Every finding on record at Faith Lutheran Home

Based on observation, document review, menu review, policy review and staff interview the facility failed to properly prepare pureed food to ensure each resident received the appropriate serving size and nutrients for 7 of 7 residents sampled (Residents #2, #4, #7, #17, #19, #20, and #37). The facility reported a census of 39 residents.Findings include:On 7/14/25 the Certified Dietary Manager (CDM) provided an untitled document with a list of residents who received a pureed diet. The list included Residents #2, #4, #7, #17, #19, #20 and #37.A Week 2, Tuesday Noon Meal Puree Menu documented the following:a. Beef cube pepper steak pureed serving #8 scoop (4 ounces (oz))b. French onion rice, #8 scoopc. Wax beans, #12 scoop (3.25 oz)On 7/15/25 at 11:15 AM Staff A, Cook, reported the facility had 7 residents that required pureed meat, and she planned to prepare seven servings of the beef cube pepper steak. At 11:16 AM Staff A placed 7, 4 oz serving of beef cube pepper steak into the food processor, added milk multiple times into the food processor without referring to any standardized recipe for a measured amount of milk. Staff A scraped the mixture from the food processor directly into a steam pan and placed the steam pan on the steam table without measuring the total volume of the pureed beef steak.On 7/15/25 at 11:23 AM Staff A explained 6 residents required pureed rice and peas. She planned to prepare 6 servings of pureed rice and peas. Staff A placed 6, 4 oz servings of French onion rice into a blender and poured milk into the blender without referring to any standard recipe or measuring out the amount of milk. Staff A placed the pureed rice mixture directly into a steam pan and placed in the steam table without measuring a total volume of the pureed rice mixture.Observation on 7/15/25 at 11:28 AM Staff A placed the blade into the food processor with her bare hand, then placed 6, 4 oz servings of green peas into the food processor, added milk without measuring the milk or referring to a standardized recipe, and blended the peas. Staff A scraped the pureed pea mixture from the blender directly into a steam pan without measuring the total volume. On 7/15/25 at 12:15 PM, Staff B, Dietary Aide, initiated the main dining room meal service. While under continuous observation, Staff B served Residents #2, #20, and #37 their pureed food with scoops not full as posted on the standardized, Dietitian approved menu, resulting in smaller portions. Staff B, Dietary Aide, completed meal service at 12:47 PM with approximately a 1/2 pan of pureed steak left over; 1/4 steam pan of pureed peas left over, and almost a 1/2 steam pan of pureed rice left over. All of the pureed steam pans measured as a size six steam pan (approximate measurements 6-78 inch in length x 6-516-inch width x 6 inches in depth).On 7/15/25 the post-noon meal observations revealed Residents #2 and #4 ate all of their pureed food items served. While Resident #37 continued to eat his last few bites of remaining peas.During an interview on 7/15/25 at 1:01 PM Staff A reviewed the Week 2, Tuesday Noon Meal Menu and stated she serves the serving size on the pureed menu. Staff A pointed to the Puree Menu and indicated a #8 scoop serving size for the steak and rice. Staff A didn't state anything about peas being served versus the wax beans listed on the dietician approved menu.Interview on 7/15/25 at 1:09 PM the CDM verbalized she expected the staff to follow the established menu, unless a resident has a special request. On 7/15/25 at 2:12 PM Staff A reported she watched training videos and observed previous cooks pureed food. Some of the cooks measured the total volume and some didn't. She didn't receive training to measure the total volume of the puree mixture and use the Pureed Diet Portion Sizes/Scoop Chart to identify the number of servings and the total volume to have a correct serving size. She only got trained to look at the chart to see the color and scoop sizes. Interview completed on 7/15/25 at 2:23 PM the CDM explained they recently received training at the hospital on how to correctly prepare pureed food. She added they stumbled on the part with adding more volume to the puree food and the serving sizes. They followed the menu for serving sizes and pointed to the Week 2, Noon Meal Menu serving sizes under the Pureed column (beef cube pepper steak #8 scoop, French onion rice #8 scoop and vegetables #12 scoop). She voiced no one explained to her how to correctly use the Pureed Diet Portion Sizes/Scoops chart. The CDM stated the food vendor Pureed Process hanging on the wall by the preparation table is the procedure that staff should follow. They just had a cook retire and she knew how to do all that, she wished she still worked at the facility to show her that stuff.During an interview on 7/16/25 at 10:12 AM the Consulting Dietitian reported the dietary staff just completed training at the hospital on pureed diet consistencies. They went over following a standardized recipe from the food vendor. She expected the dietary staff to prepare each pureed meal separately to ensure the resident received the entire serving rather than preparing all residents meals together. In regard to, preparing multiple pureed servings at the same time, the Dietician explained the facility could use the food vendor software to enter the number of puree servings, then print out a standardized menu that will calculate how much fluid to add to the food, approximately, give or take a little bit and the correct serving size. They could customize the serving size and print out for the standard recipe to know how much fluid to add when they prepared the pureed food to have an accurate serving size. They should follow the standardized recipe on how much fluid to add. If they just added fluid without measuring, the residents might not get enough nutrients from the provided serving. The facility should follow the established pureed process from the food vendor.The undated Food Vendor Puree Process directed the following steps:Measure out the desired number of servings into a container for pureeing.Puree the foodAdd any necessary thickener or appropriate liquid of nutritive value and flavor to obtain the desired consistency. Measure the total volume of the food after it is pureed.Divide the total volume of the pureed food by the original number of portions (see Puree Scoop Chart). Heat or chill the pureed food to safe serving temperatures.The Pureed Food Preparation and Service Policy, effective 1/1/25, defined the purpose as to prepare and serve pureed food safely, attractively and in accordance with the resident's individualized dietary needs. The Policy directed all dietary staff must receive hands-on training in puree preparation and be able to prepare and plate pureed meals correctly. The Policy directed the Dietitian to monitor the nutritional adequacy of the pureed diet.

