**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, resident record reviews, review of the facility policy titled, Comprehensive Care Plans, and review of the Minimum Data Set (MDS) Nurse's Job Description, the facility failed to ensure care plan meetings for Resident (RI) #7 and RI #25 were conducted timely. This affected RI #7 and RI #25, two of eighteen sampled residents whose care plans were reviewed. Findings include: A review of a facility policy titled, Comprehensive Care Plans with a revision date of 01/24/2023 revealed: . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. 2. The comprehensive care plan will be developed within 7 days after the completion of the Comprehensive MDS assessment. Employee Identifier (EI) #6's job description documented: MDS NURSE JOB DESCRIPTION . Position Purpose Conducts and coordinates the completion of required Resident Assessment Instrument (RAI) and is responsible for the implementation and ongoing evaluation of each resident's comprehensive plan of care. Major Duties and Responsibilities . Implementation and ongoing evaluation of each resident's comprehensive plan of care. Scheduling and leading interdisciplinary care plan team meetings. RI #7 was admitted to the facility on [DATE] and had diagnoses to include Adjustment Disorder with Anxiety, Bipolar Disorder, and Orthopedic aftercare. RI #7's care plan sign-in sheets were reviewed. There was no care plan meeting following the annual MDS assessment dated [DATE]. RI #25 was re-admitted to the facility 03/07/2022 and had diagnoses to include Infectious Gastroenteritis and Colitis, and Hypokalemia. RI #25's care plan sign-in sheets were reviewed. There was no care plan meeting following the annual MDS assessment dated [DATE] or the quarterly MDS assessment on 03/03/2023. The facility Care Plan Conference schedule dated December 2022 was reviewed. RI #25 was scheduled for a care plan conference on 12/20/2022 at 1:45 PM. The facility Care Plan Conference schedule dated March 2023 was reviewed. RI #7 was scheduled for a care plan conference on 03/14/2023 at 1:45 PM and RI #25 was scheduled for a care plan conference on 03/28/2023 at 1:30 PM. The facility was unable to provide documentation of these care plan conferences or evidence the conferences had taken place. On 06/23/23 09:29 AM an interview was conducted with EI #6, MDS Coordinator. EI #6 was asked what part she had in ensuring the care plans are addressed after MDS assessments. She answered that she notified the representative, residents and the IDT team members. EI #6 was asked when should care plan meetings be scheduled. She said around a week after the assessment was completed. EI #6 was asked why that was not done since 09/27/22 for RI #25. EI #6 said, RI #25 was in the hospital in December when it was scheduled. EI #6 was asked when was it re-scheduled. EI #6 said, she never re-scheduled it. EI #6 was asked why not, and she answered, she forgot. EI #6 was asked when the next care plan meeting have been due for RI #25. EI #6 said, in March. She said she failed to schedule it because of other duties such as working the med cart. EI #6 said the next care plan meeting for RI #25 would have been in March, but she failed to schedule it because of other duties such as working the med cart. EI #6 was asked what was the concern of residents not having a care plan review and meeting. EI #6 answered, the care plan was the basis of what the resident needs, so, it would be important to make sure their needs were met appropriately and changes identified. On 06/23/2023 at 9:39 AM EI #6 was asked about RI #7's care plan meetings. EI #6 said RI #7 should have had a care plan meeting after the annual MDS assessment that was completed in February. When EI #6 was asked why there was no care plan meeting held, she said, other duties kept her from following through, having the meeting, and reviewing the care plan with the IDT (Interdisciplinary Team). On 06/23/2023 at 10:45 AM an interview was conducted with EI #2, the Director of Nursing. EI #2 was asked when a care plan meeting should be held and care plans reviewed. She said after an MDS assessment. EI #2 was asked why care plan meetings had not been conducted for RI #25 and RI #7. EI #2 said, they should have been. EI #2 said, she did not know why they were not done. EI #2 said, the MDS coordinator had filled in on the medication cart at times. EI #2 was asked what should be done when EI #6 was on the cart to ensure the resident's care plans are being reviewed. EI #2 said, the other person in the MDS office should assist. EI #2 was asked if she should you have known that was not being done and she said yes. EI #2 was asked what the concern of residents not having a care plan review and meeting was. She said the residents and family need to be informed of the most recent assessment and their potential needs. EI #2 was asked how the IDT team met to discuss the MDS assessment if a meeting was not scheduled to discuss the residents. She said she did not have any evidence documented to show they met.

Based on observation, interview, the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to prevent potential cross contamination from the food preparation sink drain pipe extending into a floor drain and also from the dishwashing machine drain pipe extending into a floor drain. This had the potential to affect 81 of 81 residents receiving meals from the kitchen. Findings include: The U.S. FDA 2022 Food Code included: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 06/20/2023 at 6:53 PM, the food preparation sink was observed. The food preparation sink drain pipe extended into the floor drain without an air gap. On 06/21/2023 at 9:28 AM, Employee Identifier (EI) #5, the Maintenance Technician, measured the distance from the floor level to the end of the food preparation sink drain pipe. EI #5 said the depth of the food preparation sink drain pipe into the floor drain was four inches. EI #5 said cross contamination would be a potential concern. EI #5 further said that we need to cut the pipe shorter. On 06/22/2023 at 9:31 AM, dishwashing was observed. The draining pipe from the dishwashing machine was observed to be extending into the floor drain. When asked the potential problem with the dishwashing machine drain pipe going down into the floor drain; EI #4, the Dietary Manager, said cross contamination. On 06/22/2023 at 9:39 AM, EI #3, the Registered Dietitian, was interviewed about the potential problems which could result from the dishwashing machine drain pipe extending into the floor drain. EI #3 said there could be a danger of backup into the dishwashing machine via the pipe, which could result in cross contamination. On 06/22/2023 at 10:05 AM, EI #5, the Maintenance Technician, looked at the drain pipe extending into the floor drain and confirmed that it was connected to the tank of the dishwashing machine. EI #5 measured 2.5 inches as the distance from floor level to the end of the dishwashing machine drain pipe inside the floor drain. EI #5 said the potential concern would be sewage backup from the floor drain into the dishwashing machine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident Identifier (RI) #24's 05/21/18, Annual Minimum Status Data (MDS) assessment was not coded for the use of an anticoagulant and hypnotic medication when RI #24 was not receiving these medications. This deficient practice affected RI #24, one of 21 residents whose MDS assessments were reviewed. Findings Include: RI #24 was admitted to the facility on [DATE], and readmitted on [DATE]. A review of RI #24's 05/21/18, Annual MDS assessment revealed RI #24 was coded as receiving an anticoagulant and hypnotic medication. A review of RI #24's May 2018 Physician's Orders and Medication Administration Record (MAR) revealed RI #24 was not receiving an anticoagulant or hypnotic medication. On 07/12/18 at 10:50 a.m., an interview was conducted with Employee Identifier (EI) #1, a MDS/Care Plan Coordinator. The surveyor asked EI #1 if RI #24 was receiving an anticoagulant and hypnotic medication during the month of May 2018. EI #1 looked at RI #1's MDS and said according to what she coded, yes. However, after EI #1 reviewed RI #24's May 2018 MAR, she stated the anticoagulant and hypnotic medications should not have been coded on RI #24's 05/21/18 Annual MDS. The surveyor asked EI #1 if it was an accurate assessment. EI #1 said no.