**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observation, interview, the facility failed to ensure foods that are stored in the walk-in freezer, refrigerator and unit refrigerators were labeled and discarded after manufacturer's expiration date. Findings include: Review of facility's policy titled, Storage of Food and Supplies dated 08/2010, revealed Procedure 5: Staple, frozen and refrigerated foods are stored with the new product to the back of the older products. Foods removed from the original packaging will be labeled with the received date, either individually or as a unit. Procedure 6: Potentially hazardous foods are stored in the refrigerator in a manner to prevent cross-contamination. When meat/poultry/fish products require simultaneous refrigerated storage, the items are stored from bottom shelf to top in this under poultry, meat, fish, then ready-to-eat. All items are labeled with a use-by date as well as the contents (if not readily identifiable). Procedure 7: All opened items are securely wrapped or stored in a secure storage container and labeled to identify the product (if not readily identifiable) as well as a use by date no greater than 72 hours after opening unless documentation available for a longer shelf life is available. Staple products such as flour, sugar, cornmeal, dried pasta, etc., may be stored in designated secured bins, staple bin scoops may be stored in the product if the handle is out of the product in a manner to prevent touching the food. Review of facility's policy titled, Food brought into facility for residents dated 08/2010, revealed Procedure 2: Foods requiring refrigeration and stored as outlined about may be stored in the unit refrigerator for up to 3 days unless approved by the Dietary Director. Foods that are improperly stored or labeled or stored for more than 3 days will be discarded by nursing staff. Review of facility's policy titled, Responsibility for Ensuring Infection Control (Sanitation/Infection Control) dated 08/2010 revealed, The Dietary Director is responsible for oversight of infection control processes to ensure food served by the Dietary Department is safe. Review of a Dietary In-Service dated 07/05/23 presented by the Kitchen Manager (KM) revealed training on labeling and documentation and rotation of foods. During an observation on 07/09/23 at approximately 10:45 AM, in the walk-in refrigerator lying on the shelves were the following: unlabeled, undated, and not in the original box/container; an 8 ounces (oz) bag of low moisture Mozzarella cheese, 8 oz [NAME] Shredded Cheese, 8 oz bag of Pimento Cheese. Kitchen Staff (KS)1 confirmed the items had no date nor were they in the original packaging. Further observations in the walk-in refrigerator revealed two (2) spiral hams on a long silver serving tray. One of the spiral hams packaging had a hole on the top right-hand side, the size of a fist, with a white circle like substance where the opening was located and an expiration date of 06/16/23. KS1 stated the ham was taken out of the freezer and placed in the refrigerator to be served this week. The [NAME] acknowledged the opening and the expiration date of 06/16/23. In the walk-in freezer, an opened box of [NAME] Choice [NAME] (one package) undated, an opened box with an expiration date of 06/06/23 with the contents of a plastic bag full of breadsticks and an opened box of pureed shaped seasoned fish, undated. KS1 acknowledged that an open date should have been listed somewhere on the box. During an observation on 07/11/23 at approximately 11:41 AM of the Unit 300 Refrigerator, revealed an open 46 fl oz. box of Thickened Sweetener (Ready Care) with an expiration date of 06/16/23. In an interview with Licensed Practical Nurse (LPN)1, she acknowledged the expiration date of the Thickener, and stated items in refrigerator are monitored by Nursing and normally they throw the expired items in the trash. Further observation of Unit 100 Hall at 12:11 PM with the Consulting Dietician (CD) revealed an unlabeled McDonald's Cup with a frozen product and a Vitamin Water frozen that were unlabeled/undated. A pink water jug was discovered with no name or date. The CD and staff at the nurses station confirmed that it was a staff's water jug and not a resident's. The CD further stated that the refrigerator temperatures are not recorded on a log, but are monitored by the nurses on the unit. In an interview with the Kitchen Manager on 07/09/23 she stated she has been with the facility for one week. She stated she completed some in-services with the staff on proper labeling and documentation of foods and provided a recent in-service