**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident and staff interviews, the facility failed to conduct care plan meetings for 2 of 3 residents reviewed for care planning (Resident #10, and Resident #24), and failed to update a care plan for Resident 1of 3 residents reviewed for care planning (Resident #24). The findings included: 1. Resident #10 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact. During an interview with Resident #10 on 10/7/2024 at 10:23 A.M. he disclosed he could not remember the last time he participated in a care plan meeting. Calls to the Representative of Person for Resident #10 on 10/8/2024 at 3:47 P.M., and on 10/9/2024 at 8:47 A.M. went unanswered. A review of Resident #10's care plan revealed it had been updated on 6/12/2024 and on 6/19/2024. In an interview with the Social Worker (SW) on 10/8/2024 at 3:35 P.M. she revealed it was her responsibility to schedule care plan meetings, and to send out invites to participants. She stated it was an error on her part not to schedule a care plan meeting for Resident #10. The SW revealed the last care plan meeting for Resident #10 was held on 2/17/2024. During an interview with the Director of Nursing (DON) on 10/8/2024 at 3:40 P.M she revealed care plans were reviewed every 3 months and was not aware Resident #10's last care plan meeting was held on 2/17/2024. She further stated Resident #10's care plan was reviewed on 6/12/2024 and 6/19/2024. In an interview with the Administrator on 10/09/24 at 9:50 A.M. she revealed she was not aware Resident #10 had not had a care plan meeting since 2/17/2024. She further revealed it was the responsibility of SW to schedule the meetings and the responsibility of the DON to ensure the care plan was updated accordingly. 2. Resident #24 was admitted to the facility on [DATE]. Resident #24's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and her own responsible party. In an interview with Resident #24 on 10/7/2024 at 10:58 A.M. she revealed she had not participated in any care plan meetings since arrival at the facility on 4/11/2024. Review of Resident #24's care plan initiated on 4/11/2024 revealed the care plan had not been updated. The Social Worker (SW) was interviewed on 10/8/2024 at 3:35 P.M. SW revealed that Resident #24 was supposed to have had a care plan meeting in July 2024. She further stated it was her responsibility to schedule the meeting and it was an error on her part for not scheduling a meeting. An interview with the MDS Nurse on 10/8/2024 at 10:12 A.M. revealed she was responsible for ensuring the care plan was updated. She stated it was an error that Resident #24's care plan had not been updated. The MDS Nurse revealed it was the responsibility of the SW to schedule care plan meetings. During an interview with the Director of Nursing (DON) on 10/8/2024 at 3:40 P.M she revealed the care plan is reviewed every 3 months and was not aware Resident #24's care plan meeting had not been held. She revealed it was the responsibility of the SW to schedule and call for the care plan meetings for residents. During an interview with the Administrator on 10/9/2024 at 9:50 A.M. she revealed it was the responsibility of the Social Worker and the DON to ensure care plan meetings for Resident #24 were held quarterly or as needed.

Based on lunch meal tray line observation, and staff interviews, the facility failed to maintain the plate warmer, essential equipment to the dietary department, in good operating condition, as evidenced by the plate warmer being inoperable. The findings included: An observation of the lunch meal tray line occurred on 10/09/24 at 11:50 AM. The two cylinder plate warmer was not plugged in or warm to the touch. In an interview on 10/09/24 at 12:04 PM Dietary Staff #1 stated the plate warmer had not worked for over 2 months. In an interview on 10/09/24 at 12:20 PM the Maintenance Assistant revealed he had worked at the facility for 2 months and was not aware the plate warmer was not working or had attempted to repair it. In an interview on 10/09/24 at 1:04 PM the Dietary Manager revealed she had been at the facility for over 2 months and the plate warmer had not worked since she arrived. She revealed the prior maintenance director had been unable to repair the plate warmer and she told the Administrator it was not working. In an interview on 10/09/24 at 12:17 PM the Administrator revealed that the prior Maintenance Director had been unable to repair the plate warmer. She indicated the dietary staff utilized insulated plates and staff served food immediately after it reached the halls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, the facility failed to accurately code an admission Minimum Data Set (MDS) in the area of anticoagulants for 1 of 16 (Resident #17) residents reviewed for MDS accuracy. Findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (an irregular heartbeat). Resident #17's admission MDS dated [DATE] indicated she received 7 of 7 days of an anticoagulant (a blood thinner that prevents blood clots). Review of Resident #17's physician's orders included an order for Clopidogrel (an anti-platelet medication that prevents blood clots) by mouth one time daily. During an interview on 6/14/23 at 1:40 PM, the MDS nurse revealed Resident #17 was on Clopidogrel. She was not aware an anti-platelet medication should not be coded as an anti-coagulant. During an interview on 6/15/23 at 11:30 AM, the Director of Nursing (DON) revealed Clopidogrel should not be coded as an anticoagulant. During an interview on 6/15/23 at 12:50 PM, the Administrator revealed that Clopidogrel should not be coded as an anticoagulant. The MDS nurse had been made aware of the issue.

