Every finding on record at Granbury Rehab & Nursing

Based on interview and record review, the facility must not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual has completed a training and competency evaluation program for 1 of 4 (NA C) non-certified nurse aides reviewed. The facility failed to ensure full-time NA C was certified within four months of the date of hire.This failure placed residents at risk of receiving inappropriate care from an individual whose skill level was not known. Findings included:Record review of the facility's employee files reflected NA C was hired on 12/03/2025 as a full-time nurse aide in training. Further review reflected NA C filled out employment application for CNA position on 11/19/2025. Pre-Employment Checklist for NA C with Yes circled by CNA Certification Verification and completed by [NA C name] on 12/03/2025. No staff member signed or dated approved to start employment section of NA C's Pre-Employment Checklist form.Record review of NA C's training documents reflected he completed skills check-off form on 12/22/2025 and was satisfactory for direct patient care. Further review reflected a NATCEP certificate dated 12/22/2025 for completing the nurse aide training program at [facility name].Record review of Nurse Staffing schedules from April 23, 2026 - May 1, 2026 reflected NA C worked as only nurse aide on hall with one nurse:-Hall C from 2 p.m. - 10 p.m. on April 23, 2026;-Hall C from 2 p.m. - 10 p.m. on April 24, 2026;-Hall C from 2 p.m. - 10 p.m. on April 27, 2026;-Hall C from 2 p.m. - 10 p.m. on April 28, 2026;-Hall C from 2 p.m. - 10 p.m. on April 29, 2026;-Hall C from 2 p.m. - 10 p.m. on April 30, 2026;-Hall C from 2 p.m. - 10 p.m. on May 1, 2026;-Hall C from 2 p.m. - 10 p.m. on May 4, 2026;-Hall C from 2 p.m. - 10 p.m. on May 5, 2026;-Hall C from 2 p.m. - 10 p.m. on May 6, 2026;-Hall C from 2 p.m. - 10 p.m. on May 7, 2026;-Hall A from 6 a.m. - 2 p.m. on May 9, 2026;-Hall C from 2 p.m. - 10 p.m. on May 11, 2026;-Hall B from 2 p.m. - 10 p.m. on May 12, 2026;-Hall B from 2 p.m. - 10 p.m. on May 13, 2026;-Hall B from 2 p.m. - 10 p.m. on May 14, 2026;-Hall B from 2 p.m. - 10 p.m. on May 15, 2026;-Hall B from 2 p.m. - 10 p.m. on May 18, 2026; -Hall B from 2 p.m. - 10 p.m. on May 19, 2026;-Hall B from 2 p.m. - 10 p.m. on May 20, 2026;-Hall B from 2 p.m. - 10 p.m. on May 21, 2026;-Hall C from 2 p.m. - 10 p.m. on May 22, 2026;-Hall C from 2 p.m. - 10 p.m. on May 25, 2026;-Hall B from 2 p.m. - 10 p.m. on May 26, 2026; -Hall B from 2 p.m. - 10 p.m. on May 27, 2026; -Hall C from 2 p.m. - 10 p.m. on May 28, 2026;-Hall B from 2 p.m. - 10 p.m. on June 1, 2026; -Hall B from 2 p.m. - 10 p.m. on June 2, 2026; -Hall B from 2 p.m. - 10 p.m. on June 4, 2026;-Hall B from 2 p.m. - 10 p.m. on June 5, 2026;-Hall B from 2 p.m. - 10 p.m. on June 8, 2026;-Hall B from 2 p.m. - 10 p.m. on June 9, 2026;-Hall B from 2 p.m. - 10 p.m. on June 10, 2026;-Hall C from 2 p.m. - 10 p.m. on June 15, 2026;-Hall B from 2 p.m. - 10 p.m. on June 16, 2026;-Hall B from 2 p.m. - 10 p.m. on June 17, 2026;-Hall B from 2 p.m. - 10 p.m. on June 18, 2026;-Hall C from 2 p.m. - 10 p.m. on June 19, 2026;-Hall D from 10 p.m. - 6 a.m. on June 23, 2026.Record review of the facility census report, dated 06/23/2026, reflected there were 24 residents who resided on Hall B and 20 residents who resided on Hall C.During a telephone interview on 06/24/2026 at 3:45 p.m., NA C stated he was hired as a nurse aide in training and went through the CNA class at the facility. He stated he passed his written exam for certification but did not pass his clinical exam the first attempt. He stated he was scheduled for the clinical exam again and took it without passing in April 2026. He did not give specific date that second attempt performed. He stated he was let go from the facility today and stated the facility told him he should have been let go in April 2026 when he did not get certification. He stated the facility told him that it was overlooked then because the facility went through a change in ownership. He stated he normally worked on the 2-10 shift in the facility. He stated he worked with RN E and CNA D some and both were present at times when he performed resident care. He stated he was allowed to pass water and perform resident care with other staff present. He denied transferring residents, performing incontinent care, assisting with feeding, and showering residents alone.During an interview on 06/24/2026 at 3:52 p.m., CNA D stated she would assist NA C when he needed her for resident transfers. She stated she worked on a different hall, but the nurses and CNAs would help out other areas when needed. She stated she did not know if another CNA or nurse was with NA C all the time when he performed resident care. She stated she was not aware of any stipulations on what NA C could or could not do when working in the facility. During an interview on 06/24/2026 at 3:57 p.m., RN E stated she had been working at the facility for approximately one month. She stated she was unsure if NA C ever performed resident care without another CNA or nurse present. She stated she was not comfortable answering questions on what NA C could or could not do in the facility.During an interview on 06/25/2026 at 10:45 a.m., ADON B stated she did participate in the scheduling of staff including nurse aides among other duties. She stated NA C had worked as an NA on the floor after he went through the nurse aide course at the facility. She stated NA C was allowed to continue to work at the facility after he had failed his clinical test due to the facility was trying to work with him and help him get certified. She stated NAs were not allowed to transfer someone alone but could do incontinent care and showers alone because NA C had completed the skills check-off at the facility as competent. She stated the DON would know more about NA C's training, skills check-offs, and when he had failed his clinical test for certification. She stated she worked on the halls and monitored the nurses and nurse aides every day that she worked. She stated she had no concerns with NA C's direct resident care when she worked. She stated she had not been told he was not eligible to continue working in the facility after not being certified within four months. She stated she did not feel NA C was unsafe to provide resident care.During an interview on 06/25/2026 at 12:15 p.m., the HR stated she started working for the facility in December of 2025. She stated she did not have any information of NA C's job description with signature in his employee file. She stated she did not have any information of NA C's skills check-off form in his employee file, but ADON B may have that information. She stated she would put the skills check-off forms in the employee's file if she was given those documents but did not have a process of monitoring that she was given those documents. She stated she was able to provide NA C's employment application that stated he was applying for CNA position. The HR stated she did not know why NA C's Pre-Employment Checklist form was not signed or dated by a staff member approving he was approved to start employment. She stated the ADMN was responsible for signing the Pre-Employment Checklist form. She stated NA C was interviewed for job on 11/19/2025 by ADON B but she did not know when he was approved to be hired.During an interview on 06/25/2026 at 1:25 p.m., the DON stated ADON B was responsible for nursing staff scheduling. She stated she had looked for NA C's signed job description and could not find the document. She stated she was able to find and provided the skills check-off form for NA C dated 12/22/2025 along with his NATCEP certificate dated 12/22/2025 for completing the nurse aide training program at [facility name]. She stated she expected nurse aides to be demoted to hospitality aides who could not obtain certification by 120 days after hire. She stated HR was responsible for keeping up with licensures and certifications. She did not give an explanation of why NA C continued to be allowed to work as a nurse aide. She stated she felt confident in his ability to provide resident care since he had passed the skills check off during his nurse aide training at the facility. She stated she did not know why he was unable to pass the clinical test for his certification but stated he may just not be good at taking tests because of nerves. She stated she did not feel any negative impact on residents had occurred due to him continuing to work as a nurse aide but stated there was a potential for infection spread and falls from uncertified staff working after not being able to pass certification tests. She stated she had looked for a policy on sufficient and competent nurse staffing and could not find one. She stated she would continue to look but the company had gone through a change in ownership and the policies had changed.During an interview on 06/25/2026 at 2:23 p.m., the interim ADMN stated he expected HR to monitor that nurse aides were certified. He stated nurse aides should be termed if they were unable to get certified within 4 months per regulation. He stated not being certified could cause residents to be at a greater risk for infections and falls from inappropriate care. He stated NA C should have had a person with him when he provided care at all times. The interim ADMN stated he had NA C termed on 06/24/2026 when he found out that he had been allowed to work full time over 4 months without obtaining his certification. Record review of the facility's document titled, Facility Assessment for [facility name], dated 06/20/2026, reflected Our facility considered the ethnic, cultural, religious, and clinical characteristics of the resident population to determine the skills and competencies required to meet out resident needs. We identified four categories of competencies: knowledge, assessment, pharmacological/treatment/care considerations, and technical/hands-on skills. Refer to the worksheet Facility Education / Staff Competencies Necessary to Care for resident Population. The worksheet identified which staff require certain competencies and skill sets, and the frequency of education. See also Staff Development Training Plan.At the time of exit on 6/25/2026 at 3:30 PM, the requested policy for Sufficient / Competent Nurse Staffing was not provided by by the interim ADMN or the DON.

Based on observation, interview and record review the facility failed to ensure that residents were free of a med error rate of 5% or greater for 2 (Resident #7) of 25 medication pass opportunities reviewed for medication administration. The facility failed to ensure the medication error rate (8%) was less than 5% for Resident #7. This failure placed residents at risk of incorrect doses of medications and optimal therapeutic response. Findings included: Record review Resident #7's electronic face sheet, dated 06/25/2026, reflected an [AGE] year-old female admitted on [DATE]. She had an active diagnoses of GERD (indigestion caused by gastric fluids refluxing back into the esophagus after consumption), chronic kidney disease (inability for the kidneys to filter out toxins from the blood and get rid of excess fluids through urination) and CHF (chronic heart disease causing heart to not pump as much blood through the body with every beat). Record review of Resident #7's electronic physician orders, dated 06/25/2026, reflected an order for: Pantoprazole sodium 20mg tablet delayed release give 20mg by mouth one time a day for GERD ordered on 04/02/2026; Furosemide 20mg tablet give 0.5 tablet (10mg) by mouth one time a day every other day for CHF ordered on 04/01/2026. During an observation on 06/25/2026 at 8:31a.m., LVN F gave pantoprazole sodium 40mg tablet and furosemide 20mg full tablet to Resident #7. During an interview on 06/25/2026 at 8:45 a.m., LVN F stated she gave Resident #7 40mg of pantoprazole sodium and 20mg of furosemide. She stated the facility received medications from Resident #7's hospice provider and she did not know why the pharmacy delivered a different dose of medications that did not match the physician orders. She stated she should have noticed that the medication doses did not match the physician orders and get clarification about the physician order prior to administering the medications. She stated she did not notice because she was used to giving the dose on the pharmacy medication label. She stated she would call and get clarification about the medication dosage.During an interview on 06/25/2026 at 1:25 p.m., the DON stated her expectation would be for nurses to check that the dose of medication being administered matched the physician orders. She stated that if there was a discrepancy with the dosage and order, she expected for the nurse to stop and get clarification about the physician order prior to administering the medication. She stated administering a dose of medication that did not match the physician order would be considered a medication error because one of the rights of medication administration was right dose. She stated not receiving enough pantoprazole sodium could cause exacerbated epigastric symptoms (heart burn). She stated not receiving enough furosemide could cause too much fluid in the body and receiving too much furosemide could cause too little fluid in the body. She stated the nurses had been trained on the rights of medication administration and she did not know why LVN F did not check the dosage to the physician order prior to medications being given. She stated ADON A monitored nurses administering medication but she was ultimately responsible for monitoring nursing staff including medication administration.During an interview on 06/25/2026 at 2:20 p.m., ADON A stated she monitored nurses were passing medications appropriately. She stated LVN F had always done good when she monitored her administering medications in the past. She stated LVN F may have been nervous from medication pass being observed that could have caused her to not administer the correct dosage. She stated staff should follow the medication rights including right dose before administering medications to residents. During an interview on 06/25/2026 at 2:23 p.m., the interim ADMN stated he expected for nurses to pass the right medication dosage when administering medications. He stated ADON A was responsible for monitoring that nursing staff administered medications appropriately. Record review of facility policy titled Administering Medications, dated April 2019, reflected 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview and record review the facility failed to post nurse staffing information that included the resident census for 70 days of 70 days reviewed for required postings.The facility failed to update the daily nurse staffing required posting in a prominent location of the facility since April 16, 2026.This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census. Findings included:During an observation on 06/24/2026 at 10:52 a.m., the daily nurse staffing was posted in a binder where visitors signed in at desk in front lobby. The date on the most current daily nurse staffing posting was April 16th 2026.During an observation on 06/25/2026 at 8:20 a.m., the daily nurse staffing was posted in a binder where visitors signed in at desk in front lobby. The date on the most current daily nurse staffing posting was April 16th 2026.During an interview on 06/25/2026 at 10:45 a.m., ADON B stated she was responsible for posting the daily nurse staffing. She stated back in April she could no longer pull the report from the computer system as she had been doing. She stated the daily staffing would be posted in the binder in the front lobby for visitors to review. She stated she was not sure if anyone was posting it anymore but would ask the interim ADMN if he was able to pull the report from a computer system. She stated she had not asked prior to today if anyone had access to a system to pull report.During an interview on 06/25/2026 at 11:35 a.m., the interim ADMN stated his expectation would be for the daily nurse staffing posting to be posted daily. She stated ADON B was responsible for posting that report in the binder at the front entrance for visitors, families, or residents to review. He stated no posting could cause people to not be informed about the census or nursing staff hours. He stated he was not aware ADON B was having issues with printing out the posting until today. He stated ADON B was using another system for the posting and with the change in ownership the previous system was no longer available. He stated ADON B should have notified him that she was not able to pull the information. He did not feel any negative impact had occurred from the posting not being updated since April 16th 2026 because he would have provided that information had he been asked.During an interview on 06/25/2026 at 1:25 p.m., the DON stated her expectation would be for the daily nurse staffing posting to be updated daily and placed in the binder at the entrance to the facility per regulation. She stated that if visitors, families, or residents wanted to know about staffing, they could always look in the schedule binder at the nurses' station. She stated the schedule binder did not have the census documented on it. She stated she did not agree with the requirement because anyone could ask any member of management for the information and it would be provided. She stated ADON B was responsible for the daily nurse staff posting but she was ultimately responsible for the posting being updated daily.Review of facility policy titled, Posting Direct Care Daily Staffing Numbers, dated August 2022, reflected Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.1. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPN, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.2. Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care including but not limited to: assisting with activities of daily living (ADLs), administering medications, supervising care provided by CNAs, and performing nursing assessments. Medication aides, feeding assistants, hospice staff, private duty aides and administrative staff are not calculated in direct care staffing numbers. Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following: a. The name of the facility; b. The current date (the date for which the information is posted); c. The resident census at the beginning of the shift for which the information is posted; d. Twenty-four (24)-hour shift schedule operated by the facility; e. The shift for which the information is posted; f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff); g. The actual time worked during that shift for each category and type of nursing staff; and h. Total number of licensed and non-licensed nursing staff working for the posted shift.