sheet completed on 07/05/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and family interviews and facility policy review, the facility failed to notify the family of one (1) Resident #16 of a significant weight loss in accordance with Notification of Change. This affected one (1) of 23 sampled residents. Findings include: Review of facility's policy titled Education (effective date 4/18/2017) noted the following: Education is provided to staff, residents, family members, visitors and volunteers on as needed basis related to newly diagnosed conditions and/or communicable diseases that warrant special precautions (may be verbal, or written or both). Through, verbal and instruction, nurse initially makes staff aware of special precautions indicated for an individual resident's care and updating of the resident plan of care. Unit nurses notifies family members of change in the resident's condition, care, and treatment plan. Clinical record review for Resident #16, revealed the resident was admitted [DATE] with diagnoses that included: Type 2 diabetes mellitus, Hyperlipidemia, Hypomagnesemia, Dementia, Hypertension, Acute on chronic diastolic congestive heart failure, Chronic obstructive pulmonary disease, Dysphagia and Personal history of COVID-19. A review of the progress notes dated 12/18/2020, revealed the resident was charted as having a weight of 142lbs (pounds). Further review of the progress notes dated 5/27/2021, revealed the resident was charted as having a weight of 129lbs (pounds) for a total of 9.15% in five (5) months. There was no documentation that the family had been notified about the weight loss. A review of the Dietician progress notes dated 12/2020 through 5/27/2021, revealed Resident #16's weight loss was addressed with additional measures put in place, but there was no documentation the family was notified. An interview was conducted on 6/7/21 at approximately 6:59 p.m. with Resident #16's daughter. The daughter revealed, I saw my family member a week ago and felt s/he was going down due to advanced stage Alzheimer's. Before COVID-19, I would visit once a week. I never heard from the Dietician or Nurses about his/her weight loss; or given the opportunity to make a decision about Hospice or any alternative things related to his/her care. An interview was conducted on 6/8/21 at 1:20 p.m. with the Dietician revealed, The nurses are responsible for calling the families about any weight loss. The dietician stated, I'm usually given a note or informed by the nurses of any weight loss in the building and follow up from there. I am not sure who is responsible for reporting weight loss to the family. An interview was conducted on 6/8/21 at 1:25 p.m. with the Corporate Dietician. The Corporate Dietician revealed, Usually the nurses are responsible for reporting the weight loss to the family, we are not sure who makes the call, but we will find out. An interview conducted on 6/8/21 at 1:30 p.m. with License Practical Nurse #7 revealed, I am not the one responsible for informing the family about any weight loss, I call them about medication changes and physician orders. An interview was conducted on 6/8/21 at 1:45 p.m. with the Social Worker (SW). The SW revealed, I spoke with Resident #16's family on the phone about the last care plan meeting, but I did not inform him/her about the resident's weight loss; The SW stated: I do not call the families to inform them of weight loss. An interview was conducted on 6/8/21 at 2:01 p.m. with Resident Assessment Nurse #5. The nurse revealed, We had a quarterly assessment done recently and the family was not notified at that time about Resident #16's weight loss. An interview conducted on 6/8/21 at 2:11 p.m. with the SW revealed, a post card was sent out to the family on 3/23/2021 to attend the care plan meeting, we do not call. The SW stated, the family member called after receiving the post card invite, but we did not discuss the weight loss from May of 2021. I have not notified the family of Resident's #16's weight loss, but we have a care plan meeting next Tuesday and will discuss it then. An interview was conducted on 6/9/21 at 9:07 a.m. with the Director of Nursing (DON). The DON revealed, it is his/her expectation that the family is to be notified of any weight loss and that unit nurses are responsible for informing the family. An interview was conducted on 6/9/21 at 9:17 a.m. with the Administrator, who revealed, it is my expectation that the Dietician be responsible for informing the family of the weight loss the nurses have enough to do, and we will make sure from now on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to