Based on observation, policy review, 2022 United States (US) Food and Drug Administration (FDA) Food Code, consulting Dietitian and staff interviews, the facility failed to prevent soiled gloves from coming into contact with food during the food preparation for 4 of 4 residents (Resident #14, #23, #34 and #39). The facility reported a census of 39 residents.Findings include: On 7/15/25 observed the following during the kitchen service:At 11:28 AM without completing hand hygiene, Staff A, Cook, placed the blade into the food processor with her bare right hand, she used to touch multiple other surfaces prior to touching the food processor blade. Staff A placed 6, 4-ounce (oz) servings of green peas into the food processor to prepare pureed for Residents #2, #4, #7, #19, #20, and #37.At 11:59 AM Staff B, Dietary Aide, wore gloves used to touch multiple items (scoops, lids, plates, meal tickets, trays, a Styrofoam container, and plate warmer), and without completing hand hygiene, picked up a knife and fork on the utensil end and placed in a plastic bag. Staff B placed the plastic bag on Resident #39's room tray. At 12:05 PM Staff B stated she needed to make a cheese sandwich for Resident #39. Without washing her hands, Staff B put on new gloves, opened a bag of bread, pulled 2 slices of bread from the bag, and laid the bread slices inside a Styrofoam container. Staff B then picked up the 2 slices of bread from the Styrofoam container and placed them on the preparation table. Staff B changed her right-hand glove without performing hand hygiene and opened the walk-in refrigerator (fridge) and came back out with a plastic container of cheese slices. While they continued to wear the same used gloves, Staff B opened the cheese container and placed cheese slices on top of the bread. Staff B held the sandwich in place to cut the sandwich in half, then picked up the sandwich and placed it inside the Styrofoam container. A further observation revealed Staff B had a hole in the third finger of right-hand glove. The staff served the cheese sandwich on Resident #39's room tray. At 12:26 PM the Certified Dietary Manager (CDM) applied gloves without completing hand hygiene. She opened a bag of bread, removed 2 slices of bread, laid the bread on a tray, and tied the bread bag. Staff A wore gloves, opened the walk-in fridge, and went in. Staff A returned from the walk-in fridge with a plastic bag of lunchmeat and a plastic container of cheese slices. As the CDM, continued to wear the same gloves, opened a plastic bag, removed meat, and placed it on a slice of bread. Staff A proceeded to place a small skillet on the stove. Staff A returned to the preparation table, changed her glove on her right-hand without completing hand hygiene, picked up bread slices in her right hand, and buttered them with a knife in her left hand. Staff A opened the cheese container, placed cheese slices on the bread, placed the lid back on the cheese container, picked up the sandwich, and walked over to the stove placing the cheese sandwich in the skillet. Staff A removed her gloves and continued cooking the cheese sandwich without performing hand hygiene. Observation at 12:37 PM revealed Staff B removed a plastic bag containing a sandwich from a rack above the steam table. Staff B opened a plastic bag, removed the sandwich, and placed it on a plate wearing the same gloves, they used to touch multiple meal tickets, plate warmer lid, plates, scoops, steam lid covers, trays, every plate, scoop, meal ticket, and plate warmer. The staff served Resident #14 the sandwich. At 12:40 PM Staff A applied gloves without completing hand hygiene, opened a bread bag, removed 2 slices of bread, and tied the bread bag back up. Staff A opened a bag of wheat bread with the same gloves, removed 2 slices of bread, and tied the bread bag back up. Staff A held the bread in her right gloved hand and buttered the bread with a knife in her left gloved hand. She opened a plastic container, removed cheese slices, and placed them on the bread. Staff A picked up the sandwich with the dirty gloves and proceeded to place the cheese sandwich in a skillet on the stove. The staff served the cheese sandwich to Resident #34. Staff A continued to use the same dirty gloves and technique to prepare a peanut butter sandwich, as she touched multiple surfaces with her dirty gloves. The staff served the peanut butter sandwich to Resident #23.During an interview on 7/15/25 at 2:12 PM Staff A reported she didn't wash her hands between glove changes and confirmed she touched food with the same gloves she used to touch other items when preparing the sandwiches. Staff A explained she wore gloves when she served and used utensils, except when she made sandwiches. They always put gloves on and prepared all the sandwiches at one time. No one taught her to use tongs. She liked to use gloves but didn't like to wash her hands between glove changes, as they got trained.Interview on 7/15/25 at 2:23 PM the CDM explained she expected the staff to change their gloves between tasks and wash their hands.During an interview on 7/16/25 at 10:12 AM the Consulting Dietitian reported the dietary staff should wash their hands before applying gloves, when changing gloves, and when changing tasks. They should wash their hands if they changed from handling meat to making a sandwich. The Consulting Dietitian explained she checked with the nursing staff and CDM during visits to see if they had any concerns when she visited on-site weekly but didn't mention completing food handling audits as part of her duties.The Glove Use During Food Service Policy, dated 1/1/25, defined the purpose as to prevent foodborne illness and cross-contamination by ensuring appropriate glove use when handling and serving food in the facility. The policy directed all dietary and food service staff must wear gloves when there is a risk of direct hand contact with ready-to-eat (RTE) foods or food contact surfaces during food service. Proper glove use is required to protect resident health and comply with infection control and food safety standards. The Policy Procedure directed gloves must be worn when handling RTE foods (e.g. cooked meats, bread) and when serving food without utensils.The Glove Use during Food Service Policy effective 1/1/25 directed to change gloves after handling raw meat, when switching tasks, and when gloves become damaged, soiled or contaminated. Perform hand hygiene before putting on gloves, after removing gloves and between glove changes. The Policy under Monitoring and Compliance outlined supervisors and dietary managers would conduct routine compliance checks, and address any improper glove use promptly through coaching or disciplinary action per the facility policy. The 2022 US FDA Food Code under 2-301.14 When to Wash (hands) directed food employees to clean their hands and exposed portions of their arms immediately before engaging in food preparation, after handling soiled equipment or utensils, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, before donning gloves to initiate a task that involves working with food, and after engaging in other activities that contaminate the hands. The Food Code at 3-301.11 Preventing Contamination from Hands directed food employees may not contact exposed, ready to eat food with their bare hands, and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves or dispensing equipment.

Based on observation, clinical record review and staff interview the facility failed to provide the therapy recommended restorative program to prevent potential decline for 2 of 3 residents (Resident #14 and #30) sampled. The facility identified a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #14 with a long/short term memory impairment and severely impaired decision making ability. The Resident required total assistance with bed mobility, transfer, dressing, toileting and personal hygiene. The MDS listed a diagnosis of generalized weakness, osteoarthritis and limitation of functional range of motion of bilateral upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) body. A Progress Note dated 12/06/22 at 6:11 a.m. documented by Staff A, Restorative Aide, documented a Restorative Program Note and referred to the Physical Therapy recommendations received on 12/05/22. The Care Plan revised 12/07/22 directed the staff to provide passive range of motion (PROM) to the lower and upper body, 10 repetitions for 1 set, bilateral lower extremity (BLE) hip flexion, hip abduction, knee flexion and ankle dorsiflexion and plantar flexion. A Restorative Therapy Program signed by the Physical Therapist on 12/05/22 documented Resident # 14 to complete a restorative program 3-5 times per week of passive range of motion to the upper and lower body. The Program consisted of bilateral lower extremity (BLE) hip flexion, hip abduction, knee flexion, ankle dorsiflexion and plantar flexion and bilateral upper extremity (BUE) shoulder flexion, elbow curls and wrist flexion, 10 repetitions for one set. The 12/07/22 - 12/30/22 Restorative Care Record documented Resident # 14 received the BUE and BLE range of motion program on 12/16/22 and 12/19/22 only. A review of the 1/01/23 - 1/11/23 Restorative Care Record documented Resident #14 only received the BUE and BLE restorative program on 1/06/23. During an interview on 1/10/23 at 1:55 p.m. Staff A, Certified Nursing Assistant (CNA) and Restorative Aide, reported Resident #14 is supposed to have her restorative program completed three times a week, but she has only been able to provide her the restorative program about one time a week. Staff A reported she just wanted to be honest. During an observation on 1/10/23 at 1:58 p.m. Resident #14 lay in bed supine in bed with a finger separator and palm splint to the left hand and a palm splint to the right hand. Staff A performed hand hygiene, explained restorative program to Resident #14 and proceed to provide the following exercises for ten repetitions to each extremity for one set: a). Right and left shoulder flexion and extension b). Right and left wrist flexion/extension and flexsion/extions of the thumb and fingers. c). Right and left leg raises followed by BLE hip abduction and hip adduction exercises. Staff A failed to perform the restorative program as written by the physician therapist. Staff A failed to do the BUE elbow curls and BLE ankle range of motion. Staff A then applied the palm protector to the Resident's right hand and applied the finger separator and palm splint to the left hand before leaving the room. Staff A reported she is scheduled from 6 a.m. to 10 a.m. to work as a CNA to get residents up for the day. At 10 a.m. she does group exercise followed by the exercise programs of those resident in their Minimum Data Set (MDS) assessment seven day assessment window, then whatever time is left she uses to do the rest of the resident's exercise programs. She reported she had not informed the Director of Nursing (DON) that she has not gotten the restorative programs done as written. During an interview on 1/11/23 at 8:30 a.m. the DON reported the facility has two restorative aides. She expected the restorative staff to complete the minimum requirements for the resident restorative programs. She stated the staff may be scheduled to work the floor as a aide for half a shift, but she would still expect they could complete the minimum times per week for the restorative program as range of motion or exercises could be completed as part of the activities of daily living. She reported the facility did not have a restorative program policy. 37072 2.) Resident # 30's Quarterly Minimum Data Set (MDS) assessment dated [DATE] shown the diagnoses for the resident include high blood pressure, aphasia and cerebrovascular accident with hemiplegia. The resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Resident #30 required extensive assist of 1- 2 staff with bed mobility, transfers,ambulation, toileting, dressing and personal hygiene. She had functional impairment to one side of the upper body and to both sides of the lower body for range of motion. The Restorative Nursing Program showed three days of active and passive range of motion received. The care plan with revision date 7/27/22 directed staff to provide nursing rehab/restorative 1-2 times a day for 5-7 days per week. The task directed staff to provide a.) active range of motion to lower body 15 repetitions one times per day 5-7 times per week. b.) 2 pound weight green resistance band. Left lower extremity only for long arc quad, marching, hip abduction/adduction, bedtime curl, heel to toe raises. c.) passive range of motion to both lower extremities knee extension 5 repititions 1-2 times daily and right ankle dorsiflexion with holds x 30-45 seconds. d.) seated balance kicks, balloon hit, standing at parallel bars with blue boot on right lower extremity, Record review shown the Restorative Nursing Program Flow Sheets are signed by the Restorative Aides when the active range of motion (AROM) completed. The Restorative Program Flow Sheet showed the resident's goals to be maintain current strength levels. Review of the The Rtorative Nursing Program Flow Sheets for Resident #30 shown the following days that the Restorative Aides completed the AROM exercises: a. For November 2022: 3 of 30 days completed. b. For December 2022: 1 of 31days completed. c. For January 2022: 1 days completed thus far as of 1/11/23.

