Based on record review, interview and policy review, the facility failed to ensure quarterly care conferences were held and the resident and/or their representative were invited to participate. This affected one (Resident #04) of twelve screened for participation in care planning. The facility census was 38. Findings include: Review of the medical record for Resident #04 revealed an admission date of 06/19/22. Medical diagnoses included paranoid schizophrenia, neuroleptic-inducted parkinsonism, and epilepsy. Review of Resident #04's Minimum Data Set (MDS) annual assessment, dated 04/02/24, revealed the resident had severely impaired cognition. Review of Resident #04's interdisciplinary care conference notes revealed care conferences were held on 04/20/23, 07/27/23, and 10/19/23. Each care conference note indicated the care conferences were only attended by a Registered Nurse (RN) and a Social Services Designee (SSD). An interview on 05/28/24 at 1:35 P.M. with a family member of Resident #04 revealed the facility only held care conferences approximately once a year and she could not recall when the last care conference was held. During an interview on 05/29/24 at 10:36 A.M. with the Assistant Director of Nursing (ADON) #66 revealed the Director of Nursing (DON) has been setting up and coordinating care conferences as the facility had been without a Social Services Designee (SSD) for a few months. An interview on 05/30/24 at 9:25 A.M. with the DON revealed typically social services was responsible for coordinating care conferences, but she had been helping coordinate while the position remained unfilled. The DON verified the facility had no recent documentation or evidence of a care conference being held for Resident #04 since the last documented meeting on 10/19/23. Review of the policy titled Resident Participation - Assessment/Care Plans, revised December 2016, revealed the resident and his representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The Social Services Director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. The notices should include the date, time and location of the conference, who was contacted and on which date, the method of contact, input from the resident or representative if they are not able to attend, refusal of participation (if applicable), and the date and signature of the individual making the contact.

Based on record review and interview, the facility failed to provide the resident council with responses and action regarding their concerns regarding activities. This affected five residents (Resident #3, #5, #20, #27 and #36) who regularly attend council meetings and had the potential to affect all residents. The facility census was 38. Findings include: Review of the facility resident council meeting minutes from 11/22/23 to 05/14/24 revealed the residents had voiced the following concerns related to activities during resident council meetings: a. At the resident council meeting held 11/22/23 , residents voiced concerns regarding knowing when activities are held, and where activity calendars were placed in their rooms. Residents requested more physical activities and more variety of activities. Listed action taken included giving reminders throughout the day and adding more variety to the calendar. There was additionally a concern with bingo candy raised, with the action taken including AD #88 speaking to the administrator about bingo candy. The Administrator's recorded written response stated bingo treats and prizes were available for residents. b. At the resident council meeting held 12/26/23 , residents requested longer bingo games. Action taken included adding two more games to each bingo date, and increased bingo frequency to three times per week. c. At the resident council meeting held 01/16/24, residents voiced concerns that there were not enough games, games needed to be an hour long, and that activities were short. Action to be taken listed a notation of bingo going well and speaking to the residents of trying other ways to play games. d. At the resident council meeting held 02/13/24, residents voiced concerns regarding wanting better games, with suggestions including Uno, Yahtzee, and pong. Residents additionally requested more card games, board games, and bible studies. More cooking classes were additionally requested as the residents enjoyed making chocolate covered strawberries. e. At the resident council meeting held 04/16/24, residents voiced concerns regarding wanting more outdoor activities since the weather was improving and requested music in the courtyard. Review of the facility activity calendar dated November 2023 revealed there were three to four activities per weekday, with the latest activity, sudoku games, timed for 3:00 P.M. on only one day during the month. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated December 2023 revealed there were three to four activities per weekday, with the latest activity, a holiday movie, timed for 3:00 P.M. on only one day during the month. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated January 2024 revealed there were three to four activities scheduled per weekday, with the latest activity, bingo, timed for 2:30 P.M. on one day. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated February 2024 revealed three to four activities scheduled per weekday. There was one listed evening activity, a Valentine's Day dinner in the evening on 02/13/24. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time, except for a super bowl party held on 02/11/24 at 2:00 P.M. Review of the facility activity calendar dated April 2024 revealed three to four activities listed per weekday, with the latest activity, a movie, listed on one day at 4:00 P.M. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated May 2024 revealed no scheduled activities were listed for Mother's Day or Memorial Day. Three to four activities were scheduled per weekday, with the latest activity listed as 4:15 P.M. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. During the resident council interview on 05/29/24 at 9:40 A.M. with Residents #3, #5, #20, #27, and #36 revealed that their biggest concern was with activities. The residents stated that they needed more activities because there are none on the weekends or in the evenings. Resident #5 stated that they mentioned concerns with activities before to administration. Resident #5 stated that there used to be coloring books, games and different things but are not available anymore. During an interview on 05/29/24 at 2:46 P.M., Activities Director (AD) #88 stated she had been the Activity Director since October 2023. She worked at the facility full-time, from 8:00 A.M. to 4:30 P.M. Monday through Friday. Occasionally she would come to work on the weekend, but not consistently. AD #88 confirmed she was the only activity staff member who worked at the facility, and she was responsible for creating the monthly activity calendars. AD #88 stated she tried to accommodate resident preferences and requests, but the key word was try. She stated the residents want more games, but it is hard as she had never played the requested games and had to be taught by the residents. AD #88 confirmed there are no consistent, planned activities in the evening and on the weekends as those are times she is not scheduled to work. AD #88 stated she would like to eventually find volunteers to help facilitate some activities but currently there are no volunteers. AD #88 stated she had not heard concerns related to the timing of activities voiced by residents but when she does coordinate the occasional weekend activities the residents enjoy it immensely. AD #88 stated that she does not think that the radio was waterproof, so that music can be played outside.

Based on observation, record review, interview and policy review, the facility failed to ensure an adequate number and variety of therapeutic activities were being provided to meet the resident preferences and failed to ensure activities were scheduled on evenings and weekends. This had the potential to affect all 38 residents residing in the facility. The facility census was 38. Findings include: Review of the Activity Participation Logs for March 2024, April 2024, and May 2024 revealed all residents had their own log for each month, on which residents' activity participation was logged. Residents were recorded as participating in activities, based on the date, and participation was logged as active, passive, or refusal to participate. The logs consistently were blank for Saturdays and Sundays, indicating no participation in activities. During an interview on 05/28/24 at 9:19 A.M., Resident #14 stated there used to be activities on the weekend but there are no longer. The resident stated he felt like he was in jail as there was nothing to do. During an interview on 05/28/24 at 9:26 A.M., Resident #21 stated there were no activities, as the activity director had left her position a few weeks prior. During an interview on 05/28/24 at 10:52 A.M., Resident #10 stated there were never any activities in the evenings or on the weekends. Resident #10 stated the activity director had left or was leaving her position, and the facility likely would no longer have any activities. Review of the activity calendar revealed a badminton activity. During an observation on 05/28/24 from 10:55 A.M. to 11:07 A.M., there was no badminton activity taking place. Eight residents were observed seated in the common area near the nurses' station, with seven of them sleeping. During an interview on 05/28/24 at 11:07 A.M., Resident #03 stated he had just returned to his room after visiting the common area by the nurse's station. He had attempted to go to the listed badminton activity but there was no one there. Resident #03 stated the activities frequently do not follow the calendar. Resident #03 voiced concern that there had been no activities on Memorial Day (05/27/24), nor did the facility have weekend activities. He checked his posted activity calendar in his room which listed additional activities of a cookout at 12:00 P.M. and cornhole games at 1:30 P.M. The resident stated yeah right about the facility holding a cookout. During an observation on 05/28/24 at 12:07 P.M., there was no cookout taking place. 19 residents were observed eating a normal lunch in the dining room. During an interview on 05/28/24 at 1:24 P.M., Resident #19 stated activities were great when they have them, but staff did not always follow the schedule. The resident stated there were not many participants and was not sure what would happen as Activity Director (AD) #88 was leaving her position. AD #88 was nearby and joined the conversation. Resident #19 asked AD #88 who would be taking over activities, and AD #88 responded that the facility was still trying to figure that out. AD #88 confirmed at that time she was the only activity staff member employed at the facility. During an observation on 05/29/24 at 8:39 A.M. eight residents seated in the common area near the nursing station. One resident was in a tilt in space wheelchair, facing away from the television. The television was on with a news program playing, with the television volume so low it was difficult to hear. During interview at the time of the observation, Resident #12 and Resident #24 stated they could not hear the television. During an interview on 05/29/24 at 8:41 A.M., State Tested Nursing Assistant (STNA) #84 verified the television was turned low, but she was unsure how to work the television. Resident #12, seated nearby, informed the staff member there were two remotes attached to the wall by Velcro next to the television, out of all the resident's reach. STNA #84 retrieved the remotes and raised the volume from the level of 22 to 48. During the resident council meeting survey task on 05/29/24 at 9:40 A.M., Residents #03, #05, #20, and #36 stated there were no activities in the evenings, nor on the weekends. Resident #05 stated there used to be coloring books, games, and different things to do which were no longer available. Resident #05 stated residents had voiced these concerns at prior facility-led resident council meetings and nothing was done. Review of the facility activity calendar dated November 2023 revealed there were three to four activities per weekday, with the latest activity, sudoku games, timed for 3:00 P.M. on only one day during the month. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated December 2023 revealed there were three to four activities per weekday, with the latest activity, a holiday movie, timed for 3:00 P.M. on only one day during the month. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated January 2024 revealed there were three to four activities scheduled per weekday, with the latest activity, bingo, timed for 2:30 P.M. on one day. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated February 2024 revealed three to four activities scheduled per weekday. There was one listed evening activity, a Valentine's Day dinner in the evening on 02/13/24. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time, except for a super bowl party held on 02/11/24 at 2:00 P.M. Review of the facility activity calendar dated April 2024 revealed three to four activities listed per weekday, with the latest activity, a movie, listed on one day at 4:00 P.M. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. Review of the facility activity calendar dated May 2024 revealed no scheduled activities were listed for Mother's Day or Memorial Day. Three to four activities were scheduled per weekday, with the latest activity listed as 4:15 P.M. The activity calendar listed only independent activities of choice for Saturdays, and on Sundays the activities listed was church services on the television in the lobby, with no listed time. During an interview on 05/29/24 at 2:46 P.M., AD #88 stated she had been the Activity Director since October 2023. She worked at the facility full-time, from 8:00 A.M. to 4:30 P.M. Monday through Friday. Occasionally she would come to work on the weekend, but not consistently. AD #88 confirmed she was the only activity staff member who worked at the facility, and she was responsible for creating the monthly activity calendars. AD #88 stated she tried to accommodate resident preferences and requests, but the key word was try. She stated the residents want more games, but it is hard as she had never played the requested games and had to be taught by the residents. AD #88 confirmed there are no consistent, planned activities in the evening and on the weekends as those are times she is not scheduled to work. AD #88 stated she would like to eventually find volunteers to help facilitate some activities but currently there were no volunteers. AD #88 stated she had not heard concerns related to the timing of activities voiced by residents but when she does coordinate the occasional weekend activities the residents enjoy it immensely. AD #88 verified that the scheduled activities of badminton and a cookout on 05/28/24 did not occur as posted on the activity calendar as she had an urgent personal matter to attend to, and verified she did not post an activity schedule change anywhere but had told the aides she would reschedule it. AD #88 additionally verified the previous listed activity on 05/23/24 of gardening did not occur, and she was not beginning gardening until 05/30/24. Review of the policy titled Activity Programs, revised August 2006, revealed activity programs designed to meet the needs of each resident are available daily. Activities are scheduled 7 days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the activity program.

Based on personnel record review, staff interview, and review of the facility activity director job description, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all 38 residents residing in the facility. The facility census was 38. Findings include: Review of Activity Director (AD) #88's personnel record revealed a hire date of 10/04/23. AD #88 signed the Activity Director job description on the date of hire, which listed primary functions and responsibilities of then position which included planning, scheduling, and implementing a program of individual and group activities based on the residents' schedule, plan and implement evening and weekend functions as necessary, and recruit, schedule and supervise assistants and volunteers, and maintain an activity attendance record for each resident. The section on Education/Experience, noted as to be completed by the facility, was blank. AD #88's personnel record contained no evidence of formal training in an activities or therapeutic recreation program or full-time experience in a therapeutic activities program. During an interview on 05/29/24 at 2:46 P.M., AD #88 confirmed she was not a certified activity director. AD #88 revealed she had previously worked part-time at another skilled nursing facility as an activities assistant for approximately two years. AD #88 stated in her prior role she worked two days per week in the activities department, on weekends, and sought new employment because of a lack of days and hours. AD #88 indicated she had discussions with the Administrator off and on about getting certified as an activity director but had not yet committed to completing nor was she enrolled in a program to become a certified activities professional. During an interview on 05/30/24 at 9:20 A.M., the Administrator verified he was aware AD #88 did not meet the minimum qualifications of an activities professional and had discussed the certification process with AD #88 on multiple occasions. The Administrator stated he believed AD #88 fell under the umbrella of a sister facility's former activity director who was certified. The Administrator stated he was aware of the regulatory requirements and would discuss with AD #88 a plan to get her certified or recruit a certified activity director to oversee the activities program. Review of the form titled Job Description and Performance Standards for the position of Activity Director, revised 01/07/10, revealed the purpose of this position is to develop and implement an activity program in compliance with requirements to meet residents' needs.