Based on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 (Resident #2 and Resident #4) of 6 residents reviewed for administration.1. The facility failed to provide care as ordered to Resident #1's left lower leg wound on 06/01/2026.2. The facility failed to document Resident #2's72 hours surveillance, and notifications of the physician and representative in the chart following a fall on 5/27/2026. 3.The facility failed to document Resident #4's fall in nurses notes, 72 hours surveillance, and notifications of the physician and representative in the chart following a fall on 05/26/2026.4. The facility failed to document Resident #4 72 hours surveillance, and notifications of the physician and representative in the chart following a fall on 04/27/2026. These failures could place residents at risk of health and safety due to incomplete medical records. Findings included:Record review of Resident #1's electronic face sheet, dated 06/01/2026, reflected an [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with diagnoses including: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (inability to move or weakened left side after a stroke), and muscle wasting and atrophy (decreased muscle and weakness). Record review of Resident #1's quarterly MDS assessment, dated 04/28/2026, reflected Resident #1 had a BIMS score of 14 indicating intact cognition. Further review reflected her range of motion was impaired on both lower extremities, she used a wheelchair for mobility, she was dependent on staff for lower body dressing including putting on and taking off footwear, and she was at risk of developing pressure ulcers. Record review of Resident #1's comprehensive care plan, dated 06/01/2026, reflected Resident #1 needed assistance of one staff for bed mobility and dressing, Resident #1 was at risk for pressure ulcer with new intervention on 6/1/2026 to apply air mattress, and Resident #1 had fragile skin and staff to keep skin clean and dry and use lotion on dry scaly skin as needed. Record review of Resident #1's wound evaluation, dated 05/01/2026, reflected stage 4 pressure wound of the left lateral calf resolved (healed) with recommendations for prevention, continue offloading measures and skin prep daily for 7 days. Review of Resident #1's progress notes reflected: 5/27/2026 nurse practitioner rounded on resident and documented Patient is a high risk of developing pressure sores, indicated by a score of 12 on Braden Scale for Predicting Pressure Sore Risk. 5/31/2026 Re-Opened wound to left posterior calf. 06/01/2026 Plan of care meeting with Resident #1's family member who was concerned about the recurring wound on Resident #1's calf. Air mattress to be placed on resident bed.Record review of Resident #1's physician orders dated 06/02/2026 reflected: Order with start date of 06/01/2026 cleanse 1 x 1 cm opened area to left calf region with NS (normal saline), apply telfa (sterile, non-adherent wound pad) non-adherent pad, then cover with bordered gauze daily until healed in the morning for wound care; Order with start date of 06/02/2026 cleanse area to posterior (toward the back of) left calf with NS or wound cleanser, pat dry, apply mupirocin (prescription antibiotic ointment) ointment to wound bed, then cover with bordered gauze daily and PRN until healed.Record review of Resident #1's June 2026 TAR reflected: No staff documented that care was performed on the 10p - 6a shift on 5/2/2026 for Left posterior calf: Healed wound: Apply skin prep every shift and LOTA for 7 days every shift. There was no rationale why treatment was not performed.Record review of Resident #1's May 2026 MAR reflected: 06/01/2026 LVN B documented she completed the wound care scheduled for 9:00 a.m. cleanse 1 x 1 cm opened area to left calf region with NS (normal saline), apply telfa (sterile, non-adherent wound pad) non-adherent pad, then cover with bordered gauze daily until healed.Record review of facility document titled weekly measurements, dated 6/1/2026, reflected Resident #1 had a wound to the left posterior leg (calf), old pressure reopened with measurements of 3 x 1.5 x 0.1.During an observation and interview on 06/01/2026 at 4:10 p.m., Resident #1 was sitting in a reclining wheelchair in her room and her left leg was propped on a wedge. Her family member was sitting beside her. Resident #1's family member stated the wound on Resident #1's left leg started looking redder last Friday, and RN A assessed the wound and did not feel it needed intervention. Resident #1's family member stated the nurse practitioner was in the building and looked at the leg also with no new intervention. Resident #1 stated, over the weekend, the wound opened and the nurse put a dressing last on Sunday. Resident #1stated no wound care had been done today. Resident #1's family member pulled up her pant leg and 4 x 4 island dressing observed covering the skin on Resident #1's left calf with the date of 5/31 written on the dressing. Resident #1 stated there was no consistency with wound care in the past. Resident #1's family member stated the facility was going to try an air mattress. Resident #1's family member stated she felt the wound developed because her mother may be putting her right foot / ankle under the left calf when she was in bed and thought that staff should be putting a pillow in between her legs to help prevent the sore from getting worse. She stated the staff should know how to take care of Resident #1 without her having to tell them.During an observation and interview on 06/02/2026 at 8:30 a.m., Resident #1 was lying in her bed and leg was offloaded with a wedge. RN A performed wound care to Resident #1's left calf. RN A stated she had performed the wound care for Resident #1 yesterday late afternoon. She showed the old dressing with the date of 06/01/2026 proving that the wound care had been performed. She stated she did not know why LVN B charted that she had performed the dressing change on 06/01/2026 morning because the dressing she took off later in the day on 06/01/2026 was dated 5/31 from Sunday. Resident #1's wound bed was pink with small amount clear drainage, no unhealthy tissue present, no odors, and no concerns were observed with the wound care RN A provided. Resident #1 did not voice any pain during the treatment. RN A stated that Resident #1 did have a pressure ulcer that was healed in the same area. She stated Resident #1 had been seen by the wound care physician that rounded until it was healed. She stated she obtained measurements of Resident #1's wound yesterday when she performed the treatment and would provide the document where those measurements were documented. She stated she had to update the order in the medical record that morning so that the treatment would show up on the TAR because it was showing up on the LVN MAR before which may have led to the confusion. She stated nurses should not document a treatment that they did not perform.During an interview on 06/02/2026 at 8:55 a.m., LVN B stated she did not perform wound care on Resident #1's left calf yesterday. She stated she was not aware that she had documented that she completed the wound care. She pulled up Resident #1's MAR and saw that she did chart completed at 10:45 a.m. on 06/01/2026. She stated she must have documented the treatment done in error. She stated she was not told about the wound during shift change, and that may have led to her missing the wound care on the MAR. She stated nurses could let each other know about changes in resident condition by putting in a communication note and she did not remember seeing the communication note on Resident #1. She stated she knew not to document treatments that she did not perform and did it in error. She stated documenting a treatment that wasn't done could cause the resident to miss that treatment and could make the wound worsen.During an interview on 06/02/2026 at 9:05 a.m., the DON stated she expected nurses to document only the treatment that they administered. She stated it was not appropriate for a nurse to document a treatment was performed even when another nurse performed that treatment because it could lead to the treatment being missed. She stated there was a communication note in Resident #1's chart and that was how the nurses could communicate changes in condition. She stated LVN B should have known about the wound from the communication note and it should have been communicated verbally at shift change. She stated RN A knew about the wound because of the communication note and that was how she knew to perform the wound care on 06/01/2026. She stated not performing wound care could cause the wound to become worse but stated the wound care was performed. She stated she had a conversation with Resident #1's family member yesterday during a care plan meeting and the facility did get an air mattress to help offload skin but she was unsure if Resident #1's wound met the definition of a pressure ulcer since it was not over a bony prominence. She did not believe the treatment being performed in the afternoon by the treatment nurse would have caused any wound deterioration but stated that it did not make it appropriate for LVN B to document it was done when she did not perform the wound care. She stated she monitored that nurses were performing treatments and documenting during morning meetings. She stated she was not aware that LVN B had documented the treatment when she did not perform it. During an interview on 06/02/2026 at 2:55 p.m., the interim ADMN stated nurses were responsible for documenting what happened on their shift. He stated he expected nurses to follow policy for documenting treatments. He stated the DON monitored the nursing staff documented and performed patient treatments. He stated not documenting correctly could cause confusion on what occurred and could interfere with the next shift not being aware of wound care needs. Record review of the facility's in-services, titled False Documentation, dated 02/18/2026, reflected Charting something that is not true means documenting information in the medical record that did not actually occur, was not observed, or is knowingly inaccurate. In healthcare, this is considered falsification of medical records. What this includes.Charting care of treatments that were not provided.If you didn't see it, do it, hear it, or verify it - don't chart it. LVN B's signature was on the in-service along with other nursing staff members.Review of the facility's policy, titled Clinical Document Guideline, dated 02/14/2020, reflected Clinical document entries should be objective, factual information and communication that pertain to the care of the patient i.e. patient centered.Each healthcare team member must document his or her own clinical record entries.Review of the facility's policy, titled Skin Prevention and Management Guidelines, dated 02/14/2022, reflected Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present.Interventions will be documented in the care plan and communicated to all relevant staff. Compliance with interventions will be documented in the monthly wound note summary charting.Record review of Resident #2's electronic face sheet, dated 06/01/2026, reflected an [AGE] year-old female admitted on [DATE] with diagnoses including dementia (a condition where the brain gradually loses its ability to think, remember, and make decisions, affecting daily life), repeated falls, muscle wasting and atrophy (a wasting or thinning of muscle mass). Record review of Resident #2's annual MDS assessment, dated 05/01/2026, reflected a BIMS score of 6 indicating severe cognitive impairment. Further review reflected she used a wheelchair for mobility and had range of motion impairment to one of her lower extremities. She needed supervision for transfers and had no falls since last assessment. Record review of Resident #2's comprehensive care plan, dated 06/01/2026, reflected Resident #2 needed limited assist with toileting and had fall due to debility and poor safety awareness with interventions to anticipate and meet needs, ensure that she wore appropriate footwear when mobilizing in wheelchair, keep bed in the lowest position when not providing care, and make sure call light was in reach. Record review of Resident #2's progress notes, dated 05/27/2026, reflected Resident #2 was found in bed with wet wipes cleaning left posterior forearm. Resident stated that she got up in the middle of the night to use the bathroom and when she was getting off of the toilet her shoe slipped off and she slid down to the floor. Physical exam completed and vital signs taken. ADON notified. There was no documentation of resident representative or physician notifications. There was no documentation of after-fall surveillance every shift for 72 hours. Record review of Resident #2's medical chart assessments reflected neuros were started and documented at least every shift for 72 hours following her un-witnessed fall on 05/27/2026.Record review of facility's incident report , dated 05/27/2026, reflected Resident #2 had an un-witnessed fall, was alert and oriented to person, place, and situation, had skin tears to left forearm and left knee, no physical environment factors, had gait imbalance, and was ambulating without assistance. The DON, physician, family member, and ADON were notified. 2/3.Record review of Resident #4's electronic face sheet, dated 06/01/2026, reflected a [AGE] year-old female admitted on [DATE] and discharged on 05/29/2026 to acute care hospital with diagnoses including dementia (a condition where the brain gradually loses its ability to think, remember, and make decisions, affecting daily life), multiple myeloma (type of blood cancer that affects plasma cells in your bone marrow, causing problems with your bones, blood, and immune system), and malignant neoplasm of liver and intrahepatic bile duct (cancer that has spread to the liver and small tubes inside the liver that carry bile). Record review of Resident #4's admission MDS assessment, dated 04/28/2026, reflected a BIMS score of 4 indicating severe cognitive impairment. Further review reflected she used a wheelchair for mobility, needed substantial assistance for bed mobility and transfers, and had a life expectancy of less than 6 months.Record review of Resident #4's progress note, dated 04/27/2026, reflected resident had a witnessed fall on 4/27/2026 in the dining room where she fell out of wheelchair and sustained abrasion to left wrist. There was no documented notification of fall to representative or physician observed. There was no documentation of after fall surveillance every shift for 72 hours . Record review of Resident #4's progress notes, dated 05/26/2026 - 05/28/2026, reflected no evidence of fall, representative, or physician notification of fall. There was no documentation of after fall surveillance every shift for 72 hours. Record review of Resident #4's medical chart assessments reflected neuros were started and documented at least every shift for 72 hours following an un-witnessed fall on 05/26/2026. Record review of Resident #4's post fall evaluation, dated 05/26/2026, reflected Resident #4 rolled out of bed onto a fall mat.During an interview on 06/02/2026 at 8:40 a.m., RN A stated she did not see Resident #2 fall but was told by Resident #2 that she fell in the bathroom. She stated she assessed Resident #2, did an incident report, and performed wound care on resident #2. She stated she put in a progress note on Resident #2 and neuro assessments were started and documented under the assessments tab which lasted for 72 hours. She stated she did not know the incident report did not flow into the medical record with physician or representative notification but she documented those notifications on the incident report. She was unaware of any further documentation that would be needed after a fall. She stated neuro assessments were performed whenever there was an unwitnessed fall.During an interview on 06/02/2026 at 8:55 a.m., LVN B stated when a resident fell, the nurse would assess the resident, start neuro assessments if the fall was unwitnessed that would last for 72 hours which were documented under the assessments tab in the medical record. She stated the nurse called the physician and representative and triggered an incident report in the medical record. She stated the incident report would populate a nurses note. She did not voice any further documentation that would be needed after a fall. During an interview on 06/02/2026 at 1:21 p.m., the DON stated there should be a nurses note entered into the medical record by the nurse on duty when the fall occurred. She stated they did not know why there was no nurses note documenting Resident #4's fall on 5/26/2026. She stated the nurses documented notification of management, physician, and resident representative in the incident reports. She stated the nurses may be thinking that incident report was going into the medical record and needed to be taught again that it was an internal QA document and not part of the medical record. She stated the nurses had access to the incident reports so she did not feel, not having a progress note, would interfere with direct care staff being notified of a fall. She stated families and other individuals would not be able to see the incident report such as state agency unless the incident reports were requested so could be confusing on whether there was a fall or not. She stated she monitored that falls were documented appropriately when she completed the second section of post fall evaluation note. She stated she had not noticed that there wasn't a progress note about Resident #4's fall on 05/26/2026. She stated she was unsure what the policy stated about documenting falls in the medical record.During a follow-up interview on 06/02/2026 at 2:50 p.m., the DON stated the fall policy stated for staff to document every shift post fall in the medical record of residents who had a fall for 72 hours. She stated the nurses should document the post fall by initiating a 72 hour occurrence assessment which had not been initiated after the falls for Resident #2 and Resident #4. She stated the nurses were assessing the residents post fall every shift but were not documenting those assessments and for Resident #2 and Resident #4 neuro assessments were documented after 2 of the 3 falls. She stated the nurses needed more education on documentation post falls. During an interview on 06/02/2026 at 2:55 p.m., the interim ADMN stated he expected for nurses to document what happened on their shift. He stated he expected for the nurses to follow policy when performing nursing assessments and documentation. He stated the DON monitored the nurses were documenting appropriately and he monitored the documentation some including the post fall neuro assessments during the morning meetings. He stated not documenting correctly could cause confusion on what occurred and could interfere with the next shift not being aware of incidents. Record review of the facility's policy titled Fall Management System, dated 02/19/2021, reflected A licensed nurse will complete an Incident/Accident Report after each fall. The Incident/Accident report is not part of the medical record and documentation is not to reflect that an incident report was completed. The licensed nurse will document the fall on the nurses notes of the medical record. The documentation will reflect notifications to legal representatives and attending physician or their agent of the fall. The licensed nurse will assess and document the condition of the resident at least once per shift for at least 72 hours post fall. Documentation in the nurses' notes and/or care plan will reflect interventions attempted.An Administrative nurse will ensure that the fall is logged on the Resident Fall Tracking Log and is entered on the Incident Report QA/CQI form.

Based on observation, interview and record review, the facility failed to make sure that its menus are followed and document any substitutions made to the menus on 4 of 4 halls reviewed for food and nutrition services. The facility failed to ensure residents who ate from the kitchen received all food items according to the menu or an approved alternative during lunch meal on 9/15/2025. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss.Findings included:Resident #54Record review of Resident #54's electronic face sheet dated 9/16/2025 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: unspecified severe protein-calorie malnutrition (significant loss of body weight without trying), and dysphagia (difficulty swallowing). Record review of Resident #54's admission MDS dated [DATE] revealed: BIMS score of 12 which indicated moderate cognitive impairment. Further review of the MDS Section K - Swallowing/Nutritional Status reflected Resident #54 was on a mechanically altered diet. Record review of Resident #54's care plan dated 9/15/2025 reflected she had a swallowing problem with intervention Diet to be followed as prescribed Date Initiated: 08/26/2025. Record review of facility document with lunch notes revealed there were 2 residents (Resident #10 & Resident #54) with puree diets 9/15/2025 for the lunch service. Record review of facility's grievance log in 2025 reflected: 2/3/2025 grievance about not getting what was asked for most of the time; 2/12/2025 grievance about resident not getting a tray for breakfast and only had some bacon left so bacon and cold cereal offered to resident; 2/17/2025 grievance about lunch supposed to be pot roast and a baked potato but received a grilled cheese; 3/30/2025 grievance about resident receiving chicken tenders for lunch instead of fried chicken; 4/10/2025 another grievance about resident receiving chicken tenders instead of fried chicken; 8/4/2025 grievance about receiving grilled cheese sandwiches for 2 days in a row because the kitchen ran out of food; 8/28/2025 grievance about not getting all items that belong on delivery tray (i.e. missing drinks, missing food, and missing utensils). During an observation on 9/15/2025 at 12:32 p.m., the dry erase board in the dining room titled Menu had Week 3 written to the left side of it and Monday 9/15/25 Lunch Kielbasa Sausage, Macaroni Salad, [NAME] Peas, Dinner Roll, and Chocolate Brownie. During an observation on 9/15/2025 at 12:30 p.m., the DON was standing at the door from the kitchen leading into the dining room and asked that the food be served without the macaroni salad since the residents were waiting on the food. She stated that she realized that there were regulations, but the residents needed to eat. During an observation on 9/15/2025 at 12:33 p.m., [NAME] B started plating food. She plated food for the hall that Resident #54 resided on. Resident #54 received all items except pureed roll. All other residents residing on that hall did not receive macaroni salad. During an observation on 9/15/2025 at 12:39 p.m., ADON D observed checking trays at the door between the kitchen and the dining room for the hall that Resident #54 resided on. During an observation on 9/15/2025 at 12:41 p.m., trays left the dining room and were served down A hall without macaroni salad for residents with diets other than puree. Dining room was served trays without macaroni salad. During an observation on 9/15/2025 at 1:02 p.m., several residents left the dining room without receiving macaroni salad or a substitute. During an observation on 9/15/2025 at 1:04 p.m., trays left the dining room and were served down B hall without macaroni salad for resident with diets other than puree. During an interview on 9/15/2025 at 1:14 p.m., CNA I stated there had not been any macaroni salad served on the trays due to the kitchen did not have it available. She stated she had not informed the residents that macaroni salad did not get served. She stated not informing the residents could cause residents to have confusion from not receiving all of their food as well as residents not getting their full nutrition for their disease processes and healing. During an observation on 9/15/2025 at 1:16 p.m., trays left the dining room and were served down C hall without macaroni salad for residents with diets other than puree. During an observation on 9/15/2025 at 1:23 p.m., [NAME] B started plating food for the hall that Resident #10 resided on. No pureed roll was added to the plate for Resident #10. During an observation on 9/15/2025 at 1:29 p.m., trays left the dining room and were served down D hall without macaroni salad for residents with diets other than puree. During an observation and interview on 9/15/2025 at 1:30 p.m., Resident #54's tray observed in her room to not have pureed roll. Beside her plate, there was a meal ticket dated 9/15/2025 with items listed that included pureed dinner roll buttered. She stated she had not been given a bread option in the past. She stated she would have added the roll to her broth and drank the broth if the roll were given. During an interview on 9/15/2025 at 1:32 p.m., ADON D stated all residents should get the items on the menu when eating out of the kitchen. She stated she thought that the pureed macaroni salad was a roll and that is why she did not catch the roll was not served to Resident #10 & Resident #54. She stated she would get a pureed roll from the kitchen for Resident #10 after she was asked about items on the plate. During an interview on 9/15/2025 at 1:34 p.m., the DM stated residents on a pureed diet should have gotten a roll served with their meal. She stated she felt the cook being nervous from being watched led to the failure of the roll not being served to the 2 residents with pureed diet. She confirmed both Resident #10 and Resident # 54 had order for pureed diet. She stated macaroni salad not being appropriate temperature was the reason it was not served to the residents with diets other than pureed. She stated residents not getting all of the menu items could cause them to not get all the nutrients with their meal. She stated she monitored that all menu items were served during the meals. During an observation and interview on 9/15/2025 at 4:06 p.m., the DM provided a substitution log for August and September 2025 after she filled in the substitution for lunch service. She stated she had spoken to the dietician after meal service. She stated chips, or mashed potatoes were offered to the residents. She stated she was not responsible for notifying the residents of the substitution and the nursing staff did. Facility document titled Menu Substitution Log reflected on lunch meal 9/15/2025 chips and mashed potatoes were substituted for macaroni salad. During a confidential group interview on an undisclosed date at an undisclosed time, 9 of 9 residents voiced that they did not get macaroni salad with 9/15/2025's lunch. They stated chips or mashed potatoes were offered during the singing activity later that afternoon after 2 p.m. They stated they would have liked to be informed preferably before 2 p.m. if something during the lunch meal was going to be changed. They stated they had brought up missing items from their trays before and it continued to occur. During an interview on 9/17/2025 at 8:33 a.m., the DOO for [dietary staff contracted] stated his expectation would be for the ADON or DON to be notified of food substitution. He stated he did not know the nursing process for notifying the residents but expected for the residents to be notified of food substitution during the meal and given options when the meal was served. He stated that residents on a pureed diet should have gotten all the menu items including a roll with their meal. He stated not getting all the items or offered substitutes could lead to nutritional deficiencies. He stated he heard about items missing after the lunch meal on 9/15/2025 and [NAME] B was most likely nervous causing her to miss the roll on pureed diet trays. During a telephone interview on 9/17/2025, the dietitian stated she expected for residents to get all items on the menu during food service. She stated food offered after 2:00 p.m. would be considered a snack and substitution needed to be offered when it was determined that the macaroni salad was not going to be served. She stated the meal trays should not have been served without substitution on them. She stated all items should be served to residents for them to get nutritional adequacy. She stated the DM monitored that menus were followed, and she would monitor sometimes during her visits to the facility approximately 2-3 times a month. Record review of facility policy titled Menus and Nutritional Adequacy revised on 2/20/2018 reflected: A pre-planned menu is provided to the facility, which has been planned or reviewed by a Registered Dietitian and includes meals that are adequate to meet the average resident's nutritional needs. The meal planning guide in the Facility Diet Manual is used as the basis for menu planning. Record review of facility policy titled Menu Changes and Substitutions revised on 8/2/2017 reflected: Any variation from the planned menu will be properly documented by the Dietary Services Manager (DSM) and reviewed and signed by the Dietitian. Menu changes and substitutions, when necessary, will be made with foods of equivalent nutritive value. Menu substitutions are one time menu changes.Menu substitutions should be of equivalent nutritive value and are recorded on the menu substitution log prior to the meal being served.

Based on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 9 of 9 confidential resident council members reviewed for resident/group response. The facility failed to provide a verbal or written response to the Resident Council addressing the grievances reported from their meetings on February 2025, March 2025, and August 2025 which included issues with nursing services, dietary services, and housekeeping services. These failures could place residents at risk of unresolved grievances, a decreased sense of self-worth, and a decline in quality of life.Findings Included:Record review of the Grievance logs for February 2025 reflected Resident Council made 2 grievances. The first grievance dated 2/28/2025 involving housekeeping services reflected the SW documented that residents were notified of resolution by one-to-one discussion. The second grievance dated 2/28/2025 involving nursing services reflected no documentation that residents were notified of resolution. Record review of the Grievance logs for March 2025 reflected the Resident Council made 3 grievances. The first grievance dated 3/27/2025 involving housekeeping services reflected the SW documented that residents were notified of resolution by one-to-one discussion. The second grievance dated 3/27/2025 involving dietary services reflected the SW documented that residents were notified of resolution by one-to-one discussion. The third grievance dated 3/27/2025 involving nursing services reflected the SW documented that residents were notified of resolution by one-to-one discussion. Record review of the Grievance logs for August 2025 reflected the Resident Council made 10 grievances dated 8/28/2025. There were 3 grievances involving nursing services and seven grievances involving dietary services. On all the grievances the SW documented that residents were notified of resolution by one-to-one discussion. Record review of the Grievance logs reflected an undated grievance by Resident Council involving residents not being assisted outside for smoke breaks by staff at designated time with no facility follow up documented and no documentation that residents were notified of resolution. In a confidential group interview at an undisclosed date at an undisclosed time, 9 of 9 residents stated that no one had gotten back with them about their grievances from August. They stated that rarely anyone had come into the meeting and verified those people were the administrator and the dietary manager. They stated the issues they had filed grievances on all the issues were still ongoing. During an interview on 9/17/2025 at 10:53 a.m., the AD stated she was present during the Resident Council meetings per the residents' request. She stated she would take notes and would fill out grievance forms for the council members. She stated she would hand the completed grievance forms to the SW. The AD stated she believed those forms were then distributed to the various departments. She stated that no staff would come to the Resident Council meetings to go over the resolutions unless the Resident Council members asked for those staff members to attend. She stated the ADMN and DM had come to the meeting before to discuss resolutions. She stated she felt bad that the residents felt they were not notified of grievance notifications. She confirmed that there had never been a nurse or SW invited to the meetings. She stated there had not been any follow up on the grievances that she was aware of. She stated her plan moving forward would be to get the grievance resolutions from the SW prior to the Resident Council meetings to discuss them with the council members. During an interview on 9/17/2025 at 11:17 a.m., the SW stated she was responsible for grievances. She stated she would receive grievance forms and then would hand them to the department head they pertained to. She stated the department heads would then fill out the form with what they had done and hand them back to her. She stated she would ask for the form if she did not get them back. She stated one-to-one meant that she would talk to the resident or family member who made the grievance about how it was resolved. She stated that if the resident council had made the grievance, she believed one-to-one meant that she may have spoken to the Resident Council president but had no documentation of that occurring. She stated that moving forward, the facility decided the AD would announce the resolutions at the next council meeting but that had not been done before. She stated she monitored grievances weekly. She stated the failure occurred due to there was too much for one person to do especially if the grievance was resolved by another department head. She stated the effect of not notifying the Resident Council members of resolution to their grievances could cause them to feel that their concerns were not acknowledged. During an interview on 9/17/2025 at 1:40 p.m., the ADMN stated he expected for grievances to be handled by the SW. He stated after grievances were made, the department heads would investigate the issue and then the person who made the grievance would be informed of the outcome of the investigation. He stated he believed that the Resident Council members had been informed of the outcome of the investigation, but they may have forgotten that discussion. He stated he knew that he, the DM, and the DON had notified the Resident Council members of some of the issue resolutions. He stated not informing residents of the outcome of a grievance could make them feel that they were not being heard. He did not feel that any negative outcome had occurred because he, the SW and the DON had an open-door policy and felt that all residents could come to them if there were any issues. During a confidential follow up interview on 9/18/2025 at 10:21 a.m., a resident revealed they attended all the Resident Council meetings. They stated only once had the ADMN addressed the Resident Council about their grievances. The stated only twice had the DM addressed the Resident Council about their grievances. They verified no SW or nurse had ever addressed the Resident Council's grievances. They stated that the dietary issues, laundry issues, nursing issues have not been resolved from what was reported by the resident council during their meetings. Record review of the facility's policy titled Grievance Policy revised on 11/19/2016 reflected The designated grievance officer is the Administrator. Resident concerns should be taken seriously and that the ability to voice a grievance is an important right and protection for residents. Social Service under the guidance of the Administrator is responsible for the following: *maintains a system to keep records (file, log, copy of grievance registration forms, etc.) of all complaints reported which contains the date of report, circumstances, specifics of investigation, action taken, and follow-up with the complainant *Conduct/designate routine interviews with residents and families related to specific areas of facility life and resident ca. Document negative findings on a grievance form. The Administrator (grievance officer) is responsible for the following *Maintains a Grievance Log for 3 years *Review grievances to validate investigation of the facts and circumstances of the grievance *Written findings of fact, conclusion and recommendations and validate with person issuing the grievance timely *Establish a mechanism for all associates to communicate resident or family grievances to the designated staff so that all grievances will be documented and timely response developed and implemented.*Coordinate orientation and in-service training to ensure that all facility associates are knowledgeable of the facility grievance procedures and their role in providing responsive customer service to residents and families in grievance resolution. *Validates designee follows up with resident/family regarding resolution or explanation.

