**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to provide written notice to the resident and resident's representative at the time of transfer for hospitalizations that specified the duration of the bed-hold policy for two (2) of five (5) sampled residents (Resident #46 and #37). The findings include: Review of the facility policy titled, Resident Bed Hold, dated 06/08/2021, revealed the facility would follow regulatory guidance for bed hold procedure. 1. Record review revealed the facility admitted Resident #37 on 09/30/2019, with diagnoses which included Cerebral Infarction, Hemiplegia and Hemiparesis and Aphasia. Review of this resident's Nursing Home to Hospital Transfer documentation, dated 12/23/21, revealed Resident #37 was transferred to an acute care hospital on [DATE]; however, there was no documented evidence in the medical record of a Bed Hold offered to this resident or resident's representative until 12/29/2021 approximately six (6) days after transfer. 2. Record review revealed the facility admitted Resident #46 on 03/23/2021 with diagnoses of Congestive Heart Failure,Chronic Obstructive Pulmonary Disease and Diabetes Mellitus. Review of facility transfer to hospital documentation dated 10/25/2021, revealed Resident #46 was transferred to an acute care hospital on [DATE]; however, the facility had no documented evidence of a Bed Hold offered to the resident until 11/01/2021, when the resident was re-admitted to the facility approximately six (6) day after the transfer. Interview with Bookkeeper, on 01/05/2022 at 6:00 PM and 6:20 PM, revealed she was responsible for providing residents with bed hold notification. She stated that she was unaware that the regulatory guidance indicated a specified time frame. Interview with the Director of Nursing (DON), on 01/07/2022 at 1:35 PM, revealed she was unaware that the facility was not providing bed hold upon transfer per regulatory guidelines. Interview with the Administrator, on 01/07/2022 at 1:45 PM, revealed she was unaware the facility was not providing bed hold upon transfer per regulatory guidelines. She stated after the Bookkeeper and/or Minimum Data Set (MDS) Nurse was responsible for notification of bed hold. She stated that Resident #46 and #37 should have had been offered bed hold upon transfer/discharge from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to complete a Level II Preadmission Screening and Resident Review (PASARR) for two (2) of three (3) sampled residents. (Resident #43 and Resident #15). Resident #43 was diagnosed with Major Depressive Disorder on 09/06/2021 and Resident #43 was diagnosed with Moderate Major Depressive Disorder on 08/06/2020; however, the facility failed to ensure a Level II PASARR assessment was completed. The findings include: Review of the facility policy titled Preadmission Screening and Resident Review, dated 01/2021 revealed the designated facility personnel will be responsible for: Accurately completing and submitting the PASARR Level I screening for all individuals prior to admission; providing (with the Level I screening) a complete history and physical that reflects the individual's current functioning, lists all current medications, and is signed by a physician; providing the completed provisional admission forms (with the Level I screening) as applicable; ensure final determinations for PASARR are complete prior to admission (except for provisional admissions); appropriately reporting Significant Changes for PASARR/potentially PASARR individuals; and ensuring PASARR recommendations are part of the Nursing Facility (NF) Care Plan and are followed. Further view revealed, individuals who are found to have a potential serious mental illness, intellectual disability, or related condition through the Level I screen must participate in the Level II process in order to be admitted to, or remain in the facility, regardless of payment source. 1. Review of Resident #43's medical record revealed the facility admitted the resident on 05/30/2019 with diagnoses that included Type II Diabetes Mellitus, Hyperlipidemia, Gastro-esophageal Reflux Disease and Hypertension. Further review of the resident's medical record revealed a Level I PASARR was completed for Resident #43 on 05/30/2019. Review of Resident #43's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status score of six (6), indicating the resident was significantly cognitively impaired. Further record review revealed Resident #43 received a new diagnosis of Major Depressive Disorder on 09/06/2021. There was no documented evidence that Resident #43 had a Level II PASARR assessment when the resident was newly diagnosed with Major Depressive Disorder on 09/06/2021. 2. Review of Resident #15's medical record revealed the facility admitted the resident on 10/02/2015 with diagnoses that included Type II Diabetes Mellitus and Dementia with Behavioral Disturbance. Further review of the resident's medical record revealed a Level I PASARR was completed for Resident #15 on 10/02/2015. Review of Resident #15's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status score of fourteen (14), indicating the resident was cognitively intact. Further review revealed Resident #15 was diagnosed with Moderate Major Depressive Disorder on 08/06/2020. There was no documented evidence that Resident #15 had a Level II PASARR assessment when the resident was newly diagnosed with Moderate Major Depressive Disorder on 08/06/2021. Interview with the Admissions Coordinator, on 01/05/2021 at 12:00 PM, revealed he/she was responsible for completing PASARR screening assessments for residents and was unaware that she was supposed to ensure a Level II PASARR assessment was completed on Resident #43 and Resident #15 following new diagnoses of Major Depressive Disorder. She further stated the Level I PASARR assessment completed upon admission was the only PASARR assessment that had been completed for both Resident #43 and Resident #15. Interview with Director of Nursing (DON), on 01/07/2022 at 1:35 PM, revealed she was not aware PASARR Level II was to be completed for new psychiatric diagnoses such as Major Depressive Disorder. The DON stated the facility was currently developing a better process to identify those residents and ensure PASARR Level ll were completed within regulatory guidelines. She further stated a PASARR Level ll should have been completed for Resident #43 following his/her diagnosis of Major Depressive Disorder on 09/06/2021 as well as Resident #15 following his/her diagnosis of Major Depressive Disorder on 08/06/2020. Interview with the Administrator, on 01/07/202 at 2:10 PM, revealed she was not aware the Level II PASARR's were not being completed when residents received a new psychiatric diagnosis. She further stated Level II PASARR's should have been completed for Resident #43 and Resident #15 when the residents both received a new diagnosis of Major Depressive Disorder.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to assure the accuracy of Section M of the Minimum Data Set (MDS) Assessment, for one (1) of twenty-two (22) sampled residents, (Resident #50). Resident #50's MDS Assessment was coded to reflect a pressure ulcer was present on admission; however, during the resident's stay, the pressure ulcer subsequently worsened and the MDS was incorrectly coded as present upon admission. The findings include: Review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, dated October 2017, Chapter 3, revealed the intent of Section M: Skin Conditions, was to document the risk, presence, appearance, and change of pressure ulcers. This section also notes other skin ulcers, wounds, or lesions and documents some treatment categories related to skin injury or avoiding injury. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. Per the RAI Manual, a complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program. Further review of the RAI Version 3.0 User Manual, revealed if a pressure ulcer was present on admission/entry or re-entry and subsequently worsened to a higher stage during the resident's stay, the pressure ulcer is coded at that higher stage, and that higher stage should not be considered present on admission. Review of Resident #50's medical record revealed the facility originally admitted the resident on 04/15/13 and re-admitted the resident on 05/31/15. The resident's diagnoses included Anxiety disorder, Dysphagia, Hemiplegia and Hemiparesis affecting the left side, Hypothyroidism, Major Depressive Disorder, Type Two (2) Diabetes Mellitus and Cerebrovascular disease. Review of Resident #50's MDS Quarterly Assessment, Section M (skin conditions), dated 08/23/17, revealed the resident was assessed to have no unhealed pressure ulcers at stage 1 or higher. Review of the MDS Quarterly Assessment, Section M, dated 11/22/17, revealed Resident #50 was assessed to have one (1) stage two (2) pressure ulcer that was not present upon admission or re-entry to the facility. Review of the MDS Annual assessment, Section M, dated 02/14/18, revealed Resident #50 was assessed to have one (1) stage two ( 2) pressure ulcer that was present upon admission or re-entry to the facility. Review of the MDS Quarterly Assessment, Section M, dated 05/16/18, revealed Resident #50 was assessed to have one (1) stage three (3) pressure ulcer that was present upon admission or re-entry to the facility. Review of the MDS Quarterly Assessment, Section M, dated 08/15/18 and 