Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/28/2024 from 8:00 AM through 3:30 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect 15 out of 15 residents receiving services. Findings include: During observational tour at approximately 10:00 AM of April 28, 2025, two dirty linen carts were observed un attended in the extrerior patio area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #204 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During the record review performed on 04/29/25 at 1:00 PM, it was found that has physician ordered on 04/27/2025 at 1:15 PM the antibiotic Augmentin 875 milligram (mg) 1 tablet (tab) per mouth (PO) twice daily (BID) per 20 doses. No evidence was found for the justification for the use of this antibiotic in the physician progress notes. During the interview with the Director of Nursing (employee #1) on 04/29/2025 at 1:30 PM she stated that residents arrive with instructions and a prescription from their orthopedic surgeon to continue treatment at the facility. The facility failed to provide evidence in the physician's progress notes justifying the use of this medication. 4. Resident #205 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During the record review performed on 04/29/25 at 2:00 PM, it was found that has physician ordered on 04/25/2025 at 8:10 PM the antibiotic Keflex 500 mg 1 tab PO three time daily (TID) per 10 doses. No evidence was found related of the justification for the use of this antibiotic in the physician progress notes. During the interview with the Director of Nursing (employee #1) on 04/29/2025 at 1:30 PM she stated that residents arrive with instructions and a prescription from their orthopedic surgeon to continue treatment at the facility. The facility failed to provide evidence in the physician's progress notes justifying the use of this medication. Based on reviews of 8 medical records and interviews conducted on 04/28/2025 to 04/29/2025 from 8:00 AM to 4:00 PM, it was determined that the facility failed to ensure that each resident's medication regimen is free of unnecessary medications. This deficient practice affects 3 out of 8 receiving services at the facility (RS# 102, # 201 and 204). Findings include: During the investigations carried out in the clinical records concerning antibiotic treatment, the following was observed: 1. Resident #201 is a [AGE] year-old female admitted on [DATE] with Right Total Knee Replacement. a. During the medical record review on 04/29/2025 at 2:35 PM, it was noted in the medical order made on 04/26/2025 at 8:00 PM, Augmentin 875 mg 1 oral tablet twice a day for 20 doses. On 04/29/2025 at 3:03 PM, the clinical record was reviewed the admission care plan in the skin status the nursing staff only wrote that the knee area was noted with surgical patch and edema. The medical record was reviewed on 04/29/2025 at 3:15 PM, no physician's progress note was found that could justify prolonging the resident's antibiotic treatment. 2. Resident #102 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During the record review performed on 04/29/25 at 12:00 PM, it was found that has physician order on 04/24/2025 for the antibiotic Cipro 750mg orally every 12 hours for 20 doses. No justification for the use of this antibiotic was observed in the physician notes. a) During the interview with the Director of Nursing (employee #1) she stated that residents arrive with instructions and a prescription from their orthopedic surgeon to continue treatment at her facility. The facility failed to provide evidence in the physician's progress notes justifying the use of this medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #205 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During the record review performed on 04/29/25 at 2:00 PM, it was found that has physician ordered on 04/25/2025 at 8:10 PM Cymbalta 30 mg 1 tab PO Hour Sleep (HS). No evidence was found related of the justification for the use of this antidepressant in the physician progress notes. During the interview with the Director of Nursing (employee #1) on 04/29/2025 at 2:00 PM she stated that residents arrive with instructions and a prescription from their orthopedic surgeon to continue treatment at the facility. She states that the orthopedic surgeon prescribed Cymbalta for pain management, not as an antidepressant. The physician at the time of admission fills the order based on the orthopedist's prescription order. The facility failed to provide evidence in the physician's progress notes justifying the use of this medication. 2. Resident #201 is a [AGE] year-old female admitted on [DATE] with Right Total Knee Replacement. a. During the medical record review on 04/29/2025 at 2:35 PM, it was noted in the medical order made on 04/26/2025 at 8:00 PM, Trazodone 100 miligrans (mg) 1 tablet oral at bedtime. On 04/29/2025 at 3:03 PM, the medical history was reviewed and no history of depression was found in the pre-admission screening sheet. The medical record was reviewed on 04/29/2025 at 3:15 PM, no physician's progress note was found that could justify the use of antidepressant for the resident. The Director of Nursing (DON) (employee #1) was interviewed on 04/29/2025 at 2:45 PM, stated that when the resident is admitted he/she arrives with a prescription order. The physician at the time of admission fills the order based on the orthopedist's prescription order. Based on reviews of 8 medical records and interviews conducted on 04/28/2025 to 04/29/2025 from 8:00 AM to 4:00 PM, it was determined that the facility failed to ensure that the residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficient practice affects 3 out of 8 receiving services at the facility (RS #102,# 201 and #205). Findings include: 1. Resident 102 is a [AGE] year-old female admitted to the facility on [DATE], with a diagnosis of Right Total Knee Replacement. During the record review, performed on 04/29/2025, at 12:00 P.M., it was found that has a physician order on 04/24/2025, for medication Cymbalta 30 mg orally at bedtime. On the high-risk medication review sheet, the pharmacist documented that this was an antidepressant. No justification for the use of this antidepressant was observed in the physician notes. a) During the interview with the Director of Nursing (employee #1), she stated that the residents arrived with instructions and a prescription from their orthopedic surgeon to continue treatment at her facility. She states that the orthopedic surgeon prescribed Cymbalta for pain management, not as an antidepressant. The facility failed to provide evidence in the physician's progress notes justifying the use of this medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment and facility staff interview performed on 04/28/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. Findings include: 1. During the observations performed in the resident's rooms, the following was observed: a) On 04/28/2025 at 10:23 AM several spiders (3) were observed in room [ROOM NUMBER].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview with the Minimum Data Set- (MDS) coordinator (employee #2), it was determined that the facility failed to accurately electronically transmit resident assessment instrument status correctly in 2 out of 2 closed records reviewed (RR). (Resident #1 and #2) Findings include: 1. During the records reviewed the electronic system identified resident #1 as a Hospitalization. On 04/29/24 at 10:00 AM during the record review it was found that Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Left Total Knee Replacement, in the record appears that resident #1 receive her treatment and on 03/14/2025 the resident have an appointment with the Orthopedic physician and do not want to return to the facility to completed her treatment per one day due to the physician planned to discharge on [DATE]. She requests to the facility exonerate one day on 03/14/2025 of rehabilitation, and resident was discharged to home on [DATE], with a discharge summary with Home Care, and medical equipment. The MDS Section A A0310 F, she marks 10 discharge assessment- return not administrate. The MDS was completed on 03/14/2025. During the interview on 04/29/205 at 10:15 AM with the MDS Coordinator Employee #2, stated, this resident was discharged to the community, however when the information was entered to the system on 03/18/2025 was documented by error short-term general hospital. On 04/29/2025 at 10:25 AM, she corrects this error as Discharge and was transmitted correctly and accepted. 2. During the records reviewed the electronic system identified resident #2 as a Unplanned (facility Initiated) Discharge. On 4/29/25 10:30 AM during the record review it was found that Resident #2 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement (Rt TKR). The record revealed that the social work planned the discharge from the moment of admission. Discharge notification was not made because the resident presented changes in health, therefore, he was transferred to the hospital on [DATE] due to an rule out (R/O) of kidney failure. The MDS coordinator employee #2 interviewed on 04/29/2025 at 10:43 AM refer that this resident was hospitalized , however when the information was entered to the system was document by error discharge Home. On 4/29/2025 at 9:41 AM she corrects this error and was transmitted correctly and accepted.

Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/28/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: During observational tour of kitchen on April 28, 2025, approximately from 8:27 AM through 12:00 PM the following was identified: 1. Chicken pieces were observed in the freezer. They were found in a broken, sealed package with exposed parts outside the wrapping and covered in plastic wrap. Kitchen staff indicated that they had been received from the supplier in that condition. 2. Kitchen staff were observed using a scoop to serve rice. Staff cleaned the utensil without the proper process of letting it air dry after sanitizing. 3. The kitchen supervisor was observed near the food serving area without wearing a hairnet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the medication Pass performed on 4/29/2025 from 8:10 AM till 8:50 AM it was observed the following: a. During the medication pass with the registered nurse employee #3, it was observed that the failed to wash her hand on 4 out of 10 opportunity to wash her hands before open the door of 5 resident rooms. Based on observations, staff interviews and review of policies and procedures on 04/28/2025 through 04/29/2025 at 8:12 AM through 3:30 PM, it was determined that 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. Findings incliude: 1. During the round conducted in the residents' rooms, the following was observed: a. On 04/28/2025 at 9:48 AM, the physical therapy assistant (employee #4) was observed entering room [ROOM NUMBER] A without washing her hands and without wearing gloves while placing ice packs on Resident #201. The Director of Nursing (DON) (employee #1) was interviewed on 04/29/2025 at 10:45 AM, and asked for a policy and procedure for the placement of cold compresses. When the DON provided the policy, the lack of integration of hand washing and glove use into the procedure was noted.