Based on document review and staff interview the facility failed to provide a Skilled Nursing Facility Beneficiary Notice of Non-coverage (SNF ABN) form CMS (Center for Medicare and Medicaid) 10055 to notify the resident an/or the legal representative of the ending of Medicare services for 2 of 3 residents (Resident #25 and #95) sampled. The facility identified a census of 42 residents. Findings include: 1. An electronic health record (EHR) census showed Resident #25 admitted to the facility on Medicare Part A services on 9/09/22 and transferred to private pay on 11/12/22. A Skilled Nursing (SNF) Beneficiary Protection Review Form CMS form 20052 completed by the facility on 1/10/23 documented Resident #25 admitted to the facility on Part A Medicare services on 9/09/22 with a last covered day on 11/11/22. A review of the beneficiary notices on 1/10/23 revealed the facility failed to serve Resident #25 or legal representative a SNF ABN CMS 10055 form as required. 2. An EHR census showed Resident #95 admitted to the facility on Medicare Part A services on 10/27/22 and transferred to private pay status on 11/26/22. A SNF Beneficiary Protection Review Form CMS 20052 completed by the facility on 1/10/23 documented Resident #95 admitted to the facility on Part A Medicare services on 10/27/22 with a last covered day for Part A services on 11/25/22. A review of the beneficiary notices on 1/10/23 revealed the facility failed to serve Resident #95 or the legal representative with a SNF ABN Form CMS 10055 form as required. During an interview on 1/11/23 at 8:35 a.m. the Director of Nursing (DON) reported the prior Social Service Director had not been getting things done. She stated the Minimum Data Set (MDS) Assessment Coordinator had been serving the beneficiary notices in the meantime and a new Social Service Director was coming on board this week and would be trained to do the beneficiary notices. During an interview on 1/11/23 at 2:25 p.m. the MDS Coordinator reported she had provided the beneficiary notices during the interim time after the Social Service Director was no longer with the facility. She had not had any formal training on how to serve the beneficiary letters. She utilized a benificiary notice guideline tool. She reported going forward the new Social Service Director would be responsible for providing the beneficiary notices to resident and/or the legal representative. The Beneficiary Notice Guideline Tool specified when the Part A stay ends because the skilled nursing facility determines the beneficiary no longer requires a daily skilled service; the Resident has days remaining in the benefit period and the Resident will remain in the facility on custodial care, the facilty should serve the CMS 10055 SNF ABN.

Based on clinical record review and staff interview, the facility failed to submit a significant change in PASRR (Pre-admission Screening and Resident Review) evaluation for 1 of 2 residents (Resident #19) sampled. The facility identified a census of 42 residents. Findings include: A Level I PASRR dated 4/29/18, section Mental Illness question #1 asked if the resident had any of the following Major Mental Illnesses (MMI). The facility's documentation indicated No the resident didn't have a MMI. The list of options to select included the diagnosis of major depression. The PASRR under Psychotropic Medications specified the resident did not take psychotropic (antipsychotic, antidepressant) medications. A review of Resident #19's Diagnosis list in the electronic health record (EHR) documented a diagnosis of major depressive disorder, single episode, unspecified dated 4/28/19. The Minimum Data Set (MDS) dated [DATE] documented Resident #19 had not been evaluated for a level 2 Pre-admission Screening and Resident Review (PASRR). The MDS dated [DATE] for Resident #19 showed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive loss and a Patient Health Questionnaire (PHQ9) score of 6 indicating mild depression. The Resident required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. The MDS listed a diagnosis of depression, psychotic disorder other than schizophrenia and identified the use of antidepressant 7 days per week and antipsychotic medications 7 days a week used on a regular basis. A Physician Order Sheet signed by the Provider on 11/29/22 showed the following medication orders: a). Quetiapine tablet (antipsychotic medication) 100 milligrams (mg) take 1 tablet by mouth twice a day. b). Sertraline tablet (antidepressant medication) 50 mg take 1 tablet at bedtime. Review of the chart completed on 1/09/23 at 3:25 p.m. lacked documentation of an updated PASRR evaluation. During an interview on 1/11/23 at 8:40 a.m. the DON reported Resident #19 had not had an updated PASRR evaluation completed. She had been hired to do a compliance review of the facility and then decided to come on board as the DON. During that time she had identified that the prior Social Service Director had not been keeping the PASRR evaluations updated. She stated the prior Social Service Director had informed her the PASRR evaluation only needed to be done once. She stated the facility has a new Social Service Director starting this week that will receive training and take over the PASRR process. The Minimum Data Set (MDS) Assessment Coordinator is currently completing the PASRR evaluations in the interim. She reported she would expect the PASRR evaluations to be updated with a change in the resident's condition. The facility did not have a policy regarding updating the PASRR evaluations.