11/14/18, revealed Resident #50 was assessed to have one (1) stage four (4) pressure ulcer that was present upon admission or re-entry to the facility. Interview with the MDS Coordinator, on 04/04/19 at 3:54 PM, revealed she uses the RAI manual for completing MDS assessments. She stated she is responsible for the accurate completion of section M of the MDS, for Resident #50. Continued interview revealed she is responsible for ensuring MDS accuracy before transmission. The MDS Coordinator stated that she retrieves the information used to fill out section M of the MDS from the resident's chart, weekly wound and skin assessments, and nurses notes. Further interview revealed Resident #50's pressure ulcer was not coded accurately due to the pressure ulcer being facility acquired. Interview with the Director of Nursing (DON), on 04/04/19 at 4:52 PM, revealed the MDS Coordinators use the RAI manual for completing assessments. The DON further stated the MDS coordinator is responsible for filling out section M of the MDS, and is also responsible for assuring MDS accuracy before transmission. Continued interview revealed information used to complete MDS assessments would be found in resident charts, physician orders, physician visits, diagnoses, and MDS Coordinators should be assessing the resident. Further interview revealed, the DON does not audit MDS assessments. The DON further stated, Section M of the MDS for Resident # 50 was inaccurately coded, due to the Resident's pressure ulcer being facility acquired. Interview with the Administrator, on 04/04/19 at 4:45 PM, revealed it was her expectation that all MDS assessments were coded accurately, and that the MDS coordinator would be checking for documentation to be coded correctly. She stated, MDS Coordinators should rely on good communication with floor staff, nurse aides, and nurses to ensure accuracy. Continued interview revealed the facility requires all MDS documentation to be correct because it drives the Resident's Comprehensive Care Plan and will provide staff with the most accurate information available, in order to provide appropriate resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility's policies, it was determined the facility failed to ensure the Comprehensive Care Plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care for two (2) of twenty-two (22) sampled residents (Resident #37 and Resident #46). The facility failed to revise the activity program to meet the needs of Resident #37 and Resident #46. 1. Resident #37's Care Plan and Activity Log revealed the resident watched television, the resident did not have a television and no staff had observed the resident watching television. In addition, at the time of survey, Resident #37 was confined to his/ her room based on his/her roommate's medical condition requiring isolation precautions. Resident #37 enjoyed being in the hallway and was deprived of this activity with no individual activities offered in the room. 2. Resident #46's Activity logs were not complete, and did not provide activities per Resident #46's preferences, nor did the facility provide any 1:1 activities while the resident was confined to his/ her room for tube feeding. The findings include: Review of facility's Policy titled, Individual and Interdisciplinary Plan of Care, undated, revealed the facility maintains a patient focused approach to all functions and responsibilities within its organization; therefore, it shall be the policy of the facility to maintain an up-to-date plan of care on each resident. Per the policy, the primary reason for Interdisciplinary Team (IDT) is to meet the changing needs of the patient by using an interdisciplinary system. The care plan will be comprehensive and reasonable and it would be reflective of the needs of the patient. Continued review revealed, the comprehensive care plan would contain approaches to care that will benefit the needs of the resident and the care planning and updates would be made in a reasonable and timely manner. Further review revealed team members involved in the development of the Care Plan included activities. Review of facility's Policy titled, Activity Program Policy and Procedure, revised 11/01/18, revealed individual activities were developed in accordance with the comprehensive assessment. The policy further stated periodic evaluation of the appropriateness of activities would be conducted with changes in programming as needed. The Activities Coordinator was responsible for the direction of the ongoing plan for resident activities. Review of the facility job description titled, Activity Coordinator revealed the Activity Coordinator was responsible for developing, initiating, implementing, and maintaining a comprehensive resident centered activity program for each resident. The job responsibilities included assessing each resident's activity needs, assessment and completion of assigned sections of the Minimum Data Set (MDS), development of the resident's activity care plan with review, and updating to the Care Plan as needed. Review of the Activity Calendars for January 2019, February 2019, and March 2019, revealed group activities were offered each day. Further review revealed in January two (2) Sunday activities were TV Time, in February one (1) Sunday activity was TV Time, and in March two (2) Sundays offered TV Time as the only scheduled activity. All Saturdays offered Bingo as the only activity. Review of the facility activity log titled, One on One List, undated, revealed Resident #37 and Resident #46 were not on the list for individualized activities. 1. Record review revealed Resident #37 was initially admitted by the facility on 09/12/14 and was readmitted on [DATE] with diagnoses to include Dementia, Diabetes Type ll, Psychotic Disorder with Delusions, Muscle Weakness, Gastrostomy Malfunction, and Essential Hypertension. Review of Resident #37's Quarterly Minimum Data Set (MDS) Assessment, dated 01/30/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of one (1) out of fifteen (15), indicating the resident had severe cognitive impairment. Continued review of the MDS revealed the facility assessed the resident as having disorganized thinking and illogical flow of ideas (Section C). The MDS further revealed the resident had difficulty concentrating on television nearly every day (Section D, #G). Review of Resident #37's Comprehensive Care Plan, with admission date 12/11/18, revealed a Focus Area for Resident #37's socialization with others when the resident sat in the hall before meals. The focus area also included the resident's attendance at special events including parties and music. The goal was for the resident to be out of the room daily and in attendance at activities as desired. Interventions included encouraging the resident to be more social during the day, reminding the resident of daily activities, times and places in the facility, monitoring for signs and symptoms of Clostridium DIfficile (C. Diff) and reminders for Resident #37 to have his/her fingernails polished weekly. Continued review of the care plan revealed Resident #37 had Alzheimer's Dementia with mood/behavioral disturbances and anxiety. Review of the Focus Area revealed the resident was disoriented, gave his/her first name at times, had a short attention span, and rambling conversation. The goal was for the resident to be able to state his/her name through the quarter and be cooperative with staff during care needs as much as possible. Interventions included an Activities Calendar in the room, calling the resident by name, reassuring the resident when the resident was worrisome or had unrealistic fears, medications as ordered, and keeping a clock and calendar in the room. Review of facility document titled, Documentation Survey Report v2(activity log) for Resident #37, dated January 2019, revealed his/her activities included six (6) days with no activities, eight (8) days of activities of watching television and observing. Continued review revealed no group activities were documented nor were any manicures or fingernail painting documented. Review of Resident #37's activity log, dated February 2019, revealed Resident #37 did not attend any group activities. Continued review revealed four (4) days during the month had no activities documented. Further review revealed nineteen (19) days documented activities included observing or passive socialization with others. Review of Resident #37's activity log, dated March 2019, revealed eight (8) days with no activities recorded. Continued review revealed Resident #37 did not attend any group activities for the month. Passive television watching was recorded on two (2) days and four (4) days were listed as NA which was an unknown code. Passive socialization was recorded on ten (10) days and active socialization was recorded on six (6) days. Observation of Resident #37, on 04/02/19 at 12:38 PM, 2:39 PM, and 5:32 PM, on 04/03/19 at 10:23 AM and 2:43 PM, and on 04/04/19 at 8:30 AM and 11:00 AM revealed the resident did not have a television. Although the roommate had a television, it was on the wall farthest from Resident #37 and was often out of sight when the curtain was pulled. The resident was not permitted out of the room on the three (3) days of observation because the roommate was on isolation precautions. No individualized activities with the resident were observed. Interview with State Registered Nursing Assistant (SRNA) #3, on 04/04/19 at 2:21 