Every finding on record at California Pacific Medical CTR- Davies Campus Hosp

Based on interview and record review the facility failed to ensure as needed (PRN) psychotropic medications (a class of psychiatric drugs that helps manage severe mental health symptoms) for two out of three residents (Residents 10 and 30) were limited to 14 days and/or attending physician or prescribing practitioner documentation to support medication order extension.This failure had the potential to result in adverse consequences ranging from functional decline, hospitalization, permanent injury, or death.Findings:During a concurrent interview and record review on 1/08/2025 at 1:45 PM with Pharmacy Manager (Pharm), Resident 30's Hospital Medication Detail (undated) was reviewed. The hospital medication detail indicated, an order for Lorazepam (ATIVAN) tab 2 mg.Frequency: Bedtime PRN for Anxiety, Trouble Sleeping.Start Date/Time:01/02/26.End Date/Time: --. Pharm stated, the order was a low dose psychotropic medication, that was appropriately prescribed as needed (PRN) for anxiety and insomnia (trouble sleeping). When asked if as needed (PRN) medications required a specific duration, Pharm stated, Oh yes. I'm sorry. The system just puts the medication in, but we should be able to manually go in and add a 14-day stop date. I'll look into that. Pharm acknowledged no stop date was noted on Resident 30's current order. Pharm was unable to locate clinical documentation to support use beyond 14-day limit. During a concurrent interview and record review on 1/08/2025 at 2:37 PM with Nurse Manager (NM), Resident 10's Hospital Medication Detail undated was reviewed. The hospital medication detail indicated, an order for Lorazepam (ATIVAN) tab 2 mg.Frequency: Every 5 minutes PRN for Seizures (a sudden burst of electrical activity in the brain), If develops convulsive (irregular movement of a limb or of the body) seizure > 2 minutes, administer 2mg IV Ativan.Start Date/Time:03/07/25.End Date/Time: -- . NM stated, the reviewed medication order was currently active on Resident 10's electronic medical record and indicated for as needed use. When asked if as needed (PRN) medications required a specific duration, NM stated, My understanding is that a 14 day stop date is needed for this anti-anxiety medication, so if I were to see this order then I would call the pharmacy and ask them to add a stop date. NM was unable to locate clinical documentation to support use beyond 14-day limit. During an interview on 1/8/2026 at 2:42 PM with Pharm, Pharm provided confirmation that pharmacy staff has access to manually add stop dates to as needed (PRN) psychotropic medication orders, unless attending physician or prescribing practitioner rationale is documented. Pharm stated, Yes. We will do that moving forward. That will be our fix.During a review of the facility's policy and procedure titled, Procedure- Post Acute Services- Behavior Monitoring and Psychotherapeutic Drug Use, Protocol, last revised on 12/19/2019, indicated, .2. PRN Psychotherapeutic Drug; PRN Psychotherapeutic drugs should be limited to 14 days, unless appropriate documentation is provided in the medical record.

Based on interview and record review, the facility failed to ensure Resident 14 (one out of 12 sample residents) was free from unnecessary medication when Remeron (a medication that treats depression and other conditions by adjusting brain chemistry to improve mood, energy, and feelings of well-being, helping to regulate mood, sleep, and appetite ) was prescribed with no identified target behaviors and no diagnosis related to depression (a serious mood disorder causing persistent sadness, loss of interest, and impacting daily life, affecting how you feel, think, and handle activities like sleeping, eating, or working). This failure may result in the use of Remeron as an unnecessary medication.Findings: Review of Resident 14's record titled Manage Orders, dated 12/21/2025, indicated Resident 14 was prescribed 15 mg (milligram) of Remeron at bedtime. Review of Resident 14's record titled Minimum Data Set (MDS), dated [DATE], indicated she was admitted to the Skilled Nursing Facility (SNF) on 12/19/2025 and had multiple diagnoses. None of the diagnoses was depression or related to depression. During a concurrent interview and review of Resident 14's electronic records with RN Leader (RNL) on 1/7/2026 at 1:42 PM, the RNL stated she will search for diagnoses and target behaviors regarding why Remeron was prescribed for Resident 14. The RNL stated she will also search for documented evidence of an actual depression diagnosis and how staff were monitoring target symptoms related to depression. RNL stated these depression target symptoms may manifest as: self-isolation, insomnia, loss of interest, tearful, etc. and she will search the records for these symptoms. After searching Resident 14's records, RNL was unable to find documentation for the items discussed. During a concurrent interview and record review on 1/8/2026 at 2:37 PM, the Pharmacy Manager (Pharm), the Pharm stated an anti-depression should not be prescribed without an active diagnosis of depression or other forms of depression. The Pharm stated when a physician orders a medication, a pharmacist would review the chart to ensure there was a diagnosis associated with the medication. The Pharm stated if indication for use was not documented, there would be a discussion with the care team (including a physician). The Pharm stated there are off label use for Remeron such as for anxiety and insomnia. The Pharm was asked to search Resident 14's records for any clinical rationale and/or diagnosis for Resident 14's use of Remeron. The Pharm was unable to find a diagnosis for use of Remeron for Resident 14 (after admission to the SNF). The Pharm did find a check box indicating Remeron was discussed with the care team. The Pharm explained they may have to re-examine their drug prescribing system as the current system did not prevent Remeron from being prescribed without documented diagnoses and/or clinical rationales. Review of the facility's policy titled Post Acute Services - Behavior Monitoring and Psychotherapeutic Drug Use, Protocol, revised on 12/19/2019, indicated .To outline the management and documentation requirements for patients with behavioral symptoms .diagnosis with a description of symptoms.discussion of the differential psychiatric and medical diagnosis. description of the justification of the choice of a particular treatment .

Based on interview and record review, the facility failed to monitor weights according to physician orders for two (Resident 14 and Resident 16) out of 12 sampled residents.This failure may limit and/or negatively impact clinicians' treatment decisions due to unavailable information. Findings:Review of Resident 14's record titled Minimum Data Set (MDS), dated [DATE], indicated she was admitted to the Skilled Nursing Facility (SNF) on 12/19/2025 and had multiple diagnoses including malnutrition (not eating enough nutrients to maintain body functions).Review of Resident 14's record titled Manage Orders, dated 12/21/2025, indicated staff was supposed to obtain her .Weight Weekly.Review of Resident 14's record titled NUTRITIONAL ASSESSMENT, dated 12/26/2025, and authored by Registered Dietitian (RD1), indicated weight .Readings from last 10 Encounters: 12/19/25 59.8 Kg (kilogram).stated 12/17/25 59.8 kg . stated.During a concurrent interview and review of Resident 14's electronic records with the Nurse Manager (NM) on 1/8/2026 at 10:00 AM, the NM was asked to search for documented evidence Resident 14 was weighed upon admission to the SNF and on a weekly basis. The NM only found stated weights within her records. The NM explained stated weight was what Resident 14 told staff her weight was. The NM confirmed staff did not put Resident 14 on a scale and obtained an actual weight. The NM also searched Resident 14's records for any clinical reasons (pain, refusal, out of the facility etc.) why staff did not obtain an actual weight. The NM was unable to find any clinical rationales why staff did not obtain an admission weight and/or weekly weights for Resident 14.Review of Resident 16's record titled MDS, dated 1/6/2026, indicated he was admitted to the SNF on 12/25/2025 and had multiple diagnoses including malnutrition.Review of Resident 16's record titled Manage Orders, dated 12/25/2025, indicated staff was supposed to obtain his weight .on admission and daily.During a concurrent interview and record review on 1/8/2026, at 10:00 AM, with NM, Resident 16's electronic records were reviewed. NM stated weights were not obtained and/or documented for these dates 12/26/2025 to 12/312025, 1/2/2026, 1/4/2026, and 1/5/2026 (a total of nine missing daily weights). The NM also searched Resident 16's records for any clinical reasons (pain, refusal, out of the facility etc.) why staff did not obtain an actual weight. The NM was unable to find any clinical rationales why staff did not obtain daily weights for Resident 16 for those nine days.During an interview on 01/08/2026 at 11:53 AM, RD 1 stated part of his assessment included checking for actual weights and physician orders for weights. RD 1 stated if weights were missing, he would alert/remind nursing staff to weigh the resident. RD 1 stated he was aware of missing weights for Resident 14 and 16. The RD stated it would be difficult to recommend treatment plans without actual weights. RD 1 stated staff were alerted about the missing weights and offered no explanation regarding the missing weights for Resident 14 and Resident 16.Review of the facility's policy titled Acute Care and Post Acute Services - Patient Weights, revised on 4/20/2023, indicated .All patients will be weighed: .Within .(24 hours) of admission .will be weighed every 30 days unless otherwise ordered by the physician.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner when:1.A container of soup and an opened bag of meatballs were not dated.2.Food debris, an avocado, a packet of parsley, and a packet of cilantro were found on the floor of the walk-in refrigerator and freezer.Failure to store food in a sanitary manner had the potential to subject residents to contaminated food and/or foodborne illnesses.Findings:During a concurrent observation and interview on 1/6/2026 at 10:03 AM with the Food Service Manager (FSM), these were found within the kitchen:1.A container of soup and an opened bag of meatballs were not dated.2.Food debris, an avocado, a packet of parsley, and a packet of cilantro were found on the floor of the walk-in refrigerator and freezer.During an interview, the FSM acknowledged the soup should have been dated for today and the bag of meatballs should have been dated when staff opened the bag. When the observation regarding the walk-in refrigerator and freezer were shared with the FSM, she stated staff should have been cleaning these areas on a daily basis. The FSM acknowledged staff may not have been cleaning these areas on a daily basis due to the decomposed state of the parsley and cilantro. The parsley and cilantro appeared limp and slimy and was releasing moisture and odors. Some of the dark greenish fluid from the decomposing cilantro and parsley bags were leaking onto the refrigerator floor.Review of the facility's policy titled Infection Control-Cleaning and Sanitation in Food & Nutrition Services, revised on 4/29/2024, indicated .Clean floors at least once daily.Review of the facility's policy titled LABELING PROCESSES STANDARDS AND PROCEDURES, dated 2025, indicated . REFRIGERATED FOOD LABEL REQUIREMENTS.These food labels intended for storage must include this information: Item Name Preparation Date Use-by Date. Employee Initials.

