**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 19 residents (Resident #1) reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #1 who was listed for having a urinary catheter on her 9-3-2024 quarterly MDS. This failure to accurately assess a resident could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Finding include: Record review of Resident #1's face sheet printed 12-5-2024 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include cerebrovascular disease (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), Lupus (an illness that occurs when the immune system attacks health tissue and organs), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #1's quarterly MDS assessment started 9-3-2024 and completed 9-16-2024 revealed she had a BIMS of 7 indicating she was severely cognitively impaired, and she had a functionality of being dependent on staff for most of her adl's and activities. Record review of Section H, Bladder and Bowel, H0100 Appliances-Resident #1 was marked as having an Indwelling Catheter. Record review of Resident #1's Order Summary Report with active orders from 11-10-2022 to 12-5-2024 revealed no orders for an indwelling catheter or for indwelling catheter care. Record review of Resident #1's care plan with admission date of 5-29-2018 with last revision on 9-16-2024 revealed no care plans for an indwelling catheter or indwelling catheter care. During an observation on 12-3-2024 at 08:56 AM revealed Resident #1 was in her bed with a pillow under her right arm for positioning. Resident #1 was unable to respond to questions appropriately. Resident #1 was noted to not not have an indwelling catheter present. During an interview on 12-4-2024 at 01:15 PM MDS Coordinator A verified that Resident #1 did not have and has not had an indwelling catheter. MDS Coordinator A reviewed the 9-3-2023 Quarterly MDS for Resident #1 and reported that it was marked as Resident #1 having an indwelling catheter and that the MDS was marked incorrectly. MDS Coordinator A stated, I think someone marked it by accident. MDS Coordinator A then checked Resident #1's chart, orders, and care plans, MDS Coordinator A found no information that Resident #1 had a catheter. MDS Coordinator A reported that if a MDS was marked incorrectly the facility could lose money and the residents could be affected in that that way (they may not receive some services or supplies because the facility could not afford it) and it could be considered fraud if a staff member was marking the MDS with information on purpose. MDS Coordinator A reported that the facility used the RAI manual to complete all MDS's. During an interview on 12-4-2024 at 01:49 PM the DON reported that an MDS should accurately reflect a resident's condition and that if the MDS did not reflect the residents condition it was a problem and could affect reimbursement, billing, and could be considered fraud. Record review of the facility provided policy titled MDS Assessment Policy dated 8-29-2017, revealed the following: Policy: The assessment will accurately reflect the resident's current status at the time of the assessment. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023 revealed the following: SECTION H: BLADDER AND BOWEL H0100: Appliances Steps for Assessment 1. Examine the resident to note the presence of any urinary or bowel appliances. 2. Review the medical record, including bladder and bowel records, for documentation of current or past use of urinary or bowel appliances. Coding Instructions Check next to each appliance that was used at any time in the past 7 days. Select none of the above if none of the appliances A-D were used in the past 7 days. o H0100A, indwelling catheter (including suprapubic catheter and nephrostomy tube)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 2 (Resident #6 and Resident #79) of 5 residents reviewed for respiratory care. The facility failed to change nebulizer tubing for Resident #6 for 4 months. The facility failed to change nebulizer tubing for Resident #79 for 6 months. This failure could affect residents on respiratory therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition. Findings include: Resident #6 Record review of Resident #6's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), chronic bronchitis(productive cough for more than 3 months occurring within a span of 2 years), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), macular degeneration(a degenerative condition affecting the central part of the retina), and dependent on supplemental oxygen. Record review of Resident #6's clinical record revealed her last MDS was a quarterly completed 10-10-2024 listing her with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of requiring partial/moderate assistance with most of her activities of daily living. Record review of Resident #6's Order Summary Report with Active Orders as of 12-5-2024 revealed the following order: -Albuterol Sulfate Inhalation Nebulization Solution -1 vial inhale every 6 hours as needed for SOB four times daily as needed. - Start date 7-3-2024 -no orders were noted for respiratory equipment care to include the changing of tubing to masks. Record review of Resident #6's clinical record revealed a care plan with the admission date of 1-3-2024, last review date of 10-23-2024 revealed the following: Focus: Resident has impaired breathing and impaired oxygen absorption related to her medical diagnosis of COPD/Asthma. - Date initiated 1-3-2024. Revision 4-22-2024 Procedure: 7-3-2024 - Albuterol Sulfate Inhalation Nebulization Solution . 1 vial inhale orally every 6 hours as needed of for SOB 4 times daily as needed. - Initiation Date 7-24-2024. -No procedures were listed with care of any respiratory equipment to include changing of the nebulizer tubing or masks. During an observation on 12-03-2024 at 08:37 AM revealed Resident #6 was not in her room. There was an O2 concentrator next to the bed with water/hydration bottle dated 11-1-2024, no date on the O2 tubing or cannula. A nebulizer was on the bed with tubing dated 8-1-2024 and no date on nebulizer mask. The tubing appeared cloudy and the mask appeared to have small particles on the inside of the mask. There was no date on the nebulizer mask. During an observation and interview on 12-03-2024 at 09:16 AM Resident #6 was in her room in her wheelchair wearing her O2 at 2L/min via her nasal cannula. Resident #6's nebulizer was wrapped in a bag on her bedside dresser. Resident #6 reported that the staff have provided all her respiratory care to include her tubing, cannula, and mask changes and that she had no particular concerns. Resident #79 Record review of Resident #79's clinical record revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include obstructive sleep apnea (a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort), allergic rhinitis (a common condition that occurs when the immune system overreacts to allergens), dementia (a group of thinking and social symptoms that interferes with daily functioning), traumatic brain injury(an injury to the brain cause by an external force, such as a blow to the head or an object piercing the skull), anxiety (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dependence on other enabling machines and devices (such as a nebulizer and respiratory equipment). Record review of Resident #79's clinical record revealed his last MDS was an annual completed 11-9-2024 listing him with a BIMS of 10 indicating he was moderately cognitively impaired, and he had a functionality of being dependent on staff for assistance with most of his activities of daily living. Record review of Resident #79's Order Summary Report with Active Orders as of 12-5-2024 revealed the following order: -Albuterol Sulfate Inhalation Nebulization Solution -1 vial inhale orally via nebulizer every 8 hours as needed for cough. - Start date 3-16-2024 -no orders were noted for respiratory equipment care to include the changing of tubing to masks. Record review of Resident #79's clinical record revealed a care plan with the admission date of 11-2-2023, last review date of 5-22-2024 revealed the following: Focus: Resident has impaired breathing and impaired oxygen absorption. - Revision on 5-22-2024. Procedure: -No procedures were listed with care of any respiratory equipment to include changing of the nebulizer tubing or masks. During an observation on 12-03-24 at 09:25 AM Resident #79 was in his room sitting in his chair. When questioned he did not respond. Noted was a nebulizer on Resident #79's bedside dresser. The tubing on the nebulizer machine was dated 6-1-2024. The nebulizer tubing appeared cloudy with some discoloration and the mask was noted to have some small particles on the inner surface. There was no date on the nebulizer mask. During an observation and interview on 12-0424 at 11:34 AM this surveyor observed LVN B checked Resident #79's nebulizer tubing and found that the tubing had been removed with no replacement provided and then checked Resident #6's nebulizer tubing and found it dated 12-3-2024. When presented with the photo of Resident #6's tubing with it dated 8-1-2024 LVN B reported that the tubing was supposed to be changed each month according to the facility policy and that with Resident #6's tubing being left for 4 months and Resident #79's tubing being left for 6 months was too long and that not changing the tubing could place a resident at risk for infection especially respiratory infection and that would affect the residents health. During an interview on 12-04-2024 at 01:47 PM the DON reported that the policy for oxygen/nebulizer/respiratory equipment care was that they were changed monthly and assessed nightly. The secondary equipment such as tubing, cannula, and mask were changed monthly and checked nightly for defects or damage. The DON reported that if a nebulizer tubing that was left for 4 month or even 6 months was a problem, that they should be replaced monthly. The DON reported that if they were not replaced then the resident was placed at higher risk for infection and exposure to bacteria. During an interview on 12-5-2024 at 01:44 PM the Administrator reported that the facility did not have a policy that specifically listed when respiratory equipment care would be provided, just that it would be provided. Record review of the facility provided policy titled Respiratory Equipment Maintenance dated 12-27-2016, revealed the following: Policy: Respiratory maintenance will be performed in a standardized manner. Equipment will be changed out consistently to ensure clean, properly maintained equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review; the facility failed to provide pharmaceutical services that included the accurate acquiring and dispensing of all drugs and biologicals to meet the needs of each resident for 1 (Resident #75) of 19 residents reviewed for medication therapy and 2 (the Rehabilitation and Long-Term Care medication room and the 1-North medication room) of 8 medication storage areas reviewed for medication storage. -LVN B left the morning medications with Resident #75 unattended and did not verify if Resident #75 took the AM medications. -the Rehabilitation and Long-Term Care medication room had an expired OTC medication. -the 1-North medication room had an expired OTC medication. The facility's failure to ensure medications were dispensed in accordance with currently accepted professional principles which could result in a resident receiving or not receiving the correct medication therapy that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings include: Record review of Resident #75's clinical record revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include rheumatoid arthritis (autoimmune inflammation of the joints), osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes or deficiency of calcium of vitamin D), pain in right shoulder, muscle wasting (the loss of muscle mass and strength due to disease, injury, or lack of use), unsteadiness on feet, depressive episodes (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and traumatic hemorrhage of the cerebrum (bleeding in the brain tissue that occurs after a head injury). Record review of Resident #75's last MDS revealed a quarterly assessment completed on 9-1-2024 with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of requiring supervision or touching assistance with most of her activities of daily living. Record review of the care plan with admission date of 11-22-2022 for Resident #75 revealed the following: Problem: [Resident #75] is at risk of aspiration, swallowing, and pain related to the medical diagnoses of GERD. Revision on: 6-8-2023 -There was no care plan for self-administration of medications. Record review of Resident #75's Medication Administration Report revealed 12 p.o. medications were administered at 08:00 AM the morning of 12-3-2024 to Resident #75 by LVN B. During an observation and interview on 12-03-2024 at 08:54 AM revealed Resident #75 was noted in her room sitting in her recliner with her bedside table in front of her. Resident #75 was watching her TV and had finished her breakfast. On her bedside table was a medication cup with her morning pills. Noted 8-10 pills were present. Resident #75 reported that she was slow to swallow her pills because she often gets choked so they just leave them for me. During an interview on 12-4-2024 at 11:31 AM LVN B reported that Resident #75 would often eat her meals in the dining room and sometimes eat them in her room. Either way, Resident #75 would often take a bite then take one of her pills. Resident #75 would usually take between 20-30 minutes to take her medications and due to that and the fact that Resident #75 was pretty much with it LVN B felt that Resident #75 was safe to take her medications independently. LVN B stated, I don't feel uncomfortable leaving her pills with her. LVN B reported that they have only one resident on Resident #75's hallway that wandered and that Resident #75 leaves her door shut and the resident that wanders would not enter a room when the door was shut. LVN B reported that she did not feel there would be any negative outcomes from letting Resident #75 take her medications independently and unsupervised. During an interview on 12-4-2024 at 01:51 PM the DON reported that a nurse was expected take medications to a resident, make sure the resident took those medications, then document what medications were taken and when. The DON reported that a nurse leaving medications in a resident's room unattended was an issue. The DON reported the nurse would not know if that resident had taken those medications and if that resident was receiving the treatment the Resident was supposed to get. The DON reported that if that was to occur then the residents care could be affected in several ways especially if the resident intended for the medication did not take the medication or another resident were to get ahold of it. During an observation on 12-4-2024 at 08:19 AM of the Rehabilitation and Long-Term Care medication room extra stock storage area of OTC medications available for use with LVN C revealed an unopened bottle of CertaVite that expired 11-2024. During an interview on 12-4-2024 at 08:31 AM LVN C reported that an expired medication was an issue due to a staff member could administer the expired medication to a resident and the medication would not be as affective affecting the residents care and health. During an observation on 12-04-2024 at 08:47 AM of the 1-North medication room extra stock storage area of OTC medications available for use with LVN D, noted was an unopened bottle of Meclizine that expired 6-2024. During an interview on 12-4-2024 at 08:49 AM LVN D reported that using an expired medication can affect the way a medication acts and the way a resident reacts to that medication. LVN D reported that giving an expired medication would negatively affect a resident because they would not be receiving ordered treatment. During an interview on 12-4-2024 at 01:51 PM the DON reported that nurses should check all medications for expirations and if the medication is expired then it should be disposed of properly. The DON reported that it was the floor nurses' job to check medications for expiration. The DON reported that giving an expired medication to a resident can result in it not being effective and the resident not receiving the needed care and treatment. Record Review of the facility provided policy titled Drug Administration Policy dated 1-26-2017, revealed the following: Policy: Except for self-administration, drugs and biologicals are administer in accordance with physicians' orders only by the following: a. Physicians b. Licensed nursing personnel c. Medication aides; or d. Student nurse, student medication aides, or graduate nurses who are directly supervised by a licensed nurse . 12-4-2024 at 2:49 PM requested policy for mediation storage from Administrator with no response. 12-5-2024 at 08:19 AM reviewed provided policies and noted no policy for medication storage, requested from DON. 12-5-2024 at 1:10 PM requested policy for medication storage from Administrator with no response. Record review on 12-5-2024 at 09:28 AM of facility policy manual noted at 1-North Unit nurses station revealed no policy for medication/narcotic storage.