assess and receive a physicians order for the use of a seatbelt restraint for one (1) resident #40 out of a sample of twenty-three (23) residents. Findings include: Review of facility's policy entitled Physical Device Data Collection Tool/Restraint Reduction Plan: dated 11/2019 revealed, nursing staff completes this form for all devices/restraints. It assists in determining whether a device is a restraint and if there are appropriate indications for use and identifies alternatives when possible. Information for the completion of this form will be obtained by observation, interview of the resident or family, the admission data collection, the history and physical, other discipline specific data collection, physician orders, therapy evaluations, the Minimum Data Set (MDS) and selected Care Area Assessment (CAA) reviews, dependent on the length of stay of the resident at the time a resident is considered. The Restraint Reduction Plan portion of the form is completed at least quarterly in conjunction with the Minimum Data Set (MDS) schedule. Review of the Social/Activity history along with the customary daily routine information (MDS) section F. The information may be useful in determining appropriate alternatives to restraint usage. Safety Committee Review: The safety committee should consider the information gathered and recommended alternatives to the restraint (device) or the least restrictive type of restraint (device). The team is also responsible for determining the conditions under which it is to be used. The device must be the least restrictive of all choices The risks and benefits must be specifically identified and described to the resident There must be indications that use of the restraint (device) enables or promotes greater functional independence A specific care plan must be developed that addresses the potential risks associated with the selective device. Physician's orders: A specific physician's order is obtained for the selected device. The facility may not utilize standing or blanket orders for physical devices/restraints. All devices used as restraints must have a physician's order that includes: The type of device/restraint The reasons for using/medical symptom being treated When it may be used How and when the restraint is to be monitored When the restraint must be released and the type of care to be provided when released. A review of the Resident's Face Sheet revealed Resident #40 was admitted on [DATE] with diagnoses which included Vascular dementia, Hypertension, Thyroid disorder, Non-Alzheimer's disease, Cataracts, Glaucoma, Unspecified blepharitis, and Profound intellectual disabilities. The Annual Minimum Data Set (MDS) dated [DATE] revealed, Resident #40 had a Brief Interview for Mental Status Score (BIMS) of three (3) indicating severe cognitive impairment and rejection of care none during the seven (7) day observation period. The resident required extensive assistance with bed mobility, transfers, toileting and personal hygiene, walking on and off the unit did not occur and the resident required extensive assistance with locomotion full staff performance over the entire seven (7) day observation period. The Physical Restraint Care Area Assessment (CAA) part for the Annual MDS dated [DATE], documented Resident #40 as not using any Restraint devices during the seven (7) day observation period. Review of physician's orders and assessment on 6/9/21 at 9:00 a.m. with Unit Nurse #7 revealed no orders or assessment for the use of a wheelchair restraint for Resident #40. An observation was made on 6/7/21 at 10:45 a.m. Resident # 40 was sitting up in his/her wheelchair with the seatbelt restraint around the waist and the anti-slip belt restraint across the top of his/her legs. The resident was observed trying to release the seatbelt but could not. An observation was made on 6/7/21 at 11:30 a.m. Resident #40 remained sitting up in the wheelchair in his/her room with the seatbelt around the waist and the anti-slip belt across the top of his/her legs. The resident was unable to release the restraints. An interview was conducted on 6/9/21 at 8:49 a.m. with Certified Nursing Assistant #10 revealed he/she was informed by the unit charge nurse not to get Resident #40 up and place him/her in the wheelchair today, because the facility does not have an order or assessment for the use of the seatbelt. An interview was conducted on 6/9/21 at 9:00 a.m. with License Practical Nurse (LPN) #7, revealed Resident #40 has not been assessed or has an order for the use of the seatbelt restraint. An interview was conducted on 6/9/21 at 9:07 a.m. with the Director of Nursing, revealed that