**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy, and interviews for one of three sampled residents (Resident #27) reviewed for advance directives, the facility failed to accurately document the resident's life support choices. The acute care Hospital Discharge summary dated [DATE] identified Resident #27's code status (directs the medical team to administer or withhold life support systems in the event of a cardiac or respiratory arrest) was: full resuscitation (all resuscitative and aggressive curative treatments are provided). Resident #27 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia, and pneumonia. The Advance Directive form dated 5/2/24 and signed by the Resident #27's Representative and the Physician on 5/3/24 identified Resident #27's options for medical care and treatment were do not resuscitate (DNR) and do not intubate (DNI). Review of physician's orders from 5/2/24 through 8/22/24 directed Resident #27's code status was full code (resuscitate and directed to ensure Resident #27 signs the Advance Directive form and place a copy in the chart. The admission MDS dated [DATE] identified Resident #27 had severely impaired cognition. Interview and clinical record review with RN #3 on 8/22/24 at 9:43 AM failed to identify that the advance directive form and the physician's order were congruent. RN #3 indicated that Resident #27 was a full code on admission, and that the face sheet had been updated to reflect Resident #27's DNR/DNI status, but the physician's order was not updated to reflect the change. RN #3 further indicated that it was the responsibility of the charge nurse or nursing supervisor to update the orders when the advance directive form was completed. Interview with the DNS on 8/22/24 at 2:48 PM identified that when a code status is changed, she expects the order to be updated in the resident's clinical record by the charge nurse or RN supervisor. The Advance Directives policy directs that resident preferences regarding end-of-life decisions and medical decisions are always respected. Nursing reviews the advanced directive options and completes the form, the form is filed in the medical chart, and a doctor's order is written into the electronic medical record. The policy further identified that advance directives can be changed at any time by the appropriate party and in all cases, the decision of the individual resident and/or designee will be respected within the state and federal guidelines. These wishes will be brought to the attention of staff on the advance directives form and in the electronic medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of facility policy, and interviews for one of five sampled residents (Resident #59) observed for medication administration, the facility failed to ensure that an extended-release medication was not crushed and that a physician's order was in place to administer crushed medications to a resident. The findings include: Resident #59's diagnoses included Alzheimer's disease, dysphagia, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #59 had severe cognitive impairment, required set up assistance for meals, had no swallowing difficulties and was on a therapeutic diet. The physician's order dated 5/7/24 directed regular diet, regular texture, thin liquids, magic cup every day with Boost (nutritional supplement), aspiration precautions, upright for all meals, set up for all meals, assist of one as needed for initiation. The orders further directed; Metoprolol Succinate tablet extended release 24 hr., 25mg, 1 tab by mouth once a day, Depakote Sprinkles delayed release capsule 125 mg by mouth once a day, Buspirone tablet 12.5 mg by mouth twice a day, Cranberry capsule once in the morning. The Care Plan dated 5/17/24 identified Resident #59 had dysphagia and was an aspiration risk with interventions that included: alternate liquids with solids, small sips and bites, monitor for signs and symptoms (s/s) of coughing and aspiration during meals, observe for s/s of respiratory infection from silent aspiration: cough, fever, wheeze, dyspnea, malaise, provide dietary consistency per physician's orders, provide supervision and assistance per therapy recommendations. Observation on 8/27/24 at 7:42 AM of medication administration identified LPN #7 prepared the following medications for Resident #59: 1 tablet of Buspirone 10mg, 1 tablet of Buspirone 5 mg, 1 capsule of Divalproex 125 mg delayed release,1 tablet of Irbesartan 300 mg, 1 tablet of Metoprolol Succinate 25mg extended release, and 1 Cranberry capsule 425 mg. LPN #7 placed the Buspirone, the Irbesartan, and the Metoprolol Succinate into a plastic envelope and crushed the medication, she then mixed the crushed medications into chocolate pudding and then opened the Divalproex and Cranberry capsules and sprinkled the contents onto the chocolate pudding mixture. She mixed all of the medications into the chocolate pudding and went into the resident room to administer the medications to Resident #59. Once LPN #7 approached the resident, this surveyor interrupted and asked to speak with LPN #7 in the corridor. Interview with LPN #7 identified Resident #59 did not have a physician's order to crush medications and noted that extended-release medications should not be crushed. She further noted that administering the medications mixed with pudding was a better way to administer the medications to Resident #59 because the resident chewed the medications. LPN #7 further identified that she did not know if this behavior had been reported to the physician. Observation of the medication administration following the interview and following LPN #7 pouring the same medications into a medication cup and administering them to the residents with water, identified the resident chewed the medications prior to swallowing them. Interview with the RN Supervisor on 8/27/24 at 8:10 AM identified there is usually an order for medications to be crushed. The RN supervisor identified that aspiration precautions could indicate there are swallowing problems but there should still be an order for crushed medications, if that is how they are to be administered. Interview with the DNS on 8/27/24 at 9:05 AM identified medications should be administered whole unless there is an order for the medications to be crushed or the capsules opened. The aspiration precautions in the care plan do not indicate the medications should be crushed. Interview with Pharmacist #3 on 8/29/24 at 1:39 PM identified that there should be a physician's order if medications are to be crushed for administration. Pharmacist #3 identified that extended-release medications should not be crushed because they lose the extended-release properties and act faster than intended. The Metoprolol Succinate could cause decreased blood pressure. Pharmacist #3 further identified that Depakote Sprinkles can be opened and sprinkled but should be swallowed in the pudding and not chewed or crushed because it could change the timed effect and could affect the resident negatively. The Medication Administration policy identified a provider order is required before administration of any medication and should include the five rights: right person, right medication, right route, right dose, right time. Right route gives further direction to check the provider's order and ensure that the medication can be safely administered to the resident via this route.

Basedonclinicalrecordreview reviewoffacilitypolicy andinterviewsforoneofthreesampledresidents(Resident#26) reviewedfordischargeplanning thefacilityfailedtodevelopadischargeplaninatimelymanner Thefindingsinclude Resident#26 wasadmitted inthefacilityon7/3/24 withdiagnosesthatincludedpericardialeffusion hypertensiveheartdiseasewithheartfailure orthostatichypotension atrialfibrillation andimplantablecardiacdefibrillator Theinitialcareplandated7/4/24 identifiedthefocusedareaofdischargeplanningwithandinterventiontoevaluateshorttermorlongtermstayplacementandsocialserviceevaluation TheadmissionMDSassessmentdated7/10/24 identifiedResident#26 waswithoutcognitivedeficits andrequiredextensiveassistancefortoileting hygiene bedmobility dressing andtransfers Theassessmentfurtheridentifiedtheresidentreceivedoccupationalandphysicaltherapyandhadadischargeplaninplace Reviewofsocialserviceprogressnotesfrom7/3/24 to8/27/24 failedtoidentifyResident#26 dischargeplanwasdiscussedwiththeresident Interviewon8/26/24 at11:00 AMwithResident#26 identifiedheshehadnothadanyinteractionwithaSocialWorkersincebeingadmitted tothefacility Resident#26 furtheridentifiedheshehadnotparticipatedinthecareplanprocessandorthedischargeplanningprocess Heshefurthernotedhishergoalwastoreturntothecommunitybutdidnotknowatthatpointwhenthiswouldoccurorwhatwasneededforthistooccur InterviewwithSW1 (coveringsocialworker on8/26/24 at1:40 PMidentifiedthatthesocialworkerisresponsiblefortimelydischargeplanning anditshouldstartwhenaresidentisadmitted tothefacility Shealsoidentifiedthatmembersoftheinterdisciplinaryteamshouldmeetwiththeresidentwithin72 hourstodiscusstheresidentsdischargeplan SW#1 furthernotedthatthesocialworkerascertainstheresidentslivingarrangements equipmentneeded residentsupportinthecommunityandhisherprimarycarephysicianinthecommunitytoplanforeffectivedischarge Thedischargeplanningisdocumentedinthesocialserviceprogressnotes Additionally sheidentifiedthatnodischargeplanninghadbeenaddressedforResident#26 eitherinthesocialworkprogressnotesorthecomprehensivecareplan InterviewwiththeDNSon8/28/24 at12:30 PMidentifiedthatdischargeplanningwouldstartuponadmissionoftheresidentinthefacility Thedischargeplanningwouldbedocumentedintheprogressnotesandorthecoordinationofdischargeplanningwouldbereflectedinthecareplan anditwouldbeupdatedasneeded SheidentifiedthatResident#26 didnothaveadischargeplantimelybecausethefacilitydidnothaveafulltimesocialworker

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documents, review of facility policy, and interviews for one sampled resident (Resident #69) reviewed for activities. The facility failed to provide weekend recreation activities. The findings include: Resident #69's diagnoses include cerebral infarction due to embolism, ischemic cardiomyopathy, and adjustment disorder with depressed mood. The admission MDS assessment dated [DATE] identified Resident #69 had moderate cognitive impairment, utilized a walker and wheelchair for mobility, utilized set up assistance with eating, and utilized moderate assistance with dressing. It further identified the resident did not have behaviors and it was somewhat important for him/her to read books, listen to music, have access to the news, have access to his/her favorite activities and to be able to experience fresh air. The care plan dated 7/8/24 identified Resident #69 preferred in room activities, with an interventions to offer transport to programs. Interview with Resident #69 on 8/21/24 at 10:35 AM identified he/she did not like that there were no activities offered through recreation on the weekends. Resident #69 further noted that although he/she sometimes prefers in room activities, he/she also prefers to attend group activities and would like the option of having weekend activities available. The resident further noted that there is no recreation staff working on the weekend and it is boring because he/she does not receive visitors. Review of the activities calendar for the month of August identified that the only activities noted for Saturday and Sunday were family visits. Interview with the Director of Activities on 8/27/24 at 2:15 PM identified there was no recreation programming on the weekend due to budgetary constraints. She noted that prior to the COVID pandemic there were two recreation staff members; one scheduled for twenty-four hours a week and one scheduled for eight hours a week, in addition to herself who worked forty hours a week. Further, she identified that post pandemic, she works 40 hours but is in charge of maintaining the website, going out to the community to promote the facility, is in charge of petty cash for the residents, and resident funds. Additionally, there is one other recreation staff member who works twenty hours a week (M-F 10 AM-2 PM). She noted that the estimated time per week she spends on recreation activities with the residents is about twenty hours per week and no extra hours are permitted per management. The Director of Activities further identified that she has spoken to the Administrator and the owner of the facility regarding the need for more hours/staff, and was told it was not in the budget. She added that she feels the residents get bored and restless on the weekends and feel that if they had more activities there may be fewer behavioral episodes. The Activity Programs policy directed activity programs are designed to meet the interests of and support the physical, mental and psychosocial wellbeing of each resident. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. Individualized and group activities are provided that: Reflect the schedules, choices and rights of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, review of facility policy and review of facility documentation for two of four sampled residents (Resident #1 and #27) reviewed for skin conditions, the facility failed to implement the neurologist's orders for over 3 months and failed to ensure a compression glove ordered for dependent edema and comfort was applied and removed, per the physician's orders. The findings include: 1. Resident #1's diagnoses included chronic obstructive pulmonary disease, Type 2 diabetes mellitus, dementia, and skin-picking disorder. The quarterly MDS assessment dated [DATE] identified Resident #1 had intact cognition, required set up assistance with eating, oral and personal hygiene, and upper and lower body dressing. The assessment further identified the resident was independent mobility but required supervision or touching assistance with shower transfers. Review of the clinical record identified a neurology consultant's physician's order dated 7/11/2024 that directed Primidone (a barbiturate medication that is used to treat partial and generalized seizures and essential tremors. It's common side effects include sleepiness, poor coordination, nausea, and loss of appetite. Severe side effects may include suicide and psychosis) was to be discontinued and the resident was to start Sinemet 10-100mg three times daily with meals for persistent tremor, due to the resident being poorly responsive to primidone. Review of the Medication Administration Record (MAR) for July 2024 identified two orders. The first was Primidone tablet 50 mg with directions to administer ½ tab to equal 25 mg as part of 75 mgs every night for tremors. This medication was administered every day in July with the exception of July 18th, where there was no indication of administered or not administered. The second order identified an order for Primidone tablet 50 mg with directions to administer 1 tablet by mouth every night for tremors as part of 75 mg dose at bedtime. The MAR identified this medication had been administered July 1 through July 10, 2024, and was marked not administered for the rest of the month. Physician's orders dated 8/1/24-8/27/2024 identified resident was prescribed Primidone tablet 50mg ½ tab at bedtime with instructions to take 25 mgs = ½ tab as part of 75 mg QHS for tremors. Review of the MAR for August 2024 identified an order for Primidone tablet 50 mg with directions to administer ½ tablet to equal 25mg at bedtime as part of 75 mg at bedtime for tremors. There were no additional orders for Primidone. There were not orders for Sinemet. Review of the neurology consultation progress note dated 8/8/2024 indicated Resident #1 was seen in July (2024) and Primidone was discontinued due to lack of therapeutic benefit, but Primidone had not been discontinued at that time. Recommendations were to trial Sinemet 10-100mg three times daily with meals for persistent tremor, poorly responsive to Primidone and Cogentin, and to discontinue Primidone at that time. Review of the Resident visit list dated 8/8/2024 indicated Resident #1 was seen as a follow-up to a visit on 7/11/2024 with recommendation to add Sinemet 10-100mg three times a day. Interview and record review with PA #1, neurology consultant, on 08/26/24 at 9:58 AM indicated when recommendations are made for a resident, PA #1 gives a list of the recommendations to the nursing supervisor to either make the changes when approved by the provider or write a note if it is something that won't be implemented. PA #1 indicated she made the recommendation on the resident visit list and gave it to the nursing supervisor. PA#1 identified she had been working at the facility for three years and that had been the practice. PA#1 further indicated the medication she wanted to discontinue wasn't at a high enough dose to be toxic or have negative side effects, but it was not providing a benefit to the resident and another medication might. Interview with RN#2 on 8/22/24 at 11:57 AM indicated the RN supervisor on shift is responsible for inputting the consultant recommendations. Additionally, RN #2 identified that the RN supervisors are able to be pulled to the floor to work and RN#2 also held other positions, Infection Control and Staff Development and that being pulled in several directions made it difficult to complete all tasks. In the event that something is not completed by one supervisor, it is passed on to the next shift. Interview and chart review with the DNS on 8/22/24 at 1:41 PM identified the supervisors on duty make sure the consultant or MD recommendations were reviewed or put in place. Review of the neurology visit for 7/11/24 with the DNS and it was indicated that the nursing supervisor should have changed the orders as directed at that time. Review of the facility policy for MD consults/Appointments identified the purpose of the policy was to ensure residents receive timely and coordinated care. Additionally, the policy identified follow-up included to review any instructions or recommendations provided and implement any necessary care plan changes or follow-up needed. 