Based on record review, observation, interview and record review, the facility failed to ensure proper ware washing and failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 38 residents that received meals from the facility. No residents were identified as receiving nothing by mouth. The facility census was 38. Findings include: During a tour of the kitchen on 05/28/24 at 7:49 A.M., the reach-in freezer contained frozen fruit and waffles that were out of their original package and were not labeled or dated. In the dry storeroom, there was a can of baked beans and a can of sliced apples that were dented and were not separated from the other canned goods. Dietary Manager (DM) #55 verified observations on 05/28/24 at 8:10 A.M. DM #55 stated that he did not know that dented cans needed to be separated. During observation on 05/29/24 at 8:30 A.M., Dietary Aide (DA) #40 check for the chlorine concentration of the dish machine and it was not registering any sanitizer. The dish machine was repaired and on 05/29/24 at 9:50 A.M., registered 50 ppm of chlorine. Review of the facility policy dated 07/2014 titled, Food Receiving and Storage, revealed that food should be labeled and dated when removed from original package. Review of the facility policy dated 03/2010 titled, Dishwashing Machine Use, revealed that dishwashing machine chemical sanitizer concentration was 50-100 parts per million (ppm) for chlorine-based sanitizer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect. This affected two (Residents #30 and #6) of two residents reviewed. The facility census was 35. Findings include: 1. Record review revealed Resident #30 was admitted on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, pseudobulbar affect (a condition that causes uncontrollable crying and or laughing that happens suddenly and or frequently), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/16/22, revealed Resident #30 was severely cognitively impaired. Resident required extensive assistance for activities of daily living. Resident #30 used a wheelchair for mobility and required extensive assistance of one person physical assist for mobility. Resident #30 required set up help of one for meals. Resident had no verbal or physical behaviors exhibited including rejection of care. Resident #30's hearing was adequate and vision moderately impaired. Resident wore corrective lenses. Review of the care plan, dated 04/14/22, revealed resident was dependent on staff for meeting emotional, intellectual, physical and social needs related to disease process, diagnosed with dementia. Interventions included all staff to converse with resident while providing care. Resident has behavior problems which included tearful bouts, fluctuating in mood related to dementia. Interventions included to explain all procedures to the resident before starting and allow resident adequate time to adjust to changes. During observation on 06/07/22 at 8:36 A.M., Resident #30 was sitting in the facility lounge, in her wheelchair, sleeping. Resident #30 had a clothing protector on. State Tested Nursing Assistant (STNA) #846 walked up behind Resident #30, quickly removed the clothing protector from behind and walked away without addressing the resident. Resident #30 startled, woke up, began holding her arms in the air crying, no, no. Licensed Practical Nurse (LPN) #822 was present during the observation, verified this was not a correct approach by STNA #846. During interview on 06/07/22 at 8:38 A.M., STNA #846 confirmed the above observation. STNA #846 stated Resident #30 would scream anyway and the best approach is to sneak up on her. During interview on 06/07/22 at 2:50 P.M., the Director of Nursing (DON) confirmed STNA 846's approach was not appropriate and stated sometimes Resident #30 does yell with hands on care. 2. During observation on 06/06/22 at 9:27 A.M., Resident #6 was sitting in her recliner chair in her room. The chair was elevated back in the reclined position with her feet reclined up on the foot rest. Resident #6 was attempting to reach the remote for the chair which was located on the far right side in back of the chair. Resident #6 was unable to reach the remote. State Tested Nursing Assistant (STNA) #846 and #824 was walking by Resident #6's room and overheard the conversation. STNA #846 revealed Resident #6 had to be reclined back in her recliner chair because she was a fall risk. Resident #6 again asked for the remote. STNA #846 told the resident she could not have the remote because she will set the chair up and fall. STNA #846 and #824 then left the room without offering to assist the resident to get up as she requested. During interview on 06/08/22 at 10:23 A.M., the DON stated Resident #30 would not be able to get out of the chair without assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility failed to investigate and report an injury of unknown origin. This affected one (Resident #30) of one resident reviewed. The facility census was 35. Findings include: Record review revealed Resident #30 was admitted on [DATE]. Diagnosis included unspecified dementia without behavioral disturbances, pseudobulbar affect (a condition that causes uncontrollable crying and or laughing that happens suddenly and or frequently), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was severely cognitively impaired. Resident required extensive assistance of two for bed mobility and transfers, Resident #30 used a wheelchair for mobility and required extensive assistance of one person physical assist for mobility. During interview on 06/06/22 at 9:18 A.M., Hospice Registered Nurse (RN) #847 revealed Resident #30 had bruises on both of her upper arms. Hospice Nurse RN #847 stated she observed the bruising on 06/02/22 and reported it to the Director of Nursing (DON) on that date. Hospice Nurse RN #847 revealed she was unsure how the bruising occurred. During interview on 06/06/22 at 9:48 A.M., the DON stated that Hospice had made her aware either the prior week of the bruising on Resident #30's arms. The DON stated she assessed the bruises at that time. During interview on 06/08/22 at 03:20 P.M., the DON again confirmed she was aware of the bruises to Resident #30's upper arms. DON revealed she had looked at the bruises but did not investigate how the bruises occurred, did not talk to staff about how they may have occurred and did not interview the resident or other residents regarding how they may have occurred because Resident #30 will flail her arms and she probably hit something or she was fighting staff during a shower or transfer. She told staff to be more careful. She stated she did not document the areas, measure the areas, or notify the resident's representative. She did not do an SRI or any investigation. During observation on 06/08/22 at 3:24 P.M., Resident #30 had a large faded bruise to the right and left upper arm. During interview on 06/09/22 at 9:21 A.M., Licensed Practical Nurse (LPN) #837 revealed she was first aware of the bruises on 06/06/22. LPN #837 confirmed she did not assess, document or notify the family of the bruises because it was near the end of her shift. LPN #837 measured the bruise on Resident #30's right upper arm and it was five centimeters (cm) by five and one half cm. The bruise was faded purple brown in color. The left arm bruise measured three and a half cm by two and a half cm and light purple in color. There was an additional bruise on the right wrist that measured four cm by three cm and light purple in color. LPN #837 confirmed she was not aware how the bruises occurred. Record review of the progress notes from 03/01/22 through 06/09/22 revealed no documentation regarding bruising on residents body. Record review of facility Self Reported Incidents (SRI) revealed no reports for Resident #30 having injuries of unknown origin. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property dated 10/27/17, revealed its the facilities policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of a residents property including injuries of an unknown source.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to perform incontinence care on a resident. This affected one (Resident #30) of one resident reviewed for incontinence care. The facility census was 35. Findings include: Record review revealed Resident #30 was admitted on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was severely cognitively impaired. Resident #30 was occasionally incontinent of urine and frequently incontinent of bowel and required total dependence of one for toilet use. Review of the care plan dated 04/14/22 revealed Resident #30 had mixed bladder incontinence related to dementia. Interventions included to toilet every two hours and as required for incontinence. Wash, rinse and dry perineum after incontinent episode. Ruing observation on 06/07/22 at 9:15 A.M., State Tested Nursing Assistant (STNA) #846 and #824 stood Resident #30 up to a standing position from her wheel chair and removed Resident #30's incontinence brief, which was soiled with urine. Without performing incontinent care, STNA #846 placed a clean incontinence brief on Resident #30 and returned her to the wheelchair. During interview at the time of the observation, STNA 846 and #824 verified they did not perform incontinence care. STNA #846 stated she would perform care when she put the resident to bed later. Review of the facility policy titled, Perineal Care, dated October 2010 revealed the purpose of the procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the residents skin condition.