Based on observations, interviews, and record reviews, the facility failed to include in the care plan services that will be provided to the resident for 3 (Resident #9, Resident #54, and Resident #72) of 22 residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #9's comprehensive care plan had resident specific care needs for pressure ulcer.2. The facility failed to ensure Resident #54's comprehensive care plan had interventions care needs and interventions for dialysis.3. The facility failed to ensure Resident #72's comprehensive care plan had appropriate interventions for current transfer and sleeping status.4. The facility failed to ensure Resident #72's comprehensive care plan had correct code status and interventions to match her orders and wishes. These failures could affect the residents by placing them at risk for not receiving care and services to meet their wishes and needs.The findings included: Resident #9Record review of Resident #9's electronic face sheet dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, muscle wasting and atrophy (decrease in muscle mass causing weakness), and left knee effusion (fluid buildup in joint of left knee). Record review of Resident #9's admission MDS dated [DATE] reflected: BIMS score of 07 which indicated severe cognitive impairment. Further review of the MDS Section M - Skin Conditions reflected that resident had a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) that was present upon admission. Record review of Resident #9's care plan dated [DATE] and revised on [DATE] reflected Resident has a pressure ulcer and is at risk for infection, pain, and a decline in functional abilities.Interventions: Negative pressure wound therapy (a device with a suction pump, tubing, and a dressing that promotes wound healing by placing foam in wound bed which is sealed with a dressing so that there is negative pressure sucking out wound drainage to store in bin attached to the device) date initiated: [DATE]. Record review of Resident #9's electronic physician orders dated [DATE] reflected no order for negative pressure therapy. During an observation and interview on [DATE] at 8:58 a.m., Resident #9 was sitting in a wheelchair in his room beside his bed. There was foam device in his bed that he stated was for his foot. He stated staff changed the dressing on his left foot that was covered with sock during this observation. No evidence of negative pressure therapy (a device with a suction pump, tubing, and a dressing that promotes wound healing by placing foam in wound bed which is sealed with a dressing so that there is negative pressure sucking out wound drainage to store in bin attached to the device) observed. During an interview on [DATE] at 4:00 p.m., LVN F stated Resident #9 did not have a negative pressure therapy that she was aware of. LVN F stated if Resident #9 did not use negative pressure therapy, then it should not be in his care plan. She stated she did not update care plans but the nurse managers and MDS nurse were responsible for updating the care plans. Resident #54Record review of Resident #54's electronic face sheet dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: unspecified severe protein-calorie malnutrition (significant loss of body weight without trying), muscle wasting and atrophy (decrease in muscle mass causing weakness), dysphagia (difficulty swallowing), and overactive bladder. Record review of Resident #54's admission MDS dated [DATE] revealed: BIMS score of 12 which indicated moderate cognitive impairment. Further review of the MDS Section O - Special Treatments reflected Resident #54 was on hemodialysis (dialysis from blood being taken from the body and ran through a machine to clear out the toxins then put back into the body) on admission and while a resident. Record review of Resident #54's care plan dated [DATE] reflected she required Enhanced Barrier Precautions for implanted vascular access device for dialysis with intervention to wear gown and gloved during high-contact resident care activities. Further review of the care plan reflected no evidence to assess the resident's condition and monitor for complications before and after dialysis treatments received as a certified dialysis facility. There was no evidence of ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Record review of Resident #54's medical record reflected an admission letter dated [DATE] from dialysis center with dialysis schedule starting on [DATE]. During an observation and interview on [DATE] at 12:00 p.m., Resident #54 was sitting in wheelchair talking to a visitor. Resident #54 appeared to have a central line dressing that was dry and intact, with no drainage noted. The dressing was also labeled with staff initials, date, and time. This resident was alert and oriented providing information of dialysis transport twice a week. Resident #72Record review of Resident #72's electronic face sheet dated [DATE] reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: muscle wasting and atrophy (decrease in muscle mass causing weakness), lack of coordination, bilateral osteoarthritis of knee (degenerative condition in which the cartilage in your joint slowly breaks down which could lead to swelling, pain, and stiffness of both knees), and chronic instability of both right and left knee. Record review of Resident #72's admission MDS dated [DATE] reflected: BIMS score of 15 which indicated cognition was intact. Further review of the MDS Section GG - Functional Abilities reflected Resident #72 was dependent on staff (helper did all the effort) during transfer from bed to chair transfer and sit to stand was not attempted due to medical condition or safety concerns. Record review of Resident #72's care plan dated [DATE] reflected Focus: [Resident #72] prefers to sleep in a recliner and requests the bed be removed from her room. Date Initiated [DATE]. Further review of Resident #72's care plan reflected [Resident #72] has physician's orders that include a status of full code. Date Initiated: [DATE] with interventions that included Ensure Full Code order on chart and Begin CPR after absence of vital signs, call 911, notify physician and notify family/responsible party. Continued review reflected Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to: debility Date Initiated: [DATE] with interventions that included ADL Assistance required.Transfers: x1 Record review of Resident #72's electronic physician orders dated [DATE] reflected Resident #72 was a DNR on [DATE]. Record review of Resident #72's medical record reflected OOH-DNR form completed on [DATE]. During an observation and interview on [DATE] at 9:05 a.m., Resident #72 was lying in the bed in her room. She stated she used to sleep in a recliner at home but since she cannot stand, the facility staff use a machine to lift her and transfer her from the bed to wheelchair and then back into the bed. She stated the facility had asked her if she would like to have CPR and she stated she did. During an interview on [DATE] at 9:31 a.m., CNA E stated Resident #72 transferred with a mechanical lift and it took 2 staff to transfer her from the bed to the wheelchair then back to the bed. During an interview on [DATE] at 10:07 a.m., RN C stated Resident #72 was a DNR because she had physician's order to be a DNR. She stated she also could tell a resident's code status by looking in the medical record under code status. RN C confirmed that Resident #72 was transferred using a mechanical lift and 2 staff members. During an interview on [DATE] at 4:03 p.m., the MDS nurse stated as she looked through Resident #9's medical record that she did not see any orders or documentation that he was ever on negative pressure therapy. She stated Resident #72 did not sleep in a recliner and did not know if she ever did during her stay at the facility. She stated that care plan transfer should reflect 2 people if resident used a mechanical lift. She stated transfer x1 meant one person assistance was needed. The MDS nurse also confirmed that Resident #72 had order for DNR and stated that care plan should match the code status in the orders. She stated her expectation would be that care plans to match current needs of the residents. The MDS nurse stated it was her responsibility to initiate the care plans then the IDT were responsible for maintaining them. She stated the IDT included herself, DON, ADONs, therapy, DM, AD, and SW. She stated the DOR was responsible for maintaining the transfer status and the SW was responsible for maintaining the code status. She stated she did not know why the care plans were not updated that the resident's current needs. She stated the DOR was away from facility on vacation at this time and she had been away on medical leave until recently. During an interview on [DATE] at 2:54 p.m., the DON stated Resident #54's dialysis treatment and anything needed concerning dialysis should be on the care plan. She verified the only the Enhanced Barrier Precautions were in the comprehensive care plan for Resident #54. She stated the last care plan conference for Resident #54 was on [DATE]. She stated she did not attend that conference and did not know why care plan did not have information on monitoring of dialysis site. She stated she and the nurses that worked the hall monitored the care plans were completed. She stated she had faith that the RNs would complete and update the care plans as needed. She stated the effect could lead to someone not knowing that she had dialysis access site that could cause bleeding or infection. During an interview on [DATE] at 3:10 p.m., the SW stated the IDT addressed care needs for the resident during care plan meetings. She stated if someone is on dialysis, it should have been addressed on preadmission and physician's orders reviewed the day of admission. She stated the nurses should have known Resident #54 was being admitted to facility on dialysis. She verified that she did attend care plan meetings and that it was the nurse's responsibility for maintaining the care plan to include dialysis care needs. She stated the IDT reviewed care plans and did not know why dialysis needs were not addressed on the care plan. She stated the failure occurred during IDT review. During an interview on [DATE] at 4:24 p.m., ADON D stated Resident #9 had never been on negative pressure therapy that she could remember. She stated negative pressure therapy was an option when pressure ulcer was triggered by MDS, and she felt that someone didn't uncheck that option which led to negative pressure therapy showing up on care plan. She stated she was not sure why Resident #72's code status, bed preference, and transfer status were not correct to match Resident #72's status and wishes. She stated the MDS nurse had been out on medical leave and that may have led to the failure, but she was not sure. She stated when the MDS nurse was on leave, corporate performed the MDS nurses duties. She stated care plans should match the residents' current needs and wishes. She stated care plans were updated by the IDT during quarterly care plan meetings. She stated the effect of care plans not being updated could lead to care not being provided as needed to the residents. During a follow up interview on [DATE] at 4:31 p.m., the DON stated her expectation would be that the care plan reflects the residents' current needs. She stated the IDT were responsible for monitoring the care plans were correct. She stated the IDT included the SW, DOR, AD, DM, ADONs and herself. She stated Resident #72 may have come to the facility with a recliner and ability to stand. She felt the failure on Resident #72's sleeping preference and transfer status may have occurred due to changing rooms from the rehabilitation hall to long term care hall. She was not sure what may have led to Resident #72's code status and Resident #9's negative pressure therapy not being accurate in the care plans. She stated the effect could be inappropriate care to the residents. Record review of facility policy titled Comprehensive Care Plans revised on [DATE] reflected: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.

Based on interviews and record review, the facility failed to ensure a qualified professional directs the activities program for 1 of 1 activity director (AD) reviewed for qualifications. The facility failed to ensure the AD, hired on July 17, 2024, was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements.This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.The findings included:Record review of the AD's employee file revealed the AD was hired, on July 17, 2024, as the activity director. Further review revealed no evidence of certification or training as a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements.During an interview on 09/17/2025 at 2:30 PM the AD stated she was hired July 2024 as the activity director. The AD stated she had difficulty getting signed up for the class due to her finances and time.During an interview on 9/18/2025 at 4:30 PM the ADMN stated his expectation was to have a certified activity director. The ADMN stated he was aware the AD did not have a certification when hired, and that the AD was responsible for completing the required courses. The ADMN stated the AD had difficulty paying for the course. The ADMN stated in September 2025 he was able to get the facility's corporate organization to pay for the course and they were waiting for the AD to receive the course. The ADMN stated he did not feel there was a negative effect on the residents due to the AD not being certified. The ADMN stated the AD was the best AD he had ever worked with, she had residents engaged in activities and residents loved her. The ADMN stated what led to failure was the AD had financial issues which delayed her paying for the program, and then it took time to get the facility's cooperation to pay for the program. Record review of the AD's Job Description signed on July 17, 2024, revealed: Qualifications: Successful completion on a state-approved and certified course of instruction in patient activities.successfully completes the state-approved and Certified Activity Director's course within nine months of beginning employment.

Based on observation, interview, and record review the facility failed to provide food prepared and served on time for 1 of 1 dining room and 4 (A, B, C, and D) of 4 halls. The facility failed to ensure that 1 of 1 lunch observed on 9/15/2025 was served at the posted mealtime 11:45 a.m. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for unplanned weight loss, side effects from medication given without food, and diminished quality of life. Findings included:During an observation on 09/15/2025 at 12:32 p.m., resident mealtimes posted outside of kitchen: Breakfast 7:00AM, Lunch 11:45AM, and Dinner 5:00PM. During an observation on 9/15/2025 at 12:30 p.m., the DON was standing at the door from the kitchen leading into the dining room and asked that the food be served without the macaroni salad since the residents were waiting on the food. She stated that she realized that there were regulations, but the residents needed to eat. During an observation on 9/15/2025 at 12:41 p.m., trays left the dining room and were served down A hall then dining room started to be served. During an observation on 9/15/2025 at 1:04 p.m., trays left the dining room and were served down B hall. During an observation on 9/15/2025 at 1:16 p.m., trays left the dining room and were served down C hall. During an observation on 9/15/2025 at 1:29 p.m., trays left the dining room and were served down D hall. All trays had been served at 1:32 p.m. During a confidential group interview on an undisclosed date at an undisclosed time, 9 of 9 residents voiced meals are not on time and they would like to have food served by 12:30 p.m. They stated they had filed a grievance in the past about mealtimes, but it continued to be late at times. During an interview on 9/15/2025 at 4:06 p.m., the DM stated she had asked her supervisor if there was a policy on meal service timing and there was not one. She did not know if there was a specific time that meals had to be served. She stated not serving meals on time could upset residents. During an interview on 9/17/2025 at 8:33 a.m., the DOO for [dietary staff contracted] stated there was no policy on meal service timing. He stated that if lunch was to be served at 11:45 a.m. and the last resident to receive a tray was at 1:30 p.m., then the meal service was not timely. During a telephone interview on 9/17/2025 at 9:51 a.m., the dietitian stated her expectation would be for meal trays to all be served within 45 minutes of the posted mealtime. She stated the DM was responsible for monitoring meals were served timely. She stated she monitored meal service sometimes when she was in the facility approximately two to three times a month. She did not know why lunch service was not timely on 9/15/2025. She stated more education was needed for the kitchen staff. Record review of facility's grievance log in 2025 reflected: 1/30/2025 grievance about food delivery service being late and food and/or plates cold; 2/3/2025 grievance about resident not getting food tray until 20 minutes after other residents served and having to go get her tray because she didn't get one at all three to four times; 8/4/2025 grievance about meals ran 30 minutes to an hour late; 8/28/2025 grievance about food delivery service more than an hour late.

Based on observations, interviews, and record reviews the facility failed to make sure that all persons in food service meet local, state, and federal requirements for 1 of 1 kitchen reviewed. 1. The facility failed to ensure holding temperatures were taken on food served during lunch service on 9/15/2025.2. The facility failed to ensure pureed kielbasa sausage, pureed greens beans, and pureed macaroni salad were heated to appropriate temperature after mechanically altering the food on 9/15/2025 during lunch service. 3. The facility failed to ensure required temperatures were documented on temperature log for 9/8/2025 breakfast, 9/8/2025 lunch, 9/9/2025 breakfast, 9/9/2025 lunch, 9/9/2025 dinner, 9/10/2025 breakfast, 9/10/2025 lunch, 9/10/2025 dinner, 9/11/2025 breakfast, 9/11/2025 lunch, 9/12/2025 breakfast, 9/12/2025 lunch, 9/13/2025 breakfast, 9/13/2025 lunch, 9/13/2025 dinner, 9/14/2025 dinner, 9/15/2025 breakfast, 9/15/2025 lunch, and 9/15/2025 dinner.These failures could place residents that eat out of the kitchen at risk for food borne illnesses.The findings included:During an observation and interview on 9/15/2025 between 11:18 a.m. and 12:30 p.m., [NAME] B pureed kielbasa sausage using cold milk as the thinning liquid. She then placed pureed kielbasa sausage into metal bin and took a temperature reading 127 F. She then put a lid on the metal bin and placed it into the steam table. [NAME] B pureed green beans using cold milk as the thinning liquid. She then placed pureed green beans into metal bin and took a temperature reading 133 F. She then put a lid on the metal bin and placed it into the steam table. [NAME] B pureed macaroni salad using cold milk as the thinning liquid. She then placed pureed macaroni salad into metal bin and took a temperature reading 127 F. She put a lid on the metal bin and placed it into the steam table. [NAME] B failed to take another temperature of any foods prior to the food being plated and placed on cart ready to leave the kitchen. [NAME] B stated she thought the steam table would bring food to correct temperature so she did not heat or cool the foods after mechanically altering them. She stated foods not being the correct temperatures could cause residents to become sick. During an interview on 9/15/2025 at 12:02 p.m., the DM stated foods should be heated to greater than 165 F for warm food and less than 40 F for cold foods after they had been prepared. She stated foods did not have to have temperatures taken again while on the steam table prior to meal service if they were appropriate temperatures after being prepared. The DM stated she felt [NAME] B being nervous caused her to not heat / cool the food after temperatures were obtained for the pureed foods. She stated food not being the correct temperature could lead to bacteria growth. During a follow-up interview on 9/15/2025 at 4:06 p.m., the DM stated the cook was responsible for obtaining temperatures. She stated that if the recipe stated food temperatures should be taken every 30 minutes then cooks should take temperatures every 30 minutes, but the food usually doesn't sit that long. She stated she monitored that the cooks were taking temperatures. She stated she did not know why temperature log on 9/13/2025 breakfast meal had no evidence that temperatures were taken. During an interview on 9/17/2025 at 8:33 a.m., the DOO for [dietary staff contracted] stated he expected for staff to follow recipes. He stated milk was an appropriate liquid to add to pureed foods, but he expected for the milk to be warmed up prior to adding to pureed warm foods. He stated pureed warm foods should be brought back up to 165 F after being mechanically altered. He stated he expected for cold foods to be kept in the refrigerator until the food was going to be served to keep it from getting warm. He stated the steam table was not appropriate for warming up food. The DOO for [dietary staff contracted] stated food temperatures should be obtained after being prepared and then again prior to food service. He stated temperatures not being done correctly could cause sickness. He stated it was the responsibility of the DM to monitor that food temperatures were being done correctly. During an interview on 9/17/2025 at 9:51 a.m., the dietitian stated she expected for food temperatures to be taken at the end of the cook time and when food was on the steam table prior to service. She stated cold foods should be stored in the refrigerator right up until service so that the temperature would be less than 41 F. She stated holding temperatures for hot foods needed to be greater than 135 and foods that were below needed to be brought up to greater than 165 F to kill any bacteria. She stated the cooks were responsible for storing prepared foods at the correct temperature and the DM monitored the cooks. She stated she monitored food temperatures at times when she was in the building approximately two to three times a month. The dietitian stated adding cold milk to hot foods could have caused the foods to become below appropriate temperature. She stated foods not being the correct temperature could cause residents to get food borne illnesses. Record review of facility document titled Food Temperature and Evaluation Log: dated 9/8/2025 - 9/15/2025 reflected: No evidence that holding temperatures taken for 9/8/2025 breakfast, 9/8/2025 lunch, 9/9/2025 breakfast, 9/9/2025 lunch, 9/9/2025 dinner, 9/10/2025 breakfast, 9/10/2025 lunch, 9/10/2025 dinner, 9/11/2025 breakfast, 9/11/2025 lunch, 9/12/2025 breakfast, 9/12/2025 lunch, 9/13/2025 lunch, 9/13/2025 dinner, 9/14/2025 dinner, 9/15/2025 breakfast, 9/15/2025 lunch, and 9/15/2025 dinner. No evidence that any temperatures taken for 9/13/2025. Record review of facility policy titled Safe Food Preparation dated 12/5/2017 reflected: Monitoring the food's internal temperature is important and will help ensure microorganisms can no longer survive and food is safe for consumption. Foods should reach the following internal temperatures for at least 15 seconds. 165 F Poultry, stuffed foods, reheating leftovers and mechanically altered foods (i.e. pureed meat, pureed vegetables).Modified Consistency: Residents who require a modified consistency diet may be at risk for developing foodborne illness because of the increased number of food handling steps required when preparing pureed and other modified consistency foods. When hot pureed, ground, or diced foods drop into the danger zone (below 135 F), the mechanically altered food must be reheated to 165 F for 15 seconds, if holding for hot service.Proper Hot-holding- All foods kept in a hot holding unit (steam-table, [NAME]-[NAME], soup warmer, etc.) must be kept at or above 135 F.If food in hot holding equipment drops below 135 F the item must be removed from hot holding and quickly re-heated to 165 F.Food holding for service: Foods and beverages will be placed on the steam table or tray line no more than 30 minutes prior to service. Designated staff will take and record temperatures of all potentially hazardous hot and cold foods prior to the beginning of meal service. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 09/15/2025 revealed: 3-403.11 Reheating for Hot Holding.(A) Except as specified under (B) and (C) and in (E) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74 C (165 F) for 15 seconds.(B) Except as specified under (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD reheated in a microwave oven for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74 C (165 F) and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating.(C) READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that has been commercially processed and PACKAGED in a FOOD PROCESSING PLANT that is inspected by the REGULATORY AUTHORITY that has jurisdiction over the plant, shall be heated to a temperature of at least 57 C (135 F) when being reheated for hot holding.(D) Reheating for hot holding as specified under (A) - (C) of this section shall be done rapidly and the time the FOOD is between 5 C (41 F) and the temperatures specified under (A) - (C) of this section may not exceed 2 hours.

Based on observation, interview and record review, the facility failed to ensure that a medication cart not being used was secured for 1 of 4 medication carts (Cart Hall D). The facility failed to ensure Cart Hall D was not left unlocked and unsecured while unattended. These failures could place all residents at risk of harm or decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions.The findings included: During an observation and interview on 09/15/2025 between 1:30 PM and 1:50 PM the medication cart on Hall D (Cart Hall D) was left unattended and unlocked from 1:30 PM to 1:35PM. There were three CNA's and residents walking up and down hall D, within arm's reach of the medication cart. The nurse was not in sight of the medication cart. ADON was walking down the hall and stated LVN A was responsible for the medication cart. ADON stated the medication cart should not have been left unlocked and unattended. Contents of the medication cart included: Zoloft (anti-depressant), Trazodone (anti-depressant), Eliquis (blood thinner), Pradaxa (anti-coagulant), Metoprolol (high blood pressure), Lisinopril (high blood pressure), Furosemide (diuretic), Bumex (diuretic), Glargine Insulin Pen (anti-diabetic), Lispro Insulin Pen (anti-diabetic), Lidocaine patches (pain relief), Seroquel (anti-psychotic), Buspar (anti-anxiety), Depakote (used for epilepsy). The medication cart also contained creams, syringes,liquid medications, alcohol pads and over the counter medications. LVN A stated she was distracted by a family member who was upset and followed the family member down the hall. LVN A stated she never left her cart unlocked. LVN A stated medication carts being left unlocked could have had negative effects to residents. During an interview on 09/18/2025 at 4:32 PM the DON stated her expectations was that all medication carts be locked when out of direct vision of the nurse. The DON stated that she was responsible to ensure medications carts are locked when not in use. The DON stated she checks to see if medication carts are locked periodically throughout the day. The DON stated this failure occurred due to poor judgement on the nurse's part. The DON stated residents could be affected if they were to get something out of the medication cart that could potentially cause them harm. Record review of the facility policy titled, Storage Medications dated 09/2018 revealed: Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts and medication supplies are locked when they are not attended by persons with authorized access.

Based on interviews and record reviews, the facility failed to follow their written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property 2 of 15 employees (RN J and DM) reviewed for employability.The facility failed to ensure the record of the initial EMR/NAR check was completed and maintained for DM hired on 7/1/2025 per facility policy. The facility failed to ensure the initial EMR check was completed and maintained for the DM hired on 06/2/2025 per facility policy. These findings placed residents at risk of receiving care by someone that was unemployable.The findings included: Record review of the RN J's employee file revealed a hire date of 07/14/2025 and no evidence of an EMR/NAR check was completed prior to hire. Record review of the DM's employee file revealed a hire date of 06/03/2025 and no evidence of an EMR/NAR check was completed prior to hire.During an interview on 09/18/2025 at 2:30 PM the HR stated she was responsible for running EMR checks upon hire and annually. The HR stated she remembered running RN J's but must have put in the shredder because she could not locate a copy of the EMR. The HR stated the only way to prove she ran the EMR was the copy of the EMR. The HR stated she ran an EMR on 9/16/2025 for RN J, which was after the survey team entered the facility. The HR stated DM was contracted and she assumed the company that was contracted was running checks. The HR stated the facility could not provide a copy of EMR check being completed. During an interview on 9/18/2025 at 4:30 PM the ADMN stated his expectation was EMR checks were to be ran prior to hiring for all staff and should have been maintained. The AMDN stated HR was responsible for running and maintaining EMR checks in resident file. The ADMN stated he was ultimately responsible to ensure employee records were maintained. The ADMN stated residents could have been affected because policy was not followed. The ADMN stated what led to failure was a new HR staff. The ADMN stated that the DM was contracted staff, and he was at the mercy of the contracted company. The ADMN stated they should have had an EMR completed for the DM because their policy required all employees to have an EMR check completed, if they had contact with residents. Record review of facility policy titled, Texas Background Screening Procedures dated 04/27/2021 revealed, All offers of employment are contingent upon the prospective Team Member (Applicant) successfully completing a background screening process conducted according to applicable federal and state laws.Employability Status Check.Regardless of position ALL Team Members are subject to this verification.