2. Resident #27 was admitted to the facility on [DATE] with diagnoses that included pneumonia, dementia, and seborrheic dermatitis. The admission MDS assessment dated [DATE] identified Resident #27 had severely impaired cognition, was dependent for lower body dressing and required moderate assistance with upper body dressing. The care plan dated 6/11/24 identified Resident #27 had cellulitis to the right upper extremity and was on antibiotic therapy with an intervention to observe and report signs of localized infection (localized pain, redness, swelling, tenderness, loss of function, and heat at the infected area). A physician's order dated 6/18/24 directed to apply a compression wrap to the right upper extremity during the day and remove nightly. A care plan intervention dated 7/4/24 directed to apply a compression glove to the right-hand during AM care, remove after 8 hours, hand wash the glove and allow to drip dry. Review of the Medication Administration Records (MAR) and the Treatment Administration Records (TAR) from 6/18/24 through 8/22/24 failed to identify documentation that the compression glove and/or wrap was applied during AM care, removed after 8 hours, hand washed and drip dried, and/or that the resident's skin was assessed for signs and symptoms of localized infection. Interview with Resident #27's representative on 8/21/24 at 12:25 PM identified Resident #27 had occasionally complained that his/her right hand hurt and that sometimes the skin felt dry and itchy due to wearing the compression wrap. Observation on 8/22/24 at 1:50 PM identified the skin to Resident #27's right upper arm was intact, skin color was normal, sporadic dry patchy areas observed with no noted swelling. Interview and clinical record review with APRN #1 on 8/22/24 at 2:09 PM identified that in June Resident #27 was treated for cellulitis to the right upper extremity. APRN #1 further identified that she ordered a compression sleeve for dependent edema and comfort, which was to be applied in the morning and removed nightly. Interview and clinical record review with the DNS on 8/22/24 at 2:47 PM identified that the order to apply a compression wrap to the right upper extremity during the day and remove nightly was not entered into the system correctly so the task did not populate to the MAR or the TAR, therefore the nurses were not prompted to sign off the task; the clinical record failed to reflect daily documentation that the compression sleeve was applied during AM care and removed at night. The DNS indicated that there were 2 progress notes documenting the presence of the compression sleeve, but she would expect daily documentation to be in the clinical record upon applying and removing the sleeve. The DNS further indicated that, in addition to the weekly skin assessments, ordered by the physician, she would expect the area under the compression sleeve to be assessed every shift and documented on the MAR or TAR. The facility's Skin and Wound Management policy directs the following information should be recorded in the resident's medical record utilizing facility forms: the type of assessment conducted, the date/time and type of skin care provided, the name and title of the individual who conducted the assessment, any change in the resident's condition, the condition of the skin, how the resident tolerated the procedure and/or ability to participate in the procedure, any problems or complaints related to the procedure, and observations of anything unusual exhibited by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and interviews for one of three sampled residents (Resident #36) reviewed for accidents, the facility failed to ensure adequate supervision was provided during toileting resulting in a fall. The findings include: Resident #36 was admitted to the facility with diagnoses that included Alzheimer's disease, schizoaffective disorder, spinal stenosis, and delusional disorder. The Resident Care Plan (RCP) dated 7/20/23 identified Resident #36 was at risk for falls related to decline in functional mobility. Care plan interventions directed to encourage resident to come and sit at the nurses' station, check wheelchair brakes and instruct on proper use, and provide assistance with toileting. A fall risk assessment dated [DATE] identified Resident #36 was not at high risk for falls. The annual MDS assessment dated [DATE] identified that Resident # 36 had severe cognitive impairment, required extensive assistance for toilet transfers, required total assistance with toileting hygiene, was frequently incontinent of bowel and bladder, utilized a wheelchair mobility, and had not sustained falls within the past three months but the care area of falls triggered, and the assessment indicated that it would be included on the care plan. The nurse's note dated 8/15/24 at 10:28 PM identified Resident #36 sustained an unwitnessed fall in the bathroom, while attempting to transfer himself/herself to an unlocked wheelchair. The note further identified Resident #36 had been left unattended in the bathroom while on the toilet. In addition, when discovered, Resident #36 was crying and complained of back pain when attempting to move. The note further indicated that the on-call Physician and the family were notified, and Resident #36 was sent to the acute care hospital to be evaluated. The nurse's note dated 8/16/24 at 12:45 AM identified Resident #36 returned to the facility and was alert and at baseline mentation, denied pain and/or discomfort; in addition, the hospital record identified that the Computed Tomography (CT) scan (a medical imaging to create 3D images of the inside of the body) for cervical spine, head, and lumbar spine without contrast were unremarkable. The note further noted that the resident was resting in bed and would be monitored. Interview with LPN #1 on 8/22/24 at 10:50 AM identified Resident #36 fell in the bathroom when NA#1 left the resident unattended while the resident was seated on the toilet. She identified that Resident #36 required assistance for toilet use and was not safe to be left alone in the bathroom. She further identified that NA #1 was a new nurses' aide and NA #1 was provided education to not leave the resident alone in the bathroom. Interview with the Rehabilitation Manager (OT #1) on 8/22/24 at 11:10 AM identified Resident #36 required assistance to use the bathroom and should not have been left alone in the bathroom. She also identified that Resident #36 was not safe to be alone in the bathroom and required supervision while using the toilet. She further identified that she was aware that Resident #36 had a fall in the bathroom because NA #1 left the resident alone in the bathroom. Interview with the DNS on 8/22/24 at 12:30 PM identified Resident #36 had a fall in the bathroom because NA #1 left the resident alone in the bathroom. She identified that Resident #36 should not be left alone in the bathroom and NA #1 was educated to not leave the resident alone in the bathroom. Interview with NA#1 on 8/23/24 at 10:40 AM identified that he transferred Resident #36 to the toilet and left the resident alone in the bathroom. He further identified that he was not aware that Resident #36 was not safe alone in the bathroom. The facility fall prevention policy identified that the facility would initiate interventions to prevent falls and reduce the risk of injury related to the fall.

Based on observations, review of facility policy and procedures, and interviews, the facility failed to ensure expired medications were not in use and removed from the medication cart, and failed to ensure medications were stored according to the manufacture's recommendation. The findings include: Observation of the South unit's medication cart with LPN #5 on 8/27/24 at 10:10 AM identified an opened bottle of Lorazepam Intensol concentrate 2 milligram/milliliter (mg/ml) containing a label that identified the medication was ordered for Resident #13. The bottle contained 1.75 ml of liquid and contained instructions that the medication should be stored in the refrigerator and once opened should be discarded after 90 days. The bottle was labeled with an opened date of 7/19/24 but did not contain a discard date. Interview with LPN #5 on 8/27/24 at 10:30 AM identified the medication was being administered daily to Resident #13. She further noted that the medication is stored in the refrigerator until it is opened but once it is opened, it is dated and stored in the medication cart, but was unsure for how long it could remain opened and unrefrigerated in the cart. Interview with the Pharmacist (Pharmacist #1) on 8/27/24 at 1:15 PM identified Lorazepam Intensol Concentrate should be stored in the refrigerator but if opened and in use the medication can be stored at room temperature for 30 days and discarded after 30 days. The Pharmacist further identified that best practice is to follow the manufacture's guidelines to maintain the drug integrity and potency. The observed bottle of Lorazepam Intensol Concentrate contained an opened date of 7/19/24 and should have been discarded on 8/18/24, but was still in use nine days nine days after the date that it should have been discarded. Resident #13's physician orders for the month of August 2024 directed to administer Lorazepam Intensol Concentrate 2mg/ml by mouth 0.25ml every eight hours for anxiety disorder. The Controlled Drug Receipt and Record sheet identified that Resident #13 was administered Lorazepam Intensol Concentrate 0.25 ml at 6am, 2pm and 10pm daily from August 19, 2024, to August 27, 2024. Interview with the DNS on 8/27/24 at 1:45 PM identified that the Lorazepam should had been stored in the refrigerator. She further identified that she would contact the provider immediately for a new prescription and remove and discard the Lorazepam medication. Observation of the South unit medication room refrigerator on 8/27/24 at 10:20 AM with Charge Nurse (LPN #5) identified an affixed locked box with the refrigerator thermometer read 40 degrees Fahrenheit that contained: One unopened bottle of Morphine Sulfate Oral Concentrate (Opioid) 100mg/5ml that contained 30ml for Resident #37 and had a manufacture's label that stated to store at 68 to 77 degrees Fahrenheit, room temperature and two unopened bottles of Morphine Sulfate Oral Concentrate (Opioid) 100mg/5ml that contained 15ml each for Resident #43 and had a manufacture's label that stated to store at 68 to 77 degrees Fahrenheit, room temperature. Interview with LPN #5 on 8/27/24 at 10:30 AM identified that she was unaware of whether the Morphine Concentrate should be stored in the fridge as the controlled medication lock box in the cart was full. LPN #5 indicated that she did not receive the medication from the pharmacy and the Morphine Sulfate medication was in the fridge during the shift-to-shift count, and during the count nurses would match the medication amount on hand with the controlled substance disposition record for accuracy. Interview with the Pharmacist (Pharmacist #1) on 8/27/24 at 1:15 PM identified that when medications such as the Morphine Concentrate is stored outside of the normal recommended temperature it can cause crystallization of the medication resulting in changes to the drug integrity and potency. He identified that it was best practice to follow the manufacture's guidelines, and that the pharmacy would affix a label on the medication which indicated the appropriate storage requirements. Interview with the DNS on 8/27/24 at 1:45 PM identified that the medication was stored incorrectly and should be in the cart. She also indicated that she would have to call the pharmacy as the drug may not be effective. Review of the Medication Storage policy and procedure identified that medications should be stored in accordance with the manufacturer's specifications. The policy and procedure further identified that prior to and after opening all medications, that the medication would expire on the date specified by the manufacturer on the product label, unless the manufacture has specifically indicated a shortened expiration once opened on the product label itself.

Based on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure proper hand hygiene was utilized by staff and failed to ensure the infection prevention and control policies were reviewed and signed annually. The findings include: 1. Observation on 8/21/24 at 11:52 AM identified LPN #6 performed hand hygiene, donned gloves, and obtained a blood glucose level via glucometer from Resident #35. She then removed her gloves and went into the corridor to discard the used lancet into the sharps container and clean the glucometer with a bleach wipe. Interview with LPN #6 at the time of the observation identified that she forgot to wash her hands following the removal of her gloves and noted that she held the lancet in her ungloved hand because they are not allowed to wear gloves in the corridor. She further noted that the lancet has a safety cover on it. She further noted that she usually brings the treatment cart to the door of the room. Observation on 8/27/24 at 8:02 AM of the medication pass with LPN #7 identified LPN #7 completed hand hygiene prior to preparing medication for Resident #23, administered medications, performed hand hygiene in the resident room and exited the resident's room. LPN #7 then returned to Resident #23's room to complete the medication administration as the resident had not swallowed the medications completely. LPN#7 had to get more water for the resident and encouraged the resident to swallow the medication. LPN #7 then left the room, returned to the medication administration cart and began preparing medications for Resident #28. When asked about hand hygiene, LPN#7 identified that she should have completed hand hygiene after leaving Resident #23's room. LPN #7 performed hand hygiene and continued preparing the medication for Resident #28. LPN #7 administered medications to Resident #28 and returned to the medication administration cart and began preparing medications for Resident #59. LPN #7 popped 3 pills, Buspirone 10mg and 5mg and Divalproex 125mg capsule, for resident #59 when another resident, Resident #1, had a reported emergency, had slipped to the floor, and the NA was requesting LPN #7 to respond to the room. LPN#7 secured the medication and the cart and responded to Resident #1's room, physically assisted Resident #1 off of the floor and then returned to the medication cart and began preparing Resident #59's medications. LPN#7 then went into Resident #59's room and attempted to wake her. LPN#7 was stopped because of the preparation of medications. After leaving the room and returning to the cart and proceeded to access the computer. When asked, LPN #7 identified that hand hygiene should have been performed after contact with a resident and going in or out of resident rooms. Interview with the RN #2 on 8/27/2024 at 8:10 AM identified hand hygiene should be provided in between tasks or patient care. Interview and review of Infection control policies with the DNS and RN #2 on 8/27/2024 at 10:39 AM identified LPN #6 discussed infection control and glucometer use with the DNS and LPN#6 should not have carried the lancet bare handed and should have discarded the lancet in the resident's bathroom sharps box and washed hands with soap and water. The DNS also identified staff should be performing hand hygiene before and after patient care. Review of facility annual training and competencies identified LPN #6 and #7 both participated in annual competency training in June 2024 which included glucometer use and hand hygiene. The facility policy for Performing Hand Hygiene identified hand hygiene, either use of the hand sanitizer or hand washing, should be performed before and after resident care, and immediately after exposure to bodily fluids The facility policy for medication administration identified that staff should always wash hands before preparing or administering medications. 2. The facility policy for the IPCP identified the IPCP is reviewed at least annually and whenever the Facility Assessment is reviewed. The Facility Assessment 2023 identified 1 person designated as the Infection Control/Staff Development as one position and Lists RN #2 as holding that position. Additionally, the Infection Control section of the policy identified the Infection Control preventionist as a staff member not employed by the facility since February 2024. The Infection Control Policy Manual was reviewed 1/31/2024 and signed by the Administrator, Director of Nursing, and the Medical Director. The policy is not singed by the Infection Preventionist, nor is the facility able to provide signature pages from 2023 or 2022. Interview with the DNS on 8/27/2024 at 12:00 PM identified she was not able to locate the signature pages from 2023 or 2022.

