**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure a quiet and homelike environment on one of four units (GNR 300), during three of four days observed (8/12/2024, 8/13/2024, 8/14/2024). It was observed and overheard a resident was yelling and causing loud noises for long periods of time and affecting Residents on the entire GNR 300 hallway to include Residents #32, #49, #15, #1, and 14. Findings included: On 8/12/2024 and 8/13/2024 during the 7-3 shift (over four observations from 9:55 a.m. - 10:45 a.m.), Resident #69 was observed in her room and lying flat in bed. She was observed all four times not presenting with any behaviors, pain or discomfort. Upon visiting the room she did present with confusion and cognitive deficits. Resident #69 was not able to answer specific questions related to her medical care and services. On 8/12/2024 at 11:00 a.m. while seated at the GNR 300 Nurses' Station, a resident could be overheard from the GNR 300 hall yelling out loud. The yelling was intermittent and could not at first be determined who the resident was. After walking out from the nurse station and approximately thirty-five feet down the GNR 300 hall, it was determined Resident #69 was observed in her bed and yelling. It appeared she was yelling out words intermittently. An interview conducted at that time revealed she talked at a normal level and revealed she was ok and having a good day. She was asked if she needed anyone and she revealed that she did not. Resident #69 said she was fine. There were no identifiable concerns during the observation and interview that would indicate the resident was neglected, in pain or in discomfort. Interview with several unidentified staff who walked by Resident #69's room and room area, said, she does that, she yells out all the time, but just does that for no reason and that is her normal behavior. The staff continued to say that once they go in the room to visit with her and talk with her, she calms down and talks at a lower volume. However, when they leave the room Resident #69 starts to be loud again very shortly after they leave. It was measured Resident #69's room was thirty-five feet up the GNR 300 hall, from the nurse station. Resident #69's room was in the middle of the hallway. It was overheard of one resident from an unknown room saying aloud; please stop her, who is that? On 8/12/2024 at 1:45 p.m. Resident #69 was overheard yelling out and could be heard throughout the GNR 300 hallway, and past the unit station. Staff were observed to go in and out from the room but after they left the resident would keep calling out unrecognizable words and phrases intermittently. On 8/13/2024 at 9:20 a.m. through 10:00 a.m. Resident #69 was overheard from her room yelling out loud and was doing this intermittently for about twenty minutes until 10:20 a.m. Some residents could be overheard in other rooms shouting out, shut up, please stop her from yelling. Staff would go in the resident's room and intervene, but as soon as they left the room the resident would begin to yell out loud again. On 8/14/2024 at 8:15 a.m. Resident #69 was noted in room. A Nurse was in her room passing medication to her, and she accepted with no observable concerns. On 8/14/2024 from 10:00 a.m. through to 11:00 a.m. Resident #69 could be overheard calling out loudly and talking to herself, but was speaking in a very loud manner and she could be overheard throughout the GNR 300 hall and at the unit station. Staff did intervene, but as soon as staff left, she would speak loudly to herself too. There were times the room mate would also call out very loudly. Some residents in other nearby rooms could be overheard saying , please be quiet. On 8/15/2024 at 8:03 a.m. while walking down the GNR 300 hall, Resident #69's room door was closed all the way. At 8:20 a.m. the room door was still observed closed. Another tour on the GNR 300 hall at 8:32 a.m. revealed the resident's room door was now wide open and she was noted in her low bed and lying on her side watching television. She was not presenting with any behaviors, pain, discomfort, and was not yelling or calling out. On 8/15/2024 during the 7-3 shift the following random residents, who reside in the GNR 300 hall, were interviewed with relation to the noise coming from the resident's room: 1. Resident #32, who's room was thirty feet from Resident #69's room, revealed she hears some resident yelling all the time. She has mentioned this to staff before, but the resident has not stopped. She would rather the resident stop yelling, but feels there is no use of complaining anymore. Review of Resident #32's medical record revealed she was admitted at the facility on 9/6/2018. Review of the advance directives revealed Resident #32 was her own decision maker. Review of the current Minimum Data Set (MDS) assessment (Quarterly), dated 5/28/2024, revealed: Cognition/Brief Interview Mental Status BIMS (Brief Interview for Mental Status) score 15 of 15, which revealed the resident was able to speak related to her day and medical care. 2. Resident #49, who's room was ten feet from Resident #69's room, revealed she hears Resident #69 yelling out all the time, especially the past week or two. Hears her at night as well. She has complained and was told by staff that the resident could not help yelling out at times. She would like for her to stop. Review of Resident #49's medical record revealed she was admitted at the facility on 5/24/2019. Review of the advance directives revealed Resident #49 was her own decision maker. Review of the current MDS assessment (Annual), dated 5/17/2024, revealed: Cognition/BIMS score 13 of 15, which indicated the resident was able to speak about the day and her medical care. 3. Resident #15, who's room was fifteen feet from Resident #69's room, revealed he has overheard the resident yell out. He did not think she was in pain, she just yells out words and yells out to herself. He has spoken to staff about it before, but things have not changed. Review of Resident #15's medical record revealed he was admitted to the facility on [DATE]. Review of the advance directives revealed Resident #15 was his own decision maker. Review of the current MDS assessment (Annual), dated 6/14/2024, revealed: Cognition/BIMS score 15 of 15, which indicated the resident was able to speak related to his day and medical care. 4. Resident #1, who's room was eight feet from Resident #69's room revealed, she not care for the resident yelling out and knows she can't help it, but would like for the hallway to be more quiet. She believed she has spoken to staff about it before. Resident #1 revealed she has been a nurse for over 40 years and she knows that residents can sometimes yell out. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Review of the advance directives revealed the resident was her own decision maker. Review of the current MDS assessment (Quarterly), dated 7/18/2024, revealed: Cognition/BIMS score 15 of 15, which indicated the resident was able to speak related to her day and medical care. 5. Resident #14, who's room is seven feet from Resident #69's room, revealed; He is not really ok with all the yelling from the resident. He is normally out from his room during the day. Has overheard her yelling at night and that is problematic. He has spoken to staff before, but no real changes. Review of Resident #14's medical record revealed he was admitted at the facility on 5/2/2022. Review of the advance directives revealed the resident was his own decision maker. Review of the current MDS assessment (Modified Annual), dated 5/7/2024), revealed: Cognition/BIMS score 15 of 15, which indicated the resident was able to speak related to his day and medical care). On 8/12/2024 at 10:50 a.m., an interview with Staff H, Licensed Practical Nurse (LPN), who was a nurse on the GNR 300 unit, and knew Resident #69, revealed; she has heard her yell out at times and usually other staff will report to the room an intervene. She knows that Resident #69 is easily redirected, but it seems the resident will at times continue with her behaviors after the staff leave. On 8/14/2024 at 2:40 p.m. an interview with the Director of Nursing (DON) revealed she did know of Resident #69 and her yelling out behaviors. She revealed the resident is care planned with interventions for staff to help reduce the behaviors, and that the resident is being seen by psychology services. The DON was not sure of the exact interventions. The DON revealed she knows the resident yells out loud at times during the main 7-3 shift and that staff will respond and she will then subside with the yelling. The DON did confirm that once staff leave the room, she will at times begin to call out loud again. The DON revealed she did know that Resident #69 is not yelling out in pain or discomfort. On 8/15/2024 at 8:05 a.m. an interview with Staff G, LPN, who had Resident #69 on her schedule, and has had the resident on her routine schedule, revealed; she is well aware of the resident's calling out and yelling behaviors. She revealed the resident has been known to call out very loudly for awhile now and they have developed care planning measures with interventions to try and subside it. Staff G revealed she, along with any other staff will intervene when she starts to yell out and as soon as the resident is visited, she calms and talks normally, but is very confused and has cognition deficits. Staff G further revealed she has heard other residents in other rooms call out, shut up, who is yelling, at times. Staff G revealed she and other staff try to keep the hallway comfortable and explain to the other residents in the hall that the resident doesn't know what she is doing and she doesn't mean to yell out loud. Staff G also confirmed the resident is being seen by Psychology services routinely and there has been medication adjustments, but with no changes. Staff G feels they have put in so many different interventions to have the resident subside with the yelling out, but she just keeps yelling out at times for no reason. Staff G again revealed she will speak with the resident and will tell her everything is fine, but then will speak in unknown subject matter and will see the resident will ask and answer her own questions like she is talking with someone else. Staff G revealed they try to keep the hallway and room quiet for all the residents who reside on the unit to enjoy. She revealed she monitors staff/resident and resident/resident interactions as well as monitors residents behaviors through her shift. She revealed that aides are to report to her if there are any problems or behaviors with any of the residents. Then she will report to the supervisor and DON as well. On 8/15/2024 at 8:40 a.m. an interview with Staff D, Certified Nursing Assistant (CNA), who had resident on her assignment revealed; she knows the resident well and she is usually pleasant to speak with. She confirmed that as of late, the resident has been yelling out and screaming during the day. She revealed that when she reports to the yelling out, the resident will then stop and become very nice and talkative. Staff D also revealed as soon as she leaves the room, the resident will again start to yell for periods of time. Some of the things they try to do to reduce her from those behaviors are: Routine monitoring of the resident, offer the resident out from bed to group activities, talk with her about the day, turn the television on in the room to what she wants to watch. On 8/15/2024 at 9:00 a.m. an interview with Staff I, Restorative Aide, who has had the resident on her assignments at times, revealed; Resident #69 does yell out at times and if she hears her, she will report to the room and intervene. Review of Resident #69's medical record revealed she was admitted at the facility on 9/30/2021. Review of the advance directives revealed the resident had a guardian who was her responsible party. Review of the Diagnosis sheet revealed diagnoses to include but not limited to: Dementia, Anxiety. Review of the current MDS assessment (Quarterly), dated 7/11/2024, revealed; (Cognition/BIMS score - No score; Checked for Short Term Memory Problem, Long Term Memory Problem, Severely Impaired Decision Making Skills); (Behaviors - Part C Other behaviors symptoms not directed towards others e.g. verbal/vocal symptoms like screaming, disruptive sounds was checked 0 - Behavior not exhibited). Review of the current care plans with a next review date 10/13/2024 revealed the following but not limited to areas: 1. Resident has an alteration in sleep/wake cycles r/t [related to] insomnia, with interventions in place 2. Resident has cognitive deficits and mood disorder with episodes of unprovoked agitation, indifference, and poor decision making, leading to undesired behaviors. Behaviors include episodes of declination of needed personal care, medications and yelling out, with interventions in place as reviewed and observed. 3. Has impaired cognitive function related to dementia with interventions in place as reviewed and observed 4. Resident requires 24 hour care/supervision and wishes to stay in this facility under long term care, with interventions in place as reviewed 5. Resident uses anti-anxiety medication r/t Anxiety, with interventions in place as per review On 8/15/2024 at 11:00 a.m. the Nursing Home Administrator provided the Quality of Live - Homelike Environment Policy and Procedure, with a revision date of May, 2017, for review. The policy statement indicated; Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The Policy Interpretation and Implementation section revealed; 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include but no limited to: i. Comfortable noise levels.