Based on interview and record review, the facility failed to measure pressure injuries for 1 of 12 sampled residents (Resident 8) upon admission and on a regular basis. This failure to measure Resident 8's pressure injuries on his left and right heels upon admission and on a regular basis did not ensure the facility was objectively monitoring these pressure injuries over time (102 days). Findings: Review of Resident 8's medical record titled MINIMUM DATA SET (MDS, a standardized resident assessment tool), dated 03/29/2023, indicated he was admitted to the facility on [DATE]. He was totally dependent on two staff for bed mobility, and he was totally dependent on one staff for: dressing, toilet use, and personal hygiene. His MDS indicated he was admitted with unhealed pressure injuries. During an interview and concurrent record review on 04/27/2023 at 10:45 AM, RN 2 (Registered Nurse) stated Resident 8 was originally admitted to the hospital's emergency room with two pressure injuries back in 01/02/2023. On 01/15/2023, Resident 8 was transferred to the hospital's skilled nursing facility (SNF) for care. A search of Resident 8's medical record with RN 2 found no evidence staff measured these pressure injuries upon admission to the SNF. Furthermore, RN 2 could find no documented evidence these pressure injuries were measured on a regular basis (from 01/15/2023 to 04/27/2023, a total of 102 days). RN 2 was asked to search hospital records (prior to the SNF admission) in order to provide a baseline of how large these pressure injuries were prior to his SNF admission. Review of Resident 8's medical record from the hospital titled Wound and Ostomy Care Team Note, dated 01/04/2023, indicated wound size measurements for .right heel 8 x 6 cm left heel 2.5 x 2.5 cm . During an interview on 04/27/2023 at 3:11 PM, RN 4 was asked to explain the facility's pressure injury monitoring process. RN 4 stated he worked as a wound care nurse. RN 4 stated in general, nurses in the SNF will assess and chart on a pressure injury. These nurses may put in a consult for the wound care team depending on the severity of the pressure injury. The assessments of these SNF nurses may or may not involve measuring the pressure injury. However, if the wound care team was consulted, RN 4 stated he would measure the pressure injury as part of his assessment. RN 4 was asked how frequently these pressure injuries should be measured? RN 4 answered, in general, these pressure injuries should be assessed once a week and sometimes longer depending on the clinical conditions of the resident. For example, frequency of assessments may be longer for residents on comfort care, use of a specialty wound dressing or if the resident was experiencing a lot of pain. During an interview on 04/28/2023 at 10:52 AM, RN 4 was asked to clarify his expectations on pressure injury assessments and how he was trained as a wound care nurse regarding pressure injury documentation. RN 4 stated he was trained to describe pressure injuries and measure pressure injuries as part of his assessments. RN 4 stated serial pressure injury measurements is one of the parameters clinicians look at to determine if a pressure injury was healing or deteriorating. Review of the facility's policy titled Procedure - Pressure Injury Intervention, revised on 03/18/2021, found no mention of pressure injury measurements or frequency of pressure injury measurements. Additionally, the facility did not have a pressure injury policy that clearly states when and how often pressure injuries should be measured. During an interview on 04/28/2023 at 1:00 PM, the DAL (Director of Accreditation and Licensing) was asked to clarify the facility's pressure injury assessment/monitoring policy. The DAL stated the facility does not currently have policies regarding pressure injury measurements nor how frequently these pressure injuries should be measured.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage when nine expired nutrition supplements were found in the kitchen storage room. This failure had the potential to put residents at risk for foodborne illnesses. Findings: During a concurrent observation and interview on [DATE], at 11:20 AM, with Registered Dietitian (RD), there were nine items of nutrition supplements labeled, Katefarms Peptide 1.5 cal/mL plain in the kitchen storage room, with marks indicating Best if used by: [DATE]. When asked if these nine items were expired, RD stated, Expired. Yes, correct. During an interview on [DATE], at 11:24 AM, with Food and Nutrition Manager (FNM) who was witnessing this incident stated, Yes, I agree . when asked if these nine items were expired. During an interview on [DATE], at 11:33 AM, with Nursing Operations Manager (NOM) who was also witnessing this incident acknowledged, these nine items were expired. Review of the facility's policy and procedure (P&P) titled, Receiving and Storage Standards, revised on [DATE] indicated, . Storage . 4. Discard out-of-date products . Review of the Guidance of Appendix PP, revised on [DATE], from Centers for Medicare and Medicaid Services (CMS) indicated, the facility should follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Appendix PP also indicated, unsafe food handling practices represent a potential source of pathogen exposure for residents. Review of U.S. Food and Drug Administration's 2022 Food Code indicated, . The Food Code states the person in charge of a food establishment is accountable for developing, carrying out, and enforcing procedures aimed at preventing food-borne illness .

Based on observation, interview, and record review, the facility failed to ensure a refuse (solid waste not carried by water through the sewage system) container had a lid and refuse were disposed in a proper manner. This failure had the potential to promote development and spread of communicable diseases and infections that could jeopardize the health of the residents in the facility. Findings: During a concurrent observation and interview on 4/26/23, at 8:53 AM, with food service supervisor (FSS), outside of the facility building far enough from the kitchen, there was a green plastic garbage container full of trash. There was no lid attached to the garbage container. There were also several very tiny flies flying around the garbage container. FSS stated, It should be shut when asked about the policy of the garbage container. When asked if he could see the tiny flies around the garbage container, FSS stated, Yes. Observation of another metal garbage container nearby indicated, it was closed but a garbage bag with dark brownish wet material inside was protruding outside the closed lid. FSS also acknowledged, refuse was not disposed in a proper manner when asked about the garbage bag hanging outside the garbage container. During an interview on 4/26/23, at 8:55 AM, with Nursing Operations Manager (NOM) who witnessed this incident, NOM acknowledged, Yes . I did when asked if she saw the green plastic garbage container without the lid, tiny flies around it and the garbage bag hanging outside the closed lid of another metal garbage container. During an interview on 4/26/23, at 8:59 AM, with Food and Nutrition Manager (FNM) who also witnessed this incident together, FNM also acknowledged, there was no lid with the green plastic garbage container and refuse was not disposed in a proper manner. During an interview on 4/26/23, at 9:12 AM, with EVS (environmental services) Lead Manager (EVSLM), EVSLM acknowledged, the garbage container should have been closed with a lid when this surveyor showed the garbage containers. EVSLM stated, . Always (covered) . when asked the policy of the garbage container. He also acknowledged, refuse was not disposed in a proper manner with the metal garbage container. During an interview on 4/26/23, at 9:19 AM, with EVS Senior Manager (EVSSM), EVSSM stated, That should be covered when asked about the policy regarding the garbage containers. He also acknowledged, refuse was not disposed in a proper manner. Review of the facility's policy and procedure (P&P) titled, Policy-Infection Control: Solid Waste Disposal in Food & Nutrition Services, revised on 6/23/21 indicated, . Garbage containers are kept covered . Review of U.S. Food and Drug Administration's 2022 Food Code indicated, . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE . and used outside the FOOD ESTABLISHMENT (any operations, including without limitation schools, farmers markets and other public venues that store, prepare, package, serve, vend or otherwise provide food for human consumption) shall be designed and constructed to have tight-fitting lids, doors, or covers . 5-501.110 Storing Refuse, Recyclables, and Returnables. REFUSE . shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents . 5-501.113 Covering Receptacles . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT . Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents . Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils . All containers must be maintained in good repair . in order to store garbage and refuse under sanitary conditions as well as to prevent the breeding of flies . Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents .

Based on observation, interview and record review, a nurse failed to follow facility policy regarding disinfecting a shared device after medication administration. Failure to disinfect a shared device did not ensure other residents were protected from infection. Findings: Review of Resident 12's medical records titled INFECTIOUS DISEASES FOLLOW UP PROGRESS NOTE, dated 04/17/2023, indicated he has a history of infections with MDRO (multi drug resistant organism) and was currently on three antibiotics to treat a bacterial infection. Review of the front page of Resident 12's electronic medical record with RN 2 on 04/28/2023 at 11:49 AM indicated Resident 12 was on contact precaution. Review of the facility's policy titled Policy - Infection Control Strategies- Guidelines for Use of Transmission Based Precautions: Airborne, Droplet, Contact Precautions, and Enhanced Contact Precautions, revised on 01/20/2022, indicated .Contact, or touch, is the most common and most significant mode of transmission of infectious agents. Contact transmission can occur by directly touching the patient, through contact with the patient's environment, and by contaminated gloves or equipment. During medication administration observation on 04/26/2023 at 9:31 AM, RN 3 was administering a medication to Resident 12 and brought a (shared) ID bar code scanner into Resident 12's room. These ID bar code scanners are used to scan a resident ID band and to scan in the resident's medications prior to medication administration. Each scanner is electronically tethered to a specific mobile workstation. After medication administration, RN 3 did not disinfect the scanner and placed the scanner on her mobile workstation and later on she placed the scanner back onto the charging port behind her mobile workstation. The Director of Nursing (DON) was present during the medication administration observation. The DON was asked to comment on the observation. The DON stated RN 3 should have disinfected the scanner prior to placing the scanner on her mobile workstation. Review of the facility's policy titled Policy - Infection Control Strategies- Guidelines for Use of Transmission Based Precautions: Airborne, Droplet, Contact Precautions, and Enhanced Contact Precautions, revised on 01/20/2022, indicated .If shared equipment is used, it must be cleaned with hospital disinfectant after each use.

Based on observation, interview and record review, the facility failed to ensure two out of 12 sampled residents' (Resident 11 and 22) dignity were protected when their urinary bags were clearly visible from the hallway and were not contained in urinary bags. This failure may cause feelings of embarrassment to both Residents 11 and 22. Findings: During initial observation on 04/25/2023 at 10:00 AM, Resident 11's urinary bag was hanging by the foot of his bed and was clearly visible from the hallway. During initial observation on 04/25/2023 at 11:25 AM, Resident 22's urinary bag was hanging by the foot of her bed and was clearly visible from the hallway. During an interview on 04/28/2023 at 8:49 AM, the Charge Nurse (CN) stated the facility has privacy bags to cover up a resident's urinary bag. However, staff only put the privacy bags on when a resident goes out. Review of the facility's policy titled Policy - Indwelling Urinary Catheter Insertion, Maintenance, and Removal (Adults and Pediatrics), revised on 06/06/2022, found no information about use of privacy bags.

Based on interview, and record review, the facility failed to send a copy of the written notice to a representative of the Office of the State Long-Term Care Ombudsman after the facility-initiated discharge for Resident 20. This failure had the potential not to provide added protection to residents from being inappropriately discharged , provide residents with access to an advocate who can inform them of their options and rights, and to ensure that the Ombudsman is aware of facility practices and activities related to transfers and discharges. Findings: Review of Resident 20's Discharge Summary, dated 4/24/23, indicated, he was admitted in the facility on 2/8/23, then discharged on [DATE] with discharge diagnoses including heart failure (a condition that develops when your heart does not pump enough blood for your body's needs), acute renal failure (a condition in which the kidneys suddenly cannot filter waste from the blood), and diabetes mellitus (a disease of inadequate control of blood sugar). Review of Resident 20's Care Team Note, dated 4/24/23, indicated, . Left unit via wheelchair, escorted downstairs by hospital staff . During a concurrent interview and record review, on 4/28/23, at 9:34 AM, with Registered Nurse (RN) 1, Resident 20's clinical medical records were reviewed. RN 1 stated, Resident 20 was discharged on [DATE] to a shelter with home health and accommodation. RN 1 stated, his discharge was a planned, facility initiated, and safe discharge. But, when asked if staff sent the copy of the written notice to Ombudsman after his discharge, she stated, No. A search of Resident 20's medical record with RN 1 found no evidence of the notice to Ombudsman. During an interview on 4/28/23, at 10:43 AM, with Nursing Operations Manager (NOM), NOM stated, They did not send the notice to the Ombudsman when asked about the notice to Ombudsman. During an interview on 4/28/23, at 10:45 AM, with Interim Director of Care Coordination (IDoCC), IDoCC stated, We were not aware that we have to send the notice to the Ombudsman. During an interview on 4/28/23, at 11:05 AM, with IDoCC, IDoCC acknowledged, We didn't send when asked about the notice to the Ombudsman. During a concurrent interview and record review, on 4/28/23, at 1:20 PM, with NOM, the facility's policy and procedure (P&P) titled, Policy-Discharge of Patients, revised on 4/1/14, was reviewed. A search of the P&P with NOM found no mention of the notice to Ombudsman on it. NOM acknowledged, there was no mention of the Ombudsman notice on the P&P.