Based on an interview with the Infection Control coordinator (employee #1) on 4/29/2025, it was determined that the facility failed to ensure an antibiotic stewardship program that promoted appropriate antibiotic use and included education of nursing and medical staff. Findings include: 1. During the review and interview of the Infection Control Program's Stewardship antibiotic program, the following were identified: a. Prolonged use of antibiotics in residents without documented justification in a report sent to the Puerto Rico Department of Health on a monthly basis. The report demonstrates the monthly volume of patients using antibiotics but is not specific. b. Policies and procedures that include written stewardship material were reviewed: dosage, indication, renal adjustment, administration, precaution, monitoring, and dilution and stability of the antibiotic. Despite having them available, they do not maintain an educational program on the appropriate use of antibiotics for physicians and nursing professionals, thus impeding the appropriate use of antibiotics and their justification in residents. On 4/29/25 3:30 PM during the interview with the Infection Control Program Coordinator (Employee # 1) revealed that they have no education on the appropriate use of antibiotics of Stewardship for physicians and nursing professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/28/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This deficient practice had the potential to affect 18 out of 18 residents receiving services at areas where the deficient environment and items. Findings include: 1. Water damage and humidity noticed on bathroom ceiling and A bed area of room [ROOM NUMBER]. 2. Water drops caused by condensation on air conditioning vents were observed wetting the floor in front of exit door to back patio, this is a slip and fall risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed (RR) and interview with the Minimum Data Set- MDS coordinator (employee #1) it was identified that the facility failed to transmit as required, MDS (Minimum Data Set) with review of health data and resident status in 1 out of 1 MDS record over 120 days old. Findings include: RR#11 is a [AGE] year-old female resident admitted [DATE] with a diagnosis of Right Hip Replacement. The resident admission was on 10/22/2023 and discharge home was on 11/01/2023. On 04/23/2024 at 10:35 AM in an interview with MDS Coordinator (employee #1) it was identified that the MDS discharge data was not transmitted when finished because of lack of assessment data of the physical therapy personnel. The case remain open and that is the reason why the case appears with an MDS record over 120 days old. She explains that the case must be coded and transmitted as an admission and as discharge both before being transmitted and this was not performed. MDS coding was corrected on 04/23/2024 and transmitted with the correction. Resident assessment validation and entry system report was reviewed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview with the Minimum Data Set- (MDS) coordinator (employee #1), it was determined that the facility failed to accurately electronically transmit resident assessment instrument status correctly in 1 out of 2 closed records reviewed (RR). (Resident #2) Findings include: During the records reviewed the electronic system identified resident #2 as a Hospitalization. On 04/23/24 at 1:30 PM during the record review it was found that Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Status post-surgery of Lumbar stenosis, in the record appears that resident #2 was a planned Discharge Home to the community due to completing goal and was discharged on 1/30/24 with appointment with primary physician and surgeon for follow up and continue treatment with home care for Physical Therapy Services for 10 days and Nursing Services for wound care. The MDS coordinator employee #1 interviewed on 04/23/2024 at 01:40 PM refer that this resident was discharged to the community, however when the information was enter to the system was document by error short-term general hospital. On 4/23/2024 at 3:01 PM she corrects this error and was transmitted correctly and accepted.

Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/22/2024 through 04/23/2024 to from 8:00 AM through 4:00 PM, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: During observational tour of kitchen on April 22, 2024, approximately at 8:52 AM, products such as cheese and meat were found unlabeled on the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/22/2024 through 04/23/2024 to from 8:00 AM through 5:00 PM, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This deficient practice had the potential to affect 18 out of 18 residents receiving services at areas where the deficient environment and items. Findings include: 1. room [ROOM NUMBER] was observed detached from the wall behind bed and in bathroom. 2. Towel rack on room was found loose from the wall. 3. Chipped Formica was found chipped in most of the facility' rooms as detailed: 111 Bathroom door with chipped panel near doorknob 110 Chipped Formica on closets 109 Chipped Formica on night tables 108 Chipped Formica on night tables and closet of resident A and B 107 Chipped Formica on night tables and closet of resident A and B 106 Chipped Formica on night tables and closet of resident A and B 105. Chipped Formica on night tables and closet of resident A and B. Glue was observed on side of closet A 104. Chipped Formica on night tables and closet of resident A and B. Hinges on closets in need of repair 103. Chipped Formica on night table resident A 102. Chipped Formica on Closet A 101. Chipped Formica on closet resident B and night tables of resident A and B

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on recertification survey and interview with the Minimum Data Set- (MDS) coordinator (employee #6), it was determined that the facility failed to accurately electronically transmit resident assessment instrument status correctly in 1 out of 2 closed records reviewed. (Resident #1) Findings include: During the recertification survey the electronic system identified the resident #1 as a Hospitalization On 05/04/23 at 1:15 PM during the record review it was found that Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with an history of Anemia with a diagnosis of Right Total hip replacement and history of anemia, high blood pressure, arthritis, and asthma. In the record appears that resident #1 was at a planned Discharge Home due to completing goal and was discharged with home care PT services per 10 days. The MDS coordinator employee #6 telephonic interview on 05/04/2023 at 02:02 PM refer that she was with a sick license and did not have access to their system cloud to verify the resident disposition in the validation report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. Resident #152 is a [AGE] year-old female admitted on [DATE] with diagnosis of Left Total Knee Replacement. The resident was asked on 5/04/2023 at 1:15 PM his participation in the recreative activities provided by the facility. The resident reports that the same day was admitted , began to participate in activities with crossword puzzles and later with wooden crafts. During review of the medical record of Resident # 152 on 5/04/2023 at 11:08 AM, no evidence was found of the care plan by the interdisciplinary team that allows the identification of the resident's recreative activities for the physical, mental, and psychosocial well-being for create the resident's independence in the community. f. Resident # 153 is a [AGE] year-old male admitted on [DATE] with diagnosis of Status Post Stenosis Lumbar Surgery. The resident was asked on 5/03/2023 at 2:10 PM his participation in the recreative activities provide by the facility. The resident stated that no one had told him that there were recreational activities at the facility. During review of the medical record of Resident # 153 on 5/04/2023 at 11:49 AM, no evidence was found of the care plan by the interdisciplinary team that allows the identification of the resident's recreative activities for the physical, mental, and psychosocial well-being for create the resident's independence in the community. g. Resident #155 is a [AGE] year-old female admitted on [DATE] with diagnosis of Left Total Knee Replacement. The resident was asked on 5/04/2023 at 1:15 PM his participation in the recreative activities provided by the facility. The resident indicated that was aware of the activities but had not yet participated. During review of the medical record of Resident # 155 on 5/04/2023 at 11:08 AM, no evidence was found of the care plan by the interdisciplinary team that allows the identification of the resident's recreative activities for the physical, mental, and psychosocial well-being for create the resident's independence in the community. A Recreative Therapist (Employee #4) on 5/04/2023 at 11:28 AM was interviewed and no evidence was found of the recreative activities comprehensive care plan on the RR # 152, #153 and #155 she was on vacation since from 4/23/2023 to 4/30/2023 in the meantime, she will complete the initial plan and progress note. c. RR# 166 is [AGE] years old a male resident admitted on [DATE] with a diagnosis of Status Post Right Total Knee Replacement. Resident was asked on 05/03/2023 at 11:09 AM about his participation on recreative activities provided by facility personnel or sponsored by facility. He stated that he participates in a recreational activity program playing