Based on observation and staff interviews, the facility failed to maintain a medication storage refrigerator within the recommended temperature range for 1 of 1 medication refrigerator reviewed (100 Hall medication storage refrigerator). Findings included: An observation of the medication storage refrigerator located in the 100 hall medication storage room was made on 6/14/23 at 11:59 AM with Nurse #1. The refrigerator thermometer was observed at 30 degrees Fahrenheit (°F). Nurse #1 viewed the refrigerator thermometer and stated it appeared to read between 30 and 32 degrees. The June 2023 temperature monitoring log for the medication storage refrigerator had been noted daily with temperatures between 38°F and 40°F. The instructions at the bottom of the monitoring log indicated refrigerator temps must be between 36 and 46 degrees. If temps are not between these ranges all medications must be moved to a different refrigerator. The refrigerator contained: 8 Insulin aspart 100 unit pens. Insulin package instructions note to store unopened insulin in a refrigerator at 36°F to 46°F and do not freeze. 7 Insulin glargine 100 unit pens. Insulin package instructions note to store unopened insulin in a refrigerator at 36°F to 46°F and do not freeze. 6 Acetaminophen 650 milligram suppositories. The package instructions note to store at 68°F -77°F or in a cool place. 4 Tuberculin purified protein 1 milliliter vials. The package instructions note to store at 35°F -46°F and do not freeze. 8 Pneumococcal 20-valent Conjugate vaccines. The package instructions note to store refrigerated at 36°F -46°F, do not freeze and discard if the vaccine has been frozen. An interview with the Administrator was conducted on 6/14/23 at 12:22 PM was conducted. The Administrator stated the refrigerator temperatures should be in the recommended range.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to develop a baseline care plan within 48 hours of admission and failed to develop a resident centered baseline care plan to address wound care on admission and readmission for 1 of 13 residents reviewed for baseline care plans (Resident #184). The findings included: 1.a. Resident #184 was admitted on [DATE] with diagnoses that included a Stage 2 pressure ulcer to the sacrum and an unstageable pressure ulcer to the left buttock. Review of Resident #184 ' s physician orders dated 2/10/22 revealed an order for calcium alginate to the sacrum and left buttock wounds one time per day. Review of Resident #184 ' s base line care plan dated 2/14/22 revealed there was no baseline care plan developed within 48 hours of admission on [DATE] and that it failed to address pressure ulcers. b. Resident #184 ' s Minimum Data Set indicated a discharge assessment was completed on 2/14/22 and a reentry was completed on 2/22/22. Review of Resident #184 ' s medical record revealed resident was readmitted on [DATE] with an unstageable pressure ulcer to the left buttock and shear wound to right buttock. Review of Resident #184 ' s physician orders dated 2/22/22 revealed orders for collagenase ointment to buttock wound and zinc oxide to shear wound every shift. Review of Resident #184 ' s base line care plan dated 2/23/22 revealed there was no baseline care plan developed to address pressure ulcers. An interview on 3/3/22 at 1:44 PM with MDS nurse revealed that wounds should be included in the baseline care plan which is developed 48 hours after admission. She further stated the baseline care plans generated the information to the [NAME] which informed the staff how to care for the resident. An interview at 2:16 PM on 3/3/22 with the Administrator revealed that the baseline care plans should be developed within 48 hours, should be person centered and include areas such as wounds that are significant to each resident ' s care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to revise the comprehensive care plan based on current interventions including physical and occupational therapy recommendations for 1 of 13 residents (Resident # 7) reviewed for care plans. The findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses that included history of stroke with hemiparesis. A review of Resident #7 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that resident required extensive assistance with bed mobility, transfers, eating and toileting. Review of the Care Planning Process policy dated 12/2021 indicated that care plans are to include information from a variety of documentation sources, are to include pertinent areas of care, assign relevant items to the [NAME] for nursing assistant (NA) communication and are updated with changes by the MDS and Nurse Management Team. Review of Resident #7 ' s physical therapy