Based on observations, interviews, and record reviews, the facility failed to implement its infection control program in accordance with internal policies and procedures, nationally recognized infection control guidelines and regulations when: 1. COVID-19 (a highly contagious respiratory disease) response testing was not implemented to identify and mitigate possible active transmission of infection. 2a. Respirator was not properly worn by staff. A respirator is a device worn over the nose and mouth to protect the wearer from inhaling dangerous particles. b. Extended use respirator mask and reusable eye protection were not properly stored. Eye protection such as goggles and face shield, provides barrier to infectious material from entering the eyes. c. Staff did not know how to perform respirator seal or leak check. Failure to implement infection prevention practices may contribute to the cross contamination of infection that can jeopardize the health of residents, staff, and visitors. Findings: 1. Review of facility linelist provided by Infection Preventionist (IP) on 1/14/22 indicated a total of 10 COVID 19 laboratory confirmed positive cases from 12/30/21 to 1/14/22. Staff were tested positive of COVID 19 infection on the following days: 12/30/21, 1/2/22, 1/4/22, 1/5/22, and 1/13/22. Residents were tested positive of COVID 19 infection on the following days: 1/8/22, 1/11/22 and 1/11/22. During an interview on 1/14/22 at 11:20 AM, the IP stated from 12/30/21 to 1/14/22 the facility had a total of 10 confirmed COVID positive. The IP also stated the facility is implementing contact tracing and testing only those who were identified as close contact and not the whole unit. The IP confirmed the facility did not implement response testing because we are doing a good job on contact tracing. The CDC (Centers for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, under New Infection in Healthcare Personnel or Residents indicated, When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction ' s public health authority .Because of the risk of unrecognized infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in any HCP or a nursing home-onset [CONDITION(S)]-CoV-2 infection in a resident should be evaluated as a potential outbreak .if testing of close contacts reveals additional HCP or residents with [CONDITION(S)]-CoV-2 infection, contact tracing should be continued to identify residents with close contact or HCP with higher-risk exposures to the newly identified individual(s) with [CONDITION(S)]-CoV-2 infection. A facility-wide approach should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission . 2 a. During an observation on 1/14/22 at 12:42 PM all staff are wearing surgical mask (facemask) over the N95 respirator mask. During concurrent interview, the IP explained the practice of using surgical mask over the respirator was a system-wide instruction to preserve the use of respirator. The Occupational Safety Health Administration (OSHA, a government agency) defines facemasks as a surgical, medical procedure, dental, or isolation mask that is FDA (Food Drug Administration) cleared, or offered or distributed as described in an FDA enforcement policy. Facemasks, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays. During an observation on 1/14/22 at 12:50 PM, Registered Nurse (RN) 1 was wearing surgical mask over and under the respirator. RN 1 stated she needed to wear surgical mask below the the respirator because It wets easily (referring to the N95 mask). I perspire a lot, that's why I need one under (referring to surgical mask). During an observation on 1/14/22, at 1:02 PM, in front of the elevator by the nursing station, Environmental Services Staff (EVS) 1 was wearing a respirator mask. The lower band/strap of the respirator mask was placed under the chin. EVS 1 did not perform hand hygiene after touching the front part of the respirator. b. During an interview with the IP on 1/14/22, at 11:59 AM, the IP stated that respirators are being re-used due to shortage of respirators. The IP explained the current practice is to wear a surgical mask over the N-95 respirator to protect it and to replace the surgical mask when soiled. The IP stated that during break, the staff are expected to discard the surgical mask, store the used respirator in a bag, and wear a new surgical mask over the respirator after their break. During an observation on 1/14/22, at 12:49 PM, in front of resident's room, Registered Nurse (RN) 2 was wiping a face shield with bleach wipes and placed it on a paper towel on top of the medication cart. During concurrent interview, RN 2 stated, We don't store our face shield and N95 (respirator). We changed them daily. There's no shortage. RN 2 stated that during his break, he put his respirator and face shield on a clean paper towel on the table. During an observation on 1/14/22, at 1:03 PM, at the staff breakroom, Certified Nursing Assistant (CNA) 1 was eating with the N-95 respirator mask, surgical mask, and face shield placed on a paper towel on the table. During concurrent interview, CNA 1 stated she stores her used N-95 respirator mask, surgical mask, and face shield in a clean paper towel during her break. c. During an observation and concurrent interview on 1/14/22 at 12:51 PM, Registered Nurse (RN) 1 was wearing surgical mask over and below the respirator. RN 1 was not able to explain how to do respirator seal check or leak test. RN 1 stated, I forgot, I will review it again. According to NIOSH Eye Safety, accessed on 2/1/22, at https://www.cdc.gov/niosh/topics/eye/eye-infectious.html, . Non-disposable eye protection should be placed in a designated receptacle for subsequent cleaning and disinfection. The sequence of PPE removal should follow a defined regimen that should be developed by infection control staff and take into consideration the need to remove other PPE (see donning and removing PPE) .The eyewear described above is generally not disposable and must be disinfected before reuse. Where possible, each individual worker should be assigned his/her own eye protection to insure appropriate fit and to minimize the potential of exposing the next wearer. A labeled container for used (potentially contaminated) eye protection should be available in the HCW change-out/locker room. Eye protection deposited here can be collected, disinfected, washed, and then reused .Healthcare setting-specific procedures for cleaning and disinfecting used patient care equipment should be followed for reprocessing reusable eye protection devices. Manufacturers may be consulted for their guidance and experience in disinfecting their respective products. Contaminated eye protection devices should be reprocessed in an area where other soiled equipment is handled. Eye protection should be physically cleaned and disinfected with the designated hospital disinfectant, rinsed, and allowed to air dry. Gloves should be worn when cleaning and disinfecting these devices. The Cal/OSHA Interim Guidance on COVID-19 for Health Care Facilities: Severe Respirator Supply Shortages dated 2/6/22 indicated, .Acceptable Optimization Strategies to Extend Respirator Use: While there are still respirator shortages in some sectors, California health care providers are no longer experiencing an extreme respirator shortage. Manufacturers are increasing respirator production. Many manufacturers and distributors make respirators available to employers through allocation protocols. In addition, state and local governments are procuring respirators to support health care facilities. All employers should continue efforts to obtain a sufficient supply of NIOSH certified respirators through private supply chain .6.1 Extended use of respirators. Extended use occurs when health care employees use the same respirator during encounters with several patients without removing the respirator between patient encounters. Employers must ensure that the respirators are kept clean, sanitary, and in good working order at all times. Extended use is practiced when multiple patients are infected with the same respiratory pathogen and patients are placed together in dedicated areas (cohorting). When patients are cohorted together: The maximum recommended respirator extended use period is 8 to 12 hours. Respirators should be removed and carefully stored in a clean paper bag before activities such as meals, restroom breaks, and other breaks and then re-donned and worn through the remainder of the shift. The respirator must be discarded if it any time it becomes contaminated or does not fit or function correctly . According to CDC Optimizing Supply of PPE and Other Equipment during Shortages, updated on 7/22/20, .Crisis capacity: strategies that are not commensurate with U.S. standards of care but may need to be considered during periods of known PPE shortages. Crisis capacity strategies should only be implemented after considering and implementing conventional and contingency capacity strategies. Facilities can consider crisis capacity strategies when the supply is not able to meet the facility's current or anticipated utilization rate . According to the Centers for Disease Control and Prevention article on performing a user seal check retrieved from https://www.cdc.gov/niosh/docs/2018-130/pdfs/2018-130.pdf, .The Occupational Safety and Health Administration (OSHA) (29 CFR 1910.134) requires an annual fit test to confirm the fit of any respirator that forms a tight seal on the wearer's face before it is used in the workplace. Once a fit test has been done to determine the best respirator model and size for a particular user, a user seal check should be done every time the respirator is to be worn to ensure an adequate seal is achieved. A user seal check is a procedure conducted by the respirator wearer to determine if the respirator is being properly worn . A user seal check is sometimes referred to as a fit check. A user seal check should be completed each time the respirator is donned (put on). It is only applicable when a respirator has already been successfully fit tested on the individual . The CDC article on Considerations for Covering N95s to Extend Use accessed at https://blogs.cdc.gov/niosh-science-blog/2020/06/16/covering-n95s/ indicated, . During times of increased demand for N95 filtering facepiece respirators (FFRs), hospitals or other medical facilities may want to protect these devices from surface contamination in order to prolong their use. When protection against surface contamination is needed, CDC recommends wearing a cleanable face shield over an N95 FFR. Wearing a surgical mask or cloth covering over an FFR, such as an N95, is not approved or recommended by NIOSH because it is not consistent with the conditions of the approval, therefore voiding the certification, however this is a strategy that can be used in a crisis situation as described in the CDC strategies for Optimizing the Supply of N95 Respirators .

Based on interview and record review, the facility failed to demonstrate how it communicated to residents and their responsible parties the newly confirmed COVID-19 infections along with the mitigating actions in a timely manner for all residents admitted in the facility. Failure to communicate newly confirmed COVID-19 infections and what mitigating actions are being implemented by the facility may contribute anxiety associated with the COVID-19 pandemic. Findings: During an interview with the Infection Preventionist (IP) on 1/14/22, at 11:31 AM, the IP stated resident's families were not notified of every single confirmed case(s) of COVID-19 infection. The IP explained that only residents with confirmed positive result for COVID-19 and highly exposed residents are notified by the clinicians. Review of linelist provided by the IP on 1/14/22 indicated, six staff and three residents were tested positive for COVID-19 infection from 12/30/21 through 1/14/22. During an interview on 1/14/22, at 11:31 AM, the Nurse Manager (NM) 1 explained that physician will inform the residents with laboratory confirmed positive result for COVID test and Nurse Manager notify their responsible parties. NM 1 was not able to provide evidence that other residents or the responsible party were notified of new COVID-19 prevalence (residents or staff) in the unit. Review of the facility COVID-19 Mitigation Plan, last reviewed on 5/10/21, by Director of Nursing, under Communication indicated, It is the policy of this facility to protect our residents, staff and others who may be in our facility from harm during emergency events .Communication to residents, families, and staff will include the prevalence of cases in staff and residents in the facility . The CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes accessed on 2/2/22 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, indicated, .Notify HCP, residents, and families promptly about identification of [CONDITION(S)]-CoV-2 in the facility and maintain ongoing, frequent communication with HCP, residents, and families with updates on the situation and facility actions .