Based on interviews, record review, and review of the facility's policy titled Baseline Care Plan, the facility failed to ensure two residents (Resident #98 and #260) of the five residents sampled for baseline care plans. The findings include: Review of Resident #98's admission record revealed an admission date of 6/25/2024 with diagnoses of coronary artery bypass graft(s) with complications, urinary retention, Percutaneous endoscopic gastrostomy (PEG) tube, and other co-morbidities Review of Resident #98's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 5000-3008) dated 6/25/2024 revealed resident at risk for falls, resident has a foley catheter, a PEG tube, and diet order of NPO (nothing by mouth). Review of Resident #98's Interim Care Plan dated 6/25/2024 and completed 7/8/2024 revealed no care plan for a urinary catheter, nor dietary instructions for PEG tube. Review of Resident #260's admission record revealed an admission date of 7/24/2024 with diagnoses of chronic obstructive pulmonary disease with exacerbation (COPD), Pulmonary fibrosis, atrial fibrillation (A-Fib), and other co-morbidities Review of Resident #260's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 5000-3008) dated 7/21/2024 revealed resident at risk for falls, pressure ulcers, oxygen at 4 liters a minute, primary diagnosis of bilateral lower extremity weakness, pulmonary fibrosis, A-Fib and COPD. Review of Resident #260's Interim Care Plan dated 7/24/2024 and completed 8/6/2024 revealed no evidence completed and given to resident within the 48-72 hours of admission. During an interview on 8/12/2024 at 10:45 AM with Resident #260 and spouse. Resident #260 stated not being given any treatment plan or plan of care. During an interview on 8/14/2020 at 10:20 AM, the Minimum Data Set Coordinator (MDS) Coordinator, stated the baseline care plans are started on admission and updated until the full comprehensive care plan is completed. Review of Resident #98's interim care plan was started on 6/25/2024 but not completed until 7/8/2024. Review of Resident #260's interim care plan was started on 7/24/2024 but not completed until 8/6/2024. The MDS Coordinator stated In hindsight, the interim care plan is completed outside of the required time frame of 48 to 72 hours. During an interview on 08/14/24 at 10:55 AM, the Director of Nursing (DON) stated the expectation for the baseline care plans to be completed within 48-72 hours of admission, reviewed with the resident and resident representative and a copy provided. Review of the facility's policy titled Baseline Care Plan dated 3/1/2023, revealed The facility will develop and implement a baseline care plan for each resident that includes that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. Be developed within 48 hours of of a resident's admission. B. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders. iv. Therapy services. v. Social services. vi. PASSR recommendation, if applicable. 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. A. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. b. interventions shall be initiated that address the resident's current needs including i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. Iii. Any special needs such as IV therapy, dialysis, or wound care. c. Once established, goals and interventions shall be documented in the designated format. 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. 5. A supervising nurse or MDS nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative. This will be provided by completion of the comprehensive care plan. 6. The person providing the written summary of the baseline care plan shall: a. Obtain a signature from the resident/representative to verify that the summary was provided. b. Make a copy of the summary for the medical record. 7. If the summary was provided via telephone, the nurse shall indicate the discussion, sign the summary document, and make a copy of the written summary before mailing the summary to the resident/representative. 8. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable. This will be provided by the MDS nurse/designee by the comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident #21's admission Record revealed resident was readmitted on [DATE] with the following diagnosis: Parkinson's Disease, Post Traumatic Stress Disorder (PTSD), Mood Disorder due to known physiological condition, delusional disorder, Major depressive disorder, unspecified psychosis, anxiety and other co-morbidities. Review of Resident #21's care plan revealed the following Focus Areas: - Resident #21 has impaired cognitive function or impaired thought process related to impaired mobility delusion, PTSD, date initiated 3/20/2024 revised on 8/21/2023. Under interventions/Tasks no mention of the triggers for the resident's PTSD. - The resident has moments of anxiousness, PTSD, date initiated: 6/16/2023 revised on: 7/4/2023. No interventions/tasks of any triggers for resident's PTSD. - The resident has a psychosocial well-being problem related to trauma as a child-triggers PTSD screen. Becomes delusional at times mania, date imitated 4/1/2023 and revised on 6/21/2023. Under interventions/Tasks no mention of the triggers for the resident's PTSD. During an interview on 8/14/24 at 9:36 a.m., Staff A, Certified Nursing Assistant (CNA) stated there was no Resident that she knew of with a history of trauma or a diagnosis of Post Traumatic Stress Disorder (PTSD). Staff, CNA stated that Resident #21 talked to her past family history but she is demented. CNA stated, No one had discussed in report that Resident #21 had PTSD or had a history of trauma. During an interview on 8/14/24 at 9:38 a.m., Staff B, Licensed Practical Nurse (LPN) stated she was not aware of any Residents with a diagnosis of PTSD and had not heard anything in report about any residents with a diagnosis of PTSD. Staff B, LPN stated that she did know that Resident #21 had a diagnosis of schizophrenia though. Review of the facility's policy Quality of Care- Trauma-informed care dated 06/01/24 showed, Policy: The facility shall provide adequate care and services that residents attain and maintain the highest practical physical, mental and psychological well-being. Procedure: The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with profession standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Based on record review and interview, the facility failed to ensure two residents (#21 and #216) out of two residents with history of trauma had triggers identified to prevent re-traumatization. Findings included: Review of the admission Record showed Resident #216 was admitted to the facility on [DATE] with diagnoses that included but not limited to Post-Traumatic Stress Disorder (PTSD) Chronic, Schizoaffective Disorder, Bipolar Disorder, Generalized Anxiety Disorder and Major Depressive Disorder, Recurrent. Review of the baseline care plan showed no social service goals related to the diagnosis of PTSD or identified triggers. Review of the Informed Trauma Questionnaire dated 08/06/24 showed I. Assessment 1. Have you ever had an experience that was so upsetting to you that is changed you emotionally, spiritually, physically and behaviorally? Answer No. Review of the of Admission Minimum Data Set (MDS) dated [DATE] Section C-Cognitive Patterns showed Resident #216 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact). During an interview on 08/13/24 at 5:11 p.m., Resident #216 stated that she was a Veteran and was diagnosed with PTSD. Resident # 216 stated that since being admitted to the facility no one had discussed the diagnosis of PTSD or any triggers that would cause her re-traumatization. During an interview on 08/14/24 at 9:41 a.m., Staff C Registered Nurse (RN) stated she was not aware of any Residents in the facility with the diagnosis of PTSD or with a history of trauma. During an interview on 08/14/24 at 9:43 a.m., Staff D Certified Nursing Assistant (CNA) stated she was not aware of any Residents, including Resident #216, with a diagnosis of PTSD or a history of trauma in the facility. Staff D, CNA stated that if there was a resident diagnosed with PTSD, she would have received that information in report. During an interview on 08/14/24 at 9:45 a.m., Resident #216 stated that she received her diagnosis of PTSD from her military experience. Resident #216 stated her identified trigger for PTSD was being startled for example, being woke up fast. During an interview on 08/14/24 at 9:55 a.m., Staff E Social Services Director (SSD) stated that a diagnoses of PTSD or history of trauma has to go on the baseline care plan. Staff E, SSD stated that she would expect the trauma assessment questionnaire to reflect a diagnosis of PTSD in some manner especially if residents are veterans. Staff E, SSD stated Staff F, Social Service Assistant (SSA) was a new assistant who worked part time and was completing assessments on residents. During an additional interview on 08/14/24 at 10:15 a.m., Staff E, SSD identified Residents #216 and #21 as the two residents in the facility with a diagnosis of PTSD. Staff E, SSD stated she would have expected Resident #216's Trauma Assessment Questionnaire dated 08/06/24 to accurately depict the diagnosis of PTSD so triggers could have been identified. Staff E, SSD stated she would compete an accurate assessment of Resident #216's history of trauma so triggers can be identified to prevent re-traumatization.