Based on interview and record review, the facility did not develop a baseline care plan, or comprehensive care plan with necessary information within 48 hours of the resident's admission for 2 (Resident #1 and Resident #54) of 24 residents reviewed for care plan completion.The facility failed to complete a new baseline care plan for Resident #1 upon admission.This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.Resident #1Review of Resident #1's Face Sheet revealed a [AGE] year-old male initially admitted on [DATE] with a recent admission date of 09/10/2025. Resident #1's medical diagnoses of Pneumonia, acute respiratory failure, depression, cognitive communication deficit and anemia. Review of Resident #1's Baseline Care Plan initiated 08/16/2025 and reviewed/revised upon readmission, 09/10/2025, had used the prior Baseline Care Plan. There was no evidence of updated signatures after readmission. Review of Resident #1's physician orders reviewed on 09/17/2025 revealed: Anticoagulant monitoring, Anticonvulsant medication, antidepressant, CPAP at night. Record review of Resident #54's baseline care plan revealed there was no evidence that the summary of the baseline care plan was given to Resident #54 or her representative. During an interview on 09/17/2025 at 2:54 PM, the ADON stated, the admitting nurse and the RN on duty were responsible for making sure the baseline care plans were updated and completed. She stated it was the DON who monitored signatures and signing off on the baseline care plans. The ADON stated the policy for discharged to home residents with a readmission was based on their referral information and discussed with the IDT team. She stated for Resident #1, they considered his admission a new admission and should start all new admission paperwork and a new baseline care plan. The ADON stated when Resident #1 was readmitted they had not populated a new Baseline Care Plan. She stated in reviewing Resident #1's Baseline Care Plan, it had not been completed based on the facility policy and recommendations. During an interview on 09/17/2025 at 3:10 PM, the SW stated she did all the notifications for Baseline Care and conference meetings. She stated she believed the deadline for care plan conferences was 72 hrs. The SW stated IDT Team were to address each issue. The SW stated it was the nurses who monitored, and it would have been their responsibility to address dialysis at the care plan and baseline care conference. She stated they (IDT team) review the diagnosis and do not know why the dialysis diagnosis was missed. The SW stated, the failure occurred with the IDT team, that if they knew she had been on dialysis coming in it should have been placed on the Baseline Care Plan. During an interview on 09/18/2025 at 8:16 AM, the DON stated, any RN monitored and/or was responsible to follow up on the responsibilities of making sure that all paperwork was completed and correct. She stated if a resident came back after being discharged , there should have been a new admission paperwork started with a readmission assessment and new orders. The DON stated there should have been a new and updated MDS, all paperwork. She then stated Resident #1 was readmission and his baseline had been established and is in care plan review right now. she stated they have 48 hrs. for the baseline but since he was a readmit, it establishes it, it was dated 9/17/2025. There was no evidence of a readmission policy provided. Record review of facility policy Baseline Care Plans dated 11/08/2016 and revised 2/14/2024 revealed: Policy:Resident person-centered baseline care plans are developed and implemented for new admission residents. Fundamental Information:Resident person-centered baseline care plans communicate fundamental care approaches and goals for resident related clinical diagnosis, identified concerns and as a result of the admission evaluation/assessment of each healthcare discipline.The baseline care plans are inclusive to support effective individualized resident care that meet professional standards of quality care and services. Baseline care plans are developed and implemented within 48 hours of a resident new admission.Process:1. The baseline care plans will be developed and implemented from minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders, admission evaluation/assessments, physician orders, dietary orders, therapy services, social services, and resident choices.4. The baseline care plans are time limited and serves as the basis for the comprehensive care plans.7. The facility provides the residents and representative with a summary of the baseline care plan in a form and manner and resident can understand.

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program 2 of 2 (CNA-E and CNA-I) staff observed during incontinent care. The facility failed to ensure CNA E, and CNA I performed proper peri-care (incontinent care) and proper hand hygiene during peri-care for Resident #91. These failures placed residents of the facility at risk of infections from improper incontinent care and hand hygiene while performing incontinent care.Findings included: Resident #91Record Review of the Resident #91's Face Sheet dated 09/18/2025, revealed she was a [AGE] year-old female. Her original admission to the facility was on 3/06/2025 with the most recent admission on [DATE]. Resident #91 had diagnoses of metabolic encephalopathy (brain lesions), cystitis (inflammation of the bladder). Record review of Resident #91's MDS assessment Section C, Cognitive Patterns dated 06/02/2025, revealed a BIMS score of 13 (cognitively intact). Record review of Resident #91's Comprehensive Care Plan initiated 09/11/2025 revealed the following focused areas:Incontinence: Resident is incontinent of bowel/bladder related to age related deficits. Goal: The resident will be clean and odor free through next review date . Interventions for the focus on incontinent care included checking frequently for wetness and being soiled, change as needed. During an observation on 09/16/2025 at 09:45 AM, CNA-E and CNA-I both performed peri-care for Resident #91. Neither CNA-E nor CNA-I washed their hands nor used hand sanitizer throughout peri-care. CNA-E was also observed folding a wipe 2 times and wiped resident before being discarded. It was observed that Resident #1 had a BM. During an Interview on 09/16/2025 at 9:55 AM, CNA E stated she knew she had failed the skills of peri-care. She stated she had double wiped as well as not using hand hygiene between the changing of dirty gloves and after incontinent care. CNA E stated she had not used hand hygiene between the changing of gloves because they had not brought hand gel into the room with them. CNA E stated she had done Infection Control/peri-care training about 3 months ago. She stated the negative impact to resident could possibly have been cross contamination, and transferring of bacteria between residents. During an interview on 09/16/2025 at 10:00 AM, the DON stated what staff should had typically followed the facility policy. She stated the facility monitored the staff on a regular basis. The DON stated she felt if the surveyor had not been watching, the CNA E would not have been nervous and would have performed it correctly. The DON stated, It would be hard to tell what the negative impact for the resident would have been on residents for not performing proper peri care. The DON stated, you should observe another incontinent care because we are always monitoring our staff. She stated the potential harm could have possibly been infection and/or cross contamination. The DON stated the facility failure was that the survey team was in the facility watching, which made the staff member nervous. Record review of facility policy Incontinent care dated 4/10/17 and revised 2/14/20 revealed: Purpose: To outline a procedure for cleansing the perineum and buttocks after an incontinence episode. Procedure.8. If feces present, remove with.disposable wipe by wiping from front or perineum toward rectum. Discard soiled materials and gloves. Wash hands. 9. Put on non-sterile, latex free gloves.15. Remove and discard gloves. 16. Wash hands.

Based on observation, interview and record review, the facility failed to make sure that its menus are followed and document any substitutions made to the menus on 4 of 4 halls reviewed for food and nutrition services. The facility failed to ensure residents who ate from the kitchen received all food items according to the menu or an approved alternative during lunch meal on 9/15/2025. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss.Findings included:Resident #54Record review of Resident #54's electronic face sheet dated 9/16/2025 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: unspecified severe protein-calorie malnutrition (significant loss of body weight without trying), and dysphagia (difficulty swallowing). Record review of Resident #54's admission MDS dated [DATE] revealed: BIMS score of 12 which indicated moderate cognitive impairment. Further review of the MDS Section K - Swallowing/Nutritional Status reflected Resident #54 was on a mechanically altered diet. Record review of Resident #54's care plan dated 9/15/2025 reflected she had a swallowing problem with intervention Diet to be followed as prescribed Date Initiated: 08/26/2025. Record review of facility document with lunch notes revealed there were 2 residents (Resident #10 & Resident #54) with puree diets 9/15/2025 for the lunch service. Record review of facility's grievance log in 2025 reflected: 2/3/2025 grievance about not getting what was asked for most of the time; 2/12/2025 grievance about resident not getting a tray for breakfast and only had some bacon left so bacon and cold cereal offered to resident; 2/17/2025 grievance about lunch supposed to be pot roast and a baked potato but received a grilled cheese; 3/30/2025 grievance about resident receiving chicken tenders for lunch instead of fried chicken; 4/10/2025 another grievance about resident receiving chicken tenders instead of fried chicken; 8/4/2025 grievance about receiving grilled cheese sandwiches for 2 days in a row because the kitchen ran out of food; 8/28/2025 grievance about not getting all items that belong on delivery tray (i.e. missing drinks, missing food, and missing utensils). During an observation on 9/15/2025 at 12:32 p.m., the dry erase board in the dining room titled Menu had Week 3 written to the left side of it and Monday 9/15/25 Lunch Kielbasa Sausage, Macaroni Salad, [NAME] Peas, Dinner Roll, and Chocolate Brownie. During an observation on 9/15/2025 at 12:30 p.m., the DON was standing at the door from the kitchen leading into the dining room and asked that the food be served without the macaroni salad since the residents were waiting on the food. She stated that she realized that there were regulations, but the residents needed to eat. During an observation on 9/15/2025 at 12:33 p.m., [NAME] B started plating food. She plated food for the hall that Resident #54 resided on. Resident #54 received all items except pureed roll. All other residents residing on that hall did not receive macaroni salad. During an observation on 9/15/2025 at 12:39 p.m., ADON D observed checking trays at the door between the kitchen and the dining room for the hall that Resident #54 resided on. During an observation on 9/15/2025 at 12:41 p.m., trays left the dining room and were served down A hall without macaroni salad for residents with diets other than puree. Dining room was served trays without macaroni salad. During an observation on 9/15/2025 at 1:02 p.m., several residents left the dining room without receiving macaroni salad or a substitute. During an observation on 9/15/2025 at 1:04 p.m., trays left the dining room and were served down B hall without macaroni salad for resident with diets other than puree. During an interview on 9/15/2025 at 1:14 p.m., CNA I stated there had not been any macaroni salad served on the trays due to the kitchen did not have it available. She stated she had not informed the residents that macaroni salad did not get served. She stated not informing the residents could cause residents to have confusion from not receiving all of their food as well as residents not getting their full nutrition for their disease processes and healing. During an observation on 9/15/2025 at 1:16 p.m., trays left the dining room and were served down C hall without macaroni salad for residents with diets other than puree. During an observation on 9/15/2025 at 1:23 p.m., [NAME] B started plating food for the hall that Resident #10 resided on. No pureed roll was added to the plate for Resident #10. During an observation on 9/15/2025 at 1:29 p.m., trays left the dining room and were served down D hall without macaroni salad for residents with diets other than puree. During an observation and interview on 9/15/2025 at 1:30 p.m., Resident #54's tray observed in her room to not have pureed roll. Beside her plate, there was a meal ticket dated 9/15/2025 with items listed that included pureed dinner roll buttered. She stated she had not been given a bread option in the past. She stated she would have added the roll to her broth and drank the broth if the roll were given. During an interview on 9/15/2025 at 1:32 p.m., ADON D stated all residents should get the items on the menu when eating out of the kitchen. She stated she thought that the pureed macaroni salad was a roll and that is why she did not catch the roll was not served to Resident #10 & Resident #54. She stated she would get a pureed roll from the kitchen for Resident #10 after she was asked about items on the plate. During an interview on 9/15/2025 at 1:34 p.m., the DM stated residents on a pureed diet should have gotten a roll served with their meal. She stated she felt the cook being nervous from being watched led to the failure of the roll not being served to the 2 residents with pureed diet. She confirmed both Resident #10 and Resident # 54 had order for pureed diet. She stated macaroni salad not being appropriate temperature was the reason it was not served to the residents with diets other than pureed. She stated residents not getting all of the menu items could cause them to not get all the nutrients with their meal. She stated she monitored that all menu items were served during the meals. During an observation and interview on 9/15/2025 at 4:06 p.m., the DM provided a substitution log for August and September 2025 after she filled in the substitution for lunch service. She stated she had spoken to the dietician after meal service. She stated chips, or mashed potatoes were offered to the residents. She stated she was not responsible for notifying the residents of the substitution and the nursing staff did. Facility document titled Menu Substitution Log reflected on lunch meal 9/15/2025 chips and mashed potatoes were substituted for macaroni salad. During a confidential group interview on an undisclosed date at an undisclosed time, 9 of 9 residents voiced that they did not get macaroni salad with 9/15/2025's lunch. They stated chips or mashed potatoes were offered during the singing activity later that afternoon after 2 p.m. They stated they would have liked to be informed preferably before 2 p.m. if something during the lunch meal was going to be changed. They stated they had brought up missing items from their trays before and it continued to occur. During an interview on 9/17/2025 at 8:33 a.m., the DOO for [dietary staff contracted] stated his expectation would be for the ADON or DON to be notified of food substitution. He stated he did not know the nursing process for notifying the residents but expected for the residents to be notified of food substitution during the meal and given options when the meal was served. He stated that residents on a pureed diet should have gotten all the menu items including a roll with their meal. He stated not getting all the items or offered substitutes could lead to nutritional deficiencies. He stated he heard about items missing after the lunch meal on 9/15/2025 and [NAME] B was most likely nervous causing her to miss the roll on pureed diet trays. During a telephone interview on 9/17/2025, the dietitian stated she expected for residents to get all items on the menu during food service. She stated food offered after 2:00 p.m. would be considered a snack and substitution needed to be offered when it was determined that the macaroni salad was not going to be served. She stated the meal trays should not have been served without substitution on them. She stated all items should be served to residents for them to get nutritional adequacy. She stated the DM monitored that menus were followed, and she would monitor sometimes during her visits to the facility approximately 2-3 times a month. Record review of facility policy titled Menus and Nutritional Adequacy revised on 2/20/2018 reflected: A pre-planned menu is provided to the facility, which has been planned or reviewed by a Registered Dietitian and includes meals that are adequate to meet the average resident's nutritional needs. The meal planning guide in the Facility Diet Manual is used as the basis for menu planning. Record review of facility policy titled Menu Changes and Substitutions revised on 8/2/2017 reflected: Any variation from the planned menu will be properly documented by the Dietary Services Manager (DSM) and reviewed and signed by the Dietitian. Menu changes and substitutions, when necessary, will be made with foods of equivalent nutritive value. Menu substitutions are one time menu changes.Menu substitutions should be of equivalent nutritive value and are recorded on the menu substitution log prior to the meal being served.

Based on observations, interviews, and record reviews, the facility failed to include in the care plan services that will be provided to the resident for 3 (Resident #9, Resident #54, and Resident #72) of 22 residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #9's comprehensive care plan had resident specific care needs for pressure ulcer.2. The facility failed to ensure Resident #54's comprehensive care plan had interventions care needs and interventions for dialysis.3. The facility failed to ensure Resident #72's comprehensive care plan had appropriate interventions for current transfer and sleeping status.4. The facility failed to ensure Resident #72's comprehensive care plan had correct code status and interventions to match her orders and wishes. These failures could affect the residents by placing them at risk for not receiving care and services to meet their wishes and needs.The findings included: Resident #9Record review of Resident #9's electronic face sheet dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, muscle wasting and atrophy (decrease in muscle mass causing weakness), and left knee effusion (fluid buildup in joint of left knee). Record review of Resident #9's admission MDS dated [DATE] reflected: BIMS score of 07 which indicated severe cognitive impairment. Further review of the MDS Section M - Skin Conditions reflected that resident had a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) that was present upon admission. Record review of Resident #9's care plan dated [DATE] and revised on [DATE] reflected Resident has a pressure ulcer and is at risk for infection, pain, and a decline in functional abilities.Interventions: Negative pressure wound therapy (a device with a suction pump, tubing, and a dressing that promotes wound healing by placing foam in wound bed which is sealed with a dressing so that there is negative pressure sucking out wound drainage to store in bin attached to the device) date initiated: [DATE]. Record review of Resident #9's electronic physician orders dated [DATE] reflected no order for negative pressure therapy. During an observation and interview on [DATE] at 8:58 a.m., Resident #9 was sitting in a wheelchair in his room beside his bed. There was foam device in his bed that he stated was for his foot. He stated staff changed the dressing on his left foot that was covered with sock during this observation. No evidence of negative pressure therapy (a device with a suction pump, tubing, and a dressing that promotes wound healing by placing foam in wound bed which is sealed with a dressing so that there is negative pressure sucking out wound drainage to store in bin attached to the device) observed. During an interview on [DATE] at 4:00 p.m., LVN F stated Resident #9 did not have a negative pressure therapy that she was aware of. LVN F stated if Resident #9 did not use negative pressure therapy, then it should not be in his care plan. She stated she did not update care plans but the nurse managers and MDS nurse were responsible for updating the care plans. Resident #54Record review of Resident #54's electronic face sheet dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: unspecified severe protein-calorie malnutrition (significant loss of body weight without trying), muscle wasting and atrophy (decrease in muscle mass causing weakness), dysphagia (difficulty swallowing), and overactive bladder. Record review of Resident #54's admission MDS dated [DATE] revealed: BIMS score of 12 which indicated moderate cognitive impairment. Further review of the MDS Section O - Special Treatments reflected Resident #54 was on hemodialysis (dialysis from blood being taken from the body and ran through a machine to clear out the toxins then put back into the body) on admission and while a resident. Record review of Resident #54's care plan dated [DATE] reflected she required Enhanced Barrier Precautions for implanted vascular access device for dialysis with intervention to wear gown and gloved during high-contact resident care activities. Further review of the care plan reflected no evidence to assess the resident's condition and monitor for complications before and after dialysis treatments received as a certified dialysis facility. There was no evidence of ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Record review of Resident #54's medical record reflected an admission letter dated [DATE] from dialysis center with dialysis schedule starting on [DATE]. During an observation and interview on [DATE] at 12:00 p.m., Resident #54 was sitting in wheelchair talking to a visitor. Resident #54 appeared to have a central line dressing that was dry and intact, with no drainage noted. The dressing was also labeled with staff initials, date, and time. This resident was alert and oriented providing information of dialysis transport twice a week. Resident #72Record review of Resident #72's electronic face sheet dated [DATE] reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: muscle wasting and atrophy (decrease in muscle mass causing weakness), lack of coordination, bilateral osteoarthritis of knee (degenerative condition in which the cartilage in your joint slowly breaks down which could lead to swelling, pain, and stiffness of both knees), and chronic instability of both right and left knee. Record review of Resident #72's admission MDS dated [DATE] reflected: BIMS score of 15 which indicated cognition was intact. Further review of the MDS Section GG - Functional Abilities reflected Resident #72 was dependent on staff (helper did all the effort) during transfer from bed to chair transfer and sit to stand was not attempted due to medical condition or safety concerns. Record review of Resident #72's care plan dated [DATE] reflected Focus: [Resident #72] prefers to sleep in a recliner and requests the bed be removed from her room. Date Initiated [DATE]. Further review of Resident #72's care plan reflected [Resident #72] has physician's orders that include a status of full code. Date Initiated: [DATE] with interventions that included Ensure Full Code order on chart and Begin CPR after absence of vital signs, call 911, notify physician and notify family/responsible party. Continued review reflected Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to: debility Date Initiated: [DATE] with interventions that included ADL Assistance required.Transfers: x1 Record review of Resident #72's electronic physician orders dated [DATE] reflected Resident #72 was a DNR on [DATE]. Record review of Resident #72's medical record reflected OOH-DNR form completed on [DATE]. During an observation and interview on [DATE] at 9:05 a.m., Resident #72 was lying in the bed in her room. She stated she used to sleep in a recliner at home but since she cannot stand, the facility staff use a machine to lift her and transfer her from the bed to wheelchair and then back into the bed. She stated the facility had asked her if she would like to have CPR and she stated she did. During an interview on [DATE] at 9:31 a.m., CNA E stated Resident #72 transferred with a mechanical lift and it took 2 staff to transfer her from the bed to the wheelchair then back to the bed. During an interview on [DATE] at 10:07 a.m., RN C stated Resident #72 was a DNR because she had physician's order to be a DNR. She stated she also could tell a resident's code status by looking in the medical record under code status. RN C confirmed that Resident #72 was transferred using a mechanical lift and 2 staff members. During an interview on [DATE] at 4:03 p.m., the MDS nurse stated as she looked through Resident #9's medical record that she did not see any orders or documentation that he was ever on negative pressure therapy. She stated Resident #72 did not sleep in a recliner and did not know if she ever did during her stay at the facility. She stated that care plan transfer should reflect 2 people if resident used a mechanical lift. She stated transfer x1 meant one person assistance was needed. The MDS nurse also confirmed that Resident #72 had order for DNR and stated that care plan should match the code status in the orders. She stated her expectation would be that care plans to match current needs of the residents. The MDS nurse stated it was her responsibility to initiate the care plans then the IDT were responsible for maintaining them. She stated the IDT included herself, DON, ADONs, therapy, DM, AD, and SW. She stated the DOR was responsible for maintaining the transfer status and the SW was responsible for maintaining the code status. She stated she did not know why the care plans were not updated that the resident's current needs. She stated the DOR was away from facility on vacation at this time and she had been away on medical leave until recently. During an interview on [DATE] at 2:54 p.m., the DON stated Resident #54's dialysis treatment and anything needed concerning dialysis should be on the care plan. She verified the only the Enhanced Barrier Precautions were in the comprehensive care plan for Resident #54. She stated the last care plan conference for Resident #54 was on [DATE]. She stated she did not attend that conference and did not know why care plan did not have information on monitoring of dialysis site. She stated she and the nurses that worked the hall monitored the care plans were completed. She stated she had faith that the RNs would complete and update the care plans as needed. She stated the effect could lead to someone not knowing that she had dialysis access site that could cause bleeding or infection. During an interview on [DATE] at 3:10 p.m., the SW stated the IDT addressed care needs for the resident during care plan meetings. She stated if someone is on dialysis, it should have been addressed on preadmission and physician's orders reviewed the day of admission. She stated the nurses should have known Resident #54 was being admitted to facility on dialysis. She verified that she did attend care plan meetings and that it was the nurse's responsibility for maintaining the care plan to include dialysis care needs. She stated the IDT reviewed care plans and did not know why dialysis needs were not addressed on the care plan. She stated the failure occurred during IDT review. During an interview on [DATE] at 4:24 p.m., ADON D stated Resident #9 had never been on negative pressure therapy that she could remember. She stated negative pressure therapy was an option when pressure ulcer was triggered by MDS, and she felt that someone didn't uncheck that option which led to negative pressure therapy showing up on care plan. She stated she was not sure why Resident #72's code status, bed preference, and transfer status were not correct to match Resident #72's status and wishes. She stated the MDS nurse had been out on medical leave and that may have led to the failure, but she was not sure. She stated when the MDS nurse was on leave, corporate performed the MDS nurses duties. She stated care plans should match the residents' current needs and wishes. She stated care plans were updated by the IDT during quarterly care plan meetings. She stated the effect of care plans not being updated could lead to care not being provided as needed to the residents. During a follow up interview on [DATE] at 4:31 p.m., the DON stated her expectation would be that the care plan reflects the residents' current needs. She stated the IDT were responsible for monitoring the care plans were correct. She stated the IDT included the SW, DOR, AD, DM, ADONs and herself. She stated Resident #72 may have come to the facility with a recliner and ability to stand. She felt the failure on Resident #72's sleeping preference and transfer status may have occurred due to changing rooms from the rehabilitation hall to long term care hall. She was not sure what may have led to Resident #72's code status and Resident #9's negative pressure therapy not being accurate in the care plans. She stated the effect could be inappropriate care to the residents. Record review of facility policy titled Comprehensive Care Plans revised on [DATE] reflected: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.