Based on observation, interview and record review, the facility failed to ensure essential equipment, including a walk -in freezer and T-pump, was maintained in a safe operating condition. This failure had the potential to cause contamination in food storage equipment, which could affect overall food service operations and injury to residents and staff. Findings: 1. During the initial kitchen tour on 9/9/19 at 10 AM, there were three large racks with large boxes of frozen food stacked on the shelves of the walk-in freezer. Condensation was noted on the racks and boxes and there was ice build-up on the ceiling and around the fans at the back of the freezer. The floor was made of red brick and it also had ice build-up on the floor. During an interview with the FSND 2 she acknowledged the condensation. During an observation on 9/11/19 at 2 PM, moisture was noted on the outer door of the walk-in freezer close to the electrical switch. Condensation remains on the walls and ceiling and floor of the freezer. A review of the facility maintenance request on 11/2/18 indicated condensation build-up on outer wall of freezer, insulation had degraded and recommended new walls be installed, once the insulation has been compromised it will no longer have the R factor needed to prevent this from happening. According to Refrigeration and Freezer Mechanics, the build-up of ice on the interior freezer components may be the result of issues within the condenser, evaporator or issues with the defrost cycle (Humitec Corporation , 2013). 2. Resident 7 was admitted on [DATE] with [DIAGNOSES REDACTED]. During an observation on 9/9/19 at 9:55 AM, Resident 7 was in bed, awake, and able to respond to questions. The T/Pump (warming and cooling machine) on the floor was turned on, and connected to a pad placed underneath the resident's lower legs. The pad was warm to touch. The sticker affixed on the machine indicated, PM (Preventive Maintenance) DUE (MONTH) 15, 2019. During an interview with Registered Nurse (RN) 2 on 9/9/19 at 10:01 AM, she confirmed the preventive maintenance on the heating pad machine was past due and stated, we have to get a new one. When asked who checked preventive maintenance on the machine, RN 2 stated Biomed and Nursing should have checked on it. Review of Resident 7's care plan notes dated 12/10/18 indicated, .Electric heating pad also provided to patient for pain management . During an interview with Resident 7 on 9/10/19 at 12:16 PM, she stated the heating pad was used to keep her legs warm. Resident 7 stated that she would call the staff if she wanted the machine turned off or turned back on. The facility's undated, policy and procedure titled, Sutter Health Medical Equipment Management Program - Section 3. Inspection and Maintenance Strategies, indicated, I. Policy - To ensure that all medical equipment included in the inventory is appropriately inspected, tested and maintained for achieving safe, effective and reliable operation. II. Purpose - To provide a consistent set of inspection procedures to ensure a safe operation of all medical equipment used to treat Sutter Health patients regardless of ownership. III. Procedures - .B . The following maintenance strategies are used: 1 . interval-based maintenance are inspections in which the activities and frequencies are scheduled and performed in accordance with the manufacturer's recommendations . 2. AEM (Alternative Equipment Management) inspections based on interval-based maintenance are inspections in which the activities and/or frequencies are scheduled and performed in accordance with the AEM program .

Based on observation, interview, and record review, the facility failed to ensure medications and medical supplies were properly labeled and stored when: 1. Expired supplies were found in the supplies pyxis (an automated storage device) and crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) 2. Unlabeled medications were found in the medication room 3. Expired medications were found in the medication pyxis (an automated medication dispensing system) 4. Expired medications were found in the medication refrigerator These failures had the potential to cause unsafe and inappropriate storage and administration of medications to residents. Findings: 1. During an observation of the supplies pyxis and crash cart on 9/10/19 at 7:53 AM, accompanied by Registered Nurse (RN) 3 and Director of Nursing (DON), the following were found: 1.1 seven vacutainer blood collection sets (a device used to draw blood) in the pyxis had expiration dates of 7/31/19. 1.2 two 18 gauge intravenous catheters (a small, flexible tube inserted into the vein used for medication or fluid administration, or blood sampling) in the crash cart had expiration dates of 8/31/19. During an interview with RN 3 and DON on 9/10/19 at 7:55 AM, they both confirmed the vacutainer sets were expired. RN 3 stated the Central Supplies Department was responsible for checking and stocking the supplies pyxis. During an interview with RN 3 on 9/10/19 at 8:16 AM, she confirmed the intravenous catheters were expired, and stated the crash cart was stocked by the Central Supplies Department. 2. During an observation of the medication room and concurrent interviews on 9/10/19 at 8:35 AM, with RN 3, DON, and Pharmacist (Pharm) 1 present, the following medications were found: 2.1 one unlabeled tablet of Senna Lax (used to treat constipation) 8.6 mg (milligram) was stored in a cassette (holding bin) marked for room [ROOM NUMBER]-B 2.2 one unlabeled unit dose container of Chlorehexidine [MEDICATION NAME] Oral Rinse (germicidal mouth wash) 0.12% 15 ml (milliliter) and one unlabeled packet of Healthylax Polythylene [MEDICATION NAME] 3350 Powder for Oral Laxative Solution (used to treat constipation) 0.6 oz. were stored in a cassette marked for room [ROOM NUMBER]-C Pharm 1 stated medications not stocked in the pyxis would be filled by pharmacy and placed in cassettes. Pharm 1 stated all medications in cassettes should be labeled with the patient's name, medical record number, date filled (by pharmacy), room number and packaged in a small, plastic re-sealable bag. RN 3 acknowledged the above medications should be labeled or should be placed in the bin marked Pharmacy Returns. 3. During an observation of the medication pyxis and concurrent interview on 9/10/19 at 8:47 AM, with Pharm 1, RN 3 and DON present, the following were found: 3.1 one tablet [MEDICATION NAME] (used to treat high cholesterol levels) 20 mg had an expiration date of 5/2019 3.2 two tablets of Spirinolactone (used to treat high blood pressure) 50 mg had expiration dates of 4/2019 Pharm 1 confirmed the above medications were expired, and that Pharmacy was responsible for checking outdated medications in the pyxis weekly. 4. During an observation of the medication refrigerator closest to the medication pyxis and concurrent interview on 9/10/19 at 10:45 AM, accompanied by Pharm 2 and DON, the following were found: 4.1 four single dose 2 ml vials of [MEDICATION NAME] (used to prevent or control [MEDICAL CONDITION]) 100 mg PE/2 ml had expiration dates of 8/2019 4.2 two single dose 5 ml vials of [MEDICATION NAME] Adult Multiple Vitamins (used to prevent vitamin deficiency) Injection Vial 1 and two single dose 5 ml vials of [MEDICATION NAME] Adult Multiple Vitamins Injection Vial 2 had expiration dates of 7/2019 Pharm 2 confirmed the medications were expired. The DON stated the Pharmacy was responsible for checking expirations of the above medication refrigerator. The facility policy and procedure titled, Procedure - Drug Storage and Inspections, last revision dated 7/12/18, indicated, . Procedure: 1. Medications (drugs, chemicals, and biologicals) shall be stored within the Pharmacy Department and in other appropriate areas of the Medical Center in accordance with State and Federal regulations, TJC and USP guidelines and manufacturer's recommendations and in a secure fashion. 2. The Pharmacy Department shall have full access to all hospital storage areas of medication . The inspection shall be conducted by a licensed pharmacist every 30 days documenting the following: .Outdated, recalled, and discontinued medications, discharged patient medications, illegibly labeled medications or otherwise unusable products are removed and returned to Pharmacy for destruction in a timely fashion .3. Labeling: . Pharmacy will label all medications with proper storage, use and safety information as appropriate. Products for external use only must be clearly labeled as such and where possible, segregated from internal and [MEDICATION NAME] medications . The facility policy and procedure titled, Policy - Crash Cart Maintenance and Module Exchange, last revision dated 4/17/19, indicated, Policy: All crash carts will be inspected routinely for intact locks, . and for outdated or unusable drugs and/or supplies . Procedure: I. Cart checks: Performed by designated Department/Unit staff . B. Daily checks include: .3. The supply list posted in the sheet protector attached on the side of the cart is checked for expirations . Notify Supply Chain to replace items that are within one week of expiration . II. Every 30 days . B. Performed by a Supply Chain employee: 1. All supplies stocked on the cart, including the Respiratory Module . will be inspected every 30 days by Supply Chain . 4. Any supplies due to expire prior to the next scheduled inspection will be replaced .

Based on observation, interview and record review the facility failed to ensure safe and sanitary conditions were met for food storage and service, and in and out of the Food and Nutrition Services department when: 1) Expired Potentially Hazardous Food (PHF)/Time and Temperature Control for Safety (TCS) food items were stored in the refrigerators 2) Food items in the refrigerators and dry storage area were not properly labeled and dated 3) Potentially hazardous foods (eggs) procured from vendor was not pasteurized 4) Food preparation equipment (grills, deep fryer, refrigerators) were not clean 5) Serving trays were stacked wet 6) Nutrition refrigerator of DP/SNF was dirty and contained expired food This deficient practice had the potential to put residents at risk for foodborne illness. Findings: 1) During the initial kitchen tour, observation and interview with the Director of Food and Nutrition Services 1 (DFNS 1), Food and Nutrition Service Director[NAME]Campus 2 (FNSD 2), Registered Dietician (RD) and Food and Nutrition Service Manager (FNSM) on [DATE] at 9:30 AM the following items were found inside the reach-in and walk in refrigerators: a.Reach in refrigerator #1 green bell peppers and red bell peppers dated [DATE], no Use By Date (UBD), broccoli dated [DATE] no UBD, a metal container, covered with plastic wrap, containing diced white onion, no label or UBD. During an interview on [DATE] at 9:35 AM with the FNSD 2, she stated that these items are expired. b. The small chefs reach in refrigerator contained alfredo sauce expired on [DATE], clam base expired on [DATE] and diced jalapeno expired on [DATE]. During a concurrent interview on [DATE] at 9:50 AM, the DFNS 1 stated, These are all expired, and threw them out. c.Reach in refrigerator #8 zucchini dated [DATE] and broccoli dated [DATE]. During an interview on [DATE] at 10 AM with FNSD 2, DFNS 1 stated, these are expired. d. Walk in refrigerator A, uncooked chicken with UBD of [DATE], biscuits with no label or UBD, open bag of cooked sausage no label, date opened or UBD, 3 large pieces of beef, with no label or UBD, 4 large white unlabled bakery boxes one contained chibata rolls with blue and black spots on the rolls, three boxes contained partial amounts of dry cornbread with no UBD. The DFNS 1 on [DATE] at 10:15 AM acknowledged, these are all expired. e. Walk in refrigerator D, 40 yoplait peach yogurt with UBD of [DATE], several packages of sliced cheese opened with no UBD, 8 tubs of ricotta cheese with expiration date of [DATE]. During interview on [DATE] at 10:30 AM, FNSD 2 stated that these items were all expired. 2) a. During an observation of the walk in refrigerator C on [DATE] at 10:45 AM, the shelves contained plastic crates of vegetables with no labels or UBD's. One of the shelves contained half of a watermelon that was covered with plastic wrap with no label or UBD. b. Reach in refrigerator #2 contained an unlabeled and undated plastic bag with 3 large green melons with black spots on them. During an interview with the FNSD 2 on [DATE] at 9:40 AM, she stated that this must belong to staff . When the FNSD 2 was asked if it was the facility practice to store staff food in the kitchen refrigerators she stated, No, it is not our policy to store staff food in the kitchen refrigerator. c. During an observation in the kitchen, there was a shelve with many containers of unlabeled and undated items: almonds, chia seeds, flax seeds and raisins and a 12 quart tub of unlabeled and undated bulgur wheat. During an interview with FSND 2, she acknowledged, these items should be labeled and dated. d. During an observation of the onion bin in the kitchen, there were 6 onions with black spots. The FSND 2 acknowledged the items were rotten. Review of the Hospital policy, Infection Control-Food Handling and Monitoring in FNS, dated [DATE], indicated, .All foods that are received into Aramark locations must be labeled .Follow the shelp-life guidelines in Section 8.2 Aramark Use by Dates to determine the Use By date to apply when using the refrigerated/frozen food label .Discard foods that are not labeled in accordance with these standards. 3) During an observation in the kitchen, the reach in refrigerator #2 contained 15 dozen eggs with no evidence of pasteurization. Eggs were not stamped with a letter P to indicate if the eggs were pasteurized. A pasteurized egg is an egg that has been heated to eliminate bacteria. During an interview on [DATE] at 9:45 AM with the DFNS 1, she stated, I will have to check to see if the eggs are pasteurized. During an interview on [DATE] at 2 PM with FNSD 2, she stated, the eggs were not pasteurized and DFNS 1 is checking to see how they were delivered here. According to the Federal Food Code (YEAR), although foodborne illnesses can be severe or even fatal, milder cases are often not detected through routine surveillance. According to the Food Code, eggs are still a major source of Salmonella infections, causing large outbreaks when they are combined and undercooked so special added precautions need to be in place with those most susceptible to foodborne illness. The Food Code defines a highly susceptible population as persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining food at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney [MEDICAL TREATMENT] center, hospital or nursing home, or nutritional or socialization services such as a senior center. 4) During an observation in the kitchen [DATE] at 9:50 AM, the two large grills were greasy, many food particles were on the grills. Black grease was splattered and caked on to the back of the grills. During concurrent interview with FNSD 2 when asked who is responsible for cleaning the grills, she stated, the cooks clean the grills. The deep fryer had dark colored oil and many food crumbs along the side of the trays. During an interview with FNSD 2, she stated, the oil is changed every 2 days. The chefs refrigerator contained food spillage on the inside door and the shelves appeared grimy with food drops. DFNS 1 acknowledged that, It was dirty and will have someone come and clean it. According to the (YEAR) Federal Food Code all food-contact surfaces of cooking equipment and pans shall be kept free of soil accumulations and nonfood-contact surfaces of equipment shall be kept free of and accumulation of dust, dirt, food residue, and other debris. 5) During an observation and concurrent interview on [DATE] at 10 AM, serving trays small and long were stacked wet along the back wall of the kitchen. The DFNS 1 stated, these should not be stacked wet, they should be dry before stacking and pulled them all and had them rewashed and dried. According to the (YEAR) Federal Food Code, section ,[DATE].11 titled Equipment and Utensils, Air-Drying Required; .After cleaning and sanitizing, equipment and utensils shall be air-dried 6) During an observation and concurrent interview with DON on [DATE] at 11:30 AM, the nutrition refrigerator in the medication room of the Skilled Nursing Unit contained expired items: pineapple with use by date of [DATE], lettuce salad with use by date of [DATE]. The refrigerator was dirty with food spillage on the shelves. The DON stated, it should be wiped down.

Based on observation, interview and record review, the facility failed to ensure use of PRN (pro re nata as needed) [MEDICAL CONDITION] medication (any drug that affects brain activities associated with mental processes and behavior) was limited to 14 days for one of 12 sampled residents (Resident 3) when there was no end date and documented rationale for continued use of [MEDICATION NAME] (a drug used to treat anxiety). This failure had the potential to result in unnecessary use of [MEDICAL CONDITION] medications. Finding: Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. During an observation on 9/9/19 at 10:30 AM, Resident 3 was lying in bed, eyes closed with contractures on both hands and feet. Resident 3 was with a [MEDICAL CONDITION] (a surgical opening through the neck into the trachea (windpipe) and ventilator (a machine that supports breathing) in use. Review of physician progress notes [REDACTED]. Review of Resident 3's physician order dated 9/12/19, indicated, [MEDICATION NAME] ([MEDICATION NAME]) . 1 mg (milligram) . Intravenous . Q4H (every 4 hours) PRN for Agitation .Scheduled Start Date . 08/21/19 . Behavior: persistent movement/grimacing despite addressing any obvious physiologic issues . End Date/Time: Blank . PRN [MEDICATION NAME] was prescribed beyond the 14-day limit. Review of Resident 3's Medication Administration Record [REDACTED].Intravenous .Q4H PRN: Agitation was last administered on 8/23/19. During a record review of Resident 3's physician order and concurrent interview with the Pharmacist (Pharm) 2, and Director of Pharmacy (DOP) on 9/12/19 at 10:20 AM, when asked about duration of use on PRN [MEDICAL CONDITION] drug such [MEDICATION NAME], Pharm 2 said, we give three months .quarterly, we recommend tapering .if not used within 2 weeks, if not needed, recommend to discontinue . Pharm 2 confirmed there was no end date on Resident 3's physician order for [REDACTED]. Review of the facility policy and procedure titled, Policy - Patient Care Service Standards, last revision dated 1/18/19, indicated, Policy: The Department of Pharmacy Services shall endeavor to provide highest quality patient care in compliance with State and Federal regulations and The Joint Commission guidelines. Procedure: . 33. All skilled nursing unit patients will have their medical charts reviewed every thirty days by a pharmacist in accordance with State and Federal regulations . If there is an irregularity in drug regimen, pharmacist will document into electronic health record and contact the prescriber as needed upon the urgency of the matter. Irregularity includes (but not limited to) wrong dose, indication, frequency, route, duration, duplication of therapy, and inappropriate use of [MEDICAL CONDITION] drugs . 34. Use of [MEDICAL CONDITION] Drugs on the Skilled Nursing Unit - [NAME] Refer to Post Acute Services policy on Behavior Monitoring and Psychotherapeutic Drug Use Protocol for further details on gradual dose reduction . Review of the facility policy and procedure titled, Procedure - Post Acute Services - Behavior Monitoring and Pyschotherapeutic Drug Use, Protocol last revision dated 6/1/10, indicated .Protocol . 3. Anxiolytics/Psychopharmacological medications other than antipsychotics and sedative/hypnotics - During the first year in which a resident is admitted on an anxiolytic ., or after the facility has initiated one, a gradual dose reduction should be attempted during at least 2 separate quarters with at least 1 month between attempts . medications: [REDACTED]. PRN Psychotherapeutic Drug - Physician's prescribing as needed psychotherapeutic medications will clearly specify the behavioral indications for administering the drug in the medication order . There was no reference in the policy on limitations for PRN [MEDICAL CONDITION] medication.

Based on observation, interviews, and record review the facility failed to develop and/or revise a Disaster Menu consistent with available food supplies. This deficient practice had the potential to compromise the nutritional needs of residents during emergency/disaster situations. Findings: During disaster menu review and concurrent observation of the emergency food (EF)supply storage room (SR), located in the basement area of the hospital, on [DATE] at 11:25 AM, there were approximately four (4) to five (5) - four layered metal shelves, about two of the metal shelves had cases of bottled water and the rest of the shelves had boxes of canned goods, bags of grain and other non- perishable food items. The Manager of Food and Nutrition Services (MFNS) was handed a copy of the binder that has the list of emergency food items and was asked to show cases of tuna and cases of pineapple tidbits. MFNS searched the entire storage area and verified they were not in stock. The MFNS stated there was construction next door which included the food SR and there are no other area where EF was stored in the hospital. During an interview with the District Manager Food and Nutrition Services (DMFNS, staff from a contract company) and Staff 6 on [DATE] at 1:30 PM, the DMFNS stated the disaster food items were about to expire maybe ,[DATE] or ,[DATE] and the facility purchased the ready to eat meal (REM, a whole meal in a pack) as a replacement for the Emergency Food supply, which was scheduled to arrive in December, (YEAR). The DMFNS verified some of the food items were rotated into the daily menu. Additionally, the DMFNS stated there was remodeling to the kitchen, and there was not enough space to put the food items. When asked, what other items are not being replaced besides the tuna and the pineapple, the DMFNS stated, for example there should be 30 boxes of saltine, only 20 boxes would be ordered. Staff 6 stated she was not aware the emergency food was being used for daily consumption and not being replaced. In an interview with DMFNS, Staff 14 and Staff 6, on [DATE] beginning at 2 p.m., Staff 14 stated he was unaware that food supplies for disaster preparedness were either expired, rotated into the regular food supply, or were not replaced. Staff 6 stated the hospitals' disaster preparedness committee was unaware that the current food supply was depleted. The DMFNS stated he was unsure if he notified the Registered Dietitian, the position responsible for menu review and approval of any plan not to replace disaster food supplies. The DMFNS stated he was unsure the percentage of disaster foods that were either discarded or rotated into the general food supply. Review of the facility policy titled: Emergency -Disaster Preparedness with the last revised date of [DATE] indicated: Policy: The Food and Nutrition Services Department maintains a state of preparedness in order to respond efficiently and effectively to disaster conditions. Procedure: I. iii. Preparedness: Food/ Supplies: A. As required by state/local regulations . The list should support the preplanned disaster menus.

Based on observation, interview, and record review the facility failed to develop and implement policies and procedures prior to the use of bed rails for 29 of 30 sampled residents. The deficient practice resulted in a Substandard Quality of Care (SQC) deficiency when the facility failed to: Identify alternatives prior to using bedrails Review the risk and benefits for use of bed rails for each residents or their representatives Obtain informed consent prior to use Develop and implement policy and procedure to monitor the use of bed rails This deficient practice had the potential to put residents at risk for entrapment, fall or injury. DEFINITIONS: Bed rails (BRs) are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed, according to the definition stated in the State Operation Manual (SOM). Examples of bed rails include, but are not limited to: Side rails, bed side rails, and safety rails; and Grab bars and assist bars. Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, as define in the SOM. Substandard Quality of Care (SQC) is defined as: One or more deficiencies which constitute either immediate jeopardy to resident health or safety; a pattern of or widespread actual harm that is not immediate jeopardy; or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm, related to participation requirements under . Quality of Care, as define by the Centers for Medicare & Medicaid Services (CMS). Minimum data set (MDS) is an assessment tool. Brief interview for mental status (BIMS), Summary Score Total: (00-15) is used to assess residents' orientation to year, month, day; ability to understand questions and repeat and recall words. Findings: During the initial tour accompanied by Staff 5 on 9/4/18 at 11:09 AM, Resident 4 was in bed, with a [MEDICAL CONDITION] (an incision in the windpipe made to relieve an obstruction to breathing), able to converse, the three (3) bed rails (BRs) were in the up position. The minimum data set (MDS - an assessment tool) dated 7/13/18 indicated the brief interview for mental status (BIMS) had a score of 15/15 (means resident is alert, awake oriented and able to recall). Staff 5 stated Resident 4 had a muscular disorder (a group of inherited disease in which the muscles that control movement (called voluntary muscles) progressively weakens). Staff 5 stated that Resident 4 gets out of bed, has limited range of motion and is functioning at her highest level. Staff 5 stated the BRs was for safety. During an interview with Resident 4, on 9/7/18 at 10:38 AM, Resident 4 was asked about the three BRs that were in the up position and stated no one had explained the risk and benefits for use of the BR's and no one had asked for her informed consent to get the BRs up. Continued tour of the unit on 9/4/18 at 11:12 AM, Resident 7 was in bed, with a tracheotomy to ventilator (a machine designed to move breathable air into and out of the lungs, to provide breathing for a patient who is physically unable to breathe, or breathing insufficiently) and Tube Feeding (TF - a means of providing nutrition via a tube inserted into the gastrointestinal tract) via machine pump. Staff 5 acknowledged the three BRs were in the up position and stated Resident 7 was non-verbal, and in a persistent vegetative state (a condition wherein a person is not able to move or correspond with others, not aware of their self or the setting they're in, and not responsive to stimuli). During an observation on 9/4/18 at 11:45 AM, Resident 13 was awake, bed in low position with four (4) BRs in the up position. Staff 5 stated BRs were used for restraint. During an observation on 9/4/18 at 11:13 AM, Resident 1 was in bed with [MEDICAL CONDITION] to ventilator, the three BRs were in the up position. Staff 5 acknowledged the three (3) BRs were in the up position and stated Resident 1 was non-verbal, and was in a persistent vegetative state. During an interview with the Responsible Party (RP) for Resident 1, on 9/10/18 at 1:25 PM, the RP stated she knew that there were three BRs in the up position at all times, there was no discussion to explain the risk and benefits and no consent was obtained for the use of the BRs. During an observation on 9/4/18 at 11:51 AM, Resident 12 was in bed on his left side, with tracheotomy to vent and TF via machine pump, the three BRs were in the up position. Staff 5 stated Resident 12 was non-verbal. During an interview with the RP for Resident 12, on 9/7/18 at 9:27 AM, the RP was asked about the use of the BRs, the RP stated no one had explained the risk and benefits in the use of BRs, my father don't move, and verified there was no informed consent for the use of the BRs. During an observation on 9/4/18 at 11:57 AM Resident 11 was in bed with three BRs were in the up position, [MEDICAL CONDITION] to ventilator and TF was infusing via a machine pump. Staff 5 acknowledged that the three BRs were in the up position and stated resident was non-verbal. During an observation on 9/06/18 at 2:00 PM, Resident 10 was in bed, eyes opened, non-verbal with [MEDICAL CONDITION] to vent and TF infusing via machine pump, with three BRs in the up position. Staff 9 stated the BRs was for safety. During an observation on 9/4/18 at 12:15 PM, Resident 27 was in bed with [MEDICAL CONDITION] and TF infusing via a machine pump, three BRs were in the up position. Staff 5 stated Resident 27 was non-verbal and acknowledged the three BRs were in the up position. During an interview with Staff 9, on 9/06/18 at 1:48 PM, Staff 9 stated the BRs' assessment was done only if the BRs were used as a restraint and if the three BRs were in the up position, it was for safety. During an interview with Staff 1 and the Director of Regulatory Affairs (DRA) on 9/5/18 at 1:45 PM, Staff 1 stated the facility used the Stryker (brand name of the bed) with bed rails, and during admission residents were assessed by the licensed nurses for the use of BRs for safety check, it was part of their assessment. During an interview on 9/06/18 at 2:01 PM, the Staff 13 stated assessment of BRs was done if it was used as restraints but for mobility there was no assessment. During an interview with Staff 7, on 9/06/18 at 2:39 PM, Staff 7 verified that there was no Interdisciplinary Team Meeting (IDT Meeting - group of professionals from a range of disciplines with different but complementary skills, knowledge and experience who work together to deliver comprehensive healthcare aimed at providing the best possible outcome for the physical and psychosocial needs of a patient and their families) that occurred to discuss the use of BRs. During an interview with the DRA, on 9/06/18 at 10:38 AM, the DRA verified there was no assessment to identify alternatives prior to use of BRs, and no consent obtained explaining the risk and benefits to residents and/or resident representatives, and there was no policy developed to implement the process. During an observation on 9/4/18 at 9:21 AM, Resident 15 was in bed, eyes closed, with [MEDICAL CONDITION], and on tube feeding. Both upper and left lower BRs were in the up position. During an interview with the RP for Resident 15, through an online language services on 9/7/18 at 1:46 PM, the RP stated she is not sure if consent was obtained for the use of bed rails. During an interview and a concurrent review of the clinical record for Resident 15, on 9/10/18 at 2:44 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During an observation on 9/4/18 at 9:24 AM, Resident 6 was in bed, asleep, and on a ventilator. Both upper BRs were in the up position. During a phone interview with the RP for Resident 6, on 9/10/18 at 9:41 AM, the RP stated he was aware that the bed rails are in the up position but was not aware what they were for. The RP stated, I didn't know there was supposed to be a consent . He stated that no information was given to him by the physician or by the staff. . I don't remember the doctor talking to me about the rails. During an interview and a concurrent review of the clinical record for Resident 6, on 9/10/18 at 2:41 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During an observation on 9/4/18 at 9:27 AM, Resident 16 was in bed with Staff 5 and Staff 10 providing care. Both upper BRs were in the up position. Staff 10 stated resident was non-verbal. During an observation on 9/7/18 at 9:25 AM, Resident 16 was in bed, asleep with both upper BRs in the up position. During an interview and a concurrent review of the clinical record for Resident 16, on 9/10/18 at 2:43 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During an observation on 9/4/18 at 9:43 AM, Resident 8 was in bed, awake, with [MEDICAL CONDITION] and on tube feeding. Both upper and right lower BRs were in the up position. During an interview and a concurrent review of the clinical record for Resident 8, on 9/10/18 at 2:45 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During a phone interview with the RP for Resident 8, on 9/12/18 at 11:56 AM, the RP stated the risks and benefits of the use of bed rails was not discussed with her by the attending physician nor the staff. When asked, the RP stated she is aware bed rails are being used, and added, .I've always seen the rails in the up position but they've never talked to me about that until a few days ago . someone from there . told me about it . said it's a new regulation that they have to get my consent for the rails . I'm gonna to have to speak with the doctor then . During an observation on 9/4/18 at 9:58 AM, Resident 130 was in bed, asleep. The left upper BR was in the up position. Review of the MDS for Resident 130 dated 8/30/18, indicated Resident 130 had a BIMS score of 15. During an interview with Resident 130, on 9/7/18 at 11:42 AM, when asked about the bed rail use, Resident 130 stated, I think it's for safety . no, I did not request for it . She stated she does not recall the physician speaking with her regarding the risks and benefits of use of bed rails. During an interview and a concurrent review of the clinical record for Resident 130, on 9/10/18 at 2:46 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During an observation on 9/4/18 at 9:57 AM, Resident 24 was asleep with one left upper BR in the up position. During an observation on 9/7/18 at 11:39 AM, Resident 24 was awake, alert, sitting up on the right side of the bed with both feet on the floor. Both upper and right lower BRs were in the up position. During an interview and a concurrent review of the clinical record for Resident 24, on 9/10/18 at 2:46 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During an observation on 9/4/18 at 10:05 AM, Resident 25 was alert, sitting up in bed, eating a meal. The left upper BR was in the up position. During an observation and a concurrent interview on 9/7/18 at 11:45 AM, Resident 25 was in bed, awake, and alert. The left upper BR was in the up position. When asked if he consented to the use of bed rails, Resident 25 stated, . can't remember . check my record. It should be there. During an interview and a concurrent review of the clinical record for Resident 25, on 9/10/18 at 2:47 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During an observation and concurrent interview on 9/4/18 at 10:06 AM, Resident 23 was awake, alert, and conversant. Both upper BRs were in the up position. When asked about the bed rails, Resident 23 stated, I use them to reposition myself. I also use this thing (pointed to the bed trapeze (a mobility device hanging overhead that provides a patient with something secure to grasp when trying to change positions while in bed)) to pull myself up. Review of the MDS for Resident 23, dated 8/26/18 indicated a BIMS score of 15. During an observation on 9/4/18 at 10:01 AM, Resident 14 was in bed, awake, eyes closed. Both upper BRs were in the up position. During an observation and concurrent interview on 9/7/18 at 11:51 AM, Resident 14 was awake, alert, in bed, in the supine position. Both upper BRs were in the up position. When asked if she consented with the use of bed rails, she stated, . I don't know. During an observation on 9/4/18 at 10:02 AM, Resident 2 was awake, alert, sitting up in bed, eating breakfast. Both upper BRs were in the up position. Review of the MDS for Resident 2, dated 6/29/18 indicated Resident 2 had a BIMS score of 15. During an interview with Resident 2, on 9/7/18 at 11:47 AM, Resident 2 stated she cannot recall if she gave a consent to use the bed rails, and added, .I don't know if they asked for my consent . During an interview with Staff 1, on 9/10/18 at 2:51 PM, Staff 1 stated no consent was obtained from the patients when they were admitted , . we did not realize that it was needed due to different interpretation of the new regulation . During an observation on 9/04/18 at 9:40 AM, Resident 26 was sitting at the side of her bed. She was alert and verbal. Her upper bedrails were in the up position. During an interview with Resident 26, on 9/12/18 at 11:13 AM, Resident 26 stated she used her bedrails to help her when she gets out of bed. Review of the MDS for Resident 26, dated 8/29/18, indicated Resident 26 had a BIMS score of 15; clear speech, able to understand others, able to express her ideas and wants, independent with her care needs, and had no range of motion impairment of bilateral upper and lower extremities . During an observation on 9/04/18 at 9:41 AM, Resident 131 was in bed, alert and verbal. Her upper bedrails were in the up position. During an interview with Resident 131, on 9/12/18 at 11:13 AM, Resident 131 stated she used her bedrails for help when she is turned in bed. Review of the MDS for Resident 131, dated 8/29/18, indicated Resident 131 had a BIMS score of 14; needed total staff assistance with her care needs, and had no range of motion impairment of bilateral upper and lower extremities. During an observation on 9/04/18 at 9:42 AM, Resident 21 was sitting up in bed. She was alert and non- verbal, with a [MEDICAL CONDITION] (provides an air passage to help you breathe when the usual route for breathing is obstructed or impaired. https://www.mayoclinic.org Accessed 9/13/18), her upper bedrails were both in the up position. Review of the MDS for Resident 21, dated 8/29/18, indicated Resident 21 had moderate cognition impairment and needed limited staff assistance with her care needs, and had no range of motion impairment of bilateral upper and lower extremities. During an observation on 9/04/18 at 9:42 AM, Resident 20 was sitting up in bed. She was alert and non- verbal, with a [MEDICAL CONDITION]. Her upper bedrails were both in the up position. During an interview with Resident 20, on 9/12/18 at 11:13 AM, Resident 20 gestured she used her bedrails to help her reposition in bed. Review of the MDS for Resident 20, dated 8/18/18, indicated Resident 20 had a BIMS score of 15; did not ambulate, was independent with her care and had no impairment of bilateral upper and lower extremities range of motion. During an observation on 9/04/18 at 9:45 AM, Resident 3 was in bed. She was alert and verbal, with a [MEDICAL CONDITION]. Her upper bedrails were both in the up position. During a telephone interview with Resident 3, on 9/12/18 at 1 PM, Resident 3 stated she used the bedrails when out of bed. Review of the MDS for Resident 3, dated 7/12/18, indicated Resident 3 had a BIMS score of 15; needed supervised to limited assistance with her care needs, ambulated with a walker and had no impairment of bilateral upper and lower extremities range of motion. During an observation on 9/04/18 at 10:23 AM, Resident 17 was in bed, non- verbal, with a [MEDICAL CONDITION], on a ventilator and tube feeding. She had bilateral upper bed rails in the up position. A private sitter was at her bedside. Review of the MDS for Resident 17, dated 8/15/18, indicated Resident 17 had severe cognitive impairment and needed total staff assistance with her care needs. During an observation on 9/04/18 at 10:23 AM, Resident 5 was in bed, non-verbal, with a [MEDICAL CONDITION], on a ventilator and tube feeding. She had bilateral upper bed rails in the up position. During a telephone interview with a family member of Resident 5, on 9/7/18, at 11:24 AM, the family member stated he was not informed about use of bedrails for Resident 5. Review of the clinical record for Resident 5, dated 7/1/18, indicated the family member had durable power of attorney (medical/health needs decision maker) for Resident 5. Review of the MDS for Resident 5, dated 7/10/18, indicated Resident 5 needed total staff assistance with her care needs. During an observation on 9/04/18 at 10:30 AM, Resident 19 was in bed, verbal but confused. He had bilateral upper bed rails in the up position. During an observation on 9/04/18 at 10:40 AM, Resident 9 was in bed, alert and verbal. He stated that he would be discharged . He had bilateral upper bed rails in the up position. During an observation on 9/04/18 at 10:55 AM, Resident 129 was in bed, alert and verbal. His upper bedrails were both in the up position. During an interview with Resident 129, on 9/7/18 at 12:30 PM, Resident 129 stated he used his bedrail when he repositioned himself in bed. During an observation on 9/04/18 at 11:30 AM, Resident 28 was with physical therapy at his bed side. He was alert and verbal. His upper bedrails were both in the up position. During an interview with Resident 28, on 9/7/18 at 12:30 PM, Resident 28 stated he used his bedrail for mobility when he was out of bed. Review of the MDS for Resident 28, dated 8/2/18, indicated Resident 28 had a BIMS score of15; clear speech; able to understand others, able to express his ideas and wants, and needed limited to extensive assistance with his care needs, ambulated with a walker and had no range of motion impairment of bilateral upper and lower extremities . During an interview with Staff 9, on 9/04/18 at 11 AM, Staff 9 stated bedrails were used for safety. No orders or consents were obtained prior to use of bed rails. Requested bedrail policies and procedures on 9/4/18, reply written on request list, N/A (not applicable), addressed in Restraint Policy On 9/10/18 at 10:45 AM, Staff 1 and Staff 2 were notified of substandard quality of care deficiencies for failure to implement action plans prior to the use of bed rails. During an interview with Staff 2, on 9/12/18, at 12:01 PM, Staff 2 stated, People were confused regarding the bedrail regulation because the bedrails were attached and not installed when placed in the skilled nursing facility (SNF) and subacute unit. Staff 2 stated the beds purchased and used in unit were the same type of beds used in the acute care units in the facility. Review of Policy- Assessment of Patients, revised 4/26/16, indicated, Purpose: Assessment . established to obtain appropriate and necessary information about each patient . used to match the patient's needs to the care and level and interventions required . Policy: initially assessed and reassessed throughout the patient's hospitalization Review of Policy- Restraint Management: Non Violent Restraint (Non-Behavioral), Violent Restraints (Behavioral), & Seclusion, revised 4/26/16, indicated, Policy . protects and promotes patient health, safety, dignity, rights and well- being by limiting the use of restraints . to clinically appropriate and justified situations . based on evaluation of individual patient needs . Patients have the right to be free from restraints . are not allowed . Restraints are defined as any manual, physical or mechanical device, material, or equipment attached to or adjacent to a patient's body .

Based on dietary management staff interviews and departmental document review the facility failed to ensure oversight of food service operations by a Registered Dietitian when the hospitals' disaster food supplies were partially depleted. Findings: During menu evaluation for disaster preparedness on [DATE] it was determined there were inadequate food supplies (Cross Reference F803). In an interview on [DATE] beginning at 2 p.m., Staff 14 stated he was unaware that food supplies for disaster preparedness were either expired, rotated into the regular food supply, or were not replaced. In a concurrent interview Staff 6 also stated the hospitals ' disaster preparedness committee was unaware the current food supply was depleted. In a concurrent interview DMFNS stated he was unsure if he notified the Registered Dietitian (RD), the position responsible for menu review and approval of the plan not to replace disaster food supplies. In an interview on [DATE] beginning at 2 p.m., Staff 15 stated that she was unaware the disaster supplies were not maintained in accordance with the hospitals ' RD approved menu. The food and nutrition services departmental organizational structure was concurrently reviewed with Staff 15. Onsite leadership of dietetic services was provided by DMFNS who was not a Registered Dietitian. Staff 15 also stated Staff 8 ' s oversight responsibilities for food service was limited to weekly evaluation of tray accuracy. There was no independent comprehensive evaluation of food service operations by a Registered Dietitian. Review of hospital documents titled Tray Accuracy Audit Form dated ,[DATE] and [DATE] completed by Staff 8 was limited tray presentation. Similarly, facility document titled Test Tray Evaluation dated [DATE] was limited to an evaluation of temperature and appearance of the sample tray.