dominoes, viewing movies, painting, motivational coffee break chat. He stated that he is happy with recreative activities provided by the facility because meets his interests and promotes interaction with other residents. Review of the medical record of RR# 166 performed on 05/04/2023 at 2:07 PM did not have evidence of the recreative activities development and implementation of a comprehensive care plan prepared by the interdisciplinary team to meet resident preferences and goals and address the resident's mental and psychosocial needs. d. RR# 167 is [AGE] years old a male resident admitted on [DATE] with a diagnosis of Status Post Stenosis Lumbar surgery. Resident was asked on 05/03/2023 at 10:50 AM about his participation on recreative activities provided by facility personnel or sponsored by facility. He stated that he participates on recreative activity program as painting and viewing movies, but he likes to stay in the room, but he does not have concern with recreative activities provided by the facility because promote the interaction with other residents. Review of the medical record of RR# 167 performed on 05/04/2023 at 2:07 PM did not have evidence of the recreative activities development and implementation of a comprehensive care plan prepared by the interdisciplinary team to meet resident preferences and goals and address the resident's mental and psychosocial needs. Recreative Therapist (employee #4) was interviewed on 05/04/2023 at 4:00 PM. during interview she stated that RR# 166 and # 167 did not have evidence of the recreative activities comprehensive care plan revision, because she began vacations on 04/23/2023 through 04/30/2023 and cases admitted on this period did not have the documentation required. She stated that she is in the process of complete recreative activities and comprehensive care plan with the interdisciplinary team members. h. RR # 161 is [AGE] years old a female resident admitted on [DATE] with a diagnosis of post Left Total Knee Replacement. Resident was asked on 05/03/2023 at 10:40 AM about his participation in procreative activities provided by facility personnel or sponsored by facility. She stated that she participates in a recreational activity program preparing handcrafts, playing golf in a computer game provided by personnel, in a motivational coffee break chat, see a movie and read. She stated that is very happy with recreative activities provided by the facility because meets her interests and promotes interaction with other residents. Review of the medical record of RR# 161 performed on 05/04/2023 at 10:00 AM did not have evidence of the recreative activities development and implementation of a comprehensive care plan prepared by the interdisciplinary team to meet resident preferences and goals and address the resident's mental and psychosocial needs. Recreative Therapist (employee #4) was interviewed on 05/04/2023 at 4:00 PM. During interview she stated that RR #161 did not have evidence of the recreative activities comprehensive care plan revision, because she began vacations on 04/23/2023 through 04/30/2023 and cases admitted on this period did not have the documentation required. She stated that she is in the process of complete recreative activities and comprehensive care plan with the interdisciplinary team members. Based on a recertification survey, review of eleven medical records, resident interview and interview with the Nursing Supervisor (employee #2) performed from 05/01/2023 thru 05/02/2023, from 8:30 AM thru 4:30 PM, it was determined that the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This deficient practice was identified in 8 out of 8 cases reviewed. (RR #152, #153, #155, #161, #162, #165, #166 and #167). Findings include: 1. While reviewing comprehensive care development and implementation based on a comprehensive assessment to support residents in their choice of recreative activities the following was identified: a. RR# 162 is [AGE] years old a female resident admitted on [DATE] with a diagnosis of Status post Right Total Hip Replacement. Resident was asked on 05/04/2023 at 2:15 PM about her participation on recreative activities provided by facility personnel or sponsored by facility. She stated that she participates in a recreational activity program playing dominoes making crosswords games, participate in a religious service and in a motivational coffee break chat. She stated that she is very happy with recreative activities provided by the facility because meets her interests and promotes interaction with other residents. Review of the medical record of RR# 162 performed on 05/04/2023 at 3:00 PM did not have evidence of the recreative activities development and implementation of a comprehensive care plan prepared by the interdisciplinary team to meet resident preferences and goals and address the resident's mental and psychosocial needs. b. RR# 165 is [AGE] years old a male resident admitted on [DATE] with a diagnosis of Status post Right Total Hip Replacement. Resident was asked on 05/04/2023 at 1:00 PM about his participation in procreative activities provided by facility personnel or sponsored by facility. He stated that he participates in a recreational activity program preparing handcrafts, playing golf in a computer game provided by personnel, in a motivational coffee break chat, see a movie and read. He