PM, revealed he was assigned to Resident #37. SRNA #3 stated the Resident #64 did not pay attention to the television. The SRNA further stated he never turned on the television for Resident #37 because the resident never requested to watch television and because Resident #37 did not have a television in the room. The television in the room belonged to the roommate and was across the room from Resident #37. SRNA #3 further stated the Activity Staff did all activities with Resident #37. Interview with SRNA #2, on 04/04/19 at 2:28 PM, revealed he cared for the resident on occasion. SRNA #2 stated Resident #37 never asked to watch television. The SRNA further stated the resident talked to his/her roommate on occasion but was unaware of any other activities for the resident. SRNA #2 stated the Activities Staff had responsibility for resident activities. Interview with SRNA #1, on 04/04/19 at 2:35 PM, revealed she cared for Resident #37 at various times. The SRNA stated the resident did not have a television in his/her room and never asked to watch TV (television). SRNA #1 further stated it was doubtful that Resident #37 could understand what was on TV. The SRNA stated she fed the resident and talked to the resident during meal times. She also stated Resident #37 talked to his/her roommate at times, although the resident was confused. Interview with Licensed Practical Nurse (LPN) #1, on 04/04/19 at 2:38 PM, revealed she was assigned to Resident #37. She stated the resident generally roamed the facility in his/her wheelchair when not on isolation precautions. LPN #1 stated staff were told during report the resident could not leave the room because his/her roommate was on isolation precautions for shingles. She stated staff talked to the resident but did not do activities with the resident. Upon continued interview, she had never observed Resident #37 watching television nor did she ever turn on a TV for the resident. Interview with LPN #2, on 04/04/19 at 2:46 PM, revealed she generally did not work the hall where Resident #37 lived. She stated she did know the resident and had never observed the resident watching TV. She further stated the resident usually socialized with other residents; however, she had never observed Resident #37 attending planned activities. Interview the Unit Manager, on 04/04/19 at 2:53 PM, revealed she was very familiar with Resident #37. She stated the resident came out of his/her room on normal days but currently was not permitted out of the room because his/her roommate was on isolation precautions. She stated the television in Resident #37's room did not belong to the resident. She further stated Resident #37 had never asked her to turn the television on. Per interview, she had not observed any one to one (1:1) activities with Resident #37. She stated the activity staff had responsibility for planning and delivering activities for all residents. Interview with the Activity Coordinator, on 04/04/19 at 1:47 PM, revealed she was unaware Resident #37 was on isolation precautions due to a roommate with shingles. She then verbalized she had not received any information Resident #37 was confined to the room based on the roommate's condition. She stated one to one (1:1) activities has been planned for the resident; however, she could not locate any documentation of planned 1:1 activities. The Activity Coordinator stated usually Resident #37 sat in the hallway. She stated the resident did not have a television for watching TV activities but the roommate did. Upon further interview, the Activity Coordinator stated she was not sure Resident #37 could see the roommate's television nor could she see the TV when the privacy curtain was pulled. 2. Review of Resident #46's medical record revealed the resident was originally admitted by the facility on 11/15/16 with diagnoses to include Alzheimer's Disease, Acute on Chronic Congestive Heart Failure, Gastrointestinal Hemorrhage, Extended Spectrum Beta Lactamase (ESBL) Resistance, Bradycardia, Diabetes Mellitus Type Two (2), Chronic Kidney Disease Stage Three (3), Benign Prostatic Hyperplasia, Gastrostomy Status, Anorexia, Dysphagia, Muscle Weakness, Anxiety Disorder, Essential Hypertension, Atrial Fibrillation, and Chronic Ischemic Heart Disease. Review of Resident #46's Annual MDS Assessment, dated 02/06/19, revealed the facility assessed the resident to have a BIMS score of two (2) out of fifteen (15), indicating the resident was severely cognitively impaired. Continued review revealed Section B assessed the resident to usually understand others and usually makes self-understood. Section D revealed Resident #46 indicated he/she was having trouble concentrating on things such as newspapers or watching television. Further review revealed Resident #46 was the primary respondent for the Daily and Activities Preferences. Resident #46's highest ranked activity preferences were listening to music and participating in religious services/ practices. Resident #46 ranked as secondary preferences being around animals/ pets, keeping up with the news, doing things with a group of people, engaging in his/her favorite activities and going outside to get fresh air when the weather was good. Having books, newspapers, and magazines were coded as his/ her least favorite activity. Review of Resident #46's feeding tube orders as of April 3, 2019 revealed Resident #46's Physician ordered the resident to be administered tube feeding to be turned on each day at 6:00 PM, continue through the night and to be turned off at 12:00 PM, for a total of six (6) hours without the tube feed infusing. Review of Resident #46's Comprehensive Care Plan, dated 09/05/18 and revised 02/19/18, revealed a focus area for alteration in thought process with a goal that he/she will make decisions in care daily and will remain oriented to person and facility with the interventions to include staff to encourage the resident to be out of bed when the tube feeding is off to receive social stimulation, talk to the resident about current events, weather, upcoming holidays to help with time orientation, and talk with the resident daily during care. Continued review revealed a focus area initiated 06/21/15 and revised 02/19/19 was the potential for alteration in mood and behavior with a goal that the resident will not exhibit depressed mood or behaviors. Interventions in place included 1:1 activities two (2) times each week and to encourage the resident to attend activities and group events. Further review revealed a focus area, initiated 02/13/19, with the goal for the resident to continue socializing and moving self around the facility. Interventions in place included to encourage the resident to be out of his/her room daily or as he/she can tolerate, re-direct the resident to activities, locations with others when he/she is out in the hallway, continue to attend activities as can tolerate and staff to transport the resident to and from activities as he/she can tolerate attending. Review of Resident #46's Activity log, dated January 2019, revealed no activities were documented on any Sunday, and one Monday was lacking documentation of activities. The remainder of January revealed seven (7) days with passive television and observing the socialization of others was the documented activities most prevalent. Review of Resident #46's Activity log, dated February 2019, revealed no activities were documented on any Sunday, and one Friday. Continued review revealed passive TV watching was recorded twelve (12) times as the day's activity. Eight (8) other days involved passive observations. One group activity was documented as attended by Resident #46. Review of Resident # 46's Activity log, dated March 2019, reveal no activities were documented on any Sunday and two (2) Saturdays. Four (4) days were documented as NA as the activity with no key code to corresponded to NA to identify the activity. Ten (10) days documented only passive TV as the activity. Four (4) days had documented actively socialization with others. Observation of Resident #46, on 04/02/19 at 12:45 PM, revealed the resident was noted to be up in a wheel chair sitting near the nurse's station by the wall with no interaction with other residents or staff. Continued observation revealed the resident had no activities occurring at this time. Observation of Resident #46, on 04/02/19 at 6:30 PM, revealed the resident was noted to be lying in bed on his/her right side facing the wall, which had a television mounted approximately twenty-four (24) inches above the resident's head. The resident's bed was up against the wall. The resident's television was on, with cartoons playing. Tube feeding was in progress per physician orders. Observation of Resident #46, on 04/03/19 at 8:00 AM, revealed Resident #46 was noted to be lying in bed, facing the wall, with the television on cartoons. No activities or conversation was noted at this time. Tube feeding in progress per physician orders. Observation of Resident # 46, on 04/03/19 at 9:00 AM, revealed the resident was lying in bed on his/ her right side, facing the wall. The television was on, with cartoons playing. No activities were being provided. Tube feeding in progress per physician orders. Observation of Resident #46, on 04/03/19 at 10:00 AM, revealed he/she was lying in bed, facing the wall, with cartoons playing on the television. Tube feeding in progress per physician orders. Continued observation revealed a church