Based on review of the resident council meeting minutes, review of facility documentation, review of facility policy and interviews, the facility failed to respond to concerns identified by the resident council regarding the need to speak with a Social Worker in the facility. The findings include: Review of the Resident Council meeting minutes dated 4/26/24, 5/31/24, 6/28/24, and 7/26/24 identified the expressed wish to speak with the Social Worker and although, there were designated resident council department response forms that were utilized to answer resident council requests, concerns and grievances, there were no resolutions identified to the residents' expressed aspirations and no indication that the social worker had attended any of the meetings to address the requests from the period of 4/26/24 through 7/26/24. The group interview held on 8/22/24 with nine members of resident council identified their on-going concern of wanting to speak with a social worker during their monthly resident council meetings and they further identified that it had been a while since they'd had a full-time social worker. Additionally, the Residents noted they were told that the facility was working on hiring someone for the position, but they still did not have a full-time social worker and their requests to see a social worker had not been obliged. Interview with the Director of Recreation on 8/22/24 at 2:15 PM identified that she is responsible for documenting the resident council minutes, completing the top portion of the Resident Council Department Response form and distributing the forms to the appropriate departmental heads. She identified that after the meeting concludes, the expectation is for the Resident Council Department Response form to be completed and returned to her within a week. The Director of Recreation further identified the concern of wanting a social worker was an ongoing concern of the residents that she has brought to the Administrator's attention, who has not addressed the concerns regarding the lack of a social worker at any of the resident council meetings. Interview with the Administrator on 8/22/24 at 2:52 PM identified the Director of Recreation provides him with the Resident Council Department Response forms after the resident council meetings and he returns the form within a week. The Administrator further identified that he is responsible for concerns related to the Social Worker. He noted that he made the Social Worker aware of the residents' requests to see the social worker, but he could not provide any information regarding the follow up with the resident council by the Social Worker or himself. Interview on 8/26/24 at 1:31 PM with Social Worker #1 (employed from January 11 to May 1, 2024) identified that she started working at the facility in January of 2024 one day a week until April of 2024. During this timeframe she worked on money follows the person (MFP), discharges, PASRR (Preadmission Screening and Resident Review), Level of Consciousness (LOC) and some 72 hours initial assessments. She identified that she was not able to complete all the task as she was only in the building for one day and worked remotely if the facility had any concerns. Social Worker #1 identified when shown her timesheet for the time period of January 2024 through May 2024, that for most of those hours she was at another facility that was owned by the same company, when this facility would call with questions or concerns which she would address remotely. Interview with the Administrator on 8/26/24 at 2:54 PM identified that he could not recall if he had returned the Resident Council Department Response forms, as the issue of the Social Worker was an ongoing concern, and he was unable to recall if he notified the Social Worker at the time. Review of the Resident Council policy identified that a Resident Council Response form will be utilized to track issues and their resolution, and the facility department related to any issues would be responsible to address the item (s) of concern. The policy further identified that the Administrator would review minutes and any response from the departments within the facility and responses are presented at the next meeting, or sooner if indicated.

1. Based on observations, and interviews, the facility failed to provide a homelike, safe, and sanitary environment for two shower rooms on the central and middle unit and for the identified carpeted areas on the central unit. The findings include: Observation of the shower room area on 8/21/24 at 10:16 AM identified two of three shower rooms in the central shower area to have several items stored to include two rolling shower chairs stacked two high, six IV poles, a lounging shower chair, a utility cart, a cardboard box, and a black substance on the ceiling and a shower curtain with holes in it. The third shower room contained two rolling shower chairs. Observation on 8/21/24 at 10:25 AM of the south wing hallway identified several dark brown stains of unknown substance on the carpet. Interview with Resident #61 on 8/21/24 at 11:08 AM identified that she/he had an issue with the shower rooms being so cluttered and that it did not provide a homelike environment. The shower rooms had been like this for some time and was unsure if the two that were cluttered even functioned anymore, one had a leak at one point. Anytime someone had to go in the shower room they had to see all the clutter, and could not utilize the other shower areas, just one was able to be utilized. Also, the shower chairs that were utilized by the residents did not have a basin under them so when a resident is wheeled through the hallway in the shower chair they sometimes are incontinent of urine or feces and there are several stains on the carpet in the hallways due to this. Interview with NA#2 on 8/22/24 at 11:17 AM identified the one shower room was utilized a couple times each day, and that items had been stored in the shower for about two years. Interview with Housekeeper #1 on 8/22/24 at 11:25 AM identified that the black substance on the ceiling in the shower room was mold or dirt and was unsure when the area was last cleaned. Interview with the Maintenance Director on 8/27/24 at 1:45 PM identified the shower rooms were being utilized for storage due to the lack of storage in the building. The shower leaks in the wall and will be part of the remodel project where the wall will be removed to make a bigger shower. The rug in the hallway needs to be replaced as well and was unsure what the substance on the rug was. Interview with the administrator on 8/28/24 at 10:45 AM identified that the items were now cleaned from the shower area and the area has been cleaned, but the items were stored there due to lack of storage. Environmental rounds were conducted however just with a hot list and not a formal documentation. This list would then be given to whomever it was designated on the list to fix it. The showers were not identified to be an issue because they were being utilized for storage. Interview with the Infection Preventionist on 8/28/24 at 12:56 PM identified she did complete environmental rounds however did not list the shower room stalls on the environmental rounds as an issue due to the fact they had been like that for approximately two years, and it wasn't something new that jumped out at her. Review of the Environmental Round Policy indicated it is the policy of the facility to provide a safe, clean, comfortable homelike environment in a such a manner to acknowledge and respect resident rights to the extent possible. This includes providing housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. the facility failed to provide a homelike, safe, sanitary environment for three of three showers sampled. The findings include: Observation of the shower room area on 8/21/24 at 10:16 AM identified two of three shower rooms in the central shower area to have several items stored to include two rolling shower chairs stacked two high, six IV poles, a lounging shower chair, a utility cart, a carboard box, and a black substance on the ceiling and a shower curtain with holes in it. The third shower room contained two rolling shower chairs. Observation on 8/21/24 at 10:25 AM of the south wing hallway identified several dark brown stains of unknown substance on the carpet. Interview with Resident #61 on 8/21/24 at 11:08 AM identified that she/he had an issue with the shower rooms being so cluttered and that it did not provide a homelike environment. The shower rooms had been like this for some time and was unsure if the two that were cluttered even functioned anymore, one had a leak at one point. Anytime someone had to go in the shower room they had to see all the clutter, and could not utilize the other shower areas, just one was able to be utilized. Also, the shower chairs that were utilized by the residents did not have a basin under them so when a resident is wheeled through the hallway in the shower chair, they sometimes are incontinent of urine or feces and there are several stains on the carpet in the hallways due to this. Interview with NA#2 on 8/22/24 at 11:17 AM identified the one shower room was utilized a couple times each day, and that items had been stored in the shower for about two years. Interview with Housekeeper #1 on 8/22/24 at 11:25 AM identified that the black substance on the ceiling in the shower room was mold or dirt and was unsure when the area was last cleaned. Interview with Maintenance Director on 8/27/24 at 1:45 PM identified the shower rooms were being utilized for storage due to the lack of storage in the building. The shower leaks in the wall and will be part of the remodel project where the wall will be removed to make a bigger shower. The rug in the hallway needs to be replaced as well and was unsure what the substance on the rug was. Interview with the Administrator on 8/28/24 at 10:45 AM identified that the items were now cleaned from the shower area and the area has been cleaned, but the items were stored there due to lack of storage. Environmental rounds were conducted however just with a hot list and not a formal documentation. This list would then be given to whomever it was designated on the list to fix it. The showers were not identified to be an issue because they were being utilized for storage. Interview with the Infection Preventionist on 8/28/24 at 12:56 PM identified she did complete environmental rounds however did not list the shower room stalls on the environmental rounds as an issue due to the fact they had been like that for approximately two years, and it wasn't something new that jumped out at her. Review of the Environmental Round Policy indicated it is the policy of the facility to provide a safe, clean, comfortable homelike environment in a such a manner to acknowledge and respect resident rights to the extent possible. This includes providing housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. 2. Observation on 8/21/24 at 9:53 AM of the Central unit shower room identified kit was filled with numerous items such as intravenous poles, rolling plastic cart (not for laundry), cardboard box, a bucket, a bedpan, and multiple ripped shower curtains. Observation on 8/22/24 at 11:15 AM of the Central unit shower room identified the following items: 4 intravenous poles, 1 unopened box sitting on the bottom of the intravenous pole, 1 rolling plastic cart that had a cardboard box on it, 1 bucket, and 1 bed pan. Observation on 8/22/24 at 9:03 AM of the Middle unit shower room identified it was untidy, and did not appear homelike. A rusty pipe was observed along the ceiling of the shower room, a dirty glove was on the floor, the ceiling light fixture cover was cracked and had a burnt-out light bulb, there was a ripped shower curtain that contained holes and was ripped along the top causing it to not be able to hang properly. In addition, there were also numerous areas of the shower room that appeared to be stained with rust and a brown substance. Interview with NA#2, on 8/22/24 at 11:17 AM identified that she utilized the both the Central and Middle shower rooms for residents. NA#2 identified that the Central shower room has had multiple items stored in it for over a month and that the facility was limited on storage. NA#2 identified that maintenance oversees maintaining the shower rooms, equipment and that the showers was not homelike. Interview with Housekeeper #1 on 8/22/24 at 11:25 AM identified that the brown substance was mold and Housekeeper #1 was unsure of when the Middle shower room was cleaned last. Interview with Maintenance Director on 8/22/24 at 11:39 AM identified that the Central shower room had parts that were used for storage because the facility was limited on storage. Also identified was that the Middle shower room brown substance was dirt and dust, had a cracked light cover, and a ripped shower curtain. Interview with Administrator on 8/22/24 at 2:49 PM identified that he was aware of the rusty wire cover, burnt out light bulb, and broken cover on overhead light and that they will be fixing those items. The Administrator identified that the Middle shower room was not homelike.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and interviews for five sample residents (Resident #26, #35, #69, and #376) who required psychosocial support, the facility failed to ensure a Social Worker was available to meet resident needs. The findings include: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included pericardial effusion, hypertensive heart disease with heart failure, orthostatic hypotension, atrial fibrillation, and implantable cardiac defibrillator. The RCP dated 7/4/24 identified Resident #26 was at risk for alteration in psychosocial well-being. Care plan interventions directed to encourage communication with visitation, monitor for psychosocial changes, observe and report any changes in mental status caused by situational stress, and provide opportunity to express feelings related to situational stressors. The admission MDS assessment dated [DATE] identified Resident #26 had intact cognition and required extensive assistance with toileting, hygiene, bed mobility, dressing, and transfers. Interview with Resident #26 on 8/26/24 at 11:00 AM identified he/she had not been seen by a social worker since his/her admission to the facility. Review of the clinical record failed to identify social service progress notes and /or social service assessments for the time period of 7/3/24 to 8/27/24. Interview with Social Worker #1 (covering social worker) on 8/26/24 at 1:40 PM identified that the Social Worker is responsible for evaluating residents upon admission to the facility and documenting in the progress notes. The Social Worker typically meets with the resident within 72 hours of admission to the facility and assesses needs such as the resident's community support, equipment that may be needed upon discharge, and any follow up necessary with the community physician. She further identified that the facility did not have a full-time social worker, and she only worked one day per week. Additionally, she confirmed that she had not seen Resident #26. 2. Resident #35's diagnoses included acute respiratory failure with hypoxia, other chronic osteomyelitis, morbid obesity and other cirrhosis of the liver. Review of the Social Service progress notes dated 1/31/2024, the last social service entry, indicated that an application for Money Follows the Person was submitted by Social Worker #1. The 5 day MDS dated [DATE] identified Resident #35 was cognitively intact, was dependent with toileting hygiene and transfers and required substantial/maximal assistance with lying to sitting or sitting to lying. Interview with Resident #35 on 8/21/2024 at 10:27 AM identified the resident was unhappy with care and follow up at the facility. Resident #35 identified he/she was waiting for updates on Money Follows the Person and was ready to be discharged from the facility over the previous year. The Care Plan dated 6/1/2024 identified Resident #35 was very independent and self-scheduled medical appointments and contact with family. Resident #35 was care planned for ADLs and identified the resident was admitted for short-term rehab and expected to be discharged to the community with interventions that social work will utilize community resources to ensure a safe discharge. Interview with the Administrator on 8/26/2024 at 1:22 PM identified the facility hasn't had a social worker and identified SW #1 had been in the facility, since May, 16 hours weekly. Interview with Social Worker #1 on 8/26/2024 at 1:30 PM identified she had been intermittent, on loan, in this facility off and on over the last year but does not have dedicated hours. She indicated she was helping with discharges, getting caught up on admissions and significant things. SW #1indicated that discharge planning starts at admission and should be reflected in the care plan and social worker documentation. Additionally, she indicated that any resident with Money Follows the Person (MFP) there is a monthly meeting and there should be a monthly note or update In the progress notes. Specifically with Resident #35 there should have been a follow up with the resident regarding status of the MFP program, and at least a quarterly note. SW#1 indicated that based on the absence of social worker notes, it would appear that Resident #35 had not been interacted with since January. 3. Resident #69 was admitted to the facility on [DATE] with diagnoses included cerebral infarction due to embolism, ischemic cardiomyopathy, and unspecified psychosis. The admission MDS assessment dated [DATE] identified Resident #69 had moderate cognitive impairment, utilized a walker and wheelchair for mobility, utilized set up or clean up assistance with eating, oral hygiene, moderate assistance with shower/bathing, personal hygiene and dressing. The 48-hour baseline care plan dated 6/19/24 identified Resident #69 required assist with activities of daily living and functional mobility with interventions that included assist of one for bathing, bed mobility, personal hygiene and transfers. Interview with Resident #69 on 8/21/24 at 10:40 AM identified that he/she never had a care plan meeting upon admission and never saw a social worker since he/she has been admitted to the facility but has wanted to speak with a social worker. Review of the Social Worker progress notes from 6/18/24 to 8/27/24 failed to identify Resident #69 was seen or evaluated by the facility's Social Worker since admission. Review of the Social Worker hours from October of 2023 to August of 2024 with the Administrator on 8/26/24 at 1:30 PM identified the following: From October 16, 2023, to December 27, 2023, the facility had one full time Social Worker. From January 11, 2024, to May 1, 2024, the facility had one Social Worker who was not full time and was in the building 1-2 days weekly for 16 hours and would work remotely at times. From May 11, 2024, to August 14, 2024, the facility had one Social Worker who worked part time and was in the building infrequently at least twice weekly. Interview with the Administrator on 8/22/24 at 2:52 PM identified he was aware of the concerns that the residents had regarding not having a Social Worker in the building and that he was actively seeking a full-time social worker however had not had success in finding a qualified one. Interview on 8/26/24 at 1:31 PM with Social Worker #1 (who worked from January 11 to May 1, 2024) identified that she started working at the facility in January of 2024 one day per week for 8 hours until April of 2024, when shown her timesheet for the time period of January 2024 through May 2024, Social Worker #1 identified that for most of those hours she was at another facility that was owned by the same company and would work remotely if this facility had any questions or concerns. She further identified that the Administrator contacted her on 8/16/24 to return to the facility as he was unable to reach the previous Social Worker, hence her first day back was on 8/21/24. SW#1 further identified that there should be daily contact with the residents with a note written monthly in the resident's record at minimum. The Social Worker job description provided by the facility identified that the Social Worker provides direct clinical case work and group work services to residents and their families through supportive services, participate in resident assessment process and discharge planning, available to deal with psycho-social-emotional or with family-related problems of the residents as they arise during the resident's stay in the facility, and interviews resident/family to obtain biographies, psychological and social history. 4. Resident #376 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, anxiety, depressive episodes, and extended spectrum eta lactamase (ESBL) resistance. The admission nursing assessment dated [DATE] identified Resident #376 was alert and oriented to person, place and time, required assistance with bed mobility, transfers, and dressing. The RCP dated 7/14/24 identified Resident #376 was at risk for alteration in psychosocial well-being with interventions that included: encourage communication with visitation, monitor for psychosocial changes, observe and report any changes in mental status caused by a situational stress, and provide opportunity to express feelings related to situational stressor. Interview with the Resident #376 on 8/26/24 at 1:40 PM identified he/she requested to see a Social Worker when first he/she was first admitted to the facility and has to date not been seen by the Social Worker. Review of the clinical record failed to identify social service progress notes and /or social service assessments for the time period of 7/12/24 to 8/27/24. Interview with the Administrator on 8/22/24 at 2:52 PM that he was aware of the concerns that the resident's had regarding not having a Social Worker in the building and that he was actively seeking a full-time social worker however had not had success in finding a qualified one. Review of the Social Worker hours from October of 2023 to August of 2024 with the Administrator on 8/26/24 at 1:30 PM identified the following: From October 16, 2023, to December 27, 2023, the facility had one full time Social Worker. From January 11, 2024, to May 1, 2024, the facility had one Social Worker who was not full time and was in the building 1-2 days weekly for 16 hours and would work remotely at times. From May 11, 2024, to August 14, 2024, the facility had one Social Worker who worked part time and was in the building infrequently at least twice weekly. Interview on 8/26/24 at 1:31 PM with Social Worker #1 (who worked from January 11 to May 1, 2024) identified that she started working at the facility in January of 2024 one day per week for 8 hours until April of 2024, when shown her timesheet for the time period of January 2024 through May 2024, Social Worker #1 identified that for most of those hours she was at another facility that was owned by the same company and would work remotely if this facility had any questions or concerns. She further identified that the Administrator contacted her on 8/16/24 to return to the facility as he was unable to reach the previous Social Worker, hence her first day back was on 8/21/24. SW#1 further identified that there should be daily contact with the residents with a note written monthly in the resident's record at minimum. On 8/28/24 (after surveyor inquiry) Resident #376 was seen by SW #1 who wrote a progress note that identified Resident #376 needed to return to the community and was requesting a referral for Money Follows the Person (MFP). The Social Worker job description provided by the facility identified that the Social Worker provides direct clinical case work and group work services to residents and their families through supportive services, participate in resident assessment process and discharge planning, available to deal with psycho-social-emotional or with family-related problems of the residents as they arise during the resident's stay in the facility, and interviews resident/family to obtain biographies, psychological and social history.