Based on observation, interview and policy review, the failed to ensure a resident refrigerator was clean and that food items were labeled and dated. This had the potential to affect all 35 residents residing at the facility. Findings include: During observation on 06/06/22 at 4:35 P.M. , the refrigerator located in the medication storage room was full of undated and unlabeled food items. The refrigerator had a foul odor. The Director of Nursing (DON), present during the observation, stated the refrigerator held resident food items. Food items include a prepared meal with the store print enjoy by 5/25/22 with no name; a Tupperware bowl and lid with a white liquid that had no name and no date; a plastic bag of bagels that was stuck to the refrigerator shelf that had no name and no date; a half stick of butter that was unwrapped with no name and no date; deli lunch meat that appeared slimy and was dated 5/26/22 with no name; a plastic bag of cobbler undated and with no name; a plastic bag of ham dated 05/13/22 with no name; a plastic bag of cooked bacon, undated with no name; a piece of ham dated 05/07/22 with no name; a container of potato salad, undated with no name; a container of cottage cheese with a use by date of 01/01/22 and no name; and a chicken sandwich with no name and no date. The back of the refrigerator had approximately one and a half inches of ice build up from top to bottom. There were undated drinks with no names and the shelves had fluid spills that had dried and were sticky. The DON verified the above findings at the time of the observation. Review of the policy titled Refrigerators and Freezers, dated December 2014, revealed the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expiration guidelines. All food shall be appropriately dated . Use by dates will be completed with expiration dates on all prepared food in refrigerators.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's had updated care plans reflecting catheter care for Resident #12 and care of a tracheostomy stoma site for Resident #7. This affected two residents (Resident #7 and Resident #12) of 12 residents who were reviewed for accurate care plans. The facility census was 40. Findings Include: 1. Record review for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, neuromuscular dysfunction of the bladder and chronic kidney disease. The resident was admitted with a urinary catheter in place. Review of the quarterly Minimum Data Set Assessment (MDS) assessment, dated 03/31/19, revealed Resident #12 was cognitively intact and had a urinary catheter in place. Review of the physician orders, dated 06/26/18, revealed the physician ordered for urinary catheter care to be done every shift. Review of the resident's plan of care dated 06/18/18 showed that this resident had an indwelling urinary catheter related to a neurogenic bladder (bladder is flaccid and does not contract to empty). Interventions for this plan of care included positioning of the catheter, changing the catheter as needed including the urinary catheter bag and monitoring for signs and symptoms of a urinary tract infection. There was no inclusion in this plan of care for urinary catheter care to be provided daily on every shift. Interview with the Director of Nursing (DON) on 05/20/19 at 1:40 P.M. verified that the care plan did not include urinary catheter care. 2. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, cancer of the larynx, tracheostomy stoma and quadriplegia. Review of the quarterly MDS assessment, dated 03/07/19, revealed Resident #7 was cognitively intact and required extensive assistance for transfers, dressing and personal hygiene. This resident had a stoma sight from a tracheostomy. Review of the physician order, dated 06/26/18, revealed an order for the area around the stoma site to be cleansed with normal saline twice a day and as needed. Review of the plan of care, titled ineffective breathing pattern related to the tracheostomy, dated 05/30/18 revealed interventions including oxygen settings as five liters via trach site to maintain pulse oximetry above 92%, monitor for level of consciousness, mental status and lethargy; and to monitor for difficulty breathing. There was no intervention listed for the care of the area around the stoma site. Interview with the Director of Nursing (DON) on 05/21/19 at 3:15 P.M. verified that the resident's care plan was not updated to include the care to the skin area around the stoma site.

Based on observation and staff interview, the facility failed to ensure medications were stored in a secured manner. This affected the 14 residents (Residents #10, #14, #16, #20, #21, #28, #31, #33, #34, #36, #37, #38 and #40) who resided on the birch unit of the facility and one of two medication carts observed. The facility census was 40. Findings Include: Observation of the birch hall nurse's medication cart on 05/19/19 between 9:36 A.M. and 9:49 A.M. with Licensed Practical Nurse (LPN) #300 revealed six unidentified loose pills at the bottom of multiple drawers through out the medication cart. LPN #300 verified the findings at the time of discovery. Review of the facilities policy entitled Storage of Medications, revised April 2007, revealed Drugs shall be stored in an orderly manner in cabinet, drawers, carts or automatic dispensing systems. The facility identified 14 residents (Residents #10, #14, #16, #20, #21, #28, #31, #33, #34, #36, #37, #38 and #40) who resided on the birch unit and had medication in the cart observed.