Based on observations, staff interviews and record review, the facility failed to maintain the kitchen and kitchen equipment in a sanitary and functional manner during two of four days observed (8/12/2024, 8/13/2024), related to; 1. Kitchen dish washing machine not operating per the machine's maintenance service specifications/recommendations; 2. Not maintaining ceiling vents above food preparation stations in a dust/debris free environment; and 3. Not maintaining the walk in freezer free from heavy ice build up on various boxes of food items. Findings included: 1. On 08/12/2023 at 9:10 a.m. the kitchen was toured with Dietary Manager. He provided a general kitchen tour of the kitchen and other kitchen spaces. The Dietary Manager was asked if he or his staff were utilizing the dish washing machine and he confirmed that a Dietary Aide Staff K was running the machine and has been doing so for about twenty minutes. The Dietary Manager revealed they are running a High Temperature dish washing machine and was being maintained by an outside dish washing machine maintenance service. The Dietary Manager and Staff K both revealed that the maintenance service technician had not been out recently as there had not been any problems with the dish washing machine. Staff K revealed the High Temperature Wash cycle should reach 150 degrees F (Fahrenheit)., and the Rinse cycle should reach 180 degrees F. This was confirmed through interview with the Dietary Manager and review of the machine's specification plate. Staff K was asked to provide a demonstration of the wash and rinse cycle. He noted he has already been washing dishes and has ran crates of dishes and other eating utensils through the machine with no concerns. Staff K revealed he did not have to prime the machine to make temperatures, as the machine has a heating booster, which supplies hot water on demand. The following were dishwashing machine wash and rinse cycles, as demonstrated by Staff K; 1. Demonstration on 8/12/2024 at 9:15 a.m.; Wash -150 +degrees F., Rinse - 160 degrees F. Both Staff K and the Dietary Manager confirmed the Rinse temperature and revealed it should reach 180 degrees F.+, but it did not. 2. Demonstration on 8/12/2024 at 9:16 a.m.; Wash - 150 + degrees F., Rinse - 165 degrees F. Both Staff K and the Dietary Manager confirmed the Rinse temperature and revealed it should reach 180 degrees F.+, but it did not. 3. Demonstration on 8/12/2024 at 9:18 a.m.; Wash - 150 + degrees F. ; Rinse - 169 degrees F. Both Staff K and the Dietary Manager confirmed the Rinse temperature and revealed it should reach 180 degrees F.+, but it did not. 4. Demonstration 8/12/2024 at 9:26 a.m.; Wash - 150 + degrees F., Rinse - 170 degrees F. Both Staff K and the Dietary Manager confirmed the Rinse temperature and revealed it should reach 180 degrees F.+, but it did not. The Dietary Manager provided the dish washing machine temperature logs for the past two months (8/2024 and 7/2024), for review. The dish washing machine temperature logs revealed staff were documenting the following: - July, 2024, 1st through 29th; Wash and Rinse temperatures documented 200 degrees F. for all three meals for both wash and rinse cycles. The chemical sanitizer was documented at 150 parts per million (ppm). NOTE: The machine was not operating as a Low Temp machine, therefore, there was no actual chemical sanitizer delivery system. Staff had documented 150 ppm when there was no sanitizer. Further, days 7/6/24 - 7/30/24 for the dinner cycle, staff did not initial completion. Photographic evidence of the log was taken. - August, 2024, 1st though 12th; Wash and Rinse temperatures documented 200 degrees F. for all three meal services, with a chemical sanitizer = 150 ppm. NOTE: The machine was not operating as a Low Temp machine, therefore, there was no actual chemical sanitizer delivery system. Staff had documented 150 ppm when there was no sanitizer. Photographic evidence obtained. The Dietary Manager confirmed the logs did not appear to be correct and filled out appropriately. He revealed he has only been employed at the facility for a few weeks and was not able to speak on why the logs were wrong. An interview was conducted at that time with dietary staff K and J, who operate the dish washing machine routinely, both revealed they were not sure why the dish machine logs were reading PPM at 150 as the machine was not operating with a chemical sanitizer delivery system. They were also not able to explain why the logs had 200 degrees F. for both wash and rinse for every day and every meal service. A continued interview with Staff K revealed the dish washing machine maintenance technician was out at the facility about a week maybe two ago an did some adjustments but did not remember what was adjusted. However, in a later interview with the Dietary Manager, he revealed he did not believe the Maintenance technician was out recently to do any work on the dish washing machine. Both Staff K and the Dietary Manager confirmed the dish washing machine was not working appropriately and the dish washing machine service technician will be called to come out for service. At this time he will use the three compartment sink to wash and rinse dishes until the machine is repaired and working appropriately. On 8/13/2024 at 8:05 a.m. The Dietary Manager revealed the dish machine maintenance service technician made it out this a.m. to change the dish machine from a High Temperature machine to a Low Temperature machine. The Dietary Manager revealed the technician said the machine should reach 120 + Wash, and 120 + Rinse with a chemical sanitizer to reach 50-100 ppm. He revealed the [name of company] technician changed the machine and tested it several times before he left. The Dietary Manager revealed the Wash cycle reached 120 + and the Rinse reached 120 + and the PPM was between 50 - 100 ppm. On 8/14/2024 at approximately 12:10 p.m. The Kitchen was toured and the dish machine service technician was at the dish washing machine making adjustments to the chemical solution delivery system. The technician revealed he was earlier able to switch the machine from a High temp, to a Low temp machine as the machine could no longer get to high temperature wash and rinse cycle. 