Based on review of facility documentation, facility policy and interviews, during a review of the facility antibiotic stewardship program, the facility failed to ensure that the facility's antibiotic surveillance tracking form was completed as directed and failed to ensure that the reports presented at the monthly and quarterly medical staff meetings contained the Antibiotic Stewardship review. The findings include: A review of the Antibiotic Stewardship program for the past two years with the DNS and the Infection Preventionist (RN#2) on 08/27/24 at 10:39 AM identified RN#2 had been the IP since the end of May, beginning of June 2024. The DNS indicated RN#2 had other duties that she is responsible for including weekly IP reports and is able to work remotely to complete these tasks. RN#2 indicated her practice for infection control included surveillance but was unable to show the tracking/surveillance when asked. RN#2 identified Antibiotic stewardship is tracked monthly and used McGeer's criteria to tract they labs are reviewed and checked off in the antibiotic stewardship book but the labs are not included in the book. RN#2 indicated that she reviewed the labs in the chart and marks on the stewardship book whether they are within range, however, was not able to produce the stewardship book. Interview with the DNS on 8/28/24 at 1:14 PM identified that Antibiotic stewardship is discussed at the Interdisciplinary Team meetings. However, she then identified that the meeting minutes do not document what exactly is discussed in the meetings and I am still attempting to locate the antibiotic stewardship paperwork. The DNS was able to provide antibiotic stewardship review from Trident care from 1/1/2022 to 12/31/2022 She had already given me the 10/23 through the 2/24 and identified that she was not able to locate anything that would identify they were reviewed or discussed. Review of the facility policy for antibiotic stewardship identified Antibiotic stewardship activities included regular review of antibiotic utilization patterns and sensitivity patterns at the committee meeting, including reports from the laboratory on sensitivity and resistance patterns over time (quarter, year, past years), and review of antibiotic utilization over time.

Based on observations, interviews, facility documentation, and policy for the facility Infection Prevention position, the facility failed to ensure the Infection Preventionist had appropriate time to complete IP duties at the facility. The findings included: The Facility Assessment 2023, signed on 1/31/2024, identified RN #2 as the team member holding the Infection Preventionist/Staff Development position. Additionally, the Infection Control section of the Facility Assessment identified the facility conducted an infection control risk assessment yearly, which evaluated and determined the risk or potential vulnerabilities within the resident population and the surrounding community. According to CT Public Act 22-58 identified that each nursing home with more than 60 residents shall employ a full-time Infection prevention and control specialist and that each infection prevention and control specialist worked on a rotating schedule that ensures the specialist covered each eight-hour shift at least once per month. Review of the facility Monthly schedules from May 16th, 2024 through September 4th, 2024 identified RN #2 was scheduled 7a-3p at least 5 days per week and was scheduled as the RN supervisor. Review of the daily schedules for this time period identified RN #2 was scheduled as the RN Supervisor almost daily. Interview with the DNS and RN #2 on 8/27/24 at 10:39 AM identified RN #2 had been the Infection preventionist since the beginning of June 2024. The DNS identified that RN #2 does not have designated hours for Infection Prevention. The DNS identified RN #2 is in the building as the RN Supervisor and is sometimes pulled to the floor to cover call-outs or short staffing. The DNS identified the RN supervisor position as a free float supervisor position, so RN #2 is able to get other work done if time allowed and RN #2 was able to work from home. Interview with the DNS on 8/28/2024 at 10:30 AM identified the previous IP/staff development person worked 32 hours as the IP and 8 hours at staff development. The previous position holder was not an RN supervisor. The DNS identified the corporate entities identified there was no Federal minimum for hours for an Infection Preventionist, and, now the position is a combined position of IP/staff development and RN supervisor. The DNS identified that RN #2 is scheduled predominantly as the RN Supervisor and completed other tasks as time allowed. Facility documentation reviewed 8/27/2024 at 1 PM identified RN #2 had completed the Nursing Home Infection Preventionist training 3/2/2024 and had the appropriate education for the Infection Prevention position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy and interviews for nine sampled residents (#26, #27, #32, #43, #50, #61, #64, #69, and #376) reviewed for care planning, the facility failed to ensure the interdisciplinary team (IDT) resident care plan meetings were held following comprehensive and quarterly assessments and failed to ensure comprehensive care plans were developed by the IDT team with resident/family/responsible party involvement. The findings include: 1. Resident #26 admitted in the facility on 7/3/24 with diagnoses that included pericardial effusion, hypertensive heart disease with heart failure, orthostatic hypotension, atrial fibrillation, and implantable cardiac defibrillator. The admission MDS assessment should have been completed by 7/17/24 and the comprehensive care plan developed by the interdisciplinary team should have been developed by 7/24/24. Review of Resident #26's clinical record failed to identify that an interdisciplinary team care plan conference meeting inclusive of the resident and/or the resident's responsible party took place between 7/17/25 and 7/24/24. Interview on 8/26/24 at 11:00 AM with Resident #26 identified he/she had not seen the social worker since being admitted to the facility. Additionally, Resident #26 noted that he/she had not been invited or participated in a care plan meeting. Interview with LPN #3 (MDS Coordinator) on 8/25/24 at 10:30 AM identified she is responsible for completing and developing the resident care plans when a resident is admitted to the facility and an interdisciplinary care plan meeting is held to discuss resident goals of care. She further identified that the interdisciplinary care plan meeting and development of the comprehensive care plan should occur within 21 days of resident's admission in the facility. LPN #2 noted Resident #26 did not have a care plan meeting held because she just started in the position of MDS Coordinator, and they did not have a Social Worker to coordinate the care plan meetings. Interview with SW #1 (covering social worker) on 8/26/24 at 1:40 PM identified she was only in the building for one day and worked remotely if the facility had any concerns. Interview with the DNS on 8/27/24 at 10:30 AM identified that although, Resident #26 should have had an interdisciplinary care plan meeting held with the resident in attendance to discuss goals of care, no meeting had taken place, and the comprehensive care plan was not developed because they did not have an MDS Coordinator, and they did not have a full-time Social Worker to coordinate the meeting. The RAI user manual 3.0 identified that the comprehensive admission MDS needed to be completed on the 14th calendar day of the resident's admission (admission date + 13 calendar days), Care Area Assessment (CAA) also need to be completed on the 14th calendar day, and comprehensive care plan completion need to complete CAA completion date + 7 calendar days. Review of Comprehensive care planning policy directed the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident. The policy further identified that the comprehensive care plan would be developed no later than 21 days after admission or day of the care planning meeting, whichever comes first. 2. Resident #27 was admitted to the facility on [DATE] with diagnoses that included pneumonia, dementia, and seborrheic dermatitis. The admission MDS assessment dated [DATE] identified Resident #27 had severely impaired cognition. The care plan dated 5/10/24 failed to identify that Resident #27 and/or his/her representative participated in choosing treatment options or were given the opportunity to have input in the development of the plan of care. Interview with Resident #27's representative on 8/21/24 at 12:25 PM identified that he/she had not yet attended a resident care conference but one was scheduled for the following day and he/she planned on attending. Interview with the DNS on 8/22/24 at 2:58 PM identified that resident care conferences were not being completed routinely, due to multiple staff changes in the facility's social work and MDS positions. The DNS further identified that while the facility had corporate support and the support of a consultant company, not having the social work and MDS positions filled with permanent employees created a break down in scheduling and implementing the resident care conferences. The DNS indicated that the facility had hired an MDS coordinator and that she had been in the position for less than one month and over the past 2 weeks had started to schedule and complete resident care conferences; including Resident #27's care conference, which was completed earlier that afternoon. The DNS further indicated that she would have expected Resident #27 to have had an initial meeting, completed within 72 hours of admission, and then another conference around Day 14. The DNS identified that the meetings include participation from various members of the interdisciplinary team, as well as the resident and resident representative. The facility's Resident Participation-Assessment/Care Plans policy directs the resident, and his/her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The resident and his/her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. The policy further directs that the resident/representative's right to participate in the development and implementation of his/her plan of care includes the right to: participate in the planning process, identify individuals to be included in the planning process, request meetings, request revisions, participate in establishing goals and expected outcomes of care plan, participate in the type, amount, frequency and duration of care, receive the services and/or items included in the care plan, refuse, request changes to and/or discontinue care or treatment offered or proposed, be informed in advance of the risks and benefits of the care or treatment proposed, have access to and review the care plan, and be informed of, review & sign the care plan after any significant changes are made. Resident assessments are begun on the first day of admission and completed no later than the 14th day after admission, and a comprehensive care plan is developed within seven days of completing the resident assessment. 3. Resident #32's diagnoses included Type 2 diabetes mellitus, anemia, and vitamin D deficiency. The quarterly MDS assessment dated [DATE] identified Resident #32 had intact cognition, required maximal assistance with personal hygiene, transfers and utilized a wheelchair for mobility. Resident #32's care plan identified that it was last reviewed and revised on 4/28/24. Interview on 8/22/24 at 10:30 AM with Resident #32 identified that he/she had not been invited and or attended a care conference meeting since 2023. Review of the care conference sign in records identified the last interdisciplinary care plan conference meeting was held on 8/2/2023. Review of the clinical record identified the resident had an annual MDS assessment dated [DATE], and quarterly assessments dated 12/18/23 and 4/1/23 (care plan conferences should have been held after each of the stated quarterly assessments as well as the annual assessment in September but were not according to the documentation and the interviews). Interview with Social Worker #1 on 8/26/24 at 1:31 identified she worked one day per week from January to April of 2024. SW#1 further identified that on a daily basis, there should be social work contact with the residents and at a minimum there should be monthly notes and quarterly reviews and participation in the quarterly care conferences. Interview with the Administrator on 8/22/24 at 2:52 PM identified that he was aware of the concerns that the residents had regarding not having a Social Worker in the building and that he was actively seeking a full-time social worker; however, he identified he had not had success in finding a qualified social worker to fill the position. Review of Comprehensive care planning policy directed the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative would develop and implement a comprehensive, person-centered care plan for each resident. The policy further identified that the IDT must review and update the care plan at least quarterly, in conjunction with the required quarterly MDS assessment. Review of the Resident Participation-Assessment/Care plans policy identified that the Social Service Director or designee was responsible for notifying the resident/representative and for maintaining records of such notices of the care conferences. 4. Resident #43's diagnoses included dementia, heart failure, depression, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #43 had severe cognitive impairment and required total assistance with dressing, toileting, hygiene, and transfers. Review of the clinical record and the care plan dated 3/9/24 on 8/27/24 identified that there had not been an interdisciplinary care conference (inclusive of the resident/responsible party) held to review and/or revise the comprehensive care plan. A care conference should have been held in July/2024. Interview with LPN #3 (MDS Coordinator) on 8/25/24 at 10:30 AM identified she is responsible for reviewing the quarterly care plans and scheduling the care plan conference meetings. She further identified that the care plan indicates the dates when it was last reviewed. In addition, she identified that care plan conferences are held at least every quarter where the care plans are all reviewed. Further, LPN #3 identified Resident #43's care plan was not reviewed because the facility did not have an MDS Coordinator. Interview with the DNS on 8/25/24 at 11:30 AM identified she was aware that the interdisciplinary care conference meetings were not being held every quarter and care plans were not being reviewed and/or revised because the MDS position had been vacant. The care plan policy identified that required assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 5. Resident #50's diagnoses included alcoholic cirrhosis of the liver, anxiety and respiratory failure. The quarterly MDS assessment dated [DATE] identified Resident #50 was cognitively intact, required set up for eating, required substantial assistance with bed mobility and utilized a manual wheelchair for mobility. review of Resident #50's care plan identified several revision dates throughout the document, the most recent reviewed and revised date was noted as 8/17/24. Interview on 8/21/24 at 10:46 AM with Resident #50 identified he/she had never been invited, attended and/or anyone discussed his/her plan of care with him/her. Interview on 8/22/24 at 12:11 PM with the Director of Nursing (DNS) identified that the position of Minimum Data Set Nurse had been filled for the past 3 weeks, the previous MDS nurse had taken a leave for about 4 months and in the interim, a consultant company was hired. She also identified that the facility was limited on having care plan meetings because the facility did not have a Social Worker employed in the building for a long time. Interview on 8/22/24 at 1:36 PM with LPN #3 identified Resident #50 had not had a care plan meeting held since being admitted to the facility (7/17/23). Review of the clinical record identified Resident #50 had an admission assessment dated [DATE], and quarterly assessments dated 10/23/23, 1/14/24 and 4/15/24. Interdisciplinary care conferences should have been held following each of these assessments (four in total) Review of Comprehensive care planning policy directed the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident. 