Discharge summary dated [DATE] indicated resident was discharged from skilled therapy services on a functional maintenance program which included daily ambulation with a front wheeled walker and cueing with a goal of 50 feet at a time. Review of Resident #7 ' s occupational therapy functional therapy maintenance program for feeding dated 2/19/22 indicated staff were to set up each meal by cutting and slicing items and placing drink in plastic cup with lid and straw and utilize plastic utensils. Plastic utensils were to be kept in resident ' s room on bedside table. The goal of this plan was that resident would continue to self-feed with set up assistance. Review of Resident #7 ' s care plan dated 2/25/22 indicated resident had an ADL (Activities of Daily Living) self-care problem related to cerebrovascular accident (stroke) with hemiparesis. Interventions included in part, able to feed herself independently with set up, limited assist with eating as needed, set up and supervision for meals. Ambulation was not included in the care plan. On 3/3/22 at 8:30 AM Nursing Assistant (NA)#1 was observed standing beside Resident #7 ' s bed feeding her using standard silverware, not plastic. Interview on 3/3/22 at 8:30 AM with NA#1 revealed she was not aware of self-feeding interventions for Resident #7. She further stated, I think she is walked sometimes but I am not sure who does it. Interview with the Social Worker (SW) on 3/3/22 at 9:08 AM indicated that care plan meetings are not held unless there is a grievance and there was no way to know what was discussed or revisions to be made to the care plan. Interview on 3/3/22 at 9:15 AM with Occupational Therapy Assistant revealed Resident #7 received occupational therapy services for strengthening and improving fine motor skills. Resident #7 was able to feed herself with interventions in place upon discharge from occupational therapy. Interview with Nurse #1 on 3/3/22at 10:30 AM indicated she assisted with some administrative duties and updated the MDS nurse about the residents as needed. Nurse #1 indicated that interventions from the functional maintenance program should be added to the care plan to generate information to the [NAME] for the NA ' s. Interview via phone at 1:44 PM on 3/3/22 with MDS nurse revealed she completed MDS and care plans remotely for the facility. She indicated she reviewed nurse notes, physician orders and medications to develop and revise the care plan. She further stated she did not attend care plan meetings for the residents. She indicated that she called the facility or sent an e mail if she needed further information or clarification. She stated that Resident #7 ' s care plan should have been revised to include the functional maintenance program interventions from physical and occupational therapy. Interview at 2:16 PM on 3/3/22 with the administrator revealed that she expected care plans were revised to include current interventions including physical and occupational therapy recommendations. The administrator indicated that care plans were to be up to date, individualized and contain goals that were appropriate for each resident

Based on observations and staff interviews the facility failed to date potential hazardous food items stored for use in 1 of 1 walk-in cooler and 1 of 1 reach-in cooler. This practice had the potential to affect food served to residents. The findings included: 1. a. Initial observation of the kitchen walk-in cooler on 02/28/2022 at 11:24 AM revealed the following foods were unlabeled and undated: 1 opened container of thickened liquid 1 opened package of cheese b. Initial observation of the kitchen reach-in refrigerator on 02/28/2022 at 11:26 AM revealed the following food was unlabeled and undated: 1 bag of opened shredded cheese c. Observation of the kitchen reach-in refrigerator on 03/03/2022 at 11:32 AM revealed the following food was unlabeled and undated: 1 opened container of pimiento cheese An interview with the Dietary Manager (DM) on 02/28/2022 at 11:26 AM revealed that all opened food in the kitchen walk-in refrigerator, the reach-in refrigerator should be labeled and dated at the time it was opened. She further revealed that any unlabeled and undated food should be discarded. The DM stated staff who opened a container was responsible for labeling and dating that container at the time it was opened. She further stated she was responsible for checking the units for proper storage of opened food. An interview with the Administrator on 03/03/2022 at 11:48 AM revealed it was her expectation that kitchen staff make sure all food was labeled and dated upon opening the packaging. She also stated if food was not labeled and dated it should be discarded.