stated that he is very happy with recreative activities provided by the facility because meets his interests and promotes interaction with other residents. Review of the medical record of RR# 162 performed on 05/04/2023 at 2:00 PM did not had evidence of the recreative activities development and implementation of a comprehensive care plan prepared by the interdisciplinary team to meet resident preferences and goals and address the resident's mental and psychosocial needs. Recreative Therapist (employee #4) was interviewed on 05/04/2023 at 4:00 PM. During interview she stated that RR# 162 and # 165 did not have evidence of the recreative activities comprehensive care plan revision, because she began vacations on 04/23/2023 through 04/30/2023 and cases admitted on this period did not have the documentation required. She stated that she is in the process of complete recreative activities and comprehensive care plan with the interdisciplinary team members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. Resident #152 is a [AGE] year-old female admitted on [DATE] with diagnosis of Left Total Knee Replacement. The resident was asked on 5/04/2023 at 1:15 PM his participation in the recreative activities provided by the facility. The resident reports that the same day was admitted , began to participate in activities with crossword puzzles and later with wooden crafts. Observed the medical record of Resident # 152 on 5/04/2023 at 11:08 AM, no evidence was found of the care plan by the interdisciplinary team that allows the identification of the resident's recreative activities for the physical, mental, and psychosocial well-being for create the resident's independence in the community. f. Resident # 153 is a [AGE] year-old male admitted on [DATE] with diagnosis of Status Post Stenosis Lumbar Surgery. The resident was asked on 5/03/2023 at 2:10 PM his participation in the recreative activities provide by the facility. The resident stated that no one had told him that there were recreational activities at the facility. Review of the medical record of Resident # 153 on 5/04/2023 at 11:49 AM, no evidence was found of the care plan by the interdisciplinary team that allows the identification of the resident's recreative activities for the physical, mental, and psychosocial well-being for create the resident's independence in the community. g. Resident #155 is a [AGE] year-old female admitted on [DATE] with diagnosis of Left Total Knee Replacement. The resident was asked on 5/04/2023 at 1:15 PM his participation in the recreative activities provided by the facility. The resident indicated that who was aware of the activities but had not yet participated. Observed the medical record of Resident # 155 on 5/04/2023 at 1:10 PM, no evidence was found of the care plan by the interdisciplinary team that allows the identification of the resident's recreative activities for the physical, mental and psychosocial well-being for create the resident's independence in the community. A Recreative Therapist (Employee #4) on 5/04/2023 at 11:28 AM was interviewed and no evidence was found of the recreative activities comprehensive care plan on the RR # 152, #153 and #155 she was on vacation since from 4/23/2023 to 4/30/2023 in the meantime, she will complete the initial plan and progress note. c. RR# 166 is [AGE] years old a male resident admitted on [DATE] with a diagnosis of Status Post Right Total Knee Replacement. Resident was asked on 05/03/2023 at 11:09 AM about his participation on recreative activities provided by facility personnel or sponsored by facility. He stated that he participates in a recreational activity program playing dominoes, viewing movies, painting, motivational coffee break chat. He stated that he is happy with recreative activities provided by the facility because meets her interests and promotes interaction with other residents. Review of the medical record of RR# 166 performed on 05/04/2023 at 2:07 PM, did not have evidence of the recreative activities comprehensive care plan revision by the interdisciplinary team members with information that permit identify if recreative designed meet resident interests support his physical, mental, and psychosocial well-being and encourage his independence and interaction in the community. Did not have evidence of the recreative activities development and implementation of a comprehensive care plan prepared by the interdisciplinary team to meet resident preferences and goals and address the resident's mental and psychosocial needs. d. RR# 167 is [AGE] years old a male resident admitted on [DATE] with a diagnosis of Status Post Stenosis Lumbar surgery. Resident was asked on 05/03/2023 at 10:50 AM about his participation on recreative activities provided by facility personnel or sponsored by facility. He stated that he participates on recreative activity program as painting and viewing movies, but he likes to stay in the room, but he does not have concern with recreative activities provided by the facility because promote the interaction with other residents. Review of the medical record of RR#167 performed on 05/04/2023 at 2:07 PM, did not have evidence of the recreative activities comprehensive care plan revision by the interdisciplinary team members with information that permit identify if recreative designed meet resident interests support his