Based on observation, interview, and record review; the facility failed to store a controlled drug subject to abuse properly for 1 (the Rehabilitation and Long-Term Care medication room) of 8 medication storage areas reviewed for medication storage. The Rehabilitation and Long-Term Care medication room had a Schedule III narcotic stored improperly in the refrigerator. The facility's failure to ensure medications were stored properly could result in medication diversion leading to a resident not receiving ordered treatment affecting the resident's treatment and care leading to deterioration in their health. Findings included: During an observation on 12-4-2024 at 08:19 AM of the Rehabilitation and Long-Term Care medication room storage refrigerator revealed a container with Buprenorphine (a schedule III narcotic) 0.25mg (3 tablets present in the package) that were on the refrigerator shelf. The narcotic was not stored in the locked box provided on the refrigerator door. During an interview on 12-4-2024 at 08:32 AM LVN C reported that storing a narcotic in the refrigerator and not in a locked box could be a big issue. LVN C stated that any nurse could access the narcotic and the facility would not know since there was no log for the narcotic when it was in the refrigerator and not being used. LVN C reported that it would affect the residents care negatively because the medication would not be available to provide for the resident's treatment. During an interview on 12-4-2024 at 01:51 PM the DON reported that a refrigerated narcotic was supposed to be stored in a refrigerator in a locked box to comply with the double lock system. The DON reported that they have had a problem with not having a key to the lock box in the refrigerator in the medication room and she feels that someone put the narcotic in the refrigerator and probably forgot about it. The DON reported that they have called maintenance and it is supposed to be fixed today. The DON reported that leaving a narcotic medication stored incorrectly can result in that medication being stolen. 12-4-2024 at 2:49 PM requested policy for medication storage from Administrator with no response. 12-5-2024 at 08:19 AM reviewed provided policies and noted no policy for medication storage, requested from DON. 12-5-2024 at 1:10 PM requested policy for medication storage from Administrator with no response. Record review on 12-5-2024 at 09:28 AM of facility policy manual noted at 1-North Unit nurses station revealed no policy for medication/narcotic storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to be informed in advance if the risks and benefits of proposed care, or treatment and treatment alternatives or treatment options and to chose the alternative or options he or she prefers for 5 of 19 residents (Resident #13, #15, #47, #70, and #75) and 5 residents interviewed during an anonymous interview reviewed for self-determination. The facility failed to ensure Resident #13, #15, #47, #70, and #75 and 5 anonymous residents received requested bedrails for 10 days or more after requested by the resident or family. This failure could cause residents to feel uncomfortable and disrespected leading to feeling of anxiety, anger, isolation, and deterioration in general health conditions. Findings include: Resident #13 Record review of Resident #13's clinical record revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), Alzheimer's (a progressive disease that destroys memory and other important mental functions), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), osteoarthritis(a type of arthritis that occurs when flexible tissue at the ends of bones wears down), chronic respiratory failure(a long-term condition that occurs when the body's respiratory system can't exchange oxygen and carbon dioxide properly), and muscle weakness (a lack of muscle strength). Record review of Resident #13's last MDS revealed a quarterly assessment completed on 9-1-2024 with a BIMS of 15 indicating he was cognitively intact, and he had a functionality of requiring substantial/maximal assistance with chair/bed-to-chair transfers and rolling left and right. Record review of the care plan with admission date of 03-12-2014 for Resident #13 revealed the following: Problem: [Resident #13] requires assistance from staff with performance of daily living and functional abilities related to HTN (hypertension-a condition in which the force of the blood against the artery walls is too high), DM (diabetes-a chronic condition that affects the way the body processes blood sugar (glucose), HLD (hyperlipidemia-a condition in which there are high levels of fat particles in the blood), Seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), and Intellectual Disabilities. - Revision on 12-7-2023 Interventions: [Resident #13] may use ½ rails for mobility, positioning, and comfort. - Revision 7-17-2023. Record review of Resident #13's Order Summary Report with Active Orders as of 12-5-2024 revealed no physician orders for side rails. During an interview on 12-03-2024 at 09:44 AM Resident #13 reported that he was very upset that his bedrails were removed. Resident #13 reported that he used his bedrails for everything, to include getting in and out of bed, moving around in bed, and making sure he stayed safe. Resident #13 reported that he was told state told the facility they had to be removed and he did not appreciate that. Resident #13 wanted it corrected immediately and the bedrails returned. Resident #13 reported that he requested his bedrails be returned the day they were removed. Resident #13 reported that he has talked with multiple staff about getting bedrails back and on several different occasions and that he was going to a care plan meeting at 10:00 AM this day and was going to bring it up again. Resident #15 Record review of Resident #15's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include CHF (a chronic condition in which the heart dose not pump blood as well as it should), morbid obesity (a disorder involving excessive body fat that increase the risk of health problems), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), polyneuropathy (malfunction of many peripheral nerves throughout the body), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), PVD (a circulatory condition in which narrowed blood vessels recue blood flow to the limbs), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record review of Resident #15's last MDS revealed a quarterly assessment completed on 11-5-2024 with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of being dependent with chair/bed-to-chair transfers and partial/moderate assistance with rolling left and right. Record review of the care plan with admission date of 07-29-2024 for Resident #15 revealed the following: Problem: [Resident #15] requires assistance from staff with performance of daily living and functional abilities related to CHF (congestive heart failure-a chronic condition in which the heart dose not pump blood as well as it should), AFIB (atrial fibrillation-an irregular, often rapid heart rate that commonly causes poor blood flow), HTN (hypertension-a condition in which the force of the blood against the artery walls is too high), OA (Osteoarthritis-a type of arthritis that occurs when flexible tissue at the ends of bones wears down), COPD chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), Epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and weakness. - Revision on 7-30-2024 Interventions: [Resident #15] may use ½ rails for mobility, positioning, and comfort. - Revision 8-2-2024. Record review of Resident #15's Order Summary Report with Active Orders as of 12-5-2024 revealed the following physician's order: May use side rails for comfort and to aid in positioning and mobility . Order dated 08-29-2024. During an interview on 12-03-24 at 09:37 AM Resident #15 was in her room in her wheelchair. Resident #15 reported that her bedrails had been recently removed and she would like them back. Resident #15 reported that she had reported this to staff the day the bedrails were removed and a couple of times since then but she had not received any response other than to report that state told the facility they could not have bedrails. Resident #15 reported she uses the bedrails to get in and out of bed safely. Resident #47 Record review of Resident #47's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), CAD (damage or disease in the hearts major blood vessels), chronic pain(persistent pain that can last years), macular degeneration (a degenerative condition affecting the central part of the retina), history of falls, and weakness. (a lack of muscle strength). Record review of Resident #47's last MDS revealed an annual assessment completed on 11-11-2024 with a BIMS of 13 indicating she was cognitively intact, and she had a functionality of requiring partial/moderate assistance with chair/bed-to-chair transfers. and rolling left and right. Record review of the care plan with admission date of 10-27-2022 for Resident #47 revealed there were no care plans related to the use of bedrails. Record review of Resident #47's Order Summary Report with Active Orders as of 12-5-2024 revealed no physician orders for side rails. During an interview on 12-3-2024 at 09:04 AM Resident #47 was in her room in her wheelchair. Resident #47's bed was made with her bedrails under her bed. This surveyor attempted to move them and noted that they were securely locked in place. Resident #47 reported that she was currently [AGE] years old, had been in the facility for several years and that she has always used bedrails but the facility removed them and she wants them back. Resident #47 reported that the facility had locked her bedrails down. Resident #47 reported that she told the facility staff that she wanted her bedrails back, but they told her that state would not allow them, and she could not have her bedrails back. Resident #47 reported that she requested her bedrails be returned the day they were removed and several times since. Resident #70 Record review of Resident #70's clinical record revealed an [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include Alzheimer's (a progressive disease that destroys memory and other important mental functions), muscle weakness (a lack of muscle strength), pain, fracture for femur (thigh bone), history of falling, and peripheral vascular disease (blood circulation disorder) Record review of Resident #70's last MDS revealed a quarterly assessment completed on 11-6-2024 with a BIMS of 4 indicating he was severely cognitively impaired, and he had a functionality of being dependent on staff for chair/bed-to-chair transfers and rolling left and right. Record review of the care plan with admission date of 4-13-2022 for Resident #70 revealed the following: Problem: [Resident #70] uses side rail for positioning. - Revision on 7-05-2024 Record review of Resident #70's Order Summary Report with Active Orders as of 12-4-2024 revealed no physician orders for side rails. During an interview on 12-3-2024 at 09:59 AM FM H reported that the care and facility had been good except for one issue. The facility removed Resident #70's bedrails approximately 2 weeks ago and told FM H that state would not let them have bedrails for Resident #70 to use. FM H reported that Resident #70 was a tall/big man and used his bedrails all the time to reposition and transfer in and out of bed. FM H reported that since they have removed the bedrails and tied them down Resident #70 has been unable to access them. FM H reported that she requested Resident #70's bedrails be returned the day they were removed. This surveyor did note that Resident #70 did have his bedrails on his bed, they were under the bed and locked in place with zip ties. The bedrails could not be moved. Resident #75 Record review of Resident #75's clinical record revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include rheumatoid arthritis(autoimmune inflammation of the joints), osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes or deficiency of calcium of vitamin D), pain in right shoulder, muscle wasting(the loss of muscle mass and strength due to disease, injury, or lack of use), unsteadiness on feet, and history of fractures. Record review of Resident #75's last MDS revealed a quarterly assessment completed on 9-1-2024 with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of requiring supervision or touching assistance with chair/bed-to-chair transfers and setup or clean-up assistance with rolling left and right. Record review of the care plan with admission date of 11-22-2022 for Resident #75 revealed the following: Problem: [Resident #75] uses side rail for position, mobility, and comfort. - Revision on 7-21-2024 Record review of Resident #75's Order Summary Report with Active Orders as of 12-5-2024 revealed no physician orders for side rails. During an interview on 12-3-2024 at 08:54 AM Resident #75 was noted in her room sitting in her recliner. She reported no issues with the facility other that they had removed her bedrails and she would like them back so she would be steadier with her transfers and she could move around in bed. Resident #75 reported that she requested the bedrails be returned the day the facility locked them down. During an anonymous interview with 5 residents on 12-4-2024 at 10:35 AM revealed all 5 residents reported that they were upset their bedrails were removed. One resident reported that the aides made her turn every two hours when in bed and that it hurts now because they had to push and pull her, and she had nothing that she could hold on to so she could assist them with turning or moving. Another resident stated he was mad about the bedrails and that they were still on the bed but underneath the bead and locked where he could not get them up. During an interview on 12-4-2024 at 01:40 PM the DON reported that the bedrails for residents had been used for mobility and positioning, that they (the DON and Managers) went through the facility on 9-22-2024 and zip tied all the bedrails down so resident would not be able to use them. The plan was to reassess each resident to see if they needed and could use the bedrails, obtain new consents and new orders for the bedrails, and add the bedrails to the resident's care plans. The DON reported that she herself and the managers would redo the evaluations and they did one on 12-3-2024 and planned to redo one today 12-4-2024. The DON reported that she has received multiple resident reports that they want the bedrails returned. The DON reported that she has 4-6 residents on each unit that have reported they want their bedrails back (this will be a total of 16-24 residents who have requested the return of their bedrails). The DON reported that they have notified all families by mail of the change in policy but did not say if they have discussed the policy with the residents. During an interview on 12-05-2024 at 08:21 AM the Administrator reported that during last year's survey the facility was cited for a bedrail deficiency, that her nurse managers, DON, general management, and herself decided to rewrite the bedrail policy. The Administrator had the management nursing staff evaluate each resident to determine who had bedrails and found out that all but 9 residents had some type of bedrail, so they decided to remove all the bedrails and restart to determine which residents really needed them. The Administrator reported that they sent a letter to the families of the residents who could not respond and provided the letter to residents who were oriented on 11-19-2024 and removed all the bedrails on 11-22-2024. The Administrator reported that each resident would be reevaluated and if they qualified, they would get their bedrails back and if they did not qualify but wanted something for mobility then they would get a U-Bar which was a small rail that is less than 1/8th the length of the resident's bed. The Administrator reported that they planned to completely phase out the bedrails and replace them with the U-Bar's unless ordered by physical therapy. The Administrator reported that the intent was to evaluate and replace all the bed rails this week but state had taken the time of the management nursing staff and they have been unable to address the bedrail situation. The Administrator reported that as of 12-5-2024 the facility had evaluated 5-6 residents for bedrails. The Administrator reported that they were aware of 20 resident who either the family or resident had specifically requested the bedrails be put back in place and that with the current residents that have been evaluated they have approximately 15 of those Residents left. The Administrator reported that she feels the residents do have the right to participate in their care and make decisions about their care. The administrator reported that she feels 10 days, or more is not too much time to wait to make sure that they address this issue with the bedrails correctly. The Administrator stated, We have 4 nurse managers that could do this in one day if they needed to but currently, they have other things that are taking up their time. We had plans to do them this week, but state walked in. During an interview on 12-05-2024 at 01:07 PM the Administrator reported they had completed 8 more resident evaluations for the use of bedrails, and she expected they would complete the other 7 by the end of the day to have all 20 residents who requested the return of the bedrails evaluated. The Administrator stated, two weeks is a little too long to wait to get something done but we just have had too many distractions. Record review of the facility provided Resident Rights undated, provided as part of the facility's admission process to each resident revealed the following: Residents of Texas nursing facilities have all the rights .granted by the Constitution and laws of the stated and the United States. They have the right to be free of . and reprisal exercising these rights as a citizen of the United States. Freedom of Choice You have the right to: -make your own choices regarding personal affairs, care, benefits, and services. Record review of the policy provided by the Administrator on 12-5-2024 at 08:41 AM revealed the following: Texas Administrative Code Resident Rights Fee Choice (3) participate in planning care and treatment or changes in care and treatment, to the extent practicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 residents (Resident #31, Resident #82, and Resident #240) reviewed for Medicare/Medicaid coverage. 