6. Resident #61's diagnoses included Type 2 diabetes mellitus, and right and left below knee amputations. The annual MDS assessment dated [DATE] identified Resident #61 was without cognitive impairments, utilized a wheelchair, utilized set up or clean up assistance for eating, was independent for oral hygiene, toileting hygiene, and shower and bathing as well as upper body dressing. Resident #61's care plan dated 6/2/24 identified resident is at risk of an alteration in psychosocial wellbeing related to possible temporary room change and loud noise due to construction in building with interventions that included: assist the resident to a quiet area if one is available, afford the resident the opportunity to ventilate feeling and concerns regarding room change, and social work intervention as indicated to assist with resolution of concerns related to the change. Interview with Resident #61 on 8/21/24 at 10:30 AM identified he/she had not been invited and/or attended a care conference meeting or had anyone discussed his/or care plan with him/her since last year. Resident #61 further identified that he/she was interested in being considered for the Money Follows the Person (MFP) program and discharge to the community. He/she further noted that there had not been a Social Worker in the building to speak to about the above in the past year. Review of the care conference sign in records identified the last interdisciplinary care plan conference meeting was held was on 8/16/23 (Resident #61 was noted to attend) Review of the clinical record identified the resident had a quarterly MDS assessments dated 11/3/23, 1/29/24 and 3/22/24 (care plan conferences should have been held after each of the stated quarterly assessments as well as the annual assessment in June). Review of the social service notes identified that there were no notes documented after 2/22/24. Interview with Social Worker #1 on 8/26/24 at 1:31 identified she worked one day per week from January to April of 2024. SW#1 further identified that on a daily basis, there should be social work contact with the residents and at a minimum there should be monthly notes and quarterly reviews and participation in the quarterly care conferences. Interview with the Administrator on 8/22/24 at 2:52 PM identified that he was aware of the concerns that the residents had regarding not having a Social Worker in the building and that he was actively seeking a full-time social worker; however, he identified he had not had success in finding a qualified social worker to fill the position. The comprehensive care plan policy directed the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident. 7. Resident #64's diagnoses included type 2 diabetes mellitus, obstructive and reflux uropathy, depression, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #64 had severe cognitive impairment and required extensive assistance with dressing, toileting, hygiene, and transfers. Review of the clinical record and the care plan dated 11/11/23 on 8/27/24 identified that there had not been an interdisciplinary care conference (inclusive of the resident/responsible party) held to review and/or revise the comprehensive care plan in March/2024 or July/2024 following the dates where MDS assessments were due to be completed. Interview with LPN #3 (MDS Coordinator) on 8/25/24 at 10:30 AM identified she is responsible for reviewing the quarterly care plans and scheduling the care plan conference meetings. She further identified that the care plan indicates the dates when it was last reviewed. In addition, she identified that care plan conferences are held at least every quarter where the care plans are all reviewed. Further, LPN #3 identified Resident #64's care plan was not reviewed because the facility did not have an MDS Coordinator. Interview with the DNS on 8/25/24 at 11:30 AM identified she was aware that the interdisciplinary care conference meetings were not being held every quarter and care plans were not being reviewed and/or revised because the MDS position had been vacant. The care plan policy identified that required assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 8. Resident #69 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to embolism, ischemic cardiomyopathy, and unspecified psychosis. The admission MDS assessment dated [DATE] identified Resident #69 had moderate cognitive impairment, utilized a walker and wheelchair for mobility, utilized set up or clean up assistance with eating, oral hygiene, moderate assistance with shower/bathing, personal hygiene and utilized moderate assistance with dressing. Review of the facility documentation on Resident's Care Conferences held for Resident #69 failed to identify that a Resident care conference was completed upon admission or thereafter. Interview with Resident #69 on 8/21/24 at 10:40 AM identified that he/she had not attended a care plan meeting since admission to the facility. Review of Resident #69's clinical record failed to identify that an interdisciplinary team care plan conference meeting inclusive of the resident and/or the resident's responsible party took place between 6/25/24 and 7/9/24. Interview with Social Worker (SW #1) (who worked from January 11th, 2024, to May 1, 2024) on 8/26/24 at 1:31 PM identified that she started working in the facility in January of 2024 only one day per week for 8 hours until April of 2024. During this timeframe she would work on MFP, discharges, PASSR, Level of Consciousness (LOC) and some 72 hours initial assessments. She identified that she was not able to complete all the task as she was only in the building for one day, and worked at another facility, which was owned by the same company, where she would be contacted to work remotely on urgent concerns for this facility. She further identified that the Administrator contacted her on 8/16/24 to return to the facility as he was unable to reach the previous Social Worker, hence her first day back was on 8/21/24. SW#1 identified that daily there should be social worker contact with the residents, minimum a monthly note and quarterly review for the resident care conference. Interview with the Administrator on 8/22/24 at 2:52 PM that he was aware of the concerns that the resident's had regarding not having a Social Worker in the building and that he was actively seeking a full-time social worker however had not had success in finding a qualified one. Review of the Social Worker hours from October of 2023 to August of 2024 with the Administrator on 8/26/24 at 1:30 PM identified the following: From October 16, 2023, to December 27, 2023, the facility had one full time Social Worker. From January 11, 2024, to May 1, 2024, the facility had one Social Worker who was not full time and was in the building 1-2 days weekly for 16 hours and would work remotely at times. From May 11, 2024, to August 14, 2024, the facility had one Social Worker who worked part time and was in the building infrequently at least twice weekly. Review of Comprehensive care planning policy directed the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident. The policy further identified that the comprehensive care plan would be developed no later than 21 days after admission or day of the care planning meeting, whichever comes first. 9. Resident #376 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, anxiety, depressive episodes, and extended spectrum eta lactamase (ESBL) resistance. The admission nursing assessment dated [DATE] identified Resident #376 was alert and oriented to person, place and time, required assistance with bed mobility, transfers, and dressing. The admission MDS assessment should have been completed by 7/26/24 and the comprehensive care plan developed by the interdisciplinary team should have been developed by 8/2/24. Review of Resident #376's clinical record on 8/26/24 failed to identify that an interdisciplinary team care plan conference meeting inclusive of the resident and/or the resident's responsible party took place between 7/26/24 and 8/2/24 (making the comprehensive care plan 24 days late at that point in time). Review of Comprehensive care planning policy directed the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident. The policy further identified that the comprehensive care plan would be developed no later than 21 days after admission or day of the care planning meeting, whichever comes first.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for 1 of 1 sampled resident (Resident #79) reviewed for an indwelling urinary catheter (foley catheter), the facility failed to ensure the Resident Care Plan (RCP) was comprehensive to include the presence and interventions related to the presence of an indwelling urinary catheter. The findings include: Resident #79 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included major depressive disorder, neuromuscular dysfunction of the bladder and a degenerative disease. Physician orders upon hospital readmission to the facility and dated 2/14/22 directed to provide foley catheter care every shift and change foley catheter as needed for leakage/blockage. A Treatment Medication Administration Record dated 2/14/22 through 3/24/22 identified Resident #79 utilized a foley catheter. A quarterly MDS assessment dated [DATE] identified Resident #79 was moderately cognitively impaired, required extensive assistance of two for bed mobility, transfers, personal hygiene and toilet use. The MDS further identified Resident #79 as having an indwelling urinary catheter. On 3/24/22 at 12:20 PM, review of the RCP and interview with the MDS Coordinator failed to identify a RCP was developed/implemented with measurable goals/interventions to address the presence of an indwelling urinary catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, and interviews for 1 of 2 residents (Resident #430) reviewed for pressure ulcers, the facility failed to ensure appropriate settings were identified and maintained for an air mattress and failed to ensure Resident #430 was provided off-loading of the heels. The findings include: Resident #430 was admitted to the facility on [DATE] with diagnoses that included pressure induced deep tissue damage of the right heel, pressure ulcer of unspecified site, and osteomyelitis sepsis. Nurse's notes dated 3/2/22 at 8:19 PM indicated Resident #430 had a pressure area to the right heel, right buttock and sacrum, multiple scabs and osteomyelitis to the toe. Nurse's notes dated 3/2/22 at 10:00 PM indicated Resident #430 had an area on the coccyx measuring 3.5 cm by 2.5 cm by 1.5 cm deep and an open area on the right heel measuring 1.5 cm. The Resident Care Plan (RCP) dated 3/2/22 identified a problem of altered health maintenance, having a deep tissue injury of the right heel and osteomyelitis. Interventions included to assess Resident #430 for the presence of risk factors, treat, reduce, eliminate risk factors to the extent possible, conduct a systematic skin inspection, pay particular attention to bony prominences, keep clean and dry as possible, and minimize exposure to moisture. The admission MDS assessment dated [DATE] identified Resident #430 had intact cognition and required extensive assistance of 1 person for bed mobility and toilet use. The MDS further identified Resident #430 required a transfer with total assistance of 2 persons, limited assistance of 1 for bathing and resident #430 was able to feed self with set up. The MDS further identified Resident #430 was at risk for developing pressure ulcers, had one or more unhealed pressure ulcers. Resident #430 had 2, Stage 3 unhealed pressure ulcers (full thickness tissue loss, may have undermining or tunneling) that were present on admission, one Unstageable pressure ulcer due to wound bed covered by slough or eschar that was present on admission, and an Unstageable deep tissue injury that was present on admission. a. Interview and review of the RCP, Treatment Administration Record, and nurse's notes with the DNS and Infection Preventionist on 3/23/22 at 9:50 AM failed to reflect interventions for off-loading of Resident #430's heels were implemented from admission [DATE]) up to 3/14/22 (Resident #430 had a deep tissue injury to the right heel on admission) when the Wound Physician recommended to offload heels, however, there was no evidence that off loading had been occurring. Additionally, the DNS indicated that the admitting nurse was responsible for initiating a care plan with interventions for pressure relief. Interview with RN #1 on 3/23/22 at 1:00 PM indicated that an admission RCP needed to include, falls, pressure prevention, and infections if present. Additionally, the Nursing Supervisor that was on at time Resident #430 was admitted was RN #2 but Resident #430 arrived just before RN #2 was coming off duty at 7:00 PM, so she did not complete that admission. Interview with RN #2 on 3/23/22 at 1:30 PM indicated she came on duty at 7:00 PM and admitted Resident #430. Additionally, RN #2 indicated that she only minimally completed a care plan to address Resident #430's heels but did not include off-loading. b. Observations on 3/21/22 at 11:00 AM and 3/22/22 at 11:30 AM identified a pressure reliving mattress was on Resident #430's bed with control box at foot of bed set at 350 (weight) and Normal. Interview and review of the physician orders, RCP and Treatment Administration Record with the DNS on 3/23/22 at 9:50 AM failed to identify what setting the air mattress control was to be set at. Additionally, the DNS identified some air mattresses in the facility were set by a resident's weight and some were set by other factors. Further review with the DNS identified Resident #430's air mattress was to be set by Resident #430's weight which was 152 pounds on 3/21/22 (and not at 350). Additionally, the DNS identified the air mattress setting should be documented in the physician orders, Treatment Administration Record and/or care plan. Interview with RN #2 on 3/23/22 at 1:30 PM indicated she came on duty at 7:00 PM on 3/2/22 and admitted Resident #430. Additionally, RN #2 identified she left a note for the Infection Preventionist requesting an air mattress for Resident #430. Interview with Maintenance Director on 3/23/22 at 2:45 PM confirmed that he was responsible for applying air mattresses to the beds, puts the setting as high as it goes to inflate, checks back that it's inflated and stated that nursing sets the control box to what the setting should be for the resident. Additionally, the Maintenance Director identified that Resident #430 received a pressure relieving mattress on 3/3/22 as the DNS called to order it. Although policy for air mattresses was requested by the survey team, one was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 sampled resident observed eating with plastic cutlery (Resident #44), the facility failed to ensure a dignified dining experience and for 1 of 1 sampled residents reviewed for dignity (Resident #56), the facility failed to ensure Resident #56 was treated in a dignified manner. The findings include: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dementia and bipolar disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 was moderately cognitively impaired and required supervision, set up with eating and personal care. The Resident Care Plan dated 6/11/19 identified Resident #44 had an activity of daily living self-care performance deficit and impaired cognitive function. Interventions included to cue and reorient Resident #44 as needed and provide assistance of one for personal care. An Occupational Therapy (OT) Treatment Encounter note dated 7/26/19 identified Resident #44 continued to be issued light weight plastic/disposable utensils that are difficult to retrieve food from plate and do not hold food well causing increased spillage. Additionally, the OT note identified therapist to research more appropriate utensils/present to administration for approval to maximize patients self feeding experience at all meals. An Occupational Therapy Treatment Encounter note dated 7/30/19 noted the Therapist researched appropriate eating utensils and brought to the attention of the Occupational Therapist for approval. An Occupational Therapy Treatment Encounter note dated 8/8/18 noted Resident #44 complained of the use of utensils and was having difficulty with use at all meals (using the plastic/lightweight utensils). An Occupational Progress Note dated 8/17/19 noted spillage due to poor quality utensils and awaiting appropriate utensils that prevent increased spillage. An Occupational Discharge Summary Note dated 8/29/19 noted spillage due to poor quality utensils and awaiting appropriate utensils that prevent increased spillage. An interview on 9/17/19 at 10:28 AM with Person #1 identified Resident #44 was required to use flimsy, plastic/disposable utensils during mealtimes because Resident #44 had an incident where he/she had attempted to place a knife into a light socket when he/she was a resident at another facility over two years ago. Person #1 believed that Resident #44's previous employment as an electrician and diagnosis of dementia were the reason for this attempt. Person #1 stated there had been no further attempts to place items into light sockets and was never reviewed by psychiatry to determine if Resident #44 would be safe to return to using silverware adding Resident #44 would like to use silverware with his/her meals. An interview on 9/18/19 at 9:03 AM with the Food Service Director (FSD) identified Resident #44 was required to use plastic/disposable utensils for meals and that Resident #44 does not like it. The FSD stated Resident #44 had a history of sticking silver utensils in outlets while residing at another facility and was unable to have silver utensils at this facility for that reason, adding therapy had worked with Resident #44 in an attempt to get something stronger than the current plasticware provided, but had been unsuccessful. The FSD stated that while she never directly observed Resident #44 attempt to place cutlery in an electric socket, she had observed Resident #44 trying to get up and fix things and believed he/she may attempt to place an item in a socket. An interview and clinical record review on 9/18/19 at 9:22 AM with the Rehabilitation Director identified the facility had been looking for alternative eating utensils that were not metal as Resident #44 had a prior history for sticking metal utensils in sockets while residing at another facility. The Rehabilitation Director stated the nursing department would not clear Resident #44 for the use of metal utensils. Alternatives were researched at one point and referred to OT for approval. However, the discharge summary did not include documentation that the concern had been addressed. The Rehabilitation Director stated she would have expected a follow up note to have been completed by OT. The Rehabilitation Director added that while she had been working with Resident #44's family member to find alternatives, it had been challenging to find an appropriate substitute and that Resident #44's family member also desired Resident #44 to use metal eating utensils. The Rehabilitation Director could not provide any documentation detailing attempts to trial alternate eating utensils. The Rehabilitation Director was also not aware of any further attempts to place items in electric sockets. An interview and clinical record review on 9/18/19 at 9:50 AM with the DNS identified that she was aware of Resident #44's history of attempting to stick metal utensils in electrical sockets at his/her previous residence as she was the DNS at that facility as well. In order to prevent an accident hazard, the DNS directed that Resident #44 only use plastic eating utensils. The DNS stated while she was aware therapy was trying to acquire alternative eating utensils, she was unaware alternatives were researched and referred to OT for approval with no documented follow up. The DNS also indicated there had been no referral to psychiatry to evaluate if Resident #44 can safely manage metal eating utensils adding she was not aware of any further attempts where Resident #44 attempted to place items in electric sockets. An observation on 9/18/19 at 12:15 PM identified Resident #44 eating meatloaf with his/her fingers. A small white plastic/disposable utensil was observed on the tray. An interview and clinical record review with OT #1 on 9/19/19 at 12:35 PM identified while it had been documented that she was requested to review eating utensils by OT #2, she could not recall if that was done. OT #2 was unavailable for an interview. A review of the Resident rights direct the resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. The facility failed to facilitate resident self-determination through support of resident choice. 