service with music was occurring in the dining room; however, Resident #46 was not in attendance. Observation of Resident #46, on 04/03/19 at 11:30 AM, revealed the resident remained lying in bed on the right side facing the wall with cartoons on television. Continued observation revealed SRNA #7 was preparing to perform daily care in order to get the resident up for the day. Tube feeding in progress per physician orders. Observation of Resident # 46, on 04/03/19 at 2:15 PM to 4:30 PM, revealed the resident was sitting up in a wheel chair by the wall near the nurse's station, very near the same spot occupied the afternoon of 04/02/19. There was one other resident noted to be briefly in that area, but was taken to their room by staff. No activities, other than the staff occasionally speaking to the resident, were occurring. Continued observation revealed various activities were being held in the Florida Dining Room during the afternoon; however, Resident #46 was not involved in the activities and was sitting in a wheel chair by the nurse's station. Observation of Resident #46, on 04/04/19 at 11:00 AM, revealed the resident again noted to be lying in bed, on his/her right side, facing the wall, with the television on and cartoons playing. Observation of Resident #46 on 04/04/19 at 12:05 PM, revealed the resident was again up in wheel chair sitting by the wall near the nurse's station, on the opposite wall from 04/03/19. Observation of Resident #46, on 04/04/19 at 3:00 PM, revealed the resident to be in a wheel chair still at the nurse's station. Continued observation revealed the facility passed out fruit and dip as the activity of the afternoon; however, per physician orders, Resident #46 is allowed only honey-thickened water upon his request and therefore not involved in this activity. No alternate activity was provided to Resident #46. Observation of Resident #46, on 04/04/19 at 5:00 PM, revealed the resident in a wheel chair by the wall facing the nurse's station. Continued observation revealed other residents were beginning to be directed to the dining room for dinner. No activities of any type were being held for this resident. The resident was not in conversation with other residents or staff at this time. Further observation revealed around 6:00 PM, the resident was wheeled back into his/her room, and placed in bed. Tube feeding was resumed per orders. The television remained on and tuned to cartoons. No 1:1 activities were taking place. Interview with SRNA #7, on 04/03/19 at 9:24 AM, revealed she cared for the resident regularly. SRNA #7 stated Resident #46's typical day consisted of getting out of bed around lunch, and then the resident would lay back down around supper due to the tube feeding. SRNA #7 stated Resident #46 is able to let the staff know when he/ she need to use the toilet. Interview with SRNA #6, on 04/03/19 at 1:15 PM, revealed she cares for the resident regularly. SRNA #6 stated Resident #46 does not really watch television; he/she does glance at it once in a while. SRNA #6 was unable to relay how the television came to be on only cartoons during this survey, did not know how long the TV had been on that channel, and was unaware of who was responsible for ensuring someone spends time with resident. SRNA #6 stated she talks to the resident during care each day she is here. SRNA #6 stated the resident's family visit once or twice per month, but not that much. Per interview Resident #46 doesn't do anything while sitting in the wheel chair by the nurse's station, just sits. SRNA #6 further stated Resident #46 does not go to activities, does not go to church, or participate in food activities. SRNA #6 is aware that the resident is not to have any solid food or thin liquids by mouth. SRNA #6 further revealed the resident never goes on field trips; she was unaware if the resident was asked to go on the trips. SRNA stated the resident just sits during the winter. SRNA #6 also stated that resident really does not talk to anyone. Interview with Unit Manager for East Hall, on 04/04/19 at 10:00 AM, revealed the activities department assesses the residents for their preference on activities and holds activities with the residents, spends time with the other residents, and provides socialization. The Unit Manager stated the activities help calm down the residents. Per interview, the resident's preference are care planned. The Unit Manager stated she is very familiar with Resident #46, who likes to watch Westerns in the evenings, but was unsure if the resident likes cartoons. Per interview, the SRNAs will change the channel on the television. Continued interview revealed Resident #46 sits at the nurse's station, but he/she is able to self-propel in the wheel chair around the building, even occasionally setting off alarms. The Unit manager clarified the self-propelling is not a consistent event; it depended on Resident #46's personal preference. Further interview revealed Resident #46 knows his/her family, is able to converse with spouse, who visits at least weekly and is able to make needs known, especially when needing to be toileted. The Unit Manager did not recall the resident attending activities and does not recall the activities staff conducting any 1:1 activities with Resident #46. Further, the Unit Manager stated Resident #46 does not go to group activities, as many are food based and the resident is unable to have solid foods. The Unit Manager stated the nursing staff would talk to the resident, as they are caring for him/her. Interview with the Wellness Coach (who also worked as a part time activity assistant), on 04/04/19 at 3:10 PM, revealed she was new to the position. She stated she worked part time, usually in the evenings or weekends to provide resident activities. The Wellness Coach stated she did not provide any group or 1:1 activity for Resident #37 or Resident #46. She further stated she did not have a form to document individual activities but was in the process of creating a 1:1 documentation form. The Wellness Coach stated she had not received any activity assessments from the Activity Coordinator; however, she was just initiating visits to residents to determine likes and dislikes. The Wellness Coach stated she focuses on sensory activities such as fleece tying of lap blankets and pillows. The Wellness Coach stated she comes in on Sunday to hold make up sessions for resident who may have missed activities earlier in the week. She stated she utilized the [NAME] technique for 1:1 activities, usually once per week. Per interview, she had never been given any 1:1 activities by the AD. Additional interview with Activity Coordinator/ Director (AD), on 04/04/19 at 1:47 PM revealed she was responsible for creating and updating Care Plans for activities for the residents. Per interview, the care plan should be up-to-date based on the resident's needs. Continued interview revealed she completes an assessment on each of the facility's residents. Per interview, all 1:1 activities go in to the resident's care plan just as the other activities for the other residents and it was the activities department that was responsible to conduct the activities. The Activity Coordinator stated Resident #37 and Resident #46 liked to attend music activities; however, the activity log for the residents did not reflect attendance at the music events offered on 01/02/19, 01/08/19, 01/09/19, 01/16/19, 01/23/19, 01/30/19 and 01/31/19. Fifteen (15) music activities were offered in February and March; however, there was no documented evidence either of the residents attended any music events. She stated she had completed an activity assessment for Resident #37 and Resident #46 but she had given those to a volunteer and kept no copies. Additional interview with the Activity Coordinator, on 04/04/19 at 5:01 PM, revealed she had no activity assessment for Resident #37 or Resident #46 as stated in the facility policy. She further stated there was no documentation located for any 1:1 individualized activities for Resident #37 or Resident #46. Per interview, Resident #37 and Resident #46 should had their care plans up dated to reflect the need to be in their room for extended periods of time and should have been offered individualized activities based on each resident's preference. Interview with the Director of Nursing (DON), on 04/04/19 at 4:48 PM, revealed the Activity Coordinator created the activity portion of the Care Plan and arranged for resident activities. Nursing staff did not deliver activity services. She stated Resident #37 liked to be out in the hallway rather than in his/her room. She further stated Resident #37 was deprived of that activity while on isolation precautions. The DON stated there was a communication gap between Nursing, Infection Control, and the Activities staff and acknowledged Resident #37 should not have been isolated for any infection control issue. The DON stated she had never observed Resident #37 watching television nor did the resident ever ask for someone to turn the TV on. She further stated one to one (1:1) individualized activities were planned and should be delivered to residents who could not or would not attend group activities. Per interview, the care plan should be updated if a resident could not or would not leave their room, or any change in the resident's status. The Care Plan should reflect the current needs of each resident consistent with the resident's abilities. Interview with the Administrator, on 04/04/19 at 5:11 PM, revealed her expectation for the Activity Coordinator was to gather the likes and dislikes of residents and create the Activity Care Plan consistent with the capabilities of each resident. As residents experienced changes, the activity section of the Care Plan should be revised by the Activities Coordinator. Upon continued interview, she stated it was important for each resident to have meaningful activities for the residents' well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility's Policies, it was determined the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support the residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (2) of twenty-two (22) sampled residents (Resident #37 and Resident #46). 