be signed. He/She said if bed rails are used for positioning, he/she would not expect another intervention; but depending on the use of the bed rails, would require another intervention to be attempted first. He/she said staff monitor residents for risk of entrapment. During an interview on 8/25/22 at 4:16 P.M., RN E said the admitting nurse is responsible for getting the bed rail consent form signed upon admission. He/She said the admission paperwork automatically prints out the consent form, but he/she did not know why the consent forms were missing for the residents. He/She said he/she did not know if there is a system in place to ensure all the required paperwork is signed. He/She said he/she is not sure if a physician order is required for the use of bed rails. He/She said there are no interventions attempted prior to the use of bedrails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility staff failed to store food in a manner to protect it from potential contamination and out-dated use. The facility census was seven. 1. Review of the facility's Storage of Food-Labeling, Storing and Dating policy, dated 11/09/16, showed: -Cold items are put into storage containers, covered, labeled and dated with and in and discard date before they are refrigerated. -Once a week, the walk-in and all refrigerators are thoroughly cleaned. Any any time, any food dated longer than seven days is discarded. Freezer leftovers are not kept longer than a year. -Manufacturers recommended storage dates are used when storing food. Observation on 08/22/22 at 10:25 A.M., showed the dry goods pantry contained: -an opened and undated 160 ounce (oz.) bag of dried farfalle pasta; -an opened and undated 160 oz. bag of dried cavatappi pasta; -an opened and undated large bag of dried ditalini pasta; -an opened and undated five pound bag of cocoa powder. Observation on 08/22/22 10:35 A.M., showed an opened and undated one gallon jar of sliced banana peppers in the walk-in refrigerator. Observation showed an unidentifiable black speckled mold-like substance on multiple storage shelves in the walk-in. During an interview on 08/22/22 at 10:35 A.M., DSD said they did not have a cleaning schedule for the walk-in storage shelves. Observation on 08/22/22 at 10:38 A.M., showed the reach-in cooler in the cook's station contained: -an opened and undated one gallon bottle of soy sauce; -an opened and undated one gallon bottle of worcestershire sauce; -an opened and undated one gallon bottle of lemon juice; -an opened one gallon bottle of honey siracha dated 01/24 with a use by date of 02/24 -an opened and undated four pound and nine ounce bottle of szechuane sauce; -an opened and undated 32 oz. bottle of Dijon mustard; -an opened and undated one pound and 14 oz. carton of Southwest Chipotle Pesto. Observation on 08/22/22 at 10:45 A.M., showed the bottom shelf at the end of the cook's station contained: -an opened and undated one gallon bottle of gourmet red wine vinegar; -an opened and undated one gallon bottle of white cooking wine; -an opened and undated one gallon bottle of liquid smoke; -an opened and undated one gallon bottle of light corn syrup; -an opened and undated one gallon bottle of apple cider vinegar; -an opened and undated one gallon bottle of rice vinegar; -an opened and undated one gallon bottle of distilled vinegar; -an opened and undated one gallon bottle of molasses; -an opened and undated one gallon bottle of fine [NAME] cooking wine; -an opened and undated five pound bottle of honey. During an interview on 08/22/22 at 10:45 A.M., the DSD said staff should seal, date, and label all opened food items which would include bottles of sauces and condiments. The DSD said the chef is responsible to monitor the food storage on-going throughout the day and he/she does a food storage audit monthly. The DSD said dating of opened food items had been a consistent problem identified during his/her audits and he/she talks about it with staff during the daily meetings. Observation on 08/22/22 at 10:50 A.M., showed the reach-in freezer in the cook's station contained: -an undated bag of chicken strips opened to the air; -an undated bag of battered onion rings opened to the air; -an undated bag of breaded chicken fillets opened to the air; -an opened and undated bag of vegan chicken strips. During an interview on 08/22/22 at 10:50 A.M., the Chef said he/she routinely looks at the food storage to make sure it is stored appropriately which would include looking to see if opened food items are dated, labeled and sealed. The chef said he/she primarily looks at the food prepared for the day and does not pay attention to bottles of sauces and condiments due to their shelf stability. The chef said staff did not date the opened bottles stored on the bottom shelf in the cook's station when he/she started, so he/she let that continue. The chef also said he/she did not expect staff to date the opened food items stored in the reach-in freezer in the cook's station because they use those items up so quickly.