2. Resident #56 was admitted to the facility on [DATE] with diagnoses that included fracture of right humerus, benign prostatic hyperplasia, and history of falls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #56 had intact cognition, was always continent of bowel and bladder, and required limited assistance of 1 person for dressing, toilet use, hygiene and transfers. The care plan dated 6/20/19 identified to have resident do toilet transfers independently with rolling walker, and transfer out of bed to standard wheelchair with rolling walker. Resident #56 will transfer independently with rolling walker and ambulate independently in the hallway. A physician's order dated 7/25/19 directed Resident #56 be independent in ambulation with a rolling walker. Review of a Supervisor's Communication Log form dated 9/4/19 identified to please let 11:00 PM to 7:00 AM nurse aides know not to startle Resident #56 by checking the brief without telling him/her while the resident is asleep. Interview with Resident #56 on 9/16/19 at 11:10 AM identified approximately 1 month ago, he/she was groped by one of the staff, and reported it to the Licensed Psychologist, the next day. Resident #56 indicated that one night he/she had gone to bed at approximately 10:00 PM, and the Nurse Aide (NA) wanted to know if he/she was dry, and the next thing I know she had her hands on my privates. Resident #56 indicated he/she was upset and angry by the incident, did not want it to happen again, and he/she told the NA not to do that again. Interview on 9/17/19 at 8:36 AM with the DNS and Social Worker identified they were not aware of the incident, and indicated they will begin an investigation. Subsequent to surveyor inquiry, review of an e-mail dated 9/17/19 at 10:22 AM identified Licensed Psychologist #1 indicated on 9/4/19, Resident #56 verbalized that he/she was frustrated when he/she was woken up by the night NA who placed her hand on his/her brief to see if he/she was wet. Resident #56 stated he/she did not want this to happen again. Licensed Psychologist #1 indicated she had told the day Supervisor (RN #5) of the incident the same day it was reported to her. Interview on 9/17/19 at 2:30 PM with RN #5 indicated on 9/4/19, Licensed Psychologist #1 told her the NA on nights touched his/her brief to check to see if he/she was wet. Additionally, RN #5 indicated she did not report the incident to the DNS or Administrator, however, she put it in the communication log. Furthermore, RN #5 indicated she did not start an investigation because she did not think it was abuse. Interview on 9/18/19 at 12:19 PM with Licensed Psychologist #1 indicated she meets with Resident #56 on a weekly basis, and on 9/4/19, the resident stated that a women came in and touched his/her brief to see if he/she was wet. Resident #56 was frustrated and did not want it to happen again because he/she was embarrassed it happened. Licensed Psychologist #1 asked the residents permission to tell the supervisor, and he/she agreed because he/she did not want it to happen again. Licensed Psychologist #1 went out and told RN #5 at that time. Additionally, Licensed Psychologist #1 indicated this was an invasion of privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 18 residents reviewed for advance directives (Resident #228), the facility failed to provide documentation of an advance directives and/or ensure physician progress notes accurately reflected Resident #228's code status. The findings include: Resident #228 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, spinal stenosis, diabetes, and malignant neoplasm of the breast. A Facility admission Checklist dated 7/26/19 at 5:00 PM identified advanced directives order and form completed on 3:00 PM to 11:00 PM shift by RN #1 (but the clinical record failed to include an advanced directive form that had been completed). The Resident Care Plan dated 7/26/19 failed to identify a code status. A physician's verbal order dated 7/26/19 directed Resident #228 as Do Not Resuscitate/DNR. Physician progress notes dated 7/29/19 at 10:10 PM, 7/31/19 at 6:56 PM, and 8/11/19 at 9:59 AM, identified code status as full scope of treatment (despite a physician's verbal order dated 7/26/19 of DNR). A Social Worker note dated 7/30/19 at 10:51 AM identified a 72 hour meeting was held and failed to identify a review of code status was done. Interview with Administrator and Director of Social Work on 9/18/19 at 8:55 AM identified that the process was for the admitting nurse to obtain the code status, and for the Social Worker to review code status at the 72 hour meeting. The Director of Social Work further identified that he/she did not locate the DNR paperwork in the chart, and now that it was identified he/she will work on completing the form. Additionally, the Director of Social Work and the Administrator could not identify how a DNR order was formulated and that the physician did not sign off on the DNR order. Interview with DNS on 9/18/19 at 9:05 AM identified that the process was for the admission paperwork to be completed and for the nurse to notify the physician of the code status. From there, the physician was to complete the code status order and sign it. Until the physician signs the order for code status, the resident would remain a Full Code. Furthermore, the DNS was not aware that the code status in the physician progress notes did not match Resident #228 wishes, and that she would follow up with the paperwork. Review of facility advance directives policy dated November 2017 identified that prior to, or upon admission, the social services director will inquire of the resident, his/her family member about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents reviewed for psychoactive medications (Resident #43) the facility failed to ensure the resident care plan was comprehensive for the use of an antipsychotic. The findings include:, Resident #43 was originally admitted to the facility on [DATE] with diagnoses that included heart failure and chronic kidney disease. An Advanced Practice Registered Nurse (APRN) order dated 2/25/18 directed Seroquel 25 mg at bedtime, however, failed to identify a corresponding note for the reason Seroquel was ordered. Physician's orders from 2/25/18 to current (9/19/19) renewed the order for Seroquel 25 mg at bedtime. A 8/9/18 psychiatry note identified Resident #43 was started on Celexa (an antidepressant) 10 mg daily. Physician's orders from 2/25/18 to current (9/19/19) renewed the order for Celexa 10 mg daily. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #43 was moderately cognitively impaired, required total assistance of one to two staff for activities of daily living, had no behaviors and receiving antipsychotic medications. Review of the resident care plan failed to identify a care plan had been developed for behaviors and/or the use of psychoactive medication from 2/25/18 when Resident #43 was prescibed an antipsychotic and/or antidepressant until present. Interview with Registered Nurse (RN) #2 on 9/19/19 at 10:30 AM indicated although RN #2 had not worked in the building consistently, RN #2 was responsible for the residents' care plans. RN #2 further indicated he/she did not notice Resident #43 was on Seroquel when the record was reviewed, even if a resident does not exhibit any behaviors or none are monitored there should be a care plan for the use of psychoactive medications and would include a care plan for the use of the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #30) reviewed for accidents and who sustained a fracture, the facility failed to revise the care plan in a timely manner after the resident was injured in the shower. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included dementia, and chronic kidney disease stage III. A physician's order dated 6/29/19 directed to provide Resident #30 a shower on Monday's during the day shift. The care plan dated 7/1/19 indicated to provide a sponge bath when a full bath or shower cannot be tolerated by the resident. The admission MDS dated [DATE] identified Resident #30 had severely impaired cognition, was frequently incontinent of bowel and bladder, and required extensive assistance for dressing, eating, toilet use, and personal hygiene, and was totally dependent for bathing. A nurse's note dated 7/22/19 1:39 PM identified Resident #30 had complaints of right arm pain near the elbow with slight swelling and guarding. The resident was seen by the APRN with new orders to obtain right elbow x-ray and administer Tramadol 25mg every 12 hours for pain. The resident representative was made aware. A nurse's note dated 7/22/19 at 5:50 PM identified Resident #30 left AMA for the hospital. Hospital documentation dated 7/22/19 identified Resident #30 in emergency department for complaints of right elbow pain since this morning. The resident was in the shower and struck the right elbow against the wall. Since then there has been increased swelling, discomfort and pain with range of motion. A hospital orthopedic consultation dated 7/22/19 identified Resident #30 had an x-ray which revealed a distal supracondylar humeral fracture as well as a nondisplaced radial head fracture. The resident was placed in a sling and splinted. The resident is in a well-padded dressing as well as a splint with the application of sling. The resident was placed in a long-arm posterior splint with the application of a sling and a dressing by the emergency room provider. A physician's order dated 7/24/19 directed to provide Resident #30 a shower on Monday's during the day shift. A reportable event form dated 7/22/19 at 10:00 AM identified Resident #30 was in the shower with 2 care givers, was agitated, and banged his/her elbow on the shower chair. Interventions to prevent a reoccurrence included to have 2 care givers in shower with the resident. The care plan dated 7/24/19 identified Resident #30 has a right radial fracture with interventions that included to provide Resident #30 with the use of supportive devices, splints as recommended, and follow physician orders for weight bearing status. A nurse's note dated 8/8/19 at 11:51 PM identified Resident #30 was seen by the psychiatric APRN subsequent to a complaint by the resident representative that Resident #30 appeared agitated while visiting prior to meal. New order for Ativan 0.25mg every 24 hours as needed for anxiety/restlessness. Resident representative present and aware of new order. A physicians order dated 8/8/19 directed to administer Ativan (antianxiety medication) 0.25mg once every 24 hours as needed for anxiety/restlessness x 14 days. The care plan dated 8/23/19 identified to provide the assistance of 2 staff with showers. Interview with RN #4 on 9/18/19 at 2:00 PM identified although the reportable event form dated 7/22/19 indicated the intervention to prevent a reoccurrence included to have 2 care givers in shower with the resident, there were already 2 care givers in the shower with the resident at the time of the incident. Additionally, RN #4 indicated the intervention subsequent to the incident on 7/22/19 (right arm fracture) was an order put in place by the physician on 8/8/19 for Ativan 0.25mg as needed prior to showers. The facility failed to revise the plan of care in a timely manner, to prevent a future occurrence and/or injury, after Resident #30 exhibited agitation and was injured in the shower with 2 care givers present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews for 1 of 1 sampled resident reviewed for activities (Resident #24), the facility failed to ensure Resident #24 was able to attend activities of choice. The findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses that included dementia and depression. Recreation activity progress notes dated 10/3/18 indicated Resident #24 had been coming to coffee social and sitting with peers, appeared happier, not crying as often, enjoyed staying near writer and talking. Recreation activity notes dated 12/20/18 indicated Resident #24 wanders in and out of programs and activities, once in will stay for a short period of time but preferred to look around and leave, and enjoyed walking around facility and socializing with peers. A Resident Care Plan (RCP) for falls indicated that on 12/22/18 Resident #24 was found on the floor, sent to the hospital and was diagnosed with a left hip fracture. A significant change Minimum Data Set assessment dated [DATE] identified Resident #24 was severely cognitively impaired with cognition and required total assistance of one to two staff for activities of daily living (ADL's). The RCP dated 2/22/19 identified a problem with a decline in mobility and ADL's indicated Resident #24 is now a change in condition and the goal will be to accept 1 to 1 with Recreation staff 2 to 3 times a week, accept items of comfort and listen to music daily. Review of the activity logs from June 2019 to August 2019 identified daily in room/independent activities, almost daily visits from others, multiple 1 to 1 sensory visits and rare entertainment/craft/social out-of-room activities. Recreation Activity note dated 2/22/19 indicated Resident #24 was now a change of condition due to ambulation and a decline in all ADL's, recreation will increase 1 to 1 visits to 3 times a week and will offer items of comfort to calm. Recreaation Activity note of 5/28/19 indicated Resident #24 had become more quiet since last review, fall, recreation wheels resident around and outside, will come to coffee social but is an observer more than talker. Interview with the Director of Recreation (DOR) on 9/18/19 at 11:27 AM indicated Resident #24 loves people, was previously walking with assist of one staff, then fell and fractured his/her hip and now stays in the chair. The DOR further indicated Resident #24 had been previously going to coffee social at 10:00 AM, music and crafts, would not always particiapte but would sit and talk. When inquired about Resident #24 currently attending coffee at 10:00 AM, the DOR indicated the program was announced and if the DOR had time, will walk around and bring residents down or the resident can come by themselves. The DOR, however, indicated that with the change in Resident #24's condition (decline), the resident was not usually up by 10:00 AM, therefore, did not attend the coffee social program. The DOR indicated Resident #24 was in bed at 10:00 AM today, did not attend the program and the DOR was unable to leave the program once it starts to bring residents down to the program. Interview with Nurse Aide (NA) #3 indicated Resident #24 was gotten up today at 10:45 AM and did not attend morning coffee. NA #3 was unaware this was an event Resident #24 attended prior to Resident #24's change of condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #30) reviewed for accidents and who sustained a fracture, the facility failed to provide care according to physician's orders and/or professional standards of practice. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included dementia, and chronic kidney disease stage III. The admission MDS dated [DATE] identified Resident #30 had severely impaired cognition, was frequently incontinent of bowel and bladder, and required extensive assistance for dressing, eating, toilet use, and personal hygiene, and was totally dependent for bathing. A nurse's note dated 7/22/19 1:39 PM identified Resident #30 had complaints of right arm pain near the elbow with slight swelling and guarding. The resident was seen by the APRN with new orders to obtain right elbow x-ray and administer Tramadol 25mg every 12 hours for pain. The resident representative was made aware. A nurse's note dated 7/22/19 at 5:50 PM identified Resident #30 left AMA for the hospital. Hospital documentation dated 7/22/19 identified Resident #30 in emergency department for complaints of right elbow pain since this morning. The resident was in the shower and struck the right elbow against the wall. Since then there has been increased swelling, discomfort and pain with range of motion. A hospital orthopedic consultation dated 7/22/19 identified Resident #30 had an x-ray which revealed a distal supracondylar humeral fracture as well as a nondisplaced radial head fracture. The resident was placed in a sling and splinted. The resident is in a well-padded dressing as well as a splint with the application of sling. The resident was placed in a long-arm posterior splint with the application of a sling and a dressing by the emergency room provider. Upon Resident #30's return to the facility, the interagency referral form dated 7/24/19 directed fracture care, use of sling, follow up with orthopedic and resume care. A physician's order dated 7/24/19 directed to do a skin audit weekly every Monday and administer a multivitamin once a day for vitamin replacement. A nurse's note dated 7/24/19 at 10:10 PM identified Resident #30 returned from the hospital with a diagnosis of right arm fracture with a soft cast/sling in place. The resident was very restless and removed most of wrap to the right arm. The care plan dated 7/24/19 identified Resident #30 has fracture of the right arm with interventions to provide assistance with the use of supportive devices, splints as recommended, and follow physician orders for weight bearing status. A nurse's note dated 7/26/19 at 4:31 AM identified Resident #30 refuses to keep the right arm sling in place. It was removed for the night. A nurse's note dated 7/27/19 at 10:16 PM identified Resident #30 pulls at the bottom edges of cast/splint at times. Edema to the right hand persists, and sling in place, readjusted as needed due to restlessness. An APRN note dated 7/27/19 identified Resident #30 is status post re-admission to nursing facility with a fracture of the right elbow. The right arm is in a sling for comfort, the plan is to continue to monitor and use the sling for comfort and support. A skin assessment dated [DATE] identified Resident #30 was at moderate risk for skin breakdown. The care plan dated 7/31/19 identified Resident #30 has a right radial fracture with interventions that include the use of a sling to the right arm as ordered, and monitor color/motion/sensation (cms). Review of an orthopedic consultation report dated 8/1/19 identified Resident #30 has a splint to the right upper extremity status post right elbow fracture. Recommendations included to continue posterior splint, apply ice and elevate, use sling and follow up in 2 weeks. Too swollen to place in cast. A physician's order dated 8/2/19 directed posterior splint in place, ice, elevate and sling. Too swollen to place in cast. The nurse's note dated 8/10/19 at 10:30 PM identified Resident #30 frequently plays with wrapping on splint and with sling. An APRN note dated 8/14/19 identified Resident #30 is being seen for pain to the right elbow due to the fracture, and the elbow is wrapped with an ace wrap, and a sling for comfort. Right elbow swelling is mild. Plan is to start Norco (narcotic pain medication) for pain, and continue to use sling for support and comfort. Review of an orthopedic consultation report dated 8/15/19 identified x-rays of the right elbow indicate no shifting, and mild bony callus formation. Recommendations include to keep splint intact, digit range of motion okay. The care plan dated 8/15/19 identified Resident #30 has a right radial fracture with interventions that include to keep splint intact, and may do digit range of motion. A nurse's note dated 8/23/19 at identified Resident #30 had a new open area to the right elbow that measured 2.0cm x 2.0cm, with an area of slough, and 5.0cm of pink/red erythema around the wound. Subsequent to APRN notification, a new order for wound care was obtained. Staff were unable to re-apply splint due to odorous drainage. Sling removed and washed, will reapply when dry. A physician's order dated 8/23/19 directed to cleanse the right elbow with normal saline and apply calcium alginate, followed by dry protective dressing twice a day for 14 days and re-evaluate. A pressure ulcer documentation flow sheet dated 8/30/19 identified Resident #30 had a stage III pressure ulcer on the right elbow that measured 2.0cm x 1.4cm x 0.4cm, with moderate drainage, 100% slough, and macerated wound edges. A wound specialist note dated 8/30/19 identified Resident #30 had a stage III pressure ulcer to the right elbow with heavy purulent drainage, and 100% slough that measured 2.0cm x 1.4cm x 0.4cm. Additionally, recommendations included to optimize nutrition. A physicians order dated 8/30/19 directed to apply sanytl to the right elbow followed by alginate topically daily for stage III to the right elbow followed by foam dressing. A nurse's note dated 9/5/19 at 3:55 PM identified undermining was noted to the right elbow wound, and slough present to wound bed. A wound specialist note dated 9/6/19 identified the right elbow pressure ulcer deteriorated to a stage IV that measured 1.5cm x 1.3cm x 0.5cm with moderate serous exudate, 50% slough, 50% granulation. Although a nurse's note dated 8/23/19 identified Resident #30 had a new open area to the right elbow that measured 2.0cm x 2.0cm, with an area of slough, and 5.0cm of pink/red erythema around the wound, review of the skin observation tool dated 8/26 and 8/28/19 documented no new skin issues, and failed to reflect the wound on the elbow. Interview with the DNS on 9/18/19 at 11:00 AM identified she thought the facility was told they could not remove the splint from Resident #30's arm. However, she was not able to recall who told her. Additionally, she was not aware if staff had clarified the order regarding removal of the splint with the orthopedic physician to facilitate skin checks under the splint. The DNS indicated there should have been an physician order if staff are not to remove the splint. Review of the skin checks policy identified skin checks are done to identify changes in skin integrity through weekly skin audits head to toe on all residents. Licensed nurses will perform skin body audits on a weekly basis on shower day. The licensed nurse performs a weekly head to toe check of the resident's skin paying particular attention to boney prominences elbows, heels, tailbone, etc. Additionally, the surface of the skin that come in contact with any orthotic device, tube, brace or positioning device. Observe for open area, redness, injury, abnormalities will be placed on the body sheet. Any significant abnormal findings are reported to the residents' physician and family. Review of the policy pressure ulcer prevention identified the most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles and toes. Pressure can come from splints, casts, and bandages. Interventions and preventative measures include; routinely assess and document the condition of the residents' skin per weekly skin integrity form for any signs and symptoms of irritation or breakdown. Additionally, monitor the placement of splints and casts to assure they are not placing friction on the residents' skin. Although Resident #30 was diagnosed with a distal supracondylar humeral fracture as well as a nondisplaced radial head fracture of the right arm on 7/22/19, upon return from the hospital, the facility failed to consistently implement the care plan intervention dated 7/31/19 which indicated to monitor color/motion/sensation (cms) of the fractured arm, failed to clarify with the orthopedic physician and implement the recommendations dated 8/1/19 which directed to apply ice and elevate the right elbow (8/1/19 - 9/12/19), failed to clarify with the orthopedic physician the weight bearing status of the right arm, whether the splint could or should be removed for skin checks, and failed to communicate with the orthopedic physician that Resident #30 was intermittently refusing/removing the posterior splint/sling, and/or that staff were removing the splint/sling due to the refusals, without a physician's order. Additionally, the facility failed to accurately document on the weekly skin observation tool the condition of the resident's skin (elbow wound) on 8/26 and 8/28/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #2) reviewed for dialysis, the facility failed to administer medications and fluids according to the physician's orders, and failed to provide ongoing communication and collaboration with the dialysis provider and the physician, and/or consistently monitor fluid intake/output per physician's orders. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that includes diabetes, and end stage renal disease. Physician's order dated 3/7/19 directed to administer Pravastatin (a medication used to treat high cholesterol) 80 mg daily at bedtime. Physician's order dated 6/2/19 directed to obtain a blood pressure and pulse every shift. Physician's order dated 6/3/19 directed to administer Metoprolol (a medication used to treat high blood pressure) 50mg and nephro-vite 0.8mg daily at bedtime. A physician's order dated 7/2/19 directed to administer PhosLo (a medication to control the level of phosphate in the blood for patients on dialysis) capsule 667mg, give 3 capsules with meals, Midodrine 10mg (a medication used to treat low blood pressure) daily, Aspirin 81mg daily, Furosemide 80mg (a medication used to treat fluid retention (edema) and swelling) daily on Sunday, Tuesday, Thursday, Saturday, and Amlodipine (a medication used to treat high blood pressure) 10mg daily at bedtime. The quarterly MDS dated [DATE] identified Resident #2 had moderately impaired cognition, was always continent of bowel and bladder, and required supervision for dressing and personal hygiene. The care plan dated 7/11/19 identified Resident #2 required hemodialysis related to end stage renal disease and was non-compliant with medications. Interventions included to encourage the resident to go for scheduled dialysis, monitor intake and output, and notify the physician if the resident refuses medication and/or treatments. Review of the July 2019 MAR identified Resident #2 refused the following medications/care; Amlodipine 10mg 12 times, Aspirin 81mg 9 times, Furosemide 80 mg 5 times, Metoprolol 50mg 9 times, Midodrine 10mg 7 times, Nephro-vite 0.8mg 9 times, Pravastatin 80mg 10 times, Phoslo 667mg 3 caps 39 times, and refused the blood pressure and pulse 10 times. Review of the August 2019 MAR identified Resident #2 refused the following medications/care; Amlodipine 10mg 7 times, Aspirin 81mg 9 times, Furosemide 80 mg 7 times, Metoprolol 50mg 7 times, Midodrine 10mg 10 times, Nephro-vite 0.8mg 8 times, Pravastatin 80mg 10 times, Phoslo 667mg 3 caps 44 times, and refused the blood pressure and pulse 47 of 93 times. A physician's order dated 8/10/19 directed Resident #2 be on a 1200ml fluid restriction per day. Review of the September 2019 MAR identified Resident #2 refused the following medications between/care 9/1/19 - 9/19/19; Amlodipine 10mg 12 times, Aspirin 81mg 2 times, Furosemide 80 mg 4 times, Metoprolol 50mg 8 times, Midodrine 10mg 2 times, Nephron-vite 0.8mg 8 times, Pravastatin 80mg 9 times, Phoslo 667mg 3 caps 24 times, and refused the blood pressure and pulse 22 of 57 times. Review of the intake and output records dated 8/13/19 through 9/17/19, 34 days, identified although Resident #2 had a physician's order for a 1200ml daily fluid restriction, the resident was over the 1200ml restriction during 25 days; 8/13, 8/14, 8/15, 8/16, 8/17, 8/19, 8/20, 8/24, 8/25, 8/26, 8/27, 8/28, 8/29, 8/30, 9/1 9/2, 9/9, 9/10, 9/11, 9/12, 9/13, 9/14, 9/15, 9/16, and 9/17/19. Additionally, the intake and output record was not completed on 8/18, 8/21, 8/22, 8/23, 8/31/19, further, the facility was not able to provide intake and output documentation for 9/3/19 through 9/8/19. Interview with the DNS on 9/9/19 at 10:47 AM identified that her expectation is that the nursing staff or supervisor would update the physician and/or the dialysis provider every time Resident #2 refused medications, that day or by the next day. Additionally, when a resident is on a fluid restriction for dialysis, the physician and dialysis should be notified if the resident went over the fluid restriction for 3 days. The facility failed to provide documentation that the physician and the dialysis center were notified of refusal of medications, blood pressures/pulse, and when the resident was over the fluid restriction. Although requested, a policy on dialysis and physician notification of refusal of medications was not provided. The facility failed to ensure ongoing communication and collaboration with the dialysis provider when Resident #2 refused medications, blood pressures and pulse monitoring during July, August and September 2019, and/or went over the fluid restriction during 25 days in August and September 2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility documentation, review of facility policy, and interviews for 2 of 2 medication storage rooms, the facility failed to ensure that medications were dated when opened and/or discarded of when expired. The findings include: 1. Observation of the North Unit medication storage room on [DATE] at 9:30 AM identified an opened bottle of Tuberculin Purified Protein Derivative Solution (PPD) with a date of [DATE] (112 days ago) written on bottle that was located in the refrigerator. A sign was observed posted in the medication storage room identifying PPD keep stored in refrigerator, date when opened, and discard after 30 days. An interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 9:30 AM identified the date on the bottle was the date the bottle of Tuberculin Purified Protein Derivative Solution was opened. 2. Observation of the South Unit medication storage room on [DATE] at 9:40 AM identified an opened bottle of Tuberculin Purified Protein Derivative Solution (PPD) which was not dated. A sign posted in the medication storage room identified PPD keep stored in refrigerator, date when opened, and discard after 30 days An interview with LPN #2 on [DATE] at 9:45 AM identified when the PPD multi dose vial of solution was opened, the nurse opening it was supposed to date it when it was opened. LPN #2 could not indicate when it had been opened. Review of the facility Policy titled Medication Storage identified all multiple use vials i.e. insulin, insulin pens, influenza, tuberculin solution (ppd) will be dated upon opening and discarded per manufacture guidelines. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #56) who had a history of a Multi-Drug Resistant Organism, (MDRO; common bacteria that have developed resistance to multiple types of antibiotics), the facility failed to implement transmission based precautions in a timely manner and/or implement infection control practices according to professional standards. The findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included Methicillin-resistant Staphylococcus aureus (MRSA) (an infection that's become resistant to many antibiotics), and fracture to right humerus. The quarterly MDS dated [DATE] identified Resident #56 had intact cognition, was always continent of bowel and bladder, and required limited assistance for dressing, toileting, hygiene and transfers. The care plan dated 6/20/19 included to have Resident #56 transfer to the toilet independently with a rolling walker. Additionally, the care plan indicated Resident #56 had a potential for impaired skin integrity with intervention to have the resident avoid scratching self, keep hands and body parts from excessive moisture, and keep fingernails short. A physician's order dated 7/25/19 directed Resident #56 be independent with ambulation with a rolling walker. An APRN progress note dated 9/11/19 identified Resident #56 was evaluated for a boil on the right posterior thigh. Resident #56 had also been seen on 9/4/19 for this boil (which was dry and crusted at that time). Since that visit, the wound APRN opened the boil up to allow it to drain. Staff reports that it has drained a lot of blood and pus. Today the boil is very painful for the resident and appears infected at this time. A physician's order dated 9/11/19 directed to obtain a wound culture, and gram positive stain for a right upper posterior thigh boil. Additionally, start Keflex (antibiotic) 500mg twice daily for 7 days. A laboratory report dated 9/15/19 identified that the right thigh wound culture has heavy growth of MRSA. A nurse's note dated 9/16/19 at 7:48 PM identified that the APRN was notified of the right abscess wound culture. Physician's order dated 9/18/19 directed to place Resident #56 on precautions for MRSA in wound, and maintain until antibiotics completed and wound is closed. A nurse's note dated 9/18/19 at 11:55 AM identified that contact precautions were in place for positive MRSA to the abscess. Observation on 9/19/19 at 10:00 AM and at 1:15 PM identified an isolation cart was inside Resident #56's semi-private room, in the middle of the room, against the wall, at the foot of the resident's window side bed. Additionally, a commode was not present in the room. Observation identified the resident's roommate was noted to independently walk in the room and was observed to independently go into the bathroom and close the door. Interview with the DNS on 9/19/19 at 11:45 AM identified that although Resident #56 had a history of MRSA, she would not have placed the resident on any precautions, despite the draining boil, but as soon as the wound culture results came back and identified MRSA, the resident should have been placed on precautions immediately. The DNS indicated that when Resident #56 was identified to have MRSA on 9/15/19, he/she should have been placed on contact precautions. Review of the isolation of resident with infection policy indicated to implement contact precautions for residents with