1. Resident #37's Care Plan and Activity Log revealed the resident watched television, the resident did not have a television and no staff had observed the resident watching television. In addition, at the time of survey, Resident #37 was confined to his/ her room based on his/her roommate's medical condition requiring isolation precautions. Resident #37 enjoyed being in the hallway and was deprived of this activity with no individual activities offered in the room. 2. Resident #46's Activity logs were not complete, and did not provide activities per Resident #46's preferences, nor did the facility provide any 1:1 activities while the resident was confined to his/ her room for tube feeding. The findings include: Review of facility's Policy titled, Activity Program Policy and Procedure, revised 11/01/18, revealed individual activities were developed in accordance with the comprehensive assessment. The policy further stated periodic evaluation of the appropriateness of activities would be conducted with changes in programming as needed. The Activities Coordinator was responsible for the direction of the ongoing plan for resident activities. Review of the facility job description titled, Activity Coordinator revealed the Activity Coordinator was responsible for developing, initiating, implementing, and maintaining a comprehensive resident centered activity program for each resident. The job responsibilities included assessing each resident's activity needs, assessment and completion of assigned sections of the Minimum Data Set (MDS), development of the resident's activity care plan with review, and updating to the Care Plan as needed. Review of Activity Calendars for January 2019, February 2019, and March 2019 revealed group activities were offered each day. Further review revealed in January two (2) Sunday activities were TV Time, in February one (1) Sunday activity was TV Time, and in March two (2) Sundays offered TV Time as the only scheduled activity. All Saturdays offered Bingo as the only activity. Review of the facility activity log titled, One on One List, undated, revealed Resident #37 and Resident #46 were not on the list for individualized activities. 1. Record review revealed Resident #37 was initially admitted by the facility on 09/12/14 and was readmitted on [DATE] with diagnoses to include Dementia, Diabetes Type ll, Psychotic Disorder with Delusions, Muscle Weakness, Gastrostomy Malfunction, and Essential Hypertension. Review of Resident #37's Quarterly Minimum Data Set (MDS) Assessment, dated 01/301/9, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of one (1) out of fifteen (15), indicating the resident to have severe cognitive impairment. Continued review of the MDS revealed the resident had disorganized thinking and illogical flow of ideas (Section C). The MDS further revealed the resident had difficulty concentrating on television nearly every day (Section D, #G). Review of Resident #37's Comprehensive Care Plan, with admission date 12/11/18, revealed a Focus Area for Resident #37's socialization with others when the resident sat in the hall before meals. The focus area also included the resident's attendance at special events including parties and music. The goal was for the resident to be out of the room daily and in attendance at activities as desired. Interventions included encouraging the resident to be more social during the day, reminding the resident of daily activities, times and places in the facility, monitoring for signs and symptoms of Clostridium DIfficile (C. Diff) and reminders for Resident #37 to have his/her fingernails polished weekly. The Care Plan further revealed Resident #37 had Alzheimer's Dementia with mood/behavioral disturbances and anxiety The Focus Area revealed the resident was disoriented, gave his/her first name at times, had a short attention span, and rambling conversation. The goal was for the resident to be able to state his/her name through the quarter and be cooperative with staff during care needs as much as possible. Interventions included an Activities Calendar in the room, calling the resident by name, reassuring the resident when the resident was worrisome or had unrealistic fears, medications as ordered, and keeping a clock and calendar in the room. Review of facility document titled, Documentation Survey Report v2(activity log) for Resident #37, dated January 2019, revealed his/her activities included six (6) days with no activities, eight (8) days of activities of watching television and observing. No group activities were documented nor were any manicures or fingernail painting documented. Review of Resident #37's activity log, dated February 2019, revealed Resident #37 did not attend any group activities. Four (4) days during the month had no activities documented. Continued review revealed there were nineteen (19) days activities documented included observing or passive socialization with others. Review of Resident #37's activity log, dated March 2019, revealed eight (8) days with no activities recorded. Resident #37 did not attend any group activities. Passive television watching was recorded on two (2) days. Four (4) days were listed as NA which was an unknown code. Passive socialization was recorded on ten (10) days and active socialization was recorded on six (6) days. Observation of Resident #37, on 04/02/19 at 12:38 PM, 2:39 PM, and 5:32 PM, on 04/03/19 at 10:23 AM and 2:43 PM, and on 04/04/19 at 8:30 AM and 11:00 AM revealed the resident did not have a television. Although the roommate had a television, it was on the wall farthest from Resident #37 and was often out of sight when the curtain was pulled. The resident was not permitted out of the room on the three (3) days of observation because the roommate was on isolation precautions. No individualized activities with the resident were observed. Interview with State Registered Nursing Assistant (SRNA) #3, on 04/04/19 at 2:21 PM, revealed he was assigned to Resident #37. SRNA #3 stated the resident did not pay attention to the television. The SRNA further stated he never turned on the television for Resident #37 because the resident never requested to watch television and because Resident #37 did not have a television in the room. The television in the room belonged to the roommate and was across the room from Resident #37. SRNA #3 further stated the Activity Staff did all activities with Resident #37. Interview with SRNA #2, on 04/04/19 at 2:28 PM, revealed he cared for the resident on occasion. SRNA #2 stated Resident #37 never asked to watch television. The SRNA further stated the resident talked to the roommate on occasion but he was unaware of any other activities for the resident. SRNA #2 stated the Activities Staff had responsibility for resident activities. Interview with SRNA #1, on 04/04/19 at 2:35 PM, revealed she cared for Resident #37 at various times. The SRNA stated the resident did not have a television and never asked to watch TV (television). SRNA #1 further stated it was doubtful that Resident #37 could understand what was on TV. The SRNA stated she fed the resident and talked to the resident during meal times. She also stated Resident #37 talked to his/her roommate at times, although the resident was confused. Interview with Licensed Practical Nurse (LPN) #1, on 04/04/19 at 2:38 PM, revealed she was assigned to Resident #37. She stated the resident generally roamed the facility in his/her wheelchair when not on isolation precautions. LPN #1 stated staff were told during report the resident could not leave the room because the roommate was on isolation precautions for shingles. She stated staff talked to the resident but did not do activities with the resident. Upon continued interview, she had never observed Resident #37 watching television nor did she ever turn on a TV for the resident. Interview with LPN #2, on 04/04/19 at 2:46 PM, revealed she generally did not work the hall where Resident #37 lived. She stated she did know the resident and had never observed the resident watching TV. She further stated the resident socialized with other residents; however, she had never observed Resident #37 attending planned activities. Interview the Unit Manager, on 04/04/19 at 2:53 PM, revealed she was very familiar with Resident #37. She stated the resident came out of his/her room on normal days but currently was not permitted out of the room because the roommate was on isolation precautions. She stated the television in Resident #37's room did not belong to the resident. She further stated Resident #37 had never asked her to turn the television on. Per interview, she had not observed any one to one (1:1) activities with Resident #37. She stated the activity staff had responsibility for planning and delivering activities for all residents. Interview with the Infection Control Preventionist, on 04/04/19 at 3:52 PM, revealed it was acceptable for Resident #37 to be out of the room despite the roommate's condition. She stated she was not aware the resident was on isolation precautions due to the roommate. She stated there must have been a lack of communication causing the unnecessary isolation of Resident #37. Interview with the Activity Coordinator, on 04/04/19 at 1:47 PM, revealed she was unaware Resident #37 was on isolation precautions due to a roommate with shingles. She then verbalized she had not received any information Resident #37 was confined to the room based on the roommate's condition. She stated one to one (1:1) activities has been planned for the resident; however, she could not locate any documentation of planned 1:1 activities. The Activity Coordinator stated usually Resident #37 sat in the hallway. She stated the resident did not have a television for watching TV activities but the roommate did. Upon further interview, the Activity Coordinator stated she was not sure Resident #37 could see the roommate's television nor could she see the TV when the privacy curtain was pulled. 2. Review of Resident #46's medical record revealed the resident was originally admitted by the facility on 11/15/16 with diagnoses to include Alzheimer's Disease, Acute on Chronic Congestive Heart Failure, Gastrointestinal Hemorrhage, Extended Spectrum Beta Lactamase (ESBL) Resistance, Bradycardia, Diabetes Mellitus Type Two (2), Chronic Kidney Disease Stage Three (3), Benign Prostatic Hyperplasia, Gastrostomy Status, Anorexia, Dysphagia, Muscle Weakness, Anxiety Disorder, Essential Hypertension, Atrial Fibrillation, and Chronic Ischemic Heart Disease. Review of Resident #46's Annual MDS Assessment, dated 02/06/19, revealed the facility assessed the resident to have a BIMS score of two (2) out of fifteen (15), indicating the resident was severely cognitively impaired. Continued review revealed Section B assessed the resident to usually understand others and usually makes self-understood. Section D revealed Resident #46 indicated he/she was having trouble concentrating on things such as newspapers or watching television. Further review revealed Resident #46 was the primary respondent for the Daily and Activities Preferences. Resident #46's highest ranked activity preferences were listening to music and participating in religious services/ practices. Resident #46 ranked as secondary preferences being around animals/ pets, keeping up with the news, doing things with a group of people, engaging in his/her favorite activities and going outside to get fresh air when the weather was good. Having books, newspapers, and magazines were coded as his/ her least favorite activity. Review of Resident #46's feeding tube orders as of April 3, 2019 revealed Resident #46's Physician ordered the resident to be administered tube feeding to be turned on each day at 6:00 PM, continue through the night and to be turned off at 12:00 PM, for a total of six (6) hours without the tube feed infusing. Review of Resident #46's Comprehensive Care Plan, dated 09/05/18 and revised 02/19/18, revealed a focus area for alteration in thought process with a goal that he/she will make decisions in care daily and will remain oriented to person and facility with the interventions to include staff to encourage the resident to be out of bed when the tube feeding is off to receive social stimulation, talk to the resident about current events, weather, upcoming holidays to help with time orientation, and talk with the resident daily during care. Continued review revealed a focus area initiated 06/21/15 and revised 02/19/19 was the potential for alteration in mood and behavior with a goal that the resident will not exhibit depressed mood or behaviors. Interventions in place included 1:1 activities two (2) times each week and to encourage the resident to attend activities and group events. Further review revealed a focus area, initiated 02/13/19, with the goal for the resident to continue socializing and moving self around the facility. Interventions in place included to encourage the resident to be out of his/her room daily or as he/she can tolerate, re-direct the resident to activities, locations with others when he/she is out in the hallway, continue to attend activities as can tolerate and staff to transport the resident to and from activities as he/she can tolerate attending. Review of Resident #46's Activity log, dated January 2019, revealed no activities were documented on any Sunday, and one Monday was lacking documentation of activities. The remainder of January revealed seven (7) days with passive television and observing the socialization of others was the documented activities most prevalent. Review of Resident #46's Activity log, dated February 2019, revealed no activities were documented on any Sunday, and one Friday. Continued review revealed passive TV watching was recorded twelve (12) times as the day's activity. Eight (8) other days involved passive observations. One group activity was documented as attended by Resident #46. Review of Resident # 46's Activity log, dated March 2019, reveal no activities were documented on any Sunday and two (2) Saturdays. Four (4) days were documented as NA as the activity with no key code to corresponded to NA to identify the activity. Ten (10) days documented only passive TV as the activity. Four (4) days had documented actively socialization with others. Observation of Resident #46, on 04/02/19 at 12:45 PM, revealed the resident was noted to be up in a wheel chair sitting near the nurse's station by the wall with no interaction with other residents or staff. Continued observation revealed the resident had no activities occurring at this time. Observation of Resident #46, on 04/02/19 at 6:30 PM, revealed the resident was noted to be lying in bed on his/her right side facing the wall, which had a television mounted approximately twenty-four (24) inches above the resident's head. The resident's bed was up against the wall. The resident's television was on, with cartoons playing. Tube feeding was in progress per physician orders. Observation of Resident #46, on 04/03/19 at 8:00 AM, revealed Resident #46 was noted to be lying in bed, facing the wall, with the television on cartoons. No activities or conversation was noted at this time. Tube feeding in progress per physician orders. Observation of Resident # 46, on 04/03/19 at 9:00 AM, revealed the resident was lying in bed on his/ her right side, facing the wall. The television was on, with cartoons playing. No activities were being provided. Tube feeding in progress per physician orders. Observation of Resident #46, on 04/03/19 at 10:00 AM, revealed he/she was lying in bed, facing the wall, with cartoons playing on the television. Tube feeding in progress per physician orders. Continued observation revealed a church service with music was occurring in the dining room; however, Resident #46 was not in attendance. Observation of Resident #46, on 04/03/19 at 11:30 AM, revealed the resident remained lying in bed on the right side facing the wall with cartoons on television. Continued observation revealed SRNA #7 was preparing to perform daily care in order to get the resident up for the day. Tube feeding in progress per physician orders. Observation of Resident # 46, on 04/03/19 at 2:15 PM to 4:30 PM, revealed the resident was sitting up in a wheel chair by the wall near the nurse's station, very near the same spot occupied the afternoon of 04/02/19. There was one other resident noted to be briefly in that area, but was taken to their room by staff. No activities, other than the staff occasionally speaking to the resident, were occurring. Continued observation revealed various activities were being held in the Florida Dining Room during the afternoon; however, Resident #46 was not involved in the activities and was sitting in a wheel chair by the nurse's station. Observation of Resident #46, on 04/04/19 at 11:00 AM, revealed the resident again noted to be lying in bed, on his/her right side, facing the wall, with the television on and cartoons playing. Observation of Resident #46 on 04/04/19 at 12:05 PM, revealed the resident was again up in wheel chair sitting by the wall near the nurse's station, on the opposite wall from 04/03/19. Observation of Resident #46, on 04/04/19 at 3:00 PM, revealed the resident to be in a wheel chair still at the nurse's station. Continued observation revealed the facility passed out fruit and dip as the activity of the afternoon; however, per physician orders, Resident #46 is allowed only honey-thickened water upon his request and therefore not involved in this activity. No alternate activity was provided to Resident #46. Observation of Resident #46, on 04/04/19 at 5:00 PM, revealed the resident in a wheel chair by the wall facing the nurse's station. Continued observation revealed other residents were beginning to be directed to the dining room for dinner. No activities of any type were being held for this resident. The resident was not in conversation with other residents or staff at this time. Further observation revealed around 6:00 PM, the resident was wheeled back into his/her room, and placed in bed. Tube feeding was resumed per orders. The television remained on and tuned to cartoons. No 1:1 activities were taking place. Interview with SRNA #7, on 04/03/19 at 9:24 AM, revealed he/she cared for the resident regularly. SRNA #7 stated Resident #46's typical day consisted of getting out of bed around lunch, and then the resident lays back down around supper due to the tube feeding. SRNA #7 stated Resident #46 is able to let the staff know when he/ she need to use the toilet. Interview with SRNA #6, on 04/03/19 at 1:15 PM, revealed he/she cares for the resident regularly. SRNA #6 stated Resident #46 does not really watch television; he does glance at it once in a while. SRNA #6 was unable to relay how the television came to be on only cartoons during this survey, did not know how long the TV had been on that channel, and was unaware of who was responsible for ensuring someone spends time with resident. SRNA #6 stated she talks to the resident during care each day she is here. SRNA #6 stated the resident's family visit once or twice per month, but not that much. Per interview Resident #46 doesn't do anything while sitting in the wheel chair by the nurse's station, just sits. SRNA #6 further stated Resident #46 does not go to activities, does not go to church, or participate in food activities. SRNA #6 is aware that the resident is not to have any solid food or thin liquids by mouth. SRNA #6 further revealed the resident never goes on field trips; she was unaware if the resident was asked to go on the trips. SRNA stated the resident just sits during the winter. SRNA #6 also stated that resident really does not talk to anyone. Interview with LPN #2, on 04/04/19 at 9:45 AM, revealed she was on a float schedule' and had very limited knowledge of Resident #46. Interview with Unit Manager for East Hall, on 04/04/19 at 10:00 AM, revealed the activities department holds activities with the residents, spends time with the other residents, and provides socialization. The Unit Manager stated the activities help calm down the residents. The Unit Manager stated she is very familiar with Resident #46, who likes to watch Westerns in the evenings, but was unsure if the resident likes cartoons. Per interview, the SRNAs will change the channel on the television. Continued interview revealed Resident #46 sits at the nurse's station, but he/she is able to self-propel in the wheel chair around the building, even occasionally setting off alarms. The Unit manager clarified the self-propelling is not a consistent event; it depended on Resident #46's personal preference. Further interview revealed Resident #46 knows his/her family, is able to converse with spouse, who visits at least weekly and is able to make needs known, especially when needing to be toileted. The Unit Manager did not recall the resident attending activities and does not recall the activities staff conducting any 1:1 activities with Resident #46. Further, the Unit Manager stated Resident #46 does not go to group activities, as many are food based. The Unit Manager stated the nursing staff would talk to the resident, as they are caring for him / her. Interview with the Wellness Coach (who also worked as a part time activity assistant), on 04/04/19 at 3:10 PM, revealed she was new to the position. She stated she worked part time, usually in the evenings or weekends to provide resident activities. The Wellness Coach stated she did not provide any group or 1:1 activity for Resident #37 or Resident #46. She further stated she did not have a form to document individual activities but was in the process of creating a 1:1 documentation form. The Wellness Coach stated she had not received any activity assessments from the Activity Coordinator; however, she was just initiating visits to residents to determine likes and dislikes. The Wellness Coach stated she focuses on sensory activities such as fleece tying of lap blankets and pillows. The Wellness Coach stated she comes in on Sunday to hold make up sessions for resident who may have missed activities earlier in the week. She stated she utilized the [NAME] technique for 1:1 activities, usually once per week. Per interview, she had never been given any 1:1 activities by the AD. Additional interview with Activity Coordinator/ Director (AD), on 04/04/19 at 1:47 PM revealed she was responsible for creating and updating Care Plans for activities for the residents. Continued interview revealed she completes an assessment on each of the facility's residents. Per interview, all 1:1 activities go in to the resident's care plan just as the other activities for the other residents and it was the activities department that was responsible to conduct the activities. The Activity Coordinator stated Resident #37 and Resident #46 liked to attend music activities; however, the activity log for the residents did not reflect attendance at the music events offered on 01/02/19, 01/08/19, 01/09/19, 01/16/19, 01/23/19, 01/30/19 and 01/31/19. Fifteen (15) music activities were offered in February and March; however, there was no documented evidence either of the residents attended any music events. She stated she had completed an activity assessment for Resident #37 and Resident #46 but she had given those to a volunteer and kept no copies. Additional interview with the Activity Coordinator, on 04/04/19 at 5:01 PM, revealed she had no activity assessment for Resident #37 or Resident #46 as stated in the facility policy. She further stated there was no documentation located for any 1:1 individualized activities for Resident #37 or Resident #46. Interview with the Director of Nursing (DON), on 04/04/19 at 4:48 PM, revealed the Activity Coordinator created the activity portion of the Care Plan and arranged for resident activities. Nursing staff did not deliver activity services. She stated Resident #37 liked to be out in the hallway rather than in his/her room. She further stated Resident #37 was deprived of that activity while on isolation precautions. The DON stated there was a communication gap between Nursing, Infection Control, and the Activities staff and acknowledged Resident #37 should not have been isolated for any infection control issue. The DON stated she had never observed Resident #37 watching television nor did the resident ever ask for someone to turn the TV on. She further stated one to one (1:1) individualized activities were planned and should be delivered to residents who could not or would not attend group activities. The Care Plan should reflect the current needs of each resident consistent with the resident's abilities. Interview with the Administrator, on 04/04/19 at 5:11 PM, revealed her expectation for the Activity Coordinator was to gather the likes and dislikes of residents and create the Activity Care Plan consistent with the capabilities of each resident. As residents experienced changes, the activity section of the Care Plan should be revised by the Activities Coordinator. She further stated Resident #37 did not watch television. Other one to one activities appropriate to the resident should have been planned and delivered. The Administrator stated there should have been better communication between Infection Control, Nursing, and the Activity staff to avoid unnecessary isolation of Resident #37. Upon continued interview, she stated it was important for each resident to have meaningful activities for the residents' well-being.

Based on observation, interview and review of the facility's Policy, it was determined the facility failed to store and label medications in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observation on 04/03/19 revealed an opened and undated Humalog Insulin multi-dose pen in the East Unit refrigerator and expired Lantaprost eye drops in the East Hall Medication Cart. Observation of the East Medication Cart, on 04/04/19, revealed ten (10) medications were left in a drawer, not in their pharmacy dispensed packaging, and were loose in a cup labeled with a resident's name. The findings include: Review of the facility's Policy, titled Medication Storage in the Facility undated, revealed medications and biologicals are stored properly, following manufacturer's recommendations or those of the supplier. Per review, outdated, contaminated medications are to be immediately removed from stock and disposed of and reordered from pharmacy. Continued review revealed each medication label should include an accessory label including storage requirements. Interview with the Director of Nursing (DON), on 04/04/19 at 5:00 PM, revealed the facility utilized Lippincott Manual of Nursing Practice, Ninth edition for their Standard of Practice. Review of the Lippincott Manual of Nursing Practice, Ninth edition, under section Specific Medication Administration Proceduresrevealed the policy was to ensure medications were administered in a safe and effective manner. Continued review revealed the medication cart is locked at all times unless in use and under the direct observation of the medication nurse or aide. Further review revealed staff should check the expiration date on the package or container prior to administration. Per the policy, once a medication was removed from the package or container, unused doses should be disposed of in accordance with the medication destruction policy. 1. Observation of the East Medication Room, on 04/03/19 at 11:00 AM, revealed a Humalog Insulin multi-dose pen opened and undated. Observation of the East Medication Cart, on 04/03/19 at 4:30 PM, revealed one (1) bottle of Lantaprost eye drops opened and labeled with an open date of 01/24/19. Interview with Licensed Practical Nurse (LPN) #1, on 04/04/19 at 3:00 PM, revealed the medication was in the medication cart for resident use. Continued interview revealed once a medication was open, it expired in approximately 30 days and the eye drops were expired. Per interview, expired medications should not be used because it could be less effective or cause adverse effects for the resident. Continued interview revealed the facility has a policy not to use expired medications. 2. Observation of East Hall Medication Cart, on 04/04/19 at 8:45 AM, revealed the top drawer of the locked cart contained medications not in their pharmacy dispensed packaging, and were loose in a cup labeled with a resident's name. Interview with LPN #2, on 04/04/19 at 8:50 AM, revealed she had removed the medications from the original pharmacy packaging and placed them in the cup found in the cart. Per LPN #2 the medications were: Baclofen, Donepezil, Escitlapram, Folic Acid, Jardiance, Multivitamin, Calcium Carbonate, Magnesium Oxide, Metformin and Divalproex. Continued interview revealed her intent was to administer the medications to a resident, per the physician orders; however, did not find the resident in his/her assigned room. LPN #2 stated she then placed the cup of pills in the top drawer. LPN #2 further stated she knew she should not have put the medications in the drawer opened and without their pharmacy packaging. She stated she should have stopped, located the resident and administered the medications as ordered. Interview with the Unit Manager, on 04/03/19 at 11:05 AM, revealed medications should be dated when opened and expiration date put on the label. Continued interview revealed open medications should be then put in the medications cart and not left in the refrigerator. Per interview, the medication is only effective for so many days after the date it is opened so the medication needs to be labeled with the date opened to know when it expires. Additional interview, on 04/04/19 at 9:45 AM, revealed medications should never be pulled and stored without the pharmacy packaging, even in a locked medication cart drawer. Per interview, after realizing the resident was not in his/her room, the LPN should have gone immediately to find the resident to administer the medications. Further interview revealed the consequences of storing medications not in their pharmacy packaging would include a wandering resident may pick them up and consume them or the nurse could become distracted and administer them to the wrong resident. Interview with the Director of Nursing (DON), on 04/04/19 at 4:00 PM, revealed the facility does have a policy related to the storage of medications. Per interview, the facility's policy was to date and label the medication after it was opened. Continued interview revealed staff need to know when the medication was opened to know when it expires. Further interview revealed it was important to date the medication so expired medications were not administered to a resident. Per interview, expired medications could be stronger or weaker in strength. Additional interview on 04/04/19 at 5:00 PM, revealed staff should never leave a cup of medications in the top drawer of the cart. Per interview, she stated this was an infection control issue and someone else could take them resulting in drug diversion. The DON further stated the nurse should have either wasted the medications or located the resident to have the correct resident consume the medications. The DON stated the facility should have followed the facility's policy. Interview with the Administrator, on 04/04/19 at 3:59 PM, revealed medications should be dated when opened to be able to determine when the medication has expired. Continued interview revealed expired medications should be pulled from stock and not available for resident use. Further interview revealed medication is to be discarded per the manufacturer's recommendations. It was her expectation that staff follow the facility's policy. Per interview, expired medications should not be administered to residents for the safety of the resident. Additional interview, on 04/04/19 at 5:15 PM, revealed opened medications not in the pharmacy packaging should not be put back into the medication cart. Per interview, the nurse should find the resident to administer the medications or dispose of them. Further interview revealed it was not acceptable to leave the medications in the top of the cart due to the possibility of error because the nurse could not know whose pills were in the cup nor how long they had been in there. The Administrator further stated there was increased room for error when not following the facility's medication pass policy.

Based on interview, record review and review of facility's Policies, it was determined the facility failed to establish an Infection Prevention and Control Program (IPCP) that included an annual review of its IPCP in order to update their program as necessary. The facility was unable to submit documented evidence its IPCP and infection control policies were reviewed annually. The findings include: Review of facility's Policy titled, Antibiotic Stewardship Policy, dated 01/04/18, revealed there was no documented evidence an annual review was performed in January 2019. Review of facility's Policy titled, Procedural Guideline for Isolation Precautions, undated, revealed there was no documented evidence an annual review was performed. Review of facility's Policy titled, Policy for Influenza/Pneumococcal Vaccination of Residents, undated, revealed there was no documented evidence an annual review was performed. Review of facility's procedure titled, Procedure for Isolation: Initiation of Isolation, undated, revealed there was no documented evidence an annual review was performed. Interview with the Infection Control Preventionist, on 04/04/19 at 3:52 PM, revealed infection control policies had not undergone annual review. She stated she was unaware of the review requirement and had not facilitated an annual infection control policy review. The Infection Control Preventionist stated she was new to the role and was learning infection control requirements. Interview with the Director of Nursing (DON), on 04/04/19 at 4:48 PM, revealed the facility had reviewed the Infection Prevention and Control policy on 09/17/18; however, other infection control policies had not received an annual review. She stated the Infection Control Preventionist was new and learning the position and all infection control policies had not received annual review. The DON stated the purpose of annual infection control policy review was to ensure policies reflected current best practice and residents received optimal care. Interview with the Administrator, on 04/04/19 at 5:11 PM, revealed the Infection Control Preventionist (ICP) had responsibility for coordinating infection control policy reviews. The Director of Nursing (DON) had oversight responsibility for Infection Control. The Administrator stated it was important for infection control policies to undergo annual review to ensure the policies were consistent with current practice.

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to establish an Infection Prevention and Control Program (IPCP) that included an Antibiotic Stewardship Program to include antibiotic use protocols and a system to monitor antibiotic use. The facility was unable to submit documented evidence of an Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use in order to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The findings include: Review of facility policy titled, Antibiotic Stewardship Policy, dated 01/04/18, revealed the Antibiotic Stewardship Committee would support and promote antibiotic use protocols. Interview with the Infection Control Preventionist, on 04/04/19 at 3:52 PM, revealed the facility did not have antibiotic use protocols in place. She further stated the Antibiotic Stewardship Program was not yet off the ground. The Infection Control Preventionist stated the pharmacist was unable to attend meetings for the last four (4) months to review antibiotic prescribing. Continued interview revealed the Committee was working on the implementation of Antibiotic Stewardship Requirements. Interview with the Director of Nursing (DON), on 04/04/19 at 3:52 PM and 4:48 PM, revealed she had oversight for the Infection Control Preventionist and the Antibiotic Stewardship Program. She stated antibiotic prescribing protocols were important to reduce unnecessary antibiotic usage. Continued interview revealed the protocols for the Antibiotic Stewardship Program were not yet developed and utilized. Upon further interview, the DON stated the regulations for antibiotic usage prescribing protocols would help the Antibiotic Stewardship Program engage the providers. The DON stated the use of antibiotic prescribing protocols would help prevent resistant organisms and the unnecessary use of antibiotics which, in turn, helped residents achieve better outcomes. Interview with the Administrator, on 04/04/19 at 5:11 PM, revealed her expectation for the Director of Nursing and the Infection Control Preventionist to manage the infection control activities for the facility. She stated adherence to the Antibiotic Stewardship processes was important for ensuring optimal outcomes for residents.