it is the expectation that staff should have assessed and received an order for Resident #40's seatbelt restraint. An interview was conducted on 6/9/21 at 9:17 a.m. with Administrator, revealed, I agree with you, we should have completed the assessment and got an order for the use of the seatbelt restraint for Resident #40. An interview conducted on 6/10/21 at 9:36 a.m. with the RN Safety Nurse revealed, he/she was informed on 6/9/21 about Resident #40's wheelchair with seatbelt restraint. The RN stated once a wheelchair or any device is delivered, he/she should be notified as soon as the device or wheelchair is brought through the front door, so that the resident can be assessed prior to use. The facility failed to ensure an assessment and physician order was in place for this cognitive impaired resident. The facility failed to have a medical justification for the use of the restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to review and revise a care plan for one (1) of 23 sampled residents, (Resident #40). The care plan for Resident #40 was not reviewed or revised with goals or interventions, to reflect the use of a wheelchair with a seat belt restraint. Findings include: Review of facility's Policy entitled Care Plan Policy Comprehensive Team Care Planning dated 1/9/2012 and revised 6/8/2017 revealed, it is the policy of [NAME] Oak Management Inc, to provide care planning for all residents; to formulate individualize plans of care for each resident that will be an effective and useful approach for providing quality care and to help the resident meet his/her mental, emotional, social, and physical needs during his stay. This shall be a team approach for resolving the resident's problems or needs with emphasis on normalization of daily life to the highest level of dignity and ability. The residents plan of care guides the necessary care and services based on the findings of the Resident Assessment Instrument (RAI). The services are implemented and updated on the care plan. Outcome evaluation and revisions for interventions/approaches are an ongoing process. Review of the facility's Policy entitled Physical Device Collection Tool/Restraint Reduction Plan dated 11/2019 revealed, the safety committee should consider the information gathered and recommended alternatives to the restraint (device) or the least restrictive type of restraint (device). The team is also responsible for determining the conditions under which it is to be used. A specific care plan must be developed that addresses the potential risks associated with the selective device. A review of the resident's Face Sheet revealed Resident #40 was admitted on [DATE] with diagnoses which included Vascular dementia, Hypertension, Thyroid disorder, Non-Alzheimer's disease, Cataracts, Glaucoma, Unspecified blepharitis, and Profound intellectual disabilities. Review of the Annual Minimum Data Set (MDS) Assessment; dated 4/7/21 revealed Resident #40 to have a Brief Interview Mental Status (BIMS) score of three (3) indicating severe cognitive decline. The resident was assessed not to resist or reject care and/or treatments. The assessment identified the resident as having no impairment to the upper and lower extremities and required extensive assistance with all Activities of daily living (ADL's). Under the restraint section the resident was assessed to not have use of any restraint devices. Review of Resident #40's plan of care dated 4/15/21 revealed, provide pressure reducing surfaces on bed and chair assist with repositioning on rounds and as needed (PRN). There was no care plan goal or intervention for the use of a wheelchair with seatbelt restraint. An interview conducted on 6/10/21 at 8:55 a.m. with Resident Assessment Nurse #11 revealed, the start date of the care plan dated for 4/15/21 does not have a care plan goal, or intervention for the use of a wheelchair with a seatbelt restraint for Resident #40. An interview conducted on 6/10/21 at 9:27 a.m. with Resident Assessment Nurse #12 revealed, Resident # 40's care plan was just updated on 6/9/21 to reflect the use of the wheelchair with a seat belt restraint. An interview conducted on 6/10/21 at 10:00 a.m. with the Assistant Director of Nursing (ADON) revealed, it is my expectation that the Resident Assessment Nurses update the care plans and any information that is discussed in the morning meetings; the care plan was not updated to reflect the use of the wheelchair with the seatbelt restraint. The facility failed to review, revise and update Resident #40's Care Plan to include, approaches, goals and interventions for the use of a wheelchair with a seatbelt restraint.