known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident, or indirect contact with the environment surfaces, or resident care items in the resident's environment. Resident will be placed in a private room if possible, if not available resident will be placed with a low risk resident or cohorted. Staff should wear a disposable gown upon entering the contact precaution room. Resident should use a bedside commode to avoid sharing a bathroom between residents. Although Resident #56 was admitted with a history of MRSA, had an open draining infected wound on the posterior thigh (identified on 9/11/19), shared a bathroom with his/her roommate, and had a laboratory report dated 9/15/19 which identified heavy growth of MRSA, the resident was not placed on transmission based precautions until 9/18/19, (7 days after the wound started draining, and 3 days after the culture was obtained), was not provided a commode per the facility policy, and the isolation cart was located inside residents room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews for 1 of 1 sampled reviewed for weight loss (Resident #30), the facility failed to ensure a resident with special dietary and safety needs had a nutritional assessment in a timely manner and for 1 resident reviewed for hydration (Resident #62), the facility failed to ensure a nutritional assessment was completed quarterly according to facility policy. The findings include: 1. Resident #30 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia, and chronic kidney disease stage III. An admission weight dated 6/29/19 identified Resident #30 weighed 115.6 pounds (lbs). A physician's order dated 7/1/19 directed to provide Resident #30 a mechanical soft texture and thin liquids diet, assistance with feeding, the resident should be in upright at 90 degrees for all oral intake and be up for 30 minutes after meals. Additionally, the order directed Resident #30 take small bites and sips, one at a time, and allow extra time between each bite and or sip. The admission Minimum Data Set assessment dated [DATE] identified Resident #30 had severely impaired cognition, was frequently incontinent of bowel and bladder, and required extensive assistance for dressing, eating, toilet use, and personal hygiene. Physician's order dated 7/6/19 directed to administer House Supplement 2 times daily. The care plan dated 7/18/19 identified Resident #30 has swallowing problems related to dysphasia with interventions that included to downgrade diet to mechanical soft thin liquids, aspiration precautions, provide assistance of one for feeding, upright at 90 degrees for all oral intake and up to 30 minutes after, small bites and/or sips at one time, allow extra time between each bite and/or sip. Review of the clinical record failed to reflect an admission Nutritional assessment had been completed by the Dietician from admission on [DATE] and/or re-admission on [DATE]. Interview with Dietician #1 on 9/18/19 at 8:00 AM identified she started the admission comprehensive nutritional assessment (for the admission of 6/29/19) but must have forgotten to lock the assessment and that was the reason it was not electronically visible, signed or dated until 9/18/19. Dietician #1 indicated that was the only comprehensive nutritional assessment she had completed for Resident #30. Additionally, for newly admitted residents, Dietician #1 indicated she would see them the next time she was in the facility, and although the policy says by the 14th day, she indicated she completes a nutritional assessment within a week. Review of the policy for nutritional assessments indicates an assessment will be conducted for each resident admitted . The clinical Dietitian in conjunction with the nursing staff and attending physician will assess nutritional issues for each resident admitted to the facility. Nutritional assessments will be completed prior to developing the resident's MDS assessment and care plan. The Dietician failed to complete a comprehensive nutritional assessment within 14 days of the resident's admission on [DATE], and re-admission on [DATE]. 2. Resident #62 was admitted to the facility on [DATE] with diagnoses that include major depressive disorder, history of other mental and behavioral disorders and type II diabetes with unspecified complications. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #62 as having intact cognition and requiring supervision with bed mobility, transfers and toilet use. The MDS further identified Resident #62 required limited assistance of one for eating. A Dietician's progress note dated 4/24/19 identified Resident #62 refused a monthly weight for April, current weight was recorded at 229 pounds (lbs), prior weight was 224 lbs., that Resident #62 continued on a calorie controlled diet with large vegetable portions and evening snack. Preferences discussed and no nutritional problems or issues were noted. Review of the Nutritional progress notes failed to identify a quarterly Nutritional/Dietician assessment had been completed since 4/24/19 (a quarterly Nutritional note was due to be completed in July 2019). The Resident Care Plan dated 7/3/19 identified Resident #62 had a problem with dehydration and/or potential for fluid deficit related to diuretic use. Interventions included to monitor and document intake and output per facility policy, monitor, document, and report signs and symptoms of dehydration and notify the physician for persistent symptoms of diarrhea and/or nausea/vomiting. An interview and clinical record review on 9/18/19 at 8:36 AM with Dietician #1 identified Resident #62's food and fluid intake was adequate. Resident #62 could make needs known and obtained fluids independently. Dietician #1 indicated that Resident #62's nutritional concerns were discussed within the past couple of weeks at a resident care conference. Dietician #1 further indicated that while she was aware that a nutritional assessments were to be completed on admission and quarterly, she was unsure as to the reason a quarterly nutritional assessment had not been completed since 4/24/19. Additionally, Dietician #1 identified that the completion of the most recent MDS prompted her to complete a Nutritional assessment on 9/18/19 as she had no other reliable tracking system. The facility policy for Nutritional Assessments effective 4/17 directed a Nutritional Assessment shall be conducted on admission and prior to developing the resident's MDS assessment and care plan. Nutritional assessments will be reviewed quarterly and revised as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews for 2 of 4 residents reviewed for psychoactive medications (Resident #43 and Resident #73), the facility failed to ensure there was an indication for the use of an antipsychotic medication and target behaviors were not identified or monitored. The finding include: 1. Resident #43 was originally admitted to the facility on [DATE] with diagnoses that included heart failure and chronic kidney disease. An Advanced Practice Registered Nurse (APRN) order dated 2/25/18 directed Seroquel (an antipsychotic) 25 mg at bedtime, however, failed to identify the reason Seroquel was ordered. Physician's orders from 2/25/18 to current (9/19/19) renewed the order for Seroquel 25 mg at bedtime. Review of a consultation by the psychologist dated 2/26/18 indicated Resident #43 was appropriate, cooperative, had memory and judgement impairments, diagnosed with dementia and adjustment disorder with mood disturbance (anxiety and depression) with recommendations for individual psychotherapy. The psychologist consultation did not refer to or discuss the recent initiation of Seroquel or indications for its use. The quarterly Minimum Data Set assessment dated [DATE] indicated moderate impairment in cognition, requiring total assistance of one to two staff for activities of daily living, no behaviors and receiving antipsychotic medications. The resident care plan failed to identify a care plan had been developed for behaviors or the use of antipsychotic medication from 2/25/18 when Resident #43 was prescribed an antipsychotic until present. Review of the only behavior/intervention monthly flow record provided by the facility identified a behavior record dated 2/20/18 which only had the shifts circled, lacking the behaviors to be monitored and number of episodes. Further review of the mental health notes identified the next psychiatry note was dated 8/1/18 and identified the resident was not receiving any psychiatric medications (although physician's orders directed Seroquel 25 mg at bedtime since 2/25/18). A 8/9/18 psychiatry note identified the resident was started on Celexa (an antidepressant) 10 mg daily. Review of the pharmacy consultant recommendation dated 2/26/19 requested supporting documentation for the use of the Seroquel in which the APRN responded general anxiety disorder and targeted behaviors to be monitored which the APRN responded agitation and anxiety. Not until a psychiatric consult dated 3/20/19 did the consult identify the current psychiatric meds of Seroquel and Celexa; diagnoses of depression, anxiety, memory impairment, is stable on psychotropic meds; continue to monitor mood, anxiety, sleep and appetite; and gradual dose reduction not indicated. Subsequent psychiatric consults dated 3/28/19, 4/11/19, 5/3/19, 6/6/19, 7/2/19, 7/25/19 and 8/1/19 identified that same documentation as the 3/20/19 note. Interview with Licensed Practice Nurse (LPN) #4 on 9/18/19 at 12:30 PM indicated any behavior monitoring completed would be found on paper until July 2019 when it monitoring was then completed electronically in the computer. LPN #4 further indicated any behaviors to be monitored would be contained in the physician orders. Review of the physician orders failed to identify behaviors to be tracked. Interview with the DNS on 9/18/19 at 12:45 PM indicated the facility changed behavior monitoring tracking from paper to the computer, was unsure when, thought inservicing was done by staff but apparently was not done. Interview with APRN #1, who originally ordered the Seroqel on 2/25/18, was unsuccessful. On 9/19/19 at 11:00 AM, Interview with APRN #2, who was currently managing the resident, indicated the APRN felt without the use of Seroquel Resident #43 would be restless and agitated. The APRN further indicated he/she always recommends behaviors are monitored to see what is going on with the resident and speaks to the staff. In addition, the APRN indicated he/she was very conservative and always tried other medications that are not antipsychotics first. The APRN planned on seeing the resident on 9/20/19 to re-evaluate the use of the medication. Interview with the Pharmacy Consultant on 9/19/19 at 11:25 AM indicated the resident had a diagnosis of major depressive disorder and anxiety, would not be able to recommend a gradual dose reduction of the medication if behaviors were not tracked and the APRN indicated a gradual dose reduction was not indicated although there was no documentation of what is going on with the resident. APRN consult dated 9/24/19 indicated Seroquel was reduced to 12.5mg at bedtime on 9/21/19 and the resident was tolerating it well. 2. Resident #73 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder, major depressive disorder and dementia with behavioral disturbance. The quarterly MDS dated [DATE] identified Resident #73 Quarterly MDS dated [DATE] indicated intact cognition, exhibited no mood symptoms or behaviors. The care plan dated 8/15/19 identified Resident #73 went to another Resident's room and verbally threatened to punch him. Interventions directed to attempt to redirect to vent frustrations more appropriately. Care plan further identified that Resident #73 uses psychotropic medications, with interventions directed to Monitor/document/report PRN any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. A physician's order dated 8/5/19 directed Quetiapine Fumarate (Seroquel which is an antipsychotic medication) tablet give 37.5 mg by mouth two times a day related to anxiety disorder. The psychiatric APRN note dated 8/8/19 noted to continue to monitor mood, anxiety, sleep and appetite. The psychiatric APRN note dated 9/5/19 noted to continue to monitor mood, anxiety, sleep and appetite. Interview and clinical record review with Licensed Practical Nurse #3 on 9/18/19 at 9:04 AM failed to provide any documentation of behavior monitoring for Resident #73 for the month of September 2019. Interview and clinical record review with DNS on 9/18/19 at 11:59 AM , noted that daily behavior monitoring for Residents on antipsychotic medication was expected to be documented on the Medication Administration Record (MAR). Facility policy for psychoactive medication identified that residents receiving antipsychotics with a diagnosis of organic mental syndrome with agitated/psychotic behaviors must have their target behaviors identified and monitored. Additionally, the policy indicates antipsychotics will be prescribed only when a resident has a documented diagnosis or condition appropriate for the use of these medications with a listing which includes dementia with associated psychotic and/or agitated features demonstrated by specific behaviors which are quantitatively documented, (i.e., kicking, biting, scratching, crying out, yelling, pacing, etc). The facility failed to identify a corresponding diagnosis when Resident #43 was started on Seroquel. Additionally, Resident #43's and Resident # 73's target behaviors were not identified or monitored consistently.

Based on observations, review of facility documentation, review of facility policy, and interviews for 2 of 2 nourishment refrigerator freezers, the facility failed to intervene when temperatures were out of acceptable range and maintain, clean, or defrost the nourishment refrigerator freezers per the facility policy. The findings include: Observation of the North Unit nourishment room's refrigerator and freezer on 9/17/19 at 9:30 AM identified a thick buildup of ice in the freezer section and spilled juice on the bottom of the refrigerator. A temperature tracking sheet taped to the side of the refrigerator identified the acceptable ranges of temperatures 33-40 degrees Fahrenheit (F). A review of the North Unit nourishment room's refrigerator and freezer temperature tracking logs for June, July, August, and September 2019 identified the temperature were not within the acceptable ranges on 7/10/19 as 31 degrees F, 8/2/19 as 32 degrees F, 8/8/19 as 31 degrees F, 8/9/19 as 31 degrees F, 8/12/19 as 32 F degrees, 8/30/19 as 31 degrees F, 9/16/19 as 29 degrees F, 9/17/19 as 30 degrees F , and 9/18/18 as 31 degrees F. Observation of the South Unit nourishment room's refrigerator and freezer on 9/18/19 at 7:30 AM identified a thick buildup of ice in the freezer section and spilled dried up juices on the racks. A temperatures tracking sheet taped to the refrigerator identified the acceptable ranges of temperatures 33-40 degrees Fahrenheit (F). A review of the South Unit nourishment refrigerator and freezer temperature tracking logs for June, July, August, and September 2019 identified the temperature were not within the acceptable ranges on 6/3/19 as 34 degrees F, 6/14/19 as 45 degrees F, 6/29/19 as 50 degrees F, 7/9/19 as 30 degrees F, 7/10/19 as 30 degrees F, 7/12/19 as 30 degrees F, 7/22/19 as 30 degrees F, 7/23/19 as 50 degrees F, 7/26/19 as 30 degrees F, 7/28/19 as 50 degrees F, 8/7/19 as 45 degrees F, 8/13/19 as 50 degrees F, 8/21/19 as 31 degrees F, 8/30/19 as 30 degrees F, 8/31/19 as 32 degrees F, 9/3/19 as 30 degrees F, 9/4/19 as 30 30 degrees F, 9/5/19 as 30 degrees F, 9/11/19 as 50 degrees F, and 9/18/19 as 30 degrees F. An interview with the Administrator on 9/18/19 at 7:45 AM indicated the Director of Housekeeping was responsible for ensuring that daily temperatures of the refrigerator and freezer are obtained daily are within acceptable ranges, maintaining cleaning, and defrosting the units when needed. Interview and observation with the Director of Housekeeping on 9/18/19 at 8:00 AM identified housekeeping was responsible for obtaining and recording the temperatures once per day, maintaining the nourishment refrigerators which included sanitizing and defrosting. He/she further indicated if the temperatures were not within 33-40 degrees F he/she would expect staff to communicate that information to him/her so another temperature could be obtained later in the day to identify if there was an issue with that refrigerator. Observation at that time with the Director of Housekeeping of the nourishment refrigerator on the North Unit identified a thick layer of ice build up inside the freezer section with an cup of ice cream melting inside. The Director of Housekeeping could not explain the reason that the freezer had not been defrosted or the last time either nourishment freezer had been defrosted or cleaned nor provide documentation to reflect that the North unit and South unit's nourishment refrigerator freezers have had any maintenance, cleaning, or defrosting completed. Subsequent to surveyor inquiry the north unit nourishment refrigerator was being cleaned and the freezer was being defrosted. Review of facility Refrigerators and Freezers Policy identified the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation. Maintenance schedules per manufactures guideline will be scheduled and followed. Supervisors will take immediate action if temperatures are out of ranges. Actions necessary to correct temperatures will be recorded on the tracking sheets, including repair, personnel and/or department to contact. Refrigerators and freezers will be kept clean, free of debris, cleaned with sanitizing solution on a scheduled basis and more often as necessary.