1. The facility failed to ensure Resident #31, Resident #82, and Resident #240 were given a NOMNC (a notice that indicates when care is set to end from a home health agency, skilled nursing facility, comprehensive outpatient rehabilitation facility, or hospice) with information on how to appeal the decision when residents were discharged from skilled services prior to covered days being exhausted. 2. The facility failed to ensure Resident #31, Resident #82, and Resident #240 were given a SNF ABN (document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. These failures could place residents at risk of not being aware of their right to appeal the decision to end Medicare coverage for skilled services and/or changes to provided services. Findings Included: Record review of Resident #31's admission record dated 12/04/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 11/20/24 to an assisted living facility. She had diagnoses that included, but were not limited to, unspecified sequalae of unspecified cerebrovascular disease (the resultant symptoms of stroke, transient ischemic attack, aneurysm, or vascular malformation), chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), heart failure (heart muscle fails to pump blood as it should), and dysphagia (difficulty in swallowing). Resident #31's primary payer was Private Pay, and her second payer was Medicare A coinsurance from insurance. She was admitted from an acute care hospital, and her admission type was listed as short term. Record review of Resident #31's admission MDS completed on 10/24/24 revealed the following: Section A: Resident #31's most recent Medicare stay started on 10/15/24. Section C: Resident #31 had a BIMS of 11 which indicated moderately impaired cognition. Section I: Resident #31's primary medical condition was Stroke. Record review of Resident #31's care plan revealed an initiation date of 10/31/24. The care plan noted Resident #31's normal social routine had been disrupted by admission to the SNU and she required assistance from staff with ADLs due to CVA. Resident #31 was at risk for injuries related to impaired balance and was to receive of skilled occupational and physical therapy five times a week for 30 days. Attempted interview on 12/05/24 at 09:11 AM, a voicemail message was left for Resident #31. The call was not returned. Attempted interview on 12/05/24 at 09:13 AM, a voicemail message was left for Resident #31's family member. The call was not returned. Record review of Resident #31's SNF Beneficiary Review form revealed Resident #31's Medicare Part A start date of 10/15/24 and the last covered day of Medicare Part A service was 11/15/24. In answer to the question How was the Medicare Part A Service Termination/Discharge determined? the IP checked the box for Other and added a handwritten note which reflected, Resident met Part A stay then moved to [name of assisted living facility] on 11/25/24. There were no answers to the following questions on the form: 1. Was a SNF ABN, Form CMS-10055 provided to the resident? 2. Was a NOMNC, Form CMS 10123 provided to the resident? Record review of Resident #82's admission record dated 12/04/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, other symptoms and signs involving the musculoskeletal system (affecting muscles, bones, joints and connective tissue), unspecified fall, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and muscle weakness. He was admitted from an acute care hospital and his admission type was Short Term. Resident #82 had Medicare Part A and B coverage and his primary payer was listed as Private Pay. Record review of Resident #82's admission MDS completed on 11/11/24 revealed the following: Section A: Resident #82's most recent Medicare stay started on 10/31/24. Section C: Resident #82 had a BIMS of 15 which indicated intact cognition. Section I: Resident #82's primary medical condition was Medically Complex Conditions. Record review of Resident #82's care plan revealed an initiation date of 11/18/24. The care plan noted Resident #82's normal social routine had been disrupted by admission to the SNU and he required assistance from staff with ADLs due to his diagnoses. Resident #82 was at risk for injuries related to impaired balance and weakness and was to receive skilled occupational and physical therapy five times a week for 30 days. Record review of Resident #82's SNF Beneficiary Review form revealed Resident #82's Medicare Part A start date of 10/31/24 and the last covered day of Medicare Part A service was 11/27/24. In answer to the question How was the Medicare Part A Service Termination/Discharge determined? the IP checked the box for Other and added a handwritten note which reflected, Respite on 11/27/24 Respite still in the facility. Resident no longer making progress in SNU. The plan was to transition him to our LTC. There were no answers to the following questions on the form: 1. Was a SNF ABN, Form CMS-10055 provided to the resident? . 2. Was a NOMNC, Form CMS 10123 provided to the resident? During an interview on 12/05/24 at 08:57 AM the IP stated Resident #82 came into the facility on respite and was hesitant to give the facility his financial information to get Medicaid Pending in progress. She did not have an answer when asked if he would have wanted to appeal the decision to end his skilled care. During an interview on 12/05/24 at 09:21 AM Resident #82's family member stated the facility did not inform her or Resident #82 of the right to appeal the decision to end his skilled care. She stated private pay since skilled care ended, This $274.00 a day is gonna break us. We will be in the poor house. Record review of Resident #240's admission record dated 12/04/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, nondisplaced fracture of medial condyle of left tibia (broken left lower leg), osteoarthritis of knee (degenerative joint disease), acute chronic diastolic heart failure (heart muscle fails to pump blood as it should), and muscle weakness. Resident #240 was admitted from an acute care hospital and her primary payer was Private Pay. Her second payer was Medicare A coinsurance from insurance. Her admission type was Short Term. Record review of Resident #240's discharge MDS [her admission MDS was requested from facility but was not provided] completed on 11/14/24 revealed the following: Section A: The MDS was a SNF Part A Discharge Assessment. Resident #240's most recent Medicare-covered stay started on 10/17/24 and ended on 11/08/24. Section C: Resident #240 had a BIMS of 11 which indicated moderately impaired cognition. Record review of Resident #240's care plan revealed an initiation date of 11/04/24. The care plan noted Resident #240's normal social routine had been disrupted by admission to the SNU and she required assistance from staff with ADLs due to her diagnoses. Resident #240 was at risk for injuries related to impaired balance and weakness and was to receive skilled occupational therapy five times a week for 360 days and physical therapy five times a week for 30 days. Record review of Resident #240's SNF Beneficiary Review form revealed Resident #240's Medicare Part A start date of 10/17/24 and the last covered day of Medicare Part A service was 11/08/24. In answer to the question How was the Medicare Part A Service Termination/Discharge determined? the IP checked the box for Other and added a handwritten note which reflected, Resident transitioned to LTC room [room number of Resident #240] (private pay) met part A stay then transitioned to our LTC. There were no answers to the following questions on the form: 1. Was a SNF ABN, Form CMS-10055 provided to the resident? . 2. Was a NOMNC, Form CMS 10123 provided to the resident? During an interview on 12/05/24 at 09:14 AM Resident #240's family member stated a facility staff member (he could not remember which one) told him he could appeal the decision to end Resident #240's skilled care but it would only extend care for 2-3 more days and there were a lot of hoops to jump through. He stated because of the 2-3-day extension and because he was receiving cancer treatments and his wife was in the hospital for a hip replacement he decided not to appeal. He stated, There is no doubt she (Resident #240) should have had longer (skilled care). Because she's 97 and they don't respond as fast (to treatment). We were just at a place were filling out forms was not an option, especially for just a few more days of services. During an interview on 12/05/24 at 08:57 AM the IP stated she was responsible for issuing NOMNCs and SNF ABN notices to residents. She stated she had not had to do any SNF ABN notices in the facility. She stated the facility became licensed for SNF in September of 2023. The IP stated she had not received any training on NOMNCs or SNF ABNs, but she worked closely with the Social Worker who was in charge of them at her last facility, so she was familiar with the process. When asked why Resident #31, Resident #82, and Resident #240 did not receive either notice she stated they did not need the notices because they transitioned to a lower level of care due to not needing skilled care any longer. The IP stated the three residents would not have needed to appeal the decisions to lower their care as it was a team decision made during team meetings so they would not have wanted to appeal. The IP stated none of the three residents exhausted their 100 days of skilled care but they could not receive skilled care for 100 days if they did not need it. During an interview on 12/05/24 at 08:57 AM the DON stated she was only partially familiar with NOMNCS and SNF ABNs. She stated, We get them for issues with insurance. If (the resident is) not progressing with goals, we get the information to discharge them from services. I know there is an appeal process. We give them (the residents) a heads up (that services are ending). The DON stated residents were told that they could appeal and if their benefits ran out before the appeal was approved, they would be responsible for the cost of care. She stated a possible negative outcome for residents not receiving the NOMNC and SNF ABN was they could miss out on more services. During an interview on 12/05/24 at 08:59 AM the ADM stated she did not know anything about NOMNCs or SNF ABNs. She stated the IP was responsible for both. During an interview on 12/05/24 at 10:36 AM the ADM stated the facility did not have policies addressing NOMNCs or SNF ABNs. She said, I looked high and low, and didn't find any.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 7 out of 8 resident snack refrigerators located in the residents dining rooms, reviewed for kitchen sanitation. 1. The facility failed to ensure food items were properly stored, labeled, and dated. 2. The facility failed to ensure refrigerators were free of expired foods, non-food items and staff items. 3. The facility failed to ensure cleanliness was maintained in the refrigerators. These failures could place residents who ate food served by the kitchen, and stored food in the resident refrigerators were at risk of food-borne illness. Findings include: North Side First Floor In an observation and interview on 12/3/24 at 8:25 am of the initial tour of the lower-level resident dining room on the North side called the North First Floor Dining there were 2 refrigerators in the dining room. The refrigerators were stainless steel and had freezers on the bottom portion of the refrigerator. There were no postings on the refrigerators and no cleaning sheets. Residents in the dining room eating breakfast and staff in the dining room assisting residents confirmed the refrigerators were for resident foods. In an observation on 12/3/24 at 8:36 am, of the resident refrigerators located on the North side Lower-Level Dining called the North First Floor Dining room the following was observed: In the freezer: 1. A Michelina frozen dinner, no residents name, no label or date. 2. A Thai Curry Chicken frozen dinner, no resident name, no label or date. 3. Frozen spicy beef dinner, no resident name, open to air, no label or date with an expiration date of 11/18/24. 4. Assorted ice cream bars loose in the freezer, no label or date, no resident name, not in original box. 5. A Ziplock baggie with one breaded meat patty, no label or date, no resident name, not in original package. 6. Food spills and food crumbs were observed in the bottom of the freezer bin. South Side Second Floor In an observation and interview on 12/3/24 at 8:55 am of the initial tour of the upper -level resident dining room on the South side titled South Second Floor Dining there were 2 refrigerators in the dining room. The refrigerators were stainless steel and had freezers on the bottom portion of the refrigerator. There were no postings on the refrigerators and no cleaning sheets. Residents and staff in the dining room area confirmed the refrigerators were for resident foods. In an observation on 12/3/24 at 9:55 am of the resident refrigerators located on the South Second Floor Dining room the following was observed: In the refrigerator: 1. A sandwich, partially wrapped in torn foil with holes in the foil, no label or date, no resident name. 2. A slice of pumpkin pie no label or date, no resident name, not in original container. 3. A plastic grocery bag containing a bag of green fruit and a banana and empty plastic storage bowls, no resident name, no label or date. 4. A yeti soft sided lunch cooler, no label or date, no resident name. 5. A glass of thickened liquid, no resident name, no label or date 6. A plastic storage container that appeared to hold a noodle substance, no label or date, no resident name, a foul smell coming from the container. 7. A Dairy Queen cup of frozen blizzard type ice cream laying on its side in the bottom of the freezer, , no resident name, no lid or covering for the top of the blizzard, no date. South First Floor In an observation on 12/3/24 at 11:30 am, of the resident refrigerators located on the South First Floor Dining room the following was observed: 1. 1 red plastic container with fruit salad, no label or date, no resident name 2. A piece of cheesecake, no resident name, dated 11/28/24. 3. There were crumbs on the shelves and food spills in the refrigerator. 