Based on interviews and record review, the facility failed to ensure a qualified professional directs the activities program for 1 of 1 activity director (AD) reviewed for qualifications. The facility failed to ensure the AD, hired on July 17, 2024, was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements.This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.The findings included:Record review of the AD's employee file revealed the AD was hired, on July 17, 2024, as the activity director. Further review revealed no evidence of certification or training as a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements.During an interview on 09/17/2025 at 2:30 PM the AD stated she was hired July 2024 as the activity director. The AD stated she had difficulty getting signed up for the class due to her finances and time.During an interview on 9/18/2025 at 4:30 PM the ADMN stated his expectation was to have a certified activity director. The ADMN stated he was aware the AD did not have a certification when hired, and that the AD was responsible for completing the required courses. The ADMN stated the AD had difficulty paying for the course. The ADMN stated in September 2025 he was able to get the facility's corporate organization to pay for the course and they were waiting for the AD to receive the course. The ADMN stated he did not feel there was a negative effect on the residents due to the AD not being certified. The ADMN stated the AD was the best AD he had ever worked with, she had residents engaged in activities and residents loved her. The ADMN stated what led to failure was the AD had financial issues which delayed her paying for the program, and then it took time to get the facility's cooperation to pay for the program. Record review of the AD's Job Description signed on July 17, 2024, revealed: Qualifications: Successful completion on a state-approved and certified course of instruction in patient activities.successfully completes the state-approved and Certified Activity Director's course within nine months of beginning employment.

Based on observation, interview, and record review the facility failed to provide food prepared and served on time for 1 of 1 dining room and 4 (A, B, C, and D) of 4 halls. The facility failed to ensure that 1 of 1 lunch observed on 9/15/2025 was served at the posted mealtime 11:45 a.m. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for unplanned weight loss, side effects from medication given without food, and diminished quality of life. Findings included:During an observation on 09/15/2025 at 12:32 p.m., resident mealtimes posted outside of kitchen: Breakfast 7:00AM, Lunch 11:45AM, and Dinner 5:00PM. During an observation on 9/15/2025 at 12:30 p.m., the DON was standing at the door from the kitchen leading into the dining room and asked that the food be served without the macaroni salad since the residents were waiting on the food. She stated that she realized that there were regulations, but the residents needed to eat. During an observation on 9/15/2025 at 12:41 p.m., trays left the dining room and were served down A hall then dining room started to be served. During an observation on 9/15/2025 at 1:04 p.m., trays left the dining room and were served down B hall. During an observation on 9/15/2025 at 1:16 p.m., trays left the dining room and were served down C hall. During an observation on 9/15/2025 at 1:29 p.m., trays left the dining room and were served down D hall. All trays had been served at 1:32 p.m. During a confidential group interview on an undisclosed date at an undisclosed time, 9 of 9 residents voiced meals are not on time and they would like to have food served by 12:30 p.m. They stated they had filed a grievance in the past about mealtimes, but it continued to be late at times. During an interview on 9/15/2025 at 4:06 p.m., the DM stated she had asked her supervisor if there was a policy on meal service timing and there was not one. She did not know if there was a specific time that meals had to be served. She stated not serving meals on time could upset residents. During an interview on 9/17/2025 at 8:33 a.m., the DOO for [dietary staff contracted] stated there was no policy on meal service timing. He stated that if lunch was to be served at 11:45 a.m. and the last resident to receive a tray was at 1:30 p.m., then the meal service was not timely. During a telephone interview on 9/17/2025 at 9:51 a.m., the dietitian stated her expectation would be for meal trays to all be served within 45 minutes of the posted mealtime. She stated the DM was responsible for monitoring meals were served timely. She stated she monitored meal service sometimes when she was in the facility approximately two to three times a month. She did not know why lunch service was not timely on 9/15/2025. She stated more education was needed for the kitchen staff. Record review of facility's grievance log in 2025 reflected: 1/30/2025 grievance about food delivery service being late and food and/or plates cold; 2/3/2025 grievance about resident not getting food tray until 20 minutes after other residents served and having to go get her tray because she didn't get one at all three to four times; 8/4/2025 grievance about meals ran 30 minutes to an hour late; 8/28/2025 grievance about food delivery service more than an hour late.

Based on observations, interviews, and record reviews the facility failed to make sure that all persons in food service meet local, state, and federal requirements for 1 of 1 kitchen reviewed. 1. The facility failed to ensure holding temperatures were taken on food served during lunch service on 9/15/2025.2. The facility failed to ensure pureed kielbasa sausage, pureed greens beans, and pureed macaroni salad were heated to appropriate temperature after mechanically altering the food on 9/15/2025 during lunch service. 3. The facility failed to ensure required temperatures were documented on temperature log for 9/8/2025 breakfast, 9/8/2025 lunch, 9/9/2025 breakfast, 9/9/2025 lunch, 9/9/2025 dinner, 9/10/2025 breakfast, 9/10/2025 lunch, 9/10/2025 dinner, 9/11/2025 breakfast, 9/11/2025 lunch, 9/12/2025 breakfast, 9/12/2025 lunch, 9/13/2025 breakfast, 9/13/2025 lunch, 9/13/2025 dinner, 9/14/2025 dinner, 9/15/2025 breakfast, 9/15/2025 lunch, and 9/15/2025 dinner.These failures could place residents that eat out of the kitchen at risk for food borne illnesses.The findings included:During an observation and interview on 9/15/2025 between 11:18 a.m. and 12:30 p.m., [NAME] B pureed kielbasa sausage using cold milk as the thinning liquid. She then placed pureed kielbasa sausage into metal bin and took a temperature reading 127 F. She then put a lid on the metal bin and placed it into the steam table. [NAME] B pureed green beans using cold milk as the thinning liquid. She then placed pureed green beans into metal bin and took a temperature reading 133 F. She then put a lid on the metal bin and placed it into the steam table. [NAME] B pureed macaroni salad using cold milk as the thinning liquid. She then placed pureed macaroni salad into metal bin and took a temperature reading 127 F. She put a lid on the metal bin and placed it into the steam table. [NAME] B failed to take another temperature of any foods prior to the food being plated and placed on cart ready to leave the kitchen. [NAME] B stated she thought the steam table would bring food to correct temperature so she did not heat or cool the foods after mechanically altering them. She stated foods not being the correct temperatures could cause residents to become sick. During an interview on 9/15/2025 at 12:02 p.m., the DM stated foods should be heated to greater than 165 F for warm food and less than 40 F for cold foods after they had been prepared. She stated foods did not have to have temperatures taken again while on the steam table prior to meal service if they were appropriate temperatures after being prepared. The DM stated she felt [NAME] B being nervous caused her to not heat / cool the food after temperatures were obtained for the pureed foods. She stated food not being the correct temperature could lead to bacteria growth. During a follow-up interview on 9/15/2025 at 4:06 p.m., the DM stated the cook was responsible for obtaining temperatures. She stated that if the recipe stated food temperatures should be taken every 30 minutes then cooks should take temperatures every 30 minutes, but the food usually doesn't sit that long. She stated she monitored that the cooks were taking temperatures. She stated she did not know why temperature log on 9/13/2025 breakfast meal had no evidence that temperatures were taken. During an interview on 9/17/2025 at 8:33 a.m., the DOO for [dietary staff contracted] stated he expected for staff to follow recipes. He stated milk was an appropriate liquid to add to pureed foods, but he expected for the milk to be warmed up prior to adding to pureed warm foods. He stated pureed warm foods should be brought back up to 165 F after being mechanically altered. He stated he expected for cold foods to be kept in the refrigerator until the food was going to be served to keep it from getting warm. He stated the steam table was not appropriate for warming up food. The DOO for [dietary staff contracted] stated food temperatures should be obtained after being prepared and then again prior to food service. He stated temperatures not being done correctly could cause sickness. He stated it was the responsibility of the DM to monitor that food temperatures were being done correctly. During an interview on 9/17/2025 at 9:51 a.m., the dietitian stated she expected for food temperatures to be taken at the end of the cook time and when food was on the steam table prior to service. She stated cold foods should be stored in the refrigerator right up until service so that the temperature would be less than 41 F. She stated holding temperatures for hot foods needed to be greater than 135 and foods that were below needed to be brought up to greater than 165 F to kill any bacteria. She stated the cooks were responsible for storing prepared foods at the correct temperature and the DM monitored the cooks. She stated she monitored food temperatures at times when she was in the building approximately two to three times a month. The dietitian stated adding cold milk to hot foods could have caused the foods to become below appropriate temperature. She stated foods not being the correct temperature could cause residents to get food borne illnesses. Record review of facility document titled Food Temperature and Evaluation Log: dated 9/8/2025 - 9/15/2025 reflected: No evidence that holding temperatures taken for 9/8/2025 breakfast, 9/8/2025 lunch, 9/9/2025 breakfast, 9/9/2025 lunch, 9/9/2025 dinner, 9/10/2025 breakfast, 9/10/2025 lunch, 9/10/2025 dinner, 9/11/2025 breakfast, 9/11/2025 lunch, 9/12/2025 breakfast, 9/12/2025 lunch, 9/13/2025 lunch, 9/13/2025 dinner, 9/14/2025 dinner, 9/15/2025 breakfast, 9/15/2025 lunch, and 9/15/2025 dinner. No evidence that any temperatures taken for 9/13/2025. Record review of facility policy titled Safe Food Preparation dated 12/5/2017 reflected: Monitoring the food's internal temperature is important and will help ensure microorganisms can no longer survive and food is safe for consumption. Foods should reach the following internal temperatures for at least 15 seconds. 165 F Poultry, stuffed foods, reheating leftovers and mechanically altered foods (i.e. pureed meat, pureed vegetables).Modified Consistency: Residents who require a modified consistency diet may be at risk for developing foodborne illness because of the increased number of food handling steps required when preparing pureed and other modified consistency foods. When hot pureed, ground, or diced foods drop into the danger zone (below 135 F), the mechanically altered food must be reheated to 165 F for 15 seconds, if holding for hot service.Proper Hot-holding- All foods kept in a hot holding unit (steam-table, [NAME]-[NAME], soup warmer, etc.) must be kept at or above 135 F.If food in hot holding equipment drops below 135 F the item must be removed from hot holding and quickly re-heated to 165 F.Food holding for service: Foods and beverages will be placed on the steam table or tray line no more than 30 minutes prior to service. Designated staff will take and record temperatures of all potentially hazardous hot and cold foods prior to the beginning of meal service. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 09/15/2025 revealed: 3-403.11 Reheating for Hot Holding.(A) Except as specified under (B) and (C) and in (E) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74 C (165 F) for 15 seconds.(B) Except as specified under (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD reheated in a microwave oven for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74 C (165 F) and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating.(C) READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that has been commercially processed and PACKAGED in a FOOD PROCESSING PLANT that is inspected by the REGULATORY AUTHORITY that has jurisdiction over the plant, shall be heated to a temperature of at least 57 C (135 F) when being reheated for hot holding.(D) Reheating for hot holding as specified under (A) - (C) of this section shall be done rapidly and the time the FOOD is between 5 C (41 F) and the temperatures specified under (A) - (C) of this section may not exceed 2 hours.

Based on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 9 of 9 confidential resident council members reviewed for resident/group response. The facility failed to provide a verbal or written response to the Resident Council addressing the grievances reported from their meetings on February 2025, March 2025, and August 2025 which included issues with nursing services, dietary services, and housekeeping services. These failures could place residents at risk of unresolved grievances, a decreased sense of self-worth, and a decline in quality of life.Findings Included:Record review of the Grievance logs for February 2025 reflected Resident Council made 2 grievances. The first grievance dated 2/28/2025 involving housekeeping services reflected the SW documented that residents were notified of resolution by one-to-one discussion. The second grievance dated 2/28/2025 involving nursing services reflected no documentation that residents were notified of resolution. Record review of the Grievance logs for March 2025 reflected the Resident Council made 3 grievances. The first grievance dated 3/27/2025 involving housekeeping services reflected the SW documented that residents were notified of resolution by one-to-one discussion. The second grievance dated 3/27/2025 involving dietary services reflected the SW documented that residents were notified of resolution by one-to-one discussion. The third grievance dated 3/27/2025 involving nursing services reflected the SW documented that residents were notified of resolution by one-to-one discussion. Record review of the Grievance logs for August 2025 reflected the Resident Council made 10 grievances dated 8/28/2025. There were 3 grievances involving nursing services and seven grievances involving dietary services. On all the grievances the SW documented that residents were notified of resolution by one-to-one discussion. Record review of the Grievance logs reflected an undated grievance by Resident Council involving residents not being assisted outside for smoke breaks by staff at designated time with no facility follow up documented and no documentation that residents were notified of resolution. In a confidential group interview at an undisclosed date at an undisclosed time, 9 of 9 residents stated that no one had gotten back with them about their grievances from August. They stated that rarely anyone had come into the meeting and verified those people were the administrator and the dietary manager. They stated the issues they had filed grievances on all the issues were still ongoing. During an interview on 9/17/2025 at 10:53 a.m., the AD stated she was present during the Resident Council meetings per the residents' request. She stated she would take notes and would fill out grievance forms for the council members. She stated she would hand the completed grievance forms to the SW. The AD stated she believed those forms were then distributed to the various departments. She stated that no staff would come to the Resident Council meetings to go over the resolutions unless the Resident Council members asked for those staff members to attend. She stated the ADMN and DM had come to the meeting before to discuss resolutions. She stated she felt bad that the residents felt they were not notified of grievance notifications. She confirmed that there had never been a nurse or SW invited to the meetings. She stated there had not been any follow up on the grievances that she was aware of. She stated her plan moving forward would be to get the grievance resolutions from the SW prior to the Resident Council meetings to discuss them with the council members. During an interview on 9/17/2025 at 11:17 a.m., the SW stated she was responsible for grievances. She stated she would receive grievance forms and then would hand them to the department head they pertained to. She stated the department heads would then fill out the form with what they had done and hand them back to her. She stated she would ask for the form if she did not get them back. She stated one-to-one meant that she would talk to the resident or family member who made the grievance about how it was resolved. She stated that if the resident council had made the grievance, she believed one-to-one meant that she may have spoken to the Resident Council president but had no documentation of that occurring. She stated that moving forward, the facility decided the AD would announce the resolutions at the next council meeting but that had not been done before. She stated she monitored grievances weekly. She stated the failure occurred due to there was too much for one person to do especially if the grievance was resolved by another department head. She stated the effect of not notifying the Resident Council members of resolution to their grievances could cause them to feel that their concerns were not acknowledged. During an interview on 9/17/2025 at 1:40 p.m., the ADMN stated he expected for grievances to be handled by the SW. He stated after grievances were made, the department heads would investigate the issue and then the person who made the grievance would be informed of the outcome of the investigation. He stated he believed that the Resident Council members had been informed of the outcome of the investigation, but they may have forgotten that discussion. He stated he knew that he, the DM, and the DON had notified the Resident Council members of some of the issue resolutions. He stated not informing residents of the outcome of a grievance could make them feel that they were not being heard. He did not feel that any negative outcome had occurred because he, the SW and the DON had an open-door policy and felt that all residents could come to them if there were any issues. During a confidential follow up interview on 9/18/2025 at 10:21 a.m., a resident revealed they attended all the Resident Council meetings. They stated only once had the ADMN addressed the Resident Council about their grievances. The stated only twice had the DM addressed the Resident Council about their grievances. They verified no SW or nurse had ever addressed the Resident Council's grievances. They stated that the dietary issues, laundry issues, nursing issues have not been resolved from what was reported by the resident council during their meetings. Record review of the facility's policy titled Grievance Policy revised on 11/19/2016 reflected The designated grievance officer is the Administrator. Resident concerns should be taken seriously and that the ability to voice a grievance is an important right and protection for residents. Social Service under the guidance of the Administrator is responsible for the following: *maintains a system to keep records (file, log, copy of grievance registration forms, etc.) of all complaints reported which contains the date of report, circumstances, specifics of investigation, action taken, and follow-up with the complainant *Conduct/designate routine interviews with residents and families related to specific areas of facility life and resident ca. Document negative findings on a grievance form. The Administrator (grievance officer) is responsible for the following *Maintains a Grievance Log for 3 years *Review grievances to validate investigation of the facts and circumstances of the grievance *Written findings of fact, conclusion and recommendations and validate with person issuing the grievance timely *Establish a mechanism for all associates to communicate resident or family grievances to the designated staff so that all grievances will be documented and timely response developed and implemented.*Coordinate orientation and in-service training to ensure that all facility associates are knowledgeable of the facility grievance procedures and their role in providing responsive customer service to residents and families in grievance resolution. *Validates designee follows up with resident/family regarding resolution or explanation.

Based on observation, interview and record review, the facility failed to ensure residents were provided with adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for adequate supervision. 1. The facility failed to implement effective interventions to address Resident #1's wandering and entering other residents' rooms and provide adequate supervision to prevent resident-to-resident altercations between Resident #1 and Residents #2 and #3. On 08/08/17, Resident #1 was kicked, choked, shaken and yelled at by Resident #2 after entering the resident's room. That same day, Resident #1 was kicked by Resident #3 when she entered the resident's room. 2. The facility failed to provide adequate supervision to Resident #1 who entered Resident #4's room on 08/15/17 and drank that resident's cup of sputum. Resident #4 was being monitored by the PCP for communicable diseases. 3. The facility failed to provide adequate supervision and effective interventions to prevent Resident #1 from entering a conference room and drinking what looked like an old cup of tea with a napkin in the cup and other things floating in the cup. An Immediate Jeopardy was identified on 09/14/17. While the IJ was removed on 09/15/17, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the facility was monitoring the effectiveness of their plan of removal. These failures could affect the five residents, who wandered, by placing them at risk for verbal aggression, physical aggression and injuries. Findings included: Review of Resident #1's Quarterly MDS assessment, dated 08/17/17, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. She had short term and long term memory problems and her cognition was severely impaired. Under area Acute Onset Mental Status Change the resident was coded a 2 (behavior present, fluctuates) for inattention and disorganized thinking. Under area Behavior Resident #1 was coded a 3 (behavior of this type occurred daily) for wandering. Resident #1 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #1 utilized a wheelchair and required supervision for locomotion on and off unit (self-sufficiency once in wheelchair). Review of Resident #1's care plan revealed a care plan for wandering/exit seeking related to cognitive impairment with an initiation date of 12/26/16. The goal reflected: Resident will wander in a safe environment without occurrence of injury and dignity will be maintained through the next review date. Identified interventions reflected the following: Redirect if resident enters a restricted area, encourage social and activity attendance, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, etc ., and resident prefers folding towels and holding her baby. Further review of Resident #1's care plan revealed a care plan for wandering, dated 09/01/17, as evidence by dementia/Alzheimer. The care plan reflected Resident #1 was kicked by another resident on 08/08/17 and wandering into a resident room and drank sputum on 08/15/17. The goal reflected: Will be able to wander in a safe environment without the occurrence of injury and dignity will be maintained over the next 90 days. Identified interventions reflected, Observe and document residents location every two hours; monitor; redirect as much as possible; start activity calendar; one on one while awake. Observation on 09/01/2017 at 11:15AM revealed Resident #1 going into Resident #5's room. Resident #5 was in his room lying down and when whenever Resident #1 was trying tried to enter his room he tried to get out of the bed. Resident #5 was talking at Resident #1 but words were not understandable. The surveyor approached Resident #1 and attempted to talk with the resident but the resident just looked at surveyor and self-propelled down the hall. Staff was at the nurse's station and no staff was present to redirect Resident #1. Observation on 09/01/17 at 11:25AM revealed Resident #1 self-propelling down Hall B in and out of residents' rooms. Staff did not redirect the resident. Resident #1 did not enter resident rooms due to residents yelling at her to get out when she would attempt to enter. Resident #1's Nurse's Notes reflected on 08/08/17 at 12:45 PM Resident #1 was found in Resident #2's room rummaging through her personal possessions. Resident #2 took items away from Resident #1 and was yelling get out get out get out while shaking Resident #1 and putting her hands on her neck and shoulders. Review of the facility's Incident/Accident Report, undated, revealed on 08/08/17 Resident #1 wandered into Resident #2's room and was rummaging through her things. Resident #2 took the items away from Resident #1 and yelled get out get out get out as she was shaking the resident and putting her hands on her neck and shoulders. No injuries were noted. The Past Interventions Attempted reflected the resident was redirected all day, every day. She was given activities to try to keep her occupied. The Recommendations/New Interventions reflected the resident was alert and oriented times one with severe confusion due to disease process and to keep the resident occupied. Interview on 09/14/17 at 1:30 PM with Resident #2 revealed she could not recall the incident between Resident #1 and herself. When asked what she would do if someone entered her room and started taking her belongings, she stated she would yell for help. Interview on 09/14/17 at 1:36 PM with CNA D revealed she was working when the altercation occurred between Resident #1 and Resident #2. She stated Resident #1 went into Resident #2's room and Resident #2 told her to get out. She stated Resident #2 was holding onto Resident #1's shoulders. She stated she did not see her with her hands on Resident #1's neck. She stated she redirected Resident #1 out of the room and reported the incident to ADON E. An interview on 09/14/17 at 11:57 AM with LVN A, she stated Resident #1 would come onto her hall and go into residents' rooms multiple times throughout her shift. She stated some of the residents would get angry. LVN A stated there was an altercation between Resident #1 and Resident #2. She stated she did not witness the incident. She stated on the day of the incident (no date provided) she heard Resident #2 yell get out get out get out. She stated Resident #1 was in Resident #2's room trying to take her belongings and Resident #2 had her hands on Resident #1's shoulders and was shaking her. She stated an incident report was completed. LVN A stated Resident #1 needed to be redirected and even if she was removed from the hall she would turn around and go back onto the hall. She stated Resident #1 did not understand what she was doing but it was aggravating to the other residents. She stated staff would try to give Resident #1 things to do to keep her busy but the activities would not last long. Review of Resident #2's Quarterly MDS assessment, dated 07/26/17, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #2's [DIAGNOSES REDACTED]. Resident #2 was usually understood by others, could usually understand others, her cognition was moderately impaired. Resident #2 utilized a walker. Resident #1's Nurse's Notes dated 08/08/17, no time noted, reflected Resident #1 went into another resident room (Resident #3). Resident #3 got angry and kicked Resident #1 on her right lower leg. No bruise or redness was noted to Resident #1 but stated it did hurt. Review of the facility's Incident/Accident Report, undated, revealed on 08/08/17 at 12:55 PM Resident #1 went into Resident #3's room and Resident #3 kicked Resident #1's right lower leg. No bruise or abrasion was noted. The Recommendation/New Interventions reflected to monitor the resident. Interview on 09/14/17 at 2:27 PM with ADON E revealed she observed Resident #3 kick Resident #1 when Resident #1 attempted to enter her room. She stated Resident #1 stated that hurt and both residents were assessed and neither had an injury. She stated an incident report was completed. ADON E stated Resident #1 was ambulatory when she admitted to the facility and she did not recall Resident #1 wandering into resident rooms. She stated the behavior developed over time. ADON E stated Resident #3 was confused. Interview on 09/14/17 at 1:19 PM with Resident #3 revealed there was a woman that walked into her room and would steal from everyone. She stated, They know who she is. When asked if she kicked the female that went into her room, she stated she pushed her walker at her (other resident) and it hit her. She stated she yelled so staff would come to get the female out of her room. She stated she would close her door to keep her out but wanted her door to be open because she got claustrophobic. Review of Resident #3's Quarterly MDS assessment, dated 08/25/17, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #3 was able to be understood by others, able to understand others, and her cognition was severely impaired. Under area Behavioral Symptoms Resident #3 was coded as a 2 (behavior of this type occurred four to six days) for verbal behavioral symptoms directed toward others. Resident #3 utilized a walker and wheelchair. Resident #1's Nurse's Notes dated 08/15/17 at 4:30 PM, documented by LVN F, reflected Resident #1 entered another resident room (Resident #4). Resident #4 reported to the nurse Resident #1 drank sputum out of a cup he had been coughing and spitting into. Review of the facility's Incident/Accident Report, dated 08/16/17, revealed on 08/15/17 at 4:30 PM Resident #1 went into Resident #4's room where the door was closed and drank sputum out of a cup that belonged to Resident #4. The Type of Injury noted was unknown; possible bacterial infection. The Description of Situation reflected Resident #1 entered Resident #4's and Resident #4 was in his recliner. He tried to persuade Resident #1 to leave, however, Resident #1 went over by the window and picked up a cup of sputum and drank it. The Summary Of Investigation reflected the PCP to review communicable diseases and investigate if patient has bacterial pneumonia and treat accordingly. The Past Interventions Attempted reflected Resident #1 had activities in public areas to keep her from wandering into other rooms and was redirected off halls. The Recommendations/New Interventions reflected the resident needed to be moved to a secure facility specifically for Alzheimer's patients. Interview on 09/15/17 at 2:10 PM with LVN F reveled Resident #1 drank Resident #4's sputum. She stated Resident #4 told her. She stated the physician was consulted and he said to monitor Resident #1. LVN F stated Resident #1 was difficult to redirect at times and required a lot of redirection. Resident #1's Nurse's Notes dated 08/17/17 at 7:15 AM, documented by LVN B, reflected Resident #1 came out of room with a cup that appeared to have old tea, a napkin, and other things in the cup. Resident drank from the cup before the nurse could retrieve it from the resident. Review of the facility's Incident/Accident Report, undated, revealed on 08/17/17 at 7:15 AM Resident #1 was observed coming out of the conference room with a cup of tea that had a napkin and other tings floating in it. The resident took a drink from the cup and then handed it to the staff. The Past Interventions Attempted reflected redirection. The Recommendations/New Interventions was blank. Resident #1's Nurse's Notes dated 08/09/17 at 2:00 PM, documented by LVN B, reflected Resident #1 had been up and down all halls and going into other resident rooms and offices. There was no documentation noted regarding redirection offered to Resident #1. The notes further reflected on 08/09/17 at 10:00 PM, documented by LVN P, Resident #1 had been noted to continue wandering up and down hallways, going in and out of rooms, and misplacing items. There was no additional documentation noted regarding redirection offered to Resident #1. Resident #1's Nurse's Notes dated 08/10/17 at 10:50 AM, documented by LVN B, reflected Resident #1 had been up and down halls, into resident rooms, into offices, and setting off the alarm on the front door. There was no additional documentation noted regarding redirection offered to Resident #1. Resident #1's Nurse's Notes dated 08/14/17 at 10:30 AM, documented by LVN B, reflected Resident #1 was redirected multiple times due to going onto other resident rooms and onto other halls. Staff had to remove her from rooms. There was no evidence documented on how Resident #1 was redirected. Resident #1's Nurse's Notes dated 08/17/17 at 2:00 PM, documented by LVN B, reflected Resident was in and out of resident rooms and up and down hallways. There was no additional documentation noted regarding redirection offered to Resident #1. Resident #1's Nurse's Notes dated 08/18/17 at 1:30 PM, documented by LVN B, reflected Resident #1 slept off on and when she woke up about 1:00 PM she started going into resident rooms taking their things. The note reflected the resident had been redirected each time. There was no evidence documented on how Resident #1 was redirected. Resident #1's Nurse's Notes dated 08/22/17 at 1:30 PM, documented by LVN B, reflected Resident #1 had been going into resident rooms, taking their belongings. Staff would give the resident tasks to do which lasted about five to 15 minutes and then she would start wandering up and down the hall and into resident rooms. The note reflected the resident had been redirected each time. There was no additional documentation noted regarding redirection offered to Resident #1. Resident #1's Nurse's Notes dated 08/24/17 at 1:15 PM, documented by LVN B, reflected Resident #1 was up and down the halls and going into resident rooms, into offices, and taking items. Resident #1 was given laundry to fold, books to look at, and music but does not last long and resident was back to wandering halls. Resident #1's Nurse's Notes dated 08/25/17, no time noted, documented by RN M, reflected the resident was found in multiple rooms on multiple halls specifically B hall at least seven times. Resident #1's Nurse's Notes dated 08/27/17 at 1:50 PM, documented by LVN L, reflected Resident #1 continued to wander halls; entering resident rooms and taking their items. Interview on 09/01/17 at 1:44 PM with Resident #6 revealed she hated Resident #1 because she would come into her room and take her things. Resident #6 stated Resident #1 knew what she was doing because she would say mine and grab her belongings. Resident #6 stated Resident #1 came into her room at least three times a day and she had to stop the resident at the door by holding Resident #1's wheelchair. Resident #6 stated Resident #1 had hit her on her hand. Resident #6 stated she told Resident #1 she would hit her (Resident #1) if she hit Resident #6 again. Resident #6 stated she would have to scream and yell for staff to come to her room but it took them 15 minutes to remove Resident #1 from her room. Resident #6 stated she told staff about Resident #1 coming into her room daily and their only response was for her to keep her door closed. Resident #6 stated she liked to keep her door open because it got hot in her room and she liked the air flow. Interview on 09/01/2017 at 1:57 PM with Resident #7 revealed she got annoyed with Resident #1 coming into her room and she would yell at her to get out. Resident #7 stated Resident #1 would come into her room daily several times and staff had to remove Resident #1. Interview on 09/01/17 at 11:34 AM with Resident #8 revealed she was frustrated with Resident #1 going into her room. Interview on 09/15/17 at 10:04 AM with Resident #9 revealed it bothered him when Resident #1 would enter his room. He stated he would block her wheelchair from coming into the room but she was very persistent. He stated she would get aggravated and try to hit him. He stated he felt his privacy was violated. He stated staff would assist her out of the room. Interview on 09/15/17 at 10:17 AM with Resident #10 revealed Resident #1 would enter her room and she would tell her to get out. She stated Resident #1 did not understand she needed to leave her room. She stated she would put on her call light and call for help to get Resident #1 out of her room. She stated Resident #1 would grab her personal belongings. She stated she did not like people entering her room unless they were invited and felt her privacy was invaded. Interview on 09/15/17 at 10:21 AM with Resident #11 revealed Resident #1 would enter her room and grab her personal items. She stated it bothered her and she felt her privacy was invaded. She stated she would holler and staff would have to remove Resident #1. She stated she would push Resident #1 away and Resident #1 had thrown a stuffed animal at her. Interview on 09/01/2017 at 1:30 PM with CNA C revealed she worked with Resident #1 for a week and Resident #1 refused care and constantly wandered throughout the facility going from room to room upsetting other residents. CNA C stated residents would yell at Resident #1 telling her to get out of their room and they would curse at her and even threaten to hit her. CNA C stated it was hard to keep her out of other residents' rooms. She stated if she needed to provide care to another resident she would not be able to monitor Resident #1. CNA C stated sometimes she would not get to Resident #1 before she entered another resident's room and she would hear the other resident yelling at Resident #1 to get out. Interview on 09/01/2017 at 1:22 PM with LVN B revealed she was Resident #1's nurse. LVN B stated she felt the resident was not safe and she was afraid another resident would hurt her badly. She stated Resident #1 required more supervision and it was difficult to redirect the resident and she required a lot of redirection. She stated Resident #1 was provided with activities such as folding towels and books to look at it but the activity only lasted a few minutes. LVN B stated Resident #1 would go from one resident room to another which would upset other residents. She stated there were no altercations between Resident #1 and Resident #6 that she was aware of but Resident #6 stated she was going to hurt Resident #1. LVN B said it was hard to keep up with the resident if she went to a different hall which was common. She stated she tried her best to stay on the hall in order to redirect Resident #1 and she consumed a lot of her time. She stated she had reported her concerns to the DON and ADM but nothing had really been done about it. LVN B stated since Resident #1 had been placed on one on one supervision things had been better. Interview on 09/01/2017 at 12:40 PM with LVN A, whom worked a different hall, revealed Resident #1 was a danger to herself and other residents and she was afraid Resident #1 would get hurt by other residents. LVN A stated she had reported her concerns to the DON and ADM but nothing had been resolved. In another interview with LVN A on 09/14/17 at 11:57 AM she stated Resident #1 would have to be redirected off her hall. She stated she would remove her from the hall but Resident #1 may turn back around and be back on the hall once again. She stated Resident #1 did not understand what she was doing. She stated Resident #1's wandering was very aggravating for other residents. LVN A since Resident #1 was placed on one on one supervision (09/01/17) things had improved. Interview on 09/15/17 at 2:43 PM with the facility's Psychologist revealed Resident #1 was not on his caseload because she could not communicate. He stated he was aware of who Resident #1 was. He stated he would redirect her and remove her from resident rooms. He stated he visited the facility three times a week. He stated he knew a lot of the residents were frustrated with Resident #1. He stated his impression of Resident #1 was there was too much stimulation and he thought that was why she would go down the halls. Interview on 09/01/2017 at 2:20 PM with the DON revealed she was aware of Resident #1 wandering from room to room upsetting other residents. The DON stated Resident #1 was not appropriately placed at the facility and the resident was a danger to herself and other residents. The DON stated if staff focused on Resident #1 at every moment, then staff would be neglecting other residents and if staff did not focus on Resident #1 every moment then the resident would be neglected. The DON revealed Resident #1 had an incident report filled out daily from being hit and yelled at by other residents as well as the resident picking up things from other resident's room and drinking unknown substances in rooms. The DON stated she had tried to discharge the resident because of the need for increased supervision and her infringing on other residents' rights. The DON said she and the family had a meeting on 05/17/2017 which explained the concerns they were having keeping the resident safe and supervised. The DON stated she had asked the former and current Administrator if she could give the family a discharge notice but was told she could not. The DON stated she did not know what else to do. Interview on 09/01/2017 at 4:03 PM with the ADM, revealed he had been employed with the facility since July 2017. The ADM stated, (Resident #1) needs to be placed elsewhere, but was informed that her last care plan meeting did not go well. The ADM stated he was aware Resident #1 had been hit and yelled at by other residents and he had not provided a discharge to her family. The ADM stated Resident #1 had a care plan meeting scheduled for 09/12/17 and he would go from there. Observation on 09/14/17 at 12:18 PM of Resident #1 revealed she was in the dining room for the lunch meal. CNA S was sitting with her. Observation on 09/14/17 at 1:08 PM of Resident #1 revealed she was self-propelling herself out of the dining room. She had some cooking utensils in her hands and was not aware she was running into other residents with her wheelchair as LVN O attempted to redirect her. The surveyor attempted to speak with Resident #1. Resident #1 said hi to the surveyor but propelled herself away and headed towards Hall B. LVN O was with Resident #1. Interview on 09/15/17 at 2:10 PM with LVN F reveled Resident #1 was difficult to redirect at times and required a lot of redirection. She stated things had been better since she was placed on one on one supervision. Interview on 09/15/17 at 10:04 AM with Resident #9 revealed he had not issues since she was placed on one on one supervision. Interview on 09/15/17 at 10:17 AM with Resident #10 revealed things had been better since Resident #1 was placed on one on one supervision. Interview on 09/15/17 at 10:21 AM with Resident #11 revealed things had improved since Resident #1 was placed on one on one supervision. Interview on 09/14/17 at 10:50 AM with the ADM revealed Resident #1 was placed on one on one supervision on 09/01/17. He stated she would be on one on one supervision until she discharged from the facility (30 days from 09/05/17). The ADM stated he knew about the incident involving Resident #1 and Resident #3. He stated he was not aware of the incident in which a resident was choking Resident #1. The ADM stated Resident #1 was issued a 30 day discharge letter on 09/05/17. The ADM stated the facility was supposed to meet with Resident #1's family on 09/12/17, however, her family member did not show up. He stated there was a meeting in June 2017 with the family, however, the meeting was not helpful. He stated some residents were frustrated and angry with Resident #1's behavior. Review of a 30 day discharge letter issued to Resident #1's Responsible Party reflected the letter was effective on 09/05/17. The reason for the discharge was safety of the resident and other individual residents in the facility. Review of the facility's Behavior Management, revised 04/15/17, revealed, Procedure: Determine whether there is medical, physical, functional, psychological, emotional, psychiatric, social or environmental cause of the behaviors. Document in the clinical record the pact there factors have or do not have a causing the dementia patient's behaviors. Considerations: Person-Centered- Care- evaluate if the environment is supportive and promotes comfort toward, understanding, preventing, relieving and recognizing individual needs and preferences. Activities are relevant, cognitively appropriate and force on patient individualized needs. Resident #1 was in an Immediate Jeopardy situation from 08/08/17 through 09/01/17. The Immediate Jeopardy was identified on 09/14/17 at 10:50 AM. The ADM and DON were notified, and a Plan of Removal was requested at that time. The revised Plan of Removal was accepted on 09/15/17 at 12:11 PM. It reflected the: -(Resident #1) has been on 1:1 (one on one) observation since September 1, 2017 with no negative outcome to her or to other potential residents. -Today September 14, 2017 center used the resident response analyzer to identify any other residents that have a tendency for wandering. Four residents were identified as having potential for wandering but no current issues with these residents 1. (Resident #12) 2. (Resident #13) 3. (Resident #14) 4. (Resident #15) -All four resident were placed on 1:1 observation at 1:30 PM September 14, 2017 and will remain on 1:1 observation until an assessment can be done to determine their extent/if any wandering. Additional staff was brought for this assignment. -Assessment of these four residents was started today September 14, 2017 and completed today September 14, 2017. -If resident is determine not be actively wandering in other resident's rooms, these identified residents will be placed on every 1 hour checking using a Resident location QAPI tool. -If any resident is determine to be actively wandering, they will remain 1:1 observation until alternate placement can be found. -Residents placed on every 1 hour checked will remain on this system for 2 weeks for observation to evaluate pattern of behavior if any. -These 4 residents were reviewed and revaluated on September 14, 2017 and completed September 14, 2017 used MDS CAA form by DON and RNC. This assessment demonstrated that these 4 residents do not wander into other resident rooms or disturb other residents. Resident questionnaires on alert residents completed on September 14, 2017 by DON, ADON, and RNC validated these assessments. -Social Services interviewed 34 alert residents to determine if there were any psychosocial issues related to (Resident #1) previous wandering into other resident's rooms. This resident interview began on September 14, 2017. Sixteen residents interviewed voiced mostly frustration over her prior wandering into their rooms. These 16 residents were interviewed by social services today regarding their frustration. Psychologist (name) is at the center and will conduct interviews with these 16 residents to determine if/any psychosocial issues are present. These evaluations were started on September 14, 2017 and were completed on September 14, 2017. In service education started today September 14, 2017 on: 1. Behavior Management Policy. This in service began today September 14. 2017 by (ADON G) LVN and will completed by September 15, 2017. 2. Wandering Patient Practice Guidelines (to include how to identify wandering and reporting of wandering) to include Post Test. This in service began today September 14, 2017 by (ADON G) LVN and will be completed by September 15, 2017. 3. Abuse and neglect (including what and when to report) to include Post Test. This in service began today September 14, 2017 by (ADON G) LVN will be completed by September 15, 2017. -All in service begin today September 14, 2017 and will be completed September 15, 2017 and any staff that has not had this education will not be allowed to return to work until it is completed. Interview on 09/15/17 at 9:33 AM with ADON G revealed she conducted the in-services with staff regarding the IJ. She stated she discussed behavior management, redirection, and cognitive impairment. ADON G stated she discussed wandering, the different types, and what to do if a resident was wandering. On 09/15/17 at 11:13 AM the ADM informed the surveyor another facility had accepted Resident #1 and she would be transferring on 09/18/17. On 09/15/17 thirteen individual staff interviews were conducted. Staff were asked to explain what they would do if a resident was wandering unsafely, how they redirect the resident, what they would do if a resident was not responding to the redirection, how they would handle a resident to resident altercation, what they would do if a resident had a new or worsening behavior, and about abuse/neglect policy and procedure. All employees interviewed were able to sufficiently answer the questions. The employees were as follows: -Day shift: (6:00 AM to 2:00 PM, Monday through Friday): LVN A, HA I, CNA N, and LVN O -Evening shift: (2:00 PM to 10:00 PM, Monday through Friday): LVN F, LVN P, CNA Q, and CNA R -Double weekend shift: LVN H, CNA J, CNA K, LVN L, and RN M On 09/15/17 at 12:11 PM, the ADM was informed the Immediate Jeopardy was removed. While the IJ was removed on 09/15/17, the facility remained out of compliance because the facility was monitoring the effectiveness of their plan of removal. On 09/14/17 the ADM provided the surveyor with a list of four residents identified as having a wandering behavior.

Based on observation, interview and record review, the facility failed to ensure each resident was free from neglect, for one (Resident #1) of 17 residents reviewed for neglect. 1. The facility failed to implement effective interventions to address Resident #1's wandering and entering other residents' rooms and provide adequate supervision to prevent resident-to-resident altercations between Resident #1 and Residents #2 and #3. On 08/08/17, Resident #1 was kicked, choked, shaken and yelled at by Resident #2 after entering the resident's room. That same day, Resident #1 was kicked by Resident #3 when she entered the resident's room. 2. The facility failed to provide adequate supervision to Resident #1 who entered Resident #4's room on 08/15/17 and drank that resident's cup of sputum. Resident #4 was being monitored by the PCP for communicable diseases. 3. The facility failed to provide adequate supervision and effective interventions to prevent Resident #1 from entering a conference room and drinking what looked like an old cup of tea with a napkin in the cup and other things floating in the cup. An Immediate Jeopardy was identified on 09/14/17. While the IJ was removed on 09/15/17, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the facility was monitoring the effectiveness of their plan of removal. These failures could affect the five residents, who wandered, by placing them at risk for verbal aggression, physical aggression and injuries. Findings included: Review of Resident #1's Quarterly MDS assessment, dated 08/17/17, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. She had short term and long term memory problems and her cognition was severely impaired. Under area Acute Onset Mental Status Change the resident was coded a 2 (behavior present, fluctuates) for inattention and disorganized thinking. Under area Behavior Resident #1 was coded a 3 (behavior of this type occurred daily) for wandering. Resident #1 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #1 utilized a wheelchair and required supervision for locomotion on and off unit (self-sufficiency once in wheelchair). Review of Resident #1's care plan revealed a care plan for wandering/exit seeking related to cognitive impairment with an initiation date of 12/26/16. The goal reflected: Resident will wander in a safe environment without occurrence of injury and dignity will be maintained through the next review date. Identified interventions reflected the following: Redirect if resident enters a restricted area, encourage social and activity attendance, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, etc ., and resident prefers folding towels and holding her baby. Further review of Resident #1's care plan revealed a care plan for wandering, dated 09/01/17, as evidence by dementia/Alzheimer. The care plan reflected Resident #1 was kicked by another resident on 08/08/17 and wandering into a resident room and drank sputum on 08/15/17. The goal reflected: Will be able to wander in a safe environment without the occurrence of injury and dignity will be maintained over the next 90 days. Identified interventions reflected, Observe and document residents location every two hours; monitor; redirect as much as possible; start activity calendar; one on one while awake. Observation on 09/01/2017 at 11:15AM revealed Resident #1 going into Resident #5's room. Resident #5 was in his room lying down and when whenever Resident #1 was trying tried to enter his room he tried to get out of the bed. Resident #5 was talking at Resident #1 but words were not understandable. The surveyor approached Resident #1 and attempted to talk with the resident but the resident just looked at surveyor and self-propelled down the hall. Staff was at the nurse's station and no staff was present to redirect Resident #1. Observation on 09/01/17 at 11:25AM revealed Resident #1 self-propelling down Hall B in and out of residents' rooms. Staff did not redirect the resident. Resident #1 did not enter resident rooms due to residents yelling at her to get out when she would attempt to enter. Resident #1's Nurse's Notes reflected on 08/08/17 at 12:45 PM Resident #1 was found in Resident #2's room rummaging through her personal possessions. Resident #2 took items away from Resident #1 and was yelling get out get out get out while shaking Resident #1 and putting her hands on her neck and shoulders. Review of the facility's Incident/Accident Report, undated, revealed on 08/08/17 Resident #1 wandered into Resident #2's room and was rummaging through her things. Resident #2 took the items away from Resident #1 and yelled get out get out get out as she was shaking the resident and putting her hands on her neck and shoulders. No injuries were noted. The Past Interventions Attempted reflected the resident was redirected all day, every day. She was given activities to try to keep her occupied. The Recommendations/New Interventions reflected the resident was alert and oriented times one with severe confusion due to disease process and to keep the resident occupied. Interview on 09/14/17 at 1:30 PM with Resident #2 revealed she could not recall the incident between Resident #1 and herself. When asked what she would do if someone entered her room and started taking her belongings, she stated she would yell for help. Interview on 09/14/17 at 1:36 PM with CNA D revealed she was working when the altercation occurred between Resident #1 and Resident #2. She stated Resident #1 went into Resident #2's room and Resident #2 told her to get out. She stated Resident #2 was holding onto Resident #1's shoulders. She stated she did not see her with her hands on Resident #1's neck. She stated she redirected Resident #1 out of the room and reported the incident to ADON E. An interview on 09/14/17 at 11:57 AM with LVN A, she stated Resident #1 would come onto her hall and go into residents' rooms multiple times throughout her shift. She stated some of the residents would get angry. LVN A stated there was an altercation between Resident #1 and Resident #2. She stated she did not witness the incident. She stated on the day of the incident (no date provided) she heard Resident #2 yell get out get out get out. She stated Resident #1 was in Resident #2's room trying to take her belongings and Resident #2 had her hands on Resident #1's shoulders and was shaking her. She stated an incident report was completed. LVN A stated Resident #1 needed to be redirected and even if she was removed from the hall she would turn around and go back onto the hall. She stated Resident #1 did not understand what she was doing but it was aggravating to the other residents. She stated staff would try to give Resident #1 things to do to keep her busy but the activities would not last long. Review of Resident #2's Quarterly MDS assessment, dated 07/26/17, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #2's [DIAGNOSES REDACTED]. Resident #2 was usually understood by others, could usually understand others, her cognition was moderately impaired. Resident #2 utilized a walker. Resident #1's Nurse's Notes dated 08/08/17, no time noted, reflected Resident #1 went into another resident room (Resident #3). Resident #3 got angry and kicked Resident #1 on her right lower leg. No bruise or redness was noted to Resident #1 but stated it did hurt. Review of the facility's Incident/Accident Report, undated, revealed on 08/08/17 at 12:55 PM Resident #1 went into Resident #3's room and Resident #3 kicked Resident #1's right lower leg. No bruise or abrasion was noted. The Recommendation/New Interventions reflected to monitor the resident. Interview on 09/14/17 at 2:27 PM with ADON E revealed she observed Resident #3 kick Resident #1 when Resident #1 attempted to enter her room. She stated Resident #1 stated that hurt and both residents were assessed and neither had an injury. She stated an incident report was completed. ADON E stated Resident #1 was ambulatory when she admitted to the facility and she did not recall Resident #1 wandering into resident rooms. She stated the behavior developed over time. ADON E stated Resident #3 was confused. Interview on 09/14/17 at 1:19 PM with Resident #3 revealed there was a woman that walked into her room and would steal from everyone. She stated, They know who she is. When asked if she kicked the female that went into her room, she stated she pushed her walker at her (other resident) and it hit her. She stated she yelled so staff would come to get the female out of her room. She stated she would close her door to keep her out but wanted her door to be open because she got claustrophobic. Review of Resident #3's Quarterly MDS assessment, dated 08/25/17, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #3 was able to be understood by others, able to understand others, and her cognition was severely impaired. Under area Behavioral Symptoms Resident #3 was coded as a 2 (behavior of this type occurred four to six days) for verbal behavioral symptoms directed toward others. Resident #3 utilized a walker and wheelchair. Resident #1's Nurse's Notes dated 08/15/17 at 4:30 PM, documented by LVN F, reflected Resident #1 entered another resident room (Resident #4). Resident #4 reported to the nurse Resident #1 drank sputum out of a cup he had been coughing and spitting into. Review of the facility's Incident/Accident Report, dated 08/16/17, revealed on 08/15/17 at 4:30 PM Resident #1 went into Resident #4's room where the door was closed and drank sputum out of a cup that belonged to Resident #4. The Type of Injury noted was unknown; possible bacterial infection. The Description of Situation reflected Resident #1 entered Resident #4's and Resident #4 was in his recliner. He tried to persuade Resident #1 to leave, however, Resident #1 went over by the window and picked up a cup of sputum and drank it. The Summary Of Investigation reflected the PCP to review communicable diseases and investigate if patient has bacterial pneumonia and treat accordingly. The Past Interventions Attempted reflected Resident #1 had activities in public areas to keep her from wandering into other rooms and was redirected off halls. The Recommendations/New Interventions reflected the resident needed to be moved to a secure facility specifically for Alzheimer's patients. Interview on 09/15/17 at 2:10 PM with LVN F reveled Resident #1 drank Resident #4's sputum. She stated Resident #4 told her. She stated the physician was consulted and he said to monitor Resident #1. LVN F stated Resident #1 was difficult to redirect at times and required a lot of redirection. Resident #1's Nurse's Notes dated 08/17/17 at 7:15 AM, documented by LVN B, reflected Resident #1 came out of room with a cup that appeared to have old tea, a napkin, and other things in the cup. Resident drank from the cup before the nurse could retrieve it from the resident. Review of the facility's Incident/Accident Report, undated, revealed on 08/17/17 at 7:15 AM Resident #1 was observed coming out of the conference room with a cup of tea that had a napkin and other tings floating in it. The resident took a drink from the cup and then handed it to the staff. The Past Interventions Attempted reflected redirection. The Recommendations/New Interventions was blank. Resident #1's Nurse's Notes dated 08/09/17 at 2:00 PM, documented by LVN B, reflected Resident #1 had been up and down all halls and going into other resident rooms and offices. There was no documentation noted regarding redirection offered to Resident #1. The notes further reflected on 08/09/17 at 10:00 PM, documented by LVN P, Resident #1 had been noted to continue wandering up and down hallways, going in and out of rooms, and misplacing items. There was no additional documentation noted regarding redirection offered to Resident #1. Resident #1's Nurse's Notes dated 08/10/17 at 10:50 AM, documented by LVN B, reflected Resident #1 had been up and down halls, into resident rooms, into offices, and setting off the alarm on the front door. There was no additional documentation noted regarding redirection offered to Resident #1. Resident #1's Nurse's Notes dated 08/14/17 at 10:30 AM, documented by LVN B, reflected Resident #1 was redirected multiple times due to going onto other resident rooms and onto other halls. Staff had to remove her from rooms. There was no evidence documented on how Resident #1 was redirected. Resident #1's Nurse's Notes dated 08/17/17 at 2:00 PM, documented by LVN B, reflected Resident was in and out of resident rooms and up and down hallways. There was no additional documentation noted regarding redirection offered to Resident #1. Resident #1's Nurse's Notes dated 08/18/17 at 1:30 PM, documented by LVN B, reflected Resident #1 slept off on and when she woke up about 1:00 PM she started going into resident rooms taking their things. The note reflected the resident had been redirected each time. There was no evidence documented on how Resident #1 was redirected. Resident #1's Nurse's Notes dated 08/22/17 at 1:30 PM, documented by LVN B, reflected Resident #1 had been going into resident rooms, taking their belongings. Staff would give the resident tasks to do which lasted about five to 15 minutes and then she would start wandering up and down the hall and into resident rooms. The note reflected the resident had been redirected each time. There was no evidence documented on how Resident #1 was redirected. Resident #1's Nurse's Notes dated 08/24/17 at 1:15 PM, documented by LVN B, reflected Resident #1 was up and down the halls and going into resident rooms, into offices, and taking items. Resident #1 was given laundry to fold, books to look at, and music but does not last long and resident was back to wandering halls. Resident #1's Nurse's Notes dated 08/25/17, no time noted, documented by RN M, reflected the resident was found in multiple rooms on multiple halls specifically B hall at least seven times. Resident #1's Nurse's Notes dated 08/27/17 at 1:50 PM, documented by LVN L, reflected Resident #1 continued to wander halls; entering resident rooms and taking their items. Interview on 09/01/17 at 1:44 PM with Resident #6 revealed she hated Resident #1 because she would come into her room and take her things. Resident #6 stated Resident #1 knew what she was doing because she would say mine and grab her belongings. Resident #6 stated Resident #1 came into her room at least three times a day and she had to stop the resident at the door by holding Resident #1's wheelchair. Resident #6 stated Resident #1 had hit her on her hand. Resident #6 stated she told Resident #1 she would hit her (Resident #1) if she hit Resident #6 again. Resident #6 stated she would have to scream and yell for staff to come to her room but it took them 15 minutes to remove Resident #1 from her room. Resident #6 stated she told staff about Resident #1 coming into her room daily and their only response was for her to keep her door closed. Resident #6 stated she liked to keep her door open because it got hot in her room and she liked the air flow. Interview on 09/01/2017 at 1:57 PM with Resident #7 revealed she got annoyed with Resident #1 coming into her room and she would yell at her to get out. Resident #7 stated Resident #1 would come into her room daily several times and staff had to remove Resident #1. Interview on 09/01/17 at 11:34 AM with Resident #8 revealed she was frustrated with Resident #1 going into her room. Interview on 09/15/17 at 10:04 AM with Resident #9 revealed it bothered him when Resident #1 would enter his room. He stated he would block her wheelchair from coming into the room but she was very persistent. He stated she would get aggravated and try to hit him. He stated he felt his privacy was violated. He stated staff would assist her out of the room. Interview on 09/15/17 at 10:17 AM with Resident #10 revealed Resident #1 would enter her room and she would tell her to get out. She stated Resident #1 did not understand she needed to leave her room. She stated she would put on her call light and call for help to get Resident #1 out of her room. She stated Resident #1 would grab her personal belongings. She stated she did not like people entering her room unless they were invited and felt her privacy was invaded. Interview on 09/15/17 at 10:21 AM with Resident #11 revealed Resident #1 would enter her room and grab her personal items. She stated it bothered her and she felt her privacy was invaded. She stated she would holler and staff would have to remove Resident #1. She stated she would push Resident #1 away and Resident #1 had thrown a stuffed animal at her. Interview on 09/01/2017 at 1:30 PM with CNA C revealed she worked with Resident #1 for a week and Resident #1 refused care and constantly wandered throughout the facility going from room to room upsetting other residents. CNA C stated residents would yell at Resident #1 telling her to get out of their room and they would curse at her and even threaten to hit her. CNA C stated it was hard to keep her out of other residents' rooms. She stated if she needed to provide care to another resident she would not be able to monitor Resident #1. CNA C stated sometimes she would not get to Resident #1 before she entered another resident's room and she would hear the other resident yelling at Resident #1 to get out. Interview on 09/01/2017 at 1:22 PM with LVN B revealed she was Resident #1's nurse. LVN B stated she felt the resident was not safe and she was afraid another resident would hurt her badly. She stated Resident #1 required more supervision and it was difficult to redirect the resident and she required a lot of redirection. She stated Resident #1 was provided with activities such as folding towels and books to look at it but the activity only lasted a few minutes. LVN B stated Resident #1 would go from one resident room to another which would upset other residents. She stated there were no altercations between Resident #1 and Resident #6 that she was aware of but Resident #6 stated she was going to hurt Resident #1. LVN B said it was hard to keep up with the resident if she went to a different hall which was common. She stated she tried her best to stay on the hall in order to redirect Resident #1 and she consumed a lot of her time. She stated she had reported her concerns to the DON and ADM but nothing had really been done about it. LVN B stated since Resident #1 had been placed on one on one supervision things had been better. Interview on 09/01/2017 at 12:40 PM with LVN A, whom worked a different hall, revealed Resident #1 was a danger to herself and other residents and she was afraid Resident #1 would get hurt by other residents. LVN A stated she had reported her concerns to the DON and ADM but nothing had been resolved. In another interview with LVN A on 09/14/17 at 11:57 AM she stated Resident #1 would have to be redirected off her hall. She stated she would remove her from the hall but Resident #1 may turn back around and be back on the hall once again. She stated Resident #1 did not understand what she was doing. She stated Resident #1's wandering was very aggravating for other residents. LVN A since Resident #1 was placed on one on one supervision (09/01/17) things had improved. Interview on 09/15/17 at 2:43 PM with the facility's Psychologist revealed Resident #1 was not on his caseload because she could not communicate. He stated he was aware of who Resident #1 was. He stated he would redirect her and remove her from resident rooms. He stated he visited the facility three times a week. He stated he knew a lot of the residents were frustrated with Resident #1. He stated his impression of Resident #1 was there was too much stimulation and he thought that was why she would go down the halls. Interview on 09/01/2017 at 2:20 PM with the DON revealed she was aware of Resident #1 wandering from room to room upsetting other residents. The DON stated Resident #1 was not appropriately placed at the facility and the resident was a danger to herself and other residents. The DON stated if staff focused on Resident #1 at every moment, then staff would be neglecting other residents and if staff did not focus on Resident #1 every moment then the resident would be neglected. The DON revealed Resident #1 had an incident report filled out daily from being hit and yelled at by other residents as well as the resident picking up things from other resident's room and drinking unknown substances in rooms. The DON stated she had tried to discharge the resident because of the need for increased supervision and her infringing on other residents' rights. The DON said she and the family had a meeting on 05/17/2017 which explained the concerns they were having keeping the resident safe and supervised. The DON stated she had asked the former and current Administrator if she could give the family a discharge notice but was told she could not. The DON stated she did not know what else to do. Interview on 09/01/2017 at 4:03 PM with the ADM, revealed he had been employed with the facility since July 2017. The ADM stated, (Resident #1) needs to be placed elsewhere, but was informed that her last care plan meeting did not go well. The ADM stated he was aware Resident #1 had been hit and yelled at by other residents and he had not provided a discharge to her family. The ADM stated Resident #1 had a care plan meeting scheduled for 09/12/17 and he would go from there. Observation on 09/14/17 at 12:18 PM of Resident #1 revealed she was in the dining room for the lunch meal. CNA S was sitting with her. Observation on 09/14/17 at 1:08 PM of Resident #1 revealed she was self-propelling herself out of the dining room. She had some cooking utensils in her hands and was not aware she was running into other residents with her wheelchair as LVN O attempted to redirect her. The surveyor attempted to speak with Resident #1. Resident #1 said hi to the surveyor but propelled herself away and headed towards Hall B. LVN O was with Resident #1. Interview on 09/15/17 at 2:10 PM with LVN F reveled Resident #1 was difficult to redirect at times and required a lot of redirection. She stated things had been better since she was placed on one on one supervision. Interview on 09/15/17 at 10:04 AM with Resident #9 revealed he had not issues since she was placed on one on one supervision. Interview on 09/15/17 at 10:17 AM with Resident #10 revealed things had been better since Resident #1 was placed on one on one supervision. Interview on 09/15/17 at 10:21 AM with Resident #11 revealed things had improved since Resident #1 was placed on one on one supervision. Interview on 09/14/17 at 10:50 AM with the ADM revealed Resident #1 was placed on one on one supervision on 09/01/17. He stated she would be on one on one supervision until she discharged from the facility (30 days from 09/05/17). The ADM stated he knew about the incident involving Resident #1 and Resident #3. He stated he was not aware of the incident in which a resident was choking Resident #1. The ADM stated Resident #1 was issued a 30 day discharge letter on 09/05/17. The ADM stated the facility was supposed to meet with Resident #1's family on 09/12/17, however, her family member did not show up. He stated there was a meeting in June 2017 with the family, however, the meeting was not helpful. He stated some residents were frustrated and angry with Resident #1's behavior. Review of a 30 day discharge letter issued to Resident #1's Responsible Party reflected the letter was effective on 09/05/17. The reason for the discharge was safety of the resident and other individual residents in the facility. Review of the facility's Abuse Policy, revised on 09/13/17, revealed, Policy: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion and corporal punishment. Review of the facility's Behavior Management, revised 04/15/17, revealed, Procedure: Determine whether there is medical, physical, functional, psychological, emotional, psychiatric, social or environmental cause of the behaviors. Document in the clinical record the pact there factors have or do not have a causing the dementia patient's behaviors. Considerations: Person-Centered- Care- evaluate if the environment is supportive and promotes comfort toward, understanding, preventing, relieving and recognizing individual needs and preferences. Activities are relevant, cognitively appropriate and force on patient individualized needs. Resident #1 was in an Immediate Jeopardy situation from 08/08/17 through 09/01/17. The Immediate Jeopardy was identified on 09/14/17 at 10:50 AM. The ADM and DON were notified, and a Plan of Removal was requested at that time. The revised Plan of Removal was accepted on 09/15/17 at 12:11 PM. It reflected the: -(Resident #1) has been on 1:1 (one on one) observation since September 1, 2017 with no negative outcome to her or to other potential residents. -Today September 14, 2017 center used the resident response analyzer to identify any other residents that have a tendency for wandering. Four residents were identified as having potential for wandering but no current issues with these residents 1. (Resident #12) 2. (Resident #13) 3. (Resident #14) 4. (Resident #15) -All four resident were placed on 1:1 observation at 1:30 PM September 14, 2017 and will remain on 1:1 observation until an assessment can be done to determine their extent/if any wandering. Additional staff was brought for this assignment. -Assessment of these four residents was started today September 14, 2017 and completed today September 14, 2017. -If resident is determine not be actively wandering in other resident's rooms, these identified residents will be placed on every 1 hour checking using a Resident location QAPI tool. -If any resident is determine to be actively wandering, they will remain 1:1 observation until alternate placement can be found. -Residents placed on every 1 hour checked will remain on this system for 2 weeks for observation to evaluate pattern of behavior if any. -These 4 residents were reviewed and revaluated on September 14, 2017 and completed September 14, 2017 used MDS CAA form by DON and RNC. This assessment demonstrated that these 4 residents do not wander into other resident rooms or disturb other residents. Resident questionnaires on alert residents completed on September 14, 2017 by DON, ADON, and RNC validated these assessments. -Social Services interviewed 34 alert residents to determine if there were any psychosocial issues related to (Resident #1) previous wandering into other resident's rooms. This resident interview began on September 14, 2017. Sixteen residents interviewed voiced mostly frustration over her prior wandering into their rooms. These 16 residents were interviewed by social services today regarding their frustration. Psychologist (name) is at the center and will conduct interviews with these 16 residents to determine if/any psychosocial issues are present. These evaluations were started on September 14, 2017 and were completed on September 14, 2017. In service education started today September 14, 2017 on: 1. Behavior Management Policy. This in service began today September 14. 2017 by (ADON G) LVN and will completed by September 15, 2017. 2. Wandering Patient Practice Guidelines (to include how to identify wandering and reporting of wandering) to include Post Test. This in service began today September 14, 2017 by (ADON G) LVN and will be completed by September 15, 2017. 3. Abuse and neglect (including what and when to report) to include Post Test. This in service began today September 14, 2017 by (ADON G) LVN will be completed by September 15, 2017. -All in service begin today September 14, 2017 and will be completed September 15, 2017 and any staff that has not had this education will not be allowed to return to work until it is completed. Interview on 09/15/17 at 9:33 AM with ADON G revealed she conducted the in-services with staff regarding the IJ. She stated she discussed behavior management, redirection, and cognitive impairment. ADON G stated she discussed wandering, the different types, and what to do if a resident was wandering. On 09/15/17 at 11:13 AM the ADM informed the surveyor another facility had accepted Resident #1 and she would be transferring on 09/18/17. On 09/15/17 thirteen individual staff interviews were conducted. Staff were asked to explain what they would do if a resident was wandering unsafely, how they redirect the resident, what they would do if a resident was not responding to the redirection, how they would handle a resident to resident altercation, what they would do if a resident had a new or worsening behavior, and about abuse/neglect policy and procedure. All employees interviewed were able to sufficiently answer the questions. The employees were as follows: -Day shift: (6:00 AM to 2:00 PM, Monday through Friday): LVN A, HA I, CNA N, and LVN O -Evening shift: (2:00 PM to 10:00 PM, Monday through Friday): LVN F, LVN P, CNA Q, and CNA R -Double weekend shift: LVN H, CNA J, CNA K, LVN L, and RN M On 09/15/17 at 12:11 PM, the ADM was informed the Immediate Jeopardy was removed. While the IJ was removed on 09/15/17, the facility remained out of compliance because the facility was monitoring the effectiveness of their plan of removal. On 09/14/17 the ADM provided the surveyor with a list of four residents identified as having a wandering behavior.

Based on interview and record review, the facility failed to implement their written policies and procedures that prohibit and prevent neglect of residents for one (Resident #1) of five residents reviewed for neglect. Based on observation, interview and record review, the facility failed to ensure each resident was free from neglect, for one (Resident #1) of 17 residents reviewed for neglect. 1. The facility failed to implement effective interventions to address Resident #1's wandering and entering other residents' rooms and provide adequate supervision to prevent resident-to-resident altercations between Resident #1 and Residents #2 and #3. On 08/08/17, Resident #1 was kicked, choked, shaken and yelled at by Resident #2 after entering the resident's room. That same day, Resident #1 was kicked by Resident #3 when she entered the resident's room. 2. The facility failed to provide adequate supervision to Resident #1 who entered Resident #4's room on 08/15/17 and drank that resident's cup of sputum. Resident #4 was being monitored by the PCP for communicable diseases. 3. The facility failed to provide adequate supervision and effective interventions to prevent Resident #1 from entering a conference room and drinking what looked like an old cup of tea with a napkin in the cup and other things floating in the cup. An Immediate Jeopardy was identified on 09/14/17. While the IJ was removed on 09/15/17, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the facility was monitoring the effectiveness of their plan of removal. These failures could affect the five residents, who wandered, by placing them at risk for verbal aggression, physical aggression and injuries. Findings included: Review of the facility's Abuse Policy, revised on 09/13/17, revealed, Policy: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion and corporal punishment. Review of the facility's Behavior Management, revised 04/15/17, revealed, Procedure: Determine whether there is medical, physical, functional, psychological, emotional, psychiatric, social or environmental cause of the behaviors. Document in the clinical record the pact there factors have or do not have a causing the dementia patient's behaviors. Considerations: Person-Centered- Care- evaluate if the environment is supportive and promotes comfort toward, understanding, preventing, relieving and recognizing individual needs and preferences. Activities are relevant, cognitively appropriate and force on patient individualized needs. Review of Resident #1's Quarterly MDS assessment, dated 08/17/17, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. She had short term and long term memory problems and her cognition was severely impaired. Under area Acute Onset Mental Status Change the resident was coded a 2 (behavior present, fluctuates) for inattention and disorganized thinking. Under area Behavior Resident #1 was coded a 3 (behavior of this type occurred daily) for wandering. Resident #1 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #1 utilized a wheelchair and required supervision for locomotion on and off unit (self-sufficiency once in wheelchair). Review of Resident #1's care plan revealed a care plan for wandering/exit seeking related to cognitive impairment with an initiation date of 12/26/16. The goal reflected: Resident will wander in a safe environment without occurrence of injury and dignity will be maintained through the next review date. Identified interventions reflected the following: Redirect if resident enters a restricted area, encourage social and activity attendance, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, etc ., and resident prefers folding towels and holding her baby. Further review of Resident #1's care plan revealed a care plan for wandering, dated 09/01/17, as evidence by dementia/Alzheimer. The care plan reflected Resident #1 was kicked by another resident on 08/08/17 and wandering into a resident room and drank sputum on 08/15/17. The goal reflected: Will be able to wander in a safe environment without the occurrence of injury and dignity will be maintained over the next 90 days. Identified interventions reflected, Observe and document residents location every two hours; monitor; redirect as much as possible; start activity calendar; one on one while awake. Observation on 09/01/2017 at 11:15AM revealed Resident #1 going into Resident #5's room. Resident #5 was in his room lying down and when whenever Resident #1 was trying tried to enter his room he tried to get out of the bed. Resident #5 was talking at Resident #1 but words were not understandable. The surveyor approached Resident #1 and attempted to talk with the resident but the resident just looked at surveyor and self-propelled down the hall. Staff was at the nurse's station and no staff was present to redirect Resident #1. Observation on 09/01/17 at 11:25AM revealed Resident #1 self-propelling down Hall B in and out of residents' rooms. Staff did not redirect the resident. Resident #1 did not enter resident rooms due to residents yelling at her to get out when she would attempt to enter. Resident #1's Nurse's Notes reflected on 08/08/17 at 12:45 PM Resident #1 was found in Resident #2's room rummaging through her personal possessions. Resident #2 took items away from Resident #1 and was yelling get out get out get out while shaking Resident #1 and putting her hands on her neck and shoulders. Review of the facility's Incident/Accident Report, undated, revealed on 08/08/17 Resident #1 wandered into Resident #2's room and was rummaging through her things. Resident #2 took the items away from Resident #1 and yelled get out get out get out as she was shaking the resident and putting her hands on her neck and shoulders. No injuries were noted. The Past Interventions Attempted reflected the resident was redirected all day, every day. She was given activities to try to keep her occupied. The Recommendations/New Interventions reflected the resident was alert and oriented times one with severe confusion due to disease process and to keep the resident occupied. Interview on 09/14/17 at 1:30 PM with Resident #2 revealed she could not recall the incident between Resident #1 and herself. When asked what she would do if someone entered her room and started taking her belongings, she stated she would yell for help. Interview on 09/14/17 at 1:36 PM with CNA D revealed she was working when the altercation occurred between Resident #1 and Resident #2. She stated Resident #1 went into Resident #2's room and Resident #2 told her to get out. She stated Resident #2 was holding onto Resident #1's shoulders. She stated she did not see her with her hands on Resident #1's neck. She stated she redirected Resident #1 out of the room and reported the incident to ADON E. An interview on 09/14/17 at 11:57 AM with LVN A, she stated Resident #1 would come onto her hall and go into residents' rooms multiple times throughout her shift. She stated some of the residents would get angry. LVN A stated there was an altercation between Resident #1 and Resident #2. She stated she did not witness the incident. She stated on the day of the incident (no date provided) she heard Resident #2 yell get out get out get out. She stated Resident #1 was in Resident #2's room trying to take her belongings and Resident #2 had her hands on Resident #1's shoulders and was shaking her. She stated an incident report was completed. LVN A stated Resident #1 needed to be redirected and even if she was removed from the hall she would turn around and go back onto the hall. She stated Resident #1 did not understand what she was doing but it was aggravating to the other residents. She stated staff would try to give Resident #1 things to do to keep her busy but the activities would not last long. Review of Resident #2's Quarterly MDS assessment, dated 07/26/17, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #2's [DIAGNOSES REDACTED]. Resident #2 was usually understood by others, could usually understand others, her cognition was moderately impaired. Resident #2 utilized a walker. Resident #1's Nurse's Notes dated 08/08/17, no time noted, reflected Resident #1 went into another resident room (Resident #3). Resident #3 got angry and kicked Resident #1 on her right lower leg. No bruise or redness was noted to Resident #1 but stated it did hurt. Review of the facility's Incident/Accident Report, undated, revealed on 08/08/17 at 12:55 PM Resident #1 went into Resident #3's room and Resident #3 kicked Resident #1's right lower leg. No bruise or abrasion was noted. The Recommendation/New Interventions reflected to monitor the resident. Interview on 09/14/17 at 2:27 PM with ADON E revealed she observed Resident #3 kick Resident #1 when Resident #1 attempted to enter her room. She stated Resident #1 stated that hurt and both residents were assessed and neither had an injury. She stated an incident report was completed. ADON E stated Resident #1 was ambulatory when she admitted to the facility and she did not recall Resident #1 wandering into resident rooms. She stated the behavior developed over time. ADON E stated Resident #3 was confused. Interview on 09/14/17 at 1:19 PM with Resident #3 revealed there was a woman that walked into her room and would steal from everyone. She stated, They know who she is. When asked if she kicked the female that went into her room, she stated she pushed her walker at her (other resident) and it hit her. She stated she yelled so staff would come to get the female out of her room. She stated she would close her door to keep her out but wanted her door to be open because she got claustrophobic. Review of Resident #3's Quarterly MDS assessment, dated 08/25/17, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #3 was able to be understood by others, able to understand others, and her cognition was severely impaired. Under area Behavioral Symptoms Resident #3 was coded as a 2 (behavior of this type occurred four to six days) for verbal behavioral symptoms directed toward others. Resident #3 utilized a walker and wheelchair. Resident #1's Nurse's Notes dated 08/15/17 at 4:30 PM, documented by LVN F, reflected Resident #1 entered another resident room (Resident #4). Resident #4 reported to the nurse Resident #1 drank sputum out of a cup he had been coughing and spitting into. Review of the facility's Incident/Accident Report, dated 08/16/17, revealed on 08/15/17 at 4:30 PM Resident #1 went into Resident #4's room where the door was closed and drank sputum out of a cup that belonged to Resident #4. The Type of Injury noted was unknown; possible bacterial infection. The Description of Situation reflected Resident #1 entered Resident #4's and Resident #4 was in his recliner. He tried to persuade Resident #1 to leave, however, Resident #1 went over by the window and picked up a cup of sputum and drank it. The Summary Of Investigation reflected the PCP to review communicable diseases and investigate if patient has bacterial pneumonia and treat accordingly. The Past Interventions Attempted reflected Resident #1 had activities in public areas to keep her from wandering into other rooms and was redirected off halls. The Recommendations/New Interventions reflected the resident needed to be moved to a secure facility specifically for Alzheimer's patients. Interview on 09/15/17 at 2:10 PM with LVN F reveled Resident #1 drank Resident #4's sputum. She stated Resident #4 told her. She stated the physician was consulted and he said to monitor Resident #1. LVN F stated Resident #1 was difficult to redirect at times and required a lot of redirection. Resident #1's Nurse's Notes dated 08/17/17 at 7:15 AM, documented by LVN B, reflected Resident #1 came out of room with a cup that appeared to have old tea, a napkin, and other things in the cup. Resident drank from the cup before the nurse could retrieve it from the resident. Review of the facility's Incident/Accident Report, undated, revealed on 08/17/17 at 7:15 AM Resident #1 was observed coming out of the conference room with a cup of tea that had a napkin and other tings floating in it. The resident took a drink from the cup and then handed it to the staff. The Past Interventions Attempted reflected redirection. The Recommendations/New Interventions was blank. Resident #1's Nurse's Notes dated 08/09/17 at 2:00 PM, documented by LVN B, reflected Resident #1 had been up and down all halls and going into other resident rooms and offices. There was no documentation noted regarding redirection offered to Resident #1. The notes further reflected on 08/09/17 at 10:00 PM, documented by LVN P, Resident #1 had been noted to continue wandering up and down hallways, going in and out of rooms, and misplacing items. There was no additional documentation noted regarding redirection offered to Resident #1. Resident #1's Nurse's Notes dated 08/10/17 at 10:50 AM, documented by LVN B, reflected Resident #1 had been up and down halls, into resident rooms, into offices, and setting off the alarm on the front door. There was no additional documentation noted regarding redirection offered to Resident #1. Resident #1's Nurse's Notes dated 08/14/17 at 10:30 AM, documented by LVN B, reflected Resident #1 was redirected multiple times due to going onto other resident rooms and onto other halls. Staff had to remove her from rooms. There was no evidence documented on how Resident #1 was redirected. Resident #1's Nurse's Notes dated 08/17/17 at 2:00 PM, documented by LVN B, reflected Resident was in and out of resident rooms and up and down hallways. There was no additional documentation noted regarding redirection offered to Resident #1. Resident #1's Nurse's Notes dated 08/18/17 at 1:30 PM, documented by LVN B, reflected Resident #1 slept off on and when she woke up about 1:00 PM she started going into resident rooms taking their things. The note reflected the resident had been redirected each time. There was no evidence documented on how Resident #1 was redirected. Resident #1's Nurse's Notes dated 08/22/17 at 1:30 PM, documented by LVN B, reflected Resident #1 had been going into resident rooms, taking their belongings. Staff would give the resident tasks to do which lasted about five to 15 minutes and then she would start wandering up and down the hall and into resident rooms. The note reflected the resident had been redirected each time. There was no additional documentation noted regarding redirection offered to Resident #1. Resident #1's Nurse's Notes dated 08/24/17 at 1:15 PM, documented by LVN B, reflected Resident #1 was up and down the halls and going into resident rooms, into offices, and taking items. Resident #1 was given laundry to fold, books to look at, and music but does not last long and resident was back to wandering halls. Resident #1's Nurse's Notes dated 08/25/17, no time noted, documented by RN M, reflected the resident was found in multiple rooms on multiple halls specifically B hall at least seven times. Resident #1's Nurse's Notes dated 08/27/17 at 1:50 PM, documented by LVN L, reflected Resident #1 continued to wander halls; entering resident rooms and taking their items. Interview on 09/01/17 at 1:44 PM with Resident #6 revealed she hated Resident #1 because she would come into her room and take her things. Resident #6 stated Resident #1 knew what she was doing because she would say mine and grab her belongings. Resident #6 stated Resident #1 came into her room at least three times a day and she had to stop the resident at the door by holding Resident #1's wheelchair. Resident #6 stated Resident #1 had hit her on her hand. Resident #6 stated she told Resident #1 she would hit her (Resident #1) if she hit Resident #6 again. Resident #6 stated she would have to scream and yell for staff to come to her room but it took them 15 minutes to remove Resident #1 from her room. Resident #6 stated she told staff about Resident #1 coming into her room daily and their only response was for her to keep her door closed. Resident #6 stated she liked to keep her door open because it got hot in her room and she liked the air flow. Interview on 09/01/2017 at 1:57 PM with Resident #7 revealed she got annoyed with Resident #1 coming into her room and she would yell at her to get out. Resident #7 stated Resident #1 would come into her room daily several times and staff had to remove Resident #1. Interview on 09/01/17 at 11:34 AM with Resident #8 revealed she was frustrated with Resident #1 going into her room. Interview on 09/15/17 at 10:04 AM with Resident #9 revealed it bothered him when Resident #1 would enter his room. He stated he would block her wheelchair from coming into the room but she was very persistent. He stated she would get aggravated and try to hit him. He stated he felt his privacy was violated. He stated staff would assist her out of the room. Interview on 09/15/17 at 10:17 AM with Resident #10 revealed Resident #1 would enter her room and she would tell her to get out. She stated Resident #1 did not understand she needed to leave her room. She stated she would put on her call light and call for help to get Resident #1 out of her room. She stated Resident #1 would grab her personal belongings. She stated she did not like people entering her room unless they were invited and felt her privacy was invaded. Interview on 09/15/17 at 10:21 AM with Resident #11 revealed Resident #1 would enter her room and grab her personal items. She stated it bothered her and she felt her privacy was invaded. She stated she would holler and staff would have to remove Resident #1. She stated she would push Resident #1 away and Resident #1 had thrown a stuffed animal at her. Interview on 09/01/2017 at 1:30 PM with CNA C revealed she worked with Resident #1 for a week and Resident #1 refused care and constantly wandered throughout the facility going from room to room upsetting other residents. CNA C stated residents would yell at Resident #1 telling her to get out of their room and they would curse at her and even threaten to hit her. CNA C stated it was hard to keep her out of other residents' rooms. She stated if she needed to provide care to another resident she would not be able to monitor Resident #1. CNA C stated sometimes she would not get to Resident #1 before she entered another resident's room and she would hear the other resident yelling at Resident #1 to get out. Interview on 09/01/2017 at 1:22 PM with LVN B revealed she was Resident #1's nurse. LVN B stated she felt the resident was not safe and she was afraid another resident would hurt her badly. She stated Resident #1 required more supervision and it was difficult to redirect the resident and she required a lot of redirection. She stated Resident #1 was provided with activities such as folding towels and books to look at it but the activity only lasted a few minutes. LVN B stated Resident #1 would go from one resident room to another which would upset other residents. She stated there were no altercations between Resident #1 and Resident #6 that she was aware of but Resident #6 stated she was going to hurt Resident #1. LVN B said it was hard to keep up with the resident if she went to a different hall which was common. She stated she tried her best to stay on the hall in order to redirect Resident #1 and she consumed a lot of her time. She stated she had reported her concerns to the DON and ADM but nothing had really been done about it. LVN B stated since Resident #1 had been placed on one on one supervision things had been better. Interview on 09/01/2017 at 12:40 PM with LVN A, whom worked a different hall, revealed Resident #1 was a danger to herself and other residents and she was afraid Resident #1 would get hurt by other residents. LVN A stated she had reported her concerns to the DON and ADM but nothing had been resolved. In another interview with LVN A on 09/14/17 at 11:57 AM she stated Resident #1 would have to be redirected off her hall. She stated she would remove her from the hall but Resident #1 may turn back around and be back on the hall once again. She stated Resident #1 did not understand what she was doing. She stated Resident #1's wandering was very aggravating for other residents. LVN A since Resident #1 was placed on one on one supervision (09/01/17) things had improved. Interview on 09/15/17 at 2:43 PM with the facility's Psychologist revealed Resident #1 was not on his caseload because she could not communicate. He stated he was aware of who Resident #1 was. He stated he would redirect her and remove her from resident rooms. He stated he visited the facility three times a week. He stated he knew a lot of the residents were frustrated with Resident #1. He stated his impression of Resident #1 was there was too much stimulation and he thought that was why she would go down the halls. Interview on 09/01/2017 at 2:20 PM with the DON revealed she was aware of Resident #1 wandering from room to room upsetting other residents. The DON stated Resident #1 was not appropriately placed at the facility and the resident was a danger to herself and other residents. The DON stated if staff focused on Resident #1 at every moment, then staff would be neglecting other residents and if staff did not focus on Resident #1 every moment then the resident would be neglected. The DON revealed Resident #1 had an incident report filled out daily from being hit and yelled at by other residents as well as the resident picking up things from other resident's room and drinking unknown substances in rooms. The DON stated she had tried to discharge the resident because of the need for increased supervision and her infringing on other residents' rights. The DON said she and the family had a meeting on 05/17/2017 which explained the concerns they were having keeping the resident safe and supervised. The DON stated she had asked the former and current Administrator if she could give the family a discharge notice but was told she could not. The DON stated she did not know what else to do. Interview on 09/01/2017 at 4:03 PM with the ADM, revealed he had been employed with the facility since July 2017. The ADM stated, (Resident #1) needs to be placed elsewhere, but was informed that her last care plan meeting did not go well. The ADM stated he was aware Resident #1 had been hit and yelled at by other residents and he had not provided a discharge to her family. The ADM stated Resident #1 had a care plan meeting scheduled for 09/12/17 and he would go from there. Observation on 09/14/17 at 12:18 PM of Resident #1 revealed she was in the dining room for the lunch meal. CNA S was sitting with her. Observation on 09/14/17 at 1:08 PM of Resident #1 revealed she was self-propelling herself out of the dining room. She had some cooking utensils in her hands and was not aware she was running into other residents with her wheelchair as LVN O attempted to redirect her. The surveyor attempted to speak with Resident #1. Resident #1 said hi to the surveyor but propelled herself away and headed towards Hall B. LVN O was with Resident #1. Interview on 09/15/17 at 2:10 PM with LVN F reveled Resident #1 was difficult to redirect at times and required a lot of redirection. She stated things had been better since she was placed on one on one supervision. Interview on 09/15/17 at 10:04 AM with Resident #9 revealed he had not issues since she was placed on one on one supervision. Interview on 09/15/17 at 10:17 AM with Resident #10 revealed things had been better since Resident #1 was placed on one on one supervision. Interview on 09/15/17 at 10:21 AM with Resident #11 revealed things had improved since Resident #1 was placed on one on one supervision. Interview on 09/14/17 at 10:50 AM with the ADM revealed Resident #1 was placed on one on one supervision on 09/01/17. He stated she would be on one on one supervision until she discharged from the facility (30 days from 09/05/17). The ADM stated he knew about the incident involving Resident #1 and Resident #3. He stated he was not aware of the incident in which a resident was choking Resident #1. The ADM stated Resident #1 was issued a 30 day discharge letter on 09/05/17. The ADM stated the facility was supposed to meet with Resident #1's family on 09/12/17, however, her family member did not show up. He stated there was a meeting in June 2017 with the family, however, the meeting was not helpful. He stated some residents were frustrated and angry with Resident #1's behavior. Review of a 30 day discharge letter issued to Resident #1's Responsible Party reflected the letter was effective on 09/05/17. The reason for the discharge was safety of the resident and other individual residents in the facility. Resident #1 was in an Immediate Jeopardy situation from 08/08/17 through 09/01/17. The Immediate Jeopardy was identified on 09/14/17 at 10:50 AM. The ADM and DON were notified, and a Plan of Removal was requested at that time. The revised Plan of Removal was accepted on 09/15/17 at 12:11 PM. It reflected the: -(Resident #1) has been on 1:1 (one on one) observation since September 1, 2017 with no negative outcome to her or to other potential residents. -Today September 14, 2017 center used the resident response analyzer to identify any other residents that have a tendency for wandering. Four residents were identified as having potential for wandering but no current issues with these residents 1. (Resident #12) 2. (Resident #13) 3. (Resident #14) 4. (Resident #15) -All four resident were placed on 1:1 observation at 1:30 PM September 14, 2017 and will remain on 1:1 observation until an assessment can be done to determine their extent/if any wandering. Additional staff was brought for this assignment. -Assessment of these four residents was started today September 14, 2017 and completed today September 14, 2017. -If resident is determine not be actively wandering in other resident's rooms, these identified residents will be placed on every 1 hour checking using a Resident location QAPI tool. -If any resident is determine to be actively wandering, they will remain 1:1 observation until alternate placement can be found. -Residents placed on every 1 hour checked will remain on this system for 2 weeks for observation to evaluate pattern of behavior if any. -These 4 residents were reviewed and revaluated on September 14, 2017 and completed September 14, 2017 used MDS CAA form by DON and RNC. This assessment demonstrated that these 4 residents do not wander into other resident rooms or disturb other residents. Resident questionnaires on alert residents completed on September 14, 2017 by DON, ADON, and RNC validated these assessments. -Social Services interviewed 34 alert residents to determine if there were any psychosocial issues related to (Resident #1) previous wandering into other resident's rooms. This resident interview began on September 14, 2017. Sixteen residents interviewed voiced mostly frustration over her prior wandering into their rooms. These 16 residents were interviewed by social services today regarding their frustration. Psychologist (name) is at the center and will conduct interviews with these 16 residents to determine if/any psychosocial issues are present. These evaluations were started on September 14, 2017 and were completed on September 14, 2017. In service education started today September 14, 2017 on: 1. Behavior Management Policy. This in service began today September 14. 2017 by (ADON G) LVN and will completed by September 15, 2017. 2. Wandering Patient Practice Guidelines (to include how to identify wandering and reporting of wandering) to include Post Test. This in service began today September 14, 2017 by (ADON G) LVN and will be completed by September 15, 2017. 3. Abuse and neglect (including what and when to report) to include Post Test. This in service began today September 14, 2017 by (ADON G) LVN will be completed by September 15, 2017. -All in service begin today September 14, 2017 and will be completed September 15, 2017 and any staff that has not had this education will not be allowed to return to work until it is completed. Interview on 09/15/17 at 9:33 AM with ADON G revealed she conducted the in-services with staff regarding the IJ. She stated she discussed behavior management, redirection, and cognitive impairment. ADON G stated she discussed wandering, the different types, and what to do if a resident was wandering. On 09/15/17 at 11:13 AM the ADM informed the surveyor another facility had accepted Resident #1 and she would be transferring on 09/18/17. On 09/15/17 thirteen individual staff interviews were conducted. Staff were asked to explain what they would do if a resident was wandering unsafely, how they redirect the resident, what they would do if a resident was not responding to the redirection, how they would handle a resident to resident altercation, what they would do if a resident had a new or worsening behavior, and about abuse/neglect policy and procedure. All employees interviewed were able to sufficiently answer the questions. The employees were as follows: -Day shift: (6:00 AM to 2:00 PM, Monday through Friday): LVN A, HA I, CNA N, and LVN O -Evening shift: (2:00 PM to 10:00 PM, Monday through Friday): LVN F, LVN P, CNA Q, and CNA R -Double weekend shift: LVN H, CNA J, CNA K, LVN L, and RN M On 09/15/17 at 12:11 PM, the ADM was informed the Immediate Jeopardy was removed. While the IJ was removed on 09/15/17, the facility remained out of compliance because the facility was monitoring the effectiveness of their plan of removal. On 09/14/17 the ADM provided the surveyor with a list of four residents identified as having a wandering behavior.