Based on observations, staff interviews, clinical record review, policy review, and the United States Food & Drug Administration's Guide, the facility failed to assess for initial medical need and risk of entrapment of bed rails for 4 of 14 residents (#17, #27, #28, #36) and maintain ongoing bed rail evaluations for 14 of 14 residents (#8, #13, #17, #18, #19,#20, #24, #25, #27, #28, #29, #30, #32, #36); obtain consent with education of possible risk of entrapment for 6 of 14 residents (#8, #17, #18, #20, #27, #36), and the entrapment of a resident (#27) between the side rail and mattress, all of which resulted in an immediate jeopardy and could lead to serious injury, impairment, or death. The facility reported a census of residents 33. Findings include: 1. The MDS dated [DATE] indicated Resident #27 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #27 required the assistance of 2 with bed mobility, transfers, toileting, and assistance of 1 for eating. The assessment documented a history of a fall with injury. Facility document titled Care Plan dated [DATE] lacked documentation of bed rails use and revealed: my head became entangled in the side (bed) rail and the rest of my body was torso down beside my bed tonight. Please do not put up the side rail on the room side of my bed. Facility document titled Fall Risk assessment dated [DATE] revealed resident #27 as fall risk with a score of 65. Review of resident #27 EMR revealed lack of documentation of consent for bed rails, assessment for risk entrapment prior to installation and bed rail evaluations. Review of facility document titled Incident Report dated [DATE] at 3:14 a.m. revealed: a. Resident #27 found with her head caught face down in the side rail b. Resident #27 shoulder, abdomen, and feet were on the floor parallel with the length of the bed c. Resident #27 was attempting to hold herself up with her hands d. Staff was unable to obtain vital signs due to position of resident when entrapped e. Staff G, RN compressed mattress to ensure airway was intact while entrapped f. Hoyer lift was required to free resident safely from the side rail entrapment Observation on [DATE] at 9:30 a.m. Resident #27 had a dip bed without bed rails present. During an interview with Staff G, RN on [DATE] at 9:14 a.m. revealed she had been called to the resident's room on [DATE] at 3:15 a.m. visualized the resident with her head caught between the side rail and the mattress, stated her legs appeared to be coming out of the bed. Staff G stated she had been concerned that Resident #27 could not breathe and pushed down on the mattress, resident did not display shortness of breath, and her color was appropriate. Staff G stated Resident #27 had her head wedged and the staff used a Hoyer lift to lift her body, allowing her head to slip out. Staff G stated approximately ,d+[DATE] minutes elapsed during the event from start to finish. Staff G stated it had not been long since the resident had last been checked. Staff G could not recall whom she had worked with on [DATE] and stated she did not call the family or management because of the time of day. Staff G stated the mattress appropriately fit the bed frame. Staff G verbalized side rail consent forms obtained prior to installation. During an interview on [DATE] at 9:38 a.m., Staff D, RN reported her understanding of the event on [DATE] with Resident #27 was the resident was on her knees with her head slightly between the bed rail and the mattress. The resident used her arms to escape the mattress, by pushing up from the bed. She reported the resident had one arm through the bedrail on the outside and another free. She reported she is unsure how the event took place or how the resident could have ended up in that position. During an interview with Staff F, RN on [DATE] at 9:50 a.m. revealed she arrived to work at 6 a.m. on [DATE]. Staff F stated she learned in the morning report that Resident #27 rolled out of bed to the right and had her legs out of bed, which caused her head to become wedged between the side rail and mattress. Staff F stated the mattress size was appropriate. She stated the overnight staff not expected to call family or management with a fall when there are not any injuries during off shift hours which was why she called the family the following day shift. Staff F stated she believed Resident #27 had a consent for her side rail as it was required which the management team would be responsible to obtain. During an interview on [DATE] at 10:00 a.m., Staff D, RN revealed there was not an investigation conducted after the event with Resident #27 on [DATE]. Staff D stated the event discussed at morning huddle and she had a knee jerk reaction and requested all resident side rails be removed from the beds. Staff D stated the DON would have investigated the event if an injury had occurred. Staff D stated the facility does not have a policy indicating when an investigation should take place. During interview on [DATE] at 11:26 a.m.-12:17 p.m., Staff E, Maintenance Supervisor revealed: a. Beds with full side rails are from Direct Supply and use a standard foam mattress b. The facility warehouse contains two brand new beds with full side rails c. Staff E removed approximately ,d+[DATE] side rails various sizes on [DATE] after the event that involved Resident #27. d. Staff E stated he had worked maintenance at the facility 2 years and became supervisor this past February. e. Staff E stated he has never completed an assessment for possible entrapment on the side rails during his employment at the facility. f. Staff E stated the facility lacked bed manufacture documentation for side rails, mattresses, and bed frames. g. Staff E stated the mattresses used in the facility are universal and usable on both [NAME] and Direct Supply bed frames, the two bed types found in the facility. h. Foam Panacea mattress measured 41x 84 from Direct Supply i. Air mattress measured 36 x 80 pressure guard j. Concave (dip bed) measured 36 x 80 During interview on [DATE] at 6:26 p.m., Staff H, RN revealed she had been employed 3 months as an overnight nurse at the facility; her second shift was [DATE] when resident #27 trapped in the bed rail. Staff H recalled Staff J, Certified Nurse Assistant (CNA) notified staff of entrapment. Staff H stated resident #27's head was between the mattress and bed rail on her stomach and her body laid the length of the bed. She recalled the resident yelled for help. Staff H stated, Per policy we had to use a Hoyer lift to lift the resident up. She stated one staff pushed on resident mattress to allow her to move her position, one staff pushed the mattress down to assist the resident in breathing easier, and two staff members used the Hoyer lift. She stated the resident did not suffer any injuries and she is uncertain how long it had been since resident #27 last checked on. Staff H stated since the event occurred the facility has removed many other resident side rails. During interview on [DATE] at 6:40 p.m., Staff I, CNA revealed being employed at the facility for [AGE] years as a CNA and had worked for [AGE] years as a CNA. Staff I recalled the event on [DATE] with resident #27's entrapment. She recalled two nurses, Staff G and Staff H and Staff J, CNA at work when the even occurred at approximately 3:15 a.m. as she worked the A and B halls. Staff I stated Staff J called staff to resident #27's room where the resident found with her legs on the floor and clinging to the side rails and mattress and appeared as though she could not breathe. She recalled the resident yelled, I can't breathe! Staff I stated she brought the Hoyer lift to the room where the staff assisted the resident back to bed. Staff I stated the resident did not suffer any injuries and other resident side rails removed since the event occurred. During an interview on [DATE] at 6:54 p.m., Staff J, CNA revealed being employed at the facility for 8 years and had worked for 9 years as a CNA. Staff J recalled assigned to the C and D hall on [DATE] overnight shift and stated it had been an hour since she had last checked on resident #27 when she heard her yell for help. She stated when she entered the room he head was between the mattress and side rail with a ,d+[DATE] inch gap between them. Staff J stated she pushed on the mattress to assist the resident with her breathing; resident #27 did not appear short of breath. She stated once all staff were present a Hoyer lift was used to place the resident back to bed. Staff J stated the resident did not suffer any injury and recalled the facility removed bed rails from other resident beds after the event on [DATE] occurred. The situation detailed above resulted in Immediate Jeopardy (IJ) for the facility. The facility officially notified of the Immediate Jeopardy on [DATE]. The facility removed the IJ situation on [DATE] by submitting an acceptable plan of correction and immediately implementing the plan. The scope and severity of the deficiency lowered from a K to a D after the removal of immediacy verified by surveyors' onsite. The facility Plan of Correction identified the following: a. MDS Coordinator performed the assist rail assessment on all 13 residents with bed rails. The team of Director of Nursing, Administrator, MDS Coordinator, and Social Service Director reviewed the assessments to determine the appropriateness of assist rail usage and if other measures would be appropriately effective for the residents. b. The Maintenance Director performed a bed sizing risk assessment utilizing the FDA Bed Assessment Guidelines on the occupied beds with assist rails. All bed and assist rail measurements were less than the maximum allowed 4 ,d+[DATE] inches. The Maintenance Director will perform bed rail risk assessments of beds on a monthly basis. The Maintenance Director will remove the assist rails from the beds of residents who, through the MDS risk assessment process, are no longer determined to need them. The Maintenance Director will remove assist rails from unoccupied beds as well. c. The Social Service Director and the MDS Coordinator will contact impacted residents and their responsible parties to provide education on the potential risks, such as entrapment, bruising, and skin tears, of assist rail utilization and the rail removal where necessary. The educational material provided to them will be from FDA. The education conversation documented in the resident charts under the family communication heading. Consent forms were obtained for the 2 residents that met the assessment criteria for assist rails. All other assistive rails removed from occupied beds. Residents that meet the MDS assessment requirements will continue to have the assist rails attached to their beds, provided the safety education, and have a consent form signed. d. For new admissions, the education and consent forms will be in the admission packets. At the time of admission, the DON/MDS Coordinator will perform the assist rail assessment if the resident condition indicates that an assist rail may be beneficial. For existing residents, if a change in condition warrants an assistive device on the bed, the DON/MDS Coordinator will perform the assist rail assessment, provide education to the responsible party, and obtain the consent form if the assist rail deemed appropriate. e. Education was provided to the employees that engage in the assessment and installation of assist rails through the safety documents provided by the FDA on the subject matter. Side rail evaluation will be performed quarterly during the MDS process on affected residents. An addendum to the Care Conference sign-in sheet will include confirmation of continued education of families on assist rail safety utilizing the FDA educational material. Consent forms will be reviewed with families at the quarterly care conference. Continued assessment progress will be monitored through the monthly QAPI meetings. 1. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Restraints and alarms indicate bed rail not used during lookback period. Resident #8 required the assistance of 2 with bed mobility, transfers, toileting, and she is independent with eating. Facility document titled Care Plan dated [DATE] lacked documentation of bed rails use. Facility document titled Fall Risk assessment dated [DATE] revealed resident #8 as fall risk with a score of 55. Observation on [DATE] at 11:38 a.m. revealed two full sized side rails up on resident #8 bed. Review of the side rail assessments in the electronic medical record (EMR) revealed only one side rail evaluation dated [DATE]. Further review revealed a bed rail consent dated [DATE]. During a walk through on [DATE], revealed Resident #8 bed with half-length bed rails. During a second walk through on [DATE] at 11:30 am revealed the bed rails remained on the bed. 2. The MDS assessment dated [DATE] indicated Resident #17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 99, indicating severe cognitive impairment. Resident #17 required the assistance of 2 with bed mobility, transfers, toileting, and assistance of 1 for eating. The assessment documented did indicate of history of a fall with major injury. Facility document titled Care Plan dated [DATE] lacked documentation of bed rails use. Facility document titled Fall Risk assessment dated [DATE] revealed resident #17 as fall risk with a score of 55. Review of resident #17 EMR revealed lack of documentation of consent for bed rails, assessment for risk entrapment prior to installation and bed rail evaluations. Observation on [DATE] at 1:51 p.m. revealed two-quarter length bed rails (U bar) up on resident #17 bed. Observation on [DATE] at 9:02 a.m. Resident #17 had two U side rails up on her bed. During a walk through on [DATE], revealed Resident #17 bed with U bar in place. During a second walk through on [DATE] at 11:30 am revealed the U bar removed from the bed. 4. The MDS assessment dated [DATE] indicated Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Brief Interview for BIMS score of 03, indicating severe cognitive impairment. Resident #13 required the assistance of 2 with bed mobility, transfers, toileting, and extensive assistance for eating. The assessment documented history of a fall without injury. Facility document titled Care Plan dated [DATE] lacked documentation of bed rails use. Facility document titled Fall Risk assessment dated [DATE] revealed resident #13 as fall risk with a score of 55. Review of resident #13 EMR revealed one bed rail evaluation dated [DATE]. Further review revealed a bed rail consent dated [DATE]. Observation on [DATE] at 1:47 p.m. Resident #13 asleep in bed with U bars in upright position. During a walk through on [DATE], revealed Resident #13 bed with U bar in place. During a second walk through on [DATE] at 11:30 am revealed the U bar removed from the bed. 5. The MDS assessment dated [DATE] indicated Resident #18 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 99, indicating severe cognitive impairment. Resident #18 required the assistance of 1 with bed mobility, transfers, toileting, and eating. The assessment documented did indicate of history of a fall without injury. Facility document titled Care Plan dated [DATE] lacked documentation of bed rails use. Facility document titled Fall Risk assessment dated [DATE] revealed resident #18 as fall risk with a score of 65. Review of the side rail assessments in the electronic medical record (EMR) revealed only one side rail evaluation dated [DATE]. Further review revealed a bed rail consent undated. Observation on [DATE] at 1:50 p.m. Resident #18 asleep in bed with air mattress, U bars in upright position. During a walk through on [DATE], revealed Resident #18 bed with U bar bed rails. During a second walk through on [DATE] at 11:30 am revealed the bed rails removed from the bed. 6. The MDS assessment dated [DATE] indicated Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 99, indicating severe cognitive impairment. Resident #25 required the assistance of 2 with bed mobility, transfers, toileting, and assistance of 1 with eating. The assessment documented did indicate of history of a fall without injury. Facility document titled Care Plan dated [DATE] revealed: I have a left sided transfer bar to my bed, to assist me with positioning. Facility document titled Fall Risk assessment dated [DATE] revealed resident #25 as fall risk with a score of 75. Review of the side rail assessments in the electronic medical record (EMR) revealed only one side rail evaluation dated [DATE]. Further review revealed a bed rail consent dated [DATE]. During a walk through on [DATE], revealed Resident #25 bed with U bar bed rails. During a second walk through on [DATE] at 11:30 am revealed the bed rails removed from the bed. 7. The MDS assessment dated [DATE] indicated Resident #28 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 03, indicating severe cognitive impairment. Resident #28 required the assistance of 1 with bed mobility, toileting, eating and independent with transfers. The assessment documented did indicate of history of a fall without injury. Facility document titled Care Plan dated [DATE] lacked documentation of bed rails use. Facility document titled Fall Risk assessment dated [DATE] revealed resident #28 as fall risk with a score of 55. Review of resident #28 chart revealed lack of assessment for risk of entrapment prior to installation and bed rail evaluations. Review of the side rail assessments in the electronic medical record (EMR) revealed lack of documentation of bed rail evaluation. Further review revealed a bed rail consent dated [DATE]. During a walk through on [DATE], revealed Resident #28 bed with U bar bed rails. During a second walk through on [DATE] at 11:30 am revealed the bed rails removed from the bed. 8. The MDS assessment dated [DATE] indicated Resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 99, indicating severe cognitive impairment. Resident #30 was independent of staff with bed mobility, toilet use, required the assistance of 1 with transfers, and stand by assistance with eating. The assessment revealed no falls since admission. Facility document titled Care Plan dated [DATE] lacked documentation of bed rails use. Facility document titled Fall Risk assessment dated [DATE] revealed resident #30 as fall risk with a score of 75. Review of the side rail assessments in the electronic medical record (EMR) revealed only one side rail evaluation dated [DATE]. Further review revealed a bed rail consent dated [DATE]. Observation on [DATE] at 1:32 p.m. Resident #30 asleep in bed, call light within reach, U bars attached to bed. During a walk through on [DATE], revealed Resident #30 bed with U bar bed rails. During a second walk through on [DATE] at 11:30 am revealed the bed rails removed from the bed. 9. The MDS assessment dated [DATE] indicated Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident requires staff assistance of 2 with bed mobility, toilet use, and staff assist of 1 with transfers and eating. The assessment revealed no falls since admission. Facility document titled Care Plan dated [DATE] revealed: U rails up as per doctor order for safety during care provision, to assist with bed mobility. Observe for entrapment related to side rail use. Review of the side rail assessments in the electronic medical record (EMR) revealed only one side rail evaluation dated [DATE]. Further review revealed a bed rail consent dated [DATE]. Observation of resident #32 sitting in her wheelchair in her room talking to herself and U bar on bed. During a walk through on [DATE], revealed Resident #32 bed with U bar bed rails. During a second walk through on [DATE] at 11:30 a.m. revealed the bed rails removed from the bed. 10. The MDS assessment dated [DATE] indicated Resident #36 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Brief Interview for BIMS score of 03, indicating severe cognitive impairment. Resident #36 required staff assistance of 2 for bed mobility, transfer, toilet use, and assistance of 1 with eating. The assessment revealed no falls since admission. Review of the Care Plan dated [DATE] revealed no documentation of bed rails use. Facility document titled Fall Risk assessment dated [DATE] revealed resident #36 as fall risk with a score of 75. Review of resident #36 chart revealed lack of assessment for risk entrapment prior to installation and bed rail evaluations. During a walk through on [DATE], revealed Resident #36's bed with U bar bed rails. During a second walk through on [DATE] at 11:30 am revealed the bed rails removed from the bed. Observation on [DATE] at 1:48 p.m. Resident #36 asleep in bed, call light within reach, U bars attached to bed. Fall mat on floor next to bed. 11. The MDS assessment dated [DATE] revealed Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident's cognition intact with a BIMS score of 15 out of 15. The resident's MDS showed the resident required extensive assistance with one staff member for transfers, bed mobility, and toileting. The resident's Care Plan dated [DATE] revealed the resident required assistance of one staff member for transfers and ADLs. The Care Plan also showed the resident utilized bed rails. A fall risk assessment dated [DATE] revealed the resident a high risk for falls. Review of the side rail assessments in the electronic medical record (EMR) revealed only one side rail evaluation dated [DATE]. Further review revealed a bed rail consent dated [DATE]. During a walk through on [DATE], revealed Resident #20's bed with half-length bed rails. During a second walk through on [DATE] at 11:30 am revealed the bed rails removed from the bed. 12. The MDS assessment dated [DATE] revealed Resident #19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed resident had intact cognition with a score of 15 out of 15. The MDS revealed the resident required only supervision for bed mobility and toileting. The resident required limited assistance with setup for transfers. A Care Plan dated [DATE] revealed Resident #19 required assistance for transfers and utilized side rails. A fall risk assessment dated [DATE] revealed the resident a high risk for falls. During a walk through on [DATE], revealed Resident #19's bed with quarter-length bed rails. During a second walk through on [DATE] at 11:30 am revealed the bed rails removed from the bed. Review of the side rail assessments in the electronic medical record (EMR) revealed only one side rail evaluation dated [DATE]. Further review revealed a bed rail consent dated [DATE] and bed rail order dated [DATE]. 13. The MDS dated [DATE] revealed Resident #29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident had slight cognitive impairment with a BIMS score of 11. The MDS showed Resident #29 required assistance of one staff member for bed mobility, transfers, and toileting. A Care Plan dated [DATE] for Resident #29 revealed the resident required assistance for transfers and ADLs. However, the Care Plan did not reflect use of side rails. A fall risk scale dated [DATE] revealed the resident as a high risk for falls. Review of the side rail assessments in the electronic medical record (EMR) revealed only one side rail evaluation dated [DATE]. Further review revealed no bed rail consent. Observation of resident #29 on [DATE] at 1:40 p.m. revealed resident walking independently with front wheeled walker, U bar in place on bed. Stated she liked living there. 14. The MDS dated [DATE] revealed Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident's cognition intact with a BIMS score of 15. The resident's MDS showed the resident required extensive assistance with one staff member for transfers, bed mobility, and toileting. The resident's Care Plan dated [DATE] revealed the resident required assistance of one staff member for transfers and ADLs. The Care Plan also showed the resident utilized bed rails. A fall risk assessment dated [DATE] revealed the resident a high risk for falls. During a walk through on [DATE], revealed Resident #24 bed with half-length bed rails. During a second walk through on [DATE] at 11:30 am revealed the bed rails removed from the bed. Review of the side rail assessments in the electronic medical record (EMR) revealed only one side rail evaluation dated [DATE]. Further review revealed a bed rail consent dated [DATE]. During an observation on [DATE] at 11:44 a.m. Resident #24 laid in bed watching television, full side rails (half-length of bed) x2 were in an upright position. Observation on [DATE] at 10:45 a.m. facility beds with side rails: a. 11 U bar side rails measured w-10 ,d+[DATE] x h-16 ½ b. 2 full side rails measured w-28 x h-11 ½ with 1 gap During an interview on [DATE] at 9:02 a.m., Director of Nursing (DON) revealed Staff D, Registered Nurse (RN) was to complete all bed rail assessments upon admission. During an interview with Staff D, RN on [DATE] at 9:21 a.m. revealed the facility installs a U bar for mobility purposes but she did not think they had classified it as an actual side rail or that a consent was required. Staff D stated she had been inconsistent with obtaining consents. Staff D stated Staff E, Maintenance Supervisor installed all U bar side rails, and she is unaware if he assessed for entrapment. Staff D stated all documentation goes under the miscellaneous tab in Point Click Care. During an interview with Staff E, Maintenance Supervisor on [DATE] at 11:20 a.m. revealed when side rails request are made he directed staff to Staff D. Staff E stated Staff D will obtain a consent and then he will install side rails. Staff E stated he does not obtain consent, nor complete assessment of side rails for possible entrapment or functionality. Staff E stated when a side rail is broke the staff will inform him. Staff D stated he has not had any work orders regarding side rails that needed fixed. Review of the Food & Drug Administration's (FDA) Hospital Bed Safety Workgroup (HBSW) article, Clinical Guidance For the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings, dated [DATE], indicated, Use of bed rails should be based on patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team . Bed rail use for patient's mobility and/or transferring, for example, turning and positioning within the bed and providing a hand-hold for getting into and out of bed, should be accompanied by a care plan .Inspected, evaluated, maintained, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards and appropriately match the equipment of patient needs, considering all relevant risk factors . If it is determined that bed rails are required .the mattress and bed. Maintenance and monitoring of the bed, mattress, and accessories such as patient/caregiver assist items . should be ongoing. According to the FDA's Guidance for Industry and FDA Staff article, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued [DATE], For [AGE] years, FDA has received reports in which vulnerable patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term entrapment describes and event, in which a patient/resident is caught, trapped or entangled in the or about the bed rail, mattress, or hospital bed frame. Patient entrapment may result in death and serious injuries. FDA received appropriately 691 entrapment reports over a period of [AGE] years from [DATE] to [DATE]. In these reports, 413 people died , 120 were injured, and 158 were near- miss events with in serious injury as a result of intervention. These entrapment events have occurred in opening within the bed rails, and between the bed rails and head or footboards. The population most vulnerable to entrapments are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Entrapments have occurred in a variety of patient care settings. The HBSW considers a resident to be at high risk to injury when he or she cannot move safely from a bed to a wheelchair, cannot move safely from the toilet without assistance, had previous entrapment episodes, had previous bed-related injuries, or had fallen from a bed, or had difficulties using call alarms. -