4. An individual fruit salad in a cup from the kitchen, no label or date, no resident name. 5. In the freezer there was a package with one corn on the cobb, open to air, no label or date. There were crumbs and food spills in the bottom of the freezer. South Second Floor In an Observation and Interview on 12/4/24 at 9:15 am, of the South Second Floor refrigerator, DA J stated the resident refrigerators were for resident use only and staff were supposed to use the employee refrigerators in the breakroom. She stated she thought staff had used the resident refrigerators for their personal foods. She stated she did not know who was responsible for maintaining the refrigerators but thought it was housekeeping or nursing services. DA J stated of the half-wrapped sandwich wrapped in foil, that it should have a label, date and be covered completely. She stated she would throw it out. DAJ also took the pumpkin pie with no label or date and a bottle of Gatorade out of the refrigerator and threw them away. In an observation on 12/4/24 at 9:25 am of the South Second Floor refrigerator there was a cup of thickened liquid from the kitchen, no label or date, no resident name. The Dairy Queen Blizzard type ice cream was in the bottom of the freezer, on its side, no covering, no label or date, no resident name. North First Floor In an observation on 12/4/24 at 11:30 am of the North First Floor resident refrigerator the following was observed: 1. A package of opened partially used blood worms in the freezer with an expiration date of 2/2021. The package stated Not for Human Consumption. 2. A breaded meat patty in a Ziplock bag, no resident name, no label or date. 3. The refrigerator and freezer had food spills and crumbs on the shelves. South Second Floor In an observation on 12/4/24 at 2:10 pm, of the resident refrigerators located on the South Second Floor Dining room the refrigerator contained a glass of thickened liquid, no label or date, no resident name, and the Dairy Queen cup of ice cream, open to air, no label or date, no resident name lying on its side in the bottom of the freezer. North Second Floor In an observation on 12/4/24 at 3:07 pm of the resident refrigerators located on the North Second Floor Dining room the following was observed: In the refrigerator: 1. A package of turkey breast, no label or date, no resident name. 2. A bowl of fruit from a deli grocery store, no label or date, no resident name. 3. A plastic grocery bag containing a piece of pie dated 11/25, no resident name. 4. A frozen pizza, no resident name, no label or date. 5. A plastic storage container that appeared to hold a noodle substance, no label or date, no resident name, a foul smell coming from the container. In an observation on 12/4/24 at 2:00 pm, of the facility break room for employees revealed a black refrigerator in the locked breakroom that was labeled for staff use. In an interview on 12/4/24 at 3:15 pm, the ADM stated she believed the staff were using the resident refrigerators on the units. She stated the nursing staff were not supposed to use the resident refrigerators. She stated everything must be labeled, dated, and have the residents name on the food item. She stated if the food item did not have a name or date on it, it should be thrown out. The ADM stated the kitchen is responsible for cleaning the refrigerators. She stated the consequences of not labeling and dating foods would be foodborne illness. In an interview on 12/5/24 at 8:30 am the AD stated she had only one refrigerator used for activities, and it was locked all the time. She stated the residents know the refrigerators in the dining areas were for their use. She stated she thought housekeeping was in charge of cleaning the refrigerators but was not sure who was responsible to clean them. She confirmed all the other refrigerators on the ding area units were the resident refrigerators and were not supposed to be used by staff. In an interview on 12/5/24 at 8:35 am LVN I stated the refrigerators on the units were the resident refrigerators and were not for staff use. She stated there was a refrigerator in the employee breakroom for employees to use. She stated she was not sure who was responsible for cleaning the refrigerators but stated the cooks stock the refrigerators with snacks and juices for the residents' snacks and residents put food in the refrigerators for eating later. She stated when a resident puts food in the refrigerator the nursing staff were supposed assist the resident to label and date the food. She stated all foods should have the residents name and the date the food was put in the refrigerator. She stated a consequence of unlabeled, undated foods and expired foods would be a food borne illness. She stated she was not aware of the current condition of the refrigerator where food was uncovered or unlabeled and undated. In an interview and observation on 12/5/24 at 9:20 am Dietary Manager F stated the housekeepers clean the resident refrigerators on the units. He stated he was aware nursing staff frequently puts their foods in the resident refrigerators but were not supposed to. When told there were expired foods, foods were not labeled and dated, there were dirt, food spills and food crumbs he stated he was not aware of that. He stated the consequences of not keeping food refrigerators in order were food borne illness. He stated he was trained by the dietician in all areas of the kitchen, and he trained his staff in all aspects of the kitchen duties. He stated he had no cleaning sheets for the resident refrigerators. He stated he had no policies for the resident refrigerators. In an interview and observation on 12/5/24 at 9:40 am Housekeeper E stated the housekeepers do not clean the resident refrigerators on the unit. She stated she has never been told to clean the resident refrigerators. She stated the housekeepers do clean the staff refrigerator and pointed to the black refrigerator in the breakroom that the staff use. She stated she has never been told by her supervisor to clean the resident refrigerators. In an interview and observation on 12/5/24 at 9:40 am Housekeeper E stated the housekeepers do not clean the resident refrigerators on the unit. She stated the resident refrigerators were for resident foods only. She stated she did not know who was supposed to clean the resident refrigerators. She confirmed the black refrigerator in the break room was for employees. In an interview and observation on 12/5/24 at 9:48 am Housekeeping Supervisor F stated the housekeepers do not clean the resident refrigerators on the units. She stated the housekeepers have never been told to clean the resident's refrigerators. She stated no one had ever told her to clean the refrigerator but thought the kitchen was supposed to clean the refrigerators. She stated there was a problem with not labeling or dating foods and not putting resident's names on the food. She stated there was one activity refrigerator which is always locked, and she assumed the activity personnel clean that one. She stated she had no policies for cleaning. She stated residents could get food borne illnesses from expired and unlabeled undated foods. She stated the one refrigerator that is locked is the AD refrigerator for resident activities. She confirmed none of the refrigerators were labeled as to being the resident refrigerators, but everyone knew the refrigerators were for residents to use. In an interview on 12/4/24 at 8;30 am, the DM was asked for policies regarding such topics as resident refrigerators, discarding foods from the resident refrigerators, refrigerators on the units, employee food, labeling and dating, in and out procedures for storing foods, cleaning resident refrigerators in the dining room, policies for staff and residents for resident refrigerators. The DM stated he would look for these policies. In an interview on 12/5/24 at 9:20 am, the DM stated he could not locate any policies for the resident refrigerators. In an interview on 12/5/24 at 10:36 am, the ADM stated she did not have any policies for the resident refrigerators. In an interview on 12/5/24 at 2:09 pm, CNA G stated the CNAs are supposed to use the black refrigerator in the employee break room for their food storage. She stated she had been told not to use the refrigerators on the units as they are for the resident's food. She stated she had known of staff who had used the resident refrigerators for their personal food. She stated she had never been told the CNAs were responsible for cleaning the resident refrigerators. She stated she thought the kitchen staff were responsible to clean the resident refrigerators. She stated she had been told to label and date foods they put in the resident refrigerators. She stated both refrigerators on the east and west were resident refrigerators. Record review of the facility policy titled, Special Meal Arrangements and Guest Tray Policies, dated 2/15/18, revealed the following documentation, . Food may be brought to the facility by family and visitors. The facility is responsible for storing food brought in by family or visitors in a way that is separate and distinguishable from facility food. The facility is responsible for helping family and visitors understand safe food handling practices. Facility staff must use safe food handling practices. Record review of the facility policy titled Eating /Drinking in Food Service Areas , dated 1/16/2017, revealed the following documentation, . The Food Service manager will encourage the use of employee break rooms for staff use. Record review of the facility policy titled Cleaning and Sanitation of Food Service Areas and Equipment dated 1/16/2017, revealed the following documentation, . The Food Service Department will clean and sanitize the food service area and any equipment used daily and weekly by following the daily and weekly cleaning schedule provided by the Food Service Manager. The facility will follow proper cleaning procedures on all equipment used. Record review of the facility policy titled Food Storage, Food Safety in Display and Service , dated 11/27/23, revealed the following documentation, . While being stored, served . food shall be protected from potential contamination, including dust, insects, unclean equipment and utensils, unnecessary handling, coughs, and sneezes, Food will be stored in a clean covered container when not in use or preparation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete, accurate, readily accessible, and systemically organized records for 1 (Resident #1) of 8 residents reviewed for medical records. The facility failed to document the fall risk evaluation for Resident #1's history of falls within the last 90 days. This failure could place all residents at risk of not receiving appropriate care through inadequate documentation possibly resulting in deterioration in condition, exacerbation of disease process, and increased risk of harm or injury. Finding include: Record review of Resident #1's medical record revealed an [AGE] year-old-female admitted to the facility on [DATE]. Resident #1's current diagnoses include muscle weakness, history of falling, insomnia, unspecified dementia, unspecified severity, with other behavioral disturbance, hallucination, long term use of anticoagulants. Resident #1's last MDS, dated [DATE] was a quarterly with a BIMS of 13 indicating Resident #1 is cognitively intact. Resident #1 had a functionality of total dependency with mobility tasks while needing partial/moderate assistance with other self-care areas. Further record review of Resident #1's nurse's notes (NN) revealed that a fall risk evaluation dated 01/08/2024 stated the resident slid out of her raising lift recliner that resulted in a bruise to the left hip, no other injury noted. Fall Risk evaluation noted 1-2 falls in past 3 months. Record review of a NN note dated 02/16/2024 stated that Resident #1 was trying to toilet herself and slid from the bed, no injury s/t this fall, fall risk evaluation stated no Hx of falls in the last 3 months. Record review of a NN note dated 03/16/2024 stated that Resident #1 had a fall when she rolled out of her bed, resident hit her head on the floor, laceration to forehead and transfer to ER was performed. Fall risk evaluation stated no Hx of falls in the last 3 months. Record review of a NN note dated 03/17/2024 stated that Resident #1 received 3 stitches at local ER, no other injury noted. Record review of Resident 1's care plan reveals that resident is at risk for falls s/t to Resident 1's in ability to transfer alone. Observation and interview on 04/02/2024 at 11:11am with Resident #1 was on TBP for COVID, Resident #1 was lying in bed in a green night gown under her blankets. The left side of Resident #1's face was slightly bruised with bruising in different stages of healing. Resident did have a laceration to the left side of her forehead and was healing stages, no signs of infection present at site. Resident #1 was able to recall the night that she fell. She stated that she was lying in bed watching a ball game and was close to the edge of the bed. She stated that she went to push herself further back into the bed and just toppled right off the side of the bed. Resident #1 stated that staff came quickly to assist her and sent her to the ER very quickly since she hit her head and was bleeding a lot. No further concerns were voiced by Resident #1. Interview on 04/02/2024 at 12:49pm DON was asked why Resident #1's fall assessments after her falls in February and March indicated that the resident has had no falls in the last 3 months, when in fact she had. DON stated that she would get the nurse's contact information that performed those evaluations for the resident in question. Interview on 04/02/2024 at 1:55pm LVN A stated that she just didn't recall that the resident had fallen in January and that the assessment was made in error. LVN A stated that a negative outcome of not filling out the assessment correctly would be that there just isn't the right documentation for it. Interview on 04/02/2024 at 2:58pm LVN B stated that this was the first time in this building that she was filling out the assessment. LVN B was asked what a negative outcome would be with not filling out the assessment correctly. LVN B stated The next person that looked it up will have the incorrect information as well. Interview on 04/02/2024 at 4:31pm DON stated that a negative outcome to not having the correct documentation on a fall risk evaluation is that the next team member to come in would not have accurate information. Record review of facility provided policy titled Electronic Health Record, dated 06/07/2023, revealed the following: The purpose of the E.H.R. is to provide a basis for planning resident care as well as documenting the provision of such care and the outcomes relating to the evaluation, treatment, and changes in condition noted. Indiscriminate use of addenda, amendments, corrections, or deletions must be avoided. All reasonable attempts must be made by facility staff to assure documentation is accurate and complete prior to signing and saving the entries in the E.H.R. This facility recognizes the requirements of clinical providers to edit electronic health information in ta functional manner and protect the integrity of the E.H.R. simultaneously. In order to accommodate the needed functions, it is essential to define some terms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of the residents needs and preferences for 1 of 18 residents (Resident #23) reviewed for accommodation of needs. Resident #23's call light was not within her reach. The call light's cord was wrapped around the bed rail and was placed at the top of the bed rail out of reach and sight of resident. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life. Findings included: Record review of Resident #23's face sheet , dated 10/24/2023, revealed an [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, psoriatic arthritis (swollen joints), venous insufficiency (swelling due to blood flow in legs), age-related osteoporosis (weak bones), age related cognitive decline and systemic sclerosis (stiff skin and organs). Record review of Resident #23's quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated Resident #23 was cognitively intact. Resident #23 required extensive two-person staff assistance with bed mobility and dressing, total two-person staff dependence with transferring and toilet use and with impairment to upper and lower extremity with regard to range of motion. Record review of Resident #23's care plan, dated 02/16/23, revealed, in part, Resident #23 is at risk for injuries from falling related to impaired mobility .Be sure her call light is within reach . find out why Resident #23 Is attempting to get up and proactively place items of interest in reach . Resident #23 has impaired vision .place frequently used items within reach . During an observation and interview on 10/24/2023 beginning at 9:13 AM, Resident #23 was lying in her bed, resident stated she did not feel well and that she felt a little congested. Observation of call light on resident's right side of bed wrapped around the bed rail above the resident's head, out of reach of resident. LVN A was in the hall near resident's room. Once LVN A was in the resident's room an observation occurred of LVN A moving the call light in a lower position on the bed rail. LVN A stated that the negative outcome for a resident not being able to reach their call light would be that a resident may soil themselves or not get the help they need. During an observation and interview on 10/23/23 beginning at 9:34 AM, Resident #23 was lying in her bed, her blanket was off her legs, and she appeared agitated. Resident #23 stated that she had been trying to reach her call light so she could call for assistance but hasn't been able to reach it. Resident #23 continued to try to reach her call light but was not able to reach it due to her limited range of motion and where the call light was located. The location of the call light was on the resident's right side of bed on a bed rail, the call light's cord was wrapped around the bed rail and was placed at the top of the bed rail out of reach and sight of resident. During an interview on 10/24/2023 at 2:49 PM, DON stated that the facility does not have a policy regarding call lights. During an interview on 10/25/2023 at 9:26 AM, CNA E stated that when she makes the resident's bed, she puts both bed rails down and lays the call light on the bed. CNA E stated that she believes it was the night staff that attaches the call light to the bed rails. CNA E stated the negative outcome for a resident not being able to reach their call light would be that they would not be able to call for assistance. During an interview on 10/25/2023 at 9:49 AM, LVN B stated that she puts the call light in reach of her residents, LVN B stated that a negative outcome of not putting the call light in reach would that a resident could fall. During an interview on 10/25/2023 at 9:50 AM LVN C stated that she puts the call light where the resident requests it to be, sometimes it is on the bed rail, blanket, or clothes. LVN C stated that the negative outcome for a resident not being able to reach the call light would be that the resident may try to get up and get hurt. During an interview on 10/25/2023 at 10:52 AM, Resident #23 stated that her call light placement has always been a problem. During the exit conference on 10/25/2023 at 1:15 PM, ADM asked about the potential reasonable accommodations cite, Surveyor stated that on two occasions she observed a resident not being able to see or reach her call light. Administrator referred to resident by name and indicated that she has always had issues with her call light.

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 (Resident #61) of 18 residents reviewed for DNR orders. Resident #61 had an Out-of-Hospital DNR order that was invalid, as the date of signature of the Physician, Medical Power of Attorney and Notary did not match. This failure could place residents with DNR orders at risk for receiving, or not receiving, life-saving measures that align with their medical preferences. Findings included: Record review on 10/24/23 at 9:50AM revealed that the DNR was signed by MPOA (Medical Power of Attorney), who was her family member, on 1/13/23. The Physician's signature was dated 1/13/22 and the Notary's signature had no date. The last section of the DNR states that all 3 (MPOA, Physician and Notary) must agree that the document has been completed accurately. All 3 had signed that section. In an interview at on 10/24/23 at 9:59AM the DON confirmed that there had been a Care Plan entry on 1/13/23 which changed Resident #63 from Full Code status to DNR. The DNR with the Physician's signature was produced. She stated that the Physician's signature did not match the date of the change in status from Full Code to DNR. In an interview on 10/24/23 at 10:11AM LVN D revealed that he would have to speak with the DON in the event of an emergency, due to the date of the physician's signature on the DNR not matching the change in status of the Care Plan. He stated that he could not execute the DNR and would have to get an update from the DON before life-saving measures were put in place. In an interview on 10/24/23 at 10:22AM the MPOA (Medical Power of Attorney) revealed he had signed his family member's DNR in January 2023. Prior to this, his family member had been a Full Code and he had helped her change the status from Full Code to DNR. He was unaware that the physician's signature was dated 1/13/22, making the DNR inactive. He understood the difference between Full Code status and DNR and wondered what would be done for Resident #63 in the event of an emergency. He stated that he did not want life-saving measures taken for Resident #63 and that her wishes, matched his. In an interview on 10/24/23 at 10:43AM the DON stated that the SW was tasked with ensuring the accuracy of final wishes for residents and would immediately speak with the SW to ensure the proper changes to the DNR were made and signed by the appropriate parties. In an interview on 10/24/23 at 10:46AM the SW stated that the DON had brought the inaccuracy to her attention, and she had reached out to the MPOA, to execute a new and accurate DNR. The SW stated that in the event of an emergency, prior to execution of the new DNR, the MPOA would have to be called to verbally execute Resident #63's wishes.

Based on observation, interviews and record review the facility failed to provide a homelike environment, which allowed comfortable temperature levels for 3 of 5 residents in a confidential group interview. The facility failed to maintain comfortable temperature levels between 71 degrees and 81 degrees in 1 of 4 dining rooms at the facility. This failure could place residents at risk of an uncomfortable environment and diminish their quality of life. Findings included: Observation of 2nd floor South Dining Room on 10/23/23 at 12:13 PM, observation of thermostat located on the interior wall which divided the dining room revealed it was 68 degrees in the dining room where 19 of the 21 residents that were in the dining room were wearing a jacket or had a blanket covering them. Confidential interview and observation on 10/23/23 beginning at 12:16 PM resident was observed sitting in the 2nd floor South Dining Room, resident stated that she was cold. Confidential Interview on 10/24/23 at 10:00 AM, 3 out of 5 residents stated that the dining room and the activity room upstairs were always cold. One of the five residents stated that the cold was uncomfortable as some of us take blood thinners. Observation of 2nd floor South Dining Room on 10/24/23 11:41 AM, observation of thermostat that was located on the interior wall dividing the dining room, thermostat read 68 degrees. Confidential interview/observation on 10/24/23 11:46 AM, resident was observed sitting at a table in the 2nd floor South Dining Room wearing a long-sleeved shirt and a sweater cardigan, and a double ply flannel clothing protector: Resident stated it was always cold in the dining room. Resident said It's never hot! I think it is the air conditioner, they keep it going. Observation of 2nd floor South Dining Room on 10/25/23 08:13 AM, observation of thermostat that was located on the interior wall dividing the dining room, thermostat read 69 degrees. Interview with MS on 10/25/2023 at 8:06 AM, MS stated that the air conditioning is on an automated system, which he controls. MS stated MS went to the 2nd floor South Dining room where he observed the thermostat to read 69.5 degrees. MS stated he is not sure what the comfortable temperatures for the facility but would guess between 69 degrees and 78 degrees. Interview with MS on 10/25/2023 at 8:40 AM, stated that he turned the temperature up 3 degrees for both dining rooms on the south side. Interview with LVN C on 10/25/2023 at 9:49 AM, LVN C was on the second floor near the 2nd floor dining room. LVN C stated that she has had some residents recently complain about the cold air; LVN C stated she offers residents blankets or sweaters when they complain. Interview with DON on 10/25/2023 at 9:53 AM, DON stated that she had been told that residents have complained about the coldness in the upstairs Activity Room and upstairs dining room. Record Review of Quality-of-Life Policy, subject: Environment, Closet Space, Lighting, Temperature and Sound Level dated 1/15/2019 revealed that the comfortable and safe temperature level ranges between 71-81 degrees Fahrenheit will be maintained by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident's assessment accurately reflected the resident's status for 1 (Resident #19) of 18 residents reviewed for accurate assessments. The facility failed to correctly code bed rails for Resident#19. The facility had bed rails incorrectly coded as restraints on the MDS Assessments of Resident #19. This failure could place residents at risk of receiving inaccurate/unnecessary levels of care. Findings included: Record review of Resident #19's face sheet dated 10/24/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), hypertension (high blood pressure), and generalized muscle weakness. Record review of Resident #19's care plan dated 10/11/23 revealed a focus area of [Resident #19] is at risk for impaired skin integrity related to limited mobility. One of the interventions related to this focus area was, Side rails for positioning/support and/or comfort. A second focus area revealed, [Resident #19] requires assistance from staff with performance of daily living . One of the interventions for this focus area was, [Resident #19] may use ½ rails for mobility, positioning, and comfort. Record review of Resident #19's Quarterly MDS completed on 10/10/23 revealed a BIMS of 15 which indicated intact cognition. Section GG of the MDS revealed Resident #19 was independent across all ADLs except for upper body dressing where she required partial assistance. Section P of the MDS coded Resident #19's bed rail as a restraint used less than daily. Record review of Resident #19's active orders dated 10/24/23 revealed an order of, Side rails in use for positioning, mobility and/or comfort with a date of 11/23/22. Record review of Resident #19's Bed Rail Assessment revealed Resident #19 had expressed a desire to have Side Rails/Assist Bar for safety and/or comfort. This form was signed by Resident #19 and an LVN from the facility and dated 10/03/23. During an observation and interview on 10/23/23 at 12:38 PM Resident #19 was in her room sitting in her w/c next to her bed. She had bed rails up on both sides of the top half of her bed. She stated she used the bed rails to position herself in bed. During an observation on 10/24/23 at 09:46 AM Resident #19 was asleep in her bed with bed rails up on both sides of the top half of the bed. During an observation and interview on 10/25/23 at 08:14 AM Resident #19 was sitting in her w/c next to her made bed. The bed rail on the right side of her bed was still up but the left side was down. Resident #19 stated she used her bed rails every day and she was able to move them up and down as desired. She said, In fact, this morning I put that one down [gesturing to the left side bed rail]. During an interview on 10/25/23 at 08:20 AM MDS RN was asked why Section P of the MDS for Resident #61 and Resident #19 coded bed rails as a physical restraint she stated, I didn't do those. When asked who does the MDS assessment she said she usually does them, but RN N helped her occasionally. She said, She [RN N] is my backup for MDS. MDS RN said RN N believed if the resident had bed rails they had to be coded as a restraint. MDS RN said, We had a disagreement about that. During an interview on 10/25/23 at 08:38 AM RN N was asked when a bed rail was a restraint and she stated, I don't really think it is a restraint, it's just the RAI manual, and I think it is important to document that. I just follow the RAI instructions. During an interview on 10/25/23 at 09:51 AM DON stated, regarding residents who had bedrails coded as restraints on the MDS, I was just talking to MDS RN about that because we use them [bed rails] as enablers and back up coordinator [RN N] thinks you have to code them as restraints. DON stated the facility did not use bed rails as restraints. She said a possible negative outcome of having inaccurate medical records was, Well, inaccurate care of the resident, specifically restraint related, looking at potential for injuries affecting their dignity and their rights. During an interview on 10/25/23 at 10:28 AM MDS RN stated a possible negative outcome of having bedrails incorrectly coded as restraints was residents could get entangled in the bed rail and choke or get strangled. Record review of facility policy titled, Restraint Policy and dated 09/01/16 revealed in part: [Name of facility] makes every effort to maintain a restraint free environment. The Facility will prohibit the use of restraints for discipline or convenience and will limit the use of restraints; either physical or chemical, to circumstances in which the resident's medical symptoms warrant the use of a restraint. Record review of facility policy titled, Clinical Records, Contents and Service Requirements Policy and dated 02/01/2017 revealed in part: . The Facility will maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices that are: . 2. Accurately documented . Record review of Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI) revealed in part: . Definition Physical Restraints Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 3 Medication Carts and one Treatment Cart. [DATE] at 8:59AM on Second floor NW Medication Cart, 3 loose medications were found in the second drawer of the Medication Cart 1 expired medication found in Treatment Cart located on the first floor NW Hall, in a room labeled 'Linen Closet.' 1 vial Insulin found open with no expiration date on Medication Cart #2 second floor SW Hall. This failure could place 81 residents receiving medications at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident which could lead to exacerbation of their disease process and deterioration in general health. Findings included: During observation and interview beginning on [DATE] at 08:59AM of Medication Cart #1 for first floor NW Hall with LVN F identified the three loose medications as Aricept, Coreg, and Requip. LVN F was asked what would be done with pills upon discovery. She stated they would be placed in the medication room in a gray liquid that will destroy the medications. During observation on [DATE] at 09:16AM of the Treatment Cart for first floor NW Hall with LVN F, expired medication TP CRM Gabapentin-DIC-LIDO-PRIL expired on [DATE]. LVN F took the medication and placed it with the medications to be destroyed. During observation/interview on [DATE] at 10:43 AM of Medication Cart #2 on second Floor SE Hall with LVN B, observation of drawer holding insulin, found 1 vial of Humalog Insulin, with an opened date penned in as [DATE], but without an expiration date. When LVN B was asked why there was an open date written on the vial, but no expiration date she responded, We don't have to put the expiration date on them all the time. On [DATE] at 1:00 PM an interview with DON, she was asked what could be a negative outcome for a patient who received insulin that was expired? DON responded, Don't know the efficacy. On [DATE] at 1:10 PM an interview with LVN G she was asked what could be a negative outcome for a patient who received insulin that was expired? She responded, Make them sick. May not work so good. On [DATE] at 1:19 PM an interview with LVN H she was asked what could be a negative outcome for a patient who received insulin that was expired? She responded, An adverse reaction. On [DATE] at 2:59 PM requested from the DON for the facilities medication policies, as she was delivering the policy on Drug Security. DON was specifically asked for a policy on Expiration Labeling of Medications. She stated, The facility has no policy on expiration labeling of medications. Surveyor did not receive any other medication policies prior to exit. Record Review of facility policy revealed: Policy Section/#: Pharmacy Services #L-6 Drug Security Policy Date: [DATE] Policy: Medications must be properly labeled and stored in a locked medication room, cabinet, or cart. Only authorized personnel have access to the keys. Record Review of Pharmaceutical Company that manufactures Humalog Insulin reflected on their web site on [DATE] states: 'Opened Humalog vials, prefilled pens, and cartridges must be thrown away 28 days after first use, even if they still contain insulin.'