physical, mental, and psychosocial well-being and encourage his independence and interaction in the community. Recreative Therapist (employee #4) was interviewed on 05/04/2023 at 4:00 PM. During interview she stated that RR# 166 and # 167 did not have evidence of the recreative activities comprehensive care plan revision, because she begins vacations on 04/23/2023 through 04/30/2023 and cases admitted on this period did not have the documentation required. She stated that she is in the process of completing recreative activities comprehensive care plan and revision with the interdisciplinary team members. h. RR# 161 is [AGE] years old a female resident admitted on [DATE] with a diagnosis of Left Total Knee Replacement. Resident was asked on 05/01/2023 at 10:40 AM about her participation on recreative activities provided by facility personnel or sponsored by facility. She stated that she participates on recreative activity program as viewing movies, painting, craft, and other activities. I like to stay in the room, I do not have concern with recreative activities provided by the facility because promote the interaction with other residents. Review of the medical record of RR#161 performed on 05/04/2023 at 10:40 AM, did not have evidence of the recreative activities comprehensive care plan revision by the interdisciplinary team members with information that permit identify if recreative designed meet resident interests support his/her physical, mental, and psychosocial well-being and encourage his/her independence and interaction in the community. Recreative Therapist (employee #4) was interviewed on 05/04/2023 at 4:00 PM. During interview she stated that RR# 161 did not have evidence of the recreative activities initial assessment, comprehensive care plan revision, because she begins vacations on 04/23/2023 through 04/30/2023 and cases admitted on this period did not have the documentation required. She stated that she is in the process of completing recreative activities, a comprehensive care plan and revision with the interdisciplinary team members. Based on a recertification survey, review of eleven medical records, resident interview and interview with the Nursing Supervisor (employee #2) performed from 05/01/2023 thru 05/02/2023, from 8:30 AM thru 4:30 PM, it was determined that the facility failed to review and revise the care plan based on the comprehensive assessment designed to support residents in their choice of recreative activities. This deficient practice was identified in 8 out of 8 cases reviewed. (RR #152, #153, #155, #161, #162, #165, #166, and #167). Findings include: 1. While reviewing comprehensive care revision that must be developed after the implementation of the comprehensive care plan for recreative activities the following was identified: a. RR# 162 is [AGE] years old a female resident admitted on [DATE] with a diagnosis of Status post Right Total Hip Replacement. Resident was asked on 05/04/2023 at 2:15 PM about her participation on recreative activities provided by facility personnel or sponsored by facility. She stated that she participates in a recreational activity program playing dominoes making crosswords games, participate in a religious service and in a motivational coffee break chat. She stated that she is very happy with recreative activities provided by the facility because meets her interests and promotes interaction with other residents. Review of the medical record of RR# 162 performed on 05/04/2023 at 3:00 PM did not had evidence of the recreative activities comprehensive care plan revision by the interdisciplinary team members with information that permit identify if recreative designed meet resident interests support her physical, mental, and psychosocial well-being and encourage her independence and interaction in the community. b. RR# 165 is [AGE] years old a male resident admitted on [DATE] with a diagnosis of Status post Right Total Hip Replacement. Resident was asked on 05/04/2023 at 1:00 PM about his participation in procreative activities provided by facility personnel or sponsored by facility. He stated that he participates in a recreational activity program preparing handcrafts, playing golf in a computer game provided by personnel, in a motivational coffee break chat, see a movie and read. He stated that he is very happy with recreative activities provided by the facility because meets his interests and promotes interaction with other residents. Review of the medical record of RR# 165 performed on 05/04/2023 at 1:45 PM did not have evidence of the recreative activities comprehensive care plan revision by the interdisciplinary team members with information that permit identify if recreative designed meet resident interests support his physical, mental, and psychosocial well-being and encourage his independence and interaction in the community. Recreative Therapist (employee #4) was interviewed on 05/04/2023 at 4:00 PM. During interview she stated that RR# 162 and # 165 did not have evidence of the recreative activities comprehensive care plan revision, because she begins vacations on 04/23/2023 through 04/30/2023 and cases admitted on this period did not have the documentation required. She stated that she is in the process of completing recreative activities comprehensive care plan and revision with the interdisciplinary team members