Based on observation, interview and record review, the facility failed to establish a comprehensive approach prior to the use of bed rails for 29 of 30 residents. (Refer F 700). The deficient practice resulted in a Substandard Quality of Care (SQC) deficiency for failure to: Identify alternatives prior to using bed rails Review risk and benefits with each resident or resident representative Obtain informed consent prior to use Follow manufacturer's maintenance recommendations Develop and implement a process to monitor the use of bed rails. Substandard Quality of Care (SQC) is defined as: One or more deficiencies which constitute either immediate jeopardy to resident health or safety; a pattern of or widespread actual harm that is not immediate jeopardy; or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm, related to participation requirements under . Quality of Care, as define by the Centers for Medicare & Medicaid Services (CMS). Minimum data set (MDS) is an assessment tool. Brief interview for mental status (BIMS), Summary Score Total: (00-15) is used to assess residents' orientation to year, month, day; ability to understand questions and repeat and recall words. Findings: During the initial tour accompanied by Staff 5 on 9/4/18 at 11:09 AM, Resident 4 was in bed, with a [MEDICAL CONDITION] (an incision in the windpipe made to relieve an obstruction to breathing), able to converse, the three (3) bed rails (BRs) were in the up position. The minimum data set (MDS - an assessment tool) dated 7/13/18 indicated the brief interview for mental status (BIMS) had a score of 15/15 (means resident is alert, awake oriented and able to recall). Staff 5 stated Resident 4 had a muscular disorder (a group of inherited disease in which the muscles that control movement (called voluntary muscles) progressively weakens). Staff 5 stated that Resident 4 gets out of bed, has limited range of motion and is functioning at her highest level. Staff 5 stated the BRs was for safety. During an interview with Resident 4, on 9/7/18 at 10:38 AM, Resident 4 was asked about the three BRs that were in the up position and stated no one had explained the risk and benefits for use of the BR's and no one had asked for her informed consent to get the BRs up. Continued tour of the unit on 9/4/18 at 11:12 AM, Resident 7 was in bed, with a tracheotomy to ventilator (a machine designed to move breathable air into and out of the lungs, to provide breathing for a patient who is physically unable to breathe, or breathing insufficiently) and Tube Feeding (TF - a means of providing nutrition via a tube inserted into the gastrointestinal tract) via machine pump. Staff 5 acknowledged the three BRs were in the up position and stated Resident 7 was non-verbal, and in a persistent vegetative state (a condition wherein a person is not able to move or correspond with others, not aware of their self or the setting they're in, and not responsive to stimuli). During an observation on 9/4/18 at 11:45 AM, Resident 13 was awake, bed in low position with four (4) BRs in the up position. Staff 5 stated BRs were used for restraint. During an observation on 9/4/18 at 11:13 AM, Resident 1 was in bed with [MEDICAL CONDITION] to ventilator, the three BRs were in the up position. Staff 5 acknowledged the three (3) BRs were in the up position and stated Resident 1 was non-verbal, and was in a persistent vegetative state. During an interview with the Responsible Party (RP) for Resident 1, on 9/10/18 at 1:25 PM, the RP stated she knew that there were three BRs in the up position at all times, there was no discussion to explain the risk and benefits and no consent was obtained for the use of the BRs. During an observation on 9/4/18 at 11:51 AM, Resident 12 was in bed on his left side, with tracheotomy to vent and TF via machine pump, the three BRs were in the up position. Staff 5 stated Resident 12 was non-verbal. During an interview with the RP for Resident 12, on 9/7/18 at 9:27 AM, the RP was asked about the use of the BRs, the RP stated no one had explained the risk and benefits in the use of BRs, my father don't move, and verified there was no informed consent for the use of the BRs. During an observation on 9/4/18 at 11:57 AM Resident 11 was in bed with three BRs were in the up position, [MEDICAL CONDITION] to ventilator and TF was infusing via a machine pump. Staff 5 acknowledged that the three BRs were in the up position and stated resident was non-verbal. During an observation on 9/06/18 at 2:00 PM, Resident 10 was in bed, eyes opened, non-verbal with [MEDICAL CONDITION] to vent and TF infusing via machine pump, with three BRs in the up position. Staff 9 stated the BRs was for safety. During an observation on 9/4/18 at 12:15 PM, Resident 27 was in bed with [MEDICAL CONDITION] and TF infusing via a machine pump, three BRs were in the up position. Staff 5 stated Resident 27 was non-verbal and acknowledged the three BRs were in the up position. During an interview with Staff 9, on 9/06/18 at 1:48 PM, Staff 9 stated the BRs' assessment was done only if the BRs were used as a restraint and if the three BRs were in the up position, it was for safety. During an interview with Staff 1 and the Director of Regulatory Affairs (DRA) on 9/5/18 at 1:45 PM, Staff 1 stated the facility used the Stryker (brand name of the bed) with bed rails, and during admission residents were assessed by the licensed nurses for the use of BRs for safety check, it was part of their assessment. During an interview on 9/06/18 at 2:01 PM, the Staff 13 stated assessment of BRs was done if it was used as restraints but for mobility there was no assessment. During an interview with Staff 7, on 9/06/18 at 2:39 PM, Staff 7 verified that there was no Interdisciplinary Team Meeting (IDT Meeting - group of professionals from a range of disciplines with different but complementary skills, knowledge and experience who work together to deliver comprehensive healthcare aimed at providing the best possible outcome for the physical and psychosocial needs of a patient and their families) that occurred to discuss the use of BRs. During an interview with the DRA, on 9/06/18 at 10:38 AM, the DRA verified there was no assessment to identify alternatives prior to use of BRs, and no consent obtained explaining the risk and benefits to residents and/or resident representatives, and there was no policy developed to implement the process. During an observation on 9/4/18 at 9:21 AM, Resident 15 was in bed, eyes closed, with [MEDICAL CONDITION], and on tube feeding. Both upper and left lower BRs were in the up position. During an interview with the RP for Resident 15, through an online language services on 9/7/18 at 1:46 PM, the RP stated she is not sure if consent was obtained for the use of bed rails. During an interview and a concurrent review of the clinical record for Resident 15, on 9/10/18 at 2:44 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During an observation on 9/4/18 at 9:24 AM, Resident 6 was in bed, asleep, and on a ventilator. Both upper BRs were in the up position. During a phone interview with the RP for Resident 6, on 9/10/18 at 9:41 AM, the RP stated he was aware that the bed rails are in the up position but was not aware what they were for. The RP stated, I didn't know there was supposed to be a consent . He stated that no information was given to him by the physician or by the staff. . I don't remember the doctor talking to me about the rails. During an interview and a concurrent review of the clinical record for Resident 6, on 9/10/18 at 2:41 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During an observation on 9/4/18 at 9:27 AM, Resident 16 was in bed with Staff 5 and Staff 10 providing care. Both upper BRs were in the up position. Staff 10 stated resident was non-verbal. During an observation on 9/7/18 at 9:25 AM, Resident 16 was in bed, asleep with both upper BRs in the up position. During an interview and a concurrent review of the clinical record for Resident 16, on 9/10/18 at 2:43 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During an observation on 9/4/18 at 9:43 AM, Resident 8 was in bed, awake, with [MEDICAL CONDITION] and on tube feeding. Both upper and right lower BRs were in the up position. During an interview and a concurrent review of the clinical record for Resident 8, on 9/10/18 at 2:45 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During a phone interview with the RP for Resident 8, on 9/12/18 at 11:56 AM, the RP stated the risks and benefits of the use of bed rails was not discussed with her by the attending physician nor the staff. When asked, the RP stated she is aware bed rails are being used, and added, .I've always seen the rails in the up position but they've never talked to me about that until a few days ago . someone from there . told me about it . said it's a new regulation that they have to get my consent for the rails . I'm gonna to have to speak with the doctor then . During an observation on 9/4/18 at 9:58 AM, Resident 130 was in bed, asleep. The left upper BR was in the up position. Review of the MDS for Resident 130 dated 8/30/18, indicated Resident 130 had a BIMS score of 15. During an interview with Resident 130, on 9/7/18 at 11:42 AM, when asked about the bed rail use, Resident 130 stated, I think it's for safety . no, I did not request for it . She stated she does not recall the physician speaking with her regarding the risks and benefits of use of bed rails. During an interview and a concurrent review of the clinical record for Resident 130, on 9/10/18 at 2:46 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During an observation on 9/4/18 at 9:57 AM, Resident 24 was asleep with one left upper BR in the up position. During an observation on 9/7/18 at 11:39 AM, Resident 24 was awake, alert, sitting up on the right side of the bed with both feet on the floor. Both upper and right lower BRs were in the up position. During an interview and a concurrent review of the clinical record for Resident 24, on 9/10/18 at 2:46 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During an observation on 9/4/18 at 10:05 AM, Resident 25 was alert, sitting up in bed, eating a meal. The left upper BR was in the up position. During an observation and a concurrent interview on 9/7/18 at 11:45 AM, Resident 25 was in bed, awake, and alert. The left upper BR was in the up position. When asked if he consented to the use of bed rails, Resident 25 stated, . can't remember . check my record. It should be there. During an interview and a concurrent review of the clinical record for Resident 25, on 9/10/18 at 2:47 PM, Staff 13 was unable to find documentation of informed consent for the use of bed rails. During an observation and concurrent interview on 9/4/18 at 10:06 AM, Resident 23 was awake, alert, and conversant. Both upper BRs were in the up position. When asked about the bed rails, Resident 23 stated, I use them to reposition myself. I also use this thing (pointed to the bed trapeze (a mobility device hanging overhead that provides a patient with something secure to grasp when trying to change positions while in bed)) to pull myself up. Review of the MDS for Resident 23, dated 8/26/18 indicated a BIMS score of 15. During an observation on 9/4/18 at 10:01 AM, Resident 14 was in bed, awake, eyes closed. Both upper BRs were in the up position. During an observation and concurrent interview on 9/7/18 at 11:51 AM, Resident 14 was awake, alert, in bed, in the supine position. Both upper BRs were in the up position. When asked if she consented with the use of bed rails, she stated, . I don't know. During an observation on 9/4/18 at 10:02 AM, Resident 2 was awake, alert, sitting up in bed, eating breakfast. Both upper BRs were in the up position. Review of the MDS for Resident 2, dated 6/29/18 indicated Resident 2 had a BIMS score of 15. During an interview with Resident 2, on 9/7/18 at 11:47 AM, Resident 2 stated she cannot recall if she gave a consent to use the bed rails, and added, .I don't know if they asked for my consent . During an interview with Staff 1, on 9/10/18 at 2:51 PM, Staff 1 stated no consent was obtained from the patients when they were admitted , . we did not realize that it was needed due to different interpretation of the new regulation . During an observation on 9/04/18 at 9:40 AM, Resident 26 was sitting at the side of her bed. She was alert and verbal. Her upper bedrails were in the up position. During an interview with Resident 26, on 9/12/18 at 11:13 AM, Resident 26 stated she used her bedrails to help her when she gets out of bed. Review of the MDS for Resident 26, dated 8/29/18, indicated Resident 26 had a BIMS score of 15; clear speech, able to understand others, able to express her ideas and wants, independent with her care needs, and had no range of motion impairment of bilateral upper and lower extremities . During an observation on 9/04/18 at 9:41 AM, Resident 131 was in bed, alert and verbal. Her upper bedrails were in the up position. During an interview with Resident 131, on 9/12/18 at 11:13 AM, Resident 131 stated she used her bedrails for help when she is turned in bed. Review of the MDS for Resident 131, dated 8/29/18, indicated Resident 131 had a BIMS score of 14; needed total staff assistance with her care needs, and had no range of motion impairment of bilateral upper and lower extremities. During an observation on 09/04/18 at 9:42 AM, Resident 21 was sitting up in bed. She was alert and non- verbal, with a [MEDICAL CONDITION] (provides an air passage to help you breathe when the usual route for breathing is obstructed or impaired. https://www.mayoclinic.org Accessed 9/13/18), her upper bedrails were both in the up position. Review of the MDS for Resident 21, dated 8/29/18, indicated Resident 21 had moderate cognition impairment and needed limited staff assistance with her care needs, and had no range of motion impairment of bilateral upper and lower extremities. During an observation on 9/04/18 at 9:42 AM, Resident 20 was sitting up in bed. She was alert and non- verbal, with a [MEDICAL CONDITION]. Her upper bedrails were both in the up position. During an interview with Resident 20, on 9/12/18 at 11:13 AM, Resident 20 gestured she used her bedrails to help her reposition in bed. Review of the MDS for Resident 20, dated 8/18/18, indicated Resident 20 had a BIMS score of 15; did not ambulate, was independent with her care and had no impairment of bilateral upper and lower extremities range of motion. During an observation on 9/04/18 at 9:45 AM, Resident 3 was in bed. She was alert and verbal, with a [MEDICAL CONDITION]. Her upper bedrails were both in the up position. During a telephone interview with Resident 3, on 9/12/18 at 1 PM, Resident 3 stated she used the bedrails when out of bed. Review of the MDS for Resident 3, dated 7/12/18, indicated Resident 3 had a BIMS score of 15; needed supervised to limited assistance with her care needs, ambulated with a walker and had no impairment of bilateral upper and lower extremities range of motion. During an observation on 9/04/18 at 10:23 AM, Resident 17 was in bed, non- verbal, with a [MEDICAL CONDITION], on a ventilator and tube feeding. She had bilateral upper bed rails in the up position. A private sitter was at her bedside. Review of the MDS for Resident 17, dated 8/15/18, indicated Resident 17 had severe cognitive impairment and needed total staff assistance with her care needs. During an observation on 9/04/18 at 10:23 AM, Resident 5 was in bed, non-verbal, with a [MEDICAL CONDITION], on a ventilator and tube feeding. She had bilateral upper bed rails in the up position. During a telephone interview with a family member of Resident 5, on 9/7/18, at 11:24 AM, the family member stated he was not informed about use of bedrails for Resident 5. Review of the clinical record for Resident 5, dated 7/1/18, indicated the family member had durable power of attorney (medical/health needs decision maker) for Resident 5. Review of the MDS for Resident 5, dated 7/10/18, indicated Resident 5 needed total staff assistance with her care needs. During an observation on 9/04/18 at 10:30 AM, Resident 19 was in bed, verbal but confused. He had bilateral upper bed rails in the up position. During an observation on 9/04/18 at 10:40 AM, Resident 9 was in bed, alert and verbal. He stated that he would be discharged . He had bilateral upper bed rails in the up position. During an observation on 9/04/18 at 10:55 AM, Resident 129 was in bed, alert and verbal. His upper bedrails were both in the up position. During an interview with Resident 129, on 9/7/18 at 12:30 PM, Resident 129 stated he used his bedrail when he repositioned himself in bed. During an observation on 09/04/18 at 11:30 AM, Resident 28 was with physical therapy at his bed side. He was alert and verbal. His upper bedrails were both in the up position. During an interview with Resident 28, on 9/7/18 at 12:30 PM, Resident 28 stated he used his bedrail for mobility when he was out of bed. Review of the MDS for Resident 28, dated 8/2/18, indicated Resident 28 had a BIMS score of15; clear speech; able to understand others, able to express his ideas and wants, and needed limited to extensive assistance with his care needs, ambulated with a walker and had no range of motion impairment of bilateral upper and lower extremities . During an interview with Staff 9, on 9/04/18 at 11 AM, Staff 9 stated bedrails were used for safety. No orders or consents were obtained prior to use of bed rails. Requested bedrail policies and procedures on 9/4/18, reply written on request list, N/A (not applicable), addressed in Restraint Policy On 9/10/18 at 10:45 AM, Staff 1 and Staff 2 were notified of substandard quality of care deficiencies for failure to implement action plans prior to the use of bed rails. During an interview with Staff 1, on 9/10/18, at 2:51 PM, Staff 1 stated no consent was obtained from residents when they were admitted , .we did not realize that it was needed due to different interpretation of the new regulation . During an interview with Staff 2, on 9/12/18, at 12:01 PM, Staff 2 stated, People were confused regarding the bedrail regulation because the bedrails were attached and not installed when placed in the skilled nursing facility (SNF) and subacute unit. Staff 2 stated the beds purchased and used in unit were the same type of beds used in the acute care units in the facility.