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 25 resident (Resident #232) reviewed for infection control. 1. The facility failed to ensure that contact precaution signage was in place for Resident #232 who was positive for C-diff upon admission. 2. The facility failed to implement isolation precautions for a Resident #232 who was positive for C-Diff. This failure could place the residents at an increased risk for potentially exposing them to infections, which could lead to abdominal cramping, lethargy, increased risk for diarrhea, dehydration, and feelings of isolation. Findings included: Observation on 10/23/23 8:30 AM revealed that Resident #232 was not in room. Asked CNA where patient was, she stated he was eating breakfast but will be back in room after breakfast. Observation on 10/23/23 09:10 AM No posting was observed on room door or wall in hallway stating any type of contact precautions needed to be taken before entering room. Resident #232 was sitting in recliner with blanket over him, Resident #232 opened eyes but did not respond when spoken to and was asked if he would allow an interview. He closed his eyes and did not respond. Interview on 10/23/23 03:31 PM with DON stated Resident #232 was still positive for C-diff. DON stated, The last I heard he was having some loose stools and we still have him on contact precautions. Observation on 10/23/23 03:32 PM revealed outside of room Resident #232, there is a 3-drawer cabinet with gloves on top. Once the drawers were open the top drawer is empty, there are gowns in the second drawer, and third drawer has biohazard bags. There was no signage on the door stating that the resident is on contact precautions for C-Diff. Interview on 10/23/23 03:39 PM with LVN H, she stated that resident does have C-Diff. LVN H stated that since the infection was in the stool, there was no need for signage on the door. LVN H did state that she did talk to the manager about this the lack of signage this morning with no change taking place. LVN H stated that a negative outcome would be the chance of others getting c-diff. Interview on 10/23/23 03:52 PM with Resident #232's family member, she stated that Resident #232 has been positive for c-diff since his admission to facility on 10/13/2023. Family member stated that resident goes to the dining room for every meal in the dining room and the staff was getting him ready to attend the evening meal. Observation on 10/23/2023 3:55 PM Resident #232 was then wheeled out of his room by CNA J and placed at table with family member. Interview on 10/23/23 03:57 PM with CNA J stated that she knows that c-diff is contagious and communicable. What would a negative outcome be if the resident was positive, CAN J stated that it could be given to another resident. Record Review on 10/23/23 04:17 PM of Resident #232's physicians orders revealed an order for Continue contact isolation x 48 hours or until asymptomatic. Interview on 10/23/23 04:26 PM with DON stated that Resident #232 was admitted with c-diff, but no further lab work has been performed in confirming or denying resident was still positive for c-diff. Observation on 10/24/23 07:45 AM revealed sign on door stating Stop please see nurse before entering there was no signage for isolation or contact precautions in place. Interview on 10/24/23 08:12 AM with Resident #232's family member revealed that resident was in no condition to leave his room for the first few days, after his admittance to facility, due to being too weak and unable to leave his room. Family member stated, We really thought we were going to lose him. Family member stated that there was no signage on the door for the first few days that Resident #232 was in facility. Family member stated that she has not observed any hand hygiene for her husband while she was in the facility. She was in facility every day at different times and for extended periods of time. She stated that she has seen staff wash his face, but not his hands. Observation on 10/24/23 08:20 AM Resident #232 was in dining room eating breakfast. Resident #232 requested more biscuits and gravy. Staff got it for him. Interview on 10/24/23 10:27 AM with MD, stated that if the resident was free from symptoms (diarrhea, cramps, lethargic) and the resident was being actively treated there should be no concern regarding the resident being around other residents. Interview on 10/24/23 01:33 PM with LVN J stated that hand hygiene that was performed for a resident with c-diff was to be performed with hot soapy water, LVN J stated that mask, gown, gloves, and shield if needed are to be used. PPE is donned outside of room and doffing of PPE takes place inside of the room. Interview on 10/24/23 01:38 PM with CNA K, stated that hot soapy water was to be used when dealing with a resident with c-diff. Alcohol-Based Hand Sanitizer was not to be used, it won't work. PPE is to be put on before entering the room and taken off right inside the door of the residents room. Interview on 10/25/2023 with DON during exit conference did confirm that Resident #232 was still positive for C-diff, secondary to still having loose stools. Record review of facility policy titled Infection Control with a Subject of Handwashing by residents dated 12/14/2016 states but not limited to the following: POLICY: Hand washing by residents is an important part of the infection control program. Residents are encouraged to wash their hands before meals, after using the toilet, and at other times as indicated by the general policy on hand washing. In the case of the non-ambulatory resident, the use of waterless hand cleaners may be appropriate and effective. Education of alert resident, family members and visitors should emphasize the importance of hand washing. Staff will assist residents as needed with hand washing. Record review of facility policy titled Infection Control with a Subject of Clostricium Difficile, dated 12/14/2016 states but not limited to the following: POLICY: Residents with diarrhea of unknown origin or cause will be treated as if contagious in nature. Employees will practice Universal Precautions when coming in contact with any blood or body fluids/waste. Clostridium Difficile (C. Difficile) is a spore forming bacillus that produces toxins that cause gastrointestinal illness. C Difficile can cause asymptomatic colonization or produce illness ranging from severe diarrhea with pseudomembranous colitis to toxic megacolon complicated by bowel perforation and death. C. Difficile infection occurs most often when the following constellation of events has occurred: I. The resident has been treated with antibiotics at some time in the preceding 8 weeks 2. The resident has been exposed to and colonized by C. Difficile 3. The resident's immune system alone cannot suppress the spread of C. Difficile. A. Signs and symptoms: 1. Mild to moderate diarrhea, sometimes accompanied by lower abdominal cramping; 2. Occurs most often when the resident has been treated with antibiotics at some time in the preceding 8 weeks. 3. Stool; typically very foul smelling and may have a green to dark brown appearance. 4. Diagnosed by culturing stool. 5. May be asymptomatic B. Transmission: 1. . Direct or indirect contact: a. Person to person via hands; b. Environmental surfaces; can persist for long periods on surfaces and is resistant to conventional cleaning and disinfection. C. Clostridium Difficile should be considered as the cause of the diarrhea, especially with residents who have a tube feeding, have received antibiotics or other anti-neoplastics within the past (2) weeks, and those who have had Closttridium Difficile. Record review of facility policy titled Infection Control with a Subject of Transmission-Based Precautions, dated 12/27/2016 states but not limited to the following: POLICY: Transmission-based precautions are used for resident who are known to be, or suspected of being infected or colonized with infectious agents, including pathogens that require additional control measure to prevent transmission. T11e Facility will use standard approaches, as defined by the CDC for transmission-based precautions: airborne, contact and droplet precautions. Personnel will be notified of the particular type of precautions being utilized. Standard/ Universal precautions will be used in conjunction with transmission-based precautions Record review of facility policy titled Infection Control with a Subject of Contact Precautions, dated 12/13/2016 states but not limited to the following: POLICY: Contact isolation is initiated to prevent the transmission of highly transmissible or epidemiologically important infections or colonization. Diseases or conditions included in this category are spread by close or direct contact with infective material. This category requires the use of personal protective equipment according to the task being done. Microorganisms can be transmitted by direct contact with the resident (skin to skin) or indirect contact (touching) with environmental surfaces or resident care items in the resident's environment. A. Examples of such illnesses include: I. Gastrointestinal, respiratory, skin or wound infections or colonization with multi-drug resistant bacteria judged by the infection control program, based on current state, regional or national recommendations to be of special clinical and epidemiologic significance. 2. Enteric infections with a low infectious dose of prolonged environmental survival including; a. Clostridium difficile b. Enterohemorrhagic Escherichia Coli c. Shigella d. Hepatitis A e. Rotavirus .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail for 7 (Residents #4, #6, #10, #17, #19, #23, and #61) of 18 residents reviewed for bed rails. The facility placed bed rails on the beds of Residents #4, #6, #10, #17, #19, #23, and #61 on the day the residents were admitted without attempting other interventions first. This failure could place residents at risk of entrapment or injury due to bed rails. Finding included: Record review of Resident #4's face sheet dated 10/24/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), hypertensive heart disease (heart problems that occur because of high blood pressure), and chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #4's care plan dated 09/13/23 revealed a focus area indicating Resident #4 was at risk for impaired skin integrity. One of the interventions related to this focus area was the use of side rails for positioning/support and/or comfort. This intervention had an initiation date of 09/01/23. The care plan revealed a second focus area which stated, [Resident #4] requires assistance from staff with performance of daily living . One of the interventions related to this focus area was, [Resident #4] may use ½ rails for positioning, mobility and/or comfort. Record review of Resident #4's admission MDS completed on 09/12/23 revealed a BIMS of 13 which indicated intact cognition. Section G of the MDS revealed Resident #4 required extensive assistance by one to two staff members across all ADLs. Record review of Resident #4's active orders dated 10/24/23 revealed no order for side rails. Record review of Resident #4's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. Low bed, frequent staff monitoring, assisted toileting, and reminders to use call light had been checked as Attempted but Failed. Resident #4's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was signed by Resident #4's POA and dated 08/31/23. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given. This signature line had a place for the nurse to sign and indicate who gave consent on what date at what time. This line was unsigned. Record review of Resident #4's Bed Rail Assessment revealed Resident #4 was non-ambulatory, had displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed, had difficulty with balance or poor trunk control, and expressed a desire to have Side Rails/Assist Bar for safety and/or comfort. This form was signed by Resident #4's POA and an RN from the facility and dated 08/31/23. Record review of Resident #6's face sheet dated 10/25/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, fracture of neck, fracture of arm, fracture of leg, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), and senile degeneration of the brain (a state of mental, emotional, and social deterioration resulting primarily from degeneration of the brain in old age). Record review of Resident #6's care plan dated 10/04/23 revealed a focus area of [Resident #6] requires assistance from staff with performance of daily living related to self care deficit . One of the interventions related to this focus area was, [Resident #6] may use ½ rails for mobility, positioning, and comfort. This intervention had an initiation date of 03/14/23. The care plan revealed another focus area of [Resident #6] is at risk for impaired skin integrity related to impaired mobility . One of the interventions related to this focus area was, Side rails for positioning/support and/or comfort. This intervention had an initiation date of 03/14/23. Record review of Resident #6's quarterly MDS completed on 10/04/23 revealed a BIMS of 3 which indicated severely impaired cognition. Section GG of the MDS revealed Resident #6 was dependent across all ADLs except for eating where she required partial to moderate assistance. Record review of Resident #6's active orders dated 10/25/23 revealed an order for Side rails in use for positioning, mobility and/or comfort. The order date was 03/13/23. Record review of Resident #6's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. The options of low bed, frequent staff monitoring, assisted toileting, and reminders to use call light had been checked as Attempted but Failed. Resident #6's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was blank. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given by [Resident #6's POA] date 03/13/23 time 1100 [11 AM] This signature line had a place for the nurse to sign and was signed by a facility nurse. Record review of Resident #6's Bed Rail Assessment revealed Resident #6 was non-ambulatory, had fluctuation in her level of consciousness, had a history of fall, displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed, had difficulty with balance or poor trunk control, and expressed a desire to have Side Rails/Assist Bar for safety and/or comfort. This form was signed by Resident #6's POA and an LVN from the facility and dated 03/13/23. Record review of Resident #10's face sheet dated 10/24/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, generalized osteoarthritis (degenerative joint disease), hypertension (high blood pressure), and repeated falls. Record review of Resident #10's care plan dated 09/13/23 revealed a focus area indicating Resident #10 was at risk for impaired skin integrity. One of the interventions related to this focus area was the use of side rails for positioning/support and/or comfort. The care plan revealed a second focus area which stated, [Resident #10] requires assistance from staff with performance of daily living . One of the interventions related to this focus area was, [Resident #10] may use ½ rails for mobility, positioning, and comfort. Record review of Resident #10's Significant Change MDS completed on 09/11/23 revealed a BIMS of 12 which indicated moderately impaired cognition. Section G of the MDS revealed Resident #10 required extensive assistance by one staff member for bed mobility, transfer, locomotion on unit, locomotion off unit, dressing, and toilet use. Resident #10 required supervision by one staff member for walking in her room, walking in the corridor, eating, and personal hygiene. Record review of Resident #10's active orders dated 10/24/23 revealed an order for Side rails for positioning, comfort and mobility with an order date of 11/16/22. Record review of Resident #10's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. No options were checked on the form. Resident #10's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was signed by Resident #10 and dated 01/28/20. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given. This signature line had a place for the nurse to sign and indicate who gave consent on what date at what time. This line contained only the nurse's signature and was dated 01/28/20. Record review of Resident #10's Bed Rail Assessment revealed Resident #10 was non-ambulatory, had a fluctuating level of consciousness, had alteration in safety awareness due to cognitive decline, had a history of falls, had difficulty with balance or poor trunk control, and expressed a desire to have Side Rails/Assist Bar for safety and/or comfort. This form was signed by Resident #10's family member and an RN from the facility and dated 09/06/23. Record review of Resident #17's face sheet dated 10/24/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, paraplegia (impairment in motor or sensory function of the lower extremities), hypertension (high blood pressure), and age-related physical debility. Record review of Resident #17's care plan dated 10/17/23 revealed a focus area indicating Resident #17 required assistance from staff with Functional Abilities and performance of daily living related to . limited mobility. One of the interventions related to this focus area was, [Resident #17] may use ½ rails for mobility, positioning, and comfort. Record review of Resident #17's Quarterly MDS completed on 07/17/23 revealed a BIMS of 99 which indicated severely impaired cognition. Section G of the MDS revealed Resident #17 required extensive assistance by one to two staff members for bed mobility, locomotion, dressing, and personal hygiene. She was totally dependent on two staff members for transfer and toilet use and required set up help only for eating. Record review of Resident #17's active orders dated 10/24/23 revealed an order of, Side rails in use for positioning, mobility and/or comfort with an order date of 11/22/22. Record review of Resident #17's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. Low bed, frequent staff monitoring, assisted toileting, and reminders to use call light had been checked as Attempted but Failed. Resident #17's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was signed by Resident #17's family member and dated 04/05/21. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given. This signature line had a place for the nurse to sign and indicate Resident #17's family member gave consent on 04/05/21 at 16:30 [04:30 PM]. This line was signed by a nurse. Record review of Resident #17's Bed Rail Assessment revealed Resident #17 was non-ambulatory, had fluctuation of consciousness, had alteration in safety awareness due to cognitive decline, had displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed, had difficulty with balance or poor trunk control, was visually challenged, and expressed a desire to have Side Rails/Assist Bar for safety and/or comfort. This form was signed by Resident #17 and an LVN from the facility and dated 10/08/23. Record review of Resident #19's face sheet dated 10/24/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), hypertension (high blood pressure), and generalized muscle weakness. Record review of Resident #19's care plan dated 10/11/23 revealed a focus area of [Resident #19] is at risk for impaired skin integrity related to limited mobility. One of the interventions related to this focus area was, Side rails for positioning/support and/or comfort. A second focus area revealed, [Resident #19] requires assistance from staff with performance of daily living . One of the interventions for this focus area was, [Resident #19] may use ½ rails for mobility, positioning, and comfort. Record review of Resident #19's Quarterly MDS completed on 10/10/23 revealed a BIMS of 15 which indicated intact cognition. Section GG of the MDS revealed Resident #19 was independent across all ADLs except for upper body dressing where she required partial assistance. Section P of the MDS coded Resident #19's bed rail as a restraint used less than daily. Record review of Resident #19's active orders dated 10/24/23 revealed an order of, Side rails in use for positioning, mobility and/or comfort with a date of 11/23/22. Record review of Resident #19's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. The options of low bed, frequent staff monitoring, assisted toileting, assistive device at bedside and reminders to use call light had been checked as Attempted but Failed. The option floor mats had been checked as Considered Inappropriate. Resident #19's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was signed by Resident #19's POA and dated 03/31/22. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given. This signature line had a place for the nurse to sign and indicate who gave consent on what date at what time. This line was signed by a nurse and dated 03/31/23. Record review of Resident #19's Bed Rail Assessment revealed Resident #19 had expressed a desire to have Side Rails/Assist Bar for safety and/or comfort. This form was signed by Resident #19 and an LVN from the facility and dated 10/03/23. Record review of Resident #23's face sheet dated 10/24/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, psoriatic arthritis mutilans (an inflammatory illness that results in stiff joints, joint pain, and ultimately bone loss), Raynaud's syndrome (a medical condition that affects the small arteries in your fingers and toes causing a reduction in blood flow), age-related cognitive decline, and venous insufficiency (condition in which the flow of blood through the veins is blocked, causing blood to pool in the legs). Record review of Resident #23's care plan dated 08/08/23 revealed a focus area of, [Resident #23] requires assistance from staff with performance of daily living . One of the interventions related to this focus area was,[Resident #23] may use ½ rails for mobility, positioning, and comfort. Record review of Resident #23's Quarterly MDS completed on 08/07/23 revealed a BIMS of 15 which indicated intact cognition. Section G of the MDS revealed Resident #23 required extensive assistance by one to two staff members across all ADLs except for eating where she required set up help and supervision only. Record review of Resident #23's active orders dated 10/24/23 revealed an order of, Side rails in use for positioning, mobility and/or comfort. The order was dated 11/22/22. Record review of Resident #23's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. The options of low bed, frequent staff monitoring, and reminders to use call light had been checked as Attempted but Failed. Resident #23's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was signed by Resident #23's family member and dated 07/14/20. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given. This signature line had a place for the nurse to sign and indicate who gave consent on what date at what time. This line was signed by a nurse and dated 07/14/20. Record review of Resident #23's Comprehensive Assessment revealed Resident #23 requested side rails and preferred for the rails to be raised when she was in bed. Record review of Resident #61's face sheet dated 10/24/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), paroxysmal atrial fibrillation (irregular heartbeat), congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), hypertension (high blood pressure) and a history of falling. Record review of Resident #61's care plan dated 10/17/23 revealed a focus area which stated, [Resident #61] requires assistance from staff with performance of daily living . One of the interventions related to this focus area was, [Resident #61] may use ½ rails for mobility, positioning, and comfort. This intervention had an initiation date of 01/04/23. The care plan revealed another focus area of, [Resident #61] needs routine licensed services . One of the interventions related to this focus area stated, Requires side rails for mobility and comfort. A third focus area revealed, [Resident #61] is at risk for impaired skin integrity related to impaired mobility and incontinence. One of the interventions related to this focus area was, Side rails for positioning/support and/or comfort. Record review of Resident #61's Quarterly MDS completed on 10/17/23 revealed Resident #61 had moderately impaired cognitive skills for daily decision making and a short and long-term memory problem. Section GG of the MDS revealed Resident #61 was dependent on staff for toileting, bathing, lower body dressing, putting on and taking off footwear, personal hygiene, transfers, and bed mobility. Resident #61 needed partial assistance for oral hygiene and upper body dressing and was independent in eating. Section P of the MDS coded Resident #61's bed rail as a restraint used less than daily. Record review of Resident #61's active orders dated 10/24/23 revealed and order for side rails for mobility, positioning, and comfort with an order date of 01/03/23. Record review of Resident #61's, Informed Consent for use of Side Rail revealed in part: The interdisciplinary Team along with your physician has determined that a side rail is appropriate. The facility has assessed and determined that side rails will promote bed mobility and independence or individual resident has stated a preference to have side rails in place. The form contained a graph with alternatives to bed rails that had been Attempted but Failed or were Considered Inappropriate. Low bed, frequent staff monitoring, assisted toileting, and reminders to use call light had been checked as Attempted but Failed. Resident #61's name and room number were listed at the top of page one. Page two of the form contained two signature lines. The first stated The RISKS and BENEFITS of side rails have been explained to me. I understand and I consent to the use of side rails. This signature line was illegibly signed and dated 01/03/23. The second signature line stated, This Informed Consent for use of Side Rails was read to the legal representative with understanding and verbal consent for use of side rails given. This signature line had a place for the nurse to sign and indicate who gave consent on what date at what time. This line was signed by a facility nurse and the areas for who gave consent and what day at what time contained the same nurse's name, 01/03/23, and 11:30 a.m. respectively. Record review of Resident #61's Bed Rail Assessment revealed Resident #61 was non-ambulatory, had fluctuation in level of consciousness, had alteration in safety awareness due to cognitive decline, displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed, and expressed a desire to have Side Rails/Assist Bar for safety and/or comfort. This form was signed by Resident #61's family member and an LVN from the facility and dated 10/12/23. During an observation on 10/23/23 at 09:04 AM Resident #6's bed had bed rails up on both sides of the top half of the bed. During an observation on 10/23/23 at 09:24 AM Resident #23's bed had bed rails up on both sides of the top half of the bed. During an observation on 10/23/23 at 11:12 AM Resident #4 was in bed with bed rails up on both sides of the top half of her bed. During an observation and interview on 10/23/23 at 12:38 PM Resident #19 was in her room sitting in her w/c next to her bed. She had bed rails up on both sides of the top half of her bed. She stated she used the bed rails to position herself in bed. During an observation and interview on 10/23/23 at 02:24 PM Resident #6 was laying in her bed on her back under a blanket. The bed was in the lowest position and fall mats were on either side of the bed. Bed rails were up on both sides of the top of the bed. When asked if she used her bed rails, Resident #6 stated, That's my bed. When asked again if she used her bed rails, Resident #6 said, You can have it. During an observation on 10/23/23 at 02:35 PM Resident #61 was in her bed with bed at lowest position and bed rails up on both sides of the top of her bed. When asked if she would be able to put the bed rails down if she needed to she said she could if she had the strength to do it but she did not feel like she had the strength at that time. During an observation and interview on 10/23/23 at 02:43 PM Resident # 10 was lying in bed with bed rails up on both sides of the bed. Resident #10 stated she loved the bed rails because they helped her to feel secure. During an observation on 10/24/23 at 09:43 AM Resident #6 was lying in bed. Bed was in lowest position and bed rails were up on both sides of the top half of the bed. During an observation on 10/24/23 at 09:46 AM Resident #19 was asleep in her bed with bed rails up on both sides of the top half of the bed. During an observation on 10/24/23 at 11:08 AM Resident #17 was receiving catheter care in her bed with bed rails upright on both sides of the top half of the bed. Resident #17 used the rails to help herself turn from side to side. During an observation on 10/24/23 at 11:40 AM Resident #17 was seated in her w/c next to her bed. Bed rails were up on both sides of the top half of the bed. During an observation and interview on 10/25/23 at 08:14 AM Resident #19 was sitting in her w/c next to her made bed. The bed rail on the right side of her bed was still up but the left side was down. Resident #19 stated she used her bed rails every day and she was able to move them up and down as desired. She said, In fact, this morning I put that one down [gesturing to the left side bed rail]. During an observation on 10/25/23 at 08:16 AM Resident #17 was asleep in her bed and bed rails were up on both sides of the top half of her bed. During an interview on 10/25/23 at 09:38 AM LVN A stated she