Based on review of infection prevention policies and procedures, staff interviews, observations, and review of hand washing policy, the facility failed to maintain infection prevention policy containing documents for transmission based precautions, antibiotic stewardship and other facility policy and procedures. During a dining observation staff failed to wash their hands appropriately. At the time of the survey, the facility reported a census of 33 residents. Resource: Centers for Disease Control and Prevention. (2021, January 8). Healthcare Providers. Centers for Disease Control and Prevention. https://www.cdc.gov/handhygiene/providers/index.html. Findings include: 1. During a dining observation on 6/8/21 at 12:22 pm revealed Staff G, CNA, assisted Resident #4 with cutting up her food, after assisting the resident Staff G went to Resident #25's table and began to rub Resident #25's back. After rubbing Resident #25's back, she assisted another resident in tying their clothing protector. After assisting the resident with their clothing protector, Staff G went to the kitchen and sanitized her hands. Staff G pushed a resident closer to the table for lunch, and then Resident #8 began to cough. Staff G left the resident to assist Resident #8, placed a napkin to the resident's mouth, and told her to cough out the food. After Resident #8's coughing ceased. Staff G went to the kitchen and sanitized her hands. Review of the undated handwashing policy which referenced the Centers for Disease Control (CDC) website, revealed staff are to wash their hands to cleanse hands to prevent the spread of potentially delay infections and provide a clean and health environment for residents, visitors and their peers. Review of the CDC website on 6/16/21 at 10:41 am revealed staff should wash their hands before touching a resident and after touching resident or the resident's immediate environment. 2. During an interview with DON on 6/9/21 at 10:18 a.m. revealed: a. The facility does not have an active Infection Preventionist employed; the facility did hire a new nurse who has yet to start b. The facility lacks Infection Prevention Control Program (IPCP) including standards of care, policies, and procedures. c. Nursing staff are to refer to Lippincott, 2006 Edition for standards of practice and communicable diseases d. Lack of Antibiotic stewardship log of resident infectious processes tracked beyond the date of 6/2020 e. Lack of IPCP policies and procedures reviewed annually f. Lack of nursing staff infectious processes/absences Review of facility document titled Infection Control Policy, undated revealed facility expectations for IPCP including definitions. The policy provided lacked demonstration of implementation of categories listed: a. Surveillance for communicable diseases or infections b. Reporting of communicable diseases or infections c. Standard and transmission-based precautions for the spread of infections d. When and how isolation should be used for residents e. Respiratory hygiene f. Antibiotic stewardship program g. Annual review of IPCP h. Documentation to QA of IPCP on a regular basis -

Based on clinical record review and staff interview, the facility failed to ensure all staff were aware of residents' health decisions regarding advanced directives (to be resuscitated or not) and failed to document an accurate code status for 1 of 1 current residents reviewed for advanced directives (Resident #21 ). The facility reported a census of residents 33. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident diagnoses; hypertension, diabetes mellitus, [CONDITION(S)] or renal failure, history of pulmonary embolism and history of Covid infection. The MDS revealed the resident's Brief Interview for Mental Status (BIMS) of 10 out of 15 (some impaired cognition). Review of Resident #21's care plan revealed no advanced directives. Review of Resident #21's orders on the electronic medical record (EMR) revealed an advanced directive order for do not resuscitate (DNR). Review of the EMR's dashboard revealed the resident's advanced directives as DNR status. An IPOST dated [DATE] scanned into the resident's EMR revealed the resident's code status as a full code. A paper from the facility asking the resident's wishes for advanced directives revealed a full code status. Review of the copy in the hard chart on [DATE] at 4:30 pm revealed an IPOST for Resident #21 as a full code status. During an interview on [DATE] at 5:30 pm, Staff A, LPN, reported if a resident coded he would check the IPOST in the hard chart to see whether the resident is a full code or DNR An interview [DATE] at 5:45 pm with Staff B, revealed the staff member unsure of where to look for the code status. The staff member went to check with another staff member and then reported she would look the advanced directives up in the EMR and located the code status on the resident's dashboard. An interview on [DATE] at 5:46 pm with Staff C revealed he would check the care plan for the code status. During an observation of the pocket care plan for Resident #21 on [DATE] at 9:45 a.m., revealed advanced directive status of DNR. An undated CPR policy revealed physicians would sign an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Each resident has the right to formulate his or her own advanced directives. CPR should be provided to all residents when CPR is requested on the advanced directives, who have not formulated an advanced directive, who do not have a valid DNR order, or who show signs of clinical death. During an interview on [DATE] at 9:30 a.m., the social worker and the MDS coordinator reported they have worked on a system where staff should look at the PCC (Point Click Care) dashboard and then there is a pocket care plan on the back of the mirror in the resident's room. The MDS coordinator made aware of the resident's status and reported she would change the status on the dashboard for staff to follow The social worker reported she spoke with family and reported to her they wanted resident #21 to be a DNR, however, she reported she spoke with the Resident #21 who wished to be a full code because she just had another grandbaby. The social worker reported Resident #21's BIMS of ,d+[DATE]. -

Based on resident interview, observation and record review, the facility failed to develop and implement a Comprehensive Person Centered Care Plan that included [CONDITION(S)] medications for 1 of 17 residents reviewed (Resident #25). The facility had a census of 33. Findings Include: Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further exploration of the MDS revealed that on a seven-day look back, the resident received anti-depressants 7 out of 7 days. Review of Resident #25's orders on the electronic medical record (EMR) revealed the resident prescribed [MEDICATION(S)] (an anti-depressant) and [MEDICATION(S)] (anti-depressant and nerve medication) for major depressive disorder diagnoses. Review of Resident #25's Care Plan dated 4/7/21 revealed no documentation for [CONDITION(S)] medications on the care plan. -

Based on facility schedule reviews the facility failed to have a registered nurse (RN) on duty 8 hours daily 7 days per week. The facility identified a census of 33. Findings include: 1. Review of the facility's nursing staff schedule for April 2021 through June 2021 revealed no registered nurse coverage for hours between 12 am till 10 pm on 5/31/21. There was no nurse coverage on overnights the night prior from 5/30/21 through 5/31/21. The schedule showed a nurse scheduled for the night shift of 5/31/21 from 10 pm until 6 am the next morning of 6/1/21 equating to six hours of no RN coverage for 5/31/21. Review of the schedule for 6/6/21 showed nurse coverage for the previous night 6/5/21, from 10 pm until 6 am. However, the schedule reflected no further nurse coverage for the remainder of the day on 6/6/21 resulting in 2 hours not covered by a registered nurse. Review of the working schedule revealed neither the DON nor the MDS Coordinator were assigned to work on the above-listed dates. Review of an undated nursing services policy revealed the facility is expected to provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents except when waived. The facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. During the entrance conference of the survey on 6/7/21 at 11:35 am, the administrator reported the facility did not have any nursing waivers. -

Based on observations, clinical record review and staff interviews, the facility staff failed to provide an end date for an as needed (PRN) [CONDITION(S)] medication for 1 of 4 residents reviewed (#36). The facility reported a census of 33. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 had a diagnoses of dementia with behavioral disturbances, [CONDITION(S)] (CVA), hypertension, non-Alzheimer's dementia, anxiety, and depression. The resident had a Brief Interview of Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Resident #36 received 7 of 7 days and displayed verbal behaviors 1-3 days during lookback period. Resident #36 required assistance of 2 with bed mobility, transfers, toileting assistance, and assistance of 1 with eating. Resident #36 is frequently incontinent of urine and continent of bowels. Facility document titled MD/Nursing Communication dated 5/22/21 revealed nursing request per family for [MEDICATION(S)] prn due to increased restlessness, wandering, and anxiety. Physician order indicated Lorazepam 0.5mg prn acute anxiety without an end date. Facility document titled Medication Administration Record (MAR) dated 6/1/21-6/30/21 revealed Lorazepam 0.5mg to be given as needed anxiety twice per day (BID), start date 5/24/21, without an end date. The care plan initiated 5/19/21 revealed a lack of documentation on prescribed [CONDITION(S)] medications, diagnosis, behaviors, evaluation of effectiveness for possible side effects and elimination of the [CONDITION(S)] drug, instruction to monitor resident mood or behaviors and indications to administer. Facility lacks policy on administering PRN [CONDITION(S)] medications. During an interview with Staff F, Registered Nurse (RN) on 6/10/21 at 9:50 a.m. revealed a PRN [MEDICATION(S)] physician order is only to be for 14 days and if received would need to be clarified with the physician. Staff F said there is not a facility policy that states PRN [CONDITION(S)] needs an end date. -

Based on observation, staff interview, and facility policy review, the facility failed to store and prepare food in accordance with professional standards for food service safety. The facility reported a census of 33. Findings include: Observation of the initial kitchen tour on 6/7/21 at 10:40 a.m. revealed the following: a. Two unopened bottles of lemon juice with an expiration date of 4/24/20 b. Opened and undated bottle of Planter's peanuts c. Opened and unlocked cabinet of cleaning products located next to standup freezer d. Uncovered and undated pan of bars e. Cart of staff drinks on food cart in walk in refrigerator f. Box of tomatoes with white fuzz on two tomatoes Observation of follow up kitchen tour on 6/8/21 at 10:45 a.m. revealed the following: a. Opened and undated bottle of Planter's peanuts b. Plate of covered dessert bars without date made c. Opened bag of potato pearls on counter During a staff interview with Dietary Manager on 6/7/21 at 10:40 a.m. revealed all food items in the kitchen will have date delivered (dd) and date it was opened. Facility document titled Standard Operating Procedure for Dietary department without a date, revealed: a. Dry food storage: receipt and storage of dry food are manage: removing foods not safe for consumption, dry food products kept in closed containers, and supplies are rotated. b. Refrigerated/frozen storage: refrigerated foods are labeled, dated, and monitored refrigerated so it is used by its use-by date or frozen (where applicable) or discarded. -

Based on facility policy review and staff interview, the facility failed to implement an Antibiotic Stewardship Program. The facility reported a census of 33 residents. Findings include: Review of the facility's policy and procedure for Infection Control revealed no policies and procedures pertaining to an Antibiotic Stewardship Program that included antibiotic use protocols or a system to monitor antibiotic use. In an interview on 6/9/21 at 1:57 p.m., the Director of Nursing (DON) stated there was a book with the infection prevention policies and procedures but the last infection preventionist left and took the book with them. The DON reported she could not produce the facility's antibiotic stewardship at the time of the survey. The DON did report the facility utilized the McGeer's criteria for antibiotics. -

Based on observation, staff interview, screening review and policy review the facility failed to ensure employees with signs and symptoms of COVID-19 were not working with COVID-19 negative residents. The facility reported a census of 48. Findings include: Staff A filled out the Preventing COVID-19 screening log on 10/13/2020 twice, with no times documented, 10/14/2020 at 1:25 PM, 10/15/2020 with no time documented, and 10/16/2020 at 1:25 PM and 10:00 PM. Each time she documented she was afebrile and had none of the symptoms on the screening log. On 10/18/2020 with no time documented, Staff A documented on the screening log she was afebrile. She circled both yes and no to having a cough, yes to sore throat, yes to new shortness of breath or difficulty breathing, yes to chills and/or repeated shaking with chills, and yes to headache. On 10/19/2020 with no time documented, Staff A documented on the screening log she was afebrile. She circled yes and no to having a cough, yes and no to new shortness of breath or difficulty breathing, yes to chills and/or repeated shaking with chills, yes to muscle pain, and yes to headache. On 10/20/2020 with no time documented, Staff A documented on the screening log she was afebrile. She circled yes to having a cough, yes to new shortness of breath or difficulty breathing, yes to chills and/or repeated shaking with chills, and yes to headache. On 10/20/2020 there is a second entry on the screening log with no time documented for Staff A. She documented she was afebrile. She circled yes to cough, yes to new shortness of breath or difficulty breathing, yes to chills and/or repeated shaking with chills, and yes to headache. On 10/21/2020 with no time documented, Staff A documented on the screening log she was afebrile. She circled yes to cough, yes to new shortness of breath or difficulty breathing, yes to chills and/or repeated shaking with chills, and yes to headache. On 10/22/2020 with no time documented, Staff A documented on the screening log she was afebrile. She circled yes to cough, yes to new shortness of breath or difficulty breathing, yes to vomiting and/or diarrhea, and yes to headache. On 10/24/2020 with no time documented, Staff A documented she was afebrile. She circled yes to cough, yes to new shortness of breath or difficulty breathing, yes to muscle pain, and yes to headache. During an interview with Staff B, Staff A was at work for an hour on 10/24/2020 and was sent home. Staff A called off on 10/25/2020 and 10/26/2020. Documentation provided by Staff B showed Staff A had negative COVID-19 tests on 10/13/2020 and 10/18/2020. Staff A tested positive on 10/24/2020. The facility had 28 residents that were COVID negative on 10/18/2020. On 10/19/2020, 10 residents tested positive. On 10/20/2020, 2 residents tested positive. On 10/22/2020, the remaining 16 residents tested positive. During an interview with Staff B on 10/27/2020 at 9:30 AM, she stated no one monitors the screening log. She stated she relies on staff telling her they don't feel well. She stated she had no idea Staff A was having symptoms, if she had known, they would have sent her home. During an interview on 10/27/2020 at 1:47 PM, Staff C stated the screening process would include having your temperature taken and completing the screening log. She stated the expectation is for staff to call the facility on their cell phones if they answer yes to any of the questions and a nurse would complete an assessment.

Based on clinical record review, resident, family and staff interviews, the facility failed to provide baths for 5 of 5 residents reviewed. The facility reported a census of 48. 1. According to the Minimum Data Set (MDS) with Assessment Reference Date (ARD) 8/18/2020, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12, moderately impaired cognitive skills. The resident required staff assist with bathing. During an interview with Resident #1 on 10/26/20 at 1:25 p.m., she stated she did not know when her last bath was. She stated it had been a long time. She stated she would like a shower. During the interview, the surveyor noted the resident's hair to appear greasy. Resident #1's Point Of Care (POC) Response History documented the resident is to have a bath 2 times a week to help with pain and odor. The POC Response History showed No Data Found when reviewed on 10/26/1010 for the prior 14 days. Review on 10/26/2020 for the previous 30 days documented baths on 9/27/2020, 10/2/2020 and 10/9/2020. 2. According to the MDS with ARD of 8/18/20 Resident #2 had a BIMS score of 10, moderately impaired cognitive skills. The resident required total dependence with bathing. Resident #2's POC Response History for bathing showed No Data Found when reviewed on 10/26/1010 for the prior 14 days. Review on 10/26/2020 for the previous 30 days documented baths on 10/9/2020 and 10/12/2020. No other baths were documented for the prior 30 days. The facility did provide a hand written bath list showing Resident #2 received a bed bath on 10/23/2020. Resident #2's Care plan documented the resident is to have a bath or shower 2 times a week or more, revised on 12/31/19. 3. According to the MDS with ARD of 7/28/20 Resident #3 had a BIMS score of 15, cognitively intact skills for daily decision making. The resident required physical help with bathing. During an interview with Resident #3 on 10/26/20, she stated her last bath was over a week ago. She did not recall exactly how long it had been. She stated she would like a shower. During the interview, the surveyor noted the resident's hair to appear greasy. Resident #3's POC Response History showed No Data Found when reviewed on 10/26/1010 for the prior 14 days. Review on 10/26/2020 for the previous 30 days documented no baths. The Resident's Care Plan shows she prefers to have a shower in the morning with no frequency specified, revised on 4/17/20. 4. According to the MDS with ARD of 7/28/20 Resident #4 Had a BIMS score of 15, cognitively intact skills for daily decision making. The resident required physical help with bathing. During an interview with Resident #4 on 10/26/20 at 1:28 p.m., she stated she did not know when her last bath was. She stated it had been a while. She stated she would like a shower. During the interview, the surveyor noted the resident's hair to appear greasy. Resident #4's POC Response History showed No Data Found when reviewed on 10/26/1010 for the prior 14 days. Review on 10/26/2020 for the previous 30 days documented baths on 9/27/2020, 10/6/2020 and 10/10/2020. 5. According to the MDS with ARD of 7/21/20 Resident #5 had a BIMS score of 15. The resident required physical help with bathing. During an interview with Resident #5 on 10/26/20, she stated she had not had a shower in a while. She stated her hair felt like it needed washed. During the interview, the surveyor noted the resident's hair to appear greasy. Resident #5's The POC Response History documented the resident is to have a bath on Tuesday's and Friday's in the morning. The POC Response History showed a bath on 10/13/2020 when reviewed on 10/26/1010 for the prior 14 days. Review on 10/26/2020 for the previous 30 days documented baths given on 9/27/2020, 10/2/2020 and 10/9/2020. During an interview on 10/27/2020 at 8:43 AM with Staff C, Assistant Director of Nursing she stated staff was doing bed baths for residents in the COVID unit as there was no shower room available. She stated they were using shower caps for washing hair once a week. She acknowledged the lack of shower documentation and stated she know if it isn't documented, it isn't done.

Based on clinical record review, resident and staff interview, the facility failed to notify families of confirmed COVID-19 positive lab results by 5:00 PM the next calendar day, for 4 of 5 residents reviewed. The facility reported a census of 48. Review of Resident #1's Progress Note dated10/18/2020 documented communication with the physician that the resident had a nonproductive cough and was afebrile. A Rapid COVID 19 test had been administered and returned with positive results. The Progress Note dated 10/21/2020 documented the family was notified of the resident's condition with education and reassurance provided. Review of Resident #2's Progress Note dated 10/22/2020 documented the nurse called the resident's daughter to inform of COVID testing being done today and updated on current condition. A Progress Note dated 10/25/2020 documented the nurse called the resident's daughter and let her know the resident was positive for COVID. Review of Resident #3's Progress Note dated 10/19/2020 documented communication with the physician that the resident was administered a Rapid COVID 19 test with positive results. The resident was afebrile and had no respiratory symptoms. The Progress Note dated 10/21/2020 documented the family was updated on the resident's condition with education and reassurance provided. Review of Resident #5's Progress Note dated 10/19/2020 documented a Rapid COVID 19 test was administered with positive results. The resident was afebrile with no respiratory symptoms noted. The Progress Note dated 10/21/2020 documented the family was updated on condition with education and reassurance provided. During an interview with the Administrator on 10/26/2020 at 10:15 AM, he stated he was the one making the phone calls to families regarding the COVID- 19 status in the building. He stated when he tested positive and was unable to work in the facility, the responsibility to notify families fell to the charge nurse.

Based on clinical record review and staff interview, the facility failed to notify one residents physician of an increase in a non-pressure wound. (Resident #10) The facility census was 53 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #10 had [DIAGNOSES REDACTED]. and [MEDICAL CONDITION]. A skin report initiated 5/21/19 showed a superficial pink open area to the residents right upper buttock increased in size from 0.2 centimeters (cm) on 6/20/19 to 0.7 (cm) on 7/4/19. Progress notes from 6/20/19 through 7/9/10, showed no notification to physician of the change in the wound size to the residents right upper buttock. During interview on 7/10/19 at 9:05 a.m., the Director of Nursing (DON) confirmed the physician was not notified of the increased size in the residents wound to the right buttock and stated the physician should have been notified.

Based on clinical record review and staff interview, the facility failed to submit a PASSAR (Pre Admission Screening and Resident Review) for review for one resident with a new mental health diagnosis. (Resident #3). The facility census was 53 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], showed active [DIAGNOSES REDACTED]. In review of PASSAR assessment dated [DATE] showed resident without major mental health [DIAGNOSES REDACTED]. The Resident [DIAGNOSES REDACTED]. During interview on 7/10/19 at 1:29 p.m., the Director of Nursing stated a new PASSAR should have been submitted for the resident to include [DIAGNOSES REDACTED].

Based on observation, clinical record review and staff interview, the facility failed to assess bed side rails for risk of entrapment and obtain consent for use for two of four residents reviewed. (Resident #2 & #33) The facility census was 53 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #2 had [DIAGNOSES REDACTED]. Observation on 7/8/19 at 1:19 p.m., showed the resident bed with upper side rails in the upright position. Observation on 7/10/19 at 8:26 a.m., showed the resident in bed with upper side rails in the upright position. The care plan last revised 7/2/19, showed the resident utilized ¼ side rails for safety during care provision and to assist with bed mobility. During interview on 7/10/19 at 12:41 p.m., the Director of Nursing (DON) confirmed the facility does not have a consent signed by the resident or representative for use of side rails. During interview on 7/10/19 at 3:50 p.m., the DON stated the facility had no side rail assessment for use of side rails. 2. The MDS assessment dated [DATE], showed Resident #33 had [DIAGNOSES REDACTED]. Observation on 7/9/19 at 10:33 a.m., showed the resident in bed with a short upper side rail on the bed in the upright position. Observation on 7/10/19 at 6:43 a.m., showed the resident in bed with a short upper side rail in the upright position. The care plan last revised 6/17/19, showed the resident utilized ½ side rails for comfort and mobility in bed. During interview on 7/10/19 at 12:42 p.m., the DON confirmed the facility does not have a consent signed by resident or representative for the use of side rails.

Based on clinical record review and staff interview, the facility failed to ensure the comprehensive care plan included the antidepressant and antianxiety medications for one of five residents reviewed. (Resident #34) The facility census was 53 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 had [DIAGNOSES REDACTED]. Current Physician order [REDACTED].>The care plan revised on 6/6/19, failed to show the use of the antidepressant and antianxiety medications and failed to identify adverse side effects related to the use of the medications. During interview on 7/10/19 at 2:33 p.m., the Director of Nursing (DON) reported she expected the care plan to address the use of the antianxiety and antidepressant medications. During interview on 7/10/19 at 3:00 p.m., the MDS Coordinator reported the care plans must be individualized.