2. On 8/12/2024 at 9:10 a.m., the kitchen was toured with the Dietary Manager. During the tour, three ceiling vents and the surrounding ceiling area was observed with heavy black dust/debris. The debris was hanging off the ceiling and vents in a manner that was or was at risk for falling directly downward towards and on food preparation tables and food serving areas. The Dietary Manager revealed it was the maintenance department's responsibility for cleaning and maintaining the ceiling vents. The Dietary Manager revealed he had only been working at the facility for a short time and was not sure when the last time the ceiling vents and ceiling were cleaned from debris. Photographic evidence was obtained. On 8/15/2024 at 10:00 a.m., an interview with the Maintenance Director revealed he and the maintenance department staff are responsible for cleaning the ceiling vents in the kitchen and other kitchen area spaces. He revealed the ceiling vents are on an electronic cleaning program schedule. The Maintenance Director believed the system schedules cleaning of the vents at least once a quarter. He was not able to say how long ago the vents were cleaned and confirmed the vents and ceiling areas in the kitchen would need to be cleaned more frequently. 3. On 8/12/2024 at 9:10 a.m. the kitchen was toured with the Dietary Manager. During the tour, the walk in freezer was entered and observed. During that time, the left rear inside of the freezer was observed with a top shelf of packaged food. The top of the packaged food was observed with heavy ice frosting and ice build up. The top shelf of the same area was also observed with heaving ice frosting and ice build up. Directly above the area in question was observed with the electric fan motors and insulated tubing. The entire tubing area was observed heavily iced around and with ice cycles approximately five to seven inches long. Photographic evidence obtained. An interview with the Dietary Manager confirmed the ice build up on the shelves and packaged food and revealed he does clean the ice machine and defrosts it when it is needed. He also confirmed that ice does build up quickly and was not sure if the mechanics has a leak or not. He revealed he would need to put in a work order with the Maintenance department. He did not believe Maintenance was aware of the leak in the back as of yet. On 8/15/2024 at 10:00 a.m. an interview with the Maintenance Director revealed he was not aware of the ice build up in the ice machine and he would look into it and ensure if there is a leak, he would fix it, or if the seals on the door needed to be replaced, he would replace them. He further revealed it is up to the Dietary staff/manager to get with him if there is anything wrong with the mechanics of the walk in refrigerator or walk in freezer. On 8/15/2024 at 10:00 a.m. the Nursing Home Administrator provided the Dishwasher Temperature policy and procedure with a revision date 6/2024, for review. The policy stated; It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwater temperatures. The Policy Explanation and Compliance Guidelines revealed; 1. All the items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. 2. Manufacturer's instructions shall be followed for machine washing and sanitizing. 3. For High Temperature dishwashers (heat sanitation); a. The wash temperature shall be 150 - 165 degrees F. b. The final rinse temperature shall be 180 degrees F. or above but not to exceed 194 degrees F. (165 degrees F for stationary rack, single temperature machine). Corrective actions shall be taken for final temperatures below the required final rinse temperatures. 4. For low temperature dishwashers (chemical sanitation): a. The wash temperature shall be 120 degrees F. b. The sanitizing solution shall be 50 ppm (parts per million) hypochlorite (chlorine_ on dish surface in final rinse. 5. Chemical solutions shall be maintained at the corrected concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of the concentration checks shall be recorded. 6. Waster temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. On 8/15/2024 at 10:00 a.m. the Nursing Home Administrator provided the Preventative Maintenance Program policy with a 6/1/2024 revision date for review. The policy stated; A preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The guideline revealed; 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if preventive maintenance (PM) is required. Required PM may be determined from the manufacture's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be competed and how often to complete them. 4. Documentation shall be completed for all tasks and kept in the Maintenance Director's office for at least three years.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident record, and interviews, the facility failed to develop care plan problem areas with interventions related to behaviors and the development of a potential rash for one (Resident #29) of thirty-eight sampled residents. Findings included: On 7/25/2022 at 10:00 a.m. and 12:40 p.m., Resident #29 was observed in her room and lying in bed. Both her left and right forearms and shoulder areas revealed multiple small scabbed areas. She was asked about her arms and she revealed staff had told her to stop scratching. She said she had tried to control her scratching and indicated the scabbed areas were from a rash that she could not explain. On 7/26/2022 at 11:40 a.m., Resident #29 was noted in her room with three staff members. The staff were about to transfer her from her wheelchair back to bed after she just returned from receiving a shower. The resident was observed with all the same scabbed areas on both her forearms and shoulders. The staff in the room could not explain the scabbed areas and did not know much about the resident. A review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Review of the advance directives revealed Resident #29 was her own responsible party. Review of the admission diagnosis list revealed diagnoses to included: Chronic Kidney disease and Fibromyalgia, A review of the current Quarterly Minimum Data Set (MDS) assessment, dated 5/9/2022 revealed: Cognition/Brief Interview Mental Status or BIMS score 13 of 15, which indicated the resident was able to answer questions related to her medical health and care; Activities of Daily Living or ADL - Bed Mobility = Resident requires Limited Assist with one person physical, Personal Hygiene = Resident requires Limited Assist with one person physical assist, Bathing = Is Self performance. Review of the current Physician's Order Sheet (POS) for the month of 7/2022 revealed the following orders: - Apply skin prep to Right heel x shift for wound care. - Cleanse area to Right forearm with NS (normal saline), pat dry, apply xeroform cover with DCD (dry clean dressing) for abrasion (order date 6/23/2022). - Hydroxyzine HCL 25 mg 1 PO x 8 hours PRN for itching. (6/23/2022). Review of the progress notes dated from 4/8/2022 through 7/27/2022 revealed one note with documentation related to resident's forearms and read as follows. Nurse notes on 6/5/202, Pt has rashes on both arms which are not new. She scratched some areas on bilateral forearms. Cleaned with water and betadine. Bandages and a gauze wrap was applied supplied and labeled on both arms. The skin assessment dated [DATE] indicated multiple closed scratch marks to BUE (bilateral upper extremities) and BLE (bilateral lower extremities). Receiving medication with good effect. Areas showing signs of improvement. No open spots at this time. There were no other skin assessments with documentation related to the scratches or scabs. On 7/27/2022 at 9:30 a.m., an interview with the Licensed Practical Nurse (LPN) Staff T revealed he was aware of Resident #29's upper arms scabbing and that things had been getting better. He also stated her arms were much worse in the past but did not give a specific timeframe. He indicated the resident she had a history of picking her arms. Staff T revealed he knew there was treatment to her right arm but could not provide any evidence for treatment for the left arm. He further indicated he would speak to Resident #29's Nurse Practitioner today (7/27/2022) to clarify the order. Staff T said the order was not clarified for Hydroxyzine HCL treatment for both arms. Staff T confirmed Resident #29 had a history of picking, but was unable to show documentation to support it. There were no nurse progress notes or care plans that indicated the resident picks at her arms, and no care planning problem area to support that behavior. On 7/27/2022 at 11:45 a.m., an interview with Resident #29's Nurse Practitioner revealed he had been treating her arms for what he believed to be Pruritis. He said there might be a neurological condition related to her picking at the areas and he would now order a psych consult to address it. Review of Resident #29's current care plans with a next review date of 8/7/2022, revealed the following areas: - ADL self care deficit r/t (related to) impaired balance, ROM (range of motion), history of fracture right ankle with interventions in place and as per observation - Does not cooperate with care r/t refusing meds at times with interventions in place as reviewed and observed There were no care plan problem areas related to either behaviors of picking, or treatment for arm rashes. On 7/28/2022 at 7:45 a.m., an interview with both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed they were aware Resident #29 had scabbing on her arms and the physician was treating the areas with ointment. They were not aware of the reason for the ointment until today (7/28/2022). After review of the electronic record they confirmed the resident has had this scabbing/itching since 6/5/2022. They confirmed the physician's orders for the current month of 7/2022 only indicated treatment for the right arm, and did not indicate treatment for the left arm. They confirmed the care plans with problem areas related to behaviors of picking were not developed. The DON and ADON did not know why the care plans were not developed, but confirmed that there should have been a care plan developed for either behaviors of picking or for skin conditions specific to rash/pruritis. On 7/27/2022 the Director of Nursing provided the Comprehensive Resident Centered Care Plans policy and procedure, not dated, for review. The Intent of the policy revealed: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharged for each resident. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. It will be consistent with the medical plan of care and those disciplines that have direct involvement with the resident's care. The care plan will contain information about the physical, emotional, psychosocial, spiritual educational and environmental needs as appropriate. It is our (facility) purpose to ensure that each resident is provided with individualized, goal directed care, which is reasonable, measurable and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care. Procedure: (2.) The facility must develop and implement a comprehensive person centered care plan for each resident , consistent with the resident rights set forth at 483.10( c )(2) and 483.10( c )(3), that includes measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (a) The services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well being as required under 483.24, 483.25 or 483.40. Developing the Care Plan: (3) Each discipline will check and / or add interventions/approaches to include but not limited to: (a) The intervention statements describe those measures performed by the staff to help the resident achieve the expected outcomes. (b) Interventional entries reflect activities that incorporate observations, assessments, management and teaching components that will restore, maintain and /or promote the resident's well-being. Updating Care Plans: (1) Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems and goals. (3.) The care plans will be updated and/ or revised for the following reasons: a. Significant change in the resident's condition b. A change in planned interventions c. Goals are obtained and new goals established to meet current resident needs and/or goals d. New diagnosis, new medications, or abnormalities (4.) Any revision, additions, or deletion to the care plan will be dated and initiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure behavior monitoring was in place for one (Resident #67) of three sampled residents on psychotropic medications. Findings Included: A review of admission records indicated Resident #67 was admitted on [DATE] with diagnoses including atrial fibrillation, unspecified dementia without behavioral disturbances, and alcohol abuse. A review of orders revealed an order for SEROquel Tablet 25 milligrams (mg). Give 25 mg by mouth at bedtime related to Unspecified .Dementia without Behavioral Disturbances. Start date: 01/04/22. Review of the electronic Medication Adminsitration Record (eMAR) and the electronic Treatment Administration Record (eTAR) for the months of May, June, and July of 2022 did not include any behavior or side effects monitoring for psychotropic medications. Resident #67's Minimum Data Set (MDS) dated [DATE] was reviewed. Section C. (Cognitive Patterns) revealed Resident #67 had a BIMS (Brief Interview for Mental Status) score of 1, which indicated severe cognitive impairment. Resident #67's MDS dated [DATE] was reviewed. Section N. (Medications) of the MDS indicated Yes-Antipsychotics were received on a routine basis only. Review of the care plan with a focus area dated 10/28/21 and revised on 07/27/22, revealed Resident #67 has cognitive deficits and mood disorder with episodes of unprovoked agitation, indifference, and poor decision making, leading to undesired behaviors .The goal dated 10/28/21 and revised on 07/27/22, revealed Resident #67 will be free from negative outcome related to (r/t) declination of medication .The interventions include .observe/report any change in condition (07/27/22) .A focus area dated 11/16/21 and revised on 07/27/22, revealed Resident #67 has impaired cognitive function/dementia and impaired thought processes r/t Dementia. The goal dated 11/16/21 and revised on 07/27/22, revealed Resident #67 will be able to communicate basic needs on a daily basis .No care plans were currently in place for behavioral monitoring or use of psychotropic medication. An interview was conducted on 07/27/22 at 9:24 a.m. with Staff B, Certified Nursing Assistant (CNA). She stated Resident #67 hollers out a lot and answers herself a lot. She noted Resident #67 has conversations with herself. Staff B said she usually reports changes in moods to the nurse. In an interview with the Director of Nursing (DON) conducted on 07/27/22 at 9:42 a.m., he stated the expectation for residents with Dementia taking antipsychotic medications was to have behavioral monitoring in place. Observed the DON look through Resident #67 orders to find an order for behavioral monitoring. The DON confirmed there was not an order in place for behavioral monitoring. Review of the Behavior and Psychoactive Management Problem under Facility's Behavior Management Program will consist of: 3. Monitoring the resident's behavior(s) to establish patterns, determine intensity and behavior frequency, and identifying the specific (targeted) behavior(s) that are distressing to the resident which are decreasing the resident's quality of life. Under Behavior Management Team Care Process: 1 .The behavior Management Team will effectively manage the psychoactive medication process for the residents by: d. Monitoring on a regular basis, and with change in the approaches implemented for effectiveness

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** (3) Based on observation, interviews, and record review, the facility failed to follow their policy to 1. store medications appropriately in three of five (100-400 Hall) medication carts, failed to ensure controlled substances were appropriately stored in a locked drawer in one of two medications storage rooms (SSU Hall), and did not ensure expired tuberculin testing syringes were disposed of in one of two medication storage room refrigerators (100-300 Hall); 2. Failed to appropriately secure medications for two Residents (#67 and #334) of four residents. Findings included: A facility provided policy titled, Medication Storage, with no date, Page 01 of 01, was reviewed and read Policy: Medications must be stored in accordance with manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. Access to medications is limited to only authorized personnel. Procedure: 1. Storage areas may include, but are not limited to, drawers, cabinet, medication rooms, refrigerators, and carts. 3. Schedule II-IV medications must be maintained in a separately locked, permanently affixed compartments or cabinets. 6. Prior to and after opening, all medications shall expire on the date specified by the manufacturer on the product label, unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself. 1. On 07/20/2022 at 3:10 p.m., an observation of the 400 Hall medication cart included in the second drawer from the top of the medication cart, two white round tablets, one half square white tablet, one quarter white tablet, and one round red tablet. Staff D, Registered Nurse (RN), confirmed the presence of the unsecured tablets. (Photographic Evidence Obtained.) On 07/27/2022 at 3:25 p.m., an observation of the medication the cart for 100-300 Halls included Twenty- and one-half loose pills in the second drawer from the top of the medication cart, two loose tablets in the fourth drawer from the top of the medication cart, and in the third drawer from the top of the medication cart, three loose pills. Staff C, (RN), confirmed the presence of the unsecured medications. On 07/27/2022 at 3:48 p.m., an observation of the medication cart located on the 200-300 Odd Hall included one loose pink tablet in the second drawer from the top of the medication cart. Staff E, (RN) confirmed the presence of the unsecured tablet. An observation was conducted on 07/27/2022 of the medication storage room for 100-300 Halls. During the observation with Staff C, (RN) she confirmed the presence of fifteen packets of Tubersol Injection 5/0.1 ML Tuberculin purified protein derivative (PPD) injections, that had various expiration dates in the refrigerator as follows: (4) 7/19/2022 (1) 7/22/2022 (1) 7/16/2022 (1) 7/15/2022 (1) 7/14/2022 (1) 7/15/2022 (6) 7/24/2022 During an observation on 07/27/22 at 04:30 p.m., of medication room (SSU Hall) with Staff F, (LPN), the lockbox, that was affixed to the refrigerator, was seen to be open and not locked. Staff F, (LPN) confirmed the presence of a small white box containing two vials of Schedule IV Narcotic medication of Lorazepam (Ativan) 2MG/ML in it. Staff F, (LPN) further revealed that the lockbox drawer should be closed for all controlled substances, and that he was not aware the lockbox was open. According to The United States Drug Enforcement Administration (DEA) drug scheduling alphabetical listing, dated July 25, 2022- List of Scheduling Actions, Controlled Substances and Regulated Chemicals (usdoj.gov), with URL link: https://www.deadiversion.usdoj.gov/schedules/orangebook/orangebook.pdf Page 11 of 19, Lorazepam (Ativan) DEA number 2885, is a Benzodiazepine, a Schedule IV medication and a considered a controlled substance. On 07/27/2022 at 4:54 p.m., an interview was conducted with the Director of Nursing (DON). During the interview the DON was informed of the fifteen expired (PPD) medications in one of two medication storage rooms and was shown the picture of it. He was also informed of observations of unsecured medications found in the three medication carts. The DON revealed that his staff had notified him of the loose medications prior to the interview. The DON stated, My expectation is that the refrigerator permanently affixed lockbox will be locked appropriately, all unsecured medications, and expired medications should be checked for daily by all staff. On 07/27/2022 at 5:15 p.m., an interview with the DON and Assistant Director of Nursing (ADON) was conducted. The DON revealed he removed the Scheduled IV narcotic medication from the refrigerator and placed it in a double locked drawer for disposal. He was replacing the medication and reordered from the pharmacy. The ADON stated We did not know about the issue of the drawer being broken in the lock box, and we will fix it. 2. An observation was made on 07/26/22 at 9:25 a.m. of a Nystatin Powder bottle in a basket on Resident #67's bedside table. Photographic evidence was obtained. An observation was made on 07/27/22 at 9:07 a.m. of a Nystatin Powder bottle in a basket on the bedside table of Resident #67. Photographic evidenced was obtained. An observation was made of Staff A, Licensed Practical Nurse (LPN), on 07/28/22 at 9:13 a.m. looking into the basket on Resident #67's bedside table and pull the Nystatin Powder bottle out of it. Staff A stated the bottle of medication should not be in the basket. She said there was a Nystatin Powder bottle on the cart for Resident #67. Staff A stated Resident #67 did not have an order to self-administer the medication. Review of Resident #67's admission Record revealed an admission date of 09/30/21 with a diagnoses of Atrial Fibrillation and local infection of the skin and subcutaneous tissue Unspecified. Review of Resident #67's orders revealed an order dated 06/22/22 for Nystatin Powder 10000 UNIT/GM to apply to abdominal folds topically every shift for abdominal fold redness. No documentation was found related to self-administering the medication. Review of the Minimum Date Set (MDS) dated [DATE] revealed in Section C. Resident #67 had a Brief Interview for Mental status (BIMS) score of 01, which indicated severe cognitive impairment. Review of the MDS dated [DATE] revealed in Section D. Resident #67 was rarely or never understood and a mood interview should not be conducted. Review of the admission Data Collection dated 09/30/21 revealed in Section O. Medication Review Resident #67 does not self-administer medications. 3. On 7/25/22 at 10:15 am, an observation was made of Resident #334 sitting in her room. During this time, a bottle of unsecured medication was observed on the bedside table. The medication was labeled [name brand], Natural laxative with an expiration date of 12/2021. (Photographic Evidence was taken). On 7/27/22 at 9:15 a.m., Resident #334 was observed relaxing in bed. The bottle of medication was still on the bedside table. She was asked if she used the medication. She stated her son brought it, but she never used it. On 7/27/22 at 9:40 a.m., an interview was conducted with Staff G, LPN. He explained that on admission, it is explained to the residents that outside medications are not allowed due to possible reactions with medications that the nursing home is giving or wandering residents that may take the medication. Staff G removed the medication and discussed the above procedure with Resident #334.

Based on observations and staff interviews, the facility failed to post the total number, and the actual hours worked of the direct care staff for the benefit of the facility residents and the public on 04/05/21 through 04/07/21 as evidenced by the position and location of the clipboard that was identified by the Staffing Coordinator as the posting location. Findings included Upon entry to the facility at approximately 09:00 am on Monday 04/05/21 surveyors did not observe the information required by statutes concerning the posting for the nurse staffing information. The nurse posting information was not available for viewing until the last day of the survey, 04/08/21, when the staffing coordinator stated that the information was on a clipboard at one of the nursing stations. The staffing coordinator identified the location as being on the wall to the right of the skilled step-down unit (SSU). The observed clipboard was not identified as holding the staffing information and hung in a manner that did not allow viewing for visitors or any other passerby unless they knew to take it off the wall and turn the clipboard over. This clipboard was observed in this position during the four days of the survey (photographic evidence was obtained). This clipboard was not accessible to visitors who did not come to this particular unit and the staffing coordinator stated that she had been posting the information in this way for months. The Nursing Home Administrator stated that she was not aware of the posting requirements prior to our interview on 04/08/21, but that the posting would be available for prominent viewing by all the residents and their visitors at the reception counter from now on.

Based on observations, interviews and record review the facility did not ensure that Controlled substances were locked and stored in a permanently affixed compartment in two of two medication storage rooms sampled. Findings included: On 04/07/21 at 10:28 a.m. during the performance of the medication storage and labeling task the locked medication room on the Skilled Subacute Unit (SSU) inspection of the refrigerator in the same medication room at 10:30 a.m. accessed by Staff A, LPN, revealed a locked box. The box was not secured or maintained in a permanently affixed compartment in the refrigerator. Staff A, LPN unlocked the box, which revealed two clear plastic cases. The clear plastic cases were sealed with a green tamper proof seal and the contents could be seen through the plastic. Each plastic case contained three, 2mg/ml vials of the controlled substance lorazepam (photographic evidence was obtained). An interview with Staff A, LPN. He stated that he was not aware that the box containing control substances lorazepam had to be secured in a permanently affixed compartment. At 10:35 a.m. in an Interview with the Regional Nurse providing Clinical Services, she confirmed that the box should have been secured to a permanently affixed compartment in the refrigerator, but she thought it did not apply to Schedule II controlled substances. An inspection of the medication room located on the Geriatric Nursing Restorative (GNR) unit at 10:48 a.m. with Staff B, LPN, revealed a locked box in the refrigerator. The locked box was not secured or maintained in a permanently affixed compartment in the refrigerator. The locked box was accessed and opened by Staff B, LPN, which revealed two individual bags of the controlled substance Lorazepam 2mg/ml labeled with residents' name. One bag contains 10 vials and the other bag contains 8 vials. In-addition there were two clear plastic cases sealed with a green tamper proof seal. The contents could be seen through the clear plastic. Each plastic case contained three, 2mg/ml vials of the controlled substance lorazepam (photographic evidence obtained). In an interview with Staff B, LPN, she stated that she was not aware that the box containing control substances lorazepam should have been maintained in a permanently affixed compartment. On 4/7/21 11:40 a.m. in an interview with the Nurse Home Administrator, she concurred that the medications should have been maintained in a separately locked, permanently affixed compartment. A review of the facility policy Titled Long Term Care (LTC) Facility's Pharmacy Services and Procedure Manual revised 10/28/2019, under the subheading General Storage Procedures 3.1.1 It reads: Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separate locked, permanently affixed compartments . Under the subheading Control Substances Storage13.3 it reads: Facility should ensure that all II-V controlled substances are only stored in a manner that maintains their integrity and security.