had worked for the facility for 12 years. She stated nurses were responsible for filling out bed rail consent forms if we either get a new resident or they have the criteria for bed rails. When asked how the interventions on the consent form were attempted but failed the same day the resident was admitted she said, I guess there is no way we tried them unless the family said they were tried. She stated if any of the interventions in the Attempted but Failed section of the consent form were checked it was because the family said they had been tried. During an interview on 10/25/23 at 09:42 AM LVN C stated she had worked for the company for 20 years. She said bed rail consent forms were filled out by the nurses on admission. When asked about the Attempted but Failed section of the form she said, I don't usually put that on there. I usually explain the pros and cons and of the bed rails. I don't put anything in that section. During an interview on 10/25/23 at 09:42 AM LVN B stated she had worked for the company for 9 years. She said bed rail consents were filled out by the nurses on admission. She stated residents often wanted bed rails as enablers. During an interview on 10/25/23 at 09:47 AM LVN G stated she had worked for the facility for two years. She said nurses were responsible for filling out the bed rail consents when residents were admitted . She said, I usually put that they [residents] requested them [bed rails] on the consent form. During an interview on 10/25/23 at 09:47 AM LVN M stated she had worked for the facility for one year. She said nurses were responsible for filling out the bed rail consents upon admission. She said, A lot of them [residents] request them for safety. During an interview on 10/25/23 at 09:51 AM DON stated she knew about some of the residents having physical restraints coded in the MDS for bedrails. She stated, I was just talking to MDS RN about that because we use them as enablers and back up coordinator thinks you have to code them as restraints. DON stated nurses were responsible for getting bed rail consents filled out. She said, Usually we do it on admission. We visit with the resident and family and ask them when they come in and we get the initial assessment from them and go from there. When asked what the consent form meant when it stated an intervention was Attempted but Failed DON stated, I think during that initial day is when they will try those things it is probably not enough time depending on your view point. When asked how multiple interventions could be attempted but fail on the same day a resident is admitted to the facility, DON stated, I guess that is what we get from the resident or their family member during admission interview. When asked for possible negative outcomes for not attempting other interventions before using bed rails DON stated, Well, you are not using the least restrictive option, I guess. You are not trying something else instead of going to what may be your last resort. During an interview on 10/25/23 at 10:26 AM LVN G was asked if she knew what the facility policy on bed rails stated. She responded, Um .no. During an interview on 10/25/23 at 10:28 AM LVN B was asked if she knew what the facility policy on bed rails stated. She responded, About bed rails in what way? When reminded that the first line of the policy stated bed rails would not be available to residents upon admission she stated, Oh yeah, they [bed rails] are tied down with straps until the resident's family signs [the bed rail consent form] and then we can cut them [the straps]. During an interview on 10/25/23 at 10:33 AM DON was asked if the facility's nurses had received training on the facility's bed rail policy. She stated, You know, I'm not sure. I mean we discuss it, but I don't know if I've ever brought the policy out. I mean, it [a copy of the policy] is in each unit. Record review of facility policy titled Protocol: Side Rails and dated 01/16/19 revealed in part: On admission to [name of facility] side rails will not be available. Alternatives will be utilized and documented. (See informed consent for alternative suggestions.) Charge Nurse will: Document alternative interventions used by facility Assess resident for the use of side rails . If assessment shows side rail use is appropriate for resident to improve mobility or meet their preference, [NAME][TRUNCATED]

Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure stored food was properly labeled, dated, and stored. These failures placed all residents who ate food served by the kitchen at risk of food-borne illness. Findings included: An observation of the facility walk-in cooler on 10/23/23 at 8:07AM revealed: 2 watermelons, no date received. 1 Food Service box of head of Romaine lettuce; open to air; no date. 2 8-count packages of pancakes; no label; no date. 1 6-count box of thawed pork tenderloin; no label; no date. 2 boxes, 24-count each, blueberry muffins, no label; no date. 3 thawed briskets; no label; no date. 2 13-ounce bottles of mint flavoring; no date. An observation of the dry pantry on 10/23/23 at 8:33AM revealed: 3 red potatoes laying on the floor of the pantry. 1 50-pound box of red potatoes; sitting on floor; open; no date. 1 50-pound box of white potatoes; sitting on floor; open; no date. 3 12-count packages of hot dog buns, expiration date 9/29/23. 2 12-count packages of hot dog buns, expiration date 10/17/23. An observation of the freezer on 10/23/23 at 8:51AM revealed: 7 ½ Food Service bags of French fries, no date. 1 Food Service bag of tater tots; open to air; no date. 1 box 12-count frozen fudge bar treats; no date. 1 Food Service bag of cauliflower bites; open to air; no date. In an interview on 10/23/23 at 9:18AM, the Dietary Supervisor stated all food should be labeled and dated; there should be no bags of fresh or frozen food, open to air. The DS stated foods should be labeled and dated as soon as they come in or are taken out of their box. The DS stated all kitchen staff know they should secure foods and/or date foods when storing. The DS stated that residents could become sick if these standards are not followed. Record review of the facility's policy entitled Food Storage, Food Safety in Display and Service Policy with a revised date of 1/16/17, documented: The receiving date is written on the top of all food cases or containers. All food in its original containers, will have the expiration date written on it. Record review of the USDA food Code dated 2022, revealed, in part: 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakable recognize, such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-202.15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure resideents the right to be free from abuse and/or neglect for 1 (Resident #1) of 7 residents reviewed for abuse and/or neglect. CNA A yelled or spoke loudly at Resident #1. The facility's failure to provide a safe environment free of verbal abuse places residents at risk of psychosocial harm. Findings included: Record review of Resident #1's face sheet, dated 8/3/23, revealed Resident #1 is a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included but are not limited to unspecified dementia with other behavioral disturbance (deterioration of memory, language, and other thinking abilities), systemic lupus erythematosus (autoimmune disease possibly causing skin rash, erosion of joints or kidney failure), hyperlipidemia (high cholesterol), hypothyroidism (underactive thyroid gland). Record review of Resident #1's MDS (Minimum Data Set), Section C (cognition), dated 6/1/23, revealed an absent BIMS (Brief Interview of Mental Status) score due to question C0100 being answered with 0. No (Resident is rarely/never understood). Record review of Resident #1 care plan, dated 3/8/23, reflected a goal of Behaviors: Impaired social Interaction: Resident #1 has impaired social interaction as evidenced by swinging and cursing at staff and refusing care. Record review of Resident #1 progress notes revealed incident of verbal abuse between Resident #1 and CNA A on July 25th, 2023 was not documented in patient chart. Record review of written witness statement signed by CNA B, dated 7/25/23, revealed that Resident #1 was standing in front of the television and CNA A approached Resident #1 yelling to sit down and take the book CNA A was offering. Resident #1 slapped the book out of CNA A's hand and CNA B told CNA A to leave her alone. CNA B also identified LVN A advised CNA A to leave resident alone. Record review of written witness statement signed by LVN A, dated 7/25/23, revealed LVN A heard CNA A speaking to Resident #1 in a loud voice. When CNA A offered Resident #1 a book, CNA A spoke loudly to Resident #1 and stated Sit down. Here. Here. LVN A had written that she verbally instructed CNA A to leave Resident #1 alone and walk away. Record review of written witness statement signed by LVN B, dated 7/26/23, revealed CNA A yelled at Resident #1 during incident and stated, No ma'am. Leave her alone. She isn't doing anything to you. Come sit down. LVN B revealed LVN A asked CNA A to leave the resident alone. During an interview with CNA A on 8/2/23 at 3:42 PM, CNA A stated abuse and neglect was verbal, physical, sexual, and financial. CNA A stated she received trainings regularly. CNA A revealed during interview that a negative outcome could be a down fall for the resident and the resident can be severely injured. The family should be involved, physical harm, and emotional harm. Interview with CNA B on 8/3/23 at 10:17 AM revealed that CNA A began yelling at Resident #1 after incident of resident physically chasing another staff member into another resident's room on 7/25/23. CNA B identified that Resident # 1 was not aggressive at the time CNA A began yelling at the resident. CNA B confirmed CNA B and LVN A told CNA A to leave Resident #1 alone. Interview with LVN A on 8/3/23 at 10:27 AM, revealed LVN A had seen CNA A yelling at Resident #1 stating here, here, here while waving a book in Resident #1's face. LVN A reported she told CNA A to walk away. LVN A reported that CNA B verbally told CNA A to leave her alone. Interview with DON on 8/3/23 at 11:59 AM stated that the resident was assessed after the incident and appeared smiling, calm, wasn't crying, and did not seem anxious. Interview with CNA A on 8/3/23 at 1:01 PM, stated CNA A knew where they went wrong in the situation by using a stern, raised voice. CNA A verified that abuse and neglect can be a situation a person is put in against their will whether it is a sexual, verbal, or financial situation. Interview with CNA D on 8/3/23 at 1:44 PM stated that CNA A was real firm and loud with Resident #1. Record review of CNA A's training revealed training on the following dates: Abuse, Neglect, and Exploitation dated 3/29/23. Dementia Care: Understanding Alzheimer's Disease dated 3/28/23; Essentials of Resident Rights dated 3/28/23 and Knowing the Rights of Residents dated 4/20/23. Record review of Abuse and Neglect Policy, dated 2/19/20, revealed that the resident has the right to be free from verbal .abuse. Residents must not be subjected to abuse by anyone including facility staff.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure staff did not use hands when serving food B. Ensure stored food was properly labeled, dated and stored These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: An observation of the facility freezer on 8/16/22 at 8:54 AM, revealed: 1 bag of frozen breaded chicken, no label or date, not in original box, open to air 1 bag of frozen potatoes, no label or date, not in original box, open to air In an observation and interview on 8/16/22 at 11:55 AM, [NAME] A was observed touching kitchen surfaces with gloved hands in the kitchen. [NAME] A touched the steam table and picked up serving utensils and plates during the noon meal service. [NAME] A did not wash her hands or change her gloves. During that time, [NAME] A began plating the food then picked up a dinner roll with her gloved hand and placed the roll on the plate. This was done 3 times before surveyor intervention. The DM was also present and observed [NAME] A pick up a roll with her gloved hand. [NAME] A did not wash hands or change gloves between tsks. [NAME] A stated she just forgot and was supposed to use tongs when touching bread. [NAME] A stated not changing gloves and using tongs could cause cross contamination and illness for the residents. In an interview and observation on 8/16/22 at 11:57 AM, the DM was present and also observed [NAME] A plating the food and using her gloved hand to pick up the bread. The DM stated he was in charge of training, and he talked to the staff all the time about hand washing and the use of tongs. The DM stated [NAME] A knows better than to use her hands. The DM stated this could cause cross contamination for the residents. In an interview on 8/17/22 at 2:25 PM, the DM stated all food items should be labeled and dated when taken out of the box. He stated all food has to have a date and a label. The DM stated foods should be labeled and dated as soon as it comes in or is taken out of the box. The DM stated all kitchen staff know they should secure foods when storing. The DM stated he has done an in-service on all the kitchen issues with the staff and they are aware of the kitchen policies. Record review of the facility's policy titled Food Storage with a revised date of 1/16/17, documented: Food shall be protected from potential contamination. All foods out of the original containers will be labeled and dated to avoid contamination. Food must be stored in a properly covered container with a label and date. Any foods removed from the box must be labeled and dated. To avoid manual contact with food, suitable utensil must be used. Record review for the facility's undated policy titled Prevention of Food Borne Illness documented: It is critical that staff involved in food preparation consistently use good hygiene. The appropriate use of utensils such as tongs and gloves is essential in preventing food borne illness. Gloves are considered a food contact surface that can get contaminated or soiled. Failure to change gloves between tasks can contribute to cross contamination. Record review of the USDA Food Code dated 2017, revealed, in part: Preventing Contamination by Employees 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under § 2-301.12. (B) Except when washing fruits and vegetables as specified under §3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. P (C) FOOD EMPLOYEES shall minimize bare hand and arm contact with exposed FOOD that is not in a READY-TO-EAT form. 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-304.15 Gloves, Use Limitation. (A) If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD or with raw animal FOOD, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms;