**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 sampled residents, (Resident (R)79). The findings include: Review of a facility policy titled Enhanced Barrier Precautions (EBP), undated, revealed EBP were used in conjunction with standard precautions. Per review, EBP expanded the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provided opportunities for transfer of multi-drug resistant organisms (MDRO) to staffs' hands and clothing. Further review of the policy revealed EBP precautions were indicated for residents with wounds and/or indwelling medical devices such as urinary catheters, even if the resident was not known to be infected or colonized with a MDRO. Observation of the facility's 600-hall on 05/20/2025 at 10:00 AM, revealed two enhanced barrier carts located in hallway against the walls in between every other door on one side of the hallway, resident rooms [ROOM NUMBERS] and rooms [ROOM NUMBERS]. Continued observation revealed enhanced barrier and contact precaution signs lying on top of the carts. In interview with Hydration Aide 1 on 05/20/2025 at 10:02 AM, she stated the (EBP) carts in the hallway stored the PPE supplies for the aides and nurses. She reported the yellow stickers on the name plates outside of the residents' rooms meant the resident was either on contact precautions or EBP. The Hydration Aide further stated she was not sure how to differentiate whether a resident was on contact precautions or EBP. In interview with CNA 1 on 05/20/2025 at 10:29 AM, she stated there were usually signs on the residents' doors indicating if the resident was on EBP, contact precautions or not. She stated she did not know if there were any residents currently on the 600-hall who were on contact precautions or EBP. In interview with Licensed Practical Nurse (LPN) 1 on 05/20/2025 at 10:52 AM, she stated residents had yellow dots by their names outside of their doors if they were on EBP. She said only certain wounds were placed on EBP. LPN 1 reported for residents on contact precautions, they had pouches with supplies hanging outside the residents' doors. She further stated she did not know if there was anyone on contact precautions or EBP. 1. Review of the facesheet for R79 revealed the facility admitted the resident on 03/06/2025, with diagnoses that included chronic obstructive pulmonary disease, emphysema, acute respiratory failure with hypoxia, and urinary tract infection. Review of admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 04/01/2025, revealed the facility assessed R79 to have a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating the resident had moderate cognitive impairment. Review of R79's physician orders revealed the resident was to be on EBP related to an indwelling urinary catheter. Observation of the 600-hall on 05/22/2025 at 11:00 AM, revealed a yellow dot beside R79's name outside the room door, with PPE in an EBP cart located between rooms [ROOM NUMBERS]. Continued observation revealed Certified Nurse Aide (CNA) 7 and CNA 4 providing direct care for R79 in the resident's room (603-A), at bedside without wearing the necessary personal protective equipment (PPE) required for the resident's enhanced barrier precautions. In interview with CNA 4 on 05/21/2025 at 8:30 AM, she stated the yellow stickers beside residents' names meant the resident was on EBP. She reported if the resident was on contact precautions there would be a bag with supplies and a sign that said see the nurse hanging outside of the resident's door. In additional interview with CNA 4 on 05/22/2025 at 11:05 AM, she stated she typically wore a gown and other PPE when required and she should have done so this time, but, she stated I honestly forgot. She said R79 was on EBP possibly because he had a catheter. CNA 4 reported residents were usually on EBP because they had a catheter and/or wounds. She stated she had received training on how to wear PPE and on infection control through monthly meetings and if there was anything that needed to be addressed. The CNA further stated a negative outcome of not following proper EBP was the spread of a harmful infection. In interview with CNA 7 on 05/22/2025 at 11:10 AM, she stated she knew the yellow dot on the outside of the residents' doors by their name indicated the resident was on EBP. She said she normally worked on the 400-hall and stated she was not very familiar with R79 and did not pay attention to whether he was on EBP or not. CNA 7 reported she had received training on proper PPE use and how to put on PPE; however, did not know how often she had received those trainings. She stated it was important to follow the facility's policy related to EBP and contact precautions to protect the resident from their germs and the germs of other residents. The CNA further stated negative outcomes of not following the facility's infection control and EBP policies could be swapping infections between residents. In interview with the Infection Preventionist (IP) on 05/22/2025 at 9:00 AM, she stated she and the unit managers (UMs) did audits of staff for surveillance of appropriate handwashing and appropriate use of PPE once per week and more often than that if there were more residents on precautions. She reported for residents with chronic wounds that required a dressing, those residents should be on EBP. The IP said EBP was indicated by a yellow dot by the resident's name outside of their door. She additionally stated contact precautions were indicated by the supply bag hanging right outside of the resident's door and a sign placed on the door. In interview with the Director of Nursing (DON) on 05/23/2025 at 1:01 PM, she stated her expectation of her staff regarding the use of EBP was to use it appropriately and follow the facility's policy. She reported examples of high contact care were changing linens, bathing residents, changing their briefs, and performing their catheter care. The DON said using EBP properly was important to prevent the spread of disease. She stated everyone that worked in the facility received infection control training upon hire and yearly thereafter. The DON further stated the training included return demonstration of donning and doffing PPE and the difference between the different types of transmission-based precautions. In interview with the facility's Administrator on 05/23/2025 at 1:33 PM, she stated she expected staff to wear appropriate PPE according to the facility's EBP policy. She stated a negative outcome of her staff not using appropriate PPE per the EBP policy was the spread of infection from staff to residents and staff possibly taking infections home with them.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the Comprehensive Care Plan for one (1) of two (2) sampled residents (Residents #49). Resident #49 was care planned to administer Oxygen (O2) at four (4) liters per nasal cannula (N/C); however, observations revealed the O2 was being administered at three (3) liters per N/C. The findings Include: Review of facility policy titled, Comprehensive Care Plan, last revised 01/02/2020, revealed it is the purpose of this form to document how each residents' daily needs are provided by the nursing staff in accordance with the guidelines of the RAI process and in keeping with the Medicare/Medicaid requirements. Residents receive care and treatment based on an assessment of their needs, the severity of their diagnosis or disease, condition, impairment of disability. The data obtained from the assessment is used to determine and prioritize the residents Comprehensive Plan of Care. The nurse overseeing the resident's care will complete and implement the initial form. The development, implementation, and maintenance of a resident's care plan as initiated by the admitting licensed nurse, and it is an interdisciplinary process. All disciplines involved in the care of the resident collaborate to develop a comprehensive plan of care. The resident/family or resident's representative is included to the extent possible in the implementation, maintenance, and evaluation of the care provided. Record review revealed the facility admitted Resident #49 on 12/02/2019 with the diagnoses which included Acute and Chronic Respiratory Failure with Hypoxia. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 11/17/2019 revealed the facility assessed Resident #49's cognition as intact with a Brief Interview for Mental Status (BIMS) score of twelve (12) which indicated the resident was interviewable. Review of Resident #49's Comprehensive Care Plan for at risk for Respiratory Distress with use of O2, dated 01/21/2020 revealed an intervention to administer O2 as ordered. Review of Resident #49's February 2020 Physician's Orders, revealed to administer O2 at three (3) liters via N/C every day and night; however, observation on 02/06/2020 at 9:09 AM and 02/07/2020 at 2:23 PM, revealed Resident #49's 02 concentrator was set at four (4) liters per N/C. Interview with the Administrator on 02/07/2020 at 3:15 PM revealed she expected staff to follow the resident's care plan.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of twenty-two (22) sampled residents received respiratory care that was consistent with professional standards of practice, and the comprehensive person-centered care plan ( Residents #60 and #49). Resident #49 and #60 were physician ordered and care planned to receive Oxygen (O2) at three (3) and two (2) liters respectively, per nasal cannula (N/C). However, observations revealed Resident #49 was receiving O2 at four (4) liters per N/C and Resident #60 was found not to be wearing wearing his/her O2. In addition, the nurse failed to obtain the Resident's 60's O2 sat, even though the resident was stating he/she could not breath. The findings include: Review of facility policy titled, Oxygen Policy and Procedure, last revised 02/01/2020, revealed the purpose of oxygen is to supplement oxygen supply when insufficient oxygen is being carried by the blood to the tissue. Responsibility: Licensed Nurse a. Procedure - Check physician's order for liter flow and method of administration. Note Physician order should include as needed (PRN) or continuous. If at any time the oxygen saturation (O2 sat.) below 88%, initiate oxygen and notify the physician. b. Oxygen saturations are to be checked every shift and documented on the Treatment Administration Record (TAR). c. If oxygen saturations fall below 88%, check O2 sat's every two hours until oxygen reaches 88% or greater and record on the TAR. 1. Record review revealed the facility admitted Resident #49 on 12/02/2019 with the diagnoses which included Acute and Chronic Respiratory Failure with Hypoxia. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 11/17/2019 revealed the facility assessed Resident #49's cognition as intact with a Brief Interview for Mental Status (BIMS) score of twelve (12) which indicated the resident was interviewable. Review of Resident #49's Comprehensive Care Plan for at risk for Respiratory Distress with use of oxygen (O2), dated 01/21/2020 revealed to administer O2 as ordered. Review of Resident #49's February 2020 Physician's Orders, revealed to administer O2 at three (3) liters via Nasal Cannula (N/C) every day and night, desat weekly on Monday, and document SP 02 on room air (without 02) after leaving 02 off for fifteen (15) minutes. Observation on 02/06/2020 at 9:09 AM revealed Resident #49's 02 concentrator was set at four (4) liters per N/C. Further observations on 02/07/2020 revealed the 02 setting was at 3 liters at 10:00 AM, then at 2:23 PM observed the 02 to now to be on 4 liters again. Interview with Resident #49, on 02/07/2020 at 2:30 PM revealed a Certified Nurse Aide (CNA) was in the room earlier and I asked her to turn it up, and she went to ask the nurse and the nurse told her she could turn it up a little. The CNA was identified to be CNA #4. Interview with CNA# 4 on 02/07/2020 at 2:45 PM revealed she had asked the nurse, Licensed Practical Nurse (LPN) #2, and she said go make it look as though you turn the 02 up to keep the resident happy. Interview with LPN #2 on 02/07/2020 at 3:00 PM revealed she told the CNA to go in the resident's room and check it out, but told the CNA not to touch it. When questioned the LPN if the CNA should have been assessing the need to turn up the O2, she stated no. Further interview at 3:36 PM revealed, she should have assessed the resident, and when asked why she didn't she stated just scatter brained, I guess. Interview with Registered Nurse (RN) #2 on 02/07/2020 at 3:10 PM revealed CNA's are never to assess or adjust the O2, but should report it to the nurse for the nurse to assess. Interview with the Administrator on 02/07/2020 at 3:15 PM revealed she expected the nurse only, to a assess a resident's 02 needs, and if needed to be turned up or down, to call the physician and get an order. 2. Record review revealed the facility admitted Resident #60 on 03/12/19 with diagnoses which included Respiratory Failure, and Alzheimer's Disease. Review of the Significant Change MDS assessment, dated 12/03/19 revealed the facility assessed Resident #60's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Review of Resident #60's Comprehensive Care Plan for at risk for Respiratory Distress, dated 01/15/19, revealed an intervention to administer 02 as ordered and desat weekly on room air. Review of Resident #60's February 2020 Physician Orders revealed to administer 02 at two (2) liters via N/C continuous, and desat on room air every week on Monday for fifteen (15) minutes. Observation on 02/07/2020 at 10:20 AM revealed Resident #60 was sitting on the side of bed with his/her head down. Further observation revealed the 02 tubing was laying on the floor and not connected to the concentrator, and the water bottle was also laying on the floor. CNA #3, who was in the room at the time, got the assistance of RN #2, who got a portable 02 tank to use while getting new tubing and humidity. Observation on 02/07/2020 at 10:25 AM revealed Registered Nurse (RN) #2 hooked up the resident to the portable 02 tank to replace the dirty tubing that had been on the floor, but did not check the resident's 02 sat (the amount of oxygen in the blood) even though it was not known how long the 02 had been off, and the resident was complaining of not being able to breath. When the RN was asked to check the resident's 02 SAT's, the resident's O2 sat was 89%. Interview with RN #2 on 02/07/2020 at 4:58 PM revealed she visually assessed the resident and did not see a concern with the resident and, also, was desating the resident, which required 02 to be off for fifteen (15) minutes only. However, it was unknown how long the 02 had been off and the resident was complaining of not being able to breath. Interview with the Assistant Director of Nursing (ADON) on 02/07/2020 at approximately 5:10 PM revealed a CNA was never to assess a resident on 02, or alter the administration of 02 in any way. She stated it was the licensed nurse's responsibility. The interview further revealed anytime a resident was off 02 for an unknown amount of time, and the order is for continuous, she expected the resident to be assessed including checking the 02 saturation of the resident.

Based on observation, interview, record review and facility policy review, it was determined the facility failed maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of twenty-two (22) sampled residents (Resident #60). The Certified Nurse Aide (CNA) failed to wash his/her hands during pericare and handle linen properly to prevent the spread of infection. The findings include: Review of facility policy titled, Precautions for Managing Infection, last revised 03/09/10 revealed: 1. Hand washing a. Wash hands after touching body fluids secretions, excretions and contaminated items, whether or not gloves are worn. b Wash hands immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environment. Wash hands between task and procedures on the same resident to prevent cross-contamination of different body sites. 2. Gloves: a. Wear gloves (clean, non sterile) when touching blood, body fluids, secretions, excretions, and contaminated items. b. Put on clean gloves just before touching mucous membranes and non-intact skin. c. Change gloves between task and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. d. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of microorganisms to other residents or environment. 3. Linen: transport, and process linen soiled with blood, body fluids, secretions, or excretions in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents. Record review revealed the facility admitted Resident #60 on 03/12/19 with diagnoses which included Renal Insufficiency, Respiratory Failure, History of Urinary Track Infections (UTI), and Alzheimer's Disease. Observation of Resident #60's incontinent care provided by CNA #3 and #4, on 02/07/20 at 10:50 AM revealed the two (2) CNA's prepared for incontinent care by washing their hands and applying gloves and obtaining a bath basin of water with multiple washcloths and towels. Further observation revealed CNA #3 removed the resident's soiled brief and washed the resident's peri area, and CNA #4 completed perineal (peri) care by cleaning the buttocks and rectal area. Further observation revealed after CNA #4 washed the resident, the resident was incontinent of stool. The CNA washed the resident and laid the soiled washcloth on the bed side tray (BST), touching the resident's water picture. The two CNA's then provided occupied bed care due to the sheets being soiled. The soiled sheets were removed and since there was no bag in place to place the dirty linen in, CNA #3 attempted to hold the linen in her hands while applying the clean linen. CNA #3 then placed the dirty linen at the foot of the bed on the clean linen to free up both hands, and a clean brief applied. Further observation revealed at no time did either CNA wash hands or change gloves after going from a dirty area and prior going to a clean area. CNA #4 then removed the tub from the BST without cleaning off the BST, took a trash bag and placed the soiled laundry inside the bag, and removed it out of the room, still with the same dirty gloves on. CNA #4 was observed, a few minutes later, without gloves, preparing to transfer another resident in the wheel chair. When asked where she had washed her hands, she stated to tell the truth, I did not wash them. Interview with CNA #3 on 02/07/2020 at 11:15 AM revealed she should have came better prepared, by having a bag ready for the soiled linen. She stated she realized she should have washed her hands and changed gloves after giving peri care and prior to applying clean linen and clothing, but failed to do so. Interview with CNA #4 on 02/07/2020 at 11:20 AM revealed she had not been a CNA very long, but did realize she should have washed hands and changed gloves before applying clean linen and clothing, and should have cleaned off the BST after laying dirty linen on the table. She also stated she should have washed her hands after disposing of the soiled linen, and before assisting another resident. Interview with the Assistant Director of Nursing (ADON) on 02/07/2020 at approximately 5:00 PM revealed CNA #4 had been certified only a short time so may need more education, but she expected all CNA's to follow the facility policy of proper hand hygiene, glove use, handling of linen, and the cleaning of dirty surfaces after exposure to soiled items, to ensure good infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, it was determined the facility failed to ensure a Minimum Data Set (MDS) Discharge assessment was completed for one (1) of twenty-four (24) sampled residents who was discharged to an acute care hospital on [DATE] with return anticipated (Resident #50). Resident #50 was transferred to the hospital on [DATE]; however, a Discharge-Return Anticipated Minimum Data Set (MDS) assessment was not initiated and/or completed. The findings include: Interview with the Administrator on 11/28/18 at 11:02 AM revealed the facility follows the Resident Assessment Instrument (RAI) manual for completion of MDS assessments. Review of the RAI manual, October, 2018, revealed a Discharge Assessment-Return Anticipated must be completed when the resident is discharged from the facility and the resident is expected to return to the facility within 30 days; For a resident discharged to a hospital or other setting who comes in and out of the facility on a relatively frequent basis and reentry can be expected, the resident is discharged return anticipated unless it is known on discharge that he or she will not return within 30 days. This status requires an Entry tracking record each time the resident returns to the facility and a Discharge assessment each time the resident is discharged ; Must be completed within fourteen (14) days after the discharge date ; and Must be submitted within fourteen (14) days after the MDS completion date. Record review revealed the facility admitted Resident #50 on 04/09/14 with diagnoses which included Cerebrovascular Vasospasm and Vasoconstrition. Review of the Physician's order dated 09/12/18 revealed the resident was sent out of the facility to the emergency room (ER) for evaluation and was admitted to the hospital. Review of the MDS submission list revealed on 09/14/18 an Entry Assessment was completed when Resident #50 returned to the facility. However, there was no documented evidence of a Discharge-Return Anticipated assessment completed on 09/12/18, when the resident was admitted to the hospital. Interview with Registered Nurse (RN) #1, MDS Coordinator, revealed she failed to submit a Discharge-Return Anticipated assessment on 09/12/18 when Resident #50 was admitted to the hospital. RN #1 stated it was an oversight. Interview with the Administrator on 11/28/18 at 11:02 AM revealed he expected the MDS Coordinators to follow the RAI manual when completing the MDS assessments.

**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 ensure each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline for two (2) of twenty-four (24) sampled residents (Residents #24 and #31) and for one (1) of three (3) closed records reviewed (Resident #101). The findings include: Review of facility policy titled, Minimum Data Set (MDS) Completion, dated 06/27/17, revealed each section of the MDS will be completed in accordance with the Resident Assessment Instrument (RAI) Manual. 1. Record review revealed the facility admitted Resident #101 on 09/30/18 and discharged Resident #101 to the hospital on [DATE]. Review of Resident #101's Quarterly MDS assessment, dated 10/07/18, revealed the facility assessed this resident's Brief Interview for Mental Status (BIMS) score to be a fifteen (15) which indicated this resident was interviewable. Review of a Nursing Progress Note, dated 08/31/18 at 11:27 AM, revealed Resident #101 was discharged home with family; however, review of Resident #101's Discharge Return Not Anticipated (DRNA) MDS assessment, dated 08/31/18, revealed the facility coded this resident as discharged to an acute care hospital. Interview with MDS Coordinator #1 on 11/21/18 at 9:03 AM, revealed she coded Resident #101's discharge status inaccurately on Resident #101's DRNA MDS assessment, dated 10/19/18. She stated this resident did not discharge to the community, he/she was discharged to the hospital. She stated she is expected to ensure the accuracy of the MDS assessments that she codes. 2. Record review, revealed the facility admitted Resident #31 to the facility on [DATE] with diagnoses which included Hypertension, Hyperlipidemia and Alzheimer's. Review of Resident #31's Quarterly MDS assessment, dated 09/06/18, revealed the facility was unable to complete a BIMS score due to to resident having severely impaired cognition Review of Resident #31's Quarterly MDS assessment, dated 06/06/18, revealed the facility assessed Resident #31 required extensive assistance of two (2) staff for bed mobility and dressing; and, extensive assistance of one (1) staff for eating. However, review of the Quarterly MDS assessment, dated 09/06/18, revealed the facility assessed the resident had a decline as the resident required total assistance of two (2) staff for bed mobility and dressing; and, total assistance of one (1) staff for eating. Interview with MDS Coordinator #2 on 11/21/18 at 01:52 PM, revealed the September 2018 assessment was not coded accurately. She stated Resident #31 did not have an actual change/decline from one assessment to the next and the Certified Nurse Aide (CNA) coding was inaccurate on the look back sheets that she gathered her information from due to one CNA coding the resident required total assistance on one day which was not accurate. She revealed when she finds erroneous information on the look back sheets she does not just follow that information or code the MDS with that wrong information and it was just an oversight on her part. She stated she expected the MDS assessments that are transmitted to be accurate and reflect the residents' true status at that time of doing the MDS assessments and transmitting the MDS assessments. 3. Record review revealed the facility admitted Resident #24 on 03/18/14 with diagnoses which included Alzheimer's Disease; Periodontal Disease; and Hypertension. Review of the Quarterly MDS, assessment dated [DATE], revealed the resident was rarely/never understood, therefore a Brief Interview for Mental Status (BIMS) was not completed. Observation with the Speech Therapist on 11/21/18 at 12:52 PM revealed Resident #24's top teeth had missing and broken teeth and the resident's bottom teeth were difficult to observe but appeared to be unclean. However, further review of the 08/10/18 Quarterly MDS assessment revealed Section L - Oral/Dental Status section had not been completed. There were no check marks indicating Resident #24 had dental issues. The appropriate coding would have been a check mark for items 'L0200A', indicating broken or loosely fitting full or partial denture (chipped, cracked, unclean, or loose) and 'L0200D', indicating obvious or likely cavity or broken natural teeth. Review of the Comprehensive Care Plan, revised 02/04/16, revealed Resident #24 had his/her natural teeth with several missing with #30 broken at the gumline. Interview with MDS Coordinator #1 on 11/21/18 at 1:36 PM revealed she is responsible for completing the MDS assessments for Resident #24. She stated she did not realize Section L had not been completed for the 08/10/18 Quarterly assessment and it must have been missed when completing the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, it was determined the facility failed to complete a recapitulation of the resident's stay for one (1) of three (3) closed records reviewed (Resident #102). Resident #102 was discharged home on [DATE]; however, there was no documented evidence a recapitulation of stay was completed. The findings include: Interview with the facility Medical Records Director on 11/21/18 at 09:20 AM, revealed the facility did not have a specific policy on discharge summaries/recapitulation of stay and they follow the federal regulations. Record review revealed the facility admitted Resident #102 on 08/09/18 and discharged the resident to home on [DATE]. Further review of this resident's closed record, revealed no evidence a recapitulation of stay for Resident #102 had been completed. Interview with the facility Medical Records Director on 11/21/18 at 8:35 AM, revealed they were unable to find a recapitulation of stay for Resident #102. She stated she was unaware of the requirement for a recapitulation of stay to be done for residents who discharge to the community/home. Interview with facility Administrator on 11/28/18 at 1:56 PM, revealed he expected the recapitulation of stay to be completed according to the federal guidelines for residents discharging to the community/home.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure that residents obtain routine dental services for one (1) of twenty-four (24) sampled residents (Resident #24). Record review revealed Resident #24's last dental exam was on 08/02/17, over one (1) year from annual survey date. The findings include: Review of the facility policy titled Dental Services, last revised 10/04/17, revealed all residents have both routine and emergent dental services available to them to address oral health and hygiene in order to prevent systemic disease and promote quality of life. All residents receive oral evaluation at least annually, with consent of resident/resident representative, by facility contracted dentist or outside resource if requested or required. Routine dental visits include but not limited to examination of oral cavity for signs of disease, dental radiographs if needed, dental cleaning both preventative and therapeutic if needed, temporary and permanent fillings as needed, fitting and impressions for dentures/partials, uncomplicated extractions, referrals to outside dental services if necessary. Record review revealed the facility admitted Resident #24 on 03/18/14 with diagnoses which included Alzheimer's Disease; Periodontal Disease; and Hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/10/18, revealed the facility assessed Resident #24 was rarely/never understood, therefore a Brief Interview for Status (BIMS) was not completed, which indicated the Resident was not interviewable. Further review of the MDS revealed the resident required total care for personal hygiene. Review of the Physician's Order Summary for November, 2018, revealed May see Dentist, Podiatrist, Optometrist, Ophthalmologist, Dermatologist, Psychiatrist of choice. Review of dental notes from the facility contracted agency revealed Resident #24 received a comprehensive dental exam and prophylaxis cleaning on 08/02/17; however, further review of the record revealed was no documented evidence a dental exam had been completed for 2018 per policy and federal regulation. Observation on 11/21/18 at 12:52 PM revealed Resident #24's top teeth had missing and broken teeth. The resident's bottom teeth were difficult to observe but appeared to be unclean. The Speech Therapist was assisting in asking the resident to open his/her mouth, but the resident was unable to follow commands. Interview with the Speech Therapist (ST) on 11/21/18 at 12:52 PM, revealed Resident #24 was not having difficulty eating/chewing. The ST stated that the Medical Records Clerk was responsible for setting up routine dental visits, but if it is an emergent situation, nursing arranges exams. Interview with the Medical Records Clerk on 11/21/18 at 1:13 PM revealed the contract dentist visits the facility every eight (8) to ten (10) weeks. She stated the contractor provides a list of residents that will be seen on the next visit and she ties to follow up and reconcile the list to assure everyone is seen in a timely manner. She revealed Resident #24 was over looked when his/her annual exam was due. Interview with the Administrator on 11/21/18 at 2:17 PM revealed he expected all residents to receive annual dental care per facility policy.

Based on interview, record review, review of restorative log, and review of facility policy, it was determined the facility failed to ensure thirteen (13) of twenty-four (24) sampled residents' Comprehensive Care Plans were implemented related to restorative services (Residents #2, #14, #20, #31, #32, #35, #44, #54, #55, #62, #81, #88, and #92) . Interviews with Registered Nurse (RN) #1 and RN #2 revealed there were fifty-six (56) residents on the facility's restorative program roster. Review of the Care Plans and October and November 2018 Restorative Service logs for Resident #2, #14, #20, #31, #32, #35, #44, #54, #55, #62, #81, #88, and #92 and remaining forty-three (43) residents' who were also on the Restorative Program revealed the residents did not receive restorative services two (2) to five times a week from 10/28/18-11/17/18 (three (3) weeks) . The findings include: Review of the facility policy titled Comprehensive Care Plan, last revised 02/10/15, revealed residents receive care and treatment based on an assessment of their needs, the severity of their diagnosis or disease, condition, impairment or disability. The data obtained from the assessment is used to determine and prioritize the resident's comprehensive care plan. The nurse overseeing the resident's care will complete and implement the initial care plan. The interdisciplinary team (IDT) and or Minimum Data Set (MDS) Coordinator will review and finalize the care plan for continued provision of care. The plan is based upon: Assessment by licensed nursing, current orders including therapy, history and physical, Physician and consultant notes, condition of the resident, documented individualized care, and other relevant documentation that relates to the care of the resident. The development, implementation, and maintenance of a resident's care plan is an interdisciplinary process. 1. Record review revealed the facility admitted Resident #2 on 09/03/16 with diagnoses which included Quadriplegia, unspecified, abnormal posture, and Sequelae of other Cerebrovascular Disease. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/13/18, revealed the facility assessed Resident #2's cognition as intact which indicated the resident was interviewable. Review of the Comprehensive Care Plan for At Risk for Actual Contractures and/or Limited Range of Motion , dated 06/13/17 revealed interventions for Passive Range of Motion (PROM) to bilateral upper extremities (BUE), two (2) sets of fifteen (15) repetitions daily equal to or greater than fifteen (15) minutes. However, review of the Restorative Service Log for October and November, 2018, revealed Resident #2 received restorative services four days a week for three (3) weeks from October 28, 2018 through November 17, 2018 instead of daily (seven {7} days a week) as care planned. 2. Record review revealed the facility admitted Resident #14 on 08/07/15 with diagnoses which included Chronic Pain, Muscle Wasting and Atrophy, History of Falling, and Muscle Weakness. Review of the Annual MDS assessment, dated 08/14/18, revealed the facility assessed Resident #14's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, dated 06/05/17 and 07/09/18 revealed interventions for Active ROM to BUE one (1) set of 75 repetitions daily with one (1) pound weight; at least six (6) out of seven (7) days; and splint/brace to bilateral lower extremities (BLE) to be donned after stretching of BLE, leave brace on for eight (8) hours of duration daily. However, review of the Restorative Service Logs for October and November, 2018, revealed the resident received restorative services two (2) days the week of 10/28/18 and four (4) days the week of 11/04/18, instead of six (6) days a week and daily as care planned. 3. Record review revealed the facility admitted Resident #31 on 11/15/17 with diagnoses which included Abnormal Posture, Reduced Mobility, and History of Falling. Review of the Quarterly MDS assessment, dated 09/06/18, revealed the facility assessed Resident #31's cognition as severely impaired as he/she rarely or never understood and was unable to complete a BIMS assessment. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, dated 02/19/18, revealed interventions for passive ROM to BLE, two (2) sets of twenty (20) repetitions daily. However, review of the Restorative Services Logs for October and November, 2018, revealed Resident #31 received services four (4) or five (5) days days for three (3) weeks from October 28, 2018 to November 17, 2018 instead of daily as care planned. 4. Record review revealed the facility admitted Resident #44 on 02/05/18 with diagnoses which included History of Falling, and Primary Generalized Osteoarthritis. Review of the Annual MDS assessment, dated 09/20/18, revealed the facility assessed Resident #44's cognition as severely impaired with a BIMS score of three (3) which indicated the Resident was not interviewable. Review of the Comprehensive Care Plan for self care deficits, dated 12/12/17 revealed interventions to cue/prompt/assist self feeding equal to or greater than fifteen (15) minutes for meals six (6) out of seven (7) days per week; at least six (6) out of seven (7) days. Review of a Care Plan for At Risk for Contractures and/or Limited Range of Motion, with interventions for passive ROM to BUE twenty (20) repetitions for one (1) set, once daily, equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days a week. However, review of the Restorative Service Logs for October and November, 2018, revealed Resident #44 received restorative services four (4) days the week of 10/28/18 and five (5) days the following two (2) weeks instead of six (6) days a week as care planned. 5. Record review revealed the facility admitted Resident #62 on 04/03/17 with diagnoses which included Generalized Muscle Weakness, History of Falling and Major Depressive Disorder. Review of the Quarterly MDS assessment,, dated 10/11/18, revealed the facility assessed Resident #62's cognition as severely impaired with a BIMS score of four (4) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan for self care deficits with bed mobility, dated 08/24/18 revealed interventions to cue/prompt/assist resident for bed mobility, at least six (6) out of seven (7) days. Review of a Care Plan for At Risk for Contractures and/or Limited Range of Motion, dated 10/16/17 revealed interventions for active ROM to BUE and bilateral lower extremities (BLE) twenty (20) repetitions for one (1) set equal to or greater than fifteen (15) minutes once daily, six (6) out of seven (7) days a week. However, review of the Restorative Service Logs for October and November, 2018, revealed Resident #44 received restorative services three (3) days a week from 10/28/18 to 11/10/18 (two weeks) and four (4) days the following week instead of six (6) days a week as care planned. 6. Record review revealed the facility admitted Resident #54 on 02/24/14 with diagnoses which included Cerebral Palsy and Hypertension. Review of the Quarterly MDS assessment, dated 10/03/18, revealed the facility assessed Resident #54's cognition as intact with a BIMS score of thirteen (13) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, last revised 11/05/18 revealed interventions for active ROM to BLE two (2) sets of ten (10) repetitions all planes as tolerated by the resident daily equal to or greater than fifteen (15) minutes for at least six (6) out of seven (7) days. However, review of the Restorative Service Log for November, 2018 revealed the resident received restorative services four days the first week and five (5) days the second week of November instead of six (6) days as care planned. 7. Record review revealed the facility admitted Resident #55 on 09/05/18 with diagnoses which included Parkinson's Disease, Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of the admission MDS assessment, dated 09/12/18, revealed the facility assessed Resident #55's cognition as severely impaired with a BIMS score of eight (8) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for impaired physical mobility, initiated 11/05/18, revealed an intervention to ambulate (200 feet) with assistance of one (1) with rolling walker daily. However, review of the Restorative Services Log for November, 2018, revealed the resident received restorative services four days the first and second weeks after restorative therapy was initiated instead of daily as care planned. 8. Record review revealed the facility admitted Resident #32 on 12/01/17 with diagnoses which included Chronic Kidney Disease, Stage 4, Hypertension, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/07/18, revealed the facility assessed Resident #32's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for self care deficits in dressing/grooming , last revised on 02/19/18 revealed an intervention to cue/prompt/assist resident to brush hair and teeth daily. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, revealed an intervention for active ROM to BUE with two (2) pound weight, one (1) set of twenty (2) repetitions daily. However, review of the Restorative Services Logs for October and November, 2018, revealed the resident received restorative services three (3) days the week of 10/28/18, four (4) days the week of 11/04/18, and six (6) days the week of 11/11/18; instead of daily as care planned. 9. Record review revealed the facility admitted Resident #35 on 05/19/18 with diagnoses which included Nonalcoholic Seatohepatitis, Anemia, and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. Review of the admission MDS assessment, dated 09/27/18, revealed the facility assessed Resident #35's cognition as intact with a BIMS score of fourteen (14) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, last revised 09/26/18, revealed an intervention to provide active ROM to BLE, knee flexion/extension and ankle mobility two (2) sets of fifteen (15) repetitions daily. However, review of the Restorative Services Logs for October and November, 2018, revealed the resident received restorative services two (2) days the week of 10/28/18, four (4) days the week of 11/04/18, and six (6) days the week of 11/11/18; instead of daily as care planned. 10. Record review revealed the facility admitted Resident #20 on 05/19/16 with diagnoses which included Type 2 Diabetes Mellitus; Major Depressive Disorder; and obesity. Review of the Quarterly MDS assessment, dated 08/24/18, revealed the facility assessed Resident #20's cognition as severely impaired with a BIMS score of two (2) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, last revised on 02/22/17, revealed an interventions for active ROM to RUE twenty (20) repetitions, one (1) set equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days per week; passive ROM to left upper extremity (LUE) one (1) set of twenty (20) repetitions daily equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days per week; and splint/brace to LUE six (6) hours daily. However, review of the Restorative Services Logs for October and November, 2018, revealed Resident #20 received restorative services four (4) days the weeks of 10/28/18 and 11/04/18; and five (5) days the week of 11/11/18; instead of six (6) days as care planned . 11. Record review revealed the facility admitted Resident #81 on 01/25/18 with diagnoses which included Alzheimer's Disease, Chronic Pain, and Hypertension. Review of the Quarterly MDS assessment, dated 10/23/18, revealed the facility assessed Resident #81's cognition as severely impaired as the resident was rarely or never understood and the BIMS assessment was not completed. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, last revised 11/21/18, revealed an intervention for passive ROM to BUE twenty (20) repetitions equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days per week. However, further review of the logs revealed the resident received restorative services two (2) days the week of 10/28/18; three (3) days the week of 11/04/18; and four (4) days the week of 11/11/18; instead of six (6) days a week as care planned. 12. Record review revealed the facility admitted Resident #88 on 02/23/16 with diagnoses which included Alzheimer's Disease, Anemia, and Age Related Osteoporosis. Review of the Quarterly MDS assessment, dated 10/25/18, revealed the facility assessed Resident #88's cognition as severely impaired as he/she was unable to complete the BIMS assessment due to being rarely or never understood, therefore, the resident was not interviewable. Review of the Comprehensive Care Plan for self care deficit of dressing/grooming and inability to convey food into mouth, last revised 06/07/17, revealed interventions to cue/prompt/assist resident to brush hair and teeth and dress upper and lower extremities daily, equal to or greater than fifteen (15) minutes, six (6) out of seven (7) days per week. Further review revealed to provide verbal cues with meals allowing resident to do as much for self as possible with an acceptable amount of time then assist, encourage resident to stay at table, check mouth frequently for pocketing foot equal to or greater than fifteen (15) minutes six (6) out of seven (7) days per week. However, review of the Restorative Services Logs for October and November, 2018, revealed Resident #88 received restorative nursing services four (4) days the week of 10/28/18 and five (5) days the week of 11/04/18, instead of six (6) days a week as care planned. 13. Record review revealed the facility admitted Resident #92 on 05/08/18 with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left non-dominant side. Review of the Quarterly MDS assessment, dated 10/26/18, revealed the facility assessed Resident #92's cognition as intact with a BIMS score of fourteen (14) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, , initiated on 06/18/18, revealed an interventions for a splint/brace to left upper hand six (6) hours daily, remove every two (2) hours to check for circulation, skin condition and to reposition, six (6) out of seven (7) days per week; and passive ROM to LUE, gentle ROM fifteen (15) repetitions daily equal to or greater than fifteen (15) minutes six (6) out of seven (7) days per week. However, review of the Restorative Services Logs for October and November, 2018, revealed the resident received restorative nursing services three (3) days the week of 10/28/18 and 11/04/18; and four (4) days the week of 11/11/18 instead of six (6) days as care planned. In addition, review of the Comprehensive Care Plans and Restorative Service Logs for the other forty-two (42) residents in the restorative program revealed the Restorative Services were not provided two (2) to five (5) days out of six (6) to seven (7) days a week from 10/28/18-11/17/18 (three (3) weeks). Interviews on 11/21/18 with Restorative Aide (RA) #2 at 8:41 AM, RA #3 at 8:48 AM, RA #4 at 1:18 PM, and RA #1 at 8:00 AM revealed RA #2, RA #3, and RA #4 are not able to follow the care plan for restorative services everyday because they are pulled from restorative services frequently to work the floor as nursing assistants or to go out to doctor's appointments with a resident. RA #1 stated she works for the therapy department so cannot be pulled to the floor so she provides restorative services when the other aides get pulled. She stated she primarily provides walking services, applies splints and completes assessments, and attempts to provide programs to other residents when the RA's are pulled but cannot get all the work done when it is just her providing restorative services. Interview with the MDS Coordinator, Restorative Supervisor, RN #1, on 11/21/18 at 8:10 AM revealed she and RN #2 are responsible for the Restorative Program. She stated due to the restorative staff being pulled frequently, the restorative care had not been provided consistently. RN #1 revealed she expected the care plans to be followed as written. Interview with the Director of Nursing (DON) on 11/28/18 at 11:36 AM revealed she is not responsible for the Restorative Program or the Restorative care plans what-so-ever. She stated the MDS Coordinators, RN #1 and RN #2, are responsible for that program and she expected the care plans to be followed as written.

Based on interview, record review, review of restorative logs, and review of facility policy, it was determined the facility failed to ensure three (3) of three (3) residents in the restorative nursing program for Activities of Daily Living (ADL's) of twenty-four (24) sampled residents received the care and services to ensure that a resident's abilities in Activities of Daily Living (ADL's) are maintained or improved (Residents #32, #55, and #88). Review of the Restorative Services logs for October and November 2018, for Residents #32, Resident #88, Resident #55 and the remaining twenty-eight (28) residents who were also in the facility Restorative Program for ADL's, revealed the staff failed to provide restorative services two (2) to five (5) days out of six (6) to seven (7) days a week from 10/28/18-11/17/18 (three (3) weeks). The findings include: Interview with the Administrator on 11/21/18 at 10:46 AM revealed the facility does not have a Restorative policy, but refers to the Resident Assessment Instrument (RAI) Manual for provision of care. He further stated physician's orders are not written for restorative care, the services are provided according to Restorative Nursing Care Referral form completed by the therapy department when the resident is discharged from their therapy program. 1. Record review revealed the facility admitted Resident #32 on 12/01/17 with diagnoses which included Chronic Kidney Disease, Stage 4, Hypertension, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/07/18, revealed the facility assessed Resident #32's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of the Restorative Nursing Care Referral dated 01/23/18, revealed Resident #32 was to receive hygiene and grooming tasks. Review of the Comprehensive Care Plan, last revised on 02/19/18 revealed Resident #32 had self care deficits in dressing/grooming related to decreased independence with grooming with an intervention to cue/prompt/assist resident to brush hair and teeth daily. Review of the Restorative Services Logs for October and November 2018, revealed staff were to cue/prompt/assist resident to brush hair and teeth daily. However, further review revealed the resident received restorative services three (3) of seven (7) days the week of 10/28/18; four (4) of seven (7) days the week of 11/04/18; and six (6) of seven (7) days the week of 11/11/18. 2. Record review revealed the facility admitted Resident #88 on 02/23/16 with diagnoses which included Alzheimer's Disease, Anemia, and Age Related Osteoporosis. Review of the Quarterly MDS assessment, dated 10/25/18, revealed the facility assessed Resident #88's cognition as severely impaired as he/she was unable to complete the BIMS assessment due to being rarely or never understood, therefore, the resident was not interviewable. Further review of the MDS revealed the resident required limited assistance of one (1) staff with eating and dressing; and, extensive assistance with two (2) staff for grooming. Review of the Comprehensive Care Plan, last revised 06/07/17, revealed Resident #88 had a self care deficit of dressing/grooming and inability to convey food into mouth related to impaired cognition and decreased independence with eating. Further review revealed interventions to cue/prompt/assist resident to brush hair and teeth. Dress upper and lower extremities daily, equal to or greater than fifteen (15) minutes, six (6) out of seven (7) days per week; provide verbal cues with meals allowing resident to do as much for self as possible with an acceptable amount of time then assist, encourage resident to stay at table, check mouth frequently for pocketing foot equal to or greater than fifteen (15) minutes six (6) out of seven (7) days per week. Review of the Restorative Nursing Care Referral, dated 07/27/17, revealed Resident #88 was to receive verbal cuing and redirection as needed during meals to encourage independent self feeding. Review of the Restorative Services Logs for October and November 2018, revealed staff were to cue/prompt/assist resident to brush hair and teeth and with dressing daily, six (6) out of seven (7) days per week; and provide verbal cues with meals six (6) out of seven (7) days per week. However, further review revealed the resident received restorative nursing services four (4) of six (6) days the week of 10/28/18 and five (5) of six (6) days the week of 11/04/18. 3. Record review revealed the facility admitted Resident #55 on 09/05/18 with diagnoses which included Parkinson's Disease, Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of the admission MDS assessment, dated 09/12/18, revealed the facility assessed Resident #55's cognition as severely impaired with a BIMS score of eight (8) which indicated the resident was not interviewable. Further review of the MDS revealed the resident required limited assistance to extensive assistance with ADL's. Review of the Restorative Nursing Care Referral dated 10/12/18 revealed Resident #55 was to receive ambulation assistant up to 200 feet to maintain current functional mobility five (5) times per week, daily. Review of the Comprehensive Care Plan, initiated 11/05/18, revealed Resident #55 had impaired physical mobility related to decreased ambulation with an interventions to ambulate 200 feet with assistance of one (1) with rolling walker daily. Review of the Restorative Services Logs for November 2018, revealed Resident #55 was to ambulate 200 feet daily. However, further review revealed restorative services began on 11/05/18, over three (3) weeks after the referral date and the resident received restorative services four (4) of seven (7) days the first and second weeks after restorative therapy was initiated. In addition, review of the Restorative Service Logs for the remaining twenty-eight (28) sampled residents' in the restorative program for eating, ambulation and transfers revealed staff failed to provide restorative services two (2) to five (5) days out of six (6) to seven (7) days a week from 10/28/18-11/17/18 (three (3) weeks). Interviews on 11/21/18 with Restorative Aide (RA) #2 at 8:41 AM, RA #3 at 8:48 AM, and RA #4 at 1:18 PM, they are pulled from restorative services frequently to work the floor as nursing assistants or to go out to doctor's appointments with a resident. They stated they are pulled from restorative on average one (1) to two (2) times per week and weekends were the worse for getting pulled out of restorative services, because of a lot of call ins. They stated when they are pulled to the floor the remaining RA's are unable to complete the Restorative care. Interview with RA #1 on 11/21/18 at 8:00 AM revealed she is a restorative aide but is employed through the therapy department, so she cannot get pulled to work the floor as a nurse assistant. She stated she works five (5) days a week. RA #1 stated she provides restorative services when other aides get pulled. She revealed stated she primarily provides walking services, applies splints and completes assessments, but will attempt to provide programs to other residents when the RA's are pulled but cannot get all the work done when it is just her providing restorative services. Interviews on 11/21/18 with RN #1, Restorative Supervisor at 8:10 AM and RN #2, Restorative Supervisor at 9:25 AM revealed restorative aides are often pulled to fill certified nurse Aide (CNA) spots when there are call-ins or residents have doctor's appointments. They stated they expected the RA's to provide restorative care to their assigned residents when they are pulled to the floor. RN #2 stated RA #1 was out on surgical leave for a few weeks the end of October and returned in early November, 2018. RN#1 stated they monitor the restorative logs to ensure services were being provided, but they had not reviewed the logs recently. Interview with Therapy Director on 11/21/18 at 9:45 AM revealed there is a potential for decline when residents are only receiving restorative therapy four (4) to five (5) times per week. Interview with the Administrator on 11/21/18 at 10:17 AM revealed prior to survey date, nothing had been implemented to identify and assess residents for potential declines in ADL's. He stated the facility's process is if a CNA sees a decline in resident function, it should be reported to the charge nurse and the charge nurse reports it to the therapy department, and notifies the physician for orders to evaluate and treat the resident. The Administrator revealed he knew there were holes in the provision of care, but was not aware how many because he had not reviewed the logs either. He further stated there was no plan or back up system in place to assure restorative services were provided prior to this annual survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of restorative logs, and review of facility policy, it was determined the facility failed to ensure eleven (11) of eleven (11) residents receiving restorative services for range of motion (ROM)/mobility of twenty-four (24) sampled residents, received appropriate treatment and services to increase range of motion/mobility and/or to prevent further decrease in range of motion/mobility (Residents #2, #14, #31, #44, #62, #54, #32, #35, #20, #81, and #92). Review of the Restorative Services logs for October and November 2018, for Residents #2, #14, #31, #44, #62, #54, #32, #35, #20, #81, and #92 and the remaining thirty-nine (39) residents who were also in the facility Restorative Program for ROM/mobility, revealed the staff failed to provide restorative services two (2) to five (5) days out of six (6) to seven (7) days a week from 10/28/18-11/17/18 (three (3) weeks). The findings include: Interview with the Administrator on 11/21/18 at 10:46 AM revealed the facility does not have a Restorative policy, but refers to the Resident Assessment Instrument (RAI) Manual for provision of care. He further stated physician's orders are not written for restorative care, the services are provided according to Restorative Nursing Care Referral form completed by the therapy department when the resident is discharged from their therapy program. 1. Record review revealed the facility admitted Resident #2 on 09/03/16 with diagnoses which included Quadriplegia, unspecified, abnormal posture, and Sequelae of other Cerebrovascular Disease. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #2's cognition as intact which indicated the resident was interviewable. Further review of the MDS revealed the resident had functional limitations in range of motion (ROM) in bilateral upper and lower extremities. Review of the Restorative Nursing Care Referral, dated 12/21/16, revealed Resident #2 was to receive restorative care six (6) times per week with bilateral elbow orthotics donned for three (3) to four (4) hours daily and range of motion (ROM) to bilateral upper extremities (BUE), especially shoulders for assisted active range of motion (AAROM) all planes two (2) sets of fifteen (15). Review of the Comprehensive Care Plan, dated 06/13/17 revealed Resident #1 was At Risk for Actual Contractures and/or Limited Range of Motion related to Decreased Range of Motion with interventions which included Passive Range of Motion (PROM) to BUE two (2) sets of fifteen (15) repetitions daily equal to or greater than fifteen (15) minutes. Review of the Restorative Service Log for October and November, 2018, revealed Resident #2 was to receive passive ROM to BUE two (2) sets of fifteen (15) repetitions daily, equal to or greater than fifteen (15) minutes. However, further review of the logs revealed the resident received restorative services four (4) of seven (7) days each week for three (3) weeks from October 28, 2018 through November 17, 2018. 2. Record review revealed the facility admitted Resident #14 on 08/07/15 with diagnoses which included Chronic Pain, Muscle Wasting and Atrophy, History of Falling, and Muscle Weakness. Review of the Annual MDS assessment, dated 08/14/18, revealed the facility assessed Resident #14's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS revealed the resident had functional limitations in ROM to one side of upper extremities and bilateral lower extremities. Review of the Restorative Nursing Care Referrals, dated 06/23/16 and 07/04/18 revealed Resident #14 was to receive bilateral lower extremity (BLE) brace application after stretching of BLE. Leave brace on for one (1) hour and begin to increase in hour increments week by week until achieving six (6) to eight (8) hours duration, five (5) times per week. The resident was to also receive BLE exercises to increase flexibility and strength five (5) times per week. Review of the Comprehensive Care Plans, dated 06/05/17 and 07/09/18 revealed Resident #14 was At Risk for Contractures and/or Limited Range of Motion Related to Decreased Mobility and Requiring Splint/Brace Application. Further review revealed Interventions for Active ROM to BUE one (1) set of 75 repetitions daily with one (1) pound weight; Minimum requirements state that the resident have at least two (2) restorative services provided for a minimum of fifteen (15) minutes, at least six (6) out of seven (7) days; and splint/brace to BLE to be donned after stretching of BLE, leave brace on for eight (8) hours of duration daily. Review of the Restorative Service Logs for October and November 2018, revealed Resident #14 was to receive active ROM to BUE one (1) set of seventy-five (75) repetitions daily; passive ROM to BLE two (2) sets for thirty (30) repetitions daily; and splint/brace to BLE to be donned after stretching daily. However, further review of the logs revealed the resident received restorative services only two (2) of seven (7) days the week of 10/28/18 and four (4) of seven (7) days the week of 11/04/18. 3. Record review revealed the facility admitted Resident #31 on 11/15/17 with diagnoses which included Abnormal Posture, Reduced Mobility, and History of Falling. Review of the Quarterly MDS assessment, dated 09/06/18, revealed the facility assessed Resident #31's cognition as severely impaired as he/she rarely or never understood and was unable to complete a BIMS assessment. Further review of the MDS revealed the resident had functional limitations in ROM in bilateral upper and lower extremities. Review of the Restorative Nursing Care Referral, dated 01/31/18, revealed Resident #31 was to receive BLE ROM/stretches, heel slides, hip abduction and adduction ten (10) to fifteen (15) repetitions five (5) times per week. Review of the Comprehensive Care Plan, dated 02/19/18, revealed Resident #31 was at risk for contractures and/or limited ROM related to decreased mobility with interventions for passive ROM to BLE, two (2) sets of twenty (20) repetitions daily. Review of the Restorative Services Logs for October and November 2018, revealed Resident #31 was to received restorative services for passive ROM to BLE two (2) sets of twenty (20) daily. However, further review of the logs revealed the resident received services four (4) to five (5) days per week from October 28, 2018 to November 17, 2018. 4. Record review revealed the facility admitted Resident #44 on 02/05/18 with diagnoses which included History of Falling, and Primary Generalized Osteoarthritis. Review of the Annual MDS assessment, dated 09/20/18, revealed the facility assessed Resident #44's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Further review of the MDS revealed the resident had no functional limitations in ROM. Review of the Comprehensive Care Plans, dated 12/12/17 revealed Resident #44 was at risk for actual contracture and/or limited ROM related to decreased ROM and impaired cognition with interventions of passive ROM to BUE twenty (20) repetitions for one (1) set, once daily, equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days a week. Review of the Restorative Service Logs for October and November 2018, revealed Resident #44 was to receive Passive ROM to BUE six (6) out of seven (7) days a week. However, further review of the logs revealed the resident received restorative services four (4) of six (6) days the week of 10/28/18 and five (5) of six (6) days each week the following two (2) weeks. 5. Record review revealed the facility admitted Resident #62 on 04/03/17 with diagnoses which included Generalized Muscle Weakness, History of Falling and Major Depressive Disorder. Review of the Quarterly MDS, assessment, dated 10/11/18, revealed the facility assessed Resident #62's cognition as severely impaired with a BIMS score of four (4) which indicated the resident was not interviewable. Further review of the MDS revealed the resident required extensive assistance with two (2) staff for bed mobility and the resident had no functional limitations in ROM Review of the Restorative Nursing Care Referral, dated 08/23/18, revealed Resident #62 was to receive active assisted ROM/passive ROM to BUE with gentle stretch to elbows and all joints; and active assisted ROM to all joints of BLE. No recommendations were made as to the frequently of care. Review of the Comprehensive Care Plans dated 08/24/18 and 10/16/17 revealed Resident #44 had self care deficits with bed mobility related to decreased mobility and decreased strength. Further review revealed interventions to cue/prompt/assist resident for bed mobility, roll side to side in bed, equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days; Minimum requirements state the resident have at lease two (2) restorative services, provided a minimum of fifteen (15) minutes per twenty-four (24) hours, at least six (6) out of seven (7) days. Additionally, further review revealed Resident #44 was at risk for actual contracture and/or limited ROM related to decreased ROM and impaired cognition with an interventions for active ROM to BUE and BLE twenty (20) repetitions for one (1) set equal to or greater than fifteen (15) minutes once daily, six (6) out of seven (7) days a week. Review of the Restorative Service Logs for October and November 2018, revealed Resident #44 was to receive active ROM to BUE and BLE six (6) out of seven (7) days a week and cue/prompt/assist resident with bed mobility six (6) out of seven (7) days. However, further review of the logs revealed the resident received restorative services only three (3) of six (6) days each week from 10/28/18 to 11/10/18 and four (4) of six (6) days the following week. 6. Record review revealed the facility admitted Resident #54 on 02/24/14 with diagnoses which included Cerebral Palsy and Hypertension. Review of the Quarterly MDS assessment, dated 10/03/18, revealed the facility assessed Resident #54's cognition as intact with a BIMS score of thirteen (13) which indicated the resident was interviewable. Further review of the MDS revealed had functional limitations in ROM to bilateral upper and lower extremities. Review of the Restorative Nursing Care Referral dated 10/26/18 revealed Resident #54 was to receive complete Active ROM to BLE two (2) sets of ten (10) repetitions in all planes as tolerated. Review of the Comprehensive Care Plan, last revised 11/05/18 revealed Resident #54 was at risk for actual contracture and/or limited ROM related to decreased ROM with an intervention for active ROM to BLE two (2) set of ten (10) repetitions all planes as tolerated by the resident daily equal to or greater than fifteen (15) minutes for at least six (6) out of seven (7) days. Review of the Restorative Service Log for November 2018 revealed Resident #54 was to receive active ROM to BLE daily equal to or greater than fifteen (15) minutes for at least six (6) of seven (7) days. However, further review of the log revealed restorative services did not begin until 11/05/18, ten (10) days after the referral date and the resident received restorative services four (4) of six (6) days the first week and five (5) of six (6) days the second week of November. 7. Record review revealed the facility admitted Resident #32 on 12/01/17 with diagnoses which included Chronic Kidney Disease, Stage 4, Hypertension, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Quarterly MDS assessment, dated 09/07/18, revealed the facility assessed Resident #32's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS revealed the resident had functional limitations in ROM to bilateral lower extremities. Review of the Restorative Nursing Care Referral dated 01/23/18, revealed Resident #32 was to receive BUE exercise with two (2) pound weight in all planes. Review of the Comprehensive Care Plan, last revised on 02/19/18 revealed Resident #32 was at risk for actual contracture and/or limited range of motion related to decreased mobility with an intervention for active ROM to BUE with two (2) pound weight, one (1) set of twenty (2) repetitions. Review of the Restorative Services Logs for October and November, 2018, revealed Resident #32 was to receive active ROM to BUE with two (2) pounds weight daily; however, further review of the logs revealed the resident received restorative services three (3) of seven (7) days the week of 10/28/18; four (4) of seven (7) days the week of 11/04/18; and six (6) of seven (7) days the week of 11/11/18 8. Record review revealed the facility admitted Resident #35 on 05/19/18 with diagnoses which included Nonalcoholic Seatohepatitis, Anemia, and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. Review of the admission MDS assessment, dated 09/27/18, revealed the facility assessed Resident #35's cognition as intact with a BIMS score of fourteen (14) which indicated the resident was interviewable. Further review of the MDS revealed the resident required extensive to total care with all ADL's, was non-ambulatory and had no functional limitations in ROM. Review of the Restorative Nursing Care Referral dated 09/24/18 revealed Resident #35 was to received active ROM to BLE, hip flexion, knee flexion/extension and ankle mobility, five (5) times per week. Review of the Comprehensive Care Plan, revised on 09/26/18, revealed Resident #35 was at risk for actual contracture and/or limited ROM related to acute illness, decreased ROM, decreased cognition with an interventions for active ROM to BLE, knee flexion/extension and ankle mobility two (2) sets of fifteen (15) repetitions daily. Review of the Restorative Services Logs for October and November, 2018, revealed Resident #35 was to receive active ROM to BLE hip, knee flexion/extension and ankle mobility daily. However, further review of the logs revealed the resident received restorative services two (2) of seven (7) days the week of 10/28/18; four (4) of seven (7) days the week of 11/04/18, and six (6) of seven (7) days the week of 11/11/18. 9. Record review revealed the facility admitted Resident #20 on 05/19/16 with diagnoses which included Type 2 Diabetes Mellitus; Major Depressive Disorder; and obesity. Review of the Quarterly MDS assessment, dated 08/24/18, revealed the facility assessed Resident #20's cognition as severely impaired with a BIMS score of two (2) which indicated the resident was not interviewable. Further review of the MDS revealed the resident had functional limitation in ROM to one (1) side upper extremity. Review of the Restorative Nursing Care Referral dated 02/10/17, revealed Resident #20 was to receive gentle stretch to left hand; active assisted ROM to BUE all joints and bilateral hands; blue hand orthotic with finger separating six (6) hours daily. Review of the Comprehensive Care Plan, last revised on 02/22/17, revealed Resident #20 was at risk for actual contracture and/or limited ROM related to progressive bulbar palsy, and decreased ROM. Further review revealed interventions for active ROM to RUE twenty (20) repetitions, one (1) set equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days per week; passive ROM to left upper extremity (LUE) one (1) set of twenty (20) repetitions daily equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days per week; splint/brace to LUE six (6) hours daily observe for redness, discolorations, increased temperature in extremities and expression or complains of pain during program procedures. Review of the Restorative Services Logs for October and November 2018, revealed Resident #20 was to receive active ROM to RUE daily six (6) of seven (7) days per week; passive ROM to LUE daily six (6) of seven (7) days per week; and splint/brace to LUE six (6) hours daily. However, further review of the logs revealed the resident received restorative services four (4) of six (6) days the weeks of 10/28/18 and 11/04/18; and five (5) of six (6) days the week of 11/11/18. 10. Record review revealed the facility admitted Resident #81 on 01/25/18 with diagnoses which included Alzheimer's Disease, Chronic Pain, and Hypertension. Review of the Quarterly MDS assessment, dated 10/23/18, revealed the facility assessed Resident #81's cognition as severely impaired as the resident was rarely or never understood and the BIMS assessment was not completed. Further review of the MDS revealed the resident had functional limitations in ROM to bilateral upper and lower extremities. Review of the Restorative Nursing Care Referral, dated 02/05/18, revealed resident #81 was to receive passive ROM to BUE in all planes; apply blue resting hand splints to both hands for four (4) hours. Review of the Comprehensive Care Plan, revised on 11/21/18, revealed Resident #81 was at risk for actual contracture and/or limited ROM related to decreased ROM, impaired cognition with an intervention for passive ROM to BUE twenty (20) repetitions equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days per week. Review of the Restorative Services Logs for October and November 2018, revealed Resident #81 was to receive passive ROM to BUE six (6) of seven (7) days per week; and resting hand orthotics to BUE four (4) hours per day six (6) of seven (7) days per week. However, further review of the logs revealed the resident received restorative services two (2) of six (6) days the week on 10/28/18; three (3) of six (6) days the week of 11/04/18; and four (4) of six (6) days the week of 11/11/18. 11. Record review revealed the facility admitted Resident #92 on 05/08/18 with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left non-dominant side. Review of the Quarterly MDS assessment, dated 10/26/18, revealed the facility assessed Resident #92's cognition as intact with a BIMS score of fourteen (14) which indicated the resident was interviewable. Further review of the MDS revealed the resident had functional limitations in ROM to bilateral upper and lower extremities. Review of the Restorative Nursing Care Referral, dated 06/04/18, revealed Resident #92 was to receive gentle ROM with LUE; place blue resting hand splint for six (6) hours daily. Review of the Comprehensive Care Plan, initiated on 06/18/18, revealed Resident #92 was at risk for contracture and/or limited ROM requiring splint/brace application related to decreased ROM, contracture to left hand. Further review revealed interventions for splint/brace to left upper hand six (6) hours daily, remove every two (2) hours to check for circulation, skin condition and to reposition, six (6) out of seven (7) days per week; and, passive ROM to LUE, gentle ROM fifteen (15) repetitions daily equal to or greater than fifteen (15) minutes six (6) out of seven (7) days per week. Review of the Restorative Services Logs for October and November 2018, revealed the resident was to receive passive ROM to LUE six (6) of seven (7) days per week; and splint;/brace to left upper hand six (6) hours daily six (6) of seven (7) days per week. However, further review of the logs revealed the resident received restorative nursing services three (3) of six (6) days the week of 10/28/18 and 11/04/18; and, four (4) of six (6) days the week of 11/11/18. In addition, review of the Restorative Logs for the remaining thirty-nine (39) residents who were also in the restorative program for ROM/mobility revealed the staff failed to provide restorative services two (2) to five (5) days out of six (6) to seven (7) days a week from 10/28/18-11/17/18 (three (3) weeks). Interview with Restorative Aide (RA) #2 on 11/21/18 at 8:41 AM revealed restorative aides are pulled from restorative services frequently to work the floor as nursing assistants or to go out to doctor's appointments with a resident. RA #2 stated she was pulled from restorative an average of one (1) to two (2) times per week. She further revealed the weekends were the worse for getting pulled out of restorative services, because of a lot of call ins. RA #2 stated when she was pulled to work the floor, she could not always get the restorative program done. Interview with RA #3 on 11/21/18 at 8:48 AM revealed restorative aides are pulled to the floor to work as nursing assistants or to go out with residents for doctor's appointments quite often. She stated she was pulled to work the floor most weekends. RA #3 stated there is a restorative aide in the therapy department that does not get pulled (RA #1). RA #3 stated RA #1 does what she can to provide restorative services when the other RA's are pulled. Interview with RA #4 on 11/21/18 at 1:18 PM revealed some weeks she gets to provide restorative two (2) to three (3) times. RA #4 stated she often gets pulled from restorative to work the floor or go with residents to doctor's appointments. She stated most times one (1) restorative aide and the restorative aide from the therapy department are the only two (2) scheduled to provide restorative services. RA #4 stated there had been times when she was pulled to work the floor, and she was unable to provide restorative services. Interview with RA #1 on 11/21/18 at 8:00 AM revealed she is a restorative aide but is employed through the therapy department, so she cannot get pulled to work the floor as a nurse assistant. She stated she works five (5) days a week. RA #1 further stated she provided restorative services when other aides get pulled but she primarily provides walking services, applies splints, and completes assessments. She revealed she attempted to provide programs to other residents when the RA's were pulled but cannot get all the work done when it is just her providing restorative services. Interview with RN #1, Restorative Supervisor, on 11/21/18 at 8:10 AM revealed restorative aides are often pulled to fill certified nurse aide (CNA) spots when there are call-ins or residents have doctor's appointments. She stated when RA's are pulled to the floor as CNA's, she expected restorative services to be provided when daily care was provided. RN #1 stated I'm sure there has been a time when restorative care was not provided as it should be. RN #1 further stated RA #1 does not ever get pulled to the floor and is available to provide the needed services RN #1 revealed she reviewed the logs to assure services were being provided, but had not reviewed the logs recently. Interview with RN #2, Restorative Supervisor, on 11/21/18 at 9:25 AM revealed RA #1 was out on surgical leave for a few weeks the end of October and returned in early November, 2018. She stated RA's are pulled often to work the floor, at least a couple times per week and she expected the RA's to provide restorative care to their assigned residents when they are pulled to the floor. She further stated she expected restorative services to be provided the way it is supposed to be and according to the care plan. Interview with the Assistant Director of Nursing (ADON) on 11/21/18 at 9:08 AM revealed restorative aides are pulled to the floor when there are staffing issues. The ADON stated when restorative aides are pulled to the floor, it is her expectation that the restorative program is completed while providing activities of daily living care. Interview with Therapy Director on 11/21/18 at 9:45 AM revealed there is a potential for decline based on the residents only receiving restorative therapy four (4) to five (5) times per week. Interview with the Administrator on 11/21/18 at 10:17 AM revealed prior to survey date, nothing had been implemented to assess residents for potential declines. He stated the facility's process is if a CNA sees a decline in resident function, it should be reported to the charge nurse and the charge nurse reports it to the therapy department and notifies the physician for orders to evaluate and treat the resident. The Administrator revealed he knew there were holes in the provision of care, but was not aware how many because he had not reviewed the logs either. The Administrator further stated there was no plan or back up system in place to assure restorative services were provided prior to this annual survey.

Based on interview, record review and facility policy review it was determined the facility failed to ensure there was sufficient nursing staff to provide restorative nursing services for thirteen (13) of thirteen (13) residents in the restorative program of twenty-four (24) sampled residents (Residents #2, #14, #20, #31, #32, #35, #44, #54, #55, #62, #81, #88, and #91). Interview with Registered Nurse (RN) #1 and RN #2 revealed fifty-six (56) residents were on the facility's restorative program roster. Review of the Restorative Services logs for October and November, 2018, for Residents #2, #14, #20, #31, #32, #35, #44, #54, #55, #62, #81, #88, and #91 and the remaining forty (43) residents in the restorative program revealed the staff failed to provide restorative services for ADL's, ROM/mobility/bracing two (2) to five (5) days a week from 10/28/18-11/17/18 (three (3) weeks) because the Restorative staff were pulled to the floor. The findings include: Review of signed statement from the facility Administrator, dated 11/28/18, revealed the facility does not have a specific staffing policy and the facility follows the state guidelines for staffing. Review of the Restorative Logs for October and November 2018 revealed Residents #2, #14, #20, #31, #32, #35, #44, #54, #55, #62, #81, #88, and #91 and the remaining forty-three (43) residents who were in the Restorative Program for ADL's and ROM/mobility/splinting, revealed facility staff failed to provide restorative services two (2) to five (5) days out of six (6) to seven (7) days a week from 10/28/18-11/17/18 (three (3) weeks). Interviews on 11/21/18 with Restorative Aide (RA) #2 at 8:41 AM, RA #3 at 8:48 AM, and RA #4 at 1:18 PM, revealed they are pulled from restorative services frequently to work the floor as nursing assistants or to go out to doctor's appointments with a resident. They stated they are pulled from restorative an average of one (1) to two (2) times per week and weekends were the worse for getting pulled out of restorative services, because of a lot of call ins. They stated when they are pulled to the floor the remaining RA's are unable to complete the Restorative care. Interview with RA #1 on 11/21/18 at 8:00 AM revealed she is a restorative aide but is employed through the therapy department, so she cannot get pulled to work the floor as a nurse assistant. She stated she works five (5) days a week and provides restorative services when other aides get pulled. She revealed she primarily provides walking services, applies splints and completes assessments, but will attempt to provide programs to other residents when the RA's are pulled but cannot get all the work done when it is just her providing restorative services. Interviews on 11/21/18 with RN #1, Restorative Supervisor at 8:10 AM and RN #2, Restorative Supervisor at 9:25 AM revealed restorative aides are often pulled to fill certified nurse Aide (CNA) spots when there are call-ins or residents have doctor's appointments. They stated they expected the RA's to provide restorative care to their assigned residents when they are pulled to the floor. RN #2 stated RA #1 was out on surgical leave for a few weeks the end of October and returned in early November, 2018. RN#1 stated they monitor the restorative logs to ensure services were being provided, but they had not reviewed the logs recently. Interview with the Assistant Director of Nursing (ADON) on 11/21/18 at 9:08 AM revealed restorative aides are pulled to the floor when there are staffing issues. The ADON stated when restorative aides are pulled to the floor, it is her expectation that the restorative program is completed while providing activities of daily living care.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Kitchen observations on 11/19/18, revealed foods were not labeled, dated or sealed completely in the walk-in refrigerator or walk-in freezer and the kitchen's manual can opener was visibly dirty. Review of the Census and Condition, dated 11/19/18, revealed one-hundred-four (104) of one-hundred-five (105) residents received their food from the kitchen. The findings include: 1. Review of facility policy titled, Refrigerated Food Storage, not dated, revealed all refrigerated products shall be labeled indicating product name, date product was received and date product was opened. Observation of the walk-in refrigeration on 11/19/18 at 11:34 AM, revealed a Ziploc bag of white, sliced cheese, a bag of shredded cheese and bag of parmesan cheese on a shelf with no labeling or dating present on these items to know when they were opened or when the use by date was. 2. Review of facility policy Frozen Food Storage, not dated, revealed all refrigerated products shall be labeled indicating product name, date product was received and date product was opened. It further states food shall be covered completely in its original box or in a production pan to prevent air exposure. Observation of the walk-in freezer on 11/19/18 at 11:40 AM, revealed a open bag of diced carrots open to the air and an open bag of beef patties open to the air. 3. Review of facility policy Equipment Cleaning, not dated, revealed the can opener is to be cleaned and sanitized after each use or at the end of each shift. Observation of the kitchen on 11/19/18 at 11:44 AM, revealed the kitchen's manual can opener had a build up of black crusted material on the cutting edge. Interview with Dietary Manager on 11/19/18 at 11:50 AM, revealed she expected all foods stored in the refrigerators and freezers to be labeled, dated and sealed completely. She stated she expected the manual can opener to be cleaned after each use which would prevent any buildup on the cutting edge.